VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical...
Transcript of VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical...
![Page 1: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/1.jpg)
VILKA MIKROORGANISMER EXPONERAS VI FÖR VID FÄSTINGBETT-RISKER?
Pia Forsberg
Professor emerita Infektionsmedicin
Department of Clinical and Experimental Medicine
Linköping University
![Page 2: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/2.jpg)
TICK-BORNE MICROBES
Bacteria
Borrelia spp.
Anaplasma phagocytophilum
Rickettsia spp.
Candidatus Neoehrlichia mikurensis
Bartonella spp.
Francisella tularensis
Parasites and viruses
Babesia spp.
Toxoplasma gondii
TBE virus
Nairovirus
![Page 3: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/3.jpg)
Few studies have investigated
the incidence of infection
by tick-borne microbes
after a tick bite
![Page 4: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/4.jpg)
E.G.
BORRELIA BURGDORFERI SENSU LATO
No investigations of Borrelia in ticks that have bitten humans have been performed in Sweden
![Page 5: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/5.jpg)
E.G. BORRELIA BURGDORFERI SENSU LATO
but worldwide: 20 % on the Dutch island of Ameland (Jacobs et al., 2008)
10 % in the western part of Switzerland (Nahimana et al., 2004)
1% in Texas, United States (Williamson et al., 2010)
BUT
Serological and clinical data were not notified
No attempts to quantify Borrelia cells were made
Duration of feeding was empirically estimated by direct observation of the ticks
![Page 6: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/6.jpg)
THE
TBD STING
STUDY
![Page 7: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/7.jpg)
AIMS
How large is the RISK to become infected/develop disease after a
tick bite?
How many of the ticks that have bitten humans contain
tick-borne microbes - which?
![Page 8: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/8.jpg)
AIMS
What tick-borne microbes are present in ticks from Nordic countries?
Geographical differences?
Species/subtypes of microbes?
Do the risk of developing disease correlate with the ticks:
Quantity of microbes?
Species/subtype of microbes?
Feeding time duration?
![Page 9: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/9.jpg)
TBD STING STUDY
2007 - 2015
10 000 fästingar DNA
3 mån studieperiod
5500 bitna individers blod x 2
5500 enkäter x 2
18år, mest kvinnor, 60-65 år
> 60 vårdcentraler Norge
Sverige
Åland, Finland
![Page 10: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/10.jpg)
Questionnaires
Tick
Blood sample
Hmm...
Intressant
Real-time PCR
Tick-borne microbes?
Serology
Immune response?
Antibody production?
STUDY DESIGN
Health status?
Clinical diagnosis?
• 3 months follow-up
• Collection of
additional ticks
• Health records
![Page 11: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/11.jpg)
ANNONSEN + MASSMEDIAL KOMMUNIKATION
![Page 12: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/12.jpg)
Questionnaires
Tick
Blood sample
Hmm...
Intressant
Real-time PCR
Tick-borne microbes?
Serology
Immune response?
Antibody production?
STUDY DESIGN
Health status?
Clinical diagnosis?
• 3 months follow-up
• Collection of
additional ticks
• Health records
![Page 13: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/13.jpg)
Blood sample
0mo. + 3mos.
Health status?
Clinical outcome?
2 ELISA tests
(anti-flagellum
& anti-C6)
New production of
antibodies?
Borrelia-caused infection? Line immunoblot
(8 antigens, 4 species)
Questionnaires
0mo. + 3mos.
+ medical records
ANALYSING THE TICK-BITTEN INDIVIDUALS - SEROLOGY AND CLINICAL OUTCOME
![Page 14: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/14.jpg)
Jeremy Gray, Gerold Stanek, Michael Kundi, Elena Kocianova
International Journal of Medical Microbiology 295 (2005) 567-572
DinoLite USB-microscope
> 24h
< 24h
Photo & measure
Scutal index, SI = A/B
Coxal index, CI = A/c
Analysing the ticks
![Page 15: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/15.jpg)
![Page 16: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/16.jpg)
TICKS IN SWEDEN
11 species– Ixodes ricinus > 95%
Ticks are active down to 4°C
Life stages: egg, larva, nymph and adult
Food for parasitoid wasps, beetles, birds, ants and spiders
Lack eyes but have a good ”sense of smell”
![Page 17: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/17.jpg)
RESULTS BORRELIA SPP.
![Page 18: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/18.jpg)
WHAT DID THE TICKS CONTAIN?
26% of the 2154 ticks were Borrelia positive
50%
20%
6%
4%
2% 1%
0.5%
0.5% 16%
Detected Borrelia species, n=556
B. afzelii
B. garinii
B. valaisiana
B. burgdorferi
B. miyamotoi
B. spielmanii
B. lusitaniae
mixed species
untypeable
![Page 19: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/19.jpg)
* p < 0.05
** p < 0.01
*** p < 0.001
BORRELIA SPECIES AND CELL QUANTITY
![Page 20: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/20.jpg)
BORRELIA
26% (n=428/1546) were bitten by Borrelia-positive ticks
![Page 21: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/21.jpg)
BORRELIA
In total:
2.1% (n=32) of all 1546 participants
developed LB.
2.5% (n=39) of all participants developed
asymptomatic infection (seroconversion)
![Page 22: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/22.jpg)
BORRELIA INFECTION
22
428 bitten by Borrelia-positive
ticks
32 (7.5%)
Borrelia-infected individuals
16
LB cases
16 seroconversions (no LB cases)
396
uninfected individuals
1118 bitten by Borrelia-negative
ticks
39 (3.5%)
Borrelia-infected individuals
16
LB cases
23 seroconversions (no LB cases)
1079
uninfected individuals
![Page 23: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/23.jpg)
CLINICAL MANIFESTATIONS
32 participants received a LB diagnosis during the 3 months study period
27 (84%) EM
2 (6%) NB
2 (6%) non-specific LB
1 (3%) Borrelia lymphocytoma
23
![Page 24: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/24.jpg)
SELF-REPORTED NON-SPECIFIC SYMPTOMS
23% (349/1546) of all participants reported non-specific symptoms possibly associated with LB
Of which 20.3% (n=71) visited health care
24
Symptoms:
Fatigue
Myalgia/
Arthralgia
Headache
Neck pain
Numbness
Radiating
pain
Vertigo
Cognitive
difficulties
Nausea
Loss of
appetite
Fever
Loss of
weight
![Page 25: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/25.jpg)
CONCLUSION BORRELIA
Every fourth tick Borrelia infected
7 Borrelia species detected
2.1% was diagnosed with LB 84% EM
68.8 % of all seroconversions did not experience non-specific symptoms or developed LB
Wilhelmsson P et al Parasites & Vectors, 2013 Wilhelmsson P et al PLoS One, 2013
Wilhelmsson P et al Ticks Tick Borne Dis. 2016
![Page 26: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/26.jpg)
RESULTS TBE-VIRUS
![Page 27: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/27.jpg)
5 / 2167 ticks positive for TBE-
V
Åland Kalmar Åland Saringe
Month of tick-bite
August August September June July
Life stage Nymph Nymph Nymph Nymph Nymph
Feeding time (h) < 12 24-36 < 12 12-24 >60
Virus copies in tick
< 400 ~ 4200 < 400 ~ 1800 ~ 7 700 000
Location of tick Leg Waist Back thigh Leg Behind ear
Visited health care
No Yes (Borrelia) No No Yes
Symptoms No Yes (Borrelia) No No Yes
TBE vaccinated Yes Yes Yes No Vacc, after
Co-infection Borrelia No Anaplasma No Borrelia
Location: Åland
Results: TBE-V qPCR
![Page 28: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/28.jpg)
Conclusion TBE-V
• Over all very low risk of TBE-V
• 5 / 2167 (0,23 %) ticks that had bitten persons were positive for TBE-V. One developed symptoms (not serious)
• To few for conclusions on feeding-time and virus copy number or the riskassesment
Lindblom P et al Ticks and Tick Borne Diseases, 2014
![Page 29: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/29.jpg)
RESULTS ANAPLASMA PHAGOCYTOPHILUM
![Page 30: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/30.jpg)
ANAPLASMA
1291 ticks were analysed
40 of 1291 (3.1%) were positive for A. phagocytophilum
0.8% of all ticks were co-infected with Borrelia and Anaplasma
24% of the Anaplasma positive ticks were co-infected with Borrelia
No symptoms
Henningsson AJ et al Ticks Tick Borne Dis. 2015
![Page 31: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/31.jpg)
RESULTS RICKETTSIA SPP.
![Page 32: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/32.jpg)
RICKETTSIA
473 ticks were analysed
23 of 473 (4.9%) were positive for Rickettsia helvetica
Kalmar (n=1/82)
Östergötland (4/98)
Jönköping (7/97)
Lidköping (11/98)
All samples from Åland were negative (98)!!!!!!
Vague symptoms, nausea, radiating pain more common in seroconverted persons.
Lindblom A et al European Journal of Clinical Microbiology and Infectious Diseases, 2013
Lindblom A et al PLoS One. 2016
![Page 33: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/33.jpg)
RESULTS NEOEHRLICHIA
3248 tick-bitten individuals
103 to primary health care center (during study period 3 m)
2/103 pos PCR in blood (1,9%)
EM
Co-infection Borrelia (1) serology
Co-infection Anaplasma (1) serology
Grankvist A et al Emerg Infect Dis. 2015
![Page 34: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/34.jpg)
RESULTS BABESIA 65/2098 ticks pos Babesia (3,1%) from 1769 bitten persons
B microti 50,8%
B venatorum 41,5%
B divergens 7,7%
46% of the 65 Babesia pos ticks were Co-infected with Borrelia
Number of Babesia / tick = <10 - 1miljon
Feeding time <24h - >72h
![Page 35: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/35.jpg)
65 BITTEN PERSONS BY BABESIA POS TICK
PCR in blood neg
Serology:
no seroconversion during 3 months
6% had Babesia ab:s in the 1:st blood sample!!
10 persons had vague ospecific symptoms
To be submitted M
Lövmar et al
![Page 36: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/36.jpg)
ON GOING INVESTIGATION
Francisella tularensis
Bartonella spp.
Toxoplasma gondii
![Page 37: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/37.jpg)
TICK-BORNE MICROBES
Bacteria
Borrelia spp.
Anaplasma phagocytophilum
Rickettsia spp.
Candidatus Neoehrlichia mikurensis
Bartonella spp.
Francisella tularensis
Parasites and viruses
Babesia spp.
Toxoplasma gondii
TBE virus
Nairovirus
![Page 38: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/38.jpg)
CO-INFECTIONS
![Page 39: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/39.jpg)
TBD STING STUDY
Infectious Medicine, LiU
Pia Forsberg
Johanna Sjöwall
Liselott Lindvall
Lisa Gunnarsson
Clinical Immunology, LiU
Christina Ekerfelt
Linda Fryland
Mari-Anne Åkeson
Karin Söderman
Medical Microbiology, LiU
Per-Eric Lindgren
Peter Wilhelmsson
Pontus Lindblom
Others
Sven Bergström
Anna Jonsson Henningsson
Barbro Hedin Skogman
Johan Berglund
Katharina Ornstein
Ivar Tjernberg
Dag Nyman (Åland)
Marika Nordberg (Åland)
Peter Nolskog
Mats Haglund
Clas Ahlm
Knut Eirik Eliassen (Norway)
Harald Reiso (Norway)
Matilda Lövmar
and other collaborating partners
![Page 40: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/40.jpg)
FINANCIAL SUPPORT
The Swedish Research Council
Linköping University
County Council of Östergötland
The Medical Research Council of Southeast Sweden
Wilhelm and Else Stockmann Foundation
Foundation for Åland Medical Research
of the Åland Culture Foundation
EU Interreg IV A, ScandTick
![Page 41: VILKA MIKROORGANISMER EXPONERAS VI FÖR …...2018/05/06 · Lisa Gunnarsson Ivar Clinical Immunology, LiU Christina Ekerfelt Linda Fryland Mari-Anne Åkeson Knut Karin Söderman](https://reader033.fdocuments.us/reader033/viewer/2022060209/5f0456237e708231d40d7a3b/html5/thumbnails/41.jpg)
www.liu.se