Perception of Health Care Professionals on Transplantation in the Treatment of COVID-19 Patients

Corona virus disease 2019 (COVID-19) emerged from China in December 2019 caused by severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) has been spread globally and has now become a pandemic¹. The mortality rate of patients with COVID-19 can be as high as 4.2%². Despite improved medical treatment, some patients with end-stage COVID-19 pneumonia advanced to irreversible loss of lung function, those critical patients need to be admitted to the intensive care unit (ICU)^{3, 4, 5}. Lung transplantation is an effective treatment for end-stage pulmonary chronic diseases⁶,⁷. However, it was rarely used for the management of acute infectious pneumonia-like COVID-19. Unlike chronic lung diseases, COVID-19 is an emerging communicable disease, and the complete profile of the disease is ambiguous⁸. It is difficult to ascertain whether lung injury in COVID-19 patients is irreversible⁸. At present, there are very fierce reports of lung transplantation in patients with COVID-19. Six COVID-19 patients have received lung transplants in China as a last resort to save virus patients in critical situation⁹.

The Department of Surgery of MedUni Vienna/Vienna General Hospital carried out a crucial and highly cumbersome lung transplant to save a 45-year-old woman from Austria, her condition had advanced to complete respiratory failure as a result of Covid-19, so that she could only be sustained by means of a circulation pump (ECMO – extracorporeal membrane oxygenation). This was a Europe's first lung transplant on a COVID-19 patient¹⁰. Successful double lung transplantation was done as a last resort has saved the life of an 18-years-male whose lungs were damaged by COVID-19 at Policlinico Hospital in Milan, northern Italy¹¹.

A 20-years-female received a double lung transplant following end-stage lung disease (Figure 1 & Figure 2) by COVID-19 at Northwestern Medicine in Chicago¹². She was the first COVID-19 lung transplant case for the United States of America¹². COVID-19 pandemic which started from China outspread to Europe and the United States of America, reached to South Asian countries at last. Thus this provides us with an opportunity to act accordingly those already affected countries have acted to control this pandemic before it is out of control. In Nepal there are many cardiothoracic and vascular surgeons capable enough for lung transplantation, however its legal system lag behind the clinical system. The first law enacted to regulate human organ transplantation in Nepal with title "The Human Body Organ Transplantation (Regulation and Prohibition) Act, 2055 (1998) provides provision for only Kidney transplantation as solid organ transplantation¹³. Recent modification in the existing law in the form of Human Body Organ Transplantation (Regulation and Prohibition) Act 2072¹⁴ and Human Body Organ Transplantation (Regulation and Prohibition) legislation 2073¹⁵ has provided provision for Liver transplantation too but not for other solid organ transplantation like lung. Keeping in view of urgent need of lung transplantation to save the life of end-stage COVID-19 cases as shown in the cases done in China, Europe and the United States of America, this research has been done as a small step towards the preparedness for ongoing COVID-19 pandemic with an aim to see the perception of health care professionals of tertiary care centre of eastern Nepal regarding the legal aspects of lung transplantation.

Figure 1.An X-ray of the patient’s lungs before surgery. Northwestern Medicine

Figure 2.Damaged lung removed following transplantation. Northwestern Medicine

It is a descriptive and cross-sectional study in which a pre-established valid and reliable self-administered questionnairewas used among health care professionals of the tertiary care centre of eastern Nepal¹⁶.  Those who gave consent were included in the study. Purposive samplingof 221, among health care professionals (Faculties, Nursing In-charges, Lab- technicians, Radiology technicians) participated in the study. Collected data was entered in Microsoft Excel and coded accordingly. The statistical analysis was performed by statistical package for social science (SPSS) and frequency was calculated.

Structured Questionnaire: (Malaysia has no laws regulating living donation and in the absence of laws, living donation is presumed to be legally permissible under valid donor’s consent). If liver or heart or other organ transplant surgeon transplanted liver or heart or another organ with intention to save the life, in the absence of their specific law in Nepal, should the surgeon be punished? The responses were 86.87% as "No if done in an emergency condition"; 6.33% as "No"; 4.07% as "Can’t say" and 2.71% as "Yes".

Majority (86.87%) of health care professionals support the organ transplantation even in the absence of the specific law in the country for the emergency condition. Organ transplantation in Asia is usually regarded as a policy issue, rather than a clinical issue, but Malaysia is an exception to this consideration. Malaysia has no laws regulating living donation and in the absence of laws, living donation is presumed to be legally permissible under valid donor’s consent¹⁷. Nepal has cardiothoracic and vascular surgeons but they cannot practice in the absence of laws for specific organ transplantation. A similar situation can be seen in other Asian countries as well, the Lancet has shown that the regulatory system in China is relatively lagging behind its medical development¹⁸. Due to the cumbersome process in amending the legal system of nation, it sometimes can’t keep pace with the sudden change in the urgency in the health care system; especially in the situation like COVID-19 Pandemic. Such situation need to be addressed by collecting consensus from the concerned experts for new or revised policy as stated by World Medical Association ¹⁹.

Now the whole world is fighting against COVID-19 Pandemic with different measures in which Lung transplantation is done for the first time on COVID-19 patients as the only available treatment option in the United States of America, Europe and China has shown its importance in the era when its treatment is a challenge to entire humanity. The only research article on COVID-19 lung transplantation found in the scientific literature conducted by Weili Han et. al.⁸ at School of Medicine, Zhejiang University has shown that despite all the available treatment modalities like a course of antiviral therapy, hormonal therapy, convalescent plasma, immune-enhancing supportive treatments, and methylprednisolone, life supporting extracorporeal membrane oxygenation (ECMO) with mechanical ventilation was initiated, lung function continued to deteriorate in two cases of 66 years and 70 years old individuals. Those cases finally got rescued with the help of lung transplantation done after their “SARS-CoV2 RT-PCR” tests for COVID-19 turned negative⁸. Thus transplantation offers the terminally ill COVID-19 patients another alternative for survival. Despite the promising successful initial results from the reported cases of lung transplantation, the study reflects some potential concern about the systemic virus that it could damage the donor's lungs after lung transplantation and medical staff would be put at risk to a virus with a high contagious index²⁰.

The article has shown a distinct perception of health care professionals in support of the therapeutic part of transplantation over its legal aspect in the emergency conditions like COVID-19 Pandemic. Thus, it is recommended for its consideration as the preparedness of Nepal towards the COVID-19 Pandemic.

It has been taken from “Institutional Review Committee, B. P. Koirala Institute of Health Sciences, Dharan, Nepal”.

The authors received no financial support for the research, authorship, and/or publication of this article.

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