About one in 10 lung transplants in the United States now go to COVID-19 patients, according to data from the United Network for Organ Sharing, or UNOS.
The trend raises questions about the ethics of allocating scarce resources to people who have chosen not to be vaccinated against the coronavirus.
“They’re steadily piling up. So it’s really something,” said David Klassen, UNOS chief medical officer.
“If more lungs were available for transplants, I think the numbers would be greater than they are,” he says.
A total of 238 people across the country have had lung transplants as a result of COVID-19 since the first such surgeries were tracked in August 2020, according to the latest UNOS figures from October this year.
Lung transplants for COVID patients have increased tenfold between the first year of the pandemic and 2021, according to UNOS data, which also shows that transplants for other top lung diseases, such as emphysema, cystic fibrosis and pulmonary fibrosis, have declined compared to previous years.
“It’s happening in the US. It’s happening in Canada too. There was just a paper out of Western Canada that this was causing a huge increase in lung transplants there. It’s a big problem,” said David Mulligan, president of the Yale Institute. New Haven Health Transplantation Center.
Typically, more than 2,000 lung transplants are performed in the US each year, costing about € $1.2 million for a double lung transplant.
The rise in COVID-related transplants is forcing doctors to struggle with how best to manage who gets them, especially now that vaccines are widely available.
“If someone gets a COVID virus so severe that they need a lung transplant, and they refuse to get a vaccine, it’s a real ethical dilemma,” Mulligan says. “How can they just jump in and take a lung away from someone who is sick but has done their best to take care of themselves and avoid getting COVID?”
Ethics of non-judgment
Transplantation centers consider many different factors when listing people in need of an organ. But social and behavioral factors — like how people got sick — aren’t usually one of them.
Smokers may be eligible for a lung transplant, just as people who have drunk too much alcohol are also eligible for a new liver if they have remained smoke-free or sober for six months.
Not judging people’s past behavior is pretty standard in medicine. But future behavior, when it comes to transplants, is fair game, according to Olivia Kates, an assistant professor of medicine at Johns Hopkins.
“I think [COVID-19 patients] should have the same expectation that they either need to be vaccinated or can demonstrate immunity to COVID-19 in the future so their next set of lungs isn’t at the same risk,” Kates says.
Some transplant centers have said patients will lose their spot on the list if they are not vaccinated against the coronavirus.
But some say it may be unfair to exclude someone who has not had a COVID vaccine from even being eligible for an organ, as it could exclude racial, religious or ethnic groups with lower vaccination rates.
The current system of putting people on transplant waiting lists strives for equality and gives priority to “people who can’t wait much longer for their organ, but if they get one, they have a good chance of benefiting from it and that organ.” to keep,” says Govind. Persad, who teaches bioethics and health law at the University of Denver.
When a transplant is the only option
Candidates for lung transplants after COVID-19 are often young and otherwise healthy, such as 41-year-old Vezna Hang. He contracted COVID in March of this year, not long after moving to Tampa from New York. His symptoms were barely noticeable, just a loss of taste and smell at first.
“One day I just looked in the mirror and saw that my lips and my fingertips were blue,” he says.
Hang had no underlying conditions. But COVID-19 caused inflammation in his lungs that led to permanent scarring. A transplant was his only option.
“For the first moment in my life I was scared. And day by day there were times when I honestly didn’t think I would make it. And leaving my son, you know, that was heavy on my mind. “
The father of a 5-year-old Hang had not been vaccinated when he became ill. Florida didn’t open access to vaccines to his age group, 40 and older, until late March after he fell ill.
But Hang understands people who aren’t sure if they should get the shot. He says he was one of them before he got sick.
“This terrible virus affects everyone differently. It’s not predictable at all,” Hang says.
“From what I’ve been through, being in the hospital and seeing all the people who weren’t vaccinated were hospitalized, it really pushed me to get myself vaccinated, encouraging my family and my friends,” added he to it.
The caregiving dilemma
There is no national, overarching policy on how to deal with vaccine refusal when it comes to transplants. The American Society of Transplant Surgeons recommends vaccination for anyone waiting for a transplant. Doctors say this is because the immune response is stronger if a patient receives the vaccine before, rather than after, their transplant.
Deborah Adey, a kidney transplant specialist at the University of California San Francisco, says it’s often not the patients who are hard to convince.
“Where we ran into trouble was with health care providers,” says Adey, who years ago saw transplant patients become dangerously ill with COVID after living with unvaccinated relatives.
“There have always been anti-vaxxers. That’s not exactly new. But this level of resistance to doing something for the common good? I’ve just never seen anything like it,” Adey added.
Community exposure poses serious risks, especially with a highly contagious strain like delta, said Kiran Dhanireddy, executive director of the transplant institute at Tampa General Hospital.
“Especially during this latest wave, we have had several transplant patients die from COVID,” he says. “And these were patients who were vaccinated for the most part, but because their immune system is suppressed, they don’t get a normal immune response to the vaccine and therefore don’t have the same level of protection that a normal individual would.”
People living with donated organs must take lifelong immune-suppressing drugs to prevent their bodies from attacking and rejecting the new organs, making them more vulnerable to COVID-19 as long as it’s around.