Correspondence
The Incidence of Post-Transfusion Hepatitis
N Engl J Med 1993; 328:1280-1281April 29, 1993
- Article
To the Editor:
We question the validity of the conclusion of Donahue et al. (Aug. 6 issue)1 that testing for non-A, non-B hepatitis surrogate markers caused a reduction in the incidence of post-transfusion hepatitis C virus (HCV) infection. Their data are also consistent with the hypothesis that there is only a temporal association between the institution of surrogate-marker testing and the reduction in the incidence of post-transfusion hepatitis between 1985 and 1990. Such a temporal association could be due to the concurrent institution of changes in blood-screening and transfusion practices. Whether the observed differences are causally or temporally associated could be determined by an analysis of trends over time within each of the time frames studied.
Unlike the United States, Canada did not begin testing its blood supply for non-A, non-B hepatitis surrogate markers. Thus, any reduction in the incidence of post-transfusion hepatitis in Canada during the years covered by the study of Donahue et al. would have to be attributed to factors other than surrogate-marker testing. In Canada, testing for antibodies to human immunodeficiency virus type 1 began in September 1985, and testing for antibodies to HCV began in May 1990. As outlined by Dodd (Aug. 6 issue),2 in addition to these tests, several other measures have been introduced since 1985 to improve blood-donor screening in both the United States and Canada. These include the direct questioning of blood donors about their medical history and social behavior, with the deferral of those admitting to high-risk activity3.
The incidence of post-transfusion non-A, non-B hepatitis in Canada was reported to be 9.2 percent in 19854. In 1988, a multicenter, prospective, double-blind, randomized, controlled study was initiated to investigate the effect of testing blood donors for non-A, non-B hepatitis surrogate markers. Enrollment in this study is now complete (with 4621 participants), and the final results should be available soon. Preliminary data indicate that the incidence of post-transfusion non-A, non-B hepatitis in patients who received unscreened blood is less than 1.5 percent. This reduction in incidence in Canada, from 9.2 percent in 1985 to less than 1.5 percent in the late 1980s, cannot be attributed to surrogate-marker testing, but rather to improved methods of donor screening. The possible role of surrogate-marker testing in reducing the incidence of post-transfusion hepatitis will be clearer when the results of our prospective, randomized, controlled trial become available.
4 ReferencesM.A. Blajchman, M.D.
McMaster University Medical Centre, Hamilton, ON L8N 3Z5, CanadaS.V. Feinman, M.D.
Mount Sinai HospitalS.B. Bull, Ph.D.
Samuel Lunenfeld Research Institute of Mount Sinai Hospital, Toronto, ON M5G 1X5, Canadafor The Canadian Post-Transfusion Hepatitis Prevention Project
1
Donahue JG ,Munoz A ,Ness PM , et al. The declining risk of post-transfusion hepatitis C virus infection. N Engl J Med 1992;327:369-373
Full Text | Web of Science | Medline2
Dodd RY . The risk of transfusion-transmitted infection. N Engl J Med 1992;327:419-421
Full Text | Web of Science | Medline3
Chiavetta JA ,Nusbacher J ,Wall A . Donor self-exclusion patterns and human immunodeficiency virus antibody test results over a twelve-month period. Transfusion 1989;29:81-83
CrossRef | Web of Science | Medline4
Feinman SV ,Berris B ,Bojarski S . Posttransfusion hepatitis in Toronto, Canada. Gastroenterology 1988;95:464-469
Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: Blajchman et al. point out that in addition to surrogate-marker testing and testing for antibodies to HCV, several procedures used for the selection and exclusion of blood donors in both the United States and Canada between 1985 and 1991 could have influenced the risk of post-transfusion hepatitis. We certainly agree that other selection procedures could have influenced the risk of post-transfusion hepatitis from HCV. However, we believe that the introduction of surrogate-marker testing in October 1986 produced a major reduction in the risk of post-transfusion HCV in the patients in our study. Our data suggest that other procedures for donor exclusion and selection did little to reduce the rate of transfusion-associated HCV infection in the interval between October 1986 and May 1990. We base our conclusion on an analysis of the rates of transfusion-associated HCV infections in the years after routine surrogate-marker screening was instituted in October 1986. These data were obtained by testing our entire cohort of patients undergoing cardiac surgery who received transfusions, using a licensed second-generation enzyme-linked immunosorbent assay (Ortho/Chiron) for HCV antibodies. These results were confirmed by a recombinant immunoblot assay (RIBA-4, Ortho Diagnostics), and the data are shown in Table 1Table 1
Rates of HCV Seroconversion in Patients Undergoing Cardiac Surgery Who Received Transfusions, According to Whether Screening for Surrogate Markers Was Performed..Our data show that there was an abrupt decrease in the rate of post-transfusion HCV infection when surrogate-marker testing was introduced in October 1986. However, there was no further change in the rate until May 1990, when serologic testing for antibodies to HCV was introduced.
We are aware that other countries did not institute surrogate-marker testing. Several of those countries, however, including Canada, Japan, and Spain, have reported higher rates of post-transfusion hepatitis than the United States for the interval from 1986 through 1989. In 1985 and 1986, we detected a rate of post-transfusion HCV infection of 4.49 per 100 patients receiving transfusions; the reported rate of post-transfusion hepatitis in Canada was 9.2 percent1. Similarly high rates have been reported in Japan2 and Spain3.
A separate, very important question is whether surrogate-marker screening should be continued, since it is now possible to test for antibodies to HCV. Perhaps a study such as that described by Blajchman et al. could provide an estimate of the current efficacy of surrogate-marker screening.
3 ReferencesKenrad E. Nelson, M.D.
Faruque Ahmed, M.B.B.S., M.P.H.
Paul Ness, M.D.
Johns Hopkins Medical Institutions, Baltimore, MD 21205James G. Donahue, D.V.M., Ph.D.
Channing Laboratory, Boston, MA 021151
Feinman SV ,Berris B ,Bojarski S . Posttransfusion hepatitis in Toronto, Canada. Gastroenterology 1988;95:464-469
Web of Science | Medline2
Japanese Red Cross Non-A, Non-B Hepatitis Research Group
CrossRef | Web of Science | Medline3
Esteban JI, Gonzalez A, Hernandez JM, et al. Open prospective efficacy trial of anti-HCV screening of blood donors to prevent posttransfusion hepatitis: interim report of the Barcelona PTH study. In: Hollinger FB, Lemon SM, Margolis HS, eds. Viral hepatitis and liver disease. Baltimore: Williams & Wilkins, 1991:431-3.
To the Editor:
There is no question that the incidence of post-transfusion non-A, non-B hepatitis decreased significantly in the United States, coincident with the widespread implemention of surrogate-marker screening. This has been demonstrated not only by the serologic studies of Donahue et al.1 but also by an evaluation of trends in the reporting of post-transfusion hepatitis to the American Red Cross2 and by surveillance studies conducted by the Centers for Disease Control and Prevention3. Interestingly, the decrease seemed to occur somewhat earlier than would have been expected had it been solely due to the effects of the testing. Chambers and Popovsky showed that in Massachusetts there was a significant decline in community reporting rates for hepatitis B and non-A, non-B hepatitis during the period from 1985 through 19884. The decline in the number of cases of post-transfusion non-A, non-B hepatitis reported to the Red Cross from Massachusetts and Maine paralleled the overall decline that occurred from 1985 to 1986, after which there was a further decrease beyond that for overall reporting. This decrease was attributed to the additional effect of surrogate-marker testing4.
The observation of Blajchman et al. thus supports the concept that there was indeed a decrease in the incidence of post-transfusion non-A, non-B hepatitis that was not associated with testing alone. Until the Canadian study is fully analyzed, however, it will not be possible to establish the independent contributions of factors other than surrogate-marker testing. Although the data from Canada may not be fully comparable to those from the United States, I look forward to the publication of these data with considerable interest. Perhaps of more importance will be the light that should be shed on the critical question of whether surrogate-marker testing continues to contribute to transfusion safety, given the efficacy of current tests for antibodies to HCV.
4 ReferencesRoger Y. Dodd, Ph.D.
American Red Cross, Rockville, MD 208781
Donahue JG ,Munoz A ,Ness PM , et al. The declining risk of post-transfusion hepatitis C virus infection. N Engl J Med 1992;327:369-373
Full Text | Web of Science | Medline2
Dodd RY . Screening for hepatitis infectivity among blood donors: a model for blood safety? Arch Pathol Lab Med 1989;113:227-231
Web of Science | Medline3
Alter MJ ,Hadler SC ,Judson FN , et al. Risk factors for acute non-A, non-B hepatitis in the United States and association with hepatitis C virus infection. JAMA 1990;264:2231-2235
CrossRef | Web of Science | Medline4
Chambers LA ,Popovsky MA . Decrease in reported posttransfusion hepatitis: contributions of donor screening for alanine aminotransferase and antibodies to hepatitis B core antigen and changes in the general population. Arch Intern Med 1991;151:2445-2448
CrossRef | Web of Science | Medline
- Citing Articles (3)
Citing Articles
1
Fumitomo Sato, Yoshinobu Hata, Shuichi Sasamoto, Nobuhide Kato, Keigo Takagi, Yujiro Takai, Chikako Hasegawa, Kazutoshi Shibuya. (2007) A case of postoperative pulmonary cavity triggered by nasal CPAP after partial resection using an ultrasonic scalpel. The Journal of the Japanese Associtation for Chest Surgery 21:6, 809-813
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Michael P. Busch. (2006) Transfusion-transmitted viral infections: building bridges to transfusion medicine to reduce risks and understand epidemiology and pathogenesis. Transfusion 46:9, 1624-1640
CrossRef3
CHRISTOPHER J GRESENS, PAUL V HOLLAND. (1998) Current risks of viral hepatitis from blood transfusions. Journal of Gastroenterology and Hepatology 13:4, 443-449
CrossRef
