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

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, Andrew P. Keaveny, MD, Mayo Clinic in Florida; Rebecca Alcantara, Saad Zaheer, MD, Duval County Health Dept; Robyn Kay, MPH, Florida Dept of Health. Scott Pringle, Kevin Stump, Shirley Schlessinger, MD, Mississippi Organ Recovery Agency. Greg Richardson, Barnes-Jewish Hospital, St. Louis, Missouri. Jannifer Anderson, Paul Byers, MD, Mississippi State Dept of Health. Matthew Crist, Beth A. Frost, Marion A. Kainer, MD, Tennessee Dept of Health. Mary T. Killackey, MD, Amanda M. Caruso, Luis A. Balart, MD, Tulane Univ Health Sciences Center, New Orleans, Louisiana. Rasmey Hachem, MD, Washington Univ School of Medicine. George 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: Carrie F. Nielsen, CDC, cnielsen@cdc.gov, 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, Morris 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.