 | A patient or a number? On October 8th, 2014, after a long and desperate struggle for life, Thomas Eric Duncan, also known as “Patient Zero,” became the first publicized casualty of the initial American Ebola outbreak. Though originally misdiagnosed and |
sent home without proper treatment, further allegations of malpractice have followed in the wake of Duncan’s death. Namely, why were certain aspects of his treatment delayed or absent during his subsequent hospitalization?
The most unique aspect of Duncan’s treatment plan was that he received no transfusion of convalescent blood or plasma. This potentially life-saving procedure provides anti-viral antibodies from a donor who is recovering from Ebola (1). Ideally, these antibodies could have assisted Duncan’s immune system in overcoming the infection. Kent Brantly, a recent Ebola survivor was willing to donate his plasma but, as he informed ABC News, Duncan’s differing blood type made him an “incompatible donor” (2). An “expert” in transfusion science seemed to back up this position:
“Had Duncan received a blood transfusion from Brantly, it would have caused hemolysis - the breakdown of red blood cells - according to Dr. Christopher Stowell, director of Transfusion Medicine at Massachusetts General Hospital” (ibid).
Transfusion basics: it’s simple as A, B, O…
Can we really be so certain that this transfusion would have caused major destruction of Duncan’s red blood cells? How, why, and to what extent does this destruction of red blood cells occur? Is it truly more dangerous than Ebola? Well, to answer these questions we will need to first gain a simple understanding of blood transfusion terminology and protocol…
To start, we need to recognize that there are four blood types: A, B, AB, and O. Each one of these types can also be designated as either – or +. However, this is a completely irrelevant factor for plasma-only transfusions. Thus, the major factor in convalescent whole blood or plasma-only transfusions has to do with ABO, or type, compatibility. The chart below is a useful visual tool for checking compatibilities in normal or routine blood transfusions.
The most unique aspect of Duncan’s treatment plan was that he received no transfusion of convalescent blood or plasma. This potentially life-saving procedure provides anti-viral antibodies from a donor who is recovering from Ebola (1). Ideally, these antibodies could have assisted Duncan’s immune system in overcoming the infection. Kent Brantly, a recent Ebola survivor was willing to donate his plasma but, as he informed ABC News, Duncan’s differing blood type made him an “incompatible donor” (2). An “expert” in transfusion science seemed to back up this position:
“Had Duncan received a blood transfusion from Brantly, it would have caused hemolysis - the breakdown of red blood cells - according to Dr. Christopher Stowell, director of Transfusion Medicine at Massachusetts General Hospital” (ibid).
Transfusion basics: it’s simple as A, B, O…
Can we really be so certain that this transfusion would have caused major destruction of Duncan’s red blood cells? How, why, and to what extent does this destruction of red blood cells occur? Is it truly more dangerous than Ebola? Well, to answer these questions we will need to first gain a simple understanding of blood transfusion terminology and protocol…
To start, we need to recognize that there are four blood types: A, B, AB, and O. Each one of these types can also be designated as either – or +. However, this is a completely irrelevant factor for plasma-only transfusions. Thus, the major factor in convalescent whole blood or plasma-only transfusions has to do with ABO, or type, compatibility. The chart below is a useful visual tool for checking compatibilities in normal or routine blood transfusions.
Just to summarize what this chart depicts: in routine blood transfusions, whole blood ideally should be matched by type (ex: A to A, B to B, etc.) whereas plasma-only transfusions are much more flexible. In fact, if a donor has type AB blood, they can give plasma to any type because their serum does not contain antibodies to type A or to type B red blood cells. That being said, Kent Brantly’s A+ blood could indeed have the potential to cause a hemolytic, or destructive, reaction if his “whole blood” (plasma and red blood cells), were to be transfused into Duncan’s bloodstream.
A case of transfusion confusion?
So, given the classic rules of transfusion, Mr. Duncan ideally should not have received whole blood or plasma from Brantly. This is where the media has drawn the line in their investigation of the subject. There was, however, another possibility: another recovered Ebola patient named Nancy Writebol. While Writebol publicly refuses to disclose her blood type, it can actually be conditionally deduced as being type O. See the Chart below.
A case of transfusion confusion?
So, given the classic rules of transfusion, Mr. Duncan ideally should not have received whole blood or plasma from Brantly. This is where the media has drawn the line in their investigation of the subject. There was, however, another possibility: another recovered Ebola patient named Nancy Writebol. While Writebol publicly refuses to disclose her blood type, it can actually be conditionally deduced as being type O. See the Chart below.
Thus, Nancy Writebol would also be an “incompatible donor,” at least based upon these common blood transfusion protocols. But wait… There’s more here than meets the eye. Let’s review what we have learned so far. Brantly has type A blood and Writebol has type O… Now that these facts are established, let us examine a September, 2014 report published by the World Health Organization regarding Ebola and the transfusion of convalescent blood and plasma...
WHO sets the standard for convalescent plasma transfusion?
The formulation of this report was no small-scale endeavor as numerous governmental agencies from over a dozen countries, including the United States’ CDC, took part in the formulation of these guidelines and protocols. I must warn you: reading this excerpt may cause your jaw to drop…
“When it is not possible to test the patient’s ABO group or if ABO matched [convalescent whole blood/ convalescent plasma] is not available then:
• For whole blood transfusion: Group O convalescent whole blood, ideally from donors with low [amounts of] anti-A and anti-B, should be used;
• For plasma transfusion: Group AB convalescent plasma separated by centrifugation should be used.
- Non ABO-matched CP [convalescent plasma] separated by centrifugation could also be considered if group AB plasma is not available, but should preferably be group A or group B” (3).
Thus, according to the WHO, Duncan should have received Writebol’s type O whole blood or even Brantly’s type A plasma (4). It is important to note that the plasma is the truly important factor in these types of transfusions because it actually contains the Ebola-fighting antibodies. According to numerous studies, the most severe reactions following ABO type-incompatible plasma transfusions may arise from type-O donors, which could have elevated amounts of anti-A and/or anti-B antibodies in their serum (5,6). Because of this factor, the even better transfusion option may have been for Brantly to donate his type A plasma (as indicated in the WHO report).
WHO was right?
Why are the guidelines for administration of convalescent plasma different than the classical protocols? The answer is well documented and very clear… One study found that: “In emergency lifesaving resuscitation, the risk of hemolytic transfusion reactions from transfusion of group O blood to nongroup O recipients constitutes risk that is outweighed by the benefits” (7). Why is this? Simply because the risk of an incompatible plasma reaction is actually quite low– around 0.15% (8)! For example, one hospital reported that one case of hemolytic reaction occurred out of almost 10,000 transfusions of ABO type-incompatible plasma (6). Thus, this diminutive risk pales in comparison to the 79% mortality rate of the Zaire Ebola Virus (9). Furthermore, numerous studies reveal the fact that type-incompatible plasma transfusions are not really out-of-the ordinary. In fact, type-incompatible plasma is routinely given about 15-20% of the time (6,8)!
Someone may try to counter the facts presented in this article by mentioning the remote possibility that Brantly or Writebol could have had higher than normal amounts of anti-B antibodies in their plasma– a factor that could theoretically increase the risk of an adverse reaction. Let’s examine this seemingly logical argument… First of all, even when they do rarely occur, most plasma-related hemolytic reactions are actually very mild– generating little less than fever, chills, and a negligible decrease in red blood cells (10). Also, even the most severe side effects of hemolytic reactions are still more manageable than the complications of advanced Ebola infection (11). Secondly, this argument of refusing convalescent plasma donation because of high titers of RBC directed antibodies doesn’t stand up to the latest research findings that, in fact, high levels of red blood cell directed antibodies (anti-A or anti-B) have been found to be a poor predictor of actual hemolytic reaction (8)!
WHO’s got your back?
Thus, in summary, according to the research-based convalescent plasma protocols of the World Health Organization, Thomas Eric Duncan did have two viable and potentially life-saving transfusion options. Why then were these withheld? Obviously, there is no valid excuse. Therefore, whether through intent or ignorance– gross provider malpractice was involved. However, since Duncan’s case was so highly publicized, why did the CDC and WHO stand back and let his health care team make such an inadvisable blunder? And, furthermore, why was the media so united in covering up this mistake (12, 13, 14)? There are only two plausible options: either our health officials are dangerously incompetent or there is some sort of higher-level deception going on here…
Out of Africa…
Was there motive for Duncan’s demise? Well, what if he had survived? Imagine the thousands of West Africans who, at the earliest indication of possible Ebola infection, would have been inspired to book the next available flight on a plane bound for the “land of cure.” What would this have done for black Friday sales and fourth quarter earnings reports in a country already plagued with economic difficulties?
Obviously our healthcare system has flaws that need to be addressed and our media outlets need to get their stories straight before reporting myths as fact, but as for decreasing the potential for the mass influx of infectious refugees– I think it would have been better to have just settled for flight restrictions…
References:
1) Transfus Apher Sci. 2014 Oct 16;51(2):120-125. doi: 10.1016/j.transci.2014.10.003. [Epub ahead of print]
2) http://abcnews.go.com/Health/dr-kent-brantly-donate-blood-thomas-eric-duncan/story?id=26226388
3) http://apps.who.int/iris/bitstream/10665/135591/1/WHO_HIS_SDS_2014.8_eng.pdf
4) http://www.recombinomics.com/News/10141401/Ebola_MM_Convalescence.html
5) Transfusion. 1985 Jan-Feb;25(1):60-2.
6) Transfusion. 1998 Jan;38(1):51-5.
7) Transfusion. 2013 Jan;53 Suppl 1:114S-123S. doi: 10.1111/trf.12045.
8) Transfusion. 2012 Oct;52(10):2087-93. doi: 10.1111/j.1537-2995.2012.03574.x. Epub 2012 Feb 17.
9) Epidemics. 2014 Dec;9:70-8. doi: 10.1016/j.epidem.2014.09.003. Epub 2014 Oct 6.
10) Transfusion. 1998 Jan;38(1):51-5.
11) Transplantation. 1988 Aug;46(2):246-9.
12) http://abcnews.go.com/Health/dr-kent-brantly-donate-blood-thomas-eric-duncan/story?id=26226388
13) http://www.nbcnews.com/storyline/ebola-virus-outbreak/why-cant-we-have-more-magic-blood-ebola-n225536
14) http://www.fox19.com/story/26827172/ebola-outbreak-in-the-west-why-some-survive-some-dont
WHO sets the standard for convalescent plasma transfusion?
The formulation of this report was no small-scale endeavor as numerous governmental agencies from over a dozen countries, including the United States’ CDC, took part in the formulation of these guidelines and protocols. I must warn you: reading this excerpt may cause your jaw to drop…
“When it is not possible to test the patient’s ABO group or if ABO matched [convalescent whole blood/ convalescent plasma] is not available then:
• For whole blood transfusion: Group O convalescent whole blood, ideally from donors with low [amounts of] anti-A and anti-B, should be used;
• For plasma transfusion: Group AB convalescent plasma separated by centrifugation should be used.
- Non ABO-matched CP [convalescent plasma] separated by centrifugation could also be considered if group AB plasma is not available, but should preferably be group A or group B” (3).
Thus, according to the WHO, Duncan should have received Writebol’s type O whole blood or even Brantly’s type A plasma (4). It is important to note that the plasma is the truly important factor in these types of transfusions because it actually contains the Ebola-fighting antibodies. According to numerous studies, the most severe reactions following ABO type-incompatible plasma transfusions may arise from type-O donors, which could have elevated amounts of anti-A and/or anti-B antibodies in their serum (5,6). Because of this factor, the even better transfusion option may have been for Brantly to donate his type A plasma (as indicated in the WHO report).
WHO was right?
Why are the guidelines for administration of convalescent plasma different than the classical protocols? The answer is well documented and very clear… One study found that: “In emergency lifesaving resuscitation, the risk of hemolytic transfusion reactions from transfusion of group O blood to nongroup O recipients constitutes risk that is outweighed by the benefits” (7). Why is this? Simply because the risk of an incompatible plasma reaction is actually quite low– around 0.15% (8)! For example, one hospital reported that one case of hemolytic reaction occurred out of almost 10,000 transfusions of ABO type-incompatible plasma (6). Thus, this diminutive risk pales in comparison to the 79% mortality rate of the Zaire Ebola Virus (9). Furthermore, numerous studies reveal the fact that type-incompatible plasma transfusions are not really out-of-the ordinary. In fact, type-incompatible plasma is routinely given about 15-20% of the time (6,8)!
Someone may try to counter the facts presented in this article by mentioning the remote possibility that Brantly or Writebol could have had higher than normal amounts of anti-B antibodies in their plasma– a factor that could theoretically increase the risk of an adverse reaction. Let’s examine this seemingly logical argument… First of all, even when they do rarely occur, most plasma-related hemolytic reactions are actually very mild– generating little less than fever, chills, and a negligible decrease in red blood cells (10). Also, even the most severe side effects of hemolytic reactions are still more manageable than the complications of advanced Ebola infection (11). Secondly, this argument of refusing convalescent plasma donation because of high titers of RBC directed antibodies doesn’t stand up to the latest research findings that, in fact, high levels of red blood cell directed antibodies (anti-A or anti-B) have been found to be a poor predictor of actual hemolytic reaction (8)!
WHO’s got your back?
Thus, in summary, according to the research-based convalescent plasma protocols of the World Health Organization, Thomas Eric Duncan did have two viable and potentially life-saving transfusion options. Why then were these withheld? Obviously, there is no valid excuse. Therefore, whether through intent or ignorance– gross provider malpractice was involved. However, since Duncan’s case was so highly publicized, why did the CDC and WHO stand back and let his health care team make such an inadvisable blunder? And, furthermore, why was the media so united in covering up this mistake (12, 13, 14)? There are only two plausible options: either our health officials are dangerously incompetent or there is some sort of higher-level deception going on here…
Out of Africa…
Was there motive for Duncan’s demise? Well, what if he had survived? Imagine the thousands of West Africans who, at the earliest indication of possible Ebola infection, would have been inspired to book the next available flight on a plane bound for the “land of cure.” What would this have done for black Friday sales and fourth quarter earnings reports in a country already plagued with economic difficulties?
Obviously our healthcare system has flaws that need to be addressed and our media outlets need to get their stories straight before reporting myths as fact, but as for decreasing the potential for the mass influx of infectious refugees– I think it would have been better to have just settled for flight restrictions…
References:
1) Transfus Apher Sci. 2014 Oct 16;51(2):120-125. doi: 10.1016/j.transci.2014.10.003. [Epub ahead of print]
2) http://abcnews.go.com/Health/dr-kent-brantly-donate-blood-thomas-eric-duncan/story?id=26226388
3) http://apps.who.int/iris/bitstream/10665/135591/1/WHO_HIS_SDS_2014.8_eng.pdf
4) http://www.recombinomics.com/News/10141401/Ebola_MM_Convalescence.html
5) Transfusion. 1985 Jan-Feb;25(1):60-2.
6) Transfusion. 1998 Jan;38(1):51-5.
7) Transfusion. 2013 Jan;53 Suppl 1:114S-123S. doi: 10.1111/trf.12045.
8) Transfusion. 2012 Oct;52(10):2087-93. doi: 10.1111/j.1537-2995.2012.03574.x. Epub 2012 Feb 17.
9) Epidemics. 2014 Dec;9:70-8. doi: 10.1016/j.epidem.2014.09.003. Epub 2014 Oct 6.
10) Transfusion. 1998 Jan;38(1):51-5.
11) Transplantation. 1988 Aug;46(2):246-9.
12) http://abcnews.go.com/Health/dr-kent-brantly-donate-blood-thomas-eric-duncan/story?id=26226388
13) http://www.nbcnews.com/storyline/ebola-virus-outbreak/why-cant-we-have-more-magic-blood-ebola-n225536
14) http://www.fox19.com/story/26827172/ebola-outbreak-in-the-west-why-some-survive-some-dont
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