COVID-19 and Hematopoietic Cell Transplantation: Frequently Asked Questions
(Version 1.1; last updated October 1, 2020)
Input from Marco Mielcarek, Helene Schoemans, Sergio Giralt, and Helen Heslop
Note: Please review ASH's disclaimer regarding the use of the following information.
Are transplant and immunotherapy programs accepting new patients?
Transplant and immunotherapy centers are modulating new patient numbers based on COVID-19 activity in their regions. Some centers never decreased their activity. Other transplant and immunotherapy programs curtailed clinical activity preparing for or responding to a COVID-19 surge, but most have started the process of reopening, with the majority of centers back to normal patient numbers.
Centers that have reopened are generally using the same criteria for recommending transplantation or cell therapies that they were using pre-COVID-19. The exception is centers located in communities with ongoing or increasingly high levels of COVID-19 activity; these centers may still be deferring non-urgent patients. Even at these centers, patients are being treated urgently if delay would result in greater risk of disease progression than COVID-19. Patients who are positive for SARS-CoV-2 should have transplantation delayed until their viral test is negative, or at least 14 days removed from symptoms or first positive test.
How are patients, donors and caregivers protected from SARS-CoV-2 at transplant centers?
Given the intense immunosuppression associated with HCT, the number of these patients infected with SARS-CoV-2 seems to be lower than expected. This may be due to the rigorous infection-control procedures already in place before COVID-19, as well as patient awareness and risk-adverse behavior. For patients undergoing transplant, rigorous use of personal protective equipment (PPE) and infection control measures are very effective in preventing infections in health care providers and nosocomial cross infection. Visitors are still limited at most centers; caregivers are not being tested at most centers unless they are symptomatic. All medical staff are screened for symptoms daily. At most programs, patients are tested on arrival and/or prior to the start of conditioning regimens. Some centers are testing asymptomatic patients intermittently after transplant.
Since March 2020, there has been a move to cryopreserve unrelated donor products with most retrospective studies showing no compromise of transplant success, but no prospective studies. There is geographic variability in this practice now, with some registries requiring justification for cryopreservation. The one exception is bone marrow destined for a patient with aplastic anemia; this is the one case where cryopreservation has been associated with poor engraftment and higher mortality. A few centers are cryopreserving family member stem cells.
What is known about outcomes in transplanted patients with COVID-19?
Immunosuppressed transplant patients have variable presentations of COVID-19 disease. At MSKCC, 70 transplant patients were diagnosed with COVID-19. EBMT, CIBMTR and ASH are collecting data on transplant patients with COVID-19.
Are SARS-CoV-2 PCR and antibody tests accurate in transplant patients?
There is no evidence that the standard COVID-19 PCR and antibody tests are misleading in HCT patients. Studies need to be performed to see if patient receiving rituximab or B-cell directed CAR-T therapy are able to mount a detectable and sustained antibody response.
My patient has graft-versus-host disease and is being treated with immunosuppressive drugs. Should I take them off these medications, adjust dosages or switch regimens?
Generally not. This decision needs to be individualized, considering the risk that stopping, adjusting dosages or switching regimens for GVHD treatment will incite a flare (for example, 50% of people who stop immunosuppression when chronic GVHD is controlled will subsequently flare their symptoms and need to restart, a median of 3-6 months after stopping) versus a potentially worse outcome if they get COVID-19 while on immunosuppression. If a GVHD flare occurs, then more intensive immunosuppressive treatment may be needed initially to control symptoms, putting patients at higher risk for severe COVID-19 disease. Thus, if a patient is doing well on their current immunosuppressive regimen, we would not adjust GVHD treatments due to COVID-19 risk or actual infection.
Any special considerations for CAR-T patients?
Centers that have reopened and have ICU capacity and access to tocilizumab are giving patients CAR-T therapy.