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Mohanty MC, Govindaraj G, Ahmad M, Varose SY, Tatkare M, Shete A, Yadav S, Joshi Y, Yadav P, Sharma D, Kumar A, Verma H, Patil AP, Edavazhipurath A, Dhanasooraj D, Othayoth Kandy S, Puthenpurayil JM, Chakyar K, Melarcode Ramanan K, Madkaikar M. Immunodeficiency-Related Vaccine-Derived Poliovirus (iVDPV) Excretion in an Infant with Severe Combined Immune Deficiency with Spillover to a Parent. Vaccines (Basel) 2024; 12:759. [PMID: 39066397 PMCID: PMC11281642 DOI: 10.3390/vaccines12070759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/24/2024] [Accepted: 05/27/2024] [Indexed: 07/28/2024] Open
Abstract
In order to maintain the polio eradication status, it has become evident that the surveillance of cases with acute flaccid paralysis and of environmental samples must be urgently supplemented with the surveillance of poliovirus excretions among individuals with inborn errors of immunity (IEI). All children with IEI were screened for the excretion of poliovirus during a collaborative study conducted by the ICMR-National Institute of Virology, Mumbai Unit, ICMR-National Institute of Immunohaematology, and World Health Organization, India. A seven-month -old male baby who presented with persistent pneumonia and lymphopenia was found to have severe combined immune deficiency (SCID) due to a missense variant in the RAG1 gene. He had received OPV at birth and at 20 weeks. Four stool samples collected at 4 weekly intervals yielded iVDPV type 1. The child's father, an asymptomatic 32-year-old male, was also found to be excreting iVDPV. A haploidentical hematopoietic stem cell transplant was performed, but the child succumbed due to severe myocarditis and pneumonia three weeks later. We report a rare case of transmission of iVDPV from an individual with IEI to a healthy household contact, demonstrating the threat of the spread of iVDPV from persons with IEI and the necessity to develop effective antivirals.
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Affiliation(s)
- Madhu Chhanda Mohanty
- Mumbai Unit, ICMR-National Institute of Virology, Haffkine Institute Campus, Acharya Donde Marg, Parel, Mumbai 400012, India; (S.Y.V.); (M.T.); (A.P.P.)
| | - Geeta Govindaraj
- Government Medical College, Kozhikode 673008, India; (G.G.); (A.E.); (D.D.); (S.O.K.); (J.M.P.); (K.C.)
| | - Mohammad Ahmad
- Country Office, World Health Organization, New Delhi 110011, India; (M.A.); (D.S.); (A.K.)
| | - Swapnil Y. Varose
- Mumbai Unit, ICMR-National Institute of Virology, Haffkine Institute Campus, Acharya Donde Marg, Parel, Mumbai 400012, India; (S.Y.V.); (M.T.); (A.P.P.)
| | - Manogat Tatkare
- Mumbai Unit, ICMR-National Institute of Virology, Haffkine Institute Campus, Acharya Donde Marg, Parel, Mumbai 400012, India; (S.Y.V.); (M.T.); (A.P.P.)
| | - Anita Shete
- Microbial Containment Laboratory, ICMR-National Institute of Virology, Pune 411021, India; (A.S.); (S.Y.); (Y.J.); (P.Y.)
| | - Savita Yadav
- Microbial Containment Laboratory, ICMR-National Institute of Virology, Pune 411021, India; (A.S.); (S.Y.); (Y.J.); (P.Y.)
| | - Yash Joshi
- Microbial Containment Laboratory, ICMR-National Institute of Virology, Pune 411021, India; (A.S.); (S.Y.); (Y.J.); (P.Y.)
| | - Pragya Yadav
- Microbial Containment Laboratory, ICMR-National Institute of Virology, Pune 411021, India; (A.S.); (S.Y.); (Y.J.); (P.Y.)
| | - Deepa Sharma
- Country Office, World Health Organization, New Delhi 110011, India; (M.A.); (D.S.); (A.K.)
| | - Arun Kumar
- Country Office, World Health Organization, New Delhi 110011, India; (M.A.); (D.S.); (A.K.)
| | - Harish Verma
- World Health Organization, 1209 Geneva, Switzerland;
| | - Ankita P. Patil
- Mumbai Unit, ICMR-National Institute of Virology, Haffkine Institute Campus, Acharya Donde Marg, Parel, Mumbai 400012, India; (S.Y.V.); (M.T.); (A.P.P.)
| | - Athulya Edavazhipurath
- Government Medical College, Kozhikode 673008, India; (G.G.); (A.E.); (D.D.); (S.O.K.); (J.M.P.); (K.C.)
| | - Dhananjayan Dhanasooraj
- Government Medical College, Kozhikode 673008, India; (G.G.); (A.E.); (D.D.); (S.O.K.); (J.M.P.); (K.C.)
| | - Sheena Othayoth Kandy
- Government Medical College, Kozhikode 673008, India; (G.G.); (A.E.); (D.D.); (S.O.K.); (J.M.P.); (K.C.)
| | | | - Krishnan Chakyar
- Government Medical College, Kozhikode 673008, India; (G.G.); (A.E.); (D.D.); (S.O.K.); (J.M.P.); (K.C.)
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Mohanty MC, Desai M, Mohammad A, Aggarwal A, Govindaraj G, Bhattad S, Lashkari HP, Rajasekhar L, Verma H, Kumar A, Sawant U, Varose SY, Taur P, Yadav RM, Tatkare M, Fernandes M, Bargir U, Majumdar S, Edavazhippurath A, Rangarajan J, Manthri R, Madkaikar MR. Assessment of Enterovirus Excretion and Identification of VDPVs in Patients with Primary Immunodeficiency in India: Outcome of ICMR-WHO Collaborative Study Phase-I. Vaccines (Basel) 2023; 11:1211. [PMID: 37515027 PMCID: PMC10383878 DOI: 10.3390/vaccines11071211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 07/30/2023] Open
Abstract
The emergence of vaccine-derived polioviruses (VDPVs) in patients with Primary Immunodeficiency (PID) is a threat to the polio-eradication program. In a first of its kind pilot study for successful screening and identification of VDPV excretion among patients with PID in India, enteroviruses were assessed in stool specimens of 154 PID patients across India in a period of two years. A total of 21.42% of patients were tested positive for enteroviruses, 2.59% tested positive for polioviruses (PV), whereas 18.83% of patients were positive for non-polio enteroviruses (NPEV). A male child of 3 years and 6 months of age diagnosed with Hyper IgM syndrome was detected positive for type1 VDPV (iVDPV1) with 1.6% nucleotide divergence from the parent Sabin strain. E21 (19.4%), E14 (9%), E11 (9%), E16 (7.5%), and CVA2 (7.5%) were the five most frequently observed NPEV types in PID patients. Patients with combined immunodeficiency were at a higher risk for enterovirus infection as compared to antibody deficiency. The high susceptibility of PID patients to enterovirus infection emphasizes the need for enhanced surveillance of these patients until the use of OPV is stopped. The expansion of PID surveillance and integration with a national program will facilitate early detection and follow-up of iVDPV excretion to mitigate the risk for iVDPV spread.
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Affiliation(s)
| | - Mukesh Desai
- Department of Immunology, Bai Jerbai Wadia Hospital for Children, Mumbai 400012, India
| | - Ahmad Mohammad
- World Health Organization, Country Office, New Delhi 110011, India
| | - Amita Aggarwal
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India
| | - Geeta Govindaraj
- Department of Pediatrics, Government Medical College, Kozhikode 673008, India
| | - Sagar Bhattad
- Department of Pediatrics, Aster CMI Hospital, Bangalore 560092, India
| | | | - Liza Rajasekhar
- Department of Clinical Immunology and Rheumatology, Nizam’s Institute of Medical Sciences, Hyderabad 500082, India
| | - Harish Verma
- World Health Organization, CH-1211 Geneva, Switzerland
| | - Arun Kumar
- World Health Organization, Country Office, New Delhi 110011, India
| | - Unnati Sawant
- Mumbai Unit, ICMR-National Institute of Virology (ICMR-NIV), Mumbai 400012, India
| | | | - Prasad Taur
- Department of Immunology, Bai Jerbai Wadia Hospital for Children, Mumbai 400012, India
| | - Reetika Malik Yadav
- ICMR-National Institute of Immunohaematology (ICMR-NIIH), Mumbai 400012, India
| | - Manogat Tatkare
- Mumbai Unit, ICMR-National Institute of Virology (ICMR-NIV), Mumbai 400012, India
| | - Mevis Fernandes
- Mumbai Unit, ICMR-National Institute of Virology (ICMR-NIV), Mumbai 400012, India
| | - Umair Bargir
- ICMR-National Institute of Immunohaematology (ICMR-NIIH), Mumbai 400012, India
| | - Sanjukta Majumdar
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India
| | | | - Jyoti Rangarajan
- Department of Pediatrics, Aster CMI Hospital, Bangalore 560092, India
| | - Ramesh Manthri
- Department of Clinical Immunology and Rheumatology, Nizam’s Institute of Medical Sciences, Hyderabad 500082, India
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Singanayagam A, Klapsa D, Burton-Fanning S, Hand J, Wilton T, Stephens L, Mate R, Shillitoe B, Celma C, Slatter M, Flood T, Gopal R, Martin J, Zambon M. Asymptomatic immunodeficiency-associated vaccine-derived poliovirus infections in two UK children. Nat Commun 2023; 14:3413. [PMID: 37296153 PMCID: PMC10251316 DOI: 10.1038/s41467-023-39094-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 05/18/2023] [Indexed: 06/12/2023] Open
Abstract
Increasing detections of vaccine-derived poliovirus (VDPV) globally, including in countries previously declared polio free, is a public health emergency of international concern. Individuals with primary immunodeficiency (PID) can excrete polioviruses for prolonged periods, which could act as a source of cryptic transmission of viruses with potential to cause neurological disease. Here, we report on the detection of immunodeficiency-associated VDPVs (iVDPV) from two asymptomatic male PID children in the UK in 2019. The first child cleared poliovirus with increased doses of intravenous immunoglobulin, the second child following haematopoetic stem cell transplantation. We perform genetic and phenotypic characterisation of the infecting strains, demonstrating intra-host evolution and a neurovirulent phenotype in transgenic mice. Our findings highlight a pressing need to strengthen polio surveillance. Systematic collection of stool from asymptomatic PID patients who are at high risk for poliovirus excretion could improve the ability to detect and contain iVDPVs.
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Affiliation(s)
- Anika Singanayagam
- Polio Reference Service, UK Health Security Agency, Colindale, London, UK.
- Department of Infectious Disease, Imperial College London, London, UK.
| | - Dimitra Klapsa
- Division of Vaccines, National Institute for Biological Standards and Control, Medicines and Healthcare products Regulatory Agency, Potters Bar, London, UK
| | - Shirelle Burton-Fanning
- Microbiology and Virology Services, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Julian Hand
- Polio Reference Service, UK Health Security Agency, Colindale, London, UK
| | - Thomas Wilton
- Division of Vaccines, National Institute for Biological Standards and Control, Medicines and Healthcare products Regulatory Agency, Potters Bar, London, UK
| | - Laura Stephens
- Division of Vaccines, National Institute for Biological Standards and Control, Medicines and Healthcare products Regulatory Agency, Potters Bar, London, UK
| | - Ryan Mate
- Division of Vaccines, National Institute for Biological Standards and Control, Medicines and Healthcare products Regulatory Agency, Potters Bar, London, UK
| | - Benjamin Shillitoe
- Paediatric Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne, UK
- Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Cristina Celma
- Polio Reference Service, UK Health Security Agency, Colindale, London, UK
| | - Mary Slatter
- Paediatric Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Terry Flood
- Paediatric Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Robin Gopal
- Polio Reference Service, UK Health Security Agency, Colindale, London, UK
| | - Javier Martin
- Division of Vaccines, National Institute for Biological Standards and Control, Medicines and Healthcare products Regulatory Agency, Potters Bar, London, UK
| | - Maria Zambon
- Polio Reference Service, UK Health Security Agency, Colindale, London, UK.
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Baris S, Abolhassani H, Massaad MJ, Al-Nesf M, Chavoshzadeh Z, Keles S, Reisli I, Tahiat A, Shendi HM, Elaziz DA, Belaid B, Al Dhaheri F, Haskologlu S, Dogu F, Ben-Mustapha I, Sobh A, Galal N, Meshaal S, Elhawary R, El-Marsafy A, Alroqi FJ, Al-Saud B, Al-Ahmad M, Al Farsi T, Al Sukaiti N, Al-Tamemi S, Mehawej C, Dbaibo G, ElGhazali G, Kilic SS, Genel F, Kiykim A, Musabak U, Artac H, Guner SN, Boukari R, Djidjik R, Kechout N, Cagdas D, El-Sayed ZA, Karakoc-Aydiner E, Alzyoud R, Barbouche MR, Adeli M, Wakim RH, Reda SM, Ikinciogullari A, Ozen A, Bousfiha A, Al-Mousa H, Rezaei N, Al-Herz W, Geha RS. The Middle East and North Africa Diagnosis and Management Guidelines for Inborn Errors of Immunity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:158-180.e11. [PMID: 36265766 DOI: 10.1016/j.jaip.2022.10.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/07/2022] [Accepted: 10/03/2022] [Indexed: 11/09/2022]
Abstract
Human inborn errors of immunity (IEI) are a group of 485 distinct genetic disorders affecting children and adults. Signs and symptoms of IEI are heterogeneous, and accurate diagnosis can be challenging and depends on the available human expertise and laboratory resources. The Middle East and North Africa (MENA) region has an increased prevalence of IEI because of the high rate of consanguinity with a predominance of autosomal recessive disorders. This area also exhibits more severe disease phenotypes compared with other regions, probably due to the delay in diagnosis. The MENA-IEI registry network has designed protocols and guidelines for the diagnosis and treatment of IEI, taking into consideration the variable regional expertise and resources. These guidelines are primarily meant to improve the care of patients within the region, but can also be followed in other regions with similar patient populations.
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Affiliation(s)
- Safa Baris
- Faculty of Medicine, Division of Pediatric Allergy and Immunology, Marmara University, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul Jeffrey Modell Foundation Diagnostic Center for Primary Immune Deficiencies, Istanbul, Turkey.
| | - Hassan Abolhassani
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran; Division of Clinical Immunology, Department of Biosciences and Nutrition, Karolinska Institute, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Michel J Massaad
- Department of Experimental Pathology, Immunology, and Microbiology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon; Center for Infectious Diseases Research (CIDR) and WHO Collaborating Center for Reference and Research on Bacterial Pathogens, American University of Beirut, Beirut, Lebanon
| | - Maryam Al-Nesf
- Allergy and Immunology Division, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Zahra Chavoshzadeh
- Allergy and Clinical Immunology Department, Mofid Children Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sevgi Keles
- Division of Pediatric Allergy and Immunology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Ismail Reisli
- Division of Pediatric Allergy and Immunology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Azzeddine Tahiat
- Laboratory of Immunology, Department of Medical Biology, University of Algiers, Rouiba Hospital, Algiers, Algeria
| | - Hiba Mohammad Shendi
- Division of Pediatric Allergy and Immunology, Tawam Hospital, Abu Dhabi, United Arab Emirates
| | - Dalia Abd Elaziz
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Brahim Belaid
- Department of Medical Immunology, Beni Messous University Hospital Center, Faculty of Pharmacy, University of Algiers, Algiers, Algeria
| | - Fatima Al Dhaheri
- Department of Pediatrics, Pediatric Infectious Diseases, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Sule Haskologlu
- Department of Pediatric Immunology and Allergy, Ankara University School of Medicine, Ankara, Turkey
| | - Figen Dogu
- Department of Pediatric Immunology and Allergy, Ankara University School of Medicine, Ankara, Turkey
| | - Imen Ben-Mustapha
- Department of Immunology, Institut Pasteur de Tunis and University Tunis El Manar, Tunis, Tunisia
| | - Ali Sobh
- Department of Pediatrics, Mansoura University Children's Hospital, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Nermeen Galal
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Safa Meshaal
- Clinical Pathology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rabab Elhawary
- Clinical Pathology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Aisha El-Marsafy
- Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Fayhan J Alroqi
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Bandar Al-Saud
- Department of Pediatrics, Division of Allergy and Immunology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Mona Al-Ahmad
- Department of Microbiology, College of Medicine, Kuwait University, Kuwait
| | - Tariq Al Farsi
- Department of Pediatric Allergy and Clinical Immunology, The Royal Hospital, Muscat, Oman
| | - Nashat Al Sukaiti
- Department of Pediatric Allergy and Clinical Immunology, The Royal Hospital, Muscat, Oman
| | - Salem Al-Tamemi
- Department of Child Health, Sultan Qaboos University Hospital, Muscat, Oman
| | - Cybel Mehawej
- Department of Human Genetics, Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Byblos, Lebanon
| | - Ghassan Dbaibo
- Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon; Center for Infectious Diseases Research (CIDR) and WHO Collaborating Center for Reference and Research on Bacterial Pathogens, American University of Beirut, Beirut, Lebanon
| | - Gehad ElGhazali
- Department of Immunology, Sheikh Khalifa Medical City-Union 71-Purehealth, Abu Dhabi, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Sara Sebnem Kilic
- Department of Pediatric Immunology and Rheumatology, Faculty of Medicine, Bursa Uludag University, Bursa, Turkey
| | - Ferah Genel
- Department of Pediatric Immunology and Allergy, University of Health Sciences Dr. Behcet Uz Children's Hospital, İzmir, Turkey
| | - Ayca Kiykim
- Division of Pediatric Allergy and Immunology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ugur Musabak
- Department of Internal Medicine, Division of Immunology and Allergy, Faculty of Medicine, Baskent University, Ankara, Turkey
| | - Hasibe Artac
- Division of Immunology and Allergy, Department of Pediatrics, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Sukru Nail Guner
- Division of Pediatric Allergy and Immunology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Rachida Boukari
- Department of Pediatrics, Mustapha Pacha Faculty of Medicine, Algiers University, Algeria
| | - Reda Djidjik
- Department of Medical Immunology, Beni Messous University Hospital Center, Faculty of Pharmacy, University of Algiers, Algiers, Algeria
| | - Nadia Kechout
- Department of Immunology, Pasteur Institute of Algeria, Faculty of Medicine, Algiers, Algeria
| | - Deniz Cagdas
- Department of Pediatrics, Section of Pediatric Immunology, Ihsan Dogramaci Children's Hospital, Institute of Child Health, Hacettepe University Medical School, Ankara, Turkey
| | - Zeinab Awad El-Sayed
- Pediatric Allergy, Immunology and Rheumatology Unit, Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Elif Karakoc-Aydiner
- Faculty of Medicine, Division of Pediatric Allergy and Immunology, Marmara University, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul Jeffrey Modell Foundation Diagnostic Center for Primary Immune Deficiencies, Istanbul, Turkey
| | - Raed Alzyoud
- Section of Immunology, Allergy and Rheumatology, Queen Rania Children Hospital, Amman, Jordan
| | - Mohamed Ridha Barbouche
- Department of Immunology, Institut Pasteur de Tunis and University Tunis El Manar, Tunis, Tunisia
| | - Mehdi Adeli
- Department of Immunology, Sidra Medicine, Ar-Rayyan, Qatar
| | - Rima Hanna Wakim
- Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon; Center for Infectious Diseases Research (CIDR) and WHO Collaborating Center for Reference and Research on Bacterial Pathogens, American University of Beirut, Beirut, Lebanon
| | - Shereen M Reda
- Pediatric Allergy, Immunology and Rheumatology Unit, Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Aydan Ikinciogullari
- Department of Pediatric Immunology and Allergy, Ankara University School of Medicine, Ankara, Turkey
| | - Ahmet Ozen
- Faculty of Medicine, Division of Pediatric Allergy and Immunology, Marmara University, Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Istanbul Jeffrey Modell Foundation Diagnostic Center for Primary Immune Deficiencies, Istanbul, Turkey
| | - Aziz Bousfiha
- Laboratory of Clinical Immunology, Inflammation and Allergy, Faculty of Medicine and Pharmacy of Casablanca, Department of pediatric infectious and immunological diseases, Ibn Rushd Children Hospital, King Hassan II University, Casablanca, Morocco
| | - Hamoud Al-Mousa
- Department of Pediatrics, Division of Allergy and Immunology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Pediatrics Center of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran; Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Waleed Al-Herz
- Department of Pediatrics, Faculty of Medicine, Kuwait University, Safat, Kuwait City, Kuwait; Allergy and Clinical Immunology Unit, Pediatric Department, Al-Sabah Hospital, Kuwait City, Kuwait
| | - Raif S Geha
- Division of Immunology, Boston Children's Hospital and Harvard Medical School, Boston, Mass
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