The CDC is calling for improved donor screening and culture-based testing of donor organs and tissues after the second outbreak of tuberculosis in transplant cases.
Between July 7 and 11, the CDC received reports of two patients in different states with tuberculosis who received contaminated human bone tissue products used in hospitals, surgical centers and dental clinics. The CDC established the tissue to be from a single donor, and the contaminated products were distributed to 13 healthcare facilities in seven states. As of Dec. 20, five of 36 surgical bone allograft recipients had confirmed tuberculosis diagnoses, and two patients died of the disease. The manufacturer voluntarily recalled products on July 13 — testing showed that 53 additional cases were prevented by the recall.
The outbreak was similar to a 2021 situation involving 113 patients in 18 states who received contaminated bone allografts; however, the CDC confirmed that both outbreaks were from different donors. Both donors had evidence of sepsis, which should have disqualified them as donors, and the most recent donor also had pneumonia and radiographic changes consistent with a tuberculosis diagnosis, but neither were tested for tuberculosis.
"This second outbreak of bone allograft-related TB in recent years underscores the urgent need to implement improved donor screening and culture-based testing to prevent tissue-derived Mycobacterium tuberculosis transmission," the authors wrote.
The American Association of Tissue Banks revised its donor screening requirements for tuberculosis in August after the second outbreak.
Before the 2021 outbreak, the last reported transmission from bone allografts happened in 1953 in the U.K.