N = 176
Data is presented in number (percent) unless otherwise stated. BMI: body mass index; SD: standard deviation.
The serum levels of SARS-CoV-2 spike IgG, SARS-CoV-2 RBD IgG, and SARS-CoV-2 NAB were evaluated ( Table 2 and Table 3 ). More than 90% of the study population had positive levels of SARS-CoV-2 spike IgG (mean± SD, 68.5 ± 32.5). The frequency of positive spike IgG was higher in individuals who received three doses than in individuals with two doses, but it was not statistically significant (96.9% vs. 90.2%, respectively; OR, 3.4, 95% CI, 0.7–15.6; p -value, 0.137). Meanwhile, the level of spike IgG was higher in those who received three doses than in those who received two doses (82.8 ± 24.2 vs. 60.4 ± 33.8, respectively; p -value < 0.001).
Frequency of immune level of antibodies in groups of 2 and 3 doses of COVID-19 vaccine.
Whole Sample N = 176 | Receiving Two Doses N = 112 | Receiving Three Doses N = 64 | OR (95% CI) | -Value | |
---|---|---|---|---|---|
SARS-CoV-2 spike IgG | 3.37 (0.72–15.62) | 0.137 | |||
Positive | 163 (92.6) | 101 (90.2) | 62 (96.9) | ||
Negative | 13 (7.4) | 11 (9.8) | 2 (3.1) | ||
SARS-CoV-2 RBD IgG | 7.46 (2.16–25.64) | <0.001 | |||
Positive | 143 (81.3) | 82 (73.2) | 61 (95.3) | ||
Negative | 33 (18.8) | 30 (26.8) | 3 (4.7) | ||
SARS-CoV-2 NAB | 8.33 (2.81–24.39) | <0.001 | |||
Positive | 132 (75.0) | 72 (64.3) | 60 (93.8) | ||
Negative | 44 (25.0) | 40 (35.7) | 4 (6.3) |
Data are presented in numbers (percentage). IgG: immunoglobulin G; NAB: neutralizing antibody; RBD: receptor binding domain.
The level of anti-SARS-CoV-2 antibodies regarding the number of received vaccine doses.
Whole Sample N = 176 | Receiving Two Doses N = 112 | Receiving Three Doses N = 64 | -Value | |
---|---|---|---|---|
SARS-CoV-2 spike IgG (RU/mL) | 68.5 ± 32.5 | 60.4 ± 33.8 | 82.8 ± 24.2 | <0.001 |
SARS-CoV-2 RBD IgG (RU/mL) | 36.5 ± 29.2 | 28.2 ± 25.6 | 51.0 ± 29.7 | <0.001 |
SARS-CoV-2 NAB (µg/mL) | 33.9 ± 29.4 | 23.9 ± 27.5 | 51.3 ± 24.1 | <0.001 |
Data are presented as mean ± SD. IgG: immunoglobulin G; NAB: neutralizing antibody; RBD: receptor binding domain; RU/mL: relative units per milliliter; µg/mL: micrograms per milliliter.
The frequency of positive levels of RBD IgG and NAB was 81.3% and 75.0% in the whole sample, respectively. Administration of the third dose increased the frequency of the protective rate considering RBD IgG (OR, 7.5; 95% CI, 2.1–25.6; p -value < 0.001) and NAB (OR, 8.3; 95% CI, 2.8–24.3; p -value < 0.001). RBD AB increased significantly with the third dose of the COVID-19 vaccine (from 28.2 ± 25.6 to 51.0 ± 29.7, p -value < 0.001). The increase in NAB was also notable, from 23.9 ± 27.5 to 51.3 ± 24.1 ( p -value < 0.001). The serum level of SARS-CoV-2 Spike IgG, SARS-CoV-2 RBD IgG, and SARS-CoV-2 NAB are presented in Figure 1 .
Comparison of the serum level of antibodies in twice- and triple-vaccinated individuals.
To control the confounding variables in the prediction of positive levels of antibodies, age, gender, BMI, past medical history of autoimmune disease, past medical history of chicken pox, and past medical history of influenza vaccination, along with the number of COVID-19 vaccine dosages, have been entered into three separate logistic regression models. The result of the logistic regression for each antibody is presented in Table 4 .
Logistic regression analysis predicting the positivity of antibodies.
Type of Antibody | Variables | B | S.E. | OR | -Value | 95% CI for OR | |
---|---|---|---|---|---|---|---|
Lower | Upper | ||||||
SARS-CoV-2 spike IgG | Number of dosages * | 1.98 | 1.08 | 7.69 | 0.066 | 0.87 | 100.00 |
Age | 0.08 | 0.02 | 1.08 | 0.005 | 1.02 | 1.14 | |
BMI *** | −1.84 | 0.85 | 0.15 | 0.031 | 0.02 | 0.84 | |
SARS-CoV-2 RBD IgG | Number of dosages * | 3.11 | 1.03 | 2.27 | 0.003 | 2.95 | 166.66 |
Autoimmune disease ** | −3.36 | 1.58 | 0.03 | 0.034 | 0.00 | 0.77 | |
SARS-CoV-2 NAB | Number of dosages * | 2.80 | 0.75 | 16.66 | 0.000 | 3.84 | 100.00 |
* The reference is receiving two doses of COVID-19 vaccine. ** The reference is a negative history. *** The reference is BMI < 25. IgG: immunoglobulin G; RBD: receptor binding domain; NAB: neutralizing antibody; BMI: body mass index.
In the logistic regression for the prediction of positive anti-spike antibody (Cox and Snell R squared, 0.1), as in the univariate analysis, the number of vaccine dosages was not associated with positive anti-spike antibody levels in the study population ( p -value, 0.066). Moreover, the association between age (OR, 1.08; 95% CI, 1.02–1.14; p -value, 0.005) and BMI (OR, 0.15; 95% CI, 0.02–0.84; p -value, 0.031) with the positive level of SARS-CoV-2 Spike IgG was statistically significant.
The positive level of SARS-CoV-2 RBD IgG showed a positive association with the number of COVID-19 vaccine dosages (OR, 2.27; 95%CI, 2.95–166.66; p -value, 0.003) and a negative association with a medical history of autoimmune disease (OR, 0.03; 95% CI, 0.00–0.77; p -value, 0.034) (Cox and Snell R squared, 0.134).
The association between the number of dosages with the frequency of protective SARS-CoV-2 NAB levels remained statistically significant (OR, 16.66; 95% CI, 3.84–100.00; p -value < 0.001) in multiple logistic regression analysis. Other variables showed no significant association (Cox and Snell R squared, 0.16).
Although we are in the third year of the COVID-19 pandemic, there are still unanswered questions, especially regarding the COVID-19 vaccines. The level of protective antibodies, the role of heterologous vaccine regimens, and optimum dose intervals are still under question. A higher titer of antibodies is supposed to be associated with more extended and higher protection, especially against emerging COVID-19 variants [ 20 , 21 ]. No matter the type of COVID-19 vaccine administered, the waning of humoral responses is observed, especially in older adults, immunosuppressed individuals, and males [ 22 , 23 ]. Meanwhile, the willingness to receive a booster dose has decreased in communities, and “doubt on the necessity of further vaccination” is mentioned as the main reason [ 24 , 25 , 26 ].
The vaccine-induced immune response is strongly affected by host factors (age, gender, genetics, history of COVID-19 infection, and comorbidities) and vaccine factors (vaccine type, adjuvants, number of doses, and vaccination schedule) [ 27 , 28 , 29 ]. We examined the relationships of different factors as determinants of vaccine response, including age, gender, BMI, comorbidities, medications, history of measles, influenza, and chicken pox, history of COVID-19, administration of influenza vaccine in the past year, and the number of vaccine doses.
The results of our study, in line with other studies, showed that the number of doses is a significant determinant of antibody concentration [ 30 , 31 , 32 ]. Our study indicated that the level of SARS-CoV-2 spike IgG, SARS-CoV-2 RBD IgG, and SARS-CoV-2 NAB were significantly higher after the booster dose with about a 1.5–2-fold increase in their titer.
Age is a determinant of immunity response, as the production of antibodies decreases with age due to impairment in T-cells and maturation of B-cells [ 33 ]. However, the only antibody associated with age in our study was the SARS-CoV-2 Spike IgG. In contrast to our study, in a survey by Uysal et al., age had no statistically significant relationship with the titer of RBD antibody [ 34 ]. This contradiction could be explained by the time of antibody measurement, as the antibody level decreases over time, which could be apart from the effect of age on the antibody level. The results of a study by Levin et al. show that adults over 65 years old have lower levels of antibodies compared to younger adults [ 22 ]. In this study, the mean age of the participants was around 36 years old, and older adults did not participate, which could explain the difference in the association of age with the frequency of protective antibodies in our study with previous studies.
Immunosuppression is a determinant of antibody concentration after vaccination. The results of two studies by Boyarski et al. show an increase in immunity after the second dose in organ transplant receivers. Immunity is detected in 15% and 54% after the first and second doses, respectively [ 35 , 36 ]. The result of our study was in line with previous studies. In our study, having an autoimmune disease is negatively associated with positive levels of RBD IgG. In contrast, administering the third dose was positively associated with positive levels of RBD IgG. In organ transplant recipients and cancer patients, the levels of antibodies were boosted after the third dose [ 37 , 38 ]. In a study on a group of solid organ transplant recipients, about half of those who were seronegative after the second dose became seropositive after the third dose [ 39 ]. It has also been indicated that the odds of having a positive test and hospitalization decrease after three doses of the BNT162B2 vaccine compared to two doses [ 40 ].
Another determinant of vaccine-induced immunity is obesity, which is negatively associated with antibody concentration, and obese individuals are more at risk of breakthrough COVID-19 infection [ 41 ]. Individuals with a BMI of 25 or higher had a lower likelihood of having positive SARS-CoV-2 spike Ab.
There are some limitations to acknowledge in our study. First, we did not measure the period between the vaccine shot and antibody evaluation, so we cannot make a definite conclusion regarding the titer of antibodies. Second, due to our limited sample size, this study has no claim on the effectiveness of different vaccines. Third, we aim to investigate the level of humoral response at a particular point in time. Still, the lack of follow-up data, especially on clinical outcomes, could be mentioned as another limitation, and longitudinal studies are needed. Finally, the power of our models is not high enough. Therefore, there are other factors influencing the level of antibodies that are not included in our study.
Different variables are associated with the titer of protective antibodies induced by COVID-19 vaccines. In conclusion, the results of our study show that the booster dose of the COVID-19 vaccine is a strong determinant of positive SARS-CoV-2 RBD IgG and SARS-CoV-2 NAB, which best correlates with immunity.
The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/vaccines10101708/s1 , Table S1: The frequency of COVID-19 vaccine types received.
This research was funded by the Tehran University of Medical Sciences.
Conceptualization, A.A., Y.A. and A.M.; Data curation, A.M.; Formal analysis, Y.A., A.V. and A.M.; Investigation, Y.A., A.V. and A.M.; Methodology, A.M.; Project administration, A.M.; Software, Y.A.; Supervision, A.M.; Validation, A.A. and A.V.; Writing—original draft, Y.A. and A.V.; Writing—review & editing, A.A. and A.M. All authors have read and agreed to the published version of the manuscript.
The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee of the Tehran University of Medical Sciences (IR.TUMS.Medicine.REC.1400.1297).
Informed consent was obtained from all subjects involved in the study.
Conflicts of interest.
The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Objectives: This study aimed to examine the coverage of coronavirus disease 2019 (COVID-19) vaccination and its cognitive determinants among older adults.
Methods: A cross-sectional study was conducted using a questionnaire to conduct a survey among 725 Chinese older adults aged 60 years and above in June 2022, 2 months after the mass COVID-19 outbreak in Shanghai, China. The questionnaire covered demographic characteristics, COVID-19 vaccination status, internal risk perception, knowledge, and attitude toward the efficacy and safety of COVID-19 vaccines.
Results: The vaccination rate was 78.3% among the surveyed individuals. Self-reported reasons for unwillingness to get vaccinated (multiple selections) were "concerns about acute exacerbation of chronic diseases after vaccination (57.3%)" and "concerns regarding vaccine side effects (41.4%)." Compared to the unvaccinated group, the vaccinated group tended to have a higher score in internal risk perception ( t = 2.64, P < 0.05), better knowledge of COVID-19 vaccines ( t = 5.84, P < 0.05), and a more positive attitude toward the efficacy and safety of COVID-19 vaccines ( t = 7.92, P < 0.05). The path analysis showed that the cognitive effect on vaccination behavior is relatively large, followed by the internal risk perception, and then the attitude toward COVID-19 vaccines. The more knowledgeable the participants were about COVID-19 vaccines, the more likely they were to receive the COVID-19 vaccines. In the multivariate logistic regression, the increased coverage of COVID-19 vaccination was associated with reduced age (OR = 0.53 95% CI 0.43-0.66, P < 0.001), being a resident in other places than Shanghai (OR = 0.40, 95% CI 0.17-0.92, P < 0.05), a shorter time of lockdown (OR = 0.33, 95% CI 0.13-0.83, P < 0.05), a history of other vaccines (OR = 2.58, 95% CI 1.45-4.60, P < 0.01), a fewer number of chronic diseases (OR = 0.49, 95% CI 0.38-0.62, P < 0.001), better knowledge about COVID-19 vaccines (OR = 1.60, 95% CI 1.17-2.19, P < 0.01), and a positive attitude toward COVID-19 vaccines (OR = 9.22, 95% CI 4.69-18.09, P < 0.001).
Conclusion: Acquiring accurate knowledge and developing a positive attitude toward COVID-19 vaccines are important factors associated with COVID-19 vaccination. Disseminating informed information on COVID-19 vaccines and ensuring efficacious communication regarding their efficacy and safety would enhance awareness about COVID-19 vaccination among older adults and consequently boost their vaccination coverage.
Keywords: COVID-19; attitude; cognition; older adults; vaccine; vaccine hesitancy.
Copyright © 2023 Wei, Zeng, Huang, Ye, Chen, Yang and Cai.
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Vaccination status among older adults (N = 725).
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Reasons for willingness and unwillingness to get vaccinated.
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Path analysis of vaccination with internal risk perception, cognition, and attitude. ** P…
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