Blood and marrow transplantation during the emerging COVID-19 pandemic: the Seattle approach

Abstract

On January 20, 2020, the first patient with coronavirus disease 2019 (COVID-19) in the United States of America was diagnosed in Washington state, which subsequently experienced rapidly increasing numbers of COVID-19 cases, hospitalizations, and deaths. This placed the Seattle Blood and Marrow Transplant Program at Fred Hutchinson Cancer Research Center (Fred Hutch) in the national epicenter of this pandemic. Here, we summarize the experience gained during our rapid response to the COVID-19 pandemic. Our efforts were aimed at safely performing urgent and potentially life-saving stem cell transplants in the setting of pandemic-related stresses on healthcare resources and shelter-in-place public health measures. We describe the unique circumstances and challenges encountered, the current state of the program amidst evolving COVID-19 cases in our community, and the guiding principles for recovery. We also estimate the collateral impact of directing clinical resources toward COVID-19-related care on cancer patients in need of stem cell transplantation. Although our experience was influenced by specific regional and institutional factors, it may help inform how transplant programs respond to COVID-19 and future pandemics.

Fig. 1. COVID-19 activity in Washington state and King County.

The Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance are located in north-western King County. The frequency of confirmed COVID-19 cases in Washington state according to county is shown on the map. The inserted table list confirmed cases, hospitalizations, deaths, and case-fatality rates related to COVID-19 in Washington state and King County. This information was updated on July 18, 2020. The map was adapted from data provided by the Washington State Department of Health (doh.wa.gov).

Fig. 2. Timeline of arrival restrictions for patients scheduled for transplant at the Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance according to increasing COVID-19 activity in Washington state.

Top panel: confirmed daily case counts; middle panel: daily hospitalizations; and lower panel: daily mortality. This information was updated on July 7, 2020. The graphs were adapted from data provided by the Washington State Department of Health (doh.wa.gov) [2].

Fig. 3. Impact of COVID-19-related arrival restrictions on patient census.

Effective March 6, 2020, only higher urgency patients were accepted for evaluation and transplantation at the Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance (see also Table 2). Data are shown according to allogeneic and autologous transplant patients under our program’s care. As indicated, phase 1 of the ramp up was initiated on April 27, 2020.

Fig. 4. Phased ramp up of hematopoietic cell transplantation activity after the peak of COVID-19-related hospitalizations in the University of Washington hospital system.

Effective April 27, 2020, the first phase of a measured ramp up (30% of new transplant patient arrivals compared to typical arrival volumes) was initiated. Phases 2 and 3 (60 and 100% of typical arrival volumes) were initiated on May 18 and June 1, respectively, as indicated. The graph shows the daily number of patients hospitalized (intensive care unit [ICU] beds and regular beds) with COVID-19 in the University of Washington hospital system, which provides inpatient care for Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance hematopoietic cell transplant patients.