Though hepatitis A virus (HAV) has spread via blood transfusion, the virus had never transmitted from a transplant patient. Now, through a circuitous chain of events, it has. Indeed, HAV spread from an organ donor to the transplant recipient, and then to three nurses providing post-transplant care, the CDC reports.1
The investigation began in August 2015 when two home healthcare workers in Texas were diagnosed with hepatitis A, which causes a range of symptoms from diarrhea, nausea, abdominal and joint pain, and fever. The nurses were not vaccinated for HAV.
“Hepatitis A is a reportable disease, so two separate local health departments in Texas received notifications of these two separate nurses’ infections and that were kind of clustered in time,” says Monique A. Foster, MD, MPH, the lead author of the investigation and a medical epidemiologist at the CDC. “It was then noticed that they worked for the same home health company.”
They cared for one patient in common, a seven-year-old who underwent liver, small bowel, and pancreas transplantation. The transplant patient had been previously immunized for HAV, but was in an immune-compromised state that must have undermined vaccine efficacy.
“The only thing they had in common was the same patient,” Foster says. “So initially, when the investigation started, we thought maybe one of the parents [of the transplant patient were infected]. We initially didn’t think that the HAV came from the patient because she had been previously vaccinated. But when we did the laboratory testing we found out that she was, indeed, the source of the nurses’ infections. The index case spread it to all three nurses — the home health nurses, and a nurse who took care of the patient in the hospital.”
The hospital nurse developed jaundice, diarrhea, and joint pain, and was hospitalized. HAV infection was diagnosed by serologic testing, and this nurse also had not received hepatitis A vaccination.
“[That nurse] was hospitalized briefly and that is not uncommon with hepatitis A,” Foster says. “About 20% of people will be hospitalized when they are infected. It’s a very acute illness. It’s short, but older people tend to have a worse course [of infection]. Anyone who has any underlying liver disease or other diseases can end of being hospitalized. Thankfully, no one died. Sometimes in large hepatitis A outbreaks, there will be one or two deaths.”
CDC: No Changes to Guidance
Though none of the nurses were vaccinated for HAV and one was ill enough to be hospitalized, the outbreak does not warrant changing current employee health recommendations, the CDC concluded.
“We don’t recommend universal vaccination for healthcare workers because nosocomial spread of hepatitis A is incredibly rare,” says Foster. “If someone is symptomatic enough to be hospitalized [with HAV] it’s usually known, and healthcare workers are pretty adherent to wearing gloves and other precautions that would prevent spread of a fecal-oral pathogen.”
Also, the home health nurses were spending 12 hours per shift inside the patient’s home, where they ate meals and shared space with the patient’s family, the CDC reported.
“Studies conducted before childhood vaccine was universal show that the longer you spent time with someone with hepatitis A, the more likely you are to get infected,” Foster says. “The nurses from the home health company definitely would be considered, from our standpoint, as household contacts. That is why we recommend post-exposure prophylaxis [PEP] with hepatitis A vaccine for any household contact of someone who has been diagnosed with HAV.”
While contacts of the nurses received PEP vaccination, the healthcare workers had to ride out the infection until all fully recovered.
“We only recommend PEP for people who are exposed to hepatitis A, not for those who already have it,” she says. “You basically have to wait it out. There is really no medication or intervention we can do.”
Care for the organ recipient provided by all three nurses included exposures to watery feces while changing diapers and ostomy bags.
“So even if the nurses were adhering to perfect hand hygiene, it is really hard not to become infected,” Foster says. “I’m sure the nurses were involved in changing her stoma bag and things like that, where they would come into contact with fecal materials.”
It was later discovered that the organ donor — an eight-year-old who died in a car accident — had not been immunized and had acute HAV infection at the time of death.
“We were able to get a specimen from her donor,” Foster says. “And for the donor to end up positive was also surprising. In an acute illness, the donor would have only been infectious for a few weeks. To have died in a car accident at the same time that they were infectious with HAV — which led to the recipient getting it — is all kind of a one-in-a-million type of thing.”
Vaccine Uptake Low
Specimens from the nurses, the recipient, and the donor contained genetically identical HAV, showing that the virus was transmitted to the recipient through the transplanted organs. Vaccination of the organ donor might have prevented the subsequent chain of infections.
“Unfortunately, the data that we have show that HAV vaccine — even though it has been recommended universally as part of childhood vaccination for the last 20 years — still has pretty low uptake compared to the other childhood vaccines,” Foster says. “So only around 53% of children age 15 to 35 months — who should have received both doses of HAV vaccine at that age — have actually received two doses.”
However, no screening tests for HAV infection are required for blood, organ, or tissue donation in the United States. Because of the low U.S. incidence of HAV infection and typically brief self-limiting course of disease, an HAV-unvaccinated organ donor is unlikely to be acutely infected at death and transmit HAV to a patient, the CDC reports.
Once the infection was detected, contact precautions were instituted during subsequent hospitalizations, the local health department recommended the patient’s home health nurses be fully vaccinated against HAV, and no further transmissions to healthcare workers were detected during the subsequent eight months of continued viral shedding in the patient’s feces.
“For someone to be infected that long is very surprising, as typical infection only lasts two to four weeks — and that is symptomatic infection,” she says.
Additional recipients of the donor’s heart and kidneys had evidence of immunity and probably were protected through previous HAV vaccination.
“The acute nature of HAV infection, low population HAV infection rate, and low rate of HAV infection-associated hospitalization make universal vaccination of healthcare workers and testing for patients impractical,” the CDC concluded.
REFERENCE
- Foster MA, Weil LM, Jin S, et al. Transmission of Hepatitis A Virus through Combined Liver–Small Intestine–Pancreas Transplantation. Emerg Infect Dis 2017 23;(4):590-596.
