Emergency medicine for people with weak defenses against corona despite vaccinations

“What?! Am I a first in the hospital?” says Edson (35) while the nurse at Erasmus MC in Rotterdam gives him an IV with antibodies. “How does that feel to your arm?” she asks.

Edson (he does not want his last name in the newspaper) is the first corona patient at Erasmus MC to receive treatment with so-called monoclonal antibodies. Because he received a kidney transplant in 2014 – and his body does not have to reject the new kidney – he takes anti-defensive drugs. Although Edson is fully vaccinated against corona, his body does not make any antibodies at all, so he ended up in hospital with Covid earlier that week.

People with immune disorders, the most vulnerable group in the corona pandemic, are fully vaccinated against Covid early as a priority. But precisely because their defenses are failing, it is often impossible to build up protection with a vaccine. When they run into the virus, they are much more likely to become seriously ill. They are also often ill for much longer and sometimes remain contagious for weeks.

“In the Netherlands, it is estimated that half to one million people are involved,” says Bart Rijnders, internist-infectiologist at Erasmus MC. Due to the use of immunosuppressive drugs, a disease or hereditary predisposition, all these people cannot build up a strong immune system. Doctors and researchers are trying to find ways to better protect this group.

British research

The powerful monoclonal antibodies have recently been approved as ’emergency medicine’. The treatment became available after the positive outcomes of a large comparative British study. This shows that the death risk of Covid patients who end up in hospital without measurable antibodies decreases from one in three to one in four if they receive monoclonal antibodies.

Four weeks ago, Erasmus MC was the first hospital in the Netherlands to order this therapy from RIVM, which manages the national stock. After Edson, five more patients were treated with it at Erasmus.

“It is difficult for the individual patient to say whether it will work, you cannot predict that,” says Rijnders. “But for the group as a whole, research has clearly shown that this drug reduces the risk of death, hospitalization and ICU admission. That’s why we’re now giving it to everyone who qualifies for it.”

The antibodies in the blood are immediately measured in every patient who ends up in hospital with Covid, says Rijnders. “If there are none, we will immediately treat those people with monoclonals. If we do measure antibodies, we will not give monoclonals, not for the time being, even if we know that the person has a weak immune system. The British study also shows that if you give this to people who already have antibodies themselves, you may actually increase the risk of death. The monoclonal antibodies probably interfere with the antibodies that the patient already makes.”

Severe obesity

Treatment with monoclonal antibodies works best if it is given to corona patients very early, i.e. before people end up in hospital. Research shows that treatment within days of infection can prevent hospitalization in 70 to 80 percent of people with Covid, Rijnders says. “The opportunity to quickly treat people from risk groups, for example people over 50 with severe obesity who may also not produce antibodies, is still often missed. We could organize this through treatment centers throughout the country to which GPs can refer patients at risk. ”

In other countries, for example in France, patients with immune disorders can already receive a third shot to boost their immune system. The RIVM is still considering this. The big question is whether additional vaccinations are effective if the first two apparently did not work well.

Internist-infectiologist Bram Goorhuis of Amsterdam UMC thinks so: “What we know about vaccinations against other diseases is that an extra shot can work in this group. But we need to investigate whether this is also the case with Covid. Some people may need a fourth or fifth shot. We are also monitoring whether the protection after vaccination in this group may wear off more quickly.”

In collaboration with other centers, Goorhuis has started a study into the effect of Covid vaccination in haematological patients. These are people who suffer from blood cancer or have had a stem cell transplant, which means they have to rebuild their immunity against all kinds of diseases. Goorhuis: “Within all patients with immune disorders, this group reacts the worst to Covid vaccination.”

In France, patients with immune disorders can already receive a third shot. The RIVM is still considering this

Antibodies in the blood do not tell the whole story about immunity. The immune system can also fight the virus in other ways. Goorhuis: “Simply put: the antibodies protect you against infection and once the virus is inside, a good T-cell defense (by white blood cells that recognize and clear infected cells) ensures that you get rid of it quickly.”

Preventive treatment

Nevertheless, research by the RIVM shows that there is a relationship between the strength of the antibody response and the strength of the T-cell response, at least in healthy people. “On the basis of this, we use a limit value for the antibody concentration in the blood to determine whether or not someone is sufficiently protected,” says Goorhuis.

Patients with a weak immune system preventive Administering monoclonal antibodies as protection against Covid may also work, says Bart Rijnders, who has just started research into this. “But such a treatment has to be repeated every four weeks and it is expensive. You could do this temporarily, for example if someone close to the patient tests positive. These people are rightly concerned about becoming infected.”

“When I heard that I had no antibodies even after my vaccination, I was off the track,” says a 62-year-old woman from Rotterdam, a participant in the Erasmus MC study. She has a rare lung disease and is taking anti-defensive drugs for it. Fearing losing her job, she wishes to remain anonymous (her name is known to the editors).

Corona is life-threatening for her and she is very concerned that she will become infected sooner or later. Her children like to go out and she wants to go on holiday again. “Soon I will have to isolate myself from my surroundings.”

When she discussed her concerns with her pulmonologist, she pointed out this research. Today she gets her dose of antibodies.

Intravenous drip

The woman from Rotterdam has just been on an IV for two and a half hours. Before and after the infusion, blood was taken to see how many antibodies can be seen immediately afterwards. Now she has to wait a little longer before she can go home. She may not be feeling well.

In the coming weeks she will have to go back to the hospital ten to twelve times to have her blood values ​​checked. Participating in the study costs her time, but she thinks it will be better anyway, she thinks.

“I would like to emphasize that we do not know how long and how well the antibodies work,” Bart Rijnders told the woman. “So you still have to protect yourself in the coming time.” In a month’s time, Rijnders and his team will be able to assess the results of twenty test subjects.

However, the most important protection for this vulnerable group will have to come from a high vaccination coverage in the general population, emphasizes Bram Goorhuis. “Take measles, for example,” he says, “one of the most contagious diseases known. If people with an immune disorder contract this virus, they have a risk of dying from it. Yet you rarely hear that, and that is thanks to the fact that 95 percent of the Dutch have been vaccinated against measles. When it breaks out, it is quickly smothered by the large group of people who have resistance. As a result, it rarely reaches the vulnerable.”

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