How Effective Are COVID-19 Vaccines for the Immunosuppressed?

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Emotions are running high right now in the dental hygiene community. The American Dental Hygienists’ Association (ADHA) supports mandatory vaccinations for oral health care workers. But not all oral health care workers are in favor of this mandate. In posts on the Facebook group Atlanta Dental Peeps, hygienists have been commenting on the ADHA’s announcement. One post is from a hygienist who was puzzled by a case of a patient who is a cancer survivor. Apparently, the patient has no detectible spike protein antibodies despite being vaccinated.

Immunocompromised patients can be at different levels of immunosuppression throughout their lives. During active treatment, they are often moderately to severely immunosuppressed. Once they are in remission, their level of immunosuppression may vary. Patients with cancer in active treatment/chemotherapy, autoimmune patients who are actively being treated with biologics, or solid organ transplant recipients (SOTRs) are all considered moderately to severely immunosuppressed. If an individual had cancer, is in remission, and is no longer receiving chemotherapy, they are likely immunocompromised; however, this individual may not be categorized as “immunosuppressed.”

Approximately 3% of the general population is categorized as “moderately to severely” immunosuppressed and at higher risk for negative outcomes if infected with COVID-19. In addition, immunosuppressed patients should exercise caution after vaccination with the understanding that published vaccine efficacy data taken from the general population cannot be applied to them.¹ Approximately 60% of this population group did not build detectable spike protein antibodies after the second vaccine, according to most studies completed to date on COVID-19 vaccine efficacy. No data have yet been published determining the efficacy of a third COVID-19 booster vaccine in moderately to severely immunocompromised individuals. Just how much less protection an immunosuppressed individual gets seems to be driven by the type of underlying condition.²

The spike protein antibody test is not perfect, and scientists are not sure that it gives a true representation of coverage in moderately to severely immunosuppressed individuals. Scientists suspect that patients may get some protection from various branches of the immune system and that the spike protein antibody test is not a representation of T-cell immunity. And although a T-cell test is currently being investigated, at this time, the spike protein antibody test is the only tool available to measure coverage of the vaccine.

Who Are Defined as Immunosuppressed?

Individuals who are immunosuppressed are those who are taking immunosuppressants, have an autoimmune disorder that is being actively treated with biologics, have had an organ or stem cell transplant, or are undergoing cancer treatment. Immunosuppressant drugs suppress or reduce the strength of the body’s immune system, and they are used to make the body less likely to reject a transplanted organ. Immunosuppressant drugs are often used to treat autoimmune diseases such as lupus, psoriasis, or rheumatoid arthritis. It is the mechanism of action of these stronger immunosuppressants that inhibit the immunosuppressed person’s immune system to recognize the COVID-19 vaccine.

On August 13, 2021, the US Food and Drug Administration announced that moderately to severely immunosuppressed patients should get a third booster dose with the same COVID-19 mRNA vaccines. At this time, no booster vaccine has been announced for the Johnson & Johnson vaccine as research continues on its long-term efficacy.

Many SOTRs have already made appointments to secure their booster vaccine. Why is this population group so eager to get a booster?

In December 2020, Johns Hopkins University in Baltimore, Maryland, began an observational study entitled COVID-19 Antibody Testing of Solid Organ Transplant Recipients (SOTRs) with Chronic Disease. The purpose of this study was to determine the COVID-19 antibody levels in solid organ transplant recipients post vaccine.1 The vaccine itself was not supplied. The study began as soon as the first vaccine became available; however, it was evident early on that the moderately to severely immunosuppressed patient population was not responding robustly to the COVID-19 vaccines.

In June 2021, Johns Hopkins Medicine announced that study findings suggested booster doses should be investigated for those who are immunocompromised.³ Investigators in France reported that the immune system of certain immunosuppressed patients would have difficulty recognizing the COVID-19 vaccine and some of the participants observed only achieved a weak immune response with 2 vaccines.⁴ In addition, severe cases of COVID-19 have been reported in transplant recipients who received 2 doses of vaccine.⁴ With a third vaccine, findings showed that most, though not all, transplant recipients would achieve immunity.⁴

Impact of Immunosuppressants on COVID-19 Vaccine Response

Immune suppression does appear to decrease antibody response to COVID-19 mRNA vaccines. This seems to be particularly significant among SOTRs. Patients receiving rituximab (Rituxan), mycophenolate, and other medications seem less likely to experience an antibody response. The extent to which antibody response findings relate to overall vaccine responsiveness and infection risk is unclear.⁵

No unique COVID-19 vaccine-related adverse effects have been identified in patients receiving immunosuppressants.⁴ It is recommended that patients finish the COVID-19 vaccine series at least 2 weeks before starting an immunosuppressant.⁵

Below are several questions to ask immunosuppressed patients:

• Have you recently been tested for the COVID-19 virus?
• Do you live/work in a population/environment that exposes you more frequently to the SARS-CoV-2 virus?
• Have you discussed with your health care team the possible need for a booster (third) vaccine shot?

During the COVID-19 outbreak, a large number of individuals have had an acute kidney injury and may be on dialysis. Patients with acute kidney injury and chronic kidney disease who are on dialysis should consult their medical team about the need of a booster vaccine. They may need a booster vaccine earlier than the general population.

Many moderately to severely immunosuppressed patients don’t know that their bodies may not be creating enough spike protein antibodies to be considered covered. As a health care provider, encourage patients to discuss with their medical team the pros and cons of a booster vaccine.

References

1. Epidemiology Research Group in Organ Transplantation. COVID-19 antibody testing of recipients of solid organ transplants and patients with chronic diseases. Johns Hopkins University. 2021. Accessed August 2021. https://transplantvaccine.org/
2. Berg S. What to tell immunocompromised patients about COVID-19 vaccines. American Medical Association. August 17, 2021. Accessed August 2021. https://www.ama-assn.org/delivering-care/public-health/what-tell-immunocompromised-patients-about-covid-19-vaccines
3. Johns Hopkins Medicine. For transplant recipients, third time may be the charm for better COVID vaccine protection. June 14, 2021. Accessed August 2021. https://www.hopkinsmedicine.org/news/newsroom/news-releases/for-transplant-recipients-third-time-may-be-the-charm-for-better-covid-vaccine-protection
4. Kamar N, Abravanel F, Marion O, Couat C, Izopet J, Del Bello A. Three doses of an mRNA COVID-19 vaccine in solid organ transplant recipients. N Engl J Med. 2021;385(7):661-662. Accessed August 2021. doi:10.1056/NEJMc2108861
5. Streetman, D. Impact of immunosuppressants on COVID-19 vaccine response. PharmaTimes. July 5, 2021. Accessed August 2021. https://www.pharmatimes.com/web_exclusives/Impact_of_immunosuppressants_on_COVID-19_vaccine_response_1372703