A transfusion service in Illinois was notified in early July by a blood center in Nebraska that an autologous donor's only unit, collected 10 days before planned surgery at their hospital, was reactive in the West Nile virus NAT. In this case, the patient was feeling well subsequently, but had left on vacation in the interim, and there was not time to do repeat WNV NAT or antibody testing before the patient's surgery. After consulting with their infection control office, the hospital transfusion service decided to decline the unit, reasoning that if this were a true positive, they would not want to re-expose the patient to another inoculation. (They did not receive followup on whether the infection was confirmed.) They would be interested in comments as to what other colleagues would do if an autologous donor is reactive in WNV nucleic acid testing.

The following responses were received.

1. A transfusion medicine physician at an academic center in Minnesota reports that he would have taken the same action as the inquiring colleague. The Minnesota physician is of the opinion that no one really knows yet what might have happened if such a unit was re-infused into the donor ... perhaps nothing! However, he cautions to just consider the legal implications if something had occurred (related or totally unconnected to WNV).

2. A physician who works at a blood center reports that he agrees with the hospital's conservative approach and would not have used the WNV NAT reactive unit either. He states that given that the virus seems to be present in the patient and surgery may be 'immunologically traumatic' this course seems prudent. He concedes that once more is known about the infectivity of the virus he might think differently.

ADDENDA Apr. 27, 2005

3. A transfusion medicine consultant reports on a 62 year old male (who lives in an area of the country that was a "hot spot" for WNV last summer) donated a unit of autologous blood in advance of a scheduled knee replacement surgery. Because his autologous donation was collected in a facility different than the hospital where his surgery will take place, the autologous donation was tested for disease markers and found to be positive by a WNV NAT test. The patient was asymptomatic for WNV at the time of his autologous donation. The consultant wonders if colleagues would offer any advice on whether this autologous unit should be kept available for the patient's surgery, or be discarded.

4. A very knowledgeable physician in Northern California recommends that if the unit is WNV RNA+, he would discard it, both due to caution over mistransfusion to someone else and because "we do not know if prior WNV infection is protective from reinfection"; thus if reinfused the patient could develop a new WNV infection which could be more severe than the first one due to immunosuppression.

5. A transfusion medicine scientist who works in the Western USA reports that in his opinion an autologous donor who tests positive for WNV at the time he/she donates for themselves should not be given back their blood at the time of surgery. His reasoning is as follows:

• WNV infection seems to be rather short lived, therefore transfusion of WNV infected blood at the time of surgery might actually reinfect the donor/recipient and
• Having gone through surgery himself, he believes the donor/recipient would be partially immunocompromised from the surgical process, potentially resulting in a much more virulent infection. The source of the enhanced virulence could be twofold: 1) immunocompromised and 2) secondary immune response, which could be beneficial or detrimental.

ADDENDA May 3, 2005

6. A transfusion medicine physician and senior medical consultant in Florida reports that their community-wide preoperative autologous program was recently modified to require the discard of any autologous unit that tests confirmed positive or indeterminate for HCV, HIV, HTLV, HBsAg, or WNV. Their justification for this policy is as follows: 1) the protection of the patient/donor; 2) the protection of operating room personnel (2% chance of blood exposure); 3) the protection of the innocent bystander (patient) inadvertently issued and transfused with the "wrong" autologous unit (a not so rare occurrence as documented in a 1992 CAP hospital survey).

ADDENDA May 4, 2005

7. A transfusion medicine colleague in New York wonders how the policy described by the colleague in Florida (ADDENDA #6) stands with the Americans with Disabilities Act (ADA)? He adds that at his institution, they "use" HIV, HCV and HBsAg reactive autologous units (if new finding) after consultation with the referring surgeon. They collect such units (if already known to be infected) only after consultation with the referring surgeon. He adds that in his opinion, the first two concerns of the Florida colleague (to protect donor-patient and operating room professional staff by discarding autologous units) is contrary to the spirit of Standard Precautions (what was formerly referred to as Universal Precautions). He comments that the third concern of the Floridian is addressed by "better management" as he claims his hospital has done for years. He concludes with the following question: "Do HCV (or other marker) -positive patients have right to prevent acquiring other transfusion-transmitted viral diseases under the ADA?"

Editor's note: Additional discussions regarding discarding infected autologous blood and the Americans with Disability Act can be found at "Autologous Units Positive for ID Markers - Should they be collected and made available for transfusion?"

ADDENDA May 7, 2005

8. The transfusion medicine physician and senior medical consultant in Florida (whose input was posted in ADDENDA #6) has provided the following response to the questions/comments raised by the colleague from New York (see ADDENDA #7). The Floridian writes (quoted) "I would preface my remarks by asserting that this is an area where equally well-intentioned practitioners can legitimately disagree. There are several important considerations, one of which is the true benefit of an autologous donation to the patient; is this form of hemodilution of significant enough benefit to the patient/donor to justify putting other transfusion recipients (I will agree with the comment about operating room staff being obliged to use good "Standard Precautions") at risk? The list of hospitals transfusing blood to the wrong patient includes some outstanding hospitals, many of which probably assumed, as does the New Yorker, that they were immune from human error. If, as my colleague asserts, the benefits to the patient/donor are significant, and the patient is protected under ADA, why, then, is the surgeon consulted, other than to inform him/her that the blood is infected? Given the assertions about the patient's rights and the patient's needs, it would seem that conferencing about whether or not to use the collected unit is unnecessary; it should be a non-negotiable decision that the unit is available and should be used.

As for the ADA issue itself, I am sure that I am in the minority, but I respectfully disagree (with AABB) that the ADA applies equally to an infected patient's right to put infected blood into the system (imagine if patients with active TB claimed a similar right to travel without the inconvenience of a face mask on airplanes) versus denying them treatment. There is an acceptable option for the infected patient: screened, allogeneic blood. While it may carry a fraction more risk to the auto patient, using it eliminates the risk that someone else may inadvertently be infected with blood known to be hazardous."

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator