Letters to Blood TO THE EDITOR: COVID-19 in vaccinated adult patients with hematological malignancies: preliminary results from EPICOVIDEHA Livio Pagano,1,2,* Jon Salmanton-Garcıa,3,4,* Francesco Marchesi,5,* Alberto L opez-Garcıa,6 Sylvain Lamure,7 Federico Itri,8 Maria Gomes-Silva,9 Giulia Dragonetti,1,2 Iker Falces-Romero,10 Jaap van Doesum,11 Uluhan Sili,12 Jorge Labrador,13 Maria Calbacho,14 Downloaded from http://ashpublications.org/blood/article-pdf/139/10/1588/1879387/bloodbld2021014124.pdf by guest on 20 January 2023 Yavuz M. Bilgin,15 Barbora Weinbergerov e-Marıa Ribera-Santa Susana,18 Sandra Malak,19 Jos a,16 Laura Serrano,17 Jos e Loureiro-Amigo,20 Andreas Glenthøj,21 Raul C nano,6 Raquel Nunes-Rodrigues,22 Tom ordoba-Mascu~ as-Jos e Gonz opez,13 Linda Katharina Karlsson,23 alez-L Marıa-Josefa Jim 24 enez-Lorenzo, Jos  e-Angel Hern 25 26 andez-Rivas, Ozren Jaksic, Zden acil, Alessandro Busca,28 Paolo Corradini,29 ek R 27 Martin Hoenigl,30-32 Nikolai Klimko,33 Philipp Koehler,3,4 Antonio Pagliuca,34 Francesco Passamonti,35 and Oliver A. Cornely,3,4,36-38 on behalf of the EPICOVIDEHA working group 1 Department of Hematology, Fondazione Policlinico Universitario Agostino Gemelli–Institute for Cancer Research and Care (IRCCS), Rome, Italy; 2Department of Hematology, Universit a Cattolica del Sacro Cuore, Rome, Italy; 3Department I of Internal Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Excellence Center for Medical Mycology (ECMM), Cologne, Germany; 4University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; 5Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy; 6Fundacion Jimenez Diaz University Hospital, Health Research Institute, Instituto de Investigacion Sanitaria–Fundacion Jim enez-Dıaz (IIS-FJD), Madrid, Spain; 7Departement d’Hematologie Clinique, Centre Hospitalier Universitaire (CHU) de Montpellier, Unit e Mixte de Recherche–Centre National de la Recherche Scientifique (UMR-CNRS) 5535, Universite de Montpellier, Montpellier, France; 8 San Luigi Gonzaga Hospital–Orbassano, Orbassano, Italy; 9Portuguese Institute of Oncology, Lisbon, Portugal; 10La Paz University Hospital, Madrid, Spain; 11 Department of Hematology, University Medical Center Groningen, Groningen, The Netherlands; 12Department of Infectious Diseases and Clinical Microbiology, Marmara University, Istanbul, Turkey; 13Department of Hematology, Hospital Universitario de Burgos, Burgos, Spain; 14Hospital Universitario 12 de Octubre, Madrid, Spain; 15Admiraal de Ruijter Hospital, Goes, The Netherlands; 16Department of Internal Medicine–Hematology and Oncology, Masaryk University and University Hospital Brno, Brno, Czech Republic; 17Hospital Universitario de Cabue~ nes, Gijon, Spain; 18Hospital Germans Trias i Pujol-Institut Catala d’Oncologia Badalona Servicio de Hematologıa Clınica, Barcelona, Spain; 19Departement d’Oncologie Medicale, Hematologie, Institut Curie, Saint Cloud, France; 20Hospital de Sant Joan Despı Mois es Broggi, Sant Joan Despı, Spain; 21Rigshospitalet, Copenhagen, Denmark; 22Departamento de Hematolo- es de Oncologia, Lisboa, Portugal; 23Department of Hematology, Center for Hemoglobinopathies, Herlev and Gentofte Hospital, Herlev, gia, Instituto Portugu^ Denmark; 24Hospital Germans Trias i Pujol-Institut Catal a d’Oncologia Badalona Servicio de Hematologıa Clınica, Barcelona, Spain; 25Servicio de Hematologıa y Hemoterapia, Hospital Universitario Infanta Leonor, Madrid, Spain; 26Department of Hematology, Dubrava University Hospital, Zagreb, Croatia; 27 Institute of Hematology and Blood Transfusion, Prague, Czech Republic; 28Stem Cell Transplant Center, Azienda Ospedaliera- Universitaria (AOU) Citta’ della Salute e della Scienza, Turin, Italy; 29University of Milan and Fondazione, IRCCS, Istituto Nazionale dei Tumori, Milan, Italy; 30 Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, San Diego, CA; 31Clinical and Translational Fungal-Working Group, University of California San Diego, La Jolla, CA; 32Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria; 33North-Western State Medical University (named after) Ili echnikov, Saint-Petersburg, Russia; 34Department a Ilich M of Hematological Medicine, King’s College Hospital National Health Service (NHS) Foundation Trust, London, United Kingdom; 35Department of Medicine, Surgery, University of Insubria and Azienda socio sanitaria territoriale (ASST) Sette Laghi, Ospedale di Circolo of Varese, Varese, Italy; 36University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (Zentrum f€ ur Klinische Studien [ZKS] K€oln), Cologne, Germany; 37University of Cologne, Faculty of Medicine and University Hospital Cologne, Center for Molecular Medicine Cologne (CMMC), Cologne, Germany; and 38German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany Coronavirus disease 2019 (COVID-19) is a life-threatening condition identify categories of patients that may be less protected by vac- of high relevance for comorbid patients, such as those with baseline cines. With this report, we share our findings of the first 113 patients hematological malignancies (HM).1-3 In April 2020, the European included in the registry. Hematology Association - Infectious Diseases Working Party opened an open web-based registry to collect all cases of HM adult EPICOVIDEHA survey has been approved centrally by the Insti- patients that developed COVID-19 infections (EPICOVIDEHA sur- tutional Review Board and Ethics Committee of Fondazione Poli- vey).4 This registry aimed to describe the epidemiology, risk factors, clinico Universitario A. Gemelli – IRCCS – Universit a Cattolica and mortality rates of HM patients. Overall, we collected 3801 valid del Sacro Cuore (Rome, Italy) and by the respective local part- cases, and we observed an overall mortality rate of 31%.5 ners as appropriate. EPICOVIDEHA has been registered at www.clinicaltrials.gov with the identifier NCT04733729.4 From 1 Nearly 1 year after the first described COVID-19 case, in December January 2021 until 31 December 2021, all participating institu- 2020, the first vaccines against the severe acute respiratory syn- tions document episodes of COVID-19 in their patients with drome coronavirus 2 (SARS-CoV-2) were available,6,7 and adminis- baseline HM that received a vaccination against SARS-CoV-2. tration to the highest risk populations including HM patients Data are collected via the EPICOVIDEHA electronic case report started.8,9 From 1 January 2021, we prospectively collected registry form, available at www.clinicalsurveys.net. This online survey is data on adult fully or partially vaccinated HM patients that devel- provided by Enterprise Feedback Suite Fall 2018 (Questback, oped COVID-19 to assess the vaccine efficacy and potentially Cologne, Germany). Clinical and epidemiological data from 1588 blood® 10 MARCH 2022 | VOLUME 139, NUMBER 10 Table 1. Clinical characteristics of 113 vaccinated HM Table 1. (continued) patients that developed COVID-19 infection Patients, Patients, n % n % Moderna COVE 20 17.7 Sex Vector-based Female/male 44/69 38.9/61.1 AstraZeneca Oxford 10 8.8 Age (y.o.) (IQR) [range] 66 (58 - 78) [21 - 94] Inactivated 50/.50 y.o. 16/97 14.2/85.8 Sinovac 4 3.5 Comorbidities Antispike protein Ig dosage after vaccination (referring to WHO None/1-2-3 comorbidities 36/77 31.9/68.1 international standards, BAU/mL) Smoking history 17 15.0 No response (,30) 27 23.9 Downloaded from http://ashpublications.org/blood/article-pdf/139/10/1588/1879387/bloodbld2021014124.pdf by guest on 20 January 2023 Malignancy Weak response (31-250) 5 4.4 Acute lymphoid leukemia 3 2.6 Optimal response (.250) 8 7 Chronic lymphoid leukemia 28 24.8 Unknown/not measured 73 64.7 Acute myeloid leukemia 5 4.4 COVID-19 infection Chronic myeloid leukemia 1 0.9 WT 11 9.7 Myelodysplastic syndrome 7 6.2 English: alpha (a) 16 14.2 Hodgkin lymphoma 4 3.5 South African: beta (b) 1 0.9 Non-Hodgkin lymphoma 36 31.9 Indian: delta (d) 9 8.0 Myelofibrosis 3 2.7 Not tested 76 67.3 Polycythemia vera 2 1.8 Severity Systemic mastocytosis 2 1.8 Asymptomatic 22 19.5 Multiple myeloma 20 17.7 Mild infection 12 10.6 Aplastic anemia 2 1.8 Severe infection 63 55.8 Malignancy status before COVID-19 Critical infection 16 14.2 Controlled disease* 51 45.1 Symptomatology at onset Active disease 60 53.1 Asymptomatic 23 20.4 Not reported 2 1.8 Pulmonary symptoms 37 32.7 Last malignancy treatment Extrapulmonary symptoms 14 12.4 (in the last 3 mo) Pulmonary and extrapulmonary 39 34.5 alloHSCT (in the last 6 mo) 1 0.9 Chemotherapy 77 68.1 Neutrophil count Conventional chemotherapy 13 11.5 $500/mm3 98 86.7 Hypomethylating agents 4 3.5 Lymphocyte count Immunotherapy 9 8.0 $200/mm3 92 81.4 Immunochemotherapy 30 26.5 alloHSCT, allogeneic hematopoietic stem cell transplantation; BAU, binding antibody Targeted therapy 21 18.6 units; COVE, Coronavirus Efficacy and Safety Study; IQR, interquartile range; LNP, lipid nanoparticles; mRNA, messenger RNA; N, number; WT, wild type; y.o., years old. No treatment 35 31.0 *Controlled disease: partial remission or better. Patients with previous COVID-19 2 1.8 infections Yes/no 2/111 1.8/98.2 Vaccination patients with the laboratory-based diagnosis of SARS-CoV-2 infection after partial or complete vaccination are collected. Data One dose 25 22.1 captured included underlying conditions before SARS-CoV-2, HM Two doses 88 77.8 status and management before SARS-CoV-2, SARS-CoV-2 vacci- Patient that received vaccination at 87 77.0 nation, and infection details and mortality. The diagnosis of least 14 d before COVID-19 infection COVID-19 accords to the international recommendations of the Type of vaccine World Health Organization (WHO).10 The severity of COVID-19 at mRNA 1 LNP admission is graded according to the China Centers for Disease Control and Prevention definitions.11 Patients are considered fully BioNTech/Pfizer 79 69.9 vaccinated if the final dose was administered at least 14 days LETTERS TO BLOOD blood® 10 MARCH 2022 | VOLUME 139, NUMBER 10 1589 Table 2. Outcome of vaccinated patients that Table 2. (continued) developed COVID-19 infection N patients % N patients % Acute myeloid leukemia 0/5 0.0 Stay during COVID-19 Chronic myeloid leukemia 0/1 0.0 Hospital 75 66.4 Myelodysplastic syndrome 2/7 28.6 COVID-19 ward 59 83.8 Hodgkin lymphoma 1/4 25.0 ICU 16 14.2 Non-Hodgkin lymphoma 6/36 16.7 Of which, invasive 10 8.8 Myelofibrosis 1/3 33.3 mechanical ventilation Polycythemia vera 0/2 0.0 Home 38 33.6 Systemic mastocytosis 1/2 50.0 Overall mortality at 30 d 14 12.4 Multiple myeloma 1/20 5.0 Attributable to COVID-19 9/14 64.3 Aplastic anemia 0/2 0.0 Downloaded from http://ashpublications.org/blood/article-pdf/139/10/1588/1879387/bloodbld2021014124.pdf by guest on 20 January 2023 1 Hematological 3/14 21.4 malignancy Mortality for patients with active hematological Contributable by COVID-19 4/14 28.6 malignancy 1 Other reasons* 2/14 14.3 Yes/no 7/7 50.0/50.0 Not related to COVID-19 1/14 7.1 Mortality for patients with 1 Hematological 1/14 7.1 chemo-immuno or malignancy radiotherapy Mortality according to severity in the last 3 mo 10/14 71.4 Asymptomatic 1/14 7.1 more than 3 mo/w&w 4/14 28.6 Mild infection 1/14 7.1 alloHSCT, allogeneic hematopoietic stem cell transplantation; COVE, Coronavirus Severe infection 7/14 50.0 Efficacy and Safety Study; ICU, intensive care unit; w&w, watch and wait. *Renal impairment plus bacterial infection; intestinal subocclusion. Critical infection 5/14 35.7 Mortality for stay Hospital 13/14 11.5 before symptom onset or a positive polymerase chain reaction test for SARS-CoV-2. ICU 5/14 35.7 Of which, invasive 5/5 100.0 As of 31 August 2021, 113 COVID-19 episodes among partially or mechanical ventilation completely vaccinated patients with HM have been registered in Home 1/14 7.1 EPICOVIDEHA. These patients have been reported from 42 out of Mortality according to type of 163 centers in 14 out of 38 European and non-European countries vaccine participating in the survey. The clinical characteristics of these BioNTech/Pfizer 12/79 15.2 patients are reported in Table 1. The majority of them were males (61.1%) and over 50 years of age (85.8%). More than 80% of Moderna COVE 1/20 5.0 patients had underlying lymphoproliferative malignancies (chronic AstraZeneca Oxford 1/10 10.0 lymphoid leukemia [CLL], non-Hodgkin lymphoma [NHL], acute Sinovac 0/4 0.0 lymphoblastic leukemia, Hodgkin’s lymphoma, and multiple mye- loma). Seventy-eight (68.1%) patients received active treatment of Mortality according to SARS-CoV-2 variant underlying HM at the time of COVID-19 or within the prior 3 months. Following the recommendations of major international WT 0/14 0.0 scientific societies,8,9 the majority of our patients received an English: alpha (a) 4/14 28.6 mRNA vaccine (BioNTech/Pfizer n 5 79 [69.9%], Moderna n 5 20 South African: beta (b) 0/14 0.0 [17.7%]), whereas the remaining 14 (12.4%) received a vector- Indian: delta (d) 0/14 0.0 based vaccine (AstraZeneca Oxford, n 5 10) or an inactivated vaccine (Sinovac CoronaVac, n 5 4); overall, the median time from Not tested 10/14 71.4 the last dose of vaccine and COVID-19 diagnosis was of 64 days Mortality according to vaccine (IQR: 33.5-108). Eighty-seven patients (77%) were considered fully scheme vaccinated, whereas the remaining 26 received only 1 shot; in all 1 dose 4/25 28.6 fully vaccinated patients, COVID-19 was diagnosed more than 2 Full dose 10/78 71.4 weeks after the second vaccine dose. Viral genomes of infection were analyzed in only 37 (32.7%) cases and the a-variant was the Mortality according to type of most frequently observed (supplemental Figure 1). Postvaccine IgG hematological malignancy levels against SARS-CoV-2 spike protein were analyzed in 40 Acute lymphoid leukemia 0/3 0.0 (35.4%) fully vaccinated patients, 2 to 4 weeks from the last vaccine Chronic lymphoid leukemia 2/28 7.1 dose. Among these patients, only 13 (32.5%) presented an 1590 blood® 10 MARCH 2022 | VOLUME 139, NUMBER 10 LETTERS TO BLOOD antibody response to vaccine (optimal: 8; weak: 5), whereas the Recruitment to this survey continues, and larger numbers of cases remaining 27 (67.5%) were considered no responders (BAU ,30/ will enable us to draw more conclusions in order to develop strat- mL). Overall, 79 (60.4%) patients had a severe or critical infection. egies to prevent severe COVID-19 in this frail population. Seventy-five patients (66.4%) were admitted to the hospital: 16 (21.3%) of them to an ICU, and 10/16 required mechanical ventila- Informed consent was collected as applicable. tion (Table 2); detailed data about COVID-19 symptoms and sever- ity according HM diagnosis have been described in supplemental Table 1. After a follow-up of 30 days post-COVID-19 diagnosis, the Acknowledgment Universit a Cattolica del Sacro Cuore contributed to the funding of overall mortality rate was 12.4% (n 5 14). COVID-19 was the main this research project and its publication. or a secondary cause of death for all but 1 patient; interestingly, we did not observe any statistical difference in terms of mortality between partially or fully vaccinated patients (15.4% vs 11.5%; P 5 Authorship .734) and between patients achieving a serological response to vac- Contribution: L.P. set up EPICOVIDEHA, conceived the study idea, pro- vided clinical details from local patients, interpreted the data, wrote cine vs nonresponders (13.3% vs 15.6%; P 5 1). In addition, we did the initial draft of the manuscript, and revised and approved the final not find any significant differences in terms of age or comorbidities manuscript; J.S.-G. enrolled patients and performed formal validation Downloaded from http://ashpublications.org/blood/article-pdf/139/10/1588/1879387/bloodbld2021014124.pdf by guest on 20 January 2023 comparing responder vs nonresponder patients. Moreover, our of the clinical details, extracted data from EPICOVIDEHA patients, per- multivariable analysis showed that the only factor independently formed the statistical analysis and interpreted the data, wrote the initial related to the risk of death in our cohort of vaccinated patients was draft of the manuscript, created tables, and revised and approved the final manuscript; F.M. provided clinical details from local patients inter- the age (P 5 .035; HR 1.053, 95% CI: 1.004-1.105) (supplemental preted the data, interpreted the data, wrote the initial draft of the man- Table 2). Ten of 14 (71.4%) patients who died had underlying lym- uscript, and revised and approved the final manuscript; A.L.-G., S.L., phoproliferative malignancies. With the caution due to the limited F.I., M.G.-S., G.D., I.F.-R., J.v.D., U.S., J.L., M.C., Y.M.B., B.W., L.S., number of reported cases, it is worth it to underline that none of the J.-M.R.-S.S., S.M., J.L.-A., A.G., R.C.-M., R.N.-R., T.-J.G.-L., L.K.K., patients who died had underlying acute myeloid leukemia, which in M.-J.J.-L., J.-A.H.-R., O.J., Z.R., and the researchers listed in the study our previous analysis in nonvaccinated patients was the category group provided clinical details from local patients and revised and approved the final manuscript; and A.B., P.C., M.H., N.K., P.K., A.P., with one of the highest mortality rates.5 F.P., and O.A.C. set up EPICOVIDEHA, conceived the study idea, and revised and approved the final manuscript. A generalized anti-SARS-CoV-2 vaccination policy has allowed a marked reduction in the incidence of severe COVID-19 in the gen- Conflict-of-interest disclosure: The authors declare no competing financial interests. eral population. However, some reports indicate the occurrence of the infection in a limited number of vaccinated subjects.12-14 These A list of the members of the EPICOVIDEHA study group appears in are mostly subjects who have not developed protective immunity. “Appendix.” Our survey, involving 42 hematology departments around the world, provides some preliminary insights. The majority of patients ORCID profiles: L.P., 0000-0001-8287-928X; J.S-G., 0000-0002-6766- who do not respond to vaccination are patients with lymphoproli- 8297; F.M., 0000-0001-6353-2272; A.L.-Garcıa, 0000-0002-5354-5261; S.L., 0000-0001-5980-305X; F.I., 0000-0002-3532-5281; M.G-S., 0000- ferative diseases, mainly CLL and NHL. This has also been 0002-6993-2450; G.D., 0000-0003-1775-6333; I.F-R., 0000-0001-5888- observed for other vaccinations (eg, influenza).15,16 Our results sug- 7706; J.vanD., 0000-0003-0214-3219; U.S., 0000-0002-9939-9298; J.L., gest that the low serologic response rate to anti-SARS-CoV-2 vac- 0000-0002-3696-0287; M.C., 0000-0001-8106-4863; Y.M.B., 0000-0003- cines in patients with HM may translate to higher rates of 4854-5424; B.W., 0000-0001-6460-2471; J-M.R-S.S., 0000-0003-1042- infections. This has previously been described following monoclo- 6024; S.M., 0000-0001-8823-5055; J.L-A., 0000-0002-6451-8971; A.G., 0000-0003-2082-0738; R.C.-Mascu~ nano, 0000-0002-7654-8836; R.N-R., nal antibody treatment.17-23 Unfortunately, only little data are avail- 0000-0002-8347-4281; T-J.Gonz alez-L., 0000-0001-9575-1816; L.K.K., able on the genomic characterization of the virus. We expect to 0000-0003-3317-7550; M-J.J-L., 0000-0002-5469-5237; J.-ngelH-R., have more detailed data at the end of this survey. Given policies 0000-0003-4550-757X; Z.Racil, 0000-0003-3511-4596; A.B., 0000-0001- that differ between sites, postvaccination serology results were 5361-5613; P.C., 0000-0002-9186-1353; M.H., 0000-0002-1653-2824; available in only 35% of patients, and of those about two-thirds N.K., 0000-0001-6095-7531; P.K., 0000-0002-7386-7495; A.P., 0000- were serologically nonresponders. An important limitation of these 0003-2519-0333; F.P., 0000-0001-8068-5289; O.A.C., 0000-0001-9599- 3137. data is that methods for evaluating anti-SARS-CoV-2 antibodies were different among enrolling centers; as a consequence we tried Correspondence: Livio Pagano, Fondazione Policlinico Universitario A. to reduce this interlaboratory variability by referring to the WHO Gemelli–IRCCS–Universit a Cattolica del Sacro Cuore, Largo Francesco standardized method (https://www.who.int/news-room/feature- Vito 1, 00168 Roma, Italia; e-mail:Livio.Pagano@unicatt.it. stories/detail/standardization-of-vaccines-for-coronavirus-disease- covid-19). Importantly, the overall mortality observed in our patients, although lower than in the prevaccination period Footnotes (31%), remained high (12.4%). This percentage, on one hand, Submitted 15 September 2021; accepted 13 October 2021; prepub- remains quite worrying for hematologists, but on the other hand lished online on Blood First Edition 8 November 2021. should be interpreted as a significant achievement following the spread of vaccination programs around the world. The hospitali- *L.P., J.S.-G., and F.M. are joint first authors. zation and mortality rates are still higher than the ones observed Requests for data sharing may be submitted to Livio Pagano (livio. in the fully vaccinated general population, where hospitalization pagano@unicatt.it). rates of 2% to 3% have been reported.12,13,24,25 Our study reports preliminary observations, and the low number of vaccinated The online version of this article contains a data supplement. patients is the main weakness, for now limiting the possibility to define the real incidence of breakthrough COVID-19 in HM. There is a Blood Commentary on this article in this issue. LETTERS TO BLOOD blood® 10 MARCH 2022 | VOLUME 139, NUMBER 10 1591 Appendix 12. Bergwerk M, Gonen T, Lustig Y, et al. Covid-19 breakthrough infections in vaccinated health care workers. N Engl J Med. 2021; Members of the EPICOVIDEHA study group: Florian Reizine (Rennes, 385(16):1474-1484. France); Malgorzata Mikulska (Genoa, Italy); Hytham K. S. Hamid (Caserta, Italy); Nicola S. Fracchiolla (Milan, Italy); Francesca Farina 13. Brown CM, Vostok J, Johnson H, et al. Outbreak of SARS-CoV-2 (Milan, Italy); Nicola Coppola (Naples, Italy); Caterina Buquicchio (Bar- infections, including COVID-19 vaccine breakthrough infections, associ- letta, Italy); Avinash Aujayeb (Cramlington, United Kingdom); Przemy- ated with large public gatherings - Barnstable County, Massachusetts, slaw Zdziarski (Wroclaw, Poland); Maria Chiara Tisi (Vicenza, Italy); July 2021. MMWR Morb Mortal Wkly Rep. 2021;70(31):1059-1062. Martin Sch€ onlein (Hamburg, Germany); Gianpaolo Nadali (Verona, Italy); Martin Kolditz (Dresden, Germany); Michaela Hanakova (Czech 14. Juthami PV, Gupta A, Borges KA et al. Hospitalisation among vaccine Republic); Monica Fung (San Francisco); Maureen Chbat (Chesnay, breakthrough COVID-19 infections. Lancet Infect Dis. 2021;21(11): 1485-1486. France); Caroline Besson (Versailles, France); Valentina Bonuomo, (Verona, Italy); and Ghaith Abu-Zeinah (New York, NY). 15. Ljungman P, Nahi H, Linde A. Vaccination of patients with haematological malignancies with one or two doses of influenza vaccine: a randomised study. Br J Haematol. 2005;130(1):96-98. REFERENCES 1. Wood WA, Neuberg DS, Thompson JC, et al. Outcomes of patients 16. Cordonnier C, Mikulska M, Einarsdottir S, Cesaro S, Ljungman P; ECIL with hematologic malignancies and COVID-19: a report from the vaccine group. 2017 ECIL 7 vaccine guidelines. Lancet Infect Dis. 2019; ASH Research Collaborative Data Hub. 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MMWR Morb guidance. 2021. https://www.who.int/publications/i/item/WHO-2019- Mortal Wkly Rep. 2021;70(34):1170-1176. nCoV-clinical-2021-1. Accessed 24 September 2021. DOI 10.1182/blood.2021014124 11. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary © 2022 by The American Society of Hematology. Licensed under Creative Commons of a report of 72 314 cases from the Chinese Center for Disease Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0), permit- Control and Prevention. JAMA. 2020;323(13):1239-1242. ting only noncommercial, nonderivative use with attribution. All other rights reserved. 1592 blood® 10 MARCH 2022 | VOLUME 139, NUMBER 10 LETTERS TO BLOOD