02181nas a2200253   4500008003900000245010400039210006900143260000800212490002600220520143900246100001701685700001301702700001601715700001701731700002501748700001601773700001501789700001901804700001501823700001601838700000501854700001901859856004901878       2023                          d00aIncomplete tissue product tracing during an investigation of a tissue-derived tuberculosis outbreak0 aIncomplete tissue product tracing during an investigation of a t  cSep0 vS1600-6135(23)00693-73 aIn 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.1 aMarshall, KE1 aFree, RJ1 aFilardo, TD1 aSchwartz, NG1 aHernandez-Romieu, AC1 aThacker, TC1 aLehman, KA1 aAnnambhotla, P1 aDupree, PB1 aGlowicz, JB1 a1 aBasavaraju, SV  uhttps://www.notifylibrary.org/reference/5042