Ethical review of COVID-19 vaccination requirements for transplant center staff and patients

Comparison of outcomes in vaccinated versus unvaccinated COVID-19 kidney transplant recipients, a single center retrospective study-Is the taboo justified?

INTRODUCTION

We assessed differences in the post-transplant outcomes between COVID-19 vaccinated and unvaccinated Kidney transplant (KTx) recipients.

METHODS

We conducted a retrospective, single-center study of 400 KTx from 2/1/2021 to 4/30/2022 with 6-21 months follow-up. Primary outcomes included differences in the incidence of post-transplant COVID-19, ICU admission for COVID-19, death, and graft failure between the two groups. Secondary outcomes were inpatient floor admission, outpatient-management, length of hospital stay during COVID-19 admission. We also reported rejection, DGF, CMV needing treatment, and BK PCR >10 000 in baseline characteristics.

RESULT

70.5% (282/400) were fully vaccinated, and 29.5% (118/400) were unvaccinated. 33% (92/282) of vaccinated and 39% (46/118) of unvaccinated patients developed COVID-19 (p-value .03). In both groups, 16% received outpatient treatments for COVID-19. 3% (12/282) of the vaccinated and 8% (11/118) unvaccinated were admitted to the general floors (p-value .06), and 1% (3/282) of the vaccinated and 3.3% (4/118) of the unvaccinated patients needed admission to the ICU (p-value .2). The length of stay was 12 days in both groups. 13/282 (4.6%) vaccinated patients and 7/118 (5.93%) unvaccinated patients died during the follow-up period (p-value = .3). COVID-19 was deemed the etiology of death in 5/13 cases in the vaccinated and 3/7 in the unvaccinated. DGF, rejection, CMV requiring treatment, and BK PCR >10 000 were comparable between groups.

CONCLUSION

The incidence of COVID-19 was higher in unvaccinated than in vaccinated KTx. The two groups were not statistically different for other primary outcomes, including the need for hospital admissions (outpatient, general floor, ICU), length of hospital stay, death, and graft failure.

Pretransplantation coronavirus disease 2019 vaccination requirements: A matched case-control study of factors associated with waitlist inactivation

Numerous United States transplant centers require solid organ transplantation candidates to be vaccinated against the coronavirus disease of 2019 to be active on the United Network for Organ Sharing waiting list. This study examined characteristics of adult patients on one center's kidney transplantation waiting list whose status was inactivated due to a lack of coronavirus disease 2019 vaccination by July 1, 2022, and who did not subsequently provide proof of vaccination by August 31, 2022 (cases). Patients in the control group were retrospectively matched to patients in the case group in a 4-to-1 fashion according to age, sex, and "active" status on the waiting list. Multivariable logistic regression was performed, with race/ethnicity, primary language, health insurance, education, and Vaccine Equity Metric (VEM, a measure of health equity at the zip code level) quartile as covariates. Results revealed that patients from zip codes in the lowest VEM quartile (odds ratio [OR] 1.89; P = .02) and those insured by governmental payors (Medicare: OR, 2.00; P < .01 and Medicaid: OR, 2.89; P < .01) had higher odds of being inactivated than those from zip codes that make up the highest VEM quartile and those insured by commercial payors, respectively. These findings serve as a cautionary tale regarding universal pretransplantation vaccination requirements, which may raise equity concerns that should be considered upon policy implementation.

Adherence to recommended vaccination policies for pre- and post-solid organ transplantation patients: A national questionnaire survey in Japan

BACKGROUND

Pre-transplant vaccination is recommended for patients undergoing solid organ transplantation (SOT). While appropriate vaccination protocols are implemented at some facilities, transplantation is sometimes performed with inadequate preoperative vaccine management. Vaccination rates vary across facilities, but those of SOT centers in Japan have never been investigated. This study aimed to conduct a nationwide questionnaire survey to assess pre- and post-transplant vaccination policies among SOT facilities in Japan.

METHODS

The survey was conducted from September to November 2022. All registered (n = 221) solid organ (namely, the lungs, liver, kidneys, pancreas, heart, and small intestine) transplant facilities were asked to complete a web-based survey.

RESULTS

The survey response rate was 70.2 %. Live and inactivated vaccines were recommended at 64.9 % and 68.9 % of the responding facilities, respectively. The following vaccines were incorporated into the vaccination protocols of facilities: pneumococcal vaccine, 31.7 % (13-valent pneumococcal conjugate vaccine) and 65.4 % (23-valent pneumococcal polysaccharide vaccine); hepatitis B virus vaccine, 67.3 %; severe acute respiratory syndrome coronavirus 2 vaccine, 73.1 %; influenza vaccine, 73.1 %; and zoster vaccines, 23.1 %. The reasons for unresponsiveness to vaccinations included inadequate time before transplantation (60.3 %), cost burden (41.1 %), high number of vaccinations (21.9 %), no recognition of the need for vaccination (17.9 %), and the requirement to explain the need for vaccination (15.2 %).

CONCLUSIONS

Our study revealed gaps in vaccination practices across nationwide facilities in Japan. The findings indicate the importance of promoting scheduled efficiency and encouraging the national health system to reduce vaccine costs with the support of public subsidies.

Chronological Changes in Emotional Status and Vaccine Implementation Rate Among Patients on the Waiting List for Deceased-Donor Kidney Transplantation During the Prolonged COVID-19 Pandemic

BACKGROUND

To investigate the emotional attributes and vaccine implementation rate of patients waiting for kidney transplants during the prolonged COVID-19 pandemic.

METHODS

We included 145 patients who were on the waiting list at our institution. Clinical information was obtained from medical charts, and emotional changes were assessed using a telephone questionnaire comprising 13 questions, including vaccine implementation. We also investigated factors affecting the decision to accept or decline deceased-donor kidney transplantation during the COVID-19 pandemic.

RESULTS

Of the 145 patients, 121 (83.4%) provided informed consent and completed the questionnaire. The median age at registration on the waiting list for deceased-donor kidney transplantation and the median waiting period was 45.5 years and 103 months, respectively. This cohort comprised 84 males and 37 females. Twenty patients (16.5%) were diagnosed with COVID-19, and 15 (12.4%) were more curious about deceased-donor kidney transplantation. One hundred patients (82.6%) were vaccinated against COVID-19 more than thrice. Thirty patients (24.8%) declined, and 91 patients (75.2%) accepted an organ transplant offer during the COVID-19 pandemic. Multivariate analysis revealed that the long-term waiting period (P = .038) and anxiety about COVID-19, such as visiting the transplant facility (P < .0001) and prudence over time (P < .0001), were independent factors influencing the decline of a kidney transplant offer.

CONCLUSIONS

Our findings suggest that some patients hesitated to undergo deceased-donor kidney transplantation during the pandemic. There is a need to develop an appropriate system to ensure safe and secure kidney transplantation during prolonged pandemics.

Survey of pediatric transplant center practices regarding COVID-19 vaccine mandates for transplant candidates and living donors and use of COVID-19-positive deceased organs

BACKGROUND

COVID-19 vaccine is recommended for individuals ages ≥6 months; however, whether vaccination should be mandated for transplant candidates and living donors remains controversial. This study assessed COVID-19 policies at US pediatric solid organ transplant centers.

METHODS

A 79-item survey was emailed between March and April 2022 to 200 UNOS Medical Directors detailing center COVID-19 vaccine policies for transplant candidates and living donors and use of grafts from COVID-19-positive deceased donors.

RESULTS

The response rate was 77% (154/200). For children aged 5-15 years, 23% (35/154 centers) have a COVID-19 vaccine mandate, 27% (42/154) anticipate implementing a future mandate, and 47% (72/154) have not considered or do not anticipate implementing a mandate. For children ≥16 years, 32% (50/154 centers) have a COVID-19 vaccine mandate, 25% (39/154) anticipate implementing a future mandate, and 40% (62/154) have not considered or do not anticipate implementing a mandate. The top two reasons for not implementing a COVID-19 vaccine mandate were concerns about penalizing a child for their parent's decision and worsening inequities in transplant. Of 85 kidney and liver living donor centers, 32% (27/85) require vaccination of donors. Twenty percent (31/154) of centers accept organs from COVID-19-positive deceased donors.

CONCLUSIONS

There is great variation among pediatric SOT centers in both the implementation and details of COVID-19 vaccine mandates for candidates and living donors. To guide more uniform policies, further data are needed on COVID-19 disease, vaccine efficacy, and use of grafts from donors positive for COVID-19 in the pediatric transplant population.

Factors influencing Australian nursing and midwifery students COVID-19 vaccination intentions

Background

Vaccination for COVID-19 has become a cornerstone management plan for many countries. Australian state governments made vaccinations mandatory for all healthcare workers. Despite evidence on the important role vaccines hold in preventing or decreasing serious disease, there have been many nurses and midwives who have demonstrated vaccine hesitancy. This hesitancy has also been present in undergraduate nursing and midwifery students. The aim of this study was to explore factors influencing Australian nursing and midwifery students' intentions towards receiving the COVID-19 vaccine; identify the barriers and facilitators to obtaining the COVID-19 vaccine; and understand students' perceptions of mandating the COVID-19 vaccine and identify any impact on their studies..

Methods

Cross-sectional mixed method study utilising an online survey platform. Data were analysed using binomial and multinomial logistic regression through Statistical Package for the Social Sciences. A content analysis was completed for the qualitative data.

Results

There were 715 participants and 556 who completed the survey in full. Nurses made up the majority of participants (n = 409), 133 participants were midwives and 30 were in dual nursing/midwifery programs. Education and communication were identified as two major factors that facilitate vaccine acceptance.

Conclusions

Vaccines are integral in the prevention of contracting COVID-19 or reducing the severity of the symptoms. However, many nursing and midwifery students have shown reluctance towards getting vaccinated. The mandate to be vaccinated to attend clinical placement has led to the inability of some students to complete their course. The findings from this study are valuable in informing the future COVID-19 vaccination strategies and improving vaccine acceptance. COVID-19 remains a global health risk and therefore further research is needed of vaccine acceptance amongst the future health workforces. It is crucial knowledge for policy makers and healthcare services as they plan for any future pandemics and implement Australia's national vaccine strategy.

COVID-19 Vaccination Status and Operative Outcomes after Kidney Transplantation

BACKGROUND

Kidney transplantation remains the best available treatment for end-stage renal disease. However, promoting graft longevity and preventing allosensitization requires strict adherence with a stringent immunosuppression regimen. The COVID-19 pandemic has offered new challenges for kidney transplant patients and many transplant centers are denying transplantation to unvaccinated patients. The aim of this study was to evaluate whether unvaccinated patients had inferior adherence after kidney transplantation along with a reduction in graft survival.

STUDY DESIGN

Patients undergoing a deceased donor kidney transplantation at a single academic medical center from February 2021 to May 2022 were retrospectively reviewed. February 2021 was chosen as the start date for record review because it was 3 months after the first COVID-19 vaccination was authorized for emergency use. Patients were considered to be vaccinated if they received at least 1 dose of any mRNA vaccine by their transplantation date.

RESULTS

Of the 301 patients who met study criteria, 234 were vaccinated and 67 were unvaccinated. Cohorts stratified by vaccination status were well matched. Younger age was an independent risk factor for nonvaccination. Interestingly, unvaccinated patients had worse postoperative adherence with a greater average number of missed postoperative clinic visits (p = 0.03) and a strong trend toward missing 3 or more postoperative clinic visits (p = 0.07). Finally, unvaccinated patients had statistically more subtherapeutic tacrolimus troughs (p = 0.01).

CONCLUSIONS

Patients not vaccinated against COVID-19 had higher rate of postoperative nonadherence in key areas of immunosuppression monitoring and clinic visit attendance. Providers should be cognizant that an unvaccinated status may be a harbinger for poor adherence; therefore, stricter strategies for patient outreach are critical to ensure graft success in this vulnerable patient population.

Orthotopic Liver Transplantation of a SARS-CoV-2 Negative Recipient from a Positive Donor: The Border between Uncertainty and Necessity in a Pandemic Era- Case Report and Overview of the Literature

(1) Introduction: Liver transplantation represents the gold-standard therapy in eligible patients with acute liver failure or end-stage liver disease. The COVID-19 pandemic dramatically affected the transplantation landscape by reducing patients' addressability to specialized healthcare facilities. Since evidence-based acceptance guidelines for non-lung solid organ transplantation from SARS-CoV-2 positive donors are lacking, and the risk of bloodstream-related transmission of the disease is debatable, liver transplantation from SARS-CoV-2 positive donors could be lifesaving, even if long-term interactions are unpredictable. The aim of this case report is to highlight the relevance of performing liver transplantation from SARS-CoV-2 positive donors to negative recipients by emphasizing the perioperative care and short-term outcome. (2) Case presentation: A 20-year-old female patient underwent orthotropic liver transplantation for Child-Pugh C liver cirrhosis secondary to overlap syndrome, from a SARS-CoV-2 positive brain death donor. The patient was not infected nor vaccinated against SARS-CoV-2, and the titer of neutralizing antibodies against the spike protein was negative. The liver transplantation was performed with no significant complications. As immunosuppression therapy, the patient received 20 mg basiliximab (Novartis Farmacéutica S.A., Barcelona, Spain) and 500 mg methylprednisolone (Pfizer Manufacturing Belgium N.V, Puurs, Belgium) intraoperatively. Considering the risk of non-aerogene-related SARS-CoV-2 reactivation syndrome, the patient received remdesivir 200 mg (Gilead Sciences Ireland UC, Carrigtohill County Cork, Ireland) in the neo-hepatic stage, which was continued with 100 mg/day for 5 days. The postoperative immunosuppression therapy consisted of tacrolimus (Astellas Ireland Co., Ltd., Killorglin, County Kerry, Ireland) and mycophenolate mofetil (Roche România S.R.L, Bucharest, Romania) according to the local protocol. Despite the persistent negative PCR results for SARS-CoV-2 in the upper airway tract, the blood titer of neutralizing antibodies turned out positive on postoperative day 7. The patient had a favorable outcome, and she was discharged from the ICU facility seven days later. (3) Conclusions: We illustrated a case of liver transplantation of a SARS-CoV-2 negative recipient, whose donor was SARS-CoV-2 positive, performed in a tertiary, university-affiliated national center of liver surgery, with a good outcome, in order to raise the medical community awareness on the acceptance limits in the case of COVID-19 incompatibility for non-lung solid organs transplantation procedures.

Update on Covid-19: vaccines, timing of transplant after COVID-19 infection and use of positive donors

PURPOSE OF REVIEW

SARS-CoV-2 resulted in a global pandemic that had a chilling effect on transplantation early in the pandemic and continues to result in significant morbidity and mortality of transplant recipients. Over the past 2.5 years, our understanding of the clinical utility of vaccination and mAbs to prevent COVID-19 in solid organ transplant (SOT) recipients has been studied. Likewise, approach to donors and candidates with SARS-CoV-2 has been better understood. This review will attempt to summarize our current understanding of these important COVID-19 topics.

RECENT FINDINGS

Vaccination against SARS-CoV-2 is effective in reducing the risk of severe disease and death among transplant patients. Unfortunately, humoral and, to a lesser extent, cellular immune response to existing COVID-19 vaccines is reduced in SOT recipients compared with healthy controls. Additional doses of vaccine are required to optimize protection of this population and still may be insufficient in those who are highly immunosuppressed, those receiving belatacept, rituximab and other B-cell active mAbs. Until recently, mAbs were options for the prevention of SARS-CoV-2 but are markedly less effective with recent omicron variants. SARS-CoV-2-infected donors can generally be used for nonlung, nonsmall bowel transplants unless they have died of acute severe COVID-19 or COVID-19-associated clotting disorders.

SUMMARY

Our transplant recipients require a three-dose mRNA or adenovirus-vector and one dose of mRNA vaccine to be optimally protected initially; they then need to receive a bivalent booster 2+ months after completing their initial series. Most nonlung, nonsmall bowel donors with SARS-CoV-2 can be utilized as organ donors.

Ethical considerations of the vaccine development process and vaccination: a scoping review

BACKGROUND

Various vaccines have been developed and distributed worldwide to control and cope with COVID-19 disease. To ensure vaccines benefit the global community, the ethical principles of beneficence, justice, non-maleficence, and autonomy should be examined and adhered to in the process of development, distribution, and implementation. This study, therefore, aimed to examine ethical considerations of vaccine development and vaccination processes.

METHODS

A scoping review of the literature was conducted based on the Arkesy and O'Malley protocol to identify eligible studies published until November 2021. We searched Web of Science, PubMed, Scopus, and SciELO databases. The search was conducted using combinations of Medical Subject Heading (MeSH) search terms and keywords for Ethics, COVID-19, and vaccines in abstract, keywords, and title fields to retrieve potentially relevant publications. We included any study that reported one of the four principles of medical ethics: autonomy, justice, non-maleficence, and beneficence in the COVID-19 vaccine development and distribution and implementation of vaccinations. Letters, notes, protocols, and brief communications were excluded. In addition, we searched gray literature to include relevant studies (ProQuest database, conferences, and reports). Data were analyzed using framework analysis.

RESULTS

In total, 43 studies were included. Ethical considerations concluded two themes: (1) production and (2) distribution and vaccination. The production process consisted of 16 codes and 4 main Categories, distribution and vaccination process consisted of 12 codes and 4 main Categories. Moreover, the ethical considerations of special groups were divided into four main groups: health care workers (HCWs) (five codes), children and adolescents (five codes), the elderly (one code), and ethnic and racial minorities (three codes).

CONCLUSION

Due to the externalities of pandemics and the public and social benefits and harms of vaccination, it is not feasible to adhere to all four principles of medical ethics simultaneously and perfectly. This issue confronts individuals and policymakers with several moral dilemmas. It seems that decision-making based on the balance between social benefit and social harm is a better criterion in this regard, and the final decision should be made based on maximizing the public benefit and minimizing the public harm.

Exploring the ethical complexity of pediatric organ transplant candidates and COVID-19 vaccination: Tensions between autonomy and beneficence, children and parents

BACKGROUND

POT is emotionally sensitive due to cohort vulnerability, their lack of decisional capacity, and waitlist mortality. The COVID-19 pandemic has added complexity to the setting of pediatric transplantation, as well as living donation, due to tensions about COVID-19 vaccination for recipients, donors, and parent-caregivers.

METHODS

In the context of COVID-19 vaccination, two ethicists present four pediatric donation and transplant dilemmas for ethical exploration and offer guidance to clinical teams, noting that mandates are controversial, and there is no global harmonization regarding requirements.

RESULTS

As with all vaccinations, they are a tool of organ stewardship aimed to optimize outcomes and, in the setting of pediatrics, ensure optimal caregiving for these vulnerable recipients. Current evidence supports the ethical permissibility of COVID-19 vaccination mandates for transplant candidates aged 6 months and older.

CONCLUSION

Our guidance considers the tensions of autonomy and beneficence and the ethical duty of organ stewardship. The harms of being unvaccinated and risking the harms of COVID-19 and long-COVID post-transplant support the ethical permissibility of vaccination mandates in countries where the vaccine has pediatric regulatory approval.

Liver transplantation amidst the COVID-19 era: Our center’s experience

Coronavirus disease 2019 significantly impacted the liver transplant process worldwide. Consequently, it brought significant challenges and limitations to transplant policies and organ allocation forcing liver transplant centers to adjust their protocols to ensure maximum benefit and avoid harm to their patients. Our center, like many others, was obliged to adapt to the challenges. This paper provided an overview of the effects of coronavirus disease 2019 on liver transplantations and detailed our center’s experience and efforts during this unprecedented pandemic to serve as a guide for future public health crises.

Social support and transplantation

PURPOSE OF REVIEW

Social support has many benefits for patients undergoing organ transplantation, though inclusion of it as criteria for transplant listing has been debated. This review highlights recent developments in the research regarding social support and organ transplantation, including the impact of social support on transplantation and caregivers, interventions, COVID-19, and ethical perspectives.

RECENT FINDINGS

Social support and perceived social support have benefits for transplant patients, including increased quality of life and adherence. The providers of social support may also be impacted and the impact may vary based on patient and caregiver characteristics, including organ group and caregiver ethnicity. Debates regarding COVID-19 vaccine requirements for caregivers and ethical concerns about the inclusion of social support as criteria for transplant listing are also explored.

SUMMARY

Transplant patients benefit from social support, though additional research is needed on the impact of social support on transplant outcomes and the utility of the use of social support as criteria for transplant listing. There is also a need for more robust research on diverse caregiver populations, including the identification and use of supportive interventions for caregivers.

Vaccination for coronavirus disease 2019 in liver transplantation candidates should be recommended but not mandated

Content available: Author Interview and Audio Recording.

Impact of COVID-19 on the liver and on the care of patients with chronic liver disease, hepatobiliary cancer, and liver transplantation: An updated EASL position paper

The COVID-19 pandemic has presented a serious challenge to the hepatology community, particularly healthcare professionals and patients. While the rapid development of safe and effective vaccines and treatments has improved the clinical landscape, the emergence of the omicron variant has presented new challenges. Thus, it is timely that the European Association for the Study of the Liver provides a summary of the latest data on the impact of COVID-19 on the liver and issues guidance on the care of patients with chronic liver disease, hepatobiliary cancer, and previous liver transplantation, as the world continues to deal with the consequences of the COVID-19 pandemic.

COVID-19 in the perioperative setting: A review of the literature and the clinical landscape

The COVID-19 pandemic has dramatically affected societies and healthcare systems around the globe. The perioperative care continuum has also been under significant strain due to the pandemic—tasked with simultaneously addressing surgical strains and backlogs, infection prevention strategies, and emerging data regarding significantly higher perioperative risk for COVID-19 patients and survivors. Many uncertainties persist regarding the perioperative risk, assessment, and management of COVID-19 survivors—and the energy to catch up on surgical backlogs must be tempered with strategies to continue to mitigate COVID-19 related perioperative risk. Here, we review the available data for COVID-19-related perioperative risk, discuss areas of persistent uncertainty, and empower the perioperative teams to pursue evidence-based strategies for high quality, patient-centered, team-based care as we enter the third year of the COVID-19 pandemic.

International Practices on COVID-19 Vaccine Mandates for Transplant Candidates

Background

The coronavirus disease 2019 (COVID-19) pandemic created unprecedented challenges for solid organ transplant centers worldwide. We sought to assess an international perspective on COVID-19 vaccine mandates and rationales for or against mandate policies.

Methods

We administered an electronic survey to staff at transplant centers outside the United States (October 14, 2021-January 28, 2022) assessing the reasons cited by transplant centers for or against implementing a COVID-19 vaccine mandate. Each responding center was represented once in the analysis.

Results

Respondents (N=90) represented 27 countries on five continents. Half (51%) of responding transplant center representatives reported implementing a COVID-19 vaccine mandate, 38% did not, and 12% were unsure. Staff at centers implementing a vaccine mandate cited efficacy of pretransplant vaccination versus post-transplant vaccination, importance for public health, and minimizing exposure of other patients as rationale for the mandate. Of centers with a mandate, the majority (81%) of the centers mandate vaccination regardless of prior SARS-CoV-2 infection status and regardless of prevaccination spike-protein antibody titer or other markers of prior infection. Only 27% of centers with a vaccine mandate for transplant candidates also extended a vaccine requirement to living donor candidates. Centers not implementing a vaccine mandate cited concerns for undue pressure on transplant candidates, insufficient evidence to support vaccine mandates, equity, and legal considerations.

Conclusions

The approach to pretransplant COVID-19 vaccination mandate policies at international transplant centers is heterogeneous. International transplant centers with a vaccine mandate were more willing to extend vaccine requirements to candidates' support persons, cohabitants, and living donors. Broader stakeholder engagement to overcome vaccine hesitancy across the world is needed to increase the acceptance of pretransplant COVID-19 vaccination to protect the health of transplant patients.

Navigating the unknown: the coronavirus disease 2019 pandemic and solid organ transplantation

PURPOSE OF REVIEW

This review summarizes the impact of coronavirus disease 2019 (COVID-19) on solid organ transplantation and the most recent data pertinent to disease course and outcomes in this patient population.

RECENT FINDINGS

The COVID-19 pandemic negatively impacted solid organ transplantation with decreased transplant rates in 2020 but improved in 2021, albeit not entirely to prepandemic levels. Mortality rates of COVID-19 in this patient population continued to be higher, although have improved with more available therapeutic options and vaccination. Immunosuppressed patients were found to require additional vaccine doses given blunted response and continue to be more vulnerable to the infection. Data on immunosuppression alteration when patients have COVID-19 are not available and is an area of ongoing research. Significant interaction with the metabolism of immunosuppression limits the use of some of the new antiviral therapies in patients with organ transplants. Finally, many logistical challenges continue to face the transplantation discipline, especially with pretransplant vaccine hesitancy, however acceptance of organs from donor who had COVID-19 recent infection or died from the infection is increasing.

SUMMARY

Immunosuppressed solid organ transplant recipients continue to be vulnerable to COVID-19 infection with a blunted response to the available vaccines and will likely remain more susceptible to infection.

Vaccination policies for healthcare personnel: Current challenges and future perspectives

Healthcare personnel (HCP) are at occupational risk for acquisition of several vaccine-preventable diseases and transmission to patients. Vaccinations of HCP are justified to confer them immunity but also to protect susceptible patients and healthcare services from outbreaks, HCP absenteeism and presenteeism. Mandatory vaccination policies for HCP are increasingly adopted and achieve high and sustainable vaccination rates in short term. In this article we review the scientific evidence for HCP vaccination. We also address issues pertaining to vaccination policies for HCP and present the challenges of implementation of mandatory versus voluntary vaccination policies. Finally, we discuss the issue of mandatory vaccination of HCP against COVID-19.

Approaches to pretransplant vaccination

PURPOSE OF REVIEW

The aim of this study was to summarize new data and perspectives in pretransplant vaccination, with a particular focus on COVID-19 vaccination and vaccination requirements.

RECENT FINDINGS

Pretransplant vaccination produces superior markers of immunity and is expected to have greater clinical benefit, compared with posttransplant vaccination. As such, efforts are underway to identify and characterize barriers to pretransplant vaccination, with a particular focus on COVID-19 vaccine hesitancy. Unfortunately, vaccine hesitancy is common in transplant patients, often motivated by individual side effect and safety concerns. COVID-19 vaccination requirements have been implemented in some centres, informed by ethical principles, including beneficence, utility and justice.

SUMMARY

Barriers to pretransplant vaccination can be understood in three categories: hard stops, including issues of vaccine availability, eligibility, safety and feasibility; soft stops, including issues of convenience, prioritization and care coordination; and volitional stops related to vaccine hesitancy and refusal. All of these barriers present opportunities for improvement based on recent data.

The Global Impact of COVID-19 on Solid Organ Transplantation: Two Years Into a Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has had a major global impact on solid organ transplantation (SOT). An estimated 16% global reduction in transplant activity occurred over the course of 2020, most markedly impacting kidney transplant and living donor programs, resulting in substantial knock-on effects for waitlisted patients. The increased severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection risk and excess deaths in transplant candidates has resulted in substantial effort to prioritize the safe restart and continuation of transplant programs over the second year of the pandemic, with transplant rates returning towards prepandemic levels. Over the past 2 y, COVID-19 mortality in SOT recipients has fallen from 20%-25% to 8%-10%, attributed to the increased and early availability of SARS-CoV-2 testing, adherence to nonpharmaceutical interventions, development of novel treatments, and vaccination. Despite these positive steps, transplant programs and SOT recipients continue to face challenges. Vaccine efficacy in SOT recipients is substantially lower than the general population and SOT recipients remain at an increased risk of adverse outcomes if they develop COVID-19. SOT recipients and transplant teams need to remain vigilant and ongoing adherence to nonpharmaceutical interventions appears essential. In this review, we summarize the global impact of COVID-19 on transplant activity, donor evaluation, and patient outcomes over the past 2 y, discuss the current strategies aimed at preventing and treating SARS-CoV-2 infection in SOT recipients, and based on lessons learnt from this pandemic, propose steps the transplant community could consider as preparation for future pandemics.

Ethical Issues in Kidney Transplant and Donation During COVID-19 Pandemic

The coronavirus disease-19 pandemic caused by the severe acute respiratory syndrome coronavirus has faced the transplant community with unprecedented clinical challenges in a highly vulnerable patient category. These were associated with many uncertainties for patients and health care professionals and prompted many ethical debates regarding the safe delivery of kidney transplantation. In this article, we highlight some of the most important ethical questions that were raised during the pandemic and attempt to analyze ethical arguments in light of core principles of medical ethics to either suspend or continue kidney transplantation, and to mandate vaccination in transplant patients, transplant candidates, and, finally, health care providers. We have come up with frameworks to deal responsibly with these ethical challenges, and formulated recommendations to cope with the issues imposed on patients and transplant professionals.

Caregiver COVID-19 vaccination for solid organ transplant candidates

An increasing proportion of transplant centers have implemented a mandate for vaccination against COVID-19 for solid organ transplant candidates. There has been comparatively little exploration of the ethical considerations of mandating vaccination of a candidate's primary caregiver, despite a high risk of transmission given the close nature of contact between the candidate and caregiver. We examine how a caregiver mandate can improve overall utility in organ allocation, particularly in circumstances where vaccine effectiveness at preventing transmission and serious disease is low among recipients but high in caregivers. Our analysis reveals how sensitive such mandates must be to the evolving circumstances of disease severity, transmissibility, and vaccine effectiveness: as the facts change, the degree of benefit gained and therefore the degree of infringement on access to transplant and caregiver choice that is tolerated will likewise change.

The case against COVID-19 vaccine mandates in pediatric solid organ transplantation

BACKGROUND

The American Society of Transplantation in conjunction with the International Society for Heart and Lung Transplantation released a joint statement on August 13, 2021 in which they strongly recommend that solid organ transplant (SOT) recipients and their eligible household members and close contacts be vaccinated against SARS-CoV-2 with an approved COVID-19 vaccine. Some SOT programs have gone further and will refuse to list or transplant candidates unless the candidate and their household are vaccinated against SARS-CoV-2.

METHODS

Two general pediatrician-ethicists use current best evidence and moral theory to argue why it is unethical to mandate COVID-19 vaccination for pediatric SOT candidates, their primary support person, and their households.

RESULTS

Pediatric vaccine mandates are most justifiable when they prevent the harm of a serious vaccine preventable disease (VPD) in children in settings where transmission is highly likely and there are no alternatives that are effective in preventing transmission that intrude less on individual freedom. An additional justification for a vaccine mandate in the SOT context is stewardship of a scarce resource if there is significant risk of graft loss from the VPD to an unvaccinated SOT candidate or recipient. Current evidence does not support fulfillment of these criteria in pediatric solid organ transplantation.

CONCLUSIONS

Making SOT listing contingent on COVID-19 vaccination is problematic. Though there is some risk of harm to a pediatric SOT candidate in remaining unvaccinated, the risk of harm of not being listed and transplanted is greater and overriding.

Vaccine mandates: A transplant recipient's perspective

COVID-19 vaccination mandates: A patient’s view from the transplant trenches (see Kates et al. and Hippen, pages 371 and 381).

Considering a COVID-19 vaccine mandate for pediatric kidney transplant candidates

The world continues to face the effects of the SARS-CoV-2 pandemic. COVID-19 vaccines are safe and effective in protecting recipients, decreasing the risk of COVID-19 acquisition, transmission, hospitalization, and death. Transplant recipients may be at greater risk for severe SARS-CoV-2 infection. As a result, transplant programs have begun instituting mandates for COVID-19 vaccine for transplant candidacy. While the question of mandating COVID-19 vaccine for adult transplant candidates has garnered attention in the lay and academic press, these discussions have not explicitly addressed children who may be otherwise eligible for kidney transplants. In this paper we seek to examine the potential ethical justifications of a COVID-19 vaccine mandate for pediatric kidney transplant candidacy through an examination of relevant ethical principles, analogous cases of the use of mandates, differences between adult and pediatric kidney transplant candidates, and the role of gatekeeping in transplant vaccine mandates. At present, it does not appear that pediatric kidney transplant centers are justified to institute a COVID-19 vaccine mandate for candidates. Finally, we will offer suggestions to be considered prior to the implementation of a COVID-19 vaccine mandate.