I am fielding questions from my blood bank pals about any impact of the Ebola epidemic in West Africa on transfusion medicine here. I understand Ebola transmission dynamics in the context of the deleterious impact of lack of development (and mistrust of “experts”) in sub-Saharan Africa compared to here. As a result, I pretty much dismissed Ebola as an important threat to what we do in the US – even given the lightning speed of international travel, as discussed in this week’s commentary by Anthony S. Fauci, MD, in The New England Journal of Medicine (http://bit.ly/1yA7OHe).
It is a given in hospital infection control to consider all blood and body fluids infectious, no matter what one knows or doesn’t know about their source. Standard infection control precautions require barriers to contamination when it can be anticipated. We may add more measures when we suspect or know an infectious diagnosis, for a margin of safety that I always accepted.
I am getting inquiries about whether transfusion services should provide un-typed O-negative red blood cells and AB platelets and plasma to patients with suspected or known Ebola to avoid sending specimens to the transfusion service that might expose someone. It reminds me just a bit of the anxiety during the early days of AIDS when my clinical colleagues would not shake hands with me, and consultations were done from the hallway. Ebola is communicable by direct contact – really not very contagious compared to airborne bugs like influenza, chickenpox, and measles – but there are legitimate concerns about lab accidents. Most of the “suspect” patients we will be asked to transfuse will not have Ebola, but another fever associated with their recent travel, (e.g., malaria or dengue). The key question, for which we have no answer, is “What’s the relative risk to patients from transfusion without pre-transfusion testing compared with the risk to lab techs handling specimens in the lab?”
Using the Centers for Disease Control and Prevention’s guidance, which I read as supporting appropriate use of the laboratory to deliver needed care to these patients, I would not suspend crossmatching (http://bitly.com/1y7vClq). The guidelines are the minimal requirements, and an organization or institution can clearly go further, but wearing my hospital epidemiologist hat, my advice to my (former) institution would be along the lines of: “Use appropriate barrier and containment measures. Then perform appropriate pre-transfusion testing (in the microbiology department hood if feasible), and follow up your work with appropriate disinfection and disposal of residual samples.” The bottom line is to reach a consensus on how to deliver the right care, our bottom line mission, to a group of potentially very sick folks and to avoid disproportionate risk to lab personnel.
Louis Katz, MD, Chief Medical Officer; LKatz@americasblood.org