key: cord-349124-nhnl7zgi authors: de Sandes‐Freitas, Tainá Veras; Canito Brasil, Ivelise Regina; Oliveira Sales, Maria Luiza de Mattos Brito; Studart e Neves Lunguinho, Marina Seixas; Pimentel, Ítalo Rossy Sousa; Josino da Costa, Lucianna Auxi Teixeira; Esmeraldo, Ronaldo de Matos title: Lessons from SARS‐CoV‐2 screening in a Brazilian organ transplant unit date: 2020-07-13 journal: Transpl Infect Dis DOI: 10.1111/tid.13376 sha: doc_id: 349124 cord_uid: nhnl7zgi Protecting immunosuppressed patients during infectious disease outbreaks is crucial. During this novel coronavirus disease 2019 pandemic, preserving “clean areas” in hospitals assisting organ transplant recipients is key to protect them and to preserve transplantation activity. Evidence suggests that asymptomatic carriers might transmit the SARS‐CoV‐2, challenging the implementation of transmission preventive strategies. We report a single‐center experience using universal SARS‐CoV‐2 screening for all inpatients and newly admitted patients to an Organ Transplant Unit located in a region with significantly high community‐based transmission. The novel coronavirus disease 2019 (COVID-19) emerged in Wuhan, China, in December 2019 and rapidly spread to many countries around the globe. On February 25, 2020, Brazil had its first tested positive patient and, on March 16, the first patient was diagnosed in our State (Ceara, located in the Northeast of the country), which is currently the third Brazilian State with the highest number of cases. 1 Infected people usually present mild upper respiratory symptoms, favoring quickly spread of the virus. Each infected patient transmits the SARS-CoV-2 to 2-3 healthy persons. 2 It is unclear whether asymptomatic people shed SARS-CoV-2, potentially transmitting the virus. Previous studies demonstrated that asymptomatic carriers can transmit MERS-CoV, 3 and similar transmission pattern has been suggested for SARS-CoV-2. [4] [5] [6] Given the unknown contribution of an asymptomatic carrier to spread the COVID-19 and the paucity of diagnostic tests in most countries, screening strategies are not widely performed. We will describe the experience of a single center of screening all inpatients and newly admitted patients to the Organ Transplant Unit. The strategy was motivated by the occurrence of possible cases of nosocomial transmission. From this event, all newly admitted patients have been tested for COVID-19 and maintained isolated from other patients until the test result is known. On March 31, 2020, a 43-year-old man with alcoholic liver cirrhosis, hospitalized since March 23rd presented acute dyspnea and fever and was tested positive for SARS-CoV-2 (patient 1). He had severe chronic liver failure and had recently been hospitalized for similar cirrhosis symptoms. On the same day, a health professional We reported the COVID-19 screening strategy adopted by our center in a attempt to prevent nosocomial transmission and keep "clean" the Transplant Unit. This report aims to bring into the light important unanswered questions on COVID-19 and to make some hypotheses. It is known that COVID-19 is a highly contagious disease. The reported basic reproductive number (R 0 ) is 2.2, which means that, on average, one case generates 2-3 additional cases, resulting in an exponential rate of infected patients. The scarce available evidence suggests that this high transmissibility potential is a result of: (a) prolonged virus survival on surfaces; (b) transmission by respiratory and aerosolized droplets; (c) relatively low mortality, preserving the host; and (d) the possibility of transmission by asymptomatic and presymptomatic people. 2, 7 The mechanism by which asymptomatic carriers could transmit the coronavirus is still understood. However, ensuring the complete absence of symptoms is a challenge. In addition, new non-respiratory symptoms, which can initially be attributed to other pathologies, have recently been associated with COVID-19, such as abdominal pain, glomerulopathy, cutaneous lesions, conjunctivitis, encephalitis, hepatitis, myocarditis, and thromboembolic manifestations. [8] [9] [10] [11] Researchers at Columbia University Irving Medical Center, New York, recently reported their experience using universal screening for obstetrical population admitted to the hospital for delivery. From 215 interviewed pregnant women, 4 (1.9%) presented signs/symptoms and were tested positive. From asymptomatic ones, the quantitative RT-PCR was positive in 29 (13.7%). 12 As a limitation of our strategy, our RT-PCR test was qualitative and we could not estimate the magnitude of viral load, which implies the risk of transmission and possibly the chance of developing symptoms. In the context of organ transplantation, there are a lot of unanswered questions. It was suggested that lymphopenia is associate with severe clinical symptoms and death, 13 but we do not know whether the immunosuppressive drug-induced modulation on immune and inflammatory response can modify the clinical, laboratory, and radiographic presentation, as well as the outcomes. We also do not know if asymptomatic carrier transplant recipients have higher risk to develop symptoms when compared to the general population. Evidence points out that the shedding of viral RNA from sputum outlasts the end of symptoms. 14 Similar to other viral infections, it is possible that viral shedding is more prolonged in transplant recipients, suggesting that more than one swab is necessary to discontinue the isolation precautions. 15, 16 We opted not treating those patients unless they develop COVID-19 symptoms. In fact, no preventive strategy is available for contacts and for SARS-CoV-2 carriers. The aim of this report is not to identify an index case, nor correlate patient with a source of contagion, but to demonstrate that screening is possibly a good strategy to preserve "clean units" assigned to immunosuppressed patient care, maintaining transplantation activity more safely. The universal screening might guide hospital isolation practices and bed assignments, and the proper use of personal protective equipment (PPE). 12 Since the sensitivity of RT-PCR is not 100%, active and rigorous clinical investigation of subtle signs and symptoms in this population is also essential. 17 In addition, recommendations for biosafety and hospital infection control should be strictly followed, including the use of PPE and hands hygiene. Authors would like to thank the health professional team of our Transplant Unit for the dedication and resilience during this pandemic. The authors of this manuscript have no conflicts of interests to disclosure. 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