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Guidelines for Fully Vaccinated Immunocompromised People
Tatiana Ayazo

The U.S. Centers for Disease Control and Prevention (CDC) recently released new guidance outlining what fully vaccinated people can feel comfortable doing during the COVID-19 pandemic. However, it’s less clear is what this guidance may mean for those who are immunocompromised because they take immunosuppressant medication or have an autoimmune condition.

Here’s what experts say you need to know about the new guidelines, and what they may mean for you.

What the New CDC Guidelines Say

The CDC defines “fully vaccinated” as those who have been vaccinated for two weeks or more after they have received the second dose in a two-dose series (the Pfizer or Moderna vaccines) or the single-dose vaccine (Johnson & Johnson).

The guidelines only apply to certain settings, such as small gatherings in private homes. They do not apply to health care settings.

“This is a first iteration, and I suspect you’re going to see this guidance be continually updated as more and more people get vaccinated and more and more data is available about the benefits of these vaccines,” says infectious disease physician Amesh A. Adalja, MD, a Senior Scholar at Johns Hopkins Center for Health Security.

According to the new guidance, fully vaccinated people can:

  • Visit with other fully vaccinated people indoors without wearing masks or physical distancing
  • Visit with unvaccinated people from a single household who are at low risk for severe COVID-19 disease indoors without wearing masks or physical distancing
  • Refrain from quarantine and testing after a known coronavirus exposure if asymptomatic

For now, the guidelines say that fully vaccinated people should continue to:

  • Take precautions in public like wearing a well-fitted mask and physical distancing
  • Wear masks, practice physical distancing, and adhere to other prevention measures when visiting with unvaccinated people who are at increased risk for severe COVID-19 disease or who have an unvaccinated household member who is at increased risk for severe COVID-19 disease
  • Wear masks, maintain physical distance, and practice other prevention measures when visiting with unvaccinated people from multiple households
  • Avoid medium- and large-sized in-person gatherings
  • Get tested if experiencing COVID-19 symptoms
  • Follow guidance issued by individual employers
  • Follow CDC and health department travel requirements and recommendations

“At this time, it is thought that vaccinated people may still transmit coronavirus and need to take precautions with those who are not vaccinated and at risk by continuing to follow social distancing, facial covering, and handwashing,” says Lynn Ludmer, MD, Medical Director of Rheumatology at Mercy Medical Center in Baltimore.

This thinking may change as researchers learn more about virus transmission among those who are vaccinated.

However, there’s also a very important note at the bottom of the guidance that’s easy to pass by: “People should discuss with their provider if they have any questions about their individual situation, such as immunocompromising conditions or other concerns.”

Based on that guidance and the limited available data on how well the vaccine works in immunocompromised patients, some experts are urging caution among those who have an autoimmune disease or are taking immunomodulatory drugs.

What Should You Do If You’re Immunocompromised?

Researchers are still not sure how fully the COVID-19 vaccine protects immunocompromised individuals because they weren’t included in the initial clinical trials (as is typical with vaccine development). Of course, it’s critical to get the vaccine if you’re immunocompromised, because even reduced protection from coronavirus is far better than none.

However, some experts believe it’s best to continue abiding by current public health advice for mitigating COVID-19 risk if you’re immunocompromised — even if you’re fully vaccinated.

The general advice to follow is simple, yet not always easy to adhere to:

  • Wear face coverings and maintain a social distance of six feet or more from people outside of your household whenever possible.
  • Wear face coverings when out in public and when you can’t be socially distant.
  • Wash or sanitize your hands frequently and disinfect commonly touched surfaces.
  • Avoid large groups or situations when it will be hard to be socially distant.
  • When spending time with others, being outdoors is safer than indoors.

“I would say if someone is immunocompromised and vaccinated, that they should still take precautions like wearing a mask and abiding by the six-foot social distancing recommendations, even if they’re around vaccinated people,” says David Aronoff, MD, Director of the Division of Infectious Diseases at Vanderbilt University School of Medicine in Nashville, Tennessee.

Ask loved ones outside of your household who are fully vaccinated to continue to follow mitigation efforts when they’re around you.

“It would be ideal if vaccinated people continued to wear masks while they’re around people who are immunocompromised, even if they are also vaccinated, until this pandemic is a little further away from us and the risk that any one person will be infected is very low,” adds Dr. Aronoff. “We’re not totally out of this pandemic’s embrace yet.”

That means it may be best to continue to follow the original risk mitigation guidelines if:

  • You’re immunocompromised, vaccinated, and around vaccinated people from a different household.
  • You’re immunocompromised, vaccinated, and around unvaccinated people from a different household.
  • You’re immunocompromised, unvaccinated, and around vaccinated people from a different household.
  • You’re immunocompromised, unvaccinated, and around unvaccinated people from a different household.

The fact that the CDC differentiated patients with “immunocompromising conditions” in its guidance is telling and potentially reflective of the current lack of data on these patient populations.

“The way I would interpret the CDC recommendations is that patients at high risk, which means all of our patients who are on immunosuppressive treatments, should continue to take the precautions they have been taking as before these recommendations came out,” says Vivek Nagaraja, MD, a clinical rheumatologist and researcher at Michigan Medicine.

Different Degrees of Being Immunocompromised

If you’re reading this, you may be wondering: Does this mean I can’t hug my grandchildren yet because of rheumatoid arthritis? If I have psoriatic arthritis and am fully vaccinated, should I not have dinner indoors with a friend who is also fully vaccinated?

There are no easy answers. Keep in mind that being immunocompromised can have different levels of severity.

Your doctor will be able to best guide your COVID-19 prevention efforts based on your condition, the medications you take, and your disease activity.

Consider a patient who is taking only hydroxychloroquine for rheumatoid arthritis  and is very well-controlled versus another patient who is taking steroids, methotrexate, and a biologic. The latter is considered more immunosuppressed.

Likewise, somebody with a mild autoimmune disease likely has a much lower level of immunosuppression than somebody undergoing chemotherapy or a recipient of an organ transplant on very high-dose immunomodulatory medications.

“It’s going to be an individualized discussion with your doctor, but until then, I would certainly take all the precautions you have been taking as before these recommendations came out — until we have further guidance for this patient population,” says Dr. Nagaraja.

How Long Will I Have to Follow Mitigation Efforts For?

Here’s the good news: Although experts say it’s best to play it safe for a little longer by following current COVID-19 prevention methods if you’re immunocompromised even if you’re fully vaccinated, the COVID-19 pandemic appears to be improving and more data is expected to be available soon.

As of mid-March, nearly 30 percent of Americans have been infected with the coronavirus, per data scientist Youyang Gu. Meanwhile, about 18 percent have received at least one shot of the COVID-19 vaccine. Because of overlap between the groups, that means about 40 percent of Americans have some protection from COVID-19, per the New York Times.

Dr. Nagaraja says he expects much more data will emerge over the course of this year to better guide fully vaccinated immunocompromised patients on this topic.

In the meantime, he notes these key points to keep in mind:

  1. All immunocompromised patients should get vaccinated if they’re eligible, because the benefits outweigh any potential unknowns. (There’s no reason to think the vaccine would be less safe in immunocompromised patients, but it could be less effective.)
  2. The timing of the vaccination with respect to individual treatments should be discussed with your rheumatology health care provider. (The American College of Rheumatology released clinical guidance on how to time your medication with the vaccine.)
  3. It’s important to discuss your personal risk level with your health care provider before forgoing any of the standard mitigation efforts you’ve maintained throughout the pandemic, such as social distancing and wearing a face mask.
  4. The recommendations may continue to evolve so it’s important to check back with the CDC for more information.
  5. If you have any symptoms of COVID-19, you should still get tested — even if you’ve been vaccinated.

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Interim Public Health Recommendations for Fully Vaccinated People. COVID-19. U.S. Centers for Disease Control and Prevention. March 8, 2021. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated-guidance.html.

Interview with infectious disease physician Amesh A. Adalja, MD, a Senior Scholar at Johns Hopkins Center for Health Security

Interview with David Aronoff, MD, Director of the Division of Infectious Diseases at Vanderbilt University School of Medicine in Nashville, Tennessee

Interview with Lynn Ludmer, MD, Medical Director of Rheumatology at Mercy Medical Center in Baltimore

Interview with Vivek Nagaraja, MD, a clinical rheumatologist and researcher at Michigan Medicine

See How the Vaccine Rollout Is Going in Your State. The New York Times. March 10, 2021. https://www.nytimes.com/interactive/2020/us/covid-19-vaccine-doses.html.

United States Infections. COVID-19 Projections Using Machine Learning. March 7, 2021. https://covid19-projections.com/infections/us.