|Year : 2020 | Volume
| Issue : 4 | Page : 247-251
Prevalence of transfusion-transmissible infections among blood donors in Riyadh: A tertiary care hospital-based experience
Fahad AL Majid
Division of Infectious Diseases, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
|Date of Submission||22-Mar-2020|
|Date of Decision||05-Apr-2020|
|Date of Acceptance||10-Apr-2020|
|Date of Web Publication||17-Jul-2020|
Fahad AL Majid
Division of Infectious Diseases, King Khalid University Hospital, King Saud University, PO Box 7805 (38), Riyadh 11472
Source of Support: None, Conflict of Interest: None
Background: Transfusion-transmissible infections (TTIs) such as hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), and Treponema pallidum are a serious threat to the safety of recipients. Materials and Methods: This was a retrospective analysis of 38,621 blood donors screened for TTIs between January 2016 and December 2018 at King Khalid University Hospital, Riyadh, Saudi Arabia. Viral serology comprised of detection of hepatitis B surface antigen (HBsAg) and anti-core HBV antibody (anti-HBc), HCV antibody, and HIV antigen/antibody assays. Nucleic acid testing for viral genetic material was performed using Roche Cobas TaqScreen MPX v2 (Roche Molecular Systems, NJ, USA.) on Cobas s201 system. T. pallidum infection was confirmed by a reactive T. pallidum hemagglutination assay. Results: Of the total donors, 37,202 (96%) were males and 1419 (4%) were females, with a mean age of 30.3 ± 5 years. Majority of the donors (27,963; 72.4%) were Saudi nationals, whereas 10,658 (27.6%) individuals were of other nationalities comprising 24,356 (63%) volunteers and 14,265 (37%) repeat donors. The overall prevalence of TTIs among blood donors was 0.7%, with a prevalence of HBsAg of 0.29%, anti-HBc of 4%, HCV of 0.3%, HIV of 0.005%, human T-lymphotropic virus type I and II of 0.002%, and T. pallidum of 0.02%. No significant differences were observed in the annual prevalence rates of TTIs. Conclusion: Relatively low prevalence rates of TTIs were observed among the blood donors during the study period.
Keywords: Blood donors, hepatitis B virus, hepatitis C virus, human immunodeficiency virus, prevalence, transfusion-transmissible infections
|How to cite this article:|
AL Majid F. Prevalence of transfusion-transmissible infections among blood donors in Riyadh: A tertiary care hospital-based experience. J Nat Sci Med 2020;3:247-51
|How to cite this URL:|
AL Majid F. Prevalence of transfusion-transmissible infections among blood donors in Riyadh: A tertiary care hospital-based experience. J Nat Sci Med [serial online] 2020 [cited 2020 Oct 19];3:247-51. Available from: https://www.jnsmonline.org/text.asp?2020/3/4/247/291092
| Introduction|| |
Transfusion-transmissible infections (TTIs) such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and among blood donors continue to be a serious public health problem. The World Health Organization (WHO) emphasized the need for mandatory screening of all blood donations for HBV, HCV, HIV, and Treponema pallidum. Implementation of stringent donor screening protocols for blood-borne pathogens by the WHO, however, has resulted in remarkable reduction in the prevalence of TTIs., Despite all these efforts, the prevalence of TTIs among blood donors still remains a potent threat for the safety of blood transfusion. It is possible that the window period particularly for the transmission of viral infections may be critical because of failure to detect specific antibodies during the window period using conventional testing strategies. Introduction of nucleic acid test (NAT) has significantly contributed to accurate and early detection of viral infections., The benefits of NAT, however, should be balanced with complexities associated with procedure and its cost-effectiveness.
Unsafe blood or blood components appears to be a global concern as it not only affects the recipients but also their families and communities at large in terms of financial burden on the health-care resources. Periodic evaluation of blood donor population, therefore, is not only essential for safe blood supply but is also useful in gathering valuable data regarding the epidemiology of TTIs in a community. Several studies reporting similar prevalence rates of TTIs among blood donors and general population highlight the importance of blood donor screening for TTIs in a community., Increasing prevalence rates of infections in the blood donor population may therefore reflect changes in population risk, thus necessitating improvements in blood-screening protocols. Despite these observations, there are, however, certain pitfalls as blood donors constitute a group of selected population with low risk of infectious diseases, low percentage of female gander, and the age ranging between 18 and 60 years.
This study was performed at King Khalid University Hospital, Riyadh, to assess the prevalence of HBV, HCV, HIV, and T. pallidum among the blood donors during a period of 3 years.
| Materials and Methods|| |
This was a retrospective analysis of data of 38,621 blood donors between January 2016 and December 2018 at King Khalid University Hospital, Riyadh, Saudi Arabia. Before blood donation, each donor was screened by a trained medical personnel. In accordance with the Saudi Food and Drug Administration guidelines for blood donation, each donor underwent complete physical examination, responded to a standard questionnaire, and signed his or her consent. All blood donations were screened for TTIs both by serological tests and nucleic acid testing for viral diseases. Relevant data including demographic details were obtained from each donor record in the blood bank of King Khalid University Hospital, Riyadh. The study was approved by the Institutional Review Board at the College of Medicine, King Saud University.
Serological screening for transfusion-transmissible infections
Each sample was screened for HBV, HCV, HIV, and T. pallidum infections. Viral serology for the detection of hepatitis B surface antigen (HBsAg) and core HBV antibody (anti-HBc), HCV antibody, and HIV antigen/antibody assays was performed using Architect system (Abbot Diagnostics, Wiesbaden, Germany). Samples with sample/cutoff ratio of equal to or more than 1.00 were considered reactive. Reactive samples were tested again in duplicate and further confirmation was performed for HBsAg and anti-HBc on Murex ELISA assay (Diasorin Ltd., Italy) that functions by means of specific antibody neutralization of HBsAg in specimens that are repeatedly reactive, whereas the presence of anti-HCV and anti-HIV antibodies was confirmed by immunoblot assays (INNO-LIA, Innogenetics, Belgium). Indeterminate or nonreactive confirmatory tests were flagged for donor follow-up investigations. Screening protocol for T. pallidum comprised of initial screening for T. pallidum-specific antibodies by chemiluminescent enzyme immune assay using Immulite-2000 XPi system (Siemens Healthcare Diagnostic Products Ltd. UK). Reactive samples were tested by rapid plasma regain test (Immutrep RPR, Omega Diagnostics, UK) and T. pallidum hemagglutination assay test (Immutrep RPR, Omega Diagnostics, UK) for the confirmation of T. pallidum infection.
Molecular screening for transfusion-transmissible infections
Nucleic acid testing for the confirmation of viral genetic material was performed using Roche Cobas TaqScreen MPX v2 (Roche Molecular Systems, NJ, USA.) on Cobas s201 system (Roche Instrument Centre, Rotkreuz, Switzerland). The MPX v2 assay is a qualitative viral multiplex assay for simultaneous detection and discrimination of HBV-DNA, HCV-RNA, and HIV-RNA. All blood donations were screened in batches of six. Batch testing either yielded reactive or nonreactive results, but failed to identify the individual blood donation. The constituents of infected batch were tested individually to identify the donor and the infectious agent. The reactive samples were subsequently confirmed by Procleix Ultrio Plus assay (Novartis, Emeryville, CA, USA) using multiplex format for the detection of HBV-DNA, HCV-RNA, and HIV-RNA. Indeterminate or nonreactive specimens by confirmatory assays were flagged for donor follow-up investigations.
Data analysis was performed using MedCalc computer software version 17 (MedCalc Software bvba, Ostend, Belgium). Categorical data were summarized as numbers and percentages, and numeric data were summarized as mean and standard deviation. Comparisons among groups were performed by using Chi-square test. P < 0.05 was considered statistically significant.
| Results|| |
Out of the total 38,621 blood donors, 37,202 (96%) were males and 1419 (4%) were females, with a mean age of 30.3 ± 5 years. This group comprised of 27,963 (72.4%) individuals of Saudi nationality and 10,658 (27.6%) individuals of other nationalities. Commercial blood donation is illegal in the Kingdom of Saudi Arabia, thus the population of blood donors comprised of 24,356 (63%) volunteers and 14,265 (37%) replacement donors [Table 1]. TTIs among the blood donors were detected among 234/38,621 donors with an overall prevalence of 0.7%. All the infected donors had single infection, with none suffering from co-existing infections. [Figure 1] shows data for the prevalence of TTIs among the blood donors. Evidence for HBsAg was present among 113 (0.29%), anti-core HBV (anti-HBc) among 1694 (4%), HCV was detected among 118 (0.3%), HIV was present among 2 (0.005%), human T-lymphotropic virus type I and II (HTLVI/II) among 1 (0.002%), and T. pallidum infection was confirmed among 10 (0.02%) blood donors. [Figure 2] shows data for NAT screening for viral infections among the blood donors. HBV DNA was found in 83 (0.2%), HCV RNA in 4 (0.01%), and HIV RNA in 3 (0.007%) blood donors. No significant differences were observed in the prevalence rates of TTIs among blood donors during the study period [Table 2].
|Figure 1: Prevalence of transfusion-transmissible infections among blood donors. HBsAg: Hepatitis B surface antigen, Anti-HBc: Anti-core hepatitis B antibody, HCV Ab: Hepatitis C virus antibody, HIV Ab: Human immunodeficiency virus antibody, HTLVI/II: Human T-lymphotropic virus type I and II, T. pallidum: Treponema pallidum|
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|Figure 2: Nucleic acid testing for transfusion-transmissible viral infections among blood donors. HBV: Hepatitis B virus, HCV: Hepatitis C virus, HIV: Human immunodeficiency virus|
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|Table 2: Yearly prevalence of transfusion-transmissible infections among blood donors during the study period|
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| Discussion|| |
The present study revealed an overall prevalence rate of 0.7% for TTIs among the blood donors. HBV infection was found among 0.29%, HCV in 0.3%, HIV in 0.005%, human T-lymphotropic virus type (HTLV) in 0.002%, and T. pallidum among 0.02%. A prevalence of TTIs as low as 0.2% has been reported among Serbian blood donors, which is lower than 0.7% observed in the present study. Comparatively higher prevalence rate of TTIs (9.4%) among blood donors has also been reported from Western Kenya. Alarmingly, higher prevalence rates of TTIs among blood donors of 18.7% in Mozambique, 21.2% in Cameroon, 28.8% in South-West Nigeria, and 29.8% in Burkina Faso pose a serious threat to the safety issues concerning blood transfusion services in the local communities. These observations not only indicate a substantial regional variation in the prevalence rates of TTIs, but also emphasize the need for monitoring the prevalence rates of TTIs in different communities. Despite the fact that the prevalence rates of TTIs during the study period remained steady in the present study, there appears to be a need for the implementation of policies for further reduction in the prevalence of TTIs.
The prevalence of HBsAg among the blood donors was 0.29%. Globally, the prevalence of HBsAg infection ranges between 0.1% in the developed countries and 20% in the developing countries. Varying prevalence rates for HBsAg infection have been reported among the blood donors, with 0.087% prevalence from Serbia, 4.1% from Nigeria, and 9.8% from Ethiopia. The prevalence of HBsAg among blood donors in the present study was among the low prevalence rates. In the Kingdom of Saudi Arabia, HBV prevalence exhibits regional variations. Among the blood donors, 3% prevalence of HBsAg has been reported in a northwestern city of Tabuk, which was lower than 5.4% prevalence observed in the southwest of the Kingdom of Saudi Arabia. A study performed in the central region of the Kingdom in 2004 reported 1.5% HBV prevalence among blood donors. The HBV prevalence observed in the present study (0.29%), also performed in the central region, revealed a remarkable decline in HBsAg prevalence among the blood donors over a period of 15 years. Mass vaccination against HBV and increasing awareness of HBV infection are believed to have played a critical role in the decreasing prevalence of HBsAg. This was evident in a community-based study reporting a decline in HBsAg prevalence from 7% in 1989 to 0.3% in 1997 among 12-year-old children subsequent to mass HBV vaccination.
Although significantly higher than HBsAg, anti-HBc also declined from 15.32% to 9.15% between the years 1998 and 2001 among the blood donors in the eastern region of the Kingdom of Saudi Arabia. The downward trend in the prevalence of anti-HBc appears to have continued ever since, and the present study observed 4% prevalence of anti-HBc antibody among the blood donors. In accordance with the current blood bank policies at King Khalid University Hospital, all anti-HBc antibody-positive donations are discarded. There is, however, evidence that the positivity rate for HBV in anti-HBc antibody-positive donations is extremely low. Based on these observations, anti-HBc-positive donations with high titers of anti-HBsAg antibodies and negative HBV DNA have been recommended for use in emergencies. The issue remains controversial as the presence of anti-HBc antibody may indicate active HBV exposure, chronic infection, or resolving infection.
The prevalence of HCV infection in the present study was 0.3%. HCV prevalence among blood donors of 0.41% in Jazan during 2012 and 4.3% from Hail in the year 1999 supports a regional variation in the prevalence of HCV in the Kingdom of Saudi Arabia. Two studies from Riyadh reported 1.1% prevalence of HCV in 2003 and 0.4% prevalence of HCV in 2004 among blood donors, which indicate a notable decline in the prevalence of HCV. The prevalence rate of 0.3% HCV among blood donors from Riyadh in the present study suggests persistence of low-level HCV among blood donors in Riyadh for 15 years. The diagnosis of HCV infection is conventionally performed by screening for HCV antibodies. Screening for HCV core antigen has revealed 2% HCV core antigen reactivity among samples tested negative for HCV antibodies. HCV window period and failure to mount anti-HCV antibody responses have been implicated in the negative test for anti-HCV antibodies among such individuals. Screening for HCV core antigen thus appears to be a useful test for screening of blood donors to minimize the risk of HCV transmission.
The prevalence of HIV among blood donors was 0.005% and HTLV was 0.002%. A study performed in the same institute in 2004 reported zero prevalence rate for HIV and HTLV among blood donors. Recently, a study performed in Majmaah reported 0.13% prevalence of HIV and 0.20% prevalence of HTLV among blood donors. Recently, zero prevalence rates of HTLV1 and II were reported from Riyadh located in the central region of Kingdom of Saudi Arabia. Similarly, 0.07% prevalence of HIV and 0.04% prevalence of HTLV I/II have been reported from Al-Baha. Collectively, these data indicate that despite some regional variation in the Kingdom, the prevalence rates for both the viruses (HIV and HTLV I/II) are low. The difference is evident when compared with 3.1% and 6.2% HIV prevalence rates in Nigeria, and 8.5% in Mozambique among blood donors.
The prevalence of syphilis in the present study was 0.02% among the blood donors. Almost similar prevalence of 0.04% has recently been reported from Riyadh after screening of almost 240,000 blood donors. Relatively higher prevalence of syphilis (0.53%) has recently been reported from Majmaah among the blood donors in the Kingdom. A 0.18% prevalence of T. pallidum prevalence has been observed in Turkey, whereas 0% prevalence rate for T. pallidum infection among blood donors was found in Iran and Jordan., Collectively, these data indicate a low prevalence of syphilis, particularly in the Kingdom of Saudi Arabia and generally among the Middle Eastern countries. Sexual promiscuity has been shown to be associated with higher prevalence rates for syphilis. The foundations of society in the Kingdom of Saudi Arabia are laid on the teachings of Islam, a religion that forbids sexual promiscuity. It is, therefore, not surprising to witness extremely low prevalence of syphilis in a practicing Muslim society in the Kingdom.
| Conclusion|| |
The prevalence of TTIs in the present study was low among blood donors. The prevalence rates of both HBV and HCV among blood donors were low and appeared to have declined over a period of 15 years. Although the prevalence rates of both HIV and HTLV I/II exhibited regional variations in the Kingdom, the prevalence rates remained low. This was a single-center study, and the observations of the present study may not be applicable across the board. Large-scale studies are recommended to validate the findings of this study.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Barbara J, Eglin R. Introduction: Transfusion-transmitted infections, then and now. In: Barbara J, Regan F, Contreras M, editors. Transfusion Microbiology. New York: Cambridge University Press; 2008. p. 1-7.
Luban NL. Transfusion safety: Where are we today? Ann N
Y Acad Sci 2005;1054:325-41.
Brown MR, Fritsma MG, Marques MB. Transfusion safety: What has been done; what is still needed? MLO Med Lab Obs 2005;37:20, 22-3, 26.
Motayo BO, Akpa OM, Ezeani I, Faneye AO, Udo UA, Onoja B. Seroprevalence rates of hepatitis C virus (HCV) antibody and hepatitis B virus surface antigen (HBsAG) in blood donors in a Southwestern Nigerian city. J Immunoassay Immunochem 2015;36:91-9.
Kleinman S, Busch MP, Korelitz JJ, Schreiber GB. The incidence/window period model and its use to assess the risk of transfusion-transmitted human immunodeficiency virus and hepatitis C virus infection. Transfus Med Rev 1997;11:155-72.
Makroo RN, Hegde V, Chowdhry M, Bhatia A, Rosamma NL. Seroprevalence of infectious markers their trends in blood donors in a hospital based blood bank in north India. Indian J Med Res 2015;142:317-22.
] [Full text]
Laperche S. Antigen-antibody combination assays for blood donor screening: Weighing the advantages and costs. Transfusion 2008;48:576-9.
Buseri FI, Muhibi MA, Jeremiah ZA. Sero-epidemiology of transfusion-transmissible infectious diseases among blood donors in Osogbo, south-west Nigeria. Blood Transfus 2009;7:293-9.
Bhawani Y, Raghava Rao P, Sudhakar V. Seroprevalence of transfusion transmissible infections among blood donors in a tertiary care hospital of Andhra Pradesh. Biol Med 2010;2:45-8.
Yooda AP, Soubeiga ST, Nebie KY, Diarra B, Sawadogo S, Ouattara AK, et al
. Impact of multiplex PCR in reducing the risk of residual transfusion-transmitted human immunodeficiency and hepatitis B and C viruses in Burkina Faso. Mediterr J Hematol Infect Dis 2018;10:e2018041.
Diarra B, Yonli AT, Ouattara AK, Zohoncon TM, Traore L, Nadembega C, et al
. World hepatitis day in Burkina Faso, 2017: Seroprevalence and vaccination against hepatitis B virus to achieve the 2030 elimination goal. Virol J 2018;15:121.
Glynn SA, Kleinman SH, Schreiber GB, Busch MP, Wright DJ, Smith JW, et al
. Trends in incidence and prevalence of major transfusion-transmissible viral infections in US blood donors, 1991 to 1996. Retrovirus Epidemiology Donor Study (REDS) JAMA 2000;284:229-35.
Mahmoodian-Shooshtari M, Pourfathollah A. An overview analysis of blood donation in the Islamic Republic of Iran. Arch Iran Med 2006;9:200-3.
Vučetić D, Jovičić M, Maslovarić I, Bogdanović S, Antić A, Stanojković Z, et al
. Transfusion-transmissible infections among Serbian blood donors: Declining trends over the period 2005-2017. Blood Transfus 2019;17:336-46.
Onyango CG, Ogonda L, Guyah B, Okoth P, Shiluli C, Humwa F, et al
. Seroprevalence and determinants of transfusion transmissible infections among voluntary blood donors in Homabay, Kisumu and Siaya counties in western Kenya. BMC Res Notes 2018;11:171.
Stokx J, Gillet P, De Weggheleire A, Casas EC, Maendaenda R, Beulane AJ, et al
. Seroprevalence of transfusion-transmissible infections and evaluation of the pre-donation screening performance at the Provincial Hospital of Tete, Mozambique. BMC Infect Dis 2011;11:141.
Noubiap JJ, Joko WY, Nansseu JR, Tene UG, Siaka C. Sero-epidemiology of human immunodeficiency virus, hepatitis B and C viruses, and syphilis infections among first-time blood donors in Edéa, Cameroon. Int J Infect Dis 2013;17:e832-7.
Buseri FI, Muhibi MA, Jeremiah ZA. Sero-epidemiology of transfusion-transmissible infectious diseases among blood donors in Osogbo, south-west Nigeria. Blood Transfus 2009;7:293-9.
Nagalo MB, Sanou M, Bisseye C, Kaboré MI, Nebie YK, Kienou K, et al
. Seroprevalence of human immunodeficiency virus, hepatitis B and C viruses and syphilis among blood donors in Koudougou (Burkina Faso) in 2009. Blood Transfus 2011;9:419-24.
Geo FB, Karen CC, Janet SB, Strephen AM. Medical Microbiology; Virology. 24th
ed. USA: Mc Graw Hill; 2007. p. 466-85.
Okoroiwu HU, Okafor IM, Asemota EA, Okpokam DC. Seroprevalence of transfusion-transmissible infections (HBV, HCV, syphilis and HIV) among prospective blood donors in a tertiary health care facility in Calabar, Nigeria; an eleven years evaluation. BMC Public Health 2018;18:645.
Abate M, Wolde T. Seroprevalence of human immunodeficiency virus, hepatitis B virus, hepatitis C virus, and syphilis among blood donors at Jigjiga blood bank, Eastern Ethiopia. Ethiop J Health Sci 2016;26:153-60.
El Beltagy KE, Al Balawi IA, Almuneef M, Memish ZA. Prevalence of hepatitis B virus markers among blood donors in a tertiary hospital in Tabuk, northwestern Saudi Arabia. Int J Infect Dis 2008;12:495-9.
Ayoola AE, Tobaigy MS, Gadour MO, Ahmad BS, Hamza MK, Ageel AM. The decline of hepatitis B viral infection in South-Western Saudi Arabia. Saudi Med J 2003;24:991-5.
El-Hazmi MM. Prevalence of HBV, HCV, HIV-1, 2 and HTLV-I/II infections among blood donors in a teaching hospital in the Central region of Saudi Arabia. Saudi Med J 2004;25:26-33.
Al-Faleh FZ, Al-Jeffri M, Ramia S, Al-Rashed R, Arif M, Rezeig M, et al
. Seroepidemiology of hepatitis B virus infection in Saudi children 8 years after a mass hepatitis B vaccination programme. J Infect 1999;38:167-70.
Bashawri LA, Fawaz NA, Ahmad MS, Qadi AA, Almawi WY. Prevalence of seromarkers of HBV and HCV among blood donors in eastern Saudi Arabia, 1998-2001. Clin Lab Haematol 2004;26:225-8.
Zekri AR, Awlia AA, El Mahalawi H, Ismail EF, Mabrouk GM. Evaluation of blood units with isolated anti HBC for the presence of HBV DNA. Dis Markers 2002;18:107-10.
Mohammed Abdullah S. Prevalence of hepatitis B and C in donated blood from the jazan region of Saudi Arabia. Malays J Med Sci 2013;20:41-6.
Mahaba H, el-Tayeb Ael-K, Elbaz H. The prevalence of antibodies to hepatitis C virus in Hail region, Saudi Arabia. J Egypt Public Health Assoc 1999;74:69-80.
Shobokshi OA, Serebour FE, Al-Drees AZ, Mitwalli AH, Qahtani A, Skakni LI. Hepatitis C virus seroprevalence rate among Saudis. Saudi Med J 2003;24 Suppl 2:S81-6.
Alzahrani AJ, Obeid OE. Detection of hepatitis C virus core antigen in blood donors using a new enzyme immunoassay. J Family Community Med 2004;11:103-7.
Alaidarous M, Choudhary RK, Waly MI, Mir S, Bin Dukhyil A, Banawas SS, et al
. The prevalence of transfusion-transmitted infections and nucleic acid testing among blood donors in Majmaah, Saudi Arabia. J Infect Public Health 2018;11:702-6.
Mohamud HS, AlGhamdi E, Alhetheel AF, AlMajid FM, Ahmed AH, Somily AM, et al
. Mandatory blood donor screening for human T-cell lymphotropic virus type I and type II in Saudi Arabia: Need for review. J Blood Disord Transfus 2016,7:371.
AlMutairi HH, AlAhmari MM, Al-Zahran BH, Abbas IS, Al Ghamdi JA, Raja A YA, et al
. Prevalence of serological markers and nucleic acid for blood-borne viral infections in blood donors in Al-Baha, Saudi Arabia. J Infect Dev Ctries 2016;10:619-25.
Motayo BO, Faneye AO, Udo UA, Olusola BA, Ezeani I, Ogiogwa JI. Seroprevalence of transfusion transmissible infections (TTI), in first time blood donors in Abeokuta, Nigeria. Afr Health Sci 2015;15:19-24.
Elyamany G, Al Amro M, Pereira WC, Alsuhaibani O. Prevalence of Syphilis among Blood and Stem Cell Donors in Saudi Arabia: An Institutional Experience. Electron Physician 2016;8:2747-51.
Yildiz SM, Candevir A, Kibar F, Karaboga G, Turhan FT, Kis C, et al
. Hepatitis B, Hepatitis C, Human immunodeficiency virus and syphilis frequency among blood donors: A single center study. Transfus Apher Sci 2015;53:308-14.
Niazkar HR, Dorgalaleh A, Rad F. First-time blood donors are double-edged swords for blood transfusion centers: A retrospective study in Southwest Iran Turk J Haematol 2020;37:30-5.
Souan L, Tout F, Siag M, Sughayer MA. Seroprevalence rates of transfusion-transmitted infections among blood donors in Jordan. J Infect Dev Ctries 2016;10:377-83.
Oxman GL, Smolkowski K, Noell J. Mathematical modeling of epidemic syphilis transmission. Implications for syphilis control programs. Sex Transm Dis 1996;23:30-9.
[Figure 1], [Figure 2]
[Table 1], [Table 2]