scope:

Preface

Human immunodeficiency virus (HIV) infection has become the most feared complication of blood transfusion. Fear of acquired immunodeficiency syndrome (AIDS) has triggered a series of radical changes in transfusion medicine. These changes have focused mostly on the transmission of viruses. Other infectious and noninfectious complications have been less well appreciated. One of the major goals of this book is to examine transfusion risks in a broader context, and to present some strategies to minimize these risks. A special effort was dedicated to areas that have received less attention in recent years, particularly errors and accidents, and the role of public health agencies as expressed by those in charge of monitoring and regulation. Between 1990 and 1999, as risks of transmission of HIV and hepatitis became relatively minuscule, there were 168 reports to FDA of fatal hemolytic reactions due to ABO-incompatible transfusion through error. This is an average of 17 cases a year, far exceeding deaths from transfusionassociated infectious agents. The book also attempts to provide physicians and other health care providers with the information necessary for appropriate counseling of patients who may need, or who have received, blood transfusions and for counseling of blood donors with abnormal screening test results.

The first chapter examines the contributions that blood donor screening procedures make to transfusion safety. The remainder of the book is organized in related sections to facilitate reference. Immunological complications discussed include hemolytic transfusion reactions, other types of reactions, alloimmunization, graft-versus-host disease, transfusion-related acute lung injury, and immunomodulation resulting from allogeneic transfusion. Also included is an overview of transfusion-related errors and methods to prevent errors that may lead to transfusion of incompatible blood. The following section describes various infection- related complications resulting from infectious agents that 1) are present at least transiently in the circulation of donors, 2) survive the blood collection and storage conditions in at least one component, and 3) are infectious to human recipients when infused. Some agents pose risk mostly to immunocompromised patients, who constitute an increasing proportion of recipients of blood and blood products today because of HIV infection, transplants, and chemotherapy for malignancies.

Diseases that pose transfusion risks in various parts of the world are included because the book is intended for a worldwide audience, and also because some of these diseases could potentially become important in North America. An overview of infectious disease risks sets the stage for the remaining chapters in this section, including a description of current screening for transmissible disease markers, bacterial contamination, viruses transmissible by transfusion (hepatitis viruses, human T-lymphotropic virus, cytomegalovirus, and others), and other infectious agents, including parasites and prions.

The last section focuses on methods employed to reduce risks of transmission of disease by transfusion of blood and blood products. Contents include a summary of current surveillance efforts in the United States, alternatives to allogeneic blood transfusion, leukoreduction, viral inactivation, and red blood cell substitutes. They also review the contributions of quality programs, professional standards, and federal regulatory oversight to blood safety. A chapter presenting a cost-effectiveness analysis of various risk reduction strategies completes this section.

Efforts have been made to present the text in a user-friendly fashion for easy reference. Tables have been presented whenever possible. A comprehensive index facilitates the location of pertinent material. Reference lists are not intended to be comprehensive, but to present relevant, recent references, including review articles that could be consulted for further detail. A zero-risk blood supply is not possible. However, we hope that this book will provide information to put risks in perspective and encourage employment of risk reduction strategies.

We wish to thank all the authors for their efforts. They are a diverse group of experts in their fields. We believe their aggregate contributions have resulted in a well-rounded single resource for a multifaceted and highly complex subject.