Donor and recipient HCMV-seropositive (D+R+) lung transplant recipients (LTRs) often harbour multiple human cytomegalovirus (HCMV) strains, likely due to transmitted donor (D) strains and reactivated recipient (R) strains. To date, the extent and timely occurrence of each likely source in shaping the post-transplantation (post-Tx) strain population is unknown. Here, we deciphered the D and R origin of the post-Tx HCMV strain composition in blood, bronchoalveolar lavage (BAL), and CD45+ BAL cell subsets. We investigated either D and/or R formalin-fixed paraffin-embedded blocks or fresh D lung tissue from four D+R+ LTRs obtained prior to transplantation. HCMV strains were characterised by short amplicon deep sequencing. In two LTRs, we show that the transplanted lung is reseeded by R strains within the first six months after transplantation, likely by infiltrating CD14+ CD163+/- alveolar macrophages. In three LTRs, we demonstrate both rapid D-strain dissemination and persistence in the transplanted lung for >1 year post-Tx. Broad inter-host diversity contrasts with intra-host genotype sequence stability upon transmission, during follow-up and across compartments. In D+R+ LTRs, HCMV strains of both, D and R origin can emerge first and dominate long‑term in subsequent episodes of infection, suggesting no replication advantage of one source over the other despite pre-existing R strain-specific immunity.

The SARS-CoV-2 Omicron variant is characterized by its high transmissibility, which has caused a worldwide epidemiological event. Yet, it turns ominous once the disease progression degenerates into severe pneumonia and sepsis, presenting a horrendous lethality. To elucidate the alveolar immune or inflammatory landscapes of Omicron critical-ill patients, we performed single-cell RNA-sequencing (scRNA-seq) of bronchoalveolar lavage fluid (BALF) from the patients with critical pneumonia caused by Omicron infection, and analyzed the correlation between the clinical severity scores and different immune cell subpopulations. In the BALF of Omicron critical patients, the alveolar violent myeloid inflammatory environment was determined. ISG15 + neutrophils and CXCL10 + macrophages, both expressed the interferon-stimulated genes (ISGs), were negatively correlated with Clinical Pulmonary Infection Score (CPIS), while septic CST7 + neutrophils and inflammatory VCAN + macrophages were positively correlated with Sequential Organ Failure Assessment (SOFA). The percentages of ISG15 + neutrophils were associated with more protective alveolar epithelial cells, and may reshape CD4 + T cells to the exhaustive phenotype, thus preventing immune injuries. The CXCL10 + macrophages may promote plasmablast/plasma cell survival and activation as well as the production of specific antibodies. As compared to the previous BALF scRNA-seq data from SARS-CoV-2 wild-type/Alpha critical patients, the subsets of neutrophils and macrophages with pro-inflammatory and immunoregulatory features presented obvious distinctions, suggesting an immune disparity in Omicron variants. Overall, this study provides a BALF single-cell atlas of Omicron critical patients, and suggests that alveolar interferon-responsive neutrophils and macrophages may extricate SARS-CoV-2 Omicron critical patients from the nasty fate of sepsis.

Objective Throughout the COVID-19 pandemic, Rhinovirus (RV) remained notable persistence, maintaining its presence while other seasonal respiratory viruses were largely suppressed by pandemic restrictions during national lockdowns. This research explores the epidemiological dynamics of RV infections among pediatric populations on Hainan Island, China, specifically focusing on the impact before and after the zero-COVID policy was lifted. Methods From January 2021 to December 2023, 19,680 samples were collected from pediatric patients hospitalized with acute lower respiratory tract infections (ARTIs) at the Hainan Maternal and Child Health Hospital. The infection of RV was detected by tNGS. RV species and subtypes were identified in 32 RV-positive samples representing diverse time points by analyzing the VP4/VP2 partial regions. Results Among the 19,680 pediatric inpatients with ARTIs analyzed, 21.55% were found to be positive for RV infection, with notable peaks observed in April 2021 and November 2022. A gradual annual decline in RV infections was observed, alongside a seasonal pattern of higher prevalence during the colder months. The highest proportion of RV infections was observed in the 0-1 year age group. Phylogenetic analysis revealed 23 distinct RV subtypes, with a shift in dominance from RV-A to RV-C in 2022, suggesting evolving RV dynamics. Conclusions The research emphasizes the necessity for ongoing surveillance and targeted management, particularly for populations highly susceptible to severe illnesses caused by RV infections.

Description of the transmission characteristics among older adults is helpful for the tailored interventions. Epidemiological investigation combined with phylogenetic analysis were performed to reveal potential transmission linkage among the older people in Nanjing. During 2018-2022, 188 pol sequences were successfully amplified. Multiple genotypes were identified, including CRF07_BC (55.3%), CRF01_AE (30.3%), CRF08_BC (8.0%), B (3.2%), CRF55_01B (1.1%), CRF67_01B (0.5%),CRF68_01B (0.5%), and unique recombinant forms (URF) (1.1%). Transmission network analysis found 120 genetically linked patients forming 23 clusters (2-26 individuals). Multivariable logistic regression analysis showed that compared with farmers and heterosexuals, patients with other occupation (OR= 0.404, 95% CI:0.173-0.945) and MSM (OR= 0.193, 95% CI:0.050-0.738) were less likely to have high linkage. Subjects who lived in suburban places were more likely to have high linkage (OR= 10.932, 95% CI:3.335-35.830). The Sankey diagram suggested that patients who lived in suburban places mainly transmitted the disease within the locally district (χ 2=24.192, P＜0.001). Among 188 pol segments, the prevalence of pretreatment drug resistance was 8%. In suburban places with an increasing HIV-1 epidemic, there is a need to improve early detection and timely treatment. More tailored interventions for this subgroup are urgently needed.

Objective: To investigate the distribution characteristics of HPV16 E6 gene 295T/G and E7 gene 647A/G variants in different cervical tissues in Xinjiang, to study the effects of these two loci on the expression of molecules in IFNκ and its pathway, to explore the molecular mechanism of their roles, and to analyse the relationship between these two variants and the occurrence and development of cervical cancer. Methods: (1) A total of 461 cervical paraffin-embedded tissue samples were collected and tissue DNA was extracted to detect the type of HPV infection by PCR, and the distribution of HPV16 viral E6-T295G and E7-A647G variants in cervical tissues was analysed by Sanger sequencing. Immunohistochemistry was used to detect the expression of IFNκ and molecules on its pathway including IFNκ, STAT1, IRF9, IFI27, IFI44L,OAS1 in cervical cancer and normal cervical tissues. Results: (1) The HPV16 infection rate of cervical paraffin-embedded tissue samples from women in Xinjiang region was 64.0% by PCR. And the HPV16 infection rate of Uyghur was 75.7%, of which the infection rate of Uyghur CIN1 and CIN2 with HPV16 was 60.6%, and the infection rate of CIN3 and cervical cancer was 82.9%. The HPV16 infection rate of Han ethnic group was 54.5%, among which the infection rate of Han ethnic group CIN1 and CIN2 of HPV16 was 34.0%, and the infection rate of CIN3 and cervical cancer was 66.5%. (2) The variant rate of Uyghur CIN1 patients presenting with E6-295T/G variant was 41.7%, and the variant rate of squamous cervical cancer patients presenting with E6-295T/G variant was 43.4%. The variant rate of Han ethnic group CIN1 patients presenting with the E6-295T/G variant was 33.3%, and the variant rate of squamous cervical cancer patients presenting with the E6-295T/G variant was 16.1%. The variant rate of Uyghur CIN1 patients presenting with the E7-647A/G variant was 41.7%, and the variant rate of squamous cervical cancer patients presenting with the E7-647A/G variant was 9.2%. The variant rate of E7-647A/G variant was 45.8% in Han ethnic group of CIN1 patients and 50.0% in squamous cervical cancer patients. (3) The results showed that the expression of IFNκ, IRF9, OAS1, IFI27, and IFI44L molecules on the IFNκ pathway was higher in normal cervical tissues uninfected with HPV than that of CIN1 with HPV infection, and the difference was statistically significant ( P<0.05). The expression of IFNκ, STAT1, IRF9, OAS1, IFI27, IFI44L molecules in CIN3, moderately differentiated, poorly differentiated cervical squamous carcinoma and adenocarcinoma were higher than that of CIN1, and the molecular expression of IFN-κ and its pathway in cervical squamous cell carcinoma and adenocarcinoma was higher than that in normal tissues, and the difference was statistically significant ( P<0.05). Conclusion: The rate of E6-295T/G variation in cervical cancer patients infected with HPV16 in Uyghur is higher than that in Han, while the rate of E7-647A/G variation in cervical cancer patients infected with HPV16 in Han is higher than that in Uyghur.

Background: SARS-CoV-2 infection has been associated with the increased incidence of acute macular neuroretinopathy (AMN), an infrequent ocular disorder. However, the precise mechanisms underpinning AMN in the context of SARS-CoV-2 infection (AMN-SARS-CoV-2) remain elusive. Methods: In this case-control study 14 patients diagnosed with AMN-SARS-CoV-2 between 2022/12 and 2023/3 were enrolled in this study. 14 SARS-CoV-2-infected individuals without AMN (SARS-CoV-2-no AMN) as control. 14 AMN-SARS-CoV-2 patients were compared with 14 SARS-CoV-2-no AMN. Metabolomic profiling using Ultra-High-Performance Liquid Chromatography-Online Electrospray Mass Spectrometry (UHPLC-OE-MS) revealed significant alterations in serum metabolites in AMN-SARS-CoV-2 patients. Abnormal blood clotting was observed in AMN-SARS-CoV-2 patients, and its relationship with metabolic disorders was studied. Finally, a predictive model for AMN-SARS-CoV-2 was established. Results: 76 upregulated and 42 downregulated metabolites were discovered in AMN-SARS-CoV-2. Notably, arginine metabolism within the urea cycle showed substantial changes, evidenced by variations in ornithine, citrulline, L-proline, and ADAM levels, correlating with abnormal coagulation markers like platelet crit (PCT), fibrinogen degradation products (FDP), and fibrinogen (Fbg). Additionally, increased arginase 1 (AGR1) activity within the urea cycle and reduced nitric oxide synthase (NOS) activity were observed in AMN-SARS-CoV-2. Combining these urea cycle metabolites with coagulation parameters effectively distinguished AMN-SARS-CoV-2 from SARS-CoV-2-no AMN, with an area under the curve (AUC) value of 0.96. Conclusion: The findings of the present study enhance our comprehension of the underlying metabolic mechanisms associated with AMN-SARS-CoV-2 and offer potential diagnostic markers for this uncommon ocular disorder within the context of SARS-CoV-2 infection.

Background & Aims: Hepatitis B virus (HBV) can be completely suppressed after antiviral treatment; however, some patients with chronic hepatitis B (CHB) still exhibit elevated alanine aminotransferase (ALT) levels and sustained disease progression. The aim of this study was to provide novel insights into the mechanism and potential predictive biomarkers of persistently elevated ALT (PeALT) in patients with CHB after complete viral inhibition. Methods: CHB Patients with undetectable HBV DNA at least 12 months after antiviral treatment were enrolled from a prospective, observational cohort. Correlations between plasma metabolites and the risk of elevated ALT were examined using multivariate logistic regression. Results: Of the 1238 patients with CHB who achieved complete viral suppression, 40 (3.23%) had PeALT levels during follow-up (median follow-up: 2.42 years). Additionally, 40 patients with persistently normal ALT (PnALT) levels were matched 1:1 as controls. Ser-Phe-Ala (variable importance in projection [VIP] = 4.28), Lys-Ala-Leu-Glu (VIP = 4.49), 3-methylhippuric acid (VIP = 3.04), 3-methylxanthine (VIP = 2.62), and 7-methylxanthine (VIP = 3.35) were identified as critical differential metabolites between the two groups and independently associated with PeALT risk. Ser-Phe-Ala and Lys-Ala-Leu-Glu levels could be used to discriminate patients with PeALT from those with PnALT. Furthermore, N-acetyl-l-methionine (NALM) demonstrated the strongest negative correlation with ALT levels. NALM supplementation alleviated liver injury and hepatic necrosis induced by carbon tetrachloride in mice. Conclusions: Changes in circulating metabolites may contribute to PeALT levels in patients with CHB who have achieved complete viral suppression after antiviral treatment.

A document by Haleema Qayyum Abbasi. Click on the document to view its contents.

A document by Lu Zhang. Click on the document to view its contents.

Background: While dysfunctional exhausted CD8+ T cells hamper viral control when children acquire hepatitis B virus (HBV) infection, it’s crucial to recognize that CD8+ T cells have diverse phenotypes and functions. This study explored a subset of CD8+ T cells expressing C - C chemokine receptor type 5 (CCR5) in children with HBV infection. Methods: 36 patients in the immune tolerant (IT) group, 33 patients in the immune active (IA) group, and 55 patients in the combined response (CR) group were enrolled. The frequency, functional molecules and effector functions of the CCR5+CD8+ T cells population in different groups were evaluated. Results: The frequency of CCR5+CD8+ T cells correlated positively with the frequency of CCR5+ CD4+ T cells and patient age, and it correlated negatively with ALT, AST, HBV DNA, HBsAg and lactic dehydrogenase levels. CCR5+CD8+ T cells had higher levels of inhibitory and activated receptors and produced higher levels of IFN-γ, IL-2, and TNF-α than CCR5-CD8+ T cells. Conclusion：CCR5+CD8+T cells were partially exhausted but possessed a stronger antiviral activity than CCR5-CD8+T cells. The identification of this subset increases our understanding of CD8+ T cell functions and serve as a potential immunotherapeutic target for children with HBV infection.

Interferon-induced helicase C domain-containing protein 1 (IFIH1) is one of the main pattern recognition receptors that sense viral RNA and activate host cells to mount an effective antiviral immunity. Therefore, a case-control study (90 patients with mild/moderate COVID-19 and 90 matched controls) was performed to explore the association of two variants of the IFIH1 gene with COVID-19 risk using the tetra-primer amplification refractory mutation system-polymerase-chain-reaction method. The first is a missense variant, rs1990760 C/T, and the second is an intergenic variant, rs2111485 A/G. In addition, serum IFIH1 levels were assessed using an ELISA kit. Results revealed that mutant alleles ( T and G, respectively) and corresponding homozygous genotypes (TT and GG, respectively) of both variants were significantly associated with increased risk of COVID-19. IFIH1 levels were significantly higher in patients compared to controls and were favorably affected by the rs1990760 and rs2111485 mutant-type genotypes. In conclusion, IFIH1 protein showed up-regulated levels in the serum of patients with mild/moderate COVID-19. In addition, the IFIH1 gene variants rs1990760 C/T and rs2111485 A/G were associated with susceptibility to COVID-19, and the study suggests that their mutant-type genotypes are not only associated with increased risk of COVID-19 but also contributed to higher serum IFIH1 levels.

Obesity has been identified as an independent risk factor for severe outcomes in humans with coronavirus disease 2019 (COVID-19) and other infectious diseases. Here, we established a mouse model of COVID-19 using the murine betacoronavirus, mouse hepatitis virus 1 (MHV-1). C57BL/6 and C3H/HeJ mice exposed to MHV-1 developed mild and severe disease, respectively. Obese C57BL/6 mice developed clinical manifestations similar to those of lean controls. In contrast, all obese C3H/HeJ mice succumbed by 8 days post-infection, compared to a 50% mortality rate in lean controls. Notably, both lean and obese C3H/HeJ mice exposed to MHV-1 developed lung lesions consistent with severe human COVID-19, with marked evidence of diffuse alveolar damage (DAD). To identify early predictive biomarkers of worsened disease outcomes in obese C3H/HeJ mice, we sequenced RNA from whole blood 2 days post-infection and assessed changes in gene and pathway expression. Many pathways uniquely altered in obese C3H/HeJ mice post-infection aligned with those found in humans with severe COVID-19. Furthermore, we observed altered gene expression related to the unfolded protein response and lipid metabolism in infected obese mice compared to their lean counterparts, suggesting a role in the severity of disease outcomes. This study presents a novel model for studying COVID-19 and elucidating the mechanisms underlying severe disease outcomes in obese and other hosts.

Human Papillomaviruses (HPV) are a diverse family of non-enveloped dsDNA viruses that infect the skin and mucosal epithelia. Persistent HPV infections can lead to cancer frequently involving integration of the virus into the host genome, leading to sustained oncogene expression and loss of capsid and genome maintenance proteins. Microhomology-mediated double-strand break repair, a DNA double-stranded breaks repair pathway present in many organisms, was initially thought to be a backup but it’s now seen as vital, especially in homologous recombination-deficient contexts. Increasing evidence has identified microhomology (MH) near HPV integration junctions, suggesting MH-mediated repair pathways drive integration. In this comprehensive review, we present a detailed summary of both the mechanisms underlying MH-mediated repair and the evidence for its involvement in HPV integration in cancer. Lastly, we highlight the involvement of these processes in the integration of other DNA viruses and the broader implications on virus lifecycles and host innate immune response.

Background: Major screening abnormalities in pre-colposcopic stage are tests results that imply direct referral to colposcopy (and/or expedited treatment) without performing additional high-grade squamous intraepithelial lesions or worse (HSIL+) risk selection testing. Currently, both clinically validated HSIL+ risk selection tests, reflex cytology and reflex p16/Ki67 dual staining (DS), are being compared for use in primary HPV-based screening to avoid possible overtreatment, but there is still no sufficient data available for their performance. Methods: Among 30,066 liquid-based cervical cancer screening tests results, a group of 332 women was selected with available HRHPV tests results with 16/18 limited genotyping, liquid-based cytology, DS, and histology results from standardized colposcopy with biopsy. In HPV 16/18+ cases, three triage approaches were retrospectively analyzed. Predictive values for detection of HSIL+ were calculated and number of colposcopies required in each strategy. Results: Both triage models with DS used (reflex cytology followed by DS, and reflex DS alone in all cases) had significantly higher PPV for HSIL+ than strategy with reflex cytology alone (44.2%/45.7% vs. 28.3%; p<0.0001). In models with DS, less colposcopies were required (95/92 vs. 152) and less colposcopies were needed per HSIL+ detection (2,26/2,19 vs. 3,54). Only 1 HSIL+ case was missed in both triage models with DS incorporation. Conclusions: p16/Ki67 dual-stain may be an effective, alone or combined with cytology, triage test to detect HSIL+ in patients with major screening abnormalities in primary HPV-based cervical cancer screening. Performing cytology as the first triage test improves the strategy by enabling referrals to expedited treatment in selected cases.

Influenza constitutes a critical respiratory infection that imposes significant public health burdens. The precise influence of these pollutants on influenza activity remains unclear. This study aimed to investigate the effects of different air pollutants on the incidence of influenza-like illness (ILI), influenza A (Flu A), and influenza B (Flu B) in China based on nationwide data on air pollution and the influenza data from 554 sentinel hospitals across 30 provinces and municipalities from 2014 to 2017. Distributed Lag Nonlinear Model (DLNM) was employed to discern the lagged effects amid the concentrations of six distinct air pollutants, namely PM2.5, PM10, O 3, CO, SO 2, and NO 2, and the incidence of ILI, Flu A, as well as Flu B. Our analysis indicated that there was generally no distinction in the effects of air pollutants on the incidence of ILI, Flu A, and Flu B, although variations existed in terms of the specific level of risk associated with each of these categories. Specifically, elevated levels of PM2.5, PM10, CO, SO 2, and NO 2 were predominantly associated with an increased risk of influenza. In contrast, the effect of O 3 concentration on influenza was bidirectional whereby it promoted influenza outbreaks at low and high levels.

The mid-term impact of SARS-CoV-2 infection on senescence profile and immune checkpoints biomarkers in people living with HIV (PLWH) was assessed. Cross-sectional study in 95 PLWH on ART stratified by SARS-CoV-2 infection: a) 48 PLWH previously infected (PCR+) (HIV/SARS); b) 47 PLWH controls without previous infection (HIV). Plasma biomarkers (n=44) related to cell immune checkpoint molecules, associated with the Senescence-Associated Secretory Phenotype (SASP), and related to pro and anti-inflammatory cytokines were assessed by Procartaplex Multiplex Immunoassays (Xmap-Luminex technology). Differences between groups were analyzed using a generalized linear model, adjusted by sex and ethnicity and corrected by false discovery rate. Significant values were defined as the adjusted arithmetic mean ratio ≥1.2 or ≤0.8; q-value<0.1. The relationship between plasma biomarkers was evaluated by Spearman correlation (significant correlations rho≥0.3 and q-value<0.1). PLWH had a median age of 45 years and 80% were men. All PLWH infected by SARS-CoV-2 had a symptomatic infection, 83.3% as mild, and with a median of 12 weeks after diagnosis of SARS-CoV-2 infection. HIV/SARS group showed higher levels of the cell immune checkpoint plasma biomarkers CD80, PDCD1LG2, CD276, PDCD1, CD47, HAVCR2, TIMD4, TNFRSF9, TNFRSF18, and TNFRSF14 respect to HIV group. The SASP biomarkers LTA, CXCL8, and IL13 and the inflammatory biomarkers IL4, IL12B, IL17A, CCL3, CCL4, and INF1A showed significantly higher levels in the HIV/SARS group. SARS-CoV-2 infection in PLWH leads to significant medium-term disruption in plasma immune checkpoint molecules and inflammatory cytokines, highlighting SASP-related. This could be a risk factor for the emergence of complications in PLWH.

Background: Starting from May 31 st, 2023, the local transmission of monkeypox (Mpox) in mainland China began in Beijing. Till now, the transmission characteristics have not been explored. Method: Based on the daily Mpox incidence data in the first three weeks of Beijing (from May 31 st to June 21 st, 2023) , we employed the instant-individual heterogeneity transmission model to simultaneously calculate the effective reproduction number ( R e) and the degree of heterogeneity ( k) of the Beijing epidemic. We additionally simulated the monthly infection size in Beijing from July to September and compared with the reported data to project subsequent transmission dynamics. Results: We estimated R e to be 1.68 [95% HPD:1.12, 2.41], and k to be 2.57 [95% HPD: 0.54, 83.88], suggesting the transmission of Mpox in Beijing was supercritical and didn’t have considerable transmission heterogeneity. We projected that R e fell in the range of 0.95 to 1.0 from July to September, highlighting more efforts needed to further reduce the Mpox transmissibility. Conclusion: Our findings revealed supercritical and homogeneous transmission of the Mpox epidemic in Beijing. Our results may provide reference for understanding and predicting of the on-going Mpox transmission in other regions of China and assess the effect of control measures.

Objective: This study investigated the efficacy of the prophylactic human papillomavirus (HPV) vaccine started at 2009- 2013 in Japan. Materials and Methods: The study involved 1529 eligible women aged 16 to 39 years who visited 11 outpatient clinics for various reasons in Japan. All these patients underwent an examination of HPV genotype and a Pap test using cervical cell samples. Two hundred ninty-nine women (19.6%) received the prophylactic HPV vaccine (bivalent :quadrivalent vaccine ratio = 2:1). Of the 5062 participants in the Japanese Human Papillomavirus Disease Education and Research Survey (J-HERS 2011), which was conducted in the pre-vaccination era, 3236 eligible participants were included as controls. Results: In the present study (J-HERS 2021), highest rate for HPV vaccination (53%) was observed in 22- to 27-year-old patients. Vaccinated ones showed 49% protection against low-grade intraepithelial lesions (LSIL) and atypical squamous cells not excluding high-grade squamous intraepithelial lesions (ASCH) or worse (LSIL/ASCH+), and 100% protection against high-grade squamous intraepithelial lesions (HSIL) or worse (HSIL+). The prevalences of HPV16 and HPV18 infections also significantly decreased (HPV16; 95% and HPV18; 100%), but there were no differences in HPV6 and HPV11 infections by the vaccination. The prevalences of HPV51 and HPV59 increased with vaccination, although these changes were not confirmed in the comparative study with J-HERS 2011. Comparisons between the pre-vaccination period (J-HERS 2011) and post-vaccination period (J-HERS 2021) revealed reduction rates of 43%, 51%, 88%, and 62% were observed for HPV16, HPV18, HPV16/18, and HPV31/58 infections, respectively. Similarly, reduction rates of 62% and 71% for LSIL/ASCH+ and HSIL+, respectively. The reduction rate for LSIL/ASCH+ was 88% in 16- to 21-year-old patients, whereas the rate for HSIL+ was 87% in 28- to 33-year-old patients. C onclusion: Bivalent or quadrivalent vaccines provided 100% protection against high-grade squamous cell lesions (suggestive of CIN2 or CIN3) in young women aged < 39 years at 9 to 12 years after initiation of the first nationwide HPV vaccination program in Japan. Cross-protection against HPV31 and HPV58 is likely to occur, although some HPV type replacements are inconsistent across vaccination regimens. This demonstrates a high effectiveness of HPV vaccine. In contrast, we worry about no reduction of cervical cancer in younger generation (born in 1997-2007) who are rarely vaccinated due to long term suspension of this vaccine recommendation in Japan.