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| ## #03-14                                                             |
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|   **Date:**   October 10, 2003                                        |
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|   **To:**     AABB Members                                            |
|                                                                       |
|   **From:**   Roger Y. Dodd, PhD - President\                         |
|               Karen Shoos Lipton, JD - Chief Executive Officer        |
|                                                                       |
|   **Re:**     Deferral for Risk of Leishmaniasis Exposure             |
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|                                                                       |
| Due to the risk of transfusion-transmitted leishmania, blood          |
| collection facilities should begin deferring prospective donors who   |
| have been to Iraq as soon as possible, but no later than October 30,  |
| 2003. The deferral is effective for 12 months from the last date of   |
| departure from Iraq. The Armed Services Blood Program (ASBP) has      |
| reported cases of leishmaniasis among personnel stationed in Iraq and |
| is implementing a 12-month deferral for individuals who have traveled |
| to Iraq. The ASBP has required that this deferral be implemented by   |
| all armed services blood collection facilities by October 30, 2003.   |
|                                                                       |
| Armed services personnel, especially members of the National Guard,   |
| often donate regularly at civilian facilities. Therefore, all blood   |
| collection facilities should implement this deferral no later than    |
| October 30, 2003, for consistency with the ASBP policy. The deferral  |
| applies to the whole country of Iraq and includes any civilians,      |
| contractors, or other individuals who have visited the country, in    |
| addition to service personnel stationed there.                        |
|                                                                       |
| A similar deferral was in effect from August 1, 1990 to January 1,    |
| 1993 as a result of Operation Desert Storm. As was the case from 1990 |
| to 1993, blood collection facilities are not required to ask donors   |
| specifically whether they have visited Iraq because donors are asked  |
| about their travel outside of the United States and Canada in the     |
| past 3 years. A response that indicates the donor has traveled to     |
| Iraq should be considered reason for a 12-month deferral from the     |
| last date of departure from Iraq.                                     |
|                                                                       |
| The impact of this deferral on the blood supply is expected to be     |
| significant, although it is difficult to project the exact number of  |
| donors who will be deferred. The heightened concern over Iraq is a    |
| result of the large number of individuals likely to have been exposed |
| to leishmaniasis that are expected to return to the U.S. in the near  |
| future.                                                               |
|                                                                       |
| There are no expectations that look-back will be necessary at this    |
| time. In addition, it should be noted that donors of plasma intended  |
| for further manufacture need not be similarly deferred.               |
|                                                                       |
| **Background**\                                                       |
| *Leishmania* spp. are intracellular protozoan parasites that cause    |
| leishmaniasis. As a group, they cause a spectrum of disease in humans |
| that ranges from simple, self-curing cutaneous lesions to visceral    |
| infections associated with parasitism of the reticuloendothelial      |
| system^1^.                                                            |
|                                                                       |
| The *Leishmania* spp. are primarily endemic to the subtropical and    |
| tropical areas of the Middle East, Mediterranean coast, Asia, Africa, |
| Central America and South America. The parasite is transmitted to     |
| humans through the bite of a *Leishmania*-infected sand fly. The      |
| incubation period can vary from days to years, but detectable         |
| infections generally appear within months of infection. Thus, the     |
| one-year deferral period should be sufficient to prevent the          |
| collection of blood from a *Leishmania*-infected, yet asymptomatic    |
| donor, in virtually all cases. However, this deferral period does not |
| rule out the possibility of rare, asymptomatic, chronic carriers,     |
| although scientific evidence of such carriers remains equivocal.      |
|                                                                       |
| There have been at least 10 probable or confirmed cases of            |
| transfusion-transmitted leishmaniasis reported in the                 |
| literature^2-9^. Several of these cases occurred more than 40 years   |
| ago and the majority of infected recipients were young children or    |
| neonates. In all cases where *Leishmania* spp. were identified,       |
| infections were attributed to either *L. donovani* or *L. infantum*,  |
| which cause visceral disease. In Iraq, leishmaniasis appears in       |
| cutaneous and visceral forms that are caused by several species of    |
| *Leishmania*. At this time it is unclear what species of *Leishmania* |
| U.S. military personnel have been exposed to in Iraq, but based on    |
| the literature and past experience with *L. tropica*, all species     |
| should be of concern. *Leishmania tropica* has been proven to survive |
| for at least 25 days in blood products stored under standard          |
| conditions^10^.\                                                      |
| \                                                                     |
| Conditions in Iraq have produced an environment favorable to sand fly |
| reproduction and positive vector monitoring indicates sand flies are  |
| infected with *Leishmania* spp. Several cases of leishmaniasis have   |
| recently been diagnosed in U.S. armed services personnel deployed to  |
| Iraq.                                                                 |
|                                                                       |
| [References]{.underline}                                              |
|                                                                       |
| 1.  Herwaldt BL. Leishmaniasis. Lancet 1999;354:1191-9.               |
|                                                                       |
| 2.  Magill AJ, Grögl M, Gasser RA, et al. Visceral infection caused   |
|     by *Leishmania tropica* in veterans of Operation Desert Storm. N  |
|     Engl J Med 1993;328:1383-7.                                       |
|                                                                       |
| 3.  Chung H-L, Chow H-K, Lu J-P. The first two cases of transfusion   |
|     kala-azar. Chinese Med J 1948;66:325-6.                           |
|                                                                       |
| 4.  André R, Brumpt L, Dreyfus B, et al. Cutaneous leishmaniasis,     |
|     cutaneous-glandular leishmaniasis and transfusional kala-azar.    |
|     Trop Dis Bull 1958;44:379-81.                                     |
|                                                                       |
| 5.  Kostmann R, Barr M, Bengtsson E, et al. Kala-azar transferred by  |
|     exchange blood transfusions in two Swedish infants. Proceedings   |
|     of the Seventh International Congress of Tropical Medicine and    |
|     Malaria. 1963;2:384.                                              |
|                                                                       |
| 6.  Cohen C, Corazza F, De Mol P, Brasseur D. Leishmaniasis acquired  |
|     in t Belgium (letter). Lancet 1991;338:128.                       |
|                                                                       |
| 7.  Mauny I, Blanchot I, Degeilh B, et al. \[Visceral leishmaniasis   |
|     in an infant in Brittany: Discussion on the modes of transmission |
|     outside of the endemic zone\]. Pediatrie 1993;48:237-9.           |
|                                                                       |
| 8.  Cummins D, Amin S, Halil O, et al. Visceral leishmaniasis after   |
|     cardiac surgery. Arch Dis Child 1995;72:235-6.                    |
|                                                                       |
| 9.  Singh S, Chaudhry VP, Wali JP. Transfusion-transmitted kala-azar  |
|     in India. Transfusion 1996;36:848-9.                              |
|                                                                       |
| 10. Grögl M, Daugirda JL, Hoover DL, et al. Survivability and         |
|     infectivity of viscerotropic *Leishmania tropica* from Operation  |
|     Desert Storm participants in human blood products maintained      |
|     under blood bank conditions. Am J Trop Med Hyg 1993;49:308-15.    |
|                                                                       |
| [**Association Bulletin                                               |
| #03-14**](http://                                                     |
| www.aabb.org/Members_Only/Archives/Association_Bulletins/ab03-14.pdf) |
| **(PDF Format)**                                                      |
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