Background and aims Patients with immune-mediated inflammatory diseases (IMIDs) have an increased risk of COVID-19, primarily attributed to the use of immunosuppressive drugs such as glucocorticoids, which may attenuate the response to vaccines. This meta-analysis aims to assess the serologic response to COVID-19 vaccination in patients with IMIDs. Methods Electronic databases were searched on August 1, 2021 for observational studies. Data including reference population, medications, vaccination, and proportion of patients achieving a serologic response were extracted. Results Twenty-five observational studies (5360 patients) were included for analyses. A majority of the studies used mRNA vaccines (BNT162b2, mRNA-1273) with a small number of studies including other types of vaccines (AZD1222, Coronavac, BBV152, Ad26.COV2.S). Serologic response after a single (6 studies) and two doses (17 studies) of mRNA vaccine were 73.2% (95% confidence interval [CI] 65.7-79.5) and 83.4% (95%CI 76.8-88.4), respectively. On meta-regression, anti-CD20 therapy was associated with lower response rates ( P <0.001) and anti-TNF therapy also showed a trend toward lower response rates ( P = 0.058). Patients with IMIDs were less likely to achieve a serologic response compared to controls after two doses of mRNA vaccine (6 studies; odds ratio 0.086, 95% CI 0.036-0.206, P < .001). There were not enough studies to assess response to the adenoviral or inactivated vaccines. Conclusions Our meta-analysis demonstrated that patients with IMIDs have a reduced response to mRNA COVID-19 vaccines. These results suggest that IMID patients receiving mRNA vaccines should complete the vaccine series without delay and support the strategy of providing a 3rd dose of the vaccine.

Solid organ transplant (SOT) recipients are at greater risk of coronavirus disease 2019 (COVID-19) and have attenuated response to vaccinations. In the present meta-analysis, we aimed to evaluate the serologic response to the COVID-19 vaccine in SOT recipients. A search of electronic databases was conducted to identify SOT studies that reported the serologic response to COVID-19 vaccination. We analyzed 44 observational studies including 6158 SOT recipients. Most studies were on mRNA vaccination (mRNA-1273 or BNT162b2). After a single and two doses of vaccine, serologic response rates were 8.6% (95% CI 6.8–11.0) and 34.2% (95% CI 30.1–38.7), respectively. Compared to controls, response rates were lower after a single and two doses of vaccine (OR 0.0049 [95% CI 0.0021–0.012] and 0.0057 [95% CI 0.0030–0.011], respectively). A third dose improved the rate to 65.6% (95% CI 60.4–70.2), but in a subset of patients who had not achieved a response after two doses, it remained low at 35.7% (95% CI 21.2–53.3). In summary, only a small proportion of SOT recipients achieved serologic response to the COVID-19 mRNA vaccine, and that even the third dose had an insufficient response. Alternative strategies for prophylaxis in SOT patients need to be developed. Key Contribution: In this meta-analysis that included 6158 solid organ transplant recipients, the serologic response to the COVID-19 vaccine was extremely low after one (8.6%) and two doses (34.2%). The third dose of the vaccine improved the rate only to 66%, and in the subset of patients who had not achieved a response after two doses, it remained low at 36%. The results of our study suggest that a significant proportion of solid organ transplant recipients are unable to achieve a sufficient serologic response after completing not only the two series of vaccination but also the third booster dose. There is an urgent need to develop strategies for prophylaxis including modified vaccine schedules or the use of monoclonal antibodies in this vulnerable patient population.

Purpose Patients with cancer have an increased risk of coronavirus disease 2019 (COVID-19) and an attenuated responses to various vaccines. This meta-analysis aims to assess the serologic response to COVID-19 vaccination in patients with cancer. Methods Electronic databases were systematically searched on August 1, 2021 for studies that reported the serologic response to COVID-19 vaccine in cancer patients. Random effects models were used to achieve pooled serologic response rates and odds ratios (ORs). Results We analyzed 16 observational studies with a total of 1453 patients with cancer. A majority of studies used mRNA vaccines (BNT162b2 or mRNA-1273). The proportion of patients achieving a serologic response after a single and two doses of COVID-19 vaccine were 54.2% (95% confidence interval [CI] 41.0–66.9) and 87.7% (95% CI 82.5–91.5), respectively. Patients with hematologic cancers had a lower response rate after the second dose of vaccine compared to those with solid organ cancers (63.7% vs. 94.9%), which was attributable to the low response rates associated with certain conditions (chronic lymphocytic leukemia, lymphoma) and therapies (anti-CD20, kinase inhibitors). A lower proportion of patients with cancer achieved a serologic response compared to control patients after one and two doses of vaccine (OR0.073 [95% CI 0.026–0.20] and 0.10 [95% CI 0.039–0.26], respectively). Conclusions Patients with cancer, especially those with hematologic B-cell malignancies, have a lower serologic response to COVID-19 vaccines. The results suggest that cancer patients should continue to follow safety measures including mask-wearing after vaccination and suggest the need for additional strategies for prophylaxis.

Background: Incoming emergency medicine residents may feel unsure of their ability to handle common emergency department scenarios, even if they are well educated on the proper steps to take in those scenarios. This may not stem from a lack of skill so much as a lack of confidence in their ability to perform with skills they have. Objective: We look to establish a link between completion of simulationbased training in common emergency medicine scenarios and learner self-reported confidence in their ability to perform competently in those scenarios. Methods: Fourth-year medical students who matched into an emergency medicine residency program participated in a Transitional Educational Program (TEP) at the Interprofessional Immersive Simulation Center at the University of Toledo in April 2021. Simulations of 16 procedural skills and clinical judgement cases were carried out using high-fidelity mannequins and real medical equipment in a hospital-based setting. Subjects were given pre-and post-TEP survey questionnaires assessing their self-reported confidence to competently perform in common emergency medicine clinical scenarios, using a 5-grade Likert scale. Data was analyzed using a one-tailed Wilcoxon signed-rank matched-pairs test. Results: Of 19 participating subjects, 16 (84.2%) consented and responded to the pre-survey. Of those 16 subjects, 10 (62.5%) completed the surveys at the correct time and order. The pre-and post-surveys consisted of the same 14 questions. In 11 of 14 survey questions, there was a significant increase in subject self-reported confidence (p<.05) between pre-and post-survey. Conclusions: Simulation-based training in the setting of high-fidelity equipment and faculty guidance improved the self-reported confidence of incoming emergency medicine residents to perform in common emergency medicine scenarios.