PROVINCETOWN — The novel coronavirus threatens us all — but not equally. Since the earliest days of the outbreak, scientists and ordinary people alike have hunted for information about who it seems to hit harder, and why. The science continues to evolve, and so does the virus. Our minds would like certainties and neat divisions, but this pandemic hasn’t obliged.
Most lists of the vulnerable include “the immunosuppressed.” This word turns out to embrace a lot of very different conditions. For many people though, memory brings up a related word: “immunodeficiency” — which is the “I” in HIV, and in AIDS.
“It did give me pause,” said Nicholas Gulde, a former resident of Wellfleet and then Provincetown who now lives in New York and is HIV-positive. “They talk about ‘compromised immune system,’ and a lot of people are going to immediately think HIV. When they don’t explain what it means, it does make you a little bit nervous.”
Gulde’s doctor, Joseph Rahimian, is an infectious disease and HIV specialist at NYU’s Grossman School of Medicine. “We are not seeing an overrepresentation of HIV-infected patients who are sick” with Covid-19, Dr. Rahimian said. “I suspect that those with well-controlled HIV are not extremely high risk.”
Merely having HIV doesn’t mean the immune system is suppressed, explained Dr. Susan Troyan, a cancer surgeon who serves on the Provincetown Board of Health. “People with adequate immune counts — CD4s over 200 — would not be considered immunosuppressed,” she said. CD4 cells, or lymphocytes, are the most important laboratory indicator of immune function.
Immunosuppression is usually the result of medical treatments, either as the deliberate effect or as an unwanted side effect.
“Most of the chemotherapies are immunosuppressive,” said Dr. Troyan, “and not only while people are going through it, but for some time after. They target cells that divide rapidly, which, in addition to cancer cells, also includes things like hair follicles, the lining of the mouth and gut, and the bone marrow. Bone marrow cells make the red and white blood cells. Radiation and chemotherapy at the same time can really drop the white blood cell counts.
“Then there’s the immunosuppression we cause on purpose,” Dr. Troyan continued. “For transplant patients, we carefully titrate the immunosuppression so their body won’t reject the new organ as foreign. We also suppress with autoimmune diseases like multiple sclerosis or rheumatoid arthritis. And for asthma and allergies, with inhaled steroids you’re trying to decrease the immune response locally, in the lungs or sinuses.”
Whether to continue these immunosuppressive treatments in the face of the pandemic is a difficult question.
“With cancer therapies,” said Dr. Troyan, “it’s very common that a surgery comes right before or right after the chemo and radiation. Some of the surgeries have a high chance of an ICU stay, and some of these hospitals have ICUs full of Covid patients. It’s a very difficult triage, trying to weigh the risk of exposing this cancer patient to Covid versus keeping them out of the system and away from treatments for however long.”
For people with asthma, on the other hand, “the important thing seems to be keeping the asthma controlled, keeping the normal drugs,” said Dr. Troyan. “There was an obvious worry about immunosuppressing the lungs, when this virus attacks the lungs. But we have not seen the severe problems in asthmatics that we thought we might.
“I’d like to point out,” Dr. Troyan added, “for a lot of immunosuppressed conditions, our concern is based in theory. There’s a potential for greater risk. We don’t have studies that show that. We want to keep them more protected, but I don’t want to scare people that have these conditions that they’re gonna die if they get this disease.”
Cancer patients forgoing treatment, though, is not theoretical. “Many of the operating rooms are being converted into ICUs,” said Dr. Troyan. “At some point we’ll need those back, for cancer care. In many ways, we have been asking cancer patients to make sacrifices for the rest of the population, which is understandable for short periods of time. But it really rocks me when I see people out demonstrating in close proximity to each other, when meanwhile we have cancer patients not getting treatments. They have no idea the sacrifices that are being made.”
