Perspectives on COVID-19 vaccination among kidney and pancreas transplant recipients living in New York City - Oxford Academic Journals
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Practice Research Report
Perspectives on COVID-19 vaccination among kidney
and pancreas transplant recipients living in New
York City
Demetra Tsapepas, PharmD, MBA,
NewYork-Presbyterian Hospital, New Purpose. Solid organ transplant recipients are at increased risk of
York, NY, and Division of Abdominal
Transplant, Department of Surgery,
morbidity and mortality from coronavirus disease 2019 (COVID-19), but
Columbia University Medical Center, New limited vaccine access and vaccine hesitancy can complicate efforts for
York, NY, USA expanded vaccination. We report patient perspectives and outcomes
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S. Ali Husain, MD, MPH, Division of from a vaccine outreach initiative for a vulnerable population of transplant
Nephrology, Department of Medicine, recipients living in New York City.
Columbia University Medical Center, New
York, NY, USA
Methods. This was a retrospective review of qualitative perspectives
Kristen L. King, MPH, Division of
Nephrology, Department of Medicine, from a COVID-19 vaccine outreach initiative. In the outreach effort, kidney
Columbia University Medical Center, New and pancreas transplant recipients under care at the transplant center at
York, NY, USA NewYork-Presbyterian Hospital were initially contacted electronically with
Yvonne Burgos, BSc, Division of educational material about vaccination followed by telephone outreach to
Abdominal Transplant, Department of
Surgery, Columbia University Medical
eligible unvaccinated patients. Calls were used to schedule vaccine ap-
Center, New York, NY, USA pointments for patients who agreed, answer questions, and assess at-
David J. Cohen, MD, Division of titudes and concerns for patients not yet ready to be vaccinated, with
Nephrology, Department of Medicine, conversational themes recorded.
Columbia University Medical Center, New
York, NY, USA
Results. Of the 1,078 patients living in the 5 New York City boroughs who
Sumit Mohan, MD, MPH, Division of had not reported receiving COVID-19 vaccination, 320 eligible patients
Nephrology, Department of Medicine,
Columbia University Medical Center, were contacted by telephone. Of these, 210 patients were scheduled for
New York, NY, and Department of vaccination at our vaccine site (including 13 who agreed to vaccination
Epidemiology, Mailman School of Public after initially declining), while 110 patients were either not ready or not
Health, Columbia University, New York,
NY, USA interested in being vaccinated. The total number of patients willing to be
vaccinated was 554 when also including those already vaccinated. Unwill-
ingness to be vaccinated was associated with younger age (median age of
47 vs 60 years, P < 0.001), Black race (P = 0.004), and residence in Bronx
or Brooklyn counties (P = 0.018) or a zip code with a medium level of pov-
erty (P = 0.044). The most common issues raised by patients who were
ambivalent or not interested in vaccination were regarding unknown safety
of the vaccines in general, a belief that there was a lack of data about the
vaccines in transplant recipients, and a lack of trust in the scientific pro-
cess underlying vaccine development, with 34% of the patients contacted
expressing vaccine hesitancy overall.
Conclusion. Our qualitative summary identifies determinants of COVID-19
vaccine hesitancy in a diverse transplant patient population, supporting
the need for transplant centers to implement tailored interventions to in-
crease vaccine acceptance in this vulnerable population.
Keywords: COVID-19, kidney transplant, vaccine
Am J Health-Syst Pharm. 2021;78:2040-2045
Address correspondence to Dr. Tsapepas
(det9021@nyp.org).
S
© American Society of Health-System olid organ transplant recipients morbidity and mortality.1,2 Vaccination
Pharmacists 2021. All rights reserved.
For permissions, please e-mail: journals. have been significantly impacted by represents an important strategy for
permissions@oup.com. the coronavirus disease 2019 (COVID- prevention of severe acute respiratory
https://doi.org/10.1093/ajhp/zxab272 19) pandemic with increased risk of syndrome coronavirus 2 (SARS-CoV-2)
2040 AM J HEALTH-SYST PHARM | VOLUME 78 | NUMBER 22 | November 15, 2021COVID-19 VACCINE OUTREACH IN TRANSPLANT RECIPIENTS Practice Research Report
infections and severe disease.3,4 center experience, comments about
However, limited vaccine access and KEY POINTS how the vaccines work, adverse ef-
vaccine hesitancy complicate efforts to • COVID-19 vaccination in a fects in transplant patients vs the gen-
rapidly expand vaccination.5 Herein we highly vulnerable transplant eral population, the risks and benefits
describe the outcomes and patient per- population represents an area of the vaccine vs COVID-19 infection,
spectives from a vaccine scheduling out- of opportunity for transplant and other concerns raised by patients
reach effort for a particularly susceptible programs to intervene. were discussed. Interpreter services
cohort of patients—transplant recipients were utilized to communicate with
• COVID-19 vaccine hesitancy
living in New York City. non–English-speaking patients.
was most common among
To summarize the population
Methods individuals of younger age
demographics and COVID-19 vaccine
and/or Black race and those
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This was a retrospective review of perspectives, patients were stratified
residing in Brooklyn or Bronx
qualitative perspectives of kidney and into 2 groups: (1) those agreeable to
counties or a zip code with a
pancreas transplant recipients who receiving COVID-19 vaccine and (2)
poverty level between 10%
were contacted as part of a vaccination those not ready to receive COVID-19
and 20%.
outreach initiative. All kidney and pan- vaccine. The proportion of individuals
creas transplant recipients with func- • Clinicians should share object- living in zip codes with higher levels of
tioning allografts under the care of ive data and expert opinions poverty was obtained using data from
the Kidney and Pancreas Transplant and provide the necessary au- the American Community Survey, and
Center at NewYork-Presbyterian tonomy for patients to make patients were divided into 3 groups
Hospital Columbia University Irving informed decisions about with a low (0%-10%), medium (11%-
Medical Center who lived in the 5 bor- COVID-19 vaccination. 20%), or high (>20%) level of poverty on
oughs of New York City were contacted the basis of the zip code of their primary
to schedule appointments to receive address.6 Continuous variables were
COVID-19 vaccine. Geographic re- compared using the nonparametric
strictions on vaccine allocation pre- Mann-Whitney U test, and categorical
cluded scheduling visits for patients outreach call process to eligible un- variables were compared using a χ2
living in other areas. Patients who had vaccinated patients was implemented or Fisher’s exact test as appropriate. P
a medical indication to defer vaccin- to schedule vaccine appointments values less than 0.05 were considered
ation, including having undergone for interested patients, answer ques- statistically significant. Statistical ana-
transplant surgery, treatment for re- tions, and assess attitudes and con- lysis was performed using Stata 16.1
jection, or chemotherapy within the cerns for patients who reported that (StataCorp, College Station, TX). This
last 3 months, were excluded from the they were not ready or not interested study was approved by the institutional
outreach initiative. The outreach effort in the COVID-19 vaccine. A pharma- review board at Columbia University
began with electronic dissemination cist used a semistructured approach Irving Medical Center.
(email and patient portal–based com- that began by informing the patient
munications) of educational mater- that the transplant center was calling Results
ials that were formatted as “frequently patients to schedule COVID-19 vac- At the start of the vaccine outreach
asked questions” and coupled with cine appointments at the hospital loca- intervention, there were 3,067 patients
a safety and efficacy summary, with tion. For patients who were agreeable under the care of the transplant pro-
this information shared in English and to receiving the COVID-19 vaccine, an gram. Of these, 1,222 patients lived in
Spanish. In addition, patients were appointment was scheduled within a 1 of the 5 New York City boroughs and
sent a letter indicating that they were week of the call. For patients that were 1,078 had not yet reported receiving
transplant recipients and under the not ready to receive COVID-19 vac- COVID-19 vaccination and were con-
care of the transplant program, which cination, a conversational approach tacted by telephone. Contact was made
they could share with vaccine sites was used to identify the underlying with 592 patients; of the 320 eligible pa-
should this become necessary to dem- concerns and/or questions in order tients, 210 were scheduled to receive
onstrate eligibility at different stages to be able to address them and also to the COVID-19 vaccine at our vaccine
of vaccine rollout. On March 1, 2021, understand how patients were making site during the outreach telephone
the transplant department was au- their choices with respect to vaccin- calls and 110 patients were either not
thorized to schedule COVID-19 vac- ation. The conversation themes were ready yet or not interested in receiving
cine appointments for patients who recorded. In addition, existing data on COVID-19 vaccine (Figure 1).
lived in the 5 New York City boroughs COVID-19 vaccine administrations in For comparative analysis of patient
at a centralized hospital vaccination transplant recipients both in published characteristics based on willingness
site. Over a 2-week span, a systematic literature and from the transplant to be vaccinated, patients who had
AM J HEALTH-SYST PHARM | VOLUME 78 | NUMBER 22 | November 15, 2021 2041Practice Research Report COVID-19 VACCINE OUTREACH IN TRANSPLANT RECIPIENTS
Figure 1. Population summary. An asterisk indicates 13 patients who were originally not ready to receive the COVID-19
vaccine. COVID-19 indicates coronavirus disease 2019; NYC, New York City.
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informed us that they had been vac- medium levels of poverty (P = 0.044). some college education (54%) from
cinated for COVID-19 before the out- Most patients contacted spoke English high-poverty areas (62%).
reach effort (n = 144) were combined (80%) or Spanish (17%), but, when ne- Patients who were contacted as part
with patients who reported that they cessary, interpreter services were used of the outreach effort in both groups ex-
had already been vaccinated during the to speak with patients in their native pressed concerns and asked questions
outreach call (n = 200) as well as those language (Bengali, Korean, Malayalam, about vaccination during the telephone
who were newly scheduled for vaccin- Mandarin, or Spanish). Access to the calls. The most common questions
ation (n = 210), for a total of 554 patients hospital’s patient portal was not as- among patients who were scheduled for
who were willing to be vaccinated and sociated with willingness to receive vaccination were about adverse effects
110 patients who were not ready to COVID-19 vaccine (P = 0.199). Of note, (20%; n = 41), whether the transplant
be vaccinated. The characteristics of 13 patients who initially stated that center had confirmed that vaccination
each group are summarized in Table 1. they were not ready to be vaccinated was safe and was in support of the vac-
Patients who were not currently willing called to request appointments after cine (8%; n = 17), which vaccine was
to be vaccinated were younger (median the initial conversation. These individ- being administered (7%; n = 14), and
age of 47 vs 60 years), more frequently uals are included in the group that was how many doses were going to be ne-
Black (P = 0.004), more frequently from agreeable to COVID-19 vaccination cessary (4%; n = 9). Patients also asked
the Bronx or Brooklyn (P = 0.018), and and as a subgroup were predominantly whether vaccination had any poten-
more commonly living in areas with Hispanic (46%) with high school and tial interactions with their transplant
2042 AM J HEALTH-SYST PHARM | VOLUME 78 | NUMBER 22 | November 15, 2021COVID-19 VACCINE OUTREACH IN TRANSPLANT RECIPIENTS Practice Research Report
Table 1. Demographic Characteristics
Agreeable to Receive Not Ready to Receive
COVID-19 Vaccine COVID-19 Vaccine
Characteristic (n = 554) (n = 110) P value
Age, median (IQR), years 59.6 (47.7-67.9) 46.6 (35-63.6)Practice Research Report COVID-19 VACCINE OUTREACH IN TRANSPLANT RECIPIENTS
more access to the healthcare system,
Table 2. Vaccine Concerns Among Patients Who Were Not Willing to
whereas those in high-poverty areas
Receive COVID-19 Vaccination
were most impacted by COVID-19 and
Patients Not Willing have directly experienced the impact of
to Receive Vaccine disease. We believe that it is important
Comment (n = 110)a
for healthcare providers to increase the
Concerned about safety in transplant recipients 22 (20) confidence of patients about vaccin-
ation by, for example, sharing that the
Lack of data in transplant recipients 15 (14)
COVID-19 vaccines have undergone
Rushed development 13 (12) thorough testing and that safe adminis-
No reason shared 13 (12) tration has been demonstrated among
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transplant recipients in the early vac-
Prefers Janssen/Johnson & Johnson vaccine 12 (11)
cine distribution phases in real-world
Adverse effect concerns 12 (11)
experience.3,4,9 Clinicians should share
Concerned about drug interactions with 12 (11) objective data and expert opinions and
immunosuppressants provide the necessary autonomy for pa-
General skepticism 11 (10) tients to make informed decisions.
Wanted to hear from physician 10 (9)
It is also notable that hesitancy did
not indicate vaccine refusal; using this
Does not receive vaccines in general 10 (9)
approach, 13 patients who were initially
Concerned about the unknown long-term effects 9 (8) hesitant about vaccination during our
Had COVID-19 infection and feels protected by antibodies 4 (4) outreach effort called back and booked
appointments. This observation indi-
Believes that the vaccine is a test for society and does not 3 (3)
want to participate cates that an appropriate method to
influence patients with respect to re-
Concerns about vaccine ingredients 2 (2)
ceiving a vaccine is by giving patients
Does not want to leave the house 2 (2) facts about vaccine safety and sharing
Anxious and not mentally prepared 1 (1) what is known, as well as the perspec-
tive of the transplant program.
Abbreviation: COVID-19, coronavirus disease 2019.
a
All data are shown as No. (%). Patients should also be counseled
on the risks of COVID-19 vaccination vs
COVID-19 disease and the benefits of
medications (3%; n = 6). The most opportunity for transplant programs to vaccination. It is known that transplant
common issues raised by patients who intervene. recipients have an increased likelihood
were ambivalent or not interested in We found that patient characteris- of poor outcomes from SARS-CoV-2 in-
vaccination were regarding unknown tics associated with vaccine hesitancy fection in comparison to individuals
safety of the vaccine in general (20%; included younger age, Black race, and who are not transplant recipients, owing
n = 22), a belief that there was a lack of residence in Brooklyn or Bronx coun- to comorbidities or immunosuppres-
data about the vaccines in transplant ties or a zip code with a poverty level sion.1,2 We recommend that clinicians
recipients (14%; n = 15), and a lack between 10% and 20%. These results are relay this information to patients in a
of trust in the scientific process that similar to broader national question- realistic but sensitive way by informing
brought the vaccines to market (12%; naire distributions in which younger them that, on the basis of the compos-
n = 13), or the patient did not want to individuals and Black and/or Hispanic ition of currently available vaccines and
articulate a reason (Table 2). individuals have indicated that they do their mechanism of action, we do not
not intend to be vaccinated.7,8 Although anticipate transplant patients experien-
Discussion the majority of the patients contacted cing any unique adverse effects different
COVID-19 vaccination is the most were scheduled for appointments, the from those in the general population
effective method to build widespread findings from this outreach effort indi- and our expert opinion is that the vac-
SARS-CoV-2 immunity to ensure the cate a concern about vaccine hesitancy cines are safe in that they are unlikely
safety of the population. We found and a need for intervention, particularly to trigger a rejection episode or have a
that 34% of transplant recipients who among individuals living in areas that negative effect on allograft function.
we contacted expressed vaccine hesi- have a medium level of poverty, ran-
tancy. Our results indicate that vaccine ging from 10% to 20%. We hypothesize Conclusion
hesitancy in a highly vulnerable trans- that this is because individuals living Limitations of this report include
plant population represents an area of in areas with low levels of poverty have the small study population in a single
2044 AM J HEALTH-SYST PHARM | VOLUME 78 | NUMBER 22 | November 15, 2021COVID-19 VACCINE OUTREACH IN TRANSPLANT RECIPIENTS Practice Research Report
transplant center location. However, our are a critical component. Consideration the US epicenter. Am J Transplant.
qualitative summary characterizes de- should be given to ensure that individ- 2020;20(7):1800-1808.
3. Baden LR, El Sahly HM, Essink B, et al.
terminants of COVID-19 hesitancy in a uals receive messaging from an indi-
Efficacy and safety of the mRNA-1273
diverse transplant patient population vidual who speaks the patient’s native SARS-CoV-2 vaccine. N Engl J Med.
and supports the need for transplant language who can best relay the mes- 2021;384(5):403-416.
centers to implement tailored interven- sage using appropriate word choices. In 4. Polack FP, Thomas SJ, Kitchin N, et al.
tions to increase vaccine acceptance addition, transplant programs should in- Safety and efficacy of the BNT162b2
mRNA Covid-19 vaccine. N Engl J Med.
in this vulnerable population. The vac- vest resources for outreach to areas with
2020;383(27):2603-2615.
cine hesitancy rate in this study (18.6%) lower socioeconomic backgrounds, as 5. Dror AA, Eisenbach N, Taiber S, et al.
is similar to rates reported among adult individuals in these areas are more likely Vaccine hesitancy: the next challenge
individuals surveyed across the United to demonstrate vaccine hesitancy and in the fight against COVID-19. Eur J
Downloaded from https://academic.oup.com/ajhp/article/78/22/2040/6311243 by guest on 12 December 2021
States (18.6%) and higher than those may benefit the most from additional Epidemiol. 2020;35(8):775-779.
in New York state (12.6%) when com- outreach. Although over 750 kidney 6. US Census Bureau. American
Community Survey. Accessed March
paring to estimates that were obtained transplant recipients at our institution 25, 2021. https://www.census.gov/
at the same time point as this interven- have been vaccinated for COVID-19, this programs-surveys/acs
tion on March 1, 2021.10 New York state only represents 24% of the total kidney 7. Fisher KA, Bloomstone SJ, Walder J,
reporting from the general population transplant population under active Crawford S, Fouayzi H, Mazor KM.
during this period indicates that patients follow-up care at the transplant program, Attitudes toward a potential
SARS-CoV-2 vaccine: a survey
not willing to receive COVID-19 vaccin- and thus additional work to vaccinate
of US adults. Ann Intern Med.
ation were concerned about adverse ef- patients and ease concerns is ongoing. 2020;173(12):964-973.
fects, preferred to wait and see, and did 8. Khubchandani J, Sharma S, Price JH,
not trust the COVID-19 vaccines, while Disclosures Wiblishauser MJ, Sharma M, Webb FJ.
transplant patients were concerned Dr. Husain is supported by the National COVID-19 vaccination hesitancy in
Center for Advancing Translational Sciences the United States: a rapid national
about a lack of efficacy and safety data
(KL2 TR001874). The authors have declared assessment. J Community Health.
among transplant recipients. Thoughts 2021;46(2):270-277.
no potential conflicts of interest.
and concerns shared by patients repre- 9. Boyarsky BJ, Ou MT, Greenberg RS,
sent an opportunity for the healthcare et al. Safety of the first dose of SARS-
References CoV-2 vaccination in solid organ
community to mobilize to better edu-
1. Columbia University Kidney Transplant transplant recipients. Transplantation.
cate the public and ensure a consistent Program. Early description of corona- 2021;105(5):e56-e57.
and, more importantly, accurate mes- virus 2019 disease in kidney trans- 10. US Census Bureau. Household Pulse
sage in conversations. Targeted inter- plant recipients in New York. J Am Soc Survey COVID-19 Vaccination Tracker.
ventions with structured talking points Nephrol. 2020;31(6):1150-1156. Accessed May 13, 2021. https://www.
2. Pereira MR, Mohan S, Cohen DJ, census.gov/library/visualizations/inter-
that are consistent and aligned across
et al. COVID-19 in solid organ trans- active/household-pulse-survey-covid-
all multidisciplinary care team members plant recipients: initial report from 19-vaccination-tracker.html
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