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Tuesday, June 22, 2021

So should octogenarians doff their masks and not worry?

 The CDC guidelines now say that for persons who are fully vaccinated they can do most anything mask less. Did the CDC mean everyone ?

Did CDC mean that the  recommendation apply to adults of all ages and what about the immunosuppressed? No, not  for the immunocompromised, but I heard no special mention of the  elderly.

Was there find print in the CDC guidelines? Did everyone just hear the headline?

In general terms both the innate and adaptive arms of the immune system are impaired as a function of age. We know that the flu vaccine, for  example is less immunogenic in the  elderly ,What does fully vaccinated mean for the elderly in particular the 80 and over crowd as relates to covid19 vaccination?

Recently published data addresses that question.

Muller et al (1) conducted a cohort study on subjects less than 60 years of age and those over the age of 80 who received the Pfizer vaccine. Specific IgG antibody tiers against SARS-COV-2 spike protein were lower in the elderly and the elderly had no detectable neutralizing antibodies. In the younger group 2.2% had no detectable antibodies.

A large Danish Cohort study (2) compared vaccine effectiveness in health care workers and long term care patients. After the second dose the effectiveness in the patients was 64% ( 95% CI  14-84) while in  health care workers the   effectiveness was 95% (95% CI  82 -95. The median age of the 39 040 patients was 84 and there were 488 PCR confirmed cases of SARS-COV 2 cases. If this study can be generalized the widely quoted 90 % plus vaccine effectiveness does not apply to the elderly.

So how safe is it for fully vaccinated octogenarians to toss their masks? Is there risk for the 30% who have no  neutralizing antibodies. Going mask less assumes than only the fully vaccinated are going to go mask free? How valid is that assumption. Viewing baseball, hockey and basketball crowds televised from areas in the country in which there is at most 40 % vaccination rate and seeing everyone without a mask leads me to think not very valid.

The Danish and German studies are not the final word but , in my opinion, are sufficient for the over 80 crowd to consider it may not quite be time to throw the masks away and join the crowds.

It has been estimated there are 6 million immunosuppressed patients in the US? How effective are the Covid 9 vaccines in that group? There are sub groups, including organ transplant patients,patients with IBD and with psoriasis and lupus etc  who may be on medications impairing  the immune system. There are also patients on chemotherapy for various hematologic diseases. 

Data is available indicating that some of these patients do not have adequate vaccine mediated immune responses.? A large study from Johns Hopkins found that 46% of solid organ transplant patients had no response to covid19 vaccination. A study from Mt Sinai in New York found good immune response in IBD patients on therapy.

Both the CDC and the FDA have not recommended checking antibody levels nor getting a booster shot if the levels were low or absent. The American Society of Transplantation also agree with that position. Their reasoning escapes me. 

Addendum 6/23/2021 A more optimistic view of the effectiveness of Covid 19 vaccination in the elderly is found here. The article describes national  surveillance data regarding the administration of the Pfizer-BioNtech mRNA vaccine.They report effectiveness of 95.2 to 97.6  %for symptomatic cases in people 85 years of age or older. I am not able to offer an explanation of the large  discrepancy between this study and the Danish data. 

Addendum: 6/26/2021 As of at least 6/25/21 The health authority in Israel has reissued the indoor mask mandate following some cases reports of Covid 19 in fully vaccinated people .At about the same time WHO has stated that immunized people should wear masks  based on concern of the widespread incidence of the Delta ( India) variant. 

1)Muller,L et al Age-dependent immune response to Biotech/Pfizer BNT 162b2 COVID-19 vaccination Clin infectg Dis 2021 Apr 27

 2)Moustsen-Helms,IR et al Vaccine effectiveness after 1st and 2 nd dose of the BNT162b2 Covid-19 Vaccine in long term care facility residents and healthcare workser A Danish cohort study. Pre Print from Medrxiv 09 March 2021.


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