VIRUDHUNAGAR: In a shocking instance of negligence, blood from an HIV+ person was transfused to a 23-year-old pregnant woman at Sattur Government Hospital in early December. The incident came to light when the blood donor voluntarily informed the lab technicians at the Sivakasi Government Hospital, where he had made the donation, after learning he had tested positive for HIV. The woman has since tested positive for HIV. Health officials said the services of a lab technician, a counsellor and the blood bank’s medical officer had been terminated.
According to Joint Director of Health Services, Dr R Manoharan, Abirami (name changed), who was eight months pregnant, came for a check-up at the Sattur GH. Doctors told her she was anaemic and required a blood transfusion. The doctors brought one unit of ‘O’ positive blood from the blood bank at Sivakasi GH and transfused the blood to her on December 3. Dr K Senthil Raj, project director, State AIDS Control Society said Abirami started showing symptoms, such as chills, fever and diarrhoea within a week of the transfusion.
Dr Manoharan said Murugan (name changed) had donated blood in November to replace blood from the bank used to treat his relative at the Sivakasi GH. As Murugan was planning to travel abroad, he underwent a medical check-up in Madurai district where he learnt he was HIV+. Murugan informed the Sivakasi GH blood bank of this on December 13. The lab technicians tested Murugan’s blood and confirmed he was HIV+, Dr Manoharan said, appreciating Murugan’s efforts.
It is only then that the lab technicians discovered that Murugan’s blood had been transfused to Abirami. The doctors brought Abirami to the Sattur GH and, after running tests, confirmed she was HIV+ as a result of the blood transfusion. “Abirami is under medical observation. Paediatricians say chances of the infection passing on to her child are low. Abirami’s delivery will be performed at Virudhunagar GH,” Dr Manoharan said.
Manoharan has assured that steps will be taken to provide a job in the Health Department for Abirami and her husband. Dr Senthil Raj said that Abirami (name changed) was expected to deliver at the end of January. “The regular regime of treatment will be given to neutralise the viral load, as she is already infected,” he explained.
How did this happen?
Elaborating on how such a gargantuan error had occurred, Dr Senthil Raj said it was believed that the lab technician had been careless with the procedure. “The lab technician labelled the blood as HIV Negative and stored it. The technician claims it was negative when tested,” he said. When asked if the testing kits are sensitive, Dr Senthil Raj said, “Testing kits are supplied by National AIDS Control Organisation (NACO) and every year over 8 lakh people are donating blood in Tamil Nadu and over 12 lakh people are benefiting from it. There has been no issue so far,” he said, adding there is a mechanism in place to ensure quality and quality testing of kits is also done regularly.
“However, we will do a technical analysis in the lab on Wednesday with experts,” he said. “We have terminated the services of the lab technician, who gave the daily report, the counsellor who did not identify that the donor was in the high-risk category, and the blood bank’s medical officer,” he said.
“While this incident is a serious error and has taught an important lesson to the Health Department, this should not create panic around blood donation, as the blood bank system has been extremely crucial to the success of our healthcare system,” Senthil Raj, member secretary of State Blood Transfusion Council, said.
Speaking to Express, J Radhakrishnan, State Health Secretary, said Tamil Nadu had a zero tolerance policy towards such errors. “While the first level of inquiry has been conducted to identify where the mistake took place, we will conduct further investigations to identify all loose ends. We will also strengthen the counselling procedure to improve the screening,” he said
'Murugan' HIV status detected in 2016?
Alarmingly, Murugan’s (name changed) status could have been detected at least two years earlier. “In 2016, he donated blood at a blood donation camp conducted by a private institution. Usually, after collection of blood, lab technicians screen the blood for infectious diseases such as Hepatitis B and C, HIV 1 and 2. Only if the results are negative will the blood be stored at the blood bank. Murugan tested positive for HIV in 2016, but the institution which collected the blood failed to inform him of that at the time,” Dr Manoharan said.
‘Lab technician labelled blood as HIV Negative’
Elaborating on how such a gargantuan error had occurred, Dr Senthil Raj, project director, State AIDS Control Society, said it was believed that the lab technician had been careless with procedure. “The lab technician labelled the blood as HIV Negative and stored it. The technician claims it was negative when tested,” he said. When asked if the testing kits are sensitive, Dr Senthil Raj said, “Testing kits are supplied by National AIDS Control Organisation (NACO) and every year over 8 lakh people are donating blood in Tamil Nadu and over 12 lakh people are benefiting from it. There has been no issue so far,” he said.
‘Will identify loose ends’
Health Secretary J Radhakrishnan said, “Inquiry was held to identify where mistake took place. We will conduct probes to identify all loose ends.”
(With inputs from Sinduja Jane & Sushmitha Ramakrishnan in Chennai)