Adherence to preventive measures after SARS-CoV-2 vaccination and after awareness of antibody response in kidney transplant recipients in the Netherlands: a nationwide questionnaire study

Abstract

Background: Kidney transplant recipients (KTRs) were advised to tightly adhere to government recommendations to curb the spread of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) because of a high risk of morbidity and mortality and decreased immunogenicity after vaccination. The aim of this study was to analyse the change in adherence to preventive measures after vaccination and awareness of antibody response, and to evaluate its effectiveness.

Methods: In this large-scale, national questionnaire study, questionnaires were sent to 3531 KTRs enrolled in the Dutch RECOVAC studies, retrospectively asking for adherence to nine preventive measures on a 5-point Likert scale before and after SARS-CoV-2 vaccination and after awareness of antibody response. Blood samples were collected 28 days after the second vaccination. Antibody response was categorised as non-responder (≤50 BAU/mL), low-responder (>50 ≤ 300 BAU/mL) or high-responder (>300 BAU/mL), and shared with participants as a correlate of protection. Participants of whom demographics on sex and age, blood samples and completed questionnaires were available, were included. Our study took place between February 2021 and January 2022. The primary outcome of adherence before and after vaccination was assessed between August and October 2021 and compared via the Wilcoxon signed rank sum test. Logistic regression analysis was performed to estimate the association between antibody response and non-adherence, and adherence on acquiring SARS-CoV-2 infection. This study is registered at ClinicalTrials.gov (NCT04841785).

Findings: In 2939 KTRs (83%) who completed the first questionnaire on adherence to preventive measures, adherence was higher before than after vaccination (4.56, IQR 4.11-4.78 and 4.22, IQR 3.67-4.67, p < 0.001). Adherence after awareness of antibody response was analysed in 2399 KTRs (82%) of whom also blood samples were available, containing 949 non-responders, 500 low-responders and 950 high-responders. Compared to non-responders, low- and high-responders reported higher non-adherence. Higher adherence was associated with lower infection rates before and after vaccination (OR 0.67 [0.51-0.91], p = 0.008 and OR 0.48 [0.28-0.86], p = 0.010).

Interpretation: Adherence decreased after SARS-CoV-2 vaccination and in KTRs who were aware of a subsequent antibody response compared with those without. Preventive measures in this vulnerable group seem to be effective, regardless of vaccination status. This study starts a debate on sharing antibody results with the patient and future studies should elucidate whether decreased adherence in antibody responders is justified, also in view of future pandemics.

Funding: The Netherlands Organization for Health Research and Development and the Dutch Kidney Foundation.

Keywords: Adherence; Behavior; Kidney transplantation; SARS-CoV-2; Vaccination.

Fig. 1

Flow diagram of study inclusion for analysis 1 (change in adherence after severe acute respiratory syndrome coronavirus-2 vaccination) and analysis 2 (adherence after awareness of antibody response). KTRs, kidney transplant recipients.

Fig. 2

Boxplot for average adherence scores over all preventive measures before (4.56, interquartile range (IQR) 4.11–4.78) and after severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) vaccination (4.22, IQR 3.67–4.67) in kidney transplant recipients (KTRs). ∗∗∗Indicate a p-value of less than 0.001. Adherence to preventive measures was reported on a 5-point Likert scale, ranging from never (Likert score 1) to always (Likert score 5).

Fig. 3

Forest plot for non-adherence to preventive measures after awareness of antibody response by group, corrected for the final association model (age and previous severe acute respiratory syndrome coronavirus-2 infection), taking the non-responder group as reference (N = 949). Please see Supplementary Table S5 for defined odds ratio (OR), confidence interval (CI) and p-value.