Seroprevalence and Risk Factors for Transfusion-transmitted Infections among Blood Donors in Dera Ismail Khan, Pakistan: A Single-Center Cross-sectional Study

Abstract

Background

Although the highly prophylactic precautions and measures for keeping safe blood transfusions, transfusion-transmitted infections (TTIs) still constitute a remarkably significant risk in medicine. Few documents recorded the situation of TTIs in Dera Ismail khan (D.I. Khan) district, Pakistan so this study aimed to assess the prevalence of TTIs among blood donors in the district, to update and enhance the management of a secure blood supply.

Methods

A cross-sectional observational study was conducted at the Regional Blood Centre in D.I. Khan, encompassing all eligible blood donors over three months. Screening for hepatitis B virus, hepatitis C virus, human immunodeficiency virus, and syphilis was performed by using chemiluminescence immunoassay, while malaria parasite testing was performed by immunochromatographic technique.

Results

The results revealed that a total of 1221 people had attended the Regional Blood Center in D.I. Khan for blood donation. Only 1129 (92.46%) individuals were permitted to be screened as pre-donation scanning measures for TTIs, while the rest had medical histories that prevented them from donating. Out of 1129, eight (0.7%) were only females, and 1121 (99.29%) were males. The majority of donors, 550 (48.9%), were aged 30 years or younger. The number of voluntary donors, 87 (7.7%), was lower than the number of professional paid donors, 1042 (92.3%). The prevalence of TTIs among all donors was 60 (5.31%). The prevalence of syphilis, HBV, HCV, HIV, and malaria were 1.94%, 1.50%, 1.32%, 0.35%, and 0.17%, respectively. The infection rates among positive donors were notable for syphilis 22 (36.66%), hepatitis B 17 (28.0%), hepatitis C 15 (25.0%), HIV 4 (6.66%), and malaria 2 (3.33%). Professional paid donors showed slightly higher rates of TTIs 57 (5.47%) than that among voluntary donors 3 (3.44%).

Conclusion

The study reflected the high prevalence of TTIs among blood donors in D. I. Khan, Pakistan. It also emphasized the role of blood screening, where the most prevalent TTIs were syphilis, HBV, HCV, HIV, and malaria. Encouraging voluntary blood donors and health education provide the community with safer blood with a higher quality.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44197-026-00601-3.

Introduction

Transfusion-transmitted infections (TTIs) constitute a major public health problem in transfusion medicine, where it can harm both the neglected untreated blood donors and recipients [1]. According to the World Health Organization (WHO), everyone has a right to receive safe blood. So, national donor selection, recruiting, retention, and health education programs are necessary to ensure blood safety [2, 3]. The voluntary donors are usually the non-ruminated patient’s family, relatives or close friends who wish to support them during their time of need while the majority of donors are professional paid donors of low to middle economic status. Worldwide, 58% out of the estimated 118.2 million blood donations were recorded in low- and middle-income countries [4, 5]. In 2006, only 38 countries obtained over 75% of their blood donors from relatives; the other nations hired trained blood donors to supply the necessary blood [3, 6]. The transfusion of untreated blood and blood additives will raise the risk of morbidity and death related to blood transfusions. Extremely dramatic consequences of acquiring infection through blood transfusion may threaten the person, their family, and their community. Furthermore, according to WHO guidelines, every blood donor should be screened for the TTIs [4]. According to Ndakotsu and Musa, the primary worry is the spread of blood-borne infections like HIV, syphilis, and the viral hepatitis B and C. Blood donors are subjected to serological and the various serological tests in order to prevent TTIs [7]. Novel and emerging pathogens continue to pose a concern in spite of these precautions [8].

Donating blood can save millions of lives by giving surgical and medical patients vital support. On the other hand, recipients of incorrect transfusions run the grave risk of contracting TTIs [9]. A secure blood supply with low risk of disease transmission is required by modern expectations, which calls for the use of sensitive screening tests and pathogen inactivation procedures, as well as an effective screening for the high-risk behaviors [10–12].

Tight donor testing and screening have dramatically reduced the danger of HIV infection through blood transfusions [13]. For avoiding the spread of hepatitis B and C, screening for anti-HCV antibodies and the hepatitis B surface antigen (HBsAg) is crucial [14]. The dangers associated with viral infections, such as HBV, HIV, HCV, cytomegalovirus (CMV), human T-lymphotropic virus (HTLV), and West Nile virus (WNV), as well as other viruses such SEN virus, Torque Teno virus (TTV), Epstein-Bar virus (EBV), Human Herpesvirus 6, human papilloma virus (HAV), human parvovirus (HPV-B19), and Hepatitis G and E viruses, have decreased due to improved screening techniques [13]. According to La Hoz et al., blood transfusion can also transmit parasitic diseases like, malaria, babesiosis, toxoplasmosis, and chagas disease [15].

Syphilis, HCV, HBV, and HIV 1 & 2 tests are commonly included in routine blood screenings; other tests may be requested according to the prevalence of the disease in the area and the accessibility of testing [16]. With risks of transmission during the window period, lab errors, and mutant infections, HIV has had a substantial global impact since the first AIDS cases from blood transfusions in 1982 [17].There is no cure for infection with HIV where the number of cases reached 1.3 million people in 2023. Moreover, approximately 630 000 persons died due to HIV-related complications [18, 19]. Research on HBsAg escape mutants is being conducted since hepatitis B can result in serious illnesses like as cirrhosis and hepatocellular cancer [20]. An estimated 3% of people worldwide are afflicted with hepatitis C, however serologic testing has significantly decreased the danger of transmission [21]. Serologic testing has led to a considerable decrease in syphilis, which is caused by Treponema pallidum [22].

In Pakistan, a nation of almost 1.8 billion people, 1.5 million bags of blood are collected annually [6]. In Karachi and Lahore, the two largest cities, the private sector provides 60% of the needed blood, while the remaining 40% is provided by the public sector [23]. Despite the high prevalence of HBV and HCV in Pakistan, a study carried out from 1995 to 2004 has cast doubt on the possibility of an increase in other TTIs, such as HIV and syphilis [24]. The most recent review recorded a wide range of TTIs prevalences in Pakistan ranged between 1.57% and 8.34% in Pakistan in different regions [25, 26] The most common serological tests for TTIs used in Pakistan are Chemiluminescence immunoassay technique CLIA and immunochromatographic method (ICT) [27]. The continuous screening policy of transfusion-transmitted infections (TTIs) is crucial to guarantee the security and sufficiency of the blood supply in our communities [28–30]. Due to a lack of recorded information, screening test availability, healthcare service availability, and lack of planed surveillance system, the exact prevalence of TTIs in our population is unknown [31]. The only paper focused on TTIs in Dera Ismail Khan (D. I. Khan), Pakistan covered the period from July to November 2022 [32]. So, this study tried to fill this gap by providing additional assessment of the TTIs prevalences among blood donors in D. I. Khan, Khyber Pakhtunkhwa, Pakistan’s District Dera Ismail Khan, and to provide suggestions for preventing TTIs and keeping blood transfusion safety.

Materials and Methods

Study Design

The chosen research design for this study involved a cross-sectional observational hospital-based study at the Regional Blood Center, D. I. Khan, Khyber Pakhtunkhwa, Pakistan during a three-month period from 1 January to 31 March 2024. The study was designed to determine the prevalence of common transfusion-transmitted infections (TTIs) and to identify associated risk factors. This cross-sectional study was reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines, and the completed checklist will be submitted as supplementary material.

Inclusion Criteria

All persons between 18 and 50 years that attended Regional Blood Center, Dera Ismail Khan, Khyber Pakhtunkhwa, Pakistan for blood donation during the study period.

Exclusion Criteria

The attendees that were deferred due to their medical history of surgical operation during the last 6 months, low hemoglobin level, pregnancy, periods, malaria, epilepsy/ seizure disorder, fever (their temperature must not exceed 37.5C0), last donation within the preceding three months, multiple sexual relationships, sharing of blades, viral hepatitis, medicine intake, diabetes mellitus, being under 18 years or above 50 years, underweight (less than 50 kg.), blood pressure was not within the normal range (systolic 100–180 mmHg and diastolic 50–100 mmHg) or even was not feeling well [33].

Sample Size

The number of included persons was higher than the calculated sample size for a population with prevalence 8.34% in Pakistan [25, 26] and anticipated prevalence in D.I. Khan 5.22% for TTIs [32]. The calculated sample size was 703 persons using ClinCalc.com with Alpha 0.05, Beta 0.2, and power 90% [34].

Sample and Data Collection

All the attendees to the center were welcomed and received health education about TTIs and how to avoid and decrease them in the community, then they were asked to participate in the current research. Personal and medical historical data were collected from the attendees for excluding these were deferred with medical reasons. The remaining included attendees were asked to provide written consent for participation in the research. Blood samples were collected for screening five pre-donation serological tests; three of them were viral (HBV, HCV, and HIV), one of them was bacterial (syphilis), where the last one was a parasitic disease (malaria). Screening for HBV, HCV, and HIV was carried out using the chemiluminescence immunoassay technique CLIA (Siemens Atellica IM 1600), while the screening of malarial parasites was tested by the immunochromatographic method (ICT). The tests were performed according to the guidelines and procedures recommended by the kits.

Ethical Consideration

According to ethical norms and guidelines, the protocol of the study titled “Seroprevalence and Risk Factors of Transfusion-Transmitted Infection in Dera Ismail Khan District, Pakistan” was approved by the Ethical Review Board of Gomal University (No. 534/ERB/GU). All donors received health education about TTIs and their prevention, and written informed consent was obtained before participation. The study procedures complied with ethical principles and recommendations for medical research.

Statistical Analysis

Data were analyzed using SPSS version 25. Categorical variables were summarized as frequencies and percentages. The overall seroprevalence of transfusion-transmitted infections and the distribution of individual infections were calculated. Associations between donor characteristics and TTI positivity were assessed using the chi-square test or Fisher’s exact test, as appropriate, according to the expected cell counts. A two-sided p-value of less than 0.05 was considered statistically significant [35].

Results

Data was collected from 1,221 persons who attended the Regional Blood Centre in D.I. Khan for blood donation during the study period. Out of them, 75 persons (6.14%) were deferred due to various causes. 12(0.98%) persons didn’t complete their medical history and left the center, and 5(0.4%) people refused to participate in the study.

Only 1129 (92.46%) were accepted to be screened before donation, where this is the number that was eligible for donation. The majority of their gender was 1121(99.29%) males, while females were only 8(0.7%) persons. Among the screened individuals, 1,042 (92.2%) persons were professional paid donors, and only 87 (7.7%) individuals were voluntary donors. (Table 1; Fig. 1).

Table 1.

Reasons for Pre-donation deferral

Causes of deferral	Number of deferred persons	Percentage of deferred persons
Low hemoglobin level	5	6.66%
Not feeling well	4	5.33%
Malaria	2	2.66%
Epilepsy/ seizure disorder	2	2.66%
Last donation within 3 months	10	13.33%
Multiple sexual relationships	3	4.0%
History of surgery within 6 months	2	2.66%
Sharing of blades	1	1.33%
Viral hepatitis	7	9.33%
Medicine intake	8	10.66%
Diabetes mellitus	7	9.33%
Under age	5	6.66%
Above age limit	4	5.33%
Pregnancy	3	4.0%
Menstruation	4	5.33%
Underweight	5	6.66%
Blood pressure not in the normal range	3	4.0%
Total deferred persons	75	100%

Fig. 1.

Characteristics of attendees and screened blood donors at the Regional Blood Centre

Regarding the age group of the screened donors; Table 2 showed that most blood donors were in the younger age group of 18–30 years (48.71%), followed by donors aged 31–45 years (33.65%), whereas donors aged 46–50 years constituted the lowest proportion (17.62%). This distribution was statistically significant (χ² = 163.74, df = 2, p < 0.0001), showing that blood donation was more common among younger adults in the studied population. In Table 3, among a total of 1129 blood samples were collected and screened for five TTI markers before transfusion; HBV, HCV, HIV, syphilis, and malaria. The results of the serological tests revealed that 60 blood donors (5.31%) came out to be reactive for TTIs; syphilis was the most frequent transfusion-transmitted infection, followed by HBV and HCV, whereas HIV and malaria were much less frequent. The distribution of reactive cases across the five TTI categories differed significantly from an equal distribution (χ² = 24.83, df = 4, p < 0.001).

Table 2.

Distribution of blood donors according to their age groups

Age group (years)	Total donors	Percentage	Significance
18–30	550	48.71%	χ² = 163.74, p < 0.001
31–45	380	33.65%
46–50	199	17.62%
Total	1129	100%

Table 3.

Transfusion-Transmitted infections among examined donors

TTI	No. of reactive donors (n = 1129)	Percentage among positive TTIs (%)	Prevalence among all examined donors (%)	Significance
Syphilis	22	36.67	1.95	χ² = 24.83, p < 0.001
HBV	17	28.33	1.51
HCV	15	25.00	1.33
HIV	4	6.67	0.35
Malaria	2	3.33	0.18
Total	60	100	5.31

Figure 2 showed that among the professional paid donors at the Regional Blood Centre, 57 were found to be positive for transfusion transmitted infections (TTIs) based on various testing techniques. Specifically, using the chemiluminescence immunoassay (CLIA) technique, 16 professional paid donors (26.66%) tested reactive for HBV, while 15 (25.0%) tested positive for hepatitis C. Additionally, 3 donors (5.0%) were found to have HIV, 21 (35.0%) were tested positive for syphilis, and only 2 professional paid donors (3.33%) were identified as positive for malaria through the ICT technique.

Fig. 2.

Distribution of specific transfusion-transmitted infections by donor type

Table 4 shows that the prevalence of transfusion-transmitted infections was numerically higher among professional paid donors (5.47%) than among voluntary donors (3.45%). However, this difference was not statistically significant (Fisher’s exact test, p = 0.618).

Table 4.

Association between donor type and overall TTI positivity among examined blood donors

Donor type	TTI-positive n (%)	TTI-negative n (%)	Total donors	P-value
Professional paid donors	57 (5.47)	985 (94.53)	1042	Fisher’s exact test, p = 0.618
Voluntary donors	3 (3.45)	84 (96.55)	87
Total	60 (5.31)	1069 (94.69)	1129

The positive professional paid donors for TTIs constituted 57 (5.47%) of the total professional paid donors. On other hand only 3 (3.44%) voluntary donors were tested positive for transfusion transmitted infections; one voluntary donor (1.66%) was positive for HBV, one for HIV, and the last was positive for syphilis, while no cases of hepatitis C or malaria were detected among the voluntary donors.

Discussion

The present study revealed that the overall TTI prevalence was (5.31%) among blood donors in D.I. Khan. Syphilis was the most frequent infection, followed by HBV and HCV, whereas HIV and malaria were less common. Professional paid donors showed a numerically higher prevalence than voluntary donors, although the difference was not statistically significant. Although blood transfusion is considered a magic solution in keeping some urgent cases alive, unsafe blood transfusion may also convert the lives of other patients into a dramatic disaster. Viral, bacterial, and parasitic infections can be transmitted through the blood transfusion. The viral TTIs that may infect blood recipients are hepatitis B, C, D, and G viruses, HIV, human T lymphotropic virus (HTLV I and II), and CMV [36]. The bacterial TTIs are caused by Treponema pallidum, Brucella species. Also, some protozoa can be transmitted through blood transfusion such as Toxoplasma gondii, Plasmodium species, and Trypanosoma cruzi [24].

A recent study by the WHO found that there are 2 billion, 200 million, and 33.4 million cases of HBV, HCV, and HIV infections, respectively. This means that it is still impossible to completely eradicate the risk factors associated with TTIs. In Pakistan, 97,000–125,000 individuals had HIV. Three million pints of blood are donated annually in Pakistan, so the risk of TTIs should be taken into consideration. Enabling efficient TTIs agent pre-screening can help decrease the number of healthy people who might afflicted by these infectious agents [31].

The screening of transfusion-transmitted infections (TTIs) is very important to guarantee the security and sufficiency of the blood supply in our communities. So, the purpose of the present study was to spotlight on the prevalences of some of the most prevalent TTIs in Pakistan, where the continuous screening of TTIs sharply decrease the chance of their transmission [28, 29].

The results of the present study revealed that 1,221 people tried to donate blood in D.I. Khan, with a high acceptance rate of 92.46%. This reflected a high tendency towards blood donation and screening. The low percent of females 0.70% compared to the percent of male donors 99.29% aligned with the global observations of this imbalance which may be attributed to the cultural, social, and physiological causes as pregnancy, period, lactation and related fatigue [26]. In Pakistan, similar results were recorded in the Armed Forces Institute of Transfusion, Rawalpindi, from 2017 to 2021 [37]. Also, the percent of male donors ranged from 95% to 100% according to a systematic review conducted on 33 articles [27] and 98.7% in the studied area, D.I. Khan, during 2022 [32].

The present study showed that only 7.70% of donors were voluntary, while the majority of donors (92.29%) were professional paid donors. Encouraging the healthy people to be voluntary, non-remunerated donations was recommended by the World Health Organization (WHO), where the voluntary donors are more sustainable, available, and safer. Voluntary donors provide blood of good quality, free of cost affordable and suitable for poor patients [5, 38], Regular donations by voluntary contributors lower the possibility of shortages and improve safety [39, 40].

Concerning the age groups of the donors, the present study showed that the higher percentage of donors included the younger age (18–30 y) constituting 49%. This may be attributed to the better health and immunity of this group. This aligned with Sabir who reported that the age groups(< 25) and (26–35 years) were the highest age groups participated as blood donors constituting 38.3% and 45.5% in a Regional Transfusion Centre, Northern Pakistan [37] .

Alarmingly, the study showed high rates of TTIs (5.3%), including syphilis (1.94%), hepatitis B (1.50%), hepatitis C (1.32%), HIV (0.35%), and malaria (0.17%), were found among donors in D.I. Khan.

The result of TTIs prevalence reflected to some extent the possible prevalences of these diseases in the community. The prevalences agreed with the conclusion and the cumulative results of a systemic review conducted in 2020 about the prevalences of TTIs in Pakistan that ranged from 1.57% to 8.34% (26) and 5.22% in D. I. Khan in 2022 [32].

The highest prevalences reported in the present study was that of syphilis (1.94%), where its ratio among positive TTIs represented (36.66%). The result agreed with the cumulative frequency (1.10%) derived from 24 studies on 6974 blood donors for syphilis. Out of them, seven studies reported prevalence 2.0% [26]. Moreover, Syphilis is considered an important cause for stillbirth and neonatal mortality where the positive women for active syphilis that become pregnant are about one million annually. About 33% of the untreated women deliver babies with low birth weight and high chance for death during the first month of their life. So, early screening and treating the positive cases are very important before 28 weeks’ gestation [41].

A recent study conducted a surveillance on sexually transmitted infection in Pakistan. The study concluded that syphilis was the most prominent disease among transgender among transgender especially sex worker group [42]. Syphilis is not only transmitted through blood transfusion bur also sexually to the partner of the blood recipient so, more attention should be paid for TTIs diseases that can transmitted sexually to the partners like HIV, HCV, and syphilis.

Concerning HBV prevalences, the prevalence (1.50%) among blood donors was within the range of HBV all over Pakistan which ranging from 0.81% to 4.22% with a mean prevalence 2.04% estimated from 24 studies including 16,230 blood donors [26]. Worldwide, approximately 350 million of the two billion individuals infected with HBV have a chronic infection, detected by the virus’s persistent antigens like HBsAg levels in the blood. Chronic liver disease associated with HBV kills one million people annually. Hepatocellular carcinoma (HCC), cirrhosis, and liver disease affect 15 to 40% of those with chronic HBV infection. Saliva, semen, vaginal fluids, menstrual blood, and blood are all contaminated with HBV in infected persons [41]. HBV carriers can move in silence without being detected throughout the infection’s window period [43]. When the quantity of detectable HBsAg is low, nucleic acid testing (NAT) should be used to find such carriers [7] .

According to the findings of the present work, the prevalence of HCV was (1.32%) constituting (25.0%) among all positive TTI cases. The result is consistent with the systematic review that estimated the prevalence of HCV cases from 26 studies including serological blood examinations of 17,660 persons. The results revealed that the mean prevalence of HCV was 2.44 (ranging between 1.57% and 8.34%) over all Pakistan [26].

Regarding HIV, the present study revealed that the prevalence of HIV among the examined blood donors was (0.35%) which slightly exceeded the mean prevalence 0.038% derived from a systematic review where the ranges of HCV prevalences varied between 0% and 0.18% [26].

The lowest prevalence detected in the present study was that of malaria where only two positive cases were detected by ICT with prevalence (0.17%). This result agreed with the review recorded a mean prevalence (0.11%) all over Pakistan with range from 0.005% to 1.20% [26]. Although the main mode of malaria transmission is through the bite of infective female Anopheles mosquitoes, malaria can be also transmitted by blood containing the erythrocytic stages of Plasmodium sp. The person acquired malaria infection via blood transfusion is called induced malarial cases [44]. Screening of blood donors for malaria is very important and the possibility of transfusion transmitted malaria (TTM) should not be neglected even in non-endemic areas according to Verra who conducted a systematic review on transfusion transmitted malaria (TTM) in non- endemic areas. He reported 100 TTM cases positive for Plasmodium species. Out of them 45% were P. falciparum, 30% P. malariae, 16% P. vivax, 4% P. ovale, 2% P. knowlesi, and 1% mixed infection of P. falciparum/P. malariae. Most of the mortality was caused by P. falciparum. It was noticed that the incubation periods of all Plasmodium sp by TTM were longer than theses in cases of natural infection particularly in cases of P. malariae [45]. Another example for TTM even in non-endemic countries, the malaria case that was reported in Egypt and attributed to blood transfusion [46], where there was no evidence of indigenous malaria cases in Egypt now, and the last indigenous cases were before about ten years [47–50] so, WHO declared that Egypt was free of malaria [51, 52].

Syphilis and malaria tests were not included in all TTIs screening in Pakistan, where they were recorded only in 38% and 46% respectively in the screening of blood donors [26]. The neglection of surveying and early discovering such diseases especially syphilis may be the main cause of their spreading.

To lower these infections, strict screening procedures and public health initiatives are required. When pathogens in blood components cannot be detected by antibody testing methods, NAT testing has enhanced the accurate result of low pathogen burden in blood samples [7]. Also, the number of healthy and safe blood donors should be increased as recommended by WHO which focused on encouraging the voluntary non-ruminated donors where they pose a lesser risk of TTI because of their lower-risk behaviors and altruistic motivations [38]. This is supported by the fact that voluntary donors had notably lower incidences of malaria and hepatitis C [39, 40].

Medical history, recent donations, and low hemoglobin levels are common causes of donor deferral. Improved health education regarding donation intervals is necessary, as indicated by the high deferral rate of 13.33% for recent gifts. Resolving health conditions that can be changed, such as high blood pressure and diabetes, might also make a donor more eligible. Health maintenance-focused educational programs may help create a more robust pool of potential donors [38].

Generally, the results of the present work are coincident with these conducted on 3329 in the same area in 2022 with prevalence 5.22% ,2.2%, 0.9%, 0.3%,1.9% and 0.1% for TTIs, HBV. HCV, HIV, syphilis, and malaria respectively while the prevalences of the present work were 5.31%, 1.50, 1.32, 0.35, 1.94, and 0.17% respectively [32]. The risk factors related TTIs that affect D.I. Khan community were the prevalences of HBV. HCV, HIV, syphilis, and malaria among people that may be donors anytime, low health education and health promotion. Also, the low percentage of voluntary donors compared with professional paid blood doners may participated in the spreading of TTIs in D.I. Khan, Pakistan. The D.I. Khan study’s findings draw attention to more general issues facing blood donation around the world and stress the need for legislative changes, health promotion initiatives, and public education to boost voluntary giving and enhance the security of the blood supply. These tactics are in line with WHO guidelines and international best practices [38].

Limitations

The limitation of this centered study was the low number of females and voluntary blood donors where the larger number can represent these groups in a better way. Also, the short duration of the study limited the number of possible participants.

Conclusion

The surveillance among donors carried out in the Regional Blood Center in D.I Khan reveals several significant insights. Firstly, the high acceptance rate of donors (92.46%) indicates a strong willingness among the population to contribute to blood donation, with a majority being male and professional paid donors. However, the low percentage of voluntary donors compared with professional paid blood donors as well as the higher prevalence of TTIs among the professional paid donors may participate in the spreading of TTIs. So, the community needs more encouragement and awareness by health education. The presence of TTIs among donors, particularly hepatitis B and C, HIV, syphilis, and malaria, reflects to great extent the prevalences of these diseases in the whole community and highlights the importance of stringent screening protocols including all possible TTIs in Pakistan to ensure the safety of donated blood. The national policy of Pakistan should focus on health promotion and education of the community providing encouragement and facilities for voluntary blood donors and regular surveillance parallel to high quality and infection control.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

TTIs

Transfusion transmitted-infections

TTM

Transfusion transmitted malaria

HBV

Hepatitis B virus

HCV

Hepatitis C virus

HIV

Human immunodeficiency Virus

HBsAg

Hepatitis B surface antigen

ICT

Immunochromatographic technique

CLIA

Chemiluminescence immunoassay

Author Contributions

Dahesh S. M. and Asif M. both are the principal investigators and responsible for all parts of the study plus supervision. Concept and design were carried out by Aziz M., Shah MK, Nadeem M., and Roshdy A.M. Definition of intellectual content, literature search: were written by Aziz M, Shah M.K., Nadeem M., Roshdy A.M., and Dahesh S.M.A. Experimental studies and data acquisition were performed by Asif M., Aziz M., Shah M.K., Shah A., and Nadeem M. Statistical analysis, manuscript preparation, manuscript editing, and manuscript review were done by all authors, mainly Asif M., Aziz M., Roshdy A.M., and Dahesh S. M. A. The corresponding and guarantor authors are Dahesh S. M. A. and Aziz M. The manuscript has been read and approved by all the authors, that the requirements for authorship as stated earlier in this document have been met, and that each author believes that the manuscript represents honest work if that information is not provided in another form.

Funding

No external funding was received.

Data Availability

Data is provided within the manuscript file.

Declarations

Human Ethics and Consent to Participate

https://www.strobe-statement.org/index.php?id=available-checklists According to ethical norms and guidelines [53, 54], the protocol of the study titled "Seroprevalence and Risk Factors of Transfusion-Transmitted Infection in Dera Ismail Khan District, Pakistan" was approved by the Ethical Review Board of Gomal University (No. 534/ERB/GU). All participants received health education about TTIs and their prevention, and written informed consent was obtained from all participants before participation. The study complied with the ethical guidelines and recommendations governing medical research. IRB No. 534/ERB/GU.

Consent for Publication

All authors reviewed the manuscript and agreed to its publication.

Clinical Trial Number

Not applicable.

Competing interests

The authors declare no competing interests.