A report published in the Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report said a donor transmitted hepatitis C to recipients of two kidneys and one blood vessel tissue patch because the donor likely was recently infected and the antibody test did not detect infection.
"In addition, a hepatitis C nucleic acid test performed for tissue screening was incorrectly read," the report said. "Ultimately, repeat nucleic acid testing confirmed the donor was hepatitis C virus positive at the time of donation. Hepatitis C antibody testing alone might not be adequate to detect disease in organ donors with recent infection; hepatitis C nucleic acid test screening for organ donors should be considered to prevent such transmissions."
Word about possible risk of disease transmission was not received by one surgeon implanting tissue until after the vessel had already been implanted, resulting in further infection, the report said.
Rapid communication of information on suspected transplantation transmission to all agencies involved in organ and tissue procurement is necessary to prevent similar events, health officials said.