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Contents : WNV BLOOD TRANSFUSION-RELATED INFECTIONMACEDO DE OLIVEIRA ET AL. Blackwell Science LtdOxford UKTRFTransfusion0041-11322004 American Association of Blood BanksDecember 2004441216951699Case Report TRANSFUSION COMPLICATIONS West Nile virus blood transfusion-related infection despite nucleic acid testing Alexandre Macedo de Oliveira Brady D. Beecham Susan P Montgomery Robert S. Lanciotti . Jeffrey M. Linnen Cristina Giachetti Larry A. Pietrelli Susan L. Stramer and Thomas J. Safranek BACKGROUND: A case of West Nile virus (WNV) encephalitis associated with transfusion of blood that did not react when tested for WNV by minipool (MP) nucleic acid testing (NAT) is described. A Nebraska man developed clinical encephalitis 13 days after surgery and transfusion of 26 blood components. Antibody testing con rmed WNV infection. An investigation was initiated to determine the source of this infection. STUDY DESIGN AND METHODS: The patient s family members were interviewed to identify risk factors for WNV infection. Residual samples were retested for WNV RNA using transcription-mediated ampli cation (TMA) assay and two polymerase chain reaction (PCR) assays. Blood donors follow-up serum samples were collected. All samples were tested for WNV-speci c immunoglobulin M antibodies. RESULTS: The patient s family denied recent mosquito exposure. The 20 blood components collected after July 2003 did not react when tested for WNV in a six-member MP-NAT at the time of donation. Retrospective individual testing identi ed one sample as WNV-reactive by the TMA assay and one of the PCR assays. Seroconversion was demonstrated in the donor associated with this sample. CONCLUSION: WNV RNA detection by individual donation NAT demonstrates viremic blood escaping MPNAT and supports transfusion-related WNV transmission. MP-NAT may not detect all WNV-infected blood donors allowing WNV transmission to continue at low levels. WNV NAT assays might vary in sensitivity and pooling donations could further impact test performance. Understanding MP NAT limitations can improve strategies to maintain safety of the blood supply in the United States. W est Nile virus (WNV) a mosquito-borne avivirus was initially seen in the US in 1999 and rst reported among Nebraska residents in 2002.1 2 Humans serve as incidental hosts and most infections are asymptomatic approximately 30 percent of infections result in a nonneuroinvasive disease known as West Nile fever and less than 1 percent of infected individuals develop severe diseases such as meningitis and/or encephalitis.3-5 In the US a total of 9862 human cases of WNV disease were reported in 45 states and the District of Columbia in 2003. Nebraska reported more than 1900 human WNV cases in 2003 ranking second only to Colorado.6 Blood transfusion-related transmission of WNV infection during the 2002 US epidemic prompted rapid development of two investigational nucleic acid testing (NAT) assays to screen donated blood for WNV viremia: the TaqScreen WNV test (Roche ABBREVIATIONS: IDT individual donation testing IND investigational new drug MP(s) minipool(s) PRNT plaque reduction neutralization test SLE St Louis encephalitis WNV West Nile virus. From the Epidemic Intelligence Service Division of Applied Public Health Training Epidemiology Program Of ce Centers for Disease Control and Prevention Atlanta Georgia the Of ce of Epidemiology Nebraska Health and Human Services System Lincoln Nebraska the Division of Vector-Borne Infectious Diseases National Center for Infectious Diseases Centers for Disease Control and Prevention Fort Collins Colorado GenProbe Inc. San Diego California Roche Molecular Systems Inc. Pleasanton California and the American Red Cross Gaithersburg Maryland. Address reprint requests to: Thomas J. Safranek Nebraska Health and Human Services 301 Centennial Mall South PO Box 95007 Lincoln NE 68509-5007 e-mail: tom.safranek@hhss.state.ne.us. Received for publication April 9 2004 revision received June 14 2004 and accepted June 30 2004. TRANSFUSION 2004 44:1695-1699. Volume 44 December 2004 TRANSFUSION 1695 MACEDO DE OLIVEIRA ET AL. Molecular Systems Inc. Pleasanton CA) and the Procleix WNV assay (Gen-Probe Inc. San Diego CA).7 8 (Use of trade names is for identi cation purposes only and does not constitute endorsement by the US Public Health Service or the Centers for Disease Control and Prevention CDC .) The tests were implemented between June and August 2003.9 10 Because of automation constraints the tests are performed with minipools (MPs) of either six (TaqScreen assay) or 16 (Procleix assay) donations. A limited number of blood centers have the capacity to routinely screen by individual donation testing (IDT) in addition some programs converted to IDT for limited periods during the 2003 epidemic. Donated blood from reactive pools is individually retested to identify the WNVreactiv

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