Vox Sanguinis International Forum on Hospital Transfusion Services' Response to COVID‐19: Responses

Naomi Rahimi-Levene & Victoria Peer Demographics: Our hospital blood bank accepts samples for pre-transfusion testing from patients who were confirmed or suspected to be infected with novel coronavirus. We do not release products for an individual patient in a cooler. We have a plan to deal with samples with novel pathogens, which was implemented during the 2003 SARS epidemic. Instruction was mandatory for all laboratory personnel explaining the infectivity of the virus and how to use personal protective clothing when handling a suspected or confirmed sample. They were also instructed on how to work in the BSC, where to store the samples and how to dispose of the waste. The utilization of blood components has not changed since the start of the epidemic. But since elective surgical procedures have been postponed due to the epidemic, we expect our usage to go down. No, we do not expect shortages in our hospital, as the national blood service Magen David Adom does not have shortages at this stage. However, if the situation in the country changes and the national blood services will have a shortage in donors, we will be affected by this as they are our only supplier. It is important to have both a national and a local policy for dealing with infected samples, and the staff must be familiar with all aspects of it. It is important to have a national entity that can answer questions arising during the pandemic, as unexpected scenarios may occur. Communication between the blood supplier and the hospital blood banks is cardinal. Especially as there are already look-back issues of donors either in quarantine or infected, whose donated units have already been issued. Locally, in the laboratory it is important to have a plan dividing the staff into shifts that rotate and do not have contact with other in order to avoid neutralizing the whole team if an individual is infected. Magen David Adom, the national blood service, is beginning to collect convalescent plasma from COVID-19 patients tomorrow. The plan is to collect 600 ml for each convalescent. Pathogen reduction will be performed either by the Intercept® Blood System or by the Mirasol® Pathogen Reduction Technology System. The decision is being made at this time. There will be a national policy to whom it will be transfused (Personal Communication, Prof. Eilat Shinar, Director of Magen David Adom National Blood Services). José Luis Bueno Yes, our hospital blood bank accepts samples for pre-transfusion testing from patients who were confirmed or suspected to be infected with novel coronavirus. At our hospital, we are assuming that all the patients and workers are actually infected. We have improved the infection risks (hypoclorite, hand washing, alcoholic dilutions…but for every sample and everybody). Yes, I think so, but nobody had read it before, I guess. Yes, definitely. All workers have been trained according to their risk assessment. It has been dramatically reduced. Our transfusion activity has been reduced to just urgent transfusion. We have begun today a clinical trial to transfuse convalescent plasma from recovered patients/donors to mild–severe new patients. Actually, the first randomized patient has received today a plasma transfusion. We think this new strategy will increase our transfusion activity in the next weeks. No, we do not anticipate blood component shortages. At the beginning of the epidemic in Madrid, we expected a shortage, and we implemented different strategies, but at the end it was not necessary, as lot of donors came during the first days to donate. This, beside the blood component reduction due to routine surgery suspension, took to a reduced need of blood components. Be ready to implement a quick and efficient convalescent plasma programme. Yes, our centre will offer convalescent plasma. Please see our plasma manufacturing protocols in Annex 1. Information on the clinical trial may be obtained by writing directly to the corresponding author. Convalescent donors will be recruited according to the inclusion and exclusion criteria included in the protocol of this clinical trial. (See protocol). Briefly, convalescent donors are cured patients after the COVID-19 infection. To verify their cure, a double-negative RNA RT-PCT (with at least 24 h interval) and a specific antibodies against SARS-CoV-2 will be performed. Also, these donors will fulfil the requirements to be accepted as a general altruistic blood donor, as is defined in the European Guidelines 1 and the Spanish RD 1088/2005. CD will be contacted by phone using the regional or national COVID-19 patient's database. CD candidates will be asked to participate in this trial and will be pre-screened according to the previous inclusion and exclusion criteria. If agree, CD will be appointed to the apheresis collection centre, for: Note: Any apheresis machines and kits able to collect the defined product would be also acceptable. Note: Any other plasma inactivation system validated for transfusion products could also acceptable. (Consider, e.g. Methilene Blue or Amotosalen procedures). Plasmapheresis data, donor tests and labelling will be done using the software Coyote, or any other software designed for managing blood components. PR-HP used in this study is the same product used for the plasma transfusion indications in the clinical practice. These products are collected and manufactured by the Regional Blood Transfusion Centers in Spain and are distributed to hospital transfusion services for their use. The properties, preparation, quality requirements, storage and transport requirements, labelling requirements and warnings for the manufacturing of these products are well described in the chapter 2 of the Guide to the preparation, use and quality assurance of blood components. 18th ed. 1. For an easy consultation of those requirements, we have added this chapter as an annex. at the end of this document. The investigators of this trial do not consider these differences between the two plasma products to be critical, and regarding objectives of this trial both product can be considered as equivalent on the manufacture procedure, being the only critical difference the presence of high title of neutralizing anti SARS-CoV-2 antibodies, in contrast to the plasma coming from healthy donors. Ryan P. Jackson & Hua Shan Demographics: Yes, we accept samples for pre-transfusion testing. Yes. Under our standard operating protocols, universal precautions apply to all specimen handling. There is, however, no specific detail regarding novel pathogens. Our protocols refer transfusion laboratory staff to follow the SHC Lab administration policies and procedures as well. Therefore, our policy for how to handle PUI blood specimens and our COVID-19 response in general were shaped by guidance provided by the SHC Lab Quality programme. At each occurrence or encounter of a future novel pathogen, we will look to the SHC and Lab Quality/Safety leadership for guidance. Yes. During operational staff huddles, the SHC and SHC Lab published guidelines were discussed. SHC Lab Quality also assigned lessons (i.e. readings with required quizzes and signatures at completion) to all AP and Clin Lab staff. All Transfusion Service staff, supervisors and manager were included in these trainings. Overall blood usage has decreased by about 30% since the start of the pandemic. ‘With a continued risk to blood product supply, we ask for your quick review of and adherence to transfusion and care guidelines below. The use of restrictive transfusion practices has been shown to be equivalent or better for patient care in many scenarios and should always be practised. During this time of uncertainty, it is imperative to use transfusion judiciously. RBC transfusions: Platelet transfusions: transfusions should be considered for counts below the following thresholds: Plasma transfusions: avoid prophylactic therapy based on INR prior to procedures. Meta-analysis finds that patients with INR ≤2·0 do not have higher bleeding risk compared to normal range INR across a wide variety of minor and major procedures 7. Consultation with transfusion medicine (Pager #12027 staffed 24/7) and haematology (SHC: p#27436 SCH/LPCH #24362) is encouraged with any blood product questions, especially on patients with platelet refractoriness or bleeding.’ The Transfusion Service/Blood Bank remains a ‘little different’ and therefore ‘unique’ from the rest of laboratory operations within the hospital as biological blood products, besides blood specimens, are handled in our setting. During the COVID-19 pandemic, the first version of the Laboratory ‘One-Point Lesson (OPL) regarding specimen handling’ for our institution did not quite cover the manual serology of blood specimens, which remains a common practice even during this era of automation, and other blood product manipulations (e.g. modification methods such as separation, aliquoting and washing). In the absence of strong guidance from the CDC, this led to some uncertainty, and personnel became concerned about safety. We were able to abate these concerns and ensure safety through a process of self-assessment, adaptation of some best practices from other institutions and, ultimately, implementation of further guidelines from the CDC. In sum, we think a thorough, independent assessment of the Transfusion Service, Blood Bank and blood collection centre as to the physical environment, methods of specimen or blood product processing, and equipment in use should be initiated early in preparation for ‘safe handling’ guidance to be issued as quickly as possible to working personnel. We are currently planning to use convalescent plasma from COVID-19 patients in a trial and for compassionate use. The dosing scheme is still being worked out, but eligible patients are expected to get one unit of plasma. Patient eligibility will be determined per FDA IND criteria 8. We plan to exclude patients who are eligible for any other active trials at Stanford (currently, this will mostly pertain to patients who are eligible for remdesivir). Due to practical considerations, we will not seek pathogen inactivation of the plasma at this time. Luiz Amorim-Filho, Maria Esther Lopes & Carla Boquimpani Demographics: Yes. No, we did not have this specific preparedness plan. Now we are developing a comprehensive plan to encompass those situations. Yes. Everyday there is a training session, with a limited number of attendees. Red blood cell concentrates’ utilization was reduced by 21·2% since the start of the pandemic in Rio de Janeiro. Platelet utilization is stable; plasma utilization was reduced by 24%. It should be stressed that we only treat patients with primary haematological diseases (leukaemia, lymphoma, myeloma, sickle cell disease, etc.). The reduction in red blood cell and plasma utilization was due to the fact that many outpatients are missing their medical appointments, even if they were scheduled to be transfused. This is especially true for sickle patients in a chronic transfusion programme. Platelets are almost exclusively transfused for inpatients, that is why platelet utilization rate is stable during the pandemic. YES, we anticipate component shortages. Our hospital is part of a complex which includes the main blood centre in Rio de Janeiro city. Since it is very hard to reduce or adapt blood utilization in patients with severe haematological diseases, we concentrated our efforts on alternative strategies to donor recruitment during the pandemic. Namely, replacing mobile drive in universities, companies and churches (all of them closed) by mobile drives in the armed forces locals and in the large private condominiums. More than 1000 people live in each one of these condominiums, and the vast majority are staying at home due to the lockdown recommendation. For our fixed site, we are stimulating blood donation under appointment, in order to comply with social distance measures. Regarding the blood utilization side, the only difference was a more restrictive transfusion policy for sickle cell patients. If we had a blood shortage, we could opt for simple transfusion instead of partial exchange transfusion in some situations (but so far we did not have a blood shortage). The main difficulty is related to our workforce. A large proportion is ill or have had close contact with a confirmed case. In addition, public transport is restricted and our employees face many problems in leaving their homes. A reduction in the number of workers able to go to the hospital was taken into account in our contingency plan. However, the mitigating measures that we established were not sufficient, due to the magnitude of the pandemic and to the number of health professionals directly affected by COVID-19. The lessons we learned about this are that we need to update the plan daily and adapt our activities to the availability of employees—for example suspending the activity of the centralized transfusion team. Yes, we are collecting it for use in other hospitals to where we refer COVID-19 patients. We are selecting donors with an anti-SARS-CoV-2 IgG titre ≥80; these donors must also have a neutralizing antibody titre ≥1:64. The plasma dose is 200–300 ml/patient (a single transfusion). We accept female if they have already we their plasma for For plasma donors and we are also an for We are with Amotosalen & Demographics: Yes, we accept all samples for pre-transfusion We do not release products for an individual patient in a cooler. far as we it does contingency in of with patients with or biological A mandatory hand and other protective measures was by hospital medical staff further training regarding the use of protective face of of of No, we do not anticipate blood component shortages. No, we do not have any further Yes, patients will with 2 ml convalescent anti-SARS-CoV-2 plasma. units are to be within a will not be pathogen & Demographics: Yes, samples were If a of blood products is our practices are described below. Yes. The novel pathogen was and a protocol was for COVID-19. This was distributed to all laboratory staff as part of COVID-19 Laboratory protocols and the use of were with laboratory staff. The laboratory staff are required to social and laboratory have been to implement However, this is to the virus from between staff than laboratory workers from infection from to Yes, shortages are as below. 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