Anda di halaman 1dari 9

TRANSFUSION COMPLICATIONS

Transfusion-transmitted and community-acquired babesiosis in


New York, 2004 to 2015

Jeanne V. Linden ,1 Melissa A. Prusinski,2 Lauren A. Crowder,3 Laura Tonnetti,3


Susan L. Stramer,3 Debra A. Kessler,4 Jennifer White,2 Beth Shaz,4 and Danuta Olkowska1

B
abesiosis is a zoonotic infection caused by the
BACKGROUND: Babesiosis is a potentially life-
tickborne intraerythrocytic protozoan parasite
threatening zoonotic infection most frequently caused by
Babesia.1 In the United States, human babesiosis
the intraerythrocytic parasite Babesia microti. The
is attributed primarily to infection with
pathogen is usually tickborne, but may also be
transfusion or vertically transmitted. Healthy persons,
B. microti, which is endemic to portions of the Northeast
including blood donors, may be asymptomatic and and upper Midwest.2-5 Seven states have historically been
unaware they are infected. Immunocompromised considered endemic: Connecticut, Rhode Island, New
patients are at increased risk for symptomatic disease. York, Massachusetts, New Jersey, Minnesota, and Wiscon-
STUDY DESIGN AND METHODS: All reported sin. In addition, we consider Maine and New Hampshire
community-acquired babesiosis cases in New York from endemic based on recent published literature and Penn-
2004 to 2015 were evaluated, enumerated, and sylvania has seen increasing incidence and some endemic
characterized. All potential transfusion-transmitted foci.6-10 Distribution is variable; endemic states have
babesiosis (TTB) cases reported through one or more of hyperendemic foci and areas at much lower risk. Babesio-
three public health surveillance systems were sis can also be caused by other Babesia species, such as
investigated to determine the likelihood of transfusion B. duncani on the West Coast of the United States.11-14
transmission. In addition, host-seeking ticks were actively B. microti is usually transmitted to humans, as an
collected in public parks and other likely sites of human incidental host, by the black-legged tick, Ixodes scapularis.
exposure to B. microti. The organism is maintained naturally through an enzootic
RESULTS: From 2004 to 2015, a total of 3799 cases of reservoir, primarily the white-footed mouse (Peromyscus
babesiosis were found; 55 (1.4%) of these were linked to leucopus), while deer can nourish and transport adult ticks
transfusion. The incidence of both community-acquired to expanding geographic areas.15,16 Tick larvae acquire the
babesiosis and TTB increased significantly during the 12-
year study period. The geographic range of both ticks ABBREVIATIONS: ERI(s) 5 entomologic risk index(-es);
and tickborne infections also expanded. Among TTB IFA 5 indirect fluorescent antibody; TTB 5 transfusion-
cases, 95% of recipients had at least one risk factor for transmitted babesiosis.
symptomatic disease. Implicated donors resided in five
From the 1Wadsworth Center and the 2Bureau of
states, including in 10 New York counties. More than half
Communicable Disease Control, New York State Department of
of implicated donors resided in counties known to be
Health, Albany, New York; 3Biomedical Services, Scientific
B. microti endemic.
Affairs, American Red Cross, Rockville and Gaithersburg,
CONCLUSION: The increasing incidence of TTB
Maryland; and 4New York Blood Center, New York, New York.
correlated with increases in community-acquired
Address reprint requests to: Susan L. Stramer, Scientific
babesiosis and infection of ticks with B. microti.
Support Office, American Red Cross, 9315 Gaither Road, Gai-
Surveillance of ticks and community-acquired cases may
thersburg, MD 20877; e-mail: Susan.Stramer@redcross.org.
aid identification of emerging areas at risk for Babesia
This study was funded in part by US National Institutes of
transfusion transmission.
Health, Grant AI097137.
Received for publication September 12, 2017; revision
received November 3, 2017; and accepted November 11, 2017.
doi:10.1111/trf.14476
C 2018 AABB
V
TRANSFUSION 2018;;660–668

660 TRANSFUSION Volume , March 2018


BABESIOSIS IN NEW YORK, 2004-2015

organism via a blood meal from an infected rodent host MATERIALS AND METHODS
and continue to carry the parasite as they develop into
Case finding
nymphs (approximately the size of a poppy seed), the
stage most likely to transmit the organism to humans. In This is a retrospective study of reported community-
addition to tickborne transmission, B. microti may be acquired babesiosis and TTB cases that occurred in New
transmitted by blood transfusion from asymptomatic York from 2004 to 2015. For TTB cases, the date of expo-
blood donors.17 Vertical transmission has also been sure was based on the date of implicated transfusion. The
reported rarely.18 The parasite invades red blood cells primary data source was public health records. Physicians
(RBCs), resulting in an infection that can range from are required to report babesiosis cases to the local health
asymptomatic to severe disease. Symptomatic disease department of the patient’s county of residence. The pub-
presents most commonly with fever, chills, malaise, myal- lic health surveillance investigation process includes two
gia, gastrointestinal symptoms, and/or hemolytic ane- questions regarding possible transfusion or transplanta-
mia.19 Fulminant disease can manifest with disseminated tion within the previous 6 months. Cases with an affirma-
intravascular coagulation, hemodynamic instability, and tive response to either question are referred to the blood
potentially fatal multiorgan dysfunction.19 and tissue oversight program for investigation. Also, labo-
The first case of human babesiosis in New York was ratories must report positive Babesia-related test results to
identified in 1975, and the disease was designated a the State Department of Health using an electronic report-
reportable communicable disease by the New York State ing system. In addition, babesiosis cases that may be
Department of Health in 1986.20 Shelter Island and the
transfusion transmitted are reportable directly to the
South Fork of Long Island, east of the Shinnecock Canal,
blood and tissue oversight program. Case investigation
have been and continue to be hyperendemic foci. How-
included assessing time frames and recipient medical cir-
ever, cases have been reported in larger numbers and in
cumstances, donor laboratory testing, and follow-up
expanding geographic areas. Outside New York, other
interviews. If a blood component and donor were impli-
high-incidence areas include coastal regions of southern
cated, efforts were made to identify recipients of cocom-
New England, especially all coastal regions of Connecti-
cut, Martha’s Vineyard and Nantucket Island in Massachu- ponents from the implicated donation and previous
setts, and Block Island in Rhode Island. Babesiosis recipients of blood components from the implicated
became nationally notifiable in 2011, meaning that, in donor.
states in which babesiosis is a reportable communicable
disease (31 as of 2014), the state health department is Case criteria and classification
expected to report confirmed cases to the Centers for Dis- We used the following case criteria to determine Babesia
ease Control and Prevention in a nonidentifying fashion, infection in patients: diagnosed Babesia infection con-
for surveillance purposes, using a standardized case defi- firmed by laboratory testing. Parasitologic evidence
nition.21 To be classified as confirmed, a case of babesiosis included observation of Babesia organisms on peripheral
requires symptoms and supportive laboratory findings. blood smear or detection of Babesia DNA by a molecular
However, a blood donor may be considered implicated method. Serologic evidence included positive results
even if confirmed case criteria are not met. (titer  256) by indirect fluorescent antibody (IFA) or
The incidence of transfusion-transmitted babesiosis immunoglobin G (IgG) immunoblot. Additional criteria
(TTB) in the United States is increasing. A 2011 report
for TTB were: 1) receipt of a blood component within a
identified 159 cases of TTB attributed to B. microti from
plausible time frame and 2) absence of evidence that
1979 to 2009, with the majority of them (77%) occurring
another route was more likely than transfusion. A TTB
between 2000 and 2009.17 TTB cases have been linked to
case was considered definite if an extant segment dem-
RBCs, frozen deglycerolized RBCs, and whole blood–
onstrated evidence of infection. A TTB case was consid-
derived platelet (PLT) concentrates (presumably from
ered probable if linked, in a plausible time frame, to a
residual RBCs).17,22 There have been no confirmed reports
of cases associated with fresh-frozen plasma, plasma fro- donor found positive by nucleic acid testing or a titer of
zen within 24 hours, apheresis PLTs, or cryoprecipitate. 64 or more on serologic testing on a specimen collected
B. microti is currently the most common RBC transfusion- subsequently. A TTB case was considered possible if no
transmitted pathogen reported to the US Food and Drug donor was implicated, but it was not possible to test all
Administration through the Biological Product Deviations donors, and the patient had no other plausible risk. If all
Reporting system, accounting for 20 of 26 (77%) reports of associated donors were seronegative or the patient’s
pathogen transmission in Fiscal Year 2015.23 Babesia was infection predated any transfusion(s), the case was
linked to three of five reports of fatalities in the United excluded as transfusion transmitted. Cases not linked to
States attributed to RBCs contaminated with an infectious transfusion or transplantation were considered commu-
agent in Fiscal Year 2011 to 2015.24 nity acquired.

Volume , March 2018 TRANSFUSION 661


LINDEN ET AL.

Tick surveillance nymphal tick density and B. microti prevalence in host-


Host-seeking I. scapularis ticks were collected using stan- seeking nymphs, as described.26
dardized drag surveys, conducted during peak tick activity
periods in New York (May-July and October-December) as Statistical analysis
described.20 Sites included publicly accessible lands We calculated incidence rates as the number of babesiosis
across New York, primarily parks and nature preserves, cases per 100,000 population per year. We employed linear
considered to be at high risk of human exposure to regression to analyze trends over time. Sex differences
B. microti due to the presence of suitable tick and small between TTB patients and donors were compared using
mammal habitat and recreational trails. After species con- chi-square comparisons with Bonferroni adjustment.
firmation, individual I. scapularis ticks were homogenized Spearman correlation tests were used to explore the rela-
and tested for B. microti DNA by polymerase chain reac- tionship between ERI and incidence of babesiosis at the
tion (PCR).25 county level. Data analyses were performed using com-
puter software (SAS, v9.4 SAS Institute, Inc.). A p value of
Data collection and analysis less than 0.05 was considered significant in this analysis.
Data on community-acquired cases, including geographic Incidence rates and pathogen prevalence in host-seeking
location, were obtained through investigation of reported nymphal ticks were mapped using computer software
cases of the disease and laboratory reporting of positive (ArcGIS, Version 10.4, ESRI).
test results indicative of infection. The cases determined
to be confirmed were enumerated, characterized, and RESULTS
stratified by county of patient residence for each year. The
four highest-incidence counties were identified for further A total of 3799 cases of babesiosis were identified in New
analysis. The community-acquired group was stratified by York State from 2004 to 2015. There was a significant
age and sex. increase in the number of community-acquired cases over
For each reported potential TTB case, we obtained the study period, with 91 cases reported in 2004 and 576
and evaluated the recipient’s clinical history and course, reported in 2015 (R2 5 0.8180, p < 0.0001). There were 55
including outcome, and laboratory test results, including (1.4%) definite or probable TTB cases. TTB cases
consideration of date(s) of pertinent transfusion(s) and increased from two in 2004 to eight in 2015 (R2 5 0.4134,
type(s) of component(s) received. After identification of p 5 0.0241; Fig. 1). Tick surveillance data demonstrated a
potentially implicated transfusion(s), we determined similar increase over time. Figure 2 displays the preva-
whether any extant segment(s) from pertinent unit(s) lence of B. microti in I. scapularis nymphs from 2004 to
were available for testing, along with any possible extant 2015, along with the incidence of human babesiosis.
cocomponents in storage or units donated subsequently Of the 55 TTB cases included in the analysis, four met
by a suspect donor. If no other sample was available, sus- the criteria for definite TTB based on testing of an extant
pect donors were contacted and asked to provide a new segment. One segment was positive by PCR; the other
sample for testing. Testing, performed or confirmed at the three were positive by IFA, with titers of 1024, 1024, and
state public health laboratory, included IFA and PCR. 256, respectively. The other 51 cases met criteria as proba-
When an implicated unit and donor were identified, the ble TTB. In addition, 10 reported potential cases were
following data were determined and recorded in a data- excluded as TTB (most frequently when a retrospective
base: 1) date of implicated donation, 2) type of compo- review of blood smears demonstrated B. microti parasites
nent transfused, 3) interval between donation and before any transfusion) and 26 cases meeting only the def-
transfusion, 4) interval between transfusion and develop- inition of possible TTB were identified. These 36 were not
ment of recipient symptoms, and 5) implicated donor included in the analysis of TTB cases, but were included
demographics, including the counties of residence and of in “all” cases.
donation. In our analysis, we considered cases in which In 54 TTB cases, the implicated component was
transfusion transmission was excluded and those that met RBCs; in the other case, a unit of frozen deglycerolized
only possible criteria not to be transfusion transmitted. RBCs was implicated. There were two clusters; in each,
We stratified the implicated donor group by age and sex. blood collected from the same donor on two different
Ticks testing positive for B. microti were enumerated occasions resulted in infection in two recipients. In one
by county of collection. We calculated county-level preva- cluster, 2 units of RBCs donated by a single donor, 56 days
lence rates by determining the mean percentage of ticks apart, were each implicated in transmission of Babesia to
infected with B. microti. Tick density was summarized as a (different) recipient. In the other cluster, 2 units of RBCs
the mean number of nymphs collected per man-hour at donated 69 days apart were each implicated in transmis-
the site and county levels. Site- and county-level entomo- sion to a (different) recipient. The mean observed incuba-
logic risk indexes (ERIs) were calculated as a product of tion period from date of implicated transfusion to onset of

662 TRANSFUSION Volume , March 2018


BABESIOSIS IN NEW YORK, 2004-2015

Fig. 1. Number of community-acquired and TTB cases, 2004 to 2015. [Color figure can be viewed at wileyonlinelibrary.com]

Fig. 2. Incidence rate (per 100,000 population) of human babesiosis, prevalence of B. microti in host-seeking I. scapularis
nymphs, and ERI in New York State, 2008 to 2015. [Color figure can be viewed at wileyonlinelibrary.com]

symptoms was 35.9 days (median, 34 days; range, 8- and 31% of all patients less than 5 years of age. While
91 days). The mean maximum parasitemia, when known, there was an even distribution of TTB cases across the
in TTB cases was 6.1% (median, 5%; range, 0.01%-29%). sexes (49% male, 51% female), the distribution of all
For both all cases and TTB cases, the patient age and reported babesiosis cases was more heavily skewed
sex distributions are shown in Table 1. TTB cases toward males (62% male, 38% female). Although the dif-
accounted for 9.2% of cases among children up to age 19, ference was not significant (v2 5 3.8213, p 5 0.0506), it is

Volume , March 2018 TRANSFUSION 663


LINDEN ET AL.

meaningful in that it highlights the difference between the the 12 years studied (data not shown). A large proportion
sex distribution of TTB versus all cases. The implicated (27/55, 49%) of implicated donations took place in July,
donors in the TTB cases were more likely to be male (84% August, or September, consistent with exposure occurring
male, 16% female), compared to the overall donor popula- during the known peak nymphal I. scapularis tick activity
tion, which is more evenly split between the sexes (57% from mid-May through mid-August.6 In contrast, little
male, 43% female). Comparison of the sex distribution of activity was seen in March and April, providing only two
the three groups specific to this study, TTB cases, (4%) of the total implicated donations over the 12-year
community-acquired babesiosis cases, and implicated study interval. However, it is important to note that at
donors, showed a significant difference (v2 5 14.77, least one implicated donation took place in each month
p 5 0.0006). of the year.
Figure 3 shows all implicated donations for years Entomologic risk index is a measure of tickborne dis-
2004 to 2015 stratified by month of donation. Month of ease risk: the product of tick abundance and pathogen
implicated donation was relatively evenly distributed over prevalence in host-seeking ticks from a given location.
Babesiosis incidence rates per 100,000 population and
B. microti ERI, by New York county, for years 2004, 2008,
TABLE 1. Age and sex distribution of TTB and 2012, and 2015 are shown in Fig. 4. The increase in inci-
community-acquired babesiosis cases and sex dence across the counties in the Downstate and Lower- to
distribution of implicated donors*
Mid-Hudson Valley regions can be seen in the time pro-
All babesiosis
Age (years) cases TTB cases % TTB cases gression displayed, with a corresponding increase in
<1 7 (0.2) 2 (3.6) 28.6 B. microti ERI. Three counties—Columbia, Dutchess, and
1-4 6 (0.2) 2 (3.6) 33.3 Suffolk—saw significant increases in incidence over the
5-19 85 (2.2) 5 (9.1) 5.9 12-year study period (Fig. 5): Columbia County’s inci-
20-29 99 (2.6) 3 (5.5) 3.0
30-39 238 (6.3) 4 (7.3) 1.7 dence increased from 0.0 to 37 cases per 100,000 popula-
40-49 488 (12.8) 9 (16.4) 1.8 tion from 2004 to 2015 (R2 5 0.6634, p 5 0.0013);
50-59 809 (21.3) 4 (7.3) 0.5 Dutchess County’s incidence increased from 2.4 to 25.3
601 2063 (54.3) 26 (47.3) 1.3
Unknown 4 (0.1) 0 (0.0) 0.0 cases per 100,000 population (R2 5 0.4385, p 5 0.0190);
Suffolk County’s incidence increased from 4.0 to 14.2
Sex All babesiosis cases TTB cases Implicated donors
cases per 100,000 population (R2 5 0.7980, p < 0.0001);
Male 2355 (62.0) 27 (49.1) 46 (83.6)
Female 1444 (38.0) 28 (50.9) 9 (16.4) and Westchester County’s incidence increased from 1.0
Total 3799 55 55 to 5.8 cases per 100,000 population during this
* Data are reported as number (%). period, although this increase was not statistically signifi-
cant. New York State also saw a significant increase from

Fig. 3. Distribution of TTB cases by month of implicated donation, 2004 to 2015. [Color figure can be viewed at wileyonlineli-
brary.com]

664 TRANSFUSION Volume , March 2018


BABESIOSIS IN NEW YORK, 2004-2015

Fig. 4. County-level incidence rates (per 100,000 population) of human babesiosis (left) and B. microti ERIs (right), 2004, 2008,
2012, and 2015.

0.5 to 3.0 cases per 100,000 population from 2004 to 2015 prevalence rates of B. microti in host-seeking nymphs and
(R2 5 0.8136, p < 0.0001). During the study period, there human babesiosis incidence (r 5 0.57, p < 0.0001), and 3)
was a positive association between 1) nymphal tick density B. microti ERI and human babesiosis incidence (r 5 0.58,
and human babesiosis incidence (r 5 0.58, p < 0.0001), 2) p < 0.0001; Table 2).

Volume , March 2018 TRANSFUSION 665


LINDEN ET AL.

Fig. 5. Babesiosis incidence rates (per 100,000 population) in New York State and four highest incidence counties, 2004 to 2015.
[Color figure can be viewed at wileyonlinelibrary.com]

TABLE 2. Association between B. microti ERI and human babesiosis incidence rates in New York State,
2008 to 2015
Number Mean nymph Mean babesiosis Spearman
Year of counties density (ticks/m) Mean ERI* incidence correlation p value
2008 18 0.466 0.009 2.283 0.681 0.0019
2009 23 0.428 0.003 1.530 0.502 0.0146
2010 21 0.207 0.002 1.681 0.472 0.0308
2011 20 0.424 0.005 2.590 0.572 0.0084
2012 24 0.191 0.005 1.625 0.699 0.0001
2013 32 0.426 0.020 4.281 0.776 <0.0001
2014 54 0.135 0.004 2.367 0.612 <0.0001
2015 50 0.189 0.004 3.532 0.681 <0.0001
* ERI is the product of B. microti prevalence in host-seeking ticks and tick abundance.

All implicated donors resided in the northeastern undergone splenectomy, 11 (65%) had a hemoglobinopa-
region of the United States, with a majority (55%) residing thy (b-thalassemia or sickle cell disease). In addition, two
within one of the four known highest-incidence counties spleen-intact patients had sickle cell disease, in which
(of 62) in New York (Suffolk, Westchester, Dutchess, and functional hyposplenism is common.27 Other identified
Columbia Counties). In addition, one upstate donor had risk factors included treatment for a malignancy or other
traveled to Connecticut, seven implicated units were col- immunosuppression (11, 20%), and history of hematopoi-
lected in New Jersey, and blood units imported from out- etic progenitor cell or solid organ transplant (two and
of-state blood centers had been collected in Massachu- three patients, respectively). One patient (2%) had three
setts (3), Rhode Island (1), or Pennsylvania (1). risk factors, eight (15%) had two risk factors, and 44 (80%)
All except two (5%) of the reported TTB patients had had one risk factor. The two cases (4%) not linked to a rec-
at least one established risk factor for symptomatic babe- ognized risk factor included a 58-year-old with liver dis-
siosis among their age or underlying comorbidity(-ies). ease and a 50-year-old with iron deficiency anemia. Two
Although more than half (28/55, 51%) of affected recipi- patients (4%) died of Babesia infection in the context of
ents were either 60 years of age or older (26, 48%) or less their underlying comorbidities: a woman in her 90s with
than 1 year of age (two, 4%), the most notable risk factor gastrointestinal bleeding and a man in his 60s status post–
was asplenia (17/55, 32%). Of the 17 patients who had hip surgery complicated by infection.

666 TRANSFUSION Volume , March 2018


BABESIOSIS IN NEW YORK, 2004-2015

DISCUSSION possible emerging tick activity from 2008 to 2015, rather


than known hyperendemic foci sampled in 2004, and may
This study identified 3799 babesiosis cases in New York
thus underestimate abundance of infected ticks on a
from 2004 to 2015, of which 55 (1.4%) were linked to
statewide level.
transfusion. More than 200 TTB cases have been reported
Transfusion-transmitted babesiosis is a serious prob-
in the United States.9,10,17,28 While the incidence per pop-
lem that can result in morbidity and mortality in transfu-
ulation is higher in Connecticut and Rhode Island, a sig-
sion recipients. The data herein present a comprehensive
nificant portion of TTB cases have occurred in New
longitudinal statewide compilation of reported babesiosis
York—105 definite, probable, or possible cases to date—
cases and show increasing frequency and geographic
more than twice as many as in any other state.17 In this
expansion, corresponding with an expansion of
series, all implicated donors resided in one of nine states
B. microti–infected ticks, over the 12-year period in a
now considered endemic or in Pennsylvania, which is rec-
Babesia-endemic state. Blood donor testing in some
ognized as having emerging B. microti.7 More than half
highly endemic areas has been initiated by some blood
(55%) resided in one of four known highly endemic coun-
collection organizations under investigational product
ties in New York. Babesia seroprevalence in blood donors
release testing protocols. Efficacy of such screening in
has been found to be as high in 4.3% in hyperendemic
reducing the risk of TTB has been demonstrated.9,10 How-
foci in New York29 and 3.0% in coastal Connecticut.30
Temporal and geographic changes in the incidence of ever, no licensed test for donor screening is available and
community-acquired babesiosis and TTB, as well as tick investigational testing is not available in all areas. Also,
activity, demonstrated oscillations between years. For testing cannot be relied on to detect all infectious dona-
example, 2012 was a low year for both tick activity and tions, and temporal and geographic expansion may sur-
human cases in New York, as well as in the United States.6 pass testing availability. In addition, testing for evidence of
Annual fluctuations in human babesiosis may be due to B. microti infection may not detect other species of Babe-
fluctuations in I. scapularis density. Field studies have sia or other agents, such as Anaplasma phagocytophilum,
described annual oscillations of I. scapularis nymph pop- which is carried by the same tick vector and can result in
ulations, attributed to the influence of multiple biotic and signs and symptoms very similar to those seen in
abiotic factors.31,32 Such temporal fluctuations in tick den- babesiosis.
sity have occurred in parallel with fluctuations in annual Public health efforts, including surveillance of
human Lyme disease incidence,32,33 and it is likely that community-acquired babesiosis and of tick abundance
the incidence of babesiosis is also influenced by fluctua- and infection, may be useful tools in identifying emerging
tions in tick density. An ERI based on the number of areas of risk that could pose a hazard to transfusion recip-
I. scapularis ticks infected by Borrelia burgdorferi in a ients. Establishing communication channels with public
12-town area of Connecticut correlated highly with the health agencies could facilitate blood collection organiza-
incidence of Lyme disease in the same area.32 Site-level tions’ abilities to tap such resources effectively to inform
ERI values have been found to be a significant predictor of blood supply safety policies.
the total number of reported cases of babesiosis by
municipality.32 In this study, a strong positive relationship ACKNOWLEDGMENTS
between ERI and human babesiosis incidence rates sug-
We thank Adam Rowe and Alexis Russell of the New York State
gests that the ERI is predictive of human babesiosis risk in
Department of Health, Bureau of Communicable Disease Con-
New York. ERI appears to be useful for assessing human
trol, for generating human incidence maps and updating statis-
risk of babesiosis, which could be an important factor in
tics in Table 2 and for generating ERI maps, respectively. We also
planning interventional strategies to reduce disease risk
thank Dr Erin Moritz of the American Red Cross, Biomedical Serv-
effectively.
ices, Scientific Affairs, for initial advice on statistical analyses.
The vast majority (95%) of TTB patients identified in
this study had at least one identified risk factor for symp-
CONFLICT OF INTEREST
tomatic disease; in two patients (4%), their Babesia infec-
tion proved fatal. The median incubation period from The authors have disclosed no conflicts of interest.
implicated transfusion to development of symptoms was
34 days, consistent with other studies.17
REFERENCES
Limitations of the study include reliance on passive
reporting of cases, although three avenues of reporting 1. Vannier E, Krause PJ. Human babesiosis. N Engl J Med 2012;
were in place. Passive reporting relies on a patient being 366:2397-407.
diagnosed with clinical babesiosis, so these numbers do 2. Krause PJ, McKay K, Gadbaw J, et al. Increasing health bur-
not reflect asymptomatic cases. In addition, collection of den of human babesiosis in endemic sites. Am J Trop Med
host-seeking I. scapularis nymphs overselected sites of Hyg 2003;68:431-6.

Volume , March 2018 TRANSFUSION 667


LINDEN ET AL.

3. Joseph JT, Roy SS, Shams N, et al. Babesiosis in lower Hud- 20. Kogut SJ, Thill CD, Prusinski MA, et al. Babesia microti,
son Valley, New York, USA. Emerg Infect Dis 2011;17:843-7. upstate New York. Emerg Infect Dis 2005;11:476–8.
4. Krause PJ, Telford SR III, Ryan R, et al. Geographical and 21. Babesiosis (Babesia spp.) 2011 case definition [Internet].
temporal distribution of babesial infection in Connecticut. Atlanta (GA): Centers for Disease Control and Prevention
J Clin Microbiol 1991;29:1-4. (CDC); 2011 [cited 2017 Jun 1]. Available from: https://
5. White DJ, Talarico J, Chang HG, et al. Human babesiosis in wwwn.cdc.gov/nndss/conditions/babesiosis/case-defini-
New York State: review of 139 hospitalized cases and tion/2011/.
analysis of prognostic factors. Arch Intern Med 1998;158: 22. Leiby DA. Transfusion-transmitted Babesia spp.: bull’s-eye
2149-54. on Babesia microti. Clin Microbiol Rev 2011;24:14-28.
6. Surveillance for babesiosis—United States, 2014. Annual 23. FY 2015: number of BPD reports by type of blood and
summary [Internet]. Atlanta (GA): Centers for Disease Con- plasma establishment [Internet]. Silver Spring (MD): U.S.
trol and Prevention (CDC); 2016 [cited 2017 Jun 1]. Available Food and Drug Administration [cited 2018 Jan 3]. Available
from: www.cdc.gov/parasites/babesiosis/resources/babesio- from: http://wayback.archive-it.org/7993/20171115105917/
sis_surveillance_summary_2016.pdf. https://www.fda.gov/BiologicsBloodVaccines/SafetyAvaila-
7. Genda J, Negron EA, Lotfipour M, et al. Severe Babesia biliyt/ReportaProblem/BiologicalProductDeviations/
microti infection in an immunocompetent host in Pennsyl- ucm506031.htm.
vania. J Investig Med High Impact Case Rep 2016;4: 24. Fatalities reported to FDA following blood collection and
2324709616663774. transfusion annual summary for FY 2015 [Internet]. Silver
8. Smith RP Jr, Elias SP, Borelli TJ, et al. Human babesiosis, Spring (MD): U.S. Food and Drug Administration; 2016
Maine, USA, 1995-2011. Emerg Infect Dis 2014;12:1727–30. [cited 2017 Jun 12]. Available from: https://www.fda.gov/
9. Moritz ED, Winton CS, Tonnetti L, et al. Screening for Babe- downloads/BiologicsBloodVaccines/SafetyAvailability/
sia microti in the U.S. blood supply. N Engl J Med 2016;375: ReportaProblem/TransfusionDonationFatalities/
2236–45. UCM518148.pdf.
10. Moritz ED, Tonnetti L, Hewins ME, et al. Description of 15 25. Prusinski MA, Kokas JE, Hukey KT, et al. Prevalence of Borrelia
DNA-positive and antibody-negative “window period” blood burgdorferi (Spirochaetales: Spirochaetaceae), Anaplasma phag-
donations identified during prospective screening for Babe- ocytophilum (Rickettsiales: Anaplasmataceae), and Babesia
sia microti. Transfusion 2017;57:1781–6. microti (Piroplasmida: Babesiidae) in Ixodes scapularis (Acari:
11. Quick RE, Herwaldt BL, Thomford JW, et al. Babesiosis in Ixodidae) collected from recreational lands in the Hudson Valley
Washington State: a new species of Babesia? Ann Intern Med Region, New York State. J Med Entomol 2014;51:226-36.
1993;119:284–90. 26. Mather TN, Nicholson MC, Donnelly EF, et al. Entomologic
12. Herwaldt BL, Kjemtrup AM, Conrad PA, et al. Transfusion- index for human risk of Lyme disease. Am J Epidemiol 1996;
transmitted babesiosis in Washington State: first reported 144:1066-9.
case caused by a WA1-type parasite. J Infect Dis 1997;175: 27. Nottage KA, Ware RE, Winter B, et al. Predictors of splenic
1259–62. function preservation in children with sickle cell anemia
13. Kjemtrup AM, Lee B, Fritz CL, et al. Investigation of transfu- treated with hydroxyurea. Eur J Haematol 2014;93:377-83.
sion transmission of a WA1-type babesial parasite to a pre- 28. Fang DC, McCullough J. Transfusion-transmitted Babesia
mature infant in California. Transfusion 2002;42:1482–7. microti. Transfus Med Rev 2016;30:132-8.
14. Bloch EM, Herwaldt BL, Leiby DA, et al. The third described 29. Linden JV, Wong SJ, Chu FK, et al. Transfusion-associated
case of transfusion-transmitted Babesia duncani. Transfu- transmission of babesiosis in New York State. Transfusion
sion 2012;52:1517–22. 2000;40:285-9.
15. Gray J, Zintl A, Hildebrandt A, et al. Zoonotic babesiosis: 30. Johnson ST, Cable RG, Tonnetti L, et al. Seroprevalence of
overview of the disease and novel aspects of pathogen iden- Babesia microti in blood donors from Babesia-endemic
tity. Ticks Tick Borne Dis 2010;1:3–10. areas of the northeastern United States: 2000 through 2007.
16. Hersh MH, Tibbetts M, Strauss M, et al. Reservoir compe- Transfusion 2009;49:2574-82.
tence of wildlife host species for Babesia microti. Emerg 31. Falco RC, Daniels TJ, Fish D. Increase in abundance of
Infect Dis 2012;18:1951–7. immature Ixodes scapularis (Acari: Ixodidae) in an emergent
17. Herwaldt BL, Linden JV, Bosserman E, et al. Transfusion- Lyme disease endemic area. J Med Entomol 1995;32:522-6.
associated babesiosis in the United States: a description of 32. Stafford KC III, Cartter ML, Magnarelli LA, et al. Temporal
cases. Ann Intern Med 2011;155:509–19. correlations between tick abundance and prevalence of ticks
18. Joseph JT, Purtill K, Wong SJ, et al. Vertical transmission of infected with Borrelia burgdorferi and increasing incidence
Babesia microti, United States. Emerg Infect Dis 2012;18: of Lyme disease. J Clin Microbiol 1998;36:1240-4.
1318–21. 33. White DJ, Chang HG, Benach JL, et al. The geographic
19. Vannier EG, Diuk-Wasser MA, Ben Mamoun C, et al. Babesi- spread and temporal increase of the Lyme disease epidemic.
osis. Infect Dis Clin North Am 2015;29:357–70. JAMA 1991;266:1230-6.

668 TRANSFUSION Volume , March 2018

Anda mungkin juga menyukai