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Higher Risk of HEV Transmission and Exposure among Blood Donors in Europe and Asia in Comparison to North America: A Meta-Analysis. Pathogens 2023; 12:pathogens12030425. [PMID: 36986347 PMCID: PMC10059948 DOI: 10.3390/pathogens12030425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/01/2023] [Accepted: 03/05/2023] [Indexed: 03/10/2023] Open
Abstract
Background and aims: The increasing number of diagnosed hepatitis E virus (HEV) infections in Europe has led to the implementation of the testing of blood products in various countries. Many nations have not yet implemented such screening. To assess the need for HEV screening in blood products worldwide, we conducted a systematic review and meta-analysis assessing HEV RNA positivity and anti-HEV seroprevalence in blood donors. Methods: Studies reporting anti-HEV IgG/IgM or HEV RNA positivity rates among blood donors worldwide were identified via predefined search terms in PubMed and Scopus. Estimates were calculated by pooling study data with multivariable linear mixed-effects metaregression analysis. Results: A total of 157 (14%) of 1144 studies were included in the final analysis. The estimated HEV PCR positivity rate ranged from 0.01 to 0.14% worldwide, with strikingly higher rates in Asia (0.14%) and Europe (0.10%) in comparison to North America (0.01%). In line with this, anti-HEV IgG seroprevalence in North America (13%) was lower than that in Europe (19%). Conclusions: Our data demonstrate large regional differences regarding the risk of HEV exposure and blood-borne HEV transmission. Considering the cost–benefit ratio, this supports blood product screening in high endemic areas, such as Europe and Asia, in contrast to low endemic regions, such as the U.S.
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de Oliveira JM, dos Santos DRL, Pinto MA. Hepatitis E Virus Research in Brazil: Looking Back and Forwards. Viruses 2023; 15:548. [PMID: 36851763 PMCID: PMC9965705 DOI: 10.3390/v15020548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/03/2023] [Accepted: 02/06/2023] [Indexed: 02/19/2023] Open
Abstract
Hepatitis E virus (HEV) has emerged as a public health concern in Brazil. From the first identification and characterization of porcine and human HEV-3 strains in the 2000s, new HEV subtypes have been identified from animal, human, and environmental isolates. As new potential animal reservoirs have emerged, there is a need to compile evidence on the zoonotic dissemination of the virus in animal hosts and the environment. The increasing amount of seroprevalence data on sampled and randomly selected populations must be systematically retrieved, interpreted, and considered under the One Health concept. This review focused on HEV seroprevalence data in distinct animal reservoirs and human populations reported in the last two decades. Furthermore, the expertise with experimental infection models using non-human primates may provide new insights into HEV pathogenesis, prevention, and environmental surveillance.
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Affiliation(s)
- Jaqueline Mendes de Oliveira
- Laboratório de Desenvolvimento Tecnológico em Virologia, Instituto Oswaldo Cruz, Fiocruz, Rio de Janeiro 21040-360, Brazil
| | | | - Marcelo Alves Pinto
- Laboratório de Desenvolvimento Tecnológico em Virologia, Instituto Oswaldo Cruz, Fiocruz, Rio de Janeiro 21040-360, Brazil
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Fernández Villalobos NV, Kessel B, Rodiah I, Ott JJ, Lange B, Krause G. Seroprevalence of hepatitis E virus infection in the Americas: Estimates from a systematic review and meta-analysis. PLoS One 2022; 17:e0269253. [PMID: 35648773 PMCID: PMC9159553 DOI: 10.1371/journal.pone.0269253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/17/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Hepatitis E virus (HEV) infection is responsible for inflammatory liver disease and can cause severe health problems. Because the seroprevalence of HEV varies within different population groups and between regions of the continent, we conducted a systematic review on the topic in order to provide evidence for targeted prevention strategies.
Methods
We performed a systematic review in PubMed, SCIELO, LILACS, EBSCO, and Cochrane Library and included reports up to 25 May 2021 (PROSPERO registration number: CRD42020173934). We assessed the risk of bias, publication bias, and heterogeneity between studies and conducted a random-effect meta-analysis for proportions using a (binomial-normal) generalized linear mixed model (GLMM) fitted by Maximum Likelihood (ML). We also reported other characteristics like genotype and risk factors.
Results
Of 1212 identified records, 142 fulfilled the inclusion criteria and were included in the qualitative analysis and 132 in the quantitative analysis. Our random-effects GLMM pooled overall estimate for past infection (IgG) was 7.7% (95% CI 6.4%–9.2%) with high heterogeneity (I2 = 97%). We found higher seroprevalence in certain population groups, for example in people with pig related exposure for IgG (ranges from 6.2%–28% and pooled estimate of 13.8%, 95% CI: 7.6%–23.6%), or with diagnosed or suspected acute viral hepatitis for IgM (ranges from 0.3%–23.9% and pooled estimate of 5.5%, 95% CI: 2.0%–14.1%). Increasing age, contact with pigs and meat products, and low socioeconomic conditions are the main risk factors for HEV infection. Genotype 1 and 3 were documented across the region.
Conclusion
HEV seroprevalence estimates demonstrated high variability within the Americas. There are population groups with higher seroprevalence and reported risk factors for HEV infection that need to be prioritized for further research. Due to human transmission and zoonotic infections in the region, preventive strategies should include water sanitation, occupational health, and food safety.
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Affiliation(s)
| | - Barbora Kessel
- Department of Epidemiology, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
| | - Isti Rodiah
- Department of Epidemiology, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
| | - Jördis Jennifer Ott
- Department of Epidemiology, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
- Hannover Medical School, Hannover, Germany
| | - Berit Lange
- Department of Epidemiology, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
- German Centre for Infection Research (DZIF), Braunschweig, Germany
| | - Gérard Krause
- Department of Epidemiology, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
- Hannover Medical School, Hannover, Germany
- German Centre for Infection Research (DZIF), Braunschweig, Germany
- Twincore, Centre for Experimental and Clinical Infection Research, Braunschweig-Hannover, Germany
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Moraes DFDSD, Mesquita JR, Dutra V, Nascimento MSJ. Systematic Review of Hepatitis E Virus in Brazil: A One-Health Approach of the Human-Animal-Environment Triad. Animals (Basel) 2021; 11:ani11082290. [PMID: 34438747 PMCID: PMC8388429 DOI: 10.3390/ani11082290] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 12/11/2022] Open
Abstract
Simple Summary Hepatitis E virus (HEV) is an important causative agent of acute and chronic hepatitis worldwide. Originally identified in epidemics associated with flooding in Asia, it nowadays shows very distinct genetic and epidemiological patterns. While HEV genotypes (HEV-) 1 and 2 are associated with the original outbreaks (waterborne diseases), HEV-3 and HEV-4 present a zoonotic pattern (associated with consumption of meat from infected animals), HEV-5 and 6 have been found only in wild boar in Japan, and HEV-7 and 8 have been detected in camels and dromedary seldom affecting humans. Brazil, with a precarious sanitary structure and being an important world meat producer, was the focus of this study in order to identify patterns of occurrence of HEV. After reviewing scientific studies, it was identified that the only genotype found in Brazil is HEV-3 and the area where there were more reports was the South region of the country. This is the region that produces more pork. These results indicate that HEV-3 is widespread in the country and sanitary surveillance is essential in the national production of pigs, as well as the implementation of monitoring protocols in hospitals. Abstract Brazil is the fifth largest country in the world with diverse socioeconomic and sanitary conditions, also being the fourth largest pig producer in the world. The aim of the present systematic review was to collect and summarize all HEV published data from Brazil (from 1995 to October 2020) performed in humans, animals, and the environment, in a One Health perspective. A total of 2173 papers were retrieved from five search databases (LILACs, Mendeley, PubMed, Scopus, and Web of Science) resulting in 71 eligible papers after application of exclusion/inclusion criteria. Data shows that HEV genotype 3 (HEV-3) was the only retrieved genotype in humans, animals, and environment in Brazil. The South region showed the highest human seroprevalence and also the highest pig density and industry, suggesting a zoonotic link. HEV-1 and 2 were not detected in Brazil, despite the low sanitary conditions of some regions. From the present review we infer that HEV epidemiology in Brazil is similar to that of industrialized countries (only HEV-3, swine reservoirs, no waterborne transmission, no association with low sanitary conditions). Hence, we alert for the implementation of HEV surveillance systems in swine and for the consideration of HEV in the diagnostic routine of acute and chronic hepatitis in humans.
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Affiliation(s)
- Danny Franciele da Silva Dias Moraes
- Faculty of Veterinary Medicine, Federal University of Mato Grosso, Cuiabá 78060-900, Brazil; (D.F.d.S.D.M.); (V.D.)
- Secretaria de Estado do Meio Ambiente de Mato Grosso (SEMA), Cuiabá 78050-970, Brazil
- Abel Salazar Institute of Biomedical Sciences (ICBAS), University of Porto, 4050-313 Porto, Portugal
| | - João R. Mesquita
- Abel Salazar Institute of Biomedical Sciences (ICBAS), University of Porto, 4050-313 Porto, Portugal
- Epidemiology Research Unit (EPIUnit), Instituto de Saúde Pública da Universidade do Porto, 4050-600 Porto, Portugal
- Correspondence:
| | - Valéria Dutra
- Faculty of Veterinary Medicine, Federal University of Mato Grosso, Cuiabá 78060-900, Brazil; (D.F.d.S.D.M.); (V.D.)
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Seroprevalence of hepatitis E virus in risk populations and blood donors in a referral hospital in the south of Brazil. Sci Rep 2021; 11:6011. [PMID: 33727656 PMCID: PMC7966736 DOI: 10.1038/s41598-021-85365-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 02/12/2021] [Indexed: 12/21/2022] Open
Abstract
The prevalence of anti-hepatitis E virus (HEV) antibodies has a high heterogeneity worldwide. South American data are still scarce. The aim of this study was to evaluate the prevalence of HEV in populations at risk in comparison to blood donors (BD). A cross-sectional study was carried out in adults of different risk populations including crack users (CK), residents in a low income area (LIA), cirrhotic (CIR) and liver transplant patients (LT) compared with BD. The WANTAI HEV ELISA test was used and real-time PCR (in-house for screening and ALTONA as confirmatory test) for HEV RNA screening. A total of 400 participants were included. Anti-HEV IgG was positive in 19.5% of the total sample, reaching the highest rate in the CIR group, 22.5%, followed by CK, LT, and LIA (20%, 18.7%, and 17.5%, respectively). The prevalence found in BD individuals was of 18.7% (p = NS). Anti-HEV IgM was positive in only 1.5% of the sample (6/400). No blood or stools samples were positive for HEV RNA. The seroprevalence reported is among the highest rates ever found in Brazil. Considering the intense diagnostic investigation, data show that HEV circulation is more common that might be expected in our country.
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Magri MC, Manchiero C, Dantas BP, da Silva Nunes AK, Figueiredo GM, Barone AA, Tengan FM. Hepatitis E virus seroprevalence in patients with chronic hepatitis C at a university hospital in Brazil. Future Virol 2020. [DOI: 10.2217/fvl-2020-0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aim: We investigated the prevalence of anti-hepatitis E virus (HEV) antibodies in patients with chronic hepatitis C and the relationship with liver injury stage. Materials & methods: In total, 451 patients were included and the presence of anti-HEV antibodies was evaluated by ELISA. Results: Anti-HEV IgG antibodies were detected in 45 (10.0%) patients and anti-HEV IgM were detected in two IgG-positive patients (4.4%). The distributions of liver fibrosis, steatosis, inflammatory activity, homeostasis model assessment of insulin resistance and liver enzyme levels were similar between HEV-positive and HEV-negative patients. However, HEV-positive patients had a higher mean age (p = 0.030). The seroprevalence by age group increased from 2.2 (18–30 years) to 53.3% (>60 years). HEV infection was not related to advanced fibrosis. Conclusion: This investigation showed that the seroprevalence of HEV among patients with chronic hepatitis C is similar to that of blood donors in the same region.
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Affiliation(s)
- Mariana Cavalheiro Magri
- Laboratorio de Investigacao Medica em Hepatologia por Virus (LIM-47), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo CEP 05403-000, Brazil
| | - Caroline Manchiero
- Laboratorio de Investigacao Medica em Hepatologia por Virus (LIM-47), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo CEP 05403-000, Brazil
| | - Bianca Peixoto Dantas
- Laboratorio de Investigacao Medica em Hepatologia por Virus (LIM-47), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo CEP 05403-000, Brazil
| | - Arielle Karen da Silva Nunes
- Laboratorio de Investigacao Medica em Hepatologia por Virus (LIM-47), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo CEP 05403-000, Brazil
| | - Gerusa Maria Figueiredo
- Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo CEP 05403-000, Brazil
| | - Antonio Alci Barone
- Laboratorio de Investigacao Medica em Hepatologia por Virus (LIM-47), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo CEP 05403-000, Brazil
- Departamento de Molestias Infecciosas e Parasitarias, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo CEP 05403-000, Brazil
| | - Fátima Mitiko Tengan
- Laboratorio de Investigacao Medica em Hepatologia por Virus (LIM-47), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo CEP 05403-000, Brazil
- Departamento de Molestias Infecciosas e Parasitarias, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo CEP 05403-000, Brazil
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Tissera G, Lardizabal MC, Torres SB, Fantilli AC, Martínez Wassaf MG, Venezuela F, Capra R, Balderramo DC, Travella C, Ré VE, Pisano MB. Hepatitis E virus infection in pregnant women, Argentina. BMC Infect Dis 2020; 20:368. [PMID: 32448132 PMCID: PMC7245834 DOI: 10.1186/s12879-020-05087-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 05/12/2020] [Indexed: 12/27/2022] Open
Abstract
Background Hepatitis E virus (HEV) infection is an important cause of acute hepatitis worldwide. In pregnant women, HEV can cause more severe symptoms, with high rates of fatal hepatic failure in endemic countries. However, HEV prevalence and circulation among pregnant women from South America is almost unknown. We aimed to investigate HEV infection in pregnant women for the first time in Argentina. Methods IgG and IgM anti-HEV antibodies and RNA-HEV were investigated (by ELISA assays and RT-Nested-PCR, respectively) in 202 serum samples from pregnant women collected in the central region of Argentina between 2015 and 2017. A control group of 155 non-pregnant women was included (year 2018). Results The IgG anti-HEV positivity rate was 8.4% (17/202), higher than the 2.6% (4/155) obtained for the non-pregnant women control group, and showing association between pregnancy and HEV infection (p = 0.023, OR = 3.5, CI95% = 1.1–10.5). Women younger than 25 years old presented higher levels of antibodies, and there were no differences in the prevalences between trimesters of pregnancy. Two samples were reactive for IgM anti-HEV, showing recent infections, although no symptoms were registered in these patients. All samples were negative for RNA-HEV amplification. Conclusions HEV produces infections in pregnant women from Argentina, alerting health teams to consider it as a possible cause of liver disease.
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Affiliation(s)
- Gabriela Tissera
- Instituto de Virología "Dr. J. M. Vanella", Facultad de Ciencias Médicas, Universidad Nacional de Córdoba (UNC), Enfermera Gordillo Gómez, s/n (without number), X5016, Córdoba, Argentina
| | - María Cecilia Lardizabal
- Servicio de ginecología y obstetricia, Hospital Privado Universitario de Córdoba, X5016, Córdoba, Argentina
| | - Sofía Belén Torres
- Servicio de ginecología y obstetricia, Hospital Privado Universitario de Córdoba, X5016, Córdoba, Argentina
| | - Anabella Clara Fantilli
- Instituto de Virología "Dr. J. M. Vanella", Facultad de Ciencias Médicas, Universidad Nacional de Córdoba (UNC), Enfermera Gordillo Gómez, s/n (without number), X5016, Córdoba, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), C1425FQB, Buenos Aires, Argentina
| | | | - Fernando Venezuela
- Instituto de Virología "Dr. J. M. Vanella", Facultad de Ciencias Médicas, Universidad Nacional de Córdoba (UNC), Enfermera Gordillo Gómez, s/n (without number), X5016, Córdoba, Argentina
| | - Raúl Capra
- Laboratorio de análisis clínicos, Hospital Privado Universitario de Córdoba, X5016, Córdoba, Argentina
| | - Domingo C Balderramo
- Servicio de gastroenterología y endoscopía digestiva, Hospital Privado Universitario de Córdoba, X5016, Córdoba, Argentina.,Instituto Universitario de Ciencias Biomédicas de Córdoba (IUCBC), X5016, Córdoba, Argentina
| | - Claudia Travella
- Servicio de ginecología y obstetricia, Hospital Privado Universitario de Córdoba, X5016, Córdoba, Argentina
| | - Viviana E Ré
- Instituto de Virología "Dr. J. M. Vanella", Facultad de Ciencias Médicas, Universidad Nacional de Córdoba (UNC), Enfermera Gordillo Gómez, s/n (without number), X5016, Córdoba, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), C1425FQB, Buenos Aires, Argentina
| | - María Belén Pisano
- Instituto de Virología "Dr. J. M. Vanella", Facultad de Ciencias Médicas, Universidad Nacional de Córdoba (UNC), Enfermera Gordillo Gómez, s/n (without number), X5016, Córdoba, Argentina. .,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), C1425FQB, Buenos Aires, Argentina.
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Goel A, Vijay HJ, Katiyar H, Aggarwal R. Prevalence of hepatitis E viraemia among blood donors: a systematic review. Vox Sang 2020; 115:120-132. [PMID: 32030767 DOI: 10.1111/vox.12887] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 12/18/2019] [Accepted: 12/19/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hepatitis E virus (HEV) is usually transmitted by faecal-oral route. Recent reports have documented HEV viraemia in donated blood units and HEV transmission through blood transfusion. This systematic review summarizes the available data on prevalence of HEV viraemia in blood donors. METHODS Electronic databases were searched on 17 December 2018 to identify full-text English papers reporting original data on prevalence of HEV RNA in donated blood units. Two authors independently extracted the relevant data, which were pooled using simple aggregation as well as a random-effects meta-analysis; heterogeneity was assessed using the I2 method. RESULTS In all, 59 data sets from 28 countries were identified. The available data showed marked heterogeneity. Of a total of 2 127 832 units studied, 561 (263·6 [95% confidence intervals = 242·7-286·4] per million units) tested positive for HEV RNA. On random-effects meta-analysis, the pooled prevalence was 60·9 [6·7-155·4] per million units. In the viraemic units, HEV RNA titre varied by nearly one million-fold, and most had genotype 3 HEV. The prevalence was higher in blood units with anti-HEV antibodies or elevated alanine aminotransferase. Only nearly one-fourth of viraemic units had anti-HEV antibodies. CONCLUSIONS The prevalence of HEV viraemia among healthy blood donors is low, though the available data had limited geographical representation and marked heterogeneity. There is a need for further data on HEV viraemia in blood donors from areas with non-3 HEV genotype preponderance.
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Affiliation(s)
- Amit Goel
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | | | - Harshita Katiyar
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Rakesh Aggarwal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Detection and characterization of hepatitis E virus genotype 3 in HIV-infected patients and blood donors from southern Brazil. Int J Infect Dis 2019; 86:114-121. [PMID: 31279609 DOI: 10.1016/j.ijid.2019.06.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 06/21/2019] [Accepted: 06/30/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Hepatitis E virus genotype 3 (HEV-3) infection usually causes self-limited acute hepatitis. In immunosuppressed patients, HEV-3 infection can rapidly progress to chronic hepatitis and cirrhosis. In southern Brazil, data on HEV seroprevalence are scarce. METHODS Testing for HEV RNA and antibodies (anti-HEV) was performed for 320 HIV-infected patients followed at the HIV/AIDS Service of the Federal University of Rio Grande between 2012 and 2013, as well as 281 blood donor samples obtained in 2015. Variables associated with anti-HEV positivity were assessed by multivariable logistic regression analysis. RESULTS HIV and blood donor groups showed similar HEV seroprevalence (6.7% and 7.1%, respectively). Risk factors associated with anti-HEV detection were older age, marital status, a higher number of sexual partners, poor sanitation, and alcohol use (HIV group), and living in a rural area (blood donors). HEV RNA was detected in eight serum samples from HIV-infected patients and in one blood donor, who was also positive for anti-HEV IgM and IgG. CONCLUSIONS The prevalence rates of HEV infection were comparable between HIV-seropositive patients who were not severely immunocompromised and blood donors. The blood donor's HEV isolate showed high similarity with swine HEV strains from Brazilian herds in the same region, thus indicating a potential risk of foodborne and parenteral transmission via blood transfusion.
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