Organs and tissue from a Kentucky donor apparently have caused three patients to test positive for hepatitis C virus infection, according to the Centers for Disease Control in Atlanta.
Two of the patients received kidney transplants at Jewish Hospital in Louisville, and a child in Massachusetts received tissue. Hepatitis C, transmitted by blood and body fluids, can result in liver failure and liver cancer.
The recipients of the kidneys, a 41-year-old man and a 46-year-old woman, were both diagnosed after testing in September, the CDC said.
A piece of a blood vessel from the hepatitis C donor was implanted as a cardiopulmonary patch at a Massachusetts health care facility on Sept. 26, the CDC said. That patient later tested positive for hepatitis C on a nucleic acid test. The Boston Globe said in a Thursday article that the Massachusetts patient was a child treated at Children's Hospital Boston.
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In addition, a man who received a liver from the same donor had been diagnosed with hepatitis C before receiving his transplant. A positive hepatitis C test from the donor was misread as negative, the CDC report said.
However, the case reveals two larger issues, the CDC report said. First, the groups overseeing testing for solid organs do not use the same, more-complex standards used in testing tissue and human cells; second, communication once an infection is suspected is inefficient among the various players in transplant medicine.
When Jewish Hospital became aware that both of the kidney patients had tested positive, the hospital immediately reported the issue, spokesman Jeff Polson said.
Polson said the hospital reported the postoperative test results from the kidney donors to the Kentucky Organ Tissue affiliate network Sept. 28. Jewish Hospital's transplant team did postoperative care for one of the patients, who had been a health care worker and so had other risk factors for the disease, Polson said.
In addition to the kidneys and blood vessel, 15 musculoskeletal tissues from the infected donor had been implanted; 14 of those recipients tested negative for hepatitis C as of Dec. 16. Results were not available for the 15th.
Kentucky state epidemiologist Kraig Humbaugh said that 1 percent to 2 percent of Kentuckians have chronic hepatitis C. Treatment through antiviral medication is available but is costly, Humbaugh said.
Humbaugh said that only a small percentage of hepatitis C donors are not spotted, but he said this case was important because "it helps us to raise awareness of this disease" to make organ transplant procedures and screening safer.
The CDC said the error in reporting the donor's hepatitis highlights "the need for rapid communication between transplant centers, organ procurement organizations, tissue banks and public health authorities" about organs and tissues when contamination is suspected.
In this case, that was difficult because the names and contact information for the surgeons who implanted the diseased tissues "were not uniformly available" when the tissue was recalled Sept. 30, according to the CDC report. The recall was not completed until Oct. 27.
The donated tissue and organs came from a middle-age man in Kentucky who suffered a traumatic brain injury in an all-terrain vehicle accident in March and died two days later.
The CDC said the donor was incarcerated for five months about 10 years before his death. He also had schizophrenia and substance-abuse issues.
His donated tissues included 43 musculoskeletal grafts and one cardiopulmonary patch. The CDC said 28 of the 43 grafts had not been implanted; they were returned to the tissue bank.