COVID-19 CoronaVac in Patients With Autoimmune Rheumatic Diseases and HIV/AIDS

A sample of 1254 patients with rheumatic diseases and 542 healthy controls matched for age
and sex was calculated as follows.

1.A) Evaluation of patients with SLE compared to a healthy control group matched for age and
sex. The investigators calculated 74 patients in each arm, which will be compared
independently to the healthy control group:

- 74 SLE patients treated with hydroxychloroquine alone;

- 74 SLE patients with mild immunosuppression (azathioprine or methotrexate and prednisone
<10 mg/day);

- 74 patients with moderate to severe immunosuppression (mycophenolate mofetil or
cyclophosphamide and/or prednisone >10 mg/day);

- 50 patients with belimumab (convenience sample). Total: 272 SLE patients and 74 healthy
controls.

1.B) Evaluation of RA patients compared to healthy controls matched for age and sex. The
investigators calculated 61 patients in each arm, which will be independently compared
to the control group:

- 61 RA patients only with conventional synthetic disease-modifying drugs (DMARDs);

- 61 RA patients with biological disease-modifying drugs (bDMARDs) with anti-TNF
(anti-tumor necrosis factor) action;

- 61 RA patients with bDMARDs with non-anti-TNF action and with impact on the production
of immunoglobulins (abatacept and rituximab);

- 61 RA patients with bDMARDs with anti-IL-6 (anti-interleukin-6) action (tocilizumab) and
synthetic drugs with anti-JAK (anti-janus kinase) action (tofacitinib).

Total: 244 RA patients vs. 61 healthy controls. 1.C) Evaluation of the interruption of the
use of methotrexate (MTX) for 4 weeks from the first dose of vaccination in RA patients.
Inclusion: patients using MTX in a stable dose for at least 4 weeks, prednisone maximum dose
of 7.5 mg/day, in association or not with other drugs, to be randomized in two arms: one that
keeps the therapy stable and the other which suspends MTX for 4 weeks from the first dose.
The investigators calculated 96 patients in each arm:

- 96 MTX patients who will not have their therapy changed;

- 96 MTX patients who will stop only MTX on the day of vaccination for 4 weekly
applications.

Total: 192 RA patients.

1.D) Evaluation of patients with AS/psoriatic arthritis compared to a healthy control group
matched for age and sex. The investigators calculated 136 patients in each arm, 136 with
synthetic DMARDs and 136 with bDMARDs, to be compared with 136 healthy controls matched for
age and sex.

Total: 272 patients with AS/psoriatic arthritis vs. 136 healthy controls.

1. E) A convenience sample of 250 (50 in each group) patients with other rare rheumatic
diseases (SSc, PM/DM, pSS, systemic vasculitis, and primary antiphospholipid antibody
syndrome) being followed up in Rheumatology Division (HCFMUSP) will be vaccinated and
matched using the pool of controls from the other samples.

Controls: 271 healthy controls matched for age and sex will be included according to the
need for controls for SLE (n = 74), RA (n = 61) and AS/psoriatic arthritis (n = 136)
will be selected to receive the vaccine at HCFMUSP.

2. PEOPLE LIVING WITH HIV/AIDS (PLWHA) The investigators considered the immunogenicity of
the vaccine for Yellow Fever as a parameter in a previous study carried out by our
group. The response found was p1 = 92% induction of neutralizing antibodies in PLWHA.
Considering the 1:1 ratio between vaccinated and controls, alpha error of 5% with 80%
power, the sample size will be 271 vaccinated in the PLWHA group and 271 in the control
group, with an effect size of 0.25.

Total population: 1254 ARD patients + 542 controls + 271 patients in PLWHA group = 2067
patients.

In addition to a symptom diary (provided to research subjects on the 1st and 2nd vaccine
doses), all patients and controls were instructed to contact the researchers by email,
WhatsApp, and telephone in case of adverse effects or symptoms of COVID. In cases of
suspected COVID, RT-PCR and genotyping are being performed.

Extension phase of the project

There are clinical trials using a booster dose (third dose of mRNA vaccine against COVID-19)
in renal transplant recipients, who similarly to patients with autoimmune rheumatic diseases
(ARDs), had high rates (about 40%) of poor humoral response. Antibody titers increased after
the third dose in one third of patients who had negative response and in all patients who had
low antibody titers. In addition, patients on therapy with specific drugs (tacrolimus,
mycophenolate and glucocorticoids) were less likely to develop anti-SARS-CoV-2 antibodies
than those treated with other regimes. No serious adverse events were observed after the
third dose (Werbel et al., 2021; Benotmane et al., 2021).

Therefore, we consider a booster dose (third dose of Sinovac-CoronaVac) for ARDs patients 6
months after the primary vaccination. The monitoring of anti-SARS-CoV-2 humoral response
[anti-SARS-CoV-2 IgG seroconversion and neutralizing antibody (NAb)] will be carried out
immediately before the third dose and 6 weeks after.

This extension phase of the study was approved by the National Research Ethics Committee
(Comissão Nacional de Ética em Pesquisa) (4.951.263). Only participants (patients/controls)
who agree to participate in the extension phase of the study will be included according to
the signed updated informed consent form. The expected sample is 1300 patients and 340
controls.

Guidance on use of immunosuppressive medications during the vaccination period will be
according to the updated recommendations of the American College of Rheumatology (ACR)
(https://www.rheumatology.org/Portals/0/Files/COVID-19-Vaccine-Clinical-…
easesSummary.pdf).

Similar to the first phase of the study, in addition to a symptom diary (provided to research
subjects on the 3th vaccine doses), all patients and controls were instructed to contact the
researchers by email, WhatsApp, and telephone in case of adverse effects or symptoms of
COVID. In cases of suspected COVID, RT-PCR and genotyping are being performed.

In an exploratory substudy nested within this phase 4 trial, a subsample composed by
AS/psoriatic arthritis (n=60) will be randomly assigned to receive exercise or nothing 1 hour
before vaccination, under the working hypothesis that exercise may boost immune responses to
the vaccine, wich would benefit immunocompromised patients. The exercise session will be
conducted by experienced exercise physiologists and will comprise a brief specific warm-up
and 3 unilateral resistance exercises (lateral raise, biceps curl and overhead extension) in
the left arm (the same arm used for vaccination). The exercises will be performed using
dumbbells, with eccentric and concentric contractions (4 sets of 8-12 repetition maximum).
Interval between exercises and sets will be 30 seconds. The total duration of the exercise
session will be approximately 20 minutes. Thirty minutes after the end of the exercise
session, patients will receive the vaccine in the same arm (i.e., left arm). Immediately, 24h
and 48h after the exercise session, local pain (muscle soreness) in the exercised arm will be
assessed by visual analogue scale (0 [no pain] to 100 [worst possible pain]).
Exercise-induced edema will be determined by circumference measures of the biceps.
Participants will also report self-perceived exertion after exercise using the Borg scale.
Blood sample to assess immunogenicity (primary outcome) will follow the same schedule
proposed in the phase 4 trial. Control group will receive no intervention and will follow the
vaccination scheme adopted in the phase 4 trial.

Amendment to the extension phase of the project

Rationale: There are clinical trials comparing homologous vaccine scheme (two first doses)
against COVID-19 versus heterologous immunization suggesting that the latter was well
tolerated and improved immunogenicity healthy individuals (Hillus et al., 2021). In animal
models, there is evidence that application of a third vaccine dose (booster) with an mRNA
vaccine after two vaccine doses of inactivated against COVID-19 induce a relatively higher
level of neutralizing antibodies and T cell response (Zhang et al., 2021). Thus, we will
include the following extension analyses in this project:

1. For patients and controls without humoral response (anti-SARS-CoV-2 S1/S2 IgG and/or
neutralizing antibodies) after the 3rd dose of CoronaVac vaccine, a booster dose with
the available heterologous vaccine will be given as per the Plan National Vaccination of
COVID-19 in ARD patients.

2. A new serology analysis will be performed (anti-SARS-CoV-2 S1/S2 IgG and neutralizing
antibodies) 4-8 weeks after the heterologous vaccine booster. Immunogenicity will be
assessed through seroconversion rates of total IgG antibodies against S1 and S2 antigens
and neutralizing antibodies.

3. In addition, the participants will be instructed to write down in a diary standardized
changes that occur and to contact investigators by e-mail or WhatsApp.

4. The updated recommendations of the American College of Rheumatology (ACR) regarding to
the use of immunosuppressive medications during the vaccination period will be followed
(https://www.rheumatology.org/Portals/0/Files/COVID-19-Vaccine-Clinical-…
icDiseasesSummary.pdf).

This amendment to the extension phase of the project was approved by the National Research
Ethics Committee (Comissão Nacional de Ética em Pesquisa) (5.014.175). Only participants
(patients/controls) who agree to participate in this amendment to extension phase of the
study will be included according to the signed updated informed consent form.