1 Armed Services Blood Program Update COL Frank Rentas Director, Armed Services Blood Program Office 2009 Society.

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Armed Services Blood ProgramUpdate

COL Frank RentasDirector, Armed Services Blood Program Office

www.militaryblood.dod.mil UNCLASSIFIED

2009 Society of Armed Forces Medical Laboratory Scientists

Annual Meeting

Reno, Nevada23 March 2009

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ASBPO Organizational Structure Service Blood Program Officers COCOM JBPOs OIF/OEF Blood Transfusion Statistics Background- Whole Blood Background- Platelets Blood Product Availability Current Policy/Guidance for HIV, HBV, HCV Screening Prior to

Deployment Transfusion-Transmitted Disease Residual Risk Estimates Transmission Countermeasures Current Initiatives Frozen Blood use in Theater Improved Rapid Test Kits DBSS Fresher Blood in Theater Non-FDA Compliant Transfusions Visit to Iraq


Agenda

3www.militaryblood.dod.mil UNCLASSIFIED

ASBPO Organizational Structure

DirectorCOL Francisco J. Rentas

Blood Donor Recruiter Supervisor

Mr. Marty Ricker

Deputy Director, Information Technology

Mr. Don Dahlheimer

Communications and Marketing

Ms. Julie Oliveri

Administrative SpecialistMs. Ginger-Rogers Bass

Deputy Director, Operations

MAJ David Lincoln

Deputy Director, Policy

LCDR Corey Jenkins

Blood Donor RecruitersMarketing Specialist

Ms. Melissa YuNCOIC

SFC Peter Maas

# Military: 4

# Civilians: 25 (5 at ASBPO, the rest all over the world)

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Air Force Blood ProgramDirector: Lt Col Dianne Davis

QA Manager: Maj George HestilowMedical Consultant: Lt Col Joseph P.R. Pelletier

Navy Blood ProgramDirector: CDR Brian Williamson

QA Manager: Ms. Kathleen WhitlockMedical Consultant: CDR Karin M. Hollis-Perry

Army Blood ProgramDirector: LTC Mike Lopatka

QA Manager: Ms. Kathleen ElderAssistant QA Manager: Mr. Dave Reiber

Medical Consultant: LTC Frank Chiricosta

Service Blood Program Officers


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COCOM JBPOs


USEUCOM – MAJ Jose Quesada, USA, Landstuhl, GE

USPACOM –CDR Roland Fahie, USN, Camp H. M. Smith, HI

USCENTCOM – LtCol Richard McBride, USAF, Tampa, FL MAJ Kristine Fumia, USAF, CAOC Qatar

USNORTHCOM – LTC Jonathan Branch, USA, JFHQ, Peterson AFB CO

USSOUTHCOM – Mr. Walter I. Diaz, DAC, Miami, FL

http://upload.wikimedia.org/wikipedia/commons/6/65/USCENTCOM.jpg

http://en.wikipedia.org/wiki/Image:United_States_Northern_Command_emblem.png

http://en.wikipedia.org/wiki/Image:USSOUTHCOM_emblem.jpg

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As of 31 December 2008

OIF/OEF Blood Transfusion Statistics

OIF - 58% reduction in the monthly average of blood products transfused during the last 12 months as compared to 2007

OEF - 23% increase in the monthly average of blood products transfused as well as a 31% increase in red cells during the last 12 months as compared to 2007

Total U.S. Only Non-U.S.Percent

U.S. OnlyPercent

Non-U.S.

Transfused Patients 20,829 4,762 16,067 22.9% 77.1%

WB 6,705 3,571 3,134 53.3% 46.7%

RBCs 112,736 29,494 83,242 26.2% 73.8%

Platelets 5,532 1,857 3,675 33.6% 66.4%

FFP 59,516 16,837 42,679 28.3% 71.7%

CRYO 14,774 5,341 9,433 36.2% 63.8%


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Whole blood (WB) has been used extensively to resuscitate casualties in military conflicts since World War I

As of 31 December 2008, 3,571 whole blood units have been transfused in theater to 497 US patients

One documented emergency transfusion associated HCV transmission

76% of WB transfusions have taken place in Level II+ facilities (2006-2008)

WB transfusions are down 81.5%, and 83.4% from 2007 and 2006 respectively

Samples for retrospective testing collected on most donations Current JTTS CPG on Whole Blood – Updated November 2008

WB is neither intended nor indicated for routine use WB is to be used only when other blood products are unable

to be delivered at an acceptable rate to sustain the resuscitation of an actively bleeding patient or when specific components are not available


Background- Whole Blood



OIF/OEF COMBINED*

308

1086851

21661948

333

0

500

1000

1500

2000

2500

YEAR

WH

OL

E B

LO

OD

T

RA

NS

FU

SIO

NS

2003 2004 2005 2006 2007 2008

*Includes all transfusions until 31 December 2008 (US and Non-US)



OIF LEVEL III17%

OEF LEVEL III7%

OIF LEVEL II65%

OEF LEVEL II11%

OIF LEVEL III

OEF LEVEL III

OIF LEVEL II

OEF LEVEL II

Whole Blood Transfusions 2006-2008 OIF/OEF



Whole Blood Transfusions 2006-2008 OIF



Whole Blood Transfusions 2006-2008 OEF

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As of 31 December 2008, 1,857 Platelet (PLT) units have been transfused in theater to 744 US patients

Collections in much more controlled environments than WB All collections at level III facilities Donors are pre-screened with all FDA-mandated tests before

allowed to donate Donors normally allowed to donate every two weeks Samples for retrospective testing collected during every donation HIV, HBV, and HCV Rapid testing of most donations Products tested for bacterial contamination

84% of PLT transfusions have taken place in Level III facilities (2006-2008)

PLT transfusions are down 46.5%, and 37.2% from 2007 and 2006 respectively

Current JTTS CPG on Damage Control Resuscitation addresses use of PLTs - Updated February 2009

1:6 PLT/RBC ratio memo signed by Army TSG- February 2009


Background- Platelets



OIF/OEF COMBINED*

0 25

940

1601

1879

1043

0

300

600

900

1200

1500

1800

2100

2400

YEAR

PL

AT

EL

ET

TR

AN

SF

US

ION

S

2003 2004 2005 2006 2007 2008

*Includes all transfusions until 31 December 2008 (US and Non-US)



OIF LEVEL III80%

OEF LEVEL III4%

OIF LEVEL II15%

OEF LEVEL II1%

OIF LEVEL III

OEF LEVEL III

OIF LEVEL II

OEF LEVEL II

Platelets Transfusions 2006-2008



Platelets Transfusions 2006-2008 OIF



Platelets Transfusions 2006-2008 OEF

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Level III MTFs Red Blood Cells - all blood types but AB Fresh Frozen Plasma - all blood types Cryoprecipitate Platelets Fresh Whole Blood – as needed for emergencies. Destroyed if not

used within 24 hours Level II+ (18 in OIF, 13 in OEF)

Red Blood Cells – mostly Os Fresh Frozen Plasma – 12 MTFs in OEF, 10 in OIF, mostly A and

AB Platelets – very limited, 4 in OIF, one in OEF Fresh Whole Blood – as needed for emergencies. Destroyed if not

used within 24 hours Level II (no surgical capability) and I – No blood products

delivered* * SOF teams have blood available during missions


Blood Product Availability

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HIV Current USCENTCOM Individual Protection and

Individual/Unit Deployment Policy (MOD Nine, September 2008) requires that HIV screening be performed within 90 days of deployment

HBV No current policy/guidance for screening prior to

deployment. Current USCENTCOM Individual Protection and Individual/Unit Deployment Policy (MOD Nine, September 2008) requires all deploying military personnel to be vaccinated against both Hepatitis A and B

HCV No current policy/guidance for screening prior to deployment


Current Policy/Guidance for HIV, HBV, HCV

Screening Prior to Deployment


Transfusion-Transmitted Disease Residual Risk Estimates

US Military Donors Seroprevalence US Military Rapid Screen Residual Risk (New test

kits)

US FDA-Cleared Testing Residual Risk

HIV:Medical Surveillance Report 2008 - ArmyActive 1:5882ANG 1:4167AR 1:2381Retrospective testing of 17,387 samples

from actual donors in theater (caveat sample integrity):

No HIV cases identified

OraQuick Advance, WB, kit insert Sensitivity =99.6%

1:1,470,5001:1,041,7501:595,250No cases

Bihl J Trans Med 20071:2,135,000

HCV:Hyams et al. Am J Epi 2001Military 1:208Retrospective testing of 17,387 samples


Military 1:1932

Axiom, WB, Sensitivity =95.2%1:43331:40,250

Bihl J Trans Med 20071:1,930,000

HBsAg:Retrospective testing of 17,387 samples


Military 1:2898

First Vue, WB, Sensitivity =84.3%1:18,458

Bihl J Trans Med 20071:277,000


Transmission Countermeasures

HIV HCV HBVForce Screen 2 years - -

Theater Entrance 90 days - -

Vaccination Not Available Not Available Required by all Services

Pre-Screens ** Yes Yes Yes

Retrospective Testing Yes Yes Yes

Improved Rapid Testing

Yes Yes Yes

** For all PLTs and some WB collections

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HBV seroprevalence/seroincidence study of recently deployed forces to define epidemiology of HBV in deployed force pending USACHPPM EPICON per CENTCOM SG request to JS

HCV seroprevalence study of recently deployed forces to define epidemiology of HCV in deployed force pending USACHPPM EPICON per CENTCOM SG request to J4S

Draft HA policy to address rapid testing, pre-screening, retrospective testing, and follow up of recipients

Increasing fresh frozen plasma availability at level II+ facilities Making improved rapid test kits available at level II+ facilities Increasing number of facilities collecting apheresis platelets Deglycerolized RBCs available Shipments directly from BTC to Kandahar Navy laboratory technicians assigned to BSD in ATO


Current Initiatives

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Frozen Blood Use in Theater

www.militaryblood.dod.mil

FDA-approved product: 10 year expiration Tested with all FDA-required tests Frozen fresh (w/6 days): storage lesion issue DoD freezing – ASBPO monitoring production/use Deglycerolized: 14 day expiration Supplement to liquid red cells Washed product (↓ leukocytes; removes plasma

proteins and cytokines which have been involved recently with ↑ infections in transfused recipients)

Being transfused at all 3-level III trauma centers

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Much improved Hepatitis C and Hepatitis B kits are now available in theater

Level III MTFs and Blood Support Detachments Blood personnel making them available to level II+ facilities

Intent is to test as many whole blood units as possible and all platelet collections in theater before transfusion

HIV rapid test kits continue to perform with high degree of specificity and sensitivity

New Rapid Test Kits in Theater

www.militaryblood.dod.mil

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DBSS COTS


Armed Services Blood Program


Fresher Blood to Theater

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Non-FDA Compliant Transfusions

Past Thank you for your support.

Present 1096 Individuals in system 20 Countries 7 countries presently linked into the Non-FDA database system Process on track and monitored closely

Future Incorporate NATO countries - future conflicts Establish international agreement for the exchange of

transfusion related information. Incorporate Veterans Administration into system


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Balad


Fresher blood (<15 days old) shelf

Deglycerolized Red Cell units (frozen red cells)

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BTC Qatar working nights


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Good Luck!!

Best Wishes!!

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Thanks for everything you do to take care of our customers!!

1 Armed Services Blood Program Update COL Frank Rentas Director, Armed Services Blood Program Office 2009 Society.

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