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Conomos I. Disease of social injustice: Acute rheumatic fever in Indigenous paediatric populations. J Paediatr Child Health 2024. [PMID: 38940194 DOI: 10.1111/jpc.16604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 05/18/2024] [Accepted: 06/11/2024] [Indexed: 06/29/2024]
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Lacey JA, Bennett J, James TB, Hines BS, Chen T, Lee D, Sika-Paotonu D, Anderson A, Harwood M, Tong SY, Baker MG, Williamson DA, Moreland NJ. A worldwide population of Streptococcus pyogenes strains circulating among school-aged children in Auckland, New Zealand: a genomic epidemiology analysis. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 42:100964. [PMID: 38035130 PMCID: PMC10684382 DOI: 10.1016/j.lanwpc.2023.100964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 09/20/2023] [Accepted: 10/29/2023] [Indexed: 12/02/2023]
Abstract
Background Acute rheumatic fever (ARF) is a serious post-infectious sequala of Group A Streptococcus (GAS, Streptococcus pyogenes). In New Zealand (NZ) ARF is a major cause of health inequity. This study describes the genomic analysis of GAS isolates associated with childhood skin and throat infections in Auckland NZ. Methods Isolates (n = 469) collected between March 2018 and October 2019 from the throats and skin of children (5-14 years) underwent whole genomic sequencing. Equal representation across three ethnic groups was ensured through sample quotas with isolates obtained from Indigenous Māori (n = 157, 33%), NZ European/Other (n = 149, 32%) and Pacific Peoples children (n = 163, 35%). Using in silico techniques isolates were classified, assessed for diversity, and examined for distribution differences between groups. Comparisons were also made with GAS strains identified globally. Findings Genomic analysis revealed a diverse population consisting of 65 distinct sequence clusters. These sequence clusters spanned 49 emm-types, with 11 emm-types comprised of several, distinct sequence clusters. There is evidence of multiple global introductions of different lineages into the population, as well as local clonal expansion. The M1UK lineage comprised 35% of all emm1 isolates. Interpretation The GAS population was characterized by a high diversity of strains, resembling patterns observed in low- and middle-income countries. However, strains associated with outbreaks and antimicrobial resistance commonly found in high-income countries were also observed. This unique combination poses challenges for vaccine development, disease management and control. Funding The work was supported by the Health Research Council of New Zealand (HRC), award number 16/005.
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Affiliation(s)
- Jake A. Lacey
- Department of Microbiology and Immunology at the Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
| | - Julie Bennett
- The Department of Public Health, University of Otago, Wellington, New Zealand
- The Maurice Wilkins Centre for Biodiscovery, The University of Auckland, Auckland, New Zealand
| | - Taylah B. James
- Department of Microbiology and Immunology at the Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
| | - Benjamin S. Hines
- School of Mathematics and Statistics, University of Melbourne, Melbourne, Victoria, Australia
| | - Tiffany Chen
- Department of Molecular Medicine and Pathology, School of Medical Sciences, The University of Auckland, Auckland, New Zealand
| | - Darren Lee
- Department of Microbiology and Immunology at the Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Anneka Anderson
- Te Kupenga Hauora Māori, The University of Auckland, New Zealand
| | - Matire Harwood
- Department of General Practice and Primary Healthcare, The University of Auckland, Auckland, New Zealand
| | - Steven Y.C. Tong
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- Department of Infectious Diseases at the Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
| | - Michael G. Baker
- The Department of Public Health, University of Otago, Wellington, New Zealand
- The Maurice Wilkins Centre for Biodiscovery, The University of Auckland, Auckland, New Zealand
| | - Deborah A. Williamson
- Department of Infectious Diseases at the Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Reference Laboratory, The Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Nicole J. Moreland
- The Maurice Wilkins Centre for Biodiscovery, The University of Auckland, Auckland, New Zealand
- Department of Molecular Medicine and Pathology, School of Medical Sciences, The University of Auckland, Auckland, New Zealand
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Lee JS, Kim S, Excler JL, Kim JH, Mogasale V. Global economic burden per episode for multiple diseases caused by group A Streptococcus. NPJ Vaccines 2023; 8:69. [PMID: 37188693 PMCID: PMC10184078 DOI: 10.1038/s41541-023-00659-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
Considering the lack of existing evidence on economic burden for diseases caused by group A Streptococcus, we estimated the economic burden per episode for selected diseases. Each cost component of direct medical costs (DMCs), direct non-medical costs (DNMCs), and indirect costs (ICs) was separately extrapolated and aggregated to estimate the economic burden per episode by income group as classified by the World Bank. Adjustment factors for DMC and DNMC were generated to overcome related data insufficiencies. To address uncertainty surrounding input parameters, a probabilistic multivariate sensitivity was carried out. The average economic burden per episode ranged from $22 to $392 for pharyngitis, $25 to $2,903 for impetigo, $47 to $2,725 for cellulitis, $662 to $34,330 for invasive and toxin-mediated infections, $231 to $6,332 for acute rheumatic fever (ARF), $449 to $11,717 for rheumatic heart disease (RHD), and $949 to $39,560 for severe RHD across income groups. The economic burden for multiple Group A Streptococcus diseases underscores an urgent need to develop effective prevention strategies including vaccines.
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Affiliation(s)
- Jung-Seok Lee
- International Vaccine Institute, Seoul, South Korea.
| | - Sol Kim
- International Vaccine Institute, Seoul, South Korea
| | | | - Jerome H Kim
- International Vaccine Institute, Seoul, South Korea
- College of Natural Sciences, Seoul National University, Seoul, South Korea
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Evaluating efficiency and equity of prevention and control strategies for rheumatic fever and rheumatic heart disease in India: an extended cost-effectiveness analysis. Lancet Glob Health 2023; 11:e445-e455. [PMID: 36796988 DOI: 10.1016/s2214-109x(22)00552-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 12/01/2022] [Accepted: 12/12/2022] [Indexed: 02/16/2023]
Abstract
BACKGROUND There is a dearth of evidence on the cost-effectiveness of a combination of population-based primary, secondary, and tertiary prevention and control strategies for rheumatic fever and rheumatic heart disease. The present analysis evaluated the cost-effectiveness and distributional effect of primary, secondary, and tertiary interventions and their combinations for the prevention and control of rheumatic fever and rheumatic heart disease in India. METHODS A Markov model was constructed to estimate the lifetime costs and consequences among a hypothetical cohort of 5-year-old healthy children. Both health system costs and out-of-pocket expenditure (OOPE) were included. OOPE and health-related quality-of-life were assessed by interviewing 702 patients enrolled in a population-based rheumatic fever and rheumatic heart disease registry in India. Health consequences were measured in terms of life-years and quality-adjusted life-years (QALY) gained. Furthermore, an extended cost-effectiveness analysis was undertaken to assess the costs and outcomes across different wealth quartiles. All future costs and consequences were discounted at an annual rate of 3%. FINDINGS A combination of secondary and tertiary prevention strategies, which had an incremental cost of ₹23 051 (US$30) per QALY gained, was the most cost-effective strategy for the prevention and control of rheumatic fever and rheumatic heart disease in India. The number of rheumatic heart disease cases prevented among the population belonging to the poorest quartile (four cases per 1000) was four times higher than the richest quartile (one per 1000). Similarly, the reduction in OOPE after the intervention was higher among the poorest income group (29·8%) than among the richest income group (27·0%). INTERPRETATION The combined secondary and tertiary prevention and control strategy is the most cost-effective option for the management of rheumatic fever and rheumatic heart disease in India, and the benefits of public spending are likely to be accrued much more by those in the lowest income groups. The quantification of non-health gains provides strong evidence for informing policy decisions by efficient resource allocation on rheumatic fever and rheumatic heart disease prevention and control in India. FUNDING Department of Health Research, Ministry of Health and Family Welfare, New Delhi.
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Bennett J, Moreland NJ, Zhang J, Crane J, Sika-Paotonu D, Carapetis J, Williamson DA, Baker MG. Risk factors for group A streptococcal pharyngitis and skin infections: A case control study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2022; 26:100507. [PMID: 35789826 PMCID: PMC9250036 DOI: 10.1016/j.lanwpc.2022.100507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Group A streptococcal (GAS) infections can trigger an immune-mediated response resulting in acute rheumatic fever (ARF). The role of social and environmental risk factors for GAS pharyngitis and skin infections are not well understood. This study aimed to identify factors associated with GAS pharyngitis and skin infections, and to determine if these are the same as those for ARF. METHODS A case-control study, including 733 children aged 5-14 years, was undertaken between March 2018 and October 2019 in Auckland, New Zealand. Healthy controls (n = 190) and symptomatic cases including GAS pharyngitis (n = 210), GAS seronegative carriers (n = 182), and GAS skin infections (n = 151) were recruited. Trained interviewers administered a comprehensive, pre-tested, face-to-face questionnaire. FINDINGS Multivariable analysis identified strong associations between barriers to accessing primary healthcare and having GAS pharyngitis (adjusted OR 3·3; 95% CI 1·8-6·0), GAS carriage (aOR 2·9; 95% CI 1·5-6·0) or a GAS skin infection (aOR 3·5; 95% CI 1·6-7·6). Children who had GAS skin infections were more likely than all other groups to report living in a crowded home (aOR 1·9; 95% CI 1·0-3·4), have Māori or Pacific grandparents (aOR 3·0; 95% CI 1·2-7·6), a family history of ARF (aOR 2·2; 95% CI 1·1-4·3), or having a previous diagnosis of eczema (aOR 3·9; 95% CI 2·2-6·9). INTERPRETATION Reducing barriers to accessing primary healthcare (including financial restrictions, the inability to book an appointment, lack of transport, and lack of childcare for other children) to treat GAS pharyngitis and skin infections could potentially reduce these infections and lead to a reduction in their sequelae, including ARF. These strategies should be co-designed and culturally appropriate for the communities being served and carefully evaluated. FUNDING This work was supported by the Health Research Council of New Zealand (HRC), award number 16/005.
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Affiliation(s)
- Julie Bennett
- Department of Public Health, University of Otago, 23A Mein Street, Newtown, Wellington 6021, New Zealand
| | - Nicole J. Moreland
- School of Medical Sciences, the University of Auckland, 85 Park Road, Grafton, Auckland 1023, New Zealand
- Maurice Wilkins Centre, the University of Auckland, 85 Park Road, Grafton, Auckland 1023, New Zealand
| | - Jane Zhang
- Department of Public Health, University of Otago, 23A Mein Street, Newtown, Wellington 6021, New Zealand
| | - Julian Crane
- Department of Medicine, University of Otago, 23A Mein Street, Newtown, Wellington 6021, New Zealand
| | - Dianne Sika-Paotonu
- Department of Pathology and Molecular Medicine, University of Otago, 23A Mein Street, Newtown, Wellington 6021, New Zealand
| | - Jonathan Carapetis
- Telethon Kids Institute, 15 Hospital Ave, Nedlands, Perth, 6009, Western Australia
- Centre for Child Health and Research, University of Western Australia, 35 Stirling Hwy, Crawley, Perth 6009, Western Australia
- Perth Children's Hospital, 15 Hospital Ave, Nedlands, Perth, 6009, Western Australia
| | - Deborah A. Williamson
- Department of Infectious Disease, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3004, Australia
| | - Michael G. Baker
- Department of Public Health, University of Otago, 23A Mein Street, Newtown, Wellington 6021, New Zealand
- Maurice Wilkins Centre, the University of Auckland, 85 Park Road, Grafton, Auckland 1023, New Zealand
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Acute Rheumatic Fever and Rheumatic Heart Disease: Highlighting the Role of Group A Streptococcus in the Global Burden of Cardiovascular Disease. Pathogens 2022; 11:pathogens11050496. [PMID: 35631018 PMCID: PMC9145486 DOI: 10.3390/pathogens11050496] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/27/2022] [Accepted: 04/01/2022] [Indexed: 02/01/2023] Open
Abstract
Group A Streptococcus (GAS) causes superficial and invasive infections and immune mediated post-infectious sequalae (including acute rheumatic fever/rheumatic heart disease). Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are important determinants of global cardiovascular morbidity and mortality. ARF is a multiorgan inflammatory disease that is triggered by GAS infection that activates the innate immune system. In susceptible hosts the response against GAS elicits autoimmune reactions targeting the heart, joints, brain, skin, and subcutaneous tissue. Repeated episodes of ARF—undetected, subclinical, or diagnosed—may progressively lead to RHD, unless prevented by periodic administration of penicillin. The recently modified Duckett Jones criteria with stratification by population risk remains relevant for the diagnosis of ARF and includes subclinical carditis detected by echocardiography as a major criterion. Chronic RHD is defined by valve regurgitation and/or stenosis that presents with complications such as arrhythmias, systemic embolism, infective endocarditis, pulmonary hypertension, heart failure, and death. RHD predominantly affects children, adolescents, and young adults in LMICs. National programs with compulsory notification of ARF/RHD are needed to highlight the role of GAS in the global burden of cardiovascular disease and to allow prioritisation of these diseases aimed at reducing health inequalities and to achieve universal health coverage.
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Whitcombe AL, McGregor R, Bennett J, Gurney JK, Williamson DA, Baker MG, Moreland NJ. OUP accepted manuscript. J Infect Dis 2022; 226:167-176. [PMID: 35134931 PMCID: PMC9373162 DOI: 10.1093/infdis/jiac043] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/01/2022] [Indexed: 11/26/2022] Open
Abstract
Background Group A Streptococcus (GAS) causes superficial pharyngitis and skin infections as well as serious autoimmune sequelae such as acute rheumatic fever (ARF) and subsequent rheumatic heart disease. ARF pathogenesis remains poorly understood. Immune priming by repeated GAS infections is thought to trigger ARF, and there is growing evidence for the role of skin infections in this process. Methods We utilized our recently developed 8-plex immunoassay, comprising antigens used in clinical serology for diagnosis of ARF (SLO, DNase B, SpnA), and 5 conserved putative GAS vaccine antigens (Spy0843, SCPA, SpyCEP, SpyAD, Group A carbohydrate), to characterize antibody responses in sera from New Zealand children with a range of clinically diagnosed GAS disease: ARF (n = 79), GAS-positive pharyngitis (n = 94), GAS-positive skin infection (n = 51), and matched healthy controls (n = 90). Results The magnitude and breadth of antibodies in ARF was very high, giving rise to a distinct serological profile. An average of 6.5 antigen-specific reactivities per individual was observed in ARF, compared to 4.2 in skin infections and 3.3 in pharyngitis. Conclusions ARF patients have a unique serological profile, which may be the result of repeated precursor pharyngitis and skin infections that progressively boost antibody breadth and magnitude.
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Affiliation(s)
- Alana L Whitcombe
- School of Medical Sciences and Maurice Wilkins Centre, University of Auckland, Auckland, New Zealand
| | - Reuben McGregor
- School of Medical Sciences and Maurice Wilkins Centre, University of Auckland, Auckland, New Zealand
| | - Julie Bennett
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Jason K Gurney
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Deborah A Williamson
- University of Melbourne at The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Michael G Baker
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Nicole J Moreland
- Correspondence: Nicole J. Moreland, BSc, PhD, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand ()
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Bennett J, Moreland NJ, Williamson DA, Carapetis J, Crane J, Whitcombe AL, Jack S, Harwood M, Baker MG. Comparison of group A streptococcal titres in healthy children and those with pharyngitis and skin infections. J Infect 2021; 84:24-30. [PMID: 34710392 DOI: 10.1016/j.jinf.2021.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/04/2021] [Accepted: 10/15/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Rates of acute rheumatic fever, a sequelae of group A Streptococcal (GAS) infection, remain unacceptably high in Indigenous Māori and Pacific children in New Zealand. This prospective study aimed to describe GAS antibody titres in healthy children (5-14 years) by ethnicity, and to determine how paired titres vary with GAS culture positive and negative pharyngitis, and GAS skin infections. METHODS Analysis included 887 children (32% Māori, 36% Pacific, 33% European/Other) from Auckland, New Zealand. Cases comprise 772 children who had a sore throat or skin infection, which resulted in a swab taken for culture. Healthy controls were asymptomatic (N = 154) and matched by age, ethnicity and region. All participants had a serum sample, with a second sample collected from cases only. Sera were analysed for anti-streptolysin O (ASO) and anti-DNase-B (ADB) antibodies. RESULTS Healthy Māori and Pacific children had higher GAS antibody titres than healthy European/Other children. Children with GAS-positive sore throat had the highest mean ASO titres and children with GAS-positive skin infection had the highest mean ADB titres. When a two-fold increase or an upper limit of normal cut-off (ASO 450 IU/ml, ADB 400 U/ml) was applied to titres from children with GAS-positive sore throat, 62.1% were classified as having serologically confirmed GAS pharyngitis and 37.9% had GAS detected without serological response. CONCLUSIONS Elevated ASO titres were associated with GAS pharyngitis and elevated ADB titres were associated with GAS skin infections in New Zealand children. Higher ASO/ADB titres in healthy Māori and Pacific children could indicate a greater prior exposure to GAS infections.
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Affiliation(s)
- Julie Bennett
- Department of Public Health, University of Otago, 23A Mein Street, Newtown, Wellington 6021, New Zealand.
| | - Nicole J Moreland
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand; Maurice Wilkins Centre, The University of Auckland, Auckland, New Zealand
| | - Deborah A Williamson
- Peter Doherty Institute for Infection and Immunity, University of Melbourne, Victoria, Australia
| | - Jonathan Carapetis
- Telethon Kids Institute and Perth Children's Hospital, University of Western Australia, Perth 6009, Australia
| | - Julian Crane
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Alana L Whitcombe
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand; Maurice Wilkins Centre, The University of Auckland, Auckland, New Zealand
| | - Susan Jack
- Public Health South, Southern District Health Board, Dunedin, New Zealand
| | - Matire Harwood
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Michael G Baker
- Department of Public Health, University of Otago, 23A Mein Street, Newtown, Wellington 6021, New Zealand; Maurice Wilkins Centre, The University of Auckland, Auckland, New Zealand
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Lee JS, Kim S, Excler JL, Kim J, Mogasale V. Existing cost-effectiveness analyses for diseases caused by Group A Streptococcus: A systematic review to guide future research. Wellcome Open Res 2021. [DOI: 10.12688/wellcomeopenres.17116.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Group A Streptococcus (Strep A) causes a broad spectrum of disease manifestations, ranging from benign symptoms including throat or skin infections, to fatal illness such as rheumatic heart disease, or chronic renal failure. Currently, there is no vaccine available against Strep A infections. Despite the high burden of Strep A-associated infections worldwide, little attention has been paid to the research of these diseases, including standardized surveillance programs, resulting in a lack of economic evaluations for prevention efforts. This study aims at identifying existing cost-effectiveness analyses (CEA) on any Strep A infections. Methods: A systematic literature review was conducted by searching the PubMed electronic database. Results: Of a total of 321, 44 articles met the criteria for inclusion. Overall, CEA studies on Strep A remain limited in number. In particular, a number of available CEA studies on Strep A are disproportionately lower in low-income countries than in high-income countries. Decision-analytic models were the most popular choice for CEA on Strep A. A majority of the models considered pharyngitis and acute rheumatic fever, but it was rare to observe a model which covered a wide range of disease manifestations. Conclusions: Future research is needed to address missing clinical outcomes, imbalance on study locations by income group, and the transmission dynamic of selected diseases.
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McGregor R, Tay ML, Carlton LH, Hanson-Manful P, Raynes JM, Forsyth WO, Brewster DT, Middleditch MJ, Bennett J, Martin WJ, Wilson N, Atatoa Carr P, Baker MG, Moreland NJ. Mapping Autoantibodies in Children With Acute Rheumatic Fever. Front Immunol 2021; 12:702877. [PMID: 34335616 PMCID: PMC8320770 DOI: 10.3389/fimmu.2021.702877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/02/2021] [Indexed: 01/16/2023] Open
Abstract
Background Acute rheumatic fever (ARF) is a serious sequela of Group A Streptococcus (GAS) infection associated with significant global mortality. Pathogenesis remains poorly understood, with the current prevailing hypothesis based on molecular mimicry and the notion that antibodies generated in response to GAS infection cross-react with cardiac proteins such as myosin. Contemporary investigations of the broader autoantibody response in ARF are needed to both inform pathogenesis models and identify new biomarkers for the disease. Methods This study has utilised a multi-platform approach to profile circulating autoantibodies in ARF. Sera from patients with ARF, matched healthy controls and patients with uncomplicated GAS pharyngitis were initially analysed for autoreactivity using high content protein arrays (Protoarray, 9000 autoantigens), and further explored using a second protein array platform (HuProt Array, 16,000 autoantigens) and 2-D gel electrophoresis of heart tissue combined with mass spectrometry. Selected autoantigens were orthogonally validated using conventional immunoassays with sera from an ARF case-control study (n=79 cases and n=89 matched healthy controls) and a related study of GAS pharyngitis (n=39) conducted in New Zealand. Results Global analysis of the protein array data showed an increase in total autoantigen reactivity in ARF patients compared with controls, as well as marked heterogeneity in the autoantibody profiles between ARF patients. Autoantigens previously implicated in ARF pathogenesis, such as myosin and collagens were detected, as were novel candidates. Disease pathway analysis revealed several autoantigens within pathways linked to arthritic and myocardial disease. Orthogonal validation of three novel autoantigens (PTPN2, DMD and ANXA6) showed significant elevation of serum antibodies in ARF (p < 0.05), and further highlighted heterogeneity with patients reactive to different combinations of the three antigens. Conclusions The broad yet heterogenous elevation of autoantibodies observed suggests epitope spreading, and an expansion of the autoantibody repertoire, likely plays a key role in ARF pathogenesis and disease progression. Multiple autoantigens may be needed as diagnostic biomarkers to capture this heterogeneity.
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Affiliation(s)
- Reuben McGregor
- School of Medical Sciences, The University of Auckland, Auckland, New Zealand
- Maurice Wilkins Centre, The University of Auckland, Auckland, New Zealand
| | - Mei Lin Tay
- School of Medical Sciences, The University of Auckland, Auckland, New Zealand
| | - Lauren H. Carlton
- School of Medical Sciences, The University of Auckland, Auckland, New Zealand
| | | | - Jeremy M. Raynes
- School of Medical Sciences, The University of Auckland, Auckland, New Zealand
| | - Wasan O. Forsyth
- School of Medical Sciences, The University of Auckland, Auckland, New Zealand
| | | | | | - Julie Bennett
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - William John Martin
- Science for Technological Innovation Science Challenge, Callaghan Innovation, Wellington, New Zealand
| | - Nigel Wilson
- Starship Children’s Hospital, Auckland, New Zealand
| | - Polly Atatoa Carr
- Waikato District Health Board and Waikato University, Hamilton, New Zealand
| | - Michael G. Baker
- Maurice Wilkins Centre, The University of Auckland, Auckland, New Zealand
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Nicole J. Moreland
- School of Medical Sciences, The University of Auckland, Auckland, New Zealand
- Maurice Wilkins Centre, The University of Auckland, Auckland, New Zealand
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Abstract
During the 1920s, acute rheumatic fever (ARF) was the leading cause of mortality in children in the United States. By the 1980s, many felt ARF had all but disappeared from the US. However, although ARF and rheumatic heart disease (RHD) rates remain low in the US today, disease burden is unequal and tracks along other disparities of cardiovascular health. It is estimated that 1% to 3% of patients with untreated group A streptococcus (GAS) infection, most typically GAS pharyngitis, will develop ARF, and of these, up to 60% of cases will result in chronic RHD. This article reviews the epidemiology, pathogenesis, diagnosis, and management of ARF/RHD to increase awareness of ARF/RHD for clinicians based in the US. [Pediatr Ann. 2021;50(3):e98-e104.].
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Ozberk V, Reynolds S, Huo Y, Calcutt A, Eskandari S, Dooley J, Mills JL, Rasmussen IS, Dietrich J, Pandey M, Good MF. Prime-Pull Immunization with a Bivalent M-Protein and Spy-CEP Peptide Vaccine Adjuvanted with CAF®01 Liposomes Induces Both Mucosal and Peripheral Protection from covR/S Mutant Streptococcus pyogenes. mBio 2021; 12:e03537-20. [PMID: 33622722 PMCID: PMC8545125 DOI: 10.1128/mbio.03537-20] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 01/15/2021] [Indexed: 11/20/2022] Open
Abstract
Infections with Streptococcus pyogenes and their sequelae are responsible for an estimated 18 million cases of serious disease with >700 million new primary cases and 500,000 deaths per year. Despite the burden of disease, there is currently no vaccine available for this organism. Here, we define a combination vaccine P*17/K4S2 comprising of 20-mer B-cell peptide epitopes, p*17 (a mutant derived from the highly conserved C3-repeat region of the M-protein), and K4S2 (derived from the streptococcal anti-neutrophil factor, Spy-CEP). The peptides are chemically conjugated to either diphtheria toxoid (DT) or a nontoxic mutant form of diphtheria toxin, CRM197. We demonstrate that a prime-pull immunization regimen involving two intramuscular inoculations with P*17/K4S2 adjuvanted with a two-component liposomal adjuvant system (CAF01; developed by Statens Serum Institut [SSI], Denmark), followed by an intranasal inoculation of unadjuvanted vaccine (in Tris) induces peptide- and S. pyogenes-binding antibodies and protects from mucosal and skin infection with hypervirulent covR/S mutant organisms. Prior vaccination with DT does not diminish the response to the conjugate peptide vaccines. Detailed Good Laboratory Practice (GLP) toxicological evaluation in male and female rats did not reveal any gross or histopathological adverse effects.IMPORTANCE A vaccine to control S. pyogenes infection is desperately warranted. S. pyogenes colonizes the upper respiratory tract (URT) and skin, from where it can progress to invasive and immune-mediated diseases. Global mortality estimates for S. pyogenes-associated diseases exceeds 500,000 deaths per year. S. pyogenes utilizes antigenic variation as a defense mechanism to circumvent host immune responses and thus a successful vaccine needs to provide strain-transcending and multicompartment (mucosal and skin) immunity. By defining highly conserved and protective epitopes from two critical virulence factors (M-protein and Spy-CEP) and combining them with a potent immunostimulant, CAF®01, we are addressing an unmet clinical need for a mucosally and skin-active subunit vaccine. We demonstrate that prime-pull immunization (2× intramuscular injections followed by intranasal immunization) promotes high sustained antibody levels in the airway mucosa and serum and protects against URT and invasive disease.
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MESH Headings
- Adjuvants, Immunologic/administration & dosage
- Animals
- Antibodies, Bacterial/blood
- Antigens, Bacterial/genetics
- Antigens, Bacterial/immunology
- Bacterial Outer Membrane Proteins/administration & dosage
- Bacterial Outer Membrane Proteins/genetics
- Bacterial Outer Membrane Proteins/immunology
- Epitopes, B-Lymphocyte/genetics
- Epitopes, B-Lymphocyte/immunology
- Female
- Immunity, Mucosal
- Immunization/methods
- Liposomes/administration & dosage
- Liposomes/chemistry
- Male
- Mice, Inbred BALB C
- Rats
- Rats, Sprague-Dawley
- Streptococcal Infections/prevention & control
- Streptococcal Vaccines/administration & dosage
- Streptococcal Vaccines/immunology
- Streptococcus pyogenes/genetics
- Streptococcus pyogenes/immunology
- Vaccines, Subunit/administration & dosage
- Vaccines, Subunit/immunology
- Mice
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Affiliation(s)
- Victoria Ozberk
- Institute for Glycomics, Griffith University, Gold Coast, Australia
| | - Simone Reynolds
- Institute for Glycomics, Griffith University, Gold Coast, Australia
| | - Yongbao Huo
- Institute for Glycomics, Griffith University, Gold Coast, Australia
| | - Ainslie Calcutt
- Institute for Glycomics, Griffith University, Gold Coast, Australia
| | | | - Jessica Dooley
- Institute for Glycomics, Griffith University, Gold Coast, Australia
| | - Jamie-Lee Mills
- Institute for Glycomics, Griffith University, Gold Coast, Australia
| | - Ida S Rasmussen
- Center for Vaccine Research, Statens Serum Institut, Copenhagen, Denmark
| | - Jes Dietrich
- Center for Vaccine Research, Statens Serum Institut, Copenhagen, Denmark
| | - Manisha Pandey
- Institute for Glycomics, Griffith University, Gold Coast, Australia
| | - Michael F Good
- Institute for Glycomics, Griffith University, Gold Coast, Australia
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13
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Avire NJ, Whiley H, Ross K. A Review of Streptococcus pyogenes: Public Health Risk Factors, Prevention and Control. Pathogens 2021; 10:pathogens10020248. [PMID: 33671684 PMCID: PMC7926438 DOI: 10.3390/pathogens10020248] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 01/10/2023] Open
Abstract
Streptococcus pyogenes, (colloquially named “group A streptococcus” (GAS)), is a pathogen of public health significance, infecting 18.1 million people worldwide and resulting in 500,000 deaths each year. This review identified published articles on the risk factors and public health prevention and control strategies for mitigating GAS diseases. The pathogen causing GAS diseases is commonly transmitted via respiratory droplets, touching skin sores caused by GAS or through contact with contaminated material or equipment. Foodborne transmission is also possible, although there is need for further research to quantify this route of infection. It was found that GAS diseases are highly prevalent in developing countries, and among indigenous populations and low socioeconomic areas in developed countries. Children, the immunocompromised and the elderly are at the greatest risk of S. pyogenes infections and the associated sequelae, with transmission rates being higher in schools, kindergartens, hospitals and residential care homes. This was attributed to overcrowding and the higher level of social contact in these settings. Prevention and control measures should target the improvement of living conditions, and personal and hand hygiene. Adherence to infection prevention and control practices should be emphasized in high-risk settings. Resource distribution by governments, especially in developed countries, should also be considered.
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14
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Middleton K, Bowen AC. Addressing normalization using culturally relevant approaches: An important adjunct to reducing the burden of impetigo and scabies. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2021; 7:100102. [PMID: 34327421 PMCID: PMC8315659 DOI: 10.1016/j.lanwpc.2021.100102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 01/20/2021] [Indexed: 11/23/2022]
Affiliation(s)
- Katherine Middleton
- Division of Paediatrics, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Asha C Bowen
- Division of Paediatrics, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Perth Children's Hospital, Child and Adolescent Health Service, Perth, Western Australia, Australia
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Institute for Health Research, The University of Notre Dame Australia, Perth, Western Australia, Australia
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15
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Mendes N, Miguéis C, Lindo J, Gonçalves T, Miguéis A. Retrospective study of group A Streptococcus oropharyngeal infection diagnosis using a rapid antigenic detection test in a paediatric population from the central region of Portugal. Eur J Clin Microbiol Infect Dis 2021; 40:1235-1243. [PMID: 33452546 DOI: 10.1007/s10096-021-04157-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/07/2021] [Indexed: 11/26/2022]
Abstract
Group A Streptococcus (GAS) is one of the most important agents of oropharyngeal infection. To avoid unnecessary antibiotic prescription, it is recommended the confirmation of GAS infection in pharyngeal swabs using culture or rapid antigen detection test (RADT). This study aimed to retrospectively analyse the incidence of GAS oropharyngeal infection, detected by RADT, in a paediatric population in the Centre of Portugal. Data was collected from the database of the Paediatric Hospital Emergency Department (ED) regarding patients admitted with symptoms suggesting acute pharyngitis, from January 2013 to December 2018, in a total of 18,304 cases. Among these, 130 clinical files were searched for symptoms, complications and additional visits to the ED. The results showed an average GAS infection prevalence of 33%, with seasonal variation. In preschool children, especially in patients less than 3 years old, where the guidelines do not routinely encourage RADT, GAS tonsillitis assumed an unexpected importance, with 731 positive tests in a total of 3128 cases. Scarlatiniform rash and oral cavity petechiae had significant correlation with streptococcal aetiology (p < 0.05). The statistical analysis also showed that different signs and symptoms assume different weights depending on the age group of the patient. The main conclusion is that the incidence of GAS infection in the studied population is higher than generally described in preschool children, suggesting the need for a more cautious approach to children under 3 years presenting acute pharyngitis, and that RADT in this age group would contribute to a decrease in the number of unnoticed cases.
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Affiliation(s)
- Nuno Mendes
- University Clinic of Otorhinolaryngology, FMUC-Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Serviço de Otorrinolaringologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Carmo Miguéis
- University Clinic of Otorhinolaryngology, FMUC-Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Serviço de Otorrinolaringologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Jorge Lindo
- University Clinic of Otorhinolaryngology, FMUC-Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Institute of Microbiology, FMUC-Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- CNC - Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal
| | - Teresa Gonçalves
- Institute of Microbiology, FMUC-Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- CNC - Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal
| | - António Miguéis
- University Clinic of Otorhinolaryngology, FMUC-Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
- Serviço de Otorrinolaringologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
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16
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Heard MA, Green MC, Royer M. Acute Rheumatic Fever: A Review of Essential Cutaneous and Histological Findings. Cureus 2021; 13:e12577. [PMID: 33575142 PMCID: PMC7870119 DOI: 10.7759/cureus.12577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Acute rheumatic fever (ARF) is an autoimmune response that may occur after infection with group A Streptococcus. Clinical manifestations are protean, making the syndrome difficult to recognize in the 21st century. Secondary prophylaxis with benzathine penicillin is given for 10 years after an episode of ARF to prevent recurrence and reduce the risk of rheumatic heart disease. This case highlights the importance of providing a detailed clinical history to the dermatopathologist when considering ARF in the differential diagnosis.
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Affiliation(s)
- Matthew A Heard
- College of Osteopathic Medicine, University of New England, Biddeford, USA
| | - Margaret C Green
- Dermatology, Walter Reed National Military Medical Center, Bethesda, USA
| | - Michael Royer
- Dermatopathology, Joint Pathology Center, Silver Spring, USA
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17
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Abrha S, Tesfaye W, Thomas J. Intolerable Burden of Impetigo in Endemic Settings: A Review of the Current State of Play and Future Directions for Alternative Treatments. Antibiotics (Basel) 2020; 9:E909. [PMID: 33333955 PMCID: PMC7765423 DOI: 10.3390/antibiotics9120909] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/11/2020] [Accepted: 12/14/2020] [Indexed: 01/22/2023] Open
Abstract
Impetigo (school sores) is a common superficial bacterial skin infection affecting around 162 million children worldwide, with the highest burden in Australian Aboriginal children. While impetigo itself is treatable, if left untreated, it can lead to life-threatening conditions, such as chronic heart and kidney diseases. Topical antibiotics are often considered the treatment of choice for impetigo, but the clinical efficacy of these treatments is declining at an alarming rate due to the rapid emergence and spread of resistant bacteria. In remote settings in Australia, topical antibiotics are no longer used for impetigo due to the troubling rise of antimicrobial resistance, demanding the use of oral and injectable antibiotic therapies. However, widespread use of these agents not only contributes to existing resistance, but also associated with adverse consequences for individuals and communities. These underscore the urgent need to reinvigorate the antibiotic discovery and alternative impetigo therapies in these settings. This review discusses the current impetigo treatment challenges in endemic settings in Australia and explores potential alternative antimicrobial therapies. The goals are to promote intensified research programs to facilitate effective use of currently available treatments, as well as developing new alternatives for impetigo.
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Affiliation(s)
- Solomon Abrha
- Faculty of Health, University of Canberra, Canberra, ACT 2617, Australia; (S.A.); (W.T.)
- Department of Pharmaceutics, School of Pharmacy, College of Health Sciences, Mekelle University, Mekelle 7000, Ethiopia
| | - Wubshet Tesfaye
- Faculty of Health, University of Canberra, Canberra, ACT 2617, Australia; (S.A.); (W.T.)
| | - Jackson Thomas
- Faculty of Health, University of Canberra, Canberra, ACT 2617, Australia; (S.A.); (W.T.)
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18
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McGregor R, Whitcombe AL, Sheen CR, Dickson JM, Day CL, Carlton LH, Sharma P, Lott JS, Koch B, Bennett J, Baker MG, Ritchie SR, Fox-Lewis S, Morpeth SC, Taylor SL, Roberts SA, Webb RH, Moreland NJ. Collaborative networks enable the rapid establishment of serological assays for SARS-CoV-2 during nationwide lockdown in New Zealand. PeerJ 2020; 8:e9863. [PMID: 32953275 PMCID: PMC7474877 DOI: 10.7717/peerj.9863] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 08/13/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Serological assays that detect antibodies to SARS-CoV-2 are critical for determining past infection and investigating immune responses in the COVID-19 pandemic. We established ELISA-based immunoassays using locally produced antigens when New Zealand went into a nationwide lockdown and the supply chain of diagnostic reagents was a widely held domestic concern. The relationship between serum antibody binding measured by ELISA and neutralising capacity was investigated using a surrogate viral neutralisation test (sVNT). METHODS A pre-pandemic sera panel (n = 113), including respiratory infections with symptom overlap with COVID-19, was used to establish assay specificity. Sera from PCR‑confirmed SARS-CoV-2 patients (n = 21), and PCR-negative patients with respiratory symptoms suggestive of COVID-19 (n = 82) that presented to the two largest hospitals in Auckland during the lockdown period were included. A two-step IgG ELISA based on the receptor binding domain (RBD) and spike protein was adapted to determine seropositivity, and neutralising antibodies that block the RBD/hACE‑2 interaction were quantified by sVNT. RESULTS The calculated cut-off (>0.2) in the two-step ELISA maximised specificity by classifying all pre-pandemic samples as negative. Sera from all PCR-confirmed COVID-19 patients were classified as seropositive by ELISA ≥7 days after symptom onset. There was 100% concordance between the two-step ELISA and the sVNT with all 7+ day sera from PCR‑confirmed COVID-19 patients also classified as positive with respect to neutralising antibodies. Of the symptomatic PCR-negative cohort, one individual with notable travel history was classified as positive by two-step ELISA and sVNT, demonstrating the value of serology in detecting prior infection. CONCLUSIONS These serological assays were established and assessed at a time when human activity was severely restricted in New Zealand. This was achieved by generous sharing of reagents and technical expertise by the international scientific community, and highly collaborative efforts of scientists and clinicians across the country. The assays have immediate utility in supporting clinical diagnostics, understanding transmission in high-risk cohorts and underpinning longer‑term 'exit' strategies based on effective vaccines and therapeutics.
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Affiliation(s)
- Reuben McGregor
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Maurice Wilkins Centre, University of Auckland, Auckland, New Zealand
| | - Alana L. Whitcombe
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Maurice Wilkins Centre, University of Auckland, Auckland, New Zealand
| | - Campbell R. Sheen
- Protein Science and Engineering, Callaghan Innovation, Christchurch, New Zealand
| | - James M. Dickson
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Catherine L. Day
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Lauren H. Carlton
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Prachi Sharma
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - J. Shaun Lott
- Maurice Wilkins Centre, University of Auckland, Auckland, New Zealand
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Barbara Koch
- Protein Science and Engineering, Callaghan Innovation, Christchurch, New Zealand
| | - Julie Bennett
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Michael G. Baker
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Stephen R. Ritchie
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Infectious Diseases Department, Auckland City Hospital, Auckland, New Zealand
| | - Shivani Fox-Lewis
- Department of Microbiology, LabPLUS, Auckland City Hospital, Auckland, New Zealand
| | | | | | - Sally A. Roberts
- Maurice Wilkins Centre, University of Auckland, Auckland, New Zealand
- Department of Microbiology, LabPLUS, Auckland City Hospital, Auckland, New Zealand
| | - Rachel H. Webb
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Starship Children’s Hospital, Auckland, New Zealand
| | - Nicole J. Moreland
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Maurice Wilkins Centre, University of Auckland, Auckland, New Zealand
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