MSCOVID19 Vaccine responses and Immunosuppression

M

I am still waiting for the avalanche of vaccine responses…we continue to chug through ours but as the majority of samples are from people with anti-CD20, we already know what will happen. We have seen it published with the Pfizer vaccine, we will see it with the Astra-zeneca vaccine and we will see it with other vaccines too. We have seen it with ocrelizumab, we have seen it with rituximab. We have seen it with cancer, arthrtis and other conditions and MS will be no different. On the positive side, we have seen that T cell responses can be made, we will soon see it in MS I suspect, and also that whilst people do get infected…the important point is that disease is milder. This is immunology 101 in action and shows why it is a good reason to be vaccinated.

The reason that it was considered likely immunosuppressed people would respond to the Astrazeneca vaccine (as stated in the Green Book) was because of Ebola studies in people, some of which had HIV. However, when you looked there were less than 5% of people and none of the subjects had AIDS. So in this study of so called immunosuppressed people who had HIV infection and vaccine what did they find. So it comes as no surprise to me most people made a T and B cell response. It has to be said that no-one had AIDS and no-one had T cells in the alemtuzumab range and CD4 count at enrolment was 694·0 cells per μL (IQR 573·5–859·5). Unsurprisingly when “Compared with participants without HIV, they found no difference in magnitude or persistence of SARS-CoV-2 spike-specific humoral or cellular responses (p>0·05 for all analyses)”. https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(21)00103-X/fulltext

However, the drip drip drip maybe starting to trickle. However some good news for people on fingolimod, this Milan study is not quite as bad as the Israeli study reports. They report 10/16 had a positive response, however, I have to say it looks like 2 of those had a response that was a bit pants, so maybe 50% gave a response. So more like I thought was going to happen as people with fingolimod getting covid were seroconverting. Bigger N =number is needed

Now to the CD20 depleted. Again suggsting a inhibition they say no trend but maybe if your CD19+ B cells are over 1.5% of the population or you have waited over 5.3 months then below this you have 1/9 positive (11%) and over then 5/7 (71%) positive, so maybe worth a test and a wait to maximize your response. This is why we need more data you help inform you to make the best choice. You could ask are there any people that have waited for 6.6 months and not had a postive response?

Percentage of B cells (symbols with cross had missing data)

Serological response to SARS-CoV-2 vaccination in multiple sclerosis patients treated with fingolimod or ocrelizumab: an initial real-life experience. Guerrieri et al. J Neurol. 2021 Jun 26. doi: 10.1007/s00415-021-10663-x. Online ahead of print.

Background: Recent observations suggest a lack of humoral response after SARS-CoV-2 vaccination in multiple sclerosis (MS) patients treated with fingolimod or ocrelizumab

OBJECTIVES: To assess serological response to SARS-CoV-2 vaccination in MS patients receiving these disease-modifying treatments (DMTs) in a real-life setting. (Not sure what other setting we are talking about as there are no major trials solely in MS)

Methods: Retrospective clinical data collection from MS patients followed at San Raffaele Hospital MS Centre (Milan, Italy). All patients treated with fingolimod or ocrelizumab who had received a complete anti-COVID-19 vaccination course, with no clinical history suggestive of previous SARS-CoV-2 infection and with an available post-vaccination serological assay obtained at least 14 days after vaccination completion were considered for the study.

Results: We collected data from 32 MS patients, 16 treated with fingolimod and 16 receiving ocrelizumab. Among the fingolimod group 10 patients (62.5%) had a positive serological response after vaccination and among ocrelizumab-treated patients a positive serological test was found in six cases (37.5%). No relation between serological response and clinical features (i.e., treatment duration, time between vaccination and last treatment dose, and white blood cells count) was identified (Not surprsing because the time between vaccination and infusion was less than).

Conclusions: Our initial real-life experience suggests a variable antibody production in MS patients receiving these DMTs. At present, there are no sufficient data to do not recommend anti-SARS-CoV-2 vaccine in these patients.

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11 comments

  • Although I’ve been following the blog and I am aware of the issue of poor vaccine response for those on ocrevus, I’m not sure how this would apply to someone who had IRT? I had hsct 1 year before my first vaccine and dosing was 12 weeks apart second shot. I had flare of symptoms for about 3 weeks after 2nd jab which I hope was pseudo, and which I hope indicates some immune response, although I’ve saw on here that such reactions can be poor reflections of antibody response ?

    • From the data I have seen so far most people on alemtuzumab have made a response and most people on cladribne have made a response. If you had HSCT before vaccine I would think it is long enough for you to make a response. However I have not seen CD8 T cell responses yet

  • About these autumn booster (3rd) doses…
    One professor on Radio 4 seemed to say there is possibility that repeated doses of vaccine could be counterproductive, i.e. immune system could start to mount response to vaccine body/carrier material, rather than target protein.

    Oh dear? Or unlikely?

  • Do you think weight would play a part in the response rate? I know there has been talk that lighter people are effectively getting a bigger drug hit every 6 months for ocrelizumab.

    I’ve been watching the news about kids and the vaccine roll out not yet being offered to them. I feel like those of us with school age kids, who may not have had the best vaccine response, are being left more exposed whilst covid spreads in their age group. I don’t know whether the autumn programme would cover kids, not just other adults, living with others more at risk. It didn’t last time.

    • I was also wondering about those points, I had no antibodies after my 2x AZ. I work in a primary school and have been WFH throughout the pandemic but my employer wants me back (and this week we have roughly half the school closed because of covid or isolating)

      • This perhaps where giving you a protective antibody response would help give you some confidence.

  • When is the best time post vaccine to test for antibody response? My last Ocrevus infusion was very end of Jan 2020. My bcell zero for a long time. Just prior to vaccine I tested at borderline normal values. I then went ahead & got the 2-part Pfizer jab on May 4, 2021 & May 28th.

    • Within a week of vaccination 2, but we have been doing 4 weeks, gives time to give response and it will still be there, So seems time now to test….but you have waited 18 months post last dose…it you dont make a response I would be very surprised at near normal B cell levels it will be as good as it gets and it seems that you are using ocrelizumab as an IRT…are their plans to resume

  • I have recently had my vaccine immunity test results back. I had AZ covid vaccine at 6. 5 months after ocrevus but still got a negative vaccine immunity result. I am so worried about what this will mean going forward in terms of risk.

    • I think the answer is we dont know, but if you are young and get infected on the whole you do OK.

  • I’d like to boil down to layman’s terms, the vax issue as I see it for immuno-suppressed people. Apparently, there is sufficient remaining ability of the immune system, for otherwise healthy people who are on B cell depleters, to deal with covid and have a successful outcome. I think for many people however, at least here in The US, the political issues behind vaxxing are as strong, or perhaps even stronger, than the realistic issues. So mask wearing is out, but when it is still observed here, often the conclusion is that the person just feels more comfortable wearing a mask. Rarely is there a mention in the media that immuno-compromised people should still wear masks and be thought of as people who need to be protected. Most people, I will suggest, do not want to be seen as needing protection from anything. And I myself consider wearing a mask, if not needed, to be borderline “overkill”. So peer pressure is on, to take off your mask, with little understanding for those continuing to protect themselves. I suggest this has broad social implications for many people who are not independent minded and are likely to be influenced by “the many”. This influence will happen at the grocery store as well as at work too. I suggest many who are not as diligent in weighing options and understanding facts will just “go with the flow”. And none of what I have mentioned includes the fact that the unvaxxed and immono-compromised are potential virus spreaders. Will wearing a mask mean that the person is a potential spreader? In the US, we are seeing that the unvaxxed are the only ones winding in the hospital. And I live at “ground zero” for anti-vaccination (50%-50%). How much of a problem will this be? I guess time will tell.

    (We also still have to consider people not succumbing to covid but becoming “long haulers”, as a risk for immuno-compromised people on B cell depleters (according to my MS Doc). There is more to covid than simple survival. That is another topic.)

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