A Boston hospital’s denial of a heart transplant to a man who is unvaccinated for Covid-19 has generated national attention, but experts say mandating vaccines is in keeping with other long-standing requirements that patients have to meet to receive an organ — including getting other shots.
In this case, Brigham and Women’s Hospital dropped a 31-year-old man named DJ Ferguson from its transplant waitlist, his family said. Ferguson was concerned about side effects and the speed with which the vaccines were developed, his mother told WCVB.
This is not the first such case to make headlines. Last year, both the Cleveland Clinic and University of Colorado Hospital refused to perform organ transplants for recipients who hadn’t been vaccinated.
Perhaps because of the politicization of Covid-19 vaccines more broadly, the reaction to such decisions is sometimes greeted with outrage. But ethicists and transplant physicians stress that organ allocation has to be partially determined by who can survive and thrive with a scarce resource. With so many people waiting for an organ, clinicians try to maximize the chances of a successful transplant. Hospitals don’t want to allocate an organ to people who are putting themselves at higher risk of dying after a transplant — especially since that organ can’t then go to someone else.
“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.
With Covid-19, the risk of being unvaccinated is particularly stark for transplant recipients, some of whom have a number of comorbidities. They also have to take immunosuppression treatments so their bodies don’t attack the organs, and those drugs contribute to the increased risk of severe illness from the coronavirus. A study based on data from more than 50 transplant centers during the early Covid-19 period found that mortality among hospitalized solid organ transplant recipients was 20.5%. (More recent data suggest that as doctors got better at treating Covid-19 generally, outcomes also improved for transplant recipients.)
The coronavirus is also much more prevalent than other pathogens that cause concerns for transplant recipients (with a possible exception being influenza during its seasonal peaks).
And because transplant recipients have trouble mounting a robust immune response to vaccines — another result of the immunosuppression regimens they’re on — experts stress that they should be vaccinated before they get a new organ.
“We strongly recommend that all eligible children and adult transplant candidates and recipients be vaccinated” against Covid-19, 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.
The U.S. government outlines guidelines for how transplant centers should consider candidates, and notes that “predicted years of life added” is one factor that can be weighed. Individual centers establish their own policies, but there are some common practices. Hospitals will typically require transplant candidates to abstain from smoking, for example. Recipients generally have to go through psychosocial evaluations, and often have to be vaccinated against hepatitis B, commit to getting annual flu shots, and show they’re immune to measles.
Kates, who is also a bioethicist who studies vaccine policies, said there wasn’t a good estimate for the percentage of transplant centers that had already instituted a Covid-19 vaccination requirement, but that the number was growing as more centers implement policies.
It’s possible for patients to try to seek care at another center if they’re denied at one hospital.
DJ Ferguson’s mother Tracey Ferguson told WCVB that DJ was concerned about the vaccines because of his heart issues. Scientists have determined that two types of heart inflammation called myocarditis and pericarditis can occur after people receive the mRNA vaccines — typically after the second shot and occurring at highest rates in men in their late teens and early 20s. Most of these incidents have been mild. Overall, the risk of myocarditis is higher following a case of Covid-19 than it is from the vaccines.
Tracey Ferguson also said that DJ knew vaccines typically took longer to develop than the Covid-19 shots. While it’s true that the Covid-19 vaccines were made in record time following the discovery of the coronavirus, they relied on decades of advancements in vaccine research and development.
DJ’s father David Ferguson also told WBZ that vaccination against Covid-19 went against his son’s “basic principles. He doesn’t believe in it.”
The Brigham wouldn’t comment specifically about Ferguson’s case, but said in a statement that its 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.”
Kates, of Johns Hopkins, said that Covid-19 vaccine policies seem to have become a point of conflict for transplant centers in a way that other requirements haven’t been.
“This has previously been a very rare event, and I hope it remains a rare event, but it’s much more visible now,” she said.
But still, she added, “The vast majority of transplant candidates are enthusiastic about protecting themselves” from infections that can complicate their transplants.