Racial differences in seroprevalence of HAV and HEV in blood donors in the Western Cape, South Africa: a clue to the predominant HEV genotype?

Hepatitis E virus (HEV) infection is a major cause of acute hepatitis worldwide. This infection causes major water-borne outbreaks in low- and middle-income countries, whilst in industrialised countries this infection is zoonotic. These differences in epidemiology are related to different HEV genotypes. HEV genotype 3 is a zoonotic infection, whilst genotype 2 causes large outbreaks. This study determined the seroprevalence of HEV in blood donors from the Western Cape. Anti-hepatitis A virus (anti-HAV) antibody was detected in 184/300 (61%) donors. Antibody to HEV (anti-HEV) was detected in 78 of 300 donors (26%). It was highest in mixed race donors (62/100), followed by white donors (23/100) and lowest in black donors (19/100) P = 0.019. Since it is thought that genotypes 1 and 2 predominate both viruses would be acquired by the oro-faecal route, it is surprising that HEV seroprevalence does not mirror that of HAV. We postulate that this may reflect differences in socio-economic status and consumption of dietary meat. So the marked divergence between HEV and HAV seroprevalence may be the result of different routes of transmission. Further data are needed to explore the risk factors associated with HEV infection.

The strategies to reduce iron deficiency in blood donors randomized trial: design, enrolment and early retention.

BACKGROUND AND OBJECTIVES: Repeated blood donation produces iron deficiency. Changes in dietary iron intake do not prevent donation-induced iron deficiency. Prolonging the interdonation interval or using oral iron supplements can mitigate donation-induced iron deficiency. The most effective operational methods for reducing iron deficiency in donors are unknown. MATERIALS AND METHODS: 'Strategies To Reduce Iron Deficiency' (STRIDE) was a two-year, randomized, placebo-controlled study in blood donors. 692 donors were randomized into one of two educational groups or one of three interventional groups. Donors randomized to educational groups either received letters thanking them for donating, or, suggesting iron supplements or delayed donation if they had low ferritin. Donors randomized to interventional groups either received placebo, 19-mg or 38-mg iron pills. RESULTS: Iron deficient erythropoiesis was present in 52·7% of males and 74·6% of females at enrolment. Adverse events within 60 days of enrolment were primarily mild gastrointestinal symptoms (64%). The incidence of de-enrolment within 60 days was more common in the interventional groups than in the educational groups (P = 0·002), but not more common in those receiving iron than placebo (P = 0·68). CONCLUSION: The prevalence of iron deficient erythropoiesis in donors enrolled in the STRIDE study is comparable to previously described cohorts of regular blood donors. De-enrolment within 60 days was higher for donors receiving tablets, although no more common in donors receiving iron than placebo.

Reduction of the risk of transfusion-transmitted viral infection by nucleic acid amplification testing in the Western Cape of South Africa: a 5-year review.

BACKGROUND AND OBJECTIVES: In October 2005, individual donation nucleic acid amplification testing (ID-NAT) for HIV, HBV and HCV was introduced in the Western Cape Province of South Africa. After 5 years, the impact on HIV, HBV and HCV transmission risk was assessed. MATERIALS AND METHODS: A total of 649745 donations were tested by ID-NAT using the Ultrio assay on the Tigris instrument (Novartis Diagnostics) and for anti-HIV, HBsAg and anti-HCV (Abbott Prism). Initial reactive samples were repeated in duplicate. Discrepant repeat reactive samples were subjected to confirmatory assays. ID-NAT nonrepeat reactive donations were further screened for occult HBV infection (OBI) by anti-HBc assay. RESULTS: ID-NAT yielded 6 HIV-RNA-positive donations in the anti-HIV-negative window period (WP) but only 2 were p24 Ag nonreactive (1:325000). Mathematical modelling estimated a similar HIV transmission risk for lapsed and repeat donations, in the order of 3 per million. The WP risk for HBV was 13 per million. Eight acute (1:81000) and 13 chronic OBI yield cases (1:50000) were interdicted. There were significantly more anti-HBc-positive donors in the Ultrio initial reactive/nonrepeat reactive group (12%) than in an Ultrio nonreactive control group (6%). CONCLUSION: ID-NAT in the Western Cape Province of South Africa has contributed significantly to enhancing blood safety, particularly for HBV transmission risk and to a lesser extent for HIV. Anti-HBc testing of NAT nonrepeat reactive donations seems useful in identifying a subgroup of donors with OBI who may be at risk of transmitting HBV.

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.

Babesiosis in a renal transplant recipient acquired through blood transfusion.

BACKGROUND: The success of organ-replacement therapies has resulted in a population of chronically immunosuppressed but active people who experience increased vulnerability to tick-borne zoonoses. Several of these infections may be life threatening. Human babesiosis is an emerging zoonosis that is transmitted by the same tick that transmits Lyme disease and human granulocytic ehrlichiosis. METHODS: We briefly review these zoonoses and present a case of a renal transplant recipient who survived infection by Babesia microti contracted through blood transfusion. RESULTS: A recipient of a living-related renal transplant developed acute postoperative hemolytic anemia. The etiology of this anemia was diagnosed by peripheral red blood cell smear as Babesia microti. The patient was managed by a reduction in transplant immunosuppressive therapy and administration of clindamycin and quinine antimicrobials. CONCLUSIONS: Transplant patients may contract babesiosis after tick exposure and/or via blood transfusion. The diagnosis of babesiosis may be confused with malaria and should be included in the differential diagnosis of posttransplant hemolytic-uremic syndrome in organ transplant patients.

A case-controlled multicenter study of vasovagal reactions in blood donors: influence of sex, age, donation status, weight, blood pressure, and pulse.

BACKGROUND: Vasovagal reactions occur in a small, but significant number of blood donors. These reactions may decrease return donation and disrupt blood collection activities. The purpose of this study was to define the contributory role of sex, age, weight, blood pressure, and pulse in vasovagal reactions with syncope in blood donors. STUDY DESIGN AND METHODS: A retrospective case-control study involved 1890 blood donors with syncope from three large United States blood centers during 1994 and 1995. Case controls and random population controls were used in a logistic regression analysis to determine the significance of individual variables to syncopal reactions. RESULTS: Female donors, young donors, first-time donors, low-weight donors, and donors with low predonation blood pressure had higher absolute donation reaction rates than other donors. When each variable was adjusted for other variables by regression analysis, age, weight, and donation status (first-time or repeat donor) were significant (p<0.0001), and sex, predonation blood pressure, and predonation pulse were not. The most important variables, in descending order, were age, weight, and donation status (first-time or repeat donor). CONCLUSIONS: Donation-related vasovagal syncopal reactions are a multifactorial process determined largely by age, weight, and first-time donor status.

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.

Limited utility of alanine aminotransferase screening of hepatitis C antibody-screened blood donors.

BACKGROUND: The introduction of hepatitis C virus (HCV) screening has significantly reduced the frequency of posttransfusion hepatitis C. To examine the current added value of alanine aminotransferase (ALT) screening, all donor screening at two large blood centers was reviewed. STUDY DESIGN AND METHODS: From July 1991 through March 1994, 1,258,000 allogeneic blood donors were screened by enzyme immunoassay for anti-HCV: 343,000 donations by the first-generation test (HCV 1.0) and 915,000 donations by the second-generation test (HCV 2.0). Donations with positive EIA results were confirmed with a recombinant immunoblot assay. RESULTS: Of these donors, 1,637 (0.13%) were confirmed as HCV-positive and 21,666 (1.72%) had elevated ALT. To estimate the additional margin of safety due to ALT screening, all donors who seroconverted were reviewed, and those donors who had elevated ALT but were HCV negative on a previous donation were identified. One hundred eleven HCV seroconversions were observed: 19 seroconversions from HCV 1.0-negative to HCV 1.0-confirmed-positive, 82 apparent seroconversions from HCV 1.0-negative to HCV 2.0-confirmed-positive, and 10 seroconversions from HCV 2.0-negative to HCV 2.0-confirmed-positive. The number of apparent HCV 1.0-negative to HCV 2.0-positive seroconversions was much greater than expected, which reflected the increased sensitivity of HCV 2.0. Only 15 donors were identified who had an elevated ALT on a previous HCV-negative blood donation, and all of these were among those who apparently seroconverted from HCV 1.0-negative to HCV 2.0-confirmed-positive. Out of the 10 HCV 2.0-seroconverting donors, no donor was found who was initially HCV 2.0 negative with elevated ALT and later was HCV 2.0 positive; nor were such donors found among 4 additional HCV 2.0-seroconverting donors. CONCLUSION: With the introduction of HCV 2.0 screening. ALT appears to have little value as a surrogate test for hepatitis C, and ALT testing was unable to detect any donors who later seroconverted, as detected by HCV 2.0.

Laparoscopic pelvic lymphadenectomy for malignant melanoma.

Therapeutic laparoscopic techniques are well accepted in many areas of general surgery. The use of laparoscopy for the staging of malignancy, in a diagnostic role, is not used widely. Urologists use pelvic lymph node dissection (LPLND) to define those patients who are suitable for curative local therapy in carcinoma of the prostate. We present a case of a patient with metastatic malignant melanoma in whom LPLND was employed as a minimally invasive way of staging and treating her disease.

A comprehensive transfusion medicine curriculum for medical students. Transfusion Medicine Academic Award Group.

BACKGROUND: The Transfusion Medicine Academic Awards (TMAA) program, sponsored by the National Heart, Lung, and Blood Institute, has provided grants to medical schools to help them develop comprehensive curricula in transfusion medicine. In 1989, the TMAA Group published a set of comprehensive curricular goals for teaching transfusion medicine. The medical student portion of this curriculum has now been revised to reflect new developments in transfusion medicine and recent trends in medical school education. STUDY DESIGN AND METHODS: Two medical schools independently revised the 1989 curriculum for their students. Because significant similarities were noted between curricula of the two institutions, the two revisions were combined and submitted to all TMAA institutions for comment. As a result, a revised medical school curriculum was developed and approved by the TMAA Group. RESULTS: The revised curriculum consists of 28 objectives in six major areas of transfusion medicine. It is presented in its entirety in this article. CONCLUSION: The TMAA transfusion medicine curriculum should provide to medical schools a valuable resource for evaluating their teaching of transfusion medicine and should provide to medical school deans and curriculum committees an authoritative source of transfusion medicine expertise.

The risk of acquiring Lyme disease or babesiosis from a blood transfusion.

To determine the risk of acquiring Lyme disease or babesiosis from blood transfusion, serum was collected before and 6 weeks after patients received multiple transfusions during cardiothoracic surgery and antibodies to Borrelia burgdorferi and Babesia microti were measured. Of 155 subjects, 149 received 601 total units of packed red blood cells (PRBC) and 48 received 371 total units of platelets. No patient developed clinical or serologic evidence of Lyme disease; 1 (who received 5 units of PRBC) developed clinical and serologic evidence of babesiosis. The risk of acquiring Lyme disease from a transfused unit of PRBC was 0 (95% confidence interval [CI], 0-0.5%) and from a transfused unit of platelets was 0 (95% CI, 0-0.8%); the same risks for babesiosis were 0.17% (95% CI, 0.004%-0.9%) and 0 (95% CI, 0-0.8%), respectively. The risk of acquiring either Lyme disease or babesiosis from a blood transfusion in Connecticut is very low.

Laparoscopic extraperitoneal inguinal hernia repair using a balloon dissection technique.

A laparoscopic extraperitoneal approach using a balloon dissection technique was used to repair 40 inguinal hernias in 35 patients. The initial experience with this method is presented. Thirty-four of these hernias were indirect, five direct and one sliding. Three were recurrent hernias. The operation time ranged from 40 to 135 min. Thirty-two of the patients stayed overnight in the hospital; Three stayed 2 nights. Return to normal activities ranged from 3 to 21 days. None of the patients had problems with nerve entrapment and to date there have been no recurrences of the hernias following the repairs. The procedure has been very well-tolerated by all patients.