key: cord-0770427-ayd59zpj
authors: Stefanski, Ana L.; Rincon‐Arevalo, Hector; Schrezenmeier, Eva; Karberg, Kirsten; Szelinski, Franziska; Ritter, Jacob; Jahrsdörfer, Bernd; Schrezenmeier, Hubert; Ludwig, Carolin; Sattler, Arne; Kotsch, Katja; Chen, Yidan; Claußnitzer, Anne; Haibel, Hildrun; Proft, Fabian; Guerra, Gabriela; Durek, Pawel; Heinrich, Frederik; Ferreira‐Gomes, Marta; Burmester, Gerd R.; Radbruch, Andreas; Mashreghi, Mir F.; Lino, Andreia C.; Dörner, Thomas
title: B cell numbers predict humoral and cellular response upon SARS‐CoV‐2 vaccination among patients treated with rituximab
date: 2021-12-28
journal: Arthritis Rheumatol
DOI: 10.1002/art.42060
sha: 92d9d5114ba7d2e7fad0883d0360ffe58be787e8
doc_id: 770427
cord_uid: ayd59zpj

OBJECTIVES: Patients with autoimmune inflammatory rheumatic diseases receiving rituximab (RTX) therapy are at higher risk for poor COVID‐19 outcomes and show substantially impaired humoral anti‐SARS‐CoV‐2 vaccine responses. However, the complex relationship between antigen‐specific B and T cells and the level of B cell repopulation necessary to achieve anti‐vaccine responses remain largely unknown. METHODS: Antibody responses to SARS‐CoV‐2 vaccines and induction of antigen‐specific B and CD4/CD8 T cell subsets were studied in 19 rheumatoid arthritis (RA) and ANCA‐associated vasculitis (AAV) patients receiving RTX, 12 RA patients on other therapies and 30 healthy controls after SARS‐CoV‐2 vaccination with either mRNA or vector based vaccines. RESULTS: A minimum of 10 B cells/μL (0,4% of lymphocytes) in the peripheral circulation appeared to be required in RTX patients to mount seroconversion to anti‐S1 IgG upon SARS‐CoV‐2 vaccination. RTX patients lacking IgG seroconversion showed reduced RBD+ B cells, lower frequency of TfH‐like cells as well as less activated CD4 and CD8 T cells compared to IgG seroconverted RTX patients. Functionally relevant B cell depletion resulted in impaired IFNγ secretion by spike‐specific CD4 T cells. In contrast, antigen‐specific CD8 T cells were reduced in patients, independently of IgG formation. CONCLUSIONS: In patients receiving RTX, a minimum of 10 B cells/μl in the peripheral circulation candidates as biomarker for a high likelihood of an appropriate cellular and humoral response after SARS‐CoV‐2 vaccination. Mechanistically, the data emphasize the crucial role of co‐stimulatory B cell functions for the proper induction of CD4 responses propagating vaccine‐specific B and plasma cell differentiation.

Infectious diseases and associated complications comprise an important cause of morbidity and mortality in patients with autoimmune inflammatory rheumatic diseases (AIIRDs) (1). Increased susceptibility to infectious diseases in these patients is most likely due to an immunosuppressive effect of the disease itself and/or related to immunosuppressive treatment (2) . COVID-19, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) requires particular considerations in AIIRD patients by rheumatologists. Rituximab (RTX), an anti-CD20 monoclonal antibody leading to B cell depletion and used in AIIRDs like rheumatoid arthritis (RA) and ANCA-associated vasculitis (AAV), has been found as risk factor for poor COVID-19 associated outcomes. (3, 4) . Since a suitable treatment for COVID-19 has not been developed yet, vaccination is of crucial importance to protect these vulnerable patients. Meanwhile, various phase III clinical trials have demonstrated the efficacy and safety of mRNA-based vaccines (BNT162b2 (5, 6) , mRNA-1273 (7)) and viral vector-based vaccines (ChAdOx1 (8),

Ad26.COV2.S (9)) to prevent severe COVID-19 disease or death.

In AIIRD patients, vaccination is generally regarded safe and efficacious (10) . However, in particular under B cell depleting therapy with RTX, hampered humoral and cellular responses following influenza, pneumococcal and hepatitis B vaccination have been reported (11) (12) (13) (14) (15) (16) . Data available about SARS-CoV-2 vaccine response in rituximab treated AIIRD patients reveal substantially impaired humoral (17) (18) (19) but partly inducible cellular immune responses (20). However, little is known about the complex mechanisms between T, B and plasma cells, as well as the level of B cell repopulation necessary for proper vaccine response among RTX patients.

In this study, we investigated the characteristics of humoral and cellular antigen-specific CD4/CD8 and B cell immune response upon SARS-CoV-2 vaccines in patients treated with RTX compared with HC and RA patients on other therapies.

Outpatient rheumatic patients treated with rituximab, who received SARS-CoV-2 vaccination according to federal and Berlin state recommendations between February and May 2021, were asked to participate into this study. We included 16 RA patients (according 2010 ACR Rheumatoid Arthritis Classification Criteria (21) ) and 3 AAV patients (defined as (22) ) on RTX treatment as well as 12 RA patients on other therapies and 30 HC as control groups. All participants gave written informed consent according to the approval of the ethics committee at the Charité University Hospital Berlin (EA2/010/21, EA4/188/20). Peripheral blood samples (EDTA anti-coagulated or serumtubes, BD Vacutainersystem, BD Diagnostics, Franklin Lakes, NJ, USA) were collected at 6 ± 3 days after vaccination with either 2x SARS-CoV-2 BNT162b2, 2x ChAdOx1 nCoV-19 or 1x ChAdOx1 nCoV-19 followed by 1x SARS-CoV-2 BNT162b2. Serologic and B cell data of HC have partially been published (23 and d7 after 2nd vaccination (data not shown)."Donor information is summarized in Table   1 and more detailed in supplementary Table S1 .

The assays were performed according to the manufacturer´s instructions, as described (23) . Briefly, serum samples were diluted at 1:100 in sample buffer and pipetted onto strips of 8 single wells of a 96-well microtiter plate, precoated with recombinant SARS-CoV-2 spike or nucleocapsid proteins. Calibrators, a positive and a negative control were carried out on each plate. After incubation for 60 minutes at 37°C, wells were washed 3 times and the peroxidase-labelled anti-IgG or anti-IgA antibody solution was added, followed by a second incubation step for 30 min. After three additional washing steps, substrate solution was added and the samples incubated for 15 -30 minutes in the dark.

OD values were measured on a POLARstar Omega plate reader (BMG Labtech, Ortenberg, Germany) at 450 nm and at 620 nm. Finally, OD ratios were calculated based on the sample and calibrator OD values. To identify previously SARS-CoV-2 infected individuals we measured antibodies against the nucleocapsid protein (NCP, not a vaccine component) 6±3 days after 2 nd vaccination (Suppl. Fig. S1 ).

PBMCs were prepared by density gradient centrifugation using Ficoll-Paque PLUS (GE Healthcare Bio-Sciences, Chicago, IL, USA). For antigen-specific T cell analysis PBMCs were cryopreserved at -80°. For surface staining 1-3 x 10 6 

To identify RBD-specific B cells, recombinant purified RBD (DAGC149, Creative Diagnostics, New York, USA) was labeled with either AF647 or AF488 as reported (23) .

Double positive cells were considered as antigen-specific. A blocking experiment using unlabeled RBD in 100-fold concentration was used to ensure specificity of detection. 

Sequencing was performed on a NextSeq500 device (Illumina) using High Output v2 Kits (150 cycles) with the recommended sequencing conditions for 5' GEX libraries and as reported (23) . In particular, transcriptome profiles were merged, normalized, variable genes were detected and a Uniform Manifold Approximation and Projection (UMAP) was performed in default parameter settings using FindVariableGenes, RunPCA and RunUMAP with 30 principle components. Expression values are represented as ln (10,000 * UMIsGene) /UMIsTotal +1). Transcriptionally similar clusters were identified using shared nearest neighbor (SNN) modularity optimization, SNN resolutions ranging from 0.1 to 1.0 in 0.1 increments were computed, or gating was performed manually using the Loupe Browser (10x Genomics). Data from transcriptome and immune profiling were merged by the same cellular barcodes.

All samples included in the final analyses had at least 1 × 10 6 events with a minimum threshold for CD19+ cells of 5,000 events apart from RTX patients: minimal recorded 

This study recruited 19 patients receiving rituximab (16 RA and 3 AAV patients, RTX group), 30 healthy controls (HC group) and 12 RA patients on other therapies as additional control group (RA group). Most study participants were vaccinated twice with the mRNA vaccine BNT162b2, one RTX patient received 2x mRNA-1273. There were three HC, one RA and one RTX vaccinated twice with the viral vector vaccine ChAdOx1 (indicated in green throughout the figures). According to national recommendations (25), 3 RTX patients and 3 HC received 1x ChAdOx1 followed by a heterologous vaccination with 1x BNT162b2 (indicated in blue throughout the figures). Regarding demographics, HC were younger than RA patients, while age-matched to RTX patients. As known for patients with rheumatic diseases, the majority of RA and RTX patients were female.

Disease activity at the time of first vaccination was comparable between the RA control group and RA patients under RTX. At the time of vaccination, median time since the last RTX treatment was 9 months. RTX patients had received B cell depleting therapy on average for 3 years, presenting with a range of circulating B cell number between 0 -484/µl blood. Demographics and co-medication of all study participants are summarized in Table 1 (Further details of the patient cohorts are provided in supplementary table S1).

Antibody responses to SARS-CoV-2 vaccines were assessed in all individuals, 6±3 days after 2 nd vaccination. All HC became positive for anti-S1 IgG and IgA and showed more than 90% SARS-CoV-2 neutralisation. Noteworthy, IgA and IgG anti-vaccine titres were significantly diminished 6±3 days after 2 nd vaccination in the RA control group and especially in RTX patients compared to HC (Fig. 1A) . Anti-S1 IgG were detected in 8/12 (66.7%) of the RA group and 8/19 (42.1%) of the RTX group. Simultaneously, 5/12 (41.7%) and 9/19 (47.4%) of the RA and RTX group, respectively developed anti-S1 IgA antibodies. Virus neutralizing antibodies were found significantly diminished in 8/12 (66.7%) among RA control patients and 9/19 (47.4%) RTX group (Fig. 1A) .

Two RTX patients with unknown prior infection (identified as anti-nucleocapsid protein positive, Suppl. Fig. S1 , red quadrates), developed high titers of anti-S1 IgG, IgA and neutralizing antibodies comparable with HC.

As previously reported (26) , AIIRD patients may show a delayed humoral immune response after vaccination. To address this question, we collected additional samples from RA and RTX patients 3-4 weeks after 2 nd vaccination (Fig. 1B) . Two RA and five RTX patients developed positive IgG antibodies, IgA was found in two RA and one RTX patients 3-4 weeks after 2 nd vaccination. Neutralizing antibodies were detected in two RA and six RTX at this later time point. Among the RTX patients, who did not show seroconversion at day 7 after 2 nd vaccination, there was a significant increase in IgG and neutralizing antibody formation at the later time point (Fig. 1C) . Noteworthy, IgG titers correlated with neutralizing antibodies (Fig. 1D, r=0 .8957, p<0.0001). Thus, and considering the delayed vaccine response, 10/12 (83.3%) of RA patients and 13/19 (68.4%) of the RTX patients showed IgG seroconversion with neutralizing antibodies after SARS-CoV-2 vaccination, even though in lower titers compared with HC. Interestingly, the data suggested that patients under RTX exhibited a potential dichotomous response: 13/19 RTX patients seroconverted to IgG (RTX IgG+), while 6/19 did not (RTX IgG-). To identify potential factors resulting in IgG seroconversion among RTX patients, further study addressed potential differences between the two groups. With regard to comedication, we found a negative correlation between prednisolone dose and IgG formation as well as B cell counts, while there was no significant relation with the use of methotrexate (Suppl. Fig. S2A-C) . There was no association between DAS28 in RA and vaccine induced humoral response (Suppl. Fig. S2D) .

We analyzed the B cell compartment (gating strategy shown in Fig. 2A ) and RBD-specific B cells (Fig. 2B) among the different groups. RTX patients presented with significantly lower relative and absolute B cell numbers compared to HC and RA control group (Fig.   2C ). Notably, a significant difference in the frequency and absolute B cell number was also found between RTX IgG+ and non-seroconverted RTX patients (Fig 2D) . In our RTX cohort, 10 B cells/µl in peripheral circulation (or 0.4% of lymphocytes accordingly) were identified as the minimum to mount seroconversion to anti-S1 IgG among RTX treated patients (Fig 2D) .

In the RTX group, B cell numbers correlated with humoral anti-vaccine responses since the absolute number of B cells (Fig. 2E) and B cell frequency (Suppl. Fig. S3A ) correlated significantly with anti-S1 IgG titers (r=0,5975, p=0,0044 and r=0.6391, p=0.0021 respectively) and even more pronounced with neutralizing antibodies (r=0.7296, p=0.003 and r=0,7744, p>0.0001 respectively). This clearly suggests that humoral protection elicited by vaccination is dependent on the critical availability of B cells in RTX treated patients. In the RA and HC groups we did not find a significant correlation between B cell numbers and serologic response (data not shown), suggesting that the correlation between B cell numbers and IgG response is restricted to patients with B cell counts below the lower limits of normal.

Next, we studied SARS-CoV-2 specific B cell responses in RTX treated patients, using flow cytometry to quantify RBD-specific B cells in peripheral blood (23) (gating strategy shown in Fig 2B) . While no significant difference was seen between HC, RA and the RTX group (Fig. 2F) , RTX patients lacking seroconversion upon 2 nd vaccination (RTX IgG-) showed significantly reduced frequencies and absolute numbers of RBD+ specific B cells compared with RTX IgG+ patients (Fig. 2G ). The number (Fig. 2H ) and frequency (Suppl. for HC (23), RA control and RTX patients who were able to mount RBD+ B cells, were also able to generate IgG+ plasmablasts upon vaccination. We found no significant difference between the groups regarding RBD+ B cell subset distribution or immunoglobulin isotypes ( Fig. 2I and Suppl. Fig. S3B , C).

Simultaneously, we wondered how dynamics of CD4/8 T cell subsets interrelate with induction of vaccine-specific B cells and IgG. Contrary to B cells, there was no significant difference regarding the frequency, absolute numbers or memory formation in CD4 (Suppl. Fig. S4A , C) and CD8 T cells (Suppl. Fig. S4B, D) between HC, RA and RTX patients. Subsequent analysis addressed the differences between vaccine-responders and non-responders among RTX patients (representative gates shown in Fig. 3A) .

Interestingly, patients who lacked anti-vaccine IgG antibodies showed significantly lower frequencies of circulating TfH-like CD4 T cells, defined as CD4+CXCR5+PD1+, as well as of activated CD4/8 T cells co-expressing CD38+HLA-DR+ (Fig. 3B) . Activated CD4 T cells correlated significantly with absolute B cell numbers (Fig. 3C, r=0,5490, p=0,0122) .

B cell depletion that results in insufficient vaccination-induced humoral immunity.

The overall occurrence of spike-specific CD4 T cells (representative gates shown in 3D and Suppl. Fig. S5A ) compared with unstimulated controls was found similar in all groups: 86.7% (13/15) in HC, 83% (10/12) in RA and 73.7% (14/19) in RTX patients (Fig 3E) . This was also consistent with a comparable magnitude of the response between the groups ( Fig. 3F ) as well as similar memory subset distribution (Suppl. Fig. S5E) . A more detailed study of the RTX group showed that the majority of RTX IgG+ patients (10/13, 76.9%) versus 50% of RTX IgG-(3/6) patients showed an appropriate antigen-specific CD4 T cell increase upon stimulation. With regard to functional analyses of cytokine secretion by spike-specific CD4 T cells, non-seroconverted RTX patients showed a significantly reduced TNFα (Fig 3G) and IFNγ (Fig. 3H ) production compared to RTX IgG+ responders (representative gates shown in Suppl. Fig. S5B ).

Since most patients in the non-seroconverted RTX group had very low circulating B cell counts, we wondered if there is a relation between reduced B cells and impaired cytokine production by antigen-specific CD4+ T cells. Indeed, IFNγ but not TNFα production showed a significant correlation with absolute B cell numbers (r=0,5342, p=0,0112), suggesting the importance of B cell co-stimulatory functions for the proper and interactive induction of CD4 responses.

Compared with unstimulated controls, 93.3% of HC (14/15) but only 58.3% of RA control (7/12) and 57.9% of RTX patients (11/19) showed an increase of spike-specific CD8 T cells co-expressing CD137 and IFNγ (representative gates shown in Fig. 3J and Suppl. (Fig. 3K) . To assess the degranulation function of CD8 T cells, we analyzed the co-expression of CD107a and IFNγ. The responder rate for CD8 T cells co-expressing CD107a and IFNγ after stimulation was overall low with 60% in HC (9/15), 41.6% (5/12) in the RA control and 42.1% (8/19) in the RTX group (data not shown).

Regarding the amplitude of CD8 responses, spike-specific CD8 T cells, co-expressing CD137 and IFNγ (Fig. 3L ) and CD107a and IFNγ (Suppl. Fig. S5D) , as well as their memory subset distribution were comparable between all groups (Suppl. Fig. S5E ).

To identify further predictive factors for IgG seroconversion in RTX patients, we performed a correlation matrix (Fig. 4) including antigen-specific T and B cell subsets as well as demographic data. IgG titers and neutralizing antibodies correlated significantly with RBD+ plasmablasts and memory compartments, as we previously showed (23) . Interestingly, induced antigen-specific CD8 responses upon stimulation did not correlate significantly with humoral immunity, neither with B nor with CD4 T cell subsets, suggesting an independent, more direct antigen-driven cellular immunity compared with CD4/CD19interaction required for IgG formation.

To further investigate the specific differences during SARS-CoV-2 vaccination in RTX pronounced among IgG non-responders in the RTX group (Fig. 5 D, Suppl. Fig. S6, Fig.   S7 ).

in clinical trials (5) (6) (7) (8) . However, certain patient groups receiving immunosuppressive therapies appear to develop insufficient humoral and cellular responses (18, 23, 27, 28) , but limited data about the underlying limitations is available. Protection through immunization is achieved by an orchestrated immune response between different cellular subsets of innate (APCs) and adaptive immunity, such as B and T cells. Anti-B cell therapies like anti-CD20 antibodies (rituximab, obinutuzumab and ocrelizumab) and BTK inhibitors are associated with poor humoral SARS-CoV-2 vaccination responses, in patients with AIIRD (17) (18) (19) (20) , multiple sclerosis (29) and CLL (30) . Since B cell depletion enhances the risks for poor Covid-19 outcomes (3), but also can reduce anti-SARS-CoV-2 vaccine responses, it is of utmost importance to delineate the level of B cell repopulation necessary to achieve anti-vaccine responses and get insights into the complex relationship between antigen-specific B and T cells.

Therefore, our study aimed to investigate humoral and cellular responses in RTX treated patients versus controls. Consistent with previous data (17) (18) (19) 26) , serologic IgG conversion with formation of neutralizing antibodies was significantly lower and delayed in both, RA and even more pronounced in the RTX cohort compared to HC. This finding was closely linked to the availability of peripheral B cells, activated CD4/8 T cells as well as circulating TFH-like cells. Another risk factor identified for developing a substantially diminished vaccination response was the prednisolone dose. Ongoing antigen exposure through mRNA vaccines seems to permit prolonged GC maturation (31) , which might be an explanation for the further increase in antibody titers during an additional period in some patients.

Besides IgG non-responders among RTX patients, two patients in the RA group with normal B cell numbers did not develop anti-S1 IgG antibodies. After completing the analysis, the underlying cause may be most probably related to impaired T cell responses: in one patient due to inhibition of co-stimulation by abatacept, consistent with a prior report (18) . The other patient treated with a JAK inhibitor lacked cytokine production by antigen-specific T cells after receiving 2x vaccination with ChAdOx1. Even though significantly lower IgG responses were reported upon 2x ChAdOx1 vaccination in healthy vaccinees (32) , it remains to be delineated whether the treatment and/or selected vaccine may account for this finding. Induction of vaccine-specific IgG in individuals upon ChAdOx1/BNT162b2 was comparable with twice BNT162b2 vaccinations. Interestingly, IgA formation was comparable across all groups, although the protective potency of IgA remains to be determined.

Of utmost importance, our RTX cohort showed a correlation between IgG seroconversion, neutralizing antibodies and absolute B cell number. Here, a minimum of 10 B cells/µl in the peripheral circulation candidates as biomarker for a high likelihood of an appropriate cellular and humoral vaccination response. Patients with B cell numbers below this range presented not only with lower antigen-specific B cells, but they also showed substantially diminished circulating TfH-like CD4 T cells, reduced activated CD4/8 T cells coexpressing CD38 and HLA-DR, as well as impaired IFNγ secretion of spike-specific CD4 T cells. The frequency of IFNγ secreting antigen-specific CD4 T cells also correlated with the absolute number of B cells, suggesting that these cells interact to achieve proper anti-S1 responses. Mechanistically, the current data suggest the critical role of available costimulatory B cell functions for the induction of proper CD4 Th response. This is consistent with observations of previously described impaired B-T cell crosstalk in rituximab treated patients (33) (34) (35) , leading to reduced frequencies of activated T cells (35) , downregulation of CD40L in CD4 T cells (33, 34) , and reduced antigen-specific CD8 T cells after influenza vaccination (14) .

With regard to induction of antigen-specific CD8 T cells upon stimulation, the RTX and RA groups showed both a tendency to reduced responder rates compared with HC, although it was not statistically significant. However, other than for antigen-specific CD4 T cells, neither B cell depletion nor IgG formation correlated with spike-specific CD8 T cells, suggesting that their induction occurred independently upon SARS-CoV-2 vaccination. It is not clear how these vaccine-specific CD8 T cells provide antiviral protection on clinical grounds.

The debate about what correlates with protection after vaccination against SARS-CoV-2 is ongoing, while it is widely accepted, that neutralizing antibodies are considered to be a reliable surrogate of protection against virus variants (36, 37) . The threshold for protective SARS-CoV-2 IgG-titer is still unknown, although non-human primate studies suggest that it is likely very effective already at low titers (38) . Our study provides evidence that detection of RBD-specific B and spike-specific CD4 T cells may provide cellular correlates of this response, while the CD8 response occurred in an independent way. The role of these two lines of vaccine response needs to be further delineated.

Limitations of the study are the small number of RA and RTX patients and the heterogeneity of the groups (including different DMARD regimes, different vaccination strategies). In this regard, Mrak et al (39) analyzed the impact of co-medication on vaccination response in 74 RTX patients and did not observe differences in the levels of antibodies in the presence or absence of co-medication with csDMARDs or prednisolone. This suggests that the impact of RTX on B cells is more relevant than the effect of csDMARDs.

Here, we present a first study investigating humoral as well as antigen-specific T and B cellular responses in RTX treated patients after SARS-CoV-2 vaccination.

Mechanistically, the data provide insights into the crucial role of available B cells equipped with proper co-stimulatory function to interactively cross-talk with CD4 T cells.

These functions likely result into GC formation, plasma cell differentiation and vaccinespecific IgG production. As a clinical consequence, we propose a range of absolute B cells signifying expansion of vaccine responses after RTX treatment, which may support optimization of vaccination protocols among this vulnerable patient group.

https://datadryad.org/stash/. In particular the genetic data will be available in a gene bank. (A) Humoral immune response against SARS-CoV-2 was assessed by ELISA for spike protein S1 IgG, spike protein S1 IgA and virus neutralization by a blocking ELISA in HC (n=30), RA (n=12) and RTX (n=19) 6±3 days after 2 nd SARS-CoV-2 vaccination.

Threshold of upper limit of normal is indicated by dotted lines. (B) Follow-up sera were collected for 12 RA and 19 RTX patients, respectively, 3-4 weeks after 2 nd vaccination and investigated for S1 IgG, IgA and virus neutralization. (C) Delayed IgG response in 5/11 of initially (day 7 after 2 nd vaccination) non-seroconverted RTX patients at day 21. 

Comparing the burdens of opportunistic infections among patients with systemic rheumatic diseases: a nationally representative cohort study

Incidence and prevalence of vaccine preventable infections in adult patients with autoimmune inflammatory rheumatic diseases (AIIRD): a systemic literature review informing the 2019 update of the EULAR recommendations for vaccination in adult patients with

Factors associated with COVID-19-related death in people with rheumatic diseases: results from the COVID-19

Global Rheumatology Alliance physician-reported registry

COVID-19 Outcomes in Patients Undergoing B Cell Depletion Therapy and Those with Humoral Immunodeficiency States: A Scoping Review

Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine

Vaccine in a Nationwide Mass Vaccination Setting

Efficacy and Safety of the mRNA-1273 SARS-CoV-2 Vaccine

Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK

Safety and Efficacy of Single-Dose Ad26.COV2.S Vaccine against Covid-19

2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases

Effect of methotrexate, anti-tumor necrosis factor α, and rituximab on the immune response to influenza and pneumococcal vaccines in patients with rheumatoid arthritis: a systematic review and meta-analysis

Is rheumatoid arthritis associated with reduced immunogenicity of the influenza vaccination? A systematic review and meta-analysis

Immunization responses in rheumatoid arthritis patients treated with rituximab: results from a controlled clinical trial

B cell depletion impairs vaccination-induced CD8<sup>+</sup> T cell responses in a type I interferon-dependent manner

The effect of rituximab on vaccine responses in patients with immune thrombocytopenia

Evaluation of the immune response to hepatitis B vaccine in patients on biological therapy: results of the RIER cohort study

SARS-CoV-2 vaccination in rituximabtreated patients: evidence for impaired humoral but inducible cellular immune response

LB0003 IMMUNOGENICITY AND SAFETY OF THE BNT162b2 mRNA COVID-19 VACCINE IN ADULT PATIENTS WITH AUTOIMMUNE INFLAMMATORY RHEUMATIC DISEASES AND GENERAL POPULATION: A MULTICENTER STUDY

Correspondence on 'SARS-CoV-2 vaccination in rituximab-treated patients: evidence for impaired humoral but inducible cellular immune response

Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative

Revised International Chapel Hill Consensus Conference Nomenclature of Vasculitides

Impaired humoral immunity to SARS-CoV-2 BNT162b2 vaccine in kidney transplant recipients and dialysis patients

Impaired humoral and cellular immunity after SARS-CoV2 BNT162b2 (Tozinameran) prime-boost vaccination in kidney transplant recipients. The Journal of Clinical Investigation. 2021. 25. Nakamura A, Nukiwa T, Takai T. Deregulation of peripheral B-cell development in enhanced severity of collagen-induced arthritis in FcgammaRIIB-deficient mice

SARS-CoV-2 vaccination responses in untreated, conventionally treated and anticytokine-treated patients with immunemediated inflammatory diseases

Immunogenicity and safety of anti-SARS-CoV-2 mRNA vaccines in patients with chronic inflammatory conditions and immunosuppressive therapy in a monocentric cohort

Methotrexate hampers immunogenicity to BNT162b2 mRNA COVID-19 vaccine in immune-mediated inflammatory disease

Cellular and humoral immune responses following SARS-CoV-2 mRNA vaccination in patients with multiple sclerosis on anti-CD20 therapy

Efficacy of the BNT162b2 mRNA COVID-19 vaccine in patients with chronic lymphocytic leukemia

SARS-CoV-2 mRNA vaccines induce persistent human germinal centre responses

Safety and Immunogenicity Report from the Com-COV Study -a Single-Blind Randomised Non-Inferiority Trial Comparing Heterologous And Homologous Prime-Boost Schedules with An Adenoviral Vectored and mRNA COVID-19 Vaccine

B cell depletion treatment decreases CD4+IL4+ and CD4+CD40L+ T cells in patients with systemic sclerosis

Remission of proliferative lupus nephritis following B cell depletion therapy is preceded by down-regulation of the T cell costimulatory molecule CD40 ligand: an open-label trial

Effect of rituximab treatment on T and B cell subsets in lymph node biopsies of patients with rheumatoid arthritis

Neutralizing antibody levels are highly predictive of immune protection from symptomatic SARS-CoV-2 infection

SARS-CoV-2 infection rates of antibody-positive compared with antibody-negative health-care workers in England: a large, multicentre, prospective cohort study (SIREN)

Correlates of protection against SARS-CoV-2 in rhesus macaques

SARS-CoV-2 vaccination in rituximab-treated patients: B cells promote humoral immune responses in the presence of T-cell-mediated immunity. Annals of the rheumatic diseases

ART_42060_Fig3v9 (002).tiff

The theoretical framework was developed by TD, ALS and HRA.The work was supervised by ACL, AS, KK, AR, GRB, and TD.All authors developed, read, and approved the current manuscript.

All data, code, and materials used in the analysis will be available at