Infection with SARS-CoV-2, the causative agent of COVID-19, causes mild to moderate disease in most patients but carries a risk of morbidity and mortality. Seriously affected individuals manifest disorders of hemostasis and a cytokine storm, but it is not understood how these manifestations of severe COVID-19 are linked. Here, we showed that the SARS-CoV-2 Spike protein engaged the CD42b receptor to activate platelet via two distinct signaling pathways, and promoted platelet-monocyte communication through the engagement of P-selectin/PGSL-1 and CD40L/CD40, which led to pro-inflammatory cytokine production by monocytes. These results explain why hypercoagulation, monocyte activation and a cytokine storm are correlated in severely affected COVID-19 patients, and suggest a potential target for therapeutic intervention.
Tianyang Li, Yang Yang, Yongqi Li, Zhengmin Wang, Faxiang Ma, Runqi Luo, Xiaoming Xu, Guo Zhou, Jianhua Wang, Junqi Niu, Guoyue Lv, Ian N Crispe, Zhengkun Tu
Anthony T. Tan, Nina Le Bert, Antonio Bertoletti
BACKGROUND. Severe coronavirus disease 2019 (COVID-19) infection is associated with a dysregulated immune response, which can result in cytokine release syndrome and acute respiratory distress syndrome (ARDS). Patients with COVID-19–associated ARDS have elevated free serum levels of the cytokine lymphotoxin-like inducible protein that competes with glycoprotein D for herpesvirus entry on T cells (LIGHT; also known as TNFSF14). Such patients may benefit from LIGHT neutralization therapy. METHODS. This randomized, double-blind, multicenter, proof-of-concept trial enrolled adults hospitalized with COVID-19–associated pneumonia and mild to moderate ARDS. Patients received standard of care plus a single dose of CERC-002 or placebo. The primary endpoint was the proportion of patients receiving CERC-002 who remained alive and free of respiratory failure through day 28. Safety was assessed via adverse event monitoring. RESULTS. For most of the 83 enrolled patients, standard of care included systemic corticosteroids (88.0%) or remdesivir (57.8%). A higher proportion of patients remained alive and free of respiratory failure through day 28 after receiving CERC-002 (83.9%) versus placebo (64.5%; P = .044), including in patients ≥60 years (76.5% vs 47.1%, respectively; P = .042). Mortality rates were 7.7% (CERC-002) and 14.3% (placebo) at day 28 and 10.8% and 22.5%, respectively, at day 60. Treatment-emergent adverse events were less frequent with CERC-002 than placebo. CONCLUSION. For patients with COVID-19–associated ARDS, adding CERC-002 to standard of care treatment reduces LIGHT levels and might reduce the risk of respiratory failure and death. TRIAL REGISTRATION. ClinicalTrials.gov NCT04412057. FUNDING. Avalo Therapeutics (formerly Cerecor, Inc.)
David S. Perlin, Garry A. Neil, Colleen Anderson, Inbal Zafir-Lavie, Shane Raines, Carl F. Ware, H. Jeffrey Wilkins
Dear Editor, We read with interest the article by Li and colleagues on the association between ACE inhibitors/angiotensin receptor blockers (ACE-I/ARB) use and in-hospital mortality among COVID-19 patients (1). The authors concluded that the use of ARB was associated with a significant reduction in in-hospital mortality among African American (AA) patients but not non-AA patients. However, we believe this conclusion is not per statistical principles and potentially misguiding readers. As noted by Altman and Bland (2), statistical analysis should be targeted to the clinical question: is the association between ARB use and in-hospital mortality different between AA and non-AA patients? To answer this question, one should directly compare the estimates (interaction test) (2), performed and reported by the authors. Here we argue that they did not accurately interpret this analysis. The authors showed an odds ratio (OR) of 0.196 (95% confidence interval [CI], 0.074 – 0.516) in the AA population and an OR of 0.687 (95% CI, 0.427 – 1.106) in the non-AA population. Accordingly, the interaction term was non-significant (95% CI, 0.185–1.292; P = 0.149).[1] As the authors stated that “Statistical significance was defined as a 2-sided P value less than 0.05”, the correct interpretation of this result would be: the association of ACEi/ARB use and in-hospital mortality was not significantly different between these two populations (2). In contrast to this interpretation, the authors concluded that the association was only present in the AA population, which is not compatible with their analysis. The potential association between ACEi/ARB use and COVID-19 in-hospital mortality is of great interest to the medical community. Further, the ability to provide reliable subgroup analyses is vital in clinical decision-making (3). Interaction analyses are essential to answer the clinically relevant question of whether a specific subgroup of patients can benefit more from an intervention. However, we believe the correct interpretation of these results does not support the author’s conclusion.
Arthur M. Albuquerque, Carolina B. Santolia, Ashish Verma
Dear Editor, We appreciate Albuquerque, et al.’s interest in our paper [1,2], who raised the concern that we did not accurately interpret the interaction test, noting that “one should directly compare the estimates (interaction test)” and “the authors concluded that the association was only present in the AA population, which is not compatible with their analysis.” We would like to clarify that our primary clinical question is whether ACE-I/ARB use is associated with the COVID-19 outcomes in each sub-group. We used stratified analysis to answer the question because when race/ethnicity serves as a non-specific proxy for numerous (confounding) factors, these can be (partially) controlled for through stratification [3]. Joint modeling of multiple groups is often used to gain power, but one needs to assume certain coherent distributions across different groups, which is not always true. Additionally, testing the interaction term is to assess association heterogeneity between groups, but it does not directly address whether the treatment is effective in each group. Specifically, we would like to elaborate on the following: 1) Our conclusion: “the use of ARB was associated with a significant reduction in in-hospital mortality among African American (AA) patients but not non-AA patients” was based on results from the stratified analysis. We reported that ARB in-hospital use was associated with reduced mortality in the AA stratum (OR=0.196; 95%CI:0.074-0.516; P=0.001) with statistical significance. On the other hand, the association in the non-AA stratum is not statistically significant (OR=0.687; 95%CI:0.427-1.106; P=0.122). As stated previously, our primary objective is to assess whether ACE-I/ARB use among AA patients is associated with COVID-19 mortality, rather than the difference between AA and non-AA patients. We were also aware that the estimated ORs across different stratum were not comparable as noted in [4-6]. 2) We performed the joint modeling of AA and non-AA patients as suggested by [6]. Here, ARB in-hospital use was associated with reduced mortality in entire study population (OR=0.560; 95%CI:0.371-0.846; P=0.006). The interaction term added to the model was not significant (95%CI:0.185-1.292; P=0.149). Interpreting interaction terms in logistic regression is complex and a significant interaction term in log-odds may not be significant in difference-in-differences for probability[7]. Furthermore, the assumption of the additive effects and imbalanced sample sizes could impact the inference. We believe these results and the interpretation are appropriate. We acknowledge that there are cases where comparing the interaction term in greater detail would be an important next step for understanding the association between COVID-19 mortality and race/ethnicity.
Shilong Li, Pei Wang, Li Li
Memory B cells (MBC) can provide a recall response able to supplement waning antibodies with an affinity-matured response better able to neutralise variant viruses. We studied a cohort of elderly care home residents and younger staff (median age 87yrs and 56yrs respectively) who had survived COVID-19 outbreaks with only mild/asymptomatic infection. The cohort was selected to enrich for a high proportion who had lost neutralising antibodies (nAb), to specifically investigate the reserve immunity from SARS-CoV-2-specific MBC in this setting. Class-switched spike and RBD-tetramer-binding MBC persisted five months post-mild/asymptomatic SARS-CoV-2 infection, irrespective of age. The majority of spike/RBD-specific MBC had a classical phenotype but activated memory B cells, that may indicate ongoing antigenic stimulation or inflammation, were expanded in the elderly. Spike/RBD-specific MBC remained detectable in the majority who had lost nAb, although at lower frequencies and with a reduced IgG/IgA isotype ratio. Functional spike/S1/RBD-specific recall was also detectable by ELISpot in some who had lost nAb, but was significantly impaired in the elderly. Our findings demonstrate a reserve of SARS-CoV-2-specific MBC persists beyond loss of nAb, but highlight the need for careful monitoring of functional defects in spike/RBD-specific B cell immunity in the elderly.
Anna Jeffery-Smith, Alice R. Burton, Sabela Lens, Chloe Rees-Spear, Jessica Davies, Monika Patel, Robin Gopal, Luke Muir, Felicity Aiano, Katie J. Doores, J. Yimmy Chow, Shamez N. Ladhani, Maria Zambon, Laura E. McCoy, Mala K. Maini.
BACKGROUND. Antibody-based strategies for COVID-19 have shown promise in prevention and treatment of early disease. COVID-19 convalescent plasma (CCP) has been widely used but results from randomized trials supporting its benefit in hospitalized patients with pneumonia are limited. Here, we assess the efficacy of CCP in severely ill, hospitalized adults with COVID-19 pneumonia. METHODS. We performed a randomized control trial (PennCCP2), in 80 adults hospitalized with COVID-19 pneumonia, comparing up to 2 units of locally-sourced CCP plus standard care vs. standard care alone. The primary efficacy endpoint was comparison of a clinical severity score. Key secondary outcomes include 14- and 28-day mortality, 14- and 28-day WHO8 score, duration of supplemental oxygenation or mechanical ventilation, respiratory SARS-CoV-2 RNA, and anti-SARS-CoV-2 antibodies. RESULTS. 80 hospitalized adults with confirmed COVID-19 pneumonia were enrolled at median day 6 of symptoms and day 1 of hospitalization; 60% were anti-SARS-CoV-2 antibody seronegative. Participants had a median of 3 comorbidities, including risk factors for severe COVID-19 and immunosuppression. CCP treatment was safe and conferred significant benefit by clinical severity score (MED (IQR) 10 (5.5,30) vs. 7 (2.75,12.25), p=0.037) and 28-day mortality (n=10, 26% vs. n=2, 5%; p=0.013). All other pre-specified outcome measures showed weak evidence towards benefit of CCP. CONCLUSIONS. Two units of locally-sourced CCP administered early in hospitalization to majority seronegative participants conferred a significant benefit in clinical severity score and 28-day mortality. Results suggest CCP may benefit select populations, especially those with comorbidities who are treated early. TRIAL REGISTRATION. ClinicalTrials.gov: NCT04397757 FUNDING. University of Pennsylvania.
Katharine J. Bar, Pamela A. Shaw, Grace H. Choi, Nicole Aqui, Andrew Fesnak, Jasper B. Yang, Haideliza Soto-Calderon, Lizette Grajales, Julie Starr, Michelle Andronov, Miranda Mastellone, Chigozie Amonu, Geoff Feret, Maureen DeMarshall, Marie Buchanan, Maria Caturla, James Gordon, Alan Wanicur, M. Alexandra Monroy, Felicity Mampe, Emily Lindemuth, Sigrid Gouma, Anne M. Mullin, Holly Barilla, Anastasiya Pronina, Leah Irwin, Raeann Thomas, Risa A. Eichinger, Faye Demuth, Eline T. Luning Prak, Jose L. Pascual, William R. Short, Michal A. Elovitz, Jillian Baron, Nuala J. Meyer, Kathleen O. Degnan, Ian Frank, Scott E. Hensley, Donald L. Siegel, Pablo Tebas
To explore how the immune system controls clearance of SARS-CoV-2, we used a single-cell, mass cytometry–based proteomics platform to profile the immune systems of 21 patients who had recovered from SARS-CoV-2 infection without need for admission to an intensive care unit or for mechanical ventilation. We focused on receptors involved in interactions between immune cells and virus-infected cells. We found that the diversity of receptor repertoires on natural killer (NK) cells was negatively correlated with the viral clearance rate. In addition, NK subsets expressing the receptor DNAM1 were increased in patients who more rapidly recovered from infection. Ex vivo functional studies revealed that NK subpopulations with high DNAM1 expression had cytolytic activities in response to target cell stimulation. We also found that SARS-CoV-2 infection induced the expression of CD155 and nectin-4, ligands of DNAM1 and its paired coinhibitory receptor TIGIT, which counterbalanced the cytolytic activities of NK cells. Collectively, our results link the cytolytic immune responses of NK cells to the clearance of SARS-CoV-2 and show that the DNAM1 pathway modulates host-pathogen interactions during SARS-CoV-2 infection.
Wan-Chen Hsieh, En-Yu Lai, Yu-Ting Liu, Yi-Fu Wang, Yi-Shiuan Tzeng, Lu Cui, Yun-Ju Lai, Hsiang-Chi Huang, Jia-Hsin Huang, Hung-Chih Ni, Dong-Yan Tsai, Jian-Jong Liang, Chun-Che Liao, Ya-Ting Lu, Laurence Jiang, Ming-Tsan Liu, Jann-Tay Wang, Sui-Yuan Chang, Chung-Yu Chen, Hsing-Chen Tsai, Yao-Ming Chang, Gerlinde Wernig, Chia-Wei Li, Kuo-I Lin, Yi-Ling Lin, Huai-Kuang Tsai, Yen-Tsung Huang, Shih-Yu Chen
Although Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) vaccines have shown efficacy against SARS-CoV-2, it is unknown if coronavirus vaccines can also protect against other coronaviruses that may infect humans in the future. Here, we show that coronavirus vaccines elicit cross-protective immune responses against heterologous coronaviruses. In particular, we show that a Severe Acute Respiratory Syndrome Coronavirus 1 (SARS-CoV-1) vaccine developed in 2004 and known to protect against SARS-CoV-1, confers robust heterologous protection against SARS-CoV-2 in mice. Similarly, prior coronavirus infections conferred heterologous protection against distinct coronaviruses. Cross-reactive immunity was also reported in Coronavirus Disease 2019 (COVID-19) patients and humans who received SARS-CoV-2 vaccines, and transfer of plasma from these individuals into mice improved protection against coronavirus challenges. These findings provide the first demonstration that coronavirus vaccines (and prior coronavirus infections) can confer broad protection against heterologous coronaviruses, providing a rationale for universal coronavirus vaccines.
Tanushree Dangi, Nicole Palacio, Sarah Sanchez, Mincheol Park, Jake Class, Lavanya Visvabharathy, Thomas Ciucci, Igor J. Koralnik, Justin M. Richner, Pablo Penaloza-MacMaster
BACKGROUND. SARS-CoV-2 infection in pregnancy is associated with a higher risk of pregnancy-related complications and neonatal respiratory distress and hospitalization. Effectiveness of SARS-CoV-2 vaccines in pregnant women is not known. METHODS. All women with confirmed pregnancy who presented to the national referral hospital in Qatar between December 20, 2020 and May 30, 2021 with at least one SARS-CoV-2 test and not testing prior to pregnancy were included. We determined the vaccine effectiveness of mRNA vaccines in preventing confirmed SARS-CoV-2 infection during pregnancy using both cohort and test-negative case-control designs. Analyses were adjusted for age group, nationality, and gestational age. RESULTS. Among 4,534 pregnant women, there were 407 vaccinated and unvaccinated women in the matched cohort analysis. Vaccine effectiveness was 87.6% (95%CI 44.1-97.2%) ≥ 14 days after the second dose. There were 386 test-positive and 834 matched women in the test-negative case-control analysis. Vaccine effectiveness was 86.8% (95%CI 47.5-98.5) ≥ 14 days after the second dose. Adjustment for age, nationality and gestational age yielded similar results for both designs. In the test-negative analysis, vaccine effectiveness ≥ 14 days after the first dose but before the second dose was 40.8% (95% CI 0.0-80.4). Of the 386 test-positive pregnant women, 74 were Alpha variant, 163 were Beta variant, and 156 were variants of unknown status. There were nine severe/critical disease cases, and no deaths in the PCR-positive pregnant women, all among unvaccinated. CONCLUSIONS. The mRNA vaccines provide high level of protection against documented SARS-CoV-2 infection, which supports including pregnant women in vaccination campaigns.
Adeel A. Butt, Hiam Chemaitelly, Abdullatif Al Khal, Peter V Coyle, Huda Saleh, Anvar Kaleeckal, Ali N. Latif, Roberto Bertollini, Abdul Badi Abou-Samra, Laith J. Abu-Raddad
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