No COVID Vax, No Transplant: Unfair or Good Medicine?

Kathleen Doheny

February 04, 2022

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Right now, more than 106,600 people in the U.S. are on the national transplant waiting list, each hoping to hear soon that a lung, kidney, heart, or other vital organ has been found for them. It's the promise not just of a new organ, but a new life.

Well before they are placed on that list, transplant candidates, as they're known, are evaluated with a battery of tests and exams to be sure they are infection-free, their other organs are healthy, and that all their vaccinations are up to date.

Now, COVID vaccinations — and some people's resistance to them — have turned what used to be routine preparation controversial.

In January, a 31-year-old Boston father of two declined to get the COVID-19 vaccine, and Brigham and Women's Hospital officials removed him from the heart transplant waiting list. And in North Carolina, a 38-year-old man in need of a kidney transplant says he, too, was denied the organ when he declined to get the vaccination.

Those are just two of the most recent cases. The decisions by the transplant centers to remove the candidates from the waitlist have set off a national debate among ethicists, family members, doctors, patients, and others.

On social media and in conversation, the question persists: Is removing them from the list unfair and cruel, or simply business as usual to keep the patient as healthy as possible and the transplant as successful as possible?

Two recent tweets sum up the debate.

"The people responsible for this should be charged with attempted homicide," one Twitter user said, while another suggested that the more accurate way to headline the news about a transplant candidate refusing the COVID-19 vaccine would be: "Patient voluntarily forfeits donor organ."

Doctors and ethics experts, as well as other patients on the waiting list, say it's simply good medicine to require the COVID vaccine, along with a host of other pre-transplant requirements.

Transplant Protocols

"Transplant medicine has always been a strong promoter of vaccination," says Silas Prescod Norman, MD, a clinical associate professor of nephrology and internal medicine at the University of Michigan, Ann Arbor. He is a kidney specialist, or nephrologist, who works in the university's transplant clinic.

Requiring the COVID vaccine is in line with requirements to get numerous other vaccines, he says.

"Promoting the COVID vaccine among our transplant candidates and recipients is just an extension of our usual practice."

"In transplantation, first and foremost is patient safety," Norman says. "And we know that solid organ transplant patients are at substantially higher risk of contracting COVID than non-transplant patients."

After the transplant, they are placed on immunosuppressant drugs, also called anti-rejection drugs, that weaken the immune system while also decreasing the body's ability to reject the new organ.

"We know now, because there is good data about the vaccine to show that people who are on transplant medications are less likely to make detectable antibodies after vaccination," says Norman, who's also a medical adviser for the American Kidney Fund, a nonprofit that provides kidney health information and financial assistance for dialysis.

And this is not a surprise due to the immunosuppressive effects, he says.

"So it only makes sense to get people vaccinated before transplantation," Norman says.

Researchers compared the cases of more than 17,000 people who had received organ transplants and were hospitalized from April through November 2020, either for COVID (1,682 of them) or other health issues. Those who had COVID were more likely to have complications and to die in the hospital than those who did not have it.

Vaccination Guidelines, Policies

Federal COVID-19 treatment guidelines from the National Institutes of Health state that transplant patients on immunosuppressant drugs used after the procedure should be considered at a higher risk of getting severe COVID if infected.

In a joint statement from the American Society of Transplant Surgeons, the American Society of Transplantation, and the International Society for Heart and Lung Transplantation, the organizations say they "strongly recommend that all eligible children and adult transplant candidates and recipients be vaccinated with a COVID-19 vaccine [and booster] that is approved or authorized in their jurisdiction. Whenever possible, vaccination should occur prior to transplantation."

Ideally, it should be completed at least 2 weeks before the transplant, it says.

The organizations also "support the development of institutional policies regarding pre-transplant vaccination. We believe that this is in the best interest of the transplant candidate, optimizing their chances of getting through the perioperative and post-transplant periods without severe COVID-19 disease, especially at times of greater infection prevalence."

Officials at Brigham and Women's Hospital, where the 31-year-old father was removed from the list, issued a statement that reads, in part: "Our Mass General Brigham healthcare system requires several CDC-recommended vaccines, including the COVID-19 vaccine, and lifestyle behaviors for transplant candidates to create both the best chance for a successful operation and to optimize the patient's survival after transplantation, given that their immune system is drastically suppressed. Patients are not active on the waitlist without this."

Ethics Amid Organ Shortage

"Organs are scarce," says Arthur L. Caplan, PhD, director of the Division of Medical Ethics at NYU Langone Medical Center and School of Medicine in New York City. That makes the goal of choosing the very best candidates for success even more crucial.

"You try to maximize the chance the organ will work," he says. Vaccination pre-transplant is one way.

The shortage is most severe for kidney transplants. In 2020, according to federal statistics, more than 91,000 kidney transplants were needed, but fewer than 23,000 were received. During 2021, 41,354 transplants were done, an increase of nearly 6% over the previous year. The total includes kidneys, hearts, lungs, and other organs, with kidneys accounting for more than 24,000 of the total.

Even with the rise in transplant numbers, supply does not meet demand. According to federal statistics, 17 people in the U.S. die each day waiting for an organ transplant. Every 9 minutes, someone is added to the waitlist.

"This isn't and it shouldn't be a fight about the COVID vaccine," Caplan says. "This isn't an issue about punishing non-COVID vaccinators. It's deciding who is going to get a scarce organ."

"A lot of people [opposed to removing the nonvaccinated from the list] think, 'Oh, they are just killing those people who won't take a COVID vaccine.' That's not what is going on."

The transplant candidate must be in the best possible shape overall, Caplan and doctors agree. Someone who is smoking, drinking heavily, or abusing drugs isn't going to the top of the list either, Caplan says. And for other procedures, such as bariatric surgery or knee surgery, some patients are told first to lose weight before a surgeon will operate, he says.

The worry about side effects from the vaccine, which some patients have cited as a concern, is misplaced, Caplan says. What transplant candidates who refuse the COVID vaccine may not be thinking about is that they are facing a serious operation and will be on numerous anti-rejection drugs, with side effects, after the surgery.

"So to be worried about the side effects of a COVID vaccine is irrational," he says.

Transplants: The Process

The patients who were recently removed from the transplant list could seek care and a transplant at an alternate center, says Anne Paschke, a spokesperson for the United Network for Organ Sharing (UNOS), a nonprofit group that is under contract with the federal government and operates the national Organ Procurement and Transplantation Network (OPTN).

"Transplant hospitals decide which patients to add to the waitlist based on their own criteria and medical judgment to create the best chance for a positive transplant outcome," she says. That's done with the understanding that patients will help with their medical care.

So, if one program won't accept a patient, another may. But, if a patient turned down at one center due to refusing to get the COVID vaccine tries another center, the requirements at that hospital may be the same, she says.

OPTN maintains a list of transplant centers. As of Jan. 28, there were 251 transplant centers, according to UNOS, which manages the waitlist, matches donors and recipients, and strives for equity, among other duties.

Pre-Transplant Refusers Not Typical

"The cases we are seeing are outliers," Caplan says of the handful of known candidates who have refused the vaccine. Most, he suspects, ask their doctor exactly what they need to do to live and follow those instructions.

Norman agrees. Most of the kidney patients he cares for who are hoping for a transplant have been on dialysis, he says, "which they do not like. They are doing whatever they can to make sure they don't go back on dialysis. As a group, they tend to be very adherent, very safety-conscious because they understand their risk and they understand the gift they have received [or will receive] through transplantation. They want to do everything they can to respect and protect that gift."

Not surprisingly, some on the transplant list who are vaccinated have strong opinions about those who refuse to get the vaccine. Dana J. Ufkes, 61, a Seattle Realtor, has been on the kidney transplant list — this time — since 2003, hoping for her third transplant. When asked if potential recipients should be removed from the list if they refuse the COVID vaccine, her answer was immediate: "Absolutely."

At age 17, Ufkes got a serious kidney infection that went undiagnosed and untreated. Her kidney health worsened, and she needed a transplant. She got her first one in 1986, then again in 1992.

"They last longer than they used to," she says. But not forever. (According to the American Kidney Fund, transplants from a living kidney donor last about 15-20 years; from a deceased donor, 10-15.)

The decision to decline the vaccine is, of course, each person's choice, Ufkes says. But "if they don't want to be vaccinated [and still want to be on the list], I think that's BS."

Citing the lack of organs, "it's not like they are handing these out like jellybeans," she says.

Sources

Silas Prescod Norman, MD, clinical associate professor of nephrology and internal medicine, University of Michigan, Ann Arbor; medical adviser, American Kidney Fund.

Dana J. Ufkes, Realtor, Seattle.

Arthur Caplan, PhD, director, Division of Medical Ethics, NYU Langone Medical Center and School of Medicine, New York City.

Anne Paschke, spokesperson, United Network for Organ Sharing (UNOS).

NIH COVID-19 Treatment Guidelines: "Special Considerations in Solid Organ Transplant, Hematopoietic Stem Cell Transplant, and Cellular Immunotherapy Candidates, Donors, and Recipients."

Joint statement, American Society of Transplant Surgeons, American Society of Transplantation, and International Society for Heart and Lung Transplantation: "Joint Statement about COVID-19 Vaccination in Organ Transplant Candidates and Recipients."

News release, Brigham and Women's Hospital: "COVID-19 vaccination for transplant candidates."

Health Resources & Services Administration: "Organ Donation Statistics."

United Network for Organ Sharing (UNOS): "All-time records again set in 2021 for organ transplants, organ donation from deceased donors."

Clinical Transplantation: "Excess mortality in solid organ transplant recipients hospitalized with COVID-19: A large-scale comparison of SOT recipients hospitalized with or without COVID-19."

American Kidney Fund: "Preparing for Transplant."

Twitter: @emeriticus, Jan. 25, 2022.

CBS News: "Hospital refusing heart transplant for man who won't get vaccinated."

The Charlotte Observer: "Man denied vital kidney transplant in North Carolina over not getting the COVID vaccine, he says."

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