For over a year, Andrew Wollowitz has spent most of his time secluded at home of Mamaroneck, New York.
At 63, as director of emergency medicine at Montefiore Medical Center in the Bronx, Wollowitz, he was eager to help treat patients when the coronavirus began to spread by the city.
However, the cancer treatment he underwent in 2019 wiped out his immune cells, which left him defenseless against the virus, so he had to start leading his team through Zoom.
Immunologist Charlotte Cunningham-Rundles has 600 patients who depend on gamma globulin to protect themselves from pathogens. Photo: Joshua Bright for The New York Times.
A year later, the people in Wollowitz’s life are returning to something of a normalcy. His wife, a dancer and choreographer, is preparing to travel to Austria and work with the National Ballet Company of that country.
His vaccinated friends are gathering, but he only sees them when the weather is favorable enough that he can sit in his backyard. “I spend very little time in public areas,” he mentioned.
Like his friends, Wollowitz received the vaccine in January. But it did not produce antibodies as a consequence, as he suspected. He is one of the millions of immunocompromised Americans whose bodies cannot learn to deploy immune agents to fight the virus.
Some immunocompromised people were born with non-existent or poor immune systemsWhile others, like Wollowitz, suffer from diseases or have received therapies that suppressed their immune defenses.
Many of them produce little or no antibodies in response to a vaccine or infection, which leaves them susceptible to the virus. When infected, they can suffer long-term illnesses, with death rates as high as 55 percent.
Most people who have lived with immune deficiencies for a long time are likely already aware of their vulnerability. But there are others who have no idea that the drugs may have put them at risk.
“They walk outside thinking they are protected, but maybe they are not,” said Lee Greenberger, scientific director of the Leukemia and Lymphoma Society, which funds research on blood cancers.
The only recourse these patients have – other than staying home until the virus recedes – may be to receive regular infusions of monoclonal antibodies, which are mass-produced copies of antibodies obtained from people who have recovered from COVID-19.
The United States Food and Drug Administration authorized several monoclonal antibody treatments against COVID-19But now some are also being tested to prevent infection.
The convalescent plasma or gamma globulin – antibodies distilled from the blood of healthy donors – could also help immunocompromised people, although a version of the second that includes antibodies against the coronavirus will not be available for several months.
“It’s certainly an area of need that is being neglected,” said Hala Mirza, a spokeswoman for Regeneron, who has delivered her monoclonal antibody treatment to a handful of immunocompromised patients through a compassionate use program.
This week, Regeneron published the results of a clinical trial that showed that the treatment rreduces symptomatic infections by 81 percent in people with normal immune systems.
Still It is not clear how many immunocompromised people do not respond to COVID-19 vaccines. However, it appears that the list at least includes survivors of various types of blood cancer, organ transplant recipients, and anyone taking the widely used drug Rituxan, or the cancer drugs Gazyva or Imbruvica – both of which kill or they block B lymphocytes, the immune cells that produce antibodies en masse — or Remicade, a popular drug for treating irritable bowel syndrome.
It could also include some people over the age of 80 whose immune responses have deteriorated with age.
“We are very concerned and interested in trying to see how we can help those specific patients“Said Elad Sharon, an immunotherapy expert at the National Cancer Institute.
As the pandemic spread, doctors specializing in treating blood cancer or caring for immunocompromised people expected that at least some of their patients would experience difficulties.
Charlotte Cunningham-Rundles, an immunologist at the Icahn School of Medicine at Mount Sinai in New York, has about 600 patients almost completely dependent on regular doses of gamma globulin to be safe from pathogens.
Still, 44 of his patients contracted the coronavirus; four died, and another four or five suffered from long-term illnesses (chronic infections could give the virus opportunities to mutate and lead to dangerous variants).
Steven Lotito, one of Cunningham-Rundles’ patients, 56, was diagnosed with a condition called common variable immune deficiency when he was 13 years old.
Before the pandemic, she lived an active life, exercised and ate well. “I’ve always known that I have to take very good care of my body,” he explained. This included gamma globulin infusions every three weeks.
Despite taking precautions, Lotito caught the virus from his daughter in mid-October. He had a fever for almost a month, and spent a week in the hospital.
Got better for a couple of weeks with convalescent plasma and remdesivir, an antiviral drug, but then her fever returned. Finally, he felt better after one more gamma globulin infusion, during which he sweated so much that he changed his shirt four times.
However, after almost seven weeks with the disease, Lotito had not generated any antibodies. “I still have to take the same precautions I was taking a year ago,” he said. “It’s a bit daunting.”
Cunningham-Rundles has monitored the level of antibodies in his patients and has enrolled some in treatment with Regeneron monoclonal antibodies, but many other people with these conditions are not aware of the risk they are exposed to or the treatment options that exist.
The Leukemia and Lymphoma Society opened a registry to provide information and antibody tests to people with some type of blood cancer.
In addition, several studies are Assessing the Response to COVID-19 Vaccines in People with Cancer, autoimmune diseases such as lupus or rheumatoid arthritis, or taking medications that block the immune response.
In one of these studies, a group of British researchers followed almost 7,000 people with the Crohn’s disease or ulcerative colitis treated in 90 hospitals in the country. They found that less than half of the patients taking Remicade produced an immune response after contracting the coronavirus.
In a follow-up study, scientists found that 34 percent of people taking the drug were protected after receiving a single dose of the vaccine. Pfizer and only 27 percent experienced the same after receiving a dose of the vaccine AstraZeneca (In the UK the current procedure is to delay second doses to extend vaccine availability).
Also, another study published last month indicated that less than 15 percent of patients with some type of cancer of the blood or immune system, and less than 40 percent of people with solid tumors produced antibodies after receiving a single dose of the Pfizer-BioNTech vaccine.
And another study published last month in the journal JAMA He reported that only 17 percent of the 436 transplant recipients who received a dose of the Pfizer-BioNTech or Moderna vaccine had generated antibodies detectable three weeks after inoculation.
Despite the slim odds, immunocompromised people still need to get vaccinationsas they may produce some immune cells that can protect them, including antibodies in a subset of patients.
“Maybe these patients should be prioritized to receive both doses at the right time, ”said Tariq Ahmad, a gastroenterologist at the Royal Devon and Exeter NHS Foundation Trust who was involved in the infliximab studies.
Ahmad suggested that clinicians should routinely measure antibody responses in immunocompromised people even after they receive both doses of the vaccine, to identify those who may also need monoclonal antibodies to prevent infection or a third dose of the vaccine.
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