About one in 10 lung transplants in the United States now go to COVID-19 patients, according to data from the United Network for Organ Sharing, or UNOS.
The trend is raising questions about the ethics of allocating a scarce resource to people who have chosen not to be vaccinated against the coronavirus.
"They are accumulating on a steady basis. So it's very much a real thing," says David Klassen, chief medical officer for UNOS.
"If there were more lungs available for transplants, I believe the numbers would be greater than they are," he says.
In all, 238 people across the country have received lung transplants due to COVID-19 since the first such operations were tracked in August of 2020, according to the latest UNOS figures from October of this year.
Lung transplants for COVID patients rose tenfold between the first year of the pandemic and 2021, according to UNOS data, which also shows transplants for other top lung diseases, like emphysema, cystic fibrosis and pulmonary fibrosis, are down compared to prior years.
"It's happening in the U.S. It's also happening in Canada. There was just a paper out from Western Canada about this causing a huge surge in the number of lung transplants there. It's a big problem," says David Mulligan, chair of the Yale-New Haven Health Transplantation Center.
More than 2,000 lung transplant operations are usually done each year in the U.S., costing around $1.2 million for a double lung transplant.
The rise in COVID-related transplants is forcing doctors to grapple with how to best manage who gets them, especially now that vaccines are widely available.
"When somebody contracts such severe COVID that they need a lung transplant, and they got it refusing to get a vaccine, it's a really ethical dilemma," says Mulligan. "How can they just jump in and take a lung away from somebody who's sick, but has been doing the best they can to take care of themselves and avoid getting COVID?"
Ethics of non-judgment
Transplant centers weigh a lot of different factors when listing people who need an organ. But social and behavioral factors — such as how people came to be sick — are not usually among them.
People who smoked can be eligible for a lung transplant, just like people who drank alcohol in excess can also be listed for a new liver if they've stayed smoke-free or sober for six months.
Not judging people's past behavior is fairly standard in medicine. But future behavior, when it comes to transplants, is fair game, according to Olivia Kates, an assistant professor of medicine at Johns Hopkins.
"I think [COVID-19 patients] should be subject to the same expectation, that they should either be vaccinated or be able to demonstrate immunity to COVID-19 going forward, so that their next set of lungs is not subject to the same risk," Kates says.
Some transplant centers have said patients will lose their spot on the list if they are not vaccinated against coronavirus.
But some say eliminating anyone who hasn't had a COVID vaccine from even being considered for an organ may be unfair because it could exclude racial, religious or ethnic groups that have lower vaccination rates.
The current system of waitlisting people for transplant strives for equity and prioritizes "people who can't wait much longer for their organ, but if they get one, they have a good chance of being able to benefit and keep that organ," says Govind Persad, who teaches bioethics and health law at the University of Denver.
When a transplant is the only option
Candidates for lung transplants after COVID-19 are often young and otherwise healthy, like 41-year-old Vezna Hang. He got COVID in March of this year, not long after moving to Tampa from New York. His symptoms were barely noticeable, just a loss of taste and smell at first.
"One day, I just looked in the mirror and saw that my lips and my fingertips were blue," he says.
Hang had no underlying conditions. But COVID-19 caused inflammation in his lungs that led to permanent scars. A transplant was his only option.
"For the first moment in my life, I was scared. And from day to day, there were times that I honestly didn't think I was going to make it. And to leave behind my son, you know, that was heavily on my mind."
The father of a 5-year-old, Hang was not vaccinated when he fell ill. Florida didn't open up vaccine access to his age group, 40 and up, until late March, after he got sick.
But Hang understands people who are unsure about getting the shot. He says he was one of them before he got sick.
"This horrible virus hits everybody different. It's not predictable at all," Hang says.
"From what I experienced, being inside the hospital setting, and seeing all the people that weren't vaccinated being hospitalized, it really made me push to get myself vaccinated, my family and encourage my friends," he added.
The caregiver dilemma
There is no national, overarching policy on how to handle vaccine refusal when it comes to transplants. The American Society of Transplant Surgeons recommends vaccination for anyone awaiting a transplant. Doctors say that's because the immune response is stronger if a patient gets the vaccine before, rather than after, their transplant.
Deborah Adey, a kidney transplant specialist at the University of California San Francisco says that often it's not the patients who are difficult to convince.
"Where we have run into trouble has been with caregivers," says Adey, who has seen patients who were transplanted years ago fall dangerously ill with COVID after living with unvaccinated family members.
"There have always been anti-vaxxers around. That's not exactly new. But this degree of resistance to doing something for the public good? I've just never seen anything like this," Adey adds.
Community exposure poses serious risks, especially with a highly contagious variant like delta, says Kiran Dhanireddy, executive director of the transplant institute at Tampa General Hospital.
"Particularly in this last surge, we've had several transplant patients die of COVID" he says. "And these were patients that were for the majority vaccinated, but because their immune systems are suppressed, they don't mount a normal immunologic response to the vaccine, and therefore don't have the same degree of protection as a normal individual would."
People who live with donated organs must take immune-suppressing drugs for life in order to prevent their bodies from attacking and rejecting the new organs, making them more vulnerable to COVID-19 as long as it's around.