"Back to normal? Many immunocompromised people feel left behind as U.S. lifts pandemic measures."
The past few months have turned up a rash of articles with similar headlines and subheadings. The articles all make the same claim: while healthy people welcome the return to normal living, the immunocompromised don't have this option. They can't risk brushing up against a maskless person in the grocery store. They can't risk flying in a mask-optional aircraft. And with vaccine passports being phased out, they certainly can't risk eating in a restaurant. Lifting the remaining COVID-19 restrictions effectively consigns them to the living room sofa and takeout food.
To add emotional heft to the argument, the articles include quotes from people with conditions or treatments that affect immune function. "I could just go outside and within two weeks, I could be dead," said one woman with fibromyalgia in an ABC News article. "I'm not risking that to go to Target." Around the same time, an immunocompromised woman featured in a WHYY report maintained that "I'm getting left behind. I feel like we're looking at extinction of part of the species, but nobody's paying attention."
It's not just patients who make such statements, but also the health providers who care for them. On April 18 this year, the same day the U.S. transportation mask mandate was lifted, a doctor tweeted: "One of my patients tearfully told me she's cancelling her flight to her daughter's (outdoor) wedding on Saturday. It's wild some people's *mild discomfort* while wearing a mask is more important than immunocompromised people's ability to LIVE through a pandemic."
Amid a torrent of comments supportive of the patient (who the doctor later described as being actively on chemotherapy), with several posters lamenting the selfishness and cruelty in the world, a few respondents called out the doctor for stoking what they saw as unnecessary fear. Harsh perhaps, but for much of the immunocompromised population, the science largely agrees. Let's look at some studies.
Risk Reality Check
In late 2021, Johns Hopkins University published a study of 200,000 U.S. adults hospitalized with COVID-19. The study investigators found that "overall, patients taking immunosuppressive drugs do not face increased risk of being put on a ventilator or death." Of the 303 drugs they examined, just one -- rituximab (Rituxan), a monoclonal antibody used for blood cancers, rheumatoid arthritis, and other conditions -- was associated with a substantially increased risk of death compared to medically similar patients not taking the medication. Another study, published in April 2021, considered the effect of four types of immunodeficiency on COVID-19 mortality: hematologic malignancy (HM) and hematopoietic stem cell transplant (HCT), solid organ transplant, rheumatological disease, and HIV. The verdict: "In these four populations, iatrogenic or disease-related immunosuppression is not clearly associated with poor prognosis." (It should be noted that the study did not include formal comparisons to the immunocompetent population for adult patients with HM and following HCT.) In a pediatric study in the U.K. that ran until March 2021, an increased risk for severe disease was not seen among the 38 immunocompromised subjects who contracted COVID-19, and no children died in the study.
By the same token, the mRNA vaccines don't require an intact immune system to do their job. A study published in The BMJ, reporting on the Delta-dominant period, found that three shots brought the risk of hospital admission for COVID-19 down to 13.6% in immunocompromised subjects -- a significant drop from 44% if unvaccinated, and slightly lower than the 15.6% risk in the unvaccinated immunocompetent population. While the antibody response (which matters most for preventing illness) in the immunocompromised has dropped significantly during Omicron, research has shown this group to achieve a similar proportion of benefit from the shots as healthy people. And one investigation, a randomized trial nested into the Swiss HIV Cohort Study, revealed an antibody response to mRNA vaccines in all participants living with HIV.
Why doesn't everyone know about these studies? Why haven't news outlets blasted the reassuring news over and over? Why do journalists continue to grab quotes like, "I'm risking my life every time I go to the drugstore" from people with suppressed immune systems?
To be fair, some studies have found that a weakened immune system does raise the odds of a bad outcome from COVID-19 -- but not by orders of magnitude and not equally for all underlying conditions. A Korean study of over 6,000 patients, for example, connected poor immune function to a twofold mortality risk from the virus. Some people may deem this multiplier too large for comfort, but with the risk-reducing measures at their disposal, like respirator masks and antiviral treatments if they do catch the virus, does the level of risk really warrant the catastrophizing narrative we're seeing?
A very small proportion of immunocompromised people, such as organ transplant patients, do face markedly higher risks from COVID-19, but most people with reduced immune function do not fall into this category and deserve to know it. Instead, public health experts and communicators have allowed people's misguided assumptions to metastasize.
Throughout the pandemic, those who downplayed COVID-19 risks have been called out for spreading misinformation. If we're going to point fingers, we also need to expose the mirror-image error: failing to dial down a distorted perception of risk. When media outlets perpetuate this distortion, experts should step in and set the record straight.
Widening the Lens
At this stage of the pandemic, we also need to zoom out and look beyond protection from one particular virus -- especially since we can't protect ourselves forever.
We will never achieve zero risk for every immunocompromised person on the planet -- or anyone else, for that matter -- so we need to ask ourselves the big-picture questions: Does an indefinitely masked, distanced world serve our best interests? Do we want to remove the human face from public life? As social animals, humans thrive when given the opportunity to connect freely with other humans. Keeping our faces covered, and especially "social distancing," make these connections smaller and sadder -- for all of us, including people with weaker immune systems. We must weigh these costs as well.
While my own immune system appears to be in working order, my age alone -- 65 years -- puts me in a higher-risk bracket. Even so, I don't want to organize my life solely around protection from risk: I want opportunity and connection, too.
As masking and other COVID-19 restrictions continue to fall away, all immunocompromised people need not put their lives on hold. Armed with the truth about their risks, they can weigh the numbers against their personal risk tolerance and make decisions accordingly. If they opt for extreme caution, we can respect this choice -- but we shouldn't insist on it. Instead, we should supply them with the facts and course-correct them when their fears outpace reality.
I want for immunocompromised people what I want for everyone: a life that has a whole lot of living in it.
Gabrielle Bauer, MSc, is a Toronto-based medical writer.