The Challenge of Covid-19 Vaccines for the Immunosuppressed

The Challenge of Covid-19 Vaccines for the Immunosuppressed

COVID VACCINATION IN the US has been framed as a binary: People either seek out the inoculation, or they distrust the formula—or the politics that produced it—and reject the shot. People who accept the vaccine get to return to normal life. For the people who don’t, “Your health is in your hands,” as Rochelle Walensky, director of the Centers for Disease Control and Prevention, tweeted in May.

But that binary never accounted for the many people who wanted the shot but couldn’t obtain it: because vaccine campaigns didn’t come to their neighborhoods, or lack of sick leave wouldn’t let them risk side effects, or they didn’t meet eligibility criteria in the early days when supply was limited. Now it’s becoming clear that this binary also excludes another enormous group: People who received the shot but were not protected by it, because their immune systems didn’t manufacture an adequate defense.

Millions of Americans are immunosuppressed or immune-compromised. That is, they take drugs to make sure that a transplanted organ is not rejected or to tamp down the overactive immunity that produces rheumatoid arthritis and lupus; or, alternatively, they have illnesses that undermine their ability to defend against pathogens. A handful of research papers published over the past few months all find the same result: When these patients receive Covid vaccines, their bodies don’t create as many defensive antibodies as those of healthy people. Some have contracted the disease despite being fully vaccinated—meaning that, to protect themselves, they must continue to behave as though their vaccinations never occurred.

As a result, some are seeking extra vaccinations, arranging for third doses that they hope will act like booster shots. A study published Monday in the Annals of Internal Medicine by a team at Johns Hopkins University School of Medicine documents the experience of 30 people living with organ transplants who sought out a third shot in hopes of boosting their immune responses. After their second shots, none of the 30 had high antibody levels; in fact, only six showed any antibody response at all. After the third shot, 14 out of 30 saw some improvement, and 12 of 30 had antibody levels that the researchers considered protective.

This is an important finding—even though it was made in a small group of self-selected volunteers, something that’s typically thought of as a weak study design—because it might point the way to letting still-vulnerable people rejoin a post-Covid society. It might also help explain some of the rare and not-well-explained “breakthrough” infections that occur in a small fraction of fully vaccinated people. (There was a high-profile cluster of breakthrough infections last month among people who work for the New York Yankees baseball team. No underlying conditions have been linked to them.)

“What we have found is hope,” says Dorry L. Segev, the study’s senior author and a Hopkins professor of surgery. “A lot of transplant patients were very excited about the vaccine, and then they got their antibodies checked and they were very suboptimal, and that was frustrating and demoralizing. We’re showing something can be done about that.”

 

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