A transplant recipient's pandemic perspective

To the editor,

I write to request help for my fellow transplant recipients in this traumatic time. Although others return to their normal routines confidently protected by vaccination, transplant recipients face an uncertain future unsure if vaccines, or any other measures, will protect us. We desperately need better guidance from our care teams, who should, in my opinion, encourage not only vaccination, but also more frequent COVID‐19 testing. We also need priority access to existing monoclonal antibody therapy, antivirals, and any new vaccines.

First, I would like to thank everyone trying to understand how SARS‐CoV‐2 affects transplant recipients. I am particularly glad that some of this work convinced the CDC to allow us to receive priory access to a third vaccine dose. The fact that the decision was made so rapidly delighted many of us, who felt ignored for the past year. For example, when the first mRNA‐based vaccines were approved my elation soon turned to despair when I learned I was not vaccine eligible. I needed to return to the classroom in January and was so desperate that I joined a clinical trial examining vaccine safety and efficacy in transplant recipients, only to learn that the research team could not administer the vaccines they sought to study. I received my first dose in March, months after many of my students, only because I teach in person, not because I am immunosuppressed. I still do not understand why many of us spent longer waiting for a COVID‐19 vaccine after they were approved than we did for our organs.

When I learned my transplant team could not administer vaccines, I was also shocked to learn that many of their patients were vaccine hesitant. This attitude baffled me because, like countless others, I never would have needed a transplant had a hepatitis C virus (HCV) vaccine been available. After some reflection, I could understand their reluctance because mRNA‐induced antigen production in a transplanted organ might, in theory, cause rejection. I was also worried at the time that such an attitude might be due to initial reports that transplant recipients make fewer antibodies than others after receiving one dose of an mRNA vaccine. ¹ Thankfully, neither concern seems warranted. The COVID‐19 mRNA vaccines are safe, more transplant recipients produce antibodies after a second dose, ² and even more raise antibodies after a third ³ or fourth dose. ⁴

Whether or not these serum antibodies protect us from infection, and more importantly, severe disease, still needs to be determined. Until we know more, I will always wear a good mask in public and keep as socially distant as possible. Quality masks are important, and I encourage everyone to wear a KN95, or better. Good masks are now inexpensive and widely available. Perhaps they could be distributed in clinics instead of cloth or surgical masks?

After a virus destroyed my first liver, I spent 20 years developing better antiviral drugs. Regretfully, during those years, antiviral research focused almost exclusively on chronic infections, and most of it ended with the approval of our HCV drugs. Had we persisted, despite the lack of government or industry interest, we might have avoided our present catastrophe. Until we can design vaccines that work better for the immunocompromised, direct acting antivirals, that is, those targeting viral rather than host proteins, are the best safety net for transplant recipients. The vaccine hesitant also embrace antivirals, as is clear from their insatiable appetite for hydroxychloroquine and ivermectin, neither of which are direct acting, nor particularly effective. At present, the best option for therapy seems to be monoclonal antibodies, but I fear they might not be available to transplant patients who need them as hospitals swell to capacity with the unvaccinated sick. If monoclonal antibody supplies continue to dwindle, transplant centers should reserve some of these important therapeutics for their patients that vaccines might not protect.

For monoclonals and antivirals help, they must be administered early, and for COVID‐19 this likely means before symptoms arise. Even though I have had three vaccine doses I still use rapid antigen tests every few days. Fortunately, these are still available at my university, but it would be nice if we could all have these tests at home. Please encourage your readers to visit https://www.rapidtests.org and ask their representatives to make this a reality.

All deaths from vaccine‐preventable illnesses are equally tragic, but when COVID‐19 kills a transplant recipient, we must also mourn anew for the donor whose gift of life also ended. More can be done to help, and we all must combat vaccine hesitancy, encourage frequent testing, and have and ample supply of antivirals on hand when needed.

CONFLICT OF INTEREST

The author declares no conflict of interest.