Alicia Merritt had received two doses of Covid-19 vaccine and was thinking about taking down a shower curtain she hung over the bar in her small Baltimore tavern to separate herself from customers when she recently learned some troubling news.
For many people like her, a liver transplant patient who must take immunosuppressants daily to prevent her body from rejecting the organ, the vaccines are proving less effective than for people with normal immune systems, a new study found.
“I’m putting myself out there in the public, and I could be still getting Covid,” said Ms. Merritt, the 71-year-old owner and bartender at Birds of a Feather. She said she later found out she had no antibodies against the virus.
Now, Ms. Merritt and millions of other people with compromised immune systems and their doctors are scrambling to figure out what to do in an evolving science project playing out in real time.
‘I’m putting myself out there in the public, and I could be still getting Covid,’ said Alicia Merritt, owner of the Birds of a Feather tavern in Baltimore.
Photo: Matt Roth for The Wall Street JournalSome are taking a third shot to try to jar their immune systems into generating the antibodies that protect them from the virus. Others are considering modifying their immunosuppressants in consultation with their doctors in hopes another shot will be effective. And a few are jumping through bureaucratic hoops to get access to monoclonal antibodies, which could provide protection until more people in the general population are vaccinated.
Meanwhile, researchers are seeking approval to study these options more formally.
The Centers for Disease Control and Prevention currently recommends that vaccinated people with compromised immune systems talk to their doctors about the need for additional personal protective equipment, and many transplant doctors say they should behave as if they weren’t vaccinated. The CDC also said more study needs to be done before it can recommend that immunocompromised people get an extra shot.
About 10 million people in the U.S. take immunosuppressants for various conditions, including Lupus and organ recipients, said Dorry Segev, a transplant surgeon and researcher at Johns Hopkins University School of Medicine, who since January has co-written numerous papers on vaccines in immunocompromised patients. Cancer patients and others with compromised immune systems are also at risk, but transplant recipients, who often take a cocktail of powerful immunosuppressants, are some of the least likely to develop antibodies from the vaccines, he said.
In a paper published in the Journal of the American Medical Association last month, Dr. Segev’s team found that 46% of transplant recipients had no antibodies after two vaccination shots. Of the 54% who did develop antibodies, their levels were generally lower than people with normal immune systems.
Transplant patients and other immunosuppressed people often get less of a response from vaccines, but the results for the Covid-19 shots were particularly bad, Dr. Segev said.
“We knew there would be a drop in immune response, but we didn’t anticipate that it would be this stark,” he said.
The question is what to do to respond.
“Unfortunately, it’s not known what should be done. We don’t have data,” said Mark Mulligan, director of New York University’s Langone Vaccination Center. Dr. Mulligan said more research needs to be done into whether immunocompromised vaccine recipients are getting immunity in other ways besides antibodies, such as through their T and B cells, other actors in the immune system.
He said the idea of temporarily altering immunosuppressants has been shown to help the effectiveness of flu vaccines in patients with certain conditions, but that approach is generally not recommended with transplant patients because of the risk of organ rejection.
“Remember, that is a precious gift of life, that transplanted organ,” he said.
Dr. Segev said he is hoping for approval soon from federal authorities to launch a study of the effect of giving transplant patients a booster shot. There is a theoretical risk that the immune activation might cause rejections or other problems with the transplanted organs, he said.
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Ms. Merritt is torn between waiting and trying to get a third shot on her own. She doesn’t want to wait, but she also doesn’t want to get herself or anyone else in trouble for getting a third shot, since it isn’t yet recommended by the CDC.
“It’s terrible, it’s a Catch-22. You’re right in the middle. You don’t know what to do,” she said. So for now, she is keeping up the plastic sheet in her bar, using plastic cups and requiring patrons to register and wear masks. And she and her husband have put summer travel plans on hold.
Neil Emmott, a 58-year-old with a transplanted kidney in Fort Lauderdale, Fla., had very low antibodies after his first two shots but isn’t waiting around for the medical community to make up its mind on an extra shot.
Yacht broker Neil Emmott made a trip to Italy late last month after getting a third Covid-19 vaccine shot.
Photo: Neil EmmottAs a participant in the study recently published in JAMA, Mr. Emmott, a yacht broker and former banker, heard Dr. Segev talk about the possibility of getting a booster shot on a webinar and decided he would try to get one. After getting approval from his nephrologist, he went to a large drugstore chain and got another shot. His antibody levels are now in the middle range for normal patients.
“There’s risk with everything but there’s also reward,” said Mr. Emmott, who spoke on the phone from an airport security line as he waited to board a flight to Italy for his work—a trip he wouldn’t have been able to make before getting the third shot.
Robert Montgomery, head of surgery at NYU Langone Health and director of its transplant institute, was in the same boat as some of these patients back in March. Dr. Montgomery, who received a heart from a person with hepatitis C in a groundbreaking procedure, found out that he had no antibodies after two shots.
When he got the news, he sent an email to Dr. Segev with the subject line: “Houston, we have a problem,” both doctors said.
In consultation with the doctors who take care of him at NYU, he decided to become one of the first people to try getting a booster, and it worked. Now, he said, he is pushing for the medical community to offer other patients the chance to get tested for antibodies and to get a third shot if needed.
“We should be out in front of this, you know, rather than kind of leaving people to their own devices,” Dr. Montgomery said.
Write to Joe Barrett at joseph.barrett@wsj.com
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