Immunocompromised in the COVID-19 Era: Vaccines, Prevention, Treatment – Everyday Health

Though COVID-19 vaccines didnt end the pandemic, they have helped beat back the virus, preventing an estimated 66 million infections and 2.2 million deaths in the United States alone, according to the Commonwealth Fund.

But the vaccines dont provide equal protection for all. If youre one of the estimated 3 percent of the population who are moderately or severely immunocompromised, you are still very much at risk for severe disease, hospitalization, and worse even after two doses of the Pfizer-BioNTech or Moderna mRNA vaccines.

Fortunately, the outlook is improving, thanks to vaccine boosters and medications that the U.S. Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) have okayed to treat COVID-19 in high-risk groups and prevent infection in exceptionally vulnerable people.

Shireesha Dhanireddy, MD, a professor of medicine in the division of allergy and infectious diseases and an infectious-disease specialist with UW Medicine in Seattle, explains how immunocompromised people can protect themselves.

When we say someone is immunocompromised, generally what it means is the person isnt able to mount a good immune response to the [COVID-19] vaccine for whatever reason, says Dr. Dhanireddy.

That could be due to an underlying medical problem that makes the immune system weaker, or a medication that weakens or suppresses the immune system, she adds.

Theres a broad range of people who are considered immunocompromised, Dhanireddy says. Usually, these individuals would be under the care of a provider who would be managing their chronic condition.

According to the University of Pittsburgh Medical Center, you may be considered immunocompromised if you:

This is not a comprehensive list of immune-system issues that might dramatically increase your COVID-19 risk. Talk to your doctor if you are unsure about your status.

Vaccine recommendations for the immunocompromised are special because both laboratory studies and real-world data have shown these individuals are less likely to respond well to immunization, says Dhanireddy.

A meta-analysis published in December 2021 in the Journal of Infection found that although COVID-19 vaccines were effective against symptomatic COVID-19 in immunocompromised people, the protective antibodies they generated were much lower than in people with normally functioning immune systems.

While most people get two doses of the Pfizer or Moderna vaccine for their so-called primary series, immunocompromised individuals should get three, according to current public-health guidelines. Studies have noted that there was very low response in terms of antibodies after two doses for immunocompromised individuals, particularly in solid organ transplant patients, but a third primary dose led to a much more significant response, Dhanireddy says.

People who are immunocompromised are now eligible for a second COVID-19 booster, which means that some of these individuals will be getting five doses of vaccine, says Dhanireddy. People who are moderately to severely immunocompromised can get a second booster if they got their first booster at least four months before, according to the CDC.

The CDC states that the Pfizer and Moderna mRNA vaccines are preferable to the Johnson & Johnson (J&J)/Janssen vaccine in most cases. If a person does receive the J&J vaccine for whatever reason, the CDC advises that anyone age 18 and older who is moderately or severely immunocompromised get a single primary dose, followed by a second (additional) dose of an mRNA COVID-19 vaccine at least 28 days (four weeks) later.

The agency recommends a single booster dose at least two months after the second (additional) dose, for a total of three doses (one J&J vaccine dose followed by one additional mRNA vaccine dose, then one booster dose).

Some individuals who may have been on heavy immunosuppressants around a transplant period, or those who were vaccinated pre-transplant and then had to take immunosuppressive medications that wiped out their immune system, may actually have to restart their vaccinations and get another primary series, says Dhanireddy.

It can get a little complicated for these individuals regarding timing of these medications and whether to restart that series or not; thats something they should discuss with their doctor, she says.

Evusheld (tixagevimab and cilgavimab) is a monoclonal antibody treatment administered by injection that is designed to prevent COVID-19 in vulnerable and immunocompromised people who may not have an adequate immune response to COVID-19 vaccination.

The FDA granted the drug emergency use authorization (EUA) in December of 2021 for pre-exposure prophylaxis meaning its not intended for people who already have COVID-19.

Evusheld is authorized for individuals who are immunosuppressed and for those who cant tolerate COVID-19 immunization because of severe allergies to components in the vaccine, says Dhanireddy.

Evusheld can provide an extra boost to immunocompromised people who didnt get a robust immune response from vaccination. These lab-created antibodies are given by injection to be ready to fight against the virus in case of infection, says Dhanireddy.

Protection is estimated to last between three and six months, but data is still forthcoming, Dhanireddy adds.

Experts are recommending a two-pronged approach both vaccination and Evusheld to provide maximum protection for immunocompromised people, notes an article published April 27 in JAMA.

According to a spokesperson from the U.S. Department of Health and Human Services (HHS) whose remarks were reported in the JAMA commentary, the federal governments supply of Evusheld currently exceeds demand from states and territories.

If you are eligible to receive Evusheld, contact your healthcare provider or your local health department. The federal government will pay for the drug, but you may be charged for the products administration, depending on the health system and your insurance coverage.

Immunocompromised people should be aware that two different drugs can be taken in pill form after COVID-19 symptoms emerge, in order to prevent severe disease and hospitalization: molnupiravir (sold under the brand name Lagerviro) and Paxlovid.

There are also treatments that can be administered by injection or IV: the antiviral drug remdesivir and the monoclonal antibody therapy bebtelovimab.

PaxlovidThis antiviral medication combines two generic drugs, nirmatrelvir and ritonavir. The FDA granted it emergency use authorization (EUA) in December 2021, and the National Institutes of Health (NIH) has prioritized it over all other available treatments for people with a current COVID-19 infection.

The drug was 89 percent effective against hospitalization and death in the clinical trial that led to its approval and that study included both vaccinated and unvaccinated individuals. Its a five-day course of medication that has to be given within five days of when symptoms develop, says Dhanireddy.

Paxlovid can interact with other medications, including blood thinners and cholesterol medicines, so it may not be a good choice for everyone. This drug can be especially problematic for solid organ transplant patients Paxlovid is not a great option for them, says Dhanireddy.

MolnupiravirThis oral antiviral is 30 percent effective at preventing hospitalization and death in people with COVID-19. The drug is still effective, but the efficacy is lower than some of the other available treatments, says Dhanireddy.

The CDC did not authorize the medication for people who are pregnant, and anyone of childbearing age needs to use it with caution, Dhanireddy says. It is also not known if the drug may impact sperm.

Doctors should prescribe molnupiravir only when Paxlovid and the medication remdesivir are not available, feasible to use, or clinically appropriate, per theNIH.

As with Paxlovid, treatment with molnupiravir must begin within five days of symptom onset.

RemdesivirSold under the brand name Veklury, remdesivir is the first (and so far only) COVID-19 therapy to have full FDA approval for treatment of critically ill COVID-19 patients who are hospitalized.

Earlier this year, the drug was also granted authorization to be used for a shorter course of therapy three days for patients with mild to moderate COVID-19 who are recovering at home.

Remdesivir provides an 87 percent reduction in risk of hospitalization in nonhospitalized people who received the three-day dose, according to a study published in January 2022 in the New England Journal of Medicine.

Logistics for this are a little bit difficult because its three days in a row of IV medication that has to be delivered in a healthcare setting, Dhanireddy says.

Patients must begin treatment within seven days of the onset of symptoms.

BebtelovimabIn February 2022 the FDA authorized this monoclonal antibody treatment for people with a current COVID-19 infection.

Not all monoclonal antibodies have been effective against all variants, but data indicates that bebtelovimab is effective against omicron and its BA.2 subvariant, says Dhanireddy.

To be eligible for bebtelovimab, people must be at high risk for severe COVID-19.

Bebtelovimab is considered an alternative treatment and should be used only when Paxlovid and remdesivir are not available, feasible to use, or clinically appropriate, according to theNIH.

The medication must be administered by injection within seven days of symptom onset.

A well-fitting N95 or KN95 mask provides a good defense against COVID-19 infection, says Dhanireddy. Although two-way masking is best, there is evidence that a high quality mask offers substantial protection even if others arent wearing face coverings, according to a modeling study published in December 2021 in the journal PNAS.

When youre immunocompromised, you want to try to reduce your risk as much as possible, says Dhanireddy. She calls using multiple approaches such as vaccines, boosters, medications, and masking creating a cocoon of protection around yourself.

The cocoon should also include those in your household or close circle, who should all be mitigating their risk to keep you safe by protecting themselves with masking and other measures, Dhanireddy says.

The CDC has created a COVID-19 tool kit designed to help people understand the risk COVID-19 poses in their community, and it includes information on where to find free masks and Test-to-Treat programs where you can get tested and obtain treatment if you are diagnosed with COVID-19.

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Immunocompromised in the COVID-19 Era: Vaccines, Prevention, Treatment - Everyday Health