Protecting the Immune-Compromised Keeps Everyone Safe
It isn’t just about social responsibility. It’s about ending the pandemic and not giving the coronavirus chances to evolve.Earlier this summer, when I began planning my family’s first real vacation in two years, I carefully chose which National Parks we’d visit. White Sands, Arches, Bryce Canyon, Capitol Reef, Joshua Tree, and Sequoia National Park easily made the cutâ€"lots of open-air hiking where we could avoid people. We skipped Zionâ€"traversing the crowds and taking the requisite sardined shuttle felt too risky. My kids also really wanted to see Roswell and its aliens, but the main draw was an indoor museum. Though my husband and I are vaccinated, both of our kids are under 12 and therefore unvaccinated. Since the Centers for Disease Control and Prevention had recklessly rolled back its mask recommendations in May, we kept asking, could we visit safely? How many people would be there? How many would be wearing masks?
The main reason for our caution and anxiety was my husband. He takes medication that weakens his immune system. Throughout the pandemicâ€"and especially in the past six months, as restrictions have increasingly loosenedâ€"perhaps no other group has been more neglected by Covid guidelines or more forgotten by the general public than immune-compromised people. The only reason my husband agreed to our road trip was that nearly every site was outside. Yet it was hard not to feel on edge every time we stopped at a gas station or entered a hotel lobby and found no one else masked but ourselves.
We wore KN-95s, but we knew that masks offer the most protection when others around you also wear them. While many of my vaccinated friends had begun visiting places like restaurants, bars, and fitness clubs again, our family still did delivery or curbside pickup for most our shopping, and the kids knew movies or arcades were out of the question. The CDC’s mask guidance shift had made basic errands riskier for families like ours. Virtually no one where we live in North Texas wore masks in stores, and with less than half our county fully vaccinated, basic math told us they weren’t all vaccinated.
This lack of consideration for immune-compromised people, from public health authorities and the public at large, is dangerous not only for the more than 10 million people with weakened immune systems but also for public health in general. The Alpha variant, as Science reported in December, almost certainly arose from an infection in an immune-compromised person whose prolonged battle against Covid provided ample opportunity for the virus to evolve. Emerging evidence suggests that other variants, possibly including Delta, could have evolved similarly, and a recent report from the UK warns of the potential for more variants to develop the same way. Our collective national choice not to protect the most vulnerable among us is also likely a choice to prolong the pandemic.
By the time we took our trip in June, preliminary evidence suggested that my husband’s medication probably didn’t stop his immune system from mounting a response to the vaccine, so he likely had some antibodies. But we didn’t know how many, how rare breakthrough infections really were, or how his body might respond to one.
Flash forward to last week: When new data about Delta transmission among vaccinated people led the CDC to tighten its mask recommendations, we felt more anger than relief. We knew you couldn’t put the genie back in the bottle. We saw a small uptick in masking, but most people in our area still aren’t masking, since stores stopped requiring it in May. When the CDC released the data explaining its decision a few days later, worried friends sent me a slew of messages: How likely were they to get a breakthrough infection? Should they stop eating at indoor restaurants? Was it still safe enough to fly?
The uncertainty and uneasiness many vaccinated people have been feeling in the past week is what our family and millions of others with immune-compromised members have lived with for the past year and a half. Except the stakes are higher now for immune-compromised people, given how much more contagious, and possibly more virulent, Delta is.
Despite the CDC’s muddled messaging, the vaccines remain highly protective against severe illness for most people. “Mild†Covid-19 infections, however, don’t necessarily feel mild to those infected. While many experience something akin to a light cold or no symptoms at all, others are laid up in bed for two to four days with an illness “on par with having debilitating food poisoning,†as Susan Matthews recently wrote in Slate. If that’s what some healthy people experience, what does a breakthrough infection look like for immune-compromised people? It could be much more serious, whether they have antibodies from the vaccine or not.
We don’t yet have data on Delta infections in this population, but the scarce data on pre-Delta infections in immune-compromised people is contradictory, varies by immunosuppressive conditions, or is discouraging. One study of nearly 1,000 British patients found that immunosuppressed people were twice as likely to die of Covid. Another found higher mortality among organ transplant recipients, but that was largely due to their other underlying conditions, which many immune-compromised people have.
The situation is more dire for organ transplant recipients because the cocktail of drugs they must take to prevent organ rejection gives them not much better than a 50-50 chance of having no antibodies at all after two doses of an mRNA vaccine. People with blood cancers, including those unaware they have one, and people taking steroids or drugs like rituximab are in a similar predicamentâ€"the virus remains deadly to them. New evidence suggests that some breakthrough infections can lead to long-haul symptoms in a small proportion of vaccinated people. While that phenomenon appears rare so far, it poses much greater risk to immune-compromised people, even if they have antibodies.
Yet most public health policies disregard these increased risks. The CDC only recommends masking for vaccinated people in areas with substantial or high transmission, failing to acknowledge that Delta’s far higher transmissibility means a “low†transmission county can become substantial overnight.
A number of states, especially in the South and Midwest, won’t allow mask mandates. Eight states currently won’t allow schools to require masking for everyone, which the CDC and the American Academy of Pediatrics both recommend.
Further, many schools aren’t offering virtual instruction for immune-compromised students or students who have immune-compromised family members, forcing families like mine to pit our children’s mental, social, and educational needs against the threat of death for people we loveâ€"if the family has a choice at all. We withdrew our children from public school, but many families don’t have that option.
We’re all tired of masking, of social distancing, of being deprived of the activities we once all took for granted, tired of the shifting science, the unpredictability of new variants, the seemingly endless doom and gloom of public health experts. That doesn’t make it acceptable to tacitly accept the deaths of those who remain vulnerable or make up excuses for ignoring their risk.
When I bring up the plight of immune-compromised people on social media, I consistently hear two kinds of responses. One is from immune-compromised people talking about how left behind and neglected they feel. The other responses are from people who are dismissive about the risks or who say it’s not their responsibility to suffer inconvenience for the sake of someone else’s safety, especially when immune-compromised people have always faced the risk of severe illness or death from germs circulating in society.
But we do have a social responsibility to protect others, and it’s patently false that daily life for immune-compromised people before Covid was a game of Russian roulette. For the most part, they could go grocery shopping, meet for happy hour, or see the latest Marvel movie in the theater without worrying about dying. Bugs like the flu, common colds, RSV, and pneumonia were around, but most are survivable even for immune-compromised people. “With Covid, it’s a different story,†hematologist and oncologist Mounzer Agha told me for another story I wrote about immune-compromised people. “There’s a real risk of dying from the disease.†A study from March, for example, found that immunocompromised patients with Covid-19 were three times more likely to die of Covid-19 than of fluâ€"despite the Covid patients being younger and having fewer underlying conditions.
It’s also in everyone’s best interest to prevent infections in immune-compromised people if we ever want this pandemic to end. It’s almost certain that Alpha, the B.1.1.7 variant first identified in the United Kingdom, developed in someone whose immune system wasn’t strong enough to kick the infection over many weeks or months. It’s the best explanation scientists have for how 17 mutations could have developed nearly overnight in the variant when the virus typically only acquires two mutations a month. Researchers already knew flu viruses could mutate substantially in immune-compromised people, and a host of recent case studies have shown that Covid-19 infections can persist for months in some immune-compromised peopleâ€"even shedding virus for up to two months.
Infections like these can give rise to the nightmare scenario that Yale vaccine researcher Saad Omer says keeps him up at night: “a post-Delta variant for which vaccines have lower effectiveness for severe outcomes overlapping with the Northern hemisphere winter.†Our failure to act “urgently on global vaccine equity†is already increasing this possibility, he saidâ€"as evidenced by the fact that Delta arose while infections raged through India, where demand for vaccines far outstripped supply. But our failure to consider the nation’s millions of immune-compromised people in public health recommendations is doing the same.
These failures take me back to one of the last parks we visited, Sequoia National Park, and the tension we felt standing before the General Sherman tree, the world’s largest. It was swarming with tourists, and we quickly headed off to explore other giants on the nearby Congress Trail: the President, the Senate, Lincoln, the Founders Group. The last time I'd seen these trees, I was about the age of my 7-year-old son, and their names suited their awe-inspiring stature.
As an adult taking my kids to see them in the midst of a pandemic, my feelings were more complicated. Names like the Founders reminded me of a time when our nation came together to fight a national threat, something that feels more remote than ever. Lincoln, Sherman, and McKinley reminded me of the devastation that comes of a nation torn apart, not unlike we are today. The President and Senate reminded me how much our leaders have collectively failed at protecting families like mine. But I’m also an eternal optimist, so I try to remember that it’s still possible for our leaders to do the right thing. Those trees, which live up to 3,000 years, have persevered through countless cataclysmic events, largely because the forest as a whole offers protection to young saplings and the less robust trees.
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