The COVID 19 pandemic has hit the entire world in an almost unprecedented way. The crisis has spread rapidly, disease burden and casualties continue to rise, and the impact of the crisis is spreading through developing countries. Social distancing, travel restrictions, and intensified testing have improved the rate of rise in new cases in some regions, however, it remains unclear when normality will return. Mechanisms of the disease remain largely unclear; treatment, if available, is mostly supportive. As during times of war, the challenges of the Coronavirus crisis change our views in almost any aspect.

Transplant patients and those with end-stage organ failure are in a particular vulnerable position. Elective surgeries including live donor transplant procedures have paused in many countries. Deceased donor transplants, where the procedure is established, continue in some countries, albeit with modified donor and recipient criteria, in an attempt to reduce the risk of COVID transmission or an infection after transplantation. Those who are immunocompromised are probably at increased risk of severe disease, though the role of immunosuppression is debated and uncertain.

Communication of knowledge is a critical component of the current crisis. Responses, experiences, and outcomes have been different around the world as different countries and regions experience different impacts and different rates of infection and death. Sharing how others have coped in practice will assist in planning and managing this most stressful and challenging situation for patients and health workers alike.

As a transplant community, many are currently engaged in optimizing our immediate responses. With our actions largely based on epidemiological assessments, there is a critical lack of data on the consequences of COVID on transplant patients or those with End-stage organ disease. This report is designed to assist in understanding the approaches taken in other countries and in different phases of the epidemic. There are new opportunities coming to the forefront in these otherwise gloomy days: Virtual meetings, clinical visits, increased use of electronic communication and improved remote monitoring may very well be one of the beneficial legacies of this crisis and our responses.  

Editors and contributors to Transplantation have shared their thoughts on how they are dealing with the current crisis. While we understand that the information of today may be quite different tomorrow in this fast-moving pandemic, this report will open our forum of an international exchange on COVID for the transplant community.

There are some common themes arising in different nations depending on the phase of the epidemic and the underlying health services capacity.

1. Hospital facilities and workforce are being diverted from transplantation to COVID-19
2. There is uncertainty about the risks of transmission from use of COVID-19 Positive donors
3. Prioritization of Intensive Care capacity for COVID-19 patients and thus restricted availability for care of both donors and post-operative non-renal transplant recipients
4. There is substantial concern about creation of high risk immunosuppressed patients from stable medium risk dialysis patients with reduced staff available to look after them post operatively.
5. Most programs have moved to telephone consultation for outpatient follow up and the busiest services are using telephone for in patient management as much as possible.
6. There is no agreement on how to manage immunosuppression in the context of 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.   

April 8 Update - CHINA-HONG KONG: Kidney, heart and lung transplantation

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

DDKT: deceased donor kidney transplantation; LDKT : living donor kidney transplantation; DDLT: deceased donor liver transplant; LDLT: living donor liver transplantation

Hong Kong, Update 6th April 2020
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.

Original March update

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.

India, Mumbai Update 6 April 2020
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.

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.

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.
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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.
 

Denmark, Aarhus Update 7 April 2020
Henrik Birn, Aarhus
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 5071 on April 7, with 472 in hospital, 127 in Intensive care and 203 have died. 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 are 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. Currently, the number of COVID-19 patients admitted to hospital and in intensive care has stabilized and is manageable by current health care resources. Shortage of personal protective equipment and SARS-Co-2 test reagents has been 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. 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 others have cancelled these. No new living donor kidney transplants are being 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. There are reports of COVID-19 infected transplant recipients, of which at least one died. Locally (at Aarhus University Hospital) we have only one confirmed case, which did not require admission. We have implemented a protocol for reduction in anti-proliferative immunosuppression (MMF or azathioprine) in COVID-19 infected kidney transplant patients; however, there is insufficient experience with the outcome of this. Standard letters have been offered to kidney transplant patients to inform their employers of their risk status.

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.

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.

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.

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.

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.  

COVID-19 IN SPAIN AND ITS IMPACT UPON DONATION AND TRANSPLANTATION
Beatriz Domínguez-Gil, Elisabeth Coll, Organización Nacional de Trasplantes, Madrid, Spain

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.    

April 13 Update - Spanish recommendations on organ donation and transplantation (ENG)
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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.

Turkey update 04 April 2020

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.

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

Iran
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.https://www.myast.org/sites/default/files/COVID19%20FAQ%20Tx%20Centers%2003.20.2020- FINAL.pdf. 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.

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.

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.

USA Baltimore 4th April 2020 Update
Daniel Brennan
Johns 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.

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.