Untreated BTSB blood clotting agent infected HIV seven

Two batches of blood-clotting agents manufactured by the Blood Transfusion Service Board have been identified as the source of…

Two batches of blood-clotting agents manufactured by the Blood Transfusion Service Board have been identified as the source of the infection of seven haemophiliacs who developed the HIV virus, the Lindsay tribunal heard yesterday.

In a two-hour opening statement into the second phase of the tribunal's investigations, which will examine the role of the BTSB in the infection of haemophiliacs, counsel for the tribunal Mr John Finlay SC said the seven patients tested HIV positive between July 1985 and August 1986.

Yet it was known in 1984 that if the clotting agent was heat treated, the virus which caused AIDS could be inactivated, he said.

He said the evidence would be that the first heat-treated batch of factor 9 clotting agent was not issued by the BTSB until October 1985, but the blood bank continued to issue non-heat-treated factor 9 after that date.

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An untreated batch was sent to the Cork BTSB and to a Drogheda hospital in December 1985 and was not formally recalled until June 1986.

"It appears one of the seven persons infected with BTSB factor 9, a St James's patient, continued to use non-heat-treated product from batch number 90753 (the second batch) at home up to February 20th, 1986," counsel said.

Mr Finlay said Dr Emer Lawlor, a consultant haematologist and deputy national medical director of the BTSB, believed they became infected as a result of treatment with factor 9 clotting agent made by the BTSB. She had identified two batches manufactured in 1985 from donations made in 1984 as the source of infection.

The first batch was issued to the Cork BTSB in June 1985 and to a Drogheda hospital in three lots in June and July 1985.

The second batch included a unit of cryoprecipitate, another clotting agent, made in December 1984 from blood given by a firsttime donor who was found to be HIV positive in 1990. It was issued to hospitals in 1985.

The batches were not heat-treated despite an awareness at the time that this practice was an effective form of viral inactivation against the HIV virus.

He said it was known from September 1984 that heat treatment was effective in eradicating the AIDS virus from factor concentrates.

Prof Ian Temperley, the then director of the National Haemophilia Treatment Centre, had in December 1984 written to the late Dr Jack O'Riordan, former director of the BTSB, stating that he would only purchase heat-treated factor 8 and 9 concentrates from commercial firms in 1985 and asked the BTSB to consider urgently the question of heat treating all BTSB products produced for the treatment of haemophiliacs, he said.

In a further letter in 1985, Prof Temperley referred, "in stark terms, to the risk of infection from non-heat-treated products and the severity of the consequences of infection", counsel said.

Mr Finlay added that the BTSB issued heat-treated commercially produced factor 9 from January 1985. It was purchased from Hyland Travenol.

He said questions would have to be answered as to why the BTSB did not offer this to patients while it was waiting to heat-treat its own product.

Counsel said that a test to screen blood donations for the HIV virus was available from March 1985 but was not introduced by the BTSB until October 1985. The only means of guarding against the risk of infected donations before that lay in the process of selecting and screening donors.

He said that in July 1983 the BTSB issued a leaflet to all potential donors which identified a number of groups of people considered to be at risk of transmitting AIDS and asked them to refrain from donating.

Questions would have to be answered as to why they did not include one group included in a leaflet issued by the American Red Cross which asked people with symptoms suggestive of AIDS not to donate. The BTSB had this leaflet.