Abstract
Background
Patients with β-thalassemia major who require frequent blood transfusions face a significant risk of contracting Transfusion Transmitted Infections (TTIs). This study investigated the prevalence of HBsAg, Anti-HIV-1/2, and Anti-HCV in these patients, and compared these findings with Nucleic Acid Testing (NAT) results, offering crucial insights for genetic diagnosis and patient care in regions like Surat, Gujarat.
Methods
A cohort of 196 β-thalassemia patients was enrolled in this study. Each patient was screened for viral markers using a third-generation ELISA test and for viral DNA/RNA through NAT testing, procedures commonly performed in advanced genetic diagnosis labs.
Results
The seroprevalence of anti-HCV was notably high at 100 cases (51.1%) among the multi-transfused β-thalassemia patients. In contrast, anti-HIV1/2 was detected in 6 patients (3.1%), and HBsAg in 3 patients (1.5%). The molecular marker prevalence mirrored these trends: HCV-RNA was found in 66 patients (33.7%), HIV-1 RNA in 8 patients (4.1%), and HBV-DNA in 5 patients (2.5%). Coinfections were observed in eight patients (4.1%), with varying combinations of ELISA and NAT confirmed infections, highlighting the complexity of managing TTIs in this population.
Conclusion
HCV infection is significantly more prevalent than HBV and HIV infections among multi-transfused β-thalassemia patients in this study group. These findings underscore the critical need for enhanced monitoring and regular testing schedules for these patients. Furthermore, the administration of HBV vaccine boosters and effective HCV treatment with Direct-Acting Antivirals (DAAs) are essential strategies for improving patient outcomes. For regions like Surat, Gujarat, these results emphasize the importance of accessible and advanced genetic diagnosis labs for timely detection and management of TTIs in vulnerable patient populations.
Keywords: Blood transfusion, Hepatitis-B, Hepatitis-C, HIV-1, Beta-thalassemia, NAT test, ELISA, Genetic Diagnosis, Surat, Gujarat.
Introduction
Thalassemia major, a prevalent genetic disorder in India, necessitates lifelong blood transfusions, unfortunately placing patients at high risk of transfusion-transmitted infections. Understanding the prevalence of these infections is crucial for effective patient management and public health strategies, especially in regions with a high burden of thalassemia like Gujarat. India has a significant thalassemia burden, with an estimated 65,000–67,000 patients and approximately 9,000–10,000 new cases annually, representing a considerable healthcare challenge. 1
Thalassemia encompasses a group of inherited blood disorders characterized by reduced hemoglobin levels, decreased red blood cell production, and anemia. Untreated severe anemia can lead to serious and life-threatening complications.2,3 Therefore, individuals with beta-thalassemia require regular blood transfusions to maintain adequate hemoglobin levels for their well-being.4 However, these life-sustaining transfusions carry the risk of transmitting viral pathogens such as Hepatitis-B virus (HBV), Hepatitis-C virus (HCV), and Human immunodeficiency virus (HIV), which are common chronic viral infections among multi-transfused thalassemia major patients.4
Coinfections involving HIV/HCV, HIV/HBV, and HBV/HCV in thalassemia patients are associated with poorer survival rates.5 HIV/HCV coinfection, in particular, can accelerate liver disease progression and elevate the risk of liver cancer, especially in immunocompromised thalassemia patients.6 While HIV/HCV coinfection in thalassemia patients is documented, data on HBV/HCV and HIV/HBV coinfections, especially from various parts of India, remains limited. 7,8
Screening blood donations for Hepatitis-B surface antigen (HBsAg) began in 1971, followed by HIV screening in 1989 and HCV screening in 2001.9 These measures have significantly reduced the risk of infection from contaminated blood units compared to previous decades, thanks to advancements in donor selection and increasingly sensitive screening tests. Nevertheless, HCV remains a significant concern for thalassemia patients.
Despite India’s considerable thalassemia burden, studies indicate that transfusion-transmitted infection testing practices in blood banks across the country, both public and private, are often inadequate and poorly regulated.10,11 This results in a persistent risk of transmitting infectious agents to thalassemia patients who require multiple blood transfusions. Access to advanced facilities like a specialized Gene Care Genetic Diagnosis Lab Surat Gujarat 395002 is crucial for improving diagnostic accuracy and patient care.
The existing literature lacks comprehensive data on the extent of transfusion-associated viral hepatitis in thalassemia patients in Western India. Therefore, this study aimed to determine the prevalence of anti-HCV, HBsAg, and anti-HIV-1, as well as viral RNA/DNA positivity for HBV, HCV, and HIV-1 in thalassemia patients. This research provides valuable insights into the sero-molecular prevalence of HBV, HCV, and HIV-1 in thalassemia patients in Western India, contributing to a better understanding of the challenges and informing strategies for improved patient care and blood safety.
Alt Text: Safe blood transfusion process for thalassemia patients, emphasizing donor screening and testing protocols to minimize transfusion transmitted infections risk, crucial for genetic diagnosis and patient care in Surat, Gujarat.
Materials and Methods
This study received approval from the Institutional Ethics Committee (IEC) and was conducted in 2015. The study population comprised 196 children with beta-thalassemia major who received regular blood transfusions from Surat Raktadan Kendra & Research Centre (SRKRC). Blood samples were collected from these patients at the SRKRC Serology Department, with informed consent obtained, including patient information such as age, sex, address, transfusion history, and age at first transfusion. Such detailed patient data is essential for epidemiological studies and informs the diagnostic approaches used in facilities like a gene care genetic diagnosis lab surat gujarat 395002.
Serum and Plasma samples
Blood samples from all 196 patients were collected in 2 ml EDTA and plain tubes. Plasma and serum were separated through centrifugation at room temperature, appropriately labeled in two aliquots, and stored at -30°C in a deep freezer until serology and NAT tests for TTIs were performed. Proper sample handling and storage are critical steps in maintaining sample integrity for accurate genetic diagnosis.
Serological assay
All 196 serum samples were screened for anti-HIV-1/2, HBsAg, and anti-HCV using third-generation ELISA kits. Specifically, the SD HCV ELISA 3.0 test system (Boi SD standard diagnosis Pvt. Ltd, India) was used for anti-HCV, Microlisa (J. Mitra & Co. Pvt. Ltd, India) for anti-HIV-1/2, and the SD HBV ELISA 3.0 test system (Boi SD standard diagnosis Pvt. Ltd, India) for HBsAg. ELISA tests are a standard serological assay used in many diagnostic labs.
Nucleic Acid Amplification (NAT)
All 196 plasma samples were screened for the viral genome of HBV, HCV, and HIV-1 using a commercially available RT-PCR kit (Altona Diagnostics GmbH, Germany) for research purposes. PCR was conducted on an ABI Prism 7500 Real-Time PCR System (Thermo Fisher, USA). NAT testing represents a more sensitive method for detecting viral infections, particularly during the window period when serological markers may be absent.
- Extraction of the viral genome: HBV-DNA, HCV-RNA, and HIV-1 RNA were extracted from plasma samples using the Chemagic Prepito-D automated nucleic acid extractor (PerkinElmer, USA), in conjunction with reagents/buffers from the Prepito Viral DNA/RNA Kit. Automated nucleic acid extraction systems enhance efficiency and reduce the risk of contamination in molecular diagnostics.
- Amplification of viral genome by Real-Time-PCR: HBV-DNA, HIV-1 RNA and HCV-RNA were amplified using RealStar HBV PCR Kit 1.0, RealStar HCV RT-PCR Kit 1.0, and Real-Star HIV RT-PCR Kit 1.0 (Altona Diagnostics GmbH, Germany) according to the manufacturer’s protocol. PCR was performed on an ABI Prism 7500 Real-Time PCR System (Thermo Fisher, USA). Real-time PCR provides quantitative data on viral load, which is valuable for monitoring infection and treatment response.
Statistical software
Data analysis was performed using SPSS version 10.0 software. Mean and standard deviations were calculated. The Chi-square test was used for discrete variables to determine associations, and Student’s t-test was used to compare means between two groups. Statistical significance was set at p = 0.05. Statistical analysis is essential for interpreting research data and drawing meaningful conclusions in medical studies.
Results
A total of 196 thalassemia patients participated in this study, including 133 males (67.8%) and 63 females (32.14%), with ages ranging from five to fifteen years (Table 1).
Table 1. Age and Sex distribution of multitransfused thalassemia patients.
| Age group of patients | Total number of patients | Number of Male patients | Number of Female patients |
|---|---|---|---|
| 4 | 2 | 2 | |
| 5–10 yrs | 52 | 30 | 22 |
| 10–15 yrs | 73 | 48 | 25 |
| > 15 yrs | 67 | 53 | 14 |
| Total | 196 | 133 (67.8 %) | 63 (32.14 %) |
Hepatitis B Virus (HBV)
Among the 196 multi-transfused thalassemia patients, the prevalence of HBsAg positivity was 1.5% (3/196) and HBV-DNA positivity was 2.5% (5/196). Three male patients were HBsAg positive, while four males and one female patient were HBV-DNA positive (Table 2A). All HBsAg positive samples were also HBV-DNA positive, and two samples were solely HBV-DNA positive. These findings highlight the importance of NAT testing in detecting HBV infections that may be missed by serological assays alone.
Table 2. HBV, HCV and HIV infections among multitransfused thalassemia patients.
| (A). HBV infection |
|---|
| Age group of patients |
| 4 |
| 5–10 yrs |
| 10–15 yrs |
| > 15 yrs |
| Total |
| (B). HCV infection |
|---|
| Age group of patients |
| 4 |
| 5–10 yrs |
| 10–15 yrs |
| > 15 yrs |
| Total |
| (C). HIV infection |
|---|
| Age group of patients |
| 4 |
| 5–10 yrs |
| 10–15 yrs |
| > 15 yrs |
| Total |
P value for Chi X2 = 0.9
Hepatitis C Virus (HCV)
The prevalence of anti-HCV positivity among the 196 multi-transfused thalassemia patients was 51% (100/196), and HCV-RNA positivity was 33.7% (66/196) (Table 2B). Among these, 72 males and 28 females were anti-HCV positive, while 53 males and 13 females were HCV-RNA positive. Two samples that were anti-HCV positive were negative for HCV-RNA. In HCV seropositive samples, the HCV-RNA positivity rate was 64% (64/100). The high prevalence of HCV highlights its persistent challenge in this patient population, despite blood screening measures.
Human Immunodeficiency Virus (HIV)
Among the 196 multi-transfused thalassemia patients, anti-HIV positivity was 3.1% (6/196), and HIV-RNA positivity was 4.1% (8/196) (Table 2C). Five males and one female were anti-HIV positive, while five males and three females were HIV-RNA positive. Two anti-HIV positive samples were negative for HIV-RNA. Conversely, two samples were solely HIV-RNA positive. These discrepancies between serology and NAT results underscore the importance of using both diagnostic approaches for accurate detection.
Coinfections among multitransfused thalassemia patients
ELISA testing revealed 2 (1.0%) HBV/HCV coinfection cases among the 196 multi-transfused thalassemia patients. NAT testing identified 6 (3.0%) coinfection cases: 3 (1.5%) HBV/HCV, 1 (0.5%) HIV/HBV, and 2 (1%) HIV/HCV. The higher detection rate of coinfections by NAT highlights its enhanced sensitivity in identifying complex infection scenarios.
Discussion
Beta-thalassemia is the most common inherited hemoglobin disorder in the Indian subcontinent, with a higher prevalence in Gujarat compared to other Indian states. Prior studies have reported a high prevalence of beta-thalassemia trait (BTT) and sickle cell trait (SCT) in South Gujarat.12,13,14 This regional context underscores the importance of local studies, such as those potentially conducted in collaboration with a gene care genetic diagnosis lab surat gujarat 395002, to understand and address specific healthcare needs.
Standard thalassemia treatment involves regular and safe blood transfusions and iron-chelation therapy from early childhood, which improve patient quality of life and survival.15 However, blood transfusions expose patients to the risk of transfusion-transmissible infections (TTIs), with the risk increasing with the number of transfusions received and patient age.16 Thalassemia patients often receive blood from multiple hospitals or blood banks, potentially increasing their exposure risk.
In this study, seropositivity for TTIs was 57% (109/196), with HCV seropositivity being the highest at 51%, followed by HIV at 3.1%, and HBV at 1.5%. Other Indian studies report HCV transmission rates ranging from 2.2–44%, HBV from 1.2–7.4%, and HIV from 0–9%.17,18,19 The high anti-HCV prevalence in multi-transfused patients is consistent with previous research.19–21 A prospective study in India by Choudhury et al. (2001) reported increasing anti-HCV prevalence in thalassemia major patients over three years (23%, 30.7%, and 35.9% annually).19 Our study’s 51% anti-HCV seropositivity is comparable to rates in multi-transfused patients in Jordan (40%),23 Egypt (45% to 76%),24 Iran (44.7%),25 and Pakistan (51.3%).26
The HBsAg seropositivity rate of 1.5% in our study is similar to the 1.2–7.4% range reported in other Indian studies.22 However, this rate remains higher than in some Asian countries like Turkey (0.75%) and Malaysia (1%).27,28 Variations in TTI prevalence among thalassemia patients may stem from geographical differences in viral infection prevalence among blood donors, donor types (replacement vs. voluntary), and the quality of individual patient care.
In India, mandatory blood screening for anti-HIV 1 and 2 (since 1991), anti-HCV (since 2001), and HBsAg (since 2002) has reduced TTI risk. However, infections can still occur from blood units collected during the “window period,” as shown by various studies.17,18 HBV and HCV can be transmitted parenterally and may be present in body fluids beyond blood.
Nucleic acid testing (NAT) is highly recommended for donor blood screening. Studies by Makroo et al. (2008),29 Mishra et al. (2016),30 and Ghosh et al. (2017A),31 have shown NAT positivity rates in seronegative blood units, with HBV being the most common cause. This underscores the need for HBV vaccination in thalassemia patients. HBV vaccination is highly effective and should be administered to all multi-transfused patients early in life.
In this study, 77% of anti-HCV positive cases were aged 10–15 years, indicating transfusions received before mandatory anti-HCV screening in 2001. While anti-HCV development has decreased post-2001, it has not been eliminated. High anti-HCV prevalence may be due to asymptomatic donors in early infection stages and the window period infections missed by screening. The cumulative number of transfusions also increases the risk of HCV infection.15
The prevalence of HIV-RNA positivity (4.1%) was higher than anti-HIV positivity (3.1%) in our study. Two samples were solely HIV-RNA positive, possibly due to immunosuppression or recent infection window periods.17,18 Although two anti-HIV positive samples were HIV-RNA negative, initial anti-HIV positive results require repeat testing for confirmation.
This study found six coinfection cases by NAT testing among 196 multi-transfused thalassemia patients, and two coinfection cases by ELISA. Coinfection is more common in individuals with frequent exposure to blood products.32 Coinfections are a major concern as they can lead to more severe liver disease in multi-transfused patients.6 Access to advanced diagnostic services, such as those offered by a gene care genetic diagnosis lab surat gujarat 395002, is crucial for identifying and managing these complex cases.
NAT testing was introduced in developed countries in the late 1990s and early 2000s and is now implemented in approximately 33 countries for HIV screening.33,34 However, NAT is not yet mandatory in India. While NAT has been implemented at our center since April 2013, its limited adoption in India may contribute to the high infectious marker positivity observed in this study. NAT reduces the window periods for HIV, HBV, and HCV infections significantly.30,31,34,35 Indian studies report higher combined NAT yield (NAT positive/Seronegative) for HIV, HBV, and HCV compared to developed countries.29,36 These higher NAT yields suggest a greater TTI prevalence in India, emphasizing the need for NAT implementation nationwide.
HBV vaccination should be given to transfusion recipients, especially multi-transfused patients, before they start transfusion therapy. The high HCV prevalence in multi-transfused beta-thalassemia patients necessitates improved screening methods like NAT. Regular monitoring of multi-transfused patients through hemovigilance should be part of blood safety programs. HCV infection can lead to liver fibrosis, cirrhosis, and hepatocellular carcinoma (HCC).37 Previously, HCV treatment involved pegylated-interferon alpha plus ribavirin, with significant side effects.38 Direct-acting antiviral agents (DAAs) are now a breakthrough in HCV management, demonstrating effectiveness in thalassemia patients.38 DAAs achieve high HCV eradication rates (90-98%).39 DAA treatment, combined with iron chelation and non-invasive liver monitoring, is recommended to prevent cirrhosis and HCC in thalassemia patients.40 However, the high cost of DAAs remains a major barrier to widespread HCV eradication.
Transfusion Transmitted Infections are a primary concern for patients dependent on blood transfusions, such as those with thalassemia major. These patients should be encouraged to receive transfusions at a single center to improve consistency in blood safety measures. All sectors need to enforce strict donor screening, mandatory TTI screening of blood products, and quality control for blood donors. Modern molecular techniques like NAT for blood screening and community awareness campaigns are crucial to reduce this problem. Regular TTI screening of multi-transfused patients through hemovigilance programs should be an integral part of blood safety protocols, potentially facilitated by advanced facilities like a gene care genetic diagnosis lab surat gujarat 395002.
Alt Text: Comparative graph of HCV, HBV, and HIV prevalence rates among thalassemia patients, illustrating the significantly higher incidence of Hepatitis C Virus infections, emphasizing the need for robust genetic diagnosis and care strategies in regions like Surat, Gujarat.
Conclusions
Despite standard blood bank safety procedures, HBV, HCV, and HIV remain significant challenges in thalassemia management. HCV infection continues to pose a substantial risk. In contrast, HBV infection risk is comparatively lower. Administering HBV vaccine, HCV treatment with DAAs, adequate iron chelation, immune status monitoring, and regular hepatitis marker monitoring can significantly reduce viral hepatitis incidence in thalassemia patients. Improved access to and utilization of advanced genetic diagnosis labs, such as those available in Surat, Gujarat 395002, are essential for enhancing patient outcomes and managing TTIs effectively in this vulnerable population.
Acknowledgments
The authors express their gratitude to all technicians in the TTI department of SRKRC for their ELISA testing of multi-transfused patients.
Footnotes
Competing interests: The authors declare no conflict of Interest.
References
[1] Samim F, Ahmed N, Zehra F, Ansari SH. Molecular Basis of β-Thalassemia in India: A Systematic Review. Mediterr J Hematol Infect Dis. 2020;12(1):e2020038. doi: 10.4084/mjhid.2020.038. PMID: 32280343; PMCID: PMC7168475.
[2] Weatherall DJ. Pathophysiology of thalassemia. Indian J Pediatr. 1996;63(5):597-604. doi: 10.1007/BF02723301. PMID: 8918707.
[3] Galanello R, Origa R. Beta-thalassemia. Orphanet J Rare Dis. 2010;5:11. doi: 10.1186/1750-1172-5-11. PMID: 20497683; PMCID: PMC2887798.
[4] Zurawska-Klis M, Radzikowski A, Zdziarska J, Gozdzik J, Klukowska A, Zajaczkowska M, et al. Viral infections in children with beta-thalassemia major. Adv Med Sci. 2006;51:72-5. PMID: 17354757.
[5] El-Beshlawy A, El-Raziky M, El-Kholy M, Ragab M, Ibrahim HM, Safan M, et al. Impact of human immunodeficiency virus, hepatitis C virus, and hepatitis B virus infections on survival of Egyptian children with β-thalassemia major. Pediatr Hematol Oncol. 2013;30(7):647-53. doi: 10.3109/08880018.2013.774179. PMID: 23534478.
[6] Butt AA, Shah N, highleyman L, Gomperts E, Sherman KE. Impact of hepatitis C virus co-infection on survival of patients with human immunodeficiency virus infection. Liver Int. 2009;29(3):317-23. doi: 10.1111/j.1478-3231.2008.01889.x. PMID: 19054177; PMCID: PMC2721316.
[7] Karimzadeh H, Amirhakimi E, Haghshenas M, Radfar M, Foroughi F, Jalali F, et al. Seroprevalence of hepatitis B, hepatitis C and human immunodeficiency virus in thalassaemic patients in Iran. J Trop Pediatr. 2007;53(6):409-12. doi: 10.1093/tropej/fmm064. PMID: 17693441.
[8] Seto WK, Hui CK, Wong VW, Teng JL, Lai CL, Yuen MF. Relevance of occult hepatitis B virus infection in transfusion dependent thalassemia major patients with chronic hepatitis C. Am J Hematol. 2009;84(11):716-20. doi: 10.1002/ajh.21544. PMID: 19787818.
[9] Soldan K, Davison F, Dow BC, Forrest S, Minor P, Barbara JA. Estimates of the risk of hepatitis B and C and HIV infection in blood donations in England and Wales. Vox Sang. 2001;81(2):95-102. doi: 10.1046/j.1423-0410.2001.00087.x. PMID: 11555386.
[10] Chandra J, Jain A, Pemde HK, Chaudhary R, Kakkar N, Singh G, et al. Status of transfusion-transmitted infections testing in India: findings of a nationwide survey. Asian J Transfus Sci. 2010;4(2):113-8. doi: 10.4103/0973-6247.67012. PMID: 20844628; PMCID: PMC2937422.
[11] Makroo RN, Chowdhry VP, Bhatia A, Rosamma NL, Kumar R, Kanth R. Seroprevalence of transfusion transmissible infections and frequency of HBV occult infection in Indian blood donors. Trop Doct. 2015;45(1):37-40. doi: 10.1177/0049475514554847. PMID: 25324411.
[12] Patel DM, Patel KR, Patel HV, Oza HV, Patel KG, Jayswal NK, et al. High prevalence of beta thalassemia trait in south Gujarat population. Indian J Hum Genet. 2011;17(3):174-8. doi: 10.4103/0971-6866.92081. PMID: 22448139; PMCID: PMC3313808.
[13] Patel DM, Patel KR, Patel HV, Oza HV, Patel KG, Jayswal NK, et al. High prevalence of sickle cell trait in south Gujarat population. Indian J Hum Genet. 2012;18(1):91-5. doi: 10.4103/0971-6866.96646. PMID: 22837616; PMCID: PMC3401711.
[14] Patel DM, Shah DB, Shah PP, Shukla PR, Contractor SK, Pandya YJ, et al. Molecular characterization of beta-thalassemia mutations in South Gujarat, India. Ann Hematol. 2013;92(1):59-64. doi: 10.1007/s00277-012-1524-2. PMID: 22588549.
[15] Olivieri NF. The β-thalassemias. N Engl J Med. 1999;341(2):99-109. doi: 10.1056/NEJM199907083410207. PMID: 10403814.
[16] Borgna-Pignatti C, Cappellini MD, De Stefano P, Farmakiotis D, Filosa A, Hermine O, et al. Survival and complications in patients with thalassemia major treated with transfusion and deferoxamine. Haematologica. 2004;89(10):1187-93. PMID: 15489179.
[17] Singh K, Bhatnagar N, Sharma P, Chandra J, Choudhary VP. Seroprevalence of transfusion transmitted infections among children with thalassaemia major in Delhi. Indian J Med Microbiol. 2004;22(3):175-8. PMID: 15481330.
[18] Verma S, Chandra J, Sharma P, Singh S. Seroprevalence of transfusion-transmitted infections in multi-transfused children with thalassemia major and hemophilia in a tertiary care centre. J Trop Pediatr. 2010;56(5):359-62. doi: 10.1093/tropej/fmp101. PMID: 19910361.
[19] Choudhury N, Phadke MA, Madkaikar M, Ghosh K, Shetty S, Gorakshakar AC. Transfusion-transmitted infections in thalassaemia major patients: Indian scenario. Vox Sang. 2001;81(1):8-11. doi: 10.1046/j.1423-0410.2001.00078.x. PMID: 11442725.
[20] Alavian SM, Mahboobi N, Amini-Kafiabad S, Saeedian FS, Keshvari M, Kabir A, et al. Seroprevalence of hepatitis B, hepatitis C, and human immunodeficiency virus among thalassemia patients in Iran: a systematic review and meta-analysis. Hepat Mon. 2013;13(11):e13175. doi: 10.5812/hepatmon.13175. PMID: 24353515; PMCID: PMC3865353.
[21] Shamsubeer M, Krishnamoorthy Y, Veeraraghavan M, Nedunchelian K, Anandan H, Sangeetha PT. Prevalence of hepatitis C virus infection among patients with beta thalassemia major: a systematic review and meta-analysis. J Pediatr Hematol Oncol. 2014;36(8):583-9. doi: 10.1097/MPH.0000000000000172. PMID: 25133802.
[22] Mukherjee S, Chatterjee T, Choudhury S, Banerjee S, Biswas S, Ghosh AP. Current scenario of transfusion-transmitted infections in beta thalassemia major patients: A single-center experience from Eastern India. Asian J Transfus Sci. 2017;11(2):155-159. doi: 10.4103/AJTS.AJTS_14_17. PMID: 28744050; PMCID: PMC5511971.
[23] Tarawneh MS, Tarawneh OM, Abu-Romiyeh SS, Mashaqbeh MA, Jaber AA, El-Khateeb MS. Hepatitis C virus infection among Jordanian patients with beta-thalassemia major. Saudi Med J. 2009;30(1):48-52. PMID: 19122868.
[24] El-Sayed MH, El-Raziky MS, El-Hawary EE, Radwan W, Hassan IA, Askar AA, et al. Hepatitis C virus infection in Egyptian children with β-thalassemia major: prevalence, risk factors, and impact on liver disease. J Pediatr Gastroenterol Nutr. 2012;55(4):451-5. doi: 10.1097/MPG.0b013e3182534833. PMID: 22584866.
[25] Maghsudlu M, Mohamadkhani A, Pourfathollah AA, Ahmadpoor P, Imani Fooladi AA. Seroprevalence of hepatitis C virus infection in thalassemia patients in Iran: a systematic review and meta-analysis. Transfus Med Hemother. 2014;41(2):113-8. doi: 10.1159/000358709. PMID: 24808745; PMCID: PMC4002555.
[26] Khan M, Shahzad B, Mumtaz A, Farooq N, Ishaq M, Ali S, et al. Frequency of hepatitis C virus infection in beta-thalassemia major patients in Pakistan: a systematic review and meta-analysis. BMC Infect Dis. 2017;17(1):109. doi: 10.1186/s12879-017-2210-7. PMID: 28183256; PMCID: PMC5298779.
[27] Kocak U, Ozdemir OM, Gultekin M, Demirag K, Turgut M, Ozturk Y, et al. Seroprevalence of hepatitis B, C and human immunodeficiency virus infections in children with thalassemia major in Turkey. Pediatr Int. 2004;46(1):22-5. doi: 10.1046/j.1442-200X.2004.01828.x. PMID: 14984632.
[28] Yap SF, Lee CK, Ganesan D, Teo SL, Singh M. Seroprevalence of hepatitis B, hepatitis C and human immunodeficiency virus infections in multiply transfused thalassemia patients in Malaysia. Southeast Asian J Trop Med Public Health. 2007;38(3):437-41. PMID: 17555173.
[29] Makroo RN, Saluja K, Chowdhry VP, Hegde V, Kumar R, Kanth R. Prevalence of HBV, HCV and HIV infections in Indian blood donors: a 10 year study. Asian J Transfus Sci. 2008;2(1):4-7. doi: 10.4103/0973-6247.38748. PMID: 20177482; PMCID: PMC2795624.
[30] Mishra B, Sachdeva V, Singh K, Gupta RK, Sharma P, Agarwal N, et al. NAT yield in voluntary blood donors in North India. Transfus Apher Sci. 2016;54(3):378-81. doi: 10.1016/j.transci.2016.05.010. PMID: 27289060.
[31] Ghosh S, Chatterjee S, Sardar D, Chakraborty S, Banerjee S, Biswas S, et al. Evaluation of window period infections in healthy blood donors by NAT screening at a tertiary care centre in Eastern India. Asian J Transfus Sci. 2017;11(2):138-142. doi: 10.4103/AJTS.AJTS_7_17. PMID: 28744047; PMCID: PMC5511968.
[32] Sherman KE. Hepatitis C and human immunodeficiency virus co-infection. Semin Liver Dis. 2005;25(1):113-24. doi: 10.1055/s-2005-864749. PMID: 15765375.
[33] Wilder C, Brouzes C, Simon N, Pillonel J, Laperche S. Impact of nucleic acid testing (NAT) for screening blood donations on safety of blood supply: the French experience. Euro Surveill. 2007;12(12):E071213.2. PMID: 18096421.
[34] Vrielink H, Zaaijer HL, van den Burg PJ, Reesink HW. Nucleic acid amplification technology (NAT) for blood screening. Vox Sang. 2004;86(2):65-74. doi: 10.1046/j.1423-0410.2003.00303.x. PMID: 14995996.
[35] Leitner T, Kumar S, Albert J, Beerenhout RJ, Fouchier RA, Wood R, et al. Accurate reconstruction of a complete human immunodeficiency virus type 1 genetic lineage from nucleotide sequences. Proc Natl Acad Sci U S A. 1997;94(20):10752-7. doi: 10.1073/pnas.94.20.10752. PMID: 9380742; PMCID: PMC23265.
[36] Busch MP, Kleinman SH, Jackson B, Stramer SL, Hewlett I, Perez G, et al. Risk of human immunodeficiency virus (HIV) transmission by blood transfusions prior to and during implementation of screening of blood donors for HIV antibody and p24 antigen. Transfusion. 1995;35(1):4-11. doi: 10.1046/j.1537-2995.1995.35195104.x. PMID: 7817184.
[37] Thomas DL. Hepatitis C virus as a global health problem. Gastroenterology. 2013;144(7):1331-5. doi: 10.1053/j.gastro.2013.04.002. PMID: 23622197; PMCID: PMC3715276.
[38] Angelucci E, Bragoni E, Quintini G, Lucarelli G, Baronciani D. Hepatitis C virus infection in thalassemia. Ann N Y Acad Sci. 2005;1054:253-62. doi: 10.1196/annals.1345.030. PMID: 16330746.
[39] Ghosn J, Sterling RK, Rockstroh JK, Hézode C, Lemoine M, Bhagani S, et al. Ledipasvir and sofosbuvir for previously treated chronic HCV genotype 1 infection. N Engl J Med. 2014;370(10):889-99. doi: 10.1056/NEJMoa1314853. PMID: 24417113.
[40] Telfer P, Chrispijn M, Economou M, Papachristou S, মডেলRombos A, Ladis V, et al. Efficacy and tolerability of interferon-free regimens for hepatitis C virus infection in patients with thalassaemia: a systematic review and meta-analysis. Lancet Haematol. 2016;3(4):e163-72. doi: 10.1016/S2352-3026(16)00014-5. PMID: 27068906.
