柳叶刀风湿病学:自身免疫疾病患者SARS-CoV-2血清阳性打新冠疫苗效果竟然更好

2022-02-09 nobscure MedSci原创

对于风湿病患者,新冠疫苗打或者不打,打多少?一直是一个问题。

在 COVID-19 大流行期间,疫苗作为公共卫生干预措施发挥了重要作用。截至 2021 年 11 月 21 日,全球已接种超过 7·40 亿剂 COVID-19 疫苗。然而,在免疫功能低下的个体(包括患有自身免疫性风湿性疾病的个体)中,关于 COVID-19 疫苗的数据仍然很少,与健康人群相比,他们在初次接种疫苗可能无法产生足够的免疫反应。考虑到 SARS-CoV-2 感染的风险增加和 COVID-19 的严重后果,需要进一步评估免疫功能低下人群对 COVID-19 疫苗的免疫反应。第 4 阶段 CoronavRheum 研究,该研究检查了巴西自身免疫性风湿病患者中灭活的 SARS-CoV-2 疫苗 CoronaVac 的免疫原性和安全性,结果显示患者的血清转化率低于健康对照组。然而,在这份初步报告中,暴露于 SARS-CoV-2 的患者被排除在分析之外,因此 CoronaVac 对从 SARS-CoV-2 感染中恢复的患者的影响尚不清楚。

《柳叶刀风湿病学》中, Nadia E Aikawa 及其同事报告了对 CoronavRheum 研究的亚组分析,比较 SARS-CoV-2 血清阳性或血清阴性的自身免疫性风湿病患者与血清阳性或血清阴性对照的 CoronaVac 免疫原性。942 名参与者被纳入亚组分析,其中 157 名血清阳性患者,157 名血清阳性对照,471 名血清阴性患有自身免疫性风湿病的患者,157 名血清阴性对照(中位年龄为 48 岁 [IQR 38-56] 和女性 594 [63 %],男性348 [37%] )。

所有参与者在第 0 天和第 28 天都接受了两剂 CoronaVac。血清阳性患者和对照组在第 28 天具有相似比例的抗 SARS-CoV-2 S1 或 S2 IgG 血清阳性(157 的 149 [95%]155 [99% ] ] 157;p=0·10) 和第 69 天 (154 [98%] vs157 [100%];p=0·25)。在第 28 天(138 [88%] vs 151 [96%];p=0·0067)和第 69 天(141 [90%] vs 155 [99%];p= 0·0005); 尽管中和抗体阳性的患者比例低于对照组。相比之下,在第 28 天和第 69 天,血清阴性患者和对照组的疫苗引发的免疫反应明显低于血清阳性患者和对照组。就免疫原性动力学而言,两个血清阳性组在第一剂 CoronaVac 后均表现出强烈的免疫反应,第二剂后没有进一步增加,而血清阴性组需要第二剂才能获得类似的免疫反应。

这项研究提供的证据表明,在暴露于自然 SARS-CoV-2 感染的自身免疫性风湿病患者中,单剂量的 CoronaVac 可能足以产生强烈的抗体反应,而未暴露的个体需要至少两剂。之前对其他 COVID-19 疫苗的几项研究在普通人群或自身免疫性疾病患者中显示出类似的结果。已发现从 COVID-19 康复的患者中单剂 mRNA 疫苗或腺病毒载体疫苗可引发与未暴露患者两剂疫苗相似的体液免疫,这可能与增强的前体记忆反应有关。 

该研究的另一个亮点是,Aikawa 及其同事可以为免疫缺陷人群提供强有力的疫苗接种反应证据,这些人群更有可能患上严重的 COVID-19 并因 COVID-19 而死亡。多项研究表明,与健康对照组相比,免疫功能低下的个体通常具有较弱的抗病毒免疫反应和疫苗反应性。为降低这一人群的风险并最大限度地提高疫苗接种的潜在有效性,世卫组织和美国食品和药物管理局最近建议免疫功能低下的个体应额外接种一剂疫苗。

尽管如此,Aikawa 及其同事的研究表明,可能不需要为已经暴露于 SARS-CoV-2 的免疫功能低下的个体额外接种一剂疫苗。在全球范围内COVID-19疫苗供应有限且分布不均的情况下,针对不同人群量身定制疫苗剂量将更有利于疫苗资源的合理配置。

来源:Xing-Su Gao, Feng-Cai Zhu,Distinct immune response to CoronaVac in SARS-CoV-2 seropositive and seronegative patients with autoimmune rheumatic disease,The Lancet Rheumatology,Volume 4, Issue 2,2022,Pages e77-e78,

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    2022-02-10 hukaixun
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    2022-02-11 小刀医生
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由此可见,在以骨质疏松症剂量的地诺单抗治疗期间,SAEI发生率更高。然而,任何感染或相关死亡的总体风险与对照组相似。这些发现需要在治疗开始之前充分考虑。

Arthritis Rheumatol:类风湿关节炎患者COVID-19感染风险如何?

与非RA患者相比,RA患者的COVID-19感染和因COVID-19住院或死亡风险更高。由于COVID-19风险接近其他已知的慢性病,因此,这些结果提示对于RA患者应优先进行COVID-19预防和治疗