Prevalence of malaria among blood donors in blood bank, Jhalawar Hospital & Medical College Society, Jhalawar, Rajasthan

Introduction: Transfusion Transmitted Malaria (TTM) is the great concern in endemic countries. Transmission of malaria by blood transfusion was one of the first recorded incidents of transfusion transmitted infection. The drugs and cosmetic act in India mandates the testing of all blood donations for human immunodeficiency virus (HIV) hepatitis B surface antigen (HbsAg), hepatitis C virus (HCV), malaria and syphilis. The present study aims to determine the prevalence of malarial among voluntary and replacement blood donors in Blood Bank, Jhalawar Hospital & Medical college society, Jhalawar, Rajasthan. Material and Methods: A retrospective review of donors record covering the period between Jan 2017 to Dec 2017 at Blood Bank, Jhalawar Hospital & Medical college society, Jhalawar, Rajasthan, India. The blood samples were then obtained by standard procedures of venepuncture. Malarial parasites were screened by microscopy (peripheral blood smear) and rapid Antigen card detection in blood bank. The study detected the presence of malaria parasites in donated blood units. Results: 5 out of 16495 donor population were positive (Prevalence 0.03%) on Immunochromatographic rapid diagnostic test for malarial antigen detection (Rapid Antigen Card Test). Conclusion: Blood donors in Blood Bank, Jhalawar Hospital & Medical college society, Jhalawar, Rajasthan, India have a 0.03% prevalence and voluntary donations are safer as compared to replacement donation. By strict donor selection, proper donor testing and post testing counselling,the rate of TTM can be further minimized.


Introduction
Blood donation is the most important and essential part of blood transfusion services, usually donated voluntarily or in the form of replacement. Millions of lives are saved each year through blood transfusions, who have lost large volumes of blood from serious accidents, major Surgical Operation, Cancer patients requiring therapy, women with haemorrhage at child birth, patients of hereditary disorders like Haemophilia and Thalassaemia, severe burn victims as well as for individuals who have symptomatic anemia from medical or hematologic conditions or cancers.
Blood transfusion carries the risk of transmitting major infections such as hepatitis, HIV, syphilis, and malaria. In minority cases, viral infections such as cytomegalovirus, herpes virus, and Epstein-Barr virus along with toxoplasmosis and brucellosis may be transmitted [1]. Therefore Blood banks are obligated to provide adequate and safe blood to the community. In India, it is mandatory to test every unit of blood collected for hepatitis B, hepatitis C, HIV, syphilis and malaria [2]. The donated blood was discarded whenever the pilot donor sample was found positive for any TTI. Transmission of malaria by blood transfusion was one of the first recorded incidents of transfusion transmitted infection [3]. Testing of blood for malarial parasite is mandatory as per the drugs and cosmetic act part X11 B of Schedule F.  [4]. The microscopic detection of blood though considered the gold standard for malaria diagnosis for decades, it is quite labor intensive and require adequate technical skill and man power. This had spurred the development of other microscopic malarial and rapid detection test based on the detection of malarial parasite antigen in the whole blood [5]. Donors who are implicated as the source of transfusion transmitted malaria cases typically have very low level of parasitemia undetectable even on several thick films [6].
The parasites load in infected donors may be very low; therefore, no clinical symptoms may be observed and Plasmodium species may live in the donors for years. This study was undertaken to determine the prevalence of malaria among voluntary and replacement blood donors.

Type of study: Retrospective study
Place of study: Blood Bank, Jhalawar hospital & Medical college society, Jhalawar, Rajasthan covering the period between Jan 2017 to Dec 2017.
Sampling Methods: All records including TTI records, donor registers, completely filled donor forms, which included the type of donation (voluntary/replacement), the patient's details, pre-donation questionnaire, counselling details and medical examination findings available for each case were analysed. The samples from all blood donations were screened for HIV 1-2, HBsAg, HCV, syphilis and malaria. We at our blood bank, have been routinely screening all donated units of blood for malaria using RDT, based on immunochromatographic methods detecting antigens, histidinerich protein 2 (HRP2-P. falciparum), and p-lactate dehydrogenase (pLDH-P. vivax). Field stained thick and thin smears were madeof all positive cases to corroborate the results of RDT.
Statistical Methods: All Data were collected for malaria and analysed.

Result
Out of the 16495 blood donors, 5013(30.39%) were voluntary donors and 11482 (69.61%) were replacement donors. Maximum blood donors were Rh positive. There was a higher rate of male blood donation than females. Most of the donors were from age groups of 20-40 years. Thus indicating more youngster population as donors

Discussion
Malaria, one of the most important parasitic diseases inunder-developed countries, is a serious transfusion transmitted infection ranked after viral hepatitis and HIV.
The extensive use of blood and its products, and close contacts of human beings, enhanced the risk of transfusion transmitted malaria. Plasmodium species can be transmitted by transfusion of cellular components in labile blood products, and unlikely by frozen/thawed therapeutic plasma. All Plasmodium species are able to survive in stored blood, even if frozen, and retain their viability for at least 1 week, possibly well over 10 days depending on the conditions of storage; in fact, microscopically detectable malaria parasites were present even after 28 days of storage at 4°C although a decrease of infectivity after 2 weeks was observed [6,7,8]. Asymptomatic carriers have potential role as the source of infection for Anopheles vectors as well as blood recipient.
Presence of Plasmodium falciparum inblood may lead to fatalities when the blood is transfused especially in the children under 5 years, pregnant women, and accident victims etc [6]. A recent international forum showed that in Europe, as well as the USA, prevention of transfusion associated protozoa infections depend mainly on selection of donors using questionnaires. A donor is rejected for 3 years after their last visit to the endemicarea [9]. Persons from the non endemic areas, who visited the malaria endemic area, are rejected for 4-12 months [10]. Over the last decade only a few cases of transfusion transmitted malaria were reported in various countries.
There is evidence that ABO histocompatibility of blood groupis not correlated to the incidence of malaria [9], but it has been linked as a coreceptor in parasite and vascular cytoadherence with higher rosette rates among non group O compared to group Oerythrocytes [11]. Donors who are implicated asthe source of transfusion transmitted malariacases typically have very low level of parasitemia undetectable even on several thick films [12]. Several studies have demonstrated an overall high sensitivity of Histidine Rich Protein (HRP 2) based diagnostic assays and their potential clinical utility for the diagnosis of malaria in symptomatic patients [13,14,15].  [24], Owusu-Ofori Alex K et al [25] found very high prevalence of 6-55% in their studies may be due to high endemic area.  [24] 30.2% 11 Owusu-Ofori Alex K et al, Northern Nigeria [25] 55% 12 Present study 0.03% The drugs and cosmetic act in India mandates the testing for malaria but there is no definite guidelines onthe choice of the test. Since apparently healthy individuals those selected for blood donation may have very low density and may be easily missed [26]. Donors who are considered as the source of transfusion transmitted malaria cases, typically have very low level of parasitemia. Which undetectable even on thick smears. Malaria antibody screeningis not indicative of active infection andresults in unnecessary high discarding of collected blood units. Malaria antibody may persist up to several years after infection. PCR test have limited availability. Also malaria immunoprophylaxis to all blood recipients is also not feasible practically. Post-transfusion malaria may cause severe clinical symptoms in the recipients, especially in those with no previous exposure to malaria or in immunocompromised patients due to other coexisting diseases [27]. An important difference between the natural infection and TTM is that the former undergoes an initial asymptomatic phase (pre-erythrocytic) which allows the activation of innate immunity cells against malaria parasites. Infected blood transfusions directly release malaria parasites in the recipient's blood stream triggering the development of high risk complications and potentially leading to a fatal outcome [28]. Delayed or missed diagnosis of P. falciparum in particular increases the risk of severe disease which may be fatal especially in non-immune individuals.

Original Research Article
In case a patient is transfused with a malaria positive blood, the patient can be given a curative regimen of antimalarials, especially when the patient falls into the malaria vulnerable group (children, pregnant women, immigrants from outside malarious regions).

Conclusion
Our