February 27, 2020

The concern for global spread of the coronavirus strain, Covid-19, initially found in Wuhan, China must be recognized by the organ transplant community.  To our knowledge, Covid-19 has not been described in blood, tissue or organ transplant recipients. However, as with SARS and MERS infections that were reported in transplant recipients during their outbreaks, it is likely just a matter of time.(1),(2)  Prior experience suggests that there will be a spectrum from asymptomatic to severe illness and that viral shedding (and risk of transmission to others) may be prolonged in organ recipients.

The risk of a recipient obtaining the virus from a donor is low, however, it is important to note that 15% (6/41) of people admitted with confirmed Covid-19 had viral RNA identified in the plasma. The risk of contracting the virus from an organ of an infected donor is real but unknown. Human-to-human spread occurs primarily through respiratory droplets, but the virus is also present in other bodily secretions with an undetermined duration of viremia and shedding.(3)  As there are no readily available screening tools or therapies, the community must rely upon general concepts. The Transplantation Society and the US Organ Procurement and Transplant Network (OPTN/UNOS) have released guidelines regarding Covid-19.(4),(5)

General consensus has led to the following recommendations:

1. Organ donation: Be cognizant of respiratory symptoms in donors and query for fever or acute illness symptoms. Avoid deceased and living organs retrieved from donors within endemic/high prevalence areas. If a live donor has been within an endemic area, wait at least 14 days (presumed incubation period) for symptom development prior to proceeding with donation.
2. Candidate: Avoid transplanting and immunosuppressing someone with developing or active disease. The recommendation of waiting 14 days if the candidate traveled through an endemic area is current, but subject to change. Clinical prudence is paramount.
3. Recipient: Respiratory viruses in transplant recipients can be severe. It is unclear whether the transplant recipient is more susceptible to acquiring acute infection. The uninfected recipient should take respiratory precautions and wash hands frequently and thoroughly. Respiratory isolation and supportive therapy is the first line treatment for people who contract Covid-19. This is true for transplant recipients as well. While there is no proven effective antiviral treatment, the field is rapidly evolving.
4. Healthcare team and uninfected individuals: There is a proven risk of patient-to-provider disease transmission. It is incumbent that all organ donor teams, transplant providers and support staff are aware of the risks and take appropriate respiratory contact precautions. Frequent hand washings (at least 20 seconds with soap) and frequent disinfection of surfaces is recommended. Avoid hand-face contact as much as possible. Avoid close contact with coughing or sneezing individuals that may have viral infections. If contact is unavoidable, use of a N95 mask and eye cover is recommended.

Updates of recommendations should be followed on the CDC or WHO information web pages.

Timothy Pruett  & Varvara Kirchner

Infectious Diseases and Liver Transplantation SIG Topic Coordinators

1. Kumar D., Tellier R., Draker R. et al., Severe Acute Respiratory Syndrome (SARS) in a Liver Transplant Recipient and Guidelines for Donor SARS Screening. Am J Transplant. 2003 Aug;3(8):977-81.
2. AlGhamdi M., Mushtaq F, Awn N., et al., MERS CoV Infection in Two Renal Transplant Recipients: Case Report. Am J Transplant. 2015 Apr; 15(4):1101-4.
3. CDC: https://www.cdc.gov/coronavirus/2019-ncov/index.html
4. TTS:https://tts.org/23-tid/tid-news/657-tid-update-and-guidance-on-2019-novel-coronavirus-2019-ncov-for-transplant-id-.%20%20
5. OPTN/UNOS:https://optn.transplant.hrsa.gov/news/information-for-transplant-programs-and-opos-regarding-2019-novel-coronavirus/