PEMERIKSAAN PASCA VAKSINASI COVID-19 - PROF. DR. ARYATI, DR., MS, SPPK(K) KETUA UMUM PENGURUS PUSAT - PDS PATKLIN
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PEMERIKSAAN
PASCA VAKSINASI COVID-19
Prof. Dr. Aryati, dr., MS, SpPK(K)
Ketua Umum Pengurus Pusat
Perhimpunan Dokter Spesialis Patologi Klinik (PDS PatKLIn)
Sabtu, 20 Maret 2021
3
25 Februari 2021
4
Mahmood et al. 6 August 2020. Vaccines 2020, 8, 443; doi:10.3390/vaccines8030443
VAKSIN YANG AKAN MASUK KE INDONESIA
https://indonesia.go.id/narasi/indonesia-dalam-angka/sosial/vaksinasi-mandiri-masih-
https://sehatnegeriku.kemkes.go.id
menunggu-hari
Ophinni et al, 2020. Acta Med Indones - Indones J Intern Med • Vol 52 • Number 4 • October 2020
7
APA YANG DIHARAPKAN DARI VAKSINASI?
8
Potential Endpoints of An Efficacious COVID-19 Vaccine (Hodgson et al, 2020)
Penilaian efikasi vaksin dengan
membandingkan clinical endpoint antara
kelompok yang divaksin dan tidak divaksin
adalah metode yang paling efektif
Penilaian yang mengandalkan paparan alami
SARS-CoV-2 rentan dipengaruhi banyak faktor
Hodgson et al, 27 October 2020 https://doi.org/10.1016/S1473-3099(20)30773-8 9
A variety of approaches have been used to identifiy, confirm
and evaluate immunological markers as indicators of vaccine-
induced protection
Trials and Other Experimental Designs
• Randomized Controlled Trials with Clinical Endpoints
• Immunogenicity Studies
• Passive Immunization Studies
• Challenge Studies
Observational Studies
• Cohort Studies
• Natural history studies
• Maternal-newborn studies
• Case-control studies
• Ecological studies
WHO, 2013. Correlates of Vaccine-Induced Protection: Methods and Implications
10Phase 3 efficacy trial:
• Very costly and time
consuming
• Involve more than
• Immune marker (either humoral/cellular thousands individuals in
response) could reliably predict risk of SARS-CoV-2
protection against disease exposure2
• Can be used as surrogate endpoint to
assess vaccine efficacy2
1 WHO, 2013. Correlates of Vaccine-Induced Protection: Methods and Implications
2Jin et al,2021 Signal Transduction and Targeted Therapy (2021) 6:48 11ANTIBODI KUANTITATIF SEBAGAI PENANDA
PROTEKSI?
12STRUKTUR SARS-COV-2
Mahmood et al. 6 August 2020. Vaccines 2020, 8, 443; doi:10.3390/vaccines8030443Viruses 2019, 11, 59; doi:10.3390/v11010059 • Spike proteins mediate the contact with the host cell by binding to ACE2 receptor, a process necessary for the virus The Nucleocapsid protein regulates the viral entry genome transcription, replication and packaging, • S protein contains 2 subunits: S1N-terminal domain, and it is essential for viability. The N protein is of responsible for receptor binding, and S2 C-terminal domain, potential interest for vaccine development as it is responsible for the fusion. highly immunogenic and its amino acid sequence is • S2 subunit is the most conserved one highly conserved • While the S1 subunit differs even within species of the same coronaviruses. The S1 contains two sub-domains (N- terminal and C-terminal), which are both show receptor- binding functions Forcelloni et al, 2020. https://doi.org/10.1101/2020.05.14.095133 14
• Life cycle of highly pathogenic human CoVs. 15
Jiang et al, 2020. https://doi.org/10.1016/j.it.2020.03.007Schematic representation of convalescent plasma components
and its mechanisms of action
Rojas et al, 2020 https://doi.org/10.1016/j.autrev.2020.102554Galipeau et al, 2020. Front. Immunol., 18 December 2020 | https://doi.org/10.3389/fimmu.2020.610688
Pan-SARS-CoV-2 S1-RBD Ig in levels at the first follow-up was a
median of 66 U/L (IQR, 25–174).
Interestingly, the antibody levels significantly increased to the
second follow-up (median 139 days) to a median of 109 U/L
(IQR, 46–227) (p < 0.001).
Anti-RBD S1 antibody = Elecsys® Anti-SARS-CoV-2
S antibody assay (pan-SARS-CoV-2 S1-RBD Ig) Schaffner et al, J Clin Med 2020 Dec 9;9(12):3989. doi: 10.3390/jcm9123989Titer antibodi anti-RBD tinggi
berkorelasi dengan netralisasi,
antibody-mediated complement
deposition (ADCD), and antibody-
dependent neutrophil phagocytosis
(ADNP)
Respon imun humoral terbatas tampak
pada individu dengan titer anti-RBD
rendah
0,1 ug/mL 0,1 ug/mL 0,25 ug/mL
IgG RBD = in-house ELISA
Positive cutoff = mean OD - converted μg/ml values
of the negative control wells on the respective
plate + five times the standard deviation of the
concentration from negative plasma samples
Bartsch et al, 15 February 2021
https://doi.org/10.1038/s41467-021-21336-8In order to mount a robust immune
response against an invading pathogen,
both adaptive and innate arms of the
immune system work in conjunction.
Though antibodies are traditionally
considered as necessary molecules of
immune defense, their generation relies
on effective cross-talk with the T-cells.
MARKER OF PROTECTION?
Jain et al, 3 November 2020. Vaccines 2020, 8(4), 649; https://doi.org/10.3390/vaccines8040649Zhou & Zhao, 2020; 16(10): 1718-1723. doi: 10.7150/ijbs.45123
The titers of NAb correlated with the
spike-binding antibodies targeting S1,
RBD, and S2 regions (Wu et al, 2020)
21
Speiser & Bachmann. 22 July 2020. Vaccines 2020, 8, 404; doi:10.3390/vaccines8030404Terdapat ikatan spesifik dose-
dependent antara hACE2
dengan RBD atau S1, namun
tidak terhadap nucleocapsid Berbagai tes antibodi terhadap Spike atau S-RBD berkorelasi
positif dengan Neutralization Test (r 0,237 – 0,447), kecuali anti-
RBD lebih baik dibandingkan NP (r = 0,094)2
S1 dalam mendeteksi Nab
(pada sVNT)1 Neutralizing Ab = HIV-1 pseudotyped virus neutralizing assay
Anti-RBD/S1/N = indirect ELISA
sVNT = Genscript
1Tan et al. 23 July 2020 Nature Biotechnology volume 38, pages1073–1078(2020)
Neutralizing Ab = cVNT & pVNT
2Luchsinger et al, 2020. Journal of Clinical Microbiology doi: 10.1128/JCM.02005-20SUMMARY OF THE KEY COMPONENTS OF A VIRAL NEUTRALIZATION ASSAY
Plaque Reduction Neutralization Test
(PRNT) → gold standard neutralizing
antibody
Prosedur rumit, butuh kultur sel
Membutuhkan BSL-2 atau BSL-3 Focosi et al. 12 August 2020 Rev Med Virol. 2020;e2170. https://doi.org/10.1002/rmv.2170Surrogate Virus Neutralization Test → deteksi Nab
dengan meniru interaksi virus-host pada plate ELISA
Anti-SARS-CoV-2 neutralizing antibodies block the SARS- Anti-SARS-CoV-2 neutralizing antibodies block HRP-
CoV-2 spike protein from binding to hACE2 receptor conjugated RBD protein from binding to the hACE2
proteins on the host cell surface protein pre-coated on an ELISA plate
Tan et al. 23 July 2020 Nature Biotechnology volume 38, pages1073–1078(2020)Terdapat korelasi antara sVNT (Genscript
Pass) dengan PRNT-50 (r = 0,73) serta
dengan PRNT-90 (r = 0,65)
Kelemahan sVNT:
• Deteksi antibodi non netralisasi
• Crossreactivity dengan SARS-CoV-1 dan
syphilis
Valcourt et al. 24 December 2020. https://doi.org/10.1016/j.diagmicrobio.2020.115294All binding assays except the DiaSorin S1/2 IgG showed a quadratic relationship with the sVNT. However, for the DiaSorin S1/2, the quadratic curve approached a straight line, indicating a mostly linear relationship between this binding assay and the sVNT within the observed range. Perkmann et al, 08 March, 2021 . medRxiv (preprint) doi: https://doi.org/10.1101/2021.03.05.21252977
Kelompok sera pasien konvalesen COVID-19 dengan
kadar IgM dan IgG rendah (ELISA) masih menunjukkan
inhibisi 70-90% pada sVNT (Genscript) Tan et al, 23 July 2020. Nat Biotechnol 38, 1073–1078 (2020).
https://doi.org/10.1038/s41587-020-0631-zAnti-RBD IgG dan anti-ECD (anti-spike ectodomain)
berkorelasi dengan microneutralization assays (0.67 versus
IgG anti-RBD berkorelasi dengan 0.62)
antibodi netralisasi
Terdapat 80% of donor memiliki titer virus neutralization
IgG-RBD = ELISA ≥1:160 pada plasma konvelesen ketika titer serum anti-RBD
Ab neutralisasi = neutralization assay atau anti-EDC titers ≥ 1:1350
IgG-RBD/EDC = ELISA
Ab neutralisasi = microneutralization assay
Peterhoff et al. Infection volume 49, pages75–82(2021) Salazar et al, 2020 bioRxiv. Preprint. 2020 Jun 9. doi: 10.1101/2020.06.08.138990RESPON IMUN PASCA VAKSINASI
GMT 121 GMT 247 GMT 74 GMT 215
Total IgG anti (whole virus) SARS-CoV-2 = ELISA
Effect of an Inactivated Vaccine Against SARS-CoV-2 on Safety Neutralizing Ab = PRNT50
and Immunogenicity Outcomes (Sinopharm) GMT = Geometric Mean Titer
Xia et al. 13 August 2020 JAMA. doi:10.1001/jama.2020.15543Immune responses induced by the days 0 and 28 vaccination The level of neutralising antibodies (of vaccination) was schedule were larger than those induced by the days 0 and 14 lower than those of convalescent patients who previously vaccination schedule, regardless of the dose. had COVID-19 IgG anti-RBD = in-house ELISA Zhang et al. 17 November 2020. https://doi.org/10.1016/ S1473- Neutralizing Ab = micro cytopathogenic effect assay (pseudovirus) 3099(20)308434 (CoronaVac Phase 1/2 Clinical Trial)
Studi pada 69 partisipan 21 hari pasca vaksinasi Pfizer
dosis pertama
In conclusion, the results of the investigated test
systems correlate well but are not necessarily
interchangeable
Perkmann et al, 08 March, 2021 . medRxiv (preprint) doi: https://doi.org/10.1101/2021.03.05.21252977GMT 235,228 GMT 151,761 GMT 157,946
GMT 182 GMT 167 GMT 109
At the 100-μg dose, mRNA-1273 produced high levels of binding and GMT: Geometric Mean Titer
neutralizing antibodies that declined slightly over time, as expected, but they
remained elevated in all participants 3 months after the booster vaccination
(the injections were received 28 days apart) Felson & Smolen, 7 January 2021 DOI: 10.1056/NEJMc2032195GMT 775 GMT 685 GMT 552
GMT 430 GMT 269 GMT 165
At day 119, the binding and neutralizing GMTs exceeded the median
GMTs in a panel of 41 controls who were convalescing from Covid-19,
with a median of 34 days since diagnosis (range, 23 to 54)
Felson & Smolen, 7 January 2021 DOI: 10.1056/NEJMc2032195Exponential Increase in Neutralizing and Spike Specific Antibodies
Following Vaccination of COVID-19 Convalescent Plasma Donors
Spike IgG level
14 days post
2nd dose
4137 AU/mL
Male 60s
1452 AU/mL
Female
60s
3410 AU/mL
Male 50s
Spike IgG = Diasorin (positive >15 AU/mL) Rata-rata kadar IgG-Spike pasca vaksinasi
Total Ig Nucleocapsid = Roche (positive COI>1,0) pada 10 subjek dengan riwayat COVID-19
4166 AU/mL (rentang 1235 – 7854)
Vickers et al, 05 Fen 2021. https://doi.org/10.1101/2021.02.02.21250836
35Studi terhadap 126 subjek terkonfirmasi COVID-19
Terdapat satu subjek konvalesen dengan
antibodi negatif (BAGAIMANA MENENTUKAN KADAR
SEROPROTEKTIF?
VE = Vaccine efficacy
WHO, 2013. Correlates of Vaccine-Induced Protection: Methods and Implications
Jin et al, 2 Feb 2021 Signal Transduction and Targeted Therapy (2021) 6:48
37Other Issues Related to Immunological Markers
for Protection
Endpoint Definition Exposure intensity / Host Factors
• Protection against clinical challenge dose
endpoints may require not just • Age
• The level of protection provided • Socioeconomic status
different quantities of a specific
by a specific Ab titre in one
immune marker but involve • Environmental factors
different markers population may be higher than in
different population setting
Antigen Factors Immunological Factors Measurement Error and Noise
• Type of antibody (qualitative • Lack of standardization, laboratory
• Immunity observed from natural variability, high intra-individual
exposure can be qualitatively and quantitative aspects, variability
and/or quantitatively different include avidity and titre of • The need for valid and reliable
from those vaccinated protection) assays is thus emphasized by
• Composition of the vaccine • Kinetics of immune response regulatory agencies
WHO, 2013. Correlates of Vaccine-Induced Protection: Methods and Implications
38Angka yang tertera pada tabel merupakan batas cut-off “high titer” donor plasma konvalesen yang direkomendasikan • Plasma konvalesen akan terdilusi ketika masuk ke tubuh pasien • Batas cut-off tidak dapat dikatakan berkorelasi dengan kadar seroprotektif pasca vaksinasi
Jin et al, 2 Feb 2021 Signal Transduction and Targeted Therapy (2021) 6:48
40FAKTOR YANG MEMPENGARUHI RESPON IMUN PASCA VAKSINASI
Zimmerman & Curtis. 13 March 2019. Clin Microbiol Rev. 2019 Apr; 32(2): e00084-18.BAGAIMANA REKOMENDASI PEMERIKSAAN
ANTIBODI KUANTITATIF PASCA VAKSINASI?
42Anti SARS-CoV-2 antibodies titer (preferably quantitative, anti-spike/RBD) shall be assesed before
vaccination, so that SARS-CoV-2 vaccine administration can be prioritized to sero-negative individuals
IgG anti-spike/RBD shall be monitored for up to 6-8 months, preferably starting 1-2 weeks after the last dose of
vaccine, using always the same assay. This would timely identify lack of seropositivity or seronegativization
Antibodies assesment and monitoring, before and after vaccination, are necessary in patients with
immunodeficiencies and cancer
The performance characteristics (both analytical and diagnostic) of each specific test shall then be
validated
When feasible and clinically advisable, assesment of cellular immunity may also be an option
Lippi et al, 2021. Clin Chem Lab Med 2021; aop. https://doi.org/10.1515/cclm-2021-0038
435 March, 2021 • Antibody testing is not currently recommended to assess for immunity to SARS-CoV-2 following COVID-19 vaccination because the clinical utility of post-vaccination testing has not been established. • Antibody tests currently authorized under an EUA have variable sensitivity, specificity, as well as positive and negative predictive values, and are not authorized for the assessment of immune response in vaccinated people • The serologic correlates of protection have not been established, and antibody testing does not evaluate the cellular immune response, which may also play a role in vaccine-mediated protection. • Finally, antibody testing against nucleocapsid will not detect immune responses resulting from vaccination, but patients may not always know what type of antibody test was used. • If antibody testing was performed following vaccination, additional doses of the same or different COVID-19 vaccines are not recommended based on antibody test results at this time. • If antibody testing was done after the first dose of an mRNA vaccine, the vaccination series should be completed regardless of the antibody test result.
Pembentukan antibodi pasca vaksinasi tidak mengurangi kewajiban protokol kesehatan 5 M → belum diketahui pasti efektivitas vaksin dalam mencegah penularan
TAKE HOME MESSAGES
1. Pasca vaksinasi respon imun pasti terjadi.
2. Pembentukan antibodi bergantung pada banyak faktor (faktor vaksin,
faktor host, dan faktor assay).
3. Belum terdapat standarisasi internasional antibodi netralisasi yang sesuai
dengan berbagai tes antibodi kuantitatif yang beredar. Gold standard
adalah PRNT.
4. Pemeriksaan antibodi kuantitatif RBD-S untuk monitoring mandiri respon
imun vaksinasi harus menggunakan alat dan reagen yang sama.
5. Target utama vaksinasi saat ini adalah untuk mencapai meningkatkan
cakupan untuk mencapai herd immunity → belum ada rekomendasi
penambahan/perubahan jenis vaksin/dosis berdasarkan hasil antibodi
6. Penentuan cut-off kadar antibodi seroprotektif masih membutuhkan
penelitian
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48TERIMA KASIH
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