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:

• fever
• cough
• difficulty breathing
• muscle pain
• tiredness

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).

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.

• CDC: https://www.cdc.gov/coronavirus/2019-nCoV/summary.html
• World Health Organization: https://www.who.int/emergencies/diseases/novel-coronavirus-2019
• In Canada: https://www.canada.ca/en/publichealth/services/diseases/2019-novel-coronavirusinfection.html

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).

Useful links:

1. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19) Situation Summary. March 09, 2020. Accessible here:  https://www.cdc.gov/coronavirus/2019-nCoV/summary.html.
2. European Centre for Disease Prevention and Control. Q & A on COVID-19. March 06, 2020. Accessible here:  https://www.ecdc.europa.eu/en/novel-coronavirus-china/questions-answers
3. British Liver Trust. Coronavirus (COVID-19) – health advice for people with liver disease and liver transplant patients. .  Updated 28 February 2020. Accessible here: https://britishlivertrust.org.uk/coronavirus-covid-19-health-advice-for-people-with-liver-disease-and-liver-transplant-patients/
4. American Society of Transplantation. COVID-19 (Coronavirus): FAQs for Organ Transplantation. Updated: February 29, 2020. Accessible here: https://www.myast.org/sites/default/files/COVID19%20FAQ%20Tx%20Centers%20030220-1.pdf
5. World health organization. Coronavirus disease (COVID-19) outbreak. Accessible here: https://www.who.int/news-room/q-a-detail/q-a-coronaviruses
6. Organ Procurement and Transplantation Network. Information for transplant programs and OPOs regarding 2019 Novel Coronavirus.  Updated 28 February 2020. Accessible here: https://optn.transplant.hrsa.gov/news/information-for-transplant-programs-and-opos-regarding-2019-novel-coronavirus/
7. The Transplantation Society. An Update and Guidance on 2019 Novel Coronavirus (2019-nCov) for Transplant ID Clinicians. Updated 27 February 2020. Accessible here: https://tts.org/23-tid/tid-news/657-tid-update-and-guidance-on-2019-novel-coronavirus-2019-ncov-for-transplant-id-clinicians