BTSB unable to say what happened to records of contaminated products


THE central difficulty facing the BTSB in tracing the destinations of the contaminated HIV blood products is the loss of the documentation recording where they were sent.

The chief executive of the BTSB, Mr Liam Dunbar, said last night dispatch records for the period before 1986 are missing. "Nobody can say what happened to them. This is also a problem with the hepatitis C look back as well. They were stored in a warehouse in Dublin. We don't know what happened to them."

The lack of records meant the board had to write to 45 hospitals around the State, informing them it was unable to find despatch information, about certain donations. The letters were sent out in September but up to yesterday only 14 of the 45 hospitals had replied.

The issue came to light publicly when it was disclosed on Monday that a nurse working in St Luke's Hospital in Kilkenny had tested positive for HIV as a result of a transfusion in 1985. She had received one of 16 issues of blood product which were infected with HIV.

Mr Dunbar said that in 1989 the board decided to establish a look back programme for newly presented HIV positive donors. Testing for HIV was first introduced in 1985.

From October 1985 to the present, 24 donors have been diagnosed as HIV positive. Eight of these were "first time donors", so no risk of HIV transmission to recipients was involved. They were informed and directed to the appropriate authorities.

In the case of nine of the 16 "repeat donors", recipients of products regarded as being at risk were traced. None of the recipients tested positive.

However, a problem arose in tracing recipients of seven donors, who gave blood between 1877 and 1985.

Despite these seven people testing positive and no further donations being taken from them, the BTSB did not go on to trace where their donations went at the time. Mr Dunbar said he could offer no explanation for this.

He said that 31 blood products, mainly red cells, platelets and plasma, were made from their donations and issued to hospitals by the BTSB.

Fifteen of these product issues were released prior to 1981, which health experts agree, puts them outside the period of risk, as the earliest date of infection of blood by donors here has been established as 1981.

That left 16 potentially infected issues - at least 12 of these have not been accounted for.

In May, the BTSB became aware of this and obtained the names of the donors and the blood products that were made from their donations, but not where they went.

"When we looked at the dates we became aware that we were dealing with an historic situation which related to 11 to 17 years previously. We were aware from international literature that people who get HIV through transfusions manifest it 10 to 12 years later," said Mr Dunbar.

The BTSB wrote to all of the hospitals on September 25th last. The letter did not state that the BTSB believed the products may have been taken from people who were HIV positive, because - according to Mr Dunbar - it did not want to "cause a panic".

The letter referred to donations' from hepatitis C infected donors and, without mentioning HIV, said the board was "unable to find dispatch information" for a short list of pre 1986 donations from donors.

The letter said the BTSB would be grateful if the hospitals concerned arranged for somebody to check transfusion records to see if any such donations went to recipients there.

Mr Dunbar said the hospitals would have "been used to getting these type of letters" and had always come back with the information, although it would take time to trace old records.

By yesterday, only 14 of the 45 hospitals had contacted the BTSB regarding their request. Mr Dunbar said the BTSB had been due to contact them again last week but had been too busy with the Hepatitis C Tribunal.

The South Eastern Health Board, which employs the nurse infected through a transfusion with HIV, has cofirmed that its investigation has shown three units of blood from the suspect lists were used in their region. The first was administered to the nurse; the second was given to an elderly male, also from Kilkenny, in 1981. He died in 1986. The board does not know if the blood was contaminated.

The third related to another "quite elderly" man, who received the blood product at Waterford Regional Hospital - formerly Ardkeen. The SEHB said the incident related to the 1970s and the cause of death was not related to the transfusion.

In a statement last night, the Eastern Health Board said it had established that one of the donations mentioned in the letter from the BTSB in September was given to an elderly patient in 1987. He died in 1989 from a condition related to his original illness.

The EHB said it supplied the information sought by the BTSB, immediately it requested it.

However, the EHB statement pointed out that the letter asked about blood donations from potentially hepatitis C infected donors.

Mr Dunbar emphasised last night that the board had not considered the latest incident a "major issue".

He said the first time he communicated the problem to the Department of Health was on Monday. He assumed the officials had passed it on to the Minister.

"I hope the public understand the contained nature of the whole thing and the historic nature of it.

The last thing we want to happen is for donations to fall," he said.

He said the board is "hyper sensitive" to all situations now and "no stone is left unturned" to ensure the highest standards are maintained.