Overview of revised measures to prevent malaria transmission by blood transfusion in France.

Plasmodial transmission by blood donation is rare in non-endemic countries, but a very serious complication of blood transfusion. The French national blood service (Etablissement Français du Sang and Centre de Transfusion sanguine des Armees) intended to revise the measures to strengthen blood safety with regard to Plasmodiae as transmissible pathogens. To limit the risk of transmission during infusion, serious additive measures have been taken for more than a decade in France, which is the European country with the highest rate of exposure to imported plasmodial infections or malaria. These measures were revised and strengthened after the occurrence of a lethal transfusion-transmitted infection in 2002, but did not prevent another occurrence in 2006. This report examines the weaknesses of the systems and aims at emphasizing the safety measures already taken and addresses issues to best respond to that risk.

[One case report of anti-JK1 antibody undetected on plasma sample]. / A propos d'un cas d'allo-immunisation anti-JK1 non dépisté sur plasma.

The sensitivity of the detection of irregular antibodies (DIA) is one of the fundamental bases of transfusion safety. Its implementation is specified in accordance with a very specific framework that allows the use of serum or plasma. The case reported here points out a failure to detect irregular antibodies in plasma sample. Thus a low intensity anti-JK1 antibody detected and identified in serum slipped through unnoticed in plasma. The difficulties to detect and identify this antibody, well-known as a deceptive and dangerous one, are being discussed in order to better assess the limitations of DIA.

[French training program for medical students in transfusion medicine. Transfusion Medicine Teachers' College]. / Programme en transfusion des étudiants en médecine. Collège des enseignants en transfusion sanguine.

In France, transfusion medicine training program has been updated. A national committee of professors in transfusion medicine propose a series of 13 items which represent the minimum knowledge that general practitioners should possess. This overview of transfusion medicine is far below the level that specialists should reach and they will need an additional specialized training. Several French universities have set up their own training program which is quite similar to the work of the committee of professors. The following recommendations are not strict guidelines but is a common basis which will be improved in 2005 according to new evidence based transfusion medicine.

Allogeneic bone marrow transplantation for postpolycythemic myeloid metaplasia with myelofibrosis: a case report.

Myeloid metaplasia with myelofibrosis develops in about 10% of patients with polycythemia vera. We report a case of a 48-year-old female with postpolycythemic myelofibrosis successfully treated with allogeneic HLA-matched bone marrow transplantation.

[Specificity of immunofluorescent methods detecting malarial antibodies: comparative study in the screening of blood donations]. / Spécificité des techniques sérologiques de dépistage des anticorps anti-paludéens en immunofluorescence: étude comparative dans la pratique de qualification du don de sang.

UNLABELLED: In France, no case of transfusion-transmitted malaria has been reported since 1994, reflecting the efficiency of the blood donations screening. However, an insufficiently specific serological assay leads to an unjustified loss of red cell units. MATERIALS AND METHODS: A retrospective study included 55 sera previously disqualified for the presence of malarial antibodies. We used different assays detecting these antibodies: Paludix, Falciparum-Spot without or with the elimination of natural antiglobulins by two different methods. RESULTS: Using Paludix, 87% of sera were negative (P < 0.001). With the sera treated for the elimination of natural antiglobulins by neutralisation or absorption, Falciparum-Spot(TM) gave respectively 87% and 94.5% of negative results. CONCLUSION: When using assays avoiding non-specific fluorescence, the number of false positive results significantly decreased. Because the number of blood donors travelling in at-risk countries is continuously rising, a sufficiently specific method to detect malarial antibodies should save a lot of red cell units.

[Transfusional record and blood grouping methods: essential factors of transfusion safety]. / Dossier transfusionnel et techniques de groupage sanguin: éléments essentiels de la sécurité transfusionnelle.

The clinical and biological control of the whole transfusion process is a major preoccupation for everyone dealing with blood transfusion. Specially when the patient is a female recipient or belongs to a group with a high prevalence of alloimmunisation. This case report points out the outstanding importance of the immune compatibility, which must be strongly maintained to prevent any harmful consequences. The transfusional record transmission and a simple and sensitive blood grouping test are essential to increase transfusion safety.

[Consequences for labile blood products of leukocyte depletion by whole blood filtration using the Leucoflex LST1 in-line filter. Evaluation of the Leucoflex LST1 filter]. / Conséquences sur les PSL de la déleucocytation par filtration du sang total avec le filtre intégré Leucoflex LST1. Evaluation du filtre Leucoflex LST1.

The aim of this study is to evaluate the effects of whole blood filtration after a storage time of 20-24 hours at laboratory temperature using the in line filter Leucoflex LST1. The study concerns 49 blood donations in which we studied leukocyte depletion, proteins (IgG, IgA, IgM, haptoglobin, C3, C4), coagulation factors (fibrinogen, factors XII, XI, IX, VIII, V, proteins S and C, plasminogen, tPA, D-Dimers, PDF) at day 1, the parameters of conservation (ATP, 2-3 DPG, extra cellular potassium, haemolysis, pH) of red blood cell concentrates (RCCs) and bacteriological sterility at day 1 and 42. Despite a correct leukocyte depletion (mean depletion of 3.96 log), a 10 fold higher mean level of residual leukocytes/unit than with buffy coat poor RCC filtration (0.514.10(6) vs 0.051.10(6)) is observed. Moreover a lot of concentrates are not in accordance with French regulations (7/42 with more than 1.10(6) leukocytes/unit). The variation of the rates of IgG, IgA, IgM, haptoglobin, C4 and protein C is not significant. For the others there is a slight decrease with a mean level remaining in a physiological range. No sign of activation is noted. The sterility assays remain negative and the RCC conservation is not altered. In conclusion, even if the quality of the leukocyte depletion is not satisfactory in our study and has to be stated more precisely by multicenter studies, the whole blood filtration does not alter the quality of the derived components and allows us obtain RCC in a bigger volume and containing more haemoglobin than with the classical procedure after removing the buffy-coat [10].

[Erythrocyte concentrated and air transport: evaluation of quality]. / Concentrés érythrocytaires et transport aérien: évaluation de la qualité.

The available supply of blood products determines the resuscitation capabilities after natural disasters or armed conflicts. Air flight reduces transport delay. The purpose of the present study was to assess the quality of red blood cell concentrates (RCC) immediately after air transport (j0) and after preservation (j30). We exposed RCC to a real air flight (P) or to low pressure (V) corresponding to an air transport in experimental conditions. The quality of RCC was altered immediately after only the real air flight (hemolysis P = 0.11% versus 0.04% for witness (T)). These alterations were not observed immediately after the simulated flight (hemolysis V = 0.02%). After preservation, the RCC was altered both for those exposed to an air flight or to a low pressure (hemolysis: P = 1.09%, V = 0.78%, T = 0.25%). Other biological alterations (pH, K+, hemoglobin level) suggested that pressure variations are not the only one responsible constraint. Other studies are necessary to point the mechanism and the optimal life of conservation after flight. Exposure of preserved red blood cells to air transport alters their therapeutic properties during aging. However, the therapeutic use of RCC thus transported is not questioned.

[Blood preservation and air transport: study of physical constraints (temperature and pressure)]. / Conservation du sang et transport aérien: étude des contraintes physiques (température et pression)

We study physical compulsions of packed red cells during air transport. We found important variations of pressure and temperatures in blood transport box. These variations explain the biological alterations found in the first part. New rules for blood air transport are proposed.

[Fall in the seroprevalence of hepatitis A in French youth]. / Effondrement de la séroprévalence de l'hépatite virale A chez les jeunes français.

OBJECTIVE: An anti-hepatitis A virus seroprevalence survey was performed in 1997 in 1052 French army recruits (mean age: 21.2 years). To describe epidemiological trends, the current pattern was compared to previous results obtained by similar methods in 1985, 1990 and 1993. RESULTS: In 1997, overall anti-hepatitis A virus seroprevalence was 11.5%. The greatest risk factor of hepatitis A infection was related to travel in intermediate or highly endemic areas for hepatitis A virus: 46% of overseas residents (odds ratio = 10.3), 28% of recruits who had travelled in developing countries (odds ratio = 3.7) and 7.65% of French living in industrialised countries are anti-hepatitis A virus antibody positive. Moreover, seroprevalence was higher in subjects with a history of icteria (adjusted odds ratio = 3.5) and families with at least 3 children (adjusted odds ratio = 3). No association was found with drinking water, socioeconomic status such as baccalaureat degree, or parents profession. The seroepidemiological shift of hepatitis A, as assessed in three previous studies, shows a marked decrease of 20% in 12 years from 30.4% in 1985, to 21.3% in 1990, to 16.3% in 1993, and to 11.5% in 1997. The decrease in the prevalence of anti-hepatitis A virus was more marked in young adults who had never travelled in endemic countries (decrease of 20%) than those who had visited or lived in developing countries (decrease of 10%). CONCLUSION: Although France is not highly endemic for hepatitis A thanks to improved hygiene and housing conditions over the past 20 years, a pattern of intermediate endemicity was seen in French overseas areas in which the risk of outbreaks of hepatitis A was higher. The decrease in anti-hepatitis A virus seroprevalence in French youth can be used to draft a public health policy for hepatitis A control.

[Blood transfusion security: one train may conceal another!]. / Sécurité transfusionnelle: un train peut en cacher un autre!

The discovery of antibodies with specificities that are directed toward antigens of high prevalence is a difficult situation to manage in emergency blood transfusion. The reactions they produce interfere with the identification of reactions due to other, clinically significant antibodies. We report a case which illustrates this problem in terms of transfusion safety and time to carry out the tests.

[Results of ultrasonographic and cytologic follow-up of 311 initially non-suspicious thyroid nodules]. / Résultats de la surveillance échographique et cytologique de 311 nodules thyroïdiens initialement non suspects.

The follow-up of initially non suspect thyroid nodules after fine needle biopsy is not completely worked out. Since 1985, we have entered upon a prospective study concerning the followup of thyroid nodules supposed to be benign after initial evaluation. What are the nature and the frequency of means to be used for their follow-up? Three hundred and eleven nodules are followed up on a mean duration of 2.44 years. The follow-up of 65 of them is 4 years or more. The follow-up of 120 others is 3 to 4 years; 197 nodules are followed up during 2 to 3 years. A physical examination, an ultrasonography completed with a fine needle biopsy or an ultrasonically guided fine needle biopsy are worked out every year. Twenty-three per cent of initial biopsies are non significant and 90% of them are ultrasonically guided biopsies. At the end of the study, the repeating biopsies reduce to 6% the non significant biopsies ratio. Four histological thyroid cancers are detected in three female patients 1 year, 2 years and 5 years after the initial evaluation. Ultrasound alterations of nodules are observed in case of very suspect biopsies. Ninety-six per cent of the followed up thyroid nodules remain not cytologically suspect. These findings allow us to propose the following guidelines for the assessment of a non suspect thyroid nodule: half-yearly or yearly physical examination, yearly or biennial ultrasonography, repeat biopsy after 2 or 3 years when clinical or ultrasound suspect modification is wanting.

[Treatment of fulminant falciparum malaria with erythrapheresis]. / Traitement par érythrophérèse d'un accès pernicieux palustre.

Ten days after his return from Cameroon, a twenty-six year old Frenchman, serving on voluntary service overseas, presented with fulminant falciparum malaria: shock, altered consciousness, haemolytic anaemia, threatening disseminated coagulation (platelets less than 150 X 10(-6).l-1; prothrombin time and Stuart factor less than 50%; fibrinogen less than 1.5 g.l-1). In spite of quinine therapy, parasitaemia increased from 4 to 35% within 24 h. Using an Haemonetics V50, the exchange of one and a half red blood cell masses was carried out with 17 red blood cell packs. Calcium gluconate was used to prevent the hypocalcaemia induced by the anticoagulant solution. The patient's platelets and plasma were completely reinjected. The result was very satisfactory. This kind of exchange, well tolerated clinically and biologically, would seem better than the classical exchange transfusion. When 10% of the red blood cells are infected by Plasmodium falciparum, it is necessary to exchange from one and a half to two blood masses. Lesser exchanges are always associated with important relapses and quinine therapy must be carried on during and after the exchange. Restricting this exchange only to red blood cells enabled the patient to benefit from his own coagulation factors, antibodies and platelets, and consequently to reduce the number of blood donors involved. However, metabolites (especially bilirubin and circulating immune complexes) were not eliminated. Partial plasmapheresis may be associated with erythropheresis using human albumin as plasma substitute. This technique needs to be assessed, in order to optimize immediate efficiency and post-transfusion infectious risk.

[Comparison of techniques used to screen blood donations for malaria antibodies]. / Comparaison de techniques de dépistage des anticorps antipaludiques utilisées en transfusion.

In France all but one of the serological tests used to screen blood donations rely on ELISA-based techniques. The exception is malaria antibody detection that is performed by the indirect fluorescent antibody technique using commercially available kits. The reagent kit used at the French Army Blood Bank (FABB) is Falciparum-Spot IF (bioMerieux). However since the antigens in this kit are obtained from group A1 red blood cell cultures, false positive results can occur due to binding of natural antiglobulins. Over a 10-month period at the FABB, we disqualified a total of 55 donations (5.02% of total donations) because of positive Falciparum-Spot IF@1000 test results. Most disqualified donations (84%) involved donations with group O red blood cells. In the present retrospective study, these 55 disqualified donations were used to compare the specificity of three other serological tests used for detection of malaria antibodies: Falciparum-SpotIF after elimination of natural antiglobulins by absorption and neutralization with Witebski reagent and Paludix (Diagast). Use of all three techniques provided a specificity gain of over 87% but elimination using Witebski reagent led to a loss of sensitivity. At the FABB we have been using the Falciparum-Spot IF kit after elimination of natural antiglobulins since April 2001. Only 1.62% of donations tested have been disqualified due to the presence of malaria antibodies including 52% with group O red blood cells.

[The transfusion card: value, limitations]. / La fiche transfusionnelle: intérêt, limites.

The transfusion-sheet is an important document which appears first in the French legislation on May 1985 the 17. Its aim is to keep a close watch over transfusion of red blood cells, platelet concentrates and fresh frozen plasma and also immunohematologic evolution of data for every patient. In spite of its importance for everyone in charge of transfusion practice (physicians, biologists, transfusion center,...), a lot of problems may be observed in the strict and complete updating of the document. Informatisation of all the steps of the medical and biological practice appears of crucial interest to perfect its use.

[The blood donors' haemovigilance in France]. / L'hémovigilance des donneurs de sang en France.

This work aim to present the descriptive analysis of serious adverse reactions in donors (dSAR's), which were notified in 2010 and 2011 in the French national haemovigilance database "e-FIT" (Internet secured haemovigilance reporting system). Some data, which are necessary for this analysis, also come from the regional haemovigilance coordinators' reports (RHC). The other parts of haemovigilance in the context of donation, without donors adverse reactions, such as post-donation information (PDI), adverse events occurred in the blood collection steps of the transfusion chain and epidemiology are not subject to this work analysis. This work shows that the quality of the data gradually improved since the setting up of the notification system of dSAR's. These data are particularly rich in learning lessons, but are still improving. It allows us to confirm that donor's safety, blood components quality, while preserving the blood components self-sufficiency in France, remains a priority. For these reasons, it is important to continue this haemovigilance awareness and to implement necessary actions that would be required for the protection of the donor's health and comfort during donation.