Oregon: 40 People Unknowingly Got Tissue or Organs from Donor With Hepatitis C; 5 Died

Forty people received tissue or organs from an Oregon man who died two years ago with an undiagnosed case of viral hepatitis, according to state health officials. Five of the six organ recipients have died, one of them from liver disease that may have originated with the donor, said Dr. Barna Tugwell, a CDC epidemiologist who is assigned to the Oregon Health Department and is the leader of the investigation. Whether the hepatitis contributed to the other deaths is still unknown, Tugwell said. The remaining organ recipient has hepatitis C.

Of the 34 people who received tissue from the Oregon man, four have hepatitis C; three tested positive but were found to have had the disease before their transplant; and nine have no sign of liver disease. Health officials are still trying to find the others, who are scattered through 14 states, South Korea and Italy. After learning of the infections June 27, the tissue bank quarantined everything from the donor in inventory and recalled 44 tissues that had gone out to other tissue processors and transplant surgeons.

The Oregon tissue bank did "everything by the book," Tugwell said. CDC epidemiologist Dr. Ian Williams said the donor was probably a "window case" -- that is, he was unknowingly infected shortly before he died and never showed any disease symptoms.

The donor's blood was tested at death with a standard procedure, but it cannot detect the virus for weeks or even months after infection, Williams said. A newer viral nucleic acid blood test can detect the virus one to two weeks after infection, he said, but it is not accurate when used on cadavers.

"We assume what happened is a very rare circumstance," said Tugwell, who reported on the case Saturday at the annual meeting of the American Society for Microbiology in San Diego. "But we really don't know how big a problem this is or how frequently we'll see it." In the early 1990's, a handful of people got AIDS or hepatitis from transplanted tissue. The last known hepatitis C infection from a transplant occurred in 1995. Since the early cases, blood and tissue banks have been required to ask donors or their relatives whether they have ever used drugs intravenously or have had a blood transfusion. However, a relative may not know that a donor engaged in risky behavior, Williams said.

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