key: cord-0738590-xsrxhm6p
authors: Manisty, Charlotte; Otter, Ashley D; Treibel, Thomas A; McKnight, Áine; Altmann, Daniel M; Brooks, Timothy; Noursadeghi, Mahdad; Boyton, Rosemary J; Semper, Amanda; Moon, James C
title: Antibody response to first BNT162b2 dose in previously SARS-CoV-2-infected individuals
date: 2021-02-25
journal: Lancet
DOI: 10.1016/s0140-6736(21)00501-8
sha: 2d08b4b5098fb5aa4d429cfb8a0ed74a65b582b6
doc_id: 738590
cord_uid: xsrxhm6p

nan

Rapid vaccine-induced population immunity is a key global strategy to control COVID-19. Vaccination programmes must maximise early impact, particularly with accelerated spread of new variants. 1 Most vaccine platforms use a two-dose prime-boost approach to generate an immune response against the virus S1 spike protein, the titres of which correlate with functional virus neutralisation and increase with boosting. 2, 3 To enable larger numbers of people to receive the first dose, delayed administration of the second dose has been advocated and implemented by some. 1 The impact of previous SARS-CoV-2 infection on the need for boosting is not known.

We reasoned that previous infection could be analogous to immune priming. As such, a first prime vaccine dose would effectively act as boost, so a second dose might not be needed. To test this, we undertook a nested case-control analysis of 51 participants of COVIDsortium, 4,5 an ongoing longitudinal observational study of health-care workers (HCWs) in London who underwent weekly PCR and quantitative serology testing from the day of the first UK lockdown on March 23, 2020, and for 16 weeks onwards. 24 of 51 HCWs had a previous laboratory-confirmed mild or asympto matic SARS-CoV-2 infection, as confirmed by positive detection of antibodies against the SARS-CoV-2 nucleocapsid (Elecsys Anti-SARS-CoV-2 N ECLIA, Roche Diagnostics, Burgess Hill, UK) or the receptor binding domain of the SARS-CoV-2 S1 subunit of the spike protein (anti-S; Elecsys anti-SARS-CoV-2 spike ECLIA, Roche Diagnostics), whereas 27 HCWs remained seronegative. A median of 12·5 sampling timepoints per participant permitted the identification of peak antibody titres in seropositive individuals while avoiding false negatives.

All participants received their first dose of the BNT162b2 mRNA COVID-19 vaccine (Pfizer-BioNTech, Mainz, Germany) 2,3 and were tested 19-29 days later (median 22 days, IQR 2). Among previously uninfected, seronegative individuals, anti-S titres after one vaccine dose were comparable to peak anti-S titres in individuals with a previous natural infection who had not yet been vaccinated. Among those with a previous SARS-CoV-2 infection, vaccination increased anti-S titres more than 140-fold from peak prevaccine levels ( figure) . This increase appears to be at least one order of magnitude greater than reported after a conventional prime-boost vaccine strategy in previously uninfected individuals. 3 These serological data suggest that for individuals receiving the BNT162b2 mRNA vaccine, a potential approach is to include serology testing at or before the time of first vaccination to prioritise use of booster doses for individuals with no previous infection. This could potentially accelerate vaccine rollout. With increasing variants (UK, South Africa, Brazil), wider coverage without compromising vaccine-induced immunity could help reduce variant emergence. Furthermore, reactogenicity after unnecessary boost risks an avoidable and unwelcome increase in vaccine hesitancy.

Whether enhanced vaccine-induced antibody responses among previously seropositive individuals will show differential longevity compared to boosted vaccines remains to be seen. In the meantime, our findings provide a rationale for serology-based vaccine dosing to maximise coverage and impact. CM 

We thank Keerti Gedela as well as Pascale Allotey and Daniel Reidpath for their responses to our Perspective on decolonising global health. 1 We welcome and completely agree with the points they highlighted for additional emphasis: greater production of health or with the political arguments based on myriad values that fall outside of the traditional medical and health sciences. It is impossible to decolonise global health if crucial geopolitical analyses, and the impact on relationships between high-income countries (HICs) and low-income and middle-income countries (LMICs), remain chronically marginalised. Additionally, decolonising global health extends beyond relations between LMICs and HICs; it is also about the relationships within them. Decolonisation is fundamentally about redressing inequity and power imbalance. It cannot be achieved without also addressing gender inequity, racism, and other forms of structural violence. The colonised also have to be at least as reflective about the status quo as the colonisers. This mindset goes beyond engagement and participation between HICs and LMICs, to disrupting the norms of dependency within LMICs that enable the inequities and replicate the hierarchies of neocolonialism. In real terms, LMICs must confront their own internal power relations inherent in the discourse of immutable culture, which protect cronyism, tribalism, poor governance, and patriarchy.

Ultimately, a decolonised global health can only exist within a broader geopolitical and economic environment that supports rights, equity, and justice.

We declare no competing interests. in directing global health endeavours do not have the opportunities or training to prove why or how they are valuable in meaningful ways to academia. Under some circumstances, they can be actively oppressed.

There is a refusal to learn from local populations, especially those from the margins of society, and ethnic superiority exists within societal, political, and academic structures in both HICs and LMICs, which is rising amid right-wing conservatism in some settings. How do we effectively empower valuable leaders to push forward necessary global health measures when they are restricted from the outset?

Colonisation has left a pervasive mark. Its legacy in LMICs still needs to be unpicked. Creating truly equitable global health must involve diverse groups of people who view challenges through differing lenses from their backgrounds, lived experiences, and skills, and who have wider, inclusive visions that do not focus on individual career success and are not at the mercy of prescribed academic agendas in HICs.

I declare no competing interests.

Chelsea and Westminster NHS Foundation Trust, London SW10 9NH, UK Undoing supremacy in global health will require more than decolonisation I read with interest Seye Abimbola and Madhukar Pai's Perspective. 1 It provides an enlightening and hopeful vision of decolonised global health detangled from supremacy in its many forms. However, it left me feeling that the vast mark that colonisation has left on society, politics, and system hierarchy within low-income and middle-income countries (LMICs) has been less considered. Without paying due consideration to the challenges of supremacy and oppression within LMICs, we cannot realistically equalise global health and progress to ensure that it upholds health equity and social justice.

Globally, we observe how rich academics in high-income countries (HICs), particularly from the UK and USA, tend to get richer. For example, the ways in which global health funding and publication are dominated by prominent academics and high-income prestigious institutions mean that worthy work can be dismissed when teams are less valued. Importantly, many individuals from LMICs who are valuable Seye Abimbola and Madhukar Pai 1 describe eloquently how, for historical reasons, global health is operationalised as a saviourism model. To redress the balance of power between saviour and saved, they envision a utopic global health fuelled by respect and humility, and motivated by an adherence to values based on rights, equity, and justice.

Unfortunately, the disciplines that dominate global health attend to the causes of and solutions to disease endpoints on the health and wellbeing spectrum. Such disciplines have not engaged adequately with a crucial understanding of the sociostructural

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