The Kiwis that vaccination could leave behind

ROSS GIBLIN/FAIRFAX NZ

Lily Leadbetter was New Zealand’s youngest heart transplant patient when she received a life-saving new heart in Melbourne in 2016, aged two. (First published in 2016)

Some Kiwis can’t get the vaccine. In others, who have suppressed immune systems, the jabs might not work as well. It’s no coincidence that these are also some of the people at highest risk from Covid-19. Their best hope for full protection is for enough healthy Kiwis to get vaccinated to create a protective cocoon around them. Nikki Macdonald meets the people who need your help.

In February, Lily Leadbetter got a tummy bug. It put the 7-year-old heart transplant recipient in a hospital isolation room for more than a week.

For almost five weeks, she was penned in at home 24/7 with mum Veronika Klingler. Her beloved bulldog and chief comforter, Millie, had just died.

“It was really pretty tough,” Klingler says. “Not only for her body, but also her mental wellbeing, and ours.”

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That was a simple tummy bug. Klingler doesn’t want to think what would happen if Lily caught Covid-19.

“You don’t know how her body reacts to any bug or virus … The more unknown, the more you have no insurance to cover her wellbeing. So it is kind of massive for us.”

In 2016, the gift of a donor heart transformed a listless, blue-tinged sickling into a thriving 2-year-old. But as with any organ transplant recipient, Lily takes drugs to dampen down her immune system to prevent her body recognising the heart as foreign and rejecting it.

That makes her more vulnerable to every little infection, including Covid-19. But it could also mean the Covid-19 vaccine won’t work as well for her and other transplant recipients.

KEVIN STENT/STUFF

Seven-year-old Lily Leadbetter with her beloved British Bulldog Millie, who died in February.

For Lily that’s academic, as she’s too young to even be offered a jab. At present, the Pfizer vaccine being used in New Zealand is only approved for Kiwis aged 12 and over. No Covid vaccine has yet been approved for younger children.

While Klingler and Lily’s dad Adam will get vaccinated to help protect Lily, Klingler dreads the outcome if healthy Kiwis turn down the jab, and we reopen to tourists anyway.

“If they open the borders and not everyone is vaccinated, it is super tricky for us. I don’t know how we’re going to manage, to be honest. Because it’s just a bit scary, thinking about that.”

KEVIN STENT/STUFF

Lily is at high risk if she gets Covid-19, but she doesn’t have the luxury of choosing whether or not to be vaccinated. Mum Veronika Klingler wants all Kiwis to get the jab to help protect her daughter.

Because clinical trials generally include only healthy people, scientists are only now discovering who might be left behind by global vaccination rollouts.

Vaccines work by training the immune system to identify and fight off invaders. But if your immune system isn’t operating at full power, the fighting army kicked into action by the injection is likely to be diminished.

It’s no surprise then, that researchers have found the vaccines might not work as well in people with compromised immune systems.

That spans everyone from organ transplant recipients and people with blood cancers at the more severe end, to rheumatoid arthritis, solid cancer and kidney failure and dialysis patients at the other.

As an indication of how many people might be affected, Pharmac figures show 29,183 New Zealanders received funded immunosuppressant drugs in 2019-20.

But understanding exactly how different people are impacted is complicated.

Amanda Adachi

Kidney transplant recipient Liz Carrick is one of thousands of immune-suppressed Kiwis who could have a lower response to the Covid vaccine.

Who is most at risk?

By the time Liz Carrick needed a kidney transplant, her family was running out of disease-free donor options. The brother who had been mercifully spared the family’s genetic polycystic kidney disease had already donated one of his healthy organs to her other brother.

Her father, aunty, grandparents and her two daughters have all been afflicted with the degenerative disease, which usually causes the kidneys to fail in the late 40s or early 50s. For 57-year-old Carrick that happened about 2012.

The assistant head of senior school at Ashburton College did home dialysis for four hours every second night, until 2019, when a family generously donated their loved one’s kidney. Now, she takes eight tablets in the morning and seven in the evening, including immunosuppressants to prevent her body rejecting the life-saving gift.

Over the past year, she’s been reading the grim statistics about kidney patients getting Covid. One report said one in five died. New York hospitals scrambled to find more dialysis machines, as Covid destroyed previously problem-free kidneys.

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So it was a no-brainer to have the vaccine. As one of about 2100 Kiwis living with someone else’s kidney, she’s frustrated that transplant patients are not being prioritised – she only got a jab because there were leftover doses.

Her specialist told her the vaccine might not work as well for her, although it is likely to prevent more serious disease.

That means her best insurance policy is for everyone else to get vaccinated, to keep the virus out.

“The more people in the community who get immunisation, no matter who they are, the better it is for all the immune-compromised people. Once you get that herd immunity, I think we’ve got more chance of survival.”

Troels Sommerville/Stuff

Prime Minister Jacinda Ardern receives her first Covid-19 vaccine at Manurewa Marae.

There’s no suggestion Covid vaccines are unsafe for people with sluggish immune systems. But they might not produce as many virus-fighting antibodies.

The only people who can’t get the jab for safety reasons are those with a history of severe allergic reactions to one of the vaccine’s components.

So how bad is it? People with organ transplants seem to be worst off.

A study of 658 organ transplant patients who received the Pfizer or Moderna mRNA vaccines found only 15 per cent produced antibodies after the first dose. Even after two doses, almost half (46%) still had no antibody response.

“These data suggest that a substantial proportion of transplant recipients likely remain at risk for Covid-19 after two doses of mRNA vaccine,” the researchers concluded.

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Kidney specialist and Otago University Professor Rob Walker says both kidney transplant patients and those with kidney failure have depleted immune systems.

However, the vaccine response in dialysis patients is only about six per cent below that of normal healthy people.

Kidney patients are at much higher risk from Covid-19, meaning vaccination is still absolutely critical, Walker says.

Antibody levels also don’t tell the whole story, as other parts of the immune system could also provide protection.

“It doesn’t mean to say the vaccine is not providing protection. It’s not an all or nothing thing, at all. It’s just a change in the extent of the response.”

However, it does reinforce the need for everyone to be vaccinated, Walker says.

“Get vaccinated. It’s a no-brainer. Because it’s not only protecting yourself, it’s protecting everybody else.”

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The Pfizer vaccine is safe for immunosuppressed patients, but might not work as well.

Some arthritis patients also take immunosuppressant drugs. Rheumatoid arthritis is caused by the immune system mistakenly attacking the body’s own tissues, so immunosuppressants dampen down that attack.

Rheumatologist Dr William Taylor says the most significant drug used is rituximab, which affects the immune cells that make antibodies.

Rheumatoid arthritis patients usually take that once or twice a year, so specialists need to be able to time the vaccine for 4-6 months after their last course, to limit any effects.

Immune suppressant methotrexate and steroid drug prednisone might also impair vaccine response, but that could be managed by reducing dosage or skipping a treatment.

Taylor also reinforces the need for everyone to get vaccinated.

“If most of the population were protected to some degree, even if it’s not perfect, then that would reduce the spread and likelihood of infection … It’s a reason both for healthy people to get the vaccine, but also for people to get the vaccine even if it’s not 100 per cent effective. Because some protection is better than none.”

Cancer treatment can also weaken the immune system, which puts cancer patients at greater risk from Covid-19, and means they might not respond as well to the vaccine.

Cancer Society medical director Dr Chris Jackson says research suggests people undergoing chemotherapy for solid tumours have a weaker response to the first vaccine dose.

“But by the second vaccination dose, they appear to have close to normal immunity. So that’s extremely encouraging.”

Supplied

Chronic Lymphocytic Leukaemia sufferer and advocate Dr Neil Graham is one of more than 29,000 New Zealanders taking immune suppressing drugs.

What about blood cancers?

Dr Neil Graham calls himself a medical success story.

Diagnosed more than 20 years ago with blood cancer chronic lymphocytic leukaemia (CLL), he’s survived lung cancer and respiratory failure and still gets out for a 15km bike ride most days.

The reason the 70-something medical specialist has made it this far is an unfunded drug called ibrutinib.

But he knows the Covid vaccine is unlikely to work as well for him.

“Cancer of the blood is cancer of your immune system … In addition, the medication used to treat cancer will often result in the immune system being compromised by the treatment. So it’s a double-edged sword.”

With overseas Covid-19 death rates of about one in three for CLL patients, that’s worrying. But Graham has two hopes – that the vaccine will still protect him against severe disease. And that Kiwis who are unsure about having the vaccine, change their minds.

“Global herd immunity is going to be a very important question for people like me.”

Ross Giblin

Malaghan Institute clinical director and blood cancer specialist Dr Robert Weinkove believes the Government should consider making vaccinations compulsory for health and care workers treating immune-compromised patients.

Blood cancer specialist and Malaghan Institute clinical director Dr Robert Weinkove says reduced vaccine response is a huge issue for his patients. It’s critical that those patients get both doses to maximise their response, he says.

“In patients with chronic lymphocytic leukaemia, that are actively on treatment, only about 20 per cent will develop antibodies to the Covid vaccine. But even the low level of antibodies they make might be enough to make all the difference between getting sick with a bad flu, compared to being on a ventilator in intensive care.“

But it’s also critical that everyone around those people also gets vaccinated, to create a protective ring fence. There’s a good case for making vaccination compulsory for health or care workers looking after immune-compromised patients, he says.

“I would feel deeply uncomfortable treating some of the patients that I treat, without knowing I’d done all I can to prevent myself from giving them something.”

What’s the solution?

There are options for boosting weak immune responses.

A study of 30 organ transplant patients receiving a range of vaccines found a third dose boosted the response in some.

A different vaccine could also be given as a third booster dose, to rev up the immune system in a different way. Changing the vaccine dosage, or the spacing between doses, might also improve the response.

Weinkove says New Zealand needs treatment strategies to keep immune compromised patients out of intensive care, in case Covid breaks out in New Zealand. That might be antibody treatments – a kind of “infused immunity”, such as those taken by Donald Trump.

But everyone spoken to agrees the best protection for those at greatest risk from Covid is for all who can to get vaccinated.

If you think you don’t need the vaccine, Veronika Klingler has a message: ”It’s about thinking about your neighbour, your community, the most vulnerable people to protect.”

Supplied

Fran Priddy, clinical director of Vaccine Alliance Aotearoa NZ at Malaghan Institute, is studying vaccine responses in Kiwis.

Scientists don’t yet understand exactly how the body builds immunity to Covid-19.

“We think it’s neutralising antibodies, but we’re not sure,” says Dr Fran Priddy, clinical director of Vaccine Alliance Aotearoa New Zealand at the Malaghan Institute.

It’s not unusual for vaccine immune responses to vary, with some people producing as little as half as many antibodies, Priddy says.

The science isn’t yet advanced enough to predict whose immune systems will mount a gutsy response. But antibody production can decline with age and obese people can also have a lower immune response.

Priddy is running a study in Rotorua and Christchurch investigating New Zealanders’ Covid vaccine response.

A one-month post-vaccine snapshot should indicate whether our antibody production is similar to populations overseas. Follow-up of 6-12 months will show how that immune response might wane.

The study is focused on Māori, Pasifika and older people, as they’re more likely to get very sick or die if they contract Covid-19.

BENN BATHGATE/Stuff

Robert Bon Gillies, the last surviving member of the Maori Battalion, gets his Covid-19 vaccination.

The tricky thing is that no-one knows what antibody level is protective against Covid-19. So even a 50 per cent reduction in antibody levels might not make a vaccine ineffective, Priddy says.

“That doesn’t mean they’re not protected, even though that sounds huge.”

What it might mean, though, is that protection wears off more quickly. If someone has an initial response of 500, and that falls off by 100 points a month, their immunity will wane more quickly than someone with a starting response of 1000, Priddy says.

But it’s still worth getting vaccinated, as it will help prevent severe disease and limit the development of new variants, she says.

“The answer to every question is ‘Get the vaccine’.”