Clinical presentation and outcomes of COVID-19 following hematopoietic cell transplantation and cellular therapy

Severe acute respiratory syndrome coronavirus 2 infection in hematopoietic stem cell transplant recipients in Mexico City

BACKGROUND

Hematopoietic stem cell transplant (HSCT) recipients are among patients with highest risk of adverse coronavirus disease 2019 (COVID-19) outcomes.

OBJECTIVE

We compared clinical outcomes in post-HSCT patients with COVID-19 before and during the Omicron period.

STUDY DESIGN

This was a retrospective study including patients post-HSCT with severe acute respiratory syndrome coronavirus 2 infection from April 2020 to March 2023 at Instituto Nacional de Cancerología, Mexico City. We describe their clinical characteristics and report the variables associated with severe clinical disease, hospitalization, and death.

RESULTS

Fifty-three patients were included; 31 (58.5%) from the pre-Omicron period and 22 (41.5%) from the Omicron period. Median age was 42-years old (interquartile range 26-53), and 31 patients (59%) were men. Only four patients (16%) had received a vaccine prior to COVID-19 diagnosis in the pre-Omicron period versus 20 (91%) in the Omicron period (p < 0.001). COVID-19 severe cases were more common before Omicron: seven patients (23%) versus two patients (9%). Only one patient (3%) received an antiviral in the pre-Omicron period compared to 11 patients (50%) during the Omicron period (p < 0.01). COVID-19-associated mortality was almost double in the pre-Omicron period (16% vs. 9%, p = 0.6).

CONCLUSIONS

This study reports patients with a high proportion of severe outcomes during the first 2 years of the pandemic. Outcomes improved during Omicron with better access to vaccines and antivirals and no in-hospital cases. Variables associated with worse outcomes were similar to other reports. Strengthening infection control measures in the hospital and better access to preventive strategies and therapeutic options are mandatory in these high-risk patients.

Clinical characteristics and outcomes of allogeneic hematopoietic stem cell transplantation recipients with coronavirus disease 2019 caused by the Omicron variant: a prospective, observational cohort study

We aimed to describe the clinical characteristics, particularly the occurrence and risk factors of severe/critical illness, in allogeneic hematopoietic stem cell (allo-HSCT) recipients infected with coronavirus disease 2019 (COVID-19) caused by Omicron variant in an observational prospective study (n = 311). The median time from allo-HSCT to COVID-19 diagnosis was 8.5 months (range 0.8-106.1) months. Four patients (1.3%) were reported to be asymptomatic during Omicron variant infection, and 135 (43.4%) patients showed lower respiratory tract disease. Thirty-four (10.9%) patients were categorized into serious infection (severe illness n = 25; critical illness n = 9) and the median duration from COVID-19 diagnosis to serious infections was 6 days (range, 0-29) days. Thirteen (4.2%) and 6 (1.9%) patients required intensive care unit care and invasive mechanical ventilation, respectively. Receiving more than 1 type of immunosuppressive therapies at COVID-19 diagnosis was associated with severity and persistence of infection. Six patients (1.9%) died after diagnosis of COVID-19 infection. The 4-week probability of overall survival after COVID-19 diagnosis was 98.7%, which was 100% and 88.2% for non-serious and serious infection group (P < 0.001), respectively. Thus, we observed a relatively low serious infection and mortality rate in allo-HSCT recipients infected with COVID-19 caused by Omicron variant.

COVID-19 in hematopoietic stem cell transplant recipients during three years of the pandemic: a multicenter study in Brazil

Hematopoietic stem cell transplant (HSCT) recipients are at -increased risk for severe COVID-19. The aim of this study was to evaluate the burden of COVID-19 in a cohort of HSCT recipients. This retrospective study evaluated a cohort of adult hospitalized HSCT recipients diagnosed with COVID-19 in two large hospitals in São Paulo, Brazil post-HSCT, from January 2020 to June 2022. The primary outcome was all-cause mortality. Of 49 cases, 63.2% were male with a median age of 47 years. Allogeneic-HSCT (51.2%) and autologous-HSCT (48.9%) patients were included. The median time from HSCT to COVID-19 diagnosis was 398 days (IQR: 1211-134), with 22 (44.8%) cases occurring within 12 months of transplantation. Most cases occurred during the first year of the pandemic, in non-vaccinated patients (n=35; 71.4%). Most patients developed severe (24.4%) or critical (40.8%) disease; 67.3% received some medication for COVID-19, primarily corticosteroids (53.0%). The probable invasive aspergillosis prevalence was 10.2%. All-cause mortality was 40.8%, 51.4% in non-vaccinated patients and 14.2% in patients who received at least one dose of the vaccine. In the multiple regression analyses, the variables mechanical ventilation (OR: 101.01; 95% CI: 8.205 - 1,242.93; p = 0.003) and chest CT involvement at diagnosis ≥50% (OR: 26.61; 95% CI: 1.06 - 664.26; p = 0.04) remained associated with all-cause mortality. Thus, HSCT recipients with COVID-19 experienced high mortality, highlighting the need for full vaccination and infection prevention measures.

Lessons learned from COVID-19 pandemic: outcomes after SARS-CoV-2 infection in hematopoietic cell transplant and cell therapy recipients

We investigated the outcomes after Coronavirus disease 2019 (COVID) in hematopoietic cell transplant (HCT) or chimeric antigen receptor-T cell (CART) therapy recipients in a single-centre study including all (n = 261)HCT/CART recipients (allogeneic-HCT 49%, autologous-HCT 40%, CART 11%). The median age was 60 (22-80) years. COVID severity was mild (74%), moderate (11%), and severe/critical (16%) with a mortality rate of 7% and a median duration of infection of 5.7 weeks. Significant predictors of COVID severe disease or mortality included concurrent infection (HR 14.9, 95% CI 2.2-5.6) and immunosuppressive therapy (OR 4.8, 95% CI 1.2-3.4).HCT/CART recipients have a higher risk of mortality with COVID and warrant vigilant interventions.

COVID-19 in hematopoietic stem-cell transplant recipients: A systematic review and meta-analysis of clinical characteristics and outcomes

Patients who undergo hematopoietic stem-cell transplantation (HSCT) are more susceptible to developing severe forms of COVID-19 with an increased risk of mortality. The aim of this study was to analyze, by performing a systematic review and meta-analysis, all studies that evaluated COVID-19 in HSCT adult recipients and present clinical characteristics and outcomes. Studies were eligible for inclusion if they: (I) described the clinical characteristics of COVID-19 in adult (aged 18 years old or above) HSCT recipients; (II) described outcomes of COVID-19 in this population, mainly lethality; (III) were full-text articles. We searched MedLine, Embase, SCOPUS, LILACS and Web of Science for full-text studies that evaluated COVID-19 in adult HSCT patients until 26 Apr 2023. Two independent reviewers screened the articles and extracted the data. The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Studies Reporting Prevalence Data was used to assess quality of the included studies. Meta-analysis was performed and the pooled prevalence of severe/critical disease and of death with a 95% CI was calculated with the random-effects model. Sixteen studies were included; seven (43.7%) were multicenter. Most of the studies were from Europe (37.5%). All of them had a low risk of bias using the JBI Checklist. A total of 1186 patients were included. Allogeneic HSCT patients were the majority in most studies, with a total of 861 patients (72.5%). The symptomatic rate was 79.4%. The pooled prevalence of severe/critical COVID-19 was 24.0% (95% CI 0.13-0.36; I2  = 94%; n = 334/990). The pooled prevalence of death for the entire population was 17% (95% CI 0.13-0.22; I2  = 76%; n = 221/1117), 17% (95% CI 0.12-0.23; I2  = 67%; n = 152/822) for allogeneic-HSCT and 14% (95% CI 0.08-0.22; I4  = 65%; n = 48/293) for autologous-HSCT. In conclusion, frequently the infection of SARS-CoV-2 in HSCT was symptomatic and lethality is higher than in general population. Thus, it is essential to focus on the implementation of measures to mitigate the risk of SARS-CoV-2 infection in this population, as well as to carefully assess HSCT recipients who develop COVID-19.

Expert Consensus: Main Risk Factors for Poor Prognosis in COVID-19 and the Implications for Targeted Measures against SARS-CoV-2

The clinical evolution of patients infected with the Severe Acute Respiratory Coronavirus type 2 (SARS-CoV-2) depends on the complex interplay between viral and host factors. The evolution to less aggressive but better-transmitted viral variants, and the presence of immune memory responses in a growing number of vaccinated and/or virus-exposed individuals, has caused the pandemic to slowly wane in virulence. However, there are still patients with risk factors or comorbidities that put them at risk of poor outcomes in the event of having the coronavirus infectious disease 2019 (COVID-19). Among the different treatment options for patients with COVID-19, virus-targeted measures include antiviral drugs or monoclonal antibodies that may be provided in the early days of infection. The present expert consensus is based on a review of all the literature published between 1 July 2021 and 15 February 2022 that was carried out to establish the characteristics of patients, in terms of presence of risk factors or comorbidities, that may make them candidates for receiving any of the virus-targeted measures available in order to prevent a fatal outcome, such as severe disease or death. A total of 119 studies were included from the review of the literature and 159 were from the additional independent review carried out by the panelists a posteriori. Conditions found related to strong recommendation of the use of virus-targeted measures in the first days of COVID-19 were age above 80 years, or above 65 years with another risk factor; antineoplastic chemotherapy or active malignancy; HIV infection with CD4+ cell counts < 200/mm³; and treatment with anti-CD20 immunosuppressive drugs. There is also a strong recommendation against using the studied interventions in HIV-infected patients with a CD4+ nadir <200/mm³ or treatment with other immunosuppressants. Indications of therapies against SARS-CoV-2, regardless of vaccination status or history of infection, may still exist for some populations, even after COVID-19 has been declared to no longer be a global health emergency by the WHO.

Functional SARS-CoV-2-specific T cells of donor origin in allogeneic stem cell transplant recipients of a T-cell-replete infusion: A prospective observational study

In the current post-pandemic era, recipients of an allogeneic hematopoietic stem cell transplant (HCT) deserve special attention. In these vulnerable patients, vaccine effectiveness is reduced by post-transplant immune-suppressive therapy; consequently, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (COVID-19) is often associated with elevated morbidity and mortality. Characterizing SARS-CoV-2 adaptive immunity transfer from immune donors to HCT recipients in the context of immunosuppression will help identify optimal timing and vaccination strategies that can provide adequate protection to HCT recipients against infection with evolving SARS-CoV-2 variants. We performed a prospective observational study (NCT04666025 at ClinicalTrials.gov) to longitudinally monitor the transfer of SARS-CoV-2-specific antiviral immunity from HCT donors, who were either vaccinated or had a history of COVID-19, to their recipients via T-cell replete graft. Levels, function, and quality of SARS-CoV-2-specific immune responses were longitudinally analyzed up to 6 months post-HCT in 14 matched unrelated donor/recipients and four haploidentical donor/recipient pairs. A markedly skewed donor-derived SARS-CoV-2 CD4 T-cell response was measurable in 15 (83%) recipients. It showed a polarized Th1 functional profile, with the prevalence of central memory phenotype subsets. SARS-CoV-2-specific IFN-γ was detectable throughout the observation period, including early post-transplant (day +30). Functionally experienced SARS-CoV-2 Th1-type T cells promptly expanded in two recipients at the time of post-HCT vaccination and in two others who were infected and survived post-transplant COVID-19 infection. Our data suggest that donor-derived SARS-CoV-2 T-cell responses are functional in immunosuppressed recipients and may play a critical role in post-HCT vaccine response and protection from the fatal disease.

Clinical trial registration

clinicaltrials.gov, identifier NCT04666025.

Outcome of COVID-19 in allogeneic stem cell transplant recipients: Results from the EPICOVIDEHA registry

Background

The outcome of COVID-19 in allogeneic hematopoietic stem cell transplantation (HSCT) recipients is almost uniformely considered poor. The aim of present study was to retrospectively analyse the outcome and risk factors for mortality in a large series of patients who developed COVID-19 infection after an allogeneic HSCT.

Methods

This multicenter retrospective study promoted by the European Hematology Association - Infections in Hematology Study Working Group, included 326 adult HSCT patients who had COVID-19 between January 2020 and March 2022.

Results

The median time from HSCT to the diagnosis of COVID-19 was 268 days (IQR 86-713; range 0-185 days). COVID-19 severity was mild in 21% of the patients, severe in 39% and critical in 16% of the patients. In multivariable analysis factors associated with a higher risk of mortality were, age above 50 years, presence of 3 or more comorbidities, active hematologic disease at time of COVID-19 infection, development of COVID-19 within 12 months of HSCT, and severe/critical infections. Overall mortality rate was 21% (n=68): COVID-19 was the main or secondary cause of death in 16% of the patients (n=53).

Conclusions

Mortality in HSCT recipients who develop COVID-19 is high and largely dependent on age, comorbidities, active hematologic disease, timing from transplant and severity of the infection.

Early administration of SARS-CoV-2 monoclonal antibody reduces the risk of mortality in hematologic malignancy and hematopoietic cell transplant patients with COVID-19

BACKGROUND

Data on severe acute respiratory distress syndrome coronavirus 2 monoclonal antibody (SARS-CoV-2-specific mAb) use in hematologic malignancy and hematopoietic cell transplantation (HM/HCT) patients are limited. Here, we describe our experience with the use of casirivimab-imdevimab or bamlanivimab for the treatment of coronavirus disease 2019 (COVID-19) in HM/HCT patients.

METHODS

This was a retrospective chart review at the University of Miami Hospital and Sylvester Comprehensive Cancer Center for HM/HCT patients with COVID-19 who received casirivimab-imdevimab or bamlanivimab from November 21, 2020, to September 30, 2021. Outcomes measured were mortality, hospital admission, and infusion reaction to SARS-CoV-2-specific mAbs.

RESULTS

We identified 59 HM/HCT patients with mild to moderate COVID-19 who received casirivimab-imdevimab or bamlanivimab. Median age was 57 years (interquartile range [IQR]: 45-65). Among the 59 patients, 25 (42%) received cellular therapy: 14 (24%) had undergone allogeneic HCT, nine (15%) autologous HCT, and two (3%) received chimeric antigen receptor T-cell therapy. The median time from COVID-19 symptom onset to SARS-CoV-2-specific mAb administration was 4 (IQR: 3-6) days. Forty-six (78%) patients received SARS-CoV-2-specific mAbs as outpatients and 13 (22%) patients received SARS-CoV-2-specific mAbs during hospitalization. Among patients who received SARS-CoV-2-specific mAbs as outpatients, only four (9%) visited the emergency department at days 10, 11, 15, and 35 after SARS-CoV-2-specific mAb administration. None of these four patients required hospital admission. Among the hospitalized patients, five (38%) were admitted to the hospital with neutropenic fever, four (31%) were already hospitalized for transplantation and cellular therapy, three (23%) were admitted for monitoring of COVID-19 symptoms, and one (8%) was admitted with acute kidney injury. Three hospitalized patients (23%) died at 14, 35, and 59 days after SARS-CoV-2-specific mAb administration; two of these three deaths were attributed to COVID-19 infection. One patient developed an immediate infusion reaction to bamlanivimab, and no infusion reactions were reported to casirivimab-imdevimab use.

CONCLUSION

During the alpha and delta variant surges, early administration of bamlanivimab or casirivimab-imdevimab prevented hospitalization and death when given in the outpatient setting. Among patients who received mAbs at or after hospital admission, the risk of COVID-19 disease progression and death remains significant. Larger studies of the use of mAb therapy to treat COVID-19 in this population are needed.

Risk of Mortality in Bone Marrow Transplant Patients During SARS-CoV-2 Infection: A Systematic Review

OBJECTIVES

Recipients of bone marrow transplant with COVID-19 are at high risk of mortality and morbidity from their underlying immunocompromised state. Graft-versus-host disease and other comorbidities lead to poor COVID-19 outcomes in these patients. Understanding the outcomes and clinical characteristics of bone marrow transplant recipients with COVID-19 is needed to devise potential life-saving therapies for patients with hematologic malignancies. Reviewing large data sets from different ethnic groups and regions can lead to better understanding. We conducted a systematic review ofreal-world data from prospective and retrospective observational cohort studies that reported the clinical outcomes of COVID- 19 in bone marrow transplant patients.

MATERIALS AND METHODS

We used electronic databases (PubMed, ScienceDirect, Google Scholar), with a cut off date of May 31, 2022, to conduct our search. After screening 349 articles, we selected 33 original reports for screening. After screening these articles for eligibility criteria, we selected 12 studies for final data extraction. We extracted data per the preferred reporting items followed for systematic reviews. Quality evaluation was done with a Cochrane risk-of bias tool for nonrandomized studies (ROBINS-1).

RESULTS

Bone marrow transplant recipients with COVID-19 experienced poor disease outcomes and high mortality rates. Patient age, immunosuppressant intensity, and presence of graft-versus-host disease or other underlying comorbidities directly affected mortality rates of bone marrow transplant recipients with COVID-19. Other factors, like type of malignancy, type of transplant, and time between transplant and COVID-19 diagnosis, did not affect mortality or poor outcomes of COVID-19.

CONCLUSIONS

Bone marrow transplant recipients have a higher risk of mortality and poor disease outcomes from COVID-19. Because curative therapies for COVID- 19 are not available, the only option available is its prevention. Transplant centers worldwide, as pertheir capacities, should develop and adhere to strict standard operating procedures based on international or national guidelines related to transplant recipients with COVID-19.

Allogeneic hematopoietic stem cell transplantation in the COVID-19 era

Allogeneic hematopoietic stem-cell transplantation (allo-HSCT) recipients are especially vulnerable to coronavirus disease 19 (COVID-19), because of their profound immunodeficiency. Indeed, the first pandemic wave was marked by a high mortality rate in this population. Factors increasing immunodepression such as older age, immunosuppressive treatments or a short delay between transplant and infection appear to worsen the prognosis. Many changes in clinical practice had to be implemented in order to limit this risk, including postponing of transplant for non-malignant diseases, preference for local rather than international donations and for peripheral blood as stem cell source, and the widespread use of cryopreservation. The great revolution in the COVID-19 pandemic came from the development of mRNA vaccines that have shown to be able to prevent severe forms of the disease. More than 75% of allo-HSCT recipients develop seroconversion after 2 doses of vaccine. Multiple studies have identified lymphopenia, exposure to immunosuppressive or anti-CD20 therapies, and a short post-transplant period as factors associated with a poor response to vaccination. The use of repeated injections of the vaccine, including a third dose, not only improves the seroconversion rate but also intensifies the immune response, both in B cells and T cells. Vaccines are an effective and well-tolerated method in this high-risk population. Some studies investigated the possibility of immune protection being transferred from a vaccinated donor to a recipient, with encouraging initial results. However, dynamic mutations and immune escape of the virus can lead to breakthrough infections with new variants in vaccinated individuals and still represent a threat of severe disease in allo-HSCT recipients. New challenges include the need to adapt vaccine protection to emerging variants.

Revised Guidelines for Coronavirus Disease 19 Management in Hematopoietic Cell Transplantation and Cellular Therapy Recipients (August 2022)

This document is intended as a guide for diagnosis and management of Coronavirus Disease 2019 (COVID-19), caused by the virus SARS-CoV-2, in adult and pediatric HCT and cellular therapy patients. This document was prepared using available data and with expert opinion provided by members of the (ASTCT) Infectious Diseases Special Interest Group (ID-SIG) and is an update of pervious publication. Since our original publication in 2020, the NIH and IDSA have published extensive guidelines for management of COVID-19 which are readily accessible ( NIH Guidelines , IDSA Guidelines ). This update focuses primarily on issues pertaining specifically to HCT/cellular therapy recipients. Information provided in this manuscript may change as new information becomes available.

COVID-19 and HSCT (Hematopoietic stem cell transplant)

HSCT recipients are at increased risk for COVID-19-associated morbidity and mortality. Early treatment of symptomatic SARS-CoV-2 infection is an important means to decreasing risk for severe disease and death. While some HSCT recipients, particularly those who are early post-transplant and severely immunosuppressed, may have diminished response to COVID-19 vaccines, the benefits of vaccination are uncontested. Public health, healthcare facility and individual level approaches are all necessary to mitigate risk for infection in this vulnerable population.

COVID‐19 outcomes in haematopoietic cell transplant recipients: A systematic review and meta‐analysis

Up‐to‐date information on coronavirus disease 2019 (COVID‐19) outcomes and risk factors in haematopoietic cell transplantation (HCT) recipients is required to inform on decisions about cancer treatment and COVID‐19 mitigation strategies. We performed a meta‐analysis to address this knowledge gap. All studies with at least five patients who reported COVID‐19‐related deaths in HCT recipients were included. The primary outcome was COVID‐19‐related death. Secondary outcomes were COVID‐19‐related mechanical ventilation (MV) and intensive care unit (ITU) admission. The cumulative COVID‐19‐related death rate among HCT recipients was 21% (95% confidence interval [CI] 18%–24%), while MV and ITU admission rates were 14% (95% CI 11%–17%) and 18% (95% CI 14%–22%), respectively. Subgroup analysis showed higher death rates in patients who developed COVID‐19 within 12 months of HCT (risk ratio [RR] 1.82, 95% CI 1.09–3.03), within 6 months of receiving immunosuppressant drugs (RR 2.11, 95% CI 1.38–3.20) or in the context of active graft‐versus‐host disease (RR 2.38, 95% CI 1.10–5.16). Our findings support the idea that HCT should remain an integral part of cancer treatment during the COVID‐19 pandemic but also highlight the need to prioritise preventative measures in those patients who are at increased risk of adverse COVID‐19 outcomes.

Zelltherapie in den Zeiten von SARS-CoV-2

Ein breites Spektrum von Disruptionen, aber auch blitzschnelle Innovationen, hat die SARS-CoV-2 Pandemie gebracht. Dieser Übersichtsartikel betrachtet die Pandemie aus der Warte der Zelltherapie; konkret werden vier Aspekte untersucht: Wie unterscheiden sich die Risiken von Zelltherapie-Patienten mit SARS-CoV-2 Infektion und COVID von denen der Allgemeinbevölkerung? Sind Empfänger von Zelltherapien, hier speziell autologe und allogene Stammzelltransplantationsempfänger sowie Empfänger von CAR-T-Zell-Präparaten, klinisch relevant durch SARS-CoV-2 Vakzine immunisierbar? Welche Auswirkungen hat die Pandemie mit Spenderausfallrisiko und Zusammenbruch von Supply Chains auf die Versorgung mit Zelltherapeutika? Gibt es Zelltherapeutika, die bei schwerem COVID therapeutisch nutzbringend eingesetzt werden können? In aller Kürze, das erwartete massiv erhöhte Risiko von Zelltherapie-Patienten, im Infektionsfall einen schweren Verlauf zu erleiden oder zu sterben, wurde bestätigt. Die Vakzine induziert jedoch bei vielen dieser Patienten humorale und zelluläre Immunität, wenn auch weniger zuverlässig als bei Gesunden. Dank kreativer Lösungen gelang es, die Versorgung mit Zelltherapeutika im Wesentlichen uneingeschränkt aufrecht zu erhalten. SARS-CoV-2-spezifische T-Zell-Präparate für den adoptiven Immuntransfer wurden entwickelt, eine therapeutische Konstellation diese anzuwenden ergab sich jedoch nicht. Therapiestudien mit mesenchymalen Stromazellen beim schweren COVID laufen weltweit; die Frage der Wirksamkeit bleibt zurzeit offen, bei jedoch substanziellem Optimismus in der Szene. Einige der Erkenntnisse und Innovationen aus der SARS-CoV-2-Pandemie können möglicherweise verallgemeinert werden und so auf die Zeit nach ihrem Ende langfristig nachwirken.

Coronavirus disease 2019 in immunocompromised patients: a comprehensive review of coronavirus disease 2019 in hematopoietic stem cell recipients

PURPOSE OF REVIEW

Immunocompromised patients are notably vulnerable to severe coronavirus disease 2019. This review summarizes COVID-19 features and outcomes in autologous and allogeneic hematopoietic stem cell transplantation (HSCT) recipients.

RECENT FINDINGS

Recent findings suggest that HSCT recipients exhibit a high burden of comorbidities and COVID-19 clinical features almost similar to the general COVID population. Furthermore, HSCT recipients exhibit a protracted SARS-CoV-2 shedding, prolonging duration of symptoms and promoting the generation of highly mutated viruses. Last, most of studies report a higher COVID-19 mortality in HSCT recipients, mainly driven by age, comorbidities, time from transplantation, and immunosuppression because of both treatments and underlying hematological malignancy.

SUMMARY

Further studies are warranted to determine the proper impact of HSCT-related immune disorders on COVID-19 outcomes, and to evaluate specific treatments and vaccination strategy in this high-risk population. Taken together, those findings emphasize the need for more rigorous surveillance and preemptive measures for all HSCT recipients.

Impact of COVID-19 in Hematopoietic stem cell transplant recipients: A systematic review and meta-analysis

BACKGROUND

Hematopoietic stem cell transplant (HSCT) recipients are at increased risk of mortality and morbidity with Coronavirus Disease 2019 (COVID-19) due to severe immune dysfunction.

METHODS

A literature search was performed on PubMed, Cochrane, and Clinical trials.gov from the date of inception to 12/08/2021. We identified 19 original studies reporting data on COVID-19 in HSCT recipients after screening 292 articles. Data was extracted following PRISMA guidelines. Quality evaluation was done using the NIH quality assessment tool. Inter-study variance was calculated using Der Simonian-Laird Estimator. Pooled analysis was conducted using MetaXL. A random-effects model was used to estimate the proportions with 95% confidence intervals (CI).

RESULTS

Of 6711 patients in 19 studies, 2031 HSCT patients with SARS-CoV-2 infection were analyzed. The median age of patients was 56.9 (range 1-81.6) years, and 63% patients were men according to 14 studies. The median time from transplant to SARS-CoV-2 infection for autologous (auto) and allogeneic (allo) HSCT patients was 23.2 (0.33- 350.5) months and 16.4 (0.2- 292.7) months respectively. The median follow-up time after COVID-19 diagnosis was 28 (0-262) days. The COVID-19 mortality rate was 19% (95% CI 0.15- 0.24, I² = 76%, n = 373/2031). The pooled mortality rate was 17% (95% CI 0.12- 0.24, I² = 78%, n = 147/904) in auto-HSCT patients and 21% (95% CI 0.16- 0.25, I² = 60%, n = 231/1103) in allo-HSCT patients.

CONCLUSIONS

HSCT recipients have a high risk of mortality and clinical complications due to COVID-19. There is a need for ongoing vigilance, masks, and social distancing, vaccination, and aggressive management of SARS-CoV-2 infection in HSCT recipients. This article is protected by copyright. All rights reserved.

A Portrait of SARS-CoV-2 Infection in Patients Undergoing Hematopoietic Cell Transplantation: A Systematic Review of the Literature

The management of COVID-19 in hematopoietic cell transplant (HCT) recipients represents a special challenge given the variable states of immune dysregulation and altered vaccine efficacy in this population. A systematic search (Ovid Medline and Embase on 1 June 2021) was needed to better understand the presenting features, prognostic factors, and treatment options. Of 897 records, 29 studies were identified in our search. Most studies reporting on adults and pediatric recipients described signs and symptoms that were typical of COVID-19. Overall, the mortality rates were high, with 21% of adults and 6% of pediatric HCT recipients succumbing to COVID-19. The factors reported to be associated with increased mortality included age (HR = 1.21, 95% CI 1.03-1.43, p = 0.02), ICU admission (HR = 4.42, 95% CI 2.25-8.65, p < 0.001 and HR = 2.26, 95% CI 1.22-4.20, p = 0.01 for allogeneic and autologous HCT recipients), and low platelet count (OR = 21.37, 95% CI 1.71-267.11, p = 0.01). Performance status was associated with decreased mortality (HR = 0.83, 95% CI 0.74-0.93, p = 0.001). A broad range of treatments was described, although no controlled studies were identified. The risk of bias, using the Newcastle-Ottawa scale, was low. Patients undergoing HCT are at a high risk of severe morbidity and mortality associated with COVID-19. Controlled studies investigating potential treatments are required to determine the efficacy and safety in this population.

Severe acute respiratory syndrome coronavirus 2 infection in the stem cell transplant recipient - clinical spectrum and outcome

PURPOSE OF REVIEW

Focusing on large multicenter cohorts reported over the last months, this review aims at summarizing the available evidence by July 2021 on the impact of coronavirus disease 2019 (COVID-19) on hematopoietic stem cell transplant (HSCT) recipients in terms of epidemiology, clinical features, and outcome.

RECENT FINDINGS

The incidence of COVID-19 in institutional cohorts varied according to different regions and study periods from 0.4% to 8.3%. Clinical presentation was overall comparable to other immunocompromised hosts and the general population. Microbiologically confirmed superinfection occurred in 13-25% of recipients, with most episodes due to hospital-acquired bacteria and few reported cases of COVID-19-associated aspergillosis. Prolonged nasopharyngeal severe acute respiratory syndrome coronavirus 2 shedding has been demonstrated for as long as 210 days. Mortality rates were similar across studies (14.8-28.4%) and did not markedly differ from those observed in nontransplant hematological patients during the first wave. Older age and shorter time from transplantation were associated with mortality, as well as underlying disease status and amount of immunosuppression. No outcome differences were found in most studies between allogeneic and autologous procedures.

SUMMARY

Considerable advances have been achieved in the characterization of COVID-19 in the HSCT population, although uncertainties remain in the optimal therapeutic management.

Clinical presentation and outcomes of COVID-19 following hematopoietic cell transplantation and cellular therapy

BACKGROUND

One year into the pandemic, published data on hematopoietic cell transplantation (HCT) recipients with coronavirus disease 2019 (COVID-19) remain limited.

METHODS

Single-center retrospective cohort study of adult HCT recipients with polymerase chain reaction (PCR)-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

RESULTS

Twenty-eight consecutive transplantation and cellular therapy patients (autologous, n = 12; allogeneic, n = 15; chimeric antigen receptor T-cell therapy [CAR-T], n = 1) with COVID-19 were identified. The median age was 57 years. The median time from HCT to COVID-19 diagnosis was 656 days (interquartile range [IQR], 33-1274). Patients were followed for a median of 59 days (IQR, 40-88). Among assessable patients (n = 19), 10 (53%) had documented virological clearance; median time to clearance was 34 days (range, 21-56). Out of 28, 12 (43%), 6 (21%), and 10 (36%) patients had mild, moderate, and severe/critical disease, respectively. Overall mortality was 25%, nearly identical for autologous and allogeneic HCT, and exclusively seen in hospitalized patients, older than 50 years of age with severe COVID-19. None of the patients with mild (n = 12) or moderate (n = 6) COVID-19 died whereas 7/10 patients (70%) with severe/critical COVID-19 died (P = .0001). Patients diagnosed with COVID-19 within 12 months of HCT exhibited higher mortality (57% vs 14%; P = .04). All-cause 30-day mortality (n = 4) was 14%. A higher proportion of patients who died within 30 days of COVID-19 diagnosis (3/4) were receiving ≥2 immunosuppressants, compared with patients who survived beyond 30 days after COVID-19 diagnosis (2/24; 75% vs. 8%; P = .01).

CONCLUSIONS

Mortality in COVID-19 HCT patients is higher than that of the age-comparable general population and largely dependent on age, disease severity, timing from HCT, and intensity of immunosuppression.