While others begin to shed their masks and celebrate post-vaccine COVID-19 immunity, Michelle Geri Farris and her family will stay hunkered down in North Seattle.
Both her sons were born with an immune disorder that prevents their bodies from producing antibodies against infection or responding to inoculations. And Farris isn’t about to gamble their health on the goodwill of strangers.
“I can’t trust that somebody who is unmasked is actually vaccinated,” she said. “So my kids won’t be going indoors anywhere that’s not essential for a long time.”
Owen, 12, and Luke, 10, are among an estimated 10 million Americans whose weakened immune systems might leave them vulnerable to the novel coronavirus even if they get a vaccine. They include cancer patients undergoing treatments that debilitate their disease-fighting machinery and transplant recipients dependent on immune-suppressing drugs to prevent rejection. People with rheumatoid arthritis, lupus and other autoimmune disorders keep their symptoms in check with medications that can also impair antibody production.
Since they don’t know whether vaccines will protect them, many immune-compromised people can’t share in the joy as everyone else resumes some of life’s small delights, like laughing with friends over a restaurant meal, sharing fellowship in church, or playing indoors with other kids on a rainy day.
“A lot of people are moving on, talking about the pandemic in the past tense,” said Portland teacher Heather Braaten, 44, who was diagnosed with ovarian cancer last fall. “That makes me pretty emotional, because it’s not close to over for a lot of people.”
Braaten got vaccinated but doesn’t know whether chemotherapy undermined the shots’ effectiveness. So at a time when she and her wife would like to start traveling again and reconnect with family, they’re stuck in the same isolating routines.
Farris is in a similar situation. She won’t risk sending her sons back for in-person education for at least another year. That means she’ll continue to curtail her law practice so she can home-school Owen and help with the outdoor-only cooperative school Luke attends.
Masking, frequent testing and other precautions will remain part of the Farris household’s routine until herd immunity, or something like it, is achieved — and not just because of the protective shield high vaccination rates provide. Luke and Owen are able to live relatively normal lives thanks to weekly infusions of antibodies extracted from blood plasma. Until antibodies to the novel coronavirus are ubiquitous in plasma donors, they will remain at risk.
“We really do rely on herd immunity to keep our kids safe,” Farris said.
Especially nerve-wracking
Vulnerability to infection isn’t a new experience for people with impaired immune function. They often don’t mount strong responses to vaccines, including those for flu and pneumonia — but the pandemic is especially nerve-wracking, said Dr. Sara Jo Grethlein, executive medical director of the Swedish Cancer Institute.
“They don’t want to win the battle against cancer, then lose the battle against COVID.”
Data so far shows mixed results for COVID-19 vaccines, with transplant recipients of greatest concern. Researchers at Johns Hopkins University reported last month that 46% of organ transplant patients studied mounted no antibody response after two doses of the Pfizer or Moderna vaccines. Those who did produce antibodies generally had levels far below people with normal immune function. Another study found similar results in people with blood cancers.
Preliminary analyses in people with a wide range of autoimmune diseases are more encouraging, with the majority producing antibodies, though often at reduced levels. Treatment type matters. Among people taking the steroid prednisone, more than a third produced no antibodies, while other drugs had even more severe impacts.
Medical experts still recommend vaccination for their immunocompromised patients because the consequences of novel coronavirus infection can be so dire. The fatality rate among bone marrow transplant recipients with COVID-19 is 30%, while nearly a quarter of solid organ transplant patients succumb to the disease, said Dr. Steven Pergam, director of infection control at Seattle Cancer Care Alliance.
A kidney transplant recipient himself, Pergam advises all of his patients to get vaccinated, then behave as if they weren’t — taking the same pandemic precautions as always.
Developing better strategies to protect immune compromised people is not just a pressing issue for the individuals affected, said Dr. Ajit Limaye, director of the Solid Organ Transplant Infectious Disease Program at UW Medicine.
People whose bodies can’t fight off COVID-19 can remain infectious for months, potentially spreading the virus to others. Evidence is also mounting that new, rapidly spreading variants arose in patients with severe immunosuppression, where the pathogen was able to evolve and develop new survival strategies.
“We know that people who are immunosuppressed can have viral replication at high levels for prolonged periods and that’s the kind of biological environment in which variants might emerge that become resistant to therapy,” Limaye said.
Studies underway
Multiple studies of immune compromised people and COVID-19 are underway, including in Seattle. Limaye is part of a nationwide project to figure out how the Moderna vaccine works in kidney and liver transplant recipients. Similar research is starting with bone marrow transplant and other blood cancer patients at Fred Hutchinson Cancer Research Center and elsewhere.
Researchers at Seattle’s Institute for Systems Biology are collaborating with physicians at Swedish Medical Center on a deep dive that looks at the entire immune response to vaccines, not just antibodies.
Seattleite Maggie Kim, 50, volunteered for Limaye’s study shortly after the first discouraging news about transplant recipients and vaccines broke this year. Diagnosed with liver cancer more than a decade ago, Kim received two transplants in quick succession after her first donor organ failed within days.
She got her initial Moderna dose a couple of weeks ago. Limaye and his team collected baseline data before the shot and will follow up at regular intervals.
Being able to participate in research is a source of optimism, Kim said. “It just feels like the only hope we have is for the scientists and doctors and researchers and, hopefully, pharmaceutical companies, to try and find something that will work better.”
An accounting and benefits manager, she’s able to do her job from home. But Kim is also an accordion player and would love to get back onstage again when it’s safe. Meanwhile, all she can do is wait.
“It doesn’t feel like the light is green to go yet.”
Some cancer patients are able to take a more active role by timing chemotherapy and other treatments to minimize immune system impacts.
Carnation resident Troy Anderson has a type of non-Hodgkin lymphoma that will probably require lifelong management with multiple drugs. The disease also puts him at high risk if he gets infected with the novel coronavirus.
“The stakes are extremely high for me to avoid getting COVID,” said Anderson, 43.
But the infusions he takes to kill malignant blood cells also wipe out healthy B cells, the body’s antibody factories. The effect lingers for six months, so Anderson and his doctor postponed one round of treatment to allow his immune system to recover before he got the vaccine in early spring.
Antibody testing confirmed a robust immune response to the shots. “That’s a huge weight off my shoulders,” said Anderson, who works at Microsoft and is co-owner of a brewery.
He hopes future treatments won’t erode his immunity, but isn’t sure. Anderson also has a few friends and family members who won’t get vaccinated, which has led to some uncomfortable conversations.
“I understand getting the vaccine is a personal choice,” he said. “But it isn’t a choice that just affects one person.”
Third doses?
There’s not much doctors can do for patients who don’t mount an immune response after COVID-19 vaccination. Monoclonal antibody infusions can confer at least short-term protection, said Dr. Joshua Hill, a physician and researcher at “The Hutch” who has prescribed the treatment to a few vulnerable patients.
Researchers at University Health Network in Toronto recently launched a study to see if a third dose of the Moderna vaccine will boost antibody levels in organ transplant recipients.
Until those and other study results are in, most doctors don’t recommend extra shots. They also advise against antibody tests, which is frustrating for immune compromised people who have no idea whether the vaccine is working for them.
But antibody tests can be misleading because no one knows yet what level of antibodies is sufficient, Hill explained. The tests also don’t say anything about other immune functions, like T-cells, that can also provide protection.
“Antibody tests are just the tip of the iceberg of what the immune system is doing,” Hill said.
Some doctors and patients are proceeding anyway.
A heart transplant surgeon at NYU Langone Transplant Institute in New York City — who is also a heart transplant recipient — got a dose of the Johnson & Johnson vaccine after learning his two Pfizer shots didn’t induce antibodies. In an interview on “CBS This Morning,” Dr. Robert Montgomery said the extra dose triggered a strong reaction.
Shoreline resident Sharon Lloyd, who got a liver transplant three years ago, says her doctor recommended a third dose of the Pfizer vaccine after antibody testing showed a lackluster response to her first two shots. It took a little explaining to convince officials at her neighborhood clinic that the request was legitimate, but she got the third jab and will follow up in a few weeks with another antibody test ordered by her physician.
Lloyd, 65, shared her experience with online transplant groups, where interest in extra doses is high. “I know quite a few people across the U.S. who are planning on getting a third shot,” she said.
Safeguarding others
Until research provides a clearer picture, medical experts urge continued vigilance on the part of immune compromised people who may not realize they could still be in danger despite vaccination. “Please don’t use the COVID vaccine as your get-out-of-jail-free card,” Limaye cautioned.
One of the best ways to safeguard immunologically defenseless people is for everyone else to get vaccinated, Pergam stressed. The classic definition of herd immunity is the point where enough members of a population are immune that the few who aren’t are also protected.
With states now offering million-dollar lottery prizes and companies dangling bonuses and vacation days to entice people to get the shots, immune compromised people and their advocates offer another incentive: knowing your actions might save someone else’s life.
“If we don’t do this together, the people who are most at risk are going to be left behind to deal with the consequences,” said Pergam. “Getting vaccinated is not just about yourself, it’s about protecting the most vulnerable people in the community.”