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Alexiou ZW, van Aar F, Hoenderboom BM, Morre SA, Heijne JCM. Trends in Chlamydia trachomatis IgG seroprevalence in the general population of the Netherlands over 20 years. Sex Transm Infect 2024; 100:31-38. [PMID: 37985129 PMCID: PMC10850662 DOI: 10.1136/sextrans-2023-055888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/08/2023] [Indexed: 11/22/2023] Open
Abstract
OBJECTIVES To report sex and age-specific Chlamydia trachomatis (Ct) seroprevalence estimates in the general population of the Netherlands between 1996 and 2017 and identify risk factors associated with Ct seropositivity. METHODS Participants (n=5158, aged 15-59 years) were included from three independent nationwide population-based serosurveillance studies in 1996, 2007 and 2017. Participants completed a questionnaire on demographics and sexual behaviour. Serum antibodies were analysed using Medac Ct IgG ELISA test. Census weights were assigned to achieve seroprevalence estimates representative of the general Dutch population. Weighted seroprevalence estimates were stratified by gender, age and birth cohort. Trends and risk factors in men and women were identified using multivariable logistic regression. RESULTS Weighted overall Ct seroprevalence was 10.5% (95% CI: 9.2% to 12.0%) in women and 5.8% (95% CI: 4.7% to 7.0%) in men. Among women <25 years, there was a non-significant increase in seroprevalence from 5.9% (95% CI 3.7% to 9.2%) in 1996, to 7.6% (95% CI 5.1% to 11.1%) in 2007 and 8.8% (95% CI 5.5% to 13.9%) in 2017. Among women ≥25 years, the seroprevalence significantly decreased from 15.6% (95% CI: 12.2% to 19.7%) in 1996 to 9.5% (95% CI: 7.2% to 12.4%) in 2007 but did not further drop (11.2% (95% CI 8.1% to 15.3%) in 2017). In men, we did not observe trends between study rounds. In both men and women, having a non-Western migration background was a risk factor for seropositivity. In women, having had a prior sexually transmitted infection and ≥2 recent sex partners were risk factors for seropositivity as well. CONCLUSIONS We have not found evidence for a decrease in population seroprevalence in those under 25 years old despite decades of intensified testing-and-treatment efforts in the Netherlands. This suggests further monitoring of Ct burden in the general population is needed. If serum banks are used for this, specifically individuals <25 years old and with diverse migration backgrounds should be included.
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Affiliation(s)
- Zoïe Willemijn Alexiou
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
- Department of Genetics and Cell Biology, GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Fleur van Aar
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Bernice Maria Hoenderboom
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Servaas Antonie Morre
- Department of Genetics and Cell Biology, GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
- Dutch Chlamydia trachomatis Reference Laboratory, Department of Medical Microbiology, Faculty of Health, Medicine & Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Molecular and Cellular Engineering, Jacob Institute of Biotechnology and Bioengineering, Sam Higginbottom University of Agriculture, Technology and Sciences, Allahabad, India
| | - Janneke Cornelia Maria Heijne
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
- Department of Social Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
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Liu C, Mokashi NV, Darville T, Sun X, O’Connell CM, Hufnagel K, Waterboer T, Zheng X. A Machine Learning-Based Analytic Pipeline Applied to Clinical and Serum IgG Immunoproteome Data To Predict Chlamydia trachomatis Genital Tract Ascension and Incident Infection in Women. Microbiol Spectr 2023; 11:e0468922. [PMID: 37318345 PMCID: PMC10434056 DOI: 10.1128/spectrum.04689-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 06/01/2023] [Indexed: 06/16/2023] Open
Abstract
We developed a reusable and open-source machine learning (ML) pipeline that can provide an analytical framework for rigorous biomarker discovery. We implemented the ML pipeline to determine the predictive potential of clinical and immunoproteome antibody data for outcomes associated with Chlamydia trachomatis (Ct) infection collected from 222 cis-gender females with high Ct exposure. We compared the predictive performance of 4 ML algorithms (naive Bayes, random forest, extreme gradient boosting with linear booster [xgbLinear], and k-nearest neighbors [KNN]), screened from 215 ML methods, in combination with two different feature selection strategies, Boruta and recursive feature elimination. Recursive feature elimination performed better than Boruta in this study. In prediction of Ct ascending infection, naive Bayes yielded a slightly higher median value of are under the receiver operating characteristic curve (AUROC) 0.57 (95% confidence interval [CI], 0.54 to 0.59) than other methods and provided biological interpretability. For prediction of incident infection among women uninfected at enrollment, KNN performed slightly better than other algorithms, with a median AUROC of 0.61 (95% CI, 0.49 to 0.70). In contrast, xgbLinear and random forest had higher predictive performances, with median AUROC of 0.63 (95% CI, 0.58 to 0.67) and 0.62 (95% CI, 0.58 to 0.64), respectively, for women infected at enrollment. Our findings suggest that clinical factors and serum anti-Ct protein IgGs are inadequate biomarkers for ascension or incident Ct infection. Nevertheless, our analysis highlights the utility of a pipeline that searches for biomarkers and evaluates prediction performance and interpretability. IMPORTANCE Biomarker discovery to aid early diagnosis and treatment using machine learning (ML) approaches is a rapidly developing area in host-microbe studies. However, lack of reproducibility and interpretability of ML-driven biomarker analysis hinders selection of robust biomarkers that can be applied in clinical practice. We thus developed a rigorous ML analytical framework and provide recommendations for enhancing reproducibility of biomarkers. We emphasize the importance of robustness in selection of ML methods, evaluation of performance, and interpretability of biomarkers. Our ML pipeline is reusable and open-source and can be used not only to identify host-pathogen interaction biomarkers but also in microbiome studies and ecological and environmental microbiology research.
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Affiliation(s)
- Chuwen Liu
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Neha Vivek Mokashi
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Toni Darville
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Xuejun Sun
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Catherine M. O’Connell
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Katrin Hufnagel
- Infections and Cancer Epidemiology, German Cancer Research Center (Deutsches Krebsforschungszentrum), Heidelberg, Germany
| | - Tim Waterboer
- Infections and Cancer Epidemiology, German Cancer Research Center (Deutsches Krebsforschungszentrum), Heidelberg, Germany
| | - Xiaojing Zheng
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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3
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Scharbaai-Vázquez R, J. López Font F, A. Zayas Rodríguez F. Persistence in Chlamydia. Infect Dis (Lond) 2022. [DOI: 10.5772/intechopen.109299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Chlamydia spp. are important causes of acute and persistent/chronic infections. All Chlamydia spp. display a unique biphasic developmental cycle alternating between an infectious elementary body (EB) and a replicative form, the reticulate body (RB), followed by the multiplication of RBs by binary fission and progressive differentiation back into EBs. During its intracellular life, Chlamydia employs multiple mechanisms to ensure its persistence inside the host. These include evasion of diverse innate immune responses, modulation of host cell structure and endocytosis, inhibition of apoptosis, activation of pro-signaling pathways, and conversion to enlarged, non-replicative but viable “aberrant bodies” (ABs). Early research described several systems for Chlamydial persistence with a significant number of variables that make a direct comparison of results difficult. Now, emerging tools for genetic manipulations in Chlamydia and advances in global microarray, transcriptomics, and proteomics have opened new and exciting opportunities to understand the persistent state of Chlamydia and link the immune and molecular events of persistence with the pathogenesis of recurrent and chronic Chlamydial infections. This chapter reviews our current understanding and advances in the molecular biology of Chlamydia persistence.
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Zubair M, Wang J, Yu Y, Faisal M, Qi M, Shah AU, Feng Z, Shao G, Wang Y, Xiong Q. Proteomics approaches: A review regarding an importance of proteome analyses in understanding the pathogens and diseases. Front Vet Sci 2022; 9:1079359. [PMID: 36601329 PMCID: PMC9806867 DOI: 10.3389/fvets.2022.1079359] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
Proteomics is playing an increasingly important role in identifying pathogens, emerging and re-emerging infectious agents, understanding pathogenesis, and diagnosis of diseases. Recently, more advanced and sophisticated proteomics technologies have transformed disease diagnostics and vaccines development. The detection of pathogens is made possible by more accurate and time-constrained technologies, resulting in an early diagnosis. More detailed and comprehensive information regarding the proteome of any noxious agent is made possible by combining mass spectrometry with various gel-based or short-gun proteomics approaches recently. MALDI-ToF has been proved quite useful in identifying and distinguishing bacterial pathogens. Other quantitative approaches are doing their best to investigate bacterial virulent factors, diagnostic markers and vaccine candidates. Proteomics is also helping in the identification of secreted proteins and their virulence-related functions. This review aims to highlight the role of cutting-edge proteomics approaches in better understanding the functional genomics of pathogens. This also underlines the limitations of proteomics in bacterial secretome research.
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Affiliation(s)
- Muhammad Zubair
- Key Laboratory of Veterinary Biological Engineering and Technology, Ministry of Agriculture, Institute of Veterinary Medicine, Jiangsu Academy of Agricultural Sciences, Nanjing, China
| | - Jia Wang
- Key Laboratory of Veterinary Biological Engineering and Technology, Ministry of Agriculture, Institute of Veterinary Medicine, Jiangsu Academy of Agricultural Sciences, Nanjing, China
| | - Yanfei Yu
- Key Laboratory of Veterinary Biological Engineering and Technology, Ministry of Agriculture, Institute of Veterinary Medicine, Jiangsu Academy of Agricultural Sciences, Nanjing, China,School of Food and Biological Engineering, Jiangsu University, Zhenjiang, China,College of Veterinary Medicine, Nanjing Agricultural University, Nanjing, China
| | - Muhammad Faisal
- Division of Hematology, Department of Medicine, The Ohio State University College of Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH, United States
| | - Mingpu Qi
- College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, China
| | - Abid Ullah Shah
- National Research Centre of Engineering and Technology for Veterinary Biologicals, Institute of Veterinary Immunology and Engineering, Jiangsu Academy of Agricultural Sciences, Nanjing, China
| | - Zhixin Feng
- Key Laboratory of Veterinary Biological Engineering and Technology, Ministry of Agriculture, Institute of Veterinary Medicine, Jiangsu Academy of Agricultural Sciences, Nanjing, China
| | - Guoqing Shao
- Key Laboratory of Veterinary Biological Engineering and Technology, Ministry of Agriculture, Institute of Veterinary Medicine, Jiangsu Academy of Agricultural Sciences, Nanjing, China,School of Food and Biological Engineering, Jiangsu University, Zhenjiang, China
| | - Yu Wang
- China Pharmaceutical University, Nanjing, China,*Correspondence: Yu Wang
| | - Qiyan Xiong
- Key Laboratory of Veterinary Biological Engineering and Technology, Ministry of Agriculture, Institute of Veterinary Medicine, Jiangsu Academy of Agricultural Sciences, Nanjing, China,College of Veterinary Medicine, Nanjing Agricultural University, Nanjing, China,School of Life Sciences, Jiangsu University, Zhenjiang, China,Qiyan Xiong
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Liu C, Hufnagel K, O'Connell CM, Goonetilleke N, Mokashi N, Waterboer T, Tollison TS, Peng X, Wiesenfeld HC, Hillier SL, Zheng X, Darville T. Reduced Endometrial Ascension and Enhanced Reinfection Associated with IgG Antibodies to Specific Chlamydia trachomatis Proteins in Women at Risk for Chlamydia. J Infect Dis 2021; 225:846-855. [PMID: 34610131 DOI: 10.1093/infdis/jiab496] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 09/28/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Previous research revealed antibodies targeting Chlamydia trachomatis (CT) elementary bodies was not associated with reduced endometrial or incident infection in CT-exposed women. However, data on the role of CT protein-specific antibodies in protection are limited. METHODS A whole-proteome CT array screening serum pools from CT-exposed women identified 121 immunoprevalent proteins. Individual sera were probed using a focused array. IgG antibody frequencies and endometrial or incident infection relationships were examined using Wilcoxon Rank sum test. The impact of breadth and magnitude of protein-specific IgGs on ascension and incident infection were examined using multivariable stepwise logistic regression. Complementary RNA-sequencing quantified CT gene transcripts in cervical swabs from infected women. RESULTS IgG to Pgp3 and CT005 were associated with reduced endometrial infection; anti-CT443, -CT486 and -CT123 were associated with increased incident infection. Increased breadth of protein recognition did not however predict protection from endometrial or incident infection. mRNAs for immunoprevalent CT proteins were highly abundant in the cervix. CONCLUSIONS Protein-specific CT antibodies are not sufficient to protect against ascending or incident infection but broad recognition of CT proteins by IgG correlates with cervical CT gene transcript abundance, suggesting CT protein abundance correlates with immunogenicity and signifies their potential as vaccine candidates.
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Affiliation(s)
- Chuwen Liu
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Katrin Hufnagel
- Division of Infections and Cancer Epidemiology, German Cancer Research Center (Deutsches Krebsforschungszentrum, DKFZ), Heidelberg, Germany
| | - Catherine M O'Connell
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nilu Goonetilleke
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Neha Mokashi
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Tim Waterboer
- Division of Infections and Cancer Epidemiology, German Cancer Research Center (Deutsches Krebsforschungszentrum, DKFZ), Heidelberg, Germany
| | - Tammy S Tollison
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, North Carolina, USA
| | - Xinxia Peng
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, North Carolina, USA.,Bioinformatics Research Center, North Carolina State University, Raleigh, North Carolina, USA
| | - Harold C Wiesenfeld
- Department of Obstetrics, Gynecology and Reproductive Sciences, The University of Pittsburgh School of Medicine, The Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA
| | - Sharon L Hillier
- Department of Obstetrics, Gynecology and Reproductive Sciences, The University of Pittsburgh School of Medicine, The Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA
| | - Xiaojing Zheng
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Toni Darville
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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6
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Horner PJ, Anyalechi GE, Geisler WM. What Can Serology Tell Us About the Burden of Infertility in Women Caused by Chlamydia? J Infect Dis 2021; 224:S80-S85. [PMID: 34396401 DOI: 10.1093/infdis/jiab047] [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] [Indexed: 11/13/2022] Open
Abstract
Chlamydia trachomatis (CT) causes pelvic inflammatory disease, which may result in tubal factor infertility (TFI) in women. Serologic assays may be used to determine the proportion of women with and without TFI who have had previous CT infection and to generate estimates of infertility attributable to chlamydia. Unfortunately, most existing CT serologic assays are challenged by low sensitivity and, sometimes, specificity for prior CT infection; however, they are currently the only available tests available to detect prior CT infection. Modeling methods such as finite mixture modeling may be a useful adjunct to quantitative serologic data to obtain better estimates of CT-related infertility. In this article, we review CT serological assays, including the use of antigens preferentially expressed during upper genital tract infection, and suggest future research directions. These methodologic improvements, coupled with creation of new biomarkers for previous CT infection, should improve our understanding of chlamydia's contribution to female infertility.
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Affiliation(s)
- Patrick J Horner
- Population Health Sciences, University of Bristol, Bristol, United Kingdom.,National Institute for Health Research, Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, United Kingdom
| | - Gloria E Anyalechi
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - William M Geisler
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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7
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Jeske R, Reininger D, Turgu B, Brauer A, Harmel C, Fernández de Larrea-Baz N, Martín V, Moreno V, Kogevinas M, Pollán M, Hoheisel JD, Waterboer T, Butt J, Aragonés N, Hufnagel K. Development of Helicobacter pylori Whole-Proteome Arrays and Identification of Serologic Biomarkers for Noncardia Gastric Cancer in the MCC-Spain Study. Cancer Epidemiol Biomarkers Prev 2020; 29:2235-2242. [PMID: 32998950 DOI: 10.1158/1055-9965.epi-20-0348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 06/25/2020] [Accepted: 09/04/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Helicobacter pylori (H. pylori) is a bacterial carcinogen and the leading risk factor for noncardia gastric cancer (NCGC). Detecting antibodies against specific H. pylori proteins in peripheral blood can be applied to characterize infection and determine disease associations. Most studies analyzing the association between H. pylori infection and gastric cancer have focused on previously identified antigens, predominantly the virulence factor cytotoxin-associated gene A (CagA). Selecting antigens in an unbiased approach may, however, allow the identification of novel biomarkers. METHODS Using a combination of multiple spotting technique and cell-free, on-chip protein expression, we displayed the H. pylori genome (strain 26695) on high-density microarrays. Immunogenic proteins were identified by serum pool incubations and henceforth analyzed in individual samples. To test its applicability, we used sera from a multicase-control (MCC)-Spain study. Serologic responses between NCGC cases and controls were assessed by conditional logistic regression estimating ORs and 95% confidence intervals. RESULTS We successfully expressed 93% of the 1,440 H. pylori open reading frames in situ. Of these, 231 (17%) were found to be immunogenic. By comparing 58 NCGC cases with 58 matched controls, we confirmed a higher seroprevalence of CagA among cases (66%) than controls (31%). We further identified a potential novel marker, the Helicobacter outer membrane protein A (HopA). CONCLUSIONS In this study, we provide evidence that our H. pylori whole-proteome microarray offers a platform for unbiased de novo identification of serologic biomarkers. IMPACT Given its versatile workflow, antibody responses against other H. pylori strains and possible associations with diverse H. pylori-related outcomes can be systematically analyzed.
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Affiliation(s)
- Rima Jeske
- Infections and Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany. .,Faculty of Biosciences, Heidelberg University, Heidelberg, Germany
| | - Dennis Reininger
- Infections and Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Busra Turgu
- Infections and Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Amber Brauer
- Infections and Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christoph Harmel
- Infections and Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Nerea Fernández de Larrea-Baz
- Environmental and Cancer Epidemiology Area, National Center of Epidemiology, Carlos III Health Institute (ISCIII), Madrid, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP)-CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Vicente Martín
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP)-CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain.,The Research Group in Gene-Environment and Health Interactions, University of León, León, Spain
| | - Victor Moreno
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP)-CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain.,Cancer Prevention and Control Program, Catalan Institute of Oncology (ICO), Hospitalet de Llobregat, Barcelona, Spain
| | - Manolis Kogevinas
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP)-CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain.,ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain
| | - Marina Pollán
- Environmental and Cancer Epidemiology Area, National Center of Epidemiology, Carlos III Health Institute (ISCIII), Madrid, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP)-CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Jörg D Hoheisel
- Functional Genome Analysis, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Tim Waterboer
- Infections and Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Julia Butt
- Infections and Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Nuria Aragonés
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP)-CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain.,Epidemiology Section, Division of Public Health, Department of Health, Madrid, Spain
| | - Katrin Hufnagel
- Infections and Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
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