Breach in protocol resulted in HIV+ blood labelled ‘safe’

While it is mandatory for all blood banks to screen donated blood for five mandatory tests under the Drugs and Cosmetics Act, a case in Sivakasi highlighted the lack of seriousness on the part of some institutions in following the protocol. In this case, blood donated by an HIV positive man was labelled “safe blood” and used in transfusion for a pregnant woman.

The incident came to light when the 23-year-old woman was tested positive for the virus after the donor returned to Sivakasi Government Hospital where he had donated his blood to inform the authorities that he might have HIV. The 19-year-old had donated blood in November without knowing that he had the virus. But, a recent blood test done as per his job requirement revealed that he was HIV positive.

Wanting to get a second opinion, he returned to Sivakasi Government Hospital, where they diagnosed him with HIV. Later, the hospital authorities realised that the blood was used in transfusion for a pregnant woman in Sattur Government Hospital who was being treated for anaemia in November. When the woman was tested, doctors found the presence of the virus in her as well.

On the preliminary enquiry, Dr Manoharan, the joint director of health in Virudhunagar, said, “The youngster, at the age of 17, had donated blood for the first time at a private camp in August, 2016. He was tested positive for HIV and attempts were made to inform him, but he did not turn up.”

“Also, the procedure is flawed. The hospital forms have options such as ‘If I am positive, inform me/don’t inform me’ which affects donation and patients’ health. At that time, however, the youth’s blood was discarded,” Dr Manoharan added.

“On November 19, this year, he donated blood for a relative, which was not used as they had sourced blood already. But, the blood was preserved as ‘safe blood’,” he said.

While the hospital that took his blood drew flak, doctors stressed on the importance of following the protocol to test donated blood. Dr N Rajakumar, professor and head of the department of transfusion medicine, Government Stanley Medical College and Hospital, said, “Blood transfusion is a double-edged weapon that can either be extremely useful to the patient or disastrous. It is like a mini transplant and its major threat is the possibility of infections.”

Stating that there can be only two possibilities in the Sivakasi case, Dr S Subash, doctor in-charge at the blood bank in Rajiv Gandhi Government General Hospital (RGGGH) in the city, said, “The blood donated was either not tested for HIV or the test did not yield correct results at that time.”

Here, Dr N Kumarasamy, the chief medical officer at Voluntary Health Services (VHS) Hospital, in the city, said, “Investigators must find out whether the hospital even tested his blood or not, or if it was an error on part of the lab technicians.”

The doctor added that it is essential that the patient is tested first to see if he is eligible to donate and even after donation, the blood needs to undergo five major tests. “Any blood bank must test the donated blood for HIV 1 and 2, Hepatitis B and C, Malaria and Syphilis bacteria. Unless these tests are done, one cannot avoid transfusion-related infections,” Kumarasamy said.

Speaking about a blood donor’s eligibility, he added, “He has to be physically examined by a qualified blood bank medical officer and subjected to pre-donation counselling, during which he should be explained about the procedure. Only then will he be allowed to donate blood.”

Speaking to DT Next, Health Secretary J Radhakrishnan said, “A team of experts have been put together to conduct a detailed investigation into this case. As of now, we have dismissed one lab technician from Sivakasi Government Hospital, another lab technician from the ICTC and an ICTC counsellor. Based on the results of the probe, we will decide the further course of action.”

The pregnant woman developed fever, headache and diarrhoea soon after the transfusion and on December 17, a test conducted at the Integrated Counselling and Testing Centre (ICTC) at Sattur confirmed her with HIV. 

The joint director of Virudhunagar has been instructed to take precautions for her delivery and ensure the safety of both the mother and the baby. Following the enquiry, based on the mother’s qualification, she will be given a job and her family too will be taken care of, a government release said. The health department has also assured that such a mistake would never be repeated.

The relatives of the pregnant woman, who contracted HIV after being transfused with infected blood, staged road blockage in front of the Government Hospital at Sattur and Virudhunagar collecorate on Wednesday, seeking strict action against the healthcare professionals responsible. 

A case has been filed against the nurses at Sattur GH and Sivakasi hospital for negligence among others, while the State Human Rights Commission has decided to initiate suo motu proceedings against the doctors.

The woman, now referred to Madurai Government Rajaji Hospital for treatment, was stable, said Health Secretary J Radhakrishnan, adding that high quality medical treatment would be given to her. Also, antiretroviral therapy would be given to prevent transmitting the infection to the baby. Further, antenatal and post-natal care would be given to the nine-month pregnant woman, and after delivery, special care would be given for twelve weeks, the official added.

Preliminary inquiry into the incident was over and detailed enquiry would go on for the next 15 days, said Radhakrishnan, adding that the two lab technicians and a counsellor involved in the case have already been terminated from service for negligence of duty.

The victim’s husband did not seek compensation or government job, but insisted on getting her best quality treatment. A three-member special team will reassess the pregnant woman and provide treatment, and also probe the blood bank staff and the supervisory lab, said the secretary.

In the light of the incident, the blood bank in Virudhunagar would be retested and random tests would be undertaken at blood banks across the State. As per procedure, the National Blood Transfusion Council would review and assess external quality assurance service in blood banks.

Radhakrishnan added that a draft is ready to revamp blood safety protocol in 45 days after convening stakeholders meeting.

Meanwhile, district police Superintendent M Rajarajan said based on a complaint lodged by the victim, a case had been filed against nurses in Sattur Government Hospital and Sivakasi Hospital under Sections 269 (act of negligence) and 338 (causing grievous hurt by endangering life) of the IPC.

Speaking to the media in Tirunelveli, State Human Rights Commission chairman D Jayachandran said the commission would initiate suo motu proceedings against negligence of doctors and would seek reports from the Virudhunagar Joint Director of Health and Health Secretary on what actions had been taken against those held responsible. Apart from this, the Commission would also take steps to ensure adequate compensation for the victim’s family.

Vellore: A WhatsApp message doing rounds alleged that blood samples sent from Vellore Government Hospital to a primary health centre (PHC) in Pernamallur near Arni in Tiruvannamalai district too were contaminated and that it had resulted in another pregnant woman being tested positive for HIV. The message sent everyone into a tizzy with recipients of blood transfusion from the hospital and the centre calling up the authorities to check if the message was true. Medical officials immediately ordered that all available blood samples be checked to ensure that they were safe. When contacted GH blood bank officials said the message was fake as all the blood in the bank were sent out or used in transfusions only after it was thoroughly screened for various infectious diseases, including HIV. Medical officials at Pernamallur PHC and Arni government hospital also reassured that there was no contamination.