PONE-D-21-33288Association between history of HBV vaccine response and neutralizing antibody response to the BioNTech/Pfizer’s BNT162b2 mRNA SARS-CoV-2 vaccine among healthcare workers in Japan:A prospective observational studyPLOS ONE

Dear Dr. Ukimura,

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Additional Editor Comments:

This is a study of COVID-19  and HBV vaccine responses in health care workers in Japan.

The study question is an important one and worthy of investigation.

The timing of HBV vaccination is unclear.  The authors should provide more information about when HBV vaccination and boosters were given relative to COVID-19 vaccinations.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This manuscript summarizes a laboratory-based study assessing the immune response to the BioNTech/Pfizer’s BNT162b2 mRNA SARS-CoV-2 vaccine, comparing health care workers (HCW) who had a weak or non-response to the hepatitis B vaccine (HBV) to those who had a strong/normal response. HCWs who had a weak response to the HBV vaccine (i.e., HBs-Ab titer < 10 mlU/mL) were more likely to have a non-neutralizing S-protein antibody response to the first BNT162b2 mRNA SARS-CoV-2 vaccine compared to those who had a normal response to the HBV vaccine (i.e., HBs-Ab titer > 100 mIU/mL). This difference diminished to non-significance after the second vaccine. The researchers acknowledge the study is not novel, however the findings are useful to build knowledge on risk of non-response to the BNT162b2 mRNA SARS-CoV-2 vaccine. For example, with vaccine in short supply in some countries, decision-makers may utilize such study results to priority who obtains a second dose first. Additionally, as the authors stated, prior vaccine response may be informative on whose protective immunity against SARS-CoV-2 wanes faster.

The odds ratios overestimate the relative risks. Thus, relative risks need to be estimated directly.

Minor comments:

71 Consider changing “promoting the scientific” to “prompting the medical”

81 Consider adding the word “male” before “gender” given the factors are specific to higher risk.

86 Delete “to”

87 Instead of “no previous studies” maybe say there is a “dearth on studies” as no studies would be difficult to document

given the vast among of publications on SARS-CoV-2.

How many HCWs were invited into the study?

147 “protein antibodies and six were unaware of their previous COVID-19 infection” needs editing. This sentence is unclear.

167 The comma after “302” needs to be removed.

191 “in our study population was slightly higher in our study” needs to be edited.

214 “We were not able to adjust for these potential confounders in our analysis as 12% (n=117/968) responded anonymously to the survey…” While it is unlikely that it will change the final conclusions of the study, you could assess confounding based on a sub analysis of those HCWs whose surveys can be linked to laboratory data.

Table 1 is difficult to read. Consider landscape (that is, rotating the page) so the information in table cells do not wrap around. Also, column labels are needed.

Table 2 (Analysis): The odds ratios overestimate the relative risks. Thus, relative risks need to be estimated directly.

Unavailability of HCW data is acceptable due to privacy concerns. The authors state that analyses can be conducted to facilitate providing information from the study to researchers.

Reviewer #2: This manuscript reports on an interesting study aimed at finding a way to predict which individuals may be at-risk for a limited response to SARS-CoV-2 mRNA vaccination by using data related to HBV vaccination response history. At a stage in the pandemic where COVID-19 vaccine boosting is being considered and durability of vaccine response is uncertain, such an approach is intriguing. There is a major limitation to the analysis and interpretation of the results, however, as the threshold for determining “neutralizing” antibodies, which the authors discuss in great detail, is of unclear origin. This must be resolved, along with a response to the other comments noted below, before this reviewer would deem this manuscript acceptable for publication.

Major Comments:

1. In the referenced article by Rubio-Acero et al., the authors find that the Roche Elecsys Anti-SARS-CoV-2 S [Ro-RBD-Ig-quant]) had a different threshold than used in the manuscript under review. From the article’s conclusion, which is supported by the results (Table 4 in Rubio-Acero et al): “For example, raw values above 28.67 U/mL for Ro-RBD-Ig-quant and above 49.78 U/mL for EI-S1-IgGquant, respectively, predicted virus neutralization > 1:5 in 95% of cases. We may hypothesize that when the value of the quantitative tests is above the predictive value (e.g., 95%), there is little benefit in performing NT and that this could act as a surrogate marker for neutralizing titers, e.g., after mass vaccinations or post-infection.” This paper also uses a surrogate test for neutralization (GS-cPass), but the threshold for the Ro-RBD-Ig-quant corresponding to ≥ 20% is ≥ 6.99. Furthermore, in reviewing the other reference cited for this cutoff, the Elecsys package insert, the reviewer could not find any indication of an appropriate cutoff value correlating with neutralizing antibody levels. Instead, the package insert states: “The results of this semi quantitative test should not be interpreted as an indication or degree of immunity or protection from reinfection” and “The clinical applicability of semi quantitative results is currently unknown and cannot be interpreted as an indication or degree of immunity nor protection from reinfection, nor compared to other SARS CoV 2 antibody assays.” Thus, it is unclear why a cut-off of 15 U/mL was used to define neutralizing immunity within this study and it seems inappropriate to state “according to manufacturer information” (line 119) in reference to any threshold used to suggest neutralizing antibody response. Clarifying this threshold is critical for the interpretation of the results, particularly those reported in line 164-170, and for the overall conclusion of the manuscript. It is unclear if a larger proportion of the weak or normal HBV vaccine responders would have not achieved a “neutralizing” threshold if a higher cutoff was used.

2. It is important to note the limitations of the assay used for this analysis. Specifically, the manufacturer states that “The performance of this test has not been established in individuals that have received a COVID 19 vaccine. The clinical significance of a positive or negative antibody result following COVID 19 vaccination has not been established, and the result from this test should not be interpreted as an indication or degree of protection from infection after vaccination.” While the reviewer understands that EUA-platforms are often evaluated in-house for off-label usage, it is important for readers to be aware of this noted limitation within the text of the article.

3. The use of the word “neutralizing” to describe the spike protein receptor binding domain (line 112) is inconsistent with the platform package insert and should be deleted, as it suggest the assay itself detects neutralizing antibodies

4. In line 117, and then later throughout when referring to the antibody results, the terms “positive” and “negative” should be used to be consistent with the manufacturer interpretation language found within the package insert

Minor Comments:

1. Test platform appears to be spelled incorrectly in some locations (line 114, 116)

2. “of” should be “or” in line 131… “three or more”

3. Why weren’t the 11 patients with reactive antibodies prior to vaccination excluded from the analysis? It seems that inclusion of these data in the analysis could confound the interpretation, specifically as it relates to predicting which individuals will or will not mount a strong response to vaccination based on HBV vaccine response (not based on HBV vaccine response + history of previous infection)

4. Maintain units when describing the semi-quantitative results, as use of the word “titer” along with a number without units may be confusing to readers (example: line 153 where only 56.1 is listed as the result)

5. Phrasing of lines 158-159 inconsistent with disease vs. pathogen (ie. “no one reported having COVID-19” or “no one reported being infected with SARS-CoV-2”)

6. For lines 170-175, please clarify what summary statistics is being used for the group comparison (median?)

7. As the authors note, the occupational health environment in Japan offers screening and additional dose series to ensure antibody levels reach the 10 mIU/mL cut-off. In what way may this bias the definition of “non-responders” compared to other settings? Is it possible to identify the cohort of individuals that did not initially respond to HBV vaccination, but ultimately achieved a weak response through additional dose series? This group may still be considered a “non-responder” in other healthcare settings where antibody level testing and additional dose series are not conducted. Some expanded discussion within lines 194-209 may help relate this study to other settings where the occupational health environment is different.

Reviewer #3: This is cohort analysis from Japan, where HBV vaccination is a strong part of public health. The investigators, through review of medical records of health workers getting COVID vaccine, identified an association between non-response to HBV vaccine and suboptimal response to first dose of COVID vaccine (the association didn’t hold after additional COVID vaccine doses). This is nice finding and is supported by what we know about vaccine efficacy. The implications of the finding could be more clearly stated to give the paper more impact.

Background:

• Scientific premise is good

• Could better explain why the focus on HBV vaccine response; people receive a wide range of vaccines. I think the reason is here is that its more common in clinical practice to check anti-HBs compared to antibodies to other vaccine-preventable infections (like measles, tetanus, etc.) . I suggest better justify the focus on HBV as part of background of the paper.

Methods:

• If the anti-HBs was low was HBV vaccine given together with COVID vaccine. I’m not aware of much data on co-administration of other vaccines with COVID. How was this handled in the program (the need to give COVID vaccine and HBV vaccine in weak/non reponders?

Results:

• Before presenting that non/weak responders to HBV vaccine were less likely to respond to COVID vaccine, please describe the # and % of non/weak HBV responders…so we have that context. Also, did they have a history of non/weak response in the past or was this based on repeat HBV vaccination (maybe I’m confused on the study design)..?

• This important line was very hard to read. Could you organize the sentence so that the % and the group are together “After a single vaccine dose, HBV non-responders were significantly less likely to reach neutralizing S-protein response compared to normal and weak HBV vaccine responders (87.1% [95% CI 84.2–166 89.5], 84.7% [95% CI, 80.2–88.4], 64.5% [95% CI 45.5–79.9] among 621 normal HBV vaccine 167 responders, 302, weak responders, and 31 non-responders, respectively [p=0.004]).”

Discussion:

• I think what is missing is more details on the implications of the paper on public health. Are you suggesting that occupational health programs should perhaps prioritize HCW with history of HBV non-response for COVID vaccines? Or booster doses? Should anti-HBs testing and HBV vaccine history assessment be expanded in places giving COVID vaccines to target outreach to certain individuals…to make sure they get 2nd, additional doses?

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Michael Vinikoor

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Association between history of HBV vaccine response and anti-SARS-CoV-2 spike antibody response to the BioNTech/Pfizer’s BNT162b2 mRNA SARS-CoV-2 vaccine among healthcare workers in Japan: A prospective observational study

PONE-D-21-33288R1

Dear Dr. Ukimura,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Jason T. Blackard, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

None

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: No

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: The authors have made strong attempts to respond to all reviewer comments. The additional information regarding the threshold used to determine a significant response is very clarifying. Although this reviewer appreciates the attempt to improve accuracy by no longer using the phrase "neutralizing antibodies," the use of "seroconversion" may not be the most appropriate replacement. This reviewer thinks it may confuse readers to have a "positive" antibody response (<0.8 U/ml but < 15 U/ml) be different from "seroconversion" (> 15 U/ml). Perhaps using either "strong responder" (which contrasts nicely with "weak responder") would work, or use similar language to the Kennedy et al. supplemental figure that describes the 15 U/ml threshold as maximizing "neutralizing potential." Instead of saying either "seroconverted" or "had neutralizing responses", either saying "had strong responses" or "had neutralizing potential" may help achieve the balance and clarity required (as long as both "strong response" or "neutralizing potential" were well-defined using the Kennedy reference, as is currently done for "seroconversion" in the authors' text.

Reviewer #3: (No Response)

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Reviewer #2: No

Reviewer #3: Yes: Michael Vinikoor