key: cord-010088-s9tfvtao
authors: nan
title: Oral Abstracts
date: 2013-11-01
journal: Vox Sang
DOI: 10.1111/vox.12100_1
sha: 
doc_id: 10088
cord_uid: s9tfvtao

nan

Tadokoro K and Satake M Japanese Red Cross Society, Tokyo, Japan It is estimated that there are 2 billion HBV-infected people including 350 million HBV-carriers in the world. It is highly endemic in South Africa, Amazon, and Southeast-Central Asia. The genotype of HBV is geographically characteristic, e.g. genotype B and C are the major in East Asia. HBV transmission remains the most frequent transfusion-transmitted viral infection despite the implementation of various screening tests applied in different settings. The residual risk is mainly related to donations either in the pre-sero (or pre-DNA)-conversion window period or occult HBV infection (OBI) where blood test is HBV-DNA-positive and HBs-Ag-negative. Infectivity of HBV depends on the transfused blood (viral load, phase of infection, genotype, and anti-HBs in the concurrent blood) and immune status of the recipients (anti-HBs, immunocompetence). It was shown that infectivity is dependent on viral load. Allain et al reported that FFPs is more infectious than PCs or RBCs. The minimal infectious dose of blood in late acute infection phase in chimpanzee and chimeric mice is approximately 10 times higher than that of pre-acute phase. Satake et al reported that transmission rate of OBI-derived components with low titer anti-HBc was 1/33(3%), whereas that of anti-HBc-negative components was 11/22(50%), which was verified in the lookback programme conducted in Japan. Allain et al showed in the study conducted in Europe that adjusted transmission rate of OBI blood was 28%, and the rate was higher without anti-HBs(63.8%) and lower with anti-HBs(15.4%). Discrepancy of transmission rate of OBI-derived blood between above two reports might be related to the different cutoff levels of anti-HBc and presence or absence of anti-HBs. DNA-positivity rate among OBI-derived components is higher in those with the higher levels of anti-HBc and lower in those with the presence of anti-HBs. There has been no report of transmission by OBI-derived blood with anti-HBs of 200mIU/ml or more. Screening test for HBV is different between countries. Low endemic countries screen blood for HBs-Ag, anti-HBc and mini-pooled NAT, while highly endemic countries test for HBs-Ag without anti-HBc, because high prevalence of anti-HBc-positive donation hamper securing necessary blood. Japan as a moderately endemic country had tested for HBs-Ag, mini-pool NAT and anti-HBc/anti-HBs where anti-HBs of more than 200 mIU/ml irrespective of anti-HBc and low anti-HBc with agglutination-inhibition titer of no more than 2 5 is qualified. Transfusion-transmitted HBV cases related to window period donations declined by increasing the sensitivity of mini pool NAT, whereas those related to blood with low titer anti-HBc remained stable with around 10 cases annually. In order to decrease such transmission Japanese Red Cross implemented a novel strategy to eliminate all anti-HBc-positive donations with anti-HBs <200 mIU/ml. Considering the frequency of donations with low titer anti-HBc has decreased to 1.3%, loss of those donations was estimated to be covered by promoting donations, Each country should establish its own HBV screening strategy considering the prevalence of HBV, residual risk of transmission, balance between safety and securing blood, and cost-effectiveness. Implementation of individual donation NAT and universal vaccination could further reduce further the risk of HBV transmission. our blood service is to motivate other population groups to diversify the age and gender composition of our donors. Forty-two percent of the whole blood donors participate in blood donation only once a year, so we need develop programs to motivate them to re-join blood donation. Also, we have to solve the annually recurring problem of blood shortages for transfusion during the winter and summer season. In the long term, our donor base is going to decrease gradually because of the low birth rate in Korea and our rapidly aging population. Therefore we should prepare a sustainable solution for a stable blood supply. Aims: Present methods to recruit blood donors based on age, gender and occupation groups for a stable blood supply. Methods: To make blood donation more accessible to individual donors, fixed donation sites are continuously developed. Facilities of our fixed and mobile sites are improved to provide safe and comfortable environment to donors. Since 1999, we have been operating the 'Registered donor system' for registered donors who agreed to donate their blood on a regular basis. To raise awareness of the importance of blood donation among youth, high-school students blood donor groups called 'Red Campaigners' and groups of university students called 'Blood Donation Supporters' are actively participating in blood donation campaigns. To increase participation of the middle-aged group, agreements were made not only with enterprises and organizations but also with the government and public institutions. We have developed a computerized system for scheduling group donations according to demand and supply and for performance management. To recognize the necessity of blood donation, every 13th was designated as 'Blood Donation Day' in 2012. To deal with donor complaints and requests, a Customer Relationship Management Center has been established. Results: By increasing the number of fixed donation sites and making donation more accessible, rate of individual donations is getting increased. As of the end of June 2013, 250 agreements for blood donation had been signed with enterprises and organizations. Every year more than 100 thousand donors agree to donate on a regular basis, and so far about 600 thousand donors have been registered in the 'Registered donor system'. The campaign 'Every 13th is Blood Donation Day' has contributed to spread a positive perception about blood donation. Conclusions: We have been very successful in engaging youth in blood donation. Diversification of the donor group will take time and constant effort. However, with more participation of female donors and retention of our first-time donors, it will be possible to be self-sufficient in blood supply for transfusion and plasma fractionation. The provision of sufficient safe blood products to patients requiring transfusion is the common goal of blood transfusion services and the public expectation of absolute safety continues to be a challenge. Although the focus of blood safety falls on laboratory testing, the role of pre-donation donor selection cannot be underestimated. Transfusion-transmitted infections (TTIs) are blood-borne microbes that can be spread from blood donor to recipient via transfusion. To prevent TTI, donated blood must go through validated laboratory testing. In most countries, blood is tested for HIV, HBV, HCV, and Syphilis. Screening for other TTIs may also be implemented in some countries after individual assessment of the prevalence of the infection in their general populations, for example, West Nile virus in the United States. With the advance in testing technology, in particular the nucleic acid test, the window periods for the detection of various TTIs have been significantly shortened. However, the risk of window donation still exists. Furthermore, there are known or emerging TTIs such as the variant CreutzfeldtJakcob disease (vCJD) where there is still no suitable testing system for routine screening of donated blood. Therefore, blood transfusion services have to continue practicing effective pre-donation donor selection to mitigate the TTI risks. WHO recommends selecting voluntary, non-remunerated donors from low-risk populations for blood collection as the first step in reducing the risk of TTIs. Donor selection is usually conducted by a health history questionnaire to be completed by potential donors and a confidential interview. The questions asked should be effective in assessing whether the respondent's health status is suitable to donate and there is no TTI risk factor. People who are deferred should be counseled and given the reason for and duration of the deferral. WHO has published a document titled 'Blood donor selection -Guidelines on assessing donor suitability for blood donation'. It recommends the following: National donor selection guidelines and criteria should be based on epidemiological and/or scientific evidence or, where evidence is limited or lacking, on best practice. Donor acceptance and deferral policies for the prevention of TTI should be based on up-to-date information on the local epidemiology of infections, the markers screened for, the availability of suitable blood screening and confirmatory assays, and the technologies in use. National donor selection criteria should define conditions of acceptance and deferral for each criterion. Adequate resources, including a sufficient number of qualified and trained staff, should be made available for the consistent and reliable assessment of donor suitability for blood donation. Quality systems should be in place for donor selection, including selection criteria, staff training and documentation. Blood transfusion services should establish mechanisms for monitoring and evaluation to assess the implementation and effectiveness of donor selection criteria. In conclusion, pre-donation selection is essential to protect the safety and sufficiency of blood supply, and safeguard the health of recipients and donors.

Background: Blood components may be contaminated by a variety of commensal, pathogenic or environmental bacteria during collection, manufacture or storage. The outcome of transfusion is dependent on the ability of the specific strain to multiply to clinically-relevant titers during storage, the pathogenicity of the strain and the patients' situation. Platelets in particular are stored in conditions conducive to bacterial growth and septic reactions to these products are the most frequently documented infectious risk of transfusion. Aim: The objective of this update is to review estimates of risk of bacterial sepsis and contamination of platelets, and recent findings describing interventions designed to safeguard patients. Methods: This update will use recent reports and unpublished data to describe our current understanding of the role of bacteria in transfusion safety. Results: Historical data suggests that~1:1-3000 platelet products are contaminated with bacteria, and septic transfusion reactions occurred in 1:15-100,000 transfusions. Clinical awareness of the danger and a 2004 AABB standard to 'limit and detect bacteria' in platelet products have driven the development of safety systems. The last decade has seen substantial progress in the implementation of optimal skin disinfection techniques and sample diversion strategies to reduce contamination, and many centers implemented either bacterial culture testing or pathogen inactivation processes to reduce the risk. Culture testing can reduce but cannot eliminate the risk of exposure to contaminated components and sepsis. The majority of contaminated products do not cause adverse reactions, however, at the time of collection and manufacture the only means to prevent serious and fatal reactions is to ensure that that the component is functionally sterile. Pathogen inactivation technologies show variable efficacy at killing bacteria, suggesting a need for strict adherence to the manufacturers suggested protocols to ensure optimum performance. Alternatively, assays performed on the day of transfusion prevent the transfusion of high concentrations of bacteria that are associated with the most severe adverse reactions. Conclusions: Bacterial contamination and sepsis remain the greatest infectious risks of transfusion. Enhanced testing or pathogen inactivation should be implemented to ensure patient safety.

The Australian Red Cross Blood Service, Sydney, Australia Background: Pathogen reduction technologies have been developed as a means of reducing the risk of transfusion transmission of blood-borne pathogens. Published literature indicates that systems currently in use or under development effectively inactivate a range of pathogens in platelets and plasma, with the exception of some non-lipid enveloped viruses, bacterial spores and prions. Development of pathogen reduction technology (PRT) is ongoing, and many countries have adopted PRT as part of their routine blood component processing. The aim of this update will be to review technologies currently in use or under development for treatment of labile blood components during processing. The impact of PRT on blood component quality as well as ongoing challenges will be reviewed. Platelets: There are currently three systems for PRT treatment of platelets. These are the Mirasol TM system (TerumoBCT), the INTERCEPT Blood System TM (Cerus Corporation) and the Theraflex UVC TM system (MacoPharma). The INTERCEPT and Mirasol systems are used widely in blood centres in Europe, Asia and the Middle East for the treatment of both platelets and plasma, whereas clinical trials of platelets treated using the Theraflex UVC system are ongoing. In vitro data suggests PRT treatment leads to some loss of platelet function. However, haemovigilance reports from sev-eral countries where INTERCEPT treated platelets are transfused indicate no change in component usage, and indeed a reduction in transfusion related adverse events. Similarly, there have been no reports to date of serious adverse events relating to clinical use of Mirasol-treated platelets. Plasma: The INTERCEPT and Mirasol systems can be used to treat both plasma and platelets, and the Theraflex system utilises methylene blue (MB) with visible light for PRT treatment of plasma. There are some losses of coagulation factors following treatment with each of these systems. Theraflex MB plasma has been transfused world-wide since 1999, and haemovigilance data indicates there is not a higher incidence of allergic reactions or other adverse events with MB-treated plasma. Red cells/whole blood: Commercial PRT systems for red cell or whole blood components are under development. Cerus Corporation has continued development of a second-generation S-303 system for red cells, demonstrating in vivo recovery after 35 days storage. A Mirasol PRT system for treatment of whole blood is also being developed by TerumoBCT. Preliminary in vitro quality and in vivo recovery and survival data indicate that this technology may eventually become available, but further development and clinical trials are still required. Challenges: Concerns still exist regarding long term effects on patients receiving PRT treated blood components, particularly the potential toxic effects of residual products following photochemical treatment. Ongoing post-marketing surveillance and clinical trials are required to address these concerns. Ideally, PRT should provide proactive protection against emerging pathogens and reduce the need to introduce additional pathogen testing, minimise bacterial contamination and potentially replace processing steps such as gamma irradiation. The challenge for blood services is to understand and rationalise the costs, risks and benefits of PRT compared to removing any of these tests or processes, whilst aiming to provide the highest level of blood safety.

Steps in getting a Paper Published/Abstract Accepted 1B-H4-01 No Abstract available.

1B-H4-02 HOW TO GET YOUR ABSTRACT ACCEPTED AND HOW TO PRESENT IT Daniels G

Many abstracts are submitted to the ISBT for presentation at international and regional congresses. All abstracts are refereed by a large panel of international experts, who decide which abstracts should be accepted and which ones should be rejected. They also decide which of the accepted should be presented orally or as a poster. Most of the submitted abstracts are accepted, though there is plenty of room for improvement in the quality of many of those abstracts. In this session I will describe why some abstracts are rejected and discuss how you might avoid this pitfall. I will also discuss some methods for improving your abstracts so that they represent the quality of the work you are describing and enhance the reputation of yourself and your institution. Once your abstract has been accepted you will have to present it at the congress. If it is accepted for poster presentation, you will have to make a poster. The easiest way to produce a poster is to design it on a single PowerPoint slide and then send the file to a company that will turn it into a poster on paper, or even on cloth for easier transportation. If your budget does not run to that, there are cheaper ways, such as printing it on single pages of A4 with the text printed in a very large font. The best posters do not have too much written information (bullet points are often best), contain diagrams and/or pictures, and are colourful and visually attractive. If, however, your abstract is accepted for oral presentation, then you will have to give a talk, usually of 10 min, and then be prepared to answer questions. This may be a daunting prospect, especially if you are not experienced in public speaking, and particularly if English is not your first language. I will discuss techniques for improving your presentation skills, both from the points of your spoken presentation and your visual aids, which will usually be a PowerPoint presentation. If you are thoroughly prepared before you stand up in front of an audience, you will feel more confident and, consequently, less nervous.

Devine D

Publication of research findings and novel concepts in the biomedical literature is the mainstay of knowledge mobilization. The communication of scientific work as papers follows a well-established framework. A clear understanding of the nature of this framework and how to assess one's own work against it is critical to successful acceptance and subsequent publication of manuscripts. In this session, we will review the standard framework for scientific communication. Communicating your findings is a form of scientific story telling. One must clearly explain why it was important to write the paper so that the reader will be interested and want to keep reading it. Generally, an author must capture the interest of a potential reader right at the abstract which is sometimes the only way a reader sees the paper if they have discovered the work using a search engine such as Medline. In the main body of the paper, the author must clearly explain how the study was designed and carried out with careful attention paid to any important details and to the statistical analysis, if appropriate. Results must be presented in a manner that is clear and easily interpreted by the reader. Then the work should be discussed in the context of other work in the area, emphasizing the novel findings. In this session, we will also address the following questions: How do I know if I have enough information to write a paper? Where should I try to publish the paper? How should my paper be put together to give it the best chance of being accepted? What happens to my paper after I submit it? If it is returned to me with comments from the reviewers, what should I do? What is my next step if my paper is rejected, either without review or with review? We will also consider how to prepare papers in a language other than one's native language. The various sorts of scientific communications (original papers, review articles, reports, letters to the editor) will be discussed. The session is intended to provide general guidance for the publication of papers in the biomedical literature rather than be specifically focused on publication in the Society's journal Vox Sanguinis. The membership survey commissioned by the ISBT Central Office in 2012 gave a good insight into what members and non-members expect from the Society. The main message was that members and potential members would like more educational and training resources to be available. Many respondents requested that ISBT should write international guidelines and develop standards. Developing international guidelines when so many are already available and when countries and regions have different requirements would be a titanic task. The ISBT Board decided that the Society should put together a repository (library) of guidelines, standards and regulatory documents that are already currently available. The repository is now ready and launched during the 24th Regional congress of the ISBT in Kuala Lumpur. For practical purposes the repository contains recent guidelines in the English language that are freely available, however following consultation with experts some manuals are included that are either relatively old or are not yet freely available on line. Approximately 250 documents are in the repository from around 25 countries. The repository is a work in progress and further documents will be added in other languages. The repository is available via a link on the ISBT home page www.isbtweb.org to the ISBT Academy e-learning portal. It can be accessed by country and by subject and a search facility is available. The guidelines are organised by six main subjects; donor, clinical, laboratory, quality/haemovigilance, processing and regulatory. There are sub topics for each main subject. ISBT anticipates that you will find the repository a useful resource. Background: Blood Services in Africa operate at different levels of development from those comparable to the first world to those operating at a basic level with just hospital based blood banks and no national coordination. In recent years, countries have made efforts to improve their blood services based on voluntary non-remunerated blood donation. Major challenges include low knowledge levels, inadequate funding, weak regulatory framework and poor quality systems. Many international standards are too stringent for most economies in sub-Saharan Africa. To address these challenges, the Africa Society for Blood Transfusion (AfSBT) started a program to develop blood transfusion standards relevant to Africa. The AfSBT step-wise accreditation standards: These Standards were drafted by an AfSBT Task Team for Accreditation with guidance from the AABB and input from a team of experts. They were initially based on the WHO Aide Memoire for Blood Safety. An evidence-based decision-making process, where possible, was used to modify existing requirements or create new specific requirements. The goal of the Standards is to provide a benchmark for accreditation of facilities and to maintain and enhance the quality and safety of blood transfusion in Africa. The development process started in 2009. There is one standard with 3 progressively more rigorous steps of achievement as follows: Level 1: Minimum quality and operational requirements Level 2: Intermediate quality and operational requirements Level 3: Full accreditation at international standard A facility chooses the level to be assessed at. However accreditation at any grade is attained if facilities meet standards of the grade but also comply with specific requirements in section 11 which deals with legal and regulatory requirements, blood supply, equipment and supplies and clinical use of blood and blood products. Application of the standards: They apply to facilities that perform any or all of the following functions: mobilization, recruitment and selection of blood donors; blood collection; components preparation; blood group and serological testing; compatibility testing; storage, handling, transportation and distribution of blood products. Requirements do not apply in cases where the blood transfusion service is not responsible for an activity e.g compatibility testing.

Guidance document: There is a guidance document which clarifies and enhances understanding of the requirements of some of the standards. Other standards are straight forward and do not need guidance. The guidance document is being updated as queries are received from the field. Training: To facilitate meeting the requirements of the Standards, there is a training committee, tasked with supporting training for blood services. A full training program is currently being developed. Piloting: The standards were piloted in Namibia and Malawi. The Namibia piloting was completed in 2012 while the Malawi piloting will be completed in 2013. Comments from these pilot sites have provided valuable input into the standards development process. Conclusion: Stepwise accreditation program is relevant in encouraging improvements for developing blood transfusion services. Accreditation standards need to be commensurate with local needs. Training is very important in helping developing blood transfusion services attain accreditation status. Blood transfusion has become an integral part of modern healthcare. When it is required, it is an essential element of therapy, helps safe lives and improves quality of life. However, it is not without risk. Being of human tissue origin, this risk is related to its source as well as the process involved in its provision. To ensure that blood transfusion is safe and does not cause harm to patients, these risks have to be monitored, evaluated and managed appropriately. Therefore it is essential to develop system of ensuring safe blood supply and safe transfusion. Quality systems should be developed covering the whole transfusion chain. Policies, standards and guidelines are important tools. To ensure that the system is effective, there are various mechanisms to monitor, evaluate and analyse in order to bring about improvement. These include developing indicators, quality and clinical or transfusion audits, quality assessment programmes and haemovigilance programme. Indicators can be used to monitor transfusion practice such as prevalence of transfusion transmitted disease among blood donors, crossmatch transfusion ratio, expiry fate of blood components and transfusion error. These indicators not only measure safety but also efficiency of the blood service. In countries where the blood supply is not consistent, the rate of blood requirement not met is an important indicator to monitor. Performance of laboratories providing blood can be measured using quality assessment programmes. This is an important element that links the source of blood to the patient. Audits covering all processes and procedures ensure that the quality and safety of blood is maintained. While these processes and procedures are controlled in ensuring safety and quality of the blood supply, the process involved in the transfusion process is sometimes not controlled by documented procedures and poorly supervised. Auditing blood usage which is more complex and laborious provides an important mechanism for ensuring that this precious national resource is utilised efficiently. Guidelines whether national or international are required against which these audits are performed. Transfusion audits looks at the quality of care of patients besides the use of blood. It analyses the process of diagnosis, the decision making in treatment and the use of available resources. Over the last two decades, haemovigilance has evolved and expanded worldwide. It focuses on adverse events that occurred throughout the transfusion chain, analysis of the facts and provide an avenue for corrective actions to be taken to prevent further recurrence. Initially, its focus was more on adverse events that occurred to patients, it is now used to monitor adverse events relating to blood donors and blood donating process. In resource limited economies these tools can be used effectively when a stepwise approach is adopted. The aim is to create a culture of professionalism in delivering quality of care to patient with efficient use of available resources. However, its benefit can be extended to influence change and improvement in healthcare in general. Only when deficiencies are demonstrated that request for resources can be shown to be justified. Serological methods have the advantage of being fast, simple, and determining the expression of antigens directly. However, genotyping and molecular diagnostic methods have their advantages in determining subtypes and variants, as well as in detecting other rare blood groups. Commercial blood group genotyping kits have been widely used, not only in clinical blood banks but also in transfusion services. These commercial kits mainly aim to analyze coding genes of ABO and Rh blood group systems. Common alleles found in local populations are included in these kits. At present, many kinds of molecular diagnostic methods are employed in detecting blood group alleles by transfusion laboratories in China. These methods include multiplex PCR, multiplex PCR combined with Pool system, sequencing, and gene chip technology. Considering the genetic background of several rare phenotypes with clinical importance in Chinese persons, one multiplex PCR system was developed to detect Fy a , s, and Ok a antigens, and the other system was developed to detect Di b , k, and Js b antigens. Using the existing multiplex PCR-SSP assays, only one sample can be detected in a single PCR tube because the primers used in these assays are specifically devised for corresponding high-frequency alleles, and aim to screen for the negative results. Therefore, the positive results would mask the negative results by adding more samples in one PCR tube. To improve the efficiency of screening, recently we established a novel method combining the multiplex PCR-SSP assays with the DNA pooling strategy. The primers were designed to amplify the corresponding low-frequency SNP sites. In each multiplex PCR-SSP assay, every DNA pool is tested for the presence of the low-frequency SNP sites. A pool is released for further processing when the positive results were found in any site. After then, each individual DNA sample of the positive pool was detected respectively to determine the positive sample. Finally, PCR-SSP methods were used to determine whether the positive result was caused by homozygous or heterozygous alleles. Normally, the homozygous low-frequency alleles would lead to rare phenotypes. At the same time, the control system based on site-directed mutagenesis solves the problem of the lack of experiment controls due to unavailable negative or positive DNA control samples. With large scale screening of population samples and diagnosis of various clinical special samples, the relationship between blood group coding genes and the expression of proteins is being clear. The frequency of multiple blood group alleles has also been investigated. The specific molecular events found in Asians and Chinese populations are revealing the difference among races and regions, as well as the expression diversity of blood group alleles.

1C-H6-02 DIAGNOSIS AND TREATMENT OF AUTOIMMUNE HAEMOLYTIC ANAEMIA

Autoimmune haemolytic anaemia (AIHA) occurs as a result of antibodies directed against self-red blood cell (RBC) antigens, leading to the premature destruction of RBC. RBC destruction may occur within the vasculature, often mediated by the membrane-lysing complex, which is generated upon complement activation or occur extravascularly, within the reticulo-endothelial system that expresses FcΥR and C3 receptors, that bind antibody and complement coated RBC. The laboratory hallmark of AIHA is a positive direct antiglobulin test (DAT) although it has to be recognized that occasional cases of DAT-negative AIHA may occur. Secondary causes for AIHA such as an underlying autoimmune disorder, infections or malignancies should be considered as part of the investigation process for AIHA. Immunohaematology investigations for AIHA should always include a DAT using monospecific anti-IgG and anti-C3d. On occasions, further testing with anti-IgA or -IgG subtypes may be necessary. While the DAT provides information on bound RBC antibodies, the indirect antiglobulin test (IAT) using screening and antibody identification cells will provide information on the specificity of circulating antibodies. Often this will give a pan-reactive pattern although it is not unusual to identify coincident autoantibodies with defined red cell specificity. Negative IAT with screening and identification cells in the presence of a positive DAT should raise suspicion of drug-induced AIHA. In patients who may have been potentially alloimmunized, further procedures should be performed to exclude the coincident presence of alloantibodies as failure to recognize alloantibodies may result in an immediate or delayed haemolytic transfusion reaction if red cell transfusions are initiated. Elution and auto-or alloadsorbtion techniques are useful to separate allo-and autoantibodies. Complete red cell phenotyping should be concurrently performed to aid in identifying antibody specificities. Heavily antibody-coated red cells may be difficult to phenotype with some anti-sera, in which case, molecular based red cell genotyping should be initiated. Molecular based red cell typing is also particularly useful where the patient has recently been transfused and the initial red cell phenotype of the patient is not known. The primary management of the patient with AIHA is amelioration of the underlying condition and suppression of immune mediated haemolysis. This is usually achieved with administration of steroids or immunosuppressive agents. Splenectomy may be an effective second line treatment. Rituximab is increasingly becoming a promising treatment option in patients who are steroid-refractory and not suitable for splenectomy. Other treatment modalities for the refractory patient include intravenous immunoglobulin and Danazol. Red cell transfusions in patients with AIHA should be undertaken carefully although they should never be denied blood transfusions because of inability to find compatible units. As far as possible, phenotype matched red cells, cross-match compatible with the patient's autoadsorbed serum should be transfused. If coincident alloantibodies are identified, antigen-negative red cells will need to be selected.

Clinical Immunology and Transfusion Medicine, University & Regional Laboratories, Lund, Sweden

What is the value of discussing case studies? They provide us with a forum for sharing our combined experience and permit the development of ideas and techniques as well as the possibility to see a given situation from another perspective. Cases that illustrate the following will be discussed:

(1) The presence of polyagglutination in a patient with a bacterial infection In Europe and the USA, polyagglutination is rarely seen since monoclonal blood grouping reagents are the norm; however across Asia, a broad spectrum of blood typing reagents are used and polyagglutination maybe encountered.

(2) Investigation of an antibody to a low-prevalence antigen in a case of haemolytic disease of the foetus and newborn Antibodies to low-prevalence antigens occur not infrequently. How can they be investigated and what should be considered? (3) Antibodies to a high-prevalence antigen The discussion will consider how to resolve such a case in laboratories with different levels of resources. What should be considered in different clinical situations? The goal is provide useful tips for investigation of difficult serological cases and information on how to proceed when the investigation is beyond the resources of the laboratory. Haemovigilance is an important element of blood safety. It aims to identify, monitor and prevent adverse reactions, incidents and adverse events related to transfusion for both donors and patients (from 'vein to vein'). Various local, regional and national haemovigilance models exist, which reflect the range of health systems and blood systems in different countries; for example, some haemovigilance systems are coordinated by professional bodies, some by blood suppliers, and some by health authorities (health departments or regulators). Participation may be voluntary or mandatory, and may differ depending on whether all events or only serious ones are reportable. Some systems capture events with all levels of imputability, whereas others record only those which are confirmed or highly probable. 'Near miss' events are captured by some systems, and many valuable lessons can be learned from these cases. From an early stage of haemovigilance reporting it has been identified that processrelated problems are a major cause of serious transfusion complications. These include 'incorrect blood component transfused' events, where the blood component was intended for another recipient (frequently due to errors in patient identification at the time of collection of the pre-transfusion sample, or at the time of bedside administration), or did not meet the patient's special needs (such as a patient with a red cell antibody who did not receive the required antigen-negative unit). Human and system factors, such as lack of awareness or training, working environment, interruptions and inadequate communications between clinical teams, or between the clinical teams and the transfusion laboratory, are very important contributors to these events. Investigation of transfusion reactions, incidents and events at the hospital level is essential to identify clinical consequences, contributing factors and to develop and implement plans to prevent recurrence. Reportable incidents should be notified to the haemovigilance programme. Transfusion safety officers, transfusion nurses and similar roles have been introduced in many countries and they play important roles in haemovigilance, especially at the hospital level. Adequate medical and transfusion laboratory support for hospital haemovigilance activities is also essential for success. Hospital transfusion committees should oversee haemovigilance activities and reporting, and should ensure that hospital senior management is aware of and responds to serious reactions and events, especially where systems issues are identified to be contributory. At an international level, ISBT's Working Party on Haemovigilance brings together ISBT members with an interest in haemovigilance. ISBT works closely with IHN, an international collaboration of regional or national haemovigilance programmes, and other partners. IHN operates the ISTARE database for international data sharing and benchmarking. Haemovigilance reporting can identify priority areas for action (either where the events have serious clinical consequences, and/or occur frequently) and can help identify and monitor the implementation of solutions. An important feature of haemovigilance programs is the sharing of experiences and results. Haemovigilance reports can both provide valuable feedback to clinical teams and hospitals locally, as well as share experiences nationally and internationally to improve patient outcomes.

Wiersum-Osselton JC TRIP National hemo-and biovigilance office, The Hague, The Netherlands

Background: Haemovigilance systems capture data on adverse reactions and infections in recipients of blood transfusions as well as on errors and incidents in the transfusion chain. The objective is to analyse them and make recommendations for improving transfusion safety. Many haemovigilance systems also collect data on complications in blood donors with a view to monitoring and improving blood donor safety. Standardised definitions are necessary for classifying and comparing data in all these domains and at all levels. Method: Since 2004, at international meetings of blood transfusion professionals, members the International Haemovigilance Network (IHN) and the haemovigilance working party of the International Society for Blood Transfusion (ISBT) have collaborated in developing and validating definitions for non-infectious transfusion complications, errors and incidents in the transfusion chain as well as adverse reactions in blood donors. From 2012 contacts with other groups including the WHO have been put in place to ensure wide consultation as well as awareness and use of the definitions. Results: Standardised definitions have been published for recipient adverse reactions, for complications of blood donation and for a limited number of types of incident in the transfusion chain. The ISBT haemovigilance working party and IHN are committed to ensuring that the definitions remain up-to-date and that revisions and improvements are conducted with wide consultation of professionals in relevant organisations worldwide. The haemovigilance working party and working party on transfusion-transmitted infections are collaborating on the development of definitions and criteria for assessing suspected transfusion-transmitted infections. Conclusion: Internationally agreed definitions are available for registration and surveillance of complications of blood donation and most types of adverse reaction in patients receiving blood transfusions. For errors and incidents in the transfusion chain, further work is necessary to improve comparability of data between hemovigilance systems.

1D-H7-03

Distler PB and Ashford P

Critical to patient safety is the capability of rapidly tracing a medical product of human origin (MPHO) from donor to recipient and vice versa. Traceability requires that each product be uniquely identified in order to provide a clear, unambiguous path. Historically, uniqueness was defined only in the context of a single organization. For example, a blood product identifier was unique only to the blood bank that assigned it. Because some medical products of human origin (MPHO), especially cells and tissues, are frequently distributed across international borders, it is becoming increasingly important that identifiers of MPHO need to be unique not only within an organization, but globally as well. In 2010, the World Health Assembly urged member states 'to encourage the implementation of globally consistent coding systems for human cells, tissues, and organs as such in order to facilitate national and international traceability of materials of human origin for transplantation.' More recently WHO has recognized the need for common strategies for global governance of all MHPO, including the global use of ISBT 128, to ensure unique identification, optimal traceability, and interoperability between countries and across all MPHO for both routine and emergency use. This requires a globally consistent coding system that can provide: A mechanism to allow distinct items to be uniquely identified and consistently characterized to all participants within the system, The means to allocate identifiers in a manner that avoids duplication, and The information infrastructure on which effective traceability can be built. ISBT 128 is an international terminology, coding, and labelling system that supports the assignment of unique identifiers to support global traceability of MPHO. It is currently in use by many blood banks, tissue banks, and cellular therapy facilities around the world and the WHO Global Forum on Blood Safety has recognized promotion of the use of ISBT 128 as a priority for action in improving quality management and haemovigilance.

1D-H8-01

The University of Tokyo, Tokyo, Japan Antibodies directed to human platelet antigens (HPA) play important roles in the pathogenesis of neonatal alloimmune thrombocytopenia (NAIT), platelet transfusion refractoriness (PTR) and post-transfusion purpura (PTP). Presently, six HPA biallelic systems, namely HPA-1 to -5 and -15, which are involved in immune mediated thrombocytopenia, are characterized. There are important ethnic differences in the frequency distribution of these HPA systems, the incompatibility of the HPA-1 system being the mostly involved in thrombocytopenic conditions in Caucasian, whereas in Japanese, the HPA-4 system is the mostly involved. The frequency distribution of HPA systems reported in other parts of Asia seems to be different from Caucasian as well as Japanese, especially related to HPA-1 and -4, respectively. In addition to HPA, antibodies to human leukocyte antigen (HLA), blood group ABO, and human neutrophil antigens (HNA) have also been shown to be involved in immune mediated thrombocytopenia. In fact, the majority of the cases of PTR are dependent on anti-HLA antibodies, and anti-HPA antibodies comprise only a small proportion. The identification of the causative antibody is very important for the implementation of preventive/therapeutic measures for PTR, such as the selection of HLA-and/or HPA-compatible platelets. On the other hand, the involvement of anti-HLA antibodies in the pathogenesis of NAIT is questioned, but cases in which the causative antibody cannot be determined still remain relatively high. Thus, for the implementation of preventive and therapeutic measures for the immune mediated thrombocytopenia, the detection and identification of the causative antibody is essential. The standard methods applied varies among the regions, the monoclonal antibody-specific immobilization of platelet antigens (MAIPA) and the platelet immunofluorescence test (PFIT) being the preferred methods in the US and Europe, whereas in Japan, the mixed-passive hemagglutination is the most applied one. Neither of the methods alone, however, is able to detect all the clinically significant antibodies, thus, improvement of the available methods as well as the development of new technologies is required. Considering the ethnical differences of the HPA frequency distribution, we considered important to develop the research of this field also in Asia, and for this purpose, the ISBT Platelet Immunobiology Working Party, Asia Regional (ISBT PIWP-AR) was launched in 2010, during the XXXIst International Congress of the ISBT in Berlin, which aims the sharing of knowledge and improvement of technology in Asia. A training course on platelet immunology methods and genotyping was provided in Tokyo in 2010, and the first workshop of the PIWP-AR was organized in Taipei in 2011. In May 2013, the second training course on platelet immunology methods and genotyping was organized in Guangzhou, China, and the 2nd workshop of the PIWP-AR is going to be held in Kuala Lumpur, Malaysia, during the 24th Regional Congress of the ISBT. The presently available methods for the antigen/antibody testing, the problems related with antibody detection, and the activities of the Platelet Working Party will be presented.

Nanning Institute of Transfusion Medicine, Nanning, China Background: Immunization against human platelet antigens (HPA) is associated with a number of clinical syndromes, including neonatal alloimmune thrombocytopenia (NAIT), platelet transfusion refractoriness (PTR), post-transfusion purpura (PTP), and other platelet immune disorders. The detection and identification of the clinical relevant platelet antibodies are important for the diagnosis and management of the affected patients with immune thrombocytopenia. Aims: The aims of this study is to investigate the characteristic of the detection of clinical relevant platelet antibodies in the Asian population, and to evaluate the ability for the detection and identification of platelet antibodies in the platelet immunology laboratories in Asian countries.

Methods: Total of 378 cases that were diagnosed and studied as NAITP (70), PTR (305) and PTP (3) in Asian platelet immunology laboratories were reviewed. Of the 378 cases, 167 were Japanese in Japan, 142 were Chinese in China, 30 were in India, 24 were Chinese in Taiwan, China, 5 were in South Korea, 4 were in Thailand, 3 were in Kuwait, and 1 case each for Oman, Lebanese and Palestinian. The specificities of platelet antibodies in these cases were investigated and compared with the data from western country's laboratories. The methodology of detection and identification of antiplatelet antibodies in Asian labs were also reviewed. Results: Among 378 cases, the immune thrombocytopenia associated antiplatelet antibodies were two cases of anti-HPA-1(in Kuwait), 2 of anti-HPA-2 (1 in China and 1 in Japan), 5 of anti-HPA-3 (three in Japan, one in China and one in Taiwan, China), 5 of anti-HPA-4 (all in Japan), 4 of anti-HPA-5 (1 in China and 3 in Japan), 1 of anti-HPA-7new(antiHit a )(in Japan), 1 of anti-HPA-15 (in Japan), 2 of anti-HPA-21bw (in Japan), 309 of anti-HLA(101 in China, 147 in Japan, 5 in Korea,3 in Thailand, 23 in Taiwan, China and 30 in India), 1 of anti-A (in Japan) as well as 15 cases of anti-CD36(Nak a ) isoantibody (eight in China, three in Japan and one case each in Thailand, Oman, Lebanese and Palestinian). Thirty one cases of antibodies could not find the specificities (30 in China and 1 in Kuwait). The methods of detection and identification of antiplatelet antibody, such as monoclonal antibody immobilization of platelet antigens (MAIPA), mixed passive hemagglutination (MPHA) assay, platelet immunofluorescence test (PIFT), modified antigen capture ELISA (MACE), and solid phase red cell adherence (SPAA) have been used in Asian laboratories Summary/conclusions: Platelet alloantibodies are found with variable frequencies in different ethnic groups in Asian population. Anti-HPA-4 is mainly found in Japanese individuals, while anti-CD36 (Nak a ) isoantibody that occurred in CD36 type I deficient individuals is most frequent found in Asian population especially in Chinese population. Only two cases of anti-HPA-1 antibodies were found in Asian population (all in Kuwait), while anti-HPA-1 is the most frequent antibody associated with severe complications in Caucasian populations. However, Anti-CD36 isoantibody is of a risk factor of immune thrombocytopenia in Asian population, as the incidence of CD36 deficiency is 3-11%. The human platelet antigens (HPA) are a group of polymorphic antigens, expressed relatively specific on platelets, capable of eliciting an immunological response with development of alloantibodies. HPA directed alloantibodies have been implicated in neonatal alloimmune thrombocytopenia (NAIT), post-transfusion purpura and refractoriness to platelet transfusions. Twenty-seven HPA are recognized, of which antibodies to both the given alloantigen and the antithetical alloantigen has been reported for HPA-1 to 5 and HPA-15. The remaining HPA are designated with a 'w' as an alloantibody to the antithetical antigen has yet to be reported. Most HPA polymorphisms are a result of a mis-sense single nucleotide alteration and are readily detectable using standard molecular typing methods. DNA based population wide genotyping have revealed considerable variation in HPA allele frequencies among different ethnic groups. The 'b' forms of HPA-1, -2, -3, and -5 are common among Caucasians while HPA-4b is extremely rare. In the Chinese however, HPA-1b is extremely rare while uncommon in Malays. HPA-4b and HPA-21bw meanwhile are more commonly seen among Asians compared to Caucasians. Consequent to this, alloanti-HPA-4b is the most common cause for NAIT in the Asian population as compared to alloanti-HPA-1a among Caucasians. Several cases of NAIT due to anti-HPA-21bw have also been reported in Asia. In contrast, NAIT due to anti-HPA-6b is rare despite the alloantigen being more common among Asians. Although platelet transfusion refractoriness is more commonly associated with HLA antibodies, anti-HPA antibodies have been implicated in some cases. Management of NAIT and platelet transfusion refractoriness include the supply of antigen negative platelet units. A platelet donor registry with a critical mass of HLA and HPA typed blood donors is therefore necessary for effective management of these conditions. Ready availability of low-cost high-throughput SNP genotyping platforms allow for establishment of large HPA genotyped donor pools. Knowledge of HPA genotype prevalence in the local population as well as its implications on NAIT and platelet refractoriness is however crucial before deciding on donor screening strategies, Careful considerations would also need to be made with regards to the cost-effectiveness of such ventures in light of alternative management strategies and local incidence rates of NAIT.

Clinical -Improving Patient Outcomes 2A-S01-01 SETTING UP A PATIENT BLOOD MANAGEMENT PROGRAMME Wood E 1 , Engelbrecht S 1,2 and Robinson K 2 1 Transfusion Research Unit, Monash University, Melbourne, Australia 2 Australian Red Cross Blood Service, Adelaide, Australia Patient blood management (PBM) aims to minimise unnecessary transfusions, and also to ensure that if transfusion is required it is managed appropriatelyby individualising care so that patients receive what they need when they need it. PBM is comprehensive and patient-centred, with active participation by patients and a multidisciplinary approach from the hospital team to achieving these aims. 'Three pillars' of PBM have been suggested, to optimise a patient's red cell mass, reduce bleeding and improve tolerance of anaemia. In the perioperative setting, important elements of PBM include attention to medical, surgical and anaesthetic interventions and techniques to improve haemostasis and reduce blood loss. Where significant intraoperative blood loss is anticipated, use of cell salvage techniques can be very valuable. PBM concepts also apply outside the perioperative setting, and the broad principles can be applied to a wide range of clinical settings, including obstetrics, trauma, critical care and haematology/oncology and other medical settings (e.g. gastroenterology). An effective hospital PBM programme requires planning and communication, with a stepby-step approach to implementation, identifying priority areas for action, engagement, education and training of staff, and on-going monitoring against plans to demonstrate progress and identify areas for improvement. Feedback to staff on progress provides a sense of achievement and helps engagement. Adequate resources are required, including from medical, nursing and laboratory staff from a range of disciplines who have important contributions to make in clinical practice, education and training, and audit and review. Minimisation of unnecessary transfusions saves money for hospitals and the community, and other resources such as staff time, and therefore offsets the costs of establishing and maintaining a PBM programme. Effective implementation requires change at individual and organizational levels, and therefore support of hospital executive management, local health authorities and the blood supplier are also very valuable. Oversight of the program can be by the hospital transfusion committee or a PBM programme committee, but the particular structure and governance arrangements should be developed to suit local needs. General practitioners can play key roles in preparing patients for surgery by identification and management of anaemia, as well as other PBM activities. Ultimately an effective PBM programme can optimise care and outcomes for patients, make better use of limited and precious blood supplies, and reduce risks and costs. Trauma is a leading cause of death around the world, with haemorrhage accounting for more than a third of the preventable mortality, with the majority of these deaths occurring within the initial 24 h. Massive blood transfusion is generally defined as the replacement bytransfusion of more than 10 units of red cells over 24 h. Massive transfusionprotocols (MTPs) have evolved over the past decade and are especially importantin facilitating the early delivery of copious amounts of blood products topatients who have major injuries and severe haemorrhage. Various studies havealso demonstrated that with MTPS, there is a more efficient use and lesswastage of blood products. However, for trauma patients, stopping thehaemorrhage and resuscitating the patient does not only involve the expedientdelivery of red cells to the injured patient. MTPs have also emphasized theneed for a more balanced ratio of delivery of blood products, includingplatelets and plasma, to patients who sustain massive blood loss and havedeveloped acute traumatic coagulopathy (ATC). Often times, MTPs also stress theimportance of the consideration of use of haemostatic adjuncts, such astranexamic acid, activated factor VII, level one transfusion units and the useof blood warmers to reverse the potential effects of hypothermia with sustainedtransfusions of large amounts of blood products. Ultimately, in tandem withdamage control resuscitation, which allows permissive hypotension whilstsecuring haemostasis, MTPs have been shown to also improve survival of theseseverely injured patients. A more recent paper describes the development of amassive haemorrhage protocol to aid in the identification of patients who wouldbenefit from the MTP and this may be the next step in the evolution of a workprocess by which resuscitation for severely injured patients may be optimized. Background: Rh blood group antigens are highly immunogenic and transfusion of Rh D positive blood in Rh D negative recipients is avoided. Platelets do not express Rh antigens, however they may contain significant amount of contaminating red cells to illicit an immune response in the patient. Due to limited shelf life of platelets and inventory issues, Rh D positive platelets which are not visibly contaminated with red blood cells maybe transfused to Rh D negative patients including children and females of child bearing age. There has been increased focus on whether Rh immunoglobulin should be routinely administered after such transfusions. In Saudi Arabia no clear guidelines exist on the administration of Rh immunoglobulin after D positive transfusions in D negative patients. Aim: The purpose of this study was to determine whether the transfusion of Rh D positive platelets to patients who are Rh D negative, results in D alloimmunization and whether Rh immunoglobulin should be routinely administered in such patients. Methods: Eligibility criteria for inclusion in the study included the following: transfusion of Rh D positive platelets, no anti D detectable before transfusion, no previous exposure to Rh D positive blood components, and results of follow-up testing of anti-D in patients serum available. The patients blood group and antibody screening was done using LISS-IAT gel technology (DiaMed). Results: One hundred Rh D negative patients who received Rh D positive blood components were identified. Out of this 63 (63%) patients received Rh D positive platelet transfusions. In 47 (74%) patients out of this, the results for post transfusion antibody screening were available. The mean age of the patients was 46.5 years and included 30 males and 17 females. Average number of Rh D positive platelets transfused per patient was 11.3 units and total number of platelet units transfused was 523. Anti D was detectable in 4 (8.5%) patients post transfusion and included one male and three female patients. Of the female patients one was a 3 year old child who received 50 units of random donor platelets and second a 21 year old women who presented in the emergency department as a case of trauma. The third female was 54 year old post-menopausal woman. Conclusion: We conclude that the chances of developing D alloimmunization after receiving Rh D positive platelets is generally low. However keeping in view the antenatal complications which can arise in the future in females due to this alloimmunization, it is highly recommended that Rh immunoglobulin be administered to all Rh D negative women in the reproductive age group and female children who receive Rh D positive platelets. Background: Hemovigilance is a quality process which takes into account all the activities of a blood transfusion chain with the aim to improve quality and enhance safety of blood transfusion. We have implemented a transfusion feedback reporting mechanism in our hospital as a part of hemovigilance. The current study aims to collect and analyze this data to improve our transfusion system. Aim: To systematically analyze the transfusion process from issue of blood components to completion of the transfusion Material and methods: The transfusion feedback forms received back at the transfusion medicine department during a 3 months period were systematically analyzed for documentation related to patient identification, product identification, documentation, completeness, etc. Results were analyzed statistically for specific co-relation with patient's location, time of transfusion and type of component transfused. Results: Of 3474 blood components were issued during the study period. Transfusion feedback form were received for 2000 (57.5%) blood components, as follows: PRBC-800 (40%), platelets-651 (32.5%), FFP -441 (20.7%). Patient identification number /wristband check was not done in 25 (1.25%) cases. Pre-transfusion verification of blood group, patients name and patient's identification number was done in 1963 (98.15%) cases. Cross checking of component unit with request form was missed in 16 (0.8) cases. Pre-transfusion and post-transfusion monitoring of blood pressure was documented in 698 (34.9%) episodes, monitoring of pulse in 696 (34.8%) episodes and patient's temperature was monitored in 681 (34%) episodes. Signature of nurse was missing in 86 (4.3%) and that of medical officer in 11 (05%) of the form. Adverse transfusion reaction was documented in 1/2000 forms, whereas the transfusion reactions notified at the blood bank during the same period were 2. Of 553 (27.65%) transfusions were carried out during non routine work hours. The mean time between the issue of the components and start of transfusion was 28 min for RBC components, 21 min for platelets and 16 min for FFP. Patient identification and monitoring and product identification related non-compliances significantly correlated with out of routine transfusions (P = 0.002). Conclusion: Though overall compliance with established procedure for transfusion was evident, activities related to unit identification, patient monitoring and identification and reporting of adverse reactions were not well documented. This emphasizes the need for ongoing training of nursing staff and medical doctors in safe blood administration practices.

Introduction and method: Matrix-Assisted Laser Desorption/Ionisation, Time-Of-Flight Mass Spectrometry (MALDI-TOF MS) is an ideal tool for high-throughput blood group genotyping. Using this technique, this Swiss (BTS Zurich) -German (Sequenom GmbH, Hamburg) cooperation aims to genotype Swiss blood donors for blood groups Rh, Kell, Kidd, Duffy, MNSs (n = 6000), HPA and HNA (n = 3000) and high frequency antigens (HFA, n = 36,000) within 3 years. Specificities are grouped into single multiplex reactions (MPX, n = 10) with up to 17 SNPs tested simultaneously in one tube. Results: Using the KEL-JK-FY MPX, more than 4000 donor DNAs have been tested and compared to serological pre-values. Concordance between geno-and phenotypes reached 100% for K/k, 99.98 for Kp a 99.93% for Jkand 99.23% for Fy a/b/x/0 . Only one discrepancy each for Kp, Jk and Fy could be attributed to genetics, the others were erroneous serotypes revealed by genotyping. Genetic discrepancies were three new variants: KEL*02.03(R700G)nulla Kp a relative, JK*B(mutation n.d.) and FY*B (G261R)null. Serology for Js a/b of some few KEL*02.06 positives confirmed validity of genotyping. Numbers of detected known KEL*mod and null, JK*null and FY*null (GATA) alleles were 3, 2 and 51, respectively. Call failures (no result) were observed in less than 2% of all MPXs. Genotyping for RHD, RHCE (5 MPX), GYPA and B (MNSs, 1 MPX) on more than 4000 samples, delivered results with discrepancy rates for MNSs comparable to above, and better rates for RHDCE. Call failure were at approximately 2% again. Reproducibility, robustness and analytical accuracy of the technique allowed measurement of gene copy numbers with relevance for RHD zygosity estimation and detection of the GYPB deletion in U negatives. RHD category, partial, weak, DEL and null alleles and the genetic correspondents of Vw, Mg, Mi(a), He, and Uvar were observed. Genotyping for HPA and HNA (1 MPX) showed expected results among 2300 samples with the exception of HNA-1a, b and c, where frequent duplications and deletions of FCGRIIIB pose difficulties for all genotyping approaches in general. In HFA ('RARE') genotyping (2 MPX), currently, more than 13,000 blood donors were analyzed, and delivered: 29 KK, 2 Kp(a+bÀ), 48 Js(a+bÀ), 41 KEL11+KEL17+, 20 Lu(a+bÀ), 3 LU14+LU08À, 52 Yt(aÀb+), 17 Co(aÀb+), 11 Kn (aÀb+), 98 LW(a+b+), and >10 others. Specificities for Vel negativity and Scianna have been included into HFA typing, recently. Conclusion: Analysis for Kell, Kidd and Duffy showed that genotyping worked qualitatively better and to costs comparable to serology. Consequently, genotyping Kell, Kidd and Duffy instead of routinely performing a second round of serotyping as mandatory for donors in Switzerland, is recommended. Ahead of comparable suggestions with regard to Rh and MNSs, a more detailed statistical analysis of existing raw data is needed. However, genetically identified donors with rare blood phenotypes, e.g. such as Yt(aÀb+), are already selected for respective transfusions and are a strong indicator for the value of the presented project. The serological data suggest that retention of the 208-210 TCC (51S in glycophorin Bs) codon from the GYPB pseudoexon, prior to the gene conversion insertion of GYPA sequence and coding for serine in the hybrid glycophorin, is the basis of 'Anek-like' activity for both hybrid glycophorins. It should be considered that these antisera react with a new Kipp-related MNS system antigen. Genetic studies revealed the same crossover for GP.Kipp and GP.Yak that have been independently reported in conference abstracts, suggesting that these are in fact the same hybrid glycophorin. Background: With the increasing knowledge of the genetics of blood group antigens, molecular immunohaematology is gaining popularity. Molecular immunohaematology refers to the use of genotyping to encode red blood cell antigens, representing an indirect method used to predict one's phenotype. There are certain advantages of genotyping, namely, typing of red blood cells with autoantibodies, prenatal testing and patients with multiple transfusions. Molecular methods are also useful in phenotyping donors as it enables the prediction of numerous phenotypes in one single test. However, there are several misgivings about the cost of molecular methods used to genotype antigens. Aim: To evaluate and compare the cost of conventional serological phenotyping and molecular genotyping. Methods: A batch of 30 donor samples was typed using both serological and molecular methods. The test kit used for molecular methods, from Gen-Probe, included the typing for the following antigens -Kell (K, k, Kpa, Kpb, Kpc, Jsa and Jsb), Kidd -(Jka, Jkb, Jk), Duffy (Fya, Fyb, Fyx, FyGATAsil) , MNS (M, N, S, s, S-s-Uvar), Rh (C, c, E, e) and Dombrock (Doa, Dob). Negatives that are obtained using this method were confirmed using serology. Serological typing was performed with available antisera according to the various manufacturers' instructions. This includes Kell (K, k), Kidd (Jka, Jkb), Duffy (Fya, Fyb), MNS (M, N, S, s) and Rh (C, c, E, e). The cost for the different tests were tabulated and compared. The cost includes labour, consumables and equipments. Results: The results show that molecular method of typing red blood cells is more expensive than the traditional serological method. The cost of consumables is comparable for both methods. The consumables make up about 80% of the total cost for serological methods, and about 82% for molecular methods. The cost of labour is about 9% for serological methods and <1% for molecular. Equipment cost contributes to <1% of the cost using serological methods and about 14% using molecular methods. Conclusion: Molecular methods may seem more expensive, about two times the cost of serology but results are obtained faster and are less labour intensive which could prove to be an advantage when phenotyping samples in large quantities, especially for donor phenotyping. Molecular immunohaematology is a relatively new process, thus kits for these methods are expensive at the moment. As development and adoption of genotyping progresses, consumables and equipment costs are expected to become more affordable. Serological methods do have their limitations even for patient testing, especially for patients with autoantibodies and patients who have had multiple transfusions. Molecular methods may serve useful in overcoming these limitations. Background: Transfusion dependant patients often develop multiple antibodies to red cell antigens on exposure to red cells and require antigen-negative red blood cells for further transfusions. Finding suitable red cell units for such patients is often difficult and time consuming, requiring phenotyping of large numbers of red cell units in inventory. The increasing cost and scarcity of anti-sera also makes this an expensive exercise. Aim: In order to improve provision of phenotype-matched blood for such patients, we studied the feasibility of large-scale SNP-based genotyping of common blood groups for establishment of an antigen-negative red blood cell inventory. Methods: Genomic DNA was extracted from donor blood samples using an automated platform. Samples were subjected to SNP-typing for common local polymorphisms of RHCE (CcEe), FY (Fy a /Fy b ), JK (Jk a /Jk b ), MNS (S/s) and CO (Co a /Co b ) using TaqMan â SNP genotyping assays in 384-well plates at 5 ll final reaction volume, on a LightCy-clerII 480 real-time instrument. Identification of the Cc polymorphism was by probes targeted to the 48C>G and 307T>C of the RHCE allele while probes targeted to 676C>G was utilised for Ee detection. For the remaining alleles, probes were designed only to detect the most common mutation for the polymorphism within an East-Asian population. Results were analysed and integrated into the blood donor software system. Results: The 48C>G probe designed for identification of C was unsuccessful with poor discrimination between genotype calls. The remaining probes showed satisfactory discrimination between genotypes, with 462 of the 505 (91%) samples analysed, fully genotyped for the five alleles studied. Relatively rare genotypes were successfully identified using this strategy: ccEE (15/505, 3.0%), FYA-/FYB+ (19/505, 3.8%), SS (5/505, 1.0%). The CO2 allele responsible for Co b was identified in the heterozygous state in four of 494 evaluable samples giving an allele frequency of 0.4% in our population. The estimated reagent and consumables cost for sample DNA preparation and SNP testing was USD12.00 compared to USD27.15 for phenotyping using commercial anti-sera. We did not factor in the cost of capital acquisition of instruments for genotyping as we used facilities which were common for other molecular tests in the hospital. Conclusions: Results of this study indicate that SNP genotyping would be a costeffective strategy for screening and establishment of an antigen-negative red cell inventory and genotyped whole blood donor pool. The cost of genotype screening was effectively reduced by use of small final reaction volume and extensive use of automation. In addition, genotyping allowed us to identify local prevalence of blood groups which were previously unidentifiable due to lack of commercially available anti-sera. Background: Over the past 20 years the molecular, biochemical and serological basis of almost all blood groups have been determined, highlighting the different frequencies of antigen, related to different ethnic groups. Since October 2012, in our Transfusion Center (ASL Caserta) in order to have a blood bank that ensures the different transfusion needs, extended erythrocyte typing is practiced on periodic donors with specific features such as age, group and Rh phenotype. Aims: The aim of our study was to test the validity of the molecular method of erthrocyte phenotype typing with the serological technique by comparing the results obtained by each procedure. We also compared each method in regards to reliability, ease of use and reproducibility of results. Methods: We selected 250 donors aged <45 years old, group O and A, Rh homozygous phenotype. Samples from each patient were tested by serological typing in solid phase (Capture R Immucor) and then DNA was extracted and each sample was tested by molecular typing in microarray (BioArray Solutions Immucor) Results: See Table 1 . Table 1 :

Summary/Conclusions: The results show that the frequencies of more immunogenic antigens (K, FyA, JkA) reflect the specific and ethnic frequencies of the donors. We emphasise the absence of donors having an antigenic structure that is defined as rare (that is present with a frequency of 1:1000 according to American Rare Donor Program (ARDP), Council of Europe, International Donor Panel (IDP), International Society of Blood Transfusion (ISBT), Council of Europe, Japanese Red Cross). We only found one case of a donor expressing weak Fyb which is due to mutation in Fy 265C> T. The results were confirmed in 99.6% of cases by serological technique. However for the phenotype FyB Weak, the result was discordant in serology, where the result was fyb-. In conclusion we can confirm the validity and the need to use both techniques in order to obtain a reliable and reproducible result. The molecular technique is able to identify mutations in particular genes, especially in specificity whilst the serological technique excels in sensitivity and speed but fails to confirm the data obtained. Background: Pathogen inactivation of blood components promises a new layer of transfusion safety, enhancing existing strategies and providing proactive protection against emerging infectious risks. Processes for plasma and platelets are well established in many blood centers and those for red cells and whole blood are in development. Clinical acceptance of new technologies depends on the demonstration of product safety, a minimal effect on product efficacy both in vitro and in vivo, and the range and degree of pathogens inactivated. Aims: To review the major processes of pathogen inactivation of plasma and cellular blood components with a focus on the range and degree of inactivation of relevant pathogens, especially with regards to platelet pathogen inactivation. Methods: This review will use recent reports and unpublished data to describe our current understanding of the potential efficacy of pathogen inactivation in improving transfusion safety. Results: The major indication for platelet pathogen inactivation is bacterial contamination, a persistent problem despite multiple innovations to minimize and detect contamination. Pathogen inactivation processes need to cover a wide range of possible bacterial concentrations and species. There have been few published reports using the current commercially available systems: Optimized in vitro testing documents the ability of the Terumo BCT Mirasol TM , Cerus Intercept TM and Macopharma THERAFLEX TM UV systems to effect a 10 2 ->10 6 log reduction of various bacterial species. Most systems are less effective at inactivating bacterial spores, a particular problem as Bacillus spp. is common platelet contaminant. Testing the level of pathogen inactivation under clinical conditions at very low and high concentrations of bacteria reveals further weaknesses in pathogen inactivation strategies. Conclusions: Clinical trials of pathogen inactivated platelets have focused on the safety and clinical efficacy of pathogen inactivated treated platelets, but little has been reported on the efficacy of pathogen inactivation to reduce the risk of infection transmission. Blood centers should focus on this aspect of efficacy as they decide whether to implement, and to favor those commercially available systems that best meets the clinical need for pathogen protection. for pathogen inactivation (PI) using amotosalen and UVA light induces the formation of covalent adducts and interstrand crosslinks between amotosalen and nucleic acids, thus preventing DNA replication and RNA translation. PI technology has been adopted into routine use in some European countries and is under FDA review for licensure in the US. Current documentation of PI efficacy relies on illuminator sensors that measure the UVA light dose delivered. An indirect methodology is utilized for the validation and QC of the process in some centers that measures the amount of amotosalen consumed during illumination in platelets and before removal with the Compound Removal Device. The% amotosalen remaining is a direct measurement of the UVA light delivered and photochemical conversion of amotosalen. However, a functional QC method that measures a direct target within the treated blood product has not been introduced into clinical use. Residual leukocytes, platelets and potentially plasma contain mitochondrial DNA (mtDNA) which is a collateral target of the PI process.

Aims: The goal of this study was to quantify the impact of INTERCEPT treatment on platelet-derived mtDNA by real-time PCR. Methods: To evaluate the feasibility of detecting PI-induced mtDNA modifications by real-time PCR, we spiked purified human leukocyte DNA into human plasma, 35% plasma/65% InterSol, or PBS. Each sample (3.6 ml) was treated with 150 lM amotosalen and 3 J/cm 2 UVA (N = 2). Control samples were either untreated or treated in the absence of amotosalen or UVA. DNA was extracted from each sample (0.2 ml) in duplicate and assessed by measuring the inhibition of real-time PCR amplification in duplicate wells using mtDNA-specific primers and SYBR Greenbased detection. Amplification of sequences ranging in size from 73 to 1065 bp was evaluated over 45 cycles of amplification. Subsequent to the initial feasibility tests, a pilot validation was performed by treatment of platelets in 35% plasma/65% Inter-Sol (30 ml). Six different platelet units were tested as outlined above for inhibition of amplification of endogenous mtDNA sequences. Results: Treatment of purified DNA with amotosalen plus UVA resulted in 1.3 log to >6.0 log inhibition of PCR amplification (results shown in Table) . The extent of PCR reduction roughly correlated with the size of the amplicon, as well as with the type of diluent in the following order: PBS > 35% plasma > 100% plasma. Exposure of platelets to amotosalen and UVA showed an average of 2.5 log to 3.6 log reduction in PCR signal, with increasing inhibition observed for larger amplicons. In all cases, no PCR inhibition was observed in the absence of amotosalen and/or UVA. Conclusions: A quantitative real-time PCR assay specific for mtDNA is capable of documenting PI-induced collateral nucleic acid modification in platelets. Based on this work, this assay can be developed further for use as a quality control method for PI efficacy. Background and aims: Pathogen reduction technology (PRT) provides a proactive approach to improving transfusion safety for platelet concentrates (PCs). However, PRT treatment is known to exacerbate the effects of the platelet storage lesion, leading to increased platelet activation and secretion of immunomodulatory factors. Little is known regarding how PRT-treated platelets may affect the cells of the recipient's immune system once transfused; therefore the aim of this study was to examine the cytokine responses of a recipient's inflammatory cells after exposure to PRT-treated platelets using an in vitro whole blood model of transfusion. Methods: Two ABO/RhD matched buffy coat derived PCs were pooled and split to form matched pairs on day-1 post-collection (n = 11). One unit was treated with the Mirasol PRT TM system (Terumo BCT), while the other unit remained as an untreated control. All units were stored at 22°C with agitation and samples were taken on day 2 and 7 post-collection for 'in vitro transfusion' experiments. To represent a transfusion in vitro, 10% v/v platelets were incubated with ABO/RhD-matched fresh whole blood, with or without lipopolysaccharide (LPS; 1 mg/ml) for 6 h at 37°C/5% CO 2 . Protein secretion was inhibited using brefeldin (2 lg/ml) to allow detection of intra-cellular cytokine production in monocytes (CD45 + /CD14 + ) and neutrophils (CD45 + / CD16 + ), using multi-colour flow cytometry. The fold change of cytokine production was calculated by comparison to a 'no-transfusion control' (whole blood without addition of platelets). Data was analysed using a one way ANOVA with post-hoc tests for pair-wise comparisons. Results: In the absence of LPS, both PRT-treated and untreated platelets stored for 7 days significantly increased monocyte MIP-1b expression (1.5-fold; P = 0.047), whereas exposure to day 2 platelets did not result in any significant differences in MIP-1b expression. As expected, LPS stimulation significantly increased monocyte production of both IL-12 (5.0-to 7.4-fold) and MIP-1b (1.8-to 2.4-fold). However, LPS-induced monocyte IL-12 production was significantly reduced by exposure to PRT-treated or untreated platelets stored for 2 days (PRT-treated: 3.0-fold, untreated: 2.5-fold; P < 0.0001) and 7 days (PRT-treated: 4-fold, untreated: 2.1-fold; P < 0.0001). Furthermore, IL-12 production was significantly lower following exposure to day 7 PRT-treated platelets compared to untreated platelets (P = 0.006); however there was no significant difference following exposure to day 2 platelets. LPS-induced MIP-1b production was not significantly differentfollowing exposure to either day 2 or day 7PRT-treated or untreated platelets. Exposure to platelets (untreated or PRT-treated) did not significantly modulate monocyte production of IP-10, MCP-1, MIP-1a, IL-1a, IL-1b, IL-6, IL-8, IL-10, or TNF-a. Co-culture of platelets and whole blood did not result in any significant changes to cytokine expression in neutrophils. Conclusion: Using an in vitro whole blood transfusion model, we have demonstrated that exposure to PRT-treated platelets stored for 7 days results in significant changes in the IL-12 production by monocytes. These changes may reflect the way PRT-treated platelets interact with immune cells upon transfusion. Therefore, the effect of stored PRT-treated platelets, especially in recipients with underlying inflammation, should be further examined.

Backgrounds: Hepatitis C virus (HCV) infection is one of the major causes of chronic hepatitic disease. HCV has six genotypes and more than 80 subtypes. The epidemiology of HCV subtypes vary with different geographic distribution. Understand the subtypes prevalent in certain area will help to understand the transmission modes and the spreading trend of HCV and thus help to make effective precautionary measures. HCV subtypes are also closely related with clinical therapeutic effect. It is important for guiding clinical therapy and prognosis and predicting the possible burden of HCV infection and treatment in the future. Aims: To investigate and compare the prevalence of HCV subtypes in clinical patients and blood donors in Guangdong China. Methods: Of 191 samples ofclinical patients and 222 samples of blood donors whose HCV RNA were positive were collected from Guangdong province. HCV NS5B gene was amplified by RT-nested PCR and then sequenced. HCV subtypes were assigned by constructing phylogenetic trees with MEGA5 software. Moreover, SPSS16.0 software was applied to compare the difference between these two groups. Results: Of 191 clinical patients, HCV genotype 1a, 1b, 2a, 3a,3b, 6a and 6n was 2 (1.05%), 127 (66.49%), 17 (8.90%), 5 (2.62%), 5 (2.62%), 34 (17.80%) and 1 (0.52%), respectively. Of 222 blood donors, HCV genotype 1a, 1b, 2a, 3a,3b, 6a and 6n was 1 (0.45%), 92 (41.44%), 1 (6.76%), 19 (8.56%), 11 (4.95%), 83 (37.39%) and 1 (0.45%), respectively. The proportion of HCV 1b was higher in clinical patients than in blood donors(v 2 = 25.866, P = 3.66E-07), while the proportion of 3a and 6a subtypes were higher in blood donors than in clinical patients(v 2 = 6.602, P = 0.010; v 2 = 19.398, P = 1.06E-05). One possible cause was the transmission modes varied with different HCV subtypes. HCV 1b is more related with blood transfusion while 3a and 6a are more relevant to intravenous drug abuse and sexual behavior. With the anti-HCV screen implemented from 1993, the risk of HCV infection by transfusion is diminishing. The other reason was the average time from HCV infection to serious pathological lesions is about 20 years and HCV 6a was transmitted into Guangdong later than 1b. Conclusions: In Guangdong province, HCV 1b and 6a were the predominant subtypes in clinical patients and blood donors. The proportion of HCV 1b, 3a and 6a subtypes were significantly different between clinical patients and blood donors. The reason may relate with the time of HCV transmission into Guangdong area and the HCV propagation modes. Blood safety and increased public health initiatives to reduce HCV infection from those in these high risk groups to the general population remain a priority.

Background: In Japan, we routinely evaluate the presence of transmission of HBV, HCV and HIV in all transfused patients at three months after the last transfusion. Although the sensitivity of detection of hepatitis B virus (HBV) in blood donation improved during recent years, transfusion transmitted HBV infection is left as a serious problem. The Japanese Society of Transfusion Medicine and Cellular Therapy (JSTMCT) conducts the nationwide questionnaire survey about the clinical blood transfusion activities, supported by Ministry of Health, Labour, and Welfare, every year. In this survey, we can collect detailed characteristics of patients, who showed a positive result of post-transfusion HBV-marker-test. Aims: The aim of this study is to elucidate the cause of HBV positive in transfused patients.

Materials and methods: Data concerning to transfused patients with positive HBVmarker were collected using results of the nationwide questionnaire survey in 2007-2011. In this questionnaire, if there is a patient showing a positive result of HBsAg and/or HBVDNA evaluated by post-transfusion-test, it is requested that detailed patient's characteristics, including a total amount of transfusion, disease (hematologic or non-hematologic), therapeutic methods (surgery, use of anticancer drugs, use of immunosuppressive drugs, use of molecular target drugs, blood stem cell transplantation), and results of HBV-marker-test prior to the first transfusion, should report to the JSTMCT office. A number of HBsAg and/or HBVDNA positive patients were 234 cases in 2007-2011. Among them, 19 patients were not eligible because of the absence of results of HBV-related markers. Finally, a total number of 215 patients (36, 37, 41, 43, 45 patients in 2007, 2008, 2009, 2010, 2011, respectively) were enrolled for the present study. Results: All the eligible patients showed positive results of HBsAg and/or HBVDNA in samples obtained from three months after the last transfusion. We classified the cause of these results into five categories according to results of HBV-markers tests prior to the first transfusion. (i) If a result of HBsAg and/or HBVDNA performed prior to transfusion is positive, a patient is categorized as the HBV carrier group. (ii) A patient showing both a negative result of HBsAg and positive results of anti-HBs and/or anti-HBc are categorized as the HBV past-infection group. (iii) If a patient shows no HBV-related marker prior to the first transfusion and patient's HBVDNA is identical to donor's HBVDNA, we categorized as the transfusion transmitted infections (TTI) group. (iv) If a patient does not show any HBV-related marker prior to the first transfusion and HBVDNA is not detected in donor's blood by single NAT, we categorized as the unknown cause group. Results were summarized in Table 1 .

Conclusion: Although the positive result of HBsAg and/or HBVDNA of transfused patients has been considered the sequel of blood transfusion, we showed that HBV reactivation was also an important cause of it. To distinguish HBV reactivation from transfusion transmitted infection, we have to perform HBV-marker-test prior to the first transfusion, or we should freeze pre-transfusion patient's serum.

Plenary Session: It's All About Red Cells 2B-PL1

The English dictionary provides several definitions for the word 'myth'. One definition is, 'A widely held but false belief'. This seems suitable for the purposes of this presentation. But who decides what is false? As we shall see in the course of this presentation, some 'myths' of blood groups may not be myths at all, and some established facts may indeed be myths. Perhaps a more scientific definition would be, 'A widely held but unproven belief'. ABO, the original and most important blood group in transfusion and transplantation medicine, has engendered many 'myths'. These have mostly arisen through associations between ABO groups and other characteristics such as personality, dis-ease, psychological traits, and ideal diet. Although many may indeed be myths, or even fabrications advanced for political reasons or financial gain, some are not. For example, the statistical associations between ABO type and thrombosis, where a biochemical basis involving clearance of von Willebrand factor from the blood by enzymatic cleavage appears to be affected by ABH glycosylation. In Rh, the first myth was that the human antibody, now called anti-D, was the same as the antibodies made by immunising rabbits with rhesus monkey red cells. Hence the name Rhesus, now Rh, for the blood group system. In the 1940s, early serological work with Rh antibodies led to two genetic theories, involving either one or three Rh genes. Both theories have now been rejected because molecular genetics revealed two Rh genes. But was the three-gene theory really wrong, when the boundaries of genes were not understood at the time? Since the 1960s it has been commonly understood that there are two types of variant D antigens: weak D and partial D. Policies for transfusing patients with these variants have often been based on this dichotomy. But is this a myth? The difficulty we have in defining the terms weak D and partial D suggests that it might be. It is always tempting to dismiss anything that we don't agree with as a myth. AS Wiener, one of the discoverers of the 'rhesus' antigen, wrote several papers on 'Blood group mythology', doing just that. Scientists should beware of falling into this trap. Perhaps 'myth' is a term best avoided in science.

FIVE NEW BLOOD GROUPS -WHAT NEXT?

The past 2 years has seen the discovery of five new blood groups. At the ISBT meeting in 2012, FORS, JR and LAN were ratified as blood group systems and since then, the molecular basis of the Vel blood group antigen has been elucidated, and the complement regulator protein, CD59 has been shown itself to be a blood group antigen. These last two discoveries will no doubt lead to their elevation to blood group systems. How has this happened? It turns out to be a mixture of old and new techniques. Rapid advances in molecular biology and in our understanding of the human genome have opened new fields of discovery within human blood groups. The development of comprehensive SNP arrays, exome sequencing and rapid sequencing techniques, e.g. Next-Generation sequencing, has provide us with tools for rapid discovery. Combining these with sophisticated algorithms for database mining has resulted in the identification of the molecular bases behind the hitherto unresolved, clinically relevant blood group antigens Jr a and Vel. However classic biochemistry and subsequent peptide and DNAsequencing still play an important role and lie behind the (simultaneous) discoveries of Jr a and Vel, but also of Lan and FORS. A rare CD59-deficient patient produced an alloantibody to a high-prevalence antigen that was shown to be targeted at the CD59 protein, which was confirmed by routine DNA-sequencing. The Jr a and Lan antigens were assigned to already well-investigated ABC-transporter proteins (ABCG2 and ABCB6 respectively) whose presence on the red blood cell (RBC) had not been established previously and for which the function on RBCs is still not known. FORS antigen was shown to result from the reactivation of the human pseudogene GBGT1. This enzyme builds the carbohydrate Forssman antigen on sheep and dog RBCs but is normally inactive in humans. A mutation that reactivated the enzyme explained the unusual A pae phenotype in two families. Vel was shown to be carried on a hitherto unknown protein on the RBC, SMIM1. The function of the protein remains unknown although the protein is highly conserved across all species, which is both intriguing and hints at a fundamental function. Absence of CD59 whose function in complement regulation is well-understood, resulted in production of an alloanti-CD59, demonstrating immunogenicity of this protein for the first time. These simultaneous discoveries have shown that regardless of the route of identification, assignation of orphan antigens to their blood group 'home' continues at a rate unparalleled since the 1990s. As the '-omics' fields identify new erythroid genes and proteins, and next generation sequencing permits rapid genome sequencing of individuals, we can anticipate that many more currently unassigned antigens will find their genetic and molecular home.

2C-S04-01

Teo D Blood Services Group, Health Sciences Authority, Singapore, Singapore An emerging infectious disease (EID) is defined as one that has appeared in a population for the first time, or that may have existed previously but is rapidly increasing in incidence or geographic range. In 1992, an Institute of Medicine report predicted continued emergence and re-emergence of microbial pathogens, facilitated by changes in human populations, environment and infectious agents. East and Southeast Asia, with 30% of global population, has a reputation as a hot spot for EID. Within the region, the forces of rapid social, economic and environmental change have resulted in factors such as urbanization, deforestation, agricultural intensification, rapid population growth and mobility which contribute to the increased exposure and efficient transmission of new pathogens. The emergence of severe acute respiratory syndrome (SARS) exactly 10 years ago has dramatically transformed individual and national awareness and capabilities for identifying and responding to regional EID threats. The re-emergence of highly pathogenic avian influenza A(H5N1) virus in 2004, isolation of novel bat-associated reoviruses in 2006, emergence of Artemisinin-resistant malaria and discovery of a tick-borne bunyavirus associated with fever and thrombocytopenia in 2009 are some examples of EID emerging within the region since SARS. At the time of writing, the situation involving human cases infected with avian influenza A(H7N9) virus is evolving, and there has been a recent report of human infection with avian influenza A(H6N1) virus as well. Additionally, there are imported EIDs such as influenza A(H1N1) virus, West Nile virus, and the present cause for concern in Middle East Respiratory Syndrome Coronavirus. Climate changes in recent years have also accelerated the increase in incidence and range of existing diseases such as dengue and chikungunya. 40% of the world's population is now at risk of dengue, with the majority living in the Asia-Pacific region. The scourge of dengue is sufficiently high in the region for the Association of Southeast Asian Nations (ASEAN) in 2011 to designate 15 June as ASEAN Dengue Day. Hepatitis E is another infection that is widespread in some parts of the region, and reports of silent infection in blood donors are cause for further study. The impact of EIDs on the blood supply may be direct through the potential for transmission through transfusion, the effect on blood donor attendance and eligibility and the effect on blood demand. Blood products such as hyper-immune plasma preparations may be useful treatment options in some EIDs. There is a need for constant surveillance and the capacity to identify, assess and manage EID risks to the blood supply. In recent years, the strengthening of regional and international partnerships and the availability of new diagnostic tools has improved our ability to respond to infectious threats. Nonetheless, the volatile and ever-changing nature of EIDs will remain a constant challenge to the vigilance and response capabilities of the transfusion medicine community. Summary: The residual transmission risk is relatively high in HBV followed by HCV and HIV-1. This finding is not new as Malaysia is a country of medium seroprevalence for HBV which ranges from 1.5% to 9.8% in the general population, but is relatively low in blood donor population (0.04%). The OBI NAT yield was higher than acute phase WP in HBV-NAT yield. These OBI positivity have shown inconsistent NAT results on repeat testing and also low viral loads ranging from <12 to 317 IU/ml. In contrast for HIV and HCV NAT yields, their viral loads were consistently high (34,220-424,310 cp/ml and 42,780-5,980 ,350 IU/ml respectively). Implementation of ID-NAT is probably the best option to improve blood safety especially for the detection of low viral load such as in OBI and sero-negative WP donation in Malaysia scenario. Blood centers reported to KCDC. Repository samples of these donors were tested for anti-HAV IgM/IgG and HAV-RNA. If any of these test result was positive, the recipients of the blood components generated from these donations were traced. Transfusion records of hospital were reviewed to identify recipients of blood suspected to be contaminated with HAV. Recipients were contacted by telephone. If the recipients agreed participating in the investigation, laboratory test was performed. Results: From May 2007 to December 2011, 15 donors notified the blood center of having been diagnosed with hepatitis A. The median interval from donation to diagnosis in donors was 18.2 days (Table) . Eleven (73%) of these 15 were male donors, and the median age was 28 years (range 19-42 years). The PCR for HAV RNA was positive in all of 15 depository samples of these donors. None of the repository samples showed positive result of anti-HAV IgM. A total of 44 blood components (RBC 15 units, PC 14 units and FFP 15 units) were delivered to hospitals. Twenty six products were transfused to 26 patients, and the rest 18 blood components (4 RBCs, 1 PC, and 13 FFPs) were recalled immediately and discarded. Twelve recipients (46%) were already expired. Fourteen recipients agreed to participate in the lookback procedure through testing. Twelve recipients did not showed viremic for HAV, however two recipients showed positive either on the test for anti-HAV IgM or HAV-RNA. These two recipients who were 35 and 37 years old developed symptoms on 46 and 48 days after blood transfusion respectively. They were treated for hepatitis A successfully. Summary/conclusions: Recipients who had anti-HAV IgG were not infected with HAV, even though they were transfused with blood suspected to be contaminated with HAV. However TTHA cases were those who did not have anti-HAV IgG and all of them were 30s. In Korea, most people under 40 years old are susceptible to HAV because of low immunity. There is a risk of transfusion transmitted infection, if recipients received blood contaminated with HAV.

2C-S04-04

Cable RT 1 , Pistorius C 1 , Andersson M 2 , Maponga T 2 , Lopez T 2 , Preiser W 2 and Tedder R 3 1 HAV seroprevalence was highest in the Black donors (86%), lower in Coloured donors (62%) and lowest White donors (36%). All were HAV IgM negative. There was an age-related increase from 44.8% (52/116) in those 16-25 years old to 81% (47/58) in those >46 years. Although no active HEV infection was identified by PCR on pooled samples, 25% of donors were HEV IgG positive. Rates were highest in Whites at 33%, followed by Coloured at 23% and lowest in Black at 19%. Again prevalence increased with age from 12.1% in those 16-25 years to 48.3% in those >46 years. Discussion: The results show a lower HAV seroprevalence in the White population compared to the Black and Coloured population groups, likely to be due to socioeconomic living conditions Such a contrast is striking given the introduction of democracy in South Africa almost 20 years ago. The reduction in anti-HBc (as a marker of past HBV infection) with age is reassuring, suggesting that HBV vaccination is impacting HBV population prevalence. The pattern of HEV exposure appears to implicate a zoonotic transmission route rather than being related to socio-economic circumstances. Given the subclinical nature of HEV infection in healthy donors, larger studies are urgently needed to establish the prevalence of active infection in blood donors. Background: HBV demonstrates remarkable genetic variability, with eight genotypes and more subgenotypes. In addition, mutations in the polymerase region may lead to drug resistance and changes in the PreS region (including deletions and mutations such as T31C and T53C) and PreC/BCP region (mutations including A1762T/G1764A, G1896A, T1896A, C1766T, T1768A) are associated with higher risk of hepatocellular carcinoma (HCC). Aims: To study the HBV subgenotype distribution and analyze the changes in PreS region, PreC/BCP and the polymerase region of HBV in Chinese blood donors. Methods: Of 245 blood samples were selected randomly from HBsAg positive blood donors from five blood centers in China. The PreS plus S region or the whole genome of HBV was amplified and sequenced and HBV subgenotype was determined. The amino acid sequences of the polymerase region were aligned and the mutations related to drug resistance were determined. The nucleotide sequences of PreS region and PreC/BCP region were aligned and the mutations related to HCC were determined. Distribution of genotype, subgenotype, and mutations by different regions were examined using Chi-square statistics. Results: Of 200 samples (81.6%)were subgenotyped successfully. The predominant subgenotypes were B2, C2, D1 and A1 which accounted for 50.5%, 19.2%, 5.3%, and 3.4% respectively. Deletions and mutations (T31C and T53C) in PreS region were found in 28 (28/200, 14.0%) samples. Five of these 28 samples (2.5% of all samples) have deletions and no deletions specific to genotype D was detected. The prevalence of mutations in PreS region was significantly higher in genotype C than in genotype B (P < 0.001). Mutations in polymerase region were found in 14 samples (7%, 14/ 200), most of which were related to resistance to Adefovir and Lamivudine. Mutations in PreC/BCP region were found in 68 samples (29.8%, 68/228). The prevalence of HBeAg was significantly lower in samples with mutations in PreC/BCP region than that in the samples with no mutation (P = 0.02). More A1762T/G1764A mutations were found in C than B genotype while the opposite was observed for G1896A mutation (P's < 0.01). Conclusions: Subgenotype B2 was the most frequent strain circulating in HBV infected Chinese blood donors, followed by C2. HCC related mutations were found less in PreS region but more in PreC/BCP region in blood donors. The prevalence of mutations in PreS region and A1762T/G1764A mutations was higher in genotype C than in genotype B while the opposite is the case for G1896A mutations. This is consistent with the distribution of HCC related mutations in general HBV carriers in China. Since all donors in this study reported not having received HBV treatment, it is not clear whether drug resistance mutations occurred spontaneously in the HBV-infected blood donors or were acquired by the donors from HBV infected patients who underwent antiviral therapy.

2C-S05-01 A FRESH LOOK AT MEASURING QUALITY IN BLOOD COMPONENTS Devine D

Confidence in the quality of blood components produced for transfusion, particularly with respect to their safety and efficacy, is a necessity for clinicians and patients alike. The assurance of blood product quality is dependent upon the collection of data that can demonstrate products are within specification. However, the linkage between confidence that an individual blood component unit will perform as expected and the conduct of quality testing is imperfect. This begins with the manner in which we conduct these tests. Although we describe our practice as 'quality control', it is, in fact, a type of process control testing in which we test a small proportion of our production inventory to ensure that the process was conducted properly. This testing is often conducted at product outdate, long after problem products have been issued and used in hospitals. In addition, the standards used to assess blood components often have 'wiggle room'. For example, the North American standards for the number of platelets in a whole blood-derived platelet concentrate require that at least 75% of tested products meet or exceed the required platelet count. In practice, this means that up to 25% of individual platelet components issued to hospitals may have fewer platelets than the user specification requires. There are other examples in component quality standards of this same phenomenon. In an utopian blood production laboratory, there would be real time quality control measures that would be made prior to release of a unit to the hospital blood bank or transfusion service, and these measures would be highly predictive of product efficacy. As a community, we have considerable work to do to get to this utopian ideal. First we must identify better product characteristics to use as standards for blood component production. Modern science, especially in the field of cell biology, has made huge strides since quality standards were first introduced some 50 years ago, yet we have not applied these advances to quality assessment for blood products. Those studying blood component quality have begun to collect data sets that will help to inform this change over to new standards. Production methods are only one way to impact component quality; another is the actual features of the donors themselves. This biological variation includes not only well known phenomena such as the range of platelet counts in normal healthy humans or the distribution of plasma factor VIII or fibrinogen levels, but also appears to extend to storage characteristics of components made from individual donations. This presentation will review the state of the science of product quality and the regulation of blood products, including new information arising from clinical trials, and the application of modern scientific methods such as proteomics and metabolomics to the broad question of blood component quality. Background: Blood transfusion has been shown to be associated with poorer surgical outcomes such as higher incidence of infection, higher mortality, and increased number of serious adverse events. Microparticles (MP) released in packed red cells (PC) in storage have been suggested to be mediators for transfusion-related complications. However, the underlying mechanism for MP release during storage is mostly unresolved. Aims: To examine MP released in PC in storage for procoagulant and proinflammatory activity and define the role of residual platelets in PC in generation of MP during storage.

Methods: (i) Leukoreduced (LR) and non-LR (NLR) packed cells (PC) were stored according to blood bank standards and sampled at day 0, 10, 20, 30, and 40. Assay of MP was by flow cytometry using mAb to label CD235a, CD45, CD41, and CD62E. Thrombin generation (TG) and CD11b expression were used as measures of procoagulance and proinflammation, respectively. (ii) The impact of platelets was further evaluated by reconstituting LR PC with increasing concentrations of platelets at day 0. Results: (i) Multiple species of MP were released in a time-dependent manner. Using NLR PC, we found that, relative to day 0, red cell MP (RMP) were increased by 2.59 at day 20, and by 8.59 by day 40. Small amounts of MP from leukocytes (LMP), platelets (PMP), and endothelia (EMP) were detected, generally <20% as many as RMP. Levels of PMP rose rapidly from day 0 and peaked at day 20. LMP began rising at 20 days, increasing to 1.59 at day 30 and 2.49 at day 40. EMP changed little over 40 days. (ii) Comparing MP in NLR vs LR PC. As expected, PMP and LMP were higher in NLR PC. Unexpectedly, however, the rate of RMP production was <50% as fast in LR vs NLR PC. The levels of RMP were found to be significantly associated with residual platelet counts. Therefore, we investigated the possible role of platelets in RMP production. (iii) Effects of residual platelets on RMP release. When LR PC were incubated with increasing numbers of platelets (0-200,000 per ll), RMP as well as PMP generation increased. Rate of increase of RMP was closely associated with platelet count and storage time. This shows that residual platelets catalyze RMP generation. (iv) Procoagulant and proinflammatory activities. MP-mediated thrombin generation and CD11b expression increased from day 0 to day 40 in both LR and NLR PC, but in LR PC, it was only 30-50% magnitude of NLR PC. The time course curves did not match any specific MP species. Conclusions: Procoagulant and pro-inflammatory MP were generated in a timedependent manner. The new finding is that residual platelets markedly augment release of RMP, which is a known indicator for storage lesion. The benefits of leukoreduction may be due to reduction of platelets and MP production in addition to reduction of WBC. Reducing platelet count in PC may be beneficial in reducing storage lesion and transfusion related complications. Background: It has been reported the soluble CD40 ligand (sCD40L, sCD154) that was accumulated during platelet storage induce polymorphonuclear leukocyte (PMN) mediated damage of human pulmonary microvascular endothelial cells(HMVECs), was a potential cofactor in developing the transfusion-related acute lung injury (TRALI). However the amount of sCD40L was only slightly elevated in the recipient by transfused blood components as it was fully diluted in the recipient's blood circulation. The mechanism by which CD40L exert its effect is still needs to be elucidated. Aim: To determine the effect of platelet derived microparticles (PMP) on PMN mediated HMVECs damage, and its correlation with PMP bounded CD40L. Method: The PMPs were isolated by centrifugation of the platelet-free plasma from 10 apheresis platelet concentrates (A-PLTs) at 20,000 g for 1 h. The PMPs were counted by flow cytometric analysis, followed by western blotting that was performed on isolated PMPs. The sCD40L was assayed with ELISA. The priming of the formyl-Met-Leu-Phe (fMLP) activated PMN respiratory burst was measured with the hydrogen-peroxide production. A two-insult in vitro model of PMN-mediated HMVECs damage was used to investigate the effect of PMP. Result: The PMP priming activity to PMN are correlative with PMP accumulations and their level of sCD40L during 5 days storage (correlation was significant at the 0.05 level); PMN respiratory burst are declined by removing PMP with 0.1 lm PVDF membrane filtration or depletion PMP with CD154 monoclonal antibody combining magnetic Dynabeads Pan Mouse IgG; The Lipopolysaccharides(LPS) activated HMVECs were damaged more significantly by PMP isolated from 5-day stored A-PLTs compared with 1-day stored A-PLTs (P < 0.05). Conclusion: Platelet-derived microparticles carry concentrated CD40L signal, promote PMN mediated HMVECs damage, may be relative to developing of TRALI. Background: Continuous efforts has spared on improving the quality of platelets harvested from plateletpheresis. Little is known about the contribution of donors on the variation of platelet quality, particular the effect of frequent platelet donation on donor's platelet function. Aims: Aim of this study is to investigate the effect of frequent platelet donation on the state of in vivo platelet activation in platelet donors. Material and methods: Of 107 whole blood donors and 335 platelet donors with vary donation history from 1 to 74 times (mean at 11.5 AE 12.7) were recruited. They were stratified into three subgroups according to their previous plateletpheresis history (G1: 0-1 time, G2: 2-10 times and G3: >10 times). Blood sample were collected from each participant for the determination of plasma levels of soluble P-selectin (sP-selectin), marker of platelet activation and total platelet P-selectin (tP-selectin), as well as platelet count and platelet indices. Results: Following the increase of donation times, sP-selectin levels were steady increase (G1: 20.50 AE 5.76, G2: 23.21 AE 6.70 and G3: 25.33AE7.67 ng/ml respectly, P = 0.001) and mean platelet volume (MPV) was decrease (G1: 9.29 AE 0.89, G2: 9.17 AE 0.84 and G3: 9.02 AE 0.91 fL respectly, P = 0.039) as estimated by the analysis of covariance adjusted for sex and gender. No significant changes in tP-selectin, platelet count, platelet distribution width (PDW) were observed. Further multivariate regression analysis including variables of ABO blood groups as well as donation history, sex, age indicated that increased plateletpheresis donations are positively associated with the elevated sP-selectin levels in blood donors (t = 4.16, P < 0.0001). Conclusion: Our data suggested that frequent plateletpheresis result in the increased level of sP-selectin in platelet donors, implicating a higher state of platelet activation in vivo in frequent platelet donors. The potential effects of frequent plateletpheresis on the quality of platelet harvested and the donor complication are worthy of attention. Background/aims: Structural and functional changes in erythrocytes occur during ex vivo storage, including the accumulation of bioactive substances in the supernatant of red cell concentrates (RCCs). Many of the constituents of the supernatant fraction, which are potential mediators of transfusion-related complications, may be reduced by washing of RCCs. With emerging paediatric clinical data supporting a beneficial effect of RCC washing prior to transfusion, the aim of the current study was to characterise the effects of RCC age and post-washing storage on erythrocyte structure, function and the accumulation of bioactive substances in paediatric-sized washed RCCs. Methods: Two units of ABO/RhD-and age-matched RCCs (either 1-or 4-days old; n = 11 each) were pooled and equally split to obtain matched pairs (day 0). One unit was washed with 0.9% saline by repeated centrifugation then resuspended in 100 ml SAG-M, while the other remained unwashed. Subsequently, both RCC units were divided equally to produce 4 units of paediatric-sized washed or unwashed RCCs. All units were stored at 2-8°C and samples were taken on days 0, 1, 2, 7, and 14 of storage to measure metabolic activity and quality of RCCs, as well as the concentration and activity of bioactive substances in the RCC supernatant. The overall effects of washing and storage were compared using repeated measures ANOVA with posthoc paired t-tests as required, with P < 0.05 considered significant. Results: The washing process resulted in reductions in red cell count (9.3%), haemoglobin (9.2%) and haematocrit (5.9%) compared to unwashed RCCs. Overall, washing and subsequent storage of 1-and 4-day old RCCs significantly reduced the pH (P < 0.0001), lactate production rate (P < 0.0001), and 2,3-diphosphoglycerate concentration (P = 0.046). Although the ATP content of the RCC decreased during storage, it was not changed by washing (P = 0.570). Haemolysis in the RCCs was increased by the washing process, but remained <0.15% on day 14 for all products. Extracellular potassium was significantly reduced by washing (P < 0.0001), but increased during storage in both washed and unwashed red cells (P < 0.0001 for both). Washing significantly reduced the number of microparticles in the supernatant of both 1-and 4-day-old RCC compared to unwashed RCCs (P = 0.01 and 0.012 respectively). However, the microparticle number in the supernatant of all RCCs increased during storage. Washing of both 1-and 4-day old RCC also markedly reduced the supernatant concentration of monocyte chemoattractant protein-1, sCD62P, RANTES, anaphylatoxins (C3a, C4a, and C5a) and IgA to levels below or near the limit of detection. Incubation of cultured human umbilical vein endothelial cells (HUVECs) with supernatant from unwashed RCC led to endothelial cell activation, with increased cell-surface expression of E-selectin and VCAM (P < 0.0001 for both). However, little or no activation was observed when HUVECs were incubated with supernatant from washed RCC. Conclusion: Although washing affected some aspects of the in vitro quality of RCCs, it effectively reduced the concentration and activity of bioactive substances in the supernatant of RCCs, leading to reduced endothelial cell activation. Such a reduction may be clinically beneficial in selected patient groups.

Blood Services Group, Health Sciences Authority, Singapore, Singapore

Many of the critical issues associated withBiobanking have been effectively addressed in blood banking. Blood transfusion therapy with its emphasison traceability has developed robust systems for inventory and product release. The ethos of proper quality management hasalso been an integral part of blood banking. The lessons learnt have been applied into the biobanking of cord blood, stem cells, tissue and organs. Biobanking includes both banking of tissuefor research only as well as public cord blood banks that play a vital rolesupporting clinical stem cell transplantation. The growth of regenerative medicine will only increase the scope, variety and numbers in biobanking. Similarly, the discovery of induced pluripotent stem cells (iPS) and itspotential myriad applications has highlighted the central role of biobanking inboth diagnostics, research and therapeutics. Principles and key considerations in biobanking including biospecimenprocurement, consent, processing, preservation and traceability will beaddressed.

Introduction: Cell therapy generally includes the extraction, processing, manipulation and implantation of characterized cells effectuating specific functions in a patient. However, adjacent fields like tissue banking or tissue engineering should be incorporated. All together have donor selection and validated core procedures in common. Production cycles are carried out in GMP clean rooms. Furthermore, quality control includes assays which are common in transfusion medicine. It might be tempting to speculate, that cell therapy is closely related with transfusion medicine and requires minor adaptions. The big moat surrounding cell therapy: But there are huge differences: Cell therapy is a domain of specialists rooted in patient care with profound knowledge about specific pathologies and how to target them. Cell therapy derives from individual clinical needs and rarely is a prefabricated procedure. This is in stark contrast to transfusion medicine, which focuses on standardized products for any patient in need. Today, complex regulations for cell therapy surpass those in transfusion medicine. This distracts clinicians in a cell therapy program. This may aspire transfusion medicine specialists to engage in cell therapies. However, only a small niche is left for blood centers, as two major trends arise: One is the more or less 'academic GMP' setting, utilizing the hospital exemption status. The other is the commercial arena, where companies produce standardized cell therapies to achieve maximized market shares. 'Academic GMP' entities promote individualizedmainly autologoustherapies, which require a constant flow of financial assets to keep underused clean rooms running. Therefore it is serious to ask why and where blood centers should engage in cell therapies. Strategy first: Transfusion medicine has been heavily influenced by external factors such as viral safety, blood usage, cost pressures and low resources. The term 'transfusion medicine' misleads outsiders to suppose, that it deals with transfusions, nothing else. A wise strategy must include a change in the mind-set of all. This is the most crucial issue as many clinicians are needed to collaborate and co-develop cell therapies. Without deeply rooted partnerships it is impossible to establish sustainable cell therapy programs in a blood center. Furthermore, a thorough evaluation includes possible products, quantities, as well reimbursement schemes. Cell therapy is one of the most expensive treatments and financial assets must be secured first. Second: establishing a cell therapy facility: A mock-up facility, without clean room status is highly recommended. Processes will be developed, staff is enabled to learn and define procedures, before a cell therapy unit is planned. Planning and establishing a cell therapy unit is very complex and specific expertise is scarce. A basic prerequisite is a project manager carrying out final decisions with a profound knowledge about processes interacting with different technologies (HVAC, controls, microbiology). Cell therapy units fail if project management has flaws and deep involvement of engineering with medical expertise is ignored. A cell therapy unit is an endless, stressful, path riddled with expensive failures, but rewards in the long run a blood center with exciting future prospects integrating grateful clinicians and patients.

Any kind of accreditation, either by regulatory authorities or any professional entity, like JACIE/FACT, is an important milestone in the time line of a new cell therapy and a possible showstopper of a long, expensive and enduring project. Honest and thorough preparations before accreditation should start before an application may be sent. Three phases are distinguishable: Keeping the basics on track: Running a cell therapy unit is a high wire task. Fundamental knowledge about the medical background, processes, quality control, specifications is interwoven with engineering and controlling tasks. It is inevitable for anyone working in this environment to know about air quality, hygiene, staff education and additional technical features. Especially controls and the design of engineering and its qualification should be documented continuously. Maintenance, re-qualifications, adjustments in the control-system of a clean room facility offer chances to learn the interplay of systems. Build a sufficient knowledge base and freeze the process: Protocols for cell therapy are often introduced on primary events and work well in first shot experiments. As further patients are included it is very probable, that the whole process and specifications will be modified and sometimes fundamentals and documentation are out of focus. Altering and scaling methods, processes and assays may or may not change the product or its intended use. Slippage is often not detected and therefore first steps aim at the build-up of as much information as possible. Firstly, current literature has to be collected, reanalyzed and mirrored onto the own processes. Then the regulatory framework has to be analyzed. The main question is, how the product fits into the regulatory system. Is it an ATMP or non-manipulated cell product, is it a blood product or a pharmaceutical? Pros and cons about alterations should be meticulously discussed and alternative procedures highlighted in this phaseespecially those which are already accredited. It will be very probable that the same inspectors, who have inspected similar cell therapy units, know about alternative procedures and will raise comparative questions. After building up the knowledge base it is advisable to finish a risk assessment focused on the intended use in patients and to revamp the process. After adjusting all methods, processes and assays the whole production has to be frozen. Further changes are prohibited and the documentation has to be refreshed. The last test trial: In the last phase before accreditation all aspects of quality management have to be finished. Risk assessments should focus on the safety and effectivity of the cell therapy. Donor/patient eligibility criteria, quality control of incoming cells and tissues, production processes and their internal quality control criteria as well storage conditions have to be well documented and validated. Under certain circumstances a file of clinical studies has to be prepared. All documents and clinical studies should be reviewed, regulatory aspects should be clear. A preparation project gives better chances to pass the last milestone before patients can be treated on a regular cell therapy.

2D-S07-01

Burnouf T

Plasma fractionation is a complex biotechnological process exhibiting unique features compared to downstream technologies used for recombinant proteins, vaccines, and animal-derived antisera. In human plasma fractionation, by contrast to other biological products, multiple end-products (typically 5-10 or more) are obtained from the same manufacturing pool. Some of the targeted proteins are present in plasma in large amounts, as is the case for albumin and immunoglobulin, whereas, by contrast, others, such as coagulation factors and anticoagulant proteins are in trace amounts. With the emergence of selective hemotherapy, plasma fractionation has, over the years, turned into a highly integrated protein separation process carefully designed to isolate various proteins under optimized conditions of yield and purity. Current plasma fractionation methodologies combine diverse protein purification tools based on 'crude' precipitation techniques and refined chromatographic procedures. Some proteins are stable and not prone to degradation, while others, with specialized functional activity, are fragile and prone to enzymatic degradation, activation, or aggregation. Contamination of plasma products with harmful residual plasma protein impurities (such as activated coagulation factors or proteases) can lead to serious adverse events in some patients. In addition, while a few plasma products, like albumin and immunoglobulin, can be formulated as liquid preparations, all others products are freeze-dried to ensure long-term stability, which increases cost and technical difficulties. The diversity of protein products made from plasma explains why plasma fractionation facilities have complex design. The manufacturing lines of the various fractions should be strictly segregated from one another. In addition, the risk of viral contamination of plasma pools requires that each product be subjected to several (typically two or more) dedicated viral reduction treatments, the goal being to gradually increase the degree of viral safety along the downstream process. Production zones should therefore be physically segregated to limit risks of cross-or downstream contaminations, adding to the complexity of the plant design, flows of product, personnel and wastes, and working procedures. The plasma fractionation industry has a long history from the years 1940's, when Cohn and co-workers developed a sequential cold ethanol precipitation process. This method which evolved over the years, remains the core fractionation process, albeit integrated with cryoprecipitation and multiple chromatographic steps. Combined with modern viral removal treatments, the current fractionation process ensures therapeutic protein products of established quality and safety, at more or less acceptable yields. The current safety record of plasma products, which contrasts with that of earlier product generations, somehow represent an impediment to the emergence of new fractionation technologies. Novel plasma fractionation processes based on integrated chromatographic steps, membrane electrophoresis, aqueous two-phase system, mini-pool fractionation in disposable equipment, are being developed at pilot-scale and represent interesting alternatives. To reach the market, such technologies should be integrated with robust viral reduction steps and proven to achieve at least equal, if not superior, products yield, quality, safety, and productivity to justify the regulatory load, clinical trials, and licensing of what would be regarded by most regulatory agencies as new plasma products requiring full validation. Effective specific antiviral agent is generally not available for emerging infectious disease agents such as SARS-coronavirus and Middle-East-respiratory-syndromecoronavirus. Passive immunotherapy with plasma or plasma derived hyperimmune globulins have been used for treatment or prophylaxis against many exotoxin mediated bacterial or viral diseases such as viral hemorrhagic fever and 1918 influenza despite the lack of data from randomized control trial. Antigenically shifted influ-enza A virus causes pandemics and antigenically drifted viruses are associated with seasonal outbreaks. Poultry to human transmission of avian influenza A H7N9 and H5N1 virus can cause acute community acquired pneumonia with 25 to 50% mortality. Risk factors including extremes of age, pregnancy, underlying medical illness and low serum IgG2 are associated with severe pneumonia with delayed clearance of viral load and excessive proinflammatory response. Though treatment with neuraminidase inhibitors within 48 hours after onset of symptoms should be effective, those with severe disease and respiratory failure usually present later than 5 days after symptom onset. During the 2009 pandemic of H1N1 influenza, we harvested convalescent plasma from a small percentage of recovered adults sufficient for a case control study for treating severe cases during the pandemic in Hong Kong. Plasma supply is constrained by plasmapheresis capacity during most stages of the epidemic. Between August 26 to October 31, 2009, a total of 9101 persons were successfully contacted. A total of 1309 screening and 619 whole blood donation appointments were made. In the former 786 (60.0%) attended screening but only 301 could donate plasma by apheresis because of failure to meet blood donation eligibility criteria, failed laboratory tests, insufficient neutralization antibody titers, and inability to make the apheresis appointment. For those who opted for whole blood donation, 379 (61.2%) had attended and donated. 10.5 l (21 units) and 276 l of convalescent plasma with sufficient neutralization antibodies titers was collected for passive immunotherapy as convalescent plasma or H-IVIG production respectively. We recruited 93 patients with severe H1N1 2009 infection already put on neuraminidase inhibitors and requiring intensive care. Twenty patients (21.5%) received convalescent plasma. Mortality in the treatment group was significantly lower than the demographically matched control nontreatment group (20.0% vs 54.8%; P = 0.01). Convalescent plasma treatment was associated with significantly lower day 3, 5, and 7 viral load, compared with the control group (P < 0.05) and corresponding lower serum levels of IL6, IL10, and TNF (P < 0.05). Between 2010 and 2011, 35 patients were randomized to receive H-IVIG (17 patients) or IVIG (18 patients). No adverse event related to treatment was reported. Serial respiratory viral load demonstrated that H-IVIG treatment was associated with significantly lower day 5 and 7 posttreatment viral load when compared to the control (P = 0.04 and P = 0.02 respectively). The initial serum cytokine level was significantly higher in the H-IVIG group but fell to similar level 3 days after treatment. Subgroup multivariate analysis of the 22 patients who received treatment within 5 days of symptom onset demonstrated that H-IVIG treatment was the only factor which independently reduced mortality [OR:0.14, 95% CI, 0.02-0.92; P = 0.04]. Background: In recent years, with the global spread of the West Nile virus (WNV), dengue virus (DENV) and chikungunya virus (CHIKV) that are transmissible by mosquitoes, concern has arisen regarding their entry to Japan. Furthermore, CHIKV as well as WNV and DENV are potentially transfusion-transmissible, posing a serious risk for transfusion medicine. Of these, WNV and DENV belong to the Flavivirus genus, as does the Japanese encephalitis virus (JEV), and they have similar antigenicity. Since most Japanese people are periodically vaccinated against JEV, there is a possibility that anti-JEV antibodies cross-react with WNV and DENV and induce a protective immune response. However, because WNV and DENV have similar antigenicity to JEV, there is concern that the anti-JEV antibodies are present in Japanese plasma against WNV and DENV owing to antibody-dependent enhancement (ADE) in FccR-expressing cells. Furthermore, if the anti-JEV antibodies present in Japanese plasma have high ADE activity, these antibodies may act in an infection-enhancing manner rather than an infection-neutralizing manner against WNV and DENV in vivo. Aims: Using intravenous immunoglobulin (IVIG) prepared from pooled plasma from Japanese donors, we evaluated its neutralizing activity and ADE activity against these viruses for the purpose of estimating the potency of the Japanese individuals to protect themselves against these viruses. Methods: Neutralizing activity (TCID 50 ) and ADE activity were compared among three types of IVIG, Nisseki Polyglobin N (made in Japan), Gammagard (made in Germany) and Sanglopor (made in the USA). TCID 50 was calculated from the results of cytopathic effect (CPE) assay using Vero cells as target cells. ADE activity was measured by plaque assay using BHK cells and FccR-expressing BHK cells as target cells. Results: Nisseki polyglobin N showed a significantly higher neutralizing activity against JEV than Gammagard and Sanglopor. The neutralizing activity of Nisseki polyglobin N against WNV was approximately a log reduction factor of 2.3 higher than that of Sanglopor. Furthermore, the neutralizing activity of Nisseki polyglobin N showed approximately the same neutralizing activity as Gammagard against WNV. None of the IVIG preparations showed significant neutralizing activity against DENV or CHIKV. Nisseki polyglobin N showed only marginal ADE activity against any of the viruses. Conclusion: Although the neutralizing activity of plasma from Japanese individuals is not known, it is suggested that the Japanese population as a whole has a potency to protect themselves from infection by WNV to some extent, probably due to the cross-reaction of anti-JEV antibodies to WNV as a result of JEV vaccination and natural infection. Therefore, if WNV invades Japan, a pandemic may not occur and the risk of WNV infection by blood transfusion may be low. It was suggested that plasma from the Japanese individuals has almost no neutralizing activity against DENV and CHIKV. Nisseki polyglobin N showed only marginal ADE activity against WNV and DENV, suggesting the low possibility of the anti-JEV antibodies present in Japanese plasma acting as infection-enhancing agents against WNV and DENV as a function of ADE. Background: Platelet-rich-plasma (PRP), platelet gel (PG), and platelet lysate (PL), are used in regenerative medicine to stimulate the healing of soft and hard tissues. In addition to their tissue regenerative properties, platelet materials are claimed, mostly through anecdotal observations, to limit post-surgical inflammation and decrease pain. The anti-inflammatory properties are thought to be due to the release of platelet components, including transforming growth factor-b1 (TGF-b1) and hepatocyte growth factor (HGF), which are known to inhibit some inflammatory pathways in vitro. However, there is a large diversity in the type of platelet fractions used in clinics. They differ significantly in protein composition and content of proinflammatory and anti-inflammatory molecules and may therefore not be equally effective in controlling inflammation. One needs to elucidate the factors responsible for the possible anti-inflammatory properties of platelet materials to standardize the preparation and clinical use of these products when an anti-inflammation effect is clinically beneficial. Aims: To investigate the potential anti-inflammatory effect of various plasma/ platelet fractions using an established in vitro model of RAW 264.7 mice macrophages stimulated by lipopolysaccharide (LPS), and studying the production of nitric oxide (NO), inducible nitric oxide synthase (iNOS), and cyclooxygenase-2 (COX-2). Methods: Apheresis platelet concentrates (PC) were obtained from three donors and separated within 3 days into PC, platelet poor plasma (PPP), platelet gel releasate (PG), frozen-thawed platelet lysate (PL), and solvent-treated platelet lysate (S/D-PL). Proteins were determined, SDS-PAGE patterns obtained, and growth factors quantified by ELISA. RAW 264.7 cells were grown in medium supplemented with 10% of fetal bovine serum (FBS) or plasma/platelet fractions, with or without LPS (500 ng/ ml added after 24 h of culture). Cell growth and cytotoxicity were checked by cell count determination and MTT assay. NO was determined in cell culture supernatants by colorimetric assay and iNOS and COX-2 in cell extracts by Western blot. PRP from mice and quercetin, a known anti-inflammatory compound, were used as controls. Results: PC and S/D-PL had the highest mean TGF-b1 content ranging from approximately 100-200 ng/ml, and PPP the lowest (5-10 ng/ml). Cell count analysis and MTT assays showed consistent cell growth and viability in all conditions evaluated but were slightly lower in the presence of LPS and quercetin, as expected. There was no NO, iNOS, COX-2 detected in absence of LPS stimulation. The plasma and platelet fractions were all found to reduce NO production and iNOS expression, when compared to FBS, after LPS stimulation. Interestingly, inhibition of NO production and iNOS was generally more pronounced with S/D-PL. COX-2 synthesis was lower in the presence of S/D-PL compared to other plasma/platelet fractions and higher with PG. The mice PRP did not exert any stronger anti-inflammatory action in this mice cellular model suggesting absence of species specificity. Conclusions: The plasma and platelet fractions evaluated exert, to various degrees, an anti-inflammatory effect mostly revealed by inhibition of NO production and iNOS. Impact on COX-2 synthesis is less obvious. The fact that S/D-PL exhibits stronger global anti-inflammatory activity requires further studies.

2D-S08-01

Tani Y Japanese Red Cross Kinki Block Blood Center, Ibaraki, Japan

Rare blood is generally defined as one that occurs at a frequency of 1:100~1000 individuals or less, and it is sometimes difficult to provide such blood types to patients because of their rarities. The Japanese Red Cross (JRC) Society lists 46 rare blood phenotypes that are divided in two categories as shown in Table 1 . The rare blood types listed in Category I occur much less frequently than those listed in Category II. We screen for rare blood cells using monoclonal antibodies (MoAbs). Since 1987, our blood center has established 93 MoAbs (32 human and 61murine), and has provided them to the other blood centers. Many of IgG MoAbs are available on the machine such as Beckman Coulter PK-7300 Blood Grouping Analyzer by saline or bromelin method by cross-linking with anti-human or anti-mouse IgG. In addition, we routinely screen for antigen negative-cells (RhC, c, E, e, Jk a , Jk b , Fy b , Di a , M, Le a , S to which antibodies are believed to be clinically significant). Thus, more than 10,000 donors with rare blood phenotypes (Category I, 748; Category II, 9314) are registered in Japan, but the number of donors with some Category I blood types are insufficient. We freeze rare blood, particularly Category I types, and domestically and sometimes internationally supply these units of blood. Since 1977, a total of 576 units of rare blood with phenotypes Di(b-), D-, Jr(a-), Ko, Jk(a-b-), (para-)Bombay, p, En(a-), M k M k , Lan-and Rhnull have been supplied to 23 international countries. Thus, the JRC contributes to the International Panel of Donors of Rare Blood Type (IDP) which is maintained by the International Blood Group Reference Laboratory (IBGRL) in Bristol, UK. The IDP provides information on the location of rare blood donors when they cannot be found in their respective countries. The JRC has encountered difficulties in finding rare donors with Rhnull, P k , M k M k , En(a-), U-and Ge-phenotypes. We also joined the ISBT Working Party on Rare Donors which handles all matters related to rare blood. Our rare blood donor program is successful because of international cooperation.

2D-S08-02

The China National Rare Blood Group Screening program started in 2008. The program has screened more than 1,500,000 donors in thirteen regional blood centers by using large-scale serological tests, gene diagnosis, and other different specific screening technique. Now, more than 1300 donors with rare blood phenotypes have been found. Including Rh null, D --, Wrb-, Lu(a-b-), JK(a-b-), Vel-, Lan-, Coa-, K 0 , Dib-, s-as well as Yta-. The primary target for the project is to screen the negative blood antigens whose conjugational antigens have high frequency, and the blood groups which is easy to produce antibodies and the negative antigen in the system is very rare in Chinese population (for example, Fya-, whose frequency was 1/400 in Chinese Han population). A professional website for rare blood groups (http://www.chinarareblood.cn)was set up and serviced in Jan, 2010. The information of blood donors with rare blood types is registered into the National Registering System for Blood Donors with Rare Blood Types by professional technician from organizations join the program. The information includes the specificity of the rare blood types, other common blood groups, personal data of donors, and the information of contacts. Except the network administrator, other visitors could only see the specificity of the rare blood type and the number of the rare blood in rare blood bank storage. Application for the rare blood products should communicate with contacts through administrator. According to the standard of the pretransfusion test in China, all the donors and recipients must be identified the ABO and Rh systems and done the cross-match test, in addition, all the donors must pass the test for contagious marks. Nowadays, more and more Chinese blood centers use nucleic acid technique to detect HIV and HCV. The results of infection test must be added to the information of the blood products at every time for collecting the rare blood. In recent 2 years, 21 units (1 unit = 200 ml) blood products with different rare blood types have been used in clinical treatment. Background: Anti-Emm is a rare specificity detecting the high-prevalence red blood cell (RBC) antigen Emm (ISBT 901008). Five cases were reported by Daniels et al, (Transfusion, 1987; 27:319) and two by Reid et al, (Transfusion 1998; 38 (Suppl) :101S). Six of these were in untransfused males and anti-Emm had not been implicated in a transfusion reaction, most likely because the patients were not transfused. Case study: A 58-year-old, untransfused, Japanese man with group A, D+, DATnegative RBCs, urgently needed transfusion due to an abdominal stab wound. Pretransfusion testing using gel column agglutination and PEG-IAT, demonstrated an antibody reactive with all panel cells, but non-reactive with autologous RBCs; anti-Le a was detected by papain methods using gel column. Unavoidably, one bag of crossmatch-incompatible Le(a-) RBCs had to be transfused. Thirty minutes after transfusion, he experienced a drop in blood pressure and hematuria. However, as his Hb level was 5.5 g/dl, another two RBC bags were transfused, and his vital signs became stable. On Day 3, he was transfused one RBC bag without a hemolytic transfusion reaction. On Day 6, after receiving 30mL of RBCs, the patient vomited and had cola-colored urine (T-Bil 6.1 mg/dl, LDH 912 U/l) and the transfusion was stopped. Following transfusion, his RBCs reacted in the DAT: 1+ on Day 1, 2+ on Day 3 and negative on Day 7. Thereafter his anemia improved gradually by iron medication and he was discharged on Day 24. Aims: To identify the antibody in the patient's plasma that caused the transfusion reaction. Methods: Serological testing was performed by standard methods. Result: The patient's plasma reacted in saline at 4C (2+), by albumin IAT (2+), PEG-IAT (2+), and papain-IAT (3+) with all panel cells, and by PEG-IAT with 30 samples lacking high-prevalence antigens; the autologous RBCs were non-reactive. Testing his plasma against phenotypically-similar enzyme or chemically treated RBCs showed that the antigen detected was resistant to bromelin, papain, ficin, trypsin, a-chymotrypsin, pronase, DTT, AET, and acid. Two examples of Emm-RBCs were non-reactive and the antibody was identified as anti-Emm. The reactivity of enzyme and chemically treated RBCs is consistent with anti-Emm. His RBCs reacted with antibodies to 17 high-prevalence antigens, but could not be confirmed as Emmbecause anti-Emm was not available. The anti-Emm was IgG1 and IgG3 with a titer of 16 by PEG-IAT before transfusion rising to 128 on Day 10; his serum demonstrated hemolysis after Day 6. No other underlying antibodies were detected in the patient's plasma alloadsorbed to remove the anti-Emm. Conclusions: We report the first Japanese case of anti-Emm and the first to cause an acute hemolytic transfusion reaction (AHTR). In previous reports, six people with anti-Emm were untransfused men and one was in a woman whose transfusion history was unknown, suggesting that the antibodies may be 'naturally-occurring'. The anti-Emm reported here, also in an untransfused man, also may be considered a 'naturally-occurring' antibody. Similar to the first reported example of anti-Emm, the antibody reacted, albeit weakly, at 4C. Our case suggests that anti-Emm is clinically-significant as the patient experienced an AHTR.

2D-S09-01

Background: To recruit blood donation volunteers and provide stable blood supply according to demand, it is more important to change the overall social perception than to carry out one-time event or short-term campaign. The social understanding of blood donation is formed as valuable and honorable service over certain level in Korean society. Nevertheless, there still are many people who don't even try to participate in blood donation because of fear, health concern, and expectation for reward. To change this culture and social awareness, it is important for the present and future blood donors to have a perception that the blood donation is the sharing one's life and a genuine service which helps other people for nothing. Aim: The main purpose of this article is to introduce Korean Red Cross' recent efforts (operation of the Red Campaigner and blood donation supporters, the construction of virtual blood donation experience center, the Blood donation promotion program) to change the blood donation culture and widen the donor base in Korea and to present their effect and improvement direction.

(1) This article is comprised of the case study and analysis on the operation of Red Campaigner and blood donation supporters, the construction of virtual blood donation experience center and blood donation promotion program (2) This article outlines the Red Campaigner and the Blood donation supporters and the related programs and addresses their significance In addition, describes the effect and direction for improvement, presenting research related data.

(3) This article outlines virtual blood donation experience center construction and presents the exhibition in it And it suggests the effect and possibility on the authority of the research case that the education with fun has more considerable impact than learning by rote.

Result: To change current culture and increase positive understanding about blood donation, Korean Red Cross is making various efforts. The Red Campaigner, consisting of high school students and the Blood donation supporters, consisting of college students, aim to influence the youth, the potential blood donors, to have a positive understanding of blood donation and to carry out continuous and organized publicity of its importance and safety. In addition, Korean Red Cross is making a progress in the construction of the virtual blood donation experience center which is going to be completed by the end of 2013. We expect that we can achieve the educational purpose that sends a message that the blood donation is a volunteer work to save life and make future donors to recognize the blood donation as an object of not fear, but interest. Finally, 'the blood donation promotion program' which began in 2009 is designed to encourage for general groups or organizations to participate in the blood donation campaign and to create the voluntary blood donation culture. Conclusion: Various projects operated by Korean Red Cross contribute to widen blood donor based by changing blood donation culture in Korea and are expected to make continuous contribution. But these projects have a limitation that the partici-pant is restricted and continuous participation isn't progressing in terms of national participation. Continuous and positive endeavor to foster these projects as a national campaign should be encouraged. Although it is possible to increase the blood donor temporarily through one-time event when blood shortage recurs, widening the donor base by changing blood donation culture should be the fundamental solution. The changing blood donation culture and donor understanding may not be optimistic for a short-term blood shortage problem but will be useful to make conditions that expand the donor base and increase voluntary donors in the medium to longer term. Understanding our future donors is of critical importance to blood collection agencies worldwide. Not only do we need to know who they are, but also why they do or do not engage in the required behaviour of blood (product) donation. The surge in psychological research into blood donation in the last decade has provided significant insight into understanding the psychological factors underpinning the commencement and continuation of blood donation. This review will summarise the state of our current understanding of knowing how to effectively recruit the non-donor and the complexities that lie ahead for all involved. At the descriptive level, and stemming from the systematic application of various psychological theories and models within blood donation contexts, we now know more than ever about the key factors that non-donors report impact on their blood donation intentions and behaviour. From this, certain psychological elements such as perceived control or self-efficacythe individuals' self perception that they can cope with donationhave emerged as key determinants of donor recruitment. Drawing on these results, research psychologists have worked collaboratively with blood collection agencies to develop and evaluate recruitment materials designed to target these central constructs. Both laboratory and in field trials have been undertaken which have consistently shown positive effects. For example, participants receiving these materials are more likely to volunteer to donate blood than those receiving standard recruitment materials. The collaboration of researchers and blood collection agencies has furthered understanding and recruitment efficacy generating measurable, operational deliverables. However, this collaborative research has also served to highlight the challenges that lie ahead both in terms of the diversity of our non-donor population as well as the limitations of our current theoretical models. Further, there is an increasing need for large scale randomized controlled field trials to systematically evaluate interventions designed on the basis of psychological research. While these needs may provide substantial challenges for researchers and blood collection agencies alike, the promise of psychology in providing the 'who' and 'how' to effectively recruit remains. Background: Developed countries rely solely on voluntary non-remunerated donors to ensure adequate blood supply but ageing has brought in significant pressure on the health care system including blood supply. In Hong Kong, blood demand has recorded a 17% increase in blood demand from year 2008 to 2012 with almost 60% blood being transfused to patients aged >60. Therefore, sourcing for more blood to meet demand is one of the most urgent issues in blood service. In this report, we report how we successfully modeled donation preference into the development of a new collection site to leverage the blood demand. Material and methods: Demographic information of all donors with successful donations was retrieved from blood bank computer system for the years 2004-2007. Statistical analyses were performed to determine how frequent they came back to donate, whether residential location affected their donation frequencies and lastly identify potential district in Hong Kong to build a new donor center against the donor and general population distribution.

Results: Of 775,690 donations made by 191,302 male and 201,446 female donors were analyzed. On average 75.8% of donors donated only once during the calendar year but donors were more likely to make repeated donations at donor centers than mobile venues. Significantly more donors would come back for second or more donations at donor center (36.1% vs 20.1%, P < 0.05). Male were more likely to come back for repeated donations than female (43.3% vs 30.9%, P < 0.05). A total of 466,121 donations made at donor centers were further studied. Upon matching with their residential address, distance from donor centers was shown to be a determining factor on their choice of donation through linear regression analysis. Reduced donation frequencies were observed with increasing distance from donor centers. Regression analysis then identified several districts where many donors had to travel a long distance to the nearest donor center. The district with the highest expected increase in donations, adjusted by the expected growth rate, was then chosen as the site for building the new donor center. A fixed donor center was so selected at Yuen Long district and open to donors by 29 July 2011. By the end of year 2011, 6160 donations (consisting of 3047 males and 3113 females) were made with more than 88.1% collection given by donors residing at Yuen Long and the nearby district, Tuen Mun. When the whole year figure was reviewed in 2012, 16,990 donations were collected which already exceeded the planned collection target of 15,000 by year 3. Interestingly, same 88.1% donations were given by donors residing at these two districts. Conclusion: Despite being a small city, the retrospective analysis of donation behavior has provided valuable information in the service planning in Hong Kong. The new donor center was able to reach the planned third-year collection target by 15 months earlier. Further work is being done by using the more recent data to identify the next optimal collection sites for future expansion under most best cost effective way.

Singapore Red Cross, Singapore, Singapore Background: Singapore is moving towards providing more fixed blood donation sites with the aim of enhancing donation experience and encouraging repeat donations. It was recognized that the choice of location and an understanding of the human traffic in the vicinity are elements of success. A 2-prong approach was undertaken to:

Collect information on the footfalls, the social profile and demographics in the designated location. Collect information from potential donors on their preferences and sentiments in relation to operating hours and outreach channels for marketing communications. Method: A month-long study was conducted in the vicinity by observing and counting the human traffic, the crowd density at various exit/entry points at various timings, the flow and direction of the general foot traffic, overall make up of the surrounding district such as types of corporate, civic & religious organizations operating in the vicinity and number of educational institutions. In addition, an on-site survey to determine potential donor preferences and sentiments in relation to operating hours, tactical outreach and design mechanism of the blood centre was also conducted to help develop a tactical marketing communications strategy. The results indicated that during week days, about 85% of people visiting that vicinity were youths aged 16 to 25 (50.5%) and young adults aged 26 to 39 (33.4%). The main purposes of the visit were for work related activities (22%), attending school (19.1%) and shopping (38.1%). On weekends, 76% of these age groups visited the vicinity for leisure activities or to church. Another 24% who visited there were adults age 40-60 years old. Most of the respondents had a specific destinations, and most of them indicated lunch time and after office hours as their preferred donation periods. A tactical marketing communications strategy targeting youth and young adults was developed to meet the behavior and preferences of the target group. Social media platforms such as online mobile app advertising and locational media buys were employed. In addition, partnerships were developed with nearby educational institutions and churches to host road shows and blood donation awareness activities to engage youths and to foster fun and excitement in the social media atmosphere for the blood collection center. The strategies undertaken proofed favorable as the daily attendance at the new blood collection center has surpassed its baseline target collection of 50 units of blood a day within the 3 months of its operation (Jan 2013); and now, has a daily average collection of 60 units of blood.

3A-S10-01 SETTING UP HAEMOVIGILANCE PROGRAMME FROM THE VERY FIRST STEP Background: National haemovigilance programmes wherever established have yielded significant data to implement blood safety initiatives. Settting up a national haemovigilance programme requires meticulous planning and the following issues need to be addressed; whether reporting will be voluntary or mandatory, what is to be reported and by whom, reporting formats and data submission, resources to sustain the programme, staff training and responsibilities. India is a country of 1.18 billion people, 2700 blood centres, one-third each in public, charitable and private healthcare sectors and annual blood collection of 9 million. Given the diversity of blood centre management, setting up such a national programme is a complex task. Aim: To set up a national haemovigilance programme in India. Method: The Ministry of Health and Family Welfare (MoHFW), Govt. of India had launched the Pharmacovigilance Programme of India (PvPI) in July 2010, with oversight by the Indian Pharmacopoeia Commission (IPC). Adverse Drug Reaction (ADR) monitoring centres were setup in 90 medical institutions in the country and trained staff was recruited, for data collection and submission. After the successful launch of PvPI, the MoHFW, initiated the haemovigilance programme, distinct from PvPI with the co-ordinating centre at National Institute of Biologicals (NIB), but in close collaboration with IPC. The broad organizational structure of the programme is as follows; reports will be generated in the medical institution based blood centressubmitted online to the Haemovigilance National Co-ordinating centre at NIBreports will be reviewed by the National Advisory Committee which will make recommendations to the National Co-ordinating Centre, IPC for onward transmission to the regulatory authoritythe Central Drugs Standards Control Organisation to formulate safety related regulatory changes and communicate to blood centres. The programme was formally launched in December 2012. Terms of reference of the National Advisory Committee are: To finalize Transfusion Reaction Reporting Form (TRRF) for the country. To give expert opinion for collection, collation and analysis of data and development of software for the same.

To monitor the quality of data collected. To develop training modules and guidelines for implementation of Haemovigilance Programme.

Results: Based on recommendations of the committee, the initial focus is on reporting serious adverse reactions as defined by the Working Party of the International Society of Blood Transfusion, reporting is voluntary and a Guidance Document and TRRF have been made available to the medical institution blood centres, which are the designated reporting centres. The reporting is online through a software -Haemo-Vigil accessible on the NIB website. Each centre has been given a unique username and password for login. The security of data submitted through the software has been validated. Reporting commenced from February 2013 and till date 434 reports of adverse reactions have been submitted. The data is yet to be analysed. A series of awareness workshops are planned countrywide, five have already been organized. Specific funds have been allocated by the MoHFW for this programme. Conclusion: A well structured programme of haemovigilance has been initiated in India and is now in a phase of development.

3A-S10-02

Background: Congenital haptoglobin (Hp) deficiency being homozygous for a deleted allele of the Hp gene, Hpdel, was identified in a Japanese pregnant woman who had experienced severe anaphylactic transfusion reactions (TRs) after infusion of red blood cells (RBCs) and human serum albumin in 1998. In addition, the allelic frequency of Hpdel was calculated to be 0.015 by a genetic study of a limited number of the Japanese individuals, suggesting that Hp deficiency might distribute among the Japanese population as a phenotype of serum Hp. Aims: In this report, we present the results obtained from a hemovigilance survey carried out between 1998 and 2012, in which Hp deficiency was identified among Japanese patients who had experienced nonhemolytic TRs (NHTRs), and those obtained from a screening of Hp-deficient Japanese healthy blood donors. Materials and methods: Patients with NHTRs: A total of 19,675 patients who had experienced NHTRs, reported by hospitals to the Japanese Red Cross Society between January 1998 and December 2012, were examined. Healthy blood donors: A total of 272,068 blood donors who visited the Japanese Red Cross Blood Centers in the Tokyo area between June and August 2010 were examined. Testing for identification of Hp deficiency: (i) Serum Hp concentration was determined using peak-rate nephelometry with the detection limit of 6 mg/dl followed by simplified sandwich ELISA with the detection limit of 3 lg/dl. Individuals who showed a negative result of ELISA were assessed as Hp-deficient. (ii) The presence of the Hpdel allele was analyzed using an allele-specific PCR method. Testing for anti-Hp antibody: The anti-Hp antibody produced in all the Hp-deficient individuals was measured by ELISA and western blot analysis. It was further analyzed using Ouchterlony or surface plasmon resonance technology in some cases. Results: Thirty-one individuals were identified as Hp-deficient among the 19,675 patients who had experienced NHTRs (0.16%). All the patients, except three who could not be tested, were homozygous for the Hpdel allele. They were transfused blood products [PC, 17; FFP, 1; RBCs, 9; Mixed, 4] . Nineteen of them (61%) experienced anaphylactic TRs accompanied by severe hypotension and the other patients (39%) experienced milder NHTRs. All the patients except one had a history of transfusion. The anti-Hp IgG antibody was detected in 28 patients (90%). In addition to the IgG antibody, the anti-Hp IgE antibody was detected in 20 patients (64%). Hpdeficient individuals were identified among Japanese blood donors with a prevalence of 105/272,068 (0.039%). All the donors were homozygous for Hpdel, except one who was heterozygous for Hpdel, Hpdel/Hp2. The anti-Hp antibody was not detected in 104/105 (99%) of the Hp-deficient donors. Conclusions: The higher prevalence of Hp deficiency caused by Hpdel -homozygosity producing the anti-Hp antibody among the patients with NHTRs than in the normal donors (P < 0.001), suggests a higher risk of such TRs in Hp-deficient patients. Hp-deficient individuals are present among normal healthy donors with a prevalence that is expected from its allele frequency. They might be expected as suitable donors for Hp-deficient patients to prevent Hp-related anaphylaxis.

Hlaing AA

Background and objective: Collection of the correct blood sample from the correct patient is a vital step in the process of safe blood transfusion. Transfusion Labora- Methods: A study on all reports of mislabeled and miscollected specimens from January 2010 to December 2012 was undertaken and the results were analyzed. Mislabeled samples were defined as samples that were incorrectly labeled at the time of collection and miscollected samples were 'wrong blood in tube' samples due to patient misidentification. Errors resulting in discrepancies in blood group between the current blood sample and historical records were identified by program flagging during validation of blood group results. These discrepancies were resolved by requesting a second sample from the patient collected by another person. Some errors detected at the ward level, were reported by the staff member who had sent the blood sample. Workload data for Group and Screen samples received during 2010-2012 was collected from the Annual Transfusion Laboratory Records. Using these data, ratio of errors from mislabeled and miscollected samples, to number of group and screen samples received was calculated.

Results: Between January 2010 and December 2012 a total of 162,999 samples were received for ABO grouping. Of 77 incidents were recorded relating to errors in either sampling or labeling. The overall sample error rate was 0.047% or 1 in 2116 samples. Of 52 cases resulted from wrong labeling during collection, 17 cases were due to patient misidentification, five were errors that had occurred during the initial request, in two incidents the cause could not be identified and one labeling error occurred in the laboratory. All errors in labeling resulted from failure to check the pre printed name label with the label on the patient's identity band. In 14 incidents, labeling was performed away from the bedside, in 11 cases name labels of a different patient were found in the correct patient's medical file, in 25 cases labels were taken from wrong patient's file and two errors were due to using prelabeled tubes. Of 17 patients had been misidentified and blood taken from the wrong person. Root cause for these errors was not following hospital polices in patient identification and sample collection. Sixty-four percent of the errors occurred out of normal working hours, mainly during the night while the rest 36% had occurred during normal hours. Conclusion: We conclude that mislabeling and miscollected sample errors represent a potential for mistransfusion in our institution. The rates of mislabeled and miscollected samples can be used as key performance indicators in this important step in the clinical transfusion process. This baseline data will be used in formulating standards of performance for sample collection and patient identification and, for implementing risk -reducing strategies. Background: Haemovigilance is a surveillance programme dedicated for the practice of blood transfusion. It is an important part of the quality system of the blood programme. Haemovigilance programme in Malaysia was initiated as a national programme in 2003 under the Ministry of Health (MOH). Since its inception in 2003 the Programme has evolved and has become an integral part of our transfusion service. All adverse events and near misses were reported to the National Coordinating Haemovigilance Unit at the National Blood Centre (NBC) using a standardised form and predefined criteria. These were compiled and analysed into an annual report for the National Background: The process of blood transfusion from blood collection and processing to issue and bedside transfusion of blood components involves several areas of human participation. Human error is therefore inevitable in this chain of events. Transfusion laboratories have long focused their attention on quality control methods and quality assessment programmes dealing with analytical aspects of blood testing. However, there is enough evidence to suggest that the steps most prone to error are in fact in the pre and post analytical phases. Various international accreditation bodies now require clear and effective incident reporting protocols to enhance measures for error trapping and error avoidance.

Aims: This study aims to quantify and characterize transfusion errors in a Joint Commission International (JCI) accredited tertiary care centre in India.

Methods: All reports of transfusion related errors, registered in the blood bank or outside, between January 2008 till December 2012 were reviewed and categorised into pre-analytical, analytical and post-analytical events. The process adopted at our centre for assessing Transfusion related events at the patient's side uses widely tested criteria of:

(1) Incident reporting (2) Root cause analysis (3) Identification of corrective actions Results: During the study period 89,156 requests for blood and blood components were received and total of 1,98,505 blood components were issued within the hospital. A total of 16,834 reported errors were analysed. Pre-analytical errors comprised a large majority (13,676; 81.24%), most of them being errors of inadequate patient information on request forms (10976; 65.2%) followed by sampling errors (1756; 10.4%). Analytical errors comprised (563; 3.3%) and post analytical errors accounted for (2595; 15.4%) of the total errors reported. There was no incidence of acute haemolytic transfusion reaction or direct patient harm during the study period but on several occasions near miss events were reported which, if missed could have Background: In Australia, we rely on non-remunerated, voluntary donors to provide sufficient blood to meet patients' needs. For fresh components, the Australian Red Cross Blood Service (Blood Service) is unable to import components for routine use, so is 100% self-sufficient. Hospitals and pathology laboratories are under increasing pressure from Government/s to improve value for money for blood and blood products, which is resulting in extra demands being placed on the Blood Service, especially in relation to lower age at issue and a continuing trend to hold more Group O stock and less of the other groups, especially AB. With a typically seasonal inventory pattern for red cells, the Blood Service has focussed on closer management of Blood Inventory. Aim: The aim of the inventory program was to improve reliability of blood coming into the supply chain and therefore improved reliability in delivery to customers. This is measured by average and variance in the number of whole blood collection packs being receipted at the processing centre. The aim was to reduce the variability in this metric, which would naturally lead to decreased inventory holding requirements, greater control and efficiency, and increased reliability and service to the customers. Order fulfilment is another measure used to demonstrate improvement. Methods: In order to manage blood inventory effectively, the first step was to introduce a minimum and maximum inventory level, by blood type, by state. This provided a transparent target to aim for. The bands were calculated by firstly setting a minimum inventory level using traditional supply chain safety stock calculations. The next step was to develop a 12 week inventory forecast, using a number of planning assumptions. One of the core assumptions is the number of appointments booked in the lead up to a donation. In order to improve reliability, minimum tar-gets were agreed at 3 months out (re-booking time) through to one week out. A 'traffic light' style appointments portal was developed to provide improved visibility of appointment levels for each collection mode and by state.

Results: Results show that the quarterly standard deviation of blood coming in to inventory has improved from 1711 to 1285 in the last four financial yearsa 25% reduction. In addition, order fulfilment has improved from 82% to 95%, demonstrating that, with improved planning systems and processes, it is possible to manage inventory effectively. The results are demonstrated in the two graphs attached. Summary/conclusion: The Blood Service in Australia set a goal to improve reliability of fresh components, in particular, red cells entering finished goods inventory, to improve order fulfilment and provide service excellence to customers. By implementing robust and disciplined planning and reporting systems, reliability has improved which shows that there are methods available to improve the effectiveness of inventory management for blood components.

3A-S11-02

Wooi-Seong K

One of the fundamentals of a blood collection center that procures, processes, stores and supplies blood and blood components to hospitals or other blood banks is an effective and sound management of blood inventory. As blood supply is dynamic, blood supply management requires continuous monitoring and interfacing between blood procurement and inventory management and with hospitals. In an effort to provide adequate, safe and equitable blood supply from voluntary non-remunerated blood donors in the face of increasing demand and decreasing donor population, blood collection centers are also challenged with blood shortages, which unless managed, could impact the healthcare delivery and negatively affect patient care. In order to provide a consistent and reliable blood supply blood centres will have to resort to creative and innovative measure. Malaysia, a unique multicultural and multiethnic country celebrates significant religious and historic events as well as commemorations. As such, Malaysia observes numerous national and state holidays. In fact, Malaysia is ranked as the seventh country in the world in the number of observed holidays. By virtue of its geographical location, Malaysia is not exempt from natural and man-made disasters, the most severe being seasonal monsoon floods and flash floods. These and the poor response to blood donation campaigns as a result of 'balik kampung' phenomenon during major holidays due to mass exodus of Malaysians to their hometowns, contribute to acute seasonal blood shortages in blood collection centers around the country as well as within the region. Adopting a proactive approach to blood shortages includes embracing new measures to recruit and retain blood donors, establishing a blood forecast system, developing a strong network among blood collection centers, being transparent with the blood inventory levels which will lead to greater trust and increased confidence in BTS and having a contingency plan. At National Blood Centre (NBC), the Blood Action Team was formed in 2010. It is a multidisciplinary team comprising of members from the donor education and publicity, donor recruitment, blood procurement, component and processing and inventory divisions as well as medical officers, transfusion medicine specialists and consultant. Meetings are held regularly and this has greatly improved the communication interdepartmentally, and has fostered a team whose members are committed to improving blood supply management and preventing blood shortages through discussion and brainstorming sessions. Also, blood forecasting is carried out as far ahead as months in advance. The blood stock forecasts are also communicated to blood banks from public and private hospitals which are supplied by NBC, a measure to increase transparency.

Since the implementation of these measures, NBC has successfully and effectively overcome the annual seasonal blood shortages for the last 3 years. Evidently, blood shortages are largely preventable by adopting a proactive approach.

3A-S11-03 . The C/T ratios were calculated and analyzed for each major department. NBC and HKL had continuously introduced several interventions to reduce C/T ratios during the period of this study.

Results: The overall C/T ratio for HKL had been reduced from 2.2 in year 2005 to 1.9 in year 2012. The four major departments in HKL that showed high reductions in C/T ratio for the same period were Obstetrics and Gynecology (6.4 reduced to 2.5), Surgical (2.6 reduced to 2.1), Orthopedic (2.6 reduced to 2.1) and Neurology (3.8 reduced to 2.2). In this study, interventions that had contributed to the drastic reduction in C/T ratio were compliance to the Maximum Surgical Blood Order Schedule (MSBOS) which was periodically updated within each department, effective communication between clinician and blood bank staff, and continuous medical education (CME) for house officers and clinicians. The active Hospital Transfusion Committee (HTC) and Hospital Transfusion Team (HTT) also played an important role in reducing the C/T ratio by creating awareness among the paramedics and medical officers regarding the judicious use of blood and blood products, and regular monitoring and audits of the whole transfusion process starting from blood sampling to monitoring of patients during and after transfusion. Summary/conclusions: This study showed that several interventions that have been introduced by HKL and NBC such as continuous medical education, compliance with updated MSBOS, active role of HTC and HTT, and effective communication between clinician and blood bank staff have successfully reduced C/T ratio in four major departments in HKL. This successful achievement needs continuous monitoring and evaluation to ensure consistency. This can also be a role model that is shared with other hospitals to ensure that the C/T ratio is within the set target.

3A-S11-04 fusion) were collected. During second step, a modeling and simulation were used to define the optimal RCl inventory for the metropolitan area. Average RC cell shelflife of regional inventory as well as the number of transfused RCs were calculated. In addition it was hypothesized that an efficient turnover of RC inventory will result in inventory reduction and relatively fresh blood for the transfusion reducing the blood utilization and frequency of transfusion among non-surgical patients especially those with chronic transfusion. Results: Dynamic inventory management and application of inventory index at regional level (four referral hospitals providing direct health care services to 1.4 and specialized services to 2.0 million population) reduced the regional RC inventory by 32% (1100 RCs to 750 RCs; Optimal hospital inventory index of 7.5). This change in inventory was accompanied by a reduction in shelf-life of transfused red cells at 36% (average shelf-life of transfused RCs reduced from 3.45 to 2.21 weeks). The total annual RC utilization and specific categorical data of patients prior to and after the implementation of BUMP (2010 and 2012) included in Table 1 .

Conclusion: Optimization of RC inventory by application of Inventory Index improved the pattern of regional blood utilization. Red cell utilization among chronically transfused patients was decreased by 20% (average). Chronically transfused hematology and renal patients showed the highest reduction on RCU (21-26%, P value < 0.0001). That was no change in amount of surgical transfusions. Non-surgical (medical) category showed a mild reduction (4%) but statistically was not significant. The results indicate that implementation of BUMP could significantly improve red cell utilization among chronically transfused patients. This change may also result in reduction of transfusion associated adverse reactions and long term complications like as iron overload.

3A-S12-01

No Abstract available.

3A-S12-02

Burnouf T 1 , Tzeng YS 2 , Deng SC 2 , Wang CH 2 , Tsai JC 3 and Chen TM 2 1 Taipei Medical University, Taipei, Taiwan 2 Tri-Service General Hospital, Taipei, Taiwan 3 Tatung University, Taipei, Taiwan

Background: Approximately 15% of diabetic patients develop chronic ulcers, and 25% of those may undergo foot amputation. Activated platelet gel, which contains growth factors, has been proposed as an adjunct to promote healing of small diabetic foot ulcers. For large un-healing diabetic ulcers, skin graft is usually needed. We have demonstrated that single-donor allogeneic platelet gel and fibrin glue improve skin grafting to achieve successful persistent healing of large ulcers [1]. However, it is not known whether autologous platelet gel can be beneficial in this application. Aims: To evaluate in a prospective study the safety and efficacy of using autologous platelet gel to enhance skin graft take in non-healing diabetic lower extremity ulcers. Methods: Approval was obtained from the Institutional Review Board of our hospital. Eight consecutive diabetic patients aged 25-82 with nine non-healing lower extremity ulcers (median size of 50 cm 2 ; range 15-150 cm 2 ) were enrolled. Their median duration of diabetes and ulcer was 10.6 years (range 5-25 years) and 6.5 months (range 3-24 months). None of the patients had received conventional skin grafting in the past. PRP was prepared from 100 ml of venous blood using SEP-AX-VGR protocol (Biosafe SA, Switzerland). Autologous thrombin was prepared by activating 10 ml of plasma (TGD-001; Merries International Inc., Taiwan). Skin ulcer was debrided to remove the infected and necrotic tissues and covered with moist saline dressing. Daily dressing change without additional treatment was performed. The wound was sprayed after 7 to 10 days with equal volumes (5 to 7 ml) of autologous PRP and autologous thrombin to form the platelet gel within 5-10 s. Thin-splitthickness skin graft with multiple slits was then applied on the wound bed and fixed with staples or cat-gut sutures. Each patient was placed on antibiotics during the course according to wound cultural results. Bolster dressing with sofa-tulle were used to avoid post-graft hematoma formation. Negative pressure wound therapy (VAC) was not used in this study.

Results: There was no adverse reaction during the study. Eight out of nine skin grafts took well (88% healing rate). The interval between skin graft and complete wound healing ranged from 2 to 3 weeks in the eight successful cases. No ulcer recurrence was noted during the 2-19 months follow-up period. The non-successful case was an attempt to treat an ulcer that was deep to the periosteum of calcaneus bone. Free tissue transfer would have been required, but the patient refused the microsurgery, due to age and medical condition, which led to skin graft loss.

Conclusion: This study shows for the first time, to our knowledge, the possibility to use platelet materials in combination with skin graft procedures to treat large nonhealing diabetic ulcers of lower extremity Recently, human platelet lysates (PL) rich in growth factors were shown to replace FBS for ex vivo expansion of various cells, but whether they can be used for CEC expansion is unknown. Aims: To evaluate the possibility to isolate and propagate CECs ex vivo using a xenogeneic-free, recombinant growth factor-free medium supplemented exclusively with human PL. Methods: PL was prepared by CaCl 2 activation of apheresis platelet concentrates from three volunteer donors, and centrifuged to obtain a fibrin-free supernatant that was heat-treated (56°C/30 min; HPL) or not. PL was characterized for proteins, platelet growth factors (PDGF-AB, BDNF, EGF and VEGF) and chemical composition. CECs were obtained from over 10 bovine corneas (BCECs) using standard procedures and grown in a DMEM-F12 medium (containing sodium bicarbonate, selenium, and antibiotics) supplemented either with (i) 5% FBS, 0.5% DMSO, 2 ng/ml rhu-EGF, 5 lg/ml insulin, 5 lg/ml transferrin, and 1 nM cholera toxin (termed '5% FBS medium'), or with (ii) 2.5%, 5%, 7.5%, or 10% PL or HPL as the only source of protein nutrients and growth factors. Cells were grown in duplicates in 6, 24 or 96-well plates at 37°C in a controlled atmosphere containing 5% CO 2 , with medium changes every two days. Viable cells were counted for 7 days and cell viability was determined by MTT assay. BCEC phenotype was determined by immunostaining using anti-phospho-connexin 43, anti-Na/K ATPase alpha-1 subunit, anti-ZO-1 and purified anti-N-Cadherin. Anti-mouse and anti-rabbit IgG FITC were used as the second fluorescent antibodies. Results: PL or HPL contained 55-60 mg/ml total proteins, and a range of approximately 30-40.5, 23.1-32, 0.44-1.82, and 0.24-0.39 ng/ml of PDGF-AB, BDNF, EGF, and VEGF platelet growth factors, respectively. CECs could be expanded in a med-ium supplemented with 2.5-10% PL or HPL. Interestingly, better cell BCEC morphology and adherence was found when using HPL compared to PL. Cell growth and MTT equivalent to that of the '5% FBS medium' could be achieved only using 10% HPL. In addition, BCECs could be isolated from bovine corneas and subsequently expanded using the DMEM/F12 medium supplemented with 10% HPL. BCECs expanded in the HPL-medium maintained their typical morphology, adherence, transparency and phenotype. Conclusion: BCECs can be isolated and expanded ex vivo in a growth medium supplemented solely with human platelet lysate material. Although further studies using CEC from human origin are mandatory to confirm these conclusions, such findings open a possible new paradigm for GMP-compliant, clinical-grade ex vivo propagation of CEC and regenerative therapy protocols of human corneal endothelium. Platelets are the smallest and second most abundant circulating cells in the blood and their primary role is to maintain the integrity of the vasculature. When blood vessel injury occurs, platelet adhesion and activation receptors recognize subendothelial matrix proteins such as collagen and this can initiate a coordinated series of reactions leading to the formation of a fibrin clot to arrest bleeding. It appears, however, that in addition to hemostasis, platelets also have important inflammatory and immunological functions. As early as the 1960's, reports began to demonstrate that platelets may play an active role in the stimulation and regulation of immune responses. For example, platelets can store and secrete several pro-and anti-inflammatory chemokines (e.g. Platelet factor 4 and RANTES) and cytokines (e.g. Interleukin-1b and Transforming growth factor-b) that can affect local immune responses such as chemoattracting neutrophils to sites of tissue damage. On the other hand, platelets may be able to directly regulate adaptive immune responses via their ability to express and secrete CD40/ CD40L co-stimulatory molecules. More recent reports have also suggested that depending on their activation state, platelets may be able to either suppress CD8+ T cell responses or under certain circumstances, present MHC class I associated peptides to activate CD8+ T cells. These studies have suggested that platelets represent a critical link between innate and adaptive immunity. Platelet MHC class I expression may also have a detrimental role by conferring tumor cell resistance against immune attack. Of perhaps greater interest, platelets have been shown to express the entire family of Tolllike receptors (TLR) and this may allow them to act as circulating sentinel cells that first encounter bacterial products for presentation to the innate immune system. In particular, surface expression of platelet TLR4 enables platelets to present lipopolysaccharide to mononuclear cells and neutrophils which modulates their phagocytic capabilities and this has implications for the development of immune platelet disorders.

Furthermore, TLR9 appears to be contained within a unique platelet granule underneath the cell surface that can be expressed by platelet activation. Thus, elucidating the role of platelets in sepsis and a better understanding of the apparent central role that they play as immune cells may be important for the potential development of efficient therapeutic modalities against infections. This lecture will highlight the many characteristics of platelets as immune-like cells will discuss how platelets may be the major controllers of immune responses.

Macquarie University, Sydney, Australia

Malaria remains a major health problem in most of the tropics, and is especially burdensome in economically underprivileged areas. Our ability to reduce the high rates of morbidity and mortality due to malaria are hampered by wanning efficacy of current antimalarial drugs and the spread of insecticide-resistant mosquitoes. We desperately need a greater understanding of how the Plasmodium parasite succeeds in invading and growing within red cells, how the host responds to an infection, and importantly, the protective mechanisms employed by the host to combat the infection. Platelets regulate blood haemostasis, but are now also regarded as an important component of the body's early innate defense against invading microbial pathogens.

Recently, my laboratory discovered that platelets are able to protect against a malaria infection. In mouse models of malaria, survival to a chronic infection is reduced when platelet levels are artificially depleted. Purified human platelets directly bind to P. falciparum-infected red cells in culture and kill parasite within. Our current work is exploring how platelets can kill intrerythrocytic malaria parasites. I will present our current understanding of the platelet and red cell molecules involved in the killing mechanism. These include the platelet cytocidal molecule, Platelet factor 4 (PF4) and the erythrocyte Duffy-antigen molecule, which binds PF4 and mediates the platelet killing effect. The critical requirement of Duffy has lead us to propose that platelet-mediated protection against P. falciparum infection is compromised in individuals homozygous for the common Duffy-antigen negative allele.

3C-S13-01

Graduate School of Medicine, The University of Tokyo, Tokyo, Japan

Although bleeding is a major side effect of heparin, which is used for treatment of thrombosis, heparin also causes a prothrombotic adverse drug reaction called heparininduced thrombocytopenia (HIT). HIT is caused by the development of platelet-activating antibodies (HIT antibody), which is directed against the heparin and platelet factor 4 (PF4) complex. These reactions accelerate platelet activation and coagulation, leading to thrombosis. Thus, if HIT is strongly suspected clinically in cases of thrombocytopenia and thromboembolism that occur during or after heparin therapy, it is vital to stop all heparins and start administering an alternative antithrombotic drug immediately.

In Japan, a test to screen for HIT antibody (the automated immunoassays based on two types of chemiluminescent immunoassay and a latex-enhanced immunoturbidimetric assay) was approved as a clinical laboratory test in the medical insurance system, in September 2012. Only the latex agglutination test is now widely used clinically because of its simplicity, convenience and cost-effectiveness. However, these immunological methods, including enzyme immunoassays (EIAs), which detect binding of antibodies to immobilized PF4/heparin complexes, may not be employed suitably. The immunological HIT tests are useful in diagnosing HIT because of their high sensitivity; however, they also often cause overdiagnosis of HIT. The value of the selected cut-offs is the key element in ruling out HIT. Consequently, HIT should be confirmed through laboratory detection of platelet-activating antibodies by using functional assays for the HIT antibody; it must also be diagnosed based on careful consideration of the clinical picture. In order to diagnose HIT properly, our laboratory asks clinicians to assess the pretest probability of HIT by using the scoring system (the '4T' scoring: thrombocytopenia, timing, thrombosis, and other explanations). Furthermore, our expert staff ensures that the diagnosis is correctly performed, since HIT has not been fully recognized in clinical practice in Japan as compared to in Western countries. The functional assay for HIT antibody has been regarded as the gold standard for diagnosing HIT in patients in spite of its disadvantages. The platelet activation test procedure is cumbersome, the tests are technically challenging, and limited to specialized laboratories. Additionally, the most important requirement for the test is the selection of platelet donors with high reactivity to the platelet activation antibodies. Accordingly, in Japan, there are very few places where the functional assay is conducted, whereas many institutions still assess patients with only the immunological assay. In our laboratory, the heparin-induced platelet aggregation method is performed, as isotopes such as radiolabeled serotonin release assay should not be commonly used in routine laboratories.

In an attempt to improve the sensitivity of the functional assay, we developed two methods for increasing HIT antibody reactivity in donor platelets. One is the cooling donor platelet method, used for improving reactivity, and the other a way of donor selection by using monoclonal HIT antibody. Further studies are necessary to introduce a simple assay method in ordinary laboratory testing to detect platelet-activating antibodies.

3C-S13-02

Autoimmune or immune thrombocytopenia (ITP) is an acquired bleeding disorder with a low platelet count mediated by immune-mediated mechanisms. This condition is seen in patients with various associated diseases, such as systemic lupus erythematosus, and can also occur without an underlying disease. Production of IgG autoantibodies to platelet surface glycoproteins, such as GPIIb/IIIa and GPIb, is the hallmark of the disease. It has been thought that anti-platelet autoantibodies promote platelet clearance in the reticuloendothelial system, but recent findings indicate that anti-platelet antibodies also suppress megakaryogenesis, resulting in impaired platelet production. The diagnosis of ITP continues to be one of exclusion. Several antigen-specific assays for detection of anti-GPIIb/IIIa and anti-GPIb antibodies are reported to be useful in identifying ITP patients, but these assays require complicated procedures such as platelet solubilization, and use of commercially unavailable monoclonal antibodies. To solve these problems, we have developed an enzyme-linked immunospot (ELISPOT) assay for detection of circulating B cells secreting IgG anti-GPIIb/IIIa and GPIb antibodies, which is a sensitive, specific, and convenient method for evaluating the anti-platelet autoantibody response. In addition, reticulated platelets and circulating thrombopoietin (TPO) are useful in evaluating platelet production status. These findings led us to propose preliminary diagnostic criteria for ITP based on a combination of ITP-associated laboratory findings, including erythrocyte and leukocyte counts, anti-GPIIb/IIIa antibody-producing B cells, platelet-associated anti-GPIIb/IIIa antibodies, percentage of reticulated platelets, and plasma TPO.

Although the etiology of ITP remains unknown, complex dysregulation of the immune system is observed in ITP patients. Based on a series of experiments using CD4+ T cells reactive with GPIIb/IIIa derived from ITP patients, we have proposed a 'continuous pathogenic loop' model as a mechanism that explains ongoing antiplatelet antibody response in ITP patients. This model includes B cells that produce anti-platelet antibodies, reticuloendothelial macrophages that phagocytose opsonized platelets via Fcc receptors and present platelet-derived antigenic peptides, and platelet-reactive CD4+ T cells that exert their helper activity upon recognition of the antigenic peptides. Once this pathogenic loop is established, anti-platelet antibody production would go on endlessly. Recently, regulatory systems that control this pathogenic loop are attracting a great deal of attention. A series of studies in ITP patients have found that FoxP3+ regulatory T cells are reduced in circulation, bone marrow, and spleen, and are deficient in their suppressive function. In addition, a critical role of regulatory T cells in preventing the anti-platelet autoimmune response has been demonstrated in mice deficient in regulatory T cells, which spontaneously develop anti-platelet autoantibody-mediated thrombocytopenia. In addition, our recent analysis indicates that the eradication of Helicobacter pylori leads to up-regulated expression of inhibitory FccgRIIB on macrophages, resulting in the attenuation of the pathogenic loop. Therefore, therapeutic strategies aimed at interrupting this pathogenic loop would inhibit anti-platelet autoantibody production and subsequent increase in platelet count. In fact, current treatment regimens for ITP, including corticosteroids, splenectomy, and rituximab, are able to suppress the pathogenic loop. Interestingly, TPO mimietics have a potential to induce peripherally induced regulatory T cells, resulting in suppression of the pathogenic loop.

3C-S13-03

Seguchi S 1 , Maeda T 1 , Kanaumi Y 1 , Kawamura S 1 , Kodama M 1 , Kawai T 1 , Okazaki H 2 and Miyata S 1 1 National Cerebral and Cardiovascular Center, Osaka, Japan 2 The University of Tokyo Hospital, Tokyo, Japan

Background: Heparin-induced thrombocytopenia (HIT) is a devastating immunemediated thromboembolic complication of heparin therapy. Heparin administration can cause conformational changes in platelet factor 4 (PF4), resulting in the production of anti-PF4/heparin antibodies. A subset of these antibodies can activate platelets and monocytes (HIT antibodies), leading to thrombocytopenia and a thrombininduced hypercoagulable state. Up to half of HIT patients suffer from arterial or venous thrombosis. If platelet concentrates are transfused into HIT patients, it is conceivable that the transfused platelets can be activated by the same mechanisms that affect the patient's own platelets and trigger the onset of new thromboembolism or exacerbate HIT-associated thromboembolism. Thus, platelet transfusion is thought to be contraindicated in acute HIT patients. However, it remains uncertain whether platelet transfusion is a risk factor for thrombosis in HIT patients since only a few studies have investigated this issue systematically. Aim: The goal is to clarify whether platelet transfusion increases the risk of thrombosis in HIT patients. Methods: We constructed a nationwide registry for HIT with the approval of the Ethical Review Committee. Between August 2008 and May 2013, 329 patients from 185 hospitals clinically suspected of having HIT were retrospectively included in the registry with clinical information such as changes in platelet count, timing of heparin administration, episodes of transfusion, thromboembolic events, and the results of serological assays for HIT antibodies. HIT was definitely diagnosed by the detection of anti-PF4/heparin IgG with platelet-activating properties at a therapeutic heparin concentration, but not at a high heparin concentration or with anti-FccRIIa antibodies. The assay was performed using washed platelets prepared from HIT antibody-sensitive healthy volunteers at a reference laboratory. We examined patients who received transfusions of platelet concentrates after HIT was suspected. Results: Of the 329 patients, 85 patients were ultimately diagnosed with HIT (25.8%). Optical density values of anti-PF4/heparin antibodies detected by ELISA were significantly higher in HIT patients than in non-HIT patients (2.3 AE 0.95 vs 0.36 AE 0.53 for IgG/A/M, P < 0.001; 1.68 AE 0.80 vs 0.25 AE 0.37 for IgG, P < 0.001). The incidence of thromboembolic events was significantly higher in HIT patients (51.8%) than that in non-HIT patients (28.3%; P < 0.001). Among the 85 HIT patients, 20 patients received platelet transfusions after the onset of HIT. Only two of them experienced a thromboembolic event after platelet transfusion, one within 24 h and the other after 9 days. Notably, neither patient was being treated with a thrombin inhibitor at the time. The incidence of thromboembolic events in HIT patients who received platelet transfusions was not significantly higher compared to HIT patients who did not receive platelet transfusion or non-HIT patients who received platelet transfusions after the suspicion of HIT arose, respectively. Conclusions: To our best knowledge, this is the first systematic report that clarifies the clinical impact of platelet transfusion on the occurrence of thromboembolic events in acute HIT patients whose diagnosis was confirmed by a washed plateletactivating assay. Even in acute HIT patients who possess platelet-activating antibodies, the transfusion of platelet concentrates does not appear to increase the risk of thromboembolism, especially while on thrombin inhibitor therapy.

3C-S13-04

Lu P, Ling B and Li RS

Background: Transfusion platelet matches with antigenic similarity would evoke less allorecognition and immune activation. Strategies have been based on the theory that selection for HLA-A and HLA-B cross-reactive groups (CREGs) compatible donor as well as ABO/HPA-matched donor will predict good increment in platelet corrected count after platelet transfusion. Aim: Establish large-sized platelet donor registry with HLA class I,HPA,ABO-typed to meet the needs of immunized patients with platelet transfusion refractoriness. Evaluate the effectiveness of platelet transfusion therapy in PTR patients. Progressive management to PTR patients maintain a long-term platelet transfusion strategy. Methods: To establish platelet aphaeresis donor registry in Shanghai, 1931 repeat donors were typed for HLA-A, -B and HPA-1,-2, -3, -4, -5, -6 and -15 using standard PCR-SSP method. Eighteen patients with hematologic or oncologic diseases which refractoriness to platelet transfusions from random donors who are receiving 36 units of apheresis platelet products transfusion were studied. Results: Eighteen patients(eight male, 10 female)showing platelet refractoriness to random donor platelets [1 h corrected count increment (CCI) <7500 ml/m 2 , percentage of platelet recovery (PPR) <20%] before. Patients phenotyped for both HLA-A,B and HPA-1,-2, -3, -4, -5, -6 and -15. Apheresis platelets from donor registry in Shanghai matched to patients ABO, HPA and HLA-A and HLA-B cross-reactive groups (CREGs) are transfused. Ten patients ( show 24 h PPR >20%. The mean 1, 24 h CCI and PPR values from the best donors were significantly higher than those from random donors they transfused before.

Conclusion: The use of HLA-A,-B and HPA,ABO-compatible aphaeresis platelet improves posttransfusion 1, 24 h CCI values and percentage of platelet recovery in refractory patients. Transfusion with HLA-A,-B and HPA,ABO-matched platelets is mandatory to reduce the risk of bleeding in PTR patients. Refractoriness to platelet transfusions developed at least in 50% of the patients we observed and to maintain a long-term platelet transfusion strategy. Establish large-sized platelet donor registry with HLA class I, HPA, ABO-typed may be needed to circumvent platelet-specific antibodies of unknown specificity in all chronically transfused patients. The optimal strategy for platelet substitution in immunized patients remains a challenge.

3C-S13-05

Xia W 1 , Xu X 1 , Ye X 1 , Fu Y 1 , Deng J 1 , Liu J 1 , Ding H 1 , Chen Y 1 , Shao Y 1 , Wang J 1 , LI H 2 and Santoso S 3 1 Guangzhou blood center, Guangzhou, China 2 Department of Biotechnology, Guangdong Food and Drug Vocational College, Guangzhou, China 3 He Institute for Clinical Immunology & Transfusion Medicine, Justus-Liebig Univ., Giessen, Germany

Background: Immunization against CD36 leads to the production of anti-Nak a antibodies associated with fetal/neonatal alloimmune thrombocytopenia (FNAIT), platelet transfusion refractoriness (PTR) and post-transfusion purpura (PTP). However, no data regarding the clinical relevance of CD36 immunization is currently available for Chinese population. Study design and methods: Platelets and monocytes derived from 998 healthy blood donors were typed for CD36 deficiency using flow cytometry. In addition, four patients with suspected FNAIT (one case) and PTR (three cases) were investigated. Nucleotide sequencing was performed to identify the mutations underlying the CD36 deficiency. Transfection in mammalian cells (HEK-293T) with CD36 mutated constructs was conducted to confirm these results. Anti-Nak a antibodies were screened by the use of platelet solid-phase kit (PAK-PLUS, GTI Diagnostics).

Results: Of 18/998 blood donors failed to express CD36 on their platelets surface. In 5/12 individuals no CD36 expression was detected both on platelets and monocytes, suggesting that the frequencies of type I CD36 deficiency (platelets and monocytes) and type II CD36 deficiency (platelets only) were approximately 0.5% and 1.3%, respectively. Nucleotide sequencing analysis of type I CD36 deficient individuals revealed eight different mutations; four of them were not described so far. However, 1228-1239del ATTGTGCCTATT and 329-330delAC appeared to be the most common mutations related to type I CD36 deficiency in South Chinese population. Further analysis showed that the presence of anti-Nak a antibodies in one healthy donor (Donor 1) as well as in three cases of PTR (Patients 2-4) and one case of FNAIT (Patient 1). These results could be confirmed by immunoprecipitation using biotinylated platelets and by antigen capture assay with stable transfected CD36 cell lines. In all PTR patients, transfusion with platelets derived from CD36 negative donors resulted in good increment (24 h, PPR >20%). Table 1 shows the mutations found in these five GPIV defective individuals. Conclusions: More than 0.5% of CD36 type I deficient individuals are at risk to be immunized through blood transfusion or pregnancy in China. In this study, we could demonstrate that this immunization is of clinical relevance for the development of PTR and FNAIT. Therefore, testing of anti-Nak a antibodies should be considered in suspected immune mediated thrombocytopenia. A national registry of CD36 deficient blood donors should be established to maintain bleeding disorders associated with anti-Nak a antibodies. Since immunization against CD36 is conceivable for other Asian populations an international network within laboratories in South Asian region should be established in the future.

3C-S14-01 DO WE REALLY NEED FFP? THE EVOLVING ROLE OF PF24 AND PRE-THAWED PLASMA Devine D

Fresh frozen plasma (FFP) is defined as plasma frozen within 8 hours of collection. While this product maintains a high functional activity of both coagulation factors and anticoagulant proteins, there has been recent movement in some jurisdictions away from reliance on FFP. In many blood systems, an increasing role for plasma frozen within 24 h of collection (FP24) is seen. Such plasma shows little difference in functional protein levels when compared to FFP, with the exception of FVIII levels which a show time related decay of activity. Even factor VIII loss can be consistently minimized if whole blood is held on controlled rate cooling plates prior to preparation of FP24. In addition, the activity profiles of coagulation proteins in FP24 prepared in routine production closely resemble those of commercial pooled plasma products. Taken together, these observations have led many blood systems to move from the exclusive use of FFP to a mix of inventory of FFP and FP24, if not to the complete removal of FFP from their menu of offerings. The preparation of cryoprecipitate has also been a driver for the retention of plasma frozen within 8 h of collection. Since the most common labeling of cryoprecipitate has focused on the content of both fibrinogen and factor VIII, in part owing to original role of the latter in the treatment of hemophilia A, collection of FFP has persisted as the starting material for cryoprecipitate production. In jurisdictions where hemophilia or other factor VIII deficiencies are treated with factor concentrates, the labeling of cryoprecipitate to emphasize its antihemophilic factor activity is no longer warranted. As data began to accumulate on FP24, similar studies began to appear that investigated the effect of prolonged cold storage of plasma that had been thawed. This led to the introduction in some jurisdictions of the extension of the allowable period of use for thawed plasma from 24 h to up to 5 days, if stored at 4°C. Such practice is increasingly widespread and there is no evidence that patients receiving such products are compromised. From the perspective of health resources management, the use of both FP24 and pre-thawed plasma reduces discard of products or prevents the use of these products in non-group specific recipients. With the advent of massive transfusion protocols which may require pre-thawed plasma at the ready, it also allows better use of relatively scarce but high demand products such as AB plasma. This presentation will focus on a review of the relevant studies of plasma quality for FFP, FP24 and pre-thawed plasma. We will review the appropriate uses of these different components as well as groups of patients for whom specific products should be restricted or supplemented.

3C-S14-02

Background: In 2008, the Australian Red Cross Blood Service (Blood Service) began a programme of process improvement aimed at maximising the manufacture of clinical plasma components from male donors, which is a key mitigation to the risk of TRALI (Transfusion Related Acute Lung Injury). The challenge of sourcing all clinical plasma from male donors is exacerbated in Australia due to its adherence to the Council of Europe guidelines that stipulate a maximum allowable time between collection and freeze of apheresis-derived clinical plasma of six hours, which is considerably more stringent than for most other blood services despite the greater tyranny of distance that exists in Australia.

Aim: The aim of the programme was to achieve a result of 100% of clinical plasma sourced from male only donors. Methods: Work began in early 2008 to gather detailed quantitative data that linked information on donor panel to collection centre to production facility, and that could be broken down by blood group and by day of the week. This was then formulated into a suite of reports, highlighting opportunities and variance in performance. Based on those reports, a cross-functional team designed a range of improvement initiatives across disciplines such as transport, systems enhancements, donor acquisition and processing, such as: Incoming blood donation shippers were marked with colour coded labels that notified the receiving production facility of clinical suitability. This assisted with prioritisation and workflow management. Additional deliveries of blood from collection centres to processing centres. A range of targeted campaigns and marketing collateral were produced to attract male donors to apheresis plasma donation Donor centre collection staff were trained to convert male AB donors over to plasmapheresis donation activity.

Changes to Progesa to prevent manufacture of female plasma were made (after a time).

Results: The first report in July 2008 showed that the Blood Service were issuing 87.71% male clinical plasma; the Group AB rate was 57.86%. The results improved dramatically by November 2010 in groups O, A and B (99.64%, 99.72% and 99.62% respectively), allowing for Progesa to be configured to prevent the routine manufacture of female plasma from those groups, whilst still allowing supervisor over-ride. By March 2012, the results in group AB had improved to 97.77% (chart below) and the directive was given to manufacture male clinical plasma only as routine. January 2013 was the first month ever where 100% of all clinical plasma was sourced from male donors only. In 2012/13, 99.98% of clinical plasma was male onlythe 0.02% constituted short lead time requests for IgA deficient plasma. Subsequent to a system change that allowed for a donor identification marker for IgA deficient donors, inventory levels of this sub-product have increased by 34%, negating the need to turn female production on to accommodate sporadic demand. Summary/conclusion: The multi-disciplinary efforts over an extended period of time have resulted in the practical removal of the risk of TRALI in Australia. This is an achievement that many thought impossible and one that many other blood services have been unable to attain. Results: Quality control (QC) parameters were measured in the prepared blood components and were listed in Table 1 . By standardising BC volume and haematocrit in the primary separation, recovery of red cells and plasma was optimised in both the red cells in SAGM and plasma units while WBC and RBC contamination levels in PC and plasma were maintained low. All parameters were well within the blood component specifications set out in the Council of Europe Guide (16th Edition), the standard adopted by HKRCBTS. QC parameters of the pathogen reduction-treated platelet concentrates in PAS so produced were also within the HKRCBTS blood component specifications. Low contamination with red cells and white cells were demonstrated and the pH range was acceptable after 5 days of storage at 20-24°C.

The new T&B production method for the separation of 450-ml Quadruple WB and the preparation of INTERCEPT platelet concentrates in SSP+ PAS was successfully developed and can be applied to the production of high quality blood components in preparation for clinical evaluation of the pathogen reduction-treated platelet concentrates.

3C-S15-01

Blood donors are healthy volunteers who give whole blood or blood components by apheresis for altruistic motives. They should be managed in a way that ensures high standards of care. Nevertheless, there are recognized adverse reactions that can occur during blood donation. The overall incidence of complications directly related to blood donation is 1%. They are generally more common in women, in younger and in first-time donors. Although the incidence seems to be small, it is of great importance considering the large number of people giving blood each day worldwide. Adverse blood donation reactions can generally be minimized or avoided by appropriate donor selection and care, and appropriately trained staff. Vasovagal episodes and soft tissue injuries (bruises/haematomas at the venepuncture site) are the most common donor reactions. The majority of these are minor and donors usually recover quickly; however, these reactions can be of concern to donors and reassurance should be provided. Other reactions include nerve injury and arterial puncture which, although less frequent, may require medical care outside the blood service and may lead to prolonged symptoms or incapacity. Staff should be trained to recognize and manage such adverse reactions, including the provision of first aid. The incidence of bruising should be monitored so that further venepuncture training may be provided to staff as necessary.

Iron deficiency in regular blood donors has been a top donor health and safety concern in many countries. As each donation causes a loss of 213-236 mg of iron, repeat donation can lead to a continuous depletion of body iron stores. Studies have shown that donation frequency had the greatest impact on iron deficiency and further risk factors were lower weight and female gender. To address this issue, many blood services encourage donors to take iron-rich food and/or give them iron supplements. Adverse reactions such as delayed faint may occur after the donor leaves the donation venue. Donors should be advised to inform the donor centre staff of any ill-effects they suffer after donating. A system for the reporting and investigation of adverse donor events and reactions should be in place as part of the donor haemovigilance system. All adverse events and reactions in donors should be identified, documented and reported. These data should be regularly analysed for possible corrective and preventive actions. The goal of donor haemovigilance is to reduce the occurrence of adverse events and reactions and improve the outcomes both for donors and patients. For various reasons, even today, donors often do not receive detailed information on the blood donation procedure and possible complications. Not only do blood services have the ethical duty to inform donors of possible adverse events to enable them to give informed consent and take action for preventing adverse effects, protecting the safety of donors is also important for donor retention because a safe and good donation experience ensures donors will return regularly.

3C-S15-02

Wiersum-Osselton JC TRIP National hemo-and biovigilance office, The Hague, The Netherlands

Background: Without blood donations and the availability of blood transfusion, many important therapeutic advances could not have been achieved. Donor hemovigilance is the systematic monitoring of adverse reactions and incidents in the whole chain of blood donor care, with a view to improving quality and safety for blood donors.

Method: This 'global update' draws on work by the International Haemovigilance Network and International Society for Blood Transfusion haemovigilance working party, experience in The Netherlands, as well as a Pubmed search using terms blood donor and adverse reaction. Results are discussed for vasovagal reactions, needlerelated complications, long-term morbidity, donor iron status and frequent apheresis.

Results and discussion: The occurrence of vasovagal reactions is associated with young, female donors, lower body weight and estimated blood volume, first-time donor status. A reduction of vasovagal reactions has been documented with use of a water drink before donation, muscle tensing, social distraction and lower collection volume for donors with small estimated blood volume. Needle injury is relatively frequent as a cause in cases of long-term morbidity; needle injury is associated with traumatic phlebotomy and in some cases nerve damage is documented. Repeated whole blood donations lead to reduction of body iron stores and in some cases anaemia. Some blood services adjust donation intervals to avoid or reduce this, while others have or are considering a policy of iron replacement therapy. Fewer studies on acute complications in plasma and other types of apheresis have been published. Preliminary studies of bone density and protein levels in non-commercial frequent plasma donors have not substantiated any specific hazard despite theoretical concerns of calcium or protein depletion. International collaboration in strengthening donor vigilance definitions and data analysis may in future increase potential for study of risk factors and measures to improve donor care worldwide. Conclusion: Donor vigilance is gaining international interest and has increased knowledge of risk factors for vasovagal reactions associated with blood donation. There remains a need of research and of developing preventive measures, including prevention and treatment of needle injury as well as possible long-term effects of frequent donation. Assuming that these donors were newly infected, it is crucial for BTS to monitor the prevalence of this category of donors in order to strategize specific measures to these targeted groups to improve blood safety.

Aims: This study aimed to profile blood donors who donated during the HIV serological window period and to identify the risk factors of these blood donors.

Methods: Past donor records of blood donors who had donated blood during the HIV serological window period (NAT Ultrio and discriminatory detected and negative for both anti-HIV and p24 antigen) at NBC or at blood mobiles organized by NBC from November 2007 until July 2013 were retrieved and analyzed using SPSS 15.0.

Results: A total of 18 donors were NAT detected and negative for anti-HIV and p24 antigen (none in 2007, 2 in 2008, 2 in 2009, 1 in 2010, 6 in 2011, 4 in 2012 and 3 in 2013 Introduction: In Pakistan, the predominant reliance for blood supply is on the Replacement donors, as sufficient numbers of voluntary blood donors are not available. An increase in the proportion of voluntary donors following the promotion of the concept of Voluntary Non-Remunerated Blood Donation (VNRBD) will enhance safety and will also help to shift the responsibility for arranging blood availability from the patients to the health care system. Objective:

The objective of the current study was to promote VNRBD through a Public Awareness Campaign (PAC) based on a thorough analysis of the Knowledge, Attitudes and Practices (KAP) of a key segment of the society, i.e. 18-25 years old college and university students. Material and methods: A cross-sectional, descriptive study was conducted over a period of three months (Jan-Mar 2012). Multi-stage random cluster sampling approach was followed and college and university students were targeted through 20 University based Blood Donor Organisations (BDOs) out of a total 56 BDOs identified. All the participants voluntarily participated in the study and informed consent was obtained orally. A pre-tested questionnaire comprising of 28 questions related to Knowledge, Attitudes and Practices was applied. The questionnaire was kept anonymous and each question included multiple options or statements. Statistical analysis was conducted by the assistance of Statistical Package for Social Sciences (SPSS) software version 17. Results: A majority (65%) of the students had heard about blood donation through family/friends and a minority (9%) through the internet, although 45% preferred internet as spare time activity. Majority (+85%) of the students had access to the internet and mobile phone. More than 50% of the respondents had donated blood: 22% donated for family, relatives or friends, 4% donated voluntarily as an act of altruism, and 25% donated voluntarily once and then stopped donating, but 55% of these respondents still considered themselves as volunteer blood donors. 35% indicated that important people in their environment had an influence on crucial decisions that they made. Motivation for blood donation was a desire to help other people (73%), 28% followed friends invitations, in 21% cases respondents family or friends had received blood transfusions, 16% followed the example of fellow students. Restriction for blood donation: 40% generally feared donation, 25% had a specific fear of the needle, 20% had no confidence in the public (health) sector, 25% condemned blood selling practice, 14% had no confidence in the donation procedure (hygiene), 13% experienced parental discouragement. Conclusion: To overcome the apprehensions and fears of the donors it is important to provide adequate information about donation to potential donors. This strategy will help convince family replacement donors to become VNRBD and also recruit healthy individuals to become a VNRBD. The approaches and strategies for this transition can be based on the findings of the study. The reported preference for internet as leisure time activity suggests that internet can be utilized as an important tool for information dissemination in a PAC, for which detailed study is required.

3D-S16-01

Murphy MF

Platelet refractoriness is the repeated failure to obtain satisfactory responses to platelet transfusions. There are immune and non-immune causes of platelet refractoriness. The main immune cause is HLA alloimmunisation which occurs predominantly in females with a history of pregnancy. Other immune causes include HPA alloimmunisation, ABO incompatibility, platelet autoantibodies and drug-related platelet antibodies. The incidence of alloimmune platelet refractoriness due to HLA antibodies has declined due to leucocyte-reduction of blood components and more aggressive treatment for patients with haematological malignancies and other cancers. In current practice, platelet refractoriness is mainly due to shortened platelet survival associated with non-immune clinical factors, such as infection and its treatment with antibiotics and antifungal drugs, DIC and splenomegaly. If there are poor responses to HLA-matched platelet transfusions, the reasons should be sought including HLA incompatibility which is most likely to occur in patients with unusual HLA types with few well-matched donors, non-immune platelet consumption, and HPA and ABO incompatibility. Further serological investigations including testing for HPA antibodies may be used to differentiate between these possibilities. Depending on the results, the appropriate management could be the use of ABO-identical or HPA-matched platelet concentrates if the specificity of the HPA antibodies can be identified. Platelet crossmatching may be helpful in some patients with non-specific HPA antibodies. The management of patients with HLA and/or HPA alloimmunisation and no compatible donors may be very difficult. There is no evidence that alloimmunised patients benefit from incompatible platelet transfusions which do not produce an increase in the platelet count, and prophylactic platelet support should be discontinued. If bleeding occurs, platelet transfusions from random donors or the bestmatched donors, despite being incompatible, may reduce the severity of haemorrhage although increased doses of platelets may be required. Other management approaches such as the use of high-dose intravenous immunoglobulin, splenectomy, and plasma exchange have not been shown to be effective. The management of patients with non-immune platelet consumption is similarly problematic. The usual practice is to continue with daily platelet transfusions as prophylactic platelet support, but it is not known whether this approach is effective, or whether platelet transfusions should be discontinued or the dose of platelets increased.

3D-S16-02

Managing bleeding in cardiac surgery: Despite major advances in the management of perioperative blood conservation, transfusion rates in cardiac surgery remain very high, with large variations among individual centres. Among all major surgical procedures, cardiac surgery with CPB still consumes a large part of the available blood supply. In England indicated that 10-15% of the blood units supplied by the National Blood Service is used in cardiac surgery units. In the USA, nearly 20% of blood transfusions are associated with cardiac surgery. During the early history of cardiac surgery, patients received large amounts of allogeneic blood. In the 50's, most operations were performed to correct congenital heart disease. During the 60's and 70's, the introduction of satisfactory valve prosthesis and direct grafting for atherosclerotic coronary artery disease led to rapid growth in the scope and number of patients having open heart surgery. In the 80's pharmacological methods to reduce bleeding were introduced and the focus of blood conservation was expanded to include blood components as well as red cells.

With increasing application of cardiac surgery in acutely ill older patients with more comorbidities as well as the increasing safety of blood supply have contributed to an increasing incidence of allogeneic transfusions. Not surprisingly, physicians, surgeons and anaesthesiologists have shown a great interest in the promotion of safe and effective alternatives to the transfusion of allogeneic blood in cardiac surgery. Perioperative risk factors for allogeneic transfusion can be regrouped in three main categories: factors affecting the patient's preoperative RBC mass, factors affecting the perioperative blood losses, and factors affecting the transfusion practice. The ability to predict a patients risk for transfusion allows modification of patient management with the goal of decreasing allogeneic transfusions. Using the TRAC and TRUST scoring system predicts candidates likely for transfusion. Diminished RBC mass appears to be one of the strongest predictors of transfusion. The acceptance of a lower postoperative haematocrit (in IJN the Hct on bypass is 20-25% and post bypass is >25%) or haemoglobin concentration represent an important element in current blood conservation practice. The decision to transfuse a patient cannot be based only on haematocrit concentration. Optimizing preoperative RBC mass involves the early detection of anaemia and its correction before surgery. Preoperative autologous blood donation can be used to conserve allogeneic blood. Besides economic concerns, one essential argument against PAD is the lack of sufficient time because of the uncertainty of waiting list. Erythropoietin has also been used to augment PAD in elective cardiac surgery. Acute normovolaemic haemodilution (ANH) aims at reducing allogeneic blood exposure through a reduction in the net red blood cell mass lost during or just after surgery. Perioperative cell salvage (CS) also aims at reducing allogeneic blood exposure through a reduction in perioperative blood loss. Antifibrinolytics (ltranexamic acid or epsilon aminoaproic acid) or serine protease inhibitors (aprotininnow unavailable) may reduce excessive fibrinolysis and platelet dysfunction. The use of activated F VII has been reported in intractable bleeding post cardiac surgery. 

3D-S17-01

The University of Tokyo, Tokyo, Japan

Antibodies against human neutrophil antigens (HNA) are involved in the pathogenesis of immune neutropenia, such as neonatal alloimmune neutropenia (NAN), refractoriness to granulocyte transfusions, and transfusion reactions, such as febrile non-hemolytic transfusion reactions, and transfusion-related acute lung injury (TRALI). The HNA systems are assigned to five antigen groups, namely HNA-1 to 5. HNA-1, -2, and -3a alloantibodies have been implicated in the pathogenesis of TRALI, and especially HNA-3a alloantibody has been found in the severe cases requiring artificial ventilation or with fatal reactions. Besides alloantibodies to HNA-1, -2 and -3, those against HNA-4a and HNA-5a have been implicated in NAN. The identification of the causative antibodies is essential for the diagnosis as well as for the prevention of these disorders. The detection of HNA antibodies has been mainly dependent on cell-based assays so far. Among them, the granulocyte agglutination test (GAT), the granulocyte immunofluorescence test (GIFT) and the monoclonal antibody immobilization of granulocyte antigens (MAIGA) are the most commonly applied. According to the ISBT Working Party on Granulocyte Immunobiology, the combination of GAT and GIFT is presently the best means of HNA antibody detection. GIFT is usually more sensitive than GAT, however, HNA-3a antibodies associated with severe cases of TRALI are better detectable by GAT.

In GAT and GIFT, the presence of HLA antibodies with broad specificities may affect the detection of HNA antibodies. On the other hand, the MAIGA assay allows the differentiation between HNA and HLA antibodies. These classical methods, however, require fresh neutrophils from HNA-typed donors. Also, these assays are time-consuming, which makes them not appropriate for the large-scale antibody screening. In our lab, we modified the mixed-passive hemagglutination (MPHA) assay, the method largely applied in Japan for platelet antigen/antibody detection, for the detection of HNA antibodies.

Recently, alternative assays have been developed, including ELISA with recombinant HNA (rHNA), and immunofluorescence tests with transfectant cells of HNA (HNA-1, -2, -4, and -5). More recently, the molecular basis of HNA-3 antigen has been elucidated, and stable cell lines expressing HNA-3 antigens became available. These cell lines seem to have low background, and do not express detectable levels of HLA antigens, which make the identification of HNA antibodies easier. Additionally, kits that use Luminex microbeads coated with HNA antigen are being developed. These kits, however, do not include HNA-3 antigens. These new technologies significantly help improving the detection and identification of HNA antibodies, and allow the large scale screening of HNA antibodies, contributing for the reduction of the risk of the pathological conditions associated with HNA antibodies, especially TRALI. However, these new technologies significantly increase the cost of the tests. Presently, although many assays have been developed, the standard HNA antisera are not necessarily available in every lab, which makes their validation difficult to be conducted. Thus, the collaborative study among the various labs, by exchanging the available antisera, and comparing the test results, is essential for the improvement of this field.

3D-S17-02 One of the main sites where PMNs carry out vital to surveillance functions is in the lungs. The large surface area of the lung is needed for gaseous exchange but lungs also present a vital direct mechanical barrier to the external environment. To patrol and protect this interface, about 28% of the body's total PMNs are located in the pulmonary microvasculature. Illness may increase the number of lung PMNs as well as change their phenotype from quiescent to primed. In TRALI, the transfusion of blood products with either PMN reactive antibodies or biological response modifiers can activate this concentration of primed PMNs to produce an augmented respiratory burst. This causes injury to the pulmonary microvasculature and consequently the symptoms of TRALI. Circulating antibodies to PMNs also can compromise their numbers and function. PMNs carry human neutrophil antigens (HNA) as well as Class I HLA, which can become targets for PMN reactive antibodies. The granulocyte immunofluorescence test (GIFT) and granulocyte agglutination test (GAT) are primary tools for investigating these PMN reactions, as they are able to detect reaction of HNA as well as some HLA class I antibodies.

Immune neutropenias: Alloimmune neonatal neutropenia (ANN) occurs when a neonate's PMNs are destroyed by transferred maternal antibodies developed against an inherited paternal neutrophil antigen. This is similar to haemolytic disease of the newborn, but importantly can occur with the first pregnancy.

In early childhood, some children develop severe neutropenia as a result of PMN auto-antibodies. Although the pathogenesis of such chronic benign autoimmune neutropenia is still not understood most of these autoantibodies demonstrate specificity for the HNA system. Passively acquired autoimmune neutropenia, wherein PMNs are destroyed by maternal PMN auto-antibodies crossing the placenta are a rare finding. HNA specificity is unlikely. Autoimmune neutropenia in adults is either primary, secondary to another autoimmune disease or drug related. It can present a clinical and diagnostic challenge as many adults invariably have alloantibodies to neutrophils and the patient's neutrophil count is too low to make a definitive identification of a self reactive autoantibody. HNA specificity is extremely rare. The severity of TRALI and immune neutropenias demand rapid and precise diagnosis with reliable neutrophil serology. The ISBT Granulocyte Immunobiology Working Party maintains a list of granulocyte immunobiology reference laboratories around the world.

3D-S17-03 When seven sera from 778 donors were screened for neutrophil specific antibodies, 9% samples showed positive reaction. These results, however, could not be confirmed by GIFT and GAT.

Conclusions: In this study, we found alloimmunization against HLA class I and II in 4.6% male,~4.3% nulliparous and~13.9% parous females. In contrast, alloimmunization against HNA was not detectable in this cohort. These results indicate that the use of plasma containing blood products from parous females without HLA antibodies pre-testing may increase the risk of TRALI reaction. Although alloimmunization against HNA seems to be a rare event in China, further observation is necessary to exclude the necessity of HNA antibodies screening in our blood products. It is becoming clear that the CCN family of extracellular proteins play an important role in the health and function of several cells of the hematopoietic lineage. CCN2, also known as Connective Tissue Growth Factor, CTGF, has recently been found to be in high abundance in platelets and released upon activation, an effect inhibited by aspirin, suggesting a role in blood clotting and/or wound healing. On the other hand, CCN3, also known as nephroblastoma-overexpressed, NOV, has been found to play an important role in hematopoietic stem cell health and function. In fact, treatment with CCN3 has recently been shown to promote hematopoietic potential, a discovery with dramatic clinical potential. Initially using bioinformatics, our laboratory has discovered a signaling pathway that connects these two discoveries and appears to be a key functional node within the development of blood cells. Specifically, we have found that the Myeloid zinc finger protein 1, MZF1, is a transcription factor that trans-activates both CCN2 and CCN3, in distinct cell types. For example, we have shown that MZF1 can stimulate CCN2 production and secretion in stromal fibroblasts, which is then taken up by megakaryocytes and loaded into platelets. This is the first time that CCN2 loading into developing platelets has been directly achieved and observed in vitro. Secondly, we have discovered that MZF1 also regulates the synthesis of CCN3 in several hematopoietic cell types.

Putting these results together with previous data suggests a new and immediately testable clinical treatment. It is known that both vitamin D (calcitriol) and vitamin A (all-trans retinoic acid) stimulate transcription of the MZF1 gene. (We also have new data exploring the mechanism and suggesting other pharmacological ligands). We have confirmed that treatments with either vitamin A or D activate this pathway and results in increased production of CCN2 in stromal fibroblasts, which in turn results in enhanced loading of CCN2 into developing platelets in vitro. Similarly, we have observed that both vitamin A and vitamin D induce CCN3 expression, through MZF-1, and we are currently testing if this will lead to enhanced hematopoietic potential. This work could impact the efficacy of blood donation and transfusion, bone marrow transplants, and the treatment of bleeding and clotting diseases as well as lymphomas and leukemias.

3D-S18-05 Background: Foxp3 + T regulatory cells (Tregs) consisting of natural and induced Treg subsets play a crucial role in the maintenance of immune homeostasis against self-antigen. While recent studies demonstrated that natural Tregs are instable and dysfunctional in the inflammatory condition, induced Tregs (iTregs) may have a different feature. Furthermore, it was reported that tolerogenic dendritic cells (tDCs) could expand iTregs in vitro and this action designed to correct defects in numbers or functions of iTregs may be therapeutic in the treatment of autoimmune diseases. In this study, the suppression efficacy of TGF-beta-induced Tregs expanded by tDCs in vitro and in mouse model of autoimmune arthritis was determined. Method: In vitro, first, CD4+ CD25À T cells were purified from splenocytes of D1 mice and stimulated by anti-CD3/CD28 in the presence of TGF-b1 for 5 days, which were termed 'iTreg'. And tDCs derived from bone marrow of D1 mice were induced by GM-CSF, IL-10 and TGF-b1 and harvested after 10-day cultivation. Then, iTregs were expanded by tDCs at the ratio 5:1 and collected after 4 days (termed 'iTreg tDC '). The phenotype, proliferation, suppression of CD4T proliferation, induction of Foxp3 + Tregs from Foxp3À T cells and suppression of Th17 cell differentiation were assessed. For in vivo experiments, the animal models of RA were established. In this model, arthritis was induced in D1 mice after immunized with bovine type II collagen (CII) on Day 0 and Day 21, termed collagen-induced arthritis (CIA). And 1 9 10 6 iTregs or iTreg tDC cells were transferred <iv. into CIA recipient mice when CIA onset. Control mice were treated with PBS. Clinical and histopathologic scores, cytokine and anti-CII antibody secretion in serum and CD4 + Th subsets were analyzed. Results: After 5-day induction in vitro, the percent of Foxp3 + iTregs increased from 9.8 AE 1.5% to 54.9 AE 2.5%. And these iTregs could be expanded effectively by tDC in additional 5-day co-incubation, which continued to express higher levers of Foxp3 (82 AE 3.6%) and increased 4.17 AE 0.17 fold. Compared with iTregs, the iTreg tDC cells showed stronger inhibitory effect, and could prompt CD4T cells converting to Foxp3 + iTreg and resistant to Th17 cell differentiation more effectively. During the 4-weekobservation-period, a more remarkable anti-arthritic activity, improved clinical scores and histological end-points were found in the iTreg tDC -treated group than those in iTreg-treated group. Serological levels of TNF-a, IL-6, IL-17 and anti-CII antibodies were also significantly lower and TGF-b production were higher in CIA mice following adoptive transfer of iTreg tDC cells as compared with iTregs. Moreover, the iTreg tDC treatment resulted in an increase in the number of Tregs (CD4+ Foxp3+) and a decrease in the percentage of Th17 cells (CD4+ IL-17+) more obviously. Conclusion: These results indicated that iTregs expanded by tDCs showed more effective suppression in vitro, and reduced more markedly the severity and progression of CIA than iTregs. This reduction was associated with modulating inflammatory cytokine and anti-CII IgG secretions to lower levels and polarizing the Treg/ Th17 balance to Treg more obviously. This study highlights the potential therapeutic utility of iTregs expanded by tDCs in autoimmune arthritis and should facilitate the future design of iTreg tDC immunotherapeutic strategies against RA. In May 2010 the World Health Assembly passed a resolution, WHA 63.12, on the availability, safety and quality of blood products. This urges member states to 'take all necessary steps to establish, implement and support nationally co-ordinated BTS with the aim of achieving self-sufficiency'. The resolution applies to both fresh blood components and plasma derived medicinal products (PDMPs). WHO defines self-sufficiency as meeting national needs for six products from blood and plasma collected locally. These comprise red cells, platelet concentrates, fresh frozen plasma, and Factor VIII, immunoglobulin and albumin solution. The definition and overall goals were established by a WHO Expert Consensus Statement on 'Achieving Self-Sufficiency Based on VNRBD' developed at a meeting of WHO experts in Geneva Switzerland in 2011. Blood Services develop in line with the health care system that they support. Typically this involves a transition from a supply for whole blood mainly in the context of emergency management of trauma and child birth to the implementation of blood component therapy. Blood component production will likely lead to an excess of recovered plasma. Effective utilisation of this requires access to plasma fractionation facilities. If this can be achieved then this will reduce reliance on commercial PDMPs and ensure maximal utilisation of the donated whole blood. Increasing demand for PDMPs will potentially lead to a requirement for introduction of plasmapheresis programmes if the goal of self-sufficiency is to be maintained.

There are a number of significant barriers to both utilisation of recovered plasma and the implementation of effective plasmapheresis programmes. Individual countries will need to consider these as part of their long term strategic planning process. The main barriers for low and medium HDI index countries are access to suitable plasma fractionation facilities. Few countries will be able to justify creation of a national fractionation plant. Regional co-operation and development of facilities will be needed. Secondly plasma for fractionation is seen as a critical material in the manufacture of a medicine. Quality system requirements, including full compliance with a code of Good Manufacturing Practice will be a pre-requisite for acceptance of the plasma as suitable for fractionation. There is an urgent need to develop support programmes to raise standards to achieve this. In contrast the main barrier for most high HDI countries is cost and the easy availability of PDMPs produced by commercial countries from paid plasma. The safety profile of PDMPs is currently excellent since the integration of a number of specific viral inactivation steps in the manufacturing process overcomes any infectious burden associated with payment for plasma. The critical question is then how a country can assure ongoing supply at a reasonable cost. Ethical principles will play an important role in defining the strategy and individual countries should be able to define their own approach without unnecessary intervention and competition from the commercial plasma industry.

4A-S19-02

Background: Blood Transfusion Service of Nepal Red Cross Society was established in the year 1966. Since the beginning NRCS has been running the service exclusively with assurance of Government of Nepal. In 1991 the Government of Nepal elaborated the mandate with clear policies and declared Nepal Red Cross Society as the sole authority to conduct the National Blood Program through out the Country. At present it consists of 86 Centers in 62 districts. National leadership and oversight of management and quality standards is the responsibility of the Central Blood Transfusion Service, who in partnership with regional and district centers and aims to provide a safe and secure supply of blood/blood products to all needy in the country. In the initial years the service was made possible through collection of blood from professional donors but since 1982 collection of blood was emphasized from voluntary non-remunerated donors only.

Aims: Blood Service is provided according to the need base and with the expansion of health services, establishments of medical colleges, government hospitals, private hospitals and Nursing homes the demand of blood is rapidly going up through out the country. Nationwide more than 250,000 units of blood were served to the needy and around 60% of it is served through the Central Blood Transfusion Service. Results: With the view of providing safe blood and bloodproducts to the needy patients all collected blood is routinely tested for HIV, HbsAg, HCV, Syphilis besides grouping, cross-matching and anti-D antibody identification. Blood components service is limited in few centers.

Conclusion: Blood Program is run through cost recovery basis with material and nominal service charge Nationwide. No defined budget is allocated for blood program. There is on and off support provided from Nepal Government, UN Agencies, National Societies and International Non Government organizations. Currently, the total revenue raised for the blood program is insufficient to meet the total cost of production of blood and blood products.

4A-S19-03 Background: Blood transfusion services in Cambodia face a number of significant challenges in providing a supply of safe blood and blood products sufficient to meet the clinical needs of patients. These challenges include access to adequate and sustainable financing, trained staff, sufficient voluntary non-remunerated blood donors (VNRBD) and appropriate equipment and facilities. Aims: A 2011 programme funded by the US Presidents Emergency Plan for AIDS Relief (PEPFAR) and managed by the US Centres for Disease Control (CDC) was initiated by the Cambodian based US CDC office, in a collaborative partnership with the NBTS and Ministry of Health (MoH). Specific blood program needs were identified and presented in a logical task order framework. The task order required support at both the national and provincial level across the whole blood sector; and priorities three key deliverables: Comprehensive assessment of the country's current practices and infrastructure including national policy, legislation, collection, testing and the clinical use of blood. VNRBD recruitment strategies/protocols. A new 5 year National Strategic Blood Plan. Methods: The selected technical assistance partner (TA) developed a proposal that addressed the areas of the task order, and utilised a number of strategies to deliver the technical program; including: A critical initial design phase with an introductory visit to map prior local and development partner work and draw on in-country. Seeking ongoing engagement and advocacy from local thought leaders. Tailoring assessment and strategy planning tools to local requirements. Use of inclusive communications with all stakeholders. Strengthening of local governance infrastructure (Blood Safety Working Group) .

The 1 year program resulted in development and delivery of an assessment report on Cambodia's blood transfusion services, a Knowledge, Attitudes and Practices survey and a five year National Strategic Blood Plan (NSP Background: Indonesia has recognized that blood transfusion plays a key role in their modern health care; yet ensuring the availability of safe blood is a challenge for a population of over 250 million living on 6000 islands with limited health care resources with a high background prevalence of hepatitis B virus (HBV) of 9.4%, human immunodeficiency virus (HIV) of 0.2%, and hepatitis C virus (HCV) 0.4%. Aim: A health economic study was performed by the IRC to evaluate the economic impact of individual donor (ID) NAT on the burden of disease (HBV, HCV, HIV) associated with transfusion transmitted infections (TTIs) and understand the comprehensive costs to the Ministry of Health (MOH) of providing ID-NAT-tested blood. Method: A health economic analysis was performed using a Markov method, which predicts the probability of an outcome based on a chain of outcomes and defined transition probabilities. The two arms of the analysis compared the testing costs and treatment costs of: (i) serology alone, and (ii) serology and NAT. Testing costs were defined as the total costs to the Indonesian MOH of purchasing the reagents used in conducting either serological testing alone or serological and ID-NAT testing on donor blood units. The treatment costs were defined by the outcomes associated with each of the three viruses (HBV, HIV, HCV) and the likelihood of various clinical outcomes for patients infected by transfusion. Indonesia-specific data drawn from peerreviewed published sources was used to populate the model. In cases where published local data was not available, proxy published data from other geographies and data collected from interviews with local transfusion experts were used. Cost information for ID-NAT and serology testing was sourced from test manufacturers.

Results: Previous effectiveness of NAT testingin annual collection of 2.1 million donations determined that ID-NAT could prevent 3187 infections missed by serology screening. If ID-NAT assays were not available TTIs represents a calculated USD $73 million in treatment costs for the Indonesian Healthcare system. The introduction of ID-NAT could saveUSD $27 million per year (or~20% savings) due to reduced treatment costs by preventing TTIs. The estimated savings exclude costs associated with lost productivity and litigation. Conclusion: Sincethe initial analysis, additional testing has been performed in variousdemographic locations and it is now estimated that 8500 whole blood units andup to 15,000 blood components could be interdicted with ID-NAT. These new datarepresent even more favorable economics to the MOH. While ID-NAT represents an additional cost tokeep blood as safe as possible, the incremental cost comparison of serology andID-NAT compared to serology testing alone shows a minimum estimated savings ofUSD $27 million. Based on these results, ID-NAT blood screening appears to be aclinically and cost-effective way to prevent transmission of infection to patients.

4A-S20-01

Yee-Sin L Tan Tock Seng Hospital, Singapore, Singapore

Arbovirus is an acronym for a group of viruses that are transmitted by arthropod vectors, commonly mosquitoes and ticks. Person-to-person transmission of arboviruses is not common. However, transmission can occur through transfusion of blood and blood products, and organ transplantation, if the virus is present in the donor's blood or organ. The majority of arboviral infections in humans are asymptomatic. If symptomatic, the symptoms generally occur 3-15 days after exposure. Clinical features of arboviral infections can be classified into four groups: acute central nervous system illness, acute benign fever with or without exanthem, hemorrhagic fever, and polyarthritis.

There have been published reports of transfusion-transmitted infections of a number of arboviruses, including West Nile and dengue viruses, as well as Colorado tick fever and tick-borne encephalitis viruses. The risk of transmission depends largely on the burden of the disease in a particular geographical location, the proportion of asymptomatic infections in which clinical diagnosis is not possible, and the availability of diagnostics to detect low levels of viruses in the blood. West Nile virus (WNV) entered the United States (US) in 1999 and has spread across the entire North American continent. WNV is now the most significant arboviral infection in the US. One out of every five exposed individuals will develop illness and 1 out of 150 may suffer from severe infection with significant neurological sequelae. In 2002, 23 transfusion-transmitted WNV infections were described. Since 2003, all blood donations in the US have been routinely screened for WNV RNA using WNV nucleic acid test (NAT). Since the implementation of screening, 13 transfusion-associated transmissions of WNV have been documented (MMWR 2012) . Dengue is the most common arboviral infection in the world. The World Health organisation (WHO) estimates that 50 million dengue infections occur annually and approximately 2.5 billion people live in dengue endemic countries (WHO 2009 ). The ratio of asymptomatic to symptomatic infections vary widely. Singapore reported three cases of transfusion-associated dengue infections involving one blood donation episode. An asymptomatic repeat blood donor informed the national blood bank that he had fever the day after blood donation. By then, packed red cells and other blood products from his donation had already been transfused to three recipients. All three recipients were infected; two of the recipients' blood and the donor's stored serum sample were tested positive for dengue serotype 2 virus by PCR. Wilder-Smith et al. estimated the risk for transfusion-associated dengue transmission in Singapore to be 1.6-6/10,000 blood transfusions in the year 2005, assuming a ration of asymptomatic-to-symptomatic infections of 2:1 to 10:1. Subsequently, Teo et al. reported the practice of deferring blood donation from recently returned travellers from dengue endemic areas. The massive outbreaks of Chikungunya fever in the Indian Ocean and Southeast Asia again raise concerns about blood safety. Although there has yet to be a reported case of transfusion-associated chikungunya virus infection, such a transmission route remains a distinct possibility. Liumbruno GM et al. reported an economic loss of approximately 2 million euros, resulting from the suspension of blood donations at the peak of the chikungunya outbreak in Italy in 2008.

4A-S20-02

Australian Red Cross Blood Service, Perth, Australia

Background: Arthropod-borne viruses (arboviruses) are an expanding global threat to human health. Among them dengue (DENV) and West Nile virus (WNV) have both been documented to be transfusion-transmissible and transfusion is a plausible route of infection for several others including chikungunya virus (CHIKV) and Ross River virus (RRV). Addressing the transfusion risk associated with arboviral outbreaks poses new challenges. Unlike established viral threats to the blood supply (e.g. HIV, HCV and HBV) in which the risk is generalized to the population-at-large and chronic infection is common, arboviruses are characterised by focal and often seasonal outbreaks of acute, predominantly self-limiting infection. Thus, unlike traditional viral threats the risk is not 'continuous' in nature complicating risk mitigation strategies. Aims: To describe possible risk management strategies for arboviral transmission including; geographical donor deferral/restrictions on labile component manufacture, donation testing and pathogen inactivation (PI) which can be applied individually or in combination. Methods: How strategies are applied depends on the nature of the risk i.e. whether internal (i.e. local outbreak) or an external (i.e. potentially viraemic donors returning from an outbreak affected country). Geographical donor deferral can take several forms ranging from deferral of donors returning from precisely defined 'outbreak risk' areas (e.g. WNV deferral for travel to N. America) to a 'blanket' deferral of all donors returning for a defined period after return from overseas (e.g. the Netherlands). While this can be an effective risk mitigation strategy it can lead to the deferral of significant numbers of donors and the impact on sufficiency needs careful consideration. In some cases (e.g. for local dengue outbreaks in Australia) this can be partially addressed by restricting manufacture to 'plasma for fractionation' since PI within the fractionation process satisfactorily addresses the transmission risk. Triggering implementation of deferrals for specific outbreaks is problematic because a high proportion of arboviral infections are asymptomatic so asymptomatic donor viraemia poses a risk before the first symptomatic case is apparent. Instituting a deferral only during the 'transmission season' is complicated because of the difficulty in precisely defining the beginning and end donors for major transfusion-transmitted infectious diseases (TTIDs; HIV, HBV and HCV) has evolved from performance of serologic assays only to include nucleic acid testing (NAT) for detection of window phase and occult infections in most developed and some developing countries. NAT screening has also been implemented for other viruses known to be transmitted by blood components and/or plasma derivatives (Parvovirus B19, HAV), and for several emerging/expanding infectious disease (EID) agents that threaten blood safety in some regions (e.g., WNV in the US, HEV in Japan, and dengue virus in Puerto Rico). Despite this dramatic progress, EID threats continue to be identified and cause pressure to further enhance the safety of transfusions. The concept of a 'global village' has emerged, which reflects the fact that a potential blood-borne infectious agent present in any region of the world could 'traffic' to other regions overnight. There are increasing examples of zoonotic transmissions of infectious agents, with the potential for rapid adaptation to humans and subsequent spread to blood donors and recipients. There is also intense research to identify new blood born infectious agents using novel molecular discovery strategies.

Although recent examples of putative new agents have proven to be non-pathogenic (HGV/GBVc, TTV and Sen-V), not transmitted at significant rates by transfusions (HHV-8), or contaminants (XMRV), every newly discovered agent requires serious investigation to assess its relevance to transfusion safety. This presentation will highlight recent progress in developing approaches for systematic assessment of EID risks and for applying rational approaches to respond to new pathogens. In an effort to proactively assess transfusion safety threats in the United States and Canada, the Transfusion-Transmitted Diseases Committee of the AABB has systematically reviewed relevant data and prioritized the risks of individual established and emerging disease agents; this program includes AABB website accessible Fact Sheets for~100 agents which are updated as new information becomes available or new agents of concern are identified. Recently a research program has been started using data of ID-NAT users for analyses of the efficacy of various testing strategies This allows comparison of the yield and risk reduction obtained by NAT and serology assays in countries with differing incidence and prevalence rates of the three major viral infections. Furthermore the AABB EID sub-group and the European CDC have developed 'toolkits' for assessing the risk of EIDs with respect to potential impact on blood safety and availability, and for evaluating and validating the effectiveness of proposed interventions. The toolkit process, including methods to monitor EID agent emergence, identify and recognize a transfusion-transmission threat, processes to quantify risk, and the appropriate management of such threats using formal decision analysis methodologies, should be considered for implementation by all blood systems.

The main challenges for hospital transfusion are patient safety, the effective use of blood, robust methods for documentation and monitoring practice, good blood stock management and low wastage, good staff training, and the rapid availability of blood for those patients who need it urgently. Patient safety is paramount, but haemovigilance schemes worldwide continue to demonstrate that errors in the transfusion process result in patient morbidity and mortality. This talk will indicate where progress has been made in improving transfusion safety in hospitals in the UK, and use the implementation of an electronic transfusion management system in Oxford as an example of improving patient safety. The project involved the development of an end-to-end electronic transfusion process involving barcode patient identification, handheld computers at the bedside and electronically controlled blood fridges linked to the blood transfusion laboratory information system. It was taken through pilot stages between 2001 and 2006 through to its full implementation across the acute hospitals in Oxfordshire in 2006/07, and its maintenance and further development since then. There was an improvement from 11.8% to 100% of staff following the process for correct bedside patient identification; no ABO incompatible red cell transfusions or serious wrong blood events in over 10years; a reduction in wrong blood in tube events; reduced nursing (one nurse rather than 2 and half the time to administer blood) and laboratory workload; and more rapid delivery of urgently required red cell units (from a median of 18 min to 45 s). The electronic system provided a simple mechanism for compliance with UK/EU regulatory requirements for the traceability of blood, and the documentation of transfusion and training. Feedback from both staff and patients was positive. Our group wrote a national specification and provided the material for a national recommendation for hospitals to adopt the electronic transfusion process, but wider implementation by other hospitals has been slow. An additional module into the electronic transfusion process is being implemented to provide decision support for doctors ordering blood to minimise inappropriate use of blood as part of a patient blood management programme. There are considerable barriers to improving the safety of transfusion practice in hospitals, but they can be overcome by 're-engineering' the process with the support of a multidisciplinary team with shared, achievable and measurable objectives, engaging with senior hospital management, and having a determination to see the development of a new process through to completion and its implementation as routine practice.

WHATS NEW WITH TRALI? In the last 20 years there have been substantial efforts to minimise or eliminate TRALI. Despite these activities, in 2012 the FDA still reported TRALI as the top cause of transfusion-associated mortality. The pathophysiology of TRALI follows a two event mechanism. The patient's illness leads to activation of the pulmonary endothelium with the sequestration of primed neutrophilsthe first event. The transfusion is the second event, and leucocyte antibodies or biological responsive modifiers (BRMs), present in the blood product, activate the microbicidal arsenal of the primed neutrophils to cause injury to the pulmonary microvasculature and consequently acute lung injury (ALI). Hence, TRALI may be antibody-mediated or BRM-mediated. Antibodies to human neutrophil antigens (HNA), HLA class I and class II have been associated and implicated with TRALI. Interestingly, a large prospective case-controlled study of over 400,000 transfusions reported that recipients with cognate antigens to HNA and HLA class II antibodies had increased risk of TRALI but found no statistical significance with HLA class I (Toy et al. 2012 Blood) . That HNA-3a antibodies are associated with more severe TRALI indicates that antibody specificity is another determinant of TRALI injury (Reil et al. 2008 Vox Sang) . Additionally, murine models demonstrated that antibody titre also determined the severity of injury (Fung et al. 2010 Blood) . While the use of male predominant plasma has significantly reduced the incidence of antibody-mediated cases, TRALI still occurs likely due to BRMs. BRMs are generated during the routine storage of blood products. A meta-analysis of cardiac and trauma patients concluded that older blood is associated with a significant risk of death (Wang et al. et al. 2012 Blood) . Given the success of male predominant plasma in managing the risk of antibody-mediated TRALI, ongoing efforts to reduce the risk of TRALI are likely to focus on BRM-mediated TRALI. Developing a better understanding of the how specific BRMs may contribute, either individually or in combination, to the development of TRALI, and how BRM concentrations vary between donors, will be crucial to the future development of strategies to manage the risk of BRM-mediated TRALI.

They were all Thais and their forebears have lived in Northeast Thailand for at least two generations. HNA-1,-3, and -4 were typed by the PCR-sequence specific primer (PCR-SSP). Results: The gene frequencies of HNA-1a, -1b, -1c were 0.697, 0.302 and 0.001, respectively. HNA-1 null allele was found in one sample. The gene frequencies of HNA-3a and -3b were 0.780 and 0.220, respectively. HNA-4a and -4b gene frequenfrom Asian populations

Aims: To assess whether symptoms consistent with dengue are more common in transfused patients who test positive for DENV RNA compared to patients who do not. Methods: In 2012 and Rio de Janeiro, patients who were transfused were enrolled and interviews inquiring about symptoms (fever, headache, bone or joint pain, body or muscle pain, vomiting, rash, painful eyes, and bruising) were conducted between 3 to 7 days, and about 30 days following transfusion. Inpatients and outpatients were included. Blood samples were collected at the time of first interview. Subsequently, coded samples were tested for DENV RNA using the Hologic/Novartis TMA assay. We used two definitions for DENV disease: the WHO clinical definition consisting of fever with at least two contemporaneous symptoms, and a more general definition of having ≥3 symptoms of any kind. We calculated odds ratios (OR) and 95% confidence intervals (CI) for symptomatic infection comparing transfused DENV RNA+ to RNAÀ patients. Results: Of 595 patients with samples and interviews 3-7 days following transfusion 54% were inpatients

While it is possible that viremia was missed in some recipients who had symptoms consistent with dengue, we did not find evidence of significantly increased rates of symptomatic infection in DENV RNA+ compared to RNAÀ recipients. Investigation into whether any of these patients acquired DENV through transfusion

and Mie prefectures) where there are many immigrants from Latin America including Japanese-Latin Americans. Methods: We conducted a questionnaire survey on Chagas disease for the subjects who were borne or grew up in Latin America. Since Jan. 8th 2013 we have performed testing for anti-T. cruzi for donors from whom informed consent for epidemiological study was obtained. Tests used were Ortho T. cruzi ELISA assay and an immunochromatographic assay

Donors who were aware of Chagas disease and kissing bug were 67% and 56%, respectively. Nobody has ever been bitten by kissing bug. 14% of the donors had been tested for anti-T. cruzi in their country. Four donors had a family member with Chagas disease and they were all Brazilian. Four donors had been diagnosed as having a cardiac or digestive system disease before. All of the 287 blood samples obtained from the subjects were anti-T. cruzi-negative except for one false positive result. Conclusions: None of the subjects surveyed were anti-T. cruzi-positive. Most of Latin American blood donors in Tokai region of Japan are Brazilian and about twothirds of them were younger than 40 years. We consider that the risk of transfusion

Background: Leukocyte antibodies presence in the blood product(s) was responsible for the development of immune mediated transfusion related acute lung injury (TRALI) in recipients. Several studies had demonstrated that HLA antibodies (class I and class II) as well as HNA antibodies (HNA-1, -2, and -3) were capable to induce TRALI reaction. Among them, HLA class II and HNA-3a antibodies seemed to be the most frequent antibodies responsible for severe TRALI reaction. Therefore, screening of HLA and HNA antibodies in our female blood donors may reduce the risk of TRALI. However, the prevalence of leukocyte antibodies among parous female blood donors in China is currently not available. Study design and methods: Blood samples were collected from 142 nulliparous females, 343 parous females and 453 male donors. Pregnancy history was obtained from consenting donors. HLA class I and II antibodies were screened by the use of Lifecodes LifeScreen Deluxe (LMX), and antibody specificities were determined with LIFECODES LSATMClass I & II (Single Antigen). Antibodies against neutrophil antigens HNA-1 and -2 were screened by the LABscreen Assay (One lambda, Inc) and Rapid ELISA detection (Bayat et al, 2009; Werth et al, 2013). HNA-3 antibodies were analyzed by antigen capture assay (Bayat et al, 2012). The specificity of positive samples was reanalyzed by the granulocyte immunofluorescence test (GIFT), the granulocyte agglutination test (GAT). Results: Screening of the total cohort of 938 donors (453 males and 485 females) showed higher prevalence of HLA antibodies production in female compared with male donors (18.9% vs 4.63%). We found in 61 out of 485 females donors alloantibodies against HLA class I (12.58%) and HLA class II (10.10%). Analysis among female

Additional immunosuppression may be used in patients with low ADAMTS13 due to autoantibodies. Aims: To investigate differences between idiopathic and secondary TTP with regard to clinical presentation, management and outcomes. Methods: The Australian TTP registry was established in 2009, and expanded in 2012 to include all TMA. Of 34 hospitals currently participate in the registry. Of 103 cases in 94 patients were registered from 18 sites; eight were excluded for incomplete data, leaving 95 episodes in 86 patients. Results: Median age was 46 years (15-83 years), 53% were female, 16% were relapses. Of 51% were idiopathic and 49% had ≥1 identified precipitant, including infection 23%, autoimmune 18%, malignancy 12%, medication 14%, pregnant/postpartum 4%, solid organ transplant 3%, and allograft 3%. ADAMTS13 levels were available in 66 cases (37 idiopathic and 29 secondary). ADAMTS13 was <10% in 22/37 (59%) idiopathic and 9/29 (31%) secondary cases. Precipitants in cases with ADAMTS13 <10% included infection (n = 5), autoimmune (n = 5), medication (n = 1), and pregnancy (n = 1). Neurological, gastro-renal, bleeding and thrombotic presentations were similar in idiopathic and secondary cases. Data on plasma therapy were available in 88 cases (Table 1) . Of 84/88 (95%) received PEx, by centrifugation in 28/84, membrane filtration in 25/84 (30%), and unknown method in 29/84 (35%). Plasma infusions were used in 11/88 cases (without PEx in 4). Data on additional therapy was available for 89 cases (Table 2) . Rituximab was given in 12/45 cases with ≥1 precipitant, including infection (n = 5), non-haematological malignancy (n = 1), haematological malignancy (n = 3), autoimmune (n = 5), medication (n = 2), and pregnancy (n = 1). Death rates were lower in idiopathic than in secondary cases (8% vs 25%, P = 0.05). Conclusion: Our data confirm that very low ADAMTS13 does occur in cases with secondary causes identified. Clinical presentation did not differ between idiopathic and secondary cases. Plasma therapy was similar in both groups and additional immunosuppression was not only used in idiopathic cases, but also in secondary cases. Mortality remains high, and more data to support improved diagnostic and therapeutic approaches are needed. Background: Living donor liver transplantation (LDLT) is a curative treatment for patients with end-stage liver disease. LDLT is associated with major blood loss and allogenic blood transfusions. Although transfusion practices in adult Liver Transplant (LT) has been widely studied, the same in pediatric LT has not been well documented in India. Aims: The purpose of the study was to evaluate the intraoperative transfusion requirements in pediatric LDLT recipients (<192 months) against the diagnosis, preoperative clinical and laboratory variables. Methods: The data was collected retrospectively from blood bank and patient records. Demographic and important preoperative variables namely clinical diagnosis, PELD score, Hemoglobin (Hb), Platelet count, INR, Albumin, and fibrinogen levels were reviewed. Data on intraoperative transfusion of Packed red cells (PRC), Fresh frozen plasma (FFP), Platelet concentrates (PLT), cryoprecipitate was computed as ml/kg BW. Massive transfusion (MT) was defined as >80 ml/kg of blood components during the surgery. Analysis was done using SPSS software version 16. Median levels were compared between MT and non-MT group using Mann Whitney test. Results: Between August 2010 to July 2013, 60 pediatric LDLT were performed in a single center in South India. Thirty five (58.3%) of them were females and 25 (41.7%) males; 32 (54%) of the recipients blood group were O positive, 14 (23%) B, 9 (15%) A and 5 (8%) AB. Recipient characteristics are given in Table. Transplant indications were biliary atresia and cirrhosis in 28, metabolic /hereditary liver disease in 24, hepatic tumors in 5 and acute liver failure in 3 recipients. Of 56 (93.3%) patients received PRC, 40 (70%) FFP, 17 (28.3%) PLT and 34 (56.4%) cryoprecipitate. Sixteen (26.7%) patients received massive transfusion (MT) with a median PELD score of 22 (À7 to 43) compared to 9 (À9 to 46) recipients without MT (P < 0.005). Also, MT group had significantly lowered median levels (preoperative) compared to non-MT group, viz. Hb (8.6 vs 10.3 mg/dl), Platelet count (96 vs 186 9 10 3 per mm 3 ), Fibrinogen (137 vs 248 mg/dl), and a higher bilirubin (16.5 vs 3.7 g/dl). Transfusion requirements of FFP was higher in Acute liver failure (53 AE 17.3 ml/kg) compared to metabolic liver disease (11.1 AE 2.2 ml/kg) and biliary atresia (19.5 AE 4.2 ml/kg); (P = 0.001). Conclusion: To conclude, massive blood transfusion requirement in pediatric recipients during LDLT was associated with higher PELD score, and more deranged preoperative hematological and coagulation status. In depth analysis of recipient disease status, controlling for the effect of surgical interventional variables on larger samples are recommended to develop predictive models of transfusion therapy. Conclusions: This study is the first report of HNA gene frequencies in ethnic northeast Thais. It could be used for the risk prediction of alloimmunization to HNA and estimation of alloimmune neutropenia and TRALI in the ethnic northeast Thai population.

3D-S18-01

Distler PB 1 , Slaper-Cortenbach I 2 and Ashford P 1 1 ICCBBA, San Bernardino, United States of America 2 University Medical Center Utrecht, Utrecht, The NetherlandsBackground: Standardized ISBT 128 terminology is used by cellular therapy organizations in many countries. As products evolve and new products are created, terminology is required to support the new products. Changes to the terminology are managed by the Cellular Therapy Coding and Labeling Advisory Group (CTCLAG), a committee of experts representing international professional cell therapy societies, technical experts, and regulatory liaisons. Since the early nomenclature was devel-oped, the CTCLAG has approved classes and terminology for very innovative products, including some for which therapeutic benefit has yet to be clearly demonstrated. Because the term 'therapeutic cell' was used in the terminology, this became a great concern to the US FDA, even to such an extent that the use of ISBT 128 for cellular therapy products in the USA could be problematic. Aims: The CTCLAG recognized the concerns raised by regulators and determined it needed to revise nomenclature to address these concerns and to be consistent with ISBT 128 nomenclature used in related fields. Methods: The CTCLAG held a face-to-face meeting and reconsidered the use of TC (therapeutic cells) terminology for products and proposed new nomenclature for the problematic terms. A draft of new nomenclature was developed and made available for public comment as well as review by the boards of CTCLAG sponsoring organizations (AABB, APBMT, ASBMT, ASFA, EBMT, FACT, ISBT, ISCT, JACIE, NMDP and WMDA). Following this review, terminology was updated. Results: Major changes are:(1) The Class name will comprise the type of cells and, where appropriate, the source (eg. 'T Cells, Cord Blood').(2) Hyphenated class names will be replaced (3) TC and therapeutic terminology will be replaced (4) Modifiers will be replaced with attributes providing the same information (5) New attributes will be added The terminology remains compatible with the Single European Coding System. Summary/conclusions: Changing terminology will create rework for facilities that have implemented ISBT 128 and delay for those in the process of implementation. However, it was felt the revised terminology will provide a strong foundation for consistent nomenclature as new products are developed and address regulatory concerns. An appropriate timescale for implementation of the revised terminology in facilities already using ISBT 128 will be developed. This presentation will describe the revised terminology and explain the reasoning supporting the changes.3D-S18-02

Kordelas L 1 , Rebmann V 2 , Ludwig A-K 2 , Radtke S 2 , Beelen DW 1 , Giebel B 2 and Horn P 3 1 Department of Bone Marrow Transplantation, University Hospital Essen, Essen, Germany 2 Institute for Transfusion Medicine, University Hospital Essen, Essen, Germany 3 University Hospital Essen, Essen, GermanyBackground: Graft-versus-Host Disease (GvHD) is a major cause of morbidity and mortality after allogeneic stem cell transplantation. A number of studies reported positive impacts of systemically applied mesenchymal stem cells (MSCs) for preventing or treating acute GvHD. In contrast to the initial paradigm that MSCs intercalate into injured tissues and thus reduce tissue damage, it is now widely assumed that MSCs secrete a number of immune-modulatory factors, which impair inflammation and thus help to suppress GvHD. Exosomes are secreted cell organelles, which exert immune-modulatory properties. These small membrane vesicles are released by a huge variety of different cell species, including MSCs. Methods: Here, we enriched exosomes from bone-marrow derived MSCs of four different unrelated stem cell donors and compared their immune modulatory properties in vitro. Next, we administered immunosuppressive MSC-derived exosomes in escalating doses into a 22-years female GvHD patient. This patient suffered a severe and therapy-refractory cutaneous and intestinal GvHD grade IV. We monitored the clinical effects on an in-hospital basis and correlated this with the levels of inflammatory cytokines measured in the patient's plasma. Results: We show that even though all propagated MSC lines released exosomes, exosome-enriched fractions differed in their potential to modulate immune responses in vitro. Administration of the exosome-enriched fraction with the strongest immune suppressive in vitro effect into the GvHD patient was well tolerated and appeared to be safe. During the course of the exosome therapy a clear reduction of the proinflammatory cytokines IL-6, IL-8 and IL-17 was observed in the patient's plasma. In line with that, the clinical cutaneous and intestinal GvHD symptoms improved significantly and the dosage of the immunosuppressive agentsparticularly of steroidscould be reduced. In total the patient was stable for 5 months. Interpretation: MSC exosome-enriched fractions exert immune suppressive functions in vitro and in vivo. Since the in vivo administration seems to be safe, MSC exosome administration appears as a promising new treatment option for steroid refractory GvHD patients.