1. Blood and Blood Components Dr. Soheila Zareifar Pediatric Hematology/Oncology Department January 2016

2. Goals Of Blood Collection Maintain viability and function Maintain viability and function Prevent physical changes Prevent physical changes Minimize bacterial contamination Minimize bacterial contamination

3. Blood safety/ Transfusion safety SAFE TRANSFUSION PROCESS SAFE BLOOD COMPONENT

4. Blood Transfusion -Guidance and Regulations WHO recommendations WHO recommendations safe and adequate blood supply safe and adequate blood supply also clinical transfusion process also clinical transfusion process –Appropriate use of blood –Collection samples, patient ID –compatibility testing –Administration of blood –Adverse event reporting –Hospital transfusion committee ‘Better Blood Transfusion’ ‘Better Blood Transfusion’ EU Optimal Blood Use manual EU Optimal Blood Use manual (www.optimalblooduse.eu) (www.optimalblooduse.eu) Council of Europe 47 member countries

5. Infective risks Infective risks National Institutes of Health

6. Management chronic viral hepatitis in thalassemia: recommendations of an international panel Marco et al Blood 2010 116 2875 Hep C antibody in thalassemia patients Ref no. Anti- HCV + % 2006 Iran73219.3 2006 Turkey3994.4 2003 Thailand10421.2 2002 Lebanon39514 2001 India10421 Malaysia8522.4 2006 Iraq55967.3 Pakistan3560 Italy148185.2 Bahrain24220.5 Brazil3246.8 Hong Kong 9934 27 UK7323.3 Wonke B et al Clin Pathol 1990;43:638 23.3% of 73 patients positive Thompson et al 2011 Brit Journal of Haematol, 153, 121–128 Thalassemia Clinical Research Network Investigators: 169 of 697 Hep C Ab pos – 24% Cunningham et al 2004 Blood 104, 34 5% patients aged<16yrs 23% aged 16-24yrs; 70% aged 25yrs or older 1998

7. Viruses HIV HIV Hepatitis A Hepatitis A Hepatitis B Hepatitis B Hepatitis C Hepatitis C HTLV(I,II) HTLV(I,II) CMV CMV West nile virus West nile virus Simian foamy virus(SFV) Simian foamy virus(SFV) SARS SARS

8. Parasite and specific bacteria Malaria Malaria Babesiosis Babesiosis Chagas disease Chagas disease Leishmaniasis Leishmaniasis Syphilis Syphilis Lyme disease Lyme disease Other bacteria Other bacteria Skin flora Skin flora Variant Creutzfeld-Jacob disease(vCJD) Variant Creutzfeld-Jacob disease(vCJD)

9. Disease transmission. Donor selection criteria and subsequent screening of all donations are designed to prevent disease transmission, but these do not completely eliminate the hazards.

10. Hepatitis A Hepatitis A is rarely transmitted by transfusion. Hepatitis A is rarely transmitted by transfusion. Any donor who has been in close contact with Hepatitis A patient or develops hepatitis A is deferred for 12 months. Any donor who has been in close contact with Hepatitis A patient or develops hepatitis A is deferred for 12 months.

11. Hepatitis B Hepatitis B is a frequent sequel to blood transfusion. Hepatitis B is a frequent sequel to blood transfusion. Currently all blood donations are tested for HBsAg by very sensitive third generation techniques ( eg; ELISA ), able to detect at least 0.5 iu of HBsAg per ml of serum. Currently all blood donations are tested for HBsAg by very sensitive third generation techniques ( eg; ELISA ), able to detect at least 0.5 iu of HBsAg per ml of serum. Enzyme immunoassay (EIA) method is used with 99.9 % sensitivity. Enzyme immunoassay (EIA) method is used with 99.9 % sensitivity. HBsAg positive subjects are permanently excluded from donations.

12. Hepatitis C All donated blood are tested for anti – HCV. All donated blood are tested for anti – HCV. Improved screening assays based on Improved screening assays based on multiple recombinant or synthetic antigens multiple recombinant or synthetic antigens including viral core protein are now including viral core protein are now available. available. Individuals with a history of jaundice may be accepted as donors 1 year after the illness provided they tested and negative for HBsAg and anti HCV. Individuals with a history of jaundice may be accepted as donors 1 year after the illness provided they tested and negative for HBsAg and anti HCV.

13. Syphilis The organism is more likely to be transmitted in platelet concentrate due to their room temperature storage and short shelf life. The organism is more likely to be transmitted in platelet concentrate due to their room temperature storage and short shelf life. Treponema pallidum does not survive well at 4º c and red cell preparation are likely to be non infective after 4 days refrigeration. Passive transmission of the antibody to the recepient may cause diagnostic confusion. Treponema pallidum does not survive well at 4º c and red cell preparation are likely to be non infective after 4 days refrigeration. Passive transmission of the antibody to the recepient may cause diagnostic confusion. Any donations with positive result is discarded, any subjects with positive tests are permanently deferred, even after effective therapy. Any donations with positive result is discarded, any subjects with positive tests are permanently deferred, even after effective therapy.

14. Malaria Malarial parasites remain viable in blood stored at 4º C and easily transmitted by blood transfusion. Malarial parasites remain viable in blood stored at 4º C and easily transmitted by blood transfusion. In some endemic areas, all recipients are treated with antimalarial drugs. In some endemic areas, all recipients are treated with antimalarial drugs. Donors who come from endemic area or have had an attack of malaria can be accepted, their plasma can be used for fractionation but red cells must be discarded. Donors who come from endemic area or have had an attack of malaria can be accepted, their plasma can be used for fractionation but red cells must be discarded.

15. Cytomegalovirus Post transfusion CMV infection is not uncommon. Post transfusion CMV infection is not uncommon. The infection is characterized by fever, splenomegaly, and atypical lymphoid cells in the peripheral blood. The infection is characterized by fever, splenomegaly, and atypical lymphoid cells in the peripheral blood. Due to its benign course, screening for past infection among donors are not necessary. Due to its benign course, screening for past infection among donors are not necessary. However, there are patient at risk of developing fatal pneumonitis or disseminated CMV infection : premature baby < 1500g, BM or and other organ transplant recipient, pregnant women ( risk to fetus ). However, there are patient at risk of developing fatal pneumonitis or disseminated CMV infection : premature baby < 1500g, BM or and other organ transplant recipient, pregnant women ( risk to fetus ).

16. For them, anti – CMV free blood & components should be provided. In UK, incidence of CMV antibodies in adult population is 50 to 60 %. As an alternative, since CMV is cell associated, leukodepleted blood may be used.

17. Human immunodeficiency virus HIV can be transmitted both in cellular and plasma components. HIV can be transmitted both in cellular and plasma components. The majority of recipient of blood or blood products who have been infected in the past were transfused before 1985 with unheated, non pasteurized pooled plasma products, Factor VIII and IX. The majority of recipient of blood or blood products who have been infected in the past were transfused before 1985 with unheated, non pasteurized pooled plasma products, Factor VIII and IX. HIV is heat labile, therefore prolonged heat treatment of Factor VIII for hemophiliacs is effective. HIV is heat labile, therefore prolonged heat treatment of Factor VIII for hemophiliacs is effective.

18. Human immunodeficiency virus Routine screening of all donated blood started in October 1985. Routine screening of all donated blood started in October 1985. This in combination with donor education, and self deferral has reduced the risk of HIV transmission through contaminated blood. This in combination with donor education, and self deferral has reduced the risk of HIV transmission through contaminated blood. With screening program, HIV transmission still occur through donations given in the window period of infectivity. With screening program, HIV transmission still occur through donations given in the window period of infectivity. With current antibody screening technique, the estimated window period is about 3 weeks. With current antibody screening technique, the estimated window period is about 3 weeks. PCR for HIV RNA is able to reduce the window period to approximately 1 week. PCR for HIV RNA is able to reduce the window period to approximately 1 week.

19. Human T- cell leukemia viruses. HTLV I and II are related retroviruses. HTLV I and II are related retroviruses. HTLV I is endemic in the Caribbean, parts of Africa and in Japan, 3 – 6 % of the population are seropositive. HTLV I is endemic in the Caribbean, parts of Africa and in Japan, 3 – 6 % of the population are seropositive. HTLV I is associated with tropical spastic Para paresis and adult T cell – leukemia. HTLV I is associated with tropical spastic Para paresis and adult T cell – leukemia. Importance of HTLV II is not clear. Importance of HTLV II is not clear. Both HTLV I and II are cell associated and not transmitted in plasma. Both HTLV I and II are cell associated and not transmitted in plasma. Currently available test include ELISA and gelatin particle assay, but confirmation of positive result are difficult due to cross reactivity with other retroviruses. Currently available test include ELISA and gelatin particle assay, but confirmation of positive result are difficult due to cross reactivity with other retroviruses.

20. Viral Safety in Blood Transfusion Public concern was heightened by the disastrous consequences of HIV epidemic in 1980s Public concern was heightened by the disastrous consequences of HIV epidemic in 1980s In France, government officials and minister were charged with manslaughter for allowing HIV-contaminated blood to be used for transfusion at a time when screening test were available (1985) In France, government officials and minister were charged with manslaughter for allowing HIV-contaminated blood to be used for transfusion at a time when screening test were available (1985)

21. Viral Safety in Blood Transfusion Red Cross officials in Belgium, Switzerland, Canada were also convicted for distributing contaminated blood during the same period Red Cross officials in Belgium, Switzerland, Canada were also convicted for distributing contaminated blood during the same period Public perception – blood transfusion should involve absolute no risk of transmitting viral infection Public perception – blood transfusion should involve absolute no risk of transmitting viral infection

22. Viral Safety in Blood Transfusion Risk of transmitting infection to recipients has been drastically reduced in the past decades, due to Risk of transmitting infection to recipients has been drastically reduced in the past decades, due to a)Improved donor selection b)Sensitive serologic screening assays c)Application of viral inactivation procedures during manufacturing of plasma products

23. Residual Risk Major sources of remaining risk are: Major sources of remaining risk are: 1. Window period donation 2. Viral variants not detect by current assays 3. Immunosilent donor 4. Laboratory testing error

24. Residual Risk The greatest threat to the safety of blood supply is the donation by seronegative donors during the infectious window period The greatest threat to the safety of blood supply is the donation by seronegative donors during the infectious window period Window period donation account for 90% or more of the residual risk (Report of the Interorganization Task Force on NAT Testing of Blood Donors, 2000) Window period donation account for 90% or more of the residual risk (Report of the Interorganization Task Force on NAT Testing of Blood Donors, 2000)

25. Window Period Period precedes the development of antibodies during the initial infection Period precedes the development of antibodies during the initial infection Eclipse phase of the window period - the very initial phase after exposure when virus replication is restricted to tissue sites and there is no detectable viremia Eclipse phase of the window period - the very initial phase after exposure when virus replication is restricted to tissue sites and there is no detectable viremia Infectious phase of window period is after eclipse and before seroconversion Infectious phase of window period is after eclipse and before seroconversion

26. Window Period Animal study in chimpanzees (Murthy KK et al, Transfusion 1999) suggested that the eclipse phase is non- infectious for HIV Animal study in chimpanzees (Murthy KK et al, Transfusion 1999) suggested that the eclipse phase is non- infectious for HIV Direct detection of virus by very sensitive method theoretically eliminate the infective window phase if the assay sensitive exceeds the minimum infective dose for that virus (window period closure) Direct detection of virus by very sensitive method theoretically eliminate the infective window phase if the assay sensitive exceeds the minimum infective dose for that virus (window period closure)

28. Residual Risk Risk of acquiring a transfusion-transmitted viral infection depends not only on the length of specific window period but also on the incidence of the infection among blood donors Risk of acquiring a transfusion-transmitted viral infection depends not only on the length of specific window period but also on the incidence of the infection among blood donors

29. Determination of Residual Risk Study the rate of infection prospectively in transfusion recipients Study the rate of infection prospectively in transfusion recipients  Some pathogens, HIV & HCV, the risk is so low that exceeding large number of recipients & lengthy period are required for the risk to be measured accurately  Under-reporting

30. USAUKItalyAustraliaHK HIV1:493,000< 1: 2,000,000 1:408,0001:1,200,0001:877,147 HCV1:103,000< 1 : 200,000 1:230,0001:250,0001:86,137 HBV1:63,0001 : 50,000 – 170,000 1:63,4001:160,0001:3357 Source: (1) Muller-Breitkreutz K for the EPFA Working Group on Quality Assurance. Results of viral marker screening of unpaid donations and probability of window donations in 1997. Vox Sang 2000;78:149-157 (2) Aubuchon JP, Birkmeyer JD, Busch MP. Safety of the blood supply in the United States: opportunites and controversies. Ann Int Med 1997;127:904-909. (3) Regan FAM, Hewitt P, Barabara JAJ, Contreras M.on behalf of the current TTI Study Group Prospective investigation of transfusion in transmitted infection in recipients of over 20000 units of blood, Br Med J 2000;320:403-406. (4) Tosti ME, et al, An estimate of the current risk of transmitting blood-borne infections through blood transfusion in Itly. Br J Haemat, 2002;117:215-219.

31. THE END Thank you for your attention.