Compromised Humoral Functional Evolution Tracks with SARS-CoV-2 Mortality

The urgent need for an effective SARS-CoV-2 vaccine has forced development to progress in the absence of well-defined correlates of immunity. While neutralization has been linked to protection against other pathogens, whether neutralization alone will be sufficient to drive protection against SARS-CoV-2 in the broader population remains unclear. Therefore, to fully define protective humoral immunity, we dissected the early evolution of the humoral response in 193 hospitalized individuals ranging from moderate to severe. Although robust IgM and IgA responses evolved in both survivors and non-survivors with severe disease, non-survivors showed attenuated IgG responses, accompanied by compromised Fcɣ receptor binding and Fc effector activity, pointing to deficient humoral development rather than disease-enhancing humoral immunity. In contrast, individuals with moderate disease exhibited delayed responses that ultimately matured. These data highlight distinct humoral trajectories associated with resolution of SARS-CoV-2 infection and the need for early functional humoral immunity. [Display omitted] •IgA and IgM evolve rapidly across all levels of disease severity•Rapid and potent IgG class switching is linked to survival•Moderate disease is associated with a delay but ultimate convergence of IgG•Early S2-cross-reactivity is linked to survival after severe disease Analyses of the functional humoral trajectories associated with the resolution of SARS-CoV-2 infection find that despite equivalent IgM and IgA immunity to the virus across all levels of disease severity, survival and recovery are linked to early class switching to IgG and the ability to leverage Fcγ receptors targeting the spike protein.