Hospitals weigh COVID vaccine mandates for patients in need of lifesaving organ transplants

Ken Alltucker

The recent uproar over a hospital requiring a Colorado woman to get a coronavirus vaccine before being considered for an organ transplant reveals the kind of decisions transplant centers make every day. 

Hospitals that transplant hearts, livers, lungs or other organs have strict requirements and prioritize patients based on a range of factors, including medical need, suitability and likelihood of success.

“Organs are a scarce resource,” said Deepali Kumar, president-elect of the American Society of Transplantation. “We have a duty to make sure that gift is protected and also that our patients have the best possible outcomes.”

With more than 106,000 Americans who need a transplant, there are more candidates than the nation can accommodate even at this year's pace of 31,361 transplants through Sept. 4

People on wait lists typically already are vaccinated to protect against hepatitis A & B, pneumonia, shingles and the flu, Kumar said. Several high-profile health systems are considering rules to add COVID-19 vaccines to the required list of immunizations.

“Every single center is considering which way to go on this,” Kumar said. “You will see a lot more centers put some type of policy in place.”

While Colorado's UCHealth said almost all organ transplant patients need to get the COVID-19 vaccine, other health systems are pursuing vaccine mandates. Cleveland Clinic will give existing patients on a waiting list until Nov. 1 to get vaccinated or they will be moved to an inactive list. University Hospitals of Ohio, citing the risk of coronavirus for transplant patients, also will require vaccines.

Mayo Clinic “strongly recommends” patients on wait lists and those who have already received transplants to get vaccinated. The Rochester, Minnesota-based health system is now reviewing vaccine requirements for transplant patients, said spokeswoman Heather Carlson Kehren.

NYU Langone in New York Citydoesn't mandate vaccinations. But the health system recommends vaccines and employs a “comprehensive approach to vaccination assessment” when evaluating transplant candidates with the goal of making sure all vaccinations are up to date or in progress, according to Dr. Sapna Mehta, clinical director of the NYU Langone Transplant Institute.

Experts say the medical evidence shows vaccines are necessary to protect people from sickness before and after transplant. Post-transplant patients are placed on anti-rejection drugs that weaken immune systems and leave them vulnerable to complications or disease, experts say.

“There’s no reason to be shocked, surprised or outraged about COVID vaccine,” said Dr. Art Caplan, head of the division of medical ethics at NYU Grossman School of Medicine. “It’s just adding to a list of prudent and required vaccines to prevent the death of an immunosuppressed person after transplant.”

Vaccines make sense for transplant patients

There are two main reasons transplant doctors recommend patients get a COVID-19 vaccine before they received a transplant. 

Studies have shown people with an organ transplant are more likely to die if they contract COVID-19 compared with the general population. One French study of more than 1,000 people hospitalized with COVID found 18% of kidney transplant patients died, compared with 11% of nontransplant COVID-19 patients. Other studies found 20% to 30% of hospitalized transplant patients infected with COVID-19 died, a higher rate than nontransplant COVID-19 patients. 

Vaccines are less effective in post-transplant patients who must take anti-rejection medications. A lower percentage of post-transplant patients develop a "demonstrable antibody response" from the vaccine compared with the general population, said David Klassen, chief medical officer of the United Network for Organ Sharing, a nonprofit that manages the nation's transplant waiting list.

"It's quite clear, they do not have the same response," Klassen said. "That's one reason transplant patients were singled out early on for booster shots and being eligible for a third dose of Pfizer vaccine."

Colorado state Rep. Tim Geitner shared on social media a letter UCHealth sent to a woman informing her she would not be considered for a kidney transplant until she received a COVID-19 vaccine. In a Facebook live segment, Geitner was critical of the health system's stance, describing it as "incredibly frustrating, incredibly sad, incredibly disgusting."

The American Society of Transplantation hasn't polled transplant centers to find out what percentage will mandate COVID-19 vaccines, but AST recommends centers require patients get vaccinated at least two weeks before transplant operations. The group recommends eligible household members and close contacts be immunized, too. 

Transplant centers for years have debated the merits of mandating vaccines for infectious disease. AST decided to recommend COVID-19 vaccines because infections are so prevalent during the pandemic. 

Kumar said said most people on wait lists generally comply with what centers recommend and are likely vaccinated against COVID-19 and other infectious diseases. She thinks vaccine objectors represent a "handful that may be more vocal" about their concerns. 

"There are so many things that transplant recipients go through after their transplant," Kumar said. "There’s no reason COVID has to be part of that. Getting vaccinated just reduces risk in a big way."

Experts say vaccinations are among the least onerous requirements for transplant hopefuls. There's a long list of circumstances, situations or behaviors that transplant centers scrutinize before agreeing to list a candidate, Caplan said 

Smokers vetted for lung transplant are asked to quit tobacco months before an operation. Potential liver recipients are asked to quit drinking alcohol. Some obese patients might need to lose weight before an operation. 

Patients who are disabled and institutionalized might find it more challenging to get a transplant due to higher infection rates. There also can be barriers for people who are in prison, are mentally ill or do not have access to a caregiver, Caplan said. 

Less-experienced transplant centers also might reject complex cases. For example, a newer center might find it too difficult to manage a patient with lung failure, heart problems, lupus and diabetes. 

"Each transplant center has a lot of discretion," Caplan said. "The transplant center doesn’t have to take you. It’s not like you have a right to get in there."

Ken Alltucker is on Twitter as @kalltucker or can be emailed at