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International Blood Safety Forum Washington, DC Confronting Emerging Pathogens with Limited Resources Jos Eduardo Levi MARCH 20 th, 2015 Slide 2 MANDATORY TESTING IN BRAZIL Hepatitis B anti-HBc + HBsAg + HBV-DNA Hepatitis C anti-HCV + HCV-RNA HIV anti-HIV (1, 2 and O) + HIV-RNA Chagas Disease anti-T. cruzi Syphilis Treponemic or non-treponemic assay HTLV-1 and HTLV-2 anti-HTLV 1 and 2 Malaria In endemic areas (Amazon) CMV Selected recipients Abnormal hemoglobin Sickle cell trait Slide 3 DENGUE Slide 4 Slide 5 Affected municipalities and Incidence Slide 6 Slide 7 Sao Paulo 15,000,000 inhabitants < 1,000 dengue cases in 2010 Santos 800,000 inhabitants > 20,000 dengue cases in 2010 60 km Slide 8 Tabela 1 Nmero de casos de dengue comprovados e incidncia por 100.000 habitantes em municpios da baixada santista. Fonte: Secretaria do estado da Sade (Grupo de Vigilncia Epidemiolgica) e IBGE. DENGUE LABORATORY MARKERS AMONG BLOOD DONORS FROM SANTOS, BRAZIL. LEVI, UNPUBLISHED IgGIgMIgG + IgMTMA MONTH/YEARN= JAN/201050074,0%7,2%5,8%0,0% FEB/201049364,5%8,5%6,9%1,4% MARCH/201049568,7%15,2%13,7%1,2% APRIL/201050070,2%24,4%23,8%0,8% JULY/201050071,6%17,8% 0,0% JULY/201150074,4%8,6%7,8%0,0% MEAN 70,6%13,6%12,6%0,6% Slide 9 Rate symptomatic/ asymptomatic = 1:3 Slide 10 VIREMIC DONOR (RNA+) RECIPIENT PRE-TX NEGATIVE AND POST-TX NEGATIVE SIGNS, SYMPTOMS AND LABORATORY MARKERS COMPATIBLE WIH DENGUE OCCURRING 1-14 DAYS POST-TRANSFUSION EVIDENCE OF TRANSFUSION-TRANSMITTED DENGUE Slide 11 Slide 12 STRAMER SL, TRANSFUSION 2012, IN PRESS Slide 13 Transfusion.Transfusion. 2015 Jan 21. doi: 10.1111/trf.12944. [Epub ahead of print Slide 14 Slide 15 HYPOTHESIS FOR THE LOW NUMBER OF TT CASES REPORTED: 1)Hemovigilance may be deficient 2) Presence of protective immunity in recipients in endemic areas 3) Frequent cotransfusion of antibody-positive units which neutralize infectivity of viremic donations 4) Clinical outcomes may not be as severe in immunosuppressed patients infected with dengue 5) Need for mosquito saliva to enhance dengue replication and virulence; Slide 16 ? Slide 17 Slide 18 HYPOTHESIS FOR THE LOW NUMBER OF TT CASES REPORTED: 1)Hemovigilance may be deficient 2) Presence of protective immunity in recipients in endemic areas 3) Frequent cotransfusion of antibody-positive units which neutralize infectivity of viremic donations 4) Clinical outcomes may not be as severe in immunosuppressed patients infected with dengue 5) Need for mosquito saliva to enhance dengue replication and virulence; Slide 19 Tabela 1 Nmero de casos de dengue comprovados e incidncia por 100.000 habitantes em municpios da baixada santista. Fonte: Secretaria do estado da Sade (Grupo de Vigilncia Epidemiolgica) e IBGE. DENGUE LABORATORY MARKERS AMONG BLOOD DONORS FROM SANTOS, BRAZIL. LEVI, UNPUBLISHED IgGIgMIgG + IgMTMA MONTH/YEARN= JAN/201050074,0%7,2%5,8%0,0% FEB/201049364,5%8,5%6,9%1,4% MARCH/201049568,7%15,2%13,7%1,2% APRIL/201050070,2%24,4%23,8%0,8% JULY/201050071,6%17,8% 0,0% JULY/201150074,4%8,6%7,8%0,0% MEAN 70,6%13,6%12,6%0,6% Slide 20 DENGUE SEROTYPES CIRCULATING IN BRAZIL, 2012 Slide 21 Slide 22 HYPOTHESIS FOR THE LOW NUMBER OF TT CASES REPORTED: 1)Hemovigilance may be deficient 2) Presence of protective immunity in recipients in endemic areas 3) Frequent cotransfusion of antibody-positive units which neutralize infectivity of viremic donations 4) Clinical outcomes may not be as severe in immunosuppressed patients infected with dengue 5) Need for mosquito saliva to enhance dengue replication and virulence; Slide 23 2 casos de dengue, 1 DF e 1 DSS, ambos transplante de fgado cerca de 8 meses ps-transplante. Slide 24 HYPOTHESIS FOR THE LOW NUMBER OF TT CASES REPORTED: 1)Hemovigilance may be deficient 2) Presence of protective immunity in recipients in endemic areas 3) Frequent cotransfusion of antibody-positive units which neutralize infectivity of viremic donations 4) Clinical outcomes may not be as severe in immunosuppressed patients infected with dengue 5) Need for mosquito saliva to enhance dengue replication and virulence; Slide 25 Slide 26 Slide 27 DONOR`S SCREENING: IF AND HOW -EPIDEMIOLOGY Important negative impact on donor availability -CLINICAL SIGNS Low efficiency -LABORATORIAL ? Slide 28 Slide 29 Slide 30 PROOF OF TT WNV - USA Slide 31 WNV INTRODUCTION IN SOUTH AMERICA Slide 32 Slide 33 Slide 34 No cases Imported(38) Autoctonous (850) CHIKUNGUNYA CASES BRAZIL NOVEMBER 2014 Slide 35 NEW/EMERGING AGENTS Slide 36 Slide 37 A. albopictusA. aegypti Slide 38 MEASURES TAKEN AT SO PAULO BLOOD BANK: -DEVELOPMENT OF A DENGUE/CHKV REAL-TIME PCR ASSAY FOR APHERESIS PLATELET UNITS -EMERGENCY PLAN TO STOP BLOOD COLLECTION AT AREAS OF HIGH INCIDENCE -MOBILIZATION OF FIDELIZED BLOOD DONORS FROM NON-AFFECTED AREAS - ESTABLISHMENT OF EPIDEMIOLOGICAL CRITERIA FOR RESTARTING BLOOD COLLECTION (TRIGGERS) Slide 39 ACKNOWLEDGMENTS Dr sper G. Kallas and team - Immunology Dept., So Paulo University Medical School Eliana Perroud Santos Blood Center Dr Cludio Pannuti and team Virology Lab, tropical medicine Institute, University of So Paulo Dr Ester Sabino Infectious Diseases Dept., So Paulo University Medical School Dr Alfredo Mendrone and team Fundao Pr-Sangue Dr Michael P. Busch - Blood Systems Research Institute, EUA Novartis (Grifols) Sponsor, Santos Dengue Blood Donors Study