@article {5042,
	title = {Incomplete tissue product tracing during an investigation of a tissue-derived tuberculosis outbreak},
	volume = {S1600-6135(23)00693-7},
	year = {2023},
	month = {Sep},
	abstract = {In the United States, there is currently no system to track donated human tissue products to individual recipients. This posed a challenge during an investigation of a nationwide tuberculosis outbreak that occurred when bone allograft contaminated with Mycobacterium tuberculosis (Lot A) was implanted into 113 patients in 18 US states, including 2 patients at 1 health care facility in Colorado. A third patient at the same facility developed spinal tuberculosis with an isolate genetically identical to the Lot A outbreak strain. However, health care records indicated this patient had received bone allograft from a different donor (Lot B). We investigated the source of this newly identified infection, including the possibilities of Lot B donor infection, product switch or contamination during manufacturing, product switch at the health care facility, person-to-person transmission, and laboratory error. The findings included gaps in tissue traceability at the health care facility, creating the possibility for a product switch at the point of care despite detailed tissue-tracking policies. Nationally, 6 (3.9\%) of 155 Lot B units could not be traced to final disposition. This investigation highlights the critical need to improve tissue-tracking systems to ensure unbroken traceability, facilitating investigations of recipient adverse events and enabling timely public health responses to prevent morbidity and mortality.},
	doi = {10.1016/j.ajt.2023.09.005},
	author = {Marshall, KE and Free, RJ and Filardo, TD and Schwartz, NG and Hernandez-Romieu, AC and Thacker, TC and Lehman, KA and Annambhotla, P and Dupree, PB and Glowicz, JB and Scarpita, AM, Brubaker, SA, Czaja, CA and Basavaraju, SV}
}
