05/01/2023

Immunocompromised hosts and transplant recipientsPeter V. Chin-Hong, MD

05/01/20232

The population

Immunocompromised patients• HIV/AIDS• Stem cell transplant recipients• Organ transplant recipients• Biologics

Donors• Organ donors (live and

deceased)• Tissue donors (live and

deceased)

Zika virus rash

05/01/20233

The population

Immunocompromised patients• HIV/AIDS• Stem cell transplant

recipients• Organ transplant recipients• Biologics

Donors• Organ donors (live and

deceased)• Tissue donors (live and

deceased)

Zika virus rash

05/01/20234

Immunocompromised (IC) patients: ClinicalPathogen Transmiss

ionClinical: general

Clinical:neuro

IC

Zika Flavivirus Aedes aegyptusAedes albopictus mosquito

Fever, rash, arthralgia, conjunctivitis

MicrocephalyIntracranial calcificationsGuillain-Barré

No known increase in severity (yet)

Dengue Flavivirus Aedes aegyptusAedes albopictus mosquito

High fever, severe myalgia, headache. No conjunctivitis

Encephalitis, seizures (1%)

>40 published cases including fatal cases. No known increase in severity

Chikungunya Flavivirus Aedes aegyptusAedes albopictus mosquito

High fever, severe arthralgia. No conjunctivitis

Encephalitis, Guillain-Barré

Published cases in transplant. No known increase in severity

05/01/20235

Immunocompromised (IC) patients: ClinicalPathogen Transmiss

ionClinical: general

Clinical:neuro

IC

Zika Flavivirus Aedes aegyptusAedes albopictusmosquito

Fever, rash, arthralgia, conjunctivitis

MicrocephalyCalcificationsFetal demiseGuillain-Barré

No known increase in severity (yet)

West Nile Virus

Flavivirus Culex mosquito

Fever, rash, myalgia, headache. No conjunctivitis

Meningitis, Encephalitis, Flaccid paralysis

Increased neuro-invasive disease

Cytomegalovirus (CMV)

Herpesvirus Close contact, sexual, blood or tissue, perinatal exposure

Mono-like illness, hepatitis

MicrocephalyCalcificationsFetal demiseEncephalitis, Guillain-Barré

Common and life threateningMono-like illness, hepatitis, retinitis, colitis, pneumonitis

05/01/20236

The population

Immunocompromised patients• HIV/AIDS• Stem cell transplant recipients• Organ transplant recipients• Biologics

Donors• Organ donors (live and

deceased)• Tissue donors (live and

deceased)

Zika virus rash

05/01/20237

Patient safety following organ and tissue transplantation OPTN Policy 15.3: Informed Consent of

Transmissible Disease Risk

• The Host OPO (for deceased organ donors) and the Procuring Center (for live organ donors) must obtain the donor’s medical/behavioral history

• If the donor meets Current PHS Criteria for being at

Increased Risk of Transmitting HIV, HBV or HCV

There is a recognized disease present in the donor that, in the opinion of the transplant center, be transmitted to the recipient

o Special informed consent must be obtained

o Follow-up testing and treatment must be offered to the transplant recipient

Potential donor derived transmission events

2013 = 443

05/01/20238

Guidelines for donor screening to reduce transmission of Zika Virus

Regulatory body Guidelines issued

Medical & Social History

Exclude as donor if:

Human cells and tissues

FDA FDA 3/1/16 Screen for Zika -Zika diagnosed in past 6 months (live and deceased)-Residence in, or travel to Zika area in past 6 months (live)-Sex with male with above risk factors (live)

Organs Organ Procurement and Transplantation Network (OPTN)

OPTN/UNOS/DTAC, AST, ASTS 2/3/16

Screen for Zika: “focus on recent travel history, epidemiologic risk factors, …symptoms” of donor

-Travel to Zika-endemic area in past 28 days and recipient pregnant or of child-bearing age -Donor with active Zika (live)…”Do not believe concern for Zika should…exclude donors”

05/01/2023

The need continues to grow

21 people die each day while waiting for a transplant

122,000 people on waiting list 31,000 organ transplants

performed in 2015 from 15,000 donors

The gap between supply and demand continues to widen

Why be so conservative with Zika screening in organ transplant?

Preparedness for the Zika Virus: A Public Health Emergency

05/01/202310

Zika virus in immunocompromised (IC)

No evidence so far of increased incidence or severity in immunocompromised

Other flaviruses with same vector (Dengue, Chikungunya) have overlap in symptoms except congenital effects, and have no increased severity in IC

Other flavivirus with different vector (WNV) with more neurotropic disease in IC

CMV has interesting parallel to Zika in terms of congenital effects

Zika will result in potentially fewer tissue donations but not organ donations (yet)

Summary

Immunostaining of Flaviviral Antigens in Neurons WNV