Thread by @swinndong

#IDWeek2020
Session: Cutting edge adult&ped #TxID

First up, @BrianFisher95 on adenovirus and EBV

#IDWeek2020
Session: Cutting edge adult&ped #TxID
@BrianFisher95

Adenovirus reactivation is more common in pediatric HCT pts, so age is significant risk factor

Chart with reactivation rates, mostly ped data 👇 Progression to sx dz in peds is not uncommon

#IDWeek2020
Session: Cutting edge adult&ped #TxID
@BrianFisher95

So what to do when adenovirus is positive

#IDWeek2020
Session: Cutting edge adult&ped #TxID
@BrianFisher95

Cidofovir?

#IDWeek2020
Session: Cutting edge adult&ped #TxID
@BrianFisher95

What about brincidofovir?

#IDWeek2020
Session: Cutting edge adult&ped #TxID
@BrianFisher95

Turning to adoptive immunotherapy

Many types of adenovirus

#IDWeek2020
Session: Cutting edge adult&ped #TxID
@BrianFisher95

Summary on adenovirus management

May need to consider specific spp/type

#IDWeek2020
Session: Cutting edge adult&ped #TxID
@BrianFisher95

EBV risk factors and epi

Range of reactivation is variable

#IDWeek2020
Session: Cutting edge adult&ped #TxID
@BrianFisher95

Interventions to reduce EBV risk

#IDWeek2020
Session: Cutting edge adult&ped #TxID
@BrianFisher95

No one knows the exact threshold, but pre-emptive ritux is often considered standard of care. Does seem to decrease PTLD risk to 4% or less

Also notes on Ritux as ppx

#IDWeek2020
Session: Cutting edge adult&ped #TxID
@BrianFisher95

Donor derived EBV-CTLs led to 12% breakthrough EBV DNAemia rate but no PTLD in ppx use

#IDWeek2020
Session: Cutting edge adult&ped #TxID

Next up, C.Bollard on cell therapy

#IDWeek2020
Session: Cutting edge adult&ped #TxID
C.Bollard

Introduction to virus specific T-cell therapy

#IDWeek2020
Session: Cutting edge adult&ped #TxID
C.Bollard

2 manufacturing strategies 👇

#IDWeek2020
Session: Cutting edge adult&ped #TxID
C.Bollard

Are virus-specific T-cells safe?
Likely minimal toxicity
No evidence of GVHD in this cohort
Risk of cytokine release syndrome is low (particularly outside of EBV)

#IDWeek2020
Session: Cutting edge adult&ped #TxID
C.Bollard

Do these virus-specific T-cells persist, remain effective?

#IDWeek2020
Session: Cutting edge adult&ped #TxID
C.Bollard

Summary

#IDWeek2020
Session: Cutting edge adult&ped #TxID
C.Bollard

What if the donor not available?

Taking from boutique ➡️ off the shelf with third-party VST

Clinical responses ranged from 50-90+% depending on study

#IDWeek2020
Session: Cutting edge adult&ped #TxID
C.Bollard

Wow, pt with EBV PTLD -- after 2 doses

#IDWeek2020
Session: Cutting edge adult&ped #TxID
C.Bollard

#IDWeek2020
Session: Cutting edge adult&ped #TxID
C.Bollard

Can track these cells

Important to match through shared allele

#IDWeek2020
Session: Cutting edge adult&ped #TxID
C.Bollard

Can VSTs target multiple viruses/pathogens after BMT?

6 virus product 👇 ~75% response rate so far

Still a lot to learn

#IDWeek2020
Session: Cutting edge adult&ped #TxID
C.Bollard

Developing T cell therapies for SARS-CoV-2

#IDWeek2020
Session: Cutting edge adult&ped #TxID
C.Bollard

When are they ready for prime-time? Why are VSTs not more widely used?

Drugs vs VSTs

#IDWeek2020
Session: Cutting edge adult&ped #TxID

Next, Paul Carpenter

Discussing revaccination after BMT - who needs it and why, when to start

#IDWeek2020
Session: Cutting edge adult&ped #TxID
P.Carpenter

We need to re-vaccinate all recipients of BMT

Those with immunity from vaccination lose their immunity more quickly than those with prior dz

#IDWeek2020
Session: Cutting edge adult&ped #TxID
P.Carpenter

Guidelines are quite general and based on the best of circumstances - so start of vaccination in these pts is variable across centers

Seattle "how I treat" article pubmed.ncbi.nlm.nih.gov/27048212/

#IDWeek2020
Session: Cutting edge adult&ped #TxID
P.Carpenter

Pts with PID can have very variable B-cell recovery after BMT, so not as straight forward as "regular" transplant pt

Guidelines are too generic for this category of pts

#IDWeek2020
Session: Cutting edge adult&ped #TxID
P.Carpenter

But what about live vaccines after BMT? When to give MMR to BMT pts? When should we bend rules?

BBMT paper: bbmt.org/article/S1083-…

JAMA paper: jamanetwork.com/journals/jamao…

#IDWeek2020
Session: Cutting edge adult&ped #TxID
P.Carpenter

Another chart from paper in last tweet...criteria to consider early MMR vaccination in high risk BMT or CAR-T recipients when there is presence of community outbreak/cluster

#IDWeek2020
Session: Cutting edge adult&ped #TxID
P.Carpenter

The importance of 2 MMR doses

Are measles titers helpful and what other advice for BMT recipients

#IDWeek2020
Session: Cutting edge adult&ped #TxID
P.Carpenter

Great slide and discussion

Still can't give to someone too early or if too much IS, but can consider in certain other cases

#IDWeek2020
Session: Cutting edge adult&ped #TxID
P.Carpenter

Switching to varicella

#IDWeek2020
Session: Cutting edge adult&ped #TxID
P.Carpenter

pubmed.ncbi.nlm.nih.gov/25790386/