key: cord-0706389-649lgrj1
authors: Jajosky, Ryan Philip; Jajosky, Audrey N.; Jajosky, Philip G.
title: The Centers for Disease Control and Prevention and State Health Departments should include Blood-Type Variables in their Babesiosis Case Reports
date: 2020-05-25
journal: Transfus Apher Sci
DOI: 10.1016/j.transci.2020.102824
sha: d796ff9b6cd4e7327598d4ee896f7f6fd5b98379
doc_id: 706389
cord_uid: 649lgrj1

nan

Rhode Island's babesiosis CRF is impressive: It includes data elements relevant for disease risk and prognosis, including age, immunosuppressive conditions, history of tick bite, travel, prior transfusion, organ transplantation, and splenectomy. 6 Unfortunately, we have never seen blood-type variables (ABO blood group, RhD status, etc.) of the patient -and of the donor when simple or exchange transfusion has been used -among the data elements specifically requested on any babesiosis CRF (neither state CRFs nor CDC's CRF). [6] [7] Yet blood-type is likely an important, yet unknown, risk / prognostic factor for babesiosis.

Notably, blood-type is strongly linked to the morbidity and mortality [8] [9] of Plasmodium falciparum (Pf) malaria (a parasitic disease similar to babesiosis). Regarding ABO blood type, "ABO is an independent risk factor for survival among children with malaria" 8 . Pf malaria patients who have the following RBCs have significantly better clinical outcomes: type O 8 , HbAS 9 , HbAE 10 , HbAC 11 , α-12 and β-13 thalassemia minor, heterozygous southeast Asian ovalocytosis 14 , and other "malaria-resistant RBCs" 15 . In sharp contrast to Pf malaria, the impact of RBC variables on babesiosis disease progression is unknown. We were unable to find any study which correlated blood type with babesiosis outcomes. This is unfortunate because RBC variables may have therapeutic implications for the treatment of babesiosis patients. Public health officials should be aware that researchers have recommended that malariaresistant RBCs be used when Pf-malaria patients need simple or exchange transfusion. [16] [17] [18] [19] [20] [21] [22] Since the pathogenesis of babesiosis is also likely to be affected by RBC-related variables, it seems prudent to report the RBC variables of babesiosis patients -and of the donors when transfusion is used to treat babesiosis.

Perhaps this disparity in RBC-related research is because the number of babesisosis cases is small compared to the estimated 228 million 23 24 Historically, studies have analyzed small sample sizes that can make it difficult to identify new associations between, for example, RBC variables and babesiosis-disease progression.

Fortunately, guided by recent malaria-research findings, CDC and state health officials now have the opportunity to help clinicians assess how key RBC variables of both patients and transfusion donors impact babesiosis outcomes. Currently, state babesiosis CRFs ask about (1) risk factors such as age, travel history, recent transfusions, splenectomy, immunosuppressive medications, etc. and (2) complications and outcomes such as acute respiratory distress, altered mental status, disseminated intravascular coagulation, hepatic compromise, etc. 6 Using this (limited) data, CDC was able to explain that hospitalizations for babesiosis were more common among asplenic and elderly patients. 2 CDC noted that "72.6% among those aged ≥80 years (552 of 760)" and "106 of 126 [84.1%]" of babesiosis patients who were apslenic had to be hospitalized. 2 If blood type and other RBC variables were to be added to CRFs, more patient-outcome associations could be quantified -some of which might have important therapeutic implications.

It seems prudent to assume ABO and RhD blood types (such as O+, O-, A+, etc.) impact babesiosis outcomes given that RBC variables are strongly linked to Pf-malaria morbidity and mortality. Hospitalized babesiosis patients have their blood typed if transfusion is anticipated to correct anemia or exchange transfusion is warranted because disease is severe. Of note, the MNS blood-group system might be especially relevant because in vitro studies found that Babesia divergens (the parasite that most often causes babesiosis in Europe) uses M and S antigens to invade human RBCs. [25] [26] Interestingly, the Pf parasite also uses antigens in the MNS blood group to invade RBCs. 27 Although not all babesiosis patients need blood transfusions, conceivably, all hospitalized babesiosis patients could be typed for ABO and MNS blood-group antigens if babesiosis trends worsen and collecting this data becomes a priority in the US. Regardless, given the potential therapeutic implications, it seems prudent to assume ABO and MNS blood types may impact babesiosis outcomes given that RBC variables markedly impact Pf-malaria outcomes.

In conclusion, based on prior Babesia-and Pf-parasite research data, it is biologically plausible that ABO and MNS blood types (and other RBC variables) are relevant for the prognosis and treatment of babesiosis patients. So, to advance patient care, we urge CDC and state health officials to modify the CRFs for babesiosis. Of note, CDC's example CRFs 7 serve as guides for state CRFs to "promote standard data collection" 2 . We recommend reporting patient blood type -or, if simple or exchange transfusions were used, donor as well as patient blood type -by adding these 2 data elements: "ABO/RhD blood type (O+, O-, A+, etc.)" and "MNS-antigen blood type." Furthermore, it would be ideal if babesiosis CRFs encouraged clinicians to report "all other known RBC variables" (such as RBC phenotype / genotype, sickle-trait status, G6PD deficiency, etc.) because such data might also help improve patient care. In general, RBC-and transfusion-related data may help clinicians and researchers (1) better understand why some patients become severely ill and (2) determine if exchange transfusions of special babesiosisresistant RBCs can reduce morbidity and mortality. Although this extra reporting might be considered an unwarranted burden, Mary Lasker warned, "If you think research is expensive, try disease!" 28 Also, the COVID-19 pandemic is reminding us that preparing for the "worst-case" babesiosis scenario may be prudent as babesiosis cases in the US continue to increase.

N Increased risk of tick-borne diseases with climate and environmental changes

Babesiosis Surveillance -United States

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice -Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue

Zoonotic Babesia microti in the northeastern U.S.: Evidence for the expansion of a specific parasite lineage

Rhode Island's Reportable Diseases and Conditions

Rhode Island's Babesiosis Case Report Form

CDC's Babesiosis Case Report Form

Cytoadherence in paediatric malaria: ABO blood group, CD36, and ICAM1 expression and severe Plasmodium falciparum infection

Protective effects of the sickle cell gene against malaria morbidity and mortality

Influence of hemoglobin E trait on the severity of Falciparum malaria

Hemoglobin C and resistance to severe malaria in Ghanaian children

Alpha(+)-thalassemia protects African children from severe malaria

The role of the red blood cell in host defence against falciparum malaria: an expanding repertoire of evolutionary alterations

The evolutionary origins of Southeast Asian Ovalocytosis

X-linked G6PD deficiency protects hemizygous males but not heterozygous females against severe malaria

Can therapeutically-rational exchange (T-REX) of type-O red blood cells (RBCs) benefit Plasmodium falciparum malaria patients?

Can Therapeutically-Rational Exchange (T-REX) of Thalassemic Red Blood Cells Improve the Clinical Course of Malaria?

Can Exchange Transfusions Using Red Blood Cells from Donors with Hemoglobin E Trait Prevent or Ameliorate Severe Malaria in Patients with Multi-drug Resistant ?

Can the Therapeutically-rational Exchange (T-REX) of Glucose-6-phosphate Dehydrogenase Deficient Red Blood Cells Reduce Plasmodium falciparum Malaria Morbidity and Mortality?

To prevent or ameliorate severe Plasmodium falciparum malaria, why not evaluate the impact of exchange transfusions of sickle cell trait red blood cells?

Can exchange transfusions using red blood cells from donors with Southeast Asian ovalocytosis prevent or ameliorate cerebral malaria in patients with multi-drug resistant Plasmodium falciparum?

Dual-gene" malaria-resistance: Therapeutically-rational exchange (T-REX) of group-O sickle trait and group-O C-traittrait red blood cells can be evaluated in Benin and Nigeria

Babesiosis: A Retrospective Review of 38 Cases in the Upper Midwest

Identification of binding domains on red blood cell glycophorins for Babesia divergens

Optimizing exchange transfusion for patients with severe Babesia divergens babesiosis: Therapeutically-Rational Exchange (T-REX) of M antigen-negative and/or S antigennegative red blood cells should be evaluated now

None.J o u r n a l P r e -p r o o f