Ask the Experts

Questions about transplantation?

Send it to transplant@lhsc.on.ca and we will have one of our experts address it. For questions that would be of interest to most LHSC transplant recipients, we will post them here.

For more information regarding COVID-19 or COVID-19 vaccines please visit Ontario Health at https://www.ontario.ca/page/covid-19-coronavirus (website for Ontario Health/Covid)

COVID Vaccine Update - October 2024

Based on guidance from Health Canada and the National Advisory Committee on Immunization (NACI), Ontario’s Chief Medical Officer of Health is recommending high-risk individuals receive their next COVID-19 booster this fall if it has been more than six (6) months since your last COVID-19 vaccine OR since you had a confirmed case of COVID-19.  This updated vaccine is recommended to better protect against the currently circulating variants.

Individuals in the following high-risk groups are recommended to book an appointment for a spring COVID-19 booster.

  • Individuals aged 65 years or older
  • Residents of long-term care homes, retirement homes, Elder Care lodges and other congregate living settings for seniors;
  • Individuals aged 18 years and older living in a congregate setting for people with complex medical care needs;
  • Pregnant individuals;
  • Individuals aged 18 years and older who are moderately to severely immunocompromised; and
  • Individuals aged 55 years and older who identify as First Nations, Inuit or Métis and their non-Indigenous household members aged 55 years and older.

The updated COVID-19 vaccine is now (October 17) available in Ontario for high-risk individuals.  For the general population the updated vaccine will be available on October 28, 2024.

Eligible individuals can book an appointment through public health units, Indigenous-led vaccination clinics, participating health care providers and participating pharmacies.

What should I do if I think I have COVID-19?

If you develop cold/flu/COVID or respiratory symptoms and are experiencing moderate to severe shortness of breath, chest pain, or fever (Temperature greater than 38º C) PROCEED TO YOUR LOCAL EMERGENCY ROOM.  Please consider swabbing for COVID in the event you require IV remdesivir treatment for a COVID infection. Many viral respiratory infections are circulating in the community that are NOT COVID. If you become positive for COVID and would like information on treatment, please call the clinic at 519-663-3346 Extension. 2 (Nurse Line available: Mon. - Fri. 8AM-4PM) or After-Hours call 519-685-8500 Extension. '0' and ask the switchboard operator to page the nephrologist on-call for University Hospital and Kidney Transplants.

Measles

What is measles? 

Measles is a highly contagious respiratory virus. Symptoms of measles include fever, a red blotchy rash, red watery eyes and cough.  In Ontario, measles has been rare, owing to the successful elimination of measles in Canada and high immunization coverage. As a result, measles cases have typically been predominantly associated with travel (often referred to as “measles importations”).

What are the symptoms of Measles?

Measles usually starts with fever, “flu-like” symptoms, sore throat, and lack of appetite.  Some patients also develop red eyes, sneezing, coughing and then a typical rash.  Red rashes usually start on the face and then spread to form red patches on the body.  Patients start to improve as soon as 1-2 days after the rash starts, but they may still have a cough for many days.  Although there is little data, it is possible that transplant patients may be at higher risk of measles complications of the lungs, ears or brain.

What is the current situation in Ontario: 

Between October 18, 2024, and March 26, 2025, a total of 557 cases (464 confirmed cases) of measles have been reported in Ontario. Ontario with 62.9% occurring in unimmunized adults and 93.8% in unimmunized children.

How can we protect ourselves from measles? 

Immunization is the best protection against measles by receiving (MMR vaccine) which is a live vaccine and therefore, not considered safe in someone who received a solid organ transplant. 

What do I do to protect myself? 

Make sure close contacts have been vaccinated against measles. Maintain distance from someone with respiratory symptoms particularly if they have a skin rash.

What do I do if I came in contact with someone who developed measles? 

Individuals with measles are considered infectious from 4 days prior to rash onset through to 4 days after rash onset (9 days total). If you come in contact with someone during the infectious period, contact the transplant clinic.
Intravenous immunoglobulins are recommended for immunocompromised patients who are exposed to someone with measles.

What do I do if I came in contact with someone who developed measles? 

If not immune to measles (no antibodies to measles) and had a significant exposure.

An example would be speaking to someone or living in the same household with someone who has measles.

Would being in the same supermarket during the same week when someone with measles had been, be considered a significant exposure?

No, it is not considered a significant exposure.

Source:

Measles in Ontario

What’s new with the RSV vaccine?

What is RSV? As mentioned in our last update, RSV is the Respiratory Syncytial Virus that cause infections of the respiratory tract. It is contagious, affects all ages and is seen more during winter. It usually presents as a common cold but can be more serious and result in pneumonia in both the elderly and the immunocompromised including transplant patients.

What is the RSV vaccine? Arexvy is a Health Canada approved vaccine to help protect against RSV. Because transplant recipients were not included in the study, it is not yet known whether the vaccine would be as effective in transplant recipients as it is in the general population.

Who is eligible for the RSV vaccine? Anyone over the age of 60 is able to receive the vaccine. Individuals at high-risk, such as transplant recipients who are 60 years of age and older, qualify for a publicly funded vaccine and can receive it at no-cost.

For awareness, the high-risk groups include individuals 60 years and older in the following populations:

  • Transplant recipients
  • Dialysis patients
  • Homeless individuals
  • Hospital ALC patients
  • Indigenous individuals, including urban dwelling

How many doses are needed? For now, a single dose is recommended. We do not know at this time if additional doses will be needed for transplant recipients. There are on-going studies happening to help guide this decision.

What will this vaccine cost? The Ministry of Health recently announced that this vaccine is now covered for the transplant recipients 60 years old or greater.

When should I get the vaccine? You can get the vaccine as soon as possible. If you have recently received your transplant, we recommend that you wait one month post-transplant before getting the vaccine.  It is recommended that the RSV vaccine be administered at least 2 weeks before or after any other vaccine.  

What are the side effects? Side effects can include pain, redness and swelling where the shot is given, fatigue (feeling tired), fever, headache, nausea, diarrhea and muscle or joint pain.

How do I get the vaccine? As noted above, transplant patients over the age of 60 qualify for publicly-funded RSV vaccination. To obtain the vaccine at no-cost, you will need to see your primary health care provider, specialist or hospital program where you are receiving care to receive it.

For further information you can access Ontario Health here. (Ontario Health – Respiratory Syncytial Virus)

Mental health can be a struggle at any time for many – is there anything out there to support transplant recipients?

Researchers at the University of Alberta have started a 12-week online wellness program. This research study, “EMPOWER,” aims to improve mental health in recipients of an organ transplant by giving them access to a fun, 12-week online wellness program with weekly movement, breathwork, meditation, education from clinicians, and psychology skills.

To learn more about this voluntary study opportunity, you can get more information through the links below: 

More information: Watch this video to learn more about EMPOWER!
Study website: https://empower-program.com/
You can connect with the study team at the University of Alberta through email: empower@ualberta.ca

What medications can I take for a cough or cold?

Here is a chart with some common products that will help you manage your cough or cold safely. Cough and cold medications that contain acetaminophen, dextromethorphan or guaifenesin are considered safe as long as you stick to the recommended daily dose. Do not take more than what is recommended. If a cough or cold persist, do not hesitate to seek medical attention.

Symptom

Cough 
Products: Dextromethorphan Brands available: Robitussin cough gels, Robitussin DM (contains guaifenesin)

Pain and headache 
Product: Acetaminophen

Congestion and phlegm 
Product: Guaifenesin

Decongestant 
Product: Pseudoephedrine - Patients with uncontrolled and high blood pressure should avoid pseudoephedrine.

Sneezing and allergies 
Products: Chlorpheniramine, Diphenhydramine, cetirizine and loratadine

Sore throat 
Products: Acetaminophen, Menthol and Benzocaine

Should I get the flu shot?

Yes! You should get the high dose. This is a one-time dose shot. If the high dose is not available, you will need to get 2 doses of the regular dose, 1 month apart.

You do NOT need to wait for any time period before or after your COVID-19 vaccine to get your flu shot.

The flu shot is available, now, for free, in Ontario, for those in the high-risk category. The high-risk category includes:

  • People 65 years old and older
  • Residents, staff and care providers of congregate living settings (such as chronic care facilities, retirement homes)
  • People with underlying health conditions, such as asthma, heart disease or diabetes.

The flu shot will be available to the general public as of October 28, 2024.  The flu shot is available through your doctor or participating pharmacy.  Some workplaces may also provide a vaccine clinic during the fall season. 

How long should isolate for if I get COVID-19?

While Public Health guidelines recommend 5 days of isolation from either the start of symptoms or your positive test date, whichever came first, we recommend a 10 day isolation period for transplant patients. After this time period, you should continue to wear a mask whenever in public (both indoor and outdoor) for a further 10 days. This is because there is data that show that immunocompromised patients can shed the virus and therefore are contagious for a longer period of time.

What about Evusheld?

Unfortunately, while Evusheld was effective against early variants of COVID-19, current variants are resistant to Evusheld. Because of this, as of December 12, 2022, Ontario Health does NOT recommend routine use of Evusheld to prevent infection for any patient group, including immunocompromised patients.

Is the Smallpox Vaccine safe for transplant recipients?

Monkeypox is a rare disease caused by infection with the monkeypox virus. Monkeypox symptoms are similar to smallpox symptoms, but much milder, and monkeypox is rarely fatal.

The smallpox vaccine ACAM2000 is contraindicated as this is live replicating virus. Transplant recipients should NOT receive this.

There is a modified vaccine Ankara (MVA) that does not have replicating potential and is safe to give to transplant recipients. It is only being offered to the high risk population. Immunocompromised patients are not considered a high risk population. For eligibility criteria, refer to Ontario Health’s Monkeypox Vaccine (Imvamune®) Guidance for Health Care Providers.

How many transplant recipients are getting COVID-19 and how are they doing?

It is difficult to say how common COVID-19 is among transplants - we are only able to track recipients who report to us that they have tested positive for COVID-19.

In the first couple of years of the pandemic, of all the cases reported to our program, about one third have ended up being admitted to hospital and the mortality rate was about 15%. This rate was about 10 times higher than the general public. Patients at the greatest risk of death are those who have other illnesses as well, such as diabetes.

Since January 2022, mortality rates have declined with it now being approximately 4% for transplant recipients with COVID-19. This is largely because of enhanced immunity with vaccines and with past infections.

Early treatment has been effective in reducing the severity of illness and death. If you are concerned that you may have COVID-19, report it to your transplant team as soon as possible.

The best treatment for COVID-19 continues to be prevention and that includes vaccinations, masks, hand hygiene, distancing and avoiding higher risk environments.

What treatment choices do I have?

Paxlovid is a drug many of you may have heard about and some have asked us about. It is a pill that you can take daily for 5 days at home. Paxlovid is effective in treating COVID but it will interfere with your anti-rejection drugs. If Paxlovid is determined to be the best choice for you, it is important that this is managed by your transplant team.

Remdesivir is an antiviral drug that is given as an outpatient through IV. It requires a daily dose for 3 days. This may be difficult to manage for some transplant patients or the IV therapy may not be available in your area. Again, you need to contact your transplant team to determine your best option.

Can transplant patients still receive Sotrovimab treatment?

The latest variant of Omicron (BA2) is resistant to the Sotrovimab - the latest treatment we were using very successfully with our recipients. Therefore it is no longer our treatment of choice.

How accurate is a rapid test for COVID-19?

A rapid test, also called a rapid antigen test, looks for pieces of the viral proteins (also called antigens) from the SARS-CoV-2 virus. This is the virus that causes COVID-19. A PCR (polymer chain reaction) test looks at the genetic material or nucleic acid of the virus.

The PCR test is the preferred test - it is more accurate and can detect the virus earlier (e.g. in individuals who have a low viral load and are still asymptomatic).

The rapid antigen test is useful in that it provides results in a short time, is fairly inexpensive, can be done at home and can be taken repeatedly. However it can report a negative result even in people with COVID if the amount of virus is low or if the test  is not done properly.

If you are concerned that you might have COVID-19 and have access to a rapid antigen test, you should test yourself. If the test is positive, call your transplant team. If the test is negative, you  could still have COVID and if concerned, you should  arrange to have a PCR test done at a local testing centre. 

Should I reduce my antirejection drugs to help fight COVID-19?

Anti-rejection drugs increase your risk of COVID infection and reduces your reponse to vaccines. However, you should never change the dose of your anti-rejection medications without consulting your transplant physician.

Reducing or stopping your anti-rejection medications will not help prevent you getting COVID-19 but it will increase your risk of rejection.

If you get COVID-19, early treatment is available and effective. For  patients with moderate to severe illness, treatment may include reducing or discontinuing some of your anti-rejection medications.

What is the best type of mask? Does the mask protect me or others or both?

All patients should wear the best mask they have access to, excluding cloth masks which are very low in effectiveness. Surgical masks that are sold now in drug stores etc, are generally of good quality. N95 masks are actually 'respirators' and not masks. They offer the best protection but need to be fitted properly as to filter. A poorly fitting N95 is no better than a poorly fitting surgical mask. In Canada, N95 respirators should have a "NIOSH" label and an approval number stamped on the device.  Similarly for the popular KN95 versions.

Infectious Diseases Society of America masking evidence

The CDC in the US is also an excellent source of reliable information and it recommends that you a wear a mask to protect both yourself and others. Cloth masks are poor for protection unless double layered with a filter layer between. It is best to use proper medical masks that are widely available now. N95/KN95 are considered the 'best' masks but work only when well fitting without big gaps from the face. And of course any mask below the nose loses all protection. Plastic face shields should not be considered protective. 

Remember:

How long can I stay 6 feet away from an infected person indoors and still be safe?

There is no single answer for this as it depends on the amount of virus in the air, if you have had a good response to vaccine and if masks are being worn properly. The best  advice is to avoid of anyone who is infected or potentially infected.

Should I wear a mask outdoors?

Spreading COVID infection outdoors is much less of a risk than indoors, as more ventilation occurs outdoors and people usually are more distanced. However, infection can occur in crowds so they should be avoided, and if not avoidable, masks should be worn.

Can I eat indoors at a restaurant?

Indoor exposure to COVID remains a risk, particularly in restaurants as people need to remove masks to eat. Generally we advise against indoor dining for transplant patients even with vaccinations, at this time. If unavoidable, try distancing as much as possible, dine with vaccinated friends and family and remove masks only when actually required.

What do I do if a household member gets COVID-19?

If you think that you have been exposed to COVID-19, or have had close contact with anyone who has or may have COVID-19, you are at an increased risk for being infected. You should be tested for COVID-19 at a local screening centre within a few days of exposure. Incubation times vary but can be within 3 or 4 days of exposure.  If you have access to a rapid test, you can test yourself, but a PCR test will be more sensitive as it has a lower rate of 'false negatives'. It is important that you get tested with exposure or any symptoms - as early treatment is extremely important.

If someone in your household has COVID-19, they should isolate as much as possible within your home.

Symptoms of COVID-19 include a sore throat, loss of smell, runny nose, cough, fever, headache or new diarrhea. If you are concerned that you have COVID-19, please contact your transplant team or clinic as soon as possible. Treatment may be available to you but must be started within 7 days of symptoms start.

Is Covid-19 is airborne or is it large droplet spread?

There is ongoing debate on droplet vs aerosol but it is meaningless really. A very small droplet essentially becomes an aerosol. The best thing that can protect you from aerosols is a good mask, distance from its origin and good ventilation. Assessing ventilation is well beyond our ability to advise. HEPA filters are definitely effective but they need to be sized to the room and there are websites that evaluate these filters and adequacy for room sizes. The more a room's air is filtered, the better. If you feel that a space is poorly ventilated, it probably is.

As we move back to working in offices, how do I know it is safe for me?

The OSHA  (Occupational Safety and Health Administration) has provided the following statement regarding ventilation systems:

"Maintain Ventilation Systems. The virus that causes COVID-19 spreads between people more readily indoors than outdoors. Improving ventilation is a key engineering control that can be used as part of a layered strategy to reduce the concentration of viral particles in indoor air and the risk of virus transmission to unvaccinated and otherwise at-risk workers in particular. A well-maintained ventilation system is particularly important in any indoor workplace setting and when working properly, ventilation is an important control measure to limit the spread of COVID-19. Some measures to improve ventilation are discussed in CDC's Ventilation in Buildings and in the OSHA Alert: COVID-19 Guidance on Ventilation in the Workplace. These recommendations are based on American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Guidance for Building Operations and Industrial Settings during the COVID-19 Pandemic. Adequate ventilation will protect all people in a closed space. Key measures include ensuring heating, ventilation, and air conditioning (HVAC) systems are operating in accordance with the manufacturer's instructions and design specifications, conducting all regularly scheduled inspections and maintenance procedures, maximizing the amount of outside air supplied, installing air filters with a Minimum Efficiency Reporting Value (MERV) 13 or higher where feasible, maximizing natural ventilation in buildings without HVAC systems by opening windows or doors, when conditions allow (if that does not pose a safety risk), and considering the use of portable air cleaners with High Efficiency Particulate Air (HEPA) filters in spaces with high occupancy or limited ventilation."

The Transplant Program cannot dictate what your working conditions must be. We encourage you to discuss your particular concerns with your employer and work together toward building a safer work environment.

Where possible, request 6 feet space between you and coworkers. Wear a mask to protect yourself.

Contact your Transplant Team directly with any further specific concerns regarding your environment for further support or guidance.

Can transplant patients take ivermectin?

Ivermectin is an anti parasitic medication used for the treatment of some tropical diseases such as scabies.

There is NO evidence to support the use of ivermectin for the treatment of COVID-19 and in fact may be dangerous. Similarly other products like bleach, hydrogen peroxide, mouth washes, etc that are advertised on social media are ineffective or dangerous. Always talk to your doctor or transplant team for advice and read only sites known to have reliable information like our transplant site, Health Canada or the CDC.