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Purpose: The SARS-CoV-2 or coronavirus disease 2019 (COVID-19) pandemic has disproportionately impacted racial and ethnic minority groups in the United States. Although, kidney transplant procedures decreased following onset of the pandemic, the differential impact of the pandemic on racial and ethnic minority groups remains unknown. Method(s): We examined kidney-alone procedures captured in the national Scientific Registry of Transplant Recipients (SRTR) analytic files and compared the change in deceased donor kidney transplant (DDKT) and living donor kidney transplant (LDKT) pre- and post- pandemic and the associated factors. Result(s): We found that the counts of LDKT declined more for Black patients in the 12 months following onset of the pandemic, March 2020 to Feb 2021, compared with counts in the same period in the preceding 12 months. LDKT counts among Black patients fell by 42.6% compared with 33.3% in White patients (P=0.02). This pattern of decrease in LDKT counts among Black patients occurred in all geographic areas of the country (based on current UNOS COVID-19 reporting) except for the Northeast and South Midwest (Figure 1). Along with recipient race, other factors associated with a significant decline in LDKT counts included public insurance, Black living donor race, and location of residence. In contrast, DDKT counts for both Black and White candidates declined initially (10% vs. 5.9% lower respectively, P=0.11) during the pandemic and then recovered closer to pre-pandemic levels. Conclusion(s): The COVID-19 pandemic disproportionately impacted Black patients' access to LDKT. While the current rate of DDKT procedures has recovered in 2021, it is unclear whether LDKT rates will recover to parity. As locoregional surge conditions can have differential effects, ongoing attention to transplant disparities resulting from the pandemic, with appropriately targeted interventions, is warranted.
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Purpose: CMS introduced new performance metrics for Organ Procurement Organizations (OPO). CDC death records define donation eligible deaths, the denominator of the donation and transplant rate metrics. The COVID-19 pandemic has had an unprecedented and geographically varied impact on United States death statistics. Thus, we examined the potential impact of COVID-19 on the calculation of the OPO performance metrics. Method(s): Eligible deaths include hospitalized decedents with "donation appropriate" diagnoses. We extracted death certificate data from the CDC WONDER system for baseline years (2015-2019) and the CDC COVID Data Tracker (after 2019). CDC aggregates data by state and broad disease groups including Circulatory Death (CD), death from Cerebrovascular Disease ICD-10 i60-i69 and Ischemic Heart Disease ICD-10 i20-i25. Deaths related to COVID (ICD-10 U07.1) were separately grouped. The proportion of CD during the pandemic was compared to baseline and correlated with COVID. Result(s): At baseline, CD accounted for 66.2% of OPO eligible deaths, increasing markedly in 2020 and 2021. (Figure A) The week of April 11, 2020, the national proportion of CD peaked at +23.8% over baseline, paralleling the dramatic increase in the proportion of deaths due to COVID (20%). Early in the pandemic, the proportion of CD and COVID deaths were strongly correlated (2020 r=.44). This attenuated over time (2021: r=.25). The CD and COVID death association evolved as the pandemic spread geographically. (Figure B) In 2020, the change in proportion of CD varied from New York (+20.6%) to Massachusetts (-6.5%). The COVID - CD correlation was highest in the Northeast and Florida, (New Jersey [.78], New York [.75] and Florida [.75]). By 2021, the change in proportion of CD was highest in Mississippi (+14.5%) and lowest in West Virginia (-28.6%), while the COVID - CD correlation diminished and spread west (Florida [.65], Tennessee [.54] and California [.53]. Conclusion(s): Accurate eligible death assessment has been difficult, leading to a shift in calculations based on ICD-10 coded death certificates instead of OPO reported deaths. CD constitutes 2/3 of recorded donation eligible deaths historically, which has been substantially, but variably, impacted by the COVID-19 pandemic. Thus, these metrics based on CDC data may be sensitive to unanticipated and uneven shocks such as disease outbreaks, leading to inaccurate estimates of donor potential. CMS metrics should be refined to better account for external shocks such as the COVID-19 pandemic. (Figure Presented).
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Purpose: The coronavirus disease 2019 (COVID-19) pandemic has created unprecedented challenges and there are practice differences for solid organ transplant programs worldwide. We sought to assess an international perspective on COVID-19 vaccine mandates and rationales for or against a mandate policy. Method(s): We administered an electronic survey instrument to staff at transplant programs outside the United States (October-November 2021) that comprised of 23 questions addressing the reasons cited by centers for or against implementing a vaccine mandate. Each responding transplant program was represented once in the analysis. Result(s): Respondents (n=63) represented 19 countries on 5 continents. More than half (52.6%) of centers reported implementing a vaccine mandate, however 37.2% reported that their center has not considered (27.1%) or unsure (10.2%) on vaccination requirement. The main rationale for centers not implementing a vaccine mandate were concerns for undue pressure to transplant candidates, equity and legal considerations. (Fig. 1) The main rationale for centers with a vaccine mandate were efficacy of pre-transplant vaccination then post-transplant, importance for public health and minimizing exposure of other patients. (Fig. 2) The majority (79%) of the centers mandate vaccine regardless of prior SARS-CoV-2 infection status, and regardless of pre-vaccination spike-protein antibody titer or other markers or prior infection. Only 24.4% of centers with a vaccine mandate for transplant candidates also extended a vaccine requirement to potential living donors. Conclusion(s): The approach to pre-transplant COVID-19 vaccination mandate is heterogeneous across different countries and centers. More than one third of centers are reluctant to consider vaccine mandates for a varies of reasons including ethical, legal and equity concerns. (Figure Presented).
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Purpose: We surveyed current policies of transplant centers regarding a COVID-19 vaccine mandate, and rationales for or against a mandate policy. Method(s): An electronic survey was distributed to clinicians at U.S. solid organ transplant programs from 2020-2021. Result(s): 56.4% of transplant programs representing 78.5% of all kidney transplant volume and 82.4% of liver transplant volume in the US from 9/1/20-9/1/21 responded to the survey. 35.7% of centers reported implementing a vaccine mandate, while 60.7% reported not that vaccination was not required and 3.6% were uncertain. Centers without a vaccine mandate policy cited administrative, equity, and legal considerations (Figure A). Centers with a vaccine mandate cited clinical evidence supporting the efficacy of pre-transplant vaccination (82.0%) and stewardship obligations to ensure organs were transplanted into the lowest risk patients (64.0%) (Figure B). Among centers with a mandate, few required confirmation of vaccine responsiveness through antibody testing (2.6%), required a support person (10.0%) or co-habitants (5.0%) to be vaccinated. 42.5% of centers with a mandate also required living donor candidates to be vaccinated. There was no correlation between the presence or absence of a vaccine mandate and the point prevalence rate of COVID-19 vaccination by the home State of the transplant center. Conclusion(s): Solid organ transplant centers in the US exhibit significant heterogeneity in the requirement for a COVID-19 vaccination prior to receiving an organ. While all centers encourage vaccination, most programs do not require all candidates and living donors to receive the COVID-19 vaccine prior to surgery, citing administrative opposition, legal prohibitions, and concern about equity in access to transplants. Among the minority of centers mandating COVID-19 vaccination for candidates, few centers also mandate vaccination for support persons or co-habitants, require additional testing to demonstrate adequate vaccine responsiveness, and less than half of these centers also mandate vaccination for living donor candidates. (Figure Presented).
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Background: The COVID-19 pandemic strained healthcare systems worldwide, delaying breast cancer screening and surgery. In 2019, approximately 80% of breast cancers in the U.S. were diagnosed on screening examinations, with 76.4% of eligible Medicare patients undergoing screening at least every two years. Since the start of the pandemic, many women have been reluctant to seek elective screening mammography, even with the lifting of "lock-down". We describe the effect of the COVID-19 pandemic on breast cancer presentation at an academic medical center in a city hit hard by the pandemic. Materials and Methods: The institutional IRB-approved Breast Cancer Registry Database was queried for patients enrolled during two time periods, those undergoing first surgical procedure before the start of the pandemic (4/1/2019-3/31/2020) to those the year after the pandemic started (4/1/2020-3/31/2021). Elective cancer surgery was paused for 3 weeks, ending 4/20/2020, and access to routine breast care was limited for 3 months. Variables included age, method of detection, palpability, histologic subtype and staging, neoadjuvant systemic therapy, cancer specific treatments, and radiation uptake. Results: 349 patients were in the 2019 cohort;246 in the 2020 cohort. No differences in baseline characteristics, including age at presentation, nodal status, or operation type. Fewer cancers were detected on routine mammography post-COVID vs. pre-COVID. Increase in detection of breast cancer through self-Sexams in 2020 was seen compared to 2019. Palpability on presentation also increased. More patients were treated with neo-adjuvant therapy chemotherapy, and 36 of 45 (80%) eligible early-stage breast cancer patients accepted neoadjuvant hormonal therapy during the period that elective cancer surgery was on hold. Patients received radiation therapy less frequently during the pandemic. The proportion of patients diagnosed with invasive ductal cancers was higher in the 2020 cohort and the proportion of patients diagnosed with ductal carcinoma in situ (DCIS) and for invasive lobular cancers (ILC) was lower. Conclusions: Patients at an academic New York City medical center presented with more palpable and invasive breast cancers during the COVID-19 pandemic compared to the preceding year, and fewer patients with DCIS and ILC, cancers typically detected following screening mammography. While stage migration with an increase in diagnosis of late stage cancers has been described, in our population the stage shift occurred in early stage breast cancer, with decreases in DCIS and increases in Stages I-II, with the higher stages III-IV essentially unchanged. This reflects the effect of delay in our previously highly-screened population, with an average screening delay of 3 + months, and many patients missing their yearly screening altogether. While many medical interactions during COVID-19 were via telemedicine, radiation therapy requires daily office visits, and fear of exposure contributed to the lower rate of radiation. Given the increase in invasiveness and stage of breast cancers diagnosed during the COVID-19 pandemic, this study emphasizes the importance of screening for diagnosis and treatment of breast cancer, even in the face of a concurrent health crisis.
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Background: Anaesthesiologists are at high risk for exposure to SARS-CoV-2. We describe the development, implementation and efficacy of a high-fidelity simulation course for anaesthesiologists in response to this threat. Methods: This is an observational study of preparedness conferred by a simulation course. The following four knowledge gaps were identified: i) personal protective equipment (PPE) selection and donning/doffing;ii) operating room and anaesthesia machine turnover;iii) routine and difficult airway management;and iv) emergent airway management and Advanced Cardiac Life Support (ACLS) protocols. Four simulations were developed and offered to faculty, residents and Certified Registered Nurse Anaesthetists (CRNAs) at an anaesthesiology department. A survey estimated prior knowledge and assessed knowledge gained after the course. Results: Prior to the simulations, 27% and 26% of the participants estimated ability, respectively, to don and doff PPE, compared to 99% of the participants who demonstrated knowledge after the simulations: donning, odds ratio (OR) = infinity (19.6, infinity);doffing, OR = infinity (19.9, infinity). Prior to the simulations, 28% of the participants estimated knowledge specific to airway management;while after the simulations, 84% of the participants identified correct principles of airway management (OR = 9.1 [4.3, 20.2]). Prior to the simulations, 15% of the participants estimated knowledge of principles guiding emergency airway management and/or ACLS protocols, compared to 94% of the participants who correctly identified those principles after the simulations (OR = infinity [21.9, infinity]). Only 18% of clinicians estimated that they were competent prior to the simulations, while 89% of clinicians demonstrated competency on the written survey after the simulations (OR = 37 [10.8, 212]). Conclusion: Our results suggest that this simulation course effectively prepared anaesthesiology faculty, residents and staff to select appropriate PPE, and don and doff it, as well as apply best practices during airway management and ACLS protocols.
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Purpose: The rapid spread and high infectivity of COVID-19 resulted in disruption of transplant procedures at many centers, including pauses in living donor transplantation and limitation of life-saving transplants to candidates with highest need. We examined the contemporary trend of liver transplant, donor volume, and recipient induction regimens prior and during the pandemic. Methods: Data on liver transplant procedures from the national organ registries, Organ Procurement and Transplantation Network, 1/1/2019-5/31/2020) and Scientific Registry of Transplant Recipients (6/1/2020-9/30/2020) were used. We excluded multiple organ transplantation. Results: There were 6,316 liver transplant performed between Jan 2020 and Sep 2020, compared to 5,972 in the same period in 2019. The volume of deceased donor liver transplant plummeted in March, reached a nadir in April, and increased starting from May to return to the level similar to the same month in 2019. Similar trends were seen for the liver organs that were recovered for transplant. For induction regimens, there was a decrease in the use of thymoglobulin and basiliximab, and an increase of no induction regimen, which usually involves intravenous steroids without antibody induction. Figure 1. Figure 2 Conclusions: While there is a decrease in the use of thymoglobulin and basiliximab, there is no evidence that avoiding induction agents will result in better outcomes if transplant recipients get exposed to SARS-CoV-2 shortly after transplant. More data is needed to examine the risk and severity of infection according to induction therapy.
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The global spread of the novel coronavirus is affected by the spread of related misinformation—the so-called COVID-19 Infodemic—that makes populations more vulnerable to the disease through resistance to mitigation efforts. Here, we analyze the prevalence and diffusion of links to low-credibility content about the pandemic across two major social media platforms, Twitter and Facebook. We characterize cross-platform similarities and differences in popular sources, diffusion patterns, influencers, coordination, and automation. Comparing the two platforms, we find divergence among the prevalence of popular low-credibility sources and suspicious videos. A minority of accounts and pages exert a strong influence on each platform. These misinformation “superspreaders” are often associated with the low-credibility sources and tend to be verified by the platforms. On both platforms, there is evidence of coordinated sharing of Infodemic content. The overt nature of this manipulation points to the need for societal-level solutions in addition to mitigation strategies within the platforms. However, we highlight limits imposed by inconsistent data-access policies on our capability to study harmful manipulations of information ecosystems. © The Author(s) 2021.
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Background: We surveyed U.S. transplant programs to assess practices, strategies and barriers related to living donor kidney transplantation (LDKT) in the context of the COVID-19 pandemic. Methods: After IRB approval, the survey was launched 5/9/20 by email and postings to professional society list-servs, using the Qualtrics platform. Data are reported through 5/27/20, and examined by state COVID-19 prevalence. Results: Staff at 117 unique centers responded, representing 58% of U.S. living donor recovery centers and 75% of LKDT volume in the year before pandemic declaration. Overall, 66% reported LDKT surgery was on hold (82% in high vs. 50% in low prevalence states). 36% reported that evaluation of new donor candidates had paused, 27% reported evaluations were very decreased (>0% to <25% typical) and 23% reported evaluations were moderately decreased (25% to <50% typical). Barriers to LDKT surgery included program concerns for donor (84%) and recipient (75%) safety, patients concerns (54%), restrictions on elective cases (47%) and hospital administrative restrictions (47%). Programs with higher local COVID-19 prevalence reported more barriers related to staff and resource diversion (Figure). Most centers continuing donor evaluations used remote strategies (video 82%;telephone 43%). 61% of centers plan to continue more telehealth after the pandemic. 32% plan to resume some LDKT within 2 wks and 27% within 1 month. When surgery resumes, all will screen for COVID-19 before donation surgery, although timeframe and modalities vary. Conclusions: COVID-19 has created many barriers to LDKT, especially in areas of highest prevalence. Transplant centers are planning to restart LKDT cautiously. Consensus-building is needed to reduce barriers, guide optimal practice, and facilitate safe restoration of LDKT across centers.