Intradermal COVID-19 Vaccination in the Immunocompromised

Immunogenicity, Safety and Tolerability of Intradermal COVID-19 Vaccination Strategy in Immunocompromised Patients: a Prospective, Randomized Trial.

COVID-19 is an infectious disease caused by SARS-CoV-2 virus, causing millions of deaths around the globe since the beginning of the pandemic. COVID-19 vaccination was proven to be effective at reducing both mortality and development of severe COVID-19 after infection. Vaccine-elicited protection is particularly important for immunocompromised patients, as they are more susceptible to infections with their defective immune response, for instance, previous review had suggested that patients with malignancies and recipients of solid organ transplants may be at increased risk of developing severe COVID-19 disease and even death.

To further complicate the scenario, there are two obstacles: firstly, immunocompromised individuals may have suboptimal response from vaccinations, as studies have shown that recipients of solid organ transplant have suboptimal or even are seronegative after the fourth dose booster vaccination . Secondly, with constant mutation of the SARS-CoV-2 viruses, new variants evolve over time, leading to reduction in vaccine efficacy and breakthrough infection in healthy individuals. Therefore, novel vaccine strategy should be considered to enhance the vaccine response in these immunocompromised individuals.

In this study, intradermal injection instead of intramuscular injection for vaccine delivery is proposed, as we have observed improved immunogenicity and few adverse events from our experience of influenza vaccination. Our study aims to evaluate the immunogenicity, safety and tolerability of intradermal COVID-19 vaccination in immunocompromised patients.

Study Overview

• Status: Recruiting
• Conditions: Immunocompromised Patients; Intradermal Covid-19 Vaccine; Immungenicity and Safety; Randomized Trial
• Intervention / Treatment: Biological: ID BNT162b2 vaccine; Biological: IM BNT162b2 vaccine

Detailed Description

This is a randomized controlled trial performed in the Hong Kong West Cluster Hospitals under the Hospital Authority in Hong Kong. Immunocompromised individuals who completed two doses of COVID-19 vaccine are recruited and received a booster dose of BNT162b2 vaccine. Recruited individuals include patients who received solid organ transplant (SOT), patients who received stem cell or bone marrow transplant (SCBOT), patients who are undergoing chemotherapy or immunotherapy (COI) and patients who are receiving biologics therapy (BI). The study was approved by the institutional review board of the University of Hong Kong and Hospital Authority (UW 21-214).

After recruitment, participants are randomized to receive either one 30-μg dose (0.3 mL) of intramuscular BNT162b2 booster dose vaccination or one 30-μg dose (0.3 mL) of intradermal BNT162b2 booster dose vaccination. In addition, participants are further subdivided into different groups based on the priming vaccine they received. Participant's blood samples are collected before booster vaccination (baseline), 28 days after booster dose, 3 months after booster dose and 6 months after booster dose vaccination. Blood samples collected are tested with live virus microneutralization assay (vMN), performed in the Biosafety level 3 facility of HKU to determine the level of neutralizing antibody in sera. Serial 2-fold dilutions of serum starting from 1:10 are incubated with 100 median tissue culture infectious doses (TCID50) of ancestral strain SARS-CoV-2, BA.1, BA.5.2, and XBB for 1.5 h at 37 °C (7). Then, a serum-virus mixture is added to VeroE6/TMPRSS2 cells (JCRB Cell Bank Catalogue no. JCRB1819) on 96-well plates (8). After 72 h of incubation at 37 °C and 5% CO2, the cytopathic effect (CPE) is examined and the antibody titre is determined by the highest dilution with 50% inhibition of CPE. In addition, A Surrogate SARS-CoV-2 neutralizing antibody (NAb) is performed to determine the level of NAb in serum sample. Testing is performed using a one-step competitive chemiluminescence immunoassay on the iFlash 1800 analyzer, as described in our previous study.

To assess the safety and adverse events of the vaccination, participants are asked to record any adverse events for 4 weeks after the booster dose.

The primary endpoint of this study is the vMN geometric mean titre (GMT) against WT, BA.1, BA.5.2 and XBB. The secondary endpoints are GMT fold increase and safety. Severe adverse events (SAEs) are defined as death, disabling or life-threatening conditions related to vaccine; Adverse events (AE) include fever (>38 °C), chills, headache, tiredness, nausea, vomit, diarrhea, muscle pain, joint pain, facial dropping, skin rash or injection site reactions (pain, redness, swelling, ecchymoses, itching).

• Study Type: Interventional
• Enrollment (Anticipated): 130
• Phase: Phase 2

Contacts and Locations

• Study Contact: Name: Ivan FN Hung, MD; Phone Number: 22553424; Email: ivanhung@hku.hk
• Study Contact Backup: Name: Ricky Zhang, PhD; Phone Number: 22554049; Email: zhangrq@hku.hk

Study Locations

• Hong Kong
  • Hong Kong, Hong Kong, 852
    • Recruiting
    • Queen Mary Hospital
    • Contact: Ivan FN Hung, MD; Phone Number: 22553424; Email: ivanhung@hku.hk
    • Contact: Ricky Zhang, PhD; Phone Number: 22554049; Email: zhangrq@hku.hk

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. Recruited subjects include adult subjects ≥18 years

2. Immunocompromised subjects as defined by the following.

   1. Patients who have undergone solid organ or stem cell transplantation and on immunosuppressive medication.
   2. Patients who are on chemotherapy, biologics or other immunosuppressive therapy.
   3. Patients who are on high-dose corticosteroid (prednisolone 0.5mg/kg daily or equivalent)
3. Negative IgG antibody response against Covid19 14 days after the second dose of Covid19 vaccination.
4. All subjects have to give written informed consent.
5. Subjects must be available to complete the study and comply with study procedures. Willingness to allow for serum samples to be stored beyond the study period, for potential additional future testing to better characterize immune response

Exclusion Criteria:

1. Inability to comprehend and to follow all required study procedures.
2. Have a recent history (documented, confirmed or suspected) of a flu-like disease within a week of vaccination.
3. Have a known allergy to polyethylene glycol (PEG) or other components of the study vaccines, or history of any anaphylaxis, serious vaccine reactions, to any excipients.
4. Have known active human immunodeficiency virus (HIV) infection.
5. Received an experimental agent (vaccine, drug, biologic, device, blood product, or medication) within 1 month prior to vaccination in this study or expect to receive an experimental agent during this study. Unwilling to refuse participation in another clinical study through the end of this study.
6. Tympanic temperature ≥ 38°C within 3 days of intended study vaccination
7. Have a history of alcohol or drug abuse in the last 5 years.
8. Have any condition that the investigator believes may interfere with successful completion of the study

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Intradermal; One dose of 30ug (0.3mL) intradermal BNT162b2	Biological: ID BNT162b2 vaccine; intradermal BNT162b2 vaccine
Active Comparator: Intramuscular; One dose of 30ug (0.3mL) intramuscular BNT162b2	Biological: IM BNT162b2 vaccine; intramuscular BNT162b2 vaccine

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
vMN geometric mean titre	microneutralization GMT	day 28 after vaccination

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
vMN geometric meant titre fold increase	microneutralization fold increase	day 28 after vaccination
Safety of the intradermal vaccination	adverse events	day 28 after vaccination

Collaborators and Investigators

• Sponsor: The University of Hong Kong
• Investigators: Principal Investigator: Ivan FN Hung, MD, The University of Hong Kong

Study record dates

Study Major Dates

• Study Start (Actual): April 1, 2021
• Primary Completion (Anticipated): March 31, 2023
• Study Completion (Anticipated): June 30, 2023

Study Registration Dates

• First Submitted: February 19, 2023
• First Submitted That Met QC Criteria: February 19, 2023
• First Posted (Estimate): February 21, 2023

Study Record Updates

• Last Update Posted (Estimate): February 21, 2023
• Last Update Submitted That Met QC Criteria: February 19, 2023
• Last Verified: February 1, 2023

More Information

Terms related to this study

• Keywords: safety; vaccine; Covid-19; immunogenicity; intradermal; immunocompromised
• Additional Relevant MeSH Terms: Coronavirus Infections; Coronaviridae Infections; Nidovirales Infections; RNA Virus Infections; Virus Diseases; Infections; Respiratory Tract Infections; Respiratory Tract Diseases; Pneumonia, Viral; Pneumonia; Lung Diseases; COVID-19; Physiological Effects of Drugs; Immunologic Factors; Vaccines
• Other Study ID Numbers: UW 21-214

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: Anonymous patient's immunogenicity and safety data
• IPD Sharing Time Frame: 12 months
• IPD Sharing Access Criteria: email to the principal investigator
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; CSR

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No