Immunological and clinical efficacy of COVID-19 vaccines in immunocompromised populations: a systematic review

Abstract

Background: Available data show that COVID-19 vaccines may be less effective in immunocompromised populations, who are at increased risk of severe COVID-19.

Objectives: We conducted a systematic review of literature to assess immunogenicity, efficacy and effectiveness of COVID-19 vaccines in immunocompromised populations.

Data sources: We searched Medline and Embase databases.

Study eligibility criteria, patients, interventions: We included studies of COVID-19 vaccines after complete vaccination in immunocompromised patients until 31 August 2021. Studies with <10 patients, safety data only and case series of breakthrough infections were excluded.

Methods: Risk of bias was assessed via the tool developed by the National Institutes of Health on interventional and observational studies. Immunogenicity was assessed through non-response rate defined as no anti-SARS-CoV-2 spike protein antibodies, efficacy and effectiveness by the relative reduction in risk of SARS-CoV-2 infection or COVID-19. We collected factors associated with the risk of non-response. We presented collected data by immunosuppression type.

Results: We screened 5917 results, included 162 studies. There were 157 on immunogenicity in 25 209 participants, including 7835 cancer or haematological malignancy patients (31.1%), 6302 patients on dialysis (25.0%), 5974 solid organ transplant recipients (23.7%) and 4680 immune-mediated disease patients (18.6%). Proportion of non-responders seemed higher among solid organ transplant recipients (range 18-100%) and patients with haematological malignancy (range 14-61%), and lower in patients with cancer (range 2-36%) and patients on dialysis (range 2-30%). Risk factors for non-response included older age, use of corticosteroids, immunosuppressive or anti-CD20 agent. Ten studies evaluated immunogenicity of an additional dose. Five studies evaluated vaccine efficacy or effectiveness: three on SARS-CoV-2 infection (range 71-81%), one on COVID-19-related hospitalization (62.9%), one had a too small sample size.

Conclusions: This systematic review highlights the risk of low immunogenicity of COVID-19 vaccines in immunocompromised populations, especially solid organ transplant recipients and patients with haematological malignancy. Despite lack of vaccine effectiveness data, enhanced vaccine regimens may be necessary.

Keywords: COVID-19; Cancer; Dialysis; Effectiveness; Efficacy; Immunogenicity; SARS-CoV-2 immunocompromised; Solid organ transplant; Vaccine.

Fig. 1

Flow chart of study selection.

Fig. 2

Rates of non-response in patients with haematological malignancy (A) and cancer (B). Grey dashes represent the 95% CI. The studies are ordered by population size. Only studies with subgroup size n ≥ 10 are represented.

Fig. 3

Rates of non-response in patients on dialysis. We reported the latest endpoint within 30 days following vaccine completion if several endpoints were available. We reported the outcome following second dose in the studies reporting post-vaccine immunity following an additional dose. The studies are ordered by population size. Grey dashes represent the 95% CI. Only studies with subgroup size n ≥ 10 are represented. ∗Speer et al. [128].

Fig. 4

Rates of non-response in solid organ transplant recipients. We reported the latest endpoint within 30 days following vaccine completion if several endpoints were available. We reported the outcome following second dose in the studies reporting post-vaccine immunity following an additional dose. Grey dashes represent the 95% CI. The studies are ordered by population size. ∗Hall et al. [72]. ∗Boyarsky et al. [29].

Fig. 5

Rates of non-response in solid organ transplant recipients: kidney (A), liver (B), heart (C) and lung (D). We reported the latest endpoint within 30 days following vaccine completion if several endpoints were available. We reported the outcome following second dose in the studies reporting post-vaccine immunity following an additional dose. Grey dashes represent the 95% CI. The studies are ordered by population size. Only studies with subgroup size n ≥ 10 are represented. ∗Hall et al. [72].

Fig. 6

Rates of non-response in patients with autoimmune inflammatory diseases. Grey dashes represent the 95% CI. The studies are ordered by population size.