Significant impact of COVID-19 on organ donation and transplantation in a low-prevalence country: Australia

To the editor:

The incidence and impact of coronavirus disease 2019 (COVID-19) has varied enormously across the globe. The pandemic has negatively impacted organ donation and transplantation in countries that have experienced high rates of infection, including the United States, France, and the United Kindgom, all reporting >50% reductions in transplant activity.^{1 , 2} Australia has experienced a significantly lower incidence of COVID-19 (Table 1 ). Despite this, the impact on organ transplantation has been significant.

Table 1.

Country-specific epidemiology of coronavirus disease 2019 as of September 23, 2020

Country	Population (in millions)	Cases	Deaths	Fatality rate per 1000 cases	Incidence rate per 100,000 population	Mortality rate per 100,000 population
United States	328,240	6,361,265	190,859	30	1938	58
Spain	46,755	525,549	29,516	56	1124	63
France	67,064	383,718	30,805	80	572	46
United Kingdom	66,797	354,292	41,683	118	530	62
Canada	37,742	134,295	9196	68	356	24
Australia	25,522	26,524	788	30	104	3

Cases of COVID-19 were first detected in Australia in late January 2020 and from March 18 the incidence had exceeded 100 cases per day. Given data from China and Europe revealing exponential increases, overwhelming demand for intensive care unit beds and ventilators and rapidly rising cumulative mortality from COVID-19, Australia anticipated similar outcomes.

Australia’s National Incident Room was engaged, and public health policies to support case detection, contact tracing, quarantine, social distancing, and hand hygiene were implemented nationally. Health care facilities prepared for a surge of hospital admissions to manage severe cases of COVID-19.

The Australian Organ and Tissue Authority and the Transplantation Society of Australia and New Zealand formed the National Transplantation and Donation Rapid Response Taskforce—COVID-19 (Taskforce), including experts in transplantation, organ donation, infectious diseases, and data analytics. The Taskforce was charged with devising and coordinating a national approach to transplantation and donation during the pandemic. Concerned that early posttransplant acquisition of COVID-19 may produce severe disease and mortality, and that growing case numbers in hospitals may limit capacity and compromise safety of donation and transplantation, during March, the Taskforce recommended suspension of all adult kidney transplantation. Urgent heart, lung, liver, and pediatric transplantation continued, following case-by-case assessment of risks and benefits.³ Early communication between donation and transplant clinicians was recommended to minimize futile donor work-ups. All recommendations were implemented nationally.

By mid-April, incident cases had fallen below 20 per day and intensive care unit capacity was uncompromised. The Taskforce recommended resumption of usual donation and transplantation activity on April 24, subject to precautions including donor and recipient screening for COVID-19, which was approved by all government Chief Medical Officers and implemented by all state-based health jurisdictions.

Following suppression of the initial outbreak in March and April 2020, a second wave occurred, primarily in Victoria (Figure 1 ). A jurisdictional response occurred, primarily addressed by public health measures including case detection, contact tracing, and containment via “lock down” border closures and strict travel restrictions. Donation and transplantation services continued but remain impacted by logistical barriers to transportation of organs, medical teams, and patients. Further isolated “outbreaks” are expected for the foreseeable future.

Figure 1.

Daily count and total coronavirus disease 2019 cases since February 20, 2020, by date and status: Australia.

Consequent to COVID-19, kidney transplantation activity is down 27% compared with in 2019, with lesser reductions in liver (8%) and lung (12%). Heart (26%) and pancreas (32%) transplant activity have increased, as seen elsewhere.² COVID-19 infections have been reported in 19 kidney transplant recipients in Australia, yielding an incidence of 0.15%, similar to the 0.103% seen among the general population, and 1 death in a multimorbid 70-year-old recipient. Ten dialysis patients have contracted COVID-19, 6 of whom died as a result. COVID has been rare among recipients of nonrenal organs. A further impact has been the fear and uncertainty experienced by transplant recipients, those waiting for transplantation, and their carers, both through news of COVID-19 and also resulting from the temporary suspension of transplantation.⁴

Taken within a global context, the demonstrable negative impact of COVID-19 on donation and transplantation in Australia has been less than that reported for countries with higher caseloads.^{1 , 2} However, the pattern of impact has been similar² and remains significant to patients and health systems alike. Despite a lesser impact to date, answers to the same questions posed by more heavily impacted countries are required here too: Is it safer to be transplanted or to remain on dialysis? Can COVID-19 be transmitted by organ transplantation? What treatments are effective, and what are the outcomes of COVID-19 in immunosuppressed patients? Can immunity to COVID-19 be acquired through infection or vaccination, will it be protective, is it durable, and does any of this apply to immunosuppressed populations? Despite differences in global COVID-19 epidemiology, for the organ donation and transplant communities, the questions are essentially the same.