How might the unprecedented rabies transmission chain—from a skunk bite to a transplant recipient—reshape public‑health surveillance, organ‑donation screening, and zoonotic‑disease policy in the United States?
The unprecedented case of rabies transmission from a bat-infected skunk to a human organ donor—and subsequently to a kidney transplant recipient—has catalyzed wide-ranging reassessment of US public health, organ-donation screening practices, and zoonotic-disease policy.
This fourth documented US event of transplant-transmitted rabies, involving a three-stage vector chain (bat→skunk→human→human), has directly exposed critical vulnerabilities in the detection and mitigation of zoonotic infectious threats within the US organ transplantation system. The highly illustrative breakdown: while the skunk scratch was noted in screening, the lack of mandatory protocols for rabies risk stratification, CDC consultation, or rapid diagnostic testing permitted organ recovery and transplant before suspicion arose—culminating in recipient fatality. This “sentinel” case is driving immediate proposals for amended screening policy, surveillance improvements, and risk communication strategies, especially as cross-species transmission of bat rabies variants into terrestrial mammals is increasingly recognizedHuman-to-Human Rabies Transmission via Solid Organ ...cdc +2.
Spillover Complexity: The detection of silver-haired bat rabies virus variant in a donor infected by a skunk highlights that wildlife rabies risk is not limited to known primary reservoirs. In Idaho, for example, skunks are not native rabies reservoirs, but bat variants are enzootic, and skunks serve as spillover hostsMorbidity and Mortality Weekly Reportcdc +1. Surveillance systems must now account for cases where traditional “low-risk” species acquire rabies from bats, broadening the definition of “risky animal contact” for both public health and transplantation purposesRabies surveillance in the United States during 2006 inavma +1.
Data-driven Expansion: Approximately 800 cross-species (spillover) rabies infections were reported in the US in 2022, underscoring the need for enhanced molecular surveillance, host mapping, and genetic tracing to rapidly identify emerging spillover risks that might alter risk protocols or regional risk mapsMorbidity and Mortality Weekly Reportcdc +1.
Failure Identified: In this case, the deceased donor’s skunk scratch and behavioral symptoms were documented in the Uniform Donor Risk Assessment Interview (UDRAI), but went unflagged due to lack of actionable guidelines—demonstrating a critical gap between reporting and interventionHuman-to-Human Rabies Transmission via Solid Organ ...cdc +1. The current UDRAI structure makes it difficult to systematically identify or query risk factors such as animal bites or scratches, especially if not directly linked to classical “high-risk” speciesOPTN Data Advisory Committee Meeting Summaryhrsa .
Proposed Policy Overhauls: In response, concrete proposals are under review for OPTN/DTAC (Organ Procurement and Transplantation Network / Disease Transmission Advisory Committee) policy and form updates:
Universal Data Collection Improvement: Add new fields to both DonorNet® and Living Donor Risk (LDR) forms to capture explicit rabies risk factors: direct bat contact in last 12 months, any wild mammal (including skunk, raccoon, fox, mongoose) bite or scratch in US in last 12 months, and any wild/domestic mammal contact outside US. These revisions will allow system-wide querying and risk stratification, with the aim of ensuring such exposures always trigger risk reviewsOPTN Ad Hoc Disease Transmission Advisory Committee ...hrsa +1.
Risk-triggered CDC Consultation: If any risk criterion is met (e.g., bite or scratch by a high-risk animal), mandatory consultation with local/state health departments or the CDC is triggered before organ procurement. CDC consultation may recommend further testing or post-exposure prophylaxis (PEP) for recipients, and data must be documented in the recipient medical recordOPTN Ad Hoc Disease Transmission Advisory Committee ...hrsa +1.
Living Donor Extension: Parallel donor screening requirements (animal exposure) and CDC consultation protocols will now apply to living donorsOPTN Ad Hoc Disease Transmission Advisory Committee ...hrsa .
Risk Disclosure: New mandatory risk disclosure to intended recipients, with specific documentation, when a donor with potential rabies risk is identifiedOPTN Ad Hoc Disease Transmission Advisory Committee ...hrsa .
No Routine Laboratory Rabies Testing Yet: Routine rapid testing for rabies in all potential donors is not currently being considered due to methodological and logistic limits. Instead, protocols focus on risk factor identification and responsive laboratory workupsHuman-to-Human Rabies Transmission via Solid Organ Transplantation from a Donor with Undiagnosed Rabies — United States, October 2024–February 2025 | MMWRcdc +2.
Encephalopathy and Neurologic Symptom Exclusion: New or unexplained neurological symptoms in a potential donor (especially when fever or exposure history is present) increasingly warrant infectious causes, including rabies, to be considered and may represent a “hard stop” for procurement, especially for viral pathogens without treatment optionsGuidance for Recognizing Central Nervous System Infections ...hrsa .
Revised High-risk Exposures List: The “short list” of high-risk exposures for policy action now reflects the complexities of viral spillover chains. Criteria include not only classic bat bites, but all wild mammal and unprovoked domestic mammal bites/scratches, occupational contact with wildlife, and any incomplete medical/social history. Regional and behavioral risk (e.g., aggression, daytime activity in nocturnal species) is also under review8.21.2025 OPTN Organ Procurement Organization Committee ...hrsa +1.
Universal Standardization Push: Proposals would standardize, at the national OPTN level, what triggers rabies risk conversations and organ-use decision-making, ending the current “interpretation gap” whereby factual reporting of exposure is not followed by a uniform response1 . OPTN Operations and Safety Committee Meeting Summary February 27, 2025hrsa .
Integration of CDC Tools: Proposals favor making CDC risk estimation tools accessible through Donor Data and Matching Systems, potentially automating step-up alerts for flagged risk factors8.21.2025 OPTN Organ Procurement Organization Committee ...hrsa .
Antemortem Molecular Diagnostics: While molecular techniques (RT-PCR) for rabies diagnosis from saliva, CSF, or tissue are available and have been validated for antemortem testing, their less-than-perfect sensitivity (especially in paralytic rabies) and need for repeat sampling, plus the post-mortem time-critical organ allocation window, limit their routine applicability. They may still be deployed in “flagged” risk donor cases, and there is a call for further validation of rapid molecular and serologic assays for inclusion in time-pressured donor workflowsHuman-to-Human Rabies Transmission via Solid Organ Transplantation from a Donor with Undiagnosed Rabies — United States, October 2024–February 2025 | MMWRcdc +2.
Policy Trajectory: The OPTN/CDC pathway is “risk-factor screening first, then targeted lab testing and public health consultation”—not blanket universal testing, which would risk discarding viable organs for a vanishingly rare diseaseOPTN Ad Hoc Disease Transmission Advisory Committee ...unos +1.
Since 1978, only four US donors (including the current skunk chain) have transmitted rabies to 13 organ/tissue recipients, of whom seven have died and six survived after PEPMorbidity and Mortality Weekly Reportcdc +1.
Annually, about 1.4 million Americans receive care for possible rabies exposure; fewer than 10 die per year due to effective prevention effortsKidney transplant recipient dies of rabies after donor scratched by skunk: CDC | Fox Newsfoxnews .
Routine donor screening includes HIV, hepatitis B/C, and syphilis, but not rabies, due to time-to-result and extraordinarily low riskHuman-to-Human Rabies Transmission via Solid Organ Transplantation from a Donor with Undiagnosed Rabies — United States, October 2024–February 2025 | MMWRcdc +1.
Bat maintenance of rabies virus variants—and their spillover to “low reservoir” species like skunks—makes animal exposure histories (including scratches, not only bites) newly critical. Approximately 800 spillover cases into non-reservoir hosts occur annually; CDC will now monitor these trends more closely to refine local and national guidanceMorbidity and Mortality Weekly Reportcdc .
The US is now reshaping its organ donor screening and zoonotic-disease policy in direct response to this case:
This rare event is accelerating a nationwide shift toward a risk-stratification, data-centric model for managing rare but deadly zoonoses in transplantation—balancing the lifesaving potential of organ donation against new, evolving biosecurity risks in an era of increasing wildlife spillover.Human-to-Human Rabies Transmission via Solid Organ Transplantation from a Donor with Undiagnosed Rabies — United States, October 2024–February 2025 | MMWRcdc +2