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Boosters for Immunocompromised and Patients at High Risk

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Boosters for Immunocompromised and Patients at High Risk

  1. 1. Continuing Education Credits In support of improving patient care, Community Health Center, Inc. / Weitzman Institute is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. A comprehensive certificate will be sent after the end of the series, December 2021.
  2. 2. Disclosures & Disclaimers With respect to the following presentation, there has been no relevant (direct or indirect) financial relationship between the faculty listed above or other activity planners (or spouse/partner) and any for-profit company in the past 12 months which would be considered a conflict of interest. The views expressed in this presentation are those of the faculty and may not reflect official policy of Community Health Center, Inc. and its Weitzman Institute. We are obligated to disclose any products which are off-label, unlabeled, experimental, and/or under investigation (not FDA approved) and any limitations on the information that are presented, such as data that are preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion. This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $137,500 with 0% financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.
  3. 3. At the Weitzman Institute, we value a culture of equity, inclusiveness, diversity, and mutually respectful dialogue. We want to ensure that all feel welcome. If there is anything said in our program that makes you feel uncomfortable, please let us know.
  4. 4. 20 Oct 2021
  5. 5. 44,937,514 cases on 10/18/21 with 724,417 deaths https://coronavirus.jhu.edu/us-map COVID-19 in the United States: TOTAL
  6. 6. COVID-19 Hot Spots https://www.nytimes.com/interactive/2021/us/covid-cases.html
  7. 7. https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html Summer Surge
  8. 8. https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html
  9. 9. Delta Variant – “like COVID on steroids” • It is a variant of concern! (VOC) • One of the most transmissible viruses known – (Up there with chickenpox, varicella) • Contains at least 13 mutations from the original strain – 4 of these are of particular concern affecting the Spike protein • Higher transmissibility, more amounts of virus (1200x) • Stronger attachment to ACE-2 receptor • Decreased recognition by the immune system • Increased cell to cell infectivity (?) • Delta itself is mutating further: DELTA VARIANTS – AY.1 to AY.38 – ‘Delta plus’ AY.1 and AY.2
  10. 10. ‘Bully in the Playground’
  11. 11. Groups at Higher Risk for Infection Risk Factor Asthma Serious Heart Disease Chronic Lung Disease Hemoglobin Disorders Diabetes Nursing home residents/LTC Chronic Kidney Disease - Dialysis Aged 65 and older Liver Disease Immunocompromised Morbid Obesity https://www.cdc.gov/coronavirus/2019-ncov/need-extra- precautions/groups-at-higher-risk.html
  12. 12. The Amazing Immune System Working ‘Behind the Scenes’
  13. 13. Immunity 101 • Receive the vaccine, immunity starts to go up • Get a second shot – and immunity increases nicely
  14. 14. Do we need boosters? What might happen immunologically after a booster?
  15. 15. Immunity 201 • Receive the primary series, immunity very good after 2nd shot Get a booster shot …. Get a booster shot expect immunity to explode upwards!
  16. 16. Booster Immunizations “It's very, very clear that there's waning immunity, and we need to boost individuals who have received any of the three products that we've been dealing with right now” – Dr. Anthony Fauci
  17. 17. Boosters • Pfizer vaccine approved 3rd shot 6 months out • Moderna, J&J - could get approval as booster shots this week - by Wednesday evening? – Up to the full FDA and CDC to give the green light – 15 million Americans got Johnson & Johnson • “Mix and match” study showed increased immunity: – J&J vaccines given another J&J booster = 4x – J&J vaccines given Moderna = 76x increase
  18. 18. “Mixing and Matching” • The immune system will respond to what it ‘sees’ – NIH study: Atma RL et al. Heterologous SARS-CoV- 2 Booster Vaccinations – Preliminary Report • COVID-19 vaccines are robust! • Analogy: – Pfizer vaccine: Left hook – Moderna vaccine: Right jab – J&J: Big punch www.animatedimages.org
  19. 19. Moderna or Pfizer Boosters for Johnson & Johnson Recipients? • Providers should be given a measure of discretion as the campaign ramps up – Dr. Paul A. Offit, FDA and Children’s Hospital of Philadelphia, noted “we should move quickly on this, because it’s already happening.” • Operationally: try to make it easy…
  20. 20. COVID-19 Vaccinations Across the Nation https://covid.cdc.gov/covid-data-tracker/#vaccinations
  21. 21. COVID-19 Boosters Across the Nation https://covid.cdc.gov/covid-data-tracker/#vaccinations
  22. 22. https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-people-fully-percent-total Percent Fully Vaccinated by State for the Total Population
  23. 23. Trusted Resources • Johns Hopkins https://coronavirus.jhu.edu/map.html • CDC https://www.cdc.gov/coronavirus/2019-ncov/index.html https://emergency.cdc.gov/coca/calls/2020/ • WHO: https://www.who.int/emergencies/diseases/novel-coronavirus- 2019 • Others https://www.nytimes.com/interactive/2021/us/covid-cases.html https://www.thelancet.com/coronavirus https://covidactnow.org/

Editor's Notes

  • 10/18: Welcome everyone – today’s topic concerns immunocompromised and high risk patients: with a focus on boosting immunization.
  • 10/4/21: Here you can see from the map the ‘hot spots’ occurring around the country. The Darker colors mean more active infections: Alaska, the “Mountain West”, some parts of the midwest – Coal mining areas (W Virginia).

    10/19: . ~86,000 new cases/day (down from 160,000 daily beginning of September)
    -most states are rebounding… TROUBLE spots: Colorado, Vermont, Michigan
    ALASKA – still having trouble - may have peaked? ANCHORAGE approved a MASK MANDATE – who would believe??
    -FLORIDA is much better – one of the lowest average daily cases in the U.S.
  • 10/18/21: Here you can see with the red arrow where we are with ‘new’ reported cases… the Summer Surge is thankfully declining nicely…
    For 10/17 – 7 day average was 83,576 cases/day.
    Monday 22,152 (always low on a Monday)
  • 10/18/21: New Cases are trending downwards…
  • B.1.617.2 (India) – DELTA variant
    -"like Covid on steroids," Andy Slavitt, former White House senior adviser for Covid-19 response
    -thee dominant strain: 99% of all new infections
    (in the middle of June – just 20%) CDC
    -Researchers: 1260x more virus in nasopharynx than wild type
    -shorter onset: 4 days rather than 6
  • Of course those who were never immunized: Now at higher risk of contracting it
    The vaccines work – up to a point, in the face of this new threat.

    Who are those most at risk?

    The most important diseases as risk factors:
    Cancer
    Cerebrovascular disease
    Chronic kidney disease*
    COPD (chronic obstructive pulmonary disease)
    Diabetes mellitus, type 1 and type 2*
    Heart conditions (such as heart failure, coronary artery disease, or cardiomyopathies)
    Obesity (BMI ≥30 kg/m2)*
    Pregnancy and recent pregnancy
    Smoking, current and former

  • Enormously complex
    ‘work of art’
    As you can see – there are different parts to it… B cell arm – creating antibodies…. T cell arm- army of cellular defenses – cells that go on the attack!
    Myriad other supports – FEVER being an example of that… the FEVER response. It turns on and starts to ‘hurt’ the invaders.
  • Should be getting 3rd shots – booster shots as of now…
  • Should be getting 3rd shots – booster shots as of now…
  • *antibody increases were seen after 15 days from the booster…
    J&J vaccinee given a PFIZER booster – also increased the titers.
    (They were only measuring antibodies –NOT the cellular immune response)
    COULD NOT COMPARE mRNA vaccines based on this study – not designed to…
    Johnson & Johnson is headed for a booster shot of its vaccine at least two months after the first dose.
  • This is interim data from an ongoing study
    study has limitations. It was not designed to directly compare responses between different booster regimens.
    Still a lot that’s unknown: The immunogenicity data are limited to immune responses through Study Day 29, and only serologic responses are reported. The different homologous and heterologous vaccination regimens may vary in terms of cellular and humoral immune responses as well as longevity of the response.
  • unclear what dosage of Moderna’s vaccine might be authorized for use as a booster for recipients of other vaccines
  • 10/19:
    Connecticut 69.9%
    Vermont: 70.6%
    Puerto Rico – doing very well: 72% immunized
    Alaska – 51.7%

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