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Effect Monitoring and Insights from Vaccination program of Healthcare

Workforce from a tertiary level hospital in India against SARS-CoV-2
Rajat Ujjainiya1,2#, Akansha Tyagi3#, Viren Sardana1,2#, Salwa Naushin1,2, Nitin Bhatheja1,
Kartik Kumar1, Joydeb Barman1, Satyartha Prakash1, Rintu Kutum1,2,Menka Loomba3, Yukti
Khanna3, Chestha Walecha3, Rizwan Ahmed3, Ashutosh Yadav4, Archana Bajaj11, Gaurav
Malik11, Sahar Qureshi10, Swati Waghdhare4, Samreen Siddiqui4, Kamal Krishan Trehan11,
Manju Mani10, Rajiv Dang9, Poonam Das6, Pankaj Dougall7, Monica Mahajan8, Sandeep
Buddhiraja5 , Anurag Agrawal1,2, Debasis Dash1,2*, Sujeet Jha4*, Shantanu Sengupta1,2*

1
CSIR-Institute of Genomics and Integrative Biology, New Delhi
2
Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, Uttar Pradesh
3
Department of Clinical Research Max Superspeciality Hospital, Saket, New Delhi
4
Institute of Endocrinology, Diabetes, and Metabolism, New Delhi
5
Department of Internal Medicine, Max Superspeciality Hospital, Saket, New Delhi
6
Institute of Laboratory Medicine & Transfusion Services. Max Hospital, Saket, New Delhi
7
Max Hospital, Saket, New Delhi
8
Max Hospital Panchsheel, New Delhi
9
Max Hospital, Gurgaon, New Delhi
10
Max Smart Super Speciality Hospital, New Delhi
11
Max Hospital Shalimar Bagh, New Delhi

#
Equal contribution
*
Corresponding authors

NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.
medRxiv preprint doi: https://doi.org/10.1101/2021.02.28.21252621; this version posted March 2, 2021. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

Abstract
The Oxford-Astra Zeneca COVID 19 vaccine (AZD1222 or ChAdOx1) is an important
part of the global vaccine roll-out against SARS-CoV-2, and a locally manufactured
version (Covishield by Serum Institute, Pune, India) is the most commonly used
vaccine in India. The vaccination program started in January 2021 and here we
report effectiveness of the first dose of Covishield in generating antibody response
and its kinetics. We further report differences in the quantitative antibody response
amongst individuals who had pre-existing antibodies to SARS CoV2 and those who
did not. In a group of 135 healthcare workers administered Covishield, we measured
antibodies to SARS-CoV-2 directed against the spike protein (S-antigen) using
Elecsys Anti-SARS-CoV-2 S quantitative antibody detection kit (Roche Diagnostics)
at days 0, 7, 14, and 28. In 44 subjects (32.5%) who had already developed
antibodies to SARS-CoV-2 at day 0 (before immunization), it was observed that
antibody response was significantly higher at each time point, with the maximum
increase seen between days 0 and 7. In contrast the sero-negative group (n=91)
started developing antibody response only after 14 days or later. Three sero-
negative individuals did not develop any antibody response even at day 28 of
vaccination. It is noted that median antibody response at 28 days in seronegative
subjects was similar to that of seropositive subjects at baseline (day 0) and was on a
rising trajectory. Our data suggests that ChAdOx1 is highly immunogenic, particularly
so where previous SARS CoV2 antibody-response is established. Given the high
background seropositivity in India, this may be useful in determining optimal timing of
the second dose during mass immunization within the constraints of vaccine supply
and administration.

Keywords:
Covid 19, Vaccine, Antibody Response, SARS-CoV-2, Immunity, Public Health
Introduction
As the covid pandemic swept global economies last year, tireless efforts to develop
vaccines against SARS-CoV-2 were underway and a few vaccines have already
been developed in record time to control the spread of SARS-CoV-2 infection
worldwide. To protect at the earliest the vulnerable and exposed from acquiring the
dreaded infection; frontline healthcare workers, sanitization staff, elderly with co-
morbidities etc. was at high priority of governments around the world. India began its
ambitious vaccination program from January 2021 after approval of two candidate
vaccines; one being Covishield (AZD1222 technology acquired from co-development
of Oxford University and AstraZeneca, by Serum Institute of India, Pune) and the
other being Covaxin (Bharat Biotech developed vaccine using Vero cell lines in
collaboration with ICMR, India) after an emergency restricted use approval by the
Directorate General of Health Services (DGHS).1 Both vaccines had peer reviewed
studies published demonstrating the immunogenicity after extensive clinical trials,
though Covaxin was to undergo phase III trials, it was given an approval for
restricted use under these emergency conditions.2-4
medRxiv preprint doi: https://doi.org/10.1101/2021.02.28.21252621; this version posted March 2, 2021. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

With the introduction and approval of vaccines, it became imperative to understand

the immunogenicity and efficacy in antibody development. In an earlier published
preprint, a similar study was carried out to understand the antibody response after
receiving the Pfizer and Modern Vaccine in New York and Paris. They observed a
significant difference in antibody response amongst people who already had pre-
existing immunity to the disease in comparison to those who did not.5 6 Another study
from Maryland utilizing an IgG ELISA based assay to spike protein observed similar
response type albeit in healthcare workers.6 7
This, as one of the early studies from the country and regions utilizing Covishield
vaccine aimed to understand the kinetics of antibody development in health-care
workforce who stand as one of the most vulnerable in our fight against this
pandemic. A large percentage of the health-care workforce had already been
infected with SARS-CoV-2 and had developed antibodies against the virus. Thus, we
also checked if being sero-positive leads to measurable differences in antibody
levels compared to sero negative individuals after the administration of the first dose
of vaccine.
The present study was carried at a tertiary level healthcare chain in Delhi, India
where Covishield was administered to all personnel. Covishield is an in-activated
viral vaccine and utilizes the S-antigen to generate an antibody response. It had to
be given in two doses spread 4-6 weeks apart to attain immunogenic levels, though
it was observed through observational studies as mentioned in factsheet that the
response is attainable even when the two doses are given 12 weeks apart rather
being more effective at 12 weeks interval.

Materials and Methodology

The study was approved by the ethics committee of Max Hospital, New Delhi and
CSIR-IGIB, New Delhi. Subjects were enrolled under the study who were to receive
the Covishield vaccine under a voluntary enrolment process to monitor their antibody
response before getting the vaccine followed by measurement at various time
intervals. Herein, we analysed data of 135 subjects who had provided their samples
on the day of receiving the first dose and on the 28th day i.e., the day they receive
their second dose as per standard protocol. Of these 135 subjects 82 and 69 also
gave samples at 7 and 14 days, respectively.
Blood samples (6 ml) were collected in EDTA vials from each participant and
antibodies to SARS-CoV-2 directed against the spike protein (S-antigen) were
assayed using Elecsys Anti-SARS-CoV-2 S quantitative antibody detection kit
(Roche Diagnostics) according to the manufacturer’s protocol. Antibody levels >0.8
U/ml were sero-positive
Friedman’s ANOVA was utilized to assess difference in antibody response on serial
follow up for individuals who gave samples at all data points. Non-Parametric Mann-
Whitney test was utilized to assess two groups i.e., those that had pre-existing
antibodies and those who did not for time specific significant differences if any after
medRxiv preprint doi: https://doi.org/10.1101/2021.02.28.21252621; this version posted March 2, 2021. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

assessment of data distribution. Statistical analysis was carried out with visualization
in R version 3.6.1 and MS-Excel 2016 and OriginPro V2021.
Role of the funding source
The sponsor of this study had no role in study design, data collection, data analysis,
data interpretation, or writing of the report. The corresponding authors had full
access to all the data in the study and had final responsibility for the decision to
submit for publication.
Results and Discussion
This study was done in 135 subjects for whom we had both baseline (pre-
vaccination) and 28 day post vaccination data. Of these 135 subjects, 44 (32.5%)
had already developed antibodies to SARS-CoV-2. These personnel were then
assigned to two groups, one who had developed antibodies prior to vaccination and
the other who had not. In addition to baseline and 28 days post vaccination, 53
subjects also gave their samples at 7 days and 14 days post vaccination i.e. data for
these individuals are available at all 4 time points. It was observed that the antibody
response at 7 days in the people who already had antibodies was significantly higher
than the individuals who did not had antibodies prior to vaccination (p<0.0001);
rather, greater than ninety percent of naïve individuals didn’t develop any
measurable response at all at day 7. (Figure 1). This was corroborated at day 14
when both groups had started developing antibodies though the difference was still
significant amongst them (p<0.0001). On day 28, before the second dose of
vaccination, most of the individuals except three amongst sero-negative group had
measurable antibody response and the difference was greater than 500 times in
median antibody titre levels amongst two groups when compared for 53 individuals
who gave samples at all 4 time points and 200 times when compared for all 135
individuals. There was significant response when compared to baseline at day 14
and day 28 of vaccination in both groups for 53 individuals on repeated measure
ANOVA. Though, the antibody response needs to be monitored for a longer term for
evaluation on sustenance of this response and demonstratable difference if any
amongst the two groups.
medRxiv preprint doi: https://doi.org/10.1101/2021.02.28.21252621; this version posted March 2, 2021. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

Figure 1: Antibody titres in U/ml at Day 0, 7,14 and 28 for the two groups; sero-
positive on day 0 before vaccination (red) and sero-negative on day 0 before
vaccination (blue). A) Data for all individuals available in the study at 4 time points.
B) Data for individuals who gave their samples at all 4 time points.
Oxford/AstraZeneca vaccine which is being produced as Covishield in India had
acceptable rather a better response when two doses are given 12 weeks apart.8 9
This has led to certainly a confusion not only amongst healthcare workforce but also
researchers worldwide who had observed similar outcomes with other vaccine
candidates too. As the study in NY, Maryland and Paris concluded single dose of
Pfizer and Moderna vaccine to be effective in people with pre-existing immunity in
argument of more doses being made available to target a larger population seeing
the limited supply of the vaccine,5 7 there were reports who were not in agreement
with them. It was explicitly stated that the vaccine efficiency of Pfizer improved
substantially after second dose10 and a single dose was not good enough from a
large scale study from Israel.11 Dr Livingston at JAMA has expressed some
important concerns in view of delaying the second dose which should be taken
seriously in context of current vaccination program and pandemic spread.12 The
vaccination dosing has been deliberately kept short to elicit brisk immune response
for the pandemic could be brought under control and if the majority of population
doesn’t get their second dose, the purpose of this vaccine drive gets defeated.
While there is still a standing debate going on between the timing of second dose,
and though we agree with Dr Livingston’s opinion, the vaccine being administered in
India is different and has been tested at different dosing intervals. 13 It has
demonstrated considerable efficacy response after a single dose, and the effect is
likely to be even higher amongst individuals with pre-existing immunity. Thus this
data could be utilized to design an effective vaccine strategy where vaccine could be
prioritized based on sero-prevalence studies. Our data supports safely delaying the
second dose in recipient groups with high sero-positivity. This could be adopted as a
universal strategy, given that the first dose seems to give adequate protection lasting
for about three months in other studies, or could be one part of a dual strategy where
high-risk or vulnerable populations receive the second dose earlier, while normal-risk
subjects have a delayed second dose.
medRxiv preprint doi: https://doi.org/10.1101/2021.02.28.21252621; this version posted March 2, 2021. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .

Conclusion
This work aimed to study pre-existing antibody status and antibody kinetics upon
vaccination in healthcare workers being given Covishield before the second dose.
We could observe a significant difference in antibody response in personnel who
already had pre-existing antibodies in comparison to those who did not. This work
could help generate useful policy changes for having the second dose at later time
points for selected individuals.

Funding
Council of Scientific and Industrial Research, India
Conflict of Interest
Authors declare no competing interests
Acknowledgment
SSG would like to acknowledge CSIR grant for this work. SSG would like to
acknowledge Manish Chowdhary, Yasmeen Khan and Preeti Subramani for sample
analysis. SJ, SSG and DD would like to acknowledge all participants of the study.
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