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Scott LE, Hsiao NY, Dor G, Hans L, Marokane P, da Silva MP, Preiser W, Vreede H, Tsoka J, Mlisana K, Stevens WS. How South Africa Used National Cycle Threshold (Ct) Values to Continuously Monitor SARS-CoV-2 Laboratory Test Quality. Diagnostics (Basel) 2023; 13:2554. [PMID: 37568917 PMCID: PMC10416981 DOI: 10.3390/diagnostics13152554] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/24/2023] [Accepted: 07/29/2023] [Indexed: 08/13/2023] Open
Abstract
The high demand for SARS-CoV-2 tests but limited supply to South African laboratories early in the COVID-19 pandemic resulted in a heterogenous diagnostic footprint of open and closed molecular testing platforms being implemented. Ongoing monitoring of the performance of these multiple and varied systems required novel approaches, especially during the circulation of variants. The National Health Laboratory Service centrally collected cycle threshold (Ct) values from 1,497,669 test results reported from 6 commonly used PCR assays in 36 months, and visually monitored changes in their median Ct within a 28-day centered moving average for each assays' gene targets. This continuous quality monitoring rapidly identified delayed hybridization of RdRp in the Allplex™ SARS-CoV-2 assay due to the Delta (B.1.617.2) variant; S-gene target failure in the TaqPath™ COVID-19 assay due to B.1.1.7 (Alpha) and the B.1.1.529 (Omicron); and recently E-gene delayed hybridization in the Xpert® Xpress SARS-CoV-2 due to XBB.1.5. This near "real-time" monitoring helped inform the need for sequencing and the importance of multiplex molecular nucleic acid amplification technology designs used in diagnostics for patient care. This continuous quality monitoring approach at the granularity of Ct values should be included in ongoing surveillance and with application to other disease use cases that rely on molecular diagnostics.
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Affiliation(s)
- Lesley Erica Scott
- Wits Diagnostic Innovation Hub, Faculty of Health Science, University of the Witwatersrand, Johannesburg 2093, South Africa (L.H.); (M.P.d.S.); (J.T.); (W.S.S.)
| | - Nei-yuan Hsiao
- Division of Medical Virology, Faculty of Heath Sciences, University of Cape Town, Cape Town 7700, South Africa;
- The National Health Laboratory Service, Johannesburg, Private Bag X8, Sandringham 2131, South Africa; (W.P.); (H.V.); (K.M.)
| | - Graeme Dor
- Wits Diagnostic Innovation Hub, Faculty of Health Science, University of the Witwatersrand, Johannesburg 2093, South Africa (L.H.); (M.P.d.S.); (J.T.); (W.S.S.)
| | - Lucia Hans
- Wits Diagnostic Innovation Hub, Faculty of Health Science, University of the Witwatersrand, Johannesburg 2093, South Africa (L.H.); (M.P.d.S.); (J.T.); (W.S.S.)
- The National Priority Program of the National Health Laboratory Service, Johannesburg, Private Bag X8, Sandringham 2131, South Africa;
| | - Puleng Marokane
- The National Priority Program of the National Health Laboratory Service, Johannesburg, Private Bag X8, Sandringham 2131, South Africa;
| | - Manuel Pedro da Silva
- Wits Diagnostic Innovation Hub, Faculty of Health Science, University of the Witwatersrand, Johannesburg 2093, South Africa (L.H.); (M.P.d.S.); (J.T.); (W.S.S.)
- The National Priority Program of the National Health Laboratory Service, Johannesburg, Private Bag X8, Sandringham 2131, South Africa;
| | - Wolfgang Preiser
- The National Health Laboratory Service, Johannesburg, Private Bag X8, Sandringham 2131, South Africa; (W.P.); (H.V.); (K.M.)
- Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch 7600, South Africa
| | - Helena Vreede
- The National Health Laboratory Service, Johannesburg, Private Bag X8, Sandringham 2131, South Africa; (W.P.); (H.V.); (K.M.)
- Division of Chemical Pathology, Faculty of Heath Sciences, University of Cape Town, Cape Town 7700, South Africa
| | - Jonathan Tsoka
- Wits Diagnostic Innovation Hub, Faculty of Health Science, University of the Witwatersrand, Johannesburg 2093, South Africa (L.H.); (M.P.d.S.); (J.T.); (W.S.S.)
| | - Koleka Mlisana
- The National Health Laboratory Service, Johannesburg, Private Bag X8, Sandringham 2131, South Africa; (W.P.); (H.V.); (K.M.)
| | - Wendy Susan Stevens
- Wits Diagnostic Innovation Hub, Faculty of Health Science, University of the Witwatersrand, Johannesburg 2093, South Africa (L.H.); (M.P.d.S.); (J.T.); (W.S.S.)
- The National Priority Program of the National Health Laboratory Service, Johannesburg, Private Bag X8, Sandringham 2131, South Africa;
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Samsunder N, Lustig G, Ngubane S, Maseko TG, Rambaran S, Ngcapu S, Magini SN, Lewis L, Cawood C, Kharsany ABM, Karim QA, Karim SA, Naidoo K, Sivro A. Field evaluations of four SARS-CoV-2 rapid antigen tests during SARS-CoV-2 Delta variant wave in South Africa. Diagn Progn Res 2023; 7:14. [PMID: 37491317 PMCID: PMC10369830 DOI: 10.1186/s41512-023-00151-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 07/11/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Rapid antigen tests detecting SARS-CoV-2 were shown to be a useful tool in managing the COVID-19 pandemic. Here, we report on the results of a prospective diagnostic accuracy study of four SARS-CoV-2 rapid antigen tests in a South African setting. METHODS Rapid antigen test evaluations were performed through drive-through testing centres in Durban, South Africa, from July to December 2021. Two evaluation studies were performed: nasal Panbio COVID-19 Ag Rapid Test Device (Abbott) was evaluated in parallel with the nasopharyngeal Espline SARS-CoV-2 Ag test (Fujirebio), followed by the evaluation of nasal RightSign COVID-19 Antigen Rapid test Cassette (Hangzhou Biotest Biotech) in parallel with the nasopharyngeal STANDARD Q COVID-19 Ag test (SD Biosensor). The Abbott RealTime SARS-CoV-2 assay was used as a reference test. RESULTS Evaluation of Panbio and Espline Ag tests was performed on 494 samples (31% positivity), while the evaluation of Standard Q and RightTest Ag tests was performed on 539 samples (13.17% positivity). The overall sensitivity for all four tests ranged between 60 and 72% with excellent specificity values (> 98%). Sensitivity increased to > 80% in all tests in samples with cycle number value < 20. All four tests performed best in samples from patients presenting within the first week of symptom onset. CONCLUSIONS All four evaluated tests detected a majority of the cases within the first week of symptom onset with high viral load.
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Affiliation(s)
- Natasha Samsunder
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Gila Lustig
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Slindile Ngubane
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Thando Glory Maseko
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Santhuri Rambaran
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Sinaye Ngcapu
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
- Department of Medical Microbiology, University of KwaZulu-Natal, Durban, South Africa
| | - Stanley Nzuzo Magini
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Lara Lewis
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Cherie Cawood
- Epicentre AIDS Risk Management (Pty) Limited, Durban, South Africa
| | - Ayesha B M Kharsany
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
- Department of Medical Microbiology, University of KwaZulu-Natal, Durban, South Africa
| | - Quarraisha Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
- Department of Epidemiology, Columbia University, New York City, USA
| | - Salim Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
- Department of Epidemiology, Columbia University, New York City, USA
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
- South African Medical Research Council (SAMRC), CAPRISA-TB-HIV Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal Nelson R. Mandela School of Medicine, Durban, South Africa
| | - Aida Sivro
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa.
- Department of Medical Microbiology, University of KwaZulu-Natal, Durban, South Africa.
- South African Medical Research Council (SAMRC), CAPRISA-TB-HIV Pathogenesis and Treatment Research Unit, University of KwaZulu-Natal Nelson R. Mandela School of Medicine, Durban, South Africa.
- JC Wilt Infectious Disease Research Centre, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, MB, Canada.
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MB, Canada.
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Brumwell AN, Babatunde GB, Wilson MW, le Roux K, Marks MM, Adam JK, Ivanova E, Batheja D, Goel S, Shilton S, Martínez-Pérez GZ. Values of COVID-19 Self-Testing among Urban and Rural South Africans: A Cross-Sectional Survey. Prev Med Rep 2023; 32:102114. [PMID: 36686721 PMCID: PMC9847323 DOI: 10.1016/j.pmedr.2023.102114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/15/2023] [Accepted: 01/16/2023] [Indexed: 01/19/2023] Open
Abstract
Self-testing for COVID-19 may be a preferable strategy for identifying SARS-CoV-2 infection among populations in low- and middle-income settings. To determine South Africans' values related to COVID-19 self-testing should it become widely available, a cross-sectional survey was administered in Durban, KwaZulu-Natal Province and the King Sabata Dalindyebo sub-district of the Eastern Cape. A 35-question survey was administered to 531 participants (268 female) in one urban and one rural setting of South Africa. Survey participants were randomly selected by household in the rural setting, while in the urban setting participants were approached in randomly selected public places. The survey assessed participants' likelihood of using and willingness to pay for a COVID-19 self-test and actions they would take following a COVID-19 self-test. The results were analysed using descriptive statistics and bivariate and multivariate regression. Overall, 93.03% of participants supported COVID-19 self-testing, 61.62% of participants were willing to pay for self-testing, and 90.15% indicated they would communicate their results if they tested positive. Rural participants were more positively associated with each of these outcomes compared with urban-based participants. Should they test positive, most participants said they would: go in-person to a health facility for counselling (76.45%), self-isolate (95.85%), notify close contacts (97.74%), and inform their employer (95.14%). COVID-19 self-testing was a preferable option for most participants, although this varied with setting and demographic characteristics. Self-testing may overcome barriers to care for South Africans, but to achieve this, policies for self-testing and delivery methods must not exacerbate individuals' underlying economic vulnerabilities.
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Affiliation(s)
- Amanda N. Brumwell
- Advance Access & Delivery South Africa (AA&D SA), Durban, South Africa
- Corresponding author.
| | | | - Michael W. Wilson
- Advance Access & Delivery South Africa (AA&D SA), Durban, South Africa
- Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Karl le Roux
- Zithulele Hospital, Zithulele, Mqanduli, South Africa
| | | | | | - Elena Ivanova
- FIND, the global alliance for diagnostics, Geneva, Switzerland
| | | | - Srishti Goel
- Centre for Disease Dynamics, Economics and Policy, India
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Humphries H, Lewis L, Lamontagne E, Choonara S, Dikgale K, Yakusik A, Massawe D, Mkhize N, Mzungu F, Karim QA. Impact of COVID-19 public health responses on income, food security and health services among key and vulnerable women in South Africa. African Journal of AIDS Research 2022; 21:317-329. [DOI: 10.2989/16085906.2022.2144392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Hilton Humphries
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Psychology, School of Applied Human Sciences, University of KwaZulu-Natal. Durbanm, South Africa
| | - Lara Lewis
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Erik Lamontagne
- UNAIDS, Strategic Information, Geneva, Switzerland
- Aix Marseille University, CNRS, Aix-Marseilfe School of Economics, Marseille, France
| | - Shakira Choonara
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Keabetswe Dikgale
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Anna Yakusik
- UNAIDS, Strategic Information, Geneva, Switzerland
| | | | | | | | - Quarraisha Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Mailman School of Public Health, Columbia University, New York, USA
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Abdool Karim Q, Baxter C. COVID-19: Impact on the HIV and Tuberculosis Response, Service Delivery, and Research in South Africa. Curr HIV/AIDS Rep 2022; 19:46-53. [PMID: 35064888 PMCID: PMC8783194 DOI: 10.1007/s11904-021-00588-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 01/01/2023]
Abstract
Purpose of Review To describe how mitigation measures against COVID-19 have impacted HIV and TB research in South Africa. Recent Findings South Africa has the highest number of COVID-19 (34%) cases in Africa, accounting for 43% of all reported COVID-19-related deaths on the continent. The country accounts for 20% of all people living with HIV and ranked third in the world for new TB infections in 2019. Summary While South Africa’s investments in its HIV and TB responses enabled it to pivot rapidly to respond to the emerging COVID-19 epidemic, it negatively impacted the HIV and TB response through temporary suspension of research, diversion of key resources for HIV and TB control, and patient access to health care facilities; the full extent of this has yet to emerge. Success in integrating responses to the colliding epidemics could potentially enhance survival outcomes and ensure gains made to date in HIV and TB are not reversed and we stay on track toward achieving the UN 2030 Sustainable Development Goals.
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Dzinamarira T, Murewanhema G, Iradukunda PG, Madziva R, Herrera H, Cuadros DF, Tungwarara N, Chitungo I, Musuka G. Utilization of SARS-CoV-2 Wastewater Surveillance in Africa-A Rapid Review. Int J Environ Res Public Health 2022; 19:969. [PMID: 35055789 PMCID: PMC8775514 DOI: 10.3390/ijerph19020969] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/04/2022] [Accepted: 01/13/2022] [Indexed: 02/06/2023]
Abstract
Wastewater-based epidemiology for SARS-CoV-2 RNA detection in wastewater is desirable for understanding COVID-19 in settings where financial resources and diagnostic facilities for mass individual testing are severely limited. We conducted a rapid review to map research evidence on the utilization of SARS-CoV-2 wastewater surveillance in Africa. We searched PubMed, Google Scholar, and the World Health Organization library databases for relevant reports, reviews, and primary observational studies. Eight studies met the inclusion criteria. Narrative synthesis of the findings from included primary studies revealed the testing methodologies utilized and that detected amount of SARS-CoV-2 viral RNA correlated with the number of new cases in the studied areas. The included reviews revealed the epidemiological significance and environmental risks of SARS-CoV-2 wastewater. Wastewater surveillance data at the community level can be leveraged for the rapid assessment of emerging threats and aid pandemic preparedness. Our rapid review revealed a glaring gap in the primary literature on SARS-CoV-2 wastewater surveillance on the continent, and accelerated and adequate investment into research is urgently needed to address this gap.
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Affiliation(s)
- Tafadzwa Dzinamarira
- School of Health Systems & Public Health, University of Pretoria, Pretoria 0002, South Africa
- ICAP at Columbia University, Harare, Zimbabwe;
| | - Grant Murewanhema
- Unit of Obstetrics and Gynaecology, Department of Primary Health Care Sciences, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe;
| | - Patrick Gad Iradukunda
- London School of Hygiene and Tropical Medicine, University of London, London WC1E 7HU, UK;
| | - Roda Madziva
- School of Sociology and Social Policy, University of Nottingham, Nottingham NG7 2RD, UK;
| | - Helena Herrera
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth PO1 2UP, UK;
| | - Diego F. Cuadros
- Department of Geography and Geographic Information Science, University of Cincinnati, Cincinnati, OH 45221, USA;
| | - Nigel Tungwarara
- Department of Health Studies, University of South Africa, Pretoria 0002, South Africa;
| | - Itai Chitungo
- Chemical Pathology Unit, Department of Laboratory Diagnostic and Investigative Sciences, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe;
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Sun Q, McMahon DE, Ugwu-Dike PO, Sun Q, Tang K, Zhang H, Suchonwanit P, Oh CC, Chong AH, Willems A, Galván C, Dodiuk-Gad RP, Fantini F, Recalcati S, Avancini J, Miyamoto D, Sanches JA, Raboobee N, Bravo F, Freeman EE. How Coronavirus Disease 2019 Changed Dermatology Practice in 1 Year Around the World: Perspectives from 11 Countries. Dermatol Clin 2021; 39:639-651. [PMID: 34556253 PMCID: PMC8452267 DOI: 10.1016/j.det.2021.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Qisi Sun
- Department of Dermatology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Devon E McMahon
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Pearl O Ugwu-Dike
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Qiuning Sun
- Department of Dermatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 9 Dongdan 3rd Alley, Dong Dan, Dongcheng Qu, Beijing Shi, China
| | - Keyun Tang
- Department of Dermatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 9 Dongdan 3rd Alley, Dong Dan, Dongcheng Qu, Beijing Shi, China
| | - Hanlin Zhang
- Department of Dermatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 9 Dongdan 3rd Alley, Dong Dan, Dongcheng Qu, Beijing Shi, China
| | - Poonkiat Suchonwanit
- Division of Dermatology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Thanon Rama VI, Khwaeng Thung Phaya Thai, Khet Ratchathewi, Krung Thep Maha Nakhon 10400, Thailand
| | - Choon Chiat Oh
- Department of Dermatology, Singapore General Hospital, Singapore, Outram Rd, Singapore 169608, Singapore
| | - Alvin H Chong
- Skin Health Institute, level 1/80 Drummond St, Carlton, VIC 3053, Australia; Department of Medicine (Dermatology), St Vincent's Hospital Melbourne, University of Melbourne, Parkville, VIC 3010, Australia
| | - Anneliese Willems
- Skin Health Institute, level 1/80 Drummond St, Carlton, VIC 3053, Australia
| | - Cristina Galván
- Department of Dermatology, Hospital Universitario de Móstoles, Calle Río Júcar, S/N, 28935 Móstoles, Madrid, Spain
| | - Roni P Dodiuk-Gad
- Bruce Rappaport Faculty of Medicine, Technion - Institute of Technology, Haifa, 3200003, Israel; Department of Dermatology, Emek Medical Center, Yitshak Rabin Boulevard 21, Afula, 1834111, Israel; Division of Dermatology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON M4N 3M5, Canada
| | - Fabrizio Fantini
- Department of Dermatology, Dermatology Unit, ASST Lecco, Alessandro Manzoni Hospital, Via dell'Eremo, 9/11, 23900 Lecco LC, Italy
| | - Sebastiano Recalcati
- Department of Dermatology, Dermatology Unit, ASST Lecco, Alessandro Manzoni Hospital, Via dell'Eremo, 9/11, 23900 Lecco LC, Italy
| | - Joao Avancini
- Department of Dermatology, Hospital das Clínicas of the University of Sao Paulo, Rua, Av. Dr. Enéas Carvalho de Aguiar, 255-Cerqueira César, São Paulo-SP, 05403-000, Brazil
| | - Denise Miyamoto
- Department of Dermatology, Hospital das Clínicas of the University of Sao Paulo, Rua, Av. Dr. Enéas Carvalho de Aguiar, 255-Cerqueira César, São Paulo-SP, 05403-000, Brazil
| | - Jose A Sanches
- Department of Dermatology, Hospital das Clínicas of the University of Sao Paulo, Rua, Av. Dr. Enéas Carvalho de Aguiar, 255-Cerqueira César, São Paulo-SP, 05403-000, Brazil
| | - Noufal Raboobee
- Department of Dermatology, Westville Hospital, 7 Harry Gwala Rd, Westville, Durban, 3630, South Africa
| | - Francisco Bravo
- Department of Dermatology, Universidad Peruana Cayetano Heredia, Hospital Cayetano Heredia, Av. Honorio Delgado 430, San Martín de Porres 15102, Peru; Department of Pathology, Universidad Peruana Cayetano Heredia, Hospital Cayetano Heredia, 1 CV Zac, Av. Honorio Delgado 262, San Martín de Porres 15102, Peru
| | - Esther E Freeman
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
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