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Suryadevara M. Passive Immunization Strategies to Prevent Severe Respiratory Syncytial Virus Infection Among Newborns and Young Infants. J Pediatric Infect Dis Soc 2024; 13:S110-S114. [PMID: 38995085 DOI: 10.1093/jpids/piae058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 06/03/2024] [Indexed: 07/13/2024]
Abstract
Newborns and young infants are at risk for severe respiratory syncytial virus (RSV) lower respiratory tract infection. Passive immunity is the mainstay of infection prevention in this cohort. Transplacental transfer of maternal antibodies provides the newborn with immediate protection from life-threatening infections, however, is dependent upon gestational age, birth weight, mother's age, recent maternal vaccination, maternal nutritional status, maternal immunocompetence and medical conditions, and placental integrity. Efficient transplacental transfer of RSV-neutralizing antibodies have led to the development and approval of maternal RSV immunization for the protection of the newborn. Additionally, administration of RSV-specific antibodies to infants leads to high serum titers of RSV-neutralizing antibodies and further protection from severe disease.
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Affiliation(s)
- Manika Suryadevara
- Department of Pediatrics, SUNY Upstate Medical University, Syracuse, New York 13210, USA
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Davies HG, Thorley EV, Al-Bahadili R, Sutton N, Burt J, Hookham L, Karampatsas K, Lambach P, Muñoz F, Cutland CL, Omer S, Le Doare K. Defining and reporting adverse events of special interest in comparative maternal vaccine studies: a systematic review. Vaccine X 2024; 18:100464. [PMID: 38495929 PMCID: PMC10943481 DOI: 10.1016/j.jvacx.2024.100464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/07/2024] [Accepted: 02/18/2024] [Indexed: 03/19/2024] Open
Abstract
Introduction The GAIA (Global Alignment on Immunisation Safety Assessment in Pregnancy) consortium was established in 2014 with the aim of creating a standardised, globally coordinated approach to monitoring the safety of vaccines administered in pregnancy. The consortium developed twenty-six standardised definitions for classifying obstetric and infant adverse events. This systematic review sought to evaluate the current state of adverse event reporting in maternal vaccine trials following the publication of the case definitions by GAIA, and the extent to which these case definitions have been adopted in maternal vaccine safety research. Methods A comprehensive search of published literature was undertaken to identify maternal vaccine research studies. PubMed, EMBASE, Web of Science, and Cochrane were searched using a combination of MeSH terms and keyword searches to identify observational or interventional studies that examined vaccine safety in pregnant women with a comparator group. A two-reviewer screening process was undertaken, and a narrative synthesis of the results presented. Results 14,737 titles were identified from database searches, 435 titles were selected as potentially relevant, 256 were excluded, the remaining 116 papers were included. Influenza vaccine was the most studied (25.0%), followed by TDaP (20.7%) and SARS-CoV-2 (12.9%).Ninety-one studies (78.4%) were conducted in high-income settings. Forty-eight (41.4%) utilised electronic health-records. The majority focused on reporting adverse events of special interest (AESI) in pregnancy (65.0%) alone or in addition to reactogenicity (27.6%). The most frequently reported AESI were preterm birth, small for gestational age and hypertensive disorders. Fewer than 10 studies reported use of GAIA definitions. Gestational age assessment was poorly described; of 39 studies reporting stillbirths 30.8% provided no description of the gestational age threshold. Conclusions Low-income settings remain under-represented in comparative maternal vaccine safety research. There has been poor uptake of GAIA case definitions. A lack of harmonisation and standardisation persists limiting comparability of the generated safety data.
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Affiliation(s)
- Hannah G Davies
- Centre for Neonatal and Paediatric Infection, Institute of Infection & Immunity, St George’s, University of London, Cranmer Terrace, Tooting, London, United Kingdom
- MRC, UVRI & LSHTM Uganda Research Centre, Entebbe, Uganda
- Makerere University John Hopkins Research Unit, Kampala, Uganda
| | - Emma V Thorley
- Centre for Neonatal and Paediatric Infection, Institute of Infection & Immunity, St George’s, University of London, Cranmer Terrace, Tooting, London, United Kingdom
| | - Rossul Al-Bahadili
- Centre for Neonatal and Paediatric Infection, Institute of Infection & Immunity, St George’s, University of London, Cranmer Terrace, Tooting, London, United Kingdom
| | - Natalina Sutton
- Centre for Neonatal and Paediatric Infection, Institute of Infection & Immunity, St George’s, University of London, Cranmer Terrace, Tooting, London, United Kingdom
| | - Jessica Burt
- Centre for Neonatal and Paediatric Infection, Institute of Infection & Immunity, St George’s, University of London, Cranmer Terrace, Tooting, London, United Kingdom
| | - Lauren Hookham
- Centre for Neonatal and Paediatric Infection, Institute of Infection & Immunity, St George’s, University of London, Cranmer Terrace, Tooting, London, United Kingdom
| | - Kostas Karampatsas
- Centre for Neonatal and Paediatric Infection, Institute of Infection & Immunity, St George’s, University of London, Cranmer Terrace, Tooting, London, United Kingdom
| | | | - Flor Muñoz
- Paediatric Infectious Diseases Department, Baylor College of Medicine, Houston, TX, USA
| | - Clare L Cutland
- Wits African Leadership in Vaccinology Expertise (Wits-Alive), School of Pathology, Faculty of Health Science, University of the Witwatersrand, Johannesburg, South Africa
| | - Saad Omer
- O’Donnell School of Public Health, UT Southwestern Medical Center, Texas, USA
| | - Kirsty Le Doare
- Centre for Neonatal and Paediatric Infection, Institute of Infection & Immunity, St George’s, University of London, Cranmer Terrace, Tooting, London, United Kingdom
- Makerere University John Hopkins Research Unit, Kampala, Uganda
- World Health Organization, Geneva, Switzerland
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Oz-Alcalay L, Elron E, Davidovich R, Chodick G, Osovsky M, Chen R, Ashkenazi-Hoffnung L. The association of neonatal SARS-CoV-2 anti-spike protein receptor-binding domain antibodies at delivery with infant SARS-CoV-2 infection under the age of 6 months: a prospective cohort study. Clin Microbiol Infect 2023:S1198-743X(23)00048-4. [PMID: 36739973 PMCID: PMC9897870 DOI: 10.1016/j.cmi.2023.01.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 01/24/2023] [Accepted: 01/29/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The aim of this study was to assess the association between neonatal SARS-CoV-2 antibody level at delivery and infant SARS-CoV-2 infection under the age of 6 months and to identify predictive factors for neonatal antibody level at delivery. METHODS In a prospective observational study, conducted between September 2021 and mid-February 2022, cord blood sera were tested for SARS-CoV-2 anti-spike receptor-binding domain antibodies after maternal BNT162b2 vaccination or infection. Infants were followed up for 6 months for SARS-CoV-2 infection. RESULTS Sixty-seven mother-infant dyads were enrolled; nine of those did not meet the eligibility criteria. Of the 58 mother-infant dyads included, 6-month follow-up data were available for 57 mother-infant dyads. The mean ± standard deviation log SARS-CoV-2 anti-spike antibody level at delivery was lower among infants who were COVID-19 positive versus negative during follow-up (3.41 ± 0.74 AU/mL, n = 12; vs. 3.87 ± 0.84 AU/mL, n = 46; p 0.036); a log titre of ≥4.07 AU/mL (11 750) at delivery was associated with a significantly lower likelihood of infant infection (1/26 vs. 11/32 in infants with antibody level of <4.07 log AU/mL, OR = 0.076 [95% CI, 0.076, 0.64], p 0.018). A spline curve model showed a linear decrease in antibody levels when the last dose was administered at ≤30 weeks of gestation (50 days before delivery), after which the antibody levels increased (R2 = 0.50). In multivariate analysis, more vaccine doses, prior maternal infection, and last administered dose at ≥31 weeks of gestation were associated with higher antibody levels at delivery. DISCUSSION Higher anti-spike antibodies at delivery were associated with decreased risk of COVID-19 at the age of <6 months; the antibody level decreased linearly when the last dose was administered at ≤30 weeks of gestation. Future research should assess the effectiveness of a second booster during pregnancy against infant infection.
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Affiliation(s)
- Lital Oz-Alcalay
- Department of Day Hospitalization, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Eyal Elron
- Department of Day Hospitalization, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Rotem Davidovich
- Department of Day Hospitalization, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Gabriel Chodick
- Epidemiology and Database Research, Maccabi Healthcare Services, Israel,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Micky Osovsky
- Department of Neonatology, Rabin Medical Center-Beilinson Hospital, Petach Tikva, Israel
| | - Rony Chen
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel,Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center-Beilinson Hospital, Petach Tikva, Israel
| | - Liat Ashkenazi-Hoffnung
- Department of Day Hospitalization, Schneider Children's Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel; Pediatric Infectious Diseases Unit, Schneider Children's Medical Center, Petach Tikva, Israel.
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Sadarangani M, Soe P, Shulha HP, Valiquette L, Vanderkooi OG, Kellner JD, Muller MP, Top KA, Isenor JE, McGeer A, Irvine M, De Serres G, Marty K, Bettinger JA. Safety of COVID-19 vaccines in pregnancy: a Canadian National Vaccine Safety (CANVAS) network cohort study. THE LANCET. INFECTIOUS DISEASES 2022; 22:1553-1564. [PMID: 35964614 PMCID: PMC9371587 DOI: 10.1016/s1473-3099(22)00426-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 05/10/2022] [Accepted: 06/08/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pregnant individuals have been receiving COVID-19 vaccines following pre-authorisation clinical trials in non-pregnant people. This study aimed to determine the frequency and nature of significant health events among pregnant females after COVID-19 vaccination, compared with unvaccinated pregnant controls and vaccinated non-pregnant individuals. METHODS We did an observational cohort study, set in seven Canadian provinces and territories including Ontario, Quebec, British Columbia, Alberta, Nova Scotia, Yukon, and Prince Edward Island. Eligibility criteria for vaccinated individuals were a first dose of a COVID-19 vaccine within the previous 7 days; an active email address and telephone number; ability to communicate in English or French; and residence in the aforementioned provinces or territories. Study participants were pregnant and non-pregnant females aged 15-49 years. Individuals were able to participate as controls if they were unvaccinated and fulfilled the other criteria. Data were collected primarily by self-reported survey after both vaccine doses, with telephone follow-up for those reporting any medically attended event. Participants reported significant health events (new or worsening of a health event sufficient to cause work or school absenteeism, medical consultation, or prevent daily activities) occurring within 7 days of vaccination or within the past 7 days for unvaccinated individuals. We employed multivariable logistic regression to examine significant health events associated with mRNA vaccines, adjusting for age group, previous SARS-CoV-2 infection, and trimester, as appropriate. FINDINGS As of Nov 4, 2021, 191 360 women aged 15-49 years with known pregnancy status had completed the first vaccine dose survey and 94 937 had completed the second dose survey. 180 388 received one dose and 94 262 received a second dose of an mRNA vaccine, with 5597 pregnant participants receiving dose one and 3108 receiving dose two, and 174 765 non-pregnant participants receiving dose one and 91 131 receiving dose two. Of 6179 included unvaccinated control participants, 339 were pregnant and 5840 were not pregnant. Overall, 226 (4·0%) of 5597 vaccinated pregnant females reported a significant health event after dose one of an mRNA vaccine, and 227 (7·3%) of 3108 after dose two, compared with 11 (3·2%) of 339 pregnant unvaccinated females. Pregnant vaccinated females had an increased odds of a significant health event within 7 days of the vaccine after dose two of mRNA-1273 (adjusted odds ratio [aOR] 4·4 [95% CI 2·4-8·3]) compared with pregnant unvaccinated controls within the past 7 days, but not after dose one of mRNA-1273 or any dose of BNT162b2. Pregnant vaccinated females had decreased odds of a significant health event compared with non-pregnant vaccinated females after both dose one (aOR 0·63 [95% CI 0·55-0·72]) and dose two (aOR 0·62 [0·54-0·71]) of any mRNA vaccination. There were no significant differences in any analyses when restricted to events which led to medical attention. INTERPRETATION COVID-19 mRNA vaccines have a good safety profile in pregnancy. These data can be used to appropriately inform pregnant people regarding reactogenicity of COVID-19 vaccines during pregnancy, and should be considered alongside effectiveness and immunogenicity data to make appropriate recommendations about best use of COVID-19 vaccines in pregnancy. FUNDING Canadian Institutes of Health Research, Public Health Agency of Canada.
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Affiliation(s)
- Manish Sadarangani
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, Vancouver, BC, Canada; Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.
| | - Phyumar Soe
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, Vancouver, BC, Canada; Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Hennady P Shulha
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Louis Valiquette
- Department of Microbiology and Infectious Diseases, Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Otto G Vanderkooi
- Alberta Children's Hospital Research Institute, Calgary, AB, Canada; Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - James D Kellner
- Alberta Children's Hospital Research Institute, Calgary, AB, Canada; Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Matthew P Muller
- Department of Medicine, Unity Health Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Karina A Top
- Canadian Center for Vaccinology, IWK Health, Halifax, NS, Canada; Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Jennifer E Isenor
- Canadian Center for Vaccinology, IWK Health, Halifax, NS, Canada; College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | - Allison McGeer
- Department of Microbiology, University of Toronto, Toronto, ON, Canada; Sinai Health System, Toronto, ON, Canada
| | - Mike Irvine
- BC Centre for Disease Control, Vancouver, BC, Canada
| | - Gaston De Serres
- CHU de Québec-Université Laval, Quebec, QC, Canada; Institut national de santé publique du Québec, QC, Canada
| | - Kimberly Marty
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, Vancouver, BC, Canada; Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Julie A Bettinger
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, Vancouver, BC, Canada; Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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Jennewein MF, Kosikova M, Noelette FJ, Radvak P, Boudreau CM, Campbell JD, Chen WH, Xie H, Alter G, Pasetti MF. Functional and structural modifications of influenza antibodies during pregnancy. iScience 2022; 25:104088. [PMID: 35402869 PMCID: PMC8991102 DOI: 10.1016/j.isci.2022.104088] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 10/14/2021] [Accepted: 03/14/2022] [Indexed: 12/17/2022] Open
Abstract
Pregnancy represents a unique tolerogenic immune state which may alter susceptibility to infection and vaccine response. Here, we characterized humoral immunity to seasonal influenza vaccine strains in pregnant and non-pregnant women. Although serological responses to influenza remained largely intact during late pregnancy, distinct modifications were observed. Pregnant women had reduced hemagglutinin subtype-1 (H1)- IgG, IgG1, IgG2, and IgG3, hemagglutination inhibition, and group 1 and 2 stem IgG titers. Intriguingly, H1-specific avidity and FcγR1 binding increased, and influenza antibodies had distinct Fc and Fab glycans characterized by increased di-galactosylation and di-sialylation. H1-specific Fc-functionality (i.e. monocyte phagocytosis and complement deposition) was moderately reduced in pregnancy. Multivariate antibody analysis revealed two distinct populations (pregnant vs. non-pregnant) segregated by H1 FcγR1 binding, H1-IgG levels, and Fab and Fc glycosylation. Our results demonstrated a structural and functional modulation of influenza humoral immunity during pregnancy that was antigen-specific and consistent with reduced inflammation and efficient placental transport.
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Affiliation(s)
| | - Martina Kosikova
- Laboratory of Pediatric and Respiratory Viral Diseases, Division of Viral Products, Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD 20993, USA
| | | | - Peter Radvak
- Laboratory of Pediatric and Respiratory Viral Diseases, Division of Viral Products, Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD 20993, USA
| | | | - James D. Campbell
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Wilbur H. Chen
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Hang Xie
- Laboratory of Pediatric and Respiratory Viral Diseases, Division of Viral Products, Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD 20993, USA
| | - Galit Alter
- The Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA
| | - Marcela F. Pasetti
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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Semmes EC, Li SH, Hurst JH, Yang Z, Niedzwiecki D, Fouda GG, Kurtzberg J, Walsh KM, Permar SR. Congenital Human Cytomegalovirus Infection Is Associated With Decreased Transplacental IgG Transfer Efficiency Due to Maternal Hypergammaglobulinemia. Clin Infect Dis 2022; 74:1131-1140. [PMID: 34260701 PMCID: PMC8994583 DOI: 10.1093/cid/ciab627] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Placentally transferred maternal immunoglobulin G (IgG) protects against pathogens in early life, yet vertically transmitted infections can interfere with transplacental IgG transfer. Although human cytomegalovirus (HCMV) is the most common placentally-transmitted viral infection worldwide, the impact of congenital HCMV (cCMV) infection on transplacental IgG transfer has been underexplored. METHODS We evaluated total and antigen-specific maternal and cord blood IgG levels and transplacental IgG transfer efficiency in a US-based cohort of 93 mother-infant pairs including 27 cCMV-infected and 66 cCMV-uninfected pairs, of which 29 infants were born to HCMV-seropositive nontransmitting mothers and 37 to HCMV-seronegative mothers. Controls were matched on sex, race/ethnicity, maternal age, and delivery year. RESULTS Transplacental IgG transfer efficiency was decreased by 23% (95% confidence interval [CI] 10-36%, P = .0079) in cCMV-infected pairs and 75% of this effect (95% CI 28-174%, P = .0085) was mediated by elevated maternal IgG levels (ie, hypergammaglobulinemia) in HCMV-transmitting women. Despite reduced transfer efficiency, IgG levels were similar in cord blood from infants with and without cCMV infection. CONCLUSIONS Our results indicate that cCMV infection moderately reduces transplacental IgG transfer efficiency due to maternal hypergammaglobulinemia; however, infants with and without cCMV infection had similar antigen-specific IgG levels, suggesting comparable protection from maternal IgG acquired via transplacental transfer.
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Affiliation(s)
- Eleanor C Semmes
- Medical Scientist Training Program, Department of Molecular Genetics and Microbiology, Duke University, Durham, North Carolina, USA
- Duke Human Vaccine Institute, Duke University, Durham, North Carolina, USA
- Duke Children’s Health & Discovery Initiative, Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Shuk Hang Li
- Duke Human Vaccine Institute, Duke University, Durham, North Carolina, USA
| | - Jillian H Hurst
- Department of Pediatrics, Division of Infectious Diseases, Duke University, Durham, North Carolina, USA
- Duke Children’s Health & Discovery Initiative, Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Zidanyue Yang
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Genevieve G Fouda
- Duke Human Vaccine Institute, Duke University, Durham, North Carolina, USA
- Department of Pediatrics, Division of Infectious Diseases, Duke University, Durham, North Carolina, USA
- Duke Children’s Health & Discovery Initiative, Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Joanne Kurtzberg
- Carolinas Cord Blood Bank, Duke University Medical Center, Durham, North Carolina, USA
| | - Kyle M Walsh
- Duke Children’s Health & Discovery Initiative, Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Sallie R Permar
- Duke Human Vaccine Institute, Duke University, Durham, North Carolina, USA
- Duke Children’s Health & Discovery Initiative, Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Department of Pediatrics, Weill Cornell School of Medicine, New York City, New York, USA
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Nir O, Schwartz A, Toussia-Cohen S, Leibovitch L, Strauss T, Asraf K, Doolman R, Sharabi S, Cohen C, Lustig Y, Regev-Yochay G, Yinon Y. Maternal-neonatal transfer of SARS-CoV-2 immunoglobulin G antibodies among parturient women treated with BNT162b2 messenger RNA vaccine during pregnancy. Am J Obstet Gynecol MFM 2022; 4:100492. [PMID: 34547533 PMCID: PMC8451978 DOI: 10.1016/j.ajogmf.2021.100492] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 09/11/2021] [Accepted: 09/14/2021] [Indexed: 10/29/2022]
Abstract
BACKGROUND The exclusion of pregnant women from initial COVID-19 messenger RNA vaccine trials raised hesitancy regarding the benefits of vaccination for pregnant women, hence little is known about vaccines' efficacy in this population. OBJECTIVE To determine the maternal-neonatal transplacental transfer of SARS-CoV-2 antibodies among vaccinated parturient women. A control group of COVID-19-recovered patients was included to compare the immunoglobulin G levels between vaccinated and recovered patients. STUDY DESIGN This is a prospective cohort study conducted in a single tertiary medical center in Israel between February and March 2021; parturient women vaccinated with the BNT162b2 messenger RNA vaccine during pregnancy were included and compared with COVID-19-recovered parturient women. SARS-CoV-2 immunoglobulin G antibodies were measured in maternal and cord sera, dried blood spot samples taken from newborns, and breast milk samples. The primary aim was to determine whether neonatal cord and dried blood spot samples were positive for SARS-CoV-2 antibodies and to evaluate the transfer ratio, defined as cord blood immunoglobulin G divided by maternal immunoglobulin G levels. RESULTS The study included 64 vaccinated parturient women and 11 parturient women who had COVID-19 during pregnancy. All maternal blood sera samples and 98.3% of the cord blood sera samples were positive for SARS-Cov-2 immunoglobulin G with median concentrations of 26.1 (interquartile range, 22.0-39.7) and 20.2 (interquartile range, 12.7-29.0), respectively. Similarly, 96.4% of neonatal blood spot samples and all breast milk samples were positive for SARS-CoV-2 immunoglobulin G with median concentrations of 11.0 (interquartile range, 7.2-12.8) and 4.9 (interquartile range, 3.8-6.0), respectively. There was a significant positive correlation between maternal serum levels of SARS-CoV-2 immunoglobulin G and cord blood (r=0.483; P=.0001), neonatal blood spot (r=0.515; P=.004), and breast milk levels (r=0.396; P=.005) of SARS-CoV-2 immunoglobulin G. The median placental transfer ratio of SARS-COV-2 immunoglobulin G was 0.77. Comparison of vaccinated and recovered COVID-19 patients revealed significantly higher SARS-CoV-2 immunoglobulin G levels in maternal serum and cord blood among vaccinated women (P<.0001). CONCLUSION Our study demonstrated the efficient transfer of SARS-CoV-2 immunoglobulin G across the placenta in women, vaccinated with the BNT162b2 messenger RNA vaccine during pregnancy, to their neonates, with a positive correlation between maternal serum and cord blood antibody concentrations. In addition to maternal protection against COVID-19, the vaccine may also provide neonatal humoral immunity.
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Affiliation(s)
- Omer Nir
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel HaShomer, Israel (Drs Nir, Schwartz, Toussia-Cohen, and Yinon); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Nir, Schwartz, Toussia-Cohen, Leibovitch, Strauss, Cohen, Lustig, Regev-Yochay, and Yinon)
| | - Anat Schwartz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel HaShomer, Israel (Drs Nir, Schwartz, Toussia-Cohen, and Yinon); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Nir, Schwartz, Toussia-Cohen, Leibovitch, Strauss, Cohen, Lustig, Regev-Yochay, and Yinon)
| | - Shlomi Toussia-Cohen
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel HaShomer, Israel (Drs Nir, Schwartz, Toussia-Cohen, and Yinon); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Nir, Schwartz, Toussia-Cohen, Leibovitch, Strauss, Cohen, Lustig, Regev-Yochay, and Yinon)
| | - Leah Leibovitch
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Nir, Schwartz, Toussia-Cohen, Leibovitch, Strauss, Cohen, Lustig, Regev-Yochay, and Yinon); Department of Neonataology, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel HaShomer, Israel (Drs Leibovitch and Strauss)
| | - Tzipi Strauss
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Nir, Schwartz, Toussia-Cohen, Leibovitch, Strauss, Cohen, Lustig, Regev-Yochay, and Yinon); Department of Neonataology, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel HaShomer, Israel (Drs Leibovitch and Strauss)
| | - Keren Asraf
- The Dworman Automated Mega Laboratory, Sheba Medical Center, Tel HaShomer, Israel (Drs Asraf and Doolman and Ms Sharabi)
| | - Ram Doolman
- The Dworman Automated Mega Laboratory, Sheba Medical Center, Tel HaShomer, Israel (Drs Asraf and Doolman and Ms Sharabi)
| | - Sivan Sharabi
- The Dworman Automated Mega Laboratory, Sheba Medical Center, Tel HaShomer, Israel (Drs Asraf and Doolman and Ms Sharabi)
| | - Carmit Cohen
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Nir, Schwartz, Toussia-Cohen, Leibovitch, Strauss, Cohen, Lustig, Regev-Yochay, and Yinon); Infection Prevention & Control Unit, Sheba Medical Center, Tel HaShomer, Israel (Drs Cohen and Regev-Yochay)
| | - Yaniv Lustig
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Nir, Schwartz, Toussia-Cohen, Leibovitch, Strauss, Cohen, Lustig, Regev-Yochay, and Yinon); Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Tel HaShomer, Israel (Dr Lustig)
| | - Gili Regev-Yochay
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Nir, Schwartz, Toussia-Cohen, Leibovitch, Strauss, Cohen, Lustig, Regev-Yochay, and Yinon); Infection Prevention & Control Unit, Sheba Medical Center, Tel HaShomer, Israel (Drs Cohen and Regev-Yochay)
| | - Yoav Yinon
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel HaShomer, Israel (Drs Nir, Schwartz, Toussia-Cohen, and Yinon); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Nir, Schwartz, Toussia-Cohen, Leibovitch, Strauss, Cohen, Lustig, Regev-Yochay, and Yinon).
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Ben-Mayor Bashi T, Amikam U, Ashwal E, Hershkovitz G, Attali E, Berkovitz-Shperling R, Dominsky O, Halperin T, Goldshmidt H, Gamzu R, Yogev Y, Kuperminc M, Hiersch L. The association of maternal SARS-CoV-2 vaccination-to-delivery interval and the levels of maternal and cord blood antibodies. Int J Gynaecol Obstet 2021; 156:436-443. [PMID: 34762739 PMCID: PMC9087624 DOI: 10.1002/ijgo.14014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 11/16/2021] [Accepted: 11/09/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate the correlation of maternal and cord blood levels of SARS-CoV-2 antibodies in pregnant women immunized against COVID-19. METHODS A prospective cohort study was performed of pregnant women who delivered at a single university affiliated tertiary medical center. Women who received the COVID-19 vaccine (BNT162b2 Pfizer©) were approached. The correlation between levels of maternal sera and umbilical cord SARS-CoV-2 specific IgG was assessed. RESULTS Overall, 58 women were included; of them, 19 had received a single dose and 39 received two doses of the COVID-19 vaccine. Positive levels of umbilical cord IgG were found in 13/19 (68.4%) and 38/39 (97.4%) women after the administration of a single dose and two doses of the vaccine, respectively. The levels of SARS-CoV-2 IgG antibodies in the maternal sera of vaccinated women were positively correlated to their respective concentrations in cord blood sera (ρ = 0.857; R2 linear = 0.719; P < 0.001). Thirteen days after vaccination, the ratio of maternal-to-umbilical cord anti Spike IgG antibodies was approximately 1, indicating relatively similar levels in maternal and cord sera. CONCLUSION After the SARS-CoV-2 vaccine, levels of maternal and cord blood antibodies were positively correlated, especially when tested after 13 days following administration of the first dose of the vaccine.
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Affiliation(s)
- Tali Ben-Mayor Bashi
- Department of Obstetrics and Gynecology, Lis Maternity and Women's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Amikam
- Department of Obstetrics and Gynecology, Lis Maternity and Women's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Ashwal
- Department of Obstetrics and Gynecology, Lis Maternity and Women's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gal Hershkovitz
- Department of Obstetrics and Gynecology, Lis Maternity and Women's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Emmanuel Attali
- Department of Obstetrics and Gynecology, Lis Maternity and Women's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roza Berkovitz-Shperling
- Department of Obstetrics and Gynecology, Lis Maternity and Women's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Omri Dominsky
- Department of Obstetrics and Gynecology, Lis Maternity and Women's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tami Halperin
- Laboratory Medicine Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Hanoch Goldshmidt
- Laboratory Medicine Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ronni Gamzu
- Department of Obstetrics and Gynecology, Lis Maternity and Women's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yariv Yogev
- Department of Obstetrics and Gynecology, Lis Maternity and Women's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Kuperminc
- Department of Obstetrics and Gynecology, Lis Maternity and Women's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liran Hiersch
- Department of Obstetrics and Gynecology, Lis Maternity and Women's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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9
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Nakphook S, Patumanond J, Shrestha M, Prasert K, Chittaganpitch M, Mott JA, Praphasiri P. Antibody responses induced by trivalent inactivated influenza vaccine among pregnant and non-pregnant women in Thailand: A matched cohort study. PLoS One 2021; 16:e0253028. [PMID: 34106994 PMCID: PMC8189519 DOI: 10.1371/journal.pone.0253028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/21/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We compared influenza antibody titers among vaccinated and unvaccinated pregnant and non-pregnant women. METHODS During 1st June- 30th September 2018, four groups of cohort participants-vaccinated pregnant, unvaccinated pregnant, vaccinated non-pregnant, and unvaccinated non-pregnant women were selected by matching age, gestational age, and the week of vaccination. Serum antibody titers against each strain of 2018 Southern Hemisphere inactivated trivalent influenza vaccine (IIV3) were assessed by hemagglutination inhibition (HI) assay on Day 0 (pre-vaccination) and Day 28 (one month post-vaccination) serum samples. Geometric mean titer (GMT), GMT ratio (GMR), seroconversion (defined as ≥4 fold increase in HI titer), and seroprotection (i.e. HI titer ≥1:40) were compared across the study groups using multilevel regression analyses, controlling for previous year vaccination from medical records and baseline antibody levels. RESULTS A total of 132 participants were enrolled in the study (33 in each of the four study groups). The baseline GMTs for influenza A(H1N1), A(H3N2), and B vaccine strains were not significantly different among all four groups (all p-values >0.05). After one month, both vaccinated groups had significantly higher GMT, GMR, seroconversion, and seroprotection than their unvaccinated controls (all p-values <0.05). The seroconversion rate was over 60% for any strain among the vaccinated groups, with the highest (88.8%) observed against A(H1N1) in the vaccinated pregnant group. Similarly, at least 75% of the vaccinated participants developed seroprotective antibody levels against all three strains; the highest seroprotection was found against A(H3N2) at 92.6% among vaccinated non-pregnant participants. Antibody responses (post-vaccination GMT, GMR, seroconversion, and seroprotection) were not significantly different between pregnant and non-pregnant women for all three strains of IIV3 (all p>0.05). CONCLUSIONS The 2018 seasonal IIV3 was immunogenic against all three vaccine strains and pregnancy did not seem to alter the immune response to IIV3. These findings support the current influenza vaccination recommendations for pregnant women.
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Affiliation(s)
- Sutthichai Nakphook
- Department of Disease Control, Institute of Preventive Medicine, Ministry of Public Health, Nonthaburi, Thailand
- Faculty of Medicine, Thammasat University, Pathum Thani, Bangkok, Thailand
| | - Jayanton Patumanond
- Faculty of Medicine, Center for Clinical Epidemiology and Clinical Statistics, Chiang Mai University, Chiang Mai, Thailand
| | - Manash Shrestha
- Faculty of Social Sciences and Humanities, Department of Society and Health, Mahidol University, Nakhon Pathom, Thailand
- * E-mail:
| | - Kriengkrai Prasert
- Department of Primary Care Unit and Family Medicine, Nakhon Phanom Provincial Hospital, Nakhon Phanom, Thailand
| | | | - Joshua A. Mott
- Influenza Program, Thailand Ministry of Public Health - US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
- Influenza Division, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Prabda Praphasiri
- Influenza Program, Thailand Ministry of Public Health - US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
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Flannery DD, Gouma S, Dhudasia MB, Mukhopadhyay S, Pfeifer MR, Woodford EC, Triebwasser JE, Gerber JS, Morris JS, Weirick ME, McAllister CM, Bolton MJ, Arevalo CP, Anderson EM, Goodwin EC, Hensley SE, Puopolo KM. Assessment of Maternal and Neonatal Cord Blood SARS-CoV-2 Antibodies and Placental Transfer Ratios. JAMA Pediatr 2021; 175:594-600. [PMID: 33512440 PMCID: PMC7846944 DOI: 10.1001/jamapediatrics.2021.0038] [Citation(s) in RCA: 171] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Maternally derived antibodies are a key element of neonatal immunity. Understanding the dynamics of maternal antibody responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy and subsequent transplacental antibody transfer can inform neonatal management as well as maternal vaccination strategies. OBJECTIVE To assess the association between maternal and neonatal SARS-CoV-2-specific antibody concentrations. DESIGN, SETTING, AND PARTICIPANTS This cohort study took place at Pennsylvania Hospital in Philadelphia, Pennsylvania. A total of 1714 women delivered at the study site between April 9 and August 8, 2020. Maternal and cord blood sera were available for antibody measurement for 1471 mother/newborn dyads. EXPOSURES SARS-CoV-2. MAIN OUTCOMES AND MEASURES IgG and IgM antibodies to the receptor-binding domain of the SARS-CoV-2 spike protein were measured by enzyme-linked immunosorbent assay. Antibody concentrations and transplacental transfer ratios were analyzed in combination with demographic and clinical data. RESULTS The study cohort consisted of 1714 parturient women, with median (interquartile range) age of 32 (28-35) years, of whom 450 (26.3%) identified as Black/non-Hispanic, 879 (51.3%) as White/non-Hispanic, 203 (11.8%) as Hispanic, 126 (7.3%) as Asian, and 56 (3.3%) as other race/ethnicity. Among 1471 mother/newborn dyads for which matched sera were available, SARS-CoV-2 IgG and/or IgM antibodies were detected in 83 of 1471 women (6%; 95% CI, 5%-7%) at the time of delivery, and IgG was detected in cord blood from 72 of 83 newborns (87%; 95% CI, 78%-93%). IgM was not detected in any cord blood specimen, and antibodies were not detected in any infant born to a seronegative mother. Eleven infants born to seropositive mothers were seronegative: 5 of 11 (45%) were born to mothers with IgM antibody only, and 6 of 11 (55%) were born to mothers with significantly lower IgG concentrations compared with those found among mothers of seropositive infants. Cord blood IgG concentrations were positively correlated with maternal IgG concentrations (r = 0.886; P < .001). Placental transfer ratios more than 1.0 were observed among women with asymptomatic SARS-CoV-2 infections as well as those with mild, moderate, and severe coronavirus disease 2019. Transfer ratios increased with increasing time between onset of maternal infection and delivery. CONCLUSIONS AND RELEVANCE In this cohort study, maternal IgG antibodies to SARS-CoV-2 were transferred across the placenta after asymptomatic as well as symptomatic infection during pregnancy. Cord blood antibody concentrations correlated with maternal antibody concentrations and with duration between onset of infection and delivery. Our findings demonstrate the potential for maternally derived SARS-CoV-2 specific antibodies to provide neonatal protection from coronavirus disease 2019.
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Affiliation(s)
- Dustin D. Flannery
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Sigrid Gouma
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Miren B. Dhudasia
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sagori Mukhopadhyay
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Madeline R. Pfeifer
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Emily C. Woodford
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jourdan E. Triebwasser
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Jeffrey S. Gerber
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia,Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Biostatistics Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Jeffrey S. Morris
- Department of Biostatistics Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Madison E. Weirick
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | | | - Marcus J. Bolton
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Claudia P. Arevalo
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Elizabeth M. Anderson
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Eileen C. Goodwin
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Scott E. Hensley
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Karen M. Puopolo
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia
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11
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Rottenstreich A, Zarbiv G, Oiknine-Djian E, Zigron R, Wolf DG, Porat S. Efficient maternofetal transplacental transfer of anti- SARS-CoV-2 spike antibodies after antenatal SARS-CoV-2 BNT162b2 mRNA vaccination. Clin Infect Dis 2021; 73:1909-1912. [PMID: 33822014 PMCID: PMC8083549 DOI: 10.1093/cid/ciab266] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Indexed: 11/25/2022] Open
Abstract
Maternal and cord blood sera were collected from 20 parturients who received the BNT162b2 vaccine. All women and infants were positive for anti S- and anti-RBD-specific IgG. Cord blood antibody concentrations were correlated to maternal levels and to time since vaccination. Antenatal SARS-CoV-2 vaccination may provide maternal and neonatal protection.
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Affiliation(s)
- Amihai Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Gila Zarbiv
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Esther Oiknine-Djian
- Clinical virology unit, Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Roy Zigron
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Dana G Wolf
- Clinical virology unit, Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Shay Porat
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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