171 International Journal of Human and Health Sciences Vol. 07 No. 02 April’23 Original Article Occurrence of Transfusion Transmitted Infections Among Transfusion Dependent Thalassemia Patients in A Tertiary Care Hospital in India Banduriap Lyngdoh1,Sunita Bagdi1, Sulekha Ghosh2,Tapan K. Ghosh3 Abstract Background: Blood transfusion is an important treatment modality in the modern health care system; however, transfusion transmitted infections(TTI) could be fatal or life-threatening in some cases. Objective: To determine the occurrence of transfusion transmitted infections among transfusion dependent thalassemia patients and to study the socio-demographic characteristics of the recipients. Methods: This hospital-based descriptive longitudinal studywas conducted between February 2019 and June 2020, on 102 transfusion-dependentthalassaemic patients receiving blood transfusion at Bankura Sammilani Medical College & Hospital, Bankura,West Bengal, India. They were tested for HIV, HBV, HCV, syphilis and malaria by ELISA (Enzyme Linked Immunosorbent Assay) Lisa Scan EM, Merilisa HBsAg, Merilisa HCV, RPR kit and Maleriscan malaria Pf/Pv. Results: Out of 102 patients, 5.90% were positive for TTI. The highest occurrence was found to be of HCV 3.90%. HBV and HIV showed similar occurrence of 0.98% and none came out positive for syphilis or malaria. The highest occurrence of TTI was found among females 66.7%. The average age of the participants was 7.97±3.27years. The average number of blood transfusion received per year was 11.95±2.71units. Majority of the participants belong to low socio- economic group family 62(60.8%). In respect to ethnicity 14.7%were tribal, while 85.3%were non-tribal population. Conclusion: The cause of high prevalence of HCV may be due to donors being asymptomatic in early stages and failure of detection due to window period of infection. More sensitive screening tests should be done for HIV, HBV, and HCV. All donors must be screened by NAT if not possible the patients must be screened for TTI regularly.Thalassemia patients being the most affected, premarital screening for thalassemia should be done.Every patient should be vaccinated with hepatitis B vaccine. Keywords: transfusion transmitted infections, blood transfusion, thalassemia Correspondence to: Dr. Banduriap Lyngdoh, Senior Resident and Demonstrator, Department of Pathology, Bankura Sammilani Medical College & Hospital, Bankura, West Bengal, India. Email: banduriap@gmail.com 1. Senior Resident and Demonstrator, Department of Pathology, Bankura Sammilani Medical College& Hospital, Bankura, West Bengal, India 2. Professor, Shantiniketan Medical College, Bolpur, West Bengal, India.. 3. Blood Bank Centre,Shantiniketan Medical College Central Laboratory, Bolpur, Birbhum, West Bengal, India Introduction FDA defines a TTI as a pathogen that is known to be fatal, to be life-threatening, or to cause severe impairment and that is potentially transmissible through the blood supply.1 Blood transfusion is an important treatment modality in the modern health care system and though lifesaving but unfortunately it can be one of the sources of infective diseases.2A number of blood-borne infectious agents can be transmitted through transfusion of blood and blood products donated by apparently healthy and asymptomatic donors.3 International Journal of Human and Health Sciences Vol. 07 No. 02 April’23 DOI: http://dx.doi.org/10.31344/ijhhs.v7i2.570 International Journal of Human and Health Sciences Vol. 07 No. 02 April’23 172 The diversity of infectious agents includes human immunodeficiency viruses 1 and 2, hepatitis A to E (HAV, HBV, HCV, HDV and HEV), malaria, syphilis, human T-lymphotropic virus types 1 and 2 ( HTLV type 1 and 2) and in certain circumstances cytomegalovirus, parvovirus B19, and many more.4-6 Besides, the established viral, bacterial, and parasitic diseases, novel agents have now appeared and are still emerging as potential threats in transfusion medicine.7The most common TTI are due to viral infections. Incidence of bacterial contamination is greatly reduced due to improved collection techniques and use of antibiotics in patients. According to NACO guidelines, all mandatory tests should be carried out on donor’s blood samples for HIV, HBV, HCV, syphilis and malaria.8In India, it is mandatory to screen donated blood for anti-HIV 1 and 2 (since 1991), anti-HCV (since 2001), HBsAg, syphilis, and malaria. Blood TTIs mainly occur in patients who are dependent on blood transfusion such as haemoglobinopathies, myelodysplastic syndromes and some haemato-oncology patients, receiving multiple transfusion episodes, either over long periods or over shorter periods.9Beta thalassemia major is a hemoglobinopathy also known as Cooley’s anemia, is a global health problem characterized by severe hemolysis.10 Though regular blood transfusion improves the overall survival of patients with β-thalassemia, a definite risk of infection with blood-borne viruses occurs.11While in the past it was believed that transfusion transmitted infections were unavoidable, but a low risk of blood supply is expected today.12The provision of safe blood for transfusion involves a number of processes, from the selection of blood donors to collection, processing and testing of blood donors by sensitive methods to the testing of patient samples for detection of various infections. Methods This hospital-based descriptive longitudinal study was conducted between February 2019 and June 2020, on 102 transfusion-dependent thalassaemic patients receiving blood transfusion at Bankura Sammilani Medical College & Hospital, Bankura, West Bengal, India. Inclusion criteria:All the seronegative thalassemia patients receiving blood transfusion from BSMC&Hospital, Bankura, West Bengal, India during the study period from February 2019 to June 2020 were included in the study by complete enumeration. Exclusion criteria: Seriously ill recipients and seropositive thalassemic patients All transfusion dependent thalassaemicpatients receiving blood transfusion from the blood bank of the study site hospital were tested for HIV, HBV, HCV, Syphilis and malaria by ELISA(Enzyme Linked Immunosorbent Assay) Microwell Plate, Lisa Scan EM, Merilisa HBsAg, Merilisa HCV, RPR kit and Maleriscan malaria Pf/Pv. History of educational status of the parents, income, address was taken. Then seronegative recipients were approached. After obtaining consent they were included in the study. They were interviewed with the help of a structured questionnaire. Their blood samples were tested at the time of presentation and thereafter every five months for HIV, HBV and HCV, syphilis, and malaria for a period of twelve months. Techniques: • HIV status is detected by ELISA (Enzyme Linked Immunosorbent Assay) Microwell Plate, Lisa Scan EM for the detection of antibodies to HIV1 and HIV 2 • Hepatitis B status is detected by using Merilisa HBsAg for the detection of hepatitis B surface antigen • Hepatitis C status is detected by using Merilisa HCV for the detection of antibodies to hepatitis C virus • Syphilis status is detected by Rapid plasma reagin kit test • Malaria is tested by rapid diagnostic kit (MALERISCAN) Statistical analysis:All data were analyzed through standard statistical methods by using Statistical Package for Social Science (SPSS) software version 22.0 (SPSS Inc., Chicago, USA). Results All the 102 participants were tested for HCV antibodies by Merilisa HCV in February 2019 and all were seronegative for HCV. The patients 173 International Journal of Human and Health Sciences Vol. 07 No. 02 April’23 were further tested in August 2019 and showed two HCV positive patients. In February2020, the patients were again tested, and another two new patients were positive as shown in the table 1.The same participants were tested for HIV antibodiesby ELISA (Enzyme Linked Immunosorbent Assay) Microwell Plate, Lisa Scan EM on different dates in February 2019 and were seronegative. They were again tested in the month of August 2019 and February 2020 and one patient as shown positive in the table 2. The same patients were tested for HBV antigen by Merilisa HBsAg in February 2019, August 2019, February 2020 and one patient came positive during the last test (Table 3). None of the patients showed double positivity for the infection. The participants were tested for syphilis by (RPR) and malaria (Maleriscan Pf/Pv) in February 2019, August 2019, and February 2020. None were positive for syphilis and malaria. Among 102 patients, 6/102 (5.90%) were positive for TTI (Figure 1). The highest occurrence of was HCV 4/102 (3.90%), followed by HBV and HIV 1/102 (0.98%) (Figure 2). None of the patients were positive for syphilis and malaria during the study. The average age of the participants was7.97±3.27 years. Out of 102 patient 35were females and 67were males, showing ratio of Male:Female=1.9:1, and the average number of blood transfusion received per year was 11.95±2.71 units. Majority of the participants came from low socio- economic group family 62(60.8%), 30(29.4%) from middle group of socio-economic status and 10(9.8%) from high socio-economic group. In respect to ethnicity 14.7% (15) were tribal and 85.3% (87/102) were non-tribal population. Table 1:Result of HCV screening No of patient tested Date Report of HCV ELISA N=102 Feb 2019 All non reactive N =102 August 2019 2 seropositive N =102 Feb 2020 2 patient sero reactive Total 4 Figure 2:Result of HIV screening No of patients tested Date Report of HIV ELISA N=102 Feb 2019 All non reactive N =102 August 2019 All seronegative N =102 Feb 2020 One patient sero-reactive Total 1 Table 3: Result of HBsAg screening No of patient tested Date Report of HBs Ag ELISA N=102 Feb 2019 All negative N =102 August 2019 All negative N =102 Feb 2020 1 patient sero reactive Total 1 Figure 1: Percentage of TTI positive patient Figure 2:Incidence of HCV, HIV, HBV Discussion The probability of acquiring TTIs is related to the probability of being exposed to the infected units of blood. The probability of being exposed to infectious units of blood depends on the number of units transfused and prevalence of carriers among the donor population .Variations in the prevalence of TTIs amongst thalassemics could be related to geographical differences in prevalence of the viral infections among blood donors and the nature of blood donors whether replacement or voluntary. The countries with a higher prevalence of HCV in the general population had a higher prevalence of HCV among thalassemia patients too.13 There International Journal of Human and Health Sciences Vol. 07 No. 02 April’23 174 is high prevalence of HCV in thalassemics in all countries because of the unique profile of HCV with very long window period for antibody development. Our study showed highest occurrence of HCV infection 4/102 (3.90%). The highest prevalence of HCV was also seen in studies like Gugnani et al.14 of 13.4%, Sidhu et al.15 of 13.04%, Manisha et al.16of 18.2%. Post-transfusion transmission of HCV has still remained a major health concern in multi-transfused patients. Hepatitis B infection was found in one patient out of 102 patients (0.98%). Gugnani et al.15 found the prevalence of HBV to be 0.79% which was comparable to the present study being 0.98%. Jain et al.17showed positivity of 1.04% for HBV.The reduction in the prevalence of HBV may be due to hepatitis B vaccination prior blood transfusion. However, only few studies have been done on transfusion transmitted syphilis and malaria.15,16 Those two previous studies also found no positive cases for syphilis and malaria, which is similar to our study finding. The highest incidence of TTI was found among females 66.7% (4/6) in our study, although the male participants were in higher number i.e., 65.7% (67/102). Our finding is notcongruent with the findings ofAhmed Kiani et al.18, which showed that male became more TTI positive than in females (73.4% vs. 26.6%). In the present study 60.8% (62/102) participants belong to low socioeconomic status. Yasmeen & Hasnain19studied that post transfused TTI positivity is more in low socioeconomic status.19 The average age of the participants was 7.97±3.27 years. The average number of blood transfused per year 11.95±2.71 units and majority of the recipients 85.3% (87/102) were non-tribal population. Over the decade, TTI magnitude has significantly reduced, but hepatitis C is still a main hazard. HBV vaccination have led to a dramatically decrease in prevalence of TTIs particularly HBV during the last decades in various countries. TTIs can still occur even after regular screening for the markers for these infections, as found in different Indian and international studies. This risk of acquiring a TTI from screened blood depends upon the sensitivity of the screening tests used, window-period of the virus, and other reasons, such as mutant strains. Nucleic acid testing (NAT) is widely recommended for the screening of donor blood. It reduces the window period of 2.93 days for HIV, to 10.24 days for HBV, and to 1.37 days for HCV and better chances of detecting false negative cases.19 Though the cost for NAT testing is considered unaffordable for a medium development country such as India, the burden of TTIs will place an unmanageable cost burden on the society. Now with the introduction of the fourth-generation ELISA test that detects p24 antigen along with antibodies, the window period can be reduced to 2 weeks. Conclusion The highest occurrence was found to be HCV which reflects the unsafe practices. The causes of high prevalence of HCV may be due to donors being usually asymptomatic in early stages, despite being screened for HCV possibly due to missing early window period infections. Awareness about screening should be made so that more patients are diagnosed early. Thalassemia patients being the most affected, premarital screening for thalassemia should be done. Screening of all the registered pregnant women for thalassemia status must be done. Parents should be counselled for prenatal testing of thalassemia. Every patient should be vaccinated with hepatitis B vaccine. More sensitive screening tests should be used for HIV, HBV, and HCV. All donors must be screened by NAT if not possible the patients must be screened for TTI regularly. Proper precautions for safe transfusion practices should be adhered to. Conflict of interest:None declared. Funding statement: No funding. Ethical Clearance: The study was approved by the Ethical Review Committee of Bankura Sammilani Medical College & Hospital, Bankura, West Bengal, India. Authors’ contribution:All authors were equally involved in data collection, analysis, manuscript preparation, revision and finalization. 175 International Journal of Human and Health Sciences Vol. 07 No. 02 April’23 References 1. 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