TORONTO -- They risk being exposed to COVID-19 multiple times a week, are more likely than the general population to be hospitalized with the virus, and have a mortality rate between 20 and 30 per cent.
This may sound like a description of those living in long-term care, but it’s actually about dialysis patients with chronic kidney failure — a group that doctors say has fallen through the cracks when it comes to vaccine priority.
“People are getting sick and people are dying and no one's paying attention,” Dr. Sanjay Pandeya, a kidney specialist, told CTVNews.ca in a phone interview.
Pandeya is president of the Canadian Society of Nephrology (CSN), and has been trying to raise awareness for months about the need for dialysis patients to be prioritized for vaccines. Hemodialysis and peritoneal dialysis are essential, ongoing treatments that filter toxins out of a patient’s blood after their kidney fails.
“In our chronic dialysis population in Ontario, we've had 750 [COVID-19] cases […] and 150 deaths,” he said.
Although some dialysis patients were included in the first phases of each province’s rollout of the vaccine because of their age or long-term care living settings, the lack of understanding that all dialysis patients are at a heightened risk has led to outbreaks in dialysis units and doctors scrambling to get their patients vaccinated, according to Pandeya.
One of the main problems is that those with chronic kidney failure receiving in-centre treatment are unable to follow the oft-repeated slogan of ‘just stay home.’
They have to travel to a hospital or medical centre around three times a week for dialysis treatment, which takes around four hours for each treatment. Without this treatment, they could die.
“They're very vulnerable because they cannot self-isolate,” Pandeya said. “And if they get it, because of their co-morbidities, their mortality is quite high.”
Dialysis patients often have a lot of overlapping risk factors, as they tend to be of higher ages or have other conditions that contribute to their vulnerability.
A study published in Canadian Medical Association Journal last month made the severity of the issue clear. The study tracked patients undergoing long-term dialysis in Ontario, and found that when dialysis patients contracted COVID-19, 62 per cent were hospitalized and 28 per cent died.
Data was gathered for the study between March and August 2020, and as of August 20, the case fatality rate for the province in general was 6.8 per cent.
This meant that the dialysis patients in the first wave were four times more likely to die of COVID-19 than the general population.
When the study was extended until January, around 20 per cent of the dialysis patients died due to the virus.
“These patients actually have a really striking mortality and morbidity, right on par with long-term care, actually,” Dr. Michelle Hladunewich, a nephrologist at Sunnybrook Hospital and a professor at the University of Toronto, told CTVNews.ca in a phone interview.
Pandeya pointed out that those in long-term care were immediately prioritized for vaccines.
In January, CSN sent a letter to the provincial and territorial ministers of health, asking them to consider prioritizing dialysis patients.
But across Canada, dialysis patients as a group were largely left out of the first phases of the vaccine rollout, which focused on other high-risk groups such as long-term care, health-care workers, remote Indigenous communities and older Canadians.
Only New Brunswick included dialysis patients specifically in its first stage of the vaccine rollout.
Now, as we move into spring, some provinces are shifting into new stages that do include dialysis patients among those who are prioritized.
But doctors are saying that this move should’ve been made earlier, and that confusion around who gets precedence when a vaccine phase includes numerous groups and ages could leave dialysis patients waiting weeks or months to receive vaccines -- all while visiting the hospital three times a week for life-sustaining treatment, leaving them more vulnerable to contracting COVID-19.
INSIDE ONE HOSPITAL’S STRUGGLE TO VACCINATE
At Sunnybrook Health Sciences Centre, in Toronto, Hladunewich and her colleagues in the dialysis unit saw the writing on the wall early on.
“We were witnessing really bad outcomes in our patients, like extraordinarily bad outcomes,” she said.
Hladunewich made sure to get patients included in Phase 1 vaccinated as soon as humanly possible.
“The minute I […] had permission based on the priority for age, I did everybody over 80, right. The minute they said, [those] getting home care [were eligible], I looked up every single dialysis patient on home care, and I did them,” she said.
Then it became her quest to ensure the other patients in the dialysis unit received vaccines.
“At times we had extra doses sometimes in a day, especially when we were doing all the health-care providers, there could have been drawn up doses that weren't being utilized,” she explained. “I was waiting most days and taking that to the dialysis unit. So we ended up vaccinating them […] sort of in bits and pieces.”
All those in her unit who wanted the vaccine have received at least one dose now, she said, but it took from January until now to achieve it.
“Had the severity of their condition been recognized, it would've been a lot easier to do them all as one as part of priority one,” she said.
There are around 12,000 patients who rely on dialysis in Ontario, and three out of four dialysis patients receive in-centre treatments as opposed to home care.
“The home dialysis patients also have a pretty high case fatality rate, but the highest risk is in the in-centre group,” Pandeya said.
Hladunewich said she has lost patients to the virus, and that those who survive COVID-19 are still more likely to suffer severe illness.
“One of our patients is still in hospital from the first wave,” Hladunewich said. She added that she had just checked in on the patient in question, and she had given Hladunewich permission to share the story.
“She said, ‘tell everybody to take care of themselves, cause it's terrible,’” Hladunewich said.
But not every hospital has been so proactive. She and Pandeya both said that several hospitals in Ontario had vaccinated their dialysis units only after an outbreak had swept through.
“It does make it very hard because everybody is trying very hard to follow the priorities sequencing,” Hladunewich said.
“It’s all catch up,” Pandeya added.
It’s a situation echoed in Quebec, according to Dr. Francois Madore, president of the Quebec Society of Nephrology.
“It varies from one region or one hospital to another,” he told CTVNews.ca in a phone interview. “Why not put a province-wide policy and prioritize these patients?”
Quebec was one of the provinces hit the hardest by the virus, and the dialysis community suffered as a result, Madore said. The death rate for their patients who got COVID-19 in the first wave was 28 per cent, like in Ontario.
There are around 5,000 dialysis patients in Quebec who receive in-centre treatments and around 900 who manage their condition at home, he said. Madore’s own clinic was one of the first dialysis units to suffer an outbreak in the country in the first wave.
“In the second wave, we had almost 30 patients as well who tested positive for COVID-19,” he said.
But according to Madore, the province’s vaccine plan is vague when it comes to those with chronic health conditions.
Quebec’s vaccine rollout is done in 10 stages, and currently most regions are at the seventh stage, vaccinating people 60 to 69 years of age. Dialysis patients aren’t mentioned specifically in the plan — those who are not eligible due to their age would presumably become eligible in the eighth stage, which specifies “adults under 60 years of age who have a chronic disease or health problem that increases the risk of complications of COVID 19.”
“So the people with chronic conditions will be prioritized, but you don't even know exactly how this priority will take place,” Madore said.
THE VACCINE SCENE MOVING FORWARD
This week, or soon after, many provinces are entering new stages of their rollout.
In Manitoba, as of March 29, the AstraZeneca vaccine will be offered to those with a high-risk condition between the ages of 55 - 64 years, with dialysis patients listed among those receiving first priority.
British Columbia, Newfoundland and Labrador, Prince Edward Island and Ontario shift into new phases at the start of April that include those with kidney disease as one of the high-risk groups to be vaccinated.
Alberta will be vaccinating those 16 - 64 years of age with high-risk health conditions, including dialysis patients, starting Tuesday.
And Saskatchewan has been vaccinating those who are extremely clinically vulnerable, including dialysis patients, since its Phase 2 began on March 18.
But the sheer number of people covered in these new phases muddy the waters, doctors say.
While some provinces have more detailed priority lists, it’s uncertain in other provinces, like Quebec, whether specific chronic conditions will garner a sooner vaccination date than others, Madore pointed out, or whether it will run on a first-come, first-serve basis.
“How are dialysis patients going to be evaluated in this general system?” Madore said. “Others [may have] just hypertension, but if you have chronic kidney disease, you're on dialysis, you have diabetes, well, shouldn't you be prioritized differently?”
With variants on the rise, if dialysis patients have to wait weeks or months for vaccines, they’re more at risk than others because they’re unable to self-isolate.
“There's many chronic conditions that are higher risk, but they're not necessarily coming to a hospital three times a week for life-sustaining therapy,” Hladunewich said. “These guys cannot isolate. And many of them have to take public transit or wheel trans or Ubers and taxis to get here. And many of them have actually gotten the virus due to the transport.”
“You have all those touch points and they do it 150 times a year,” Pandeya added.
Hladunewich expressed relief that dialysis patients in Ontario are front of the line in Phase 2, which begins this week.
But it brings up another concern for her. Ontario shifted strategies in March regarding the second dose of vaccines, and now those who receive their vaccine as part of Phase 2 will have to wait around four months to receive another dose.
“I'm extremely worried about the notion that they're getting a single dose as part of priority two, with another dose not coming for four months,” Hladunewich said. “We don’t know that that’s safe in this population.
“And there's probably not another patient population with equal mortality where we're doing that. Long-term care, all the priority one groups were given two doses, and that's one of the things I'm extremely concerned about.”
She added that dialysis patients often don’t respond as well to vaccination as other groups do.
She believes provinces should consider ensuring that dialysis patients receive the second dose of their vaccine within the recommended time limit proposed by the manufacturer.
It would also be easy to vaccinate this population quickly, she pointed out, because they are always at the hospital.
“They all come in three times a week, it’s literally the easiest thing to do,” she said.
Although it’s too late in most provinces to add dialysis patients to the first phase of vaccines, it’s not too late to ensure that dialysis patients are prioritized moving forward, Pandeya said.
He emphasized that he understands there’s a lot of aspects to weigh in creating the vaccine priority lists, and that governments are working under a lot of stress and considerations, but he believes the data regarding the need for dialysis patients to receive more attention is clear.
“It strains credulity that it's not in your face as to why this population [needs vaccines],” he said.
“I got into the business of medicine to save lives and I think this [decision] saves lives. And I think it's an easy decision.”
