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van der Drift AMR, Haver A, Kloosterman A, van der Beek RFHJ, Nagelkerke E, Eggink D, Laros JFJ, Nrs C, van Dissel JT, de Roda Husman AM, Lodder WJ. Long-term wastewater monitoring of SARS-CoV-2 viral loads and variants at the major international passenger hub Amsterdam Schiphol Airport: A valuable addition to COVID-19 surveillance. THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 937:173535. [PMID: 38802021 DOI: 10.1016/j.scitotenv.2024.173535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 05/07/2024] [Accepted: 05/24/2024] [Indexed: 05/29/2024]
Abstract
Wastewater-based epidemiological surveillance at municipal wastewater treatment plants has proven to play an important role in COVID-19 surveillance. Considering international passenger hubs contribute extensively to global transmission of viruses, wastewater surveillance at this type of location may be of added value as well. The aim of this study is to explore the potential of long-term wastewater surveillance at a large passenger hub as an additional tool for public health surveillance during different stages of a pandemic. Here, we present an analysis of SARS-CoV-2 viral loads in airport wastewater by reverse-transcription quantitative polymerase chain reaction (RT-qPCR) from the beginning of the COVID-19 pandemic in Feb 2020, and an analysis of SARS-CoV-2 variants by whole-genome next-generation sequencing from Sep 2020, both until Sep 2022, in the Netherlands. Results are contextualized using (inter)national measures and data sources such as passenger numbers, clinical surveillance data and national wastewater surveillance data. Our findings show that wastewater surveillance was possible throughout the study period, irrespective of measures, as viral loads were detected and quantified in 98.6 % (273/277) of samples. Emergence of SARS-CoV-2 variants, identified in 91.0 % (161/177) of sequenced samples, coincided with increases in viral loads. Furthermore, trends in viral load and variant detection in airport wastewater closely followed, and in some cases preceded, trends in national daily average viral load in wastewater and variants detected in clinical surveillance. Wastewater-based epidemiology at a large international airport is a valuable addition to classical COVID-19 surveillance and the developed expertise can be applied in pandemic preparedness plans for other (emerging) pathogens in the future.
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Affiliation(s)
- Anne-Merel R van der Drift
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Antonie van Leeuwenhoeklaan 9, 3721 MA Bilthoven, the Netherlands; Institute for Risk Assessment Science (IRAS), Utrecht University (UU), Yalelaan 2, 3584 CM Utrecht, the Netherlands
| | - Auke Haver
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Antonie van Leeuwenhoeklaan 9, 3721 MA Bilthoven, the Netherlands
| | - Astrid Kloosterman
- Centre for Environmental Safety and Security (M&V), National Institute for Public Health and the Environment (RIVM), Antonie van Leeuwenhoeklaan 9, 3721, MA, Bilthoven, the Netherlands
| | - Rudolf F H J van der Beek
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Antonie van Leeuwenhoeklaan 9, 3721 MA Bilthoven, the Netherlands
| | - Erwin Nagelkerke
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Antonie van Leeuwenhoeklaan 9, 3721 MA Bilthoven, the Netherlands
| | - Dirk Eggink
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Antonie van Leeuwenhoeklaan 9, 3721 MA Bilthoven, the Netherlands; Amsterdam UMC Location University of Amsterdam, Department of Medical Microbiology and Infection prevention, Laboratory of Applied Evolutionary Biology, 1105 AZ Amsterdam, the Netherlands
| | - Jeroen F J Laros
- Department of Human Genetics (HG), Leiden University Medical Center (LUMC); Einthovenweg 20, 2333 ZC Leiden, the Netherlands; Department of BioInformatics and computational services (BIR), National Institute for Public Health and the Environment (RIVM), Antonie van Leeuwenhoeklaan 9, 3721, MA, Bilthoven, the Netherlands
| | - Consortium Nrs
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Antonie van Leeuwenhoeklaan 9, 3721 MA Bilthoven, the Netherlands
| | - Jaap T van Dissel
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Antonie van Leeuwenhoeklaan 9, 3721 MA Bilthoven, the Netherlands; Department of Infectious Diseases, Leiden University Medical Center (LUMC); Albinusdreef 2, 2333, ZA, Leiden, the Netherlands
| | - Ana Maria de Roda Husman
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Antonie van Leeuwenhoeklaan 9, 3721 MA Bilthoven, the Netherlands; Institute for Risk Assessment Science (IRAS), Utrecht University (UU), Yalelaan 2, 3584 CM Utrecht, the Netherlands
| | - Willemijn J Lodder
- Centre for Infectious Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Antonie van Leeuwenhoeklaan 9, 3721 MA Bilthoven, the Netherlands.
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Champredon D, Becker D, Peterson SW, Mejia E, Hizon N, Schertzer A, Djebli M, Oloye FF, Xie Y, Asadi M, Cantin J, Pu X, Osunla CA, Brinkmann M, McPhedran KN, Servos MR, Giesy JP, Mangat C. Emergence and spread of SARS-CoV-2 variants of concern in Canada: a retrospective analysis from clinical and wastewater data. BMC Infect Dis 2024; 24:139. [PMID: 38287244 PMCID: PMC10823614 DOI: 10.1186/s12879-024-08997-8] [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: 06/14/2023] [Accepted: 01/09/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND The spread of SARS-CoV-2 has been studied at unprecedented levels worldwide. In jurisdictions where molecular analysis was performed on large scales, the emergence and competition of numerous SARS-CoV-2lineages have been observed in near real-time. Lineage identification, traditionally performed from clinical samples, can also be determined by sampling wastewater from sewersheds serving populations of interest. Variants of concern (VOCs) and SARS-CoV-2 lineages associated with increased transmissibility and/or severity are of particular interest. METHOD Here, we consider clinical and wastewater data sources to assess the emergence and spread of VOCs in Canada retrospectively. RESULTS We show that, overall, wastewater-based VOC identification provides similar insights to the surveillance based on clinical samples. Based on clinical data, we observed synchrony in VOC introduction as well as similar emergence speeds across most Canadian provinces despite the large geographical size of the country and differences in provincial public health measures. CONCLUSION In particular, it took approximately four months for VOC Alpha and Delta to contribute to half of the incidence. In contrast, VOC Omicron achieved the same contribution in less than one month. This study provides significant benchmarks to enhance planning for future VOCs, and to some extent for future pandemics caused by other pathogens, by quantifying the rate of SARS-CoV-2 VOCs invasion in Canada.
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Affiliation(s)
- David Champredon
- Public Health Agency of Canada, National Microbiology Laboratory, Public Health Risk Sciences Division, Guelph, ON, Canada.
| | - Devan Becker
- Public Health Agency of Canada, National Microbiology Laboratory, Public Health Risk Sciences Division, Guelph, ON, Canada
| | - Shelley W Peterson
- Public Health Agency of Canada, National Microbiology Laboratory, One Health Division, Winnipeg, MB, Canada
| | - Edgard Mejia
- Public Health Agency of Canada, National Microbiology Laboratory, One Health Division, Winnipeg, MB, Canada
| | - Nikho Hizon
- Public Health Agency of Canada, National Microbiology Laboratory, One Health Division, Winnipeg, MB, Canada
| | - Andrea Schertzer
- Public Health Agency of Canada, Centre for Immunization and Respiratory Infectious Diseases, Ottawa, ON, Canada
| | - Mohamed Djebli
- Public Health Agency of Canada, Centre for Immunization and Respiratory Infectious Diseases, Ottawa, ON, Canada
| | - Femi F Oloye
- Toxicology Program, University of Saskatchewan, Saskatoon, SK, Canada.
- Department of Chemistry, Division of Physical and Computational Sciences, University of Pittsburgh at Bradford, Bradford, United States.
| | - Yuwei Xie
- Toxicology Program, University of Saskatchewan, Saskatoon, SK, Canada
| | - Mohsen Asadi
- Department of Civil, Geological and Environmental Engineering, College of Engineering, University of Saskatchewan, Saskatoon, SK, Canada
| | - Jenna Cantin
- Toxicology Program, University of Saskatchewan, Saskatoon, SK, Canada
| | - Xia Pu
- Toxicology Program, University of Saskatchewan, Saskatoon, SK, Canada
| | - Charles A Osunla
- Toxicology Program, University of Saskatchewan, Saskatoon, SK, Canada
| | - Markus Brinkmann
- Toxicology Program, University of Saskatchewan, Saskatoon, SK, Canada
- School of Environment and Sustainability, University of Saskatchewan, Saskatoon, SK, Canada
| | - Kerry N McPhedran
- Department of Civil, Geological and Environmental Engineering, College of Engineering, University of Saskatchewan, Saskatoon, SK, Canada
- Global Institute for Water Security, University of Saskatchewan, Saskatoon, SK, Canada
| | - Mark R Servos
- Department of Biology, University of Waterloo, Waterloo, ON, Canada
| | - John P Giesy
- Toxicology Program, University of Saskatchewan, Saskatoon, SK, Canada.
- Department of Veterinary Biomedical Sciences, University of Saskatchewan, Saskatoon, SK, Canada.
- Department of Environmental Sciences, Baylor University, Waco, TX, USA.
- Department of Zoology and Center for Integrative Toxicology, Michigan State University, East Lansing, MI, USA.
| | - Chand Mangat
- Public Health Agency of Canada, National Microbiology Laboratory, One Health Division, Winnipeg, MB, Canada
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3
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Chen Z, Lemey P, Yu H. Approaches and challenges to inferring the geographical source of infectious disease outbreaks using genomic data. THE LANCET. MICROBE 2024; 5:e81-e92. [PMID: 38042165 DOI: 10.1016/s2666-5247(23)00296-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/03/2023] [Accepted: 09/13/2023] [Indexed: 12/04/2023]
Abstract
Genomic data hold increasing potential in the elucidation of transmission dynamics and geographical sources of infectious disease outbreaks. Phylogeographic methods that use epidemiological and genomic data obtained from surveillance enable us to infer the history of spatial transmission that is naturally embedded in the topology of phylogenetic trees as a record of the dispersal of infectious agents between geographical locations. In this Review, we provide an overview of phylogeographic approaches widely used for reconstructing the geographical sources of outbreaks of interest. These approaches can be classified into ancestral trait or state reconstruction and structured population models, with structured population models including popular structured coalescent and birth-death models. We also describe the major challenges associated with sequencing technologies, surveillance strategies, data sharing, and analysis frameworks that became apparent during the generation of large-scale genomic data in recent years, extending beyond inference approaches. Finally, we highlight the role of genomic data in geographical source inference and clarify how this enhances understanding and molecular investigations of outbreak sources.
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Affiliation(s)
- Zhiyuan Chen
- School of Public Health, Fudan University, Key Laboratory of Public Health Safety, Ministry of Education, Shanghai, China
| | - Philippe Lemey
- Department of Microbiology, Immunology and Transplantation, Rega Institute, Laboratory of Clinical and Evolutionary Virology, KU Leuven, Leuven, Belgium
| | - Hongjie Yu
- School of Public Health, Fudan University, Key Laboratory of Public Health Safety, Ministry of Education, Shanghai, China.
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4
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Geubbels ELPE, Backer JA, Bakhshi-Raiez F, van der Beek RFHJ, van Benthem BHB, van den Boogaard J, Broekman EH, Dongelmans DA, Eggink D, van Gaalen RD, van Gageldonk A, Hahné S, Hajji K, Hofhuis A, van Hoek AJ, Kooijman MN, Kroneman A, Lodder W, van Rooijen M, Roorda W, Smorenburg N, Zwagemaker F, de Keizer NF, van Walle I, de Roda Husman AM, Ruijs C, van den Hof S. The daily updated Dutch national database on COVID-19 epidemiology, vaccination and sewage surveillance. Sci Data 2023; 10:469. [PMID: 37474530 PMCID: PMC10359398 DOI: 10.1038/s41597-023-02232-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 05/12/2023] [Indexed: 07/22/2023] Open
Abstract
The Dutch national open database on COVID-19 has been incrementally expanded since its start on 30 April 2020 and now includes datasets on symptoms, tests performed, individual-level positive cases and deaths, cases and deaths among vulnerable populations, settings of transmission, hospital and ICU admissions, SARS-CoV-2 variants, viral loads in sewage, vaccinations and the effective reproduction number. This data is collected by municipal health services, laboratories, hospitals, sewage treatment plants, vaccination providers and citizens and is cleaned, analysed and published, mostly daily, by the National Institute for Public Health and the Environment (RIVM) in the Netherlands, using automated scripts. Because these datasets cover the key aspects of the pandemic and are available at detailed geographical level, they are essential to gain a thorough understanding of the past and current COVID-19 epidemiology in the Netherlands. Future purposes of these datasets include country-level comparative analysis on the effect of non-pharmaceutical interventions against COVID-19 in different contexts, such as different cultural values or levels of socio-economic disparity, and studies on COVID-19 and weather factors.
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Affiliation(s)
- E L P E Geubbels
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands.
| | - J A Backer
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - F Bakhshi-Raiez
- National Intensive Care Evaluation (NICE) foundation, Amsterdam, the Netherlands
| | - R F H J van der Beek
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - B H B van Benthem
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - J van den Boogaard
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
- The network of regional epidemiological consultants (REC), Bilthoven, the Netherlands
| | | | - D A Dongelmans
- National Intensive Care Evaluation (NICE) foundation, Amsterdam, the Netherlands
- Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - D Eggink
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - R D van Gaalen
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - A van Gageldonk
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - S Hahné
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - K Hajji
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - A Hofhuis
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - A J van Hoek
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - M N Kooijman
- Centre of Information Services and CIO office, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - A Kroneman
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - W Lodder
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - M van Rooijen
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - W Roorda
- GGD GHOR Nederland, Utrecht, the Netherlands
| | - N Smorenburg
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - F Zwagemaker
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - N F de Keizer
- National Intensive Care Evaluation (NICE) foundation, Amsterdam, the Netherlands
- Department of Medical Informatics, Amsterdam UMC, Amsterdam Public Health research institute, University of Amsterdam, Amsterdam, the Netherlands
| | - I van Walle
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - A M de Roda Husman
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - C Ruijs
- GGD GHOR Nederland, Utrecht, the Netherlands
| | - S van den Hof
- Centre for Infectious Diseases Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands.
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5
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Tegally H, Wilkinson E, Tsui JLH, Moir M, Martin D, Brito AF, Giovanetti M, Khan K, Huber C, Bogoch II, San JE, Poongavanan J, Xavier JS, Candido DDS, Romero F, Baxter C, Pybus OG, Lessells RJ, Faria NR, Kraemer MUG, de Oliveira T. Dispersal patterns and influence of air travel during the global expansion of SARS-CoV-2 variants of concern. Cell 2023; 186:3277-3290.e16. [PMID: 37413988 PMCID: PMC10247138 DOI: 10.1016/j.cell.2023.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 05/31/2023] [Accepted: 06/02/2023] [Indexed: 07/08/2023]
Abstract
The Alpha, Beta, and Gamma SARS-CoV-2 variants of concern (VOCs) co-circulated globally during 2020 and 2021, fueling waves of infections. They were displaced by Delta during a third wave worldwide in 2021, which, in turn, was displaced by Omicron in late 2021. In this study, we use phylogenetic and phylogeographic methods to reconstruct the dispersal patterns of VOCs worldwide. We find that source-sink dynamics varied substantially by VOC and identify countries that acted as global and regional hubs of dissemination. We demonstrate the declining role of presumed origin countries of VOCs in their global dispersal, estimating that India contributed <15% of Delta exports and South Africa <1%-2% of Omicron dispersal. We estimate that >80 countries had received introductions of Omicron within 100 days of its emergence, associated with accelerated passenger air travel and higher transmissibility. Our study highlights the rapid dispersal of highly transmissible variants, with implications for genomic surveillance along the hierarchical airline network.
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Affiliation(s)
- Houriiyah Tegally
- Centre for Epidemic Response and Innovation (CERI), School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa; KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
| | - Eduan Wilkinson
- Centre for Epidemic Response and Innovation (CERI), School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
| | | | - Monika Moir
- Centre for Epidemic Response and Innovation (CERI), School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
| | - Darren Martin
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Cape Town, South Africa; Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Marta Giovanetti
- Laboratorio de Flavivirus, Fundacao Oswaldo Cruz, Rio de Janeiro, Brazil; Laboratório de Genética Celular e Molecular, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; Department of Science and Technology for Humans and the Environment, University of Campus Bio-Medico di Roma, Rome, Italy
| | - Kamran Khan
- BlueDot, Toronto, ON, Canada; Department of Medicine, Division of Infectious Diseases, University of Toronto, Toronto, ON, Canada
| | | | - Isaac I Bogoch
- Department of Medicine, Division of Infectious Diseases, University of Toronto, Toronto, ON, Canada
| | - James Emmanuel San
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Jenicca Poongavanan
- Centre for Epidemic Response and Innovation (CERI), School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
| | - Joicymara S Xavier
- Centre for Epidemic Response and Innovation (CERI), School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa; Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; Institute of Agricultural Sciences, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Unaí, Brazil
| | - Darlan da S Candido
- MRC Centre for Global Infectious Disease Analysis and Department of Infectious Disease Epidemiology, Jameel Institute, School of Public Health, Imperial College London, London, UK
| | - Filipe Romero
- MRC Centre for Global Infectious Disease Analysis and Department of Infectious Disease Epidemiology, Jameel Institute, School of Public Health, Imperial College London, London, UK
| | - Cheryl Baxter
- Centre for Epidemic Response and Innovation (CERI), School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
| | - Oliver G Pybus
- Department of Biology, University of Oxford, Oxford, UK; Pandemic Sciences Institute, University of Oxford, Oxford, UK; Department of Pathobiology and Population Sciences, Royal Veterinary College London, London, UK
| | - Richard J Lessells
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Nuno R Faria
- Department of Biology, University of Oxford, Oxford, UK; MRC Centre for Global Infectious Disease Analysis and Department of Infectious Disease Epidemiology, Jameel Institute, School of Public Health, Imperial College London, London, UK; Departamento de Moléstias Infecciosas e Parasitárias e Instituto de Medicina Tropical da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Moritz U G Kraemer
- Department of Biology, University of Oxford, Oxford, UK; Pandemic Sciences Institute, University of Oxford, Oxford, UK.
| | - Tulio de Oliveira
- Centre for Epidemic Response and Innovation (CERI), School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa; KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Department of Global Health, University of Washington, Seattle, WA, USA.
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6
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Martínez-Martínez FJ, Massinga AJ, De Jesus Á, Ernesto RM, Cano-Jiménez P, Chiner-Oms Á, Gómez-Navarro I, Guillot-Fernández M, Guinovart C, Sitoe A, Vubil D, Bila R, Gujamo R, Enosse S, Jiménez-Serrano S, Torres-Puente M, Comas I, Mandomando I, López MG, Mayor A. Tracking SARS-CoV-2 introductions in Mozambique using pandemic-scale phylogenies: a retrospective observational study. Lancet Glob Health 2023; 11:e933-e941. [PMID: 37202028 DOI: 10.1016/s2214-109x(23)00169-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 03/09/2023] [Accepted: 03/23/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND From the start of the SARS-CoV-2 outbreak, global sequencing efforts have generated an unprecedented amount of genomic data. Nonetheless, unequal sampling between high-income and low-income countries hinders the implementation of genomic surveillance systems at the global and local level. Filling the knowledge gaps of genomic information and understanding pandemic dynamics in low-income countries is essential for public health decision making and to prepare for future pandemics. In this context, we aimed to discover the timing and origin of SARS-CoV-2 variant introductions in Mozambique, taking advantage of pandemic-scale phylogenies. METHODS We did a retrospective, observational study in southern Mozambique. Patients from Manhiça presenting with respiratory symptoms were recruited, and those enrolled in clinical trials were excluded. Data were included from three sources: (1) a prospective hospital-based surveillance study (MozCOVID), recruiting patients living in Manhiça, attending the Manhiça district hospital, and fulfilling the criteria of suspected COVID-19 case according to WHO; (2) symptomatic and asymptomatic individuals with SARS-CoV-2 infection recruited by the National Surveillance system; and (3) sequences from SARS-CoV-2-infected Mozambican cases deposited on the Global Initiative on Sharing Avian Influenza Data database. Positive samples amenable for sequencing were analysed. We used Ultrafast Sample placement on Existing tRees to understand the dynamics of beta and delta waves, using available genomic data. This tool can reconstruct a phylogeny with millions of sequences by efficient sample placement in a tree. We reconstructed a phylogeny (~7·6 million sequences) adding new and publicly available beta and delta sequences. FINDINGS A total of 5793 patients were recruited between Nov 1, 2020, and Aug 31, 2021. During this time, 133 328 COVID-19 cases were reported in Mozambique. 280 good quality new SARS-CoV-2 sequences were obtained after the inclusion criteria were applied and an additional 652 beta (B.1.351) and delta (B.1.617.2) public sequences were included from Mozambique. We evaluated 373 beta and 559 delta sequences. We identified 187 beta introductions (including 295 sequences), divided in 42 transmission groups and 145 unique introductions, mostly from South Africa, between August, 2020 and July, 2021. For delta, we identified 220 introductions (including 494 sequences), with 49 transmission groups and 171 unique introductions, mostly from the UK, India, and South Africa, between April and November, 2021. INTERPRETATION The timing and origin of introductions suggests that movement restrictions effectively avoided introductions from non-African countries, but not from surrounding countries. Our results raise questions about the imbalance between the consequences of restrictions and health benefits. This new understanding of pandemic dynamics in Mozambique can be used to inform public health interventions to control the spread of new variants. FUNDING European and Developing Countries Clinical Trials, European Research Council, Bill & Melinda Gates Foundation, and Agència de Gestió d'Ajuts Universitaris i de Recerca.
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Affiliation(s)
- Francisco José Martínez-Martínez
- Tuberculosis Genomics Unit, Instituto de Biomedicina de Valencia, Consejo Superior de Investigaciones Científicas, Valencia, Spain
| | | | - Áuria De Jesus
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Rita M Ernesto
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Pablo Cano-Jiménez
- Tuberculosis Genomics Unit, Instituto de Biomedicina de Valencia, Consejo Superior de Investigaciones Científicas, Valencia, Spain
| | - Álvaro Chiner-Oms
- Tuberculosis Genomics Unit, Instituto de Biomedicina de Valencia, Consejo Superior de Investigaciones Científicas, Valencia, Spain
| | - Inmaculada Gómez-Navarro
- Tuberculosis Genomics Unit, Instituto de Biomedicina de Valencia, Consejo Superior de Investigaciones Científicas, Valencia, Spain
| | - Marina Guillot-Fernández
- Tuberculosis Genomics Unit, Instituto de Biomedicina de Valencia, Consejo Superior de Investigaciones Científicas, Valencia, Spain
| | | | - António Sitoe
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Delfino Vubil
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Rubão Bila
- Hospital Distrital da Manhiça, Marracuene, Mozambique
| | | | - Sónia Enosse
- Instituto Nacional de Saúde, Marracuene, Mozambique
| | - Santiago Jiménez-Serrano
- Tuberculosis Genomics Unit, Instituto de Biomedicina de Valencia, Consejo Superior de Investigaciones Científicas, Valencia, Spain
| | - Manuela Torres-Puente
- Tuberculosis Genomics Unit, Instituto de Biomedicina de Valencia, Consejo Superior de Investigaciones Científicas, Valencia, Spain
| | - Iñaki Comas
- Tuberculosis Genomics Unit, Instituto de Biomedicina de Valencia, Consejo Superior de Investigaciones Científicas, Valencia, Spain; Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Inácio Mandomando
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique; Instituto Nacional de Saúde, Marracuene, Mozambique
| | - Mariana G López
- Tuberculosis Genomics Unit, Instituto de Biomedicina de Valencia, Consejo Superior de Investigaciones Científicas, Valencia, Spain.
| | - Alfredo Mayor
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique; ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Department of Physiologic Sciences, Faculty of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique
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7
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Han AX, Toporowski A, Sacks JA, Perkins MD, Briand S, van Kerkhove M, Hannay E, Carmona S, Rodriguez B, Parker E, Nichols BE, Russell CA. SARS-CoV-2 diagnostic testing rates determine the sensitivity of genomic surveillance programs. Nat Genet 2023; 55:26-33. [PMID: 36624344 PMCID: PMC9839449 DOI: 10.1038/s41588-022-01267-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 11/11/2022] [Indexed: 01/11/2023]
Abstract
The first step in SARS-CoV-2 genomic surveillance is testing to identify people who are infected. However, global testing rates are falling as we emerge from the acute health emergency and remain low in many low- and middle-income countries (mean = 27 tests per 100,000 people per day). We simulated COVID-19 epidemics in a prototypical low- and middle-income country to investigate how testing rates, sampling strategies and sequencing proportions jointly impact surveillance outcomes, and showed that low testing rates and spatiotemporal biases delay time to detection of new variants by weeks to months and can lead to unreliable estimates of variant prevalence, even when the proportion of samples sequenced is increased. Accordingly, investments in wider access to diagnostics to support testing rates of approximately 100 tests per 100,000 people per day could enable more timely detection of new variants and reliable estimates of variant prevalence. The performance of global SARS-CoV-2 genomic surveillance programs is fundamentally limited by access to diagnostic testing.
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Affiliation(s)
- Alvin X Han
- Department of Medical Microbiology and Infection Prevention, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
| | - Amy Toporowski
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Jilian A Sacks
- Department of Epidemic and Pandemic Preparedness and Prevention, Emergency Preparedness Programme, World Health Organization, Geneva, Switzerland
| | - Mark D Perkins
- Department of Epidemic and Pandemic Preparedness and Prevention, Emergency Preparedness Programme, World Health Organization, Geneva, Switzerland
| | - Sylvie Briand
- Department of Epidemic and Pandemic Preparedness and Prevention, Emergency Preparedness Programme, World Health Organization, Geneva, Switzerland
| | - Maria van Kerkhove
- Department of Epidemic and Pandemic Preparedness and Prevention, Emergency Preparedness Programme, World Health Organization, Geneva, Switzerland
| | - Emma Hannay
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Sergio Carmona
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Bill Rodriguez
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Edyth Parker
- Department of Immunology and Microbiology, The Scripps Research Institute, La Jolla, CA, USA
| | - Brooke E Nichols
- Department of Medical Microbiology and Infection Prevention, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA
| | - Colin A Russell
- Department of Medical Microbiology and Infection Prevention, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA.
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8
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Tegally H, Wilkinson E, Martin D, Moir M, Brito A, Giovanetti M, Khan K, Huber C, Bogoch II, San JE, Tsui JLH, Poongavanan J, Xavier JS, Candido DDS, Romero F, Baxter C, Pybus OG, Lessells R, Faria NR, Kraemer MUG, de Oliveira T. Global Expansion of SARS-CoV-2 Variants of Concern: Dispersal Patterns and Influence of Air Travel. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2022:2022.11.22.22282629. [PMID: 36451885 PMCID: PMC9709793 DOI: 10.1101/2022.11.22.22282629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
In many regions of the world, the Alpha, Beta and Gamma SARS-CoV-2 Variants of Concern (VOCs) co-circulated during 2020-21 and fueled waves of infections. During 2021, these variants were almost completely displaced by the Delta variant, causing a third wave of infections worldwide. This phenomenon of global viral lineage displacement was observed again in late 2021, when the Omicron variant disseminated globally. In this study, we use phylogenetic and phylogeographic methods to reconstruct the dispersal patterns of SARS-CoV-2 VOCs worldwide. We find that the source-sink dynamics of SARS-CoV-2 varied substantially by VOC, and identify countries that acted as global hubs of variant dissemination, while other countries became regional contributors to the export of specific variants. We demonstrate a declining role of presumed origin countries of VOCs to their global dispersal: we estimate that India contributed <15% of all global exports of Delta to other countries and South Africa <1-2% of all global Omicron exports globally. We further estimate that >80 countries had received introductions of Omicron BA.1 100 days after its inferred date of emergence, compared to just over 25 countries for the Alpha variant. This increased speed of global dissemination was associated with a rebound in air travel volume prior to Omicron emergence in addition to the higher transmissibility of Omicron relative to Alpha. Our study highlights the importance of global and regional hubs in VOC dispersal, and the speed at which highly transmissible variants disseminate through these hubs, even before their detection and characterization through genomic surveillance. Highlights Global phylogenetic analysis reveals relationship between air travel and speed of dispersal of SARS-CoV-2 variants of concern (VOCs)Omicron VOC spread to 5x more countries within 100 days of its emergence compared to all other VOCsOnward transmission and dissemination of VOCs Delta and Omicron was primarily from secondary hubs rather than initial country of detection during a time of increased global air travelAnalysis highlights highly connected countries identified as major global and regional exporters of VOCs.
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Affiliation(s)
- Houriiyah Tegally
- Centre for Epidemic Response and Innovation (CERI), School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Eduan Wilkinson
- Centre for Epidemic Response and Innovation (CERI), School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
| | - Darren Martin
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Monika Moir
- Centre for Epidemic Response and Innovation (CERI), School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
| | - Anderson Brito
- Instituto Todos pela Saúde, São Paulo, São Paulo, Brazil
| | - Marta Giovanetti
- Laboratorio de Flavivirus, Fundacao Oswaldo Cruz, Rio de Janeiro, Brazil
- Laboratório de Genética Celular e Molecular, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Department of Science and Technology for Humans and the Environment, University of Campus Bio-Medico di Roma, Rome, Italy
| | - Kamran Khan
- BlueDot, Toronto, Canada
- Department of Medicine, Division of Infectious Diseases, University of Toronto, Toronto, Canada
| | | | - Isaac I Bogoch
- Department of Medicine, Division of Infectious Diseases, University of Toronto, Toronto, Canada
| | - James Emmanuel San
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | | | - Jenicca Poongavanan
- Centre for Epidemic Response and Innovation (CERI), School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
| | - Joicymara S Xavier
- Centre for Epidemic Response and Innovation (CERI), School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
- Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Institute of Agricultural Sciences, Universidade Federal dos Vales do Jequitinhonha e Mucuri, Unaí, Brazil
| | - Darlan da S Candido
- MRC Centre for Global Infectious Disease Analysis and Department of Infectious Disease Epidemiology, Jameel Institute, School of Public Health, Imperial College London, London, UK
| | - Filipe Romero
- MRC Centre for Global Infectious Disease Analysis and Department of Infectious Disease Epidemiology, Jameel Institute, School of Public Health, Imperial College London, London, UK
| | - Cheryl Baxter
- Centre for Epidemic Response and Innovation (CERI), School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
| | - Oliver G Pybus
- Department of Biology, University of Oxford, Oxford, UK
- Pandemic Sciences Institute, University of Oxford, Oxford, UK
- Department of Pathobiology and Population Sciences, Royal Veterinary College London, London, UK
| | - Richard Lessells
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Nuno R Faria
- MRC Centre for Global Infectious Disease Analysis and Department of Infectious Disease Epidemiology, Jameel Institute, School of Public Health, Imperial College London, London, UK
- Departamento de Moléstias Infecciosas e Parasitárias e Instituto de Medicina Tropical da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Department of Biology, University of Oxford, Oxford, UK
| | - Moritz U G Kraemer
- Department of Biology, University of Oxford, Oxford, UK
- Pandemic Sciences Institute, University of Oxford, Oxford, UK
| | - Tulio de Oliveira
- Centre for Epidemic Response and Innovation (CERI), School of Data Science and Computational Thinking, Stellenbosch University, Stellenbosch, South Africa
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Global Health, University of Washington, Seattle, WA, USA
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9
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Lai A, Bergna A, Della Ventura C, Menzo S, Bruzzone B, Sagradi F, Ceccherini-Silberstein F, Weisz A, Clementi N, Brindicci G, Vicenti I, Sasset L, Caucci S, Corvaro B, Ippoliti S, Acciarri C, De Pace V, Lanfranchi L, Bellocchi MC, Giurato G, Ferrarese R, Lagioia A, Francisci D, Colombo ML, Lazzarin S, Ogliastro M, Cappelletti MR, Iannetta M, Rizzo F, Torti C, Fumi M, d’Avenia M, Brusa S, Greco F, Menchise A, Letizia V, Vaccaro E, Santoro CR, Fraccalvieri C, Testa S, Carioti L, Rocco T, Saracino A, Cattelan A, Clementi M, Sarmati L, Riva A, Galli M, Antinori S, Zehender G. Epidemiological and Clinical Features of SARS-CoV-2 Variants Circulating between April-December 2021 in Italy. Viruses 2022; 14:v14112508. [PMID: 36423117 PMCID: PMC9699621 DOI: 10.3390/v14112508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/03/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022] Open
Abstract
SARS-CoV-2 is constantly evolving, leading to new variants. We analysed data from 4400 SARS-CoV-2-positive samples in order to pursue epidemiological variant surveillance and to evaluate their impact on public health in Italy in the period of April-December 2021. The main circulating strain (76.2%) was the Delta variant, followed by the Alpha (13.3%), the Omicron (5.3%), and the Gamma variants (2.9%). The B.1.1 lineages, Eta, Beta, Iota, Mu, and Kappa variants, represented around 1% of cases. There were 48.2% of subjects who had not been vaccinated, and they had a lower median age compared to the vaccinated subjects (47 vs. 61 years). An increasing number of infections in the vaccinated subjects were observed over time, with the highest proportion in November (85.2%). The variants correlated with clinical status; the largest proportion of symptomatic patients (59.6%) was observed with the Delta variant, while subjects harbouring the Gamma variant showed the highest proportion of asymptomatic infection (21.6%), albeit also deaths (5.4%). The Omicron variant was only found in the vaccinated subjects, of which 47% had been hospitalised. The diffusivity and pathogenicity associated with the different SARS-CoV-2 variants are likely to have relevant public health implications, both at the national and international levels. Our study provides data on the rapid changes in the epidemiological landscape of the SARS-CoV-2 variants in Italy.
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Affiliation(s)
- Alessia Lai
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20174 Milan, Italy
- Correspondence: ; Tel.: +39-0250319775
| | - Annalisa Bergna
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20174 Milan, Italy
| | - Carla Della Ventura
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20174 Milan, Italy
| | - Stefano Menzo
- Virology Unit, Department of Biomedical Sciences and Public Health, Polytechnic University of Marche, 60131 Ancona, Italy
| | | | - Fabio Sagradi
- Unit of Infectious Diseases, Azienda Socio Sanitaria Territoriale Cremona, 26100 Cremona, Italy
| | | | - Alessandro Weisz
- Laboratory of Molecular Medicine and Genomics, Department of Medicine, Surgery and Dentistry ‘Scuola Medica Salernitana’, University of Salerno, 84084 Salerno, Italy
| | - Nicola Clementi
- Laboratory of Microbiology and Virology, Università “Vita-Salute” San Raffaele, 20158 Milan, Italy
| | | | - Ilaria Vicenti
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy
| | - Lolita Sasset
- Infectious Diseases Unit, Azienda Ospedale Università di Padova, 35128 Padova, Italy
| | - Sara Caucci
- Virology Unit, Department of Biomedical Sciences and Public Health, Polytechnic University of Marche, 60131 Ancona, Italy
| | - Benedetta Corvaro
- Virology Unit, Department of Biomedical Sciences and Public Health, Polytechnic University of Marche, 60131 Ancona, Italy
| | - Silvia Ippoliti
- Virology Unit, Department of Biomedical Sciences and Public Health, Polytechnic University of Marche, 60131 Ancona, Italy
| | - Carla Acciarri
- Virology Unit, Department of Biomedical Sciences and Public Health, Polytechnic University of Marche, 60131 Ancona, Italy
| | | | - Leonardo Lanfranchi
- Unit of Infectious Diseases, Azienda Socio Sanitaria Territoriale Cremona, 26100 Cremona, Italy
| | - Maria C. Bellocchi
- Department of Experimental Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Giorgio Giurato
- Laboratory of Molecular Medicine and Genomics, Department of Medicine, Surgery and Dentistry ‘Scuola Medica Salernitana’, University of Salerno, 84084 Salerno, Italy
| | - Roberto Ferrarese
- Laboratory of Microbiology and Virology, Università “Vita-Salute” San Raffaele, 20158 Milan, Italy
| | | | - Daniela Francisci
- Department of Medicine and Surgery, Clinic of Infectious Diseases, Santa Maria della Misericordia Hospital, University of Perugia, 06123 Perugia, Italy
| | - Martina L. Colombo
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20174 Milan, Italy
| | - Samuel Lazzarin
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20174 Milan, Italy
| | - Matilde Ogliastro
- Department of Health Sciences (DISSAL), University of Genoa, 16126 Genoa, Italy
| | - Maria R. Cappelletti
- Unit of Infectious Diseases, Azienda Socio Sanitaria Territoriale Cremona, 26100 Cremona, Italy
| | - Marco Iannetta
- Infectious Disease Unit, Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Francesca Rizzo
- Laboratory of Molecular Medicine and Genomics, Department of Medicine, Surgery and Dentistry ‘Scuola Medica Salernitana’, University of Salerno, 84084 Salerno, Italy
| | - Carlo Torti
- Infectious and Tropical Disease Unit, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy
| | - Maurizio Fumi
- UOC Patologia Clinica, AO San Pio Benevento, 82100 Benevento, Italy
| | - Morena d’Avenia
- UOSVD di Citopatologia e Screening, Department of Laboratory Medicines, 70131 Bari, Italy
| | - Stefano Brusa
- Department of Translational Medical Sciences, Università Federico II, 80138 Naples, Italy
| | - Francesca Greco
- UOC Microbiologia e Virologia, PO Cosenza, 87100 Cosenza, Italy
| | - Angela Menchise
- Microbiology and Virology Laboratory, A.O.R. San Carlo Potenza, 85100 Potenza, Italy
| | - Vittoria Letizia
- UOSD Genetics and Molecular Biology, AORN Sant’Anna e San Sebastiano di Caserta, 81100 Caserta, Italy
| | - Emilia Vaccaro
- Molecular Biology Units, AOU ‘S. Giovanni di Dio e Ruggi d’Aragona’ Università di Salerno, 84131 Salerno, Italy
| | | | | | - Sophie Testa
- Unit of Infectious Diseases, Azienda Socio Sanitaria Territoriale Cremona, 26100 Cremona, Italy
| | - Luca Carioti
- Department of Experimental Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Teresa Rocco
- Laboratory of Molecular Medicine and Genomics, Department of Medicine, Surgery and Dentistry ‘Scuola Medica Salernitana’, University of Salerno, 84084 Salerno, Italy
| | | | - Annamaria Cattelan
- Infectious Diseases Unit, Azienda Ospedale Università di Padova, 35128 Padova, Italy
| | - Massimo Clementi
- Laboratory of Microbiology and Virology, Università “Vita-Salute” San Raffaele, 20158 Milan, Italy
| | - Loredana Sarmati
- Infectious Disease Unit, Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Agostino Riva
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20174 Milan, Italy
| | - Massimo Galli
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20174 Milan, Italy
| | - Spinello Antinori
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20174 Milan, Italy
| | - Gianguglielmo Zehender
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, 20174 Milan, Italy
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