Working Party on Clinical Transfusion Management, Chinese Society of Blood Transfusion

 

The Law of the People’s Republic of China on the Prevention and Treatment of Infectious Diseases stipulates that coronavirus disease 2019 (COVID-19) is a category B infectious disease and that its prevention and control should be implemented according to category A infectious diseases. To 0ensure laboratory biosafety during the control and prevention of COVID-19, the National Health Commission of the People’s Republic of China has enacted many laboratory biosafety guidelines and control and prevention plans for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (1-5) and guided medical institutions (all types and at all levels) to standardize laboratory activities. With a better understanding of the disease and an accumulation of medical experience regarding clinical blood transfusion, based on the Biosafety protection guidelines for blood group serology laboratories for clinical blood transfusions during the control and prevention of COVID-19 (First edition) (6), we have formulated the second edition after taking into account the experiences of other professional branches of the Chinese Medical Association (7) and other countries regarding the control and prevention of other acute respiratory infectious diseases, such as severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), H1N1 and H5N1 (8-9), in order to guide the blood transfusion departments (blood banks) of medical institutions (all types and at all levels) to continuously carry out effective biosafety protection.

 

 

1. Case determination

According to the Diagnosis and Treatment Protocol for COVID-19 (Trial Version 7) (10), patients are categorized into patients with confirmed (asymptomatic, mild, moderate, severe, and critical) or suspected COVID-19 and other patients. In these guidelines, patients in the first category are referred to as special patients, and patients in the second category are referred to as general patients.

 

 

2. Safety principles

2.1 Biosafety protection levels

2.1.1 According to the Laboratory biosafety guidelines for COVID-19 (Second edition) (1), the following principles should be followed. Serological testing should be carried out in Biosafety Level 2 (BSL-2) laboratories and in a biosafety cabinet as much as possible. Individuals should be protected according to BSL-2 standards, and designated hospitals should adopt Biosafety Level 3 (BSL-3) protection standards.

2.1.2 According to the requirements of the Announcement on issuing a working plan for further strengthening the use of convalescent plasma donated by recovered COVID-19 patients in treating COVID-19 patients (The Joint Prevention and Control Mechanism of the State Council, No. 29, 2020.) (11), plasma should be donated at designated hospitals, and BSL-2 standards and above should be adopted for personnel when collecting plasma from COVID-19 patients in the convalescent stage.

2.2 Storage of blood components

2.2.1 Storage of routinely used blood components should be carried out in accordance with the Technical specifications for clinical blood transfusion (National Health Commission (previous Ministry of Health) of the People’s Republic of China. No. 184, 2000.) (12).

2.2.2 Storage of plasma from COVID-19 patients in the convalescent stage

(1) Plasma donations should be stored at designated hospitals that have -20°C blood storage freezers to allow the separate storage of samples waiting for examination and qualified samples.

(2) Plasma collected from convalescent COVID-19 patients should be specially labeled with COVID-19CP (convalescent plasma).

(3) Plasma collected from convalescent COVID-19 patients (not tested) should be marked prominently and stored separately in -20°C blood storage freezers specifically for samples waiting to be tested.

(4) Plasma from convalescent COVID-19 patients should be tested in accordance with relevant national regulations.

(5) After passing all the relevant tests, the plasma from convalescent COVID-19 patients should be marked prominently and stored separately in -20°C blood storage freezers specifically for qualified samples.

(6) Access to plasma samples should follow the management principle of “double person double lock” with entry and exit registration. The data should be kept for future reference.

2.3 Thawing plasma components

2.3.1 Operating procedures should be followed for the thawing of routinely used plasma components.

2.3.2 Thawing of plasma from convalescent COVID-19 patients should be carried out in separate plasma thawing equipment and thawed in a 37°C water bath.

 

3. Individual biosafety

Biosafety Level 1 (BSL-1) protection standards include a medical surgical mask, latex gloves, uniform, medical protective cap and hand hygiene. This protection level is suitable for testing blood samples from general patients in hospitals (all types and at all levels).

 

BSL-2 protection standards include a medical protective mask or N95 mask, latex gloves, isolation gown outside of uniform, medical protective cap and hand hygiene. Goggles may be used as appropriate (if there is a risk of splashing). This protection level is suitable for testing blood samples from patients with fever in hospitals with fever clinics.

 

BSL-3 protection standards include a medical protective mask or N95 mask, single or double layered latex gloves (with different colors if conditions permit), face shield, protective gown outside of uniform, single or double layered medical protective cap and hand hygiene. Two layers of masks (with an outer medical protective mask and inner N95 mask) should be used when necessary. This is suitable testing blood samples from special patients at designated hospitals.

 

Standardized procedures should be followed when putting on and taking off biosafety protective equipment. Proper hand hygiene should be followed (six-step hand washing).

 

 

4. Workplace

4.1 Indoor space

4.1.1 Laboratory

(1) General patients and patients with fever: An environment with good lighting and ventilation should be maintained. Relevant procedures in clean areas, semicontaminated areas and contaminated areas should be followed strictly, and relevant items should be stored in difference zones. Ultraviolet (UV) sterilization should conform to industrial standards (UV sterilizer GB 19258-2012). The performance of the UV sterilizer should be tested regularly. Complete records should be maintained. Accumulative usage should not exceed the prescribed time. Sterilization should be performed before and after each experiment for at least 30 min.

(2) Special patients: A BSL-2 laboratory should be used, and relevant national regulations should be followed.

4.1.2 Plasma donation locations should be established separately and far away from blood transfusion department laboratories (blood bank). The room should be ventilated. Relevant items should be placed according to category with clear separation between clean and dirty items, and the items should be replaced regularly. UV sterilization should conform to industrial standards (UV sterilizer GB 19258-2012). The performance of the UV sterilizer should be tested regularly. Complete records should be maintained. Accumulative usage should not exceed the prescribed time. Sterilization should be performed before and after each experiment for at least 30 min.

4.2 Work benches and floor: Laboratory benches should be sterilized and impermeable. The benches should be disinfected once before and after each experiment. The benches and other objects (such as telephones, keyboards, computer mouse, markers, pipettes and reagent bottles) and the floor should be disinfected with wipes containing 75% ethanol or disinfectants with 500 mg/L effective chlorine (84 disinfectant diluted 100-fold). The disinfectant solution should be freshly prepared and used within 24 hours.

4.3 Blood collection boxes: Separate blood collection boxes should be used for general patients and special patients, and the boxes should be disinfected once before and after each use by wipes containing 75% ethanol or disinfectants with 500 mg/L effective chlorine (84 disinfectant diluted 100-fold). The disinfectant solution should be freshly prepared and used within 24 hours.

 

 

5. Specimen collection

5.1 Blood specimens from general patients should be collected using BSL-1 protection standards.

5.2 Blood specimens from patients with fever should be collected using BSL-2 protection standards, and the specimens should be labeled prominently.

5.3 Blood specimens from special patients should be collected using BSL-3 protection standards, and the specimens should be labeled prominently.

 

 

6. Specimen transfer

6.1 Blood samples from general patients should be transferred according to standard procedures.

6.2 Blood samples from patients with fever and special patients

6.2.1 Blood samples and requisitions should be sealed in double-layered yellow safety bags first and then transferred by designated personnel.

6.2.2 When receiving blood samples, the distance between the personnel at the blood transfusion department (blood bank) and the delivery personnel should be no less than 1 m.

6.2.3 The personnel at the blood transfusion department (blood bank) should spray the yellow safety bags containing the blood samples and requisitions with 75% ethanol. As a disinfection measure, the outer and inner layers of the sealed bag, the tubes containing patients’ samples and the requisitions should be sprayed with 75% ethanol.

 

 

7. Specimen centrifugation

7.1 The test tubes containing blood samples from general patients should be placed in a centrifuge (preferably a centrifuge with biosafety functions and automatic uncapping) and processed under regular procedures.

7.2 Blood samples from patients with fever and special patients

7.2.1 After removal from the sealed bag, the tubes containing blood samples should be disinfected with 75% ethanol.

7.2.2 When the tubes containing blood samples are being centrifuged (preferably a centrifuge with biosafety functions and automatic uncapping), personnel from the blood transfusion department (blood bank) should stay with the centrifuge as much as possible. The centrifuge lid should be opened within 15 min of completing the centrifugation. The tubes should be removed after they are sprayed with 75% ethanol. If no centrifuge with an automatic uncapping function is available, the tubes containing blood samples should be uncapped in a biosafety cabinet (exhausting).

Centrifugations should be stopped immediately if accidents are suspected, such as an abnormal noise during centrifugation. Personnel at the blood transfusion department should use BSL-3 protection standards. The centrifuge should be opened within 30 min after the centrifugation has stopped and then disinfected with 75% ethanol. Insertion and removal of the centrifuge tubes into and from the rotor should be conducted in a biosafety cabinet (exhausting) when possible.

7.2.3 It is not advisable to perform a heat elution or an ether elution on blood samples from special patients.

 

 

8. Specimen testing

8.1 Manual testing

8.1.1 Separate pipettes should be used for testing blood samples from special patients.

8.1.2 Manual blood group serological testing prior to blood transfusion, including but not limited to the identification of ABO blood group (positive and reverse typing), the identification of RhD blood group antigen, antibody screening and cross-matching tests, should be performed in a biosafety cabinet (exhausting). After loading the samples, the test tubes or microcolumn gel cards should be sealed prior to centrifugation. The centrifuge should be opened within 15 min after the centrifugation has ended. The test tubes or gel (glass beads) cards should be disinfected with 75% before being removed for reading and recording.

8.1.3 Test tubes with blood samples should be capped with new disposable caps and disinfected with 75% ethanol.

8.1.4 The hands of the operators should be disinfected with 75% ethanol before withdrawal from the biosafety cabinet (exhausting), and clean gloves should be used immediately after withdrawal of the hands from the cabinet.

8.1.5 Manual testing should be minimized.

8.2 Automatic testing

8.2.1 Test tubes with blood samples are placed in an automatic blood group detector for testing.

8.2.2 After testing, test tubes should be capped with new disposable caps.

 

 

9. Posttesting procedure

9.1 After testing, capped test tubes containing blood samples should be sealed in a double-layered yellow safety bag. After disinfecting the surface of the bag with 75% ethanol in accordance with the Technical specifications for clinical blood transfusion (National Health Commission (previous Ministry of Health) of the People’s Republic of China. No. 184, 2000, the bag should be stored separately for 7 days. After the required storage time, the bags should be autoclaved and processed in accordance with national regulations for medical waste disposal.

9.2 All disposable test tubes, transfer tubes and microcolumn gel cards used for testing should be sealed in double-layered trash bags. After disinfecting the surface with 75% ethanol, the bags should be autoclaved and processed in accordance with national regulations for medical waste disposal.

 

 

10. Disinfection after testing

10.1 Reusable pipettes should be disinfected with 75% ethanol spray and wipes.

10.2 Sampling tips and racks in the automatic blood group detector should be disinfected with 75% ethanol spray. The inside and outside surfaces of the equipment should be disinfected with wipes containing 75% ethanol or disinfectants with 500 mg/L effective chlorine (84 disinfectant diluted 100-fold). The disinfectant solution should be freshly prepared and used within 24 hours.

10.3 The inside of the biosafety cabinet (exhausting) should be disinfected with 75% ethanol spray and wipes.

10.4 Laboratory benches, floors, centrifuges, microscopes, and other equipment and surfaces should be disinfected with wipes containing 75% ethanol or disinfectants with 500 mg/L effective chlorine (84 disinfectant diluted 100-fold). The disinfectant solution should be freshly prepared and used within 24 hours.

10.5 Upon completion of the tests, the indoor laboratory space should be disinfected with a UV light for no less than 30 min.

 

 

11. Laboratory accident responses

11.1 The surface of the biosafety cabinet (exhausting) contaminated by blood samples from special patients should be disinfected by disinfectant containing 5500 mg/L effective chlorine for at least 30 min. The disinfectant solution should be freshly prepared and used within 24 hours.

11.2 For laboratory contamination caused by blood samples from special patients, the laboratory should be closed, and the contaminated areas should be covered with disinfecting wipes containing 5500 mg/L effective chlorine for at least 30 min. In the case of large spills, the laboratory can be fumigated with heated peracetic acid at 2 g/m3 overnight, or the room can be disinfected with 20 g/L peracetic acid disinfectant using an aerosol sprayer at 8 ml/m3 for 1-2 hours. The indoor humidity during fumigation should be 60%-80%.

 

 

12. Disinfection of blood storage freezers

12.1 Disinfection of blood storage freezers for routine storage of blood components should be carried out in accordance with the Technical specifications for clinical blood transfusion (National Health Commission (previous Ministry of Health) of the People’s Republic of China. No. 184, 2000.).

12.2 Designated -20°C freezers for the plasma from convalescent COVID-19 patients should be defrosted once each month and disinfected with wipes containing 75% ethanol or disinfectant with 500 mg/L effective chlorine (84 disinfectant diluted 100-fold). The disinfectant solution should be freshly prepared and used within 24 hours.

 

 

13. Disinfection of plasma thawing equipment

13.1 Disinfection of plasma thawing equipment used for the routine thawing of plasma components should follow standard operating procedures.

13.1 Plasma thawing equipment used to thaw plasma from convalescent COVID-19 patients should be disinfected once before and after each use with disinfectant containing 500 mg/L effective chlorine (84 disinfectant diluted 100-fold). The disinfectant solution should be freshly prepared and used within 24 hours. If plasma from convalescent COVID-19 patients leaks from its container, the equipment should be disinfected with disinfectant containing 5500 mg/L effective chlorine for at least 30 min. The disinfectant solution should be freshly prepared and used within 24 hours.

 

 

14. Disinfection of plasma collection equipment

Before and after using plasma collection equipment, its surface should be wiped with wipes containing 75% ethanol or disinfectants with 500 mg/L effective chlorine (84 disinfectants diluted 100-fold). The disinfectant solution should be freshly prepared and used within 24 hours.

 

 

15. Disinfection of records

All paper materials for special patients, such as entry/exit lists of blood component preparations, blood transfusion application forms, blood collection forms, records of blood group serology tests, and shift switching records, should be preserved after disinfection with 75% ethanol spray.

 

 

16. Blood sample retrieval and distribution

16.1 Personnel retrieving blood samples at designated hospitals should retrieve blood from the blood transfusion department with a blood retrieval requisition and sterilized blood collection boxes. Personnel at the blood transfusion department (blood bank) should stay at least 1 m away from the personnel retrieving blood samples.

16.2 Blood collection boxes specific for special patients should be used for retrieving plasma from convalescent COVID-19 patients.

 

 

References

1. Laboratory biosafety guidelines for COVID-19 (Second edition). Letter of the science and education office of the National Health Commission of the People’s Republic of China (No. 70, 2020. January 23, 2020).

2. Laboratory technical guidelines for the detection and diagnosis of COVID-19 (3rd edition). January 28, 2020.

3. Guidelines on the usage scope of common medical protective equipment in the control and prevention of COVID-19 (trial implementation). (Medical letter of the National Health Commission of the People’s Republic of China (No. 75, 2020)).

4. Regulations for the Biosafety Management of Pathogenic Microbe Labs. Decree of the State Council of the People’s Republic of China No. 424.

5. General biosafety standard for causative bacteria laboratories. (WS 233-2017).

6. Biosafety protection guidelines for blood group serology laboratories for clinical blood transfusion during the control and prevention of COVID-19 (First edition). Working Party on Clinical Transfusion Management, Chinese Society of Blood Transfusion. February 3, 2020.

7. Biosafety and prevention guidelines for the clinical laboratory examination of COVID-19 (trial version 1). (Chinese Society of Laboratory Medicine. January 30, 2020).

10. Diagnosis and Treatment Protocol for COVID-19 (Trial Version 7). (Medical letter of the National Health Commission of the People’s Republic of China (No. 77, January 27, 2020)).

11. Announcement on issuing a working plan for further strengthening the use of convalescent plasma donated by recovered COVID-19 patients in treating COVID-19 patients. (The Joint Prevention and Control Mechanism of the State Council, No. 29, 2020. February 28, 2020).

12. Technical specifications for clinical blood transfusion. (National Health Commission (previous Ministry of Health) of the People’s Republic of China. No. 184, 2000. August 1, 2000).

 

 

Note:

*This article was funded by the scientific research project of Shanghai Science and Technology Commission (No. 17DZ2200800).

Corresponding author units: 200233 The Sixth People's Hospital Affiliated to Shanghai Jiaotong University (Li Zhiqiang); 100005 Beijing Hospital (Gong Jiwu); 430030 Tongji Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology (Wei Qing)

About the author: Li Zhiqiang (1962.09-), male, from Zhejiang, chief physician, postgraduate tutor, mainly engaged in the diagnosis and treatment of blood system diseases and clinical transfusion reaction research, (Tel)021-24058722, (E-mail)kcb039@126.com .cn; Gong Jiwu (1965.12-) male, from Hebei, chief technician, mainly engaged in clinical blood transfusion blood group serology and molecular biology research and quality control, (E-mail)xkgjw@139.com; Wei Qing (1965.12) Female, from Hubei, chief physician, PhD, mainly engaged in clinical blood transfusion research, ((E-mail))wei.qing@hotmail.com

The biosafety protection guidelines for blood group serology laboratories for clinical blood transfusion during the control and prevention of COVID-19 (Version 1) was published online on February 3, 2020, by the Working Party on Clinical Transfusion Management, Chinese Society of Blood Transfusion. Authors: Juan Wang and Tongtao Tu (Tongji Hospital affiliated with Tongji Medical College, Huazhong University of Science and Technology). Proofreading: Qing Wei (Tongji Hospital affiliated with Tongji Medical College, Huazhong University of Science and Technology); Jiwu Gong (Beijing Hospital); Zhiqiang Li (The Sixth People's Hospital Affiliated with Shanghai Jiaotong University).