Antibody response after third BNT162b2 dose in recipients of allogeneic HSCT
Authors: Rabah Redjoul, Anne Le Bouter, Vincent Parinet, Slim Fourati, Sébastien Maury
Journal: The Lancet Haematology (2021)

We previously reported a weak immune response after two doses of the vaccine against SARS-CoV-2 in 36 (41%) of 88 recipients of allogeneic hematopoietic stem-cell transplantation (HSCT).1Redjoul R Le Bouter A Beckerich F Fourati S Maury S Antibody response after second BNT162b2 dose in allogeneic HSCT recipients.Lancet. 2021; 398: 298-299Summary Full Text Full Text PDF PubMed Scopus (88) Google Scholar Together with the poor prognosis of COVID-19 infection in recipients of HSCT2Sharma A Bhatt NS St Martin A et al.Clinical characteristics and outcomes of COVID-19 in haematopoietic stem-cell transplantation recipients: an observational cohort study.Lancet Haematol. 2021; 8: e185-e193Summary Full Text Full Text PDF PubMed Scopus (250) Google Scholar, 3Ljungman P de la Camara R Mikulska M et al.COVID-19 and stem cell transplantation; results from an EBMT and GETH multicenter prospective survey.Leukemia. 2021; (published online June 2.)https://doi.org/10.1038/s41375-021-01302-5Crossref PubMed Scopus (142) Google Scholar and solid-organ transplantation, this result prompted the French National Authority of Health to recommend the use of a third dose in patients who are immunosuppressed and who were not responding after a standard two-dose vaccination.4French GovernmentPrecisions sur la vaccination COVID-19 : modalites d'administration des rappels et vaccination des personnes immunodeprimes et de leurs proches.https://solidarites-sante.gouv.fr/IMG/pdf/dgs_urgent_52_precisions_sur_la_vaccination_imd.pdfDate: May 6, 2021Date accessed: July 2, 2021Google Scholar Here, we report the humoral response in patients who were recipients of HSCT in the Haematolgy Department of the Henri Mondor University Hospital (Créteil, France) and who were given three doses of the BNT162b2 mRNA vaccine (Pfizer-BioNTech, Mainz, Germany) on the basis of their quantitated low titre of anti-spike glycoprotein-specific IgG (Spike protein-receptor-binding domain [S-RBD]) of less than 4160 AU/mL at 28 (SD 6) days after the second vaccine dose. This threshold of 4160 AU/mL is recommended by the manufacturer and is used as a surrogate measure of vaccine protection because it corresponds to a 0·95 probability of obtaining an in-vitro plaque reduction neutralisation test.1Redjoul R Le Bouter A Beckerich F Fourati S Maury S Antibody response after second BNT162b2 dose in allogeneic HSCT recipients.Lancet. 2021; 398: 298-299Summary Full Text Full Text PDF PubMed Scopus (88) Google Scholar, 5Ebinger JE Fert-Bober J Printsev I et al.Antibody responses to the BNT162b2 mRNA vaccine in individuals previously infected with SARS-CoV-2.Nat Med. 2021; 27: 981-984Crossref PubMed Scopus (401) Google Scholar In our department, vaccination was systematically offered to patients, whatever their transplantation date, starting from 3 months after HSCT. The first two doses were given 1 month apart, and the third dose was administered 51 (SD 22) days after the second dose. IgG (S-RBD) titres were quantitated at a mean of 26 (SD 6) days after the third vaccine dose, using the Abbott Architect SARS-CoV-2 IgG Quant II assay (Abbott, Sligo, Ireland). One patient who had transient facial paralysis after the second vaccine dose refused to receive a third vaccine dose, despite low titre of anti-spike IgG after vaccination. All patients aged older than 18 years receiving a third vaccine dose were eligible for the present study. Clinical and biological data were collected retrospectively from medical charts. According to French law, institutional review board approval was not required, because this was an anonymous retrospective study. Categorical variables were compared by Fisher exact tests. Comparisons of continuous variables means were done using Student's t tests. Multivariable analysis included risk factors with a significance of p<0·05 in univariate comparisons and used a logistic regression model. All tests were two-sided and the type 1 error rate was fixed at 0·05. 42 patients (median, 59 years [IQR 50–64]; 27 [65%] male, 15 [35%] female) were given three doses of the BNT162b2 mRNA vaccine. All patients received a transplantation for a haematological malignancy in remission, and vaccination was initiated in the first year after HSCT in 22 (52%) of 42 patients. The third dose led to a significant increase in anti-SARS-CoV-2 antibodies with IgG (S-RBD) increasing from 737 AU/mL (SD 1009; 2·9 Log, SD 3·0) to 11 099 AU/mL (SD 18 607; 4·05 Log, SD 4·3; p=0·00069; figure). However, only 20 (48%) of 42 patients reached the protective threshold of 4160 AU/mL or more. In the univariate analysis, the two factors associated with the rise to the protective antibody threshold among the patient-associated and transplantation-associated factors were a B-cell count of more than 0·25 g/L in the peripheral blood at the time of the third vaccination (p=0·0032) and an IgG (S-RBD) concentration of more than 1000 AU/mL after the second vaccine dose (p=0·019). This IgG threshold was chosen on the basis of an independent study that used the same Abbott Architect SARS-CoV-2 IgG Quant II assay as in the present study, and which showed that a IgG (S-RBD) concentration of 1000 AU/mL is able to neutralise SARS-CoV-2 circulating variants of concern.6Gallais F Gantner P Bruel T et al.Anti-SARS-CoV-2 antibodies persist for up to 13 months and reduce risk of reinfection.medRxiv. 2021; (published online May 17.) (preprint).https://doi.org/10.1101/2021.05.07.21256823Google Scholar In a multivariable analysis, only a B-cell count of more than 0·25 g/L in the peripheral blood at the time of the third vaccination was associated with a humoral response (odds ratio 7·1 [95% CI 1·5–34·1], p=0·0016; appendix). We did not identify any transplantation-associated or disease-associated characteristics predicting the response to the booster third vaccine dose (appendix). Neither patient or donor age or sex, nor the interval between HSCT and the initiation of vaccination (less than or more than 12 months), were predictive in this primary analysis. With a median follow-up of 53 days (IQR 44·5–59·5) after the third vaccine dose, we did not observe any serious adverse event or COVID-19 infection within the vaccination schedule. We neither observed any case of graft-versus-host disease induction nor graft-versus-host disease worsening that could be associated with the vaccination schedule in this cohort. This study showed that administration of a third dose of BNT162b2 improved the immunogenicity of the vaccine in recipients of HSCT, as reported in patients of solid-organ transplantation.7Kamar N Abravanel F Marion O Couat C Izopet J Del Bello A Three doses of an mRNA COVID-19 vaccine in solid-organ transplant recipients.N Engl J Med. 2021; 385: 661-662Crossref PubMed Scopus (624) Google Scholar, 8Werbel WA Boyarsky BJ Ou MT et al.Safety and immunogenicity of a third dose of SARS-CoV-2 vaccine in solid organ transplant recipients: a case series.Ann Intern Med. 2021; (published online June 15, 2021.)https://doi.org/10.7326/L21-0282Crossref Scopus (250) Google Scholar However, approximately half (52%) of the patients requiring a third dose still had low concentrations of anti-SARS-CoV-2 antibodies thereafter, emphasising the importance of barrier measures and the vaccination of relatives. Because the B-cell immune status at the time of vaccination is the main factor predicting a humoral response in these patients, further studies will be needed to evaluate the protective effect of delayed vaccine doses given after the B-cell compartment has recovered. One limitation of this study is the absence of assays for neutralising antibodies. However, the Abbott assay quantifies anti-S-RBD antibodies, which include most neutralising antibodies generated after a natural infection or vaccination. This assay has been tested and validated against the WHO international standard, because it showed excellent correlation with the results provided by the WHO standard. Another limitation is the absence of B-cell memory and T-cell functional responses. In the present study, time since HSCT did not affect the humoral response after the third vaccine dose. With regard to the response after two vaccine doses, we previously identified that an interval of more than 12 months between HSCT and vaccination correlated with protective IgG(S-RBD) titres in univariate analyses.1Redjoul R Le Bouter A Beckerich F Fourati S Maury S Antibody response after second BNT162b2 dose in allogeneic HSCT recipients.Lancet. 2021; 398: 298-299Summary Full Text Full Text PDF PubMed Scopus (88) Google Scholar However, despite this time variable being predictive in the univariate analysis, it was not significant in the multivariable analysis, unlike the lymphocyte count in the peripheral blood at vaccination initiation and the systemic immunosuppressive drugs received within the 3 months before vaccination.1Redjoul R Le Bouter A Beckerich F Fourati S Maury S Antibody response after second BNT162b2 dose in allogeneic HSCT recipients.Lancet. 2021; 398: 298-299Summary Full Text Full Text PDF PubMed Scopus (88) Google Scholar Similarly, in one large study of 885 patients with haematological malignancies, including patients who had and had not undergone transplantation, the treatments actively received at time of vaccination were the primary determinants of the antibody response.9Maneikis K Šablauskas K Ringelevičiūtė U et al.Immunogenicity of the BNT162b2 COVID-19 mRNA vaccine and early clinical outcomes in patients with haematological malignancies in Lithuania: a national prospective cohort study.Lancet Haematol. 2021; 8: e583-e592Summary Full Text Full Text PDF PubMed Scopus (186) Google Scholar Nine cases of breakthrough severe SARS-CoV-2 infections were reported in this previous study, which we did not observe in the present study, occurring in fully vaccinated patients who had mostly low anti-S-RBD IgG antibody titres. The longevity of the vaccine-induced immunity will be a key variable in the protection against SARS-CoV-2 infections, in the general population and specifically in patients with cancer and who have undergone HSCT. Because long-term protection after other types of vaccination is known to be hard to obtain in patients who receive HSCT,10Robin C Bahuaud M Redjoul R et al.Antipneumococcal seroprotection years after vaccination in allogeneic hematopoietic cell transplant recipients.Clin Infect Dis. 2020; 71: e301-e307Crossref PubMed Scopus (8) Google Scholar specific studies will be needed to address this question, with the aim of defining the best booster programme to provide a long-term protection against COVID-19. We declare no competing interests. Download .pdf (.16 MB) Help with pdf files Supplementary appendix