In December last year, a pregnant woman was transfused with blood from a donor who was HIV-positive and had hepatitis B. The transfusion took place at a state government hospital in Sattur of Virudhunagar in Tamil Nadu; the hospital had sourced the blood from a laboratory run by a private agency in Sivakasi of the same district. Preliminary investigations have found that the lab had failed to detect that the donor’s blood was HIV-positive.
This was followed by a similar scare last week, when a woman in Chennai claimed that she too had been infected with HIV following a transfusion at a government medical college. The second case is being probed.
How do government health facilities tackle the obvious risk? What went wrong?
The standard procedure
Besides probing the donor’s medical history and current health, the standard procedure is to mandatorily screen for five diseases — HIV, hepatitis B, hepatitis C, syphilis and malaria — before blood is collected. Blood-testing equipment being used across Tamil Nadu is procured by National AIDS Control Organisation (NACO) from vendors who follow WHO standards. “They are supposed to be the best in standards and results. Our ongoing probe will look into that aspect as well,” said K Senthil Raj, project director of Tamil Nadu State AIDS Control Society (TNSACS).
NACO has an External Quality Assurance Scheme under which it conducts annual refresher programmes in tie-up with experts from CMC Vellore besides doing random sampling for laboratories and technicians. This is being held at 89 government-run and 196 private blood banks in Tamil Nadu, where about 8 lakh people donate blood annually.
According to TNSACS, the state has 780 integrated counselling and testing centres, 1,367 facility integrated counselling and testing centres, 156 designated STI/RTI (Sexually Transmitted Infection/Reproductive Tract Infections) clinics, 288 blood banks, 55 antiretroviral therapy (ART) centres, 174 link ART centres, 72 targeted intervention projects and 15 link worker schemes and HIV prevention initiatives at the rural level.
When it can go wrong
A government-appointed four-member team of microbiologists and transfusion experts is revisiting the protocol followed leading to the Virudhunagar transfusion. It is looking at two aspects — human error and the quality of equipment. A preliminary investigation by the Health Department suggests that a human error led to the donor’s blood being wrongly reported as HIV-negative. While various health experts stressed the importance of hiring qualified personnel, the lab technician who wrote the report was indeed qualified, it has emerged. She had graduated from a government medical college and was employed with the private agency that runs the lab, said an officer who is part of the probe team. She has been dismissed from service.
The investigation by the Health Department has found that the donor had given blood earlier too, in August 2016, which was discarded when it tested positive for HIV and hepatitis B. Counsellors supposed to follow up his case, however, failed to do so. Two counsellors have been dismissed.
Donor and recipient
The preliminary investigation report states that the 19-year-old donor was initially not aware that he was HIV-positive and had hepatitis B. The donor, who has since committed suicide, had last donated blood on November 30 at a Sivakasi government hospital for a relative. The relative received blood from another donor and the teenager’s blood was transported to another hospital. The pregnant woman received the blood on December 3 at Sattur government hospital, about 20 km from Sivakasi.
A week later, the donor went for a blood test in another hospital and learnt that he was HIV-positive. His revelation that he had donated blood eventually led to the woman being tracked down. “Within two days, we started Antiretroviral Therapy for her,” said R Manohar, Virudhunagar district Joint Director of Health Services.
Risk to baby
Raj of TNSACS is hopeful that the baby will not get the infection as the mother received ART within a few days of the transfusion with infected blood. ART is essentially meant to minimise the viral load in the body. “We have to be careful during the delivery too. We will have to avoid any injury on the baby’s skin during the process. The baby will be also given nevirapine syrup, an antiviral drug, in the first six to 12 weeks,” Raj said.
State Health Secretary J Radhakrishnan said a nine-member team with senior doctors has been appointed to take care of the woman at Madurai Rajaji Hospital.
A senior professor in Chennai Medical College said hepatitis B poses a bigger risk to the woman’s life; HIV can often be controlled and a normal life ensured with the support of medication.