Record number:
1060
Adverse Occurrence type:
MPHO Type:
Time to detection:
2 months
Alerting signals, symptoms, evidence of occurrence:
A male recipient with multiple medical problems on immunosuppressive therapy received 129 donor exposures during a period of intensive plasma exchange and blood transfusion in May 2012. He became HEV RNA positive in July 2012 and seroconverted in August 2012.
Demonstration of imputability or root cause:
Donor was HEV RNA positive, anti-HEV negative at the time of the index donation and had cleared the HEV virus and seroconverted at the time of the next donation 5 months later. Sequencing confirmed this donation to be the source of infection in the recipient.
Imputability grade:
3 Definite/Certain/Proven
References:
Suggest references:
Bolton-Maggs, PHB (Ed), D Poles, A Watt and D Thomas on behalf of the Serious Hazards of Transfusion (SHOT) Steering Group, UK (2014). The 2013 Annual SHOT Report (2014), p 149. ISBN 978-0-9558648-6-5