Immunocompromised people can now get 4th COVID shot, but they remain vulnerable in face of unvaccinated, maskless people

By Anna Gustafson, Michigan Advance

When Dr. Peter Gulick works with his patients who have HIV/AIDS, he always recommends they get the third COVID-19 vaccine shot that’s been available to immunocompromised individuals since August. 

For the approximately 7 million people living with weakened immune systems living in the United States, that third shot has represented a chance to avoid becoming seriously ill with COVID-19 or dying, he explained.

“I try not to be overly scary, but I remind them they could pick this disease up; they could transmit it to somebody else; they could get seriously sick,” Gulick, an infectious disease expert and a professor of medicine at Michigan State University’s College of Osteopathic Medicine, said of COVID-19.

Individuals with seriously weakened immune systems — like people with HIV/AIDS, cancer patients on chemotherapy or those who have gotten bone marrow transplants — have been far more likely to contract serious cases of COVID-19 and die than those who are not immunocompromised. And for those patients, being vaccinated with two doses — as was originally recommended for the general public — gave them nowhere near the level of protection others received.

Those two doses “were maybe only 30%” effective against hospitalization for immunocompromised patients, compared to the 90% that the Pfizer vaccine originally was for the general public, Gulick said. They’ve also contracted COVID-19 three times more often than people without weakened immune systems, according to a November 2021 study from the Journal of Medical Economics. 

And patients who are immunocompromised have seen staggeringly high COVID-19 death rates — as high as 55%.

All of which is to say: When the U.S. Centers for Disease Control and Prevention (CDC) announced in August that it recommended a third vaccine shot for this population, patients and medical professionals were relieved. That third shot is given about 28 days after the second and is a regular shot, not a booster.

The public should realize that even if you’re not immunocompromised, any number of people you run into are potentially immunocompromised and more vulnerable to infection. That’s one of the reasons to consider wearing a mask.

Dr. Liam Sullivan, an infectious disease specialist at Spectrum Health in West Michigan

Now, that protection coming from the third shot should be further strengthened with immunocompromised individuals being able to access a booster shot five months after their first three vaccine shots, the CDC said this month. For those who received their third shot in August, that means they are eligible to receive the booster this month. A booster shot typically provides a lower dose of the vaccine than the primary shots.

The CDC in October said immunocompromised individuals were eligible to receive a booster shot six months after their first three shots. That was shortened to five months in January after the highly contagious omicron variant caused cases to soar. 

This fourth shot is meant for people who received three Pfizer or Moderna shots. The CDC has not recommended an additional primary dose for those who got the single Johnson&Johnson shot, but it advised getting a booster shot of the Moderna or Pfizer vaccines two months after the original shot.

The additional vaccine dose is a welcome one for vulnerable patients and their health care providers, medical experts told the Advance. It doesn’t, however, mean those with weakened immune systems are in the clear, and individuals battling health challenges are facing lives made significantly more difficult by those who refuse to get vaccinated or wear masks because they cause the virus to spread faster, doctors said. 

For people whose immune systems are already weak, that spread means they’re more likely to encounter the virus and potentially a life-or-death situation that could have been avoided had people thought of others and gotten a vaccine or worn a mask, experts said.

‘They need to socialize and see their friends and family, as well’

Dr. Liam Sullivan, an infectious disease specialist at Spectrum Health in West Michigan, said the additional layer of protection that the fourth shot provides to those with weakened immune systems is critical — particularly in the face of the fast spreading omicron variant and the fact that people are continuing to go unmasked in public.

Going unmasked not only makes that person more susceptible to contracting COVID-19, it also means they could more easily transmit the virus to an immunocompromised person near them, Sullivan explained.

“The public should realize that even if you’re not immunocompromised, any number of people you run into are potentially immunocompromised and more vulnerable to infection” Sullivan said. “That’s one of the reasons to consider wearing a mask.”

“We can’t tell [immunocompromised individuals] to go live in a bubble,” he said. “They have to go to the pharmacy; go to the grocery store. They need to socialize and see their friends and family, as well.”

But, health experts said, those with weakened immune systems face far more risks when trying to navigate basic daily tasks — like going to the grocery store or pharmacy — due to the fact that they’re far more vulnerable to serious infection, Sullivan said. Those risks could be significantly lessened if more people were vaccinated and wore masks, health experts said.

Dr. Ryan Malosh, an infectious disease epidemiologist at the University of Michigan who studies respiratory viruses and was diagnosed with leukemia in November 2018, told the Advance last year that living with a compromised immune system during COVID-19 has been deeply frightening.

Seeing people without masks has been particularly worrisome for Malosh, and he said he always wants to tell those denouncing face coverings: Please wear one. You’re saving my life by doing so.

“I think it’s probably worse mentally than anything else,” Malosh said of the pandemic. “There’s the anxiety about being in public. We grabbed takeout from a pizza place and decided to have a picnic with the kids, and all of a sudden we found ourselves in a crowd of people. That’s scary.”

The idea of the public remembering those who are immunocompromised — at all times, but especially during this pandemic — is something about which Malosh is incredibly passionate, so much so that he penned an opinion piece in the Detroit News about it. 

“Thank you, residents of Michigan,” Malosh wrote. “Because you’ve stayed home, my children aren’t fatherless. …Your efforts have protected me and many others like me. You see, when people write off the seriousness of the COVID-19 pandemic by saying, ‘It only kills the old and sick,’ they’re talking about me.’”

‘Ready and armed with vaccines’

Michigan pharmacies have been providing the fourth COVID-19 shot to immunocompromised patients and are ready to do so further, said Farah Jalloul, the director of professional development at the Michigan Pharmacists Association. 

“We are ready and armed with vaccines,” Jalloul said. “If anyone is looking to get that fourth shot, make that appointment with your pharmacy. Most pharmacies are doing appointments for this population so they can minimize contact with people.”

Pharmacists are doing COVID testing, COVID vaccines, flu vaccines — and they’re doing that on top of their regular workload. And then you have staff contracting COVID. It’s hard.

Farah Jalloul of the Michigan Pharmacists Association

Additionally, some pharmacies have set aside time for vulnerable populations to be the only ones in the pharmacy in order for them to get their COVID-19 booster, Jalloul said and encouraged immunocompromised patients to ask their pharmacies about this possibility.

Throughout the pandemic, the Michigan Pharmacists Association has worked to ensure that pharmacies throughout the state receive up-to-date information from the CDC, such as the fact that immunocompromised patients are able to receive a fourth shot. Still, she said, it has been a challenge to navigate often changing information and the pandemic in general, and she encouraged the public to meet the pharmacists with grace. As with other health care workers, pharmacists have experienced a public that has become increasingly aggressive public as the pandemic wears on.

“Everyone in health care is so burnt out and tired,” Jalloul said. “One thing I’d like the public to know is to be patient with our health care providers. We’re here to help you and address your concerns. Just be patient and kind.

“Pharmacists are doing COVID testing, COVID vaccines, flu vaccines — and they’re doing that on top of their regular workload,” she continued. “And then you have staff contracting COVID. It’s hard.”

More vaccine shots for the general public?

It may not only be immunocompromised patients who will need to have a fourth COVID-19 shot, said Dr. Justin Skrzynski, an internal medicine physician at Beaumont Hospital, Royal Oak. For individuals who have gotten their two primary COVID-19 vaccine doses and their booster shot, another vaccine dose may be necessary in the face of aggressively spreading variants, the doctor explained.

“It’s very likely we’ll need fourth shots for the general public,” he said. “Some vaccine manufacturers are working on omicron specific boosters, which will probably be recommended for the next booster.”

Both Pfizer and Moderna began clinical trials for an omicron-specific booster shot this week.

Omicron, which spreads far more quickly than the previous delta variant, now makes up the overwhelming majority of COVID-19 cases in the United States. While it is causing less serious cases for those who are vaccinated, it is causing more breakthrough cases than delta did and it poses significant risks for those who are unvaccinated and those with weak immune systems, Gulick said. 

Currently, 58.7% of Michiganders eligible to receive a COVID-19 vaccine have gotten two doses of the Pfizer or Moderna vaccine or the one-shot Johnson & Johnson vaccine, according to the Michigan Department of Health and Human Services. Just 40% of Americans who have received their two Pfizer or Moderna shots or one Johnson & Johnson shot have gotten a booster shot, according to the CDC. 

To reach herd immunity with variants circulating, around 90% of the population needs to be vaccinated, health experts have told the Advance.

“It’s like we’re chasing the variants, and they’re more clever than we are,” Gulick said. “The issue is, the more people don’t get vaccinated, the more variants we’ll continue to get. It means more people should get vaccinated.”

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