key: cord-0916533-gfkuffjq authors: Ahmed, Ola; Brockmeier, Diane; Lee, Kevin; Chapman, William C; Doyle, Majella B title: Organ Donation during the Covid‐19 pandemic date: 2020-07-13 journal: Am J Transplant DOI: 10.1111/ajt.16199 sha: c471a55d1e4e38941e0590c6887744781b39661d doc_id: 916533 cord_uid: gfkuffjq The Covid‐19 pandemic is a rapidly changing circumstance with dramatic policy changes and universal efforts to deal with the initial crisis and minimize its consequences. To identify changes to organ donation and transplantation during this time, an anonymous web‐based survey was distributed to 19 select organ procurement organizations (OPOs) throughout the US comparing 90‐day activity during March ‐ May 2020 and March – May 2019. 17 OPOs responded to the survey (response rate of 89.5%). Organ authorization decreased by 11% during the current pandemic (n=1379 vs n=1552, p=0.0001). Organ recovery for transplantation fell by 17% (p=0.0001) with a further 18% decrease in the number of organs transplanted (p=0.0001). Donor cause of death demonstrated a 4.5% decline in trauma but a 35% increase in substance abuse cases during the Covid‐19 period. All OPOs reported significant modifications in response to the pandemic, limiting the onsite presence of staff and transitioning to telephonic approaches for donor family correspondence. Organ donation during the current climate has seen significant changes and the long‐term implications of such shifts remain unclear. These trends during the Covid‐19 era warrant further investigation to address unmet needs, plan for a proportionate response to the virus and mitigate the collateral impact. When Covid-19 was first described in Wuhan in December 2019, it was difficult to envisage the global pandemic that would later ensue and the direct and indirect impact this rapidly progressing disease would have on all health systems [1] . In contrast to previous disease pandemics of more recent times, such as the Ebola virus, Swine flu and SARS all which demonstrated a substantial lethality, the fallout of these diseases seems minimal compared to the current international crisis [2] . Notwithstanding the collateral impact on economic and social constructs, the strain on global healthcare systems has been devastating with growing concerns regarding asymptomatic person-to-person transmission, infected healthcare workers, a lack of appropriate PPE and ventilator shortages [3] [4] [5] . The paucity of high-quality level-I evidence has consequently placed a reliance on institutional experiences, expert opinions and small series from the international medical community. All health services have had to re-configure the way care is delivered to patients and their families and the implications on surgical services during the current outbreak and in the subsequent "postpandemic" era are concerning and equally unclear [6] [7] [8] [9] . Organ transplantation is an exemplar model of complex major surgery with an additional challenge of managing immunosuppressed patients and the constant scarcity of organs. Organ procurement organizations (OPOs) have had to adjust to this challenging time and the current and long-term impact of this are an important facet to consider. Moreover, the transplant community has been vocal about the potential consequences of Covid-19 on services and a radical need to implement policy changes, but no study has adequately provided a quantitative assessment of organ donation practices during this time [10, 11] . Most existing studies on transplantation and Covid-19 have approached recipient related issues and medication challenges at a transplant-center level, however, little is known about the impact on OPOs and the donor service. It may be that existing social distancing measures and health policy recommendations play a role in their functionality and, on the basis of previous observations in the surgical literature, we hypothesized that the current Covid-19 crisis may have affected donor volume, organ yield and service activity [12] [13] [14] . One important question to ask is how this pandemic has altered the process of organ donation and how long it could take to address a potentially growing waiting list. Herein, we report on a consecutive cohort of organ donors and recipients during two similar timeframes to comprehensively describe the effects of a global pandemic on donation and transplantation services within the US. Specifically, we hope to define and capture the clinical significance of this new virus on organ transplantation during the initial wave and peak phase and raise questions regarding the potential consequences of the Covid-19 pandemic through measured OPO parameters. This article is protected by copyright. All rights reserved OPOs apply the same criteria for death as outlined by OPTN [15] . The rates of extended criteria donors (ECDs) during both periods were also captured, defined as donors aged 60 years or older or over 50 years with at least 2 of the following conditions; death following a cerebrovascular accident, a history of hypertension or a serum creatinine > 1.5mg/dl. In addition, OPOs were asked what institutional practice modifications were made to the organ donation process in response to the virus. There are 58 OPOs in the US and Puerto Rico, responsible for coordinating the donation process within This article is protected by copyright. All rights reserved reported data to the authors. Participation was voluntary with completion inferring informed consent. Compensation was not offered in exchange for participation. An email request with a link to the online survey was sent on April 15 th , May 1 st and June 1st 2020 and participants were asked to complete data as comprehensively as possible. The survey was open for a 2- week period and email reminders to non-responders were sent on day 10 to optimize the response. This article is protected by copyright. All rights reserved A total of seventeen OPOs responded to the survey with an overall response rate of 89.5%. All OPO responses were anonymized and no identifiable patient or OPO data was processed. Individual OPOs were questioned on the number of organ referrals received from their own DSAs during the first 90-day period from March to May 2019 and second period from March to May 2020, with the latter period demonstrating a 12.4% increase in referral activity ( Table 1 ). The greatest difference was seen in the two corresponding April periods during which referrals increased by 25% in April 2020 (mean In total, 1162 and 953 organ donors were identified during the 2019 and 2020 study periods, a decline of 18% respectively (p = 0.0001). The total number of organs transplanted during the 90-day 2020 period fell by 18% (n= 2580 vs n= 3148 organs, p = 0.0001) when compared to the similar 90-day period in 2019. The greatest differences were reported in heart and lung transplantation ( Table 3 (Supplementary files 2 and 3) . Changes in organ recovery by transplant teams are described in Table 4 . Out-of-town and local team recovery of organs decreased by 20% and 16% during the 2020 study period (p = 0.0001). OPOs were questioned about institutional modifications made in response to the Covid-19 pandemic. All In the modern era, most practice guidelines are heavily supported by concrete scientific and clinical research. In current times, however, the rapidly changing landscape of a global pandemic has resulted in immediate health reform as all disciplines attempt to prepare for a proportionate response to the Covid-19 virus. In the context of surgery, elective procedures saw an immediate halt and a "surgery-only-if needed" philosophy was adopted by most units for cases where timely interventions can significantly alter outcomes [17] . These are truly laudable efforts during an unprecedented time and, consequently, the collateral impact of Covid-19 is perhaps best measured by studying the influence on individual services rather than considering a monolithic medical or surgical community. Organ transplantation is a highly specialized field offering the only therapeutic option for terminal organ failure. Given the rising number of cases and lack of an approved, licensed treatment for Covid-19 at present, the transplant community has seen key policy changes and expert recommendations in a short period of time [11, 18, 19] . The results of this study raise some important issues in relation to donation practices during the current viral pandemic and comprehensively report a stark decline in organ donation and transplantation from an OPO perspective. Several reports have both predicted and established a dramatic change to transplant services during the initial crisis and our study primarily aimed to explore this apparent anomaly by considering the collateral influence on organ donation [20] [21] [22] . In this context, and at a time of focus on availability. This could be consistent with our findings in which we also demonstrate an overall decline in DBDs, DCDs and ECDs. However, and notwithstanding the dramatic decline in overall organ donation and transplantation activity, the frequency of organ donors following substance abuse during the 2020 study This article is protected by copyright. All rights reserved period is substantial, an increase of 35% (2020 vs 2019; n = 220 vs n = 163, p = 0.0001). Whether this is directly attributed to the Covid-19 pandemic is unclear and the current crisis may only be a lens through which we are now viewing pre-existing social and economic constraints on population health and the delivery of care which both warrant further examination. One unique aspect to our study is our analysis of donor authorization rates and OPO interactions with donor families. In our study, organ authorization decreased by 11% between the 2 study periods. Furthermore, several OPOs cite limited onsite interactions and increased telephonic approaches with donor families for both initial contact and follow-up correspondences. It may be a plausible thesis that the shift from a visible onsite presence by OPOs and meaningful face-to-face consultations has impacted the family consent process. In addition, several units have issued policies limiting family visits to hospitals and the added quarantine rules may have resulted in missed opportunities to discuss the organ donation process with trained personnel. Recent evidence also suggests that public misinformation and speculation about the Covid-19 virus has led to a great deal of fear, anxiety and significant psychosocial implications [23] [24] [25] . In such instances, the overwhelming negative perceptions and fear of contracting the infection through hospital contact may also explain the reduced engagement of families with OPO and hospital staff. From a patient perspective, part of the challenge could be to rebuild public confidence in engaging with OPO staff and guaranteeing the safety of families in not contracting the virus through health-worker interaction. One OPO reported live video streams of donor procurement by out-of-state teams, an innovative modification in current times. Some theorists argue that, based on historical trends, global pandemics may accelerate changes already underway rather than completely shift the direction of pre-existing practices [26, 27] . This is currently evident as health systems now adopt to virtual consultations and sophisticated screening and surveillance technology. However, the approach of "contact-less" patient interactions, specifically as it applies to organ donation and the fundamental characteristics of face-to-face family authorization may expose existing fault lines in this method and complicate the organ donation process, an observation that can be interpreted from our analysis. Global health services are operating in a rapidly changing circumstance. The basis of the shutdown, physical distancing and ever-evolving health policies was and remains justifiable. Understanding the extent of the work that has been deferred and impacted by the pandemic over the past 3-months merits further consideration and, from a transplant perspective, the effects on waitlist times and subsequent morbidity are unclear. Moreover, if the downward trend in donation practices is sustained, the unmet needs of patients awaiting transplantation is a cause for concern and warrants careful health policy and capacity planning to prepare for the potential consequences. This article is protected by copyright. All rights reserved This study has some limitations. Recent changes in donor organ allocation strategies and re-calibrating geographic boundaries historically considered by DSAs may explain some of the discrepancies between the two studied periods. In addition, our results reflect the experiences of 17 OPOs and may generate a potential selection bias, especially since we provide no information from the northeast. Despite these limitations, we include responses from several regions and a wide spectrum of the population to minimize these influences. Our findings suggest that the examination of additional OPO experiences should be considered to, not only determine the changes in organ donation activity but also map the nationwide imbalance of Covid-19 cases and its proportionate impact on individual systems. This study has a broad scope, including a brief analysis on organ donation practices at a national level to This article is protected by copyright. All rights reserved Our Legacy (FL) Midwest Transplant Network (KS) Donor Network West (CA) Donor Network of Arizona (AZ) A novel coronavirus outbreak of global health concern. 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All rights reserved 16 Organ Procurement organizations Managing COVID-19 in Surgical Systems Early Impact of COVID-19 on Transplant Center Practices and Policies in the United States Covid-19 emergency policy package 2020, Organ Procurement and Transplantation Network Changes in liver transplant center practice in response to COVID-19: Unmasking dramatic center-level variability Utilization of deceased donors during a pandemic: An argument against using SARS-CoV-2 positive donors Dilemma of organ donation in transplantation and the COVID-19 pandemic Social reaction toward the 2019 novel coronavirus (COVID-19). 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