The confidential unit exclusion (CUE) option in the process to screen blood donors
was conceived in the 1980s as a possible means to reduce the risk of transfusion transmission
of HIV before sensitive tests became available.(1) The use of CUE allows blood donors
at increased risk for HIV or other sexually-transmitted diseases who may feel pressured
to complete the donation, or who are inappropriately donating blood in order to be
tested, a chance to confidentially indicate that their blood should not be used for
allogeneic transfusion. CUE has been abandoned by blood centers in many countries
but is still voluntarily used or mandated in other jurisdictions. The centers that
have eliminated CUE largely based their decisions on published evidence that the process
did not improve safety and was more often misunderstood and incorrectly used by donors,
leading to the unnecessary waste of many safe donations.(2,3) The effectiveness of
CUE, however, could still differ among blood centers because of the various methods
to administer the CUE option, variability in the criteria to select blood donors of
the performance characteristics of laboratory tests, or disparate demographics among
donor populations. Consequently, blood centers that continue to use CUE, either as
a voluntary or compulsory measure, should evaluate its effectiveness in their donor
population.
To that end, Volger and colleagues report on the effectiveness of CUE in the screening
of blood donors of a regional blood bank of Londrina, Parana State.(4) The authors
evaluated the donors' use of CUE in 51,104 successful donations during the period
of January 2004 to December 2008. Their CUE instrument consists of 4 questions related
to intravenous drug use, sexual activity with a partner of the same gender, "professional
of sex" and occasional sexual partner. The frequency of positive serology was 5.3%
in the group that used CUE and 3.5% in the group that did not use CUE (χ2 =15.66;
p-value < 0.0001). Eighty-nine of 1672 donors who used the CUE option had at least
one reactive serological test result. Follow-up testing for 8 donors who had reactive
serological tests after a positive CUE donation failed to identify seroconversion
after self-exclusion: 4 of the 8 were falselyreactive for T cruzi antibodies (2 donors)
or anti-HCV (2 donors) and were readmitted for future donations, one had inconclusive
results for Chagas' disease, two were reactive for VDRL and one failed to return to
be tested for HIV1/2.
The results are consistent with other studies that found CUE associated with a higher
prevalence of reactive markers for HIV, HBV, HCV and syphilis, but having only minimal
ability to prevent the collection of window period units.(2,3) For example, Zou et
al. evaluated the self-exclusion of over 14,000 donors among the 6.5 million donations
to the American Red Cross in 2001, after the implementation of NAT testing for HIV1/2.
The CUE process asked donors to confidentially select one of two indistinguishable
bar-coded stickers to attach to their blood donation record indicating either to use
or discard the donation for any reason. This study reported a prevalence of 0.77%
for confirmed infectious disease markers for HIV, HBsAg, HCV, syphilis or HTLV among
blood donors who self-excluded their donation compared to 0.15% among those who did
not use CUE (p-value < 0.001). With the exception of HTLV, a reactive infectious test
result was 4 to 13-fold more likely among donors who selected the CUE option compared
to donors who did not exclude their donation. Likewise, Volger and colleagues report
a 1.5 to 3-fold higher risk of reactive serologic markers associated with the use
of CUE.
Prevalence data on CUE donations, however, only reveal the likelihood of detectable
infection at the current donation. More informative is the analysis of donors who
use the CUE option when their test results are negative and would not have been excluded
from donation by other means, but who later demonstrate confirmed, laboratory evidence
of infection. Seroconversion after use of CUE provides an estimate of the possible
benefit of CUE use in reducing the residual risk of window-period donations. Volger
and colleagues found little evidence to suggest that CUE intercepted potentially infectious
units based on follow-up information on 8 donors who showed reactive serological screening
tests after using the self-exclusion option during a prior donation. Although one
donor did not return for follow-up testing to investigate an indeterminate HIV1/2
serologic result, he had used CUE on 2 different occasions. Donors who use CUE on
more than one occasion deserve special consideration, as discussed further below.
In the American Red Cross study, seroconversion and the use of CUE at the prior donation
was evaluated for more than 5,000 donors revealing a low sensitivity (0.0175) and
positive predictive value (0.0009) for detecting a window period donation. CUE may
have prevented only an estimated 0.2 to 1.3 window period units within the entire
American Red Cross system which collects more than 6.5 million donations each year.
The low positive-predictive value likely reflects errors in the selection of CUE option
by donors, either from misunderstanding or poor explanation by staff about the instrument.
The cost and waste associated with the use of the CUE instrument is not trivial. With
the accumulated evidence that the CUE option has only minimal effectiveness in further
reducing the transmission of infectious diseases through window-period units - even
prior to the introduction of NAT(2) - CUE can safely be eliminated during the routine
donor screening process. Blood centers, however, should still instruct all donors
to report after the donation if they realize for any reason that their blood should
not be used for transfusion, so that their components can be discarded. While not
"confidential" because the donors must identify themselves to the blood center staff,
they do not have to give the reason why they feel their blood is not safe. The management
of post-donation information in this way has not been subjected to the same scrutiny
as the use of CUE, but it may achieve the same purpose, possibly not with any more
sensitivity but with much less waste of acceptable donations.
Whether blood centers continue to use a CUE process or similarly manage post-donation
information from donors who exclude their donation for confidential reasons, special
consideration should be given to donors who report on two or more occasions that their
blood should not be used for transfusion. Interestingly, Volger and colleagues revealed
that most of their donors (1269) used the CUE option just once, but 158 selected the
CUE option twice, 30 donors on 3 occasions and 21 donors on 4 or more donations. One
donor who presented with both HIV and syphilis co-infection had self-excluded on five
prior occasions. Repeated use of CUE likely reflects test seeking by donors who are
at ongoing risk of parenteral infection but may be inappropriately using regular blood
donation for reassurance. The unexpected observation that the prevalence of T cruzi
antibody was higher among donors that used CUE remains unexplained but also raises
the specter of test-seeking among blood donors. Blood centers should explain the risks
of transfusion-transmitted infectious diseases to blood donors who repeatedly use
the CUE option or report post-donation information to exclude their donation for confidential
reasons on more than 2 occasions. Blood centers should also consider whether repeated
self-exclusion after donation is grounds for indefinite deferral of the individual
as it likely suggests ongoing high risk activity or test-seeking behavior.
In conclusion, the current study from the regional blood bank of Londrina, Parana
state provides some new insights, and reinforces the available published experience
with the CUE option in other countries, thus providing ample support for the conclusion
of Vogler and colleagues to eliminate CUE after the introduction of nucleic acid tests
in Brazil. In the opinion of this author, they do not have to wait for nucleic acid
tests.