Public health implications of pig-to-human xenotransplantation at scale

The current global shortage of organs from human donors has resulted in long wait lists and increasing mortality among patients with end-stage organ failure. Pig-to-human xenotransplantation has been touted as a solution to this problem. However, significant infectious diseases and public health considerations exist with such a technological advancement.

Infectious diseases hazards with public health implications of pig-to-human xenotransplantation may be categorized taxonomically, according to temporality of potential exposure and/or reactivation, or according to anthroponotic versus zoonotic transmission. Additionally, the potential for escalating proportions of immunosuppression-at-scale in the context of the theoretically less-constrained resource of xenografts warrants particular consideration given that impacts will be differentially borne by those most affected by reactivating infections including but not limited to tuberculosis (TB), hepatitis B (HBV), and strongyloidiasis. TB, HBV, and strongyloidiasis all represent chronic infections with potential for reactivation under circumstances of immunosuppression - owing to either allograft or xenograft transplantation - that differentially impact those living in rural poverty globally, and those with risk factors for acquisition related to crowding, poor sanitation, undernutrition, and economic disenfranchisement. Chagas disease and leishmaniasis portend similar possibility of reactivation and differentially affect those residing in the global South.

We herein situate the public health implications of xenotransplantation at scale within the broader landscape of infectious diseases hazards related to the technology, and propose a health equity and human rights based framework for global risk assessment.