EDITOR'S NOTE: The corresponding author of the article was invited to respond to this letter, but to date has not done so.

To The Editor:

In his case report, Dr. Trotter described an instance of Hepatitis C infection after bone grafting(1) and showed a temporal relationship that suggests that the graft is the cause. The deceased tissue donor was undoubtedly tested by the tissue bank and found negative for anti-HCV antibodies and Dr. Trotter probably assumed that the donor had been recently infected and was viremic but that HCV antibodies were at an undetectable level. This is likely to have happened.

Today, a donor in the seronegative window period would be detected and not be found acceptable for donation. Previously, tissue banks were not required to test donors for HCV RNA as they are today. Since 2004, HCV RNA testing has been required for all tissue donations.

Dr. Trotter could confirm that his patient was infected by the bone graft by determining whether any of the other recipients of tissues from the same donor became infected by HCV. The typical deceased donor has also donated organs, skin, tendons, corneas, and heart valves. Ten to fifteen whole bones are donated and there are usually 10 to 50 patients who have received various types of bone grafts from a single donor.

Dr. Trotter reported that the tissue procurement agency refused to cooperate or to divulge information about the donor. It is even more important that this tissue bank or tissue supplier inform other recipients of tissues from this donor so they can be evaluated for HCV and, if infected, that their contacts be evaluated.

Since Dr. Trotter did not get cooperation from this tissue bank, he should divulge to the readers the name of this tissue bank so it can be avoided as a potential supplier. More importantly, he should also report this to the department of health so they can open an epidemiologic investigation to protect the public health and he should report this case to the FDA by the Med Watch mechanism.

I wonder if he has done this.

The author(s) of this letter to the editor did not receive payment or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author(s) are affiliated or associated.

Reference:

1. Trotter JF. Transmission of hepatitis C by implantation of a processed bone graft. A case report. J Bone Joint Surg Am 2003;85:2215-2217)

To the Editor:

I appreciate the comments by Dr. L'Heritau. I agree that hepatitis C (HCV) transmission may occur via an infected health care worker or a contaminated multi-dose vial. I have not been able to rule out either of these options as a potential cause of transmission in our patient, although I believe that these routes were much less likely than HCV transmission via the implanted tissue.

Several years passed between the HCV infection in the patient and my awareness of the case. Therefore, meticulous documentation regarding the HCV status of health-care workers associated with the patient in the case report and identification of other patients who could have been infected during the same admission were not logistically possible.

At our center, we are currently performing a study assessing the risk of HCV transmission via contaminated multi-dose vials. Regarding the viral status of the bone donors, the tissue procurement agency refused to disclose the viral status of either donors. They have stated in writing that such disclosure is unnecessary because HCV cannot be transmitted via a bone graft. However, I believe that the viral status of the bone donors is, in fact, very important.

James F. Trotter, M.D. Division of Gastroenterology/Hepatology University of Colorado Health Sciences Center Denver

To the Editor:

We read with great interest the case report of Hepatitis virus C (HCV) transmission by implantation of a processed bone graft[1]. The author provides some compelling evidence about the possible mode of contamination. The patient had no other risk factor for HCV contamination. However some points remain unclear and concern us.

No information is provided about possible HCV seroconversion of both bone graft donors. Either a posteriori HCV seroconversion, or HCV RNA positivity of the donor could add evidence that infection was transmitted by the bone graft. Alternatively, other hypotheses about the possible route of contamination were not explored.

The risk of HCV transmission by intravenously administered multidose vial sharing is real, and some cases of transmission during anesthesia have been reported by us[2,3] as well as by others[4,5]. Reinsertion of a contaminated needle into multi dose vials shared between patients is thought to be the mechanism of transmission[2-4]. Unfortunately, Dr. Trotter gives no information about the mode of anesthesia used in this patient or the serological status of other patients who had surgery the same day.

In addition, HCV transmission from an infected surgeon[6] or anesthesiologist[7] has been described. Again, no information was given about the serological status of these health care workers. We believe that HCV transmission by IV multidose vial or from infected health care workers cannot be ruled out as the mode of disease transmission in this patient.

1. Trotter JF. Transmission of hepatitis C by implantation of a processed bone graft. A case report. J Bone Joint Surg Am 2003;85:2215-7.

2. Carbonne A, Thiers V, Germain JM, Gros H, Bouvet E, Astagneau P. Patient-to-patient Transmission of hepatitis C virus in a surgery clinic through multi-dose vials. Proceedings of the Society for Healthcare Epidemiology of America Annual Meeting; 2003 Apr 5-8; Arlington, USA.

3. Carbonne A, Thiers V. Transmissions nosocomiales de l’hépatite C de patient à patient, liées à l’anesthésie générale dans l’interrégion Nord en 2001-2002. Ann Fr Anesth Reanim 2004 in press.

4. Krause G, Trepka MJ, Whisenhunt RS, Katz D, Nainan O, Wiersma ST, et al. Nosocomial transmission of hepatitis C virus associated with the use of multidose saline vials. Infect Control Hosp Epidemiol 2003 ;24:122- 7.

5. Tallis GF, Ryan GM, Lambert SB, Bowden DS, McCaw R, Birch CJ et al. Evidence of patient-to-patient transmission of hepatitis C virus through contaminated intravenous anaesthetic ampoules. J Viral Hepat 2003;10:234-9.

6. Esteban JI, Gomez J, Martell M, Cabot B, Quer J, Camps J, et al. Transmission of hepatitis C virus by a cardiac surgeon. N Engl J Med 1996 ;334:555-60.

7. Ross RS, Viazov S, Gross T, Hofmann F, Seipp HM, Roggendorf M. Transmission of hepatitis C virus from a patient to an anesthesiology assistant to five patients. N Engl J Med 2000 ;343:1851-4.