Review

COVID-19 Vaccine: Between Myth and Truth

Pier Paolo Piccaluga 1,2,3,4, * , Antonio Di Guardo 1 , Anna Lagni 5 , Virginia Lotti 5 , Erica Diani 5 ,
Mohsen Navari 6,7,8 and Davide Gibellini 5

1 Department of Experimental, Diagnostic, and Specialty Medicine, Institute of Hematology and Medical
Oncology “L. and A. Seràgnoli”, University of Bologna School of Medicine, 40126 Bologna, Italy;
[email protected]
2 SBGT—Biomolecular Strategies, Genetics and Cutting-Edge Therapies, Istituto Euro-Mediterraneo di Scienza
e Tecnologia (IEMEST), 90139 Palermo, Italy
3 Department of Pathology, School of Medicine, Jomo Kenyatta University of Agriculture and Technology,
Juja 01001, Kenya
4 School of Medicine, Nanchang University, Nanchang 330047, China
5 Department of Diagnostic and Public Health, Verona University, 37134 Verona, Italy;
[email protected] (A.L.); [email protected] (V.L.); [email protected] (E.D.);
[email protected] (D.G.)
6 Department of Medical Biotechnology, School of Paramedical Sciences, Torbat Heydariyeh University of
Medical Sciences, Torbat Heydariyeh 33787 95169, Iran; [email protected]
7 Research Center of Advanced Technologies in Medicine, Torbat Heydariyeh University of Medical Sciences,
Torbat Heydariyeh 33787 95169, Iran
8 Bioinformatics Research Group, Mashhad University of Medical Sciences, Mashhad 91778 99191, Iran
* Correspondence: [email protected]; Tel.: +39-05-1214-4043; Fax: +39-05-1214-4037

Abstract: Since December 2019, a pandemic caused by the newly identified SARS-CoV-2 spread
across the entire globe, causing 364,191,494 confirmed cases of COVID-19 to date. SARS-CoV-2 is a
betacoronavirus, a positive-sense, single-stranded RNA virus with four structural proteins: spike





 (S), envelope (E), membrane (M), and nucleocapsid (N). The S protein plays a crucial role both in
Citation: Piccaluga, P.P.; Di Guardo,
cell binding and in the induction of a strong immune response during COVID-19 infection. The
A.; Lagni, A.; Lotti, V.; Diani, E.; clinical impact of SARS-CoV-2 and its spread led to the urgent need for vaccine development to
Navari, M.; Gibellini, D. COVID-19 prevent viral transmission and to reduce the morbidity and mortality associated with the disease.
Vaccine: Between Myth and Truth. Multiple platforms have been involved in the rapid development of vaccine candidates, with the S
Vaccines 2022, 10, 349. https:// protein representing a major target because it can stimulate the immune system, yielding neutralizing
doi.org/10.3390/vaccines10030349 antibodies (NAbs), blocking viral entry into host cells, and evoking T-cell immune responses. To date,
Academic Editors: Martin H. Bluth 178 SARS-CoV-2 vaccine candidates have been challenged in clinical trials, of which 33 were approved
and Vincenzo Baldo by various national regulatory agencies. In this review, we discuss the FDA- and/or EMA-authorized
vaccines that are mostly based on mRNA or viral vector platforms. Furthermore, we debunk false
Received: 20 December 2021
myths about the COVID-19 vaccine as well as discuss the impact of viral variants and the possible
Accepted: 21 February 2022
future developments.
Published: 23 February 2022

Publisher’s Note: MDPI stays neutral Keywords: SARS-CoV-2; coronavirus; COVID-19; vaccine; immunization; viral vector; mRNA
with regard to jurisdictional claims in
published maps and institutional affil-
iations.

1. Introduction
In December 2019, a cluster of acute pneumonia cases with unknown etiology was
Copyright: © 2022 by the authors.
detected in Wuhan, China. Afterwards, a new human coronavirus, the Severe Acute
Licensee MDPI, Basel, Switzerland. Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), was determined as the cause of this
This article is an open access article disease and was named coronavirus disease 2019 (COVID-19) [1]. This virus spread rapidly
distributed under the terms and across the world. The World Health Organization (WHO) declared a pandemic on March
conditions of the Creative Commons 11, 2020, and, according to their latest report [2], there are currently 364,191,494 confirmed
Attribution (CC BY) license (https:// cases of COVID-19 and 5,631,457 deaths (current as of 28 January 2022).
creativecommons.org/licenses/by/ SARS-CoV-2 is mainly transmitted through respiratory secretions, and infected pa-
4.0/). tients can show a broad spectrum of clinical manifestations, ranging from asymptomatic

Vaccines 2022, 10, 349. https://doi.org/10.3390/vaccines10030349 https://www.mdpi.com/journal/vaccines

Vaccines 2022, 10, 349 2 of 24

to critical illness with acute respiratory failure, septic shock, multiorgan dysfunction, and
in the worst cases, death. Fever, headache, cough, fatigue, anosmia or dysgeusia, sore
throat, myalgia, and breathlessness are common clinical characteristics of this emerging
disease [3].
SARS-CoV-2 is a member of the subgenus Sarbecovirus (betacoronavirus lineage B)
of the Coronaviridae family. Coronaviruses (CoVs) are cytoplasmic replicating, positive-
sense, single-stranded RNA viruses with four structural proteins: spike (S), envelope (E),
membrane (M), and nucleocapsid (N). The S protein plays a crucial role in cell binding and
in eliciting the immune response during the progression of the disease [4]. SARS-CoV-2
enters host cells via the binding of the S protein with the angiotensin-converting enzyme 2
(ACE2) receptor. Cell entry is also regulated by coreceptors such as transmembrane serine
protease 2 (TMPRSS2) [5–7] and furin, which are both responsible for S protein cleavage
and the priming [8] necessary for SARS-CoV-2 cell entry [9,10].
In the last two decades, emerging coronaviruses have been observed to be highly
pathologic to humans. Before December 2019, only six members of the Coronaviridae
family (229E, NL63, OC43, HKU1, MERS-CoV, and SARS-CoV) had been isolated and
characterized as causes of respiratory human disease. Outbreaks of SARS-CoV (2003) and
MERS-CoV (2009) caused severe respiratory diseases with a mortality rate of 10% and 36%,
respectively, even with a limited number of infected patients [11]. The clinical impact of
SARS-CoV-2 and its spread was different from the previously known coronaviruses; it led
to the urgent need for the development of a vaccine to limit transmission and to reduce
the morbidity and mortality associated with the disease, and multiple platforms have been
involved in the rapid development of vaccine candidates. The major target for the vaccine
development is the S protein because the immune system is able to yield neutralizing
antibodies (NAbs) against this protein, block viral entry into host cells, and induce T-cell
immune responses [12]. To date (26 January 2022), 178 SARS-CoV-2 vaccine candidates
have been challenged in clinical trials and 33 vaccine candidates have been approved
by various national regulatory agencies. To achieve this goal, multiple platforms and
technologies were used in the rapid development of SARS-CoV-2 vaccine candidates, using
both classical and new strategies, including mRNA, adenoviral vector-based, adjuvanted
recombinant protein, and inactivated virus vaccines [13].
As of 28 January 2022, a total of 9,854,237,363 vaccine doses have been administered [2],
and the most widely used are mRNA vaccines, including the BNT162b2 (Pfizer-BioNTech,
New York, NY, USA—Mainz, Germany) and mRNA-1273 (Moderna, Cambridge, MA,
USA) vaccines, and viral vector vaccines, such as Ad26.CoV2.S (Johnson & Johnson, New
Brunswick, NJ, USA), ChAdOx (AstraZeneca, Cambridge, UK), Sputnik V (Gamaleya
Research Institute of Epidemiology and Microbiology, Moscow, Russia) and the inactivated
virus alum-adjuvanted candidate vaccine CoronaVac (Sinovac, Beijing, China). All of these
vaccines were well tolerated in clinical trials and their proven efficacy was greater than 90%
in preventing symptomatic disease, except for the CoronaVac vaccine, which had a proven
effectiveness of 51% [14,15].
In this review, we will focus our attention on the false information and truths regarding
mRNA and viral vector vaccines authorized by the Food and Drug Administration (FDA)
and the European Medical Agency (EMA) (Table 1). We will also consider variants of
concern (VOCs), implications on their efficacy, and possible future developments.
es 2022, 10, x FOR PEER REVIEW 3 of 25
Vaccines
Vaccines 10, x10,
2022,
2022, FOR349PEER REVIEW 3 of 325of 24

Table 1. SARS-CoV-2 EMA/FDA-authorized vaccines.

Table
Table 1. SARS-CoV-2
1. SARS-CoV-2 EMA/FDA-authorized
EMA/FDA-authorized vaccines.
vaccines.
Features BNT162b2 mRNA-1273 ChAdOx1 Ad26.COV2.S
Features Features
BNT162b2 BNT162b2mRNA-1273
mRNA-1273 ChAdOx1
ChAdOx1 Ad26.COV2.S
Ad26.COV2.S

Vaccine Type
Vaccine Type Vaccine Type

Viral Vector
mRNA
mRNA Viral Vector
Viral Vector
mRNA
Janssen Janssen Pharmaceuti-
Manufacturer
Pfizer-BioNTech
Moderna (US)
AstraZeneca/Oxford Janssen
Pfizer-BioNTech AstraZeneca/(UK) Pharmaceutical/Joh & Johnson
cal/Johnson
Manufacturer (US—GER)Pfizer-BioNTech Moderna (US) AstraZeneca/ Pharmaceutical/Joh
Manufacturer
(US—GER) Moderna Oxford (US) (UK) nson & Johnson (US)
(US—GER) Oxford (UK) nson & Johnson
Commercial Name Comirnaty Spikevax Vaxzevria (US) Janssen COVID-19
(US)
Vaccine
Commercial Janssen COVID-19
CommercialComirnaty Spikevax Vaxzevria Janssen COVID-19
Replication- deficient
Name Comirnaty Spikevax Vaxzevria Vaccine
Name Replication-deficient humanVaccine
adenovirus
Full-length spike (S) Full-length spike (S)
chimpanzee adenoviral
Replication- serotype 26 vector
Antigen protein with proline protein with proline Replication- Replication-
vector with deficient
the human
encoding a full-length,
substitutions substitutions Replication- deficient human
Full-length spike Full-length spike deficient
SARS-CoV-2 S protein adenovirus
stabilized SARS-CoV-2
Full-length spike Full-length spike deficient adenovirus
S protein
(S) protein with (S) protein with chimpanzee serotype 26 vector
Antigen (S) protein with (S) protein with chimpanzee
10
serotype 10
26 vector
Dose Antigen
30 proline
µg proline
05 mL adenoviral5 × 10vector encoding5a×full-
Viral particles 10 Viral particles
proline proline adenoviral vector encoding a full-
Dosage 2 Dosed substitutions
21 d apart substitutions d apartwith the
2 Dosed 28substitutions SARS-28 d length,
2 Dosed apart stabilized
substitutions with the SARS- length, 1stabilized
Dose
−80 to −60 C; ◦ −25 to −15 C; ◦ CoV-2 S protein SARS-CoV-2 S
CoV-2 S protein SARS-CoV-2
20 ◦ C; S
Storage Condition 2–8 ◦ C for 5 d; 2–8 ◦ C for 30 d; 2–8 ◦ C for 6 monthsprotein ◦
2–8 protein
C for 3 months
RT ≤ 2 h RT ≤ 12 h 5 × 1010 Viral 10 5 × 1010 Viral 10
Dose 30 μg 05 mL 5 × 10 Viral 5 × 10 Viral
Dose 30 μg 94.1% 14 d05 mL particles 70.4% 14 d particles 66.9% 14 d after
Efficacy 94.6% 7 d after 2 doses particles particles
2 Dosed 21d 2 after
Dosed second
28d dose after second dose administration
Dosage 2 Dosed 21d 2 Dosed 28d 28d apart
2 Dosed 1 Dose
Dosageapart apart
Myocarditis, 2 Dosed 28d apart 1 Dose
Anaphylaxis and
apart
anaphylaxis, and
apart
other
Cerebral venous sinus Cerebral venous sinus
Serious Adverse Event −80° to -60°C; −25° to −15 °C;
Storage myocarditis −80° to -60°C; serious −25°
allergicto −15 °C;thrombosis and other20 °C;thrombosis and other
Storage
2–8°C for 5 d; 2–8°C for 30 d; 2–8 °C forvenous 6 monthsthrombosis venous20 °C;
thrombosis
Condition 2–8°C for 5 d;reactions2–8°C for 30 d; 2–8 °C for2–8 6 months
°C for 3 months
Condition RT≤ 2h RT ≤ 12 h 2–8 °C for 3 months
RT≤ 2h RT ≤ 12 h
94.1% 14 d
94.6% 7d after 2 94.1% 1470.4%
d 14 d 66.9% 14 d after
Efficacy 2. COVID-19 Vaccines:
94.6% 7d after Myths
after 2
second and Hesitancy 70.4% 14 d 66.9% 14 d after
Efficacy doses
Once the main hurdle of after
finding second
after
a waysecond
to dose
tackle the administration
COVID-19 pandemic was over-
doses dose after second dose administration
come, other challenges arose in the dose
COVID-19 immunization
Myocarditis, Cerebral venous Cerebral venousskepticism and
campaign:
Serious fear of vaccinations [16]. ThisMyocarditis, phenomenon hasCerebral
been venousby the
named Cerebral
WHOvenous as “vaccine
Serious
Anaphylaxis and anaphylaxis, and sinus thrombosis sinus thrombosis
Adverse hesitancy” Anaphylaxis
and is defined and
as anaphylaxis,
“the reluctance and sinus thrombosis
or refusal sinus thrombosis
to vaccinate despite the availability
Adverse
myocarditis other serious and other venous and other venous
Event of vaccines” [17]. myocarditis
Hesitancy towards other serious
vaccinations andisother venous and
a phenomenon thatother venoussince
has existed
Event allergic reactions thrombosis thrombosis
the first vaccine became available. allergicVaccine
reactions hesitancy is a complex problem
thrombosis closely linked
thrombosis
to the individuals social context, income, and level of education, posing dangers to both
2. COVID-19 the Vaccines:
individualMythsandandtheirHesitancy
community and increasing the risk of vaccine-preventable disease
2. COVID-19 Vaccines: Myths and Hesitancy
Once theoutbreaks
main hurdle of finding[18,19].
and epidemics a way to tackle the COVID-19 pandemic was
Once the main hurdle of finding a way to tackle the COVID-19 pandemic was
overcome, other challenges
In particular,arose
theinanti-vaccine
the COVID-19 immunization
community argues thatcampaign:
vaccines,skepticism
contrary to the claims
overcome, other challenges arose in the COVID-19 immunization campaign: skepticism
and fear of vaccinations
of most of [16]. This phenomenon
the scientific community hasdo been notnamed
have aby the WHO
sufficient orasadequate
“vaccinesafety profile.
and fear of vaccinations [16]. This phenomenon has been named by the WHO as “vaccine
hesitancy” and is defined
Major as “the
theories reluctance
against vaccination or refusal
include to vaccinate
the widespread despitefearthethat
availability
vaccines increase the
hesitancy” and is defined as “the reluctance or refusal to vaccinate despite the availability
of vaccines” [17].
risk Hesitancy
of developing towards
autism,vaccinations
a theory that is a originated
phenomenon from that has existed
a study publishedsincein 1997 in The
of vaccines” [17]. Hesitancy towards vaccinations is a phenomenon that has existed since
the first vaccine became
Lancet available.
by Andrew Vaccinein
Wakefield; hesitancy
this study, is athe
complex
authorsproblem
suggested closely
that thelinked
measles, mumps,
the first vaccine became available. Vaccine hesitancy is a complex problem closely linked
and rubella
to the individuals (MMR) income,
social context, vaccine caused
and level anof increasing
education, incidence of autism
posing dangers to in British children.
both
to the individuals social context, income, and level of education, posing dangers to both
the individualThe andpaper
their has since been
community anddiscredited
increasingdue the to serious
risk procedural errors,disease
of vaccine-preventable undeclared financial
the individual and their community and increasing the risk of vaccine-preventable disease
outbreaks andconflicts
epidemics of interest,
[18,19]. and ethical violations [20]. Another recurrent reason for vaccine refusal
outbreaks and epidemics [18,19].
is the presumed
In particular, the anti-vaccine highcommunity
number of arguesdangerous substances
that vaccines, in vaccine
contrary to theformulations,
claims such as
In particular, the
formaldehyde, anti-vaccine
mercury, and community
aluminum. argues
There is no that vaccines,
scientific contrary
basis to confirmto the claims
these claims,
of most of the scientific community do not have a sufficient or adequate safety profile.
of most of the scientific community do not have a sufficient or adequate safety profile.
Vaccines 2022, 10, 349 4 of 24

and it has been reported that the low levels of mercury or aluminum in vaccines cannot
be harmful and, moreover, that formaldehyde is produced at higher rates by our own
metabolic systems [21].
Another theory accepted by vaccine skeptics is that natural immunity (the immunity
that develops after infection) is superior to vaccine-acquired immunity. In some cases,
natural immunity results in a stronger immunity to the disease than that provided by
vaccination; however, the dangers of this approach far outweigh the relative benefits [22], as
in the case of COVID-19 whereby the prevalence of 55 long-term effects was evaluated [23].
Among the conspiracy theories of the anti-vaccine movement, a key role is played by
the observation that vaccines are one of the main sources of income for pharmaceutical
companies (often given the nickname “Big Pharma”), and therefore the establishment of a
major vaccine plan with multiple mandatory vaccinations would do nothing but increase
profits at the expense of the health care system, and not the provision of greater patient
care and disease prevention, as, in fact, is the case.
In the current day, the uncertainty caused by the pandemic and controversies sur-
rounding vaccine safety that circulate in news headlines, talk shows, and popular articles,
in addition to the spread of “fake news” on social media, have made vaccine hesitancy one
of the main themes in the fight against COVID-19 [16]. This spread of misinformation has
been defined by the WHO as another epidemic to be fought, called lymphodemics [18].
Regarding COVID-19 vaccines specifically, one of the first and major concerns in the
collective ideal and around the anti-vaccine community was their rapid development and
release, making it difficult to trust their safety and effectiveness. For this reason, many
efforts were made by the scientific community to disclose the factors responsible for the
record time of COVID-19 vaccine release: first, past research on mRNA technology and
on human coronaviruses related to SARS-CoV-2 (such as SARS-CoV and MERS-CoV)
were key starting points in the research of vaccines against COVID-19, allowing for the
reduction in development time; because the development occurred in the midst of a
pandemic, substantial human and economic resources were made available under tight
time constraints, permitting research to be conducted in parallel with the various phases of
evaluation and study; as the pandemic was a global emergency, evaluation of the results by
regulatory agencies was made straight-forward after the completion of each phase (rolling
review), and not at the completion of all studies, as is generally the case [21,24].
Another main concern of anti-vaccine community about the vaccines is the belief in
their ability to alter human DNA with mRNA technology, due to misinformation that led
to ignorance of the cornerstones on which biology and medicine are founded. The mRNA
contained in COVID-19 vaccines never enters the cell nucleus; moreover, it is sensitive to
degradation by ubiquitous ribonucleases (RNase) with metabolic decay occurring within a
few days. Regarding the viral vector vaccines, the concern was the same as with mRNA,
but studies reported that, even in this case, the genetic material delivered into host cells
reached the nucleus without integrating into the host DNA [25,26].
Recently, there has been much debate about whether variants may be caused by
COVID-19 vaccine administration, as the anti-vaccine community claims that, to escape a
vaccinated host’s immune system, the virus should be able to modify its genetic material,
which leads to development of variants. However, it is important to note that the main
issue leading to variant development concerns virus circulation and consequently the
non-immunized population, representing an ideal environment for the development of
mutations due to the absence of a defense, allowing the virus to replicate undisturbed. The
more mutations that occur, the more likely it is that variants will appear. Vaccines are able
to decrease the viral load in case of infection, thereby reducing the number of reproduction
cycles of the virus by decreasing the possibility of new mutations and the emergence of
new variants [27,28].
Given the hesitancy and false information surrounding SARS-CoV-2 vaccines, the
key responsibilities of policy, health systems, and healthcare professionals include the
Vaccines 2022, 10, 349 5 of 24

need to clear any doubts about vaccine safety and to promote an effective, science-based
information campaign.

3. SARS-CoV-2 mRNA-Based Vaccines

To date, the mRNA-based vaccine platform represents a promising alternative to con-
ventional vaccines and provides the most rapidly accessible vaccine candidates due to their
short development time, scalability, low-level biosafety requirement, safe administration,
and ability to generate Th1 and Th2 responses [29]. Although this is a novel technology, it
has already been used to develop vaccines against other infectious diseases, such as the
influenza virus, respiratory syncytial virus (RSV), Zika virus, Ebola virus, HIV, and also
against several types of cancer [26].
The delivery of mRNA in non-toxic carriers was the main challenge to ensure its
efficacy because mRNA is an unstable and easily degraded molecule, particularly due to
the widespread presence of RNases in the human body. Thanks to recent technological
advantages, novel vaccine designs were developed to improve the stability and efficiency
of protein translation, to enhance the immune response, in particular the use of lipid
nanoparticle (LNP)-encapsulated mRNA that facilitates the release of mRNA into cells
from endosomes [30].
An LNP consists of a bilayer lipid vesicle with a surface coating of polyethylene glycol
(PEG), and cholesterol, phospholipids, and ionizable lipids in the structure. This central
component is essential for the release of mRNA molecules after intramuscular (IM) injection,
with a neutral charge at physiological pH and a protonated form at a lower pH in the
endosome [31]. When injected intramuscularly, the adjuvant effect of mRNA-LNPs allows
mRNA to be internalized and quickly translated by antigen-presenting cells (APCs) at both
the injection site and in draining lymph nodes, promoting the initiation of the adaptive
immune response [30]. In a study assessing an ionizable LNP formulation, an adjuvant
effect was observed from the ionizable lipid component and IL-6 cytokine induction that
elicited strong T follicular helper cell, germinal center B-cell, long-lived plasma cell, and
memory B-cell responses that were associated with the production of long-lasting and
protective antibodies in mice [32].
Once the mRNA vaccine is injected into the patient, the lipid nanoparticles protect
the mRNA from degradation and promote its entry into cells where the mRNA is then
translated to produce the viral protein to elicit a specific immune response. The produced
viral proteins stimulate the immune system primarily through T-cells and the synthesis
of neutralizing antibodies, which aim to prevent SARS-CoV-2 infection (Figure 1) [33]. In
vaccinated patients subsequently exposed to the virus, the antibodies block the S protein
and prevent viral entry into the cells. mRNA is highly immunogenic with a self-adjuvating
effect, activating several pathogen-associated molecular pattern sensors; however, the
early triggering of a type I interferon (IFN-1) response can downregulate protein expres-
sion [34]. Therefore, in order to avoid excess inflammation and to improve the half-life and
safety, modified nucleosides can incorporate into the mRNA to create a “silenced” RNA
vaccine that avoids activation of the toll-like receptor (TLR) mechanism or the retinoic-acid-
inducible gene and does not trigger an IFN-1 response [35]. In addition, these vaccines
elicit adaptive cellular responses, stimulating Thelper cell and cytotoxic T lymphocytes
(CTLs) that play a pivotal role in the immune response. Some studies have reported a rapid
decline in anti-SARS-CoV-2 IgG levels in mild COVID-19 patients [36]. mRNA vaccines
are safe because they are non-infectious as they are not made with pathogen particles
or inactivated pathogens, and they are effective as the antigen is expressed in vivo and
induces both humoral and cell-mediated immune responses. Moreover, the manufacturing
of nucleic acid vaccines can be synthetic and entirely cell-free, avoiding the need for BSL2
laboratories; furthermore, the production is rapid and the process can be standardized,
improving the responsiveness to emerging outbreaks [37]. However, due to the low stabil-
ity and uncertainty surrounding the formulation of mRNA vaccines, no mRNA vaccine
candidates were commercialized before this pandemic; nonetheless, with recent technical
 mRNA vaccines are safe because they are non-infectious as they are not made with path-
ogen particles or inactivated pathogens, and they are effective as the antigen is expressed
in vivo and induces both humoral and cell-mediated immune responses. Moreover, the
manufacturing of nucleic acid vaccines can be synthetic and entirely cell-free, avoiding
the need for BSL2 laboratories; furthermore, the production is rapid and the process can
Vaccines 2022, 10, 349 6 of 24
be standardized, improving the responsiveness to emerging outbreaks [37]. However, due
to the low stability and uncertainty surrounding the formulation of mRNA vaccines, no
mRNA vaccine candidates were commercialized before this pandemic; nonetheless, with
advances,
recent several
technical institutions
advances, around
several the world
institutions havethe
around begun rapid
world havedevelopment
begun rapidofdevel-
mRNA
and DNA
opment vaccines
of mRNA and[38].
DNAThe Pfizer-BioNTech
vaccines (BNT162b2) and
[38]. The Pfizer-BioNTech Modernaand
(BNT162b2) (mRNA-1273)
Moderna
vaccines werevaccines
(mRNA-1273) the first were
vaccines
the to reach
first PhasetoIVreach
vaccines and involve
Phase IVtwo-dose regimens
and involve of the
two-dose
vaccine formulations, with 2 to 3 weeks between each IM dose. High efficacy
regimens of the vaccine formulations, with 2 to 3 weeks between each IM dose. High effi- was reported
withwas
cacy these vaccineswith
reported (more than
these 94% efficacy
vaccines (more in Phase
than 94%IIIefficacy
clinicalintrials)
Phaseand
III they triggered
clinical trials) a
and they triggered a rapid and effective immune response, making them the perfect mecha-
rapid and effective immune response, making them the perfect candidates as their can-
nisms utilized
didates as their the capacity of
mechanisms the host
utilized thecells to translate
capacity the encoding
of the host mRNA the
cells to translate to SARS-CoV-2
encoding
S proteins
mRNA [39].
to SARS-CoV-2 S proteins [39].

Figure
Figure1.1.Simplified
Simplifiedoverview
overviewofofthe
themRNA
mRNA vaccine mechanism
vaccine mechanism ofof
action. Once
action. thethe
Once mRNA
mRNAmolecule
molecule
isisreleased from the LNP into the cytosol, it is directly translated by ribosomes into polypeptides.
released from the LNP into the cytosol, it is directly translated by ribosomes into polypeptides.
Polypeptides can be processed by the proteasome system, leading to peptide presentation to CD8+ +
Polypeptides can be processed by the proteasome system, leading to peptide presentation to CD8
T-cells via MHC I and can also undergo post-translational modifications and be folded into a protein
T-cells via MHC I and can also undergo post-translational modifications and be folded into a protein
that can either be membrane anchored or secreted to induce antibody production.
that can either be membrane anchored or secreted to induce antibody production.
3.1.
3.1.Comirnaty
Comirnaty(BNT162b2)—Pfizer-BioNTech
(BNT162b2)—Pfizer-BioNTechVaccine Vaccine
The
The Pfizer-BioNTech COVID-19 vaccine wasthe
Pfizer-BioNTech COVID-19 vaccine was thefirst
firstvaccine
vaccine approved
approved in in
thethe
United
United
States and it has been available since 11 December 2020, under EUA
States and it has been available since 11 December 2020, under EUA (Emergency (Emergency Use Au-
Use
thorization) for people 16 years and older. The authorization was expanded
Authorization) for people 16 years and older. The authorization was expanded to include to include
people
peopleaged
aged12 12toto15
15years
yearsonon1010May
May2021,
2021,and
andchildren
children aged
aged5 to
5 to1111
years
yearsonon2929October
October
2021
2021[40].
[40].ItItwas
wasdefinitively
definitivelyapproved
approvedon on 23
23 August
August 2021,
2021, for
for the
the prevention
prevention of of COVID-
COVID-19
19 disease
disease ininindividuals
individualsaged
aged16 16 years
years and
and older,
older,and
andisisnownowmarketed
marketed asas
Comirnaty
Comirnaty [41].
[41].
The EMA granted conditional marketing authorization for this vaccine in
The EMA granted conditional marketing authorization for this vaccine in people 18 years people 18 years
and
andolder
olderon on21
21December
December20202020[42].
[42].On
On2828May
May2021,
2021,thetheEMA
EMA recommended
recommended granting
granting
an extension of indication for the Comirnaty vaccine to be used in
an extension of indication for the Comirnaty vaccine to be used in children aged children aged 12 to 12
15 to
15 years [43], and on 25 November 2021 it recommended the vaccines for use in children
aged 5 to 11 years [44].
BNT162b2 encodes a membrane-anchored, full-length SARS-CoV-2 spike protein
modified by two proline mutations to stabilize the protein in its prefusion conformation [45].
Once thawed, the vaccine can be stored for up to 5 days before use at a temperature between
2 and 8 ◦ C, and up to 2 h at a temperature not exceeding 30 ◦ C. Before use, BNT162b2 must
be reconstituted with 0.9% sodium chloride. Once reconstituted, it should be administrated
Vaccines 2022, 10, 349 7 of 24

within 6 h and stored between 2 and 30 ◦ C. Comirnaty is administered as two IM doses

injected 21 days apart, and each vial contains six doses [46].
BNT162b2 was selected for phase 2–3 of safety and efficacy evaluation due to its low
reactogenicity [45], a significant antibody response, and IFN-γ or IL-2 CD8+ and CD4+ T
helper type 1 (Th1) cell responses [47].
The efficacy of BNT162b2 was evaluated in approximately 44,000 people; based on
results from the clinical trial (NCT04368728), the vaccine was 94.6% effective in preventing
COVID-19 disease 7 days after the second dose (95% CI, 89.9–97.3%) [42,48].
Regarding the safety profile, a higher frequency of local reactions including mild-to-
moderate pain at the injection site and less frequent redness or swelling was observed in
patients who received this vaccine. Systemic reactogenicity was reported more frequently
in younger vaccine recipients and more frequently after the second dose. The most common
systemic adverse events were fatigue and headache [49].
Data on the immunological response [50] reported that vaccination with BNT162b2
induced a coordinated immune response with SARS-CoV-2 S-protein-specific neutralizing
antibodies, CD4+ T-cells, CD8+ T-cells, and immune-modulatory cytokines such as IFN-γ.
In particular, it was observed that there was a de novo S-specific CD4+ T-cell response in
all vaccinated participants, and almost 92% of participants mounted CD8+ T-cell responses;
furthermore, even with the lowest dose of BNT162b2, most of the vaccinated participants
demonstrated robust expansion of CD4+ and CD8+ T-cells. This response was directed
against the receptor-binding domain (RBD) S1 and S2 regions of the S protein, indicating
immune recognition of multiple independent major histocompatibility complex (MHC) I
and II epitopes. Plasma IgM, IgG, and IgA responses to SARS-CoV-2 S regions and the RBD
were measured by enzyme-linked immunosorbent assay (ELISA). All tested individuals
showed significant reactivity to S and RBD and, as expected, levels of anti-S and anti-RBD
IgG were higher than levels of IgM or IgA. Moreover, there was a strong positive correlation
between the anti-RBD and anti-S responses for all three immunoglobulin isotypes. It
is not yet known if the antibody responses will be sufficient for full and long-lasting
protective immunity [51], but with large-scale immunization in Israel (the first nation
to begin vaccination), the first data on the effectiveness of the BNT162b2 vaccine in a
real-world setting were reported. Adjusted estimates of vaccine effectiveness at 7 days or
longer after the second dose were 95.3% (incidence rate 91.5 per 100,000 person-days in
unvaccinated vs. 3.1 per 100,000 person-days in fully vaccinated individuals) against SARS-
CoV-2 infection, 91.5% (40.9 vs. 1.8 per 100,000 person-days) against asymptomatic SARS-
CoV-2 infection, 97% (32.5 vs. 0.8 per 100,000 person-days) against symptomatic COVID-19,
97.2% (4.6 vs. 0.3 per 100,000 person-days) against COVID-19-related hospitalization,
97.5% (2.7 vs. 0.2 per 100,000 person-days) against severe or critical COVID-19-related
hospitalization, and 96.7% (0.6 vs. 0.1 per 100,000 person-days) against COVID-19-related
death. In all age groups, as vaccine coverage increased, the incidence of SARS-CoV-2
outcomes declined [52].

3.2. Spikevax (mRNA-1273)—Moderna Vaccine

On 18 December 2020, the US FDA issued an EUA for use of the Moderna vaccine
in individuals 18 years of age and older to prevent COVID-19. The EMA recommended
granting a conditional marketing authorization for the COVID-19 Moderna vaccine to
prevent COVID-19 in people 18 years of age and older on 6 January 2021 [53,54], and, on
23 July 2021, this vaccine was authorized for use in children aged 12 to 17 years [55].
mRNA-1273 is an mRNA vaccine encoding the SARS-CoV-2 S-2P antigen, stabilized
in its prefusion conformation by two consecutive proline substitutions at positions 986
and 987 [56]. The administration of the mRNA-1273 vaccine includes two 0.5 mL doses
injected intramuscularly 28 days apart. The vaccine can be stored between −25 and −15 ◦ C
for up to 7 months, but can be stored between 2 and 8 ◦ C for 30 days. No dilution or
reconstitution is required. Before the administration, doses can be maintained at room
Vaccines 2022, 10, 349 8 of 24

temperature (8–25 ◦ C) for up to 12 h. Once the vial is opened, it should be stored at between
2 and 25 ◦ C for no more than 6 h. Each vial contains ten doses [57].
This vaccine demonstrated 94.1% efficacy (95% CI, 89.3–96.8%) in a trial (NCT04470427)
involving around 30,000 people. The most common local adverse reactions were pain
at the injection site and, more rarely, erythema, induration, and tenderness. Frequent
systemic side effects were fatigue, headache, myalgia, arthralgia, chills, nausea/vomiting,
lymphadenopathy in the injection arm, and fever, and these side effects were mostly
mild and transient. Reactions were more frequently reported after the second dose and
in younger recipients [39]. The Vaccine Adverse Event Reporting System (VAERS) has
identified rare cases of myocarditis and pericarditis following administration of Spikevax.
Myocarditis and pericarditis occurred mainly in the first week following vaccination, more
often after the second dose, and more frequently in young males [58].
Like BNT162b2, this vaccine elicits an IgG immune response together with cellular
responses and is biased mainly towards CD4+ Th1 cells, while the CD8+ T-cell responses
were marginal except for those in recipients of two vaccinations with the higher dose [59].

4. Viral Vector Vaccines

Viral vector vaccines use replication-deficient viruses (usually a modified adenovirus)
genetically engineered to express the genetic sequence of the antigen of interest in host
cells. Some of the vectors—like many of the adenoviral vectors—are developed to be
replication incompetent. Adenovirus vectors are non-enveloped double-stranded DNA
(dsDNA) viruses with a packaging capacity of 7.5 kb of foreign DNA, providing transient
episomal expression in a broad range of host cells [60]. These vectors contain deletions in
the native viruses that make them replication incompetent for safety; in particular, E1A
and E1B encoding regions, which are needed for replication in infected cells, are deleted
and replaced with the target gene [61]. Replication-incompetent adenovirus vectors have
been developed with variable success for HIV, tuberculosis, malaria, and Ebola virus,
often limited in efficacy due to pre-existing immunity to the adenovirus vector [62]. The
main advantage of vector vaccines is that the immunogenic antigen is produced within a
heterologous viral infection, leading to the innate immune responses necessary to induce
the adaptive immune response, including a robust cytotoxic T lymphocyte (CTL) response.
This response subsequently leads to the elimination of virus-infected cells without the
need for an adjuvant. Additionally, the long duration and high level of antigenic protein
expression and its rapid production makes recombinant viral vectors a popular platform
for vaccine delivery. However, this strategy may induce prior immunity to the vector and
is limited to presenting only a small number of SARS-CoV-2 antigens to the host immune
system [63].
Some of the non-replicating SARS-CoV-2 viral vector vaccines were based on aden-
ovirus types 5 and 26 (Ad5, Ad26) expressing the S protein or RBD subunit of SARS-CoV-2;
however, to bypass the action of anti-adenoviral antibodies that may already be present
in the recipients, an alternative chimpanzee adenovirus vector (ChAd) with low human
prevalence was employed as a vaccine platform [60].
Vaccines that have been granted EUA by the EMA and/or FDA are adenovirus
serotype 26 vector vaccine Ad26.CoV2.S (Johnson & Johnson, New Brunswick, NJ, USA)
and chimpanzee adenovirus vector vaccine ChAdOx (AstraZeneca, Cambridge, UK). Both
vaccines have proven efficacy in preventing hospitalization and death but have varying
efficacy in preventing clinical disease [62].

4.1. Vaxzevria (ChAdOx1-S)—AstraZeneca/Oxford Vaccine

In January 2021, the EMA granted use authorization of the ChAdOx1-S vaccine,
developed by the University of Oxford and AstraZeneca for the prevention of COVID-19
disease in people aged 18 years and older [64]. In March 2021, the EMA approved Vaxzevria
as the third vaccine after Comirnaty and Spikevax [65]. The AstraZeneca vaccine was never
authorized for use in the US [66].
Vaccines 2022, 10, 349 9 of 24

Vaxzevria is a viral vector vaccine that exploits a different approach to inducing

an immune response than the Pfizer-BioNTech and Moderna’s vaccines. ChAdOx1-S
consists of a modified version of the chimpanzee adenovirus that is no longer able to
replicate, and contains the full-length structural surface S glycoprotein of SARS-CoV-2
with a tissue plasminogen activator leader sequence. The viral vector was obtained from
genetically modified human embryonic kidney (HEK) 293 cells and through recombinant
DNA technology [67].
The vaccination course with Vaxzervria consists of two separate doses of 0.5 mL each,
administered intramuscularly. The second dose should be given 4 to 12 weeks (28 to
84 days) after the first dose [65].
The Oxford COVID-19 Vaccine Trial Group conducted a phase 1–2 trial to investigate
the immunogenicity, reactogenicity, and safety of vaccination with ChAdOx1-S [67], and
reported local and systemic reactogenicity, such as injection site pain, myalgia, headache,
asthenia, chills, and fever. No severe adverse events related to ChAdOx1-S administration
were observed. The study showed the induction of a humoral response, characterized by
anti-spike glycoprotein IgG and neutralizing antibodies, and IFN-γ T-cell responses in most
recipients after the first dose of vaccine and an additional increase in humoral immune
response after the second dose of vaccine. The neutralizing antibody response was stronger
in the booster vaccination group, and the vaccine elicited a strong T-cell response in all
subjects [67]. Subsequently, the ChAdOx1-S candidate vaccine was evaluated in terms of
safety and efficacy in four phase 2–3 clinical trials, carried out in the UK, Brazil, and South
Africa. Between April and November 2020, 23,848 people over the age of 18 years were
selected. This vaccine showed an efficacy of 64.1% against severe COVID-19 after one dose
(95% CI, 50.5–73.9%) and 70.4% 14 days after the second dose (95% CI, 54.8–80.6%) [68,69].
Rare side effects that may have a causal relationship with Vaxzevria injection have
been reported since the start of the large-scale immunization campaign. These adverse
events were collected by the EMA monitoring system and published in safety updates [65].
Guillain–Barré syndrome (GBS) and a thrombotic syndrome associated with thrombocy-
topenia, sometimes accompanied by hemorrhages, were rarely observed after vaccination
with Vaxzevria. Thrombotic syndrome with thrombocytopenia and coagulation disorders
may include severe cases of venous thrombosis in atypical sites such as cerebral venous
sinus thrombosis, splanchnic venous thrombosis, and arterial thrombosis. Most coagulation
disorders occurred in the first 3 weeks after vaccination and mainly in women under the
age of 60 years. Due to the increased risk of thromboembolic adverse events, especially
in young and female individuals, several countries have recommended the use of the
Vaxzevria vaccine in elderly people. For example, in Italy, the Ministry of Health recom-
mends preferential use of the Vaxzevria vaccine in people over the age of 60 years [70].
People younger than 60 years of age who have already received their first dose of As-
traZeneca vaccine may complete the vaccine course with the same vaccine or may receive
an mRNA vaccine as a second dose after 8–12 weeks [70].
Insufficient data are available to establish the safety and efficacy of Vaxzevria in
children and adolescents (individuals less than 18 years old) [65].

4.2. Janssen COVID-19 Vaccine (Ad26.COV2.S)—Janssen Pharmaceutical and Johnson & Johnson
In February 2021, the FDA issued an EUA for a single-dose COVID-19 vaccine devel-
oped by the Janssen Pharmaceutical Companies of Johnson & Johnson to prevent COVID-19
in people aged 18 years and older [71]. In March 2021, the vaccine received conditional
marketing authorization from the EMA [72].
The Ad26.COV2.S is a recombinant, replication-incompetent human adenovirus type
26 vector encoding a full-length SARS-CoV-2 S protein in a prefusion-stabilized conforma-
tion [73].
Ad26.COV2.S can be stored for up to 2 years in a standard freezer and up to 3 months
at refrigerator temperatures, which simplifies transport, storage, and use in a pandemic [74].
Vaccines 2022, 10, 349 10 of 24

According to a trial involving 44,325 people, this vaccine demonstrated 66.9% efficacy
against symptomatic SARS-CoV-2 14 days after administration (95% CI, 59.0–73.4%), with
higher efficacy in preventing severe-critical COVID-19, reaching 76.7% (95% CI, 54.6–89.1%)
and 84.5% (95% CI, 54.2–96.9%) efficacy after 14 and 28 days after administration, respec-
tively [73].
Concerning vaccine safety, injection-site pain was the most common local reaction
(reported in 48.6% of the participants), while the most common systemic reactions were
headache, fatigue, myalgia, and nausea. Some serious adverse events were considered
by the investigators to be related to vaccination in the Ad26.COV2.S group, but a causal
relationship between these events and Ad26.COV2.S could not be determined [73]. This
vaccine induced high titers of neutralizing antibodies 2 and 4 weeks after injection, with
the titer of neutralizing antibody significantly related to the level of protection. More than
80% of elderly and young subjects were positive for Th1 cytokines producing an S-specific
CD4+ T-cell response with a very low or absent Th2 response, confirming the safety of this
vaccine [75].

5. SARS-CoV-2 Vaccines and ADE

The main goal of all vaccines is to provoke an immune response against an antigen in
the host and to have an effective and rapid response in case of a subsequent encounter with
the antigen. A concern for SARS-CoV-2 vaccine development was that the immune response
can enhance the disease, through the clearing of diseases. Understanding vaccine-induced
immunopathology is important for all emerging infectious diseases because the mecha-
nism of antibody-dependent enhancement (ADE) makes vaccine development particularly
difficult due to its similarity to a natural infection [76].
Previous evidence for vaccine-induced ADE in animal models of SARS-CoV is con-
flicting and raises potential safety concerns. Liu et al., found that, while macaques immu-
nized with a modified Ankara viral vector vaccine expressing the SARS-CoV S protein
had reduced viral replication, anti-S IgG enhanced pulmonary infiltration of inflamma-
tory macrophages, resulting in more severe lung injury compared with the unvaccinated
animals [77]. In contrast, Qin et al., showed that an inactivated SARS-CoV vaccine pro-
tected cynomolgus macaques from viral challenge and did not result in enhanced lung
immunopathology, even in macaques with low neutralizing antibody titers [78].
Preclinical studies of SARS-CoV immunization in animals led to results that vary
greatly in terms of protective efficacy, immunopathology, and potential ADE, depending
on the vaccine strategy employed.
Animal models were used to test SARS-CoV-2 vaccines specifically as the candidates
were being assessed for ADE. ADE was evaluated and tested in vitro by Laczko et al., who
designed nucleoside-modified mRNA vaccines encoding the full-length SARS-CoV-2 S
protein encapsulated with LNPs (mRNA-LNP) that induced the production of high levels of
S-protein-specific IgG. HEK293T cells expressing mouse FcgR1 were used to investigate the
possibility of mRNA vaccines eliciting ADE, resulting in no SARS-CoV-2-associated ADE
by testing the mRNA-vaccinated mouse sera [30]. In fact, mice that were given an mRNA
vaccine expressing the prefusion SARS-CoV-2 S protein developed neutralizing antibodies
and an S-protein-specific CD8+ response that was protective against lung infection without
evidence of immunopathology [79]. Inoculation of ChAdOx1-S in rhesus macaques showed
no pneumonia infection in vaccinated monkeys and no ADE effect [80].
ADE was monitored in human trials and at the start of the large-scale immunization
campaign, and the results showed a lack of ADE-related events during the mass vaccination,
which tentatively excludes the possibility that some vaccines might worsen the disease
rather than improve or even prevent it [81].

6. Vaccine Delivery: Future Prospects

The mRNA and viral vector vaccines are delivered via the IM route, generating a
systemic immune response lacking adequate levels of mucosal IgA and mucosal immunity.
Vaccines 2022, 10, 349 11 of 24

However, to neutralize pathogens at their initial entrance site, protective mucosal immunity
is inevitably required. Therefore, an essential focus of vaccine development is related to
their route of administration.
The respiratory mucosa plays a key role in SARS-CoV-2 infection and transmission;
mucosal vaccination could thus represent an advanced approach to elicit simultaneous
mucosal and systemic immune responses. Nevertheless, this alternative approach poses a
greater challenge: the nucleic acid vaccine must penetrate the mucus layer, translocate into
target cells, and evade extracellular and intracellular degradation. Mucosal immunization
elicits an antibody response (specifically mucosal IgA antibodies), tissue-resident memory
T-cells in the respiratory mucosa, and macrophage-mediated trained immunity, inhibiting
further entry of pathogens [82]. Administration of mucosal vaccines has also been shown
to elicit strong systemic humoral immunity, neutralizing any virus particle that evades the
primary immune response at the mucosal site. For these reasons, immunization using an
oral or intranasal vaccine could be an effective strategy for immune-prophylaxis against
SARS-CoV-2 (Figure 2) [83]. This route of administration has advantages, not just in
evoking a stronger immune response at both mucosal sites and systemic circulation, but
also in offering the simplicity of needle-free administration, feasibility of mass vaccination
without demanding expert medical staff, cost-effectiveness, and less severe side effects [84].
Viral vectors are one of the most promising strategies for mucosal vaccination due to their
capacity for intracellular delivery, versatility, and intrinsic immunogenicity. An adenovirus
type 5-vectored vaccine (AdCOVID) encoding the RBD of the SARS-CoV-2 S protein was
tested in a single intranasal dose in inbred, outbred, and transgenic mice. Single intranasal
vaccination elicited a strong, durable, and focused immune response against the RBD
through the induction of mucosal IgA production in the respiratory tract, neutralizing
antibodies in the serum, CD4+ cells with a Th1-like cytokine expression profile, and CD8+
cells. Moreover, a single intranasal dose completely protected mice from lethal SARS-CoV-2,
preventing both weight loss and mortality. These data show that AdCOVID promoted
concomitant systemic and mucosal immunity, making it a promising vaccine candidate [85].
Another vaccination strategy is the oral route, which presents the added challenges of
low gastric pH and the difficulty in controlling where the nucleic acid payload is released.
To address these challenges, nanocarriers and biomaterials have been used to develop
innovative, protective delivery strategies for nucleic acids; polycationic materials, including
chitosan and polyethylenimine (PEI), complexed with nucleic acids and encapsuled nucleic
acid cargo by liposomes and polymersomes, are showing promising potential [86]. An oral
tableted vaccine, the adenovirus-based VXA-CoV2-1/Vaxart, produced protection against
SARS-CoV-2 in a Syrian hamster model in which the administration of two doses promoted
a reduction in weight loss and lung pathology, and 5 days after injection, a complete deletion
of the infectious virus was observed. Anti-spike IgG and neutralizing antibodies were
induced upon oral immunization, with the serum demonstrating neutralizing activity [87].
Preliminary phase 1 trial results showed no severe adverse events and the triggering of
multiple immune responses against SARS-CoV-2 antigens: a CD8+ cytotoxic T-cell response
to the viral S protein that is necessary for long-lasting cross-reactive immunity, an increase in
plasmablast cell numbers and an upregulation of the mucosal homing receptor, an increase
in proinflammatory Th1 cytokines responsible for orchestrating the immune response to
viral infection, and an IgA response in serum and/or nasal swab samples in 100% of the
two-dose subjects [88,89].
 events and the triggering of multiple immune responses against SARS-CoV-2 antigens: a
CD8+ cytotoxic T-cell response to the viral S protein that is necessary for long-lasting cross-
reactive immunity, an increase in plasmablast cell numbers and an upregulation of the
mucosal homing receptor, an increase in proinflammatory Th1 cytokines responsible for
Vaccines 2022, 10, 349 orchestrating the immune response to viral infection, and an IgA response in serum 12 of 24
and/or nasal swab samples in 100% of the two-dose subjects [88,89].

Figure 2. Principles of mucosal vaccination. Mucosal vaccine administration stimulates the synthesis
of immunoglobulin A (IgA) at the level of mucosa-associated lymphoid tissue (MALT). The mucosal
Figure
immune 2. response
Principlesisofcharacterized
mucosal vaccination. Mucosal
at the local level byvaccine administration
secretory stimulates
IgA (SIgA) and theT-cells,
cytotoxic synthe- and
sis of immunoglobulin A (IgA) at the level of mucosa-associated lymphoid tissue (MALT). The mu-
at the systemic level by antigen-specific humoral and cellular responses. These outcomes have been
cosal immune response is characterized at the local level by secretory IgA (SIgA) and cytotoxic T-
shown
cells, andtoat
bethe
effective
systemicin clearing various pathogens,
level by antigen-specific including
humoral respiratory
and cellular viruses.These outcomes
responses.
have been shown to be effective in clearing various pathogens, including respiratory viruses.
7. How Variants Affect the Efficacy of SARS-CoV-2 Vaccines
7. HowThe mutation
Variants rate the
Affect of the virus of
Efficacy should be considered
SARS-CoV-2 in vaccine design, as genomic
Vaccines
variations can induce immune evasion. For SARS-CoV-2, mutations in the S protein can
The mutation rate of the virus should be considered in vaccine design, as genomic
induce conformational changes that may alter antigenicity, possibly affecting vaccine design
variations can induce immune evasion. For SARS-CoV-2, mutations in the S protein can
and efficacy (Table 2) [90].
induce conformational changes that may alter antigenicity, possibly affecting vaccine de-
VOCs with increased transmissibility are contributing to the reversal of the decrease
sign and efficacy (Table 2) [90].
in COVID-19 cases that many countries have experienced.
VOCs with increased transmissibility are contributing to the reversal of the decrease
The D614G variant first appeared in the United States in the middle of 2020. Since the
in COVID-19 cases that many countries have experienced.
second half of 2020, more SARS-CoV-2 variants have emerged, including B.1.1.7 (Alpha
The D614G variant first appeared in the United States in the middle of 2020. Since the
variant) first reported in the UK, B.1.351 (Beta variant) first reported in South Africa, P.1
second half of 2020, more SARS-CoV-2 variants have emerged, including B.1.1.7 (Alpha
(Gamma variant) first reported in Brazil, and B.1.617.2 (Delta variant) first reported in India,
variant) first reported in the UK, B.1.351 (Beta variant) first reported in South Africa, P.1
causing widespread concern [91].
(Gamma variant) first reported in Brazil, and B.1.617.2 (Delta variant) first reported in
Although B.1.1.7 variant has been de-escalated and is no longer circulating, it was
India, causing widespread concern [91].
considered a VOC because of its increased binding affinity to ACE2 and its enhanced ability
Although B.1.1.7 variant has been de-escalated and is no longer circulating, it was
to enter host cells, accelerating the spread of the virus. According to studies in the UK,
considered a VOC because of its increased binding affinity to ACE2 and its enhanced abil-
the transmissibility of the B.1.1.7 variant reached up to 71% over and above the previous
ity to enter host cells, accelerating the spread of the virus. According to studies in the UK,
circulating strains of SARS-CoV-2 [92,93]. Analysis of individual-level data revealed an
the transmissibility of the B.1.1.7 variant reached up to 71% over and above the previous
increase in COVID-19 mortality associated with the B.1.1.7 lineage [94,95], but no evidence
circulating strains of SARS-CoV-2 [92,93]. Analysis of individual-level data revealed an
was found regarding the ability of the B.1.1.7 variant to escape immunity [96].
B.1.351 is classified as a VOC because it increases the transmissibility and severity
of the virus, but above all this variant appears less easily neutralized by convalescent
plasma obtained from patients infected with previous variants and by serum obtained from
vaccinees than the prototype virus on which vaccine antigens are based [94,97]. E484K
mutation of the S protein has been reported to be related to the escape of the B.1.351 variant
from neutralizing antibodies [98].
Vaccines 2022, 10, 349 13 of 24

P.1 VOC shows increased transmission, risk of hospitalization, and mortality. Like
the B.1.351 variant, P.1 was suspected to evade immunity in people who were previously
infected [99]. A Centre for Arbovirus Discovery, Diagnosis, Genomics and Epidemiology
(CADDE) study indicated variant P.1 to be twice as transmissible and was shown to
be capable of evading ~32% of inherited immunity from previous coronavirus diseases,
leading to the possibility of reinfection. These increased statistics were also reflected in
fatalities, such that P.1 infections could be ~50% more lethal [100].
The B.1.617.2 variant was first identified in the Indian state of Maharashtra in late
2020 and spread throughout the country, outcompeting pre-existing lineages. This variant
is highly transmissible, either due to higher viral burden or higher particle infectivity,
resulting in a higher probability of person-to-person transmission. Interestingly this variant
was found mainly in the younger population and the risk of COVID-19 hospital admis-
sion was approximately doubled in those with the B.1.617.2 when compared with the
B.1.1.7 VOC, with risk of admission particularly increased in those with more relevant
comorbidities [101]. In vitro, B.1.617.2 is six-fold less sensitive to serum neutralizing an-
tibodies from recovered individuals. The first sub-lineage to be detected was B.1.617.1,
followed by B.1.617.2, both bearing the L452R spike receptor binding motif mutation that
was previously reported to confer increased infectivity and a modest loss of susceptibility
to neutralizing antibodies [102].
A new variant of SARS-CoV-2, B.1.1.529 or Omicron was first reported to the WHO
in South Africa on 24 November 2021. In recent months, there has been a steep rise in
infections that coincided with the detection of the B.1.1.529 variant. On 26 November 2021,
this variant was classified as a VOC [103].
The B.1.1.529 variant has a significant number of mutations, some of which are con-
cerning: the spike gene contains nine mutations previously identified in other dangerous
variants (Alpha, Beta, Gamma, and Delta), and three novel alterations not found in other
VOCs. Almost nothing is known about the other eleven mutations, so it is not possible to
evaluate whether these mutations are advantageous or disadvantageous regarding viral
impact. Four mutations in the spike sequence modify the binding site of a monoclonal
antibody and two mutations increase the affinity of the spike for human ACE2 receptors.
Several other modifications appear to change the structure of parts of the spike, but their
significance is still unknown. In addition to these mutations, several others have been
found in other proteins of the virus [104,105].
The Omicron variant is the most divergent variant detected thus far. This has led to
obvious concerns about its potential association with increased transmissibility, reduction in
vaccine effectiveness, and an increased risk of reinfections [106]. Preliminary data indicate
increased transmissibility and risk of reinfection, with the number of cases caused by the
Omicron variant increasing in almost all South African provinces. Studies from South Africa
and the UK reported doubling times of 3.38 days and 2–2.5 days, respectively, with the
basic reproduction number (R0) above 3 and an estimated weekly increase in the Omicron-
to-Delta ratio in the range of 7.2–10.2, which was considerably higher than the increase in
the ratio of Delta to Alpha (estimated to be in in the range 2.5–4.2) [107,108]. However, the
current limited and preliminary evidence suggests that Omicron has a less severe clinical
presentation, presenting as a mild disease with predominantly upper respiratory symptoms
such as muscle aches and fatigue for 1 to 2 days, headache, itchy throat, slight cold, or
mild cough [109,110]. The UK Health Security Agency reported that Omicron-infected
individuals have a 50% lower risk of visiting or to being admitted to the hospital than
individuals infected with the Delta variant [111].
Regarding vaccine efficacy, Omicron demonstrates a greater breakthrough against
vaccine-induced immunity as compared with Delta; however, vaccines should continue to
prevent severe disease or death, although additional booster doses may be needed to protect
most people from infection and to maintain the shield effect of immunizations [103,112,113].
Vaccines 2022, 10, 349 14 of 24

Due to the presence of these variants, it is necessary to evaluate existing vaccines to

determine if they are decreasing in efficacy against the variants and to decide whether
modified or new vaccines are needed to restore efficacy against these variants.

7.1. BNT162b2
Low or no significant impact on vaccine effectiveness against the B.1.1.7 variant has
been reported. A slight effect on serum neutralizing antibody titers from BNT162b2-
immunized individuals was observed with a pseudovirus that contained the complete set
of B.1.1.7 mutations, and even though there was a slight reduction, the Pfizer-BioNTech
vaccine was found to be more than 90% effective against symptomatic infection from the
Alpha variant [96]. The Pfizer-BioNTech vaccine serum neutralization activity showed
a significant decrease against the B.1.351 variant (with an efficacy of 85%) compared
with its activity against the B.1.1.7 variant, likely due K417N and E484K mutations [114].
Considering the high number of S protein mutations accumulated by P.1 variant, the B.1.1.7
variant was supposed to be equally or more resistant than the B.1.351 variant to antibody-
mediated protection. However, laboratory serum neutralization assays using a pseudovirus
have shown that the neutralizing activity of BNT162b2-elicited antibodies was roughly
equivalent to the activity against the B.1.1.7 and P.1 virus [115]. A significant decrease in
neutralizing antibody titer was observed for B.1.617.2 compared with B.1.1.7, using sera
from individuals immunized with BNT162b2; furthermore, a vaccine effectiveness of 88%
against symptomatic disease following infection with B.1.617.2 was observed after two
doses of BNT162b2 [116].
Regarding the B.1.1.529 variant, recent data from South Africa have shown a 70%
vaccine effectiveness against hospitalization during the Omicron-dominant period com-
pared with the 93% effectiveness observed in the pre-Omicron period [113]. In vitro studies
showed that, after two doses of BNT162b2, the serum had >22-fold reduced neutralizing
titers against Omicron compared with a Wuhan pseudovirus. [112]. Live-virus neutralizing
titers against Omicron after two doses of BNT162b2 showed a 29.8-fold reduction in the
serum [117].
Despite this decrease in neutralizing titers, the BNT162b2 vaccine seems to maintain
effectiveness against hospital admission [111]; furthermore, the addition of a booster dose
of the vaccine may mitigate this reduction in vaccine effectiveness.

7.2. mRNA-1273
The neutralization capacity of the Moderna SARS-CoV-2 mRNA (mRNA-1273) vaccine
against variants decreased similarly to that of the Pfizer-BioNTech vaccine. There was no
significant impact on the neutralizing capacity of sera against the B.1.1.7 variant, with a
reported 91% efficacy against the variant. Reduced levels of neutralizing antibodies against
the other variants were reported, with 85% efficacy against P.1 and B.1.351 variants, and
70% efficacy against B.1.617.2 [114,116,118,119]. As with the BNT162b2 vaccine, recipients
of the mRNA-1273 vaccine showed a decreased antibody response and memory B-cell
response against SARS-CoV-2 variants containing E484K and N501Y mutations or the
triple combination of K417N, E484K, and N501Y mutations [120]. There are limited data
regarding vaccine efficacy against the Omicron variant; two preliminary studies found that
two-doses of mRNA-1273 provided an initial effectiveness against omicron infection of
36.7% and 42.8%, which decline rapidly [121,122].

7.3. ChAdOx1
Regarding the ChAdOx1 vaccine, the laboratory virus-neutralizing activity of vaccine-
induced antibodies was lower against the Alpha variant, demonstrating a vaccine efficacy of
70.4% [123]. A vaccine efficacy of 67.0% was reported against the B.1.617.2 variant [124] and
77.9% against the P.1 variant [125]. In a multicenter, double-blind, randomized-controlled
trial, it was reported that the NAb titer against the B.1.351 strain was significantly reduced,
with an efficacy of 10.4% [126], suggesting that this vaccine does not confer protection
Vaccines 2022, 10, 349 15 of 24

against mild-to-moderate COVID-19 caused by the Beta variant. An in vitro study showed
a 36-fold reduction in neutralizing antibodies against the B.1.1.529 variant compared with
the Delta variant [117]. An Imperial College report [127] showed a 5% vaccine effectiveness
against the Omicron variant that did not confer protection against symptomatic infection,
but still reduced hospitalization.

7.4. Ad26.COV2.S
Ad26.COV2.S vaccinated serum neutralized the B.1.1.7 variant in vitro, although less
efficiently than the reference strain. The Johnson & Johnson vaccine appears to be effective
against the B.1.617.2 variant 14 days after administration; the single-dose COVID-19 vaccine
elicited neutralizing antibody production against the Delta variant at an even higher level
than what was observed against the Beta (B.1.351) variant (vaccine efficacy of 52% against
moderate disease) [73]. In one study, it was observed that multiple plasma specimens from
recipients of the Ad26.COV2.S vaccine obtained 1 or 5 months after vaccination lacked
detectable neutralizing activity against the Omicron variant [128]. One study observed that
vaccine effectiveness against the B.1.1.529 variant for hospitalization was 63% [129].

Table 2. Effect of variants on vaccine efficacy.

SARS-CoV-2 Strains BNT162b2 mRNA-1273 ChAdOx1 Ad26.COV2.S

SARS-CoV-2 94.1% 14 d 70.4% 14 d 66.9% 14 d after
94.6% 7 d after 2 doses
Wild-Type strain after second dose after second dose administration
B.1.1.7 Variant 90% 91%
70.4% Effective
(Alpha) (85–95%) (84–95%)
85% 85% 10,4%
B.1.351 Variant (Beta) 52%
(70–93%) (80–90%) (−77–55%)
88% 85% 78%
P.1 Variant (Gamma) Effective
(75–92%) (80–90%) (69–84%)
B.1.617.2 Variant 88% 70% 67%
Effective
(Delta) (75–90%) (45–85%) (61–72%)
B.1.1.529 Variant
29.8 fold decrease 36.7%–42.8% 5% 63%
(Omicron)
References [96,114–117] [114,116,118,119,121,122] [123–127] [74,129]

In summary, a reduction in serum neutralization activity in vitro was observed against

all VOCs, and there was evidence of infection with VOCs in vaccinated populations.
However, the protection efficacy is still higher than the protection level criterion of at least
50%, as defined by the WHO; mostly importantly, the severity of disease is still reduced
following vaccination, indicating that these vaccines are still highly effective. Other VOCs
will surely emerge, and the impact of these variants on vaccine efficacy is difficult to predict.
Currently, novel vaccination strategies are being explored to increase vaccine efficacy
against variants; increasing the number of doses and heterologous vaccination to boost
the immune response would help to prevent further transmission of variants, raising the
vaccine-induced immune response level.
Moreover, the next generation of vaccines, such as multivalent vaccines, would be
effective tools to control the spread of SARS-CoV-2 variants.

8. Recommendations on Extra Doses and Boosters

Despite the initially promising results of vaccination campaigns, many countries
are experiencing a resurgence of COVID-19 dominated by the Delta (B.1.617.2) and Omi-
cron (B.1.1.529) variants. Two important factors challenge the success of the vaccination
campaigns against COVID-19: first, the emergence of new variants that may evade im-
Vaccines 2022, 10, 349 16 of 24

mune responses in previously vaccinated subjects; and second, the antibody titers may
significantly decrease over time [130].
A study conducted by the Italian Istituto Superiore di Sanità (ISS) confirmed the
increased efficacy in preventing cases of COVID-19 and severe disease (hospitalization
and/or hospitalization in intensive care and/or death) in individuals who had been fully
vaccinated for more than 6 months or less compared with the unvaccinated. Moreover,
it was stated that, 6 months after the completion of the vaccination cycle, there was a
significant decrease in vaccine efficacy in preventing diagnose in all age groups. In general,
over the entire fully vaccinated population, vaccine efficacy starts at 76% and decreases
to 50% over 6 months. In cases of severe disease, there is a small decrease in vaccine
efficacy: the efficacy decreases from 92% to 82% in fully vaccinated individuals after
6 months [131].
Due to increased COVID-19-related hospital admission, the Israeli Ministry of Health
started a campaign for administration of a third dose of the BNT162b2 mRNA COVID-19
vaccine based on evidence reporting a pronounced humoral response to a third dose of
mRNA vaccine [132,133].
In Israel, the administration of a booster dose of the BNT162b2 vaccine was first
approved to immunocompromised patients and then expanded to people 60 years of age
or older who had received a second dose of vaccine at least 5 months earlier [134,135].
Following an observational analysis conducted on this population [134], a third dose of
the BNT162b2 mRNA COVID-19 vaccine was reported to be effective in preventing severe
COVID-19-related outcomes. Vaccine effectiveness was evaluated at least 7 days after
receipt of the third dose 5 months after the second dose and compared with receiving only
two doses: the efficacy was estimated to be 93% (231 events for two doses vs. 29 events for
three doses) for hospital admission, 92% (157 vs. 17 events) for severe disease, and 81%
(44 vs. 7 events) for COVID-19-related death [134,135].
Based on the Israeli campaign data, it was established that a third booster dose of
two-dose Comirnaty vaccine was needed to restore vaccine efficacy, distinguishing between
the booster dose for individuals with weakened immune systems and for individuals with
normal immune systems.
On 4 October 2021, the EMA recommended boosters of COVID-19 vaccines based on
studies reporting that an extra dose of these vaccines increased the production of antibodies
against SARS-CoV-2 in organ transplant patients with weakened immune systems [136,137].
At first, the EMA Human Medicines Committee (CHMP) recommended an extra
dose of the Comirnaty and Spikevax vaccines for people with severely weakened immune
systems, administered at least 28 days after their second dose [138].
The EMA CHMP also evaluated data on antibody levels after a booster dose of
Comirnaty and Spikevax vaccines administered to people with normal immune systems
approximately 6 months after the second dose, and the results showed increased antibody
levels. On the basis of this data, the CHMP concluded that booster doses may be considered
at least 6 months after the second dose for people aged 18 years and older with normal
immune systems [138,139].
The EMA CHMP has also concluded that a booster dose of the Janssen vaccine may
be considered at least 2 months after the first dose in people aged 18 years and older [140].
The FDA also approved a booster dose of the Comirnaty and Spikevax vaccines for indi-
viduals aged 18 years and older at least 6 months after completion of the primary vaccine
series [141]. A single booster dose of the Janssen vaccine was also approved for individuals
aged 18 years and older, to be administered at least 2 months after completion of the
primary single-dose regimen [142].
Triple-dose vaccinations series have been initiated in many countries and their data
will be helpful in characterizing the potentially boosted immunity and therefore the clinical
importance of the triple-dosing of COVID-19 vaccines [130].
A retrospective study was conducted in a large Israeli health maintenance organi-
zation, and it was found that the infection rate of COVID-19 in the booster-vaccinated
Vaccines 2022, 10, 349 17 of 24

population decreased by 3.8% compared with the population who did not receive a booster
dose [143]. Due to the spread of the SARS-CoV-2 Omicron variant in several countries, the
administration of a third dose has been accelerated, driven by the concern about lower
vaccine efficacy with this variant.
Data from the UK Health Security Agency on hospital admissions after Omicron
infection and vaccine effectiveness analysis reported 72% protection after two doses of the
BNT162b2 vaccine for up to 6 months, rising to 88% within 2 weeks of receiving a booster
dose [111].
A third dose of the mRNA-1273 vaccine showed a vaccine efficacy of 67.7% (compared
with the ~40% efficacy of two doses) against Omicron infection [121]. Data from a South
Africa study involving healthcare workers (n = 227,310) who received the single-dose
Johnson & Johnson COVID-19 vaccine as a primary dose showed that the booster increased
vaccine effectiveness against hospitalization to 85% [129]. From these early data, it can be
deduced that, with a third dose, the antibodies generated are able to effectively neutralize
the virus, bringing protection from infection and serious disease back to high levels. It
was also observed that a third dose could substantially reduce transmission, especially in
highly vaccinated populations. A modeling study by Gardner et al., showed that titers of
neutralizing antibodies are strongly correlated not just with protection against symptomatic
disease, but also with protection against all infection and transmission [144].
On 3 January 2022, Israel began to offer a fourth dose of the COVID-19 vaccine
to healthcare workers and adults over the age of 60 years. Fourth doses are mainly
administered on a precautionary basis to control the spread of the Omicron variant. To date,
there is very little evidence for their effectiveness, either from studies of immune function or
from observational studies of clinical events. The prime minister of Israel, Naftali Bennett,
stated that in a small unpublished study conducted on 154 hospital employees, there was a
five-fold increase in antibody concentrations in subjects one week after receiving a fourth
dose of the Pfizer-BioNTech vaccine, likely leading to increased protection against severe
symptoms and hospital admission [145,146].

9. A Proven “Old” Strategy as a New Weapon against COVID-19

As described above, several vaccines using different platforms are currently available;
however, it is important to have many vaccines options using different technologies to
meet the various needs of individuals with pre-existing conditions and to increase global
production to satisfy the needs of low- and middle-income countries. On 20 December 2021,
the EMA recommended granting conditional marketing authorization for the Novavax
COVID-19 vaccine Nuvaxovid (also known as NVX-CoV2373) [147]. This vaccine was
engineered from the genetic sequence of the first strain of SARS-CoV-2 and was formulated
using Novavax’s recombinant nanoparticle technology to produce antigens derived from
the coronavirus S protein; the antigens were combined with an adjuvant to enhance the
immune response and the production of neutralizing antibodies patented by Novavax [148].
A trial in the UK reported the efficacy of this protein-based vaccine as 96.4% against the
original virus strain, 86.3% against the Alpha (B.1.1.7) variant, and 89.7% overall [149].
Protein-based vaccines have been used for decades against hepatitis, shingles, and other
viral infections, and they have several advantages as they are usually safe, well tolerated,
and do not trigger autoimmunity. It must be noted that these approaches are also favorable
in terms of cost, simplicity, production capacity, transport, and administration, with fewer
standardized steps for their production and manufacturing; these attributes make protein-
based vaccines ideal candidates for global production and usage, making them affordable
and more available all around the world for both developed and developing countries [150].

10. Conclusions and Perspectives

COVID-19 is an unusual global health threat where a vaccine was needed immediately
as vaccine immunization is, thus far, the best solution in preventing the spread of infectious
disease. Exceptional efforts have been made to develop effective and safe vaccines to be
Vaccines 2022, 10, 349 18 of 24

released rapidly at an affordable cost to all countries affected by the pandemic [37]. In spite of
this, much remains to be understood and improved upon regarding the COVID-19 pandemic.
As previously stated, an essential focus of study for future vaccines is their route of
administration. All mRNA and viral vector COVID-19 vaccines are currently delivered via
the IM route and generate a systemic immune response. Nevertheless, some authors have
explored the potential role of vaccines able to induce immunological responses directly in
the respiratory mucosa, similar to those developed for influenza or measles, which would
likely be more effective in the early control or clearance of SARS-CoV-2 [84].
Whether long-lasting protection can be provided by COVID-19 vaccines still remains
unclear, and it is essential to determine how long a protective immune response against
SARS-CoV-2 infection can be maintained in individuals. [151]. Moreover, because re-
infection has been reported in vaccinated individuals and vaccine effectiveness against
asymptomatic infection and mild COVID-19 disease may decrease over time and with
the emergence of new variants, a third booster dose of Comirnaty, Spikevax, and Janssen
vaccines has already been approved by the EMA and FDA [139,142,143].
The emergence of novel SARS-CoV-2 strains is a central consideration for present and
future vaccines. In this regard, a promising objective could be to achieve the development
of pan-coronavirus vaccines targeting the entire Coronaviridae family, eliciting cross-reactive
antibodies that may be more effective against variants of a single virus compared with
strain-specific antibodies [152], although this concept is still in its infancy.
Efforts to tackle the COVID-19 pandemic could be thwarted by the unequal distribu-
tion of SARS-CoV-2 vaccines between high-income and low-income countries. The poor
supply of COVID-19 vaccines to low-income countries could extend the duration of the
pandemic and could favor the emergence of novel SARS-CoV-2 variants [153]. Furthermore,
this unfair distribution, highlighted by the initiation of fourth-dose administration in some
countries, poses a serious ethical problem for the political leaders of high-income coun-
tries [153,154]. The WHO director-general, Tedros Adhanom Ghebreyesus, has defined
the unequal distribution of COVID-19 vaccines as a “catastrophic moral failure” and as
“another brick in the wall for the inequality between the world’s haves and have-nots” [155].
Therefore, the current potential for variants to escape vaccine-induced immunity
makes testing and sequencing a priority to rapidly identify new variants, initiate a third
booster dose, develop next-generation vaccines that elicit broad neutralizing activity, attain
an equal distribution of COVID-19 vaccines among high-income and low-income countries,
and, last but not least, to increase people’s trust in scientific evidence.

Author Contributions: Conceptualization, D.G. and P.P.P.; data curation and literature review, A.D.G.,
M.N., V.L., E.D. and A.L.; writing—original draft preparation, V.L., E.D. and A.L.; writing—review
and editing, V.L., E.D., A.L., A.D.G., D.G. and P.P.P. supervision, D.G. and P.P.P.; project administration,
D.G.; funding acquisition, D.G. and P.P.P. All authors have read and agreed to the published version
of the manuscript.
Funding: The present study was supported by Fondazione Cariverona, ENACT project VIRO-COVID
(Prof. Gibellini) and Fondi RFO (Prof. Piccaluga).
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Wang, M.Y.; Zhao, R.; Gao, L.J.; Gao, X.F.; Wang, D.P.; Cao, J.M. SARS-CoV-2: Structure, Biology, and Structure-Based Therapeutics
Development. Front. Cell. Infect. Microbiol. 2020, 10, 724. [CrossRef] [PubMed]
2. WHO Coronavirus (COVID-19) Dashboard. WHO Coronavirus (COVID-19) Dashboard With Vaccination Data. Available online:
https://covid19.who.int/ (accessed on 12 November 2021).
Vaccines 2022, 10, 349 19 of 24

3. Petersen, E.; Koopmans, M.; Go, U.; Hamer, D.H.; Petrosillo, N.; Castelli, F.; Storgaard, M.; Al Khalili, S.; Simonsen, L. Comparing
SARS-CoV-2 with SARS-CoV and influenza pandemics. Lancet Infect. Dis. 2020, 20, e238–e244. [CrossRef]
4. Chen, Y.; Liu, Q.; Guo, D. Emerging coronaviruses: Genome structure, replication, and pathogenesis. J. Med. Virol. 2020, 92,
418–423. [CrossRef] [PubMed]
5. Hoffmann, M.; Kleine-Weber, H.; Schroeder, S.; Mü, M.A.; Drosten, C.; Pö, S. SARS-CoV-2 Cell Entry Depends on ACE2 and
TMPRSS2 and Is Blocked by a Clinically Proven Protease Inhibitor. Cell 2020, 181, 271–280. [CrossRef] [PubMed]
6. Huang, C.; Wang, Y.; Li, X.; Ren, L.; Zhao, J.; Hu, Y.; Zhang, L.; Fan, G.; Xu, J.; Gu, X.; et al. Clinical features of patients infected
with 2019 novel coronavirus in Wuhan, China. Lancet 2020, 395, 497–506. [CrossRef]
7. Zhou, P.; Yang, X.L.; Wang, X.G.; Hu, B.; Zhang, L.; Zhang, W.; Si, H.R.; Zhu, Y.; Li, B.; Huang, C.L.; et al. A pneumonia outbreak
associated with a new coronavirus of probable bat origin. Nature 2020, 579, 270–273. [CrossRef] [PubMed]
8. Fuentes-Prior, P. Priming of SARS-CoV-2 S protein by several membrane-bound serine proteinases could explain enhanced viral
infectivity and systemic COVID-19 infection. J. Biol. Chem. 2021, 296, 100135. [CrossRef]
9. Rahbar Saadat, Y.; Hosseiniyan Khatibi, S.M.; Zununi Vahed, S.; Ardalan, M. Host Serine Proteases: A Potential Targeted Therapy
for COVID-19 and Influenza. Front. Mol. Biosci. 2021, 8, 816. [CrossRef]
10. Ragia, G.; Manolopoulos, V.G. Assessing COVID-19 susceptibility through analysis of the genetic and epigenetic diversity of
ACE2-mediated SARS-CoV-2 entry. Pharmacogenomics 2020, 21, 1311–1329. [CrossRef]
11. Hu, B.; Guo, H.; Zhou, P.; Shi, Z.L. Characteristics of SARS-CoV-2 and COVID-19. Nat. Rev. Microbiol. 2020, 19, 141–154.
[CrossRef]
12. Suthar, M.S.; Zimmerman, M.G.; Kauffman, R.C.; Mantus, G.; Linderman, S.L.; Hudson, W.H.; Vanderheiden, A.; Nyhoff, L.;
Davis, C.W.; Adekunle, O.; et al. Rapid Generation of Neutralizing Antibody Responses in COVID-19 Patients. Cell Rep. Med.
2020, 1, 100040. [CrossRef] [PubMed]
13. Vaccines—COVID19 Vaccine Tracker. Available online: https://covid19.trackvaccines.org/vaccines/#approved (accessed on 29
November 2021).
14. Kyriakidis, N.C.; López-Cortés, A.; González, E.V.; Grimaldos, A.B.; Prado, E.O. SARS-CoV-2 vaccines strategies: A comprehensive
review of phase 3 candidates. NPJ Vaccines 2021, 6, 28. [CrossRef] [PubMed]
15. Mallapaty, S. China’s COVID vaccines have been crucial—Now immunity is waning. Nature 2021, 598, 398–399. [CrossRef]
[PubMed]
16. Coustasse, A.; Kimble, C.; Maxik, K. COVID-19 and Vaccine Hesitancy: A Challenge the United States Must Overcome. J. Ambul.
Care Manag. 2021, 44, 71–75. [CrossRef]
17. Ten Threats to Global Health in 2019. Available online: https://www.who.int/news-room/spotlight/ten-threats-to-global-
health-in-2019 (accessed on 25 January 2022).
18. Bin Naeem, S.; Bhatti, R.; Khan, A. An exploration of how fake news is taking over social media and putting public health at risk.
Health Info. Libr. J. 2021, 38, 143–149. [CrossRef] [PubMed]
19. Dubé, E.; Laberge, C.; Guay, M.; Bramadat, P.; Roy, R.; Bettinger, J. Vaccine hesitancy. Hum. Vaccines Immunother. 2013, 9,
1763–1773. [CrossRef]
20. Davidson, M. Vaccination as a cause of autism—myths and controversies. Dialogues Clin. Neurosci. 2017, 19, 403. [CrossRef]
21. Löffler, P. Review: Vaccine Myth-Buster—Cleaning Up With Prejudices and Dangerous Misinformation. Front. Immunol. 2021, 12,
2220. [CrossRef]
22. Leung, T.; Campbell, P.T.; Hughes, B.D.; Frascoli, F.; McCaw, J.M. Infection-acquired versus vaccine-acquired immunity in an
SIRWS model. Infect. Dis. Model. 2018, 3, 118–135. [CrossRef]
23. Lopez-Leon, S.; Wegman-Ostrosky, T.; Perelman, C.; Sepulveda, R.; Rebolledo, P.A.; Cuapio, A.; Villapol, S. More than 50
long-term effects of COVID-19: A systematic review and meta-analysis. Sci. Rep. 2021, 11, 16144. [CrossRef]
24. Tregoning, J.S.; Brown, E.S.; Cheeseman, H.M.; Flight, K.E.; Higham, S.L.; Lemm, N.M.; Pierce, B.F.; Stirling, D.C.; Wang, Z.;
Pollock, K.M. Vaccines for COVID-19. Clin. Exp. Immunol. 2020, 202, 162. [CrossRef] [PubMed]
25. Doerfler, W. Adenoviral Vector DNA- and SARS-CoV-2 mRNA-Based Covid-19 Vaccines: Possible Integration into the Human
Genome—Are Adenoviral Genes Expressed in Vector-based Vaccines? Virus Res. 2021, 302, 198466. [CrossRef] [PubMed]
26. Schlake, T.; Thess, A.; Fotin-Mleczek, M.; Kallen, K.J. Developing mRNA-vaccine technologies. RNA Biol. 2012, 9, 1319. [CrossRef]
27. Vitiello, A.; Ferrara, F.; Troiano, V.; La Porta, R. COVID-19 vaccines and decreased transmission of SARS-CoV-2. Inflammopharma-
cology 2021, 29, 1357–1360. [CrossRef]
28. Justo Arevalo, S.; Zapata Sifuentes, D.; Huallpa, C.J.; Landa Bianchi, G.; Castillo Chávez, A.; Garavito-Salini Casas, R.; Uribe
Calampa, C.S.; Uceda-Campos, G.; Pineda Chavarría, R. Dynamics of SARS-CoV-2 mutations reveals regional-specificity and
similar trends of N501 and high-frequency mutation N501Y in different levels of control measures. Sci. Rep. 2021, 11, 17755.
[CrossRef] [PubMed]
29. Pardi, N.; Hogan, M.J.; Porter, F.W.; Weissman, D. mRNA vaccines—A new era in vaccinology. Nat. Rev. Drug Discov. 2018, 17,
261–279. [CrossRef]
30. Laczkó, D.; Hogan, M.J.; Toulmin, S.A.; Hicks, P.; Lederer, K.; Gaudette, B.T.; Castaño, D.; Amanat, F.; Muramatsu, H.; Oguin,
T.H.; et al. A Single Immunization with Nucleoside-Modified mRNA Vaccines Elicits Strong Cellular and Humoral Immune
Responses against SARS-CoV-2 in Mice. Immunity 2020, 53, 724–732.e7. [CrossRef]
Vaccines 2022, 10, 349 20 of 24

31. Buschmann, M.D.; Carrasco, M.J.; Alishetty, S.; Paige, M.; Alameh, M.G.; Weissman, D. Nanomaterial Delivery Systems for
mRNA Vaccines. Vaccines 2021, 9, 65. [CrossRef]
32. Alameh, M.G.; Tombácz, I.; Bettini, E.; Lederer, K.; Sittplangkoon, C.; Wilmore, J.R.; Gaudette, B.T.; Soliman, O.Y.; Pine, M.; Hicks,
P.; et al. Lipid nanoparticles enhance the efficacy of mRNA and protein subunit vaccines by inducing robust T follicular helper
cell and humoral responses. Immunity 2021, 54, 2877–2892.e7. [CrossRef]
33. Anand, P.; Stahel, V.P. Review the safety of Covid-19 mRNA vaccines: A review. Patient Saf. Surg. 2021, 15, 20. [CrossRef]
34. Pepini, T.; Pulichino, A.-M.; Carsillo, T.; Carlson, A.L.; Sari-Sarraf, F.; Ramsauer, K.; Debasitis, J.C.; Maruggi, G.; Otten, G.R.; Geall,
A.J.; et al. Induction of an IFN-Mediated Antiviral Response by a Self-Amplifying RNA Vaccine: Implications for Vaccine Design.
J. Immunol. 2017, 198, 4012–4024. [CrossRef] [PubMed]
35. Bettini, E.; Locci, M.; Varga, S.M. SARS-CoV-2 mRNA vaccines: Immunological mechanism and beyond. Vaccines 2021, 9, 147.
[CrossRef] [PubMed]
36. Ibarrondo, F.J.; Fulcher, J.A.; Goodman-Meza, D.; Elliott, J.; Hofmann, C.; Hausner, M.A.; Ferbas, K.G.; Tobin, N.H.; Aldrovandi,
G.M.; Yang, O.O. Rapid Decay of Anti–SARS-CoV-2 Antibodies in Persons with Mild COVID-19. N. Engl. J. Med. 2020, 383,
1085–1087. [CrossRef] [PubMed]
37. Chung, J.Y.; Thone, M.N.; Kwon, Y.J. COVID-19 vaccines: The status and perspectives in delivery points of view. Adv. Drug Deliv.
Rev. 2021, 170, 1–25. [CrossRef] [PubMed]
38. O’Callaghan, K.P.; Blatz, A.M.; Offit, P.A. Developing a SARS-CoV-2 Vaccine at Warp Speed. JAMA 2020, 324, 437–438. [CrossRef]
39. Baden, L.R.; El Sahly, H.M.; Essink, B.; Kotloff, K.; Frey, S.; Novak, R.; Diemert, D.; Spector, S.A.; Rouphael, N.; Creech, C.B.; et al.
Efficacy and Safety of the mRNA-1273 SARS-CoV-2 Vaccine. New Engl. J. Med. 2021, 384, 403–416. [CrossRef] [PubMed]
40. FDA. FDA Authorizes Pfizer-BioNTech COVID-19 Vaccine for Emergency Use in Children 5 through 11 Years of Age. Available
online: https://www.fda.gov/news-events/press-announcements/fda-authorizes-pfizer-biontech-covid-19-vaccine-emergency-
use-children-5-through-11-years-age (accessed on 25 November 2021).
41. FDA. FDA Approves First COVID-19 Vaccine. Available online: https://www.fda.gov/news-events/press-announcements/fda-
approves-first-covid-19-vaccine (accessed on 8 October 2021).
42. European Medicines Agency. EMA Recommends First COVID-19 Vaccine for Authorisation in the EU. Available online:
https://www.ema.europa.eu/en/news/ema-recommends-first-covid-19-vaccine-authorisation-eu (accessed on 8 October 2021).
43. European Medicines Agency. First COVID-19 Vaccine Approved for Children Aged 12 to 15 in EU. Available online: https:
//www.ema.europa.eu/en/news/first-covid-19-vaccine-approved-children-aged-12-15-eu (accessed on 25 November 2021).
44. European Medicines Agency. Comirnaty COVID-19 Vaccine: EMA Recommends Approval for Children Aged 5 to 11. Available
online: https://www.ema.europa.eu/en/news/comirnaty-covid-19-vaccine-ema-recommends-approval-children-aged-5-11
(accessed on 25 November 2021).
45. Polack, F.P.; Thomas, S.J.; Kitchin, N.; Absalon, J.; Gurtman, A.; Lockhart, S.; Perez, J.L.; Pérez Marc, G.; Moreira, E.D.; Zerbini, C.;
et al. Safety and Efficacy of the BNT162b2 mRNA COVID-19 Vaccine. N. Engl. J. Med. 2020, 383, 2603–2615. [CrossRef]
46. European Medicines Agency. Comirnaty. Available online: https://www.ema.europa.eu/en/medicines/human/EPAR/
comirnaty (accessed on 12 November 2021).
47. Sahin, U.; Muik, A.; Vogler, I.; Derhovanessian, E.; Kranz, L.M.; Vormehr, M.; Quandt, J.; Bidmon, N.; Ulges, A.; Baum, A.; et al.
BNT162b2 vaccine induces neutralizing antibodies and poly-specific T cells in humans. Nature 2021, 595, 572–577. [CrossRef]
48. CDC. Pfizer-BioNTech COVID-19 Vaccine Overview and Safety. Available online: https://www.cdc.gov/coronavirus/2019
-ncov/vaccines/different-vaccines/Pfizer-BioNTech.html (accessed on 8 October 2021).
49. Walsh, E.E.; Frenck, R.W.; Falsey, A.R.; Kitchin, N.; Absalon, J.; Gurtman, A.; Lockhart, S.; Neuzil, K.; Mulligan, M.J.; Bailey,
R.; et al. Safety and Immunogenicity of Two RNA-Based Covid-19 Vaccine Candidates. N. Engl. J. Med. 2020, 383, 2439–2450.
[CrossRef]
50. Sahin, U.; Muik, A.; Vogler, I.; Derhovanessian, E.; Kranz, L.M.; Vormehr, M.; Quandt, J.; Bidmon, N.; Ulges, A.; Baum, A.; et al.
BNT162b2 induces SARS-CoV-2-neutralising antibodies and T cells in humans. medRxiv 2020, 18. [CrossRef]
51. Wang, Z.; Schmidt, F.; Weisblum, Y.; Muecksch, F.; Barnes, C.O.; Finkin, S.; Schaefer-Babajew, D.; Cipolla, M.; Gaebler, C.;
Lieberman, J.A.; et al. mRNA vaccine-elicited antibodies to SARS-CoV-2 and circulating variants. Nature 2021, 592, 616–622.
[CrossRef]
52. Haas, E.J.; Angulo, F.J.; McLaughlin, J.M.; Anis, E.; Singer, S.R.; Khan, F.; Brooks, N.; Smaja, M.; Mircus, G.; Pan, K.; et al. Impact
and effectiveness of mRNA BNT162b2 vaccine against SARS-CoV-2 infections and COVID-19 cases, hospitalisations, and deaths
following a nationwide vaccination campaign in Israel: An observational study using national surveillance data. Lancet 2021, 397,
1819–1829. [CrossRef]
53. FDA. Moderna COVID-19 Vaccine. Available online: https://www.fda.gov/emergency-preparedness-and-response/
coronavirus-disease-2019-covid-19/moderna-covid-19-vaccine (accessed on 8 October 2021).
54. European Medicines Agency. EMA Recommends COVID-19 Vaccine Moderna for Authorisation in the EU. Available online: https:
//www.ema.europa.eu/en/news/ema-recommends-covid-19-vaccine-moderna-authorisation-eu (accessed on 8 October 2021).
55. European Medicines Agency. COVID-19 Vaccine Spikevax Approved for Children Aged 12 to 17 in EU. Available online: https://
www.ema.europa.eu/en/news/covid-19-vaccine-spikevax-approved-children-aged-12-17-eu (accessed on 25 November 2021).
Vaccines 2022, 10, 349 21 of 24

56. Jackson, L.A.; Anderson, E.J.; Rouphael, N.G.; Roberts, P.C.; Makhene, M.; Coler, R.N.; McCullough, M.P.; Chappell, J.D.; Denison,
M.R.; Stevens, L.J.; et al. An mRNA Vaccine against SARS-CoV-2—Preliminary Report. N. Engl. J. Med. 2020, 383, 1920–1931.
[CrossRef] [PubMed]
57. European Medicines Agency. Spikevax (Previously COVID-19 Vaccine Moderna). Available online: https://www.ema.europa.
eu/en/medicines/human/EPAR/spikevax#product-information-section (accessed on 15 November 2021).
58. CDC. Myocarditis and Pericarditis After mRNA COVID-19 Vaccination. Available online: https://www.cdc.gov/coronavirus/20
19-ncov/vaccines/safety/myocarditis.html (accessed on 15 November 2021).
59. Widge, A.T.; Rouphael, N.G.; Jackson, L.A.; Anderson, E.J.; Roberts, P.C.; Makhene, M.; Chappell, J.D.; Denison, M.R.; Stevens,
L.J.; Pruijssers, A.J.; et al. Durability of Responses after SARS-CoV-2 mRNA-1273 Vaccination. N. Engl. J. Med. 2021, 384, 80–82.
[CrossRef] [PubMed]
60. Lundstrom, K. Application of Viral Vectors for Vaccine Development with a Special Emphasis on COVID-19. Viruses 2020, 12,
1324. [CrossRef] [PubMed]
61. Tatsis, N.; Ertl, H.C.J. Adenoviruses as vaccine vectors. Mol. Ther. 2004, 10, 616–629. [CrossRef]
62. Lundstrom, K. Viral Vectors for COVID-19 Vaccine Development. Viruses 2021, 13, 17. [CrossRef] [PubMed]
63. Ewer, K.J.; Lambe, T.; Rollier, C.S.; Spencer, A.J.; Hill, A.V.S.; Dorrell, L. Viral vectors as vaccine platforms: From immunogenicity
to impact. Curr. Opin. Immunol. 2016, 41, 47–54. [CrossRef]
64. European Medicines Agency. EMA Recommends COVID-19 Vaccine AstraZeneca for Authorisation in the EU. Available
online: https://www.ema.europa.eu/en/news/ema-recommends-covid-19-vaccine-astrazeneca-authorisation-eu (accessed
on 15 November 2021).
65. European Medicines Agency. Vaxzevria. Available online: https://www.ema.europa.eu/en/medicines/human/EPAR/
vaxzevria-previously-covid-19-vaccine-astrazeneca (accessed on 15 November 2021).
66. FDA. Coronavirus (COVID-19) Update: 6 August 2021. Available online: https://www.fda.gov/news-events/press-
announcements/coronavirus-covid-19-update-august-6-2021 (accessed on 15 November 2021).
67. Folegatti, P.M.; Ewer, K.J.; Aley, P.K.; Angus, B.; Becker, S.; Belij-Rammerstorfer, S.; Bellamy, D.; Bibi, S.; Bittaye, M.; Clutterbuck,
E.A.; et al. Safety and immunogenicity of the ChAdOx1 nCoV-19 vaccine against SARS-CoV-2: A preliminary report of a phase
1/2, single-blind, randomised controlled trial. Lancet 2020, 396, 467. [CrossRef]
68. Ramasamy, M.N.; Minassian, A.M.; Ewer, K.J.; Flaxman, A.L.; Folegatti, P.M.; Owens, D.R.; Voysey, M.; Aley, P.K.; Angus, B.;
Babbage, G.; et al. Safety and immunogenicity of ChAdOx1 nCoV-19 vaccine administered in a prime-boost regimen in young
and old adults (COV002): A single-blind, randomised, controlled, phase 2/3 trial. Lancet 2020, 396, 1979. [CrossRef]
69. Voysey, M.; Clemens, S.A.C.; Madhi, S.A.; Weckx, L.Y.; Folegatti, P.M.; Aley, P.K.; Angus, B.; Baillie, V.L.; Barnabas, S.L.; Bhorat,
Q.E.; et al. Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: An interim analysis of four
randomised controlled trials in Brazil, South Africa, and the UK. Lancet 2021, 397, 99–111. [CrossRef]
70. Norme, Circolari E Ordinanze. Available online: https://www.salute.gov.it/portale/nuovocoronavirus/archivioNormativaNuovoCoronav
jsp (accessed on 15 November 2021).
71. FDA. Janssen COVID-19 Vaccine. Available online: https://www.fda.gov/emergency-preparedness-and-response/coronavirus-
disease-2019-covid-19/janssen-covid-19-vaccine (accessed on 15 November 2021).
72. European Medicines Agency. EMA Recommends COVID-19 Vaccine Janssen for Authorisation in the EU. Available online: https:
//www.ema.europa.eu/en/news/ema-recommends-covid-19-vaccine-janssen-authorisation-eu (accessed on 15 November
2021).
73. Sadoff, J.; Gray, G.; Vandebosch, A.; Cárdenas, V.; Shukarev, G.; Grinsztejn, B.; Goepfert, P.A.; Truyers, C.; Fennema, H.; Spiessens,
B.; et al. Safety and Efficacy of Single-Dose Ad26.COV2.S Vaccine against COVID-19. N. Engl. J. Med. 2021, 384, 2187–2201.
[CrossRef] [PubMed]
74. European Medicines Agency. COVID-19 Vaccine Janssen. Available online: https://www.ema.europa.eu/en/medicines/human/
EPAR/covid-19-vaccine-janssen (accessed on 15 November 2021).
75. Alter, G.; Yu, J.; Liu, J.; Chandrashekar, A.; Borducchi, E.N.; Tostanoski, L.H.; McMahan, K.; Jacob-Dolan, C.; Martinez, D.R.;
Chang, A.; et al. Immunogenicity of Ad26.COV2.S vaccine against SARS-CoV-2 variants in humans. Nature 2021, 596, 268–272.
[CrossRef] [PubMed]
76. Lee, W.S.; Wheatley, A.K.; Kent, S.J.; DeKosky, B.J. Antibody-dependent enhancement and SARS-CoV-2 vaccines and therapies.
Nat. Microbiol. 2020, 5, 1185–1191. [CrossRef] [PubMed]
77. Liu, L.; Wei, Q.; Lin, Q.; Fang, J.; Wang, H.; Kwok, H.; Tang, H.; Nishiura, K.; Peng, J.; Tan, Z.; et al. Anti-spike IgG causes severe
acute lung injury by skewing macrophage responses during acute SARS-CoV infection. JCI Insight 2019, 4, e123158. [CrossRef]
78. Qin, E.; Shi, H.; Tang, L.; Wang, C.; Chang, G.; Ding, Z.; Zhao, K.; Wang, J.; Chen, Z.; Yu, M.; et al. Immunogenicity and protective
efficacy in monkeys of purified inactivated Vero-cell SARS vaccine. Vaccine 2006, 24, 1028–1034. [CrossRef]
79. Corbett, K.S.; Edwards, D.K.; Leist, S.R.; Abiona, O.M.; Boyoglu-Barnum, S.; Gillespie, R.A.; Himansu, S.; Schäfer, A.; Ziwawo,
C.T.; DiPiazza, A.T.; et al. SARS-CoV-2 mRNA Vaccine Design Enabled by Prototype Pathogen Preparedness. Nature 2020, 586,
567. [CrossRef] [PubMed]
80. van Doremalen, N.; Lambe, T.; Spencer, A.; Belij-Rammerstorfer, S.; Purushotham, J.N.; Port, J.R.; Avanzato, V.A.; Bushmaker, T.;
Flaxman, A.; Ulaszewska, M.; et al. ChAdOx1 nCoV-19 vaccine prevents SARS-CoV-2 pneumonia in rhesus macaques. Nature
2020, 586, 578–582. [CrossRef]
Vaccines 2022, 10, 349 22 of 24

81. Federico, M. The conundrum of current anti-SARS-CoV-2 vaccines. Cytokine Growth Factor Rev. 2021, 60, 46–51. [CrossRef]
82. Jeyanathan, M.; Afkhami, S.; Smaill, F.; Miller, M.S.; Lichty, B.D.; Xing, Z. Immunological considerations for COVID-19 vaccine
strategies. Nat. Rev. Immunol. 2020, 20, 615–632. [CrossRef]
83. Lavelle, E.C.; Ward, R.W. Mucosal vaccines—Fortifying the frontiers. Nat. Rev. Immunol. 2021. [CrossRef] [PubMed]
84. Mudgal, R.; Nehul, S.; Tomar, S. MINI REVIEW Prospects for mucosal vaccine: Shutting the door on SARS-CoV-2. Hum. Vaccin.
Immunother. 2020, 16, 2921–2931. [CrossRef]
85. King, R.G.; Silva-Sanchez, A.; Peel, J.N.; Botta, D.; Dickson, A.M.; Pinto, A.K.; Meza-Perez, S.; Allie, S.R.; Schultz, M.D.; Liu, M.;
et al. Single-Dose Intranasal Administration of AdCOVID Elicits Systemic and Mucosal Immunity against SARS-CoV-2 and Fully
Protects Mice from Lethal Challenge. Vaccines 2021, 9, 881. [CrossRef] [PubMed]
86. Ferber, S.; Gonzalez, R.J.; Cryer, A.M.; von Andrian, U.H.; Artzi, N. Immunology-Guided Biomaterial Design for Mucosal Cancer
Vaccines. Adv. Mater. 2020, 32, 1903847. [CrossRef]
87. Johnson, S.; Martinez, C.I.; Tedjakusuma, S.N.; Peinovich, N.; Dora, E.G.; Birch, S.M.; Kajon, A.E.; Werts, A.D.; Tucker, S.N.
Oral vaccination protects against SARS-CoV-2 in a Syrian hamster challenge model. J. Infect. Dis. 2021, 225, 34–41. [CrossRef]
[PubMed]
88. Vaxart, Inc. Vaxart Announces Positive Preliminary Data from Phase 1 Clinical Trial Evaluating Its Oral COVID-19 Tablet Vaccine
Candidate. Available online: https://investors.vaxart.com/news-releases/news-release-details/vaxart-announces-positive-
preliminary-data-phase-1-clinical (accessed on 11 November 2021).
89. Hellfritzsch, M.; Scherließ, R. Mucosal Vaccination via the Respiratory Tract. Pharmaceutics 2019, 11, 375. [CrossRef]
90. Xia, X. Domains and Functions of Spike Protein in SARS-Cov-2 in the Context of Vaccine Design. Viruses 2021, 13, 109. [CrossRef]
91. Choi, J.Y.; Smith, D.M. SARS-CoV-2 Variants of Concern. Yonsei Med. J. 2021, 62, 961. [CrossRef]
92. Bal, A.; Destras, G.; Gaymard, A.; Stefic, K.; Marlet, J.; Eymieux, S.; Regue, H.; Semanas, Q.; d’Aubarede, C.; Billaud, G.; et al.
Two-step strategy for the identification of SARS-CoV-2 variant of concern 202012/01 and other variants with spike deletion
H69–V70, France, August to December 2020. Eurosurveillance 2021, 26, 2100008. [CrossRef]
93. Volz, E.; Mishra, S.; Chand, M.; Barrett, J.C.; Johnson, R.; Hopkins, S.; Gandy, A.; Rambaut, A.; Ferguson, N.M. Transmission of
SARS-CoV-2 Lineage B.1.1.7 in England: Insights from linking epidemiological and genetic data. medRxiv 2021. [CrossRef]
94. Funk, T.; Pharris, A.; Spiteri, G.; Bundle, N.; Melidou, A.; Carr, M.; Gonzalez, G.; Garcia-Leon, A.; Crispie, F.; O’Connor, L.; et al.
Characteristics of SARS-CoV-2 variants of concern B.1.1.7, B.1.351 or P.1: Data from seven EU/EEA countries, weeks 38/2020 to
10/2021. Eurosurveillance 2021, 26, 2100348. [CrossRef] [PubMed]
95. Davies, N.G.; Jarvis, C.I.; van Zandvoort, K.; Clifford, S.; Sun, F.Y.; Funk, S.; Medley, G.; Jafari, Y.; Meakin, S.R.; Lowe, R.; et al.
Increased mortality in community-tested cases of SARS-CoV-2 lineage B.1.1.7. Nature 2021, 593, 270–274. [CrossRef] [PubMed]
96. Muik, A.; Wallisch, A.-K.; Sänger, B.; Swanson, K.A.; Mühl, J.; Chen, W.; Cai, H.; Maurus, D.; Sarkar, R.; Türeci, Ö.; et al.
Neutralization of SARS-CoV-2 lineage B.1.1.7 pseudovirus by BNT162b2 vaccine–elicited human sera. Science 2021, 371, 1152.
[CrossRef]
97. Cele, S.; Gazy, I.; Jackson, L.; Hwa, S.H.; Tegally, H.; Lustig, G.; Giandhari, J.; Pillay, S.; Wilkinson, E.; Naidoo, Y.; et al. Escape of
SARS-CoV-2 501Y.V2 from neutralization by convalescent plasma. Nature 2021, 593, 142–146. [CrossRef] [PubMed]
98. Greaney, A.J.; Starr, T.N.; Gilchuk, P.; Zost, S.J.; Binshtein, E.; Loes, A.N.; Hilton, S.K.; Huddleston, J.; Eguia, R.; Crawford, K.H.D.;
et al. Complete Mapping of Mutations to the SARS-CoV-2 Spike Receptor-Binding Domain that Escape Antibody Recognition.
Cell Host Microbe 2021, 29, 44–57.e9. [CrossRef]
99. Dejnirattisai, W.; Zhou, D.; Supasa, P.; Liu, C.; Mentzer, A.J.; Ginn, H.M.; Zhao, Y.; Duyvesteyn, H.M.E.; Tuekprakhon, A.; Nutalai,
R.; et al. Antibody evasion by the P.1 strain of SARS-CoV-2. Cell 2021, 184, 2939–2954.e9. [CrossRef] [PubMed]
100. Sabino, E.C.; Buss, L.F.; Carvalho, M.P.S.; Prete, C.A.; Crispim, M.A.E.; Fraiji, N.A.; Pereira, R.H.M.; Parag, K.V.; da Silva Peixoto,
P.; Kraemer, M.U.G.; et al. Resurgence of COVID-19 in Manaus, Brazil, despite high seroprevalence. Lancet 2021, 397, 452–455.
[CrossRef]
101. Dhar, M.S.; Marwal, R.; Radhakrishnan, V.S.; Ponnusamy, K.; Jolly, B.; Bhoyar, R.C.; Sardana, V.; Naushin, S.; Rophina, M.; Mellan,
T.A.; et al. Genomic characterization and epidemiology of an emerging SARS-CoV-2 variant in Delhi, India. Science 2021, 374,
995–999. [CrossRef]
102. Mlcochova, P.; Kemp, S.; Dhar, M.S.; Papa, G.; Meng, B.; Ferreira, I.A.T.M.; Datir, R.; Collier, D.A.; Albecka, A.; Singh, S.; et al.
SARS-CoV-2 B.1.617.2 Delta variant replication and immune evasion. Nature 2021, 599, 114–119. [CrossRef]
103. Classification of Omicron (B.1.1.529): SARS-CoV-2 Variant of Concern. Available online: https://www.who.int/news/item/26-1
1-2021-classification-of-omicron-(b.1.1.529)-sars-cov-2-variant-of-concern (accessed on 30 November 2021).
104. Poudel, S.; Ishak, A.; Perez-Fernandez, J.; Garcia, E.; León-Figueroa, D.A.; Romaní, L.; Bonilla-Aldana, D.K.; Rodriguez-Morales,
A.J. Highly mutated SARS-CoV-2 Omicron variant sparks significant concern among global experts—What is known so far?
Travel Med. Infect. Dis. 2022, 45, 102234. [CrossRef]
105. Ma, W.; Yang, J.; Fu, H.; Su, C.; Yu, C.; Wang, Q.; Tereza, A.; De Vasconcelos, R.; Bazykin, G.A.; Bao, Y.; et al. Genomic perspectives
on the emerging SARS-CoV-2 omicron variant. Genomics. Proteom. Bioinform. 2022. [CrossRef] [PubMed]
106. Threat Assessment Brief: Implications of the Emergence and Spread of the SARS-CoV-2 B.1.1. 529 Variant of Concern (Omicron)
for the EU/EEA. Available online: https://www.ecdc.europa.eu/en/publications-data/threat-assessment-brief-emergence-sars-
cov-2-variant-b.1.1.529 (accessed on 30 November 2021).
Vaccines 2022, 10, 349 23 of 24

107. Grabowski, F.; Kochańczyk, M.; Lipniacki, T. The spread of SARS-CoV-2 variant Omicron with the doubling time of 2.0–3.3 days
can be explained by immune evasion. Viruses 2022, 14, 294. [CrossRef]
108. Ferguson, N.; Ghani, A.; Cori, A.; Hogan, A.; Hinsley, W.; Volz, E. Growth, population distribution and immune escape of
Omicron in England. Imp. Coll. Lond. 2021. [CrossRef]
109. Jansen, L.; Tegomoh, B.; Lange, K.; Showalter, K.; Figliomeni, J.; Abdalhamid, B.; Iwen, P.C.; Fauver, J.; Buss, B.; Donahue,
M. Investigation of a SARS-CoV-2 B.1.1.529 (Omicron) Variant Cluster—Nebraska, November–December 2021. MMWR. Morb.
Mortal. Wkly. Rep. 2021, 70, 1782–1784. [CrossRef] [PubMed]
110. CDC COVID-19 Response Team. SARS-CoV-2 B.1.1.529 (Omicron) Variant—United States, 1–8 December 2021. Morb. Mortal.
Wkly. Rep. 2021, 70, 1731. [CrossRef]
111. SARS-CoV-2 Variants of Concern and Variants under Investigation in England. Available online: https://assets.publishing.service.
gov.uk/government/uploads/system/uploads/attachment_data/file/1018547/Technical_Briefing_23_21_09_16.pdf (accessed
on 19 December 2021).
112. Muik, A.; Lui, B.G.; Wallisch, A.-K.; Bacher, M.; Mühl, J.; Reinholz, J.; Ozhelvaci, O.; Beckmann, N.; Güimil Garcia, R.d.l.C.; Poran,
A.; et al. Neutralization of SARS-CoV-2 Omicron by BNT162b2 mRNA vaccine-elicited human sera. Science 2022, 375, 678–680.
[CrossRef]
113. Collie, S.; Champion, J.; Moultrie, H.; Bekker, L.-G.; Gray, G. Effectiveness of BNT162b2 Vaccine against Omicron Variant in South
Africa. N. Engl. J. Med. 2021, 386, 494–496. [CrossRef] [PubMed]
114. Wang, P.; Nair, M.S.; Liu, L.; Iketani, S.; Luo, Y.; Guo, Y.; Wang, M.; Yu, J.; Zhang, B.; Kwong, P.D.; et al. Antibody Resistance of
SARS-CoV-2 Variants B.1.351 and B.1.1.7. bioRxiv 2021, 593, 130–135. [CrossRef]
115. Liu, Y.; Liu, J.; Xia, H.; Zhang, X.; Fontes-Garfias, C.R.; Swanson, K.A.; Cai, H.; Sarkar, R.; Chen, W.; Cutler, M.; et al. Neutralizing
Activity of BNT162b2-Elicited Serum. N. Engl. J. Med. 2021, 384, 1466–1468. [CrossRef]
116. Wall, E.C.; Wu, M.; Harvey, R.; Kelly, G.; Warchal, S.; Sawyer, C.; Daniels, R.; Hobson, P.; Hatipoglu, E.; Ngai, Y.; et al. Neutralising
antibody activity against SARS-CoV-2 VOCs B.1.617.2 and B.1.351 by BNT162b2 vaccination. Lancet 2021, 397, 2331. [CrossRef]
117. Dejnirattisai, W.; Shaw, R.H.; Supasa, P.; Liu, C.; Stuart, A.S.; Pollard, A.J.; Liu, X.; Lambe, T.; Crook, D.; Stuart, D.I.; et al. Reduced
neutralisation of SARS-CoV-2 omicron B.1.1.529 variant by post-immunisation serum. Lancet 2022, 399, 234–236. [CrossRef]
118. Supasa, P.; Zhou, D.; Dejnirattisai, W.; Liu, C.; Mentzer, A.J.; Ginn, H.M.; Zhao, Y.; Duyvesteyn, H.M.E.; Nutalai, R.; Tuekprakhon,
A.; et al. Reduced neutralization of SARS-CoV-2 B.1.1.7 variant by convalescent and vaccine sera. Cell 2021, 184, 2201–2211.e7.
[CrossRef] [PubMed]
119. Zhou, D.; Dejnirattisai, W.; Supasa, P.; Liu, C.; Mentzer, A.J.; Ginn, H.M.; Zhao, Y.; Duyvesteyn, H.M.E.; Tuekprakhon, A.; Nutalai,
R.; et al. Evidence of escape of SARS-CoV-2 variant B.1.351 from natural and vaccine-induced sera. Cell 2021, 184, 2348–2361.e6.
[CrossRef]
120. Wu, K.; Werner, A.P.; Moliva, J.I.; Koch, M.; Choi, A.; Stewart-Jones, G.B.E.; Bennett, H.; Boyoglu-Barnum, S.; Shi, W.; Graham,
B.S.; et al. mRNA-1273 vaccine induces neutralizing antibodies against spike mutants from global SARS-CoV-2 variants. bioRxiv
2021. [CrossRef]
121. Fu Tseng, H.; Ackerson, B.K.; Luo, Y.; Sy, L.S.; Talarico, C.A.; Tian, Y.; Bruxvoort, K.J.; Tubert, J.E.; Florea, A.; Ku, J.H.; et al.
Effectiveness of mRNA-1273 against SARS-CoV-2 omicron and delta variants. medRxiv 2022. [CrossRef] [PubMed]
122. Hansen, C.H.; Schelde, A.B.; Moustsen-Helm, I.R.; Emborg, H.-D.; Krause, T.G.; Mølbak, K.; Valentiner-Branth, P. Vaccine
effectiveness against SARS-CoV-2 infection with the Omicron or Delta variants following a two-dose or booster BNT162b2 or
mRNA-1273 vaccination series: A Danish cohort study. medRxiv 2021. [CrossRef]
123. Emary, K.R.W.; Golubchik, T.; Aley, P.K.; Ariani, C.V.; Angus, B.; Bibi, S.; Blane, B.; Bonsall, D.; Cicconi, P.; Charlton, S.; et al.
Efficacy of ChAdOx1 nCoV-19 (AZD1222) vaccine against SARS-CoV-2 variant of concern 202012/01 (B.1.1.7): An exploratory
analysis of a randomised controlled trial. Lancet 2021, 397, 1351. [CrossRef]
124. Lopez Bernal, J.; Andrews, N.; Gower, C.; Gallagher, E.; Simmons, R.; Thelwall, S.; Stowe, J.; Tessier, E.; Groves, N.; Dabrera, G.;
et al. Effectiveness of Covid-19 Vaccines against the B.1.617.2 (Delta) Variant. N. Engl. J. Med. 2021, 385, 585–594. [CrossRef]
125. Hitchings, M.D.T.; Ranzani, O.T.; Dorion, M.; Lang, T.D.; Cardoso de Paula, R.; Ferreira Pereira de Paula, O.; Faria de Moura
Villela, E.; Sergio Scaramuzzini Torres, M.; Barbosa de Oliveira, S.; Schulz, W.; et al. Effectiveness of ChAdOx1 vaccine in older
adults during SARS-CoV-2 Gamma variant circulation in São Paulo. Nat. Commun. 2021, 12, 6220. [CrossRef]
126. Madhi, S.A.; Baillie, V.; Cutland, C.L.; Voysey, M.; Koen, A.L.; Fairlie, L.; Padayachee, S.D.; Dheda, K.; Barnabas, S.L.; Bhorat,
Q.E.; et al. Efficacy of the ChAdOx1 nCoV-19 Covid-19 Vaccine against the B.1.351 Variant. N. Engl. J. Med. 2021, 384, 1885–1898.
[CrossRef]
127. Neil Ferguson, Azra Ghani, Wes Hinsley and Erik Volz. Hospitalisation risk for Omicron cases in England. Imp. Coll. Lond. 2021.
[CrossRef]
128. Schmidt, F.; Muecksch, F.; Weisblum, Y.; Da Silva, J.; Bednarski, E.; Cho, A.; Wang, Z.; Gaebler, C.; Caskey, M.; Nussenzweig, M.C.;
et al. Plasma Neutralization of the SARS-CoV-2 Omicron Variant. N. Engl. J. Med. 2021, 386, 599–601. [CrossRef]
129. Gray MBBCH, G.E.; Collie, S.; Garrett MBBS, N.; Goga, A.; Champion, J.; Zylstra, M.; Reddy, T.; Yende, N.; Seocharan, I.;
Takalani MBChB, A.; et al. Vaccine effectiveness against hospital admission in South African health care workers who received a
homologous booster of Ad26.COV2 during an Omicron COVID19 wave: Preliminary Results of the Sisonke 2 Study. medRxiv
2021. [CrossRef]
Vaccines 2022, 10, 349 24 of 24

130. Rahimi, F.; Abadi, A.T.B. The third booster vaccination dose against COVID-19: Indications for circulating SARS-CoV-2 variants.
Future Virol. 2021, 16, 781–784. [CrossRef] [PubMed]
131. Sorveglianza Integrata COVID-19: I Principali Dati Nazionali. Available online: https://www.epicentro.iss.it/coronavirus/sars-
cov-2-sorveglianza-dati (accessed on 18 November 2021).
132. Ducloux, D.; Colladant, M.; Chabannes, M.; Yannaraki, M.; Courivaud, C. Humoral response after 3 doses of the BNT162b2
mRNA COVID-19 vaccine in patients on hemodialysis. Kidney Int. 2021, 100, 702–704. [CrossRef] [PubMed]
133. Wu, K.; Choi, A.; Koch, M.; Ma, L.; Hill, A.; Nunna, N.; Huang, W.; Oestreicher, J.; Colpitts, T.; Bennett, H.; et al. Preliminary
Analysis of Safety and Immunogenicity of a SARS-CoV-2 Variant Vaccine Booster. medRxiv 2021. [CrossRef]
134. Barda, N.; Dagan, N.; Cohen, C.; Hernán, M.A.; Lipsitch, M.; Kohane, I.S.; Reis, B.Y.; Balicer, R.D. Effectiveness of a third dose of
the BNT162b2 mRNA COVID-19 vaccine for preventing severe outcomes in Israel: An observational study. Lancet 2021, 398,
2093–2100. [CrossRef]
135. Bar-On, Y.M.; Goldberg, Y.; Mandel, M.; Bodenheimer, O.; Freedman, L.; Kalkstein, N.; Mizrahi, B.; Alroy-Preis, S.; Ash, N.; Milo,
R.; et al. Protection of BNT162b2 Vaccine Booster against COVID-19 in Israel. N. Engl. J. Med. 2021, 385, 1393–1400. [CrossRef]
136. Kamar, N.; Abravanel, F.; Marion, O.; Couat, C.; Izopet, J.; Del Bello, A. Three Doses of an mRNA Covid-19 Vaccine in Solid-Organ
Transplant Recipients. N. Engl. J. Med. 2021, 385, 661–662. [CrossRef]
137. Hall, V.G.; Ferreira, V.H.; Ku, T.; Ierullo, M.; Majchrzak-Kita, B.; Chaparro, C.; Selzner, N.; Schiff, J.; McDonald, M.; Tomlinson, G.;
et al. Randomized Trial of a Third Dose of mRNA-1273 Vaccine in Transplant Recipients. N. Engl. J. Med. 2021, 385, 1244–1246.
[CrossRef]
138. European Medicines Agency. Comirnaty and Spikevax: EMA Recommendations on Extra Doses and Boosters. Available
online: https://www.ema.europa.eu/en/news/comirnaty-spikevax-ema-recommendations-extra-doses-boosters (accessed
on 17 November 2021).
139. Spikevax: EMA Recommendation on Booster Dose. Available online: https://www.aifa.gov.it/en/-/spikevax-raccomandazione-
ema-sulla-dose-di-richiamo (accessed on 17 November 2021).
140. European Medicines Agency. COVID-19 Vaccine Janssen: EMA Recommendation on Booster Dose. Available online: https:
//www.ema.europa.eu/en/news/covid-19-vaccine-janssen-ema-recommendation-booster-dose (accessed on 25 January 2022).
141. Coronavirus (COVID-19) Update: FDA Expands Eligibility for COVID-19 Vaccine Boosters. Available online: https://www.fda.
gov/news-events/press-announcements/coronavirus-covid-19-update-fda-expands-eligibility-covid-19-vaccine-boosters (ac-
cessed on 19 November 2021).
142. FDA. Coronavirus (COVID-19) Update: FDA Takes Additional Actions on the Use of a Booster Dose for COVID-19 Vaccines.
Available online: https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-takes-additional-
actions-use-booster-dose-covid-19-vaccines (accessed on 17 November 2021).
143. Saciuk, Y.; Kertes, J.; Stein, N.S.; Zohar, A.E. Effectiveness of a Third Dose of BNT162b2 mRNA Vaccine. J. Infect. Dis. 2022, 225,
30–33. [CrossRef] [PubMed]
144. Gardner, B.J.; Kilpatrick, A.M. Third doses of COVID-19 vaccines reduce infection and transmission of SARS-CoV-2 and could
prevent future surges in some populations. medRxiv 2021. [CrossRef]
145. Burki, T.K. Fourth dose of COVID-19 vaccines in Israel. Lancet Respir. Med. 2022, 10, e19. [CrossRef]
146. Do Fourth Vaccine Doses Really Work? What a New Israeli Study Found. Available online: https://www.advisory.com/daily-
briefing/2022/01/10/pfizer-israel (accessed on 22 January 2022).
147. European Medicines Agency. EMA Recommends Nuvaxovid for Authorisation in the EU. Available online: https://www.ema.
europa.eu/en/news/ema-recommends-nuvaxovid-authorisation-eu (accessed on 25 January 2022).
148. Novavax Confirms European Medicines Agency Review of COVID-19 Vaccine Filing for Conditional Marketing Authorization—
17 November 2021. Available online: https://ir.novavax.com/2021-11-17-Novavax-Confirms-European-Medicines-Agency-
Review-of-COVID-19-Vaccine-Filing-for-Conditional-Marketing-Authorization (accessed on 19 November 2021).
149. Heath, P.T.; Galiza, E.P.; Baxter, D.N.; Boffito, M.; Browne, D.; Burns, F.; Chadwick, D.R.; Clark, R.; Cosgrove, C.; Galloway, J.; et al.
Safety and Efficacy of NVX-CoV2373 COVID-19 Vaccine. N. Engl. J. Med. 2021, 385, 1172–1183. [CrossRef] [PubMed]
150. Keshavarz-Fathi, M.; Rezaei, N. Peptide and Protein Vaccines for Cancer. Vaccines Cancer Immunother. An Evidence-Based Rev. Curr.
Status Futur. Perspect. 2019, 150, 101–116. [CrossRef]
151. Cohen, J.I.; Burbelo, P.D. Reinfection With SARS-CoV-2: Implications for Vaccines. Clin. Infect. Dis. 2021, 73, 4223–4228. [CrossRef]
152. Burton, D.R.; Walker, L.M. Rational Vaccine Design in the Time of COVID-19. Cell Host Microbe 2020, 27, 695–698. [CrossRef]
153. Raza, A.; Ullah, I.; Tahir, M.J.; Jabbar, A.; Ahmed, A. Coronavirus disease 2019 (COVID-19) is a healthcare dilemma for human
immunodeficiency virus (HIV)–positive individuals in Pakistan. Infect. Control Hosp. Epidemiol. 2021, 1–2. [CrossRef]
154. Rogers, A.B.; Barrie, M.B.; Fallah, M.P.; Kelly, J.D. Equitable and Feasible Distribution of SARS-CoV-2 Vaccines for All in Africa.
Am. J. Trop. Med. Hyg. 2021, 105, 278–280. [CrossRef]
155. WHO Director-General’s Opening Remarks at 148th Session of the Executive Board. Available online: https://www.who.int/
director-general/speeches/detail/who-director-general-s-opening-remarks-at-148th-session-of-the-executive-board (accessed
on 25 January 2022).