This is why this document was vaccinated for the third time

One month after the second dose of Pfizer COVID-19 vaccine, Dr. Robert Montgomery, MD, noticed a lack of antibody response.

The surgeon and director of the NYU Langone Transplant Institute in New York City is himself a recipient of heart transplants. I realized that putting him in an immunocompromised state and being completely vaccinated does not necessarily mean that he is immune to COVID-19. ..

So Montgomery stepped into an unknown territory when he was vaccinated for the third time and switched to Johnson & Johnson shots.

“Now, I seem to be responding normally, just like people who are not immunocompromised,” Montgomery said. Today’s MedPage..

He warned that he was “n-of-1” and needed to address a number of questions before making broad recommendations to immunosuppressed patients, but in his case the potential for a third dose The benefits outweigh the unknown risks.

It is estimated that there are about 10 million immunocompromised patients in the United States. About 500,000 of them are transplant recipients, the rest suffer from other autoimmune diseases such as rheumatoid arthritis, lupus erythematosus, and multiple sclerosis, and are taking immunosuppressive drugs.

Rollback of CDC guidance on masking This group is particularly nervous because there are important questions about the level of immune protection even after vaccination is complete. Other than taking continuous precautions, there was little guidance on how they best protected themselves.

Staying home is not always an option for busy laboratory directors and transplant surgeons. They have to come to the hospital every day to interact with multiple patients and colleagues.

Montgomery received a heart transplant in 2018 after multiple sudden cardiac deaths. Today’s MedPage.. “Things have become very miserable.”

He had hereditary cardiomyopathy caused by a mutation RBM20 gene, And lost both his father and one of his brothers to illness.

Around the time of his transplant, he recently moved from Johns Hopkins to New York University to build a heart transplant program. It incorporates a protocol that assisted in the development of hepatitis C-positive organs in virus-negative recipients treated with new antivirals. Montgomery himself received a hepatitis C-positive heart from an overdose donor.

When the New York COVID surge struck, he recovered and began returning to full-time work. According to Montgomery, the mortality rate for transplant patients was particularly high at around 25%, which has since improved.

Since immunosuppressed patients were not included in the vaccine trial, there was little evidence to develop a vaccine strategy for this group. Montgomery first checked for antibodies two weeks after the first dose of Pfizer, but no antibodies were present.

“I sent an email to Dolly.’Houston, I have a problem,'” Montgomery said, referring to Johns Hopkins, MD. Study of vaccine response in transplant recipients Published two Relation paper To JAMA.. Montgomery is a participant in the study.

One month after the second dose, Montgomery showed minimal antibody response, but further investigation revealed no neutralizing antibodies. This is an important antibody that suppresses COVID infection. He had a similarly poor B cell response. He also measured T cell responses, but stated that it was not clear what that meant for protection at the time, so his team concluded that he was not protected.

Therefore, he chose to receive the J & J vaccine for the third time.

He then showed a very strong antibody-neutralizing antibody response, and a normal B-cell response. “Overall, that was all you see in the average person,” he said.

The anecdote raises many questions that prevent this from being widely recommended for immunocompromised patients. For example, is it the result of a crossover from an mRNA vaccine to an adenoviral vector vaccine? Or did the third dose of mRNA produce a similar reaction?

Also, although the science to correlate serum antibodies and cell-mediated immunity levels with actual protection from infection, illness, severe illness and death has not yet been established. Recent work Nature medicine Neutralizing antibody levels have been suggested to be highly predictive of immunity to the virus.

Still, FDA recently warned Antibody tests should not be done to tell if you are protected from COVID-19, especially after vaccination. In particular, not all over-the-counter antibody tests measure antibodies to speromer proteins. For example, some measure the response to nucleocapsid proteins.

The question about the value of T cell testing in this population has also not been answered. T cell tests are generally more difficult than antibody tests, but commercially available tests are now available. It’s not clear what patients can do with information that has a positive T cell test, Montgomery said.

Another question, which may be unlikely, is whether the response is solely due to the Johnson & Johnson adenovirus vector vaccine. Montgomery states that in theory it could lead to stronger immune stimuli.

Finally, it is not clear how long Montgomery’s strong response will last. “Will my reaction be shorter-lived than the average person?” He asked. “These are all important questions.”

Montgomery has admitted that it carries an unknown risk of receiving a third dose. It is not always gladly undertaken by immunocompromised patients who are at home and can protect themselves through mechanisms such as masking and social distance.

Although Montgomery’s family, including two teenage boys, was fully vaccinated, it felt worth taking the risk given the interaction with other transplant patients.

“It’s a tough moment for transplant patients because there’s no clear path forward,” he said. “We really need research.”