COVID-19: Clinical and Public Health Implications of SARS-CoV-2 Immunology
Authors: Christine Laine, Deborah Cotton, Darilyn V. Moyer
Journal: Annals of Internal Medicine (2021)

Special Articles12 October 2021COVID-19: Clinical and Public Health Implications of SARS-CoV-2 ImmunologyFREEChristine Laine, MD, MPH, Deborah Cotton, MD, MPH, Darilyn V. Moyer, MDChristine Laine, MD, MPHEditor in Chief, Annals of Internal Medicine , Deborah Cotton, MD, MPHDeputy Editor, Annals of Internal Medicine , Darilyn V. Moyer, MDExecutive Vice President and Chief Executive Officer, American College of PhysiciansAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M21-3840 CME/MOC SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In the fall of 2020, Annals of Internal Medicine and the American College of Physicians (ACP) hosted a virtual forum to address clinicians' questions related to the COVID-19 pandemic. That program, held on 16 October 2020, featured Dr. Anthony Fauci, Dr. H. Clifford Lane, Dr. David Kessler, Dr. Beth Bell, and Dr. Rachel Levine discussing evidence-based information related to the science, approval processes, development of clinical recommendations, and public health implications of COVID-19 vaccines that were under development at the time (1). Subsequent programs covered promoting vaccine uptake (2), vaccine allocation (3), common clinical considerations about COVID-19 (4), and persistent symptoms after acute SARS-CoV-2 infection (5). If you missed those programs or would like to share them with others, all are publicly available at Annals.org. We have learned an astounding amount about SARS-CoV-2 in the year since our first forum, yet many questions remain and, unfortunately, the spread of misinformation is rampant.To address new questions that are emerging about immunity, the duration of protection that follows acute infection and vaccination, and the need for booster doses of vaccine, the most recent forum, held on 8 October 2021, focused on the immunology of SARS-CoV-2 and clinical and public health implications of the virus's immune behavior. What immune mechanisms does the virus trigger? Are there reliable markers of previous infection, adequate response to vaccination, and protection from future infection? What do we know about the risks and benefits of booster doses of vaccine? Dr. John R. Mascola and Dr. Camille Nelson Kotton joined us to address these and other questions submitted by registrants of the live program. Readers can view the program in the Video that accompanies this article (available at Annals.org).Video. ACP/Annals COVID-19 Forum VI: SARS-CoV-2 Immunology: Clinical Implications The ACP/Annals COVID-19 Forum VI, held on 8 October 2021, features speakers Camille Nelson Kotton, MD; John R. Mascola, MD; and Deborah Cotton, MD, MPH. (Duration 1:25:49)Dr. Mascola is Director of the Dale and Betty Bumpers Vaccine Research Center (VRC) at the National Institute of Allergy and Infectious Diseases, National Institutes of Health. His background is in infectious diseases, viral immunology, and vaccine research. As the Scientific Director and Center Director, Dr. Mascola provides overall direction and scientific leadership to the basic, clinical, and translational research activities of the VRC. After the emergence of the COVID-19 pandemic, Dr. Mascola led an interagency team of U.S. government scientists who oversaw phase 3 vaccine trials, facilitating the successful development and authorization of COVID-19 vaccines in record time. During the forum, he provided an overview of what we have learned about coronaviruses since the emergence of SARS-CoV-1 nearly 2 decades ago. While there is still much we do not know about the pathophysiology of COVID-19—why some people are asymptomatic and others become critically ill—we know that antibodies against the spike protein on the surface of the virus are a major line of defense. He described existing vaccine platforms and how they work to prompt and amplify these antibodies and the immunologic rationale for vaccine boosting.Dr. Kotton is the Clinical Director of Transplant and Immunocompromised Host Infectious Diseases in the Infectious Diseases Division at the Massachusetts General Hospital and an active clinician. She is the past chair of the Infectious Disease Community of Practice of the American Society of Transplantation, is on the planning committee for the American Transplant Congress, and is a member of the Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices (ACIP). During the forum, Dr. Kotton reviewed what we currently know about the effectiveness of initial and booster COVID-19 vaccination in various population subgroups, such as older persons and persons with immunosuppression due to underlying disease or its treatment. Recognizing the gaps in our knowledge, she described the rationale for the recent recommendations regarding booster vaccination issued by the ACIP and the CDC.The panelists addressed a variety of questions submitted by registrants, including questions about measuring antibody levels to guide behaviors ranging from masking and social distancing to use of booster vaccination. Drs. Mascola and Kotton both emphasized that evidence is currently not sufficient to support antibody measurement in making clinical decisions for individual persons. While many people are seeking antibody tests through a variety of channels and using the results to guide their health decisions, we do not yet know the level of antibody associated with definitive protection. Thus, people may make misguided decisions about their personal risk, the risk they pose to others, and the need for vaccination on the basis of unvalidated antibody assays. Drs. Mascola and Kotton anticipate that we will someday know enough to use antibody levels to determine immune status as we currently can do for other viral illnesses, such as measles and hepatitis B, but emphasized that we are not there yet. They also recognized the adverse potential consequence of recommendations for booster vaccination in raising skepticism about the vaccine among those who have so far declined initial vaccination. They sent a clear message that primary vaccination remains our best tool in controlling this pandemic.We have much to learn about SARS-CoV-2, particularly given the rapid evolution the virus has demonstrated. However, the pace with which we have gained an understanding of SARS-CoV-2 and developed highly effective vaccines is unprecedented. As scientific knowledge advances, Annals and ACP will continue to endeavor to combat misinformation by bringing scientifically sound information to clinicians.References1. Laine C, Cotton D, Moyer DV. COVID-19 vaccine: what physicians need to know. Ann Intern Med. 2020;173:830. [PMID: 33074704] doi:10.7326/M20-6841 LinkGoogle Scholar2. Laine C, Cotton D, Moyer DV. COVID-19 vaccine: promoting vaccine acceptance. Ann Intern Med. 2021;174:252-253. [PMID: 33347321] doi:10.7326/M20-8008 LinkGoogle Scholar3. Laine C, Cotton D, Moyer DV. COVID-19 vaccine distribution and allocation: what physicians need to know. Ann Intern Med. 2021;174:413-414. [PMID: 33492990] doi:10.7326/M21-0331 LinkGoogle Scholar4. Laine C, Cotton D, Moyer DV. COVID-19 vaccine: practical clinical considerations. Ann Intern Med. 2021;174:694. [PMID: 33769829] doi:10.7326/M21-1260 LinkGoogle Scholar5. Laine C, Cotton D. COVID-19: evaluation and care of patients with persistent symptoms following acute SARS-CoV-2 infection. Ann Intern Med. 2021;174:1159-1160. [PMID: 34115532] doi:10.7326/M21-2342 LinkGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Christine Laine, MD, MPH; Deborah Cotton, MD, MPH; Darilyn V. Moyer, MDAffiliations: Editor in Chief, Annals of Internal Medicine Deputy Editor, Annals of Internal Medicine Executive Vice President and Chief Executive Officer, American College of PhysiciansDisclosures: Disclosure forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-3840.Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Stephanie Chang, MD, MPH, Deputy Editor, reports employment with the Agency for Healthcare Research and Quality, travel compensation from the Guidelines International Network, and participation in the Patient-Centered Outcomes Research Institute methodology committee. Vineet Chopra, MD, MSc, Deputy Editor, reports grants received from the Agency for Healthcare Research and Quality and royalties from UpToDate and Oxford University Press. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interests to disclose. Eliseo Guallar, MD, MPH, DrPH, Deputy Editor, Statistics, reports that he has no financial relationships or interests to disclose. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center and consultancy with Boston Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports employment with the Perelman School of Medicine, University of Pennsylvania, and consultancies with the U.S. Food and Drug Administration and the State of Colorado.Corresponding Author: Christine Laine, MD, MPH, Editor in Chief, Annals of Internal Medicine, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, claine@acponline.org.This article was published at Annals.org on 12 October 2021. 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