The latest report that blood products may carry a risk of CJDrelated infection to patients is the third major crisis in this area in recent years. In 1985 the Blood Transfusion Service Board (BTSB) found that supplies of Factor VIII (a blood product used to treat haemophiliacs which it imported from the US) carried the risk of HIV infection. It took six years for the Irish Haemophilia Society to negotiate compensation for the 40 per cent of its members affected. By the time the Government made a settlement of £8 million in 1991, 15 of the 103 haemophiliacs who contracted HIV had died. In February 1994, the BTSB announced that a possible link had been established between the hepatitis C virus and the anti-D immunoglobulin treatment given to mothers whose blood is rhesus negative. Initial screening showed that comparatively few of the 100,000 women treated had in fact contracted hepatitis C. The first criticism of the BTSB's handling of the problem came in March 1994, when it emerged that the board's records were inadequate to ensure that all 100,000 women could be traced. The group most at risk were women who received anti-D in 1977. By the end of the month 827 women had tested positive. By early 1995 there was mounting concern about the way in which the service was handling the problem, and critical media reports of poor storage of products and bad record-keeping. In March, a group of women infected by hepatitis C, calling themselves Positive Action, began to demand publication of an internal BTSB report on the screening process.
On March 31st, 1995, the then Minister for Health, Mr Michael Noonan, announced that an inquiry was to be held into the way the board was being run. By then more than 56,000 women had been screened; more than 1,000 tested positive for hepatitis C. The initial investigation was published on April 5th, 1995, and it was severely critical of the board's failure to withdraw the defective anti-D product in 1991. It also criticised the board for knowingly using plasma from a donor with jaundice in 1976 to manufacture anti-D.
There was now mounting pressure from Positive Action and Fianna Fail for senior BTSB personnel to be prosecuted. The government agreed to set up a tribunal on how the board handled the crisis. This was chaired by the former Chief Justice, Mr Thomas Finlay, and began its hearings on December 2nd, 1996.
Mr Finlay found the BTSB had breached its own safety and professional standards. Meanwhile, in January, the government had already decided to set up a new tribunal to examine HIV infection of BTSB blood and blood products.
In April 1997, the BTSB admitted it was legally liable in all cases of hepatitis C caused by its products. Last month the Garda Commissioner, Mr Pat Byrne, decided to initiate an investigation into the death of Mrs Brigid McCole. Senior former employees of the BTSB are being interviewed by the Garda.