Multiple transfusions for sickle cell disease in the Democratic Republic of Congo: The importance of the hepatitis C virus

Abstract

Background and objectives

Improvement of transfusion security in sub-Saharan countries requires the determination of priorities taking into account the specific context.

Patients and methods

One hundred and forty patients with sickle cell disease (SCD) from one clinical centre for SCD in Kisangani, DRC were tested for HBsAg, anti-HIV antibodies, anti-HCV antibodies and for alloantibodies against red blood cells and human leucocyte antigens (HLA).

Results

Thirteen patients had not been transfused and were free of HBV, HIV or HCV infection. HBV, HIV and HCV infections were detected in 2/127 (1.6%), 1/127 (0.9%) and 10/127 (7.9%) transfused patients, respectively. All ten cases of HCV infection were associated with patients who had transfusions prior to the introduction of HCV testing in 2004 (P = 0.043). Red blood cells and HLA alloantibodies were detected in 13/127 (10%) and 2/127 (1.6%), respectively.

Conclusion

HCV testing should be a priority. The rhesus (Rh) phenotype, mainly the RhD antigen and the Kell antigen should be assessed in SCD patients. Further extended phenotyping and deleucocytation should not be considered as priorities.

Résumé

Introduction

L’amélioration de la sécurité transfusionnelle en pays sub-sahariens requiert la détermination des priorités prenant en compte des contextes locales.

Patients et méthodes

Cent quarante patients drépanocytaires d’un centre pour anémie SS à Kisangani en République démocratique du Congo ont été testés pour le HBsAg, les anticorps anti-HIV, anti-HHC, ainsi que pour des anticorps antiérythrocytaires et anti-HLA.

Résultats

Treize patients, non transfusés, n’étaient pas porteurs des marqueurs de VHB, VIH et VHC. Le HBsAg, les anticorps anti-VIH et anti-VHC ont été retrouvés respectivement chez 2/127 (1,6 %), 1/127 (0,9 %) et 10/127 (7,9 %) des patients transfusés. Tous les dix patients séropositifs au VHC ont été ceux qui avaient commencé à être transfusé avant 2004 (p = 0,043), année de l’introduction du test de dépistage du VHC. Respectivement, 13/127 (10 %) et 2/127 (1,6 %) des patients avaient des anticorps anti-érythrocytaires et anti-HLA.

Conclusion

Le dépistage des anticorps anti-VHC doit être une priorité. Le phénotypage Rh, principalement l’antigène D et l’antigène Kell doivent être de mise chez les patients drépanocytaires. Le phénotypage étendu et la déleucocytation ne sont pas encore une priorité.

Introduction

In sub-Saharan Africa, the need for blood transfusions is great because of the heavy burden of anaemia due to infectious diseases, such as malaria, and perinatal morbidity. These conditions can use up to 15% of the stored blood in an entire country [1], [2]. Furthermore, a state of recurrent war exists in some areas, which often aggravates supply problems and can create an additional acute need for blood with frequent chronic shortages that compromise the self-sufficiency of regional health centres. Transfusion in these countries has been a subject of much concern recently [3], [4]. To achieve the goal of optimal transfusion safety, the importance of performing a pragmatic analysis that takes the specific context of a country into account has been highlighted [3]. Standards that are observed currently in Western countries need to be adapted to local conditions but are contravened by limited financial resources and a high prevalence of infectious diseases [4]. Poverty and the absence of a social security system that covers the costs of blood transfusion often compromise the availability of laboratory reagents and equipments dramatically, as well as the capacity to store the blood adequately.

Massive blood transfusions prescribed in emergency situations explain the common recourse to replacement donors of a familial origin, which is a practice that is in line with the cultural tradition of altruism that exists in Africa. In a recent survey performed in Kisangani, Democratic Republic of Congo (DRC), we noted that 69% of blood donors were family members of the recipients, despite efforts to increase voluntary blood donation [5].

In view of this context, it is important that countries with limited resources focus on the key priorities in order to improve the supply of blood and the safety of transfusions. One of these priorities is related to the high prevalence of infectious diseases, such as malaria, human immunodeficiency virus (HIV), syphilis and hepatitis B (HBV) and C viruses (HCV) in the general population of sub-Saharan Africa, and therefore among potential donors, which can lead to infections transmitted via transfusions [4], [5], [6]. Testing of donors for HBV, HIV and HCV and the exclusion of infected blood constitute the principal means of avoiding contamination. In the Kisangani region, blood screening for HIV and HBV infection has been generalized in 1987 and 1988, respectively; screening for HCV infection was introduced at the end of 2004. This raises the possibility that transfused patients have been exposed to blood transfusions that were contaminated with HCV.

In order to determine realisable priorities for our local context, it was decided to perform a retrospective study of patients with sickle cell disease (SCD) who had received transfusions. In our local community, 0.96% of the population has SCD [7]. Clinical manifestations of SCD, which include acute anaemia and recurrent acute episodes of vaso-occlusive, are treated with blood transfusion, which is regarded presently as the main treatment in most sub-Saharan African countries [8]. Given that SCD is often symptomatic in childhood, young patients are likely to undergo multiple transfusions and to have been exposed to the cumulative risks from each of these transfusions. In addition to infections, these risks include iron overload and alloimmunisation against red blood cells (RBC) and human leucocyte antigens (HLA) [9]. Retrospective investigations with regard to SCD are facilitated by the chronic course of this disease, which enables long-term follow-up studies.

The specific objectives of the present study were to determine: the frequency of HIV, HBV and HCV infections in a population of SCD patients, according to their transfusion status and from the point when HCV testing was introduced, and the proportion of patients that were immunised against erythrocytes and HLA, with respect to the precise nature of the transfused material, such as non-deleucocyted familial whole blood, and erythrocyte surface antigen status.