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HCV Transmission from Transplant 1 donor, missteps, 3 infected patients
  Boston Globe Staff / December 23, 2011

A child treated at Children's Hospital Boston was infected with hepatitis C by a piece of a blood vessel that was transplanted in September from a donor who was infected. Two people in Kentucky who received kidneys from the same donor also were infected, the federal Centers for Disease Control and Prevention reported today.

The agency traced the transmission in Massachusetts to an error in tissue testing and delays in communication between the Kentucky transplant center and public health officials. The incident highlights the need for improvements in transplant safety and tracking, said Dr. Matthew J. Kuehnert, director of the Office of Blood, Organ, and Other Tissue Safety at the CDC.

Such transmissions through transplants are rare. But, in this case, the infections were "entirely preventable," Kuehnert said.

His office released its investigation today and called for improved testing and a more centralized and computerized system for tracking tissues and organs and notifying transplant surgeons of problems.

Notifying doctors of a possible infection is "all done the old-fashioned way with phone calls and letters and e-mails," Kuehnert said.

That system had real consequences in this case. Ten days passed between the day the first kidney recipient in Kentucky tested positive for hepatitis C and when Kuehnert's office was notified on Sept. 28. Meanwhile, two days earlier surgeons at Children's Hospital Boston unknowingly used an infected piece of tissue to repair a malformation on a child's heart. The child's name was not disclosed because of patient confidentiality.

Six weeks later, doctors confirmed that the child was infected with hepatitis C.

About 1 percent of all organ donations result in transmission of disease, Kuehnert said. Less is known about transmission through tissue transplants, though most tissues can be treated with radiation or chemicals that greatly reduce the risk of infection. More sensitive heart tissue, such as the vessel used in the Boston transplant, typically is treated only with antibiotics, which don't prevent the spread of viruses like hepatitis or HIV.

As many as 100 body parts may be taken from a single deceased donor, including the liver, kidneys, and lungs, as well as tissues such as bone, skin, and heart valves. The distribution and regulation of tissues and organs are overseen by two separate federal agencies. Organs are distributed by a network regulated by the Health Resources and Services Administration, while tissue banks are overseen by the Food and Drug Administration.

Communication between the two industries is minimal, Kuehnert said, and there is no protocol in place for sharing information about donor infections, like this one.

The donor in this case was a middle-aged man in Kentucky who died in March after an all-terrain vehicle incident. While he had a history of substance abuse and had been jailed about a decade before his death, his father told hospital officials that he had no known history of intravenous drug use, a risk factor for hepatitis C, the report said. The donor also received blood transfusions during the hospital stay just before his death.

Kuehnert said it's likely that his infection occurred soon before his death because antibody tests on both the organs and tissue, which look for an immune response to infections, came back negative. Only tissues are required to have the more sensitive nucleic acid testing, which looks for the presence of a virus itself.

According to the report, a worker at an unnamed tissue bank incorrectly read a test in March, marking the donor's tissue as negative for hepatitis C when it, in fact, tested positive -- something only discovered in a followup investigation.

A 41-year-old man and a 46-year-old woman received the donor's kidneys that month at Jewish Hospital in Louisville. Another man, who already had hepatitis C, received the donor's liver.

On Sept. 19 and Sept. 22, tests showed that the kidney recipients had been infected with the virus. Federal regulations require that transplant centers report any diseases suspected to have come from an organ donor to a national reporting system within 24 hours. But the transplant center did not report the transmission until Sept. 28.

Dr. Michael Marvin, director of the transplant program at Jewish Hospital, said today he did not know when physicians there received the lab results showing the infection or how much time passed before they notified public health officials.

"I think there's always room for improvement," he said.

The CDC's Kuehnert said he believes the reporting delay was not purposeful. "I think that this was more just not knowing what they should do. And it is important for people to know what to do."

The child treated at Children's Hospital is infected with hepatitis C but not showing symptoms, said spokesman Robert Graham.

"The patient received counseling and a care plan that includes an evaluation every three months," he said. "Children's will continue to focus on providing care to our patient affected by this unfortunate situation."

Graham said the erroneous nucleic acid test was not conducted by Children's Hospital, which is a registered tissue bank.

In addition to the heart vessel and organs, 43 musculoskeletal transplants were taken from the Kentucky donor and 15 were implanted in patients across the country before the tissue was recalled. As of last week, federal officials had confirmed that 14 of those recipients did not have hepatitis C. Musculoskeletal transplants, mostly bone, is usually irradiated before being used.

Preventing such infections in the future will take buy-in from the transplant industry, Kuehnert said.

"It's about not only doing the most accurate and appropriate testing but also sharing information between organizations as efficiently and rapidly as possible," he said. "There are ways that we can make these transplants safer. It's only with the support of the public saying that we need to do this that we can progress."

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