1
|
Olatunji YA, Banjo AA, Jarde A, Salaudeen R, Ndiaye M, Galega LB, Odutola A, Hossain IM, Osuorah C, Sahito MS, Muhammad BS, Ikumapayi NU, Drammeh MM, Manjang A, Adegbola RA, Greenwood BM, Hill PC, Grant MA. Invasive bacterial disease in young infants in rural Gambia: Population-based surveillance. J Glob Health 2023; 13:04106. [PMID: 37772795 PMCID: PMC10540664 DOI: 10.7189/jogh.13.04106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023] Open
Abstract
Background Invasive bacterial diseases (IBD) cause significant mortality in young infants. There are limited population-based data on IBD in young infants in Sub-Saharan Africa. Methods We conducted population-based surveillance for IBD among infants aged 0-90 days in a demographic surveillance area in rural Gambia between 1 March 2011 and 31 December 2017. Infants admitted to health facilities within the study area had standardised clinical evaluation plus conventional microbiological investigation. We defined IBD as isolation of pathogenic bacteria from blood, cerebrospinal fluid, lung, or pleural aspirate. We determined incidence, aetiology and case-fatality of IBD. Results A total of 3794 infants were admitted and 3605 (95%) had at least one sample collected for culture. We detected 254 (8.0%) episodes of IBD (bacteraemia 241; meningitis 14; pneumonia seven). The incidence of IBD in infants aged 0-90 days was 25 episodes/1000 person-years (95% confidence interval (CI) = 22-28), the incidence in neonates was 50 episodes/1000 person-years (95% CI = 43-58) and the incidence in infants aged 29-90 days was 12 episodes/1000 person-years (95% CI = 9-15). The most common pathogens causing IBD were Staphylococcus aureus (n = 102, 40%), Escherichia coli (n = 37, 15%), Streptococcus pneumoniae (n = 24, 9%) and Klebsiella pneumoniae (n = 12, 5%). Case-fatality was 29% (95% CI = 23-37) in neonates and 19% (95% CI = 11-29) in infants aged 29-90 days. A minimum of 7.3% of all young infant deaths in the population were caused by IBD. Conclusions IBD are common in young infants in rural Gambia and have a high case-fatality. Strategies are needed to prevent IBD in young infants. Overcoming barriers to widespread implementation of existing vaccines and developing new vaccines against the most common pathogens causing IBD should be among top priorities for reducing the high mortality rate in young infants.
Collapse
Affiliation(s)
- Yekini A Olatunji
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara Banjul, The Gambia
| | - Adeshola A Banjo
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara Banjul, The Gambia
| | - Alexander Jarde
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara Banjul, The Gambia
| | - Rasheed Salaudeen
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara Banjul, The Gambia
| | - Malick Ndiaye
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara Banjul, The Gambia
| | - Lobga B Galega
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara Banjul, The Gambia
| | - Aderonke Odutola
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara Banjul, The Gambia
| | - Ilias M Hossain
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara Banjul, The Gambia
| | - Chidiebere Osuorah
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara Banjul, The Gambia
| | - Muhammad S Sahito
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara Banjul, The Gambia
| | - Bilquees Shah Muhammad
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara Banjul, The Gambia
| | - Nurudeen U Ikumapayi
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara Banjul, The Gambia
| | - Momodou M Drammeh
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara Banjul, The Gambia
| | - Ahmad Manjang
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara Banjul, The Gambia
| | | | - Brian M Greenwood
- London School of Hygiene & Tropical Medicine, Department of Disease Control, London, England, UK
| | - Philip C Hill
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Mackenzie A Grant
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara Banjul, The Gambia
- London School of Hygiene & Tropical Medicine, Department of Disease Control, London, England, UK
- Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| |
Collapse
|
2
|
Ikumapayi UN, Hill PC, Hossain I, Olatunji Y, Ndiaye M, Badji H, Manjang A, Salaudeen R, Ceesay L, Adegbola RA, Greenwood BM, Mackenzie GA. Childhood meningitis in rural Gambia: 10 years of population-based surveillance. PLoS One 2022; 17:e0265299. [PMID: 35947593 PMCID: PMC9365145 DOI: 10.1371/journal.pone.0265299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 07/26/2022] [Indexed: 11/24/2022] Open
Abstract
Background The introduction in many countries of conjugate vaccines against Haemophilus influenzae type b, Streptococcus pneumoniae, and Neisseria meningitidis has led to significant reductions in acute bacterial meningitis (ABM) in children. However, recent population-based data on ABM in sub-Saharan Africa are limited. Methods Population-based surveillance for meningitis was carried out in a rural area of The Gambia under demographic surveillance from 2008 to 2017, using standardised criteria for referral, diagnosis and investigation. We calculated incidence using population denominators. Results We diagnosed 1,666 patients with suspected meningitis and collected cerebrospinal fluid (n = 1,121) and/or blood (n = 1,070) from 1,427 (88%) of cases. We identified 169 cases of ABM, 209 cases of suspected non-bacterial meningitis (SNBM) and 1,049 cases of clinically suspected meningitis (CSM). The estimated average annual incidence of ABM was high at 145 per 100,000 population in the <2-month age group, 56 per 100,000 in the 2–23-month age group, but lower at 5 per 100,000 in the 5–14-year age group. The most common causes of ABM were Streptococcus pneumoniae (n = 44), Neisseria meningitidis (n = 42), and Gram-negative coliform bacteria (n = 26). Eighteen of 22 cases caused by pneumococcal serotypes included in PCV13 occurred prior to vaccine introduction and four afterwards. The overall case fatality ratio for ABM was 29% (49/169) and was highest in the <2-month age group 37% (10/27). The case fatality ratio was 8.6% (18/209) for suspected non-bacterial meningitis and 12.8% (134/1049) for clinically suspected meningitis cases. Conclusions Gambian children continue to experience substantial morbidity and mortality associated with suspected meningitis, especially acute bacterial meningitis. Such severely ill children in sub-Saharan Africa require improved diagnostics and clinical care.
Collapse
Affiliation(s)
- Usman N. Ikumapayi
- Medical Research Council Unit, The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia
- * E-mail:
| | - Philip C. Hill
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - Ilias Hossain
- Medical Research Council Unit, The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia
| | - Yekini Olatunji
- Medical Research Council Unit, The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia
| | - Malick Ndiaye
- Medical Research Council Unit, The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia
| | - Henry Badji
- Medical Research Council Unit, The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia
| | - Ahmed Manjang
- Medical Research Council Unit, The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia
| | - Rasheed Salaudeen
- Medical Research Council Unit, The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia
| | - Lamin Ceesay
- Ministry of Health, Gambia Government, Banjul, The Gambia
| | - Richard A. Adegbola
- Nigerian Institute of Medical Research, Yaba, Lagos, Nigeria
- RAMBICON, Immunisation & Global Health Consulting, Lekki, Lagos, Nigeria
| | | | - Grant A. Mackenzie
- Medical Research Council Unit, The Gambia at London School of Hygiene & Tropical Medicine, Fajara, The Gambia
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- Murdoch Children’s Research Institute, Parkville, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| |
Collapse
|
3
|
Mackenzie GA, McLellan J, Machuka E, Ndiaye M, Pathirana J, Fombah A, Abatan B, Hossain I, Manjang A, Greenwood B, Hill P. Aetiology of lobar pneumonia determined by multiplex molecular analyses of lung and pleural aspirate specimens in the Gambia: findings from population-based pneumonia surveillance. BMJ Open 2022; 12:e056706. [PMID: 35273059 PMCID: PMC8915295 DOI: 10.1136/bmjopen-2021-056706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To determine the causes of lobar pneumonia in rural Gambia. DESIGN AND SETTING Population-based pneumonia surveillance at seven peripheral health facilities and two regional hospitals in rural Gambia. 7-valent pneumococcal conjugate vaccine (PCV7) was introduced routinely in August 2009 and replaced by PCV13 from May 2011. METHODS Prospective pneumonia surveillance was undertaken among all ages with referral of suspected pneumonia cases to the regional hospitals. Blood culture and chest radiographs were performed routinely while lung or pleural aspirates were collected from selected, clinically stable patients with pleural effusion on radiograph and/or large, dense, peripheral consolidation. We used conventional microbiology, and from 8 April 2011 to 17 July 2012, used a multiplex PCR assay on lung and pleural aspirates. We calculated proportions with pathogens, associations between coinfecting pathogens and PCV effectiveness. PARTICIPANTS 2550 patients were admitted with clinical pneumonia; 741 with lobar pneumonia or pleural effusion. We performed 181 lung or pleural aspirates and multiplex PCR on 156 lung and 4 pleural aspirates. RESULTS Pathogens were detected in 116/160 specimens, the most common being Streptococcus pneumoniae(n=68), Staphylococcus aureus (n=26) and Haemophilus influenzae type b (n=11). Bacteria (n=97) were more common than viruses (n=49). Common viruses were bocavirus (n=11) and influenza (n=11). Coinfections were frequent (n=55). Moraxella catarrhalis was detected in eight patients and in every case there was coinfection with S. pneumoniae. The odds ratio of vaccine-type pneumococcal pneumonia in patients with two or three compared with zero doses of PCV was 0.17 (95% CI 0.06 to 0.51). CONCLUSIONS Lobar pneumonia in rural Gambia was caused primarily by bacteria, particularly S. pneumoniae and S. aureus. Coinfection was common and M. catarrhalis always coinfected with S. pneumoniae. PCV was highly efficacious against vaccine-type pneumococcal pneumonia.
Collapse
Affiliation(s)
- Grant Austin Mackenzie
- Disease Control and Elimination, Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, Gambia
- Infection and Immunity, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Jessica McLellan
- Disease Control and Elimination, Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, Gambia
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Eunice Machuka
- Disease Control and Elimination, Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, Gambia
| | - Malick Ndiaye
- Disease Control and Elimination, Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, Gambia
| | - Jayani Pathirana
- Disease Control and Elimination, Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, Gambia
| | - Augustin Fombah
- Disease Control and Elimination, Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, Gambia
| | - Baderinwa Abatan
- Disease Control and Elimination, Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, Gambia
| | - Ilias Hossain
- Disease Control and Elimination, Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, Gambia
| | - Ahmed Manjang
- Disease Control and Elimination, Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Fajara, Gambia
| | - Brian Greenwood
- Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Philip Hill
- Centre for International Health, University of Otago, Dunedin, New Zealand
| |
Collapse
|
4
|
Darboe S, Bradbury RS, Phelan J, Kanteh A, Muhammad AK, Worwui A, Yang S, Nwakanma D, Perez-Sepulveda B, Kariuki S, Kwambana-Adams B, Antonio M. Genomic diversity and antimicrobial resistance among non-typhoidal Salmonella associated with human disease in The Gambia. Microb Genom 2022; 8:000785. [PMID: 35302932 PMCID: PMC9176284 DOI: 10.1099/mgen.0.000785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 01/24/2022] [Indexed: 11/18/2022] Open
Abstract
Non-typhoidal Salmonella associated with multidrug resistance cause invasive disease in sub-Saharan Africa. Specific lineages of serovars Typhimurium and Enteritidis have been implicated. Here we characterized the genomic diversity of 100 clinical non-typhoidal Salmonella collected from 93 patients in 2001 from the eastern, and in 2006-2018 from the western regions of The Gambia respectively. A total of 93 isolates (64 invasive, 23 gastroenteritis and six other sites) representing a single infection episode were phenotypically tested for antimicrobial susceptibility using the Kirby-Bauer disc diffusion technique. Whole genome sequencing of 100 isolates was performed using Illumina, and the reads were assembled and analysed using SPAdes. The Salmonella in Silico Typing Resource (SISTR) was used for serotyping. SNP differences among the 93 isolates were determined using Roary, and phylogenetic analysis was performed in the context of 495 African strains from the European Nucleotide Archive. Salmonella serovars Typhimurium (26/64; 30.6 %) and Enteritidis (13/64; 20.3 %) were associated with invasive disease, whilst other serovars were mainly responsible for gastroenteritis (17/23; 73.9 %). The presence of three major serovar Enteritidis clades was confirmed, including the invasive West African clade, which made up more than half (11/16; 68.8 %) of the genomes. Multidrug resistance was confined among the serovar Enteritidis West African clade. The presence of this epidemic virulent clade has potential for spread of resistance and thus important implications for systematic patient management. Surveillance and epidemiological investigations to inform control are warranted.
Collapse
Affiliation(s)
- Saffiatou Darboe
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, The Gambia
| | | | - Jody Phelan
- London School of Hygiene and Tropical Medicine, London, UK
| | - Abdoulie Kanteh
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, The Gambia
| | - Abdul-Khalie Muhammad
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, The Gambia
| | - Archibald Worwui
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, The Gambia
| | - Shangxin Yang
- University of California, Los Angeles, California, USA
| | - Davis Nwakanma
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, The Gambia
| | | | | | - Brenda Kwambana-Adams
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, The Gambia
- University College London, London, UK
| | - Martin Antonio
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, The Gambia
| |
Collapse
|
5
|
Janusz CB, Frye M, Mutua MK, Wagner AL, Banerjee M, Boulton ML. Vaccine Delay and Its Association With Undervaccination in Children in Sub-Saharan Africa. Am J Prev Med 2021; 60:S53-S64. [PMID: 33189500 PMCID: PMC10601532 DOI: 10.1016/j.amepre.2020.10.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/02/2020] [Accepted: 10/02/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Improving the timeliness and completion of vaccination is the key to reducing under-5 childhood mortality. This study examines the prevalence of delayed vaccination for doses administered at birth and age 6 weeks, 10 weeks, 14 weeks, and 9 months and its association with undervaccination among infants in Sub-Saharan Africa. METHODS Pooling data across 33 Sub-Saharan Africa countries, vaccination timing and series completion were assessed for children aged 12-35 months who were included in the immunization module of the Demographic and Health Surveys conducted between 2010 and 2019. Survey design-adjusted logistic regression modeled the likelihood of not fully completing the basic immunization schedule associated with dose-specific delays in vaccination. Data were obtained and analyzed in May 2020. RESULTS Among children with complete date records (n=70,006), the proportion of children vaccinated with delays by ≥1 month was high: 25.9% for Bacille Calmette-Guerin (at birth); 49.1% for the third dose of pentavalent combination vaccine (at 14 weeks); and 63.9% for the first dose of measles vaccines (at 9 months). Late vaccination was more common for children born to mothers with lower levels of educational attainment (p<0.001) and wealth (p<0.001). Controlling for place, time, and sociodemographics, vaccination delays at any dose were significantly associated with not completing the immunization schedule by 12 months (Bacille Calmette-Guerin: AOR=1.93, [95% CI=1.83, 2.02]; pentavalent 3: AOR=1.50 [95% CI=1.35, 1.64]; measles: AOR=3.76 [95% CI=3.37, 4.15]). CONCLUSIONS Timely initiation of vaccination could contribute to higher rates of immunization schedule completion, improving the reach and impact of vaccination programs on child health outcomes in Sub-Saharan Africa. SUPPLEMENT INFORMATION This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.
Collapse
Affiliation(s)
- Cara Bess Janusz
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan; The Global Institute for Vaccine Equity, University of Michigan, Ann Arbor, Michigan.
| | - Margaret Frye
- Department of Sociology, College of Literature, Science, and the Arts, University of Michigan, Ann Arbor, Michigan
| | - Martin K Mutua
- African Population and Health Research Center, Nairobi, Kenya
| | - Abram L Wagner
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan; The Global Institute for Vaccine Equity, University of Michigan, Ann Arbor, Michigan
| | - Mousumi Banerjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan
| | - Matthew L Boulton
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan; The Global Institute for Vaccine Equity, University of Michigan, Ann Arbor, Michigan; Infectious Disease Division, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| |
Collapse
|
6
|
Slack M, Esposito S, Haas H, Mihalyi A, Nissen M, Mukherjee P, Harrington L. Haemophilus influenzae type b disease in the era of conjugate vaccines: critical factors for successful eradication. Expert Rev Vaccines 2020; 19:903-917. [PMID: 32962476 DOI: 10.1080/14760584.2020.1825948] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Prior to implementation of Haemophilus influenzae type b (Hib)-conjugate vaccination programs in the 1990s, Hib was the commonest cause of bacterial meningitis in children aged <5 years. While the burden of all Hib disease has significantly decreased in the post-vaccination era, Hib still accounted for >29,000 deaths worldwide in children aged <5 years in 2015. AREAS COVERED We reviewed literature data on the most widely used Hib vaccines and vaccination strategies which led to the global prevention and control of Hib disease and aim to highlight important factors for continued disease control and elimination in the future. EXPERT COMMENTARY More than 90% of countries worldwide have implemented Hib-conjugate vaccination in their national immunization programs. Vaccines containing Hib polyribosylribitol phosphate (PRP) conjugated with tetanus toxoid (Hib-TT) are the most commonly used. Neisseria meningitidis outer membrane protein complex of PRP (Hib-OMP) is also used. Although the kinetics of the immune response varies with Hib vaccine and schedule used, high control of Hib disease was observed in all settings/scenarios. Further improving global Hib vaccination coverage may result in disease elimination. Plain language summary What is the context? Haemophilus influenzae is causing a variety of diseases, from otitis media and sinusitis to invasive disease (e.g. meningitis and pneumonia). H. influenzae type b (Hib) was the most common cause of bacterial meningitis in children <5 years of age, and especially among <2-year-olds. Even with appropriate treatment, up to 40% of children with bacterial meningitis can suffer permanent disabilities and up to 5% will die. The development of vaccines to protect against Hib disease has started in the late 1970s and has culminated with the licensure of 4 Hib conjugate vaccines, of which 2 are currently widely used. What is new? In this review, we gathered evidence on the different Hib vaccines and vaccination strategies that have contributed to the global prevention and control of Hib disease. The review indicates: the incidence of Hib disease has decreased considerably due to the introduction of Hib vaccines in national immunization programs worldwide. However, Hib disease is not yet completely eradicated. the vaccines currently used offer protection against Hib over long periods of time. carriage of the pathogen by healthy individuals seem to be less frequent, but data are still needed to fully evaluate the impact of vaccination. other H. influenzae types are now more frequent. Why is this important? Despite the huge success of Hib vaccination, continuous surveillance is needed to anticipate potential re-emergences and devise the best strategies for prevention and control of disease. Hib vaccination should be considered in the few countries who have not yet implemented it, to decrease associated morbidity and mortality.
Collapse
Affiliation(s)
- Mary Slack
- School of Medicine, Griffith University, Gold Coast Campus , Queensland, Australia
| | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, Università Degli Studi Di Parma , Parma, Italia
| | - Hervé Haas
- Pediatric Hospital of Nice, Lenval University , France
| | | | | | | | | |
Collapse
|