Abstract
Objectives: To ascertain the prevalence of transfusion transmissible infections (TTIs) across diverse donor groups in the Najran province. Additionally, to establish a potential association between the development of TTI and the donors’ blood group, as determined by the ABO/Rh blood grouping system.
Methods: Blood donation data of 4120 donors, spanning from January to December 2020, were retrospectively reviewed. The blood were screened for TTI markers, including hepatitis B surface antigen (HBsAg), anti-hepatitis B core (anti-HBc), anti-hepatitis C virus (anti-HCV), anti-human immunodeficiency viruses 1 and 2 (anti-HIV1&2), anti-human T-lymphotropic virus types 1 and 2 (anti-HTLV-1&2), and syphilis antigen.
Results: Positive TTI markers were detected in 10.9% of the donors. The most detected TTI marker was anti-HBc (8.9%), followed by HBsAg (0.7%). Other markers were individually detected in <1% of the donors. Anti-HBc-positive was significantly elevated among non-Saudi blood donors. There was an association between age groups and anti-HCV (p=0.002), anti-HTLV (p=0.004) and syphilis antigen (p=0.02) markers positivity. The AB positive blood group exhibited the most positivity for TTI markers, followed by O positive blood group. Similarly, association was found between ABO group and HBsAg (p=0.01), anti-HBc (p=0.001), and anti-HCV (p<0.001) markers positivity.
Conclusion: Emphasis on implementing robust screening measures for donated blood is underscored by this study. There is the need for future study to extensively evaluate TTI status to enhance our understanding of the trend in TTI.
Blood transfusion, being a crucial component of healthcare services saves millions of lives across the globe. It is often used to support complex medical and surgical procedures, such as transplants and cardiovascular surgery in developed nations, whereas in developing nations, it is used in cases of trauma, obstetric emergencies in women, and malnourished and anemic children.1,2 Hence, scarcity of qualitative safe blood or its components may impede necessary health care services.
Transfusion transmissible infections (TTI) are major public health concerns, particularly in developing countries.3 Importantly, the frequency of TTI among blood donors varies across different nations of the world, as well as within Saudi Arabia.4-11 There is a threat of developing life-threatening illnesses, including TTI, due to unsafe blood transfusion. Human immunodeficiency virus (HIV) types 1 and 2, and hepatitis B and C viruses have all been implicated in TTI.12-16 In clinical practice, the ABO blood grouping is widely used. These blood groups are associated with susceptibility towards a number of chronic diseases and viral infections.17
In the Kingdom of Saudi Arabia (KSA), Ministry of Health (MOH) actively oversees donor blood collection and its related services. All donated blood is screened for various immunological markers including anti-HBc, anti-HBsAg, anti-HCV, anti-HIV1&2, anti-HTLV-1&2, HBsAg, the TPHA and malaria antigen test. However, it is not clear whether any of the TTI has specific prevalence among a peculiar group of donors, such as specific age, gender, or nationality within KSA. In fact, only few studies have attempted to address these issues.2 In addition, it is not clear weather incidences of infection due to transfusion is linked to the recipient’s ABO/Rh blood group. However, previous studies suggest that ABO/Rh blood groups may influence the susceptibility of a subject to a specific TTI development.18 In this study, our aim was to evaluate the occurrence of TTI in various donor groups in Najran province and establish a potential correlation between TTI development and the donors’ blood group, basing on the ABO/Rh blood grouping.
Methods
Prior to commencing data collection, ethical approval for this study was obtained from the relevant local authority. The study received approval from the Health Affairs’ General Directorate in Najran city (IRB No. 2022-39 E). Past studies related to this work were reviewed after searching well-known publicly available databases such as PubMed and Google Scholar, among others. Further, this study was conducted in agreement with Helsinki declaration.
Archived data of directed blood donations received at King Khalid Hospital (KKH), the main hospital in Najran province of the Kingdom of Saudi Arabia, were retrospectively reviewed and analyzed. The data consists of 4187 blood donations from January 2020 to December 2020. Subjects with missing demographic data (n=67) were excluded from the study. Inclusion criteria for the actual study subjects (n=4120) were age between 17-65 years, weight not less than 50 kg, being in a good health, no infectious diseases record and hemoglobin level above 13 grams/dl for men and 12 grams/dl for women. The criteria were in line with the national guidelines for blood donation. All participants were screened using appropriate screening tests. Demographic characteristics (age, gender, and nationality), ABO/Rh blood group, and serological markers for TTI were extracted from donor databases.
Blood grouping
Blood group tests including ABO and Rh typing were performed in the hospital laboratory utilizing the IH-500 fully automated blood typing system (Bio-Rad Laboratories Inc., headquartered in California, USA). This cutting-edge system conducts in vitro serological analysis to determine blood grouping and detect antibodies in blood samples, leveraging data from gel card images to deliver accurate results.
Blood screening for TTI
Every blood donation underwent screening via enzyme-linked immunosorbent assay test kits obtained from Abbot Laboratories, Chicago, US, for HBsAg, anti-HBc, anti-HCV, anti-HIV1&2 and anti-HTLV-1&2, rapid plasma reagin card (RPR) test kit (Thermo Fisher Scientific, Waltham, US) for syphilis antigen and the Care Start Malaria PF (HRP-2) Ag RDT (Access Bio, Somerset, New Jersey, USA) for malaria. Each test was performed as per the instructions of the manufacturer. All positive samples underwent additional confirmation by the regional laboratory to validate the results further.
Statistical analysis
Demographic and ABO/Rh blood group data were statistically evaluated utilizing the sixth version of Graph Pad Prism (San Diego, California, USA) to determine the relationship of age, nationality, and blood group with TTI. Pearson correlation coefficient test was performed for the association of different age groups with TTI serological markers, while Spearman’s rank correlation coefficient test was performed for the association of ABO groups with TTI serological markers. Furthermore, tests including Chi-square and ANOVA were done on each of the outcome evaluated by grouping the demographic factors of the donor. A p-value of < 0.05 was used to indicate significance.
Results
The current research involved 4120 volunteer blood donors from Najran to determine the prevalence of TTI among the subjects, and their correlation with ABO/Rh blood grouping. A total of 4020 subjects were selected for the study while 67 subjects were excluded as there were missing data. All samples were collected between January 2020 to December 2020 (Figure 1).
- A flowchart showing the study design with participant selection criteria.
The majority of subjects were males, representing 98.7% (n=4067), compared to female subjects (1.3%). The subjects were within 70 years old, and virtually all age groups were represented as depicted in Table 1. Saudi citizens constituted 70.9% (n=2922) of subjects while non-Saudi citizens constituted 29.1% (n=1198). A total of 449 (10.9%) samples had a positive TTI markers. The anti-HBc is recorded as the highest serological marker (8.9%). This was followed by HBsAg (0.7%) and other serological markers which were all individually found to be less than 1% of the entire subjects. A co-infection pattern was observed among 12 subjects as shown in Table 1. The anti-HBc was found to be the dominant marker among the subjects with co-infection. Further, the distribution of ABO/Rh blood types among the subjects revealed that O positive (+ve) was the most dominant blood group (50%) followed by A+ve (26.8%), B+ve (9.9%), and O negative (-ve) 6.5%.
- Characteristics of subjects within this study.
The association between different age groups and TTI markers positivity was analyzed using Pearson correlation coefficient test. Unlike anti-HBc, anti-HIV I/II p24 and HBsAg, the statistical analysis showed a significant association between anti-HCV, anti-HTLV and RPR with age group. The association between ABO group and TTI markers positivity is also represented in Table 2.
- Association between transfusion transmissible infections (TTIs) markers positivity and different age and ABO groups.
The correlation between age and serological markers of TTI was analyzed and showed a significant increase in anti-HBc with age (Figure 2A). The anti-HCV serological marker showed a significant result in 51-60 years age group as compared to 21-30 years (Figure 2B). Although a higher positivity rate was recorded in the age group 51-60 years, there was no significant difference in anti-HIV-I/II p24, anti-HTLV-I/II and RPR serological markers.
- Age groups versus markers of transfusion transmissible infections (TTI) from positive subjects. Comparison of different age groups yielded different statistical results for (A) Anti-hepatitis B core (anti-HBc): ≤20 versus 21-30 (p=0.14), 21-30 versus 31-40 (p<0.001), 31-40 versus 41-50 (p<0.001), 41-50 versus 51-60 (p<0.009), 51-60 versus 61-70 (p=0.76), 21-30 versus 41-50 (p<0.001) (B) Anti-hepatitis C virus (anti-HCV): ≤20 versus 21-30 (p=0.86), 21-30 versus 31-40 (p=0.92), 31-40 versus 41-50 (p=0.83), 41-50 versus 51-60 (p=0.08), 31-40 versus 51-60 (p=0.06), 21-30 versus 51-60 (p=0.03), ≤20 versus 51-60 (p=0.15) (C) Anti-human immunodeficiency viruses 1 and 2 (Anti-HIV-I/II p24): ≤20 versus 21-30 (p=0.12), ≤20versus 31-40 (p=0.16), 31-40 versus 51-60 (p=0.16), ≤20 versus 51-60 (p=0.77) (D) Anti-human T-lymphotropic virus types 1 and 2 (Anti-HTLV-I/II): ≤20 versus 21-30 (p=0.86), 21-30 versus 31-40 (p=0.45), 31-40 versus 41-50 (p=0.46) and (E) Rapid plasma reagin (RPR): ≤20 versus 21-30 (p=0.79), ≤20 versus 31-40 (p=0.37), 41-50 versus 51-60 (p=0.61), 31-40 versus 51-60 (p=0.19).
Transfusion transmissible infections test positivity was significantly associated with nationality for anti-HBc, with non-Saudi subjects significantly higher than Saudi subjects. The data of HBsAg, anti-HIV-I/II, anti-HTLV-I/II and RPR revealed that Saudi and non-Saudi subjects have fairly similar positivity rate (Figure 3).
- Nationality versus serological markers of transfusion transmissible infections (TTI) from positive subjects. Comparison of Saudi and non-Saudi participants yielded different statistical results for hepatitis B surface antigen (HBsAg) (p>0.05), anti-hepatitis B core (anti-HBc) (p<0.001), anti-hepatitis C virus (anti-HCV) (p>0.05), Anti-human immunodeficiency viruses 1 and 2 (Anti-HIV-I/II p24) (p>0.05), Anti-human T-lymphotropic virus types 1 and 2 (anti-HTLV-I/II) (p>0.05), and rapid plasma reagin (PRP) (p>0.05).
The TTI serological tests for anti-HBc among blood grouping showed a significant association between AB+ve and O-ve, as well as between O+ve and O-ve. A-ve blood group demonstrated high positivity towards the anti-HCV test. The O-ve blood group showed a significant rise in anti-HIV-I/II p24 serological marker compared to O+ve blood group. In the anti-HTLV-I/II serological test data, the A-ve and AB+ve blood groups showed the highest positivity among other blood groups. The O+ blood group had the highest positivity in PRP serological marker test (Figure 4).
- All blood groups versus serological markers of transfusion transmissible infections (TTI) from positive subjects. Comparison of different blood groups yielded different statistical results for (A) anti-hepatitis B core (anti-HBc): A+ve versus A-ve (p=0.55), B+ve versus B-ve (p=0.25), AB+ve versus AB-ve (p=0.67), O+ve versus O-ve (p<0.004) (B) Anti-hepatitis C virus (Anti-HCV): A+ve versus A-ve (p=0.14), A-ve versus B+ve (p=0.01), O+ve versus O-ve (p=0.57) (C) Anti-human immunodeficiency viruses 1 and 2 (Anti-HIV-I/II p24): B+ve versus O+ve (p=0.20), O+ve versus O-ve (p=0.003), B+ve versus O-ve (p>0.05) (D) Anti-human T-lymphotropic virus types 1 and 2 (Anti-HTLV-I/II): A+ve versus A-ve (p=0.57), AB+ versus O+ve (p=0.39) and (E) Rapid plasma reagin (PRP): B+ve versus O+ve (p=0.57), and O+ve versus O-ve (p=0.87).
Discussion
The identification of TTI antibodies in donor blood is crucial for ensuring the integrity and safety of the blood supply. It protects both donors and recipients by preventing the transmission of infectious agents during blood transfusions and other medical procedures. These have made rigorous screening protocols and compliance with regulatory standards essential components of blood safety programs worldwide. Thus, our study aims to estimate the occurrence of TTI markers among donors and their correlation with ABO/Rh blood grouping.
The donors in this study were found to be predominantly male (98.7%). This disparity in gender composition was not surprising as women tend to have higher deferral rates. Moreover, the finding is comparable to other previous reports where majority of donors were males.15,19 Few studies on TTI seroprevalence among blood donors in Saudi Arabia was conducted previously.15 The study conducted by Alshahrani et al19 in Abha, revealed that the overall prevalence of TTI serological markers was 11%, which is similar to the finding in our study (10.9%). However, our finding is higher than the overall prevalence rate reported in Qatar (2.7%), as well as in Riyadh, Saudi Arabia (0.7%).4,20 These results highlight the need for further awareness campaigns, especially in regions with higher prevalence rate of TTI.
In line with the study of Alshahrani et al19 who identified anti-HBc as dominant among other serological markers, the serological marker was the most dominant in our study with the highest rate of 8.9%. However, this rate is higher than that previously reported in Abha (5.9%) and the Eastern region of Saudi Arabia (2.9%).19 Additionally, lower rates have been reported in Croatia (1.3%) and Lebanon (7.7%). were reported.21,22 Variable rates of anti-HBc among blood donors have been reported in other parts of the world including much higher rates of 41% in Lao and 48.5% in Nigeria.23,24 Additionally, we found a significantly higher rates of anti-HBc positivity among the non-Saudi donors compared to the Saudis in this present study. The observation was, however, not startling, as anti-HBc positivity rates that hovers around 10% have been documented among some blood donor groups in neighboring Yemen which shares border with Saudi Arabia.25,26 Indeed, approximately 64% of donors with anti-HBc positivity in this study were Yemenis (data not shown). Anti-HBc serves as a valuable indicator of exposure to HBV, regardless of the individual’s current infectious status. This is particularly significant at the end of a resolving infection when HBsAg and HBV nucleic acid testing might not yield positive results.27 Notably, our study also demonstrates that anti-HBc positivity increased with age.
Unlike anti-HBc, we observed a low prevalence of anti-HBsAg (0.7%) among the donors. This rate is lower than the 5.8% reported in Asir, but comparable to the 1.1% in Makkah 29 and 0.3% in Eastern Saudi Arabia.28,30 Our finding is, however, not surprising as the prevalence of HBV chronic disease in Saudi Arabia is estimated at <2%, making the country a low-risk area for international travellers.31 The other serological markers assessed in this study were found in less than 1% of the study population, suggesting the relative safety of the donated blood. Although possible cases of co-infection were identified, the cases represented an infinitesimal fraction of the donors assessed in this study. Overall, although not accounted for in this study, the differences in the reported TTI markers occurrence could be attributed to the study participant’s economic status and lifestyle.
In our study, donors with blood group O were the most dominant, accounting for more than 50% of the donors. This is not surprising as blood group O is considered the most common blood type among people.18,32 Moreover, in a previous report in Saudi Arabia, about 47% of blood donors were identified as O+ve.15 In a study conducted in India, the highest TTI sero-reactivity was found in blood group B+ve blood donors (1.8%) followed by O+ve (1.54%).33 Another study similarly reported the highest sero-reactivity for TTIs among donors with blood group B (2.2%) and blood group A (2.2%).34 In contrast, our study detected the highest TTI sero-reactivity among AB+ve blood group donors, followed by those with O+ve blood group.
We further assessed the potential association of the donors’ blood groups and TTI positivity given that the ABO blood group has been associated with certain infectious diseases in the past. For example, a meta-analysis study found an association between blood groups and infection with SARS-CoV-2. It was hypothesized that blood group A has the highest risk, whereas the lowest risk is associated with the O blood group.35 However, a recent retrospective study in Ethiopia investigating TTI prevalence among 27027 blood donors did not find any significant association between the donors’ ABO/Rh blood group and the TTI markers tested (HIV, HBV, HCV, and syphilis).32 Interestingly, our study found an association between ABO blood group and HBsAg, anti-HBc, and anti-HCV positivity. While these associations were observed in Najran, it is crucial to evaluate the phenomena in donors from other regions of Saudi Arabia.
Study limitations
Although expected, the number of female donors were low. This hindered us from performing an extensive gender-based analysis. Further, the study is a single-center study even though it was conducted at the main hospital in Najran province. Inclusion of donors from multiple locations within Najran may provide a broader overview of the status of TTI among blood donors in Najran province.
In conclusion, TTI antibody screening plays a central role in maintaining the safety and integrity of the blood supply. It is a critical practice that helps check infectious diseases transmission, protect recipients’ health, and ensure the overall safety of blood transfusions and related medical interventions. This study investigated several TTI markers among blood donors in Najran, Saudi Arabia, and found an overall TTI rate of 10.9%, with anti-HBc being the most dominant. The findings from this study underscore the need for effective and robust screening of donor blood.
Acknowledgment
The authors are thankful to the Deanship of Graduate Studies and Scientific Research at Najran University for funding this work under the Najran Research Funding Program grant code (NU/NRP/MRC/13/191-1). The authors acknowledge ManuscriptEdit (www.manuscriptedit.com) for the English language editing.
Footnotes
Disclosure. This study was funded by Deanship of Graduate Studies and Scientific Research at Najran University under the Najran Research Funding Program grant code (NU/NRP/MRC/13/191-1).
- Received April 25, 2024.
- Accepted June 2, 2024.
- Copyright: © Saudi Medical Journal
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