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Arbel R, Wolff Sagy Y, Hoshen M, Battat E, Lavie G, Sergienko R, Friger M, Waxman JG, Dagan N, Balicer R, Ben-Shlomo Y, Peretz A, Yaron S, Serby D, Hammerman A, Netzer D. Nirmatrelvir Use and Severe Covid-19 Outcomes during the Omicron Surge. N Engl J Med 2022; 387:790-798. [PMID: 36001529 PMCID: PMC9454652 DOI: 10.1056/nejmoa2204919] [Citation(s) in RCA: 158] [Impact Index Per Article: 79.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The oral protease inhibitor nirmatrelvir has shown substantial efficacy in high-risk, unvaccinated patients infected with the B.1.617.2 (delta) variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Data regarding the effectiveness of nirmatrelvir in preventing severe coronavirus disease 2019 (Covid-19) outcomes from the B.1.1.529 (omicron) variant are limited. METHODS We obtained data for all members of Clalit Health Services who were 40 years of age or older at the start of the study period and were assessed as being eligible to receive nirmatrelvir therapy during the omicron surge. A Cox proportional-hazards regression model with time-dependent covariates was used to estimate the association of nirmatrelvir treatment with hospitalization and death due to Covid-19, with adjustment for sociodemographic factors, coexisting conditions, and previous SARS-CoV-2 immunity status. RESULTS A total of 109,254 patients met the eligibility criteria, of whom 3902 (4%) received nirmatrelvir during the study period. Among patients 65 years of age or older, the rate of hospitalization due to Covid-19 was 14.7 cases per 100,000 person-days among treated patients as compared with 58.9 cases per 100,000 person-days among untreated patients (adjusted hazard ratio, 0.27; 95% confidence interval [CI], 0.15 to 0.49). The adjusted hazard ratio for death due to Covid-19 was 0.21 (95% CI, 0.05 to 0.82). Among patients 40 to 64 years of age, the rate of hospitalization due to Covid-19 was 15.2 cases per 100,000 person-days among treated patients and 15.8 cases per 100,000 person-days among untreated patients (adjusted hazard ratio, 0.74; 95% CI, 0.35 to 1.58). The adjusted hazard ratio for death due to Covid-19 was 1.32 (95% CI, 0.16 to 10.75). CONCLUSIONS Among patients 65 years of age or older, the rates of hospitalization and death due to Covid-19 were significantly lower among those who received nirmatrelvir than among those who did not. No evidence of benefit was found in younger adults.
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Affiliation(s)
- Ronen Arbel
- From the Division of Community Medical Services (R.A., A.P., S.Y., D.S., A.H., D.N.), the Branch of Planning and Strategy (Y.W.S., M.H., E.B., G.L.), and the Clalit Research Institute, Division of Innovation (J.G.W., N.D., R.B., Y.B.-S.), Clalit Health Services, Tel Aviv, the Maximizing Health Outcomes Research Lab, Sapir College, Sderot (R.A.), the Department of Bioinformatics, Jerusalem College of Technology, Jerusalem (M.H.), the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa (G.L.), and the School of Public Health, Faculty of Health Sciences (R.S., M.F., R.B.) and Software and Information Systems Engineering (N.D.), Ben-Gurion University of the Negev, Beersheba - all in Israel; and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (N.D., R.B.), and the Department of Biomedical Informatics, Harvard Medical School (N.D.) - both in Boston
| | - Yael Wolff Sagy
- From the Division of Community Medical Services (R.A., A.P., S.Y., D.S., A.H., D.N.), the Branch of Planning and Strategy (Y.W.S., M.H., E.B., G.L.), and the Clalit Research Institute, Division of Innovation (J.G.W., N.D., R.B., Y.B.-S.), Clalit Health Services, Tel Aviv, the Maximizing Health Outcomes Research Lab, Sapir College, Sderot (R.A.), the Department of Bioinformatics, Jerusalem College of Technology, Jerusalem (M.H.), the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa (G.L.), and the School of Public Health, Faculty of Health Sciences (R.S., M.F., R.B.) and Software and Information Systems Engineering (N.D.), Ben-Gurion University of the Negev, Beersheba - all in Israel; and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (N.D., R.B.), and the Department of Biomedical Informatics, Harvard Medical School (N.D.) - both in Boston
| | - Moshe Hoshen
- From the Division of Community Medical Services (R.A., A.P., S.Y., D.S., A.H., D.N.), the Branch of Planning and Strategy (Y.W.S., M.H., E.B., G.L.), and the Clalit Research Institute, Division of Innovation (J.G.W., N.D., R.B., Y.B.-S.), Clalit Health Services, Tel Aviv, the Maximizing Health Outcomes Research Lab, Sapir College, Sderot (R.A.), the Department of Bioinformatics, Jerusalem College of Technology, Jerusalem (M.H.), the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa (G.L.), and the School of Public Health, Faculty of Health Sciences (R.S., M.F., R.B.) and Software and Information Systems Engineering (N.D.), Ben-Gurion University of the Negev, Beersheba - all in Israel; and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (N.D., R.B.), and the Department of Biomedical Informatics, Harvard Medical School (N.D.) - both in Boston
| | - Erez Battat
- From the Division of Community Medical Services (R.A., A.P., S.Y., D.S., A.H., D.N.), the Branch of Planning and Strategy (Y.W.S., M.H., E.B., G.L.), and the Clalit Research Institute, Division of Innovation (J.G.W., N.D., R.B., Y.B.-S.), Clalit Health Services, Tel Aviv, the Maximizing Health Outcomes Research Lab, Sapir College, Sderot (R.A.), the Department of Bioinformatics, Jerusalem College of Technology, Jerusalem (M.H.), the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa (G.L.), and the School of Public Health, Faculty of Health Sciences (R.S., M.F., R.B.) and Software and Information Systems Engineering (N.D.), Ben-Gurion University of the Negev, Beersheba - all in Israel; and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (N.D., R.B.), and the Department of Biomedical Informatics, Harvard Medical School (N.D.) - both in Boston
| | - Gil Lavie
- From the Division of Community Medical Services (R.A., A.P., S.Y., D.S., A.H., D.N.), the Branch of Planning and Strategy (Y.W.S., M.H., E.B., G.L.), and the Clalit Research Institute, Division of Innovation (J.G.W., N.D., R.B., Y.B.-S.), Clalit Health Services, Tel Aviv, the Maximizing Health Outcomes Research Lab, Sapir College, Sderot (R.A.), the Department of Bioinformatics, Jerusalem College of Technology, Jerusalem (M.H.), the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa (G.L.), and the School of Public Health, Faculty of Health Sciences (R.S., M.F., R.B.) and Software and Information Systems Engineering (N.D.), Ben-Gurion University of the Negev, Beersheba - all in Israel; and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (N.D., R.B.), and the Department of Biomedical Informatics, Harvard Medical School (N.D.) - both in Boston
| | - Ruslan Sergienko
- From the Division of Community Medical Services (R.A., A.P., S.Y., D.S., A.H., D.N.), the Branch of Planning and Strategy (Y.W.S., M.H., E.B., G.L.), and the Clalit Research Institute, Division of Innovation (J.G.W., N.D., R.B., Y.B.-S.), Clalit Health Services, Tel Aviv, the Maximizing Health Outcomes Research Lab, Sapir College, Sderot (R.A.), the Department of Bioinformatics, Jerusalem College of Technology, Jerusalem (M.H.), the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa (G.L.), and the School of Public Health, Faculty of Health Sciences (R.S., M.F., R.B.) and Software and Information Systems Engineering (N.D.), Ben-Gurion University of the Negev, Beersheba - all in Israel; and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (N.D., R.B.), and the Department of Biomedical Informatics, Harvard Medical School (N.D.) - both in Boston
| | - Michael Friger
- From the Division of Community Medical Services (R.A., A.P., S.Y., D.S., A.H., D.N.), the Branch of Planning and Strategy (Y.W.S., M.H., E.B., G.L.), and the Clalit Research Institute, Division of Innovation (J.G.W., N.D., R.B., Y.B.-S.), Clalit Health Services, Tel Aviv, the Maximizing Health Outcomes Research Lab, Sapir College, Sderot (R.A.), the Department of Bioinformatics, Jerusalem College of Technology, Jerusalem (M.H.), the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa (G.L.), and the School of Public Health, Faculty of Health Sciences (R.S., M.F., R.B.) and Software and Information Systems Engineering (N.D.), Ben-Gurion University of the Negev, Beersheba - all in Israel; and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (N.D., R.B.), and the Department of Biomedical Informatics, Harvard Medical School (N.D.) - both in Boston
| | - Jacob G Waxman
- From the Division of Community Medical Services (R.A., A.P., S.Y., D.S., A.H., D.N.), the Branch of Planning and Strategy (Y.W.S., M.H., E.B., G.L.), and the Clalit Research Institute, Division of Innovation (J.G.W., N.D., R.B., Y.B.-S.), Clalit Health Services, Tel Aviv, the Maximizing Health Outcomes Research Lab, Sapir College, Sderot (R.A.), the Department of Bioinformatics, Jerusalem College of Technology, Jerusalem (M.H.), the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa (G.L.), and the School of Public Health, Faculty of Health Sciences (R.S., M.F., R.B.) and Software and Information Systems Engineering (N.D.), Ben-Gurion University of the Negev, Beersheba - all in Israel; and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (N.D., R.B.), and the Department of Biomedical Informatics, Harvard Medical School (N.D.) - both in Boston
| | - Noa Dagan
- From the Division of Community Medical Services (R.A., A.P., S.Y., D.S., A.H., D.N.), the Branch of Planning and Strategy (Y.W.S., M.H., E.B., G.L.), and the Clalit Research Institute, Division of Innovation (J.G.W., N.D., R.B., Y.B.-S.), Clalit Health Services, Tel Aviv, the Maximizing Health Outcomes Research Lab, Sapir College, Sderot (R.A.), the Department of Bioinformatics, Jerusalem College of Technology, Jerusalem (M.H.), the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa (G.L.), and the School of Public Health, Faculty of Health Sciences (R.S., M.F., R.B.) and Software and Information Systems Engineering (N.D.), Ben-Gurion University of the Negev, Beersheba - all in Israel; and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (N.D., R.B.), and the Department of Biomedical Informatics, Harvard Medical School (N.D.) - both in Boston
| | - Ran Balicer
- From the Division of Community Medical Services (R.A., A.P., S.Y., D.S., A.H., D.N.), the Branch of Planning and Strategy (Y.W.S., M.H., E.B., G.L.), and the Clalit Research Institute, Division of Innovation (J.G.W., N.D., R.B., Y.B.-S.), Clalit Health Services, Tel Aviv, the Maximizing Health Outcomes Research Lab, Sapir College, Sderot (R.A.), the Department of Bioinformatics, Jerusalem College of Technology, Jerusalem (M.H.), the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa (G.L.), and the School of Public Health, Faculty of Health Sciences (R.S., M.F., R.B.) and Software and Information Systems Engineering (N.D.), Ben-Gurion University of the Negev, Beersheba - all in Israel; and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (N.D., R.B.), and the Department of Biomedical Informatics, Harvard Medical School (N.D.) - both in Boston
| | - Yatir Ben-Shlomo
- From the Division of Community Medical Services (R.A., A.P., S.Y., D.S., A.H., D.N.), the Branch of Planning and Strategy (Y.W.S., M.H., E.B., G.L.), and the Clalit Research Institute, Division of Innovation (J.G.W., N.D., R.B., Y.B.-S.), Clalit Health Services, Tel Aviv, the Maximizing Health Outcomes Research Lab, Sapir College, Sderot (R.A.), the Department of Bioinformatics, Jerusalem College of Technology, Jerusalem (M.H.), the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa (G.L.), and the School of Public Health, Faculty of Health Sciences (R.S., M.F., R.B.) and Software and Information Systems Engineering (N.D.), Ben-Gurion University of the Negev, Beersheba - all in Israel; and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (N.D., R.B.), and the Department of Biomedical Informatics, Harvard Medical School (N.D.) - both in Boston
| | - Alon Peretz
- From the Division of Community Medical Services (R.A., A.P., S.Y., D.S., A.H., D.N.), the Branch of Planning and Strategy (Y.W.S., M.H., E.B., G.L.), and the Clalit Research Institute, Division of Innovation (J.G.W., N.D., R.B., Y.B.-S.), Clalit Health Services, Tel Aviv, the Maximizing Health Outcomes Research Lab, Sapir College, Sderot (R.A.), the Department of Bioinformatics, Jerusalem College of Technology, Jerusalem (M.H.), the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa (G.L.), and the School of Public Health, Faculty of Health Sciences (R.S., M.F., R.B.) and Software and Information Systems Engineering (N.D.), Ben-Gurion University of the Negev, Beersheba - all in Israel; and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (N.D., R.B.), and the Department of Biomedical Informatics, Harvard Medical School (N.D.) - both in Boston
| | - Shlomit Yaron
- From the Division of Community Medical Services (R.A., A.P., S.Y., D.S., A.H., D.N.), the Branch of Planning and Strategy (Y.W.S., M.H., E.B., G.L.), and the Clalit Research Institute, Division of Innovation (J.G.W., N.D., R.B., Y.B.-S.), Clalit Health Services, Tel Aviv, the Maximizing Health Outcomes Research Lab, Sapir College, Sderot (R.A.), the Department of Bioinformatics, Jerusalem College of Technology, Jerusalem (M.H.), the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa (G.L.), and the School of Public Health, Faculty of Health Sciences (R.S., M.F., R.B.) and Software and Information Systems Engineering (N.D.), Ben-Gurion University of the Negev, Beersheba - all in Israel; and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (N.D., R.B.), and the Department of Biomedical Informatics, Harvard Medical School (N.D.) - both in Boston
| | - Danielle Serby
- From the Division of Community Medical Services (R.A., A.P., S.Y., D.S., A.H., D.N.), the Branch of Planning and Strategy (Y.W.S., M.H., E.B., G.L.), and the Clalit Research Institute, Division of Innovation (J.G.W., N.D., R.B., Y.B.-S.), Clalit Health Services, Tel Aviv, the Maximizing Health Outcomes Research Lab, Sapir College, Sderot (R.A.), the Department of Bioinformatics, Jerusalem College of Technology, Jerusalem (M.H.), the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa (G.L.), and the School of Public Health, Faculty of Health Sciences (R.S., M.F., R.B.) and Software and Information Systems Engineering (N.D.), Ben-Gurion University of the Negev, Beersheba - all in Israel; and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (N.D., R.B.), and the Department of Biomedical Informatics, Harvard Medical School (N.D.) - both in Boston
| | - Ariel Hammerman
- From the Division of Community Medical Services (R.A., A.P., S.Y., D.S., A.H., D.N.), the Branch of Planning and Strategy (Y.W.S., M.H., E.B., G.L.), and the Clalit Research Institute, Division of Innovation (J.G.W., N.D., R.B., Y.B.-S.), Clalit Health Services, Tel Aviv, the Maximizing Health Outcomes Research Lab, Sapir College, Sderot (R.A.), the Department of Bioinformatics, Jerusalem College of Technology, Jerusalem (M.H.), the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa (G.L.), and the School of Public Health, Faculty of Health Sciences (R.S., M.F., R.B.) and Software and Information Systems Engineering (N.D.), Ben-Gurion University of the Negev, Beersheba - all in Israel; and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (N.D., R.B.), and the Department of Biomedical Informatics, Harvard Medical School (N.D.) - both in Boston
| | - Doron Netzer
- From the Division of Community Medical Services (R.A., A.P., S.Y., D.S., A.H., D.N.), the Branch of Planning and Strategy (Y.W.S., M.H., E.B., G.L.), and the Clalit Research Institute, Division of Innovation (J.G.W., N.D., R.B., Y.B.-S.), Clalit Health Services, Tel Aviv, the Maximizing Health Outcomes Research Lab, Sapir College, Sderot (R.A.), the Department of Bioinformatics, Jerusalem College of Technology, Jerusalem (M.H.), the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa (G.L.), and the School of Public Health, Faculty of Health Sciences (R.S., M.F., R.B.) and Software and Information Systems Engineering (N.D.), Ben-Gurion University of the Negev, Beersheba - all in Israel; and the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration, Harvard Medical School and Clalit Research Institute (N.D., R.B.), and the Department of Biomedical Informatics, Harvard Medical School (N.D.) - both in Boston
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Magen O, Waxman JG, Makov-Assif M, Vered R, Dicker D, Hernán MA, Lipsitch M, Reis BY, Balicer RD, Dagan N. Fourth Dose of BNT162b2 mRNA Covid-19 Vaccine in a Nationwide Setting. N Engl J Med 2022; 386:1603-1614. [PMID: 35417631 PMCID: PMC9020581 DOI: 10.1056/nejmoa2201688] [Citation(s) in RCA: 169] [Impact Index Per Article: 84.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND With large waves of infection driven by the B.1.1.529 (omicron) variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), alongside evidence of waning immunity after the booster dose of coronavirus disease 2019 (Covid-19) vaccine, several countries have begun giving at-risk persons a fourth vaccine dose. METHODS To evaluate the early effectiveness of a fourth dose of the BNT162b2 vaccine for the prevention of Covid-19-related outcomes, we analyzed data recorded by the largest health care organization in Israel from January 3 to February 18, 2022. We evaluated the relative effectiveness of a fourth vaccine dose as compared with that of a third dose given at least 4 months earlier among persons 60 years of age or older. We compared outcomes in persons who had received a fourth dose with those in persons who had not, individually matching persons from these two groups with respect to multiple sociodemographic and clinical variables. A sensitivity analysis was performed with the use of parametric Poisson regression. RESULTS The primary analysis included 182,122 matched pairs. Relative vaccine effectiveness in days 7 to 30 after the fourth dose was estimated to be 45% (95% confidence interval [CI], 44 to 47) against polymerase-chain-reaction-confirmed SARS-CoV-2 infection, 55% (95% CI, 53 to 58) against symptomatic Covid-19, 68% (95% CI, 59 to 74) against Covid-19-related hospitalization, 62% (95% CI, 50 to 74) against severe Covid-19, and 74% (95% CI, 50 to 90) against Covid-19-related death. The corresponding estimates in days 14 to 30 after the fourth dose were 52% (95% CI, 49 to 54), 61% (95% CI, 58 to 64), 72% (95% CI, 63 to 79), 64% (95% CI, 48 to 77), and 76% (95% CI, 48 to 91). In days 7 to 30 after a fourth vaccine dose, the difference in the absolute risk (three doses vs. four doses) was 180.1 cases per 100,000 persons (95% CI, 142.8 to 211.9) for Covid-19-related hospitalization and 68.8 cases per 100,000 persons (95% CI, 48.5 to 91.9) for severe Covid-19. In sensitivity analyses, estimates of relative effectiveness against documented infection were similar to those in the primary analysis. CONCLUSIONS A fourth dose of the BNT162b2 vaccine was effective in reducing the short-term risk of Covid-19-related outcomes among persons who had received a third dose at least 4 months earlier. (Funded by the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute.).
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Affiliation(s)
- Ori Magen
- From the Clalit Research Institute, Innovation Division (O.M., J.G.W., M.M.-A., R.D.B., N.D.), and the Tel-Aviv District, Community Division (R.V.), Clalit Health Services, and the Sackler Faculty of Medicine, Tel-Aviv University (D.D.), Tel Aviv, the Department of Internal Medicine D, Hasharon Hospital Rabin Medical Center, Petah Tikva (D.D.), and the School of Public Health, Faculty of Health Sciences (R.D.B.), and the Department of Software and Information Systems Engineering (N.D.), Ben Gurion University of the Negev, Be'er Sheva - all in Israel; and the Departments of Epidemiology and Biostatistics and CAUSALab (M.A.H.) and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.), and the Departments of Pediatrics (B.Y.R.) and Biomedical Informatics (B.Y.R., N.D.), Harvard Medical School - all in Boston
| | - Jacob G Waxman
- From the Clalit Research Institute, Innovation Division (O.M., J.G.W., M.M.-A., R.D.B., N.D.), and the Tel-Aviv District, Community Division (R.V.), Clalit Health Services, and the Sackler Faculty of Medicine, Tel-Aviv University (D.D.), Tel Aviv, the Department of Internal Medicine D, Hasharon Hospital Rabin Medical Center, Petah Tikva (D.D.), and the School of Public Health, Faculty of Health Sciences (R.D.B.), and the Department of Software and Information Systems Engineering (N.D.), Ben Gurion University of the Negev, Be'er Sheva - all in Israel; and the Departments of Epidemiology and Biostatistics and CAUSALab (M.A.H.) and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.), and the Departments of Pediatrics (B.Y.R.) and Biomedical Informatics (B.Y.R., N.D.), Harvard Medical School - all in Boston
| | - Maya Makov-Assif
- From the Clalit Research Institute, Innovation Division (O.M., J.G.W., M.M.-A., R.D.B., N.D.), and the Tel-Aviv District, Community Division (R.V.), Clalit Health Services, and the Sackler Faculty of Medicine, Tel-Aviv University (D.D.), Tel Aviv, the Department of Internal Medicine D, Hasharon Hospital Rabin Medical Center, Petah Tikva (D.D.), and the School of Public Health, Faculty of Health Sciences (R.D.B.), and the Department of Software and Information Systems Engineering (N.D.), Ben Gurion University of the Negev, Be'er Sheva - all in Israel; and the Departments of Epidemiology and Biostatistics and CAUSALab (M.A.H.) and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.), and the Departments of Pediatrics (B.Y.R.) and Biomedical Informatics (B.Y.R., N.D.), Harvard Medical School - all in Boston
| | - Roni Vered
- From the Clalit Research Institute, Innovation Division (O.M., J.G.W., M.M.-A., R.D.B., N.D.), and the Tel-Aviv District, Community Division (R.V.), Clalit Health Services, and the Sackler Faculty of Medicine, Tel-Aviv University (D.D.), Tel Aviv, the Department of Internal Medicine D, Hasharon Hospital Rabin Medical Center, Petah Tikva (D.D.), and the School of Public Health, Faculty of Health Sciences (R.D.B.), and the Department of Software and Information Systems Engineering (N.D.), Ben Gurion University of the Negev, Be'er Sheva - all in Israel; and the Departments of Epidemiology and Biostatistics and CAUSALab (M.A.H.) and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.), and the Departments of Pediatrics (B.Y.R.) and Biomedical Informatics (B.Y.R., N.D.), Harvard Medical School - all in Boston
| | - Dror Dicker
- From the Clalit Research Institute, Innovation Division (O.M., J.G.W., M.M.-A., R.D.B., N.D.), and the Tel-Aviv District, Community Division (R.V.), Clalit Health Services, and the Sackler Faculty of Medicine, Tel-Aviv University (D.D.), Tel Aviv, the Department of Internal Medicine D, Hasharon Hospital Rabin Medical Center, Petah Tikva (D.D.), and the School of Public Health, Faculty of Health Sciences (R.D.B.), and the Department of Software and Information Systems Engineering (N.D.), Ben Gurion University of the Negev, Be'er Sheva - all in Israel; and the Departments of Epidemiology and Biostatistics and CAUSALab (M.A.H.) and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.), and the Departments of Pediatrics (B.Y.R.) and Biomedical Informatics (B.Y.R., N.D.), Harvard Medical School - all in Boston
| | - Miguel A Hernán
- From the Clalit Research Institute, Innovation Division (O.M., J.G.W., M.M.-A., R.D.B., N.D.), and the Tel-Aviv District, Community Division (R.V.), Clalit Health Services, and the Sackler Faculty of Medicine, Tel-Aviv University (D.D.), Tel Aviv, the Department of Internal Medicine D, Hasharon Hospital Rabin Medical Center, Petah Tikva (D.D.), and the School of Public Health, Faculty of Health Sciences (R.D.B.), and the Department of Software and Information Systems Engineering (N.D.), Ben Gurion University of the Negev, Be'er Sheva - all in Israel; and the Departments of Epidemiology and Biostatistics and CAUSALab (M.A.H.) and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.), and the Departments of Pediatrics (B.Y.R.) and Biomedical Informatics (B.Y.R., N.D.), Harvard Medical School - all in Boston
| | - Marc Lipsitch
- From the Clalit Research Institute, Innovation Division (O.M., J.G.W., M.M.-A., R.D.B., N.D.), and the Tel-Aviv District, Community Division (R.V.), Clalit Health Services, and the Sackler Faculty of Medicine, Tel-Aviv University (D.D.), Tel Aviv, the Department of Internal Medicine D, Hasharon Hospital Rabin Medical Center, Petah Tikva (D.D.), and the School of Public Health, Faculty of Health Sciences (R.D.B.), and the Department of Software and Information Systems Engineering (N.D.), Ben Gurion University of the Negev, Be'er Sheva - all in Israel; and the Departments of Epidemiology and Biostatistics and CAUSALab (M.A.H.) and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.), and the Departments of Pediatrics (B.Y.R.) and Biomedical Informatics (B.Y.R., N.D.), Harvard Medical School - all in Boston
| | - Ben Y Reis
- From the Clalit Research Institute, Innovation Division (O.M., J.G.W., M.M.-A., R.D.B., N.D.), and the Tel-Aviv District, Community Division (R.V.), Clalit Health Services, and the Sackler Faculty of Medicine, Tel-Aviv University (D.D.), Tel Aviv, the Department of Internal Medicine D, Hasharon Hospital Rabin Medical Center, Petah Tikva (D.D.), and the School of Public Health, Faculty of Health Sciences (R.D.B.), and the Department of Software and Information Systems Engineering (N.D.), Ben Gurion University of the Negev, Be'er Sheva - all in Israel; and the Departments of Epidemiology and Biostatistics and CAUSALab (M.A.H.) and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.), and the Departments of Pediatrics (B.Y.R.) and Biomedical Informatics (B.Y.R., N.D.), Harvard Medical School - all in Boston
| | - Ran D Balicer
- From the Clalit Research Institute, Innovation Division (O.M., J.G.W., M.M.-A., R.D.B., N.D.), and the Tel-Aviv District, Community Division (R.V.), Clalit Health Services, and the Sackler Faculty of Medicine, Tel-Aviv University (D.D.), Tel Aviv, the Department of Internal Medicine D, Hasharon Hospital Rabin Medical Center, Petah Tikva (D.D.), and the School of Public Health, Faculty of Health Sciences (R.D.B.), and the Department of Software and Information Systems Engineering (N.D.), Ben Gurion University of the Negev, Be'er Sheva - all in Israel; and the Departments of Epidemiology and Biostatistics and CAUSALab (M.A.H.) and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.), and the Departments of Pediatrics (B.Y.R.) and Biomedical Informatics (B.Y.R., N.D.), Harvard Medical School - all in Boston
| | - Noa Dagan
- From the Clalit Research Institute, Innovation Division (O.M., J.G.W., M.M.-A., R.D.B., N.D.), and the Tel-Aviv District, Community Division (R.V.), Clalit Health Services, and the Sackler Faculty of Medicine, Tel-Aviv University (D.D.), Tel Aviv, the Department of Internal Medicine D, Hasharon Hospital Rabin Medical Center, Petah Tikva (D.D.), and the School of Public Health, Faculty of Health Sciences (R.D.B.), and the Department of Software and Information Systems Engineering (N.D.), Ben Gurion University of the Negev, Be'er Sheva - all in Israel; and the Departments of Epidemiology and Biostatistics and CAUSALab (M.A.H.) and the Center for Communicable Disease Dynamics, Departments of Epidemiology and of Immunology and Infectious Diseases (M.L.), Harvard T.H. Chan School of Public Health, the Ivan and Francesca Berkowitz Family Living Laboratory Collaboration at Harvard Medical School and Clalit Research Institute (B.Y.R., R.D.B., N.D.), the Predictive Medicine Group, Computational Health Informatics Program, Boston Children's Hospital (B.Y.R.), and the Departments of Pediatrics (B.Y.R.) and Biomedical Informatics (B.Y.R., N.D.), Harvard Medical School - all in Boston
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