INTRODUCTION
This is the second update of Coronavirus Disease 2019 (COVID-19). It is important to note that information about this disease and our understanding of this virus and its impact on transplantation is evolving rapidly so the guidance may change over time. We plan to regularly update the guidance as new information becomes available.
Since our initial guideline, COVID-19 has been declared a “public health emergency of international concern” by WHO. (https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200131-sitrep-11-ncov.pdf?sfvrsn=de7c0f7_4) Further, the disease has been given the name Coronavirus Disease 2019 (COVID-19) and is caused by the virus named SARS CoV-2. As of 26 February 2020, there are 81,109 confirmed cases globally in China, Iran, Italy, Japan, South Korea and 33 other countries (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/). Several countries are also reporting community transmission. As this is an emerging infection, we advise that, for decision making, careful attention to reports from local health authorities as well as review of updated data is essential.
EPIDEMIOLOGY
Initially limited to Wuhan, infection with COVID-19 is being reported from multiple Chinese cities (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/). Available data suggests the presence of “sustaining localised outbreaks” in multiple cities within China.1 This has led most health authorities to recommend that all of China be considered endemic for COVID-19. Most case definitions have incorporated exposure to anywhere in China in their case definition (https://emergency.cdc.gov/han/han00427.asp).
Recently, increases in rates in Japan, Korea, Iraq and Italy have heightened concerns that further spread is likely. In fact, there have been new cases identified outside these countries linked to exposure to them. Due to the change in locations experiencing local or national outbreaks, the relevant geographic exposure has expanded; the most up to date information can be found at relevant websites: https://www.gov.uk/guidance/wuhan-novel-coronavirus-information-for-the-public.
In countries experiencing community transmission, the case definition may have to be wider still. As such, it would be prudent consult updates from your country’s public health authority.
GENERAL COMMENTS ON CLINICAL FEATURES OF RELEVANCE TO TRANSPLANT PHYSICIANS
Initial case series have been published that provide a picture of the clinical spectrum of COVID-19 from centers in Wuhan.2,3 Imaging demonstrates pneumonia in the majority of patients that are hospitalized (75-100%). Patients with less severe infections may have lower rates of abnormalities. Further, there may be differences in indication for hospitalization around the world (China appears to be admitting the more severely ill patients while other countries are admitting all that are diagnosed for public health containment purposes).4 The current mortality rate in China is 2.9% of laboratory-confirmed cases (https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200213-sitrep-24-covid-19.pdf?sfvrsn=9a7406a4_4). There is a paucity of data on mild and asymptomatic infections which will alter these estimates.
Although many patients had co-morbidities in the reported series, none has been a transplant recipient to date. Hence a description of the disease in transplant recipients is still not available. Nevertheless the lymphocyte count was lower in those who required ICU care, and in those who perished.2 It is not possible to tell if lymphopenia was a manifestation of a more severe form of disease, or if it predisposed to severe disease. Many transplant recipients have medication-induced lymphopenia. Particularly close attention should be paid to transplant patients with suspected or confirmed COVID-19 infection who are lymphopenic. Such attention may include admission (rather than care at home) and paying careful heed to oxygen saturation.
Among comorbidities of interest, more patients who required ICU care had cardiovascular diseases, compared with those who did not require ICU care.2
Patient-to-patient, and patient-to-healthcare worker infection were described and human-to-human transmission has been confirmed.2,5 As such, strict infection prevention practices are essential.6
The mainstay of diagnostic testing is the use of PCR to detect presence of virus in samples collected from the respiratory tract of persons under investigation. Negative testing may occur early when patients are asymptomatic. (Personal communications, S Vasoo) One Thai person evacuated from Wuhan was negative for COVID-19 two days in a row; he then developed a mild flu-like illness 4 days after return at which point their swab confirmed infection.( https://www.who.int/docs/default-source/searo/thailand/20200208-tha-sitrep-03-ncov-final.pdf?sfvrsn=f2aa5c07_0)
TRANSPLANT SPECIFIC RECOMMENDATIONS
Current regions experiencing local/regional Transmission
- China
- Iran
- Northern Italy, especially
- Lombardy: Codogno, Castiglione d’Adda, Casalpusterlengo, Fombio, Maleo, Somaglia, Bertonico, Terranova dei Passerini, Castelgerundo and San Fiorano
- Veneto: Vo’ Euganeo
- Special Care Zones of South Korea: Daegu and Cheongdo
- Vietnam
- Cambodia
- Laos
- Myanmar
- Updated at: https://www.gov.uk/guidance/wuhan-novel-coronavirus-information-for-the-public.
DECEASED DONORS
Persons who returned from China, Iran, Italy, South Korea, Vietnam, Cambodia, Laos or Myanmar (See above regions of concern) or been exposed to a patient with confirmed or suspected COVID-19 within 14 days should not be accepted as a donor.
While the true risk of donor-derived transmission is unclear, RNAemia was reported in at least 15% in one case series.7
In a country with widespread community transmission, temporary suspension of the deceased donor program should be considered.
A tiered suspension may also be considered (i.e. deferral of more elective transplants, i.e. kidney, pancreas and heart transplantation for patients with VADs).This was the approach in Toronto during the SARS outbreak in 2003.8
There is no clear reason to suspend deceased donor transplants in countries only experiencing sporadic cases of COVID-19 cases.
Ongoing transmission of COVID-19 has been demonstrated in several countries including China, Iran, Italy, South Korea; updated data, available from WHO (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/) should be consulted regularly for updated decision making about donors with relevant exposures.1 “Community” cases in Singapore and Japan are being investigated for links with Chinese tourists/returnees.
Special consideration should be given to countries with under resourced healthcare systems and those with high rates of travel and trade with China, Japan, South Korea and Iran; they may not be reporting cases for lack of diagnostic capacity.
When diagnostic testing becomes more widely available, approaches to testing of potential at risk donors could be considered. Such approaches are not currently recommended.
LIVING-RELATED TRANSPLANTS
Living donation should not be performed on either a donor or recipient who has returned from China, Iran, Italy, South Korea, Vietnam, Cambodia, Laos or Myanmar (See above regions of concern) or been exposed to a patient with confirmed or suspected COVID-19 within 14 days.
In countries with widespread community transmission, temporary suspension of the living-donor kidney and liver transplant programs should be considered.
When diagnostic testing becomes more widely available, approaches to testing of potential at risk donors could be considered. Such approaches are not currently recommended.
If transplantation is required as a life-saving procedure, it can be conducted with appropriate assessment of infection in donor and recipient and with appropriate informed consent.
TRANSPLANT RECIPIENTS
Like all persons, transplant recipients should adhere to travel advisories issued by their respective health authorities/government bodies. This may necessitate postponing travel to China, Iran, Italy, Japan and South Korea.
TRANSPLANT RECIPIENTS RETURNING FROM ABROAD
There are two categories of patients here – those returning from a transplant performed abroad, and those returning from a holiday or work stint abroad. From an infection prevention viewpoint, both categories of patients may be managed similarly.
Teams should follow local health department guidelines for isolating, quarantining, testing, and monitoring returned travellers from endemic areas. Examples of such guidelines include (CDC: https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html; PHE: https://www.gov.uk/guidance/wuhan-novel-coronavirus-information-for-the-public#advice-for-travellers).
All patients who have returned from China, Iran, Italy, South Korea, Vietnam, Cambodia, Laos or Myanmar (See above regions of concern) or have been exposed to a confirmed or suspected case of COVID-19 within the previous 14 days should avoid elective clinic visits and surgical procedures (including bronchoscopies in lung transplant patients). Plans should be in place to get required laboratory testing of such patients during the 14 days in such way as to avoid potential exposure of other patients.
Staff who have returned from China, Iran, Italy, South Korea, Vietnam, Cambodia, Laos or Myanmar (See above regions of concern) or have been exposed to a confirmed or suspected case of COVID-19 within the last 14 days should follow hospital policies but should likely not care for transplant patients.
Transplant units should be prepared to receive patients who, for various reasons, have been abroad. They should be housed in single rooms with an attached bathroom, and all staff attending to them should be in full PPE, until infection with COVID-19 is ruled out. Close liaison is needed with other departments (eg, Radiology) whose services are likely needed. An effort to re-arrange schedules may be needed to permit spatial and temporal separation of patients awaiting COVID-19 “rule-out”. The incubation period, the asymptomatic shedder, negative PCRs early in the course of the disease combine to make “ruling out” a very difficult task.
The situation is fluid, and all recommendations thus far are made on thin data. Preventing transmission from an infected patient to a healthcare worker is of essence. Careful attention to infection control precautions are essential. As more information becomes available, these guidelines will be updated.
Fuente: TTS.org