Blood transfusion safety in the country of Georgia: collateral benefit from a national hepatitis C elimination program

Prevalence of transfusion transmitted infections by mode of donation and remuneration status among blood donors in Georgia, 2018-2023

Global reform of blood transfusion services is underway in the country of Georgia. New legislation mandates exclusive collection of blood from non-remunerated blood donors in Georgia by July 2025. Retrospective data (2018-2023) from the National Blood Donor Registry were analyzed. The prevalence was calculated for human immunodeficiency virus (HIV) antigen/antibody (Ag/Ab), hepatitis C virus antibody (anti-HCV), hepatitis B surface antigen (HBsAg). Results were stratified by remuneration status and mode of donation. Descriptive analysis was performed to elucidate differences in positivity by year and donor type. During 2018-2023, there were a total of 548,530 donations from 221,492 blood donors in Georgia; 68.3 % of donors were male and the median age was 34 years (interquartile range: 2644). Overall, 17.0 % were paid, 24.9 % were replacement, 47.4 % were voluntary non-remunerated blood donors (VNRBD), and 10.7 % had ≥ 2 donations of varying remuneration type. Paid donors had an average of 2.5 donations per year, compared to 1.0 for replacement, and 1.1 for VNRBDs. During 2018-2023, the proportions of paid donors decreased (38.8-22.1 %); the proportions of replacement (19.1-26.0 %) and VNRBDs (38.7-48.3 %) increased. Among first-time donors, prevalence decreased during 2018-2023 for anti-HCV (2.0-0.9 %) but were stable for HBsAg (range: 1.9 %-2.1 %) and anti-HIV (range: 0.1 %-0.2 %). Among repeat donors, prevalence of anti-HCV decreased (from 0.3 % to 0.2 %) while rates were stable for anti-HIV (0.04 %-0.1 %), and HBsAg (0.1 % in all years). The findings underscore the importance of donor retention in concert with efforts to attain exclusive VNRBD.

Evaluation of Hepatitis C Virus Transmission Through Endoscopy Procedures in the Country of Georgia

Exposure to healthcare procedures might be a source of hepatitis C virus (HCV) transmission in Georgia, one of the few countries currently on track to eliminate hepatitis C. While there has been a history of iatrogenic transmission of HCV, the risk of HCV transmission related to endoscopic procedures has not been previously assessed in Georgia. The goal of this study was to assess HCV seroconversion among individuals undergoing endoscopic procedures to estimate the relative role and incidence of HCV infection attributable to endoscopic procedures. A prospective cohort study was conducted in four endoscopy units in two cities (Tbilisi and Kutaisi) of Georgia during April-September, 2021. Recruitment of study participants was conducted using convenience sampling, and every eligible patient was approached and invited to participate in the study. Study population included adults (age ≥ 18 years) who received an endoscopic procedure (gastroscopy, colonoscopy and bronchoscopy) in inpatient or outpatient unit at the study sites. HCV antibody (anti-HCV) testing was conducted using rapid diagnostic test (RDT) on the same day they underwent the endoscopic procedure. Patients with a non-reactive anti-HCV baseline test were retested after 6 months. Patients with reactive baseline tests were excluded from the study and linked to further testing and care. Participants with a reactive result on follow-up RDTs were retested using a lab-based anti-HCV and HCV ribonucleic acid (RNA) test. A total of 981 HCV antibody non-reactive participants were enrolled; 590 (64.8%) of them were reached and retested after 6 months. At retesting, two out of 590 (0.3%) individuals had a reactive anti-HCV result on RDT and both were negative on laboratory-based anti-HCV and HCV RNA tests. Based on the results of this study, endoscopic procedures were not shown to contribute to HCV transmission in Georgia.

Trends in new hepatitis C virus infections among repeat blood donors - Georgia, 2017-2023

BACKGROUND AND OBJECTIVES

Blood donor cohorts are an underappreciated resource for surveillance and public health programming for infectious diseases. The incidence of hepatitis C virus (HCV) infection was evaluated in repeat blood donors in Georgia.

MATERIALS AND METHODS

Using data from the national hepatitis C screening registry, we calculated overall hepatitis C incidence for 2017-2023 and annual incidence during 2017-2022 among adults who donated blood at least twice and had a nonreactive HCV antibody (anti-HCV) test result upon first screening and a subsequent anti-HCV test conducted in any location. Rates of anti-HCV seroconversion and current infection were calculated by year, sex, age group, and location of last HCV screening and expressed per 100,000 person-years (PY).

RESULTS

Of 101,443 blood donors with ≥ 2 anti-HCV results,775 (0.8%) seroconverted to anti-HCV reactive, of whom 403 (52.0%) had current infection. Incidence of anti-HCV seroconversion decreased from 408 per 100,000 PY in 2017 to 218 per 100,000 PY in 2022 and incidence of infection decreased from 172 per 100,000 PY in 2017 to 118 per 100,000 PY in 2022. Males, persons aged 18-39 years, and people last tested for HCV in prisons had the highest incidence rates for anti-HCV seroconversion and HCV infection, while persons last screened in blood banks and during antenatal care had the lowest.

CONCLUSION

Despite the observed decline, incidence of HCV infection among repeat blood donors remains high in specific subgroups. Hepatitis C prevention, screening and treatment interventions need to particularly focus on incarcerated populations and young adults in Georgia.

Evaluation of Knowledge, Attitudes and Practices for Hepatitis B Virus Infection Among Primary Healthcare Physicians in Georgia

A nationwide serosurvey among adults in 2021 showed a 2.7% (95% confidence interval [CI]: 2.3%-3.4%) prevalence of hepatitis B. Our analysis evaluates knowledge, attitudes and practices (KAP) for hepatitis B virus (HBV) infection among primary healthcare physicians (PHPs) in Georgia. We randomly selected 550 PHPs from medical facilities in Georgia's six largest cities. Using bivariate ordinal regression, we assessed the association of socio-demographic factors with an ordinal knowledge score (low/middle/high). Multivariable logistic regression was performed to calculate adjusted odds ratios (aOR) and 95% CI to determine associations between HBV knowledge score and practices. Of 550 selected PHPs, 506 (92.0%) agreed to participate. Among them, 62.8% scored in the medium or high knowledge tertiles, 72.7% were confident in diagnosing HBV infection, 37.3% were confident in managing patients with hepatitis B; 47.4% reported being screened for and 26.2% reported being vaccinated against HBV infection. Compared to those with low knowledge scores, PHPs with a high score were less likely to recommend activities not supported by evidence, such as: the use of 'hepatoprotective' medications (aOR 0.43, 95% CI 0.25-0.73), caesarean sections (aOR 0.47, 95% CI 0.27-0.82) and withholding breastfeeding (aOR 0.57, 95% CI 0.34-0.96) to prevent HBV transmission. The majority of PHPs were confident in diagnosing HBV infection, but only one in three were confident in managing patients with hepatitis B. PHPs with higher HBV knowledge were less likely to provide inaccurate instructions to their patients. These findings will help to develop awareness and education campaigns supporting HBV elimination in Georgia.

Blood Banking Capacity in Low-and Middle-Income Countries: Covid-19 Convalescent Plasma in Context

Blood transfusion capacity in low- and middle-income countries (LMICs), encompassing both the safety and adequacy of the blood supply, is limited. The challenges facing blood banks in LMICs include regulatory oversight, blood donor selection, collection procedures, laboratory testing, and post-transfusion surveillance. A high proportion of LMICs are unable to fully meet clinical demands for blood products, and many do not meet even the minimum threshold of collection (10 units per 1000 population). Suboptimal clinical transfusion practices, in large part due to a lack of training in transfusion medicine, contribute to blood wastage. During the COVID-19 pandemic, high- and LMICs alike experienced blood shortages, in large part due to quarantine and containment measures that impeded donor mobility. COVID-19 convalescent plasma (CCP) was particularly appealing for the treatment of patients with COVID-19 in LMICs, as it is a relatively inexpensive intervention and makes use of the existing blood collection infrastructure. Nonetheless, the challenges of using CCP in LMICs need to be contextualized among broad concerns surrounding blood safety and availability. Specifically, reliance on first time, family replacement and paid donors, coupled with deficient infectious disease testing and quality oversight, increase the risk of transfusion transmitted infections from CCP in LMICs. Furthermore, many LMICs are unable to meet general transfusion needs; therefore, CCP collection also risked exacerbation of pervasive blood shortages.

Nationwide Hepatitis C Serosurvey and Progress Towards Hepatitis C Virus Elimination in the Country of Georgia, 2021

BACKGROUND

The country of Georgia initiated its hepatitis C virus (HCV) elimination program in 2015, at which point a serosurvey showed the adult prevalence of HCV antibody (anti-HCV) and HCV RNA to be 7.7% and 5.4%, respectively. This analysis reports hepatitis C results of a follow-up serosurvey conducted in 2021, and progress towards elimination.

METHODS

The serosurvey used a stratified, multistage cluster design with systematic sampling to include adults and children (aged 5-17 years) providing consent (or assent with parental consent). Blood samples were tested for anti-HCV and if positive, HCV RNA. Weighted proportions and 95% confidence intervals (CI) were compared with 2015 age-adjusted estimates.

RESULTS

Overall, 7237 adults and 1473 children were surveyed. Among adults, the prevalence of anti-HCV was 6.8% (95% CI, 5.9-7.7). The HCV RNA prevalence was 1.8% (95% CI, 1.3-2.4), representing a 67% reduction since 2015. HCV RNA prevalence decreased among those reporting risk factors of ever injecting drugs (51.1% to 17.8%), and ever receiving a blood transfusion (13.1% to 3.8%; both P < .001). No children tested positive for anti-HCV or HCV RNA.

CONCLUSIONS

These results demonstrate substantial progress made in Georgia since 2015. These findings can inform strategies to meet HCV elimination targets.

Advancing blood transfusion safety using molecular detection in the country of Georgia

BACKGROUND

In 2015, the country of Georgia initiated its hepatitis C virus (HCV) elimination program. Given a high background incidence of HCV infection, centralized nucleic acid testing (NAT) of blood donations was prioritized for implementation.

STUDY DESIGN AND METHODS

Multiplex NAT screening for HIV, HCV and hepatitis B virus (HBV) was launched in January 2020. An analysis was conducted of serological and NAT donor/donation data for the first year of screening (through December 2020).

RESULTS

A total of 54,116 donations representing 39,164 unique donors were evaluated. Overall, 671 donors (1.7%) tested positive for at least one infectious marker by serology or NAT, with the highest prevalence among donors aged 40-49 years (2.5%; n = 200), male (1.9%; n = 524), replacement (2.8%; n = 153) and first time (2.1%; n = 642) donors. Sixty donations were seronegative but NAT positive, and therefore would not have been found by traditional serology testing alone. These were more likely among female vs. male (adjusted odds ratio [aOR] 2.06; 95% confidence interval [95%CI]: 1.05-4.05), paid (aOR 10.15; 95%CI: 2.80-36.86) or voluntary (aOR 4.30; 95%CI: 1.27-14.56) vs replacement, and repeat vs. first time (aOR 13.98; 95%CI: 4.06-48.12) donors. On repeat serological testing (including HBV core antibody [HBcAb] testing), 6 HBV + donations, 5 HCV + donations and 1 HIV + donations were deemed NAT yield (detected through the implementation of NAT, and would have otherwise been missed by serology screening alone).

CONCLUSION

This analysis offers a regional model for NAT implementation, demonstrating the feasibility and clinical utility in a nationwide blood program.

Toward reaching hepatitis B goals: hepatitis B epidemiology and the impact of two decades of vaccination, Georgia, 2021

BackgroundGeorgia has adopted the World Health Organization European Region's and global goals to eliminate viral hepatitis. A nationwide serosurvey among adults in 2015 showed 2.9% prevalence for hepatitis B virus (HBV) surface antigen (HBsAg) and 25.9% for antibodies against HBV core antigen (anti-HBc). HBV infection prevalence among children had previously not been assessed.AimWe aimed to assess HBV infection prevalence among children and update estimates for adults in Georgia.MethodsThis nationwide cross-sectional serosurvey conducted in 2021 among persons aged ≥ 5 years used multi-stage stratified cluster design. Participants aged 5-20 years were eligible for hepatitis B vaccination as infants. Blood samples were tested for anti-HBc and, if positive, for HBsAg. Weighted proportions and 95% confidence intervals (CI) were calculated for both markers.ResultsAmong 5-17 year-olds (n = 1,473), 0.03% (95% CI: 0-0.19) were HBsAg-positive and 0.7% (95% CI: 0.3-1.6) were anti-HBc-positive. Among adults (n = 7,237), 2.7% (95% CI: 2.3-3.4) were HBsAg-positive and 21.7% (95% CI: 20.4-23.2) anti-HBc-positive; HBsAg prevalence was lowest (0.2%; 95% CI: 0.0-1.5) among 18-23-year-olds and highest (8.6%; 95% CI: 6.1-12.1) among 35-39-year-olds.ConclusionsHepatitis B vaccination in Georgia had remarkable impact. In 2021, HBsAg prevalence among children was well below the 0.5% hepatitis B control target of the European Region and met the ≤ 0.1% HBsAg seroprevalence target for elimination of mother-to-child transmission of HBV. Chronic HBV infection remains a problem among adults born before vaccine introduction. Screening, treatment and preventive interventions among adults, and sustained high immunisation coverage among children, can help eliminate hepatitis B in Georgia by 2030.

Association of Treated and Untreated Chronic Hepatitis C With the Incidence of Active Tuberculosis Disease: A Population-Based Cohort Study

BACKGROUND

Hepatitis C virus (HCV) infection causes dysregulation and suppression of immune pathways involved in the control of tuberculosis (TB) infection. However, data on the role of chronic hepatitis C as a risk factor for active TB are lacking. We sought to evaluate the association between HCV infection and the development of active TB.

METHODS

We conducted a cohort study in Georgia among adults tested for HCV antibodies (January 2015-September 2020) and followed longitudinally for the development of newly diagnosed active TB. Data were obtained from the Georgian national programs of hepatitis C and TB. The exposures of interest were untreated and treated HCV infection. A Cox proportional hazards model was used to calculate adjusted hazard ratios (aHRs).

RESULTS

A total of 1 828 808 adults were included (median follow-up time: 26 months; IQR: 13-39 months). Active TB was diagnosed in 3163 (0.17%) individuals after a median of 6 months follow-up (IQR: 1-18 months). The incidence rate per 100 000 person-years was 296 among persons with untreated HCV infection, 109 among those with treated HCV infection, and 65 among HCV-negative persons. In multivariable analysis, both untreated (aHR = 2.9; 95% CI: 2.4-3.4) and treated (aHR = 1.6; 95% CI: 1.4-2.0) HCV infections were associated with a higher hazard of active TB, compared with HCV-negative persons.

CONCLUSIONS

Adults with HCV infection, particularly untreated individuals, were at higher risk of developing active TB disease. Screening for latent TB infection and active TB disease should be part of clinical evaluation of people with HCV infection, especially in high-TB-burden areas.

Guidance for the procurement of COVID-19 convalescent plasma: differences between high- and low-middle-income countries

BACKGROUND AND OBJECTIVES

COVID-19 convalescent plasma (CCP) has been used, predominantly in high-income countries (HICs) to treat COVID-19; available data suggest the safety and efficacy of use. We sought to develop guidance for procurement and use of CCP, particularly in low- and middle-income countries (LMICs) for which data are lacking.

MATERIALS AND METHODS

A multidisciplinary, geographically representative group of individuals with expertise spanning transfusion medicine, infectious diseases and haematology was tasked with the development of a guidance document for CCP, drawing on expert opinion, survey of group members and review of available evidence. Three subgroups (i.e. donor, product and patient) were established based on self-identified expertise and interest. Here, the donor and product-related challenges are summarized and contrasted between HICs and LMICs with a view to guide related practices.

RESULTS

The challenges to advance CCP therapy are different between HICs and LMICs. Early challenges in HICs related to recruitment and qualification of sufficient donors to meet the growing demand. Antibody testing also posed a specific obstacle given lack of standardization, variable performance of the assays in use and uncertain interpretation of results. In LMICs, an extant transfusion deficit, suboptimal models of donor recruitment (e.g. reliance on replacement and paid donors), limited laboratory capacity for pre-donation qualification and operational considerations could impede wide adoption.

CONCLUSION

There has been wide-scale adoption of CCP in many HICs, which could increase if clinical trials show efficacy of use. By contrast, LMICs, having received little attention, require locally applicable strategies for adoption of CCP.