Vaccines against SARS-CoV-2 are key to ending the COVID-19 pandemic, but their success depends on global availability and acceptance, as well as measures to protect the most vulnerable.
The COVID-19 pandemic has resulted in nearly 5 million deaths worldwide and has left many more people with long-term health problems, including poor kidney outcomes1. In response, the concerted global effort to develop effective vaccinations to reduce COVID-19 mortality has been a remarkable example of what can be achieved when scientific advances are backed by appropriate funding and resources. Several COVID-19 vaccines have now been approved and their real-world efficacy is evidenced by the inverse relationship between vaccination coverage, and COVID-19 hospitalizations and mortality2. However, in some individuals, the post-vaccination immune response is impaired, resulting in insufficient protection from poor outcomes.
In this issue, three Comments highlight not only the vulnerability of patients with kidney disease to SARS-CoV-2 infection but also their high risk of impaired vaccine-induced immunity. Patients who depend on immunosuppressive medications, such as transplant recipients or patients with immunity-mediated kidney disease, are at particular risk of poor vaccine outcomes. In addition, patients receiving haemodialysis, especially older individuals and those who use shared dialysis facilities, are at higher risk of SARS-CoV-2 infection and severe COVID-19 than the general population. Current vaccination approaches seem to be fairly effective in patients on dialysis but non-pharmacological measures to prevent infection, such as adequate ventilation in dialysis units and the use of face masks, remain essential. For patients with low antibody responses to the standard two doses of COVID-19 vaccine, whether because of treatment or disease-induced immunosuppression, personalized approaches to vaccination are recommended, including the monitoring of post-vaccine antibody levels as a correlate of protection, and the use of three primary and/or booster doses, where necessary. A growing body of evidence supports the benefit of three vaccine doses in vulnerable individuals but the benefits of providing boosters at the population level remain unclear.
For non-immunocompromised, healthy individuals, data collected thus far indicate clearly that COVID-19 vaccines are highly protective in the short term, but the duration of this immunity remains a crucial unknown. A preprint study suggests that protection against severe disease lasts at least 6 months in healthy individuals3. While longitudinal data are being collected, a debate has ensued about the rollout of vaccine boosters given the vast inequities in global vaccine distribution.
Indeed, the unequal distribution and availability of COVID-19 vaccines worldwide4 threatens their success. In the Majority World, where one-dose vaccination rates can be as low as <1%, mortality and the burden of long-term sequelae continue to rise; health-care systems and workers are under extreme pressure; and the economic devastation caused by illness and the efforts to limit the spread of infection continue to grow. Moreover, as demonstrated by the emergence of the Delta SARS-CoV-2 variant, the mantra ‘no one is safe until everyone is safe’ holds true. Initiatives such as COVAX aim to address vaccine affordability issues to improve global access but many barriers remain, including issues with vaccine supply5. Thus, careful management of vaccine boosters in high-income regions is important. While global vaccine distribution remains problematic, booster doses should be offered only to those individuals who are most vulnerable or at high risk of exposure.
Ensuring that as many individuals as possible have access to vaccines is imperative to stop this pandemic
Vaccines remain our best defence against COVID-19 but more must be done to ensure that everyone benefits from their protection. Individuals who are not adequately protected by current vaccination strategies might benefit from three primary doses, boosters or other mitigating strategies. In addition, global vaccine supplies and distribution to regions with low coverage must be urgently increased, along with education and transparent dissemination of information to counter vaccine mistrust and hesitancy, which have also emerged as substantial barriers to vaccination. Ensuring that as many individuals as possible have access to vaccines is imperative to stop this pandemic and create a path for recovery.
Bowe, B. et al. Kidney outcomes in long COVID. J. Am. Soc. Nephrol. https://doi.org/10.1681/ASN.2021060734 (2021).
Ledford, H. Six months of COVID vaccines: what 1.7 billion doses have taught scientists. Nature, https://www.nature.com/articles/d41586-021-01505-x (2021).
Thomas, S. J. et al. Six month safety and efficacy of the BNT162b2 mRNA COVID-19 vaccine. Preprint at https://doi.org/10.1101/2021.07.28.21261159 (2021).
United Nations Development Programme. Global dashboard for vaccine equity. Data.undp.org, https://data.undp.org/vaccineequity/accessibility/ (2021).
World Health Organization. What needs to change to enhance Covid-19 vaccine access. who.int, https://www.who.int/news/item/24-09-2021-what-needs-to-change-to-enhance-covid-19-vaccine-access (2021).
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Vaccines and the path to recovery. Nat Rev Nephrol 17, 783 (2021). https://doi.org/10.1038/s41581-021-00504-5