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Increased Risk for Breakthrough COVID-19 Infection in Vaccinated Patients with Airds

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Patients with autoimmune or inflammatory rheumatic diseases (AIRDs) may be at increased risk for breakthrough SARS-CoV-2 infection following vaccination, suggests research from two separate cohorts.

The first, presented as a late-breaking abstract at the ACR Convergence 2021 virtual meeting by Jasvinder Singh (the University of Alabama at Birmingham, USA), is based on data for 577,335 individuals from The National COVID Cohort Collaborative who had received at least one dose of vaccine against COVID-19 between December 2020 and September 2021.

The majority of patients were fully vaccinated (91%) and most received the Pfizer–BioNTech (BNT162b2) or Moderna (mRNA-1273) vaccines, at rates of 71% and 24%, respectively.

The crude prevalence of breakthrough infections occurring 14 days or more after receipt of these vaccines ranged from 35.65 to 41.46 per 1000 people among the 59,652 individuals with AIRD conditions, compared with a corresponding prevalence of 26.52 to 31.16 per 1000 people for the 490,035 individuals without rheumatic conditions.

Singh reported that the odds of breakthrough infection in the 524,624 fully vaccinated individuals were significantly increased for those with polymyositis/dermatomyositis rheumatoid arthritis (RA), vasculitis, multiple rheumatic diseases, or gout compared with non-immunosuppressed or compromised individuals, at respective odds ratios of 1.97, 1.33, 1.19, 1.17, and 1.14. This was after taking into account age, sex, race/ethnicity, study sites, number of non-rheumatic comorbid conditions, and census region.

The odds of breakthrough infection were also significantly increased by 61% with biologics and 38% with multiple AIRD medications, relative to no immunosuppressant medications, “but not for all common medications used for the treatment of AIRDs,” said Singh. He also noted that breakthrough infection risk was greater if AIRD medication exposure was within 30 days versus more than 30 days.

Singh concluded that the findings “support the use of at least a third dose of COVID-19 vaccine for immunosuppressed patients […] and continued use of other precautions.”

In a second cohort, the characteristics of 197 patients with rheumatic diseases from the COVID-19 Global Rheumatology Alliance registry who had SARS-CoV2 infection between January and September 2021 despite being partially (n=110) or fully (n=87) vaccinated were analyzed by Jean Liew (Boston University School of Medicine, Massachusetts, USA) and colleagues.

The patients had received the first or second dose of a two-dose vaccine series at least 14 days prior or at least 13 days if they had received a single-dose vaccine. The Pfizer–BioNTech and Moderna vaccines were the two most frequently received.

The mean age of the participants was 53 years and the majority of patients were women (73%), White (55%), and from North America (58%). The most common rheumatic diseases were RA (43.2%), systemic lupus erythematosus (15.4%), and psoriatic arthritis (9.6%).

In all, 51 (26.3%) of the patients were hospitalized and this included 22 (25.3%) of the fully vaccinated individuals.

Presenting the findings in a late-breaking poster session at the conference, Liew noted that “the majority of fully vaccinated individuals with breakthrough infections were on anti-metabolites or B-cell depleting therapies,” with 18% taking CD20 inhibitors and 28% glucocorticoids. And among those who were subsequently hospitalized, 10 (46%) were taking CD20 inhibitors and seven (32%) were on anti-metabolites, specifically mycophenolate.

Half of the hospitalized fully vaccinated patients needed supplemental oxygen and 18% needed invasive mechanical ventilation. Five of these patients died, out of a total of nine deaths overall.

Liew recommended that “additional risk mitigation strategies, including additional vaccine doses, monoclonal antibody treatment and possibly oral antivirals may be needed to protect this high-risk population.”

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Schedule2 Oct 2023