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Raidt J, Riepenhausen S, Pennekamp P, Olbrich H, Amirav I, Athanazio RA, Aviram M, Balinotti JE, Bar-On O, Bode SFN, Boon M, Borrelli M, Carr SB, Crowley S, Dehlink E, Diepenhorst S, Durdik P, Dworniczak B, Emiralioğlu N, Erdem E, Fonnesu R, Gracci S, Große-Onnebrink J, Gwozdziewicz K, Haarman EG, Hansen CR, Hogg C, Holgersen MG, Kerem E, Körner RW, Kötz K, Kouis P, Loebinger MR, Lorent N, Lucas JS, Maj D, Mall MA, Marthin JK, Martinu V, Mazurek H, Mitchison HM, Nöthe-Menchen T, Özçelik U, Pifferi M, Pogorzelski A, Ringshausen FC, Roehmel JF, Rovira-Amigo S, Rumman N, Schlegtendal A, Shoemark A, Sperstad Kennelly S, Staar BO, Sutharsan S, Thomas S, Ullmann N, Varghese J, von Hardenberg S, Walker WT, Wetzke M, Witt M, Yiallouros P, Zschocke A, Ziętkiewicz E, Nielsen KG, Omran H. Analyses of 1236 genotyped primary ciliary dyskinesia individuals identify regional clusters of distinct DNA variants and significant genotype-phenotype correlations. Eur Respir J 2024; 64:2301769. [PMID: 38871375 PMCID: PMC11306806 DOI: 10.1183/13993003.01769-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 05/03/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Primary ciliary dyskinesia (PCD) represents a group of rare hereditary disorders characterised by deficient ciliary airway clearance that can be associated with laterality defects. We aimed to describe the underlying gene defects, geographical differences in genotypes and their relationship to diagnostic findings and clinical phenotypes. METHODS Genetic variants and clinical findings (age, sex, body mass index, laterality defects, forced expiratory volume in 1 s (FEV1)) were collected from 19 countries using the European Reference Network's ERN-LUNG international PCD Registry. Genetic data were evaluated according to American College of Medical Genetics and Genomics guidelines. We assessed regional distribution of implicated genes and genetic variants as well as genotype correlations with laterality defects and FEV1. RESULTS The study included 1236 individuals carrying 908 distinct pathogenic DNA variants in 46 PCD genes. We found considerable variation in the distribution of PCD genotypes across countries due to the presence of distinct founder variants. The prevalence of PCD genotypes associated with pathognomonic ultrastructural defects (mean 72%, range 47-100%) and laterality defects (mean 42%, range 28-69%) varied widely among countries. The prevalence of laterality defects was significantly lower in PCD individuals without pathognomonic ciliary ultrastructure defects (18%). The PCD cohort had a reduced median FEV1 z-score (-1.66). Median FEV1 z-scores were significantly lower in CCNO (-3.26), CCDC39 (-2.49) and CCDC40 (-2.96) variant groups, while the FEV1 z-score reductions were significantly milder in DNAH11 (-0.83) and ODAD1 (-0.85) variant groups compared to the whole PCD cohort. CONCLUSION This unprecedented multinational dataset of DNA variants and information on their distribution across countries facilitates interpretation of the genetic epidemiology of PCD and indicates that the genetic variant can predict diagnostic and phenotypic features such as the course of lung function.
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Affiliation(s)
- Johanna Raidt
- Department of General Pediatrics, University Hospital Muenster, Muenster, Germany
| | - Sarah Riepenhausen
- Institute of Medical Informatics, University of Muenster, Muenster, Germany
| | - Petra Pennekamp
- Department of General Pediatrics, University Hospital Muenster, Muenster, Germany
| | - Heike Olbrich
- Department of General Pediatrics, University Hospital Muenster, Muenster, Germany
| | - Israel Amirav
- Department of Pediatrics, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Rodrigo A Athanazio
- Pulmonary Division - Heart Institute, Hospital das Clínicas da Faculdade de São Paulo, São Paulo, Brazil
| | - Micha Aviram
- Pediatric Pulmonary Unit, Soroka Medical Center, Beer Sheva, Israel
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Juan E Balinotti
- Respiratory Center, Ricardo Gutiérrez Children's Hospital, Buenos Aires, Argentina
- Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
| | - Ophir Bar-On
- Pulmonary Institute, Schneider Children's Medical Center of Israel, Petach-Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sebastian F N Bode
- Center for Pediatrics - Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Pediatric and Adolescent Medicine, University Hospital Ulm, Ulm, Germany
| | - Mieke Boon
- Department of Paediatrics, University Hospital, Leuven, Belgium
| | - Melissa Borrelli
- Department of Translational Medical Sciences, Pediatric Pulmonology, Federico II University, Naples, Italy
| | - Siobhan B Carr
- Department of Paediatric Respiratory Medicine and Primary Ciliary Dyskinesia Centre, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
| | - Suzanne Crowley
- Paediatric Department of Allergy and Lung Diseases, Oslo University Hospital, Oslo, Norway
| | - Eleonora Dehlink
- Division of Pediatric Pulmonology, Allergy and Endocrinology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Sandra Diepenhorst
- Department of Pediatric Respiratory Medicine and Allergy, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Peter Durdik
- Department of Paediatrics, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, Martin, Slovakia
| | - Bernd Dworniczak
- Department of General Pediatrics, University Hospital Muenster, Muenster, Germany
| | - Nagehan Emiralioğlu
- Division of Pediatric Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ela Erdem
- Department of Pediatric Pulmonology, Marmara University School of Medicine, Istanbul, Turkey
| | - Rossella Fonnesu
- Department of Paediatrics, University Hospital of Pisa, Pisa, Italy
| | - Serena Gracci
- Department of Paediatrics, University Hospital of Pisa, Pisa, Italy
| | - Jörg Große-Onnebrink
- Department of General Pediatrics, University Hospital Muenster, Muenster, Germany
| | - Karolina Gwozdziewicz
- Department of Pneumology and Cystic Fibrosis, Institute of Tuberculosis and Lung Diseases, Rabka, Poland
| | - Eric G Haarman
- Department of Pediatric Respiratory Medicine and Allergy, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Christine R Hansen
- Department of Pediatrics, Institution of Clinical Sciences, Lund University, Lund, Sweden
- Section for Lung Medicine, Metabolism and Neurology, Pediatrics Clinic, Skane University Hospital, Lund, Sweden
| | - Claire Hogg
- Department of Paediatric Respiratory Medicine and Primary Ciliary Dyskinesia Centre, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
| | - Mathias G Holgersen
- Danish Primary Ciliary Dyskinesia Centre, Paediatric Pulmonary Service, Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Eitan Kerem
- Department of Pediatrics and Pediatric Pulmonology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Robert W Körner
- Department of Pediatrics, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Karsten Kötz
- Department of Pediatrics, Queen Silvias Children Hospital, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Panayiotis Kouis
- Respiratory Physiology Laboratory, Medical School, University of Cyprus, Nicosia, Cyprus
| | - Michael R Loebinger
- Royal Brompton and Harefield Hospitals and National Heart and Lung Institute, Imperial College London, London, UK
| | - Natalie Lorent
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
- Department Chrometa, BREATHE Laboratory, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Jane S Lucas
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, Southampton, UK
- Primary Ciliary Dyskinesia Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Debora Maj
- Department of Paediatrics, University Hospital of Pisa, Pisa, Italy
| | - Marcus A Mall
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Center for Lung Research (DZL), associated partner site, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - June K Marthin
- Danish Primary Ciliary Dyskinesia Centre, Paediatric Pulmonary Service, Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Vendula Martinu
- Department of Paediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Henryk Mazurek
- Department of Pneumology and Cystic Fibrosis, Institute of Tuberculosis and Lung Diseases, Rabka, Poland
| | - Hannah M Mitchison
- Genetics and Genomic Medicine Department, University College London, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Tabea Nöthe-Menchen
- Department of General Pediatrics, University Hospital Muenster, Muenster, Germany
| | - Ugur Özçelik
- Division of Pediatric Pulmonology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Massimo Pifferi
- Department of Paediatrics, University Hospital of Pisa, Pisa, Italy
| | - Andrzej Pogorzelski
- Department of Pneumology and Cystic Fibrosis, Institute of Tuberculosis and Lung Diseases, Rabka, Poland
| | - Felix C Ringshausen
- Department of Respiratory Medicine, Hannover Medical School (MHH), Hannover, Germany
- Biomedical Research in End-Stage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover, Germany
| | - Jobst F Roehmel
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Center for Lung Research (DZL), associated partner site, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sandra Rovira-Amigo
- Paediatric Pulmonology Section, Department of Paediatrics, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Nisreen Rumman
- Department of Pediatrics, Faculty of Medicine, Makassed Hospital, Al-Quds University, East Jerusalem, Palestine
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Anne Schlegtendal
- University Children's Hospital, Ruhr University Bochum, Katholisches Klinikum Bochum, Bochum, Germany
| | - Amelia Shoemark
- Royal Brompton and Harefield Hospitals and National Heart and Lung Institute, Imperial College London, London, UK
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | | | - Ben O Staar
- Department of Respiratory Medicine, Hannover Medical School (MHH), Hannover, Germany
- Biomedical Research in End-Stage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover, Germany
| | - Sivagurunathan Sutharsan
- Department of Pulmonary Medicine, Adult Cystic Fibrosis Center, University Hospital Essen - Ruhrlandklinik, University of Duisburg-Essen, Essen, Germany
| | - Simon Thomas
- Wessex Regional Genetics Laboratory, Salisbury NHS Foundation Trust, Salisbury, UK
- Human Genetics and Genomic Medicine, University of Southampton Faculty of Medicine, Southampton, UK
| | - Nicola Ullmann
- Pneumology and Cystic Fibrosis Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Julian Varghese
- Institute of Medical Informatics, University of Muenster, Muenster, Germany
| | | | - Woolf T Walker
- Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, Southampton, UK
- Primary Ciliary Dyskinesia Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Martin Wetzke
- Biomedical Research in End-Stage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover, Germany
- Department of Paediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
- Airway Research Center North (ARCN) Lübeck, German Center for Lung Research (DZL), Lübeck, Germany
| | - Michal Witt
- Institute of Human Genetics, Polish Academy of Sciences, Poznan, Poland
| | - Panayiotis Yiallouros
- Respiratory Physiology Laboratory, Medical School, University of Cyprus, Nicosia, Cyprus
- Pediatric Pulmonology Unit, Hospital "Archbishop Makarios III", Nicosia, Cyprus
| | - Anna Zschocke
- Department of Pediatric and Adolescent Medicine, Pediatrics III, Medical University, Innsbruck, Austria
| | - Ewa Ziętkiewicz
- Institute of Human Genetics, Polish Academy of Sciences, Poznan, Poland
| | - Kim G Nielsen
- Danish Primary Ciliary Dyskinesia Centre, Paediatric Pulmonary Service, Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Heymut Omran
- Department of General Pediatrics, University Hospital Muenster, Muenster, Germany
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Fassad MR, Rumman N, Junger K, Patel MP, Thompson J, Goggin P, Ueffing M, Beyer T, Boldt K, Lucas JS, Mitchison HM. Defective airway intraflagellar transport underlies a combined motile and primary ciliopathy syndrome caused by IFT74 mutations. Hum Mol Genet 2023; 32:3090-3104. [PMID: 37555648 PMCID: PMC10586200 DOI: 10.1093/hmg/ddad132] [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: 06/23/2023] [Revised: 08/01/2023] [Indexed: 08/10/2023] Open
Abstract
Ciliopathies are inherited disorders caused by defective cilia. Mutations affecting motile cilia usually cause the chronic muco-obstructive sinopulmonary disease primary ciliary dyskinesia (PCD) and are associated with laterality defects, while a broad spectrum of early developmental as well as degenerative syndromes arise from mutations affecting signalling of primary (non-motile) cilia. Cilia assembly and functioning requires intraflagellar transport (IFT) of cargos assisted by IFT-B and IFT-A adaptor complexes. Within IFT-B, the N-termini of partner proteins IFT74 and IFT81 govern tubulin transport to build the ciliary microtubular cytoskeleton. We detected a homozygous 3-kb intragenic IFT74 deletion removing the exon 2 initiation codon and 40 N-terminal amino acids in two affected siblings. Both had clinical features of PCD with bronchiectasis, but no laterality defects. They also had retinal dysplasia and abnormal bone growth, with a narrowed thorax and short ribs, shortened long bones and digits, and abnormal skull shape. This resembles short-rib thoracic dysplasia, a skeletal ciliopathy previously linked to IFT defects in primary cilia, not motile cilia. Ciliated nasal epithelial cells collected from affected individuals had reduced numbers of shortened motile cilia with disarranged microtubules, some misorientation of the basal feet, and disrupted cilia structural and IFT protein distributions. No full-length IFT74 was expressed, only truncated forms that were consistent with N-terminal deletion and inframe translation from downstream initiation codons. In affinity purification mass spectrometry, exon 2-deleted IFT74 initiated from the nearest inframe downstream methionine 41 still interacts as part of the IFT-B complex, but only with reduced interaction levels and not with all its usual IFT-B partners. We propose that this is a hypomorphic mutation with some residual protein function retained, which gives rise to a primary skeletal ciliopathy combined with defective motile cilia and PCD.
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Affiliation(s)
- Mahmoud R Fassad
- Genetics and Genomic Medicine Research and Teaching Department, University College London, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London WC1N 1EH, United Kingdom
- Department of Human Genetics, Medical Research Institute, Alexandria University, 22 El-Guish Road, El-Shatby, Alexandria 21526, Egypt
| | - Nisreen Rumman
- Department of Pediatrics, Faculty of Medicine, Makassed Hospital and Al-Quds University, East Jerusalem 91220, Palestine
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, 300 Cedar St #441, New Haven, CT 06520, United States
| | - Katrin Junger
- Institute for Ophthalmic Research, Eberhard Karl University of Tübingen, Elfreide-Alhorn-Strasse 5-7, Tübingen 72076, Germany
| | - Mitali P Patel
- Genetics and Genomic Medicine Research and Teaching Department, University College London, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London WC1N 1EH, United Kingdom
- MRC Prion Unit at UCL, Institute of Prion Diseases, University College London, 33 Cleveland Street, London W1W 7FF, United Kingdom
| | - James Thompson
- Primary Ciliary Dyskinesia Centre, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, United Kingdom
- School of Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, University Road, Southampton SO17 1BJ, United Kingdom
- Biomedical Imaging Unit, University of Southampton Faculty of Medicine, University Road, Southampton SO17 1BJ, United Kingdom
| | - Patricia Goggin
- Primary Ciliary Dyskinesia Centre, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, United Kingdom
- Biomedical Imaging Unit, University of Southampton Faculty of Medicine, University Road, Southampton SO17 1BJ, United Kingdom
| | - Marius Ueffing
- Institute for Ophthalmic Research, Eberhard Karl University of Tübingen, Elfreide-Alhorn-Strasse 5-7, Tübingen 72076, Germany
| | - Tina Beyer
- Institute for Ophthalmic Research, Eberhard Karl University of Tübingen, Elfreide-Alhorn-Strasse 5-7, Tübingen 72076, Germany
| | - Karsten Boldt
- Institute for Ophthalmic Research, Eberhard Karl University of Tübingen, Elfreide-Alhorn-Strasse 5-7, Tübingen 72076, Germany
| | - Jane S Lucas
- Primary Ciliary Dyskinesia Centre, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, United Kingdom
- School of Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, University Road, Southampton SO17 1BJ, United Kingdom
| | - Hannah M Mitchison
- Genetics and Genomic Medicine Research and Teaching Department, University College London, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London WC1N 1EH, United Kingdom
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Birkhead M, Otido S, Mabaso T, Mopeli K, Tlhapi D, Verwey C, Dangor Z. Ultrastructure for the diagnosis of primary ciliary dyskinesia in South Africa, a resource-limited setting. Front Pediatr 2023; 11:1247638. [PMID: 37645034 PMCID: PMC10461090 DOI: 10.3389/fped.2023.1247638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/04/2023] [Indexed: 08/31/2023] Open
Abstract
Introduction International guidelines recommend a multi-faceted approach for successful diagnoses of primary ciliary dyskinesia (PCD). In the absence of a gold standard test, a combination of genetic testing/microscopic analysis of structure and function/nasal nitric oxide measurement is used. In resource-limited settings, often none of the above tests are available, and in South Africa, only transmission electron microscopy (TEM) is available in central anatomical pathology departments. The aim of this study was to describe the clinical and ultrastructural findings of suspected PCD cases managed by pediatric pulmonologists at a tertiary-level state funded hospital in Johannesburg. Methods Nasal brushings were taken from 14 children with chronic respiratory symptoms in keeping with a PCD phenotype. Ultrastructural analysis in accordance with the international consensus guidelines for TEM-PCD diagnostic reporting was undertaken. Results TEM observations confirmed 43% (6) of the clinically-suspected cases (hallmark ultrastructural defects in the dynein arms of the outer doublets), whilst 57% (8) required another PCD testing modality to support ultrastructural observations. Of these, 25% (2) had neither ultrastructural defects nor did they present with bronchiectasis. Of the remaining cases, 83% (5) had very few ciliated cells (all of which were sparsely ciliated), together with goblet cell hyperplasia. There was the apparent absence of ciliary rootlets in 17% (1) case. Discussion In resource-limited settings in which TEM is the only available testing modality, confirmatory and probable diagnoses of PCD can be made to facilitate early initiation of treatment of children with chronic respiratory symptoms.
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Affiliation(s)
- Monica Birkhead
- Centre for Emerging Zoonotic and Parasitic Diseases, National Institute for Communicable Diseases – a Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Samuel Otido
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Nairobi, Kenya
| | - Theodore Mabaso
- Department of Paediatrics and Child Health, Faculty of Health Sciences, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Keketso Mopeli
- Department of Paediatrics and Child Health, Faculty of Health Sciences, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Dorcas Tlhapi
- Department of Paediatrics and Child Health, Faculty of Health Sciences, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Charl Verwey
- Department of Paediatrics and Child Health, Faculty of Health Sciences, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
- Medical Research Council: Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Ziyaad Dangor
- Department of Paediatrics and Child Health, Faculty of Health Sciences, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
- Medical Research Council: Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
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