Posttransfusion hepatitis after open-heart operations. Incidence after the administration of blood from commercial and volunteer donor populations

Faecal microbiota transplantation: A life-saving therapy challenged by commercial claims for exclusivity

Faecal microbiota transplantation (FMT) is an innovative treatment which is challenged by a regulatory struggle in Europe. A recent publication in EClinicalMedicine describes the successful adaptation of FMT to a National drug legislation, but this approach fails to take into account the donor-related aspects. The European tissue and cells directive and affiliated technical guide provide extensive safety and quality standards which may readily be adopted in an FMT service to provide patients with this life-saving treatment embedded in a public blood centre.

Blood transfusion safety in the country of Georgia: collateral benefit from a national hepatitis C elimination program

BACKGROUND

In April 2015, the government of Georgia (country) initiated the world's first national hepatitis C elimination program. An analysis of blood donor infectious screening data was conducted to inform a strategic plan to advance blood transfusion safety in Georgia.

STUDY DESIGN AND METHODS

Descriptive analysis of blood donation records (2015-2017) was performed to elucidate differences in demographics, donor type, remuneration status, and seroprevalence for infectious markers (hepatitis C virus antibody [anti-HCV], human immunodeficiency virus [HIV], hepatitis B virus surface antigen [HBsAg], and Treponema pallidum). For regression analysis, final models included all variables associated with the outcome in bivariate analysis (chi-square) with a p value of less than 0.05.

RESULTS

During 2015 to 2017, there were 251,428 donations in Georgia, representing 112,093 unique donors; 68.5% were from male donors, and 51.2% of donors were paid or replacement (friends or family of intended recipient). The overall seroprevalence significantly declined from 2015 to 2017 for anti-HCV (2.3%-1.4%), HBsAg (1.5%-1.1%), and T. pallidum (1.1%-0.7%) [p < 0.0001]; the decline was not significant for HIV (0.2%-0.1%). Only 41.0% of anti-HCV seropositive donors underwent additional testing to confirm viremia. Infectious marker seroprevalence varied by age, sex, and geography. In multivariable analysis, first-time and paid donor status were associated with seropositivity for all four infectious markers.

CONCLUSION

A decline during the study period in infectious markers suggests improvement in blood safety in Georgia. Areas that need further improvement are donor recruitment, standardization of screening and diagnostic follow-up, quality assurance, and posttransfusion surveillance.

Transfusion-Transmitted Infections: an Update on Product Screening, Diagnostic Techniques, and the Path Ahead

The mandated testing of blood components for infectious diseases, to prevent transfusion-transmitted infections (TTIs), began in the 1950s. Since then, changes in predonation questionnaires and advances in testing techniques have afforded more sensitive and specific tests for pathogens, in addition to allowing earlier detection. Given that these approaches have very low but detectable failure rates, the recent development and implementation of proactive pathogen reduction approaches is the new forefront of TTI prevention strategies. With globalization and the ability of pathogens to evolve rapidly, continuous redefining of testing standards and laboratory techniques is paramount for maintaining a safe blood supply.

Role of Serologic and Molecular Diagnostic Assays in Identification and Management of Hepatitis C Virus Infection

The drugs available for the treatment of hepatitis C virus (HCV) have evolved to provide shorter treatment duration and higher rates of sustained virologic response (SVR), and the role of HCV infection diagnostic tests has had to evolve in order to meet changing clinical needs. This review gives an overview on the role of HCV infection diagnostic testing (molecular and serological tools) used in the diagnosis and management of HCV infection. All of this critical information guides physician decisions to optimize patient clinical outcomes. Also discussed is the future direction of diagnostic testing in the context of further advances in drug development.

Transfusion-associated hepatitis before the screening of blood for hepatitis risk factors

BACKGROUND

The true incidence of transfusion-associated hepatitis (TAH) before blood screening is unknown. Our aims were to reevaluate blood recipients receiving unscreened blood and analyze hepatitis viruses circulating more than 45 years ago.

STUDY DESIGN AND METHODS

Cryopreserved serum samples from 66 patients undergoing open heart surgery in the 1960s were reevaluated with modern diagnostic tests to determine the incidence of TAH and its virologic causes.

RESULTS

In this heavily transfused population receiving a mean of 20 units per patient of predominantly paid-donor blood, 30 of 66 (45%) developed biochemical evidence of hepatitis; of these, 20 (67%) were infected with hepatitis C virus (HCV) alone, four (13%) with hepatitis B virus (HBV) alone, and six (20%) with both viruses. Among the 36 patients who did not develop hepatitis, four (11%) were newly infected with HCV alone, nine (25%) with HBV alone, and one (3%) with both viruses. Overall, 100% of patients with hepatitis and 39% of those without hepatitis were infected with HBV and/or HCV; one patient was also infected with hepatitis E virus. The donor carrier rate for HBV and/or HCV was estimated to be more than 6%; contemporaneously prepared pooled normal human plasma was also contaminated with multiple hepatitis viruses.

CONCLUSION

TAH virus infections were a larger problem than perceived 50 years ago and HCV was the predominant agent transmitted. All hepatitis cases could be attributed to HCV and/or HBV and hence there was no evidence to suggest that an additional hepatitis agent existed undetected in the blood supply.

Transfusion transmission of HCV, a long but successful road map to safety

Improved blood banking practices and the development and implementation of increasingly sensitive serological and nucleic acid amplification technology assays for screening donors for HCV over the past few decades have helped minimize the residual risk from transfusion transmitted HCV in the developed world. Furthermore, studies of transfusion transmitted infections and of donors identified as infected by routine screening have provided significant insights into HCV transmission, epidemiology and pathogenesis. However, transfusion transmission of HCV is still a significant route of infection in the developing world. Key preventive mechanisms to ensure safe blood include elimination of paid donors and development of national donor pools comprising volunteer repeat blood donors, combined with implementation of standardized and maximally sensitive screening assays for HCV. There is also a need to develop up-to-date data on HCV disease burden on a global scale, in part, derived from systematic screening of donors for HCV infection. We suggest the creation of blood donor databases and specimen repositories, both at national and international levels, to facilitate epidemiological surveillance and pathogenesis and treatment studies in the future.

The hazards of blood transfusion in historical perspective

The beginning of the modern era of blood transfusion coincided with World War II and the resultant need for massive blood replacement. Soon thereafter, the hazards of transfusion, particularly hepatitis and hemolytic transfusion reactions, became increasingly evident. The past half century has seen the near eradication of transfusion-associated hepatitis as well as the emergence of multiple new pathogens, most notably HIV. Specific donor screening assays and other interventions have minimized, but not eliminated, infectious disease transmission. Other transfusion hazards persist, including human error resulting in the inadvertent transfusion of incompatible blood, acute and delayed transfusion reactions, transfusion-related acute lung injury (TRALI), transfusion-associated graft-versus-host disease (TA-GVHD), and transfusion-induced immunomodulation. These infectious and noninfectious hazards are reviewed briefly in the context of their historical evolution.

The AIDS epidemic and commercial plasmapheresis

In 1986 an epidemic of HIV infection among paid plasma donors was identified in Mexico; paid donors were iatrogenically infected in a plasmapheresis center. These paid donors sold both plasma and blood: they provided one-third of blood consumed in 1986. This led to infection of blood recipients, mainly women of childbearing age. Blood transfusion is the leading cause of AIDS in women in Mexico. The male:female ratio decreased from 30:1 in 1986 to 5:1 1990; that coincided with the increase of transfusion-associated AIDS cases. Mexico prohibited the blood trade in 1987, ending the epidemic in paid donors and recipients. latrogenic infection of paid donors in plasmapheresis facilities could help to explain the explosive AIDS epidemic in central Africa and Haiti in the 1980s. There is a temporal and geographical coincidence in the early eighties between that AIDS epidemic, high numbers of hepatitis B asymptomatic carriers and an increased production of serum inactivated hepatitis B vaccine. Plasmapheresis facilities in these developing countries may have taken advantage of the high prevalence of hepatitis B asymptomatic carriers in their populations to obtain plasma for exportation through brokers to developed countries where the vaccine and other plasma products were manufactured. This hypothesis is relevant to establishing preventive policies and warrants further investigation.

Transfusion-associated hepatitis B: past and present

Thus, it can be concluded that: (1) Hepatitis B, even before the introduction of donor screening for HBsAg, probably never accounted for more than one-quarter of all cases of transfusion-associated hepatitis. (2) As of 1988, the frequency of this viral infection in blood recipients, now that sensitive donor screening for HBsAg is routine, is less than 10%. The exception are multiply transfused populations, such as hemophiliacs, the majority of whom have evidence of current or past exposure to hepatitis B. However, new inactivation procedures are likely to reduce the attack rate in virgin populations of hemophiliacs. (3) Interdiction of paid blood has proved far more effective than donor screening for HBsAg in reducing the overall frequency of transfusion-associated hepatitis. (4) The current requirement that all donors be screened for anti-HBc and ALT as surrogate markers of non-A, non-B hepatitis infection, and for anti-HIV, is likely to reduce the hepatitis B attack rate even more, perhaps to near zero. (5) The long-term outcome of transfusion-associated hepatitis B has not been determined, a task that will remain difficult to accomplish because of the paucity of current cases. Information in this regard will need to be derived from the recall and reevaluation of pedigreed patients who participated in prospective studies that were conducted in the distant past.

Review of hepatitis non-A, non-B: the potential hazards in dental care

Several of the common viral agents that can cause hepatitis have been detected in body fluids, including saliva and blood, which may both form important routes for transmission of disease. The viruses most commonly implicated include hepatitis A virus (HAV), hepatitis B virus (HBV), cytomegalovirus (CMV), and Epstein-Barr virus. Hepatitis delta virus (HDV) can be found in persons positive for hepatitis B surface antigen (HBsAg) and presumably follows the same routes of transmission as HBV. Herpes simplex and echo viruses can cause hepatitis on rare occasion. Other agents, not yet positively identified but collectively referred to as non-A, non-B are also believed to follow the same routes as HBV and/or HAV. The aim of this reviews is twofold. First, we will discuss hepatotropic viruses other than HBV that may be spread via saliva and blood and, therefore, should be considered along with HBV as a potential health hazard to dental personnel and also to dental patients. The second aim is to highlight the epidemiology and the risk of transmission of these viral infections. The potential hazards are discussed in relation to those associated with HBV and human immunodeficiency viruses (HIV), implicated in the acquired immunodeficiency syndrome (AIDS).

Diseases transmitted by blood transfusion

Except for post-transfusion hepatitis (PTH), the transmission of disease by blood transfusion appears to be very limited. There are only a few case reports documenting the transmission of malaria and other parasitic diseases, syphilis, or bacterial infections. The ability to eradicate PTH will depend on the development of sensitive-specific tests for the non-A, non-B agent(s). In the interim, two important steps that might be taken to reduce the incidence of PTH are the careful recruitment of blood donors and, most important, the judicious use of blood and its components.

Hepatitis after the transfusion of frozen red cells and washed red cells

The large-scale use of frozen red cells and washed red cells in this transfusion service has not been effective in reducing post-transfusion hepatitis. Seventy-eight per cent of 31,125 transfusions, excluding platelets and plasma, were given in the form of frozen or washed red cells. These transfusions were associated with 56 cases of hepatitis. In 37 cases, the recipients had received only frozen or washed red cells (or both). Post-transfusion hepatitis was of the non-A, non-B type in 95% of cases. On average, commercial blood accounted for 30 per cent of the donor base during the first four years and was involved in 44 of the 56 cases. Elimination of commercial blood from the donor base resulted in a decrease in the incidence of hepatitis from 2.1 to 0.3 per 1000 transfusions.

[Prospective study in posttransfusion hepatitis in patients with open heart surgery (author's transl)]

In a prospective study in posttransfusion hepatitis 54 patients with open heart surgery received 220 blood units which were negative for HBS Ag by radioimmunoassay. 15 of these units contained anti-HBS and were given to 13 antibody negative patients. In a half year follow up period neither clinical nor biochemical (SGOT, SGPT, gamma-GT) signs of hepatitis could be found in these patients and neither HBS Ag nor anti-HBS developed. At the same time a screening for HBS Ag of hospital staff in contact with these patients revealed no carrier of the antigen. Therefore, the lack of any hepatitis in our relatively small study group may be attributable to two facts: the relative safety of blood screened by highly sensitive methods for the detection of HBS Ag and the noninfectious environment of these patients in the hospital during the observation period.

Transfusion-associated hepatitis not due to viral hepatitis type A or B

Twenty-two patients who had an episode of transfusion-associated hepatitis not positive for hepatitis B antigen were examined for development of antibody to heaptitis A and B antigens, cytomegalovirus and Epstein-Barr virus. Antibody response to the 27-nm virus-like hepatitis A antigen was measured by immune electron microscopy. In none of the 22 patients studied did serologic evidence of infection with hepatitis A virus develop during the study period. Nine of the 22 patients had antibody responses to cytomegalovirus, but it was difficult to relate these seroconversions to their hepatitis. In addition, all 22 patients had pre-existing antibody to the Epstein-Barr virus. It seems likely that at least a proportion of such antigen-negative transfusion-associated hepatitis is caused by other infectious agents, not yet identified.

Can the blood-transmitted hepatitis problem be solved?

Of the approaches presently available for prevention of blood-transmitted hepatitis, most clearly effective is the avoidance of high-risk donor populations, such as most paid commercial donors. It should be emphasized that even after screening for hepatitis B antigen most paid donor blood carries with it a five-ten times higher risk of transmitting hepatitis than volunteer donor blood. Hepatitis B screening is certainly the next most useful approach. However, it has been pointed out that even with the most sensitive of current assays, as much as two-thirds of infective blood may not be eliminated. In part this is due to failure to detect hepatitis B antige, which may be detectable by such currently investigational approaches as selective antibody inhibition or testing for Core antibody. However, a major factor is the inability of hepatitis B screening to eliminate all infectious blood appears to be due to the existence of viruses other than hepatitis B that play a major role in blood-transmitted hepatitis. Tests for detection of carriers of this virus, or viruses, remain to be developed. Improved reporting of hepatitis cases with investigation and registration of implicated donors may provide an additional means for reducing the incidence of hepatitis transmission. The efficiency of additonal approaches, such as transaminase screening of donors and passive or active immunization, remains to be determined.

Serum hepatitis after open-heart surgery

Ten cases of serum hepatitis occurring after open-heart surgery at the National Heart Hospital, London are reported. The incidence seemed to be rising and was at least 2% before antigen-screened blood became available. Investigation of 135 patients for the presence of Australia antigen and antibody showed that five (3·7%) had responses to exposure to the infective agent. All were and remained clinically well, but such patients may constitute a source of infection. Since tested blood has been used no hepatitis cases have been recognized.