This report reflects the information and guidance available at the time of writing, please see our online guidance for the latest advice .
Summary of the discussion
Thank you to all who attended and contributed to the webinar, the sixth in our series. It covered developments in our knowledge about the Covid vaccines and how people with suppressed immune systems are responding, as well as a discussion about how better to understand individual risk from Covid and use this within workplace risk assessments. We were joined by 4 kidney doctors, Dr Rebecca Suckling and Dr Fiona Harris from Epsom and St Helier hospital, Dr Sunil Daga from Leeds Teaching Hospital NHS Trust, and Dr Michelle Willicombe from Imperial College Healthcare NHS Trust, as well as consultant occupational physician Dr Tony Williams. We would like to say a big thank you to them for their advice and answering your questions.
On this occasion, because of a technical glitch we do not have the recording of the event available and so have provided a slightly longer report.
Please do keep checking the Kidney Care UK Covid-19 guidance for updates.
Dr Willicombe gave an overview of the current studies looking at the effectiveness of the Covid-19 vaccines. There are a good number of studies in the UK and globally. Some involve blood tests to look at the body’s immune response and there are also studies looking at the prevalence of the Covid-19 virus in large populations.
The Octave study is looking at immune response in different patient groups who are immunosuppressed. This includes an in-depth look at 150 haemodialysis patients in depth and also testing the blood of 850 transplant patients. A lot of the drugs taken by kidney patients are used by the study’s other patient groups and this will provide more data on vaccine response in people taking these drugs. The Octave study results are likely to report the findings in June 2021. An additional study run from Cambridge, will assess how effective Covid-19 vaccines are in kidney patients on haemodialysis and aims to identify if and when boosters are needed. It is hoped that this study can be extended to other groups of kidney patients. Other local studies are also running in renal units. The Renal Association Vaccine Efficacy group, put together to look at different data about vaccine response in kidney patients, is hoping to get the first results in May 2021.
The information about immune response gained through analysing blood samples will be combined with real life data about the number of kidney patients catching Covid-19 and getting seriously ill with the virus. Although collecting these sets of data takes time, it is important to have both. In order to better understand the protection offered by the vaccine, we need to understand how the body responds to the vaccine as well as how this translates into a reduction in cases among kidney patients.
People who would like to take part in a study should speak to their local kidney unit, as they may be running a local study or could link patients into a national study.
People who participate in studies may be offered the results of the antibody and other tests. However, this should be accompanied by an explanation of what the results can and cannot tell us.
None of the data gathered so far suggests that any of the vaccines work better than others for kidney patients.
Are people looking at alternatives to traditional vaccines?
There are studies ongoing into alternatives to vaccination, but there is no data currently that suggests antibody therapy is more effective than the vaccines. There are studies looking at different ways of offering protection, which may offer another level of protection for people who have a low immune system. For example there is a study looking at whether the drug niclosamide, usually used to treat tapeworms, can prevent Covid-19 infection in vulnerable, high risk kidney patients and reduce the number of people who become seriously ill or die from it.
Dr Sunil Daga was asked by a patient family member Donna about the recent JAMA study in America, regarding single dose vaccine in solid organ transplant recipients, which showed a 17% antibody response.
Dr Daga explained that vaccination trains the body to respond to infection in multiple ways. Antibody response is only one facet. Also, this study does not tell us about what happens after the second dose of the vaccine, which may be more similar to the rest of the population. So this study is only part of the story.
However, although it is early days, it is enough to cause concern. What the study shows is similar to what we’ve seen in other vaccines, for example the flu vaccine. There tends to be a lower immune response among kidney patients, and particularly among older patients, those who are on anti-metabolites (mycophenolate or Azathioprine) or higher combined immunosuppressive drugs and those with worse kidney function. So younger transplant recipients with a well-functioning kidney are likely to have a better response to the vaccine. Based on the data seen so far, it remains very important to keep following social distancing and hygiene rules for the present time.
In terms of different groups of kidney patients, people on dialysis seem to have a better response to the vaccine than transplant recipients and people with CKD not yet on dialysis may have an even better response. Most of the data so far concerns the Pfizer and Moderna vaccine, so we will have to wait for data about the Oxford/AstraZeneca vaccine and also for evidence about response to the second dose which should be coming soon. Past experience suggests that people with a sluggish immune system tend to respond better to the second dose.
Should I get an antibody test?
Dr Harris explained that although it is tempting to buy an antibody test, it won’t give you all the information you need to understand how well you are protected so we don’t recommend buying one. Although the body does form antibodies as part of an immune response, it is not the only way that your body responds and protects itself. Also, an antibody test will only test for one particular antibody, but there will be others which form part of the body’s defences against the virus. The test will only tell you whether or not you have the particular antibody being tested. And it will not give any information on how long protection might last.
We have something called T-cells, which are also important in the body’s immune response. These have a range of different functions within the immune system to help the body attack the virus in a number of different ways. It is not currently possibly to buy a test for t-cells.
Dr Harris explained that the immune system is like a jigsaw, with the different parts coming together to protect the body. Looking at just one part of the jigsaw does not give the whole picture. The research that is going on with the participation of patients will give us a much better understanding of how well the vaccine protects against Covid.
What is the best timing between jabs and why are there differences around the country?
Most people are recommended to have their second dose of vaccination within 12 weeks of the first. The timing recommended by the JCVI is different to the timing of the doses within the clinical trials of the vaccines. This is based on their knowledge of vaccination, evidence from the use of many other vaccines, data from clinical studies and the imperative to maximise protection in the population. Data suggested that immunity from the first dose lasted from 2 weeks post vaccination up to 12 weeks and also that a longer interval between the first and second doses promotes a stronger immune response with the AstraZeneca vaccine. With most vaccines an extended interval between the prime and booster doses leads to a better immune response to the booster dose.
However, we also know that people with suppressed immune systems tend to have a weaker response to vaccines. Therefore, the JCVI recommended that people who are about to start immunosuppressive medication should have the two doses of vaccine before they start taking the medication, wherever possible, and this may mean a minimum of 3 or 4 weeks between doses. This includes people who have a living organ transplant planned.
It might be that in different areas around the country people are offered the second vaccine at a different time, within the 12 week maximum. This might be because a clinician thinks a particular dosing schedule is best for an individual patient. Or it might be because of the resources available in that particular area.
Do we know how long immunity lasts?
The Siren study, which looks at how Covid infection rates as well as re-infection and the presence of anitbodies in previously infected people, suggests that people may be protected against reinfection with Covid for six months after initial infection. But we will need to wait for time to pass to see what real life data tells us about how long protection from the vaccine lasts. It might be that even after antibodies face we still have immunity from Covid.
What do we know about risk and returning to work?
Dr Williams spoke about how we are exposed to risk every day from a wide variety of activities, substances, and behaviours. That undercooked chicken, crossing the road or cycling to work, skiing or surfing, drinking too much. Covid adds another risk, and we need to assess the risk to ourselves in the same way. He explained that risk can be calculated and that this often helps us put risk in perspective. We expect risk to be calculated as a comparison with normal activity or health, e.g. five times the risk, or as an absolute risk of an event, e.g. one in 100 risk of dying. Once we know this we can work out how to reduce risk.
Covid has come with lots of statistics about risk, and this has sometimes been confusing. But we learnt early on that age is a major factor in increasing risk. The age effect between birth and 100 is around 10,000 times the risk. Age has to be taken into account for all risk assessments, as it became clear that an extremely young person would be very unlikely to be extremely vulnerable. We have been able to estimate the ‘age effect’ for individual conditions, and giving a ‘Covid-age’ estimate can be very helpful in understanding the risk. So for example, having had an organ transplant can add something in the region of 22 years to your Covid-age. So a 30 year old white male transplant recipient with no other health conditions may have a Covid-age of just over 50.
We estimate that the risk of dying after infection with Covid-19 is one in twenty at age 85, so we define this level as ‘very high vulnerability’ and would regard this as similar to ‘clinically extremely vulnerable’. We have chosen age 70, with a risk of dying after infection at one in a hundred, as the level for ‘high vulnerability’. Below this we have two groups, up to age 49, and 50 to 69, who are ‘low vulnerability’ and ‘moderate vulnerability’. Age 50 is a risk of dying if infected with Covid-19 of around one in six hundred. This means that younger people with conditions on the CEV list have a Covid-age lower than 85, in many cases lower than 70, which is reassuring.
Dr Williams strongly recommended that anyone who is worried about their personal risk levels use the Covid-age calculator which can be found at https://alama.org.uk/covid-19-medical-risk-assessment/ . This can also be used as part of a risk assessment when returning to the workplace. The values are averages, so some advice from your GP or specialist is needed.
Past infection or vaccination reduces Covid-age, because it can reduce your risk of serious illness from Covid. This may mean people may drop from very high to high vulnerability, or high to moderate. It is important to recognise that people on immune suppressant medication or with a condition that affects immunity may not respond so well to past infection or vaccine, so it may not be appropriate to drop groups.
Finally, perhaps the most important risk factor is viral prevalence. As this drops, risk drops too. The drop from 1000 infections per 100,000 per week to 10 per 100,000 represents a one-hundred-fold drop, which in turn equates to a Covid-age drop of around 50 years when considering overall risk. We can therefore feel much safer generally as viral levels drop. If the local prevalence rate was around 10 people with Covid per 100,000 then you would be very unlikely to meet one of those people when you were out and about in your community.
When considering risk at your workplace, it can be helpful to calculate your Covid-age and then, if appropriate, change this according to previous infection or vaccination (acknowledging that people on immunosuppressants may not respond as well). Then you can use the matrix developed by the Association of Local Authority Medical Advisors (ALAMA) to guide decisions about whether it is appropriate to undertake a workplace activity. Activities are judged to be very high, high, moderate and low, depending on an individual’s Covid-age, the risk present in the workplace, and the local viral prevalence. This should be viewed as a rough guide and tailored to account for special circumstances and the views of the worker.
So for example, working with a high number of face-to-face contacts, e.g. healthcare, teaching, supermarket staff, would be judged to be a moderate risk for people with a Covid-age of 70-84 where the local prevalence was fewer than 99 cases per 100,000 people. But it would be high risk for those same people if the local prevalence was 100 cases per 100,000 people or more. You can find the matrix and the accompanying guidance at https://alama.org.uk/covid-19-medical-risk-assessment/
You may be able to be redeployed into a safer role, but this will not always be possible. Over the next few months, employers will start asking their employees to come back into the workplace.
Risk from Covid-19 to kidney patients
Dr Daga said that COVID-19 can affect a range of kidney patients, and recovery is dependent on other medical illnesses you may have and on the level of kidney function. Severe COVID-19 infection is associated with kidney failure and a small portion of people may remain on dialysis (and not recover to baseline kidney function). The UK Renal Registry (UKRR) is collecting data on coronavirus infection in patients with kidney disease (CKD, dialysis and transplant recipients) but may not have either a complete collection of the swab-results or the patient deaths from transplant recipients, as many will not be known in the main renal centres. The swab positive infection rate, and the outcomes, will become clearer with time, when it is hoped that UKRR data is linked to the Public Health England COVID swab database.
What rates of asymptomatic infection have been observed in transplant patients?
We do not have estimates on this, as the data has not been collected. It may well be lower than the general population as many transplant patients have been shielding. However, we have all seen transplant patients as well those on dialysis who have tested positive despite having no Covid symptoms. So we know that there is a proportion of kidney patients who have had asymptomatic infection.
Keeping safe after vaccination
Dr Daga noted that outdoor activities, such as walking and cricket, were generally much safer than indoor activities because the virus could disperse more easily so you are less likely to catch it.
It will continue to be important to follow local rules and guidelines about reducing the number of people you meet with and it would be most helpful to try not to meet too many different people. Social distancing and hygiene will also continue to be important.
When will hugs be back?
Paul, a kidney transplant recipient asked “I have loved ones and family who I haven’t seen 15 months. One works in theatres / ICU in the NHS and one is a secondary school teacher, another a police officer - when can I hug them again with confidence?”
Dr Daga replied that maybe he has to wait until later in the year. However, there are things which can reduce the risk. For example, thinking about safety measures like PPE, taking a lateral flow test before meeting and even seeing if it is possible for family to isolate for a period before meeting up and vaccination of carers and family members/ friends within their social bubble – to reduce risk of the virus being present. It is also important to consider local viral prevalence rates (how many in your community have Covid-19) and if these rates are low, the risk of catching COVID would be low. It was also pointed out that working with Covid patients was less high risk than might be thought, as healthcare staff wore full PPE when with patients so were at relatively low risk of contracting Covid at work.
In terms of getting together to celebrate other events like Easter or Eid, it remains very important to follow all the Government guidance for your area and adopt safety measures, even after vaccination. Guidance from faith leaders confirms it is okay to receive coronavirus vaccination or swab testing even during the fasting month of Ramadan. Dr Daga also reassured people that the Transplant Games would be back on in 2022, but it had been cancelled this year as the paediatric patients would not have been able to join which would have been a huge shame.
What are the current guidelines and hopes for international travel and holidays in the UK?
We are awaiting advice from Government about international travel. The current bans on international travel are important as they prevent new variants entering the country. Furthermore, lots of countries currently have higher rates of Covid and lower rates of vaccination than the UK, which means it is safest to keep to essential travel only.
Dialysis away from base is also not happening at the moment. It is difficult to predict when this might change, but medical professionals, Kidney Care UK and the NHS England clinical reference group are working on new guidelines working towards restoring dialysis away from base as soon as the risk levels are sufficiently low. We know how important it is for people to be able to travel.
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