How can we improve tracking of transplanted tissue in the United States?
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Currently an estimated two million tissues are distributed for transplantation annually. With increasing use of recovered tissue, clusters of transplant-transmitted infection have shown the difficulty of tracking tissues from an infected donor to the recipient. The challenge of tissue tracking to multiple transplant recipients was illustrated in a recent investigation of transmission of hepatitis C virus infection from a donor of organs and tissues. When a tissue bank issued a recall of the donated tissue, the Centers for Disease Control and Prevention was notified to assist public health authorities; the mean time to locate and notify the physicians who had transplanted the tissue was 13 days, while the mean time to notify, inform, and test the patients was 29 days. Lack of common coding and nomenclature was one of the key challenges in tracking tissue to the recipient. Some changes that could improve timeliness in the event of a recall includes: (1) standardized tissue nomenclature and coding through unique donor identifiers; (2) tissue traceability requirements using systems similar to that used for blood products; (3) a surveillance system for adverse events that provides feedback at the provider level.
KeywordsTissue Transplantation Tracking Safety
The authors thank Susan Hocevar, MD, Division of Healthcare Quality Promotion, and Scott D Holmberg, MD, MPH, Division of Viral Hepatitis, Centers for Disease Control and Prevention for their assistance with this investigation.
Conflict of interest
No conflicts of interest have been declared for the authors on this manuscript.
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