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Jeremiah SS, Moin ASM, Butler AE. Virus-induced diabetes mellitus: revisiting infection etiology in light of SARS-CoV-2. Metabolism 2024; 156:155917. [PMID: 38642828 DOI: 10.1016/j.metabol.2024.155917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/14/2024] [Accepted: 04/14/2024] [Indexed: 04/22/2024]
Abstract
Diabetes mellitus (DM) is comprised of two predominant subtypes: type 1 diabetes mellitus (T1DM), accounting for approximately 5 % of cases worldwide and resulting from autoimmune destruction of insulin-producing β-cells, and type 2 (T2DM), accounting for approximately 95 % of cases globally and characterized by the inability of pancreatic β-cells to meet the demand for insulin due to a relative β-cell deficit in the setting of peripheral insulin resistance. Both types of DM involve derangement of glucose metabolism and are metabolic diseases generally considered to be initiated by a combination of genetic and environmental factors. Viruses have been reported to play a role as infectious etiological factors in the initiation of both types of DM in predisposed individuals. Among the reported viral infections causing DM in humans, the most studied include coxsackie B virus, cytomegalovirus and hepatitis C virus. The recent COVID-19 pandemic has highlighted the diabetogenic potential of SARS-CoV-2, rekindling interest in the field of virus-induced diabetes (VID). This review discusses the reported mechanisms of viral-induced DM, addressing emerging concepts in VID, as well as highlighting areas where knowledge is lacking, and further investigation is warranted.
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Affiliation(s)
| | - Abu Saleh Md Moin
- Royal College of Surgeons in Ireland - Medical University of Bahrain, Busaiteen, Kingdom of Bahrain.
| | - Alexandra E Butler
- Royal College of Surgeons in Ireland - Medical University of Bahrain, Busaiteen, Kingdom of Bahrain.
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2
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Alves Abrantes JJP, Veríssimo de Azevedo JC, Fernandes FL, Duarte Almeida V, Custódio De Oliveira LA, Ferreira de Oliveira MT, Galvão De Araújo JM, Lanza DCF, Bezerra FL, Andrade VS, Araújo de Medeiros Fernandes TA, Fernandes JV. Viruses as a potential environmental trigger of type 1 diabetes mellitus (Review). Biomed Rep 2024; 20:81. [PMID: 38628629 PMCID: PMC11019645 DOI: 10.3892/br.2024.1770] [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] [Received: 06/14/2023] [Accepted: 09/07/2023] [Indexed: 04/19/2024] Open
Abstract
The etiopathogenesis of type 1 diabetes mellitus (T1DM) is a complex multifactorial process that involves an intricate network of genetic, epigenetic, immunological, and environmental factors. Despite the advances in recent years, some aspects of the mechanisms involved in triggering the disease are still unclear. Infections with certain viruses have been suggested as possible environmental triggers for the autoimmune process that leads to selective and progressive destruction of pancreatic β-cells and insufficiency of insulin production, which is its hallmark. In this review, advances in knowledge and evidence that suggest the participation of certain viruses in the mechanisms of disease initiation and progression are described. It has been accepted that environmental factors, including viruses, can initiate and possibly sustain, accelerate, or slow down the autoimmune process and consequently damage insulin-producing pancreatic β-cells. Although the role of these agents, especially human enteroviruses, has been exhaustively studied as the most likely triggers of the activation of autoimmunity that destroys pancreatic islets and leads to T1DM, certain doubts remain. Clinical epidemiological and experimental studies in humans and animals provide consistent and increasing evidence that persistent viral infections, especially with human enteroviruses and rotavirus infections, are associated with an increased risk of the disease in individuals genetically predisposed to autoimmunity.
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Affiliation(s)
| | | | - Fernando Liberalino Fernandes
- Department of Biomedical Sciences, Rio Grande do Norte State University, Mossoró, Rio Grande do Norte 59607-360, Brazil
| | - Valéria Duarte Almeida
- Department of Biomedical Sciences, Rio Grande do Norte State University, Mossoró, Rio Grande do Norte 59607-360, Brazil
| | | | | | - Josélio Maria Galvão De Araújo
- Department of Microbiology and Parasitology, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte 59078-970, Brazil
| | - Daniel Carlos Ferreira Lanza
- Laboratory of Applied Molecular Biology, Department of Biochemistry, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte 59078-970, Brazil
| | - Fabiana Lima Bezerra
- Department of Microbiology and Parasitology, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte 59078-970, Brazil
| | - Vania Sousa Andrade
- Department of Microbiology and Parasitology, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte 59078-970, Brazil
| | | | - José Veríssimo Fernandes
- Department of Microbiology and Parasitology, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte 59078-970, Brazil
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Parviainen A, But A, Sund R, Arffman M, Siljander H, Knip M. Incidence of Type 1 Diabetes in Relation to Exposure to Rotavirus Infections in Pre- and Postvaccine Birth Cohorts in Finland. Diabetes Care 2024; 47:97-100. [PMID: 37861431 DOI: 10.2337/dc23-1203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/02/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVE To explore the incidence of type 1 diabetes in children in relation to exposure to rotavirus infections. RESEARCH DESIGN AND METHODS A nationwide register-based ecological study on the 1995-2015 birth cohorts in Finland compared those born before and after the national implementation of the rotavirus vaccine in 2009. RESULTS When the prevaccine 2001-2005 birth cohorts were compared with the postvaccine birth cohorts, the number of children exposed to rotavirus infection by the age of 5 years decreased from 2,522 per 100,000 children (2.5%) to 171 per 100,000 children (0.2%), while the incidence of type 1 diabetes in those aged <5 years decreased from 71.5 to 54.4 per 100,000 person-years (incidence rate ratio 0.79, 95% CI 0.71-0.86). CONCLUSIONS At the population level, a decrease in exposure to rotavirus infections was associated with a decrease in the incidence of type 1 diabetes in young children.
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Affiliation(s)
- Anna Parviainen
- Pediatric Research Center, New Children's Hospital, Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Anna But
- Biostatistics Consulting, Department of Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Reijo Sund
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Martti Arffman
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Heli Siljander
- Center for Military Medicine, Logistics Command, Finnish Defense Forces, Helsinki, Finland
| | - Mikael Knip
- Pediatric Research Center, New Children's Hospital, Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Center for Child Health Research, Tampere University Hospital, Tampere, Finland
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Rook GAW. The old friends hypothesis: evolution, immunoregulation and essential microbial inputs. FRONTIERS IN ALLERGY 2023; 4:1220481. [PMID: 37772259 PMCID: PMC10524266 DOI: 10.3389/falgy.2023.1220481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/18/2023] [Indexed: 09/30/2023] Open
Abstract
In wealthy urbanised societies there have been striking increases in chronic inflammatory disorders such as allergies, autoimmunity and inflammatory bowel diseases. There has also been an increase in the prevalence of individuals with systemically raised levels of inflammatory biomarkers correlating with increased risk of metabolic, cardiovascular and psychiatric problems. These changing disease patterns indicate a broad failure of the mechanisms that should stop the immune system from attacking harmless allergens, components of self or gut contents, and that should terminate inappropriate inflammation. The Old Friends Hypothesis postulates that this broad failure of immunoregulation is due to inadequate exposures to the microorganisms that drive development of the immune system, and drive the expansion of components such as regulatory T cells (Treg) that mediate immunoregulatory mechanisms. An evolutionary approach helps us to identify the organisms on which we are in a state of evolved dependence for this function (Old Friends). The bottom line is that most of the organisms that drive the regulatory arm of the immune system come from our mothers and family and from the natural environment (including animals) and many of these organisms are symbiotic components of a healthy microbiota. Lifestyle changes that are interrupting our exposure to these organisms can now be identified, and many are closely associated with low socioeconomic status (SES) in wealthy countries. These insights will facilitate the development of education, diets and urban planning that can correct the immunoregulatory deficit, while simultaneously reducing other contributory factors such as epithelial damage.
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Affiliation(s)
- Graham A. W. Rook
- Centre for Clinical Microbiology, Department of Infection, UCL (University College London), London, United Kingdom
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5
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Harrison LC, Bandala‐Sanchez E, Oakey H, Colman PG, Watson K, Kim KW, Wu R, Hamilton‐Williams EE, Stone NL, Haynes A, Thomson RL, Vuillermin PJ, Soldatos G, Rawlinson WD, McGorm KJ, Morahan G, Barry SC, Sinnott RO, Wentworth JM, Couper JJ, Penno MAS. A surge in serum mucosal cytokines associated with seroconversion in children at risk for type 1 diabetes. J Diabetes Investig 2023; 14:1092-1100. [PMID: 37312283 PMCID: PMC10445231 DOI: 10.1111/jdi.14031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/28/2023] [Accepted: 05/07/2023] [Indexed: 06/15/2023] Open
Abstract
AIMS/INTRODUCTION Autoantibodies to pancreatic islet antigens identify young children at high risk of type 1 diabetes. On a background of genetic susceptibility, islet autoimmunity is thought to be driven by environmental factors, of which enteric viruses are prime candidates. We sought evidence for enteric pathology in children genetically at-risk for type 1 diabetes followed from birth who had developed islet autoantibodies ("seroconverted"), by measuring mucosa-associated cytokines in their sera. MATERIALS AND METHODS Sera were collected 3 monthly from birth from children with a first-degree type 1 diabetes relative, in the Environmental Determinants of Islet Autoimmunity (ENDIA) study. Children who seroconverted were matched for sex, age, and sample availability with seronegative children. Luminex xMap technology was used to measure serum cytokines. RESULTS Of eight children who seroconverted, for whom serum samples were available at least 6 months before and after seroconversion, the serum concentrations of mucosa-associated cytokines IL-21, IL-22, IL-25, and IL-10, the Th17-related cytokines IL-17F and IL-23, as well as IL-33, IFN-γ, and IL-4, peaked from a low baseline in seven around the time of seroconversion and in one preceding seroconversion. These changes were not detected in eight sex- and age-matched seronegative controls, or in a separate cohort of 11 unmatched seronegative children. CONCLUSIONS In a cohort of children at risk for type 1 diabetes followed from birth, a transient, systemic increase in mucosa-associated cytokines around the time of seroconversion lends support to the view that mucosal infection, e.g., by an enteric virus, may drive the development of islet autoimmunity.
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Affiliation(s)
- Leonard C Harrison
- Walter and Eliza Hall Institute of Medical ResearchMelbourneVictoriaAustralia
- Department of Medical BiologyUniversity of MelbourneMelbourneVictoriaAustralia
| | - Esther Bandala‐Sanchez
- Walter and Eliza Hall Institute of Medical ResearchMelbourneVictoriaAustralia
- Department of Medical BiologyUniversity of MelbourneMelbourneVictoriaAustralia
| | - Helena Oakey
- Robinson Research Institute and Adelaide Medical SchoolUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Peter G Colman
- Department of Diabetes and EndocrinologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
| | - Kelly Watson
- Department of Diabetes and EndocrinologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
| | - Ki Wook Kim
- Virology Research Laboratory, Serology and Virology DivisionNSW Health, Prince of Wales HospitalSydneyNew South WalesAustralia
- Schools of Biomedical Sciences and Biotechnology and Biomolecular Sciences, Faculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
| | - Roy Wu
- Virology Research Laboratory, Serology and Virology DivisionNSW Health, Prince of Wales HospitalSydneyNew South WalesAustralia
- Schools of Biomedical Sciences and Biotechnology and Biomolecular Sciences, Faculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
| | | | - Natalie L Stone
- Walter and Eliza Hall Institute of Medical ResearchMelbourneVictoriaAustralia
- Department of Medical BiologyUniversity of MelbourneMelbourneVictoriaAustralia
| | - Aveni Haynes
- Telethon Kids Institute for Child Health Research, Centre for Child Health Researchthe University of Western AustraliaPerthWestern AustraliaAustralia
| | - Rebecca L Thomson
- Robinson Research Institute and Adelaide Medical SchoolUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Peter J Vuillermin
- Faculty of School of MedicineDeakin UniversityGeelongVictoriaAustralia
- Child Health Research UnitBarwon HealthGeelongVictoriaAustralia
| | - Georgia Soldatos
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Diabetes and Vascular Medicine UnitMonash HealthMelbourneVictoriaAustralia
| | - William D Rawlinson
- Virology Research Laboratory, Serology and Virology DivisionNSW Health, Prince of Wales HospitalSydneyNew South WalesAustralia
- Schools of Biomedical Sciences and Biotechnology and Biomolecular Sciences, Faculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
| | - Kelly J McGorm
- Robinson Research Institute and Adelaide Medical SchoolUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Grant Morahan
- Centre for Diabetes Research, Harry Perkins Institute of Medical ResearchThe University of Western AustraliaPerthWestern AustraliaAustralia
| | - Simon C Barry
- Robinson Research Institute and Adelaide Medical SchoolUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Richard O Sinnott
- Melbourne eResearch Group, School of Computing and Information ServicesUniversity of MelbourneMelbourneVictoriaAustralia
| | - John M Wentworth
- Walter and Eliza Hall Institute of Medical ResearchMelbourneVictoriaAustralia
- Department of Medical BiologyUniversity of MelbourneMelbourneVictoriaAustralia
- Department of Diabetes and EndocrinologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
| | - Jennifer J Couper
- Robinson Research Institute and Adelaide Medical SchoolUniversity of AdelaideAdelaideSouth AustraliaAustralia
- Women's and Children's HospitalNorth AdelaideSouth AustraliaAustralia
| | - Megan AS Penno
- Robinson Research Institute and Adelaide Medical SchoolUniversity of AdelaideAdelaideSouth AustraliaAustralia
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6
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Harrison LC. Type 1 Diabetes. Clin Immunol 2023. [DOI: 10.1016/b978-0-7020-8165-1.00071-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
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Yu Y, Li M, Zhao Y, Fan F, Wu W, Gao Y, Bai C. Immune cell-derived extracellular vesicular microRNAs induce pancreatic beta cell apoptosis. Heliyon 2022; 8:e11995. [PMID: 36561684 PMCID: PMC9763775 DOI: 10.1016/j.heliyon.2022.e11995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/01/2022] [Accepted: 11/23/2022] [Indexed: 12/03/2022] Open
Abstract
Background Type 1 diabetes mellitus (T1DM) is an autoimmune disease caused by an autoimmune response against pancreatic islet β cells. Increasing evidence indicates that specific microRNAs (miRNAs) from immune cells extracellular vesicles are involved in islet β cells apoptosis. Methods In this study, the microarray datasets GSE27997 and GSE137637 were downloaded from the Gene Expression Omnibus (GEO) database. miRNAs that promote islet β cells apoptosis in T1DM were searched in PubMed. We used the FunRich tool to determine the miRNA expression in extracellular vesicles derived from immune cells associated with islet β cell apoptosis, of which we selected candidate miRNAs based on fold change expression. Potential upstream transcription factors and downstream target genes of candidate miRNAs were predicted using TransmiR V2.0 and starBase database, respectively. Results Candidate miRNAs expressed in extracellular vesicles derived from T cells, pro-inflammatory macrophages, B cells, and dendritic cells were analyzed to identify the miRNAs involved in β cells apoptosis. Based on these candidate miRNAs, 25 downstream candidate genes, which positively regulate β cell functions, were predicted and screened; 17 transcription factors that positively regulate the candidate miRNAs were also identified. Conclusions Our study demonstrated that immune cell-derived extracellular vesicular miRNAs could promote islet β cell dysfunction and apoptosis. Based on these findings, we have constructed a transcription factor-miRNA-gene regulatory network, which provides a theoretical basis for clinical management of T1DM. This study provides novel insights into the mechanism underlying immune cell-derived extracellular vesicle-mediated islet β cell apoptosis.
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Affiliation(s)
- Yueyang Yu
- Institute of Precision Medicine, Jining Medical University, Jining, Shandong 272067, PR China
| | - Mengyin Li
- Department of Otorhinolaryngology Head and Neck Surgery, Affiliated Hospital of Jining Medical University, Jining, Shandong Province, 272067, PR China
| | - Yuxuan Zhao
- Institute of Precision Medicine, Jining Medical University, Jining, Shandong 272067, PR China
| | - Fangzhou Fan
- Institute of Precision Medicine, Jining Medical University, Jining, Shandong 272067, PR China
| | - Wenxiang Wu
- Institute of Precision Medicine, Jining Medical University, Jining, Shandong 272067, PR China
| | - Yuhua Gao
- Institute of Precision Medicine, Jining Medical University, Jining, Shandong 272067, PR China
- Corresponding author.
| | - Chunyu Bai
- Institute of Precision Medicine, Jining Medical University, Jining, Shandong 272067, PR China
- Corresponding author.
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8
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Krogvold L, Genoni A, Puggioni A, Campani D, Richardson SJ, Flaxman CS, Edwin B, Buanes T, Dahl-Jørgensen K, Toniolo A. Live enteroviruses, but not other viruses, detected in human pancreas at the onset of type 1 diabetes in the DiViD study. Diabetologia 2022; 65:2108-2120. [PMID: 35953727 PMCID: PMC9630231 DOI: 10.1007/s00125-022-05779-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/14/2022] [Indexed: 01/11/2023]
Abstract
AIMS/HYPOTHESIS Enterovirus (EV) infection of pancreatic islet cells is one possible factor contributing to type 1 diabetes development. We have reported the presence of EV genome by PCR and of EV proteins by immunohistochemistry in pancreatic sections. Here we explore multiple human virus species in the Diabetes Virus Detection (DiViD) study cases using innovative methods, including virus passage in cell cultures. METHODS Six recent-onset type 1 diabetes patients (age 24-35) were included in the DiViD study. Minimal pancreatic tail resection was performed under sterile conditions. Eleven live cases (age 43-83) of pancreatic carcinoma without diabetes served as control cases. In the present study, we used EV detection methods that combine virus growth in cell culture, gene amplification and detection of virus-coded proteins by immunofluorescence. Pancreas homogenates in cell culture medium were incubated with EV-susceptible cell lines for 3 days. Two to three blind passages were performed. DNA and RNA were extracted from both pancreas tissue and cell cultures. Real-time PCR was used for detecting 20 different viral agents other than EVs (six herpesviruses, human polyomavirus [BK virus and JC virus], parvovirus B19, hepatitis B virus, hepatitis C virus, hepatitis A virus, mumps, rubella, influenza A/B, parainfluenza 1-4, respiratory syncytial virus, astrovirus, norovirus, rotavirus). EV genomes were detected by endpoint PCR using five primer pairs targeting the partially conserved 5' untranslated region genome region of the A, B, C and D species. Amplicons were sequenced. The expression of EV capsid proteins was evaluated in cultured cells using a panel of EV antibodies. RESULTS Samples from six of six individuals with type 1 diabetes (cases) and two of 11 individuals without diabetes (control cases) contained EV genomes (p<0.05). In contrast, genomes of 20 human viruses other than EVs could be detected only once in an individual with diabetes (Epstein-Barr virus) and once in an individual without diabetes (parvovirus B19). EV detection was confirmed by immunofluorescence of cultured cells incubated with pancreatic extracts: viral antigens were expressed in the cytoplasm of approximately 1% of cells. Notably, infection could be transmitted from EV-positive cell cultures to uninfected cell cultures using supernatants filtered through 100 nm membranes, indicating that infectious agents of less than 100 nm were present in pancreases. Due to the slow progression of infection in EV-carrying cell cultures, cytopathic effects were not observed by standard microscopy but were recognised by measuring cell viability. Sequences of 5' untranslated region amplicons were compatible with EVs of the B, A and C species. Compared with control cell cultures exposed to EV-negative pancreatic extracts, EV-carrying cell cultures produced significantly higher levels of IL-6, IL-8 and monocyte chemoattractant protein-1 (MCP1). CONCLUSIONS/INTERPRETATION Sensitive assays confirm that the pancreases of all DiViD cases contain EVs but no other viruses. Analogous EV strains have been found in pancreases of two of 11 individuals without diabetes. The detected EV strains can be passaged in series from one cell culture to another in the form of poorly replicating live viruses encoding antigenic proteins recognised by multiple EV-specific antibodies. Thus, the early phase of type 1 diabetes is associated with a low-grade infection by EVs, but not by other viral agents.
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Affiliation(s)
- Lars Krogvold
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.
- Institute of Clinical Dentistry, Faculty of Dentistry, University of Oslo, Oslo, Norway.
| | - Angelo Genoni
- Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Anna Puggioni
- Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Daniela Campani
- Department of Surgical, Medical and Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy
| | - Sarah J Richardson
- Islet Biology Group (IBEx), Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter College of Medicine and Health, Exeter, UK
| | - Christine S Flaxman
- Islet Biology Group (IBEx), Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter College of Medicine and Health, Exeter, UK
| | - Bjørn Edwin
- Department for HPB Surgery, Oslo University Hospital, Oslo, Norway
| | - Trond Buanes
- Department for HPB Surgery, Oslo University Hospital, Oslo, Norway
| | - Knut Dahl-Jørgensen
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Environmental Factors and the Risk of Developing Type 1 Diabetes-Old Disease and New Data. BIOLOGY 2022; 11:biology11040608. [PMID: 35453807 PMCID: PMC9027552 DOI: 10.3390/biology11040608] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/10/2022] [Accepted: 04/14/2022] [Indexed: 12/16/2022]
Abstract
Simple Summary Despite many studies, the risk factors of type 1 diabetes (T1DM) in children and adolescents are still not fully understood and remain a big challenge. Therefore, an extensive online search for scientific research on factors related to diabetes has been performed for the identification of new factors of unexplained etiology. A better understanding of the role of viral, bacterial, and yeast-like fungi infections related to the risk of T1DM in children and adolescents and the identification of new risk factors, especially those spread by the droplet route, is of great importance for people and families with diabetes. Abstract The incidence of type 1 diabetes (T1D) is increasing worldwide. The onset of T1D usually occurs in childhood and is caused by the selective destruction of insulin-producing pancreatic islet cells (β-cells) by autoreactive T cells, leading to insulin deficiency. Despite advanced research and enormous progress in medicine, the causes of T1D are still not fully understood. Therefore, an extensive online search for scientific research on environmental factors associated with diabetes and the identification of new factors of unexplained etiology has been carried out using the PubMed, Cochrane, and Embase databases. The search results were limited to the past 11 years of research and discovered 143 manuscripts published between 2011 and 2022. Additionally, 21 manuscripts from between 2000 and 2010 and 3 manuscripts from 1974 to 2000 were referenced for historical reference as the first studies showcasing a certain phenomenon or mechanism. More and more scientists are inclined to believe that environmental factors are responsible for the increased incidence of diabetes. Research results show that higher T1D incidence is associated with vitamin D deficiency, a colder climate, and pollution of the environment, as well as the influence of viral, bacterial, and yeast-like fungi infections. The key viral infections affecting the risk of developing T1DM are rubella virus, mumps virus, Coxsackie virus, cytomegalovirus, and enterovirus. Since 2020, i.e., from the beginning of the COVID-19 pandemic, more and more studies have been looking for a link between Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and diabetes development. A better understanding of the role of viral, bacterial, and yeast-like fungi infections related to the risk of T1DM in children and adolescents and the identification of new risk factors, especially those spread by the droplet route, is of great importance for people and families with diabetes.
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Clarke SA, Phylactou M, Patel B, Mills EG, Muzi B, Izzi-Engbeaya C, Khoo B, Meeran K, Comninos AN, Abbara A, Tan T, Oliver N, Dhillo WS. Preserved C-peptide in survivors of COVID-19: Post hoc analysis. Diabetes Obes Metab 2022; 24:570-574. [PMID: 34850532 DOI: 10.1111/dom.14608] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/21/2021] [Accepted: 11/29/2021] [Indexed: 01/09/2023]
Affiliation(s)
- Sophie A Clarke
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Maria Phylactou
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Bijal Patel
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Edouard G Mills
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Beatrice Muzi
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Chioma Izzi-Engbeaya
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Bernard Khoo
- Department of Endocrinology, Division of Medicine, Faculty of Medical Sciences, Royal Free Campus, University College London, London, UK
| | - Karim Meeran
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Alexander N Comninos
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Ali Abbara
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Tricia Tan
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Clinical Biochemistry, Imperial College Healthcare NHS Trust, London, UK
| | - Nick Oliver
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Waljit S Dhillo
- Division of Diabetes, Endocrinology and Metabolism, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
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11
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Lloyd RE, Tamhankar M, Lernmark Å. Enteroviruses and Type 1 Diabetes: Multiple Mechanisms and Factors? Annu Rev Med 2022; 73:483-499. [PMID: 34794324 DOI: 10.1146/annurev-med-042320015952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Type 1 diabetes (T1D) is a chronic autoimmune disease characterized by insulin deficiency and resultant hyperglycemia. Complex interactions of genetic and environmental factors trigger the onset of autoimmune mechanisms responsible for development of autoimmunity to β cell antigens and subsequent development of T1D. A potential role of virus infections has long been hypothesized, and growing evidence continues to implicate enteroviruses as the most probable triggering viruses. Recent studies have strengthened the association between enteroviruses and development of autoimmunity in T1D patients, potentially through persistent infections. Enterovirus infections may contribute to different stages of disease development. We review data from both human cohort studies and experimental research exploring the potential roles and molecular mechanisms by which enterovirus infections can impact disease outcome.
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Affiliation(s)
- Richard E Lloyd
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas 77030, USA; ,
| | - Manasi Tamhankar
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas 77030, USA; ,
| | - Åke Lernmark
- Department of Clinical Sciences, Lund University/CRC, Skane University Hospital, Malmö 214 28, Sweden;
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Abstract
Type 1 diabetes (T1D) is a chronic autoimmune disease characterized by insulin deficiency and resultant hyperglycemia. Complex interactions of genetic and environmental factors trigger the onset of autoimmune mechanisms responsible for development of autoimmunity to β cell antigens and subsequent development of T1D. A potential role of virus infections has long been hypothesized, and growing evidence continues to implicate enteroviruses as the most probable triggering viruses. Recent studies have strengthened the association between enteroviruses and development of autoimmunity in T1D patients, potentially through persistent infections. Enterovirus infections may contribute to different stages of disease development. We review data from both human cohort studies and experimental research exploring the potential roles and molecular mechanisms by which enterovirus infections can impact disease outcome.
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Affiliation(s)
- Richard E. Lloyd
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas 77030, USA
| | - Manasi Tamhankar
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas 77030, USA
| | - Åke Lernmark
- Department of Clinical Sciences, Lund University/CRC, Skane University Hospital, Malmö 214 28, Sweden
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Hirschenberger M, Hunszinger V, Sparrer KMJ. Implications of Innate Immunity in Post-Acute Sequelae of Non-Persistent Viral Infections. Cells 2021; 10:2134. [PMID: 34440903 PMCID: PMC8391718 DOI: 10.3390/cells10082134] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/12/2021] [Accepted: 08/18/2021] [Indexed: 02/06/2023] Open
Abstract
Non-persistent viruses classically cause transient, acute infections triggering immune responses aimed at the elimination of the pathogen. Successful viruses evolved strategies to manipulate and evade these anti-viral defenses. Symptoms during the acute phase are often linked to dysregulated immune responses that disappear once the patient recovers. In some patients, however, symptoms persist or new symptoms emerge beyond the acute phase. Conditions resulting from previous transient infection are termed post-acute sequelae (PAS) and were reported for a wide range of non-persistent viruses such as rota-, influenza- or polioviruses. Here we provide an overview of non-persistent viral pathogens reported to be associated with diverse PAS, among them chronic fatigue, auto-immune disorders, or neurological complications and highlight known mechanistic details. Recently, the emergence of post-acute sequelae of COVID-19 (PASC) or long COVID highlighted the impact of PAS. Notably, PAS of non-persistent infections often resemble symptoms of persistent viral infections, defined by chronic inflammation. Inflammation maintained after the acute phase may be a key driver of PAS of non-persistent viruses. Therefore, we explore current insights into aberrant activation of innate immune signaling pathways in the post-acute phase of non-persistent viruses. Finally, conclusions are drawn and future perspectives for treatment and prevention of PAS are discussed.
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Minor alterations in the intestinal microbiota composition upon Rotavirus infection do not affect susceptibility to DSS colitis. Sci Rep 2021; 11:13485. [PMID: 34188111 PMCID: PMC8242028 DOI: 10.1038/s41598-021-92796-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 06/11/2021] [Indexed: 02/06/2023] Open
Abstract
Viral triggers at the intestinal mucosa can have multiple global effects on intestinal integrity, causing elevated intestinal barrier strength and relative protection from subsequent inflammatory bowel disease (IBD) induction in various models. As viruses can interfere with the intestinal immune system both directly and indirectly through commensal bacteria, cause-effect relationships are difficult to define. Due to the complexity of putatively causative factors, our understanding of such virus-mediated protection is currently very limited. We here set out to better understand the impact that adult enteric infection with rotavirus (RV) might have on the composition of the intestinal microbiome and on the severity of IBD. We found that RV infection neither induced significant long-lasting microbiota community changes in the small or large intestine nor affected the severity of subsequent dextran sulfate sodium-induced colitis. Hence, adult murine RV infection does not exert lasting effects on intestinal homeostasis.
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Parviainen A, But A, Siljander H, Knip M. Decreased Incidence of Type 1 Diabetes in Young Finnish Children. Diabetes Care 2020; 43:2953-2958. [PMID: 32998988 DOI: 10.2337/dc20-0604] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 09/04/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The incidence of type 1 diabetes has been rising for decades, particularly among young children. Between 2006 and 2011, the incidence rate (IR) reached a plateau in Finland. In this observational, register-based cohort study, we assess recent trends in the disease rate in Finnish children. RESEARCH DESIGN AND METHODS Based on data from the Finnish Pediatric Diabetes Register, we studied the incidence of type 1 diabetes among children younger than 15 years of age between 2003 and 2018. We assessed sex-specific IRs per 100,000 person-years (PY) by 4-year time periods in three age-groups (0.50-4.99, 5.00-9.99, and 10.00-14.99 years). RESULTS Among the 7,871 children with newly diagnosed type 1 diabetes, the median age at diagnosis increased from 7.88 to 8.33 years (P = 0.001), while the overall IR decreased from 57.9/100,000 PY in 2003-2006 to 52.2/100,000 PY in 2015-2018, yielding an IR ratio (IRR) of 0.90 (95% CI 0.85-0.96, P = 0.001). This decline was mainly due to the decrease in the youngest age-group (IRR 0.77 [95% CI 0.68-0.87]; P < 0.001), being significant both among boys and girls. In the middle age-group, a significant decrease was observed only among girls. No changes were observed in the oldest children. CONCLUSIONS The incidence of type 1 diabetes decreased among young Finnish children between 2003 and 2018. Current findings imply that environmental factors driving the immune system toward islet autoimmunity are changing in young children.
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Affiliation(s)
- Anna Parviainen
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Anna But
- Biostatistics consulting, Department of Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Heli Siljander
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Mikael Knip
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland .,Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Center for Child Health Research, Tampere University Hospital, Tampere, Finland.,Folkhälsan Research Center, Helsinki, Finland
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Haynes A, Bulsara MK, Bergman P, Cameron F, Couper J, Craig ME, Demangone K, Johnson S, Lafferty A, Titmuss A, Davis EA. Incidence of type 1 diabetes in 0 to 14 year olds in Australia from 2002 to 2017. Pediatr Diabetes 2020; 21:707-712. [PMID: 32304132 DOI: 10.1111/pedi.13025] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/08/2020] [Accepted: 04/10/2020] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To determine the incidence of childhood onset type 1 diabetes in Australia from 2002 to 2017, and analyze incidence rate trends by calendar year, sex, and age at diagnosis. RESEARCH DESIGN AND METHODS Children newly diagnosed with type 1 diabetes aged <15 years between 2002 and 2017 were identified from the National Diabetes Register, estimated to be ~99% complete. Data were obtained for diagnosis year, sex, age, and residential State/Territory at time of diagnosis. Population estimates by year, sex, single year of age, and State/Territory were obtained from the Australian Bureau of Statistics and Poisson regression used to examine incidence and trends by calendar year, sex, and age group at diagnosis. RESULTS Between 2002 and 2017, there were 16 783 newly diagnosed cases of type 1 diabetes in children aged < 15 years (8684 boys: 8099 girls), giving a mean incidence of 25.0/1 00 000 person years (95%CI: 24.6, 25.4). A sinusoidal pattern in the incidence rate trend was observed with 5-yearly cycles providing the best model fit. No significant difference was observed in boys compared to girls (IRR 0.98 [95%CI: 0.95, 1.01]). Compared to 0 to 4 year olds, the mean incidence was 75% higher in 5 to 9 year olds, and 224% higher in 10 to 14 year olds. A decreasing incidence rate trend was observed in 0 to 4 year old boys and girls. CONCLUSIONS This study reports updated incidence and incidence rate trends in children and adolescents diagnosed with type 1 diabetes in Australia. A cyclical pattern in incidence trend persists, with an overall decreasing trend observed only in the youngest age group.
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Affiliation(s)
- Aveni Haynes
- Telethon Kids Institute, Perth, Western Australia, Australia
| | - Max K Bulsara
- Institute for Health Research, University of Notre Dame, Fremantle, Western Australia, Australia
| | - Phil Bergman
- Department of Pediatric Endocrinology and Diabetes, Monash Children's Hospital, Clayton, Victoria, Australia.,Department of Pediatrics, Monash University, Melbourne, Victoria, Australia
| | - Fergus Cameron
- Department of Endocrinology and Diabetes and Center for Hormone Research, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Jennifer Couper
- Women's and Children's Hospital, Adelaide, South Australia, Australia.,Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia
| | - Maria E Craig
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Discipline of Child and Adolescent Health, University of Sydney, Sydney, New South Wales, Australia
| | | | | | - Antony Lafferty
- Department of Pediatrics, Canberra Hospital, Canberra, Australian Capital Territory, Australia.,ANU Medical School, Canberra, Australian Capital Territory, Australia
| | - Angela Titmuss
- Royal Darwin Hospital, Casuarina, Northern Territory, Australia
| | - Elizabeth A Davis
- Telethon Kids Institute, Perth, Western Australia, Australia.,Department of Diabetes and Endocrinology, Perth Children's Hospital, Nedlands, Western Australia, Australia
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Blum SI, Tse HM. Innate Viral Sensor MDA5 and Coxsackievirus Interplay in Type 1 Diabetes Development. Microorganisms 2020; 8:microorganisms8070993. [PMID: 32635205 PMCID: PMC7409145 DOI: 10.3390/microorganisms8070993] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/01/2020] [Accepted: 07/01/2020] [Indexed: 12/12/2022] Open
Abstract
Type 1 diabetes (T1D) is a polygenic autoimmune disease characterized by immune-mediated destruction of insulin-producing β-cells. The concordance rate for T1D in monozygotic twins is ≈30-50%, indicating that environmental factors also play a role in T1D development. Previous studies have demonstrated that enterovirus infections such as coxsackievirus type B (CVB) are associated with triggering T1D. Prior to autoantibody development in T1D, viral RNA and antibodies against CVB can be detected within the blood, stool, and pancreata. An innate pathogen recognition receptor, melanoma differentiation-associated protein 5 (MDA5), which is encoded by the IFIH1 gene, has been associated with T1D onset. It is unclear how single nucleotide polymorphisms in IFIH1 alter the structure and function of MDA5 that may lead to exacerbated antiviral responses contributing to increased T1D-susceptibility. Binding of viral dsRNA via MDA5 induces synthesis of antiviral proteins such as interferon-alpha and -beta (IFN-α/β). Viral infection and subsequent IFN-α/β synthesis can lead to ER stress within insulin-producing β-cells causing neo-epitope generation, activation of β-cell-specific autoreactive T cells, and β-cell destruction. Therefore, an interplay between genetics, enteroviral infections, and antiviral responses may be critical for T1D development.
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Satayarak J, Strauss ST, Duangdee C, Charunwatthana P, Jiamsomboon K, Kosoltanapiwat N, Srinukham S, Boonnak K. Prevalence and diversity of human rotavirus among Thai adults. J Med Virol 2020; 92:2582-2592. [PMID: 32470142 DOI: 10.1002/jmv.26076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 05/17/2020] [Accepted: 05/23/2020] [Indexed: 12/20/2022]
Abstract
Rotavirus infections have become one of the most common causes of infectious gastroenteritis in children. Although rotavirus infections have been intensively studied in infants and young children, the study in adults has been limited. As such, this study assessed the prevalence of rotaviruses and performed the molecular characterization of rotaviruses circulating in Thai adults experiencing acute gastroenteritis between January 2018 and December 2018. Group A human rotaviruses were detected in 100 feces samples by rapid immunochromatography. The peak incidence of infection occurred in February and began to decline in the summer months. From January 2018 to December 2018, there were 1344 acute gastroenteritis adult cases in the Hospital for Tropical Diseases, Bangkok, Thailand. Among these, 310 cases were rotavirus-suspected cases. Only 100 samples tested positive for rotavirus via an immunochromatography test. Twentynine out of the 100 rotavirus-positive samples were further characterized by real-time polymerase chain reaction. The G3[P8] strain was identified as the most prevalent (31.0%) followed by G1P[8], G8P[8] and G9P[8], and G2P[8], which accounted for 20.8%, 17.2%, and 13.8%, respectively. Because of the detection of rare rotavirus genotypes, such as G8, the surveillance of rotavirus epidemiology is crucial in monitoring new emergences of rotavirus strains, leading to a better understanding of the effects of strain variation for further vaccine development.
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Affiliation(s)
- Jantawan Satayarak
- Hospital for Tropical Diseases, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Stefan Thomas Strauss
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Chatnapa Duangdee
- Hospital for Tropical Diseases, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Prakaykaew Charunwatthana
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Nakhon Pathom, Thailand
| | - Kultida Jiamsomboon
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nathamon Kosoltanapiwat
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Sompan Srinukham
- Hospital for Tropical Diseases, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kobporn Boonnak
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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