Longitudinal Assessment of Solid Organ Transplant Recipients with SARS-CoV-2 Infection
Authors: Vuyk Will , Bobholz Max , Emmen Isla , Lail Andrew , Minor Nicolas , Bhimalli Pavan , Eickhoff Jens C. , Ries Hunter J. , Machkovech Heather , Wei Wanting , Weiler Andrea , Richardson Alex , DePagter Carson , VanSleet Grace , Bhasin Maansi , Kamal Sarah , Wolf Sydney , Virdi Aanya , Bradley Taylor , Gifford Angela , Benito Melanie , Shipe Alex , Mohamed Rana , Smith Jeannina , Wilson Nancy , Friedrich Thomas C. , O’Connor David H. , Garonzik-Wang Jacqueline 
Published: November 2024

Background

Compared to immunocompetent individuals, those who are immunocompromised, including solid organ transplant (SOT) recipients, have higher SARS-CoV-2-related morbidity and mortality. We determined the duration of SARS-CoV-2 RNA positivity to evaluate viral persistence in SOT recipients.

Methods

This study prospectively followed SOT recipients who recently tested positive for SARS-CoV-2. The duration of viral RNA shedding in nasal swabs and stool samples was tracked, and viral genome sequencing was performed where possible. Persistent infection was defined as a positive nucleic acid amplification test (NAAT) for SARS-CoV-2 at 28 days or later after initial infection. This duration was chosen based on the CDC recommendation that immunocompromised individuals isolate for at least 20 days1, compared to 10 days for non-immunocompromised individuals.

Results

Of 30 SOT recipients, 12 (40%) had SARS-CoV-2 RNA in nasal swabs or stool 28 or more days after the first positive SARS-CoV-2 test. IC-015 had high viral loads (Ct<30) at 28 days, with continued detection for 54 days.

Conclusion

In 12 of 30 SOT subjects, SARS-CoV-2 RNA was detected at or beyond 28 days post-detection (dpd), despite vaccination and antibody and/or antiviral treatment in most participants. Three subjects tested positive for SARS-CoV-2 RNA past 50 dpd. The CDC recommendation for 20 days of isolation may be insufficient for SOT recipients. Viral persistence in the setting of host immune suppression, coupled with exposure to antiviral treatments, raises concern about the selection of unusual viral variants.

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Compared to immunocompetent individuals, those who are immunocompromised, including solid organ transplant (SOT) recipients, have higher SARS-CoV-2-related morbidity and mortality. We determined the duration of SARS-CoV-2 RNA positivity to evaluate viral persistence in SOT recipients.

This study prospectively followed SOT recipients who recently tested positive for SARS-CoV-2. The duration of viral RNA shedding in nasal swabs and stool samples was tracked, and viral genome sequencing was performed where possible. Persistent infection was defined as a positive nucleic acid amplification test (NAAT) for SARS-CoV-2 at 28 days or later after initial infection. This duration was chosen based on the CDC recommendation that immunocompromised individuals isolate for at least 20 days1, compared to 10 days for non-immunocompromised individuals.

In 12 of 30 SOT subjects, SARS-CoV-2 RNA was detected at or beyond 28 days post-detection (dpd), despite vaccination and antibody and/or antiviral treatment in most participants. Three subjects tested positive for SARS-CoV-2 RNA past 50 dpd. The CDC recommendation for 20 days of isolation may be insufficient for SOT recipients. Viral persistence in the setting of host immune suppression, coupled with exposure to antiviral treatments, raises concern about the selection of unusual viral variants.

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