Organ Donors in the Opioid Crisis: More Increased-Risk Donors, More Hepatitis C

The opioid crisis has driven up overdose deaths and hepatitis C (HCV) infections, hitting young people hardest — the same people who can become organ donors. A 2013 Public Health Service guideline aims to prevent unintended transmission of hepatitis B (HBV), HCV and HIV through transplants: it defines increased risk donors (IRDs) — based on risk behaviors in the 12 months before donation — and calls for testing every donor. CDC analyzed data on every U.S. deceased donor from 2010 through 2017, reported to the Organ Procurement and Transplantation Network.

The shift in donors

Over the whole period, 70,414 people donated; 17.9% were increased risk. IRDs were younger on average (35.2 years, against 41.0), and — like people dying of opioid overdoses — more often white and male.

Infections found

Across all donors, HCV antibody positivity rose from 4.2% to 7.3%, and HCV RNA (active infection) from 3.9% (2014) to 4.9% (2017). HBV surface antigen stayed at 0.1%, and HIV antibody went from 0.0% to 0.1%.

Increased risk donors carried far more infection:

Among IRDs, HCV RNA positivity rose from 8.6% (2014) to 15.7% (2017); among standard risk donors it fell, from 2.2% to 1.1%.

Testing caught up

The guideline's recommended nucleic acid tests (NAT) began in 2014. By 2017, more than 99.9% of increased risk donors were tested by NAT for HCV and HBV, and 99.9% for HIV — up from about 4.6%. NAT caught 55 IRDs (5.3% of those with HCV RNA) whose infections were so recent that antibodies hadn't yet appeared.

NAT narrows the window in which an infection can't be detected to an average of 3–5 days for HCV, 11–13 days for HIV and 20–22 days for HBV.

What it means

• Organs from increased risk donors may be underused. With universal NAT, the authors suggest reconsidering the 12-month look-back for increased-risk status, and the terminology, to help use more organs safely.
• Recipients of IRD organs should be tested for HBV, HCV and HIV after transplant, which isn't otherwise routine — donor risk information must reach recipients and their clinicians.
• HIV transmission from a deceased donor hasn't been identified in the U.S. since 2007, but window-period HCV transmissions from IRDs have occurred. Direct-acting antivirals appear safe and effective for donor-derived HCV, and effective therapy exists for HIV and HBV.
• CDC and the Health Resources and Services Administration will keep reviewing the guideline.

Limits: recipient outcomes weren't compared; only donors whose organs were recovered are included; risk status often comes from next of kin, who may not know; some HIV-positive donations were likely research under the HOPE Act of 2013; and the 2013 guideline changed the IRD criteria, which may account for part of the rise.

Sources

Based on Winston E. Abara, Melissa G. Collier, Anne Moorman and others, "Characteristics of Deceased Solid Organ Donors and Screening Results for Hepatitis B, C, and Human Immunodeficiency Viruses — United States, 2010–2017," MMWR, volume 68, Centers for Disease Control and Prevention; a work of the United States government in the public domain. The report's count of nine antibody-negative "HCV RNA–positive donors" is described as covering all donors although it appears among standard risk donors and is lower than the 55 increased risk donors alone, so it is not given here.