COVID-19 and Weakened Immune Systems: CDC Advice After Evusheld Stopped Working, 2023

This is guidance from January 2023, posted as an MMWR Early Release on January 27, 2023. Vaccines, variants and treatments have changed since; check CDC's current advice.

Evusheld no longer protected

As of January 20, 2023, more than 90% of the SARS-CoV-2 variants circulating in the United States — the Omicron sublineages BQ.1, BQ.1.1, XBB and XBB.1.5 — were unlikely to respond to Evusheld (tixagevimab and cilgavimab), the combined monoclonal antibodies given to prevent infection. On January 26, 2023, the Food and Drug Administration announced that Evusheld was no longer authorised for that use in the United States.

That left people who are moderately to severely immunocompromised, those who may not respond well to vaccines, and those who cannot be vaccinated needing extra caution and extra prevention — and a care plan for prompt testing when symptoms start and quick access to antiviral treatment.

Vaccination first

Vaccination remained the most effective protection against serious illness, hospitalisation and death. CDC advised everyone — immunocompromised people, their households and close contacts — to stay up to date and get the updated (bivalent) booster when eligible. People with weakened immune systems may not respond strongly to vaccines, but staying up to date still gives some protection, and preliminary CDC data showed the bivalent booster added protection against symptomatic infection in people who had already had two, three or four of the original doses.

Yet uptake was low: as of January 18, 2023, only 15.3% of people aged 5 and older had received a bivalent booster. CDC recommended one bivalent booster for everyone eligible aged 6 months and older, with specific timing rules for young children depending on which primary series they had received.

Everyday protection

For immunocompromised people and those around them, CDC suggested, on top of the booster:

• a high-quality, well-fitting mask, and keeping at least 6 feet (1.8 m) from others, especially when crowded indoor places cannot be avoided;
• better ventilation — simple steps to increase air flow, CDC's interactive home-ventilation tool, and in-duct ultraviolet germicidal lights that can be added to home heating and air-conditioning systems;
• frequent handwashing with soap and water, or a hand sanitiser with at least 60% alcohol when soap and water are not available;
• a care plan worked out with a doctor in advance, in case of infection.

Fast testing and treatment

People with mild to moderate COVID-19 who are 50 or older, have an underlying condition — especially moderate to severe immunosuppression — or are unvaccinated are at risk of severe illness. Whatever their vaccination status, immunocompromised people with symptoms, and their household members and close contacts, should be tested as soon as possible and treated within 5–7 days of symptoms starting.

Early outpatient treatment with a first-line drug — nirmatrelvir with ritonavir (Paxlovid) or remdesivir (Veklury) — or the second-line molnupiravir (Lagevrio) had been shown to cut the risk of severe COVID-19, including hospitalisation and death. These drugs were expected to keep working against the circulating Omicron sublineages and were widely available. Treatment, CDC stressed, is no substitute for staying up to date with highly effective vaccines.

Sources

• Patel P, Twentyman E, Koumans E, et al. "Information for Persons Who Are Immunocompromised Regarding Prevention and Treatment of SARS-CoV-2 Infection in the Context of Currently Circulating Omicron Sublineages — United States, January 2023." MMWR, CDC. https://www.cdc.gov/mmwr/volumes/72/wr/mm7205e3.htm
• Graphic: CDC.
• Rewritten in hubnx's own words.