Forgotten Patients: The Immunocompromised Are Being Left Behind

For some individuals, the term “immunocompromised” has become shorthand for someone who needs to comply with the original rules and regulations put in place by the Centers for Disease Control and Prevention (CDC) in 2020. When used politically, the designation evokes a sense of otherness and inconvenience while the government encourages the public to lessen the daily precautions needed to stop the spread of COVID-19.

While the general public shirks off the designation, immunocompromised individuals make up about 3% of the US population—and with those odds, you likely know someone who is a part of this vulnerable group. Elderly adults and infants, as well as individuals with heart conditions, diabetes (type 1 or type 2), HIV infections, recipients of certain types of cancer treatments, current smokers, and pregnant individuals, are all at higher risk of contracting COVID-19 and can be considered immunocompromised.

In a press release from August 2022, Greata Massetti, PhD, MPH, stated, “We’re in a stronger place today as a nation, with more tools—like vaccination, boosters, and treatments—to protect ourselves, and our communities, from severe illness from COVID-19.” This could not be further from the truth. With each passing day, new developments indicate that our tried-and-true treatments are no longer as effective as we once hoped, and government funding to further the commercialization of new therapies is depleting. We must do more to protect immunocompromised patients because, given the lack of tools and treatments in place as we enter our third COVID-19 winter, becoming immunocompromised is not a far-off possibility.

Current state and efficacies of COVID-19 treatments on the market

Since March 2020, testing has only become more accessible, and to date, the US has administered over 613 million jabs of the mRNA vaccines. Currently, 4 COVID-19 vaccines are approved or authorized in the US: Pfizer-BioNTech, Modern, Novavax, and Johnson & Johnson’s Janssen vaccine (although the Janssen vaccine is only recommended in certain situations because of safety concerns). On September 2, 2022, the updated bivalent boosters from Pfizer and Moderna, intended to target the original strain of the virus and Omicron BA.4 and BA.5, became widely available for individuals over 12 years of age.

However, for the immunocompromised population, vaccines are not enough. We know this, which is why we have seen a proliferation of antivirals and monoclonal antibodies seek authorization. Whereas vaccines trigger your body to create its own antibodies, monoclonal antibodies (like Evusheld, which is currently not FDA-approved, but authorized for emergency use) are man-made antibodies that are injected into the body and tackle the virus right away, allowing the body to make its own extra antibodies. By contrast, antivirals (like Remdesivir, molnupiravir, and Paxlovid) are oral treatments that are used after an individual has been infected. (Presently, Remdesivir and Paxlovid are both fully authorized by the Food and Drug Administration (FDA), and molnupiravir received emergency use authorization). The treatments target the virus’ replication process by slowing it down or making it difficult to replicate. While they have great potential to support the immunocompromised population, many of the available monoclonal antibody therapies have continuously proven ineffective as the virus mutates and more research becomes available.

AstraZeneca’s Evusheld, for example, is the only monoclonal antibody authorized as a preventative drug. It is an essential shot for roughly 17,000 Americans with weakened immune systems – but, according to Health and Human Services (HHS) officials, it could be rendered ineffective as new variants arise. Paxlovid is a popular antiviral that has been center-stage in the media—it is used to prevent severe cases of COVID-19 in immunocompromised people. Still, it is also known to cause COVID-19 rebound, as we saw with President Joseph Biden and First Lady Jill Biden. In October 2022, a new study from the Journal of the American College of Cardiology stated that the commonly administered drug could have severe interactions with some of the most common heart medications. While there seem to be options available to protect the immunocompromised population, none of them come without an asterisk.

The solution to keeping up with these ever-changing variants and protecting the immunocompromised population? Developing more therapies and ensuring accessibility to those most in need.

We need more funding to support the commercialization of new treatments to protect the immunocompromised.

Across the board, we see the impacts of slashed COVID-19 budgets. Recent federal funding cuts have ended programs providing free COVID-19 tests, vaccines, and treatments—all crucial for protecting American communities and, particularly, the immunocompromised. Due to these cuts, COVID-19 testing labs and manufacturers are reducing their operations. As winter draws closer, yet another wave will likely rock Americans, but unlike in the past, there will be fewer measures in place, leading to rates of transmission that we have not seen since the start of the pandemic.

Pushing for more COVID-19 therapies is activism. It will help the now societally disenfranchised group we call the immunocompromised population to live uninhibited lives like much of the American population has begun to do. Developing more COVID-19 treatments with the help of the U.S. government will set a precedent as more viruses emerge in the winter months, especially as respiratory syncytial virus (RSV) continues to infect millions, including in premature infants who are considered immunocompromised. Until immunocompromised individuals have viable treatment options that offer significant protection, they will not be able to enjoy the “return to normalcy” experienced by much of the American population.

As scientists, researchers, doctors, and patient advocates, we are responsible for listening to the people most impacted by these developments: patient groups. These groups are on the ground advocating for immunocompromised people. They want more doses of antivirals and the government to fund potential antibody cocktails that could protect against emerging variants. They are pressing the administration to purchase more treatments and to fund potential new antibody therapies that may be better suited to protect against emerging variants. One thing is certain; we can never fully conquer the COVID-19 pandemic if we continue to fail to protect those most severely impacted by the disease.