Serum polyethylene glycol-specific IgE and IgG in patients with hypersensitivity to COVID-19 mRNA vaccines

mRNA-based vaccines and therapies - a revolutionary approach for conquering fast-spreading infections and other clinical applications: a review

Since the beginning of the COVID-19 pandemic, the development of messenger RNA (mRNA) vaccines has made significant progress in the pharmaceutical industry. The two COVID-19 mRNA vaccines from Moderna and Pfizer/BioNTech have been approved for marketing and have made significant contributions to preventing the spread of SARS-CoV-2. In addition, mRNA therapy has brought hope to some diseases that do not have specific treatment methods or are difficult to treat, such as the Zika virus and influenza virus infections, as well as the prevention and treatment of tumors. With the rapid development of in vitro transcription (IVT) technology, delivery systems, and adjuvants, mRNA therapy has also been applied to hereditary diseases such as Fabry's disease. This article reviews the recent development of mRNA vaccines for structural modification, treatment and prevention of different diseases; delivery carriers and adjuvants; and routes of administration to promote the clinical application of mRNA therapies.

Can Labs Help With Vaccination? In Vitro Tests in Diagnosis of Allergy to COVID-19 Vaccines-A Systematic Review

INTRODUCTION

Since the outbreak of the coronavirus pandemic in 2019, vaccinations have proven to be a key strategy in disease prophylaxis. Although vaccines are safe from the perspective of the general population, hypersensitivity reactions have still been described, causing individuals to be reluctant in their vaccination decision. Since the description of first reports of COVID-19 vaccine allergy, many protocols of allergy work-up have been developed, including In Vitro and In Vivo tests. Although In Vivo tests were more accessible, many patients preferred In Vitro tests that would not involve contact with the allergen and be safe. This applied in particular to patients that had experienced a severe delayed hypersensitivity reaction in which In Vivo tests were highly limited and provocations were deemed high risk. Taking into account these circumstances, In Vitro tests might significantly enhance allergy work-up.

METHODS

National Center for Biotechnology Information (Pubmed) database was searched in May 2024 for articles on In Vitro diagnostic methods for COVID-19 vaccine allergy and hypersensitivity.

RESULTS

This article describes the In Vitro tests developed to date in the diagnosis of COVID-19 vaccine hypersensitivity: (1) analysis of specific IgE and IgG, (2) Basophil Activation Test, (3) Histamine Release Test, (4) IgM-dependent complement activation, (5) Lymphocyte Transformation Test, (6) Flow cytometry T-Cell markers, (7) Th1/Th2 cytokines concentration in cell culture.

CONCLUSIONS

The article highlights the tests' advantages, flaws and possible clinical applications.

Polysorbate 80-containing ionizable lipid nanoparticles for mRNA delivery

Ionizable lipid nanoparticles have demonstrated remarkable success as mRNA vaccine carriers and represent one of the most promising gene drug delivery vehicles. However, polyethylene glycol (PEG), one of the major components, can cause immunogenic reactions, anaphylaxis and increased blood clearance, leading to toxic side effects and reduced efficacy. In this study, we utilize polysorbate 80 (PS80) as a PEG alternative in formulating eGFP mRNA-loaded ionizable lipid nanoparticles (PS80-iLNPs), aiming to enhance stealth properties, uptake efficiency, and biosafety. Our findings revealed that PS80-iLNPs enhanced the stealthiness and resistance to serum interference. Compared to PEG-containing ionizable lipid nanoparticles (PEG-iLNPs), PS80-iLNPs showed a 1.14-fold increase in stealthiness. Moreover, at a total lipid concentration of 50 μg mL-1, PS80-iLNPs exhibited 1.12 times higher cell viability compared to PEG-iLNPs. Notably, under serum interference, PEG-iLNPs showed a 44.97% uptake reduction, whereas PS80-iLNPs exhibited a modest 30.55% decrease, underscoring its superior serum resistance. This work demonstrated that PS80 could serve as a suitable substitute for PEG, thus signifying an excellent basis for the development of PEG-free ionizable lipid nanoparticles.

A randomized double-blinded trial to assess recurrence of systemic allergic reactions following COVID-19 mRNA vaccination

BACKGROUND

Systemic allergic reactions (sARs) following coronavirus disease 2019 (COVID-19) mRNA vaccines were initially reported at a higher rate than after traditional vaccines.

OBJECTIVE

We aimed to evaluate the safety of revaccination in these individuals and to interrogate mechanisms underlying these reactions.

METHODS

In this randomized, double-blinded, phase 2 trial, participants aged 16 to 69 years who previously reported a convincing sAR to their first dose of COVID-19 mRNA vaccine were randomly assigned to receive a second dose of BNT162b2 (Comirnaty) vaccine and placebo on consecutive days in a blinded, 1:1 crossover fashion at the National Institutes of Health. An open-label BNT162b2 booster was offered 5 months later if the second dose did not result in severe sAR. None of the participants received the mRNA-1273 (Spikevax) vaccine during the study. The primary end point was recurrence of sAR following second dose and booster vaccination; exploratory end points included biomarker measurements.

RESULTS

Of 111 screened participants, 18 were randomly assigned to receive study interventions. Eight received BNT162b2 second dose followed by placebo; 8 received placebo followed by BNT162b2 second dose; 2 withdrew before receiving any study intervention. All 16 participants received the booster dose. Following second dose and booster vaccination, sARs recurred in 2 participants (12.5%; 95% CI, 1.6 to 38.3). No sAR occurred after placebo. An anaphylaxis mimic, immunization stress-related response (ISRR), occurred more commonly than sARs following both vaccine and placebo and was associated with higher predose anxiety scores, paresthesias, and distinct vital sign and biomarker changes.

CONCLUSIONS

Our findings support revaccination of individuals who report sARs to COVID-19 mRNA vaccines. Distinct clinical and laboratory features may distinguish sARs from ISRRs.

Incidence and Outcomes of COVID-19 Vaccine Hypersensitivity Reactions and Success of COVID-19 Vaccine Provocation Tests Post Previous COVID-19 Vaccine Hypersensitivity

Background: The COVID-19 pandemic has led to high mortality rates. There have been reports of hypersensitivity reactions with mild to severe symptoms. The COVID-19 vaccine provocation test is a vaccination protocol for individuals with a history of hypersensitivity. This study aims to determine the benefits of COVID-19 vaccine provocation tests in patients with a history of hypersensitivity reactions to COVID-19 vaccines and its influencing factors. Objective: To determine the incidence, severity, outcome of hypersensitivity reactions, and success of the COVID-19 vaccine provocation test. Methods: A retrospective cohort study was conducted, using subjects taken from medical record data at the RSCM who had received COVID-19 vaccination with a history of hypersensitivity. Data was taken from the COVID-19 vaccination records at the RSCM, BPJS Health Primary Care application. Results: From a total of 29,036 doses of the COVID-19 vaccine, 44 patients experienced hypersensitivity reactions. As many as 38.64% did not continue vaccination, 2.27% experienced mild hypersensitivity, and 59.44% were successfully vaccinated. Conclusions: People with a history of hypersensitivity reactions to COVID-19 vaccines can still receive subsequent COVID-19 vaccinations at healthcare facilities equipped with anaphylaxis kits and immunology allergists.

2023 White Paper on Recent Issues in Bioanalysis: ISR for ADA Assays, the Rise of dPCR vs qPCR, International Reference Standards for Vaccine Assays, Anti-AAV TAb Post-Dose Assessment, NanoString Validation, ELISpot as Gold Standard (Part 3 - Recommendations on Gene Therapy, Cell Therapy, Vaccines Immunogenicity & Technologies; Biotherapeutics Immunogenicity & Risk Assessment; ADA/NAb Assay/Reporting Harmonization)

The 17th Workshop on Recent Issues in Bioanalysis (17th WRIB) took place in Orlando, FL, USA on June 19-23, 2023. Over 1000 professionals representing pharma/biotech companies, CROs, and multiple regulatory agencies convened to actively discuss the most current topics of interest in bioanalysis. The 17th WRIB included 3 Main Workshops and 7 Specialized Workshops that together spanned 1 week to allow an exhaustive and thorough coverage of all major issues in bioanalysis of biomarkers, immunogenicity, gene therapy, cell therapy and vaccines. Moreover, in-depth workshops on "EU IVDR 2017/746 Implementation and impact for the Global Biomarker Community: How to Comply with these NEW Regulations" and on "US FDA/OSIS Remote Regulatory Assessments (RRAs)" were the special features of the 17th edition. As in previous years, WRIB continued to gather a wide diversity of international, industry opinion leaders and regulatory authority experts working on both small and large molecules as well as gene, cell therapies and vaccines to facilitate sharing and discussions focused on improving quality, increasing regulatory compliance, and achieving scientific excellence on bioanalytical issues. This 2023 White Paper encompasses recommendations emerging from the extensive discussions held during the workshop and is aimed to provide the bioanalytical community with key information and practical solutions on topics and issues addressed, in an effort to enable advances in scientific excellence, improved quality and better regulatory compliance. Due to its length, the 2023 edition of this comprehensive White Paper has been divided into three parts for editorial reasons. This publication (Part 3) covers the recommendations on Gene Therapy, Cell therapy, Vaccines and Biotherapeutics Immunogenicity. Part 1A (Mass Spectrometry Assays and Regulated Bioanalysis/BMV), P1B (Regulatory Inputs) and Part 2 (Biomarkers, IVD/CDx, LBA and Cell-Based Assays) are published in volume 16 of Bioanalysis, issues 8 and 9 (2024), respectively.

Interactions between nanoparticle corona proteins and the immune system

The corona surrounding nanoparticles (NPs) in serum contains proteins such as complement, immunoglobulins, and apolipoproteins that can interact with the immune system. This review article describes the impact of these interactions on nanomedicine stability, biodistribution, efficacy, and safety. Notably, it highlights the latest findings on the generation of antibody responses to the polyethylene glycol (PEG) component of SARS-CoV-2 mRNA vaccines and possible mechanisms of hypersensitivity reactions induced by antibodies that bind to NPs. Finally, we briefly outline how the NP interactions with immune cells can be harnessed to enhance targeted delivery of nanocargos to disease sites.

The interplay between PEGylated nanoparticles and blood immune system

During the last two decades, an increasing number of reports have pointed out that the immunogenicity of polyethylene glycol (PEG) may trigger accelerated blood clearance (ABC) and hypersensitivity reaction (HSR) to PEGylated nanoparticles, which could make PEG modification counterproductive. These phenomena would be detrimental to the efficacy of the load and even life-threatening to patients. Consequently, further elucidation of the interplay between PEGylated nanoparticles and the blood immune system will be beneficial to developing and applying related formulations. Many groups have worked to unveil the relevance of structural factors, dosing schedule, and other factors to the ABC phenomenon and hypersensitivity reaction. Interestingly, the results of some reports seem to be difficult to interpret or contradict with other reports. In this review, we summarize the physiological mechanisms of PEG-specific immune response. Moreover, we speculate on the potential relationship between the induction phase and the effectuation phase to explain the divergent results in published reports. In addition, the role of nanoparticle-associated factors is discussed based on the classification of the action phase. This review may help researchers to develop PEGylated nanoparticles to avoid unfavorable immune responses based on the underlying mechanism.

Patients with polyethylene glycol allergy can experience immediate-type hypersensitivity reactions after exposure to analog substances

Polyethylene glycol (PEG) allergy has been recently observed after COVID-19 mRNA vaccination. We present a case of a patient with a history of two hospitalisations for unexplained recurrence of immediate-type hypersensitivity reactions and anaphylaxis who was diagnosed with PEG allergy in early childhood. Subsequently, he was instructed to avoid using PEG-containing daily necessities and drugs. However, in middle childhood, he presented with immediate-type hypersensitivity reactions after taking PEG-free antibiotics. The prick test was positive for the whole drug but negative for its active ingredient. PEG can cross-react with compounds with a C-C-O skeleton as analogue substances; accordingly, the presence of a substance with a similar skeleton in the additive may have been the causative factor. Our findings indicate that patients with PEG allergy may experience immediate-type hypersensitivity reactions to analogue substances.

Hypersensitivity reactions to anti-SARS-CoV-2 vaccines: Basophil reactivity to excipients

Basophil activation test (BAT) can tackle multiple mechanisms underlying acute and delayed hypersensitivity to drugs and vaccines and might complement conventional allergy diagnostics but its role in anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine-related hypersensitivity is ill-defined. Therefore, 89 patients with possible hypersensitivity (56 % with delayed mucocutaneous manifestations) to anti-SARS-CoV-2 vaccines were tested with BAT for Macrogol 3350, DMG-PEG 2000, PEG 20000, polysorbate-80 and trometamol and compared to 156 subjects undergoing pre-vaccine BAT. A positive BAT was associated with delayed reaction onset (p = 0.010) and resolution (p = 0.011). BAT was more frequently positive to DMG-PEG 2000 than to other excipients in both groups (p < 0.001). DMG-PEG 2000 reactivity was less frequent in vaccine-naïve (6 %) than vaccinated subjects (35 %, p < 0.001) and associated with mRNA-1273 vaccination. DMG-PEG 2000 BAT might therefore have a diagnostic role in subjects with delayed hypersensitivity reactions. Natural immunity might be a key player in basophil activation.

Evaluation of association of anti-PEG antibodies with anaphylaxis after mRNA COVID-19 vaccination

BACKGROUND

The mechanism for anaphylaxis following mRNA COVID-19 vaccination has been widely debated; understanding this serious adverse event is important for future vaccines of similar design. A mechanism proposed is type I hypersensitivity (i.e., IgE-mediated mast cell degranulation) to polyethylene glycol (PEG). Using an assay that, uniquely, had been previously assessed in patients with anaphylaxis to PEG, our objective was to compare anti-PEG IgE in serum from mRNA COVID-19 vaccine anaphylaxis case-patients and persons vaccinated without allergic reactions. Secondarily, we compared anti-PEG IgG and IgM to assess alternative mechanisms.

METHODS

Selected anaphylaxis case-patients reported to U.S. Vaccine Adverse Event Reporting System December 14, 2020-March 25, 2021 were invited to provide a serum sample. mRNA COVID-19 vaccine study participants with residual serum and no allergic reaction post-vaccination ("controls") were frequency matched to cases 3:1 on vaccine and dose number, sex and 10-year age category. Anti-PEG IgE was measured using a dual cytometric bead assay (DCBA). Anti-PEG IgG and IgM were measured using two different assays: DCBA and a PEGylated-polystyrene bead assay. Laboratorians were blinded to case/control status.

RESULTS

All 20 case-patients were women; 17 had anaphylaxis after dose 1, 3 after dose 2. Thirteen (65 %) were hospitalized and 7 (35 %) were intubated. Time from vaccination to serum collection was longer for case-patients vs controls (post-dose 1: median 105 vs 21 days). Among Moderna recipients, anti-PEG IgE was detected in 1 of 10 (10 %) case-patients vs 8 of 30 (27 %) controls (p = 0.40); among Pfizer-BioNTech recipients, it was detected in 0 of 10 case-patients (0 %) vs 1 of 30 (3 %) controls (p >n 0.99). Anti-PEG IgE quantitative signals followed this same pattern. Neither anti-PEG IgG nor IgM was associated with case status with both assay formats.

CONCLUSION

Our results support that anti-PEG IgE is not a predominant mechanism for anaphylaxis post-mRNA COVID-19 vaccination.

Polyethylene Glycol and Polysorbate 80 Skin Tests in the Context of an Allergic Risk Assessment for Hypersensitivity Reactions to Anti-SARS-CoV-2 mRNA Vaccines

Concern has arisen about hypersensitivity reactions in patients with allergic reactions to drugs containing polyethylene glycol (PEG) or polysorbate 80 (PS80), excipients of currently available anti-SARS-CoV-2 mRNA vaccines. However, the actual utility of PEG and PS80 skin allergy testing is currently still debated. We retrospectively analyzed all cases of patients on whom we performed allergometric skin tests for PEG and PS80 in the context of a pre-vaccination screening (for patients with multiple hypersensitivity reactions to drugs for which these excipients were among the suspected agents) or following suspected hypersensitivity reactions to anti-SARS-CoV-2 vaccines. A total of 134 tests were performed for PEG and PS80, eight of which produced uninterpretable results (due to dermographism or non-specific reactions). Of the remaining 126 cases (85 pre-vaccinal and 41 post-vaccine reactions), 16 (12.7%) were positive for PEG and/or PS80. Stratifying by clinical indication, there were no statistically significant differences in the proportion of positive tests between patients evaluated in the context of the pre-vaccination screening and those evaluated after a vaccine reaction (10.6% vs. 17.1%, respectively, p = 0.306). Allergometric skin tests for PEG and PS80 in our case series resulted positive in an unexpectedly high proportion of patients, suggesting that testing for allergy to these two excipients should not be ignored in case of reasonable clinical suspicion.