While Canada’s National Advisory Committee on Immunization (NACI) is recommending stretching the time span between doses of coronavirus vaccines, transplant recipients and their doctors are concerned the shift from the original schedule of three to four weeks will put people at risk.
Sara Murray of Acton, Ont., leaves her house just once a day, on average, during the COVID-19 pandemic to take a walk and breathe in fresh air.
She was born with cystic fibrosis and received a double lung transplant 17 years ago, then eventually a kidney transplant. Murray falls into the category of immunosuppressed individuals who are at high risk for becoming ill from COVID-19.
Murray is especially worried about a delay between the first and second doses of the COVID-19 vaccine since new data suggests she may have little protection after only one.
“After the first dose of the mRNA vaccine, 17 per cent of transplant patients had detectable antibodies. This is in stark contrast to 100 per cent of immunocompetent people, people with intact immune systems, who have detectable antibodies already after their first dose,” said Dr. Dorry Segev, transplant surgeon and an associate professor of surgery and epidemiology at Johns Hopkins University.
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Segev and a team of researchers tested more than 400 transplant recipients in the United States to determine the effectiveness of the COVID-19 vaccines in the transplant community.
“If you’re immunosuppressed, it means that vaccination does not necessarily mean immunity and it means that you can’t just by virtue of having received the vaccine assume that you can relax the safety behavior that you’ve so carefully had for the last year,” he said.
This is further problematic in Canada, where NACI recommended in early March that provinces and territories can delay second doses by as long as four months.
“There is a problem in that, that is based on the assumption that dose one will give you antibodies. But if you’re immunosuppressed, it basically means that we are not really providing immunity to immunosuppressed people with that first dose … and they’re going to have to wait until the second dose to have any potential impact on their lives,” explained Segev.
Derek Clark of Caledon, Ont., developed pulmonary fibrosis, a lung disease that occurs when lung tissue becomes damaged and scarred, and eventually decided, with the advice of his doctors, that the best option would be a double lung transplant.
“I went through the assessment process in 2019 and fortunately for me, I was only on the waiting list for five weeks and I did receive my donation, the gift of life, in September of 2019,” he said.
Clark is anxious to return to a “normal lifestyle” because COVID-19 has kept him mostly indoors, aside from a daily walk outside.
He has been studying the research on the effectiveness of the vaccine for transplant recipients and worries about the delay between the two doses.
“The data shows really for seniors, for organ transplant recipients, for immunocompromised individuals, cancer patients, high-risk groups … that really the efficacy drops after two months if you don’t have the second dose,” he said, adding, “for high-risk groups, we should absolutely be complying with the pharmaceutical guidelines of three or four weeks for Moderna and for Pfizer.”
Dr. Lianne Singer, the division head of respirology and critical care medicine at UHN and Sinai Health System, is calling for a tailored approach to the vaccination rollout based on the “specific risks of the individual.”
“While I agree in principle with getting the first shot into as many people as possible in this time of scarcity and rising COVID rates, we have to recognize that strategy is not working for people who have a transplant or other immune-compromised people,” she said.
Dr. Singer referenced the research out of Johns Hopkins University, noting, “I’m worried about patients having to wait four months between vaccine doses because it’s becoming increasingly clear that patients who have a transplant are not going to get very much protection from that first dose.”
She is still urging transplant recipients to get their first dose of the vaccine, as well as their family members and caregivers, but wants to remind them that it should not change their behaviour during the pandemic.
“They should still be masking and being very diligent about handwashing and following all the public health guidelines,” said Singer.
That advice was echoed by UHN transplant infectious diseases physician Dr. Deepali Kumar.
“It’s so important if you are a transplant recipient to be careful and continue to practice social distancing, masking, handwashing, because the vaccines will probably not work as well even after the two doses in this particular population,” she said.
Kumar has studied vaccine response in transplant recipients for years and pointed out that, across the board, “vaccine responses are lower in transplant recipients than in the general population.”
As a result, she noted it is “not really surprising” that the COVID-19 vaccine response is also lower among that population.
“The concern specific to this is that coronavirus is obviously widespread. It’s causing more severe disease in transplant recipients than, let’s say, even the flu does. So definitely we’re very concerned that this particular vaccine, at least after the first dose, is not giving an adequate immune response,” she said.
Therefore, like other medical professionals, Kumar is calling for a timely rollout of the two doses.
“It’s imperative that we get the second dose in on time rather than waiting for three or four months to get the second dose,” she added, noting transplant patients also face the issue of waning immunity.
“If you wait for a longer period of time, starting from the first shot, immunity will steadily decrease over time. That’s normal with anybody who gets vaccinated, but in transplant recipients, because of the immune suppression, that waning is a lot faster,” she explained. “What we may see is that the booster may not be as effective if we wait too long.”
Even amid the cloud of concern, the sun is shining and Sara Murray is out for her daily stroll with her husband and their daughter, Sadie.
“For me to get COVID and for it to attack my lungs, it could put me into rejection, it could leave me with permanent damage, which could mean I need another lung transplant. Eventually it could kill me,” she said.
Sadie has been learning virtually this year for fear she may bring COVID-19 into the family’s home, putting mom at risk.
“I don’t want her to have the guilt if she were to bring it home. My husband has been working from home. He worked in aviation. He should be flying … and he can’t, because he can’t bring it home to me. So it’s essentially shut down my household,” she said.
“We deserve to be vaccinated properly. We deserve to have this protection. We deserve to have a life like everybody else.”
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