Experts say that people with chronic conditions that affect the immune system, such as lupus and diabetes, are at a higher risk of developing severe complications from coronavirus. Here's what you need to know about immunocompromised patients and coronavirus COVID-19.

By Dominique Michelle Astorino
March 09, 2020

In light of a flu season that has unofficially become "flu-and-coronavirus season", there's a lot of buzz around those who are most at risk for severe complications from coronaviruses: specifically, the elderly and those who are immunocompromised. But what does it actually mean to be immunocompromised? And how does having a compromised immune system play out with coronavirus COVID-19? Here, experts explain everything you need to know about protecting people with immune deficiencies amid the coronavirus outbreak.

What does it mean to be immunocompromised?

Simply put, "immunocompromised" (sometimes referred to as "immunosuppressed") means you have a weakened immune system. For one reason or another, an immunocompromised person cannot fight infections as well as people with a healthy immune system, says Natasha Bhuyan, M.D., regional medical director at One Medical.

"This also makes them more vulnerable to getting bacterial, fungal, viral, and parasitic infections in the first place," she explains. "And when they get these infections, their weakened immune systems may take longer to fight off the infection."

Who is considered immunocompromised?

Immunosuppression, on its own, is more a symptom than a syndrome, notes Dr. Bhuyan. Meaning, people with certain chronic illnesses or genetic disorders tend to have a compromised immune response as a byproduct of their disease.

The reasons for being immunocompromised can be broken down into a few categories, explains Dr. Bhuyan. This includes chronic conditions (the most common), inherited conditions, medications, or functional immunosuppression.

Here are some examples of illnesses that fall into those categories:

Chronic conditions: HIV, cancer, lupus, Hashimoto's, malnutrition, rheumatoid arthritis, and diabetes

Inherited conditions: IgA deficiency (an immune system condition in which you lack or don't have enough immunoglobulin A, a protein that fights infections), X-linked agammaglobulinemia (a condition that causes the body to produce fewer B cells, aka specialized white blood cells that help fight infection), common variable immune deficiency (a disorder that impairs the immune system), severe combined immunodeficiency (a disease that causes someone—usually a child—to have little or no immune system; once known as "boy in the bubble" syndrome), among other inherited immunodeficiency diseases

Medications: Steroids, chemotherapy, and some medications for autoimmune diseases can cause immunosuppression.

Functional immunosuppression: not having a spleen or losing your spleen (The spleen detects damaged red blood cells and unwelcome bacteria and viruses in your blood.)

Keep in mind, these categories work in different ways as far as how each condition affects the immune system, says primary care physician Nate Favini, M.D., medical lead at health-care company Forward. "There are varying degrees of immunocompromisation, so some people may be more or less vulnerable to infections, depending on [their condition]," he explains.

For example, with HIV, the immune system is already being attacked by that human immunodeficiency virus, leaving the body more vulnerable to other infections and diseases (such as the novel coronavirus), explains Dr. Favini. But with autoimmune conditions such as lupus, a person experiences "dysregulations of the immune system," meaning the immune system itself is compromised or malfunctioning in some way, he says. "Individuals with lupus are in a unique position because both the lupus disease itself and the medications used to treat it can cause immunosuppression," adds Dr. Bhuyan. That said, if you're taking medication for lupus, Dr. Bhuyan says there's no need to change course; taking medication to treat an existing condition matters more than mitigating the risk for what is only a potential condition. "People with lupus should use the same precautions as with other immunosuppression, regardless of whether they are on medication," she notes.  (Related: Why Autoimmune Diseases Are On the Rise)

If someone has cancer (particularly cancers that impact the immune system or blood, like leukemia), the disease itself can compromise the body's immune response—and chemotherapy treatment can impact the immune system on top of that, adds Dr. Favini. (Note: At this time, cancer patients with scheduled chemotherapy appointments should keep them, unless they're experiencing coronavirus symptoms, according to Fred Hutchinson Cancer Research Center. If you're a cancer patient who's receiving chemo and you are experiencing COVID-19 symptoms—particularly respiratory symptoms—experts at the organization recommend letting your health-care provider know ASAP and following their instructions.)

Other chronic conditions like diabetes, heart disease, and chronic kidney disease can also make you less able to fight off a serious infection and might place you at higher risk for a virus like the novel coronavirus, explains Dr. Favini.

What extra steps do immunocompromised people need to take during the coronavirus outbreak?

As COVID-19 continues to spread, it's recommended that people who are immunocompromised follow the same general precautions as non-immunocompromised people, says Dr. Bhuyah. That includes washing your hands frequently, sneezing and coughing into the fold of your elbow, avoiding touching your face and people who may be ill, disinfecting/sanitizing surfaces regularly, and staying home if you're sick. (Related: How to Correctly Wash Your Hands Because You're Doing It Wrong)

"Vigilance about hand hygiene and self-care—sleep, good nutrition, and de-stressing—is essential for immunocompromised people," says Sandra Kesh, M.D., deputy medical director and infectious disease specialist at Westmed Medical Group.

Avoiding travel is big right now, too, adds Dr. Bhuyan. "People who are immunocompromised should be much more cautious about 'non-essential' travel and avoid crowds in regions where there is community transmission of coronavirus," she explains. "Crowded functions, like sporting events or concerts, might feel 'essential,' but they can be skipped."

Speaking of travel, Ashish Sharma, M.D., internal medicine doctor and hospitalist at Yuma Regional Medical Center, strongly advises avoiding contact with anyone who's recently traveled to countries with confirmed cases of the coronavirus (in addition to avoiding traveling to these locations yourself).

How does the coronavirus outbreak affect those with immunosuppression?

While there's still a lot to learn about this novel coronavirus, it's clear that COVID-19 can be especially threatening to people who are immunocompromised, says Dr. Favini.

The comorbidity (a fancy way of saying that you have multiple health conditions at the same time) of coronavirus and a chronic condition that compromises your immunity is something you'll want to discuss with your doctor, he says. "Certain comorbidities may dramatically impact how your body handles another condition that comes your way," he explains.

"Whether the comorbidity will impact your likelihood of developing an infection—and the severity of that infection—also depends on the type of comorbidity," adds Dr. Kesh. She notes that those who might be most at-risk among the immunosuppressed group are those with pre-existing lung conditions. "Some of these conditions, like chronic lung disease and asthma, are more worrisome than others in terms of increasing your risk of developing a respiratory infection," she explains.

People with an immunocompromising disease can also experience "atypical" (or not standard) symptoms, says Dr. Sharma. "For example, a person with an immunocompromised disease or immunosuppressive treatment with [a COVID-19] infection may not have a fever or may have increased inflammation markers like elevated white blood cell count," he explains. Considering that fever is a primary symptom of the novel coronavirus and that the majority of confirmed coronavirus cases have shown low, not elevated, white blood cell counts in lab tests (as you'd typically see with viral infections), these atypical symptoms could make coronavirus diagnosis more difficult.

To make matters even more complicated, since people who are immunocompromised can't always mount a strong immune response, they might experience only mild symptoms of the coronavirus if they become infected, says Dr. Bhuyan. But those mild symptoms might not reflect the true severity of the infection, she notes. "Symptoms of COVID-19 can range from a mild cough to more severe shortness of breath," she explains. "For those who are immunocompromised, they should contact their primary care provider (virtually, by phone, secure messaging, or video visit) to discuss their individual symptoms," even if those symptoms seem mild, she says. (Refresher: These are the most common coronavirus symptoms to look out for, according to experts.)

Overall, for those who are immunocompromised, potential complications of coronavirus COVID-19 can include respiratory failure, multi-organ failure, and septic shock, explains Dr. Kesh. The good news among all those scary terms? "Many of these can be managed and treated with timely medical intervention," she says. To be clear, experts say that all symptoms—mild, severe, and everything in between—should be taken seriously amid the coronavirus outbreak.

Should immunocompromised people stay home during the coronavirus outbreak?

If your immune system is compromised by one of the aforementioned health conditions or medication, experts say it's best to stay home as much as possible during the coronavirus outbreak. "Immunocompromised people should be early adopters of 'social distancing' strategies if a coronavirus outbreak comes to their area," notes Dr. Favini. "This means working from home, not using public transportation, and avoiding large crowds." (Related: Should You Really Work from Home Amid the Coronavirus Outbreak?)

"Stay away from anyone you know who becomes ill," adds Dr. Favini. "If you take medications for your condition, consider having enough on hand to get through the next few months and make sure you have a backup supply of a few weeks of food in case you need to isolate yourself at home through an epidemic."

Additionally, if you're infected and/or displaying symptoms (mild, severe, or otherwise), Dr. Sharma says you can avoid coronavirus transmission by wearing a mask (but please don't buy or wear one if you aren't sick) and avoiding shaking hands or sharing things, on top of staying home as much as possible. (Here are some other tips on how to prepare for coronavirus and the threat of an outbreak.)

If you're concerned about coronavirus symptoms, contact or go to your doctor ASAP for definitive testing and further treatment if necessary, says Dr. Sharma.

How to Protect the Immunosuppressed Community from Coronavirus

As you may have gathered, there are a lot of people with compromised immune function. Chances are, you know at least one immunocompromised person or you may even fall into that category yourself. With that in mind, it is everyone's responsibility to help protect against the spread of illness, including not only coronavirus but any contagious diseases. Something that may feel like an innocuous common cold to you could be devastating (and possibly lethal) to someone who doesn't have the physical capacity to fight it.

If you're not immunocompromised but you are infected (or even displaying mild symptoms), you should stay home, too, suggests Dr. Favini. Specifically, if you're ill with a fever, cough, shortness of breath, congestion, or sneezing more than a couple of times a day, "stay home to limit the risk of infecting others," he says. "It's the kind (and responsible) thing to do for people whose immune systems are not as strong—it will slow the epidemic and save lives."

Aside from the frequently repeated "wash your hands and don't touch your face" guideline, Dr. Bhuyan suggests doing due diligence for your general health: get enough sleep; eat a healthy diet rich in fresh foods, fruits, and vegetables; stay hydrated; exercise; and do what you can to manage stress. Reminder: These are practices everyone should follow regardless of flu season, coronavirus outbreak, or otherwise, says Dr. Bhuyan.

She also urges you to consider vaccinations. "While there is no vaccine for coronavirus currently, there are several vaccines that exist which can protect those who are immunocompromised from other viruses, such as the flu vaccine or MMR," she explains.

Dr. Sharma agrees: "Getting vaccinated with age-appropriate immunization vaccination for pneumonia, shingles, and annual influenza vaccine can also help prevent disease and decrease the severity of disease [for those who may] get infected."

The information in this story is accurate as of press time. As updates about coronavirus COVID-19 continue to evolve, it’s possible that some information and recommendations in this story have changed since initial publication. We encourage you to check in regularly with resources such as the CDC, the WHO, and your local public health department for the most up-to-date data and recommendations.

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