Transplant Recipients, Uncertainty & Vaccination in a time of Covid-19

RAY HARTLE

The majority of people across the world have faced fear and uncertainty since the onset of the Covid-19 pandemic. Uncertainty among ill people – described as “the inability to determine the meaning of illness-related events”[1] has become hugely evident across our population. Such emotional upheaval is exacerbated for organ transplant recipients and others living with compromised immune systems, or those with comorbidities which make them more susceptible to infection by a life-threatening virus.

None of these groups has been served by our government’s bungling effort at setting in place a priority dispensation in the national vaccination rollout.

From the early news reports confirming the Covid-19 outbreak and suggesting possible implications for the world, I’ve tried to keep track of developments, using reliable sources. As a journalist, it is crucial to write from a position of knowledge; as a heart transplant recipient, managing my lifestyle to steer clear of potential sources of infection is non-negotiable, despite the challenges, exacerbated during the pandemic.

I have tried to understand generally the implications of being infected with the virus, and specifically for immunosuppressed individuals. And later, I was concerned to know if receiving a vaccine was a viable option for transplant recipients, which vaccines were recommended, and under which circumstances they could be administered.

I have not equivocated about submitting to Covid-19 vaccination for clinical reasons, although for ethical reasons, I include myself among those who feel uncomfortable with a special vaccination dispensation for donor organ recipients.

I was content to wait until my spouse and I could receive the vaccine simultaneously in terms of the age category rollout.

(As it turns out, I am not yet vaccinated and still more exposed than most to severe illness should I become infected by the virus, my intentions to receive the vaccine being kyboshed by stock shortage on the day, the threat of unrest, and a subsequent infection necessitating a four-week wait for the first jab.)

On July 5, I became aware of a government circular allowing vaccination, outside of the age criterion, for special categories of people – including SA diplomats, business people and students who must travel abroad, and Cabinet ministers. I wrote to Dr Nicholas Crisp, deputy director general in the national health department, raising my concerns about the exclusion of transplant recipients from any special dispensation

I subsequently became aware that two private clinicians broached the possibility with government of a vaccine rollout initiative to plot clinical outcomes for heart transplant recipients. Of concern must be government’s apparent failure to engage holistically with clinical representatives of all transplant programmes – involving both the private and public sectors, and all donor organs.

At the risk of excoriation for a bad taste in jokes, this supposed policy to favour some transplant recipients to receive the Covid-19 vaccination was a classic case of the left organ not knowing what the right organ was doing.

I have not had any further communication with Crisp, unsurprising in the context of public servants’ general non-responsiveness.

Subsequently, the SA Transplant Society, a co-ordinating association for transplant clinicians established a channel on its web site for transplant recipients and patients older than 12 years waitlisted for organ transplantation to submit their personal information to be included in a document lobbying the health department for ‘at risk’ patients to be prioritized for vaccination.

I welcome the SATS’ initiative, but I fear it’s too little, too late. And it exposes the lack of co-ordination and communication among transplant programmes, let alone communication with transplant recipients. The latter could have gone a long way to dealing with patient concerns about Covid-10 and vaccination. There is no reason why patients across the country could not have been contacted very quickly and met a requirement for submission of information, or for registration.

But ultimately, a special dispensation on vaccination for organ transplant recipients – as part of a bigger cohort of immunosuppressed patients and people with comorbidities – is a government policy initiative. And government patently has done an appalling job thus far.
There is an inherent ethical dilemma in preferring one group of potential vaccinees over another. However, donor organs may also be regarded as a national asset, a scarce public resource, allocated to recipients, at some psychological cost to donors or their loved ones, and certainly at great financial cost to both publicly- and privately-funded healthcare sectors. They are an easily identifiable category of people, mostly linked to a specific transplant programme.

The opening up of private healthcare and the introduction of efficient and safe immunosuppression regimes saw transplant numbers climb. But the total current number of living transplant recipients is unlikely to reach five figures.

As far as I know, there is no single database for organ transplant recipients in SA. Available Organ Donor Foundation statistics show 5,361 solid state organ transplants were performed since 2009 mostly in the private sector. The SA Renal Registry’s latest published figures show a cumulative 1826 kidney recipients living across the country in 2017.

Government’s failure to recognise the state’s obligation to organ recipients in this Covid-19 season is in keeping with government’s failure to publish regulations on transplantation as required by section 68 of the National Health Act, as I have previously reported.

The Health Justice Initiative criticised government’s “bizarrely-crafted” effort to prioritise groups that do not warrant special treatment for vaccine access, “while people under 50 years with comorbidities are left out”.

The HJI has correctly argued that government and stakeholders ought to have engaged in a deliberative, independent, impartial and fair process to determine exceptions to the vaccine rollout programme for groups with high risk, both of contracting the disease and dying.

Such an approach would have clearly established the validity of organ recipients within a prioritised vaccination rollout. And it’s implementation, through listing individual recipients on the national vaccine registration database with supporting documentation from treating doctors, was not insurmountable. But, as we have experienced so often, political will to do the right thing is a resource in very short supply in the South African state.

[1] Mishel, M. (1990). Reconceptualization of the uncertainty in illness theory. Journal of Nursing Scholarship, Vol. 22 (4), pp. 256-262.