Maria Zambon

Public Health England, Londinium, England, United Kingdom

Are you Maria Zambon?

Claim your profile

Publications (234)1794.27 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: The 2014/15 influenza season was the second season of roll-out of a live attenuated influenza vaccine (LAIV) programme for healthy children in England. During this season, besides offering LAIV to all two to four year olds, several areas piloted vaccination of primary (4–11 years) and secondary (11–13 years) age children. Influenza A(H3N2) circulated, with strains genetically and antigenically distinct from the 2014/15 A(H3N2) vaccine strain, followed by a drifted B strain. We assessed the overall and indirect impact of vaccinating school age children, comparing cumulative disease incidence in targeted and non-targeted age groups in vaccine pilot to non-pilot areas. Uptake levels were 56.8% and 49.8% in primary and secondary school pilot areas respectively. In primary school age pilot areas, cumulative primary care influenza-like consultation, emergency department respiratory attendance, respiratory swab positivity, hospitalisation and excess respiratory mortality were consistently lower in targeted and non-targeted age groups, though less for adults and more severe end-points, compared with non-pilot areas. There was no significant reduction for excess all-cause mortality. Little impact was seen in secondary school age pilot only areas compared with non-pilot areas. Vaccination of healthy primary school age children resulted in population-level impact despite circulation of drifted A and B influenza strains. © 2015, European Centre for Disease Prevention and Control (ECDC). All rights reserved.
    European communicable disease bulletin 10/2015; 20(39):1-11. DOI:10.2807/1560-7917.ES.2015.20.39.30029 · 5.72 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The 2014/15 influenza season in the United Kingdom (UK) was characterised by circulation of predominantly antigenically and genetically drifted influenza A(H3N2) and B viruses. A universal paediatric influenza vaccination programme using a quadrivalent live attenuated influenza vaccine (LAIV) has recently been introduced in the UK. This study aims to measure the end-of-season influenza vaccine effectiveness (VE), including for LAIV, using the test negative case–control design. The overall adjusted VE against all influenza was 34.3% (95% confidence interval (CI) 17.8 to 47.5); for A(H3N2) 29.3% (95% CI: 8.6 to 45.3) and for B 46.3% (95% CI: 13.9 to 66.5). For those aged under 18 years, influenza A(H3N2) LAIV VE was 35% (95% CI: −29.9 to 67.5), whereas for influenza B the LAIV VE was 100% (95% CI:17.0 to 100.0). Although the VE against influenza A(H3N2) infection was low, there was still evidence of significant protection, together with moderate, significant protection against drifted circulating influenza B viruses. LAIV provided non-significant positive protection against influenza A, with significant protection against B. Further work to assess the population impact of the vaccine programme across the UK is underway. © 2015, European Centre for Disease Prevention and Control (ECDC). All rights reserved.
    Eurosurveillance: bulletin europeen sur les maladies transmissibles = European communicable disease bulletin 09/2015; 20(36). DOI:10.2807/1560-7917.ES.2015.20.36.30013 · 5.72 Impact Factor
  • Source

  • C I Thompson · J Ellis · M Galiano · M Ramsay · K E Brown · M Zambon ·
    [Show abstract] [Hide abstract]
    ABSTRACT: Influenza A(H3N2) virus was detected in oral fluid from 16/107 children (aged 2 to 12 years) with a clinical diagnosis of mumps, who were sampled between December 2014 and February 2015 in England, during the peak of the 2014/15 influenza season. Sequence analysis of an A(H3N2) virus from a child with suspected mumps showed the virus was similar to other circulating A(H3N2) viruses detected in winter 2014/15, which were antigenically drifted from the A(H3N2) vaccine strain. © 2015 European Centre for Disease Prevention and Control (ECDC). All rights reserved.
    Eurosurveillance: bulletin europeen sur les maladies transmissibles = European communicable disease bulletin 08/2015; 20(31). DOI:10.2807/1560-7917.ES2015.20.31.21203 · 5.72 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: By defining strategic objectives for the network of influenza laboratories that have national influenza centre status or national function within European Union Member States, Iceland and Norway, it is possible to align their priorities in undertaking virological surveillance of influenza. This will help maintain and develop the network to meet and adapt to new challenges over the next 3–5 years and underpin a longerterm strategy over 5–10 years. We analysed the key activities undertaken by influenza reference laboratories in Europe and categorised them into a framework of four key strategic objectives areas: enhancing laboratory capability, ensuring laboratory capacity, providing emergency response and translating laboratory data into information for public health action. We make recommendations on the priority areas for future development. © 2015 European Centre for Disease Prevention and Control (ECDC). All rights reserved.
    Eurosurveillance: bulletin europeen sur les maladies transmissibles = European communicable disease bulletin 08/2015; 20(30). DOI:10.2807/1560-7917.ES2015.20.30.21195 · 5.72 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Literature on influenza focuses on influenza A, despite influenza B having a large public health impact. The Global Influenza B Study aims to collect information on global epidemiology and burden of disease of influenza B since 2000. Twenty-six countries in the Southern (n = 5) and Northern (n = 7) hemispheres and intertropical belt (n = 14) provided virological and epidemiological data. We calculated the proportion of influenza cases due to type B and Victoria and Yamagata lineages in each country and season; tested the correlation between proportion of influenza B and maximum weekly influenza-like illness (ILI) rate during the same season; determined the frequency of vaccine mismatches; and described the age distribution of cases by virus type. The database included 935 673 influenza cases (2000-2013). Overall median proportion of influenza B was 22·6%, with no statistically significant differences across seasons. During seasons where influenza B was dominant or co-circulated (>20% of total detections), Victoria and Yamagata lineages predominated during 64% and 36% of seasons, respectively, and a vaccine mismatch was observed in ≈25% of seasons. Proportion of influenza B was inversely correlated with maximum ILI rate in the same season in the Northern and (with borderline significance) Southern hemispheres. Patients infected with influenza B were usually younger (5-17 years) than patients infected with influenza A. Influenza B is a common disease with some epidemiological differences from influenza A. This should be considered when optimizing control/prevention strategies in different regions and reducing the global burden of disease due to influenza. © 2015 The Authors. Influenza and Other Respiratory Viruses Published by John Wiley & Sons Ltd.
    Influenza and Other Respiratory Viruses 08/2015; 9 Suppl 1(S1):3-12. DOI:10.1111/irv.12319 · 2.20 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Middle East Respiratory Syndrome (MERS) is a highly lethal pulmonary infection caused by a previously unidentified coronavirus (CoV), likely transmitted to humans by infected camels. There is no licensed vaccine or antiviral for MERS, therefore new prophylactic and therapeutic strategies to combat human infections are needed. In this study, we describe, for the first time, to our knowledge, the isolation of a potent MERS-CoV-neutralizing antibody from memory B cells of an infected individual. The antibody, named LCA60, binds to a novel site on the spike protein and potently neutralizes infection of multiple MERS-CoV isolates by interfering with the binding to the cellular receptor CD26. Importantly, using mice transduced with adenovirus expressing human CD26 and infected with MERS-CoV, we show that LCA60 can effectively protect in both prophylactic and postexposure settings. This antibody can be used for prophylaxis, for postexposure prophylaxis of individuals at risk, or for the treatment of human cases of MERS-CoV infection. The fact that it took only 4 mo from the initial screening of B cells derived from a convalescent patient for the development of a stable chinese hamster ovary (CHO) cell line producing neutralizing antibodies at more than 5 g/L provides an example of a rapid pathway toward the generation of effective antiviral therapies against emerging viruses.
    Proceedings of the National Academy of Sciences 07/2015; 112(33). DOI:10.1073/pnas.1510199112 · 9.67 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: We determined complete viral genome sequences from three British healthcare workers infected with Ebola virus (EBOV) in Sierra Leone, directly from clinical samples. These sequences closely resemble those previously observed in the current Ebola virus disease outbreak in West Africa, with glycoprotein and polymerase genes showing the most sequence variation. Our data indicate that current PCR diagnostic assays remain suitable for detection of EBOV in this epidemic and provide confidence for their continued use in diagnosis.
    Eurosurveillance: bulletin europeen sur les maladies transmissibles = European communicable disease bulletin 05/2015; 20(20):21. DOI:10.2807/1560-7917.ES2015.20.20.21131 · 5.72 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: A high proportion of influenza infections are asymptomatic. Animal and human challenge studies and observational studies suggest T cells protect against disease among those infected, but the impact of T cell immunity at the population level is unknown. To investigate whether naturally pre-existing T cell responses targeting highly conserved internal influenza proteins could provide cross-protective immunity against pandemic and seasonal influenza. We quantified influenza A(H3N2) virus specific T cells in a population cohort during seasonal and pandemic periods between 2006-2010. Follow-up included paired serology, symptom reporting and PCR investigation of symptomatic cases. 1414 unvaccinated individuals had baseline T cell measurements: (1703 participant observation sets). T cell responses to A(H3N2) virus nucleoprotein (NP) dominated and strongly cross-reacted with A(H1N1)pdm09 NP (p<0.001) in participants lacking antibody to A(H1N1)pdm09. Comparison of paired pre- and post-season sera (1431 sets) showed 205 (14%) had evidence of infection based on four-fold influenza antibody titre rises. The presence of NP specific T cells before exposure to virus correlated with less symptomatic, PCR-positive influenza A (overall adjusted odds ratio 0.27 (95% Confidence Interval, 0.11-0.68), p=0.005, during pandemic (p=0.047) and seasonal periods (p=0.049)). Protection was independent of baseline antibodies. Influenza specific T cell responses were detected in 43% indicating a substantial population impact. Naturally occurring cross-protective T cell immunity protects against symptomatic PCR-confirmed disease in those with evidence of infection and helps to explain why many infections do not cause symptoms. Vaccines stimulating T cells may provide important cross-protective immunity.
    American Journal of Respiratory and Critical Care Medicine 04/2015; 191(12). DOI:10.1164/rccm.201411-1988OC · 13.00 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: This report aims to evaluate the usefulness of self-sampling as an approach for future national surveillance of emerging respiratory infections by comparing virological data from two parallel surveillance schemes in England. Nasal swabs were obtained via self-administered sampling from consenting adults (≥ 16 years-old) with influenza symptoms who had contacted the National Pandemic Flu Service (NPFS) health line during the 2009 influenza pandemic. Equivalent samples submitted by sentinel general practitioners participating in the national influenza surveillance scheme run jointly by the Royal College of General Practitioners (RCGP) and Health Protection Agency were also obtained. When comparable samples were analysed there was no significant difference in results obtained from self-sampling and clinician-led sampling schemes. These results demonstrate that self-sampling can be applied in a responsive and flexible manner, to supplement sentinel clinician-based sampling, to achieve a wide spread and geographically representative way of assessing community transmission of a known organism.
    Eurosurveillance: bulletin europeen sur les maladies transmissibles = European communicable disease bulletin 03/2015; 20(10). DOI:10.2807/1560-7917.ES2015.20.10.21058 · 5.72 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The influenza season 2014/15 started in Europe in week 50 2014 with influenza A(H3N2) viruses predominating. The majority of the A(H3N2) viruses characterised antigenically and/or genetically differ from the northern hemisphere vaccine component which may result in reduced vaccine effectiveness for the season. We therefore anticipate that this season may be more severe than the 2013/14 season. Treating influenza with antivirals in addition to prevention with vaccination will be important. --------------------------------------------------------------------------------
    Eurosurveillance: bulletin europeen sur les maladies transmissibles = European communicable disease bulletin 01/2015; 20(4):1-5. · 5.72 Impact Factor
  • G Dabrera · H Zhao · N Andrews · F Begum · Hk Green · J Ellis · K Elias · M Donati · M Zambon · R Pebody ·
    [Show abstract] [Hide abstract]
    ABSTRACT: In this study we used the screening method to estimate the effectiveness of seasonal influenza vaccination during pregnancy in preventing influenza virus infection and influenza-related hospitalisation in infants under six months, in England in the 2013/14 season. Seasonal influenza vaccination in pregnancy was 71% (95% CI: 24–89%) effective in preventing infant influenza virus infection and 64% (95% CI: 6–86%) effective in preventing infant influenza hospitalisation, and should be recommended in pregnancy.
    Eurosurveillance: bulletin europeen sur les maladies transmissibles = European communicable disease bulletin 11/2014; 19(45). DOI:10.2807/1560-7917.ES2014.19.45.20959 · 5.72 Impact Factor
  • Maria Zambon ·
    [Show abstract] [Hide abstract]
    ABSTRACT: Purpose of review: Cases of severe influenza may occur during seasonal epidemics, following sporadic zoonotic influenza A transmission from animal reservoirs or on a massive scale with the unpredictable emergence of a new pandemic influenza strain. Clinical experience identifies unmet medical need for additional therapies for influenza, in particular to treat severely unwell adults and children. During and following the pandemic of 2009, a wealth of data from hospitalized cases of influenza from many different countries accumulated and are now starting to emerge. Observational clinical data provide information about the efficacy of existing antiviral drugs in severely ill patients. The development pipeline for new therapies contains several promising agents which are focussed on a range of viral targets, and opens the possibility of combination antiviral therapy for the first time, which may be especially useful in clinically challenging cases. Advances in immunological methods and recombinant protein engineering support the potential for use of immunomodulating therapies as adjuncts in treatment of severe influenza. Recent findings: The main themes are the importance of treating severe influenza early, considering multiple therapy options and the relevance of observational clinical data to treatment of severely ill and risk groups. Summary: Clinicians, who may have only seen the media headlines following discussion of reviews which deal with randomized controlled trials of neuraminidase inhibitor drug use in mild uncomplicated influenza in the community, may be hesitant to prescribe these drugs. Observational data arising from treatment of severely ill individuals support use of these drugs early in illness and show improvement in outcomes associated with drug use.
    Current Opinion in Infectious Diseases 10/2014; 27(6). DOI:10.1097/QCO.0000000000000113 · 5.01 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Unlabelled: The influenza pandemic that emerged in 2009 provided an unprecedented opportunity to study adaptation of a virus recently acquired from an animal source during human transmission. In the United Kingdom, the novel virus spread in three temporally distinct waves between 2009 and 2011. Phylogenetic analysis of complete viral genomes showed that mutations accumulated over time. Second- and third-wave viruses replicated more rapidly in human airway epithelial (HAE) cells than did the first-wave virus. In infected mice, weight loss varied between viral isolates from the same wave but showed no distinct pattern with wave and did not correlate with viral load in the mouse lungs or severity of disease in the human donor. However, second- and third-wave viruses induced less alpha interferon in the infected mouse lungs. NS1 protein, an interferon antagonist, had accumulated several mutations in second- and third-wave viruses. Recombinant viruses with the third-wave NS gene induced less interferon in human cells, but this alone did not account for increased virus fitness in HAE cells. Mutations in HA and NA genes in third-wave viruses caused increased binding to α-2,6-sialic acid and enhanced infectivity in human mucus. A recombinant virus with these two segments replicated more efficiently in HAE cells. A mutation in PA (N321K) enhanced polymerase activity of third-wave viruses and also provided a replicative advantage in HAE cells. Therefore, multiple mutations allowed incremental changes in viral fitness, which together may have contributed to the apparent increase in severity of A(H1N1)pdm09 influenza virus during successive waves. Importance: Although most people infected with the 2009 pandemic influenza virus had mild or unapparent symptoms, some suffered severe and devastating disease. The reasons for this variability were unknown, but the numbers of severe cases increased during successive waves of human infection in the United Kingdom. To determine the causes of this variation, we studied genetic changes in virus isolates from individual hospitalized patients. There were no consistent differences between these viruses and those circulating in the community, but we found multiple evolutionary changes that in combination over time increased the virus's ability to infect human cells. These adaptations may explain the remarkable ability of A(H1N1)pdm09 virus to continue to circulate despite widespread immunity and the apparent increase in severity of influenza over successive waves of infection.
    Journal of Virology 09/2014; 88(22). DOI:10.1128/JVI.01636-14 · 4.44 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: During the first year of enhanced MERS coronavirus surveillance in England, 77 persons traveling from the Middle East had acute respiratory illness and were tested for the virus. Infection was confirmed in 2 travelers with acute respiratory distress syndrome and 2 of their contacts. Patients with less severe manifestations tested negative.
    Emerging infectious diseases 09/2014; 20(9):1562-1564. DOI:10.3201/eid2009.140817 · 6.75 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background Subnational variation of 2009 pandemic influenza activity in England has been reported; however, little work has been published on this topic for seasonal influenza. If variation is present, this knowledge may assist with both identifying the onset of influenza epidemics, informing community antiviral prescription and local health planning. Methods An end-of-season analysis of influenza surveillance systems (acute respiratory outbreaks, primary care consultations, virological testing, influenza-confirmed secondary care admissions and excess all-cause mortality) was undertaken at national and subnational levels for 2012/13 when influenza B and A(H3N2) dominated. Results National community antiviral prescription was recommended in Week 51 following national threshold exceedance. However, this was preceded up to 2 weeks by subnational influenza activity in 2/9 regions in England. Regional variation in circulation of influenza subtypes was observed and severe influenza surveillance data sources were able to monitor the subnational impact. Conclusions Evidence of virological activity in two or more regions above a threshold indicated the onset of the 2012/13 season. Subnational thresholds should be determined and evaluated in order to improve timeliness of the national antiviral alert. During the season, outputs should be reported at levels that can inform local public health responses and variation considered when retrospectively evaluating the impact of interventions. © 2014 The Author 2014. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: [email protected] /* */
    Journal of Public Health 08/2014; 37(2). DOI:10.1093/pubmed/fdu046 · 2.04 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: SUMMARY General Practitioner consultation rates for influenza-like illness (ILI) are monitored through several geographically distinct schemes in the UK, providing early warning to government and health services of community circulation and intensity of activity each winter. Following on from the 2009 pandemic, there has been a harmonization initiative to allow comparison across the distinct existing surveillance schemes each season. The moving epidemic method (MEM), proposed by the European Centre for Disease Prevention and Control for standardizing reporting of ILI rates, was piloted in 2011/12 and 2012/13 along with the previously proposed UK method of empirical percentiles. The MEM resulted in thresholds that were lower than traditional thresholds but more appropriate as indicators of the start of influenza virus circulation. The intensity of the influenza season assessed with the MEM was similar to that reported through the percentile approach. The MEM pre-epidemic threshold has now been adopted for reporting by each country of the UK. Further work will continue to assess intensity of activity and apply standardized methods to other influenza-related data sources.
    Epidemiology and Infection 07/2014; 143(01):1-12. DOI:10.1017/S0950268814001757 · 2.54 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The effectiveness of the 2012/13 trivalent seasonal influenza vaccine (TIV) was assessed using a testnegative case–control study of patients consulting primary care with influenza-like illness in the United Kingdom. Strain characterisation was undertaken on selected isolates. Vaccine effectiveness (VE) against confirmed influenza A(H3N2), A(H1N1) and B virus infection, adjusted for age, sex, surveillance scheme (i.e. setting) and month of sample collection was 26% (95% confidence interval (CI): -4 to 48), 73% (95% CI: 37 to 89) and 51% (95% CI: 34 to 63) respectively. There was an indication, although not significant, that VE declined by time since vaccination for influenza A(H3N2) (VE 50% within three months, 2% after three months, p=0.25). For influenza A(H3N2) this is the second season of low VE, contributing to the World Health Organization (WHO) recommendation that the 2013/14 influenza vaccine strain composition be changed to an A(H3N2) virus antigenically like cell-propagated prototype 2012/13 vaccine strain (A/Victoria/361/2011). The lower VE seen for type B is consistent with antigenic drift away from the 2012/13 vaccine strain. The majority of influenza B viruses analysed belong to the genetic clade 2 and were antigenically distinguishable from the 2012/13 vaccine virus B/Wisconsin/1/2010 clade 3. These findings supported the change to the WHO recommended influenza B vaccine component for 2013/14
    Eurosurveillance: bulletin europeen sur les maladies transmissibles = European communicable disease bulletin 07/2014; 19(27). DOI:10.2807/1560-7917.ES2014.19.27.20851 · 5.72 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Emerging H7N9 influenza virus infections in Asia have once more spurred the development of effective pre-pandemic H7 vaccines. However, many vaccines based on avian influenza viruses - including H7 - are poorly immunogenic as measured by traditional correlates of protection. Here we re-evaluated sera from an H7N1 human vaccine trial performed in 2006. We examined cross-reactive antibody responses to divergent H7 strains including H7N9, dissected the antibody response into head versus stalk reactive antibodies, and tested the in vivo potency of these human sera in a passive transfer H7N9 challenge experiment in mice. Although only a low percentage of vaccinees induced neutralizing antibody responses against the homologous vaccine strain and also H7N9, we detected strong cross-reactivity to divergent H7 HAs in a large proportion of the cohort using a quantitative ELISA method. Furthermore, H7N1 vaccination induced antibodies to both the head and the stalk domain of the HA which is in sharp contrast to seasonal inactivated vaccines. Finally, we were able to show that both, neutralizing but also non-neutralizing antibodies improved in vivo virus clearance in a passive transfer H7N9 challenge mouse model.
    Clinical and vaccine Immunology: CVI 06/2014; 21(8). DOI:10.1128/CVI.00272-14 · 2.47 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: Influenza H5N1 virus constitutes a pandemic threat and development of effective H5N1 vaccines is a global priority. Anti-influenza antibodies directed towards the haemagglutinin (HA) define a correlate of protection. Both antibody concentration and avidity may be important for virus neutralization and resolving influenza disease. Methods: We conducted a phase I clinical trial of a virosomal H5N1 vaccine adjuvanted with the immunostimulating complex Matrix M™. Sixty adults were intramuscularly immunized with two vaccine doses (21 days apart) of 30 μg HA alone or 1.5, 7.5 or 30 μg HA adjuvanted with Matrix M™. Serum H5 HA1-specific antibodies and virus neutralization were determined at days 0, 21, 42, 180 and 360 and long-term memory B cells at day 360 post-vaccination. The binding of the HA specific antibodies was measured by avidity NaSCN-elution ELISA and surface plasmon resonance (SPR). Results: The H5 HA1-specific IgG response peaked after the second dose (day 42), was dominated by IgG1 and IgG3 and was highest in the adjuvanted vaccine groups. IgG titres correlated significantly with virus neutralization at all time points (Spearman r≥0.66, p<0.0001). By elution ELISA, serum antibody avidity was highest at days 180 and 360 post vaccination and did not correlate with virus neutralization. Long-lasting H5 HA1-specific memory B cells produced high IgG antibody avidity similar to serum IgG. Conclusions: Maturation of serum antibody avidity continued up to day 360 after influenza H5N1 vaccination. Virus neutralization correlated with serum H5 HA1-specific IgG antibody concentrations and not antibody avidity.
    Vaccine 06/2014; 32(35). DOI:10.1016/j.vaccine.2014.06.009 · 3.62 Impact Factor

Publication Stats

11k Citations
1,794.27 Total Impact Points


  • 2003-2015
    • Public Health England
      • • Respiratory Diseases Department
      • • Health Protection Agency - North East
      Londinium, England, United Kingdom
  • 2012
    • University of Bonn - Medical Center
      Bonn, North Rhine-Westphalia, Germany
  • 2010
    • University of Cambridge
      • Department of Haematology
      Cambridge, England, United Kingdom
  • 2007
    • Nederlands Instituut voor onderzoek van de Gezondheidszorg
      Utrecht, Utrecht, Netherlands
  • 2006
    • Trinity College Dublin
      • Biochemistry
      Dublin, Leinster, Ireland
  • 2005
    • Environment Agency UK
      Rotherdam, England, United Kingdom
  • 2004
    • National Institute for Biological Standards and Control
      • Division of Virology
      Potters Bar, England, United Kingdom
  • 2001
    • The Bracton Centre, Oxleas NHS Trust
      Дартфорде, England, United Kingdom
  • 1996-1997
    • Royal College of General Practitioners
      Londinium, England, United Kingdom