16.

Discuss the Microbial Threats to Transfusion Safety and the Procedures that the Transfusion Service takes to Avoid their Transmission A wide range of blood-borne infectious agents is transmitted through transfusion of infected blood donated by apparently healthy and asymptomatic blood donors. There is a great diversity of infectious agents including bacteria, parasites, and viruses. The infections transmitted through blood can be divided into exogenous or endogenous; exogenous infections are those which are introduced into a blood unit from an external source and endogenous infections are those transmitted from the donors blood to the recipient. Strategies have been implemented to reduce the risk of transmitting these infectious agents by donor exclusion, screening for serological markers of infections, and nucleic acid testing by viral gene amplification for direct and sensitive identification of known infectious diseases. Consequently, transfusions are safer now than ever before. Nevertheless, many infectious agents can be transmitted through blood transfusion. Well-recognized viruses include hepatitis A-D, hepatitis G, HIV-1/2, HTLV-I/II, CMV, EBV, human herpes virus type 6 (HHV-6), SEN virus (SEN-V), and human parvovirus (HPV-B19). Bacteria such as Treponema pallidum (the agent of syphilis), Yersinia enterocolitica, and Staphylococcus and Streptococcus species (common agents of bacterial contamination), and parasites such as Plasmodium species (the agent of malaria), Trypanosoma cruzi (agent of Chagas' disease), and Babesia microti (agent of babesiosis) have also been reported to be transmitted through blood transfusion. In addition, emerging blood-borne pathogens such as hepatitis E virus (HEV), human herpes virus type 8 (HHV-8), and Borrelia burgdorferi (agent of Lyme disease) may pose a threat to the safety of blood. Babesia microti, Dengue virus, Trypanosoma cruzi (Chagas disease) and the agents of malaria, represent high threat agents. In the past 50 years, the incidence of the mosquito-born Dengue virus has increased 30-fold, and clusters of reported cases in Hong Kong and Singapore, confirm that the agent may be transfusiontransmitted. Trypanosoma cruzi infection is endemic in Latin America and has caused transfusion and transplantation transmitted infections. West Nile Virus entered the USA in 1999, and since that time the agent and disease has spread across the entire USA and has entered Canada, Mexico, Central and South America, transmitted by over 58 mosquito species and 288 avian species. The only human to human mode of transmission is through blood transfusion or organ transplantation, and in 2002, 23 transfusiontransmitted cases were described. Endogenous microbiological agents transmitted by blood transfusion have certain characteristics and the hallmark is persistence of infection e.g. long incubation period, carrier or latent state, ability to cause asymptomatic/subclinical infection and viability and stability in stored blood or plasma. Transfusion reaction due to bacterial contamination of blood units was amongst the earliest recognised complication of blood transfusion. Although technical advances have greatly reduced the incidence of bacterial contamination, bacteria remain the most common microorganisms found in blood components. The skin at the site of the venepuncture is cleansed with antiseptic, but bacteria below the surface of the skin and airborne bacteria may enter the venepuncture needle, and it is also possible that the donor could have an asymptomatic bacteraemia. Surviving bacteria will have their proliferation curtailed by storage at 46C; however some bacteria such as Pseudomonas fluorescens and Yersinia entercolitica are capable of growth at this temperature. The risk of bacterial proliferation increases if the blood bag is allowed to warm to ambient temperature, because the bacteria can enter a logarithmic growth phase, and the bacterial load can be increased by a factor of thousands. Platelets are a particularly hospitable culture media for many

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bacterial species because they are stored at room temperature. There is a limitation of 5-7 days on the storage time for platelets, due to concern over the increased incidence of septic reactions with time. The clinical consequences of transfusing a contaminated depend on the pathogen city of the bacterial strain, the concentration of the bacteria present, and host factors, such as antibiotic use and the degree of immunosuppression. The most common organisms involved are Gram-positive cocci that are part of the normal skin flora or are ubiquitous in the environment. Reactions with endotoxin producing Gram-negative organisms may be particularly severe, e.g. Yersinia enterocolitica. The differential diagnosis of mild reactions includes febrile non-haemolytic transfusion reactions, while severe reactions may mimic acute haemolytic transfusion reactions or severe allergic reactions. Data from national surveillance systems such as SHOT, suggest that severe reactions occur in approximately 1 in 10,000 transfusions, and fatal reactions occur in approximately 1 in 100,000 to 1 in 1,000,000. Transfusion of hepatitis through blood transfusion was first reported in 1943. Transmission of hepatitis virus by pooled plasma derivatives and other blood products is a rare, but well documented event. Outbreaks of hepatitis A and B virus have occurred from infected factor VIII in Europe, before the use of recombinant factor VIII. Hepatitis B is one of the most widespread and pathogenic viruses in the world, and the prevalence of the HBsAg ranges between 1:1000 and 25% in populations of blood donors, with the highest being found in West Africa, and the lowest in Western Europe. Hepatitis B remains the most likely of the viral agents to be transmissible by transfusion. Studies of transfusion-transmitted infections have resulted in the development, standardization and implementation of a large array of immunoassays, which are used worldwide in routine screening of blood donations. Exclusion of infected blood and their donors has remarkably reduced the risk of transmitting HBV, HCV, and HIV 1 and 2. The range of tests performed on blood donors varies greatly from country to country. The mandatory tests for UK blood donors includes; HBsAg, antibodies to HIV 1 & 2 and antigen, antibodies to HCV and antigen, antibodies to Treponema pallidum (the causative agent of syphilis), and NAT for HCV, HIV and HBV, HTLV. CMV antibody testing is carried out on selected donors, to protect at risk immunocompromised patient groups. Other tests that could be carried out include anti-malaria and antiChagas disease and West Nile Virus RNA. The process of donor selection is designed to protect both the donor and the recipient. In the UK, a donor must be a healthy person between the age of 17 and 70 years. Donors either complete a questionnaire or are interviewed to identify those whose donations could harm patients. The questions that are asked regard their general health, lifestyle, past medical history, and medication. Questions inquire about recent foreign travel, previous blood transfusion, recent body piercings/tattoos and sexual activity. Deferral of donors based on risk factors, to transmissible infections e.g. travels to a malaria endemic region, and prevents the collection of contaminated units. Laboratory testing for markers of infectious diseases has profoundly improved blood safety, using techniques including solid phase immunoassays (antigen globulin test, antigen sandwich assay) and nucleic acid tests. Solid phase immunoassays involve the use of an antigen or antibody-coated micro-titre plate, to which target antibody or antigen in donor sample will attach after appropriate incubation. The addition of a specific conjugate to attach to the target molecule allows detection of the molecule. The conjugate could be radio-labelled, enzyme-linked or fluorochrome-linked. In the antiglobulin test, the microtitre plate is coated with specific antigen to which a specific donor antibody could bind if present; the conjugate consists of antihuman globulin. In the antigen sandwich assay, the solid phase is coated with specific antigen to which

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specific antibody can bind. The conjugate is made from the same antigen used in the solid phase but is enzyme-linked to give antigen/antibody/antigen sandwich. The advent of PCR, and reverse-transcriptase, which reverse transcribes RNA to DNA, and then amplifies the DNA, it was recognised that nucleic acid amplification could be used in the detection of viral TTIs. Nucleic acid tests using enzymatic amplification of viral gene sequences have increased the ability to detect window period infections, such as hepatitis B, that are undetectable by the serological tests. Blood donations that are found to be initially reactive at donor testing sites should be repeat tested in duplicate. Should any of the repeat tests result in reactivity, then the donation is classified as repeatedly reactive, and submitted to the national reference laboratory and the donor is flagged on the database and all of the donation will be discarded. The vast majority of repeated reactive donations are probably reacting non-specifically to the test system (90-99%), and the role of the confirmatory laboratory is to detect which samples are a true positive. Confirming true infection in donors requires high sensitivity assays that demonstrate infection unequivocally, and can distinguish true positives from false positives. At present, the residual risk of TTIs is mainly based on mathematical modelling. The residual risks of transfusion transmitted HIV or hepatitis C virus, which are already very low, have been reduced to extremely low levels after implementation of mini-pool NAT. Nucleic acid testing has improved sensitivity of testing for a range of TTIs. In the 2009 SHOT there were no reported viral transmission and only 2 TTIs, and both were bacterial; bacteria remain the main TTI risk in the UK.

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