COVID Management Continues to Be Crucial for Immunocompromised Individuals
By Cassandra Calabrese, DO (https://providers.clevelandclinic.org/provider/cassandra-calabrese/4267744)
As we approached the end of 2023, it was reported by the U.S. Centers for Disease Control and Prevention that approximately 87% of Americans aged 16 and older had developed antibodies against SARS-CoV-2 through natural infection. Moreover, nearly 99% had some level of immunity due to both infections and vaccinations. In January of the following year, the World Health Organization announced that COVID-19 was no longer classified as a pandemic threat, citing a significant decline in both the incidence and mortality rates associated with the virus.
But here's where it gets controversial: while many perceive COVID-19 as a less severe threat, individuals with specific health conditions continue to face a heightened risk of severe illness, particularly those undergoing B-cell-depleting therapies (BCDT) for autoimmune or immune-mediated disorders.
At Cleveland Clinic, our ongoing research into COVID-19 has focused on how various drug treatments impact patient immunity and responses to the virus. We have determined that certain vulnerable patient groups require sustained caution and tailored guidance. These individuals benefit from early access to antiviral medications and may be suitable candidates for pre-exposure prophylaxis (PrEP).
Data collected throughout the pandemic consistently indicate that patients receiving B-cell-depleting therapies are at a significantly elevated risk for hospitalization and mortality. This trend persists even with the emergence of the Omicron variant, which is often associated with milder symptoms; unfortunately, these patients still experience severe outcomes at disproportionate rates. As such, they will likely need enhanced support for the foreseeable future.
Patient Education and Ongoing Support
For over 25 years, BCDT has been proven to effectively diminish auto-antibody responses and decrease inflammation central to rheumatologic diseases. However, the very mechanism that helps to alleviate symptoms simultaneously hampers natural immunity and weakens the body’s response to COVID-19 vaccines. Therefore, healthcare providers who treat patients on BCDT must remain informed about current COVID-19 trends and the latest guidelines regarding antiviral treatments and PrEP. It's vital to communicate openly with patients so they recognize their ongoing vulnerability to severe illness and the potential for hospitalization or death.
We recommend that patients on BCDT exercise caution when in contact with anyone exhibiting signs of illness, consider wearing masks in crowded places or on public transport, and most crucially, reach out to us if they begin to feel unwell. This enables us to provide guidance on testing and appropriate treatment options.
Recently, our team published findings (https://pubmed.ncbi.nlm.nih.gov/41132135/) detailing the success of outpatient antiviral therapy for patients grappling with immune-mediated diseases while on B-cell-depleting agents. Our research indicated that the administration of nirmatrelvir/ritonavir led to reduced rates of hospitalization and mortality among these patients infected with the Omicron variant, underscoring the importance of prioritizing these individuals for timely treatment.
Additionally, we advise patients on when and whether to receive COVID-19 vaccinations and boosters. Although BCDT can diminish vaccine effectiveness, receiving the vaccine still offers a degree of protection. The optimal timing for vaccination is to administer it as far from the last rituximab dose as possible, ideally two to four weeks before the next dose, to maximize the vaccine’s efficacy.
A Note on Pre-Exposure Prophylaxis (PrEP)
The U.S. Food and Drug Administration has recently expanded the Emergency Use Authorization for pemivibart (Pemgarda®), a COVID-19 pre-exposure prophylaxis, specifically for individuals at high risk of developing severe illness. At Cleveland Clinic, we focus our counseling efforts on high-risk patients, particularly those who are B-cell depleted, and ensure that they are referred for PrEP when appropriate.
In conclusion, while the general population may feel a sense of relief as the pandemic appears to wane, it is crucial not to overlook the ongoing risks faced by immunocompromised individuals. How can we better support these patients, and what additional measures should be taken to safeguard their health? We invite your thoughts and opinions in the comments below!
