key: cord-0812705-rcx3mh5p authors: Tantisattamo, Ekamol; Ferrey, Antoney J.; Reddy, Uttam G.; Ichii, Hirohito; Dafoe, Donald C.; Kalantar‐Zadeh, Kamyar title: Haddon Matrix for Kidney Transplantation during COVID‐19 Pandemic: A Problem Solving Framework for Present and Future date: 2020-06-20 journal: Transpl Infect Dis DOI: 10.1111/tid.13373 sha: 923822f7bb8ac2697700fec857a2520d2ddf1173 doc_id: 812705 cord_uid: rcx3mh5p Novel coronavirus disease 2019 (COVID‐19) pandemic is a public health emergency with several million worldwide and a quarter of a million and soon half a million deaths including a third in the United States alone (as of May 10, 2020).(1) It affects kidney transplantation and has caused mortality in waitlist dialysis and transplant patients.(2,3) This inevitably raises questions about the practicality and direction of transplant surgeries during this critical period. Tables: 1 tables in main body. To the Editor Novel coronavirus disease 2019 (COVID-19) pandemic is a public health emergency with several million worldwide and a quarter of a million and soon half a million deaths including a third in the United States alone (as of May 10, 2020). 1 It affects kidney transplantation and has caused Accepted Article mortality in waitlist dialysis and transplant patients. 2, 3 This inevitably raises questions about the practicality and direction of transplant surgeries during this critical period. Haddon matrix is a framework used for injury prevention and response strategies (table 1) . It has also been used with previous pandemics including influenza and SARS 4, 5 , and may be applied to transplantation during the current COVID-19 pandemic. The matrix investigates host and environmental factors (physical and sociocultural) during three time points: pre-event, event, and post-event. 6 The proposed application of the Haddon matrix during current COVID-19 pandemic by considering host, agent (SARS-CoV-2), and environmental factors from pre-transplant through posttransplant periods is shown in the table 1. The Haddon matrix paradigm primarily guides providers to identify strategies to minimize COVID-19 infections amongst their transplant patients. In a broader context it can be applied to the transplant community at large and facilitate strategic relationships between transplant centers. For example centers located in highly impacted areas will have reduced healthcare resources and transplantation may be temporarily halted while healthcare resources are pooled for critically ill patients. 7 A strong relationship with a center that has not yet been affected or has overcome the largest anticipated spike may allow some patients from the struggling center to be transplanted at the sister facility rather than waiting for their center to re-open. The risk of death from COVID-19 versus the risk of remaining on dialysis for patients with ESRD must be carefully considered. 8 Although highest fatality from COVID-19 is among individuals aged ≥85 years (10-27%), the mortality ranges from <1% to 1-3% among persons aged 20-54 and 55-64 years, respectively. 9 Additionally, under detected cases likely overestimate reported fatality. In comparison the mortality of patients with ESRD is 20-25% after 1 year of dialysis and their survival rate at 5-years is only 35%. 10 Notably kidney transplant waitlist candidates are generally healthier This article is protected by copyright. All rights reserved Although applying the Haddon matrix framework to transplantation can be helpful, some unmodifiable factors including our limited understanding of SARS-CoV-2 may limit its' utility in efforts to prevent and control COVID-19. SARS-CoV-2 is highly contagious and has a wide spectrum of clinical presentations making it difficult to detect all cases when screening occurs by symptoms in each transplant phase. The accuracy of the diagnostic methods for SARS-CoV-2 both RT-PCR and antibody testing in transplant recipients needs further study. 11 Moreover, prioritized healthcare resources for emergency or critically ill patients during the pandemic may decrease the number of kidney transplantations and may further limit availability of resources to optimize the control of COVID-19 in immunosuppressed patients during the post-transplant phase. Implementation of the Haddon Matrix cannot be achieved unless it is integrated into an institutions policies and procedures that can be modified as this disease continues to evolve. 4 Applying this matrix is a dynamic process and by its nature requires the provider to re-visit and re-evaluate the ever-changing situation. The information gathered during this pandemic will help pre-emptively identify future problems and better prepare the transplant community for future unprecedented infectious outbreaks. Division of Viral Diseases. Cases of Coronavirus Disease (COVID-19) in the U.S A Case of Novel Coronavirus Disease 19 in a Chronic Hemodialysis Patient Presenting with Gastroenteritis and Developing Severe Pulmonary Disease The Columbia University Kidney Transplant Program. Early Description of Coronavirus 2019 Disease in Kidney Transplant Recipients in New York. JASN 31: ccc-ccc A systematic analytic approach to pandemic influenza preparedness planning The application of the Haddon matrix to public health readiness and response planning The changing approach to the epidemiology, prevention, and amelioration of trauma: the transition to approaches etiologically rather than descriptively based Coronavirus disease 2019: Implications of emerging infections for transplantation COVID-19: A global transplant perspective on successfully navigating a pandemic Severe Outcomes Among Patients with Coronavirus Disease USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases Interpreting Diagnostic Tests for SARS-CoV-2