Improvement of humoral immunity by repeated dose-intensified COVID-19 vaccinations in primary non- to low-responders and B cell deficient rheumatic disease patients

Analysis of humoral and cellular responses after vaccination against SARS-CoV-2 in patients with immune-mediated diseases

BACKGROUND

Patients with autoimmune disease (AID) or immunodepression (ID), particularly those treated with anti-CD20, have an increased risk of COVID-19 infection.

OBJECTIVE

To characterise the humoral and cellular immune responses against specific antigens of SARS-CoV-2 in immunocompromised patients, as well as their correlation and determinants.

METHODS

This retrospective study was conducted in outpatients with AID and/or ID for which an assessment of their humoral and cellular response was carried out and analysed in relation to demographic data, comorbidities, treatments, type of vaccine and number of doses.

RESULTS

Fifty patients were included. The overall serological response rate was 76%. The cellular response was positive in 54% of patients. The main factors influencing the humoral and cellular responses were age, comorbidities and treatment with anti-CD20.

CONCLUSION

In ID patients, vaccination against COVID-19 can generate an adequate T-cell response, the character of which is an emerging issue in the context of COVID-19 infection. The main limitations of this study and those in the literature are the heterogeneity of the patients included and the absence of a control population. These results highlight the importance of evaluating the antiviral T-cell response and the impact of immunosuppressive treatments.

Safety, efficacy, and immunogenicity of SARS-CoV-2 mRNA vaccination in children and adult patients with rheumatic diseases: a comprehensive literature review

Patients with autoimmune inflammatory rheumatic diseases (AIIRD) are potentially at a higher risk of contracting the SARS-CoV-2 virus and have poorer outcomes of the infection as a result of their immunocompromised state due to the nature of the underlying autoimmune conditions and immunosuppressant use. mRNA-based vaccines provide a novel approach to establishing immunity against SARS-CoV-2. However, the implications of toll-like receptors (TLRs), type I interferon (IFN) and pro-inflammatory cytokines raise concerns on disease severity and inefficient immune response following mRNA vaccination. The use of immunosuppression to reduce disease activity may have consequential implications on immune responses following SARS-CoV-2 mRNA vaccination. This study systematically reviews the literature on the safety, efficacy, and immunogenicity of SARS-CoV-2 vaccination in patients with autoimmune rheumatic conditions. This comprehensive review was conducted in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A comprehensive literature search on "PubMed" and "EMBASE" electronic databases was conducted to identify relevant articles published from January 1, 2020 to August 31, 2023. The search yielded 106 studies. The mRNA-based vaccines were demonstrated to be safe and efficacious in AIIRD patients. Most studies investigating safety and efficacy of the mRNA-based vaccines reported low frequencies of serious adverse events and disease flares and few breakthrough infections after complete vaccination. Immunogenic response, however, appeared to be blunted in this population of patients, particularly in those who received certain immunosuppressive agents such as methotrexate, mycophenolic acid and rituximab. mRNA-based vaccines are generally safe and efficacious and produce adequate humoral response in AIIRD patients. Additional prospective studies are warranted to ascertain the long-term safety and efficacy profile and the duration of mRNA-vaccine induced immune response. This can aid in shaping guidelines surrounding optimal timing for booster doses in AIIRD patients.

Serologic Response to Vaccine for COVID-19 in Patients with Hematologic Malignancy: A Prospective Cohort Study

BACKGROUND

Patients with hematological cancers have increased COVID-19 morbidity and mortality, and these patients show attenuated vaccine responses. This study aimed to characterize the longitudinal humoral immune responses to COVID-19 vaccination in patients with hematological malignancies.

PATIENTS AND METHODS

We conducted a prospective cohort study, collecting samples from March 2021 to July 2022, from patients seen at a cancer treatment center in London, Ontario, Canada, who met the following eligibility criteria: age ≥18 years, diagnosed with a hematological malignancy, recipient of a COVID-19 vaccine during the study period, and able to provide informed consent.

RESULTS

Median anti-S titers (MST) were 0.0, 64.0, and 680.5 U/mL following first (V1), second (V2), and third (V3) vaccine doses, respectively. Patients with lymphoid malignancies' response to vaccination was attenuated compared to myeloid malignancy patients after V2 and V3 (P < .001, P < .01). Active treatment was associated with lower antibody titers (MST 10) compared to treatment 12-24 months (MST 465, P = .04367) and >24 months (MST 1660.5, P = .0025) prior to vaccination. V3 significantly increased antibody titers compared to V2 for patients less than 3 months from treatment. Increasing age was associated with smaller antibody response following V2 (P < .05), but not following V3. Patients receiving anti-CD20 therapy did not demonstrate increased antibody titer levels after V3 (V2 MST 0, V3 MST 0; P > .05).

CONCLUSION

We report an attenuated serologic response to COVID-19 vaccination in our study population of patients with hematological malignancy. The immune response to vaccination was affected by patient age, diagnosis, treatment, and timing of treatment exposure.

Effect of DMARDs on the immunogenicity of vaccines

Vaccines are important for protecting individuals at increased risk of severe infections, including patients undergoing DMARD therapy. However, DMARD therapy can also compromise the immune system, leading to impaired responses to vaccination. This Review focuses on the impact of DMARDs on influenza and SARS-CoV-2 vaccinations, as such vaccines have been investigated most thoroughly. Various data suggest that B cell depletion therapy, mycophenolate mofetil, cyclophosphamide, azathioprine and abatacept substantially reduce the immunogenicity of these vaccines. However, the effects of glucocorticoids, methotrexate, TNF inhibitors and JAK inhibitors on vaccine responses remain unclear and could depend on the dosage and type of vaccination. Vaccination is aimed at initiating robust humoral and cellular vaccine responses, which requires efficient interactions between antigen-presenting cells, T cells and B cells. DMARDs impair these cells in different ways and to different degrees, such as the prevention of antigen-presenting cell maturation, alteration of T cell differentiation and selective inhibition of B cell subsets, thus inhibiting processes that are necessary for an effective vaccine response. Innovative modified vaccination strategies are needed to improve vaccination responses in patients undergoing DMARD therapy and to protect these patients from the severe outcomes of infectious diseases.