From our friends at STARZL: Pediatric Transplant FAQ on COVID-19
Starzl Network Patient & Family Voice FAQ Acknowledgement to Drs. Mike Green, Marian Michaels, and Zachary Aldewereld UPMC Children’s Hospital of Pittsburgh
How long should transplant patients remain in isolation? Any COVID-19 positive patients should remain in isolation until we have negative tests and are clinically better or if no repeat testing available clinically better (no fever for at least three days without antipyretics and improved respiratory symptoms) and at least 14 days from start of illness. For general transplant patient who is not symptomatic - avoidance strategy is recommended while COVID-19 is circulating in the community, which is for the foreseeable future.
If transplant patients require a hospital visit, do we do anything different? Depends on reason for visit:
If ill, call first so that we can get a mask on the patient right away before being seen If routine visit, would check with coordinators first to determine if it can be delayed or if telemedicine and getting labs locally will be enough While masking when not sick is not routinely recommended it may help keep the child from touching their nose or mouth with unwashed hands, similar to what we do for children with fever and neutropenia
How has infection with COVID-19 affected pediatric transplant recipients? There are very few reported cases in pediatric transplant recipients Anecdotally we are not seeing greater problems, but it is still early in the pandemic and too early to know if they are at increased risk for severe disease. There are 3 reported cases of children with transplants in Italy who tested positive for COVID-19 who did not develop lung disease. However, it is unclear whether the small number of cases reported is because they are not severely affected, or because the families have been more rigorous about self-isolation. At least one very young child in the United States did require ICU care.
Are there cases of other types of immune suppressed kids being affected yet? Again, there have been limited numbers of immunosuppressed children being infected with COVID-19 and here again it is still too early to tell.
When media says immunocompromised are a high at risk, does that definitely include liver transplant children by virtue of being on immunosuppressants or no since doctors can technically control amount of immunosuppression? The blanket term “immunocompromised” does include those with liver transplants. However, this statement is based on observations in adult patients. To date, there simply is not enough data to know whether immunocompromised children are at similarly increased risk. Because we do not know, out of caution, we recommend strict adherence to self-isolation.
How is COVID-19 affecting the ability to be transplanted? At this time, we are considering transplant needs individually on a case-by-case basis. It is based on urgency of the transplant, the potential donor risks, and ability to be tested
If our transplant kids test positive, is there a different treatment for them compared to other kids? Currently, we would not treat transplant children with COVID-19 differently from how we would treat other children. The mainstay of treatment is supportive. If sick and requiring hospitalization, we would try to find a study to use for treatment that is applicable to pediatric patients, if no study available then we would use off label or compassionate release medications.
Is it recommended they go to their transplant center if they test positive even if we live out of state? Recipients with a positive test should contact their transplant center for discussion and to help decide on where to go for evaluation, management or even whether to stay home. Based on early adult data, not all transplant recipients will require hospitalization. It is possible that interstate travel will become more restricted as time goes on. In addition, if very sick, getting to the nearest medical center may be more important.
My daughter had a liver transplant and has asthma and we are concerned how she would handle this virus. It is very natural to be anxious during this period of a novel infection going across the world. However, many people including some transplant recipients have handled this infection similar to people without transplants. At this point in time it is not clear if children with transplants will have more trouble than other children without immunosuppression or without asthma. To help keep your child from getting infected, we recommend avoiding crowds, avoiding people who are sick, staying around the house as much as possible, and excellent attention to hand washing. We also recommend social distancing as much as possible and avoid touching things that other people have touched.
What is the recommendation on the isolation of immediate family members (those that live in the house) of transplant recipients when it comes to work/school? We would recommend that other children stay home from school. This is because children are more likely to have no symptoms or mild symptoms with the virus but could still transmit it to others. Similarly, if it is possible for working family members to work from home, this is preferred. If this is not possible, they should adhere to the following practices for trying to avoid infection: frequent hand washing/hand sanitization, don’t touch your face, and maintaining 6 feet between themselves and others. It might also be prudent to change into fresh clothes when you get home and put the ones you were wearing into the laundry.
Should we be asking about immunosuppressant dosage? Do not change your immunosuppressant medication without your transplant doctor’s instruction. Decreasing your child’s medication could lead to rejection, which itself could lead to hospitalization and potential exposure. You can be assured that if/when your child with a transplant develops an infection, your transplant doctors will consider whether they need to decrease the dose of immunosuppressive medications on a case-by-case basis.
Should the kids return to school when the province/states say? Or keep home? This may need to be on a case-by-case basis depending on when children begin returning to schools. For the time being, we encourage you to touch base with your transplant team if this question comes up.
Should they wear masks in public, when not in self isolation? We would encourage you to stay in self-isolation as much as possible. If you are going to be outside and able to maintain your distance from other people, a mask is not necessary. However, if they are going into a building, wearing a mask is advisable. We strongly recommend avoiding locations that are likely to be crowded though, such as grocery stores.
Starzl Network Patient & Family Voice FAQ starzltransplantnetwork.com March 23, 2020