Education

1997 : SMAK Depkes Makassar

Dr. Miswar Fattah, MSi
Makassar, 6th June 1978
Current position
2002 : Chemistry - UNHAS
2006 : Master of Science in Clinical Chemistry,
Biomedicine- UNHAS
2012 : Doctor of Medicine – Hasanuddin
University, Indonesia

1. Specialty & Research Laboratory Manager, Prodia Clinical Laboratory 2018- Now
2. PATELKI : Vice President 2017-Now & Member of Collegium PATELKI 2015 - Now
3. IACC: Reference Interval & Decision limit, Indonesian Association for Clinical Chemistry 2013- Now
4. President of ASEAN Association of Clinical Laboratory Scientist (AACLS) 2018-2020
5. Member of Board of Directors of Asian Association of Medical Laboratory Science (AAMLS) 2017 - Now
6. Corresponding Member Scientific Committee Asia Pacific Federation for Clinical Chemistry (APFCB)
2010 – Now
Miswar Fattah
 COVID-19 VACCINE:
PRESENT AND FUTURE COVID-19 TESTING

WEBINAR PATELKI#6
Sabtu, 13 Februari 2021

Miswar Fattah
Specialty & Research Laboratory
Prodia Clinical Laboratory
miswarfattah@gmail.com
Miswar Fattah
 THE PANDEMIC’S HIDDEN TOLL: HALF A MILLION DEATHS

Miswar Fattah 1. Wu J et al. 2020. The New York Times, April 21

 THE PANDEMIC’S HIDDEN TOLL: HALF A MILLION DEATHS

Miswar Fattah 1. Wu J et al. 2020. The New York Times, April 21

 First 1 million
cases in
ASEAN

Miswar Fattah 5 https://coronavirus.jhu.edu/map.html

Miswar Fattah 1. This GIF Only Takes 6 Seconds To Show How Herd Immunity Works | IFLScience. www.iflscience.com
 VACCINE TO REDUCE OVER CAPACITY HEALTH
CARE SYSTEM

Miswar Fattah
 TOTAL VACCINATION DOSES

153,877,062

https://ourworldindata.org/covid-vaccinations

Miswar Fattah
Miswar Fattah
Miswar Fattah 1. Srivastava M, Burn-Murdoch J. 2021. Israel provides first signs of mass vaccination driving down virus cases. www.ft.com
 CURRENT VACCINE
STRATEGIES FOR
SARS-COV-2

delivery of mRNA direct

encoding viral protein delivery(electroporation)
through lipid of plasmid DNA encoding
nanoparticle viral protein

human and chimpanzee

adenovirus-based injection of inactivated
delivery of DNA encoding viral vector
viral protein

injection of genetically
modified immune cells

1. Kevadiya BD et al. 2021. J Neuroimmune Pharmacol

Miswar Fattah
 Protein- Vaccines that contain coronavirus proteins but no genetic material.
Based Some vaccines contain whole proteins, and some contain fragments
Vaccines of them. Some pack many of these molecules on nanoparticles.

Inactivated
virus Vaccines created from weakened coronaviruses or coronaviruses
that have been killed with chemicals.

Vaccines that contain viruses engineered to carry coronavirus genes. Some viral vector vaccines
enter cells and cause them to make viral proteins. Other viral vectors slowly replicate, carrying
Viral Vector Vaccines coronavirus proteins on their surface.

Vaccines that deliver one or more of the

coronavirus’s own genes into our cells to provoke
Genetic Vaccines an immune response.
Miswar Fattah
 • Antibody specific for Spike protein or RBD
• T Cell, B Cell, memory T & B Cell specific SARS Cov-2 for
Spike protein or RBD
• All immunogenic protein will develop
antibody ( S, S1, SRBD, N, etc)
• T Cell, B Cell, memory T & B Cell specific
SARS Cov-2 for all immunogenic protein

• Antibody specific for Spike

protein
• T Cell, B Cell, memory T & B
Cell specific SARS Cov-2 for
Spike protein
Miswar Fattah
 SEROLOGY – VACCINATION VERSUS INFECTION

Vaccination Natural Infection

• Relatively homogenous • Heterogeneous response

response (judging from in general
data from the Pfizer and • Strong anti-Spike and anti-
Moderna trials) NP antibody responses
• For the majority of • Some responses to other
vaccines, there will be a proteins like ORF8
spike only responses • Mucosal sIgA response
(except inactivated
• Duration: potentially long-
vaccines)
lived
• No mucosal sIgA
responses (IgG &
monomeric IgA maybe
found in saliva)
• Duration: unknown

Miswar Fattah
 THE DURABILITY OF ANTIBODY RESPONSES OVER TIME
IN 4 DIFFERENT INFECTION/VACCINATION SCENARIOS
• In scenario A, antibody titers
peak after disease onset, and
gradually decline to a stable
plateau above the protective
threshold.
• In scenario B, although high
peak titers in acute infection
might not form, these titers
decline only slightly, and
remain above the protective
threshold long term.
• In scenarios C and D, regardless
of the peak antibody titers in
the acute phase, long-term
antibody responses are not
generated

Miswar Fattah 1. Grigoryan L, Pulendran B. 2020. Seminars in Immunology. 50:101422

 SCOPE OF VACCINE EVALUATION

Cellular response Humoral response Functional immune

• Examine of CD8+ & • Antigen specific response
CD4+ T cells antibody • Wildtype virus or
pseudovirus
neutralization assay
• Alternative methods

Miswar Fattah
Miswar Fattah 1. Chowdhury MA et al. 2020. Journal of Infection and Public Health. 13(11):1619–29
 THE ADAPTIVE IMMUNE SYSTEM RESPONDS TO THE VACCINE

T cell multiplication, which can be

programmed to identify and kill cells that
contain the pathogen (i.e., the cell-mediated
response)

B cell production of antibodies, or proteins

that neutralize SARS COV-2

Miswar Fattah
THE KINETICS OF THE HUMORAL IMMUNE RESPONSE AFTER INFECTION

Miswar Fattah
1. Alter G, Seder R. 2020. N Engl J Med
KINETICS OF SARS-COV-2 MEMORY B & T CELL RESPONSES
t1/2 = 125 days

t1/2 = 225 days

• B cell memory to SARS-CoV-2 was robust and is likely long-lasting

• circulating SARS-CoV-2–specific CD8+ T cell were consistent with
what has been reported for another virus that causes acute
infections in humans\
• SARS-CoV-2 circulating memory CD4+ T cells was observed after
SARS-CoV-2 infection, with a durability ≥6 months
Miswar Fattah
1. Dan JM et al. 2021. Science. 371(6529):
 WHY WE NEDD SEROLOGICAL TEST?
Improve Screen particular Chracterize efficacy
Define & Monitor
knowlegde sub Population & of containment
the extent of virus
immuneresponse Identify Disease mesures at local &
spread
to SARS COV-2 prevalence Global

Epidemiology: Epidemiology: Combine rRT-PCR

Screen
Establishing Monitoring herd for more accurate
convalescent sera
seroprevalence immunity diagnosis

Identify individual
Monitoring nature
Diagnosis: for later infected but
Risk prediction & duration of
stages of infection suffered only
humoral Immunity
minor symtoms
The role of serologic testing in COVID-19 Diagnosis, Mario Plebani, june 2020
TEST TO DETECT SARS COV-2 ANTIBODY

Point of Care Laboratory Based Neutralizing Antibody

(POCT): Test: Detection:
Lateral flow devices that
Determine the functional
Qualitative ELISA or ability of antibodies to
detect IgG or IgG & igM or CLIA detect IgG, IgM and
Total Ab. Whole blood, prefent infection of virus
IgA separately or in vitro. VNT: virus
serum, plasma, saliva combined as total Ab
neutralization test; pVNT
Quanlitative ELISA or CLIA presudovirus
detect IgG S or S1 or SRBD neutralization test
 WILL ANTIBODIES BE ABLE TO PROTECT US FROM COVID-19?

Miswar Fattah 1. Ramachandran R. Will antibodies be able to protect us from COVID-19? Frontline. https://frontline.thehindu.com
 IGG/IGM/IGA/NEUTRALISING AB RESPONSE OVER TIME FROM
DISEASE ONSET (META ANALYSIS)

Miswar Fattah 1. Post N et al. 2020. PLoS One. 15(12):

ANTIBODY KINETICS

Ab N protein & Anti S2 Ab Anti S1 subunit

RBD earliest to timelag of 2 days are the last to be
be detected after N & RBD detected
(100%) 13 days
after symptom
onset
The role of serologic testing in COVID-19 Diagnosis, Mario Plebani, june 2020
CIRCULATING ANTIBODIES TO SARS-COV-2 OVER TIME
Seroconversion rates range from 91 to 99% in large studies
t1/2 = 140 days t1/2 = 68 days

t1/2 = 11 days
t1/2 = 83 days

t1/2 = 27 days t1/2 = 27 days

post–symptom onset (PSO) 1. Dan JM et al. 2021. Science. 371(6529):

 INTRANASAL
VACCINATION

Miswar Fattah 1. Hassan AO et al. 2020. Cell. 183(1):169-184.e13

Miswar Fattah
 POTENTIAL DETECTED POST VACCINATE
IMMUNOASSAY TARGET Inactivated
Viral vector
DNA/RNA
Protein
protein Vaccine
viral Vaccine Vaccine (spike)
vaccine (spike) (S/S1RBD)
Abbott Architecs (CLIA) • Nucleocapsid phophoprotein (IgG)

Diasorin Liason (CLIA) • Recombinan S1/S2 Spike p (IgG)

Euroimmune (ELISA) • S1 domain of spike (IgA, IgG)

SNIBE maglumi (CLIA) • S1/S2 Spike p + N Protein (IgM, IgG)

Wantai (ELISA) • RBP domain Spike (total Ab)

Roche Quantitative (ECLIA) • IgG S RBD

Roche Cobas (ECLIA) • Nucleocapsid (total Ab)

Siemens Advia (CLIA) • S1 RBP domain spike (total Ab)

Ortho (CLIA) • S1 spike total Ab & Spike (IgG)

Mindray (CLIA) • N-Protein & Spike (S) Protein (IgG & IgM)
 BETTER STANDARDIZATION OF SARS COV-2 TEST

IU: International Units; BAU: binding antibody units.

WHO International Standard First WHO International Standard

for SARS-CoV-2 RNA NIBSC code: 20/146

First WHO International Standard for anti-SARS-CoV-2

immunoglobulin (human) NIBSC code: 20/136

WHO Reference Panel First WHO International Reference Panel

for anti-SARS-CoV-2 Immunoglubulin NIBSC code: 20/268
Miswar Fattah
 ANTIBODY SARS COV-2 STANDARDIZATION UNIT
WHO Collaborating Center for Biological Standardization and National Institute for
Biological Standards and Control (NIBSC) in UK are developing the WHO international
standard and reference panel for anti-SARS-CoV-2 antibody

RU/mL U/mL

AU/mL
Miswar Fattah
 QUANTITATIVE ANTIBODY SARS COV-2

Anti-SARS-CoV- NovaLisa® Elecsys Anti-

The Kantaro
Kit Name 2-QuantiVac- SARS-CoV-2 SARS-CoV-2 S
COVID-SeroKlir
ELISA (IgG) quantitative IgG antibody

Novatec
Manufacturers Euroimmune Roche Diagnostics EKF Diagnostics
Immundiagnostica

spike (S) protein

S1 domaine of the
Antigen target spike protein receptor binding Spike protein RBD
spike protein
domain (RBD)

Assay Method ELISA ELISA ECLIA ELISA

Miswar Fattah
 TESTS ACCEPTABLE FOR USE IN THE MANUFACTURE
OF HIGH TITER COVID-19 CONVALESCENT PLASMA
Manufacturer (listed Assay Qualifying Result
alphabetically)
Abbott SARS-CoV-2 IgG (ARCHITECT and Alinity) Index (S/C) ≥ 4.5
Beckman Coulter Access SARS-CoV-2 IgG S/CO ≥ 3.3
EUROIMMUN Anti-SARS-CoV-2 ELISA (IgG) Ratio ≥ 3.5

GenScript cPass SARS-CoV-2 Neutralization Antibody Detection Inhibition ≥ 68%

Kit
Kantaro COVID-SeroKlir, Kantaro Semi-Quantitative SARSCoV-2 Spike ELISA > 47 AU/mL
IgG Antibody Kit
Mount Sinai COVID-19 ELISA IgG Spike ELISA titer ≥ 1:2880
Ortho VITROS Anti-SARS-CoV-2 IgG S/C ≥ 9.5
Roche Elecsys Anti-SARS-CoV-2 S ≥ 132 U/mL
Siemens ADVIA Centaur SARS-CoV-2 IgG (COV2G) Index ≥ 4.8

Miswar Fattah https://www.fda.gov/media/141477/download

 EVIDENCE FOR EXISTENCE OF COVID-19
CORRELATES OF PROTECTION

• The Seattle Boat Study provides the first direct

evidence that NAbs protect against SARS-CoV-2 re-
infection in humans (none of three crew members
who had NAbs (1:174, 1:161 and 1:3082)
• SARS-CoV-2-specific memory T cells will likely prove
critical for long-term immune protection against
COVID-19 and preventing severe COVID-19
• Memory T cell response months after SARS-CoV-2
infection, even in the absence of detectable specific
circulating antibodies against SARS-CoV-2

1. Jin P et al. 2021. Signal Transduction and Targeted Therapy. 6(1):1–6

Miswar Fattah
 PROCESS OF VIRAL INVASION INTO HOST CELLS AND
MECHANISMS OF NEUTRALIZING ANTIBODIES

Miswar Fattah 1. Ni Y et al. 2021. Mol Biomed. 2(1):1

 NEUTRALIZATION ASSAY
The plaque-
surrogate virus
reduction
neutralization test
neutralization test
(sVNT)
(PRNT)

sVNT

Miswar Fattah
 NEUTRALIZATION ASSAY WORKFLOW

Miswar Fattah
 • Neutralizing antibodies to SARS-CoV-2 develop in most
individuals after infection but decay with time
• Neutralizing antibodies are effective in prevention and
therapy in animal models and are likely to have a role in
protection from reinfection in humans
• Although there is a significant decrease in plasma
neutralizing activity between 1.3 and 6.2 months,
antibody titres remain measurable in most individuals

Miswar Fattah
 WILL A COVID-19 VACCINATION AFFECT COVID-19
TEST RESULTS?
• No, COVID-19 vaccination will not affect the results of viral
tests (polymerase chain reaction [PCR] or antigen).
• The vaccine only contains mRNA that encodes for the SARS-
CoV-2 spike protein, which is not a molecular target of either
PCR or antigen COVID-19 tests. The vaccines also do not
contain any SARS-CoV-2 proteins.
• Vaccination may affect an antibody test; a positive COVID-19
antibody test could indicate vaccination OR previous infection.

Miswar Fattah
 PRESENT & FUTURE COVID-19 TESTING

Post Pre & Post

Screening Diagnosis Monitoring
Recovery vaccination
CBC CBC
Qualitative antibody
Sensitive rRTPCR Sensitive rRTPCR CRP CRP
hsTrop I hsTrop I
LDH Quantitative
LDH antibody
Low sensitive Albumin
rRTPCR + Antibody Ferritin
molecular SARS RNA Ferritin
IL6 Memory T & B cell
IL6
PaO2 D dimer

Antigen + Antibody NGS PCT PCT Risk & side effect

Vaccine
Sensitive rRTPCR Antibody

Miswar Fattah
 LOW SENSITIVITY VS HIGH SENSITIVITY

Miswar Fattah 1. Guglielmi G. 2021. Nature. 590(7845):202–5

 RAPID CORONAVIRUS TESTS:
A GUIDE FOR THE PERPLEXED

Miswar Fattah 1. Guglielmi G. 2021. Nature. 590(7845):202–5

Miswar Fattah
1. Lippi G et al. 2020. Clinical Chemistry and Laboratory Medicine (CCLM). 58(12):1965–69
 THE CURRENT OBJECTIVES OF SARS-COV-2 SEQUENCING
Investigating virus
transmission dynamics and
introductions of novel genetic
variants;
Assessing the impact of
mutations on the performance
of antigen detection methods;
Miswar Fattah
Investigating the relationship
between clades/lineages and
epidemiological data such as
transmissibility and disease
severity or risk groups to guide
public health action;
Assessing relatedness of viral
strains within epidemiological
clusters and supporting
contact tracing and other
public health interventions;
Assessing the impact of
mutations on the performance
of antiviral drugs;
Understanding the impact of
response measures on the
virus population;
Assessing and confirming
reinfections;
Assessing the impact of
mutations and modelling the
antigenic properties of the
virus to assess the risk of
vaccine escape;
Assessing the impact of
Assessing the impact of
mutations on the
mutations on the performance
performance of molecular
of serological methods;
diagnostic methods;
Prompting further basic
Monitoring emerging lineages research investigation to
within wild/domestic/farmed confirm relevance of observed
animal populations that may mutations in the pathogenesis
impact human health; of the disease (e.g. infectivity,
receptors binding);
Assessing the potential
incidence of vaccine-derived
virus infections and
transmissions should live
SARSCoV-2 vaccines become
available
Miswar Fattah 1. SARS-CoV-2 Variants vs. Vaccines. ASM.org. https://asm.org
 Variant
B.1.1.7 B.1.351 P.1 and P.2
designation
Location first identified United Kingdom South Africa Brazil

10 mutations in the S gene (3 at key

21 mutations, including 9 amino acid
23 mutations, of which 17 are of sites in the receptor binding
Mutations changes in the S gene (3 at key sites in
concern domain)3Mutations in ORF1ab, ORF8
the receptor binding domain)
and N genes

Impact on performance of molecular Minimal impact 69–70 deletion Minimal impact may impact assays Minimal impact may impact assays
diagnostics causes S gene dropout that target S gene sequences that target S gene sequences

Impact on performance of antigen-

Minimal impact Minimal impact anticipated Minimal impact anticipated
based tests

Impact on performance of serological

No data No data No data
antibody tests

Miswar Fattah
 SARS COV-2 Variant & Diagnostics Genes target

Miswar Fattah https://www.finddx.org/wp-content/uploads/2021/02/FIND_COVID-graphic_v4.pdf

 THE B.1.1.7 LINEAGE
• This group of coronaviruses came to light in Britain, where it
was named Variant of Concern 202012/01. The variant is also
known as 20I/501Y.V1, or simply called B.1.1.7.
• B.1.1.7 is about 35 percent more deadly than other variants.
On the other hand, vaccines appear to work well against it.
• — N501Y, which helps the virus latch on more tightly to
human cells. But the mutation is not likely to help the virus
evade current vaccines.
• — P681H, which may help infected cells create new spike
proteins more efficiently.
• — The H69–V70 and Y144/145 deletions, which alter the
shape of the spike and may help it evade some antibodies.
Miswar Fattah
 THE B.1.351 LINEAGE
• A variant known as 20H/501Y.V2, from
the B.1.351 lineage of coronaviruses, was
first identified in South Africa in December.
• — N501Y, which helps the virus latch on
more tightly to human cells. This mutation
also appears in the B.1.1.7 and P.1 lineages.
• — K417N, which also helps the virus bind
more tightly to human cells.
• — E484K, which may help the virus evade
some kinds of antibodies.
Miswar Fattah
 THE P.1 LINEAGE
• A variant known as 20J/501Y.V3 is from the P.1 lineage, an
offshoot of the larger B.1.1.28 lineage. The variant was first
reported in Japan, in four people who contracted P.1 on a trip
to Brazil. The lineage emerged in late 2020 in Manaus, the
largest city in Brazil’s Amazon region. It quickly became the
predominant variant there and in several other South
American cities.
• — N501Y, which helps the virus latch on more tightly to
human cells. This mutation also appears in the B.1.1.7 and
B.1.351 lineages.
• — K417T, which is the same site as the K417N mutation in the
B.1.351 lineage. It may also help the virus latch on tighter.
• — E484K, which may help the virus evade some kinds of
antibodies.

Miswar Fattah
 Mesa Biotech TaqPath COVID- Linea COVID-19
Name of kit
Accula 19 Combo Kit Assay Kit
Thermo Fisher Applied DNA
Manufacturers Mesa Biotech
Scientific Sciences
ORF1ab gene, N S1 Target , S2
Gene target N
gene, S gene target
28881 (GGG to
Variant B.1.1.7 variant B.1.1.7 variant
AAC)
does not appear to reduced reduced sensitivity
Impact
be significant sensitivity s target in target1

Miswar Fattah This Kit can utilize as Early identification of new variants in patients
 S GENE TARGET FAILURE (SGTF)
• S gene mutations in the VOC,
which deletes amino acids 69 and
70 (Δ69-70), causes a
reproducible S gene target failure
(SGTF) in the ThermoFisher
TaqPath assay used in 3 UK
lighthouse laboratories
• The weekly percentage of
VOC202012/01 and STGF
combinations, showing increasing
proportion of VOC202012/01
with SGTF

Miswar Fattah https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/959426/Variant_of_Concern_VOC_202012_01_Technical_Briefing_5.pdf

 RECOMMENDATION FOR CLINICAL LABORATORY RELATED
MOLECULAR SARS-COV-2

Be aware that genetic variants of SARS-CoV-2 arise regularly and false

negative test results can occur.

Be aware that tests that use multiple genetic targets to determine a final
result are less likely to be impacted by increased prevalence of genetic
variants.

Consider negative results in combination with clinical observations,

patient history, and epidemiological information.

Consider repeat testing with a different test (with different genetic

targets) if COVID-19 is still suspected after receiving a negative test result
Miswar Fattah
 THANK YOU

Miswar Fattah 54
Miswar Fattah
 IMMUNE RESPONSES OF LYMPHOCYTES TO SARS-COV-2 INFECTION

Miswar Fattah 1. Ni Y et al. 2021. Mol Biomed. 2(1):1