TABLE 1.

Country-specific considerations for COVID-19 vaccine mandates from a limited selection of countries

Country	Transplant activity46 (transplants per 1 million population)a	Populations targeted for vaccination	Vaccine coverage45 (September 30, 2021) (doses per 100 people)b	Available vaccines	Current vaccine mandates	Comments
Australia	2019: 69	All adults ≥16 years	108	Oxford-AstraZeneca Pfizer-BioNTech Moderna	Healthcare worker vaccine mandates issued through state-level public health directives	Vaccine availability was initially a barrier to achieving desired vaccination rates, even among groups targeted for early distribution More recently, vaccination has been expanded to all adults and healthcare worker and other industry mandates have been issued Australia must consider whether to defer additional or booster doses until other parts of the Asia Pacific region and the world have access to initial vaccination
China	2019: 14 2020: 12.4	All adults and children ≥12 years, with priority for healthcare workers; vaccination is encouraged for transplant candidates and recipients	158	Sinopharm-Beijing Sinovac CanSino Sinopharm-Wuhan Anhui Zhifei Longcom ZF2001 Minhai Biotechnology Co SARS-CoV−2 Vaccine Institute of Medical Biology of the Chinese Academy of Medical Sciences (Kunming)	No current mandates	Vaccine availability is not a barrier to achieving high vaccination rates for transplant groups Very low local COVID-19 incidence since March 2020 created low risk environment, decreased motivation for the population to be vaccinated, although current national strategy is driving a high rate of vaccinations in excess of 20 million doses per day Given low COVID-19 burden and high manufacturing capacity, China has been able to share more than 265 million doses of vaccines globally
Colombia	2019: 27	Healthcare workers, essential workers including teachers and institutional caregivers, adults with comorbidities	79	Oxford-AstraZeneca Pfizer-BioNTech Moderna Johnson & Johnson Sinovac	No current mandates	Vaccine availability has been a barrier to achieving desired vaccination rates, even among groups targeted for early distribution Vaccine is available for foreign citizens residing in Colombia or visiting the country who also meet eligibility criteria
India	2019: 9.3	All adults ≥18 years, with priority for healthcare workers, older adults, and adults with medical comorbidities	64	Oxford-AstraZeneca Moderna Johnson & Johnson Gamaleya (Sputnik V) Bharat Biotech (Covaxin) Cadila Healthcare ZyCoV-D	No current mandates for healthcare workers or transplant candidates; vaccination or negative testing is mandated for air travel	A wave of COVID-19 infections from March to June, 2021 posed a barrier to upscaling vaccination efforts because of strain on healthcare infrastructure and efforts by the population to stay distanced. More recently, increased intervals between doses of two-dose vaccine series to achieve better lasting immunity have also slowed progress of “complete” vaccination Healthcare workers have experienced a high burden of COVID-19 infections, morbidity, and mortality during periods of high transmission. Healthcare worker vaccinations have been prioritized but not mandated Transplant centers follow NOTTO guidelines for vaccination, which encourage but do not mandate COVID-19 vaccines
Italy	2019: 63c 2020: 57c	Healthcare workers, older adults, and vulnerable people including transplant recipients ≥16 years in all regions; the regions of Italy are progressing through additional vaccine priority phases at different rates	140	Oxford-AstraZeneca Pfizer-BioNTech Johnson & Johnson	As of April 1, 2021, a national government emergency decree made COVID-19 vaccination mandatory for healthcare workers in Italy Those who refuse may either be re-assigned to duties with lower risk of transmission or suspended without pay for up to 1 year6	Vaccination is mandatory for healthcare workers in Italy. Although legal challenges to the requirement may arise, the decree is thought to be consistent with Italy’s constitution The Italian strategy for non-healthcare personnel has focused on reducing severe COVID-19 illness and death to protect individuals and ease the burdens on a previously overwhelmed healthcare system. A position paper from the Italian Association for the Study of the Liver (AISF) supported priority vaccination for transplant recipients, ultimately placed in Category 1 on the basis of increased risk for severe illness with COVID-19. In some cases, caregivers were also able to be vaccinated47
Republic of Korea	2019: 84	All adults ≥18 years, with priority for healthcare workers and older adults	121	Oxford-AstraZeneca Pfizer-BioNTech Moderna Johnson & Johnson	No current mandates	South Korea has had a low rate of COVID-19 transmission and COVID-19 mortality, lessening the magnitude of harms/benefits considerations related to vaccination. After emergence of the delta variant, transmission is increasing Vaccine availability is increasing following authorization of additional vaccine products and shipments of vaccine products from countries like the United States Government is planning to introduce a ‘vaccine passport’ strategy allowing vaccinated people to attend events without other restrictions, with the aim of increasing vaccination uptake
South Africa	2016: 6.6	All adults ≥18 years	29	Pfizer-BioNTech Johnson & Johnson	No current mandates, nor are mandates permitted by the South African Constitution	Vaccine availability had been a barrier to completing vaccination for groups targeted in early phases, including healthcare workers and adults ≥60, in part because of regulatory challenges. This has improved by the Sisonke Programme, a collaboration between the National Department of Health, South African Medical Research Council, Desmond Tutu Health Foundation, CAPRISA, Janssen, and Johnson & Johnson The government is considering a petition to give additional doses to transplant recipients, as well as to healthcare workers initially vaccinated with Ad-CoV2 Based on our constitutional ethos, a person’s decision to receive a vaccine must always be voluntary and made without any undue influence. The South African Constitution undoubtedly respects and protects such a decision
United States	2019: 123 2020: 121	All adults and children ≥12 years, initially with priority for healthcare workers, older adults, and adults with medical comorbidities	111	Pfizer-BioNTech Moderna Johnson & Johnson	Mandates imposed by individual organizations expected to be legally defensible Multiple businesses, universities, and healthcare organizations impose mandates	Vaccine availability is not a barrier to achieving high vaccination rates for transplant groups. Instead, a prominent anti-vaccination movement has limited vaccine uptake, particularly in some parts of the country Countries with vaccine availability exceeding demand are in a position to share vaccine supply with other countries globally. The U.S. has moved to donate unused doses of ChAdOx1 vaccine, as well as doses of mRNA-based vaccines, but has also begun to offer booster doses to its own vaccinated population

Abbreviations: COVID-19, coronavirus disease 2019; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.

^aData listed are for the most recent year that data are publicly available. For countries with data available for 2020, 2019 transplant rates are also listed to reflect pre-COVID-19 transplant activity.

^bThe majority of available vaccines require a two-dose series for recipients to be considered fully vaccinated.

^cUnpublished data from the Italian Health Ministry and update from National Transplant Center (CNT), Rome, Italy.