key: cord-0873577-9sa8nwl5 authors: Servin‐Rojas, Maximiliano; Olivas‐Martinez, Antonio; Ramirez Del Val, Fernando; Torres‐Gomez, Armando; Navarro‐Vargas, Luis; García‐Juárez, Ignacio title: Transplant trends in Mexico during the COVID‐19 pandemic: Disparities within healthcare sectors date: 2021-09-15 journal: Am J Transplant DOI: 10.1111/ajt.16801 sha: 1cd7d81b0a1de6c833512304805049e890e079b7 doc_id: 873577 cord_uid: 9sa8nwl5 Healthcare systems worldwide were challenged during the COVID‐19 pandemic. In Mexico, the public hospitals that perform most transplants were adapted to provide care for COVID‐19 patients. Using a nationwide database, we describe the first report of the impact of COVID‐19 and related transplantation healthcare policies in a middle‐income country by comparing statistics before and during the pandemic (pre‐COVID: March 2019–February 2020 vs. COVID era: March 2020–February 2021) and by type of institution (public vs. private). The global reduction in transplantation was higher in public institutions compared with private institutions, 89% versus 62%, respectively, p < .001. When analyzing by organ, kidney transplantation decreased by 89% at public versus 57% at private, p < .001; cornea by 88% at public versus 64% at private, p < .001; liver by 88% at public versus 35% at private, p < .001; and heart by 88% in public versus 67% at private institutions, p = .4. The COVID‐19 pandemic along with the implemented health policies were associated with a decrease in donations, waiting list additions, and a decrease in transplantation, particularly at public institutions, which care for the most vulnerable. AJT SERVIN-ROJAS Et Al. into COVID-19 units; most noncorneal transplants are performed in these centers, and they belong to the public sector. The need for ventilators and intensive care unit beds has deprived surgical capacity all over the world. 5 Solid organ transplantation has not been an exception, and the number of transplants has substantially decreased across the world. 6 In addition, there are concerns regarding safety after solid organ transplantation, as recipients could be at an increased risk for severe COVID-19. In April 2020, the American Society of Transplantation (AST) and other transplant societies suggested the suspension of nonurgent transplantations in communities with a high burden of the disease to avoid exposing both the donor and the recipient. 6, 7 In Mexico, all transplant programs are regulated by the government agency Centro Nacional de Transplantes (CENATRA, National Transplant Center). In March 2020, CENATRA agreed with the recommendations of the National Transplant Organization of Spain and the Transplant Society of Latin America and the Caribbean in limiting solid organ transplants to life-saving procedures, such as liver and heart transplants. Elective procedures were canceled during the periods of high transmission to avoid the exposure of patients, donors, and healthcare workers. 8 As a result, from March to June 2020, donation and transplantation were greatly reduced in Mexico. It was until late June 2020 when the plan to reactivate transplantation was launched. A traffic light system with four increasing levels represented by different colors (green, yellow, orange, and red) was implemented in Mexico to regulate public health restrictions. Hospitals with an appropriate number of healthcare workers, hospital, and intensive care unit (ICU) beds, laboratory and imaging services, and COVID-19-free zones could perform transplants with an internal committee approval. As of June 6, 2021, 5831 patients are on the waiting list for a cornea transplant, 16890 for kidney, 48 for heart, and 323 for a liver transplant. 8 Our work aims to describe the impact of COVID-19 on Mexico's liver, kidney, heart, and corneal transplants during March 2020 to February 2021 compared with March 2019 to February 2020. We hypothesized that the implemented COVID-19 policies had more impact on the transplant programs of public institutions than those of private institutions. We conducted a retrospective review of the publicly available database of Mexico's National Transplant Registry. 9 The database includes information from all transplants performed in Mexico from January From March 2019 to February 2021, a total of 8593 transplants were performed in Mexico. Cornea was the most performed transplant (n = 4729, 55%), followed by kidney (n = 3551, 41.3%), liver (n = 273, 3.2%), and heart (n = 40, 0.5%). Most of the transplants were performed during the pre-COVID era (n = 7136, 83%), whereas only a minor proportion were from the COVID-era (n = 1457, 17%). The global reduction in the transplant volume from the pre-COVID era to the COVID-era was 80%. Overall, age and sex were similar among patients undergoing kidney, corneal, liver, and heart transplantation during both time periods. At public institutions, live donor kidney transplantation decreased by 8% while live donor liver transplantation increased by 20%, from the pre-COVID to the COVID-era. The type of donor was similar between both eras at private institutions. The distributions of live and deceased donors for kidney, cornea, liver, and heart transplants are displayed in Table 2 and Table 3 . A marked decrease in organ procurement from deceased donors occurred during the study period. In the pre-COVID era, there were a total of 7222 organ donations, whereas in the COVID-era there were only 981. This represents a reduction of 86% when comparing both periods. Waiting list additions were also reduced by 70% Table 4 . Our study reveals the impact of the COVID-19 pandemic in the national transplant program in Mexico. This is the first report of this type in a middle-income country using a nationwide database. There was a shortage of personal protective equipment and poor working conditions leading to a high rate of SARS-CoV-2 infections, the highest rate among healthcare workers in the world. 14 In June 2020, they represented 21% of all individuals with laboratory-confirmed SARS-CoV-2 infection, 15 and some institutions had to close due to COVID-19 outbreaks. 14 Afterward, vulnerable personnel were removed, reducing the workforce in public institutions, and increasing the workload and psychological burden of the remaining personnel. 16 The strategy of the Mexican government has been heavily criticized. 11, 18 During the initial stage of the COVID-19 pandemic, there was a lack of consistency among the case definitions and algorithms between institutions, and to make matters worse, access to diagnostic tests was also heavily restricted. 16 The government focused on increasing hospital capacity, mass communications for hygiene measures and social distancing. 19 A limited testing strategy and the lack of contact tracing along with an early reopening of the economy led to an accelerated transmission of the virus during the following months. 11, 18, 20 Another obstacle to resuming transplantation in Mexico was the burden of the disease in the community. 8 The public healthcare institutions in Mexico care for the most vulnerable population of patients, 24 while private institutions care for the wealthiest patients; it is estimated that only 1% of the population has access to them through private insurance of personal funds. 25 COVID-19 has increased and exposed existing healthcare disparities among patients with high and low socioeconomic status. 26 In 2012, 49% of Mexican population had no access to healthcare under the former Seguro Popular, 27 a government program aimed to guarantee universal access to healthcare, particularly in vulnerable populations. According to a study, the population living in marginalized regions have lesser access to healthcare and a lower number of physicians compared with regions with higher income (fewer than 5 vs. nearly 20 physicians per 100 000 inhabitants, respectively). 28 To complicate things further, a new health system was implemented a few months before the pandemic to substitute Seguro Popular with no intentions of including private institutions; increasing the fragmentation of the Mexican health system. 29 These disparities were also ob- The number for each organ represents the total number of transplanted patients during a specific era. *p-value obtained with a chi-square test for independence. Pre-COVID COVID-era Pre-COVID COVID-era Fragmented health systems in COVID-19: rectifying the misalignment between global health security and universal health coverage Mexico needs a fiscal twist Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services COVID-19 and solid organ transplantation: a review article American Society of Transplantation. 2019-nCoV (Coronavirus): FAQs for organ transplantation Covid-19: How denialism led Mexico's disastrous pandemic control effort Secretaria de Gobernacion ACUERDO por el que el Consejo de Salubridad General reconoce la epidemia de enfermedad por el virus SARS-CoV2 (COVID-19) en México, como una enfermedad grave de atención prioritaria, así como se establecen las actividades de preparación y respuest Health and institutional risk factors of COVID-19 mortality in Mexico, 2020 The coronavirus disease (COVID-19) challenge in Mexico: a critical and forced reflection as individuals and society. Front Public Health Clinical characteristics and mortality of health-care workers with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in Mexico city Health-care guidelines and policies during the COVID-19 pandemic in Mexico: a case of health-inequalities Experience with Covid-19 critically Ill patients in a private community hospital in Puebla city Mexico and the COVID-19 Response linea mient o-estan dariz ado-para-la-vigil ancia -epide miolo gica-y-por-labor atori o-dela-enfer medad -respi rator ia-viral Health Policy Issue Brief: COVID-19 in Mexico, an imperative to test, trace, and isolate. OSF Prepr Organ procurement and transplantation during the COVID-19 pandemic Stable and safe organ procurement and transplantation during SARS-CoV-2 pandemic in Germany Transplant programmes in areas with high SARS-CoV-2 transmission Reforma integral para mejorar el desempeño del sistema de salud en México Acceso efectivo a los servicios de salud: operacionalizando la cobertura universal en salud Racial and ethnic health disparities related to COVID-19 Effective access to health care in Mexico Addressing inequity in health and health care in Mexico Restructuring health reform, Mexican style workers, low ICU capacity, uncontrolled viral transmission in the community, and the lack of exclusive transplantation and donation centers were important factors that limited the number of transplants at public institutions. Better resource allocation and tailored health care policies are required to maintain transplantation during times of crisis at public institutions. Absence of such interventions leaves the most vulnerable population unable to access lifesaving procedures. The authors would like to thank Dr Alice Gallo De Moraes for her help with style corrections. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation. This article earned the Open Data Badge for transparent practices.The data are publicly available at https://datos.gob.mx/busca/ organ izati on/cenatra. The data that support the findings of our study are openly available in Datos Abiertos CENATRA at http://cenat ra.salud.gob.mx/trans paren cia/datos -abier tos/datos_abier tos_trasp lantes.html, reference Luis Navarro-Vargas https://orcid.org/0000-0002-6003-0303Ignacio García-Juárez https://orcid.org/0000-0003-2400-1887