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\title{"Notification Rate and Counseling for Seropositive Donors in a Tertiary Care Teaching Hospital at Amritsar (Punjab), India"}
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             \author[1]{Harjot  Kaur}

             \author[2]{Sanjay  Piplani}

             \author[3]{Rahul  Mannan}

             \author[4]{Mridu  Manjari}

             \author[5]{Swati  Arora}

             \affil[1]{  SRi GURU RAM DAS INSTITUTE OF MEDICAL SCIENCES AND RESEARCH}

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\date{\small \em Received: 12 December 2014 Accepted: 5 January 2015 Published: 15 January 2015}

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\begin{abstract}
        


Introduction: Screening for Transfusion transmitted infections (TTI's) is done to provide safe blood. Very often donors are found to be seropositive for one or more of the TTI's. The present study was undertaken in a blood bank of a tertiary care hospital to determine the response rate of the blood donors after they were notified about their reactive status.Materials and Methods: The one year observational study was done in a prospective manner from January 2013 -December 2013 taking in account of all the registered donors coming to the blood bank after notification.

\end{abstract}


\keywords{donor, notification rate, seropositivity, screening, transfusion transmitted infection.}

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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
lood donation is life saving if the blood is safe for recipient. HIV I and HIV II , Hepatitis B(HBV) , Hepatitis C (HCV), syphilis and malaria are the five major Transfusion transmitted infections (TTI's) for which screening is done. \hyperref[b0]{1} In present scenario it is realized that to prevent TTI's, the role of blood donor education along with notification and counseling of donors about their seroreactivity is of major importance for blood safety. As per objective 4.16 of the Indian action plan for blood safety, the blood donors are counseled about TTIs prior to donation and are offered the option of knowing (notify) their sero -reactive status provided they give their consent. \hyperref[b1]{2} The concept of notification and counseling is important in today's setting because as there is development of more sensitive methods to detect TTI's; the prevalence of false-positive cases has increased manifold .This in turn leads to unnecessary anxiety in donors who are notified about their reactive results.\par
Despite the benefits of the concept of notification, it has been noted that most donors who are notified of their results either do not respond at all or do not follow up their first visit to the blood centre. Some donors with deferrable risk behaviors continue to donate blood (at other blood donation centers) despite being notified about the infectious disease test results on their blood samples. This study was undertaken in a blood bank of a teaching hospital in north India to determine the response of voluntary blood donors after they were notified of their reactive status by telephone calls or letters and to analyze the reasons regarding the non compliance of defaulters. 
\section[{II.}]{II.} 
\section[{Materials and Methods}]{Materials and Methods}\par
The one year study was conducted in a prospective observational way from January 2013 -December 2013 in a blood bank of a teaching hospital catering to a rural and urban population in and around Amritsar (Punjab), India. All the blood donors (voluntary and replacement) were registered to fill up the donor screening cum registration card formulated as per the guidelines. \hyperref[b2]{3} All the donors were taken up for pre donation counseling and screened for TTI's. In all the cases a written consent was taken, procedure explained and also told about the sequence of events in case an abnormal /reactive test is obtained in blood bank TTI lab. They were reassured about the maintenance of confidentiality at each step and even encouraged to themselves enquire about their screening tests results.\par
After the donation, if a donor was identified reactive for a screening test, the donor registration record was retrieved and a telephone call was made and letter was posted by the counselor to the donor to revisit the blood bank. If the intended donor did not respond , a second call after 10 days was repeated with a positive encouragement offered to them to visit the Materials and Methods: The one year observational study was done in a prospective manner from January 2013 -December 2013 taking in account of all the registered donors coming to the blood bank after notification.\par
Discussion: Seroprevalence rate in the present study was comparable to the study done previously in the same city and elsewhere in India.\par
The notification rate in the present study was towards the lower side (27.45 \%) in comparison to various India and international studies. The notification rate was maximum in donors positive for HBV followed by HCV. The response rate amongst donors positive for HIV were low in contrast to the studies done elsewhere.\par
Results : Seropositivity in the present study was 3.36\% with HCV being the most common TTI recorded followed by HBV, syphilis HIV respectively. No case of Malaria was recorded.\par
Of the 204 seropositive cases only 181 (88.73\%) could be contacted. Of these 56(27.45 \%) were responders with rest being non responders.. 
\section[{Keywords :}]{Keywords :}\par
blood bank assuring them the confidentiality. Finally if the donor did not respond even on 2 nd call after another 10 days then he/she was considered non responder.\par
The reactive donors immunoreactive for HIV who returned back to blood bank were again tested and in event of a repeat reactive result were counseled for the health status and high risk behavior of patient. They were then referred to an integrated counseling and testing center (ICTC) where the testing and counseling was done according to the ICTC guidelines.\par
On the other hand the donor who were reactive to VDRL were referred to sexually transmitted diseases (STD) clinics for proper counseling and management of the same.\par
The donor who were reactive to HBsAg and HCV were counseled about the etiology and referred to the gastroenterology unit of medicine department for confirmation of the viral status by polymerase chain reaction (PCR).Subsequently, these patients also underwent viral load assays. The results of TTI prevalence and response rate amongst the reactive donors were recorded and tabulated for simple statistical analysis. IV. 
\section[{III.}]{III.} 
\section[{Results}]{Results} 
\section[{Discussion}]{Discussion}\par
The notification of blood donors represents a setting in which asymptomatic individuals are informed of abnormal test results .Despite pre donation counseling by counselor, screening and examination by blood bank staff; 204 donors (3.36 \%)out of all donations were found positive for one of the TTI's. This rate is comparable to the studies done previously from the same city \hyperref[b4]{6} and elsewhere in India. 7,8 A 3.36 \% seropositive rate may be attributed to the socio economic and socio cultural background of donors especially the prevalence of intravenous drug abuse amongst the young Punjabi population. \hyperref[b4]{6} Of all the TTI's hepatitis group (Hepatitis B \& Hepatitis C) form the most common infectious agent against which seropositivity rate was 3.36\%. This is in concordance with other major studies done in different regions of India (Table-1). However the prevalence of Hepatitis C if taken separately, it was more than Hepatitis B in difference to other studies conducted in India where reverse is true. \hyperref[b0]{1,}\hyperref[b3]{4,} {\ref 5} Out of 6065 donors , who came to the blood bank during the one year period of the study . 204 donors were found to be seropositive for either one or more than one TTI's. In the present study HCV(79; 38.72\%) was the commonest TTI recorded followed by HBV (58; 28.43\%). No case of malarial parasite was recorded in the present study (Table \hyperref[tab_0]{-1}).\par
Of the 204 seroreactive only 181 (88.75\% ) could be contacted over phone or by means of letter from the office of blood bank through blood bank counselor. Amongst these; while 56 (27.45\%) donors returned back to blood bank for post donation counseling (hence categorized as responders), 125 (61.27\%) of the same donors did not turn up despite The principle of repeated notification is also necessary as many researchers such as Kleinman et al 11   , have reported that upto 10\% of donors either did not open or read the letter or did not understand the content and even refused to receive the primary contact letter. Advent of telecommunication has led to negation of all the above stated facts provided that the correct phone number are provided by the donors on their donor registration form which is often not the case as many phone numbers provided are either factitious or found not in existence when tried.\par
A study by Sharma et al \hyperref[b11]{13} found an unusual behavioral pattern of many donors (who did not know about the window period) indulging in high risk behavior and continued to donate blood as they knew that the donated blood would be tested for the infectious agents anyway and would be discarded if found sero positive. .\par
Another study by Roshan et al 5 also suggest that test seekers who use blood donation as the testing also contribute to such a pool of donors .\par
Disease wise categorization showed that the response rate amongst donors positive for HIV I \& II was the lowest 18.81\% (2/11) which points towards social taboo, self denial and possibility of being a social outcast which is associated with AIDS as a possible explanation. This is in contrast with studies done elsewhere where the rate of response is a little higher on notification. \hyperref[b0]{1,} {\ref 5} In the present study response rate in Hepatitis B were slightly more than Hepatitis C although Hepatitis C per se was a more prevalent TTI than Hepatitis B. Comparison with other studies have been done in (Table  {\ref -}2) with a glaring finding of a very low average response rate of 27.45\% in contrast to other studies.\par
Notification of the abnormal results is important as although the demand for blood \& blood components is showing an exponential growth pattern in today' s hi tech medical world but the availability of safe blood as a basic therapeutic tool for patients remain a distant dream especially in developing and recourse challenged countries of the third world. Many ultra sensitive tests (such as universal NAT screening) are not economical feasible in such countries. Donors who come for counseling are benefitted in various ways over those who do not turn up after notification. During counseling donors are encouraged to ask questions about their status and their myths and anxieties are taken care of. The responsibilities of these donors towards society and their partners and the various treatment options available for the disease in question are also discussed in detail. In comparison, donors who do not seek counseling continue to be a threat to the public , their families and blood transfusion services.\par
A higher response rate is beneficial as a lower response rate has a definite impact on transmission and prevalence of infection in the community.\par
Research suggests that the it should be mandatory for all blood banks to follow up greater risk to community reactive donors as these "asymptomatic donors'' pose greater risk to community at large. Also it has been suggested that the process of notification , disclosure of results should be standardized with mandatory submission of identity proof with some unique identification number at the time of donation as this can help to search the non responder afterwards. The reactive respondent donor should be referred with a referral slip mentioning the TTI test result as well as detailed address of the concerned physician to get better response out of notification.\par
Sustained efforts of a trained counselor as well as close communication with treating physician/ dermatologist in for all reactive cases along with better community health education programs can bring a lot of change in donor notification which is great social concern of today time. In the present study, only 56 donors out of 204 reactive donors (27.45\%) responded and were counseled during the study period and 125/204 (72.54\%) donors did not turn up at blood bank despite initial willingness of them to report for counseling. Low response rate in the present study was attributed to poor health care knowledge and poor understanding of screening results of the population under study. While low response rates (21\% -67\%)have also been reported outside India by Moyer et al \hyperref[b7]{9} , Sanchez et al \hyperref[b8]{10} and Kleinman et al \hyperref[b9]{11} , but most western studies show a higher response rate. \hyperref[b10]{12} On comparing the result of the study conducted with the response rate response rate in other Indian studies by Patel et al 1 , Aggarwal \hyperref[b3]{4} and Battacharaya et al 5 (60.36\%, 68.4 \% and 34 \%) the response rate were found to be on a lower side.\begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.04434782608695652\textwidth}P{0.08376811594202899\textwidth}P{0.5518840579710145\textwidth}P{0.08376811594202899\textwidth}P{0.08623188405797101\textwidth}}
\tabcellsep \tabcellsep \multicolumn{2}{l}{Number of Reactive donors}\tabcellsep \\
TTI's\tabcellsep Present study\tabcellsep Aggarwal 4\tabcellsep Roshan et al 5\tabcellsep Patel et al 1\\
HIV\tabcellsep 11(5.39\%)\tabcellsep 17(4.08\%)\tabcellsep 87(14.8\%)\tabcellsep 15(15.09\%)\\
HBsAg\tabcellsep 58(28.43\%)\tabcellsep 225(54.08\%)\tabcellsep 209(35.5\%)\tabcellsep 176(45.01\%)\\
HCV\tabcellsep 79(38.72\%)\tabcellsep 76(18.26\%)\tabcellsep 208(35.5\%)\tabcellsep 28(7.16\%)\\
Syphilis\tabcellsep 56(27.45\%)\tabcellsep 98(23.55\%)\tabcellsep 85(14.4\%)\tabcellsep 128(32.74\%)\\
Malaria\tabcellsep 00\tabcellsep 00\tabcellsep 00\tabcellsep 00\\
Total\tabcellsep 204(100\%)\tabcellsep 416(100\%)\tabcellsep 589(100\%)\tabcellsep 391(100\%)\\
\tabcellsep \tabcellsep \multicolumn{3}{l}{giving 2 more reminder calls (hence categorized as non}\\
\tabcellsep \tabcellsep \multicolumn{3}{l}{responders).The commonest reason for not coming}\\
\tabcellsep \tabcellsep \multicolumn{3}{l}{back to blood bank was expressed unwillingness and}\\
\tabcellsep \tabcellsep \multicolumn{3}{l}{personal reasons. Later on of these 56 seropositive}\\
\tabcellsep \tabcellsep \multicolumn{3}{l}{patients who responded to blood bank were retested.}\\
\tabcellsep \tabcellsep \multicolumn{3}{l}{The most common response rate was noted in reactive}\\
\tabcellsep \tabcellsep \multicolumn{3}{l}{HBV donors followed by HCV reactive donors.(Table -2)}\end{longtable} \par
 
\caption{\label{tab_0}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.15122699386503066\textwidth}P{0.255521472392638\textwidth}P{0.22944785276073618\textwidth}P{0.21380368098159508\textwidth}}
\tabcellsep Present study\tabcellsep Roshan et al 5\tabcellsep Patel et al 1\\
HIV\tabcellsep 18.18\%\tabcellsep 54\%\tabcellsep 52.54\%\\
HBsAg\tabcellsep 32.75\%\tabcellsep 58.9\%\tabcellsep 19\%\\
HCV\tabcellsep 25.31\%\tabcellsep 70.7\%\tabcellsep 20\%\\
VDRL\tabcellsep 26.7\%\tabcellsep 32.9\%\tabcellsep 15\%\\
Malaria\tabcellsep 00\tabcellsep 00\tabcellsep 00\\
Average\tabcellsep 27.45\%\tabcellsep 63.5\%\tabcellsep 60.36\%\end{longtable} \par
  {\small\itshape [Note: TTINo of Responders]} 
\caption{\label{tab_1}Table 2 :}\end{figure}
 		 		\backmatter  			  				\begin{bibitemlist}{1}
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\end{document}
