In most centres in Sub-Saharan Africa, we do not do emergency transplantation. Most common organ transplanted is Kidney. Most centres in countries that have transplant service offer living donation apart from centres in South Africa that also offer deceased donor transplantation. Presently, transplant centres have suspended transplant activities. The RRT patients are being advised on how to protect themselves. Some do tele-consulting to keep up with management of patients. The acute and most cogent problem for transplant patients in some countries is difficulty with sourcing their medications with all borders closed. The international community and governments need to do something urgently about this! I am informed that one of our transplant patients who came back to Nigeria from Europe recently died in hospital where he presented at the A&E Dept acutely ill. He was confirmed to have died from COVID 19.

The South African population have varying levels of economic development; however, a large percentage belong to the low- and middle-income population groups. With the onset of COVID-19 in our country, we are especially concerned about the resources available, specifically in the state sector hospitals. Unfortunately, in South Africa, there is a poorly and unevenly structured health care service: 85% of our population is depending on the state sector for medical care, but the resources are mostly situated in the private sector. In large parts of the country we have limited ICU capacity and ventilators and therefore we are currently making contingency plans for critically ill patients. The availability of transplantation services are also constrained by the availability of specialist physicians and surgeons and pathology facilities. Transplant services in the state sector have stopped. In the private sector there is still capacity for transplant services, but this is limited by a lack of deceased donors. In the Western Cape most donors come from the state sector hospitals, resulting in a lack of organs available for transplantation. Living donation has come to a complete standstill in South Africa. Deceased transplantation will continue to take place in facilities that have enough staff and infrastructure available. In most state hospitals this is not possible or feasible, due to a lack of deceased donors and health care resources. We are currently trying to reduce our outpatient workload and concentrating on discharging non urgent cases from the hospital. South Africa is locking down as of 25 March 2020 and nobody will be allowed to travel. All restaurants have been closed and only essential services are taking place.

South Africa also has some of the highest rates of HIV and TB in the world which we fear might result in an increased mortality from COVID-19 if the virus spreads widely in our population.

Across the rest of sub-Saharan Africa, in those places where transplantation is active, almost all living donor transplantation has ceased and there is no deceased organ donation. No transplant patients have yet been identified with COVID-19 and logistical problems of clinical follow up and drug supply are the major issues at present.   

Submitted by Nancy Kwan Man

In response to the COVID-19 outbreak, general infection control measures in the Hong Kong public health system include universal masking in all hospitals and clinics, routine temperature screening and travel history checking for all hospital visitors. Febrile patients were managed in segregated area. From mid-March onwards, medical staff who return from overseas travel have been instructed to refrain from going to their workplace for 14 days and undergo self-isolation at home.
For the transplant-specific measures, deceased donors are screened for COVID-19 infection if they have recent travel history or positive contact history. In general, transplant candidate is not recommended to undergo transplantation within 14 days of return from travel. Living donation is not advised to be performed within 14 days of return from travel. Out-patient follow-up of transplant recipients continues. In order to limit the number of visitors in the hospital, stable transplant cases are allowed to space out their follow-up visit with interval blood taking.
Living donor kidney transplantation (LDKT) has been suspended in Hong Kong since mid-February 2020. Deceased donor kidney transplant (DDKT) continues and we have total of 12 DDKT between January to March 2020. One of our kidney transplant recipients was infected with COVID-19 on the Diamond Princess Cruise. She was treated with lopinavir/ritonavir monotherapy and viral clearance was achieved despite continuation of immunosuppressant. Lopinavir/ritonavir is an inhibitor of CYP3A and we do observe drug interaction with calcineurin inhibitor. Patient tolerated the anti-viral treatment well except mild gastrointestinal side effects including nausea and diarrhoea.
Because of the low deceased donor donation rate, only 2 heart transplantation and 2 lung transplantations were performed since January 2020.

Submitted by Dr Maggie Ma (Vice President of HKST) on behalf of the Hong Kong Society of Transplantation

Hong Kong experiences a surge of COVID-19 since mid-March as there was huge influx of Hong Kong Resident (including students and traveler) returning back to Hong Kong after the global pandemic. As of 8 April 2020, there are total of 960 confirmed COVID-19 cases and 4 deaths. We initiate early anti-viral treatment irrespective of symptomatology and adjust the anti-viral regime according to viral titre. Whether such approach contributes to the low mortality in Hong Kong requires further studies.

One of our kidney transplant recipients was infected with COVID-19 on the Diamond Princess Cruise. She was treated with lopinavir/ritonavir monotherapy. She achieves viral clearence in around 2 weeks. She was monitor closely for 2 more weeks after initial clearance of virus and had been discharged after 4-week hospitalization. Lopinavir/ritonavir is an inhibitor of CYP3A and we observed significant drug interaction with calcineurin inhibitor. Allograft function remains stable after meticulous titration of immunosuppressant. Patient tolerated the anti-viral treatment well except mild gastrointestinal side effects including nausea and diarrhoea.

During the COVID-19 outbreak, living donor kidney transplantation (LDKT) has been suspended in Hong Kong since mid-February 2020. All other organ transplantation programs continue. The number of transplantation operations performed between January to March 2020 were summarized in Table 1.

Table 1. Transplantation statistics in Hong Kong between January to March 2020

As of March, 25th, 2020, there have been 410 cases of COVID 19 in Hong Kong with a population of just under 8 million. Since the first outbreak in January 2020, we saw an initial surge in the number of infections by mid-February 2020 after the Chinese New Year, followed by a rapid decline in the number of cases from late February to early March (averaging 2-3 cases per day). However, with the recent global increase, we have seen a huge influx of returning local residents to Hong Kong. As a result, we are now witnessing a second surge in the number of new cases with over 100 new cases reported just within one week.

The liver transplant service at Queen Mary Hospital has seen a 50% reduction in elective living donor liver transplants (LDLT) in response to the hospital’s request to optimize the utilization of available PPE for frontline staff in ICU and isolation wards and to assure the availability of healthcare providers to fight the infection. LDLT for urgent conditions, however, remained unaffected. On the other hand, deceased donor liver transplantation service was severely affected with an all-time low organ donation rate from brain dead donors and only 2 DDLT occurred in February. Paradoxically, there has been a sharp increment in the number of LDLT, mostly for liver failure. As of today, a total of 12 LDLTs have been performed as compared to 5 LDLTs in the previous year. Both potential living donors and recipients are only screened for COVID infection if they have symptoms, or a history of recent travels. For deceased donors, screening is only performed in the presence of clinical symptoms, or a recent travel history.

China Shanghai, April 4 2020
Xiaowu Huang, Xin Wang, Jia Fan, Jian Zhou*
Zhongshan Hospital, Fudan University, Shanghai
As of April 4, 2020, a total of 529 patients with coronavirus disease-19 (COVID-19) pneumonia were confirmed in Shanghai, including 6 deaths. On March 24, 2020, the Shanghai Municipal Government adjusted the city's major public health emergency response level from first-level response, launched on January 24 this year, to second-level response.
Shanghai's major hospitals, medical staff and supplies have been mobilized urgently in response to the global pandemic. From the end of January elective admissions and surgery were stopped to allow personal protective equipment to be conserved for prevention and control of the epidemic. In addition more than 1500 Shanghai medical staff and hundred tons of medical equipment were dispatched to Wuhan city of Hubei Province, the response to COVID-19 .
On February 23, the Organ Transplantation Branch of the Chinese Medical Association issued "Guidelines for organ donation and transplantation in China during novel coronavirus pneumonia epidemic." Under the guidance of this consensus, organ donation and transplantation in Shanghai continued despite the difficulties, noting the urgency for some patients.
The main risks of organ donation and transplantation during the epidemic include: (1) The donor is in critical condition in ICU and thus susceptible to COVID-19. During the treatment and donation process, cross-infect is a risk for the recipient, coordinator and medical staff. (2) Organ donation and transplantation represent a significant for cross infection not conducive to epidemiology prevention and control measures. To reduce this risk we have adopted the following measures: (1) conducting a strict epidemiological survey of donors, recipients and their family members; (2) collecting detailed medical history of donors and recipients and performing chest CT, Virus-related testing to exclude COVID-19; (3) Strengthen the coordinator and medical staff's awareness of epidemic prevention by referring to the guidelines and regulations for the Public Protection of New Coronavirus Pneumonia.
The decline in population activity due to the lockdown of the city, as well as the impact of strict anti-epidemic measures and requirements, has significantly reduced the number of deceased donors. Within the first two months a total of only 6 organ donations were performed in Shanghai, compared with 13 in the same period last year. China’s domestic traffic has not been completely halted, except for Hubei Province. The major hospitals in Shanghai have thus continued to obtain organ donations from other provinces, distributed through the China national organ distribution network. The total number of transplants has thus not been greatly affected with a total of 123 liver transplants, 93 kidney transplants, 4 heart transplants, and 1 lung transplants completed in Shanghai during the period, which is similar to the same period last year. No one involved in these transplants, including donors, recipients and their families, medical staff and coordinators have been diagnosed or suspected as COVID-19 positive.
Minimizing transplant recipient exposure to potential infection risk is important and thus, if the recipient's condition is stable, we delay the follow-up visits and extend intervals. Most Shanghai hospitals have established an online service. Zhongshan hospital has established an Internet-Hospital platform, in which patients can consult doctors or coordinators using mobile phone or computer to access medical advice and instructions as well as knowledge of COVID-19 epidemic. Patients presenting with fever and pulmonary inflammation are screened to exclude COVID-19 using COVID-19, testing for nucleic acid or IgM and IgG antibodies for new coronavirus. Those who must be admitted to the hospital receive routine blood tests, chest CT and C-reactive protein to exclude COVID-19 before admission. The management of our transplant wards follows standard precautionary measures, with use of personal protection equipment, hand hygiene, environmental ventilation, cleaning and disinfection of surfaces, and medical waste management.

Compared with a total number of 67000 cases of COVID-19 in Hubei Province, only total of 22 cases were confirmed in organ transplant recipients. There were 19 kidney and 3 liver transplant patients diagnosed since the day of Wuhan’s closure on January 23. We believe this is largely due to years of health follow-up education for transplant recipients. Transplant patients have a better sense of self-protection especially wearing masks during intense influenza seasons. This provides additional evidence that transplant patients can protect themselves from infection with SARS-COV-2 using distancing, masking, hand washing and self isolating measures, even though their immunity is lower than normal.

Treatment of COVID-19 positive transplant patients was undertaken by reduction or discontinuation of immunosuppression, combined with strengthened supportive treatment according to the severity of lung lesion in patients. According to Chinese national COVID-19 treatment guidelines and our experience in the treatment of cytomegalovirus pneumonia, we made use of low-dose methylprednisolone. One of the 22 transplant patients died, the others have recovered and been discharged. After summarizing our actual treatment results in time, we immediately prepared and published new guidance on organ transplantation during the COVID-19 epidemic, and communicated with the colleagues from Chinese Organ Transplant Society through several remote video conferences, which provided guidance for the prevention and control of SARS-COV-2 infection in organ transplant recipients in other regions effectively.

In the epidemic area, the follow-up of transplant patients has been greatly affected due to the lockdown on the movement of people. In order to avoid the risk of cross-infection, we consult and deal with simple clinical problems using the hospital online outpatient consultation platform. In cooperation with courier companies, the blood samples of transplant patients were sent to the transplant centers for CNI concentration detection to allow us to guide the patients with the dosage adjustment of immunosuppressants remotely.

In the epidemic area, organ donation had stopped due to the blockage of Wuhan, risk of potential infection, as well as the heavy treatment pressure in ICU. At present, the epidemic situation in Wuhan and China has been basically controlled, and social life is gradually recovering with an emergence of new potential donors. Moreover, we are working on the protocols for evaluation and determination of organ donation of organ to ensure the safety of recipients and medical workers.

No organ transplant surgery was carried out during the COVID-19 epidemic, even living donor organ transplantation between relatives, because we have been concerned about the risk of infection and also we did not have sufficient medical resources. We now hope that the work of transplantation can recover gradually without the risk of infection in all donors, patients and our medical staff following the passing of the epidemic situation.

China, Wuxi Update 4th April 2020
Jing-Yu Chen

Wuxi Lung Transplant Center, Wuxi People’s Hospital, Nanjing Medical University, Wuxi, Jiangsu, China  

Lung transplantation may be a therapeutic option for the end stage pulmonary fibrosis resulting from acute respiratory distress syndrome from COVID-19.

We report three cases of lung transplantation for post-COVID-19 patients, as a salvage therapy. Two of the three recipients survived post-transplantation and started rehabilitation programs. All three patients required mechanical ventilation and extracorporeal membrane oxygenation (ECMO) support before transplantation. Patients 2 and 3 are up to days 12 and 22 of follow up to date.

The following three critical points were thoroughly evaluated and confirmed before deciding to proceed to Lung transplantation: (1) confirmed irreversibility of refractory respiratory failure despite maximal medical support; (2) confirmed SARS-CoV2 test positive but then confirmed negative virology status by consecutive nucleic acid tests with samples derived from multiple sites; and (3) confirmed absence of other organ system dysfunction that could contraindicate lung transplantation.

For the protection against infection of the medical team: (1) Full head covers with positive pressure  for surgeons, nurses, anesthesiologists, and cardiopulmonary physicians; (2) head covers while providing surgeons a clear field of view clear, the disadvantage is that they will negatively impact sound communication between physicians and from the alerts from monitors which the team must be alert for; (3) because of the physical demands and challenges for surgeons in full protective clothing, an intra-procedure staff rotation plan is necessary to guarantee optimal surgery; (4) remote video communication or coordinators able to be responsible for communicating between external staff and those inside the operating room; (5) all operative medical staffs need to rehearsed the procedure before surgery including gestures and actions to allow for nonverbal communication during surgery.

With careful protection and complete preparation, the success of lung transplantation may be contemplated to tackle the high mortality of end-stage COVID-19 patients.

Submitted by Shrirang Bichu, Bombay Hospital, Mumbai

On March 24, 2020 Government of India ordered a country wide complete curfew lockdown for 21 days.  Interstate borders are sealed except for essential supplies. Complete cordoning of smaller areas where COVID 19 patients were detected, is being carried out to contain the infection. The official count of confirmed cases as of today is 3374 with 77 deaths. Four states - Maharashtra, Kerala, Tamil Nadu and Delhi have been affected much more than the others. The first case in India was detected at around the same time as was in Italy. Although it could argued that the comparatively smaller numbers in India is a result of selected testing, even in the city like Mumbai with a population of 20 million and having the largest number of cases in the country (454 as of today), we do not find intensive care units burdened with COVID-19 patients and only a handful of cases are on ventilatory support in the city. It is too early to say what the impact of the virus pandemic will be in India. The trends in the next two weeks will be crucial to understand this while the current lockdown ends in 9 days with no further plans announced yet. The lockdown has severely affected routine medical services and only emergency services are offered by all hospitals.
Testing kits, PPE and essential equipment is being acquired in large numbers to cater to the impending increase in the number cases. In Mumbai five large private hospitals and three large government hospitals have been earmarked for COVID19 patients. Separate haemodialysis units for suspected and confirmed cases are being set up. On the social front, the central government is giving free supplies of food rations and direct cash transfers to the economically challenged.  Both the central and state governments are making huge efforts to support the country.
Thus, far there is just one confirmed case of COVID 19 infection in a kidney transplant recipient in Mumbai, Maharashtra. There are no cases reported from Kerala, Delhi, Gujarat and Goa. Maharashtra, Kerala and Delhi are amongst the four states with highest number of COVID19 cases in India. This single confirmed case is not needing intensive care and is being managed with keeping tacrolimus level low and hydroxychloroquine.

India took relatively early steps by stopping air traffic with affected countries and had limited the inflow of passengers to only returning Indian citizens together with airlifting of stranded Indian citizens in affected countries with COVID-19 testing prior to travel or on arrival and with strict quarantine.

Initial limitation of kits for testing meant that the test was offered only to the few who were suspected on the basis of symptoms and travel history. Testing is now available in large numbers through private laboratories and a number of private hospitals. We anticipate that the true trend in the number of infected cases will become evident and will assist us to know whether the relatively early intervention by the central government has helped.

There is poor adherence to calls for social distancing, though in the last two days more people have come to terms with the likely reality and following social distancing with some seriousness. This is mainly because of the lockdown imposed by government – a near curfew not witnessed before even during the religious riots in 1992. However, domestic trains returning migrants to their hometowns in other states were crowded. All international flights, domestic flights and long-distance railways have stopped. Interstate transport has stopped. People have been asked to work from home. Government offices are working at 20 percent capacity. All non-essential services have been stopped and total lock down has been ordered.

Hospitals have been asked to treat only emergency cases and routine outpatient clinics in hospitals have been put on hold. We have moved to online consultation wherever necessary. We are admitting only patients who need urgent attention or those that will potentially worsen without admission. All non-emergent surgeries have been stopped.

Governments particularly in large cities are making huge efforts to take on the situation that will arise with exponentially growth in three or four weeks. In Mumbai a large hospital with 1200 beds capacity has been earmarked for COVID-19 positive patients. All large private hospitals have been ordered to reserve a certain number of beds for COVID 19 patients. Since the number of known patients is still small, it is too early to understand how things will unfold. We also face hoarding. For example, a large number of N95 masks have been bought by the wealthier members of the general public leaving a huge deficit preventing protection of healthcare workers. As reports of the possible benefit of chloroquine and hydroxychloroquine started circulating, hydroxychloroquine ran out of stock in most pharmacies.

Live donor transplants have stopped across Mumbai, but each hospital is taking its own decision outside Mumbai as of today. Deceased donor kidney transplants have also stopped in Mumbai and in the region. There is no national direction from NOTTO, or from the regional body ROTTO, to stop deceased donor liver and heart transplants yet.

All non-emergency work is on hold. Chronic care patients are being encouraged to get blood tests done and then connect on phone by voice or video call to their physician. We have also instituted zero waiting time for transplant patients if they are compelled to visit the hospital. All patients have been asked to keep a minimum one month’s medicine stock. The Apex Foundation in Mumbai has resolved to support transplant patients running out of money because of loss of job/wages since many are entering a very difficult economic situation.

Indians stranded across the world have been evacuated, quarantined, tested and discharged when negative. Southern states, such as Kerala & Tamilnadu have shut down domestic borders, temperature tests are done to screen those in cars and trains and the Government has just ordered a nationwide lockdown. Schools & universities have shut, so are swimming pools, gyms, malls and movie theatres. Weddings and other public gatherings are banned. There has been an increase in the number of the research labs approved for testing for coronavirus. Government directives and guidelines have been released to provide for measures and infrastructure changes to hospitals to tackle the expected explosion in cases coming. Private & public sector hospitals are gearing up with stringent screening measures, emergency room triage areas, dedicated isolated COVID-19 floors with beds & ICU. Healthcare workers are being trained to work efficiently and safely during the crisis. Any optimism needs to be tempered. The sobering thought that if, in fact the low incidence of disease to date, the small number of patients in Intensive care and the limited mortality above observed in India to date are wrong, then India with its archaic public health system, one of the lowest per capita ICU bed ratios in the world, lack of adequately trained personnel and a large impoverished rural and slum population, will hopelessly careen towards a catastrophic health crisis. It will be an economic and social disaster, from which India might takes decades to recover.

The country is seeing a steadily increasing number of patients each day. Testing capacity is increasing, but remains insufficient. The Japanese Society for Transplantation published a guideline on March 6th 2020 aiming to prevent transmission from donors and prevent infection of recipients as well as protect medical professionals.

Japan continues life-saving transplantation with informed consent about the risks for heart, lung and Status 1 liver recipients, but it has been recommended to postpone kidney, pancreas, and bowel transplants. We recommend test screening of those with significant exposure to COVID 19, travel history to high risk countries, or with fever and respiratory symptoms. But NAT testing is not mandatory for donors though preferable. It is recommended that living donors for kidney, lung and liver transplant stay at home or isolated in hospital for 14 days prior to the donation to avoid unnecessary exposure. Where testing is available, it is recommended 14 days and 1 day before transplantation in both donors and recipients. Chest CT scan is also recommended before transplantation in donors and recipients.

We recommend education of all transplant patients about general procedures to avoid infection, extended periods between outpatient visits for as long as possible and prescription of additional drugs to prepare for possible national lockdown. We have recommended preparation of institutional policies on acceptance of transplanted patients with COVID19 and extensive use of the telephone for follow up of patients.

We postponed living donor transplantations in March, with the exception of one Liver transplantation at national cancer center on Friday 13 March. To prevent transplant patients being at risk from the general public, follow up of patients is occurring on Saturdays and in clinics isolated from general hospital care. Transplant coordinators are communicating through doctors in the provinces to reduce intercity travel visits and as much consulting is being done through the phone with both primary care doctors and patients. As of today, due to international flight restrictions, we now have very limited supplies of some immunosuppresant drugs.

Singapore took early measures to screen and isolate suspected COVID-19 cases from Jan 2nd 2020. Hospitals were at heightened vigilance setting up multidisciplinary command centers, creating capacity in emergency departments and isolation wards, implementing mandatory “mask up“ at healthcare facilities, developing contact tracing teams and setting up acute respiratory tract infection wards to accommodate patients with respiratory tract infections who would then be screened for COVID-19. Singapore opened the National Centre for Infectious Disease (NCID) in September 2019 which is a 330 bedded hospital that is equipped to handle highly contagious diseases like Ebola and SARS. As a result, most of the COVID-19 patients have been admitted to the NCID. By January 23rd 2020, Singapore had diagnosed its first confirmed case in a tourist from Wuhan. Restrictions were imposed on the number of visitors in the hospital who had to fill up a declaration form that they are free from COVID-19 risk factors, thermal scanners were set up at hospital entrances with registration of visitors. Elective procedures, including living kidney donor transplants, were postponed and clinics were downsized or rescheduled. Virtual clinics with remote monitoring have replaced physical interviews and counselling, and home delivery of medications facilitated.

Hospital staff were forbidden to take leave, meetings had to be via video conferencing. Transplant teams were split into smaller teams working separately in different areas. If staff were ill, they were required to report sick to the staff clinic and not elsewhere, for monitoring and contact tracing if required. It was also forbidden for staff to move between hospitals to work so as to avoid cross-hospital infections. Staff who have travelled to high risk countries were asked to take leave of absences for 14 days before returning to work but as the global situation worsened, overseas travel was forbidden. Routine instructions started being issued twice a day to keep all hospital staff informed on daily policies and procedures. All staff take their temperatures twice a day, practice social distancing and retrain in the use of personal protection equipment.

We set up our own acute respiratory tract infection ward where renal patients, including kidney transplant recipients, with respiratory complaints were admitted to be screened for COVID-19 while being able to be dialyzed by the bedside without moving them. Physicians from my renal medicine department are rostered to be part of the acute respiratory tract infection renal team to look after patients admitted to the acute respiratory tract infection wards. Nebulized therapies including Pentamidine prophylaxis were discontinued. Patients in the acute respiratory tract infection ward had to have 2 swabs negative for COVID-19 before transferring them to the general ward and allow sufficient bed capacity for incoming new admissions with respiratory symptoms. Up to 24th March 2020, we have had 7 kidney transplant recipients admitted to the acute respiratory tract infection ward but none has been diagnosed with COVID-19. This is an unusually low number of kidney transplant patients being admitted for respiratory tract infections and we postulate that our patients are now taking additional precautions themselves by staying at home and self-enforcing hand hygiene discipline. Advisories has been send to our patients on how to keep safe during this period.

Though an advisory was issued by our Ministry of Health on February 19th that transplant centers could continue to perform living kidney donor transplantation, we have stopped doing living kidney donor transplantation with the exception of one patient who was running out of dialysis access options. For this living kidney donor transplant recipient, throat swab for COVID-19 was performed for both recipient and her living kidney donor on D-15 and D-2 prior to kidney transplantation. CXR was also done on admission and on D-2 prior to surgery to exclude occult pneumonia. Deceased donor kidney transplantation has also been suspended except for patients who are on the priority wait-list for failing dialysis access or pure red cell aplasia but we have no such patients on the list. As a result, we have not performed any deceased donor kidney transplantation since the first case of COVID-19 was diagnosed in Singapore. Prior to this advisory, there were several referrals of potential deceased donors but we rejected all of them due to respiratory tract infections and travel history. Liver and heart/lung transplantation are permissible as long as they fulfilled certain criteria of medical urgency. So far, one liver and lung transplant has been performed from the same deceased donor who underwent PCR testing for COVID-19 thrice and a CT thorax to exclude COVID-19 infection. These recipients are reported to be doing well.

Our transplant program has ring fenced beds for gastroenteritis because of case reports of transplant recipients presenting primarily with diarrhea but with pneumonia on X-ray or becoming COVID-19 positive days later. Transplant recipients with gastroenteritis are required to be screened for COVID-19 PCR. As at March 25th 2020, the hospital has received 29 out of the 509 COVID-19 cases diagnosed in Singapore, but no transplant recipients have tested COVID-19 positive so far. Both organ donation and blood donation have diminished substantially. Morale of the healthcare sector has been enhanced by significant community and ministerial political support.

South Korea is one of the earliest country which experienced COVID-19 outbreak. Up to 25th March, 357,896 have been tested and 9,137 diagnosed as COVID-19 positive. Detection of new patients peaked at 28th Feb, which was 813 new patients on the day. Since 12th March, the number of new patients has been under 200, so the cumulative growth curve has flattened. 6,456 positive patients were in Daegu city and 1,262 patients were in Kyungpook province. To date 131 patients have died, yielding a mortality rate of 1.43%. The early explosion of COVID-19 occurred through a cult religious group - Shincheonji allowing a focus of COVID-19 screening which detected affected patients even among asymptomatic people. The heavily affected area of Daegu and Kyungpook has suffered from a shortage of hospital beds. Rigorous testing of 20,000 people a day in 633 sites with positive patient isolation enabled rapid control.

A single living liver donor is COVID-19 positive after donation of liver to her mother with both donor and recipient well. A number of COVID-19 positive solid organ transplant patients are under review in Daegu city.

Some living donor kidney transplants have been postponed, especially if undergoing desensitization for ABO or HLA incompatibility, but urgent living donor kidney transplantation and deceased donor programs have continued. All deceased donors are tested for COVID-19 by screening, while living donation COVID-19 screening has been an individual center decision. The Korean Society for Transplantation released a guideline on 13th March recommending routine COVID-19 screening of both donor and recipient.

Most centers are running daily self-reported symptom surveys of staff at the entrance of the hospital, self-reporting using a mobile phone app.

Symptomatic outpatients are obliged to use different hospital entrances leading to an isolated pathway to a secure outpatient clinic. Symptomatic in-hospital patients are managed in a negative pressure ward, and screened for COVID-19. Shortage of ICU beds for deceased donor care has not occurred. A separate set of ICU beds are used for severe COVID-19 pneumonia patients who are transferred to a national or regional hospital qualified for the COVID care including negative pressure system. However, the shortage of wards and ICU beds in Daegu/Kyungpook where the major outbreak occurred led to mortality among those awaiting admission to hospital.

The Korean Society for Transplantation released guidance statement for COVID-19, among them recommendations for transplanted patients as follows. Recommendations for care of transplant patients have been created by the Korean Society of Infectious Diseases, Korean Network for Organ Sharing, Korea Organ Donation Agency and transplantation experts.

The first confirmed case of COVID-19 in Denmark was on February 27 from a skiing holiday in Northern Italy, since when it has grown to 1724 on March 25, with 350 in hospital and 87 in Intensive care and 34 have died. Initially most patients were believed to have been infected abroad, the majority are now acquiring the disease in Denmark. To prevent rapid spread there are border closures, closing of schools, universities and non-essential public work functions, a ban on any public or private event involving more than 10 people, closure of restaurants, bars, cafes, shopping centres, hair salons and similar businesses, and an extensive set of guidelines for the public to avoid spreading of the disease.

Preparations have been made by national and regional health authorities to accommodate the expected number of patients requiring admission and Intensive care, including temporary cessation of all non-essential treatments and interventions. Shortage of ventilators, personal protective equipment and SARS-Co-2 test reagents are all of concern.

National health authorities have defined transplantations of vital organs as treatments that should not be postponed or cancelled. Deceased donor kidney, liver, lung and heart transplantations are being continued at all Danish centres performing these. Combined kidney-pancreas transplantation has been paused. Organ exchange within the Scandinavian deceased donor exchange program is maintained at present. The number of deceased donors currently appears to be stable. All potential deceased donors are tested for SARS-Co-2 and so far no donor has been tested positive. Scheduled living donor kidney transplants will proceed at some kidney renal transplant centres while other have cancelled these. No new living donor kidney transplantations are scheduled. A planned match run within the Scandinavian living donor kidney paired donation program has been cancelled. All kidney transplant centres have converted almost all follow-ups to telephone visits. Locally, standard letters have been offered to kidney transplant patients to inform their employers of their risk status. There are reports of COVID-19 infected transplant recipients, however, none of these are thought to be among the dead.

The Liver Transplant program normally undertakes 250 liver transplants per year and currently has 150 patients on the waiting list. The events are changing rapidly, by day. Currently there are 60 COVID-19 positive patients in general Intensive Care, 35 ventilated. The general theatres have been converted to Intensive Care beds with the view of increasing number of infected patient requiring ITU management. Specialized theatres, Hepatobiliary, Cardiothoracic, Orthopaedic and Neurosurgical theatres are covering general surgery emergencies. With increasing numbers of staff testing positive or in self-isolation many transplant medical personal will be helping in Intensive Care and all Clinical Academics have been asked to stop research activity and return to full-time clinical work. Surgeons will also be trained in Intensive Care management.

Patients with acute liver failure are still listed and transplanted. We are still proceeding with routine transplantation, however, we believe that it may slow because of an increasing number of COVID-19 positive donors and lack of Intensive Care beds. The 16 dedicated liver Intensive Care beds are increasingly given over to serve general Intensive Care needs. Admissions for routine transplant assessment have been cancelled. Paediatric liver transplant activity may be transferred to another ‘clean’ site; however, it will continue for now. All elective adult and paediatric living donor liver transplants have been cancelled. We are still providing the National Organ Retrieval Service (NORS) 24-hour on-call team for retrievals but the number of donors have been declining partly because of COVID-19 positivity. There are no plans to decrease or cease retrieval activities.

All elective post-transplant surgical cases have been cancelled or postponed. Most of the chronic patients have been managed with virtual clinic and their medications sent to them by post. Primary care physicians are repeating blood tests and seeing patients when required. The UK government has just published guidelines, including transplant patients among the extremely vulnerable from COVID-19 and recommended isolation for 12 weeks. Currently we are in discussion the matter of providing bloods and support to patient’s homes. All transplant patients have access to 24 hours on-line support.

To prevent transplant patients coming to the transplant center, clinics are undertaken through the phone and we have created a file of all 2300 follow up patients in order to send them information and new follow-up processes. The role of doctors has been modified to allow each of us to take care of a specific phase of care. Kidney transplantation with deceased and living donors has stopped until further notice. When transplant patients suspected of infection come to the hospital, they are seen the infectious disease unit, tested by PCR and then allocated to a COVID-19 positive hospital since ours has been designated COVID negative. In less than a week, 11 patients are positive, 10 tests are awaited, three patients are in Intensive Care and two are in a very bad situation. With COVID-19 positive patients we stop MMF and mTOR-inhibitors. In patients with ARDS, we also stop tacrolimus so patients remain only on steroids. We call each positive patient every day to monitor progress. The important clinical symptoms include anosmia and ageusia. CT scanning is critical to evaluate severity and oximetry to regulate O2 therapy.

The burden of COVID-19 infection in France is lower than in Italy but, as of March 24th, almost 20,000 infected patients have been identified and 860 died including 5 doctors. The number of infected patients is growing exponentially but there are disparities between different regions in the country with a higher prevalence in the East of France and a lower prevalence in the West. The government has declared lockdown in the whole country.

The hospitals’ priority is to create units for patients with COVID-19 infection and to educate physicians, nurses and all caregivers on how to manage these patients and to protect themselves. In Paris about 1,000 Intensive Care beds are available which we are trying to double. Non urgent medical care and elective surgery have been cancelled in all hospitals. To date, the number of medical staff tested positive is relatively limited, but three physicians died during the last 48 hours.

The national regulatory authority “Agence de la Biomédecine” has decided to continue organ procurement including DCD donors. All donors have to be tested for COVID-19. Because organs are scarce and many patients are at risk of dying on the waiting list, we have decided to continue the program of liver transplantation. However, intensivists will be massively involved by the management of ICU patients with COVID-19 infection and it can be anticipated that the number of donors will decrease in the next weeks. A dedicated COVID-free ICU where transplant recipients can be admitted may be one solution. The ward where liver transplant recipients are transferred or admitted is also COVID-free. Only the sickest patients are still active on the waiting list. Several liver transplant recipients have been tested positive in recent days and infection had a benign course except in one relatively old patient with comorbidities and who had to be transferred to the ICU with severe pneumonia. Chronic transplant patient on site clinics have been cancelled to limit traveling and avoid infection risk. Unfortunately, no dedicated telemedicine system exists in France.

All acute living and deceased donor kidney transplantation activity has totally stopped from 9th of March 2020 and most of the out patients are contacted and managed through video or tele conference. A Crisis Coordination Committee involving the manager of each medical unit helps manage the hospital on a day to day basis with a daily video conference. Patients are being separated into COVID-19 positive and negative groups when hospitalization is necessary. Medical staff are also separated, into dual on call teams on the nephrology ward, one for positive patients and one for negative.

The telephone is the most important communication tool with the patient both inside and outside the hospital. With lists of the phone numbers of patients' rooms communicated to the medical and nurse staff. Collection of functional signs, interrogation of the patient and questions and explanations of the clinical situation as well as provision of information for the patient is all undertaken by phone. We have limited the number of doctors in contact with patients. A doctor assesses the respiratory frequency, signs of respiratory distress and performs clinical examination if necessary but retains the same mask and glasses all morning. Phone communication occurs between junior and senior doctors to avoid contact. No sharing of computers, evaluation of diets, provision of physiotherapy advice and psychological support of patients and families is all through the phone.

It is important to keep the COVID-19 positive staff team with masks and protected by distance and specific procedures to prevent contagiousness. It is a rapidly evolving and very tense situation requiring transfer to ICU, sedation and high death rates with essentially no guidelines and little or no basic evidence.

Germany, Regensburg update 7th April 2020
Edward Geissler and Bernhard Banas
In Germany (83 million citizens) all numbers are still increasing, approximately 100,000 Sars-CoV-2 infections and 1,800 COVID-19-related deaths were reported so far.
The organ donation rate has dropped significantly both in Germany and all countries belonging to Eurotransplant. Although other European countries stopped kidney and pancreas transplantation programs, the transplantation activities in Germany in general and in Regensburg in particular are proceeding. Organ procurements and transplants are still being performed according to normal procedures, with the exception that living donation (especially living kidney donation) has been put on hold in the majority of transplant centers. For potential kidney transplant patients with a higher risk, the nephrologists are considering critically and carefully the individual risk/benefit before proceeding with transplantation. International organ transports are continuing to take place, however due to the nearly complete closing of inner-European borders, special efforts are necessary for both organs and transplant teams to keep the international organ exchange alive. Immunosuppressive medications are foreseen to be in adequate supply in Germany. Without a negative Sars-CoV-2 test, organ procurement and allocation does not take place; testing in all transplant recipients is recommended for safety, and to get information about the status of these more vulnerable patients.
In Regensburg, we have seen only a few cases of transplant recipients infected by Sars-CoV-2 and COVID-19 disease has so far not been severe. We have no fatalities to be reported to date.  This observation seems not to be very atypical, as many other German transplant centers are experiencing larger series of severe cases among their patients.

Throughout Germany, living kidney donor transplant procedures are mostly being postponed. Cadaveric transplantation activities are being performed as normal for the time being. Testing for COVID-19 will be performed on cadaveric donors, but the results will generally not be used to determine if the organ is transplanted; the testing is for the purpose of recording whether the donor was positive or negative for the virus.

Standard follow-up visits for transplant recipients will be kept to a minimum, but a higher density of visits will be maintained at our institution for patients with problems or those in the early period after transplantation. Where possible with regard to long-term care, patients will be contacted by telephone, or some sites have the capability of conducting video conferencing with patients; some of these systems will be provided free of charge during the coronavirus pandemic situation.

Some additional specific actions are relevant for liver transplantation. High urgency children at our institution are currently planned to receive either deceased or living donor liver transplants without major restrictions. For adults on the waiting list, normal demands for recertification of e.g. MELD score will be eased and the details surrounding this issue are under continuous discussion. Deceased donor liver transplants will still be performed in lower urgency situations on a case-by-case basis, depending on the COVID-19 burden on the system at the time. As with all hospitals at the current time, we are preparing for the expected rapid influx of patients, which might require reprioritization as necessary.

Transport of organs across country borders remains active with only some restrictions. The transplantation society in collaboration with other medical societies plans to establish a COVID-19 transplantation registry, as part of a larger existing database.

The kidney transplant program of the largest transplant center stopped on March 13, 2020. Since then neither deceased donor nor living donor kidney transplantations have been performed. All living donor transplants have been put on hold, including patients scheduled to undergo blood group ABO-incompatible kidney transplantation already treated with alemtuzumab before the decision to stop acute kidney transplants. The main reason for stopping at present is the perception that immunosuppressed patients may be at increased risk for severe COVID-19. The six other Dutch transplant centers have all ceased their living donor kidney transplant activities while the centers that at present (March 23) face a smaller influx of SARS-CoV-2 infected patients will still transplant deceased donor kidneys.

This policy has been communicated to referring nephrologists and patients via email and social media (www.niertransplantatie.info/). Patients can find information about the latest developments regarding COVID-19 on the website of the Dutch Transplantation Society (www.transplantatiestichting.nl).

At present only two renal transplant patients have been admitted to our hospital because of SARS-CoV-2 infection. The continuation and dose of immunosuppressive drugs is under discussion. Our current strategy is not to change a patient’s maintenance immunosuppressive regimen unless life-threatening complications arise.

The liver, lung and heart transplant programs are still active. However, all three programs have noted a remarkable decrease in the number of donors. Fear of SARS-CoV-2 transmission and the limited time of Dutch intensivists to identify and work-up potential donors are likely explanations. Another problem, raising a medical-ethical issue, is the current reluctance of some ICU specialists to make beds available for recipients of a liver or thoracic organ despite the fact that the ICU capacity in the Netherlands is still sufficient today.

The care of transplant recipients in the maintenance phase is ongoing although at a low ebb. Scheduled appointments are postponed or rearranged as consultations by phone or email. Moreover, patients are extremely reluctant to come and visit the outpatient clinic.

This coming week we will likely see a surge in the number of COVID-19 patients and preparations are thus ongoing through a daily discussion between representatives of all Dutch transplant centers. Yesterday the Netherlands saw the largest number of patients admitted to hospital in a single day since the start of the outbreak. It is expected that all transplant physicians will participate in the pool of medical specialists that will be redirected to one of the newly formed COVID-19 wards. Three members of our medical staff have been infected with SARS-CoV-2. To lower the risk of transmission among ourselves, all meetings related to patient care are now being conducted via Skype or Zoom.

This update was prepared in cooperation with Prof. Maciej Kosieradzki (President of Polish Union of Transplant Medicine) and Prof. Jarosław Czerwiński (Medical Director of Polish Transplant Coordinating Center Poltransplant.

In Poland we still have increasing number of patients with COVID-19 and currently (19th of April 2020) according to official data we have 9082 cases, 350 deaths and 1040 cured patients.  Numerous social restrictions are applied – “stay at home” rule, wearing face mask in public places, keeping distance, restricted number of customers in shops and churches, closed schools and universities, most of business activities are limited, no sport and cultural events allowed.  Hospitals are generally admitting urgent cases (most elective procedures except cancer cases are postponed). COVID-19 patients are treated in dedicated, infectious hospitals.
Transplant programs are active, while living kidney donor transplant procedures are postponed including qualification procedures. Pancreas programs are also stopped. Cadaveric donation and transplantation has dropped but programs are ongoing. Organ donors and recipients are genetically tested for SARS Co-2 (RT-PCR).  No donation occurs until chest CT scans and COVID-19 test prove negative. Recipient is also CT-screened at admission and swabs are taken, yet result is usually available when transplantation is completed. Positive COVID-19 cadaveric donors are rejected as the risk of transmission of virus is still uncertain.
Standard follow-up visits for transplant recipients are being kept to minimum. Most of “visits” are performed by phone. Immunosuppressive treatment monitoring, which is performed in dedicated transplant laboratories, is active but limited to patients who are in early period after transplantation or in need of detailed assessment.
Both urgent and elective transplantation (including living donor liver transplantation in children) are performed with regular standards. All recipients are informed and consent for increased risk of COVID-19, due to migration and hospital stay. As far as we know, no case of COVID-19 infection in a solid organ transplant recipient has been recorded to date. It seems that dialysis patients are at much greater risk, with difficulties in receiving urgent interventions (for instance emergency dialysis access placement) had slightest suspicion of contact with COVID-19 been put forth. There was one case reported of a teenager who recovered from COVID-19 while being in early period after bone marrow transplantation. Transplant  center in Medical University of Warsaw proposed to establish database for transplant patients infected with COVID-19.
With the support of pharmaceutical company, nephrologists and transplant experts prepared information and recommendation for dialyzed and transplant patients. They are published on websites of Polish Transplantation Society, Poltransplant, Polish Union of Transplant Medicine and patients website. Specific COVID-19 recommendation for professionals were prepared by National Transplant Consultant and by Poltransplant and published on Poltransplant and Polish Transplantation Society websites.   
Since an outbreak of pandemic in Poland with the first case registered on March 3rd, 76 kidneys, 28 livers, 13 hearts and 8 lungs have been transplanted. No serious adverse events and reactions related to SARS-Cov-2 issues has been reported to national registry so far.

Transplantation Journal Update
Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Spain has been one of the most affected countries by the COVID-19 outbreak. As of 5 April 2020, the number of confirmed cases is 135,032, including 40,437 patients recovered, 6,931 having required admission to the intensive care unit (ICU), and 13,055 deaths, with a global mortality of 9.7%.1 The country is considered at epidemiological scenarios 3 (sustained community transmission) and 4 (intensive care capacity saturated and health-care system overwhelmed), as described by the European Centre for Disease Control and Prevention.2 
The Spanish donation and transplantation system first focused on safety issues related to COVID-19. Since January 2020, national recommendations for donor evaluation and testing have been issued, that have rapidly evolved over time.3 Donation does not proceed in confirmed cases of COVID-19 or in potential donors with a compatible clinical picture even if not confirmed. In potential donors with epidemiological risk (exposure to a confirmed case of COVID-19 and/or visit to affected area during the previous 21 days), donor screening for SARS-CoV-2 by RT-PCR is performed and donation does not proceed in case of a positive or inconclusive result. Testing is also extended to potential donors with no epidemiological risk if donation of lung and/or small bowel is considered, or if they present symptoms compatible with COVID-19. For cured COVID-19 cases, a minimum period of 21 days after recovery following a cautious case by case risk/benefit assessment is required. In live donation, surgery is deferred for 21 days in donors with epidemiological risk. The deferral period of 21 days has been set to rule out potential outliers beyond the known incubation period of COVID-19. Samples from the upper (nasopharyngeal AND oropharyngeal swab) OR the inferior respiratory tract (preferentially, bronchoalveolar lavage) are used for donor screening. Patients must also be tested for SARS-CoV-2 prior to transplantation.
As Spain was entering in scenarios 3-4, the main issue has been the impact of the epidemic on donation and transplantation activities, because of the saturation of the health-care system and of the ICU capacity, and of concerns about the transmission of the infection to recipients in the post-transplant period (within the hospital or in the community). Centers in the most affected areas have been instructed to pursue donation at least from optimal donors and to focus transplantation activities on critically ill patients and those with difficulties to access transplantation, deferring less urgent procedures. The decrease in donation and transplantation activity in the country has been dramatic. Between 1 January and 12 March 2020, the mean number of actual deceased organ donors was 7.1 per day and the mean number of organ transplants from deceased donors was 15.1 per day. Since a national state of alarm was declared by the government on 13 March 2020 until 3 April 2020, corresponding figures are 1.4 and 2.3, respectively.4 All live donation procedures have been postponed.
The Spanish system has initiated a centralized data collection to build evidence on the outcome of COVID-19 in transplanted patients.

REFERENCES

1. Ministerio de Sanidad, Secretaría General de Sanidad, Dirección General de Salud Pública, Calidad e Innovación, Centro de Coordinación de Alertas y Emergencias Sanitarias. Actualización nº 67 (6 de abril de 2020). Enfermedad por el coronavirus (COVID-19) (datos consolidados a las 21:00 horas del 05.04.2020). Available at: Click here for PDF. Last access: 6 April 2020. 

2. Novel coronavirus disease 2019 (COVID-19) pandemic: increased transmission in the EU/EEA and the UK – sixth update. Available at: Click here for PDF. Last access: 6 April 2020. 

3. Spanish recommendations on donation and transplantation of organs in the COVID-19 pandemic. Available at: http://www.ont.es/infesp/Paginas/Recomen_prof.aspx. Last access: 6 April 2020.

4. Impact of the COVID-19 pandemic on organ donation and transplantation activities in Spain. Available at: http://www.ont.es/infesp/Paginas/Impacto_tx.aspx. Last access: 6 April 2020.    

When we learned about COVID-19 in China, it seemed like something happening far away that would never reach our homes. Then, we saw it happening in Italy, but still couldn’t understand the threat that the disease would become for our country. Isolation measures were decided by the government on March 12th, but it was clearly too late and the pandemic is hitting our cities to a point that medical care could collapse soon if heroic movements are not made. It is sad to see that other countries are making the same mistakes, waiting for the infection to explode before deciding drastic isolation measures that on the other side could jeopardize their economy. The infection spreads really fast: in less than two weeks our hospital has changed from not having a single case, to needing 50 intensive care beds and we are planning to open still more.

Elective and living donor transplantation have been postponed, and only emergency life saving transplant procedures continue, but with the difficulty of excluding COVID-19 in both the donor and recipient. We have cancelled all non-emergency appointments, laboratory tests and procedures. We are using telemedicine for most of our patients to avoid hospital visits. Intensive care beds need to be preserved for COVID-19 positive patients, so there are no elective procedures requiring Intensive Care. We have redirected staff to COVID positive floors and intensive care units, have hired new staff. Distinctions between specialties have disappeared and now there are only patients and physicians.

We have changed shifts and created groups of personnel that always work always together and don’t mix with the other teams to minimize contacts. Every episode of fever, even mild fever, is considered a potential COVID patient and they are always isolated while waiting for test results.

In Switzerland, Ticino, which is close to Lombardy, was the first to be hard hit by COVID described graphically: “We recorded our first local case on the 1 March, in the first week the new cases were coming in slowly, now the gates have opened up and it is like the monsoon season in the rain forest.”. It is now apparent that the hardest hit cantons in Switzerland are Geneva and Vaud. The first national case was diagnosed on Feb 25. Today there are 7,726 confirmed cases with 99 fatalities, roughly 50% being in the 3 cantons of Geneva, Vaud and Ticino, but the wave will undoubtedly move in the north-east direction…

On March 13, Swisstransplant coordinated with the 6 transplant centers in the country and the Federal Office of Public Health (FOPH) a 6-stage plan to address the progression of the epidemic. The plans stages are: i) stop all live donor transplantation activities; ii) stop all deceased donor pancreas and islet transplants; iii) stop all deceased donor kidney transplants; iv) a selected and tailored approach to urgent status for liver, lung and heart transplants; v) only urgent transplants to be performed; and vi) stop all transplant activities.

To mirror this donor activity continued initially; the second stage requires all DCD programs to stop with DBD programs still active; then a reduction of DBD detection and procurement programs, in coordination with Swisstransplant. DBD detection and procurement would then only be for urgent transplants, before all donor detection and procurement is ceased.

Hospitals are making their own decisions on the implementation of the staging with Geneva ahead of the others with my hospital governance’s grateful assent, we reached the final stages on Mar 22, and have in effect discontinued all transplant and procurement activities, urgent cases (e.g. fulminant hepatitis) being still considered.

The reason is the exponential increase of COVID patients hospitalized in Geneva University Hospitals, among whom 20% are on a vent in the ICU. Chiefs of division get a situation update 3 times daily. The hospital is working continuously on increasing its regular and ICU bed and ventilator capacity for COVID patients, currently 74 % of the capacity is utilized, but projections suggest that we may have reached full capacity before the end of the week. Most surgical activities have been discontinued. Emergency and oncological surgeries will be performed in private hospitals that have been requisitioned by the state. Geneva University Hospitals is currently the only designated COVID hospital in Geneva, but there are plans to extend this to others as the needs arise.

We still have a few transplant patients hospitalized in a non-COVID wing of the hospital, and plan to keep the number of hospitalized patients as low as possible. Most of our outpatient clinics are undertaken by phone, unless there is an absolute need to see the patient physically. The hospital has put together a versatile and user friendly solution for this.

Brazil, 6 April 2020

Prof. Jose Osmar Medina Pestana, MD, PhD

Nephrology Division, Hospital do Rim – Federal University of São Paulo

In Brazil, the first confirmed case of COVID-19 infection was registered on February 26th in São Paulo, just after the Carnival. On March 16th, with the initial exponential growth in the number of confirmed cases, social distancing measures began, with closure of schools and offices, followed by bars and restaurants and strict recommendations to stay at home. The first death occurred on March 17th, when the number of confirmed cases was 234. After 20 days 11,254 cases were recorded in all 27 Brazilian states, and there were 486 deaths (4.3%). Forecasts based on the current models predict about 45,000 cases up to April 20th. Given the known shortage of diagnostic tests, only symptomatic patients admitted to the hospital have been tested.

Currently, Brazil has 210 million inhabitants and about 2.6 ICU beds for every 10,000 inhabitants. We are dealing with the usual challenges, primarily lack of sufficient coordination between the federal and state governments, and lack of screening tests, personal protective equipment and other supplies.

In our hospital we postponed routine clinic visits and started using telemedicine. We are still performing deceased donor kidney transplants (we are now testing all donors) but those from living donors are temporarily on hold. From March 20th we started disseminating through all available media the message for patients with mild symptoms to stay at home, isolated if possible, and to call the transplant center before coming to the hospital. These home based patients then receive frequent calls from our institution to update their clinical conditions. Only symptomatic patients presenting at the emergency department have been tested. As of April 6th, the cumulative number of kidney transplant recipients who were tested positive for COVID-19 is 20. There are 5 in the ICU, 5 have already been discharged from the hospital, and 3 have died. Given the wide spectrum of the disease and the demographics of the kidney transplant population, there are no predefined protocols to handle immunosuppression. We are collecting data prospectively to report a case series. We are also developing a national database to analyze data from different centers across the country.

We believe that the control of this pandemic, considering the universal geographic dissemination requires a collective alignment among all countries to mitigate its impact on the society, especially in most under resourced regions.

Submitted by Amir Kasraianfard,  Mohssen Nassiri-Toosi, Ali Jafarian
Tehran University of Medical Sciences, Tehran, Iran

Given the rapidly spreading coronavirus infection (COVID-19), there are several concerns and debates about performing organ transplantation. Risk of donor-derived disease transmission through organ transplantation is not clear at this time. 1 However, there are definite risks for nosocomial transmission to the live donors and recipients along with healthcare workers as well as significant risks for life-threatening infection and infectivity in immunocompromised transplant recipients. 2 Iran is one of the COVID-19 epicenters with 41495 registered cases and 2757 related deaths as of March 30, 2020  3 More than 3000 organ transplantations are performed annually nationwide, so it was mandatory to provide a new uniform standard transplantation protocol for donors and recipients in regard to COVID-19 risks, exposure and isolation and organizational leadership for priority setting in this rapidly emerging situation. 4,5
A national comprehensive protocol for organ transplantation in Iran was issued based on a consensus made by representatives from various organ transplantation teams organized by the Organ Transplantation Administration under Ministry of Health and Medical Education in February 26 and revised in March 11, 2020. The highlights of this consensus are as follows:
1. Lung, intestine, living donor/deceased donor kidney and elective living donor liver transplantations are totally suspended.
2. Deceased donor organ transplantations are done only for patients with high probability of early waiting list death including patients with Model for End stage Liver Disease (MELD) score more than 20 and/or a life threatening complication for liver and INTERMACS profile 1 or 2 for heart recipients.
3. All potential recipients are evaluated for COVID-19 by medical history and physical examination, CBC, CRP, chest CT scan and infectious disease specialist consult for the possible risks of infection at the day of transplant surgery.
4. All deceased donors are also evaluated for COVID-19 using PCR assay, CBC, CRP, chest CT scan and infectious disease specialist consults.
5. Organs from epidemic areas and/or clinical high risk deceased donors should not be used for transplantation. Organs from intermediate risk deceased donors are considered as marginal and can be used for urgent transplantations.
6. Postoperatively, walk-in clinic visits and elective procedures are suspended and patients are monitored for COVID-19 symptoms and prohibited from contact with people suspected of being at risk of COVID-19.
Our National Committee for Transplantation thus decided to make strict limitations on performing organ transplantation nationwide to maintain high standards for patient safety. Meanwhile, we protect our healthcare workers and prioritize their capacity for epidemics control. The most significant challenge the transplantation programs are faced with however, is how to deal with increase in transplantation waiting list mortality and organ shortage for urgent organ transplantations if the battle with COVID-19 pandemic is a lengthy one. One possible plan in short term is to physically separate the COVID-19 floors and staff to take care of severe cases who need urgent transplantations.

References
1. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223): 497-506.
2. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020.
3. Johns Hopkins Coronavirus Resource Center. https://coronavirus.jhu.edu/map.html. Access Date:  March 30, 2020. 2020.
4. 2019-nCoV (Coronavirus): FAQs for Organ Donation and Transplantation . Access Date: March 22, 2020. 2020.
5. Guidance on Coronavirus Disease 2019 (COVID-19) for Transplant Clinicians. https://tts.org/coronavirus. Access Date: March 22, 2020. 2020.

Kuwait is a small country with a population of 4 million. The present situation as of today is as follows:

As of 6th April, there are 665 diagnosed cases of Covid-19 in Kuwait with a population of 4 million inhabitants. There are 561 admitted for treatment, 20 of whom are critical and one death. 103 recovered from the virus and 2474 are under ministry quarantine.

Kuwait has applied strict measures from the start of spread of the virus. It repatriated all Kuwaiti citizens who were in Iran, when the virus started spreading there, and quarantined them. The first identified cases were among this group but soon the number of cases platued.

Later the government started to repatriate citizens who were in Europe, mostly in Britain, initially allowing them to go for home quarantine but as many of them did not adhere to instruction the number of cases started to rise again. The authorities then reintroduced institutional quarantine for all new Kuwaiti arrivals from abroad, mostly in resorts and hotels.


Kuwait, like all Gulf states, has a large expat population constituting two third of the population, most of whom are low paid workers, who are poor, uneducated and live in unhealthy crammed places. Over the last 10 days majority of new cases are among this population. The government is trying hard to contain spread of disease in this population and has prepared many schools to quarantine all suspected cases of contact with proven cases. The number of new cases is rising but there is no shortage of medical staff, hospital and ICU beds so far. All proven cases are presently admitted in a single large hospital but other hospitals are being prepared.

The total number of PCR tests performed so far is not available to me but it is over 1000 cases daily. Quick test kits were imported in large quantities and all arrivals to Kuwait are tested. There are no regular flights but there are flights to repatriate Kuwaitis from abroad and to fly expats willing to leave Kuwait.


Transplantation service

There is a single kidney/pancreas transplant center in Kuwait which is attached to a subspecialty hospital which so far has not admitted any cases of Covid-19. Still because of worry of immunosuppression all living donor transplants were stopped 6 weeks ago but deceased donor transplants are continuing, though numbers have fallen. Today a preemptive living donor transplant was performed for a low risk patient, as she was not keen to go on dialysis.
There is also a unit for liver transplant in the general hospital dedicated for Covid-19 cases. They have stopped the program for the time being.

Other Gulf states
The following chart compares proven cases in different Gulf states per million population. Of course, the numbers are affected by number of tests performed in each country, so the chart may not be very accurate. Still the numbers in Bahrain and Qatar seem to be much higher than other Gulf states.

Kuwait is a small country with a population of 4 million.

The present situation as of today is as follows:
1. 23 new confirmed cases over last 24 hours.
2. Total number of diagnosed cases 289.
3. 73 recovered cases.
4. 13 cases in ICU.
5. No deaths so far but one case is very serious.
6. 911 cases discharged from quarantine

Course of the disease:
When the disease started spreading in nearby country, Iran, the government stopped flights to Iran and decided to return all citizens who were already in Iran and all of them were quarantined in a hotel and resort. The first case was discovered on 24 February among this group of citizens. Subsequently more cases appeared, all related to travel to Iran and by 1 March the numbers rose to around 50. Since 13 March there is no increase in cases related to travel to Iran because of successful quarantine by the MOH.

The first case not related to Iran was discovered on 8 March as disease spread in Europe and cases were discovered related to travel to Italy, Spain and UK. At present 49% of confirmed cases are related to travel to Iran, 35% related to travel to UK, 7% to Azerbaijan and 9% to other countries. The citizens who arrived from Europe were sent for self-quarantine at home.



Overall the government was doing well till travelers from UK started to come back when the numbers started to rise again. More citizens, mostly students, will be brought back from Europe in the next few days when facilities are arranged to receive and apply institutional quarantine on all of them. We hope that with enforced quarantine the curve will become flat again.

Treatment methods are mostly supportive as there is no definite treatment yet. The government sent a plain to China to bring needed equipment and diagnostic tools. So far PCR is being used for diagnosis of suspected

1. 2 new confirmed cases over last 24 hours. (The numbers ranged fro 1-17 cases daily)
2. Total number of diagnosed cases 191. 
3. 39 recovered cases. 
4. 5 cases in ICU.
5. No deaths so far but one case is very serious.
Course of the disease:
When the disease started spreading in nearby country, Iran, the government stopped flights to Iran and decided to return all citizens who were already in Iran and all of them were quarantined in a hotel and resort. The first case was discovered on 24 February among this group of citizens. Subsequently more cases appeared, all related to travel to Iran and by 1 March the numbers rose to around 50. Since 13 March there is no increase in cases related to travel to Iran because of successful quarantine by the MOH.
The first case not related to Iran was discovered on 8 March as disease spread in Europe and cases were discovered related to travel to Italy, Spain and UK. At present 49% of confirmed cases are related to travel to Iran, 35% related to travel to UK, 7% to Azerbaijan and 9% to other countries.The citizens who arrived from Europe were sent for self quarantine at home.

In Lebanon the first positive tested case was imported from Iran who was asymptomatic. She has recovered and at home Currently we have 540 cases with 18 death (the high number of death is alarming). We remained at one case for few days then we had another person who was on the same flight from Iran. 4 case were imported from Egypt 5 cases from UK and then 9 cases from Italy. The cases from Italy were the worst as they were priest who because of the Easter fast visited many families to offer the blessing for Easter which caused the spread of many cases. We have a group who attended a weeding in France and they came back with the infection. One of the cases from UK is a celebrity and upon arrival had a big birthday party for her daughter and again helped in the spread. We have a stay at home policy since the 19th of March and now we can only drive according to license plate numbers and o traffic on Sunday the stay at home is extended till 12th of April. For sample collection we have drive through for the outpatient. Many Lebanese who were outside are coming back and being tested upon arrival (430 came back on Sunday) we expect up to 12000 to come back. Most of the travelers are coming back from African countries but few are from EU. We test using PCR at designated centers by the MOH. Transmedical For Life being the reference Lab set the cost of the test for the public at 125000.00 Lebanese bounds equivalent to 80 US. But others are charging up to 300 US. The MOH has not yet allowed rapid testing. Our team is available at the airport to help testing upon arrival. There is a big shortage globally for PCR extraction kits which will soon cause problems for us. As for the accuracy of the tests we have been doing a study at our center in Canada and even with the PCR we have an error among manufacturers that is nearly 5% on average. Thus testing at different intervals may be advisable.

The kingdom of Saudi Arabia, constituting the majority of the Arabian Peninsula with a total land area of 2.15 million km2 which is geographically considered as the largest sovereign state in the Western Asia.  The Kingdom consists 34 million population which are composed of 62% citizens and 38% residents. The Kingdom have an active living and deceased donation and transplantation program including kidney (18 centers),  liver (4), heart (2), lung (1), pancreas (2), small bowel (1), and tissue banking (2: cornea and bone).

Due to the pandemic caused by the Novel Coronavirus (covid-19) and globally considered as a public health emergency by the world health organization (WHO), the Kingdom took early measures to prevent further spread of the disease  by suspending operations of public transports, domestic and international flights, schools, restaurants, malls and all government institutions excluding military, security and health sectors. Curfew hours were implemented in greatly affected regions during the 1st week of March and then 24 hour lockdown was initiated in areas where there is a trend of increase in the number of cases during the 2nd week to date.

There was a total of more than 2370 covid-19 positive cases as of April 4th, 2020 which includes 29 deaths and 420 recovered patients and due to the current situation, the donation and transplantation program took its special measures.

The Saudi Center for Organ Transplantation (SCOT) issued a position statement on organ donation and transplantation during the Corona Disease (Covid-19) pandemic, Version 1, March 23, 2020;  This includes statement of recommendation of deceased donors, deceased donor risk stratification, recommendation and guidance on living donors, recommendation and guidance on testing and management of transplant candidates and recommendation and guidance on testing and management of transplant recipients. To date, deceased donation is active with special measures taken for covid-19 testing and risk evaluation. During the pandemic, there were a total 7 deceased donors recovered in the in the Kingdom and all of which were tested negative for covid-19 virus.  Organ utilization of the deceased donors are as follows: 8 kidneys, 6 livers, 1 heart and 5 hearts as source of valves (HFV).

Deceased donation still remain active since the Kingdom did not reach the breakpoint in the number of cases at a national level in reference to the guidelines provided. Some transplant centers suspended their elective living transplant procedures in reference to the regions affected, bed capacity and other considering factors. These guidelines are updated closely every week due to the evolving and changing situation and might take into consideration a momentary suspension of deceased donation and elective living transplantation practice.

The present Covid-19 situation in Syria as of April 7, 2020
Bassam Saeed

1-The course of the disease in Syria:
According to a recent update issued by the WHO, the epidemic in Syria is in its early phase; therefore, unfortunately we should expect higher rate of reported new cases

As of today, April 07, 2020; the total number of Covid-19 reported cases inside Syria according to the Syrian Ministry of Health since the beginning of this pandemic is only 19 cases, all of them are from Damascus city and Damascus countryside and most of them were diagnosed shortly (few days) after their returns from abroad (Lebanon, Iran, and UK) or the return of one of their close relatives from the same countries

Out of theses 19 cases, so far 2 cases recovered and another 2 cases died. Therefore, the mortality rate is ~ 10% (2 out of 19) . This mortality rate seems quite high compared to what's reported elsewhere in the world. It's worth mentioning here that, until recently, PCR test for COVID-19 used to be performed only to those who have severe symptoms suggestive of Corona virus infection or being in critical condition requiring admission to hospital or ICU, therefore, since the beginning of this pandemic, this test wasn't done as routine wherever it should be done (e.g. based on travel history or presence of other family members known to have the infection. etc.), for multiple reasons but mainly because of shortage of kits according to the MOH officials (as a result of the sanctions imposed on Syria they stated). Consequently, only severe cases were diagnosed, therefore one could speculate that many milder and or asymptomatic cases should be there but unfortunately couldn't be diagnosed. However, things seem a bit better starting from the beginning of April when around 100 tests are being done on a daily basis and efforts are being done to make up to 200-300 test a day according to the Syrian Ministry of Health resources but still this is far less than needed in a country like Syria which counts 18 million people (Note that the population was nearly 24 million in the pre-war years); That is to say that the status of COVID-19 infection in Syria seems to be far from being clear and definitely underdiagnosed for technical reasons as stated above.

--In April 05, The Syrian technical and Advisory Team for Corona Epidemic Treatment held a meeting under the umbrella of the MOH and came out with a national protocol for the management of COVID-19 infection in Syria. This protocol was disseminated to all hospitals and involved parties and health care professionals from all around the country for immediate implementation.

--As of April 06, 2020, there are 450 quarantine rooms under the direct supervision of the Ministry of Health

--The government stopped flights to and from Iran and all citizens who were already in Iran and returned home were quarantined in a hotel nearby Damascus airport and resort.

--The government has instructed public to stay at home if not at work and suspended all schools, colleges, shopping malls and other shops except pharmacies, medical clinics, and food shops.

--The government imposed a partial curfew from 6 PM to 6 AM in weekdays and from 12 PM to 6AM in weekend with heavy penalties.

2-Treatment available:
--Treatment methods as mentioned in the national protocol consist of therapeutic and supportive measures based essentially on WHO guidelines including specifically Hydroxychloloquin and Azithromycin out of other therapies and interventions according to the clinical context of each patient.

--The number of beds & ventilators in the intensive care units (ICU) the country is around 500 which is a quite small number and not enough at all if the number of cases gets increased as the WHO expected. However, for the time being this number of beds seems adequate and we hope our country will not be facing such a dramatic and much challenging situation that other neighboring countries like Iran are living in.

3-Transplant patients
--Kidney transplant patients continue to regularly visit their outpatient clinics at the 6 transplant centers which are all located in Damascus where they are seen and assessed as usual and they get their immunosuppressants and are provided with advices, useful instructions and preventing measures against Corona virus


4-Effect of COVID-19 on transplantation service in Syria
--By mid-March, all kidney transplant activities (Which are all performed from living donor) in the country were stopped till further order

Bassam Saeed, MD, FRCP,
MESOT COVID-19 Committee
Consultant Pediatric Transplant Nephrologist / Damascus / Syria

1-The course of the disease in Syria: 
--According to the WHO, the epidemic in Syria is in its early phase , therefore, unfortunately we should expect higher rate of reported new cases
As of today, the total number of Covid-19 reported cases inside Syria by the MOH since the beginning of this pandemic is only 10 cases. All of them were diagnosed short time 0 - 3days) after their return from abroad (Lenanon, Iran, and UK) or the return of one of their close relatives from the same countries
--Only 2 cases out of these 10 died، therefore the mortality is 20% which is quite high compared to elsewhere. However, it's worth mentioning here that PCR test for COVID-19 is being performed only to those who have severe symptoms suggestive of Corona virus infection or being in critical condition requiring admission to hospital or ICU , therefore, this test is not being done as routine for all suspected cases (e.g. based on travel history or presence of other family members known to have the infection etc) because of shortage of kits according to the MOH officials (as a result of the sanctions imposed on Syria they stated). Consequently, only severe cases were diagnosed, therefore one could speculate that many milder and or asymptomatic cases should be there but unfortunately couldn't be diagnosed!. This is to say that the status of COVID-19 infection in Syria in my humble opinion is far from being clear and definitely underreported for technical reasons particularly, I repeat:  the nonavailability of the diagnostic tests ...
--The WHO announced just yesterday that they will send the kits to Syria and this will enable  us to do the testing to around 3000 patients but still this remains far less than needed in a country like Syria which counts 18 million people  (it was 23 million in the pre-war time)
--In March 30, The Syrian MOH held a meeting with all concerned parties and came out with a national protocol for the management of COVID-19 infection in Syria. Later on, this protocol was disseminated to all hospitalsand involved health care professionals from all around the country for implementation
--The government stopped flights to and from Iran and all citizens who were already in Iran and returned home were  quarantined in a hotel nearby Damascus airport and resort.
--The government has instructed public to stay at home if not at work and suspended all schools, colleges, shopping malls and other shops except pharmacies, medical clinics, and food shops.
--The government imposed a partial curfew from 6 PM to 6 AM with heavy penalties. 

2-Treatment available:
--Treatment methods are mostly supportive as there is no definite treatment yet
--The number of ICU beds and ventilators in country (~500) is not enough at all if the number of cases gets increased as the WHO expected , however for the time being this number is quite small and we hope will not face such a dramatic and much challenging situation similar to other countries including Iran. All other usual supportive measures are described in details and based essentially to WHO guidelines in addition to hydroxychloloquin therapy as the only approved therapy by the French health authority at the present time. The other suggested medications are not yet approved therefore they are not recommended by our local protocol. 

3-Transplant patients
--Kidney transplant patients continue to regularly visit OPDs at the 6 Tx centers in Damascus where they are seen and assessed as usual get their immunosuppressants for no cost and their are provided with advices about preventing measures against Corona virus moreover, masks and other antiseptics are distributed to them

4-Effect of COVID-19 on transplantation service in Syria
--By mid March, all kidney transplant activities (all from living donor) in the country were stopped till further order

Turkey update 04 April 2020

Submitted by Mehmet Haberal, Baskent University, Ankara

As of 04.04.2020, the number of confirmed cases in Turkey is 20921 with 425 deaths.  A total of 484 people have fully recovered following treatment. Most of the victims in Turkey have been elderly.

The first batch of rapid COVID-19 tests arrived last week and 50,000 quick diagnostic kits --which allow comprehensive results in 60 minutes-- came from China on 25.03.2020 and an additional 300,000 kits arrived the day after. All private and foundation hospitals have been designated as pandemic hospitals as of 20.03.2020.
Currently, as Baskent Ankara Hospital, we have assigned one floor for the patients, but it will be reorganized based on the circumstances. Transplant surgeries and all except acute liver failure transplantation, cancer and urgent surgery are postponed in all public and private hospitals in Turkey.
We are closely monitoring our transplant patients in our centers located in different cities of Turkey. Our transplant committee has prepared the following immunosuppressive  protocol for COVID-19 transplant recipients:

Antiproliferative immunosuppressant drugs (antimetabolites; mycophenolate mofetil, mycophenolate sodium and azathioprine) should be stopped. Dose reduction or cessation of calcineurin inhibitors (tacrolimus, cyclosporine) has not been clearly defined. Patients who need intubation and have severe pneumonia may benefit from cessation of calcineurin inhibitors. Anti-inflammatory drugs, like tocilizumab may be useful in severe cases. In mild cases, dose reduction of calcineurin inhibitors is preferred. However, calcineurin inhibitors should be stopped if antiviral therapy starts.  Steroid therapy should be tapered instead of cessation. Antiviral therapy should be started according to computed tomography scans and continued according to nasopharyngeal swap pcr results.

Fortunately, so far, there are no transplant patients diagnosed with COVID-19 at the Baskent University centers located in various cities. Interestingly, the rate of COVID-19 has been really low among our dialysis patients. We have 21 dialysis centers all over the country, with 2420 hemodialysis patients and 30 peritoneal dialysis patients. Only 3 patients have been diagnosed with COVID-19, which makes a prevalence of about one per thousand. We have commenced a randomized sample study of our 2420 dialysis patients at Baskent University. While negative for SARS-CoV2, 94.7% were hepatitis A antibody positive so we will continue this study of virus prevalence.

According to the authorities in Ministry of Health there are no transplant patients who are COVID-19 positive reported officially to date. 

Detailed information on measures taken to prevent the spread of SARS-CoV2 in Turkey can be reached through https://hsgm.saglik.gov.tr/tr/covid19

COVID-19 Committees for TOND (The Turkish Transplantation Society), MESOT (Middle East Society for Organ Transplantation) and TDTD (Turkic World Transplantation Society) have also been formed.

Turkey update March 2020

Submitted by Mehmet Haberal, Baskent University, Ankara

As of today, the number of confirmed cases is 1872 with 44 deaths. Most of the deaths in Turkey to date have been elderly, two were age 50-60, one was 91, and all the others were older than 61. Schools, universities, mosques, shopping malls and hairdressers have been temporarily closed and professional sports have been halted as part of measures to contain the virus. The Ministry of Health also announced that cafes, restaurants, pastry shops, and similar workplaces are closed and will only fulfill online orders and takeaway. There are restrictions on supermarkets, banks and public transport systems are obliged to limit their numbers to a maximum of 50% of their licensed capacity. Turkish citizens who are older than 65 and/or suffer from chronic illnesses are restricted from leaving home or even walking in open areas such as parks and gardens.

The first batch of rapid COVID-19 tests arrived last week. 50,000 quick diagnostic kits allowing comprehensive results in 60 minutes arrived today with an additional 300,000 kits arriving this week. All private and foundation hospitals have been announced as pandemic hospitals as of last Friday. At Baskent Ankara Hospital, we have currently assigned one floor for COVID-19 positive patients. Transplant surgery and general surgeries, except for transplants for acute liver failure, as well as cancer and emergency surgery are postponed in all public and private hospitals in Turkey. Detailed information can be reached through following link provided by the Ministry of Health https://hsgm.saglik.gov.tr/tr/covid19

March 19 - Regarding Turkey, the number of confirmed cases are 1236 with 30 deaths.

First batch of rapid COVID-19 tests had already arrived and all private and foundation hospitals have been announced as pandemic hospitals as of last Friday. Transplant surgeries and other surgeries except cancer and urgent ones are postponed and this applies to all public and private hospitals in Turkey as well as Baskent University hospitals.
Schools, universities and mosques have been temporarily closed and professional sports have been halted as part of measures to contain the virus. The Ministry of Health also announced that cafes, restaurants, pastry shops, and similar workplaces are closed and will only fulfill online orders and takeaway.
In addition to this, Turkish citizens who are older than 65 and/or suffer from chronic illnesses are restricted from leaving home or walking in open areas such as parks and gardens.

We have stopped Living Donor Kidney Transplantation and are not accepting offers of Deceased Donor Kidneys for recipients >70 years unless they are highly sensitized. All Deceased Donor kidney offers have been assessed on a case-by-case basis to assess individual risk/benefits for a transplant at this time, but we have now put a hold on transplants. We are planning to reassess that decision in two weeks. All donors must be tested for COVID-19 PCR before transplantation. All recipients have been screened by phone by the transplant nephrologist on-call about travel history, fever and respiratory symptoms, but we have not tested the recipients for COVID-19 PCR.

Our goal in clinic follow-up is to reduce clinic visits and maximize blood testing as needed by time post-transplant (<1 month, continue current clinic follow up; 1-4 months, blood tests 2 weekly with reassessment clinic only on a case by case need; 4-6 months, clinic visit monthly; >6 months, delay clinic by 1 month and reduce laboratory tests. We are aiming to ensure all blood tests are taken at home for patients >70 yrs. Transplant coordinators will call patients at home and document their clinical status, their BP, heart rate and weight, this will be followed by the nephrologist via telephone to review the laboratory tests to assess overall management and medications

Since March 16th, 2020, the two adult kidney transplant programs in Toronto, Canada, have suspended living donor kidney transplants and all new or ongoing workups in order to reduce the risk of COVID-19 exposure among recipient and donor candidates. Similarly, deceased donor kidney transplants and workups have been placed on pause except for patients currently active on the waiting list who have been deemed medically urgent (e.g., terminal vascular access) or those with cPRA > 99% whose access to kidneys are already very limited. The pancreas transplant program has followed a similar strategy to kidney.

The lung transplant program has been suspended to free up beds for critical patients with COVID-19, and this is being regularly re-evaluated. Lung transplants in rapidly deteriorating patients continue to be considered on a case-by-case basis. Liver transplantation from deceased donors remains active, with DCD being restricted to donors less than 35 years of age. Living liver donor transplantation continues but targeting patients with increased acuity. Heart transplants continue to be performed in patients at the highest risk of mortality while small bowel transplants have been placed on hold.

For deceased donors, we have developed a clinical screening tool in conjunction with our organ procurement organization. In addition, all deceased donors evaluated by the province’s organ donation organization are undergoing screening with NAT for COVID-19 on both nasopharyngeal swabs and endotracheal aspirates and/or BAL specimens. All recipients are also being tested for COVID-19 by NP swab in advance of their intended transplant. Test turn-around times are approximately 6-8 hours. When possible, recipient COVID-19 testing results are ascertained prior to transplantation. There is a decline in donor volumes and this may become a greater issue as critical care units become more overwhelmed with COVID-19.

Patient traffic in the transplant clinics has been reduced by 75%, with much of the follow-up now being done virtually via the local telemedicine network. For transplant recipients with confirmed or suspect COVID-19, our transplant infectious diseases service advises on the need for investigational therapies.

Submitted by Daniel Brennan, ohns Hopkins University School of Medicine, Baltimore

There are now over 815 patients who are positive for COVID in the Johns Hopkins’s system and over 400 patients are considered Persons Under Investigation (PUI).  Of these patients 342 are at home but with over 150 patients admitted in hospital and 68, are at Johns Hopkins Hospital.  30 are on ventilators and one is on ECMO. 
There have been 10 deaths.  One was an elderly ESRD International KTxp candidate who got COVID in the dialysis unit before he could get a kidney transplant.   9 solid organ transplant patients have had COVID and been admitted:  2 Liver-Kidney, 2 Liver, 4 kidney and 1 heart.  All admitted patients were SOB and became hypoxic.  One KTxp patient had returned to dialysis and was still on large doses of immunosuppression. She had done the worst.   She was attempted to be oxygenated while prone but that was unsuccessful and is now on a ventilator and deteriorating. All had MMF ceased and were treated with 5 days of Hydrochloroquine.  4 progressed and have been treated with anti-IL6, tocilizumab for cytokine release syndrome and progressive hypoxia and had dramatic responses. Two kidney patients are currently at home. The recipients of the two SLKs, the two Livers, and two of the Kidneys were able to be discharged to home.

An important issue has been the timing of return to work in a medical resident who had tested positive for COVID.  Despite the CDCs recommendation to allow health care providers who were COVID positive to return to work 72 hours after being asymptomatic and without being re-tested and found to be negative, we were not comfortable with that and insisted on retesting and a negative result prior to returning to work with immunocompromised oncology or transplant patients

COVID-19 came recently to Baltimore and is increasing at rates similar to China and Europe despite early adaption of social distancing and closing restaurants and bars one week ago and now all non-essential businesses. As of Sunday (two days ago) there were 15 patients with COVID-19 admitted to Johns Hopkins. 9 of them are on ventilators. Two patients have been transplant patients. Both have been liver transplant patients.

The Comprehensive Transplant Center has several concerns that are informing policy and approach notably: the risk of transmission from donor to recipient; availability, timing and accuracy of test results. Because of pressure on beds and workforce, all elective surgeries are cancelled and the concern remains that new transplant patients could occupy beds needed for COVID-19 patients especially in Intensive care. In response to these concerns transplants will proceed only for life saving, including liver transplant recipients with high MELD; heart transplants with high HAS implying they are already occupying an ICU bed; lung recipienmts with high LAS; and kidney transplants with 100% PRA, 0 Ag mismatch, to avoid dialysis, vascular access failure and pediatric patients.

Follow up of transplanted patients is being modified. We are considering replacing cardiac catheters for dd-cfDNA after heart transplantation. Laboratory tests will be done by home phlebotomy, the frequency will be reduced as much as possible and follow undertaken by coordinators and physicians using telemedicine.

Covid-19 arrived here later than other areas of the US, but preparations are underway for an expected exponential increase. The goal for our response is to reduce risks to transplant candidates, donors, recipients, providers and also to prepare for the expected high influx of patients with suspected and confirmed COVID-19. All elective surgical procedures are on hold. Routine, non-urgent clinic visits are on hold or transitioned to telehealth.

In the past week, a hold has been placed on all living donor transplants initially, anticipating this to continue throughout April but to be reassessed depending on the spread of COVID 19 locally and nationally. Deceased donor transplants are currently ongoing but on a case by case basis. New donor and recipient evaluations are on hold for now. Our local organ procurement organization is active and is testing all donors for COVID-19. Transplant is considered tier 3b by the centers for Medicare Services and as such can currently proceed but each program and center must decide on what is in the best interest of their patients.

Chronic care of transplant patients is being transitioned to telehealth if no urgent face to face evaluation is needed, using phone calls and video calls. We serve patients of varying duration from transplant and over a wide geographic area. These patients will be handled based on perceived risk of leaving home to visit a laboratory compared to the risk of missing an important abnormal laboratory result. A laboratory visit for someone in a low prevalence area who can drive to the laboratory and can take contact precautions, will be much lower than someone in a high prevalence area needing to take public transportation.

Our health care providers have, or have access to, the necessary equipment to conduct clinical video visits, phone visits and documentation in the electronic health record either on campus or preferably from their own home.

Since last Wednesday we have had two doublings of the volume of COVID-19 positive patients. We now have over 600 COVID-19 inpatients out of a total 4000 beds with many being admitted and about 150 in ICUs. We are testing about 1000 patients per day with 25% positive. We have been directed by the Governor to add another 2000 beds into the system by opening up all kinds of rooms to accommodate patients.

We have performed one heart, one lung, 3 livers and 5 kidneys in the past week. This is not likely to be sustained, all clinic activities have been virtualized. We have tested 76 patients at our center with some 20 COVID-19 positive results. One lung transplant patient is currently critically ill.

Quite a few of our staff have been exposed and several are ill with the disease. We have virtualized the inpatient rounds and minimized the team numbers in the hospital at any time.

The Operating Rooms have been greatly scaled down and each is to be converted to a two person Intensive Care. We are currently experimenting with double ventilation from a single machine in an attempt to double our ICU capacity. Transplants are still considered emergencies but we are having fewer donors though there are 7 active donor cases right now in the system but that referral to the Organ Procurement Organisation is slowing down as the regional hospitals are becoming overwhelmed.

It appears likely that transplant will be subsumed by the broader public health efforts, depending on the slope of the new cases curve but so far we are tracking to projections that we are about 4 weeks away from the peak.

In the south we are just starting to see the volume of COVID-19 cases in our hospital spike this week and have instituted a number of steps. We have ceased kidney transplant evaluations and limited liver transplant evaluations to those with high MELD scores. Post-transplant follow up appointments are being conducted via telemedicine to the maximum extent possible. Scheduled living donor kidney transplants are being postponed. Deceased donor kidney transplant activity continues at a lower level with emphasis on selection of donors not expected to have DGF to minimize the post-transplant hospital stay. Deceased donor liver transplantation continues with all transplant candidates screened for COVI-19 risk prior to being called in.

The local organ procurement organization is testing all donors for COVID-19 and only referring transplant donors to the recovery center once they have tested negative. External procurement teams are not allowed into the facility using local surgeons for all organ recovery.

The region started “shelter in place” on 16th March with the rest of the state following 5 days later. While there have been clusters of COVID-19 in Santa Clara and Los Angeles, San Francisco has seen relatively few cases. In UCSF there are currently three patients in Intensive Care and 8 others hospitalized. About 30 ae awaiting test results.

We continue to perform deceased donor liver and kidney transplants, but not pancreas transplants. Deceased donor testing is currently done on all potential lung donors and “as indicated” by clinical circumstances and is increasing. We continue to perform live donor kidney and liver transplants, hoping to have preoperative testing of pairs soon.

Acute Transplantation activity has substantively reduced nationally. Living donor kidney transplantation has stopped for the past few days and deceased donor transplantation which was being assessed on a case by case basis has also stopped entirely for a period, depending on hospital Intensive Care and Emergency Department capacity. All deceased donors have required COVID-testing but the number of deceased donors has dropped dramatically. We have also slowed down all elective surgery, endoscopies and bronchoscopies, as well as auxiliary and allied health services. The government has today banned all non-urgent elective surgery.

We are committed to ensure the safety and well-being of our transplant recipients and as a clinical group we have decided it would be inappropriate to subject high risk patients to intensive immunosuppression during the COVID-19 pandemic. Reduced expert staff availability and a limited supply of Personal Protective Equipment availability are additional concerns for front line clinical staff.

Chronic transplant recipients are being distributed to consultants’ private clinics as well as using Telehealth and ‘apps’ for consultations. Laboratory tests are being done outside the hospitals in private pathology labs. Clinic rooms have been converted into COVID screening rooms for at risk and exposed immunosuppressed patients. Transplant recipients are encouraged to use Telehealth for their regular clinic visits. A service, while useful for the young and IT literate, is extremely difficult for patients with culturally and linguistically diverse backgrounds. New challenges include broadband availability and connectivity, the lack of personal interactions, difficulty in directly engaging patients and their caregivers, inability to perform a full physical examination, and the acceptance and the willingness to conduct a telehealth conference varies substantially between patients.

Our trial based activity and clinical research have also been affected. We have stopped all trial recruitments and only conduct clinically relevant patient follow-up in trials when necessary.

As at 25 March 2020, there is limited community transmission of COVID-19 in New Zealand, with most cases related to overseas travel, or close contacts of people who have recently returned from overseas. NZ is currently going into ‘lockdown’, which will see all people isolating at home and only essential businesses including healthcare and food production continuing.

Health services are preparing for a substantial influx of patients, but currently, most infected patients are in self isolation at home. There are few patients in hospitals and intensive care units. All activity that can be has been deferred including elective surgery, outpatient reviews and diagnostics.

Deceased donor kidney transplantation continues to be offered at two of the three transplant centres. This is reviewed daily at each unit, who are making independent decisions about their ongoing ability to support care of recently transplanted patients. Live kidney donor transplantation activity has essentially stopped currently, due to limitation on citizen movements including that of potential donors. Patients who were suspended from the deceased donor waiting list pending kidney exchange transplantation have been reactivated on the deceased donor waiting list where appropriate for their clinical circumstance.

Telehealth and remote monitoring is being used wherever possible, as well as deferral of non-urgent reviews.

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May 5 - PERSONAL VIEWPOINT - Utilization of deceased donors during a pandemic: An argument against using SARS‐CoV‐2 positive donors
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May 12 - PERSONAL VIEWPOINT - Use of SARS‐CoV‐2 infected deceased organ donors: Should we always “just say no?”
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April 25 - Letter to the Editor - Covid-19 and Kidney Transplantation
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