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Clinical case
Immunogenicity, safety and reactogenicity of a heterogeneous booster following the CoronaVac inactivated SARS-CoV-2 vaccine in patients with SLE: a case series
  1. Theerada Assawasaksakul1,
  2. Seelwan Sathitratanacheewin2,
  3. Preeyaporn Vichaiwattana3,
  4. Nasamon Wanlapakorn3,
  5. Yong Poovorawan3,4 and
  6. Wonngarm Kittanamongkolchai5,6,7
  1. 1Division of Rheumatology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
  2. 2Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
  3. 3Center of Excellence in Clinical Virology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
  4. 4FRS(T), the Royal Society of Thailand, Sanam Sueapa, Dusit,Bangkok, Thailand
  5. 5Mahachakri Sirindhorn Clinical Research Center, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
  6. 6Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
  7. 7Renal Immunology and Transplantation Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
  1. Correspondence to Dr Wonngarm Kittanamongkolchai; wonngarm.k{at}chulacrc.org

Abstract

Since the COVID-19 pandemic, CoronaVac, an inactivated SARS-CoV-2 vaccine, has been widely deployed in several countries for emergency use. However, the immunogenicity of the inactivated vaccine was relatively lower when compared to other vaccine types and was even more attenuated in autoimmune patients with rheumatic disease. A third-dose SARS-CoV-2 vaccination in immunosuppressed population is recommended in order to improve immune response. However, the data were limited to those initially received mRNA or viral vector SARS-CoV-2 vaccine. Thus, we aimed to describe the safety, reactogenicity and immunogenicity of patients with systemic lupus erythematosus (SLE) who received a heterogenous booster SARS-CoV-2 vaccine following the initial CoronaVac inactivated vaccine series. Our findings support that the third booster dose of mRNA or viral vector vaccine following the inactivated vaccine is well tolerated and elicited a substantial humoral and cellular immune response in inactive patients with SLE having maintenance immunosuppressive therapy without interruption of immunosuppressive medications.

  • lupus erythematosus
  • systemic
  • COVID-19
  • vaccination
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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Key messages

  • The immunogenicity of the CoronaVac inactivated vaccine has been shown to be lower when compared to other vaccine types and more attenuated in patients with autoimmune rheumatic disease; booster data of mRNA or viral vector SARS-CoV-2 vaccine following the inactivated vaccine in immunosuppressed patients are lacking.

  • The third booster dose of mRNA or viral vector vaccine following the inactivated vaccine is well tolerated and elicits a substantial humoral and cellular immune response in inactive patients with systemic lupus erythematosus (SLE) receiving maintenance immunosuppressive therapy.

  • The findings support the use of mRNA or viral vector vaccine as a third booster dose vaccine in patients with SLE who have previously received CoronaVac inactivated vaccine.

CoronaVac, an inactivated SARS-CoV-2 vaccine, has been widely deployed in several countries for emergency use. The immunogenicity of the inactivated vaccine has been shown to be substantially lower when compared with other vaccine types1 and more attenuated in patients with autoimmune rheumatic disease.2 Cumulative evidence suggests that a third dose of SARS-CoV-2 vaccination in immunosuppressed populations improve immune response. Booster data have so far been limited to persons initially receiving mRNA or viral vector SARS-CoV-2 vaccine.3 4 We aimed to describe the safety, reactogenicity and immunogenicity of patients with systemic lupus erythematosus (SLE) who received a heterogeneous booster SARS-CoV-2 vaccine following an initial CoronaVac inactivated vaccine series.

Between July and August 2021, eight healthcare workers in Thailand with known SLE who had previously completed the CoronaVac series received a third booster dose of SARS-CoV-2 mRNA (Pfizer) (n=7) or adenovirus vector vaccine (ChAdOx1(1) (2)) (n=1). All were female, with a median age of 28 years (IQR 22–48 years). Half of the participants were on antimetabolite therapy or calcineurin inhibitor. Immunosuppressive medications were not altered or interrupted during the peribooster period. The median interval between the completion of CoronaVac vaccine and the booster vaccination was 92 days (IQR 84–96) (table 1).

Table 1

Characteristics of patients with SLE receiving booster vaccine

Prior to the booster dose, all patients had low-positive antispike antibodies with a median level of 83.3 (IQR 31.6–341.6) U/mL, which rose to a median of 19,986 (IQR 15 079–59 735) U/mL at day 14 after the booster vaccination (table 1). Antinucleocapsid antibodies were undetectable in patients 7 and 8, who had a robust humoral response, implying that there was no recent COVID-19 infection resulting in the high antibody titre. NeutraLISA (Euroimmun, Lübeck, Germany) was used to test prebooster and postbooster samples for neutralising activity against the SARS-CoV-2 wild type. Before the booster vaccination, all except patient 7 had negative sVNT results (<35% inhibition). After the booster dose, all patients elicited a strong immune response with at least 95% inhibition.

Cellular immunogenicity was assessed at day 14 after the booster vaccination using direct ex vivo interferon gamma enzyme-linked immunosorbent spot assay with peripheral blood mononuclear cells. The majority of patients had strong cellular immune responses, except patients one and three who received more intensive immunosuppressive therapy including mycophenolate mofetil, azathioprine and calcineurin inhibitor (62–88 spot-forming cells/106 per million peripheral blood mononuclear cells (PBMC)). While patient 4, who received a viral vector booster, had a lower humoral response (antispike antibody 6098 U/mL vs 15 076–85 024 U/mL in mRNA booster), the cellular immunogenicity was comparable to those receiving the mRNA booster.

During the study period, none of the patients experienced an SLE flare. The reactogenicity was mild and self-limiting but more prevalent in the booster dose than in the initial CoronaVac vaccination (online supplemental figure 1). The most common complaint was injection site pain followed by fatigue and fever.

Given the growing concern regarding the immunogenicity of the inactivated vaccine in immunosuppressed autoimmune patients, this is the first study to show improved humoral and cellular response to the heterogeneous booster vaccine in patients with SLE who had previously received an inactivated vaccine. In our SLE cohort, we observed a stronger humoral immunogenicity to an additional vaccine dose than previously reported among organ transplant recipients, autoimmune disease patients and healthy individuals receiving triple-dose CoronaVac vaccines.3–5 This is possibly due to the younger age, lower immunosuppressive therapy, and different initial and booster vaccine types in our cohort. It is known that the cellular immune response caused by inactivated vaccines is generally weak. Our findings show that a booster dose of mRNA or viral vector vaccine enhanced strong cellular immune responses, though responses were weaker in those given an antimetabolite or calcineurin inhibitor.

This study is limited by its observational study design and small sample of patients. It also may not offer generalisability to active patients with SLE having a higher dose of immunosuppressive therapy.

The SARS-CoV-2 pandemic continues to put immunosuppressed autoimmune patients at great risk of severe disease and death. Data attempting to isolate an optimum SARS-CoV-2 vaccine regimen for this group are scarce. Our findings provide support that the third booster dose of mRNA or viral vector vaccine following the inactivated vaccine is well tolerated and elicit a substantial humoral and cellular immune response in inactive patients with SLE receiving maintenance immunosuppressive therapy. Further studies are required to tailor the vaccine regimen according to a person’s immune status.

Ethics statements

Patient consent for publication

Acknowledgments

The authors thank Ms Sukanlaya Yoosomsuk and Ms Jariya Pongsaisopon for coordinating the study. Thanks are also due to Dr Supranee Buranapraditkun and Dr Sasiwimol Ubolyam for enzyme-linked immunosorbent spot testing, and Ms Sutthinee Lapchai for sample preparation and coding.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Contributors TA, SS and WK contributed to the conception and design of the work; acquisition, analysis, interpretation of data; and drafting and revising of the work. YP, PV and NW contributed to data acquisition and final approval of the version to be published.

  • Funding This study was supported by a Rajadapisek Sompot grant.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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