ASTS COVID 19 Strike Force Guidance to Members on the Evolving Pandemic

March 24, 2020

Below is a preliminary guidance document that has been prepared by Drs. Pruett and Teperman and has been reviewed by the ASTS Executive Committee. Please note that the guidance document represents suggestions from thoughtful individuals, and should be considered while taking into account each center’s resources, prevalence of COVID-19, and the individual patient’s needs.

Background:

 The world is being swept with a contagion of the novel coronavirus, COVID-19. COVID-19 appears to be predominantly a respiratory spectrum disease, but the virus may have other means of transmission.  The transplant community must prepare for a surge of people from the general population with acute respiratory failure that overwhelms the capacity of your hospital to perform its other functions. IF hospitals become overwhelmed, triage of who will/not receive care is going to occur.  Experience from other countries suggests that the elderly and those with preexisting morbidities such as COPD will fare poorly.  Other countries with limited resources have allowed some of these people to die. The ASTS is preparing guidance for our patients and the transplant community. We intend to keep you updated at regular intervals. 

By now, every center should have developed protocols to adhere to national standards regarding:

  1. The protection of healthcare providers,
  2. treatment of patients with the virus,
  3. prevention of transmission to other people.

The principles of social distancing, hand sanitization and respiratory caution for all of us and respiratory barrier protection for healthcare workers should be incorporated into ALL transplant program protocols.  Recently transplanted patients should follow respiratory principle and wear a mask when available.  The ASTS recommends that all programs assess program specific risk/benefit analyses in devising their own unique additions for the benefit of their staff and patients.

Transplant Events

  • Lifesaving and life altering transplants should continue to be performed
  • Living donations (assuming the recipient can wait) should be placed hold until the course of the US penetrance of COVID-19 is understood. 
  • Deceased donor transplants must be undertaken cautiously and considered on a case-by-case basis.   Consideration includes whether the facility has the current and future capacity to provide adequate post-operative care. 
    • Considerations should be given to availability of beds and adequate blood component supply
    • Testing of donors for COVID-19 should become a high priority, and recipients, also, if possible
  • The transplant team must evaluate each organ offer for the specific potential recipient in light of resource availability and total course, prior to deciding whether to proceed with transplant.
  • Informed consent processes and protocols should be assessed, so that recipients and families understand the risks and benefits during this uncertain time.
  • Induction immunosuppression places an organ recipient in a vulnerable state for many months and may jeopardize the survival or post-transplant care if the recipient contracts the virus.
    • There is a paucity of data, however, for safety we recommend limited use of induction therapy during this COVID-19 surge.  
    • Lymphocyte depletion should be used with great caution.  
  • Consideration must also include where and with whom convalescence will occur. 
    • Centers must factor what will happen if the patient or caregiver becomes exposed/infected with COVID-19?
      • Is there the capacity to quarantine, monitor and treat the recipient or caregiver?
  • Transplantation is not just the surgical procedure; it can include a protracted treatment that will likely be impacted by pandemic
  • It is possible that sick healthcare professionals will take care of sick patients.

Organ Acceptance and Donation

  • There is essentially no data on recipient risk associated with accepting an organ from an asymptomatic individual.
  • One should assume that it is likely to acquire COVID-19 disease from a blood entry pathway.
  • Whether donor derived COVID-19 outcomes differ from community acquisition remains to be assessed.
  • Prudence suggests that organs from positive donors not be accepted.
  • Testing of blood is being proposed, but it’s utility is also unknown.
  • Limitation in availability of blood and its component products is highly likely as the pandemic progresses.This resource limitation should be assessed for the safety of the recipients.

Waitlist Patients: 

  • Potential and actual transplant recipients are by definition an at-risk population.
  • They should minimize exposure and practice “social distancing”.
  • Until the true prevalence of virus is known within the community (adequate testing), it is prudent to postpone all routine visits.
  • Visits by telemedicine and increased use of phone consultations should be considered.
  • Limiting patient and healthcare contact during this time is advised.
  • For clinics that MUST go on, the general rule should be to minimize the exposure/risk to people.
  • We assume that general hospital protocols will stress that all clinics screen people for fever (with protocols to assess those for source of fever), have hand sanitizers conveniently placed throughout the waiting room and masks for anyone with cough.
  • Sufficient space needs to be available to enforce patient separation.
  • Transplant patients with a cough and fever should not be evaluated in an ED or a healthy clinic.
  • Testing sites are a national priority and should shortly be available to detect the presence of the virus.
  • It is important to follow local protocols for suspected patient infections.

Hospitalized patients:

  • While this should be under the purview of the aggregate healthcare system, all hospitals must have protocols in place to prevent person-to-person transmission.
  • As the number of COVID-19 patients increases in the hospital, it would be prudent to provide geographically (isolated floors, providers, support staff, traffic flow);
  • Patient visitors must also be limited.
  • Separated systems will keep the infected from the uninfected.
  • Transplant leadership should know and help evolve the plan for each transplant center.

Recipients:

  • Recipients should practice social distancing and all of the previous recommendations.
  • They should attempt to acquire a 90-day supply of their medications.
  • Communications with insurance providers should be attempted to reinforce the importance of continuous therapy.
  • Transplant recipients should contact their transplant center if they test positive or have symptoms of COVID-19.

Transplant Staff: 

  • Training regarding the proper use of protective gear, gloves, N95 masks and other self-protective methods should be available.
  • It is important that staff stay healthy in order to maintain the capacity to care for the immunosuppressed transplant patient.
  • To the extent feasible off-site, remote working and social distancing is prudent.

To reiterate, the above suggestions will need to be considered in light of each center’s resources, prevalence of COVID-19, and the individual patient’s needs.

The COVID-19 pandemic IS going to affect all our transplant practices.  The elected leadership of ASTS advises that we prepare for the worst and pray for the best. ASTS will continue to monitor the situation and provide advice and data at regular intervals.