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SeyedAlinaghi S, Dashti M, Afzalian A, Siami H, Ghasemzadeh A, Varshochi S, Parikhani SN, Amrollah MF, Nourian A, Mehraeen E, Dadras O. The immunologic outcomes and adverse events of COVID-19 vaccine booster dose in immunosuppressed people: A systematic review. Prev Med Rep 2024; 44:102778. [PMID: 38979481 PMCID: PMC11228787 DOI: 10.1016/j.pmedr.2024.102778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 05/20/2024] [Accepted: 05/28/2024] [Indexed: 07/10/2024] Open
Abstract
Introduction This study examines the efficacy and safety of three COVID-19 booster vaccines including mRNA-based vaccines (BNT162b2 (BioNTech/Pfizer) and/or mRNA-1273 (Moderna)), Non-Replicating Viral-Vector vaccines (ChAdOx1 nCoV-19 vaccine (AstraZeneca) and/or Ad26. COV2.S (Johnson & Johnson)), and Protein Subunit vaccine (SpikoGen) in immunosuppressed patients. Methods Relevant articles were systematically searched using medical subject heading (MeSH) and keywords "COVID-19" and "booster dose" or "booster vaccine" or ''fourth dose" in the online databases of PubMed, Embase, Scopus, and Web of Science. To identify eligible studies, a two-phase screening process was implemented. Initially, three researchers evaluated the studies based on the relevancy of the title and abstract. Results A total of 58 studies met the inclusion criteria and were included in this review. The findings suggest that booster doses offer greater protection against the disease than the primary dose. The study also compared various vaccine types, revealing that viral vector and nucleic acid vaccines outperformed inactivated vaccines. Results indicated that individuals receiving booster doses experienced superior outcomes compared to those without boosters. Vaccination against COVID-19 emerged as the most effective preventive measure against infection and symptom severity. Elevated antibody levels post-booster dose vaccination in the population signaled robust immune responses, underscoring the benefits of supplementary vaccine doses. Conclusion This systematic review highlights preliminary evidence supporting the immunologic outcomes and safety of COVID-19 vaccine boosters in enhancing immune responses against SARS-CoV-2. However, further research is needed to determine optimal timing intervals between primary vaccination series and boosters while considering global equity issues and variant-specific considerations.
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Affiliation(s)
- SeyedAhmad SeyedAlinaghi
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Dashti
- Department of Radiology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Arian Afzalian
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Haleh Siami
- School of Medicine, Islamic Azad University, Tehran, Iran
| | - Afsaneh Ghasemzadeh
- Department of Radiology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sanaz Varshochi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Masoomeh Fathi Amrollah
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
| | - Anahid Nourian
- Department of Pharmacotherapy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Esmaeil Mehraeen
- Department of Health Information Technology, Khalkhal University of Medical Sciences, Khalkhal, Iran
| | - Omid Dadras
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
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Jung SW, Jeon JJ, Kim YH, Choe SJ, Lee S. Long-term risk of autoimmune diseases after mRNA-based SARS-CoV2 vaccination in a Korean, nationwide, population-based cohort study. Nat Commun 2024; 15:6181. [PMID: 39039113 PMCID: PMC11263712 DOI: 10.1038/s41467-024-50656-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 07/10/2024] [Indexed: 07/24/2024] Open
Abstract
The long-term association between mRNA-based coronavirus disease 2019 (COVID-19) vaccination and the development of autoimmune connective tissue diseases (AI-CTDs) remains unclear. In this nationwide, population-based cohort study involving 9,258,803 individuals, we aim to determine whether the incidence of AI-CTDs is associated with mRNA vaccination. The study spans over 1 year of observation and further analyses the risk of AI-CTDs by stratifying demographics and vaccination profiles and treating booster vaccination as time-varying covariate. We report that the risk of developing most AI-CTDs did not increase following mRNA vaccination, except for systemic lupus erythematosus with a 1.16-fold risk in vaccinated individuals relative to controls. Comparable results were reported in the stratified analyses for age, sex, mRNA vaccine type, and prior history of non-mRNA vaccination. However, a booster vaccination was associated with an increased risk of some AI-CTDs including alopecia areata, psoriasis, and rheumatoid arthritis. Overall, we conclude that mRNA-based vaccinations are not associated with an increased risk of most AI-CTDs, although further research is needed regarding its potential association with certain conditions.
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Affiliation(s)
- Seung-Won Jung
- Department of Dermatology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Jae Joon Jeon
- Department of Dermatology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - You Hyun Kim
- Department of Dermatology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Sung Jay Choe
- Department of Dermatology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea.
| | - Solam Lee
- Department of Dermatology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea.
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Ørbo HS, Bjørlykke KH, Sexton J, Jyssum I, Tveter AT, Christensen IE, Mjaaland S, Kvien TK, Grødeland G, Kro GB, Jahnsen J, Haavardsholm EA, Munthe LA, Provan SA, Vaage JT, Goll GL, Jørgensen KK, Syversen SW. Incidence and outcome of COVID-19 following vaccine and hybrid immunity in patients on immunosuppressive therapy: identification of protective post-immunisation anti-RBD antibody levels in a prospective cohort study. RMD Open 2024; 10:e003545. [PMID: 38599653 PMCID: PMC11015197 DOI: 10.1136/rmdopen-2023-003545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 02/15/2024] [Indexed: 04/12/2024] Open
Abstract
OBJECTIVES To assess incidence, severity and predictors of COVID-19, including protective post-vaccination levels of antibodies to the receptor-binding domain of SARS-CoV-2 spike protein (anti-RBD), informing further vaccine strategies for patients with immune-mediated inflammatory diseases (IMIDs) on immunosuppressive medication. METHODS IMIDs on immunosuppressives and healthy controls (HC) receiving SARS-CoV-2 vaccines were included in this prospective observational study. COVID-19 and outcome were registered and anti-RBD antibodies measured 2-5 weeks post-immunisation. RESULTS Between 15 February 2021 and 15 February 2023, 1729 IMIDs and 350 HC provided blood samples and self-reported COVID-19. The incidence of COVID-19 was 66% in patients and 67% in HC, with re-infection occurring in 12% of patients. Severe COVID-19 was recorded in 22 (2%) patients and no HC. No COVID-19-related deaths occurred. Vaccine-induced immunity gave higher risk of COVID-19 (HR 5.89 (95% CI 4.45 to 7.80)) than hybrid immunity. Post-immunisation anti-RBD levels <6000 binding antibody units/mL were associated with an increased risk of COVID-19 following three (HR 1.37 (95% CI 1.08 to 1.74)) and four doses (HR 1.28 (95% CI 1.02 to 1.62)), and of COVID-19 re-infection (HR 4.47 (95% CI 1.87 to 10.67)). CONCLUSION Vaccinated patients with IMID have a low risk of severe COVID-19. Hybrid immunity lowers the risk of infection. High post-immunisation anti-RBD levels protect against COVID-19. These results suggest that knowledge on COVID-19 history, and assessment of antibody levels post-immunisation can help individualise vaccination programme series in high-risk individuals. TRIAL REGISTRATION NUMBER NCT04798625.
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Affiliation(s)
- Hilde S Ørbo
- Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Kristin H Bjørlykke
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Joseph Sexton
- Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Ingrid Jyssum
- Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anne T Tveter
- Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Ingrid E Christensen
- Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Siri Mjaaland
- Division of Infection Control, Section for Immunology, Norwegian Institute of Public Health, Oslo, Norway
| | - Tore K Kvien
- Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Gunnveig Grødeland
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Immunology, Oslo University Hospital, Oslo, Norway
| | - Grete B Kro
- Department of Microbiology, Oslo University Hospital, Oslo, Norway
| | - Jørgen Jahnsen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Espen A Haavardsholm
- Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ludvig A Munthe
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Immunology, Oslo University Hospital, Oslo, Norway
- KG Jebsen Centre for B cell Malignancies, University of Oslo, Oslo, Norway
| | - Sella A Provan
- Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
- Section for Public Health, Inland Norway University of Applied Sciences, Elverum, Norway
| | - John T Vaage
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Immunology, Oslo University Hospital, Oslo, Norway
| | - Guro Løvik Goll
- Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | | | - Silje Watterdal Syversen
- Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
- Institute of Health and Society, University of Oslo, Oslo, Norway
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Frodlund M, Nived P, Chatzidionysiou K, Södergren A, Klingberg E, Hansson M, Ohlsson S, Pin E, Bengtsson A, Klareskog L, Kapetanovic M. The serological immunogenicity of the third and fourth doses of COVID-19 vaccine in patients with inflammatory rheumatic diseases on different biologic or targeted DMARDs: a Swedish nationwide study (COVID-19-REUMA). Microbiol Spectr 2024; 12:e0298123. [PMID: 38441463 PMCID: PMC10986619 DOI: 10.1128/spectrum.02981-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 12/05/2023] [Indexed: 04/06/2024] Open
Abstract
Studies investigating the immunogenicity of additional COVID-19 vaccine doses in immunosuppressed patients with inflammatory rheumatic diseases (IRD) are still limited. The objective was to explore the antibody response including response to omicron virus subvariants (sBA.1 and sBS.2) after third and fourth COVID-19 vaccine doses in Swedish IRD patients treated with immunomodulating drugs compared to controls. Antibody levels to spike wild-type antigens (full-length protein and S1) and the omicron variants sBA.1 and sBA.2 (full-length proteins) were measured. A positive response was defined as having antibody levels over cut-off or ≥fourfold increase in post-vaccination levels for both antigens. Patients with arthritis, vasculitis, and other autoimmune diseases (n = 414), and controls (n = 61) receiving biologic/targeted synthetic disease-modifying anti-rheumatic drugs (DMARDs) with or without conventional synthetic DMARDs participated. Of these, blood samples were available for 370 patients and 52 controls after three doses, and 65 patients and 15 controls after four doses. Treatment groups after three vaccine doses were rituximab (n = 133), abatacept (n = 22), IL6r inhibitors (n = 71), JAnus Kinase inhibitors (JAK-inhibitors) (n = 56), tumor necrosis factor inhibitor (TNF-inhibitors) (n = 61), IL12/23/17 inhibitors (n = 27), and controls (n = 52). The percentage of responders after three and four vaccine doses was lower in rituximab-treated patients (59% and 57%) compared to controls (100%) (P < 0.001). After three doses, the percentage of responders in all other groups was 100%, including response to omicron sBA.1 and sBA.2. In rituximab-treated patients, higher baseline immunoglobulin G (IgG) and longer time-period between rituximab and vaccination predicted better response. In this Swedish nationwide study including IRD patients three and four COVID-19 vaccine doses were immunogenic in patients treated with IL6r inhibitors, TNF-inhibitors, JAK-inhibitors, and IL12/23/17-inhibitors but not in rituximab. As >50% of rituximab patients responded to vaccines including omicron subvariants, these patients should be prioritized for additional vaccine doses. IMPORTANCE Results from this study provide further evidence that additional doses of COVID-19 vaccines are immunogenic and result in satisfactory antibody response in a majority of patients with inflammatory rheumatic diseases (IRD) receiving potent immunomodulating treatments such as biological or targeted disease-modifying anti-rheumatic drugs (DMARDs) given as monotherapy or combined with traditional DMARDs. We observed that rituximab treatment, both as monotherapy and combined with csDMARDs, impaired antibody response, and only roughly 50% of patients developed a satisfactory antibody response including response to omicron subvariants after the third vaccine. In addition, higher IgG levels at the last rituximab course before the third vaccine dose and a longer time after the last rituximab treatment increased the chance of a satisfactory antibody response. These results indicate that rituximab-treated patients should be prioritized for additional vaccine doses. CLINICAL TRIALS EudraCT (European Union Drug Regulating Authorities Clinical Trials Database) with number 2021-000880-63.
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Affiliation(s)
- Martina Frodlund
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection/Rheumatology, Linköping University, Linköping, Sweden
| | - Per Nived
- Department of Clinical Sciences, Section for Rheumatology, Lund University, Lund and Skåne University Hospital, Lund, Lund, , Sweden
| | - Katerina Chatzidionysiou
- Department of Medicine, Rheumatology Unit, Karolinska University Hospital and Karolinska Institutet, Stockholm, Solna, Sweden
| | - Anna Södergren
- Department of Public Health and Clinical Medicine/Rheumatology, Umeå University, Umeå, Sweden
| | - Eva Klingberg
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Monica Hansson
- Department of Medicine, Rheumatology Unit, Karolinska University Hospital and Karolinska Institutet, Stockholm, Solna, Sweden
| | - Sophie Ohlsson
- Department of Clinical Sciences, Section for Nephrology, Lund University, Lund and Skåne University Hospital, Lund, Lund, , Sweden
| | - Elisa Pin
- Department of Protein Science, SciLifeLab, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Anders Bengtsson
- Department of Clinical Sciences, Section for Rheumatology, Lund University, Lund and Skåne University Hospital, Lund, Lund, , Sweden
| | - Lars Klareskog
- Department of Medicine, Rheumatology Unit, Karolinska University Hospital and Karolinska Institutet, Stockholm, Solna, Sweden
| | - Meliha Kapetanovic
- Department of Clinical Sciences, Section for Rheumatology, Lund University, Lund and Skåne University Hospital, Lund, Lund, , Sweden
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Kared H, Jyssum I, Alirezaylavasani A, Egner IM, The Tran T, Tietze L, Lund KP, Tveter AT, Provan SA, Ørbo H, Haavardsholm EA, Vaage JT, Jørgensen K, Syversen SW, Lund-Johansen F, Goll GL, Munthe LA. Dynamics of SARS-CoV-2 immunity after vaccination and breakthrough infection in rituximab-treated rheumatoid arthritis patients: a prospective cohort study. Front Immunol 2024; 15:1296273. [PMID: 38455062 PMCID: PMC10917913 DOI: 10.3389/fimmu.2024.1296273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 02/05/2024] [Indexed: 03/09/2024] Open
Abstract
Background SARS-CoV-2 vaccination in rheumatoid arthritis (RA) patients treated with B cell-depleting drugs induced limited seroconversion but robust cellular response. We aimed to document specific T and B cell immunity in response to vaccine booster doses and breakthrough infection (BTI). Methods We included 76 RA patients treated with rituximab who received up to four SARS-CoV-2 vaccine doses or three doses plus BTI, in addition to vaccinated healthy donors (HD) and control patients treated with tumor necrosis factor inhibitor (TNFi). We quantified anti-SARS-CoV-2 receptor-binding domain (RBD) Spike IgG, anti-nucleocapsid (NC) IgG, 92 circulating inflammatory proteins, Spike-binding B cells, and Spike-specific T cells along with comprehensive high-dimensional phenotyping and functional assays. Findings The time since the last rituximab infusion, persistent inflammation, and age were associated with the anti-SARS-CoV-2 RBD IgG seroconversion. The vaccine-elicited serological response was accompanied by an incomplete induction of peripheral Spike-specific memory B cells but occurred independently of T cell responses. Vaccine- and BTI-elicited cellular immunity was similar between RA and HD ex vivo in terms of frequency or phenotype of Spike-specific cytotoxic T cells and in vitro in terms of the functionality and differentiation profile of Spike-specific T cells. Interpretation SARS-CoV-2 vaccination in RA can induce persistent effector T-cell responses that are reactivated by BTI. Paused rituximab medication allowed serological responses after a booster dose (D4), especially in RA with lower inflammation, enabling efficient humoral and cellular immunity after BTI, and contributed overall to the development of potential durable immunity.
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Affiliation(s)
- Hassen Kared
- Department of Immunology, Oslo University Hospital, Oslo, Norway
- KG Jebsen Centre for B cell Malignancies, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Precision Immunotherapy Alliance, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ingrid Jyssum
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Amin Alirezaylavasani
- Department of Immunology, Oslo University Hospital, Oslo, Norway
- KG Jebsen Centre for B cell Malignancies, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Precision Immunotherapy Alliance, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ingrid M. Egner
- Department of Immunology, Oslo University Hospital, Oslo, Norway
- KG Jebsen Centre for B cell Malignancies, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Precision Immunotherapy Alliance, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Trung The Tran
- Department of Immunology, Oslo University Hospital, Oslo, Norway
- Precision Immunotherapy Alliance, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- ImmunoLingo Convergence Center, University of Oslo, Oslo, Norway
| | - Lisa Tietze
- Department of Immunology, Oslo University Hospital, Oslo, Norway
- Precision Immunotherapy Alliance, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- ImmunoLingo Convergence Center, University of Oslo, Oslo, Norway
| | - Katrine Persgård Lund
- Department of Immunology, Oslo University Hospital, Oslo, Norway
- KG Jebsen Centre for B cell Malignancies, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Precision Immunotherapy Alliance, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anne Therese Tveter
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Sella A. Provan
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Hilde Ørbo
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Espen A. Haavardsholm
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - John Torgils Vaage
- Department of Immunology, Oslo University Hospital, Oslo, Norway
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Kristin Jørgensen
- Department of Gastroenterology, Akershus University Hospital, Lørenskog, Norway
| | - Silje Watterdal Syversen
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Fridtjof Lund-Johansen
- Department of Immunology, Oslo University Hospital, Oslo, Norway
- Precision Immunotherapy Alliance, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- ImmunoLingo Convergence Center, University of Oslo, Oslo, Norway
| | - Guro Løvik Goll
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Ludvig A. Munthe
- Department of Immunology, Oslo University Hospital, Oslo, Norway
- KG Jebsen Centre for B cell Malignancies, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Hanberg JS, Fu X, Wang X, Patel NJ, Kawano Y, Schiff A, Kowalski EN, Cook CE, Vanni KMM, Guzzo K, Qian G, Bade KJ, Saavedra A, Venkat R, Srivatsan S, Zhang Y, Sparks JA, Wallace ZS. Effectiveness of a fourth dose of COVID-19 mRNA vaccine in patients with systemic autoimmune rheumatic diseases using disease-modifying antirheumatic drugs: an emulated target trial. THE LANCET. RHEUMATOLOGY 2024; 6:e21-e30. [PMID: 38258675 PMCID: PMC10806341 DOI: 10.1016/s2665-9913(23)00272-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/02/2023] [Accepted: 10/02/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Patients with systemic autoimmune rheumatic diseases using disease-modifying antirheumatic drugs (DMARDs) might have blunted responses to COVID-19 vaccines. The initial mRNA vaccine series is defined as three doses for this population and a fourth booster dose is recommended. The effectiveness of the fourth dose in patients with systemic autoimmune rheumatic diseases using DMARDs is not well established. We aimed to assess the effectiveness of receiving versus not receiving a fourth dose of COVID-19 mRNA vaccine using a target trial framework, in a cohort of patients with systemic autoimmune rheumatic diseases receiving DMARD therapy. METHODS We conducted an emulated target trial using observational data from the Mass General Brigham health-care system to compare receiving versus not receiving a fourth mRNA vaccine dose. Analysed patients had systemic autoimmune rheumatic diseases, were prescribed DMARDs, and were eligible for a fourth dose of BNT162b2 or mRNA-1273 vaccines between Jan 16 and June 11, 2022. To account for temporal changes, the study period was divided into 1-week intervals. Fourth-dose-exposed patients were included in a 1-week interval if they received a fourth mRNA dose in that interval; fourth-dose-unexposed patients were eligible for but had not received the fourth dose of the vaccine. The primary outcome was a SARS-CoV-2 infection; the secondary outcome was severe SARS-CoV-2 infection (ie, admission to hospital or death within -3 to +14 days of a positive test). We assessed the effectiveness of the fourth dose using time-stratified, overlap propensity score-weighted Cox regression models. FINDINGS We included 4305 patients, 3126 of whom received a fourth dose of vaccine and 1179 who had not. The median follow-up time was 135 days (IQR 112-154) among patients who had received a fourth dose and 65 days (30-156) among patients who had not received a fourth dose. After overlap weighting in both groups, 1863 (72·7%) of 2563 participants were women, 700 (27·3%) were men, and 2242 (87·5%) were White. Rheumatoid arthritis was present in 1392 (54·3%) of 2563 participants; the most frequent treatments were conventional synthetic DMARDs (1489 [58·1%]) or biological DMARDs (1007 [39·3%]). SARS-CoV-2 infection risk was lower among patients receiving versus not receiving a fourth dose of vaccine (HR 0·59 [95% CI 0·47-0·74]). A fourth dose reduced the risk of admission to hospital or death within -3 to +14 days of SARS-CoV-2 infection (0·35 [0·14-0·85]). INTERPRETATION In this emulated target trial, a fourth dose of COVID-19 mRNA vaccine reduced the risk of SARS-CoV-2 infection and severe COVID-19 among patients with systemic autoimmune rheumatic diseases using DMARDs during the Omicron era. Patients with systemic autoimmune rheumatic diseases should be encouraged to remain up-to-date with COVID-19 vaccinations. FUNDING The National Institutes of Health and the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
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Affiliation(s)
- Jennifer S Hanberg
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Xiaoqing Fu
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA; Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Xiaosong Wang
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Naomi J Patel
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Yumeko Kawano
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Abigail Schiff
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Emily N Kowalski
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Claire E Cook
- Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kathleen M M Vanni
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Krishan Guzzo
- Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Grace Qian
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Katarina J Bade
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Alene Saavedra
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Rathnam Venkat
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
| | - Shruthi Srivatsan
- Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Yuqing Zhang
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA; Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Jeffrey A Sparks
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Zachary S Wallace
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA; Rheumatology and Allergy Clinical Epidemiology Research Center, Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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Alnaimat F, Sweis JJG, Jansz J, Modi Z, Prasad S, AbuHelal A, Vagts C, Hanson HA, Ascoli C, Novak RM, Papanikolaou IC, Rubinstein I, Sweiss N. Vaccination in the Era of Immunosuppression. Vaccines (Basel) 2023; 11:1446. [PMID: 37766123 PMCID: PMC10537746 DOI: 10.3390/vaccines11091446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/20/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
Patients with autoimmune inflammatory rheumatic diseases (AIIRDs) are at increased risk for severe infections. Vaccine responses and safety profiles may differ between AIIRD patients and the general population. While patients with autoimmune inflammatory rheumatic diseases (AIIRDs) often experience diminished humoral responses and reduced vaccine efficacy, factors such as the type of immunosuppressant medications used and the specific vaccine employed contribute to these outcomes. Notably, individuals undergoing B cell depletion therapy tend to have poor vaccine immunogenicity. However, despite these considerations, vaccine responses are generally considered clinically sufficient. Ideally, immunosuppressed AIIRD patients should receive vaccinations at least two weeks before commencing immunosuppressive treatment. However, it is common for many patients to already be on immunosuppressants during the immunization process. Vaccination rarely triggers flares in AIIRDs; if flares occur, they are typically mild. Despite the heightened infection risk, including COVID-19, among AIIRD patients with rheumatoid arthritis, systemic lupus erythematosus, sarcoidosis, and other diseases on immunosuppressants, the vaccination rates remain suboptimal. The future directions of vaccination in the era of immunosuppression will likely involve customized vaccines with enhanced adjuvants and alternative delivery methods. By addressing the unique challenges faced by immunosuppressed individuals, we may improve vaccine efficacy, reduce the risk of infections, and ultimately enhance the health outcomes. Additionally, clinical trials to evaluate the safety and efficacy of temporarily discontinuing immunosuppressants during vaccination in various AIIRDs are crucial.
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Affiliation(s)
- Fatima Alnaimat
- Department of Internal Medicine, Division of Rheumatology, School of Medicine, University of Jordan, Amman 11942, Jordan
| | | | - Jacqueline Jansz
- Department of Medicine, University of Illinois Chicago, Chicago, IL 60612, USA; (J.J.); (Z.M.); (S.P.)
| | - Zeel Modi
- Department of Medicine, University of Illinois Chicago, Chicago, IL 60612, USA; (J.J.); (Z.M.); (S.P.)
| | - Supritha Prasad
- Department of Medicine, University of Illinois Chicago, Chicago, IL 60612, USA; (J.J.); (Z.M.); (S.P.)
| | | | - Christen Vagts
- Department of Medicine, Division of Pulmonary Critical Care Sleep and Allergy, University of Illinois Chicago, Chicago, IL 60612, USA; (C.V.); (C.A.); (I.R.)
| | - Hali A. Hanson
- College of Pharmacy, University of Illinois Hospital & Health Sciences System, Chicago, IL 60612, USA;
| | - Christian Ascoli
- Department of Medicine, Division of Pulmonary Critical Care Sleep and Allergy, University of Illinois Chicago, Chicago, IL 60612, USA; (C.V.); (C.A.); (I.R.)
| | - Richard M. Novak
- Division of Infectious Diseases, University of Illinois, Chicago, IL 60612, USA;
| | - Ilias C. Papanikolaou
- Department of Respiratory Medicine, Sarcoidosis Clinic, Corfu General Hospital, 49100 Corfu, Greece;
| | - Israel Rubinstein
- Department of Medicine, Division of Pulmonary Critical Care Sleep and Allergy, University of Illinois Chicago, Chicago, IL 60612, USA; (C.V.); (C.A.); (I.R.)
| | - Nadera Sweiss
- Division of Rheumatology, Department of Medicine, University of Illinois Chicago, Chicago, IL 60612, USA;
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Finckh A, Ciurea A, Raptis CE, Rubbert-Roth A. Susceptibility to COVID-19 and Immunologic Response to Vaccination in Patients With Immune-Mediated Inflammatory Diseases. J Infect Dis 2023; 228:S13-S23. [PMID: 37539758 PMCID: PMC10401619 DOI: 10.1093/infdis/jiad148] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/06/2023] [Indexed: 08/05/2023] Open
Abstract
Immune-mediated inflammatory diseases (IMIDs) are a highly heterogeneous group of diseases that share a common etiology of immune dysregulation, such as rheumatoid arthritis, inflammatory bowel disease, and psoriasis, among others. It is estimated that the prevalence of IMIDs ranges between 5% and 7% in developed countries. As current management of IMIDs includes the use of immunomodulatory medications, the resulting weakened immune response can increase the risk of infection, including with SARS-CoV-2 (the causative agent of COVID-19) and reduce response to vaccination, placing these individuals at continued risk of severe outcomes from COVID-19. In this article, we summarize the current literature related to COVID-19 outcomes and the immunogenicity and reactogenicity of COVID-19 mRNA vaccination among patients with rheumatologically dominated IMIDs, as well as the effect of immunomodulatory therapies on these outcomes. We conclude by providing current COVID-19 vaccination recommendations for individuals with IMID.
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Affiliation(s)
- Axel Finckh
- Division of Rheumatology, Geneva University Hospitals, Geneva, Switzerland
- Geneva Centre for Inflammation Research, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Adrian Ciurea
- Department of Rheumatology, Zurich University Hospital, University of Zurich, Zurich, Switzerland
| | | | - Andrea Rubbert-Roth
- Correspondence: A. Rubbert-Roth, MD, Division of Rheumatology, Cantonal Hospital St. Gallen, Rorschacherstr 95, 9007 St. Gallen, Switzerland ()
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9
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Wroński J, Jaszczyk B, Roszkowski L, Felis-Giemza A, Bonek K, Kornatka A, Plebańczyk M, Burakowski T, Lisowska B, Kwiatkowska B, Maśliński W, Wisłowska M, Massalska M, Kuca-Warnawin E, Ciechomska M. The Kinetics of Humoral and Cellular Responses after the Booster Dose of COVID-19 Vaccine in Inflammatory Arthritis Patients. Viruses 2023; 15:v15030620. [PMID: 36992329 PMCID: PMC10052973 DOI: 10.3390/v15030620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/09/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
Impaired immunogenicity of COVID-19 vaccinations in inflammatory arthritis (IA) patients results in diminished immunity. However, optimal booster vaccination regimens are still unknown. Therefore, this study aimed to assess the kinetics of humoral and cellular responses in IA patients after the COVID-19 booster. In 29 IA patients and 16 healthy controls (HC), humoral responses (level of IgG antibodies) and cellular responses (IFN-γ production) were assessed before (T0), after 4 weeks (T1), and after more than 6 months (T2) from the booster vaccination with BNT162b2. IA patients, but not HC, showed lower anti-S-IgG concentration and IGRA fold change at T2 compared to T1 (p = 0.026 and p = 0.031). Furthermore, in IA patients the level of cellular response at T2 returned to the pre-booster level (T0). All immunomodulatory drugs, except IL-6 and IL-17 inhibitors for the humoral and IL-17 inhibitors for the cellular response, impaired the immunogenicity of the booster dose at T2. Our study showed impaired kinetics of both humoral and cellular responses after the booster dose of the COVID-19 vaccine in IA patients, which, in the case of cellular response, did not allow the vaccination effect to be maintained for more than 6 months. Repetitive vaccination with subsequent booster doses seems to be necessary for IA patients.
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Affiliation(s)
- Jakub Wroński
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
- Correspondence:
| | - Bożena Jaszczyk
- Department of Outpatient Clinics, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Leszek Roszkowski
- Department of Outpatient Clinics, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Anna Felis-Giemza
- Biologic Therapy Center, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Krzysztof Bonek
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Anna Kornatka
- Department of Pathophysiology and Immunology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Magdalena Plebańczyk
- Department of Pathophysiology and Immunology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Tomasz Burakowski
- Department of Pathophysiology and Immunology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Barbara Lisowska
- Department of Anesthesiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Brygida Kwiatkowska
- Department of Early Arthritis, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Włodzimierz Maśliński
- Department of Pathophysiology and Immunology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Małgorzata Wisłowska
- Department of Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Magdalena Massalska
- Department of Pathophysiology and Immunology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Ewa Kuca-Warnawin
- Department of Pathophysiology and Immunology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
| | - Marzena Ciechomska
- Department of Pathophysiology and Immunology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland
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Martinelli S, Pascucci D, Laurenti P. Humoral response after a fourth dose of SARS-CoV-2 vaccine in immunocompromised patients. Results of a systematic review. Front Public Health 2023; 11:1108546. [PMID: 37033069 PMCID: PMC10076800 DOI: 10.3389/fpubh.2023.1108546] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 03/06/2023] [Indexed: 04/11/2023] Open
Abstract
Background and objective The fourth dose the COVID-19 vaccine was first proposed to immunocompromised patients. The aim of the article is to systematically review the literature and report the humoral response and outcomes after the fourth dose administration in people with impaired immune system. Methods Published studies on the humoral response, efficacy and safety of the fourth dose of the COVID-19 vaccine were analyzed in various settings of immunocompromised patients. We conducted systematic searches of PubMed, Cochrane Library and WHO COVID-19 Research Database for series published through January 31, 2023, using the search terms "fourth dose" or "second booster" or "4th dose" and "Coronavirus" or "COVID-19" or "SARS-CoV-2." All articles were selected according to the PRISMA guidelines. Results A total of 24 articles including 2,838 patients were comprised in the systematic review. All the studies involved immunocompromised patients, including solid organ transplant recipients, patients with autoimmune rheumatic disease, patients with human immunodeficiency virus (HIV) and patients with blood cancers or diseases. Almost all patients received BNT162b2 or mRNA-1273 as fourth dose. All the studies demonstrated the increase of antibody titers after the fourth dose, both in patients who had a serological strong response and in those who had a weak response after the third dose. No serious adverse events after the 4th dose have been reported by 13 studies. COVID-19 infection after the fourth dose ranged from 0 to 21%. Conclusion The present review highlights the importance of the fourth dose of covid-19 vaccines for immunocompromised patients. Across the included studies, a fourth dose was associated with improved seroconversion and antibody titer levels. In particular, a fourth dose was associated with increasing immunogenicity in organ transplant recipients and patients with hematological cancers, with a very low rate of serious side effects.
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Affiliation(s)
- Silvia Martinelli
- Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
- *Correspondence: Silvia Martinelli
| | - Domenico Pascucci
- Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Patrizia Laurenti
- Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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