|Year : 2019 | Volume
| Issue : 1 | Page : 45-51
Slump of trends in transfusion-transmissible infectious diseases: Is syphils alarming in Pakistan?
Maqsood Ahmad1, Muhammad Saeed2, Aamir Hanif3, Usman Waheed4, Muhammad Arshad5, Noor Ul Ain6, Farhan Rasheed7, Shahida Hussain6
1 Department of Transfusion Medicine, Punjab Institute of Cardiology, Punjab, Pakistan
2 Department of Pathology and Transfusion Medicine, DHQ Hospital, Mandi Bahauddin, Pakistan
3 Department of Allied Health Professionals, Directorate of Medical Sciences, Government College University, Faisalabad, Pakistan
4 Safe Blood Transfusion Programme, Ministry of National Health Services, Government of Pakistan; Department of Pathology and Blood Bank, Pakistan Institute of Medical Sciences, Islamabad, Pakistan
5 Department of Bioinformatics and Biotechnology, International Islamic University, Islamabad, Pakistan
6 Department of Microbiology and Molecular Genetics (MMG), University of Punjab, Pakistan
7 Department of Pathology, Allama Iqbal Medical College and Jinnah Hospital (AIMC and JHL) Lahore, Punjab, Pakistan
|Date of Web Publication||22-Apr-2019|
Dr. Muhammad Saeed
Department of Pathology and Transfusion Medicine, DHQ Hospital, Mandi Bahauddin
Source of Support: None, Conflict of Interest: None
Aims: This study was planned to evaluate the trends of transfusion-transmissible infectious diseases (TTID). Setting and Design: This cross-sectional retrospective study was conducted on donor community attending Transfusion Medicine Department, Punjab Institute of Cardiology, Lahore, Pakistan from January 1, 2012, to December 31, 2016. Subject and Methods: A total of 79,774 blood donors were processed for HbsAg anti-HCV, anti-human immunodeficiency virus (HIV), syphilis, and malaria detection by rapid immune chromatographic technique. Statistical Analysis: The data analysis was done through SPSS 20.0. Chi-square test was employed. Results: Males and females were 91% and 9%, respectively. The mean age was 44 ± 10 years, the prevalence of TTID was 4.0%, and year-wise decreasing trends were observed as 4.4%, 4.2%, 3.7%, 3.9%, and 3.9%, respectively, in 2012–2016. Overall Co-infection was 0.36%, HBV+HCV co-infection was most common. The seroprevalence of HBV, HCV, syphilis, malaria, and HIV was 0.9%, 1.7%, 1.1%, 0.1%, and 0%, respectively. Year-wise seroprevalence of HCV was 2.1%, 1.8%, 1.7%, 1.7%, and 1.3%; HBV was 1.2%, 0.8%, 0.8%, 1.0%, and 1.0%, syphilis was 0.8%, 0.8%, 0.9%, 1.4%, and 1.5%, and malaria was 0.1%, 0.03%, 0.1%, 0.1%, and 0.05% in 2012–2016, respectively, and no single case of HIV was detected. Conclusion: Raising trends for syphilis among blood donors underscore the concern about growing infection of this disease in the community as these blood donors represent the highly selective community. The zero prevalence of HIV in Pakistani population supports the growing awareness of this life-threatening disease. HBV and HCV infections still continue to be a menace to the society because, in spite of decreasing trend, burden of the disease is still high in general community.
Keywords: HBV, HCV, human immunodeficiency virus, MP, syphilis, TTID
|How to cite this article:|
Ahmad M, Saeed M, Hanif A, Waheed U, Arshad M, Ain NU, Rasheed F, Hussain S. Slump of trends in transfusion-transmissible infectious diseases: Is syphils alarming in Pakistan?. Glob J Transfus Med 2019;4:45-51
|How to cite this URL:|
Ahmad M, Saeed M, Hanif A, Waheed U, Arshad M, Ain NU, Rasheed F, Hussain S. Slump of trends in transfusion-transmissible infectious diseases: Is syphils alarming in Pakistan?. Glob J Transfus Med [serial online] 2019 [cited 2019 Nov 15];4:45-51. Available from: http://www.gjtmonline.com/text.asp?2019/4/1/45/256760
| Introduction|| |
Syphilis has plagued humankind for over 500 years. After the first reported outbreaks struck Europe in 1495, the disease spread speedily to further continents and swelled to a global pandemic. In the mid-twentieth century, penicillin-based treatment became available and infection rates started to decline dramatically. However, strikingly, in the last few decades, infection with Treponema pallidum (TP) has emrged; globally, >10 million cases are reported per annum, adults aged 15–49 years are more prone, and almost 90% of the burden is from developing regions.
Furthermore, in the last eras, syphilis has acquired a new potential for morbidity and mortality through its association with human immunodeficiency virus (HIV). Re-emergence of syphilis is stated from several regions including North America, Western Europe, China, and Australia. Yet, the reason for the resurgence of syphilis is poorly understood. Multiple aspects are involved that drive this burden, such as high-risk sexual activity, vertical transmission, use of contaminated syringes and unsafe blood transfusion. Moreover, immigrations and socio-ecomical changes that limit access to healing also contributes to the cause.
Syphilis is the first transfusion-transmitted infectious disease (TTID) to be screened following implementation of serological screening by blood banks in 1938. Blood transfusion is a significant part of therapeutic and surgical treatments. Although it saves millions of lives, unsafe blood transfusion is a most frequent source of transmission for infectious agents; therefore, screening for TTID is an important part of the blood transfusion. It certifies safe and unsafe transfusions.
Syphilis usually a sexually transmissible disease, while transmission is possible through many other routes i.e vertical transmission, contaminated syringes and contaminated blood transfusions. Malaria as a parasitic disease is caused by Plasmodium species. Pakistan is a moderate malaria-endemic country with annual parasite incidence rate of 1.59. Transfusion based transmissible malaria was first reported in 1911, inspite of multiple steps taken to control the spread of malaria, still it is common Transfusion transmissible infection all over the world.
To study the occurrence of these infectious diseases among the young community, screening of blood donors is used as a surrogate marker. Some drawbacks of the present study includes the exclusion of the individuals below 19 years and above 59 years of age. Moreover the low frequency of female donors in the community accounts for the imbalanced sex-ratio in the study. Therefore, the present study was planned to highlight the emergence of syphilis among TTID among blood donor community of Pakistan, entertained at blood bank PIC Lahore.
| Subject and Methods|| |
The ethical committee of Punjab Institute of Cardiology, Lahore, Punjab, Pakistan approved the study protocol. This was a cross-sectional retrospective study. Data was collected from 1st January 2012 to 31st December 2016, a tertiary care cardiac referral center of the province Punjab. A total of 79,774 blood donors of either gender attending Department of Transfusion Medicine, Punjab Institute of Cardiology, Lahore, were included in the study during the period of January 1, 2012–December 31, 2016. During the study duration, all the blood donors who met donor selection criteria and attending Department of Transfusion Medicine, Punjab Institute of Cardiology, Lahore, between the ages of 18 and 60 years were enrolled. Blood donors with the present or previous history of any TTID infection, any surgical procedure, blood transfusion, and pregnancy were excluded from the study. Before serological screening, each donor was screened for physical fitness. Malnourished, apparently unhealthy and anemic blood donors were also deferred.
From each participant, 4 ml of blood was collected (3 ml in yellow-top and 1 ml in lavender-top Vacutainer). yellow top vacutainer was placed in water bath at 37C for blood clotting, centrifugation was done at 3000 rpm for 10 minutes, serum was separated and serological analysis was done. Screening test for MP was performed with whole blood from lavender-top Vacutainer. All laboratory work was done by following the standard operating procedure of this blood bank. Every sample was processed for the WHO-recommended TTIs for our regions (HbsAg, anti-HCV, anti-TP, anti-HIV, and MP) by immunochromatography technique.
Interpretation of results for all the said tests was done after 15 minutes. The test was considered non-reactive when one colored line appeared in the control line region and no line appeared in test line region. If two lines appeared: one colored line in control region and another apparent line in test line region, the test was considered positive. the test was considered to be invalid if control line fails to appear.
All positive samples were re-analyzed for confirmation using the same technique. Written consent was also taken before enrolling the donor.
Statistically, analysis was made using the Statistical Package of Social Services (SPSS) version 20.0 (IBM, USA).
| Results|| |
Of the total, 99.9% (n = 79764) blood donors were male who were aged between 18 and 60 years. Decreasing trends were observed for all HBV, HCV, and malaria, while increasing trends were observed in the case of syphilis. The seroprevalence of HCV was 2.1% (n = 333), 1.8% (n = 297), 1.7% (n = 291), 1.7% (n = 259), and 1.3% (n = 227); for HBV, it was 1.2% (n = 184), 0.8% (n = 123), 0.8% (n = 130), 1.0% (n = 185), and 1.0% (n = 170); for syphilis, it was 0.8% (n = 135), 0.8% (n = 149), 0.9% (n = 147), 1.4% (n = 247), and 1.5% (n = 234); and for malaria, it was 0.1% (n = 27), 0.03% (n = 5), 0.1% (n = 25), 0.1% (n = 31), and 0.05% (n = 10) in 2012–2016, respectively. No single case of HIV was detected.
Of 79,774 individuals, only 4.0% (n = 3209) were found positive for any of the TTID screened. In the present study, decreasing trends were observed [4.4% (n = 679), 4.2% (n = 621) 3.7% (n = 599), 3.9% (n = 656), and 3.9% (n = 656)] in 2012–2016, respectively [Figure 1].
|Figure 1: Year-wise frequency distribution of total infected blood donors (n = 3209)|
Click here to view
A decreasing trend of HCV, HBV, and HIV and an increasing trend of MP and TP were seen [Figure 2].
The seroprevalence of HBV, HCV, syphilis, malaria, and HIV was 0.9% (n = 792), 1.7% (n = 1407), 1.1% (n = 912), 0.1% (n = 98), and 0% (n = 0), respectively. Co-infectivity was 0.36% (n = 288) [Figure 3].
From the total study population, 0.36% (n = 288) were found positive for co-infection. The most prevalent co-infection was HBV + HCV, followed by HBV + TP, HCV + TP, HCV + MP, and HBV + MP [Figure 4].
| Discussion|| |
For many decades, syphilis is a stigmatized, disgraceful disease. Each country blamed the neighboring (and sometimes enemy) countries for the outbreak of syphilis. Hence, the residents of today's Germany, United Kingdom, and Italy named syphilis “the French disease,” the French named it “the Neapolitan disease,” according to the Russians concepts it is “Polish disease,” and the Polish called it “the German disease.” The Portuguese, the Danish, and people of Northern Africa called it “the Spanish/Castilian disease.” The Turks coined the term “Christian disease;” furthermore, in North India, the Muslims blamed the Hindu for the affliction and Hindu blamed the Muslims, and in the end, everyone blamed the Europeans.
Overall, only 4.0% of participants were infected with any one or more of TTID, lower than previous studies.,, This achievement may be attributed to common awareness of health-care providers for reducing the possible risk factors of TTID and also the strict implementation of TTID screening protocols by the state.
Syphilis, which disappeared years ago, has re-emerged in Pakistani youth. The present study reported the prevalence of syphilis to be 1.1%, which is very high as compared to previous studies (0.07%–0.89%).,, Higher prevalence of syphilis may be attributed to multiple unprotected sexual contacts, improper and excessive use of contaminated injections, intravenous drug intake, and sharing infected household items. The global scenario of incidence of syphilis has been presented by some other studies, where Adjei et al. has reported it to be 7.5% in Ghanaian donors, and Matee et al reports it to be 12.7% in Tanzanian donors., Moreover is lot of published data, indicating that the prevalence of this disease is higher in replacement donors than in voluntary blood donors 
Undeniably safe blood is a universal right of all human being; therefore, every donor should be screened for at least recommended TTIDs for each region. The prevalence of these infectious diseases varies from place to place due to variation in standards for medical practices. In Pakistan 1.5 million, transfusions are being made every year. This amplified usage of blood transfusions is resulting from thalassemia, hemophilia, hemodialysis, and as well as road traffic accidents. Hemophilia patients require repeated blood transfusions with a frequency of 1:7000 patients. As the risk of TTID is higher among multitransfused patients, hemophilia and thalassemia patients are more prone to develop TTID which can limit the extent of their life expectancy.
To ensure safe blood for all human beings, all blood bags must be screened for HBV, HCV, HIV, syphilis, and MP. TTID-infected individuals are a major threat for their community; annually up to 16 million individuals are being infected by HBV and 5 million individuals are being infected with HCV around the globe, just because of contaminated blood transfusions. There is always 1% probability of TTID transmission with every blood unit transfusion. This statement enforces to adopt strategies for evaluation and selection and to retain blood donors from low risk for TTID population. As in Pakistan, we are mostly dependent on replacement or family typed blood donors, which donate blood under the influence of society, relations, and cultural traditions, it also boosts the risks for the transmission of TTID.
The present study reported 0% HIV-positive rate, supported by a previous study. From few of last decades, HIV prevalence 37.8% was reported among injectable drug users (IDUs), 7.2% among transgender and 3.1:0.8 among male and female sex workers, respectively. While among general population and pregnant womens HIV prevalence is reported 0.1 & 0.05% respectively. International literature reported 0.66% from Brazil  0.38% India. 0.1% Spain  and 0.01%–0.02% in Zhejiang Province (Eastern China was low). Another recent study also reported 0.01% prevalence of HIV.
Our findings for the prevalence of HCV (1.7%) is in agreement with previous reports from Pakistan ,, while this rate is quiet higher than few other studies from Pakistan.,,,, However, there exist a varying trend in nationwide studies, which present the decrease in the current prevalence rate, compared to the studies in the last decade.,,,,,,,,,,,,,,,,,,,, The rapid global extent of HCV infection is primarily due to transmission through blood transfusion and exposure to contaminated medical equipment.
In the case of HBV, very low rate (0.9%) of blood donors were infected in the present study, and a variable rate has been previously reported from the same region (1.1%–8.4%).,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, Incase of Malaria, present study showed 0.1% Malarial parasitemia, while about 0.1-0.5% is reported from previous studies., This up and down of Malaria prevalences may attributed to difference in geographical areas and climate changes. Moreover to reduce the production of Plasmodium larvae, improvement in sanitation infrastructure, time to time anti mosquito spray, and public awareness programs are needed on regular basis,
The present study reported about 0.36% co-infection, maximum rate was observed for HBV&HCV combination followed by HBV and TP 34.7%, HCV and TP 24.3%, HCV and MP 2.0% HBV and MP 1.3% [Figure 4].
According to data collected from 324 transfusion centers on blood safety, there were 15.4% voluntary non-remunerated blood donation (VNRBD) and 84.6% were replacement or family donations during the year of 2011., TTIDs are commonly detected among paid donors. Many advanced countries have banned the use of paid blood donors. In 1988, the Chinese government banned paid donation, and this resulted in marked reduction in the prevalence of HCV from 8.68% in 1990 and 3.2% in 2010. India also passed a law in 1998; as a result, the prevalence of HBV, HCV, and HIV has declined from 1.62%, 1.85%, and 1.16% in 2004–0.94% and 0.052% and 0.21% in 2009, respectively. In Iran, in 2003, the prevalence of HBV, HCV, and HIV was 0.71%, 0.14%, and 0.0033%, respectively, and it decreased to the frequency to 0.48%, 0.023%, and 0.0031% in 2005. This threat of TTID can only be minimized by appropriately obeying guidelines for selection of blood donors and screening of blood and blood products prior to transfusion with highly specific and sensitive techniques such as enzyme-linked immunosorbent assay or polymerase chain reaction [Table 1].
|Table 1: Frequency of hepatitis C virus-positive and hepatitis B virus-positive donors reported in previous studies|
Click here to view
Sexually transmissible infections have complicated human life for centuries. According to a universal estimate, almost 15 million new cases of sexually transmissible infections occur every year. Of these, 4 million affect <20 year olds and 6 million affect 20–24 year olds. Syphilis upsurges the risk of HIV spread by 2–5 times; in addition, co-infection is also very common. Movements in the near past from a neighboring country, gathering, poor sanitation, and untoward sexual behaviors all lead to an amplified prevalence of various diseases, while sexually transmissible infections create a prominent quantity in this regard. Movement of individuals due to war and other factors such as famines, drought, and deporting may unintentionally cause growth susceptibility to syphilis and other sexually transmissible infections. Worsening morality, extramarital sex, low literacy, and cultural reticence for sex education is further compounding the problem. Although there is no vaccine to prevent syphilis, this is curable with a single intramuscular injection of benzathine penicillin G, the first-line drug for all stages of syphilis. This can be reduced by early diagnosis, proper treatment, sex education, and promotion of condom use among infected persons and their contacts are a significant key for syphilis control programs.
| Conclusion|| |
Alarmingly increasing trends for syphilis observed among blood donors during the 5-year experience, and the second and third most common co-infections in our study were syphilis with HBV infection, followed by syphilis HCV infections. The growing prevalence of syphilis among the donors underscores the concern about growing infection of this disease in the community as these blood donors represent the highly selective community. Therefore, sexual education and common public awareness programs may increase the safety of blood as well as community; moreover, multiple strategies should be planned on urgent basis, and national and international level approaches are hardly needed for the time to stop this emerging threat on initial phases. The zero prevalence of HIV in Pakistani population supports the growing awareness of this life-threatening disease. HBV and HCV infections still continue to be a menace to the society because, in spite of decreasing trend, burden of the disease is still high in general community. However, the graph of other TTIDs is on downward trend which is attributed to hepatitis, malaria AIDS control, and safe blood transfusion programs of the region.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Sukumaran A. Resurgence of syphilis: Challenges for dental care providers. J Dent Res Rev 2016;3:115. [Full text]
Stamm LV. Syphilis: Re-emergence of an old foe. Microb Cell 2016;3:363-70.
Kane MA, Bloch EM, Bruhn R, Kaidarova Z, Murphy EL. Demographic determinants of syphilis seroprevalence among U.S. blood donors, 2011-2012. BMC Infect Dis 2015;15:63.
Saeed M, Hussain S, Rasheed F, Ahmad M, Arif M, Hamid Rahmani MT. Silent killers: Transfusion transmissible infections-TTI, among asymptomatic population of Pakistan. J Pak Med Assoc 2017;67:369-74.
Sultan F, Mehmood T, Mahmood MT. Infectious pathogens in volunteer and replacement blood donors in Pakistan: A ten-year experience. Int J Infect Dis 2007;11:407-12.
World Health Organization. Global burden of disease (GBD) for hepatitis C. J Clin Pharmacol 2004;44:20-9.
Tampa M, Sarbu I, Matei C, Benea V, Georgescu SR. Brief history of syphilis. J Med Life 2014;7:4-10.
Waheed U, Khan H, Satti H, Ansari M, Malik M, Zaheer H. Prevalence of transfusion transmitted infections among blood donors of a teaching hospital in Islamabad. Ann Pak Inst Med Sci 2012;8:236-9.
Khan S, Faqir F, Rehman N, Raziq F. Reducing the risk of transfusion-transmitted infec-tions through predonation screening of blood do-nors. Int J Pathol 2011;9:59-62.
Hussain A, Mumtaz H, Aslam M, Abbas Z. Seroprevalence of transfusion based transmissible infections among clinically healthy donors in the community of Multan. Pak J Inf Mol Biol 2015;3:47-51.
Hakim S, Kazmi S, Bagasra O. Seroprevalence of hepatitis B and C genotypes among young apparently healthy females of Karachi-Pakistan. Libyan J Med 2008;3:66-70.
Khan MA, Rehman A, Ashraf M, Ali A, Ditta A. Prevalence of HBV, HCV and HIV in blood donors at Liaquetpur. Prof Med J Q 2006;13:23-6.
Kaur G, Basu S, Kaur R, Kaur P, Garg S. Patterns of infections among blood donors in a tertiary care centre: A retrospective study. Natl Med J India 2010;23:147-9.
Adjei AA, Kudzi W, Armah H, Adiku T, Amoah AG, Ansah J. Prevalence of antibodies to syphilis among blood donors in Accra, Ghana. Jpn J Infect Dis 2003;56:165-7.
Matee MI, Magesa PM, Lyamuya EF. Seroprevalence of human immunodeficiency virus, hepatitis B and C viruses and syphilis infections among blood donors at the Muhimbili national hospital in Dar es Salaam, Tanzania. BMC Public Health 2006;6:21.
Ali SA, Donahue RM, Qureshi H, Vermund SH. Hepatitis B and hepatitis C in Pakistan: Prevalence and risk factors. Int J Infect Dis 2009;13:9-19.
Emmanuel F, Thompson LH, Salim M, Akhtar N, Reza TE, Hafeez H, et al.
The size and distribution of key populations at greater risk of HIV in Pakistan: Implications for resource allocation for scaling up HIV prevention programmes. Sex Transm Infect 2013;89 Suppl 2:ii11-7.
Monteiro DL, Taquette SR, Sodré Barmpas DB, Rodrigues NC, Teixeira SA, Villela LH, et al.
Prevalence of HTLV-1/2 in pregnant women living in the metropolitan area of Rio de Janeiro. PLoS Negl Trop Dis 2014;8:e3146.
Mehta KD, Antala S, Mistry M, Goswami Y. Seropositivity of hepatitis B, hepatitis C, syphilis, and HIV in antenatal women in India. J Infect Dev Ctries 2013;7:832-7.
Carnicer-Pont D, Almeda J, Luis Marin J, Martinez C, Gonzalez-Soler MV, Montoliu A, et al.
Unlinked anonymous testing to estimate HIV prevalence among pregnant women in Catalonia, Spain, 1994 to 2009. Euro Surveill 2011;16. pii: 19940.
Zhang XH, Lu W, Wu QY, Jiang JY, Chen DQ, Qiu LQ. Progress in prevention of mother-to-child transmission of HIV-1 in Zhejiang Province, China, 2007-2013. Curr HIV Res 2013;11:652-7.
Ali N. Frequency of hepatitis-C virus antibodies in blood donors in combined military hospital, Quetta. Pak J Med Sci 2003;19:41-4.
Khan NU, Ali I, Ahmad NU, Iqbal A, Rehman LU, Munir I, et al.
Prevalence of active HCV infection among the blood donors of Khyber Pakhtunkwa and FATA region of Pakistan and evaluation of the screening tests for anti-HCV. Virol J 2011;8:154.
Akhtar S, Younus M, Adil S, Jafri SH, Hassan F. Hepatitis C virus infection in asymptomatic male volunteer blood donors in Karachi, Pakistan. J Viral Hepat 2004;11:527-35.
Aziz MS. Prevalence of anti hepatitis C antibodies and hepatitis B surface antigen in healthy blood donors in Baltistan. Pak Armed Forces Med J 2006;56:189-91.
Mahmood MA, Khawar S, Anjum AH, Ahmed SM, Rafiq S, Nazir I, et al
. Prevalence of hepatitis B, C and HIV infection in blood donors of Multan region. Ann King Edward Med Univ 2004;10:459-61.
Waheed Y, Shafi T, Safi SZ, Qadri I. Hepatitis C virus in Pakistan: A systematic review of prevalence, genotypes and risk factors. World J Gastroenterol 2009;15:5647-53.
Khan A, Bukhari SS, Alvi MI, Qazi A. Seroprevalence of hepatitis B, hepatitis C and HIV in blood donors of Peshawar. Gomal J Med Sci 2011;9:46-50.
Mujeeb SA, Pearce MS. Temporal trends in hepatitis B and C infection in family blood donors from interior Sindh, Pakistan. BMC Infect Dis 2008;8:43.
Jehangir W, Ali F, Shahnawaz U, Iqbal T, Qureshi H. Prevalence of hepatitis B, C and HIV in blood donors of South Punjab. Esculapio 2006;2:6-7.
Ahmad A. Frequency of HBV surface antigen and anti-HCV in healthy voluntary blood donars in Swat district. J Postgrad Med Inst (Peshawar-Pak) 2009;20:187-90.
Asif N, Khokhar N, Ilahi F. Sero-prevalence of HBV, HCV, and HIV infection among voluntary non remunerated & replacement donors in Northern Pakistan. Pak J Med Sci 2004;20:24-8.
Hasan K. Study of hepatitis B and C virus seropositivity in healthy blood donors. Ann Pak Inst Med Sci 2009;5:233-6.
Khan M, Chaudhary G, Fayyaz M, Qazi MA, Ahmed G. Hepatitis B, C and HIV; seroprevalence of infection in blood donors. Prof Med J 2006;13:632-6.
Mumtaz S. Frequency of seropositive blood donors for hepatitis B, C & HIV viruses in railway hospital Rawalpindi. Pak J Med Res 2002;41:51-3.
Khattak MF, Salamat N, Bhatti FA, Qureshi TZ. Seroprevalence of hepatitis B, C and HIV in blood donors in Northern Pakistan. J Pak Med Assoc 2002;52:398-402.
Masood R, Sardar MA, Mallhi AA. Seroprevalence of hepatitis B and C among the healthy blood donors at Fauji foundation hospital, Rawalpindi. Pak J Med Sci 2007;23:64-7.
Ahmad J, Taj AS, Rahim A, Shah A, Rehman M. Frequency of hepatitis B and hepatitis C in healthy blood donors of NWFP: A single center experience. J Postgrad Med Inst 2004;18:343-52.
Farooqi JI, Farooqi RJ, Khan N. Frequency of hepatitis B and C in selected groups of population in NWFP, Pakistan. J Postgrad Med Inst 2007;21:165-8.
Khattak MN, Akhtar S, Mahmud S, Roshan TM. Factors influencing hepatitis C virus sero-prevalence among blood donors in North West Pakistan. J Public Health Policy 2008;29:207-25.
Abdul Mujeeb S, Nanan D, Sabir S, Altaf A, Kadir M. Hepatitis B and C infection in first-time blood donors in Karachi – A possible subgroup for sentinel surveillance. East Mediterr Health J 2006;12:735-41.
Azam M, Jamal N, Imtiaz F, Haque Z. Blood donor screening for hepatitis and HIV. J Dow Univ Health Sci 2007;1:82-3.
Nazar H, Nadia N, Shazia N, Zulfiqar A, Farhat A. Prevalence of hepatitis B and hepatitis C in blood donors of Karachi. Biomedica 2008;24:116-7.
Irfan SM, Uddin J, Zaheer HA, Sultan S, Baig A. Trends in transfusion transmitted infections among replacement blood donors in Karachi, Pakistan. Turk J Haematol 2013;30:163-7.
Rahman Mu, Akhtar G, Lodhi Y. Transfusion transmitted HIV and HBV infections in Punjab Pakistan. Pak J Med Sci 2002;18:18-25.
Rehman NA, Ahn1ed Z, Naeem MR, Shah WH, Chohan AH. Frequency of hepatitis B, C and human immunodeficiency virus in blood donors at Shaikh Zayed hospital, Lahore. Proc SZPGMI 2005;19:33-6.
Ijaz A, Shafiq F, Toosi N, Malik M, Qadeer R. Hepatitis B and hepatitis C in blood donors: Analysis of 2-years data. Ann King Edward Med Coll 2007;13:59-61.
Manzoor I, Hashmi N, Daud S, Ajmal S, Fatima H, Rasheed Z, et al
. Seroprevalence of transfusion transmissible infections (TTIS) in blood donors. Biomedica 2009;25:154-8.
Fayyaz K, Ali S, Khan A, Shafique M, Khan M, Majeed S, et al
. Hepatitis B carriers; diagnosis among volunteer blood donor students at Quaid-i-Azam medical college Bahawalpur. Prof Med J 2002;9:186-90.
Bhatti FA, Ullah Z, Salamat N, Ayub M, Ghani E. Anti-hepatits B core antigen testing, viral markers, and occult hepatitis B virus infection in Pakistani blood donors: Implications for transfusion practice. Transfusion 2007;47:74-9.
Ahmed F, Shah S, Tariq M, Khan J. Prevalence of hepatitis B carrier and HIV in healthy blood donors at Ayub teaching hospital. Pak J Med Res 2000;39:91-2.
Majed A, Qayyum A. Presence of hepatitis B virus in healthy donors at blood unit of Punjab institute of cardiology Lahore. Pak J Med Res 2000;39:111-2.
Ali N, Ahmed J, Ali N, Jehan F, Saleem S. Transfusion transmitted malaria in three major blood banks of Peshawar, Pakistan. Afr J Biotechnol 2010;9:5445-9.
Zaheer HA, Waheed U. Blood safety system reforms in Pakistan. Blood Transfus 2014;12:452-7.
Husain S, Kadir M, Fatmi Z. Resource allocation within the national AIDS control program of Pakistan: A qualitative assessment of decision maker's opinions. BMC Health Serv Res 2007;7:11.
Ishfaq K, Naeem SB, Ali J. Socio-economic factors of thalassemia major on patients'families: A case study of the children's hospital and the institute of child health Multan, Pakistan. Int J Med Appl Health 2013;1:22-37.
Ahmed Kiani R, Anwar M, Waheed U, Asad MJ, Abbasi S, Abbas Zaheer H. Epidemiology of transfusion transmitted infection among patients with β-thalassaemia major in Pakistan. J Blood Transfus 2016;2016:8135649.
Agrawal M, Singhal RK, Shah PH, Parghi BB, Padiyar B, Iyer RR. Sero-prevalence and trend of transfusion-transmissible infectious diseases among blood donors in Bhavnagar district, Gujarat; India – A 5 years retrospective analysis. Int J Res Med 2014;3;100-4.
Al-alwani HR. Seropositive prevalence of transfusion transmitted infections among blood donors in Al-Anbar province after war displacement period. J Pharm Sci Res 2018;10:3333.
Choudhary S, Choudhary K, Shekhawat K. Seropositivity of TTI (transfusion transmissible infections) among blood donors in blood bank of a district hospital in Northern Rajasthan: A 4 years record review. Int J Basic App Med Res 2018;8;142-8.
Chandra T, Rizvi SN, Agarwal D. Decreasing prevalence of transfusion transmitted infection in Indian Scenario. ScientificWorldJournal 2014;2014:173939.
Arshad A, Borhany M, Anwar N, Naseer I, Ansari R, Boota S, et al.
Prevalence of transfusion transmissible infections in blood donors of Pakistan. BMC Hematol 2016;16:27.
Zameer M, Shahzad F, Khan FS, Ali H, Saeed U, Farooq M. Transfusion transmissible infections among healthy blood donors at blood bank from children's hospital & institute of child health Lahore. Pak Armed Forces Med J 2017;67:131-6.
Kumar R, Gupta S, Kaur A, Jindal A, Sharma H. Sero-prevalence and changing trends of transfusion transmitted infections among blood donors in a tertiary care hospital. Indian J Community Health 2015;27:25-9.
Ara F, Alam AM, Rahman M, Jahan A, Yusuf A, Hassan MS, et al
. Prevalence of transfusion transmitted infection among blood donors at medical university in Bangladesh. J Shaheed Suhrawardy Med Coll 2014;6:11-3.
Zehra SK, Bano S, Hakim ST, Nadeem SG. Prevalence of transfusion transmitted infection in replacement and voluntary blood donor. RADS J Biol Res Appl Sci 2013;4:56-63.
Sajjadi SM, Pourfathollah AA, Mohammadi S, Nouri B, Hassanzadeh R, Rad F, et al.
The prevalence and trends of hepatitis B, hepatitis C, and HIV among voluntary blood donors in Kohgiluyeh and Boyer-Ahmad transfusion center, Southwestern Iran. Iran J Public Health 2018;47:944-51.
Oluwayemisi OH, Olasunkanmi SA, Kehinde OM. Prevalence of some transfusion-transmissible infections among first time and repeat voluntary and family replacement donors in North Central Nigeria. Sudan Med J 2016;11:1-6.
Raza MH, Ikram N, Saeed N, Waheed U, Kamran M, Iqbai R, et al
. HIV/AIDS and syphilis screening among high risk groups. J Rawalpindi Med Coll 2015;19:11-4.
United Nations Programme on HIV/AIDS, editor. AIDS Epidemic Update: Special Report on HIV/AIDS: December 2006. Geneva: United Nations Programme on HIV/AIDS; 2006.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]