The n e w e ng l a n d j o u r na l of m e dic i n e
C or r e sp ondence
Neutralization Escape by SARS-CoV-2 Omicron
Subvariants BA.2.12.1, BA.4, and BA.5
To the Editor: In recent months, multiple lin-
eages of the omicron (B.1.1.529) variant of severe
acute respiratory syndrome coronavirus 2 (SARS-
CoV-2) have emerged,1 with subvariants BA.1 and
BA.2 showing substantial escape from neutraliz-
ing antibodies.2-5 Subvariant BA.2.12.1 is now the
dominant strain in the United States, and BA.4
and BA.5 are dominant in South Africa (Fig. 1A).
Subvariants BA.4 and BA.5 have identical sequenc-
es of the spike protein.
We evaluated neutralizing antibody titers
against the reference WA1/2020 isolate of SARS-
CoV-2 along with omicron subvariants BA.1, BA.2,
BA.2.12.1, and BA.4 or BA.5 in 27 participants
who had been vaccinated and boosted with mes-
senger RNA vaccine BNT162b2 (Pfizer–BioNTech)
and in 27 participants who had been infected
with the BA.1 or BA.2 subvariant a median of 29
days earlier (range, 2 to 113) (Tables S1 and S2
in the Supplementary Appendix, available with
the full text of this letter at NEJM.org). In the
vaccine cohort, participants were excluded if they
had a history of SARS-CoV-2 infection or a posi-
this week’s letters
86 Neutralization Escape by SARS-CoV-2 Omicron
Subvariants BA.2.12.1, BA.4, and BA.5
88 SARS-CoV-2 Infection in Patients with a History
of VITT
90 Nonoperative or Surgical Treatment of Acute
Achilles’ Tendon Rupture
91 The Increasing Incidence of Early-Onset
Colorectal Cancer
94 Prone Positioning of Intubated Patients with an
Elevated BMI
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tive result on nucleocapsid serologic analysis or
if they had received another vaccine against coro-
navirus disease 2019 (Covid-19) or an immuno-
suppressive medication.
Six months after the initial two BNT162b2
immunizations, the median neutralizing anti-
body pseudovirus titer was 124 against WA1/2020
but less than 20 against all the tested omicron
subvariants (Fig. 1B). Two weeks after adminis-
tration of the booster dose, the median neutral-
izing antibody titer increased substantially, to
5783 against the WA1/2020 isolate, 900 against
the BA.1 subvariant, 829 against the BA.2 sub-
variant, 410 against the BA.2.12.1 subvariant, and
275 against the BA.4 or BA.5 subvariant. These
data show that as compared with the response
against the WA1/2020 isolate, the neutralizing
antibody titer was lower by a factor of 6.4 against
BA.1, by a factor of 7.0 against BA.2, by a factor
of 14.1 against BA.2.12.1, and by a factor of 21.0
against BA.4 or BA.5. In addition, as compared
with the median neutralizing antibody titer against
the BA.1 subvariant, the median titer was lower
by a factor of 2.2 against the BA.2.12.1 subvariant
and by a factor of 3.3 against the BA.4 or BA.5
subvariant.
Among the participants who had been infected
with the BA.1 or BA.2 subvariant of omicron, all
but one had been vaccinated against Covid-19.
Because of the variation in sampling after the
onset of infection, some samples may not reflect
peak neutralizing antibody titers (Table S2). Among
the participants with a history of Covid-19, the
median neutralizing antibody titer was 11,050
against the WA1/2020 isolate, 1740 against the
BA.1 subvariant, 1910 against the BA.2 subvari-
ant, 1150 against the BA.2.12.1 subvariant, and
590 against the BA.4 or BA.5 subvariant (Fig. 1C).
These data show that as compared with the
nejm.org July 7, 2022
 Correspondence

A Mutational Lineage of SARS-CoV-2 Subvariants

S1/S2

NTD RBD SD1 SD2 FP HR1 HR2

RBM

Y505H
G496S Q498R
N501Y

Q954H
D796Y
P681H

N764K
G339D

Q493R
S477N
T478K
S373P
BA.1 and BA.2

N440K
K417N

D614G
S375F

N679K

N969K
H655Y
G142D

E484A
BA.1 Only

T95I

L212I
∆143-145
∆211

T547K
+214EPE
∆69–70

L981F
A67V

G446S

N856K
S371L

T376A
S371F
BA.2 Only
T19I

D405N
V213G
A27S

R408S
∆24–26

BA.2.12.1 Only

L452Q

S704L
(vs. BA.2)

F486V
∆69–70

Q493
BA.4 or BA.5 Only

L452R
(vs. BA.2)

B Vaccinated Participants before and after Booster Dose C Infected Participants with BA.1 or BA.2 Subvariant
9.6×
14.1×
18.7×
21.0×
5.8× 2.9×
6.4× 3.3×
1.5×
2.2×
105 105 11,050
1910
Neutralizing Antibody Titer

Neutralizing Antibody Titer

1740
5783 590
104 104 1150
900 829
410
275
103 103
124

102 <20 102

<20 <20 <20

101 101
A

.1

.2

.5

.1

.2

.5

.1

.2

.5
2.

2.

2.
W

W
BA

BA

BA

BA

BA

BA

BA

BA

BA
.1

.1

.1
.2

.2

.2
or

or

or
BA

BA

BA
.4

.4

.4
BA

BA

BA
Before Booster After Booster

Figure 1. Omicron Subvariant Mutations and Neutralizing Antibody Responses.

Panel A shows the lineage of mutations that have been identified in the omicron BA.1, BA.2, BA.2.12.1, and BA.4 or BA.5 subvariants of
SARS-CoV-2, as compared with the reference WA1/2020 isolate. BA.4 and BA.5 have identical sequences of the spike protein and thus
have been grouped together. FP denotes fusion peptide, HR1 heptad repeat 1, HR2 heptad repeat 2, NTD N-terminal domain, RBD re-
ceptor-binding domain, RBM receptor-binding motif, SD1 subdomain 1, and SD2 subdomain 2. Panel B shows neutralizing antibody ti-
ters as determined by luciferase-based pseudovirus neutralization assays in samples obtained from 27 participants 6 months after re-
ceipt of the two-dose BNT162b2 messenger RNA vaccine series and 2 weeks after the third (booster) dose. Panel C shows neutralizing
antibody titers in participants who had been infected with the BA.1 or BA.2 subvariant. All the infected participants had been vaccinated
except for 1 participant who had a negative neutralizing antibody titer. In 9 participants, two or three time points after infection are
shown. Neutralizing antibody titers were measured against the SARS-CoV-2 reference isolate WA1/2020 and the omicron BA.1, BA.2,
BA.2.12.1, and BA.4 or BA.5 subvariants. In Panels B and C, medians (black bars) are shown numerically, and factor differences from
other subvariants are indicated; the dashed horizontal line indicates the lower limit of detection for the assay.

WA1/2020 isolate, the median neutralizing anti- median titers against the BA.1 subvariant, the
body titer was lower by a factor of 6.4 against BA.1, median titer was lower by a factor of 1.5 against
by a factor of 5.8 against BA.2, by a factor of 9.6 the BA.2.12.1 subvariant and by a factor of 2.9
against BA.2.12.1, and by a factor of 18.7 against against the BA.4 or BA.5 subvariant.
BA.4 or BA.5. In addition, as compared with the These data show that the BA.2.12.1, BA.4,

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The New England Journal of Medicine

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Copyright © 2022 Massachusetts Medical Society. All rights reserved.
 The n e w e ng l a n d j o u r na l
and BA.5 subvariants substantially escape neu-
tralizing antibodies induced by both vaccination
and infection. Moreover, neutralizing antibody
titers against the BA.4 or BA.5 subvariant and (to
a lesser extent) against the BA.2.12.1 subvariant
were lower than titers against the BA.1 and BA.2
subvariants, which suggests that the SARS-CoV-2
omicron variant has continued to evolve with
increasing neutralization escape. These findings
provide immunologic context for the current
surges caused by the BA.2.12.1, BA.4, and BA.5
subvariants in populations with high frequen-
cies of vaccination and BA.1 or BA.2 infection.
Nicole P. Hachmann, B.S.
Jessica Miller, B.S.
Ai-ris Y. Collier, M.D.
John D. Ventura, Ph.D.
Jingyou Yu, Ph.D.
Marjorie Rowe, B.S.
Esther A. Bondzie, M.S.N.
Olivia Powers, B.S.
Nehalee Surve, M.S.
Kevin Hall, B.S.
Dan H. Barouch, M.D., Ph.D.
SARS-CoV-2 Infection in Patients with a History of VITT
To the Editor: Vaccine-induced immune throm-
botic thrombocytopenia (VITT) is a prothrom-
botic adverse effect of vaccination against severe
acute respiratory syndrome coronavirus 2 (SARS-
CoV-2), an important measure in the prevention
of severe coronavirus disease 2019 (Covid-19).
VITT is caused by platelet-activating antiplatelet
factor 4 (PF4) antibodies of immunoglobulin G
class that have been rarely induced by two adeno-
virus vector–based Covid-19 vaccines, ChAdOx1
nCoV-19 (AstraZeneca) and Ad26.COV2.S (John-
son & Johnson/Janssen).1
All available Covid-19 vaccines generate an
immune response against the SARS-CoV-2 spike
protein, which arouses concern that VITT may
be triggered by cross-reactivity between PF4 and
spike protein,2 a view that has been reinforced
by the detection of antibodies against PF4 in
some patients with Covid-19.3 Despite encourag-
ing in vitro studies that provided no evidence of
a link between anti–SARS-CoV-2 and anti-PF4
immune responses,4 investigators could not pro-
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Copyright © 2022 Massachusetts Medical Society. All rights reserved.
of m e dic i n e
Beth Israel Deaconess Medical Center
Boston, MA
dbarouch@bidmc.harvard.edu
Supported by a grant (CA260476) from the National Institutes
of Health (NIH), by the Massachusetts Consortium for Pathogen
Readiness, and by the Ragon Institute. Dr. Barouch is supported
by the Musk Foundation. Dr. Collier is supported by the Repro-
ductive Scientist Development Program of the Eunice Kennedy
Shriver National Institute of Child Health and Human Develop-
ment, by a grant (HD000849) from the Burroughs Wellcome
Fund, and by a grant (AI69309) from the NIH.
Disclosure forms provided by the authors are available with
the full text of this letter at NEJM.org.
This letter was published on June 22, 2022, at NEJM.org.
1. Viana R, Moyo S, Amoako DG, et al. Rapid epidemic expan-
sion of the SARS-CoV-2 omicron variant in southern Africa. Na-
ture 2022;​603:​679-86.
2. Cele S, Jackson L, Khoury DS, et al. Omicron extensively but
incompletely escapes Pfizer BNT162b2 neutralization. Nature
2022;​602:​654-6.
3. Liu L, Iketani S, Guo Y, et al. Striking antibody evasion man-
ifested by the omicron variant of SARS-CoV-2. Nature 2022;​602:​
676-81.
4. Yu J, Collier AY, Rowe M, et al. Neutralization of the SARS-
CoV-2 omicron BA.1 and BA.2 variants. N Engl J Med 2022;​386:​
1579-80.
5. Iketani S, Liu L, Guo Y, et al. Antibody evasion properties of
SARS-CoV-2 omicron sublineages. Nature 2022;​604:​553-6.
DOI: 10.1056/NEJMc2206576
vide in vivo evidence to exclude such a link due
to the lack of an animal model. However, if both
immune responses are indeed linked, VITT sur-
vivors who subsequently contract Covid-19 should
have an increase in anti–PF4 antibodies, poten-
tially even retriggering thrombocytopenia or
thrombosis.
We performed periodic evaluation of VITT
antibody status (study registry, EUPAS45098) in
a cohort of 69 patients with a history of VITT
who had received an adenovirus vector Covid-19
vaccine. Of these patients, 24 did not receive any
subsequent doses of a Covid-19 vaccine; the re-
maining 45 patients received subsequent doses
of a messenger RNA (mRNA) vaccine (either the
BNT162b2 [Pfizer–BioNTech] or the mRNA-1273
[Moderna] vaccine). Of these patients, 31 received
a second dose and 14 received a third dose. The
characteristics of the patients are provided in
Table S1 in the Supplementary Appendix, avail-
able with the full text of this letter at NEJM.org.
Of the 69 patients, Covid-19 developed in 11
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