Ana Kolin, Ph.D. DHT, OCTGT email: ana.kolin@fda.hhs.gov CTGTAC Meeting, May 14, 2009

1. Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections of HCT/Ps recovered from the reproductive system, gestational tissues or other sources – literature review Ana Kolin, Ph.D. DHT, OCTGTemail: ana.kolin@fda.hhs.gov CTGTAC Meeting, May 14, 2009

2. Overview • Maternal and Fetal Gestational Tissues That are Used in Transplantation and Possible Routes of Intrauterine Infections • Animal Studies of Chlamydia trachomatisand Neisseria gonorrhoeaeInfections • Chlamydia trachomatisand Neisseria gonorrhoeaeInfections of Human Amniotic Membrane, Placenta and Cord Blood – literature review

3. Maternal and Fetal Gestational Tissues That are Used in Transplantation and Possible Routes of Intrauterine Infections

4. Maternal and Fetal Gestational Tissues That are Used in Transplantation Placenta Villus Menstrual blood Umbilical cordblood Foreskin Amnion Amniotic fluid Chorion Adopted from:http://www.merck.com/mmpe/sec18/ch258/ch258a.html

5. Possible Routes of IntrauterineInfection by Microorganisms Retrograde fromabdominal cavity Amniocentesis Haematogenously through placenta Ascending from vagina Adopted from: Goldenberg et al. 2008.

6. Animal Studies of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) Infections

7. Animal Studies of Chlamydia trachomatis (CT) Infections • Intravaginal inoculation resulted in: • CT ascending in the genital tract • CT replication in the superficial epithelial cervical and uterine layers (Vanrompay et al. 2005) Pig:

8. Animal Studies of Chlamydia trachomatis (CT) Infections Mouse: • - Intravaginal inoculation resulted in: • infection of the upper cervix and uterine horns • uninfectedovaries, tubes and lymph nodes • (Lyons et al. 2004) • Intraperitoneal inoculation resulted in: • efficient placenta infection (5 of 16 mice) • uninfected fetal tissues • Intravenous + intravaginal inoculation: • inefficient placenta infection (1 of 9 mice) • uninfected fetal tissues (Tuffrey et al. 1987)

9. Animal Studies of Neisseria gonorrhoeae (NG) Infections Primates: • Urethral injection of chimpanzee resulted in: • colonization of urethra • (Lucas et al. 1971) • Infection of organ cultures resulted in: • uninfected fallopian tubes of baboons • infected fallopian tubes of chimpanzee(McGee et al.1990)

10. Animal Studies of Neisseria gonorrhoeae (NG) Infections Rats: • Intraperitoneal inoculation resulted in: • mother’s genital tract infection • infection of the fetus, and fetal mortality (Nowicki et al. 1999)

11. Animal Studies of Neisseria gonorrhoeae (NG) Infections Mouse: • Intravaginal inoculation resulted in: • colonization of genital tract and endometritis (Kita et al. 1991) • infection of vaginal and cervical tissue; uninfected upper genital tract (Song et al 2008) • infection of upper genital tract (Imarai et al. 2008)

12. Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) Infections of Human Amniotic Membrane, Placenta and Cord Blood – literature review

13. Chlamydia trachomatis (CT)- Amniotic Membrane - • Amniotic cells are susceptible to infection by CT: • Untreated human amniotic epithelial cells in primary culture are as susceptible to CT infection as McCoy cells treated with diethylaminoethyl dextran and 5-iodo-2-deoxyuridine (Harrison et al. 1979) • Untreated human amniotic epithelial cells in primary culture are susceptible to CT infection in vitro(Neeper et al.1990 )

14. Can Chlamydia trachomatis (CT) cross placental membrane and infect newborns? (all newborns delivered by C-section) IF - immunofluorescence

15. Chlamydia trachomatis (CT)- Amniotic Fluid - PROM – premature rupture of the membranes

16. Chlamydia trachomatis (CT) - Placenta - - Placental cells are susceptible to infection by CT in vitro: • Successful infection of trophoblast cells (Stokes et al. 1991) - CT identified in placenta: • by DNA amplification in one miscarried fetus, out of 108 examined (Matovina et al. 2004) • by DNA amplification, in situ hybridization and immunohistochemistry in one stillborn fetus, delivered by C-section (Gencay et al. 1997)

17. Neisseria gonorrhoeae (NG) - Amniotic Membrane - • Amniotic cells are susceptible to infection by NG: • Cultured human amnion cells used for in vitro studies (Heckels et al. 1976) • NG detected in amniotic fluid: • NG cultured from amniotic fluid of an infant delivered by C-section with intact membranes (Smith et al. 1989)

18. Neisseria gonorrhoeae (NG) - Placenta - • NG was able to infect placenta: • Chorioamnionitis was diagnosed by placental pathology of an infant delivered by C-section with intact membranes (Smith et al. 1989) • NG was cultured from placentas of two infants where infection likely occurred before rupture of the membranes (Yvert et al. 1985)

19. Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) - Cord Blood- - Maternal antibody and bacterial nucleic acid detection in cord blood: • Anti-chlamydial IgG antibodies detected in cord blood of 35 infants out of 139 tested by screening sera against four representative CT antigenic pools using immunofluorescence (Mårdh et al. 1980) • CT and NG were detected in the samples of cord blood and maternal blood using Q-PCR (CT and NG cultures were not performed) : • (Hou et al. 2006)

20. Summary • There are limitations in the available published literature • Most information available are case reports • Confirmatory microbiologic testing was not performed in some of the studies • Both the animal and human literature indicates that infection of amniotic membrane and placenta by Chlamydia trachomatis and Neisseria gonorrhoeae is possible; the route of infection is open to speculation • There are no available well-designed studies evaluating whether or not cord blood collected from a mother infected with Chlamydia trachomatis and Neisseria gonorrhoeae can be infected or contaminated with the organisms

21. Acknowledgments Dr. Kimberly Benton Gail Dapolito Dr. Melissa Greenwald Dr. Ellen Lazarus Dr. Shyh-Ching Lo Dr. Mercy Quagraine Dr. Stephanie Simek Martha Wells, M. P. H.