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1. Complement lectin pathway activation is associated with COVID-19 disease severity, independent of MBL2 genotype subgroups

Author

Lisa Hurler, Ágnes Szilágyi, Federica Mescia, Laura Bergamaschi, Blanka Mező, György Sinkovits, Marienn Réti, Veronika Müller, Zsolt Iványi, János Gál, László Gopcsa, Péter Reményi, Beáta Szathmáry, Botond Lakatos, János Szlávik, Ilona Bobek, Zita Z. Prohászka, Zsolt Förhécz, Dorottya Csuka, Erika Kajdácsi, László Cervenak, Petra Kiszel, Tamás Masszi, István Vályi-Nagy, Reinhard Würzner, Cambridge Institute of Therapeutic Immunology and Infectious Disease-National Institute of Health Research (CITIID-NIHR) COVID BioResource Collaboration, Paul A. Lyons, Erik J. M. Toonen, Zoltán Prohászka, Stephen Baker, John R. Bradley, Patrick F. Chinnery, Daniel J. Cooper, Gordon Dougan, Ian G. Goodfellow, Ravindra K. Gupta, Nathalie Kingston, Paul J. Lehner, Nicholas J. Matheson, Caroline Saunders, Kenneth G. C. Smith, Charlotte Summers, James Thaventhiran, M. Estee Torok, Mark R. Toshner, Michael P. Weekes, Gisele Alvio, Sharon Baker, Areti Bermperi, Karen Brookes, Ashlea Bucke, Jo Calder, Laura Canna, Cherry Crucusio, Isabel Cruz, Rnalie de Jesus, Katie Dempsey, Giovanni Di Stephano, Jason Domingo, Anne Elmer, Julie Harris, Sarah Hewitt, Heather Jones, Sherly Jose, Jane Kennet, Yvonne King, Jenny Kourampa, Emily Li, Caroline McMahon, Anne Meadows, Vivien Mendoza, Criona O’Brien, Charmain Ocaya, Ciro Pascuale, Marlyn Perales, Jane Price, Rebecca Rastall, Carla Ribeiro, Jane Rowlands, Valentina Ruffolo, Hugo Tordesillas, Phoebe Vargas, Bensi Vergese, Laura Watson, Jieniean Worsley, Julie-Ann Zerrudo, Ariana Betancourt, Georgie Bower, Ben Bullman, Chiara Cossetti, Aloka De Sa, Benjamin J. Dunore, Maddie Epping, Stuart Fawke, Stefan Gräf, Richard Grenfell, Andrew Hinch, Josh Hodgson, Christopher Huang, Oisin Huhn, Kelvin Hunter, Isobel Jarvis, Emma Jones, Maša Josipović, Ekaterina Legchenko, Daniel Lewis, Joe Marsden, Jennifer Martin, Francesca Nice, Ciara O’Donnell, Ommar Omarjee, Marianne Perera, Linda Pointon, Nicole Pond, Nathan Richoz, Nika Romashova, Natalia Savoinykh, Rahul Sharma, Joy Shih, Mateusz Strezlecki, Rachel Sutcliffe, Tobias Tilly, Zhen Tong, Carmen Treacy, Lori Turner, Jennifer Wood, Marta Wylot, John Allison, Heather Biggs, Helen Butcher, Daniela Caputo, Debbie Clapham-Riley, Eleanor Dewhurst, Christian Fernandez, Anita Furlong, Barbara Graves, Jennifer Gray, Tasmin Ivers, Emma Le Gresley, Rachel Linger, Mary Kasanicki, Sarah Meloy, Francesca Muldoon, Nigel Ovington, Sofia Papadia, Christopher J. Penkett, Isabel Phelan, Venkatesh Ranganath, Jennifer Sambrook, Katherine Schon, Hannah Stark, Kathleen E. Stirrups, Paul Townsend, Julie von Ziegenweidt, Jennifer Webster, Ali Asaripour, Lucy Mwaura, Caroline Patterson, Gary Polwarth, Katherine Bunclark, Michael Mackay, Alice Michael, Sabrina Rossi, Mayurun Selvan, Sarah Spencer, Cissy Yong, and Petra Polgarova

Subjects
mannose binding lectin (MBL), MBL2 genotypes, COVID-19, severe acute respiratory coronavirus 2 (SARS-CoV-2), lectin pathway activation, lectin pathway of complement, Immunologic diseases. Allergy, RC581-607
Abstract

IntroductionWhile complement is a contributor to disease severity in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections, all three complement pathways might be activated by the virus. Lectin pathway activation occurs through different pattern recognition molecules, including mannan binding lectin (MBL), a protein shown to interact with SARS-CoV-2 proteins. However, the exact role of lectin pathway activation and its key pattern recognition molecule MBL in COVID-19 is still not fully understood.MethodsWe therefore investigated activation of the lectin pathway in two independent cohorts of SARS-CoV-2 infected patients, while also analysing MBL protein levels and potential effects of the six major single nucleotide polymorphisms (SNPs) found in the MBL2 gene on COVID-19 severity and outcome.ResultsWe show that the lectin pathway is activated in acute COVID-19, indicated by the correlation between complement activation product levels of the MASP-1/C1-INH complex (p=0.0011) and C4d (p

Published
2023
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2. Distinction of early complement classical and lectin pathway activation via quantification of C1s/C1-INH and MASP-1/C1-INH complexes using novel ELISAs

Author

Lisa Hurler, Erik J. M. Toonen, Erika Kajdácsi, Bregje van Bree, Ricardo J. M. G. E. Brandwijk, Wieke de Bruin, Paul A. Lyons, Laura Bergamaschi, Cambridge Institute of Therapeutic Immunology and Infectious Disease-National Institute of Health Research (CITIID-NIHR) COVID BioResource Collaboration, György Sinkovits, László Cervenak, Reinhard Würzner, Zoltán Prohászka, Stephen Baker, John R. Bradley, Patrick F. Chinnery, Daniel J. Cooper, Gordon Dougan, Ian G. Goodfellow, Ravindra K. Gupta, Nathalie Kingston, Paul J. Lehner, Nicholas J. Matheson, Caroline Saunders, Kenneth G. C. Smith, Charlotte Summers, James Thaventhiran, M. Estee Torok, Mark R. Toshner, Michael P. Weekes, Gisele Alvio, Sharon Baker, Areti Bermperi, Karen Brookes, Ashlea Bucke, Jo Calder, Laura Canna, Cherry Crucusio, Isabel Cruz, Rnalie de Jesus, Katie Dempsey, Giovanni Di Stephano, Jason Domingo, Anne Elmer, Julie Harris, Sarah Hewitt, Heather Jones, Sherly Jose, Jane Kennet, Yvonne King, Jenny Kourampa, Emily Li, Caroline McMahon, Anne Meadows, Vivien Mendoza, Criona O’Brien, Charmain Ocaya, Ciro Pascuale, Marlyn Perales, Jane Price, Rebecca Rastall, Carla Ribeiro, Jane Rowlands, Valentina Ruffolo, Hugo Tordesillas, Phoebe Vargas, Bensi Vergese, Laura Watson, Jieniean Worsley, Julie-Ann Zerrudo, Ariana Betancourt, Georgie Bower, Ben Bullman, Chiara Cossetti, Aloka De Sa, Benjamin J. Dunore, Maddie Epping, Stuart Fawke, Stefan Gräf, Richard Grenfell, Andrew Hinch, Josh Hodgson, Christopher Huang, Oisin Huhn, Kelvin Hunter, Isobel Jarvis, Emma Jones, Maša Josipović, Ekaterina Legchenko, Daniel Lewis, Joe Marsden, Jennifer Martin, Federica Mescia, Francesca Nice, Ciara O’Donnell, Ommar Omarjee, Marianne Perera, Linda Pointon, Nicole Pond, Nathan Richoz, Nika Romashova, Natalia Savoinykh, Rahul Sharma, Joy Shih, Mateusz Strezlecki, Rachel Sutcliffe, Tobias Tilly, Zhen Tong, Carmen Treacy, Lori Turner, Jennifer Wood, Marta Wylot, John Allison, Heather Biggs, Helen Butcher, Daniela Caputo, Debbie Clapham-Riley, Eleanor Dewhurst, Christian Fernandez, Anita Furlong, Barbara Graves, Jennifer Gray, Tasmin Ivers, Emma Le Gresley, Rachel Linger, Mary Kasanicki, Sarah Meloy, Francesca Muldoon, Nigel Ovington, Sofia Papadia, Christopher J. Penkett, Isabel Phelan, Venkatesh Ranganath, Jennifer Sambrook, Katherine Schon, Hannah Stark, Kathleen E. Stirrups, Paul Townsend, Julie von Ziegenweidt, Jennifer Webster, Ali Asaripour, Lucy Mwaura, Caroline Patterson, Gary Polwarth, Katherine Bunclark, Michael Mackay, Alice Michael, Sabrina Rossi, Mayurun Selvan, Sarah Spencer, Cissy Yong, and Petra Polgarova

Subjects
early complement activation, classical pathway activation, lectin pathway activation, C1-INH complexes, assay development and validation, C1s/C1-INH complex, Immunologic diseases. Allergy, RC581-607
Abstract

The most commonly used markers to assess complement activation are split products that are produced through activation of all three pathways and are located downstream of C3. In contrast, C4d derives from the cleavage of C4 and indicates either classical (CP) or lectin pathway (LP) activation. Although C4d is perfectly able to distinguish between CP/LP and alternative pathway (AP) activation, no well-established markers are available to differentiate between early CP and LP activation. Active enzymes of both pathways (C1s/C1r for the CP, MASP-1/MASP-2 for the LP) are regulated by C1 esterase inhibitor (C1-INH) through the formation of covalent complexes. Aim of this study was to develop validated immunoassays detecting C1s/C1-INH and MASP-1/C1-INH complex levels. Measurement of the complexes reveals information about the involvement of the respective pathways in complement-mediated diseases. Two sandwich ELISAs detecting C1s/C1-INH and MASP-1/C1-INH complex were developed and tested thoroughly, and it was investigated whether C1s/C1-INH and MASP-1/C1-INH complexes could serve as markers for either early CP or LP activation. In addition, a reference range for these complexes in healthy adults was defined, and the assays were clinically validated utilizing samples of 414 COVID-19 patients and 96 healthy controls. The immunoassays can reliably measure C1s/C1-INH and MASP-1/C1-INH complex concentrations in EDTA plasma from healthy and diseased individuals. Both complex levels are increased in serum when activated with zymosan, making them suitable markers for early classical and early lectin pathway activation. Furthermore, measurements of C1-INH complexes in 96 healthy adults showed normally distributed C1s/C1-INH complex levels with a physiological concentration of 1846 ± 1060 ng/mL (mean ± 2SD) and right-skewed distribution of MASP-1/C1-INH complex levels with a median concentration of 36.9 (13.18 - 87.89) ng/mL (2.5-97.5 percentile range), while levels of both complexes were increased in COVID-19 patients (p

Published
2022
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3. Levels of soluble complement regulators predict severity of COVID-19 symptoms

Author

Anna L. Tierney, Wajd Mohammed Alali, Thomas Scott, Karen S. Rees-Unwin, CITIID-NIHR BioResource COVID-19 Collaboration, Simon J. Clark, Richard D. Unwin, Stephen Baker, John Bradley, Patrick Chinnery, Daniel Cooper, Gordon Dougan, Ian Goodfellow, Ravindra Gupta, Nathalie Kingston, Paul J. Lehner, Paul A. Lyons, Nicholas J. Matheson, Caroline Saunders, Kenneth G. C. Smith, Charlotte Summers, James Thaventhiran, M. Estee Torok, Mark R. Toshner, Michael P. Weekes, Gisele Alvio, Sharon Baker, Areti Bermperi, Karen Brookes, Ashlea Bucke, Jo Calder, Laura Canna, Cherry Crucusio, Isabel Cruz, Ranalie de Jesus, Katie Dempsey, Giovanni Di Stephano, Jason Domingo, Anne Elmer, Julie Harris, Sarah Hewitt, Heather Jones, Sherly Jose, Jane Kennet, Yvonne King, Jenny Kourampa, Emily Li, Caroline McMahon, Anne Meadows, Vivien Mendoza, Criona O’Brien, Charmain Ocaya, Ciro Pasquale, Marlyn Perales, Jane Price, Rebecca Rastall, Carla Ribeiro, Jane Rowlands, Valentina Ruffolo, Hugo Tordesillas, Phoebe Vargas, Bensi Vergese, Laura Watson, Jieniean Worsley, Julie-Ann Zerrudo, Laura Bergamashi, Ariana Betancourt, Georgie Bower, Ben Bullman, Chiara Cossetti, Aloka De Sa, Benjamin J. Dunmore, Maddie Epping, Stuart Fawke, Stefan Gräf, Richard Grenfell, Andrew Hinch, Josh Hodgson, Christopher Huang, Oisin Huhn, Kelvin Hunter, Isobel Jarvis, Emma Jones, Maša Josipović, Ekaterina Legchenko, Daniel Lewis, Joe Marsden, Jennifer Martin, Federica Mescia, Ciara O’Donnell, Ommar Omarjee, Marianne Perera, Linda Pointon, Nicole Pond, Nathan Richoz, Nika Romashova, Natalia Savoinykh, Rahul Sharma, Joy Shih, Mateusz Strezlecki, Rachel Sutcliffe, Tobias Tilly, Zhen Tong, Carmen Treacy, Lori Turner, Jennifer Wood, Marta Wylot, John Allison, Heather Biggs, John R. Bradley, Helen Butcher, Daniela Caputo, Matt Chandler, Debbie Clapham-Riley, Eleanor Dewhurst, Christian Fernandez, Anita Furlong, Barbara Graves, Jennifer Gray, Sabine Hein, Tasmin Ivers, Emma Le Gresley, Rachel Linger, Mary Kasanicki, Rebecca King, Sarah Meloy, Alexei Moulton, Francesca Muldoon, Nigel Ovington, Sofia Papadia, Christopher J. Penkett, Isabel Phelan, Venkatesh Ranganath, Roxana Paraschiv, Abigail Sage, Jennifer Sambrook, Ingrid Scholtes, Katherine Schon, Hannah Stark, Kathleen E. Stirrups, Paul Townsend, Neil Walker, Jennifer Webster, Mayurun Selvan, Petra Polgarova, Sarah L. Caddy, Laura G. Caller, Yasmin Chaudhry, Martin D. Curran, Theresa Feltwell, Stewart Fuller, Iliana Georgana, Grant Hall, William L. Hamilton, Myra Hosmillo, Charlotte J. Houldcroft, Rhys Izuagbe, Aminu S. Jahun, Fahad A. Khokhar, Anna G. Kovalenko, Luke W. Meredith, Surendra Parmar, Malte L. Pinckert, Anna Yakovleva, Emily C. Horner, Lucy Booth, Alexander Ferreira, Rebecca Boston, Robert Hughes, Juan Carlos Yam Puc, Nonantzin Beristain-Covarrubias, Maria Rust, Thevinya Gurugama, Lihinya Gurugama, Thomas Mulroney, Sarah Spencer, Zhaleh Hosseini, and Kate Williamson

Subjects
COVID-19, SARS-CoV-2, complement, factor H, factor H-related proteins, biomarkers, Immunologic diseases. Allergy, RC581-607
Abstract

The SARS-CoV-2 virus continues to cause significant morbidity and mortality worldwide from COVID-19. One of the major challenges of patient management is the broad range of symptoms observed. While the majority of individuals experience relatively mild disease, a significant minority of patients require hospitalisation, with COVID-19 still proving fatal for some. As such, there remains a desperate need to better understand what drives this severe disease, both in terms of the underlying biology, but also to potentially predict at diagnosis which patients are likely to require further interventions, thus enabling better outcomes for both patients and healthcare systems. Several lines of evidence have pointed to dysregulation of the complement cascade as a major factor in severe COVID-19 outcomes. How this is underpinned mechanistically is not known. Here, we have focussed on the role of the soluble complement regulators Complement Factor H (FH), its splice variant Factor H-like 1 (FHL-1) and five Factor H-Related proteins (FHR1-5). Using a targeted mass spectrometry approach, we quantified these proteins in a cohort of 188 plasma samples from controls and SARS-CoV-2 patients taken at diagnosis. This analysis revealed significant elevations in all FHR proteins, but not FH, in patients with more severe disease, particularly FHR2 and FHR5 (FHR2: 1.97-fold, p

Published
2022
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4. Combined Point-of-Care Nucleic Acid and Antibody Testing for SARS-CoV-2 following Emergence of D614G Spike Variant

Author

Petra Mlcochova, Dami Collier, Allyson Ritchie, Sonny M. Assennato, Myra Hosmillo, Neha Goel, Bo Meng, Krishna Chatterjee, Vivien Mendoza, Nigel Temperton, Leo Kiss, Leo C. James, Katarzyna A. Ciazynska, Xiaoli Xiong, John A.G. Briggs, James A. Nathan, Federica Mescia, Laura Bergamaschi, Hongyi Zhang, Petros Barmpounakis, Nikos Demeris, Richard Skells, Paul A. Lyons, John Bradley, Steven Baker, Jean Pierre Allain, Kenneth G.C. Smith, Rachel Bousfield, Michael Wilson, Dominic Sparkes, Glenn Amoroso, Effrosyni Gkrania-Klotsas, Susie Hardwick, Adrian Boyle, Ian Goodfellow, Ravindra K. Gupta, Stephen Baker, Gordon Dougan, Ravi Gupta, Paul J. Lehner, Paul Lyons, Nicholas J. Matheson, Mark Toshner, Michael P. Weekes, Nick Brown, Martin Curran, Surendra Palmar, David Enoch, Daniel Chapman, Ashley Shaw, Sherly Jose, Areti Bermperi, Julie Ann Zerrudo, Evgenia Kourampa, Laura Watson, Jieniean Worsley, Caroline Saunders, Ranalie de Jesus, Jason Domingo, Ciro Pasquale, Bensi Vergese, Phoebe Vargas, Marivic Fabiculana, Marlyn Perales, Lee Mynott, Elizabeth Blake, Amy Bates, Anne-Laure Vallier, Alexandra Williams, David Phillips, Edmund Chiu, Alex Overhill, Nicola Ramenatte, Jamal Sipple, Steven Frost, Helena Knock, Richard Hardy, Emily Foster, Fiona Davidson, Viona Rundell, Purity Bundi, Richmond Abeseabe, Sarah Clark, Isabel Vicente, Anne Elmer, Carla Ribeiro, Jenny Kourampa, Jane Kennet, Jane Rowlands, Anne Meadows, Criona O’Brien, Rebecca Rastall, Cherry Crucusio, Sarah Hewitt, Jane Price, Jo Calder, Laura Canna, Ashlea Bucke, Hugo Tordesillas, Julie Harris, Valentina Ruffolo, Barbara Graves, Helen Butcher, Daniela Caputo, Emma Le Gresley, Benjamin J. Dunmore, Jennifer Martin, Ekaterina Legchenko, Carmen Treacy, Christopher Huang, Jennifer Wood, Rachel Sutcliffe, Josh Hodgson, Joy Shih, Stefan Graf, Zhen Tong, Tobias Tilly, Ciara O’Donnell, Kelvin Hunter, Linda Pointon, Nicole Pond, Marta Wylot, Emma Jones, Stuart Fawke, Ben Bullman, Lori Turner, Isobel Jarvis, Ommar Omarjee, Aloka De Sa, Joe Marsden, Ariana Betancourt, Marianne Perera, Maddie Epping, Nathan Richoz, Georgie Bower, Rahul Sharma, Francesca Nice, Oisin Huhn, Natalia Savoinykh Yarkoni, Nika Romashova, Daniel Lewis, Andrew Hinch, Chiara Cossetti, Mateusz Strezlecki, Richard Grenfell, Hannah Stark, Neil Walker, Kathy Stirrups, Nigel Ovington, Eleanor Dewhust, Emily Li, Sofia Papadia, Nathalie Kingston, Andrew Lever, Estee Torok, William Hamilton, Grant Hall, Aminu Jahun, Yasmin Chaudhry, Malte Pinckert, Iliana Georgana, Anna Yakovleva, Laura Caller, Sarah Caddy, Theresa Feltwell, Fahad Khokhar, Luke Meredith, Charlotte Holdcroft, and Surendra Parmar

Subjects
SARS-CoV-2, COVID-19, rapid diagnoses, point of care testing, D614G, Medicine (General), R5-920
Abstract

Summary: Rapid COVID-19 diagnosis in the hospital is essential, although this is complicated by 30%–50% of nose/throat swabs being negative by SARS-CoV-2 nucleic acid amplification testing (NAAT). Furthermore, the D614G spike mutant dominates the pandemic and it is unclear how serological tests designed to detect anti-spike antibodies perform against this variant. We assess the diagnostic accuracy of combined rapid antibody point of care (POC) and nucleic acid assays for suspected COVID-19 disease due to either wild-type or the D614G spike mutant SARS-CoV-2. The overall detection rate for COVID-19 is 79.2% (95% CI 57.8–92.9) by rapid NAAT alone. The combined point of care antibody test and rapid NAAT is not affected by D614G and results in very high sensitivity for COVID-19 diagnosis with very high specificity.

Published
2020
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5. SARS-CoV-2 spike N-terminal domain modulates TMPRSS2-dependent viral entry and fusogenicity

Author

Bo Meng, Rawlings Datir, Jinwook Choi, John R. Bradley, Kenneth G.C. Smith, Joo Hyeon Lee, Ravindra K. Gupta, Stephen Baker, Gordon Dougan, Christoph Hess, Nathalie Kingston, Paul J. Lehner, Paul A. Lyons, Nicholas J. Matheson, Willem H. Owehand, Caroline Saunders, Charlotte Summers, James E.D. Thaventhiran, Mark Toshner, Michael P. Weekes, Patrick Maxwell, Ashley Shaw, Ashlea Bucke, Jo Calder, Laura Canna, Jason Domingo, Anne Elmer, Stewart Fuller, Julie Harris, Sarah Hewitt, Jane Kennet, Sherly Jose, Jenny Kourampa, Anne Meadows, Criona O’Brien, Jane Price, Cherry Publico, Rebecca Rastall, Carla Ribeiro, Jane Rowlands, Valentina Ruffolo, Hugo Tordesillas, Ben Bullman, Benjamin J. Dunmore, Stuart Fawke, Stefan Gräf, Josh Hodgson, Christopher Huang, Kelvin Hunter, Emma Jones, Ekaterina Legchenko, Cecilia Matara, Jennifer Martin, Federica Mescia, Ciara O’Donnell, Linda Pointon, Joy Shih, Rachel Sutcliffe, Tobias Tilly, Carmen Treacy, Zhen Tong, Jennifer Wood, Marta Wylot, Ariana Betancourt, Georgie Bower, Chiara Cossetti, Aloka De Sa, Madeline Epping, Nick Gleadall, Richard Grenfell, Andrew Hinch, Sarah Jackson, Isobel Jarvis, Ben Krishna, Francesca Nice, Ommar Omarjee, Marianne Perera, Martin Potts, Nathan Richoz, Veronika Romashova, Luca Stefanucci, Mateusz Strezlecki, Lori Turner, Eckart M.D.D. De Bie, Katherine Bunclark, Masa Josipovic, Michael Mackay, John Allison, Helen Butcher, Daniela Caputo, Debbie Clapham-Riley, Eleanor Dewhurst, Anita Furlong, Barbara Graves, Jennifer Gray, Tasmin Ivers, Emma Le Gresley, Rachel Linger, Sarah Meloy, Francesca Muldoon, Nigel Ovington, Sofia Papadia, Isabel Phelan, Hannah Stark, Kathleen E. Stirrups, Paul Townsend, Neil Walker, Jennifer Webster, Ingrid Scholtes, Sabine Hein, and Rebecca King

Subjects
Organoid, Omicron, SARS-CoV-2, Serine Endopeptidases, CP: Microbiology, COVID-19, spike, Virus Internalization, General Biochemistry, Genetics and Molecular Biology, Spike Glycoprotein, Coronavirus, NTD, Delta, Spike Glycoprotein, Coronavirus, entry, Humans, fusogenicity, TMPRSS2
Abstract

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike N-terminal domain (NTD) remains poorly characterized despite enrichment of mutations in this region across variants of concern (VOCs). Here, we examine the contribution of the NTD to infection and cell-cell fusion by constructing chimeric spikes bearing B.1.617 lineage (Delta and Kappa variants) NTDs and generating spike pseudotyped lentivirus. We find that the Delta NTD on a Kappa or wild-type (WT) background increases S1/S2 cleavage efficiency and virus entry, specifically in lung cells and airway organoids, through use of TMPRSS2. Delta exhibits increased cell-cell fusogenicity that could be conferred to WT and Kappa spikes by Delta NTD transfer. However, chimeras of Omicron BA.1 and BA.2 spikes with a Delta NTD do not show more efficient TMPRSS2 use or fusogenicity. We conclude that the NTD allosterically modulates S1/S2 cleavage and spike-mediated functions in a spike context-dependent manner, and allosteric interactions may be lost when combining regions from more distantly related VOCs.

Published
2022

6. B cell receptor repertoire kinetics after SARS-CoV-2 infection and vaccination

Author

Prasanti Kotagiri, Mark R. Wills, Kelvin Hunter, William Rae, Laura Bergamaschi, Ravindra K. Gupta, John Bradley, Nicholas J Matheson, Eoin F. McKinney, Myra Hosmillo, Paul A. Lyons, Menna R. Clatworthy, Zewen Tuong, Lorinda Turner, Ian Goodfellow, Rachael Bashford-Rogers, Federica Mescia, Kenneth G. C. Smith, Federico Pehuen Pereyra Gerber, and Christoph Hess

Subjects
Resource, B cell receptor repertoire, History, medicine.medical_specialty, Polymers and Plastics, B-Cell Receptor Repertoire, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), education, Immunoglobulin Variable Region, Receptors, Antigen, B-Cell, Severity of Illness Index, Industrial and Manufacturing Engineering, General Biochemistry, Genetics and Molecular Biology, Clonal Evolution, Informed consent, Receptors, medicine, Immunoglobulin, Humans, Business and International Management, BNT162 Vaccine, B-Lymphocytes, business.industry, SARS-CoV-2, Repertoire, Vaccination, B-Cell, COVID-19, University hospital, SARS-CoV-2 vaccination, Immunoglobulin Heavy Chains, Immunoglobulin Isotypes, Kinetics, Somatic Hypermutation, Immunoglobulin, Spike Glycoprotein, Coronavirus, Somatic Hypermutation, Spike Glycoprotein, Coronavirus, Research centre, Family medicine, Antigen, Core laboratory, business
Abstract

B cells are important in immunity to both SARS-CoV-2 infection and vaccination, but B cell receptor (BCR) repertoire development in these contexts has not been compared. We analyse serial samples from 171 SARS-CoV-2-infected individuals and 63 vaccine recipients, and find the global BCR repertoire differs between them. Following infection, IgG1/3 and IgA1 BCRs increase, somatic hypermutation (SHM) decreases and, in severe disease, IgM and IgA clones are expanded. In contrast, after vaccination the proportion of IgD/M BCRs increase, SHM is unchanged and expansion of IgG clones is prominent. VH1-24, which targets the N-terminal domain (NTD) and contributes to neutralization, is expanded post-infection except in the most severe disease. Infection generates a broad distribution of SARS-CoV-2-specific clones predicted to target the spike protein, whilst a more focused response after vaccination mainly targets the spike’s receptor-binding domain. Thus the nature of SARS-CoV-2 exposure differentially impacts BCR repertoire development, potentially informing vaccine strategies., Graphical Abstract, Kotagiri et al. find that SARS-CoV-2 infection versus vaccination induces distinct changes in the B cell receptor repertoire, including prominent clonal expansion in IgA and IgM after infection, but IgG after vaccination. A broad anti-spike response to infection contrasts with a narrower RBD-focused one after vaccination, potentially informing vaccination strategies.

Published
2022

7. Combined point-of-care nucleic acid and antibody testing for SARS-CoV-2 following emergence of D614G spike variant

Author

Petra Mlcochova, Dami Collier, Allyson Ritchie, Sonny M. Assennato, Myra Hosmillo, Neha Goel, Bo Meng, Krishna Chatterjee, Vivien Mendoza, Nigel Temperton, Leo Kiss, Leo C. James, Katarzyna A. Ciazynska, Xiaoli Xiong, John A.G. Briggs, James A. Nathan, Federica Mescia, Laura Bergamaschi, Hongyi Zhang, Petros Barmpounakis, Nikos Demeris, Richard Skells, Paul A. Lyons, John Bradley, Steven Baker, Jean Pierre Allain, Kenneth G.C. Smith, Rachel Bousfield, Michael Wilson, Dominic Sparkes, Glenn Amoroso, Effrosyni Gkrania-Klotsas, Susie Hardwick, Adrian Boyle, Ian Goodfellow, Ravindra K. Gupta, Stephen Baker, Gordon Dougan, Ravi Gupta, Paul J. Lehner, Paul Lyons, Nicholas J. Matheson, Mark Toshner, Michael P. Weekes, Nick Brown, Martin Curran, Surendra Palmar, David Enoch, Daniel Chapman, Ashley Shaw, Sherly Jose, Areti Bermperi, Julie Ann Zerrudo, Evgenia Kourampa, Laura Watson, Jieniean Worsley, Caroline Saunders, Ranalie de Jesus, Jason Domingo, Ciro Pasquale, Bensi Vergese, Phoebe Vargas, Marivic Fabiculana, Marlyn Perales, Lee Mynott, Elizabeth Blake, Amy Bates, Anne-Laure Vallier, Alexandra Williams, David Phillips, Edmund Chiu, Alex Overhill, Nicola Ramenatte, Jamal Sipple, Steven Frost, Helena Knock, Richard Hardy, Emily Foster, Fiona Davidson, Viona Rundell, Purity Bundi, Richmond Abeseabe, Sarah Clark, Isabel Vicente, Anne Elmer, Carla Ribeiro, Jenny Kourampa, Jane Kennet, Jane Rowlands, Anne Meadows, Criona O’Brien, Rebecca Rastall, Cherry Crucusio, Sarah Hewitt, Jane Price, Jo Calder, Laura Canna, Ashlea Bucke, Hugo Tordesillas, Julie Harris, Valentina Ruffolo, Barbara Graves, Helen Butcher, Daniela Caputo, Emma Le Gresley, Benjamin J. Dunmore, Jennifer Martin, Ekaterina Legchenko, Carmen Treacy, Christopher Huang, Jennifer Wood, Rachel Sutcliffe, Josh Hodgson, Joy Shih, Stefan Graf, Zhen Tong, Tobias Tilly, Ciara O’Donnell, Kelvin Hunter, Linda Pointon, Nicole Pond, Marta Wylot, Emma Jones, Stuart Fawke, Ben Bullman, Lori Turner, Isobel Jarvis, Ommar Omarjee, Aloka De Sa, Joe Marsden, Ariana Betancourt, Marianne Perera, Maddie Epping, Nathan Richoz, Georgie Bower, Rahul Sharma, Francesca Nice, Oisin Huhn, Natalia Savoinykh Yarkoni, Nika Romashova, Daniel Lewis, Andrew Hinch, Chiara Cossetti, Mateusz Strezlecki, Richard Grenfell, Hannah Stark, Neil Walker, Kathy Stirrups, Nigel Ovington, Eleanor Dewhust, Emily Li, Sofia Papadia, Nathalie Kingston, Andrew Lever, Estee Torok, William Hamilton, Grant Hall, Aminu Jahun, Yasmin Chaudhry, Malte Pinckert, Iliana Georgana, Anna Yakovleva, Laura Caller, Sarah Caddy, Theresa Feltwell, Fahad Khokhar, Luke Meredith, Charlotte Holdcroft, and Surendra Parmar

Subjects
Male, Antibodies, Viral, Serology, 0302 clinical medicine, COVID-19 Testing, 80 and over, Medicine, 030212 general & internal medicine, Viral, Aged, 80 and over, Immunoassay, 0303 health sciences, lcsh:R5-920, biology, Middle Aged, D614G, Spike Glycoprotein, 3. Good health, medicine.anatomical_structure, Point-of-Care Testing, Spike Glycoprotein, Coronavirus, Spike (software development), Female, Antibody, lcsh:Medicine (General), Nucleic Acid Amplification Techniques, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), Point-of-care testing, Sensitivity and Specificity, General Biochemistry, Genetics and Molecular Biology, Antibodies, 03 medical and health sciences, rapid diagnoses, Neutralization Tests, Throat, Report, Humans, 030304 developmental biology, Point of care, Aged, QR355, COVID-19, point of care testing, SARS-CoV-2, business.industry, Virology, Coronavirus, biology.protein, Nucleic acid, business
Abstract

Rapid COVID-19 diagnosis in the hospital is essential, although this is complicated by 30%–50% of nose/throat swabs being negative by SARS-CoV-2 nucleic acid amplification testing (NAAT). Furthermore, the D614G spike mutant dominates the pandemic and it is unclear how serological tests designed to detect anti-spike antibodies perform against this variant. We assess the diagnostic accuracy of combined rapid antibody point of care (POC) and nucleic acid assays for suspected COVID-19 disease due to either wild-type or the D614G spike mutant SARS-CoV-2. The overall detection rate for COVID-19 is 79.2% (95% CI 57.8–92.9) by rapid NAAT alone. The combined point of care antibody test and rapid NAAT is not affected by D614G and results in very high sensitivity for COVID-19 diagnosis with very high specificity., Graphical Abstract, Highlights Combined rapid antibody + nucleic acid detection correctly diagnoses SARS-CoV-2 Rapid antibody tests detect immune responses against SARS-CoV-2 bearing D614G Rapid SARS-CoV-2 antibody tests do not cross-react with antibodies to seasonal CoV False positivity in SARS-CoV-2 finger prick blood antibody tests can be very low, Mlcochova et al. report that combined rapid nucleic acid amplification testing (NAAT) and finger prick blood antibody tests can substantially improve the diagnosis of COVID-19 as compared to NAAT alone and is able to detect the SARS-CoV-2 Spike D614G variant that dominates the pandemic.

Published
2021

8. Delayed bystander CD8 T cell activation, early immune pathology and persistent dysregulation characterise severe COVID-19

Author

Caroline Saunders, Jeremy K. Nicholson, Nathalie Kingston, Lorinda Turner, John Bradley, Ian Goodfellow, Erik J M Toonen, Anne Elmer, Michael D Morgan, Michael P. Weekes, Berthold Göttgens, Paul A. Lyons, Paul J. Lehner, Aloka DeSa, Oisin Huhn, Myra Hosmillo, Kelvin Hunter, Nicholas J Matheson, Prasanti Kotagiri, Christoph Hess, James Thaventhiran, Pehuen Pereyra Gerber, Laura Bergamaschi, Anna M. Petrunkina, Ravindra K. Gupta, Benjamin J. Dunmore, Gordon Dougan, Aimee Hanson, Mark R. Wills, Kenneth G. C. Smith, Hélène Ruffieux, Sylvia Richardson, Federica Mescia, Fernando Calero Nieto, Rainer Doffinger, Stephen Baker, Mark Toshner, and CambridgeInstituteofTherapeuticImmunologyandInfectiousDisease-NationalInstituteofHealthResearch(CITI)

Subjects
Immune system, business.industry, Immunopathology, Immunology, medicine, Bystander effect, Inflammation, Tumor necrosis factor alpha, medicine.symptom, Systemic inflammation, business, Asymptomatic, Viral load
Abstract

SummaryIn a study of 207 SARS-CoV2-infected individuals with a range of severities followed over 12 weeks from symptom onset, we demonstrate that an early robust bystander CD8 T cell immune response, without systemic inflammation, is characteristic of asymptomatic or mild disease. Those presenting to hospital had delayed bystander responses and systemic inflammation already evident at around symptom onset. Such early evidence of inflammation suggests immunopathology may be inevitable in some individuals, or that preventative intervention might be needed before symptom onset. Viral load does not correlate with the development of this pathological response, but does with its subsequent severity. Immune recovery is complex, with profound persistent cellular abnormalities correlating with a change in the nature of the inflammatory response, where signatures characteristic of increased oxidative phosphorylation and reactive-oxygen species-associated inflammation replace those driven by TNF and IL-6. These late immunometabolic inflammatory changes and unresolved immune defects may have clinical implications.

Published
2021

9. Author response: Effective control of SARS-CoV-2 transmission between healthcare workers during a period of diminished community prevalence of COVID-19

Author

Simone Hargreaves, Francescsa Nice, Naidine Escoffery, Paul J. Lehner, Lucy Rivett, Caroline Saunders, Julie Harris, Neil Bartholomew, Natalia Savoinykh Yarkoni, Anne Meadows, Anne-Laure Vallier, Mary Kasanicki, Joe Marsden, Jo Wright, Charlotte J. Houldcroft, Chris Workman, Mark Ferris, Carmen M. Treacy, Kelvin Hunter, Anita Furlong, Harmeet Gill, Michael P. Weekes, Surendra Parmar, Nika Romashova, Kenneth G. C. Smith, Greg Hannon, Ashlea Bucke, Chris McNicholas, Debbie Read, Myra Hosmillo, Sushmita Sridhar, Linda Pointon, Jane Gray, John Bradley, Josh Hodgson, Emma Le Gresley, Joana Pereira-Dias, Lori Turner, Nicola Ramenatte, Stefan Gräf, Ben Warne, Claire Cormie, Jane Rowlands, Jane Kennet, Penelope-Jane Eames, Christopher Huang, Barbara J. Graves, Sally Forrest, Helen Butcher, Daniela Caputo, Joanna Calder, Anna Yakovleva, Jo Price, Aileen Narcorda, M. Estée Török, Sarah Hewitt, Martin D. Curran, Ian Goodfellow, Valentina Ruffolo, Cordova Jiménez, Michelle Wantoch, Lisa Thake, Zhen Tong, Isobel Jarvis, Laura Canna, Paul A. Lyons, Isabel Cruz, Benjamin J. Dunmore, Anne Roberts, William David Córdova Jiménez, Lucy Worboys, Helen Dolling, Rebecca Rastall, Ommar Omarjee, Sarah L Caddy, Barrie Bailey, William L Hamilton, Ekaterina Legchenko, Debra Clapham-Riley, Rachel Sutcliffe, Ciara O’Donnell, Fahad A Khokhar, Laura G Caller, Kathleen E Stirrups, Fathima Nisha Begum Samad, Hongyi Zhang, Jamie Young, Sofia Papadia, Criona O Brien, Tobias Tilly, Jennifer M. Martin, Nick K Jones, Kirsty Lagadu, Carla Ribeiro, Ailsa Bowring, Nicholas J Matheson, Tim Gould, D. Johnson, Ashley Shaw, Simon McCallum, Tim Raine, Daniel Lewis, Ariana Betancourt, Stewart Fuller, Afzal N. Chaudhry, Lenette Mactavous, Heather F Jones, William David, Rachel Doughton, Theresa Feltwell, Luke W. Meredith, Nathalie Kingston, Hannah Stark, Georgie Bowyer, Gregory J. Hannon, Karen Brookes, Dominic Sparkes, Iain Kean, Ravi Gupta, Cherry Publico, Katie Dempsey, Matthew Routledge, Nicholas K Jones, Aloka De Sa, Giles Wright, Laura Bergamaschi, Claire Mather, Rutendo Nyagumbo, Maddie Epping, Jack Levy, Marianne Perera, Christian Sparke, Fatima Nb Samad, Nicola Reynolds, Michael Gill, Hugo Tordesillas, Oisin Huhn, Anne Elmer, Geraldine Martell, Mateusz Strezlecki, Grant Hall, Andrew Hinch, Gordon Dougan, Jennifer Webster, Helen Murphy, Stephen Baker, Aminu S Jahun, Mark Toshner, Angela Wright, Natalie Quinnell, Joy Shih, Caroline Trotter, Nicholas K. Brown, Federica Mescia, John S. Bradley, and Jennifer Wood

Subjects
medicine.medical_specialty, Transmission (mechanics), Coronavirus disease 2019 (COVID-19), business.industry, law, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), Period (gene), Emergency medicine, Health care, Medicine, business, law.invention
Published
2020

10. Author response: Screening of healthcare workers for SARS-CoV-2 highlights the role of asymptomatic carriage in COVID-19 transmission

Author

Jennifer Webster, Stephen Baker, Neil Bartholomew, Aminu S Jahun, Rutendo Nyagumbo, Mark Toshner, Julie Harris, Paul J. Lehner, Charlotte J. Houldcroft, Lisa Thake, Sarah L Caddy, Benjamin J. Dunmore, Afzal N. Chaudhry, Theresa Feltwell, Christian Sparke, M. Estée Török, Nick K Jones, Michael P. Weekes, Emma Le Gresley, Simon McCallum, Tim Raine, Josefin Bartholdson Scott, Grant Hall, Myra Hosmillo, Stewart Fuller, Andrew Hinch, Angela Wright, Gordon Dougan, Jane Rowlands, Aileen Narcorda, Sally Forrest, Claire Cormie, Jennifer M. Martin, Kathleen E Stirrups, Sarah Hewitt, Natalie Quinnell, Joy Shih, Katie Dempsey, Geraldine Martell, Helen Murphy, Ashley Shaw, Cherry Publico, Heather F Jones, Carmen M. Treacy, Anne-Laure Vallier, Surendra Parmar, Jennifer Wood, Ariana Betancourt, Ashlea Bucke, Debbie Read, Helen Butcher, Martin D. Curran, Penelope-Jane Eames, Sushmita Sridhar, Chris McNicholas, Dominic Sparkes, Ian Goodfellow, Nicola Reynolds, Ciara O’Donnell, Valentina Ruffolo, Jane Kennet, Fahad A Khokhar, Hannah Stark, Paul A. Lyons, Francescsa Nice, Karen Brookes, Lenette Mactavous, Claire Mather, Maddie Epping, Aloka De Sa, Lucy Warboys, Isabel Cruz, Naidine Escoffery, Carla Ribeiro, Ailsa Bowring, Nicholas J Matheson, Iain Kean, Tobias Tilly, Daniel Lewis, Ravi Gupta, Kelvin Hunter, Giles Wright, Anne Roberts, Hugo Tordesillas, Isobel Jarvis, Nicholas K. Brown, Laura Bergamaschi, Anne Elmer, Harmeet Gill, Oisin Huhn, D. Johnson, Laura G Caller, John Bradley, Caroline Saunders, Federica Mescia, Joanna Calder, Anna Yakovleva, Jo Price, Richard J. Samworth, Kenneth G. C. Smith, Mary Kasanicki, Hongyi Zhang, Laura Canna, Rebecca Rastall, Jo Wright, Ben Warne, Simone Hargreaves, Anita Furlong, Josh Hodgson, Daniela Caputo, Stefan Gräf, Jamie Young, Sofia Papadia, Criona O Brien, Kirsty Lagadu, Georgie Bowyer, Michelle Wantoch, Ekaterina Legchenko, Debra Clapham-Riley, Rachel Sutcliffe, Joe Marsden, Mark Ferris, Tim Gould, Mailis Maes, Luke W. Meredith, Joana Pereira-Dias, Nicola Ramenatte, Matthew Routledge, Nathalie Kingston, Helen Dolling, William L Hamilton, Linda Pointon, Christopher Huang, Barbara J. Graves, Lucy Rivett, Anne Meadows, and Zhen Tong

Subjects
medicine.medical_specialty, Coronavirus disease 2019 (COVID-19), business.industry, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), Asymptomatic, law.invention, Carriage, Transmission (mechanics), law, Health care, medicine, medicine.symptom, Intensive care medicine, business
Published
2020

11. Early Immune Pathology and Persistent Dysregulation Characterise Severe COVID-19

Author

Laura Bergamaschi, Federica Mescia, Lorinda Turner, Aimee Hanson, Prasanti Kotagiri, Benjamin J. Dunmore, Helene Ruffieux, Aloka De Sa, Oisin Huhn, Mark R. Wills, Stephen Baker, Rainer Doffinger, Gordon Dougan, Anne Elmer, Ian Goodfellow, Ravindra K. Gupta, Myra Hosmillo, Kelvin Hunter, Nathalie Kingston, Paul Lehner, Nicholas J. Matheson, Jeremy K. Nicholson, Anna M. Petrunkina, Sylvia Richardson, Caroline Saunders, James Thaventhiran, Erik J. M. Toonen, Michael P. Weekes, (CITIID-NIHR) COVID BioResource Col Group, Mark Toshner, Christoph Hess, John R. Bradley, Paul A. Lyons, and Kenneth G.C. Smith

Subjects
medicine.medical_specialty, business.industry, Inflammation, Systemic inflammation, Asymptomatic, Clinical research, Immune system, Internal medicine, Immunopathology, Medicine, Tumor necrosis factor alpha, medicine.symptom, business, Viral load
Abstract

In a study of 207 SARS-CoV2-infected individuals with a range of severities followed over 12 weeks from symptom onset, we demonstrate that an early robust immune response, without systemic inflammation, is characteristic of asymptomatic or mild disease. Those presenting to hospital had delayed adaptive responses and systemic inflammation already evident at around symptom onset. Such early evidence of inflammation suggests immunopathology may be inevitable in some individuals, or that preventative intervention might be needed before symptom onset. Viral load does not correlate with the development of this pathological response, but does with its subsequent severity. Immune recovery is complex, with profound persistent cellular abnormalities correlating with a change in the nature of the inflammatory response, where signatures characteristic of increased oxidative phosphorylation and reactive-oxygen species-associated inflammation replace those driven by TNF and IL-6. These late immunometabolic inflammatory changes and unresolved immune cell defects, if persistent, may contribute to “long COVID”. Funding: We are grateful for the generous support of CVC Capital Partners, the Evelyn Trust (20/75), UKRI COVID Immunology Consortium, Addenbrooke’s Charitable Trust (12/20A) and the NIHR Cambridge Biomedical Research Centre for their financial support. K.G.C.S. is the recipient of a Wellcome Investigator Award (200871/Z/16/Z); M.P.W. is the recipient of Wellcome Senior Clinical Research Fellowship (108070/Z/15/Z); C.H. was funded by a Wellcome COVID-19 Rapid Response DCF and the Fondation Botnar; N.M. was funded by the MRC (CSF MR/P008801/1) and NHSBT (WPA15-02); I.G.G. is a Wellcome Senior Fellow and was supported by funding from the Wellcome (Ref: 207498/Z/17/Z). Conflict of Interest: The authors declare they have no competing interests.

Published
2020

12. Cohort profile: prescriptions dispensed in the community linked to the national cancer registry in England

Author

Brian Shand, Katherine E Henson, Georgios Lyratzopoulos, Martin G. McCabe, Rachael Brock, Lucy Elliss-Brookes, Nina Monckton, Kwok Wong, Philip Godfrey, Robert Robson, Victoria H. Coupland, Thomas Round, Jem Rashbass, Graham Mitchell, Abigail Haigh, Kelvin Hunter, Lyratzopoulos, Georgios [0000-0002-2873-7421], and Apollo - University of Cambridge Repository

Subjects
Male, Information Storage and Retrieval, Health informatics, 0302 clinical medicine, Data Anonymization, Neoplasms, Epidemiology, 030212 general & internal medicine, Registries, health informatics, Child, Aged, 80 and over, Manchester Cancer Research Centre, General Medicine, Middle Aged, Data Accuracy, England, 030220 oncology & carcinogenesis, Child, Preschool, oncology, Hormonal therapy, epidemiology, Female, Medical Record Linkage, Adult, medicine.medical_specialty, Adolescent, Drug Prescriptions, 03 medical and health sciences, primary care, Young Adult, medicine, Humans, Medical prescription, Aged, Cohort Profile, business.industry, Public health, ResearchInstitutes_Networks_Beacons/mcrc, Infant, Newborn, Cancer, Infant, Guideline, medicine.disease, Cancer registry, Family medicine, business
Abstract

PurposeThe linked prescriptions cancer registry data resource was set up to extend our understanding of the pathway for patients with cancer past secondary care into the community, to ultimately improve patient outcomes.ParticipantsThe linked prescriptions cancer registry data resource is currently available for April to July 2015, for all patients diagnosed with cancer in England with a dispensed prescription in that time frame.The dispensed prescriptions data are collected by National Health Service (NHS) Prescription Services, and the cancer registry data are processed by Public Health England. All data are routine healthcare data, used for secondary purposes, linked using a pseudonymised version of the patient’s NHS number and date of birth.Detailed demographic and clinical information on the type of cancer diagnosed and treatment is collected by the cancer registry. The dispensed prescriptions data contain basic demographic information, geography measures of the dispensed prescription, drug information (quantity, strength and presentation), cost of the drug and the date that the dispensed prescription was submitted to NHS Business Services Authority.Findings to dateFindings include a study of end of life prescribing in the community among patients with cancer, an investigation of repeat prescriptions to derive measures of prior morbidity status in patients with cancer and studies of prescription activity surrounding the date of cancer diagnosis.Future plansThis English linked resource could be used for cancer epidemiological studies of diagnostic pathways, health outcomes and inequalities; to establish primary care comorbidity indices and for guideline concordance studies of treatment, particularly hormonal therapy, as a major treatment modality for breast and prostate cancer which has been largely delivered in the community setting for a number of years.

Published
2018

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