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Trends in incidence of AIDS associated with transfusion of blood and blood products in Europe and the United States, 1985-93

^a Servizio di Epidemiologia, Centro di Riferimento Oncologico, 12, 33081 Aviano, Italy, ^b Istituto di Ricerche Farmacologiche "Mario Negri," Milan, Italy

Correspondence to: Dr Franceschi.

Abstract

Objective: To quantify patterns and trends in incidence of AIDS associated with transfusion of blood and its products in 14 European countries and the United States.
Design: Data were derived from the World Health Organisation's European non-aggregate AIDS dataset and, for the United States, from the Centers for Disease Control AIDS public information dataset. Rates were standardised by using the world standard populations and adjusted for reporting delays in each country.
Subjects: Cases of AIDS in patients with haemophilia and recipients of transfusions.
Results: Overall, between 1985 and 1993 almost 6000 cases of AIDS associated with transfusions were registered in the 14 European countries considered and over 8000 in the United States between 1985 and 1992. Most European countries had annual age adjusted rates lower than 0.5 per million children aged 12 or less and between 1 and 2 per million adults. The United States had rates around 1 per million children and 5 per million adults in the most recent period. For children, the highest rates were generally reached in 1985-7, whereas in adults the highest rates were in the late 1980s. France had the highest overall incidence of AIDS related to transfusion in Europe (3.3 per million). Romania had a major epidemic in children (over 30 cases per million children in 1988-90). Incidence rates of AIDS associated with transfusion were still increasing in some southern European countries in the early 1990s.
Conclusions: Apart from in France and Romania it is clear that rates of bloodborne AIDS in European countries are lower than those registered in the United States.

Introduction

The issue of AIDS transmission through blood and its products has been recognised since the early 1980s, before the identification of the causative agent, HIV.¹ Between 1983 and 1985 major steps were taken to control a bloodborne HIV epidemic,² but the schedules and the degree of adoption of these measures have been different in various European countries as compared with in the United States.^{3 4 5 6 7 8 9 10}

Although several problems--for example, underreporting, inaccuracies in HIV transmission categories, lack of information on the timing of and reason for transfusion, etc--hamper the comparison of incidence of AIDS in different areas, this report represents an attempt to assess systematically cases of AIDS in haemophilic patients and transfusion recipients in different European countries and, for a comparison, in the United States in terms of age standardised incidence rates.

Materials and methods

For European countries, official AIDS notification data for the period 1985-93 were derived from the European non-aggregate AIDS dataset (ENAADS) up to March 1994. Data on the United States were derived from the AIDS public information dataset (PIDS) up to June 1993.^{11 12 13 14 15} Countries which in the examined period reported fewer than 50 bloodborne AIDS cases or did not send disaggregated data to ENAADS were not included. Rates were standardised for age^{10 16} and corrected for reporting delay^{7 17} in each country.

Results

Table 1 gives the number of cases of AIDS associated with blood and its products in various countries overall and by sex, age group, and transmission category (transfusion recipients and patients with haemophilia). Data are adjusted for delays in reporting. The figure shows the number of cases and age adjusted rates of bloodborne AIDS over the period 1985-93 in the 14 European countries considered and the United States, together with proportions of haemophilic patients and transfusion recipients. The burden of HIV infection was especially heavy in transfusion recipients in France and in Romania, where they accounted for 74% and 98%, respectively, of cases associated with blood or its products.

Table 1--Distribution of AIDS cases associated with blood and blood products by country, sex, age, transmission
category, and percentages of total AIDS cases, 1985-93
---------------------------------------------------------------------------------------------------------------
                                                               Transmission category    Proportion
                        Sex             Age (years)           -----------------------    of total
------------------------------------------------------------  Haemophilic  Transfusion  AIDS cases
Country            Male    Female    0-12    13-49   >/=50      patients   recipients      (%)
---------------------------------------------------------------------------------------------------------------
Austria             69       17        5      65      16           60          26          7.5
Belgium             49       45       11      57      26            9          85          6.0
Denmark             43       12        0      37      18           34          21          4.0
France            1213      713       95     949     881          417        1509          5.9
Germany            552      136       23     471     193          431         257          5.7
Greece              90       19        9      79      21           67          42         12.2
Italy              393      108       25     357     119          230         271          2.3
Netherlands         77       20       11      55      31           55          42          3.2
Portugal            99       33       11      89      32           50          82          6.1
Romania            374      280      630      20       4           13         641         23.9
Spain              655      142       65     557     175          529         268          2.8
Sweden              59       12        2      26      43           32          39          7.2
Switzerland         54       24        2      44      32           25          53          1.9
United Kingdom     466       76       26     411     105          439         103          5.7
United States*    5777     2246      493    4308    3223         2401        5623          2.8
---------------------------------------------------------------------------------------------------------------
*1985-92.

Table 2 shows annual incidence rates in children aged 0-12 years and adults and by HIV transmission category for three subsequent calendar periods. In children the highest rates were generally observed in 1985-7 or 1988-90 and declined thereafter. In 1991-3 three European countries, besides Romania, showed incidences above 0.5 per million children: France, Portugal, and Belgium. In adults, France showed the highest incidence rates over the examined period, similar to those seen for the United States. Adult incidence rates peaked in 1988-90 in Sweden, Switzerland, and the United Kingdom, as well as in France and the United States. Conversely, no clear decline was seen in other European countries, and upward trends persisted up to 1991-3 in Denmark, Italy, Portugal, and Spain. The separate inspection of data on haemophilic patients and transfusion recipients revealed generally consistent patterns. Recent declines in the numbers of AIDS cases associated with transfusions were seen in France and the United States, whereas an upward trend persisted in several southern European countries.

View larger version (36K): [in this window] [in a new window]   Total number and age standardised annual incidence rates of cases of AIDS associated with blood and blood products per million by country and transmission category, 1985-93

Table 2--Annual incidences of AIDS cases associated with blood and blood products per million (age standardised, world)
by country, age group, transmission category, and time
------------------------------------------------------------------------------------------------------------------------------
                    Children (0-12 years)              Adults               Haemophilic patients        Transfusion recipients
------------------------------------------------------------------------------------------------------------------------------
Country           1985-7  1988-90  1991-3   1985-7   1988-90   1991-3   1985-7   1988-90   1991-3   1985-7   1988-90   1991-3
------------------------------------------------------------------------------------------------------------------------------
Austria            0.53    0.76     0.00     0.94     1.71      1.98     0.62     0.95      1.18     0.21     0.50      0.26
Belgium            0.25    1.28     0.50     0.82     1.17      1.38     0.00     0.23      0.15     0.66     0.98      0.99
Denmark            0.00    0.00     0.00     1.17     1.27      1.89     0.67     0.52      0.98     0.18     0.40      0.39
France             1.11    0.90     0.74     2.29     5.10      5.05     0.39     1.00      1.15     1.58     2.95      2.72
Germany            0.34    0.14     0.13     0.79     1.34      1.39     0.47     0.74      0.63     0.20     0.27      0.41
Greece             0.27    0.53     0.45     0.89     1.81      1.97     0.51     0.78      1.04     0.21     0.68      0.51
Italy              0.27    0.32     0.18     0.53     1.29      1.74     0.27     0.53      0.61     0.19     0.49      0.70
Netherlands        0.40    0.32     0.37     0.29     0.96      1.03     0.11     0.46      0.57     0.20     0.33      0.28
Portugal           0.57    0.37     0.53     0.61     2.23      2.50     0.46     0.67      0.59     0.15     1.05      1.37
Romania            0.00   33.89    16.11     0.08     0.12      0.27     0.03     0.12      0.09     0.03     9.25      4.52
Spain              0.88    1.01     0.31     1.32     3.34      3.56     0.94     1.95      1.69     0.26     0.75      0.98
Sweden             0.18    0.19     0.00     0.99     1.29      0.65     0.34     0.47      0.38     0.43     0.52      0.09
Switzerland        0.00    0.25     0.28     0.45     2.14      1.88     0.15     0.67      0.56     0.18     0.95      0.89
United Kingdom     0.29    0.21     0.27     0.80     1.68      1.44     0.51     1.10      0.88     0.15     0.18      0.24
United States*     1.08    1.15     0.74     3.51     5.38      5.02     0.84     1.41      1.44     2.01     2.82      2.40
------------------------------------------------------------------------------------------------------------------------------
*1985-92.

Discussion

AIDS linked to blood and blood derivatives has been a major problem in Europe, at least up to the mid-1980s. Two European countries emerged with substantial excesses of AIDS cases. One was Romania, where the spread of AIDS among children was due to misuse of blood, blood products, and reusable non-sterilised needles (that is, nosocomial infection).^{5 6} The other was France, partly on account of the delay by French government officials in approving an American made blood test for HIV infection.^{3 4}

It is clear that transfusion recipients and haemophilics were differently represented in various countries on account of different degrees of safety achieved in blood supplies (generally from local donors) and supplies of factor VIII (mostly imported). The former accounted for more than 60% of cases of bloodborne AIDS in Belgium, Portugal, Switzerland, and France. Haemophilic patients predominated over transfusion recipients (>60%) in Denmark, Germany, Spain, and, most notably, in the United Kingdom.

The declines or at least the levelling off of rates of AIDS cases diagnosed in haemophilic patients and transfusion recipients in most European countries since the early 1990s, also in the lack of information on year of transfusion, is evidence of the favourable impact of control procedures and treatment of blood and its products from 1984 onwards.² As in the United States^{8 9} improvements were seen earlier in children largely because they have the shortest incubation period between infection and AIDS diagnosis^{18 19 20 21} and partly on account of the constraints of the incubation period imposed on this group by the definition of the age limit of 12 years. Some less encouraging patterns are, however, present among adults, with persisting upward trends in Denmark, Italy, and Spain.

Apart from France and Romania it is, however, clear that rates of bloodborne AIDS in other examined European countries are lower than those registered in the United States.

Data from the European non-aggregate AIDS dataset (ENAADS), version AIDS9403.DAT, prepared by the European Centre for the Epidemiological Monitoring of AIDS in Paris, was used in this study. Compilation of this data file was made possible by the continuing participation of clinical doctors in mandatory and voluntary national reporting schemes for AIDS cases. We wish to thank the National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, for AIDS public information dataset updated to June 1993; Dr Eva Negri for useful comments; Mrs Luigina Mei for editorial assistance; and Dr Angelo Lo Re and Mr Roberto Ricci for technical assistance.

Funding: This work was supported by two grants from the Ministero della Sanita-Istituto Superiore di Sanita, VIII Progetto AIDS contracts 9303-12 and 9303-31); it was conducted within the framework of a European Union project on sexually transmitted diseases and AIDS.

Conflict of interest: None.

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