Prevalence, incidence, and residual risk of human immunodeficiency virus and hepatitis C virus infections among United States blood donors since the introduction of nucleic acid testing

Cutibacterium acnes contamination does not enhance the proinflammatory profile of platelet concentrates

BACKGROUND

Cutibacterium acnes, a common anaerobic platelet concentrate (PC) contaminant, has been associated with rare mild adverse transfusion reactions and is often considered a harmless commensal. Notably, C. acnes can cause chronic infections and has been shown to induce the release of proinflammatory cytokines by immune cells. Since elevated concentrations of proinflammatory factors in PCs have been linked to noninfectious adverse reactions, this study aimed to assess whether C. acnes could elicit the release and accumulation of proinflammatory factors during PC storage, thereby enhancing the risk of such reactions.

STUDY DESIGN/METHODS

Four ABO-matched buffy coat PCs were pooled and split into six units, each were inoculated with either saline (negative control), a Staphylococcus aureus isolate (positive control, 30 colony forming units [CFU]/unit), or four C. acnes PC isolates (10 CFU/mL) and stored at 20-24°C with agitation. Bacterial counts, platelet activation, and concentration of proinflammatory factors were assessed on days 0, 3, and 5. N = 3.

RESULTS

C. acnes counts remained stable, while S. aureus proliferated reaching 108CFU/mL by the end of PC storage. By day 5, no significant differences in platelet activation or proinflammatory cytokine profiles were observed in C. acnes-contaminated PCs compared to the negative control (p > .05), while there was a significant increase (p ≤ .05) in sCD40L concentration (day 3), and platelet activation and IL-8 concentration (day 5) in S. aureus-contaminated units.

DISCUSSION

C. acnes contamination does not promote the accumulation of proinflammatory factors in the absence of proliferation during storage and may not enhance the risk of inflammatory reactions when transfused to patients.

Redefining Blood Donation-Path to Inclusivity and Safety

This Viewpoint reviews the vicissitudes of establishing fair and equitable blood donation policies based on research and improved serological testing and promotes expanding the pool of potential donors.

Donated Blood Screening for HIV, HCV and HBV by ID-NAT and the Residual Risk of Iatrogenic Transmission in a Tertiary Care Hospital Blood Bank in Puebla, Mexico

Hepatitis C virus (HCV), human immunodeficiency virus (HIV) and hepatitis B virus (HBV) can be transmitted by blood transfusion. Most transmission occurs during the acute viremic phase (AVP), before antibody development. To reduce transmission risk, individual donor nucleic acid testing (ID-NAT) is used. In Puebla, Mexico, serological tests and ID-NAT have been applied to screen blood donors and detect individuals in AVP. In the present study, 106,125 blood donors' data in two periods (2012-2015 and 2017-2019) were analyzed. The residual risk (RR) values were calculated considering ID-NAT results. The RR for HIV was 14 in 1 million donations or 1 in 71,428, the RR for HVC was 6.8 in 1 million donations or 1 in 147,058 and, for HBV, it was 156 in 1 million donations, or 1 in 6410. Previously, it was predicted that the transmission RR of these viruses would be reduced in Mexico through better screening with NAT. The use of ID-NAT has, indeed, increased the safety of blood reserves for HIV and HCV. However, more research is needed to determine why the residual risk of HBV did not decrease as much over the study period. ID-NAT is an important complementary tool for blood donor screening that should be implemented.

Newly diagnosed hepatitis C infection after pancreas transplantation with multiple treatment failures

This case represents the first report of a detected hepatitis C virus (HCV) infection following a pancreas transplantation that failed two different sofosbuvir (SOF)-based treatments. We present the case of a woman in her 30s with a history of kidney transplantation, who developed viremic symptoms 3 months after pancreas transplantation and with two subsequent negative HCV antibody tests. Further work-up revealed a positive HCV RNA test (genotype 1A, treatment naive). Two different direct-acting antiviral agents regimes with SOF failed in our case, and the patient achieved a sustained virological response with a 16-week course of glecaprevir/pibrentasvir.

Comparison of Two Different Serological Viral Marker Testing Assays for Screening of Apheresis Donors: Which Assay Provides Optimum Safety for Transfusion?

While whole blood testing has evolved over the years, viral marker testing for plateletpheresis donors is still performed by Rapid Diagnostic Tests (RDT). Aim of this study was to compare diagnostic accuracy of RDT and Chemiluminescence Immunoassay (CLIA) in serological testing for HBsAg, anti-HCV and anti-HIV antibodies. A prospective, analytical study was conducted in the department of Transfusion Medicine at a tertiary healthcare center in India between September 2016 and August 2018. Samples were simultaneously tested by CLIA, RDT and a confirmatory test. Sensitivity, specificity, negative and positive predictive values and mean time taken to report results were calculated. A total of 102 (1.48%) of the 6883 samples were found to be reactive by either or both the assays. A total of 74 (1.08%) samples were HBsAg reactive, 23 (0.33%) were reactive for anti-HCV antibodies and 5 (0.07%) were reactive for anti-HIV I and II antibodies. A combined sero-prevalence of 1.05% (72) was observed; 0.78% (54) for HBsAg, 0.26% (18) for anti-HCV antibodies and none for anti-HIV I and II antibodies. Four (3.85%) reactive samples were missed by RDT and therefore sensitivity of RDT was quite less as compared to CLIA. RDT and CLIA both were found to have a statistically significant shorter turnaround time than confirmatory tests. There is increasing need to develop a safe donor screening strategy for plateletpheresis. CLIA offers an excellent alterative to RDT for viral marker testing in terms of sensitivity.

Evaluation of Six Years of Appropriateness Level of Blood Transfusion in a Pediatric Ward

BACKGROUND

Blood transfusion can be considered as a life-saving treatment and is a primary health management topic. This study aims to assess the appropriateness of blood transfusion performed in a large tertiary hospital in Italy.

METHODS

a multispecialist team composed oof hematologists, public health experts and pediatricians analyzed blood transfusions performed between 2018 and 2022 in the pediatric wards comparing the appropriateness with the available NHS guidelines available. Patients' characteristics, clinical features and blood component's data were collected and analyzed.

RESULTS

considering 147 blood transfusions performed in 2018-2022, only eight (5.4%) were performed according to guidelines, while 98 (66.7%) were driven by clinicians' expertise, especially for anemia in genetic syndromes (30) (20.5%) and autoimmune diseases (20) (13.6%). Thirty-nine (26.5%) transfusions could be considered as inappropriate, while two (1.4%) blood packs were never been transfused after being requested.

CONCLUSIONS

This analysis is one of the first performed to assess the appropriateness of blood component transfusions comparing their compliance to NHS guidelines. The importance of this analysis can be explained first by the clinical point of view and second by the economic one.

Characterizing trends and associations for hepatitis C virus antibody prevalence in the Middle East and North Africa: meta-regression analyses

This study characterized population-level trends and associations with hepatitis C virus (HCV) antibody (Ab) prevalence in the Middle East and North Africa (MENA). Data source was the standardized and systematically gathered MENA HCV Epidemiology Synthesis Project Database. Random-effects univariable and multivariable meta-regressions were conducted. 2,621 HCV Ab prevalence measures on 49,824,108 individuals were analyzed. In the analysis including all populations, 71% of the variation in prevalence was explained, mostly by at-risk population type. Compared to the general population, prevalence was 23-fold higher among people who inject drugs, and 14-fold higher among high-risk clinical populations. In the analysis including only the general population, 67% of the variation in prevalence was explained, mostly by country/subregion. Compared to Afghanistan, prevalence was highest in Egypt and Pakistan. Prevalence in the general population was declining at a rate of 4% per year, but outside the general population, the decline was at only 1% per year. HCV Ab prevalence in MENA is declining rapidly, but this decline is largely occurring in the general population following introduction of blood and injection safety measures. The decline in populations at higher risk of exposure is slow and below the level needed to achieve HCV elimination by 2030.

Evolution of Blood Safety in Switzerland over the Last 25 Years for HIV, HCV, HBV and Treponema pallidum

During the last few decades, efforts to increase the safety of blood and blood products have mainly focused on preventing the viral infections HCV, HIV, HBV and Treponema pallidum. The evolution of these approaches and the achieved increase in safety is shown for the last 25 years in Switzerland. In detail, the prevalences and incidences of the infection disease and the theoretical estimated residual risks (RR) of these blood-borne infections are presented. Prevalences, incidences and, in particular, the RR have decreased considerably over the last 25 years. This was achieved primarily by the adoption of strict criteria for the selection of blood donors, refined questionnaires, the introduction of increasingly sensitive serological screening tests and the implementation of nucleic acid testing (NAT) for these blood-borne pathogens. These NAT assays have significantly shortened the window period between infection and the first detection of the infectious agent in the blood of an infected individual. A form of "real life" comparison or confirmation is provided by the reported lookback procedures (LBP) and the haemovigilance data of the Swiss competent authority, Swissmedic. These data are in agreement, and thus support the very low prevalences, incidences and RR.

Plasma Transfusion in Septic Shock—A Secondary Analysis of a Retrospective Single-Center Cohort

In sepsis, both beneficial and detrimental effects of fresh frozen plasma (FFP) transfusion have been reported. The aim of this study was to analyze the indication for and effect of FFP transfusion in patients with septic shock. We performed a secondary analysis of a retrospective single-center cohort of all patients treated for septic shock at the interdisciplinary surgical intensive care unit (ICU) of the Heidelberg University Hospital. Septic shock was defined according to sepsis-3 criteria. To assess the effects of FFP administration in the early phase of septic shock, we compared patients with and without FFP transfusion during the first 48 h of septic shock. Patients who died during the first 48 h of septic shock were excluded from the analysis. Primary endpoints were 30- and 90-day mortality. A total of 261 patients were identified, of which 100 (38.3%) received FFP transfusion within the first 48 h after septic shock onset. The unmatched analysis showed a trend toward higher 30- and 90-d mortality in the FFP group (30 d: +7% p = 0.261; 90 d: +11.9% p = 0.061). In the propensity-matched analysis, 30- and 90-day mortality were similar between groups. Plasma administration did not influence fluid or vasopressor need, lactate levels, ICU stay, or days on a ventilator. We found no significant harm or associated benefit of FFP use in the early phase of septic shock. Finally, plasma should only be used in patients with a strong indication according to current recommendations, as a conclusive evaluation of the risk-benefit ratio for plasma transfusion in septic shock cannot be made based on the current data.

Genotype Distribution and Demographic Characteristics of Hepatitis C Virus NAT Yield Cases among US Blood Donors

BACKGROUND

HCV infection rates among U.S. blood donors have been well characterized; however, few studies evaluate HCV genotypes among blood donors. Monitoring trends in disease and demographic patterns contribute to understanding the safety of the blood supply. Here we examined the demographic characteristics and the distribution of HCV genotypes/subgenotypes for nearly a 16-year period among blood donors confirmed positive for HCV RNA but antibody negative (defined as NAT yield).

METHODS

A retrospective assessment of demographic characteristics and testing data was used to determine temporal trends and geographical distribution of HCV genotypes/subgenotypes among American Red Cross blood donors confirmed positive as HCV-NAT yield.

RESULTS

From 2003-2018, 343 donors (0.38 per 100,000 donations; 95% CI, 0.35-0.43) confirmed positive as HCV-NAT-yield cases. Temporal analysis revealed a significant increase in HCV-NAT-yield cases of 54.1% between 2009-2014 (p=0.014), followed by a significant decline of 31.4% between 2015-2018 (p=0.002). Significantly more HCV-NAT-yield cases were detected among first-time donors, non-Hispanic Whites, donors aged 20-29 years, equally likely to be males as females, with the highest frequency in the South (0.52/100,000 donations). Subgenotype 1a (49.6%) was most frequent, followed by 3a (18.7%), 2b (12.5%), 1b (8.5%) and 2a (1.7%).

CONCLUSION

Voluntary non-remunerated blood donors are at low risk for HCV infection. Since 2015, the frequency of HCV-NAT-yield cases decreased despite an increase of acute HCV infection in the general population. HCV subgenotypes 1a and 3a continue to remain predominant among U.S. blood donors with recent HCV infection.

The Mirasol Evaluation of Reduction in Infections Trial (MERIT): study protocol for a randomized controlled clinical trial

BACKGROUND

Transfusion-transmitted infections (TTIs) are a global health challenge. One new approach to reduce TTIs is the use of pathogen reduction technology (PRT). In vitro, Mirasol PRT reduces the infectious load in whole blood (WB) by at least 99%. However, there are limited in vivo data on the safety and efficacy of Mirasol PRT. The objective of the Mirasol Evaluation of Reduction in Infections Trial (MERIT) is to investigate whether Mirasol PRT of WB can prevent seven targeted TTIs (malaria, bacteria, human immunodeficiency virus, hepatitis B virus, hepatitis C virus, hepatitis E virus, and human herpesvirus 8).

METHODS

MERIT is a randomized, double-blinded, controlled clinical trial. Recruitment started in November 2019 and is expected to end in 2024. Consenting participants who require transfusion as medically indicated at three hospitals in Kampala, Uganda, will be randomized to receive either Mirasol-treated WB (n = 1000) or standard WB (n = 1000). TTI testing will be performed on donor units and recipients (pre-transfusion and day 2, day 7, week 4, and week 10 after transfusion). The primary endpoint is the cumulative incidence of one or more targeted TTIs from the Mirasol-treated WB vs. standard WB in a previously negative recipient for the specific TTI that is also detected in the donor unit. Log-binomial regression models will be used to estimate the relative risk reduction of a TTI by 10 weeks associated with Mirasol PRT. The clinical effectiveness of Mirasol WB compared to standard WB products in recipients will also be evaluated.

DISCUSSION

Screening infrastructure for TTIs in low-resource settings has gaps, even for major TTIs. PRT presents a fast, potentially cost-effective, and easy-to-use technology to improve blood safety. MERIT is the largest clinical trial designed to evaluate the use of Mirasol PRT for WB. In addition, this trial will provide data on TTIs in Uganda.

TRIAL REGISTRATION

Mirasol Evaluation of Reduction in Infections Trial (MERIT) NCT03737669 . Registered on 9 November 2018.

Methods and indicators to validate country reductions in incidence of hepatitis C virus infection to elimination levels set by WHO

One of the main goals of the 2016 Global Health Sector Strategy on viral hepatitis is the elimination of hepatitis C virus (HCV) as a public health problem by 2030, defined as an 80% reduction in incidence and 65% reduction in mortality relative to 2015. Although monitoring HCV incidence is key to validating HCV elimination, use of the gold-standard method, which involves prospective HCV retesting of people at risk, can be prohibitively resource-intensive. Additionally, few countries collected quality data in 2015 to enable an 80% decrease by 2030 to be calculated. Here, we first review different methods of monitoring HCV incidence and discuss their resource implications and applicability to various populations. Second, using mathematical models developed for various global settings, we assess whether trends in HCV chronic prevalence or HCV antibody prevalence or scale-up levels for HCV testing, treatment, and preventative interventions can be used as reliable alternative indicators to validate the HCV incidence target. Third, we discuss the advantages and disadvantages of an absolute HCV incidence target and suggest a suitable threshold. Finally, we propose three options that countries can use to validate the HCV incidence target, depending on the available surveillance infrastructure.

Transfusion thresholds for guiding red blood cell transfusion

BACKGROUND

The optimal haemoglobin threshold for use of red blood cell (RBC) transfusions in anaemic patients remains an active field of research. Blood is a scarce resource, and in some countries, transfusions are less safe than in others because of inadequate testing for viral pathogens. If a liberal transfusion policy does not improve clinical outcomes, or if it is equivalent, then adopting a more restrictive approach could be recognised as the standard of care.  OBJECTIVES: The aim of this review update was to compare 30-day mortality and other clinical outcomes for participants randomised to restrictive versus liberal red blood cell (RBC) transfusion thresholds (triggers) for all clinical conditions. The restrictive transfusion threshold uses a lower haemoglobin concentration as a threshold for transfusion (most commonly, 7.0 g/dL to 8.0 g/dL), and the liberal transfusion threshold uses a higher haemoglobin concentration as a threshold for transfusion (most commonly, 9.0 g/dL to 10.0 g/dL).

SEARCH METHODS

We identified trials through updated searches: CENTRAL (2020, Issue 11), MEDLINE (1946 to November 2020), Embase (1974 to November 2020), Transfusion Evidence Library (1950 to November 2020), Web of Science Conference Proceedings Citation Index (1990 to November 2020), and trial registries (November 2020). We  checked the reference lists of other published reviews and relevant papers to identify additional trials. We were aware of one trial identified in earlier searching that was in the process of being published (in February 2021), and we were able to include it before this review was finalised.

SELECTION CRITERIA

We included randomised trials of surgical or medical participants that recruited adults or children, or both. We excluded studies that focused on neonates. Eligible trials assigned intervention groups on the basis of different transfusion schedules or thresholds or 'triggers'. These thresholds would be defined by a haemoglobin (Hb) or haematocrit (Hct) concentration below which an RBC transfusion would be administered; the haemoglobin concentration remains the most commonly applied marker of the need for RBC transfusion in clinical practice. We included trials in which investigators had allocated participants to higher thresholds or more liberal transfusion strategies compared to more restrictive ones, which might include no transfusion. As in previous versions of this review, we did not exclude unregistered trials published after 2010 (as per the policy of the Cochrane Injuries Group, 2015), however, we did conduct analyses to consider the differential impact of results of trials for which prospective registration could not be confirmed.   DATA COLLECTION AND ANALYSIS: We identified trials for inclusion and extracted data using Cochrane methods. We pooled risk ratios of clinical outcomes across trials using a random-effects model. Two review authors independently extracted data and assessed risk of bias. We conducted predefined analyses by clinical subgroups. We defined participants randomly allocated to the lower transfusion threshold as being in the 'restrictive transfusion' group and those randomly allocated to the higher transfusion threshold as being in the 'liberal transfusion' group.

MAIN RESULTS

A total of 48 trials, involving data from 21,433 participants (at baseline), across a range of clinical contexts (e.g. orthopaedic, cardiac, or vascular surgery; critical care; acute blood loss (including gastrointestinal bleeding); acute coronary syndrome; cancer; leukaemia; haematological malignancies), met the eligibility criteria. The haemoglobin concentration used to define the restrictive transfusion group in most trials (36) was between 7.0 g/dL and 8.0 g/dL.  Most trials included only adults; three trials focused on children. The included studies were generally at low risk of bias for key domains including allocation concealment and incomplete outcome data. Restrictive transfusion strategies reduced the risk of receiving at least one RBC transfusion by 41% across a broad range of clinical contexts (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.53 to 0.66; 42 studies, 20,057 participants; high-quality evidence), with a large amount of heterogeneity between trials (I² = 96%). Overall, restrictive transfusion strategies did not increase or decrease the risk of 30-day mortality compared with liberal transfusion strategies (RR 0.99, 95% CI 0.86 to 1.15; 31 studies, 16,729 participants; I² = 30%; moderate-quality evidence) or any of the other outcomes assessed (i.e. cardiac events (low-quality evidence), myocardial infarction, stroke, thromboembolism (all high-quality evidence)). High-quality evidence shows that the liberal transfusion threshold did not affect the risk of infection (pneumonia, wound infection, or bacteraemia). Transfusion-specific reactions are uncommon and were inconsistently reported within trials. We noted less certainty in the strength of evidence to support the safety of restrictive transfusion thresholds for the following predefined clinical subgroups: myocardial infarction, vascular surgery, haematological malignancies, and chronic bone-marrow disorders.

AUTHORS' CONCLUSIONS

Transfusion at a restrictive haemoglobin concentration decreased the proportion of people exposed to RBC transfusion by 41% across a broad range of clinical contexts. Across all trials, no evidence suggests that a restrictive transfusion strategy impacted 30-day mortality, mortality at other time points, or morbidity (i.e. cardiac events, myocardial infarction, stroke, pneumonia, thromboembolism, infection) compared with a liberal transfusion strategy. Despite including 17 more randomised trials (and 8846 participants), data remain insufficient to inform the safety of transfusion policies in important and selected clinical contexts, such as myocardial infarction, chronic cardiovascular disease, neurological injury or traumatic brain injury, stroke, thrombocytopenia, and cancer or haematological malignancies, including chronic bone marrow failure.  Further work is needed to improve our understanding of outcomes other than mortality. Most trials compared only two separate thresholds for haemoglobin concentration, which may not identify the actual optimal threshold for transfusion in a particular patient. Haemoglobin concentration may not be the most informative marker of the need for transfusion in individual patients with different degrees of physiological adaptation to anaemia. Notwithstanding these issues, overall findings provide good evidence that transfusions with allogeneic RBCs can be avoided in most patients with haemoglobin thresholds between the range of 7.0 g/dL and 8.0 g/dL. Some patient subgroups might benefit from RBCs to maintain higher haemoglobin concentrations; research efforts should focus on these clinical contexts.

Assessing the global burden of hemorrhage: The global blood supply, deficits, and potential solutions

There is a critical shortage of blood available for transfusion in many low- and middle-income countries. The consequences of this scarcity are dire, resulting in uncounted morbidity and mortality from trauma, obstetric hemorrhage, and pediatric anemias, among numerous other conditions. The process of collecting blood from a donor to administering it to a patient involves many facets from donor availability to blood processing to blood delivery. Each step faces particular challenges in low- and middle-income countries. Optimizing existing strategies and introducing new approaches will be imperative to ensure a safe and sufficient blood supply worldwide.

Transfusion Reactions and Adverse Events

Blood transfusions are generally safe but can carry considerable risks. This review summarizes the different types of transfusion reactions and ways to diagnose and manage them. Symptoms are often overlapping and nonspecific. When a reaction is suspected, it is critical to stop the transfusion immediately and report the reaction to the blood bank, as this can affect the patient's outcome. New evidence-based algorithms of transfusion, newer blood screening methods and donor policies and deferrals, new laboratory testing, electronic verification systems, and improved hemovigilance lead to the avoidance of unnecessary transfusions and decrease the incidence of serious transfusion reactions.

Rotational Thromboelastometry-Guided Transfusion Protocol to Reduce Allogeneic Blood Transfusion in Proximal Aortic Surgery With Deep Hypothermic Circulatory Arrest

OBJECTIVES

To determine the impact of a rotational thromboelastometry (ROTEM)-guided transfusion protocol on the use of blood products, patient outcomes, coagulation factor concentrates, and costs.

DESIGN

A single-center retrospective cohort study.

SETTING

A tertiary university hospital.

PATIENTS

Adults undergoing proximal aortic surgery with deep hypothermic circulatory arrest.

INTERVENTION

ROTEM-guided transfusion protocol compared with clinically-guided transfusion.

MEASUREMENTS AND MAIN RESULTS

Two hundred seventeen patients were included; seventy-one elective and 24 emergency patients in the clinically-guided group, and 59 elective and 63 emergency patients in the ROTEM-guided transfusion protocol group. In the ROTEM-guided transfusion protocol group, a significant reduction in transfusion of red blood cells (5 [3-8] v 2 [0-4], p < 0.001), platelet concentrate (2 [2-3] v 1 [1-2], p < 0.001), and plasma (1,980 mL [1,320-3,300] v 800 mL [0-1,000], p < 0.001) was seen in elective surgery. Emergency patients received fewer red blood cells (7 [5-10] v 5 [2-10], p = 0.040), platelet concentrate (3 [2-4] v 2 [2-3], p = 0.023), and plasma (3,140 mL [1,980-3,960] v 1,000 mL [0-1,400], p < 0.001). Prothrombin complex concentrate and fibrinogen concentrate were increased significantly in elective and emergency patients. The surgical reexploration for bleeding rate was decreased in elective patients 33.8% v 5.1%.

CONCLUSION

The implementation of a ROTEM-guided transfusion protocol might have the potential to decrease blood product transfusion and may improve patient outcomes.

Do We Store Packed Red Blood Cells under "Quasi-Diabetic" Conditions?

Red blood cell (RBC) transfusion is one of the most common therapeutic procedures in modern medicine. Although frequently lifesaving, it often has deleterious side effects. RBC quality is one of the critical factors for transfusion efficacy and safety. The role of various factors in the cells’ ability to maintain their functionality during storage is widely discussed in professional literature. Thus, the extra- and intracellular factors inducing an accelerated RBC aging need to be identified and therapeutically modified. Despite the extensively studied in vivo effect of chronic hyperglycemia on RBC hemodynamic and metabolic properties, as well as on their lifespan, only limited attention has been directed at the high sugar concentration in RBCs storage media, a possible cause of damage to red blood cells. This mini-review aims to compare the biophysical and biochemical changes observed in the red blood cells during cold storage and in patients with non-insulin-dependent diabetes mellitus (NIDDM). Given the well-described corresponding RBC alterations in NIDDM and during cold storage, we may regard the stored (especially long-stored) RBCs as “quasi-diabetic”. Keeping in mind that these RBC modifications may be crucial for the initial steps of microvascular pathogenesis, suitable preventive care for the transfused patients should be considered. We hope that our hypothesis will stimulate targeted experimental research to establish a relationship between a high sugar concentration in a storage medium and a deterioration in cells’ functional properties during storage.

A Comparison of Transfusion-Related Adverse Reactions Among Apheresis Platelets, Whole Blood-Derived Platelets, and Platelets Subjected to Pathogen Reduction Technology as Reported to the National Healthcare Safety Network Hemovigilance Module

Despite advances in transfusion safety, concerns with safety of platelet transfusions remain including platelet-related sepsis and higher reaction rates observed among patients receiving apheresis platelets (APLTs). National Healthcare Safety Network (NHSN) Hemovigilance Module (HM) data were analyzed to quantify the burden and severity of adverse reactions occurring from APLTs and whole blood-derived platelets (WBD-PLTs). Facilities participating in NHSN HM during 2010-2018 were included. Adverse reaction rates (number per 100,000 components transfused) were calculated for APLTs and WBD-PLTs stratified by severity, use of platelet additive solution (PAS), and pathogen reduction technology (PRT). Chi-square tests were used to compare rates. During the study interval, 2,000,589 platelets were transfused: 1,435,154 APLTs; 525,902 WBD-PLTs; and among APLTs, 39,533 PRT-APLTs. APLT adverse reaction rates were higher (478 vs 70/ 100,000, P< .01) and more often serious (34 vs 6/100,000; P< .01) compared with WBD-PLTs. Adverse reactions were higher among PRT-APLTs (572/100,000) and were less often serious (18/100,000) compared with non-PRT-APLTs (35/100,000) although this association was not statistically significant. Among components implicated in adverse reactions, 92% of APLTs were suspended in plasma. Compared with PRT-APLTs stored in PAS, rates were higher among units stored in plasma (760 vs 525/100,000). Most serious reactions (75%) were allergic. No transfusion-transmitted infections were reported among PRT-APLTs. APLTs were associated with a 6-fold and 2-fold higher serious adverse reaction risks compared with WBD-PLTs and PRT-APLTs, respectively. These findings demonstrate the importance of monitoring transfusion-related adverse reactions to track the safety of platelet transfusions and quantify the impact of mitigation strategies through national hemovigilance systems.

Multiplex detection of blood-borne pathogens on a self-driven microfluidic chip using loop-mediated isothermal amplification

Detection of blood-borne pathogens such as hepatitis C virus (HCV), hepatitis B virus (HBV) and human immunodeficiency virus (HIV) is essential to ensure the safety of blood transfusion. However, traditional PCR-based pathogen nucleic acid detection methods require relatively high experimental facilities and are difficult to apply in areas with limited resources. In this study, a self-driven microfluidic chip was designed to carry out multiplex detection of HBV, HCV and HIV by using loop-mediated isothermal amplification (LAMP). Benefitting from the air permeability of the polydimethylsiloxane material, the chip could accomplish sample loading within 12 min driven by the pressure difference between the reaction chambers and vacuum chambers in the chip without using pumps or any injection devices. Multiplex detection is achieved by presetting LAMP primers specific to different targets in different reaction chambers. Calcein was used as an indicator to indicate the positive amplification reaction, and the result can be recorded by a smartphone camera. After 50 min of isothermal amplification at 63 °C, 2 copies/μL of HBV, HCV and HIV target nucleic acids could be detected. The results of HBV detection of 20 clinical plasma samples by using the chip are consistent with that of the qPCR-based kit, indicating that the LAMP-based self-driven chip has the clinical application potential for blood-borne pathogen detection, especially in resource-limited areas.

HIV, HCV, and HBV incidence and residual risk in US blood donors before and after implementation of the 12-month deferral policy for men who have sex with men

BACKGROUND

In December 2015, the men who have sex with men (MSM) deferral was reduced to 12 months in the United States. We compared human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B virus (HBV) incidence and residual risk before and after this policy change using data from >50% of the US blood supply.

STUDY DESIGN AND METHODS

Three estimation intervals from the Transfusion-Transmissible Infections Monitoring System were compared: 15-months pre- and two consecutive, nonoverlapping 15-month post-MSM deferral implementation. Repeat, first-time, and weighted all-donor incidences were estimated. Residual risk was calculated for all incidence estimates using the incidence/window-period method.

RESULTS

HIV repeat donor incidence was 1.57 per 100 000 person-years (phtpy) in the second 15-month post change and not significantly different from pre-MSM incidence of 2.19 phtpy. Similar values were seen for HCV (1.49 phtpy vs 1.46 phtpy) and HBV (1.14 phtpy vs 0.97 phtpy). In some cases, higher estimated incidence, but without significant change from pre-MSM to the second post change period occurred for males and first-time donors (eg, first-time donors, second post change period: 6.12 phtpy HIV, 6.41 phtpy HCV and 5.34 phtpy HBV). Estimated per donation residual risk was 1:1.6 million for HIV, 1:2.0 million for HCV and 1:1.0 million for HBV based on weighted incidence for all donors.

CONCLUSIONS

Repeat, first-time, and overall donor incidence did not vary significantly comparing pre-MSM to either of the post-MSM estimation intervals. Residual risk estimates vary by study, but all yield residual risks in the United States of ≤1 per million, and thus far have not shown increasing risk with the 12-month MSM policy change.

Detection of dengue, chikungunya, and Zika RNA in blood donors from Southeast Asia

BACKGROUND

Chikungunya (CHIKV), dengue (DENV), and Zika (ZIKV) viruses are of concern due to the potential of transfusion transmission in blood, especially in regions such as Southeast Asia where the viruses are endemic. The recent availability of nucleic acid testing (NAT) to screen blood donations on an automated platform provides the opportunity to detect potentially infectious units in asymptomatic donors.

STUDY DESIGN AND METHODS

Three thousand blood donations from Vietnam and 6000 from Thailand were screened with a real-time polymerase chain reaction (PCR) test (cobas CHIKV/DENV, Roche Diagnostics, Indianapolis, IN) and equal numbers on cobas Zika (Roche Diagnostics). Reactive samples were tested by alternative NAT with resolution of discordant results by heminested PCR. Throughput of simultaneous testing of the two assays on the cobas 8800 system (Roche Diagnostics) was evaluated.

RESULTS

In Vietnam, 9 of 3045 samples were reactive for DENV and all were confirmed, for a prevalence (with 95% confidence interval [CI]) of 0.296% (0.135-0.560). In Thailand, 2 of 6000 samples were reactive for CHIKV, 4 of 6000 for DENV, and 1 of 6005 for ZIKV, and all confirmed. The prevalence of CHIKV is 0.033% (0.004-0.120), DENV 0.067% (0.018-0.171), and ZIKV 0.017% (0.000-0.093). The overall specificity for the cobas CHIKV/DENV and cobas Zika tests was 100% (99.959-100). For the simultaneous assay testing, 960 test results were available in 7 hours and 53 minutes.

CONCLUSION

Detection of CHIKV, DENV, and ZIKV RNA in donor samples in Vietnam and Thailand indicate the presence of the virus in asymptomatic blood donors. The cobas 6800/8800 systems (Roche Molecular Systems, Pleasanton, CA) enable screening blood donations in endemic areas for these viruses together or separately.

A Systematic Review of Transfusion-Transmissible Infections Among Blood Donors and Associated Safety Challenges in Pakistan

The blood transfusion (BT) system in Pakistan is fragmented, demand-driven and depends on weakly regulated transfusion practices. There is a considerable possibility that transfusion-transmissible infections (TTIs) are contributing to the current epidemic of hepatitis B virus (HBV) and hepatitis C virus (HCV) (affecting 7.4% of the general population) in the country. To study this issue, we conducted a systematic review to identify articles related to TTIs and transfusion safety in Pakistan from January 1, 2010 to January 31, 2020. A review of 33 articles met the final criteria for qualitative synthesis. Analysis of these studies showed a cumulative frequency of HBV 2.04%, HCV 2.44%, HIV 0.038%, syphilis 1.1% and malaria 0.11%. The frequency of coinfections among blood donors varied from 0.0099% to 0.35%. The highest number of coinfections were HCV and syphilis, followed by HCV and HBV infections. Syphilis and malaria were tested in only 38% and 46% of all the blood donations in one study. The rate of voluntary non-remunerated donations (VNRDs) was less than 13%, and male donors were 95% to 100% in these studies. There was a significant difference in the frequency of HBV and HCV in VNRDs (0.48%) as compared to replacement donors (RDs) (4.15%). In short, this review shows a high frequency of TTIs, especially HBV, HCV and syphilis in the blood donor population in Pakistan. There is a high dependency on RDs, minimal use of healthy voluntary blood donation practices, inadequate screening of high-risk donors, repeated collections of the blood from RDs, poor quality of screening methods and limited knowledge of donor health. Without standardized safe transfusion practices, there will be an ongoing increase in transmission of TTIs, especially HBV, HCV, syphilis, and HIV leading to a significant adverse public health impact.

Estimating the incidence of HIV infection in repeat blood donors with low average donation frequency

BACKGROUND

The standard approach to estimating HIV incidence in repeat blood donors includes only donors who made two or more donations in an estimation interval. In China and some other countries, large proportions of repeat donors donate only once in a 1- or 2-year interval. The standard approach may not represent risk among all repeat donors in these areas. Two approaches to including all repeat donors in the incidence estimate were evaluated in a simulation study.

STUDY DESIGN AND METHODS

Under one approach, a donor infected at the first donation contributes a partial case to incidence that equals the proportion of time since the preceding donation that is in the estimation interval. Under the other, that donor contributes a full case if at least half the time since the previous donation is in the estimation interval and nothing otherwise. Infections identified at the second or subsequent donations in the interval contribute full cases as usual. The simulations involved proportions with single donations of 11% to 65% combined with a variety of patterns of rising, falling, or constant incidence.

RESULTS

The partial-case approach was unbiased under more test conditions than the whole-case approach and exhibited smaller bias when both were biased. Under both approaches, bias >10% occurred only when rates of single donations >50% were combined with large changes in incidence over time.

CONCLUSION

The partial-case approach performed better than the whole-case approach. The conditions producing bias >10% are so extreme that they are unlikely to be encountered in the field.

A Pilot Study to Assess Transfusion Transmission of Hepatitis C Virus

Alexandria University blood bank adopted double screening tests: a fully automated chemiluminescence immunoassay followed by nucleic acid testing. The aim of the study was to assess the efficiency of dual check of HCV in preventing transfusion related infection among patients admitted to PICU. A prospective cohort study was carried on patients admitted to PICU during 6 months. The included patients performed HCV RNA detection on admission by conventional reverse transcriptase polymerase chain reaction (RT-PCR) technique. Only negative cases were recruited, then patients receiving blood or its product were checked after 4 weeks from discharge by RT-PCR for HCV RNA. A total of 33 patients received 108 transfusions: 9 patients of them deceased during PICU stay and the remaining 24 patients were all found to be negative for HCV. The dual screening of HCV should be implemented in all blood banks of Egypt especially for critically ill pediatric patients.

Comparative changes of pre-operative autologous transfusions and peri-operative cell salvage in the United States

BACKGROUND

With improved safety of allogeneic blood supply, the use of preoperative autologous donations (PADs) and perioperative autologous cell salvage (PACS) has evolved. This study evaluated temporal trends in PAD and PACS use in the United States.

METHODS

The National Inpatient Sample database, a stratified probability sample of 20% of hospitalizations in the United States, was used to compare temporal trends in hospitalizations reporting use of PADs and PACS from 1995 to 2015. Factors associated with their use were examined between 2012 and 2015 with use of multivariable Poisson regression. Sampling weights were applied to generate nationally representative estimates.

RESULTS

There was a steady decrease in hospitalizations reporting PAD transfusions from 27.90 per 100 000 in 1995 to 1.48 per 100 000 hospitalizations in 2015 (P-trend <.001). In contrast, PACS increased from a rate of 1.16 per 100 000 in 1995 to peak of 20.51 per 100 000 hospitalizations in 2008 and then steadily declined (P-trend<.001). Higher odds of PACS and PADs were observed in older patients, elective procedures (vs urgent), and urban teaching/nonteaching hospitals (vs rural hospitals) (P < .001). PACS was more common in hospitalizations in patients with higher levels of severity of illness as compared to those with minor severity (adjusted prevalence ratio [adjPR], 2.39; 95% confidence interval [CI], 2.08-2.73; P<.001), while PADs were performed less often in patients with higher underlying severity of illness (All Patient Refined Diagnosis Related Groups, 4 vs 1, adjPR, 0.61; 95% CI, [0.39-0.95]; P = .028).

CONCLUSIONS

There was a significant decrease in PAD red blood cell transfusions, while PACS has increased and subsequently decreased; PACS plays an important role in surgical blood conservation. The subsequent decline in PACS likely reflects further optimization of transfusion practice through patient blood management programs and improvement of surgical interventions.

Plasma Transfusion Practice in Adult Surgical Patients: Systematic Review of the Literature

Background

Plasma transfusions are most commonly used therapeutically for bleeding or prophylactically in non-bleeding patients prior to invasive procedures or surgery. Although plasma transfusions generally seem to decline, plasma usage for indications that lack evidence of efficacy prevail.

Summary

There is wide international, interinstitutional, and interindividual variance regarding the compliance with guidelines based on published references, supported by appropriate testing. There is furthermore a profound lack of evidence from randomized controlled trials comparing the effect of plasma transfusion with that of other therapeutic interventions for most indications, including massive bleeding. The expected benefit of a plasma transfusion needs to be balanced carefully against the associated risk of adverse events. In light of the heterogeneous nature of bleeding conditions and their rapid evolvement over time, fibrinogen and factor concentrate therapy, directed at specific phases of coagulation identified by alternative laboratory assays, may offer advantages over conventional blood product ratio-driven resuscitation. However, their outcome benefit has not been demonstrated in well-powered prospective trials. This systematic review will detail the current evidence base for plasma transfusion in adult surgical patients.

What are blood donors telling us about injecting drug use?

BACKGROUND AND OBJECTIVES

Injecting drug use (IDU), a permanent deferral for blood donors, was included in a review of donor selection criteria completed in 2017. Here, we describe what is known about IDU in blood donors in the United Kingdom (UK).

MATERIALS AND METHODS

Data were obtained from routine surveillance of donation testing and confirmed positive donors and a 2013/2014 UK survey of behaviour and compliance in screen-negative donors.

RESULTS

Between 2009 and 2018, of 22 UK million donations screened, IDU was self-reported at the post-test discussion in 5% (86/1777) of donors with confirmed positive donations. Recent injecting within 12 months was reported in 8 HCV-positive donors, but only in 1/14 donors where it was clear HCV infection had been acquired in the previous 12 months. Of 65 439 survey responders, 25 reported IDU, which when weighted to the donor population gave 99·95% compliance. Most of the 111 donors reporting IDU felt it was not important to their donation, mainly because their injecting was in the past, while three HCV-positive recent injectors reported not sharing needles so presumably felt safe to donate.

CONCLUSION

Compliance with the permanent deferral appeared extremely high with low levels of injecting reported by donors, mainly in the past. This agreed with the low-incident HCV infection observed in UK donors. These data contributed to a recommendation to reduce the deferral to 1 year. Ways of improving compliance in those few donors at current increased risk of infection need to be investigated.

Increasing Birth Cohort Screening for Chronic Hepatitis C in a Primary Care Clinic with Panel Management

Chronic hepatitis C affects millions of people worldwide and patients born between 1945 and 1965 are at elevated risk. Hepatitis C infection can lead to health complications including liver cirrhosis and hepatocellular carcinoma. Recent advancements in direct-acting antiviral treatments have placed the spotlight on primary care providers to identify undiagnosed patients with chronic hepatitis C for treatment and attaining a sustained-virologic response. Primary care providers do not routinely screen patients born between 1945 and 1965 for hepatitis C despite CDC recommendations. To evaluate the effectiveness of a hepatitis C screening protocol implemented in a primary care setting with no prior protocol. A multidisciplinary team was used to implement a hepatitis C screening protocol for patients born between 1945 and 1965 (birth cohort screening). A retrospective analysis was conducted to compare the rate of hepatitis C screening 2 years before and 2 years after the protocol was implemented. Frequency data were collected monthly and tracked in a run chart noting relevant events that affected screening. In the 2 years before the screening protocol began, 81 patients were screened (average = 3 per month); and in the 2 years after the intervention was implemented, a total of 637 patients were screened (average = 25 per month). The protocol was successful in increasing screening rates from 15 to 66% in the 2 years post-intervention. This quality improvement study demonstrated that targeting the birth cohort population was a successful method for increasing hepatitis C screening in a primary care clinic.

Risk factors for hemolytic transfusion reactions resulting from ABO and minor red cell antigen incompatibility: From mislabeled samples to stem cell transplant and sickle cell disease

Advances in laboratory testing, pathogen reduction and donor qualification have dramatically reduced the risk of acquiring an infection from a blood transfusion. Despite this progress, the most feared complication of transfusion - a hemolytic reaction due to incompatibility between donor and recipient - remains, with essentially no recent progress in the prevention or recognition of this rare but frequently lethal complication. Herein, the role that compatibility testing and transfusion practice play in the occurrence of acute hemolysis are described, with a special emphasis on clinical scenarios confer an increased risk of a severe hemolytic reaction in response to red blood cell or platelet transfusion. In addition, the signs and symptoms of a severe hemolytic reaction are summarized, along with the initial approach to clinical management.

Attributes of HIV infection over decades (1982-2018): A systematic review and meta-analysis

Understanding the risk factors for HIV infection is the foundation of successful preventive strategies, which must bundle sociocultural, behavioural and biomedical interventions to halt disease transmission. We aimed in this study to provide a pooled estimation of HIV risk factors and trace changes across decades in order to drive consensus and accurate assessment of disease transmission risk. We comprehensively searched PubMed, ISI Web of Knowledge, Medline, EMBASE, ScienceDirect, Ovid, EBSCO, Google Scholar and the Egyptian Universities Library Consortium from October to December 2018. Two independent reviewers extracted data from eligible studies. Funnel plots were inspected to identify publication bias. Heterogeneity across studies was checked using the Q and I² statistics. The results were reported based on the pooled odds ratio (pOR) with 95% CI using a random-effects model. Meta-analysis of HIV risk factors revealed a superior role for risky sexual practices (unprotected vaginal/anal sex), injecting drug use (IDU), sharing needles, sexually transmitted infections (STIs), child sexual abuse and vertical transmissions. Trends across decades (1982-1999 and 2000-2018, respectively) showed rising evidence for prostitution [pOR (95% CI)= 2.3 (1.12-4.68) versus 2.69 (1.67-4.32)] and men who have sex with men (MSM) [pOR (95% CI)= 2.28 (1.64-3.17) versus 3.67 (1.88-7.17)], while transmission through IDU [pOR (95% CI)= 3.42 (2.28-5.12) versus 2.16 (1.74-2.70)], alcoholism [pOR (95% CI)= 2.35 (0.73-7.59) versus 1.71(1.08-2.72)], and sharing syringes [pOR (95% CI)= 6.10 (2.57-14.5) versus 2.70 (2.01-6.35)] showed notable decline. Harm reduction programs and condom use have been recognized as chief HIV prevention strategies, while male circumcision contributed a partial role. Collectively, sexual risk factors continue to be a key driver of the global HIV epidemic. Persistent and emerging risk factors identified in our analysis should constitute the forefront targets of HIV prevention programmes to accelerate efforts towards HIV elimination.

Retrospective comparison between non-treponemal and treponemal tests for screening of blood donors for syphilis and their correlation with donor history in a tertiary care teaching hospital

BACKGROUND AND OBJECTIVES

Treponemal tests provide advantage of better detection during early, late and latent stages of syphilis with equal or higher sensitivity & specificity in comparison to non-treponemal tests. The objective of the present study was to analyse the level of concordance between treponemal and non-treponemal tests for donor screening and to correlate them with donor history.

MATERIALS AND METHODS

Retrospective analysis of syphilis screening by treponemal (Chemiluminescence & TPHA) and non-treponemal tests (RPR) was done and donor history for high-risk behaviour and factors associated with false positivity were collected from post-donation counselling and collected data was coded and analysed.

RESULTS

Amongst the 12,000 donors screened, reactivity rate by RPR, TPHA and Chemiluminescence was 0.45%, 0.8% and 1.17% respectively. There was discordance of 62% and 32% for reactive results by RPR and TPHA respectively when compared with Chemiluminescence. History of high-risk behaviour was present in ∼ 50% and 15% of donors with discordant results by RPR and TPHA respectively. Of 34 donors who were reactive only by Chemiluminescence and were followed up, 15% had history of high-risk behaviour and 56% had factors associated with false reactivity.

CONCLUSION

Treponemal tests showed high syphilis reactivity amongst blood donors as compared to non-treponemal tests most likely due to their ability to detect early, late and latent syphilis cases. This may confer added transfusion safety in centres dependent on replacement donors without NAT testing by identifying donors with high-risk history with negligible increase in discard rate due to false reactivity.

New strategies for the control of infectious and parasitic diseases in blood donors: the impact of pathogen inactivation methods

Around 70 infectious agents are possible threats for blood safety.

The risk for blood recipients is increasing because of new emergent agents like West Nile, Zika and Chikungunya viruses, or parasites such as Plasmodium and Trypanosoma cruzi in non-endemic regions, for instance.

Screening programmes of the donors are more and more implemented in several Countries, but these cannot prevent completely infections, especially when they are caused by new agents.

Pathogen inactivation (PI) methods might overcome the limits of the screening and different technologies have been set up in the last years.

This review aims to describe the most widely used methods focusing on their efficacy as well as on the preservation integrity of blood components.

Qualification of the Geenius HIV 1/2 supplemental assay for use in the HIV blood donation screening algorithm

BACKGROUND

A single, simplified approach for human immunodeficiency virus (HIV)-1/HIV-2 antibody confirmation/differentiation is needed for the HIV blood donation supplemental algorithm used in the United States. A clinical evaluation of the Geenius assay was performed-the same assay used for HIV diagnostic confirmation/differentiation in the United States since 2014.

STUDY DESIGN AND METHODS

Well-characterized unlinked donation samples classified as HIV negative, false positive, or confirmed positive were included in the study: 200 antibody-nonreactive, 200 HIV-1 immunofluorescence assay (IFA) confirmed-positive, and 100 antibody-screen false-positive donations, equally divided between serum and plasma. Samples were retrieved from a repository, relabeled, and tested by an immunochromatographic test (Geenius HIV 1/2 Supplemental Assay, Bio-Rad). Comparator testing involved parallel US Food and Drug Administration (FDA)-licensed HIV-1 IFA or HIV-2 enzyme immunoassay (EIA) supplemental testing for any sample missing those results as part of routine testing (otherwise test-of-record results were used). Samples with discordant results were further tested with a rapid test (Multispot HIV-1/HIV-2 Rapid Test, Bio-Rad) to provide final sample interpretations. Testing volume reductions with the Geenius were estimated from screening performed by the American Red Cross from September 2016 to April 2019.

RESULTS

Clinical results were 100% sensitivity and specificity with an indeterminate rate of 4.0% to 5.0%. From 2016 to 2019, sole use of the Geenius would reduce testing complexity for 5265 antibody repeat-reactive donations including 95.7% (5028) false positives, eliminating approximately 5000 unnecessary tests.

CONCLUSION

Geenius FDA licensure (August 26, 2019) adding the HIV-1/HIV-2 differentiation/confirmation donation supplemental claim will enable replacement of previously used FDA-licensed supplemental assays while maintaining comparable sensitivity, avoiding thousands of unnecessary HIV-1-IFA, western blot, and HIV-2-EIA tests.

Screening Blood Donors for HIV, HCV, and HBV at the American Red Cross: 10-Year Trends in Prevalence, Incidence, and Residual Risk, 2007 to 2016

Prevalence, incidence and residual risk of HIV, HCV and HBV are critical indicators of the safety of the blood supply. The American Red Cross routinely monitors these markers. Herein the results of testing over 58 million donations from 2007 to 2016 are reported. The prevalence and incidence of these infections has declined or remained essentially stable over the 7.5 to 10-year period. In 2015 to 2016, the prevalence of HIV, HCV and HBV were respectively: 1.65, 11.47 and 5.85 per hundred thousand (pht) donations with a significant decrease over the 10-year study only for HCV. Weighted incidence rates for all positives were 1.98 pht person years (py) for HIV, 2.20 pht py for HCV and 1.25 pht py for HBV. Estimates of residual risk using these incidence rates were: HIV, 1:2.3 million; HCV, 1:2.6 million; and HBV, 1:1.5 million donations, reflecting very low risk to recipients. There have been increases in the safety of the blood supply compared to prior published estimates. Demographic factors were shown to be associated with variations in infection prevalence and incidence. Continuing changes in the structure of the donor population or changes in policy could impact these measures of safety.

Initial trends of individual donation nucleic acid testing in voluntary & replacement donors from a tertiary care centre in north India

Background & objectives:

Individual donation nucleic acid testing (ID-NAT) is considered as sensitive technology to assess blood safety from viral transfusion-transmissible infections (TTIs) in blood donors. The present study was aimed to analyze the results of ID-NAT for three years (2013-2015) with special reference to different types of donors and their age ranges in a tertiary care centre in north India.

Methods:

The results of ID-NAT for three years were retrospectively analyzed at our centre. A total of 168,433 donations were tested with ID-NAT, of which 10,467 were tested with Procleix^® Ultrio^® reagents and 157,966 were tested with Procleix^® UltrioPlus^® reagents, and the results were compared with those of serology to calculate the NAT yield in voluntary, replacement, first-time and repeat donors.

Results:

A combined NAT yield was observed as one in 1031 out of 167,069 seronegative donations with HBV yield as one in 1465, HCV yield as one in 3885 and HIV-1 as one in 167,069. Yield for co-infection (HCV and HBV) was one in 41,767. A high NAT yield was observed in replacement donors (1 in 498) as compared to voluntary donors (1 in 1320).

Interpretation & conclusions:

Addition of NAT to serology improved the blood safety in our centre interdicting possibility of 150 TTIs annually. It has also reemphasized the safety of voluntary over replacement donors. The results also highlight the need of proper counselling, notification and referral guidelines of NAT yield donors in our country and other countries which lack them.

HIV prevalence and incidence estimates among blood donors in five regions in China

BACKGROUND

Previous data, although scant, indicated that the incidence of HIV in China has increased over the past decade. There is a growing concern about the impact of the HIV epidemic on blood safety.

METHODS AND MATERIALS

We used donation data from five geographically-disperse blood centers in 2013-2016 participating in the Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) China program to estimate HIV prevalence and incidence among blood donors. Multivariable logistic regression model was used to examine factors associated with HIV infection in Chinese blood donors.

RESULTS

The overall HIV prevalence among first-time donors from 2013 through 2016 was 68.04 per 100,000 donors (95% CI 61.68-74.40). The HIV incidence rate was estimated to be 37.93 per 100,000 person-years (95% CI 30.62-46.97) among first-time donors and 20.55 per 100,000 person-years (95% CI 16.95-24.91) among repeat donors. There was substantial variation in HIV prevalence and incidence rates across blood centers. Multivariable logistic regression results showed that among first-time donors, being male, older than 25 years, minority ethnicity, less than college education, and certain occupations (commercial services, factory workers, retired, unemployed, or self-employed) were associated with positive HIV confirmatory testing results.

CONCLUSION

HIV prevalence and incidence among blood donors remain low in the selected five regions in China; however, an increasing trend is observed at some blood centers. It is important to monitor HIV epidemiology in Chinese blood donors on a continuous basis, especially among populations and regions of higher risk.

Red cell transfusion in chronic kidney disease in the United States in the current era of erythropoiesis stimulating agents

Anemia is a major complication of chronic kidney disease (CKD) that leads to many symptoms of this disease and worsens cardiovascular health. Treatment of this condition was revolutionized three decades ago by the commercial availability of recombinant human erythropoietin which held the promise of completely eliminating the need for red blood cell transfusion (RBCT). Despite specific therapy now available for anemia in CKD, clinical data accumulated in the last 2 decades suggests that there is a continued need for RBCT, which, we surmise, is due to underutilization of Erythropoietin Stimulating Agents (ESA) or clinical settings such as active bleed, bone marrow resistance such as myelofibrosis or infections where ESAs are ineffective. The purpose of this narrative review is to highlight the adverse effects and summarize the current patterns of RBCT use in all stages of CKD while elaborating on the clinical characteristics of patients that increases their risks of transfusion exposure. We discuss, briefly, salient features of the pathophysiology of anemia in CKD and its contemporary therapies while presenting our perspectives on how to optimize transfusion strategies without compromising patient safety.

Red blood cell transfusion in surgery: an observational study of the trends in the USA from 2011 to 2016

Guidelines recommend restrictive red blood cell transfusion strategies. We conducted an observational study to examine whether the rate of peri-operative red blood cell transfusion in the USA had declined during the period from 01 January 2011 to 31 December 2016. We included 4,273,168 patients from all surgical subspecialties. We examined parallel trends in rates of the following: pre-operative transfusion; prevalence of bleeding disorders and coagulopathy; and minimally invasive procedures. To account for changes in population and procedure characteristics, we performed multivariable logistic regression to assess whether the risk of receiving a transfusion had declined over the study period. Clinical outcomes included peri-operative myocardial infarction, stroke and all-cause mortality at 30 days. Peri-operative red blood cell transfusion rates declined from 37,040/441,255 (8.4%) in 2011 to 46,845/1,000,195 (4.6%) in 2016 (p < 0.001) across all subspecialties. Compared with 2011, the corresponding adjusted OR (95%CI) for red blood cell transfusion decreased gradually from 0.88 (0.86-0.90) in 2012 to 0.51 (0.50-0.51) in 2016 (p < 0.001). Pre-operative red blood cell transfusion rates and the prevalence of bleeding disorders decreased, whereas haematocrit levels and the proportion of minimally invasive procedures increased. Compared with 2011, the adjusted hazard ratios (95%CI) in 2012 and 2016 were 0.96 (0.90-1.02) and 1.05 (0.99-1.11) for myocardial infarction, 0.91 (0.83-0.99) and 0.99 (0.92-1.07) for stroke and 0.98 (0.94-1.02) and 0.99 (0.96-1.03) for all-cause mortality. Use of peri-operative red blood cell transfusion declined from 2011 to 2016. This was not associated with an increase in adverse clinical outcomes.

To transfuse or not transfuse: an intensive appraisal of red blood cell transfusions in the ICU

PURPOSE OF REVIEW

This review is a critical appraisal of the current data comparing restrictive vs. liberal transfusion strategies for patients who are critically ill in ICUs. We focus on four subsets of critically ill patients: pediatric patients, patients with gastrointestinal bleeds, septic patients and patients undergoing cardiac surgery.

RECENT FINDINGS

Almost a decade after the TRICC trial, a randomized trial showing the safety of a restrictive transfusion threshold in critically ill patients, four large randomized controlled trials have shown that a restrictive transfusion strategy is safe in pediatric critically ill patients, patients with acute upper gastrointestinal bleeds, patients with septic shock and patients undergoing cardiac surgery. A large multicenter randomized trial is underway to determine the safety of a restrictive strategy in myocardial infarction.

SUMMARY

A restrictive transfusion threshold is recommended in nearly all critically ill patients. This is at least noninferior to more liberal transfusion practice; in addition, a restrictive threshold has shown improved outcomes in some patients and decreased chances of adverse events in patients. Judicious use of red cells improves patient outcome and protects the blood supply, a limited resource. More data are needed to determine appropriate transfusion threshold recommendations for patients with traumatic brain injury and acute coronary syndrome.

Problems and challenges: development of blood transfusion services in Mainland China within the context of health-care system reform

OBJECTIVE

To evaluate the development of blood transfusion services in Mainland China within the context of health-care system reform.

BACKGROUND

China launched a health-care reform program in 2009 to redistribute health-care resources, which are currently over-concentrated in well-developed cities. A geographically equitable blood transfusion service is key to achieving this goal.

METHODS

Based on the national survey of blood establishments in July 2015, total blood collection, whole-blood donations per 1000 population and the supply and demand relationship were analysed at the administrative region level. Areas at different developmental levels were compared in terms of total blood collection and human resources.

RESULTS

In 2014, Mainland China's 31 provinces showed wide variation, with total blood collection in blood facilities ranging from about 1000 units to over 600 000 units (each 200 mL), and the whole-blood donation rate per 1000 population, ranging from 1·48 to 17·09. 69% of the country's total collection, was concentrated in 29 provincial capitals, and 31% was in 311 non-capital cities. Of 97 personnel with doctorates, 74 worked in 32 provincial blood establishments, whereas the remaining 23 worked at the other 318 blood stations. In most provinces, per permanent resident donation was within 2-4 mL, and blood volume per inpatient was 10-35 mL regardless of the development of the transfusion service.

CONCLUSION

In 2014, China had an imbalanced development and insufficient access to blood transfusion services. This service must be redeployed at the national level to facilitate health-care reform in China.

Hepatitis C virus prevalence and incidence estimates among Chinese blood donors

BACKGROUND

Hepatitis C virus (HCV) is an important transfusion-transmitted virus with global significance. The objective of this study was to evaluate the HCV prevalence and incidence among Chinese blood donors from 2013 to 2016.

STUDY DESIGN AND METHODS

Whole blood and apheresis platelet donations collected from five Chinese blood centers from June 1, 2013, to December 31, 2016, were screened in parallel by two different enzyme-linked immunosorbent assays for anti-HIV 1/2, hepatitis B surface antigen, anti-HCV, and syphilis. Screening-reactive samples were further confirmed by western blot. Confirmatory positive rates among first-time and repeat donors were used to estimate the prevalence and incidence rates. Multivariable logistic regression modeling was used to examine factors associated with HCV infection.

RESULTS

A total of 1,276,544 donations were collected from five Chinese blood centers, of which an estimated 1203 were confirmed HCV positive. The overall HCV prevalence among first-time donors was 166.56 per 100,000 donors (95% confidence interval, 156.04-177.08). The HCV incidence rate was estimated to be 15.21 (95% confidence interval, 11.83-19.56) per 100,000 person-years among repeat donors. Multivariable logistic regression results showed that increased age, lower educational levels, ethnicity, and occupation were all important factors associated with HCV confirmatory status among first-time donors (p < 0.01).

CONCLUSIONS

HCV infection is still an important concern for transfusion safety in China. Our findings indicate that continued strong efforts are needed to monitor and control the risk of transfusion-transmitted HCV infection in China. Moreover, to reduce unnecessary donor loss, HCV donor screening procedures should be improved by incorporating confirmatory testing into routine blood center operations.

New Approaches and Trials in Pediatric Transfusion Medicine

Blood transfusions are frequently lifesaving, but there is growing awareness of their associated infectious and noninfectious adverse events. Patient blood management advocates for judicious use of transfusions and considerations of alternatives to correct anemia or achieve hemostasis. Several transfusion practices, either already implemented or under investigation, aim to further improve the safety of transfusions. An enduring challenge in pediatric and neonatal transfusion practice is that studies typically focus on adults, and findings are extrapolated to younger patients. This article aims to summarize some of the newer developments in transfusion medicine with a focus on the neonatal and pediatric population.

Seroprevalence and trend of human immunodeficiency virus among blood donors in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Blood transfusion is one of the routine therapeutic interventions in hospitals that can be lifesaving. However, this intervention is related to several transfusion-related infections. The human immunodeficiency virus (HIV) is one of the major public health problems associated with blood transfusion. The objective of this systematic review and meta-analysis is to estimate seroprevalence and trend of human immunodeficiency virus among blood donors in Ethiopia.

METHODS

Studies on the prevalence of human immunodeficiency virus among blood donors published until 2017 were accessed by conducting a detailed search on PubMed, Cochrane Library, Google Scholar, EMBASE and CINAHL databases using the keywords:-"Seroprevalence" AND "trend" AND "HIV" OR "human" AND "immunodeficiency" AND "virus" OR "human immunodeficiency virus" AND "blood donors" OR "blood donors" OR "Ethiopia". The quality of each article was assessed using a modified version of the Newcastle-Ottawa Scale. Meta-analysis was carried out using a random-effects method. All statistical analyses were done using STATA version 11 software.

RESULT

The estimated pooled seroprevalence of human immunodeficiency virus among blood donors in Ethiopia was 2.69% (95% CI (1.79-3.58%)). The overall seroprevalence of human immunodeficiency virus infection showed a significant decline trend from 2004 to 2016.

CONCLUSION

The overall seroprevalence of human immunodeficiency virus among blood donors in Ethiopia was high. Routine screening of donor blood for transfusion-transmissible infections is essential for ensuring the safety of blood transfusion.

History and Future of Nucleic Acid Amplification Technology Blood Donor Testing

The introduction of blood donor screening by virus nucleic acid amplification technology (NAT) in the mid to late 1990s was driven by the so-called AIDS and hepatitis C virus (HCV) epidemic, with thousands of recipients of infected blood products and components. Plasma fractionators were the first to introduce NAT testing besides pathogen reduction procedures, to reduce the virus transmission risk through their products. To achieve a similar safety standard, NAT was then also introduced for labile blood components. German transfusion centres were the first to start in-house NAT testing of their donations in pools of up to 96 samples for HCV, hepatitis B virus (HBV), and human immunodeficiency virus-1 (HIV-1). Years later the diagnostics industry provided commercial HCV and HIV-1 and later HBV NAT tests on automated platforms. NAT tests for HIV-2, hepatitis A virus, and Parvovirus B19 followed, again driven by transfusion centres with their in-house tests. When severe acute respiratory syndrome corona virus (SARS-CoV) and West Nile Virus emerged it was the NAT that enabled the manufacturers and transfusion centres to instantly introduce sensitive and specific screening tests. Subsequent automation including sample preparation has significantly reduced the costs and complexity of the procedure and made it affordable to middle income countries as well. Currently more than 60 million donations per year are NAT tested worldwide and the remaining residual risk of virus transmission by blood components and products could be reduced to almost zero. Automation rendered possible the reduction of pool size in conjunction with increased throughput and sensitivity. Thus, antibody and antigen testing may be dispensable in the long run, particularly in the combination of NAT testing with pathogen reduction. There are new technologies on the horizon like digital droplet PCR, next-generation sequencing, lab-on-a-chip, and digital antigen assays, which are comparably sensitive. However, each of these has limitations, either in throughput, costs, automation, time to result, specificity, or the need for NAT as an integral part of the technology. Thus, NAT is still the shortest and most efficient means to the result. Donor screening NAT also contributed significantly to our knowledge on how fast viruses replicate, and on the respective diagnostic window. In conjunction with animal and patient studies, we have learned more about the minimal infectious dose and the epidemics in the donor population.

Overtransfusion of Autologous Blood Identifies Opportunities for Improving Patient Blood Management

Background Preoperative autologous blood donation (PABD) has been declining in use nationally. A subset of patients scheduled for elective surgery, however, continue to be offered and choose this option. Our study aimed to understand the current impact of PABD before scheduled surgical procedures. Study design and methods A retrospective review was conducted in a single large academic center. Medical records associated with autologous units received in the transfusion service over a two-year period (1/1/2016-12/31/2017) were reviewed. Demographics, units donated, units transfused, wastage, pre-donation hemoglobin (Hb), pre-operative Hb, estimated blood loss (EBL), and clinical specialty were collected. Results During the study period, 118 patients underwent PABD, donating a total of 141 autologous red blood cell units. Patients who donated autologous units and were subsequently transfused had lower pre-donation Hb compared to patients who were not transfused (13.3 ± 1.4 g/dL vs. 14.3 ± 1.5 g/dL, p=0.004). Pre-operative Hb was lower than pre-donation Hb among both groups (12.1 ± 1.2 g/dL for patients receiving transfusion; 12.9 ± 1.5 g/dL, p=0.011 for patients who were not transfused). The majority of PABD patients (71%) had an estimated blood loss of less than 500 mL. Wastage rate of autologous units was 67%. PABD was disproportionately associated with a minority of surgeons and clinical services. Conclusion Within our institution, PABD is heavily used amongst a small subset of physicians across multiple surgical specialties and is associated with lower pre-operative Hb, tendency towards overtransfusion, and high rates of wastage of donated units. Our findings reinforce reports of inefficiencies in patient blood management and increased risks to patient health associated with PABD.

Transfusion-Transmitted Infections Reported to the National Healthcare Safety Network Hemovigilance Module

Transfusion-transmitted infections (TTIs) can be severe and result in death. Transfusion-transmitted viral pathogen transmission has been substantially reduced, whereas sepsis due to bacterial contamination of platelets and transfusion-transmitted babesiosis may occur more frequently. Quantifying the burden of TTI is important to develop targeted interventions. From January 1, 2010, to December 31, 2016, health care facilities participating in the National Healthcare Safety Network Hemovigilance Module monitored transfusion recipients for evidence of TTI and recorded the total number of units transfused. Facilities use standard criteria to report TTIs. Incidence rates of TTIs, including for bacterial contamination of platelets and transfusion-transmitted babesiosis, are presented. One hundred ninety-five facilities reported 111 TTIs and 7.9 million transfused components to the National Healthcare Safety Network Hemovigilance Module. Of these 111 reports, 54 met inclusion criteria. The most frequently reported pathogens were Babesia spp in RBCs (16/23, 70%) and Staphylococcus aureus in platelets (12/30, 40%). There were 1.95 (26 apheresis, 4 whole blood derived) TTIs per 100 000 transfused platelet units and 0.53 TTI per 100 000 transfused RBC components, compared to 0.68 TTI per 100 000 all transfused components. Bacterial contamination of platelets and transfusion-transmitted babesiosis were the most frequently reported TTIs. Interventions that reduce the burden of bacterial contamination of platelets, particularly collected by apheresis, and Babesia transmission through RBC transfusion would reduce transfusion recipient morbidity and mortality. These analyses demonstrate the value and importance of facility participation in national recipient hemovigilance using standard reporting criteria.