Single-dose SARS-CoV-2 vaccine in a prospective cohort of COVID-19 patients
Marit J. van Gils
1
, Hugo D. van Willigen
1#
, Elke Wynberg
1,2 #
, Alvin X. Han
1
, Karlijn van der
Straten
1,3
, Anouk Verveen
4
, Romy Lebbink
2
, Maartje Dijkstra
2,3
, Judith A. Burger
1
, Melissa
Oomen
1
, Khadija Tejjani
1
, Joey H. Bouhuijs
1
, Brent Appelman
5
, Ayesha H.A. Lavell
6
,
Meliawati Poniman
1
, Tom G. Caniels
1
, Ilja Bontjer
1
, Lonneke A. van Vught
5,7
, Alexander P.J.
Vlaar
7
, Jonne J. Sikkens
6
, Marije K. Bomers
6
, Rogier W. Sanders
1,8
, Neeltje A. Kootstra
9
,
Colin Russell
1
, Maria Prins
2,3
, Godelieve J. de Bree
3‡
, Menno D. de Jong
1‡
, RECoVERED
Study Group*
1
Department of Medical Microbiology & Infection Prevention, Amsterdam UMC, University of
Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands.
2
Department of Infectious Diseases, Public Health Service of Amsterdam, GGD,
Amsterdam, the Netherlands.
3
Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam
Institute for Infection and Immunity, Amsterdam, the Netherlands.
4
Department of Medical Psychology, Amsterdam UMC, University of Amsterdam,
Amsterdam School of Public Health, Amsterdam, the Netherlands.
5
Center for Experimental and Molecular Medicine, Amsterdam UMC, University of
Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands.
6
Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam,
Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands.
7
Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam,
Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands.
8
Department of Microbiology and Immunology, Weill Medical College of Cornell University,
New York, USA.
9
Department of Experimental Immunology, Amsterdam UMC, University of Amsterdam,
Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands.
#
Contributed equally
‡
Correspondence to:
Menno D. de Jong; m.d.dejong@amsterdamumc.nl
Godelieve J. de Bree; g.j.debree@amsterdamumc.nl
* RECoVERED Study Group:
Public Health Service of Amsterdam: Ivette Agard, Jane Ayal, Anders Boyd, Floor Cavder,
Marianne Craanen, Udi Davidovich, Annemarieke Deuring, Annelies van Dijk, Ertan Ersan,
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NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.
Laura del Grande, Joost Hartman, Nelleke Koedoet, Tjalling Leenstra, Dominique Loomans,
Agata Makowska, Tom du Maine, Ilja de Man, Amy Matser, Lizenka van der Meij, Marleen
van Polanen, Maria Oud, Clark Reid, Leeann Storey, Marije de Wit, Marc van Wijk
Amsterdam University Medical Centers: Joyce van Assem, Joost van den Aardweg, Marijne
van Beek, Thyra Blankert, Brigitte Boeser-Nunnink, Eric Moll van Charante, Karel van Dort,
Orlane Figaroa, Leah Frenkel, Arginell, Girigorie, Jelle van Haga, Agnes Harskamp-
Holwerda, Mette Hazenberg, Soemeja Hidad, Nina de Jong, Marcel Jonges, Suzanne
Jurriaans, Hans Knoop, Lara Kuijt, Anja Lok, Marga Mangas Ruiz, Irma Maurer, Pythia
Nieuwkerk, Ad van Nuenen, Annelou van der Veen, Bas Verkaik, Gerben-Rienk Visser
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 25, 2021. ; https://doi.org/10.1101/2021.05.25.21257797doi: medRxiv preprint
Abstract
Background
The urgent need for, but limited availability of, SARS-CoV-2 vaccines worldwide has led to
widespread consideration of dose sparing strategies, particularly single vaccine dosing of
individuals with prior SARS-CoV-2 infection.
Methods
We evaluated SARS-CoV-2 specific antibody responses following a single-dose of BNT162b2
(Pfizer-BioNTech) mRNA vaccine in 155 previously SARS-CoV-2-infected individuals
participating in a population-based prospective cohort study of COVID-19 patients.
Participants varied widely in age, comorbidities, COVID-19 severity and time since infection,
ranging from 1 to 15 months. Serum antibody titers were determined at time of vaccination
and one week after vaccination. Responses were compared to those in SARS-CoV-2-naive
health care workers after two BNT162b2 mRNA vaccine doses.
Results
Within one week of vaccination, IgG antibody levels to virus spike and RBD proteins increased
27 to 29-fold and neutralizing antibody titers increased 12-fold, exceeding titers of fully
vaccinated SARS-CoV-2-naive controls (95% credible interval (CrI): 0.56 to 0.67 v. control
95% CrI: -0.16 to -0.02). Pre-vaccination neutralizing antibody titers had the largest positive
mean effect size on titers following vaccination (95% CrI (0.16 to 0.45)). COVID-19 severity,
the presence of comorbidities and the time interval between infection and vaccination had no
discernible impact on vaccine response.
Conclusion
A single dose of BNT162b2 mRNA vaccine up to 15 months after SARS-CoV-2 infection
provides neutralizing titers exceeding two vaccine doses in previously uninfected individuals.
These findings support wide implementation of a single-dose mRNA vaccine strategy after
prior SARS-CoV-2 infection.
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 25, 2021. ; https://doi.org/10.1101/2021.05.25.21257797doi: medRxiv preprint
Introduction
The unprecedented rapid development and emergency use authorization of several
vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) allows for
optimism in the global fight against the coronavirus disease 2019 (COVID-19) pandemic.
1
However, in many regions, vaccination campaigns are hampered by limited supply or
resources, hence vaccine sparing strategies are desirable. Making use of immunological
memory after prior natural SARS-CoV-2 infection,
2,3
single dosing represents one such
strategy for vaccines requiring two doses for optimal efficacy. Indeed, a number of recent small
studies in health care workers (HCW) have shown similar or higher antibody responses and
higher vaccine efficacy to a single dose SARS-CoV-2 mRNA vaccine after prior infection,
compared to two doses in SARS-CoV-2-naive individuals.
4–11
However, these studies were
performed in relatively young and healthy individuals and provided limited information on the
possible influence of COVID-19 severity and the duration since infection on vaccine
responses. To inform potential wide implementation of a single dose strategy following natural
infection, we evaluated the titers and breadth of antibody responses to a single SARS-CoV-2
mRNA vaccine in an ongoing population-based prospective cohort study of COVID-19
patients, representing a range in age, the presence of comorbidities, COVID-19 severity and
time since infection. Antibody responses were compared to those observed after two doses in
a cohort of SARS-CoV-2 naive HCW.
Methods
Patients and study design
The current vaccine study was embedded in the RECoVERED project, an ongoing
prospective cohort study of individuals with laboratory-confirmed SARS-CoV-2 infection in
Amsterdam, the Netherlands. The RECoVERED cohort was initiated in May 2020 and as of
April 2021 enrolled 328 participants, including both home-cared patients with mild infections
and hospitalized patients with moderate to severe or critical illness. RECoVERED participants
are followed at 1-3-month intervals from illness onset whereby biological specimens and
questionnaires are collected at each follow-up visit to address RECoVERED’s primary
objectives relating to immunology and long-term sequelae of COVID-19. Clinical severity
groups were defined in line with the WHO COVID-19 disease severity criteria:
12
Mild disease
was defined as having a respiratory rate (RR) <20/min and oxygen saturation (SpO
2
) on room
air >94% during acute illness; moderate disease as having a RR of 20-30/min, SpO
2
90-94%
and/or receiving oxygen therapy; severe disease as having a RR>30/min or SpO
2
<90%; and
critical disease as requiring ICU admission.
Cohort participants, invited to receive vaccination according to the Dutch national
vaccination campaign before 12 April 2021, were asked to participate in the present vaccine
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substudy. In addition, participants not yet prioritized for vaccination according to Dutch policy
were asked to participate and receive a first dose of the BNT162b2 (Pfizer-BioNTech) mRNA
vaccine in the week of April 12 2021, made available for our research aim by the Dutch Ministry
of Health, Welfare and Sport. Participants with pregnancy, vaccine-related allergic reactions
or laboratory-confirmed infections within 4 weeks of expected vaccination were excluded as
per national guidelines. Serum samples for determination of antibody levels were collected
and participants completed questionnaires on the presence and severity of symptoms and
vaccine-related adverse effects within seven days pre-vaccination and within one week post-
vaccination.
Vaccinated HCW without longitudinal serological evidence of prior SARS-CoV-2
infection, participating in a HCW cohort study at the Amsterdam University Medical Centers
(S3 study), served as a control group.
13
In this cohort, antibody responses were measured
four weeks after the second dose of the BNT162b2 mRNA vaccine. The RECoVERED study,
including the vaccine substudy, and the S3 study were approved by the medical ethical review
board of the Amsterdam University Medical Centers (NL73759.018.20 and NL73478.029.20,
respectively). All participants provided written informed consent.
SARS-CoV-2 binding IgG antibody levels
Levels of Immunoglobulin G (IgG) binding to SARS-CoV-2 receptor-binding domain
(RBD), nucleocapsid (N) and spike (S) proteins of wild type virus (Wu-1) and variants of
concern (B.1.1.7, B.1.351 and P.1), as well as to control proteins tetanus toxoid, respiratory
syncytial virus glycoprotein (RSV-G) and influenza A/H1N1pdm09 virus HA protein, were
determined using a custom luminex assay as described previously.
14
In short, proteins were
produced in HEK293F cells (Invitrogen) and purified from the cell culture supernatant using
affinity chromatography with NiNTA agarose beads (Qiagen). Proteins were covalently
coupled to luminex magplex beads using a two-step carbodiimide reaction. Beads were
incubated overnight with 1:100,000 diluted serum followed by detection with goat-anti-human
IgG-PE (Southern Biotech) on a Magpix (Luminex) as the mean fluorescent intensity (MFI).
Pseudovirus neutralization assay
Pseudovirus neutralization assay was performed as previously described (Brouwer et
al. Cell 2021). Briefly, HEK293T/ACE2 cells
15
were seeded in poly-L-lysine pre-coated 96-well
plates. The next day, heat-inactivated 1:100 diluted sera were 3-fold serially diluted and mixed
in a 1:1 ratio with pseudovirus Wu-1 D614G (WT)
15
or B.1.1.7, B.1.351 and P.1 pseudovirus.
After 1-hour incubation at 37°C the mixtures were added to the cells and incubated for 48
hours at 37°C. The luciferase activity in cell lysates was measured using the Nano-Glo
Luciferase Assay System (Promega) and GloMax system (Turner BioSystems). The 50%
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is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted May 25, 2021. ; https://doi.org/10.1101/2021.05.25.21257797doi: medRxiv preprint
