Immunocompromised patients ‘continue to battle’ as COVID-19 restrictions ease
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When the CDC released new masking guidance at the end of February, it seemed to indicate a shift toward treating COVID-19 as something people will learn to live with.
However, there seemed to be little concern for what next steps may look like for patients who mounted poor immune responses to the COVID-19 vaccinations they received, or for patients who are unable to receive the vaccines at all. Although many have received their vaccination series and booster, and seem to have moved on, the pandemic remains an existential threat for immunocompromised patients.
Diverging epidemics
“I think it is helpful to look at where we are now in terms of COVID and where we’re going,” Cassandra Calabrese, DO, of the department of rheumatic and immunologic disease at the Cleveland Clinic, told Healio. “It’s important to realize that although the pandemic is getting better for most, that isn’t necessarily the case for many of our immunocompromised or high-risk patients, and they really do see the pandemic morphing into two epidemics.”
On one side, immunocompetent, vaccinated persons will likely continue to do well in the event they become ill with COVID-19. On the other side, many immunocompromised persons will remain at risk for severe disease despite being vaccinated.
“I think all of the guidance and lifting mandates doesn’t always consider this latter group who will remain at risk,” Calabrese said. “Although mask mandates are being actively ended or expiring, this might not be the right thing to do for many of our patients, and that is kind of the conversation we have.”
The question of when to loosen restrictions is not one with a simple answer.
“When community levels are low, perhaps, these mandates might make sense to loosen,” Jeffrey Sparks, MD, MMSc, associate physician at Brigham and Women’s Hospital and Harvard Medical School, in Boston, told Healio. “On the other hand, there is very low downside for wearing a mask, and it can perhaps be very beneficial for people, particularly, that are immune-suppressed.”
The wide variance of perspectives and biases surrounding masks make it unlikely for wide agreement among the population.
“I think what I would say is that, certainly, personal mask wearing of a high-quality mask, either an N95 or a KN95, probably offers some level of protection even if other people aren’t masked,” Sparks said.
‘Lots of frustration’
As mandates have been rescinded or allowed to expire, frustration among immunocompromised patients has grown. According to Alfred Kim, MD, PhD, assistant professor in the department of medicine at Washington University, in St. Louis, many of these patients, including those with autoimmune diseases or who receive immunosuppressants, have resigned themselves to a long, continuing battle against the pandemic.
“[There has been] lots of frustration, but they have accepted the situation they are in and are ready to continue to battle,” Kim told Healio. “They are at least grateful there are methods in place to reduce SARS-CoV-2 acquisition, and that therapies are now available both to prevent infections and following exposures.”
Frustration among patients who are immunocompromised is not an isolated incident. Many times, these patients are especially health-conscious and are aware of the difficulties they face mounting a vaccine response, Calabrese said.
“I think our patients who are higher risk, who have been so uber-cautious for the past 2 years, can be frustrated to know that they are still at-risk,” she said. “They probably are aware that they didn’t get a great response to the vaccine and that they still need to be careful. That’s very frustrating for them when they’ve been so careful and especially have seen and watched other people be not careful at all. That can be frustrating.”
Meanwhile, other patients may be just as frustrated with the pandemic — but not necessarily for the same reasons.
“I think everyone feels frustrated, no matter which viewpoint they are coming from,” Sparks said. “There are some people who are frustrated that we are still wearing masks at the clinic, there are some people that are frustrated that there isn’t more masking outside the clinic. This is a large part of what our clinic visits are about, trying to navigate all of the complex issues this brings up.”
When patients present with frustrations related to waning pandemic measures, it is important to understand them and communicate that there options to handle infection, Calabrese said. At the same time, the risk profile of every individual patient varies significantly. Rheumatologists should tailor their advice to patients based on their individual level of risk.
“For people who are more than mildly or moderately immunocompromised, they really need to continue to have a degree of caution while they are out and about,” Calabrese said. “That all depends on where they’re going, what they’re doing, and who they’re with.”
An evolving toolbox
In some ways, the toolbox used avoid COVID-19 infection has not changed since the early months of 2020. Medical-grade masks — N95 or KN95 — remain the gold standard, while avoiding crowded indoor gatherings and social distancing can go even further in reducing risk. However, there have also been many changes to the ways clinicians can help patients prevent illness and combat the infection if needed.
Prior to infection, it is important to talk to patients about their vaccination status, including how many doses and which formulations they have received, and when they received them, according to Sparks.
“A lot of immunocompromised patients have had three shots and feel like they are boosted, but really, that is their initial series,” Sparks said. “Now there is a second booster that is approved, so that means that at this moment, immunocompromised patients might even be eligible for up to five vaccine doses.”
Regardless of vaccination status, therapies such as pre-exposure prophylaxis (PrEP) in the form of Evusheld (tixagevimab plus cilgavimab, AstraZeneca), antiviral medications and monoclonal antibody therapies are all options that did not exist in the early stages of the pandemic.
“This is super important for all immunocompromised patients to really talk to their doctor and know that things change,” Sparks said. “Even though you might have been in a good state in the fall of 2021, there might be measures and things that you can do now.”
Sparks suggested that patients make a plan before getting sick, so that in the case they become infected, they have a playbook to follow.
“If I was coming up with a checklist, the first, again, would be related to the appropriate number of vaccine doses,” Sparks added. “The second would be whether or not they would be a good candidate for PrEP, and the third would be to have an action plan if there was a COVID exposure or COVID case.”
In addition to therapies, masking and home testing can also be effective tools in the fight for these patients, Calabrese said.
“The good news, as well, is that it is important for them to know, based on their level of immunocompromise, that there is still some risk, however, there are many more tools in our toolbox, now, to help prevent COVID, including vaccines, monoclonal antibodies, as well as treatment modalities we have such as oral antivirals,” Calabrese said. “We have all these tools in our toolbox to arm our patients with education and a plan to make it easier to live a more normal life.”
The power of empathy
For many rheumatologists, it is impossible to experience first-hand what patients who are immunocompromised have gone through, and continue to go through, in this pandemic, according to Sparks. As the pandemic continues, it is as important as ever to maintain empathy and inclusivity for patients, he said.
“I think a lot of empathy is needed,” Sparks said. “It is important to know that they’re going through something that I can’t necessarily completely understand given that I’m not someone who has these risk factors. I think being inclusive and somehow coalescing many different perspectives is really important in this day and age.”
In all cases, patients should know that clinicians will be standing behind them throughout the pandemic, Kim said.
“Their health care providers will stand strong with these patients,” he said. “Part of this is supporting them emotionally, but also through advocacy and awareness.”
However, even as the toolbox for preventing and treating COVID-19 in patients who are immunocompromised evolves, and clinicians stand with their patients, the potential risk posed by future variants that may evade vaccine efficacy is very real. The spreading BA.2 subvariant of omicron is one potential wrinkle clinicians have been watching with caution.
“It is concerning, largely due to the immune evasiveness of this subvariant, which will also affect the immunocompetent individual,” Kim said. “Even previously fully vaccinated — i.e. boosted — immunocompetent individuals will have reduced immunity to BA.2.”
The potential for new variants is concerning, however, according to Calabrese, the situation with BA.2 and “deltacron,” a recombinant of delta and omicron, does not appear to be a “hair-on-fire” situation.
“BA.2 is quickly taking over BA.1, the original omicron,” Calabrese said. “Assuming you responded to the vaccine, they hold up pretty good about protecting against severe protection and death, if you’ve been appropriately boosted with the current vaccines. It does not appear at present to be more severe.”
Sparks added that he expects people will “adapt” and manage their own risk level as BA.2 continues to spread, regardless of mandates.
“I think society can adapt quickly to new variants and in my impression, people do pay attention when case numbers are going up,” Sparks said. “Even if they aren’t mandated, the changes will probably still happen. We’re going to learn a lot as we navigate multiple waves of variants.”
References:
CDC. COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html. Accessed Feb. 25, 2022.
@Greggonsalves. https://twitter.com/gregggonsalves/status/1499149971840450561. March 2, 2022. Accessed April 6, 2022.
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