Dilemmas of the Immunosuppressed and COVID-19

Consider Having the Vaccine. It Can’t Hurt, But Might Help

By Howard Wolinsky

Navigating COVID-19 is particularly tricky for individuals who are immunocompromised.

This includes a broad group of people, including those suffering from chronic diseases that alter immune function - such as HIV/AIDS, autoimmune diseases, leukemia, or lymphoma, organ transplant patients who take anti-rejection medicines that purposely dampen the immune system, and people with other underlying health conditions that weaken the immune system.

About 3-4% of the population, or millions of Americans, are immunosuppressed or immunocompromised.

“The biggest medical issue we have right now about COVID-19 and preventing it is in those who are immunocompromised,” said Robert Murphy, the John Philip Phair Professor of Infectious Diseases at Northwestern University Feinberg School of Medicine, where he serves as executive director of the Institute for Global Health. Murphy is co-founder of CoVAXCEN, a coalition of experts on COVID-19 from academia, industry, and government.

John Mattison, MD, an internal medicine specialist and co-chair of the CoVAXCEN Clinical Workgroup, said there are two basic sources of immunosuppression:

“One is on the disease side; the other, on the therapy side. People with autoimmune diseases often have a hyperactive immune system which requires suppression to reduce the symptoms and arrest the progression of that disease, e.g. rheumatoid arthritis. People who have had organ transplants need to take drugs that suppress their immune systems to prevent the immune system from rejecting the transplanted organ,” he said.

“There are general categories of people that are at much higher risk of not having a good immune response from the vaccine so it is useful to test them because the range of responses is highly variable from individual to individual.”

The extent of immune response to the vaccine helps inform patients about their risk of COVID-19 infection.

If patients have a poor response, they need to consider higher vigilance on masks and physical distancing from others, said Mattison. In addition, they will be candidates for booster doses of the vaccine, and perhaps switching to a different type of vaccine for a booster. In some cases of extreme immunosuppression and lack of immunity, giving periodic infusions of monoclonal antibodies can be considered as a passive form of immunity, he said.

Virologist Judd Hultquist, PhD, assistant professor of medicine in the Division of Infectious Diseases at Feinberg School of Medicine, and associate director of the new Northwestern Center for Pathogen Genomics and Molecular Evolution in the Institute for Global Health, said, “There are many different ways that an individual could be immunocompromised. Whether or not the vaccine is going to work equally well in all of these individual groups is always a major concern,” said Hultquist, whose research before the pandemic focused on HIV/AIDS.

Mattison said, “Some immunosuppressed individuals still get a good response to the vaccine. Others don’t. And similarly with the drugs, the amount of drug that someone is taking and the susceptibility of their immune system determines whether or not they get a good response to the vaccine.

“We know that some people who are immunocompromised get absolutely great immunity from the vaccine and others do not. And the commercially available tests to say if a vaccinated immunocompromised person is actually immune or not are less than ideal, but improving over the past year.”

But it’s important that patients not change their treatment schedule without first speaking to their doctor, said Murphy.

He said complicating matters is that the immunosuppressed were excluded from the original tests of the COVID-19 vaccines. “Everybody knew that these patients were not going to respond well to the vaccines, that’s why they were excluded from the studies in the first place,” he said.

Hultquist said that the goal now is to continue prioritizing research into the safety and effectiveness of vaccines across different groups of immunocompromised individuals. “The vaccine might be perfectly efficacious but the goal is to make sure that it is safe and worth taking for all of these different groups.”

Researchers from Johns Hopkins Medicine in May reported in JAMA that two doses of a vaccine against SARS-CoV-2 — the virus that causes COVID-19 — confers some protection for people who have received solid organ transplants. But it’s still not enough to enable them to dispense with COVID-19 safety measures, such as wearing masks and maintaining social distance.

Murphy said the study showed that half of the patients had no protective antibodies after being vaccinated.

 “Is there anything that can be done? Actually, there are several options: test to see if the vaccine worked, give a higher dose, give more frequent doses or administer preventive treatment. To start with, it would be very helpful if we had access to a test that could determine if the vaccine had worked,” he said.

“Unfortunately, no such reliable commercial blood test exists today but we could work on that,” the infectious disease expert said. “Another option is we could give immunocompromised patients a higher dose, like we do with the flu vaccine. Perhaps we could administer the doses more frequently, for instance every three months is just an example. There are many dosing options that could be studied.”

He said that immunosuppressed patients potentially could be pre-emptively helped if treated with monoclonal antibodies, laboratory-made proteins that mimic the immune system’s ability to fight off harmful viruses like SARS-CoV-2. Monoclonal antibodies attack the virus and reduce its ability to spread through the body. Murphy said monoclonal antibodies may reduce hospitalizations among high-risk COVID-19 patients. The FDA has granted Emergency Use Authorizations for monoclonal antibodies for COVID-19, and some of them have demonstrated effectiveness against the variants of concern (VOCs) that have emerged during the pandemic.

He also noted that several oral medications are under development to treat or prevent infections.

“There is hope in the future with this problem. We have to think out of the box and do something about it, ” he said.

Northwestern COVID-19 Vaccine Communication and Evaluation Network (CoVAXCEN) seeks to achieve consensus on a variety of issues related to the safety and efficacy of COVID-19 vaccines and then produce and disseminate written materials for scientists, healthcare professionals, and the general public describing its conclusions.

Headquartered in the Institute for Global Health's Center for Global Communicable and Emerging Infectious Diseases with the cooperation of the Center for Communication and Health, we seek to achieve consensus on a variety of issues related to the safety and efficacy of COVID-19 vaccines and then produce and disseminate written materials for scientists, healthcare professionals, and the general public describing its conclusions.

Howard Wolinsky is a Chicago-based freelance medical writer and author. He is the former medical reporter for the Chicago Sun-Times. He has won awards for medical writing from the American Public Health Association, the American Bar Association, and the Association of Health Care Journalists, the Chicago Headline Club’s Peter Lisagor Award (“the Chicago Pulitzer''). The Sun-Times twice nominated him for the Pulitzer Prize.