Transfusion Transmitted Injuries Surveillance System
Program Report 2002-2003

Transfusion Transmitted Injuries Section Blood Safety Surveillance and Health Care Acquired Infections Division June 2005 PDF version

---

Table of Contents

1	Introduction
2	Methodology
3	Results
3.1		AdverseTransfusionEventsIncludedforAnalysis
3.2		AdverseTransfusionEventsRelatedtoBloodComponents
3.2.1			Type of Blood Components Implicated in Adverse Transfusion Events
3.2.2			Relationship of Adverse Transfusion Events to Transfusion
3.2.3			Severity of Adverse Transfusion Events
3.2.4			Diagnosis of Adverse Transfusion Events Related to Blood Components
3.2.5			Type of Adverse Transfusion Events by Relationship to Transfusion
3.2.6			Type of Adverse Transfusion Events by Severity
3.2.7			Analysis of Specific Type of Adverse Transfusion Events
			3.2.7.1	ABO Incompatibility
			3.2.7.2	Acute Hemolytic Transfusion Reactions
			3.2.7.3	Delayed Hemolytic Transfusion Reactions
			3.2.7.4	Bacterial Contamination
				A) Bacterial Contamination by Relationship to Transfusion
				B) Bacterial Contamination by Type of Blood Components Transfused
				C) Bacterial Contamination by Severity of Adverse Transfusion Events
				D) Bacterial Contamination by Type of Pathogens Involved
3.2.8			Incidence of Adverse Transfusion Events
3.3		AdverseTransfusionEventsRelatedtoPlasmaDerivativesand RecombinantProducts
		3.3.1 Diagnosis of Adverse Transfusion Events Related to Plasma Derivatives and Recombinant Products
		3.3.2 Type of Adverse Transfusion Events by Relationship to Transfusion
		3.3.3 Type of Adverse Transfusion Events by Severity
3.4		Fatalities
		.4.1 Incidence of Fatal Events Related to Transfusion of Blood Components
4	Discussion
5	References

---

The following text, figures and tables were prepared by:

Antonio Giulivi, MD, FRCPC Director Blood Safety Surveillance and Health Care Acquired Infections Division Centre for Infectious Disease Prevention and Control Public Health Agency of Canada

Magalie Cator, MD, MSc Epidemiologist Transfusion Transmitted Injuries Section Blood Safety Surveillance and Health Care Acquired Infections Division Centre for Infectious Disease Prevention and Control Public Health Agency of Canada

Pierre Robillard, MD Medical Advisor

Nancy McCombie, RN Manager Transfusion Transmitted Injuries Section Blood Safety Surveillance and Health Care Acquired Infections Division Centre for Infectious Disease Prevention and Control Public Health Agency of Canada

Micheline (Mindy) Miron Acting Surveillance Officer Transfusion Transmitted Injuries Section Blood Safety Surveillance and Health Care Acquired Infections Division Centre for Infectious Disease Prevention and Control Public Health Agency of Canada

Acknowledgement

A national surveillance system is only as strong as the participating federal/provincial/territorial partners and the Transfusion Transmitted Injuries Surveillance System is no exception. The Public Health Agency of Canada recognizes the invaluable contributions of all the stakeholders in the system including but not limited to transfusion safety officers, laboratory technologists, nurses, and blood bank physicians. Without their timely provision of data on adverse transfusion events, there could be no analysis of the national importance of these occurrences. The advice and collaboration of all participating sites and of the two blood manufacturers (Canadian Blood Services and Héma-Québec) as well as the members of the regulatory branch of Health Canada is essential to the system and to have a meaningful positive effect on the health of Canadians.

Dr. Ted Alport1 Medical Director Canadian Blood Services Regina, Saskatchewan	Dr. Grlica Bolesnikov1 Scientific Research Officer Office of the Chief Medical Officer of Health NB Department of Health and Wellness Fredericton, New Brunswick
Dr. David Anderson2 Head, Division of Hematology Professor of Medicine Associate Professor of Pathology Queen Elizabeth II Health Sciences Centre and Dalhousie University Halifax, Nova Scotia	Norman Caissie Systems Analyst Blood Safety Surveillance and Health Care Acquired Infections Division Centre for Infectious Disease Prevention and Control Public Health Agency of Canada Ottawa, Ontario
Dr. Robert Barr Formerly: Medical Director Blood Transfusion Laboratory, LLSG Victoria Campus London Health Sciences Centre Now: Medical Director Canadian Blood Services London, Ontario	Dr. Jeannie Callum Director of Transfusion Medicine & Tissue Banks Sunnybrook and Women's College Health Sciences Centre Toronto, Ontario
Dr. Gilles Delage1, 2 Vice-President Medical Affairs Héma-Québec Montréal, Québec	Eric Galton Systems Analyst Blood Safety Surveillance and Health Care Acquired Infections Division Centre for Infectious Disease Prevention and Control Public Health Agency of Canada Ottawa, Ontario
Dr. Roger Y. Dodd2 Vice President Research and Development Holland Laboratory Rockville, Maryland, U.S.A.	Mr. Robin Greig1 Manager, Diagnostic and Therapeutic Services Stanton Territorial Health Authority Yellowknife, Northwest Territories
Ms. Janet Egan Surveillance Officer Transfusion Transmitted Injuries Section Blood Safety Surveillance and Health Care Acquired Infections Division Centre for Infectious Disease Prevention and Control Public Health Agency of Canada Ottawa, Ontario	Ms. Nancy Heddle Director, McMaster Transfusion Research Program Hamilton Health Sciences Centre Hamilton, Ontario
Dr. John Freedman Director of Transfusion Medicine St. Michael's Hospital Toronto, Ontario	Dr. Farid Hindieh1 Chief, Blood and Vaccine Unit Clinical Evaluation Division Centre for Biologics Evaluation Biologics and Genetic Therapies Directorate Health Products and Food Branch Health Canada Ottawa, Ontario
Kevin Forbes Systems Analyst Blood Safety Surveillance and Health Care Acquired Infections Division Centre for Infectious Disease Prevention and Control Public Health Agency of Canada Ottawa, Ontario	Dr. Carole Légaré1, 2 Manager, Clinical Section 1 Marketed Biologicals and Biotechnology Products Division Marketed Health Products Directorate Health Products and Food Branch Health Canada Ottawa, Ontario
Ms. Judy Hoff1 Laboratory Information Systems Specialist/Technologist II Transfusions Department Regina General Hospital Regina, Saskatchewan	Ms. Ana Lima Transfusion Safety Nurse Sunnybrook and Women's College Health Sciences Centre Toronto, Ontario
Dr. Heather Hume2 Executive Medical Director Transfusion Medicine Canadian Blood Services Ottawa, Ontario	Dr. Huw Lloyd1 Consultant Ontario Ministry of Health and Long-Term Care Ottawa, Ontario
Ms. Cindy Hyson1 Nova Scotia Transfusion Practice Nurse Coordinator Provincial Blood Coordinating Program Halifax, Nova Scotia	Ms. Heather MacMillan1 Project Coordinator Department of Health and Social Services Charlottetown, Prince Edward Island
Nick Karitsiotis Senior Business & Technology Analyst Blood Safety Surveillance and Health Care Acquired Infections Division Centre for Infectious Disease Prevention and Control Public Health Agency of Canada Ottawa, Ontario	Dr. Rama Nair2 Professor and Acting Chair Department of Epidemiology and Community Medicine University of Ottawa Ottawa, Ontario
Dr. Bryce Larke2 Medical Health Officer Yukon Government Whitehorse, Yukon	Dr. Pierre Robillard2 Médecin-conseil Unité de recherche en Hémovigilance Institut national de santé publique du Québec Montréal, Québec
Mark Osmond Support Analyst Blood Safety Surveillance and Health Care Acquired Infections Division Centre for Infectious Disease Prevention and Control Public Health Agency of Canada Ottawa, Ontario	Dr. Gail Rock Formerly: Chief, Hematology and Transfusion Medicine Division Ottawa Hospital Civic Campus Ottawa, Ontario
Stew Partington Systems Analyst Blood Safety Surveillance and Health Care Acquired Infections Division Centre for Infectious Disease Prevention and Control Public Health Agency of Canada Ottawa, Ontario	Mr. John Rumboldt1 Director, Board Services Newfoundland Ministry of Health and Community Services St. John's, Newfoundland
Dr. David Pi2 Director Provincial Blood Coordinating Office Vancouver, British Columbia	John Saldanha Scientific Director, Blood Screening Roche Molecular Systems Inc. Pleasanton, California, U.S.A.
Ms. Céline Poulin1 Conseillère en Hémovigilance Secrétariat du Système du sang Direction générale de la Santé publique Ministère de la Santé et des Services sociaux Québec, Québec	Dr. Alexandra Simniceanu1 Clinical Evaluator Clinical Evaluation Division Center for Biologics Evaluation Biologics and Genetic Therapies Directorate Health Products and Food Branch Health Canada Ottawa, Ontario
Ms. Carol Renner Director of Blood Programs Manitoba Health Provincial Blood Programs Coordinating Office Winnipeg, Manitoba	Ms. Susan Shaw Information Manager Health Surveillance Branch Public Health Division Alberta Health and Wellness Edmonton, Alberta
Dr. David M.C. Sutton Medical Director, Transfusion Medicine University Health Network Associate Professor of Medicine University of Toronto Toronto, Ontario	Dr. Linda Van Til Epidemiologist Department of Health and Social Services Charlottetown, Prince Edward Island
Ms. Madelaine Swaters1 Manager, Blood Services Assistant Deputy Minister's Office Public Health Division Alberta Health and Wellness Edmonton, Alberta	Dr. Ian Wilkinson1 Special Consultant Blood Programs Manitoba Health Winnipeg, Manitoba
Ms. Susan Turnbull1 Analyst Provincial Blood Programs Coordinating Office Manitoba Health Winnipeg, Manitoba	Ms. Mary-Ann Wotherspoon Program Advisor Transfusion Transmitted Injuries Section Blood Safety Surveillance and Health Care Acquired Infections Division Centre for Infectious Disease Prevention and Control Public Health Agency of Canada Ottawa, Ontario

1. National Transfusion Transmitted Injuries Surveillance System Working Group.
2. National Working Party for Data Review.

List of Acronyms

ATE	Adverse Transfusion Event
CMVIg	Cytomegalovirus immune globulin
IBCT	Incorrect Blood Components Transfused
IVIg	Intravenous immune globulin
MS ACCESS	Microsoft Access
NTTISS WG	National Transfusion Transmitted Injuries Surveillance System Working Group
NWPDR	National Working Party for Data Review
PHAC	Public Health Agency of Canada
PTP	Post-Transfusion Purpura
RSVIg	Respiratory syncitial virus immune globulin
SHOT	Serious Hazards of Transfusion
SPSS	Statistical Package for Social Science
TRALI	Transfusion Related Acute Lung Injury
TTISS	Transfusion Transmitted Injuries Surveillance System
UK	United Kingdom

Our mission is to promote and protect the health of Canadians through leadership, partnership, innovation and action in public health Public Health Agency of Canada Published by authority of the Minister of Health This publication can be made available on computer diskette or in large print upon request.

For more information, copies of this report please contact:

Transfusion Transmitted Injuries Section
Blood Safety Surveillance and
Health Care Acquired Infections Division
Centre for Infectious Disease Prevention and Control
Public Health Agency of Canada
Building No. 6
Tunney's Pasture
Ottawa, Ontario K1A 0L2
Internal Postal Address: 0601E2
Telephone: (613) 957-6217
Facsimile: (613) 952-6668

© Her Majesty the Queen in Right of Canada, represented by
the Minister of Public Works and Government Services Canada, 2005
Cat. No. HP37-1/2003
ISBN 662-69188-1