Lapses in following a well-defined protocol for blood donation and transfusion have led to a series of tragedies in Tamil Nadu. Experts are now calling for some serious soul-searching and an audit to zero in on areas of improvement

It was her second pregnancy, and everything seemed to be going well, except for the niggle of anaemia that her gynaecologist was not too happy with. So Lakshmi (name changed) got herself a blood transfusion at the Sattur Government Hospital on December 3 last year. Initially, she seemed energised by the transfusion, but something went very wrong a short while later. She fell sick, and when the hospital did a blood panel, they found that she was HIV-positive.

The news came as a body blow to Lakshmi. Her life was suddenly rent asunder, and with very little awareness on the current, advanced treatment options for HIV infections, she and her husband thought it was a death sentence. The couple even contemplated suicide, but then turned and took the opposite road, deciding to fight this in every way known to them. “I told her that even if we die (due to infection) it should happen after putting up a fight against medical negligence. At least such a thing should not happen again to anyone else,” said the husband, who drives a cargo auto.

Going to the media was one option. As the story unravelled, in quick succession, her blood transfusion was linked firmly to the donation of blood contaminated with HIV and hepatitis B by a youngster. Therein unfolded the tragic story of Raja (name changed), the donor.

A young life lost

Raja’s sister-in-law, pregnant and anaemic, was advised to go for a blood transfusion. The government hospital transfused blood, and urged the family to find replacement donors for the blood used. Raja was one of the donors. Having donated blood two years ago, he was quite familiar with the procedure. He donated blood on November 30 and went about his business. Soon, he discovered that he was HIV-positive, after a test in order to apply for a job abroad. Advised by his brother to inform the hospital, Raja rushed to tell the doctors that he was HIV-positive and his blood should not be used.

Too late though. His blood was already coursing through Lakshmi’s blood vessels , and she had already tested positive for HIV (she would later test positive for hepatitis B too). Raja was distraught by the inadvertent error that had affected another family. The subsequent media glare also disarmed him. He attempted suicide, and was rushed to hospital. He died a few days later.

It turned out that his earlier blood donation in 2016 had been discarded by the blood bank as the blood was found to be HIV-positive. However, that’s where the first error occurs: though mandated by law (HIV Act) to inform him of his status and refer him for treatment, Raja remained in the dark. Had he been roped into the system then, he would have not donated blood, and he would have begun treatment.

Protocols and processes

Though the State follows the National AIDS Control Organisation’s protocols for blood collection, testing, storage and transfusion, yet another major error has also occurred. When Raja donated blood the second time, the Sivakasi blood bank failed to identify the infection, and the blood was used for transfusion, while it should have been discarded. In this, the State has failed both Lakshmi and Raja; the latter, repeatedly.

Guidelines followed by the T.N. govt., in accordance with NACO norms, on donation, storage and transfusion of blood Donor arrives at blood bank

Fills form

Undergoes clinical check-up -- BP, pulse etc.

Haemoglobin percentage is measured and blood group is assigned

If donor is fit, he is given a unique blood bank number

Blood is taken from donor (350 ml)

A small sample from the blood bag is sent for testing

Bag is stored in 'unscreened refrigerator'

The sample is tested for HIV, hepatitis B and C, STDs, malaria

If found negative, the blood bag is shifted to 'screened refrigerator'

If possible, blood is retested

If found positive again, the blood bag is discarded

The donor is informed, counselled, and referred for further treatment

*When a request for blood comes in, the blood is tested once again, and the group confirmed. Then cross-match is done with the patient's requirement and if there is a match, the blood is released for transfusion.

The State, after these shocking revelations, was galvanised into action. It started anti-retroviral treatment for Lakshmi, and initiated the process as per the Prevention of Parent to Child Transmission protocols. Soon her condition improved, as the viral load dropped, and her CD4 (a type of white blood cells that are part of the immune system) count increased. But for Raja, it was too late. “All three persons, two lab technicians and a counsellor at the Sivakasi blood bank, were terminated from their posts,” said Joint Director of Health Services, R. Manoharan.

Senthil Raj, Project Director, Tamil Nadu State AIDS Control Society, weighs in with a clarification and some figures. “Every year, in Tamil Nadu, we collect 8 lakh blood bags. This satisfies the WHO recommendation that 1% of the population should donate. Of this, 50% of the blood is collected in government blood banks, and the remaining in the private sector. Everyone tests for five infections – HIV, hepatitis B and C, STDs and malaria.

Out of the four lakh blood bags collected in the government sector, roughly 60-90 blood bags are discarded for HIV. Dr. Senthil adds: “In 2015-16, 67 blood bags were highlighted for HIV, and 58 of the donors were counselled and started on treatment. In 2016-17, 52 contaminated bags were found, and 44 donors were linked to the ART programme. In 2017-18, 64 bags were highlighted and 58 donors were contacted and linked up to the health system.”

Statistics bear out cold facts of performance, but among the 6 people the system missed in 2017-18, Raja was one.

“It is extremely unfortunate, no doubt,” Dr. Senthil said. “We are trying to plug all loopholes. One suggestion has been to use the sophisticated ID NAT testing device, reducing the window when the virus cannot be detected. We also have a proposal to test for HIV through the simple Card Test (in function similar to a pregnancy test kit) that can be done by the nurse, before the blood is used for transfusion.”

He assures that further corrective action will be taken after the five-member committee appointed to investigate the issue submits its report.

Karunanidhi, a representative of the Tamil Nadu Positive Network, articulates his angst at the State ignoring the staff in taluk hospitals and in the blood banks. He claims that in many hospitals, particularly in rural areas, there are no lab technicians available, though the blood bank is meant to be a round-the-clock operation. In some areas, contract employers at the blood bank face problems that are not resolved by the district AIDS Control Prevention Units, he adds.

One more

Meanwhile, a young mother from Mangadu, close to Chennai, claimed she had been infected with HIV after a blood transfusion at the Kilpauk Medical College (KMC) and Hospital. KMC dean P. Vasanthamani clarified that an inquiry carried out by her found no negligence on their part – the transfused blood was free of HIV.

“We have submitted a report to the Health Secretary. Our laboratory has quality consumables and we screen blood using fourth-generation testing facilities. Quality assurance is done by Christian Medical College and samples are routinely certified as part of protocols. The batch of samples that included the blood that was transfused was certified as properly screened,” Dr. Vasanthamani added.

‘Relook needed’

Despite all these assurances, there is still scepticism in the community. It is impossible to predict when one might need a blood transfusion, and the lack of assurance that the blood will indeed be infection free is worrisome for the people of the State.

“It is clear that the entire blood transfusion guidelines need a relook,” said Poongothai Aladi Aruna, a gynaecologist and head of the medical wing of the DMK. “Do we have strict guidelines and protocols? If so, then there has been a gross failure at all levels. Blood transfusion is the oldest and most successful form of transplant of human tissue. We must remember that the medical personnel who handle the blood, including the doctors, nurses and lab technicians, are also at risk if we allow contaminated blood to get into the system.”

She also raises the question of anaemia among the pregnant, as a subsidiary, but equally significant issue. The entire infected blood drama revolved around three women with severe anaemia. While Tamil Nadu’s standards are higher when compared to some other States, she insists that it is the state’s responsibility to ensure that its women, especially pregnant women, are not anaemic.

Gio Gnanadurai, an access-to-blood-for-all crusader, who incidentally was instrumental in setting up the Sivakasi blood bank, brings another angle to the table.

“The Sivakasi blood bank is one of the few in the locality, may be in the State, which is blood-surplus; and so was on a regular basis supplying blood to nearby blood banks as well. We have to do some soul searching; do a good audit and see if there are areas where we can improve, and then carry on with the improvements in place,” he said.

According to him, ensuring that safe blood is available to all within a limited time period is crucial. His worry is that the current incidents may derail the systems put in place in Tamil Nadu. The lessons learnt should go to strengthen health systems in the State, so that no person goes without a blood transfusion and no one gets infected blood, he says.

While acknowledging the injustice in the situation, Positive Women’s Network (PWNPlus) representative Kausalya addresses the young women who have contracted infections after blood transfusion. “HIV is no longer a death sentence. Do you know we have kids who were born with HIV and have now gone on to become mothers? Their children are HIV-free and they lead a good life. If one takes the ARTs regularly, that is possible. People with HIV have now lived on for 25 years or more. I’d urge them to continue treatment and not live in fear of a Damocles sword.”

She adds, however, that incidents such as these only serve to exacerbate the stigma against positive people in society, and the State should work on reducing the stigma, even as it is duty bound to ensure safe blood for all its people.

Confidence-building measures need to be immediately initiated to demonstrate that the State is keen on its blood safety and donation programme. This cannot be done merely through the dismissal of staff responsible for one incident, but by righting every wrong and plugging every single loophole that contributed to making victims of young men and expecting mothers.

Assistance for overcoming suicidal thoughts is available on the State’s health helpline 104 and Sneha’s suicide prevention helpline 044-24640050.

(With contributions from S. Sundar and Pon Vasanth in Madurai, and Serena Josephine M. in Chennai)