On Christmas Eve, John Nucci invited two sons and three grandchildren to visit him and his wife at their East Boston home. Everyone tested negative for COVID-19 beforehand. Everyone had been vaccinated, except the children, who are too young. John wore a mask throughout the visit.
This layering of precautions might sound a tad paranoid, but it was the most risky thing Nucci has done in two years — two years of going nowhere except for his daily walks, no restaurants, parties, or visits to his office at Suffolk University, where he is senior vice president of external affairs.
Nucci, 69, lives on a different plane of risk than most: He is a kidney transplant recipient who must take medications that suppress his immune system, to prevent rejection of the transplanted organ. As a result, his body might not be able to fend off the virus even though he has received three shots.
As word spreads that the Omicron variant appears to cause only mild illness in most people, doctors have cautioned that this soothing notion does not apply to the estimated 7 million with weakened immune systems, who do not respond to vaccines as robustly as healthy people. They include transplant recipients like Nucci, as well as cancer patients and people with certain chronic illnesses and autoimmune disorders.
“I don’t think that even the possibility that [Omicron] is more benign is very hopeful,” said Dr. Dorry Segev, a professor of transplant surgery at the Johns Hopkins School of Medicine, who has studied the effectiveness of COVID-19 vaccines in transplant recipients. “If you’re immunocompromised, you’re the one for whom it’s not going to be benign.”
Studies of earlier variants have shown that a third vaccine dose provides additional protection, but for about half of transplant patients, it’s not enough, Segev said. And Omicron spreads even more readily than previous variants.
The pandemic has sent immunocompromised folks on an especially jagged roller-coaster ride – hope for a vaccine, soon dashed by the discovery that vaccines don’t adequately protect them; then hope for preventive treatment, dashed by the news that the treatment is in short supply.
The preventive treatment, a monoclonal antibody called Evusheld, was authorized Dec. 8 for people who are not infected with COVID-19 and who cannot mount a strong immune response to vaccination. While vaccination prompts the immune system to make antibodies, Evusheld simply provides the antibodies, infusing immune protection in two injections.
“Evusheld could offer these individuals nearly immediate and long-lasting added protection,” said an e-mail from AstraZeneca, the manufacturer.
The federal government agreed to buy 700,000 doses. An AstraZeneca spokesperson said the company has on hand enough doses to meet “near-term” demand, and the capacity to make more. The Department of Health and Human Services did not respond to questions about why the federal government did not order more doses.
“There are enough doses for about 1 percent of the people who need them. Not great,” Segev said.
This last letdown has got Nucci especially angry. “We need protection from Omicron now, not weeks or months from now,” he said. “It’s inexcusable. They should have been ready to go and have enough supply to get this out to us.”
Massachusetts received 1,032 courses of Evusheld on Dec. 17 and 1,056 courses on Dec. 26, according to state health officials. They are being distributed among 10 hospitals that provide care for immunocompromised patients in the state.
Dana-Farber Cancer Institute expects to be one of them, although the hospital doesn’t know how many doses it will receive, said Dr. Andrew J. Wagner, Dana-Farber’s medical director of ambulatory oncology.
“We will plan on starting with the most vulnerable patients,” he said. “Both the cancer itself and the therapies that we often use can deplete the immune system, in particular the B cell and T cells that can help fight infections and are also critically important for developing immune response to vaccinations.”
Patients with such blood cancers as multiple myeloma or leukemia, or anyone who has had a bone marrow transplant, are most likely to have an inadequate response to vaccination.
And cancer treatment can wear a patient down, said Dr. Inga Lennes, medical director of ambulatory services at the MGH Cancer Center.
“Most of the time cancer patients who are on therapy have less reserve to be able to fight an illness,” she said. “They’re weak and fragile to begin with.”
Studies have shown that antibody levels are lower in vaccinated cancer patients and that when infected with COVID-19 they have a high risk of hospitalization and death. Those risks, however, are not as high as they are among unvaccinated patients, and the booster shot “is your best defense,” Lennes emphasized.
In advising her patients, Lennes said, “I try to focus on the basics, make sure that my cancer patients understand their particular increased risk and vulnerability, so they can make the best decisions for themselves.”
Patients have to make risk-benefit calculations, taking into account the mental health consequences of isolation. If gathering with your family is important, then do it as carefully as possible, and forgo other risky situations, she advised.
For Andrew Seto, who has been coping with advanced lung cancer since September 2014, taking “some measured risks” is essential to carrying on with life with his wife and three sons.
Seto, who is 52 and lives in Southborough, traveled to California last fall to help his son move into his freshman year dormitory, a risk he considered well worth taking. Likewise, despite the rapid spread of Omicron, he recently went to see “Spider-Man: No Way Home” at the movie theater with his sons, because he wanted “to enjoy a few hours with my kids.”
But he takes every possible precaution on such adventures. He and his wife will forgo trips to the grocery store for minor items. And they canceled plans to spend Christmas in Florida like they usually do.
Seto said the cancer has spread throughout his body. He keeps it at bay with medication, chemotherapy, and occasional radiation. In some ways, he said, cancer has been good training for coping with COVID-19. “I don’t worry about things I can’t control,” he said.
Anna Legassie has also thought about balancing risks. The 38-year-old Dorchester resident takes immune-suppressing medication to control her rheumatoid arthritis and has often gotten so sick from infections that she had to be hospitalized. She has lung problems and recurrent inflammation of the sac around her heart.
But she also remembers the toll of the near-total isolation she endured in the spring of 2020, when the world locked down against COVID-19.
“I’ve chosen to have a bit more normalcy than some people who are immunocompromised,” she said. “Some of it is taking a pragmatic approach to my mental health. That’s where the balancing act comes in.”
For a while starting in the late summer this year, Legassie returned to the gym and yoga classes and resumed seeing friends, but that has mostly ended with the rise of Omicron. A couple of weeks ago, Legassie, who is a board member of the Autoimmune Association and works at home for a small biotech company, did take a chance and went to a comedy show with her two sisters, after all tested negative. “I had to live for a night,” she said.
New Year’s Eve was different, however. Legassie and her partner sadly decided against their usual celebration of dinner and a movie out. Instead they got dressed up and cooked a nice dinner at home.
Asked on Sunday how it went, she replied by text, “Bittersweet to be home but we still had a lot of fun together.”