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Background: Immunocompromised patients with primary and secondary immunodeficiencies have shown impaired responses to SARS-CoV-2 mRNA vaccines, necessitating recommendations for additional booster doses. However, longitudinal data reflecting the real-world impact of such recommendations remains limited., Methods: This study represents a two-year follow-up of the COVAXID clinical trial, where 364 of the original 539 subjects consented to participate. 355 individuals provided blood samples for evaluation of binding antibody (Ab) titers and pseudo-neutralisation capacity against both the ancestral SARS-CoV-2 strain and prevalent Omicron variants. T cell responses were assessed in a subset of these individuals. A multivariate analysis determined the correlation between Ab responses and the number of vaccine doses received, documented infection events, immunoglobulin replacement therapy (IGRT), and specific immunosuppressive drugs. The original COVAXID clinical trial was registered in EudraCT (2021-000175-37) and clinicaltrials.gov (NCT04780659)., Findings: Several of the patient groups that responded poorly to the initial primary vaccine schedule and early booster doses presented with stronger immunogenicity-related responses including binding Ab titres and pseudo-neutralisation at the 18- and 24-month sampling time point. Responses correlated positively with the number of vaccine doses and infection. The vaccine response was blunted by an immunosuppressive state due to the underlying specific disease and/or to specific immunosuppressive treatment., Interpretation: The study results highlight the importance of continuous SARS-CoV-2 vaccine booster doses in building up and sustaining Ab responses in specific immunocompromised patient populations., Funding: The present studies were supported by the European Research Council, Karolinska Institutet, Knut and Alice Wallenberg Foundation, Nordstjernan AB, Region Stockholm, and the Swedish Research Council., Competing Interests: Declaration of interests PB has received honoraria from Takeda and Novartis for educational lectures not directly relevant to this work. SM has received honoraria from Celgene/BMS, Novartis, Gilead/Kite, and DNA Prime for lectures and educational events, and as a member and/or head of data safety monitoring boards from Miltenyi and Immunicum not directly relevant to this work. CIES has received financial support from Moderna for work not directly relevant to this work. KL has received financial support from Moderna for work not directly relevant to this work. PL has received grants from Pfizer, MSD, and personal fees from Takeda, AiCuris, and OctaPharma, not directly relevant to this work. MB has served as a consultant and received honoraria from Oxford Immunotech, Gilead, MSD, BMS, Pfizer, and Mabtech, not relevant to this work. SA has received honoraria for lectures from Gilead with payment to Karolinska University Hospital and Karolinska Institutet, participated in advisory boards/consultation for Gilead and Ribocure with waived compensation not directly related to this work, and reports grants from the Swedish Research Council on COVID-19 vaccination. HGL received honoraria from Sanofi and Vycellix for consultation not relevant to this work, served on the UK-CIC Oversight Committee, led the Karolinska Institutet COVID-19 vaccine group, and is on the scientific advisory group for the International Vaccine Institute. All other authors declare no potential or actual conflict of interest to the work presented in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Immunocompromised patients have varying responses to SARS-CoV-2 mRNA vaccination. However, there is limited information available from prospective clinical trial cohorts with respect to long-term immunogenicity-related responses in these patient groups following three or four vaccine doses, and in applicable cases infection., Methods: In a real-world setting, we assessed the long-term immunogenicity-related responses in patients with primary and secondary immunodeficiencies from the prospective open-label clinical trial COVAXID. The original clinical trial protocol included two vaccine doses given on days 0 and 21, with antibody titres measured at six different timepoints over six months. The study cohort has subsequently been followed for one year with antibody responses evaluated in relation to the third and fourth vaccine dose, and in applicable cases SARS-CoV-2 infection. In total 356/539 patients were included in the extended cohort. Blood samples were analysed for binding antibody titres and neutralisation against the Spike protein for all SARS-CoV-2 variants prevailing during the study period, including Omicron subvariants. SARS-CoV-2 infections that did not require hospital care were recorded through quarterly in-person, or phone-, interviews and assessment of IgG antibody titres against SARS-CoV-2 Nucleocapsid. The original clinical trial was registered in EudraCT (2021-000175-37) and clinicaltrials.gov (NCT04780659)., Findings: The third vaccine dose significantly increased Spike IgG titres against all the SARS-CoV-2 variants analysed in all immunocompromised patient groups. Similarly, neutralisation also increased against all variants studied, except for Omicron. Omicron-specific neutralisation, however, increased after a fourth dose as well as after three doses and infection in many of the patient subgroups. Noteworthy, however, while many patient groups mounted strong serological responses after three and four vaccine doses, comparably weak responders were found among patient subgroups with specific primary immunodeficiencies and subgroups with immunosuppressive medication., Interpretation: The study identifies particularly affected patient groups in terms of development of long-term immunity among a larger group of immunocompromised patients. In particular, the results highlight poor vaccine-elicited neutralising responses towards Omicron subvariants in specific subgroups. The results provide additional knowledge of relevance for future vaccination strategies., Funding: The present studies were supported by grants from the Swedish Research Council, the Knut and Alice Wallenberg Foundation, Nordstjernan AB, Region Stockholm, and Karolinska Institutet., Competing Interests: Declaration of interests PB has received honoraria from Takeda for educational lectures not directly relevant to this work. SM has received honoraria from Celgene/BMS, Novartis, Gilead/Kite, DNA Prime for lectures and educational events and as a member and/or head of data safety monitoring boards from Miltenyi and Immunicum not directly relevant to this work. CIES has received financial support from Moderna for work not directly relevant to this work. KL has received financial support from Moderna for work not directly relevant to this work. PL has received grants from Pfizer, MSD, and personal fees from Takeda, AiCuris, and OctaPharma, not directly relevant to the submitted work. SA has received honoraria for lectures and educational events, from Gilead, AbbVie, MSD, Biogen and Netdoktor, not directly related to this work, and reports grants from the Swedish Research Council on COVID-19 vaccination. HGL received honoraria from Sanofi for consultation not relevant to this work, and has served on the UK-CIC Oversight Committee, had led the Karolinska Institutet COVID-19 vaccine group, and is on the scientific advisory group for the International Vaccine Institute not directly relevant to this work, and reports grants from Knut and Alice Wallenberg Foundation, Nordstjernan AB, Region Stockholm, and Karolinska Institutet for studies on COVID-19 and COVID-19 vaccination. All other authors declare no potential or actual conflict of interest to the work presented in this paper., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Patients with immunocompromised disorders have mainly been excluded from clinical trials of vaccination against COVID-19. Thus, the aim of this prospective clinical trial was to investigate safety and efficacy of BNT162b2 mRNA vaccination in five selected groups of immunocompromised patients and healthy controls., Methods: 539 study subjects (449 patients and 90 controls) were included. The patients had either primary (n=90), or secondary immunodeficiency disorders due to human immunodeficiency virus infection (n=90), allogeneic hematopoietic stem cell transplantation/CAR T cell therapy (n=90), solid organ transplantation (SOT) (n=89), or chronic lymphocytic leukemia (CLL) (n=90). The primary endpoint was seroconversion rate two weeks after the second dose. The secondary endpoints were safety and documented SARS-CoV-2 infection., Findings: Adverse events were generally mild, but one case of fatal suspected unexpected serious adverse reaction occurred. 72.2% of the immunocompromised patients seroconverted compared to 100% of the controls (p=0.004). Lowest seroconversion rates were found in the SOT (43.4%) and CLL (63.3%) patient groups with observed negative impact of treatment with mycophenolate mofetil and ibrutinib, respectively., Interpretation: The results showed that the mRNA BNT162b2 vaccine was safe in immunocompromised patients. Rate of seroconversion was substantially lower than in healthy controls, with a wide range of rates and antibody titres among predefined patient groups and subgroups. This clinical trial highlights the need for additional vaccine doses in certain immunocompromised patient groups to improve immunity., Funding: Knut and Alice Wallenberg Foundation, the Swedish Research Council, Nordstjernan AB, Region Stockholm, Karolinska Institutet, and organizations for PID/CLL-patients in Sweden., Competing Interests: Declaration of Competing Interest SM received honoraria via his institution from Celgene/BMS, Novartis, Gilead/Kite, DNA Prime for lectures and educational events and as a member and/or head of data safety monitoring boards from Miltenyi and Immunicum outside the submitted work. SH has been taking part in a COVID-19 Strategic Consultancy Group and a Virtual Advisory Board, not related to the current study. KL reports grants from Knut and Alice Wallenberg Foundation for this study. HGL reports grants from Knut and Alice Wallenberg Foundation and Nordstjernan AB for studies on COVID-19, and has served on the UK-CIC Oversight Committee, is leading the Karolinska Institutet COVID-19 vaccine group, and has served on several Karolinska Institutet COVID-19 Task force and Reference groups. PL reports grants from Pfizer, grants from MSD, grants and personal fees from Takeda, personal fees from AiCuris, personal fees from OctaPharma, outside the submitted work. SA has received honoraria for lectures and educational events, not related to this work, from Gilead, AbbVie, MSD, Biogen and Netdoktor, and reports grants from Knut and Alice Wallenberg Foundation for this study., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)