April 15, 2022
6 min read
Source / Information
Calabrese reports consulting and voice fees from Sanofi. Sparks reports consulting fees from Abbvie, Boehringer Ingelheim, Bristol Myers Squibb, Gilead Sciences, Inova Diagnostics, Janssen, Optum and Pfizer; and grant / research support from the Bristol Myers Squibb. Kim does not report any relevant financial information.
When the CDC released new masking guidelines in late 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 about what the next steps might look like for patients who had poor immune responses to COVID-19 vaccinations they received, or for patients who are not at all able to receive the vaccines. Although many have received their vaccination series and booster, and appear to have progressed, the pandemic remains an existential threat to immunocompromised patients.
“I think it’s helpful to look at where we are now in terms of COVID and where we are going,” Cassandra Calabrese, DO, from the Department of Rheumatic and Immunological Disease at the Cleveland Clinic, Healio said. “It is important to realize that while the pandemic is getting better for most people, it is not necessarily the case for many of our immunocompromised or high-risk patients, and they are really seeing the pandemic develop into two epidemics.”
On the one hand, immunocompetent vaccinated individuals are likely to continue to do well in the event that they become ill with COVID-19. On the other hand, many immunocompromised individuals will continue to be at risk of serious illness despite being vaccinated.
“I think all guidelines and lifting mandates do not always take into account this latter group, which will remain in jeopardy,” Calabrese said. “Even though mask mandates are actively ending or expiring, this may not be the right thing to do for many of our patients, and it’s the kind of conversation we have.”
The question of when to loosen the restrictions is not a simple answer.
“When society’s levels are low, these mandates might make sense to loosen up,” Jeffrey Sparks, MD, MMSc, associate physician at Brigham and Women’s Hospital and Harvard Medical School in Boston, Healio said. “On the other hand, there are very low disadvantages to wearing a mask, and it may be very beneficial, especially for people who are immunosuppressed.”
The wide variety of perspectives and biases around masks make it unlikely that there is broad consensus among the population.
“I think what I want to say is that personal mask wearing a high quality mask, either an N95 or a KN95, is likely to provide some level of protection even if other people are not masked,” Sparks said. .
‘Lots of frustration’
As mandates have been revoked 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 are receiving immunosuppressants, have resigned in a long, sustained battle against the pandemic.
“[There has been] lots of frustration, but they have accepted the situation they are in and are ready to continue the fight, ”Kim told Healio. “They are at least grateful that methods are in place to reduce SARS-CoV-2 acquisition and that therapies are now available both to prevent infections and after exposure.”
Frustration among patients who are immunocompromised is not an isolated event. Many times, these patients are particularly health-conscious and are aware of the difficulties they face in getting a vaccine response, Calabrese said.
“I think our higher risk patients, who have been so extremely cautious for the last 2 years, may be frustrated to know that they are still at risk,” she said. “They are probably aware that they did not get the great response to the vaccine and that they still have to be careful. It is very frustrating for them when they have been so careful and especially have seen and seen other people not being careful at all. It 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 what point of view they come from,” Sparks said. “There are some who are frustrated that we still have masks on at the clinic, there are some who are frustrated that there is no more masking outside the clinic. This is a big part of what our clinic visit is about, trying to navigate all the complex problems this brings up. ”
When patients present frustrations related to declining pandemic measures, it is important to understand them and communicate that there are opportunities to deal with infection, Calabrese said. At the same time, the risk profile for each individual patient varies considerably. Rheumatologists should tailor their advice to patients based on their individual risk level.
“For people who are more than mildly or moderately immunocompromised, they really need to continue to exercise some caution while on the go,” Calabrese said. “It all depends on where they are going, what they are doing and who they are with.”
A toolbox in development
In some ways, the toolbox used to avoid COVID-19 infection has not changed since the first 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. But there have also been many changes in the way clinicians can help patients prevent disease and fight infection if necessary.
Prior to infection, it is important to talk to patients about their vaccination status, including how many doses and formulations they have received and when they have received them, according to Sparks.
“A lot of immunocompromised patients have gotten three shots and feel like they’m boosted, but this is really their first series,” Sparks said. “Now there is one other booster approvedso that means that at present, immunocompromised patients may 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 drugs and monoclonal antibody therapies are all options that did not exist in the early stages of the pandemic.
“This is super important for any immunocompromised patient to really talk to their doctor and know that things are changing,” Sparks said. “Even though you may have been in good shape in the fall of 2021, there may be measures and things you can do now.”
Sparks suggested that patients make a plan before they get sick so that in the event they become infected, they have a game book to follow.
“If I came up with a checklist, the first one would again be related to the appropriate number of vaccine doses,” Sparks added. “The second would be whether they would be a good candidate for PrEP or not, 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 is also that it’s important for them to know, based on their level of immune compromise, that there is still some risk, but 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 antiviral agents, “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 on their own what immunocompromised patients 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 are going through something that I do not necessarily fully understand, as I am not someone who has these risk factors. I think being inclusive and somehow gathering a lot of different perspectives is really important in this time. “
In any case, patients should know that clinicians will be behind them throughout the pandemic, Kim said.
“Their healthcare providers will stand strong with these patients,” he said. “Part of this is to support them emotionally, but also through advocacy and awareness.”
However, although the toolbox for the prevention and treatment of COVID-19 in immunocompromised patients is evolving and clinicians are working with their patients, the potential risk as future variants that may elude the vaccine’s effectiveness is very real. The dispersive BA.2 subvariant of omicron is a potential wrinkle clinician has followed with caution.
“It’s worrying, mainly because of this subvariant’s immune evasion ability, which will also affect the immunocompetent individual,” Kim said. “Even previously fully vaccinated – ie boosted – immunocompetent individuals will have reduced immunity to BA.2.”
The potential for new variants is worrying, but according to Calabrese, the situation with BA.2 and “deltacron”, a recombinant of delta and omicron, does not appear to be a “hair-in-fire” situation.
“BA.2 is quickly taking over BA.1, the original omicron,” Calabrese said. “Assuming you responded to the vaccine, they are pretty good at protecting against serious protection and death if you have been appropriately boosted with the current vaccines. It does not appear to be more serious at this time.”
Sparks added that he expects people to “adapt” and manage their own level of risk as BA.2 continues to spread, regardless of mandates.
“I think society can quickly adapt to new variants, and in my opinion, people are aware when the number of cases increases,” Sparks said. “Even if they are not mandated, the changes are likely to still happen. We are going to learn a lot when we navigate in several waves of variants.”
CDC. COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html. Accessed 25 February 2022.
@Greggonsalves. https://twitter.com/gregggonsalves/status/1499149971840450561. March 2, 2022. Opened April 6, 2022.