key: cord-0992085-kwr25lq4
authors: Pham, Michele N.; Murugesan, Kanagavel; Banaei, Niaz; Pinsky, Benjamin A.; Tang, Monica; Hoyte, Elisabeth; Lewis, David B.; Gernez, Yael
title: Immunogenicity and Tolerability of COVID-19 mRNA Vaccines in PID patients with functional B-cell defects
date: 2021-12-21
journal: J Allergy Clin Immunol
DOI: 10.1016/j.jaci.2021.11.022
sha: 1b2218fcc48bf51e66c0218cce0501ed71f5b627
doc_id: 992085
cord_uid: kwr25lq4

Background Data on the safety and efficacy of COVID-19 vaccination in people with a range of primary immune deficiencies are lacking since these patients were excluded from COVID-19 vaccine trials. This information may help in clinical management of this vulnerable patient group. Objective To assess humoral and T-cell immune responses after two doses of SARS-CoV-2 mRNA vaccines in patients with PIDs and functional B-cell defects. Methods A double-center retrospective review of patients with PID who completed COVID-19 mRNA vaccination and who had humoral responses assessed through SARS-CoV-2 spike protein receptor binding domain (RBD) IgG antibody levels with reflex assessment of the antibody to block RBD binding to ACE2 (hereafter referred to as ACE2 receptor blocking activity, as a surrogate test for neutralization) and T-cell response evaluated by an interferon-gamma release assay (IGRA). Immunization reactogenicity was also reviewed. Results A total of 33 patients with humoral defect were evaluated. 69.6% received BNT162b2 vaccine (Pfizer-BioNTech) and 30.3% received mRNA-1273 (Moderna). The mRNA vaccines were generally well tolerated without severe reactions. The IGRA was positive in 77.4% of our patients (24 of 31). About half of our subjects (16 of 33) had detectable RBD-specific IgG responses but only two of these 16 subjects had an ACE2 receptor blocking activity level of >50%. Conclusion Vaccination of this cohort of PID patients with COVID-19 mRNA vaccines was safe and cellular immunity was stimulated in a majority. However, antibody responses to the spike protein RBD were less consistent, and, when detected, was not effective at ACE2 blocking. Clinical Implication mRNA vaccination may be less effective at preventing acquisition of SARS-CoV-2 in our cohort of PID patients with functional B-cell defects. The Induction of SARS-CoV-2 spike protein-specific T-cell immunity by vaccination might help reduce the severity of disease in these patients.

antibody to block RBD binding to ACE2 (hereafter referred to as ACE2 receptor blocking 48 activity, as a surrogate test for neutralization) and T-cell response evaluated by an interferon-49 gamma release assay (IGRA). Immunization reactogenicity was also reviewed. ELISA coating with S1 receptor binding domain (RBD) antigen, with reflex to SARS-CoV-2 116 ACE2 receptor blocking activity, (9) which correlates well with antibody viral neutralization. 117 (10) Spike-protein-specific T-cell responses were evaluated using a SARS-CoV-2 interferon-118 gamma release assay (IGRA). (11) These assays were performed at Stanford Health Care 119

Clinical Virology Laboratory, a CLIA certified laboratory. 120

Testing was performed a mean of 10.9 + 5.3 weeks after the second vaccine dose and 122 most subjects had positive immune results to some degree ( Figure 1 ). vaccination, which was undetectable in all cases. None of our patients had a known history of Tolerability/reactogenicity information was gathered through chart review and revealed that the 138 vaccines were well tolerated (Table 2 ). There were no severe reactions. 139

All our patients had an antibody deficiency, which is the most common general category 140 of PID. As expected, our 4 patients with inborn errors that markedly impair IgG antibody 141 production (two with agammaglobulinemia and two with hyper-IgM syndrome secondary to 142 CD40-ligand deficiency) had negative SARS-CoV-2 IgG antibody results (Table 1, Figure 2) . antibodies that blocked the interaction of the RBD with ACE2, as assessed in the ACE2 blocking 154 antibody assay. (9) As this blocking activity correlates well with antibody that effectively 155 neutralizes SARS-CoV-2 for entry into host cells, (10) this indicated that most CVID patients did 156 not mount antibody responses that would be protective from SARS-CoV-2 infection. 157

The responsiveness of PID patients to COVID-19 vaccination might be potentially 158 difficult to assess if the patient is on Ig replacement with product that contains SARS-CoV-2 received COVID-19 vaccines. We anticipated that this was unlikely to account for the presence 161 of 46.9% of our 32 patients who were on Ig replacement having any spike protein-specific 162 antibody given the usual lag between seroprevalence in the blood donor population and the 163 specific antibody in manufactured Ig products. (12-16) To evaluate the potential impact of Ig 164 therapy on SARS-CoV-2 spike protein RBD-specific humoral responses, we evaluated two 165 patients (#24 and #32 Table 1 ) for SARS-CoV-2 ACE2 receptor blocking antibody levels pre-166 and post-IVIG therapy. For Patient#24, both pre-and post-IVIG therapy ACE2 receptor blocking 167 activity was <10% and for Patient#32, the post-IVIG ACE2 receptor blocking activity minimally 168 changed from <10% pre-infusion to 14%, post-infusion. Thus, in these two subjects, the IVIG 169 products they received in September 2021 (over 1.5 years since the start of the global COVID-19 170 pandemic) did not appreciably alter their levels of protective neutralizing antibody. 171

Our study of PID patients with functional B-cell defects is, to the best of our knowledge, 172 the first to evaluate the ACE2 receptor blocking activity after two doses of the SARS-CoV-2 173 mRNA vaccines. The receptor blocking activity competition assay evaluates the ability of the 174 antibody in serum or plasma to bind to the spike protein RBD and prevent its interaction with 175 ACE2 (9). The level of receptor blocking activity may correlate with antibody-mediated 176 neutralization assays employing viruses pseudotyped with the spike protein. (10) Thus, our 177 finding that only one out of 15 CVID patients had an ACE2 blocking level of >50% and that 178 such activity was undetectable in most of these patients raises the possibility that mRNA 179 vaccination may provide minimal protection from SARS-CoV-2 infection for CVID patients. It 180 is also important to consider that the ACE2 receptor blocking assay employed the RBD similar 181 to that encoded by the current EUA approved mRNA vaccines, and protection might be even Similar to Hagin et al. (7), 80% of our patients with CVID had a spike protein-RBD 184 specific IgG response. Additionally, 80% of our CVID patients had spike protein-specific T-cell 185 immune response. In the antibody deficient patients in our cohort, and in contrast to the study of 186

Hagin et al. (7), there was no difference between age or IgG at baseline and a positive SARS-187

CoV2-2 spike protein result but those with a positive IGRA result were younger, mean age The threshold of ACE2 receptor blocking activity of >50% for a positive result was chosen for 199 this report but further studies are needed to more precisely establish protective ranges. 

Thermo Fisher: cat. 9018) were coated with SARS-CoV-2 spike RBD protein in 48 PBS at a concentration of 0.1 μg per well overnight at 4°C. All competition ELISA steps were 49 carried out on the next day at RT. Wells were washed 3x with PBS-T and blocked with PBS-T 50 containing 3% non-fat milk powder for 1 hour. Wells were then incubated with plasma samples 51 from our

Two quality controls (Access SARS-CoV-2 IgG QC, QC1-QC2, 2 levels, catalog no

Beckman Coulter) and two blank wells incubated with PBS-T containing 1% non-fat milk were 54 included on each plate. ACE2-mFc diluted to 0.5 μg/ml in 1% non-fat milk powder was added 55 without washing steps and incubated for an additional 45 min. After washing 3x with PBS-T, 56 horseradish peroxidase conjugated goat anti-mouse IgG (Fc specific

Wells were washed 3x with PBS-T and dried by vigorous tapping of plates on paper 59 towels. TMB substrate solution was added, and the reaction was stopped after 12 min by addition 60 of 0.16 M sulfuric acid. The OD at 450 nanometers was measured with an EMax Plus microplate 61 reader (Molecular Devices

Please refer to reference (3) for detail description

The interferon-gamma (IFN-γ) release assay (IGRA) used here measured IFN-γ released by consisting of spike, S1, nucleocapsid, and membrane proteins

This assay (and its references) was performed at Stanford Health Care 71

Microsoft Excel were used for data analysis and visualization. Chisquare test was 96 performed using JMP

Normality of the data was determined and established through using the Kolmogorov-Smirnov

T-tests were calculated using the GraphPad QuickCalcs Web

Antibody responses to the SARS-CoV-2 vaccine in individuals with various inborn errors 114 of immunity

COVID-19 vaccine in patients with inborn errors of immunity

Defining the 119 features and duration of antibody responses to SARS-CoV-2 infection associated with disease 120 severity and outcome

Interferon-gamma release assay for accurate detection of SARS-CoV-2 T cell response. Clin 123 Infect Dis

Interferon Gamma Release Assays for Latent Tuberculosis

What Are the Sources of Variability?

reactive T cells in healthy donors and patients with COVID-19

ALC: absolute lymphocyte count; BTK: Burton tyrosine 137 kinase; CLL: chronic lymphoid leukemia; CIU: chronic idiopathic urticaria; Dx: 138 diagnosis; Hx: history; IBD: inflammatory bowel disease; ILD: Interstitial lung 139 disease; ITP: idiopathic thrombocytopenia; MGUS : gammopathy of unknown 140 significance; SAD: specific antibody deficiency; VUS: variants of unknown 141 significance