- Email: [email protected]
No need for bad blood over bad blood
Editorial
On March 25, UK Prime Minister David Cameron formally apologised for the events uncovered by the Penrose Inquiry into hepatitis C virus (HCV) infection in blood recipients. The inquiry concluded with a recommendation of mass screening for HCV infection of all recipients of blood and blood products in Scotland before September, 1991. The inquiry estimated that almost 3000 people had been infected with HCV and 78 with HIV. However, although some people might conclude that the apology implies culpability, the inquiry itself found that little could have been done differently. This inquiry was started in April 23, 2008, to examine the circumstances by which individuals acquired HCV from blood and blood products in Scotland up to the introduction of a test for the virus in blood introduced in 1991. The acquisition of HIV was also included in the inquiry. The reference period was set as Jan 1, 1974, to Sept 1, 1991. The comprehensive 1800 page text of the inquiry presents the history of blood transfusion in the UK and goes on to detail the stories of the identification of HCV and HIV, which will be familiar to many readers of The Lancet Infectious Diseases. Briefly, hepatitis transmission via blood transfusion was recognised by the 1940s. However, the need for blood and blood products was usually urgent, so the risk was deemed an alarming sideeffect, but for patients with the greatest need, such as those with severe haemophilia, the risk was thought to be acceptable because it was similar to that of other treatments. By the early 1970s, two viruses causing hepatitis (A and B) had been characterised, and donated blood was screened for their presence. However, the sensitivity of this testing was imperfect, so infections continued. By 1974, some recipients of blood and blood products were developing hepatitis not attributable to known viruses. The new disease was dubbed non-A non-B hepatitis and was thought at the time to be a mild disease. This perception changed only 10 years later, but little could be done to tackle the presence of non-A non-B hepatitis until the virus was identified in 1988 and given the name hepatitis C virus; these details were published in 1989. Once the virus was identified, steps were taken to assess the risk of viral infection posed by blood and blood products and subsequently to acquire www.thelancet.com/infection Vol 15 May 2015
screening tests when they became available. The formal implementation of HCV screening was delayed by concerns of whether HCV was genuinely the cause of non-A non-B hepatitis and by efforts to validate testing kits. Of course, during the same period HIV also emerged. However, its identification as a blood-borne infection progressed much more rapidly than for HCV. Within 3 years of AIDS coming to the attention of the international medical community in 1981, blood and blood products were being screened for HIV. Furthermore, heat treatment of blood products soon halted the spread of HIV via transfusion and this also greatly reduced the transmission of HCV even before it was ultimately characterised. Another, possibly more crucial, aspect of blood transfusion safety assessed by the inquiry was the selection of blood donors. During the period in question it had been proposed by international bodies, such as WHO, that injecting drug users and prisoners had an elevated risk of infection with hepatitis B and so were undesirable as blood donors. However, official guidance within the UK did not caution against the taking of donations from prisoners, and injecting drug users were only excluded if they volunteered their history of drug use. The risks posed by these donors were reassessed in the wake of HIV emergence, which, much like the heat treatment of blood products, mitigated the spread of hepatitis. It does not take particularly close inspection to reveal that the question truly at the centre of the discussion of ensuring the safety of blood and blood products, is how blood is acquired. It is easy to point out mistakes after the fact, but expecting authorities to have near omniscience about future infections is clearly not a workable approach to public health policy. In 2013, The Lancet published its Series on blood transfusion that began by outlining that HCV infection of blood recipients played an important part in revising the view that blood from apparently health donors was safe. For high-income countries such as the UK, the strongest measures to ensure blood safety are simple and practical: optimise use to limit the inherent risks and guarantee that donation is voluntary and non-renumerated, as called for by WHO. ■ The Lancet Infectious Diseases
Paul Mayall/dpa/Corbis
No need for bad blood over bad blood
For more on the Penrose Inquiry see http://www.penroseinquiry. org.uk/ For more on The Lancet Series on blood transfusion see Lancet 2013; 381: 1789 For more on the need for voluntary blood donation see http://www.who.int/ bloodsafety/ publications/9789241599696/ en/
487
On March 25, UK Prime Minister David Cameron formally apologised for the events uncovered by the Penrose Inquiry into hepatitis C virus (HCV) infection in blood recipients. The inquiry concluded with a recommendation of mass screening for HCV infection of all recipients of blood and blood products in Scotland before September, 1991. The inquiry estimated that almost 3000 people had been infected with HCV and 78 with HIV. However, although some people might conclude that the apology implies culpability, the inquiry itself found that little could have been done differently. This inquiry was started in April 23, 2008, to examine the circumstances by which individuals acquired HCV from blood and blood products in Scotland up to the introduction of a test for the virus in blood introduced in 1991. The acquisition of HIV was also included in the inquiry. The reference period was set as Jan 1, 1974, to Sept 1, 1991. The comprehensive 1800 page text of the inquiry presents the history of blood transfusion in the UK and goes on to detail the stories of the identification of HCV and HIV, which will be familiar to many readers of The Lancet Infectious Diseases. Briefly, hepatitis transmission via blood transfusion was recognised by the 1940s. However, the need for blood and blood products was usually urgent, so the risk was deemed an alarming sideeffect, but for patients with the greatest need, such as those with severe haemophilia, the risk was thought to be acceptable because it was similar to that of other treatments. By the early 1970s, two viruses causing hepatitis (A and B) had been characterised, and donated blood was screened for their presence. However, the sensitivity of this testing was imperfect, so infections continued. By 1974, some recipients of blood and blood products were developing hepatitis not attributable to known viruses. The new disease was dubbed non-A non-B hepatitis and was thought at the time to be a mild disease. This perception changed only 10 years later, but little could be done to tackle the presence of non-A non-B hepatitis until the virus was identified in 1988 and given the name hepatitis C virus; these details were published in 1989. Once the virus was identified, steps were taken to assess the risk of viral infection posed by blood and blood products and subsequently to acquire www.thelancet.com/infection Vol 15 May 2015
screening tests when they became available. The formal implementation of HCV screening was delayed by concerns of whether HCV was genuinely the cause of non-A non-B hepatitis and by efforts to validate testing kits. Of course, during the same period HIV also emerged. However, its identification as a blood-borne infection progressed much more rapidly than for HCV. Within 3 years of AIDS coming to the attention of the international medical community in 1981, blood and blood products were being screened for HIV. Furthermore, heat treatment of blood products soon halted the spread of HIV via transfusion and this also greatly reduced the transmission of HCV even before it was ultimately characterised. Another, possibly more crucial, aspect of blood transfusion safety assessed by the inquiry was the selection of blood donors. During the period in question it had been proposed by international bodies, such as WHO, that injecting drug users and prisoners had an elevated risk of infection with hepatitis B and so were undesirable as blood donors. However, official guidance within the UK did not caution against the taking of donations from prisoners, and injecting drug users were only excluded if they volunteered their history of drug use. The risks posed by these donors were reassessed in the wake of HIV emergence, which, much like the heat treatment of blood products, mitigated the spread of hepatitis. It does not take particularly close inspection to reveal that the question truly at the centre of the discussion of ensuring the safety of blood and blood products, is how blood is acquired. It is easy to point out mistakes after the fact, but expecting authorities to have near omniscience about future infections is clearly not a workable approach to public health policy. In 2013, The Lancet published its Series on blood transfusion that began by outlining that HCV infection of blood recipients played an important part in revising the view that blood from apparently health donors was safe. For high-income countries such as the UK, the strongest measures to ensure blood safety are simple and practical: optimise use to limit the inherent risks and guarantee that donation is voluntary and non-renumerated, as called for by WHO. ■ The Lancet Infectious Diseases
Paul Mayall/dpa/Corbis
No need for bad blood over bad blood
For more on the Penrose Inquiry see http://www.penroseinquiry. org.uk/ For more on The Lancet Series on blood transfusion see Lancet 2013; 381: 1789 For more on the need for voluntary blood donation see http://www.who.int/ bloodsafety/ publications/9789241599696/ en/
487