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COVID-19 vaccine safety in comorbid patients: are we missing some critical

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Preprint · December 2020

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 Rahman et.al. 2020. Commentary 1

COVID-19 vaccine safety in comorbid patients: are we missing some critical points?

Mohammad Mahmudur Rahman1, Md. Maruf Hasan2 and Asif Ahmed3*

1Department of Medical Biotechnology, Bangladesh University of Health Sciences, Dhaka, Bangladesh.

2Departmentof Biomedical Engineering. Military Institute of Science and Technology. Mirpur 1216,
Dhaka, Bangladesh

3Biotechnology and Genetic Engineering Discipline, Khulna University, Khulna 9208, Bangladesh

MOHAMMAD MAHMUDUR RAHMAN, MPH, Associate Professor

Email: maahmud@gmail.com
ORCID: https://orcid.org/0000-0002-1211-8642

MD. MARUF HASAN. PhD, Associate Professor

Email: maruf.hasan@bme.mist.ac.bd

ASIF AHMED, PhD, Associate Professor

Email: asif@bge.ku.ac.bd
ORCID: http://orcid.org/0000-0001-7401-821X

*Correspondence:

ASIF AHMED
asif@bge.ku.ac.bd

Declaration: nothing to declare.

Ethics approval and consent to participate: NA
Availability of data and material: NA
Competing interests: Authors declare no competing interests.
Funding: No funding was received for this study.
Authors' contributions: MMR and AA conceived the idea. MMR, MMH and AA contributed to the
discussion, manuscript preparation, revision and agreed to submit in its current form after necessary
corrections.

Preprint Version

COVID-19 vaccine safety in comorbid patients: are we missing some critical points?
Scientists across the globe are putting
tremendous efforts to develop functional and
safe COVID-19 vaccines to combat the
pandemic. According to WHO, a total of 48
candidate vaccines are under clinical trial and
164 are at pre-clinical evaluation phase (1).
Goal of all these vaccines is to expose the
individuals to safe antigenic particles that will
trigger and train immune systems to efficiently
protect them when challenged by original
virus. Cascade of immune cells work together
upon infection; antigen presenting cells (APC)
engulf the antigenic particles (whole virus or
proteins) and display portions of them to
activated T helper cells. Subsequently, T helper
cells empower B cells to produce antibodies
that can prevent viruses from infecting target
cells. They also facilitate the annihilation of
virus with cytotoxic T cells mediated
destruction (2).
The vaccines in the race are of protein based
(protein subunits of either spike (S) protein or
its domains and virus like particles or VLP),
nucleotide based (mRNA and DNA) which
eventually express membrane anchored or
extracellular S protein in host, original virus
based (either fully inactivated or weakened to
reduce pathogenic properties), and viral vector
based (either replicating or non-replicating
core of other viruses expressing SARS-CoV-2 S
proteins) (2). In a nutshell, final derivative of all
these vaccines inside our body is the protein
that mimics SARS-CoV-2 surface spike
glycoprotein to induce host immune response
against it and they are free from any genetic
material to induce replication or pathogenesis.
A big question arises however, that in case of
COVID-19, are S protein based vaccine
candidates safe enough for comorbid patients?
Is there any chance of these S proteins or S
protein bearing vaccine components to induce
host’s cellular homeostasis imbalance in
comorbid individuals without its own genetic
material?
Rahman et.al. 2020. Commentary 2
Before examining the possible vaccine induced
cellular consequences in comorbid individuals,
it is worth mentioning the orchestration among
membrane ACE2 (mACE2), soluble ACE2
(sACE2), angiotensin II (Ang II) and viruses.
Elevated Ang II induce mACE2 shedding
which releases sACE2 with the help of enzyme
ADAM17 (3) as positive feedback mechanism
increasing plasma sACE2 level. The plasma
sACE2 with shorter half-life is supposed to
reduce the elevated Ang II in floating condition
to reverse the renin-angiotensin imbalance.
The sustained increased sACE2 level is a
biomarker of many diseases. Two large cohort
of more than 5000 patients with atrial
fibrillation revealed strong positive association
of raised sACE2 with male sex, older age,
cardiovascular diseases and diabetes (4). Thus,
in comorbid patients, adverse effects of Ang II
is counter balanced by these sACE2. However,
if sACE2 levels is further reduced or
accumulated in certain places, the balancing
effect will hamper through the harmful role of
surplus Ang II. In COVID-19, case fatality and
severity was also very high among comorbid
individuals indicating a strong association of
sACE2 and COVID-19 severity (5). In a pooled
study covering 124 reports, association of
common comorbidities and cardiac injury was
linked to COVID-19 poor prognosis (6). In a
white paper by Fair Health, West Health
Institute and Johns Hopkins University School
of Medicine, reported that, around 83% of
COVID-19 deaths are related to comorbidity
(7). Virus binding can also down regulate
mACE2 by internalization and ADAM17
driven shedding (8). Binding induced
Internalization of mACE2 by coronaviruses
down regulate mACE2 and/or sACE2 and are
responsible for extracellular Ang II to rise
further. This elevated Ang II is responsible for
renin angiotensin system (RAS) imbalance.
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 Rahman et.al. 2020. Commentary 3

Figure 1: Proposed mechanism of vaccine constituent induced ACE2 down regulation and cellular consequences.
Clinical trial COVID-19 vaccines are nucleotide based (mRNA and plasmid DNA), replicating or non-replicating
viruses including inactivated or weak viruses, pseudo viruses and virus like particles (VLP), and protein fragments
(usually S protein). The mRNA vesicle can deliver mRNA into cytoplasm, plasmid DNA is transcribed into mRNA.
Both these mRNA can produce membrane anchored or soluble S protein. All the vaccine constituents are supposed
to produce antibodies via memory B cells by activating antigen presenting cells (APC) and T helper cells (not
shown). These antibodies can attack and destroy when healthy individual is exposed to SARS-CoV-2. As vaccine
constituent is S protein with its ACE2 binding RBD, they have potential to bind sACE2 in comorbid patients and
enter cell by receptor mediated endocytosis. S protein fragments alone can bind to mACE2 and enter cell with
mACE2. Alongside, receptor independent filopodia mediated macropinocytosis can nonspecifically uptake fluid
containing vaccine constituents. These result in reduction of both sACE2 and mACE2 and increase in extracellular
Ang II. Elevated Ang II may trigger detrimental effects in various organs via AT1R, continuous macropinocytosis,
cytokine storm and further mACE2 shedding. Altogether vaccine ingredients have potential to induce cellular
pathology in comorbid individuals who have already lower mACE2 and higher sACE2.

The role of S protein alone without viral
genome or expressed in pseudovirions have
been examined. Experiments with different cell
lines showed that both SARS-CoV (9, 10) and
SARS-CoV-2 (11, 12) soluble S protein and/or
S protein expressing pseudovirions can bind
mACE2 and follow endocytic entry. S protein
alone can exert mACE2 down regulation and
this binding and subsequent cellular entry is
independent of any influence of the genetic
material (13). Upon binding coronaviruses also
showed to induce continuous cellular
macropinocytosis, a non-specific receptor
independent bulk fluid uptake mechanism by
which extracellular particles can easily be
engulfed (14). The classical macropinocytic

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pathway induced by viruses also involve
filopodia formation capable of cell to cell
communication, migration, filopodia mediated
virus transfer and syncytium formation. These
results clearly suggest that S protein alone can
bind to mACE2/sACE2 and subsequent events
can take place similar to original virus without
the need of viral genome.
How these findings correlate while vaccinating
comorbid individuals? When comorbid
patients are immunized with vaccines having S
proteins on surfaces of inactivated or weak
viruses, pseudo viruses or VLPs, they can be
partially or mostly covered with sACE2 and
endocytic entry may follow upon binding of
the complex to few available mACE2 (Figure
1). This creates the possibility to internalize
both sACE2 and mACE2 along with vaccine
components. Vaccines with S protein
fragments and mRNA or DNA vaccine
expressed extracellular S proteins can also bind
mACE2 to trigger endocytosis loosing mACE2.
If mRNA and DNA vaccine derived S protein
is expressed on host cell surface, binding to
sACE2 will restrict the mobility of sACE2. Host
cell surface expressed S protein is also capable
of cell to cell fusion of adjacent cells (11).
Macropinocytic pathway triggered by vaccine
S proteins and further elevated Ang II in
comorbid individuals also add the chance of
internalization of vaccine components
reducing their availability to induce immune
response. Ang II modulates the functions of
many cells and tissues and regulates functions
of many organs (15). In comorbid patients due
to high Ang II concentration Ang II-AT1R axis
cascades is activated. If vaccine components
induce further reduction of mACE2 and sACE2
and increase Ang II level; vasoconstriction,
fibrosis and other associated cellular
pathologies including cytokine storm may
happen (16, 17).
Scientific community and relevant authorities
are trying their best to launch COVID-19
vaccine in quickest possible time, and older
Rahman et.al. 2020. Commentary 4
people with comorbidities are on their top
priority list (18). Already conducted preclinical
and clinical trials were found to exclude high
risk groups including older people with
comorbidity (19, 20). Their trial also did not
report any status of Ang II or sACE2 level. If
according to WHO priority, older comorbid
people are vaccinated first, chances of severe
adverse side effects cannot be overruled based
on the above-mentioned reasons.
In summary, although noninfectious in nature,
vaccine components can potentially trigger
mACE2 and sACE2 down regulation and exert
adverse cellular effects especially in comorbid
patients. After vaccination, healthy and young
individuals may face some moderate side
effects due to transient mACE2 loss which can
be tolerable and recoverable. However, at
present we are quite unsure about the cellular
consequences of vaccination in comorbid
individuals having low mACE2, higher sACE2
and elevated level of Ang II due to unavailable
data. If vaccine S protein mediated mACE2 and
sACE2 loss triggers Ang II level to rise further,
it may aggravate disease conditions and
increase severity through several mechanism
mentioned above. We therefore recommend
monitoring Ang II and sACE2 level during
vaccination both in preclinical and clinical trial
besides monitoring the titer of specific
antibodies. This is urgent to ensure maximum
safety of comorbid vaccine recipients before
sufficient antibody can be generated by their
body.
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