Should COVID-19 Vaccination be Delayed in Survivors with Serum Antibodies?

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If you’ve had COVID-19, the one uniform recommendation from CDC is to wait at least 90 days if you’ve received treatment with monoclonal antibodies or convalescent plasma.  For other COVID-19 survivors, some Medical Centers recommend receiving the vaccine within weeks after infection while others suggest waiting up to several months.

Yet, there remains a national shortage of the currently approved (Moderna and Pfizer) vaccines.  This issue will hopefully be resolved later this spring pending Johnson & Johnson’s application for emergency FDA approval using their single dose vaccine; they expect to supply 100 million U.S. doses by June.  The J&J vaccine looks especially promising not only because of its single dose, but also because of storage capability (simple refrigeration) and vaccine stability (at least 3 months).  Most impressive however, is the ~85% reduction in severe COVID-19 cases (hospitalization and COVID related deaths). Compared to earlier vaccination trials, J&J’s Phase III study included more severe COVID-19 cases with benefits extending beyond the U.S. to the U.K. and most notably, South Africa, where COVID-19 variants have raised concern re: viral transmission and vaccine effectiveness.  In other words, until the J&J vaccine is approved and ready for mass distribution, the overall supply chain is hampered. Hence the question….

Should COVID-19 Vaccination be Delayed in Survivors with Serum Antibodies?

A recently well-designed study (https://science.sciencemag.org/content/early/2021/01/06/science.abf4063) is consistent with this idea because they found immunity to persist in 95% of affected individuals for at least 5-8 months following infection.  Another study of 3 million individuals that had COVID-19 antibody testing (currently in preprint; https://www.medrxiv.org/content/10.1101/2020.12.18.20248336v1) found that only 3 out of every 1000 became reinfected 90 days or later after the initial infection as compared to 3 out of every 100 who tested positive for the first time.

The real question in the setting of current vaccine shortages, is how can we best prioritize vaccination for those who had COVID-19 more than 3 months ago?  A logical approach would be to check for antibodies using a reliable, commercially available test (such as performed by Quest or LabCorp).  This past week, I saw a patient who experienced COVID 4 months ago, for which hospitalization and high-flow oxygen treatment was required.  Yet on antibody testing this week, we were surprised to find out that he tested antibody negative.  He is now on the vaccination list.

Owing to current vaccine shortages, the CDC should consider recommending antibody testing for COVID-19 survivors beginning 3 months after initial infection with repeat testing monthly (or bimonthly).  If serum antibodies continue to be present, vaccination should be delayed in order to permit others without natural immunity, to move ahead of the line.  With more than 25 million COVID-19 survivors in the U.S. (whose rates of reinfection are exceedingly uncommon), why not prioritize vaccination to the millions of high risk men and women who do not have a known history of COVID-19?   Having recently recovered from COVID-19, this is how I plan to proceed.

Michael Miller, MD is Professor of Medicine, Epidemiology & Public Health at the University of Maryland School of Medicine in Baltimore, MD.

 

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