Top

Published in:

Open Access 01-12-2018 | Research

Molecular detection of human enteric viruses circulating among children with acute gastroenteritis in Valencia, Venezuela, before rotavirus vaccine implementation

Authors: Ana C. Alcalá, Kriss Pérez, Ruth Blanco, Rosabel González, Juan E. Ludert, Ferdinando Liprandi, Esmeralda Vizzi

Published in: Gut Pathogens | Issue 1/2018

Abstract

Background

The role of rotavirus as main etiologic agent of diarrhea has been well documented worldwide, including in Venezuela. However, information about the prevalence of gastrointestinal viruses such as calicivirus, adenovirus and astrovirus is limited and the contribution of other agents as Aichi virus and klassevirus is largely unknown. To explore the etiological spectrum of diarrhea associated with agents other than rotaviruses, 227 stool samples from children under 5 years old with acute gastroenteritis, collected in Valencia (Venezuela) from 2001 to 2005, and previously tested as rotavirus-negative, were analyzed for caliciviruses, adenoviruses, astroviruses, Aichi viruses, klasseviruses, picobirnaviruses and enteroviruses by specific RT-PCRs.

Results

At least one viral agent was detected in 134 (59%) of the samples analyzed, mainly from children under 24 months of age and most of them belonging to the lowest socioeconomic status. Overall, enterovirus was identified as the most common viral agent (37.9%), followed by calicivirus (23.3%), adenovirus (11.5%), astrovirus (3.5%), klassevirus (1.3%) and Aichi virus (0.4%), while no picobirnavirus was detected. Klasseviruses were found during 2004 and 2005 and Aichi viruses only in 2005, indicating their circulation in Venezuela; meanwhile, the rest of the viruses were detected during the whole study period. Coinfections with two or more viruses were found in 39 (29.1%) of the infected children, most under 24 months of age. Adenovirus was involved as the coinfecting agent in at least 46.9% of the cases, but no differences concerning socio-demographic variables were observed between the coinfected and the single infected children.

Conclusions

The results show that various enteric viruses, including enteroviruses, caliciviruses and adenoviruses, accounted for a significant proportion of infantile diarrhea cases in Venezuela before rotavirus vaccine implementation. In addition, emerging viruses as Aichi virus and klassevirus were found, indicating the need to continue monitoring their spreading into the communities. Efforts are needed to develop more accurate methods to identify the major causes of diarrhea and to provide tools for more effective preventive measures.

Liu L, Oza S, Hogan D, Chu Y, Perin J, Zhu J, Lawn JE, Cousens S, Mathers C, Black RE. Global, regional, and national causes of under-5 mortality in 2000–15: an updated systematic analysis with implications for the sustainable development goals. Lancet. 2016;388:3027–35. https://doi.org/10.1016/S0140-6736(16)31593-8.CrossRefPubMedPubMedCentral

GBD Diarrhoeal Diseases Collaborators. Estimates of global, regional, and national morbidity, mortality, and aetiologies of diarrhoeal diseases: a systematic analysis for the Global Burden of Disease Study 2015. Lancet Infect Dis. 2017;17:909–48. https://doi.org/10.1016/S1473-3099(17)30276-1.CrossRef

Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, Jha P, Campbell H, Walker CF, Cibulskis R, Eisele T, Liu L, Mathers C, Child Health Epidemiology Reference Group of WHO and UNICEF. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet. 2010;375:1969–87. https://doi.org/10.1016/S0140-6736(10)60549-1.CrossRefPubMed

Tate JE, Burton AH, Boschi-Pinto C, Steele AD, Duque J, Parashar UD, WHO coordinated Global Rotavirus Surveillance Network. 2008 estimate of worldwide rotavirus-associated mortality in children younger than 5 years before the introduction of universal rotavirus vaccination programmes: a systematic review and meta-analysis. Lancet Infect Dis. 2012;2012(12):136–41.CrossRef

Lanata CF, Fischer-Walker CL, Olascoaga AC, Torres CX, Aryee MJ, Black RE, Child Health Epidemiology Reference Group of the World Health Organization and UNICEF. Global causes of diarrheal disease mortality in children < 5 years of age: a systematic review. PLoS ONE. 2013;8(9):e72788. https://doi.org/10.1371/journal.pone.0072788.CrossRefPubMedPubMedCentral

Kim A, Chang JY, Shin S, Yi H, Moon JS, Ko JS, Oh S. Epidemiology and factors related to clinical severity of acute gastroenteritis in hospitalized children after the introduction of rotavirus vaccination. J Korean Med Sci. 2017;32:465–74. https://doi.org/10.3346/jkms.2017.32.3.465.CrossRefPubMedPubMedCentral

Spina A, Kerr KG, Cormican M, Barbut F, Eigentler A, Zerva L, Tassios P, Popescu GA, Rafila A, Eerola E, Batista J, Maass M, Aschbacher R, Olsen KE, Allerberger F. Spectrum of enteropathogens detected by the FilmArray GI Panel in a multicentre study of community-acquired gastroenteritis. Clin Microbiol Infect. 2015;21:719–28. https://doi.org/10.1016/j.cmi.2015.04.007.CrossRefPubMed

Thongprachum A, Khamrin P, Pham NT, Takanashi S, Okitsu S, Shimizu H, Maneekarn N, Hayakawa S, Ushijima H. Multiplex RT-PCR for rapid detection of viruses commonly causing diarrhea in pediatric patients. J Med Virol. 2017;89:818–24. https://doi.org/10.1002/jmv.24711.CrossRefPubMed

Vizzi E, Piñeros OA, Oropeza MD, Naranjo L, Suárez JA, Fernández R, Zambrano JL, Celis A, Liprandi F. Human rotavirus strains circulating in Venezuela after vaccine introduction: predominance of G2P[4] and reemergence of G1P[8]. Virol J. 2017;14:58. https://doi.org/10.1186/s12985-017-0721-9.CrossRefPubMedPubMedCentral

10.

Simpson R, Aliyu S, Iturriza-Gómara M, Desselberger U, Gray J. Infantile viral gastroenteritis: on the way to closing the diagnostic gap. J Med Virol. 2003;70:258–62.CrossRefPubMed

11.

Liu Y, Xu ZQ, Zhang Q, Jin M, Yu JM, Li JS, Liu N, Cui SX, Kong XY, Wang H, Li HY, Cheng WX, Duan ZJ. Simultaneous detection of seven enteric viruses associated with acute gastroenteritis by a multiplexed luminex-based assay. J Clin Microbiol. 2012;50:2384–9. https://doi.org/10.1128/JCM.06790-11.CrossRefPubMedPubMedCentral

12.

Valentini D, Vittucci AC, Grandin A, Tozzi AE, Russo C, Onori M, Menichella D, Bartuli A, Villani A. Coinfection in acute gastroenteritis predicts a more severe clinical course in children. Eur J Clin Microbiol Infect Dis. 2013;32:909–15. https://doi.org/10.1007/s10096-013-1825-9.CrossRefPubMed

13.

Koh H, Baek SY, Shin JI, Chung KS, Jee YM. Coinfection of viral agents in Korean children with acute watery diarrhea. J Korean Med Sci. 2008;23:937–40. https://doi.org/10.3346/jkms.2008.23.6.937.CrossRefPubMedPubMedCentral

14.

Glass RI, Bresee J, Jiang B, Gentsch J, Ando T, Fankhauser R, Noel J, Parashar U, Rosen B, Monroe SS. Gastroenteritis viruses: an overview. vol. 38. In: Novartis Found Symposium 238; New York: Wiley; 2001. p. 5–19. (discussion 19–25).

15.

Wilhelmi I, Roman E, Sánchez-Fauquier A. Viruses causing gastroenteritis. Clin Microbiol Infect. 2003;9:247–62.CrossRefPubMed

16.

De Benedictis P, Schultz-Cherry S, Burnham A, Cattoli G. Astrovirus infections in humans and animals—molecular biology, genetic diversity, and interspecies transmissions. Infect Genet Evol. 2011;11:1529–44.CrossRefPubMed

17.

Sdiri-Loulizi K, Gharbi-Khélifi H, de Rougemont A, Chouchane S, Sakly N, Ambert-Balay K, Hassine M, Guédiche MN, Aouni M, Pothier P. Acute infantile gastroenteritis associated with human enteric viruses in Tunisia. J Clin Microbiol. 2008;46:1349–55. https://doi.org/10.1128/JCM.02438-07.CrossRefPubMedPubMedCentral

18.

Jiang H, Holtz LR, Bauer I, Franz CJ, Zhao G, Bodhidatta L, Shrestha SK, Kang G, Wang D. Comparison of novel MLB-clade, VA-clade and classic human astroviruses highlights constrained evolution of the classic human astrovirus nonstructural genes. Virology. 2013;436:8–14.CrossRefPubMed

19.

Ouédraogo N, Kaplon J, Bonkoungou IJ, Traoré AS, Pothier P, Barro N, Ambert-Balay K. Prevalence and genetic diversity of enteric viruses in children with diarrhea in Ouagadougou, Burkina Faso. PLoS ONE. 2016;19(11):e0153652. https://doi.org/10.1371/journal.pone.0153652.CrossRef

20.

Pham NT, Trinh QD, Chan-It W, Khamrin P, Shimizu H, Okitsu S, Mizuguchi M, Ushijima H. A novel RT-multiplex PCR for detection of Aichi virus, human parechovirus, enteroviruses, and human bocavirus among infants and children with acute gastroenteritis. J Virol Methods. 2010;169:193–7. https://doi.org/10.1016/j.jviromet.2010.07.038.CrossRefPubMed

21.

Yamashita T, Kobayashi S, Sakae K, Nakata S, Chiba S, Ishihara Y, Isomura S. Isolation of cytopathic small round viruses with BS-C-1 cells from patients with gastroenteritis. J Infect Dis. 1991;164:954–7.CrossRefPubMed

22.

Holtz L, Finkbeiner S, Zhao G, Kirkwood C, Girones R, Pipas J, Wang D. Klassevirus 1, a previously undescribed member of the family Picornaviridae, is globally widespread. Virol J. 2009;6:86. https://doi.org/10.1186/1743-422X-6-86.CrossRefPubMedPubMedCentral

23.

Chansaenroj J, Tuanthap S, Thanusuwannasak T, Duang-In A, Klinfueng S, Thaneskongtong N, Vutithanachot V, Vongpunsawad S, Poovorawan Y. Human enteroviruses associated with and without diarrhea in Thailand between 2010 and 2016. PLoS ONE. 2017;27(12):e0182078. https://doi.org/10.1371/journal.pone.0182078.CrossRef

24.

Ambert-Balay K, Lorrot M, Bon F, Giraudon H, Kaplon J, Wolfer M, Lebon P, Gendrel D, Pothier P. Prevalence and genetic distribution of Aichi virus strains in stool samples from community and hospitalized patients. J Clin Microbiol. 2008;46:1252–8.CrossRefPubMedPubMedCentral

25.

Alcalá A, Vizzi E, Rodríguez-Díaz J, Zambrano JL, Betancourt W, Liprandi F. Molecular detection and characterization of Aichi viruses in sewage-polluted waters of Venezuela. Appl Environ Microbiol. 2010;76:4113–5.CrossRefPubMedPubMedCentral

26.

Li L, Victoria J, Kapoor A, Blinkova O, Wang C, Babrzadeh F, Mason CJ, Pandey P, Triki H, Bahri O, Oderinde BS, Baba MM, Bukbuk DN, Besser JM, Bartkus JM, Delwart EL. A novel picornavirus associated with gastroenteritis. J Virol. 2009;83:12002–6. https://doi.org/10.1128/JVI.01241-09.CrossRefPubMedPubMedCentral

27.

Han TH, Kim CH, Chung JY, Park SH, Hwang ES. Klassevirus infection in children, South Korea. Emerg Infect Dis. 2010;16:1623–5. https://doi.org/10.3201/eid1610.100539.CrossRefPubMedPubMedCentral

28.

Itta KC, Patil T, Kalal S, Ghargi KV, Roy S. Salivirus in children with diarrhoea, western India. Int J Infect Dis. 2016;52:14–5. https://doi.org/10.1016/j.ijid.2016.09.015.CrossRefPubMed

29.

Salinas B, González G, González R, Escalona M, Materán M, Pérez-Schael I. Epidemiologic and clinical characteristics of rotavirus disease during five years of surveillance in Venezuela. Pediatr Infect Dis J. 2004;23:S161–7.CrossRefPubMed

30.

World Health Organization (WHO). A manual for the treatment of diarrhea: for use by physicians and other senior health workers. Geneva: World Health Organization; 2005.

31.

O’Ryan ML, et al. Rotavirus-associated medical visits and hospitalizations in South America: a prospective study at three large sentinel hospitals. Pediatr Infect Dis J. 2001;20:685–93.CrossRefPubMed

32.

Méndez-Castellano H, De Méndez MC. Estratificación social y biología humana: método Graffar modificado. Arch Venez Pueric Pediatr. 1986;49:93–104.

33.

González R, Rivero L. Genetic diversity of rotavirus group a: correlation between G3 type and severity of the infection, Valencia, Venezuela. Invest Clin. 2013;54:34–46.PubMed

34.

Farkas T, Zhong WM, Jing Y, Huang PW, Espinosa SM, Martinez N, Morrow AL, Ruiz-Palacios GM, Pickering LK, Jiang X. Genetic diversity among sapoviruses. Arch Virol. 2004;149:1309–23.CrossRefPubMed

35.

Allard A, Girones R, Juto P, Wadell G. Polymerase chain reaction for detection of adenoviruses in stool samples. J Clin Microbiol. 1990;28:2659–67.PubMedPubMedCentral

36.

Belliot G, Laveran H, Monroe SS. Detection and genetic differentiation of human astroviruses: phylogenetic grouping varies by coding region. Arch Virol. 1997;142:1323–34.CrossRefPubMed

37.

Belliot GM, Fankhauser RL, Monroe SS. Characterization of “Norwalk-like viruses” and astroviruses by liquid hybridization assay. J Virol Methods. 2001;91:119–30.CrossRefPubMed

38.

Yamashita T, Sugiyama M, Tsuzuki H, Sakae K, Suzuki Y, Miyazaki Y. Application of a reverse transcription-PCR for identification and differentiation of Aichi virus, a new member of the Picornavirus family associated with gastroenteritis in humans. J Clin Microbiol. 2000;38:2955–61.PubMedPubMedCentral

39.

Shen S, Desselberger U, McKee TA. The development of an antigen capture polymerase chain reaction assay to detect and type human enteroviruses. J Virol Methods. 1997;65:139–44.CrossRefPubMed

40.

Rosen BI, Fang ZY, Glass RI, Monroe SS. Cloning of human picobirnavirus genomic segments and development of an RT-PCR detection assay. Virology. 2000;25(277):316–29.CrossRef

41.

Oh DY, Gaedicke G, Schreier E. Viral agents of acute gastroenteritis in German children: prevalence and molecular diversity. J Med Virol. 2003;71:82–93.CrossRefPubMed

42.

Lekana-Douki SE, Kombila-Koumavor C, Nkoghe D, Drosten C, Drexler JF, Leroy EM. Molecular epidemiology of enteric viruses and genotyping of rotavirus A, adenovirus and astrovirus among children under 5 years old in Gabon. Int J Infect Dis. 2015;34:90–5. https://doi.org/10.1016/j.ijid.2015.03.009.CrossRefPubMed

43.

Colomba C, De Grazia S, Giammanco GM, Saporito L, Scarlata F, Titone L, Arista S. Viral gastroenteritis in children hospitalised in Sicily, Italy. Eur J Clin Microbiol Infect Dis. 2006;25:570–5.CrossRefPubMed

44.

Marie-Cardin A, Gourlain K, Mouterde O, Castignolles N, Hellot MF, Mallet E, Buffet-Janvresse C. Epidemiology of acute viral gastroenteritis in children hospitalized in Rouen, France. Clin Infect Dis. 2002;34:1170–8.CrossRef

45.

Ouyang Y, Ma H, Jin M, Wang X, Wang J, Xu L, Lin S, Shen Z, Chen Z, Qiu Z, Gao Z, Peng L, Li J. Etiology and epidemiology of viral diarrhea in children under the age of five hospitalized in Tianjin, China. Arch Virol. 2012;157:881–7. https://doi.org/10.1007/s00705-012-1235-9.CrossRefPubMed

46.

González GG, Liprandi F, Ludert JE. Molecular epidemiology of enteric viruses in children with sporadic gastroenteritis in Valencia, Venezuela. J Med Virol. 2011;83:1972–82.CrossRefPubMed

47.

Thongprachum A, Takanashi S, Kalesaran AF, Okitsu S, Mizuguchi M, Hayakawa S, Ushijima H. Four-year study of viruses that cause diarrhea in Japanese pediatric outpatients. J Med Virol. 2015;87:1141–8. https://doi.org/10.1002/jmv.24155.CrossRefPubMed

48.

Pang XL, Honma S, Nakata S, Vesikari T. Human caliciviruses in acute gastroenteritis of young children in the community. J Infect Dis. 2000;181(Suppl 2):S288–94.CrossRefPubMed

49.

Wildermann N, Porto-Espinoza L, Moronta R, Bracho M, Costa L, Callejas D. Detección molecular mediante RT PCR de calicivirus y enterovirus en niños menores de 6 años con síndrome diarreico. Rev Soc Ven Microbiol. 2010;2010(30):1–8.

50.

Zhou HT, Yi HS, Guo YH, Pan YX, Tao SH, Wang B, Chen MJ, Yang M, Yu N. Enterovirus-related diarrhoea in Guangdong, China: clinical features and implications in hand, foot and mouth disease and herpangina. BMC Infect Dis. 2016;16:128. https://doi.org/10.1186/s12879-016-1463-9.CrossRefPubMedPubMedCentral

51.

Holtz LR, Cao S, Zhao G, Bauer IK, Denno DM, Klein EJ, Antonio M, Stine OC, Snelling TL, Kirkwood CD, Wang D. Geographic variation in the eukaryotic virome of human diarrhea. Virology. 2014;468–470:556–64. https://doi.org/10.1016/j.virol.2014.09.012.CrossRefPubMed

52.

Pongsuwanna Y, Tacharoenmuang R, Prapanpoj M, Sakon N, Komoto S, Guntapong R, Taniguchi K. Monthly distribution of norovirus and sapovirus causing viral gastroenteritis in Thailand. Jpn J Infect Dis. 2017;24(70):84–6. https://doi.org/10.7883/yoken.JJID.2015.440.CrossRef

53.

Chhabra P, Payne DC, Szilagyi PG, Edwards KM, Staat MA, Shirley SH, Wikswo M, Nix WA, Lu X, Parashar UD, Vinjé J. Etiology of viral gastroenteritis in children < 5 years of age in the United States, 2008–2009. J Infect Dis. 2013;208:790–800. https://doi.org/10.1093/infdis/jit254.CrossRefPubMed

54.

Rovida F, Campanini G, Piralla A, Adzasehoun KM, Sarasini A, Baldanti F. Molecular detection of gastrointestinal viral infections in hospitalized patients. Diagn Microbiol Infect Dis. 2013;77:231–5. https://doi.org/10.1016/j.diagmicrobio.2013.07.020.CrossRefPubMed

55.

Dey SK, Shimizu H, Phan TG, Hayakawa Y, Islam A, Salim AF, Khan AR, Mizuguchi M, Okitsu S, Ushijima H. Molecular epidemiology of adenovirus infection among infants and children with acute gastroenteritis in Dhaka City, Bangladesh. Infect Genet Evol. 2009;9:518–22. https://doi.org/10.1016/j.meegid.2009.02.001.CrossRefPubMed

56.

Zaraket H, Abou-El-Hassan H, Kreidieh K, Soudani N, Ali Z, Hammadi M, Reslan L, Ghanem S, Hajar F, Inati A, Rajab M, Fakhouri H, Ghanem B, Baasiri G, Melhem NM, Dbaibo G. Characterization of astrovirus-associated gastroenteritis in hospitalized children under five years of age. Infect Genet Evol. 2017;53:94–9. https://doi.org/10.1016/j.meegid.2017.05.016.CrossRefPubMed

57.

Pham NT, Khamrin P, Nguyen TA, Kanti DS, Phan TG, Okitsu S, Ushijima H. Isolation and molecular characterization of Aichi viruses from fecal specimens collected in Japan, Bangladesh, Thailand, and Vietnam. J Clin Microbiol. 2007;45:2287–8.CrossRefPubMedPubMedCentral

58.

Oh DY, Oh DY, Silva PA, Hauroeder B, Diedrich S, Cardoso DD, Schreier E. Molecular characterization of the first Aichi viruses isolated in Europe and in South America. Adv Virol. 2006;151:1199–206.

59.

Chuchaona W, Khamrin P, Yodmeeklin A, Kumthip K, Saikruang W, Thongprachum A, Okitsu S, Ushijima H, Maneekarn N. Detection and characterization of Aichi virus 1 in pediatric patients with diarrhea in Thailand. J Med Virol. 2017;89:234–8. https://doi.org/10.1002/jmv.24630.CrossRefPubMed

Title: Molecular detection of human enteric viruses circulating among children with acute gastroenteritis in Valencia, Venezuela, before rotavirus vaccine implementation
Authors: Ana C. Alcalá
Kriss Pérez
Ruth Blanco
Rosabel González
Juan E. Ludert
Ferdinando Liprandi
Esmeralda Vizzi
Publication date: 01-12-2018
Publisher: BioMed Central
Published in: Gut Pathogens / Issue 1/2018
Electronic ISSN: 1757-4749
DOI: https://doi.org/10.1186/s13099-018-0232-2

Obesity Clinical Trial Summary

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.

Developed by: Springer Medicine

Highlights from the ACC 2024 Congress

Year in Review: Pediatric cardiology

Pediatric Cardiology Video

Watch Dr. Anne Marie Valente present the last year's highlights in pediatric and congenital heart disease in the official ACC.24 Year in Review session.

Year in Review: Pulmonary vascular disease

Cardiopulmonary Comorbidity Video

The last year's highlights in pulmonary vascular disease are presented by Dr. Jane Leopold in this official video from ACC.24.

Year in Review: Valvular heart disease

Valvular Heart Disease Video

Watch Prof. William Zoghbi present the last year's highlights in valvular heart disease from the official ACC.24 Year in Review session.

Year in Review: Heart failure and cardiomyopathies

Heart Failure Video

Watch this official video from ACC.24. Dr. Biykem Bozkurt discuss last year's major advances in heart failure and cardiomyopathies.

ACC 2024 Congress Coverage

Heart Failure Video

Year in Review: Heart failure and cardiomyopathies

Watch now

Watch this official video from ACC.24. Dr. Biykem Bozkurt discuss last year's major advances in heart failure and cardiomyopathies.

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

16-04-2024 Type 2 Diabetes News

Incentivised to exercise

11-04-2024 Lifestyle Modifications News

New intervention for STEMI-related cardiogenic shock

10-04-2024 Myocardial Infarction News

» View more highlights on the ACC 2024 congress hub page

Image Credits

STEP AAG HeroTeaserCollection image/© Tarek / Generated with AI / Stock.adobe.com, ACC 2024 Pediatric and Congenital Heart Disease: Year in Review/© 2024 American College of Cardiology, ACC 2024 Pulmonary Vascular Disease: Year in Review/© 2024 American College of Cardiology, ACC 2024 Valvular Heart Disease: Year in Review/© 2024 American College of Cardiology, ACC 2024 HF and Cardiomyopathies: Year in Review/© 2024 American College of Cardiology, Woman out walking/© Seventyfour / stock.adobe.com (symbolic image with model), Woman checking smartwatch /© saltdium / stock.adobe.com (symbolic image with model), Cardiac catheterization/© Damian / stock.adobe.com

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2018

Antimicrobial resistant Helicobacter fennelliae isolated from non-diarrheal child stool sample in Battambang, Cambodia

Complete genome sequence of Enterococcus durans KLDS6.0933, a potential probiotic strain with high cholesterol removal ability

A hybrid reference-guided de novo assembly approach for generating Cyclospora mitochondrion genomes

Chlortetracycline and florfenicol induce expression of genes associated with pathogenicity in multidrug-resistant Salmonella enterica serovar Typhimurium

Clinical application of a multiplex genetic pathogen detection system remaps the aetiology of diarrhoeal infections in Shanghai

Involvement of gut microbiome in human health and disease: brief overview, knowledge gaps and research opportunities

Highlights from the ACC 2024 Congress

ACC 2024 Congress Coverage