Quality assurance of Blood safety:

Laboratory implication

Tasanee Sakuldamrongpanich

National Blood Center, Thai Red Cross Society

18072015, HIV EQA provider, NIH

Quality Assurance in Blood Transfusion service

Quality assurance deals with the maintenance of a system

to ensure that the performance in all blood bank ‘s

processes is of the required quality in order to provide

safe unit of blood and if any errors are identified, these

should be corrected.

It is the term used for all of the measures from recruitment

of the donor to transfusion of the blood/blood product to

ensure that product are of the quality required for their

intended use, and that laboratory results are reliable.

Blood Donor Screening for blood safety

Donor selection - Donor self screening (Questionnaire) - Pre-donation counseling by blood bank staff Laboratory screening - Transfusion Transmitted Infection Testing - Blood group serology

QA in laboratory –The right result,

at the right time

on the right specimen.

QA in blood bank laboratory

• Premises

- the organization should provide a safe & healthy

workplace for all employees, visitors – donors, patients

& others.

- all premises should be

- constructed in away that suits the

activities to be carried out.

- designed to allow effective cleaning.

- designed to provide a safe working

environment.

- control temperature

QA in blood bank laboratory

• Staff

Qualified personal, training of staff,

assessment of staff capability, continue

education. Individual job description.

• SOPs - provision of standard operating procedures, including documentation. Record keeping of all test’s results.

• Specification and quality control of reagents, techniques, and equipments.

Specimen collection

Collection sample from diversion Pouch

Avoid contamination of collected sample.

Avoid contamination of collected sample.

NAT sample is collected last

Avoid abnormal samples

Lipemic samples Hemolyse samples

Maintain the transport temp

appropriate for testing

Avoid Labeling error for

donor unit & sample tube

check unit No., sample tube match with donor registered form

21 May 2013

9 May 2008

Avoid Labeling error for donor unit & sample tube

Event No of

hospitals No of

samples

-Labeling error for donor

units/specimens 14 19

-Contamination in sample

collection 3 4

Occurrence of undesirable events at RBCs

(Dec 2013 – May 2014)

Pimol chiewsilp

Laboratory session

• Laboratory areas

- separated from processing area & restricted to authorized

personnel.

- enable the work to proceed in a logical sequence, allow for

effective cleaning & maintain

- Waste disposal area shall be designated for safe disposal of

waste.

9 May 2008

Donor testing laboratories

QA and QC of testing laboratory

1. Used reagents & materials from approved

suppliers that meet the documented requirements

& specifications .

2. Lab procedures shall be validated before used.

3. IQC – to monitor the reliability of the test

performance

4. Participate in proficiency testing- EQA .

Medical Device Control in Thailand

• Regulatory Authority: Medical Device Control Division, Thai

FDA

• Current Law: Medical Device Acts 2008

• All medical devices as defined in Medical Device Acts 2008

requires to be registered to obtain import license before

importing for sale in Thailand.

.

17

Medical Device Registration

Medical Device Registration Medical device can be classified into 3 groups

• Licensing Medical Device: Requires to do clinical evaluation

and submit technical specifications dossier for review and

approval e.g. HIV test kit, HIV NAT etc.

• Notification Medical Device: Same as licensing medical device

but not require to do clinical evaluation e.g. Blood bag etc.

• General Medical Device: Requires a Free Sale Certificate

(FSC) from manufacturing site or product owner country to

register for approval. (> 90% of medical devices) e.g.

- HBsAg, Anti-HCV, Syphilis , Ferritin, ABO, Rh Grouping

antibody Screening, CBC, Hb testing

18

Laboratory testing procedures

All laboratory procedures shall be validated before

used.

Validation of laboratory procedure

9 May 2008

Validation Result page.3.of3

Validation Protocol No….016………………………. Subject being validated: การใชเครองตรวจหมโลหตอตโนมต QWALSE3

Section / RBC: ภาคบรการโลหตแหงชาตท 2 จงหวดลพบร

Date of validation: 16ภมภาพนธ -30 เมษายน 2555

Refer to: SP/WI … G2WI 001, G2WI 002 Objective; เพอประเมน ความไว (Sensitivity) และ ความจ าเพาะ ( Specificity) และ ความแมนย า ( Precision)ของเครองตรวจหมโลหตอตโนมต QWALSE3

Scope: ครอบคลมการตรวจ หมโลหตระบบ ABO , Rh, Antibody Screening (Coombs’ test) ในโลหตบรจาค Validator: นางสาวพชรากร กร ากระโทก Criteria for approval of validation: ความไว ( Sensitivity) 100% ความจ าเพาะ (Specificity) 100% ส าหรบผลการตรวจ ABO Rh

ความไว ( Sensitivity) > 98% ความจ าเพาะ ( Specificity) >98% ส าหรบผลการตรวจ Antibody Screening (Coombs’ test)

List of equipment used: 1.ใชตวอยางโลหตบรจาคทตรวจดวยวธเดม microplate technique แลวน ามาตรวจดวยเครอง QWALYS3 เปรยบเทยบผลการตรวจตาม Criteria ทตงไว จ านวน 100 ตวอยางประกอบดวย หมโลหต A 20 ราย หม B 35 ราย หม O 35 ราย หม AB 10 ราย 2.ใชตวอยางโลหตบรจาคททราบผล Antibody screening จ านวน 100 ราย น ามาตรวจดวยเครอง QWALYS3 เปรยบเทยบผลการตรวจตาม Criteria ทตงไว 3. ตวอยางทมประวต subgroup จ านวน 12 ราย ประกอบดวยหม A2 2 ราย A3 2 ราย B3 1 ราย A2B 3 ราย A3B 2 ราย A1B3 2 ราย และตวอยางหมโลหต Rh (D) positive จ านวน100 ราย Weak D จ านวน 2 ราย และ Rh (D)

negative จ านวน 5 ราย น ามาตรวจดวยเครอง QWALYS3 เปรยบเทยบผลการตรวจตาม Criteria ทตงไว 4.ตวอยางแอนตบอดททราบชนดแลว จ านวน 19 ราย ประกอบดวย Anti-D 2 ราย Anti-E 3 ราย Anti-Lea 2 ราย Anti-Leb 2 ราย Anti-Lea+b 3 ราย Anti-P1 3 ราย Anti-M 2 ราย Anti-N 2 รายและAnti-c 1ราย (ถาสามารถหาได) น ามาตรวจดวยเครอง

QWALYS3 เปรยบเทยบผลการตรวจตาม Criteria ทตงไว

Process Validation Result : ( ตามเอกสารแนบ)

1. ผลการตรวจหมโลหต ABO , Rh ตรงกนกบตวอยาง 100% (Sensitivity) 100% , (Specificity) 100%

2. ใหผลการตรวจ Antibody Screening (Coombs’ test) ตรงกนกบตวอยาง 100% (Sensitivity) 100% (Specificity) 100%

Conclusion: ผลการทดสอบผาน ตาม Criteria for approval of validation

Accepted Unaccepted Revalidate

Recommendation …………………………………………………………………………….………..

Chief of section / RBC …………………………………………..……. Date ……………………….

Approved Unapproved Revalidate

Recommendation ……………………………………………………………………………………..

Quality management representative ……………………………………. Date: ……………………

Validation of laboratory procedure

Laboratory testing for TTIs

Screening for infectious markers

1. Each donation - tested for HBsAg, anti-HCV, HIVAg/Ab,

syphilis.

2. A single reactive screened, the original sample be tested in

duplicate, also with segmented from blood bag.

3. Repeatedly reactive sample - HBsAg confirmatory test,

HIV rapid test (ICS) & Serodia as supplementary test.

4. Only serology negative (HbsAg, Anti-HCV, HIV Ab/Ag )

samples tested by NAT

Quality Control for TTIs serology testing

1. Assay Calibration : New lot reagent

2. Daily Quality Control :

2.1 Reagent Kit Control

2.2 EQC samples - EM5 (HbSAg, HIV ag/Ab, anti-HCV)

& In house Syphilis Quality Control

( plot Levey-Jennings graph for both each day)

3. When new Lot of control & reagents were used, parallel

run QC (EM5) with both reagents – to adjust the L-J

graph.

1. Assay Calibration

• Cal Curve Details

2. Daily Quality Control

2.1 Kit Control

Using kit control run each day of testing.

- Follow the manufacturer’s instructions.

Results - Plot LJ graph

2.2 EM5 & In house Syphilis Quality Control

Using QC samples run each day of testing at the

beginning & end of a shift.

Results - Plot LJ graph

2. Daily Quality Control

2. Daily Quality Control

2. Daily Quality Control

Out of range

2. Daily Quality Control

Should be Exclude And add comment

3. Reagent Parallel Run New lot of control & Reagent should be analyzed in parallel

with the control in current use.

Parallel Study Reagent Parallel Run

Continue to run current lot as usual

Run new lot twice per day for 5 days

Mean for 10 runs is used as the target mean for the new

lot

Mean must fall within assay sheet range

3. Reagent Parallel Run

3. Reagent Parallel Run

New Lot Reagent

Old Lot Reagent

Daily Quality Controls

Roche cobas® TaqScreen MPX Controls Kits, v2.0

The controls are covers 5 critical viral targets (4 vials):

• Negative Control

• Multi-Positive Control includes the HIV-1 M, HBV and HCV Positive Control.

• HIV-1 O Positive Control

• HIV-2 Positive Control

Vials are loaded onto the HAMILTON Pipettor and extracted together with samples

on Cobas AmpliPrep.

In house Quality Control

In-house Quality control (IQC)

IQC ( prepared from pool of HBV DNA, HCV RNA & HIV RNA reactive plasma) is

performed daily. CT value plot LJ graph

Quality control for NAT testing

QC of NAT testing

• result

9 May 2008

Laboratory testing for blood group

serology

Blood Group Serology Testing

1. Test for ABO, Rh & screening for RBC antibody.

2. First time donor- ABO group Rh(D– test twice.

3. RBC antibody screen: saline RT, 37C papain, AHG

4. If any discrepancy is found, blood should not be

released until discrepancy is resolved.

Quality control for Blood group serology

Daily quality control of reagents

Run QC samples at the beginning and end of working

day on automatic blood group analyzer.

- Blood group A, B, O, AB, Rh(D) negative

- 2 samples of weak antibodies positive

eg. Anti-D & anti-P1

QC of blood grouping testing

IQC Blood Group

Sample Sample

IQC Blood Group

IQC antibodies (anti-D, anti-Fya , anti-E, negative)

EQAS in donor screening laboratory

Test Provider

1 HIV, HBV, HCV, Syphilis serology NRL/Australia

2 HIV serology(HIV Ag/Ab Combi, anti-HCV

Dept of Medical Science, MOPH

3 HBsAg, Syphilis EQAI, Mahidol Iniversity

4 MP6 NAT EQAP Italy

5 ABO/Rh/antobody screen & identification

Dept of Medical Science, MOPH

6 CBC Dept of Medical Science, MOPH, RIQAS

EQAS for special laboratory

Test Provider

1 Red cells serology Reference lab - Dept of Medical Science, MOPH

- Royal College of Pathologists of Australia (QA program)

2 HLA Asia Pacific Histocompatibility and Immunogenetics Association

3 Platelet antigen/antibody NIBSC,UK

4 Low level Leukocyte Enumeration UK, NEQAS

5 CD34+ Stem Cells Enumeration

UK, NEQAS

EQA HIVAg/Ab combo (NRL)

EQA HIVAg/Ab combo (NRL)

EQA Syphilis (NRL)

การรายงานผล โรงพยาบาลทใชโปรแกรมศนยฯ โรงพยาบาลทไมใชโปรแกรมศนย

1. สงขอมลผบรจาคและผล โดยโปรแกรม Data transfer จะไดเปน text file แลวสงใหทาง email

1. Scan ใบรายงานผลเปน PDF file สงใหโรงพยาบาลผานทาง email

2. Scan ใบรายงานผลเปน PDF file สงใหโรงพยาบาลผานทาง email

2. กรณไมสามารถรบผลทาง email จะสง Fax ให (กรณ internet มปญหา)

3. กรณไมสามารถรบผลทาง email จะสง Fax ให (เชน กรณ internet มปญหา)

3. เมอมาสงตวอยางครงตอมา จะสงรายงานผลฉบบจรง คนให โรงพยาบาล

4. เมอมาสงตวอยางครงตอมา จะสงรายงานผลฉบบจรง คนให โรงพยาบาล

Program Data Transfer

ตวอยาง รายงานผล จาก PDF file

Table 4 Repeat donation of previous positive infectious marker blood donors

Year HIV HBV HCV Total

Donor Unit Donor Unit Donor Unit Donor Unit

2006a 8 10 120 132 50 56 178 198

2007b 15 15 233 264 102 115 350 394

2008b 8 9 214 253 99 112 321 374

2009b 14 15 233 266 119 137 366 418

2010b 11 14 253 295 112 126 376 435

Total 57 63 1,052 1,210 483 546 1,591 1,819

a: repeat donation from previous positive detected in 2006 only

b: repeat donation from previous positive detected in the same year and the year before

Blood Donor Screening in Thailand

3/34

BTS network Composes of

BKK,

- 1 NBC and 6 branches BS in the hospital.

Province,

- 12 RBCs has been set up throughout the

country.

- 161 branches BS in the provincial H,

Central general H, university H.

( hospital based BBs)

~ 200 HBBs in BKK and 800 in the provinces.

Total population : app. 65 M

Provinces : 77

Phuket

Blood Transfusion services network

Annual blood collection in Bangkok VS in the province fiscal year 2009–2013 (Oct–Sep)

Fiscal Year 08/09 09/10 10/11 11/12 12/13

Whole country 1,836,513 1,925,568 2,023,489 2,097,868 2,205,043

% of collection /population

2.9% 3.0% 3.2% 3.3% 3.4%

Collection in BKK 662,790 693,944 709,796 723,328 772,760

% of collection /population

11.6% 12.2% 12.5% 12.7% 13.6%

6 Branches& few HBBs

123,697 122,759 121,043 126,212 130,050

At NBC 539,093 571,185 588,753 597,116 642,710

Collection in provinces

1,173,723 1,231,624 1,313,693 1,374,540 1,432,283

% of collection/ population

2.0% 2.1% 2.2% 2.3% 2.4%

At HBBs 1,156,114 1,192,639 1,227,768 1,257,424 1,270,878

At RBCs 17,609 38,985 85,925 117,116 161,405

Historical of blood donation screening at NBC, TRC

• 1952 Syphilis

• VDRL, RPR, TPHA [PK7200], CMIA

• 1972 HBsAg

• CIEP, RPHA, ELISA, Chemiluminescence

• 1987 Anti-HIV

• ELISA, Chemiluminescence

• 1990 Anti-HCV

• ELISA, Chemiluminescesnce

• 1991 HIV-p24 Antigen

• ELISA

• 2002 NAT

• HIV/HCV

• HIV, HBV, HCV 4/34

Prevalence of TTI serological markers (%) in blood donations in Thailand (2002/03 – 2012/13)

2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

Syphilis 0.61% 0.58% 0.60% 0.57% 0.57% 0.40% 0.35% 0.35% 0.37% 0.34% 0.29%

HBsAg 2.44% 2.31% 2.19% 2.06% 1.96% 1.69% 1.51% 1.29% 1.11% 1.01% 0.84%

anti HCV 0.74% 0.65% 0.60% 0.60% 0.62% 0.60% 0.51% 0.49% 0.43% 0.39% 0.32%

HIV Ag/Ab 0.34% 0.27% 0.34% 0.34% 0.29% 0.28% 0.24% 0.21% 0.16% 0.17% 0.14%

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

Fiscal year 2005

total 2.56%

Fiscal year 2006

total 2.15%

Fiscal year 2007

total 1.93%

Fiscal year 2008

total 1.65%

Fiscal year 2009

total 1.51%

Fiscal year 2010

total 1.27%

Fiscal year 2011

total 1.14%

Fiscal year 2012

total 1.05%

Fiscal year 2013

total 1.09%

Fiscal year 2014

total 0.99%

Syphilis 0.75 0.44 0.40 0.28 0.23 0.21 0.23 0.21 0.21 0.16

HBsAg 1.31 1.26 1.14 1.01 0.96 0.79 0.65 0.57 0.60 0.52

HCV-Ab 0.31 0.26 0.23 0.19 0.18 0.13 0.15 0.14 0.12 0.11

HIV Ab/Ag 0.19 0.19 0.16 0.15 0.15 0.13 0.12 0.12 0.16 0.20

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

%

Prevalence of serological markers (%) in blood donors at NBC in 2005 - 2014

Fiscal year 2009 total 3.51%

Fiscal year 2010 total 1.82%

Fiscal year 2011 total 2.35%

Fiscal year 2012 total 2.31%

Fiscal year 2013 total 1.99%

Fiscal year 2014 total 0.99%

Syphilis 0.54 0.52 0.45 0.39 0.32 0.30

HBsAg 1.99 1.73 1.43 1.44 1.20 1.07

HCV-Ab 0.47 0.43 0.36 0.35 0.35 0.27

HIV Ab/Ag 0.15 0.14 0.11 0.13 0.12 0.12

0.00

0.50

1.00

1.50

2.00

2.50

%

Prevalence of serological markers (%) in blood donations from RBCs from 2009 - 2014

7/34

National Blood Policy in Thailand

2010

Serology

• Syphilis

• Anti-HIV 1,2

• HIV Ag (p24 Ag)

• HBsAg

• Anti-HCV

with a sensitive technique eg. EIA

• Nucleic Acid Testing (NAT)

8/34

534,168 566,815 584,830 597,350 636,037

631,756

35,234 41,595

53,884 53,776

66,215 71,637

569,402 608,410

638,714 651,126

702,252 703,393

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

2009 2010 2011 2012 2013 2014

Total sample tested at NBC;TRC and Hospital BBs in Bangkok

Oct 2009 – Sept 2014

NBC TRC BB Hospital Total

10/34

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

2009 2010 2011 2012 2013 2014

75,157

201,622

422,315

607,651

768,304

1,013,996

Number of NAT tested at RBCs, TRC from 2009 – 2014 (Oct – Sep)

11/34

RBC Provincial hospital Blood

Bank (Already NAT Testing)

Provincial hospital

Blood Bank (Non NAT Testing)

Tested at NBC 3 3

RBC 2 Lopburi 7 7

RBC 3 Chonburi 7 6

RBC 4 Rachaburi 7 7

RBC 5 Nakornrachasima 5 5

RBC 6 Khon Kaen 10 10

RBC 7 Ubonrachathani 6 5

RBC 8 Nakornsawan 5 5

RBC 9 Pitsanuloke 6 2 + 1*

RBC 10 Chiangmai 6 5 +1*

RBC 11 Nakornsri. 5 5

RBC 12 Songkla 5 5

RBC Phuket 4 4

Total 76 71 (2*)

NAT Testing of provincial Blood Banks

* Tested only new donors 12/34

Year No. of

Samples tested

NAT Reactive Samples (sero-negative )

HIV HCV HBV

2009 534,168 7 (1:76,300) 0 179(1:2,980)

2010 566,815 6(1:94,500) 1 193(1:2,930

2011 584,830 6(1:97,500) 1 182(1:3,210

2012 597,350 1(1:597,350) 1 176(1:3,390)

2013 636,037 5(1:127,200) 2 169(1:3,760)

2014 631,756 14(1:45,000) 2 147(1:4,300)

Total (NAT yield)

3,550,956 39

(1:91,000) 7

(1:507,000) 1,046

(1: 3,400)

NAT reactive samples from NBC,TRCS

Oct 2009-Sep 2014

13/34

Index sample No.

Date Sex Risk

behavior Donation

time Donation

site

NAT cobas s

201 (Ct)

F/U sample shown

Seroconvert after

(Month)

1 10/13 M MSM 9 mobile 33.6 3*

2 12/13 M N/A 1 NBC 27.7 N/A

3 12/13 M MSM 8 mobile 31.5 4*

4 12/13 M N/A 40 mobile 23.7 N/A

5 12/13 F N/A 4 mobile 33.5 N/A

6 12/13 F N/A 4 mobile 32.1 N/A

7 3/14 M MSM 2 mobile 29.9 3*

HIV-1 NAT reactive samples at NBC FY 2014

* follow up sample shown seroconvert by Architect, Determine and GPA 14/34

Index sample No.

Date Sex Risk

behavior Donation

time Donation

site

NAT cobas s

201 (Ct)

F/U sample shown

Seroconvert after

(Month)

8 5/14 M MSM 5 mobile 27 2*

9 5/14 M MSM 7 NBC 28.1 2*

10 6/14 M N/A 2 mobile 29.2 N/A

11 8/14 F N/A 21 mobile

31.4

N/A

12 8/14 M N/A

1 mobile 33.3

N/A

13 9/14 M N/A 5 mobile 29.8 N/A

14 9/14 M MSM 1 mobile 38.5 2*

HIV-1 NAT reactive samples at NBC FY 2014

* follow up sample shown seroconvert by Architect, Determine and GPA 15/34

Year No. of

Samples tested

NAT Reactive Samples (sero-negative)

HIV HCV HBV No plasma

sample to be confirmed

2009 35,234 0 0 15 8

2010 41,595 1 0 21 16

2011 53,884 0 1 17 15

2012 53,776 0 0 12 73

2013 66,215 0 0 15 21

2014 71637 1 0 10 -

Total (NAT yield)

322,341 2

(1: 160,000) 1

(1:322,000) 75

(1:4,300) 112

NAT reactive samples from hospital BBs in BKK

Oct 2009-Sep 2014

16/34

Year No. of

Samples tested

NAT Reactive Samples (sero-negative)

HIV HCV HBV No plasma

sample to be confirmed/VTR

2009 59,591 2(1:29,800) 1 48 (1:1,240) 0

2010 201,622 1(1:201,600) 2(1:100,000) 143(1:1,400) 40

2011 422,315 4(1:105,000) 3(1:140,000) 240(1:1,760) 66

2012 607,651 6(1:101,000) 1 263(1:2,300) 124

2013 768,304 11(1:70,000) 5(1:154,000) 323(1:2,400) 212

2014 1,013,996 13(1:78,000) 8(1:127,000) 454(1:2,200) -

Total (NAT yield)

3,073,479 37

(1:83,000) ) 20

(1:150,000) 1,471

(1:2,100)

NAT reactive samples from HBBs in the provinces Oct 2009-Sep 2014

17/34

• In 2014, blood donation samples tested at NBC and RBCs cover

about 75% of whole country blood collection.

• The prevalence rates of serological markers for Syphilis, anti-

HCV, HIV Ag/Ab gradually declined yearly where as HBsAg

declined significantly.

However there was a rising trend of HIV prevalence rate at NBC.

• Number of NAT window cases increased yearly as number of

NAT testing increased. In 2014, the NAT yield rates for HIV

(1:45,000) at NBC hit the highest rate.

18/34

• Thus, combination of serology and NAT testing in screening of

blood donations would significantly reduce the TTID and provide

the highest level of safe blood to the patient.

• Moreover, a better & strictly donors selection will be significantly

improved the blood transfusion safety.

19/34