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( Rogelio V. Solis / Associated Press )
Dorry Segev, a professor of surgery and epidemiology and associate vice chair of surgery at Johns Hopkins University School of Medicine and Bloomberg School of Public Health, and researcher of the COVID-19 vaccine responses in immunocompromised people, talks about the developing COVID-19 treatments in immunocompromised patients.
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Brian Lehrer: Brian Lehrer on WNYC. Serious complications from COVID-19 have long been understood to impact people with weakened immune systems at higher rates, but the vaccines are also less effective at mounting protection for immunocompromised people like those who are undergoing treatment for cancer, have received transplants, or have other autoimmune conditions. In October, the CDC said immunocompromised individuals could receive a fourth shot of the Pfizer or Moderna vaccines. Earlier this month, the agency shortened the six-month waiting period for boosters to five months for them.
There are approximately seven million immunocompromised Americans, by this definition, according to the CDC, and yet with little guidance from federal regulators, some very vulnerable patient are left to cobble together their best chance of protection with their healthcare providers as society tries and tries and tries to reopen with more of the general population in mind. How can we protect people with weakened immunity from the worst-case scenarios, especially during the rise of the highly transmissible Omicron variant, and as society keeps trying to move past it and get as much back to "normal" for most people as possible?
Joining me now to discuss is Dr. Dorry Segev, a professor of surgery and epidemiology and associate vice chair of surgery at the Johns Hopkins University School of Medicine and the Bloomberg School of Public Healthcare and researcher on COVID-19 vaccine responses in immunocompromised people. He recently co-authored the op-ed in the New York Times that you might have seen called Omicron Isn't Milder For Everyone, Like Our Patients. Dr. Segev, thank you so much for making time for us. Welcome to WNYC.
Dr. Dorry Segev: Good morning and thanks for the opportunity to chat.
Brian Lehrer: When we're talking about immunocompromised people, do you want to add any more detail to who we're actually talking about?
Dr. Dorry Segev: There are two main categories of people who are immunocompromised. One are people who inherently have weakened immune systems. Their immune system has a disease or a condition that makes it inherently weak, and then there's the other side, which are people who take medications to suppress their immune systems on purpose because they want to avoid problems that the immune system is causing like transplant patients who try to avoid rejections by reducing their immune system or people with autoimmune disease who are trying to avoid flares of their autoimmune disease by suppressing their immune system.
Those are the two major categories, but you covered a lot of the conditions; people on chemotherapy, people with blood malignancies, people with organ transplants or stem cell transplants, et cetera.
Brian Lehrer: I want to read a question from somebody with an immunocompromised condition, they say, who wrote in, and it says, "As a disabled person, it has been horrifying to watch the CDC and federal government pursue a vaccine-only strategy effectively allowing the virus to spread uncontrollably throughout the population, what was previously unthinkable except to the Great Barrington Declaration." Remember that was the pro-Trump do-nothing camp early on in the pandemic, now seems to be the bipartisan consensus. Can you please speak to what this strategy means for the daily lives of your sick and disabled patients? That's a heavy question.
Dr. Dorry Segev: It's interesting to think about what is the best way for protection. If you are immunocompromised, what it means is that for some people, the vaccine will not work as well as for those with competent immune systems, and we need to do things about that. There are two general categories of what we can do. One is to give people more vaccines, and we know that that works. We showed back as early as may, that getting third doses of vaccines helped people who didn't have a good response to two doses of the vaccine, and in August, the CDC and FDA did approve third doses for people who were immunocompromised.
That's really important to continue to prime the immune system for those who have immune systems that don't react as quickly or as well as people who are immunocompetent. Now, for some people, a third dose doesn't work, and there's even some evidence that for people in whom a third dose didn't work, a fourth dose can work, and even in some people, a fifth dose can work. There's mounting evidence that the vaccines are doing something in most immunocompromised people, but that we just need a good strategy to ultimately help them reach the level of immunity that would be as protective as that in the general population.
Now, there are some people who are immunocompromised who do not have good vaccine responses and probably will never be protected just by a vaccine strategy, and for them, there is a new really good approach which is the pre-exposure monoclonal antibody approach where we give them manufactured antibodies that are known to be active against the virus because their immune system can't make these antibodies by itself. They're strong, compelling evidence that by giving people who couldn't mount the antibodies these synthetic antibodies, they can have a fair bit of protection from the virus as well.
Brian Lehrer: Listeners wondering if we have any immunocompromised people listening out there who want to call in and ask Dr. Segev a question or tell us if you are experiencing the way policy is dealing with COVID as appropriate to you or threatening to you as the listener who I just cited seems to experience it, 212-433-WNYC, 212-433-9692. Or for people who care for anyone who's seriously immunocompromised, how are you navigating getting boosters, especially during Omicron? What's your doctor telling you about potential third or fourth shots of the mRNA vaccines?
Have you made the switch from cloth or surgical masks to N95 or KN95 masks? If you have a job outside the home, are you asking for certain accommodations? Give us a call, tell us your stories. Ask Dr. Segev a question. 212-433-WNYC, 212-433-9692, or tweet at Brian Lehrer. Doctor, you wrote in New York Times op-ed relative to knowing how well these multiple boosters or I guess even the antibody infusions are working for these folks, you wrote there's no guidance for medical providers about which antibody tests would be informative for these patients.
We've had multiple guests on the show who said, "Listeners, don't bother to go get those antibody tests you can get from a lab because they don't really tell you anything." Where are you on that?
Dr. Dorry Segev: It's been very frustrating that there hasn't been a national guidance about antibody testing given that, for months now, we've had widely available commercial antibody labs and all of the CDC and FDA policies have been rooted in science that has used antibody levels. For example, why do we give third doses to people who are immunocompromised? It's because we did studies showing that antibody levels were suboptimal after two doses and that they increased after a third dose.
If we're allowing antibody levels to drive the science, why can't we also allow antibody levels with a reasonable guidance knowing that nothing is perfect today, also help drive clinical practice, help guide patients. If you're immunocompromised and you've got three doses, how do you know if need a fourth dose? If you go get your antibodies checked and they're zero, then you know you need to be extremely careful. You need to seek additional doses, you need to talk with your medical provider about what else can be done for you, you need to be seeking pre-exposure monoclonals, you need to be talking to your job about allowances to work from home and all of that.
We know if somebody's antibody levels are low, that they lack protection. It's very frustrating that there isn't a guidance to help people identify the right antibody tests and know when they are not protected.
Brian Lehrer: How do you for your patients?
Dr. Dorry Segev: For us, we have advised patients to get antibody tests, and when their antibodies are low, we work on additional strategies for protection. One limiting factor, though, also, that we talked about in the op-ed that also is very frustrating is that the FDA approvals or the authorizations for vaccines have been quite limited for the immunocompromised. Right now, if you're immunocompromised, you can get three primary doses and compare that to two primary doses that the immunocompetent get in the general population.
Then you can get a fourth dose as a booster five months after your three primary doses, but as we talked about earlier, some people require four doses as their primary vaccination, and physicians right now are not even allowed to do that. There's a one-size-fits-all restrictive authorization from FDA and CDC that limits physicians from personalized medicine, from taking care of our own patients and what we think would be the best for them.
Brian Lehrer: Mark in Eastern New York, you're on WNYC with Dr. Dorry Segev. Hi, Mark.
Mark: Hello, Brian. I'm a New Yorker who's moved to a farm upstate after retiring as a college professor. I've seen a lot of data that show that the effect of the vaccine diminishes with age. There's just no question about that. There's a lot of data in the literature about that. I'd like to know I'm 84 right now, I am boosted, isn't it possible that I should be seen as immunocompromised, that age is comorbidity? That's the question that I have.
Brian Lehrer: Even without a specific disease diagnosis, doctor, we always see the shorthand in the press for immunocompromised or very elderly patients. He's asking, he's 84, what category does he fall into?
Dr. Dorry Segev: Yes, this is a great question and a really important one that those who are immunocompromised do not all fall under the diagnosis categories that we talked about earlier. Indeed, there is a possibility that somebody who's 84 had a much lower vaccine response than somebody who's 24. The best way to identify whether you need additional doses of vaccine or additional protection, additional protective measures like working from home, et cetera, would be antibody testing. This is another one of the reasons that I'm frustrated that there's no antibody testing available. I wrote an op-ed a few months ago called It's Time to Check Antibodies and Take The Guesswork Out of The Pandemic.
This is a great example of the guesswork. Here we have somebody who wants to be protected, wants to take as good care of themselves as possible during this pandemic, and we don't have guidance on how to do this even though we have good tests for how to do this.
Brian Lehrer: Is there a test you recommend?
Dr. Dorry Segev: There are a number of semi-quantitative anti-spike antibody tests available in the big commercial labs. The important thing that would need to be done is that CDC would need to review the data, which they have a lot of data, and to help provide a guidance for people on what different antibody levels would mean. We know that antibody levels correlate with neutralization, which correlates with clinical protection that's been published multiple times at this point, and so CDC could provide some guidance, but I would even say, if you're worried, if you have any vaccine response, if you're particularly immunocompromised, you can just go and get one of these tests.
If you are negative, then you know that you need a lot more protection than anybody else. The problem is that if you're positive, you don't really know what that number means until there is national guidance for it.
Brian Lehrer: Diane in Queens, you're on WNYC with Dr. Segev. Hi, Diane.
Diane: Hi, thank you for taking my call. I'm immune-compromised due to kidney transplant. Will I ever be safe if this becomes endemic? Will I ever be able to go outside without a mask?
Dr. Dorry Segev: That's that's a very good question. I hope the answer is yes. I hope very much the answer is yes. I also think that the answer will be yes. There are a few things that are optimistic right now. One is that we know with the Omicron variant, in general, the diseases, the impact of COVID infection in those who get the Omicron variant is less severe than those who got the Delta variant, even among some immunocompromised people. We're seeing more and more optimism even if somebody happens to get COVID with the Omicron variants, although, of course, it's still important to protect yourself as much as possible.
I think ultimately, we will see the population prevalence of COVID drop dramatically and we will see better protective mechanisms for the immunocompromised. We will have a better understanding of what vaccination regimen works. For example, we're now running a national randomized trial in transplant patients where we're giving people an additional dose of the vaccine and randomizing them to either just getting the vaccine dose or getting the vaccine dose but with some modulation of their immunosuppression drugs. Maybe if we change their immunosuppression a little bit while we give an additional dose of the vaccine, that will get a better vaccine response.
We're also seeing more and more availability of the pre-exposure monoclonal antibodies. I think with a half-decent vaccine response, maybe not as good as the general population, but also supplemented with pre-exposure monoclonals, now transplant patients will be able to be as safe as anybody else in the general population and will be able to see the world open up for transplant patients as it is opening up for the general population as well. We're not quite there right now, especially with the big Omicron wave. I will tell you that I'm immunocompetent, I have a normal immune system.
I'm boosted and I'm still wearing masks in any indoor space that I share with strangers just because I also want to be as safe as I possibly can, but I do think that there's optimism for the general population, but also optimism for those who are immunocompromised.
Brian Lehrer: Diane, I hope that's encouraging. Thank you for your call as we talk about people who are seriously immunocompromised and COVID with Dr. Dorry Segev who had an op-ed in The Times about this. You talked to her and you've been talking, in general, I think, about how people who practice medicine can help protect individual patients with the various things you've been mentioning. listener writes, "We can't use individual measures to solve a pandemic and we certainly can't keep putting the onus on the vulnerable to magically protect themselves amid unchecked spread.
What can the government and local agencies do to curb the spread and prepare for future variants," which this person writes, "Are inevitable so long as vaccine patents prevent vax access for much of the globe?"
Dr. Dorry Segev: Yes, that's the big challenge. If we were able to get control of these months ago when vaccines became available, if we had 100% uptake of vaccination in this country, and then availability of vaccines outside of this country, there would be no issue for the immunocompromised. I think as the United States, the US-specific things we can do are to do everything possible to encourage people to get vaccinated, and to make the public spaces as safe as possible. If you want to drive drunk on your own property where nobody else is going to be around, that's up to you, but if you're going to drive on public streets, you better be sober and you better be driving safely.
Similarly, there are many shared indoor spaces and we need to be as safe as possible for those spaces for those who are immunocompromised, for those who are 84 years old, for those who have perfectly functioning immune systems who also are at risk of getting COVID and who also are at risk of having serious manifestations from it. I think everything we can possibly do to make the shared spaces as safe as possible will impact those who are immunocompromised. I do think that vaccines need to continue in their evolution and it seems like they are continuing.
There are variant-specific vaccines that are being targeted right now. I suspect that boosters that we get 6 to 12 months from now will not just be the original vaccine formulations that we got 6 to 12 months ago, but will be better equipped for the variants of concern that we're seeing. I think that this is going to be a realistic place we live in, and just we get yearly flu shots, we're going to be getting yearly or maybe even twice yearly something to help protect from this.
Brian Lehrer: A few more minutes with Dr. Segev and Laurence Tribe coming up next. Andrea in Manhattan, you're on WNYC. Hello, Andrea.
Andrea: Hi, Brian. Hi, Dr. Segev. I'm a huge fan of yours, Brian. I really rely on you to be there during emergencies, blackouts, and other things like that.
Brian Lehrer: Thank you.
Andrea: I have multiple sclerosis. My first question is, just having an autoimmune disease, does that make me immune-compromised? Then the second part of that is that I'm taking a medicine. It's an interferon beta-1b or something like that. It's classified as a disease-modifying therapy, a DMT, so does that make me immunocompromised?
Dr. Dorry Segev: Right, well, indeed those who take medications to modify their immune system are at risk of having a suboptimal response to the vaccine. Yes, theoretically, you're immunocompromised because you're taking a medication that modifies your immune system. How much of an impact will this have on your vaccine response is not fully clear in your individual situation. We do know that people with multiple sclerosis who take certain medications have less vaccine responses than others. This is another really good situation or a really good justification for antibody testing.
I would certainly talk to the physicians that care for you and see if they can help you get antibody tested, see how much of an antibody response you've had to the vaccine, maybe give you a little bit of reassurance that your antibody levels are off the charts and that you're doing okay, or identify that maybe your antibody levels are lower and more needs to be done like additional doses of the vaccines. As we were talking about before, Brian, without antibody testing all of this is guesswork based upon big generalizations and one-size-fits-all approaches, and we can take that guesswork out by actually testing people's antibody levels.
Brian Lehrer: One more follow-up from a listener. Now that we've talked about people who are immunocompromised because of their disease that they're diagnosed with and others who are immunocompromised because of medications they're taking to treat things, listener writes, "When speaking of the immunocompromised, are there differences in outlook for those with an overactive immune system with an autoimmune condition versus those with an insufficient or suppressed immune response?"
Dr. Dorry Segev: I think the outlook is similar and the conclusions are similar. One of the conclusions is we need to be more personalized about this and we need to get the data that we have access to, and that would be in the form of antibody testing. I think in terms of the optimism that I expressed before, I would express that same optimism for people who are immunocompromised from either of those two conditions. There are some medications that are particularly inhibitory of vaccine responses, and when we find out that somebody is on one of those, we just need to be a little bit more aggressive.
There are some conditions that are also particularly inhibitory, but as long as we know where our patients are in terms of viral protection, we can do as much as we can to keep them as safe as possible.
Brian Lehrer: Dr. Dorry Segev, professor of surgery and epidemiology, an associate vice chair of surgery at the Johns Hopkins University School of Medicine and the Bloomberg School of Public Health at Johns Hopkins, and a researcher on COVID-19 vaccine responses in immunocompromised people. He did that op-ed in the New York Times this week called Omicron Isn't Milder for Everyone, Like Our Patients. So informative, I could just see and hear and read, smell the appreciation on the part of our listeners who've been calling in and writing in. Thank you very much.
Dr. Dorry Segev: Great talking to you.
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