both Solid Organ Transplantation (SOT) and Hematopoietic Stem Cell Transplantation (HSCT) which are low-prevalence and complex conditions that requires highly specialized expertise and resources.
They aim to tackle complex or rare medical diseases or conditions that require highly specialised treatment and a concentration of knowledge and resources. Medical knowledge and expertise travel rather than patients, using a dedicated IT platform and telemedicine tools to review a patient’s diagnosis and treatment.*
There is evidence that paediatric transplantation is the only curative therapeutic procedure targeted to the children population that has the highest mortality rates in their age group. The current approach is performed focused on a specific disease or organ.
Regarding the recent outbreak of a novel coronavirus (2019-nCoV) TransplantChild network has compiled a series of information in the format of the frequently asked questions related to the transplant recipients and their families as well as to healthcare professionals. Attached are updated links to the competent bodies that are making global recommendations at the international level on issues related to coronavirus.
What is SARS-CoV-2? What is COVID-19?
Coronaviruses are a large family of viruses that are common in people and many different species of animals, including camels, cattle, cats, and bats. Rarely, animal coronaviruses can infect people and then spread between people such as with MERS-CoV, SARS-CoV, and now with this new virus (named SARS-CoV-2). (1,2)
What is the mode of transmission? How (easily) does it spread?
While animals are the original source of the virus, it is now spreading from person to person (human-to-human transmission). There is not enough epidemiological information at this time to determine how easily and sustainably this virus spreads between people, but it is currently estimated that, on average, one infected person will infect between two and three more. The virus seems to be transmitted mainly via respiratory droplets that people sneeze, cough, or exhale. The virus can also survive for several hours on surfaces such as tables and door handles. (1,2)
The incubation period for COVID-19 (i.e. the time between exposure to the virus and onset of symptoms) is currently estimated at between two and 14 days. At this stage, we know that the virus can be transmitted when people who are infected show flu-like symptoms. It is currently believed that people who are infected but who do not show symptoms cannot transmit the virus. (1,2)
What are the symptoms of COVID-19 infection?
The virus can cause mild, flu-like symptoms such as:
More serious cases develop severe pneumonia, acute respiratory distress syndrome, sepsis and septic shock that can lead to death. (3)
Are transplant patients at higher risk for COVID-19?
Infection still needs to be acquired from someone who is shedding virus. It is not proven but appears that asymptomatic transmission can occur. The incubation is 2-14 days in the general population; however, the inoculum size required to infect a transplant patient may be lower (4).
Although many patients had co-morbidities in the reported series, none has been a transplant recipient to date. Hence a description of the disease in transplant recipients is still not available. Nevertheless, the lymphocyte count was lower in those who required ICU care, and in those who perished (4).
Many transplant recipients have medication-induced lymphopenia. Particularly close attention should be paid to transplant patients with suspected or confirmed COVID-19 infection who are lymphopenic. Such attention may include admission (rather than care at home) and paying careful heed to oxygen saturation. Among comorbidities of interest, more patients who required ICU care had cardiovascular diseases, compared with those who did not require ICU care(4,5).
Based on data from influenza and SARS, if infection occurs, progression to pneumonia will likely be more common in the immunocompromised population, including transplant recipients. In addition, a greater viral burden and shedding will likely result in greater infectivity. Healthcare transmissions of COVID-19 have occurred and given the potential for greater infectivity, strict isolation precautions should be followed (2,4).
Box 1. The WHO recommendations on how to protect yourself and the others from COVID-19 (5)
1. Wash your hands frequently with an alcohol-based hand rub or with soap and water.
2. Maintain social distancing of at least 1 meter between yourself and anyone who is coughing or sneezing.
3. Avoid touching eyes, nose and mouth.
4. Practice respiratory hygiene (covering your mouth and nose with your bent elbow or tissue when you cough or sneeze and then dispose of the used tissue immediately).
5. If you have fever, cough and difficulty breathing, seek medical care early, but call in advance and follow the directions of your local health authority.
6. Stay informed and follow the advice given by your healthcare provider, your national and local public health authority since they can provide you with reliable information on whether COVID-19 is spreading in your area.
7. Additionally, in case of persons who are in or have recently visited (past 14 days) areas where COVID-19 is spreading, stay at home if you begin to feel unwell, even with mild symptoms, until you recover, but if you develop fever, cough and difficulty breathing, seek medical advice promptly by calling your health provider to so you can be quickly directed to the right health facility.
Are there any specific travel restrictions for transplant patients?
There are two categories of patients here – those returning from a transplant performed abroad, and those returning from a holiday or work stint abroad. From an infection prevention viewpoint, both categories of patients may be managed similarly (6).
Teams should follow local health department guidelines for isolating, quarantining, testing, and monitoring returned travellers from endemic areas. Examples of such guidelines include (CDC: https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html; PHE: https://www.gov.uk/guidance/wuhan-novel-coronavirus-information-for-the-public#advice-for-travellers ).
The CDC has recommended suspending all non-essential travel to China, Iran, Italy and South Korea. It is also recommended to avoid cruises into or within Asia. Enhanced precautions are recommended with travel to Japan. Transplanted patients do not travel to any of these locations. Travel restrictions to other locations will depend on virus activity and will change over time.
Like all persons, transplant recipients should adhere to travel advisories issued by their respective health authorities/government bodies. This may necessitate postponing travel to China, Iran, Italy, Japan and South Korea
The CDC and WHO maintain websites that are being updated daily as the outbreak evolves, and travel recommendations will likely change over time.
Should transplant patients wear a mask or avoid public places?
In general, transplant patients should exercise caution about being in overcrowded situations. Frequent handwashing or hand sanitizer use helps prevent infection (4). The benefit of wearing masks in public is controversial even for transplant patients and it is unknown how much wearing a mask will help prevent infection. Most surgical masks are not tight-fitting and aerosols can get through. However, they may prevent patients from touching their nose and mouth. It is unclear if an N95 mask is better than a regular surgical mask since proper fit testing has not been performed. An N95 mask can be uncomfortable to wear for prolonged periods. The CDC is not recommending mask use for infection protection outside the hospital at this time.
What is the approach to transplant recipients with flu-like/respiratory symptoms?
There are many different causes for flu-like/respiratory symptoms. Your hospital should have protocols in place for transplant patients with flu-like/respiratory symptoms. Consult your local hospital practices for outpatient transplant clinic screening or visitor restrictions for transplant recipients as these may evolve over time.
CDC has updated guidelines for infection control (https://www.cdc.gov/coronavirus/2019-ncov/infection-control/controlrecommendations.html ). Engagement of Transplant Infectious Diseases should be considered for suspected cases.
The CDC has also established interim risk criteria for exposure to the COVID-19 that are being updated as the outbreak evolves (https://www.cdc.gov/coronavirus/2019-ncov/php/risk-assessment.html ). Testing for COVID-19 is done via a specific RT-PCR on nasopharyngeal and oropharyngeal swabs. The novel coronavirus is not detected using the standard respiratory virus multiplex tests.
Should living and deceased donors be screened?
Travel history for the deceased donor is essential and should consider travel to China, Iran, Italy, South Korea, or anywhere local transmission is occurring. History of contact with a known case of COVID-19 should also be elicited. A deceased donor with known or highly suspected COVID-19 infection should be deferred for all organs to avoid transmission to the recipient as well as to the healthcare team (1,2).
Case-by case consideration is required for deceased donors with epidemiologic risks and within the 14 days incubation period, but otherwise asymptomatic or for those that were previously infected with COVID-19 but have recovered (5).
Each case should take into account the urgency of transplant and the potential risk to the recipients, as well as consider isolation interventions if organs are used.
Living donors with travel to a high-risk area in the last 14 days should be deferred until 14 days from travel. Potential living donors can be advised to not travel to areas where local transmission is occurring and to report new-onset cough and flu-like symptoms. Routine testing of living and deceased donors for COVID-19 is not suggested at this time. This may evolve over time as the outbreak situation evolves. The current outbreak is unpredictable. If widespread community-transmission occurs, healthcare infrastructure and capacity issues may have a further impact on donation and transplantation (1,2).
Are there any treatments for COVID-19?
Currently, the treatment is supportive care. Potential antiviral candidates are undergoing testing and vaccines are under development. However, it may be several months before any of these are approved (4,7).
La Paz University Hospital, TransplantChild Coordinator Centre, is organizing the II Solidary Run for Paediatric Transplantation. It will take place on March 15th in Madrid. This event aims to make visible the importance of treatment and research in transplantation in children. Registration is already open!
Check the website for more information and registration:
We are organizing the 2nd TransplantChild workshop on translational research: "Novel strategies in paediatric transplantation". We wanted to know if you wanted to collaborate with the course by giving some support or disseminating this email.
The workshop will take place in Warsaw, Poland, on May 14th 2020. The main aim is addressing training in the area of paediatric transplantation according to the holistic approach of the network, providing skills to perform a common and transversal approach to all types of paediatric transplantation procedures. This edition will be focused on medical and nursing teams involved in the follow-up of paediatric transplanted patients.
Registration for the workshop is already open. You can also submit your abstract and be eligible to obtain a grant that will cover the workshop fee. You can submit an abstract for the following categories:
The registration form, abstract submission and all the workshop information is available on the website: https://www.transplantchild.eu/course2020/workshop/
Paediatric ERNs Crosslinks: The story of Íñigo
Helping patients with low-prevalence rare or complex diseases.
Story of Paula
end-stage disease with a more sustainable chronic disease state and as such has profound clinical and psychosocial consequences, even more challenging in children, with more impact on the growing process.
Is a cross-cutting approach to supports common areas in different types of transplants as immunosuppression, rejection, tolerance, risk of infection and psychosocial wellbeing.
Transplanted children shift their primary disease to lifelong chronic condition or `disease´, mostly imposed by the necessary treatment regimens to avoid rejection.
This network is initially integrated for 18 HCP from 11 Members States with highly qualified multiprofesional teams and proven experience in PT.
TransplantChild is one of the 24 European Reference Networks (ERNs) approved by the ERN Board of Member States. The ERNs are supported by the European Commission.