Writing for STAT News, Andrew Joseph explains why some transplant centers are denying patients who have not been vaccinated against the coronavirus.

Should vaccination strategy switch from carrots to sticks?

Patients must meet certain requirements to qualify for transplants

While the U.S. government suggests guidelines for transplant centers to consider when evaluating potential candidates, such as the number of "predicted years of life added" after a transplant is performed, individual transplant centers generally establish their own policies. However, some are commonplace, Joseph claims. 

Typically, transplant centers require patients to get certain vaccinations, stop smoking, avoid drinking alcohol, or prove they will take important medications to ensure their body doesn't reject the transplant, said Dan Weaver, a spokesperson for UCHealth.

Since there are so many people waiting for organs, clinicians try to increase the chances of a successful transplant. In general, a transplant center will not allocate an organ to an individual who is putting themselves at higher risk of dying after a transplant—especially since that organ can't be transferred to another patient if the transplant is unsuccessful, Joseph writes.

"The entire transplant evaluation process, which can be very long and very demanding, is about making sure patients are in the best physical, mental, and social condition to endure a transplant, and then all the downstream effects of transplantation," said Olivia Kates, a Johns Hopkins infectious diseases physician who specializes in transplant patients.

Covid-19 poses a specific risk to transplant patients

Transplant recipients face a "particularly stark" risk if they have not been vaccinated against the coronavirus—especially if they have multiple comorbidities, Joseph writes. This risk is further amplified by the immunosuppression treatments transplant recipients must take to prevent their bodies from attacking the organs.

In a study based on data from over 50 transplant centers during the early stages of the pandemic, researchers found that mortality among hospitalized solid organ transplant recipients was 20.5%. But more recent data suggests that outcomes among transplant recipients have improved as doctors have gotten better at treating Covid-19.

However, Covid-19 is more widespread than other pathogens that cause concerns for transplant recipients—making it a more prevalent risk, Joseph writes.

Since transplant recipients typically have weaker immune responses to vaccines—largely because of the immunosuppressant drugs they must take—experts at the American Society of Transplant Surgeons, the American Society of Transplantation, and the International Society for Heart & Lung Transplantation said in a joint statement in November, "We strongly recommend that all eligible children and adult transplant candidates and recipients be vaccinated" against Covid-19.

Many health systems deny transplants for unvaccinated patients

Kates said there isn't an accurate estimate of how many transplant centers require Covid-19 vaccination for recipients, but that the number seems to be growing as more centers implement policies.

And although ethicists and transplant physicians agree that factors that influence patient outcomes—such as Covid-19 vaccination status—must be considered in the organ-allocation process, Kates said Covid-19 vaccine policies at transplant centers have been met with more resistance than other requirements.

Recently, Brigham and Women's Hospital (BWH) in Boston garnered national attention when it dropped a 31-year-old man named DJ Ferguson from its transplant list because he had not been vaccinated against Covid-19. His family said DJ is wary of Covid-19 vaccination because of heart issues.

BWH said in a statement that the health 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."

Last year, both the Cleveland Clinic and UCHealth also refused to perform organ transplants on unvaccinated recipients.

According to Weaver, "[a]n organ transplant is a unique surgery that leads to a lifetime of specialized management to ensure an organ is not rejected, which can lead to serious complications, the need for a subsequent transplant surgery, or even death. Physicians must consider the short- and long-term health risks for patients as they consider whether to recommend an organ transplant."

Ultimately, Kates said, "The vast majority of transplant candidates are enthusiastic about protecting themselves" from infections that can compromise their transplants. (Joseph, STAT News, 1/26)