Investigation of possible infection transmission

If a patient is suspected of having possible non-bacterial transfusion-transmitted infection, the case will be investigated by NHSBT clinicians working within microbiology services.

  • All reports are dealt with through:

Microbiology Services Office
NHSBT Colindale
Charcot Road

Telephone: 0208 957 2988
Secure fax: 0208 957 2884

  •  A post transfusion infection report form (Word doc) should be completed and accompanied by relevant laboratory reports
  • Email may be used for sending personal identifiable information ONLY if sending from a secure email account

Weeks or months will generally have passed following the blood transfusion before the reported infection is diagnosed so these reports are rarely urgent. However, because archive material from each donation is only kept for three years, it is important that transmission incidents are reported as soon as possible to ensure a complete investigation.

Initial details, or a broad outline of the case, may be provided in an e-mail message and then the notification form must be completed.

All cases are discussed after receipt at a weekly multi-disciplinary meeting including expert virologists and representatives of the Blood Borne Virus Unit, PHE Colindale, after which further information and/or test results may be requested.

We are happy to discuss / give advice about a case before a formal report is considered. Use the contact information above and a discussion with one of our clinicians can be arranged.

NHSBT's investigation of all cases follows these steps:

1. Written documentation using the NHSBT notification form is received.  The following information is required in order to investigate a case:

- Name, date of birth, hospital of transfusion and hospital unit number of patient

- Documented evidence of infection (i.e. copies of laboratory reports)

- The infection status of the patient, either prior to or at the time of the transfusion (not usually available, but very useful)

- A list of all units used with the unit number/s, product type/s, and date of transfusion and including the patient identity, preferably as a computer print out to avoid the risk of transcription errors and to assist the audit trails

- Details of the medical history, previous medical / surgical procedures, and any other risk for the identified infection.

2. Component unit numbers are matched to the corresponding donors. 

3. Each donor's record is checked for evidence of subsequent donations and the results of tests on later donations are reviewed. 

4. The results of subsequent tests are checked to determine whether they can be used to exclude the donor as a source of infection.

5. All other donors are recalled for specific testing for the marker in question. 

6. Archive material for genome amplification may be selected and if necessary genotyped to match source and recipient.

Where the donor has re-attended and routine donation screening includes antibody assays, a subsequent negative test result will be sufficient to eliminate the donor as a source of infection. In other cases, including all cases involving hepatitis B infection, additional tests will be needed and follow-up blood samples may be required from the donor. It may take some weeks or months to complete the investigation.

In certain circumstances, NHSBT may be requested to investigate possible transmission of an infection for which routine blood donation screening is not in place (e.g. parvovirus B19 infection) or for which selective donation screening is carried out (CMV infection, malaria). Such cases  will usually require detailed discussions between clinicians and testing laboratories.

Cases should be reported to the MHRA for haemovigilance purposes and to the local Control of Infection Officer for investigation of other possible sources of infection within the hospital setting. Further investigation may also involve the local Public Health England (PHE) laboratory or Health Protection team. NHSBT will liaise with the PHE/Control of Infection staff as necessary.

At the close of the investigation a formal report is sent to the consultant haematologist in charge of the blood transfusion laboratory which supplied the blood to the patient, the reporter, and any other interested party. All cases are reported through the NHSBT / PHE  Epidemiology team to SHOT.