Abstract Background The Bacillus Calmette-Guérin (BCG) vaccine induces trained immunity, an epigenetic-mediated increase in innate immune responsiveness. Therefore, this clinical trial evaluated if BCG-induced trained immunity could decrease COVID-19-related frequency or severity. Methods A double-blind, placebo-controlled clinical trial of healthcare workers randomized participants to vaccination with BCG TICE® or placebo (saline). Enrollment included 529 healthcare workers randomized to receive BCG or placebo. Primary analysis evaluated COVID-19 disease frequency, while secondary analysis evaluated coronavirus immunity in a subset of participants. Study enrollment ceased early in December 2020 following introduction of COVID-19-specific vaccines. Results Study enrollment was halted early, prior to reaching the targeted recruitment and was not powered to detect a decrease in COVID-19 frequency. Symptomatic COVID-19 occurred in 21 of 263 and 10 of 266 participants in the BCG and placebo arms, respectively (p= 0.50, Fisher’s exact test). Participants vaccinated with BCG, but uninfected with COVID-19, demonstrated increased coronavirus vaccine immunity (increase spike-inducible levels of TNF, IL6, and IL-1β) twelve months after BCG vaccination compared to participants receiving placebo. Immune responsiveness to COVID-19 antigens correlated with BCG-induced DNA methylation changes. Conclusion Due to early study closure, the study was not powered to evaluate COVID-19 frequency. Secondary analysis demonstrated that twelve months following vaccination, BCG increased coronavirus vaccine immunity compared to those who did not receive BCG. This increase in COVID-19 vaccine immunity correlated with BCG-induced DNA methylation changes.
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