ABSTRACT
Background: Anti-P1 is a common antibody found in the sera of P2 donors, affecting one-quarter to two-thirds of those tested. Anti-P1 is an IgM isotype antibody that is frequently found as a weak cold agglutinin. Anti-P1 antibodies that are reactive at 37 Celsius or cause in vitro hemolysis are rare. With the exception of the rare Bombay phenotype, all red cells express the H antigen. The amount of H antigen on red cells is determined by an individual's ABO type since H antigen is the precursor to both A and B antigens. The expression of the H antigen is highest in group O and lowest in group A1B (O>A2 > B > A2B > A1 > A1B). We report a case of blood discrepancy mimicking Para-Bombay due to anti-P1 and weak H antigen expression in a 46-year-old Sarawak Malay blood donor during routine blood donor regrouping with an automated immunohematology analyser. She has history of COVID19 infection in September 2021 and she completed her 1st, 2nd and booster mRNA vaccine in November 2021. Her last pregnancy was 13 years ago, and she has no history of blood transfusions. Aims: To resolve blood group discrepancies detected when using an automated immunohematology analyser. To understand the possibility of interference from natural occurring cold-reacting red cell alloantibodies during indirect antiglobulin test blood grouping. To understand the possibility of false negative in forward grouping with anti-H antisera in donors with A1B blood group. Methods: Blood donor was typed for ABO and Rh by an automated immunohematology analyser with microplates. Serological methods for antibody detection and specification were done manually with column agglutination method (gel-card) and tube method. Results: Forward grouping of the donor's first sample with an automated analyser was strongly positive for Anti-A (4+), Anti-B (4+), Anti-AB (4+) and Anti-D (4+), while reverse grouping was also strongly positive for A1-cell (3+), B-cell (3+) and O-cell (4+). Manual serological methods with gel-card and tube method yielded similar results. Anti-H showed no reaction. The first sample was negative for Direct Coomb's test (DCT). The donor's second (repeat) sample using the manual serological method yielded similar results;however, reverse grouping repeated at 37 Celcius resulted in the cessation of reactions on known cells. Anti-H showed a 1+ reaction. Antibody screening was positive and proceeded to 11 panel antibody identification with Anti-P1 identified. DCT was negative in the second sample. (P1-) and Le(a-b+) are her phenotypes. Summary/Conclusions: Anti-P1 is commonly reported as cold reacting alloantibody in patients. In this case, a combination of strong reacting anti-P1 at room temperature and commonly low H antigen volume in A1B red cells lead to a false initial suggestion of Para- Bombay phenotype. Blood grouping discrepancies detected with automation should always be repeated manually.
ABSTRACT
Background: The pandemic of COVID-19 has led to alterations in SOP across the transfusion process, including administration of blood in COVID-19 wards. COVID-19 patients who present with symptomatic anaemia and have multiple risk factors will need blood transfusions. ABO-incompatible blood transfusions leading to acute haemolytic transfusion reaction is a rare but potentially fatal complication. The National Haemovigilance Coordinating Centre of the National Blood Centre, Malaysia reported the national incidence of incorrect blood components transfused (IBCT) in relation to total blood products transfused in 2019 to be 75 per 10,000 units. Five IBCTs reported were related to administration errors. Aims: We reported two IBCTs involving two patients who required blood transfusions in a COVID-19 ward. Patient 1 was a 74 year old man who complained of chest pain, with a haemoglobin (Hb) of 5.7 g/ dl. Patient 2 was a 50 year old woman with a Hb of 6.4 g/dl. When the two units of blood arrived on the ward, one doctor completed the pre-administration checklist in the 'clean' zone, which Nurse 1 then counter-checked. Nurse 1 put the two blood bags into separate transparent plastic bags and labelled them with the wrong patient's identity sticker. She then handed both blood bags to Nurse 2 in the 'dirty' zone, without the patients' blood compatibility labels, blood request forms and bedside checklist forms. Positive patient identification was not done by Nurse 2 and the transfusions commenced. Patient 1 complained of chills around 10 min into the transfusion. The error was only realized 35 min into the transfusion when the symptoms persisted and the temperature taken was 38°C. Patient 2, who was given a unit of group O blood that belonged to Patient 1, did not report any adverse reactions. Our aim is to identify the root causes of these IBCTs and to execute the necessary changes in pre-transfusion SOP to minimize future recurrences. Methods: Samples from both patients were investigated for transfusion reactions. Rechecking of blood groups was done manually with the test tube method. Direct and indirect anti human globulin tests (DAT/IAT) and recheck of cross-matching were performed with the column agglutination technology (CAT) method at 37/AHG phase. Urine samples were tested using urine dipsticks. Isohaemagglutinin (anti-A/B titre) was performed using the CAT method at 37/AHG phase. Plasma Hb was measured with a photometer and a microcuvette. Results: Both patient 1's post-transfusion samples (immediate and post-24 h) were O-RhD positive. Blood group of the donor's bag was B-RhD positive. DAT for both samples was positive with IgG(3+) and C3D (1+). IAT for both samples was negative. Recheck of crossmatching with both samples was incompatible (4+). Urine tests were negative for haemoglobin. A low anti-B titre of 1:16 was detected. Plasma Hb was measured twice at a low level below the reference range. Patient 2's workup was unremarkable. Summary/Conclusions: Two IBCTs occurred in the COVID-19 ward, with one major ABO-mismatched IBCT due to human errors and deviation from standard SOP. Pre-transfusion SOP was still unclear in the COVID-19 ward setting prior to these incidences. All medical personnel in the COVID-19 ward underwent retraining on safe transfusion practices. One COVID-19 patient's blood compatibility label, blood request form, bedside checklist form and blood bag should be brought into 'dirty' zone to be checked by two medical personnel at one time.
ABSTRACT
Background: The first wave of COVID-19 in Malaysia started on 24 January 2020. Overall blood collection in Malaysia has shown reducing in trend following first wave of COVID-19 infection due to various factors such as Movement Control Order (MCO), blood mobile cancellation by organizers, and overall public stigmatization of contracting COVID-19 infection upon donating blood at the hospital. Aims: Implementing multiple strategies such as establishment of static mobile outside hospital, promotion in social media platform, and donor tele-recruitment to maintain sustainable blood collection during pandemic COVID-19. Methods: Retrospective analysis of blood collection data from January 2020 until December 2021 via Blood Bank Information System Version 2. Results: Our data showed that blood donors prefer to donate at static mobile in which the place is far away from patients, have large space for physical distance and able to comply to Standard Operating Procedure. During period of Movement ControlOrder(MCO) Phase 1, Phase 2, Phase 3, Phase 4 and Phase 5, our blood collection was 462,248,285,408 and 681 respectively which in total was 2084 blood bags. In comparison, blood collection at our blood donation centre was significantly less during MCO Phase 1, Phase 2, Phase 3, Phase 4 and Phase 5 which are 86,4,83,327 and 61 respectively which in total was 557 blood bags. Utilizing social media to promote blood donation is very important. On 3rd August 2020, our blood stock for Group O is reducing in trend and donor turn up at our centre was only 21 and only 8(38%) is blood group O. Hence, we created a post in our facebook platform to invite all our group O to come forward and donate urgently. The post went viral with 638,061 Reach and 10,878 Engagement, resulting significant increase of donor turn up to our blood centre for the subsequent 4 days. On 4, 5, 6 and 7 August 2020, total donor turn up was 73 with 48(66%) group O, 45 with 32(71%) group O, 41 with 26(63%) group O and 62 with 37(60%) group O respectively. Tele-recruitment is essential in the strategy to maintain blood collection. On 17 December 2021, our blood group O has reduced to 132 bags with safe level for group O is 215. There were 29 donors turn up with only 10 donors group O (34%). Hence, we initiated tele-recruitment by personal calling to all 150 blood group O donors to come donate. Subsequently, on 18th and 19th December 2021, we have 177 donors turn up with 86(48%) group O and 178 donors turn up with 88(49%) group O respectively. On 20 December 2020, our stock level for group O has increased above safe level which is 219 bags. Summary/Conclusions: Implementing multiples strategies is essential to maintain sustainable blood collection in order to meet the blood supply demand during pandemic COVID-19.