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 ]
[ Music ]>>How did the entire world
get this fat this fast? Did everyone just become a
bunch of gluttons and sloths? [ Music ] Obesity’s been around
since there were people. It’s been around for
50,000 years easy and it was around before McDonald’s,
Burger King, Wendy’s, it was around before Coca-Cola. Obesity’s part of
the human condition and there are evolutionary
reasons why obesity has been selected for in individual
populations because people who store energy are
more likely to be able to survive periods of famine. So there is a selection process
that goes on all the time but none of those things explain
how in 30 years we have gone from being svelt, if you will, to basically being
unbelievably sick. That’s what an epidemic
or a pandemic, in this case, looks like. That’s what plague,
influenza looked like and the question is what
would be the exposure that could account for this
and if it was just gluttons and sloths, how do you
explain the obese 6-month-old? We have an epidemic of obese
6-month-olds in this country. They don’t diet and
exercise, you’re going to call them a bunch
of gluttons and sloths? This goes way beyond
the question of personal responsibility.>>We have felt like it’s the
individual’s responsibility to keep their energy balance,
to eat the right amount and stay the right weight. But when something goes
wrong like the majority of the population becoming
overweight, we have to question that model and we have to
look at the forces outside of ourself this huge
societal environmental forces that are shaping obesity.>>The reason we’re in
this epidemic can be summed up with one statement, one idea
that has become so pervasive that it’s become sacrosanct,
that it has become dogma and that statement is “A
calorie is a calorie.” It’s the first thing dieticians
learned in dietary school. If you eat more than you
burn you will gain weight. If you eat less than you
burn, you will lose weight. And it doesn’t matter if those
calories come from carrots or cheesecake, the bottom line
is a calorie is a calorie, you eat too much, you
exercise too little and that’s the mantra
and guess what? It doesn’t work. And the reason it
doesn’t work is because a calorie
is not a calorie. The only dogma is there is none.>>Choose your favorite
hypothesis, there’s so many. Well you know what is
it in our environment? Is it just the excess of food? Is it the high fructose
corn syrup? Is it the antibiotics we’re
taking, the estrogens, different hormones and
hormone mimic hers? Is it the intrauterine
environment? All of these factors
play a role, so it is not just one thing. I mean if there’s one big thing, it’s of course it is
our food environment.>>Fast foods, fast
preparing, fast eating, and fast-causing disease, too. And we in our 2 parent
working, 2-hour commuting, 2 job life do not
have time for food. This is the biggest issue
that we currently face. It is the reason that the
industrial global diet has taken over the world is because with
all of our labor-saving devices, with the cars and the computers
and lawn mowers that you sit on instead of push,
et cetera, et cetera. All of those things have
actually reduced our time not created it. So this is a function of the
changes that we have made in our society extensively
for our benefit. The question is are they?>>Well there’s been a number
of changes in the last 30 years in how we interact with
food, with our food supply. There’s over 24,000
different foods that enter the marketplace
every year and there’s the issue of sleep patterning, stress,
how we feed our animals, the nutrients in the soil. There’s a number of
different issues at play. All of these converge on, I
think, adding to something to the obesity epidemic.>>The Western diet, our diet,
that we prize and export all over the globe has now become
the industrial global diet because it’s cheap,
it’s portable, it has no depreciation,
witness the 10-year old Twinkie and it was designed
to taste really good to keep people eating. This is now everywhere. This is the exposure. This is what has changed.>>I think we have
had a perfect storm. We have had the confluence of
this change food environment, the restricted activity like
no PE in schools, and chemicals that we’re not quite sure
what we’re being exposed to and they’re working together. [ Music ]>>Boy does that look good but honey what’ll these
calories do to my waistline?>>Relax, it’s diet [inaudible].>>There was a big war in the
food field back in the sixties and seventies and the
war was fat or sugar. And so we were remanded,
as a country, to reduce our consumption
of fat from 40% to 30%. Well guess what? We did it, we are there. But the total consumption
of calories and specifically carbohydrates
and especially sugar has gone through the roof, so
it was that directive, that edict of the late 1970s
that started the obesity and metabolic syndrome
ball rolling.>>It is almost impossible
to buy those packaged foods without getting a lot of extra
sugars that are just going to be toxic for your metabolism. I’m suspicious of anything
that says low fat or diet because you know that that means
that they’ve had to compensate with a lot of these
added sugars.>>A perfect example,
SnackWell’s. So what’s a SnackWell? Two grams of fat down, 13 grams
of carbohydrate increased 4 of which are sugar,
no fewer calories, same number of calories and
if fat’s not the problem and the sugar is, you can
see where we’re going here.>>And there’s also the
change in this food supply so that those highly
palatable foods are more easily accessible, so we can
reach for that comfort food at any street corner, at
any time during the day and have a few extra calories. [ Music ]>>When we talk about
the diseases of obesity, we’re talking about type
2 diabetes, hypertension, lipid problems, so blood fats,
if you will, heart disease. Those are sort of the
Big 4, if you will, that constitute what we
classically called the metabolic syndrome. However, we now know that there
are several other diseases that fall within the scope
as well, for instance, nonalcoholic fatty
liver disease, which now affects
one-third of all Americans, polycystic ovarian syndrome,
which affects 10% of all women, cancer and also dementia. Now here’s the key. Everyone thinks that those
downstream diseases are because of the obesity and
that could not be further from the truth. The obesity travels
with those diseases but the obesity is a marker for
those diseases Twenty percent of obese people have a
completely normal cellular metabolism and they will
live to a normal age. Forty percent of thin people, normal weight people have those
same chronic metabolic diseases and will die of them. Nobody dies of the obesity per
se; they die of the diseases that come from the
metabolic dysfunction. So when you do the math that
accounts for 60% of America. We are not talking
about a minority; we are talking about
the majority. So when you add up the medical
costs for those 8 diseases, that is 75% of healthcare
expenditures, not just ours, not just America but all over
the world so much so that in September of 2011, the
United Nations secretary general announced that non-communicable
disease, that is chronic metabolic
disease, type 2 diabetes, heart disease, hypertension,
cancer, dementia now posed a bigger
threat to the developing world, not the developed world,
the developing world than did acute infectious
disease and that includes HIV. This is enormous. This is mind boggling. This is absolutely staggering that developing countries have
a bigger problem with obesity and diabetes than they do with
cholera and other infections. When you think about that,
that really has to stop and give you pause,
something is going on here. [ Music ]
Stanford University The Tibetan regions of Western Sichuan are high-elevation areas on the Himalayan plateau they’re inhabited by
poor Tibetan pig farmers. These people live in small villages and they have
free-range pigs. They don’t have toilets so oftentimes they will go out into the
fields and defecate there, which means that the pigs are actually running
around in areas where there’s readily humans stool available to eat. So this
puts this area at high risk for Taenia solium which is the pork tapeworm. When
people eat undercooked pork the tapeworm develops in their GI tract and that
means that person then sheds thousands and thousands of eggs in their stool. Those eggs then contaminate the environment and are eaten by the pig
which causes the pig to get the tapeworm which it then passes back to people. Once it gets into the brain it causes a wide spectrum of disease. All developing
countries that have small-scale pig farming have this disease. It was our
theory our hypothesis that children were especially vulnerable to this disease
mainly because here was a parasite that was getting in children’s brains during a
sort of a formative time in their lives. So what we did is we went into three
counties in western Sichauan and we surveyed all fifth and sixth graders in
those counties. What we found was that disease in these schools was highly
prevalent you know in some schools up to 22% of kids had evidence in their blood
that they had the disease. If you imagine kids dropping out of school from this
disease, that could actually enforce a cycle of poverty in these already poor
communities. We have a vaccine that is effective in pigs, we have treatment that
we can give to pigs. It will kill the parasite while it’s in the pig we know how to install hygiene stations at schools. We know how to design behavioural change in schools. So if we took all of these things and we could get them into the
field in a cost-effective way we could really decrease the burden of
This is baby Jack. Vaccines help Jack fight infections by introducing a small number
of antigens into his body. Antigens are parts of germs that cause
Jack’s immune system to go to work. After Jack gets a vaccine, his immune system
will remember the vaccine antigen and attack that germ if it ever invades his body again. The antigens in vaccines are weakened
or dead, so they do not cause illness. Vaccines contain only a tiny
fraction of the antigens that Jack encounters in his
environment every day. It’ll take a few weeks for
the vaccines to start working, and Jack may need more doses
later to best protect him. That’s why Jack’s parents are following
the recommended immunization schedule – because it is designed to give him the best
protection possible from 14 serious diseases. Learn more about childhood immunizations. Visit www.cdc.gov/vaccines/parents
or talk with your child’s doctor.