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A survey of hepatitis B surface antigen-positive blood donors: degree of understanding and action taken after notification L A . MOYER,C.N. SHAPIRO,G. SHULMAN, P.D. BRUGLIERA, AND M. J. ALTER All blood donors in the United States are tested for hepatitis B surface antigen (HBsAg) upon donation; if the test result is positive, the primary method of notification is by letter. To assess the effectiveness of this notification method in stimulating HBsAgpositive donors to seek medical care and take preventive measures, 54 donors who tested HBsAg-positive on donation at the American Red Cross Blood Services, At-

lanta Region, from January 1987 to July 1989 were interviewed. Thirty-nine donors (72%) had sought medical care after notification;the only motivating factor was that the letter told the donor to consult with his or her physician. Compared with donors who did not seek medical care, donors who did so were more likely to understand that the blood test was abnormal or that they were infected, and they were more likely to understand how hepatitis B virus is transmitted and that a vaccine is available. The differences were not significant, however. Of those donors who sought medical care, less than half received appropriate recommendationsfor protection of contacts, and of those who did, only one-third received prophylaxis. In-person and telephone interviews with donors, revision of the notification letter, and hepatitis B education programs targeted at medical care providers are suggested. TRANSFUSION 1992;32:702-706.

Abbreviations: antl-HBc = antibody to hepatitis B core antigen; HBsAg = hepatitis B surface antigen; HBV = hepatitis B virus.

At the American Red Cross Blood Services, Atlanta Region, the current method of informing blood donors who test HBsAg-positive at donation is to send a registered letter informing them of their blood test results, the significance of those results, the need to seek medical care, and their ineligibility to donate again. Specifically, the notification letter informs the donor that the American Red Cross Blood Services, Atlanta Region, “tests all blood for the presence of a hepatitis marker called hepatitis B surface antigen;’’ that ‘‘tests on the unit of blood that you donated indicated the presence of this antigen;” and that “a positive hepatitis antigen test is often transient.” The letter also states that, if the test result is transient, “the immune system develops antibody to the antigen,” and “individuals with such antibody have post-infectious immunity and suffer no ill effects.” The donor is also told that the virus may be spread during sexual contact and that he or she should consult with a physician for additional information and confirmation and should refrain from donating blood again (Appendix 1). An important question has to do with the effectiveness of this method in stimulating HBsAg-positive donors to seek medical care and to take preventive measures. The objectives of this study were to assess the degree of understanding and the action taken by HBsAg-positive

DESPITETHE AVAILABILITY of a safe and effective vaccine, hepatitis B remains a major health problem in the United States. The Centers for Disease Control has estimated that 240,000 new hepatitis B virus (HBV) infections occurred in 1989. Between 5 and 10 percent of persons infected with HBV become chronic carriers of the virus and are at risk for the long-term consequences of infection, including chronic hepatitis, cirrhosis, and liver cancer. Dodd and Nath* have specifically shown that hepatitis B surface antigen (HBsAg)-positive blood donors in the United States have a greatly increased risk for these serious sequelae. An important aspect of the prevention of HBV infection is providing HBV carriers with information to prevent disease transmission, such as the need for the screening and vaccination of household and sexual contact^.^ HBV carriers identified through blood donor screening are an accessible population for education and preventive efforts. Screening of blood donors for HBsAg at all blood collection establishments in the United States is done on a routine basis, and this presents an avenue by which to reach many of these carriers. From the Hepatitis Branch, Division of Viral and Rickettsia1 Diseases, National Center for Infectious Diseases, Centers for Disease Control; and the American Red Cross B h d Services, Atlanta, Georgia. Received for publication January 10, 1992; revision received April 22, 1992, and accepted April 23, 1992.

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TRANSFUSION 1992-Vol. 32. No. 8

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SURVEY OF HBsAg-POSITIVE BLOOD DONORS

blood donors after notification and to determine if a more comprehensive health education effort is needed to better inform HBsAg-positive donors about the importance of appropriate medical care for themselves and their close contacts. Materials and Methods The study population consisted of all blood donors permanently deferred for HBsAg-positive results by the American Red Cross Blood Services, Atlanta Region, from January 1987 to July 1989. Samples of blood from donors were tested for HBsAg with a commercially available enzyme immunoassay (Abbott Laboratories, North Chicago, IL). If the initial sample was reactive, we repeated the test in duplicate on the same sample and took another sample from the full unit of blood and tested it by enzyme immunoassay. If one or both of these samples were reactive, the donor was deferred, pending further testing. Donors were also tested for antibody to the hepatitis B core antigen (anti-HBC), and we reviewed the anti-HBc status of donors who tested HBsAg-positive. If the anti-HBc result was positive in donors who were repeatably reactive for HBsAg, no further testing was done, and the donor was considered to be HBsAg positive and was permanently deferred. If the antiHBc result was negative, we performed the HBsAg neutralization test. Donors who were confirmed as HBsAg-positive by neutralization were permanently deferred. Donors who were not confirmed as HBsAg-positive by neutralization were eligible for re-entry into the system after 8 weeks. After mailing letters to the permanently deferred donors to inform them of the study purpose, we made an attempt to contact them by telephone. Multiple telephone calls were made to donors at different times of the day and evening. Donors who could be contacted were asked to complete a questionnaire so that we could 1) ascertain demographic data; 2) assess their understanding of the notification letter they received informing them of positive results; 3) assess their knowledge about HBV infection and its implications; 4) determine if they sought medical care; and 5) determine if their sexual or household contacts received prophylaxis. A combination of closed-end and multiple-choice questions was used. Medical care providers were not contacted to determine the validity of the donors' responses. We used Fisher's exact test' or the chi-square test5 to compare the distribution of demographic characteristics in participants and nonparticipants and to compare donors who sought medical care with donors who did not by variables associated with appropriate understanding of hepatitis B disease and its consequences. A probability of less than 0.05 was considered significant.

Results Of the approximately 500,000 donors tested by the American Red Cross Blood Services, Atlanta Region, between January 1987 and July 1989, 145 were permanently deferred for HBsAg-positive test results. Of these, we contacted and interviewed 54 (37%);a disconnected telephone was the most frequent reason for inability to contact the other 91 donors. We interviewed donors an average of 19 months (standard deviation, 8.5; range, 1-31 months) after their receipt of the notification letter. Of the donors interviewed, 46 (85%)were less than 40 years old, 32 (59%) were male, and 22 (41%) were black, 18 (33%)were white, and 11 (20%)were Asian. Thirtynine (72%)were born in the United States, 32 (59%)had more

than 12 years of education, 50 (93%)had some type of health insurance, and 27 (50%) donated blood at their work site. The distribution of gender, age, and site of donation among the 54 donors interviewed was not significantly different from that among the 91 donors not interviewed. Of the 54 donors interviewed, 40 (74%)understood that the letter was informing them their blood test was abnormal, and 42 (78%)understood that the test result meant that they were infected. Thirty-nine (72%) of the 54 donors sought medical care. The percentage who sought medical care was higher among donors who understood that their test result was abnormal or that they were infected than it was among donors who did not understand; however, the difference was not significant (84% vs. 60%, ~ ~ 0 . 0 5 The ) . notification letter recommended that donors consult their personal physician; of the 38 donors who understood this, 34 (89%)sought medical care, compared with 5 (37%)of the 16 donors who did not understand (p

A survey of hepatitis B surface antigen-positive blood donors: degree of understanding and action taken after notification.

All blood donors in the United States are tested for hepatitis B surface antigen (HBsAg) upon donation; if the test result is positive, the primary me...
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