Data Snapshot: Immunesuppression in the United States in the Covid-19 era.
Medical conditions and medications both leave some people vulnerable. Here's the breakdown from a recent large survey.
I’ve been thinking a lot about immunocompromised people lately. During the Delta wave, one CDC study found that nearly 11% of hospitalized patients were immunocompromised. That figure rose to 17% during the early Omicron wave.
It’s hard to know exactly how many people are immunocompromised in the population, but people with organ transplants and cancer are living longer than ever. It appears that there are more immunocompromised people than ever.
How immune-compromised are we?
Here are results from the National Health Interview Study, which reached tens of thousands of US adults. Note that these results are not adjusted to reflect the population. So while 4.8% of survey respondents report a weakened immune system due to a health condition, that might be higher than the general population for a few reasons. One reason is that women have higher response rates than men and women have a higher rate of immune-compromise both due to health conditions and medications. So while the breakdowns for males and females are probably pretty accurate, the “all adults” figure (4.8%) is probably a bit higher than reality.
That said, if these numbers are close to reflective of the general population, we might have well over 10 million immunocompromised adults in the US, and maybe even 12-15 million, depending on how some of the breakdowns went. Generally, the number of immunocompromised adults in the US is cited as being around 7 million. But that’s based on old data.
It’s notable to me that within each sex, there are more people who are immunocompromised because of health conditions than due to medications, but not by much. There are also some interesting differences by age group, region, and race/ethnicity.
Implications.
The reason this matters is that as the pandemic progresses, more people have some form of immune memory to Covid-19, be it from vaccines, infections, or both. But some immunocompromised people don’t have that immune memory, or perhaps weaker immune memory to the virus. This leaves the immunocompromised population more vulnerable by comparison.
There are two reasons this matters. First, as I wrote last week with Dr. Katelyn Jetelina, the immunocompromised should probably be given the option to get a Covid-19 booster more than once per year (which seems to be the current approach). Second, the prophylactic antibody medication Evusheld is no longer available (variants rendered it useless). We need to incentivize drug companies to make a new version. But they’re understandably worried that they won’t recoup their development costs if yet another variant comes around.
While Omicron may have staying power (it has reigned supreme for >15 months now), I could still see how the lack of predictability could spook drug companies from making the up-front investment. That’s why the US government should subsidize this. If the new antibodies don’t make money, the government should make the companies whole, or close to it. If they do end up making money, the government should get paid back after a certain amount of profit. In this way, we’ll risk will be assumed by the taxpayers and if the finances allow it, we’ll eventually get a partial return on our investment, both in terms of health outcomes and money back in the coffers.
Thanks to Benjy Renton for curating Data Snapshot.
Data: 2021 National Health Interview Survey: https://www.cdc.gov/nchs/nhis/2021nhis.htm
I met with my physician who is immune compromised due to a medication: I have a primary immune deficiency--and they tend to be under-diagnosed. She has been using Enovid--a nasal gel/spray legal in Israel. She did get Covid at a work function. Still masking in her office, but it's going away as a policy. My husband went to the eye doctor, who has had at least 2 completely asymptomatic Covid infections to date, and he will be not wearing a mask in exam rooms soon...and his patient base tend to be older. I am noticing that some physicians are coding immune deficiency due to diabetes on patient charts. Immune deficiency is a poorly characterized "condition". I did learn that B cell depletion appears to convey worse outcomes than tumor necrosis factor infusions, from a Cleveland Clinic CME. As Covid fades into invisibility in the public, I think the "at risk" category needs clarification, boosters and information.
Dr. Faust, have followed your writings, often via Med page, with much appreciation and respect for your specific field of medicine and your genuine interest and concern about immune compromised folks. And while I've been grateful to see articles like this about data (and the need for better data) I was saddened to see you "drop the ball" on your Med Page article this AM on Spring Boosters. I am severely immune compromised as I have CVID (primary immune deficiency), long term Progressive MS that has weakened my diaphragm and for which I'm on Ocrevus, have RA, high blood pressure, history of TIA's, heart issues and list goes on. Had my last COVID booster almost 7 months ago. Was told by my MS neurologist/immunologist at UMASS Memorial to get another booster as am due my next infusion of Ocrevus in 4 weeks. My pharmacist will not give it to me this time as there is STILL no formal "go ahead" from CDC. WHO has done this as have Canada and UK but US still monkeying around with our lives. Dr. Walensky, Dr. Lena Wen, and a long list of medical authorities and sadly now you seem to omit the disconnect in all recent public statements that "yes" we should get the booster...BUT WE CAN"T. Meanwhile, folks like me and my sister in Washington state who has terminal Inflammatory Breast Cancer also are facing the unmasking of the medical facilities we go to as we go into waning vax protection and a Fed gov more interested in the 2024 election than the many Americans still dying of COVID. We need our physicians in organized mass to send a letter demanding that we are not an acceptable casualty, that we currently have the boosters we need but we don't have time for complacency.