During the COVID-19 pandemic, having a strong immune system to stave off infection from the new coronavirus can only be an advantage. While even healthy young adults can become ill from the virus, COVID-19 appears to affect older adults and those with underlying health conditions more severely.
Oftentimes, people with chronic medical conditions are immunocompromised. They have a weakened immune system that’s less capable of fighting off attacks from bacteria and viruses. Conditions such as cancer and certain autoimmune diseases – or their treatments – can affect the immune system. Even normal aging weakens the immune system. Pregnancy can also temporarily put women in an immunocompromised state in many cases.
Health care providers are taking extra steps to protect all their patients from COVID-19, particularly those who might be immunocompromised. You can also take steps to protect yourself.
Medical experts in different fields all emphasize that there is still much yet to learn about the coronavirus and the effects it has on the immune system. Here’s what they’re suggesting and doing right now:
Going through pregnancy during the COVID-19 pandemic is uncharted territory for expectant mothers and OB-GYN doctors alike. Protecting pregnant women from exposure to the highly infectious coronavirus is now a factor in prenatal care. And with clear evidence that pregnancy can affect a woman’s immune system, it’s even more important to take precautions.
“As women, when we’re pregnant, we are essentially more susceptible to all types of bacterial and viral infections that otherwise might not be quite as risky,” says Dr. Natalie Rochester, medical director of the UCHealth Birth Center and vice chief of staff at Greeley Hospital in Colorado. “We are presuming, based on that knowledge, that the same would be true with COVID-19, although there is not enough data to know if that assumption is correct or not.”
Looking at how pregnant women fare during flu outbreaks may offer clues. “Those women have a slightly higher chance to have severe illness,” Rochester says. “We have not seen that hold true yet with COVID. I’m not sure if that means we just haven’t seen enough pregnant women with COVID, or if it truly is the case that pregnant women are not showing severe disease. With the limited data we have so far on pregnancy, we just don’t know.”
Prenatal care is pivoting to virtual office visits whenever possible. “Moms in the last trimester are comforted by the fact that the care team is limiting face-to-face visits” to only when they’re absolutely necessary, Rochester says. “They actually are appreciative of visitor restrictions in the hospital.” Somewhat to her surprise, mothers in late pregnancy also seem to really like having telehealth visits instead of being seen at the center.
“We definitely have high-risk patients with medical issues who still need to be seen, and their babies need to be monitored,” Rochester says. But generally she says patients are very happy with the restrictions that we have and the changes put in place not only to protect them, but to protect health providers as well. She says the recent feedback from expectant mothers is clear: They want someone healthy to deliver their babies.
Education for expectant women is adapting to accommodate social distancing. “We now officially have UCHealth online classes, modules and interactive telecommunication with our childbirth classes as well as lactation,” Rochester says.
Infection prevention during the pandemic is another key topic. At the center, clinicians are recommending that women shelter in place, practice social distancing, limit exposure to sick family members and self-quarantine at home if a household member is sick. They’re reinforcing the importance of hand-washing and of recognizing possible COVID-19 warning signs such as fever, coughing and shortness of breath, and seeking medical care.
At the time of delivery, the Centers for Disease Control and Prevention recommends that facilities consider separate rooms for newborns when the mother has known or suspected COVID-19. When women in this situation deliver their babies, doctors have a discussion with them about options including temporary separation, or mothers wearing personal protective equipment, such as a gown, gloves and a mask, when caring for their newborns.
The CDC says that whether and how a women with confirmed or suspected COVID-19 should breastfeed is determined by the mother in coordination with her family and health care providers. The agency also provides instructions on breastfeeding precautions. That includes washing hands before touching the baby and wearing a mask, if possible, while breastfeeding.
Women are understandably worried. “In our currently pregnant patients, there’s a lot of anxiety about the unknown,” Rochester says. “There is a lot of fear about getting (the virus), and coming into the hospital sick and potentially being separated from the baby.”
Pregnant women are being inundated with news and information, Rochester says, and they’re aware of the lack of hard data on how COVID-19 might affect them. She’s seeing the most anxiety from people who are considering pregnancy and women in early pregnancy. Now, she says, “there’s an opportunity for us to connect more often – virtually – with those moms.”
With autoimmune diseases, your immune system does not function normally. Rather than presenting a strong line of defense against outside invaders, your immune system attacks its host: your body.
Rheumatic diseases are autoimmune, inflammatory diseases. For conditions such as systemic lupus erythematosus, systemic vasculitis and rheumatoid arthritis, treatment may include drugs that suppress the immune system to treat the disease and symptoms. Now, the concern is whether that also makes patients more vulnerable to COVID-19 infection.
How likely it is for people with rheumatologic conditions to be immunocompromised depends on the specific disease and its current activity, says Dr. Douglas Roberts, a rheumatologist and an assistant clinical professor of medicine at the University of California Davis Medical School and medical advisor to the nonprofit Global Healthy Living Foundation and CreakyJoints online community, which are dedicated to helping people with arthritis.
“In general, we have to worry about infection in those people with severe cases of lupus or systemic vasculitis more than those in the regular population, or perhaps, than those with mild rheumatoid arthritis or psoriatic arthritis,” Roberts says. Although people with arthritis may have a slightly increased risk of infection, he says, they aren’t considered to be immunocompromised. It also depends on the treatment patients receive for those conditions, Roberts says.
While Roberts’ office is closed for now, he’s constantly on the phone with worried patients. “They’re not only concerned about COVID but also whether they should continue with their disease-modifying medications or hold (off on taking) their medications for a little while,” he says.
“I’m taking it case by case,” Roberts says. “I’m a little concerned about patients who might be on medications like methotrexate for inflammatory arthritic conditions.” Methotrexate is a treatment that suppresses the immune system. “To recover from COVID-19, it looks like you need a fairly robust antibody response,” he says. “So with anything that can thwart the immune system from mounting an entirely normal response, I’m a little cautious.”
To further complicate matters, antimalarial drugs such as chloroquine and hydroxychloroquine (Plaquenil) – also used to treat lupus and rheumatoid arthritis flare-ups – have sparked interest as potential treatments for COVID-19. However, any potential anti-COVID-19 effect of these drugs is only supported by limited laboratory evidence and anecdotal reports.
“Some patients who have been off Plaquenil for a while and (no longer) need it are calling and saying, ‘Can I go back on it?’ due to recent reports,” Roberts says. The Food and Drug Administration has not approved the use of antimalarial drugs for the treatment of coronavirus.
If you have an autoimmune condition, Roberts suggests these steps:
- Discuss your individual medication regimen with your rheumatologist. “Sometimes it could perhaps be trimmed a bit,” Roberts says. Drug holidays of one or more medications may be recommended, he says, particularly if you have another condition that may weaken your immune system, such as chronic obstructive pulmonary disease (COPD), diabetes or sickle cell disease.
- If you’re describing possible COVID-19 symptoms to other health care providers who are less familiar with your medical history – like emergency room physicians – let them know that you are on medications that might be suppressing your immune system. “Sometimes that is overlooked and not brought into the equation in term of how to treat patients, whether to hospitalize and what medications to give,” Roberts notes.
- Follow COVID-19 prevention recommendations from the CDC, which address hand-washing, social distancing, sheltering at home, respiratory etiquette and self-isolation or self-quarantine when appropriate.
Immunosuppression is a significant problem for many people with cancer. “The people who are probably most immunosuppressed are those people with blood cancers like leukemia or who have undergone blood or bone marrow transplantation for their underlying malignancy,” says Dr. Marc F. Stewart, medical director of the Seattle Cancer Care Alliance.
Chemotherapy – a form of cancer treatment sometimes used to kill cancer cells – can disrupt the immune system. “Anyone on chemotherapy may be immunosuppressed,” Stewart says. Therefore, he says, patients on chemo for conditions including breast cancer, prostate cancer or lung cancer could be more susceptible to infectious diseases.
Cancer complications themselves can also make people more vulnerable to the new coronavirus, as with lung cancer, for instance. That’s less related to the type of cancer, Stewart says, and more to the fact that, in general, people who have any kind of lung dysfunction are more susceptible to COVID-19-related infections.
An intensive type of cancer treatment – sometimes used for severe cases of cancer like lymphoma – requires extreme immunosuppression. Chimeric antigen receptor T-cell therapy, or CAR-T therapy, takes infection-fighting cells from the patients’ body, which are then genetically modified in the lab, to target that patient’s individual cancer.
“We have to deliberately wipe out their immune systems in order to give them the transplant they need with CAR-T therapy,” says Dr. Len Lichtenfeld, deputy chief medical officer for the American Cancer Society. Those patients are clearly at much higher risk for an infection like COVID-19, he says, both because of their underlying disease and its treatment.
Cancer Survivor Precautions
As a cancer survivor, the longer it’s been since your successful treatment, the less likely you are to be immunocompromised, Lichtenfeld says. “So, if somebody had treatment for breast cancer four years ago, they’re probably pretty much back to – if not completely back to – normal immune response,” he explains.
However, Lichtenfeld adds, as a general principle he advises anyone who’s had cancer treatment in the recent or somewhat recent past (even up to five or 10 years ago) and particularly if they’re older, to really be cautious in these unprecedented circumstances.
Typical follow-up treatment may encompass months or even years of periodic imaging scans, blood tests and oncology center visits. However, pandemic-related precautions have put a halt to routine oncology clinic or office visits. For now, it’s a necessary trade-off to protect cancer survivors, particularly those who are immunocompromised, from exposure to COVID-19.
One bright spot in the pandemic, at least so far, is that children appear to be less vulnerable to the new coronavirus.
“Right now, what we’ve seen is that the severe disease has been happening mostly in adults,” says Dr. Robert Frenck Jr., a professor of pediatrics in the division of infectious diseases and director of the James Gamble Center for Vaccine Research at the University of Cincinnati and Cincinnati Children’s Hospital Medical Center.
Recent data from China shows that children can be infected, Frenck Jr. says. However, he adds, “Those kids just typically aren’t getting as sick.”
In the U.S, “I think what we’ll see is that children are going to become infected but we may well not know it,” Frenck Jr. says. “Because the mom or dad are not going to take them to the doctor for testing, because looks like they’ve just got a cold.”
It’s possible that children with cancer who are being treated with immunosuppressive drugs might be at a higher risk for more severe COVID-19 infection, Frenck Jr. adds. But that’s only a theory, for now, he says. “We just haven’t seen it yet.”
Nevertheless, Frenck Jr. says, parents should make certain their children are following infection prevention measures – such as frequent hand washing, social distancing, avoiding sick people and practicing coughing and sneezing etiquette – to reduce their child’s risk and that of the entire family.