Science

The immunocompromised, great forgotten by Covid, by Pr Gilles Pialoux

The emails are sometimes worth more than all the studies to highlight a particularly painful effect of the health crisis. By dint of having become a subject of society and a political issue, we would almost forget the essentials of Covid: the affected and/or vulnerable people. And his word. Regarding the situation of the immunocompromised, several associative voices denounced in a recent column in Le Monde the “difficulties of access to preventive treatment based on monoclonal antibodies that [leur] it is vital”. It protects them from the virus, those whose deficient immune system does not react, or does so very little, to vaccination. We were talking then about 3,500 doses administered for 57,000 priority patients… Hospital under stress, lack of staff, organizational problems in the midst of the Omicron wave: none of these very real arguments is, however, acceptable to the immunosuppressed, who represent up to 30% of stays in intensive care, while in France there are less than 250,000.

At the same time that the nephrologists at the Tenon hospital were organizing an “ephemeral” day hospital in order to speed up the process and that kidney transplant patients, cancer patients undergoing chemotherapy, patients with autoimmune pathologies undergoing anti-CD20 treatment, all severely immunocompromised, you can receive the famous antibody infusions, I received two personal emails among many others. With the human in the center and the Omicron tornado, presented by some irresponsible people as a “trial epidemic” or as a “wave of colds”.

“My husband is in contact, I isolate myself in the hotel, denying myself to the cleaning staff”

Sophie* is a doctor and, paradoxically, a professor of immunology at a major university in the Paca region. Specialist in autoimmunity, in addition. But the outbreak of Covid revealed in her a profound immune deficiency. With no news since the AIDS years, he wrote me this: “I just responded very, very poorly to the Covid vaccine and so I put myself in the hands of the clinical immunology team at my university hospital. Result: a true primitive immunodeficiency in connection with a strong autoimmunity. In any case, great deficit of all the vaccine responses… Zero antibodies! And so for five weeks, here I am self-contained first at home, in intense teleworking, with the Evusheld injection [NDLR : un anticorps monoclonal utilisé à visée préventive]. In good physical shape but with very low morale. Being my husband a contact subject, I now isolate myself in the hotel, rejecting the cleaning staff, and only go out to buy fries in the back of the hotel. With that Sword of Damocles from reanimation as a backdrop, it’s hard to hide. I have read the latest patient association forums on immunocompromised patients but I tell myself that there are some general public communications missing. The 230,000 hidden French “immuno-softs”, hidden everywhere, are vaccinated 4-5 times, are already sad that they have a nasty disease and are obsessively trying not to catch the virus. To make it known a little more would be good, it would ensure a kind of national benevolence, and it would avoid being called an anxious hysteric…”.

Professor Gilles Pialoux, a columnist for L’Express, is head of the department of infectious and tropical diseases at the Tenon hospital in Paris (AP-HP).

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Two molecules bring their share of hope

Jean* was one of our externs, with no one knowing anything about her own medical training. His doctor writes to me because he is positive for Omicron: “He is symptomatic, with nephrotic syndrome treated with anti-CD20, and has been vaccinated four times without efficacy due to his immunosuppression. He is locked up with his girlfriend because his own mother has a transplant of kidney and, therefore, is at high risk. What to do? For a few days, in his case, two molecules have brought their share of hope: Sotrovimab, another monoclonal antibody used in curative treatment, active on Omicron, and Paxlovid, a direct antiviral effective in preventing severe forms after an infection, but to have access to these molecules, you have to go through the “disease” box, have a diagnosis in five days and avoid contraindications.

So, how to make the compulsive tranquilizers and the anxious politicians understand that the immunocompromised of the Omicron wave are not, like the old people of the first wave, a negligible quantity? And that when this wave, or the next one, recedes and the virus becomes endemic, it won’t be at the same time and in the same way for everyone? We will have to jointly watch over those who have forgotten about vaccination, the long Covids and the immunocompromised of all kinds.

Professor Gilles Pialoux is head of the department of infectious diseases at the Tenon Hospital (AP-HP) in Paris (XX). Member of the PandemIA collective and the Terra Nova health center, he is also the author of We were not prepared. Logbook in times of coronavirus (ed. JC Lattès), and Like a slight tremor (ed. Mialet Barrault, to be published on February 2).

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*Names have been changed.

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