Advertisement

Racial Disparities in Oropharyngeal Cancer

  • Lucia Pirisi
  • Swati Tomar
  • Saundra H. GloverEmail author
Chapter

Abstract

Significant disparities have been detected and documented over time among different racial/ethnic groups, and in particular between Black and White men, in oropharyngeal cancer (OPSCC) incidence and mortality rates. Both rates have improved in Black men in recent year, and a concomitant increase in incidence of OPSCC in Whites contributes to closing the gap, for what OPSCC incidence is concerned. However, mortality rates for OPSCC in Black men remain much higher than in Whites. The reasons for this lingering disparity are many and complex. Among all sites of head and neck cancer (HNC) the oropharynx is the most likely to harbor cancers driven by high-risk human papillomavirus (HPV): up to 60 % of OPSCC (up to 25 % of all head and neck cancers) are due to HPV, most often HPV16. HPV-positive cancers respond better to treatment and have a better prognosis than the HPV-negative ones that are mostly due to tobacco and alcohol consumption. Black men are less likely to have HPV-positive OPSCC, and this could contribute to the disparity in mortality for this cancer. However, this disparity is also deeply rooted in inequalities of treatment, access to care, and social factors that can be addressed and corrected.

Keywords

Head and neck cancer Health disparity Oropharyngeal cancer Human papillomavirus HPV Social determinants Health insurance disparities Biologic determinants Lifestyle determinants Access to care 

References

  1. Abraham A, Al-Refaie WB, Parsons HM, Dudeja V, Vickers SM, Habermann EB (2013) Disparities in pancreas cancer care. Ann Surg Oncol 20:2078–2087PubMedCrossRefGoogle Scholar
  2. Allareddy V, Konety BR (2006) Characteristics of patients and predictors of in-hospital mortality after hospitalization for head and neck cancers. Cancer 106:2382–2388PubMedCrossRefGoogle Scholar
  3. Andersen AS, Koldjaer Solling AS, Ovesen T, Rusan M (2014) The interplay between HPV and host immunity in head and neck squamous cell carcinoma. Int J Cancer 134:2755–2763PubMedCrossRefGoogle Scholar
  4. Ang KK, Chen A, Curran WJ Jr, Garden AS, Harari PM, Murphy BA, Wong SJ, Bellm LA, Schwartz M, Newman J, Adkins D, Hayes DN, Parvathaneni U, Brachman D, Ghabach B, Schneider CJ, Greenberg M, Anne PR (2012) Head and neck carcinoma in the United States: first comprehensive report of the longitudinal oncology registry of head and neck carcinoma (LORHAN). Cancer 118:5783–5792PubMedCrossRefGoogle Scholar
  5. Ang KK, Harris J, Wheeler R, Weber R, Rosenthal DI, Nguyen-Tan PF, Westra WH, Chung CH, Jordan RC, Lu C, Kim H, Axelrod R, Silverman CC, Redmond KP, Gillison ML (2010) Human papillomavirus and survival of patients with oropharyngeal cancer. N Engl J Med 363:24–35PubMedCentralPubMedCrossRefGoogle Scholar
  6. Ang KK, Sturgis EM (2012) Human papillomavirus as a marker of the natural history and response to therapy of head and neck squamous cell carcinoma. Semin Radiat Oncol 22:128–142PubMedCrossRefGoogle Scholar
  7. Begum S, Westra WH (2008) Basaloid squamous cell carcinoma of the head and neck is a mixed variant that can be further resolved by HPV status. Am J Surg Pathol 32:1044–1050PubMedCrossRefGoogle Scholar
  8. Bernard HU, Burk RD, Chen Z, van Doorslaer K, zur Hausen H, de Villiers EM (2010) Classification of papillomaviruses (PVs) based on 189 PV types and proposal of taxonomic amendments. Virology 401:70–79PubMedCentralPubMedCrossRefGoogle Scholar
  9. Brawley OW (2009) Oropharyngeal cancer, race, and the human papillomavirus. Cancer Preven Res 2:769–772CrossRefGoogle Scholar
  10. Brown LM, Check DP, Devesa SS (2011) Oropharyngeal cancer incidence trends: diminishing racial disparities. Cancer Causes Control CCC 22:753–763PubMedCrossRefGoogle Scholar
  11. Canto MT, Devesa SS (2002) Oral cavity and pharynx cancer incidence rates in the United States, 1975–1998. Oral Oncol 38:610–617PubMedCrossRefGoogle Scholar
  12. Chen LM, Li G, Reitzel LR, Pytynia KB, Zafereo ME, Wei Q, Sturgis EM (2009) Matched-pair analysis of race or ethnicity in outcomes of head and neck cancer patients receiving similar multidisciplinary care. Cancer Prev Res 2:782–791CrossRefGoogle Scholar
  13. Chernock RD, Zhang Q, El-Mofty SK, Thorstad WL, Lewis JS (2011) Human papillomavirus-related squamous cell carcinoma of the oropharynx a comparative study in whites and African Americans. Arch Otolaryngol-Head Neck Surg 137:163–169PubMedCrossRefGoogle Scholar
  14. Chung CH, Gillison ML (2009) Human papillomavirus in head and neck cancer: its role in pathogenesis and clinical implications. Clin Cancer Res: An Official J Am Assoc Cancer Res 15:6758–6762CrossRefGoogle Scholar
  15. Chung CH, Parker JS, Ely K, Carter J, Yi Y, Murphy BA, Ang KK, El-Naggar AK, Zanation AM, Cmelak AJ, Levy S, Slebos RJ, Yarbrough WG (2006) Gene expression profiles identify epithelial-to-mesenchymal transition and activation of nuclear factor-kappaB signaling as characteristics of a high-risk head and neck squamous cell carcinoma. Cancer Res 66:8210–8218PubMedCrossRefGoogle Scholar
  16. Curado MP, Boyle P (2013) Epidemiology of head and neck squamous cell carcinoma not related to tobacco or alcohol. Curr Opin Oncol 25:229–234PubMedGoogle Scholar
  17. Day GL, Blot William J, Austin Donald F et al (1993) Racial differences in risk of oral and pharyngeal cancer: alcohol, tobacco, and other determinants. J Natl Cancer Inst 85:465–473PubMedCrossRefGoogle Scholar
  18. D’Souza G, Cullen K, Bowie J, Thorpe R, Fakhry C (2014) Differences in oral sexual behaviors by gender, age, and race explain observed differences in prevalence of oral human papillomavirus infection. PLoS One 9:e86023PubMedCentralPubMedCrossRefGoogle Scholar
  19. de Villiers EM (2013) Cross-roads in the classification of papillomaviruses. Virology 445:2–10PubMedCrossRefGoogle Scholar
  20. de Villiers EM, Fauquet C, Broker TR, Bernard HU, zur Hausen H (2004) Classification of papillomaviruses. Virology 324:17–27PubMedCrossRefGoogle Scholar
  21. Doorbar J, Quint W, Banks L, Bravo IG, Stoler M, Broker TR, Stanley MA (2012) The biology and life-cycle of human papillomaviruses. Vaccine 30(Suppl 5):F55–F70PubMedCrossRefGoogle Scholar
  22. Durst M, Dzarlieva-Petrusevska RT, Boukamp P, Fusenig NE, Gissmann L (1987) Molecular and cytogenetic analysis of immortalized human primary keratinocytes obtained after transfection with human papillomavirus type 16 DNA. Oncogene 1:251–256PubMedGoogle Scholar
  23. Dwojak SM, Finkelstein DM, Emerick KS, Lee JH, Petereit DG, Deschler DG (2014) Poor survival for american Indians with head and neck squamous cell carcinoma. Otolaryngol-Head Neck Surg: Official J Am Acad Otolaryngol-Head Neck SurgGoogle Scholar
  24. Dwojak SM, Sequist TD, Emerick K, Deschler DG (2013) Survival differences among American Indians/Alaska Natives with head and neck squamous cell carcinoma. Head Neck 35:1114–1118PubMedCrossRefGoogle Scholar
  25. Elter JR, Patton LL, Strauss RP (2005) Incidence rates and trends for oral and pharyngeal cancer in North Carolina: 1990–1999. Oral Oncol 41:470–479PubMedCrossRefGoogle Scholar
  26. Favre M (1975) Structural polypeptides of rabbit, bovine, and human papillomaviruses. J Virol 15:1239–1247PubMedCentralPubMedGoogle Scholar
  27. Gage JR, Meyers C, Wettstein FO (1990) The E7 proteins of the nononcogenic human papillomavirus type 6b (HPV-6b) and of the oncogenic HPV-16 differ in retinoblastoma protein binding and other properties. J Virol 64:723–730PubMedCentralPubMedGoogle Scholar
  28. Gates GJ, Sonenstein FL (2000) Heterosexual genital sexual activity among adolescent males: 1988 and 1995. Fam Plann Perspect 32(295–297):304Google Scholar
  29. Gillison ML (2004) Human papillomavirus-associated head and neck cancer is a distinct epidemiologic, clinical, and molecular entity. Semin Oncol 31:744–754PubMedCrossRefGoogle Scholar
  30. Gillison ML (2008) Human papillomavirus-related diseases: oropharynx cancers and potential implications for adolescent HPV vaccination. J Adolesc Health: Official Publ Soc Adolesc Med 43:S52–S60CrossRefGoogle Scholar
  31. Gillison ML, Alemany L, Snijders PJ, Chaturvedi A, Steinberg BM, Schwartz S, Castellsague X (2012) Human papillomavirus and diseases of the upper airway: head and neck cancer and respiratory papillomatosis. Vaccine 30(Suppl 5):F34–F54PubMedCrossRefGoogle Scholar
  32. Hardefeldt HA, Cox MR, Eslick GD (2014) Association between human papillomavirus (HPV) and oesophageal squamous cell carcinoma: a meta-analysis. Epidemiol Infect 142:1119–1137PubMedCrossRefGoogle Scholar
  33. Hoffmann M, Tribius S, Quabius ES, Henry H, Pfannenschmidt S, Burkhardt C, Gorogh T, Halec G, Hoffmann AS, Kahn T, Rocken C, Haag J, Waterboer T, Schmitt M (2012) HPV DNA, E6*I-mRNA expression and p16INK4A immunohistochemistry in head and neck cancer—how valid is p16INK4A as surrogate marker? Cancer Lett 323:88–96PubMedCrossRefGoogle Scholar
  34. Holzinger D, Flechtenmacher C, Henfling N, Kaden I, Grabe N, Lahrmann B, Schmitt M, Hess J, Pawlita M, Bosch FX (2013) Identification of oropharyngeal squamous cell carcinomas with active HPV16 involvement by immunohistochemical analysis of the retinoblastoma protein pathway. Int J Cancer 133:1389–1399PubMedCrossRefGoogle Scholar
  35. Holzinger D, Schmitt M, Dyckhoff G, Benner A, Pawlita M, Bosch FX (2012) Viral RNA patterns and high viral load reliably define oropharynx carcinomas with active HPV16 involvement. Cancer Res 72:4993–5003PubMedCrossRefGoogle Scholar
  36. Isayeva T, Xu J, Dai Q, Whitley AC, Bonner J, Nabell L, Spencer S, Carroll W, Jones G, Ragin C, Brandwein-Gensler M (2014) African Americans with oropharyngeal carcinoma have significantly poorer outcomes despite similar rates of human papillomavirus-mediated carcinogenesis. Hum Pathol 45:310–319PubMedCrossRefGoogle Scholar
  37. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D (2011) Global cancer statistics. CA Cancer J Clin 61:69–90PubMedCrossRefGoogle Scholar
  38. Jeudin P, Liveright E, Del Carmen MG, Perkins RB (2014) Race, ethnicity, and income factors impacting human papillomavirus vaccination rates. Clin Ther 36:24–37PubMedCrossRefGoogle Scholar
  39. Jung AC, Briolat J, Millon R, de Reynies A, Rickman D, Thomas E, Abecassis J, Clavel C, Wasylyk B (2010) Biological and clinical relevance of transcriptionally active human papillomavirus (HPV) infection in oropharynx squamous cell carcinoma. Int J Cancer 126:1882–1894PubMedGoogle Scholar
  40. Kaur P, McDougall JK (1988) Characterization of primary human keratinocytes transformed by human papillomavirus type 18. J Virol 62:1917–1924PubMedCentralPubMedGoogle Scholar
  41. King CJ, Chen J, Dagher RK, Holt CL, Thomas SB (2014) Decomposing differences in medical care access among cancer survivors by race and ethnicity. Am J Med Qual: Official J Am Coll Med QualGoogle Scholar
  42. Klaes R, Friedrich T, Spitkovsky D, Ridder R, Rudy W, Petry U, Dallenbach-Hellweg G, Schmidt D, von Knebel Doeberitz M (2001) Overexpression of p16(INK4A) as a specific marker for dysplastic and neoplastic epithelial cells of the cervix uteri. Int J Cancer 92:276–284PubMedCrossRefGoogle Scholar
  43. Kolker JL, Ismail AI, Sohn W, Ramaswami N (2007) Trends in the incidence, mortality, and survival rates of oral and pharyngeal cancer in a high-risk area in Michigan, USA. Commun Dent Oral Epidemiol 35:489–499CrossRefGoogle Scholar
  44. Liang C, Marsit CJ, McClean MD, Nelson HH, Christensen BC, Haddad RI, Clark JR, Wein RO, Grillone GA, Houseman EA, Halec G, Waterboer T, Pawlita M, Krane JF, Kelsey KT (2012) Biomarkers of HPV in head and neck squamous cell carcinoma. Cancer Res 72:5004–5013PubMedCentralPubMedCrossRefGoogle Scholar
  45. Liu G-FF, Ranck MC, Solanki AA, Cao H, Kolokythas A, Wenig BL, Chen L, Ard S, Weichselbaum RR, Halpern H, Spiotto MT (2014) Racial parities in outcomes after radiotherapy for head and neck cancer. Cancer 120:244–252. doi: 10.1002/cncr.28417 PubMedCrossRefGoogle Scholar
  46. McLaughlin-Drubin ME, Crum CP, Munger K (2011) Human papillomavirus E7 oncoprotein induces KDM6A and KDM6B histone demethylase expression and causes epigenetic reprogramming. Proc Natl Acad Sci USA 108:2130–2135PubMedCentralPubMedCrossRefGoogle Scholar
  47. McLean A, LeMay W, Vila P, Wegner M, Remington P (2006) Disparities in oral and pharyngeal cancer incidence and mortality among Wisconsin residents, 1999–2002. WMJ Official Publ State Med Soc Wis 105:32–35Google Scholar
  48. Mehra R, Ang KK, Burtness B (2012) Management of human papillomavirus-positive and human papillomavirus-negative head and neck cancer. Semin Radiat Oncol 22:194–197PubMedCrossRefGoogle Scholar
  49. Miller DL, Puricelli MD, Stack MS (2012) Virology and molecular pathogenesis of HPV (human papillomavirus)-associated oropharyngeal squamous cell carcinoma. Biochem J 443:339–353PubMedCentralPubMedCrossRefGoogle Scholar
  50. Moody CA, Laimins LA (2010) Human papillomavirus oncoproteins: pathways to transformation. Nat Rev Cancer 10:550–560PubMedCrossRefGoogle Scholar
  51. Morse DE, Kerr AR (2006) Disparities in oral and pharyngeal cancer incidence, mortality and survival among black and white Americans. J Am Dent Assoc 137:203–212PubMedCentralPubMedCrossRefGoogle Scholar
  52. Munger K, Werness BA, Dyson N, Phelps WC, Harlow E, Howley PM (1989) Complex formation of human papillomavirus E7 proteins with the retinoblastoma tumor suppressor gene product. EMBO J 8:4099–4105PubMedCentralPubMedGoogle Scholar
  53. Ohba K, Ichiyama K, Yajima M, Gemma N, Nikaido M, Wu Q, Chong P, Mori S, Yamamoto R, Wong JE, Yamamoto N (2014) In Vivo and In Vitro studies suggest a possible involvement of HPV infection in the early stage of breast carcinogenesis via APOBEC3B induction. PLoS One 9:e97787PubMedCentralPubMedCrossRefGoogle Scholar
  54. Pibiri F, Kittles RA, Sandler RS, Keku TO, Kupfer SS, Xicola RM, Llor X, Ellis NA (2014) Genetic variation in vitamin D-related genes and risk of colorectal cancer in African Americans. Cancer Causes Control: CCC 25:561–570PubMedCentralPubMedCrossRefGoogle Scholar
  55. Pirisi L, Yasumoto S, Feller M, Doniger J, DiPaolo JA (1987) Transformation of human fibroblasts and keratinocytes with human papillomavirus type 16 DNA. J Virol 61:1061–1066PubMedCentralPubMedGoogle Scholar
  56. Probst JC, Bellinger JD, Walsemann KM, Hardin J, Glover SH (2011) Higher risk of death in rural blacks and whites than urbanites is related to lower incomes, education, and health coverage. Health Aff 30:1872–1879CrossRefGoogle Scholar
  57. Ragin C, Obikoya-Malomo M, Kim S, Chen Z, Flores-Obando R, Gibbs D, Koriyama C, Aguayo F, Koshiol J, Caporaso NE, Carpagnano GE, Ciotti M, Dosaka-Akita H, Fukayama M, Goto A, Spandidos DA, Gorgoulis V, Heideman DA, van Boerdonk RA, Hiroshima K, Iwakawa R, Kastrinakis NG, Kinoshita I, Akiba S, Landi MT, Eugene Liu H, Wang JL, Mehra R, Khuri FR, Lim WT, Owonikoko TK, Ramalingam S, Sarchianaki E, Syrjanen K, Tsao MS, Sykes J, Hee SW, Yokota J, Zaravinos A, Taioli E (2014) HPV-associated lung cancers: an international pooled analysis. Carcinogenesis 35:1267–1275PubMedCentralPubMedCrossRefGoogle Scholar
  58. Rietbergen MM, Leemans CR, Bloemena E, Heideman DA, Braakhuis BJ, Hesselink AT, Witte BI, Baatenburg de Jong RJ, Meijer CJ, Snijders PJ, Brakenhoff RH (2013) Increasing prevalence rates of HPV attributable oropharyngeal squamous cell carcinomas in the Netherlands as assessed by a validated test algorithm. Int J Cancer 132:1565–1571PubMedCrossRefGoogle Scholar
  59. Ryerson AB, Peters ES, Coughlin SS, Chen VW, Gillison ML, Reichman ME, Wu X, Chaturvedi AK, Kawaoka K (2008) Burden of potentially human papillomavirus-associated cancers of the oropharynx and oral cavity in the US, 1998-2003. Cancer 113:2901–2909PubMedCrossRefGoogle Scholar
  60. Sagerup CM, Nymoen DA, Halvorsen AR, Lund-Iversen M, Helland A, Brustugun OT (2014) Human papilloma virus detection and typing in 334 lung cancer patients. Acta OncolGoogle Scholar
  61. Schrank TP, Han Y, Weiss H, Resto VA (2011) Case-matching analysis of head and neck squamous cell carcinoma in racial and ethnic minorities in the United States–possible role for human papillomavirus in survival disparities. Head Neck 33:45–53PubMedCentralPubMedCrossRefGoogle Scholar
  62. Sedaghat AR, Zhang Z, Begum S, Palermo R, Best S, Ulmer KM, Levine M, Zinreich E, Messing BP, Gold D, Wu AA, Niparko KJ, Kowalski J, Hirata RM, Saunders JR, Westra WH, Pai SI (2009) Prognostic significance of human papillomavirus in oropharyngeal squamous cell carcinomas. The Laryngoscope 119:1542–1549PubMedCrossRefGoogle Scholar
  63. Settle K, Posner MR, Schumaker LM, Tan M, Suntharalingam M, Goloubeva O, Strome SE, Haddad RI, Patel SS, Cambell EV 3rd, Sarlis N, Lorch J, Cullen KJ (2009) Racial survival disparity in head and neck cancer results from low prevalence of human papillomavirus infection in black oropharyngeal cancer patients. Cancer Prev Res 2:776–781CrossRefGoogle Scholar
  64. Shavers VL, Harlan LC, Winn D, Davis WW (2003) Racial/ethnic patterns of care for cancers of the oral cavity, pharynx, larynx, sinuses, and salivary glands. Cancer Metastasis Rev 22:25–38PubMedCrossRefGoogle Scholar
  65. Shin KH, Min BM, Cherrick HM, Park NH (1994) Combined effects of human papillomavirus-18 and N-methyl-N’-nitro-N-nitrosoguanidine on the transformation of normal human oral keratinocytes. Mol Carcinog 9:76–86PubMedCrossRefGoogle Scholar
  66. Smeets SJ, Hesselink AT, Speel EJ, Haesevoets A, Snijders PJ, Pawlita M, Meijer CJ, Braakhuis BJ, Leemans CR, Brakenhoff RH (2007) A novel algorithm for reliable detection of human papillomavirus in paraffin embedded head and neck cancer specimen. Int J Cancer 121:2465–2472PubMedCrossRefGoogle Scholar
  67. Stillman M, Tailor M (2013) Dead man walking. N Engl J Med 369:1880–1881PubMedCrossRefGoogle Scholar
  68. Subramanian S, Chen A (2013) Treatment patterns and survival among low-income medicaid patients with head and neck cancer. JAMA Otolaryngol-Head Neck Surg 139:489–495PubMedCrossRefGoogle Scholar
  69. von Knebel Doeberitz M (2001) New molecular tools for efficient screening of cervical cancer. Dis Markers 17:123–128CrossRefGoogle Scholar
  70. Wagner SE, Hurley DM, Hebert JR, McNamara C, Bayakly AR, Vena JE (2012) Cancer mortality-to-incidence ratios in Georgia: describing racial cancer disparities and potential geographic determinants. Cancer 118:4032–4045PubMedCentralPubMedCrossRefGoogle Scholar
  71. Walker B, Figgs LW, Zahm SH (1995) Differences in cancer incidence, mortality, and survival between African Americans and whites. Environ Health Perspect 103(Suppl 8):275–281PubMedCentralPubMedCrossRefGoogle Scholar
  72. Wang T, Zeng X, Li W, Zhu H, Wang G, Liu X, Lv Y, Wu J, Zhuang X, Zhang J, Zhao Y, Huang H, Fan J, Yao Q, He C, Zhang X, Huang C, Chen J, Wang L (2014) Detection and analysis of human papillomavirus (HPV) DNA in breast cancer patients by an effective method of HPV capture. PLoS One 9:e90343PubMedCentralPubMedCrossRefGoogle Scholar
  73. Weinberger PM, Merkley MA, Khichi SS, Lee JR, Psyrri A, Jackson LL, Dynan WS (2010) Human papillomavirus-active head and neck cancer and ethnic health disparities. The Laryngoscope 120:1531–1537PubMedCentralPubMedCrossRefGoogle Scholar
  74. Weinberger PM, Yu Z, Kountourakis P, Sasaki C, Haffty BG, Kowalski D, Merkley MA, Rimm DL, Camp RL, Psyrri A (2009) Defining molecular phenotypes of human papillomavirus-associated oropharyngeal squamous cell carcinoma: validation of three-class hypothesis. Otolaryngol-Head Neck Surg: Official J Am Acad Otolaryngol-Head Neck Surg 141:382–389CrossRefGoogle Scholar
  75. Weng Y, Korte JE (2012) Racial disparities in being recommended to surgery for oral and oropharyngeal cancer in the United States. Commun Dent Oral Epidemiol 40:80–88CrossRefGoogle Scholar
  76. Westra WH (2014) Detection of human papillomavirus (HPV) in clinical samples: evolving methods and strategies for the accurate determination of HPV status of head and neck carcinomas. Oral OncolGoogle Scholar
  77. Wilson DD, Rahimi AS, Saylor DK, Stelow EB, Jameson MJ, Shonka DC, Reibel JF, Levine PA, Read PW (2012) p16 not a prognostic marker for hypopharyngeal squamous cell carcinoma. Archives Otolaryngol-Head Neck Surg 138 556–561Google Scholar
  78. Worsham MJ, Divine G, Kittles RA (2011) Race as a social construct in head and neck cancer outcomes. Otolaryngol-Head and Neck Surg: Official J Am Acad Otolaryngol-Head Neck Surg 144:381–389CrossRefGoogle Scholar
  79. Yen KL, Horner MJ, Reed SG, Daguise VG, Bolick-Aldrich SW, Young MR, Day TA, Wood PA, Hebert JR (2006) Head and neck cancer disparities in South Carolina: descriptive epidemiology, early detection, and special programs. J S C Med Assoc 102:192–200PubMedGoogle Scholar
  80. Zandberg DP, Liu S, Goloubeva OG, Schumaker LM, Cullen KJ (2014) Emergence of HPV16 positive oropharyngeal cancer in black patients over time: University of Maryland 1992–2007. Cancer Prev ResGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  1. 1.Department of Pathology, Microbiology and Immunology, School of MedicineUniversity of South CarolinaColumbiaUSA
  2. 2.Department of Health Services, Policies and Management, Arnold School of Public HealthUniversity of South CarolinaColumbiaUSA

Personalised recommendations