Human Immunity and Susceptibility to Influenza A(H3) Viruses of Avian, Equine, and Swine Origin.

Influenza A viruses (IAVs) of subtype H3 that infect humans are antigenically divergent from those of birds, horses, and swine. Human immunity against these viruses might be limited, implying potential pandemic risk. To determine human risk, we selected 4 avian, 1 equine, and 3 swine IAVs representing major H3 lineages. We tested serum collected during 2017-2018 from 286 persons in Belgium for hemagglutination inhibiting antibodies and virus neutralizing antibodies against those animal-origin IAVs and tested replication in human airway epithelia. Seroprevalence rates for circulating IAVs from swine in North America were >51%, swine in Europe 7%-37%, and birds and equids ≤12%. Replication was efficient for cluster IV-A IAVs from swine in North America and IAVs from swine in Europe, intermediate for IAVs from horses and poultry, and absent for IAVs from wild birds and a novel human-like swine IAV in North America. Public health risk may be highest for swine H3 IAVs.

Porphyromonas gingivalis-Helicobacter pylori co-incubation enhances Porphyromonas gingivalis virulence and increases migration of infected human oral keratinocytes.

Background: Porphyromonas gingivalis is part of the subgingival biofilm and a keystone species in the development of periodontitis. Interactions between P.gingivalis and other bacteria in biofilms have been shown to affect bacterial virulence. Helicobacter pylori also inhabits the subgingival biofilm, but the consequences of interactions there with P.gingivalis remain unknown. Here, we investigated how the pre-incubation of P.gingivalis with H.pylori affects P.gingivalis virulence. Methods: We assayed P.gingivalis internalization by oral keratinocytes (OKs), hemagglutination and biofilm formation to identify alterations in virulence after pre-incubation with H. pylori. Also, we evaluated viability and migration of OKs infected with P. gingivalis, as well as the role of toll-like receptor 4 (TLR4).   In addition, we quantified the mRNA of genes associated with P.gingivalis virulence. Results: Pre-incubation of P.gingivalis with H.pylori enhanced P.gingivalis biofilm formation, bacterial internalization into OKs and hemagglutination. Infection with pre-incubated P.gingivalis increased OK migration in a manner dependent on the O-antigen and linked to  increased expression of the gingipain RgpB. Also, OK TLR4 participates in these events, because upon TLR4 knock-down, pre-incubated P.gingivalis no longer stimulated OK migration. Discussion: We provide here for the first time insight to the consequences of direct interaction between P.gingivalis and H.pylori. In doing so, we shed light on the mechanism by which H. pylori presence in the oral cavity increases the severity or progression of periodontitis.

An Update of Lectins from Marine Organisms: Characterization, Extraction Methodology, and Potential Biofunctional Applications.

Lectins are a unique group of nonimmune carbohydrate-binding proteins or glycoproteins that exhibit specific and reversible carbohydrate-binding activity in a non-catalytic manner. Lectins have diverse sources and are classified according to their origins, such as plant lectins, animal lectins, and fish lectins. Marine organisms including fish, crustaceans, and mollusks produce a myriad of lectins, including rhamnose binding lectins (RBL), fucose-binding lectins (FTL), mannose-binding lectin, galectins, galactose binding lectins, and C-type lectins. The widely used method of extracting lectins from marine samples is a simple two-step process employing a polar salt solution and purification by column chromatography. Lectins exert several immunomodulatory functions, including pathogen recognition, inflammatory reactions, participating in various hemocyte functions (e.g., agglutination), phagocytic reactions, among others. Lectins can also control cell proliferation, protein folding, RNA splicing, and trafficking of molecules. Due to their reported biological and pharmaceutical activities, lectins have attracted the attention of scientists and industries (i.e., food, biomedical, and pharmaceutical industries). Therefore, this review aims to update current information on lectins from marine organisms, their characterization, extraction, and biofunctionalities.

Modulation of Immune Responses Against HA1 Influenza Vaccine Candidate by B-lymphocyte Stimulator Cytokine in Mice.

Utilizing subunit vaccines is one of the strategies to address influenza infection. Recent innovations have focused on high doses of vaccine antigens and immune enhancers or adjuvant to induce more robust and long-lasting immune responses. Here, an effect of the B cell-activating factor receptor (BAFF-R) to increase the magnitude and durability of immune responses of the recombinant HA1 (rHA1) protein against the H1N1 influenza virus was studied. The HA1 protein and the effector domain of BAFF-R were expressed in the pET-28a (+) vector. Eight-week-old BALB/c mice were equally grouped into five groups (n=20). The 15 and 25 µg/µL of rHA1 were mixed with 2 µg/µL of rBAFF-R and injected three times for vaccinated groups. Three control groups were received normal saline and two concentrations of rHA1. The ability of rBAFF-R in eliciting HA-specific antibody response and stimulating T lymphocyte proliferation to induce the cell-mediated immunity was assayed. Induction of protection was evaluated following the challenge with PR8 strain. Analysis of immune responses showed that the co-administration of rBAFF-R with rHA1 boosted HI responses to the antigen in mice, whilst it was not able to promote the T cell proliferation responses against influenza. Compared to rHA1alone, the rBAFF-R/rHA1 generated efficient protection for the animals. There were no significant differences in eliciting the immune responses in mice immunized with the lower dose of rHA1 than that with the higher dose. The data indicate the rBAFF-R can enhance the primary and memory immune responses to protect against influenza infection.

Quantification of lectins in Synsepalum dulcificum and comparison with reference foods.

A healthy life means a balance between physical activity and a diet rich in fruits and vegetables, however, some plant-based foods can have certain adverse effects due to the presence of anti-nutritional factors, such as lectins, capable of binding molecules and preventing their normal assimilation. The level of lectins in Synsepalum dulcificum fruit was determined by hemagglutination assays in human blood, and its comparison with foods characterized as having high and low lectin content. The relative hemagglutinating activity of berries from Synsepalum dulcificum compared to our positive high lectin content food reference (Pinto bean) corresponds to 3.13-6.25%, representing safe levels for nutritional food.

Isolates from Monechma ciliatum seeds' extract hampered Porphyromonas gingivalis hemagglutinins.

Porphyromonas gingivalis is a major periodontitis pathogen that produces several virulence factors including hemagglutinins. These proteins, which are vital molecules, allow P. gingivalis to uptake iron and heme by attaching, aggregating, and lysing erythrocytes. In this study, we evaluated the inhibitory activity of the aqueous extract of Monechma ciliatum seeds against the hemagglutination activity of P. gingivalis. M. ciliatum is a Sudanese medicinal herb that grows in arid and semi-arid lands of tropical Africa. The water extracted from dry powdered seeds was partitioned using ethyl acetate followed by reversed-phase chromatography, thin-layer chromatography, ESI-MS, and NMR analysis resulting in the isolation of four compounds identified as oleic acid, coumarin, 1,2-dioleoylglycerol, and 1,3-dioleoylglycerol with MICs of 15-100 µg/ml against hemagglutination. We believe that the isolation and purification of these compounds will expand the application of M. ciliatum as a natural therapeutic or preventative agent. PRACTICAL APPLICATIONS: Monechma ciliatum or black mahlab is a famous medicinal plant that grows in some parts of arid and semi-arid areas of tropical Africa including western Sudan. Despite its nutritional and traditional medical applications, no studies have evaluated its anti-hemagglutination activity against periodontal pathogens. In this study, four active compounds (oleic acid, coumarin, 1,2-dioleoylglycerol, and 1,3-dioleoylglycerol) were isolated and identified from an aqueous extract of M. ciliatum seeds. The isolated compounds revealed high levels of inhibitory activity against all hemagglutinin agents secreted by Porphyromonas gingivalis. This evidence of inhibitory activity will encourage the application of M. ciliatum effectively as a functional food or therapeutic agent to prevent periodontal diseases in the early stages.

[Genetic characterization of influenza A virus and assessment of vaccine efficacy in Yantai from 2014 to 2017].

In this study, the swabs were collected among patients with an influenza-like illness (ILI) admitted to 2 sentinel surveillance hospitals of Yantai from April 2014 to August 2017. All specimen were cultured and identified by hemagglutination inhibition assay. Complete sequences of Hemagglutinin (HA) of influenza A were amplified, sequenced and analyzed using molecular and phylogenetic methods. The potential vaccine efficacy were calculated using Pepitope model. The results showed that the antigenicity of A (H3N2) had changed greatly. 8 strains of influenza A (H1N1) pdm09 belonged to subclade 6B.1 and 14 strains clustered in 6B.2. 12 strains of influenza A (H3N2) fell into subgroup 3C.3a and 33 strains clustered in 3C.2a. Several residues at antigen sites and potential glycosylation sites had changed in influenza A strains. Vaccine efficacy of influenza A (H1N1) pdm09 in 2015/2016 and 2016/2017 seasons were 77.29% and 79.11% of that of a perfect match with vaccine strain, meanwhile vaccine efficacy of influenza A (H3N2) in 2014/2015, 2015/2016 and 2016/2017 were-5.18%, 16.97% and 42.05% separately. In conclusion, the influenza A virus circulated in Yantai from 2014 to 2017 presented continual genetic variation. The recommended vaccine strains still afforded protection against influenza A (H1N1) pdm09 strains and provided suboptimal protection against influenza A (H3N2) strains.

[Research progress on invasion-related virulence factors in Porphyromonas gingivalis].

Porphyromonas gingivalis (Pg) is a kind of gram-negative obligate anaerobes. It can invade and internalize within host cells. The invasion ability of Pg is very important for the occurrence and development of diseases and has been a hot topic for a long time. Remaining pathogenic characteristics in cell is one of its pathogenesis. In the process of invading host, the specific bacterial adhesin combine with the ligand of host cells, which activate various signal transduction pathways and trigger bacterial internalization. Virulence factors in Pg, such as fimbriae, gingival protease, hemagglutinins and outer membrane vesicles play significant roles in the process. This review summarized the research progress of the virulence factors which relate to Pg's invasion, which provided a serious of new ideas on exploring Pg's pathogenesis and the prevention and treatment of related diseases.

Genetic characterization of influenza A virus and assessment of vaccine efficacy in Yantai from 2014 to 2017 / 中华预防医学杂志

In this study, the swabs were collected among patients with an influenza-like illness (ILI) admitted to 2 sentinel surveillance hospitals of Yantai from April 2014 to August 2017. All specimen were cultured and identified by hemagglutination inhibition assay. Complete sequences of Hemagglutinin (HA) of influenza A were amplified, sequenced and analyzed using molecular and phylogenetic methods. The potential vaccine efficacy were calculated using Pepitope model. The results showed that the antigenicity of A (H3N2) had changed greatly. 8 strains of influenza A (H1N1) pdm09 belonged to subclade 6B.1 and 14 strains clustered in 6B.2. 12 strains of influenza A (H3N2) fell into subgroup 3C.3a and 33 strains clustered in 3C.2a. Several residues at antigen sites and potential glycosylation sites had changed in influenza A strains. Vaccine efficacy of influenza A (H1N1) pdm09 in 2015/2016 and 2016/2017 seasons were 77.29% and 79.11% of that of a perfect match with vaccine strain, meanwhile vaccine efficacy of influenza A (H3N2) in 2014/2015, 2015/2016 and 2016/2017 were-5.18%, 16.97% and 42.05% separately. In conclusion, the influenza A virus circulated in Yantai from 2014 to 2017 presented continual genetic variation. The recommended vaccine strains still afforded protection against influenza A (H1N1) pdm09 strains and provided suboptimal protection against influenza A (H3N2) strains.

Research progress on invasion-related virulence factors in Porphyromonas gingivalis / 中华口腔医学杂志

Porphyromonas gingivalis (Pg) is a kind of gram-negative obligate anaerobes. It can invade and internalize within host cells. The invasion ability of Pg is very important for the occurrence and development of diseases and has been a hot topic for a long time. Remaining pathogenic characteristics in cell is one of its pathogenesis. In the process of invading host, the specific bacterial adhesin combine with the ligand of host cells, which activate various signal transduction pathways and trigger bacterial internalization. Virulence factors in Pg, such as fimbriae, gingival protease, hemagglutinins and outer membrane vesicles play significant roles in the process. This review summarized the research progress of the virulence factors which relate to Pg′s invasion, which provided a serious of new ideas on exploring Pg′s pathogenesis and the prevention and treatment of related diseases.

N-glycan structures of human alveoli provide insight into influenza A virus infection and pathogenesis.

The rapidly evolvable influenza A virus has caused pandemics linked to millions of deaths in the past century. Influenza A viruses are categorized by H (hemagglutinin; HA) and N (neuraminidase; NA) proteins expressed on the viral envelope surface. Analyses of past pandemics suggest that the HA gene segment comes from a nonhuman virus, which is then introduced into an immunologically naïve human population with potentially devastating consequences. As a prerequisite for infection, the nonhuman HA molecules of H1-H16 viruses must be able to bind to specific sialyl receptors on the host cell surface along the human respiratory tract. Thus, additional insight into the structures of host cell glycans and how different HAs interact with different glycans might provide new insight into the mechanisms underlying sustained infection and transmission in humans. In this work, we identified the sialyl N-glycans found in normal human alveoli and characterized the influenza viruses that preferentially bound to these different structures. We also determined the amino acid changes in HA that were linked to a switch of receptor-binding preference from nonhuman to pandemic, as well as pandemic to seasonal. Our data provide insight into why seasonal viruses are associated with reduced alveolar infection and damage and suggest new considerations for designing anti-HA vaccines and drugs. The results provide a better understanding of viral tropism and pathogenesis in humans that will be important for prediction and surveillance of zoonotic, pandemic, and epidemic influenza outbreaks. DATABASE: The novel hemagglutinin nucleotide sequences reported here were deposited in GISAID under the accession numbers of EPI685738 for A/Yamaguchi/20/2006(H1N1) and EPI685740 for A/Kitakyushu/10/2006(H1N1).

Human beta defensin 3 alters matrix metalloproteinase production in human dendritic cells exposed to Porphyromonas gingivalis hemagglutinin B.

BACKGROUND: Matrix metalloproteinases (MMPs) are zinc- or calcium-dependent proteinases involved in normal maintenance of extracellular matrix. When elevated, they contribute to the tissue destruction seen in periodontal disease. Recently, we found that human beta defensin 3 (HBD3), a cationic antimicrobial peptide, alters chemokine and proinflammatory cytokine responses in human myeloid dendritic cells exposed to Porphyromonas gingivalis hemagglutinin B (HagB). In this study, the hypotheses that HagB induces MMP production in dendritic cells and that HBD3 mixed with HagB prior to treatment alters HagB-induced MMP profiles were tested. METHODS: Dendritic cells were exposed to 0.2 µM HagB alone and HagB + HBD3 (0.2 or 2.0 µM) mixtures. After 16 hours, concentrations of MMPs in cell culture media were determined with commercial multiplex fluorescent bead-based immunoassays. An integrated cell network was used to identify potential HagB-induced signaling pathways in dendritic cells leading to the production of MMPs. RESULTS: 0.2 µM HagB induced MMP1, -2, -7, -9, and -12 responses in dendritic cells. 0.2 µM HBD3 enhanced the HagB-induced MMP7 response (P < 0.05) and 2.0 µM HBD3 attenuated HagB-induced MMP1, -7, and -9 responses (P < 0.05). The MMP12 response was not affected. In the predicted network, MMPs are produced via activation of multiple pathways. Signals converge to activate numerous transcription factors, which transcribe different MMPs. CONCLUSION: HagB was an MMP stimulus and HBD3 was found to decrease HagB-induced MMP1, -7, and -9 responses in dendritic cells at 16 hours, an observation that suggests HBD3 can alter microbial antigen-induced production of MMPs.

ABO Incompatible Living Donor Liver Transplantation: A Single Center Experience / 대한이식학회지

BACKGROUND: This study examined the outcomes of ABO incompatible living donor liver transplantation (LDLT). The changes in the immunologic factors that might help predict the long term outcomes were also studied. METHODS: Twenty-three patients, who underwent ABO incompatible LDLT from 2010 to 2015, were reviewed retrospectively. The protocol was the same as for ABO compatible LDLT except for the administration of rituximab and plasma exchange. The clinical outcomes and immunologic factors, such as isoagglutinin titer and cluster of differentiation 20+ (CD20+) lymphocyte levels were reviewed. RESULTS: The center showed a 3-year survival of 64% with no case of antibody-mediated rejection. When transplantation-unrelated mortalities (for example, traffic accidents and myocardial infarction) were removed from statistical analysis, the 3-year survival was 77.8%. Although isoagglutinin titers continued to remain at low levels, the CD20+ lymphocyte levels recovered to the pre-Rituximab levels at postoperative one year. CONCLUSIONS: As donor shortages continue, ABO incompatible liver transplantation is a feasible method to expand the donor pool. On the other hand, caution is still needed until more long-term outcomes are reported. Because CD20+ lymphocytes are recovered with time, more immunologic studies will be needed in the future.

Use of an Intravascular Warming Catheter during Off-Pump Coronary Artery Bypass Surgery in a Patient with Severe Cold Hemagglutinin Disease.

Cold hemagglutinin disease with broad thermal amplitude and high titers presents challenges in treating cardiac-surgery patients. Careful planning is needed to prevent the activation of cold agglutinins and the agglutination of red blood cells as the patient's temperature drops during surgery. We describe our approach to mitigating cold agglutinin formation in a 77-year-old man with severe cold hemagglutinin disease who underwent off-pump coronary artery bypass surgery without the use of preoperative plasmapheresis. This experience shows that the use of an intravascular warming catheter can maintain normothermia and prevent the activation and subsequent formation of cold agglutinins. To our knowledge, this is the first reported use of this technique in a patient with cold hemagglutinin disease. The chief feature in this approach is the use of optimal thermal maintenance-rather than the more usual decrease in cold-agglutinin content by means of therapeutic plasma exchange.

Dangerous universal donors: the reality of the Hemocentro in Belo Horizonte, Minas Gerais.

BACKGROUND: The term dangerous universal blood donor refers to potential agglutination of the erythrocytes of non-O recipients due to plasma of an O blood group donor, which contains high titers of anti-A and/or anti-B hemagglutinins. Thus, prior titration of anti-A and anti-B hemagglutinins is recommended to prevent transfusion reactions. OBJECTIVE: The aim of this study was to estimate the frequency of dangerous universal donors in the blood bank of Belo Horizonte (Fundação Central de Imuno-Hematologia - Fundação Hemominas - Minas Gerais) by determining the titers of anti-A and anti-B hemagglutinins in O blood group donors. METHOD: A total of 400 O blood group donors were randomly selected, from March 2014 to January 2015. The titers of anti-A and anti-B hemagglutinins (IgM and IgG classes) were obtained using the tube titration technique. Dangerous donors were those whose titers of anti-A or anti-B IgM were ≥128 and/or the titers of anti-A or anti-B IgG were ≥256. Donors were characterized according to gender, age and ethnicity. The hemagglutinins were characterized by specificity (anti-A and anti-B) and antibody class (IgG and IgM). RESULTS: Almost one-third (30.5%) of the O blood group donors were universal dangerous. The frequency among women was higher than that of men (p-value=0.019; odds ratio: 1.66; 95% confidence interval: 1.08-2.56) and among young donors (18-29 years old) it was higher than for donors between 49 and 59 years old (p-value=0.015; odds ratio: 3.05; 95% confidence interval: 1.22-7.69). There was no significant association between dangerous universal donors and ethnicity, agglutinin specificity or antibody class. CONCLUSION: Especially platelet concentrates obtained by apheresis (that contain a substantial volume of plasma), coming from dangerous universal donors should be transfused in isogroup recipients whenever possible in order to prevent the occurrence of transfusion reactions.

Severe intravenous immunoglobulin-induced hemolysis with pigment nephropathy managed with red cell exchange.

We report on the use of red cell exchange in a case of severe intravenous immune globulin induced hemolysis and pigment nephropathy. Renal impairment and hemoglobinuria were not ameliorated by supportive measures including hydration. Partial red cell exchange with group O blood reduced hemoglobinuria and appeared to stabilize renal function. This is the first report on the use of red cell exchange in this clinical setting. J. Clin. Apheresis 31:464-466, 2016. © 2015 Wiley Periodicals, Inc.

Effect of evolution and mutations of H3N2 virus hemagglutinin genes on the antigenic epitopes in Guangdong / 中华传染病杂志

Objective To reveal evolution characteristics and antigenic epitope variabilities of hemagglutinin (HA) gene of H3N2 viruses in Guangdong during 2014-2015.Methods The HA gene nucleotide sequence of influenza H3N2 virus isolated during 2014-2015 in Guangdong Province was selected by spatial-temporal distribution.The HA gene nucleotide sequences were compared with global HA genes downloaded from GenBank and GISAID and the gene nucleotide mutations were analyzed.The phylogenetic tree and the entropy chart were conducted.Results Compared with HA gene of vaccine strain A/Texas/50/2012,the substitutions of 25 amino acid sites occurred in the HA gene of the 17 Guangdong strains during 2014 to 2015.The epitope A,B,D and E of the HA1 gene developed mutations,which involved 11 amino acid sites.One glycosylation site deletion occurred in A/Guangdong/ 55/2015 in virtue of the N38K site mutation.The high mutation site was at 175 with entropy value of 1.16.The 363 site might be the positive selection while the 368 and 425 sites might be the negative selection sites by comprehensive evaluation of the screening results of the single likelihood ancestor countincy (SLAC),fixed effects likelihood (FEL) and internal fixed-effects likelihood (IFEL) model.Conclusions The mutations emerge in the epitopes A,B,D and E of HA gene of the Guangdong H3N2 stains.Evolution at 363 site is positive selection while those at 368 and 425 sites are negative selection.The mutation accumulation might lead to the epidemic of influenza H3N2.

Genetic characteristic analysis of haemagglutinin of two episodes of influenza B virus outbreaks in Guizhou ;Province in 2016 / 中华传染病杂志

Objective To understand the genetic variations of influenza B virus outbreaks in Guizhou province in 2016,and to compare the matching situation of outbreak epidemic strains with the vaccine strains recommended by WHO and representative strains in China.Methods The haemagglutinin HA1 gene of 8 strains isolated from two episodes of influenza B virus outbreaks in Tongren area was amplified and sequenced.The sequencing products were analyzed by bioinformatics software DNAStar. Results The two episodes of influenza outbreaks were both caused by influenza B Victoria lineage virus (BV).The homologies of the isolated strains were 99.8%—100.0% in nucleotide and 99.5 %—100.0%in amino acid.Mutation was only detected at 274 site in some strains.Compared with reference strain B/Victoria/2/87,the homologies were 91 .8%—92.0% and 91 .5 %—92.0%,respectively.Mutations developed at 17 amino acid sites,among which,I143V,V163I and V201I site were associated with the main antigenic determinant area B,C and D.Compared with previous vaccine strain B/Brisbane/60/2008, the homologies were 98.2%—98.3% and 98.5 %—99.0%,respectively,and mutations were detected at 3 sites.Mutations at I143V and N155D were detected in all 8 strains and at T247I in some strains.The mutation of I143V was associated with antigenic determinant area B.Compared with the representative strain B/Chongqing-Yuzhong/1384/2010,the homologies were 96.7%—96.8% and 97.0%—97.5 %, respectively.A total of 6 sites developed mutations,among which,5 sites were P84L,I143V,N155D, V172I and T223N mutations.The mutation of T247I was detected in some strains,and I143V was associated with area B.Compared with the epidemic strain in Guizhou in 2016,the homologies were 99.8%—100.0% and 99.5 %—100.0%,respectively.Mutation was only detected at site 247 in some strains and was not associated with the main antigenic determinant area.Conclusions The two episodes of influenza outbreaks in Guizhou are caused by the same BV lineage epidemic virus strain.Haemagglutinin gene of BV lineage virus is constantly changing.However,there is no new mutation emerged at important site.Compared with previous influenza vaccine strain B/Brisbane/60/2008 recommended by WHO,BV lineage virus is well matched and could provide a positive protection effect.

Antibody-Based Strategies to Prevent and Treat Influenza.

Passive immunization using antibodies is a promising alternative to other antiviral treatment options. The potential for seasonal protection arising from a single injection of antibodies is appealing and has been pursued for a number of infectious agents. However, until recently, antibody-based strategies to combat infectious agents have been hampered due to the fact that most antibodies have been found to be strain specific, with the virus evolving resistance in many cases. The discovery of broadly neutralizing antibodies (bNAbs) in influenza, dengue virus, and HIV, which bind to multiple, structurally diverse strains, has provided renewed interest in this area. This review will focus on new technologies that enable the discovery of bNAbs, the challenges and opportunities of immunotherapies as an important addition to existing antiviral therapy, and the role of antibody discovery in informing rational vaccine discovery - with agents targeting influenza specifically addressed. Multiple candidates have entered the clinic and raise the possibility that a single antibody or small combination of antibodies can effectively neutralize a wide variety of strains. However, challenges remain - including combating escape variants, pharmacodynamics of antibody distribution, and development of efficacy biomarkers beyond virologic endpoints.