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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 33  |  Issue : 1  |  Page : 38-43

Reactive donor notification and counseling: Reveals concealed risk factors


Department of Transfusion Medicine, Gian Sagar Medical College and Hospital, Patiala, Punjab, India

Date of Web Publication13-Feb-2017

Correspondence Address:
Sonam Kumari
House No. 120, Sector 20-A, Chandigarh - 160 020
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9962.200096

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  Abstract 

Background and Objective: In spite of newer sensitive screening techniques, blood transfusion is still associated with a small risk of transmitting infectious diseases. A very important and efficient method of curtailing transfusion transmitted infections (TTIs) is notifying and counseling the TTI reactive donors. Materials and Methods: Totally, 4281 donations were screened for TTI, namely, human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and syphilis, by serology. All TTI reactive donors were retested and notified of their status by telephone or letter and called for repeat testing followed by face-to-face counseling and referral for treatment. Results: We evaluated 116 (2.7%) donors with reactive screening test results, i.e., 41 (1%) HBV, 61 (1.4%) HCV, 12 (0.3%) HIV, and 2 (0.05%) reactive for both HIV and HCV while none of donors were syphilis reactive. Only 35.34% (41) of donors responded to notification. The response from voluntary donors was comparatively less as compared to the replacement donors (34.6% vs. 41.7%). Around 22 (53.7%) of counseled reactive donors revealed history of high-risk behavior/factors which were not disclosed during donor registration and screening. Conclusion: In spite of strict donor screening and self-exclusion option, donors conceal their high-risk behaviors and continue to donate blood. It reflects the need to implement predonation counseling to extract the history of high-risk factors from the donors. Maintenance of privacy during donor screening, predonation education and counseling and postnotification counseling of reactive donors are recommended. National guidelines for notification of reactive donors need to be formulated.

Keywords: Blood donor, counseling, high-risk behaviors, notification, transfusion-transmitted infections


How to cite this article:
Kumari S. Reactive donor notification and counseling: Reveals concealed risk factors. Indian J Soc Psychiatry 2017;33:38-43

How to cite this URL:
Kumari S. Reactive donor notification and counseling: Reveals concealed risk factors. Indian J Soc Psychiatry [serial online] 2017 [cited 2019 Sep 16];33:38-43. Available from: http://www.indjsp.org/text.asp?2017/33/1/38/200096


  Introduction Top


In the developing countries, transmission of hepatitis C virus (HCV), hepatitis B virus (HBV), and human immunodeficiency virus (HIV) infection via transfusion of blood and blood products from unscreened or inadequately screened blood donors is one of the major sources of transmission of transfusion transmissible infections (TTI). Common modes of transmission of TTI in the developing countries are perinatal (from mother to baby at birth), early childhood infections (unapparent infection through close interpersonal contact with infected household contacts), sexual contact, unsafe injection practices, and blood (and blood product) transfusion. Blood donor screening and testing for TTI have become stringent worldwide, but transfusing blood, that is, zero risk, i.e., free from all transmissible infections, is still far from becoming reality.[1]

A very important and efficient method of curtailing TTI is notifying and counseling the TTI reactive donors, but communication of positive test results to blood donors is not a universal procedure.[2] In India, disclosure of viral TTI reactivity to the blood donor was not permitted until December 2004; at that time, the National Blood Transfusion Council, Government of India, formulated a strategy for the same.[3] The National Blood Transfusion Council now advocates the disclosure of results of TTI to blood donors. Now, it is mandatory for all blood banks to obtain a written consent from the blood or blood product donor on the donor questionnaire and consent form at the time of donation that whether they wish to be informed about a reactive test result or not. They are required to refer donors who tested HIV reactive to the designated Voluntary Counselling and Testing Centers (VCTC) or Integrated Counselling and Testing Centres (ICTC) for disclosure, counseling, and referral for treatment. All donors reactive to HBV or HCV needs to be informed and then referred to a gastroenterologist for further management while donors reactive for syphilis should be referred to the sexually transmitted diseases (STD) clinic. Postdonation counseling is an ethical duty of blood bank toward the donors. It should include informing the reactive donors about their serological status, the dangers of transmitting the infection to other people, providing emotional support, assistance in planning behavior and lifestyle modifications, and then referral for health care follow-up.

Counseling, testing, and notification together form the vital link between the donor and safe blood.[4] Predonation counseling should be a part of the process of donor selection, and privacy should be maintained to gain the donor confidence. Some of the countries and some centers in India are also practicing confidential unit exclusion, i.e., donors who have donated blood in front of their relatives and friends and could not express their risk behavior can confidentially confide to the blood bank staff, and the donated blood is removed from the stock and discarded.

Study Aim

The absence of predonation counseling prevents the donor from the opportunity of self-excluding from donation to clarify myths and misconceptions and to understand the consequences of these infections, thus compromising blood safety and neglecting an opportunity to prevent further transmission. Similarly, the absence of a program on counseling of TTI reactive blood donors deprives them of their right to know their health status, initiate the required treatment at the earliest, and plan behavior modifications accordingly. Keeping these issues in mind, this study was initiated with three main objectives:

  1. To see the response rate of notified reactive donors for counseling
  2. To elicit hidden risk factors and
  3. To propose useful recommendations that could probably improve the response rate.



  Materials and Methods Top


All the eligible blood donors were requested to fill up the blood donor questionnaire cum consent form formulated as per the rules laid down in Drugs and Cosmetics Act, Ministry of Health and Family Welfare, Government of India.[5] Informed consent was obtained from all the donors that their blood will be tested for the five mandatory TTI and whether they wish to be informed about a reactive test result or not. Donors were asked not to donate if they had AIDS-related symptoms or HIV-related risk behavior including injecting intravenous drugs, being a male who had sex with another male, promiscuous behavior, or having a sexual relationship with a prostitute.

Data from all the blood donors screening test results (whether blood donation was made within hospital or in outdoor blood donation camps) for HIV, HBV, HCV, and syphilis from May 2014 to April 2015 were collected and analyzed. The donors reactive for HIV, HBV, and HCV by enzyme-linked immunosorbent assay (ELISA) in duplicate ( first sample from pilot tube and another from blood bag) as well as by rapid tests and those reactive for syphilis by rapid plasma regain test (RPR) were notified of their reactive test results and called for counseling. The blood bank counselor informs the donor about detection of an abnormal test result with advice to report to the blood bank for face-to-face counseling and repeats sampling as well as for referral to the respective department of the hospital for further management. In every case, the notifications over telephone were provided twice (second call after a minimum gap of 1 week) and by letter once to those who could not be contacted on phone thrice. We tried to maintain confidentiality at each step. The donors who did not respond to these notifications were considered nonresponders. As per the postal communication, confidentiality was maintained by just informing the donor about detection of an abnormal test result with advice to report to the blood bank. Reactive donors reporting to blood bank were counseled face-to-face while privacy was maintained, fresh samples were taken for repeat testing as well as they were referred to the respective department (HIV reactive to ICTC, HBV or HCV reactive to gastroenterologist, and RPR positive to STD clinic) of the hospital for further management. A hospital attendant accompanies the reactive donor till he meets the concerned person in the referred department.


  Results Top


Totally, 4281 blood donors were screened for TTI from May 2014 to April 2015. Around 116 (2.7%) blood donors were identified who had reactive screening tests: 41 (1%) HBV, 61 (1.4%) HCV, 12 (0.3%) HIV, and 2 (0.05%) reactive for both HIV and HCV while none of them were syphilis reactive.

Totally, 116 reactive donors were informed telephonically, out of which 106 were contacted and 10 could not be contacted (mobile switched off, not responding, or not available). Out of 106 telephonically informed donors, 34 reported to blood bank, 2 already knew their status and refused to report in blood bank (out of which 1 was having co-infections HIV + HCV and other one was HIV reactive), and repeat calls were done to rest 70 nonresponders. Out of these 70, only 6 reported to blood bank for counseling. Repeat calls were also done to 10 noncontacted donors, but only three could be contacted out of which one reported to blood bank. Confidential letters were posted to rest of seven donors, but none of them reported [Figure 1].
Figure 1: Flow chart depicting the study process

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Of 61 HCV reactive donors, 22 (36%) responded and visited the blood bank, 39 (64%) did not while out of 41 HBV reactive donors, 14 (34.2%) responded, and 27 (65.8%) did not respond at all. Response rate was comparatively higher among HIV reactive donors, i.e., out of the 12 reactive donors, 5 (41.7%) responded, but 7 (58.3%) did not respond [Figure 2].
Figure 2: Response rate according to the TTI marker positivity

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Response rate was seen higher among the married donors 30 (26%) than unmarried 11 (9%) [Figure 3].
Figure 3: Pie chart showing the marital status of the TTI reactive donors reporting to blood bank

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Reactive donors were divided into three age groups: younger (18–30 years), middle age (31–40 years, and elderly (41–60 years). Comparison of the ages of responders and nonresponders showed significant differences. About 41–60 years age group showed maximum response 7 out of 17 (41.2%) while 36.3% and 30.3% responded in 18–30 and 31–40 years age group, respectively [Figure 4].
Figure 4: Age distribution of reporting and nonreporting TTI reactive donors

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About 96.6% of the reactive donors were male out of which 35.7% reported to blood bank, and response rate was even lower (25%) among female [Table 1].
Table 1: Response rate of reactive donors according to gender, type of donation, and first time or repeat donor

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Since maximum blood collection was from voluntary donors 3855 (90%), the TTI reactivity was also higher among voluntary donors 104 (89.7%) while the response rate was higher among replacement donors (41.6% vs. 34.6%) [Table 1].

TTI positivity rate was higher among repeat donors 61 (52.5%), but the response rate was higher among the first-time donors [Table 1].

Reactive donors response rate was also evaluated according to their occupation and found that response was highest among drivers (80%) followed by students (55%). Lowest response was seen among the laborers (12.5%) and homemakers (0%) [Table 2].
Table 2: Response rate of reactive donors according to their occupation

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Out of 116 notified donors, only 35.34% (41) of donors reported in blood bank for counseling and status confirmation. On counseling, it was evaluated that 22 (53.7%) of the total donors reported revealed history of high-risk behavior/factor some of them reported multiple risk behaviors. Among the high-risk factors, most common were promiscuous behavior 8 (19.5%) and intravenous drugs and fluids infusion for some surgical/medical causes 6 (14.6%) [Table 3].
Table 3: Evaluation of high-risk behaviors/high-risk factors among counseled reactive donors

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  Discussion Top


Notification of a blood donor about the abnormal test results is a very sensitive and crucial aspect of postdonation counseling as it has its psychological and social impacts.[6] The basic principles of donor notification should involve providing information to the donor promptly, accurately, confidentially, and in a manner that alleviates anxiety and promotes understanding.[2],[7] Maintenance of privacy and confidentiality during counseling helps in extracting hidden risk factors which were done in the present study, and obvious results were obtained 22 (53.7%) of donors revealed history of high-risk behaviors/factors.

Choudhury and Tetali in their survey found that donor counseling and reactive donor notification was almost nonexistent, testing methods were old, and only 53% of the donors were aware that the blood bank was supposed to inform TTI reactive donors about their positive status.[4] Their earlier study, on donor notification practices, also revealed that blood banks do not disclose results even if they are positive due to perceived problems of disclosure.[8] However, it is the ethical responsibility of blood banks to inform the reactive donors of their test results immediately after confirmation so that proper counseling, behavioral modifications, and required treatment could be initiated at the earliest.

In the present study, response rate of blood bank calls to donors with reactive screening tests was quite low (35.34%) which was similar to the Mukherjee et al. study (34%).[9] In Kaur et al. study, the response rate was 49%, 45.5%, 50%, and 17% for HBsAg, HCV, HIV, and syphilis, respectively.[10] Similar low responses to the reactive donors notifications were also observed by Agarwal (59.8%) and Kotwal et al. (50.6%).[1],[6] In view of the low response rate among reactive blood donors, it is important to consider the policy of predonation donor screening.[11] Repeated notification is also necessary since Kleinman et al. reported that 10% of donors did not open or read the letter and did not understand the content or refused to receive the first letter.[12]

Among the 3 TTI, response rate was higher for HIV (41.7%), higher response rate of HIV reactive donors was also noticed in Kaur et al. (50%) study from Chandigarh, which might be due to the higher awareness and fear of HIV/AIDS among the general population.[10]

In the present study, TTI positivity rate was higher among repeat donors 61 (52.5%) and voluntary donors (89.7%), but the response rate was higher among the first time donors (43.6%) and replacement donors (41.6%), which were in contrast to Roshan et al. study where response and follow-up were higher among repeat donors and voluntary donors.[11] Response rate was little higher among married donors. From these results, it could be inferred that people were aware of voluntary blood donation but least bothered about their health status.

We also compared the educational level on the basis of occupation. Response rate was highest among drivers (80%) followed by students (55%). Lowest response was seen among the laborers (12.5%) and homemakers (0%) indicating that educational level, gender, and socioeconomic status do affect the response rate. Response rate among the drivers was surprisingly higher which might be due to the fact that long route drivers were more susceptible to high-risk behaviors and high response might be the result of their test seeking attitude. Furthermore, response rate was higher among elderly (41.2%) and younger (36.3%) compared to middle age group (30.3%) which was not significant. Perceptions regarding screening tests were different among donors which may be attributed to socioeconomic and sociocultural beliefs.[11] Twenty-three percent of donors in Sharma et al. study donated blood for the purpose of being tested for HIV.[13] Similarly, Chaurasia et al. in their study perceived that individuals reporting high-risk behaviors for TTI (sex workers, homo- or bi-sexual men reporting multiple sexual partners) donate repeatedly to obtain HIV test free of charge, even when they know the possible implications of HIV transmission associated with blood donation. Even physicians are known to recommend blood donation as a fast, free, and reliable means of knowing their HIV status.[14] The results of these studies strongly indicate that predonation information and counseling should be a mandatory process at the time of donor screening with a special focus to increase donor awareness of TTI and routes of transmission. It gives the opportunity of self-deferral to people having history of high-risk behavior and who are coming only for TTI testing (test seekers). Counselors and interviewers should be well-trained and competent and at every step privacy and confidentiality should be maintained.[1]

In Kotwal et al. study, 94.75% of the notified donors who reported to blood bank contacted their health care provider when given clear instructions to do so which indicated that a major element of the notification message is acted on when it was worded clearly.[6] Thirty-nine (95.12%) of reporting reactive donors in the present study contacted the referred department while two of them wanted to contact the referral department later.

One of the important queries noticed during postdonation counseling was the cost involved and duration of the treatment. Therapy for TTI is expensive and often lifelong. A central barrier to treatment of HCV and HBV infection is cost – this includes the cost of medicines, taxes, import charges, appropriate medical facilities, and staff, as well as diagnostic and monitoring facilities.[15],[16] Financial constraint is a major issue in the developing countries which results in noncompliance to treatment. Free anti-retroviral therapy for HIV-positive patients was initiated in India by NACO on April 1, 2004, similar to that free viral load monitoring and antiviral treatment plan for HBV and HCV infection should be initiated by health authorities so that effective prevention, care, and support could be provided to the patients.

On counseling, 53.7% of the responders revealed history of high-risk behavior/factors and some of them reported multiple risk behaviors. The most common of them were promiscuous behavior 8 (19.5%) and intravenous drugs and fluids infusion for some medical/surgical causes 6 (14.6%). The second high-risk factor might be due to the fact that maximum percentage of donors being from rural areas, usually undergo preliminary treatment from quacks, who use contaminated needles for injections and fluid transfusions which are a common practice in this locality as patient satisfaction is more after being prescribed an injectable treatment. Furthermore, Patiala and adjoining areas of Punjab and Chandigarh are labeled as one of the emerging epidemics with rising prevalence of HCV (Amritsar being 48.7%, Ludhiana 25.6%, and Chandigarh 51.1%) due to the increasing drug addiction (injectable) and promiscuous behavior among the population.[17]

While technological advancements have led to the development of more sensitive methods to detect markers of TTI, the prevalence of false-positive cases has increased simultaneously leading to unnecessary anxiety among donors who are notified about their reactive results.[1] To reduce the prevalence of false HIV-positive cases, Thakral et al. implemented WHO Strategy-III prior to donor recall in their study instead of WHO Strategy-I currently being followed in India which resulted in decreased referral to VCTC.[18] In a study by Choudhury et al., they had considered that blood units from repeat donors reactive by single ELISA kit only (and nonreactive by the second ELISA kit) may not be discarded (in contrast to National Blood Transfusion Centre guidelines), but this policy needs regulatory approval.[3],[19] These data clearly depict that variable protocols for notifying the reactive donors were used at different centers, which support the fact that nationally acceptable guidelines for notification and follow-up of reactive donors needs to be formulated.[20]

To curb down the prevalence of TTI among blood donors, it is necessary to implement predonation counseling sessions and self-exclusion options for eligible blood donors. Counseled healthy donors get aware of the need for enhanced blood safety and therefore would take care to remain noninfected by these infections. However, proper predonation counseling is still a challenge, especially in the outdoor blood donation camps.[9] Due to the lack of sufficient time, a limited number of staff and lack of suitable facilities to assure privacy and confidentiality and the remote- and under-resourced facilities including outdoor blood donation camps have difficulty in implementing donor counseling. However, the essential features of blood donor counseling should be consistently followed everywhere as small facilities have the same responsibilities as large facilities regarding confidentiality and giving information to donors.


  Conclusion Top


Proper national guidelines for the notification of reactive blood donors should be formulated keeping in view the following points:

  • Informing all the TTI reactive donors of their reactive status could be helpful in reducing the spread of these infections
  • Government health authorities should be notified of the nonresponders so that they could further contact the donors
  • Reactive donors should be given confirmatory testing and treatment free of cost or on discounted affordable rates as an incentive which would further enhance the follow-up compliance and response to notifications
  • Notification messages should address common themes: Providing the donor with the test result stating their medical significance, indicating the possible modes of acquisition and secondary transmission of the agent, informing the donor of his or her eligibility regarding future blood donation, and ensuring the donor should see a physician.[6]


Predonation information and counseling should be a mandatory process at the time of donor screening which would give an opportunity to the donors to reveal the history of high-risk behaviors/factors. Counseled donors get inclined toward adaptation of healthy lifestyle and behavior to facilitate donation of safe blood in adequate quantity. This would also help in promoting the development of healthy donor pool.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Agarwal N. Response rate of blood donors in the Uttarakhand region of India after notification of reactive test results on their blood samples. Blood Transfus 2014;12 Suppl 1:s51-3.  Back to cited text no. 1
    
2.
Bianco C, Kessler D. Donor notification and counseling. Management of blood donors with positive test results. Vox Sang 1994;67 Suppl 3:255-9.  Back to cited text no. 2
    
3.
National AIDS Control Organisation. National Blood Policy of India. Available from: http://www.unpan1.unorg/intradoc/groups/public/documents/.pdf. [Last accessed on 2003 Apr 15].  Back to cited text no. 3
    
4.
Choudhury LP, Tetali S. Notification of transfusion transmitted infection. Indian J Med Ethics 2008;5:58-60.  Back to cited text no. 4
    
5.
Malik V. Drugs and Cosmetics Act 1940. 16th ed. Lucknow: Eastern Book Company; 2003. p. 279-303.  Back to cited text no. 5
    
6.
Kotwal U, Doda V, Arora S, Bhardwaj S. Blood donor notification and counseling: Our experience from a tertiary care hospital in India. Asian J Transfus Sci 2015;9:18-22.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.
Scott EP, Quinley ED. Is the deferred-donor notification process effective? Transfusion 1992;32:696-8.  Back to cited text no. 7
    
8.
Choudhury LP, Tetali S. Ethical challenges in voluntary blood donation in Kerala, India. J Med Ethics 2007;33:140-2.  Back to cited text no. 8
    
9.
Mukherjee S, Bhattacharya P, Bose A, Talukder B, Datta SS, Mukherjee K. Response to post-donation counseling is still a challenge in outdoor voluntary blood donation camps: A survey from a tertiary care regional blood center in Eastern India. Asian J Transfus Sci 2014;8:80-3.  Back to cited text no. 9
[PUBMED]  Medknow Journal  
10.
Kaur G, Kaur P, Basu S, Kaur R, Sharma S. Donor notification and counseling – Experience and challenges. Transfus Apher Sci 2013;49:291-4.  Back to cited text no. 10
    
11.
Roshan TM, Rosline H, Ahmed SA, Rapiaah M, Khattak MN. Response rate of Malaysian blood donors with reactive screening test to transfusion medicine unit calls. Southeast Asian J Trop Med Public Health 2009;40:1315-21.  Back to cited text no. 11
    
12.
Kleinman S, Wang B, Wu Y, Glynn SA, Williams A, Nass C, et al. The donor notification process from the donor's perspective. Transfusion 2004;44:658-66.  Back to cited text no. 12
    
13.
Sharma UK, Schreiber GB, Glynn SA, Nass CC, Higgins MJ, Tu Y, et al. Knowledge of HIV/AIDS transmission and screening in United States blood donors. Transfusion 2001;41:1341-50.  Back to cited text no. 13
    
14.
Carneiro-Proietti AB, Cunha IW, Souza MM, Oliveira DR, Mesquita NM, Andrade CA, et al. HIV-(1/2) indeterminate western blot results: Follow-up of asymptomatic blood donors in Belo Horizonte, Minas Gerais, brazil Rev Inst Med Trop Sao Paulo 1999;41:155-8.  Back to cited text no. 14
    
15.
WHO Guidelines for the Screening, Care and Treatment of Persons with Hepatitis C Infection; 2014. Available from: http://www.ip-watch.org/weblog/wp-content/uploads/2014/04/WHO-Hepatitis-C-Guidelines-pdf. [Last accessed on 2014 Jan 20].  Back to cited text no. 15
    
16.
Anand AC, Puri P. Indian guidelines and protocols: Hepatitis B. Gastroenterology 2013;6:242-5. Available from: http://www.apiindia.org/medicine_update_2013/chap53.pdf. [Last accessed on 2013 Feb 25].  Back to cited text no. 16
    
17.
Solomon SS, Mehta SH, Srikrishnan AK, Solomon S, McFall AM, Laeyendecker O, et al. Burden of hepatitis C virus disease and access to hepatitis C virus services in people who inject drugs in India: A cross-sectional study. Lancet Infect Dis 2015;15:36-45.  Back to cited text no. 17
    
18.
Thakral B, Saluja K, Sharma RR, Marwaha N. Algorithm for recall of HIV reactive Indian blood donors by sequential immunoassays enables selective donor referral for counseling. J Postgrad Med 2006;52:106-9.  Back to cited text no. 18
[PUBMED]  Medknow Journal  
19.
Choudhury N, Tulsiani S, Desai P, Shah R, Mathur A, Harimoorthy V. Serial follow-up of repeat voluntary blood donors reactive for anti-HCV ELISA. Asian J Transfus Sci 2011;5:26-31.  Back to cited text no. 19
[PUBMED]  Medknow Journal  
20.
Chaurasia R, Zaman S, Das B, Chatterjee K. Screening donated blood for transfusion transmitted infections by serology along with NAT and response rate to notification of reactive results: An Indian experience. J Blood Transfus 2014;2014:412105.  Back to cited text no. 20
    


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