The Brighton collaboration standardized module for vaccine benefit-risk assessment

Expanded Spectrum and Increased Incidence of Adverse Events Linked to COVID-19 Genetic Vaccines: New Concepts on Prophylactic Immuno-Gene Therapy, Iatrogenic Orphan Disease, and Platform-Inherent Challenges

The mRNA- and DNA-based "genetic" COVID-19 vaccines can induce a broad range of adverse events (AEs), with statistics showing significant variation depending on the timing and data analysis methods used. Focusing only on lipid nanoparticle-enclosed mRNA (mRNA-LNP) vaccines, this review traces the evolution of statistical conclusions on the prevalence of AEs and incidents associated with these vaccines, from initial underestimation of atypical, severe toxicities to recent claims suggesting the possible contribution of COVID-19 vaccinations to the excess deaths observed in many countries over the past few years. Among hundreds of different AEs listed in Pfizer's pharmacovigilance survey, the present analysis categorizes the main symptoms according to organ systems, with nearly all of them being affected. Using data from the US Vaccine Adverse Event Reporting System and a global vaccination dataset, a comparison of the prevalence and incidence rates of AEs induced by genetic versus flu vaccines revealed an average 26-fold increase in AEs with the use of genetic vaccines. The difference is especially pronounced in the case of severe 'Brighton-listed' AEs, which are also observed in COVID-19 and post-COVID conditions. Among these, the increases in incidence rates relative to flu vaccines, given as x-fold rises, were 1152x, 455x, 226x, 218x, 162x, 152x, and 131x for myocarditis, thrombosis, death, myocardial infarction, tachycardia, dyspnea, and hypertension, respectively. The review delineates the concept that genetic vaccines can be regarded as prophylactic immuno-gene therapies and that the observed chronic disabling AEs might be categorized as iatrogenic orphan diseases. It also examines the unique vaccine characteristics that could be causally related to abnormal immune responses which potentially lead to adverse events and complications. These new insights may contribute to improving the safety of this platform technology and assessing the risk/benefit balance of various products.

Quantitative Benefit-Risk Assessment of Vaccination Against COVID-19: A Systematic Review

PURPOSE

With the introduction of COVID-19 vaccines, there has been a proliferation of quantitative benefit-risk assessments (qBRAs). Prior work on other types of vaccines has found that published qBRAs have not always clearly reported methods and/or results needed to assist in the application of the qBRA findings. The aim was to systematically identify, review, and critically assess published COVID-19 vaccine qBRA. The ultimate goal is to support the future development of robust qBRA for existing, new, and updated vaccines.

METHODS

We systematically reviewed COVID-19 vaccine qBRAs identified from multiple sources through April 17, 2023, including literature databases, selected Health Authority websites, and a grey literature search. We critically assessed whether key features typical of qBRA were presented in these reports.

RESULTS

We identified 37 COVID-19 vaccine qBRAs from screening 2220 publications and 18 other sources. The qBRAs were conducted on two mRNA and two adenoviral vector COVID-19 vaccines. Only one qBRA represented low- and middle-income countries. Although many qBRAs used simple calculations (n = 25), more complex models were presented in 15 reports. Simple approaches were able to employ stratification by age and/or sex to highlight safety issues affecting specific demographic groups and scenarios to account for changes in viral transmission and vaccine effectiveness over time. Details regarding data sources and analytic methods were missing or limited in some reports.

CONCLUSIONS

This comprehensive description and critical assessment of COVID-19 vaccine qBRAs together with available guidance can be used to support the development of robust and transparent future vaccine qBRAs.

Direct quantitative comparison of benefits and risks of COVID-19 vaccines used in National Immunization Technical Advisory Groups Guidance during the first two years of the pandemic

INTRODUCTION

The balance of benefits and harms of vaccines are assessed by regulatory agencies and National Immunization Technical Advisory Groups (NITAGs) to inform vaccine authorization or guidance. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach has been adopted by many NITAGs to develop recommendations. During the COVID-19 pandemic, several NITAGs additionally used direct quantitative comparisons (DQCs) between benefits and risk of vaccination with or without a GRADE framework to support timely decision-making relating to emerging safety signals. This study aimed to document the role of DQCs as novel tools in NITAGs' work by identifying situations where DQCs have been clearly leveraged in NITAG guidance, as well as identifying their strengths and limitations.

METHODS

The MEDLINE database and NITAGs' websites listed in the Global NITAG Network were searched for NITAG publications on COVID-19 vaccines. Publications were included if a DQC between benefits and risks of any COVID-19 vaccine was explicitly used for NITAG decision-making. Two reviewers independently assessed publication eligibility and extracted data. A narrative description of the role of DQCs in NITAG guidance, DQCs' methods and limitations was conducted.

RESULTS

Overall, 23 publications with 18 DQCs used by seven NITAGs were included. Situations prompting these publications included new safety signals (n = 7), additional information available on previously identified safety signals (n = 4) and changing contexts (n = 15) (e.g., vaccine supply, and epidemiology). DQC simplicity made them accessible, timely, and allowed for transparent communication. DQCs heavily relied on assumptions making them sensitive to changes in model parameters. DQCs limitations made them not easily transferable to other contexts and they quickly became obsolete in the evolving context of the COVID-19 pandemic.

CONCLUSIONS

The use of DQCs by NITAGs during the COVID-19 pandemic allowed for rapid evidence-based decision-making in an evolving environment while maintaining public trust. However, if their use becomes standard practice, efforts should be made to address their limitations.

Landscape review of active vaccine safety surveillance activities for COVID-19 vaccines globally

Background

Evidence of COVID-19 vaccine safety relied upon the global vaccine monitoring infrastructure due to shortened clinical development timelines and emergency use licensure. Differences in AVSS capacity between high-income countries (HICs) versus low- and middle-income countries (LMICs) were known prior to the pandemic.

Objective

To assess the global landscape of COVID-19 vaccine AVSS activities to identify gaps in safety evidence generation across vaccine products and populations with a focus on LMICs.

Methods

A cross-sectional survey was conducted in January 2022 on AVSS activities evaluating adverse events following immunization (AEFI). Data collected included country, targeted population, COVID-19 vaccine product(s), design of surveillance/monitoring activities or study, and AEFIs to be monitored.To supplement these findings, we conducted a literature review of COVID-19 vaccine safety activities published in PubMed through January 2023. Observational activities assessing AEFI, specifically adverse events of special interest (AESI), following routine use of COVID-19 vaccines in medical practice were included; systematic reviews, benefit/risk assessments, clinical trials, and case reports/series were excluded.

Results

The survey, completed by 34 respondents and compiled with reviews of 7 publicly available Risk Management Plans from five vaccine manufacturers, identified 79 monitoring activities in HICs, 24 in LMICs, and 9 in multiple regions. Most activities in LMICs were planned cohort event monitoring (CEM) studies (n = 18); two multi-national hospital-based sentinel surveillance studies for AESI were ongoing. Activities in LMICs evaluated multiple COVID-19 vaccine products simultaneously and were sponsored by health authorities. The literature review identified 1245 unique citations, of which 379 met inclusion criteria. The majority evaluated vaccines primarily used in high-income countries: Pfizer BioNTech (Comirnaty; n = 303), Moderna (mRNA-1273; n = 164), AstraZeneca (AZD1222; n = 126), and Janssen (Ad26.COV2.S); n = 62); 14 citations assessed vaccines used exclusively in LMICs: Sinovac (CoronaVac), Beijing CNBG (BBIBP-Corv), Bharat (Covaxin), SII (Covashield), and Gamaleya (Gam-Covid-Vac) vaccines.

Conclusions

Robust safety evidence for input into benefit/risk assessments is likely unavailable for most COVID-19 vaccines used primarily in LMICs due to emphasis on cohort event monitoring methods. Goals for equitable vaccine access should be coupled with investment and support for building infrastructure and capacity for safety evidence generation to inform policy and regulatory decisions at local levels.