key: cord-0254472-1vd6cwuv
authors: Matsui, Y.; Li, L.; Prahl, M.; Cassidy, A. G.; Ozarslan, N.; Golan, Y.; Gonzalez, V. J.; Lin, C. Y.; Jigmeddagva, U.; Chidboy, M. A.; Montano, M.; Taha, T. Y.; Khalid, M. M.; Sreekumar, B.; Hayashi, J. M.; Chen, P.-Y.; Kumar, G. R.; Warrier, L.; Wu, A. H. B.; Song, D.; Jegatheesan, P.; Rai, D. S.; Govindaswami, B.; Needens, J.; Rincon, M.; Myatt, L.; Asiodu, I. V.; Flaherman, V. J.; Afshar, Y.; Jacoby, V. L.; Murtha, A. P.; Robinson, J. F.; Ott, M.; Greene, W. C.; Gaw, S. L.
title: Neutralizing Antibody Activity Against SARS-CoV-2 Variants in Gestational Age-Matched Mother-Infant Dyads
date: 2021-12-11
journal: nan
DOI: 10.1101/2021.12.09.21267557
sha: d8224c92be6b0379b47a48e8442d3ecec62e0fd3
doc_id: 254472
cord_uid: 1vd6cwuv

Pregnancy confers unique immune responses to infection and vaccination across gestation. To date, there is limited data comparing vaccine versus infection-induced nAb to COVID-19 variants in mothers during pregnancy. We analyzed paired maternal and cord plasma samples from 60 pregnant individuals. Thirty women vaccinated with mRNA vaccines were matched with 30 naturally infected women by gestational age of exposure. Neutralization activity against the five SARS-CoV-2 Spike sequences was measured by a SARS-CoV-2 pseudotyped Spike virion assay. Effective nAbs against SARS-CoV-2 were present in maternal and cord plasma after both infection and vaccination. Compared to wild type or Alpha variant Spike, these nAbs were less effective against the Kappa, Delta, and Mu Spike variants. Vaccination during the third trimester induced higher nAb levels at delivery than infection during the third trimester. In contrast, vaccine-induced nAb levels were lower at the time of delivery compared to infection during the first trimester. The transfer ratio (cord nAb level/maternal nAb level) was greatest in mothers vaccinated in the second trimester. SARS-CoV-2 vaccination or infection in pregnancy elicit effective nAbs with differing neutralization kinetics that is impacted by gestational time of exposure. Vaccine induced neutralizing activity was reduced against the Delta, Mu, and Kappa variants.

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The copyright holder for this this version posted December 11, 2021. ; https://doi.org/10.1101/2021.12.09.21267557 doi: medRxiv preprint (B.1.1.529) variants as variants of concern (VOC) to help track SARS-CoV-2 genetic lineages. 92 The Delta variant is highly contagious and led to the 2021 resurgence of COVID-19 worldwide. 93 Early data suggests sera from fully vaccinated or convalescent non-pregnant individuals display CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted December 11, 2021. ; https://doi.org/10.1101/2021.12.09.21267557 doi: medRxiv preprint which modestly affects nAb binding affinity (25). The Kappa variant possesses the E484Q 110 mutation, which reduces sensitivity to vaccine-elicited nAb, but the L452R and E484Q mutation 111 are not synergistic for loss of sensitivity to neutralizing antibodies (26). The Mu variant harbors 112 the E484K which has been shown to significantly reduce sensitivity to the nAbs (27, 28). 113 Furthermore, the Delta variant has the specific T478K mutation, which has been shown to 114 improve viral interaction with ACE2, but there is little knowledge about its potential role in 115 resistance to neutralization by antibodies (29). The Mu variant also has the specific R346K 116 mutation, which may affect the sensitivity of nAb (30). 117 Existing studies indicated that maternal IgG production and maternal-fetal transfer 118 might be influenced by timing of exposure, fetal sex or antibody glycosylation profiles (11, 31, 119 32). However, the neutralizing activity against different SARS-CoV-2 variants during pregnancy 120 and the transplacental transfer efficacy over gestation remains understudied. In this study, we 121 assessed nAb activities against five strains of SARS-CoV-2, including the wild-type (WT) 122 (Wuhan-Hu-1), Alpha, Kappa, Delta, and Mu variants in paired maternal and infant cord blood 123 plasma samples collected at the time of delivery. To understand the impact of timing during 124 pregnancy on the development of maternal-fetal humoral immunity, we compared two cohorts 125 that were matched by gestational age of exposure. Using samples from vaccinated versus 126 infected pregnant individuals, we compared and contrasted the nAbs elicited by mRNA vaccine 127 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint 154 We assessed the ability of paired maternal and infant cord plasma to neutralize entry of SARS- Figure 1A ). The composite median NT50 titers against all examined strains was higher in cord 159 blood from vaccinated mothers than those from infected mothers (202 vs. 104, P < 0.0001), but 160 not in maternal blood (128 vs. 120, P = 0.12) (Figure 2A) . 161 The total amount of neutralizing activity detected in maternal ( Figure 2B ) and cord 162 ( Figure 2C ) plasma collected at the time of delivery increased with vaccinations later in 163 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Neutralizing activities against four variants in pregnancy 177 Emerging variants with mutations in the SARS-CoV-2 RBD raise concern for the 178 efficacy of vaccine-induced and natural immunity, but the nAb activity against these variants in 179 pregnancy is unknown. Here, we analyzed the nAb activities against the Spike proteins from the 180 Alpha, Kappa and Delta and Mu variants in pregnant individuals. In the vaccinated cohort, 181 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted December 11, 2021. ; https://doi.org/10.1101/2021.12.09.21267557 doi: medRxiv preprint maternal and cord nAb against the Kappa Spike variant was reduced by 1.7-fold (P < 0.0001) 182 and 1.7-fold (P < 0.0001), respectively, compared to the WT. Anti-Delta variant was reduced by 183 2.9-fold (P < 0.0001) and 1.8-fold (P = 0.0032), in maternal and cord blood, respectively. The Among the infected cohort, maternal and cord nAb against the Kappa variant was 193 reduced by 1.1-fold (P = 0.032) and 1.5-fold (P = 0.170), respectively, compared to the WT.

Activity against the Delta variant was reduced by 2.1-fold (P = 0.120) and 3.1-fold (P < 0.0001), 195 and that against the Mu variant was reduced by 2.5-fold (P < 0.0001) and 3.0-fold (P = 0.036), 196 in maternal and cord blood, respectively ( Figure 3A) . NAb activity against the Alpha variant 197 was not significantly different from that against the WT in maternal plasma but was 1.1-fold 198 higher (P = 0.007) than that for the WT in cord plasma. Nine of thirty infected women (30%) did 199 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted December 11, 2021. ; https://doi.org/10.1101/2021.12.09.21267557 doi: medRxiv preprint not exhibit nAb activities against at least one of the five strains tested. infection-elicited nAbs. We found that the TR was <1 when mothers were vaccinated in the third 234 trimester and less than 60 days prior to delivery. When > 60 days passed from first dose 235 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted December 11, 2021. ; https://doi.org/10.1101/2021.12.09.21267557 doi: medRxiv preprint vaccination to delivery, the 73% of the TRs were > 1. Peak TR in our vaccinated cohort was 114 236 days prior to delivery (TR =2.5), which corresponded to vaccination at ~ 24 weeks gestational 237 age. Compared to vaccination, infection-induced antibody transfer did not show significant 238 change over gestation. There was no difference noted in transfer efficiency between the two 239 vaccine manufacturers (not shown). When we analyzed the maternal and cord NT50 values 240 based on the days from exposure to delivery, they were increased with the approach to delivery 241 in vaccinated group ( Figure 4C ). 242 To determine whether differences in nAb activity was explained by lower total IgG 243 levels in patient samples, we analyzed the nAb titers relative to total anti-N and anti-RBD IgG 244 antibodies. Both maternal and cord NT50 titers were significantly correlated with anti-SARS-

CoV-2 IgG titers (Supplemental Figure 3C and 3D). However, greater variability was observed 246 in the infected group, in which Pearson's r was 0.5090 (P < 0.0001) for maternal plasma and 247 0.5500 (P = 0.002) for cord plasma. In the vaccinated group, the correlation between NT50 and 248 total IgG titers in maternal plasma was stronger than that in cord, with a Pearson's r of 0.8821 (P 249 < 0.0001) and 0.6365 (P < 0.0001), respectively.

To obtain a deeper understanding regarding the transplacental transfer of maternal nAb 251 among SARS-CoV-2 strains, we performed clustering analysis of TR by participant ( Figure 4D) . 252 In general, the TR was significantly higher in vaccinated cohort (mean = 1.83) compared to 253 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted December 11, 2021. ; https://doi.org/10.1101/2021.12.09.21267557 doi: medRxiv preprint infected cohort (mean = 1.15; P = 0.0002) (Supplemental Figure 3E) . TR was not significantly 254 influenced by SARS-CoV-2 strains on its own, however, when a stratified analysis based on 255 SARS-CoV-2 strains was conducted, TR for Delta variant was significantly higher in vaccinated 256 cohort than in infected cohort (P = 0.0022) (Supplemental Figure 3F) . 259 We next explored the impact of clinical factors on maternal and cord nAb activity. First, 260 we analyzed fetal sex on nAbs, which has been shown to impact levels of total anti-SARS-CoV-2 261 IgG (11). The median NT50 for male fetuses was lower than females in maternal plasma after 262 first trimester vaccination ( Figure 5A ). Of note, all pregnancies in our cohort that were infected 263 in the first trimester had male fetuses. In contrast, nAb was higher in vaccinated maternal, and 264 infected maternal and cord plasma from mothers with male fetuses in the second trimester. No 265 significant difference by fetal sex was observed after exposure in the third trimester in all groups.

As obesity is associated with chronic inflammation and dysfunctional immune responses, CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted December 11, 2021. ; https://doi.org/10.1101/2021.12.09.21267557 doi: medRxiv preprint vaccinated in the first trimester. Interestingly, we show significant variation in nAb response and 290 nAb transfer between patients. Maternal-fetal transfer efficiency was higher in vaccinated 291 mothers versus infected mothers. Finally, our results demonstrate selective transfer of nAbs of 292 differing specificity from mother to baby. These findings are summarized in Table 2 . 293 Our findings build upon a previous study with a cohort of 30 pregnant women 294 vaccinated in the third trimester showing that mRNA vaccines were immunogenic in pregnancy, 295 but that neutralizing activity against the Alpha and Beta (B.1.351) variants were reduced (34).

Here, we provide data for all trimesters of pregnancy and report on nAb activity against the Delta is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this this version posted December 11, 2021. ; https://doi.org/10.1101/2021.12.09.21267557 doi: medRxiv preprint fetus for individuals who vaccinated in early pregnancy. However, further studies are needed to 380 evaluate the dynamics of antibody stimulation from boosters in pregnancy.

Of note, the patient demographics of the two cohorts were different in race and age. This reflecting that obesity is a risk factor for disease severity in individuals with SARS-CoV-2 392 infection due to reduced respiratory system compliance and impaired innate and adaptive immune 393 responses (57-59). Also, communities of color are at higher risk of obesity due to food apartheid, 394 limited access to healthy foods, food insecurity and communities that do not have high walkability 395 scores or green space. We found that the vaccinated individuals with BMI 25 to 29.9 at delivery 396 can produce the most amount of nAb. Assuming that these patients were of normal BMI (18.5-397 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this this version posted December 11, 2021. ; https://doi.org/10.1101/2021.12.09.21267557 doi: medRxiv preprint 24.9) prior to pregnancy, the result suggested that the vaccine response is most effective in this 398 group compared with overweight or obese individuals.

A prior study showed that maternal SARS-CoV-2-specific IgG antibody production was Maternal blood and infant cord blood used were collected at delivery in an EDTA collection tube 439 and were processed within 24 hours. Plasma was isolated from whole blood by centrifugation at 440 1500rpm for 10min, then aliquoted in the cryovial tubes and stored at -80°C until analysis.

Clinical data was abstracted from the medical record. Acknowledgements: 517 We thank the mothers and infants who participated in this study. Three separate analyses were performed on the trimester at time of first exposure (Red, first 550 trimester; blue, second trimester; yellow, third trimester). Lines connect mother:cord dyads.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint Correlations between the cord to maternal nAb ratio and days from events were analyzed using CoV-2 strain in both vaccinated and infected patients. All patients were ordered according to 558 increasing gestational age (GA) within their groups. N/A, samples are not enough. *P < 0.05; 559 ***P < 0.001; ****P < 0.0001; ns, not significant. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint Inf, infected cohort. *P < 0.05; **P < 0.01; ***P < 0.001; ns, not significant (Wilcoxon signed 589 rank test or multiple linear regression). 

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted December 11, 2021. ; https://doi.org/10.1101/2021.12.09.21267557 doi: medRxiv preprint 

Fetal sex Pregnancies with male fetuses are higher in 2 nd Pregnancies with male fetuses are higher in 2 nd Maternal pre-delivery BMI Women with BMI 25-29.9 are the highest Women with BMI 25-29.9 lower than normal weight Maternal age Maternal Age > 35y is higher in cord ND NT50, neutralizing titer-50; WT, wild type; Vac, vaccinated; Inf, infected; nAb, neutralizing antibody; TR, transfer ratio; BMI, body mass index; 1 st , 2 nd and 3 rd refer to trimester; ND, no difference. *Days from 1 st dose to delivery

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