The New York Times - November 14, 2007
Denise Grady

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 highlights a known weakness in 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.

ôThere are important policy implications,ö 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. ôClearly, the organ transplant community is going to think about the issues raised by this, and we look forward to being involved in those discussions.ö

The cases were first reported yesterday by The Chicago Tribune. 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.

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 ôthree days after traumatic injury.ö Neither the donorÆs 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 bodyÆs reaction to the infection ù the antibodies produced 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.

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 any reported cases of H.I.V. transmission.

Another more sensitive type of test can pick up viral infections earlier, but was not used. That test looks for evidence of the virus itself, and can reduce the ôwindow,ö 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 ù 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.

Dr. Robert Brown, director of the liver transplant program at NewYork-Presbyterian/Columbia said, ôThere is always a drive toward better testing, but if it leads to more organ wastage, weÆll probably hurt more people than we help.ö

According to the University of Chicago, the organ donor in Illinois was known to be ôhigh risk,ö based on a risk factor revealed by a close friend who provided ôa health and social history.ö 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.

Dr. Millis said that he did not know whether the patients there had been informed of the donorÆs 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.

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.

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.

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.

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