­­­­­COVID-19 vaccination responses with different vaccine platforms in patients with inborn errors of immunity

­­­­­COVID-19 vaccination responses with different vaccine platforms in patients with inborn errors of immunity | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article ­­­­­COVID-19 vaccination responses with different vaccine platforms in patients with inborn errors of immunity Lorenzo Erra, Ignacio Leandro Uriarte, Ana Colado, María Virginia Paolini, and 25 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1887005/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Patients with Inborn Errors of Immunity (IEI) in Argentina were encouraged to receive licensed Sputnik, AstraZeneca, Sinopharm, Moderna, and Pfizer vaccines, even though most of the data on available vaccines comes from trials conducted in healthy individuals. We aimed to evaluate the safety and immunogenicity of the different vaccines in IEI patients in Argentina. The study cohort included adults and pediatric IEI patients (n=118) and age-matched healthy-controls (HC) (n=37). Samples were collected before, 28+/-3 days after the first and the second dose of the vaccine. B-cell response was evaluated by measuring IgG anti-Spike(S)/ receptor binding domain (RBD) and anti-nucleocapsid(N) antibodies by ELISA. Neutralization antibodies were also assessed with an alpha-S protein-expressing pseudo-virus assay. The T-cell response was analyzed by IFN-γ secretion on S or N-stimulated PBMC by ELISPOT and the frequency of S-specific circulating T follicular-helper cells (TFH) was evaluated by flow cytometry. No moderate/severe vaccine-associated adverse events were observed. Regarding the antibody response, anti-S/RBD titers showed significant differences in both pediatric and adult IEI patients versus the age-matched HC cohort (p<0.05). Neutralizing antibodies were detected in 71/99 patients and were also significantly lower in the patient cohort than age-matched HC (p<0.01). Positive S-specific IFN-γ response was observed in 84.5% of IEI patients and 82.1% presented S-specific TFH cells. In conclusion, COVID-19 vaccines showed safety in IEI patients and, although immunogenicity was lower than HC, they showed specific anti-S/RBD IgG, neutralizing antibody titers and T-cell-dependent cellular immunity with IFN-γ secreting T-cells. These findings may guide the recommendation of vaccination in IEI patients to prevent COVID-19 disease . SARS-CoV-2 antibody response T-cell response COVID-19 inborn errors of immunity vaccination Figures Figure 1 Figure 2 Figure 3 Introduction In December 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in the Hubei province of China, and wreaked havoc in the world by causing the highly transmissible infectious disease coronavirus disease-2019 (COVID-19) [ 1 ]. The disease clinical spectrum is variable, ranging from asymptomatic to severe respiratory distress syndrome [ 2 , 3 ]. The current death toll reported is 6.33 million people worldwide [ 4 ] but is likely underestimated and will probably continue to rise until there is universal deployment of effective vaccines and therapeutics [ 5 – 8 ]. While data supporting the effectiveness and safety of the newly developed anti–SARS-CoV-2 vaccines is accumulating, initial studies enrolled mostly healthy volunteers. To study the response to vaccination of patients with inborn errors of immunity (IEI) or immunocompromised is of particular interest for several reasons. On the one hand, the immune response following COVID-19 vaccination may differ in people who are moderately or severely immunocompromised at the time of vaccination. Therefore, analysis of the immune response to vaccines may be critical for guidance recommendation to prevent the COVID-19 disease. The literature shows no consensus about the severity of COVID-19 developed by immunocompromised patients. Whereas some reports suggested that patients might be at increased risk of developing severe disease [ 9 ], others described that patients experienced a mild COVID-19 with few symptoms [ 10 ]. Patients with IEI could therefore benefit from a more ‘‘aggressive’’ immunization effort. On the other hand, IEI patients are characterized by reduced vaccine response, depending on the type of immune disorder [ 11 ]. Thus, in IEI patients the underlying immune abnormality might impair the ability to respond to vaccination and to develop anti–SARS-CoV-2 protective immunity, thus leading to questions regarding the benefit of the vaccination approach. In view of this, characterizing the immune response of IEI patients following SARS-CoV-2 vaccination is crucial, both for understanding their degree of protection and for formulating an optimal immunization scheme. Moreover, data gathered from analyses of the immune response of IEI patients to the anti–COVID-19 vaccine could be relevant to other patient populations, especially those with secondary and acquired immunodeficiency. To date, the information of immunogenicity in patients with IEIs is limited and there are only a few studies that measured the immunity of a restricted variety of vaccines against COVID-19 (mostly mRNA vaccines) [ 12 – 15 ]. Hence, more studies about immunogenicity and safety in patients considering other platforms in patients with IEI are needed. Currently, there are five vaccines licensed for emergency use in Argentina to prevent SARS-CoV-2 infection or severe infection and death related to COVID-19 [ 16 ]. Due to the accelerated transmission of COVID-19 and the incidence of the disease in our country and the rest of the world, it is vital to evaluate the effectiveness and impact of the vaccines applied in our territory in patients with IEI. In this work, we describe the safety and immunogenicity of the Gam-COVID-Vac (Sputnik-V), AZD1222 or Covishield (Astrazeneca), BBIBP-CorV (Sinopharm) and mRNA-1273 (Moderna) vaccines in a cohort of IEI patients. Information on vaccine-associated adverse events was collected after each vaccine dose. We evaluated the B-cell response by measuring IgG anti-Spike(S)/RBD and anti-nucleocapsid(N) antibodies by ELISA and neutralization antibodies with an alpha-S protein-expressing pseudo-virus assay. The IFN-γ production was evaluated on S or N-stimulated PBMC by ELISPOT and the frequency of S-specific circulating T follicular-helper cells (TFH) was analyzed by flow cytometry. Materials And Methods Study design and patients A total of 132 patients with IEIs (85 adults and 47 pediatrics) were enrolled sequentially between June and November 2021, according to the national vaccine strategy first adult patients then pediatric patients. This observational study included patients aged 12–78 years affected by IEI, according to IUIS phenotypic classification criteria [ 17 ]. Fourteen patients were excluded from the study because only the pre-vaccination sample was obtained. The final cohort included 118 patients (pre vaccination sample (T0) n = 77, post first vaccination dose (T1) n = 87, post second vaccination dose (T2) n = 108), 79 adult patients (AP) and 39 pediatric patients (PP). The mean age of our adult patient cohort was 39.3 years (range 19 y − 78 y), with 34 females and 45 males. The mean age of our pediatric patient cohort was 14.8 years (range 12 y – 18 y), with 16 females and 23 males. Adult (n = 27) and pediatric (n = 12) subjects without compromised immune system nor comorbidities also participated in the study. The blood samples from adult and plasma samples from pediatric subjects were analyzed as healthy control samples. The healthy adult donors were healthcare workers from the ‘Academia Nacional de Medicina’ and healthy controls from the ‘Biobanco de Enfermedades Infecciosas’ while the healthy pediatric donors were adolescent children of healthcare workers, included with the consent of their parents. The mean age of healthy adult donors was 41.8 years (range 26 y − 82 y) with 12 females and 15 males and 14.4 years (range 12 y − 17 y) for pediatric donors with 5 females and 7 males. Blood samples from patients and healthy adult donors were collected prior to vaccination (T0), 28 days (+/-3 days) after the first (T1) and the second (T2) doses. Plasma was isolated and PBMCs were obtained by Ficoll-Hypaque density gradient centrifugation (GE) and cryopreserved in liquid nitrogen in fetal bovine serum (FBS, Serendipia). Serum from healthy pediatric samples were collected at T2. Plasma and serum were preserved at -80°C. SARS-CoV-2 antibody ELISA Quantitative SARS-CoV-2 spike-specific IgG antibodies titers were measured by using the ELISA test COVIDAR (Laboratorio Lemos S.R.L, Buenos Aires, Argentina), as previously described [ 18 ]. Assay plates were coated with a mixture of spike (S) protein and receptor binding domain (RBD). Antibody concentrations of SARS-CoV-2 S protein expressed as International Units/mL (IU/mL), were determined by constructing a calibration curve with serial dilutions of the standard included in the immunoassay kit (400 IU/mL, reactive human serum adjusted to WHO First International Standard for human immunoglobulin against SARS-CoV-2, NIBSC Code 20/136, version 2.0 of 12/17/2020). Each sample was properly diluted to fit an OD 450 nm within the linear range of the calibration curve. Antibody concentrations were obtained by interpolating the OD 450 nm value for each sample into the calibration curve. Qualitative SARS-CoV-2 nucleocapsid(N)-specific IgG antibodies were measured with a validated in-house ELISA protocol. Assay plates were coated with a SARS-CoV-2 nucleocapsid protein. To set up the cutoff value we analyzed pre-pandemic donor samples (n = 100), then samples with an OD450 value above 0.5 were considered positive for anti-N antibodies. Pseudotyped lentivirus neutralization assay The neutralization activity of serum was determined by the decrease of GFP expression in infected HEK-293T [ 19 ]. Briefly, SARS-CoV-2 S-Pseudotyped lentivirus were produced by co-transfection of HEK-293T cells with plasmids bearing the S protein, a lentivirus backbone (VRC5602, NIH) and a GFP reporter gene (Addgene plasmid #11619). Neutralization assays were performed on HEK-293T cells transiently transfected 24 h before transduction with ACE2 and TMPRSS2 protease genes. The heat inactivated serum was serially diluted and incubated for 2 h with an equal volume of titrated pseudotyped lentivirus and were then added onto HEK-293T. Pseudovirus infectivity was scored 48 h later and images were obtained using an inverted fluorescence microscope (Olympus IX-71) and analyzed with the Micro-Manager Open Source Microscopy Software. Plasma antibody neutralization titers were calculated by a nonlinear regression curve fit using GraphPad Prism software Inc. (La Jolla, CA, USA). Half maximal inhibitory concentration (IC50) and eighty inhibitory concentration (IC80), corresponding to the serum antibody dilution causing a 50 and 80% reduction of GFP positive cells compared to control “virus only” treated cells, was determined using the same software according to Ferrara and Temperton [ 20 ]. ELISpot assay Evaluation of IFN-γ secreting cells was detected by using Human IFN-γ ELISPOT Pair (BD Biosciences). Briefly, 2.5 x10 5 PBMCs, from patients or healthy controls, were culture on 96-wells plates (MultiScreen IP plates; Millipore) coated with anti-human IFN-γ monoclonal antibody (BD Biosciences) and stimulated with SARS-CoV-2 S and N protein (kindly provided by Dr. J. Caramelo and Dra. A Gamarnik, Leloir Institute, Argentina) (10µg/ml). Glycerol (0,2%) and PHA (10µg/ml, Sigma) were used as negative and positive controls, respectively. After 16 h of stimulation, biotinylated anti-human IFN-γ monoclonal antibody, streptavidin-peroxidase and AEC (3-amino-9-ethylcarbazole) substrate reagent set (BD Biosciences) were used to detect spots. Scanning of plates was done on an ImmunoSpot reader and quantified with the ImmunoSpot software (Cellular Technology Ltd.). Based on control groups of pre-vaccinated individuals (n = 10) and mildly affected convalescent individuals (n = 10), we set the threshold for positive cellular response at 6 SFU (spot forming units) per 2.5 x10 5 PBMCs (data not shown). The response ratio was defined as the number of SFU obtained in the stimulated condition was relativized to SFU in the unstimulated condition. Samples were considered for analysis if the negative control was below the positive cellular response threshold and the positive control surpassed 100 SFU per 2.5 x10 5 PBMCs [ 21 ]. Flow cytometry anti-Spike T-cell receptor staining PBMCs were thawed in RPMI 2% SFB with 25 U/ml of DNAsa I (Roche) medium and washed with 10% SFB DNAse RPMI medium. PMBC, 1x10 6 cells, were stimulated overnight with SARS-CoV-2 S protein (10µg/ml), medium 0.2% glycerol (negative control) and PHA (10µg/ml, positive control), as was previously described [ 22 ]. PBMCs were stained with a mixture of antibodies at 4°C for 20 min. The antibodies used were: FITC mouse anti-human CD4, PE mouse anti-human PD1, PerCP-Cy5.5 mouse anti-human CXCR5 and APC mouse anti-human CD154. All antibodies were obtained from Biolegend. Samples were loaded onto a FACSAria II Flow Cytometer (BD) after antibody staining and cell fixation. Gating of populations positive for any marker was based on fluorescence minus one (FMO) control of each marker. Data were analyzed using FlowJo v.10.0. Data analysis Statistical significance was determined by nonparametric tests Mann–Whitney test, Column Statistics followed by Wilcoxon’s signed rank test, Kruskal-Wallis test, one way ANOVA followed by Dunn’s multiple comparison test or Spearman correlation test. In all cases, p < 0.05 was considered statistically significant. All data analyses were performed using the GraphPad 9.1.2 Prism Software (San Diego, CA, USA). Results Study design and patients The study cohort included 118 patients with IEIs (79 adults and 39 pediatrics). According to IUIS phenotypic classification criteria, 96 out of 118 patients had predominantly antibody deficiencies: 59 Common Variable Immunodeficiency (CVID), 12 Specific Antibody Deficiency (SAD), 9 Selective IgA Deficiency, 8 Hypogammaglobulinemia, 2 Hyper IgM Syndrome (HIGM) and 6 X-linked agammaglobulinemia (XLA). The other 22 out of 118 patients had: 1 auto-inflammatory disorder, 8 Combined Immunodeficiencies (CID), 2 C3 deficiency, 2 congenital defects of phagocyte, 2 defects in Intrinsic and Innate immunity, 4 immune dysregulatory disorder and 3 primary immunodeficiencies and Down Syndrome. Clinical features of IEI patients are shown in Table 1 . Participants received the initial vaccine dose between January 2021, and November 2021. Adult patients (AP) received adenoviral vector vaccines (22 AstraZeneca, 27 Sputnik V and 4 a combination of Sputnik V and AstraZeneca), inactivated vaccines (11 received Sinopharm), mRNA vaccines (4 received Moderna) and a combination of different vaccine platforms (10 Sputnik and Moderna, 1 AstraZeneca and Pfizer). In the pediatric patients (PP) cohort, 39 reported vaccinations with mRNA vaccines (37 with Moderna, 1 with Pfizer and 1 with a combination of Pfizer with Moderna). The median interval between vaccine doses was 59.4 days (range = 21–168 days). During the study, 76 IEI patients received immunoglobulin-replacement therapy; 32 patients were treated with subcutaneous immunoglobulin and 44 patients with intravenous immunoglobulins. The immunoglobulin preparations used were free of anti-SARS-CoV-2 antibodies (data provided by manufacturers). Symptomatic and PCR-confirmed COVID-19 was observed in 18 out of 118 patients before vaccination, whereas 5 out of 118 patients got SARS-CoV-2 infection between the first and the second doses or after full vaccination (Table 1 ). The healthy control (HC) cohort consists of 27 adults and 12 adolescents. Participants received vaccines between January 2021 and September 2021. Healthy Adults (HA) donors received adenoviral vector vaccines (8 with AstraZeneca and 6 with Sputnik V), inactivated vaccines (8 with Sinopharm) and a combination of different vaccine platforms (5 with Sputnik and Moderna). For healthy pediatric (HP), all donors reported vaccination with mRNA vaccines (12 with Moderna). Safety parameters No moderate or severe adverse events were observed in IEI patients following vaccination. Regarding the PP cohort, only three pediatric patients (P12, P18 and P35) presented erythema, heat and redness with Moderna at the vaccine application site, or moderated myalgia (Table 1 ). On the other hand, in the AP cohort the most common reported adverse events were fever, myalgias and pain at the site of injection. We observed that 9 out of 22 AP vaccinated with two doses of AstraZeneca presented mild systemic and/or local side effects, whereas only 3 out of 27 AP vaccinated with two doses of SputnikV presented mild local side effects. The combination of adenoviral vaccines with mRNA vaccines in AP resulted in 4 out of 11 with mild systemic and/or local side effects whereas the combination of SputnikV/AstraZeneca presented in 2 out of 4 patients with mild systemic and/or local side effects (Table 1 ). Specific humoral immune response IgG antibody responses To determine the antibody response, we analyzed the presence of serum IgG anti-S/RBD antibodies in samples from IEI patients and HC (79 AP and 27 HA; 39 PP and 12 HP). Seroconversion capacity was analyzed by comparing antibody titers at different times pre- and post-vaccination: T0, T1 and T2. The specific IgG anti-N antibodies were determined at T2 to evaluate infection, and so in patients that received Sinopharm (n = 11) were only analyzed in T0 pre-vaccination sample. The analysis of samples at T0 showed that 15.6% (12/77) of patients were positive for anti-S/RBD IgG (Table 2 , Fig. 1 a). According to the available data of COVID-19 compatible symptoms and COVID-19 confirmed laboratory test (Table 1 ), 8 out of 12 patients (A5, A9, A20, A29, A35, A60, P9 and P39) had PCR-confirmed COVID-19 and were seropositive at baseline, the remaining 4 seropositive patients were asymptomatic or non-laboratory-confirmed diagnosed; for the remaining 65 seronegative samples, 3 of them (A14, A46 and A71) were COVID-19-positive by PCR (Table 2 ). The analysis of post-vaccination serum samples in IEI patients showed that 65.5% (57/87) seroconverted at T1 and 80.6% (86/108) at T2 (Fig. 1 a). We investigated the seroconversion rate with age and found significant differences among PP (12–18 years old) and AP (older than 18 years old) but not between two AP groups (18–50 years old and older than 50 years old) (Figure S1). Regarding variation in antibody response between genders observed in previous works [ 23 ], we found no significant differences between males and females (Figure S2). Based on these findings, we grouped patients as PP (39/118), for pediatrics aged between 12 and 18 years old, and AP (79/118) for adults aged between 19 and 78 years old. Our findings showed that 46.0% of AP were positive at T1 compared to 91.9% of positivity at T1 for PP. Regarding T2, 71.4% of AP with IEI were seroconverted, whereas 97.4% of PP were positive (Fig. 1 b). We also compared IEI patients with HC at T2 and we found a significantly higher titer for control samples, both pediatrics and adults, than for IEI patients (p < 0.005 and p < 0.05, respectively) (Fig. 1 c). The absence of seroconversion in IEI patients was found in 2.6% (1/39) of PP and in 28.6% (20/70) of AP. Concerning the former, the patient was vaccinated with Moderna and had XLA (Table 1 and Figure S4a). For the latter, 3 had XLA, 13 had CVID, 2 patients had HIGM, 1 had an autoinflammatory syndrome, 1 had CID and 1 presented Selective IgA deficiency. Considering the vaccines received, our findings showed that 6 out of 10 AP vaccinated with 2 doses of Sinopharm did not seroconvert (2 had XLA), whereas antibodies resulted also negative in 5 out of 24 AP vaccinated with Sputnik V, 8 out of 20 AP with AstraZeneca (1 XLA), 1 out of 2 AP with a combination of Sputnik V/AstraZeneca vaccines, 1 out of 9 AP with a combination of adenoviral and mRNA vaccines Sputnik V/Moderna and none of the 4 that received Moderna vaccines (Table 1 and Figure S4a). We also considered in the antibody analysis the COVID-19 infection before vaccination by comparing the antibody levels between patients without COVID-19 symptoms reported and negative for anti-S/RBD antibody at baseline with respect to patients who reported symptomatic COVID-19, qPCR positive test and were positive for anti-S/RBD antibodies at T0. Remarkably, we did not observe significant differences in IgG anti-S/RBD titers at T2 between patients with or without COVID-19 history (Fig. 1 d). Regarding patients with COVID-19, unlike what was previously reported in HC [ 24 ], we observed an increment of anti-S/RBD antibodies after the first and second doses of SARS-CoV2 vaccines. The increase of antibody titers in IEI patients, regardless of previous COVID-19 diagnosis, suggested the importance of subsequent boosts for this group of patients. Those patients that suffered from COVID-19 and did not develop anti-S/RBD specific IgG had CVID (A29, A33, A46) or XLA diagnosis (A71). We also analyzed IgG anti-N in T2 samples from patients not vaccinated with Sinopharm to evaluate previous asymptomatic COVID-19. We found that 40.4% (42/104) samples were positive for anti-N IgG antibodies. We found that 6 patients (A9, A20, A29, A35, A60, P9) also had IgG anti S/RBD antibodies at baseline and were COVID-19 confirmed by PCR and symptoms, and 2 patients (A49 and P35) were positive at baseline for IgG anti-S/RBD and had neither PCR positive test nor COVID-19-compatible symptoms (Fig. 1 e, Table 1 ). In addition, we measured anti-N IgG antibodies in pre-vaccination samples from those patients who received Sinopharm. Only 1 sample (A79) was positive for anti-N antibodies, he showed neither COVID-19-compatible symptoms nor positive anti-S/RBD IgG (Table 1 ). Two out of 5 samples analyzed (A5 and A71) with anti-N negative at baseline that received Sinopharm reported previous COVID-19 symptoms with positive qPCR for SARS-CoV-2, being A5 positive for anti-S/RBD IgG at baseline (Table 1 , Fig. 1 e). This emphasizes that in this population of patients with IEI, with a broad spectrum of antibody responses, a negative antibody response for S/RBD is not indicative of the absence of asymptomatic SARS-CoV-2 infection history, nor is a negative response of antibodies against N. In other words, added to the clinic and PCR of symptomatic patients, for asymptomatic IEI patients, the sum of responses may be closer to the reality of contact with SARS-CoV-2. We next compared the antibody levels between patients without COVID-19 symptoms reported, negative for anti-S/RBD antibody at baseline and negative for anti-N antibody after two doses of vaccines with respect to patients that were symptomatic, qPCR positive for SARS-CoV-2 and seroconverted (positive prior to vaccination anti-S/RBD antibodies and/or positive for anti-N antibodies after vaccination). We did not find significant difference in the specific IgG titers in IEI patients exposed and not exposed to the virus (Figure S3). Regarding the type of vaccine, we observed less titers for all the vaccines applied in patients with IEI with respect to the HC group. In particular, we found significant differences in PP vaccinated with Moderna concerning the HP group (p < 0.005, Figure S4a) and in AP vaccinated with AstraZeneca or Sinopharm with respect to the HA group (p < 0.05, Figure S4a). Neutralizing antibodies To further assess the functionality of antibodies elicited following vaccination, we evaluated the serum neutralization capacity of a pseudovirus expressing Wuhan RBD to infect ACE2-transfected Vero cells. Serum-containing anti-S/RBD IgG from PP (36) and AP (42) at T2 were analyzed for the IC80. Furthermore, 27 samples from fully vaccinated HA and 12 from fully vaccinated HP were assessed as controls. Our findings showed neutralizing capacity in 81.0% (35/42) of sera from AP. The negative sera were from patients with CVID (A22, A40, A53, A57, A79) and hypogammaglobulinemia (A14, A19) (Table 1 , Fig. 1 f). Regarding the PP cohort, 35 out of 36 sera (97.2%) had neutralizing capacity; only 1 patient (P38) was negative and had a CD25 deficiency. Interestingly, one XLA pediatric patient (P3) was positive for anti-S/RBD IgG and also had neutralizing antibodies (Table 1 , Fig. 1 f). Remarkably, the comparison of the IC80 neutralization capacity among IEI patients and HC revealed that control subjects had higher IC80 titers than IEI patients (PP p < 0.01 and AP p < 0.05, Fig. 1 f). Furthermore, IC80 was significantly higher in PP than in AP (Fig. 1 f). We next analyzed the neutralizing capacity in vaccinated individuals according to previous COVID-19 status (patients without COVID-19 symptoms, negative for anti-S/RBD antibody at T0 and negative for anti-N antibody at T2 versus patients that were symptomatic, qPCR positive for SARS-CoV-2 and positive for anti-S/RBD antibodies at T0 and/or positive for anti-N antibodies at T2). Vaccinated subjects naïve for COVID-19 showed no significant difference of IC80 compared with COVID-19 positive patients, either in the PP or AP cohorts (Figure S5). Finally, we examined the quality of the specific humoral immune response elicited following vaccination. Our findings showed that IEI patients had a significantly lower ratio than HC (p < 0.05, Fig. 1 g), and the neutralizing ability capacity correlated with the antibody titer in both adults and minors (PP p = 0.026; HP p = 0.010; AP p < 0.0001; HA p = 0.045, Fig. 1 h and i). This reduced functional capacity was observed regardless of the vaccine received. Nevertheless, a broader difference was observed in PP administered with Moderna than in HP (p < 0.005, Figure S4b). T-cell-mediated immune responses IFN-γ Cellular response To get further insight on cellular immune response that was elicited in IEI patients, we investigated whether vaccines triggered a SARS-CoV-2-specific T-cell response. We assessed the IFN-γ secretion by ELISPOT in S or N-stimulated PBMC from 23 PP, 35 AP and 26 HA at T2 (Fig. 2 a). The S-protein stimulation rendered 82.9% (29/35) and 87.0% (20/23) of positivity in AP and PP, respectively. The spot count did not significantly differ between AP and PP cohorts (Fig. 2 b). Our findings revealed that 22/29 (75.9%) AP and 19/20 (95.0%) PP had detectable anti-S/RBD specific antibodies after full vaccination (Table 2 ). Eight out of the 30 AP that were positive for S-stimulated T-cell response did not seroconvert after the second vaccination: 5 (A10, A15, A33, A37, A61) had CVID, 2 (A42 and A78) were XLA patients and 1 (A50) had T cell deficiency. Likewise, 1 PP with XLA (P16) that showed positive S- induced IFN-γ did not seroconvert (Table 2 ). Overall, 3 patients with XLA did not mount a specific humoral immune response, but elicited cellular immunity with secretion of IFN-γ. The analysis of the S-induced IFN-γ secretion in HA showed that 25/26 of them were positive. For both, PP and AP with IEI, we observed a lesser IFN-γ response to S-protein with respect to HA but without significant differences. This assessment could not be carried out in HP due to the lack of PBMC’s samples (Fig. 2 b). Regarding patients with absence of IFN-γ induction upon COVID-19 vaccination, 5 AP (A3, A11, A40, A47 and A59) had CVID while the 3 PP had SAD (P10), hypogammaglobulinemia and CD4 T cell Lymphopenia (P17) and CVID (P20). Two out of these 5 AP (A40 and A47) showed the presence of antibodies at T2, being only 1 (A47) of them positive for neutralization antibodies. About the 3 PP, 100% developed antibodies (Figure S6a). Twenty-six samples had detectable cellular responses to N-protein stimulation. Among them, 14 were also positive for anti-N antibodies and other 2 negative for anti-N had reported COVID-19 positive (1 with positive anti-S/RBD antibodies at baseline). Overall, ten patients without history of SARS-CoV-2 infection, anti-S/RBD positive at baseline and/or anti-N antibodies after two doses of vaccination, presented cellular response to N-protein in T2, three of them with negative anti-N antibodies (close to the cut off value) (Table 2 and Figure S7). We did not observe a relationship between IFN-γ-secreting T cells and vaccines. Nevertheless, unlike the humoral response that was stronger in PP than in AP with IEI, the PP vaccinated with mRNA vaccine presented a similar T-cell responses than AP vaccinated with mRNA vaccines, adenoviral vector vaccines, or inactivated vaccines (Figure S6b). We next compared the IFN-γ secretion considering COVID-19 infection (patients without COVID-19 symptoms reported, negative for anti-S/RBD antibody at T0 and negative for anti-N antibody at T2 respect to patients that were symptomatic, qPCR positive for SARS-CoV-2 and positive for anti-S/RBD antibodies at T0 and/or positive for anti-N antibodies at T2). Although a trend was observed for a higher IFN-γ secretion in COVID-19 positive patients, only AP showed a significant increase (Fig. 2 c). In sum, only 4 AP (A3, A10, A11 and A59) did not developed humoral immune response nor cellular immune response against COVID-19 vaccines, and 1 AP (A40) did not developed cellular response nor neutralization antibody, all of them having CVID. Circulating T follicular helper cells (TFH) We finally assessed the frequency of TFH cells at T0 and T2, based on previous reports identifying the circulating TFH cells as representative of the germinal center with a critical role in T-dependent B-cell maturation and antibody production [ 25 , 26 ]. The gating strategy used to identify the PD-1 + CXCR5 + CD4 + circulating TFH cells is shown in Fig. 3 a. The frequency of total circulating TFH cells analysis showed no significant differences between pre-vaccination and post-vaccination samples from IEI patients (Fig. 3 b). As shown by others, we found that patients with IEI had a significantly reduced frequency of total circulating TFH cells compared to HC [ 27 – 29 ]. Our findings showed 8.9% (range 3.2–18.1%) vs 3.1% (range 0.7–7.5%) frequency of total TFH cells for HC and IEI patients, respectively. (p < 0.0001) (Fig. 3 c). To further examine the virus-specific TFH cells, PBMCs from 29 AP and 27 PP were stimulated with the S protein or PHA as a positive control. The S-specific TFH cell population was analyzed according to the cell surface expression of CD154 (Fig. 3 a and 3 d). We only observed a significantly higher expression of CD154 in S-stimulated TFH cells with respect to the control condition in T2 and not in T0 (Fig. 3 d). We found that 82.8% (24/29) of the AP and 81.5% (22/27) of the PP with IEI presented an increase of cell frequency at T2 (p < 0.0001, Fig. 3 e). The analysis of the impact of COVID-19 infection on circulating TFH frequency showed that the previous infection increased this S-specific cell population (p < 0.0001) (Fig. 3 f). The analysis of the TFH frequency in terms of IEI showed that from the 5 AP patients without higher expression of S-induced CD154 expression at T2, 2 had CVID (A1 and A43), 1 had HIGM (A69) and 2 had XLA (A71 and A78). Regarding PP without specific THF response, 1 had Selective IgA Deficiency (P1), 1 had CID (P2), 1 had CD4 T cell lymphopenia and Down Syndrome (P13), 1 had SAD (P14) and 1 had XLA (P16) (Table 2 and Figure S8a). Regarding vaccines, we observed that Moderna and AstraZeneca triggered a significant increase in the frequency of TFH. However, 2 AP (A6 and A51) out of the 3 patients vaccinated with Sputnik/Moderna combination were older than 50 years and had lesser vaccine response than children or younger adults (Figure S8b). We did not find correlation between circulating S-specific TFH cells and antibody titer or neutralization IC80 (data not shown). Post vaccination COVID-19 disease After the complete vaccine scheme with two doses almost all patients who presented symptomatic SARS-CoV-2 infection had a mild or moderate presentation of COVID-19 without needing to be admitted to intensive care. However, A10 and A78 presented severe COVID-19 disease and died. One of them, A10, was a CVID patient without S-specific IFN-γ T cell response neither antibody response. The other, A78, was a XLA without specific humoral immune response and with mild S-specific IFN-γ T cell response. Discussion Vaccines are the most effective intervention to combat and prevent contagious diseases and reduce mortality rates. The massive vaccination against SARS-CoV-2, with no precedents in the history of vaccinology, has been successful in controlling the most severe consequences of the pandemic and preventing severe illness and death. Vaccine safety and immunogenicity in patients with IEI, in whom adaptive immune responses triggered by vaccines are often restricted, has been a critical point of interest. Most of the studies have been carried out in healthy volunteers, whereas data regarding defined patient populations, such as IEI patients, are still being gathered. In this study we evaluated the safety, reactogenicity and immunogenicity of different vaccines used in Argentina against COVID-19 in a cohort of patients aged between 12 and 78 years diagnosed with IEI, compared to HC. We evaluated the humoral and cellular immune response to different vaccine platforms (mRNA-, adenoviral- and inactivated virus-based vaccines and the combination of adenoviral and mRNA vaccines) employed in homologous and heterologous schemes. No moderate or severe adverse events were observed in IEI patients following vaccination, only mild systemic and/or local reactions. As shown by others, severity does not appear to be increased in these patients. Our data shows that vaccines in patients with IEI were able to induce humoral response, that means specific IgG antibodies with neutralizing capacity; cellular response, with increased frequency of circulating specific TFH cells and IFN-γ-secreting cells; or both. In fact, anti-S/RBD IgG was detected in 97.4% (37/38) and 72.9% (51/70) of IEI pediatric and adult samples, respectively, at T2, whereas the seroconversion was 100% in our HC cohort. A low proportion of PP (16.7%) and AP (14.9%) showed seroconversion before vaccination, which means that these patients were exposed to the virus prior to vaccination. Our findings showed that the combination of immunity provided by infection and vaccines did not enhance the production of specific antibodies compared to vaccinated individuals, as reported by others in IEI patients [ 30 ] and healthy subjects [ 24 ]. We observed discrete differences in the antibody titer following the first and second doses between patients without SARS-CoV-2 exposure concerning patients with previous history of COVID-19. Regardless of SARs-CoV-2 exposure, the antibody titers significantly increased over time remarking the importance of subsequent boosts for this group of patients. Furthermore, the IgG median titer was higher in age-matched healthy subjects than in PP (p < 0.005) and AP (p < 0.01). While studies focused on seroconversion showed that 67–85% of IEI patients developed detectable anti-S IgG antibodies [ 13 , 31 , 32 ], other studies showed that neutralizing antibodies were detected in lower levels than in healthy controls [ 15 , 33 ]. In our study, neutralizing antibodies were detected in 70 out of 78 patients with antibody production at T2 and it was significantly higher in pediatric than in adult IEI patients (p < 0.001), but lower than in age-matched HC (p < 0.01 and p < 0.05, respectively). Almost all patients with a diagnosis of XLA, due to a defect in BTK, evaluated in this study did not develop antibody response against SARS-CoV-2 vaccines. Nevertheless, one pediatric patient (P3) presented a functional antibody response at T2, likely due to incomplete penetrance of their BTK mutation 31 . Excluding XLA patients from our analysis of humoral response, 74.6% of AP and 100% of PP showed seroconversion after two vaccination doses. Among them, 83.3% of AP and 97.1% of PP were able to neutralize the SARS-CoV2 infection. Being TFH cells critical to induce high affinity neutralizing antibodies, we found that 82.1% in total IEI patients and 87.5% excluding XLA patients, presented S-specific circulating TFH cells. Positive S-specific IFN-γ response was observed in 84.5% of IEI patients. Remarkably, all XLA patients evaluated developed specific IFN-γ-dependent cellular immune response, which highlights that vaccination in this population, despite not generating antibody protection, may provide cellular protection. Other authors have also described that T-cell compartment is normal in these patients characterized by absent or very low frequency of peripheral mature B-cells [ 34 , 35 ]. Five patients (A3, A10, A11, A40 and A59) failed to develop functional humoral response nor cellular response, all of them adults with CVID diagnosis. Patient A40 was the only AP treated with methotrexate. Previous report showed that methotrexate reduces the immunogenicity of SARS-CoV-2 vaccination and recommended pausing the treatment for at least 10 days after vaccination [ 32 ]. Although the data collected in this and other studies on vaccination against SARS-CoV2 in patients with IEI, the long-term immunogenicity of both humoral and cellular responses remains to be studied. Importantly, in our study, we did not find significant differences with respect to healthy controls in the post-vaccination cellular response, so that all the vaccines evaluated were equally beneficial for patients with IEI. While other studies demonstrated comparable cellular immune responses among IEI patients and healthy controls [ 15 , 33 ], others reported a significantly lower magnitude of their T cell response [ 36 , 37 ]. Altogether, our results support that COVID-19 vaccines have favorable safety, immunogenicity, and efficacy profiles in pediatric and adult IEI patients, although with lower immunogenicity than in control subjects. In conclusion, COVID-19 continues to represent a risk for developing severe forms of the disease in immunocompromised patients and vaccines against SARS-COV-2 proved to be an effective tool to induce a protective immune response, emphasizing the importance of vaccination. Our findings may guide the recommendation of vaccination in IEI patients to prevent COVID-19 disease and the need for subsequent boosts. Declarations Funding This work was supported by grants and fellowships from the Agencia Nacional de Promoción Científica y Tecnológica (ANPCyT), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET) and TAKEDA. Competing interests The authors declare that they have no conflict of interest. Authorship contributions LE, AC and MBA did most of the experiments and created the figures; JBF, JB, and MB contributed in the purification of patient samples, Anti-S/RBD measurement by ELISA, IFN-gamma determination by ELISPOT and Flow Cytometry experiments from patient samples; SV, MIPM and II participated in the neutralization assays; ChC contributed with patient samples purification; MNB, PB and MFQ contributed in ELISA and ELISPOT experiments in healthy donors; LT, MR, RC, GR, MF and GD collaborated with Anti-S/RBD and Anti-N experiments by ELISA measured in patient samples; RP, ILU, MVP, GS, IM, GV, ALL, DR, LRFM, MNB, PB, MFQ and LB recruited patients or healthy donors and performed clinical analysis; ILU, LB and MBA designed and supervised the research study; MBA, GD, MB, AC, ILU, RP and LB analyzed the data; MBA, LE, AC, MB and GD wrote the paper. All authors contributed to the article and approved the submitted. Data Availability Ethics approval The protocol was approved by the Ethics and research Committees of the ‘Hospital de Agudos C. G. Durand’, ‘Hospital Interzonal Especializado Materno Infantil Victorio Tetamanti’, ‘Hospital Interzonal General de Agudos Dr. Oscar Alende’ and ‘Programa Interdisciplinario de Bioética de la Universidad Nacional de Mar del Plata’, according to the ethical standards of each institutional research committee and with the 1964 Helsinki declaration. Consent to participate Participants, or their parents, signed an informed consent. Acknowledgments We acknowledge the support of the following agencies and organizations National Council for Scientific and Technical Research (CONICET), National Agency for Scientific and Technological Promotion (ANPCyT), TAKEDA, Fundación IBYME and Fundación de Ciencias Exactas y Naturales (FUNDACEN). We also acknowledge to Manuel de la Mata and Federico Fuchs for the borrowed equipment, to Julio Caramelo and Andrea Gamarnik for providing us with S and N proteins, to the members of the Laboratorio de Agrobiotecnología for the use of equipment, to Florencia Pignataro and other members of the Argentinian AntiCovid Consortium from the IB3 for producing coronavirus proteins and having made them available during our set-up of the trials for this work, to Federico Fuchs for the critical reading of this manuscript and to the Secretaries from “Centro de Inmunología Clínica” for call patients and their families and collected the informed consents. Finally, thanks to all the patients, families, and donors for participating in this study. Data Availability Statements All data generated or analyzed during this study are included in this published article (and its supplementary information files). References Qin C, Zhou L, Hu Z, Zhang S, Yang S, Tao Y, et al. 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Supplementary Files Table1andTable2.xlsx Supplementaldata.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 31 Jul, 2022 Reviewers invited by journal 31 Jul, 2022 Editor invited by journal 28 Jul, 2022 Editor assigned by journal 26 Jul, 2022 First submitted to journal 22 Jul, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Almejun","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYDACCQbGAwwMbAwM7A1AnoEFUVoYIFp4DoC0SBCtBcRIgHIJAd3ZzQ8O3ajgS9wu+fzqhh8FEgz87d0JeLWY3TlmcDjnDFviztk5ZTd7gA6TOHN2A34tNxIMDue2sSVuuJ2TdoMHqMVAIpeQlvQPh3P/AbXcPJN28w9xWnKAtjQAtdxgP3abOFvunCk4nHOMzXjDmRy22zIGEjyE/XK7fePjnJpjshuOH392880fGzn+9l78WqDgGBDzGIBYPMQoB4EaIGZ/QKzqUTAKRsEoGGEAALt8UNrMEw5/AAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0003-3138-736X","institution":"UBA Faculty of Exact and Natural Sciences: Universidad de Buenos Aires Facultad de Ciencias Exactas y Naturales","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"María","middleName":"Belén","lastName":"Almejun","suffix":""}],"badges":[],"createdAt":"2022-07-22 23:14:52","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1887005/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1887005/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":24679857,"identity":"30a0cbbe-c265-4e3f-8b72-cab27f590de7","added_by":"auto","created_at":"2022-08-02 16:59:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":110429,"visible":true,"origin":"","legend":"\u003cp\u003eHumoral response in patients before and after immunization.\u003cstrong\u003e a-b\u003c/strong\u003e Anti-S/RBD IgG levels measured by ELISA at T0 (pre-vaccination), T1 (post first vaccine dose) and T2 (post second vaccine dose) in all IEI (A) or in PP and AP populations (B). \u003cstrong\u003ec\u003c/strong\u003e Comparison of anti-S/RBD IgG levels between IEI and HC at T2\u003cstrong\u003e. d\u003c/strong\u003e Longitudinal anti-S/RBD IgG levels in IEI patients with or without history of COVID-19 infection. \u003cstrong\u003ee\u003c/strong\u003e Anti-N IgG measured by ELISA at T2 in IEI patients. \u003cstrong\u003ef\u003c/strong\u003e Comparison of neutralizing titer levels between IEI and HC at T2. \u003cstrong\u003eg\u003c/strong\u003e Ratio of neutralizing titer IC80 and IgG anti-S/RBD antibodies for IEI patients and HC according to age. \u003cstrong\u003eh-i\u003c/strong\u003e Correlation between neutralizing titer IC80 and anti-S/RBD IgG at T2 for pediatrics (H) and adults (I). AP=adult patients (blue circles), PP= pediatric patients (purple circles), HC= healthy controls, HA= healthy adults’ controls (gray squares) and HP= healthy pediatric controls (gray diamonds). Black circles represent the analysis of the total IEI population (AP + PP). IC80= eighty inhibitory concentrations. Dotted line threshold at 50 UI/ml in anti-Spike/RBD antibody titers graphs and at 0.5 OD in anti-N IgG graph. Statical analysis was performed using Kruskal-Wallis test followed by Dunn’s multiple comparison test (Figs a, b and d), Mann–Whitney test (Figs c, f and g) and Spearman’s correlation (Figs h and i). *P\u0026lt;.05, **P\u0026lt;.01, ***P\u0026lt;.001, ****P\u0026lt;.0001.\u0026nbsp;\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-1887005/v1/4703f2c3b4adb51627ab8219.png"},{"id":24679867,"identity":"27be082d-91ff-4b08-8f42-83b4c485ce56","added_by":"auto","created_at":"2022-08-02 16:59:16","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":245063,"visible":true,"origin":"","legend":"\u003cp\u003eIFN-γ production by ELISPOT after the second dose of vaccination. \u003cstrong\u003ea \u003c/strong\u003eImages of wells (IFN-γ SFU) of control/medium-, S-, N- and PHA-stimulated PBMC from IEI patients and HC. \u003cstrong\u003eb\u003c/strong\u003e Number of SFU relative to control of HA, PP and AP stimulated with S protein at T2. \u003cstrong\u003ec\u003c/strong\u003e Number of SFU relative to control of PP and AP stimulated with S protein at T2 in patients with or without history of COVID-19. Each dot represents a different individual analyzed. AP (n = 35), PP (n = 23), HA (n= 9). SFU=spot forming units, A.U.= Arbitrary Units. Dotted line in 6 was set as threshold. Statistical analysis was performed by using Kruskal-Wallis test followed by Dunn’s Multiple comparison test (b) and Mann Whitney test (c). P\u0026lt;.05, **P\u0026lt;.01, *P\u0026lt;.001, ***P\u0026lt;.0001.\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-1887005/v1/40ca40dcc9a8d415cd560d56.png"},{"id":24680796,"identity":"5a698dea-29a4-42eb-bcfa-266f9bdd8e43","added_by":"auto","created_at":"2022-08-02 17:04:16","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":372195,"visible":true,"origin":"","legend":"\u003cp\u003eCirculating total and specific TFH cells in IEI patients.\u003cstrong\u003e\u0026nbsp;a,\u003c/strong\u003e Gating strategy used to identify TFH cells by multiparametric flow cytometry. \u003cstrong\u003eb,\u003c/strong\u003e Frequency of total circulating CD4+CXCR5+PD1+ TFH cells at T0 and T2 for PP and AP. \u003cstrong\u003ec,\u003c/strong\u003e Frequency of total circulating CD4+CXCR5+PD1+ TFH cells at T2\u0026nbsp;in HC and IEI patients \u003cstrong\u003ed,\u003c/strong\u003e Spike specific CD4+CXCR5+PD1+CD154+ TFH cells at T0 and T2 for PP and AP after 24 h of stimulation with S protein. \u003cstrong\u003ee, \u003c/strong\u003eSpike-specific CD4+CXCR5+PD1+CD154+ TFH-cells relative to Control at T0 and T2 for AP and PP. \u003cstrong\u003ef,\u003c/strong\u003e Spike-specific CD4+CXCR5+PD1+CD154+ TFH-cells relative to Control at T0 and T2 for IEI patients with or without history of COVID-19 infection. AP (n = 29), PP (n = 27), HA (n= 15). Statistical analysis was performed by using Wilcoxon signed rank test (b, e and f), Mann Whitney test (c) and Friedman’s test (d). *P\u0026lt;.05, **P\u0026lt;.01, ***P\u0026lt;.001, ****P\u0026lt;.0001.\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-1887005/v1/67cb371c0a9b6d510fe4e9da.png"},{"id":24680815,"identity":"74ab6d62-ba63-437a-bb35-d83ccf09aca0","added_by":"auto","created_at":"2022-08-02 17:04:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":657142,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1887005/v1/eec3b486-edf6-402e-a53a-34493044a5da.pdf"},{"id":24680795,"identity":"17942a96-59ef-4551-8430-d6b718efff70","added_by":"auto","created_at":"2022-08-02 17:04:15","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":37501,"visible":true,"origin":"","legend":"","description":"","filename":"Table1andTable2.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-1887005/v1/7abc68b1281b3e5fe527d25b.xlsx"},{"id":24679863,"identity":"f9d9d3e4-8abb-4e4d-8b6c-5c5bcf04e38d","added_by":"auto","created_at":"2022-08-02 16:59:15","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":1942674,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaldata.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1887005/v1/d0ee8ff60ad064eeb4fa7deb.pdf"}],"financialInterests":"","formattedTitle":"­­­­­COVID-19 vaccination responses with different vaccine platforms in patients with inborn errors of immunity","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn December 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in the Hubei province of China, and wreaked havoc in the world by causing the highly transmissible infectious disease coronavirus disease-2019 (COVID-19) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The disease clinical spectrum is variable, ranging from asymptomatic to severe respiratory distress syndrome [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The current death toll reported is 6.33\u0026nbsp;million people worldwide [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] but is likely underestimated and will probably continue to rise until there is universal deployment of effective vaccines and therapeutics [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile data supporting the effectiveness and safety of the newly developed anti\u0026ndash;SARS-CoV-2 vaccines is accumulating, initial studies enrolled mostly healthy volunteers. To study the response to vaccination of patients with inborn errors of immunity (IEI) or immunocompromised is of particular interest for several reasons. On the one hand, the immune response following COVID-19 vaccination may differ in people who are moderately or severely immunocompromised at the time of vaccination. Therefore, analysis of the immune response to vaccines may be critical for guidance recommendation to prevent the COVID-19 disease. The literature shows no consensus about the severity of COVID-19 developed by immunocompromised patients. Whereas some reports suggested that patients might be at increased risk of developing severe disease [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], others described that patients experienced a mild COVID-19 with few symptoms [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Patients with IEI could therefore benefit from a more \u0026lsquo;\u0026lsquo;aggressive\u0026rsquo;\u0026rsquo; immunization effort. On the other hand, IEI patients are characterized by reduced vaccine response, depending on the type of immune disorder [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Thus, in IEI patients the underlying immune abnormality might impair the ability to respond to vaccination and to develop anti\u0026ndash;SARS-CoV-2 protective immunity, thus leading to questions regarding the benefit of the vaccination approach.\u003c/p\u003e \u003cp\u003eIn view of this, characterizing the immune response of IEI patients following SARS-CoV-2 vaccination is crucial, both for understanding their degree of protection and for formulating an optimal immunization scheme. Moreover, data gathered from analyses of the immune response of IEI patients to the anti\u0026ndash;COVID-19 vaccine could be relevant to other patient populations, especially those with secondary and acquired immunodeficiency.\u003c/p\u003e \u003cp\u003eTo date, the information of immunogenicity in patients with IEIs is limited and there are only a few studies that measured the immunity of a restricted variety of vaccines against COVID-19 (mostly mRNA vaccines) [\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Hence, more studies about immunogenicity and safety in patients considering other platforms in patients with IEI are needed.\u003c/p\u003e \u003cp\u003eCurrently, there are five vaccines licensed for emergency use in Argentina to prevent SARS-CoV-2 infection or severe infection and death related to COVID-19 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Due to the accelerated transmission of COVID-19 and the incidence of the disease in our country and the rest of the world, it is vital to evaluate the effectiveness and impact of the vaccines applied in our territory in patients with IEI. In this work, we describe the safety and immunogenicity of the Gam-COVID-Vac (Sputnik-V), AZD1222 or Covishield (Astrazeneca), BBIBP-CorV (Sinopharm) and mRNA-1273 (Moderna) vaccines in a cohort of IEI patients. Information on vaccine-associated adverse events was collected after each vaccine dose. We evaluated the B-cell response by measuring IgG anti-Spike(S)/RBD and anti-nucleocapsid(N) antibodies by ELISA and neutralization antibodies with an alpha-S protein-expressing pseudo-virus assay. The IFN-γ production was evaluated on S or N-stimulated PBMC by ELISPOT and the frequency of S-specific circulating T follicular-helper cells (TFH) was analyzed by flow cytometry.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and patients\u003c/h2\u003e \u003cp\u003eA total of 132 patients with IEIs (85 adults and 47 pediatrics) were enrolled sequentially between June and November 2021, according to the national vaccine strategy first adult patients then pediatric patients. This observational study included patients aged 12\u0026ndash;78 years affected by IEI, according to IUIS phenotypic classification criteria [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Fourteen patients were excluded from the study because only the pre-vaccination sample was obtained. The final cohort included 118 patients (pre vaccination sample (T0) n\u0026thinsp;=\u0026thinsp;77, post first vaccination dose (T1) n\u0026thinsp;=\u0026thinsp;87, post second vaccination dose (T2) n\u0026thinsp;=\u0026thinsp;108), 79 adult patients (AP) and 39 pediatric patients (PP). The mean age of our adult patient cohort was 39.3 years (range 19 y \u0026minus;\u0026thinsp;78 y), with 34 females and 45 males. The mean age of our pediatric patient cohort was 14.8 years (range 12 y \u0026ndash; 18 y), with 16 females and 23 males.\u003c/p\u003e \u003cp\u003eAdult (n\u0026thinsp;=\u0026thinsp;27) and pediatric (n\u0026thinsp;=\u0026thinsp;12) subjects without compromised immune system nor comorbidities also participated in the study. The blood samples from adult and plasma samples from pediatric subjects were analyzed as healthy control samples. The healthy adult donors were healthcare workers from the \u0026lsquo;Academia Nacional de Medicina\u0026rsquo; and healthy controls from the \u0026lsquo;Biobanco de Enfermedades Infecciosas\u0026rsquo; while the healthy pediatric donors were adolescent children of healthcare workers, included with the consent of their parents. The mean age of healthy adult donors was 41.8 years (range 26 y \u0026minus;\u0026thinsp;82 y) with 12 females and 15 males and 14.4 years (range 12 y \u0026minus;\u0026thinsp;17 y) for pediatric donors with 5 females and 7 males.\u003c/p\u003e \u003cp\u003eBlood samples from patients and healthy adult donors were collected prior to vaccination (T0), 28 days (+/-3 days) after the first (T1) and the second (T2) doses. Plasma was isolated and PBMCs were obtained by Ficoll-Hypaque density gradient centrifugation (GE) and cryopreserved in liquid nitrogen in fetal bovine serum (FBS, Serendipia). Serum from healthy pediatric samples were collected at T2. Plasma and serum were preserved at -80\u0026deg;C.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSARS-CoV-2 antibody ELISA\u003c/h2\u003e \u003cp\u003eQuantitative SARS-CoV-2 spike-specific IgG antibodies titers were measured by using the ELISA test COVIDAR (Laboratorio Lemos S.R.L, Buenos Aires, Argentina), as previously described [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Assay plates were coated with a mixture of spike (S) protein and receptor binding domain (RBD). Antibody concentrations of SARS-CoV-2 S protein expressed as International Units/mL (IU/mL), were determined by constructing a calibration curve with serial dilutions of the standard included in the immunoassay kit (400 IU/mL, reactive human serum adjusted to WHO First International Standard for human immunoglobulin against SARS-CoV-2, NIBSC Code 20/136, version 2.0 of 12/17/2020). Each sample was properly diluted to fit an OD 450 nm within the linear range of the calibration curve. Antibody concentrations were obtained by interpolating the OD 450 nm value for each sample into the calibration curve.\u003c/p\u003e \u003cp\u003eQualitative SARS-CoV-2 nucleocapsid(N)-specific IgG antibodies were measured with a validated in-house ELISA protocol. Assay plates were coated with a SARS-CoV-2 nucleocapsid protein. To set up the cutoff value we analyzed pre-pandemic donor samples (n\u0026thinsp;=\u0026thinsp;100), then samples with an OD450 value above 0.5 were considered positive for anti-N antibodies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePseudotyped lentivirus neutralization assay\u003c/h2\u003e \u003cp\u003eThe neutralization activity of serum was determined by the decrease of GFP expression in infected HEK-293T [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Briefly, SARS-CoV-2 S-Pseudotyped lentivirus were produced by co-transfection of HEK-293T cells with plasmids bearing the S protein, a lentivirus backbone (VRC5602, NIH) and a GFP reporter gene (Addgene plasmid #11619).\u003c/p\u003e \u003cp\u003eNeutralization assays were performed on HEK-293T cells transiently transfected 24 h before transduction with ACE2 and TMPRSS2 protease genes. The heat inactivated serum was serially diluted and incubated for 2 h with an equal volume of titrated pseudotyped lentivirus and were then added onto HEK-293T.\u003c/p\u003e \u003cp\u003ePseudovirus infectivity was scored 48 h later and images were obtained using an inverted fluorescence microscope (Olympus IX-71) and analyzed with the Micro-Manager Open Source Microscopy Software. Plasma antibody neutralization titers were calculated by a nonlinear regression curve fit using GraphPad Prism software Inc. (La Jolla, CA, USA). Half maximal inhibitory concentration (IC50) and eighty inhibitory concentration (IC80), corresponding to the serum antibody dilution causing a 50 and 80% reduction of GFP positive cells compared to control \u0026ldquo;virus only\u0026rdquo; treated cells, was determined using the same software according to Ferrara and Temperton [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eELISpot assay\u003c/h2\u003e \u003cp\u003eEvaluation of IFN-γ secreting cells was detected by using Human IFN-γ ELISPOT Pair (BD Biosciences). Briefly, 2.5 x10\u003csup\u003e5\u003c/sup\u003e PBMCs, from patients or healthy controls, were culture on 96-wells plates (MultiScreen IP plates; Millipore) coated with anti-human IFN-γ monoclonal antibody (BD Biosciences) and stimulated with SARS-CoV-2 S and N protein (kindly provided by Dr. J. Caramelo and Dra. A Gamarnik, Leloir Institute, Argentina) (10\u0026micro;g/ml). Glycerol (0,2%) and PHA (10\u0026micro;g/ml, Sigma) were used as negative and positive controls, respectively. After 16 h of stimulation, biotinylated anti-human IFN-γ monoclonal antibody, streptavidin-peroxidase and AEC (3-amino-9-ethylcarbazole) substrate reagent set (BD Biosciences) were used to detect spots.\u003c/p\u003e \u003cp\u003eScanning of plates was done on an ImmunoSpot reader and quantified with the ImmunoSpot software (Cellular Technology Ltd.). Based on control groups of pre-vaccinated individuals (n\u0026thinsp;=\u0026thinsp;10) and mildly affected convalescent individuals (n\u0026thinsp;=\u0026thinsp;10), we set the threshold for positive cellular response at 6 SFU (spot forming units) per 2.5 x10\u003csup\u003e5\u003c/sup\u003e PBMCs (data not shown). The response ratio was defined as the number of SFU obtained in the stimulated condition was relativized to SFU in the unstimulated condition. Samples were considered for analysis if the negative control was below the positive cellular response threshold and the positive control surpassed 100 SFU per 2.5 x10\u003csup\u003e5\u003c/sup\u003e PBMCs [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eFlow cytometry anti-Spike T-cell receptor staining\u003c/h2\u003e \u003cp\u003ePBMCs were thawed in RPMI 2% SFB with 25 U/ml of DNAsa I (Roche) medium and washed with 10% SFB DNAse RPMI medium. PMBC, 1x10\u003csup\u003e6\u003c/sup\u003e cells, were stimulated overnight with SARS-CoV-2 S protein (10\u0026micro;g/ml), medium 0.2% glycerol (negative control) and PHA (10\u0026micro;g/ml, positive control), as was previously described [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePBMCs were stained with a mixture of antibodies at 4\u0026deg;C for 20 min. The antibodies used were: FITC mouse anti-human CD4, PE mouse anti-human PD1, PerCP-Cy5.5 mouse anti-human CXCR5 and APC mouse anti-human CD154. All antibodies were obtained from Biolegend.\u003c/p\u003e \u003cp\u003eSamples were loaded onto a FACSAria II Flow Cytometer (BD) after antibody staining and cell fixation. Gating of populations positive for any marker was based on fluorescence minus one (FMO) control of each marker. Data were analyzed using FlowJo v.10.0.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eStatistical significance was determined by nonparametric tests Mann\u0026ndash;Whitney test, Column Statistics followed by Wilcoxon\u0026rsquo;s signed rank test, Kruskal-Wallis test, one way ANOVA followed by Dunn\u0026rsquo;s multiple comparison test or Spearman correlation test. In all cases, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. All data analyses were performed using the GraphPad 9.1.2 Prism Software (San Diego, CA, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and patients\u003c/h2\u003e \u003cp\u003eThe study cohort included 118 patients with IEIs (79 adults and 39 pediatrics). According to IUIS phenotypic classification criteria, 96 out of 118 patients had predominantly antibody deficiencies: 59 Common Variable Immunodeficiency (CVID), 12 Specific Antibody Deficiency (SAD), 9 Selective IgA Deficiency, 8 Hypogammaglobulinemia, 2 Hyper IgM Syndrome (HIGM) and 6 X-linked agammaglobulinemia (XLA). The other 22 out of 118 patients had: 1 auto-inflammatory disorder, 8 Combined Immunodeficiencies (CID), 2 C3 deficiency, 2 congenital defects of phagocyte, 2 defects in Intrinsic and Innate immunity, 4 immune dysregulatory disorder and 3 primary immunodeficiencies and Down Syndrome. Clinical features of IEI patients are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eParticipants received the initial vaccine dose between January 2021, and November 2021. Adult patients (AP) received adenoviral vector vaccines (22 AstraZeneca, 27 Sputnik V and 4 a combination of Sputnik V and AstraZeneca), inactivated vaccines (11 received Sinopharm), mRNA vaccines (4 received Moderna) and a combination of different vaccine platforms (10 Sputnik and Moderna, 1 AstraZeneca and Pfizer). In the pediatric patients (PP) cohort, 39 reported vaccinations with mRNA vaccines (37 with Moderna, 1 with Pfizer and 1 with a combination of Pfizer with Moderna). The median interval between vaccine doses was 59.4 days (range\u0026thinsp;=\u0026thinsp;21\u0026ndash;168 days).\u003c/p\u003e \u003cp\u003eDuring the study, 76 IEI patients received immunoglobulin-replacement therapy; 32 patients were treated with subcutaneous immunoglobulin and 44 patients with intravenous immunoglobulins. The immunoglobulin preparations used were free of anti-SARS-CoV-2 antibodies (data provided by manufacturers).\u003c/p\u003e \u003cp\u003eSymptomatic and PCR-confirmed COVID-19 was observed in 18 out of 118 patients before vaccination, whereas 5 out of 118 patients got SARS-CoV-2 infection between the first and the second doses or after full vaccination (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe healthy control (HC) cohort consists of 27 adults and 12 adolescents. Participants received vaccines between January 2021 and September 2021. Healthy Adults (HA) donors received adenoviral vector vaccines (8 with AstraZeneca and 6 with Sputnik V), inactivated vaccines (8 with Sinopharm) and a combination of different vaccine platforms (5 with Sputnik and Moderna). For healthy pediatric (HP), all donors reported vaccination with mRNA vaccines (12 with Moderna).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSafety parameters\u003c/h2\u003e \u003cp\u003eNo moderate or severe adverse events were observed in IEI patients following vaccination. Regarding the PP cohort, only three pediatric patients (P12, P18 and P35) presented erythema, heat and redness with Moderna at the vaccine application site, or moderated myalgia (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). On the other hand, in the AP cohort the most common reported adverse events were fever, myalgias and pain at the site of injection. We observed that 9 out of 22 AP vaccinated with two doses of AstraZeneca presented mild systemic and/or local side effects, whereas only 3 out of 27 AP vaccinated with two doses of SputnikV presented mild local side effects. The combination of adenoviral vaccines with mRNA vaccines in AP resulted in 4 out of 11 with mild systemic and/or local side effects whereas the combination of SputnikV/AstraZeneca presented in 2 out of 4 patients with mild systemic and/or local side effects (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSpecific humoral immune response\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003eIgG antibody responses\u003c/h2\u003e \u003cp\u003eTo determine the antibody response, we analyzed the presence of serum IgG anti-S/RBD antibodies in samples from IEI patients and HC (79 AP and 27 HA; 39 PP and 12 HP). Seroconversion capacity was analyzed by comparing antibody titers at different times pre- and post-vaccination: T0, T1 and T2. The specific IgG anti-N antibodies were determined at T2 to evaluate infection, and so in patients that received Sinopharm (n\u0026thinsp;=\u0026thinsp;11) were only analyzed in T0 pre-vaccination sample.\u003c/p\u003e \u003cp\u003eThe analysis of samples at T0 showed that 15.6% (12/77) of patients were positive for anti-S/RBD IgG (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea). According to the available data of COVID-19 compatible symptoms and COVID-19 confirmed laboratory test (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), 8 out of 12 patients (A5, A9, A20, A29, A35, A60, P9 and P39) had PCR-confirmed COVID-19 and were seropositive at baseline, the remaining 4 seropositive patients were asymptomatic or non-laboratory-confirmed diagnosed; for the remaining 65 seronegative samples, 3 of them (A14, A46 and A71) were COVID-19-positive by PCR (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe analysis of post-vaccination serum samples in IEI patients showed that 65.5% (57/87) seroconverted at T1 and 80.6% (86/108) at T2 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea).\u003c/p\u003e \u003cp\u003eWe investigated the seroconversion rate with age and found significant differences among PP (12\u0026ndash;18 years old) and AP (older than 18 years old) but not between two AP groups (18\u0026ndash;50 years old and older than 50 years old) (Figure S1). Regarding variation in antibody response between genders observed in previous works [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], we found no significant differences between males and females (Figure S2). Based on these findings, we grouped patients as PP (39/118), for pediatrics aged between 12 and 18 years old, and AP (79/118) for adults aged between 19 and 78 years old.\u003c/p\u003e \u003cp\u003eOur findings showed that 46.0% of AP were positive at T1 compared to 91.9% of positivity at T1 for PP. Regarding T2, 71.4% of AP with IEI were seroconverted, whereas 97.4% of PP were positive (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb). We also compared IEI patients with HC at T2 and we found a significantly higher titer for control samples, both pediatrics and adults, than for IEI patients (p\u0026thinsp;\u0026lt;\u0026thinsp;0.005 and p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, respectively) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec).\u003c/p\u003e \u003cp\u003eThe absence of seroconversion in IEI patients was found in 2.6% (1/39) of PP and in 28.6% (20/70) of AP. Concerning the former, the patient was vaccinated with Moderna and had XLA (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Figure S4a). For the latter, 3 had XLA, 13 had CVID, 2 patients had HIGM, 1 had an autoinflammatory syndrome, 1 had CID and 1 presented Selective IgA deficiency. Considering the vaccines received, our findings showed that 6 out of 10 AP vaccinated with 2 doses of Sinopharm did not seroconvert (2 had XLA), whereas antibodies resulted also negative in 5 out of 24 AP vaccinated with Sputnik V, 8 out of 20 AP with AstraZeneca (1 XLA), 1 out of 2 AP with a combination of Sputnik V/AstraZeneca vaccines, 1 out of 9 AP with a combination of adenoviral and mRNA vaccines Sputnik V/Moderna and none of the 4 that received Moderna vaccines (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Figure S4a).\u003c/p\u003e \u003cp\u003eWe also considered in the antibody analysis the COVID-19 infection before vaccination by comparing the antibody levels between patients without COVID-19 symptoms reported and negative for anti-S/RBD antibody at baseline with respect to patients who reported symptomatic COVID-19, qPCR positive test and were positive for anti-S/RBD antibodies at T0. Remarkably, we did not observe significant differences in IgG anti-S/RBD titers at T2 between patients with or without COVID-19 history (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ed). Regarding patients with COVID-19, unlike what was previously reported in HC [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], we observed an increment of anti-S/RBD antibodies after the first and second doses of SARS-CoV2 vaccines. The increase of antibody titers in IEI patients, regardless of previous COVID-19 diagnosis, suggested the importance of subsequent boosts for this group of patients. Those patients that suffered from COVID-19 and did not develop anti-S/RBD specific IgG had CVID (A29, A33, A46) or XLA diagnosis (A71).\u003c/p\u003e \u003cp\u003eWe also analyzed IgG anti-N in T2 samples from patients not vaccinated with Sinopharm to evaluate previous asymptomatic COVID-19. We found that 40.4% (42/104) samples were positive for anti-N IgG antibodies. We found that 6 patients (A9, A20, A29, A35, A60, P9) also had IgG anti S/RBD antibodies at baseline and were COVID-19 confirmed by PCR and symptoms, and 2 patients (A49 and P35) were positive at baseline for IgG anti-S/RBD and had neither PCR positive test nor COVID-19-compatible symptoms (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ee, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn addition, we measured anti-N IgG antibodies in pre-vaccination samples from those patients who received Sinopharm. Only 1 sample (A79) was positive for anti-N antibodies, he showed neither COVID-19-compatible symptoms nor positive anti-S/RBD IgG (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Two out of 5 samples analyzed (A5 and A71) with anti-N negative at baseline that received Sinopharm reported previous COVID-19 symptoms with positive qPCR for SARS-CoV-2, being A5 positive for anti-S/RBD IgG at baseline (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ee). This emphasizes that in this population of patients with IEI, with a broad spectrum of antibody responses, a negative antibody response for S/RBD is not indicative of the absence of asymptomatic SARS-CoV-2 infection history, nor is a negative response of antibodies against N. In other words, added to the clinic and PCR of symptomatic patients, for asymptomatic IEI patients, the sum of responses may be closer to the reality of contact with SARS-CoV-2.\u003c/p\u003e \u003cp\u003eWe next compared the antibody levels between patients without COVID-19 symptoms reported, negative for anti-S/RBD antibody at baseline and negative for anti-N antibody after two doses of vaccines with respect to patients that were symptomatic, qPCR positive for SARS-CoV-2 and seroconverted (positive prior to vaccination anti-S/RBD antibodies and/or positive for anti-N antibodies after vaccination). We did not find significant difference in the specific IgG titers in IEI patients exposed and not exposed to the virus (Figure S3).\u003c/p\u003e \u003cp\u003eRegarding the type of vaccine, we observed less titers for all the vaccines applied in patients with IEI with respect to the HC group. In particular, we found significant differences in PP vaccinated with Moderna concerning the HP group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.005, Figure S4a) and in AP vaccinated with AstraZeneca or Sinopharm with respect to the HA group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, Figure S4a).\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section4\"\u003e \u003ch2\u003eNeutralizing antibodies\u003c/h2\u003e \u003cp\u003eTo further assess the functionality of antibodies elicited following vaccination, we evaluated the serum neutralization capacity of a pseudovirus expressing Wuhan RBD to infect ACE2-transfected Vero cells. Serum-containing anti-S/RBD IgG from PP (36) and AP (42) at T2 were analyzed for the IC80. Furthermore, 27 samples from fully vaccinated HA and 12 from fully vaccinated HP were assessed as controls. Our findings showed neutralizing capacity in 81.0% (35/42) of sera from AP. The negative sera were from patients with CVID (A22, A40, A53, A57, A79) and hypogammaglobulinemia (A14, A19) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ef).\u003c/p\u003e \u003cp\u003eRegarding the PP cohort, 35 out of 36 sera (97.2%) had neutralizing capacity; only 1 patient (P38) was negative and had a CD25 deficiency. Interestingly, one XLA pediatric patient (P3) was positive for anti-S/RBD IgG and also had neutralizing antibodies (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ef).\u003c/p\u003e \u003cp\u003eRemarkably, the comparison of the IC80 neutralization capacity among IEI patients and HC revealed that control subjects had higher IC80 titers than IEI patients (PP p\u0026thinsp;\u0026lt;\u0026thinsp;0.01 and AP p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ef). Furthermore, IC80 was significantly higher in PP than in AP (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ef).\u003c/p\u003e \u003cp\u003eWe next analyzed the neutralizing capacity in vaccinated individuals according to previous COVID-19 status (patients without COVID-19 symptoms, negative for anti-S/RBD antibody at T0 and negative for anti-N antibody at T2 versus patients that were symptomatic, qPCR positive for SARS-CoV-2 and positive for anti-S/RBD antibodies at T0 and/or positive for anti-N antibodies at T2). Vaccinated subjects na\u0026iuml;ve for COVID-19 showed no significant difference of IC80 compared with COVID-19 positive patients, either in the PP or AP cohorts (Figure S5).\u003c/p\u003e \u003cp\u003eFinally, we examined the quality of the specific humoral immune response elicited following vaccination. Our findings showed that IEI patients had a significantly lower ratio than HC (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eg), and the neutralizing ability capacity correlated with the antibody titer in both adults and minors (PP p\u0026thinsp;=\u0026thinsp;0.026; HP p\u0026thinsp;=\u0026thinsp;0.010; AP p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001; HA p\u0026thinsp;=\u0026thinsp;0.045, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eh and i).\u003c/p\u003e \u003cp\u003eThis reduced functional capacity was observed regardless of the vaccine received. Nevertheless, a broader difference was observed in PP administered with Moderna than in HP (p\u0026thinsp;\u0026lt;\u0026thinsp;0.005, Figure S4b).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eT-cell-mediated immune responses\u003c/h2\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003eIFN-γ Cellular response\u003c/h2\u003e \u003cp\u003eTo get further insight on cellular immune response that was elicited in IEI patients, we investigated whether vaccines triggered a SARS-CoV-2-specific T-cell response. We assessed the IFN-γ secretion by ELISPOT in S or N-stimulated PBMC from 23 PP, 35 AP and 26 HA at T2 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea). The S-protein stimulation rendered 82.9% (29/35) and 87.0% (20/23) of positivity in AP and PP, respectively. The spot count did not significantly differ between AP and PP cohorts (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb). Our findings revealed that 22/29 (75.9%) AP and 19/20 (95.0%) PP had detectable anti-S/RBD specific antibodies after full vaccination (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eEight out of the 30 AP that were positive for S-stimulated T-cell response did not seroconvert after the second vaccination: 5 (A10, A15, A33, A37, A61) had CVID, 2 (A42 and A78) were XLA patients and 1 (A50) had T cell deficiency. Likewise, 1 PP with XLA (P16) that showed positive S- induced IFN-γ did not seroconvert (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Overall, 3 patients with XLA did not mount a specific humoral immune response, but elicited cellular immunity with secretion of IFN-γ.\u003c/p\u003e \u003cp\u003eThe analysis of the S-induced IFN-γ secretion in HA showed that 25/26 of them were positive. For both, PP and AP with IEI, we observed a lesser IFN-γ response to S-protein with respect to HA but without significant differences. This assessment could not be carried out in HP due to the lack of PBMC\u0026rsquo;s samples (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb).\u003c/p\u003e \u003cp\u003eRegarding patients with absence of IFN-γ induction upon COVID-19 vaccination, 5 AP (A3, A11, A40, A47 and A59) had CVID while the 3 PP had SAD (P10), hypogammaglobulinemia and CD4 T cell Lymphopenia (P17) and CVID (P20). Two out of these 5 AP (A40 and A47) showed the presence of antibodies at T2, being only 1 (A47) of them positive for neutralization antibodies. About the 3 PP, 100% developed antibodies (Figure S6a).\u003c/p\u003e \u003cp\u003eTwenty-six samples had detectable cellular responses to N-protein stimulation. Among them, 14 were also positive for anti-N antibodies and other 2 negative for anti-N had reported COVID-19 positive (1 with positive anti-S/RBD antibodies at baseline). Overall, ten patients without history of SARS-CoV-2 infection, anti-S/RBD positive at baseline and/or anti-N antibodies after two doses of vaccination, presented cellular response to N-protein in T2, three of them with negative anti-N antibodies (close to the cut off value) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Figure S7).\u003c/p\u003e \u003cp\u003eWe did not observe a relationship between IFN-γ-secreting T cells and vaccines. Nevertheless, unlike the humoral response that was stronger in PP than in AP with IEI, the PP vaccinated with mRNA vaccine presented a similar T-cell responses than AP vaccinated with mRNA vaccines, adenoviral vector vaccines, or inactivated vaccines (Figure S6b).\u003c/p\u003e \u003cp\u003eWe next compared the IFN-γ secretion considering COVID-19 infection (patients without COVID-19 symptoms reported, negative for anti-S/RBD antibody at T0 and negative for anti-N antibody at T2 respect to patients that were symptomatic, qPCR positive for SARS-CoV-2 and positive for anti-S/RBD antibodies at T0 and/or positive for anti-N antibodies at T2). Although a trend was observed for a higher IFN-γ secretion in COVID-19 positive patients, only AP showed a significant increase (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ec).\u003c/p\u003e \u003cp\u003eIn sum, only 4 AP (A3, A10, A11 and A59) did not developed humoral immune response nor cellular immune response against COVID-19 vaccines, and 1 AP (A40) did not developed cellular response nor neutralization antibody, all of them having CVID.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003eCirculating T follicular helper cells (TFH)\u003c/h2\u003e \u003cp\u003eWe finally assessed the frequency of TFH cells at T0 and T2, based on previous reports identifying the circulating TFH cells as representative of the germinal center with a critical role in T-dependent B-cell maturation and antibody production [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The gating strategy used to identify the PD-1\u003csup\u003e+\u003c/sup\u003eCXCR5\u003csup\u003e+\u003c/sup\u003eCD4\u003csup\u003e+\u003c/sup\u003e circulating TFH cells is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe frequency of total circulating TFH cells analysis showed no significant differences between pre-vaccination and post-vaccination samples from IEI patients (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eb). As shown by others, we found that patients with IEI had a significantly reduced frequency of total circulating TFH cells compared to HC [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Our findings showed 8.9% (range 3.2\u0026ndash;18.1%) vs 3.1% (range 0.7\u0026ndash;7.5%) frequency of total TFH cells for HC and IEI patients, respectively. (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ec).\u003c/p\u003e \u003cp\u003eTo further examine the virus-specific TFH cells, PBMCs from 29 AP and 27 PP were stimulated with the S protein or PHA as a positive control. The S-specific TFH cell population was analyzed according to the cell surface expression of CD154 (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ed). We only observed a significantly higher expression of CD154 in S-stimulated TFH cells with respect to the control condition in T2 and not in T0 (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ed). We found that 82.8% (24/29) of the AP and 81.5% (22/27) of the PP with IEI presented an increase of cell frequency at T2 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001, Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ee). The analysis of the impact of COVID-19 infection on circulating TFH frequency showed that the previous infection increased this S-specific cell population (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ef).\u003c/p\u003e \u003cp\u003eThe analysis of the TFH frequency in terms of IEI showed that from the 5 AP patients without higher expression of S-induced CD154 expression at T2, 2 had CVID (A1 and A43), 1 had HIGM (A69) and 2 had XLA (A71 and A78). Regarding PP without specific THF response, 1 had Selective IgA Deficiency (P1), 1 had CID (P2), 1 had CD4 T cell lymphopenia and Down Syndrome (P13), 1 had SAD (P14) and 1 had XLA (P16) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Figure S8a).\u003c/p\u003e \u003cp\u003eRegarding vaccines, we observed that Moderna and AstraZeneca triggered a significant increase in the frequency of TFH. However, 2 AP (A6 and A51) out of the 3 patients vaccinated with Sputnik/Moderna combination were older than 50 years and had lesser vaccine response than children or younger adults (Figure S8b).\u003c/p\u003e \u003cp\u003eWe did not find correlation between circulating S-specific TFH cells and antibody titer or neutralization IC80 (data not shown).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003ePost vaccination COVID-19 disease\u003c/h2\u003e \u003cp\u003eAfter the complete vaccine scheme with two doses almost all patients who presented symptomatic SARS-CoV-2 infection had a mild or moderate presentation of COVID-19 without needing to be admitted to intensive care. However, A10 and A78 presented severe COVID-19 disease and died. One of them, A10, was a CVID patient without S-specific IFN-γ T cell response neither antibody response. The other, A78, was a XLA without specific humoral immune response and with mild S-specific IFN-γ T cell response.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eVaccines are the most effective intervention to combat and prevent contagious diseases and reduce mortality rates. The massive vaccination against SARS-CoV-2, with no precedents in the history of vaccinology, has been successful in controlling the most severe consequences of the pandemic and preventing severe illness and death. Vaccine safety and immunogenicity in patients with IEI, in whom adaptive immune responses triggered by vaccines are often restricted, has been a critical point of interest. Most of the studies have been carried out in healthy volunteers, whereas data regarding defined patient populations, such as IEI patients, are still being gathered.\u003c/p\u003e \u003cp\u003eIn this study we evaluated the safety, reactogenicity and immunogenicity of different vaccines used in Argentina against COVID-19 in a cohort of patients aged between 12 and 78 years diagnosed with IEI, compared to HC. We evaluated the humoral and cellular immune response to different vaccine platforms (mRNA-, adenoviral- and inactivated virus-based vaccines and the combination of adenoviral and mRNA vaccines) employed in homologous and heterologous schemes. No moderate or severe adverse events were observed in IEI patients following vaccination, only mild systemic and/or local reactions. As shown by others, severity does not appear to be increased in these patients.\u003c/p\u003e \u003cp\u003eOur data shows that vaccines in patients with IEI were able to induce humoral response, that means specific IgG antibodies with neutralizing capacity; cellular response, with increased frequency of circulating specific TFH cells and IFN-γ-secreting cells; or both. In fact, anti-S/RBD IgG was detected in 97.4% (37/38) and 72.9% (51/70) of IEI pediatric and adult samples, respectively, at T2, whereas the seroconversion was 100% in our HC cohort. A low proportion of PP (16.7%) and AP (14.9%) showed seroconversion before vaccination, which means that these patients were exposed to the virus prior to vaccination. Our findings showed that the combination of immunity provided by infection and vaccines did not enhance the production of specific antibodies compared to vaccinated individuals, as reported by others in IEI patients [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] and healthy subjects [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe observed discrete differences in the antibody titer following the first and second doses between patients without SARS-CoV-2 exposure concerning patients with previous history of COVID-19. Regardless of SARs-CoV-2 exposure, the antibody titers significantly increased over time remarking the importance of subsequent boosts for this group of patients. Furthermore, the IgG median titer was higher in age-matched healthy subjects than in PP (p\u0026thinsp;\u0026lt;\u0026thinsp;0.005) and AP (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003eWhile studies focused on seroconversion showed that 67\u0026ndash;85% of IEI patients developed detectable anti-S IgG antibodies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], other studies showed that neutralizing antibodies were detected in lower levels than in healthy controls [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In our study, neutralizing antibodies were detected in 70 out of 78 patients with antibody production at T2 and it was significantly higher in pediatric than in adult IEI patients (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), but lower than in age-matched HC (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01 and p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, respectively).\u003c/p\u003e \u003cp\u003eAlmost all patients with a diagnosis of XLA, due to a defect in BTK, evaluated in this study did not develop antibody response against SARS-CoV-2 vaccines. Nevertheless, one pediatric patient (P3) presented a functional antibody response at T2, likely due to incomplete penetrance of their BTK mutation\u003csup\u003e31\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eExcluding XLA patients from our analysis of humoral response, 74.6% of AP and 100% of PP showed seroconversion after two vaccination doses. Among them, 83.3% of AP and 97.1% of PP were able to neutralize the SARS-CoV2 infection. Being TFH cells critical to induce high affinity neutralizing antibodies, we found that 82.1% in total IEI patients and 87.5% excluding XLA patients, presented S-specific circulating TFH cells.\u003c/p\u003e \u003cp\u003ePositive S-specific IFN-γ response was observed in 84.5% of IEI patients. Remarkably, all XLA patients evaluated developed specific IFN-γ-dependent cellular immune response, which highlights that vaccination in this population, despite not generating antibody protection, may provide cellular protection. Other authors have also described that T-cell compartment is normal in these patients characterized by absent or very low frequency of peripheral mature B-cells [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFive patients (A3, A10, A11, A40 and A59) failed to develop functional humoral response nor cellular response, all of them adults with CVID diagnosis. Patient A40 was the only AP treated with methotrexate. Previous report showed that methotrexate reduces the immunogenicity of SARS-CoV-2 vaccination and recommended pausing the treatment for at least 10 days after vaccination [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the data collected in this and other studies on vaccination against SARS-CoV2 in patients with IEI, the long-term immunogenicity of both humoral and cellular responses remains to be studied. Importantly, in our study, we did not find significant differences with respect to healthy controls in the post-vaccination cellular response, so that all the vaccines evaluated were equally beneficial for patients with IEI. While other studies demonstrated comparable cellular immune responses among IEI patients and healthy controls [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], others reported a significantly lower magnitude of their T cell response [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAltogether, our results support that COVID-19 vaccines have favorable safety, immunogenicity, and efficacy profiles in pediatric and adult IEI patients, although with lower immunogenicity than in control subjects. In conclusion, COVID-19 continues to represent a risk for developing severe forms of the disease in immunocompromised patients and vaccines against SARS-COV-2 proved to be an effective tool to induce a protective immune response, emphasizing the importance of vaccination. Our findings may guide the recommendation of vaccination in IEI patients to prevent COVID-19 disease and the need for subsequent boosts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by grants and fellowships from the Agencia Nacional de Promoci\u0026oacute;n Cient\u0026iacute;fica y Tecnol\u0026oacute;gica (ANPCyT), Consejo Nacional de Investigaciones Cient\u0026iacute;ficas y T\u0026eacute;cnicas (CONICET) and TAKEDA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLE, AC and MBA did most of the experiments and created the figures; JBF, JB, and MB contributed in the purification of patient samples, Anti-S/RBD measurement by ELISA, IFN-gamma determination by ELISPOT and Flow Cytometry experiments from patient samples; SV, MIPM and II participated in the neutralization assays; ChC contributed with patient samples purification; MNB, PB and MFQ contributed in ELISA and ELISPOT experiments in healthy donors; LT, MR, RC, GR, MF and GD collaborated with Anti-S/RBD and Anti-N experiments by ELISA measured in patient samples; RP, ILU, MVP, GS, IM, GV, ALL, DR, LRFM, MNB, PB, MFQ and LB recruited patients or healthy donors and performed clinical analysis; ILU, LB and MBA designed and supervised the research study; MBA, GD, MB, AC, ILU, RP and LB analyzed the data; MBA, LE, AC, MB and GD wrote the paper. All authors contributed to the article and approved the submitted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe protocol was approved by the Ethics and research Committees of the \u0026lsquo;Hospital de Agudos C. G. Durand\u0026rsquo;, \u0026lsquo;Hospital Interzonal Especializado Materno Infantil Victorio Tetamanti\u0026rsquo;, \u0026lsquo;Hospital Interzonal General de Agudos Dr. Oscar Alende\u0026rsquo; and \u0026lsquo;Programa Interdisciplinario de Bio\u0026eacute;tica de la Universidad Nacional de Mar del Plata\u0026rsquo;, according to the ethical standards of each institutional research committee and with the 1964 Helsinki declaration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants, or their parents, signed an informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge the support of the following agencies and organizations National Council for Scientific and Technical Research (CONICET), National Agency for Scientific and Technological Promotion (ANPCyT), TAKEDA, Fundaci\u0026oacute;n IBYME and Fundaci\u0026oacute;n de Ciencias Exactas y Naturales (FUNDACEN). We also acknowledge to Manuel de la Mata and Federico Fuchs for the borrowed equipment, to Julio Caramelo and Andrea Gamarnik for providing us with S and N proteins, to the members of the Laboratorio de Agrobiotecnolog\u0026iacute;a for the use of equipment, to Florencia Pignataro and other members of the Argentinian AntiCovid Consortium from the IB3 for producing coronavirus proteins and having made them available during our set-up of the trials for this work, to Federico Fuchs for the critical reading of this manuscript and to the Secretaries from \u0026ldquo;Centro de Inmunolog\u0026iacute;a Cl\u0026iacute;nica\u0026rdquo; for call patients and their families and collected the informed consents. Finally, thanks to all the patients, families, and donors for participating in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article (and its supplementary information files).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eQin C, Zhou L, Hu Z, Zhang S, Yang S, Tao Y, et al. Dysregulation of Immune Response in Patients with COVID-19 in Wuhan, China. SSRN Electron J. 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou P, Yang X, Lou, Wang XG, Hu B, Zhang L, Zhang W, et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature. 2020;579(7798):270\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu F, Zhao S, Yu B, Chen YM, Wang W, Song ZG, et al. 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EBioMedicine. 2021;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePonsford MJ, Evans K, Carne EM, Jolles S, Bramhall K, Grant L, et al. COVID-19 Vaccine Uptake and Efficacy in a National Immunodeficiency Cohort. J Clin Immunol. 2022;42(4):728\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShields AM, Faustini SE, Hill HJ, Al-Taei S, Tanner C, Ashford F, et al. SARS-CoV-2 Vaccine Responses in Individuals with Antibody Deficiency: Findings from the COV-AD Study. J Clin Immunol. 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTimmers E, de Weers M, Alt FW, Hendriks RW, Schuurman RKB. X-linked agammaglobulinemia. Clin Immunol Immunopathol. 1991 Nov;1(2):83\u0026ndash;93. 61(.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOshiro TM, da Silva LT, Ortega MM, Perazzio SF, Duarte AJdaS, Carneiro-Sampaio M. Patient with agammaglobulinemia produces anti-SARS-CoV-2 reactive T-cells after CoronaVac vaccine. Clinics. 2022;77:100007. ;(December 2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArroyo-S\u0026aacute;nchez D, Cabrera-Marante O, Laguna-Goya R, Almendro-V\u0026aacute;zquez P, Carretero O, Gil-Etayo FJ, et al. Immunogenicity of Anti-SARS-CoV-2 Vaccines in Common Variable Immunodeficiency. J Clin Immunol. 2022;42(2):240\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGupta S, Agrawal S, Sandoval A, Su H, Tran M, Demirdag Y. SARS-CoV-2-Specific and Functional Cytotoxic CD8 Cells in Primary Antibody Deficiency: Natural Infection and Response to Vaccine. J Clin Immunol. 2022;(0123456789).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1-2 are available in the Supplementary Files section.\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-clinical-immunology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joci","sideBox":"Learn more about [Journal of Clinical Immunology](https://www.springer.com/journal/10875)","snPcode":"10875","submissionUrl":"https://submission.nature.com/new-submission/10875/3","title":"Journal of Clinical Immunology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"SARS-CoV-2, antibody response, T-cell response, COVID-19, inborn errors of immunity, vaccination","lastPublishedDoi":"10.21203/rs.3.rs-1887005/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1887005/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Patients with Inborn Errors of Immunity (IEI) in Argentina were encouraged to receive licensed Sputnik, AstraZeneca, Sinopharm, Moderna, and Pfizer vaccines, even though most of the data on available vaccines comes from trials conducted in healthy individuals. We aimed to evaluate the safety and immunogenicity of the different vaccines in IEI patients in Argentina.\nThe study cohort included adults and pediatric IEI patients (n=118) and age-matched healthy-controls (HC) (n=37). Samples were collected before, 28+/-3 days after the first and the second dose of the vaccine. B-cell response was evaluated by measuring IgG anti-Spike(S)/ receptor binding domain (RBD) and anti-nucleocapsid(N) antibodies by ELISA. Neutralization antibodies were also assessed with an alpha-S protein-expressing pseudo-virus assay. The T-cell response was analyzed by IFN-γ secretion on S or N-stimulated PBMC by ELISPOT and the frequency of S-specific circulating T follicular-helper cells (TFH) was evaluated by flow cytometry.\nNo moderate/severe vaccine-associated adverse events were observed. Regarding the antibody response, anti-S/RBD titers showed significant differences in both pediatric and adult IEI patients versus the age-matched HC cohort (p\u0026lt;0.05). Neutralizing antibodies were detected in 71/99 patients and were also significantly lower in the patient cohort than age-matched HC (p\u0026lt;0.01). Positive S-specific IFN-γ response was observed in 84.5% of IEI patients and 82.1% presented S-specific TFH cells.\nIn conclusion, COVID-19 vaccines showed safety in IEI patients and, although immunogenicity was lower than HC, they showed specific anti-S/RBD IgG, neutralizing antibody titers and T-cell-dependent cellular immunity with IFN-γ secreting T-cells. These findings may guide the recommendation of vaccination in IEI patients to prevent COVID-19 disease .","manuscriptTitle":"­­­­­COVID-19 vaccination responses with different vaccine platforms in patients with inborn errors of immunity","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-08-02 16:59:13","doi":"10.21203/rs.3.rs-1887005/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2022-07-31T14:21:16+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-07-31T13:13:40+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Journal of Clinical Immunology","date":"2022-07-28T17:05:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-07-26T18:09:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Clinical Immunology","date":"2022-07-22T19:13:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-clinical-immunology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joci","sideBox":"Learn more about [Journal of Clinical Immunology](https://www.springer.com/journal/10875)","snPcode":"10875","submissionUrl":"https://submission.nature.com/new-submission/10875/3","title":"Journal of Clinical Immunology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"7a5c8f77-0f0b-41a7-8b16-733c4f5c4113","owner":[],"postedDate":"August 2nd, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2022-10-06T14:14:59+00:00","versionOfRecord":[],"versionCreatedAt":"2022-08-02 16:59:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1887005","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1887005","identity":"rs-1887005","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}