Managing COVID Risk for Immunosuppressed Individuals: An Ongoing Challenge
By Cassandra Calabrese, DO (https://providers.clevelandclinic.org/provider/cassandra-calabrese/4267744)
As we wrap up 2023, it's important to highlight a striking statistic: the U.S. Centers for Disease Control and Prevention estimates that approximately 87% of individuals aged 16 and older in the United States have developed some level of immunity against SARS-CoV-2 due to infections, while nearly 99% possess combined immunity from both infections and vaccinations. Fast forward to January of the following year, and the World Health Organization announced that COVID-19 no longer posed a pandemic-level threat, indicating a significant drop in both illness and death rates associated with the virus.
But here’s where it gets controversial: despite these favorable statistics, certain vulnerable populations continue to face heightened risks. In particular, those undergoing treatment with B-cell-depleting therapies (BCDT) for rheumatologic and other immune-mediated conditions remain particularly susceptible to severe outcomes from COVID-19.
At Cleveland Clinic, our research on COVID-19 has been extensive, focusing on how various drug therapies impact protection against the virus since the onset of the pandemic. We’ve established that specific patient groups necessitate ongoing monitoring and guidance. These individuals benefit from timely access to antiviral medications and may be suitable candidates for pre-exposure prophylaxis (PrEP).
Data collected throughout the pandemic clearly show that patients receiving B-cell-depleting therapies are at an elevated risk of hospitalization and mortality from COVID-19. Even with the emergence of the Omicron variants, commonly associated with milder symptoms, this particular demographic continues to experience disproportionately severe infections. Therefore, it’s evident that this vulnerable group will require additional support for the foreseeable future.
The Importance of Information and Patient Guidance
For over twenty-five years, BCDT has been recognized for its effectiveness in diminishing auto-antibody responses and alleviating inflammation that characterizes rheumatologic diseases. However, this same mechanism that helps control symptoms also compromises natural immunity and diminishes the response to COVID-19 vaccines. It is crucial for healthcare providers responsible for treating patients on BCDT to remain informed about current COVID infection trends, as well as guidelines regarding antiviral treatments and PrEP, so they can relay this vital information to their patients.
Patients need to understand that they are still at risk for serious illness and potential hospitalization, which could even lead to increased mortality. We strongly advise patients on BCDT to exercise caution when in the presence of anyone who is ill, consider wearing masks on airplanes or in crowded spaces, and — most critically — to reach out to us if they feel unwell. This way, we can offer guidance on testing and appropriate treatments.
Our team has recently published a study (https://pubmed.ncbi.nlm.nih.gov/41132135/) examining the efficacy of outpatient antiviral therapy for individuals with immune-mediated diseases receiving B-cell-depleting agents. Our findings indicate that treatment with nirmatrelvir/ritonavir correlates with lower rates of hospitalization and death from the COVID-19 Omicron variant specifically within this population. This underscores the necessity of prioritizing these patients for timely treatment.
Moreover, we provide advice to patients on BCDT regarding whether and when they should receive COVID vaccines and boosters. Although BCDT tends to weaken the vaccine response, it still offers some degree of protection. The optimal scenario for vaccine administration is to schedule it as far from the most recent rituximab dose as possible, ideally two to four weeks before the next dose, to enhance the vaccine's effectiveness.
A Note on Pre-Exposure Prophylaxis (PrEP)
Recently, the U.S. Food and Drug Administration has extended Emergency Use Authorization for pemivibart (Pemgarda®), a COVID-19 pre-exposure prophylactic treatment designed for individuals at high risk of developing severe illness. At Cleveland Clinic, we actively counsel high-risk patients, particularly those with B-cell depletion, and refer them to receive PrEP.
