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• W2405492042 abstract "Original ArticlesDisease Markers in Blood Donors at King Fahad Hospital, AL BAHA Abdul Salam Al Omar and PhD Fouad El ZuebiMD Abdul Salam Al Omar Address reprint requests and correspondence to Dr. Al Omar: Clinical Laboratory, King Fahad Hospital at Al Baha, P.O. Box 204, Al Baha, Saudi Arabia. From the Department of Laboratory Medicine, King Fahad Hospital at Al Baha Search for more papers by this author and Fouad El Zuebi From the Department of Laboratory Medicine, King Fahad Hospital at Al Baha Search for more papers by this author Published Online:1 Jan 1996https://doi.org/10.5144/0256-4947.1996.37SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutAbstractA total of 4683 donated blood units were screened for HCV-Ab, HBs-Ag, HIV-Ab, VDRL, malaria parasites and ALT between January 1993 and April 1994. Of the blood units, 7.7% were positive for one or two hepatitis markers (HCV-Ab, HBs-Ag), while 4.6% were positive for HCV antibody, and 3.3% of the 4.6% were accounted for by Egyptian blood donors. Thus, 73% of all positive blood units for HCV-Ab were from Egyptian donors, while the rate of positive blood units for Saudi blood donors was 0.9%. Three and one-tenth percent of the total blood units were positive for HBs antigen, 2.3% from the Saudi population. Thus, 75% of all positive blood units were from Saudi donors. The percentage for HBs-Ag blood units for Egyptians was 0.3%. The exact prevalence of HCV-Ab-positive blood units among Saudis was 1.2% and HBs-Ag-positive units was 3.3%. Prevalence of HCV-Ab-reactive blood units among Egyptians was 34% and HBs-Ag-positive units was 3.3%. HCV-RNA using PCR was detected in a total of 86% of the individuals reactive to HCV antibody. Forty-three percent of hepatitis-B- and/or C-reactive blood donors had elevated alanine aminotransferase (ALT). Elevated ALT was observed in a higher percentage among HCV-Ab-reactive blood donors as compared to HBs-Ag-reactive donors.IntroductionBlood donors are a major source of diseases, especially viral infection. The most common blood-transmitted viruses are HBV, HCV and HIV. These viruses cause fatal disease and chronic and life-threatening disorders. Local, not imported, donated blood units at King Fahad Hospital, Al Baha, are screened for HCV-Ab, HBs-Ag, HIV-antibody, VDRL, malaria parasites and liver function (alanine aminotransferase, or ALT). If blood units were reactive to any one parameter, they were rejected and the donor was advised to visit the internal medicine clinic. IgG antibody to HCV was detected in 93% of acute and 91% of chronic non-A non-B hepatitis cases.1 This finding points to the possibility of transmission of HCV even when blood units are nonreactive to HCV-Ab. The introduction of the ALT value as a parameter will help to reduce the risk of transmitting HCV through transfusion. ALT value greater than the upper limit (65 U/L) by factor 1.5 (97 U/L) was taken as the criterion for rejecting the blood unit. Repeated ALT value greater than 97 U/L by a second blood donation from the same donor was considered as permanent rejection for any blood donation in the future. Excluding the use of donated blood with abnormal ALT results may have reduced the incidence of post-transfusion hepatitis.2The prevalence of HBV or HCV varies by nationality and geography. The prevalence of HBV infection among Saudi donors is known to be about three times higher than the incidence of HCV infection3,4 and the prevalence of HCV infection among Egyptian donors is high as well.5,6 The prevalence of HCV antibody among Saudi blood donors at four hospitals in the Riyadh area ranges between 1.0 to 1.7%, averaging 1.3%.3,4,7,8MATERIAL AND METHODFour thousand, six hundred and eighty-three donated blood units were screened by six laboratory tests: HIV antibody, HCV antibody, HBs antigen, VDRL, malaria parasites and a liver function test (alanine aminotransferase or ALT). The majority of the donors were between 20 and 40 years of age and more than 95% were males. All donors had a physical and hematological examination before donating blood. Some donors were volunteers, some were in a physical examination program for foreign workers, and other donors were replacing blood units taken from the blood bank for relatives. High-risk donors were minimized. The majority of donors were Saudis (73%), followed by Egyptians (10%). The other donors were of various nationalities.SamplesWhole blood was taken for malaria (thin film) and for PCR. Serum was collected for viral markers, VDRL and ALT. All these investigations (except PCR) were performed within 24 hours of donation.Liver Function TestsAlanine aminotransferase (ALT) was screened using dimension reagents (standard method). The normal level for ALT ranged between 35 and 65 U/L. Blood units exceeding 97 IU/L of ALT (according to the formula 1.5 × the upper normal limit of 65 IU/L) were discarded.Glutamyl transferase (GT) was screened using dimension reagents (Dupont, USA) for only six specimens, which were sent to Germany for polymerase chain reaction performance.Serological Screening Investigations1) Screening of HIV-Abs was carried out using recombinant third-generation enzyme-linked immunosorbent assay (ELISA), Abbott HIV-1/HIV-2, third-generation EIA, USA.2) Screening of HBs-Ag was performed using the ELISA system, Abbott IMX HBs-Ag, USA.3) Screening of HCV-Ab was performed using recombinant second-generation to detect antibodies to proteins expressed by putative structural and nonstructural regions of the HCV genome, Abbott HCV, EIA second-generation, USA.Polymerase Chain Reaction (PCR)EDTA blood, 0.5 mL, was drawn and sent to Bioscientia (Germany) to detect HCV-RNA using PCR technique. Ribonucleic acid (RNA) is first extracted from the plasma, followed by its reverse transcription into C-DNA and its amplification by using PCR. The amplified nucleic acid can then be detected by a specific color reaction. PCR method allows the detection of as many as 2000 HCV-RNA copies per mL of plasma.9Schistosoma TiterSchistosoma titer was determined by indirect hemagglutination test (IHA) from Behring. Diagnostically significant titers are present in the case of serum dilutions of 1:16 or higher. Mean serum titers of persons with schistosomiasis are between 1:256 and 1:1024. According to the Behring test instructions, low positive serum titers up to 1:64 should only be assessed together with the positive result of a second diagnostic method.Venereal Disease Research LaboratoryA fresh serum sample was examined by VDRL for the diagnosis of syphilis. Repeatedly positive samples were confirmed by the Treponema pallidum hemagglutination test (TPHA). Blood units reactive to VDRL and TPHA were discarded. Blood units reactive to VDRL only were assessed further, taking into consideration the clinical status and history of the donor using VDRL carbon antigen, Murex, England. Wellcosyph HA kit was used for the detection of antibodies to T. pallidum, Murex, England.Screening of Malaria ParasitesBoth thick and thin films should be made for a full diagnosis of malaria. For routine screening of blood units for malaria parasites, the hematology section performs only the thin film.RESULTSFour thousand, six hundred and eighty-three donated blood units were screened in this study. Three hundred and fifty-nine blood units were reactive to either HBs-Ag, HCV-Ab, or both. The rate of reactivity of the donated blood units for the period from January 1993 to April 1994 (16 months) was 7.7%. The majority of donors were Saudis (73%), followed by Egyptians (10%). Two hundred and twelve units out of the total 4683 (4.6%) were reactive to HCV antibody. This rate differs according to nationality. The prevalence of HCV antibody among Saudi blood donors was up to 1.2% (39/3190), but this rate among the Egyptian blood donors reached 34% (143 units/420) for the 15-month period. One hundred and forty-seven units out of a total of 4683 (3.1%) were positive for HBs-Ag for the period between January 1993 and April 1994 (Table 1). Prevalence of positive HBs-Ag for both Saudi and Egyptian donors was 3.3% (Table 2).Table 1. Prevalence of HCV-Ab and HBs-Ag among blood donors at KFH, Al Baha.Table 1. Prevalence of HCV-Ab and HBs-Ag among blood donors at KFH, Al Baha.Table 2. Prevalence of HCV-Ab and HBs-Ag by nationality in blood donors at KFH, Al Baha.Table 2. Prevalence of HCV-Ab and HBs-Ag by nationality in blood donors at KFH, Al Baha.In a separate study for one month in January of 1993, 42.4% of the investigated population were antibody (HBs-Ab and/or HBc-Ab) positive.Only two blood units were reactive to HIV repeatedly using ELISA. One out of the two was confirmed using Western blot, performed in the Central Laboratory in Riyadh. The two units were discarded.Liver Function Test (ALT)Alanine aminotransferase (ALT) has been used for the screening of blood units since November 1993. One thousand, seven hundred and eighty-two blood units were donated during the six months between November 1993 and April 1994. A total of 395 (22.2%) of the donated units had elevated ALT greater than the upper normal limit of 65 U/L. Seventy-one units out of the total 1782 have shown elevated ALT greater than 97 U/L. These 71 units were nonreactive to any other marker used to assess the blood units. The incidence of elevated ALT 1.5 times greater than the normal upper range among donated nonreactive units was 4.0% and these units were rejected for transfusion.Forty-three percent (58/135) of hepatitis-B- and/or C-reactive blood donors had elevated ALT (>65 U/L). Elevated ALT was observed in 50% (39/78) of HCV-Ab-reactive blood donors but in only 33% (19/57) of HBs-Ag-reactive blood donors (Table 3).Table 3. Elevated ALT among HCV-Ab- and HBs-Ag-reactive blood donors.Table 3. Elevated ALT among HCV-Ab- and HBs-Ag-reactive blood donors.Of the 1782 screened blood units, 14.9% or 266 were nonreactive to any viral indicators and had elevated ALT ranges between 65 and 97 U/L.Polymerase Chain Reaction (PCR)Blood samples of seven HCV-Ab-reactive asymptomatic individuals were sent to Bioscientia in Germany to perform HCV-RNA to assess the disease and to detect the presence of viral replication. Six out of these seven individuals were positive for HCV-RNA, and viremia was confirmed; only one was negative for HCV-RNA. The incidence of HCV-RNA among these seven individuals was up to 86%.. ALT was screened for all seven samples at least twice, at an interval of two to four months. Four samples out of the six HCV-RNA-positive patients had elevated ALT greater than 65 U/L.Normal liver function (ALT) was observed among the other two HCV-RNA-reactive patients and the HCV-RNA-negative sample.Glutamyl transferase was at least twice elevated in three samples of the six HCV-RNA-positive patients (Table 4).Table 4. Investigation of 7 HCV-Ab-reactive patients. HCV-RNA was detected in 6 of the 7.Table 4. Investigation of 7 HCV-Ab-reactive patients. HCV-RNA was detected in 6 of the 7.Schistosoma TiterTwenty-seven out of 58 (47%) donors reactive to HCV-antibody showed a significant schistosoma titer ranging between 1:256 and 1:4096. Thirty-seven out of 58 (64%) had a titer ranging between 1:128 and 1:4096. Schistosoma titer among HCV-Ab-reactive Egyptian donors was markedly high (10 with titer 1:128, 26 with titer between 1:256 and 1:4096) in 36 out of 50 donors (72%). Only one out of eight Saudis (12.5%) with HCV-Ab-reactive donor had a significant schistosoma titer greater than 1:128 (Table 5).Table 5. Schistosoma titer among HCV-Ab-reactive Egyptian and Saudi Blood donors.Table 5. Schistosoma titer among HCV-Ab-reactive Egyptian and Saudi Blood donors.Venereal Disease Research Laboratory (VDRL)All donated blood units for the period between January 1993 and April 1994 were screened by VDRL. Fourteen units were reactive and 12 out of 14 were confirmed by the Treponema pallidum hemagglutination test (TPHA). The antibody titer using TPHA ranged between 1:640 and 1:4096. The prevalence of reactivity for VDRL and TPHA among donated blood units was three for every thousand (3/1000). All of the 14 reactive units were excluded from transfusion.Malaria Parasite InvestigationWhen the thin film preparation was used, all donated blood units proved free of the malaria parasite.DISCUSSIONThe goal of this study is to assess the seroprevalence of hepatitis B, C and HIV virus infection. In addition to this, screening is also conducted for the syphilis markers (VDRL, TPHA) and the presence of malaria parasites.The prevalence of hepatitis B and C among blood donors has revealed findings which show the percentage of asymptomatic carriers of hepatitis B and C. Seventy-seven blood units for every thousand donated units were reactive to HBs-Ag and/or HCV-Ab and so were discarded. This number represents a relatively high percentage (7.7%) in comparison with Western countries. The prevalence of HCV-antibody carriers was up to 1.2% among Saudi donors compared to a prevalence rate of 1.0% to 1.24% among Saudi donors in the Riyadh area,4,8 and of 0.3% to 1.7% found in European and American donors.9-11The sensitivity of available HCV antibody kits is not enough to detect all patients with hepatitis C viremia and to exclude transmission of HCV infection, even when HCV-Ab is nonreactive. In a 1992 study by Prince et al.,12 only 13 patients out of 19 (68%) were detected by the most sensitive of the serological assays.Zanetti et al.13 describe three blood donors with viremia detected by the PCR, who were seronegative by standard anti-HCV enzyme-linked immunosorbent assay (ELISA, Ortho I).Hepatitis C is responsible for more than 90% of posttransfusion hepatitis. Hepatic C can be transferred through blood products (Factor VIII preparation), heterosexual contact,14 semen,15 body fluids and excretions. The positivity to HCV antibody points to reactivity of the immunosystem to hepatitis C virus; however, it will not give information about recent infection.High seroprevalence of hepatitis C was recorded here among Egyptian blood donors at 34%, comparable with the study from Darwish et al.,5 in which the positivity rate was up to 14.4 % for anti-HCV by RIBA test among Egyptian nonprofessional blood donors. Most of the HCV-Ab-reactive Egyptian blood donors are farmers, which indicates that HCV is widespread in rural Egypt.The introduction of the first- and second-generation HCV-Ab has contributed to control and reduction of the transmission of HCV. In one study from Kubanek et al.,16 the transmission of HCV was reduced to less than 1:5000 per unit, as judged from German data.Many asymptomatic donors reactive to HCV antibody could be chronic carriers with a low or high grade of viral replication. The chronicity of HCV infection varied among other studies and accounted for 61% of cases17 and 83.6% of patients acquired non-A non-B hepatitis by parenteral transmission.18 Chronic HCV infection among asymptomatic HCV carriers represents a population with a high incidence of infection, considerable socioeconomic problems and health problems.The screening of all blood units for hepatitis B surface antigen has markedly reduced the transmission of hepatitis B infection. In a study from Kubanek et al.,16 the transmission of hepatitis B was estimated to be on the order of 1:50,000, 10 times lower in comparison with the transmission of hepatitis C infection. The seroprevalence of hepatitis B among blood donors at the Al Baha area was up to 3.1% and it is relatively higher than in Western countries, but within the documented rate for Saudi Arabia.HBs antigen was detected in 4% of the blood donors in Riyadh and the Al Kharj area.3 A high rate of positivity to hepatitis B surface antibody and/or hepatitis B core total antibody was registered with 42.2% among our blood donors. This rate is comparable to one study among blood donors with a rate of 36.4%3 and another study of Egyptian blood donors to anti-HBs-Ab with a rate of 41.1%.5 According to nationalities, Egyptian and Saudi blood donors shared the same percentage of reactivity to HBs-Ag at 3.3%.A correlation between hepatitis and liver function is well known. Because of the long period of formation and response of the immunity for certain viral infections, especially among risk groups (e.g., immunosuppressed patients, etc.), alanine aminotransferase (ALT) and other enzymes such as glutamyltransferase (GT) can be considered as early markers of hepatitis. Twenty-two and two-tenths percent of all donated blood units have revealed elevated ALT values (>65 U/L). This high percentage of elevated ALT points to active infection of the liver. It is difficult to answer what value ALT has as a predictor of liver disease. It is known that patients reactive for HCV antibody show important elevation of ALT; however, ALT elevations may not occur for several months after viremia recurrence.1 ALT fluctuates up and down during the course of the illness with infective hepatitis C virus. Bernvil et al.4 reported that 24.1% of all HCV-Ab-reactive blood donors had elevated ALT. Our study indicates that this percentage may be more than twice as high (50%) among HCV-Ab-reactive blood donors. One reason for this high percentage could be the high prevalence of reactivity to HCV-Ab and positivity to schistosomiasis among Egyptian blood donors.Among 1782 screened blood units, a total of 93 blood units (5.2%) have had elevated liver enzyme levels above 97 U/L and 71 (4.0%) of them were HCV-Ab nonreactive.These 71 units with elevated ALT could be an important source of HCV transmission or other agents. The use of PCR technique has revealed that 86% of seven investigated HCV-Ab-reactive asymptomatic individuals were positive and viremia was confirmed. This result corresponds with one other study from Garson et al.19 in which HCV-RNA was detected in a total of 12 patients and represented 86% of the anti-HCV-positive group.HCV-RNA is a sensitive and specific marker of liver disease in HCV-Ab-positive subjects, independent of ALT values, and challenges the idea of the existence of true healthy carriers of HCV.20 Of 19 PCR-positive sera among blood donors, only 13 (68%) were detected by the most sensitive of the serological assays (Abbott). If these results are confirmed, automated PCR assays may be required for blood donor screening to prevent transmission of HCV.21The blood bank of KFH at Al Baha actually discarded 12% of donated blood units for the period between November 1993 and April 1994 on the basis of reactivity to HBs-Ag, HCV-Ab, HIV-Ab, VDRL and elevated ALT (>97 U/L). Rossi et al.22 have reported eight patients who had persistently normal ALT; out of these, chronic liver disease was found in seven patients and HCV-RNA was detected in all of them. Among individuals at risk of HCV infection are patients with acute and chronic active liver disease of unknown origin.The study of Koshy et al.23 has revealed that when patients with schistosomiasis develop cirrhosis, associated hepatitis C virus infection should be suspected.There was a strong association between reactivity to HCV-Ab and positivity to schistosomiasis antibody among Egyptian blood donors, which was not the case among Saudi donors (Table 5). It is true that schistosomiasis is widespread in Egypt, but it is also present in the Al Baha area.HCV-RNA testing is very useful in distinguishing healthy individuals from individuals with chronic liver disease. This study demonstrates the critical need for reducing the transmission of HCV through effective screening tests.ARTICLE REFERENCES:Quiroga JA, Campillo ML, Catillo I, Basrtolome J, Porres JC, Carreno V. IgM antibody to hepatitis C virus in acute and chronic hepatitis . Hepatol. 1991; 14:38–43. Google ScholarStandards Committee American Association of Blood Bank, 15th Edition., 1993. Google ScholarSaeed AA, Fairclough D, Al Admawi AM, et al.. Hepatitis C virus in Saudi Arabia - a preliminary survey . Saudi Med J. 1990; 11:331–2. Google ScholarBernvil SS, Andrews VJ, Kariem AA. Hepatitis C antibody prevalence in Saudi Arabian blood donor population . Ann Saudi Med. 1991; 11:563–7. Google ScholarDarwish NM, Abbas MO, Abdelfattah FM, Darwish MA. Hepatitis C virus infection in blood donors in Egypt . J Egypt Pub Hlth A. 1992; 67:223–36. Google ScholarSaeed AA, Fairclough D, Al-Admawi AM, Bacchus R, Al-Raseed AM, Waller DK. High prevalence of HCV antibody among Egyptian blood donors . 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Special thanks for the Laboratory secretary, Ms. Elizabeth Castro, for typing and organizing this paper and to Jonathan Brown for his editorial assistance.InformationCopyright © 1996, Annals of Saudi MedicinePDF download" @default.
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