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Gravenstein S, DeVone F, Oyebanji OA, Abul Y, Cao Y, Chan PA, Halladay CW, Rudolph JL, Nugent C, Bosch J, King CL, Wilson BM, Balazs AB, White EM, Canaday DH, McConeghy KW. Durability of immunity and clinical protection in nursing home residents following bivalent SARS-CoV-2 vaccination. EBioMedicine 2024; 105:105180. [PMID: 38861869 PMCID: PMC11215210 DOI: 10.1016/j.ebiom.2024.105180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 05/12/2024] [Accepted: 05/17/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Bivalent SARS-CoV-2 vaccines were developed to counter increasing susceptibility to emerging SARS-CoV-2 variants. We evaluated the durability of immunity and protection following first bivalent vaccination among nursing home residents. METHODS We evaluated anti-spike and neutralization titers from blood in 653 community nursing home residents before and after each monovalent booster, and a bivalent vaccine. Concurrent clinical outcomes were evaluated using electronic health record data from a separate cohort of 3783 residents of Veterans Affairs (VA) nursing homes who had received at least the primary series monovalent vaccination. Using target trial emulation, we compared VA residents who did and did not receive the bivalent vaccine to measure vaccine effectiveness against infection, hospitalization, and death. FINDINGS In the community cohort, Omicron BA.5 neutralization activity rose after each monovalent and bivalent booster vaccination regardless of prior infection history. Titers declined over time but six months post-bivalent vaccination, BA.5 neutralization persisted at detectable levels in 75% of infection-naive and 98% of prior-infected individuals. In the VA nursing home cohort, bivalent vaccine added effectiveness to monovalent booster vaccination by 18.5% for infection (95% confidence interval (CI) -5.6, 34.0%), and 29.2% for hospitalization or death (95% CI -14.2, 56.2%) over five months. INTERPRETATION The level of protection declined after bivalent vaccination over a 6 month period and may open a window of added vulnerability before the next updated vaccine becomes available, suggesting a subset of nursing home residents may benefit from an additional vaccination booster. FUNDING CDC, NIH, VHA.
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Affiliation(s)
- Stefan Gravenstein
- Warren Alpert Medical School, Brown University, Providence, RI, USA; Department of Health Services, Policy & Practice, School of Public Health, Brown University, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Veterans Administration (VA) Medical Center, Providence, RI, USA.
| | - Frank DeVone
- Center of Innovation in Long-Term Services and Supports, Veterans Administration (VA) Medical Center, Providence, RI, USA
| | | | - Yasin Abul
- Warren Alpert Medical School, Brown University, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Veterans Administration (VA) Medical Center, Providence, RI, USA
| | - Yi Cao
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA
| | - Philip A Chan
- Warren Alpert Medical School, Brown University, Providence, RI, USA; Rhode Island Department of Health, Providence, RI, USA
| | - Christopher W Halladay
- Center of Innovation in Long-Term Services and Supports, Veterans Administration (VA) Medical Center, Providence, RI, USA
| | - James L Rudolph
- Warren Alpert Medical School, Brown University, Providence, RI, USA; Department of Health Services, Policy & Practice, School of Public Health, Brown University, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Veterans Administration (VA) Medical Center, Providence, RI, USA
| | - Clare Nugent
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Jürgen Bosch
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | | | - Brigid M Wilson
- Geriatric Research Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA
| | | | - Elizabeth M White
- Department of Health Services, Policy & Practice, School of Public Health, Brown University, Providence, RI, USA
| | - David H Canaday
- Case Western Reserve University School of Medicine, Cleveland, OH, USA; Geriatric Research Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA.
| | - Kevin W McConeghy
- Department of Health Services, Policy & Practice, School of Public Health, Brown University, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Veterans Administration (VA) Medical Center, Providence, RI, USA.
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Fisman DN, Amoako A, Simmons A, Tuite AR. Impact of immune evasion, waning and boosting on dynamics of population mixing between a vaccinated majority and unvaccinated minority. PLoS One 2024; 19:e0297093. [PMID: 38574059 PMCID: PMC10994315 DOI: 10.1371/journal.pone.0297093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 12/22/2023] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND We previously demonstrated that when vaccines prevent infection, the dynamics of mixing between vaccinated and unvaccinated sub-populations is such that use of imperfect vaccines markedly decreases risk for vaccinated people, and for the population overall. Risks to vaccinated people accrue disproportionately from contact with unvaccinated people. In the context of the emergence of Omicron SARS-CoV-2 and evolving understanding of SARS-CoV-2 epidemiology, we updated our analysis to evaluate whether our earlier conclusions remained valid. METHODS We modified a previously published Susceptible-Infectious-Recovered (SIR) compartmental model of SARS-CoV-2 with two connected sub-populations: vaccinated and unvaccinated, with non-random mixing between groups. Our expanded model incorporates diminished vaccine efficacy for preventing infection with the emergence of Omicron SARS-CoV-2 variants, waning immunity, the impact of prior immune experience on infectivity, "hybrid" effects of infection in previously vaccinated individuals, and booster vaccination. We evaluated the dynamics of an epidemic within each subgroup and in the overall population over a 10-year time horizon. RESULTS Even with vaccine efficacy as low as 20%, and in the presence of waning immunity, the incidence of COVID-19 in the vaccinated subpopulation was lower than that among the unvaccinated population across the full 10-year time horizon. The cumulative risk of infection was 3-4 fold higher among unvaccinated people than among vaccinated people, and unvaccinated people contributed to infection risk among vaccinated individuals at twice the rate that would have been expected based on the frequency of contacts. These findings were robust across a range of assumptions around the rate of waning immunity, the impact of "hybrid immunity", frequency of boosting, and the impact of prior infection on infectivity in unvaccinated people. INTERPRETATION Although the emergence of the Omicron variants of SARS-CoV-2 has diminished the protective effects of vaccination against infection with SARS-CoV-2, updating our earlier model to incorporate loss of immunity, diminished vaccine efficacy and a longer time horizon, does not qualitatively change our earlier conclusions. Vaccination against SARS-CoV-2 continues to diminish the risk of infection among vaccinated people and in the population as a whole. By contrast, the risk of infection among vaccinated people accrues disproportionately from contact with unvaccinated people.
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Affiliation(s)
- David N. Fisman
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Afia Amoako
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Alison Simmons
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Ashleigh R. Tuite
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Centre for Immunization Programs, Public Health Agency of Canada, Ottawa, Ontario, Canada
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Perez-Saez J, Zaballa ME, Lamour J, Yerly S, Dubos R, Courvoisier DS, Villers J, Balavoine JF, Pittet D, Kherad O, Vuilleumier N, Kaiser L, Guessous I, Stringhini S, Azman AS. Long term anti-SARS-CoV-2 antibody kinetics and correlate of protection against Omicron BA.1/BA.2 infection. Nat Commun 2023; 14:3032. [PMID: 37230973 DOI: 10.1038/s41467-023-38744-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 05/11/2023] [Indexed: 05/27/2023] Open
Abstract
Binding antibody levels against SARS-CoV-2 have shown to be correlates of protection against infection with pre-Omicron lineages. This has been challenged by the emergence of immune-evasive variants, notably the Omicron sublineages, in an evolving immune landscape with high levels of cumulative incidence and vaccination coverage. This in turn limits the use of widely available commercial high-throughput methods to quantify binding antibodies as a tool to monitor protection at the population-level. Here we show that anti-Spike RBD antibody levels, as quantified by the immunoassay used in this study, are an indirect correlate of protection against Omicron BA.1/BA.2 for individuals previously infected by SARS-CoV-2. Leveraging repeated serological measurements between April 2020 and December 2021 on 1083 participants of a population-based cohort in Geneva, Switzerland, and using antibody kinetic modeling, we found up to a three-fold reduction in the hazard of having a documented positive SARS-CoV-2 infection during the Omicron BA.1/BA.2 wave for anti-S antibody levels above 800 IU/mL (HR 0.30, 95% CI 0.22-0.41). However, we did not detect a reduction in hazard among uninfected participants. These results provide reassuring insights into the continued interpretation of SARS-CoV-2 binding antibody measurements as an independent marker of protection at both the individual and population levels.
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Affiliation(s)
- Javier Perez-Saez
- Unit of Population Epidemiology, Division of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland.
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - María-Eugenia Zaballa
- Unit of Population Epidemiology, Division of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Julien Lamour
- Unit of Population Epidemiology, Division of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Sabine Yerly
- Division of Laboratory Medicine, Department of Diagnostics, Geneva University Hospitals, Geneva, Switzerland
| | - Richard Dubos
- Unit of Population Epidemiology, Division of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Delphine S Courvoisier
- General Directorate of Health, Geneva, Switzerland
- Division of Quality of Care, Geneva University Hospitals, Geneva, Switzerland
| | - Jennifer Villers
- Unit of Population Epidemiology, Division of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
| | | | - Didier Pittet
- Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Infection Control Program and World Health Organization Collaborating Centre on Patient Safety, Geneva University Hospitals, Geneva, Switzerland
| | - Omar Kherad
- Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Internal Medicine, Hôpital de la Tour, Geneva, Switzerland
| | - Nicolas Vuilleumier
- Division of Laboratory Medicine, Department of Diagnostics, Geneva University Hospitals, Geneva, Switzerland
- Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Laurent Kaiser
- Division of Laboratory Medicine, Department of Diagnostics, Geneva University Hospitals, Geneva, Switzerland
- Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Infectious Diseases, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
- Geneva Centre for Emerging Viral Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Idris Guessous
- Department of Health and Community Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division and Department of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Silvia Stringhini
- Unit of Population Epidemiology, Division of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
- University Centre for General Medicine and Public Health, University of Lausanne, Lausanne, Switzerland
| | - Andrew S Azman
- Unit of Population Epidemiology, Division of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Schnittman SR, Jung W, Fitch KV, Zanni MV, McCallum S, Lee JSL, Shin S, Davis BJ, Fulda ES, Diggs MR, Giguel F, Chinchay R, Sheth AN, Fichtenbaum CJ, Malvestutto C, Aberg JA, Currier J, Lauffenburger DA, Douglas PS, Ribaudo HJ, Alter G, Grinspoon SK. Effect of host factors and COVID-19 infection on the humoral immune repertoire in treated HIV. JCI Insight 2023; 8:e166848. [PMID: 36805331 PMCID: PMC10077482 DOI: 10.1172/jci.insight.166848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/27/2023] [Indexed: 02/22/2023] Open
Abstract
People with HIV (PWH) appear to be at higher risk for suboptimal pathogen responses and for worse COVID-19 outcomes, but the effects of host factors and COVID-19 on the humoral repertoire remain unclear. We assessed the antibody isotype/subclass and Fc-receptor binding Luminex arrays of non-SARS-CoV-2 and SARS-CoV-2 humoral responses among antiretroviral therapy-treated (ART-treated) PWH. Among the entire cohort, COVID-19 infection was associated with higher cytomegalovirus (CMV) responses (vs. the COVID- cohort ), potentially signifying increased susceptibility or a consequence of persistent inflammation. Among the COVID+ participants, (a) higher BMI was associated with a striking amplification of SARS-CoV-2 responses, suggesting exaggerated inflammatory responses, and (b) lower nadir CD4 was associated with higher SARS-CoV-2 IgM and FcγRIIB binding capacity, indicating poorly functioning extrafollicular and inhibitory responses. Among the COVID-19- participants, female sex, older age, and lower nadir CD4 were associated with unique repertoire shifts. In this first comprehensive assessment of the humoral repertoire in a global cohort of PWH, we identify distinct SARS-CoV-2-specific humoral immune profiles among PWH with obesity or lower nadir CD4+ T cell count, underlining plausible mechanisms associated with worse COVID-19-related outcomes in this setting. Host factors associated with the humoral repertoire in the COVID-19- cohort enhance our understanding of these important shifts among PWH.
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Affiliation(s)
- Samuel R. Schnittman
- Division of Infectious Diseases, Department of Medicine, and
- Metabolism Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Wonyeong Jung
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, Massachusetts, USA
| | - Kathleen V. Fitch
- Metabolism Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Markella V. Zanni
- Metabolism Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sara McCallum
- Metabolism Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Sally Shin
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, Massachusetts, USA
| | - Brandon J. Davis
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, Massachusetts, USA
| | - Evelynne S. Fulda
- Metabolism Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marissa R. Diggs
- Metabolism Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Francoise Giguel
- AIDS Clinical Trials Group Lab 01, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Romina Chinchay
- Houston AIDS Research Team, University of Texas Health Science Center Houston, Houston, Texas, USA
| | - Anandi N. Sheth
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Carl J. Fichtenbaum
- Division of Infectious Diseases, Department of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Carlos Malvestutto
- Division of Infectious Diseases, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Judith A. Aberg
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Judith Currier
- Division of Infectious Diseases, Department of Medicine, UCLA, Los Angeles, California, USA
| | - Douglas A. Lauffenburger
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Pamela S. Douglas
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | | | - Galit Alter
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, Massachusetts, USA
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Dobaño C, Ramírez-Morros A, Alonso S, Rubio R, Ruiz-Olalla G, Vidal-Alaball J, Macià D, Catalina QM, Vidal M, Casanovas AF, Prados de la Torre E, Barrios D, Jiménez A, Zanoncello J, Melero NR, Carolis C, Izquierdo L, Aguilar R, Moncunill G, Ruiz-Comellas A. Sustained seropositivity up to 20.5 months after COVID-19. BMC Med 2022; 20:379. [PMID: 36224590 PMCID: PMC9556137 DOI: 10.1186/s12916-022-02570-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 09/15/2022] [Indexed: 01/09/2023] Open
Abstract
This study evaluated the persistence of IgM, IgA, and IgG to SARS-CoV-2 spike and nucleocapsid antigens up to 616 days since the onset of symptoms in a longitudinal cohort of 247 primary health care workers from Barcelona, Spain, followed up since the start of the pandemic. The study also assesses factors affecting antibody levels, including comorbidities and the responses to variants of concern as well as the frequency of reinfections. Despite a gradual and significant decline in antibody levels with time, seropositivity to five SARS-CoV-2 antigens combined was always higher than 90% over the whole study period. In a subset of 23 participants who had not yet been vaccinated by November 2021, seropositivity remained at 95.65% (47.83% IgM, 95.65% IgA, 95.65% IgG). IgG seropositivity against Alpha and Delta predominant variants was comparable to that against the Wuhan variant, while it was lower for Gamma and Beta (minority) variants and for IgA and IgM. Antibody levels at the time point closest to infection were associated with age, smoking, obesity, hospitalization, fever, anosmia/hypogeusia, chest pain, and hypertension in multivariable regression models. Up to 1 year later, just before the massive roll out of vaccination, antibody levels were associated with age, occupation, hospitalization, duration of symptoms, anosmia/hypogeusia, fever, and headache. In addition, tachycardia and cutaneous symptoms associated with slower antibody decay, and oxygen supply with faster antibody decay. Eight reinfections (3.23%) were detected in low responders, which is consistent with a sustained protective role for anti-spike naturally acquired antibodies. Stable persistence of IgG and IgA responses and cross-recognition of the predominant variants circulating in the 2020-2021 period indicate long-lasting and largely variant-transcending humoral immunity in the initial 20.5 months of the pandemic, in the absence of vaccination.
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Affiliation(s)
- Carlota Dobaño
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Carrer Roselló 153 (CEK building), E-08036, Barcelona, Spain.
- CIBER de Enfermedades Infecciosas, Barcelona, Spain.
| | - Anna Ramírez-Morros
- Unitat de Suport a la Recerca de la Catalunya Central, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Sant Fruitós de Bages, Spain
| | - Selena Alonso
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Carrer Roselló 153 (CEK building), E-08036, Barcelona, Spain
| | - Rocío Rubio
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Carrer Roselló 153 (CEK building), E-08036, Barcelona, Spain
| | - Gemma Ruiz-Olalla
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Carrer Roselló 153 (CEK building), E-08036, Barcelona, Spain
| | - Josep Vidal-Alaball
- Unitat de Suport a la Recerca de la Catalunya Central, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Sant Fruitós de Bages, Spain
- Grup de Promoció de la Salut en l'Àmbit Rural (ProSaARu), Institut Català de la Salut, Sant Fruitós de Bages, Spain
- Facultat de Medicina, Universitat de Vic-Universitat Central de Catalunya (UVIC-UCC), Vic, Spain
| | - Dídac Macià
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Carrer Roselló 153 (CEK building), E-08036, Barcelona, Spain
- CIBER de Enfermedades Infecciosas, Barcelona, Spain
| | - Queralt Miró Catalina
- Unitat de Suport a la Recerca de la Catalunya Central, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Sant Fruitós de Bages, Spain
| | - Marta Vidal
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Carrer Roselló 153 (CEK building), E-08036, Barcelona, Spain
| | - Aina Fuster Casanovas
- Unitat de Suport a la Recerca de la Catalunya Central, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Sant Fruitós de Bages, Spain
| | - Esther Prados de la Torre
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Carrer Roselló 153 (CEK building), E-08036, Barcelona, Spain
| | - Diana Barrios
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Carrer Roselló 153 (CEK building), E-08036, Barcelona, Spain
| | - Alfons Jiménez
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Carrer Roselló 153 (CEK building), E-08036, Barcelona, Spain
| | - Jasmina Zanoncello
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Carrer Roselló 153 (CEK building), E-08036, Barcelona, Spain
| | - Natalia Rodrigo Melero
- Biomolecular Screening and Protein Technologies Unit, Centre for Genomic Regulation (CRG), The Barcelona Institute of Science and Technology, Barcelona, Spain
| | - Carlo Carolis
- Biomolecular Screening and Protein Technologies Unit, Centre for Genomic Regulation (CRG), The Barcelona Institute of Science and Technology, Barcelona, Spain
| | - Luis Izquierdo
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Carrer Roselló 153 (CEK building), E-08036, Barcelona, Spain
- CIBER de Enfermedades Infecciosas, Barcelona, Spain
| | - Ruth Aguilar
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Carrer Roselló 153 (CEK building), E-08036, Barcelona, Spain
| | - Gemma Moncunill
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Carrer Roselló 153 (CEK building), E-08036, Barcelona, Spain
- CIBER de Enfermedades Infecciosas, Barcelona, Spain
| | - Anna Ruiz-Comellas
- Unitat de Suport a la Recerca de la Catalunya Central, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Sant Fruitós de Bages, Spain
- Grup de Promoció de la Salut en l'Àmbit Rural (ProSaARu), Institut Català de la Salut, Sant Fruitós de Bages, Spain
- Facultat de Medicina, Universitat de Vic-Universitat Central de Catalunya (UVIC-UCC), Vic, Spain
- Centre d'Atenció Primària (CAP) Sant Joan de Vilatorrada. Gerència Territorial de la Catalunya Central, Institut Català de la Salut, Sant Fruitós de Bages, Spain
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