Preventing Infectious Complications of Immunomodulation in COVID-19 in Foreign-Born Patients

Abstract

Immunomodulating therapies for COVID-19 may carry risks of reactivating latent infections in foreign-born people. We conducted a rapid review of infection-related complications of immunomodulatory therapies for COVID-19. We convened a committee of specialists to formulate a screening and management strategy for latent infections in our setting. Dexamethasone, used in severe COVID-19, is associated with reactivation of latent tuberculosis, hepatitis B, and dissemination/hyperinfection of Strongyloides species and should prompt screening and/ or empiric treatment in appropriate epidemiologic contexts. Other immunomodulators used in COVID-19 may also increase risk, including interleukin-6 receptor antagonist (e.g., tocilizumab) and kinase inhibitors. People with specific risk factors should also be screened for HIV, Chagas disease, and endemic mycoses. Racial and ethnic minorities in North America, including foreign-born persons, who receive immunomodulating agents for COVID-19 may be at risk for reactivation of latent infections. We develop a screening and management pathway for such patients.

Keywords: COVID-19; Chagas disease; HIV; Health disparities; Hepatitis B virus; Immigrant; Inequity; Refugee; Strongyloidiasis; Tuberculosis.

Fig. 1

Screening, monitoring, and treatment of reactivation of latent infections in the course of immunomodulatory treatment of COVID-19. Note: TB tuberculosis, HBV hepatitis B virus, LTBI latent TB infection, HBsAb HBV surface antibody, HBsAg HBV surface antigen, HBcAb total HBV core antibody. 1. These symptoms should precede the onset of acute COVID-19 symptoms by at least one month and not be otherwise explained by comorbid conditions. 2. For patients with prior history of TB, LTBI testing is not indicated. 3. A positive LTBI test does not preclude use of immunomodulatory therapy with specialist input. 4. Strongyloides can reactivate with less than one week of steroid therapy, so in the appropriate host, we recommend prescribing ivermectin regardless of steroid duration. 5. In settings where serologic testing with rapid turn-around time for Strongyloides is available and follow up can be ensured, serologic testing can be conducted prior to treatment; otherwise, empiric ivermectin treatment is recommended. Ivermectin can preferentially be dosed at 200 µg/kg PO × 2 doses 14 days apart if follow-up dosing can be ensured. Many cases of uncomplicated Strongyloides infection may be treated with a single dose. Patients from West/Central Africa may be at risk for high-titer co-infection with other filarial nematodes, including Loa Loa, which is a contraindication to ivermectin administration. Clinicians should seek specialty consultation in these cases