This document discusses Zika virus and its impact on immunocompromised patients and organ/tissue donors and recipients. It notes that while Zika seems to have no increased severity in immunocompromised patients yet, similar flaviviruses like dengue and chikungunya generally do not either. However, West Nile virus, which has a different vector, can cause increased neuroinvasive disease in immunocompromised individuals. Screening guidelines have been issued for donors exposed to Zika to reduce transmission risk, particularly for pregnant recipients or those of childbearing age. While donor screening for Zika may initially reduce tissues available for transplant, it is not expected to significantly impact organ donations at this time.

1. 3/9/2016
Immunocompromised hosts and
transplant recipients
Peter V. Chin-Hong, MD

2. 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)
3/9/20162
Zika virus rash

3. 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)
3/9/20163
Zika virus rash

4. Immunocompromised (IC) patients: Clinical
Pathogen Transmission Clinical:
general
Clinical:
neuro
IC
Zika Flavivirus Aedes aegyptus
Aedes albopictus
mosquito
Fever, rash,
arthralgia,
conjunctivitis
Microcephaly
Intracranial
calcifications
Guillain-Barré
No known
increase in
severity (yet)
Dengue Flavivirus Aedes aegyptus
Aedes 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 aegyptus
Aedes albopictus
mosquito
High fever,
severe
arthralgia. No
conjunctivitis
Encephalitis,
Guillain-Barré
Published cases
in transplant. No
known increase
in severity
3/9/20164

5. Immunocompromised (IC) patients: Clinical
Pathogen Transmission Clinical:
general
Clinical:
neuro
IC
Zika Flavivirus Aedes aegyptus
Aedes albopictus
mosquito
Fever, rash,
arthralgia,
conjunctivitis
Microcephaly
Calcifications
Fetal demise
Guillain-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
Microcephaly
Calcifications
Fetal demise
Encephalitis,
Guillain-Barré
Common and
life threatening
Mono-like
illness, hepatitis,
retinitis, colitis,
pneumonitis
3/9/20165

6. 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)
3/9/20166
Zika virus rash

7. 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
3/9/20167
Potential donor derived transmission events
2013 = 443

8. 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”
3/9/20168

9. 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?
3/9/2016Preparedness for the Zika Virus: A Public Health Emergency

10. 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
3/9/201610
Immunostaining of Flaviviral Antigens in Neurons WNV