Well, here we are. Six months into the spread of a global pandemic with little sign of it slowing. Not to be too doom and gloom, but this is all a little disheartening to say the least!
Don’t worry, I’m not going to get political. In fact, I’m not going to come within a mile of some of the hot topics that you will see the talking heads debating on your national news station, Twitter feed, or wherever else you turn for information. I hope you’ll find this article interesting and useful on a different level: addressing the impact of the COVID-19 pandemic on the field of organ, eye, and tissue donation.
An often-overlooked field in medicine, organ, eye, and tissue donation has seen unprecedented changes as a result of the pandemic. These changes are not unique to donation and transplantation—most industries probably have seen changes as well—but what is unique about our work is that it is essentially and immediately life-saving, pandemic or not. The proverbial show must go on. People don’t stop needing life-saving organ transplants because a new virus showed up on our shores. And for those who have received a transplant, or are waiting to receive one, they may rightfully be feeling elevated anxiety about how the virus will affect them.
Today we’re taking a deep(ish) dive into the state of the donation and transplantation field before and during the pandemic and what the future of the field might look like. Spoiler alert: it may not be as different as you’d think!
Summary of Donation and Transplantation Pre-COVID-19
Before we dive into the effects of COVID-19, let’s take a look at the state of donation and transplantation before the pandemic. Up until last year, organ recoveries and transplant had been increasing substantially nationwide for six straight years, according to data from the Organ Procurement and Transplant Network. Almost 11,900 people donated organs after their death in 2019, a 10.7% increase from the previous year. This led to almost 40,000 transplants, an 8.7% increase from 2018.1
“Deceased donation has increased by 38 percent since 2014,” said OPTN Board of Directors President Maryl Johnson, M.D. “This staggering increase is a tribute to the dedication of donors and their families nationwide who make the courageous decision at a time of great personal loss to give the gift of life to people who are awaiting organ transplantation. While we recognize the sacrifices that have been made to make the increase possible, we are steadfast in continuing to serve the needs of nearly 113,000 people who are still awaiting a transplant.”1
Here in Maryland, we have seen similar trends. There has been a steady increase in organ donations over the past six years. 2019 saw a total of 240 deceased donors locally, a 15% increase from the previous year, while the number of transplants has held steady over the same time.2
This increase can be attributed to a many factors. First, the donors and donor family members who make the selfless decision to designate themselves and their loved ones to give life beyond their own. Second, the dedicated organ procurement organization (OPO) and transplant center professionals who work tirelessly to ensure these life-saving transplants happen. Third, technology and medical advances mean the pool of potential donors is growing every day, such as the HOPE Act (HIV+ to HIV+ organ donation), vascular composite allograft transplants (full limb transplants), and other breakthroughs.
The system certainly has its challenges, but overall, there have been meaningful improvements over the recent years that save lives. However, like every other industry, 2020 is shaping up to be a different story. As we will see, COVID-19 has already had measurable effects on the rates of donations and transplants in the country.
Changes in Procedures
You would have difficulty finding an organization that has not been affected by COVID-19 in some way, but healthcare organizations have especially been turned upside down. Organizations have taken steps to minimize risk of transmission which means changing and adapting tried and true processes. Today we will focus on policy and procedure changes in hospitals and OPOs since they are the two that have the most direct impact on the organ, eye, and tissue donation process.
The Centers for Medicare/Medicaid Services (CMS) issued guidance at the beginning stages of their pandemic response that classified organ recovery and transplant procedures at Tier 3B meaning they should not be postponed.3 They also recommended that hospitals continue to provide OPO staff access to hospital facilities for deceased donor organ recovery.4
However, transplants from living donors were considered elective surgeries by many transplant centers, leading to many centers stopping the procedures completely for the time being. This of course lessens the pool of potential donors, leading to more people waiting for organs from deceased donors.
Additionally, hospitals have had stricter protocols for screening potential deceased donors for COVID-19. With so much unknown about the virus, public health officials recommend extreme cautiousness when dealing with it and any patient entering a hospital environment is liable to be a risk. Being a potential organ donor has the additional risk of transmitting any potential disease to the recipient. This has led to recommendations that any patient who meets the following criteria be prohibited from donation:
Any potential organ donor who is confirmed to have active COVID-19; and has not been asymptomatic and retested to be confirmed negative for COVID-19 for at least 28 days; or
Any tissue donor shown to have had or been at risk of having the infection within 28 days of their death.
It is also recommended that OPO personnel “not enter the isolation room of potential donors who are in hospital isolation and pending COVID-19 testing. Patients in hospital isolation and pending COVID-19 testing should not have direct contact with OPO personnel.”5
For those who don’t know, the process of identifying potential donors, determining whether they have given consent for donation, informing and assisting their families, and coordinating the logistics of an organ or tissue recovery is incredibly complex. Six months ago, it would not be uncommon to have hospital service coordinators, family service coordinators, community outreach personnel, volunteers, and other staff from organ procurement organizations in and around hospitals making sure all the different pieces of donation come together. Now however, as hospitals restrict visitation policies and more organ procurement staff are working remotely due to COVID-19, chances are the only OPO staff at a hospital on a given day is a recovery team, after every other step of the process has been completed. To complete those other steps, technology and the virtual space has become the primary source of communication between OPOs, hospitals, and any other party involved in the recovery and transplant process.
While this does keep people safer from COVID-19, there are significant challenges. For example, when a potential donor has not explicitly given their authorization to be a donor, either through their driver’s license or elsewhere, that decision falls to the family. Normally this conversation is had between the family and a family services coordinator through a face-to-face interaction, though now most OPOs must do these over the phone. This has had direct effects on authorization rates, which will we touch more on shortly.
Is this something that can be adapted to and overcome as time goes on? We hope so! While our mission is largely to save and enhance lives through donation, we are also strongly committed to providing quality grief support to the families we work with. We are doing everything we can to ensure that this quality of care does not suffer as we adapt to this “new normal.”
State of Donation/Transplantation Now
The article “Organ Donation During the Covid-19 Pandemic” published in the American Journal of Transplantation surveyed 17 OPOs on their rates of organ recoveries from March–May in 2019 and 2020. The study looked at several data points to determine how COVID-19 has affected organ donation.
One of the most drastic data points is the drop in number of organs recovered. The study found the total number of organs recovered for transplantation decreased by 17% during the 2020 study period, with the biggest decline of 33% in organ recovery in April 2020 when compared to April 2019. The researchers say:
“The conventional explanation for our findings would be that some transplant centers are prioritizing and only transplanting extremely sick patients, particularly at the height of the pandemic in April 2020, due to health resource limitation during an unpredictable time. An alternative explanation could be that social distancing restrictions and changes in the cause of the death landscape, specifically in the number of (motor vehicle accidents) and violent crimes as seen in our results which often yield the most suitable donors, have reduced the overall donor pool and limited organ availability.”6
Additionally, the survey showed an 11% decrease in organ authorization by donor families during March to May 2020, when compared to the same 90-day period in 2019.6 The researchers theorize that anything from the reliance on technology by family service coordinators, as mentioned in the previous section, or anxiety around the unknowns of the virus may be contributing to this.
“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 authorization 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. 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.”6
It is probably too early to get any definitive reasoning behind the drops in recovery and authorization rates: the data is too new, and we do not have enough of it. However, it is clear from the data we do have that the pandemic has affected donation and transplantation rates and more research needs to be done to determine how to best overcome and plan.
Here in Maryland, we have seen similar drops in rates, albeit slightly later and not quite as notable. In April and May 2019, we saw 20 and 16 organ donors respectively. In April and May of 2020, we had 10 and 12 donors per month, respectively. In regards to tissue, April and May 2020 saw 35 and 41 donors respectively, contrasted with 36 and 42 donors in April and May of 2019.7
In my opinion, this state data could be interpreted as somewhat optimistic. It shows a slight drop in recoveries, but recoveries and transplants are still happening regularly and saving lives. OPOs and transplant centers will continue to strive for improvements both during the COVID-19 pandemic and beyond.
Recipient and Waiting List Perspective
Rightfully so, many recipients and waiting recipients have anxieties around how COVID-19 will affect them. Transplant recipients are often immunocompromised, meaning they may be at higher risk of contracting or reacting badly to the virus. Those on the waiting list have similar risk since their health is also compromised, with the “added bonus” of it potentially affecting their chances of receiving the life-saving organ they need. Not to mention, both need to be in and around hospitals regularly for tests and other care associated with the transplant.
For many recipients, the life of wearing masks and social distancing may already be the norm. For those worried about tests, being around hospitals, or having their status on the organ waiting list affected, the United Network for Organ Sharing Transplant Living website has some information that may ease their minds.
“If the program can’t perform a test because of COVID-19, or if it believes doing a test right now would expose patients to unnecessary risk, the program may instead submit the most current results available for you. Doing so will not affect your current listing status. This is a temporary measure. Once testing can be performed routinely nationwide, programs will be expected to resume their normal schedule.”8
“Some transplant programs, using their medical judgment, are determining it is best not to currently accept organ offers for some transplant candidates. This is based on the relative risk of your potential exposure to the virus during and soon after surgery as compared to your current level of urgency for a transplant. A temporary inactivation does not mean that you are removed from the waiting list. It means that for a period of time determined by the transplant program, you would not be considered for organ offers. The transplant program may reactivate you at any time they believe they can resume transplanting patients as usual.”8
It is far from perfect and a return to normal, but I hope that those on the waiting list can take some solace in the fact that COVID-19 will have a minimal effect on their chances of receiving an organ.
The New Normal? The Future of Donation and Transplantation
What will the future of organ donation and transplantation look like? We may already be seeing it take shape. COVID-19 has given a boost to a world already hurdling towards increased digital productivity, and chances are that trend won’t stop once the disease is controlled. Professionals in the donation and transplantation community are always looking for innovative and effective ways to save lives and this pandemic has only increased that drive.
What has changed is the heightened level of caution that healthcare organizations have taken in response to the virus, and it is very likely that will remain for some time. Here at The LLF, leadership have shared that our clinical teams who spend time in and around hospitals may not be returning to work at our Baltimore office until early next year. Even our staff outside of hospitals have no definitive date yet for when we will be returning to the office. This will mean extensive changes to adapt and continue our work saving lives. I have no doubt we are up to the task.
We remain forever grateful to the essential staff—at our organization, with our hospital partners, and everywhere—who work diligently every day to both contain the pandemic and to save lives through organ, eye, and tissue donation. Whether returning to normal or finding a “new normal,” we will hold steadfast in our mission of saving lives and supporting our community, and we know all our partners will too.
The Living Legacy Foundation of Maryland Reporting Site