/ 21 October 2021

Immunocompromised finally prioritised for Covid-19 booster shots

Organ Donation
The demand for donor organs far outstrips the supply because data is not shared, not all hospitals are equipped to do transplants and the National Health Act is inadequate. Photo: Burger/Phanie /AFP

The department of health will soon enable Covid-19 booster shots for organ transplant recipients. 

This follows three months of lobbying by the South African Transplant Society (SATS), the Organ Donor Foundation (ODF) and the South African Transplant Sports Association (Satsa). All cite dramatic mortality findings and plummeting organ donations from field studies conducted in the UK and South Africa. 

With a fourth wave driven by yet another mutation possible before Christmas and just 37% of the population fully vaccinated, the race is on to save those at greatest risk.

The man at the helm of the Covid-19 vaccination campaign, Dr Nicholas Crisp, confirmed that not only would organ recipients and those on dialysis now qualify for additional vaccination doses, but also anyone on long-term oral steroid therapy or systemic biologics for autoimmune conditions, haematological and immune malignancies, bone marrow transplants, or with a primary immunodeficiency disorder. HIV is still being assessed for additional vaccine dosing.

“The minister of health has approved additional doses for immunocompromised people,” Crisp told the Mail & Guardian. A circular from Crisp to provincial health departments heads of pharmaceutical services, Covid-19 vaccine programme managers and other related departments, dated 19 October and seen by the M&G, said implementation would begin on 30 November.

Published studies in the UK have shown that the mortality rate among organ recipients drops from high 40% in those unvaccinated or vaccinated once, to just 8% after a second jab. US research shows that this again drops markedly after a booster shot.

Dr David Thomson, president of the SATS and a surgeon and critical care specialist at Groote Schuur Hospital, says in some studies when transplant recipients infected with Covid‑19 were compared to the general population, he says, there was a tenfold increase in mortality. 

“There is some conflicting evidence. You have to tease out the comorbidities – but typically transplant patients also have hypertension and are often diabetic, which also impacts on outcomes,” he said.

Fewer organ transplants are also being done. 

A Western Cape study of public and private hospitals shows a monthly average drop from 4.8 to 1.8 organ donor referrals (a 63% decrease) when the first 10 months of the pandemic were compared to the full year prior. An article due to appear in the SA Journal of Surgery       adds that this was despite a 10% increase in the consent rate for deceased donation during the Covid-19 pandemic.

Healthcare system not transplant-friendly

Covid-19 has aggravated existing underperformance in South Africa, where just 25 organ procurement nursing sisters are spread thinly across the main cities. At the height of Covid surges, they are re-assigned to ICUs where their skills are sorely needed. 

The same holds true for surgeons being “repurposed” to handle Covid loads. All elective surgery is typically cancelled during the peak of a Covid-19 surge. The most common transplants cancelled are for kidneys, which is considered elective because of a living donor is used, and the procedure is therefore not as time-critical. 

Anaesthetists are also reassigned to ICUs and high care wards to care for struggling Covid-infected patients, cutting access to theatre.

While the data is thin, the decline in transplants taking place during Covid is significant.

Declines in transplants also take place in countries with more robust healthcare systems. The US recorded a 50% drop and France a 90% drop since the pandemic hit.

Says Thomson: “We’ve had about a 67% reduction in donor referrals coming through to Groote Schuur Hospital between March and December 2020. Staff get repurposed away from various areas. Around the world deceased donors are not getting referred — and we also pause elective surgery when [Covid is] surging.”

Thomson says the big problem is the total lack of nationally mandated reporting of outcomes that would inform local practice. In some studies when transplant recipients infected with Covid-19 were compared to the general population, there was a tenfold increase in mortality. 

“There is some conflicting evidence. You have to tease out the comorbidities – but typically transplant patients also have hypertension and are often diabetic, which also impacts on outcomes,” he said.

There are other, systemic reasons for South Africa’s low numbers of donations.

South Africa unfortunately does not routinely and compassionately approach organ donation at the end of life as a standard of care, Thomson said, explaining that this needs highly skilled healthcare professionals to counsel and spend time with a grieving family to discuss donating their loved one’s organs shortly after death.

“There’s a skewed narrative that shifts the blame for our poor outcomes from the healthcare system to the population. I think the healthcare system itself is the biggest barrier. It’s easy to say the religion or culture of potential donors is to blame, but you first need to optimise the healthcare environment and practices,” he added.

South Africans ‘donor aware’

This is underscored by Samantha Nichols, operational executive director of the ODF, who told the M&G that about 3 500 organ donors are now being signed up monthly by the organisation. Yet, she said, Covid-19 has halved kidney transplants, the longest waiting list, nationally.

“A lot of donors are also slipping through the cracks because not all hospitals or funeral parlours refer [for corneas and bone donation]. We need more feet on the ground in hospitals to reach more people. Each time, it’s a massive, coordinated effort. Typically, an organ donor is brain dead, on a respirator and certified dead by two doctors not involved with the transplant team,” she explained.

Nichols adds that while South African transplant centres work together, the country lacks an umbrella body like the US’s United Network for Organ Sharing, backed by an electronic data system that helps ensure that available organs are sent to the person most in need. 

A central body holds each US state outfit accountable. 

She adds that in Spain, for example, every hospital has a transplant officer, and each death is audited for potential tissue of organ donation. 

Dr Thomson says it took Spain nearly 10 years to get transplant coordinators posted to every ICU to see actual improvement, after “opt out” (presumed consent) legislation was passed. South Africa has an “opt in” organ donation system where relatives must first consent before any organ can be recovered.

Kidney recipient and cancer survivor Dr Michael Bradfield, a geneticist and scientist whose transplant seven years ago transformed his life, told the M&G that Covid-19 had cost a lot of lives of people who needed transplants, but couldn’t get them.

Welcoming the government announcement, he added: “Initially they left us in the lurch by not allowing transplant patients to get vaccinated – we had to go as per normal in the various age groups. That cost a lot of lives – we’re all on the register and could easily have gone for earlier vaccination.”

A transplant tennis and cycling South African Protea team member, he said SATSA had paid a high price for the pandemic.  

Its chairman Stan Henkeman, who had a heart transplant 30 years ago, died of Covid-related complications in December last year and its CEO Herman Steyn, also a heart transplant recipient, succumbed in the same manner in July this year. Henkeman was also the executive director of the Institute for Justice and Reconciliation.

“We also lost advocate Louis van der Westhuizen, chair of the Gauteng branch and also a SATSA board member. There may also be others. That is a significant number of key people,” Bradfield added.

Dr Errol Gottlich, a paediatric nephrologist who heads Discovery Health’s renal programme, says the mortality rate among the 3000 plus patients on his programme was usually about 13% per annum, “but I suspect it will be quite a few percent higher over the last 18 months”. 

“We’ve now got patients sitting on chronic dialysis longer and having more complications with related death rates because of the nature of this disease,” he said.

Dialysis is not widely available in public sector hospitals, which are used by most people.

Intervention ‘just in time’

The government’s targeted intervention could not have come at a better time.

According to the Reuters Global Covid-19 tracker, South Africa is at 3% of its last Covid peak and falling, with only seven infections per 100 000 people reported in the last seven days, as at 19 October. 

There were 636 new infections reported each day of that week, 3% of the highest daily average at the peak of the pandemic on 8 July 2021. There have been 88 619 coronavirus-related deaths in SA since the pandemic began, with more than three-million people infected — 5% of the population.

“Everyone can do their part by getting vaccinated,” said Thomson.

Visit the Organ Donation Foundation. The ODF toll-free line is 0800 226611