What doctors should know about this vulnerable population and COVID-19

By Naveed Saleh, MD, MS
Published October 29, 2021

Key Takeaways

The COVID-19 pandemic has affected everyone: No city, state, country, or patient group has been spared. However, those who are immunocompromised are at the greatest risk for infection with the virus, including HIV and cancer patients, as well as transplant patients and those taking immune-suppressing medication for autoimmune conditions.

Comorbidities, such as diabetes or kidney disease, make their status especially fraught. Immunocompromised patients also face longer hospital stays and lengthier contact with staff. Concerning presentations in immunocompromised patients that require inpatient stays include severe infections and severe toxic events.

Due to concerns about resource shortages, bed availability, and exposure risk, various admissions and elective surgeries have been canceled or postponed due to COVID-19. Nevertheless, immunocompromised patients still need timely, life-saving care. These needs include chemotherapy, admission for neutropenic fever, and organ transplantation for end-stage organ failure. Physicians need to be especially cautious and practice strict prevention measures when caring for immunocompromised patients.

Here’s a closer look at strategies to prevent infection in immunocompromised patients. In an astute assessment of the problem, the International Society for Infectious Disease provided valuable insight into the care of immunocompromised in the current healthcare milieu. 

Employ strict universal contact precautions

All healthcare staff need to use recommended PPE and practice hand hygiene because immunocompromised patients are at higher risk for multidrug-resistant and other iatrogenic infections. 

Immunocompromised patients themselves should be advised to avoid crowds and practice hand hygiene, as well as to wear masks and eye protection. Physical distancing is especially important in this patient population. These measures should be extended to household members and caregivers, with frequent reinforcement of all this guidance by healthcare teams. Unfortunately, research demonstrates that even when this guidance is reinforced, transplant patients show very low adherence to hand hygiene while hospitalized. 

Various transplant and oncology units offer communal settings that contain books/movies and kitchens. Access to these facilities should be restricted while COVID-19 is at its height, and these common areas should be cleaned often when in use. 

Use telemedicine

Whenever appropriate or feasible, telemedicine appointments should be preferred to in-person visits. Lab tests and radiology orders should be scheduled only when absolutely needed. For instance, patients awaiting a liver transplant no longer need routine updates of Model for End-stage Liver Disease (MELD) scores.

For clinic patients, visual cues should be used in waiting rooms to maintain distance.

Limit visitors 

Immunocompromised patients in the inpatient setting must limit exposure by having the number of visitors cut. Furthermore, visitors must receive COVID-19 screening for infections and symptoms such as fever. Ultimately, it’s a good idea to limit visitors to immediate family or caregivers, and have these visitors follow hand hygiene and mask requirements.

Create cohort-care teams

Healthcare workers should be grouped according to shared-shift schedules to limit their exposure, as well as undergoing routine testing and quarantine as needed. This guidance is particularly useful in dialysis centers, in which immunocompromised patients spend long hours.   

Use negative-pressure rooms

Positive-pressure rooms are the norm for many hematology-oncology or transplant patients. Nevertheless, negative-pressure rooms ie, isolation rooms) are best for COVID-19 patients to keep infection from spreading to other patients. One big concern is the spread of aspergillosis from those who are infected with COVID. Immunocompromised patients are at high risk due to immunosuppressant use or neutropenia.

Form pathways of travel

Proper patient flow should be a high priority in hospital and outpatient settings. Creating a “COVID-19 free” pathway to separate entrances or in-hospital transportation routes is ideal. Those suspected or confirmed of having COVID-19 should be immediately isolated. For instance, the use of procedure suites or radiology rooms for COVID-19 patients should be separate from those without infection. Alternatively, these areas should be promptly sterilized after use. 

Limit ‘presenteeism’

It’s common for healthcare staff to come to work even when sick themselves, which is referred to as “presenteeism.” This phenomenon even occurs at high rates in those working with immunocompromised patients. 

Because asymptomatic presentations of COVID happen, prompt testing and quarantining are necessary for healthcare workers. To curb presenteeism, workers shouldn’t be penalized for calling in sick when necessary. 

Encourage COVID-19 booster shots

The CDC is currently recommending that moderately or severely immunocompromised patients receive COVID-19 booster shots. The Agency encourages clinicians to consider the patient’s current medical conditions, level of immunosuppression, and current risk of transmission or infection, as well as current or planned immunosuppressive treatments, and discuss these issues with patients. The CDC also encourages physicians to explain the difference between the initial mRNA vaccine series and booster, and explain that the booster is needed for those whose immune response has waned over time.

Stay protected

According to St. Jude Children’s Research Hospital, interacting with immunocompromised patients—including healthcare workers—should limit their exposure to other sick people. They should also make sure to receive all vaccinations, including pertussis and influenza. Of course, immunocompromised patients should receive these vaccines as well.

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