June 23, 2021

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What the CDC’s New Masks Guidelines Imply for the Immunocompromised, and What That Means for Everybody Else

Once I wrote about what it means to be immunocompromised in early March of this yr, I used to be itching to get vaccinated. Individuals are immunocompromised for quite a lot of causes—genetics, age, metabolic ailments like diabetes, and immune-suppressing drugs taken for situations together with autoimmune ailments, organ transplants, and most cancers—however what all of us have in frequent is a weaker immune system, making us extra susceptible to infections like COVID-19. The vaccine could possibly be a lifesaver for us.

I used to be elated after I acquired my second Pfizer dose on April 12, hopeful I might finish my year-plus of near-total isolation. Earlier than the week was over, nonetheless, a number of stories appeared displaying that immunocompromised folks have been not producing antibodies after getting vaccinated. Hope all of the sudden changed into worry.

Lower than a month later, on Might 13, the CDC launched new masks and distancing tips. Absolutely vaccinated folks with wholesome immune methods (aka the immunocompetent) can now safely resume pre-pandemic conduct indoors and out. In distinction, the CDC’s recommendation for the immunocompromised is that we would must proceed masking and social distancing even when vaccinated, as a result of we would not have ample immunity to guard us from a extreme case of COVID-19. These contradictory tips have implications for everybody, not simply immunocompromised folks.

In case you have a wholesome immune system and undertake the brand new CDC tips, as an example, you might doubtlessly expose immunosuppressed household, mates, colleagues, and purchasers to COVID-19 even when everyone seems to be vaccinated. Furthermore, the most effective estimate we have now for the variety of immunosuppressed Individuals—roughly 8.5 million—is an undercount. So, you is likely to be placing somebody in your circle in danger who doesn’t understand they’re immunocompromised. That somebody may even be you.

The excellent news is that the science is more and more clear on which explicit immunosuppressive situations and drugs are almost certainly to decrease vaccine immunity, even when the essential query—how a lot immunity is sufficient to defend somebody from extreme COVID-19—stays unknown.

Right here’s what the science at the moment says about vaccine immunity and immunocompromised folks, and the way you should use that information to guard your self and immunocompromised family and friends in mild of the brand new CDC tips.

There’s no take a look at that may inform you for certain in case your vaccine labored

Vaccines work by stimulating the immune system to reply to a weakened or benign model of a virus. This response produces antibodies and rallies virus-killing cells to eradicate an an infection earlier than it has time to wreak irreparable harm. Each common sense and science inform us that the extra sturdy your immune system, the simpler a vaccine can be at supplying you with immunity. Vaccine immunity is often measured by testing the blood for the presence of antibodies, and a current research concludes that antibody ranges are a very good indicator of COVID-19 vaccine immunity particularly.

That stated, scientists have constantly urged folks to not get COVID-19 antibody exams to examine their vaccine immunity, for 3 principal causes. First, the commonest antibody take a look at doesn’t search for the particular antibody stimulated by the vaccines however, relatively, for a protein produced solely by an precise COVID-19 an infection.

Upon nearer inspection, the research on vaccine immunity within the immunocompromised usually are not all doom-and-gloom.

Second, antibodies usually are not the one marker of COVID-19 immunity. Wholesome folks have recovered from COVID-19 infections without producing antibodies, because immune cells known as T cells picked up the slack. One review study, in fact, suggests that a robust T cell response not only compensates for a lack of antibodies, but also might be the most important factor in fighting off COVID-19 infection. Unfortunately, many of us who are immunocompromised have fewer or less functional T cells, so this news is not completely reassuring.

Finally, the million dollar question of “how much immunity is enough”—that is, how many antibodies or COVID-19 destroying T cells you need in your system to be protected—depends on so many variables in our incredibly individualized and complex immune systems that a valid answer remains elusive.

However, upon closer inspection, the studies on vaccine immunity in the immunocompromised are not all doom-and-gloom.

What we know about certain medical conditions

“I’m of the strong opinion that many people have been worried unnecessarily [by the media reports],” Dr. Meena Bewtra, an assistant professor of gastroenterology and epidemiology and IBD specialist at the University of Pennsylvania, told me. As more studies come out, we’re learning that fears most immunocompromised people in general would struggle to make antibodies are not coming to fruition. Here’s a little of what we know so far:

Inflammatory bowel disease

Dr. Bewtra herself is one of the principal investigators of a study that has found vaccine antibodies in 96 percent of nearly 500 Americans with inflammatory bowel disease (IBD), most of whom are on some form of immunosuppressants. “What we’ve seen here [for IBD patients] is very reassuring,” she said.

Transplant recipients

Thus far, the research has identified a few immunocompromised groups who are less likely to produce antibodies post-vaccination. One is transplant patients, especially those who take a drug called mycophenolate (brand name: Cellcept). One study found only seven percent of kidney recipients having the specific spike protein antibody created by the Pfizer and Moderna mRNA vaccines are designed to produce, whereas another study recorded a more encouraging—but hardly celebratory—54 percent. Heart and lung transplant recipients showed similarly low percentages: Only 14 percent of heart recipients and 18 to 25 percent of lung recipients had antibodies. People with blood cancers (leukemia and lymphoma) also appear to have less immunity, though the percentage of people with antibodies varies significantly—from 39.5 to 83 percent—depending on cancer type, treatment status, age, and other factors.

Rheumatic disorders

Two U.K. studies found fewer vaccine antibodies in people with rheumatic and musculoskeletal disorders taking rituximab (brand name: Rituxan) and IBD patients taking infliximab (brand name: Remicade). However, these U.K.-based studies measured antibodies after only one of two vaccine doses, because its vaccination program chose to delay second doses in order to vaccinate more of the population. Encouragingly, the people in the Remicade study who got their second dose had antibody levels similar to that of the general population.

Everybody else

Still, these studies cover only a fraction of immunosuppressive conditions and treatments, and therefore provide definitive data for only a fraction of immunocompromised people. Both Pfizer and the National Institutes of Health (NIH) are conducting broader studies on vaccine immunity and the immunocompromised, but findings likely won’t be available until next year. That’s why the CDC guidelines—that you may need to continue masking, because you might not have immunity—are so frustratingly, unhelpfully broad.

As Professor Candida Moss, who recently wrote about the difficulties of navigating the new guidelines as a kidney transplant recipient, told me, “There’s just not enough information, even among the transplant community, much less when you read a CDC infographic which clearly doesn’t apply to you.”

What immunocompromised people can do to protect themselves

The most important thing we immunocompromised people can do to protect ourselves from COVID-19 is to be healthy, and that means staying on our immunosuppressants. (You thought I was going to say get vaccinated, right?)

Getting vaccinated is the second most important thing we can do.

Don’t get me wrong: Getting vaccinated is the second most important thing we can do. However, both Dr. Bewtra and Professor Moss mentioned anecdotal evidence of people considering stopping their medications to boost their immune system before getting the COVID-19 vaccine—something I briefly considered.

In short, the answer is no; not only does active disease tax our already weakened immune system, but also we can end up exposed to COVID-19 if hospitalized or on far more aggressive immunosuppressants than the ones we’re currently taking. (However, the American College of Rheumatology does have recommendations about skipping or delaying dosages of specific medications if you are relatively healthy.)

No matter what your health and vaccination statuses are, you should reach out to your doctor, in particular any specialist who treats your particular condition or has prescribed you immunosuppressants. (If you’re not sure if the medication you’re on is immunosuppressive, check out this list.)

Admittedly, this advice is often easier said than done. The earliest appointment I could get with my specialist was a month away. Moreover, many immunocompromised people lack access to specialists or even primary care physicians because of systemic problems that disproportionately affect people with disabilities, minorities, the poor, and rural Americans.

If you have an internet connection, however, many non-profit organizations have regularly updated information and guidelines on vaccine immunity for specific conditions. On sites like the Leukemia and Lymphoma Society, the Crohn’s and Colitis Foundation of America, Creaky Joints (for patients with arthritis), or the American Society of Transplantation, you can find links to the latest studies, detailed FAQs, and even opportunities to join ongoing studies that can set you up with that elusive vaccine-specific antibody test for free.

“While I don’t think everyone has an obligation to create accessible spaces for the immunocompromised in every occasion,” Moss said, “I think they do have an obligation to communicate.”

What everyone else can do to protect the immunocompromised

The best thing healthy people can do to support the immunocompromised population is to get vaccinated. Period.

However, continuing to wear a mask and practice social distancing in most indoor spaces is almost as important, whether or not you’re vaccinated.

“It’s not that I think everyone should keep masking everywhere, forever,” said Moss, who works from home in New York City, “[but] it would be nice if essential services like grocery stores, public transportation, doctor’s offices, pharmacies—places that you have to go to—could have masking.”

Masking in public spaces like hotel and apartment lobbies also protects staff who can’t leave their posts. “You don’t know what kind of health conditions the people working in those spaces have,” Moss said. While the science suggests that fully vaccinated people spread less virus if exposed to COVID-19 than non-vaccinated people, erring on the side of caution is the surest way to prevent immunocompromised people in your life from suffering hospitalization, long-term effects, or even death.

Finally, a little more intention when planning informal and formal gatherings can make a huge difference. Be specific about whether an event will require masks, distancing, or vaccination so that people can make the right decisions for their personal safety. Whenever possible, go outdoors or hybrid. “While I don’t think everyone has an obligation to create accessible spaces for the immunocompromised in every occasion,” Moss said, “I think they do have an obligation to communicate.”

The biggest challenge is getting the information to the people who need it

In the course of writing this article, I went from the despair of believing I likely had little to no vaccine immunity to a stunned relief that the odds are actually in my favor. While speaking to Dr. Bewtra gave me hope for my personal health, my conversation with Professor Moss reminded me that my behavior has an impact beyond my immediate circle. When I do re-enter society, I want to do so compassionately, in the knowledge that not everyone can move safely in this brave new world.

I will therefore mask indoors in essential places, around essential workers, and around children. (I’ll probably mask outdoors, too, but that’s my anxiety talking and not the science.) I won’t make assumptions about why those around me are or aren’t wearing masks, though I’ll remove myself from a space if necessary to feel protected.

Most of all, I’ll be more open about this invisible disability of immunosuppression. If the pandemic has taught us anything, it’s how interconnected we all are. What hasn’t spread as successfully is information to the people who need it. This article can’t fill those gaps, even if it goes viral (pun intended). Just like the COVID-19 vaccine itself, however, the information in it could be a lifesaver.

 

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