International Blood Safety Forum
Washington, DC
Confronting Emerging Pathogens with
Limited Resources
José Eduardo Levi
MARCH 20th, 2015
MANDATORY TESTING IN BRAZIL
Hepatitis B – anti-HBc + HBsAg + HBV-DNA
Hepatitis C – anti-HCV + HCV-RNA
HIV– anti-HIV (1, 2 and O) + HIV-RNA
Chagas Disease – anti-T. cruzi
Syphilis – Treponemic or non-treponemic assay
HTLV-1 and HTLV-2 – anti-HTLV 1 and 2
Malaria – In endemic areas (Amazon)
CMV – Selected recipients
Abnormal hemoglobin – Sickle cell trait
DENGUE
Dengue Cases Brazil 1990 - 2014
1500000
1450000
1400000
1350000
1300000
1250000
1200000
1150000
1100000
1050000
1000000
950000
900000
850000
800000
750000
700000
650000
600000
550000
500000
450000
400000
350000
300000
250000
200000
150000
100000
50000
0
Year 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Affected municipalities and Incidence
Sao Paulo
15,000,000 inhabitants
< 1,000 dengue cases in 2010
60 km
Santos
800,000 inhabitants
> 20,000 dengue cases in 2010
DENGUE LABORATORY MARKERS AMONG BLOOD DONORS
FROM SANTOS, BRAZIL. LEVI, UNPUBLISHED
IgG
MONTH/YEAR
JAN/2010
FEB/2010
MARCH/2010
APRIL/2010
JULY/2010
JULY/2011
N=
500
493
495
500
500
500
IgM
IgG + IgM
TMA
Tabela 1 – Número de casos de dengue comprovados e incidência por 100.000 habitantes em municípios da baixada santista. Fonte: Secretaria do estado da Saúde (Grupo de Vigilância Epidemiológica) e IBGE.
MEAN
74,0%
64,5%
68,7%
70,2%
71,6%
74,4%
7,2%
8,5%
15,2%
24,4%
17,8%
8,6%
5,8%
6,9%
13,7%
23,8%
17,8%
7,8%
0,0%
1,4%
1,2%
0,8%
0,0%
0,0%
70,6% 13,6%
12,6%
0,6%
Rate symptomatic/ asymptomatic = 1:3
EVIDENCE OF TRANSFUSION-TRANSMITTED DENGUE
VIREMIC DONOR (RNA+)
RECIPIENT PRE-TX NEGATIVE AND POST-TX NEGATIVE
SIGNS, SYMPTOMS AND LABORATORY MARKERS COMPATIBLE
WIH DENGUE OCCURRING 1-14 DAYS POST-TRANSFUSION
STRAMER SL, TRANSFUSION 2012, IN PRESS
Transfusion. 2015 Jan 21. doi: 10.1111/trf.12944. [Epub ahead of print
HYPOTHESIS FOR THE LOW NUMBER OF
TT CASES REPORTED:
1) Hemovigilance may be deficient
2) Presence of protective immunity in recipients in endemic areas
3) Frequent cotransfusion of antibody-positive units which neutralize
infectivity of viremic donations
4) Clinical outcomes may not be as severe in immunosuppressed
patients infected with dengue
5) Need for mosquito saliva to enhance dengue replication and
virulence;
?
HYPOTHESIS FOR THE LOW NUMBER OF
TT CASES REPORTED:
1) Hemovigilance may be deficient
2) Presence of protective immunity in recipients in endemic areas
3) Frequent cotransfusion of antibody-positive units which
neutralize infectivity of viremic donations
4) Clinical outcomes may not be as severe in immunosuppressed
patients infected with dengue
5) Need for mosquito saliva to enhance dengue replication and
virulence;
DENGUE LABORATORY MARKERS AMONG BLOOD
DONORS FROM SANTOS, BRAZIL. LEVI, UNPUBLISHED
IgG
MONTH/YEAR
JAN/2010
FEB/2010
MARCH/2010
APRIL/2010
JULY/2010
JULY/2011
N=
500
493
495
500
500
500
IgM
IgG + IgM
TMA
Tabela 1 – Número de casos de dengue comprovados e incidência por 100.000 habitantes em municípios da baixada santista. Fonte: Secretaria do estado da Saúde (Grupo de Vigilância Epidemiológica) e IBGE.
MEAN
74,0%
64,5%
68,7%
70,2%
71,6%
74,4%
7,2%
8,5%
15,2%
24,4%
17,8%
8,6%
5,8%
6,9%
13,7%
23,8%
17,8%
7,8%
0,0%
1,4%
1,2%
0,8%
0,0%
0,0%
70,6% 13,6%
12,6%
0,6%
DENGUE SEROTYPES CIRCULATING IN BRAZIL, 2012
HYPOTHESIS FOR THE LOW NUMBER OF
TT CASES REPORTED:
1) Hemovigilance may be deficient
2) Presence of protective immunity in recipients in endemic areas
3) Frequent cotransfusion of antibody-positive units which neutralize
infectivity of viremic donations
4) Clinical outcomes may not be as severe in immunosuppressed
patients infected with dengue
5) Need for mosquito saliva to enhance dengue replication and
virulence;
2 casos de dengue, 1 DF e 1 DSS, ambos transplante de fígado cerca de 8 meses
pós-transplante.
HYPOTHESIS FOR THE LOW NUMBER OF
TT CASES REPORTED:
1) Hemovigilance may be deficient
2) Presence of protective immunity in recipients in endemic areas
3) Frequent cotransfusion of antibody-positive units which neutralize
infectivity of viremic donations
4) Clinical outcomes may not be as severe in immunosuppressed
patients infected with dengue
5) Need for mosquito saliva to enhance dengue replication and
virulence;
DONOR`S SCREENING: IF AND HOW
-EPIDEMIOLOGY
Important negative impact on donor
availability
-CLINICAL SIGNS
Low efficiency
-LABORATORIAL ?
PROOF OF TT WNV - USA
WNV INTRODUCTION IN SOUTH AMERICA
CHIKUNGUNYA CASES – BRAZIL NOVEMBER 2014
No cases
Imported(38)
Autoctonous (850)
NEW/EMERGING AGENTS
A. albopictus
A. aegypti
MEASURES TAKEN AT SÃO PAULO
BLOOD BANK:
- DEVELOPMENT OF A DENGUE/CHKV REAL-TIME PCR
ASSAY FOR APHERESIS PLATELET UNITS
- EMERGENCY PLAN TO STOP BLOOD COLLECTION AT
AREAS OF HIGH INCIDENCE
- MOBILIZATION OF FIDELIZED BLOOD DONORS FROM
NON-AFFECTED AREAS
- ESTABLISHMENT OF EPIDEMIOLOGICAL CRITERIA
FOR RESTARTING BLOOD COLLECTION (TRIGGERS)
ACKNOWLEDGMENTS
Dr Ésper G. Kallas and team - Immunology Dept., São Paulo University
Medical School
Eliana Perroud – Santos Blood Center
Dr Cláudio Pannuti and team – Virology Lab, tropical medicine Institute,
University of São Paulo
Dr Ester Sabino – Infectious Diseases Dept., São Paulo University Medical
School
Dr Alfredo Mendrone and team – Fundação Pró-Sangue
Dr Michael P. Busch - Blood Systems Research Institute, EUA
Novartis (Grifols) – Sponsor, Santos Dengue Blood Donors Study