key: cord-1000942-4byjbw6k
authors: Kute, Vivek B; Tullius, Stefan G; Rane, Hemant; Chauhan, Sanshriti; Mishra, Vineet; Meshram, Hari Shankar
title: Global impact of the COVID-19 pandemic on Solid organ transplantation
date: 2022-02-10
journal: Transplant Proc
DOI: 10.1016/j.transproceed.2022.02.009
sha: e73b3b33098b4f47a4050fe7c841b015d576f475
doc_id: 1000942
cord_uid: 4byjbw6k

INTRODUCTION: COVID-19 has drastically impacted the transplant services, but there is limited understanding the discrepancy in COVID-19 impact over various regions of the world. METHODS: We have explored the global observatory for organ donation and transplantation (GODT) data for assessing the transplant number changes between the calendar year 2019(n = 157301) and 2020(129681). RESULTS: There was disproportionate impact of COVID-19 for different areas of the world. Globally, there was a decline of 17.5%, in which deceased donation, kidney (20.9%), pancreas (16.2%), lung (12.7%), liver (11.3%) and heart (8%) transplantation declined disproportionally in different regions of the world. While pandemic affected almost all geographic regions and nations, but China and USA were mostly able to recover from the initial halt of the transplant practices by the pandemic, so that there was a cumulative increase in transplant numbers. CONCLUSION: Our data, shows that developing nations lagged behind and developed nations have been able to recover their transplantation programs in the pandemic. Further policy making and preparedness is required to safeguard the most vulnerable areas of the world to minimize the impact of any future pandemic in transplantation practices.

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Globally, as on January 21, 2022, there have been 340,543,962 confirmed cases of COVID-19, including 5,570,163 deaths, reported to the World Health Organization (WHO). As of 18 January 2022, a total of 9,571,502,663 vaccine doses have been administered. The Coronavirus disease has reached almost all parts of the world with a fiercer impact in America and the Indian subcontinent. 1 Transplantation communities across all regions of the world have been affected. 2, 3 Of additional concern are data showing that solid organ transplantation (SOT) recipients had higher mortality rates. 4 SOT was drastically affected by COVID-19 in many countries worldwide including the USA, 5 France 6 Spain 7 Australia, 8 China, 9 and India. 10 Globally, deceased donation (DD) was most affected in developing nations while live donations have been more prominently affected in developed nations.

Differences in transplantation rates among developed and developing nations may be addressed by establishing and optimizing deceased donor programs 11 in developing nations and expanding living donor transplantation program in developed nations. The aim of this report was to explore the differences of impact of COVID-19 over transplant services in different regions of the world.

We have explored the global observatory for organ donation and transplantation (GODT) data base for transplant numbers from various geographic areas, and compared the percentages in the two years of 2019 and 2020. No ethical committee review was required, as this is a secondary analysis of the publicly available database for the transplantation. Data is summarized as absolute numbers and in per million population. The data was expressed as frequencies and percentages. No statistical analysis was used for the report Results: We analysed the data from the GODT for the years 2019 and 2020 12 and present details on how SOT activities have been affected by the pandemic concentrating on six geographic regions ( Table 1 ) of the WHO, including those that have been most affected by COVID-19 ( Table 2) . Globally, DD declined by 11.5% and the decrease in DD was most dominant on the Indian subcontinent (50.9%) followed by the Eastern Mediterranean region (40.2%), UK (24.5%), Europe (19.6%), Brazil (19.6%) western pacific region (10%), and North America (3.5%). Globally, donations after circulatory death (DCD) declined at a lower rate compared to brain death donors (DBD) (9% vs 12.2%). Conversely, in western pacific region, DCD declined by 25% compared to a rather increase in DBD by 11% from the pre-pandemic year.

Furthermore, in contrast to other areas of the world, in USA the DCD improved by 12% and DBD by 2%. Globally, living donor kidney transplantation (LDKT) has been most affected, with a 33% decline. In India, the steepest decrease has been seen for DDKT (54.6%) compared to a 42.3% drop for LDKT. Globally, the decline in LDKT was most prominent in the Eastern Mediterranean region (60%), followed by the Brazil 

Our report clearly highlights the differential pattern of impact and different recovery rates of transplant services across the world. The discrepancy in decline of DD in different areas emphasizes on the relevance to optimize DD policies and practices in emerging societies with DD expected to be most vulnerable during future pandemics.

Those data indicate that DCD donation is playing an important role in contributing to an optimized utilization of available organs for transplantation in developed countries. Indeed, recent high-level data support that well-established DD programs show also favourable outcomes with DCD 13, 14 . Ratios of DCD/BDD in addition to hospital and staff capacities may also play a role. In the initial phase of the pandemic, many regions have avoided DCD/marginal organs for fear of prolonged hospital stays in addition to a higher probability for complications. Clearly, optimizing the balance between available resources with an enhanced utilization of available organs will be most relevant in preparing for the next pandemic. Additionally, support by the global community emphasizing on strengthening DD programs will help moving transplantation in emerging countries forward.

This trend of a better cope in living donation in nations like India, may be explained with an effective application of guidelines for living donor transplantation 15 .

Moreover, DD is still in its infancy in emerging countries while logistics for resuming DD during the pandemic were highly unfavourable and less prioritized. 16, 17 Of additional interest, the decline of LDKT differed between public and private sector hospitals in India. 18 Living donation remained suspended in major public sector programs for an extended period with the care of COVID-19 patients considered a health emergency. With treatment alternatives for end stage kidney disease and LDKT being mostly elective, the drop in LDKT is not entirely surprising. In addition, there is still a wide variation in testing strategies and protocols for transplantation in the pandemic across different centres worldwide.

SBT is mostly an emergent procedure, and the rising volume indicates the success of the policies for a smooth conduct of emergency surgeries in the pandemic 19 .

Notably, SBT are performed in low numbers independent from the pandemic and data may thus need to be interpreted with caution. An interesting case report of a SBT post-COVID-19 in a child that developed small bowel gangrene subsequent to an SMA thrombosis has been reported recently 20 . Although a rare complication of COVID, it is expected that transplants in patients developing end-stage-organ failure subsequent to COVID will become more frequent. Transplantation volumes varied across geographic areas and depended also on overall stability of health care. As an example, developing nations including India that have been overwhelmed by the increasing demand of taking care of COVID patients will have less capacity to transplant. Strengthening deceased donation program particularly in developing countries will be of paramount importance. The stability of deceased donor organ systems in some countries including the USA has shown that the decline of transplant volumes can be compensated quickly. Organ specific discrepancies shows, triaging of life saving transplantation preferred over elective procedures. Mutual support and international co-operation, bold policy and guidelines, and continued sharing of knowledge and research is needed to respond to future pandemics. Saying that, we understand that the transplant community has done an excellent job in communicating information rapidly. Table 3 : Pandemic preparedness plan  Rapid implementation of telemedicine, Telehealth, machine learning, and remote monitoring for follow-up,  Assessing the scope of home-based therapy, door-step health care delivery  Ensuring safety of health care personnel  Increasing access to vaccines,non-pharmaceutical public health measures to prevent the spread  Addressing knowledge gaps and working towards a research preparedness network  Prompt assessment of logistics and pandemic surge during procurement to minimize wastage of organs  Effective and safe restoration of transplantation with team-work  Development of an early regional plan tackling any pandemic surge  Prioritizing waitlisted candidates for an early transplant  Relaxing routine testing protocols of donor/recipient for transplantation  Rapid testing of the pathogen  Early segregation of affected individuals from non-infected ones  Consensus statements for any change in immunosuppression Long-term policy and practices  Political mobilization and priority in managing the transplantation practices, integration, financing, resilience, and equity  National and international support, collaboration and need for global cooperation for expanding organ donation  Improving legal and institutional framework , improvement of hospital and ICU protocols for transplantation  Funding sources should be prioritized to organ donation practices  Leadership at all levels, right from transplant co-ordinators to higher authorities  Promoting education and updates at all levels during the pandemic  Implementing technological infrastructure, capacity, care, collaboration building and financial stability in preparation of the next pandemic  Universal health care, international efforts to reinforce global health security, International health regulation, international pandemic treaty  Funders, policymakers, infectious disease and public health authorities need to remain vigilant, maintain surveillance and continue to plan for the next pandemic

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