FAQ now available on the third dose of COVID-19 vaccination in solid organ transplant recipients
On September 28, CDTRP held a special webinar with Dr. Dima Kabbani from the University of Alberta to discuss the latest research and what the transplant community should know about third doses. A Q & A has followed the presentation and you can find the transcript below.
Question/Answer with Dr. Dima Kabbani
Some comorbidities can be modified with a healthy lifestyle, therefore this should be encouraged. However, if comorbidities already exist (for example chronic lung or kidney disease) unfortunately, lifestyle changes won’t do much at the point of COVID-19 infection. Therefore it makes solid organ transplant patients more vulnerable to the COVID-19 disease.
The data are trickling in for pediatrics. The PREVenT-COVID study (for more information on this please go to this link) is going to have a pediatric solid organ transplant group. What we know so far, is that the safety of the COVID-19 vaccine does not appear to be a problem. We were worried about seeing more side effects with possible pericarditis and myocarditis, which we have not seen and the immunogenicity data that we have is actually very good.
It all depends on what is happening where you live. In general, if everybody is vaccinated, then try to limit the numbers of people. But what we’re seeing in Alberta with a high level of circulating virus, we are encouraging our solid organ transplant patients to wear masks indoors.
We worry that when reducing our immunosuppression medications, we’re going to see more rejection of the transplanted organ. I don’t think we should be encouraging our solid organ transplant recipients to decrease their immunosuppression so they would have more of a response to the COVID-19 vaccine.
The terminology for the vaccine booster shot is an extra dose that applies for non-transplant recipients. To be considered fully vaccinated as a solid organ transplant recipient, it should be three COVID-19 vaccine doses.
A lot of centers are looking into considering a requirement for pre-transplant vaccination. I believe the data are coming. We know that the immunogenicity of vaccines, if given pre-transplant, is much better than if it is given post-transplant. We know that the morbidity and mortality of solid organ transplant patients with SARS-CoV2 infection especially in the early period after transplant is high. Some centers have moved to mandating pre-transplant COVID-19 vaccination, but it is not the case everywhere. (Please check with your transplant centre on their COVID-19 vaccine requirements.)
There’s been just one small study that looked at this. The study showed an increase in antibody production. But the problem is that it’s not clear that continuing to give vaccine doses is going to be the answer. What about a fourth dose and a fifth dose of the vaccine? Most of these studies are just measuring antibody response. This is not the only response that we get with a vaccine. There is the T-cell immune response which we don’t measure when we just check an antibody response. So there are some patients that despite getting a third, fourth, or fifth dose of the COVID-19 vaccine, might still be at risk, lung transplant recipients, for example. In these patients, we need to think about other modalities, either to increase immunogenicity rather than continuing to give boosters, or consider another strategy to help reduce disease.
We encourage patients not to get an antibody test. First, not all antibody tests that are available measure antibody response to the COVID-19 vaccine. Some of these antibody response tests just measure if you’ve been exposed to or infected with SARS-CoV-2. So that is a problem. The other thing is even in those that don’t have an antibody response, we have the T-cell immune response that we’re not measuring. The third thing, we don’t know what these numbers mean and at what level these numbers are protective against a COVID-19 infection. We know that the vaccines will protect solid organ transplant patients compared to being non-vaccinated and that there’s been a decrease in mortality. But breakthrough infections will still happen. That’s why I would continue to follow some of these protective measures like social distancing, mask wearing, and hand hygiene.
It’s an intervention available in Canada. We’re using more monoclonal antibodies (laboratory-made proteins that mimic the immune system’s ability to fight off harmful pathogens such as viruses) in those that are infected and still early in the infection. The big question is whether in those who don’t respond to the vaccine, whether these monoclonal antibodies could be given to try to prevent infection. Most of these monoclonal treatments are available in Canada through an IV. These are things we need to look more into going forward.
Yes, absolutely. We’ve seen much more severe disease in our lung transplant patients. In the PREVenT-COVID national research study (learn more here), we’re recruiting participants with different organ types and different immunosuppression regimens to address some of these questions.
What do we know about variants, the importance of Delta versus the South African variant and others?
I don’t know about specific data in solid organ transplant recipients. However, we know that the Delta COVID-19 variant is much more transmissible in general compared to other variants and can be associated with increased disease. I don’t think that we have enough data in our solid organ transplant recipients to comment on this. But I would expect it to behave the same way.
I would think so. When that’s going to happen, I don’t know. I think there are things such as more variants, vaccination locally and worldwide, and other factors that will play into this.
I don’t know if it’s going to be related to a certain season. What we’re seeing is from activities that change from being indoors to being outdoors, is that COVID-19 is more transmissible when we’re inside. But I don’t know that if there would be a seasonal impact or not.
It depends on when and where that person is travelling. I would still follow the precaution measures when travelling. I don’t know that the antibody test should be what makes us feel protected or unprotected because we don’t know what the numbers means and there are other types of immunity. It also depends on where we’re going, what’s happening with the COVID-19 variants, and it is more than just COVID-19 antibody levels.
Correct. We need to understand what is more important in the protection against COVID-19.
We know that non-immunocompromised vaccinated individuals are less likely to become symptomatic and transmit SARS-Co-V2. If you have your cocoon or bubble that is vaccinated, transplant recipients will have much more protection, even without masking at home on a daily basis.
About Dr. Dima Kabbani
Dr. Dima Kabbani is an Assistant Professor in the division of infectious diseases at the University of Alberta. Her clinical focus is infections in the immunocompromised host. She is the education lead for the transplant Infectious diseases fellowship program at the University of Alberta. Her research areas include the epidemiology and outcomes of infections in organ transplant recipients and more recently response to COVID-19 vaccines in organ transplant.
ity of Alberta and has received training in patient-oriented research through the University of Calgary’s PACER (Patient and Community Engagement Research) Program. He is the Patient, Family, and Donor Partnerships & Education Manager with the Canadian Donation and Transplantation Research Program. In this role, Manuel builds relationships patient partners with investigators and strengthens capacity among CDTRP patient partners.
Anders Billström 
Gareth Wiltshire
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Sherrie Logan 
born and raised in Edmonton, AB. With a degree in Music Performance (saxophone performance) and Education, Lindsey has taught for over a decade in the Edmonton Public School system. When she is not teaching, she is very involved in the music community, performing in the Edmonton Winds, conducting her own community ensemble (The Beer League Band) and on numerous musical boards across the province. For the past 5 years, Lindsey has had to take a break from teaching after having her amazing son, George. Maternity leave did not goes as expected as George was diagnosed with Dilated Cardiomyopathy at 5 months old and required 2 heart transplants before the age of 4. During this time, Lindsey has also began to dedicate her time building and expanding her charity: Big Gifts for Little Lives, where they raise money to fund Pediatric Heart Transplant research at the Stollery.
Dr. Caigan Du is a scientist at the Vancouver Coastal Health Research Institute and an assistant professor in the Department of Urologic Sciences at the University of British Columbia. He received a Ph.D. degree in Biochemistry in UK and postdoctoral training in Immunology in USA. He is interested in the pathogenesis of kidney ischemia-reperfusion injury and transplant rejection, and molecular control of urinary malignancies. He has been studying the impact of kidney donor-derived factors on renal allograft rejection, and the molecular pathways of kidney injury and regeneration in experimental models. He is also interested in developing medical solution including drugs made from natural compounds for all kinds of health problems, including immune disorders, organ preservation, kidney failure and urinary cancer. He is the PI of many grant supports from the Kidney Foundation of Canada and the Canadian Institutes of Health Research.
Heather Badenoch is a non-directed living liver donor and communications strategist. As the president of Village PR, she provides strategic communications direction and training to not-for-profit clients in community and health. An active transplant volunteer, Heather helps transplant candidates find living donors by running their public appeals, small and large, pro-bono. She also mentors potential living donors on the path to living donation. Heather is a volunteer with the UHN Centre for Living Organ Donation and the Canadian Donation and Transplant Research Program. She and her spouse adopt rescue dogs and volunteer together with Community Veterinary Outreach, a group providing free veterinary care to the pets of people who are homeless.
Sean Dicks is a clinical psychologist who has 20 years’ experience supporting both families of organ donors and transplant recipients. While it is rare for him to have contact with a donor family and recipient linked to the same organ donation-transplantation event, his contact with families who have lived experience with organ donation on the one hand, and patients who have received transplants on the other hand has provided opportunities to explore how their journeys become linked when they attempt to make sense of and find meaning in their respective crises.
Terri Hansen-Gardiner is a Cree speaking Metis woman from Northern Saskatchewan as well as a 10 year Breast Cancer Survivor. Her tireless spirit and dedication to her community is undeniable. Terri is a cancer survivor who travels around the province to provide assistance, information, and support to Indigenous patients who are trying to access and navigate the cancer care system.
Dr. Golnaz Karoubi is Assistant Scientist at the Toronto General HospitalResearch Institute and principal investigator in the Latner Thoracic Research Labs. She currently holds an Assistant Professor appointment in the department of Laboratory Medicine and Pathobiology and a cross-appointment in the department of Mechanical and Industrial Engineering at the University of Toronto. Dr. Karoubi received her PhD in Applied Science and Engineering at the University of Toronto and joined the Lung Regenerative Medicine Program in the Department of Clinical Research in Berne University, Switzerland for a post-doctoral research fellowship. She stayed on as a Group Leader in 2008 to direct the basic and transitional science as related to Cancer Stem Cell and Lung Regenerative Medicine in the Department of Biomedical Research at the University of Berne until 2012. In early 2012, she joined the team of Dr. Tom Waddell at the Toronto General Hospital Research Institute as a Senior Scientific Associate and was appointed to Assistant Scientist at the Toronto General Hospital Research Institute (University Health Network) in November 2019 and to Assistant Professor in the Department of Laboratory Medicine and Pathobiology in July 2020.
Dr. Haykal graduated from the University of Ottawa Faculty of Medicine in2007 as class valedictorian and silver medalist, and subsequently completed her residency training in Plastic and Reconstructive Surgery at the University of Toronto in 2016. During her residency, she completed a four-year Doctorate of Philosophy (PhD) in tissue engineering, regenerative medicine and immunology with a focus on tracheal reconstruction. She obtained numerous grants and awards including a CIHR Vanier Scholarship. Dr. Haykal then pursued fellowship training in microsurgical reconstruction at the Albany Medical Centre in New York. Dr. Haykal joined the University Health Network and the Toronto General Hospital in 2018. Her clinical focus is on complex oncological reconstruction and microsurgical reconstruction of the breast, head and neck and extremity. She started a lymphedema program in 2019 where she offers microsurgical techniques for the treatment of lymphedema.
Dr. Ahmed is a Professor in the Cumming School of Medicine at the University of Calgary. The recipient of the 2022 Hypertension Canada Senior Investigator Award, she is a nephrologist and clinician-scientist with a focus on sex and gender differences in human cardiovascular/kidney physiology and clinical outcomes. Dr. Ahmed is the Vice Chair (Research) for the Department of Medicine, Lead of the Libin Institute Women’s Cardiovascular Health Research Initiative at the University of Calgary and Lead of the Alberta Strategy for Patient Oriented Research Capacity Development Platform. Dr. Ahmed is an Advisory Board member for the Canadian Institutes of Health Research Institute of Gender and Health, a member of the Canadian Medical Association Journal Governing Council and the President-Elect for the Organization for the Study of Sex Differences.
r. Christopher Nguan is an Associate Professor at the University of British Columbia in the Department of Urological Sciences, Surgical Head of Kidney Transplantation at Vancouver General Hospital and the Director of the Surgical Technologies Experimental Laboratory & Advanced Robotics (STELLAR) facility at Vancouver General Hospital.
r Caroline Lamarche is a clinician scientist and transplant nephrologist at Maisonneuve-Rosemont Hospital. She is an assistant clinical professor at the Université de Montréal. After her nephrology training at the Université de Montréal (2015), she completed a Master degree on the use of adoptive immunotherapy to treat/prevent BK nephropathy in kidney transplant recipients. She then pursued a post-doctoral fellowship with Dr. Megan Levings at the University of British Columbia on the use of chimeric antigen receptor (CAR) regulatory T cells (Tregs) to induce transplant tolerance. Her lab is working on the development of adoptive immunotherapy in nephrology and understanding Treg dysfunction.
Dr. Tandon is an Associate Professor of Medicine, Co-Director of the Cirrhosis Care Clinic, Transplant Hepatologist and lead of the Cirrhosis Care Alberta quality improvement program. She obtained her training at the University of Alberta, the Hospital Clinic in Barcelona and Yale University. Her clinical practice and research are focused on cirrhosis with research interests including cirrhosis related complications, malnutrition, frailty, exercise therapy, palliative care, integrative health approaches such as meditation and knowledge translation. It is her career goal to provide wholistic, interdisciplinary, evidence based, patient-centered care through education, empowerment, engagement and team-work.
Emily is a PhD student at the University of Alberta, where she completed her Master of Science (MSc) degree in medicine. With a passion for patient-oriented research and a commitment to improving health outcomes, Emily’s doctoral project focuses on EMPOWER, a 12-week online mind-body wellness program designed for adults living with chronic health conditions.
Dr Basil S. Nasir, M.B.B.Ch
Dr. Victor Ferreira is an Assistant Scientist in the Ajmera Transplant Centre at the University Health Network (UHN) and the Toronto General Hospital Research Institute (TGHRI). He is also an Assistant Professor at the University of Toronto in the Department of Laboratory Medicine and Pathobiology (LMP). He completed his PhD in Medical Sciences – Infection and Immunity Specialization at McMaster University in 2014 and post-doctoral training at UHN. His research program is focused on three pillars: I) using systems vaccinology to reveal insights into vaccine responses in immunocompromised individuals like transplant recipients; II) characterizing the impact of chronic viral infection on host immune responses; and III) developing novel methods for eliminating latent viruses in human organs. His work has been cited >2,500 times and is published in journals including the New England Journal of Medicine, Nature Immunology, the Lancet Infectious Diseases, Clinical Infectious Diseases, the American Journal of Transplantation and Journal of Infectious Diseases.