COVID-19 Vaccine Development - Milestones, Lessons and Prospects
COVID-19 Vaccine Development - Milestones, Lessons and Prospects
COVID-19 Vaccine Development - Milestones, Lessons and Prospects
com/sigtrans
With the constantly mutating of SARS-CoV-2 and the emergence of Variants of Concern (VOC), the implementation of vaccination is
critically important. Existing SARS-CoV-2 vaccines mainly include inactivated, live attenuated, viral vector, protein subunit, RNA,
DNA, and virus-like particle (VLP) vaccines. Viral vector vaccines, protein subunit vaccines, and mRNA vaccines may induce
additional cellular or humoral immune regulations, including Th cell responses and germinal center responses, and form relevant
memory cells, greatly improving their efficiency. However, some viral vector or mRNA vaccines may be associated with
complications like thrombocytopenia and myocarditis, raising concerns about the safety of these COVID-19 vaccines. Here, we
systemically assess the safety and efficacy of COVID-19 vaccines, including the possible complications and different effects on
pregnant women, the elderly, people with immune diseases and acquired immunodeficiency syndrome (AIDS), transplant
recipients, and cancer patients. Based on the current analysis, governments and relevant agencies are recommended to continue to
advance the vaccine immunization process. Simultaneously, special attention should be paid to the health status of the vaccines,
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timely treatment of complications, vaccine development, and ensuring the lives and health of patients. In addition, available
measures such as mix-and-match vaccination, developing new vaccines like nanoparticle vaccines, and optimizing immune
adjuvant to improve vaccine safety and efficacy could be considered.
INTRODUCTION the injection schedule, and establishing the effective dosage. Small
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a animals, especially rodents, are the foundation of biological and
highly infectious positive-sense, single-stranded RNA virus that immunological studies in vaccine development.9,10 Generally, rats,
spreads rapidly worldwide. The resulting infection, known as mice, guinea pigs, rabbits, and other animals can be used as animal
coronavirus disease 2019 (COVID-19), can cause several symp- models to evaluate candidate vaccines’ immunogenicity, tolerance,
toms, such as cough, fever, chest discomfort, and even respiratory and safety. However, due to species differences between these
distress syndrome in severe cases.1,2 As of March 28, 2022, there animals and humans, similar biological effects may not be
were 480,905,839 confirmed cases of COVID-19 worldwide, and produced after vaccination. The studies of non-human primates
6,123,493 patients died of viral infection or other related (NHPs) are helpful in understanding and illustrating human immune
complications (https://coronavirus.jhu.edu/). responses, owing to similar innate and adaptive immune
Effective and safe vaccines are essential to control the COVID-19 responses.9 Many reagents used to identify human immune
pandemic.3,4 Several studies have reported the progress in molecules also show similar effects on NHPs. In addition to
developing SARS-CoV and Middle East respiratory syndrome preclinical trials (animal experiments), clinical trials are essential for
coronavirus (MERS-CoV) vaccines.5–8 The preclinical data of these developing vaccines. The safety, dosage, and tolerance of vaccines
candidate vaccines partly saved the time for developing the are assessed in the Phase I trial, efficacy and adverse effects are
current marketed SARS-CoV-2 vaccines and would provide plat- investigated in Phase II and III trials.
forms for the future widespread application of SARS-CoV-2 Vaccination is a pivotal means to prevent the spread of SARS-
vaccines. The World Health Organization (WHO) classifies COVID- CoV-2 and ultimately quell the pandemic. However, vaccine
19 vaccines that have been analyzed or approved for clinical trials performance is affected by the constant acquisition of viral
into the following categories: inactivated vaccine, live attenuated, mutations due to the inherent high error rate of virus RNA-
vector, RNA, DNA, protein subunit, and virus-like particle (VLP) dependent RNA polymerase (RdRp) and the existence of a highly
vaccines. variable receptor-binding motif in the spike (S) protein.11–13 We
Animal experiments play a critical role in vaccine development, have previously noted that the B.1.351 (Beta) variant significantly
including evaluating the safety and protective efficacy, determining reduces the neutralizing geometric mean antibody titers (GMT) in
1
College of Life Science and Technology, Beijing University of Chemical Technology, Beijing, China; 2Laboratory for Clinical Immunology, Harbin Children’s Hospital, Harbin, China;
3
College of Materials Science and Engineering, Beijing University of Chemical Technology, Beijing, China; 4Institute of Cerebrovascular Disease Research and Department of
Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China and 5Beijing Advanced Innovation Center for Soft Matter Science and Engineering, Beijing University of
Chemical Technology, Beijing, China
Correspondence: Lihua Song ([email protected]) or Yigang Tong ([email protected]) or Huahao Fan ([email protected])
These authors contributed equally: Maochen Li, Han Wang, Lili Tian and Zehan Pang
Fig. 1 The milestones of COVID-19 vaccine development. With the maturity of vaccine platforms, more and more COVID-19 vaccines have
entered clinical trials and been approved for emergency use in many countries. However, the appearance of VOCs has brought great
challenges to existing COVID-19 vaccines. By changing the administration route, the protection provided by vaccines can be enhanced, and
more vaccination strategies are applied to cope with VOCs. In addition, more vaccine development methods are applied, such as developing
polyvalent vaccines and improving adjuvant and delivery systems. These enormous changes form a milestone in the COVID-19 vaccine
progress compared with post-years
Fig. 2 Vaccine-induced Th1 cell response. Some COVID-19 vaccines would induce Th1 cell responses. After recognition of the AP-MHC class II
complex and T-cell receptor (TCR), CD4+ T cells distributed in peripheral lymphoid organs can differentiate into Th1 cells, which secrete
various cytokines, such as interleukin 2 (IL-2), and simultaneously upregulate the expression of related receptors (IL-2R). Through IL-2 and IL-
2R, T-cell proliferation and CD8+ T-cell activation are promoted, CD8+ T-cell can differentiate into cytotoxic T lymphocytes (CTLs) through the
activation, producing perforin and other cytokines, which may improve the efficacy of vaccines
Fig. 3 Vaccine-induced germinal center response. Some COVID-19 vaccines would induce a germinal center response. Upon the interaction of
T cells and B cells, some activated Th cells move to the lymphatic follicles and then differentiate into Tfh cells. Activated B cells proliferate and
divide in lymphatic follicles to form the germinal center. With the help of Tfh cells, high-frequency point mutations occur in the variable
region of the antibody gene of GC B cells, and antibody category transformation occurs, finally forming memory B cells and plasma cells,
which can produce high-affinity antibodies
(including three India vaccines), including inactivated vaccines, seventh-generation virus, BJ-P-0207, was selected as the original
viral vector vaccines, mRNA vaccines, and protein subunit strain of the COVID-19 inactivated vaccine,36,37 and then
vaccines, have been approved for emergency use by WHO β-propiolactone was used to inactivate the virus.37
(Fig. 5) (https://extranet.who.int/pqweb/vaccines/vaccinescovid- An advantage of inactivated vaccines is using the entire virus as
19-vaccine-eul-issued). The features, advantages, and disadvan- an immunogen. Compared with vaccines based on the SARS-CoV-
tages of different COVID-19 vaccines are shown in Tables 1, 2. 2 S protein or partial protein fragments, such as RBD, inactivated
vaccines can induce a wider range of antibodies against more
COVID-19 inactivated vaccines epitopes.17 In addition, the overall adverse reaction rate of
Inactivated vaccines are produced by inactivating the in vitro inactivated vaccines in clinical trials is low, and no deaths have
cultured viruses using chemical reagents.35 The vaccine can been reported in clinical trials, indicating their good safety.38–40
maintain the integrity of virus particles as immunogens.17 Wang However, the production of inactivated vaccines are limited
et al. introduced the manufacturing process of the SARS-CoV-2 because the production of such vaccines must be carried out in
inactivated vaccine. In this process, SARS-CoV-2 from throat swabs biosafety level-3 laboratory or higher biosafety level.3
of COVID-19 patients were used to infect Vero cells, and the The BBIBP-CorV and CoronaVac inactivated vaccines approved by
HB02 strain with the strongest replication ability was selected WHO are independently developed in China. A total of 21 candidate
from three isolated strains (HB02, CQ01, and QD01). After COVID-19 inactivated vaccines have been approved for clinical trials
purification, the P1 library was obtained by subculturing in Vero as of March 28, 2022 (https://www.who.int/publications/m/item/draft-
cells with adaptive culturing, subculturing, and amplification. The landscape-of-COVID-19-candidate-vaccines).
Fig. 4 Vaccine-induced memory cell response. In the Th1 and GC B-cell processes, antigen-specific memory T cells and memory B cells are
usually formed. Unlike initial T-cell activation, the activation of memory T cells no longer depends on antigen-presenting cells and can induce
a stronger immune response. Most memory B cells enter the blood to participate in recycling and are rapidly activated to produce potent
antibodies upon encountering the same antigen
Fig. 5 A timeline of critical events in the COVID-19 vaccine development progress. WHO has approved the emergency use of ten vaccines
(including three India vaccines, COVISHIELD, COVAXIN, and COVOVAX). Vaccination plays a critical role in protecting people from SARS-CoV-2
infections. However, the appearance of VOCs brought big challenges to the efficacy of approved COVID-19 vaccines. These events were
summarized and displayed in the form of a timeline
Vaccine Vaccine component Mechanism of induction antibody Name of vaccine Number of clinical trials on phase III and
platforms approved by WHO Phase IV of vaccines not yet approved by
(vaccine manufacturer) WHO (Trial identifier)
(Until March 28, 2022)
Inactivated Entire viruses are cultured The entire virus as an immunogen BBIBP-CorV Twelve.
vaccine in vitro and inactivated by induces a wider range of antibodies (Sinopharm) (WIBP- CorV: NCT04885764,
chemical reagents.35 against different epitopes. 17
CoronaVac (Sinovac ChiCTR2000034780, NCT05065892;
Biotech) Inactivated SARS-CoV-2 vaccine (Vero cell)
COVAXIN (Bharat manufactured by IMBCAMS:
Biotech International) NCT04659239;
QazCovid-in®: NCT04691908;
BBV152: NCT04918797, NCT04641481;
KCONVAC: NCT04852705;
VLA2001: NCT04864561;
TURKOVAC: NCT04942405;
CovIran-Barkat: IRCT20201202049567N3;
KD-414: jRCT2071210081)
Live attenuated The virus is obtained by a) The retained viral amino acid Not yet One.
vaccine reverse genetics or sequences induce extensive (COVI-VAC: ISRCTN15779782)
adaptation.17 responses, including innate,
humoral, and cellular immunity.3
b) Induce mucosal immunity
through nasal inhalation to
protect the upper respiratory
tract.3
Viral vector Engineered viruses with Viral vector vaccines can induce Th1 AZD1222(AstraZeneca- Nine.
vaccine replication-attenuated carrying cell responses, thus inducing strong University of Oxford) (Ad5-nCoV: NCT04526990, NCT04892459;
genetic material of viral protective effects.29,50 Ad26.COV-2-S Ad5-nCoV-IH: NCT05124561;
proteins or polypeptides.35 (Johnson & Johnson) Gam-COVID-Vac: NCT04530396;
COVISHIELD (Serum GRAd-COV-2: NCT04791423;
Institute of India) DelNS1-2019-nCoV-RBD-OPT1:
ChiCTR2100051391;
IIBR-100: NCT04990466;
AZD2816: NCT04973449;
BBV154: CTRI/2022/02/040065)
Protein subunit Cell-expressing systems Induce Th1 cell responses.260 NVX-CoV2373 Twenty-three.
vaccine express viral proteins or (Novavax) (ZF2001: ChiCTR2100050849;
peptides systemically.17 COVOVAX (Serum VAT00008: ACTR202011523101903;
Institute of India) RBD Recombinant SARS-CoV-2 vaccine:
NCT04887207;
SCB-2019: NCT05012787;
SpikoGen: NCT05005559,
IRCT20150303021315N24;
aCoV2: NCT04806529;
MVC-COV1901: NCT05011526,
NCT05079633;
FINLAY-FR-2: RPCEC00000354;
EpiVacCorona: NCT04780035;
Recombinant COVID-19 vaccine (Sf9 cells):
NCT04904471;
UB-612: NCT04683224;
CIGB-66: RPCEC00000359;
BECOV2A: CTRI/2021/08/036074;
Nanocovax: NCT04922788;
S-268019: NCT05212948;
GBP510: NCT05007951;
Razi Cov Pars: IRCT20210206050259N3;
ReCOV: NCT05084989;
V-01: NCT05096832;
Noora Vaccine: IRCT20210620051639N3;
SCTV01C: NCT05043311)
DNA vaccine Viral antigens encoded by a Induce neutralizing antibodies.17 Not yet Five.
recombinant plasmid.17 (INO-4800+electroporation:
NCT04642638, ISRCTN15779782;
AG0301-COVID-19: NCT04655625;
nCov vaccine: CTRI/2020/07/026352;
GX-19N: NCT05067946)
mRNA vaccine mRNA encapsulated by Induce strong Th1 cell responses, GC BNT162b2 (Pfizer- Nine.
vectors, viral proteins, or B-cell responses and simultaneously BioNTech) (CVnCoV: NCT04652102, NCT04674189;
polypeptides.17 produce long-lived plasma cells and mRNA-1273 (Moderna) ARCoV: NCT04847102;
memory cells to elicit neutralizing mRNA-1273.351: EUCTR2021-000930-32;
antibodies.21,24 DS-5670a: jRCT2071210106;
mRNA-1273.211: NCT04927065;
ARCT-154 mRNA Vaccine: NCT05012943,
ISRCTN15779782;
mRNA-1273.529-Booster: NCT05249829)
VLP vaccine Noninfectious particles consist Antigens loading on the protein Not yet One.
of viral structural proteins and particles induce neutralizing (CoVLP: NCT04636697)
viral polypeptides.17 antibodies against immune
epitopes.
COVID-19 live attenuated vaccines produce the COVID-19 vaccine, inducing a stronger humoral
Live attenuated vaccines are based on the virus obtained by immune response via intranasal and intramuscular routes.49
reverse genetics or adaptation to reduce virulence and are used as Except for inactivated vaccines and partially attenuated
non-pathogenic or weakly pathogenic antigens.17 Currently, the vaccines, there is no need to deal with live SARS-CoV-2 in
main manufacturing processes include codon pair deoptimization manufacturing other types of vaccines (e.g., viral vector, protein
(CPD) and virulence gene knockout.3,41,42 Wang et al. and Trimpert subunit, mRNA, DNA, and VLP vaccines), so the manufacturing
et al. reported the CPD-based methods to modify SARS-CoV-2 process of these vaccines is relatively safe.3 In addition, viral vector
genes genetically. In their studies, amino acid (aa) 283 deletion vaccines can induce Th1 cell responses,29,50 thus inducing strong
was introduced into the S protein, and the furin site was also protective effects. However, adenovirus-based viral vector vac-
deleted to attenuate the virulence of the virus but retain its cines can induce complications, especially thrombocytopenia.
replication ability.43,44 Thus, it is necessary to pay attention to the platelet levels of the
Through the CPD-based method, most of the viral amino acid relevant recipients in case of thrombocytopenia.51,52 Although
sequences can be retained and induce extensive responses, adenovirus is not easily neutralized by pre-existing immunity, the
including innate, humoral, and cellular immunity against viral pre-existing Ad5 antibodies (46.4, 80, 78, 67, 64, 60, 45% and less
structural and nonstructural proteins in the recipient.3,43 The than 30% of the population with neutralizing antibodies titers for
extensive response is unlikely to diminish in efficacy due to Ad5 of >1:200 in China, India, Kenya, Thailand, Uganda, South
antigen drift. In addition, live attenuated vaccines can induce Africa, Sierra Leone, and America, respectively,26,53) these pre-
mucosal immunity through nasal inhalation to protect the upper existing adenoviruses antibodies in the serum may reduce the
respiratory tract.3 In contrast, other types of vaccines, such as immunogenicity of such vaccines. Thus an additional flexible dose
inactivated and mRNA vaccines, are usually administered intra- might be needed as a solution.26,54
muscularly and only protect the lower respiratory tract. However, The WHO has approved two viral vector vaccines (Ad26.COV-2-S
after weakening the virulence gene of the virus, virulence may be and AZD1222). As of March 28, 2022, 25 candidates’ clinical trials for
restored during replication and proliferation in the host. Thus, the COVID-19 viral vector vaccines have been approved, with four using
reverse genetic method remains challenging. replicating vectors and 21 using non-replicating vectors. Moreover,
Currently, there is no WHO-approved COVID-19 live attenuated 3 viral vectors (a type of nonreplicable vector and two types of
vaccine for emergency use. Two candidate COVID-19 live attenuated replicable vectors) + antigen-presenting cells and a vaccine based
vaccines, COVI-VAC and MV-014-212, have been approved for clinical on the bacterial antigen-spore expression vector are also approved
trials as of March 28, 2022 (https://www.who.int/publications/m/item/ for clinical trials (https://www.who.int/publications/m/item/draft-
draft-landscape-of-COVID-19-candidate-vaccines). landscape-of-covid-19-candidate-vaccines).
COVID-19 inactivated 1. Inactivated vaccines use the entire virus as an 1. Due to living viruses, the production must be carried out in a
vaccine immunogen, inducing an immune response and biosafety level-3 laboratory or higher biosafety level.3
producing antibodies against S protein, N protein, E 2. The production of inactivated vaccines is limited by cell
protein, and other regions.17 activity and viral productivity.35
2. Compared with vaccines based on the SARS-CoV-2 S
protein or partial protein fragments, inactivated vaccines
can induce a wider range of antibodies against more
epitopes.17
3. The research and development route of inactivated
vaccines is relatively complete.
4. The overall adverse reaction rate of inactivated vaccines
in clinical trials is low. No deaths have been reported in
clinical trials, which indicates that inactivated vaccines
have good safety.38–40
COVID-19 live 1. Through the CPD-based method allows most viral 1. After weakening the virulence gene of the virus, virulence
attenuated vaccines amino acid sequences to be retained and induce may be restored during replication and proliferation in the host.
extensive responses, including innate, humoral, and Thus, the reverse genetic method remains challenging.
cellular immunity against viral structural and 2. Loss of efficacy and reproductive potential of viruses during
nonstructural proteins in the recipient.3,43 vaccine production poses a significant challenge.17
2. The extensive response is unlikely to diminish in 3. There may be safety problems in producing live attenuated
efficacy due to antigen drift.3 vaccines.
3. Live attenuated vaccines can induce mucosal immunity
through nasal inhalation to protect the upper respiratory
tract. In contrast, other vaccines are usually administered
intramuscularly and only protect the lower
respiratory tract.
4. The virus replicates and proliferates in the vaccinator,
which may simultaneously induce humoral and cellular
immunity, resulting in a multidirectional antiviral effect.3,43
COVID-19 Viral vector 1. The manufacturing process of viral vector vaccines is 1. Adenovirus-based viral vector vaccines can induce
vaccines relatively safe compared with inactivated vaccines as complications, especially thrombocytopenia. Thus, it is necessary
there is no need to deal with live SARS-CoV-2.3 to pay attention to the platelet levels of the relevant recipients in
2. Viral vector vaccines can induce Th1 cell responses, case of thrombocytopenia.51,52
inducing stronger protective effects. The carrier can 2. Although adenovirus is not easily neutralized by pre-existing
strengthen immunity and have a good stimulating immunity, some individuals with neutralizing antibodies against
response to B cells and T cells.29,50 several adenoviruses (including Ad5) in the serum may reduce
3. The platform has been used in previous vaccines. the immunogenicity.26,54
Therefore, there is rich experience in the preparation of
vectors.
COVID-19 Protein 1. Could induce Th1 cell responses.31 1. The S protein has a large molecular weight, and the
subunit vaccine 2. NVX-CoV2373 can induce higher titer neutralizing expression efficiency of the S protein is relatively low compared
antibodies than inactivated and Ad5 viral vector with that of RBD.
vaccines.3 2. Although the RBD has a small molecular weight and is easy to
3. In the past, protein subunit vaccines have been express, it lacks other immune epitopes on the S protein thus is
successfully applied. Moreover, the research and prone to antigen drift.3
development idea is relatively clear.
COVID-19 DNA 1. Compared with mRNA vaccines, DNA vaccines have 1. The immunogenicity of the DNA vaccine is low.3
vaccines higher stability and can be stored for a long time.65 2. Different injection methods will affect the vaccine’s efficacy,
2. Escherichia coli can be used to prepare plasmids with such as intramuscular or electroporation injection.3
high stability. Therefore, the production risk of DNA
vaccines is relatively low.3
COVID-19 mRNA 1. Both BNT162b1 and BNT162b2 vaccines transmit the 1. The mRNA vaccines may cause complications, especially
vaccines genetic information of the antigen rather than the myocarditis.54,74,75
antigen itself.3 Therefore, mRNA vaccines only need to 2. Due to the instability of mRNA, the mRNA vaccines need to be
synthesize corresponding RNA/DNA of viral proteins, stored at a lower temperature, which puts forward certain
improving production speed.35 requirements for the storage environment of the
2. The mRNA vaccines can induce strong Th1 cell inoculation unit.
responses and GC B-cell responses and produce long-
lived plasma cells and memory B cells, which can
continuously elicit SARS-CoV-2 neutralizing
antibodies.21,24
3. The mRNA vaccines can be modified directly on the
original sequence to facilitate a timely update.
1. VLP vaccines do not contain viral genomes. Thus, they 1. The manufacturing process of the VLP vaccine is more
are not infectious.74 complex. What’s more, there is no relevant data published for
COVID-19 VLP vaccines 2. Plant-based VLP vaccines have the potentiality of oral human clinical trials.
delivery vaccines.65 2. The VLP vaccines are loaded with multiple proteins
3. By loading a variety of antigens, such as the RBD from simultaneously, and the degree of immune response caused by
different variants on the protein particles, neutralizing it is not clear.65
antibodies against multi-immune epitopes can be
induced to improve the neutralizing activity against SARS-
CoV-2 variants.
S protein spike protein, N protein nucleocapsid protein, E protein envelope protein, Ad5 adenovirus type-5, CPD codon pair deoptimization, RBD receptor-
binding domain
The protein subunit can also induce Th1 cell responses.31 In a proper length of poly (A), and the latter can obtain a length-
addition, NVX-CoV2373 can induce higher titer neutralizing controlled poly (A) tail.67,68 Corbett et al. introduced a manufac-
antibodies than inactivated and Ad5 viral vector vaccines.3 turing process for the mRNA-1273 vaccine. The optimized mRNA
However, the S protein has a large molecular weight, and the encoding SARS-CoV-2 S-2P protein with stable pre-fusion con-
expression efficiency of the S protein is relatively low compared formation was synthesized (2 P represents double proline muta-
with that of RBD. Although the RBD has a small molecular weight tions of the K986 and V987 residues mentioned above). The
and is easy to express, it lacks other immune epitopes on the S synthesized mRNA sequence was purified by oligo-dT affinity
protein and thus is prone to antigen drift.3 purification, and encapsulated in lipid nanoparticles.69 The
For emergency use, the WHO has authorized only one COVID-19 BNT162b2 vaccine also adopts a similar mRNA encoding S-
protein subunit vaccine (NVX-CoV2373). Furthermore, 51 candi- 2P,17,70 whereas the BNT162b1 vaccine adopts the mRNA
date COVID-19 protein subunit vaccines were approved for clinical encoding RBD and fuses the trimer domain of T4 fibrin to the
trials on March 28, 2022 (https://www.who.int/publications/m/ C-terminus. Furthermore, a proper delivery system like LNP can
item/draft-landscape-of-covid-19-candidate-vaccines). protect mRNA against the degradation of nuclease71 and further
enhance the efficacy of mRNA vaccines. The capsulation of mRNA
COVID-19 DNA vaccines with LNP can effectively transfer mRNA into cells and induce a
DNA vaccines are based on viral antigens encoded by a strong immune response; thus is widely used in most mRNA
recombinant plasmid. Viral proteins or polypeptides are produced vaccines, including BNT162b2 and mRNA-1273.71,72 In addition,
by transcription and translation processes in host cells.17 Smith et al. other delivery systems like lipopolyplexes, polymer nanoparticles,
synthesized the INO-4800 COVID-19 DNA vaccine based on a cationic polypeptides, and polysaccharide particles also provide
previously prepared MERS-CoV vaccine.61 The main steps are as unlimited possibilities for the improvement of mRNA vaccine .72,73
follows: (1) acquisition of the S protein sequence from GISAID; (2) The mechanism of mRNA vaccine-induced immunity is similar
addition of the N-terminal IgE leading sequence; (3) optimization of to that of the DNA vaccines. Both BNT162b1 and BNT162b2
the IgE-Spike sequence with algorithms to enhance its expression vaccines transmit the genetic information of the antigen rather
and immunogenicity and synthesize the optimized sequence; (4) than the antigen itself,3 so they only need to synthesize the
ligation of the fragment into the expression vector pGX0001 after corresponding RNA of viral proteins, improving the production
digestion.62,63 Brocato et al. constructed the DNA encoding SARS- speed.35 In addition, mRNA vaccines can induce strong Th1 cell
CoV-2 S protein into the pWRG skeleton plasmid by cloning the responses and GC B-cell responses and simultaneously produce
gene with optimized human codons, and this skeleton plasmid was long-lived plasma cells and memory cells, continuously eliciting
used to produce a DNA vaccine against hantavirus.64 SARS-CoV-2 neutralizing antibodies.21,24 However, mRNA vaccines
Compared with mRNA vaccines, DNA vaccines have higher may cause complications, especially myocarditis,54,74,75, and have
stability and can be stored for a long time.65 Escherichia coli can be a higher storage requirement due to the instability of mRNA.3
used to prepare plasmids with high stability.3 However, the The WHO has approved two types of mRNA vaccines: mRNA-
immunogenicity of the DNA vaccine is low. Furthermore, different 1273 and BNT162b2, and a total of 28 candidate COVID-19 mRNA
injection methods, such as intramuscular or electroporation vaccines have been approved for clinical trials as of March 28,
injection, also affect the vaccine’s efficacy.3 2022 (https://www.who.int/publications/m/item/draft-landscape-
There is no COVID-19 DNA vaccine authorized by the WHO for of-covid-19-candidate-vaccines).
emergency use. Sixteen candidate COVID-19 DNA vaccines have
been approved for clinical trials on March 28, 2022 (https://www. COVID-19 VLP vaccines
who.int/publications/m/item/draft-landscape-of-covid-19-candidate- VLP vaccines are based on noninfectious particles consisting of in
vaccines). vitro-expressed viral structural proteins and decorated viral
polypeptides on the surface.74 Tan et al. used Spy Tag technology
COVID-19 mRNA vaccines to modify the SARS-CoV-2 RBD on the surface of protein particles
mRNA vaccines are based on mRNA encapsulated by vectors by forming covalent iso-peptide bonds based on the previous
(usually lipid nanoparticles), viral proteins, or polypeptides protein nanoparticle platform and obtained an RBD-Spy VLP.76
produced during the translation process in the host cells.17,35 In Moreover, a self-assembled VLP vaccine based on the expression
addition to mRNA itself, the 5′ Cap and 3′ Poly (A) also play of modified full-length S proteins, including R667G, R668S, R670S,
important roles in regulating the efficiency and stability of K971P, and V972P mutations, has also been developed using a
translation.66,67 At present, mRNA vaccines usually adopt the plant expression system.77
Cap 1 structure (m7GpppN1mp, with an additional 2′ methylated VLP vaccines do not contain viral genomes, and plant-based
hydroxyl compared with Cap 0), improving translation efficiency.66 VLP vaccines have the potential of oral delivery vaccines.65 By
There are two ways of mRNA tailing: use traditional polyadenylate loading a variety of antigens, such as the RBD from different
tails to add the 3′ tail of poly (A) or design the DNA template with variants on the protein particles, neutralizing antibodies against
Fig. 6 A timeline of the preclinical and clinical trials of approved COVID-19 vaccines. Preclinical and clinical trials play important roles in
evaluating the safety and protective efficacy of COVID-19 vaccines. The information of preclinical to clinical trials of several WHO-approved
COVID-19 vaccines are provided in the form of a timeline, and partial Phase III clinical trials’ data were also displayed to show the total efficacy
multi-immune epitopes can be induced to improve the neutraliz- immunization. In different dosage groups of BALB/c mice, the
ing activity against SARS-CoV-2 variants. However, the manufac- immunogenicity of the three-dose group was significantly higher
turing process of the VLP vaccine is more complex, and no than the two- and single-dose groups. In the NHP experiment,
relevant data was published for human clinical trials. after vaccination, the neutralizing GMTs in rhesus monkeys were
There is no COVID-19 VLP vaccine authorized by the WHO for 1:860 in the high-dose group and 1:512 in the low-dose group,
emergency use. Six candidates' COVID-19 VLP vaccines have been respectively, indicating BBIBP-CorV can effectively prevent SARS-
approved for clinical trials as of March 28, 2022 (https://www.who.int/ CoV-2 infection in rhesus monkeys.
publications/m/item/draft-landscape-of-covid-19-candidate-vaccines). The PiCoVacc inactivated vaccine, also known as CoronaVac, is
highly immunogenic in BALB/c mice.37 After the injection of
PiCoVacc, the serum S-specific antibody level of mice was ten
EFFICACY OF COVID-19 VACCINES times higher than that of convalescent serum obtained from
Animal studies of COVID-19 vaccines approved by the WHO COVID-19 patients. PiCoVacc could induce high RBD antibodies, 30
Several SARS-CoV-2 animal models have been developed, includ- times higher than the induced NTD antibodies. The neutralizing
ing mice expressing human ACE2,78–80 SARS-CoV-2-adaptive antibody titer in rhesus monkeys was 1:50 in the third week after
mouse,81,82 ferret,83 hamster,84,85 and NHP models.86–88 Although one dose of PiCoVacc, similar to the titers in the convalescent
mice can be infected with SARS-CoV-2 by transferring the human serum of COVID-19 patients. One week after the third dose of
ACE2 gene or designing a virus-adapted mouse, no mouse model PiCoVacc, viral infection was induced through intranasal and
can simulate all the characteristics of human COVID-19, especially organ routes. The viral load of all vaccinated animals decreased
pulmonary vascular disease, hyperinflammatory syndrome, significantly 3–7 days after infection, indicating that PiCoVacc
observed in adults and children, respectively.10 The hamster played an important anti-SARS-CoV-2 role in the NHP model.
model can simulate serious COVID-19 diseases. Syrian hamsters Compared with BBIBP-CorV and CoronaVac, viral vector
show mild to severe symptoms 1–2 days after nasal infection,89,90 vaccines and mRNA vaccines can simultaneously induce T-cell
and progressive weight loss and dyspnea. The NHP model can responses,46,48,69,70 mainly a Th1 cell response, while Th2
reflect mild-to-moderate SARS-CoV-2 infection and can be used to responses are related to vaccine-induced respiratory diseases,
test many candidate vaccines. However, due to different adjuvants and were not detected. Viral-specific neutralizing antibodies were
and vaccine dosages, the use of serum-neutralizing antibody titer detected in all BALB/c mice following inoculation with ChAdOx1
as a direct basis for comparing the efficacy of different vaccines is nCoV-19 (AZD1222). On day 14, after the first or second dose, the
still limited. In addition, different analytical methods, such as 50% neutralizing antibody titers in rhesus monkey serum were 1:5 to
plaque reduction neutralization test (PRNT50), 80% plaque 1:40 (single dose) and 1:10 to 1:160 (two doses). In addition,
reduction neutralization test (PRNT80), and enzyme-linked immu- cytokines, including IL-4, IL-5, and IL-13, in rhesus monkey serum
nosorbent assay (ELISA), may also affect the final experimental after a single dose or two doses injection were low, indicating the
results. These data can objectively show the efficacy of each safety of ChAdOx1 nCoV-19 in NHPs.
vaccine. Here, we summarize the immunogenicity, neutralizing Another viral vector vaccine, Ad26.COV-2-S (Ad26-S.PP) induced
activity, and cell response data from animal experiments for the similar neutralizing antibody titers in the NHP model.48 RBD-
BBIBP-CorV, CoronaVac, AZD1222, Ad26.COV-2-S, NVX-CoV2373, specific neutralizing antibodies were detected in 31 of 32 rhesus
mRNA-1273, and BNT162b2 vaccines (Fig. 6). monkeys (96.9%) 2 weeks after Ad26-S.PP inoculation and the
Immunogenicity testing of BBIBP-CorV was performed in BALB/c induced titers were 1:53 to 1:233 (median 1:113) 4 weeks after
mice, rabbits, and guinea pigs.36 The animals were classified into vaccination. In addition, Ad26-S.PP also induced S-specific IgG and
three groups according to the doses: high (8 μg), medium (4 μg), IgA responses in bronchoalveolar lavage (BAL) obtained from
and low (2 μg). All dosages produced good immunogenicity, and rhesus monkeys, indicating that Ad26-S.PP has a protective effect
the serum conversion rate reached 100% on day 21 after on rhesus monkeys’ upper and lower respiratory tracts. 6 weeks
AZD1222. Phase I/II clinical trials of AZD1222 were divided into Ad26.COV-2-S. Janssen performed Phase I and Phase I-II clinical
two stages (NCT04324606).50,102 In the first stage, 1077 healthy trials of Ad26.COV-2-S (NCT04436276).29,30 A total of 25 healthy
subjects aged 18–55 years with negative laboratory-confirmed adults aged 18–55 with negative nasopharyngeal PCR and serum
SARS-CoV-2 infection or COVID-19 symptoms were recruited. Ten IgG results participated in the Phase I trial. The participants were
individuals were injected with two doses of 5 × 1010 viral particles equally allocated to receive two doses of low-dose (5 × 1010 VPs)
(VPs), the remainders were injected with a single dose of 5 × 1010 Ad26.COV-2-S (low-dose/low-dose, LL), one dose of low-dose
VPs. Those in the placebo group were injected with a licensed vaccine and one dose of placebo (low-dose/placebo, LP), two
meningococcal group A, C, W-135, and Y conjugate vaccine doses of high-dose (1 × 1011 VPs) (high-dose/high-dose, HH), one
(MenACWY). Serum neutralizing antibody levels were evaluated dose of high-dose vaccine and one dose of placebo (high-dose/
using a standardized ELISA protocol. The median level of serum placebo, HP), or two doses of placebo (placebo/placebo, PP). The
samples on day 28 after one dose was 157 ELISA units (EU). The placebo group received a 0.9% sodium chloride solution. The
median level of 10 individuals injected with the enhancer dose GMTs of serum neutralizing antibody based on the inhibition of
was 639 EU on day 28 after the second dose, indicating that two 50% of pseudovirus (ID50) were detected 14 days after the second
injection doses can induce higher neutralizing antibodies. In the dose. The ID50 values were 1:242 (LL), 1:375 (LP), 1:449 (HH), and
second stage of the trial, 52 subjects who had been injected with 1:387 (HP) in the vaccine groups. Moreover, Ad26.COV-2-S induced
the first dose received a full-dose (SD) or half-dose (LD) of CD4+ and CD8+ T-cell responses, simultaneously inducing cellular
AZD1222(ChAdOx1 nCoV-19) vaccine on days 28 and 56. The titers immunity. Adverse events after vaccination were not evaluated in
of 80% virus inhibition detected by the microneutralization assay this study.
Fig. 7 A systemic illustration of the mutation in the S protein of VOCs. VOCs were designated by WHO because of the enhanced infectivity or
immune escape ability (or with both), the specific mutations in the S protein of VOC Alpha to Omicron are displayed, and the mutations
related to enhanced immune escape ability were marked in green color, while the mutation related to decreased immune escape ability was
marked into orange color
NTD antibodies are located in N3 (residues 141-156) and N5 There were nine mutations in the S protein of Beta variant: L18F
(residues 246–260) loops, while Del144 can alter the N3 loop and (found in 43.6% reported Beta variants), D80A (97.1%), D215G
cause the immune escape of such antibodies,129 Del69/70 can (94.6%), Del241/243 (89.6%), K417N (93%), E484K (86.5%), N501Y
enhance the infectivity.130 The characteristic mutation N501Y can (87%), D614G (97.8%), and A701V (96.4%) (https://outbreak.info).
significantly increase the binding of S protein to ACE2,131 and The glycans of amino acid site 17, 174, 122, and 149 in the NTD
further enhance the infectivity. In addition, N501Y was also related region combined into seven targeted epitopes of NTD anti-
to the immune escape, in which the epitope of class A antibodies bodies137 and L18F may interfere with the binding between
was located.129 This mutation was also in other VOCs like Beta, antibodies, and residue 17 affect the neutralization of antibody.
Gamma, and Omicron. Not only VOC, but almost all circulating The Del241/243 map to the same surface as the Del144 in the
variants also had a D614G mutation. Plante JA et al. found that Alpha variant,138 which may also interfere with the neutralization
D614G can alter the fitness and enhance the replication of SARS- of antibodies. In addition, several studies have shown that K717N
CoV-2 in the lungs. However, D614G will reduce the immune and E484K mutations (as well as the K417T in Gamma variant and
escape ability of the virus and improve the sensitivity to E484A in Omicron variant) both contribute to the immune escape
neutralizing antibodies.131,132 The above studies suggested that against group A-D antibodies,129,136,139,140 and K417N can
this mutation may be essential to maintaining the survival of SARS- enhance the infectivity at the same time.129,141
CoV-2. Thereby, it can be retained continuously. The P681H Overall, the L18F, Del241/243, K417N, E484K, and N501Y
mutation near the furin-cleavage site may enhance the cleavage mutations all contribute to the immune escape ability of VOC
of S1 and S2 subunits and increase the Alpha variant’s entry. The Beta, while K417N, N501Y, and D614G can enhance the viral
P681R in VOC Delta may improve fitness compared with P681H in infection. Therefore, compared with the Alpha variant, the Beta
the Alpha variant.133 variant has poor transmissibility, but a very strong immune escape
In general, the Del69/70, N501Y, D614G, and P681H of the Alpha ability and can reduce the neutralization efficacy of WHO-
variant were helpful to improve the infection, which can explain the approved vaccines by more than 10 times.
high reproduction number of about 3.5–5.2 (https://aci.health.nsw.
gov.au/covid-19/critical-intelligence-unit/sars-cov-2-variants). How- Gamma. P.1 was first detected in Brazil in November 2020 and
ever, Del144 and N501Y affected the neutralization of antibodies, caused the second wave of the epidemic in this country, causing
the vaccines approved by WHO showed strong neutralization ability more than 76% infection of the population,142 and the average
to VOC Alpha, shown in Table 3. number of daily-confirmed COVID-19 patients in Manaus increased by
180 from January 1 to 19, which was about 30 times of the average
Beta. B.1.351 (also known as 501Y.V2) was first detected in South increased cases in December. On January 11, 2021, P.1 was
Africa in May 2020 and firstly appeared after the first epidemic designated as VOC by WHO and labeled Gamma.
wave in Nelson Mandela Bay. This variant had different There were 12 mutations in the S protein of Gamma variant: L18F
characteristics from the dominant variants B.1.154, B.1.1.56, and (found in 97.9% reported P.1 strains), T20N (97.9%), P26S (97.6%),
C.1 in the first wave of pandemic134 and had spread rapidly in D138Y (95.5%), R190S (93.6%), K417T (95.5%), E484K (95.2%), N501Y
Eastern Cape, Western Cape, and KwaZulu-Natal provinces in just (95.3%), D614G (99%), H655Y (98.5%), T1027I (97.2%), V1176F (98.1%)
a few weeks, causing the second wave of epidemic in South Africa (https://outbreak.info). Since most of the mutations of interest like
(October 2020).135 On December 18, 2020, B.1.351 was designated K417T, E484K, N501Y, and D614G have been introduced in the Alpha
as VOC by WHO and named Beta (https://www.who.int/en/ and Beta variants mentioned above, they will not be repeated here.
activities/tracking-SARS-CoV-2-variants/). Similar to the Alpha Among these mutations, L18F, K417T, E484K, and N501Y help to
variant, B.1.351 lineage also included three subtypes 501Y.V2-1/- enhance the immune escape ability, while K417T, N501Y, and D614G
2/-3, and 501.Y.V2-1 occupied mainstream, then the 501Y.V2-2 can enhance the viral infection. Therefore, VOC Gamma showed a
with additional mutations of amino acid site 18 and 417 appeared, similar immune escape ability to VOC Beta, but less than the Beta
and finally Del241/243 mutation occurred in 501Y.V2-3.136 Among variant, which may be caused by mutations outside the RBD
all detected sequences of VOC Beta, 89.6 and 93% had K417N and region,143 the infectivity of both Beta and Gamma variants were less
Del241/243 mutations, indicating that 501Y.V2-3 was the domi- than the Alpha variant (https://aci.health.nsw.gov.au/covid-19/critical-
nant subgroup of VOC Beta (https://outbreak.info/). intelligence-unit/sars-cov-2-variants).
B.1.1.7 (Alpha) 3.5–5.2 Increased risk of Unknown Unknown 70.4%261 70.2%262 85.6%262 1.2-fold decrease 89.5%264
hospitalization, of neutralizing
possible increased antibody titers263
risk of mortality.
Increased
secondary
attack rate.
B.1.351 (Beta) 5.2 Possible increased Two-dose: 5.47- Unknown 83%265 51.9%262 60%266 6.4-fold decrease 75%264
risk of severe fold decrease of of neutralizing
disease and in- plasma antibody titers263
hospital mortality. neutralization titers
compared to
against prototype.
Homologous
booster: 10.02-fold
increase.
BBIBP-CorV/ZF2001
heterologous
booster: 32.16-fold
increase.93
Li et al.
COVID-19 vaccine development: milestones, lessons and prospects
P.1 (Gamma) Increasing Possible increased Unknown 50%267 48%268 36.5%262 Unknown 3.5-fold decrease 88%268
hospitalization and of neutralizing
severe disease. antibody titers263
Increased
secondary
attack rate.
B.1.617.2 (Delta) 3.2–8 Increased risk of Two-dose: 1.47- Showed good 67.0%.269 Ad26.COV-2-S Under Two-dose: Two-dose:
emergency care fold decrease of results.267 /mRNA-1273 investigation 95%268 87–95%268
and plasma heterologous Homologous Homologous
hospitalization. neutralization titers booster: 16-fold booster:threefold booster:ninefold
Increased compared to increase.110 increase.110 increase.110
secondary against prototype.
attack rate. Homologous
booster: 10.07-fold
increase.
BBIBP- CorV/
ZF2001
heterologous
booster: 17.65-fold
increase.93
1273 heterologous
booster: 67 .2% at
BNT162b2/mRNA-
at 6–9 weeks.270
October 2020 and spread rapidly in a few months due to the
45.7% at 10 or
2 to 4 weeks,
Homologous
relaxation of prevention and control measures for COVID-19,
more weeks.
30–37%271
causing the death of more than 400,000 people.107 On May 11,
BNT162b2
Two-dose: 2021, this variant was designated as VOC by WHO and labeled Delta
(https://www.who.int/en/activities/tracking-SARS-CoV-2-variants/).
VOC Delta was a worldwide circulating VOC after VOC Alpha and
booster: 70.1% at
was detected by at least 169 countries (https://outbreak.info).
Two-dose: GMNT
decrease of 43-
6–9 weeks.270
2 to 4 weeks,
Homologous
NVX-CoV2373 mRNA-1273
booster: fourfold
Ad26.COV-2-S
Ad26.COV-2-S
heterologous
increase.110
previously
heterologous
gov.au/covid-19/critical-intelligence-unit/sars-cov-2-variants).
effect.
heterologous
CoronaVac/
vaccine.231
BNT162b2
effect.231
Efficacy of COVID-19 vaccine
https://aci.health.nsw.gov.au/covid-19/critical-intelligence-unit/sars-cov-2-variants
against prototype.
booster: 9.54-fold
booster: 5.86-fold
Homologous
BBIBP- CorV/
increase.93
increase.
death compared
attack rate.
secondary
Increased
(Omicron)
B.1.1.529
Fig. 8 A summary of some possible complications induced by COVID-19 vaccines. The possible complications induced by COVID-19 vaccines
mainly include the following categories: (1) coagulation dysfunction, such as thrombocytopenia; (2) heart diseases, such as myocarditis; (3)
immune diseases, such as allergic reactions, autoimmune hepatitis, and autoimmune thyroid diseases; (4) nervous system diseases, such as
facial paralysis and functional neurological disorders; (5) lymphatic system diseases; and (6) other diseases, such as Rowell’s syndrome, macular
rash, and chilblain-like lesions
mRNA vaccine recipients.154,164 A large number of platelet factor 4 released coagulation factors, finally forming fibrin and forming
(PF4) antibodies were presented in the patients, and the antibody extensive micro thrombosis. In this process, the over-consumed
heparin PF4 complex acted on platelet FC γ receptors, activating platelets and coagulation factors lead to the reduction of
platelets and further producing procoagulant substances.154 coagulation activity, further imbalance of coagulation and antic-
Adenoviruses can bind to platelets and activate them.165,166 oagulation, secondary hyperfibrinolysis, and the release of a large
However, trace adenoviruses in vaccines injected one or two number of plasminogen activators, eventually leaded to dissemi-
weeks before onset seem unlikely to cause platelet activation. nated intravascular coagulation (DIC), which appeared in most
Further analysis of PF4 structure revealed that PF4 antibodies from COVID-19 patients.154,169,170 Compared with COVID-19 patients,
vaccine-induced immune thrombocytopenia patients induced fewer mRNA vaccine subjects reported DIC, which may be due to
heparin-induced thrombocytopenia by binding eight surface the lower amount of S protein produced after vaccination than
amino acids on PF4.51 One study counted the cases of thrombosis natural infection, and the inflammation is also lower.
sequelae voluntarily reported after vaccination, of which at least Relevant indexes (e.g., measuring prothrombin time, platelet
169 cases of possible cerebral venous thrombosis and 53 cases of count, and D-dimer concentrations of the receptors) should be
possible visceral venous thrombosis were reported among 34 tested within 2–3 days after vaccination to prevent the platelet
million individuals vaccinated with ChAdOx1 nCoV-19 vaccine, abnormalities caused by COVID-19 vaccination.169 For patients
and 35 cases of central nervous system thrombosis among 54 with abnormal index, preventive treatment (usually heparin or low
million individuals vaccinated with BioNTech mRNA vaccine. molecular weight heparin transfusion, the latter is safer) should be
Among the 4 million subjects receiving the Moderna mRNA taken as soon as possible.169 In addition, degranulation inhibitors
vaccine, cerebral venous sinus thrombosis may have developed in may also be a feasible means to inhibit the inflammatory response
five cases. Among the more than 7 million subjects receiving and prevent lung injury and platelet abnormalities.168
Ad26.COV-2-S vaccine, cerebral venous thrombosis may have
developed in six cases.52 Although the relevant pathogenesis is Heart diseases. Myocarditis is a rare cardiac complication after
unclear, a possible trigger factor for these PF4 antibodies is free COVID-19 vaccine injection.74,75 Rosner et al. reported seven
RNA or DNA in the vaccine.167 patients hospitalized for acute cardiomyoid disease after vaccina-
Moreover, platelet activation may also relate to the injury and tion with Pfizer-BioNTech/AstraZeneca (n = 6) and Janssen (n = 1)
inflammation induced by mast cell (MC) degranulation. Wu ML vaccines. Larson et al. reported eight patients hospitalized for
et al. found that SARS-CoV-2 can induce degranulation of MCs chest pain within 2–4 days of vaccination with the BNT162b2 or
located in the mucosa, and a rapid MC degranulation could be mRNA-1273 vaccine. The laboratory diagnostic cardiac magnetic
recapitulated through the binding of RBD to ACE2, resulting in resonance imaging analysis revealed that these patients have
supra-alveolar dermatitis and lung injury.168 In addition, in the myocarditis. All the subjects had left ventricular ejection dysfunc-
case of inflammation induction and lung epithelial injury, many tion. The median ejection blood percentage was 48–59%.74,75
plasminogen activators may be released.169 Thus, the increased These two studies showed a significant temporal correlation
D-dimer (one of the products formed when plasminase degrades between mRNA-based COVID-19 vaccines (including viral vector
fibrine) concentration was observed in many COVID-19 patients, and mRNA vaccines) and myocarditis. Such systemic adverse
with a decreased level of platelets.169 These pathological events usually occur within 48 h after the second dose.114,118
characteristics of patients were very similar to the thrombotic There may be two potential mechanisms for COVID-19 mRNA
thrombocytopenia caused by the COVID-19 vaccination. Com- vaccines causing heart diseases, such as myocarditis. The first is
bined with the above studies, this mechanism may be explained the nonspecific innate inflammatory responses induced by mRNA.
as follows: after the SARS-CoV-2 infection or mRNA vaccine The second is the interaction of the S protein produced by mRNA
vaccination, S protein stimulated lung epithelial cells and induced after the translation within the heart or blood vessels, resulting in
MC degranulation, increasing the level of inflammatory mediators. cardiovascular injury.171 Since protein subunit vaccines like
These mediators increased the destructive effect of monocyte ZF2001 and NVX-CoV2373 have not been used widely, and the
macrophages on erythrocytes and led to abnormal platelet levels. relevant data are still unreleased, it is not easy to judge whether
In addition, the injury of epithelial cells activated platelets and the S protein causes myocarditis.
Fig. 9 Effect of vaccination in different populations. COVID-19 vaccines are still effective for pregnant women, patients with autoimmune
diseases, and controlled HIV-infected patients, and the overall efficacy can maintain about 80–90%, while the 30% neutralization reduction
occurs in older people. Moreover, the overall neutralizing activity of COVID-19 vaccines in solid organ transplant recipients, cancer patients,
and uncontrolled AIDS patients is significantly reduced
the past two decades, a series of new adjuvants have been used in CoVaccine HT is also an oil-in-water (O/W) emulsion, while CpG
licensed vaccines, including Aluminum hydroxide, MF59, AS03, is a synthetic DNA sequence containing an unmethylated CpG
CpG 1018, and CoVaccine HT,241 among which the Aluminum sequence.242,248 Compared with the aluminum hydroxide adju-
hydroxide can reduce the immune-related pathological reactions vant, AMP-CpG and CoVaccine HT showed better immunogeni-
while other adjuvants can trigger specific cell receptors and city.249 Using AMP-CpG as an adjuvant, persistent antibody and
induce an innate immune response in the injection site as well as T-cell reactions were still induced in elderly mice at low-dose S
the draining lymph nodes, further promoting the production of protein levels. Reducing the dose of S protein may decrease the
antibodies.225,242 Therefore, appropriate adjuvants are critical for occurrence of adverse events and improve vaccine safety.
maintaining vaccines’ durability and effectiveness. Here, some Compared to aluminum hydroxide, CoVaccine HT can promote
brief information on existing adjuvants used in COVID-19 vaccines the production and maturation of neutralizing antibodies to a
is provided in Table 4. greater extent, thereby quickly inducing an immune response to
Alum is the most widely used adjuvant in global vaccine SARS-CoV-2.248
development, which can induce the antibody response and The use of aluminum adjuvants may reduce the adverse events
different CD4+ cell responses (low level).225,241 Relevant mechan- of related vaccines and improve vaccine safety. However, the
isms can be explained as enhancing anti-phagocytosis and immunogenicity of aluminum adjuvants is poor. Therefore, the
activating the proinflammatory NLRP3 pathway.242 In addition, common use of different adjuvants may improve immunogenicity
Aluminum adjuvants can reduce immune-related pathological while ensuring subjects’ safety.
reactions and improve safety, explaining the excellent safety of
BBIBP-CorV and CoronaVac (both of the vaccines used Aluminum Change of inoculation route
hydroxide as adjuvants).221,243 However, the immunogenicity of In addition to sequential immunization (mixed-vaccination),
aluminum adjuvant is poor. The chemical modification of alum development of new vaccines (such as nanoparticle vaccine),
with short peptide antigens composed of repeated serine and adjuvant improvement, changing the vaccination route is also
phosphate residues can significantly enhance GC cell and a feasible measure to improve the protection and efficacy of
antibody responses.244 existing COVID-19 vaccines.3,250 All WHO-approved vaccines adopt
MF59 is a squalene oil-in-water emulsion adjuvant approved for the intramuscular route (i.m route), and most of them can only
use in influenza vaccines in more than 38 countries, and it is protect the lower respiratory tract except for Ad26.COV-2.S, which
biodegradable and biocompatible.245 MF59 showed good toler- can both protect the upper and lower respiratory tract.48 However,
ance and safety, and the inoculation of vaccines that use this the new VOC Omicron has stronger infectivity of the upper
adjuvant can motivate the activation of macrophages and the respiratory tract and mainly causes symptoms of the upper
production of chemokines. These chemokines will recruit neu- respiratory tract, so the existing vaccine is difficult to protect
trophils, eosinophils, and monocytes to the lymph nodes, further effectively.122,235,251 Mucosal immunity plays an important role in
form a cascade amplification reaction, and activate B cells and preventing pathogen invasion. The intranasal administration
T cells.225 In addition, MF59 can stimulate IL-4 and STAT6 signal (inhalation route, i.n route) of vaccines may achieve a better
pathways and induce the antibody response. It is worth noting protection effect on preventing SARS-CoV-2 infection (especially
that the above response does not depend on type 1 interferon or Omicron variant).3,250,252,253 Compared with the traditional i.m
inflammatory pathway.246 Thereby, MF59 has been selected as the route, the i.n route can effectively induce a local immune
adjuvant of COVID-19 vaccines. response. Vaccine antigen enters the respiratory tract and passes
AS03 is similar to MF59 but has an additional immune-enhanced through the mucus layer through inhalation to induce the
component α- tocopherol (vitamin E). Thus, it can induce the production of local IgA and provide protection at the pathogen’s
expression of proinflammatory cytokines and chemokines indepen- entry site.253 In addition, the i.n route can induce the production
dently (not depending on the type I interferon).242 In addition, AS03 of higher levels of mucosal antibodies. Although some IgG can be
can trigger a transient innate immune response, the injection of AS03 detected on the mucosal surface after the intramuscular injection,
induces the transient production of cytokines in the mice model, and the lack of mucosal IgA still makes the respiratory tract vulnerable
vitamin E can further enhance the expression of some chemokines to infection.3 In addition, the i.n route has better compliance than
and cytokines like CCL2, CCL3, and IL-6.225 AS03 is evaluated as the the i.m route, and the administration is more convenient.
adjuvant of several recombinant S protein vaccines in the clinical trial, However, the i.n route still has some disadvantages: the systemic
the add of AS03 further improve Th2-unbiased cell responses and the immune response induced by this administration method is often
production of IFN-γ, which may enhance the efficacy of COVID-19 lower than that of the i.m route because the titer of the virus may
vaccines.247 decrease when it is made into aerosol; the i.n route may cause