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An observational study spanning four continents indicated a marked decline in the number of solid organ transplants amid the COVID-19 pandemic, likely due to risk of infection and limited resources.

The France-backed study published in The Lancet Public Health journal on Monday stemmed from 22 countries, including the U.S., Canada, 16 countries across Europe and three in South America. The study period began after the 100th reported COVID-19 case in each country, as viral spread differed across regions. Researchers compared data from January-December 2020 versus the same time period in 2019.

Results indicated worldwide organ transplants declined 16% (11,253) across the 22 countries, with the largest reductions among kidney transplants (-19%), likely owing to its “non-immediate life-saving nature,” followed by lung, liver and heart transplants, down approximately 16%, 11% and 5%, respectively.

“Although the number of organ transplants decreased rapidly during the first 3 months of the pandemic, this decrease stabilised after June, 2020, as transplantation centres presumably learned to adapt after the first pandemic wave,” the study reads. “A new sharp decrease in organ transplant activity was observed from October to December, 2020.”

The declines varied across countries, and some nations like the U.S, Switzerland, Belgium and Italy maintained the rate of transplants, while others saw significant reductions, researchers wrote.

The study cited over 48,000 patient life-years lost due to the pandemic’s toll on organ transplantation. The study had its limitations; the data didn’t detail reasons for volume reductions in certain areas, and other factors could be at play (such as two earthquakes in Croatia during the study period, suspected to disrupt transplantation). The study excluded many countries and all of Africa due to insufficient data, though nations in Africa were recommended to hold a priority in future studies.

“Understanding how different countries and health-care systems responded to COVID-19-related challenges could improve pandemic preparedness, most notably, how to safely maintain transplant programmes, both those with immediate and non-immediate life-saving potential, to prevent loss of patient life-years,” the study reads.

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