The Blood Transfusion Service failed to inform either Regional Medical Directors treating haemophiliacs or the National Drugs Advisory Board when haemophiliacs were diagnosed as having AIDS anti-bodies. The disclosure was made at the Lindsay Tribunal today which is currently examining the infection of 7 haemophiliacs with AIDS antibodies from Factor 9 clotting agent produced by the BTS.
It appears the first identification of infection was made in July 1985 but might have been November. However by September the following year the neither the Regional Medical Directors nor the NDAB had been informed. Professor Ernest Egan, Regional Director for Galway, stated in a letter on September 16 that he was very disappointed that he had to hear from a third party that more than six haemophiliacs using Irish Factor 9 blood clotting agent had AIDS antibodies.
Prof Egan said this was the responsibility of the BTS, adding that he should have been informed that that the appropriate action could be taken. Earlier, Dr Emer Lawlor, Deputy Medical Director of the BTS, today stated that heat treated Factor 9 - which would have eliminated HIV, was not introduced until October 1985 for 2 reasons. She said that there was a debate in the UK over the possibility that heat-treated Factor 9 might cause thrombosis and there was also a sense that Irish blood was not a major risk of AIDS.
Dr Lawlor agreed that the HIV donor testing was introduced in 15th October 1985 and that the first donor was identified as being HIV positive ten days later. She also agreed with Counsel for the Tribunal, John Finlay, that any confidence in the Irish blood supply would have been extremely misplaced after this date.
However the Tribunal heard that Factor 9 blood product made from Irish blood but which had not been heat-treated was not immediately re-called. While Irish heat-treated Factor 9 was introduced in October 1985, the old non-heat treated Factor 9 was still being issued as late as December 1985.
The Tribunal heard that one haemophiliac was still using a non-heat treated batch at home as late as February 1986. However the BTS stated that it didn't believe anyone was infected from the later batches.
In relation to introduction of heat-treated Factor 9, the Tribunal heard from a letter from Prof Ian Temperley who wrote to the BTS in August 1985 saying Factor 9 should be heat-treated. Prof Temperley, the Director of the National Haemophilia Centre but who was on sabatical in London at the time, stated that he 'thought' he'd already made this clear to the BTS.
