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Suntronwong N, Kanokudom S, Auphimai C, Thongmee T, Assawakosri S, Vichaiwattana P, Yorsaeng R, Duangchinda T, Chantima W, Pakchotanon P, Nilyanimit P, Srimuan D, Thatsanathorn T, Sudhinaraset N, Wanlapakorn N, Poovorawan Y. Long-Term Dynamic Changes in Hybrid Immunity over Six Months after Inactivated and Adenoviral Vector Vaccination in Individuals with Previous SARS-CoV-2 Infection. Vaccines (Basel) 2024; 12:180. [PMID: 38400163 PMCID: PMC10891631 DOI: 10.3390/vaccines12020180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 01/30/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
Numerous studies have largely focused on short-term immunogenicity in recovered individuals post mRNA vaccination. However, understanding the long-term durability, particularly in inactivated and adenoviral vectored vaccines, remains limited. We evaluated antibody responses, omicron variant neutralization, and IFN-γ responses in 119 previously infected individuals vaccinated with CoronaVac or ChAdOx1 up to six months post-vaccination. Both vaccines elicited robust immune responses in recovered individuals, surpassing those who were infection-naïve, and these persisted above pre-vaccination levels for six months. However, antibody levels declined over time (geometric mean ratio (GMR) = 0.52 for both vaccines). Notably, neutralizing activities against omicron declined faster in ChAdOx1 (GMR = 0.6) compared to CoronaVac recipients (GMR = 1.03). While the first dose of ChAdOx1 adequately induced immune responses in recovered individuals, a second dose demonstrated advantages in omicron variant neutralization and slower decline. Although both vaccines induced T cell responses, the median IFN-γ level at six months returned to pre-vaccination levels. However, more individuals exhibited reactive T cell responses. Extending the interval (13-15 months) between infection and vaccination could enhance antibody levels and broaden neutralization. Together, these findings demonstrate a robust humoral and cellular response that was sustained for at least six months after vaccination, thus guiding optimal vaccination strategies based on prior infection and vaccine platforms.
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Affiliation(s)
- Nungruthai Suntronwong
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; (N.S.); (S.K.); (C.A.); (T.T.); (S.A.); (P.V.); (R.Y.); (P.N.); (D.S.); (T.T.); (N.S.); (N.W.)
| | - Sitthichai Kanokudom
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; (N.S.); (S.K.); (C.A.); (T.T.); (S.A.); (P.V.); (R.Y.); (P.N.); (D.S.); (T.T.); (N.S.); (N.W.)
- Center of Excellence in Osteoarthritis and Musculoskeleton, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Chompoonut Auphimai
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; (N.S.); (S.K.); (C.A.); (T.T.); (S.A.); (P.V.); (R.Y.); (P.N.); (D.S.); (T.T.); (N.S.); (N.W.)
| | - Thanunrat Thongmee
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; (N.S.); (S.K.); (C.A.); (T.T.); (S.A.); (P.V.); (R.Y.); (P.N.); (D.S.); (T.T.); (N.S.); (N.W.)
| | - Suvichada Assawakosri
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; (N.S.); (S.K.); (C.A.); (T.T.); (S.A.); (P.V.); (R.Y.); (P.N.); (D.S.); (T.T.); (N.S.); (N.W.)
- Center of Excellence in Osteoarthritis and Musculoskeleton, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Preeyaporn Vichaiwattana
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; (N.S.); (S.K.); (C.A.); (T.T.); (S.A.); (P.V.); (R.Y.); (P.N.); (D.S.); (T.T.); (N.S.); (N.W.)
| | - Ritthideach Yorsaeng
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; (N.S.); (S.K.); (C.A.); (T.T.); (S.A.); (P.V.); (R.Y.); (P.N.); (D.S.); (T.T.); (N.S.); (N.W.)
| | - Thaneeya Duangchinda
- Molecular Biology of Dengue and Flaviviruses Research Team, National Center for Genetic Engineering and Biotechnology (BIOTEC), National Science and Development Agency, NSTDA, Pathum Thani 12120, Thailand; (T.D.); (P.P.)
| | - Warangkana Chantima
- Division of Dengue Hemorrhagic Fever Research, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand;
- Siriraj Center of Research Excellence in Dengue and Emerging Pathogens, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Pattarakul Pakchotanon
- Molecular Biology of Dengue and Flaviviruses Research Team, National Center for Genetic Engineering and Biotechnology (BIOTEC), National Science and Development Agency, NSTDA, Pathum Thani 12120, Thailand; (T.D.); (P.P.)
| | - Pornjarim Nilyanimit
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; (N.S.); (S.K.); (C.A.); (T.T.); (S.A.); (P.V.); (R.Y.); (P.N.); (D.S.); (T.T.); (N.S.); (N.W.)
| | - Donchida Srimuan
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; (N.S.); (S.K.); (C.A.); (T.T.); (S.A.); (P.V.); (R.Y.); (P.N.); (D.S.); (T.T.); (N.S.); (N.W.)
| | - Thaksaporn Thatsanathorn
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; (N.S.); (S.K.); (C.A.); (T.T.); (S.A.); (P.V.); (R.Y.); (P.N.); (D.S.); (T.T.); (N.S.); (N.W.)
| | - Natthinee Sudhinaraset
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; (N.S.); (S.K.); (C.A.); (T.T.); (S.A.); (P.V.); (R.Y.); (P.N.); (D.S.); (T.T.); (N.S.); (N.W.)
| | - Nasamon Wanlapakorn
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; (N.S.); (S.K.); (C.A.); (T.T.); (S.A.); (P.V.); (R.Y.); (P.N.); (D.S.); (T.T.); (N.S.); (N.W.)
| | - Yong Poovorawan
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand; (N.S.); (S.K.); (C.A.); (T.T.); (S.A.); (P.V.); (R.Y.); (P.N.); (D.S.); (T.T.); (N.S.); (N.W.)
- The Royal Society of Thailand (FRS(T)), Sanam Sueapa, Dusit, Bangkok 10330, Thailand
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Tsai DY, Wang CH, Schiro PG, Chen N, Tseng JY. Tracking B Cell Memory to SARS-CoV-2 Using Rare Cell Analysis System. Vaccines (Basel) 2023; 11:vaccines11040735. [PMID: 37112647 PMCID: PMC10145117 DOI: 10.3390/vaccines11040735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/14/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
Rapid mutations within SARS-CoV-2 are driving immune escape, highlighting the need for in-depth and routine analysis of memory B cells (MBCs) to complement the important but limited information from neutralizing antibody (nAb) studies. In this study, we collected plasma samples and peripheral blood mononuclear cells (PBMCs) from 35 subjects and studied the nAb titers and the number of antigen-specific memory B cells at designated time points before and after vaccination. We developed an assay to use the MiSelect R II System with a single-use microfluidic chip to directly detect the number of spike-receptor-binding domain (RBD)-specific MBCs in PBMCs. Our results show that the number of spike-RBD-specific MBCs detected by the MiSelect R II System is highly correlated with the level of nAbs secreted by stimulated PBMCs, even 6 months after vaccination when nAbs were generally not present in plasma. We also found antigen-specific cells recognizing Omicron spike-RBD were present in PBMCs from booster vaccination of subjects, but with a high variability in the number of B cells. The MiSelect R II System provided a direct, automated, and quantitative method to isolate and analyze subsets of rare cells for tracking cellular immunity in the context of a rapidly mutating virus.
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Affiliation(s)
- Dong-Yan Tsai
- MiCareo Taiwan Co., Ltd., 5F, No. 69, Ln. 77, Xing Ai Rd., Neihu Dist., Taipei City 114, Taiwan
| | - Chun-Hung Wang
- MiCareo Taiwan Co., Ltd., 5F, No. 69, Ln. 77, Xing Ai Rd., Neihu Dist., Taipei City 114, Taiwan
| | - Perry G. Schiro
- MiCareo Taiwan Co., Ltd., 5F, No. 69, Ln. 77, Xing Ai Rd., Neihu Dist., Taipei City 114, Taiwan
| | - Nathan Chen
- Adimmune Corporation, No. 3, Sec.1, Tanxing Rd., Tanzi Dist., Taichung City 427, Taiwan
| | - Ju-Yu Tseng
- MiCareo Taiwan Co., Ltd., 5F, No. 69, Ln. 77, Xing Ai Rd., Neihu Dist., Taipei City 114, Taiwan
- Correspondence: ; Tel.: +886-2-27923976
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Madhi SA, Kwatra G, Richardson SI, Koen AL, Baillie V, Cutland CL, Fairlie L, Padayachee SD, Dheda K, Barnabas SL, Bhorat QE, Briner C, Ahmed K, Aley PK, Bhikha S, Bhorat AE, Esmail A, Horne E, Kaldine H, Mukendi CK, Madzorera VS, Manamela NP, Masilela M, Hermanus ST, Motlou T, Mzindle N, Oelofse S, Patel F, Rhead S, Rossouw L, Taoushanis C, van Eck S, Lambe T, Gilbert SC, Pollard AJ, Moore PL, Izu A. Durability of ChAdOx1 nCoV-19 (AZD1222) vaccine and hybrid humoral immunity against variants including omicron BA.1 and BA.4 6 months after vaccination (COV005): a post-hoc analysis of a randomised, phase 1b-2a trial. THE LANCET. INFECTIOUS DISEASES 2023; 23:295-306. [PMID: 36273491 PMCID: PMC9584570 DOI: 10.1016/s1473-3099(22)00596-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND COVID-19 vaccine rollout is lagging in Africa, where there has been a high rate of SARS-CoV-2 infection. We aimed to evaluate the effect of SARS-CoV-2 infection before vaccination with the ChAdOx-nCoV19 (AZD1222) vaccine on antibody responses through to 180 days. METHODS We did an unmasked post-hoc immunogenicity analysis after the first and second doses of AZD1222 in a randomised, placebo-controlled, phase 1b-2a study done in seven locations in South Africa. AZD1222 recipients who were HIV-uninfected, were stratified into baseline seropositive or seronegative groups using the serum anti-nucleocapsid (anti-N) immunoglobulin G (IgG) electroluminescence immunoassay to establish SARS-CoV-2 infection before the first dose of AZD1222. Binding IgG to spike (anti-S) and receptor binding domain (anti-RBD) were measured before the first dose (day 0), second dose (day 28), day 42, and day 180. Neutralising antibody (NAb) against SARS-CoV-2 variants D614G, beta, delta, gamma, and A.VOI.V2, and omicron BA1 and BA.4 variants, were measured by pseudovirus assay (day 28, day 42, and day 180). This trial is registered with ClinicalTrials.gov, NCT04444674, and the Pan African Clinicals Trials Registry, PACTR202006922165132. FINDINGS Of 185 individuals who were randomly assigned to AZD1222, we included 91 individuals who were baseline seropositive and 58 who were baseline seronegative, in the final analysis. In the seropositive group, there was little change of anti-S IgG (and anti-RBD IgG) or neutralising antibody (NAb) titres at day 42 compared with at day 28. Anti-S (and anti-RBD) IgG geometric mean concentrations (GMCs) were higher throughout in the seropositive compared with the seronegative group, including at day 180 (GMCs 517·8 [95% CI 411·3-651·9] vs 82·1 [55·2-122·3] BAU/mL). Also D614G NAb geometric mean titres (GMTs) were higher in the seropositive group than the seronegative group, as was the percentage with titres of at least 185 (80% putative risk reduction threshold [PRRT] against wild-type-alpha COVID-19), including at day 180 (92·0% [74·0-99·0] vs 18·2% [2·3-51·8). Similar findings were observed for beta, A.VOI.V2, and gamma. For delta, BA.1, and BA.4, NAb GMTs and the proportion with titres above the PRRT were substantially higher in the seropositive compared with seronegative group at day 28 and day 42, but no longer differed between the groups by day 180. INTERPRETATION A single dose of AZD1222 in the general African population, where COVID-19 vaccine coverage is low and SARS-CoV-2 seropositivity is 90%, could enhance the magnitude and quality of antibody responses to SARS-CoV-2. FUNDING The Bill & Melinda Gates Foundation, the South African Medical Research Council, the UK Research and Innovation, the UK National Institute for Health Research, and the South African Medical Research Council. TRANSLATION For the Zulu translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Shabir A Madhi
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; African Leadership in Vaccinology Expertise, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Gaurav Kwatra
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; African Leadership in Vaccinology Expertise, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Simone I Richardson
- South African Medical Research Council Antibody Immunity Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
| | - Anthonet L Koen
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Vicky Baillie
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Clare L Cutland
- African Leadership in Vaccinology Expertise, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lee Fairlie
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Keertan Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Cape Town, South Africa
| | - Shaun L Barnabas
- Family Centre for Research with Ubuntu, Department of Paediatrics, Stellenbosch University, Cape Town, South Africa
| | | | - Carmen Briner
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Khatija Ahmed
- Setshaba Research Centre, Tshwane, South Africa; Faculty of Health Sciences, Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
| | - Parvinder K Aley
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Sutika Bhikha
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - A E Bhorat
- Soweto Clinical Trials Centre, Soweto, South Africa
| | - Aliasgar Esmail
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Cape Town, South Africa
| | - Elizea Horne
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Haajira Kaldine
- South African Medical Research Council Antibody Immunity Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
| | - Christian K Mukendi
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Vimbai Sharon Madzorera
- South African Medical Research Council Antibody Immunity Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
| | - Nelia P Manamela
- South African Medical Research Council Antibody Immunity Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
| | | | - S Tandile Hermanus
- South African Medical Research Council Antibody Immunity Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
| | - Thopisang Motlou
- South African Medical Research Council Antibody Immunity Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
| | - Nonkululeko Mzindle
- South African Medical Research Council Antibody Immunity Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
| | - Suzette Oelofse
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute, University of Cape Town, South Africa
| | - Faeezah Patel
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sarah Rhead
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Lindie Rossouw
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Carol Taoushanis
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Samuel van Eck
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Teresa Lambe
- Division of Infection and Immunity, University College London, London, UK; Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Sarah C Gilbert
- Division of Infection and Immunity, University College London, London, UK; Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Andrew J Pollard
- Division of Infection and Immunity, University College London, London, UK; Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Penny L Moore
- South African Medical Research Council Antibody Immunity Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
| | - Alane Izu
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; African Leadership in Vaccinology Expertise, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Rueda-Fernández M, Melguizo-Rodríguez L, Costela-Ruiz VJ, González-Acedo A, Ramos-Torrecillas J, Illescas-Montes R. The current status of COVID-19 vaccines. A scoping review. Drug Discov Today 2022; 27:103336. [PMID: 35995361 PMCID: PMC9389839 DOI: 10.1016/j.drudis.2022.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/11/2022] [Accepted: 08/09/2022] [Indexed: 12/12/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new disease that has led to a worldwide pandemic, resulting in millions of deaths and a high economic burden. Here, we analyze the current status of preventive vaccines authorized by the European Medicines Agency (EMA) and the US Food and Drug Administration (FDA). Published clinical trials have shown the effectiveness of mRNA (BNT162b2 and Spikevax), adenovirus vector-based (Ad26.COV2.S and ChAdOx1 nCoV-19), and recombinant protein S (NVX-CoV2373) vaccines to be between 52.9% and 100%. The most-frequent adverse effects include local pain, fatigue, headache, or chills. Serious events are associated with Ad26.COV2.S and ChAdOx1 nCoV-19 vaccines.
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Affiliation(s)
- Manuel Rueda-Fernández
- Biomedical Group (BIO277), Department of Nursing, Faculty of Health Sciences, University of Granada, Avda. Ilustración 60, 18016 Granada, Spain; Institute of Biosanitary Research, Ibs.Granada, C/ Doctor Azpitarte 4, 4a Planta, 18012 Granada, Spain
| | - Lucía Melguizo-Rodríguez
- Biomedical Group (BIO277), Department of Nursing, Faculty of Health Sciences, University of Granada, Avda. Ilustración 60, 18016 Granada, Spain; Institute of Biosanitary Research, Ibs.Granada, C/ Doctor Azpitarte 4, 4a Planta, 18012 Granada, Spain
| | - Víctor J Costela-Ruiz
- Institute of Biosanitary Research, Ibs.Granada, C/ Doctor Azpitarte 4, 4a Planta, 18012 Granada, Spain; Biomedical Group (BIO277), Department of Nursing, Faculty of Health Sciences of Ceuta, University of Granada, C/ Cortadura del Valle, Sn, 51001 Ceuta, Spain
| | - Anabel González-Acedo
- Institute of Biosanitary Research, Ibs.Granada, C/ Doctor Azpitarte 4, 4a Planta, 18012 Granada, Spain; Biomedical Group (BIO277), Department of Nursing, Faculty of Health Sciences of Melilla, University of Granada, C/ Santander, 1, 52005 Melilla, Spain
| | - Javier Ramos-Torrecillas
- Biomedical Group (BIO277), Department of Nursing, Faculty of Health Sciences, University of Granada, Avda. Ilustración 60, 18016 Granada, Spain; Institute of Biosanitary Research, Ibs.Granada, C/ Doctor Azpitarte 4, 4a Planta, 18012 Granada, Spain.
| | - Rebeca Illescas-Montes
- Biomedical Group (BIO277), Department of Nursing, Faculty of Health Sciences, University of Granada, Avda. Ilustración 60, 18016 Granada, Spain; Institute of Biosanitary Research, Ibs.Granada, C/ Doctor Azpitarte 4, 4a Planta, 18012 Granada, Spain
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