Carlos Rosales got his second COVID-19 vaccine shot on June 7. Even so, the Brentwood man said he will continue wearing masks and avoiding most public places, because he has a weakened immune system that is less likely to produce antibodies to the coronavirus.
"It will always be on my mind that I’m at risk," Rosales said. "Even though I’ll have two [shots], I’m always going to be careful."
Rosales, 44, is one of millions of Americans who are immunocompromised, which means they have immune systems that are less able to protect them from infections and diseases. The COVID-19 vaccine typically triggers the immune system to generate antibodies to fight off the coronavirus, but that often doesn’t happen in immunocompromised people, studies show.
What to know
Many people with weakened immune systems do not create antibodies to the coronavirus after receiving the COVID-19 vaccine, which means they may not be protected from the disease.
People with cancer, transplanted organs, HIV and autoimmune diseases like lupus and inflammatory bowel disease are among those who may have weakened immune systems.
Doctors are telling many immunocompromised people to keep wearing masks and practicing social distancing, even after vaccination.
People with cancer, transplanted organs, HIV and autoimmune diseases such as lupus and rheumatoid arthritis are among those who may have weakened immune systems. Nearly 3% of Americans are immunocompromised, according to a 2016 Centers for Disease Control and Prevention analysis of self-reported health data.
Rosales had a liver transplant in 2019, and like other transplant recipients, takes medications that suppress the immune system so their bodies don’t reject their new organs, said Dr. Lewis Teperman, who performed the transplant surgery on Rosales and is director of organ transplantation at Northwell Health. Those same medications also can prevent the immune system from responding to the vaccine.
Teperman said roughly 60% of about 100 Northwell transplant recipients tested for antibody levels had none after inoculation. A recent study by Johns Hopkins University researchers found that 46% did not have antibodies. Rosales’ antibody levels can’t accurately be tested so soon after vaccination.
Rosales rarely goes out, except for work, and that will continue even though he’s vaccinated, he said. He works installing lockers and other items, and is almost sure it was on the job that he contracted the coronavirus in January. He is at higher risk for severe COVID-19, so doctors infused him with monoclonal antibodies, a treatment that studies indicate can prevent hospitalization. Rosales had only a mild case.
He still needs to work to support his family. "I try not to worry too much," he said. "I just cover myself and take care of myself as much as I can, and I leave myself in God’s hands."
Teperman urged transplant recipients to get vaccinated.
"They shouldn’t be disappointed knowing that the rates are somewhere between 40 or 50% response [to the vaccine], because those 40 or 50% of the patients will, we believe, be protected," he said.
More research is needed to determine if those without antibodies are protected by some other part of the immune system, such as T cells, he said.
But, Teperman said, "If you take the vaccine and you don’t make antibodies, you’re at risk. It’s like jumping out of the plane without a parachute. They should still practice wearing a mask and social distancing."
Experts find 'impaired response' to vaccine
At the Perlmutter Cancer Center at NYU Langone Hospital-Long Island in Mineola, doctors have found that "of patients receiving chemotherapy, a significant proportion of them have an impaired response to the vaccine," said Dr. Jeffrey Schneider, the hospital’s chief of hematology and oncology. Others produced antibodies, he said.
Doctors there have tested about 400 cancer patients for antibodies and are planning to analyze the data in a more formalized study, he said.
Chemotherapy circulates in the blood and "kills dividing cells," said Donna Farber, a professor of microbiology and immunology at Columbia University. "A lot of immune cells are dividing cells, so you kill off a lot of immune cells with chemotherapy."
People with blood-related cancers are less likely to produce antibodies even if they’re not undergoing treatment, a non-peer-reviewed study published April 7 on medRxiv found. Among chronic lymphocytic leukemia patients, only 23% produced antibodies, the study found.
Bill Nelson, 80, of Woodmere, who has chronic lymphocytic leukemia, received his second Moderna vaccine in late February. His leukemia is stable, so he delayed a resumption of treatment to make it more likely the vaccine would create antibodies. But tests showed no antibodies, Nelson said.
He opted to get a third shot — this time a Pfizer-BioNTech vaccine — last month. This time, tests showed a small number of antibodies. He got another Pfizer shot on Friday.
The CDC says "revaccination is not recommended" for immunocompromised people.
Dr. Alfred Kim, an assistant professor of medicine at Washington University in St. Louis who has researched vaccine responses in immunocompromised people, said some patients of his and his colleagues also got booster shots, but "we are certainly not recommending they get boosted."
"We think boosting will be effective," said Kim, but it’s unclear if there will be any negative reactions.
Nelson, a law professor emeritus at NYU in Manhattan, said he’s aware of the possibility of negative side effects of additional shots, and that the shots may not help. But, he said, it’s worth trying, because with his age and cancer, "If I get COVID, I’m gone quickly. I don’t know how treatable it would be."
Nelson said he has been very careful and has "just basically been in the house" with his wife and adult son during the pandemic. All food is still delivered. But, he said, he sometimes needs to go to indoor public places, and not everyone wears masks.
"Were I to develop antibodies after shots three and four, we will change our lives," he said of his wife and son. "We will do things," such as go out to dinner with family and friends.
Nelson is concerned whether Medicare will pay for his additional vaccines, as it did for the first two, but the agency said in a statement that "there is no national policy that would preclude Medicare paying in this circumstance."
Doctors: Research needed on booster shots
Research on the effect of booster shots on immunocompromised people is needed, as are studies on the vaccine’s effect on B cells — which produce antibodies — and T cells, doctors said.
Kim said he is adding research into T cells to an existing study of the vaccine’s effect on people with autoimmune disorders. Unlike measuring antibodies, which is relatively easy, measuring T cells to the spike protein of the coronavirus can only be done in a research laboratory, he said.
Farber said that although it's possible that T cells can provide protection even if the vaccine doesn’t stimulate antibody production, "All available evidence so far strongly suggests that it’s the action of these antibodies that are doing the protection."
Kim’s early, non-peer-reviewed findings, published April 9 on medRxiv, found that the vaccine led to robust antibody creation in most people with autoimmune disorders. Only 15% had undetectable or weak antibody responses, he said, and most were on drugs that suppress the immune system.
Anne Hogan, of Glendale, Queens, got vaccinated on the advice of her oncologist, who said radiation treatment for breast cancer had weakened her immune system and put her at higher risk for severe COVID-19.
Hogan, a volunteer with the Adelphi NY Statewide Breast Cancer Hotline and Support Program in Garden City, has been somewhat less cautious since she got her second dose in mid-April because she had been unaware the vaccine may not be effective. Her conversation with her doctor was before the release of most studies on immunocompromised people’s vaccine response.
"I guess I’d have to get tested and see," Hogan said. "If I truly didn’t produce any antibodies, I might wear [the mask] more."