Transmission of HIV by transfusion of HIV‐screened blood: the value of a national register

Abstract

A National Register of transfusion-transmitted infections was opened by the French Society of Blood Transfusion on 1 October, 1986. Out of 54 initially reported cases of HIV-infection, allegedly transmitted by blood components, further investigation could be completed in 33 cases. The transfusional origin of contamination was considered as established or probable in 28/33 cases, either because a potentially infectious unit was identified among those transfused to the recipient (23/28), or because the recipient was known to be seronegative before transfusion (5/28), or both (10/28). In 5/33 cases transfusion was considered as presumably responsible for contamination because no other risk factor was found in the recipient. Among the 33 documented cases of HIV-transmission by screened blood, 29 (88%) occurred between 1985 and 1987, and four (12%) during 1988. Out of 19 implicated donors later found seropositive, 16 belonged to a high-risk group for HIV-infection. The majority of HIV-infections occurred as a consequence of blood donation in the window period between contamination and the appearance of detectable antibodies in the donor's serum (11/19). In three instances, however, human and operational errors led to the release of seropositive units. We conclude that the main value of this Register is to provide a potential trend-indicator of transfusion-related infectious risks, to allow objective documentation of reported cases and to contribute to the improvement of blood transfusion practice.

Transfusion‐transmitted diseases: risks, prevention and perspectives

“…The implications of erroneous laboratory testing are illustrated by the report by Linden (165), in which 2 cases of transfusion-transmitted HIV infection from New York are described, caused by laboratory errors. In a large retrospective study using the French national register of transfusion-transmitted infections, 3 of 33 cases of HIV transmission by screened blood between 1985 and 1988 were attributable to human and operational errors (166). Automated data transfer systems and other improvements have, since then, reduced the risk for errors, but as long as manual steps are involved errors could continue to occur.…”

Transfusion errors in New York State: an analysis of 10 years' experience

“…However, the risk of adverse outcome from erroneous transfusion rivals or exceeds current estimates of the risk of acquiring infectious disease by transfusion 6,8 . In addition to donations from donors in the window period, infectious disease transmission has been reported to have resulted from error 9,10 . The use of facsimile machines for the transmission of results has been reported to contribute to this risk, 11 because text can be distorted during the transmission process, which can lead to misreading.…”

The release of unsuitable units through misinterpretation of laboratory results transmitted by facsimile

“…Although the potential for transfusion errors is well established, 3–6,11–13 with both reporting errors and laboratory errors having been documented as leading to the transmission of infectious diseases, 9,10 none of those mention transmission by fax as a contributory factor. These documents include information from oversight programs conducted by the New York State Department of Health 6 and the FDA 5 and from the United Kingdom's Serious Hazards of Transfusion program, which recently detailed 191 transfusion errors over 2 years 13…”

“…However, these estimates usually assume a negligible risk of error and the performance of testing at a blood center that utilizes the electronic transmission of data from the laboratory to the labeling location. Erroneous release of infectious units has been reported to have resulted from transcription errors, 9,10 some of which would not occur with today's blood center automation. Hospitals that collect blood on‐site seldom have access to such automated systems, however, and may have testing performed by a reference laboratory, often a blood center.…”