Donor and transplantation activity during an epidemic
Author: Chief Phys. Danica Avsec, MD, Spec. Anesth. Institute of the Republic of Slovenia for the Transplantation of Organs and Tissues Slovenija-transplant
In this article, we share how Slovenia-transplant responded to the crisis situation in a very early phase of the crisis.
The main purpose of the publication is to outline our experiences, which will motivate us through the BRAVEST project.
From the very beginning of the Covid-19 pandemic, our main concern has been how to keep the transplant programme alive because of our responsibility to the patients on the waiting list. Given the complexity of the transplantation activity, we had to take care of the donor and recipient programme, international cooperation in the field of Eurotransplant and follow the very rapidly changing instructions of the Slovenian government and international health authorities. In addition, it was necessary to follow the instructions regarding transport within the country and across the border to all Eurotransplant countries. The implementation of preventive measures to control the spread of the disease and maintain the trust of the general public and medical personnel could only be maintained on the basis of honest and adequate communication using modern means. The most suitable were regular and very frequent web meetings with local experts, the media and with colleagues in transplantation programmes. Besides all the demanding issues we, as all other countries, were facing due to the new situation, even the lack of medical human resources and a number of beds in intensive care units, as well as lack of preventive measures capacities mixed with a strong fear among health care personnel, patients and in the open public.
Based on vigilance, responsibility towards recipients, preparation and constant renewal of national guidelines, being flexible in the usage of modern communication means and strong international cooperation, we managed to keep transplant medicine active throughout the entire period of the Covid 19 pandemic. Finally, the results were even better compared to the previous (2019) year.
Introduction
Modern medicine and society have never before been confronted with a health phenomenon of such global proportions as COVID-19. The epidemic, with its persistence and unpredictability, has radically affected our public and private lives. In Slovenia, the first confirmed case of infection occurred on 4 March 2020. A quarantine was declared on 12 March 2020, international air passenger traffic was suspended on 17 March, and a number of restrictive government measures were introduced. With all the upheavals within the health system, transplantation activity - which is essentially multidisciplinary and transversal - has also faced uncertainty. In cases of international exchange of organs within Eurotransplant (ET), rapid international transport is also essential. In this article, we share how we at Slovenia-transplant responded to the crisis situation in March 2020 (which was a very early phase) in order to outline our experiences which will motivate us throughout the BRAVEST project.
Background
Due to the close geographical proximity to Italy, one of the disease hotspots in Europe, the risk assessment was higher in our country. As the national competent institution for the coordination of donor and transplantation activities in Slovenia, we issued instructions regularly to the professional public in coordination with the management of the Transplantation Centre at the University Medical Centre Ljubljana (UMCL), and in line with the epidemiological landscape and the available capacities (human resources, physical space). We established communication (regular video conferences) with members of the national donor network, central hospital coordinators and the UMCL Transplantation Centre. The first general guidelines for the prevention of the spread of infections in the donor programme were issued on 28 February, before the first confirmed case of COVID-19 in Slovenia. Through regular communication, updating of the guidelines and appropriate measures, we managed to ensure emergency transplants and to maintain activity in the donor programme at a level comparable to pre-Covid 19-period results.
COVID-19 and transplantation activity
Infectious diseases are known risks in transplantation medicine. Several epidemics have occurred in the last 50 years, ranging from Ebola, Zika virus, West Nile virus, HIV, A/H1N1 (“swine flu”) and H5N1 (“bird flu”) influenza to SARS. All previous epidemics have been geographically and/or demographically contained, and with appropriate preventive measures, the introduction of tests, transmission assessments, good information for recipients, the establishment of additional programmes (e.g., Infected for the HIV-infected), transplantation medicine has been successful in limiting the spread of infections and protecting recipients (1). However, in the context of the COVID-19 health crisis, the consequences influenced on donor and transplantation medicine on a global scale importantly. Healthcare activities were limited to emergency procedures and examinations, and certain hospital wards and intensive care units (otherwise crucial for the identification of deceased donors) focused on the treatment of COVID-19 patients. A key obstacle was the lack of staff and space. The risk of transmission of infection from donor to recipient was also unclear, and recipients are known to be at higher risk in the post-operative period (3). Internationally, the response to the epidemic has not been uniform, with countries largely restricting donor and transplantation programmes as a precaution, suspending living donor (kidney) programmes, postponing non-emergency and elective procedures and pancreas transplants from deceased donors, as well as introducing testing of donors and recipients for Sars-CoV-2 infection (either mandatory or depending on the epidemiological landscape and risk assessment) (2). COVID-19 tests on the market had different qualities, and there was a lack of clear records on the sensitivity and susceptibility of tested samples (5). In Slovenia, mandatory testing of all donors and recipients using nasopharyngeal swabs was introduced on 9 March. Preliminary data showed that the biggest reduction in transplant activities greater than 60%, was observed in epidemic hotspots and in more successful transplant countries such as Spain, Italy, France, the UK, and the USA (4). Among countries covered by Eurotransplant, only Belgium and Hungary experienced a decline in the number of active deceased donors (6).
However, in the time of an epidemic and other crisis periods, the rapid and collective response of the international transplantation community sharing experiences and experimental observations is encouraging. (8).
Reorganisation of workload at Slovenia-transplant
We responded quickly to the crisis situation caused by the COVID-19 epidemic. We took appropriate professional measures to minimise the risks for both medical staff and patients while at the same time avoiding cessation of activities in the after-death donation programme or international cooperation with Eurotransplant. Moreover, our recipient programmes were adjusted. On 16 March, we reorganised the workload in the Slovenia transplant office. We ensured the permanent and ongoing presence of two colleagues, central hospital coordinators, in the office while the rest of the staff continued to work from home. We have arranged remote access to data, adopted the relevant internal documents on temporary home working and introduced reporting instructions. Two video conferences (VCs) via Skype per day were introduced to coordinate the workload of the team. The work was carried out smoothly, without interruptions. We also linked the teams in the national donor and recipient programme through regular weekly VCs. On 12 March 2020, the general public was invited via our website and on social media (Facebook, Twitter) to choose the electronic route to register in the national register for post-mortem donation.
Actions taken in donor and transplant programmes
The most critical week was from 9 to 13 March 2020, when radical decisions and tightening of government measures took place in Slovenia. Confirmed infections among healthcare staff emerged, and panic about the development of an “Italian scenario” began to develop. Routine work was disrupted, Slovenia-transplant faced uncertainty, and planning three days in advance for the permanent availability of teams in the donor programme was not possible. Staffing and space constraints emerged. The emergency self-isolation of staff (due to contact with infected people) at the UMCL Division of Neurology meant that it was not possible to ensure the permanent availability of teams for the diagnosis and confirmation of brain death by EEG (we therefore temporarily introduced protocols B and C on 11 March). During the period from 28 February to 31 March, while regularly monitoring the evolution of the epidemic and the response in the transplantation profession, we issued five updated instructions for stakeholders in the national donor and transplantation programme. We have developed a 6-step plan to respond to the evolution of the epidemic: 1. suspension of the live donor programme, mandatory testing (9 March); 2. suspension of acceptance of offers and pancreas transplants (12 March); 3. suspension of elective kidney transplants from deceased donors (12 March); 4. adjustment of criteria for liver, heart, kidney, lung transplants (19 March, 27 March); 5. maintaining only emergency transplants; 6. suspension of all donor and transplantation activities.
In view of the evolution of the epidemic in our country, we stopped when we reached step 4. For a more detailed view of the measures taken, see www.slovenija-transplant.si (9).
Statistics on donor and transplant activity:
The results show that the activities in the donor programme are comparable to the previous year. However, there was a higher level of refusals of donation by relatives. Qualitative evaluations of the interviews suggest that three refusals were indirectly related to the COVID-19 epidemic (relatives were not allowed to enter the hospital, the feeling of being inadequately treated, and direct and personal communication between health personnel and relatives was hindered). No donor tested positive for Sars-CoV-2.
Cooperation with Eurotransplant
Our cooperation with Eurotransplant members was maintained despite a number of restrictions. Chief Phys. Avsec participated in weekly VCs, where mutual coordination and reporting on the situation in the respective countries took place. The most important task for all members was to use as many organs as possible to treat and save lives despite the crisis.
We duly fulfilled our mandate, ensuring international transport and adequate protection for all operators. We did not ban foreign donation teams from entering donor centres in Slovenia. During the epidemic, from 12 to 31 March, we received 21 organ transplant notifications from the ET. We accepted 4 and refused 17. 9 kidneys were refused due to the epidemiological situation (COVID-19) and the suspension of the kidney transplantation programme. We did not neglect the organ quality criteria, as these ensure better and longer survival of patients after transplantation.
Conclusion
During the unstable time of the epidemic, we managed to maintain the activity of the donor programme and to carry out emergency transplants in an exemplary and panic-free manner compared to other countries. It has been shown once again how important Eurotransplant membership is for a small country like Slovenia. Without cooperation, we would not have been able to provide suitable organs for highly urgent cases nor find suitable recipients from our donors. The changed way of working has also brought some positive outcomes. We have found that regular video calls with colleagues in the national programme are an effective and convenient way of communicating to exchange views, knowledge and opinions on an ongoing basis. They allowed us to adapt quickly and well to the changed situation. We will continue to use them in the future. However, after the partial stabilisation of the spread of infection at the beginning of April 2020, we had already begun to consider the ethical and long-term implications of limiting our activities. The statistical analysis of organs procured and transplanted among Eurotransplant countries (124 organs were not transplanted for various reasons) also pointed, among other things, to the problem of suspending the programmes and the consequent refusal of the organs offered. This only prolongs the waiting time of all those on the lists in need of such treatment.
The described procedures and preventive measures used in Slovenia during the Covid-19 crisis can be taken into account in one of the final results of the Bravest project, which is the Guidelines for crisis situations in general.
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