Should Patients Be Required to Receive COVID Vaccine to Be Listed for Kidney Transplant?: CON

At this time in the United States, approximately 590 M doses of coronavirus disease 2019 (COVID-19) vaccines have been given out and 222 M people are fully vaccinated, which is approximately 67% of the eligible population. People with influential voices in the medical and public health areas have an enormous amount of information about COVID 2019 (COVID-19) and the COVID-19 vaccines. This has made it easier to advance general national regulations and recommendations on how to address and fight against this deadly virus. For the general population of the United States, these regulations have turned out to be good. Being vaccinated against the virus has cut down on the rapid death rate due to COVID-19. However, one size does not fit all. What about the 33% of the population who have chosen at this time not to be vaccinated? We cannot prohibit them from going to public places, going to work, going to hospitals, or interacting with people without wearing a face mask. The 33% of the population have made a personal decision not to be vaccinated and that is something that must be respected by those who have been vaccinated. So why should a person in need of an organ transplant be required to get the COVID-19 vaccine to be listed for a kidney transplant? There are no real solid data that can support the need to be prevaccinated before being listed as a candidate for transplant.

The goal of organ transplant is not just to perform a successful operation but to provide a significant extension of the quantity and quality of a recipient's life. For many centers, it appears easier for them to follow the generic recommendation by requiring potential candidates to be vaccinated to be enrolled at their facility, but this is only a recommendation. Medicare only stipulates that every transplant center has processes to assess the suitability of a candidate's risk before being placed on the national waiting list. Eligible people are being denied a chance to celebrate life because they chose not to take a vaccine that is not proven to be effective. To deny a person a chance to even be evaluated because they are not vaccinated is inappropriate. Denying a person at receiving a life-changing/saving kidney transplant, just because they do not want to receive a vaccine, is counterproductive to the services and purpose that a transplant center is supposed to provide. The COVID-19 vaccines are not 100% effective at preventing infection.¹ Some people who are up to date with their COVID-19 vaccinations are getting COVID-19 breakthrough infection. While the transplant center is looking out for the best interest of the patient, whether a person is qualified and healthy to receive a transplant, except for not being vaccinated, what is the issue? Give them the courtesy to see whether they will be able to manage post-transplant recovery. Do not deny just based on theory. What if a doctor by their experience looked at a person affected by COVID-19 and determined they would not make it so they moved on to the next person? This evaluation time could be the best time to educate the candidate and family. Good education about kidney disease and COVID-19 is still infrequent, and not all information is dependable or true. After the initial evaluation and proper education and counseling about COVID-19 and the vaccine, the potential candidate may have a change in their thinking and decide to get vaccinated. Without education and counseling, they may forever look negatively toward vaccination, thus limiting their own chances of getting a transplant. This is true especially in communities of color and low-income communities where COVID-19 has disproportionately affected.

Many communities of color lack access to education about the COVID-19 vaccine and access to proper health facilities to receive a vaccine. Black, Hispanic, and Native American people are about four times more likely to be hospitalized and nearly three times more likely to die of COVID-19 than White people.² Lacking proper information and care leads to turning to the Internet where an estimated 80% of them will look for health information online.³ Families also will rely on family conversations as a form of information. Myths and negative medical history lead to making decisions against COVID-19 vaccination.⁴ The internet has become a major determent of health as people have more access to online information.⁵ People will look to the Internet for information and use it regardless of where the information is valid. The types of misinformation, along with the history of mistreatment by the medical community toward the African American community, Tuskegee Syphilis Study, and the experience of Henrietta Lacks, have led to a lack of trust in the government and medical communities. Real life issues such as lack of good local health care and facilities, little or no transportation, and the ability to obtain decent and affordable health insurance for COVID-19 hospital coverage only promotes a negative image of health care. This continues to lead to intense calls about structural and interpersonal racism within the medical community.

Many African American and Latinx participants cited structural and interpersonal racism and anti-immigrant discrimination as factors reducing their trust in government and public health disseminated information and their willingness to be vaccinated. Although four times more likely to be hospitalized and nearly three times more likely to die of COVID-19 than White people, 35% of Black American participants said they do not plan to get the vaccine, citing fears about safety and concerns that the vaccines are too new.⁶

Other arguments today made on nonvaccinated candidates are not because of pretransplant concerns, such as infecting other patients, the medical staff, or the center, but about the “possible chances” of what could go wrong in post-transplant. What happens “if” a recipient loses the transplanted kidney if they should contract the virus post-transplant? The concern that transplant recipients are at a higher risk of getting COVIID-19 than the general population has not been proven. There is no proof that having a vaccine will improve the odds of a person keeping or rejecting their transplanted kidney. “Though vaccinations are safe for transplant recipients—whether they are for the flu or COVID-19—there has not yet been any research on the immune response of vaccination in these individuals. As a result, it is not yet known how effective vaccinations are in protecting their health, even for annual flu vaccinations.”⁷ “The data required to accurately predict COVID-19–related disease severity in individual recipients do not exist, nor does the infectious inoculum required to produce disease or the degree of disease susceptibility introduced by immunosuppression. There is no reliable information about the durability and degree of protection provided by vaccination for any specific patient.”⁸

Vaccine makers excluded immunocompromised people from their clinical trials in their rush to develop a vaccine. If potential recipients have the option of picking a patient with high-risk kidney disease, they should have the option of facing high-risk odds of post-transplant infections.

Transplant centers should look at each patient individually and make their decision based on the patient, not by generalized recommendations or by statistics. Potential recipients and living donors are people and should be treated as so. They should have a voice in their own health. I believe it is unfair and prejudicial for the medical and health community to believe that those who do not want to be vaccinated are purposely living reckless lives. In turn, they may be living a more cautious life than a person who is vaccinated. A person may be following the guidelines, over and beyond to get listed. They may be at home and stay away from people and the public, they may do home dialysis, they closely follow their diet, or they do telehealth or telemedicine with their medical teams. They take extra precautions because they would like to receive a new lease on life by transplant. It could be lack of access to get the vaccine and keep up with the scheduled updates. What happens to the vaccinated person who tests negative but is a carrier after their transplant? The vaccine may not be safe for everyone. As we have seen, the vaccine may not work and there are long-term effects that can put you at risk for not making the list at all. The vaccines out are not full proof, and currently, no one fully knows the effects of this virus. We are already on shot/booster 4 with talks going on these boosters may have to turn into a regular routine. “This trend, along with recent Centers for Disease Control and Prevention data showing that people who received a booster shot have been catching the virus at a higher rate than those who did not, has led to some confusion around the purpose and effectiveness of boosters.”⁹ Although some may see this statement as unfair, this is the type of information in print that people use to defend their reasoning for choosing not to be vaccinated.

Let the concentration be on post-transplant plans to ensure the transplant recipient and organ are receiving the proper care and a better way of life. New studies are showing that vaccines can be started within weeks of post-transplant. There is in fact evidence of vaccine effectiveness in transplant recipients in preventing infection and prevents hospitalization and death. Therefore, vaccines are effective even if they are not perfect. Let the medical community work with the patient community to improve education for candidates to get more people vaccinated and get rid of the misinformation and myths. Let these groups also work at addressing systematic racism and break down the walls, so everyone receives the same top care. Transplant centers should be proactive with the care of a nonvaccinated person as with a vaccinated person. Start working on a care plan once a candidate has been accepted by the center and work together with the candidate. Look into alternative ideas such as weekly testing of candidates and self-isolation of 2–3 weeks before a scheduled transplant by both living donor recipients. Discuss a care plan with the patient and family, so they understand what to expect and what their role will be. However, the only way this can be done is to answer the door and have a conversation. Do not just leave them out in the cold.

Disclosures

C. Warfield reports the following: Employer: KHI Patient and Family Partnership Council; Honoraria: Chronic Kidney Disease.Net; College of Pharmacy, University of Minnesota; NEPTUNE—Nephrotic Syndrome Study Network; Patient-Centered Outcomes Research Translation Center (PCOR-TC); ProKidney; and ZS Pharma, Inc.; Advisory or Leadership Role: Member Board of Directors—Home Dialyzors United and Member Board of Directors—National Kidney Foundation-Indiana; Other Interests or Relationships: Advancing Kidney Health through Optimal Medication Management-U of Minnesota; ZS' Patients as People Co-lab; American Kidney Fund; End Stage Renal Disease Treatment Choices Learning Collaborative (ETCLC); Home Dialyzors United; Indiana Donor Network; Kidney Precision Medicine Project (KPMP); Kidney Research Institute (KRI); National Kidney Foundation; National Kidney Foundation Indiana; Organ Procurement and Transplantation Network (OPTN)/United Network Organ Services; and ZS Pharma.

Funding

None.

Author Contributions

Conceptualization: Curtis Warfield.

Writing – original draft: Curtis Warfield.

Writing – review & editing: Curtis Warfield.