Children younger than 12 years now exempt from pretransplant HIV, HBV, HCV testing
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The U.S. Public Health Service has published an updated recommendation for solid organ transplant candidates aged younger than 12 years, which now exempts them from testing for HIV and hepatitis B and C viruses during surgical admission.
“Updated guidance published in 2020 included the recommendation that all transplant candidates receive HIV, HBV and HCV testing during hospital admission for transplant surgery to more accurately assess their pretransplant infection status and to better identify donor transmitted infection,” Rebecca J. Free, MD, of the division of health care quality promotion at the CDC National Center for Emerging and Zoonotic Infectious Diseases, and colleagues wrote in Morbidity and Mortality Weekly Report.
“In 2021, CDC was notified that this recommendation might be unnecessary for pediatric organ transplant candidates because of the low likelihood of infection after the perinatal period and out of concern that the volume of blood drawn for testing could negatively affect critically ill children.”
The CDC and Health Resources and Services Administration conducted a review of HIV, HBV and HCV surveillance data from the CDC and transplant data from the Organ Procurement and Transplantation Network to better understand the number of patients affected by the 2020 PHS policy and determine whether an age-based exemption was appropriate, considering young patients with low pretransplant weight are most likely to be harmed by additional blood volume loss.
In December 2021, HHS convened the Advisory Committee on Blood and Tissue Safety and Availability to present evidence of HIV, HBV and HCV incidence among pediatric transplants by age and weight and gather expert opinion to determine whether guideline revisions were needed.
The committee initially voted to exempt solid organ transplant recipients aged 10 years and younger from testing for HIV, HBV and HCV infection at the time of transplantation, but members of the transplant community suggested a cutoff of younger than 12 years to more closely align with other transplant policies related to testing, organ allocation and comorbid disease severity classification.
The updated recommendation, which states candidates aged younger than 12 years who have received postnatal infectious disease testing are exempt from pretransplant HIV, HBV and HCV testing, was based on the following summary of evidence as well as input from experts and community members.
HIV incidence among children
According to the report, infants and children aged younger than 13 years were at the lowest risk for HIV infection in the U.S. Of 524 cases of HIV diagnosed in this population from 2015 to 2019, 35% were newborn aged 0 to 5 months, 4% were infants aged 6 to 11 months, 7% were children aged 12 to 23 months and 54% were children aged 2 to 12 years.
In contrast, youth aged 13 to 19 years were at an increased risk for HIV infection and constituted 1,667 of 36,801 new HIV cases reported in 2019.
HBV, HCV incidence among children
In 2019, HBV and HCV incidence reported to the CDC among U.S. residents aged younger than 20 years was 0 and 0.1 per 100,000 people, respectively.
Further, more than 90% of children aged 2 years and adolescents aged 13 to 17 years in the U.S. have been vaccinated against HBV.
Pediatric transplants by age and weight
From 2016 to 2020, surgeons performed 5,209 solid organ transplants in infants and children aged younger than 10 years. Among those with reported weights, 29% weighed less than 20 pounds, 46% weighed between 20 pounds and 40 pounds, and 25% weighed at least 40 pounds.
“This updated recommendation is based on transplant candidate age to more effectively protect those candidates at highest risk for potential harm from blood volume loss and maintain the ability to recognize pretransplant HIV, HBV and HCV infections among populations at highest risk,” Free and colleagues wrote.
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