What Was the Infected Blood Scandal?
Between the 1970s and early 1990s, more than 30,000 people in the United Kingdom were infected with HIV, Hepatitis C and other viruses after receiving NHS blood, blood products or tissue.
More than 3,000 deaths are attributable to what happened. People continue to live with the medical, psychological, social and financial consequences, while families continue to grieve those who died.
The infections were not simply an unavoidable tragedy. The Infected Blood Inquiry found a catalogue of individual, collective and systemic failures. It concluded that much of what happened could, and should, have been prevented.
Not one incident, but many connected failures
The term “infected blood scandal” can make what happened sound like a single contaminated batch or one disastrous decision.
It was neither.
People were infected at different haemophilia centres and other places, at different times and through different forms of blood-derived treatments. The decisions that exposed those infected to danger involved government departments, blood services, haemophilia centres, clinicians, regulators and pharmaceutical companies.
There were two principal routes of infection:
Blood products used to treat people with bleeding disorders such as haemophilia.
Blood transfusions given during surgery, childbirth and treatment for serious illness or injury.
These two different routes of infection are distinct from one another and comprise very different sets of factual matrix.
Factor VIII and Factor IX
People with haemophilia have reduced levels of proteins that allow blood to clot properly.
Haemophilia A is commonly treated by replacing Factor VIII. Haemophilia B is treated by replacing Factor IX.
Before the widespread introduction of concentrated factor blood products, patients were often treated with cryoprecipitate (Cryo). During the 1970s, Factor VIII and Factor IX concentrates became the norm for haemophilia treatment in the UK.
Some doctors, pharma companies and others argued that concentrated blood products were more convenient to use than Cryo, but the manufacturing process created an enormous and foreseeable viral risk.
Factor concentrates were made by combining plasma collected from thousands, and sometimes tens of thousands, of donors. If one donation carried a blood-borne virus, an entire batch would likely become contaminated. A single infected batch could then be given as finished product to many haemophilia patients.
As more and more concentrates were used, the poor decision-making to use such products was made even worse by the decision to import products rather than making them all in the UK from NHS blood donors. Significant volumes of commercial products were imported, particularly from the United States.
Some of the plasma used by commercial manufacturers had been collected from paid donors and from populations with a higher risk of blood-borne infection. This included plasma collected within American prisons and donors targeted due to their sexuality and previous hepatitis infection. The imported products were known to carry a particularly high risk of transmitting hepatitis.
The danger was not confined to imported products. UK-manufactured concentrates also transmitted viruses. Increasing the size of domestic plasma pools increased the likelihood that a single infected donation would contaminate an entire batch.
The Infected Blood Inquiry found that imported commercial concentrates were a principal source of HIV infection in the United Kingdom, but the scandal cannot be explained solely as a problem with American blood. It also involved domestic production, licensing, treatment policies, donor selection, delayed safety measures and failures within the NHS and government.