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Hepatitis C: “Second banana” of viruses

Posted Jun 18 2008 7:09pm

Four Transplant Recipients Contract H.I.V

Published: November 14, 2007
Correction Appended        

Four transplant recipients in Chicago have contracted H.I.V. from an organ donor, the first known cases in more than a decade in which the virus was spread by organ transplants.

The organs also gave all four patients hepatitis C, in what health officials said was the first reported instance in which the two viruses were spread simultaneously by a transplant.

Though exceedingly rare, this type of transmission highlightsa known weaknessin the system for checking organ donors for infection: the most commonly used tests can fail to detect viral diseases if they are performed too early in the course of the infection. Officials say the events in Chicago may lead to widespread changes in testing methods.

 (This is only partly correct. Antibody testing is NOT as reliable as PCR, but it is faster. The time required to get a PCR result is outside the window for using the organ. That is the real problem here-time and the cost of doing one test at a time, instead of “batching.” In any case, routine testing and prevention programs would certainly reduce the risks of infected organ donation.)

“There are important policy implications,” said Dr. Matthew Kuehnert, director of the Office of Blood, Organ and Other Tissue Safety at the federal Centers for Disease Control and Prevention, which is investigating the case. “Clearly, the organ transplant community is going to think about the issues raised by this, and we look forward to being involved in those discussions.” 

 It’s about time! There have been articles in medical journals for years on this topic. Seems the CDC is always the last to know. Why is it they ait until a catastrophy occurs before they get involved? Why, oh why, isn’t the Centers for Disase Control andPrevention  doing more controlling and prevention of disease? Shouldn’t something be proven to be safe instead of proven to be unsafe before the CDC acts? Wouldn’t less harm done as a result of that?  Isn’t that what prevention is all about? Let’s put the P back onto the CDC!

The cases were first reported yesterday by Fox News Chicago. Two patients were infected at the University of Chicago Medical Center, and one each at Rush University Medical Center and Northwestern Memorial Hospital. The transplants were coordinated by an organization called the Gift of Hope of Elmhurst, Ill.

Officials would not say what organs were transplanted, but a transplant expert not connected with the case said they were most likely the kidneys, liver and either the heart or lungs. Only four organs, and no other tissue, were taken from the donor.

 Hepatitis C has been transmitted through a tendon transplant at the OHSU, Portland, OR. What is rare is that people are informed about these incidents at all. There are numerous articles in medical journals about the problem. Rare? I think not!

The University of Chicago said that the operations took place in January, and that the donor was an adult who died in an Illinois hospital “three days after traumatic injury.” Neither the donor’s age nor sex were disclosed. The other hospitals declined to discuss what happened, except to confirm that each had an infected patient.

The situation came to light earlier this month when one of the recipients, who was being evaluated for a retransplant, tested positive for H.I.V. and hepatitis C. At that point, blood preserved from the donor was given a highly sensitive test for viruses, and the infection was found.

Dr. J. Michael Millis, the chief of transplantation at the University of Chicago, said the patients were devastated, and the doctors heartbroken. But Dr. Millis said the diseases were treatable.

Initially, the donor had tested negative for H.I.V. and hepatitis C, apparently because the infection was too recent to be detected by commonly used blood tests. Those tests do not find the virus itself, but instead look for the body’s reaction to the infection — theantibodiesproduced by the immune system. But the body takes time to react, and if the test is done too soon, within 22 days of H.I.V. infection or 82 days for hepatitis C, antibodies may not yet be detectable. 

Again, routine testing and prevention programs can reduce the risk of infected persons being donors, identify persons infected who are potentially donors. And, educational programs aimed at public health (vs pharmaceutical treatments) could make a huge difference.

Doctors say that is what probably occurred in Chicago. It has always been known that this kind of transmission was theoretically possible, but it was considered highly unlikely. And indeed, since 1994 nearly 300,000 transplants from cadavers have occurred without anyreportedcases of H.I.V. transmission. 

First, were doctors educated on the topic well enough to know what to report, exactly?

Second, are we also discussing hepatitis C? I note it sddenly dropped off the doctor’s radar screen.  Hepatitis C infection outnumbers HIV infection 4:1. Surely the risk is much higher, since there are less than lf a dozen Hepatitis C Organizations vs over 10,000 for HIV. Reason: no funding.

Another more sensitive type of test could pick up viral infections earlier, but was not used. That test looks for evidence of the virus itself, and can reduce the “window,” the early period in which the test does not work, to 12 days for H.I.V. and 25 days for hepatitis C.

That test, the nucleic acid amplification test, or Naat, is not widely available, and doctors said it was more difficult and time-consuming than other tests — and there is usually no time to spare with transplants because organs deteriorate quickly when the donor dies. Another concern is that the test is more likely than others to give false-positive results, and lead to the needless destruction of healthy organs, a scarce resource.

A PCR Qualitative test is available in every community in this country. The test is also available at every transplant center in the nation. A test can be done on viable donors as part of the protocol. Organ donors go through a rigerous screening process. This donor was hospitalized for three days before being declared a donor. Any patient being admitted who has designated themselves a potential donor should be screened on admission. Period.

Dr. Robert Brown, director of the liver transplant program at New York-Presbyterian/Columbia said, “There is always a drive toward better testing, but if it leads to more organ wastage, we’ll probably hurt more people than we help.”

It is not only about the testing, it is also about choices. People with hepatitis C, for example, can be donors for others with hepatitis C. The fact is, as this doctor knows, the new liver will become infected. Matching a viable liver (with minimal damage from hepatitis C) with a recipient who needs it is being done already.  Most liver transplants done are as a result of hepatitis C infection. 

As to the testing, it is expensive. But it can be done and it can be done quickly, in relative terms.

According to the University of Chicago, the organ donor in Illinois was known to be “high risk,” based on a risk factor revealed by a close friend who provided “a health and social history.” The exact nature of the risk was not disclosed. Federal guidelines recommend against transplanting organs from high-risk people unless the recipients are so likely to die for want of a transplant that H.I.V. seems a lesser threat.

 And hepatitis C?

Dr. Millis said that he did not know whether the patients there had been informed of the donor’s status.

About 9 percent of organ donors qualify as high-risk based on behaviors like prostitution or drug use with needle-sharing. Transplant experts say the percentage would probably be higher if they had full information on all donors.

 Or, tattooes? Since this article was published, tattooing has been shown to be a higher risk than anyone, except me, thought. What would that percentage be if we added tattooing to this list of high risk donors?  And obesity: fatty livers cause cirrhosis as early as 12 years of age! This has an impact on the availability and viability of donated organs. So far, the medical community has not connected the dots. And it doesn’t stop there, the blood supply is likewise impacted. Risk has to redefined and education on what constitutes high risk has to be updated for the sake of public health (to protect the health of the pool of potential donors), doctors (to identify people with vulnerable organs due to conditions and viruses) and the transplant community (to protect recipients)

Dr. Brown said Columbia got offers of organs from high-risk donors every week.

He also said that at Columbia, patients (or family members) were informed if a donor was high risk, and were required to sign a special consent form acknowledging it.

It is also a bad time to try and absorb complex information and make a life or death decision. This discussion also is not acknowledging the live donation option.

Dr. Millis said that although the organ supply was generally safe, he hoped it could be made safer, probably by developing regional centers around the country to perform Naat testing reliably and quickly enough to meet transplant needs.

 How about educating people about the diseases, routine testing for anyone, and programs in schools and communities to teach people how to avoid these diseases and conditionas and to connect conditions such as obesity to both the need for transplant and the viability of organ, tissue and blood donation? Get the CDC (and prevention) on the line. The truth is, we don’t know how safe the organ, tissue and blood supply really is supply is want t pay for the cost of the information. This was the fatal error made by the Canadian Red Cross, leading to the “Tainted Blood Scandal of the 90’s.”

Although it is rare, other diseases like rabies, West Nile fever and a rodent virus called LCMV have also been spread by organ transplants. In all of those cases, patients died.

Rabies, West Nile Fever, and LCMV are not PREVENTABLE diseases as HIV, obesity, and heptitis C  are. Transplant is a treatment, but not a cure. It means life long monitoring and medications.

Is there a reason to minimize the impact of 5 million people with hepatitis C, most of whom don’t know it, versus the rare cases mentioned?  Does it make people feel better about the serious consequences of a known weakness?  Does it make it easier to ignore the need for public health education and testing programs? Does anyone have the statistics for the money spent on SARS, west nile, and MCLV versus the amount (zero) spent on hepatitis C prevention and the numbers of people affected by them?

Correction: November 16, 2007

An article on Wednesday about transplant recipients who contracted H.I.V.and hepatitis Cfrom donated organs misstated the organization that first reported the news. It was Fox News Chicago, a television station, not The Chicago Tribune.

 Okay. Since this is an article intended to make corrections, I just thought I’d do my part! The opinions expressed are my own. No extra charge.

Teresa Hanbey

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