Letters to the Editor

EDITOR’S NOTE: In the May 1990 issue of TRANSFUSION, readers were invited to respond to a suggestion made by Dr. Jerry Kolins that a look-back for transfusion-trans- mitted hepatitis C virus (HCV) is essential. Three letters were received in response to that invitation and are printed below. The letters from Drs. Simon and Fawcett address the question directly. The letter from Dr. Bellobuono and colleagues presents data pertinent to the discussion. Also included in this issue is a fourth letter about HCV, from Dr. Ohto and colleagues in Japan.

Identification of recipients with hepatitis C and other transfusion-transmitted infections: we can do better than

look-back! To the Editor:

Dr. Kolins argues that a hepatitis C virus (HCV) look-back should be implemented because the medical, ethical, and legal considerations are compelling.’ I support completely a trans- fusion recipient’s need and right to know whether he could have been infected by blood. I disagree that conventional look- back will do the job; it is ineffective and inefficient, more so for hospitals and physicians than for blood centers. Only a tiny portion of the time, effort, and cost of currently conducted look-back programs for HIV and HTLV-ID1 yields productive results. With HCV, the problems are magnified. The issue is not look-back versus no look-back, but look-back versus a better alternative. Look-back provides a cosmetic approach; I propose a substantive solution.

A posttransfusion follow-up at 6 to 12 months is proposed to complete the transfusion episode. At that time, tests would be performed on the patient’s serum for agents that may be unavoidably transmitted (at present, this means HIV, hepatitis B surface antigen, HCV, HTLV-IDI, and ALT). A positive result may benefit the patient, the patient’s contacts, or both. It will not establish transfusion as the cause. This method can be refined by including pretransfusion screening, which may assuage liability concerns but is unnecessary for the patient’s potential benefit or for the public health. The advantages over look-back are clear. Because posttransfusion follow-up is in- dependent of the donor, it casts a wider net: it does not depend on a repeat donor who is now positive for the marker; it in- cludes recipients of blood from one-time donors and repeat donors who have since been eliminated from the donor pool by surrogate tests performed prior to anti-HCV screening. Fur- ther, it reduces or eliminates unproductive administrative com- plexities, including a tortuous and sometimes flawed records trail and interventions and follow-ups by blood centers, trans- fusion services, hospital records departments, and multiple physicians. It targets surviving recipients and avoids tracing deceased patients. It embraces future transmissible agents with ease and shortens the interval between putative transmission and detection. Finally, by acknowledging that zero risk for transfusion is not achievable now, it should be a powerful incentive to decrease the inappropriate use of blood components.

Implementation is simple. Informed consent, indicating pos- sible unexpected outcomes, should precede the transfusion epi- sode. On discharge, the message is reinforced and specific information is provided regarding mechanisms for follow-up. Re- sponsibility for follow-up rests with the patient, as it should. By linking it to appropriate community and physician education, with the active involvement of the US Public Health Service, state and local health departments, medical and blood service organi- zations, blood centers, hospitals, manufacturers, and, in partic- ular, the national media, routine posttransfusion follow-up becomes an extension of the HIV program recommended by the Presiden-

tial AIDS Commission and by the American Hospital Association to its member hospitals. The message must emphasize that trans- fusion accounts for a small fraction of these diseases and that the focus on transfusion recipients is merely a part of our overall health strategy. This approach is consistent with the joint statementz for future transfusion recipients and, with appropriate modifica- tions, past recipients. Implementation for HCV will be more effective when confirmatory tests become available. Neverthe- less, the time to explore the feasibility of routine posttransfusion follow-up is now!

ERNEST R. SIMON, MD Blood Systems, Inc.

Scottsdale, AZ

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References Kolins J. Hepatitis C look-back: our next challenge. Transfusion 1990;30:380. Joint statement on HCV testing. American Association of Blood Banks, American Red Cross, Council of Community Blood Cen- ters, April 30, 1990.

Let’s look back for hepatitis C virus-infected patients

To the Editor: To provide medical care to patients who have been infected

with the hepatitis C virus (HCV) via blood transfusion, a look- back program to identify them must be done. The reasons are as follows.

First, HCV-infected patients can benefit directly from know- ing of their infection. Such patients may be monitored for the development of chronic hepatitis and treated early in their course with hope for improvement in quality of life and survival.

Second, HCV-infected patients who know of their disease may elect to avoid exposure to hepatotoxins, such as occur in the workplace, or to alcohol and other hepatotoxic chemicals in the environment. This avoidance of increased risk by HCV- infected patients requires that they be identified and made aware of the hazards of hepatitis C and its propensity for chronic hepatic disease.

Third, HCV-infected patients who know of their disease may elect to change their lifestyle to decrease the likelihood of infecting others.

Most important, patients with diseases or infections, whether transfusion-transmitted or not, have a right to be informed of their condition. Physicians have a responsibility to ensure that this occurs.

KENNETH FAWCETT, MD St. Joseph Hospital

Flint, MI

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