Risks from COVID-19 are far from over for patients with a transplant
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More than 2 years have passed since the discovery of the highly infectious SARS-CoV-2 virus and for the first time, it seems the pandemic is having a diminishing effect on ordinary life.
Shopping malls, airports, swimming pools and movie theaters are once again filled with patrons, which is a stark contrast to the summer of 2020 when the world shut down. Immunocompromised individuals with an organ transplant, however, still face an elevated risk of infection from COVID-19. Despite waning virulence and the positive clinical impact on the virus, mostly due to advances in vaccine development and public health efforts, COVID-19 continues to pose challenges in preventing severe or fatal outcomes for immunosuppressed individuals. Although mortality from COVID-19 in an immunocompetent individual is 1.16% for transplant patients,1 the real-life story is vastly different.
Mortality risk
During the first wave of the COVID-19 pandemic, crude mortality for the transplant recipient was 20% to 25%, with nearly 90% of patients requiring hospitalization and 80% to 85% requiring mechanical ventilation. With wide adoption of the highly effective COVID-19 vaccines, mortality rates have been reduced to approximately 10% in unvaccinated and 8% in vaccinated transplant recipients.2
There are two components to the susceptibility of transplant recipients to COVID-19. First, the average transplant recipient has substantial comorbidities that may have evolved during decades that eventually culminated in organ failure. These comorbidities – diabetes, heart disease, hypertension and liver disease – often play an essential role in the physiologic response to stressors, such as COVID-19.
Second, immunosuppression, which is necessary for the survival of the allograft, severely dampens the host’s ability to fight against any viral infection, including COVID-19. More specifically, it is postulated that T cell-mediated immunosuppression, a central component of current immunosuppression in solid organ recipients, weakens the antiviral immune responses.
Furthermore, there are reports that viral shedding and duration of symptoms are longer in immunosuppressed individuals because of this inability to mount the appropriate response to the virus. In this context, immunosuppressed transplant patients are also thought to generate more transmissible or more pathogenic variants due to a prolonged viremic phase.3
Caution, vigilance
Taken together, these findings advocate that transplant recipients must remain cautious and vigilant even though COVID-19 restrictions continue to be lifted for the rest of the public. Regrettably, respiratory viral infections are common in transplant patients and frequently have an atypical presentation. The characteristic fever that may be present in the immunocompetent individual may not appear in the transplant patient, who is unable to mount enough of an immune response to elicit a fever. Similarly, it is not uncommon for immunosuppressed patients to have a false-negative test, which relies on an intact immune system. Therefore, common sense dictates that if transplant patients are attending a large-crowd gathering or engaged in a close-contact activity (airplane travel, riding public transportation) or in an area with a high positivity rate, they exercise measures that reduce the likelihood of infectious spread, such as wearing a face mask, social distancing and frequent hand hygiene.
I often tell my patients that before COVID-19, I expected all transplant recipients in the first year after transplant or after high-dose immunosuppression for the treatment of rejection to wear a mask in public, not gather in enclosed spaces with large crowds, not travel in public transportation or eat out. COVID-19 has normalized these measures such that transplant or immunosuppressed individuals are not the only individuals exercising these infection safety measures.
Unfortunately, as COVID-19 restrictions continue to be scaled back, millions of immunocompromised individuals find themselves with feelings of fear, despair and being left behind.4
Boosters recommended
Although light can be seen at the end of the COVID-19 tunnel, transplant patients need to remain cautious and vigilant, especially as the summer draws to a close and we head into fall and winter. Current CDC guidelines recommend boosters for high-risk individuals given the poor humoral response that has been noted to the COVID-19 vaccines.5
This, taken together with the measures mentioned above of masking when in close contact with other individuals, such as in public transportation; practicing social distancing or avoiding places of high positivity rates; and exercising good hand hygiene, should afford the best protection in these uncertain times.
Most importantly, these measures are designed to help immunosuppressed individuals navigate the pandemic to ensure their allograft remains functional for many years to come, which is the desire of transplant patients and providers alike.
- References:
- 1. https://ourworldindata.org/mortality-risk-covid. Accessed July 10, 2022.
- 2. Nimmo A, et al. Transplantation. 2022; doi:10.1097/TP.0000000000004151.
- 3. Dborska-Materkowska D, et al. Viruses. 2021; doi:10.3390/v13091879.
- 4. www.theatlantic.com/health/archive/2022/02/covid-pandemic-immunocompromised-risk-vaccines/622094. Published Feb. 16, 2022. Accessed July 10, 2022.
- 5. Boyarsky BJ, et al. JAMA. 2021;doi:10.1001/jama.2021.4385.
- For more information:
- Oscar K. Serrano, MD, is a transplant surgeon with Hartford HealthCare Medical Group, Hartford Hospital Transplant & Comprehensive Liver Center, Hartford Hospital. He is also a member of the National Kidney Foundation’s Transplant Advisory Committee. He can be reached at oscar.serrano@hhchealth.org.
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