The Washington PostDemocracy Dies in Darkness

Opinion The Checkup With Dr. Wen: We need to do more to assist the immunocompromised

A person wearing a mask walks past a sign in Grand Central Terminal in New York on Dec. 15. (Justin Lane/EPA-EFE/Shutterstock)

You’re reading The Checkup With Dr. Wen, a newsletter on how to navigate covid-19 and other public health challenges. Click here to get it in your inbox.

Last month, I received a message from Leslie in Michigan. Her husband is immunocompromised because he has Stage 4 chronic kidney disease. His nephrologist told him that a bout of covid could push him into permanent kidney failure, which would necessitate a lifetime of dialysis unless he could receive an organ transplant.

Because of his severe renal impairment, he would not able to take Paxlovid to treat a covid infection. The Food and Drug Administration has also revoked its authorization for the one remaining monoclonal antibody to treat covid and warned last week that Evusheld, the preventive therapy for those who don’t mount an adequate immune response to vaccination, might be ineffective against some subvariants, including the currently dominant XBB.1.5 strain.

“Needless to say, we are extraordinarily careful,” Leslie told me in an email. Her husband doesn’t go into any indoor public places, except for medical appointments. Though she isn’t at increased risk herself, she takes precautions to avoid infecting him. When she goes anywhere indoors, she wears an N95 mask, keeps her distance and leaves as quickly as possible.

“I realize that most Americans have moved on and are tired of the pandemic — we are too — but I am totally stunned at how selfish and unkind people can be,” Leslie wrote.

She described a recent encounter in a crowded airport bathroom. A woman came in to charge her phone, and Leslie asked her if she could please use the outlet on the other side of the bathroom.

“Rather than social distance temporarily to help protect me, she lashed out, telling me to ‘stay home’ and ‘don’t travel’ if I’m at risk,” Leslie wrote. “To make matters worse, she told people coming into the bathroom, ‘Can you believe this woman over there asked me to move because she’s at risk?’”

Most people aren’t this callous. But Leslie’s point remains: For millions of Americans who are immunocompromised or who live with someone who is, it extremely difficult to live in a country where most people no longer see covid as a threat. The same is true for elderly Americans who are more vulnerable to severe outcomes and those who simply wish to avoid the potential consequences of infection, including long covid.

Public health policy is complicated because it requires balancing the needs of various groups. Nearly every policy will be perceived as too restrictive to some and too permissive to others. Asking everyone to forgo all indoor socialization is not reasonable, nor are perpetual mask requirements in all settings.

But the challenges that Leslie’s family and many millions of others face must be acknowledged. And there are ways to address them so people are not relegated to a life of fear and isolation.

For example, I agree with Leslie’s proposals, as she wrote to me:

  • “Masks should be required in medical or dental situations until and unless covid becomes much less of a threat to those who are at risk. Many at-risk people already skip necessary medical and dental appointments due to fear of contracting covid, and optional masking in these venues only makes matters worse.”
  • “There should be an option for masked train cars and subway cars, and possibly some masked airline flights. … Public spaces should be encouraged to upgrade ventilation.”
  • “It is of the utmost importance that there be more funding for research on new treatments and monoclonal antibodies to treat immune-compromised people. Vulnerable people are dying unnecessarily because there are no good treatments for them.”
  • “Finally, it is critical that there be a public service campaign to inform the public about at-risk fellow citizens. Most people are not aware that we are out there — most at-risk people do not look any different from other people. Many not-at-risk citizens would be willing to take some steps to help protect vulnerable people if they only knew what was at stake.”

I am grateful to Leslie for sharing her story and policy prescriptions. These are reasonable policies that can safeguard the vulnerable while being minimally intrusive to everyone else. I hope governments and private entities, including medical and dentist offices, grocery stores and the travel industry, consider them.

And others should keep in mind that even if they no longer think of covid as a daily concern, there are those who still do. These individuals deserve our compassion, empathy and understanding — and our commitment to innovative solutions that can help them, too.

Ask Dr. Wen

“As a 70-year-old woman with no underlying health conditions who is up to date with all shots and boosters, I am struggling with how risky it is for me to dine indoors. In the last few months, I have traveled and eaten indoors when outside dining was not possible, but I’m wondering about whether that is wise now with covid cases and hospitalizations on the rise and lots of other viruses circulating. Similarly, I’m wondering if I should still wear a mask in public places indoors like the grocery store where I am often able to keep my distance from others. I do plan to mask if I attend a play or movie, but I guess I’m just generally confused at this point about how careful I need to be and which things to avoid and which precautions matter most.” — Carol from Maryland

Let’s take these two questions separately. How careful you need to be depends on how much you want to avoid covid. If that’s extremely important to you, then you need to take more precautions.

Which activities to avoid depends on how important they are to you and how onerous the precaution would be. It sounds as if you would like to dine indoors. If that’s the case, you could choose to go to restaurants when they are not busy. Select dining places that are well-spaced out and go with friends who are living their lives with a similar level of caution as you.

Masking in indoor public spaces is effective at reducing virus transmission. Whether you keep doing so, and in which settings, depends on how inconvenient masking is to you. A lot of people don’t mind masking in grocery stores, in which case, I think it’s sensible to keep doing so. If this is bothersome to you, consider going during off-hours when you are able to distance from others. You could take a similar approach to plays and movies and mask when in crowded settings.

“I have a question about being exposed to covid a day or two ago. I was in a staff meeting in a non-ventilated room for 45 minutes with this person who turned out positive a day later. I envision this happening many times in these winter months. What should I do after such exposure? I am ‘vaxxed to the max,’ as my wife says, including the bivalent booster.” — Brian from Ohio

The Centers for Disease Control and Prevention says people exposed to someone with covid-19 don’t need to quarantine but should wear a high-quality mask for 10 days when indoors around others. They should also test at least five days after exposure (or sooner, if they develop symptoms). These are the same recommendations regardless of vaccination status or prior infection.

I’m not sure that most people follow these guidelines, given how few are voluntarily masking in public places. I think the spirit of the recommendations is that you should be aware that you could have covid after exposure. If you live at home with someone who really needs to avoid covid, stay apart from them as much as possible at least until you test negative.

“I am a psychiatrist. I ask patients to wear masks in our common office areas but allow removal of masks in my consulting room. I am more than eight feet from the patient, and I have two HEPA filtration devices in the room. I have increased the capacity of the ventilation system in my office, and I have a door to the outdoors that I may open. Am I protecting the patient and myself enough, given no one had symptoms of illness?” — Dawn from Arizona

These are all good measures to take. Taken together, the distancing, HEPA filters and increased ventilation all reduce the risk of transmission.

You could consider asking each patient how concerned they are about contracting covid. Those who want additional protection could mask during the consultation, and you could also keep the door to the outside open for additional ventilation.

The Post has also compiled Q&As from my previous newsletters. You can read them here.

What I’m reading

A real-world study published by the Centers for Disease Control and Prevention found that in adults 65 and older, the bivalent booster reduces hospitalization for covid by at least 73 percent compared with past monovalent vaccination only. This research included patients in 22 hospitals across 18 states. Unfortunately, only about 35 percent of older adults have received the updated booster.

The Lancet published a randomized controlled study that suggests the antiviral pill molnupiravir doesn’t reduce covid hospitalizations or death. Researchers in Britain gave high-risk, nonhospitalized patients infected with the coronavirus either the oral pill or a placebo. Nearly all patients in both groups were vaccinated. Those who received molnupiravir had the same rate of hospitalization and death (0.8 percent) as those who received the placebo. There is one benefit: Those in the antiviral treatment group recovered more than four days sooner on average. Molnupiravir is still a good option for those ineligible for Paxlovid, but it does seem inferior to Paxlovid, which has been shown in several studies to avert severe disease.

Everyone knows that drinking water is good for them. New research sponsored by the National Institutes of Health explains exactly how much. This study used serum sodium levels as a proxy for hydration. Those with higher serum sodium levels had a 50 percent higher chance of being biologically older than their chronological age vs. those with sodium levels in a lower range. The former group also had a higher risk of developing chronic diseases such as heart attacks, strokes and diabetes, and their likelihood of premature death was 21 percent higher.