Are blood transfusions safe?

The latest National Aids Control Organisation (NACO) report reveals a 10 per cent rise in the number of HIV cases through blood tranfusion in the past one year in India. Highlighting the risks associated with unsafe blood transfusions, Sumit Bagaria, CEO, Hemogenomics opines that the solution is ID-NAT (Individual Donor – Nucleic Acid Testing), an international standard blood screening test

We are aware that blood transfusions are required for surgery, trauma and loss of blood (accidents or other causes), some types of cancer, thalassemia etc. Most of us also believe that that blood obtained through a blood bank is 100 per cent safe and can be transfused to our near and dear ones. It is therefore a serious cause for concern that there is a rise of infections like HIV, Hepatitis B&C etc. being transfused through blood. The latest National Aids Control Organisation (NACO) released report in response to an RTI request reveal that 14,474 cases of HIV has been caused due to unsafe blood transfusion alone in India over the last seven years. Not just this, but observations from the report also reveals that there has been a 10 per cent rise in the number of HIV cases through blood transfusion over the last one year from 1,424 in 2014-15 to 1,559 in 2015-16. This shocking data brings to light the bitter truth that screened and tested blood available in blood banks might not be safe after all.

These are the number of cases which have been self reported by patients at NACO’s Integrated Counselling and Testing Centres (ICTC) spread across the country.  There are many cases which don’t even come to light and go unreported. Apart from HIV, other dreadful diseases such as Hepatitis B&C, malaria, dengue and syphilis can also pass through blood from an infected donor to a recipient. This increase in the reporting of the spread of infections through blood transfusions is an alarming situation.

Blood donation, no doubt is a noble act that should be encouraged. But, blood banks which collect blood from donors should be properly equipped to test each unit of donated blood and ensure that only safe blood is transfused to a patient. There are close to 2750 registered blood banks in India, which follow different screening techniques. The National Blood Policy says that every unit of blood that is donated at a blood bank should be thoroughly checked and tested to ensure that the blood does not contain any viruses or other infection. The last two decades have had significant up gradation of blood banks in India including licensing based on strict guidelines, screening/ testing of all collected units, quality systems etc.

Despite the testing and screening done at blood banks, every other day there are cases of people getting infected with HIV, HBV or HCV due to blood transfusion. This is mainly due to the testing method called ELISA (Serology) used in most blood banks that has some limitation to detect very early stages of infection in a donated blood unit. So, if a person who is in an early stage infection of HIV or Hepatitis donates blood, there is a higher risk of ELISA test failing to detect the infection in that blood unit due to very low concentration of viruses or antibodies present in the blood unit. However, when that blood unit is transfused to a recipient, the viruses multiply in the recipient’s body thus infecting the person.

Blood is required by patients during emergencies and various health conditions. While conditions like sickle cell anaemia and dengue require blood transfusions occasionally, Thalassemics and patients suffering from cancers like acute myeloid leukaemia and lymphoma require blood frequently. Emergency situations like surgeries and accidents require blood during times of blood loss. While there must be consistent effort in ensuring an adequate supply of blood units, making sure that patients get safe blood must be the top priority. There should be a multi-faceted strategy to tackle this issue. Encouraging and motivating regular repeat voluntary blood donations, better screening and counselling methods at blood banks, haemovigilance etc. are some of the measures which can be implemented in order reduce the number of transfusion transmitted infections. With the rise of digitisation, technology as well can be incorporated to tackle this issue. What mobile phones did to our telecom sector, technology can do for safer transfusion. App based systems focusing on demand and supply, geographic proximity of donor and blood bank, AADHAR-based tagging of donors etc. on one side to increase regular repeat voluntary donors, combined with the latest advances in screening and inactivation for viruses and other pathogens on the other, can almost end the chances of an infected sample being transfused.

One of the latest and most effective medical techniques used globally is the ID-NAT method of screening blood.ID-NAT (Individual Donor – Nucleic Acid Testing) is an international standard blood screening test where scientific evidence has shown that it has caught many cases of HIV and Hepatitis B&C infections that were not detected by conventional Elisa tests. It is a method of testing blood that is more accurate and detects early stage thereby decreasing the possibility of transmission of infection via transfusion.

Ravi Reddy, who heads the South African National Blood Services (SANBS) and is the current President of International Society of Blood Transfusion (ISBT) states that ID-NAT is the best screening technique that can be adopted to curb the spread of infections through blood transfusions. He has time and again emphasised that through implementation of ID NAT, South Africa was able to eradicate the spread of infections through blood transfusions. His thoughts have been echoed by Dr TR Raina, Secretary General of the governing body of Indian Society for Blood Transfusion and Immuno-haematology (ISBTI) who says that ID-NAT is the best technique to ensure blood safety in India.

This test which is mandatory in many countries continues to be an optional test in India. Most countries with known prevalence of HIV or hepatitis or TTIs now test each unit of blood individually for NAT. New Zealand, Australia, Egypt, Israel, South Africa, France, Denmark, Greece, Italy, and many countries do ID_NAT to keep their blood supply safe. Almost all of Asia which has high rates of hepatitis B including Japan, South Korea, Thailand, Singapore, Hong Kong, UAE, Saudi Arabia, Indonesia, Malaysia have moved from pooled NAT to ID-NAT. even low prevalence countries use ID-NAT for Zika and in season for West Nile Virus.

Several progressive hospitals and blood banks in India also ensure that their blood supply is safer by screening with ID-NAT technology.  These include AIIMS, Apollo, Fortis Hospitals including Escorts and FMRI, Medanta, Gangaram, RML, AFTC, Artemis, Jaypee, etc. in New Delhi/ NCR; PGI Chandigarh; CMC Vellore; Hinduja, KDAH, HN etc. in Mumbai; SIMS and Global in Chennai; Amrita and Aster in Kochi; CMC and DMCH in Ludhiana, International and Marwari Hospital in Assam and many more. Also, Karnataka Government is the only state government in India which has made ID-NAT mandatory in all government hospitals and blood banks. Recently, Indian Medical Association (IMA) has urged all hospitals in Kochi to adopt this technology to curb the spread of infections through blood. Also, Governor of Andhra Pradesh and Telangana States, ESL Narasimhan has suggested the new state body to introduce Nucleic Acid Testing (NAT) of blood donors for screening of HCV and HIV.

Some other sites are pooling six samples, which while providing some cost benefits, may pick up some infections in the serological window period but may also miss some TTIs as experienced in Japan, Thailand, etc. Recent publications show, for example that Thailand is detecting over five times as many Hepatitis B infections after moving to ID-NAT.

Even after adopting various precautionary methods and latest screening practices, there still remain a few challenges. Shortage of blood arising due to lack of voluntary blood donation, lack of a centralised national blood transfusion body, policies, appropriate infrastructure, trained personnel, financial resources to support the running of a voluntary non-remunerated donor transfusion service, and old & emerging threats of transfusion-transmitted infection are a few challenges that come in the way of safe blood transfusion in India which have to addressed and looked into by the government.