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.
