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Gibbs LC, Oviedo JM, Ondigo BN, Fairfax KC. Maternal infection causes dysfunctional BCR signaling in male offspring due to aberrant Xist expression. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.02.13.528357. [PMID: 36824836 PMCID: PMC9948949 DOI: 10.1101/2023.02.13.528357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Infections during pregnancy with pathogens such as helminths correlate with altered immune responses to common childhood immunizations. However, the molecular mechanisms that underlie this remain unknown. Using our murine model of maternal schistosomiasis, when immunized, males from infected mothers had a lower frequency of antigen-specific germinal center B cells and downregulation of transcripts downstream of BCR signaling compared to males from uninfected mothers. This is driven by a reduction in developing B cell populations within the bone marrow of pups from infected mothers. Males from infected mothers were impacted to a greater extent than their female littermate counterparts. We found this defect to be caused by aberrant expression of the long non-coding RNA Xist in males leading to dysregulated Igα expression on developing B cells. This, for the first time, links dysfunctional BCR signaling with Xist expression, while also proposing a detrimental function for Xist expression in males.
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Affiliation(s)
- Lisa C. Gibbs
- Department of Pathology, University of Utah; Salt Lake City, UT, United States
| | - Juan M. Oviedo
- Department of Pathology, University of Utah; Salt Lake City, UT, United States
| | | | - Keke C. Fairfax
- Department of Pathology, University of Utah; Salt Lake City, UT, United States
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Cando LFT, Perias GAS, Tantengco OAG, Dispo MD, Ceriales JA, Girasol MJG, Leonardo LR, Tabios IKB. The Global Prevalence of Schistosoma mansoni, S. japonicum, and S. haematobium in Pregnant Women: A Systematic Review and Meta-Analysis. Trop Med Infect Dis 2022; 7:354. [PMID: 36355896 PMCID: PMC9693339 DOI: 10.3390/tropicalmed7110354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/01/2022] [Accepted: 11/01/2022] [Indexed: 10/10/2023] Open
Abstract
Schistosomiasis is a neglected tropical disease affecting 40 million women of childbearing age worldwide. Its global disease prevalence among pregnant women is still unknown. This meta-analysis determined the pooled prevalence of schistosomiasis among pregnant women globally. Additionally, this study also determined the pooled prevalence based on infection intensity based on eggs per gram. Observational studies on the prevalence of schistosomiasis among pregnant patients were obtained from Medline, Scopus, and CINAHL from January 2001 until August 2020. A review of titles and abstracts was done independently by six reviewers. The quality of the included studies was assessed using the Newcastle-Ottawa Scale for case-control, cohort, and cross-sectional studies. A total of 27 studies were included in the meta-analysis and meta-regression. The pooled prevalence of S. haematobium was 13.44 (CI: 8.90-19.80) per 100 observations, while the pooled prevalence of S. mansoni was 12.18 (CI: 4.47-29.12) per 100 observations. The prevalence of S. japonicum infection in one study was 53.54 (CI: 43.23-63.62) per 100 observations. Our results showed a prevailing health problem of schistosomiasis during pregnancy in various countries worldwide. This strengthens the need to conduct more schistosomiasis research, prevention, and control programs in pregnant women.
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Affiliation(s)
- Leslie Faye T. Cando
- College of Medicine, University of the Philippines Manila, Manila 1000, Philippines
| | | | | | - Micah D. Dispo
- Department of Epidemiology and Biostatistics, College of Public Health, University of the Philippines Manila, Manila 1000, Philippines
| | - Jeremy A. Ceriales
- College of Medicine, University of the Philippines Manila, Manila 1000, Philippines
| | - Mark John G. Girasol
- College of Medicine, University of the Philippines Manila, Manila 1000, Philippines
| | - Lydia R. Leonardo
- Office of Research Coordination, University of the East, Manila 1008, Philippines
- Institute of Biology, College of Science, University of the Philippines Diliman, Manila 1101, Philippines
| | - Ian Kim B. Tabios
- Institute of Biology, College of Science, University of the Philippines Diliman, Manila 1101, Philippines
- Institute of Human Genetics, National Institutes of Health, University of the Philippines Manila, Manila 1000, Philippines
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A descriptive qualitative case study of the experiences, perceptions and attitudes of pregnant women on Unguja island, Zanzibar, towards antischistosomal treatment. Acta Trop 2022; 225:106143. [PMID: 34562430 PMCID: PMC8646856 DOI: 10.1016/j.actatropica.2021.106143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 08/17/2021] [Accepted: 09/12/2021] [Indexed: 11/23/2022]
Abstract
Women were enthusiastic about keeping healthy during pregnancy. Women strongly valued high quality antenatal care and were encouraged to attend clinics by their families and community members. Women demonstrated poor retention of knowledge about schistosomiasis from school. The majority of women interviewed had missed mass drug administration rounds of praziquantel due to pregnancy or concerns about side effects. Women were unanimously agreeable to taking praziquantel during pregnancy if advised to do so by a healthcare professional.
Many countries exclude pregnant and lactating women from mass drug administration (MDA) programmes with praziquantel against schistosomiasis due to historic safety concerns over drug use during gestation and breast feeding. More than 10 years of empirical evidence from the field and a growing body of dedicated research has prompted the World Health Organisation and schistosomiasis control initiatives to advocate the inclusion of this vulnerable group into MDA. This qualitative descriptive case study explored, over a five-week period, the subjective experiences, perceptions, opinions, and attitudes of pregnant women attending government supported clinics on Unguja island, United Republic of Tanzania, towards praziquantel use during pregnancy in MDA programmes. The aim of the study was to identify and determine how to overcome potential barriers to effective use of MDA medications during pregnancy. Additionally, it was to determine trusted communication channels for future messaging and discover behavioural and community opportunities to increase participation of pregnant women in future MDA efforts. A 60 min, semi-structured qualitative interview was undertaken with 25 pregnant women recruited from 4 health centres on Unguja along with testing for Schistosoma haematobium infection. Using a modified-grounded theory approach, narrative data were transcribed, coded and analysed using a thematic analysis of the emergent themes. Women reported that they rely on traditional home remedies to stay healthy during pregnancy. Influenced by their mothers, husbands and neighbours, women predominately made medication choices during pregnancy and breastfeeding based on what they heard at home. Most women had been excluded from government MDA programmes in the past due to pregnancy. Women valued healthcare services for antenatal education and pregnancy advice. Women reported they would trust and follow direction from healthcare providers about taking praziquantel during pregnancy. Antenatal clinics offer an excellent opportunity to educate and expand praziquantel treatment to this cohort. Efforts should be augmented with training for providers and behavioural education for the community as a whole and family members of pregnant women.
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Adam I, ALhabardi NA, Al-Wutayd O, Khamis AH. Prevalence of schistosomiasis and its association with anemia among pregnant women: a systematic review and meta-analysis. Parasit Vectors 2021; 14:133. [PMID: 33653391 PMCID: PMC7923606 DOI: 10.1186/s13071-021-04642-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 02/16/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Schistosomiasis is a highly prevalent parasitic disease that can lead to adverse maternal and perinatal outcomes. To our knowledge, there has been no systematic review and meta-analysis of schistosomiasis during pregnancy. METHODS We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Relevant published studies were searched in international databases (PubMed, Science Direct, Scopus, Web of Science, and Google Scholar), from their inception until May 31, 2020. The retrieved studies were assessed for quality using the Modified Newcastle-Ottawa Scale. OpenMeta Analyst software was used for the statistical analysis. RESULTS Thirty-two studies enrolling 21024 pregnant women were included in this meta-analysis. All 32 of these studies were conducted in Africa. Of these studies, 19, 11, and 2 investigated S. mansoni, S. haematobium, and combined S. mansoni and S. haematobium infections, respectively. The pooled prevalence estimate of schistosomiasis during pregnancy was 13.2% (95 CI 11.0-15.4). A random model was used because of high heterogeneity (Q = 99.14; P < 0.001). In subgroup analyses, the pooled prevalence estimate of S. haematobium was significantly higher than the pooled prevalence estimates of S. mansoni [22.5% (95% CI 1.6-43.5) vs 8.7% (95% CI 6.0-11.3, P = 0.016), respectively]. The results of meta-regression analyses showed a non-significant difference in the prevalence of schistosomiasis during pregnancy according to the study sample sizes and year of publication. Only six studies evaluated the association between schistosomiasis during pregnancy and anemia. Schistosomiasis was associated with anemia in these six studies (OR = 3.02, 95% = 1.25‒7.28, P = 0.014). CONCLUSION The present meta-analysis suggests that schistosomiasis during pregnancy is an existing health problem. This meta-analysis also highlights the lack of data on the determinants and outcomes of schistosomiasis during pregnancy. Preventive measures are needed and could be part of antenatal care in areas endemic with schistosomiasis.
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Affiliation(s)
- Ishag Adam
- Department of Obstetrics and Gynecology, Unaizah College of Medicine and Medical Sciences, Qassim University, Unaizah, Kingdom of Saudi Arabia
| | - Nadiah A. ALhabardi
- Department of Obstetrics and Gynecology, Unaizah College of Medicine and Medical Sciences, Qassim University, Unaizah, Kingdom of Saudi Arabia
| | - Osama Al-Wutayd
- Department of Family and Community Medicine, Unaizah College of Medicine and Medical Sciences, Qassim University, Unaizah, Kingdom of Saudi Arabia
| | - Ammar H. Khamis
- Hamdan Bin Mohammed College of Dental Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
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Should obstetricians working in non-endemic countries care about emerging tropical diseases? Eur J Obstet Gynecol Reprod Biol 2020; 257:25-34. [PMID: 33359921 DOI: 10.1016/j.ejogrb.2020.11.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/25/2020] [Accepted: 11/26/2020] [Indexed: 11/22/2022]
Abstract
Due to migration and international travels, obstetricians are increasingly faced with a globalized obstetric setting and should adapt their daily clinical and diagnostic approach to the modifications of tropical and subtropical infections epidemiology. This paper is focused on five emerging infectious diseases, namely Chagas disease, HTLV-1 infection, malaria, schistosomiasis and Zika virus infection, having a high prevalence in migrant populations and which can affect international travelers. These diseases frequently pass unrecognized since they are characterized by few or no symptoms during pregnancy, however they may cause a relevant maternal, fetal and neonatal impact. Specific and reliable diagnostic and treatment options are available but are rarely used during routine obstetrical practice.
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Bengu MD, Dorsamy V, Moodley J. Schistosomiasis infections in South African pregnant women: A review. S Afr J Infect Dis 2020. [DOI: 10.4102/sajid.v35i1.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Abstract
Toxoplasmosis is a global health threat in which occurrence in pregnant women poses grave consequences to fetal wellbeing. Studies on prenatal Toxoplasma gondii infection are generally limited in sub-Saharan African countries, including Nigeria. The risk of transmission of toxoplasmosis is very high in Nigeria due to the favourable climatic conditions and prevailing behavioural and socio-economic factors that could aid transmission. Currently, there are no systematic and organized procedures for diagnosis and treatment of maternal toxoplasmosis in Nigeria. These conditions forecast possible unabated transmission in many areas and exponential impact on associated adverse events of the disease during pregnancy. This paper highlights the importance of early diagnosis and treatment during pregnancy which may forestall subsequent development of infection in children delivered by infected mothers. Inclusion of toxoplasmosis control policy in the routine antenatal care of pregnant women is therefore strongly recommended.
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Prevalence and Risk Factors Associated with S. haematobium Egg Excretion during the Dry Season, Six Months following Mass Distribution of Praziquantel (PZQ) in 2017 in the Bafia Health Area, South West Region Cameroon: A Cross-Sectional Study. J Parasitol Res 2019; 2019:4397263. [PMID: 31354982 PMCID: PMC6633961 DOI: 10.1155/2019/4397263] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/20/2019] [Accepted: 05/22/2019] [Indexed: 12/30/2022] Open
Abstract
Background A selective population mass drug administration of PZQ involving school-aged children was carried out in the Bafia Health Area in April 2017. This study investigated the prevalence, intensity, and factors associated with S. haematobium egg excretion in this foci during the dry season, six months after the chemotherapy campaign. Methods A cross-sectional study including 1001 consenting individuals (aged 3-62 years) was carried out in three localities (Ikata, Bafia, and Munyenge) in the Bafia Health Area between November 2017 and January 2018. Information on sociodemographic, stream usage, and contact behaviour was documented. Schistosoma haematobium ova in urine were detected using membrane filtration technique. Results The prevalence of S. haematobium egg excretion was 8% with a higher level recorded in Munyenge (13.2%) than Ikata (7.5%) and Bafia (2.8%). The difference was significant (p < 0.001). Equally, Munyenge had the highest infection intensity (36.36 range: 2-200) when compared with Ikata (16.25 range: 2-57) and Bafia (8.0 range: 0-8). Although the age group (5–15 years) was significantly (p < 0.001) associated with more exposure to infested water, this group was less likely (OR: 0.42 95% CI: 0.19-0.91) associated with S. haematobium egg excretion. The risk of egg excretion increased by 4.79 times (95% CI: 2.20-10.41) and 3.68 times (95% CI: 1.59-8.54) among residents in Munyenge and Ikata, respectively. Similarly, frequency to the stream (> thrice/day) was significantly higher (χ2 = 58.73; p < 0.001) in Munyenge. Frequent contact (three visits/day) with stream correlated with highest odds of egg excretion (OR: 8.43 95% CI: 3.71-19.13). Conclusion The prevalence of S. haematobium egg excretion was low during the dry season. This was most likely attributed to the preventive campaign with PZQ and may parallel low transmission potentials in infested waters during this period.
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Famakinde DO. Treading the Path towards Genetic Control of Snail Resistance to Schistosome Infection. Trop Med Infect Dis 2018; 3:E86. [PMID: 30274482 PMCID: PMC6160955 DOI: 10.3390/tropicalmed3030086] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 08/08/2018] [Accepted: 08/13/2018] [Indexed: 01/05/2023] Open
Abstract
Schistosomiasis remains the most important tropical snail-borne trematodiasis that threatens many millions of human lives. In achieving schistosomiasis elimination targets, sustainable control of the snail vectors represents a logical approach. Nonetheless, the ineffectiveness of the present snail control interventions emphasizes the need to develop new complementary strategies to ensure more effective control outcomes. Accordingly, the use of genetic techniques aimed at driving resistance traits into natural vector populations has been put forward as a promising tool for integrated snail control. Leveraging the Biomphalaria-Schistosoma model system, studies unraveling the complexities of the vector biology and those exploring the molecular basis of snail resistance to schistosome infection have been expanding in various breadths, generating many significant discoveries, and raising the hope for future breakthroughs. This review provides a compendium of relevant findings, and without neglecting the current existing gaps and potential future challenges, discusses how a transgenic snail approach may be adapted and harnessed to control human schistosomiasis.
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Affiliation(s)
- Damilare O Famakinde
- Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Idi-Araba, Surulere, Lagos 100254, Nigeria.
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Woodall PA, Kramer MR. Schistosomiasis and Infertility in East Africa. Am J Trop Med Hyg 2018; 98:1137-1144. [PMID: 29313478 PMCID: PMC5928810 DOI: 10.4269/ajtmh.17-0280] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 11/20/2017] [Indexed: 12/31/2022] Open
Abstract
Case reports and pathology series suggest associations of female genital schistosomiasis (Schistosoma haematobium) with infertility and ectopic pregnancy. Differential geographic distribution of infertility is not explained by analyses of known risk factors. In this cross-sectional multilevel semi-ecologic study, interpolated prevalence maps for S. haematobium and Schistosoma mansoni in East Africa were created using data from two open-access Neglected Tropical Diseases Databases. Prevalence was extracted to georeferenced survey sample points for Demographic and Health Surveys for Ethiopia, Kenya, Tanzania, and Uganda for 2000 and 2010. Exploratory spatial analyses showed that infertility was not spatially random and mapped the clustering of infertility and its co-location with schistosomiasis. Multilevel logistic regression analysis demonstrated that women living in high compared with absent S. haematobium locations had significantly higher odds of infertility (2000 odds ratio [OR] = 1.5 [confidence interval95 = 1.3, 1.8]; 2010 OR = 1.2 [1.1, 1.5]). Women in high S. haematobium compared with high S. mansoni locations had significantly higher odds of infertility (2000 OR 1.4 [1.1, 1.9]; 2010 OR 1.4 [1.1, 1.8]). Living in high compared with absent S. mansoni locations did not affect the odds of infertility. Infertility appears to be associated spatially with S. haematobium.
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Affiliation(s)
- Patricia A. Woodall
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Michael R. Kramer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Bustinduy AL, Stothard JR, Friedman JF. Paediatric and maternal schistosomiasis: shifting the paradigms. Br Med Bull 2017; 123:115-125. [PMID: 28910994 PMCID: PMC6279106 DOI: 10.1093/bmb/ldx028] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 07/16/2017] [Indexed: 11/13/2022]
Abstract
BACKGROUND In endemic areas, schistosomiasis causes both overt and subclinical disease in young children and their mothers, as well as in returned travellers. SOURCES OF DATA Key recently published literature. AREAS OF AGREEMENT An action plan for paediatric schistosomiasis and female genital schistosomiasis (FGS) is needed with expanded access to praziquantel (PZQ) treatment required. AREAS OF CONTROVERSY Schistosomiasis-related morbidity is underappreciated. Present and future demand for PZQ treatment is bottlenecked, imbalanced and inequitable. Current dosing, treatment algorithms and access plans are suboptimal with treatment stalled during pregnancy. GROWING POINTS Raised dosing of PZQ (>40 mg/kg) is being explored in young children. Surveillance of female genital schistosomiasis FGS is increasing. Use of PZQ in pregnancy is safe and preventive chemotherapy guidelines are being revised in morbidity- and transmission-control settings. AREAS TIMELY FOR DEVELOPING RESEARCH Shifting focus of population-level control to individual-case management. Detection and prevention of FGS within general health services and integration of PZQ treatment for women and children in antenatal clinics. Feasibility studies assessing alternative and expanded access to PZQ treatment to at-risk children and mothers and pregnant women.
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Affiliation(s)
- Amaya L Bustinduy
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | - J Russell Stothard
- Department of Parasitology, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Jennifer F Friedman
- Center for International Health Research, Rhode Island Hospital, 55 Claverick Street, Suite 101, Providence, RI 02903, USA
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Mazzitelli M, Matera G, Votino C, Visconti F, Strazzulla A, Loria MT, Peronace C, Settembre P, Giancotti A, Liberto MC, Focà A, Zullo F, Torti C. A case report of Schistosoma haematobium infection in a pregnant migrant raises concerns about lack of screening policies. J Travel Med 2016; 24:taw076. [PMID: 27799503 DOI: 10.1093/jtm/taw076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2016] [Indexed: 11/14/2022]
Abstract
Pregnant women with urinary schistosomiasis should be treated, but screening is not implemented in migrants. We report herein a case of a migrant diagnosed late into pregnancy, after diagnosis was made in her husband. Praziquantel was safe and effective. Schistosomiasis should be considered in pregnant women from endemic countries.
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Affiliation(s)
- Maria Mazzitelli
- Unit of Infectious and Tropical Diseases Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, Catanzaro, Italy
| | - Giovanni Matera
- Institute of Microbiology, Department of Health Sciences, "Magna Graecia" University, Viale Europa, Catanzaro, Italy
| | - Carmela Votino
- Unit of Obstetrics and Gynaecology, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, Catanzaro, Italy
| | - Federica Visconti
- Unit of Obstetrics and Gynaecology, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, Catanzaro, Italy
| | - Alessio Strazzulla
- Unit of Infectious and Tropical Diseases Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, Catanzaro, Italy
| | - Maria Teresa Loria
- Institute of Microbiology, Department of Health Sciences, "Magna Graecia" University, Viale Europa, Catanzaro, Italy
| | - Cinzia Peronace
- Institute of Microbiology, Department of Health Sciences, "Magna Graecia" University, Viale Europa, Catanzaro, Italy
| | - Pio Settembre
- Institute of Microbiology, Department of Health Sciences, "Magna Graecia" University, Viale Europa, Catanzaro, Italy
| | - Aida Giancotti
- Institute of Microbiology, Department of Health Sciences, "Magna Graecia" University, Viale Europa, Catanzaro, Italy
| | - Maria Carla Liberto
- Institute of Microbiology, Department of Health Sciences, "Magna Graecia" University, Viale Europa, Catanzaro, Italy
| | - Alfredo Focà
- Institute of Microbiology, Department of Health Sciences, "Magna Graecia" University, Viale Europa, Catanzaro, Italy
| | - Fulvio Zullo
- Unit of Obstetrics and Gynaecology, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, Catanzaro, Italy
| | - Carlo Torti
- Unit of Infectious and Tropical Diseases Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Viale Europa, Catanzaro, Italy
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