Ask the Experts

What does the new bivalent vaccine mean for me?

A bivalent vaccine from Moderna has been approved by Health Canada. This vaccine covers the B1 Omicron variant but will give you additional protection against the current B4 and B5 variants. A Pfizer bivalent vaccine targeting the B4 and B5 variants has just been approved by Health Canada and will be available in Ontario as of October 17, 2022. Check your local vaccine centres and pharmacies where COVID-19 vaccines are administered as to availability in your region. An appointment may be required.

The minimum time period for transplant recipients between any COVID-19 vaccine dose is 3 months. This is true for the bivalents as well – they are your next ‘booster’.

The bivalent vaccine cannot be used as your primary vaccine dose (first 3 doses). This is a booster shot only at this time.

Which bivalent vaccine should you get? We recommend the Pfizer bivalent but this may not be available. You should get the vaccine that is available to you. Remember that that Moderna bivalent will give you protection against the B.4 and B.5 as well.

It does not matter whether your previous vaccines were Pfizer or Moderna.

This Moderna bivalent vaccine is a full dose for everyone.

You should not require a referral but bring a list of your medications with you to the Vaccine centre as proof that you are immunocompromised.

While vaccines may not prevent you from getting COVID-19, they continue to be your best protection against getting very sick and needing hospitalization from COVID-19

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.

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.

What type of COVID-19 vaccine should I get? Is there a difference?

There are several vaccines approved by Health Canada – complete information about them is available on the Health Canada website.

If you are in the Middlesex London Health Unit: For those who are unable to receive an mRNA vaccine, the Novavax Nuvaxovid vaccine may be an option. There is a limited supply available. This vaccine has not yet been tested in transplant recipients. The Janssen vaccine is available in rare circumstances when you are unable to receive any other vaccine. Contact the MLHU at 226-289-3560.

I've had Pfizer for all my previous shots but I heard that it might be good to have a combination of the two in your system. Should I continue to get Pfizer, or should I change to Moderna or does it matter?

Some studies have shown a trend towards a stronger immune response to the Moderna vaccine compared to the Pfizer one but head to head trials to investigate this trend have not been performed and so it remains unclear whether there is an enhanced immune response to the Moderna vaccine. The situation however is evolving particularly with the new variants.

Our advice at this point is to get the bivalent booster – either Pfizer or Moderna.

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

Get tested as soon as possible. Take a rapid test at home. You do not need a PCR to get treated.

Notify your transplant team as soon as you know that you have COVID-19. Most treatments need to be started within 5-7 days. Your team will discuss your treatment options with your if treatment is indicated.

Other than heading out for medical care, our Infectious Diseases Team advises that you to isolate for 10 days after symptom start or your positive test and continue to wear a mask in public (both indoors and outdoors) for a further 10 days after.

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.

A useful link is the Infectious Diseases Society of America where they discuss the evidence behind masking: www.idsociety.org/covid-19-real-time-learning-network/infection-prevention/masks-and-face-coverings-for-the-public/   

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. 

• Masking is a critical public health tool and it is important to remember that any mask is better than no mask.

• Wear the most protective mask you can that fits well and that you will wear consistently.

• Wearing a well-fitted mask along with vaccination, self-testing, and physical distancing, helps protect you and others by reducing the chance of spreading COVID-19.

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?

There are no openable windows; the HVAC is old and shoddy; we sit 6 feet apart

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.