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April 21, 2022

Just how dangerous is Covid-19 to the immunocompromised?

Daily Briefing

    Immunocompromised people are at a greater risk of severe disease and death from Covid-19, leading many to worry how to protect themselves as pandemic restrictions are rolled back nationwide. But health experts say various tools and treatments are available to help the immunocompromised reduce their risk of infection and severe outcomes.

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    'A wide spectrum of risk'

    More than 7 million Americans are considered immunocompromised and are at an increased risk of severe Covid-19 outcomes. However, the term covers a variety of conditions, including cancer, autoimmune disorders, organ transplants, and more, resulting in "a wide spectrum of risk," Vox reports.

    "It's not like there is a clear category of 'you're immune compromised' and 'you're not at all' — there's a gradient," said Dimitri Drekonja, an infectious disease doctor at the University of Minnesota.

    For example, a CDC analysis of two-dose Covid-19 vaccine regimens among immunocompromised patients found that different conditions affected their level of protection. Rheumatologic patients saw the greatest protection against Covid-19 hospitalizations at 81%, followed by solid-cancer patients at 79%, blood cancer patients at 74%, and those born with immune deficiencies at 73%. Organ transplant recipients had the least protection at 59%.

    Currently, it is not clear which immunocompromised people face the greatest risk when it comes to Covid-19, but experts generally agree that there is an elevated risk of infection and severe outcomes for this population since the coronavirus is still so new and people have not had a chance to build up immunity, unlike with common cold and flu viruses.

    According to Megan Ryan, an advocate for people with primary immunodeficiencies, immunocompromised people should talk to their health care providers directly to gauge their individual risk.

    "It is a confusing time because there's a lot of people who are either experts or self-proclaimed experts — there's just a lot of voices in the system," she said. She recommended people consult with a health care team who knows them well "rather than crowdsourcing an answer."

    How immunocompromised people can protect themselves

    In addition to assessing individual risk directly with health care providers, immunocompromised people can stay protected against the coronavirus with the help of various tools, including:

    Vaccines

    Currently, CDC recommends immunocompromised people who initially received an mRNA Covid-19 vaccine to receive a total of four doses, with an optional fifth dose available. For those who initially received the Johnson & Johnson vaccine, the agency recommends a total of three doses, with later doses being mRNA vaccines, with a fourth dose as an option.

    However, several studies suggesting Covid-19 vaccines are less likely to generate protective antibodies and are overall less effective in immunocompromised people has led to increased vaccine hesitancy in this population.

    "The idea that the vaccines don't work for immunocompromised people has definitely contributed to hesitancy," said Michael Putman, a rheumatologist at the Medical College for Wisconsin.

    According to Jennifer Nuzzo, the director of the Pandemic Center at Brown University School of Public Health, the idea that Covid-19 vaccines do not protect immunocompromised people "is just a complete distortion ... It's just scaring people, and it's not saving lives."

    Although Covid-19 vaccines offer immunocompromised people less protection compared to those with normal immune systems, "the protection isn't zero," Vox writes.

    "Except in the most extreme circumstances, they do have some protection if they've followed the recommendations for the vaccinations," said Christine Koval, who leads the transplant infectious disease team at the Cleveland Clinic.

    For instance, a CDC study found that three doses of an mRNA vaccine reduced the risk of hospitalization by 87% in immunocompromised people, compared to 97% for people with normal immune systems. Similarly, another CDC study found that mRNA vaccines were 74% effective against the most severe Covid-19 outcomes, such as needing a ventilator or death, compared to 97% for others.

    "We're still looking at very high response rates and very robust protection against severe disease," said Anne Mills, a physician in Virginia with rheumatoid arthritis.

    Covid-19 therapeutics

    The federal government recently launched a Covid-19 therapeutics locator, which can help health care providers get the most effective treatments to their immunocompromised patients.

    For example, Astra Zeneca's Evusheld is an antibody cocktail that was authorized for emergency use in December 2021. It is intended to be used as a preventive treatment against coronavirus infection for individuals ages 12 and older who are moderately to severely immunocompromised and may not generate a strong response to vaccination.

    In August, AstraZeneca reported that Evusheld reduced the risk of symptomatic Covid-19 infection by 77% in a late-stage clinical trial of 5,197 participants, more than 75% of whom had comorbidities that could render vaccines less effective.

    Oral antivirals, such as Pfizer's Paxlovid and Merck's molnupiravir, may also benefit immunocompromised people, Vox reports. At "test to treat" locations nationwide, patients who test positive for Covid-19 can receive antiviral pills free of charge.

    Policies to reduce viral transmission

    Although many mask mandates are no longer in effect, people and organizations can still help those who are immunocompromised. Some potential steps include improving air filtration and ventilation in buildings and voluntarily masking when around high-risk people.

    Immunocompromised people can also continue wearing high-quality masks, such as a fitted N95, and encourage their household members to do the same when they're in public to avoid bringing the virus home.

    According to Koval, many immunocompromised people may "get this message that they’re at such high risk for death that they can't really function normally in the world," but that belief is not realistic.

    "It is uncomfortable to live in these muddy situations, particularly when we're two years in and the type of data that we have is just not that helpful for patients, and for us to help them make informed decisions," she said. "I'm hoping it gets better." (Mazer, The Atlantic, 4/19; Landman, Vox, 4/6)

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