Episode 28: Using Booster Shots to Increase Protection from COVID-19 for People with CKD with Dr. Jeffrey Hymes
For patients living with a chronic kidney disease, COVID-19 is a greater threat to their health than for others. That’s why the COVID-19 vaccines and subsequent booster shots are so important. Dr. Jeffrey Hymes, Executive Vice President and Global Head of Clinical Affairs for Fresenius Medical Care, and Chief Medical Officer and Chair of the Pharmacy and Therapeutics Committee for Fresenius Kidney Care, joins Field Notes to explain why boosters are necessary, why they are safe, and why they are so effective to protecting our patients.  

Brad Puffer: Welcome, everyone to this episode of Field Notes. I'm Brad Puffer, on the Medical Office Communications Team at Fresenius Medical Care North America, and your host for this discussion today. Here we interview the experts, researchers, physicians, and caregivers who bring experience, compassion, and insight into the work we do every day.

The COVID-19 pandemic has certainly impacted all of us. But for patients living with chronic kidney disease, COVID-19 creates a higher risk for complications and is a greater threat to their health. That's why the COVID-19 vaccines and subsequent booster shots are so important. They are a critical part of our efforts to keep our patients and communities safe. Well, why is it so essential for people living with kidney failure to receive this additional protection? And what do we know about how well they work in people living with kidney disease or other chronic illness?

Here to answer those questions and more is Dr. Jeffrey Hymes, Executive Vice President of Global Head of Clinical Affairs for Fresenius Medical Care. Dr. Hymes also serves as Chief Medical Officer for Fresenius Kidney Care, and Chair of the Pharmacy and Therapeutics Committee. As one of the company's pandemic response leaders, we're excited to have Dr. Hymes join us today. Dr. Hymes, welcome to Field Notes.

Dr. Jeffrey Hymes: Thank you, Brad. I'm glad to be here.

Brad Puffer: I wanted to start with just the basic question: Why are COVID-19 vaccines the key to helping us end this pandemic?

Dr. Jeffrey Hymes: Well, all vaccines are intended to prevent acquiring an infection. And so of course, the best way to prevent the spread of a disease like COVID is to keep people from getting it in the first place. Now it is also true that individuals who are vaccinated may still acquire the disease and have milder cases. I think one of the misunderstandings that's out there is that, even though you've been vaccinated, you still could be just as much of a spreader of COVID as somebody who's not vaccinated, and that is simply not true. If you don't get the disease, then you're not going to spread it.

If you are vaccinated and you do get COVID, your viral load that makes you able to spread it lasts for a shorter period of time. And in fact, you're probably about 2/3 less likely to infect somebody else, even if you do have a mild case as a vaccinated individual.

Brad Puffer: Yeah, that's a really important baseline for this conversation, Dr. Hymes. We spend a lot of time taking care of patients with chronic illness and chronic kidney disease. So what makes these booster doses, this third dose now available so important for that population?

Dr. Jeffrey Hymes: There are two characteristics of patients with chronic kidney disease that make a third dose, an additional dose important. The first is that, to some degree, more or less, most patients with chronic kidney disease have immunocompromised immune systems. In other words, they don't generate as vigorous a response to vaccinations as do healthy people. Further, we know that the antibody levels that develop in response to the vaccine tend to decrease over time.

So, both of those characteristics, a less vigorous initial response and a more rapid loss of the immunity, make it necessary to get extra doses to these patients. And the CDC has given us two options for doing that. The first is for patients who we think may be so immunocompromised that their initial response is going to be inadequate. And those individuals can get a third dose as soon as 28 days after they finish the second of the two-shot mRNA vaccine regimen.

However, all patients with CKD, regardless of how we evaluate their immune systems, are eligible to get a booster shot to overcome that decrease in antibody levels that occurs in many individuals. And they can get that booster shot six months or more after having completed the initial series.

Brad Puffer: It sounds like the recommendation is, if you have chronic kidney disease or perhaps any immunocompromised state, these booster doses are critical. And it's important for physicians working with these patients to advise their patients to get the booster.

Dr. Jeffrey Hymes: That's absolutely correct, Brad. We know that, unfortunately, this pandemic has hit patients with chronic kidney disease, as well as others with chronic illnesses, but CKD, in particular, and dialysis patients perhaps more than any other group, very, very hard.

The incidences of the disease, the severity of the disease, and the mortality of the disease in this group of patients is really, really serious and far worse than anybody had really anticipated two years ago. So, the ability to provide protection, and it's demonstrable that these patients do receive protection from the initial dose and from the booster dose is all the more important.

Brad Puffer: Well, that's certainly why I know our company has been aggressively working to educate people with kidney failure, employees, and physicians about these vaccines. And we want to ensure that every patient has access to them. What did we learn from our vaccine rollout earlier this year, where we distributed vaccine directly to patients in our centers? And do you think the message is getting out about their importance?

Dr. Jeffrey Hymes: You're right, that we rolled out vaccines widely in the early part of the vaccine availability. And we learned a number of things from it. First of all, we realized that we have to do a good job of educating patients and physicians about why vaccinations are important.

Secondly, we have to have a really well-oiled machine to get the vaccine distributed from the government to the clinics, really out to every location. As you know, we're in over 2,500 locations, some of them quite rural and some of them quite distant. So, it was an amazing effort on the part of our logistics crew that involved everybody, from nursing, technical, and operations, to create that distribution network. So, we learned that it was necessary and more importantly, we learned how to do it and how to do it well.

We also realized that speed was important. That in order to get the maximum benefit from these vaccinations, we need to get them out quickly, and we need them to get to patients rapidly when they become eligible.

Brad Puffer: And from what I've seen, it has been working. Patients are for the large majority, taking and getting this vaccine, realizing its importance. So, it seems like our efforts were working, and it sounds like we now need to translate that to this booster dose as well.

Dr. Jeffrey Hymes: That's absolutely correct. You may be aware that over the first few months before the dialysis providers were allowed to directly distribute vaccine over a period of a couple of months, about 75,000 of our patients got vaccinated. Once the vaccine was delivered directly to us as a dialysis provider, we vaccinated 75,000 patients in as little as two weeks. So yes, a very, very important effort.

Brad Puffer: Well, Dr. Hymes, there's been a lot of talk about breakthrough infections, and a lot of concern by people that might think, oh, breakthrough infections suggest the vaccines aren't working as well as advertised. If someone is vaccinated and still tests positive for COVID-19, the vaccine is offering protection from serious illness, correct?

Dr. Jeffrey Hymes: No vaccine is 100% effective, but these vaccines are very, very effective. And more importantly, not only do they provide that protection, but if somebody does acquire COVID, the fact that they are vaccinated makes it much more likely that the illness will be mild, and that they will be much less likely to be hospitalized or to die from it.

When we talk about our patients, our dialysis population, we see that the rate of breakthrough infection is quite low. Probably somewhere in the order of about 3% of our vaccinated individuals. But importantly, the rate of infection per 1,000 patients is one third of the rate that we see in unvaccinated patients. So, there's no doubt that despite being somewhat immunocompromised, our patients are getting substantial protection from COVID vaccination.

Brad Puffer: Actually, Dr. Hymes, let me just interject and ask, what are the mortality rates for unvaccinated people versus vaccinated? And are we seeing this issue exacerbated especially in our patients who are immunocompromised?

Dr. Jeffrey Hymes: I think to state the obvious, if you don't get COVID, you're not going to die from COVID. And we know that the mortality rate in dialysis patients can be quite high, between 25% and 40%. And so, when they're infected, so yes, it's inherently true that getting the vaccination will reduce mortality.

Then there's the second issue, which is, how does the vaccination itself change the course of the disease? And that is also evident, that the manifestations of the disease in a vaccinated patient are far less severe than in the unvaccinated patients. We see less hospitalization, and we see lower mortality rates.

Brad Puffer: Dr. Hymes, in our original partnership with the federal government, we were distributing the Pfizer-BioNTech vaccine. So, a lot of our patients receive that vaccine as their initial one. Can they now receive Moderna or Johnson & Johnson? What do we know at this point about mixing doses and if that works?

Dr. Jeffrey Hymes: You’re right, we primarily gave Pfizer to our patients initially, but the recommendations now from the FDA and the CDC, are that these messenger RNA vaccines are interchangeable. You can get Pfizer, for example, and be boosted with Moderna. You can get Moderna and be boosted with Pfizer. You can get J&J, Johnson & Johnson and be boosted with either of these. We are primarily, right now, using Moderna as our booster dose because it's a little bit easier to move around the country. Its temperature or storage requirements are less complicated, and so right now we're in the midst of boosting our patients with Moderna formula.

Brad Puffer: For those caregivers who may be working directly with people living with kidney failure, for example, and the physicians that might be listening to this, what is your ask? What are you hoping they can do to help make sure patients are vaccinated?

Dr. Jeffrey Hymes: Well, we know that most of the transmission that's occurred among individuals infected with COVID comes from friends and family, close contacts, and social events.

And so, it's so important for the caregivers and family of individuals with chronic kidney disease to get vaccinated to reduce the chance that they can spread that to the more vulnerable patients with CKD. The healthy individual, the caretaker may not have a severe case, but if the patient with chronic kidney disease gets that COVID infection, it certainly has much more dire potential.

Brad Puffer: So, it sounds like we need everybody to be talking about this and communicating this to ensure that patients get the message and get the information they need to make a decision and receive this booster.

Dr. Jeffrey Hymes: That's true, and there's a lot of misinformation that's out there right now about vaccines. A lot of bad information, both about its efficacy, as well as the side effects, the risks of getting vaccinated. I think probably the most important people we have in the health care system to make sure that the right message gets to the patients are our physicians. And so, we do rely heavily on our physicians to educate their patients and to encourage them to accept vaccination.

Brad Puffer: If there are people who have concerns or questions regarding these boosters and are just not sure, are there places they can turn to get more answers?

Dr. Jeffrey Hymes: Absolutely, within Fresenius of course, we have our Doctors Corner website with the COVID related information. We're always happy to take calls at the Medical Office within Fresenius Medical Care. The CDC has a website, which is easy to access, that has lots of easy-to-understand information about vaccination and about COVID, in particular. And so again, within the company, I would direct us to our internal resources. And outside, I'd direct us to the CDC.

Brad Puffer: And I would just add, Dr. Hymes, I know that if a patient happens to be listening too, there are lots of resources about the vaccine on Fresenius Kidney Care's website, so a number of different resources available, but it's always great to hear that you and others on the Medical Office team are willing to answer questions and respond as needed. I think the final question I should have for you is, did you receive your booster?

Dr. Jeffrey Hymes: Absolutely, I received my booster, and I received my flu shot. I got one on the right arm, one on the left arm, at the same time. And it was not an unpleasant experience, and I feel very lucky and very fortunate to have been able to do that.

Brad Puffer: Well, great to know, Dr. Hymes that you're vaccinated, as well. And good luck with the ongoing efforts to ensure that as many of our patients with chronic disease are vaccinated, as well as everybody else. And this will hopefully be informative to anybody who wants to learn a little bit more about their booster doses, and how important they are to protecting themselves and their loved ones. So, thanks for joining us today.

Dr. Jeffrey Hymes: Thank you, Brad. My pleasure.

Brad Puffer: And to our audience, thank you for joining us. Don't forget, you can find Field Notes on the Apple Store or Google Play, or right here at FMCNA.com, where you can also find our Annual Medical Report and other featured articles. If you have any questions about the COVID-19 vaccines, please contact your primary care physician or care delivery team.

And please if you're not already vaccinated, protect yourself and your loved ones by getting vaccinated today. Until next time, I'm Brad Puffer and you've been listening to Field Notes by Fresenius Medical Care. Take care, everyone.