March 27, 2020
Background: Travel is a proven way to acquire and spread COVID-19, via close interaction with infected individuals. Acquisition and spread of the virus have been reported in the US through live and deceased donation events. The ASTS would like to remind transplant surgeons of important issues related to COVID-19. The virus is primarily spread between people in close contact (within about 6 feet), through the virions in respiratory droplets produced when an infected person coughs or sneezes. It is also possible to acquire COVID-19 infection by touching a surface or object that has the virus on it and then passing it to one’s own mouth, nose, or possibly eyes. However, this is thought to be much less efficient means of viral spread. However, respiratory and surface awareness is central to mitigation of COVID-19 spread.
Deceased Donor Evaluation: Until more is learned about transmissibility of the virus from deceased donors to organ recovery teams and/or to recipients, the ASTS recommends that organs from COVID-19-positive donors should NOT be recovered or transplanted. The ASTS recommends that deceased donor COVID-19 testing be performed on ALL deceased donors, while acknowledging that COVID-19 testing is rapidly evolving. With the current PCR-based testing, the most reliable specimen sample for testing is a BAL (90+%). The diagnostic value of BAL samples must be balanced against provider risk associated with aerosolization of respiratory secretions. Nasopharyngeal swab has a lower detection rate (60-75%). Viremia has been (uncommonly) detected, but raises the possibility of transmission through blood and organs. Recognition that current testing leaves a relative uncertainty about a negative diagnosis, it is important to consider the extent of community penetration in the donor hospital area. Irrespective of test results, donor COVID-19 infection should be strongly considered in the setting of a recent history of suspicious febrile or respiratory illness and/or chest CT with ground glass infiltrates.
There is additional information that is associated with sound decisions regarding donor suitability:
- Are there other patients in the donor ICU being treated for COVID-19 or unknown respiratory failure?
- Are there local ICU staff that have had confirmed or suspected COVID-19 infection?
- Are patients with proven or suspected COVID-19 infection cohorted or mixed with the general hospital population?
Rapidly evolving hospital practices necessitate that each donor evaluation includes all available and up-to-date information to assess risks for potential recipients and the team tasked with the identification and donor management, recovery and transportation of deceased donor organs.
Local Deceased Donor Recovery: The best way to prevent COVID-19 spread by a donor organ recovery team is to AVOID TRAVEL BY THE TEAM. ASTS strongly recommends that local teams be requested to recover organs and ship them to the recipient center for transplantation. There may be associated trust and quality issues, but the COVID-19 transmission risks (in and out of the area) will be reduced through implementation of local organ recovery. The ASTS recognizes that local recovery is a practice deviation for many programs, but considers the aggregate benefit to greatly outweigh the inconveniences. The ASTS COVID-19 Strike force would suggest that members use this forum/chat box, to discuss organ availability/quality/logistic issues and solutions that arise during the pandemic, so that the ideas may be disseminated broadly.
Deceased Donor Recovery Teams: The general principles of respiratory and contact protection should be practiced in all phases of travel/organ recovery. Travel wearing masks (Chinese recommendation is to change face mask every four hours) and eye protection. Wear clean scrubs from the home institution to the donor hospital, wash hands frequently, bring and use hand sanitizer after touching surfaces (wearing gloves still means that one must avoid touching face near nares or mouth). Change scrubs upon arrival to the donor facility. Be as purposeful with activity and avoid intra-hospital movement as feasible, such as to ICU or cafeteria). Discussions of procedural strategies with OPO and operative staff to minimize potential exposures should done prior to incision. Use of N95 masks and face shields during the retrieval procedure is prudent and recommended, especially if lungs are recovered. After organs are packaged, change scrubs and wash skin that was exposed to donor secretion (showering may be prudent) prior to traveling back to transplant center (either leave or package first set of travel scrubs in separate bags). Travel back with respiratory barriers, clean scrubs and clean hands. All teams should be cognizant of the stressful COVID-19 environment and be respectful of the OPO and local hospital staff.
Living organ donation: It is expected that live donation will be significantly curtailed during this pandemic. Any person with respiratory symptoms or fever should not donate. Asymptomatic people may harbor SARS-CoV-2 (the etiologic viral agent causing COVID-19 disease) and it is now clear that elective surgery may be followed by symptomatic disease. Therefore, it is prudent to screen all potential living donors as close as possible to the scheduled procedure (via nasopharyngeal swab); if positive, the donation should be postponed until the virus is no longer detected. Since nosocomial transmission to the donor is also possible, all health care providers who are expected to be in close contact with living organ donors should take standard respiratory precautions. Operating surgeons, anesthesia staff, recovery room, and hospital inpatient unit staffing as well as bed location of living donors should assessed to minimize contact with health care providers or other patients with fever, cough, or suspected or documented COVID-19 infection. Given the inherent uncertainty of donor outcomes during the COVID-19 pandemic, the risk/benefit analysis must account for changing and often unknown variables. While it is not necessarily required to stop all living donor procedures, it is expected that unanticipated outcomes be recognized.
There have been COVID-19 transmissions from healthcare workers to uninfected people. All transplant surgeons and programs should re-evaluate their informed consent processes, staffing strategies and workflow processes to address the changing risks for live donation. It is prudent to test live donors at the time of discharge to assess post-operative risk with the possibility that COVID-19 was present, but not detected on the pre-operative assessment. The latter recommendation assumes that testing is available and the nasopharyngeal test sensitivity remains consistent.