Ustekinumab for type 1 diabetes in adolescents: a multicenter, double-blind, randomized phase 2 trial.


Journal

Nature medicine
ISSN: 1546-170X
Titre abrégé: Nat Med
Pays: United States
ID NLM: 9502015

Informations de publication

Date de publication:
30 Jul 2024
Historique:
received: 09 02 2024
accepted: 05 06 2024
medline: 31 7 2024
pubmed: 31 7 2024
entrez: 30 7 2024
Statut: aheadofprint

Résumé

Immunotherapy targeting the autoimmune process in type 1 diabetes (T1D) can delay the loss of β-cells but needs to have minimal adverse effects to be an adjunct to insulin in the management of T1D. Ustekinumab binds to the shared p40 subunit of interleukin (IL)-12 and IL-23, targeting development of T helper 1 cells and T helper 17 cells (T

Identifiants

pubmed: 39079992
doi: 10.1038/s41591-024-03115-2
pii: 10.1038/s41591-024-03115-2
doi:

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

IM

Subventions

Organisme : DH | National Institute for Health Research (NIHR)
ID : 16/36/01
Organisme : DH | National Institute for Health Research (NIHR)
ID : EME
Organisme : DH | National Institute for Health Research (NIHR)
ID : EME
Organisme : DH | National Institute for Health Research (NIHR)
ID : EME
Organisme : DH | National Institute for Health Research (NIHR)
ID : EME
Organisme : DH | National Institute for Health Research (NIHR)
ID : EME
Organisme : DH | National Institute for Health Research (NIHR)
ID : EME
Organisme : DH | National Institute for Health Research (NIHR)
ID : EME
Organisme : DH | National Institute for Health Research (NIHR)
ID : EME
Organisme : DH | National Institute for Health Research (NIHR)
ID : EME
Organisme : DH | National Institute for Health Research (NIHR)
ID : EME
Organisme : DH | National Institute for Health Research (NIHR)
ID : EME
Organisme : DH | National Institute for Health Research (NIHR)
ID : EME
Organisme : DH | National Institute for Health Research (NIHR)
ID : EME
Organisme : DH | National Institute for Health Research (NIHR)
ID : EME
Organisme : DH | National Institute for Health Research (NIHR)
ID : EME
Organisme : DH | National Institute for Health Research (NIHR)
ID : EME
Organisme : DH | National Institute for Health Research (NIHR)
ID : EME
Organisme : DH | National Institute for Health Research (NIHR)
ID : EME

Investigateurs

Evelien Gevers (E)
Shankar Kanumakala (S)
Sunil Nair (S)
Chris Gardner (C)
Michal Ajzensztejn (M)
Christina Wei (C)
Chris Mouditis (C)
Fiona Campbell (F)
James Greening (J)
Emma Webb (E)
Mimi Chen (M)
Rakesh Amin (R)
Billi White (B)
Ambika Shetty (A)
Chris Bidder (C)
Nicholas Conway (N)
Amalia Mayo (A)
Eleni Christakou (E)
Kamila Sychowska (K)
Yasaman Shahrabi (Y)
Maximilian Robinson (M)
Simi Ahmed (S)
Jan Dutz (J)
Laura Cook (L)

Informations de copyright

© 2024. The Author(s).

Références

Tatovic, D. & Dayan, C. M. Replacing insulin with immunotherapy: time for a paradigm change in type 1 diabetes. Diabet. Med. 38, e14696 (2021).
pubmed: 34555209 doi: 10.1111/dme.14696
Holman, N. et al. National trends in hyperglycemia and diabetic ketoacidosis in children, adolescents, and young adults with type 1 diabetes: a challenge due to age or stage of development, or is new thinking about service provision needed? Diabetes Care 46, 1404–1408 (2023).
pubmed: 37216620 pmcid: 10300515 doi: 10.2337/dc23-0180
Latres, E. et al. Evidence for C-peptide as a validated surrogate to predict clinical benefits in trials of disease-modifying therapies for type 1 diabetes. Diabetes 73, 823–833 (2024).
pubmed: 38349844 doi: 10.2337/dbi23-0012
Herold, K. C. et al. An anti-CD3 antibody, teplizumab, in relatives at risk for type 1 diabetes. N. Engl. J. Med. 381, 603–613 (2019).
pubmed: 31180194 pmcid: 6776880 doi: 10.1056/NEJMoa1902226
Quinn, L. M. et al. What does the licensing of teplizumab mean for diabetes care? Diabetes Obes. Metab. 25, 2051–2057 (2023).
pubmed: 36999237 doi: 10.1111/dom.15071
Insel, R. A. et al. Staging presymptomatic type 1 diabetes: a scientific statement of JDRF, the endocrine society, and the american diabetes association. Diabetes Care 38, 1964–1974 (2015).
pubmed: 26404926 pmcid: 5321245 doi: 10.2337/dc15-1419
Allen, L. A. & Dayan, C. M. Immunotherapy for type 1 diabetes. Br. Med. Bull. 140, 76–90 (2021).
pubmed: 34893820 doi: 10.1093/bmb/ldab027
Walker, L. S. & von Herrath, M. CD4 T cell differentiation in type 1 diabetes. Clin. Exp. Immunol. 183, 16–29 (2016).
pubmed: 26102289 doi: 10.1111/cei.12672
Li, Y., Liu, Y. & Chu, C. Q. Th17 cells in type 1 diabetes: role in the pathogenesis and regulation by gut microbiome. Mediators Inflamm. 2015, 638470 (2015).
pubmed: 26843788 pmcid: 4710950 doi: 10.1155/2015/638470
Robertson, C. C. et al. Fine-mapping, trans-ancestral and genomic analyses identify causal variants, cells, genes and drug targets for type 1 diabetes. Nat. Genet. 53, 962–971 (2021).
pubmed: 34127860 pmcid: 8273124 doi: 10.1038/s41588-021-00880-5
Li, C. R., Mueller, E. E. & Bradley, L. M. Islet antigen-specific Th17 cells can induce TNF-alpha-dependent autoimmune diabetes. J. Immunol. 192, 1425–1432 (2014).
pubmed: 24446517 doi: 10.4049/jimmunol.1301742
Vukkadapu, S. S. et al. Dynamic interaction between T cell-mediated beta-cell damage and beta-cell repair in the run up to autoimmune diabetes of the NOD mouse. Physiol. Genomics 21, 201–211 (2005).
pubmed: 15671250 doi: 10.1152/physiolgenomics.00173.2004
Bending, D. et al. Highly purified Th17 cells from BDC2.5NOD mice convert into Th1-like cells in NOD/SCID recipient mice. J. Clin. Invest. 119, 565–572 (2009).
pubmed: 19188681 pmcid: 2648686 doi: 10.1172/JCI37865
Martin-Orozco, N., Chung, Y., Chang, S. H., Wang, Y. H. & Dong, C. Th17 cells promote pancreatic inflammation but only induce diabetes efficiently in lymphopenic hosts after conversion into Th1 cells. Eur. J. Immunol. 39, 216–224 (2009).
pubmed: 19130584 pmcid: 2755057 doi: 10.1002/eji.200838475
Honkanen, J. et al. IL-17 immunity in human type 1 diabetes. J. Immunol. 185, 1959–1967 (2010).
pubmed: 20592279 doi: 10.4049/jimmunol.1000788
Ferraro, A. et al. Expansion of Th17 cells and functional defects in T regulatory cells are key features of the pancreatic lymph nodes in patients with type 1 diabetes. Diabetes 60, 2903–2913 (2011).
pubmed: 21896932 pmcid: 3198077 doi: 10.2337/db11-0090
Reinert-Hartwall, L. et al. Th1/Th17 plasticity is a marker of advanced beta cell autoimmunity and impaired glucose tolerance in humans. J. Immunol. 194, 68–75 (2015).
pubmed: 25480564 doi: 10.4049/jimmunol.1401653
Arif, S. et al. Peripheral and islet interleukin-17 pathway activation characterizes human autoimmune diabetes and promotes cytokine-mediated beta-cell death. Diabetes 60, 2112–2119 (2011).
pubmed: 21659501 pmcid: 3142078 doi: 10.2337/db10-1643
Kenefeck, R. et al. Follicular helper T cell signature in type 1 diabetes. J. Clin. Invest. 125, 292–303 (2015).
pubmed: 25485678 doi: 10.1172/JCI76238
Xu, X. et al. Inhibition of increased circulating Tfh cell by anti-CD20 monoclonal antibody in patients with type 1 diabetes. PLoS ONE 8, e79858 (2013).
pubmed: 24278195 pmcid: 3835920 doi: 10.1371/journal.pone.0079858
Patel, D. D. & Kuchroo, V. K. Th17 cell pathway in human immunity: lessons from genetics and therapeutic interventions. Immunity 43, 1040–1051 (2015).
pubmed: 26682981 doi: 10.1016/j.immuni.2015.12.003
Penso, L. et al. Association between biologics use and risk of serious infection in patients with psoriasis. JAMA Dermatol. 157, 1056–1065 (2021).
pubmed: 34287624 doi: 10.1001/jamadermatol.2021.2599
Cheng, D., Kochar, B. D., Cai, T. & Ananthakrishnan, A. N. Risk of infections with ustekinumab and tofacitinib compared to tumor necrosis factor alpha antagonists in inflammatory bowel diseases. Clin. Gastroenterol. Hepatol. 20, 2366–2372.e2366 (2022).
pubmed: 35066137 pmcid: 9296690 doi: 10.1016/j.cgh.2022.01.013
Jin, Y. et al. Risk of hospitalization for serious infection after initiation of ustekinumab or other biologics in patients with psoriasis or psoriatic arthritis. Arthritis Care Res. 74, 1792–1805 (2022).
doi: 10.1002/acr.24630
Davila-Seijo, P. et al. Infections in moderate to severe psoriasis patients treated with biological drugs compared to classic systemic drugs: findings from the BIOBADADERM registry. J. Invest. Dermatol. 137, 313–321 (2017).
pubmed: 27677836 doi: 10.1016/j.jid.2016.08.034
Doornekamp, L. et al. High immunogenicity to influenza vaccination in Crohn’s disease patients treated with ustekinumab. Vaccines 8, 455 (2020).
pubmed: 32824111 pmcid: 7565576 doi: 10.3390/vaccines8030455
Fiorentino, D. et al. Risk of malignancy with systemic psoriasis treatment in the Psoriasis Longitudinal Assessment Registry. J. Am. Acad. Dermatol 77, 845–854.e845 (2017).
pubmed: 28893407 doi: 10.1016/j.jaad.2017.07.013
Marwaha, A. K. et al. A phase 1b open-label dose-finding study of ustekinumab in young adults with type 1 diabetes. Immunother. Adv. 2, ltab022 (2022).
pubmed: 35072168 doi: 10.1093/immadv/ltab022
Adedokun, O. J. et al. Pharmacokinetics and exposure response relationships of ustekinumab in patients with Crohn’s disease. Gastroenterology 154, 1660–1671 (2018).
pubmed: 29409871 doi: 10.1053/j.gastro.2018.01.043
Schnell, A., Littman, D. R. & Kuchroo, V. K. T
pubmed: 36596896 pmcid: 10795475 doi: 10.1038/s41590-022-01387-9
Ghoreschi, K. et al. Generation of pathogenic T
pubmed: 20962846 pmcid: 3108066 doi: 10.1038/nature09447
Lee, Y. et al. Induction and molecular signature of pathogenic TH17 cells. Nat. Immunol. 13, 991–999 (2012).
pubmed: 22961052 pmcid: 3459594 doi: 10.1038/ni.2416
Gaublomme, J. T. et al. Single-cell genomics unveils critical regulators of Th17 cell pathogenicity. Cell 163, 1400–1412 (2015).
pubmed: 26607794 pmcid: 4671824 doi: 10.1016/j.cell.2015.11.009
Hirota, K. et al. Fate mapping of IL-17-producing T cells in inflammatory responses. Nat. Immunol. 12, 255–U295 (2011).
pubmed: 21278737 pmcid: 3040235 doi: 10.1038/ni.1993
Komuczki, J. et al. Fate-mapping of GM-CSF expression identifies a discrete subset of inflammation-driving T helper cells regulated by cytokines IL-23 and IL-1β. Immunity 50, 1289–1304.e6 (2019).
pubmed: 31079916 doi: 10.1016/j.immuni.2019.04.006
Langrish, C. L. et al. IL-23 drives a pathogenic T cell population that induces autoimmune inflammation. J. Exp. Med. 201, 233–240 (2005).
pubmed: 15657292 pmcid: 2212798 doi: 10.1084/jem.20041257
McGeachy, M. J. et al. The interleukin 23 receptor is essential for the terminal differentiation of interleukin 17-producing effector T helper cells. Nat. Immunol. 10, 314–324 (2009).
pubmed: 19182808 pmcid: 2945605 doi: 10.1038/ni.1698
Hamilton, J. A. GM-CSF in inflammation. J. Exp. Med. 217, e20190954 (2020).
doi: 10.1084/jem.20190945
Annunziato, F. et al. Phenotypic and functional features of human Th17 cells. J. Exp. Med. 204, 1849–1861 (2007).
pubmed: 17635957 pmcid: 2118657 doi: 10.1084/jem.20070663
Kebir, H. et al. Preferential recruitment of interferon-γ-expressing T17 cells in multiple sclerosis. Ann. Neurol. 66, 390–402 (2009).
pubmed: 19810097 doi: 10.1002/ana.21748
Knoop, J. et al. GM-CSF producing autoreactive CD4
pubmed: 29229565 doi: 10.1016/j.clim.2017.12.002
Ponomarev, E. D. et al. GM-CSF production by autoreactive T cells is required for the activation of microglial cells and the onset of experimental autoimmune encephalomyelitis. J. Immunol. 178, 39–48 (2007).
pubmed: 17182538 doi: 10.4049/jimmunol.178.1.39
Codarri, L. et al. RORgammat drives production of the cytokine GM-CSF in helper T cells, which is essential for the effector phase of autoimmune neuroinflammation. Nat. Immunol. 12, 560–567 (2011).
pubmed: 21516112 doi: 10.1038/ni.2027
Balmas, E. et al. Proinflammatory islet antigen reactive CD4 T cells are linked with response to alefacept in type 1 diabetes. JCI Insight https://doi.org/10.1172/jci.insight.167881 (2023).
Viisanen, T. et al. Circulating CXCR5
pubmed: 28108610 doi: 10.2337/db16-0714
Edner, N. M. et al. Follicular helper T cell profiles predict response to costimulation blockade in type 1 diabetes. Nat. Immunol. 21, 1244–1255 (2020).
pubmed: 32747817 pmcid: 7610476 doi: 10.1038/s41590-020-0744-z
Globig, A. M. et al. Ustekinumab inhibits T follicular helper cell differentiation in patients with Crohn’s disease. Cell Mol. Gastroenterol. Hepatol. 11, 1–12 (2021).
pubmed: 32679193 doi: 10.1016/j.jcmgh.2020.07.005
McInnes, I. B. et al. Efficacy and safety of ustekinumab in patients with active psoriatic arthritis: 1 year results of the phase 3, multicentre, double-blind, placebo-controlled PSUMMIT 1 trial. Lancet 382, 780–789 (2013).
pubmed: 23769296 doi: 10.1016/S0140-6736(13)60594-2
Sands, B. E. et al. Ustekinumab as induction and maintenance therapy for ulcerative colitis. N. Engl. J. Med. 381, 1201–1214 (2019).
pubmed: 31553833 doi: 10.1056/NEJMoa1900750
Blauvelt, A. et al. Secukinumab is superior to ustekinumab in clearing skin of subjects with moderate-to-severe plaque psoriasis up to 1 year: results from the CLEAR study. J. Am. Acad. Dermatol. 76, 60–69.e69 (2017).
pubmed: 27663079 doi: 10.1016/j.jaad.2016.08.008
Ihara, Y. et al. Ustekinumab improves active Crohn’s disease by suppressing the T helper 17 pathway. Digestion 102, 946–955 (2021).
pubmed: 34350861 doi: 10.1159/000518103
Imazu, N. et al. Ustekinumab decreases circulating Th17 cells in ulcerative colitis. Intern. Med. 63, 153–158 (2023).
pubmed: 37197955 pmcid: 10864063 doi: 10.2169/internalmedicine.1724-23
Taylor, P. N. et al. C-peptide and metabolic outcomes in trials of disease modifying therapy in new-onset type 1 diabetes: an individual participant meta-analysis. Lancet Diabetes Endo. 11, 915–925 (2023).
doi: 10.1016/S2213-8587(23)00267-X
Greenbaum, C., VanBuecken, D. & Lord, S. Disease-modifying therapies in type 1 diabetes: a look into the future of diabetes practice. Drugs 79, 43–61 (2019).
pubmed: 30612319 pmcid: 6613813 doi: 10.1007/s40265-018-1035-y
Mease, P. J. et al. Comparative effectiveness of guselkumab in psoriatic arthritis: updates to a systematic literature review and network meta-analysis. Rheumatology 62, 1417–1425 (2023).
pubmed: 36102818 doi: 10.1093/rheumatology/keac500
Campbell, K. et al. Guselkumab more effectively neutralizes psoriasis-associated histologic, transcriptomic, and clinical measures than ustekinumab. Immunohorizons 7, 273–285 (2023).
pubmed: 37071038 pmcid: 10579843 doi: 10.4049/immunohorizons.2300003
Wang, H. et al. The balance of interleukin-12 and interleukin-23 determines the bias of MAIT1 versus MAIT17 responses during bacterial infection. Immunol. Cell Biol. 100, 547–561 (2022).
pubmed: 35514192 pmcid: 9539875 doi: 10.1111/imcb.12556
Nel, I. et al. MAIT cell alterations in adults with recent-onset and long-term type 1 diabetes. Diabetologia 64, 2306–2321 (2021).
pubmed: 34350463 pmcid: 8336671 doi: 10.1007/s00125-021-05527-y
Yang, J. H. M. et al. Guidelines for standardizing T-cell cytometry assays to link biomarkers, mechanisms, and disease outcomes in type 1 diabetes. Eur. J. Immunol. 52, 372–388 (2022).
pubmed: 35025103 pmcid: 9006584 doi: 10.1002/eji.202049067
Tobias, D. K. et al. Second international consensus report on gaps and opportunities for the clinical translation of precision diabetes medicine. Nat. Med. 29, 2438–2457 (2023).
pubmed: 37794253 pmcid: 10735053 doi: 10.1038/s41591-023-02502-5
Gregory, J. W. et al. Phase II multicentre, double-blind, randomised trial of ustekinumab in adolescents with new-onset type 1 diabetes (USTEK1D): trial protocol. BMJ Open 11, e049595 (2021).
pubmed: 34663658 pmcid: 8524290 doi: 10.1136/bmjopen-2021-049595
Greenbaum, C. J. et al. Mixed-meal tolerance test versus glucagon stimulation test for the assessment of beta-cell function in therapeutic trials in type 1 diabetes. Diabetes Care 31, 1966–1971 (2008).
pubmed: 18628574 pmcid: 2551636 doi: 10.2337/dc07-2451
Seaquist, E. R. et al. Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and the Endocrine Society. Diabetes Care 36, 1384–1395 (2013).
pubmed: 23589542 pmcid: 3631867 doi: 10.2337/dc12-2480
Gonder-Frederick, L., Nyer, M., Shepard, J. A., Vajda, K. & Clarke, W. Assessing fear of hypoglycemia in children with Type 1 diabetes and their parents. Diabetes Manag. 1, 627–639 (2011).
doi: 10.2217/dmt.11.60
Gonder-Frederick, L. A. et al. Psychometric properties of the hypoglycemia fear survey-ii for adults with type 1 diabetes. Diabetes Care 34, 801–806 (2011).
pubmed: 21346182 pmcid: 3064031 doi: 10.2337/dc10-1343
Bradley, C., Plowright, R., Stewart, J., Valentine, J. & Witthaus, E. The Diabetes Treatment Satisfaction Questionnaire change version (DTSQc) evaluated in insulin glargine trials shows greater responsiveness to improvements than the original DTSQ. Health Qual. Life Outcomes 5, 57 (2007).
pubmed: 17927832 pmcid: 2170436 doi: 10.1186/1477-7525-5-57
Varni, J. W., Seid, M. & Kurtin, P. S. PedsQL 4.0: reliability and validity of the Pediatric Quality of Life Inventory version 4.0 generic core scales in healthy and patient populations. Med. Care 39, 800–812 (2001).
pubmed: 11468499 doi: 10.1097/00005650-200108000-00006
Varni, J. W., Seid, M. & Rode, C. A. The PedsQL: measurement model for the pediatric quality of life inventory. Med. Care 37, 126–139 (1999).
pubmed: 10024117 doi: 10.1097/00005650-199902000-00003
Varni, J. W. et al. PedsQL 3.2 diabetes module for children, adolescents, and young adults: reliability and validity in type 1 diabetes. Diabetes Care 41, 2064–2071 (2018).
pmcid: 6905504 doi: 10.2337/dc17-2707
Varni, J. W. et al. Pediatric Quality of Life Inventory (PedsQL) 3.2 diabetes module for youth with type 2 diabetes: reliability and validity. Diabet. Med 36, 465–472 (2019).
pubmed: 30343524 doi: 10.1111/dme.13841
Lachin, J. M. et al. Sample size requirements for studies of treatment effects on beta-cell function in newly diagnosed type 1 diabetes. PLoS ONE 6, e26471 (2011).
pubmed: 22102862 pmcid: 3213096 doi: 10.1371/journal.pone.0026471
Rigby, M. R. et al. Targeting of memory T cells with alefacept in new-onset type 1 diabetes (T1DAL study): 12 month results of a randomised, double-blind, placebo-controlled phase 2 trial. Lancet Diabetes Endocrinol. 1, 284–294 (2013).
pubmed: 24622414 pmcid: 3957186 doi: 10.1016/S2213-8587(13)70111-6
Mortensen, H. B. et al. New definition for the partial remission period in children and adolescents with type 1 diabetes. Diabetes Care 32, 1384–1390 (2009).
pubmed: 19435955 pmcid: 2713624 doi: 10.2337/dc08-1987

Auteurs

Danijela Tatovic (D)

Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK. tatovicd@cardiff.ac.uk.

Ashish Marwaha (A)

University of Calgary, Calgary, Alberta, Canada. ashish.marwaha@ahs.ca.

Peter Taylor (P)

Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK.

Stephanie J Hanna (SJ)

Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK.

Kym Carter (K)

Diabetes Research Unit Cymru, Institute for Life Sciences, Swansea University, Swansea, UK.

W Y Cheung (WY)

Diabetes Research Unit Cymru, Institute for Life Sciences, Swansea University, Swansea, UK.

Steve Luzio (S)

Diabetes Research Unit Cymru, Institute for Life Sciences, Swansea University, Swansea, UK.

Gareth Dunseath (G)

Diabetes Research Unit Cymru, Institute for Life Sciences, Swansea University, Swansea, UK.

Hayley A Hutchings (HA)

Swansea Trials Unit, Swansea University Medical School, Swansea, UK.

Gail Holland (G)

Swansea Trials Unit, Swansea University Medical School, Swansea, UK.

Steve Hiles (S)

Swansea Trials Unit, Swansea University Medical School, Swansea, UK.

Greg Fegan (G)

Swansea Trials Unit, Swansea University Medical School, Swansea, UK.

Evangelia Williams (E)

Department of Immunobiology, School of Immunology & Microbial Sciences, King's College London, Guy's Hospital, London, UK.

Jennie H M Yang (JHM)

Department of Immunobiology, School of Immunology & Microbial Sciences, King's College London, Guy's Hospital, London, UK.

Clara Domingo-Vila (C)

Department of Immunobiology, School of Immunology & Microbial Sciences, King's College London, Guy's Hospital, London, UK.

Emily Pollock (E)

Department of Immunobiology, School of Immunology & Microbial Sciences, King's College London, Guy's Hospital, London, UK.

Muntaha Wadud (M)

Department of Immunobiology, School of Immunology & Microbial Sciences, King's College London, Guy's Hospital, London, UK.

Kirsten Ward-Hartstonge (K)

BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada.
Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada.

Susie Marques-Jones (S)

Patient and Public Representative, Ammanford, UK.

Jane Bowen-Morris (J)

Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK.

Rachel Stenson (R)

Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK.

Megan K Levings (MK)

BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada.
Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada.

John W Gregory (JW)

Division of Population Medicine, Cardiff University School of Medicine, Cardiff, UK.

Timothy I M Tree (TIM)

Department of Immunobiology, School of Immunology & Microbial Sciences, King's College London, Guy's Hospital, London, UK.

Colin Dayan (C)

Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK.

Classifications MeSH