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Table 1. Laboratory results for case-patients and contacts related to HAV outbreak, Texas, 2015*  

Patient or source of specimen Outcome or status HAV rRT -PCR Serologic testing Vaccination status
IgM IgG
Donor Deceased Detected Detected Not detected Unvaccinated
Multi–visceral organ recipient Persistent infection Detected Detected Detected Vaccinated
Heart recipient Immune Not detected Not detected Detected Vaccinated
Left kidney recipient Immune Not detected Not detected Detected Vaccinated
Right kidney recipient Immune Not detected Not detected Detected Vaccinated
Home health nurse A Recovered Detected Detected Not detected Unvaccinated
Home health nurse B Recovered Detected Detected Not detected Unvaccinated
Inpatient nurse Recovered No sample Detected Not detected Unvaccinated

Table 1. Laboratory results for case-patients and contacts related to HAV outbreak, Texas, 2015*

*HAV, hepatitis A virus; rRT-PCR, real-time reverse transcription PCR.

Table 2. Pathologic, serum, and fecal HAV RNA quantification test results of multi–visceral organ recipient, Texas, 2014–2015*  

Date collected Liver HAV RNA, IU/mL Small bowel HAV RNA, IU/mL Serum HAV RNA, IU/mL Fecal HAV RNA, IU/mL
2014 Dec 18 Native liver, none detected      
2014 Dec 23 34,000      
2015 Jan 23 1,500,00      
2015 Feb 10   7,000    
2015 Mar 10   5,400    
2015 Apr 16 >90,000,000      
2015 Sep 21     >90,000,000 >90,000,000
2015 Sep 29     746,000,000 >90,000,000
2015 Oct 15     1,400,000 372,000
2015 Nov 9     27,900  
2015 Nov 16     17,300  
2015 Nov 23     13,000 1,500,000
2015 Dec 3     38,900 51,900
2016 Jan 11     68,000 22,600
2016 Mar 9       320
2016 Apr 6     Not detected 270
2016 May 4     Not detected Not detected

Table 2. Pathologic, serum, and fecal HAV RNA quantification test results of multi–visceral organ recipient, Texas, 2014–2015*

*Blank cells indicate that no specimen was available for testing. HAV, hepatitis A virus.

CME

Transmission of Hepatitis A Virus Through Combined Liver–Small Intestine–Pancreas Transplantation

  • Authors: Monique A. Foster, MD, MPH; Lauren M. Weil, PhD, MPH; Sherry Jin, MD, MPH; Thomas Johnson, BS; Tonya Mixson-Hayden, PhD; Yury Khudyakov, PhD; Pallavi D. Annambhotla, DrPH; Sridhar V. Basavaraju, MD; Saleem Kamili, PhD; Jana M. Ritter, DVM; Noele P. Nelson, MD, PhD; George Mazariegos, MD; Michael Green, MD, MPH; Ryan W. Himes, MD; David T. Kuhar, MD; Matthew J. Kuehnert, MD; Jeffrey A. Miller, MD, MPH; Rachel Wiseman, MPH; Anne C. Moorman, RN, MPH
  • CME Released: 3/15/2017
  • THIS ACTIVITY HAS EXPIRED FOR CREDIT
  • Valid for credit through: 3/15/2018, 11:59 PM EST
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Target Audience and Goal Statement

This activity is intended for infectious disease specialists and other physicians who care for organ transplant recipients.

The goal of this activity is to evaluate the potential parenteral transmission of hepatitis A virus infection through transplant and its subsequent effects.

Upon completion of this activity, participants will be able to:

  1. Analyze the epidemiology of hepatitis A virus (HAV) infection
  2. Evaluate how organ donors are assessed for HAV infection
  3. Evaluate laboratory results of the organ recipient and caregivers exposed to HAV infection in the current study


Disclosures

As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


Authors

  • Monique A. Foster, MD, MPH

    Division of Viral Hepatitis, National Centers for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia

    Disclosures

    Disclosure: Monique A. Foster, MD, MPH, has disclosed no relevant financial relationships.

  • Lauren M. Weil, PhD, MPH

    Texas Department of State Health Services, Austin, Texas

    Disclosures

    Disclosure: Lauren M. Weil, PhD, MPH, has disclosed no relevant financial relationships.

  • Sherry Jin, MD, MPH

    Harris County Public Health and Environmental Services, Houston, Texas

    Disclosures

    Disclosure: Sherry Jin, MD, MPH, has disclosed no relevant financial relationships.

  • Thomas Johnson, BS

    Houston Health Department, Houston, Texas

    Disclosures

    Disclosure: Thomas Johnson, BS, has disclosed no relevant financial relationships.

  • Tonya Mixson-Hayden, PhD

    Division of Viral Hepatitis, National Centers for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia

    Disclosures

    Disclosure: Tonya Mixson-Hayden, PhD, has disclosed no relevant financial relationships.

  • Yury Khudyakov, PhD

    Division of Viral Hepatitis, National Centers for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia

    Disclosures

    Disclosure: Yury Khudyakov, PhD, has disclosed no relevant financial relationships.

  • Pallavi D. Annambhotla, DrPH

    Office of Blood, Tissue and Organ Safety, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia

    Disclosures

    Disclosure: Pallavi D. Annambhotla, DrPH, has disclosed no relevant financial relationships.

  • Sridhar V. Basavaraju, MD

    Office of Blood, Tissue and Organ Safety, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia

    Disclosures

    Disclosure: Sridhar V. Basavaraju, MD, has disclosed no relevant financial relationships.

  • Saleem Kamili, PhD

    Division of Viral Hepatitis, National Centers for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia

    Disclosures

    Disclosure: Saleem Kamili, PhD, has disclosed no relevant financial relationships.

  • Jana M. Ritter, DVM

    Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia

    Disclosures

    Disclosure: Jana M. Ritter, DVM, has disclosed no relevant financial relationships.

  • Noele P. Nelson, MD, PhD

    Division of Viral Hepatitis, National Centers for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia

    Disclosures

    Disclosure: Noele P. Nelson, MD, PhD, has disclosed no relevant financial relationships.

  • George Mazariegos, MD

    Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania

    Disclosures

    Disclosure: George Mazariegos, MD, has disclosed no relevant financial relationships.

  • Michael Green, MD, MPH

    Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania

    Disclosures

    Disclosure: Michael Green, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Chimerix; Bristol-Myers Squibb

  • Ryan W. Himes, MD

    Texas Children's Hospital, Houston, Texas

    Disclosures

    Disclosure: Ryan W. Himes, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Alexion
    Served as a speaker or a member of a speakers bureau for: Alexion
    Received grants for clinical research from: Alexion

  • David T. Kuhar, MD

    Prevention and Response Branch, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia

    Disclosures

    Disclosure: David T. Kuhar, MD, has disclosed no relevant financial relationships.

  • Matthew J. Kuehnert, MD

    Office of Blood, Tissue and Organ Safety, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia

    Disclosures

    Disclosure: Matthew J. Kuehnert, MD, has disclosed no relevant financial relationships.

  • Jeffrey A. Miller, MD, MPH

    Career Epidemiology Field Officer, Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention (CDC), Pennsylvania Department of Health, Harrisburg, Pennsylvania

    Disclosures

    Disclosure: Jeffrey A. Miller, MD, MPH, has disclosed no relevant financial relationships.

  • Rachel Wiseman, MPH

    Texas Department of State Health Services, Austin, Texas

    Disclosures

    Disclosure: Rachel Wiseman, MPH, has disclosed no relevant financial relationships.

  • Anne C. Moorman, RN, MPH

    Division of Viral Hepatitis, National Centers for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia

    Disclosures

    Disclosure: Anne C. Moorman, RN, MPH, has disclosed no relevant financial relationships.

Editor

  • Karen L. Foster, MA

    Copyeditor, Emerging Infectious Diseases

    Disclosures

    Disclosure: Karen L. Foster, MA, has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine, University of California, Irvine, School of Medicine, Irvine, California

    Disclosures

    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Allergan, Inc.; McNeil Consumer Healthcare
    Served as a speaker or a member of a speakers bureau for: Shire

CME Reviewer

  • Robert Morris, PharmD

    Associate CME Clinical Director, Medscape, LLC

    Disclosures

    Disclosure: Robert Morris, PharmD, has disclosed no relevant financial relationships.


Accreditation Statements

This activity has been planned and implemented through the joint providership of Medscape, LLC and Emerging Infectious Diseases. Medscape, LLC is accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME), to provide continuing education for the healthcare team.

    For Physicians

  • Medscape, LLC designates this Journal-based CME activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Medscape, LLC staff have disclosed that they have no relevant financial relationships.

    Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]


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This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.

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  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.

CME

Transmission of Hepatitis A Virus Through Combined Liver–Small Intestine–Pancreas Transplantation

Authors: Monique A. Foster, MD, MPH; Lauren M. Weil, PhD, MPH; Sherry Jin, MD, MPH; Thomas Johnson, BS; Tonya Mixson-Hayden, PhD; Yury Khudyakov, PhD; Pallavi D. Annambhotla, DrPH; Sridhar V. Basavaraju, MD; Saleem Kamili, PhD; Jana M. Ritter, DVM; Noele P. Nelson, MD, PhD; George Mazariegos, MD; Michael Green, MD, MPH; Ryan W. Himes, MD; David T. Kuhar, MD; Matthew J. Kuehnert, MD; Jeffrey A. Miller, MD, MPH; Rachel Wiseman, MPH; Anne C. Moorman, RN, MPHFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED FOR CREDIT

CME Released: 3/15/2017

Valid for credit through: 3/15/2018, 11:59 PM EST

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Abstract and Introduction

Abstract

Although transmission of hepatitis A virus (HAV) through blood transfusion has been documented, transmission through organ transplantation has not been reported. In August 2015, state health officials in Texas, USA, were notified of 2 home health nurses with HAV infection whose only common exposure was a child who had undergone multi–visceral organ transplantation 9 months earlier. Specimens from the nurses, organ donor, and all organ recipients were tested and medical records reviewed to determine a possible infection source. Identical HAV RNA sequences were detected from the serum of both nurses and the organ donor, as well as from the multi–visceral organ recipient’s serum and feces; this recipient’s posttransplant liver and intestine biopsy specimens also had detectable virus. The other organ recipients tested negative for HAV RNA. Vaccination of the donor might have prevented infection in the recipient and subsequent transmission to the healthcare workers.

Introduction

Hepatitis A virus (HAV), the most common cause of viral hepatitis, is a nonenveloped RNA virus belonging to the family Picornaviridae.[1,2] Approximately 1.5 million clinical cases of HAV occur worldwide annually; the virus is commonly spread person to person through the fecal–oral route.[2] Although rates of HAV infection have declined by 95% in the United States since a vaccine became available, infections continue to result from close personal contact with an infected household member or common-source outbreaks from contaminated food or water.[3] HAV can cause relapsing and fulminant hepatitis, but fatal infection is rare.

Parenteral transmission of HAV through contaminated blood products or needles is also rare, despite the presence of viremia up to 30 days before symptom onset.[4] No screening tests for HAV infection are required for blood, organ, or tissue donation in the United States.[5] HAV transmission through solid-organ transplantation has not been reported in the literature.

In August 2015, genetically identical HAV was recovered from 2 healthcare workers (HCWs) participating in the care of a child recipient of multiple visceral organs. To prevent infection in other organ recipients and contacts, the Centers for Disease Control and Prevention (CDC), along with state and local health departments, conducted an investigation to determine the source of the HCW infection and whether HAV was transmitted through the solid-organ transplantation.