Seroprevalence of known and putative hepatitis markers in United States blood donors with ALT levels at least 120 IU per L

BACKGROUND

ALT testing of blood donors was initiated as a surrogate marker for non-A, non-B hepatitis. Increased sensitivity of subsequent HBV and HCV tests used for standard donor screening make any residual value of ALT testing questionable.

STUDY DESIGN AND METHODS

A prospective study was conducted in 166 of 645 eligible blood donors from three American Red Cross regions whose ALT was > or =120 IU per L and whose standard donor screening tests were negative. Of these enrolled donors, 124 (75%) completed follow-up. Samples obtained from the index donation, at enrollment (1 month), and at follow-up (6 months) underwent the standard donor screening tests, as well as those for HCV RNA and HGV RNA (RT-PCR), antibodies to the virus envelope E2 protein of GB virus type C (GBV-C E2 antibody), and IgM antibody for CMV, parvovirus B19, EBV VCA, and HAV. Participants completed a brief demographic and exposure history questionnaire at follow-up.

RESULTS

All study samples were negative in standard donor-screening tests. ALT levels were variable at return visits, with 80 to 86 percent <120 IU per L. No participants were positive for HCV RNA; 4 percent were positive for HGV RNA, and 10 percent were positive for GBV-C E2 antibody. Results of CMV, parvovirus B19, EBV VCA, and HAV testing were similar to published background rates. No demographic or exposure history variables had significant correlation with ALT or other testing results.

CONCLUSION

These data suggest that an ALT > or =120 IU per L in blood donors with negative standard screening tests has questionable value as a surrogate marker for seronegative HBV or HCV infection. Continued ALT testing may contribute little, if anything, to the safety of blood components or plasma for further manufacture.

Transfusion-related sepsis due to Serratia liquefaciens in the United States

BACKGROUND

Severe, often fatal, transfusion reactions due to bacterial contamination of blood components continue to occur. Serratia liquefaciens, an unusual human pathogen, is a recently recognized potential cause of transfusion-related sepsis.

CASE REPORTS

Five episodes of transfusion-related sepsis and endotoxic shock due to S. liquefaciens were reported to the CDC from July 1992 through January 1999. One episode has been described. The remaining four, all fatal, are described here: three associated with RBC transfusion and one associated with transfusion of platelets. In each instance, the source of contamination could not be found. The implicated units tended to be older (mean RBC age 28 days), and visual discoloration was noted in each RBC unit, although usually in retrospect.

CONCLUSION

S. liquefaciens is an increasingly recognized cause of transfusion-related sepsis and is associated with a high mortality rate. S. liquefaciens can contaminate both RBCs and platelets, but the mechanism(s) of contamination remain unknown. Increased attention to pretransfusion visual inspection may avert the transfusion of some S. liquefaciens-contaminated RBC units. However, more sensitive rapid diagnostic tests are needed to further reduce the risk of transfusion-related sepsis and endotoxic shock.

Predictive value of past and current screening tests for syphilis in blood donors: changing from a rapid plasma reagin test to an automated specific treponemal test for screening

BACKGROUND

This study evaluated the change from a rapid plasma reagin (RPR) test to an automated specific treponemal test (PK-TP) in screening for syphilis in blood donors.

STUDY DESIGN AND METHODS

A cross-sectional seroprevalence analysis was performed on 4,878,215 allogeneic blood donations from 19 American Red Cross Blood Services regions from May 1993 through September 1995. Positive predictive values relative to the confirmatory fluorescent treponemal antibody absorption test (FTA-ABS) were calculated. Differences in seroprevalence were compared in RPR and PK-TP tests for 1) unconfirmed and confirmed tests, 2) first-time and repeat donors, and 3) "recent" versus "past" infections. Donation data from three additional Red Cross regions were evaluated for repeat donation patterns of blood donors who had a donation that was positive in a serologic screening test for syphilis. The value of RPR and PK-TP tests as surrogate markers for HIV infection was compared.

RESULTS

Reactive rates were lower but the positive predictive values was higher for the PK-TP test than for the RPR test. Initially, donors screened by PK-TP were more likely to be confirmed as positive than were donors screened by RPR, but these rates became comparable. It is estimated that a single HIV window-period donation was removed by serologic testing for syphilis each year of this study period.

CONCLUSIONS

The change to the PK-TP test resulted in a lower repeatedly reactive rate, better prediction that a confirmed-positive test for syphilis would occur in testing in the FTA-ABS, fewer donations lost, and comparable deferral rates. Because of the high rate of reactivity to serologic testing for syphilis among donors previously confirmed positive for syphilis, indefinite deferral after a confirmed-positive index donation may be warranted. Serologic testing for syphilis is ineffective as a marker of HIV-infectious window-period donations.

Seroepidemiology of Trypanosoma cruzi, etiologic agent of Chagas' disease, in US blood donors

A comprehensive seroepidemiologic study was conducted in two Red Cross regions (Los Angeles and Miami) to determine the prevalence of Trypanosoma cruzi antibodies in at-risk blood donors, to identify additional risk factors, and to assess the likelihood of transmitting T. cruzi by transfusion. At-risk and control donors were stratified by a broad risk question, tested for T. cruzi antibodies, and if confirmed as seropositive, enrolled in case-control and lookback investigations. A total of 299,398 donors were queried; 23,978 at-risk and 25,587 control donations were tested, and T. cruzi antibodies were confirmed in 34 donors (33 and 1, respectively). Seropositive donors shared one risk factor; birth/extensive time in a T. cruzi-endemic area. Lookback studies identified 11 recipients, all negative for T. cruzi antibodies. Screening strategies that use a question are unlikely to identify all seropositive donors. The lack of definitive data on the risk of transmission by transfusion indicates additional studies of donors and recipients are needed.

Screening of selected male blood donors for p24 antigen of human immunodeficiency virus type 1. The Transfusion Safety Study Group

BACKGROUND

The p24 antigen of human immunodeficiency virus type 1 (HIV-1) is sometimes detected before antibody (anti-HIV-1) is detectable in the serum of recently infected persons. This has led to the consideration of p24-antigen testing for routine screening of blood donors.

METHODS

To estimate how many HIV-infected seronegative donors would be identified if p24-antigen screening was introduced, we tested selected donations from a repository of 200,000 serum samples from voluntary donors that was established in late 1984 and early 1985. The 8597 serum samples selected for p24-antigen screening were chosen because their donors had demographic characteristics known to be associated with a high prevalence of seropositivity.

RESULTS

The prevalence of anti-HIV-1 antibodies in the 1984-1985 serum samples selected for p24-antigen screening was 1.54 percent--more than 100 times the 0.012 percent prevalence in present-day donations in the United States. The antigen was detected in 15 of 132 serum samples (11.4 percent) from donors who had already been confirmed as seropositive. No instance of confirmed positivity for p24 antigen was found among the 8465 seronegative serum samples.

CONCLUSIONS

These data indicate that the yield of screening for p24 antigen in volunteer donors to identify HIV-1 carriers would be negligible. We therefore recommend against routine screening with currently available p24-antigen assays.

Avoiding blood transfusion. A report of two cases

It is prudent to avoid blood transfusion whenever possible. Recent reports question the standards previously considered acceptable for blood transfusion. Acute hemorrhage followed by hypovolemia, tachycardia and orthostatic hypotension with dizziness are still considered acceptable criteria for automatic blood transfusion in most patients. We report two cases in which hypovolemia, tachycardia and orthostatic hypotension with dizziness were present. Transfusion was avoided. Hypovolemia, tachycardia and orthostatic hypotension with dizziness do not require transfusion in a few carefully selected and well-monitored patients.

Increased preoperative collection of autologous blood with recombinant human erythropoietin therapy

To study whether the administration of recombinant human erythropoietin increases the amount of autologous blood that can be collected before surgery, we conducted a randomized, controlled trial of erythropoietin in 47 adults scheduled for elective orthopedic procedures. The patients received either erythropoietin (600 units per kilogram of body weight) or placebo intravenously twice a week for 21 days, during which time up to 6 units of blood was collected. Patients were excluded from donation when their hematocrit values were less than 34 percent. All patients received iron sulfate (325 mg orally three times daily). The mean number of units collected per patient (+/- SE) was 5.4 +/- 0.2 for the erythropoietin group and 4.1 +/- 0.2 for the placebo group. The mean red-cell volume donated by the patients who received erythropoietin was 41 percent greater than that donated by the patients who received placebo (961 vs. 683 ml, P less than 0.05). Only 1 of the 23 patients treated with erythropoietin was unable to donate greater than or equal to 4 units (4 percent) as compared with 7 of the 24 patients who received placebo (29 percent). No adverse effects were attributed to erythropoietin. We conclude that recombinant human erythropoietin increases the ability of patients about to undergo elective surgery to donate autologous blood.

Prevalence of antibodies to human immunodeficiency virus type 1 among blood donors prior to screening. The Transfusion Safety Study/NHLBI Donor Repository

The Transfusion Safety Study (TSS) and the National Heart, Lung, and Blood Institute (NHLBI) established a repository of approximately 200,000 sera from blood donors in late 1984 and early 1985. Collections were made in the four metropolitan areas with the highest prevalence of AIDS. Retrospective testing showed an overall anti-HIV-1 prevalence of 16 cases per 10,000 donations. In this study, the predictive value of a negative initial enzyme-linked immunoassay was estimated from both quality control specimens and the rescreening of 13,461 sera to be greater than 99.99 percent with respect to technical error. Among anti-HIV-1-positive persons, there was a 1.3- to 1.5-fold excess of first-time donors. The anti-HIV-1 prevalence among donors showed that infection was more common among young men than suggested by national reporting of AIDS cases. Anti-HIV-1 prevalence varied among the four metropolitan areas less than did reported AIDS cases, but, by 1987, the differences in the latter had decreased. Anti-HIV-1 prevalence in collection areas outside of the four major cities differed much more widely than that among the cities themselves. The TSS/NHLBI Donor Repository will remain available for the indefinite future for further evaluation of screening procedures for HIV-1 and other viruses for which transfusion is found to be an important route of transmission.

Transmission of human immunodeficiency virus (HIV) by blood transfusions screened as negative for HIV antibody

Since early 1985, blood donations in the United States have been screened for antibody to human immunodeficiency virus (HIV). To identify instances of HIV transmission by antibody-negative donations, we investigated 13 persons seropositive for HIV who had received blood from 7 donors who were screened as negative for HIV antibody at the time of donation. Twelve of the 13 recipients had no identifiable risk factors for HIV infection other than the transfusions they had received. On evaluation 8 to 20 months after transfusion, HIV-related illnesses had developed in three recipients, and the acquired immunodeficiency syndrome had developed in one. All seven donors were found to be infected with HIV. On interview, six reported a risk factor for HIV infection, and five had engaged in high-risk activities or had had an illness suggestive of acute retroviral syndrome within the four months preceding their HIV-seronegative donation. Thus, these donors had apparently been infected only recently, and so were negative at the time of blood donation according to available antibody tests. We conclude that there is a small but identifiable risk of HIV infection for recipients of screened blood. To minimize this risk, the reasons for deferral of donation need to be communicated more effectively to blood donors who are at high risk of HIV infection, and new assays that detect HIV infection earlier should be evaluated for their effectiveness in screening donated blood.

Automatic special case consultations in transfusion medicine

In the past, consultations in immunohematology were usually delivered only when there was a blood or component shortage, or when the time required for compatibility testing was prolonged due to the presence of a difficult recipient antibody problem. More recently, transfusion medicine physicians have increased their role as clinical consultants concerned about the appropriate indications for blood transfusion. This communication presents a way to begin a sound program of clinical transfusion medicine consultation. The program can fit with community-wide teaching efforts, community or hospital transfusion audits, and specific physician education programs. Automatic or unsolicited consultations appear to have been both accepted well and beneficial in large hospitals and in communities where they have been provided for more than 7 years.

Malignant histiocytosis simulating granulomatous disease

In its clinical presentation, malignant histiocytosis may mimic infections or hematologic neoplasms, and pathologically it may be mistaken for Hodgkin's disease, histiocytic lymphoma, or viral lymphadenitis. The case histories of three patients in whom malignant histiocytosis clinically and pathologically simulated granulomatous diseases are reported. Erythrophagocytosis was not present in the initial bone marrow aspirates from two of the patients. One patient was considered to hve sarcoidosis or Wegener's granulomatosis; the second patient, Weber-Christian disease, and the third patient, a granulomatous disease of infectious origin. Granulomas have been found in tissues of patients who have Hodgkin's disease, but have been found only rarely in association with malignant histocytosis. An explanation for the presence of granulomas in association with malignant histiocytosis is offered: they may represent a phase in the evolution of the disease.