COVID-19 Vaccination and Dialysis

I am not sure how many out there in US dialysis land—especially US home haemodialysis land—will recall my name. That’s OK...I have been absent from these pages for quite a long time now, so I won’t be disappointed if you look at the author’s name and ask: “who’s he?”

To put context to this blog, I am a now-retired Professor of Medicine [Nephrology] with a life-long interest in dialysis: especially home self-care haemodialysis. I have written many blogs for this site (80+, I think), and have worked with my American colleagues at Home Dialysis Central for over a decade. I have published more than 300 peer-review papers and abstracts, several book chapters, and dialysis books in a career that began in 1971, advised several dialysis companies—especially in machine development, have been an invited speaker in 16 countries, and received several “well done” awards, including the Order of Australia for services to nephrology, and the 2017 Life Achievement Award from the International Society for Haemodialysis. But perhaps the achievement which satisfies me most has been my initiating contributions to the emerging concepts of resource conservation in dialysis (green dialysis) and nephrology (green nephrology).

I am a proud Australian and, in Australia, we have always practised a very different delivery of dialysis from yours in the US: from our universal free health care to our free-dialysis-for-all funding systems, and to the level of trust we place in our patients to conduct safe self-care. As “best” is always in the eye of the beholder, I will let others judge the respective outcomes.

I retired on February 1^st, 2020. Note the date. Bad choice, as the Covid-19 pandemic was just emerging as a pandemic! And, we didn’t really understand what was about to hit us all. I had thought to retire into anonymity, slip into the local coffee set, walk the beach, and write for the local paper (which I do, in spades)...nice retirement stuff. Who in his right mind would have retired into the teeth of a pandemic and into the isolation profile of the Australian Covid Management Model: home isolation, well-accepted masking from Day 1, and the sad separation from all others—including our families? Now, well into our 6^th lockdown (5+ million Melbournians have just passed the 200^th day of their serial lockdowns), the lockdown/stay-at-home policy has proved to be a safe, relatively death-free exclusion policy. But, while we have successfully excluded the virus, we have excluded ourselves, too. Isolation has been a hard taskmaster in our national quest for health, a Covid-empty healthcare system, and the preservation of life.

While cracks are opening in the isolation tolerance of our people, we stumble towards full vaccination (or full enough to permit a fully open society), with November the target date for free movement and a resumption of commerce in a Covid-free—or, better, a Covid-managed—continent.

Australians are blessed—or cursed—by being the only nation on earth that [1] occupies its very own continent, and [2] is so physically far away from all others that we both benefit and suffer from the effects of isolation. Given there are only five inhabited continents, the Australia vs. the rest of the world “football score” is...Australia 1: Continent 1...while the rest of the world is...All Other Countries 194: All Other Continents: 4. (NB: the US is included in All Other Countries).

This continental isolation has allowed our Federal government to adopt a Fortress Australia policy when if or when it suits: no one in, no one out! For a very long time, this served us well—especially with COVID-19 if case counts, death rates, and economic outcomes are the yardsticks used. On those scores, we have done well. Even the slow and, some would accuse, laggardly roll-out of the vaccine(s) now seems to be on-target, with all of us—child and adult—"double-jabbed” by November. Vaccine “hesitancy” has happened here, too... largely around some unfortunate “over-calling of the risks” of the AstraZeneca option. Here, as in the UK, this has been the primary vaccine on offer—at least until recently. But luckily, “hesitancy” has been neither strident enough nor sufficiently numerically prevalent to prevent us from achieving our November post-Covid target for national population protection—and AstraZeneca is back in favour!

On this background...and only now do I get to the nub of this post...we watch the US vaccine wars with bemusement. True, and as above, we do have some who oppose vaccination, but they are relatively small in number. At least sufficiently small in number to permit us to reach our >80% full vaccination rate target. This should allow the virus to enter our community as an endemic but acceptably lethal beast by the end of this year. (NB: as a doctor, typing “acceptably lethal” is not an easy thing to do.)

Let me now consider four words: dialysis, fear, virus, and vaccine.

Fear is not a new concept for any dialysis patient. No matter how much we reassure, educate, de-mystify, encourage, and smooth the path—(NB: while some are much better at doing this than are others, that is a different bridge to cross)—fear, anxiety, uncertainty, pain, unplanned hospitalisation, and the ever-shrouded risk of death do stalk the dialysis patient, day by day. Indeed, perhaps this is more so than for any other health-threatened patient group, cancer included.

Risk, fear, illness, and death are constant dialysis bedfellows. This, despite that we all wish it were not so. While self-management of dialysis at home undeniably diminishes these risks, again, not for discussion here, they still lurk, and I would be “telling Porkies” if I did not say so.

Covid-19 has added one further dimension to this dialysis-normal. Fear of getting the virus—and who isn’t afraid—remains a reality and, for a dialysis patient, is a super-added fear. It is a lethal beast...despite the claims of those who would deny it. This is especially true of the new Delta variant and the likely-yet-to-emerge variants (choose-your-favourite-Greek-alphabet-letter). This nasty virus has many nasty outcomes—both immediate and long-term. Minimising it is not helpful, denying it unwise. Those who do delude themselves—and ultimately their communities, too—and imperil all.

This virus maximally impacts those with pre-existing conditions and “sleepy” immune systems—like patients with diabetes, CKD, dialysis-dependence, transplants, and other immune-sapping conditions such as autoimmune disease and malignancy. Kidney patients have several risk factors that heighten their peril. Effective treatment—while improving—remains largely supportive, not curative.

Scientific and medical advances have both tried to do their best for humanity down the ages. Think of antibiotics, safe and painless surgery under anaesthesia, insulin, joint replacements, dental amalgams, and the treatment of hypertension—just to name a few.

But, the development and deployment of vaccines should probably head this list! Think of smallpox, diphtheria, measles, rubella, tetanus, polio, hepatitis, influenza, TB, typhoid, cholera, whooping cough...again, just to name some. All of these diseases killed our ancestors in droves. Combined, these viral and bacterial infections were the major global cause of death in all populations prior to the early 20^th century. The combination of antibiotics and vaccination have suppressed them all—with vaccination arguably the greater contributor.

It is thus rather weird to accept all of these vaccines—many of which we all now receive routinely at birth or soon after—yet suddenly refuse the life-saving vaccines that science has developed (in record time) to counter the pandemic of COVID-19. E.g., AstraZeneca, Pfizer, Moderna, J&J, and the many other versions around the globe.

It is also addled thinking to decide to wait for a COVID-19 spike in one’s home community, city, or state before deciding to be vaccinated at the last minute. Sadly, at the last minute is not how a vaccine works. Vaccination takes time—and with Covid-19, it takes a pair of widely-spaced injections plus some additional waiting time for an immune response to sufficiently strengthen to ensure an adequate measure of protection.

Note I used the word adequate, for even then, the protection offered is not absolute. While the risk of infection is significantly reduced, it is not eradicated. It is still possible to contract COVID-19, but if contracted once fully vaccinated, the disease will be likely mild and hospitalisation unlikely.

Fear is a strange beast, too. It can paralyse clear thought, and warp decision-making. In this way, the fear of vaccine side-effects has oddly persuaded some that being vaccinated is somehow too great a risk. But the risk of a severe side-effect from the vaccine, i.e., more than just an ache in the arm or a brief and limited shiver and shake is infinitesimal!

Think of your US-football Super Bowl with a crowd of perhaps 100,000. If the whole 100,000-strong crowd were to be vaccinated on the same day, one—yes, one—might have a severe reaction. The risk of death from a severe side effect is even less—with maybe two or three dying from that reaction in every 1 million people vaccinated.

If the same 100,000 strong crowd—unvaccinated—were to be exposed to COVID-19 on that very same day, some 190 in that crowd would die (CDC data: 37 million cases, 2.6 million hospitalisations, and 1,895 per million deaths).

While nothing in our human existence can be regarded as risk-free—nothing—in my maths suggests a better chance against COVID-19 and a lesser risk of death than vaccination.

So, for the immune-compromised, i.e., those with a stuffed, or sleepy, immune system—like people with CKD_4-5, those on dialysis, or those immunosuppressed after transplantation—vaccination makes sense:

• None of the vaccines contain “live” virus.

• None of the vaccines contain “dead” virus.

• They do not contain any micro-chips, tricky bits, or strange codes.

They are just designed to tickle up some proteins in your own cells that will save your life and minimise the risk that you might infect, cause illness to, or cause the death of those you love.

Dialysis is already fraught enough with anxiety, fear, and risk. Don’t add the super-charger of COVID-19 to the mix. For those yet to be vaccinated—take a leaf out of the Nike ad and Just do it.