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COVID-19 hit a few weeks ago as we were on our first vacation in more than three years. We were vaxxed and boosted and I had Evusheld onboard (six months ago). We are also religious about masking in public so this came as a bit of a surprise. My husband and I were scheduled to take an Alaskan Cruise in May of 2020 with our younger daughter and her family but the Pandemic interfered and that cruise was cancelled. With the entire family vaccinated and boosted, the six of us made plans to take that cruise together at the end of July 2022 and we had the best time as a family.

Everyone boarding the ship had to show proof of a negative COVID test taken no more than 48 hours before boarding the ship, and had to be masked during the boarding process. The entire staff on board was masked with N95 masks at all times. Most passengers, however, chose not to wear their masks once onboard. The first night we were seated at our table in the dining room, a lovely round table for six in the far back corner away from other diners. It was quiet enough for conversation and we were thrilled not to be at a large table with other cruisers and be able to reconnect as a family that rarely sees each other face-to-face. At the end of dinner that evening, the hostess came to our table. Seeing we had children with us, she informed us there was a table by the window that was vacant if the kids wanted to potentially watch for whales or dolphins as we were having dinner. So the following evening we were reseated. 

The new table by the window was cramped and crowded with other parties only about a foot behind us or maybe six feet in front of or beside us. No one near us was masked. None of the four adults in our group liked the setting and crowding, and we asked to return to our old table for the remainder of our time on the ship. Two days later, I began to have a cough and scratchy throat. Two days after that I was running a fever and tested positive for COVID. Thankfully no one else in our party other than my husband ended up getting the virus.

Why am I recounting this? Most of us have been exposed to COVID or have developed some protection from it through vaccines. However, about one-third of all people with MS who are taking a disease-modifying therapy are on a category of medicines known as anti-CD20 drugs or B cell depletion drugs (Ocrevus, Rituxan, Kesimpta), which have been shown to lower the immune response to vaccines. This decreased response appears to become more pronounced the longer an individual is on this class of medications so those new to the drug may mount some antibody response to either having an actual infection or getting the vaccines. But after a year on treatment, that response may not be effective in preventing an actual infection. I have had several antibody tests (after having COVID early in the pandemic and after each dose of vaccine) and all showed no (not low) antibody levels. That is why I received Evusheld, an injected medication that combines two different types of antibodies that help to fight COVID. 

The FDA recently issued a recommendation that all individuals on this type of medication receive this injection every six months to add an extra layer of protection for those on these drugs. My last dose of Evusheld was only a week from the end of that six-month interval. The CDC also recommends that all individuals who qualify for Evusheld and members of their household continue to mask at all times when in public indoor spaces as added protection. In hindsight, I think if I were to travel with so much opportunity for exposure to such a large group of individuals, I would make sure to schedule it for soon after the Evusheld rather than just before a dose. 

While having MS does not make us more likely to get COVID (or other infections), some of our DMTs do lower our response to vaccines and even blunt our immune systems from mounting adequate protection against future infections when we actually do get the virus. This is a reminder to all on these medications (which are highly effective at helping to manage MS): you may not have the protection you think you might from your three or four doses of vaccine or extra antibodies in the form of Evusheld. You do not have protection against getting COVID again because you have already had it. Masking is still strongly recommended indoors when you are around people not in your household. As an extension, all members of your household should also be masked indoors when they are outside the home to avoid bringing the virus to you. Targeted messaging to those at greater risk needs to continue.

Author's note: In December 2022, the Centers for Disease Control issued a statement that antibody therapies were found, with current variants, to be ineffective so were no longer recommended for immunocompromised individuals. Evusheld was also found to be minimally effective with current variants, so should not be used except when an individual cannot obtain immunity because of an inability to receive the vaccine. It is recommended that all immunocompromised individuals who test positive should contact their provider and start on an antiviral therapy such as Paxlovid or Remdesivir.