COVID-19 rapid guideline: haematopoietic stem cell transplantation

The purpose of this guideline is to maximise the safety of patients who need haemopoietic stem cell transplantation and make the best use of NHS resources, while protecting staff from infection.

# Minimising the risks of COVID-19

# Reducing the risk of exposure to COVID-19
Reduce the risk of patient and donor exposure to COVID19 and make best use of resources (workforce, facilities, intensive care, equipment), such as by minimising inpatient and day-case admissions. 
Follow hospital policy to reduce the risk of contracting or spreading SARS-CoV-2, for example:
consider using telephone or video consultations, if appropriate
ask patients to attend appointments with limited family or carers
minimise time in the waiting area by:
careful scheduling
encouraging patients not to arrive early
texting patients when you are ready to see them, so that they can wait outside or in their car. 
Before patients attend the transplant centre, tell them about the measures in place to keep them safe, as well as any steps they need to take. 
All healthcare workers involved in receiving, assessing and caring for patients who have known or suspected COVID 19 should follow NHS England's national infection prevention and control manual and the UK government COVID-19 guidance for health professionals. These contain information on using personal protective equipment (PPE). 

# Vaccination
Encourage patients and donors to get vaccinated in line with the UK government COVID-19 vaccination programme and the British Society of Blood and Marrow Transplantation and Cellular Therapy Vaccination Sub-Committee (BSBMTCT-VSC) guidance on COVID-19 vaccination. # Pre-transplant care

# Transplant recipients

## Reducing risk
Advise patients that for at least 2 weeks before having haematopoietic stem cell transplantation (HSCT), they should follow the professional advice from their clinical team on how best to minimise their risk of respiratory infections (including COVID-19). Guidance for clinicians and patients to support risk assessments is available on the British Society of Blood and Marrow Transplantation and Cellular Therapy (BSBMTCT) website. 
Test patients for respiratory viruses, including for SARS-CoV-2, using a polymerase chain reaction (PCR) test: 
within 7 days before admission and
-n admission before starting conditioning if local testing turnaround times allow. If not, ensure that a test result is available within 72 hours before conditioning starts. 
Consider deferring allogeneic HSCT if the patient has been in close contact with someone with COVID-19 in the past week. Assess the risks for the individual patient of having COVID-19 against the benefits of having HSCT without delay. 

## Assessing whether to use fresh or cryopreserved cells
Transplant centres should agree with the patient whether to use fresh or cryopreserved donations, taking into account:
patient factors
the donor's risk of COVID-19
current BSBMTCT COVID-19 guidelines or specific registry requirements. The decision should be shared with local processing laboratories to ensure that they have advance notice of each donation and whether to cryopreserve or not. 
If cryopreserved cells are requested, they should be received by the transplant centre before conditioning starts, unless exceptional circumstances mean this is not possible. 

# Transplant donors

## Reducing risk
Explain to donors the importance of minimising their risk of exposure to COVID-19 before donation. Give advice on reducing risk in line with the UK government guidance on living safely with respiratory infections, including COVID-19. 
Explain to donors about the symptoms of COVID19 and advise on testing if they develop symptoms. Discuss transmission risks, donation restrictions and when to consider self-deferring from donating. 
If cells are going to be cryopreserved, test the donor for SARS-CoV-2:
at the medical assessment and
before starting granulocyte-colony stimulating factor (GCSF) for haematopoietic progenitor cell (HPC) apheresis or within 72 hours of HPC marrow collection. 
If fresh cell donations are being used, test the donor for SARS-CoV-2:
at the medical assessment and
before conditioning, ensuring that the test result is available within 72 hours before conditioning starts. 
Tell donors to contact the coordinating registry and the collection centre at which they donated if they develop any illness within 2 weeks after donating. 

## Donors with COVID19
For HPC apheresis or mononuclear cell (MNC) donors who test positive for SARS-CoV-2:
defer donations by 14 days from when their symptoms resolve or from a positive PCR test or
if donation is urgent and less than 14 days have passed since testing positive, refer to a designated donor medical officer for risk assessment and earlier discretionary clearance. 
For HPC marrow donors who test positive for SARS-Cov-2, defer donations for a period of time agreed in discussion with an anaesthetist. 
If a donor tests positive for SARS-CoV2 at a late stage, after conditioning has started, discuss with the donor registry and the collection centre whether a SARS-CoV-2-positive donation can be accepted safely. # Post-transplant care
Ensure that patients are cared for in strict protective isolation. Assess the need for any procedures outside of isolation against the risk of exposing the patient to nosocomial infections, such as COVID-19. 
Isolate patients who have tested positive for COVID19 in negative pressure cubicles, or neutral pressure cubicles if this is not possible. # Service provision and organisation
Risk assess ambulatory transplant pathways to minimise exposure to COVID-19. This review should be reflected in the quality management plans and standard operating procedures in line with NICE's guideline on haematological cancers and Joint Accreditation Committee International Society for Cell and Gene Therapy (ISCT) -Europe and European Society for Blood and Marrow Transplantation (JACIE) standards. 
Work within clinical networks to support stem cell processing and harvesting, specialised diagnostics and cryopreservation. 
Make decisions about modifications to care at an organisational level according to current quality management systems within the HSCT programme and other JACIE accreditation requirements. If a centre cannot meet quality standards, temporary closure is an option. 
If a centre is temporarily closed, work within clinical networks to prioritise clinically urgent HSCT and transfer patients as needed. If patients are transferred:
tell them who is in charge of their care
ensure that they have a named key worker that they can contact with any questions
take into account their practical needs, for example transport and accommodation. 
For patients having allogeneic HSCT, identify a back-up donor or cord blood unit in case there are problems with harvesting or transport. 
Be aware of the availability of any planned conditioning treatments and arrange alternatives based on availability and clinical indication. 
Think about undertaking viability testing on cryopreserved stem cells if there is any concern about the collection, transfer or cryopreservation of cells. This includes discretionary viability testing of cell therapy products cryopreserved in laboratories not associated with the transplant centre or at the request of the transplant director. 

# Services for children and young people
For additional advice on services for children and young people under 16 years, see the Paediatric BSBMTCT Group guidance on management of paediatric patients during the COVID-19 outbreak. 

# Services for patients with COVID-19
Services, including satellite units, should have separate pathways and accommodation for patients who test positive for COVID-19, to minimise the risk of COVID-19 for other patients. These should be reflected in quality management plans and standard operating procedures and should meet JACIE standards. 

# Policies for staff returning to work after COVID-19
Ensure that healthcare professionals are aware of and follow the local policies of their transplant unit for returning to work after COVID-19.