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Transplantation-Transmitted Tuberculosis Oklahoma and Texas, 2007
Approximately 28,000 organ transplants were performed to cerebral vasculitis. The patient continued to decline neu-
in the United States in 2007 (1). When infections are trans- rologically and met clinical criteria for brain death in early
mitted from donors, the implications can be serious for June 2007. Organs were recovered for transplantation, and
multiple recipients (2–4). Tuberculosis (TB), a known the liver and kidneys were transplanted into three recipi-
infectious disease complication associated with organ trans- ents, all Texas residents, at facilities in Oklahoma and Texas.
plantation, occurs in an estimated 0.35%-6.5% of organ Three weeks after the organ donor's death, a culture from
recipients in the United States and Europe posttrans- cerebrospinal fluid obtained as part of his clinical evalua-
plantation (2). In 2007, the Oklahoma State Department tion for fever and altered mental status grew M. tuberculosis.
of Health identified Mycobacterium tuberculosis in an organ Subsequently, M. tuberculosis also was cultured from stored
donor 3 weeks after the donor's death. This report summa- donor spleen tissue.
rizes results of the subsequent investigation, which deter-

The donor had been treated for presumed aspiration
mined that disseminated TB occurred in two of three pneumonia with left lower lobe infiltrate and pleural effu-
transplant recipients from this donor, and one recipient

sion in December 2006, 6 months before his death. In
died. Genotypes of the donor and recipient TB isolates were March 2007, 1 month before his final hospitalization, the
identical, consistent with transmission of TB by organ trans-

donor was again hospitalized for community-acquired pneu-
plantation. To reduce the risk for TB transmission associ- monia, shown on chest radiograph as involving the left
ated with organ transplantation, organ recovery personnel

upper and left lower lobe. He had no recognized history of
should consider risk factors for TB when assessing all

TB or foreign travel and had not been identified as a con-
potential donors. In addition, clinicians should recognize tact of any person with TB. Two tuberculin skin tests (TST)
hat transplant recipients with TB might have unusual signs performed during the 6 months before his death (one
or symptoms. When transmission is suspected, investigation required by a homeless shelter, the other performed by the
f potential donor-transmitted TB requires rapid communi- jail) were negative. No specimen was obtained for acid-fast
zation among physicians, transplant centers, organ procure-

bacilli (AFB) examination or mycobacterial culture.
ment organizations (OPOs), and public health authorities.

INSIDE

336 Nonfatal Maltreatment of Infants United States,
Case Report

October 2005-September 2006
Organ Donor. In April 2007, a U.S.-born man aged 46

340 Surveillance for Community-Associated Clostridium
ears with a history of seizure disorder, alcoholism,

difficile — Connecticut, 2006
melessness, and incarceration was admitted to an Okla- 343 Updated Recommendation from the Advisory Commit-
oma hospital for presumed alcohol withdrawal seizures

tee on Immunization Practices (ACIP) for Use of 7-Valent

Pneumococcal Conjugate Vaccine (PCV7) in Children
d aspiration pneumonitis. He had a prolonged hospital-

Aged 24–59 Months Who Are Not Completely Vaccinated
etion characterized by altered mental status, fever, persis-

344 Notices to Readers
mt pneumonia, hydrocephalus, multifocal cerebral

346 QuickStats
Farction, and progressive neurologic disability attributed

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR DISEASE CONTROL AND PREVENTION

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The MMWR series of publications is published by the Coordinating
Center for Health Information and Service, Centers for Disease
Control and Prevention (CDC), U.S. Department of Health and
Human Services, Atlanta, GA 30333.
Suggested Citation: Centers for Disease Control and Prevention.
[Article title). MMWR 2008;57: (inclusive page numbers).
Centers for Disease Control and Prevention
Julie L. Gerberding, MD, MPH

Director
Tanja Popovic, MD, PhD
Chief

Science Officer
James W. Stephens, PhD
Associate Director for Science

Steven L. Solomon, MD
Director, Coordinating Center for Health Information and Service

Jay M. Bernhardt, PhD, MPH
Director, National Center for Health Marketing

Katherine L. Daniel, PhD
Deputy Director, National Center for Health Marketing
Editorial and Production Staff

Frederic E. Shaw, MD, JD
Editor, MMWR Series

Teresa F. Rutledge
(Acting) Managing Editor, MMWR Series

Douglas W. Weatherwax
Lead Technical Writer-Editor
Donald G. Meadows, MA

Jude C. Rutledge

Writers-Editors

Peter M. Jenkins
(Acting) Lead Visual Information Specialist

Lynda G. Cupell

Malbea A. LaPete
Visual Information Specialists
Quang M. Doan, MBA

Erica R. Shaver
Information Technology Specialists

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Recipient A. A woman aged 50 years received one of the Buren, donor's kidneys. In late July 2007, 6 weeks after the kid. ney transplant, she developed fever, followed by pancytop nia and a sepsis-like syndrome. At notification in late June the donor's positive culture for M. tuberculosis, a bone ma 03E row aspirate was smear positive for AFB. Despite substitorial N quent treatment with anti-TB therapy, the recipient die plant 9 weeks posttransplantation. The primary causes of deats

losis listed after autopsy were disseminated TB, leukopenia, and

DESSA end-stage renal disease. M. tuberculosis was cultured from the deceased recipient's blood, liver, spleen, and lungs. The polymerase chain reaction (PCR)-based genotype and restriction fragment length polymorphism (RFLP) pattern of the recipient's M. tuberculosis isolate matched those of the donor. Recipient B. A woman aged 23 years received the donors

ved other kidney, and had fever and severe headache in late July, 7 weeks after transplantation and concurrent with notification of the donor's positive M. tuberculosis culture She was started on anti-TB medications. Her cerebrospi nal fluid was negative on AFB smear and culture. Pano topenia developed; although the patient's bone marrow aspirate revealed granulomas, the smear was negative for AFB. M. tuberculosis subsequently grew from the recipients blood and urine specimens; these isolates had a PCR-based genotype and RFLP pattern matching that of the donor. The recipient experienced renal allograft dysfunction in August 2007, approximately 10 weeks after transplantation. Biopsy of the allograft revealed interstitial nephritis with negative AFB smear and culture; anti-TB medications were adjusted, and a course of low-dose steroids was added. As of this report, the patient was doing well, had stable renal allograft function, and was tolerating anti-TB medications,

Recipient C. The liver recipient, a man aged 59 years. was started on anti-TB treatment 2 months posttransplantation and had no symptoms of TB. Granulomas suggestive of mycobacterial infection were detected from a routine posttransplantation liver biopsy in January 2008, 7 months posttransplantation, while the recipient continued anti-TB treatment. AFB smear was negative, and culture identified Mycobacterium avium complex, a nontuberculous species of mycobacteria. No M. tuberculosis was cultured.

Contact investigations were conducted to evaluate at-risking the hospital workers, close personal contacts, and family members related to the donor and recipients. No transmission of TB infection has been documented through contact investigation. Reported by: V Kohli

, MD, Integris Baptist Medical Center, Oklahoma gadjon City; L Smithee, MS, Oklahoma State Dept of Health. K Ishihara, MD, Univ of Texas Medical Branch at Galveston; L Ostrosky-Zeichner, MD,

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Editorial Board William L. Roper, MD, MPH, Chapel Hill, NC, Chairman

Virginia A. Caine, MD, Indianapolis, IN

David W. Fleming, MD, Seattle, WA
William E. Halperin, MD, DrPH, MPH, Newark, NJ
Margaret A. Hamburg, MD, Washington, DC
King K. Holmes, MD, PhD, Seattle, WA
Deborah Holtzman, PhD, Atlanta, GA

John K. Iglehart, Bethesda, MD
Dennis G. Maki, MD, Madison, WI
Sue Mallonee, MPH, Oklahoma City, OK

Stanley A. Plotkin, MD, Doylestown, PA
Patricia Quinlisk, MD, MPH, Des Moines, IA
Patrick L. Remington, MD, MPH, Madison, WI

Barbara K. Rimer, DrPH, Chapel Hill, NC
John V. Rullan, MD, MPH, San Juan, PR

Anne Schuchat, MD, Atlanta, GA
Dixie E. Snider, MD, MPH, Atlanta, GA

John W. Ward, MD, Atlanta, GA

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Van Buren, MD, J Lappin, MD, Univ of Texas Health Science Center at Houston. T Harrington, MD, Div of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; V Kuehnert, MD, Div of Healthcare Quality Promotion, National Center or Preparedness, Detection, and Control of Infectious Diseases; E Piercefield, MD, DVM, EIS Officer, CDC. Editorial Note: The majority of TB cases among organ ransplant recipients are caused by activation of latent uberculosis infection (LTBI) in the recipient once immunosuppressive medications are started to prevent organ rejection; a minority are attributed to donor transmission. n one international study, 4% of TB infections in recipiints were considered donor derived (2). In this case report, genotyping supported the conclusion that transmission of [B occurred by organ transplantation to two recipients from | common donor. Although organ procurement protocols vere followed, pretransplantation screening did not identify CB in the donor.

In the United States, all potential organ donors are creened to prevent transmission of infectious diseases, ncluding TB, by organ transplantation. Minimum stanlards for donor eligibility are defined by United Network or Organ Sharing (UNOS), a nonprofit, private organizaion under government contract with the Health Resources ind Services Administration to coordinate U.S. transplant ictivities (5). To evaluate eligibility, 1) the donor's medical ecord is reviewed for specific conditions (such as known ictive TB), 2) a medical and social history is conducted with next of kin (or other suitable person familiar with the donor), and 3) selected laboratory testing (such as testing for human immunodeficiency virus, hepatitis, and good organ function) and a chest radiograph are performed. No standard assessment is conducted to determine specifically whether the potential donor is at risk for having previously indiagnosed TB or LTBI. Although the screening process night uncover symptoms or risk factors for TB or LTBI, no urther investigation or diagnostic testing is required. For ill patients who are eligible by UNOS definitions, each OPO devises its own process for donor acceptance. The donor's medical and social history obtained by the OPO is made available for review by transplant center clinicians to independently assess risk for transmission of infection before accepting the organs for transplantation. The completeness and accuracy of this background information is variable, however, because often such information is obtained secondhand by interview of persons familiar with he donor.

Early recognition of posttransplantation TB in the recipient is critical for successful treatment. The incidence of TB among organ recipients is as much as 74 times that

of the general population (2). In addition, 49% of U.S. transplant recipients with TB have disseminated disease, and 38% die (2). Extrapulmonary and disseminated diseases are common, leading to atypical signs that might not be easily recognized as TB if unsuspected by the clinician. In transplant patients, TB should be considered in the differential diagnosis of persistent fever, pneumonia, meningitis, septic arthritis, pyelonephritis, septicemia, graft rejection, or bone marrow suppression. Clinicians should recognize that the presence of an unusual constellation of symptoms, particularly during the first few weeks after transplantation, raises the possibility of donor-transmitted infection or activation of LTBI. Even with a high index of suspicion, TB in an organ recipient can be challenging to diagnose: 75%-80% of organ recipients who developed TB had a false-negative pretransplantation TST (6), and in this immunosuppressed population, symptoms of TB might be attributed to other potential complications, including organ rejection or other infectious diseases.

Diagnosis of TB in an organ recipient, in the absence of clear risk factors or other evidence from pretransplantation screening, should prompt investigation of possible transmission from the donor. Other recipients from a common donor might be at risk and should be evaluated for TB. When transplantation-transmitted TB is suspected, healthcare providers should alert the associated OPO, tissue bank, and public health authorities.

To prevent TB transmission by transplantation, specific policies can be established to improve recognition of disease in donors. In 2004, the American Society of Transplantation developed guidelines to assist in pretransplantation screening of potential organ donors and recipients (6,7). These recommendations are not mandatory standards and, therefore, are not necessarily incorporated into OPO standard operating procedures. OPOs can enhance their pretransplantation screening protocols by incorporating these guidelines to identify risk factors for unrecognized TB in the donor. If risk factors are found, further mycobacterial testing and radiologic assessment is warranted. For risk factor assessment, OPOs should obtain donor history of symptoms consistent with active TB, past diagnosis of TB infection (active or latent), homelessness, excess alcohol or injection-drug use, incarceration, recent exposure to persons with active TB, or travel to areas where TB is endemic. Complete donor medical and social histories should be provided to transplant centers.

Regardless of risk factor assessment, testing for M. tuberculosis (e.g., AFB smear or mycobacterial culture) whenever clinical specimens for routine bacterial testing are obtained from donors can help ensure detection of

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unrecognized TB. In addition, routine retention of samples of donor tissues and serum from organ procurement (or from autopsy) that are suitable for laboratory evaluation can aid subsequent transmission investigations. Genotyping and other relatedness testing of isolates can help establish or rule out transmission links between donor and recipients, as demonstrated in this report. OPOs also should follow up on results of all tests pending at the time of organ donation and notify transplant centers immediately of any results that might have implications for recipients. Because not all disease transmission through transplantation can be prevented, rapid recognition is critical to facilitate appropriate treatment, minimize complications, enhance patient safety, and improve public health.

Acknowledgments This report is based, in part, by contributions by B Baker, MPH, S Pennington, Oklahoma City, P Lindsey, MD, C Harvey, DO, Oklahoma State Dept of Health Tuberculosis Div, S Mallonee, MPH, Oklahoma State Dept of Health, M Spinner, P Eddington, Oklahoma City County Tuberculosis Control Center; M Lambert, Cleveland County Health Dept; C Wallace, PhD, P Cruise, Texas Dept of State Health Sycs, K Finkel, MD, A Wanger, PhD, Univ of Texas Medical School at Houston, M Abramsky, MD, Houston Dept of Health and Human Svcs, S Haidry, MD, Galveston County Health District, B Seaworth, MD, Heartland National Tuberculosis Center, San Antonio; E Desmond, PhD, California Dept of Health Svcs; J Hager, MPH, United Network for Organ Sharing, Richmond, Virginia; D Seem, MPH, Div of Healthcare Quality Promotion, National Center of Preparedness, Detection, and Control of Infectious Diseases, V Tomlinson, MPA, P Moonan, DrPH, Div of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. References 1. Organ Procurement and Transplantation Network. Transplant data

(Database). Richmond, VA: Organ Procurement and Transplantation

Network; 2008. Available at http://www.optn.org/data. 2. Singh N, Paterson DL. Mycobacterium tuberculosis infection in solid

organ transplant recipients: impact and implications for management.

Clin Infect Dis 1998;27:1266–77. 3. Delmonico F. Cadaver donor screening for infectious agents in solid

organ transplantation. Clin Infec Dis 2000;31:781-6. 4. Wilck M, Fishman J. The challenges of infection in transplantation:

donor-derived infections. Curr Opin Organ Transplant 2005;10:301–6. 5. United Network for Organ Sharing. Minimum procurement standards

for an organ procurement organization (OPO). Richmond, VA: United Network for Organ Sharing; 2001. Available at http://www.unos.org/

policiesandbylaws/policies.asp. 6. American Society of Transplantation. Mycobacterium tuberculosis. Am J

Transplant 2004;4(Suppl 10):S37-41. Available at http://www.black

well-synergy.com/toc/ajt/4/s10. 7. American Society of Transplantation. Screening of donor and recipient

prior to solid organ transplantation. Am J Transplant 2004;4 (Suppl 10):S10–20. Available at http://www.blackwell-synergy.com/toc/ ajt/4/s10.

Nonfatal Maltreatment of Infants United States, October 2005-September 2006 During October 2005-September 2006 (federal fisc. year 2006), approximately 905,000 U.S. children were vi tims of maltreatment that was substantiated by state ar. local child protective services (CPS) agencies (1).* Approx mately 19% of child maltreatment fatalities occurred amon: infants (i.e., persons aged <1 year) (1), and homicide stä: tistics suggest that fatality risk might be greatest in the first week of life (2). However, the risk for nonfatal ma treatment among infants has not been examined previous at the national level. To determine the extent of nonfata infant maltreatment in the United States, CDC and th: federal Administration for Children and Families (ACF analyzed data collected in fiscal year 2006 (the mos recent data available) from the National Child Abuse and Neglect Data System (NCANDS). This report summarize the results of that analysis, which indicated that, in fisca year 2006, a total of 91,278 infants aged <l year (rate 23.2 per 1,000 population) experienced nonfatal maltrea:ment, including 29,881 (32.7%) who were aged <1 week Neglect was the maltreatment category cited for 68.5% 0; infants aged sl week, but NCANDS data did not permi further characterization of the nature of this neglect Developing effective measures to prevent maltreatment of infants aged sl week will require more detailed characterization of neglect in this age group.

NCANDS is a national data collection and analysis system created in response to the federal Child Abuse Preven tion and Treatment Act. Data have been collected annually from states and reported since 1993. States submit case level data as child-specific records for each report of allege! child maltreatment for which a completed investigation of assessment by a CPS agency has been made during the reporting period. Individual CPS agencies are responsible for determining the type of maltreatment and outcome of the maltreatment investigation based on state and federa laws. However, no standardized definitions of maltreatment are used consistently by all states; therefore, each state maps its own classification of maltreatment onto NCANDS

*Substantiated maltreatment is defined as maltreatment by a parent or other caregiver deemed to have occurred after thorough investigation by a qualified start member from a CPS agency with jurisdiction over the geographic area in which the maltreatment took place. Additional information is available at http: www.acf.hhs.gov/programs/cb/pubs/cm05/index.htm. + Public Law 93-247 as amended. Additional information is available at http: www2.acf.hhs.gov/programs/cb/laws_policies/cblaws/capta/index.htm.

Vol. 57 / No. 13

MMWR

337

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definitions before sending the final data file to NCANDS. Once a state submits its data to NCANDS, a technical alidation review is conducted by a staff supervised by the ACF Children's Bureau to assess the internal consistency of

he data and to identify probable causes for missing data. states are requested to make corrections as needed.

In fiscal year 2006, 49 states, the District of Columbia, and Puerto Rico provided case-level data to NCANDS. For his report, data from five states (Alaska, Maryland, North Dakota, Pennsylvania, and Vermont) were not available for inalysis. Only data regarding victims with a CPS agency lisposition of substantiated maltreatment issued during iscal year 2006 were analyzed. Among the approximately -3.6 million children aged <18 years who were subjects of naltreatment investigations in fiscal year 2006, maltreatnent was substantiated by CPS agencies in approximately 205,000 (25.1%) children. Substantiated maltreatment data were analyzed for victims aged <1 year by the age

of he infant victim at the time of first report, sex, racel ethnicity, type of maltreatment, and source of the report.

A total of 91,278 unique victims of substantiated malcreatment were identified in CPS agency dispositions in iscal year 2006 among infants aged <l year, an annual rate of 23.2 per 1,000 population. A total of 47,117 51.6%) victims were male. By race/ethnicity, 39,768 43.6%) infant victims were white; 23,008 (25.2%) were black or African American; 17,582 (19.3%) were Hispanic; 1,141 (1.3%) were American Indian or Alaska Native; and 583 (0.6%) were Asian. Multiple racelethnicity was identified for 2,874 (3.1%) of the infant victims, and 6,322 (6.9%) were of unknown race/ethnicity.

Among the 91,278 infant victims of substantiated maltreatment, 35,455 (38.8%) were aged <1 month (Figure 1). Of these, 29,881 (84.3%) were aged <1 week (Figure 2). Among maltreated infants aged <l week, 20,472 (68.5%) were categorized as victims of neglect (including deprivation of necessities or medical neglect), and 3,957 (13.2%) as victims of physical abuse (Table).

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Categories of maltreatment in NCANDS are as follows: physical abuse, neglect or deprivation of necessities, medical neglect, sexual abuse, psychological or emotional maltreatment, other, and unknown. For this report, neglect or deprivation of necessities and medical neglect were combined into one category; other and unknown maltreatments also were combined into one category. Examples of neglect under the NCANDS categories include educational neglect, abandonment, fetal alcohol syndrome, and congenital drug exposure or addiction. Since 2003, NCANDS has used a method for compiling racial/ethnic data based on the 1997 revised Office of Management and Budget standards for race and ethnicity, which include the following racial categories: white, black or African American, Asian, American Indian or Alaska Native, and Native Hawaiian or Other Pacific Islander. In NCANDS, persons categorized as Hispanic or Latino are not categorized by race.

Among the 29,881 infant victims aged sl week, 25,964 (86.9%) victims were reported to CPS agencies by professionals, including 19,486 (65.2%) by medical personnel and 5,542 (18.5%) by social services personnel (Table). Medical personnel also reported the greatest percentage (21,545 [60.8%]) of victims aged sl month. Of infant victims aged <l year, 29,462 (32.3%) were reported by medical personnel, followed by law enforcement personnel

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