在调查由组织衍生的结核病爆发的过程中,不完全的组织产品追踪
Kristen E Marshall1, Rebecca J Free2, Thomas D Filardo3
1Colorado Department of Public Health and Environment, Denver, Colorado, USA; Division of State and Local Readiness, Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
概括
与受污染的骨移植相关的结核病爆发突显了美国人体组织追踪的关键缺陷. 改善可追溯性对于患者安全和公共卫生响应至关重要.
科学领域:
- 公共卫生 公共卫生
- 传染病流行病学 传染病流行病学
- 生物医学科学 生物医学科学
背景情况:
- 全国范围内的结核病爆发与受污染的骨移植 (Lot A) 有关.
- 科罗拉多州的一家医院的第三名患者从不同的骨移植项目 (B项目) 患上了结核病,这促使进一步调查.
- 美国现有的系统缺乏对捐赠人体组织的全面跟踪,以提供给个别接受者.
研究的目的:
- 调查一种新发现的结核病感染的来源,可能与另一种骨科全移植批次 (B批次) 相关.
- 识别人类组织可追溯系统的漏洞,从制造到患者植入.
- 强调需要加强组织跟踪,以确保患者安全并促进公共卫生响应.
主要方法:
- 研究的潜在原因包括供体感染,制造污染,医疗机构的产品切换,人与人之间的传播和实验室错误.
- 审查了骨科全移植批次的医疗记录和组织可追溯性数据.
- 对Mycobacterium结核病分离物进行了流行病学和遗传学分析.
主要成果:
- 在医疗机构中发现了组织可追溯性的差距,这表明在护理地点更换产品的可能性.
- 尽管制定了追踪政策,但在155个B批单位中,有6个 (3.9%) 无法追踪到最终处置.
- 基因分析证实,第三名患者的结核分离物与A批疫情菌株相同,尽管接受了B批组织.
结论:
- 调查显示,即使在现有的追踪政策下,人类组织可追溯性存在严重缺陷.
- 增强的组织追踪系统对于确保从供体到受体的持续追踪至关重要.
- 改善可追溯性对于及时调查不良事件和有效的公共卫生干预来预防疾病传播和死亡率至关重要.
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