INTRODUCTION
Since the first identification of severe respiratory syndrome coronavirus 2 (SARS-CoV-2) virus in Canada, there have been four waves of activity, approximately 1.65 million cases, and 28,000 deaths due to coronavirus disease 2019 (COVID-19) (
1). A first wave occurred between late February and early July of 2020 and was followed by a higher-amplitude second wave that inflected in early August, peaked in late December, and ebbed by mid-March 2021. A third wave started in late March 2021 and was active until late June 2021. The fourth wave soon followed and was active as of November 2021 (
1). Prior seroprevalence surveys of Canadian blood donors by Canadian Blood Services suggested that donors had very low levels of seropositivity (e.g., <5 %) between April 2020 and the second week of January 2021 (
n = 172,919) (
2,
3).
By March 2020, Canadian Blood Services began to collaborate with several laboratories in Canada and the United States with the goal of characterizing the neutralizing capacity of anti-SARS-CoV-2 antibodies in Canadian blood donors (
4–7). This work supported both Canadian convalescent plasma clinical trials as well as national seroprevalence work by the Canadian COVID-19 Immunity Task Force (CITF) (
1,
6,
8–11). A variety of serological detection and neutralization assays were utilized between April 2020 and March of 2021. From these experiments, it was clear that prior to SARS-CoV-2 vaccine rollout in Canada, a strong sustained anti-SARS-CoV-2-neutralizing capacity was not evident in all blood donors and/or convalescent plasma donors with serological evidence of a past SARS-CoV-2 infection (
3,
6,
7).
The SARS-CoV-2 vaccine was first administered in Canada on 14 December 2020 (
12). As of 20 March 2021, 3,487,915 people (9.18% of the population) had received at least one dose of a SARS-CoV-2 vaccine (1 dose: 2,857,576 people [7.52% of the population]). A minute percentage of the population received two doses by that time (630,339 people [1.66% of the population]). From January to March 2021, it is unlikely that many of the blood donors had received a second dose, since vaccine rollout had not yet ramped up, and less than 2% of the Canadian population had received a second dose of vaccine (
13). Vaccine administration was skewed to mRNA vaccines, with 6.69% of the population receiving at least one dose of BNT162b2 (Pfizer-BioNTech, New York, NY, USA; 5.49% received one dose, and 1.20% received two doses). Another 1.66% of the population received at least one dose of mRNA-1273 (Moderna, Cambridge, MA, USA; 1.21% received one dose, and 0.45% received two doses). Finally, 0.81% of the population received one dose of ChAdOx1-nCOV (Serum Institute of India: Covishield, Pune, India, licensed from AstraZeneca, Cambridge, UK); no one received two doses of that vaccine. In that time period, no one in Canada had received Ad26.COV2.S (Janssen, Raritan, NJ, USA) (
13). Vaccination targeted health care workers, adults aged 80 years of age or older, and individuals living in senior citizen group care settings. SARS-CoV-2 vaccine supplies were insufficient in this time period, and Canada would later move to extended dosing intervals for Health Canada-approved vaccines (
14). A survey of Canadian blood donors from 24 March 2021 indicated that 67% of the vaccinated donors were essential or frontline workers (S. O’Brien, unpublished data).
Given differences in national definitions for variants of concern (VOCs) and variants of interest, the manuscript will use the term “variant(s) of concern” to describe Alpha (B.1.1.7), Beta (B.1.351), Gamma (P.1), and Delta (B.1.617.2) (
15,
16). The landscape of circulating VOCs during the first 3 months of 2021 was diverse and changing. By late March 2021, it was estimated that two-thirds of COVID-19 cases in the Canadian province of Ontario were due to VOCs (
17). A survey of SARS-CoV-2 in Ontario indicated that there was an increasing proportion of N501Y VOCs (e.g., Alpha, Beta, and Gamma) identified between mid-February and late March 2021 (
18). This was a very different epidemiologic landscape compared to September 2021, when most SARS-CoV-2-positive specimens (98.9%) in Canada were Delta VOCs (
17). Publicly available data on VOCs (
17) may represent a sampling of convenience, which could be biased by variability in provincial surveillance and sequencing strategies.
During the first 3 months of 2021, it was clear that multiple variables may have been impacting the humoral immunity of Canadian blood donors against wild-type and variant SARS-CoV-2. To understand these variables, this study was undertaken to characterize the neutralizing capacity of plasma from Canadian blood donors against wild-type and variant SARS-CoV-2 from this period.
DISCUSSION
This study evaluated the neutralizing capacity of stored plasma from January to March of 2021 but did not attempt to estimate seroprevalence in Canadian blood donors. A separate analysis of 16,931 specimens from April 13 to 30 indicated that anti-S seroprevalence in Canadian blood (Elecsys anti-SARS-CoV-2 S, Roche Diagnostics, Laval, PQ, Canada) was 3.2% (
21). In this study, we oversampled 320 (7.1%) of 4,500 specimens with evidence of anti-S and/or ant-RBD. These selected specimens were randomized to select a subset for VLP assays (
Fig. 1). We recently used a similar oversampling approach to identify candidate specimens for VLP and 50% plaque reduction/neutralization titer (PRNT
50) studies during the first wave of the pandemic (
6).
Our group has previously shown that the identification of anti-S, anti-RBD, or anti-N in blood donor specimens is not sufficient to predict the neutralizing antibody capacity of plasma against wild-type or variant SARS-CoV-2 (
5,
6). It is also clear that the neutralizing capacity of plasma can vary widely in unvaccinated individuals (
5,
7), even in the presence of anti-S and/or anti-RBD antibodies (
6). Both anti-S and anti-RBD assays used in this study have been previously described as being highly specific (e.g., >98%) (
2). Therefore, it is possible that this group of donors represents donors who failed to mount a neutralizing antibody response to SARS-CoV-2 (
7) or have now lost their neutralizing antibodies as well as anti-N (
7,
22). Within unvaccinated repeat routine Canadian blood donors, we have previously noted a trend to waning anti-N over time with the Abbott anti-N immunoassay and seroreversion of donors over time, with an adjusted rate of decline of −0.06 U/week (95% confidence interval of −0.08 to −0.05) (
22). Within Canadian convalescent plasma donors, we also noted a failure for some individuals to mount a strong neutralizing antibody response against wild-type SARS-CoV-2 soon after infection. Within that convalescent plasma donor population, we also noted a decrease in neutralizing antibody activity, as measured by a wild-type PRNT
50 test over a period of 3 to 4 months after infection (
7). We cannot rule out that some donors within this group may be generating anti-S and anti-RBD against other coronaviruses (
23) or may be false-positive anti-S or anti-RBD due to assay characteristics (
2).
Within the “unvaccinated and anti-N”-positive group (
Fig. 4C), we also found a reduced neutralizing capacity against Beta VLPs compared to wild-type VLPs as well as Alpha, Gamma, and Delta VLPs. Neutralization of Beta VLPs was also reduced compared to Alpha, Gamma, and Delta VLPs. In a previous pilot study in unvaccinated routine blood donors with prior evidence of infection (e.g., anti-S and/or anti-RBD), we noted a variability in plasma specimens’ ability to neutralize Beta VLPs and live virus (
6). Similarly, a Strasbourg cohort of convalescent plasma collected prior to the emergence of the VOCs also showed a reduction of neutralizing capacity against Beta (
24,
25). Convalescent plasma collected from patients in the United States during the spring of 2020 also showed a reduced neutralizing capacity against Beta (
26). In a recent meta-analysis by Chen et al., serum from previously infected individuals had the greatest decrease in Beta (4.1-fold) compared to wild-type neutralization in live virus neutralization studies. This was then followed by decreased Delta (3.2-fold), Gamma (1.8-fold), and Alpha neutralization (1.4-fold) (
27). We note that fold changes described in live virus studies may not translate to VLP studies. This variability to neutralize SARS-CoV-2 VOCs was previously described by our group using plasma collected in April and May of 2020 (
6).
Donor plasma in the “vaccinated and no anti-N” group (
Fig. 4B) tended to have peak and median neutralization to wild type that was similar to the “vaccinated with anti-N” group (
Fig. 4A). However, compared to wild-type VLPs, there was reduced neutralization of Alpha, Beta, Gamma, and Delta VLPs in this group. Neutralization of Beta VLPs was also reduced compared to Alpha and Delta VLPs. This group may represent donors who were vaccinated only or donors who were infected and vaccinated and now have a waned anti-N (
2,
3,
22). A pooled meta-analysis has recently described heterogeneity in studies assessing the neutralizing capacity of vaccinated individuals against VOCs, which may depend on a variety of factors, including agents (e.g., live virus versus pseudovirus) used in experiments (
27). However, that meta-analysis did note that geometric mean titers were lowest against Beta in a variety of studies focused on vaccinated individuals (
27). It is important to highlight that there was no absolute loss of neutralizing capacity in plasma from this group against Alpha, Beta, Gamma, and Delta.
The smallest group of specimens available in this study was from the “vaccinated and anti-N” group (
n = 5). We know from previous studies that less than 5% of Canadian blood donors exhibited evidence of infection by September of 2020 (
2). From a large unpublished seroprevalence study of Canadian blood donors, we also know that as of May 2021, that seroprevalence in this population had only reached 4% (
21). Furthermore, as of late March 2021, only 9.18% of the Canadian population had received at least one dose of vaccine (
13). This group would also most likely represent vaccinated blood donors who also had a history of natural SARS-CoV-2 infection and who had not yet lost anti-N (
22). The small numbers of plasma specimens within this group exhibited reduced neutralizing capacity against Beta VLPs compared to wild-type VLPs. Unlike the “vaccinated and no anti-N” group, reduced neutralization capacity was not significant against other variant VLPs and might be a product of cross-variant neutralizing capacity in vaccinated and previously infected individuals (
28,
29). Other trends in variant neutralization may have not been evident due to the small number of specimens in this group.
Vaccination against SARS-CoV-2 provides substantial protection against severe outcomes even with an ecological niche now dominated by Delta (
30,
31). Previous work has suggested that fully vaccinated individuals are less likely to be reinfected than previously infected individuals (
32). It is also clear that vaccinated individuals can still mount effective, albeit reduced, neutralization against VOCs (
27,
33). Two factors may be at play in this study, (i) absolute neutralizing titers against wild-type and variant SARS-CoV-2 and (ii) breadth of antibody protection against one or more strains of SARS-CoV-2. In this study, wild-type and variant neutralizing capacity was higher in vaccinated donor specimens than in nonvaccinated donor specimens who exhibited serological evidence for SARS-CoV-2 infection (Fig. S1A to E in the supplemental material). This was evidenced by the higher absolute peak and median neutralization values for vaccinated individuals as well as lack of any neutralizing capacity in a subset of unvaccinated donors (unvaccinated and no anti-N) (
Fig. 4A to
D; Table S2; Fig. S1A to E). Higher absolute neutralizing capacity may be an important defense mechanism in infections involving exceedingly high viral titers of Delta virus (
34,
35). It is also important to note that plasma from vaccinated donors displayed a greater breadth of protection against strains of SARS-CoV-2 than did plasma from unvaccinated donors.
As previously mentioned, during this time period, less than 2% of the Canadian population had received a second dose of vaccine (
13). A recent preprint suggests that a single dose of an mRNA (Pfizer-BioNTech [BNT162b2] or mRNA-1273 [Moderna]) vaccine produced neutralization titers like those measured in convalescent individuals. The study was also not able to determine which vaccine was received by donors. A recent meta-analysis of immunogenicity studies suggests that mRNA and vector vaccines stimulate measurable antibody responses to SARS-CoV-2 wild type and VOCs (
36). In contrast, Ad26.COV2.S (Janssen) yielded lower antibody concentrations and frequently negative neutralization titers (
37). Geometric mean titer (GMT) values in a proxy assay for wild-type neutralization have been shown to double after the second dose of ChAdOx1-nCOV (
38).
There are several key limitations to this study that have not already been addressed. First, this study involved a relatively small number of specimens collected from Canadian blood donors collected in a low-seroprevalence setting and prior to large-scale national vaccine coverage (
2,
13,
21). The study was not able to identify if donors had a laboratory or clinical diagnosis of SARS-CoV-2 and when infection occurred. This therefore prevents us from developing an understanding of the impact of waning neutralizing humoral immunity in this study population (
7). One drawback to our study is that for operational and ethics approval reasons, we were unable to capture information on vaccine type and if a second dose of vaccine had been administered. We were only able to assesses donors for the receipt of a SARS-CoV-2 vaccine in the prior 3 months and not the timing of the vaccine (
39). These experiments utilized VLPs and not PRNT
50 assays using live wild-type or variant SARS-CoV-2. We have not seen concerning trends in extrapolating conclusions from VLP-based experiments in our prior work (
20) nor in other studies but intend to explore these differences soon (
6,
27). Finally, this study also does not account for cell-mediated immunity as well as the development of sustained B cell immunity in vaccinated and previously infected blood donors (
40–42).
In the first 3 months of 2021, Canadian blood donors had various levels of humoral protection against wild-type and variant SARS-CoV-2. The highest absolute levels of neutralizing capacity were in vaccinated blood donors, albeit with reduced neutralization capacity against SARS-CoV-2 VOCs. One concern highlighted in this study was that unvaccinated blood donors not only had reduced neutralizing capacity against Beta but, in the absence of anti-N, also had no measurable neutralization capacity against wild-type and variant SARS-CoV-2. Therefore, the manuscript highlights the importance of vaccination in populations with low levels of seroprevalence to SARS-Co-V2, even in individuals with prior SARS-CoV-2 infection.
MATERIALS AND METHODS
Ethical considerations.
Ethics board clearance was provided by Canadian Blood Services, the University of Alberta, and the Sinai Health, Toronto (Lunenfeld-Tanenbaum Research Institute).
CIHR correlates of immunity study participants and samples.
Canadian Blood Services collects blood donations in all provinces except Quebec, with collection sites concentrated in large and small cities. Blood donors (≥17 years age) meet rigorous health selection criteria, and blood donations are used to manufacture products for transfusion. With each donation, an additional EDTA plasma retention sample is also collected alongside each donation (
43).
This study used a repeated cross-sectional design. A random cross-sectional sampling of all available Canadian Blood Services retention specimens (n = 1,500/month) was selected monthly for January, February, and March 2021.
Collection of SARS-CoV-2 vaccination history in donors.
At the time of donation, all donors were asked if they recently had a vaccination within the prior 3 months. Specifically, information on SARS-CoV-2 vaccination was routinely captured on the record of donation as standard practice by this blood operator. Due to ethics approval and operational issues, information on exact timing, vaccine producer, and dosing schedule (e.g., first or second dose) was not collected. Data from provincial vaccine databases could also not be linked to the records of donation. These data were stored in the donor database.
Samples were anonymized. Data, including donation date, birth year, sex, collection site, and residential Forward Sortation Area (FSA; first three characters of postal code), were extracted from the donor database. Plasma specimens were aliquoted at Canadian Blood Services. One aliquot (250 μL) was stored at –80°C for the remainder of the study.
Enzyme-linked immunosorbent assays for detecting IgG.
IgG analysis was undertaken at the Lunenfeld-Tanenbaum Research Institute, Sinai Health, on all retained specimens. Assays were anti-spike (anti-S), anti-receptor-binding domain (anti-RBD), and anti-nucleocapsid protein (anti-N), as previously described (
19). Ratio-converted enzyme-linked immunosorbent assay (ELISA) reads were undertaken as previously described (
5,
20), and cutoffs (positive) of each of the targets were ≥0.396 for N, ≥0.186 for RBD, and ≥0.190 for S (
2).
Abbott architect SARSCoV-2 IgG test.
Plasma samples were also tested with the Abbott Architect SARS-CoV-2 IgG test (Abbott Laboratories, USA), which detects anti-N IgG antibodies, as directed by the manufacturer, using an antibody index (AI) cutoff of 1.4 (
2,
3).
Definition of an anti-N-positive specimen.
A specimen was defined as anti-N positive if it had one or more anti-N-positive signals from either the Abbott or the Lunenfeld-Tanenbaum Research Institute, Sinai Health, assays.
Selection of specimens for neutralizing analysis.
As previously described, a tiered testing approach of specimens with any potential evidence of a signal for anti-S or anti-RBD (with or without anti-N) was used to select specimens for further analysis by neutralization methods (
4,
5). Specimens were then randomized with replacement, as previously described (
2).
Spike-pseudotyped VLP neutralization assay.
Pseudovirus generation was performed in HEK293TN cells (a cell line optimized for lentiviral particle production; Systems Biosciences; RRID:CVCL_UL49), as previously described (
5,
20), with minor modifications. Briefly, VLPs were generated from cotransfection with jetPRIME (Polyplus Inc.) of HEK293TN cells (in 10% fetal bovine serum [FBS] and 1% penicillin/streptomycin [Pen/Strep] in Dulbecco’s modified Eagle’s medium [DMEM]) with (i) viral packaging (psPAX2, Addgene), (ii) ZsGreen and luciferase reporter (pHAGE-CMV-Luc2-IRES-ZsGreen-W, kindly provided by Jesse Bloom), and (iii) spike protein constructs. Spike constructs were wild-type (a sequence based on Wuhan-Hu-1 but bearing the D614G mutation) and the following VOCs: Alpha (B.1.1.7), Beta (B.1.351), Gamma (P.1), and Delta (B.1.617.2); all were kindly provided by W. Rod Hardy of CoVaRR-Net. After 8 h of transfection, the medium was replaced by DMEM containing 5% heat-inactivated FBS and 1% Pen/Strep, and the cells were incubated for 16 h at 37°C and 5% CO
2; they were then transferred to 33°C and 5% CO
2 for an additional 24 h for VLP production. At 48 h after transfection, the supernatant was collected, centrifuged at 500 ×
g for 5 min at room temperature, filtered through a 0.45-μm filter, and frozen in aliquots at –80°C. The pseudovirus particles were used at a dilution resulting in greater than 1,000 relative luciferase units (RLUs) over control (1:20 to 1:250 dilution of virus stock, depending on the virus titers of each variant). For the neutralization assay, human sera were heat inactivated (56°C, 1 h) and diluted at 1:20 in assay medium and then serially diluted by 2.5-fold over 7 dilutions before incubation with diluted pseudovirus at a 1:1 ratio for 1 h at 37°C. The virus and serum mixture was then transferred onto HEK293T-ACE2/TMPRSS2 cells (maintained in 10% heat-inactivated FBS and 1% Pen/Strep in DMEM), a stable cell population resulting from the serial transduction (with a multiplicity of infection [MOI] of <1) first of angiotensin-converting enzyme 2 (ACE2) (in pLenti CMV Puro DEST, Addgene, 17452) and selection with puromycin (1 μg/mL) then with TMPRSS2 (in pLenti CMV Hygro DEST, Addgene, 17454) and selection with hygromycin (150 μg/mL). Both the HEK293TN and HEK293T-ACE2/TMPRSS2 cells were maintained in indicated DMEM medium and passaged before they reached 85% confluence; cells were not kept in culture for more than 25 passages. The infected cells were lysed after 48 h using BrightGlo luciferase reagent (Promega, Madison, WI) and read with a PerkinElmer EnVision instrument. Unless otherwise specified, the 50% neutralization titers (ID
50) were generated in GraphPad Prism 9, using a nonlinear regression algorithm (log [inhibitor] versus normalized response – variable slope). Data were further cleaned, analyzed, and visualized using Python (v. 3.9.7) and Seaborn (0.11.2). The assay performer was blinded to the patient sample groups.
Data storage and statistical analysis.
Blood donor data were stored on a Microsoft Excel (Redmond, WA, USA) spreadsheet. Data were analyzed as described in Results using GraphPad Prism (9.2.0, GraphPad Software, Inc, San Diego, CA, USA). Data analyses undertaken using this statistical program included descriptive statistics, Fisher’s exact test (two sided), and a Mann-Whitney U test. Friedman statistics with Dunn’s multiple-comparison tests were used when there was analysis of repeated measures within a group, such as when comparing wild-type, Alpha, Beta, Gamma, and Delta VLP neutralization within a group of plasma (e.g., “vaccinated and anti-N”). Kruskal-Wallis with Dunn’s multiple-comparisons statistics were used when repeated measures were not used and neutralization of a specific VOC (e.g., Alpha) was compared across plasma from different groups (e.g., tested “vaccinated and anti-N” versus “vaccinated and no anti-N” versus “not vaccinated and anti-N” versus “not-vaccinated and no anti-N” plasma against Alpha VLPs). Graphing of data used GraphPad Prism.
ACKNOWLEDGMENTS
We are grateful to W. Rod Hardy for the spike constructs and Jesse Bloom for VLP packaging reagents. We thank Craig Jenkins and Valerie Conrod for assistance with testing and coordination. We are also grateful to Canadian Blood Services staff and leadership for support for this project.
The following authors have no conflicts of interest: S.F.O., Q.H., R.S., K.T.A., B.R., K.C., and Q.-L.Y. S.J.D. has functioned as a content expert for respiratory viruses for Johnson & Johnson (Janssen). A.-C.G. receives research funding from Providence Therapeutics Holdings, Inc., for other projects. A.-C.G. is the Canada Research Chair (Tier 1) in Functional Proteomics and pillar lead for CoVaRR-Net.
S.J.D., S.F.O., and A.-C.G. received funding through the Canadian Institutes of Health Research (CIHR; VR2-172723) and Alberta Innovates (G2020000360 S.J.D.). A.-C.G. also received funding through the Krembil Foundation to the Sinai Health System Foundation, Ontario Together, and CIHR (VR1-172711, with supplement from the COVID-19 Immunity Task Force). The robotics equipment used for the ELISA assays is housed in the Network Biology Collaborative Centre at the Lunenfeld-Tanenbaum Research Institute (A.-C.G.), a facility supported by Canada Foundation for Innovation funding by the Ontario Government and by Genome Canada and Ontario Genomics (OGI-139). The development of the spike protein constructs and VLP assays was supported by the CIHR operating grant to the Coronavirus Variants of Concern Rapid Response Network (CoVaRR-Net) to A.-C.G. Commercial Abbott Architect SARS-Cov-2 IgG assay kit costs were partially supported by Abbott Laboratories, Abbott Park, IL. Abbott analyzers used at Canadian Blood Services were provided by the COVID-19 Immunity Task Force (CITF). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Q.H., R.S., K.T.A., and K.C. developed the methodology. Q.H., R.S., and B.R. performed the investigations. A.-C.G., S.J.D., and S.F.O. acquired funding. A.-C.G., S.J.D., and S.F.O. supervised the project. S.J.D. drafted the manuscript. S.F.O., Q.-L.Y., and S.J.D. performed data collation and analysis.