title: Transmission of hepatitis B virus among heart transplant recipients during endomyocardial biopsy procedures.
abstract: BACKGROUND
  The unexpected conversion to HBsAg seropositivity of three cardiac allograft recipients prompted us to conduct a multidisciplinary study to identify the source, transmission mode, and extent of the hepatitis B virus (HBV) infection among the 256 cardiac allograft recipients of our hospital.
  
  
  METHODS
  All recipients were retrospectively screened for serum markers of HBV infection. A selected genomic region defining subtypes of the viruses involved was amplified and sequenced. An epidemiologic case-control study for possible risk factors was conducted to identify the mode of transmission.
  
  
  RESULTS
  Eighteen additional HBV-infected patients were identified, none of whom had shown symptoms of HBV infection. The involvement of one virus (subtype ayw 3) was shown in 20 of the 21 HBV-infected patients. This virus is found in less than 10% of HBV-infected individuals in The Netherlands. The demonstration of a common source of infection, combined with results of the epidemiologic study, identified posttransplantation endomyocardial biopsy procedures as the most likely mode of transmission. However, we also found evidence of secondary virus transmission by cardiac catheterization procedures to nonallograft recipients.
  
  
  CONCLUSIONS
  The immunosuppressive therapy practiced in these patients to prevent allograft rejection may have not only facilitated virus transmission by causing high levels of viremia but also left the spreading of HBV undetected by causing a subclinical course of the infection. These findings stress the necessity of strict hygienic precautions during intravascular diagnostic procedures and indicate that vaccination against and routine monitoring for certain bloodborne infections in cardiac allograft recipients should be considered.
authors.affiliation: Department of Virology, University Hospital Rotterdam, The Netherlands.
authors.forename: A D
authors.initials: AD
authors.lastname: Osterhaus
authors.forename: M C
authors.initials: MC
authors.lastname: Vos
authors.forename: A H
authors.initials: AH
authors.lastname: Balk
authors.forename: R A
authors.initials: RA
authors.lastname: de Man
authors.forename: J W
authors.initials: JW
authors.lastname: Mouton
authors.forename: P H
authors.initials: PH
authors.lastname: Rothbarth
authors.forename: S W
authors.initials: SW
authors.lastname: Schalm
authors.forename: A M
authors.initials: AM
authors.lastname: Tomaello
authors.forename: H G
authors.initials: HG
authors.lastname: Niesters
authors.forename: H A
authors.initials: HA
authors.lastname: Verbrugh
mesh_terms: D000328:Adult; D000368:Aged; D001706:Biopsy / Q000009:adverse effects*; D006328:Cardiac Catheterization / Q000009:adverse effects; D016022:Case-Control Studies; D003428:Cross Infection / Q000453:epidemiology / Q000635:transmission* / Q000821:virology; D004797:Enzyme-Linked Immunosorbent Assay; D004812:Epidemiologic Methods; D005260:Female; D016027:Heart Transplantation / Q000009:adverse effects*; D006509:Hepatitis B / Q000453:epidemiology / Q000635:transmission*; D006510:Hepatitis B Antibodies / Q000097:blood; D006514:Hepatitis B Surface Antigens / Q000097:blood / Q000276:immunology; D006515:Hepatitis B virus / Q000145:classification / Q000235:genetics; D006801:Humans; D008297:Male; D008875:Middle Aged; D009206:Myocardium / Q000473:pathology; D012189:Retrospective Studies; D017422:Sequence Analysis, DNA
chemical_list: D006510:Hepatitis B Antibodies; D006514:Hepatitis B Surface Antigens