Record number:
944
Adverse Occurrence type:
MPHO Type:
Time to detection:
9 months
Alerting signals, symptoms, evidence of occurrence:
Elevated liver enzymes; diagnosis of hepatitis B infection not made until liver recipient suspected to have donor derived disease
Demonstration of imputability or root cause:
Proven. 3/5 infected recipients had genetically identical viruses as the donor. The two recipients who were not infected had serologic evidence of immunity resulting from vaccination or past infection. This was a serological window period HBV transmission, with negative serological markers and no apparetnt risk factors identified through donor history. Development in one recipient prompted investigations and donor sample was retrospectively found to have 29copies/ml HBV DNA.
Imputability grade:
3 Definite/Certain/Proven
Keywords:
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