key: cord-0696167-pri2ab79 authors: Lee, Jeong‐Moo title: Effect of COVID‐19 on liver transplantation in Korea date: 2020-07-13 journal: Transpl Infect Dis DOI: 10.1111/tid.13384 sha: a0cb60957ea35697b96a0ebb8a68c35e6d8d7e62 doc_id: 696167 cord_uid: pri2ab79 COVID‐19 is now a pandemic with increasing numbers of cases and deaths. In addition to the economic and social damage caused by COVID‐19 outbreak prolongation, damage caused by delayed treatment of other diseases such as severe cirrhosis is also serious. We aimed to describe the effect of COVID‐19 on the number of liver transplants (LT) in South Korea. The number of LT performed in Korea during the Middle East Respiratory Syndrome (MERS) outbreak, and the COVID‐19 pandemic was compared with the average number of LT performed in the past 5 years. There were 108.5 cases of LT performed per month during the MERS outbreak. It was 11% lower than the average of 122.8 cases per month for the last 5 years. LDLT and DDLT decreased by 13% to 75.3 cases and by 7.5% to 33.2 cases per month during the MERS epidemic, respectively. From January to March 2020 (COVID‐19 outbreak), the number of LT did not decrease significantly. The lockdown caused by COVID‐19 did not affect the number of liver transplants in Korea. Establishing a safe process and procedure of liver transplantation within safe boundaries can be beneficial in reducing the side effects of lockdown and saving patients' lives. The campaigns of "lockdown" to restrict community activity, such as restricting all kinds of movement and social activity, and recommendations to wash hands, and wear masks have been employed worldwide. [5] [6] [7] As a result, economic indicators have declined and the economic losses of the self-employed businesses, domestic industries, and global trading companies have been increasing. 8, 9 Meanwhile, in the United States, it has been announced that the schools will be closed for a semester. In Korea, the school opening has been delayed, and also recent pediatric cases of COVID-19 have been confirmed; thus, it is unclear whether schools will be opened soon. Besides, no results from a remarkable treatment have been reported, and clinical trials are still in progress, so this situation is inevitable and prolonged until promising results are released. score. [10] [11] [12] [13] The longer the waiting period until transplantation, the worse the condition becomes, and the MELD score increases, which results in poor outcomes after transplant. 14 If the outbreak of viral diseases such as COVID-19 reduces the mobility of medical staff and the searching process for potential donor candidates, the probability of receiving a liver for transplantation is inevitably reduced. There is no doubt that the reduction of social activities and the imposed meeting restrictions due to COVID-19 have a great effect on suppressing the spread of this viral disease. The complete blockade will sometimes be the best solution, but as the pandemic period is prolonged we have to think about the opportunity cost. As transplant surgeons, we have to think about how we can perform a liver transplant (LT) as safely as possible during the pandemic period. The purpose of this study was to investigate the changes in liver transplant activity during the MERS and COVID-19 periods, two unique outbreaks that greatly affected the Korean government and people and to discuss about how it had been treated and handled to date, and how long it would last. And also I would like to discuss appropriate measures to cope with the prolonged period of this pandemic. January when COVID occurred) is that the initial response is the strongest, and this policy movement, and the anxiety of patients are most reflected in the initial outbreak and clustered infection. For statistical analysis, SPSS ver. 22 (SPSS Inc) was used and analysis through variance comparisons was made for each group. In case the P-value <.05, it was considered to be statistically significant. Between January 2015 and March 2020, the total number of liver transplants (LT) was 7808 and the average monthly number was 122.8 ± 13.6. Regarding living donor liver transplantation (LDLT), the total number was 5534 cases and the mean monthly number was 87.9 ± 12.9 cases. There were 2274 deceased donor liver transplantations (DDLT) and an average of 36.1 ± 7.2 cases per month. Also, the average annual growth rate of LDLT was 5.9% and the annual number of DDLT decreased to −3.0%, showing that the total number of liver transplants increased by 2.9% over the 5 past years ( Figure 1 ). At the time of the COVID, the average increased by 9.6% compared with the average in the 5 years, but decreased by 3% compared with the previous year, but it was not a statistically significant decrease. There are 55 transplant centers in Korea where liver transplantation can be performed (Figure 4 ). In the city where COVID-19 infection incidence was massive, major medical centers entered an emergency state during the initial outbreak in which medical resources were invested into COVID-19; thus, it was difficult to proceed with liver transplantation. However, most of the transplants are usually performed at the major 5 Hospitals located in Seoul (64%); thus, the number of total cases was not reduced. During the MERS outbreak period, the number of total cases in the initial stage was slightly decreased because the hospital ranked 3rd in the total number of liver transplants performed in Korea was affected by MERS patients; therefore, normal medical service was blocked due to MERS outbreak. Organ distribution in Korea is divided into three areas. The total number of cases was initially reduced in the third most affected region by COVID-19 compared with the same period of the previous year, The number of incidences is the 2nd highest in the world, with 185 infected (10.6% of the world's incidence) and 38 deaths (5.6% of the world's deaths). As a result, the Korean government and people realized the importance of preparation for a viral disease epidemic. 15 In Korea, the number of deceased donors per million people per year is 3.15, and the number of cases of death per year is very different from that of the Western country, in a 10-33 ratio. 19 Because of this organ shortage, living donor transplantation is the main type of transplantation performed in Korea. The case of deceased organ donations has not changed significantly in the past 5 years. Because of the small number of cases of brain-dead liver, if possible, even a marginal donor liver is attempted to be used for liver transplantation, and even if it has been refused by the first allocated transplant center for other reasons including COVIDrelated policies, the organ waste is prevented through next-order hospital waiting. As a result, the number of DDLT was similar to the previous year. Since LDLT is an elective operation, whose schedule could be adjusted, it was not as emergent as a DDLT operation; thus, the number of LDLT cases has decreased in January when there was a strong lockdown due to COVD-19. Besides, the press article about COVID-19 positivity of the donor during the postoperative period in the city in which the pandemic outbreak occurred warned the population and strongly affected the transplantation society and several transplant centers. Against this background, safe management guidelines have been propagated, the number of confirmed cases has reduced, the system for preventing inter-hospital infections, and the strong screening of COVID-19 before surgery has enabled normal LDLT procedures, whose number has remained the same in many centers. This way, the number of transplants could be maintained. A complete blockade will be the best option in the initial outbreak The limitation of this study was that it did not show the mortality of recipient candidates on the waiting list. Because the COVID-19 pandemic period is still short, and KONOS data are compiled for deaths annually, it is difficult to obtain a waiting list mortality for a certain period; thus, it was not analyzed in this study. However, it could be predicted indirectly that an increase in the waiting list mortality was not observed because the number of liver transplants did not decrease significantly during this period and there might have been no delays in liver transplant procedures. We also realized the lack of infectious medicine specialists, epidemiologists, and supporting manpower even after the MERS outbreak. After this outbreak, infectious disease experts should be assigned to university hospitals, and they are managed to operate and take responsibility for designated infectious diseases. We have been working on increasing the number of infectious medicine specialists since the MERS outbreak, but we still lack the number of investigators to handle the epidemic compared with the population number. The However, the COVID-19 is still in progress and can now be seen as a step beyond the first stage of the first outbreak. In the case of South Korea, where infections occurred in the early stages, it is considered that this stage will shift to the second stage. Rapid screening examination and transparent disclosure need to provide the public with secure boundaries and areas of activity. From a transplant surgeon's point of view, in such a pandemic situation, I am worried about how to safely reduce the patient's mortality. It is important to set up a process to perform a safe liver transplant operation under appropriate control. In Europe and the United States, where the number of confirmed persons and death is increasing rapidly, it is still considered a procedure that requires activity restrictions and regulations. However, as these are expected to move to the 2nd stage over time, the current situation in Korea is considered to be an appropriate model for those countries. In conclusion, it is important to keep a social distance. However, even in these difficult periods, setting a proper and safe process and proceeding with liver transplantation within a safe boundary has the positive effect of reducing the side effects of lockdown and saving patients' lives. With safe screening and protective systems along with the COVID-19 outbreak improvement, there was no spread nor infection of COVID-19 in the recipients during this period. The final stage of COVID-19, which is prolonged, is the normalization of everyday life and social activity through the expansion of safe boundaries. As a first step, we have to create guidelines to establish an appropriate safety process in the course of liver transplantation and other solid organ transplants along with the COVID-19 outbreak improvement. I would like to thank Editage (www.edita ge.co.kr) for English language editing. The author has no conflicts of interest to declare. Jeong-Moo Lee participated in the writing/review of the paper, design of the work, research design, performance of the research, and data analysis. The data that support the findings of this study are available from Korean Network Organ Sharing upon request. Restrictions apply to the availability of these data, which were used under license for this study. Publicly available data can be found at https://www.konos. go.kr/konosis/index.jsp. 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