Thread by @LCalabreseDO

No one knows the future of #COVID-19 but its not going away and will be an ongoing threat to the #immunocompromised even w #vaccines –these r our thoughts and plan to protect them NOW NB this will change! @sax
@CarlosdelRio7 @zeynep @CCalabreseDO @alhkim @Bob_Wachter
1/15

Immunocompromised pts (autoimmune, cancer, transplants PID/IEI) make up 3%+ of the pop. But are disproportionally affected w breakthrough and severe outcomes The @CDC definition of who is immunocompromised is inadequate @fitterhappierAJ @zach_wallace_md @jeffsparks @JYazdanyMD

First issue is how do we define #immunosompromised? This is complex and not simply by ICD Dx for sure- many people carrying immune mediated Dxs are not functionally immunocompromised though defining who is more complex

We like the @IDSA graphic which shows the layers of variables that contribute to being #immunocopromised with the last row the most complex based on IMID Dx and immunosuppressive therapies which induce vastly different levels of immunosuppression

For example, some people may carry a dx of RA #lupus or @sjogrens or other have little end organ disease, 0 med conditions and only on hydroxychloroquine and not be at high risk -same for some on certain biologic mono Rx ie TNFi-

The CDC at the end of their confusing definition of #immuncompromised states that decision making between pt and practitioner is important but we say that it is vital and should decided with THE IMMUNOLOGIST managing the IMMUNE disease ! KEY POINT

We agree with the redzone of this graphic but would put on ALL PTS ON B CELL DEPLETING AGENTS which is the most prevalent significant risk factor & are used in MS RHEUM dis, Derm and oncology and beyond >2,000,000 exposed people

Even when immunized multiple times some #immunocompromised respond sub optimally quantitatively and qualitatively & remain vulnerable w vaccine response waning more quickly in #immunocompromised pts as well

ACCORDINGLY We believe an active CIRCLE of CARE is essential to comprehensively protect these patients starting with educating the pt on risks, prevention & testing strategies, appropriate care contacts and available Rx options & this can be implemented NOW!

4 PATIENTS = Access and procedural knowledge of use & limitations and assessment of capacity of pts for HOME TESTING are critical and will remain so as our current and future Rx will likely remain TIME LIMITED – When too sick pts must bypass all and reach acute care

Prevention strategies - including non-pharmacologic means- for #immunocompromised will remain important and need continual reinforcement

Antivirals are key -see @IDSA ongoing review- but are underutilized for a number of reasons including delayed diagnosis, lack of declarative and procedural knowledge of practitioners, pts contacting the WRONG provider and health disparities idsociety.org/covid-19-real-…

Health disparities are import as well and need to be addressed

There is a reasonable debate as to who should receive/offer antivirals to but in general MOST immunocompromised stand to gain the most w early Rx @RheumNow

there are innovative trials now getting underway to test new care pathways to enhance outcomes for the #immunocompromised e.g. h/t @EricTopol et al using NAA at home testing -we are enthusiastic @zeynep

Practitioners caring 4 #immuncompromised and health care systems who manage many such lives need an organized plan to reach and protect them & in the near future strategies may be effective for these pts 4 other pathogens ie flu RSV etc as well!

FOR NOW (JAN 23) our plan is doable at the individual point of care diad AS WELL as in an organized setting of a practice or institution/system- It just needs to get done! Pt groups need to be organized/vocal and demanding such care - we welcome your thoughts