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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">All living organisms&#44; in particular RNA viruses&#44; are prone to mutation&#46; It is the key of their evolution&#46; During the COVID-19 pandemic&#44; the worldwide capacity for sequencing SARS-CoV-2 in microbiology and public health laboratories has yielded enormous genetic information regarding the real time adaptation of this virus&#44; and this race will continue as long as the virus infects new individuals&#46; Many variants were detected from the first days in January to the end of February 2020&#46; However&#44; only a limited number of variants have had biological significance from the transmissibility&#44; severity&#44; or vaccine&#47;immune escape point of view&#46; These variants have been named from a public health perspective as &#8220;variants of concern&#8221; &#40;VOC&#41;&#46; With 2 years of perspective&#44; we can associate each pandemic wave to the selection and dispersion of a new VOC &#40;although this acronym was only included in Public Health reports from December 2020&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In February&#47;March 2020&#44; the SARS-CoV-2 variant responsible for the first pandemic &#40;B&#46;1&#41; wave had two changes with respect to the wild-type &#8220;Wuhan-variant&#8221;&#44; characterized by a mutation in the spike protein &#40;D614G&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This mutation appeared to enhance viral replication&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Since then&#44; practically all SARS-CoV-2 variant&#44; carry this change&#46; However&#44; when SARS-CoV-2 was globally distributed&#44; the selection of variants and pandemic waves occurred asynchronously in different regions&#46; Obviously&#44; the most notable variants were Alpha &#40;detected in September 2020 in UK&#41;&#44; Delta &#40;October 2020 in India&#41; and Omicron &#40;November 2021 in South Africa and Botswana&#41; associated in Spain with the third&#44; fifth&#44; and sixth pandemic waves&#44; respectively&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">All these new VOC have a common characteristic&#44; they are more transmissible than their parents&#44; in some cases associated with a more potential virulent trait &#40;Beta and Gamma variants&#41;&#44; but on other occasions with less virulence &#40;Omicron variant&#41;&#46; Among them&#44; the Omicron variant &#40;B&#46;1&#46;1&#46;529&#41;&#44; with a doubling time of 2&#8211;3 days spreading speed&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> is much faster than the Delta variant &#40;2&#215;&#41; and the original B&#46;1 variant &#40;10&#215;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In South Africa&#44; where Delta and Omicron variants co-existed during several weeks&#44; the weekly increase of Omicron over Delta was 5&#46;4-fold &#40;95&#37; confidence interval &#91;95&#37;CI&#93;&#44; 3&#46;1&#8211;10&#46;1&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This data revealed a short time between being infected and becoming infectious to other people &#40;generation time &#91;GT&#93;&#41; compared to other variants &#40;GT<span class="elsevierStyleInf">Alpha</span>&#44; 5&#46;5 days&#59; GT<span class="elsevierStyleInf">Delta</span>&#44; 4&#46;7 days&#44; and GT<span class="elsevierStyleInf">Omicron</span>&#44; 3&#46;2 days&#41; or other highly transmissible viruses &#40;GT<span class="elsevierStyleInf">measles</span>&#44; 12 days&#41;&#44; and suggests that variant could be &#8220;the fastest-spreading virus in history&#8221; &#40;title found in several general newspapers&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> These fears were confirmed a few weeks later&#44; when Omicron was responsible for national incidences not previously described and were resumed by the WHO Director General on February 1st 2022 at the media briefing on COVID-19&#58; &#8220;Since Omicron was first identified just 10 weeks ago&#44; almost 90 million cases have been reported to WHO&#44; more than were reported in the whole of 2020&#46;&#8221; In fact&#44; in our experience during the emergence and follow-up of different VOCs&#44; it took nearly 20 weeks for the Alpha variant to reach the maximum peak since its first detection in our institution&#46; This period was 15 weeks for the Delta variant and just 6 weeks for the Omicron &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Currently&#44; in Europe&#44; the Omicron variant represents &#62;98&#37; of sequenced samples and the Delta variant is still detected in only two countries&#58; Latvia and Slovakia &#40;<a href="https://www.ecdc.europa.eu/en/covid-19/country-overviews">https&#58;&#47;&#47;www&#46;ecdc&#46;europa&#46;eu&#47;en&#47;covid-19&#47;country-overviews</a>&#44; last access 25 February 2022&#44; corresponding to 6 weeks of 2022&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The observed increase in the infectivity of the Omicron variant is probably due to the high number of mutations &#40;10&#8211;15 changes&#41; found in the receptor-binding domain &#40;RBD&#41; compared to one or two in Alpha or Delta variants&#46; Among these mutations&#44; N501Y&#44; T478K&#44; and N440K mutations have a main role&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> N501Y is present in the Alpha variant and T478K is in the Delta variant&#46; Despite the higher infectivity of Omicron&#44; the hospitalization rate was 20&#8211;25&#37; lower than the Delta variant&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> This could be related to its higher replicative capacity in the human bronchus&#44; but 10 times lower in the human lung tissue&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> which may explain why it spreads so rapidly in human populations&#46; This characteristic was previously observed in the Alpha variant&#44; with which Omicron shares three spike-mutations &#40;N501Y&#44; P681H&#44; and D614G&#41;&#44; justifying the fast spread in the human population&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">On the other hand&#44; the ability of Omicron to evade the COVID-19 vaccine immunity and cause breakthrough infections was also predicted to be higher than with previous variants&#44; probably due to the presence of K417N&#44; E484A&#44; and Y505H mutations&#44; the two first mutations being shared with the Beta variant &#40;also described in South Africa in September 2020&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Preliminary analyses suggest that&#44; although the spike mutations involve several T cell and B cell epitopes of the immunological response&#44; the majority of epitopes &#40;&#62;70&#37;&#41; remain unaffected&#44; but initial laboratory data suggested that the Omicron variant is likely to weaken the COVID-19 vaccine protection&#46; This observation could explain the high re-infection rate observed in vaccinated and previously infected people&#46; Altarawnwh et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> found that the effectiveness of previous infection in preventing reinfection was estimated to be 90&#46;2&#37; against the Alpha variant&#44; 85&#46;7&#37; against the Beta variant&#44; 92&#46;0&#37; against the Delta variant&#44; but only 56&#46;0&#37; against the Omicron variant&#44; although the patients had high antibodies titres&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Therefore&#44; the Omicron variant is particularly insensitive to antibodies elicited against prior variants&#46; Antigenic analyses indicated that all previous VOCs belong to one large antigenic cluster&#44; whereas Omicron forms a new cluster&#44; escaping vaccine or convalescent sera&#46; For this reason&#44; several authors have suggested considering Omicron as a new serotype&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> This proposal could have important implications for the development of updated vaccines&#44; and also could improve our understanding of the cellular and humoral response&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Until today&#44; several Omicron sub-variants have been identified&#46; These include BA&#46;1 &#40;B&#46;1&#46;1&#46;529&#46;1&#41;&#44; BA&#46;2 &#40;B&#46;1&#46;1&#46;529&#46;2&#41;&#44; and BA&#46;3 &#40;B&#46;1&#46;1&#46;529&#46;3&#41;&#44; which are all being monitored by WHO under the umbrella of &#8216;Omicron&#8217;&#46; They share 31 mutations&#44; and each one of them has 1&#8211;13 specific mutations&#46; B&#46;1 is the most widely distributed sub-variant&#44; and is responsible for 98&#37; of cases&#46; BA&#46;2 &#40;1&#37;&#41; is increasing its weekly proportion&#46; In several regions it has reached 50&#37;&#44; and in Denmark&#44; 80&#37;&#46; Fortunately&#44; the global circulation of all different variants is reportedly declining&#46; BA&#46;2&#44; also called &#8220;stealth Omicron&#44;&#8221; is 1&#46;5 times as infectious as BA&#46;1 and about 4&#46;2 times as contagious as the Delta variant&#46; A worrying data is that BA&#46;2 has a 30&#37; higher potential than BA&#46;1 to escape existing vaccines&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> In fact&#44; Israel reported a handful of cases of patients who were infected with the original Omicron BA&#46;1 strain and have been reinfected with BA&#46;2 in a short period&#46; The description of these cases suggests that the antibodies generated from the early Omicron BA&#46;1 were evaded by the BA&#46;2 strain&#46; To finish the bad news regarding BA&#46;2&#44; while monoclonal antibodies such as sotrovimab and tixagevimab retain significant neutralizing activity against BA&#46;1&#44; these may be not efficient against the BA&#46;2&#46; subvariant&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The comments of this editorial reveal that SARS-CoV-2 is continuously evolving in an endless race with the host&#44; with new threats waiting a better epidemiological scenario&#46; For this reason&#44; we should not stop our efforts in SARS-CoV-2 surveillance&#44; nor should we be surprised by the capacity of the viral evolution&#46; We would like to finish with a new sentence of Tedros Ghebreyesus&#44; WHO Director General&#58; &#8220;It is premature for any country either to surrender or to declare victory&#46;&#8221;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">JG research is supported by <span class="elsevierStyleItalic">Instituto de Salud Carlos III</span> and <span class="elsevierStyleItalic">Ministerio de Ciencia e Innovaci&#243;n</span> through <span class="elsevierStyleGrantSponsor" id="gs1"><span class="elsevierStyleItalic">CIBER en Salud P&#250;blica</span></span> &#40;CIBERES&#44; <span class="elsevierStyleGrantNumber" refid="gs1">CB06&#47;02&#47;0053</span>&#41; and RC through <span class="elsevierStyleGrantSponsor" id="gs2">REIPI</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs2">RD16&#47;0016&#47;0011</span>&#41; and <span class="elsevierStyleItalic">CIBER de Enfermedades Infecciosas</span>&#44; <span class="elsevierStyleGrantSponsor" id="gs3">CIBERINFEC</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs3">CB21&#47;13&#47;00084</span>&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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Editorial
New Variants in SARS-CoV-2: What are we Learning from the Omicron Variant?
Nuevas variantes del SARS-CoV-2: ¿qué estamos aprendiendo de la variante Omicron?
Juan Carlos Galána,b, Rafael Cantóna,c,
Corresponding author
rafael.canton@salud.madrid.org

Corresponding author.
a Servicio de Microbiología, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
b CIBER en Epidemiología y Salud Pública (CIBERESP), Spain
c CIBER de Enfermedades Infecciosas (CIBERINFEC), Spain
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        "titulo" => "Nuevas variantes del SARS-CoV-2&#58; &#191;qu&#233; estamos aprendiendo de la variante Omicron&#63;"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">All living organisms&#44; in particular RNA viruses&#44; are prone to mutation&#46; It is the key of their evolution&#46; During the COVID-19 pandemic&#44; the worldwide capacity for sequencing SARS-CoV-2 in microbiology and public health laboratories has yielded enormous genetic information regarding the real time adaptation of this virus&#44; and this race will continue as long as the virus infects new individuals&#46; Many variants were detected from the first days in January to the end of February 2020&#46; However&#44; only a limited number of variants have had biological significance from the transmissibility&#44; severity&#44; or vaccine&#47;immune escape point of view&#46; These variants have been named from a public health perspective as &#8220;variants of concern&#8221; &#40;VOC&#41;&#46; With 2 years of perspective&#44; we can associate each pandemic wave to the selection and dispersion of a new VOC &#40;although this acronym was only included in Public Health reports from December 2020&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In February&#47;March 2020&#44; the SARS-CoV-2 variant responsible for the first pandemic &#40;B&#46;1&#41; wave had two changes with respect to the wild-type &#8220;Wuhan-variant&#8221;&#44; characterized by a mutation in the spike protein &#40;D614G&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This mutation appeared to enhance viral replication&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Since then&#44; practically all SARS-CoV-2 variant&#44; carry this change&#46; However&#44; when SARS-CoV-2 was globally distributed&#44; the selection of variants and pandemic waves occurred asynchronously in different regions&#46; Obviously&#44; the most notable variants were Alpha &#40;detected in September 2020 in UK&#41;&#44; Delta &#40;October 2020 in India&#41; and Omicron &#40;November 2021 in South Africa and Botswana&#41; associated in Spain with the third&#44; fifth&#44; and sixth pandemic waves&#44; respectively&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">All these new VOC have a common characteristic&#44; they are more transmissible than their parents&#44; in some cases associated with a more potential virulent trait &#40;Beta and Gamma variants&#41;&#44; but on other occasions with less virulence &#40;Omicron variant&#41;&#46; Among them&#44; the Omicron variant &#40;B&#46;1&#46;1&#46;529&#41;&#44; with a doubling time of 2&#8211;3 days spreading speed&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> is much faster than the Delta variant &#40;2&#215;&#41; and the original B&#46;1 variant &#40;10&#215;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In South Africa&#44; where Delta and Omicron variants co-existed during several weeks&#44; the weekly increase of Omicron over Delta was 5&#46;4-fold &#40;95&#37; confidence interval &#91;95&#37;CI&#93;&#44; 3&#46;1&#8211;10&#46;1&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This data revealed a short time between being infected and becoming infectious to other people &#40;generation time &#91;GT&#93;&#41; compared to other variants &#40;GT<span class="elsevierStyleInf">Alpha</span>&#44; 5&#46;5 days&#59; GT<span class="elsevierStyleInf">Delta</span>&#44; 4&#46;7 days&#44; and GT<span class="elsevierStyleInf">Omicron</span>&#44; 3&#46;2 days&#41; or other highly transmissible viruses &#40;GT<span class="elsevierStyleInf">measles</span>&#44; 12 days&#41;&#44; and suggests that variant could be &#8220;the fastest-spreading virus in history&#8221; &#40;title found in several general newspapers&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> These fears were confirmed a few weeks later&#44; when Omicron was responsible for national incidences not previously described and were resumed by the WHO Director General on February 1st 2022 at the media briefing on COVID-19&#58; &#8220;Since Omicron was first identified just 10 weeks ago&#44; almost 90 million cases have been reported to WHO&#44; more than were reported in the whole of 2020&#46;&#8221; In fact&#44; in our experience during the emergence and follow-up of different VOCs&#44; it took nearly 20 weeks for the Alpha variant to reach the maximum peak since its first detection in our institution&#46; This period was 15 weeks for the Delta variant and just 6 weeks for the Omicron &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Currently&#44; in Europe&#44; the Omicron variant represents &#62;98&#37; of sequenced samples and the Delta variant is still detected in only two countries&#58; Latvia and Slovakia &#40;<a href="https://www.ecdc.europa.eu/en/covid-19/country-overviews">https&#58;&#47;&#47;www&#46;ecdc&#46;europa&#46;eu&#47;en&#47;covid-19&#47;country-overviews</a>&#44; last access 25 February 2022&#44; corresponding to 6 weeks of 2022&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The observed increase in the infectivity of the Omicron variant is probably due to the high number of mutations &#40;10&#8211;15 changes&#41; found in the receptor-binding domain &#40;RBD&#41; compared to one or two in Alpha or Delta variants&#46; Among these mutations&#44; N501Y&#44; T478K&#44; and N440K mutations have a main role&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> N501Y is present in the Alpha variant and T478K is in the Delta variant&#46; Despite the higher infectivity of Omicron&#44; the hospitalization rate was 20&#8211;25&#37; lower than the Delta variant&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> This could be related to its higher replicative capacity in the human bronchus&#44; but 10 times lower in the human lung tissue&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> which may explain why it spreads so rapidly in human populations&#46; This characteristic was previously observed in the Alpha variant&#44; with which Omicron shares three spike-mutations &#40;N501Y&#44; P681H&#44; and D614G&#41;&#44; justifying the fast spread in the human population&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">On the other hand&#44; the ability of Omicron to evade the COVID-19 vaccine immunity and cause breakthrough infections was also predicted to be higher than with previous variants&#44; probably due to the presence of K417N&#44; E484A&#44; and Y505H mutations&#44; the two first mutations being shared with the Beta variant &#40;also described in South Africa in September 2020&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Preliminary analyses suggest that&#44; although the spike mutations involve several T cell and B cell epitopes of the immunological response&#44; the majority of epitopes &#40;&#62;70&#37;&#41; remain unaffected&#44; but initial laboratory data suggested that the Omicron variant is likely to weaken the COVID-19 vaccine protection&#46; This observation could explain the high re-infection rate observed in vaccinated and previously infected people&#46; Altarawnwh et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> found that the effectiveness of previous infection in preventing reinfection was estimated to be 90&#46;2&#37; against the Alpha variant&#44; 85&#46;7&#37; against the Beta variant&#44; 92&#46;0&#37; against the Delta variant&#44; but only 56&#46;0&#37; against the Omicron variant&#44; although the patients had high antibodies titres&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Therefore&#44; the Omicron variant is particularly insensitive to antibodies elicited against prior variants&#46; Antigenic analyses indicated that all previous VOCs belong to one large antigenic cluster&#44; whereas Omicron forms a new cluster&#44; escaping vaccine or convalescent sera&#46; For this reason&#44; several authors have suggested considering Omicron as a new serotype&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> This proposal could have important implications for the development of updated vaccines&#44; and also could improve our understanding of the cellular and humoral response&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Until today&#44; several Omicron sub-variants have been identified&#46; These include BA&#46;1 &#40;B&#46;1&#46;1&#46;529&#46;1&#41;&#44; BA&#46;2 &#40;B&#46;1&#46;1&#46;529&#46;2&#41;&#44; and BA&#46;3 &#40;B&#46;1&#46;1&#46;529&#46;3&#41;&#44; which are all being monitored by WHO under the umbrella of &#8216;Omicron&#8217;&#46; They share 31 mutations&#44; and each one of them has 1&#8211;13 specific mutations&#46; B&#46;1 is the most widely distributed sub-variant&#44; and is responsible for 98&#37; of cases&#46; BA&#46;2 &#40;1&#37;&#41; is increasing its weekly proportion&#46; In several regions it has reached 50&#37;&#44; and in Denmark&#44; 80&#37;&#46; Fortunately&#44; the global circulation of all different variants is reportedly declining&#46; BA&#46;2&#44; also called &#8220;stealth Omicron&#44;&#8221; is 1&#46;5 times as infectious as BA&#46;1 and about 4&#46;2 times as contagious as the Delta variant&#46; A worrying data is that BA&#46;2 has a 30&#37; higher potential than BA&#46;1 to escape existing vaccines&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> In fact&#44; Israel reported a handful of cases of patients who were infected with the original Omicron BA&#46;1 strain and have been reinfected with BA&#46;2 in a short period&#46; The description of these cases suggests that the antibodies generated from the early Omicron BA&#46;1 were evaded by the BA&#46;2 strain&#46; To finish the bad news regarding BA&#46;2&#44; while monoclonal antibodies such as sotrovimab and tixagevimab retain significant neutralizing activity against BA&#46;1&#44; these may be not efficient against the BA&#46;2&#46; subvariant&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The comments of this editorial reveal that SARS-CoV-2 is continuously evolving in an endless race with the host&#44; with new threats waiting a better epidemiological scenario&#46; For this reason&#44; we should not stop our efforts in SARS-CoV-2 surveillance&#44; nor should we be surprised by the capacity of the viral evolution&#46; We would like to finish with a new sentence of Tedros Ghebreyesus&#44; WHO Director General&#58; &#8220;It is premature for any country either to surrender or to declare victory&#46;&#8221;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">JG research is supported by <span class="elsevierStyleItalic">Instituto de Salud Carlos III</span> and <span class="elsevierStyleItalic">Ministerio de Ciencia e Innovaci&#243;n</span> through <span class="elsevierStyleGrantSponsor" id="gs1"><span class="elsevierStyleItalic">CIBER en Salud P&#250;blica</span></span> &#40;CIBERES&#44; <span class="elsevierStyleGrantNumber" refid="gs1">CB06&#47;02&#47;0053</span>&#41; and RC through <span class="elsevierStyleGrantSponsor" id="gs2">REIPI</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs2">RD16&#47;0016&#47;0011</span>&#41; and <span class="elsevierStyleItalic">CIBER de Enfermedades Infecciosas</span>&#44; <span class="elsevierStyleGrantSponsor" id="gs3">CIBERINFEC</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs3">CB21&#47;13&#47;00084</span>&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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Article information
ISSN: 03002896
Original language: English
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