Jean Liew, MD, MS: COVID-19 Infections Among Vaccinated Individuals with Rheumatic Disease

Rheumatology Network interviewed Jean Liew, MD, MS, about her upcoming ACR Convergence presentation entitled, “SARS-CoV-2 Infections Among Vaccinated Individuals with Rheumatic Disease: Results from the COVID-19 Global Rheumatology Alliance Provider Registry.” Liew is Assistant Professor at Boston University. We discuss how immunogenicity threatens vaccine effectiveness, the clinical significance of study results, and additional strategies that can be implemented to help protect this patient population.

Rheumatology Network: How does poor immunogenicity in immunocompromised people threaten vaccine effectiveness?

Jean Liew, MD, MS: The immune response that people make after receiving the vaccine (the immunogenicity) may be blunted from their immunomodulatory or suppressive medications. Their underlying rheumatic disease, particularly if it is very active, may also have a negative impact on the vaccine immunogenicity.

RN: Can you tell me a bit about the methods and study design your team implemented?

JL: Given the need for data to inform public health measures and for counseling immunocompromised patients in the clinical setting, we analyzed characteristics of vaccinated people with rheumatic disease with SARS-CoV-2 infections following vaccination reported to the COVID-19 Global Rheumatology Alliance registry. As you probably know, the Global Rheumatology Alliance (GRA) is a global effort of rheumatology clinicians, researchers, and patient partners to collect data relating to the impact of COVID-19 on people with rheumatic disease. The provider registry specifically collects data from clinicians about people with rheumatic disease who were diagnosed with COVID-19.

For the purposes of this study, we defined:

• Partially vaccinated as being ≥14 days after the first dose in a 2-dose series or within 13 days of a single-dose vaccine
• Fully vaccinated as being ≥14 days after the second dose in a 2-dose series or 2 weeks after a single-dose vaccine

We looked at descriptive characteristics among the partially and fully vaccinated; fully vaccinated; and fully vaccinated & hospitalized.

Overall, we included 197 partially or fully vaccinated people with rheumatic disease who developed SARS-CoV-infection and were reported to the GRA registry.

RN: What were the results of this study?

JL: The mean age of patients included overall was 53 years and 73% were female. The majority were from North America. The most common rheumatic diseases included were rheumatoid arthritis, lupus, and psoriatic arthritis. About half had one or more comorbidities, with the most common being hypertension, obesity, lung disease, and diabetes.

The majority received mRNA vaccines: 55% received Pfizer and 16% received Moderna. Among the fully vaccinated, infection occurred a mean of 112 days after the second dose. Overall, 51 were hospitalized, 34 required non-invasive or invasive ventilation, and 9 died.

Focusing now on the 87 who were considered fully vaccinated, 22 were hospitalized. Nine people who were fully vaccinated and hospitalized were taking B cell depleting therapies such as rituximab. Three were on mycophenolate and 3 were on azathioprine. The 4 patients who required invasive ventilation subsequently died, as well as one individual on non-invasive ventilation. Three of the 5 patients who died were on B cell depleting therapies at the time of vaccination.

RN: What is the clinical significance of these results?

JL: Most fully vaccinated rheumatic disease patients with breakthrough infections were on B cell depleting therapies or mycophenolate at the time of COVID-19 diagnosis. We did not find any meaningful differences in glucocorticoid use among breakthrough infections by hospitalization status.

These findings support prior laboratory data that people on antirheumatic medications such as rituximab and mycophenolate may be at higher risk for poor outcomes with breakthrough COVID-19 infections compared to the general population.

RN: What are some additional strategies that can be implemented to help protect this patient population?

JL: Additional strategies, including additional vaccine doses and monoclonal antibody prophylaxis may be needed to protect this high-risk population. The oral antiviral drug in development also seems promising at this time.

RN: Does your team plan on doing any further research on this topic?

JL: Our registry is able to capture breakthrough infections following additional doses of vaccine, so we are able to monitor those cases. We are currently in discussion about what important clinical questions we could answer with our current infrastructure.

RN: Is there anything else you’d like our audience to know?

JL: Please visit the GRA website www.rheum-covid.org or follow us on Twitter @rheum_covid for updates.