Two Doses of COVID-19 Vaccine Inadequate for Immunosuppressed Patients With AAV

Findings from a recent study suggest that immunosuppressed patients with antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) may not gain adequate protection against the B.1.617.2 (delta) variant of COVID-19 after standard 2-dose COVID-19 vaccination. While most individuals showed a strong neutralizing antibody activity against the delta variant after a third dose with BNT162b2(BioNTech/Pfizer vaccine), patients receiving rituximab maintenance therapy showed no humoral vaccine response even after a third vaccine dose.

For immunosuppressed patients with AAV, humoral and cellular immune responses after the standard 2-dose COVID-19 vaccination are reduced. With certain variants of COVID-19, such as the delta variant, exhibiting higher transmissibility and partial immune escape, AAV patients with lower neutralizing antibody levels may become particularly susceptible. Additional booster vaccination may be required for this patient population.

Researchers performed a prospective observational study of 21 patients with AAV on immunosuppressive maintenance therapy, from 3 different German vasculitis centers with the goal of investigating humoral responses against the delta variant after a third vaccine dose with BNT162b2. All participants met the 2017 provisional American College of Rheumatology /European League Against Rheumatism criteria for AAV.

The authors explained, “We investigated antispike S1 IgG and surrogate neutralizing antibodies a median (IQR) of 23 (21–58) days after standard two-dose COVID-19 vaccination, immediately before a third vaccine dose, as well as a median (IQR) of 21 (21–21) days after third vaccination.

The third vaccine dose was administered a median (IQR) of 103 (72–126) days after second vaccination.”

After a second vaccination, only 38% of patients showed neutralizing activity against the delta variant, which dropped to 13% directly before the third vaccination. Three weeks after the third vaccine dose, 57% of the patients exhibited neutralizing antibody activity against the delta variant.

The authors also noted that “patients receiving rituximab maintenance therapy had significantly lower anti-S1 IgG, surrogate neutralizing and B.1.617.2 neutralizing antibody levels after third vaccination compared with patients not receiving rituximab treatment.”

When excluding patients on rituximab maintenance therapy, 92% of participants showed neutralizing activity against the delta variant, while none of the patients on rituximab showed neutralizing activity after a third vaccine dose.

—Allison Casey

Reference:
Speer C, Tollner M, Benning L, et al. Third COVID-19 vaccine dose with BNT162b2 in patients with ANCA-associated vasculitis. Ann Rheum Dis. Published online first: January 10, 2022. doi:10.1136/annrheumdis-2021-221747