Real world use of Tixagevimab/Cilgavimab pre-exposure prophylaxis of COVID-19 in immunocompromised individuals: data from the OCTOPUS study. (preprint)

We report real world use over time in immunocompromised subjects receiving tixagevimab/cilgavimab (T/C) pre-exposure prophylaxis (PrEP). Observational study on participants receiving T/C PrEP stratified: never had COVID-19 (NoC), hybrids (H) and breakthrough infections (BTIs) if COVID-19 before or after PrEP, respectively. Anti-RBD IgG and BA.5 neutralizing antibodies (nAbs), mucosal IgG, T-cell immunity at the administration of T/C (T0), 3 (T1), 6 (T2), and 9 (T3) months after, were measured. Comparison of markers in each group across timepoints, Poisson regression model for BTIs incidence rate ratios were performed. N=231 participants: median age 63 years (IQR 54.0-73.0), 84% hematological disease, median vaccine dose of three. N=72 NoC, 103 H and 56 (24%) BTIs, mostly mild/moderate, IR 4.2 (95%CI 3.2-5.4) BTIs/100 patients-months, no factors associated with. A significant increase of anti-RBD IgG at T1 was observed in all the groups, with a decline at T2. GMTs of anti-BA.5 nAbs were low at T1 for all the groups and around/below the cut off. No changes of IFN-γ. Overall, a mucosal response was observed at T1. An incidence of 24% of mild/moderate BTIs was observed. Anti-RBD IgG levels persistence was ensured, BA.5 nAbs were low/undetectable, cellular T immunity remained stable.

Inadvertent Exposure to Pharmacologically Designed Lipid Nanoparticles Via Bodily Fluids: Biologic Plausibility and Potential Consequences (preprint)

Exposure to vaccine lipid nanoparticles, mRNA, adenoviral DNA, and or Spike protein from one of the approved Covid-19 vaccines, or through secondary exposure, as through blood transfusion, is a potential source of harm. Blood reactions are an acknowledged side-effect of Covid-19 vaccination, not limited to hemolysis, paroxysmal nocturnal hemoglobinuria, chronic cold agglutinin disease, immune thrombocytopenia, haemophagocytosis, hemophagocytic lymphohistiocytosis, and many other blood related conditions. The observation of adverse events has motivated investigation into the cardiovascular mechanisms of harm by Covid-19 vaccines, and the biodistribution of vaccine contents. Biodistribution may not be limited to the body of the vaccine recipient, as a growing body of evidence demonstrates the possibility of secondary exposure to vaccine particles. These can be via bodily fluids and include the following routes of exposure: blood transfusion, organ transplantation, breastfeeding, and possibly other means. As covid-19 vaccines are associated with an increased risk of stroke, the persistence of vaccine artifacts in the blood presents a possible threat to a recipient of a blood donation from a vaccinated donor who suffered from vaccine induced thrombosis or thrombocytopenia. (VITT) We assess the feasibility and significance of these risks through an overview of the case report literature of blood disorders in vaccinated individuals, pharmacovigilance reports from the US Vaccine Adverse Events Reporting System (VAERS) and a meta-analysis of the available literature on organ transplants from vaccinated organ donors. Our analysis establishes biological mechanistic plausibility, a coherent safety signal in pharmacovigilance databases for secondary vaccine contents exposure (for the cases of blood transfusion and breastfeeding) and also an elevated level of adverse events in organ transplants from VITT-deceased donors, echoing increases in organ transplantation related complications seen in national statistics for some countries. Secondary exposure to vaccine artifacts is a potential explanation for some of the cases put forth, and requires a deeper investigation.

Predictors of disease severity, clinical course, and therapeutic outcome in COVID-19 patients: Our experience with 1700 patients (preprint)

Objective: To investigate the impacts of demographic, hematological, and biochemical factors on the clinical course and the prognostic outcome in adult COVID-19 patients. Methods: This retrospective study was performed in the internal medicine departments of 2 hospitals and data were extracted from the medical files of 1700 adult COVID-19 patients (836 females, 49.2%; 864 males, 50.8%) with an average age of 48.23 ± 16.68 (range: 18-93). Clinical data included baseline descriptives, prior medical history, admission date, treatment, and hematological and biochemical blood test results. The relationship between the survival, length of hospitalization, hematological, and biochemical parameters was investigated. Results: Advanced age (p<0.001), presence of at least 1 comorbid disease (p=0.045), increased length of hospitalization (p=0.006), elevated white blood cell (p=0.001) and neutrophil (p=0.002) counts, increased serum levels of glucose (p=0.027), blood urea nitrogen (p<0.001), AST (p=0.006), LDH (p<0.001), CRP (p>0.001), and D-dimer (p=0.001). In contrast, diminution of serum levels of albumin (p<0.001), ALT (p=0.028), calcium (p=0.022), and platelet count (p=0.010) were associated with increased mortality. There was a positive and weak relationship between serum D-dimer levels and length of hospitalization. Conclusion: Our data imply that identification and validation of indicators that predict COVID-19 disease progression to improve health outcomes are crucial. Age, comorbidities, immunological response, radiographic abnormalities, laboratory markers, and signs of organ dysfunction may all predict poor outcomes individually or collectively. It is critical to identify characteristics that predict COVID-19 problems to guide clinical management, improve patient outcomes, and allocation of limited resources. Keywords: SARS-Cov-2, COVID-19; severity; prognosis; outcome

Health workers' perception and emotions of teleconsultation in pediatric cancer care (preprint)

Background: and aims: During the first lockdown of the novel Coronavirus pandemic (COVID-19), we developed a teleconsultation model to replace in-person visits. We conducted a survey-based study with the aim to evaluate satisfaction and emotions of health workers (HWs), to assess the feasibility of teleconsultations and to evaluate technical issues. Methods: This is a prospective monocentric exploratory study in which data were collected from March until May 2020 in the Lyon Pediatric Hematology and Oncology institute (IHOPe). We realized synchronous, video-based consultations between HWs and pediatric patients, treated for blood or solid malignancies or blood benign diseases. Every HW completed an online, pseudo-anonymized questionnaire which covered technical aspects, data concerning satisfaction, perception of the quality of the interaction with the patient and emotions felt after the teleconsultation. A score was calculated for each aspect. In order to study the relationship between the scores, the correlation coefficient method was used. Results: Eleven specialists participated in the study and we selected 84 questionnaires. With a satisfaction rate of 74%, HWs felt mostly calm (80%), relaxed (70%), stress-free (69%) and relieved (65%). We calculated the following median scores: an overall satisfaction score of 6.67 (0-10), a global feeling score of 8.79 (3.33-10.00), and a quality score of 7.34 (2.50-10.00). A strong correlation between the quality of the teleconsultation and the satisfaction of the HWs has been highlighted (r = 0,588). Conclusion: Our series is an encouragingly positive experience from the perspective of the HWs, their feelings and perceptions.

Comprehensive procedure for injecting Evusheld® for hematological diseases in a single institute (preprint)

Tixagevimab and cilgavimab (EVA, Evusheld®), monoclonal antibody combination treatments, consisted of two neutralizing antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). EVA showed prophylactic and therapeutic effects against coronavirus disease 2019. The Japanese Society of Hematology recommended EVA for such patients with active treatment, but each institution decided on comprehensive administration. We develop a systematic procedure for comprehensive EVA injection in patients with hematological malignancies without any over/under-indication. We listed all patients with the required indications from November 2022 to March 2023. We included 178 cases, 84 females and 94 males, with a median age of 70 (range: 19–90) years. Underlying diseases are myeloid neoplasms in 36 (20%), lymphoid neoplasms in 75 (73%), and others. Indications were intensively hematological malignancy treatment, rituximab treatment within 12 months, burton kinase inhibitor treatment, after chimeric antigen receptor T cell immunotherapy, and after stem cell transplantation in 74 (41%), 73 (41%), 3 (2%), 5 (3%), and 23 (13%) cases, respectively. Of the 178 cases, 22 (12.4%) refused EVA injection. Further, 42 and 136 cases were administered outpatient and inpatient, respectively. Over 95% of the listed cases received EVA injection within 3 months. No severe toxicities were observed among them (N = 156), and 8 (5.2%) cases had breakthrough SARS-CoV-2 infection, which was significantly lower (P = 0.02) than those without EVA (4 [18.2%] of 22 cases). Both groups showed no moderate or severe infection cases. This single-center experience showed that comprehensive EVA injection management effectively generated safer completion with preferable clinical impact.

Fmoc-FF hydrogels and nanogels for improved and selective delivery of Dexamethasone in leukemic cells and diagnostic applications (preprint)

Dexamethasone (DEX) is a synthetic cortisol used for the treatment of different pathological states, thus comprising cancer, ocular disorders, and COVID-19 infection. Its clinical use is hampered by the low solubility and severe side effects related to its systemic administration. The capability of peptide-based nanosystems, like hydrogels (HGs) and nanogels (NGs), to serve as vehicles for the passive target of active pharmaceutical ingredients and the selective internalization into leukemic cells has been demonstrated. Peptide based HG loaded with DEX were formulated via the “solvent-switch” method, using Fmoc-FF homopeptide as building block. Due to the tight interaction of the drug with the peptidic matrix, a significant rigidification of the gel (G’ = 67.9 kPa) was observed. The corresponding injectable NG, obtained for submicronization of the HG in the presence of two stabilizing agents (TWEEN®60 and SPAN®60, 48/52 mol/mol), were found to be stable at least up to 90 days with a mean diameter of around 105 nm. NG does not exhibit hemolytic effect on human serum and is selectively internalized by RS411 leukemic cells, passively target leukemic cells over healthy PBMCs, paving the way for the generation of new diagnostic strategies targeting onco-hematological diseases.

SARS-CoV-2 Viral Clearance and Evolution Varies by Extent of Immunodeficiency (preprint)

Despite vaccination and antiviral therapies, immunocompromised individuals are at risk for prolonged SARS-CoV-2 infection, but the immune defects that predispose to persistent COVID- 19 remain incompletely understood. In this study, we performed detailed viro-immunologic analyses of a prospective cohort of participants with COVID-19. The median time to nasal viral RNA and culture clearance in the severe hematologic malignancy/transplant group (S-HT) were 72 and 21 days, respectively, which were significantly longer than clearance rates in the severe autoimmune/B-cell deficient (S-A), non-severe, and non-immunocompromised groups (P<0.001). Participants who were severely immunocompromised had greater SARS-CoV-2 evolution and higher risk of developing antiviral treatment resistance. Both S-HT and S-A participants had diminished SARS-CoV-2-specific humoral, while only the S-HT group had reduced T cell-mediated responses. This highlights the varied risk of persistent COVID-19 across immunosuppressive conditions and suggests that suppression of both B and T cell responses results in the highest contributing risk of persistent infection.

Clinical and Immunological Characteristics of Prolonged SARS-CoV-2 Omicron Infection in Hematologic Disease (preprint)

Prolonged viral shedding (PVS) occurs when severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is not adequately cleared and has been associated with poor outcomes. However, it remains unclear whether the immunological and clinical characteristics of Omicron PVS in hematologic disease (HD) are identical to those of earlier variants. We retrospectively analyzed 160 patients with HD with Omicron breakthrough infections. Although the hospitalization rate was high (21.3 %), deaths attributable to COVID-19 occurred in only 2.5% of the cases. PVS developed in 36.9% of the evaluable patients. Factors such as B- and CD4+ T-cell depletion, recent use of anti-CD20 antibodies and bendamustine were found to be significant predictors of PVS. Analysis of T cell phenotypes showed an increase in exhausted CD4+ T cells in PVS, but not in CD8+ cells.  Neutralizing activities against recombinant spike proteins for three Omicron subvariants were significantly reduced. Notably, despite the high frequency of PVS, many patients previously treated with anti-CD20 antibodies and bendamustine ultimately recovered. Late-onset interstitial pneumonia is a fatal complication that can occur regardless of viral clearance. Despite the use of high-dose corticosteroids and potent antivirals, the optimal treatment for PVS remains unclear and should be individualized until a more effective strategy is established.

Adherence to Sars-CoV2 vaccination in hematological patients.

Background: SARS-CoV2 vaccination efficiently prevents severe COVID-19, although hematological patients, particularly under therapy, respond less well. Besides vaccine efficacy, adherence to vaccination is essential for ensuring adequate protection of this vulnerable population. Methods: We evaluated the impact of a program aimed at maximizing patient adherence by comparing the rate of SARS-CoV2 vaccination of our hematological patients and a matched sample of the general population. Results: Vaccination rates were 88.9% among 2,156 patients, aged 65.2 ± 15.8 years (M ± SD, range 19-86 years). Rates differed considerably with age, i.e. 84.2% between 18-64 years and 92.4% above 65 years (p<0.0001), but not with sex. In the general population, rates were 76.3% overall, 73.0% between 18-64 and 86.7% above 65 years, all significantly lower than among patients, overall (Standardized Incidence ratio (SIR) 1.17; 95%CI 1.12-1.22, p<0.0001) as well as among younger (SIR 1.15; 1.07-1.24, p<0.0001) or older (SIR 1.06; 1.00-1.13, p=0.046) people. Vaccination rates increased to 92.2% overall (SIR 1.21; 1.16-1.27, p<0.0001), 88.5% in younger (SIR 1.21; 1.13-1.30, p<0.0001) and 94.8% in older (SIR 1.09; 1.03-1.12, p=0.0043) patients, after excluding those with medical contraindications, and further to 95.6% overall (SIR 1.26; 1.20-1.32, p<0.0001), 93.8% in younger (SIR 1.29; 1.20-1.38, p<0.0001) and 96.9% in older (SIR 1.11; 1.05-1.18, p=0.0004) patients, after excluding those not seen in hematology in 2021. Conclusions: Vaccination rates were significantly higher in hematological patients compared to the general population regardless of age, sex and municipality. Acceptance of Covid vaccines by hematological patients may be improved by targeted information campaigns carried out by trusted health care professionals.

Distinct and overlapping immunological responses to SARS-CoV-2 and Mycobacterium tuberculosis identified by single-cell RNA-seq of co-infected whole blood (preprint)

Introduction: COVID-19 and tuberculosis (TB) exhibit similar symptomatic presentation and clinical parameters. Common underlying immunological mechanisms also highlight potential routes of immunopathogenic interaction between these diseases during co-infection. To explore immunological similarities, differences and interactions, single-cell RNA-seq (scRNA-seq) was performed on whole blood infected with Mycobacterium tuberculosis (Mtb), SARS-CoV-2, or both pathogens. Methods: Whole blood from four healthy adults, were subjected to ex vivo infection with Mtb and/or SARS-CoV-2 ancestral strain, or were maintained in an uninfected state, for 24 or 96 hours. At each timepoint, for each condition, the four biological replicates were captured, fixed and cryopreserved to be processed for scRNA-seq as a single batch. Following quality control filtering, genotype-based demultiplexing was performed to obtain data from each biological replicate for pseudobulk differential expression analysis. Results: Thirteen distinct clusters of cells were identified based on marker gene expression. Profound differences in the proportions of monocytes, T cells and neutrophils were observed between infection conditions and timepoints. The greatest divergence between pathogen responses occurred within myeloid cells at early timepoints of infection. Co-infection had the greatest synergistic effect 24 hours post-infection with 238 immunological pathways uniquely enriched, including IFN-{gamma} and TNF production, whilst by 96 hours post-infection there was a large overlap of 182 shared pathways between Mtb, SARS-CoV-2 and co-infection. SARS-CoV-2-only infection resulted in widespread cell death by 96 hours post-infection, while Mtb-only and co-infected samples remained enriched for monocyte, T cell and NK cell signatures, sharing negative regulation of extrinsic apoptotic signalling. Distinct from Mtb, SARS-Co-V-2 had unique regulating of {beta} T cell activation and differentiation at both time points. Conclusion: These data provide a high-resolution characterisation of distinct and overlapping immunological responses generated by SARS-CoV-2 and Mtb when a single infection or co-infection occurs. This sheds light on the potential effects of novel or existing host-directed therapies that target these pathways, which is particularly crucial for settings where dual presentation is common.

Viral infection of hematopoietic stem cells (preprint)

Hematopoietic stem cells (HSCs) are critical for maintaining healthy blood and immune cell populations. They’re also valuable resources and targets for medical treatments, such as HSC transplantation and gene therapy. However, these blood cell precursors are susceptible to viral infection, which can cause blood disorders and limit the efficacy of HSC-based therapies. In fact, viral infection is a leading cause of complications and death among HSC transplant recipients. For example, latent cytomegalovirus can become reactivated after transplantation leading to immunosuppression, pneumonia, encephalitis, and graft failure. HSC transplantation also reduces the numbers of T cells that are specifically cytotoxic toward the mononucleosis- inducing Epstein–Barr virus. Furthermore, recipients of HSC transplants are more susceptible to infection by SARS-CoV-2, the cause of the COVID-19 pandemic. SARS-CoV-2, in turn, can induce numerous blood abnormalities, such as thrombocytopenia, lymphocytopenia, anemia, hypercoagulability, and systemic thrombosis in part because HSCs express SARS-CoV-2 receptors. More research is needed to determine the best ways to prevent viral infection of these essential cells in both endogenous and transplantation contexts, in order to reduce serious blood disorders and related mortality in the clinic.

[Analysis of anti-SARS-CoV-2 IgG antibody titers after mRNA booster vaccination in patients with nonmalignant hematological disorders].

In our facility, anti-SARS-CoV-2 mRNA vaccines were given to 21 patients, including 8 with aplastic anemia (AA), 3 with pure red cell aplasia (PRCA), and 10 with immune thrombocytopenic purpura (ITP), and IgG antibody titers were assessed one month after vaccinations. After receiving both a second vaccine and a booster shot, all patients with AA/PRCA treated with cyclosporine A aside from one, had IgG titers that were lower than the median levels of healthy controls. Even if prednisolone (PSL) doses did not go over 10 mg/day, ITP patients receiving PSL therapy were unable to achieve adequate levels of IgG after booster immunizations.

[Outcomes of COVID-19 due to omicron variant infection complicated with hematological disorders].

When the omicron variant became the most dominant severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) variant causing coronavirus disease 2019 (COVID-19) in Japan, 11 patients with hematological diseases infected with this new variant were treated at our institution. Among them, four of the five patients who had been treated with chemotherapy progressed to moderate-II COVID-19, and two of them died. In contrast, five of the six patients who did not receive the treatment remained at mild to moderate-I stage of COVID-19, except for a single case progressing to moderate-II COVID-19. While all four patients infused with anti-coronavirus monoclonal antibodies within 8 days after the onset survived, the other two patients, being withheld from treatment or treated later, died. In these two cases, anti-SARS-Cov-2 immunoglobulin G antibodies remained at low titers. Although the omicron variant is considered a less harmful SARS-Cov-2 variant, patients with hematological disorders, particularly those who are immunosuppressed caused by chemotherapy, should be continuously cared for as they remain at a higher risk of severe COVID-19 due to insufficient or delayed anti-viral humoral immunity development. Thus, the rapid introduction of antiviral monoclonal antibodies together with anti-viral reagents may rescue these patients.

Outcome of early treatment of SARS-CoV-2 infection in patients with haematological disorders.

Outcome of early treatment of COVID-19 with antivirals or anti-spike monoclonal antibodies (MABs) in patients with haematological malignancies (HM) is unknown. A retrospective study of HM patients treated for mild/moderate COVID-19 between March 2021 and July 2022 was performed. The main composite end-point was treatment failure (severe COVID-19 or COVID-19-related death). We included 328 consecutive patients who received MABs (n = 120, 37%; sotrovimab, n = 73) or antivirals (n = 208, 63%; nirmatrelvir/ritonavir, n = 116) over a median of two days after symptoms started; 111 (33.8%) had non-Hodgkin lymphoma (NHL); 89 (27%) were transplant/CAR-T (chimaeric antigen receptor T-cell therapy) recipients. Most infections (n = 309, 94%) occurred during the Omicron period. Failure developed in 31 patients (9.5%). Its independent predictors were older age, fewer vaccine doses, and treatment with MABs. Rate of failure was lower in the Omicron versus the pre-Omicron period (7.8% versus 36.8%, p < 0.001). During the Omicron period, predictors of failure were age, fewer vaccine doses and diagnosis of acute myeloid leukaemia/myelodysplastic syndrome (AML/MDS). Independent predictors of longer viral shedding were age, comorbidities, hospital admission at diagnosis, NHL/CLL, treatment with MABs. COVID-19-associated mortality was 3.4% (n = 11). The mortality in those who developed severe COVID-19 after early treatment was 26% in the Omicron period. Patients with HM had a significant risk of failure of early treatment, even during the Omicron period, with high mortality rate.

Outcome of COVID-19 in allogeneic stem cell transplant recipients: Results from the EPICOVIDEHA registry.

Background: The outcome of COVID-19 in allogeneic hematopoietic stem cell transplantation (HSCT) recipients is almost uniformely considered poor. The aim of present study was to retrospectively analyse the outcome and risk factors for mortality in a large series of patients who developed COVID-19 infection after an allogeneic HSCT. Methods: This multicenter retrospective study promoted by the European Hematology Association - Infections in Hematology Study Working Group, included 326 adult HSCT patients who had COVID-19 between January 2020 and March 2022. Results: The median time from HSCT to the diagnosis of COVID-19 was 268 days (IQR 86-713; range 0-185 days). COVID-19 severity was mild in 21% of the patients, severe in 39% and critical in 16% of the patients. In multivariable analysis factors associated with a higher risk of mortality were, age above 50 years, presence of 3 or more comorbidities, active hematologic disease at time of COVID-19 infection, development of COVID-19 within 12 months of HSCT, and severe/critical infections. Overall mortality rate was 21% (n=68): COVID-19 was the main or secondary cause of death in 16% of the patients (n=53). Conclusions: Mortality in HSCT recipients who develop COVID-19 is high and largely dependent on age, comorbidities, active hematologic disease, timing from transplant and severity of the infection.

Immunogenicity profile after COVID-19 vaccination in patients with onco-hematological diseases.

OBJECTIVE: To evaluate the influence of onco-hematological pathologies on seroconversion to COVID-19 vaccines, in addition to the effects of chemotherapy treatment on this response. METHODS: The present study evaluated the immunogenic response of 76 patients with onco-hematological diseases to multiple vaccine platforms compared to 25 control individuals. RESULTS: Our results showed positive response rates of 74.02% in patients with onco-hematological diseases and 100% in controls. When analyzed according to etiological group, patients with lymphoproliferative disorders achieved a positive vaccine response rate of 58.7%, whereas those with myeloproliferative diseases achieved a 100% response rate. We also observed that patients previously exposed to COVID-19 presented a 75% increase in their antibody values after vaccination, and these values were 37% higher than those of patients who did not have such exposure. We found that patients who underwent B-lymphocyte-depleting therapy in the last 2 years before vaccination had a worse response rate of 18.75%. CONCLUSION: Despite the immunosuppression of patients with onco-hematological diseases, caused by the biology of their diseases and treatment, benefit and safety in vaccinating these patients are observed, in view of the important recall immune response and incidence of adverse effects similar to those of the healthy population.