European wasps are a declared pest in WA, and we don’t want them sharing our picnics here. They’re black and yellow bee-shaped insects
– and look for the black antennae. European wasps are insect predators and scavengers. They’re unique among wasps because they’re
attracted to sweet foods and proteins, as seen here with this one tearing of a chunk of meat, see the black feelers. In area of the world where they’ve established,
including the eastern states of Australia, you have to watch your food and drinks at
outdoor events such as picnics, BBQ’s or even just feeding your pets outside. Here in WA, we’ve been battling this wasp for 40 years since the 1st nest turned up in 1977. If they ever established here, quite possibly,
outdoor events like this could be a thing of the past. If you ever notice wasps with black feelers
like this, or wasps going for meat products, please call the Department of Agriculture and Food. They’re the world’s worst social wasp
pest, and we do not want them here
The department of agriculture and food
has been running the European wasp eradication program for forty years it’s
the only place in the world Western Australia to stop them establishing
within the wasps range, very successful program and largely due to our
surveillance system. Every year we will get queens shipped over accidentally from the eastern states that’s always going to happen. They’ll start new nests although
they’re not established here we will get them year-to-year. So the trap that I’m holding my hand has been around since 1993 we devised it to catch the European
wasps, just uses raw fish in there as a Lurer and it’s very effective it finds
wasps in an area eighty percent of the time the public very important to, they will report wasps in an area about 20 percent of the time. Since 1993 we started the trapping grid. The
department manages about a thousand traps it operates every year and it gets
worse every year as the wasps expand there range in the eastern states we get more
queens over here last year we had a 84 nests. We knew we needed help in 2011
which started the European wasps working group and started the Adopt-A-trap system.
Since then about 650 – 700 traps have been adopted by local government and by
members of the public. So without that we would have lost the battle years ago. The Adopt-a-trap trap is simple. We sent a trap out to you if you’re interested in trapping, your piece of raw fish in there and you hanging in the tree. You change the lure weekly or fortnightly, you check the trap periodically if there’s a wasp in there you
upload an image the department or you bring it in a will go out and look at
the wasp, it is European wasp will find the nest, will destroy it. There’s also
an interactive mapping database that we devised to go along with it points on maps. Gives the trappers the ability to edit their trap and to make comments. To see were all the other traps are across
the state and also find out where all the nests have been found and destroyed over last 40 years.
I’ve been asked to talk about pit bulls
pit bulls %uh have been a topic that to a lot of
our audience owns pit bulls and I get a lot of emails
about this and it’s something I know that a bit about and there’s a lot of misinformation out
there about pitbulls and about dogs and dog bites and dog behavior so I wanna go through a few
things there’s this idea that pit bulls are dangerous inherently okay and it’s just absolutely false and
you don’t have to believe anything I say do your own research read Malcolm
Gladwell’s peace about dangerous Pit Bull’s that he
brought for I believe it’s the new yorker ’em and that has become part of one of
his books read it all first of all a lot of people
don’t even understand what pit bulls are that that’s the the misconception number
one there are many breeds that are classified as pit bulls when they aren’t there’s really people
means it’s it’s basically three breeds an American Pit Bull Terrier a Staffordshire Bull Terrier and
American Staffordshire Terrier is a couple of other cross breeds now
for example the American Bully which some consider maybe to be part of
the pit bull umbrella or not there’s tons have dogs including the American
Bulldog various Mastiffs crossbreed Boxer mix is
that are being labeled as pit bulls when they’re not pit bulls were never bred to be violent
and the ones that are violent I’m are really violent as a result of
the ownership or of specific but a a a breeding that
is being done to make them violent and there’s this idea that pit bulls
have locking jaws that’s not true there’s the idea that pit bulls have the
strongest jobs that’s also not true they have lower job pressure than a lot of a ov other breeds and then
there’s this idea that they have a bad temperament people’s do not have bad temperaments
the past temperament tests a by be with with flying colors check
out the American temperament test society all that stuff is bogus a lot of the fatal bites are not from
pit bulls for stubble there from these other breed they’re
confused some fatal bites are indeed from pit bulls
and we have to look at a number of things there are so many pit bulls right
now because it’s become a popular breed the same way that a rottweilers at one point for the
popular kind of like a young masculine guy breed for a while it was Dobermans in at
those times you some more bites from those dogs now it happens to be pit
bulls we have to look at bites as a percentage of the number of dogs
that exist but the other thing is it really is owners if you look at
biting incidents there overwhelmingly a neutered male dogs who are often chained many hours a day and otherwise
not socialized often owned by young man without the resources to properly care
for the dogs who decides whether a dog is neutered
not the doc who decides whether to the dogs chained during the day not the
dog who decides whether the dog is socialized properly not the doc we’ve gotta figure out how
to stop the myths around pit bulls being
inherently violent dogs as opposed to any other trend breed that
is the masculine young male on you tard the dogs got this
chain is a allowed to just bark at people all day thing because it leading to the youth in his
Asian a lot of the dogs it’s a really really big problem and
we’ve just gotta fight the misinformation about it send me your
thoughts about pit bulls with your with your experience with it
so it’s about twenty years ago we got
these nutrition labels welcome agar program other we get these contrition
labels on packages and a what I think is interesting particularly interesting is that there’s a fair amount of evidence that
there is one thing that has been causing the majority of
cancers in america breast cancer prostate cancer
colon cancer you you name it one thing and one other things the points to their is of a fascinating study that was done with in you it
people on fact before that Frederick Banting was the guy who in
1923 won the Nobel Prize for the discovery of insulin and he came to the conclusion the diabetes
was caused by refined sugar he was the director the Public Health
Institute at Columbia University she’s behaving hander Emerson was the
Director of Public Health is to Columbia University in he reported and forgetting took that report he
reported that diabetes deaths in new york city had
increased 15% fall one thousand five hundred percent since the Civil War as as 1923 the deaths in New York City had gone up four-fold
alone between 1900 1920 400 percent from diabetes and this coincided almost exactly with
an increase in sugar consumption because the ninety-eight the 1890 was
when we first saw the beginning of the sugary the candy industry and the soft drink
industry years ago won the Nobel Prize was pointing that out John Yadkin a leading authority on the in and
nutrition in the United States this was the did a series of studies
back in the nineteen sixties feeding sugar and starch to rodents
chickens pigs rabbits in college students he found that the sugar or not the
starches but the sugar invariably raised blood
levels or something called triglycerides is a fancy word for fats which are we now in our risk factor for
heart disease it also raised insulin levels which tied
sugar back type 2 diabetes another interesting observation I’m
getting but by the way most to this from appease the great odds wrote in The New
York Times on April 13th 2011 titled is sugar toxic the during the korean war path dollars
is doing autopsies he writes on american soldiers killed in battle and most these american soldiers were
teenagers had plaque in the arteries being they
were already on their way to heart disease whereas the koreans that were
killed in battle during the Korean War did not regardless of their age karan’s at that
point in time like japanese were not eating high-sugar diets Americans were there is another study in the nineteen
seventies called the seven countries studies similar results they used to think that
it was fat that was leading to this buildup of heart disease I’m gonna get
to cancer in just a second I get it to the evidence for cancers even stronger but
what they found is that when the when high levels a when high levels of
sugar are introduced in the bloodstream bite like eating a candy bar or eating
something as sweet eating muffins or per I you know pancakes for breakfast or whatever that that hits the liver really fast and the liver response by producing a
type a fat that stays in the liver and you get this fatty liver fatty liver
then causes insulin resistance in fact quoting from the paper the
correlation between liver fat and insulin resistance lean or obese is remarkably strong Sam least 21 sciences bar the barman
Samuel I would it work at Yale School of
Medicine says when you posit bad delivered that’s when you become insulin resistant so what causes fat to
liver to accumulate fat newman’s he raises there’s been it is quite a
very real possibility caused by sugar in fact he notes get a job Raven at
stanford university says your cause insulin resistance in laboratory rats
feat Mr Diana HIF I must and mostly for does the easy way
to do it’s very obvious for dramatic effect or even says these changes can happen in as little as
a week if animals are fed sugar fructose and
high amount sixty to seventy percent their diets but if they if you give them 20 percent
other key at the calories node ID sugar which is the below the American average rats or develop bad deliver insulin
resistance in about two months stop feeding them the sugar and the fatty liver promptly goes away
in with the insulin resistance now this is where it gets really
interesting one other diseases he notes that
increases with instanceof obesity diabetes and metabolic syndrome is
cancer in fact the connection between obesity
diabetes and cancer first reported in 2004 by the World Health Organization is not even considered controversial is
an absolute correlation you’re more likely a cancer if you’re
obese or if you’re diabetic or both or if you have metabolic
syndrome malignant cancer a the second
observation he writes is that malignant cancer like diabetes was relatively rare
disease Impala in populations that didn’t eat with
Western diets and some others populations appear to be
virtually non-existent no cancer at all of any kind in the nineteen
fifties malignant cancer among the in you it for example was deemed sufficiently rare that
positions working in northern Canada were published case reports in medical journals when they diagnose
the same ok ace in 1984 k in for positions published in
else is a thirty years the any idea any way to the folks that
used to be called eskimos rate way up north and as they started to each a a Western
diet lung cancer cervical cancer started
going up but there was still a conspicuous deficit breast cancer rates until the sixties and as the day I became more and more
like the restive North America now they have breast cancer rates that
are at or even above that of people in the in
the the lower forty-eight so I what’s the mechanism well as Gary toms rights in is sugar toxic
cancer researchers now consider the problem insulin resistance is that leaders disagree more insulin
and insulin and at is associate with the grow a hormone
called insulin-like growth factor-i I G H right gf which actually promotes
tumor growth ourselves big come to depend on insulin to grow and multiply and he said it all
it also provides the signal to cells to grow and multiply the more
insulin the better they do and soak in some cancers develop
mutations that actually make them a well you all read some cancers develop
it asians to serve the purpose of increasing the influence about insulin on the cell Thompson believes
that many pre-cancerous cells would never acquire the mutations the
tournament a malignant tumors if they were being driven by insulin to
take up more more blood sugar metabolism at Beth Israel Hospital in in New York
the cancer center there and at Harvard Law School Louis kamli
works in both is as cancers like breast and colon
cancer up to eighty percent of human cancers are driven by the mutations are
environmental factors that enhancer mimic effective in someone on
the incipient tumor subbed so bottom line on a clean shirt back but this is this is the Newman unit
the bottom line years these new nutrition labels that the Obama
Administration’s proposed they will now list added sugar this important stuff E this is the Thom Hartmann program not a lot of other nutrients that I’d
like to know about you know like GM owes and things but added sugar I’m increasingly getting freaked out
In our previous episode we covered the Committee
of 300 and what role they play, today we are going to expose how they
are controlling the drug epidemic. Here’s part 2 of the deep state on the
Edge of Wonder. Since our last Qanon videos we have been getting
a lot of comments from you guys asking us for more. But we didn’t want to make them just for
the sake of making them since there are a lot of other great
channels already doing this already. So we decided we wanted to really dive deep
and start breaking down what exactly makes the Deep State,
who they are, and what their goal is. In our last episode we went into detail on
who the committee of 300 is and all the methods they are using to
depopulate the human race by way of Eugenics and for what reason. In this episode we are going to get way more
in depth on the drug epidemic and how this directly relates to our modern culture, especially with music. So if you haven’t watched our previous one,
it’d probably be better since we already talked about the committee of 300. We explained Eugenics and why they use it. We also introduced the book called Conspirator’s Hierarchy:
The Story of the Committee of 300, by Dr. John Coleman, which
we found on the CIA website. But since we went into detail
about it on our last one we won’t really go into the background of it, But in a nutshell, he worked for the
British intelligence in the 1980’s and had access to very top secret documents
and wrote an entire series on this. It’s mind blowing, read it. It takes forever but well worth it. We’ll put the link below for sure. So Qanon has been leaving a lot of crumbs
or clues on a lot of conspiracies that are really starting to fall in place once you start really diving deep on this… And boy have we dived deep. Just when we thought we’re at the
end of the rabbit hole, we realize how much deeper
and deeper it goes The scariest part that we found was how
perfectly everything ties in together and it can all relate back to the committee of 300 and the bloodlines of the 13 families. But that is going to be on our next episode
so keep watching for those episodes. Right, because we thought we would just do
a couple of episodes on this but now this is turning into an entire series. But since many of of Qanon’s posts
are hard to decipher, if you are not following it all the time, we thought we would start breaking
some of this stuff down for you guys. So half of Coleman’s book talks about the
drug trade, how it all works, who is behind it, and how they are all doing this. Of course we all know that Britain got all
of China hooked on Opium. China had the tea so they started to
trade opium with tea and soon the British took over
Hong Kong harbor to make it easier to trade But what most people don’t know is that
this wasn’t to trade tea, it was for trading opium. Soon China had very strict drug rules and
then started to produce it themselves. The 300 then saw what a lucrative business
it was and started to sell it to other countries, and make deals with others. Fast forward about 100 years the Rothschilds
developed a super elaborate system in which they controlled all
banks including the IMF, the Federal Reserve, which is what our Titanic Video was about, and started to make deals with
other world banks. And get this you guys, here is a Q post that lists all the 167 world banks that the Rothschilds own including the IRS. They are in charge of the Fed too
aren’t they. They own the money. But Hong Kong was the place where the
trades were happening and they have been trading gold for opium, which was priceless to the 300. There were some disagreements that broke out but soon everyone realized
how much money could be made. After a few decades and now you have a global
operation with multiple countries all taking part according to Coleman, mainstream companies are the ones
which were set up to help distribute, collect the funds, and to help make transaction
easier from country to country Coleman mentions that a major credit card
company was and possibly still is handing all of the laundering drug
money coming in to the 300 but we are choosing not to name it here. Now this was in the 90’s but Coleman
really was questioning how a company could produce
their own travelers checks that wasn’t through a government. Also what happened in the 70’s was that
the gold standard was eliminated so gold was no longer backing the
paper money anymore. This devalued the money even more. But according to Coleman, most drugs are being
traded with and especially in Hong Kong through gold which is why to this day gold is so important to China. Coleman even stated in that the 90’s that the
price of gold per kilo was on par with the price of heroin. However, now it is even more insane, a price of gold per kilo is about $40,000
the price of heroin or Fentanyl which is coming out of China is about $50,000-100,000 according to drugwarfacts.org. I mean that means Heroin is worth
more than gold! It’s just insane. So you guys might be wondering how they are
sending it here to the US which is the largest market of heroin? So according to Coleman and some other insiders
such as William Cooper, who wrote “Behold a pale horse,” you have the same person who is managing the heroin trade also make the laws against it. Tom Cruise’s movie American Made If you haven’t seen it, you should probably
check it out. was about how the CIA was bringing drugs into
the country and distributing it on a massive scale. So after Reagan, William Cooper said the Bush
family “perfected” the mass distribution behind the drug trade. Coleman said that Bush was just a servant
for the 300 to fulfill their desires. On the surface the FDA and border police were
trying to crack down on this. But everything they were doing wasn’t even
making a dent in the overall situation. Coleman hinted that the wars in the middle
east were over big oil and the opium fields. QAnon also had a very long post
which related a lot of stuff but linked Saudi Arabia to the Bush family, to 911, to oil fields Iraq, and Halliburton. Also the FBI and the DEA cracked down
on a small scale, but most are either over their heads, or paid off when it comes to the big
stuff, or just end up being out of their jurisdiction which is why none of the drugs are grown
here for mass distribution. According to Coleman though, to get this much
Heroin through on cargo ships and trucks you need an international company that can disguise
as a legitimate business, so according to Coleman this is where Triangle Internationale Routier company comes in, and I butchered that I’m sure, and I’m sure you can guess where this company is from … Geneva. When I was with the Texas border
patrol reporting last year they were saying they were really
overwhelmed by all of this. In 2014 the border patrol arrested over
700,000 illegal aliens but that’s just the number they caught, they said the number was probably even
twice as much who actually came through. And they only confiscated 5
million dollars in drugs. 5 Million? Dude that is such a joke, that’s
a drop in the ocean, it’s nothing … Also in today’s world many people are now saying
that the committee of 300 wants the MS 13 gang to create chaos here in our country with
killings, satanic worshiping, and drugs. Some say they are doing the hands on dirty
work for the cabal. So we know there is a ton of
controversy around this, but this is one of the main reason
why Trump wants to build a wall, it is actually cutting the source of
the main flow of funds to the deep state along with the MS13 gang and now child prostitution and child trafficking. In fact when girls come over the border no
matter what age they are, they will all get rapped at least 5 times by the cartels who control the Mexican side of the borders. I actually saw one of their compounds
while we were there. Yea so this is why the cabal hates Trump, they
wanted to keep their inflow coming. Coleman talks about how all of the recent
wars were over drugs and that China, Mexico, Afghanistan,
and Lisbon, has been supplying heroin with the
300 getting a huge cut. He said that the Rockefellers had or still
have a facility in Switzerland in which they were making LSD in the 70’s for 3$ a kilo and selling it for 20,000$. Do you know how much money that is? That’s like trillions, when you think
about a whole year How to market illegal drugs to
the mainstream So a lot of the police chiefs I have personally
spoken with while in the media couldn’t figure out why the dealers are
killing their users. But now after doing the show, Rob and I finally understand, it is all
about eugenics and depopulation while at the same time they are
getting filthy rich. So for the Cabal this is a win win
situation for them. Make trillions of dollars while depopulating
the “useless eaters,” to pave the way for their so
called “One World Government,” where everyone is serving them. So let’s digress a bit. The culture in the 50’s and 60’s
were so different. Back then most Americans values
were very high and drug abuse was very much
looked down upon in society. There was a huge focus on family values and
sexual freedom was definitely not part of the culture. So how do you get an entire society thinking
dealing drugs is “cool,” rebel against their parents,
and make sex a cultural acceptance? So Tavistock came along and realized that
the youth is the place to start. So they started to devise a plan in which,
using Colemans words here: turn them into mindless drug zombies who will be easier
to control than people who don’t need drugs.” Now this is the part in the plan that seems
really hard to grasp but according to Coleman, the committee realized how much the entertainment
industry can influence and re-shape our culture. So Tavisock started to devise a sinister plot
to get everyone doing drugs, rebelling against society, having wild crazy sex, also destroying the family at the same time. Now because the Committee already
owned all the media companies they realized they could promote this
everywhere on radio and TV stations everyday non stop forcing people to love it. All they needed now is something to promote. So they found 4 guys who were
already playing in Liverpool and decided to use them for their agenda. And thus the Beatlemania was born. Tavistock used them from the start with the
intention of degenerating society even further, however, Coleman mentions that the Fab Four might have never known they were
even being used for this purpose. But Tavistock also needed an
entire culture change. So Coleman claims Tavistock coined words which
seemingly came out of nowhere to go along with their new found plot: such as “beatniks,” “hippies,” “flower children” and popularized the word “Teenager,” which all became
part of the American vocabulary. It became “cool” to wear baggy clothes,
dirty jeans, go about with long unwashed hair. Everything they say about hippy basically So now that the stage was set, they just needed
to have a hidden meaning in the lyrics that “teenagers” would get but
parents might not. So “with a little help from their friends,” Coleman said that Tavistock
hired Theodor Adorno, who went to the Frankfurt School and
studied Western Marxism, to secretly write almost all of the
lyrics for the Beatles to promote the degeneration of our culture and mixed drug references in the lyrics to make
it cool now to use drugs. The excuse became the older generation
was now old fashioned and not keeping up with the
changing times of the new era. This later became a part of the culture as
other acts were then added such as the Rolling Stones and
the rest of the British Invasion leading up to even the music today. I know, it’s hard to swallow, we are just
telling you what we read. Yeah, that’s very true. Also some of the people on the cover of Beatles
St. Pepper’s album include Karl Marx , Aleister Crowley, who was
the precursor to the church of Satan and wrote the book on how to
summon demons, and Aldous Huxley who wrote
“A Brave New World” and is said by Coleman to be
the Committee’s high-priest who helped make
LSD popular in society. Soon a radical revolution was born as millions
upon millions of people all started to do drugs, wear
baggy clothes, trendy clothes, rebelling against their parents, all while mainstream media were promoting this cultural phenomena in our society non-stop. So the committee was now making a killing
on selling LSD on a massive scale, making a ton through promoting the bands, and soon realized they can replicate this movement through other forums and mediums . So do y’all see how we are their monkeys? So you guys we know this is super intense and of course this is only Coleman’s account but if you really look into what
is happening today and who is controlling the music industry and Hollywood, it’s shocking. We did a video on the Illuminati
controlling Hollywood, but since we did that video so much more has now been coming to the surface. Also we have been told by someone who played
with some very famous people that everyone in the industry who
wants to make it is forced to go to these high end parties and they have to engage in lots of sex and drugs and then promote this in their persona in public. We are trying to work on getting
one of these people on our show, but this is stuff gets very sensitive so
we are not sure if this will ever happen. But in any case, you can for sure find a lot
more of these stories coming out especially with the pedo stuff
now hitting the surface. Also each era had a new drug, like in the 70’s in was LSD,
in the 80’s it was cocaine, in the 90’s it was ecstasy
and the rave scene which oh man I’m not even
going to be getting into and then in the 2000’s it was heroin
and now it is fentanyl. Haha I wanna hear
Ben’s stories about rave Oh man, I am sure my old friends would be
more than willing to share those stories, but I’m not gonna go there, Hello? To me that was like a lifetime ago. So getting back to fentanyl what is crazy is that oxycontin is
what’s getting everyone addicted which are both made from the opium plant. Oxycontin is highly addictive
and when people run out…. They resort to the street drugs since they
need a prescription for it. Many organizations are
trying to get it banned and the insurance company
Cigna actually stopped covering it. Big pharma is another huge beast that
Trump is fighting against. Man that’s a whole other
episode on its own. In our next episode, we’re gonna get into
who these 13 families are, what they control and what their ultimate goal is … and let me tell you guys, it
is gonna get nuts as nuts can get For sure Also the more we research the more we found
everything seems to be connected which is super frightening, because once you start seeing patterns and connections, this just makes it more real. Like you research something over here and
see how it connects with something over there, and then it has a connection to that person
you are researching, and this entire web starts to take shape. Yep exactly. Well guys we’ll be making a few more of these because this was just a tiny part
of this centuries year old plan. But please hit like and subscribe
for more great content. Also don’t forget to
hit the notification bell So until next time we’ll see you guys on
the edge of the illumidonkey. Hey everyone, have you been enjoying
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Hello. I am Dr. Catherine Satterwhite, Epidemiologist in the Division of STD Prevention at the Centers for Disease Control and Prevention. I am also the lead author of the new paper released in February of 2013 estimating the number of prevalent and incident sexually transmitted infections in the United States. Every year in the United States there are nearly 20 million new sexually transmitted infections, or S-T-Is. Nearly half of these new infections occur in young people, aged 15 to 24 years. The high number of incident STIs in the U.S. underscores the ongoing need for increased prevention efforts. Most of these STIs will not cause harm, however, if left untreated, some of them can lead to serious health issues. Undiagnosed and untreated chlamydia or gonorrhea, for example, can increase a woman’s chances of infertility. Increasing strains of drug-resistant gonorrhea have made successful treatment of the infection more difficult, and have prompted CDC to update recommendations for its treatment regimen. In addition, some types of human papillomavirus infections, or HPV, can lead to genital warts and cervical cancer. For these reasons, it is important for clinicians to talk to their young patients about STI prevention and appropriate testing. Young people often face unique prevention challenges, including embarrassment and confidentiality concerns. Research shows that young patients may be afraid to initiate a conversation about STIs and will be looking to you, their health care provider, to begin the discussion. During these conversations, it is important for you to create an environment that feels safe for your young patients to talk openly without judgment. It is also important that you make it clear that you understand their health needs are different from the health needs of adults. Discussing your young patient’s sexual history is a good starting point for these discussions and will help you determine what tests and prevention counseling messages are necessary for your patient. For more information on how to take a sexual history, please visit www.cdc.gov/std. The new CDC analysis also estimated about 110 million prevalent, or existing, STIs. As with incident infections, HPV accounts for the majority of prevalent infections. Although the body’s immune system clears most HPV on its own within two years, some infections persist and can cause genital warts, cervical cancers, and other cancers. While there is no treatment for the virus itself, vaccines are available to prevent some of the most important types of HPV infection, including two of the most common types of HPV that can lead to cervical cancer. And given that most sexually active men and women will get HPV at some point in their lives, many can benefit from the protection that the HPV vaccine provides. Currently, HPV vaccine is routinely recommended for 11 or 12 year old boys and girls, as part of the adolescent vaccine schedule that also includes Tdap and the meningococcal vaccine. HPV vaccine is most effective when given before sexual debut. CDC also recommends HPV vaccination for teen girls and women through age 26 and teen boys and men through age 21 who have not been previously vaccinated. CDC recommends HPV vaccination for gay, bisexual, and other men who have sex with men through age 26, who have not been previously vaccinated. CDC also recommends screening for the following STIs: All adults and adolescents between the ages of 13 and 64 years should be tested at least once for HIV, regardless of recognized risk factors. Adolescents and adults at increased risk for HIV infection, such as those who have unprotected sex with multiple partners or exchange sex for money or drugs, should be tested annually. Clinicians should also screen all pregnant women for HIV. All sexually active women aged 25 and younger should be tested for chlamydia every year. At-risk sexually active women should be tested for gonorrhea each year. This includes women with new or multiple sex partners or women who live in communities with high burden of disease. In addition, all sexually active gay, bisexual, and other men who have sex with men should be tested at least once a year for syphilis, chlamydia, gonorrhea, and HIV. Those who have multiple or anonymous partners should be screened more frequently. For more detailed information about how to talk to your patients about sexually transmitted diseases or printable fact sheets to pass along to them, please visit CDC’s STD homepage at www.cdc.gov/std.
[Music Playing] More than a million Americans… …are living with HIV. But nearly two-thirds do not get the
care they need to stay healthy. And transmissions from
those not getting care… …account for 9 in 10 new HIV infections. Diagnosis and care can improve the
lives of people with HIV… …and reduce the likelihood of
transmitting the virus to others. A hundred people who don’t
know they have HIV… …transmit the virus to nearly 7
new people each year. But that rate drops rapidly
as people go through care. Every year, 100 people who have HIV
under control through medication… …infect less than one. But today, just 30 percent
have the virus under control… …and 50,000 people become
newly infected each year. Improving the health of
people living with HIV today… …could prevent the vast majority of
new infections tomorrow.
THANK YOU FOR JOINING US. ON BEHALF OF THE CENTERS FOR
DISEASE CONTROL AND PREVENTION I WOULD LIKE TO WELCOME YOU TO
NOVEMBER’S PUBLIC HEALTH GRAND ROUNDS.
THE LARGEST CLASS OF THE PUBLIC HEALTH ASSOCIATES THAT WE HAVE
HAD SO FAR. CONTINUING EDUCATION CREDITS FOR
PUBLIC GRAND ROUNDS ARE AVAILABLE FOR PHYSICIANS,
NURSES, PHARMACISTS, HEALTH EDUCATORS AND OTHERS.
PLEASE SEE MORE AT THE WEBSITE WHICH IS
CDC.GOV/CDCGRANDGROUNDS. ALSO AVAILABLE ON ALL YOUR
FAVORITE SOCIAL MEDIA SITES AND WE HAVE A FEATURED VIDEO SEGMENT
ON YOUTUBE CALLED BEYOND THE DATA POSTED SHORTLY AFTER THE
SESSION. WE ARE ALSO TWEETING TODAY.
SO PLEASE USE #CDCGRANDROUNDS FOR ALL YOUR TWEETING NEEDS.
IN ADDITION TO TODAY’S OUTSTANDING FEATURED SPEAKERS
WHOM I WOULD LIKE TO THANK FOR THEIR IMPORTANT AND ONGOING WORK
I WOULD LIKE TO ACKNOWLEDGE THE IMPORTANT CONTRIBUTIONS OF THE
INDIVIDUALS LISTED HERE. BECAUSE MR. ROBERT WALSH IS
VISITED, I WOULD LIKE TO POINT OUT THAT OPEN ENROLLMENT FOR
HEALTH INSURANCE IS ONGOING THROUGH FEBRUARY 15.
WE HAVE PARTNERED WITH THE CDC PUBLIC HEALTH LIBRARY AND
INFORMATION CENTER TO FEATURE ARTICLES RELEVANT TO THIS
SESSION. PLEASE SEE THE FULL LISTING AT
CDC.GOV/SCIENCECLIPS. HERE’S A PREVIEW OF UPCOMING
GRAND ROUND SESSIONS. PLEASE JOIN US LIVE OR ON THE
WEB. I WOULD LIKE TO INTRODUCE CDC’S
PRINCIPAL DEPUTY DIRECTOR. DR. ARIAS.
>>GOOD AFTERNOON AND WELCOME TO TODAY’S GRAND ROUNDS.
ORGAN TRANSPLANTS SAVE LIVES. BUT UNFORTUNATELY THERE AREN’T
ENOUGH ORGANS FOR EVERYONE THAT NEEDS THEM.
IN THE PAST FIVE YEARS OVER 140,000 AMERICANS HAVE RECEIVED
AN ORGAN TRANSPLANT. OVER 125,000 ARE WAITING FOR A
ORGAN TRANSPLANT AND LAST YEAR 10,000 AMERICANS DIED WAITING
FOR AN ORGAN OR BECAME TOO SICK TO TRANSPLANT WHILE THEY WERE
WAITING. LIVES CAN BE SAVED AND LIVES
HAVE BEEN SAVED. SO WE NEED TO SUPPORT ORGAN
TRANSPLANTATION AND MAKE SURE IT’S DONE SAFELY.
REQUIRED DONOR SCREEN TESTS AIMED TO REDUCE THE RISK OF
TRANSMISSION OF DISEASE FROM ORGAN DONORS TO RECIPIENTS.
IN EARLY RECOGNITION OF TRANSPLANT ASSOCIATED INFECTIONS
CAN LEAD TO TREATMENT OR PREVENTION OF INFECTION IN
RECIPIENTS. BUT THESE SCREENING TESTS ARE
NOT ALL INCLUSIVE. DONOR RISK AND BEHAVIOR HISTORY
PROVIDES CLUES TO WHAT ADDITIONAL TESTS MIGHT BE
NEEDED. BUT RISK AND BEHAVIOR HISTORY IS
NOT ALWAYS ACCURATE OR COMPLETE. CONSEQUENTLY INFECTIONS COULD BE
TRANSMITTED DURING TRANSPLANTATION. THE ORGAN PROCUREMENT AND TRANSPLANTATION NETWORK OR OPTN WHICH YOU’LL HEAR ABOUT MORE TODAY HAS
MECHANISMS IN PLACE TO RECEIVE AND INVESTIGATE REPORTS OF
POSSIBLE INFECTIONS RESULTING FROM ORGAN TRANSPLANT.
THAT IS WHAT WE MIGHT HAVE MISSED BY SCREENING TESTS OR
HISTORIES. HOWEVER, SOME TRANSPLANT
ASSOCIATED INFECTIONS ARE RARE AFFECTING LESS THAN 1% OF
RECIPIENTS AND THEREFORE, REQUIRE A VERY HIGH INDEX OF
SUSPICION. TO DETECT AND DIAGNOSE THEM
REQUIRES SOMEONE ACTUALLY LOOKING FOR SOMETHING UNUSUAL OR
UNEXPECTED. OFTEN RECOGNIZING THESE UNUSUAL
DONOR INFECTIONS COMES FROM CLOSE COLLABORATION AND
INVESTIGATION BY MULTIPLE CLINICAL AND PUBLIC HEALTH
PARTNERS. PRIOR COLLABORATIONS INCLUDING
THE OPTN DISEASE TRANSMISSION ADVISORY COMMITTEE, PUBLIC
HEALTH AND CLINICAL CARE EXPERTS AND CDC PATHOLOGISTS HAVE
IDENTIFIED, INVESTIGATED AND DIAGNOSED SOME UNUSUAL
TRANSPLANT ASSOCIATED INFECTIONS WHICH IN TURN HAVE LED TO
SEVERAL CHANGES THAT HAVE MADE TRANSPLANTS SAFER.
THROUGH THESE INVESTIGATIONS, ADDITIONAL STEPS HAVE BEEN
IDENTIFIED THAT COULD BE IMPLEMENTED TO FURTHER IMPROVE
THE SAFETY OF ORGAN TRANSPLANTS. FOR EXAMPLE, INSTITUTING BETTER
COMMUNICATION BETWEEN PROCUREMENT CENTERS TO RAISE
EARLY WARNINGS OF SYMPTOMS MIGHT MAKE DETECTING AN INFECTION MUCH
EASIER. A NATIONAL ACTIVE SURVEILLANCE
MIGHT LEAD TO EARLY DETECTION AND SYMPTOMS AND SIGNS AND
MAKING DIAGNOSTIC SPECIMENS AVAILABLE FOR SUBSEQUENT TESTING
SO THESE UNUSUAL INFECTIONS CAN BE CONFIRMED IN DONORS AND THE
APPROPRIATE TREATMENT OFFERED TO RECIPIENTS.
IT’S IMPORTANT TO USE EVERY ORGAN DONATED TO SAVE A LIFE
WHENEVER POSSIBLE. IT’S ALSO IMPORTANT TO IDENTIFY
INFECTIOUS AGENTS EARLY SO WHEN AN INFECTION IS TRANSMITTED
ORGAN RECIPIENTS CAN BE TREATED OR OFFERED PROPHYLACTIC
MEASURES. IMPROVING THE SAFETY OF ORGAN
TRANSPLANTS AND FURTHER REDUCE THE RISK OF INFECTIONS.
THANK YOU VERY MUCH FOR JOINING US TODAY.
WE ARE LOOKING FORWARD TO THE PRESENTATIONS AND LEARNING MORE
ABOUT WHAT’S ON THE HORIZON IN THE AREA.
[ APPLAUSE ]>>THANK YOU, DR. ARIAS.
I’M PLEASED TO INTRODUCE ROBERT WALSH.
>>THANKS. GOOD AFTERNOON.
I’M BOB WALSH THE DIRECTOR. IN 2013.
28,955 ORGAN TRANSPLANTS WERE PERFORMED IN THIS COUNTRY.
OF THESE, 22,967. AS IMPRESSIVE AS THESE NUMBERS
SEEM THE DEMAND IS GREATER. CURRENTLY WAITING ORGAN TRANSPLANTATION.
AS YOU CAN SEE THE GAP IS INCREASING.
DUE TO THIS DISPARITY APPROXIMATELY 18 OF THOSE
WAITING FOR A TRANSPLANT DIE EACH DAY.
IN 1984 IN AN EFFORT TO ADDRESS THE NATIONAL NEED FOR
TRANSPLANTS, CONGRESS PASSED THE NATIONAL TRANSPLANT ACT.
WHICH AMONG OTHER THINGS ESTABLISHED THE ORGAN
PROCUREMENT AND TRANSPLANTATION NETWORK OPERATED BY THE UNITED
NETWORK FOR ORGAN SHARING UNDER CONTRACT.
IT WAS ESTABLISHED AS A PRIVATE PARTNERSHIP THAT BRINGS TOGETHER
TRANSPLANT SURGEONS, PHYSICIANS AND OTHER PUBLIC HEALTH
REPRESENTATIVES TO MAINTAIN THE NATIONAL WAITING LIST FOR
TRANSPLANT CANDIDATES, SET POLICY FOR ORGAN TRANSPLANTATION
AND DETERMINE WHETHER HOSPITALS THAT WISH TO PROVIDE TRANSPLANT
SERVICES MEET THE MINIMUM REQUIREMENTS FOR DESIGNATION AS
A TRANSPLANT HOSPITAL. THE OPTN MEMBERSHIP INCLUDES ALL
U.S. ORGAN HOSPITALS AND PROCUREMENT ORGANIZATIONS.
IT IS IMPORTANT TO KNOW THAT THE OPTN’S PURVIEW IS LIMITED TO
SOLID ORGANS, DOES NOT EXTEND TO TISSUES.
CREATING THE CURRENT STRUCTURE, THERE ARE NOW 58 OPO’S CERTIFIED
FOR BOTH CENTERS FOR MEDICARE AND MEDICAID SERVICES THAT
PROVIDE ALL ACROSS THIS COUNTRY. ENSURING THAT THE OPTN ACTIVITY
IS CONSISTENT WITH THE ACT AS WELL AS OUR REGULATION WHICH IS
THE OPTN FINAL RULE. BECAME EFFECTIVE IN MARCH OF
2000 AND ESTABLISHED THE FUNCTIONS OF THE OPTN BY
PROVIDING HIGH LEVEL REQUIREMENTS FOR THE POLICY
PROCESS INCLUDING GOALS FOR ALLOCATION OF ORGANS FROM
DECEASED ORGAN DONORS, HOW DONORS AND CANDIDATE MATCHES ARE
CONDUCTED AND THE SUBJECT OF TODAY’S PRESENTATION,
REQUIREMENTS THAT OPTN MEMBERS CONDUCT APPROPRIATE TESTS TO
DETERMINE WHETHER ANY CONTRAINDICATIONS EXIST TO DONOR
ACCEPTANTS. THE PROHIBITION WAS A STATUTORY PROHIBITION.
BUT THE HOPE ACT, THAT PROHIBITION HAS BEEN REMOVED AND
WORKING WITH THE NATIONAL INSTITUTE OF HEALTH FOR
TRANSPLANTED PATIENTS ALREADY INFECTED WITH HIV.
THESE WILL BE IN PLACE BY THE END OF 2015.
WHILE THERE ARE NO ABSOLUTE PROHIBITIONS, THERE ARE AS I
MENTIONED, OPTN POLICIES FOR REQUIRED ORGAN DONOR SCREENING
AND THERE’S A MECHANISM IN PLACE TO RECEIVE REPORTS OF DISEASE
TRANSMISSIONS RESULTING FROM ORGAN TRANSPLANT REVIEWED BY THE
TRANSMISSION ADVISORY COMMITTEE IN COLLABORATION WITH CDC
REPRESENTATIVES. ATTEMPTS TO REDUCE THE RISK OF
DISEASE RELY ON LABORATORY TESTING OF DONORS.
A RISK ASSESSMENT INTERVIEW. THE OPTN SETS POLICY DEFINING
MINIMUM REQUIREMENTS FOR LABORATORY SCREENING OF BOTH
LIVING AND DECEASED ORGAN DONORS.
DECEASED, TIME AND OTHER CONSIDERATIONS LIMIT THE TEST
THAT CAN BE PERFORMED. CURRENTLY REQUIRED TESTING
INCLUDES TESTING FOR HIV, HEPATITIS B AND C. SYPHILIS TESTING AS WELL AS BLOOD AND URINE CULTURES.
THE RESULTS ARE USED TO DETERMINE IF PROPHYLACTIC
STRATEGIES ARE IMPACTED. TESTING DETECTS VIRAL DNA AND
VERY RECENT INFECTION PRIOR TO THE DEVELOPMENT OF ANTI-BODY.
IN ADDITION TO LABORATORY TESTING, ALL POTENTIAL DECEASED
DONORS MUST UNDERGO ASSESSMENT TO SCREEN FOR INFECTIOUS AGENTS.
COMBINED WITH INTERVIEWS OF THE POTENTIAL DONOR.
AS MANY OF THE QUESTIONS ARE PERSONAL, COMPLETE INFORMATION
MAY BE DIFFICULT TO OBTAIN. SCREENING QUESTIONS MAY ADDRESS
SEXUAL EXPOSURES, DRUG USE TO LOOK FOR NEWLY ACQUIRED
HEPATITIS B OR C OR HIV INFECTION.
ALSO ADDRESSING GEOGRAPHY ISSUES TO LOOK FOR RISK OF TUBERCULOSIS
AND SOME PAR SITES. MEDICAL HISTORY MAY REVEALS ARE
INFECTION THAT COULD BE TRANSMITTED TO A RECIPIENT.
RECENT ANIMAL EXPOSURES. EXACT LANGUAGE USED TO ASK THAT
QUESTION MAY BE CRITICAL. IN A RECENT CASE OF RACCOON RAIN
BYES, ASKED IF THERE WERE ANY EXPOSURE TO RABIES AND THE
RESPONSE WAS NO. PERHAPS IF THE QUESTION WAS
ASKED INCLUDING RACCOONS, THE DIAGNOSIS OF RABIES WOULD HAVE
BEEN APPARENT PRIOR TO ORGAN DONATION.
DR. CALL WILL PROVIDE MORE INFORMATION ON THE FACTORS
CONSIDERED WHEN EVALUATING. COUPLE MORE SLIDES.
HE’S ANXIOUS TO GET UP HERE. WHEN HE DOES HE WILL PROVIDE
MORE INFORMATION WHEN EVALUATING ORGAN OFFERS AS WELL AS THE
INFORMATION IN PLACE. I WANT TO PROVIDE MORE CONTEXT
ON THE SUPPLY AND DEMAND ISSUES. THE MORE THAN 123,000 PEOPLE
CURRENTLY WAITING FOR A TRANSPLANT INCLUDE PEOPLE OF ALL
AGES. THE VAST MAJORITY OF THOSE
WAITING NEED A KID ANY OR A LIVER.
WITH ALMOST 16,000 PEOPLE IN NEED AFTER A LIVER AND MORE THAN
100,000 WAITING FOR A KIDNEY TRANSPLANT.
IN 2013 NEARLY 29,000 OF THOSE WAITING RECEIVED A TRANSPLANT
USING ORGANS FROM BOTH DECEASED AND LIVING DONORS.
INCLUDING 17,000 KIDNEY TRANSPLANTS AND 6,500 LIVER
TRANSPLANTS. ALTHOUGH WAIT TIMES VARY
SIGNIFICANTLY BASED ON THE CANDIDATES SEVERITY OF ILLNESS,
THE NATIONAL WAITING TIME FOR KIDNEYS IS NEARLY FOUR YEARS AND
1 1/2 YEARS FOR LIVER. 6,400 CANDIDATES DIED WAITING
AND AN MANY BECAME TOO SICK TO TRANSPLANT. THEY ME DEVELOPED COMORBIDITY
AND BECAME TOO SICK AND THE RISK INCREASED TOO MUCH FOR THEM TO
BELIEVE THAT THEY WOULD SURVIVE THE TRANSPLANT PROCEDURE.
IT IS MY PLEASURE TO INTRODUCE DR. CALL.
WHO IS THE CURRENT CHAIR OF THE TRANSMISSION ADVISORY COMMITTEE.
THANK YOU. [ APPLAUSE ]
>>THANKS, BOB. IN ADDITION TO THE REQUIRED
DONOR SCREENING TESTS DESCRIBED BY BOB, SOME SCREEN FOR
GEOGRAPHICALLY PATHOGENS THAT HAVE CAUSED SERIOUS CASES OF
DONOR INFECTION. BLOOD PRODUCTS ARE SCREENED FOR
WEST NILE VIRUS. DUE TO A NUMBER CASES, MANY
OPO’S IN THE SOUTHWEST NOW SCREEN FOR IT.
MORE RESULTS FOR DECEASED DONORS MAY NOT BE AVAILABLE UNTIL AFTER
TRANSPLANTATION. PROFESSOR LAX SIS MAY BE GIVEN.
STRONG LOW TEASE CAN BE TREATED IN RECIPIENT IN POSITIVE
RECIPIENTS. HTLV-1, HIGH RISK REGIONS IS
REASONABLE. TRANSPLANT CENTERS HAVE LITTLE
TIME TO INTEGRATE A LOT OF INFORMATION IN DETERMINING IF
THE NEED FOR A TRANSPLANT FOR A RECIPIENT IS OUTWEIGHED BY THE
POSSIBLE RISK OF INFECTION IN THE DONOR.
THIS DETERMINATION REQUIRES AN ASSESSMENT BOTH OF THE DONOR
RISK AND THE URGENCY OF THE NEED FOR TRANSPLANT.
FOR EXAMPLE, GIVEN THE AVAILABILITY OF DIALYSIS, KIDNEY
TRANSPLANTATION IS RARELY URGENT.
SOME MAY HAVE POOR SURVIVAL. AS IS DEMONSTRATED ON THIS GRAPH
PATIENTS WITH HIGH SCORES INDICATING MORE SEVERE LIVER
DISEASE MAY HAVE WEEKS OR MONTHS TO LIVE AND A PARTICULAR ORGAN
OFFER MAY BE THEIR BEST CHANCE EVEN IF THE ORGAN HAS AN
INCREASED RISK OF TRANSMITTING AN INFECTION.
IN ASSESSING THE RISK OF A DONOR TRANSMITTING INFECTION, IT IS
CRITICAL TO RECOGNIZE DONOR INFECTION CAN BE MANAGED AND
EXPERIENCE PREVENTING THAT INFECTION TO THE RECIPIENT.
A DONOR WITH TREATED PNEUMOCOCCAL MENINGITIS CAN BE USED. IN CONTRAST THE DONOR WITH ENCEPHALITIS WITH UNKNOWN
ETIOLOGY HAS A SIGNIFICANT RISK OF PREVENTING INFECTION.
AND SHOULD BE USED WITH GREAT CAUTION.
IN ADDITION DONORS WITH MULTIDRUG RESISTANT ORGANISMS
HEAVILY TREATED WITH ANTIBIOTICS MAY TRANSMIT AN INFECTION THAT
CANNOT BE EASILY MANAGED IN THE RECIPIENT.
FINALLY, DONORS WHO DIE FROM SEPSIS MAY HAVE INFECTION THAT
CAN BE TRANSMITTED TO THE RECIPIENT AS WELL AS DAMAGE TO
ORGANS THAT MAY LIMIT THE VIABILITY OF THOSE ORGANS.
LET ME DESCRIBE THE POTENTIAL DONOR I WAS ASKED TO EVALUATE
REGARDING THE RISK OF TRANSMITTING INFECTION.
THE DONOR WAS A YOUNG MAN WITH THE HISTORY OF DRUG USE WHO WAS
ADMITTED TO THE HOSPITAL WITH INFECTION WHICH INCLUDED SEPTIC
EMBOLI TO THE BRAIN. HERE YOU CAN SEE GROWTH PICTURES
AND MITRAL VALVE. BY THE TIME OF ORGAN OFFER, HE
WAS AFEBRILE AND RECEIVED GREATER THAN 48 HOURS OF
ANTIBIOTIC THERAPY. THE RECIPIENT WAS CRITICALLY ILL
WITH END STAGE PULMONARY FIBROSIS AND VENTILATED IN AN
INTENSIVE CARE UNIT. THE QUESTION WE FACED SHOULD
THIS DONOR BE USED? IN PART AS THE EXPERIENCE THAT
HAD RECEIVED ANTIBIOTICS WAS FAVORABLE IF THEY WERE TREATED
WITH A COURSE OF ANTIBIOTICS COMBINED WITH THE FACT THAT THE
DONOR WAS OF HIGH QUALITY AND WE ELECTED TO USE THESE ORGANS.
HOWEVER, THERE’S NO PUBLISHED EXPERIENCE USING DONORS WITH
HIGH GRADE BACTEREMIA. TWO OF THE RECIPIENTS.
INCLUDING MINE. DEVELOPED RECURRENT INFECTION.
BOTH RECIPIENTS ARE NOW DOING WELL AND I HAVE DISCUSSED THIS
AT LENGTH WITH THE LUNG RECIPIENT WHOSE FAMILY DID SIGN
INFORMED CONSENT AND GLADLY ACCEPT THIS ORGAN OFFER AGAIN.
THIS CASE WAS PROVEN HERE AT THE CDC USING SEQUENCING.
I WOULD ADD THAT BASED ON THIS EXPERIENCE.
I PERSONALLY WOULD ONLY RECOMMEND USING A DONOR FOR A
RECIPIENT UNLIKELY TO RECEIVE ANOTHER ORGAN OFFER.
AFTER TRANSPLANTATION EARLY RECOGNITION OF DONOR DERIVED
DISEASE CAN BE LIFE SAVING. CURRENTLY THE ONLY CIRCUMSTANCE
THAT REQUIRES FOLLOW UP IS IN RECIPIENTS FOR RECENT INFECTION
WITH HIV, HEPATITIS B OR HAVE. RECOMMENDATIONS REGARDING HIV
AND VIRAL HEPATITIS FOR THOSE RECIPIENTS.
RECOGNITION OF DONOR DISEASE IN ALL OTHER CASES RELIES ON A HIGH
INDEX OF SUSPICION AMONG CLINICIANS CARING FOR
RECIPIENTS. THE CAUSE OF THE SYMPTOMS MAY
NOT ENTER THE DIAGNOSIS. IF THE EXPOSURE OCCURRED IN THE
DONOR, SHAGAS DISEASE MIGHT NOT BE CONSIDERED ONE WHO IS BORN IN
THE UNITED STATES. IF IT IS RECOGNIZED THAT THE
DONOR WAS FROM SOUTH AMERICA THE DIAGNOSIS WOULD LIKELY BE MADE.
ONE REASON IT IS IMPORTANT TO RECOGNIZE DONOR DRIVE INFECTION
EARLY IS THAT OTHER RECIPIENTS ARE AT RISK FOR DEVELOPING THE
SAME INFECTION. OVER THE PAST DECADE POLICY WAS
PUT IN PLACE TO HELP RECOGNIZE DONOR-DERIVED DISEASE AND
IMPROVE COMMUNICATION WHEN THESE RESULTS ARE LEARNED POST — TRANSPLANTATION.
IF THERE’S CONCERN THAT DONOR DRIVE DISEASE COULD OCCUR, THIS
MUST BE REPORTED TO THE OPTN. IN ADDITION, TRANSPLANT CENTERS
MUST REPORT TO THE OPTN IF THEY SUSPECT DONOR DRIVE DISEASE IN A
RECIPIENT. THIS ALLOWS THE SAME DONOR TO BE
NOTIFIED. WHEN SUSPECTED CASES ARE
REPORTED TO THE OPTN, AN OPTN COMMITTEE, THE DISEASE
TRANSMISSION ADVISORY COMMITTEE REVIEWS THESE CASES.
THEY EVALUATE WHETHER THERE MIGHT BE A POTENTIAL DONOR DRIVE
INFECTION AND EDUCATES THE TRANSPLANT COMMUNITY AND
IMPROVES THE SAFETY OF THE TRANSPLANTATION.
MEMBERSHIP INCLUDES REPRESENTATIVE FROM CDC AND FDA.
AS WELL AS VOLUNTEERS WHO WORK IN TRANSPLANT ID, SURGERY, ORGAN
PROCUREMENT AND DONOR LABORATORY TESTING.
UNEXPECTED DONOR DRIVE INFECTION REMAINS EXTREMELY RARE.
WHILE THE NUMBERS ARE OBTAINED FROM A REQUIRED BUT PASSIVE
REPORTING SYSTEM AND LIKELY UNDERESTIMATE THE INFECTION,
FROM 2008 TO 2012, 71,501 DONORS PROVIDED ORGANS FOR 141,679
RECIPIENTS. 146 TRANSMITTED UNEXPECTED
DISEASE TO 181 RECIPIENTS WITH 40 DEATHS.
0.13% HAD AN UNEXPECTED DISEASE TRANSMISSION.
AND 0.03% DIED FROM SUCH TRANSMISSION.
DURING THE SAME PERIOD 33,407 INDIVIDUALS DIED WHILE ON THE
WAIT LIST FOR AN ORGAN. THUS, WHILE PATIENT SAFETY IS A
CRITICAL CONCERN, MANY IN THE TRANSPLANT COMMUNITY FOCUS ON
INCREASING THE SUPPLY OF ORGANS AND VIEW INTERVENTIONS FOR RARE
TRANCE ADMISSIBLE DISEASE THAT MIGHT DO TO FALSE POSITIVES AND
OTHER PROCESS CONCERNS REDUCE THE NUMBER OF AVAILABLE ORGANS.
A BREAKDOWN OF REPORT REVEALED THAT VIRAL INFECTIONS ARE COMMONLY REPORTED OCCURRING AS A RESULT OF DONOR DERIVED INFECTION. HIGH PROFILE CASES OF TRANSMISSION TO VIRAL AGENTS
HAVE INCLUDED WEST NILE VIRUS, MENINGITIS VIRUS AND RABIES
VIRUS. FUNGI HAS BEEN A PROMINENT ISSUE
AMONG FUNGAL INFECTIONS. THE CDC REVIEWS ALL CASES OF SUSPECTED DONOR DRIVE DISEASE
AND FURTHER REVIEWS THOSE THAT INCLUDE NATIONAL NOTIFIABLE
DISEASES OR OF PARTICULAR PUBLIC HEALTH CONCERN.
IN 2013 THE CDC REVIEWED 31 OF 284 OR 11% OF ALL REPORTED
CASES. THE DTAC REPORTING SYSTEM IS
PASSIVE BUT REQUIRED. THE VARIABILITY OF REPORTING
ACROSS DONOR SERVICE AREAS DEMONSTRATES THAT WE NEED TO
WORK TO CONTINUE TO EDUCATE THE TRANSPLANT COMMUNITY REGARDING
WHEN A SUSPECTED DONOR DRIVE DISEASE NEEDS TO BE REPORTED.
EACH HASH MARK REPRESENTS A SINGLE PROCUREMENT
ORGANIZATION. SOME OPO’S REPORT MANY MORE
CASES THAN OTHERS. LIKELY RELATED TO CONFUSION
REGARDING REQUIREMENTS AND PER HARPS UNDO FIERCE ABOUT THE
CONSEQUENCE OF EXERCISING SOME JUDGMENT IN WHAT SHOULD BE
REPORTED. ACROSS THE U.S., THE TOTAL
REPORTING RATE IS 2.49% OF ALL DONORS.
THIS INCLUDES BOTH REPORTS BY THE ORGAN PROCUREMENT
ORGANIZATION OF INFORMATION THAT COULD LEAD TO DONOR DRIVE
DISEASE LEARNED POST TRANSPLANT AND TRANSPLANT CENTER REPORTS
WHEN THERE’S CONCERNED THAT AN UNEXPECTED DISEASE HAS OCCURRED.
PART OF THE DTAC’S MISSION IS TO PROMOTE PATIENT SAFETY IN THE
AREA OF TRANSMISSION. EXAMPLE OF ACTIVITIES INCLUDE
ANALYSIS THAT LED TO THE DISCONTINUATION FOR THE
SCREENING, A PRACTICE RESULTING IN HUNDREDS OF ORGANS WASTED DO
YOU AGREE — DUE TO FALSE POSITIVE TESTS.
AS WELL AS A GUIDANCE DOCUMENT TO HELP INFORM CLINICIANS.
WE RECENTLY PROVIDED THE TRANSPLANT COMMUNITY WITH
INFORMATION TO HELP THEM EVALUATE DONORS FOR POTENTIAL
INFECTION WITH EBOLA VIRUS. ONE OF OUR CURRENT PROJECTS
INVOLVED IMPROVING THE PROCESS WHERE BY INFORMATION LEARNED
POST TRANSPLANT, FOR EXAMPLE, AUTOPSY RESULTS, ARE
COMMUNICATED TO TRANSPLANT CENTERS AND FAILURES RESULTED IN
DONOR DRIVE INFECTIONS IN THE PAST.
I WILL TURN THE PRESENTATION OVER TO DR. ZAKI.
[ APPLAUSE ]>>THANKS, DAN.
GOOD AFTERNOON. I WOULD LIKE TO SHARE WITH YOU
SOME OF THE UNEXPECTED DONOR DRIVE INFECTIONS THAT WE HAVE
IDENTIFIED HERE AT CDC OVER THE PAST 12 YEARS.
THESE PRESENT MULTIPLE CHALLENGES INCLUDING NOT BEING
SCREENED FOR IN THE DONOR, UNKNOWN INCIDENTS ASSOCIATED
WITH SIGNIFICANT MORBIDITY AND MORTALITY.
OBVIOUSLY, WITH HIGH PROFILE EVENTS AS YOU CAN SEE FROM THE
SLIDE HERE WITH SOME OF THE HEADLINES ASSOCIATED WITH
TRANSPLANT OF RABIES, WEST NILE AND ANY OF THE CONVECTIONS.
THIS IS A LIST OF SOME OF THE AGENTS THAT WE HAVE IDENTIFIED
OVER THE PAST 12 YEARS. AND THE NUMBER BELOW THEM IS THE
NUMBER OF CLUSTERS THAT WE HAVE SINCE RECOGNIZED SINCE THE
ORIGINAL RECOGNITION OF THIS ASSOCIATION.
I WOULD LIKE TO SHARE WITH YOU THE STORY OF EVENTS THAT
OCCURRED BACK IN 2002. IT STARTED BY A YOUNG FEMALE WHO
WAS INVOLVED IN A CAR ACCIDENT. WHICH MADE IT NECESSARY FOR HER
TO GET MULTIPLE TRANSFUSIONS. UNFORTUNATELY SHE DIED.
SHE DONATED ALL OUR ORGANS AND ALL CAME DOWN WITH ALL THE
RECIPIENTS CAME DOWN WITH FEBRILE.
ONE OF THESE PATIENTS SUCCUMBED TO HIS DISEASE AT EMORY.
AND WAS THOUGHT TO BE DUE TO WEST NILE.
HOWEVER HIS HISTORY WAS NEGATIVE.
SO WE DID THE AUTOPSY AND SAW A SEVERE ENCEPHALITIS.
YOU CAN SEE THE VIRAL IN RED. THIS STIMULATED A TRACE-BACK
INVESTIGATION AND LED TO IDENTIFYING — THIS RECIPIENT
HAD RECEIVED ABOUT 60 COMPONENTS FROM 63 DONORS AND LED TO
IDENTIFICATION OF TWO COMPONENT THAT IS HAD EVIDENCE OF WEST
NILE. DIAGNOSING THIS INFECTION LED TO
DIFFERENT THINKING ABOUT OUR WEST NILE AND BLOOD TRANSFUSION AND ORGAN TRANSPLANTS. THIS EVENT OCCURRED BACK IN 2003. THE STORY STARTS WHEN A MALE DIED OF HEAD TRAUMA.
HE DONATED HIS ORGANS AND FOUR RECIPIENTS ALL OF WHOM DIED.
AT THAT POINT WE RECEIVED THE CASES FOR EVALUATION.
THE COMMON FEATURE IN ALL OF THESE PATIENTS AS YOU CAN SEE
HERE WAS THE MASSIVE NECROSIS. THE USUAL THINGS THAT YOU THINK
ABOUT IN SUCH CASES ARE THINGS LIKE HERPES OR ADD KNOW VIRUS.
WE WERE AT A DEAD END UNTIL A CULTURE IDENTIFIED A VIRUS OR
MENINGITIS VIRUS AND SUBSEQUENTLY WE WENT BACK TO THE
TISSUES AND ALL OF THEM WERE POSITIVE IN ALL THE RECIPIENTS. WE THOUGHT THIS WOULD BE AN
ISOLATED EVENT AND WE WOULD NEVER SEE IT AGAIN.
BUT WE WERE WRONG. TWO YEARS LATER IN 2005 WE
INVESTIGATED ANOTHER CLUSTER IN RHODE ISLAND WITH THREE
TRANSPLANT RECIPIENTS FROM A SINGLE DONOR.
WE ALSO MASSIVE NECROSIS AND BECAUSE OF OUR EARLIER
EXPERIENCE WE QUICKLY DIAGNOSED THIS AS BEING DUE TO LCMV.
THIS ALSO LED BACK TO A TRACE-BACK INVESTIGATION AND IT
TURNS OUT THAT THE DONOR’S DAUGHTER HAD A PET HAMSTER.
SHE HAD SEVERAL. AS A GOOD MOTHER, SHE TOOK CARE
OF CLEANING THE ANKLES AND THE AREA OF THE HAMSTER’S ACTIVITY
AND SHE GOT ENOUGH VIRUS IN HER SYSTEM NOT TO CAUSE HER CLINICAL ILLNESS.
SHE HAD ENOUGH VIRUS IN HER SYSTEM TO TRANSMIT TO THE
DONORS. AS YOU CAN SEE FROM THIS SLIDE,
THE SEQUENCE FROM ALL THE RECIPIENTS, THE HAMSTERS, THE
PET STORE HAMSTERS WERE IDENTICAL AND DIFFERENT FROM THE
2003 CLUSTER. THIS PROVIDED A DEFINITE LINK TO
ANIMAL. THIS IS JUST THE SCENE OF MY
COLLEAGUE BRIAN AT THAT FACILITY.
HE’S CHASING A MOUSE THAT GOT LOOSE.
OBVIOUSLY A GOOD WAY TO TRANSMIT INFECTION AMONG THESE RODENTS.
HE HAD A VERY HIGH RATE OF INFECTION.
JUST WANT TO POINT OUT IF YOU FOCUS ON THE AREA IN RED, WE
TESTED THE DONOR USING DIFFERENT ESSAYS AND CULTURE.
EVERYTHING WAS NEGATIVE. THIS IS NOT A GOOD INFECTION TO
ACTUALLY BE SCREENING FOR. THE BETTER WAY OF SCREENING AS
DR. WALSH POINTED OUT IS ASKING THE RIGHT QUESTION, ASKING ABOUT
THE SPECIFIC EXPOSURE TO LINK IT TO THE TRANSPLANT.
FINALLY, THIS WAS A THIRD CLUSTER.
AND THIS WAS ACTUALLY IDENTIFIED BY A TOTAL DIFFERENT WAY.
BY MOLECULAR DIAGNOSTICS TECHNIQUE.
A SHOTGUN APPROACH. IT IDENTIFIED LCMV.
I WANTED TO SHOW YOU THREE EXAMPLES OF THREE DIFFERENT
CLUSTERS. ONE DIAGNOSED BY CELL CULTURE.
THE SECOND BY HISTORY AND THE THIRD BY MOLECULAR DIAGNOSTICS.
OBVIOUSLY MOLECULAR DIAGNOSTICS IS THE RAPIDLY CHANGING FIELD.
I EXPECT IN THE NEXT YEARS THIS WILL BE ONE OF THE PRIMARY TOOLS
TO DIAGNOSE THESE INFECTIONS. WE WERE CONTACTED BY A
PATHOLOGIST IN TEXAS IN 2004 ABOUT THIS CLUSTER.
THERE WERE TWO UNEXPLAINED DEATHS AND A THIRD PATIENT WAS
OFFERED MENTAL STATUS. THE CONNECTION OF A COMMON DONOR
WAS RECOGNIZED BY THE PATIENT’S FAMILIES WHO WERE IN INTENSIVE
CARE UNIT. THE DONOR WAS A 20-YEAR-OLD
BLACK MALE ADMITTED AND DISCHARGED FROM TWO HOSPITALS ON
THE SAME DAY, COMPLAINING OF THE SYMPTOMS THAT WERE ATTRIBUTED TO
A MILD URINARY TRACT INFECTION. HIS CONDITION DETERIORATED AND
WAS DECLARED DEAD AND YOU CAN SEE FROM THE CHART HERE, HIS
COMPLAINTS, I DRAW YOUR ATTENTION — I CAN’T EVEN
SWALLOW MY OWN SPIT. EVENTUALLY ALL FOUR RECIPIENTS
DIED WITHIN TWO MONTHS. WE GOT THE TISSUE TO EXAMINE.
WHEN WE LOOKED AT THEM, THIS IS A SECTION ON THE UPPER LEFT HAND
FROM THE BRAIN AND YOU CAN SEE THE REDDISH INCLUSIONS IN THE
BRAIN. THESE ARE CHARACTERISTIC OF
RABIES AND YOU CAN SEE INFLAMED ON THE LEFT AND ON THE RIGHT YOU
CAN SEE CONFIRMING THE VIRUS IN THESE TISSUES.
NOW, DURING THE INVESTIGATION, WE GOT ANOTHER CALL FROM THE
SAME PATHOLOGIST. SHE FOUND OUT THAT THERE WAS
ENOUGH — THERE WAS A LIVER TRANCE PLANT RECIPIENT.
SHE THOUGHT IT WAS ENCEPHALITIS DUE TO WEST NILE VIRUS.
WE GOT THE TISSUES. THE DONOR WAS DIFFERENT FROM THE
PREVIOUS DONOR. SO WHEN WE LOOKED AT IT AGAIN,
YOU CAN SEE THE BODIES. IT TURNS OUT AGAIN IT WAS
RABIES. IT WAS A BIG SURPRISE.
WE DIDN’T EXPECT THAT. THIS THREW US THROUGH A LOOP.
OBVIOUSLY, THIS RAISED MANY QUESTIONS SUCH AS WAS THERE A
LINK BETWEEN THE FIRST THREE CASES AND THIS CASE?
WAS THE RECIPIENT’S INFECTION UNRELATED TRANSPLANTS?
WAS THE SECOND DONOR INFECTED? WAS THIS HEALTH CARE WORKER
TRANSMISSION OF RABIES? THIS SLIDE SHOWS YOU THE LIVER
FROM THE SECOND DONOR. BUT WHAT THE SURGEONS DID TO
TRANSPLANT THE LIVER WAS TO USE A GRAFT, A STUNT THAT YOU CAN
SEE HERE IN RED. THAT WAS FROM THE ORIGINAL
DONOR. IT WAS MADE THE — OBVIOUSLY
THAT WAS A BIG RELIEF TO FIND THAT.
AS A RESULT OF THIS INVESTIGATION, BETTER
REGULATIONS FOR TRACKING OF ORGANS AND TISSUES WERE
SUBSEQUENTLY INSTITUTED. EVENTUALLY THIS IS RABIES WAS
CONFIRMED AS THE MOST COMMON TYPE OF RABIES IN THE U.S.
THE SEQUENCE FROM ALL THREE RECIPIENTS WERE EXACTLY THE
SAME. THIS IS ANOTHER CLUSTER OF
RABIES TRANSMISSION FROM A SINGLE DONOR.
THE KIDNEY TRANSPLANT RECIPIENT DIED 18 MONTHS POST TRANSPLANT.
THE DONOR HAD A HISTORY OF RACCOON EXPOSURE, FEVER,
VOMITING, SEIZURES AND WE LOOKED AT THE TISSUES AND IT WAS
CONFIRMED IT WAS RABIES. IN THIS CASE, IT WAS RACCOON
RABIES. THE THREE OTHERS COMPLETED
PROFESSOR LA PROFESSOR LACK SIS.
TO SUMMARIZE THE IMPACT. CLUSTERS OF TRANSMITTED RABIES.
WE LEARNED IT COULD BE TRANSMITTED THROUGH ORGAN
TRANSPLANTATION AND WE INSTITUTED DIFFERENT FEDERAL
AGENCY INSTITUTED BETTER TRACKING OF THE ORGANS AND
TISSUES FROM THE DONORS. FROM THE RACCOON CLUSTER WE
LEARNED IT COULD BE TRANSMITTED FROM RACCOONS.
COULD HAVE A LONG INCUBATION, AS YOU REMEMBER 18 MONTHS SINCE THE
PATIENT GOT THE TRANSPLANT. DURING THE 2009 INFLUENZA WE
RECEIVED A LOT OF SPECIMENS FOR TESTING THAT YEAR.
EVERYTHING WAS COMING IN FOR INFLUENZA TESTING INCLUDING THIS
CASE. THIS WAS — THE ORGAN DONOR WAS
THOUGHT TO HAVE DIED OF ACUTE DEMYELINATING ENCEPHALOMYELITIS INFECTION. THE ORGANS WERE TRANSPLANTED AND
THE RENAL RECIPIENT FELL ILL. WE HAD A CHANCE TO LOOK AT THE
AUTOPSY TISSUES. IT TURNS OUT YOU CAN SEE THE —
TO BE A INFECTION. AND THREE RECIPIENTS RECOVERED
WITH THERAPY. THIS IS ANOTHER CLUSTER OF TRANSPLANTS FROM A COMMON DONOR.
TWO RECIPIENTS CAME DOWN WITH ENCEPHALITIS.
THE LIVER RECIPIENT HAD THESE ENHANCING LESIONS.
THIS IS A TISSUE FROM THE LIVER BIOPSY I BELIEVE. THESE ARE THE TROPHOZOITES AGAIN. THIS IS THE KIDNEY PANCREAS
RECIPIENT. PLACED ON THERAPY AND SURVIVED.
THE DONOR HAD THE SIMILAR MRI FINDINGS YOU CAN SEE AT THE
BOTTOM. VERY CHARACTERISTIC SKIN LESIONS
ON HIS LEFT SHOULDER. SUCH LESIONS ARE KNOWN TO
PROCEED NEUROLOGIC SIGNS PERSONS INFECTED.
SO IT WAS A MISSED CONNECTION THERE.
ANOTHER CLUSTER, THIS OCCURRED IN 2012.
THE DONOR HERE WAS A 37-YEAR-OLD WOMAN LIVING IN EL PASO.
SHE HAD DIED OF A CEREBROVASCULAR ACCIDENT.
THE ORGANS WERE TRANSPLANTED AND THE RECIPIENTS CAME DOWN
WITH FEVER. THE RIGHT KIDNEY WAS DOING WELL.
THE LEFT KIDNEY SHOWED THAT THERE WAS ANTI-BODIES.
THAT WAS THE CURRENT THINKING AND THESE WHAT THE PATIENTS WERE
BEING TREATED FOR. UNFORTUNATELY THE LEFT KIDNEY
RECIPIENT’S CONDITION DETERIORATED AND HE HAD TO HAVE
A NEPHRECTOMY AND YOU COULD SEE THE SAMPLE HERE AND THE — ON
THE RIGHT ON THE SURFACE OF THE KIDNEY.
ON EXAMINATION OF THE NEPHRECTOMY SPECIMEN WE FOUND
EVIDENCE OF MICROSPORIDIA. AND IT TURNED OUT THAT IT WAS
THE CAUSE OF THIS DISEASE. EVENTUALLY ALL THREE RECIPIENTS
WERE FOUND TO BE INFECTED. THE RIGHT KIDNEY RECIPIENTS, YOU
CAN SEE THE BIOPSY DOWN THERE, RECOVERED AFTER SIX MONTHS OF
THERAPY. IN SUMMARY ABOUT THESE UNUSUAL
TRANSPLANT ASSOCIATED INFECTIONS.
HOW UNUSUAL? THEY ARE CERTAINLY RARE BUT MORE
THAN WE EXPECTED PREVIOUSLY. AND IF YOU LEARN ABOUT A PROBLEM
YOU CAN DIAGNOSE IT. SINCE THEN AS I SHOWED YOU
EARLIER THERE WERE MULTIPLE CLUSTERS OF THESE SAME DISEASES
THAT HAVE BEEN RECOGNIZED SINCE THEN.
I WANT TO EMPHASIZE THE ROLE OF PATHOLOGY AND THE FRONTLINE IN
TERMS OF RECOGNITION OF THESE EMERGING INFECTIONS AND GUIDING
EPIDEMIOLOGIC INVESTIGATIONS. THESE INVESTIGATIONS HAVE BEEN
INCREASED CLINICAL AWARENESS OF THESE INFECTIONS AND IMPROVED
DONOR SCREENING. FINALLY, I WOULD LIKE TO STRESS
THE IMPORTANCE OF DONOR AUTOPSIES AND ARCHIVED SPECIMENS
IN THESE INVESTIGATIONS. I HOPE IN THE FUTURE DONOR
AUTOPSY WILL BE MANDATORY ON ALL DONORS.
I WOULD LIKE TO ACKNOWLEDGE MANY PEOPLE, TOO MANY TO LIST.
THIS WORK WOULD NOT HAVE BEEN POSSIBLE WITHOUT THEM.
OBVIOUSLY YOU CAN SEE THERE’S A LOT OF GROUPS BOTH WITHIN HERE
AT CDC AND OUTSIDE OF CDC IN STATE HEALTH DEPARTMENTS AND
ACADEMIC INSTITUTIONS. I WOULD LIKE TO NOW INTRODUCE
DR. SRIDHAR TO GIVE US THE NEXT TALK.
THANK YOU. [ APPLAUSE ]
>>GOOD AFTERNOON. TODAY I WANT TO DISCUSS
OVERCOMING SOME CHALLENGES TO PREVENTING UNUSUAL ASSOCIATED
INFECTIONS WHICH HAVE BEEN DISCUSSED TODAY.
BETWEEN 2002 AND 2012, CDC INVESTIGATED SEVERAL UNUSUAL
TRANSPLANT TRANSMITTED INFECTION CLUSTERS MOST PRESENTING AS
INFECTIOUS ENCEPHALITIS AMONG RECIPIENTS. THERE HAVE BEEN SIX WEST NILE.
NOT ALL DEVELOPED INFECTION. FOUR DIED.
FOUR CLUSTERS OF MENINGITIS VIRUS, TEN DEATHS.
TWO CLUSTERS OF TRANSMITTED RABIES INFECTION WITH EIGHT
TOTAL RECIPIENTS. FIVE WHICH DIED.
BECAUSE WE WERE ABLE TO CONNECT THE DOTS.
THREE WERE IDENTIFIED AND GIVEN PROPHYLAXIS AND SURVIVED.
THERE HAVE BEEN SEVEN RECIPIENTS AND THREE DEATHS. PREEMPTIVE THERAPY WAS GIVEN.
ENCEPHALITIS HAVE BEEN REPORTED TO CDC.
44 RECIPIENTS, NOT ALL WERE I INFECTED.
>>22 DIED. THROUGH CDC’S INVESTIGATION,
SEVERAL COMMON THEMES HAVE EMERGED.
FIRST THE DONOR INFECTION WAS NOT RECOGNIZED BEFORE THE ORGANS
WERE TRANSPLANTED, PROBABLY FOR SEVERAL REASONS.
THESE DISEASES ARE RARE AND INFREQUENTLY ENCOUNTER ERRED.
MANY DID NOT APPEAR TO HAVE OBVIOUS EVIDENCE OF INFECTION AT
THE TIME OF DEATH AND DEATH WAS FROM ANOTHER CAUSE.
SOME DONORS HAD EVIDENCE OF ENCEPHALITIS BUT THE DIAGNOSIS
WAS NOT MADE BY THE CLINICIANS CARING FOR THE DONOR.
RECOGNITION OF THE INFECTION CAN BE FURTHER COMPLICATED OF
INFECTIONS FOR EXAMPLE MICROSPORIDIA.
ADMINISTERED TO THE NEXT OF KIN. EVEN WHEN RISK FACTORS ARE
INCLUDED NEXT OF KIN WHO COMPLETE THE QUESTIONNAIRE MAY
BE UNAWARE OF HIGH RISK EXPOSURES OR CERTAIN BEHAVIORS.
THERE ARE NO SCREENING TESTS AVAILABLE FOR THESE INFECTIONS.
JUST LIKE THE DIFFICULTY IN DIAGNOSING THESE INFECTIONS IN
DONORS THEY’RE DIFFICULT TO DIAGNOSE IN RECIPIENTS BECAUSE
THEY’RE OFTEN SPREAD OUT AROUND THE COUNTRY RECOGNIZING THE
SYMPTOMS THAT WOULD LINK DONOR CONNECTING THE DOTS IN A TIMELY
MANNER. FINALLY, THERE’S NO ACTIVE
SURVEILLANCE SYSTEM COMPLICATING PROMPT RECOGNITION AND
COMMUNICATION OF FINDINGS. THERE ARE SOME OPPORTUNITIES FOR
PREVENTION OF TRANSPLANT TRANSMITTED I INFECTIONS
PARTICULARLY FOR THOSE PRESENTING AS INFECTIOUS
ENCEPHALITIS. ACTIVE SURVEILLANCE.
CURRENTLY TRANSPLANT INFECTIONS ARE REPORTED THROUGH A PASSIVE
REPORTING MECHANISM. WHERE TRANSPLANT CENTERS REPORT
TO THE OPTN. ONCE A DONOR DERIVE INFECTION IS
SUSPECTED. LIKELY RESULTING IN
UNDER RECOGNITION AND UNDERREPORTING.
ESTABLISHING A NATIONAL SURVEILLANCE SYSTEM COULD
ENHANCE THE RECOGNITION OF THESE INFECTIONS.
INCLUDING REPORTING OF DATA SUCH AS TOTAL TRANSPLANTS PERFORMED.
IMPLEMENTATION OF CASE DATA CRITERIA AND ELECTRONIC
NOTIFICATION SYSTEM ONCE THE CASE IS SUSPECTED OR IDENTIFIED.
ANOTHER OPPORTUNITY FOR PREVENTION IS IMPROVED SCREENING
OF DONORS. OPO’S MAY USE DIFFERENT
QUESTIONNAIRES TO GET BEHAVIORS. CANNOT SCREEN WITH 100%
SENSITIVE. COULD RESULT IN IMPROVED
RECOGNITION OF RISKS FACTORS. ANY POTENTIAL GAIN OF
IDENTIFYING DONORS OF ENCEPHALITIS, THE GOAL OF ANY
SCREENING PROGRAM IS TO BOTH DISTINGUISH ENCEPHALITIS FROM
NONINFECTIOUS ENCEPHALITIS AND FURTHER OPTIMIZE THE ORGAN ALLOCATION SYSTEM. RECOGNITION OF INFECTIOUS IN DONORS COULD BE IMPROVED.
IF RISK OF IN — EARLY IDENTIFICATION WOULD LEAD TO
PROPHYLACTIC INTERVENTION. CDC IS WORKING ON A MODEL TO
IMPROVE DONOR SCREENING OF ENCEPHALITIS.
AND FURTHER OPTIMIZE THE ORGAN ALLOCATION SYSTEM.
THIS PROJECT HAS THREE OBJECTIVES.
FIRST IS TO DEVELOP A TOOL FOR CLINICIANS THAT ALLOWS THEM TO
BETTER DONORS. TRANSPLANT ADMISSIBLE
FROM NONINFECTIOUS ENCEPHALITIS AND IMAGING RESULTS. AND THE TOOLS MUST INTEGRATE
DATA FROM DONOR QUESTIONNAIRES. THE SECOND OBJECTIVE IS TO
DEVELOP A METHOD TO ALLOCATE ORGANS FROM DONORS IDENTIFIED AS
INCREASED RISK FOR INFECTIOUS ENCEPHALITIS.
UNDERSTANDING THAT SOME MAY HAVE A SURVIVAL BECAUSE OF THEIR LIFE
EXPECTANCY. THE THIRD OBJECTIVE IS TO OPTIMIZE THE ALGORITHMS. THE GOAL IS TO REDUCE THE
OVERALL OPPORTUNITY COST BY ENSURING THE BEST USE FOR THESE
INCREASED ORGANS, BY REDUCTION OF OPPORTUNITY COST, WE WANT TO
MAXIMIZE THE COLLECTIVE OVERALL SURVIVAL AMONG
RECIPIENTS BY APPROPRIATE ORGANS IDENTIFIED AS INCREASED RISK.
MAKE USE OF EVERY ORGAN IF POSSIBLE.
TO ACCOMPLISH THESE TASKS WE HAVE GATHERED A DIVORCE GROUP OF
INDIVIDUALS BOTH WITHIN AND OUTSIDE OF CDC TO IDENTIFY
VARIABLES, CLINICIANS HAVE COLLECTED PUBLIC AVAILABLE DATA
OF INFECTIOUS AND NONINFECTIOUS ENCEPHALITIS.
OUR COLLEAGUES HAVE PROVIDED DATA ON PATIENT CHARACTERISTICS.
TO OPTIMIZE THIS PROCESS WE’RE WORKING WITH THE TEAM TO ANALYZE
THESE TO DEVELOP A DONOR RISK INDEX CLASSIFICATION AND
COMPUTING A TIPPING POINT TO MAXIMIZE SURVIVAL BENEFIT.
IN CONCLUSION, I WOULD LIKE TO EMPHASIZE THAT THE RISK FOR ANY
UNEXPECTED DONOR DERIVED INFECTIOUS DISEASE TRANSMISSION
IS LOW AND EVEN LOWER FOR AN UNUSUAL PATHOGEN DESCRIBED
TODAY. NOT ALL CAN BE ENTIRELY
PREVENTED. MANY INDIVIDUALS DIE BEFORE AN
ORGAN BECOMES AVAILABLE. FOR MOST CANDIDATES.
THE BENEFITS OUTWEIGH THE RISKS. USING AS MUCH RELEVANT DATA AS
POSSIBLE COULD IMPROVE OUTCOMES. CDC CONTINUES TO WORK WITH
PARTNERS AND THE ORGAN TRANSPLANTATION COMMUNITY TO
FURTHER REDUCE THE RISK OF TRANSMITTED INFECTIONS.
[ APPLAUSE ]>>KEEP THE QUESTIONS SHORT
SINCE WE’RE RUNNING OUT OF TIME. SUSAN.
>>WE HAVE QUESTIONS FROM OUR ONLINE AUDIENCE.
HOW DO YOU ASSESS WHEN THE RISK OF INFECTION IS TOO GREAT AND
OUTWEIGHS THE BENEFITS TO THE PATIENT?
>>SO YOU HAVE TO TAKE A WHOLE NUMBER OF FACTORS INTO
CONSIDERATION THAT ARE SPECIFIC TO THAT PARTICULAR RECIPIENT AND
HOW MUCH THAT RECIPIENT NEEDS THAT PARTICULAR ORGAN.
SO FOR INSTANCE, IF IT IS SOMEONE HAS VERY LATE STAGE
LIVER DISEASE AND MAY HAVE — THAT MAY BE THE ONLY ORGAN OFFER
THAT THEY’RE GOING TO GET. YOU MIGHT ACCEPT AN ORGAN THAT’S
OF HIGHER RISK OF INFECTION AND WE TRY AND RESOLVE MOST OF THESE
CONFLICTS BY USING — BALANCE THESE BY USING INFORMED CONSENT
AND DISCUSSING WITH THE POTENTIAL RECIPIENT OR THE
FAMILY THE PARTICULAR CHARACTERISTICS OF THAT DONOR
THAT INCREASES THE RISK AND WHAT THE CONSEQUENCES OF TRANSMISSION
MIGHT BE TO INVOLVE THEM IN THE DECISION-MAKING PROCESS.
>>PLEASE GO AHEAD.>>I CAN TOUCH ON THAT BRIEFLY.
THIS PRESENTATION FOCUSED SOLELY ON SOLID ORGAN TRANSPLANTATION.
BONE MARROW HAS DIFFERENT ISSUES.
THE INFECTION SCREENING IS TREATED DIFFERENTLY.
AS WAS STATED EARLY IN THE PRESENTATION HERE, ONE OF THE —
OR CHALLENGES THAT IS SPECIFIC WITH DECEASED DONOR SOLID ORGAN
TRANSPLANTATION IS THAT THERE’S NOT THE LUXURY OF TIME OFTEN TO
DO ALL THE SCREENING THAT ONE MIGHT WANT TO DO TO ROLE OUT AS
MUCH OF THE RISK AS POSSIBLE GIVEN THE LIMITED AMOUNT OF TIME
THAT YOU CAN MAINTAIN THE DONOR AND THE ORGANS ARE VIABLE
OUTSIDE THE BODY. BUT ON THE BONE MARROW SIDE THE
SCREENING IS DIFFERENT THAN OCCURS ON THE SOLID ORGAN SIDE.
>>BONE MARROW DONORS ARE ALSO LIVING.
THE HISTORY CAN BE MORE RELIABLY ASCERTAINED THAN IT COULD BE
FROM DECEASED DONORS AND ORGANS.>>SUSAN.>>AS A NEGLECTED TROPICAL DISEASE ENCROACHING ON THE UNITED STATES, ARE ORGAN DONORS ALWAYS BEING TESTED FOR SHAGA DISEASE?
>>NO, IT’S NOT REQUIRED TO TEST FOR SHAGA’S DISEASE.
FOR ORGAN DONORS THERE ARE SOME PROCUREMENT ORGANIZATIONS OR
LIVING DONOR CENTERS, IN PARTICULAR.
SO FOR EXAMPLE, IN MIAMI, TO MY KNOWLEDGE, THEY WILL TEST FOR
THAT AND AT RISK DONORS BUT I WOULD SAY MOST DECEASED DONORS
ARE NOT BEING TESTED FOR SHAGA’S DISEASE.
>>AGAIN FROM OUR ONLINE AUDIENCES.
HAS ANY VETERAN OR FAMILY MEMBER SERVED IN EUROPE EVER DEVELOPED
MAD COW RELATED NEUROLOGICAL SYMPTOMS?
IS.>>THE QUESTION IS RELATING TO
SOMEONE WHO SERVED IN ENGLAND AND USED TO BE A BLOOD DONOR AND
THEN WHEN THE NEW RULES CAME IN THAT THEY COULD NOT DONATE.
SO HIS QUESTION RELATES TO WHERE ARE WE ON THAT?
HAS ANYBODY EVER DEVELOPED SYMPTOMS?
>>I’M NOT CERTAIN. I DON’T HAVE THE LIKE ENTIRE SET
OF DATA IN FRONT OF ME. BLOOD SCREENING PROCEDURES ARE
DIFFERENT THAN SOLID ORGAN. I DON’T HAVE THE INFORMATION TO
BE ABLE TO ADEQUATELY ANSWER THE QUESTION.
>>BUT JUST TO CLARIFY, IT HAS BEEN TRANSMITTED BY BLOOD
TRANSFUSION IN GENERAL.>>THANK YOU ALL FOR JOINING US
AND JOIN US NEXT TIME. BYE.
[ APPLAUSE ]