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Cad . Saúd e Púb lic a, Rio d e Jane iro , 14(2):417-420, ab r-jun, 1998 N O TA RESEARCH NO TE
Counseling blood donors seropositive
for human T-lymphotropic virus types I
and II in a developing country
Ac o nse lhand o o d o ad o r d e sang ue so ro p o sitivo
p ara o Vírus Linfo tró p ic o Humano tip o I/ II
e m um p aís e m d e se nvo lvime nto
1 Fu n d ação Hem om in as. Ala m ed a Ez eq u iel Dia s 321, Belo Horiz on t e, M G 30130- 110, Bra sil.
Va léria M . A. Pa ssos 1
Fá t im a F. Ca la z a n s 1
An n a Bá rb a ra F. Ca rn eiro- Proiet t i 1
Abst ract Hu m a n T- lym p h ot rop ic v iru s t yp es I a n d II (H TLV- I/II) a re b lood - t ra n sm it t ed ret ro-v iru ses a ssocia t ed w it h leu k em ia , m yelop a t h y, a n d u ro-veit is. From 51,135 eligib le b lood d on ors a t t h e Fu n d ação Hem om in as t est ed in 1993, 689 (1.35%) w ere rep eat ed ly react iv e t o HTLV-I/II an t i-b od ies i-by en z ym e im m u n oa ssa y a n d w ere n ot ified a ccord in gly. Rou t es of t ra n sm ission a n d p re-v en t ire-ve m ea su res w ere em p h a siz ed in t h e orien t a t ion . Su p p lem en t a ry la bora t ory t est s sh ou ld be available an d free of cost . Healt h serv ices sh ou ld recom m en d t h e u se of lat ex con d om s an d m ak e t h em a va ila b le. Av oid in g sh a red u se of n eed les or syrin ges is im p ort a n t for b ot h t h e serop osit ive d on or a n d p u b lic h ea lt h in gen era l. In a cou n t ry w it h su ch w id esp rea d m a ln u t rit ion , t h e b en e-fit s of b rea st - feed in g u su a lly ou t w eigh t h e risk s of v iru s t ra n sm ission . Ba sed on ou r ex p erien ce, w e recom m en d t h a t : 1) id en t ica l orien t a t ion b e giv en t o d on ors b y a ll h ea lt h p rofession a ls in -v ol-v ed in cou n selin g; 2) le-v el of sch oolin g b e con sid ered a n d in form a t ion p ro-v id ed a ccord in gly; 3) d on ors be assist ed in u n d erst an d in g an d assessin g av ailable in form at ion ; 4) p sych ological as-sist an ce be p rov id ed t o an x iou s or d ep ressed d on ors; an d 5) join t cou n selin g be offered t o d on ors w it h st able p art n ers.
Key words Cou n selin g; HTLV I Viru ses; HTLV II Viru ses; Develop in g Cou n t ries
Resumo Os v íru s lin fot róp ico h u m a n o t ip os I e II (H T LV- I/II) sã o ret rov íru s t ra n sm it id os p or com p on en t es celu la res sa n gu ín eos e a ssocia d os à ocorrên cia d e leu cem ia , m ielop a t ia e u v eít e. De 51.135 d oad ores d e san gu e d a Fu n d ação Hem om in as t est ad os em 1993, 689 (1,35%) foram rep et id a m en t e rea t ivos a a n t icorrep os con t ra HTLVI/II n o en sa io im u n oen z im á t ico e fora m d ev id a m en t e n ot ifica d os. As v ia s d e t ra n sm issã o e m ed id a s d e con t role fora m en fa t iz a d a s n a orien t a -çã o. Test es la bora t oria is su p lem en t a res d evem ser d isp on íveis e gra t u it os. O u so d e p reserv a t ivos d eve ser recom en d ad o e os m esm os serem d isp on ív eis n os serv iços d e saú d e. O d oad or sorop osit i-v o e os seri-v iços d e sa ú d e n ã o d ei-v em reu t iliz a r a gu lh a s e serin ga s. Sen d o a d esn u t riçã o in fa n t il u m p roblem a grave n o p aís, o ben efício d a am am en t ação sobrep õe-se ao risco d e t ran sm issão d e v iroses. Ba sea d os em n ossa ex p eriên cia , recom en d a -se: 1) a m esm a orien t a çã o d eve ser d a d a p or t od os os t ra b a lh a d ores d e sa ú d e en v olv id os n o a con selh a m en t o d o d oa d or, 2) o n ív el ed u ca cio-n al d ev e ser cocio-n sid erad o e as icio-n form ações forcio-n ecid as d e acord o com as cio-n ecessid ad es icio-n d iv id u ais; 3) d ev e- se a u x ilia r o d oa d or a com p reen d er e crit ica r a s in form a ções d isp on ív eis e 4) forn ecer a ssist ên cia p sicológica a d eq u a d a a d oa d ores a n siosos ou d ep rim id os e 5) se o d oa d or t em u m p aceiro est ável, as in form ações d ev em ser d ad as ao casal, sim u lt an eam en t e.
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Cad . Saúd e Púb lic a, Rio d e Jane iro , 14(2):417-420, ab r-jun, 1998
Introduction
Hu m an T-cell lym p h otrop ic viru s typ es I an d II (HTLV I/ II) are retroviru ses th at can in fect h u -m an s an d b e tran s-m itted th rou gh con tact with b lood . HTLV-I is associated with an aggressive lym p h o m a , a d u lt T-ce ll le u ke m ia / lym p h o m a (ATL), a d egen erative d em yelin atin g n eu rologi-cal d isease kn own as trop irologi-cal sp astic p arap are-sis ( TSP) o r H TLV-I a sso cia te d m ye lo p a th y (HAM), a n d u veitis (Poiesz et a l., 1981; Osa m e e t a l., 1986; Su gim o to e t a l., 1993). De ve lo p -m en t of ATL -m ay requ ire years to d ecad es after in fe ctio n , wh ile d a ta fro m Ja p a n e se p a tie n ts with TSP/ HAM an d a h istory of b lood tran sfu -sion su ggest a m ean in terval of 2 years (ran ge: 6 m on th s to 8 years) b etween in fection an d d e-velo p m en t o f n eu ro lo gica l sym p to m s (Osa m e e t a l., 1986). H TLV-II wa s first iso la te d fro m a p a tie n t with T h a ir y-ce ll le u ke m ia , b u t th e viru s h a s n o t ye t b e e n cle a rly a sso cia te d with an y d isease (Blattn er, 1989).
H TLV in fectio n is en d em ic in severa l p a rts of th e world (Levin e & Man n s, 1993). In Brazil, a stu d y p erform ed at Fu n d ação Hem om in asin 1992 o n b lo o d d o n o rs a t low risk fo r se xu a lly tra n sm itte d d ise a se a n d b lo o d -b o r n e in fe c-tion s fou n d a p oin t p revalen ce rate of ap p roxi-m ately 0.32% (Proietti et al., 1994).
Scre e n in g p ro gra m s in b lo o d ce n te rs a n d h e m o th e ra p y se r vice s sh o u ld p rovid e e d u ca -tio n a n d su p p o rt to H TLV-I/ II p o sitive d o n o rs to h elp th em m ain tain th eir p h ysical an d em otion al h ealth an d red u ce th eir likelih ood of in -fectin g oth ers.
Im p lem en tation of rou tin e HTLV-I/ II sero-logical testin g at Fu n d ação Hem om in asin 1993 h e lp e d in cre a se o u r kn owle d ge o f th e so cia l an d p sych ological reaction s of p erson s n otified of th eir serop ositive statu s. Su ch in form ation is critical for d esign in g effective n otification an d cou n selin g p rogram s.
Diagnosis of HTLV-I/ II infection
Of 51,135 b lood d on ors from Fu n d ação Hem o-m in astested in 1993, 689 (1.35%) were rep eate d ly reate a ctiveate to H TLVI/ II a n tib o d ieate s b y eate n -zym e im m u n o a ssa y (EIA-Or th o ). Th e y h a ve b e e n in fo rm e d th a t o n ly H TLV-I is a sso cia te d with d iseases to d ate, an d th at cu rren t serolog-ica l te sts a re u n a b le to d iffe re n tia te b e twe e n HTLVI an d II. In th e USA, after th e im p lem en tation of b lood d on or screen in g, it b ecam e ap -p a re n t th a t m o re th a n h a lf o f H TLV se ro -p o si-tive d o n o rs we re in fe cte d with H TLV typ e II rath er th an typ e I (Lee et al., 1991). In ou r cou n
t r y, a lt h o u gh H TLVII wa s t h o u gh t t o b e e n -d e m ic a m o n g iso la te -d Bra zilia n Am e rin -d ia n s in Cen tral Brazil (Malon ey et al., 1992) an d th e Am a zo n Re gio n (Aze ve d o e t a l., 1994), H TLV-I/ II serop ositive b lood d on ors h ave b een fou n d in all region s of th e cou n try in a recen t n ation -al serologic-al su rvey (G-alvão et -al., 1995).
In view of th e h igh d egree of cross-reactivi-ty of cu rren t HTLV-I assays for HTLV-II, th e ex-trem ely low d isease association , an d th e u n cer-tain ty ab ou t th e availab ility of HTLV-II tests, it is n o t su rp r isin g th a t th e Fo o d a n d Dru g Ad -m in istra tio n Co -m -m itte e d id n o t re co -m -m e n d sp ecific testin g for HTLV-II (Bian co & Tegm eier, 1993). It is e xp e cte d th a t m a n u fa ctu re rs will soon su b m it tests th at are sen sitive an d sp ecif-ic e n o u gh to d istin gu ish b e twe e n H TLV-I a n d HTLV-II at n o extra cost.
Th e EIA te sts a re h igh ly se n sitive, th e re b y m in im izin g th e n u m b e r o f fa lse n e ga tive re -su lts. A m o re sign ifica n t p ro b le m with EIA is th e la ck o f sp ecificity th a t in crea ses th e likeli-h o o d o f fa lse-p o sitive resu lts. To d ifferen tia te fa lse p ositive resu lts from th e tru e p ositives, a m ore sp ecific test, th e Western b lot, is u sed . In
Fu n d a çã o Hem om in a s, o f 229 H TLV-I/ II rea c-tive sam p les tested by Western b lot, 37 (16.2%) we re p o sitive, 88 (38.4%) we re n e ga tive, a n d 104 (45.4%) were in d eterm in a te (Pa sso s et a l., 1995).
Beca u se u n certa in ty p ro d u ces grea t stress in p a tien ts with in d eter m in a te resu lts, p h ysi-cia n s sh o u ld in fo rm d o n o rs th a t th e m a jo rity o f in d ivid u a ls tested with o n e set o f co m m er-cia lly a va ila b le rea gen ts a re n o t in fected with HTLV (Kwok et al., 1990).
Counseling about transmission
Ou r cu rren t in fo rm a tio n in d ica tes th a t H TLV-I/ II serop ositive d on ors sh ou ld b e in form ed of th e d iseases associated with th e viru s, an d th at it is u n like ly th a t th e y will su ffe r a n y co n se -q u e n ce s fro m th e in fe ctio n . Th e y sh o u ld a lso b e in fo rm e d a b o u t th e fo rm s o f tra n sm issio n of th e viru s (CDC, 1993).
An im p o rta n t p o in t is in fo r m in g d o n o rs th a t H TLVI a n d II d iffe r fro m th e h u m a n im -m u n od eficien cy viru s (HIV), wh ich cau ses th e acq u ired im m u n od eficien cy syn d rom e (AIDS).
Cad . Saúd e Púb lic a, Rio d e Jane iro , 14(2):417-420, ab r-jun, 1998 2) n o t d o n a te b lo o d , se m e n , b o d y o rga n s, o r
o th er tissu es; 3) n o t sh a re n eed les o r syrin ges wit h a n yo n e ; 4) n o t b re a st - fe e d in fa n t s; a n d 5) co n sid e r u se o f la te x co n d o m s to p re ve n t sexu al tran sm ission .
In a d evelop in g cou n try like Brazil, each of th e a b ove req u ires sp ecia l a tten tio n . First, we a re rem in d ed on ce a ga in th a t th e lifesu sta in -in g b e n e fits o f b lo o d tra n sfu sio n a re n o t a ch ie ve d with o u t r isk. Th e d e cisio n to tra n s-fu se m u st b e critica lly eva lu a ted a n d th e in d i-cation s u n eq u ivocal.
Su p p lem en ta r y la b o ra to r y tests sh o u ld b e availab le an d free in all h em oth erapy services. Pu b lic h ealth au th orities m u st p rovid e sp ecial-ize d se r vice s fo r a ssistin g H TLV se ro p o sitive d on or can d id ates. Su ch cen ters m u st b e cap ab le of p erform in g con firm atory tests an d con -ven ien t clin ical follow-u p.
Elim in a tin g th e sh a re d u se o f n e e d le s o r syrin ge s is a n im p o r ta n t m e a su re fo r b o th serop ositive d on or can d id ates an d h ealth service s wh ich re u t ilize su ch m a t e ria ls. In Nige -ria , th is p ra ctice h a s b een fo u n d to b e a n ovel fo r m o f risk b e h a vio r fo r H IV tra n sm issio n (Macau lay et al., 1993). Su rveillan ce m easu res sh o u ld b e im p rove d to p re ve n t th is p ra ctice, wh ich is also com m on in Brazil.
Pa rticu la r a tte n tio n sh o u ld b e d ire cte d to cou n selin g wom en of ch ild b earin g age, d u e to th e kn owle d ge th a t ATL is la rge ly a co n se -q u en ce o f ch ild h o o d in fectio n (Mu rp h y et a l., 1989). In a co u n tr y with se rio u s so cia l p ro b -le m s, in clu d in g u n d e r n o u rish e d in fa n ts a n d ch ild ren , th e b en efits of b reast-feed in g u su ally o u twe igh th e risks o f viru s tra n sm issio n . To p re ve n t sta r va tio n a n d d e cre a se H TLV tra n s-m ission , cou n selin g s-m oth ers to b reast-feed for 6 m o n th s co u ld b e a d visa b le, sin ce tra n sm is-sio n o f th e viru s in cre a se s fro m 7 m o n th s o f a ge o n wa rd s (Hin o e t a l., 1985). An o th e r su g-ge stio n wo u ld b e to p a ste u rize o r sim p ly b o il th e b reast m ilk in ord er to in activate th e viru s. Use o f la tex co n d o m s is reco m m en d ed fo r d o n o rs with m u ltip le se xu a l p a r tn e rs. Fo r d on ors with a m on ogam ic stab le relation sh ip, it is ad visab le to test th e p artn er for HTLV an d u se p re ve n tive m e a su re s if th e p a rtn e r is seron egative. For cou p les wish in g to h ave ch il-d ren , con il-d om u se is still recom m en il-d eil-d , excep t d u rin g th e wom an’s fertile p eriod .
HTLV I AND II AND BLO O D DO NO RS 419
Emotional reactions and counseling HTLV-I/ II seropositive blood donors
Mo st o f th e resea rch o n th e p sych o lo gica l im -p a ct o f re troviru s in fe ctio n in -p e rso n s id e n ti-fied as serop ositive th rou gh rou tin e screen in g p erta in s to H IV in fectio n (Clea ry et a l., 1993), wh ich e n ta ils gre a te r risk o f d e ve lo p m e n t o f d isea se th a n H TLV-I/ II. In o u r service, severa l e m o tio n a l re a ctio n s we re n o tice d d u r in g fo l-low-u p of m ore th an 300 HTLV-I/ II serop ositive d on ors. Th e ways we h ave m an aged th ese reaction s are very im p ortan t. Th e followin g recom -m en d ation s are b ased on ou r exp erien ce: 1) Hom ogen eou s orien tation an d in form ation sh ou ld b e given to d on ors by all h ealth workers in volved in cou n selin g.
2) Co u n se lin g sh o u ld b e co n tin u o u sly d is-cu ssed a n d revised b a sed on n ew exp erien ce. Ch an ges sh ou ld b e record ed in writin g, b a sed on grou p con sen su s.
3) Le ve l o f sch o o lin g sh o u ld b e co n sid e re d an d in form ation p rovid ed accord in gly. It is n ot a d visa b le to give m o re in fo rm a tio n th a n d e -m an d ed by th e d on or in ord er to p reven t ad d itio n a l stress a n d m isu n d ersta n d in g. In fo rm a tion sh ou ld b e p rovid ed on th e b asis of in d ivid u al req u irem en ts an d read in g m aterial p rovid -ed if req u est-ed , b as-ed on level of sch oolin g. 4) Do n o rs sh o u ld b e a ssiste d in th e ir u n d e r-sta n d in g in ord er to a llow for a critica l a ssess-m en t of ssess-m ed ia in forssess-m ation , in clu d in g con tra-d ictory an tra-d sen sation alist tra-d ata.
5) Psych o lo gica l a n d / o r p sych ia tric ca re sh o u ld b e p rovid e d fo r e xtre m e ly a n xio u s o r d ep ressed d on ors, wh o h ave frequ en tly exp eri-en ced p reviou s em otion al disorders (Markowitz et al., 1994).
6) Don ors with stab le p artn ers sh ou ld receive jo in t co u n se lin g if so d e sire d . We h a ve o b -ser ved th a t th is h elp s red u ce b o th th e level o f stress an d n u m b er of su b seq u en t session s.
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