Should COVID-19 Quantitative Antibody Titers be Implemented to Guide COVID-19 Booster Vaccinations Regardless of HIV Status, Immunosuppression, or Age?
Conditions: COVID-19, COVID-19 Vaccines, Immunogenicity, Vaccine
Sponsor: Epividian

 
 
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“Should COVID-19 Quantitative Antibody Titers be 
Implemented to Guide COVID-19 Booster Vaccinations 
Regardless of HIV status, Immunosuppression, or Age?” 
 
Study Protocol 
Version 2.5 
 
 
 
 
 
 
 
 
 
Prepared by: 
Ricky K. Hsu, Laurence Brunet, and Jennifer S. Fusco 
 
October 29, 2021 

 
 
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Table of Contents 
Contents 
1. SYNOPSIS .............................................................................................................................................................. 3 
2. INTRODUCTION .................................................................................................................................................. 4 
BACKGROUND................................................................................................................................................... 4 
RATIONALE FOR THE STUDY .................................................................................................................................. 6 
3. RESEARCH OBJECTIVES ................................................................................................................................. 7 
PRIMARY OBJECTIVE(S) ........................................................................................................................................ 7 
SECONDARY OBJECTIVE(S) ................................................................................................................................... 7 
4. DATA SOURCE ..................................................................................................................................................... 8 
AHF MIDTOWN MANHATTAN HEALTHCARE CENTER ........................................................................................... 8 
DESCRIPTION OF THE DATABASE AND PREPARATION OF ANALYTICAL FILES ........................................................ 8 
5. STUDY POPULATION ....................................................................................................................................... 11 
INCLUSION CRITERIA ........................................................................................................................................... 11 
EXCLUSION CRITERIA ........................................................................................................................................... 11 
6. STUDY DESIGN .................................................................................................................................................. 12 
OVERVIEW OF STUDY DESIGN .............................................................................................................................. 12 
EXPOSURES OF INTEREST ..................................................................................................................................... 12 
SUBGROUPS OF INTEREST ..................................................................................................................................... 12 
STUDY ENDPOINTS ............................................................................................................................................... 12 
STUDY COVARIATES............................................................................................................................................. 13 
7. STATISTICAL ANALYSIS ................................................................................................................................ 14 
ANALYSIS OF DEMOGRAPHICS/BASELINE CHARACTERISTICS ............................................................................... 14 
ANALYSIS OF PRIMARY OBJECTIVES ..................................................................................................................... 14 
ANALYSIS OF SECONDARY OBJECTIVES ................................................................................................................ 15 
SENSITIVITY ANALYSES ....................................................................................................................................... 15 
SUBGROUP ANALYSES ......................................................................................................................................... 16 
8. STUDY CONDUCT ............................................................................................................................................. 17 
REGULATORY AND ETHICAL CONSIDERATIONS .................................................................................................... 17 
INFORMED CONSENT ............................................................................................................................................ 17 
DATA PRIVACY & PERSONALLY IDENTIFIABLE INFORMATION (PII) ............................................................... 17 
ADVERSE EVENT REPORTING .............................................................................................................................. 17 
9. ADMINISTRATIVE MATTERS ....................................................................................................................... 18 
QUALITY ASSURANCE ......................................................................................................................................... 18 
10. REFERENCES ..................................................................................................................................................... 19 
 

 
 
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1. Synopsis 
Little real-world data are available on the antibody response after COVID-19 vaccination in HIV-
negative and HIV-positive individuals, the potential usage of quantitative antibody testing to 
determine those at greatest risk for infection while helping guide additional vaccination timing, 
and the antibody response of vaccine boosting in individuals with no response or low response 
to initial vaccinations. At the moment, clinicians must rely on general category 
recommendations and clinical judgement when advising their patients on the utility of vaccine 
boosting, as well as their level of protection from COVID vaccination. Real-world evidence is 
needed to better inform such decisions. The aim of this study is to assess levels of COVID-19 
vaccine response through measuring surrogate Ig spike antibody measurements, to determine 
the rates of antibody level decay after vaccination, and to measure the efficacy of utilizing 
these antibody measurements to help guide the timing of booster doses among HIV-negative 
and HIV-positive patients.  
 
The study population will include adults who were fully vaccinated against SARS-CoV-2 virus 
(i.e., two doses of Pfizer or Moderna vaccines or one dose of the J&J vaccine), and have 
received a Roche SARS-CoV-2 Semi-Quant Spike Ig Ab test at least 3 weeks after full vaccination 
as part of their usual clinical care at AHF Midtown Manhattan Healthcare Center. 
 
Incidence rates of COVID vaccine response levels (i.e., adequate, low, non-response) will be 
estimated using univariate Poisson regression, overall and by vaccine type. Among individuals 
with at least two antibody measurements, rates of antibody levels decay will be estimated 
using univariate linear regression, overall and stratified by HIV status, vaccine type and baseline 
CD4 cell count. In the sub-population of individuals who received a COVID vaccine booster, 
vaccination and antibody response will be characterized at least 3 weeks after the booster is 
received. Univariate linear regression will be used to estimate rates of antibody levels decay, 
among individuals with at least two antibody measurements, including one after the booster 
dose. Rates of response decay will be produced overall, and stratified by HIV status, booster 
type and baseline CD4 cell count. 
 

 
 
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2. Introduction 
BACKGROUND 
Currently, there is little guidance as to when to give a COVID-19 booster vaccine, particularly for 
those under the age of 65, the non-immunosuppressed, and with those with different types of 
immune modifying conditions.  Clinicians have thus been asked to use clinical judgement and 
patient discussion to determine if such a booster vaccine is appropriate, leading to great 
variability in practices. In addition, there is limited real-world evidence of vaccination response 
both amongst vaccination type and amongst differing patient populations.  Hence, individuals 
who have been vaccinated, may assume they are protected, but in actuality have not 
developed, or sustained a protective antibody response.  Conversely, some people may fall into 
a category for which vaccinations may be given, but there are limited data to support giving an 
additional dose of vaccine, especially if they lie outside the guidance established for the age 
over 65 and immunosuppressed patient populations.   However, the potential need to 
proactively give additional vaccinations in this population are exemplified in studies in Israeli 
healthcare workers as well as in the general population which show that post vaccination 
waning antibody levels are highly correlated with risk of re-infection, severe disease, and 
hospitalization and booster vaccination is correlated with decreased incidence rates.i,ii  In 
contrast, those patients with sufficient antibody titers, who otherwise would have received an 
additional vaccine through general age and timeline guided recommendations, would no longer 
need to receive the additional vaccination, thus potentially conserving resources for those in 
greatest need such as for countries deficient in primary vaccinations.  Although the totality of 
an individual’s immune response from a primary vaccine series may mostly control severe 
COVID-19 illness leading to hospitalizations, in states where there are inadequate primary 
vaccination rates, even mildly symptomatic vaccinated carriers of the virus may serve as 
sources for the continued propagation of SARS-CoV-2 infection and further inhibition of 
pandemic control.  Super-spreader congregations of even mostly vaccinated populations, like in 
the outbreak reported by the MMWR in Massachusetts, further exemplify the continued 
propagation of the virus to both vaccinated and unvaccinated individuals.iii 
 
Additional vaccine doses may be particularly important for healthcare providers who are often 
in direct contact or close proximity to SARS-CoV-2 infected individuals, where resurgences of 
SARS-CoV-2 infection have been reported across the U.S., especially in the era of the SARS-CoV-
2 Delta strain.iv,v In addition, the odds of long COVID-19 symptomology were estimated in one 
study to be 50% less in the vaccinated versus the insufficiently immunized population.vi In 
contrast, those healthcare workers who have sufficient immunogenicity against prevalent SARS-
CoV-2 strains, may not fit the compartmentalization into time-based vaccination strategies, but 
rather individualized immunologic responses to vaccinations.  Furthermore, due to the 

 
 
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interpersonal variability of immunologic response, differences in the attenuation of individual 
antibody levels, and the complexity added by the availability of different vaccines, dosing 
regimens, and decay rates, a better methodology for determining when a specific individual 
requires re-vaccination should be determined.  With no current correlations of protection, 
especially in populations in which preventing infection is the goal, the higher the antibody titer 
the better.  Studies have demonstrated that those who were vaccinated for SARS-CoV-2 are 
generally in favor for receiving additional booster doses.  Furthermore,  an increase in 
significant adverse events, other than lymphadenopathy, have not been reported in recipients 
of additional SARS-CoV-2 vaccine doses beyond the primary series.vii  The effectiveness of 
additional booster vaccination over the primary vaccination series in preventing re-infection 
with SARS-CoV-2 for currently available vaccine types have been demonstrated in a number of 
studiesviii,ix,, only the timing of when and to whom to give booster dosing remains in debate.  
Lastly, multiple studies illustrate that the maximizing of timing between vaccination doses, 
regardless of mRNA or adenovirus vaccination type, results in improved immunologic responses 
both in initial degree, but also in the persistence of response.x,xi,xii,xiii   
 
Neutralizing antibody levels are predictive of immune protection from symptomatic SARS-CoV-
2 infection and are correlated with commercially available measurements with semi-
quantitative spike Ig antibodiesxiv,xv.  Although antiviral T and B cell memory cells can confirm 
additional degree of protection, current rapidly proliferating COVID-19 strains like the Delta 
strain may have shorter incubation periods that may not allow time for primed B and T memory 
cells to be activated, so protection would be more dependent on sufficient circulating 
antibodies.   Furthermore, the high R correlation of neutralizing antibodies and spike Ig 
antibody responses have been strongly associated with viral neutralization and inhibition of 
viral-cell fusion.xvi,xvii A 50% protective neutralization level has been found to equate to a 
measured in vitro neutralization titer of between 1:10 and 1:30 is approximated at 54 IU/mL for 
wild-type COVID-19 Virus [95% CI: 30–96 IU/mL]),xviii whereas 5x that level, or approximately 
250 IU/mL is the expected Spike Ig ab level correlated with in vitro neutralization of the 
predominant Delta strain of COVID-19.xix 
 
Clinical decision-making and public health policies relating to COVID-19 have been evolving 
rapidly, sometimes based on a sparse body of literature. Given the high stakes of such 
decisions, there is an urgent need for more real-world evidence to inform clinical practice and 
public health guidelines.   
 
 
 
 

 
 
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RATIONALE FOR THE STUDY 
Limited real-world data are available on the antibody response after COVID-19 vaccination 
comparing HIV-negative and HIV-positive individuals.  There are also limited information that 
would allow the potential usage of quantitative antibody testing to determine those at greatest 
risk for infection while could help in guiding the timing of additional vaccinations.  There are 
also limited information on the antibody response of vaccine boosting in individuals, especially 
those with altered immune response that might lead to no response or low response to the 
primary vaccination series. At the moment, clinicians must rely on clinical judgement when 
advising their patients on the utility of vaccine boosting, as well as their level of protection from 
COVID vaccination. Additional information would be helpful in informing decisions on third 
doses in different populations such as HIV positive people, whose responses to COVID-19 
vaccine and immune status would help define the timing and need for an additional vaccination 
based on current recommendations.  Real-world evidence is needed to better inform such 
decisions. 
 

 
 
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3. Research Objectives 
PRIMARY OBJECTIVE(S) 
Objective #1: Describe COVID-19 vaccine response including frequency of non-response, low 
response, and adequate response as measured by antibody test by HIV status (e.g., rates, and 
relationship to demographic and clinical characteristics, as well as vaccine types) 
 
Objective #2: Describe rate of decline in antibody levels over time by HIV status, vaccine type, 
and baseline CD4 count after initial vaccination as well as other parameters. 
SECONDARY OBJECTIVE(S) 
Objective #3: Describe response to COVID-19 boosters given (vaccine types, concordant vs. 
discordant boosters, duration from initial vaccine completion, antibody response, and side 
effects) 
 
Objective #4: Describe rate of decline in antibody levels over time by HIV status, baseline CD4 
count, by vaccine given, and after booster vaccination 
 
Objective #5: Recording breakthrough infections after vaccinations and assessing antibody 
levels pre-breakthrough infection 

 
 
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4. Data Source 
AHF MIDTOWN MANHATTAN HEALTHCARE CENTER 
The AHF Midtown Manhattan Healthcare Center is part of the AIDS Healthcare Foundation 
(AHF) network. AHF is a global nonprofit organization providing cutting-edge medicine and 
advocacy to over 1,500,000 people in 45 countries. Currently, the AHF Midtown Manhattan 
Healthcare Center provides care for 993 HIV-positive and 946 HIV-negative individuals who 
have had at least one clinical contact in the past 24 months.  
 
Among HIV-positive patients active in care at AHF Midtown Manhattan Healthcare Center, the 
median age is 53 years (IQR: 38, 61); 95% are men, 22% are Black and 19% are Hispanic. Most 
HIV-positive patients have their healthcare covered by commercial insurance (52%), Medicaid 
(29%), Medicare (16%) and/or ADAP/Ryan White (14%). The median follow-up time at AHF 
Midtown Manhattan Healthcare Center is 7.3 years (IQR: 2.3, 8.6); 14% have at least 10 years of 
follow-up. 
 
Among HIV-negative patients active in care at AHF Midtown Manhattan Healthcare Center, the 
median age is 44 years (34, 56); 91% are men, 11% are Black and 16% are Hispanic. Most have 
their healthcare covered by commercial insurance (70%) or Medicaid (18%). The median follow-
up time at AHF Midtown Manhattan Healthcare Center is 4.9 years (IQR: 1.6, 7.9); 8% have at 
least 10 years of follow-up. 
DESCRIPTION OF THE DATABASE AND PREPARATION OF ANALYTICAL FILES 
The OPERA® (Observational Pharmaco-Epidemiology Research & Analysis) database and 
research network is a multi-site observational database built from the complete patient health 
records managed in Electronic Health Record (EHR) systems from more than 400 participating 
caregivers at 142 separate locations throughout the U.S. (see coverage map, Figure 1).  Through 
their membership in OPERA, medical practices meet the Centers for Medicare & Medicaid 
Services (CMS) Merit-based Incentive Payment System (MIPS) Incentive Program for Integration 
with a Specialized Registry.  OPERA-participating physicians and ancillary healthcare providers 
have documented the care of nearly 1 million patients in their EHRs, including over 135,000 
people living with HIV (PLWH) of which approximately 20% are women, 47% are Black, 20% are 
Hispanic and representing 11% of all the PWLH in the U.S. The OPERA database is refreshed 
from these EHR systems at each clinic on a daily basis providing up-to-date data for both 
clinicians and researchers.  In total, there are more than 7 million documented prospective 
visits in the EHR systems for PLWH and 3 million prescriptions written for ART medications. The 
average years of follow-up (years of documenting patient visits prospectively in the EHR) for 

 
 
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PLWH in OPERA is 4.2 years and there are over 19,000 PLWH who have 10 years or more of 
follow-up. 
 
 
 
Figure 1. U.S. Map of OPERA HIV+ Population & CDC (2010) State-by-State Estimates 
 
 
Data Aggregation Methodology: 
Epividian provides participating clinicians with a variety of analytical reports that support the 
day-to-day care of patients, the management of their patient populations as well as their 
interventional and non-interventional research efforts. By utilizing these practice reports via 
the CHORUSTM portal and by pooling data in OPERA® with other clinics, clinicians can measure 
and compare quality-of-care anonymously as well as collaborate on research endeavors with 
colleagues in other geographic regions. As a result, all parties have a vested interest in 
maintaining the completeness and accuracy of the medical records stored in the EHR systems. 
 
Epividian utilizes a number of proprietary algorithms to sort, classify, and aggregate the data 
pulled from the participating clinics’ EHR systems. The process includes automated 
classification of clinical terms into common clinical terms with review by trained medical staff. 

 
 
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The standardization of the data to common terms and application of the Epividian knowledge 
base are key process steps in gathering data from multiple heterogeneous EHR systems and 
databases from many locations into a single, homogenous OPERA database for conducting 
research and commercial analyses. The patient health data gathered, classified and aggregated 
includes complete medical history & social history, visit dates, vital signs, lab orders and results, 
medications, problems & diagnoses, and procedures.  
 
Epividian has developed rigorous data management processes that include both automated 
and manual quality checks. Data quality methods include common techniques such as: 
·      Detection and reporting of outliers that lead to correction, acceptance, or exclusion 
of observations; these can include a medical review. 
·      Detection of potentially missing data (e.g., a patient taking ART medications with no 
history of HIV infection to determine whether the use was prophylactic or treatment for 
infection diagnosed elsewhere). 
·      Data completion using multiple observations and sources (e.g., using diagnoses 
codes, free text, past medical history, etc. to determine if patient is naive to HIV 
therapy). 
·      Detection of observations that are known to be (or likely to be) mutually exclusive 
for a patient (e.g., record of medications that are typically not administered 
concurrently). 
 
 

 
 
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5. Study Population  
Individuals presenting for care at AHF Midtown Manhattan Healthcare Center and followed 
through their electronic health records in the OPERA Observational Database.  
INCLUSION CRITERIA 
Patients who were: 
1. Cared for at AHF Midtown Manhattan Healthcare Center and followed in the OPERA 
observational database 
2. Active in care in the last 24 months 
3. Fully vaccinated against SARS-CoV-2 virus, implemented as 21 days after the second 
Pfizer or Moderna injections, 21 days after the one J&J injection 
4. Received a Roche SARS-CoV-2 Semi-Quant Spike Ig AB test after full vaccination as usual 
clinical care 
5.  18 years of age at vaccination 
EXCLUSION CRITERIA 
Patients who were: 
1. Unvaccinated or partially vaccinated against SARS-CoV-2 virus  
2. Never tested with a SARS-CoV-2 Semi-Quant Total AB test after full vaccination 
  

 
 
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6. Study Design  
OVERVIEW OF STUDY DESIGN 
The design for this study is an observational cohort study utilizing prospectively collected 
electronic medical record (EMR) data from usual clinical care at AHF Midtown Manhattan 
Healthcare Center, obtained from the OPERA® Observational Database. 
 
The study population will consist of adults vaccinated against SARS-CoV-2 virus receiving the 
Roche SARS-CoV-2 Semi-Quant Spike Ig AB test as part of their usual clinical care. These 
individuals will be followed from vaccination until study end. 
 
EXPOSURES OF INTEREST 
Initial vaccination with Pfizer, Moderna, and J&J COVID vaccines, booster vaccination with 
Pfizer, Moderna, and J&J vaccines, and concordant boosting versus discordant boosting 
SUBGROUPS OF INTEREST 
HIV-positive versus HIV-negative patients, individuals with at least 2 measurements of antibody 
levels, and boosted individuals are the subgroups of interest. 
STUDY ENDPOINTS 
Endpoints for both the primary and secondary objectives are non-responders and low 
responders and rates of decline of SARS-CoV-2 antibodies 
• Non-response will be defined as: 0 to <50 U/mL 
• Low response will be defined as: ≥51 to ≤250 U/mL 
• Adequate response will be defined as: >251 U/mL 
 
Roche’s Elecsys semi-quantitative spike Ab Ig assay is a commercially available assay that can 
potentially be utilized to help guide the need for an additional vaccination dose based upon the 
levels of antibodies that have been previously clinically correlated with neutralizing antibodies. 
As part of routine care, Ab Ig assays were performed for some patients at the AHF Midtown 
Manhattan Healthcare Center and results were recorded in their EHR. 
 

 
 
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To normalize across different neutralization assays utilized in phase 3 studies of various COVID-
19 vaccines, Khoury, et al., estimated that a 50% protective neutralization level equivalent to 
20% of the mean titer in the convalescent subjects equates to a measured in vitro 
neutralization titer of between 1:10 and 1:30 was approximated at 54 international units IU/ml 
(95% CI 30–96 IU/ml) against wild-type CoV-19 infection.xx  During the period of COVID-19 
infection where the Delta virus predominated, a quantitative spike Ab’s >250 IU/mL was 
deemed adequate, based on studies that show that an antibody titer of 4-6x wild-type SARS-
CoV-2 were required to effectively neutralize Delta viral strains.xxi,xxii, xxiii We thus utilized a 
threshold level of >250 (5x wild-type ab levels) IU/mL as an adequate vaccine response against 
circulating Delta virus post last vaccination recommended in a series, a level of <50 IU/mL as a 
non-responsive post vaccination titer (inadequate for even wild-type Co-V-2 infection), and 
levels between (50-250 IU/mL) as a low vaccine response.  Non and low-responders who had 
Co-V-2 Spike Ig levels that were inadequate based on the correlation of Spike Ig levels and 
neutralizing ab correlations relative to the predominant circulating viral strains were offered 
optional booster vaccinations with subsequent antibody response measurement post 
vaccination as standard of care.  These recommendations are the current one’s implemented 
during the Delta Co-V-2 19 outbreak by the Ministry of Solidarity and Health of France and the 
COVID Guidelines group in Geneva, where 260 IU/mL and 300 IU/mL, respectively, are 
considered gray zones of antibody protection against the Delta virus and where booster 
vaccinations are recommended for consideration.xxiv, xxv 
 
 
STUDY COVARIATES 
Covariates of interest include: age, sex, race, ethnicity, HIV status, region, payer, 
immunosuppressive conditions, CD4 cell count, comorbid conditions, BMI. This information will 
be obtained from each patient’s electronic health records. 

 
 
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7. Statistical Analysis 
ANALYSIS OF DEMOGRAPHICS/BASELINE CHARACTERISTICS 
Demographic and clinical characteristics will be summarized in the overall population using 
medians with interquartile ranges (IQR) for continuous variables and frequencies with 
proportions for categorical variables.  
 
ANALYSIS OF PRIMARY OBJECTIVES 
Objective #1: COVID-19 vaccine non-response and low response as measured by antibody test by 
HIV status 
 
Records will be examined retrospectively to determine which patients, both HIV-positive and 
negative, were non-responders, or who developed low or adequate quantitative Ig spike 
antibodies using the Roche Elecsys semi-quantitative spike Ab Ig assay during usual clinical care.   
 
Demographic and clinical characteristics will be summarized by vaccine response level using 
medians with interquartile ranges (IQR) for continuous variables and frequencies with 
proportions for categorical variables. Statistical comparisons between vaccine response level 
will be performed using Pearson’s chi-square or Fisher exact tests for categorical variables and 
Wilcoxon rank-sum test for continuous variables, using an adequate response as the 
comparator. 
 
Incidence rates and 95% confidence intervals of COVID vaccine adequate response, non-
response and low response to COVID vaccines will be estimated using univariate Poisson 
regression. Incidence rates will be obtained both overall and by vaccine type. The incidence rate 
is defined as the number of events during follow-up divided by person-time at risk of the event.  
Estimating incidence rates with Poisson regression allows the use of all person-time time at risk 
of the outcome, even with differential lengths of follow-up between groups.  
 
 
Objective #2: Rate of decline in antibody levels over time by HIV status, vaccine type, and 
baseline CD4 count after initial vaccination  
 
Rates and 95% confidence intervals of antibody levels decay will be estimated among 
individuals with at least two antibody measurements. Univariate linear regression, will be 
employed, using the continuous antibody level as the dependent variable, and timing of tests as 

 
 
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the dependent variable. Robust variance estimator will be used to account for repeated 
measures. Rates of decay will be produced overall, and stratified by HIV status, vaccine type 
and baseline CD4 cell count. 
 
ANALYSIS OF SECONDARY OBJECTIVES 
Objective #3: COVID-19 boosters given 
 
In the sub-population of Individuals who received a COVID vaccine booster, the following 
characteristics will be described using medians with interquartile ranges (IQR) for continuous 
variables and frequencies with proportions for categorical variables: initial and booster vaccine 
types, concordant vs. discordant boosters, duration between initial vaccine completion and 
booster dose, antibody response after the booster, and side effects recorded. Post vaccination 
responses will be determined no earlier than 2 weeks post vaccination. 
 
 
Objective #4: Rate of decline in antibody levels over time by HIV status, booster type, and 
baseline CD4 count after booster vaccination  
 
Rates and 95% confidence intervals for changes in antibody levels will be estimated using linear 
regression, among individuals with at least two antibody measurements, including one after the 
booster dose. Univariate linear regression, will be employed, using the continuous antibody 
level as the dependent variable, and timing of tests as the dependent variable. Robust variance 
estimator will be used to account for repeated measures. Rates of decay will be produced 
overall, and stratified by HIV status, booster type and baseline CD4 cell count. 
 
 
Objective #5: Recording breakthrough infections after vaccinations and assessing antibody 
levels pre-breakthrough infection 
Among all individuals with full vaccination and antibody testing, the EHR will be searched for 
documentation of COVID infection after vaccinations. If breakthrough infections are observed, 
antibody levels prior to infection will be described. Note: COVID infections may not be recorded 
in the EHR if diagnosed outside of the clinic. 
 
 SENSITIVITY ANALYSES 
NA 

 
 
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SUBGROUP ANALYSES 
Patients provided COVID boosters will be evaluated by the types and combinations of vaccines 
they received. Further, patients given sequential antibody tests will be evaluated by vaccine 
type for response over time. 
 

 
 
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8. Study Conduct 
REGULATORY AND ETHICAL CONSIDERATIONS 
OPERA® complies with all HIPAA and HITECH requirements and has received annual 
institutional review board (IRB) approval by Advarra IRB, including a waiver of informed consent 
and authorization for use of protected health information 
INFORMED CONSENT 
Informed consent has been waived for this non-interventional, observational research and 
authorization for use of the protected health information has been approved by Advarra IRB. 
DATA PRIVACY & PERSONALLY IDENTIFIABLE INFORMATION (PII) 
The data used for this research study are not identifiable by the research staff. However, all 
data, even when stripped of identifiers, are handled and treated, in motion and at rest, as 
though the data could be identified. All data are managed according to regulations including 
HIPAA and HITECH. These regulations and guidelines expand upon the ethical principles 
detailed in the 1964 Declaration of Helsinki. These data are not shared outside the researchers 
involved with the analysis. 
 
ADVERSE EVENT REPORTING 
There is no potential to collect individual level data on serious and non-serious adverse events 
(AEs), pregnancy exposures, device deficiencies and device related events or incidents related 
to any pharmaceutical product during the conduct of this research, as the minimum criteria 
needed to report AEs, pregnancy exposures, device deficiencies and device related events and 
incidents are not collected. Specifically, the data are insufficient to establish attribution 
between a potential safety event and an individual using a product as the study design is to 
analyze deidentified, secondary data collected from individual medical records. Therefore, the 
obligation for reporting any and all adverse events lies with the healthcare provider at the point 
of care. 
 
 

 
 
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9. Administrative Matters 
QUALITY ASSURANCE 
Epividian has working practices & procedures governing the use of observational data, the 
development of analysis specifications and plans, the development of analytical programming, 
the analytical quality assurance process and the scientific review of reports as well as clinical 
advisory charters for the clinical review of output intended for public domain.   
 
Working practices for the development of analysis specifications include basic identifying 
information, background material, relevant definitions of key study variables, population 
definitions, baseline definitions, specific requirements for dataset creation, statistical 
requirements such as eligibility criteria, exposures, outcomes and model fitting.  Working 
practices for programming include naming conventions, proper code documentation and 
commentary, content, appearance, efficiencies (i.e., use of macros), and organization of output, 
maintainability and generalizability.  Working practices for programming quality assurance 
include self-reviews of observational counts, missing data values, many-to-many merges, 
variable formatting, numeric-character & character-numeric conversions, uninitialized 
variables, unresolved macro references, report completeness and report-to-specification 
correspondence, and system errors and logs.   
 
The quality assurance team review may include small sample spot-checking, coding log reviews, 
complete coding review, selected observations from intermediary dataset reviews, and/or 
independent programming to reproduce the results.  Documentation of non-public domain 
reports includes market, scientific, statistical, and clinical review.  Documentation of scientific 
protocols, reports and manuscripts intended for public domain follows two sequential steps: an 
internal-to-Epividian epidemiological, statistical, and clinical review, followed by a 
clinical/epidemiological external advisory board review. 
 

 
 
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10. References 
i Bergwerk, M. et al., Covid-19 Breakthrough Infections in Vaccinated Health Care Workers NEJM 7/28/21 
 
ii Goldberg et al. Waning immunity of the BNT162b2 vaccine: A nationwide study from Israel. 
https://www.medrxiv.org/content/10.1101/2021.08.24.21262423v1.full-text 
 
iii Outbreak of SARS-CoV-2 Infections, Including COVID-19 Vaccine Breakthrough Infections, Associated 
with Large Public Gatherings — Barnstable County, Massachusetts, July 2021 CDC MMWR Weekly / 
August 6, 2021 / 70(31);1059-1062 
 
iv Fowlkes A, Gaglani M, Groover K, et al. Effectiveness of COVID-19 Vaccines in Preventing SARS-CoV-2 
Infection Among Frontline Workers Before and During B.1.617.2 (Delta) Variant Predominance —Eight 
U.S. Locations, December 2020–August 2021. MMWR Morbidity Mortality Weekly Report. ePub: 24 
August 2021.  
 
v Keehner J, Horton LE, Binkin NJ et al. Resurgence of SARS-CoV-2 Infection in a Highly Vaccinated 
Health System Workforce. NEJM, September 1, 2021. DOI: 10.1056/NEJMc2112981 
 
vi Antonelli, M., Risk factors and disease profile of post-vaccination SARS-CoV-2 infection in UK users of 
the COVID Symptom Study app: a prospective, community-based, nested, case-control study, Lancet 
Infectious Diseases, September 1, 2021 
 
 
vii Epsi et al. (2021) medRxivdoi: https://doi.org/10.1101/2021.07.02.21259913  
  
viii Bar-On YM, Goldberg Y, Mandel M, et al. Protection of BNT162b2 Vaccine Booster against Covid-19 in Israel 
[published online ahead of print, 2021 Sep 15].N Engl J Med. 2021;10.1056/NEJMoa2114255. 
 
ix Patalon et al. Short Term Reduction in the Odds of Testing Positive for SARS-CoV-2; a Comparison Between Two 
Doses and Three doses of the BNT162b2 Vaccine. MedRxiv, August 31, 2021 
 
 
      
 

 
 
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x Ledford, Heidi.  Delaying a COVID vaccine’s second dose boosts immune response, NATURE, 13 May 
2021  
 
xi BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n1875  (Published 23 July 2021)Cite this 
as: BMJ 2021;374:n1875 
 
xii Voysey, M., et al.  Single dose administration and the influence of the timing of the booster dose on 
immunogenicity and efficacy of the ChAdOx1 nCoV-19 (AZD1222) vaccine: a pooled analysis of four 
randomized trials, LANCET, Volume 397, issue 10277, p881-891, March 6, 2021.   
 
xiii J&J SARS-CoV2 Initial and booster responses, Johnson & Johnson Press release, NEW BRUNSWICK, 
N.J., September 21, 2021  
 
xiv S. Iyer et al., Persistence and decay of human antibody responses to the receptor binding domain of 
SARS-CoV-2 spike protein in COVID-19 patients. Sci Immunol 5, (2020). 
 
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