Answering the call to action: rapid implementation of an in-center hemodialysis SARS-CoV-2 vaccination program.

To the editor:

The coronavirus pandemic resulted in devastatingly high rates of infection and mortality (up to 20% and 32%, respectively) for patients receiving in-center hemodialysis (ICHD). The arrival of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines was anxiously awaited. Large trials reported vaccine efficacy of 62% to 95%. , Data from other vaccines suggested benefit in kidney patients, despite attenuated immune responses. Given the devastating toll of coronavirus disease 2019 (COVID-19), and the kidney community’s call to action, we advocated for urgent provision of SARS-CoV-2 vaccines for patients receiving ICHD.

Patients receiving ICHD spend significant time on and traveling to dialysis; it is unfair and impractical for them to attend vaccination hubs separate from dialysis. A vaccine delivery group was formed to coordinate procurement, logistics, and delivery of SARS-CoV-2 vaccines on dialysis. This group comprised volunteers (nephrologists, nurses, and pharmacists) undertaking this work in addition to their clinical responsibilities. Each vaccinator completed mandatory vaccination e-Learning.

The Joint Committee on Vaccination and Immunisation granted permission to vaccinate a cohort of patients receiving ICHD ahead of the government schedule, provided we measured their immune responses. Once a limited number of vaccines were sourced from a community vaccination hub adjacent to a satellite dialysis center, the vaccine roll-out was piloted. Twenty-four hours later, the vaccination team assembled in the selected satellite dialysis unit and offered the vaccine to all patients attending the morning, afternoon, and twilight shifts. Crucially patients had already received verbal and written vaccine information. All patients were seen by a pair of vaccinators. Patients were screened for the presence of COVID-19 symptoms, receipt of other vaccines in the preceding 7 days, allergies, use of anticoagulants, pregnancy, and previous SARS-CoV-2 vaccination. A concerted effort was made to avoid vaccine wastage. Vaccines were administered while the patients were on the dialysis machine. As most patients had anticoagulation on dialysis, pressure was applied to the injection site for 2 minutes and patients were monitored for bleeding. There were no immediate adverse events.

Buoyed by the success of the pilot vaccination day, we extended the program to the rest of our dialysis population. We care for approximately 1500 patients on ICHD across 9 hemodialysis centers, and a vaccine was offered to all patients in these centers. The vaccine type (Pfizer or AstraZeneca), source (local primary care network or hospital trust), and plan for delivery was tailored to suit each center. Vaccine reconstitution and controlled release were carried out by on-site pharmacists or by trained members of the volunteer group. In one satellite unit, the nurse in charge escorted patients to the adjacent vaccination hub before or after their dialysis session. In the remaining units, the volunteer team carried out vaccinations following the processes just detailed. Initially, the vaccines used at the in-hospital hemodialysis unit were surplus doses from the staff vaccination hub. When vaccine was available, suitable patients were identified, consented, and vaccinated on dialysis. Soon we were allocated vaccine supply. Suitable inpatients were vaccinated with surplus doses.

Two recurrent problems became apparent: inconsistent vaccine supply and surplus doses. These were intrinsically linked as the lack of advance knowledge about vaccine availability hindered our ability to plan and invite patients for vaccination. In anticipation of surplus doses, a reserve list of patients able to travel at short notice was prepared. A third challenge was vaccine hesitancy. Patients expressed concerns pertaining to the speed of vaccine development and conspiracy theories related to 5G and Bill Gates. However, following discussion with trusted members of staff, <5% declined the vaccine when offered it and most were hugely grateful and relieved to receive it.

Through excellent organization, communication, perseverance, and voluntary teamwork, we were able to offer the vaccine to all ∼1500 patients on ICHD within 16 days of them being included in the vaccine priority schedule.