Will immunocompromised patients need a COVID-19 vaccine booster every 6 months forever?
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Different tools may be used to boost immunity.
At this time, it’s unclear whether immunocompromised individuals will need to be boosted with COVID-19 vaccinations at any interval. We currently lack the robust data needed to inform this decision. What is clear, however, is that the immunocompromised need to be treated differently when it comes to COVID-19 vaccination (as is the case with many vaccinations). It has already been shown that they are clearly less likely to respond to standard vaccination regimens and are overrepresented among those with rare breakthrough hospitalizations. These data led to the recommendation that an additional messenger RNA vaccine dose be given to the immunocompromised, extending the primary vaccine series. Although the additional dose will increase the likelihood of an immunologic response, it may not occur in everyone, and the protection may wane with time. Because of the nature of being immunocompromised — and the limitations of prompting active immunity in this population — it is important to recognize that, in this special population, it may not only be vaccines that play a role in protecting these individuals because passive immunity could be critical. Passive immunity would come in the form of monoclonal antibodies, three of which are available currently for treatment and post-exposure prophylaxis. However, in addition to these indications, there are promising data on the use of monoclonal antibodies as pre-exposure prophylaxis. This would be especially valuable with longer acting monoclonal antibodies because they could be used to supplement the immunity engendered by vaccines. These passive immunity conferring antibodies could be periodically infused or injected in those in whom the protection conferred by the vaccine may not be enough. The practice of using monoclonal antibodies to augment immunity may be a more effective way to protect the immunocompromised than repeated boosting with first generation vaccines, to which they may still not respond optimally so long as they remain immunosuppressed. This type of strategy can be thought of as akin to using respiratory syncytial virus monoclonal antibodies to protect vulnerable infants seasonally. It is also important to consider the fact that there will also be second-generation vaccines that are developed that could be more immunogenic in the immunocompromised. In the end, it is likely that a few different tools may play a role in optimally protecting the immunocompromised, and some combination of vaccination and monoclonal antibody prophylaxis may prove to be optimal.
Amesh A. Adalja, MD, is a senior scholar at the Johns Hopkins Center for Health Security.
Some may not need a booster at 6 months.
It is likely that immunocompetent individuals who received an additional booster will have long-term robust immunity for many months or probably even several years. For those who are immunocompromised, much will depend on their response to their more recent booster.
We will learn over the next 6 to 12 months the subgroups of individuals who have not responded well and who may need additional boosting. My guess would be, however, that some immunosuppressed individuals will respond just fine and not need a booster in 6 months.
The obvious wild card that is unpredictable is that of the variants. If substantial viral evolution takes place over the next 6 to 12 months, this might change the need for a booster for everyone.
Keep your fingers crossed.
Kevin L. Winthrop, MD, MPH, is director of the Center for Infectious Disease Studies at the Oregon Health & Science University.
Click here to read the Cover Story, “Vaccinated yet vulnerable: COVID-19 and the immunocompromised patient.”
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