key: cord-0884264-ga5y48qs authors: Gavriatopoulou, Maria; Terpos, Evangelos; Ntanasis-Stathopoulos, Ioannis; Briasoulis, Alexandros; Gumeni, Sentiljana; Malandrakis, Panagiotis; Fotiou, Despina; Migkou, Magdalini; Theodorakakou, Foteini; Eleutherakis-Papaiakovou, Evangelos; Kanellias, Nikolaos; Kastritis, Efstathios; Trougakos, Ioannis P; Dimopoulos, Meletios A title: Poor neutralizing antibody responses in 106 patients with WM after vaccination against SARS-CoV-2: a prospective study date: 2021-09-20 journal: Blood Adv DOI: 10.1182/bloodadvances.2021005444 sha: b90aa78d8167e8bc489ae67396150d691be09d5d doc_id: 884264 cord_uid: ga5y48qs The urgency of the COVID-19 pandemic has led to accelerated vaccine development within less than a year. Immunocompromised patients with hematological malignancies are more susceptible to COVID-19 and at higher risk of severe complications and worse outcomes compared with general population. In this context, we evaluated the humoral response by determining the titers of neutralizing antibodies (NAbs) against SARS-CoV-2 in patients with Waldenstrom Macroglobulinemia (WM) after vaccination with the BNT162b2 or AZD1222 vaccine. An FDA-approved, ELISA-based methodology was implemented to evaluate NAbs on the day of the first vaccine shot, as well as on day 22 and 50 afterwards. 106 patients with WM (43% males, median age 73 years) and 212 healthy controls (46% males, median age 66 years) who were vaccinated during the same period, at the same center were enrolled in the study (which is registered at www.clinicaltrials.gov as NCT04743388). Our data indicate that vaccination with either 2 doses of the BNT162b2 or 1 dose of the AZD1222 vaccine leads to lower production of NAbs against SARS-CoV-2 in patients with WM compared with controls both on day 22 and on day 50 (P<0.001 for all comparisons). Disease-related immune dysregulation and therapy-related immunosuppression are involved in the low humoral response. Importantly, active treatment with either Rituximab or Bruton's Tyrosine Kinase inhibitors was proven as an independent prognostic factor for suboptimal antibody response following vaccination. In conclusion, patients with WM have low humoral response following COVID-19 vaccination, which underlines the need for timely vaccination ideally during a treatment-free period and for continuous vigilance on infection control measures. The urgency of the COVID-19 pandemic has led to accelerated vaccine development within less than a year. Immunocompromised patients with hematological malignancies are more susceptible to COVID-19 and at higher risk of severe complications and worse outcomes compared with general population. In this context, we evaluated the humoral response by determining the titers of neutralizing antibodies (NAbs) against SARS-CoV-2 in patients with Waldenstrom Macroglobulinemia (WM) after vaccination with the BNT162b2 or AZD1222 vaccine. An FDA-approved, ELISA-based methodology was implemented to evaluate NAbs on the day of the first vaccine shot, as well as on day 22 and 50 afterwards. 106 patients with WM (43% males, median age 73 years) and 212 healthy controls (46% males, median age 66 years) who were vaccinated during the same period, at the same center were enrolled in the study (which is registered at www.clinicaltrials.gov as NCT04743388). Our data indicate that vaccination with either 2 doses of the BNT162b2 or 1 dose of the AZD1222 vaccine leads to lower production of NAbs against SARS-CoV-2 in patients with WM compared with controls both on day 22 and on day 50 (P<0.001 for all comparisons). Disease-related immune dysregulation and therapy-related immunosuppression are involved in the low humoral response. Importantly, active treatment with either Rituximab or Bruton's Tyrosine Kinase inhibitors was proven as an independent prognostic factor for suboptimal antibody response following vaccination. In conclusion, patients with WM have low humoral response following COVID-19 vaccination, which underlines the need for timely vaccination ideally during a treatment-free period and for continuous vigilance on infection control measures.  Anti-SARS-CoV-2 vaccination leads to lower production of neutralizing antibodies against SARS-CoV-2 in WM patients compared with controls  Treatment with Rituximab or BTK inhibitors was an independent prognostic factor for suboptimal antibody response following vaccination The new type of coronavirus SARS-CoV-2, which originated from Wuhan, China has led to the worldwide pandemic of coronavirus disease -2019 (COVID- 19) and has become a global health concern. 1,2 COVID-19 is a systemic disease with both short-and long-term manifestations. 3, 4 Most patients present with mild to moderate symptoms, however up to 5-10% present with a severe and even life-threatening disease course. 3 Several phase 3 placebo-controlled, randomized clinical trials (RCTs) were performed and showed impressive efficacy for different vaccine types, however the effectiveness and the durability of protection in real world is still under investigation. 8 Considering that very few patients with underlying malignancies were enrolled in those studies, several questions remain unanswered regarding the risk-benefit ratio of these new COVID-19 vaccines in patients with cancer. 7, 9 Immunocompromised patients with hematological malignancies or solid cancer are more susceptible to COVID-19 and present a higher risk of severe complications and worse outcomes compared with general population. 10, 11 Additionally, the subgroup of patients with hematological malignancies seem to have worse clinical outcomes with higher morbidity and mortality when compared with patients with solid organ tumors. 12 Among hospitalized patients with COVID-19 and hematological cancers, the risk of death has been estimated approximately 39%. 12 Furthermore, lower seroconversion rates following COVID- 19 have been reported among patients with solid and hematological cancer compared with convalescent individuals without cancer. [13] [14] [15] [16] Waldenstrom Macroglobulinemia (WM) is a rare subgroup of indolent B-cell lymphomas. It is defined by the presence of a monoclonal IgM serum protein and at least 10% monoclonal lymphoplasmacytic cells in the bone marrow. WM accounts for 1-2% of all hematological malignancies. 17 Patients with lymphoproliferative disorders including WM are at increased risk of bacterial and viral infections and also at increased risk for severe disease and death from COVID-19, due to their immunocompromised status, older age and comorbidities. [18] [19] [20] [21] [22] [23] Herein, we describe the humoral response, as depicted by the development of neutralizing antibodies (NAbs), against SARS-CoV-2 in patients with WM after vaccination with either the mRNA BNT162b2 or viral vector AZD1222 vaccine. Major inclusion criteria for the study included: (i) age above 18 years; (ii) presence of asymptomatic or active WM irrespective of the treatment phase; and (iii) eligibility for vaccination. Volunteer controls of similar age were also included in this analysis. We included healthy individuals without malignant disease above 60 years old vaccinated during the same time period (January-May 2021). The age cut-off was selected taking into consideration the median age of patients with WM 23 After vein puncture, the serum of both patients and controls was collected on day 1 (D1; before the first BNT162b2 or AZD1222 dose), on day 22 (D22; before the second dose of the NAb titer of at least 50% has been associated with clinically relevant viral inhibition. 25 Samples of the same patient or control were measured in the same ELISA plate. All statistical analyses were performed with STATA (version 17.0, College Station, Texas). All variables were tested for normal data distribution. The analyses were performed on an intention-to-treat as well as on-treatment basis. Normally distributed data were expressed as means ± standard deviation (SD). Non-normally distributed data were presented as the median with the interquartile range. For categorical variables, the Chi-Square or Fisher exact test were used to compare the distributions for the two randomized groups. Non-paired Student's t tests were used for between-treatment comparisons of continuous variables. Post hoc mixed-model repeated measures analysis was used to evaluate the neutralizing antibodies over time with cases and controls as main effects and neutralizing antibodies as dependent variables. Mixed models were performed using direct likelihood estimation with fixed effects of groups, time of antibodies and interaction of groups (cases, controls) by timing of antibody measurement. An unstructured covariance matrix was used to model within-patient error. We also used a multivariable linear regression model adjusted for age, gender, active therapy, presence of asymptomatic WM, type of vaccine, uninvolved immunoglobulin levels and lymphocyte count, in order to evaluate the effect of these factors on NAb production at D22 and D50. NAbs, age, lymphocyte count and immunoglobulins were inserted as linear variables and the remaining as categorical. All significance tests were two tailed and conducted at the 5% significance level. For original data, please contact mgavria@med.uoa.gr. The study population included 106 patients [ Our data indicate that vaccination with either the BNT162b2 mRNA vaccine or the AZD1222 viral vector vaccine leads to lower production of NAbs against SARS-CoV-2 in patients with symptomatic and asymptomatic WM compared with controls of similar age and gender without malignant disease. Our findings were independent of the vaccine type. Interestingly, the sex distribution of the WM cases included more women than men, which is not typical for WM. 23 However, it could be attributed to a higher rate of anti-SARS-CoV-2 vaccine uptake among women compared with men, due to gender-specific and societal reasons. 26 To our knowledge this is the first report to demonstrate the antibody-mediated response in patients with WM after 2 doses of vaccination with the BNT162b2 vaccine. Furthermore, it is the first study demonstrating the effects of AZD1222 vaccine in patients with low grade lymphoproliferative neoplasms. Although vaccination against SARS-CoV-2 is considered as the most important preventive strategy against COVID-19, its efficacy in patients with hematological malignancies is largely unknown. 9 The BNT162b2 mRNA and the AZD1222 viral vector vaccines against SARS-CoV-2 have shown significant efficacy in healthy adults. 27 The underlying causes for low humoral response to vaccination in patients with WM are multifactorial and it seems that both disease-related immune dysregulation and therapy related immunosuppression are involved. In our study, active treatment (with rituximab, BTKi or combinations) was the most important prognostic factor at the multivariate analysis and was correlated with lower response rates. Therapeutic regimens that deplete B-cells may impair immune response to vaccines. Patients treated with ibrutinib and/or anti-CD20 antibodies were unlikely to respond to a single dose of vaccine and this was confirmed by our results. BTK inhibitors, including ibrutinib, acalabrutinib and zanubrutinib, block the B-cell receptor signaling, in both malignant and normal B-cells and, therefore, it impairs the humoral response to vaccination. [35] [36] [37] [38] Previous studies have described antibody-mediated response rates of 7% to 26% to influenza vaccine in patients with CLL treated with BTK inhibitors. 35, 36 It has been also demonstrated that BTK inhibitors are associated with a decreased immune response to the anti-Hepatitis B vaccine, HepB-CpG19. 39 Furthermore, we showed that patients with WM treated with an anti-CD20 antibody within the last 12 months prior to vaccination, failed to produce anti-SARS-CoV-2 antibodies, while better responses were observed in patients who completed anti-CD20 therapy at least 12 months prior to vaccination. The recent exposure to B-cell depleting agents, including anti-CD20 antibodies, reduces response to influenza vaccine, pneumococcal polysaccharide vaccine and other vaccines. 40, 41 Interestingly, hypoglobulinemia might be associated with inferior antibody response among patients with CLL and COVID-19. 16 Furthermore, it seems that patients who completed their treatment and remained in response at the time of vaccination were more likely to produce NAbs and this is probably related to a reconstitution of humoral immunity. In this context, the delay of treatment initiation may be considered when possible until the vaccination is completed. Although targeted therapies seem to negatively affect the NAb production, higher patient numbers are required to evaluate the exact effect of each regimen on the immune responses following anti-SARS-CoV-2 vaccination. Taking into consideration the humoral response after the first and second vaccine shot, it is clearly suggested that a second timely vaccine dose is necessary especially for patients with hematological malignancies that deregulate the immune homeostasis. In accordance to a previous study on healthy individuals, 42 our results may advocate for a shortening of the time interval between the two doses of the AZD1222 to less than 3 months especially for patients with WM. However, further data in a larger sample size are needed to conduct subgroup analysis and evaluate the peak antibody response from the AZD1222 vaccine compared with the BNT162b2 vaccine. It is well known that patients with cancer have increased COVID-19-related mortality, however there is significant heterogeneity among different cancer subgroups. 43 Currently, it has been demonstrated that vaccines result in lower risk for severe disease, however the studies performed were not designed to detect a signal for mortality protection from fatal COVID-19. The available data regarding vulnerable subgroups, such as patients with cancer are lacking. One of the strengths of our study is the evaluation of NAbs, which have been shown to have an important predictive value of immune protection from symptomatic COVID-19. 44 Therefore, NAbs levels can be considered valuable surrogates of vaccine efficacy. Our results suggest that patients with WM have suboptimal production of anti-SARS-CoV-2 NAbs, in analogy to the response to influenza vaccines. Existing data on patients with plasma cell dyscrasias patients are rather limited and they are based on small and retrospective studies which suggest poor seroprotection rates of less than 20% after standard influenza vaccination. 45 A prospective single arm study has demonstrated that in contrary to these historically poor results with standard influenza vaccination, a novel highdose booster vaccination strategy might lead to high rates of seroprotection. 46 Another study has shown decreased anti-pneumococcal immunity in patients with both MM and WM. 47 In addition, these results are in accordance with the low response rates of 20%-40% analyzed data, reviewed all paper drafts and gave approval to final version. The authors declare no relevant conflict of interest. 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