key: cord-0330346-f5ehoupk
authors: Ogura, W.; Ohtsuka, K.; Matsuura, S.; Okuyama, T.; Matsushima, S.; Yamasaki, S.; Miyagi, H.; Sekiguchi, K.; Ohnishi, H.; Watanabe, T.
title: Can individuals with low antibody responses to vaccines against other viruses acquire adequate SARS-CoV-2 antibody after vaccination with the BNT162b2 mRNA vaccine?
date: 2021-12-27
journal: nan
DOI: 10.1101/2021.12.26.21268358
sha: 86542a2dae8f1a4f80586e557610cae5dbaaa288
doc_id: 330346
cord_uid: f5ehoupk

Objective In Japan, healthcare workers (HCWs) are vaccinated against coronavirus disease (COVID-19) and other contagious viruses (measles, rubella, chickenpox, mumps, and hepatitis B) to prevent nosocomial infection. However, some do not produce sufficient antibodies after vaccination (low responders). This study investigated changes in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody levels among HCWs after SARS-CoV-2 vaccination and assessed whether low responders produced adequate SARS-CoV-2 anti-spike and neutralizing antibodies. Methods We conducted a prospective cohort study of HCWs before and after vaccination with the BNT162b2 mRNA vaccine in a hospital in Tokyo, Japan. The HCWs received two doses of BNT162b2 vaccine, 3 weeks apart. Those whose antibody levels against previous antiviral vaccines did not reach protective antibody levels after receiving two doses were defined as low responders, whereas those who produced adequate antibodies were defined as normal responders. SARS-CoV-2 anti-spike antibodies were measured 11 times from before the first BNT162b2 vaccination to 5 months after the second vaccination. SARS-CoV-2 neutralizing antibody activity was measured twice in low responders, 1 week to 1 month and 5 months after the second vaccination. Results Fifty HCWs were included in the analytic cohort. After vaccination, SARS-CoV-2 anti-spike antibody was detectable in the samples from both responders at each timepoint, but the level was lower at 5 months than at 1 week after the second vaccination. Low responders had SARS-CoV-2 neutralizing antibody activity 1 week to 1 month after the second vaccination, which exceeded the positive threshold after 5 months. Conclusion After BNT162b2 vaccination, low responders acquired adequate SARS-CoV-2 anti-spike and SARS-CoV-2 neutralizing antibodies to prevent SARS-CoV-2. However, SARS-CoV-2 anti-spike antibody levels were lower at 5 months than at 1 week after the second dose of BNT162b2 vaccine in low and normal responders. Therefore, low responders should also receive a third dose of BNT162b2 vaccine.

Coronavirus disease (COVID- 19) , which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become a pandemic [1] [2] [3] [4] . In view of the high number of cases of severe illness and death due to COVID-19, vaccination against SARS-CoV-2 infection is crucial.

SARS-CoV-2 has an enveloped, single, positive-stranded RNA genome that encodes four major viral structural proteins, namely, the nucleocapsid, spike, envelope, and membrane proteins; the latter three proteins are found in its membrane. The spike protein guides viral entry into host cells by binding to angiotensin-converting enzyme 2 (ACE2) receptors, which are widely expressed on epithelial cells and macrophages [5] [6] [7] and is thus an ideal target for messenger RNA (mRNA) vaccine development.

The BNT162b2 mRNA vaccine (Pfizer-BioNTech) is highly effective at preventing clinically significant COVID-19 [8] [9] [10] , reducing the incidence of asymptomatic . CC-BY-ND 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted December 27, 2021. ;  https://doi.org/10.1101/2021.12. 26.21268358 doi: medRxiv preprint infection and associated infectivity [11, 12] , and preventing the spread of COVID-19 [9] .

The BNT162b2 vaccine was the first SARS-CoV-2 vaccine to be approved in Japan, and priority vaccination of healthcare workers (HCWs) began in February 2021 in order to safeguard the medical delivery system [13] .

HCWs have a high risk of infection with contagious viruses such as measles, rubella, chickenpox, mumps, and hepatitis B; therefore, in order to prevent nosocomial infections, HCWs are vaccinated against these viruses and viral antibody titers are measured [14] . Even after vaccination, some individuals do not develop adequate antibody titers against contagious viruses (low responders). It is unclear whether low responders would produce adequate SARS-CoV-2 antibodies and acquire SARS-CoV-2 neutralizing antibody activity after vaccination with the BNT162b2 vaccine. Therefore, we investigated whether low responders would acquire SARS-CoV-2 anti-spike and SARS-CoV-2 neutralizing antibody activity after vaccination with the BNT162b2 vaccine.

We carried out a prospective cohort study of 50 HCWs. This study was conducted with the approval of the Ethics Committee of Kyorin University School of Medicine (Number R02-041; May 19, 2020). Informed consent was obtained from all study participants.

. CC-BY-ND 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The study was conducted at Kyorin University Hospital in Tokyo, Japan. HCWs at the hospital received two doses of BNT162b2 vaccine, 3 weeks apart. The participants were HCWs at the hospital who agreed to participate in the study and to periodically donate blood samples before and after vaccination. Those whose antibody levels were below the standard values for preventing infection after receiving two or more doses of vaccine against measles, rubella, chickenpox, mumps, or hepatitis B viruses, were considered as low responders.

SARS-CoV-2 anti-spike antibody measurements were performed on serum obtained from centrifuged peripheral blood using the Elecsys Anti-SARS-CoV-2 S RUO (Roche Diagnostics International Ltd, Rotkreuz, Switzerland) on a Cobas 6000 (Roche Diagnostics) analyzer via the double-antigen sandwich enzyme-linked immunoassay method [15] . Samples were collected before the first dose of BNT162b2 vaccine was administered; 3 days after the first vaccination; 1, 2, and 3 weeks after the first vaccination; 1 week after the second vaccination; and 1, 2, 3, 4, and 5 months after the second vaccination. The measurement range of the antibody titer was 0.4-250 and ≥250 U/mL, measured after dilution.

Using serum obtained from the peripheral blood of low responders after vaccination, SARS-CoV-2 neutralizing antibody activity was measured at the Osaka University Microbial Disease Research Association laboratory. A 50% inhibitory dilution factor (ID50) using pseudovirus [16] was measured, and ID50 values ≥50 were considered . CC-BY-ND 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted December 27, 2021. ; https://doi.org/10.1101/2021.12.26.21268358 doi: medRxiv preprint positive [17] . For the neutralization assay, 60 μL of pseudovirus, which is equivalent to 2.5×10 6 

Nonparametric continuous data are reported as median and interquartile range (IQR).

The Mann-Whitney U test was used to assess whether differences between cohorts were statistically significant. Two-sided P-values <0.05 were considered statistically significant. The Wilcoxon matched-pairs signed rank test was used to assess whether differences in antibody levels within an individual at different time points were statistically significant. All statistical analyses were performed with EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), which is a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria) [18] . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted December 27, 2021. ; https://doi.org/10.1101/2021.12.26.21268358 doi: medRxiv preprint Specifically, EZR is a modified version of R commander (version 1.54) that has been designed to add statistical functions frequently used in biostatistics.

The low responders comprised three males (L1, L2, L4) with a negative (titer <16.0) anti-measles immunoglobulin G (IgG) antibody titer after measles virus vaccination and one female (L3) with a negative (titer <4.0) anti-mumps IgG antibody titer after mumps virus vaccination. Forty-six participants, comprising 12 males and 34 females, had antiviral antibody titers after vaccination against other viruses above the standard value (normal responders). The four low responders were aged in their 20s or 40s, and all were non-smokers and non-obese. Moreover, none of them had a history of taking immunosuppressive drugs or having a disease that causes immunosuppression.

The median (IQR) SARS-CoV-2 anti-spike antibody was 2251.5 (1639.0-3276.3) in normal responders and 3721.0 (3255.0-4983.3) in low responders 1 week after receiving the second dose of BNT162b2 vaccine. This difference was statistically significant (P <0.05) ( Table 1 and Fig 1A) . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted December 27, 2021. ; https://doi.org/10.1101/2021.12.26.21268358 doi: medRxiv preprint 666.7 (578.9-880.6) at 1 week and 5 months, respectively, after receiving the second dose of BNT162b2 vaccine (Table 1 and Fig 1B, C) .

SARS-CoV-2 anti-spike antibody was produced by both low and normal responders, but the level was lower at 5 months than at 1 week after the second vaccination (Table 1 and Fig 1A, B, C) . Table 1 is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted December 27, 2021. ; https://doi.org/10.1101/2021.12.26.21268358 doi: medRxiv preprint respectively, at 1 month after receiving the second dose of BNT162b2 vaccine. In the 5 months after the second vaccination, SARS-CoV-2 neutralizing antibody titers were 105.5, 147.7, 485.2, and 894.4 in L1, L2, L3, and L4, respectively. All four low responders had neutralizing antibody activity within the protective range from the 1 week to 1 month and 5 months after the second vaccination (Table 2 and Fig 2) . The SARS-CoV-2 neutralizing antibody level in low responders was lower at 5 months after receiving the second dose of BNT162b2 vaccine than at 1 week to 1 month after receiving the second dose, but this difference was not statistically significant (P =0.27). is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted December 27, 2021. ; https://doi.org/10.1101/2021.12.26.21268358 doi: medRxiv preprint

The BNT162b2 vaccine has been highly effective in preventing clinically significant COVID-19 [8] [9] [10] . However, limited information is available about the effectiveness of the BNT162b2 vaccine in individuals who have produced insufficient antibodies in response to other antiviral vaccines such as measles and mumps vaccines (low responders). In this study, in the quantitation of SARS-CoV-2 anti-spike antibody after vaccination with the BNT162b2 vaccine, SARS-CoV-2 anti-spike antibody production was confirmed in low responders, as well as in those who had had an adequate antibody response to previous antiviral vaccines.

Muik et al. [19] measured the neutralization efficacy of sera from 40 healthy German subjects immunized with the BNT162b2 vaccine and a 50% inhibitory dilution factor is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted December 27, 2021. ; https://doi.org/10.1101/2021.12.26.21268358 doi: medRxiv preprint using pseudovirus by the same method we used. We assumed these 40 subjects to be normal responders and compared their responses to those of the low responders in this study. The SARS-CoV-2 neutralizing activity of the low responders in this study 1 week to 1 month after receiving the second dose of BNT162b2 vaccine was comparable to that of subjects in the German study. All four low responders also developed protective levels of neutralizing antibodies. Therefore, our results confirm the findings of previous studies that have reported that vaccination with the BNT162b2 vaccine provides sufficient humoral immunity within the first month after receiving a second dose of vaccine [20] .

Although neutralizing antibody activity was examined in only four participants, the SARS-CoV-2 neutralizing antibody activity value in the fifth month after the second dose of BNT162b2 vaccine did not show a significant decrease in activity compared to that 1 week to 1 month after receiving the second dose of BNT162b2 vaccine. In normal responders, the SARS-CoV-2 anti-spike antibody titer was significantly lower at 5 months after the second dose of BNT162b2 vaccine than at 1 week after the second dose. However, the decrease in antibody titers in the low responders was not statistically significant.

Antibody levels produced after measles-mumps-rubella vaccination tend to decrease almost 15 years after the first dose [21] . The SARS-CoV-2 anti-spike antibody level is known to peak and then decrease within months after the second vaccination reduced is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted December 27, 2021. ; https://doi.org/10.1101/2021.12.26.21268358 doi: medRxiv preprint [22, 23] . In order to achieve adequate COVID-19 disease control, a third dose of SARS-CoV-2 mRNA vaccine is needed, which is already being administered in many countries [22] . Therefore, we recommend that both low and normal responders receive a third dose of BNT162b2 vaccination.

Measles, rubella, chickenpox, and mumps vaccines are live attenuated vaccines that weaken the toxicity of pathogenic microorganisms, and hepatitis B vaccines are inactivated vaccines that cause pathogenic microorganisms to lose their ability to infect [24] . Low responders do not have effective immune induction after viral vaccinations.

The risk factors for low response to viral vaccines include male sex and age >40 years, smoking, obesity, chronic diseases, and genetic factors. In addition, approximately 2- [27] . With regard to SARS-CoV-2 anti-spike antibody production after SARS-CoV-2 vaccination, smoking has the greatest effect on SARS-CoV-2 low antibody titers after vaccination with the BNT162b2 vaccine, and antibody levels are also significantly lower values in patients with hematological malignancies [28, 29] . A recent study of 658 organ transplant recipients showed that they had a lower SARS-CoV-2 anti-spike antibody response after receiving the second dose of BNT162b2 vaccine than did immunocompetent study participants [30] . Another study found that . CC-BY-ND 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint In conclusion, after two doses of the BNT162b2 vaccine, both low and normal responders to previous antiviral vaccines developed adequate levels of SARS-CoV-2 anti-spike and SARS-CoV-2 neutralizing antibodies to protect against SARS-CoV-2.

However, both low and normal responders had lower SARS-CoV-2 anti-spike antibody levels in the fifth month than in the first month after receiving the second dose of is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted December 27, 2021. ; https://doi.org/10.1101/2021.12.26.21268358 doi: medRxiv preprint

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We thank the HCWs of the Department of Clinical Laboratory, Kyorin University Hospital involved in the SARS-CoV-2 antibody monitoring for their valuable contribution.