Managing immunocompromised patients as the COVID-19 pandemic ‘ends’

President Biden declared the COVID-19 pandemic was “over” in September 2022, as reported by Fierce Healthcare.^[] But for the estimated 2.7% of Americans with weakened immune systems, COVID-19 remains a pressing concern, according to research published by JAMA.^[]

Many of these people, some of whom are cancer patients or organ transplant recipients, require recurring medical care. How can healthcare professionals best protect these patients in clinical settings? And how can these patients better protect themselves in public?

Preventing infection

David Cennimo, MD, is an infectious disease specialist with Rutgers Health. He’s also the associate program director of the Internal Medicine and Pediatrics Residency Program at Rutgers New Jersey Medical School, where he’s an assistant professor of pediatric infectious disease.

In an interview with MDLinx, Dr. Cennimo said people with compromised immune systems face two risk categories: increased risk of severe infection and increased risk of prolonged infection. Mitigating those risks hinges on preventing infection and access to treatment, which can help a compromised immune system clear the infection.

Preventing infection involves the tried-and-true strategies of vaccinations, masking, and social distancing for the immunocompromised.

“Everyone should be maximally vaccinated,” Dr. Cennimo said, adding that patients who are immunocompromised should be advised to obtain whatever new vaccinations become available.

Business as usual

Masking and social distancing are likely business as usual for immunocompromised patients.

“We were telling them to limit social interactions, especially if they were in a part of their treatment cycle when they’d be particularly vulnerable,” Dr. Cennimo said. “That is still ongoing.”

But as social gatherings become commonplace again, Dr. Cennimo said patients need to do some risk-benefit analysis, knowing that isolation can be psychologically detrimental.

“We didn’t necessarily do a good job of communicating the gradient of risk,” Dr. Cennimo said of previous pandemic years. “Thanksgiving dinner with 10 people is more risky than [with] five people,” he said, providing an example.

Clearing infection

Timing is of the essence for immunocompromised patients who contract COVID-19, Dr. Cennimo said.

“These are the people who really need quick access to treatments,” he said. “Don’t wait at home for 3 days to see if you get better. Early adoption of these therapies, both for influenza and for COVID-19, [is] the best chance at doing well.”

Dr. Cennimo encouraged patients and clinicians who are suspicious of infection to test quickly. And for COVID-19 patients, he said rapidly administered treatment options may include monoclonal antibodies.

Cancer patients

The American Cancer Society (ACS) projected 1.9 million new cases of cancer in 2022.^[] Many of these patients will receive chemotherapy and/or radiation therapy, or undergo surgical procedures such as resection, or stem cell or bone marrow transplants, according to ACS research.^[]

Some will take steroids as part of their treatment. These interventions can lower leukocyte count, making cancer patients more susceptible to infection from COVID-19 and other pathogens.

According to current care standards, cancer care should proceed as normal in areas of low viral infection, as suggested in an article published by UpToDate.^[] But in instances of known COVID-19 exposure, cancer patients should pause treatment until they are confirmed negative for the virus, especially in instances where they are unvaccinated, behind on their vaccinations, or expected to have a weak immune response to the vaccine.

Guidance differs in areas where viral transmission is high. In such situations, clinicians must weigh the risks of delaying treatment against the patient’s risk of exposure and potential burden on the healthcare organization.

Patients who are undergoing chemo, are advanced in age, or have other comorbidities may also face greater risks.

COVID-19 management for these patients will look similar to management for the general population, with the caveat that they may develop more severe COVID-19. Dr. Cennimo cautioned that Paxlovid does have drug-drug interactions with chemotherapy drugs, as well as with some immunosuppressives.

Current guidance recommends interrupting chemotherapy or immunotherapy regardless of symptom status in these patients. Cancer treatment can resume when the patient is no longer contagious.

All eligible cancer patients, whether their cancer is active or in remission, should be up to date on COVID-19 vaccination and boosters. Even if patients are immunocompromised, vaccines are recommended, although their efficacy may be diminished in this group.

Patients receiving systemic immunosuppressive therapy, and patients with any hematologic malignancy, should receive an additional third primary dose of mRNA vaccines at least 28 days after their second dose. It should be noted that the approved bivalent boosters provide additional protection against Omicron variants.

Organ transplant recipients

Organ transplant recipients are another group of people who face additional infection challenges. In 2022, there have been more than 37,000 organ transplants according to the United Network for Organ Sharing.

Each of these organ recipients faces an increased risk of infection from conventional and opportunistic pathogens, stemming from immunosuppressive therapies given to prevent organ rejection, according to a study published by Intensive Care Medicine.^[]

For example, among heart and lung transplant recipients, infection is responsible for more than 30% of deaths within the first year, according to research published by The Journal of Heart and Lung Transplantation.^[]

Guidance calls for COVID-19 screening for all donors and transplant candidates prior to transplantation, as reported in an article published by UpToDate.^[] Clinicians should also note that following a transplant, recipients may face an increased risk of infection.

Clinically, COVID-19 runs a similar course in this group compared with the general population. The diagnostic process is also similar, although clinicians may want to lower their testing thresholds for immunocompromised recipients.

For disease management, clinicians may want to lower their threshold for monoclonal antibody use, as well as for potential drug-drug interactions, stemming from the use of immunosuppressants, which also may require adjustment, according to the UpToDate article.

Research is not clear on optimal timing, however, and response to the vaccine for transplant recipients may be less than ideal, highlighting the need for patients to wear masks and avoid crowds.

Preexposure prophylaxis with tixagevimab and cilgavimab may be appropriate for patients ages 12 and older who are also receiving an immunosuppressive, as COVID-19 vaccination may not produce an adequate immune response.

According to the UpToDate research, the only donor organs responsible for COVID-19 transmission are lungs.

Working with immunocompromised patients

Ultimately, Dr. Cennimo said that universal mask-wearing and hand hygiene during clinical encounters is likely to continue for patients and providers, in his opinion. However, he felt that clinicians may want to also require masks for waiting rooms and other communal areas.

“I think it’s important because I don’t know why the other people are there,” Dr. Cennimo said.