Prisoner Blood Donors and Posttransfusion (Icteric) Viral Hepatitis
R. S. KOFF,* T. C. CHALMERS,** AND THE BOSTON INTER-HOSPITAL LIVER GROUP
A retrospective study of the incidence of post- transfusion viral hepatitis in two state-operated hospitals with different kinds of blood procurement programs was undertaken for a nine-year period. Although one hospital relied mainly on prison donors and the other secured blood primarily from volunteer donors, no significant difference in the incidence of posttransfusion hepatitis could be demonstrated. These results suggest that carefully selected prison populations may be an important potential source of high quality donors, without undue risk of transmitting hepatitis. However, because this is a retrospective study and because it is not known whether the single penal institution studied in this report is unique, prospective studies of prisoner donors are necessary before such sources can be accepted generally.
WITH advances in other areas of medi- cine during the past two decades, demand for blood transfusion services has increased. Two striking examples of their concomi- tance are the remarkable progress made in the surgical approach to congenital and acquired heart disease and in the treatment of patients with bleeding disorders. Mas- sive blood transfusion is thus a common hospital practice today, but, as with many beneficial procedures, transfusion is not without hazard. The major complication is transmission of viral hepatitis. The risk of posttransfusion viral hepatitis increases almost linearly with the number of units transfused,l and is clearly related to stand- ards of donor selection.2 In general the high-risk hepatitis donor has usually been
Formerly Epidemic Intelligence Service Officer. National Communicable Disease Center, U. S. Pub- lic Health Service, and Research Fellow in Medi- cine, Tufts University School of Medicine, Boston, Massachusetts. Present address: Gastrointestinal Unit, Massachusetts General Hospital, Boston, Mass.
+* Professor of Medicine, Tufts University School of Medicine: Chief, Medical Services, Lem- uel Shattuck Hospital, Boston, Mass.
Received for publication July 24, 1967; accepted September 11, 1967.
the professional donor, whereas volunteer or family replacement donors carry a lower hepatitis risk for the recipient..' However, blood from paid donors when collected under medical supervision at a hospital blood bank is probably less hazardous with regard to transmitting hepatitis trhan blood supplied by commercial blood banks.2
T h e purpose of the present study was to determine whether donors from a local penal inscitution were as safe as non- prisoner or routine blood donors in an area with known high standards of donor selection and thereby a low incidence of posttransfusion viral hepatitis. T h e in- cidence of posttransfusion hepatitis was retrospectively compared, over a nine-year period (1956-1964), in two hospitals with contrasting blood procurement programs.
Description of the Two Study Hospitals and Their Patient Populations
T h e Lemuel Shattuck Hospital is a 437-bed chronic disease facility with a n average census of 381 patients i n 1964. Pondville Hospital is a 1 10-bed cancer institution located approxi- mately 20 miles south of Boston. T h e average daily census a t Pondville Hospital was 85 pa- tients i n 1964. Both institutions are operated by the Commonwealth of Massachusetts. As shown i n Table 1, total admissions for the nine years 1956-1964 were 14,303 a t the Lemuel Shattuck Hospital and 12,665 a t the Pondville Hospital. Thirty per cent of the total a t the Lemuel Shattuck Hospital were readmissions, whereas 49 per cent of Pondville Hospital ad- missions were readmissions. T h e total number of in-hospital deaths during the study period was greater a t the Lemuel Shattuck Hospital although the percentage of postmortem exam- inations performed was similar for both insti- tutions. T h e mean duration of hospitalization was almost three times longer a t the Lemuel Shattuck Hospital. However, this figure (67.8
436 Transfusion Nov.-Dec. 1967
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TABLE 1. Comparison of the Patient Populatiom at the Two Hospitals during the Period 1956-1964
Lemuel Shattuck Pondville Hospital Hospital
Number of admissions 14,703 12,664
Percentage readmissions 30% 49%
Percentage of postmortem examinations 62 Yo 65 %
Number of readmissions 4,462 6,200
Number of deaths 2,747 1,738 Number of postmortem examinations 1,709 1,127
Mean duration of hospital stay in days 67.8. 23.7
days) is weighted by the inclusion of approxi- mately 100 neurologic-disease beds. Patients admitted to that service had a mean length of hospital stay of 104 days during the period of study, but comprised less than 0.5 per cent of blood recipients. Pondville Hospital, in con- trast, has no neurologic service.
These data suggest that although there were differences in the patient populations under study, it is probable that they were not sufficient to bias the basic comparability of the two groups as indicators of minimal hepatitis incidence.
Blood Procurement Programs at the Two Hospitals
The Lemuel Shattuck Hospital, for the nine years of study, depended on blood collected by the Massachusetts Red Cross (MRC) and blood from professional donors bled at the hos- pital blood bank. For the entire study period, 68 per cent of all blood transfused was col- lected by the MRC, 29 per cent was supplied by paid donors, and 3 per cent was donated at the hospital by volunteers or family replace- ment donors. Ten thousand nine hundred two units were transfused at the Lemuel Shattuck Hospital during the years 1956-1964. AS shown in Table 2, the proportion of blood supplied by any of the three sources varied from year to year with an apparent trend toward increased use of MRC supplies during the study period.
Pondville Hospital, as shown in Table 3, used 12,423 units during the same period. Forty-four per cent of this blood was donated by prisoners at the Massachusetts Correctional Institution at Norfolk, 42 per cent was collected by the MRC, and 14 per cent came from vol- unteer or replacement donors bled at the
hospital. Over the nine years studied, a defi- nite decrease in volunteer-replacement dona- tions is apparent, and during the last four years studied, a trend toward more frequent use of prisoner donations is noted.
Blood Procurement at the Prison Colony The Norfolk Prison Colony is an interme-
diate-security, state correctional institution lo- cated about one mile from Pondville Hospital. During the nine years under review. the aver- age census was 600-800 inmates. Over 6,000 men were admitted for confinement during the study period. Each man entering the institu- tion is given a physical examination with emphasis on careful search for sites of tissue penetrations. A complete medical history is taken, and blood Hinton is determined at that time, Inmates with histories of prior jaundice or hepatitis, known drug addiction, malaria, or syphilis (or positive Hinton) are excluded from the donor list. Also excluded are those with recent infections, surgery, or hospital admis sions. Only permanent transfers (70-80 per cent of all inmates) are allowed to donate blood. Inmates who are accepted as donors are limited to one donation every three months. Prior to each donation the prospective donors com- plete medical record is checked for eligibility. Blood is collected on the prison grounds by the blood bank staff from Pondville Hospital.
Posttransfusion Viral Hepatitis Case Finding
Both hospitals medical record libraries and blood bank records were reviewed for all cases coded as serum hepatitis or infectious hepatitis. Cases were accepted as posttransfusion viral hepatitis if the patients had been transfused
438 Transfusion Nov.-Dec. 1967 KOFF AND CHALMERS
TABLE 2. Number of Units and Source of Blood Transfused, and Number of Posttransfusion Hepatitis Cases Found per Year, 1956-1964, at the Lemuel Shattuck Hospital
Mass. Red Volunteer No. of Cross Donors Paid Professional Replacement Posttransfusion
Year Units: (%) Donors (yo) Donors (7') Hepatitis Cases 1956 718 47 53 1957 612 41 59 1958 1,204 56 44 - 1959 1,449 58 42 1960 1,296 67 33 - 1961 1,411 79 14 7 0 1962 1,221 80 16 4 0 1963 1,559 75 22 3 0 1964 1,432 71 24 5 3
1 1 0 0 0
9-year Totals 10,902 68 29 3 5
15-180 days prior to onset of illness and had received whole blood or packed cells. Patients receiving plasma and fibrinogen were excluded.
Incidence of Posttransfusion Viral Hepatitis at the T w o Hospitals
Attack rates were calculated from data on blood usage and from the number of hepatitis cases found. No cases were found in which only a single unit had been transfused. Five cases of posttransfusion hepatitis were found at the Lemuel Shattuck Hospital-a minimal in- cidence of one case per 2,180 units transfused. At Pondville Hospital six cases were found, yielding a minimal attack rate of one case per 2,070 units transfused. These attack rates are not significantly different. During the last four years studied, the use of prison-collected blood increased at Pondville Hospital from 45 to 69 per cent of the total number of units trans- fused, but only one case of posttransfusion hepatitis was found.
Review of Records at the Prison Colony Two per cent (126) of the medical records
of all inmates admitted between 1956 and 1964 were randomly selected for review. Although this sample is admittedly small, no cases of viral hepatitis or illicit parenteral drug ad- ministration among inmates were recognized during the confinement periods in this group of inmates, suggesting that the endemic in- cidence of hepatitis and drug addiction was probably low in this institution. On the other hand, approximately 3 per cent of the inmates had a past history of hepatitis and 1 per cent admitted to parenteral drug addiction upon
entering the prison and were thereby excluded as blood donors.
Allen and associates reported an inci- dence of posttransfusion hepatitis of 0.3 per cent for recipients of single-unit trans- fusion from family donors, whereas the incidence was 3.2 per cent when blood was obtained from professional (largely pris- oner) donors.3 No information was pro- vided on the incidence of hepatitis in the prison population serving as donors in that area. Schafer and Mosley reported an epi- demic of parenterally transmitted hepatitis among inmates in a minimal-security prison in the southeastern United States; they concluded that closed populations in which jaundice is prevalent should be ex- cluded as blood donors.4 Thus prisoner donors have achieved widespread notoriety, although no information is available re- garding the risk of transmission of hepatitis by use of such donors when the institu- tional incidence of jaundice, hepatitis, or drug addiction is low or not different from that of the general population. The results of the present study indicate that some prison populations may serve as blood donors with relative safety.
Several defects of this study make it in- advisable to accept the data as proof that
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TABLE 3. Number of Units and Source of Blood Transfused, and Number of Posttransfusion Hefiatitis Cases Found p e r Year, 19561964, at the Pondville Hospital
Mass. Red Prison Volunteer No. of Cross Donors Donors Replacement Posttransfusion
Year Units (%) (%I Donors (%) Hepatitis C a m
1956 1957 1958 1959 1960 1961 1962 1963 1964
1,389 1,309 1,176 1,275 1,375 1,503 1,229 1,487 1,680
29 51 53 52 65 43 35 31 24
42 32 30 26 20 45 55 61 69
29 27 17 22 15 12 10 8 7
9-year Totals 12,423 42 44 14 6
blood collected in a prison is as safe as blood collected from volunteers. The exact attack rate is not known for either hospital population, and the lack of a difference might be related to the institutions rather than the source of blood, that is, the shorter hospital stay at Pondville might lead to less complete information in a record survey followup study. This is only partly miti- gated by the increased rate of readmissions.
Similarly, the very low attack rate at both institutions makes it very difficult to detect a difference, even though one may exist. However, the fact that only one case of hepatitis has been recognized among pa- tients given close to 6,000 transfusions- more than 3,500 from prisoners-makes it unlikely that a significant risk exists.
Whether or not this experience is unique to the penal institution studied must await investigation of other prison populations as donor sources. It is possible that persons confined for relatively long periods (months to years) in penal institutions are safer blood donors in part because they have less opportunity to acquire unrecognized hepa- titis exposure from extra-prison sources than prisoners confined for short periods as in most county or city jails. Studies comparing hepatitis risk in donors from state and county institutions are needed. With in- creasing demands on blood collection
agencies for whole blood supplies, lowering of donor standards may result in employ- ment of questionable donor sources such as out-of-state commercial blood banks.2 The present study suggests that some prison populations may be able to relieve these pressures on blood procurement programs. Further exploration of this problem in other regions must be undertaken before conclusions can be drawn about the general acceptability of these donor sources, and each prison must be evaluated on an indi- vidual basis.
Acknowledgment We are indebted to the blood bank and medical
record library personnel at the Lemuel Shattuck and Pondville Hospitals, and to the medical staff of the Massachusetts Correctional Institution at Norfolk, for assistance in this study.
References 1. Allen, J. G., and W. A. Sayman: Serum hepa-
titis from transfusions of blood: epidemio- logic study. JAMA 180: 1079, 1962.
2. Grady, G. F., T. C. Chalmers, and the Boston Inter-Hospital Liver Group. Risk of post- transfusion hepatitis. New Eng. J. Med. 271: 337, 19G4.
3. Allen, J. G., et al.: Blood transfusion and serum hepatitis: use of monochloroacetate as an antibacterial agent in plasma. Ann. Surg. 150455, 1959.
4. Schafer, I. A., and J. W. Mosley: A study of viral hepatitis in a penal institution. Ann. Int. Med. 49: 1162, 1958.