The Omicron variant is rapidly becoming the dominant SARS-CoV-2 virus circulating globally. It is important to define reductions in virus neutralizing activity in the serum of convalescent or vaccinated individuals to understand potential loss of protection against infection by Omicron. We previously established that a 50% plaque reduction neutralization antibody titer (PRNT50) ≥25.6 in our live virus assay corresponded to the threshold for 50% protection from infection against wild-type (WT) SARS-CoV-2. Here we show markedly reduced serum antibody titers against the Omicron variant (geometric mean titer (GMT) < 10) compared to WT virus 3–5 weeks after two doses of BNT162b2 (GMT = 218.8) or CoronaVac vaccine (GMT = 32.5). A BNT162b2 booster dose elicited Omicron PRNT50 titers ≥25.6 in 88% of individuals (22 of 25) who previously received 2 doses of BNT162b2 and 80% of individuals (24 of 30) who previously received CoronaVac. However, few (3%) previously infected individuals (1 of 30) or those vaccinated with three doses of CoronaVac (1 of 30) met this threshold. Our findings suggest that countries primarily using CoronaVac vaccines should consider messenger RNA vaccine boosters in response to the spread of Omicron. Studies evaluating the effectiveness of different vaccines against the Omicron variant are urgently needed. Serum neutralizing antibody titers against the SARS-CoV-2 Omicron variant markedly increase after a third dose of BNT162b2 vaccine in individuals who previously received either two doses of the BNT162b2 vaccine or two doses of the CoronaVac vaccine. 

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Neutralizing antibodies against the SARS-CoV-2 Omicron variant BA.1 following homologous and heterologous CoronaVac or BNT162b2 vaccination

Observational data suggest that the treatment of influenza infection with neuraminidase inhibitors decreases progression to more severe illness, especially when treatment is started soon after symptom onset. However, even early treatment might fail to prevent complications in some patients, particularly those infected with novel viruses such as the 2009 pandemic influenza A H1N1, avian influenza A H5N1 virus subtype, or the avian influenza A H7N9 virus subtype. Furthermore, treatment with one antiviral drug might promote the development of antiviral resistance, especially in immunocompromised hosts and critically ill patients. An obvious strategy to optimise antiviral therapy is to combine drugs with different modes of action. Because host immune responses to infection might also contribute to illness pathogenesis, improved outcomes might be gained from the combination of antiviral therapy with drugs that modulate the immune response in an infected individual. We review available data from preclinical and clinical studies of combination antiviral therapy and of combined antiviral-immunomodulator therapy for influenza. Early-stage data draw attention to several promising antiviral combinations with therapeutic potential in severe infections, but there remains a need to substantiate clinical benefit. Combination therapies with favourable experimental data need to be tested in carefully designed aclinical trials to assess their efficacy.

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Antiviral combinations for severe influenza

Seroprevalence surveys suggest that more than a third and possibly more than half of the global population has been infected with SARS-CoV-2 by early 2022. As large numbers of people continue to be infected, the efficacy and duration of natural immunity in terms of protection against SARS-CoV-2 reinfections and severe disease is of crucial significance for the future. This narrative review provides an overview on epidemiological studies addressing this issue. National surveys covering 2020-2021 documented that a previous SARS-CoV-2 infection is associated with a significantly reduced risk of reinfections with efficacy lasting for at least one year and only relatively moderate waning immunity. Importantly, natural immunity showed roughly similar effect sizes regarding protection against reinfection across different SARS-CoV-2 variants, with the exception of the Omicron variant for which data are just emerging before final conclusions can be drawn. Risk of hospitalizations and deaths was also reduced in SARS-CoV-2 reinfections versus primary infections. Observational studies indicate that natural immunity may offer equal or greater protection against SARS-CoV-2 infections compared to individuals receiving two doses of an mRNA vaccine, but data are not fully consistent. The combination of a previous SARS-CoV-2 infection and a respective vaccination, termed hybrid immunity, seems to confer the greatest protection against SARS-CoV-2 infections, but several knowledge gaps remain regarding this issue. Natural immunity should be considered for public health policy regarding SARS-CoV-2. 

https://doi.org/10.1016/j.envres.2022.112911

SARS-CoV-2 reinfections: Overview of efficacy and duration of natural and hybrid immunity

The emergence and global spread of the 2009 pandemic H1N1 influenza virus reminds us that we are limited in the strategies available to control influenza infection. Vaccines are the best option for the prophylaxis and control of a pandemic; however, the lag time between virus identification and vaccine distribution exceeds 6 months and concerns regarding vaccine safety are a growing issue leading to vaccination refusal. In the short-term, antiviral therapy is vital to control the spread of influenza. However, we are currently limited to four licensed anti-influenza drugs: the neuraminidase inhibitors oseltamivir and zanamivir, and the M2 ion-channel inhibitors amantadine and rimantadine. The value of neuraminidase inhibitors was clearly established during the initial phases of the 2009 pandemic when vaccines were not available, i.e. stockpiles of antivirals are valuable. Unfortunately, as drug-resistant variants continue to emerge naturally and through selective pressure applied by use of antiviral drugs, the efficacy of these drugs declines. Because we cannot predict the strain of influenza virus that will cause the next epidemic or pandemic, it is important that we develop novel anti-influenza drugs with broad reactivity against all strains and subtypes, and consider moving to multiple drug therapy in the future. In this article we review the experimental data on investigational antiviral agents undergoing clinical trials (parenteral zanamivir and peramivir, long-acting neuraminidase inhibitors and the polymerase inhibitor favipiravir [T-705]) and experimental antiviral agents that target either the virus (the haemagglutinin inhibitor cyanovirin-N and thiazolides) or the host (fusion protein inhibitors [DAS181], cyclo-oxygenase-2 inhibitors and peroxisome proliferator-activated receptor agonists).

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Drugs in Development for Influenza

(See the editorial commentary by Ison, on pages 1806–8.)

Influenza remains an infection with potential for significant morbidity and mortality. The 1918 influenza pandemic resulted in 40 million to 100 million deaths [1]. Persistent genetic changes in the virus result in highly susceptible populations and a need to develop epitope-specific vaccines yearly [2]. Additionally, immunization can be less effective in older individuals and those with compromised immune status [3, 4]. Antiviral drugs are available to treat influenza but can have reduced efficacy depending on the prevalence of viral resistance and the population being treated. Furthermore, the appearance of avian influenza (H5N1), with mortality possibly reaching 50% of those infected, supports the need for more effective treatment modalities [5].

Because all influenza viruses bind to sialic acids on respiratory epithelial cells, blockage of this interaction has the potential to decrease the magnitude of infection of all influenza variants [6]. DAS181 (Fludas) is a sialidase catalytic domain/amphiregulin glycosaminoglycan binding sequence fusion protein that cleaves both the Neu5Ac α(2,3)- and Neu5Ac α(2,6)-Gal linkages of sialic acid on host cells. DAS181 is administered as an inhalable dry powder to deliver sialidase to the pulmonary epithelium for cleavage of sialic acids, which renders the cells inaccessible to infection by virus [7]. Given the conserved nature of influenza binding to respiratory epithelium, a host-directed approach to the treatment of influenza may be applicable to the treatment of all influenza subtypes. Preclinical in vitro and in vivo studies demonstrated that DAS181 has activity against a number of seasonal influenza strains including those containing the H274Y mutation (conferring resistance to oseltamivir), highly pathogenic avian influenza strains (H5N1), and pandemic 2009 influenza A (H1N1) [8–10]. Three phase 1 studies have examined different formulations of DAS181 administered as single and multiple doses in healthy participants. In these phase 1 clinical trials, DAS181 was found to be well tolerated in all treatment groups, and no serious adverse events were observed.

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A Phase II Study of DAS181, a Novel Host Directed Antiviral for the Treatment of Influenza Infection

Long-term persistence of SARS-CoV-2 neutralizing antibody responses after infection and estimates of the duration of protection.

Pandemic H1N1 2009 and Drug Resistant Influenza Viruses are Potently Inhibited by DAS181, a Sialidase Fusion Protein

Background Children are less clinically affected by SARS-CoV-2 infection than adults with the majority of cases being mild or asymptomatic and the differences in infection outcomes are poorly understood. The kinetics, magnitude and landscape of the antibody response may impact the clinical severity and serological diagnosis of COVID-19. Thus, a comprehensive investigation of the antibody landscape in children and adults is needed. Methods We tested 254 plasma from 122 children with symptomatic and asymptomatic SARS-CoV-2 infections in Hong Kong up to 206 days post symptom onset, including 146 longitudinal samples from 58 children. Adult COVID-19 patients and pre-pandemic controls were included for comparison. We assessed antibodies to a 14-wide panel of SARS-CoV-2 structural and accessory proteins by Luciferase Immunoprecipitation System (LIPS). Findings Children have lower levels of Spike and Nucleocapsid antibodies than adults, and their cumulative humoral response is more expanded to accessory proteins (NSP1 and Open Reading Frames (ORFs)). Sensitive serology using the three N, ORF3b, ORF8 antibodies can discriminate COVID-19 in children. Principal component analysis revealed distinct serological signatures in children and the highest contribution to variance were responses to non-structural proteins ORF3b, NSP1, ORF7a and ORF8. Longitudinal sampling revealed maintenance or increase of antibodies for at least 6 months, except for ORF7b antibodies which showed decline. It was interesting to note that children have higher antibody responses towards known IFN antagonists: ORF3b, ORF6 and ORF7a. The diversified SARS-CoV-2 antibody response in children may be an important factor in driving control of SARS-CoV-2 infection.

/pdf/the-sars-cov-2-antibody-landscape-is-lower-in-magnitude-for-2uxn6v9497.pdf

The SARS-CoV-2 antibody landscape is lower in magnitude for structural proteins, diversified for accessory proteins and stable long-term in children

The duration of immunity in SARS-CoV-2 infected people remains unclear. Neutralizing antibody responses are the best available correlate of protection against re-infection. Recent studies have estimated that the correlate of 50% protection from re-infection was 20% of the mean convalescent neutralizing antibody titre. We used sera collected from a cohort of 125 individuals with RT-PCR confirmed SARS-CoV-2 infections up to 386 days after symptom onset. In the subset of 65 sera collected from day 151 to 386 after symptom onset, all remained positive in 50% plaque reduction neutralization tests (PRNT50). Because antibody waning follows a bimodal pattern with slower waning beyond day 90 after illness, we fitted lines of decay to 115 sera from 62 patients collected beyond 90 after symptom onset and estimate that PRNT50 antibody will remain detectable for around 1,717 days after symptom onset and that 50% protective antibody titers will be maintained for around 990 days post-symptom onset, in symptomatic patients. Peak PRNT titres in mildly symptomatic children did not differ from those in mildly symptomatic adults but these antibody titres appear to wane faster in children. There was a high level of correlation between PRNT50 antibody titers and the % of inhibition in surrogate virus neutralization tests. We conclude that there will be relatively long-lived protection from re-infection following symptomatic COVID-19 disease.

Funding Information: The study was supported by the Health and Medical Research Fund, Commissioned research on Novel Coronavirus Disease (COVID-19) (Reference no COVID190126) from the Food and Health Bureau, Hong Kong SAR Government and the Theme-based Research Scheme project no. T11-712/19-N, the University Grants Committee of the Hong Kong Government.

Declaration of Interests: None of the authors have any conflicts of interest to declare.

Ethics Approval Statement: Written informed consent was obtained from the participants or their parents (when the participant was a child) and the studies were approved by the institutional review boards of the respective hospitals, viz. Kowloon West Cluster (KW/EX-20-039 (144-27)), Kowloon Central / Kowloon East cluster (KC/KE-20-0154/ER2) and HKU/HA Hong Kong West Cluster (UW 20-273).

Long-Term Persistence of SARS-CoV-2 Neutralizing Antibody Responses After Infection and Estimates of the Duration of Protection

Immunomodulatory and anti-viral effects of statins in influenza H5N1 virus infection of human alveolar epithelial cells and peripheral blood–derived macrophages

WY Chan

Papers

Long-term persistence of SARS-CoV-2 neutralizing antibody responses after infection and estimates of the duration of protection.

Pandemic H1N1 2009 and Drug Resistant Influenza Viruses are Potently Inhibited by DAS181, a Sialidase Fusion Protein

The SARS-CoV-2 antibody landscape is lower in magnitude for structural proteins, diversified for accessory proteins and stable long-term in children

Long-Term Persistence of SARS-CoV-2 Neutralizing Antibody Responses After Infection and Estimates of the Duration of Protection

Immunomodulatory and anti-viral effects of statins in influenza H5N1 virus infection of human alveolar epithelial cells and peripheral blood–derived macrophages