ABSTRACT
Background: Coronavirus SARS-CoV-2 and its associated disease COVID-19 have become a worldwide pandemic since its frst case in 12/2019. Since approvement of the frst vaccines against COVID-19 in Europe in 12/2020 a large vaccination campaign was started. Our patients with infammatory diseases (ID) were graded as higher risk, thus an early vaccination was possible. Many of our patients used the possibility and got vaccinated. Until now, there is few knowledge about the efficacy and safety of vaccination in patients with rheumatic disorders. There are some reports of less vaccination response in patients with ID (1). First reports of those patients with rheumatological disorder and infection with SARS-CoV2 are available (1,2). Nevertheless, there is few knowledge about SARS-CoV2-infection in patients with ID after vaccination against COVID-19, yet. Objectives: The aim of our study was to evaluate, how many patients got infected with SARS-CoV2 after vaccination against COVID-19 and the course of the disease. Methods: All consecutive patients of the routine follow up visits from 07/2021 to 01/2022 in our rheumatological outpatient center were questioned for SARS-CoV2-infection. In case of infection, they were questioned for vaccination status and the course of the disease. Results: N=1206 patients could be evaluated. N=1183/1206 (98.1%) vaccinations were documented. N=12/1183 (1%) patients got infected with SARS-CoV2 after at least 2 doses of vaccination against COVID-19. N=1/12 (8.3%) patient got infected after 3 doses of vaccination. N=3/12 (25%) received 2 doses Vaxzev-ira (AstraZeneca), n=2/12 (16,7) patients 1st dose Vaxzevira, 2nd dose Comir-naty (Biontech), n=7/58.3%) patients two doses Comirnaty. In n=8/12 (66.7%) patients antibody levels were available. N=7/8 (87,5%) patients developed high antibody levels after 2 vaccinations. N=1/8 (21,5%) patient developed any antibodies against SARS-CoV2 after 2 doses of Comirnaty, measured ≥4 months after 2nd vaccination dose. This patient was treated with Abatacept. This patient came down with COVID-19 5 months after complete vaccination and died after long-standing highly intensive care. All other patients developed a mild to moderate course of COVID-19, without need of hospitalizing. Conclusion: There is a very high number of patients (98,1%), who got vaccinated in a real life setting of our rheumatological outpatient center. We have seen only a low number of SARS-CoV2-infections (1%). Most patients developed high antibody levels after vaccination and fortunately had a mild to moderate course of COVID-19 in case of SARS-CoV2-infection, independently from the different vaccination agents. Nevertheless, 1 patient came down with COVID-19 5 months after complete vaccination and died after long-standing highly intensive care. This patient did not develop any antibodies after vaccination. In conclusion, vaccination seems to be effective in patients with rheumatological disorders. However, we must be aware of the small group of patients without antibody development, since they are at risk to have a fatal course. Yet, antibody testing is not recommended in routine clinical care by official recommendations, largely because it is still unknown which level of antibodies predicts protection (3). The booster campaign and 3rd vaccinations will change the current state again, but a revaluation and further studies will be necessary.
ABSTRACT
Background: Since approvement of the frst vaccines against COVID-19 in European in 12/2020, a large vaccination (VAC) campaign was started. Patients with infammatory diseases (ID) were graded as higher risk. Many of our patients used the possibility and got vaccinated. Until know, there is few knowledge about the efficacy and safety of VAC in patients with ID. There are some reports of less VAC response in patients with ID (1). Many antibody (AB) studies are ongoing but monitoring of AB status is not recommended by official recommendations (1,2). Nevertheless, AB testing is commonly used in daily care in outpatient centers (OC). Objectives: To evaluate in a real life setting of a single rheumatological OC how many patients have been vaccinated against COVID-19, how many of these did not develop AB and search for possible explanations. Methods: All consecutive patients of the routine follow up visits from 03/2021 to 12/2021 were retrospectively evaluated if VAC and an AB testing (e.g. ELI-SA-tests) was done ≥4 weeks after the 2nd VAC was documented. All AB tests were classifed for AB levels (Ratio <0,8 negative, >0,8 Ratio < 4,5 low to moderate, Ratio ≥ 4,5 high level). The group of patients without AB was specifed. Results: N=1206 persons were questioned. N=23/1206 (1.9%) patients refused a VAC. N=1183/1206 (98.1%) have got a VAC. N=984/1183 (83.2%) were had an ID, n=199/1183 (16.8%) were healthy persons (HP). In n=608/1138 (51%) an AB status after ≥4 weeks after VAC was available. N=14/608 (20%) HP developed all but one high AB levels. 1 HP had a low to moderate AB level. In n=595/1183 (50%) patients with ID an AB status was available. N=438/595 (74%) patients developed high AB levels, n=126/595 (21%) low to moderate, n=30/595 (5%) had no AB. Mean age in the group without any AB was 69years (range 38-95). N=27/30 (90%) patients received ≥1 DMARD (disease modifying antirheumatic drug), n=3/30 patients were not treated with DMARD, n=2/3 of these patients received Prednisolone (P) instead. N=4/30 received Rituximab (RTX), n=1/30 Abatacept (ABA), n=1/30 MMF (3g), n=1/30 Azathioprine in combination with high P (55mg), n=15(50%) MTX alone or in combination, n=24/30(80%) P (range mg 1-55, mean 5,7). One 52y old patient without any AB did receive nether a DMARD nor P. N=3/30 patients got both vaccinations with Vaxzevira (V), n=25/30 (83,3%) Comirnaty (C), n=1/30 Spikevax, n=1/30 first V, second C. 1 patient, treated with ABA has been vaccinated with 2 doses of C. A AB testing 4 months later did not reveal any antibodies. This patient came down with COVID-19 5 months after complete VAC and died. Conclusion: There is very high number of VAC (98,1%) in a real life setting of a rheumatological OC. Many patients (95%) developed low to high AB levels after 2 VAC, independently which agent was used. Otherwise, we must be aware of the small group of patients (5%) without developing any AB. Unfortunately, our group was too small to find significant risk factors (RF). But RF seems to be the age, therapy with RTX, ABA and P. This is in line with reported RF in clinical studies (1). Furthermore, we see lower levels in elderly patients who get vaccinated with C. This could be biased by the fact that, in the first months of the VAC campaign, C was used in patients with higher age and the 2nd C-VAC was given 3 weeks after 1st VAC. Retrospectively, this interval seems to be too short. Thus now, the 2nd VAC is given 4-6 weeks after 1st VAC. In conclusion it is still unclear, which levels of AB make VAC effective and which patients will develop AB levels. AB levels should be evaluated to pick out patients with VAC gap, since the high risk of fatal course of COVID-19-disease. The booster campaign and 3rd VAC will change the current state again, therefore revaluation will be necessary.
ABSTRACT
Background: Critical illness is a frequent cause of mortality in resource-limited settings. Improved triage on admission could improve mortality, but existing tools depend on variables that often are not available. We prospectively evaluated the universal vital assessment (UVA) score to predict mortality among patients admitted to a district hospital in rural, highly HIV-prevalent South Africa. Figure 1. Receiver operator characteristic (ROC) curves for the UVA and qSOFA scoring tools. Methods: In February-March 2020, adults admitted to the medical wards were enrolled, prior to interruption by covid19, and 30-day mortality assessed. Clinical parameters including temperature, heart and respiratory rates, systolic blood pressure, oxygen saturation, Glasgow Coma Scale score, and HIV status were collected within 24 hours of admission as part of routine care. Lower respiratory tract infections (LRTI) included pneumonia and suspected pulmonary tuberculosis. To evaluate the predictive ability of the UVA score, area under the receiver operating characteristic curve (aROC) and age-sex adjusted binary logistic regression models were generated, and compared to the sequential organ failure assessment (qSOFA). Results: Sixty one patients were enrolled;outcomes were available for 56 patients. Patients had a mean age of 52 (SD+17), 51% were women, and 46% were HIV infected. The 30-day mortality was 16.1% (9/56) with infections and non-communicable diseases comprising 47% and 47% of admission diagnoses, respectively. The most common admitting diagnosis was LRTI (24.6%). The median (+IQR) UVA score was 2 (+3) accounting for 36% of participants. Medium-risk (2-4) and high-risk (>4) UVA groups were not associated with 30-day mortality, although the high-risk score trended towards significance (p=0.07). However, a UVA score > 3 was significantly associated with 30-day mortality, both alone and after adjusting for age and sex (aOR 6.2, 95% CI 1.2-33.1;p=0.03). The aROC (95% CI) for the UVA score was 0.74 (0.55 - 0.93), which performed better than qSOFA (aROC 0.59, 95% CI 0.37-0.81) and is shown in Figure 1. Conclusion: In this resource-limited, HIV-prevalent setting, the UVA score predicted mortality better than the qSOFA score. A moderate-risk UVA score (>3) was predictive of 30-day mortality, though needs to be confirmed in larger studies.