The tragic news of a young girl infected with HIV via a blood transfusion has exposed serious problems in blood screening procedures in Australia. The girl, a primary school student, was given a transfusion during surgery at a major children's hospital in Melbourne. It is the first reported case of such an infection since blood products began being tested for HIV in 1985.
The girl's parents went public in July, raising fears about the safety of current blood products being distributed through the Australian Red Cross Blood Services (ARCBS). Her father, a Melbourne surgeon, had been so concerned at the time of his daughter's surgery at Melbourne's Royal Children's Hospital, that he had volunteered his own blood.
"I was aware of the slim chance that the blood testing that is taken out by the Blood Bank can miss the patients who are just in the very first weeks of their (HIV) infection. The impression (the authorities gave me) was that it was an unnecessary hassle. The word I would use would be ‘complacent'," he said.
The authorities and the media have immediately gone into damage control mode. While admitting that the incident is shocking for the family involved, they have defended current blood testing procedures. Health officials have claimed that the infection was unavoidable and, in an attempt to prepare the public for worse, warned that it is unlikely to be the last such case.
ARCBS said the infected blood had slipped through the control system because the donor's blood was tested before antibodies to HIV could be detected. Health officials rushed to reassure a worried public, saying that the risk of receiving infected blood was minimal, around one in 1.2 million.
"There was no fault in any of the procedures carried out by the blood bank or the hospital. All the appropriate infection control measures were observed," said Dr Patrick Coghlan, a spokesman for the ARCBS.
"Almost 14 million donations have been collected and screened by the ARCBS in the past 14 years. This is the first such case in Australia since the introduction of testing," said Victoria's state chief health officer, Dr Graham Rouch.
Since then, the Red Cross has revealed that a new test is available, which would halve the window period for undetectable transmission of HIV from the current 22 days to 11 days. The ARCBS had planned to introduce the new form of screening, called nucleic acid testing (NAT) next April, but the government minister raised objections to the millions of dollars such a procedure would cost.
Currently the ARCBS has an annual budget of $150 million, of which 90 percent is required to run the day-to-day services of the blood banks—including blood collection, processing and transportation. NAT testing would cost around $30 million.
Federal Health Minister Michael Wooldridge had been increasingly critical of expensive testing. In May, he announced a 12-month review of blood banking and plasma products, citing concerns about burgeoning costs. "The international trend is for increasingly stringent testing of blood that yields marginal gains in safety but often at a high cost,” he said.
This argument was outlined more crudely and explicitly in a recent article in the Sydney Morning Herald by Julie Robotham entitled Blood Count: "For the huge cost, the NAT (Nucleic Acid Testing) technology may prevent one extra HIV case for every 1.2 million blood donations, according to the theoretical figures, or one case for 14 million donations, according to the actual incidence. And HIV is no longer a death sentence, with many people now living long and relatively well lives with HIV, thanks to new therapies. By the usual standards of cost-benefit calculations in a cash-strapped health service, NAT is an almost incomprehensible luxury."
It is hard to imagine a more callous comment, yet it is just such an attitude that underlies current government policy. Instead of calls for a major injection of funds into what is a beleaguered blood bank system, the introduction of new technology that will save lives is considered a "luxury" that cannot be justified. We are advised that the risk of contracting a serious, life-threatening infection from a blood transfusion is a reasonable risk when calculated on a cost-benefit ratio!
In fact, some in the media are taking this one step further by placing the onus on the family and the individual to provide blood for their own operations. They argue that directed donations of blood, such as that requested by the father of the young girl infected, should be considered because they represent a cheaper alternative.
Scientific research, however, has shown that donations from family members are more likely to carry viruses, and family members are less likely to reveal risky behaviours such as drug use or sexual contacts. In addition, a rare condition called graft-versus-host disease, where the transfusion takes over and rejects the recipient's original blood, is more likely among family transfusions.
As people have become more concerned about the safety of blood transfusions, there has been a trend to find a less risky option. It has become common place, for example, for people to store their own blood for their personal use.
A review panel has been established into Victoria's policy on directed blood donations, but both the girl's father and the Australian Medical Association have raised concerns about the independence of the panel. Two out of three medical specialists on the panel have direct connections to the Royal Children's Hospital, where the operation on the young girl was performed.
The real issue, however, is the running of the blood bank itself. Since the scandal erupted, the federal government has approved the funding for the NAT blood screening technology. This is ahead of the major review due next May, set down to investigate costs as well as the shortfall in supply of blood products. Currently the New South Wales branch of the ARCBS is almost running on empty with at most two days' blood supplies.
The Australian College of General Practitioners broke ranks with others in the medical profession and issued a public statement accusing both surgeons and the Red Cross of failing the young schoolgirl and saying that the blood banks had become "a little slack" with their donor screening procedures.
Dr Colin Hughes, the chair of the West Australian branch, also commented that "surgeons haven't really explained the patient options nearly as well as they should" because they were often in too much of a hurry to do so. He stated that several alternatives to blood transfusions had been developed over the years, including bloodless surgical techniques and artificial blood transfusions, but most patients went into surgery unaware of their options.
The Australian blood bank itself is facing major legal action. The service became a national operation in 1996 in line with international trends to establish a consistency in screening procedures and to consolidate services. The problems confronting the old state-based Red Cross Blood Banks, however, still persist. Three hundred people who believe they contracted hepatitis C from blood transfusions between 1985 and 1991 are suing blood banks around Australia.
Health authorities are trying to trace up to 700 Victorians to find out if they contracted hepatitis C from pre-1990 blood transfusions. Hepatitis C testing became available in Victoria only in February 1990. Since then, it has been established that a number of former blood donors, now known to be carrying hepatitis C, donated blood before the start of routine hepatitis C screening.
People are asking why it has taken nine years to track down some of the recipients. Andrew Grech, one of the lawyers representing the plaintiffs said: "The Red Cross has basically been left to its own devices to manage as best as it could. Until fairly recently there has never been any organised program, properly resourced, to look back comprehensively at blood donations through that period."
Dr Nick Crofts, one of Australia's leading hepatitis researchers, said the delay between the availability of testing and the tracing of potentially contaminated blood was the outcome of a "lack of resources".
While the Red Cross Society has denied liability for these cases, it has stated: "Negotiations are continuing with a view to limiting the financial exposure of the society arising from HCV [hepatitis C virus], current or future claims."
One gets the picture, from all these events, of a blood banking system that is seriously in crisis because of a lack of funds. The attitude of the federal government and the media has been to not only defend this situation, but to tell the public that they had better get used to it.
Blood services elsewhere face similar problems. Throughout the late 1980s many European, United States and Japanese blood bank systems came under attack after thousands of people became infected by blood that had not been screened for infectious diseases, including AIDS and hepatitis. Many of these people have since died.
The consequences of those scandals are still being felt. In France some government members were jailed for their part. The Canadian government has been forced, following a lengthy inquiry, to pay out millions in compensation to surviving victims. Canada's Red Cross blood bank was crippled by $C8 billion worth of payouts and became insolvent. In 1998 it was replaced by the Canadian Blood Services, a non-profit agency regulated by Canada's health department, and is already coming under stinging attack.
In the United States the Centres for Disease Control and Prevention has recorded a total of 39 transfusion-related cases of HIV since screening tests became available in 1985. Just recently, a man became the first person in Virginia since 1986 to contract HIV through a blood transfusion during bypass surgery at the Medical College of Virginia Hospitals.
There are, however, tests available that can greatly reduce the risk of infection. NAT is one such technology that halves the risk of contracting HIV. There are also filtering systems that reduce leukocytes (white blood cells). Clinical studies have shown that a reduction in leukocytes results in less infection, as well as fewer incidents of serious clinical transfusion complications such as rejection. At present, the Australian Red Cross does not filter out leukocytes, but is considering a change.
Unfortunately, as the case of the Melbourne schoolgirl has revealed, the decision to improve screening methods is not necessarily made on the basis of public safety, but on the “cost-effectiveness” of the procedure. As with so many victims of a failing health system, her infection is all the more tragic because it may have been preventable.