We thank Gianluca Ianiro and colleagues
1
for highlighting an important concern faced by faecal microbiota transplant (FMT)
stakeholders, including stool banks, regulators, and especially recipients, during
the current coronavirus disease 2019 (COVID-19) pandemic. The authors are right in
highlighting the concern arising from the detection of severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) in stool samples and the safety implications for FMT donor
screening policies. However, we strongly believe that the approach taken by the authors
in excluding donors on the basis of having developed COVID-19 symptoms, having had
contact with patients with confirmed COVID-19 disease, or having recently travelled
to regions affected by COVID-19, is insufficient and potentially unsafe. The world
is currently amid a global pandemic, exacerbated by a large burden of asymptomatic
or mild cases; as of March 19, 2020, more than 80 000 known cases have been reported
in Europe and the UK.
2
Exclusion on the proposed criteria of clinical disease, or travel exposure to perceived
high-risk countries, or both, can no longer be considered sufficient. This point is
particularly important, because cities and countries where FMT donor stool banks are
based now have community outbreaks and in some areas they are registering as many,
if not more, patients with COVID-19 than earlier reported rates from high-risk category
countries.
2
Furthermore, the authors have not taken into account the large group of asymptomatic
carriers who could potentially shed virus in the stool for an undefined period of
time, and that during this period they should be ineligible as donors.3, 4
There have been two safety alerts by the US Food and Drug Administration on serious
adverse events that were likely to have resulted from the transmission of pathogenic
organisms via a FMT. The alert from March 12, 2020, was the result of potentially
detectable enteropathogenic Escherichia coli and Shiga-toxin-producing E coli.
5
In the current situation, screening policies for FMT donors ought to remain stringent,
safe, effective, and scientifically justified wherever possible. The recipients of
FMT globally are often patients who are older (aged >65 years), with multiple comorbidities,
or immunocompromised with Clostridioides difficile infections. Therefore, minimising
the potential to transmit pathogens through FMT depends on FMT providers and robust
screening procedures.
The University of Birmingham Microbiome Treatment Centre is the second largest provider
of FMT for treatment globally, and we are running the largest FMT trial for inflammatory
bowel disease (STOP-Colitis)
6
in the world to date. Our donor eligibility criteria, based on our published guidelines,
would exclude FMT derived from any individual with symptoms of COVID-19.
7
In addition to these criteria, as of January, 2020, FMT produced from the date of
detection of the first cases of COVID-19 have been quarantined from use until a time
when a validated stool test for SARS-CoV-2 becomes available. We are not currently
processing any new donors, but we anticipate that this situation will delay the availability
of FMT for only a short period of time, because such tests are in rapid development.
8
We believe that the molecular screening of stool from all donors for SARS-CoV-2 will
be the safest way forward, because this approach would adequately address and mitigate
against the risk posed from asymptomatic carriage and might also provide a useful
measure of asymptomatic prevalence in the wider community.