(pt 1) exam #4 - immunohematology (cls 544)

donor selection, transfusion transmitted diseases

role of transfusion medicine 

• Blood collection: providing safe, satisfying experiences for our blood donors

• Manufacturing: accurately labeling and testing blood bank components provided to our transfusion services

• Transfusion service: accurate timely, transfusion to our clinicians and other members of the healthcare team

• Blood administration: safe, efficacious blood transfusions to our patients

purpose of blood centers

• responsible for supplying a safe and adequate blood supply to community

  • Recruiting people to donate crucial to ensuring blood available for transfusions

  • Reporting of adverse events in blood donor and recipients (hemovigilance)

volunteer vs paid donors

• Blood components intended for transfusion must indicate on the container label "paid donor" or "volunteer donor"

• Payment for donation has the potential to promote dishonestly

• Voluntary, non-paid blood donation with no coercion is felt to be the safest

governing agencies for blood collection 

• Governing agencies for processes including donor selection and donor unit processing

  • FDA

    • CFR / CBER

  • AABB Standards

  • College of American Pathologists (CAP)

  • European Union (EU) Standards

areas of regulation for blood centers

• donor selection

• blood collection & testing

• component production

• blood and component shipment / storage

• premises (fixed, temporary, and mobile) where blood is collected, processed, and stored 

donor health history screening (general)

• include donor history questionnaire (DHQ), mini physical examination, and serologic testing of the donor blood

• Donor identification and registration requirements confirm donor identity and link the donor to existing donor records

(donor health screening) physical examination & registration

• Physical examination

  • Donor's vital signs taken

  • Hemoglobin or hematocrit check performed

• Registration

  • Donors must present ID

  • Demographic information obtained

  • Donor deferral registry (DDR) or deferred donor director (DDD)

  • Donors given education materials prior to donating blood

(donor health screening) consent & informed consent

• Consent

  • Obtained prior to actual donation

  • Often incorporated with DHQ

• Informed Consent

  • AABB standards mandate that informed consent of allogenic, autologous, and apheresis donors be obtained

  • The donor must be informed of the risks of the procedure and the tests performed to reduce the risk of transmitting infectious disease(s) to the recipient

(donor health screening) confidential unit exclusion (CUE)

confidential way to indicate donor blood should not be used for transfusion

donor history questionnaire (general)

standardized set of risk-factor questions developed by a task force that included representatives from AABB, FDA, and the blood and plasma industry

• Determine eligibility of donor; protect donor and recipient

• Developed by AABB's donor history task force

• Contains more than 40 capture questions

• Available in an abbreviated format for use with qualified, frequent donors

• Self-administered questionnaires must be reviewed by trained personnel prior to blood collection

types of deferral (3)

1. Temporary: donor unable to donate blood for a limited time period

2. Permanent: donor will never eligible to donate blood for someone else

3. Indefinite: donor unable to donate blood for someone else for an unspecified period due to current regulatory requirements

medication deferral list

identifies medications that require donor deferral to protect safety of recipient

• Many medications restricted due to potential for causing teratogenic effects in the fetus of a female transfusion recipient

• Major medications types restricted from donation

  • Antiplatelet agents (i.e. Plavix, Feldene)

  • Anticoagulants (Coumadin, Xarelto, Lovenox)

  • Accutane

  • Drugs for treatment of benign prostatic hyperplasia and alopecia (Proscar, Avodart)

  • Drugs used to treat psoriasis (Soriatane, Tegison)

  • Drugs used to treat HIV

list of vaccines with no deferral period

• Allergy ; Anthrax

• Diphtheria (DPT, TDAP)

• Flu (including intranasal live attenuated)

• Recombinant vaccines

  • HPV / Hep B

• Gamma globulin (no exposure)

• RSV / Hep A (no exposure)

• Pneumonia / Paratyphoid

• Pertussis / Tetanus

• Typhoid (injection) / Polio (injection)

• Covid-19 (FDA-approved, nonreplicating, inactivated, mRNA-based)

list of vaccines with 2-week deferral period

• Measles (rubeola)

• Mumps

• Polio (sabin/oral)

• Typhoid (oral)

• Yellow fever

list of vaccines with 4-week deferral period (3)

• German measles (rubella)

• Chickenpox/shingles (varicella zoster)

• MMR (measles, mumps, rubella)

other deferral periods for select vaccines

• Hep A = 4 months

• Hep B = 3 months

• Hep A + B = 4 months

• Rabies = 12 months 

• IVIG = 4 months 

• HIV prevention (PrEP, PEP) = 2 years 

deferral period for juvenile detention, jail, prison

12 months

(miscellaneous deferrals) malaria illness + resident of malarial endemic country

3 years

(miscellaneous deferrals) travel to malarial endemic country for >24 hrs

3 months deferral

(misc deferrals) conditions that have a indefinite deferral

• dura mater graft/xenotransplant

• person with hep B/C

• person with sickle cell disease

(misc deferrals) conditions that have a permament deferral

• person w hemophilia/coag deficiencies

• polycythemia vera

• thalassemia major

• primary thrombocytosis 

(misc deferrals) conditions that have no deferral period

• person recovered from idiopathic TTP

• von willebrand’s disease not requiring treatment

• cancer in-situ of the vulva, cervix, or breast; papillary thyroid carcinoma treatment complete

• lung disease

• thalassemia minor trait

(misc deferrals) cancer & leukemia

• cancer: 1 year

• leukemia: 5 years 

(misc deferrals) cardiac bypass surgery, heart attack etc + pregnancy

• cardiac bypass surgery & heart attack: 6 month deferral period

• pregnancy: 6 week deferral

individual donor assessment

• Revised donor deferral recommendation for individual with increased risk for transmitted HIV infection

• Eliminates screening questions specific to:

  • Men who have sex w men (MSM)

  • Women who have sex w MSM

• Recommendations: assess eligibility using individual risk-based questions for all donors (regardless of sex or gender

creutzfeldt-jakob disease (CJD) vs variant CJD

• CJD--neurological disorders known as transmissible spongiform encephalopathies (TSE) or prion disease

  • Sheep, cows, and humans affected

• vCJD--a prion disease, human infection with the agent of bovine spongiform encephalopathy (BSE, "mad cow disease)

  • Prions--abnormal proteins found in the brain tissue of disease cattle, heat resistant, and UV light resistant

• Results in progressive dementia and spongiform alterations in the brain → fatal

types of donations (4)

• Autologous donation: donated by donors for their own use = "self"

• Allogenic donation: given for use by someone other than donor

• Directed or designated donation: for specific recipient

• Therapeutic donation: need further evaluation

physicial examination for blood collection (pic)

• donor center representative evaluates the prospective donor for the following:

  • General appearance, weight, temperature, pulse

(mini physical) minimum hgb levels for whole blood and plateletpheresis

• Females: 12.5 g/dL

• Males: 13.0 g/dL

• Max: 20 g/dL

• Autologous: >/= 11.0 g/dL

(mini physical) minimum hgb levels for DRBC & trima apheresis donation

• DRBC apheresis

  • 13.3 g/dL (either gender)

• Trima apheresis

  • Max: 18.4 g/dL

(mini physical) minimum hgb levels for plasmapheresis 

• Females: 12.5 g/dL

• Males: 13.0 g/dL

• Maximum 18.3 g/dL

general donation criteria

• Generally healthy, feeling well

• No infection

• No medications from the Medication Deferral List within specified timeframes

• Must read education materials (at every donation)

• No deferral on file (verify donor eligibility against donor deferral list)

frequency limits of blood/blood product donations

• Whole blood (every 56 days)

• Power red (every 112 days, up to 3x/year)

• Platelet (every 7 days, up to 24x/yr)

• Plasma--type AB (every 28 days up to 13x/yr)

whole blood collection sets

• WB collection sets are available in a variety of configurations

  • One primary bag to collect blood contains anticoagulant

  • Smaller bags (satellite) attached to main bag with plastic tubing

  • Large-bore needle (16 gauge) attached to collection set

(whole blood collection) anticoagulant preservative solutions

• Citrate phosphate dextrose (CPD) / Citrate Phosphate Double Dextrose (CP2D)

  • Shelf life of 21 days

• Citrate phosphate dextrose adenine (CPDA-1)

  • Adenine is used for making ATP

  • Shelf life of 35 days

(whole blood collection) additive solutions (AS)

preserving solutions that are added to the RBCs after removal of the plasma with/without plasma

• Extends shelf life of pRBCS to 42 days

• Currently four additive solutions are licensed in the US

  • Adsol (AS-1)

  • Nutricel (AS-3)

  • Optisol (AS-5)

  • SOLX (AS-7)

• Different formulations of saline, adenine, glucose, and mannitol (SAGM)

process of whole blood collection

• First step = confirm the donor's identity

• Select vein to be used for venipuncture and clean the area 

• Once blood collected in diversion pouch, pouch is sealed off

• Blood allowed to flow into tubing on other side of Y connector and into blood bag

• Important that blood collected is sterile

• Most whole blood donations completed within 5 to 10 minutes

RBC viability and storage lesion

• Loss of RBC viability has been correlated with the lesion of storage

• Associated with various biochemical changes within the pRBC unit

  • Glucose, ATP, pH and 2,3-DGP & # of viable cells all decreased

  • Lactic acid, plasma K+, and plasma Hgb all increased

autologous donations (general)

most autologous blood is used to treat surgical blood loss in very specific situations where there is a reasonable opportunity to avoid homologous transfusions and/or when compatible allogenic blood is not available

• Products cannot be placed into regular inventory if not used by the donor

advantages of autologous donations

• decreased risk of:

  • Disease transmission

  • Transfusion reactions

  • Alloimmunization 

disadvantages of autologous donations

• Bacterial contamination

  • Not permitted to donate if donor has condition for risk of bacteremia

• Circulatory overload

• Cytokine-mediated reactions and product/recipient misidentification

• High cost

methods of obtaining autologous blood (4)

• Preoperative Collection or Preoperative Autologous Donation (PAD)

  • Usually 5-6 weeks prior to surgery

  • max of 4 donations with 3-7 days in between, final donation no sooner than 3 days prior to surgery / transfusion

• Acute Normovolemic Hemodilution

  • Concurrent collection and replacement with crystalloids (volume replacements)

• Intraoperative Collection

  • Collecting shed blood from surgical site

• Postoperative Collection

  • Collected from a drainage tube placed at the surgical site

directed donation 

• Collected under the same requirements as allogenic donors but directed toward a specific patient

• tag for directed unit is a distinct color (pink)

• May lead to increased risk for patients

  • Infectious disease testing is performed on all directed donation units

  • If the donor is a blood relative, the unit must be irradiated to prevent GVHD

• Allogenic donations from unrelated volunteer donors may be set aside or collected for specific patient because of antigen matching

therapeutic donations

• Remove blood from patient, generally due to myeloproliferative disorder or neoplasm causing increased hematocrit

  • Hereditary hemochromatosis

  • Secondary polycythemia due to testosterone replacement therapy

• May only be performed with physician's order

• Done every few weeks as needed

apheresis (automated) collection

automated method for collecting a specific blood component while returning the remaining whole blood components back to the patient

• Blood separated into components with centrifugal force based on differences in density

• Can be used to collect large volumes of the intended component

  • Plateletpheresis, plasmapheresis, WBCs (granulocytes), single or double RBCs

• Donor requirements generally the same as for whole blood donation—time intervals between donations vary depending on component collected

donor reactions

• divided into 3 categories:

  • Mild--fainting (syncope), nausea/vomiting, hyperventilation, twitching, and muscle spasms

  • Moderate--includes mild reaction symptoms up to loss of consciousness

  • Severe--convulsions

what do you do in the case of an adverse donor reaction?

• Remove tourniquet and withdraw needle

• Place cold compress on donor's forehead

• Raise donor's legs above the level of head

• Loosen tight clothing

• Monitor vital signs

donor blood testing

• Blood donations must be tested for the following:

  • ABO/Rh typing

    • Weak D (when needed)

  • Antibody screen

    • Especially for donors with history of pregnancy(ies) and/or blood transfusion

  • Pathogens (see pic)

(transfusion transmitted diseases) what types of tests are performed on donated blood?

• Hepatitis B virus

• Hepatitis C virus

• HIV-1/2

• HTLV-I/II

• Syphilis

• West Nile virus

• Trypanosoma cruzi (Chagas' disease)

• Babesia: in states where testing is required by FDA guidance

(transfusion transmitted diseases) hepatitis A virus (HAV)

• Small, non-enveloped single stranded RNA virus in Picornaviridae family--most common of all hepatitis viruses

• Transmitted in unsanitary conditions that lead to contaminated food or water, then ingested (fecal-oral route)

• Incubation period ~4 weeks

• Symptoms include fatigue, fever, jaundice, and vomiting

• 25% of HAV infected persons are asymptomatic

hepatitis A virus transfusion testing

• Rare transmission through blood transfusion

  • HAV vaccine available since 1995

• Resistant to pathogen inactivation procedures due to no envelope

  • Pathogen inactivation is a process by which blood and blood products are treated to remove (or inactivate) infection agents

(transfusion transmitted diseases) hepatitis B virus (HBV)

• Enveloped double-stranded circular DNA viruses in the Hepadnaviridae family

• Vaccine available

• Transmitted sexually, parenterally, or vertically (from mom to fetus) via bodily fluids

• 95% of HBV infected persons have acute infection only and often asymptomatic

  • Virus can survive up to 1 week in dried blood

• Symptoms: flu-like, jaundice, fever, vomiting, and elevated liver enzymes

  • Complications include liver cirrhosis and hepatocellular carcinoma

transfusion considerations for HBV

• Antigens in serum of infected person: HBsAg, HBcAg, and HbeAg

  • Anti-HBc and anti-HBs can persist for years

• Transfusion-transmitted infection (TTI) rates declining due to deferral of high-risk donors, confidential self-exclusion, disease testing, vaccine use

(transfusion transmitted diseases) hepatitis C virus (HCV)

• Small enveloped single stranded RNA virus in Flaviviridae family

• Transmitted parenterally—e.g. infected needles

• Most acute HCV infections asymptomatic

  • Most cases go unresolved leading to chronic carriers

  • 80% of those infected become chronic carriers

• Symptoms include jaundice and elevated liver enzymes

• Long-term risks includes cirrhosis or liver and/or development of hepatocellular carcinoma

(transfusion transmitted diseases) hepatitis D virus (HDV)

• Small ssRNA virus; referred to as "delta hepatitis" virus

  • Only virus in the Deltavirus genus

  • Unique virus dependent on HBV--only occurs as a co-infection

  • Enveloped HCV particles contain HBsAG

• Transmitted through parenteral and sexual routes only in presence of HBV

• More severe, acute illness than those infected with HBV alone

• Assays to detect antibodies available but not recommended for donor testing

(transfusion transmitted diseases) hepatitis E virus (HEV)

• Nonenveloped RNA virus in the Caliciviridae family

• Mode of transmission similar to HAV via fecal-oral route

  • Not sexually transmitted

• Most cases are acute and do not proceed to chronic illness

• Serologic tests available--not recommended for donor testing

(transfusion transmitted diseases) hepatitis G virus (HGV)

• Enveloped RNA virus in Flaviviridae family

  • GBV-C/HGV

• Transmitted parenterally, sexually, and through blood transmission

• Does not cause hepatitis-like illness in humans

• Assays for identification are available but NOT recommended for donor testing

(transfusion transmitted diseases) HIV 1 / 2 (retroviruses)

• Human immunodeficiency virus (HIV) 1 & 2

  • Enveloped retrovirus in Retroviridae family

  • HIV-1 prevalent worldwide whereas HIV-2 is endemic in western Africa

  • Both are causative agents of acquired immunodeficiency syndrome (AIDS)

  • 40% of HIV infected persons exhibit flu-like symptoms

  • Can be asymptomatic for 10 years or longer

transmission and testing of HIV 1 / 2

• Transmitted parenterally, sexually, vertically, and through breast milk

• In end-stage HIV infection/AIDS, the immune system is depressed, and complications plus opportunistic infections rise

• Concerns regarding safety of blood supply led to detailed donor history requirements

• The window period has an impact on donor supply due to small percent of donors that present seronegative

  • Screening: HIV1/HIV-2 antibody and NAT

(transfusion transmitted diseases) HTLV I/II (retroviruses)

• Human T-cell lymphocytic virus (HTLV) I/II

• <10% incidence in the population

• Modes of transmission--parenteral, sexual, breast milk, and via blood transfusion

• Cell-associated virus highly concentrated in leukocytes

  • Refrigerated products (after 7 days) have demonstrated degradation of the virus

• Active infection asymptomatic and HTLV infection can be lifelong

• Screening: EIA test

(transfusion transmitted diseases) west nile virus (WNV)

single stranded enveloped RNA virus from the Flavivirus family

• Found primarily in bird species

• Transmitted through infected mosquitoes (Culex)

• Most infected persons are asymptomatic

  • Symptoms : flu-like symptoms, fever, rash, headache, vomiting

• Transmissible through blood products

  • Window period of two weeks

• Screening: NAT

• Positive: 4 months deferral

(transfusion transmitted diseases) zika virus

arbovirus in the Flaviviridae family

• Transmitted through infected mosquitoes (Aedes aegypti)

• Most infected persons are asymptomatic

  • Symptoms: flu-like symptoms, fever, rash, headache and muscle and joint pain

• Associated with severe neurological complication during pregnancy

• Transmissible through blood products

• Screening: NAT, ELISA, and immunofluorescence assay

• Positive: 120 days deferral

(transfusion transmitted diseases) cytomegalovirus

DNA virus and a member of herpesvirus group

• Transmission: direct contact of blood and body fluids, transfusion, and/or vertically

• Can remain latent for years

• Can cause severe and potentially life-threatening complications in high-risk groups

  • Immunosuppressed, fetuses/neonates, and marrow or solid organ transplant recipients

• Screening: ELISA, fluorescence assay, indirect hemagglutination, and latex agglutination testing

• Leukoreduction of blood products helps limit exposure

(transfusion transmitted diseases) epstein-barr virus (EBV)

• Herpesviridae family, dsDNA virus

• Acquired through infected saliva—”kissing disease"

  • Causative agent of infectious mononucleosis

• Symptoms include sore throat, enlarged lymph nodes, fever, lethargy, and malaise

• Bed rest and increased fluid intake resolves symptoms

• Risk population: immunocompromised

• Leukoreduction of blood products help limit exposure

(transfusion transmitted diseases) parvovirus B19

• Parvovirus B19 is the only known pathogenic human parvovirus

• Nonenveloped single stranded DNA virus

• Enters the RBC via the P antigen

• Infects RBCs and classified as an erythrovirus

• Transmitted through the respiratory route

• Associated with causing childhood illnesses such as erythema infectiosum or fifth disease

• Resistant to pathogen inactivation

(transfusion transmitted diseases) human herpes virus 6 & 8 

• Human herpes virus 6 (HHV6)

  • Viral agent causes roseola infantum or sixth disease

  • Transmitted through saliva, respiratory route

  • Not known to be transmissible through blood transfusion

• Human herpes virus 8 (HHV8)

  • Associated with Kaposi's sarcoma

  • Transmitted parenterally

  • Present in blood, and semen

  • Concern in immunosuppressed patients

(transfusion transmitted diseases) emerging viruses

• Chikungunya Virus (CHIKV)

  • Enveloped ssRNA virus of the family Togaviridae

  • Transmitted through mosquito (Aedes family) bite

  • Not known to be transmissible through blood transfusion

• Dengue Virus (DENV)

  • Enveloped ssRNA virus in Flavivirus

  • Transmitted through mosquito (Aedes family) bite

  • Concern in immunosuppressed patients

(transfusion transmitted diseases) prions

• Infectious self-replicating proteins that convert normal proteins into abnormal structures

• Group of diseases caused by prions called transmissible spongiform encephalitis (TSE)

• Affect brain and neurologic function

(transfusion transmitted diseases) creutzfeldt-jakob disease CJD

• Transmitted through human-derived pituitary growth hormones, infected electrodes for EEGs, neurosurgical equipment, and some transplant materials (cornea or dura mater)

• Symptoms:

  • Rapidly progressing dementia, poor coordination, visual problems, and involuntary movements

• All cases eventually fatal

(transfusion transmitted diseases) vCJD

• Fatal neurological disease

• Symptoms similar to classic CJD

• Occurs in persons younger than 55 yrs old

  • Classic CJD disease primarily seen in elderly persons

• Transmissible through blood transfusion

bacterial contamination of blood products

• Rare occurrence in RBCs/plasma

• Contamination during venipuncture at time of collection or manufacture and handling of blood components

• Donor with asymptomatic bacteremia

• High incidence of morbidity and mortality can lead to sepsis

• Immediate antibiotic treatment recommended

bacterial contamination in platelet products 

• Platelet products frequently implicated in transfusion-transmitted bacteremia (1 in 2,000)

• Staphylococcus,Yersinia, Pseudomonas, Serratia, Enterobacter, Bacillus and Salmonella, etc. have been identified in blood products

• Pathogen reduction methods (platelets):

  • Riboflavin +UVA/UVB

  • Cerus INTERCEPT: Psoralen + UVA (FDA approved)

  • UVC light + agitation

• Other method: leukoreduction, decontamination

(transfusion transmitted diseases) syphilis

• Infection caused by spirochete Treponema pallidum

• Spread through sexual contact

• Transfusion-transmitted syphilis is rare

• Screening: syphilis antibody EIA, FTA-ABS, TP-PA

• Positive: 3 months deferral

(transfusion transmitted diseases) lyme disease

• Spread by tick bite

• Causative agent: spirochete, Borrelia burgdorferi

• No cases of transfusion-transmitted Lyme disease have been reported

(transfusion transmitted diseases) babesiosis

•  Caused: Babesia microti

• Transmitted through deer tick bites and known to infect RBCs

• Most infected persons are asymptomatic

• Symptoms: fever, chills, lethargy, and hemolytic anemia

• May be treated with antibiotics

• Transfusion transmission reported

• Screening: NAT 

• Positive: 2-year deferral

(transfusion transmitted diseases) chagas disease

• Cause: flagellate protozoan Trypanosoma cruzi

• Transmitted through bite of reduviid bug

• Disease not common in U.S. ; prevalent in Mexico, Central and South America

• Screening: antibodies, enzyme strip assay (ESA), one time only

• If not properly treated, cardiac problems and other complications can be fatal

• Parasite resistant to refrigeration, cryopreservation procedures, and thawing

• Positive: permanent deferral

(transfusion transmitted diseases) malaria

• Caused: Plasmodium sp parasite

• Found mainly in Africa, Asia, and Latin America

• Transmitted through mosquito bite

• Symptoms: fevers, lethargy, hemolysis or RBCs with resulting anemia

• Prognosis good if treated promptly

• Screening positive: 3 years deferral

• Travel: 3 months deferral

(transfusion transmitted diseases) leishmaniasis

• Caused: Leishmania

• Transmitted by bite of infected sandfly

• Transmitted in blood and body fluids and through blood transfusion

• Endemic in Middle Eastern countries

• Positive screen: permanent deferral

• Travel: 1 year deferral

(transfusion transmitted diseases) toxoplasmosis

• Cause: Toxoplasma gondii

• Transmitted through undercooked meats and feces from farm animals and household pets

• Invades the WBCs

• Rare transmissions via blood transfusion reported

• Positive: 6-12 months deferral

(transfusion transmitted diseases) risk reduction strategoies

• Enhanced regulatory oversight of blood collection process

• Establish stringent blood donor eligibility criteria

• Tracking of infection rates for new and emerging pathogens

• New blood donor screening assays under development

• Development of pathogen inactivation methods (heat, organic solvents, and detergents)

• Quarantine and Look-Back