Notes from the Field: Transplant-Transmitted Hepatitis B Virus --- United States, 2010

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Morbidity and Mortality Weekly Report (MMWR)

Notes from the Field: Transplant-Transmitted Hepatitis B Virus --- United

States, 2010

Weekly

August 19, 2011 / 60(32);1087

On March 29, 2011, CDC was notified about a possible transplant-associated

hepatitis B virus (HBV) infection in a liver transplant recipient with no known

risk factors for HBV infection. An investigation was begun to learn if other

recipients of organs or tissues from the donor had been infected with HBV and to

investigate potential sources of the donor's infection.

The donor, a man aged 36 years, had died from a traumatic brain injury caused by

a stab wound to the head. When he was declared brain-dead, his family consented

to donation of his organs. He had no evidence of liver disease on examination,

and liver enzyme levels were normal; a drug screen was positive for

cannabinoids. He had not received any blood products during hospitalization.

On March 23, 2010, six organs from the donor were transplanted into five

recipients in multiple states; no tissues or blood vessel conduits were

procured. The investigation revealed that three of the five organ recipients had

evidence of acute HBV infection posttransplantation; all three were infected

with a genetically identical virus. The two recipients who were not infected had

serologic evidence of immunity resulting from vaccination or past infection.

Organ donors are assessed for their potential to be infected with HBV using

criteria adapted from risk factors identified in CDC guidelines for human

immunodeficiency virus (HIV) infection (1), because many of the risk factors for

HIV and HBV infection overlap. At the time of evaluation, the donor was not

identified as being at high risk for HBV infection, based on the medical history

available to the organ procurement organization and its behavioral risk

assessment, and was therefore screened for HBV infection using serology alone.

Those test results were negative initially and when repeated by CDC. However,

subsequent nucleic acid testing (NAT) of the same specimen at CDC revealed a

low-level viremia (<29 HBV DNA IU/mL), a finding consistent with recent HBV

infection.

The number of cases of transplant-transmitted HBV infection is unknown. The

cases described in this report might not have been identified had it not been

for the diligence of the hospital epidemiologist and transplant clinicians who

first suspected possible transplant-associated HBV infection in one of the organ

recipients who did not report any other risk factors for HBV infection.

Transplanted organs from an HBV seronegative donor can be infectious for HBV if

procured during the period between infection and the time when infection becomes

detectable by serology. The risk for HBV transmission can be minimized if a NAT

is used for screening because it can detect HBV sooner after infection than can

serologic testing (2). However, most referral laboratories used by organ

procurement organizations do not have access to the ultrasensitive HBV NAT

methodology that detected the low-level viremia in this organ donor. In

addition, the cost of HBV NAT screening, the ability to have test results before

transplantation, and concerns about possible false-positive results have

contributed to the limited use of HBV NAT for low-risk organ donors. New

guidelines on reducing HIV and hepatitis B and C transmission through organ

transplantation currently are being written and include recommendations to use

NAT. When possible, organ transplant candidates should be protected against HBV

by pretransplant vaccination to further reduce the risk for transmission from an

infected donor (3).

Reported by

Walter C. Hellinger, MD, Barry G. Rosser, MD, P. Keaveny, MD, Mayo Clinic

in Florida; Alcantara, Saad Zaheer, MD, Duval County Health Dept; Robyn

Kay, MPH, Florida Dept of Health. Pringle, Stump, Shirley

Schlessinger, MD, Mississippi Organ Recovery Agency. Greg ,

-Jewish Hospital, St. Louis, Missouri. Jannifer , Byers, MD,

Mississippi State Dept of Health. Crist, Beth A. Frost, n A.

Kainer, MD, Tennessee Dept of Health. T. Killackey, MD, M. Caruso,

A. Balart, MD, Tulane Univ Health Sciences Center, New Orleans, Louisiana.

Rasmey Hachem, MD, Washington Univ School of Medicine. Turabelidze,

Missouri Dept of Health. Career Epidemiology Field Officer Program, Office of

Public Health Preparedness and Response; Div of High-Consequence Pathogens and

Pathology, Div of Healthcare Quality Promotion, National Center for Emerging and

Zoonotic Infectious Diseases; Div of Viral Hepatitis, National Center for

HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. Corresponding

contributor: F. Nielsen, CDC, cnielsen@..., 404-718-8561.

References

1. CDC. Guidelines for preventing transmission of human immunodeficiency virus

through transplantation of human tissue and organs. MMWR 1994;43(No. RR-8).

2. Humar A, M, Blumberg E, et al. Nucleic acid testing (NAT) of organ

donors: is the 'best' test the right test? A consensus conference report. Am J

Transplant 2010;10:889--99.

3. Danzinger-Isakov L, Kumar D, AST Infectious Diseases Community of Practice.

Guidelines for vaccination of solid organ transplant candidates and recipients.

Am J Transplant 2009;9(Suppl 4):S258--62.

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Page last reviewed: August 19, 2011

Page last updated: August 19, 2011

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