Blood transfusion in sub-Saharan Africa: understanding the missing gap and responding to present and future challenges

Understanding supply sustainability of plasma-derived medicinal products: Drivers and consequences of shortages

Plasma-derived medicinal products (PDMPs), particularly immunoglobulins (Igs), are essential treatments for numerous diseases, often serving as the primary therapeutic option and playing a critical role in patient care. The human origin of these products, however, can lead to supply constraints due to a lack of plasma collection, market dynamics, regulatory challenges and manufacturing complexities. Many nations lack plasma self-sufficiency and often rely on the United States, which supplies approximately 70% of the world's plasma. This supply chain is vulnerable to disruptions, such as those caused by COVID-19. Additionally, plasma processing timelines are lengthy-Ig manufacturing takes 7-12 months compared with 2-3 months for biologics. Despite the global Ig market's projected growth from $13.36 billion to $24.98 billion between 2023 and 2032, plasma shortages persist. The European Medicines Agency anticipated shortages to affect 14 European countries in 2024. These factors can have significant implications for patients, with growing demand likely leading to supply challenges and forcing countries to prioritize certain indications in the face of shortages. Policy interventions may be needed to ensure the sustainable use of these products in treating immune-mediated disorders and related conditions. Exploring alternative treatments where possible could also mitigate the risk of shortages and maintain access to these life-saving therapies. This review examines the sustainability of PDMPs, focusing on drivers and consequences of shortages, insufficient plasma collection, vulnerability of the plasma supply chain and impacts on patients. A scoping literature research was conducted in PubMed, supplemented by internal knowledge and targeted web searches.

Bridging the gap: enhancing blood regulatory functions in African contexts through comparative analysis

Introduction

Independent assessments of blood regulatory systems, facilitated by tools such as the WHO's Global Benchmarking Tool (GBT) plus Blood expedites development of National Regulatory Authorites (NRAs) and thus promotes increased access to safe, effective, and quality blood, blood components, and products. The aim of this study was to assess and compare the status of implementation and performance of the regulatory functions for registration and marketing authorization as well as the system for approval of blood, blood components and plasma for fractionation or processes.

Methods

We did this by conducting assisted self-benchmarking in 12 African countries using the GBT plus Blood (registration and marketing authorization function, 34 sub-indicators and approval of blood, blood components, and plasma for fractionation or processes function, 24 sub-indicators). Comparative assessments of WHO-designated maturity level 3 (ML3) NRAs for medicines and vaccines against non-designated NRAs were made.

Results

The percentage of implemented sub-indicators was higher for the registration and marketing authorization function with an average implementation score of 73% (range: 51%-92%) compared to the approval of blood, blood components, and plasma for fractionation or processes function which had an average implementation score of 45% (range: 6%-65%). The comparison of group averages for the ML3-designated NRAs against the non-designated NRAs revealed a higher score 91% (range: 71%-100%) for ML3-designated NRAs as opposed to a lower score of 71% (range: 49%-100%) for the non-designated NRAs for the registration and marketing authorization function. This pattern, however, was not observed for the comparison of group averages for the approval of blood, blood components, and plasma for fractionation or processes function where the ML3-designated NRAs scored 47% (range 19%-72%) against 46% (range 23%-88%) for the non-ML3-designated NRAs.

Conclusion

Most of the NRAs excelled in implementing sub-indicators for the registration and marketing authorization (of plasma-derived medicines) function. All NRAs exhibited notable flaws in regulating blood, blood components, plasma for fraction, and approval of processes, indicating nascent regulatory frameworks. This study highlights the urgent need for WHO and African countries to prioritize formal benchmarking of NRAs using the GBT plus Blood to enhance their regulatory capacities in blood and blood product regulation.

Facilitators of and barriers to blood donation among voluntary non-remunerated blood donors in sub-Saharan Africa: A scoping review

BACKGROUND AND OBJECTIVES

In many countries, including Africa, the widespread gap between national blood requirements and actual blood supplies contributes to unnecessary deaths. This scoping review explores common facilitators and barriers to blood donation in sub-Saharan Africa (SSA) and strategies that are used to increase and maintain repeat blood donation.

MATERIALS AND METHODS

We conducted a scoping review of facilitators and barriers to blood donation in SSA. We searched PubMed, Ovid MEDLINE, Ovid EMBASE and COCHRANE to identify relevant papers. Of the 2225 articles screened by title, abstract and papers published after 2010, 37 were included in the final full-text screening. Article quality for inclusion was assessed on the basis of a predefined eligibility and inclusion checklist. We analysed all papers that reported barriers and facilitators to blood donation in Africa.

RESULTS

The review included 11 studies. The common facilitators for blood donation reported were altruism, the opportunity for disease testing, friendly recruitment strategies and future easy access to blood at hospitals when needed. We identified the following barriers: lack of knowledge, awareness of blood donation and place of donation, fear, ineffective incentives, bad service experiences and religious and cultural beliefs.

CONCLUSION

Findings of this review can be used to propose better strategies for improving blood donation in SSA. Strategies that encourage blood donation can be leveraged and implemented, while those that discourage blood donation can be adapted to better achieve an adequate supply.

Incidence, Causes and Outcomes of Postpartum Hemorrhage in Eastern Ethiopia: A Multicenter Surveillance Study

OBJECTIVES

Maternal mortality remains an unfinished global agenda and postpartum hemorrhage (PPH) remains one of the leading causes. The aims of this study were to describe the incidence, underlying causes, and case fatality rate of PPH in public hospitals in eastern Ethiopia.

METHODS

This study was part of a larger Ethiopian Obstetric Surveillance System (EthOSS) project - a multicenter surveillance of women admitted to 13 public hospitals in eastern Ethiopia due to any of the five major obstetric conditions: obstetric hemorrhage, eclampsia, uterine rupture, sepsis, and severe anemia - conducted from April 1, 2021 to March 31, 2022. All registers in maternity units of those hospitals were reviewed to identify eligible women and collect data on sociodemographic and obstetric characteristics, management and maternal outcomes at discharge or death. Findings were reported using descriptive statistics.

RESULTS

Among 38,782 births registered during the study period, 2043 women were admitted with at least one of the five major obstetric conditions. Of these 2043, 306 women (15%) had PPH corresponding with an incidence rate of 8 (95% CI: 7-9) per 1000 births. Uterine atony was the main underlying cause in 77%; 81% of women with PPH received at least one uterotonic drug, and 72% of women for whom blood was requested received at least one unit. Of the 70 hospital based maternal deaths, 19 (27%) died from PPH, making a case fatality rate of 6 per 100.

CONCLUSIONS

Although the overall incidence of PPH appeared low, it was still the underlying cause of death in one out of four women who died. The contributing factors might be that one in five women with PPH did not receive any uterotonic drug and the low blood transfusion. Ongoing audit, followed by targeted action, is essential to improve care quality and reduce adverse maternal outcome. The relatively low incidence may reflect under-recording in paper-based records, implying that further research into methods to optimize the surveillance is needed.

Blood donation practices, processing and utilisation of blood components in government tertiary hospitals in Nigeria: a multicentre cooperative study

BACKGROUND

Timely access to safe blood and blood components is still a challenge in Nigeria. This study aimed to determine blood donation practices, processing and utilization of blood components across government tertiary hospitals (THs) in Nigeria.

METHODS

This was a descriptive cross-sectional study done in Nigeria in June-July 2020. Data were analysed with SPSS version 21.0.

RESULTS

Data were collected from 50 THs. The majority (68%) of the THs lack facilities for blood component preparation and only 18% and 32% provide cryoprecipitate and platelet concentrate, respectively. Whole blood was most commonly requested (57.04%). All facilities tested blood for HIV, HBV and HCV, but the majority (23 [46%]) employed rapid screening tests alone and nucleic acid testing was not available in any hospitals. The manual method was the most common method of compatibility testing in 90% (45/50) and none of the THs routinely perform extended red cell typing. The average time to process routine, emergency and uncross-matched requests were a mean of 109.58±79.76 min (range 45.00-360.00), 41.62±25.23 (10.00-240.00) and 11.09±4.92 (2.00-20.00), respectively.

CONCLUSION

Facilities for blood component preparation were not widely available. Concerned government authorities should provide facilities for blood component preparation.

Improvement of blood transfusion safety using the chemiluminescence technique for viral marker screening of blood donors in sub Saharan Africa

INTRODUCTION

Sub-Saharan Africa struggles continuously with insufficient resources and inadequate infrastructure that hinder the establishment of a safer blood supply despite improvements in transfusion safety over recent decades. This study aimed to evaluate the impact of the chemiluminescence technique in combination with immunoenzymatic and immunochromatographic tests for viral marker screening of hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV) in donated blood in a country of sub-Saharan Africa.

METHOD

This study was conducted in a population of 113,406 blood donors at the National Centre of Blood Transfusion in Senegal. The data were obtained from the 'INLOG' software and donor registers. Statistical analyses used Excel 2010 and Epi Info v6. Screening for HBsAg viral markers, anti-HCV Ab, HIV p24 Ag, anti-HIV1 and anti-HIV2 antibodies were first carried out using the chemiluminescence technique. Blood donations screened positive for HBV or HCV were retested in a second chemiluminescence equipment. HIV-positive donations and their controls were subjected to solid phase immunochromatographic and indirect enzyme immunoassay techniques.

RESULTS

The prevalence among donors of HBV was 8.39 %, 0.56 % for HCV and 0.18 % for HIV. Of the donors tested positive for HIV in screenings and in doubled-controls, only 61.54 % were confirmed by the alternative tests; 34.02 % were negative and 4.44 % discordant between the three techniques.

CONCLUSION

This study shows the importance of introducing the chemiluminescence technique in association with serological screening of transfusion-transmitted viruses to improve blood supply safety in low-income countries.

The global blood donation index: an imperfect measure of transfusion need

The optimum number of units of blood and the associated number of blood donors required to meet a given population's needs remain undetermined globally. Typically, a whole blood donation rate of ten donations per 1000 population, at a minimum, is necessary to meet a country's blood needs. This rate is attributed to a WHO recommendation that 1% of a given country's population should donate blood to ensure a blood supply that is sufficient to meet clinical needs. This often cited metric was first referenced in a 1971 WHO report, yet neither supporting data or references were provided, suggesting that it was flawed at its founding. Regardless, this metric does not provide an accurate or contemporary determination of blood needs, which has ramifications for health service provision and planning, particularly in low-income and lower-middle-income countries. Modelling studies that account for geographical variability in disease burden, health-care infrastructure, and transfusion practices are needed to accurately estimate blood needs. A paucity of data to inform modelling remains a major obstacle in this regard. We discuss the history of the global blood donation index and highlight some factors that should be considered to better understand contemporary blood needs.

Seroprevalence of human immunodeficiency virus in African blood donors: a systematic review and meta-analysis

BACKGROUND

In developing countries, the safety of blood transfusions remains an important public health concern as it is associated with a higher risk of transfusion-transmissible infections (TTIs). In this study, we aimed to estimate the seroprevalence of HIV among blood donors in Africa and assess the temporal trends and regional differences within the continent through a systematic review and meta-analysis.

METHODS

Seven electronic databases (PubMed, Web of Science, Cochrane, Scopus, HINARI, Global Index Medicus and Clinical.

TRIAL

gov) were searched for relevant studies for our research. We included all primary studies that estimated the seroprevalence of HIV among blood donors in Africa with an age population from 16 to 65 years old, without language restrictions, from inception up to March 1st 2024. The pooled seroprevalence was estimated through the DerSimonian-Laird random effects model. The temporal trends and regional differences were assessed through subgroup and meta-regression analysis.

FINDINGS

We obtained 122 studies that met our inclusion criteria, comprising 7,814,996 blood donors tested for HIV. Sixty-six percent of the studies were from Western and Eastern Africa. The pooled seroprevalence of HIV among blood donors in Africa was 2.66% (95% CI: 2.17-3.20%; I2 = 99.80%, p < 0.01). The highest prevalence was observed in the Central African region, 3.28% (95% CI: 2.57%-4.06%), followed by the Eastern 3.21% (95% CI: 2.12%-4.52%), and the Western 2.66% (95% CI: 1.93%-3.49%) regions. Lower prevalences were observed in the Northern region, 0.57% (95% CI: 0.0%-2.10%), followed by the Southern African region with 0.45% (95% CI: 0.16%-0.86%). We observed a temporal decreased trend of HIV prevalence.

INTERPRETATION

The prevalence of HIV infection among African blood donors remains high and is not homogeneous across the continent. Efficient measures to strengthen HIV testing and prevent HIV transmission through blood transfusion are needed in Africa. Systematic review protocol registration: PROSPERO CRD42023395616.

FUNDING

This article was supported by National Funds through FCT - Fundação para a Ciência e a Tecnologia,I.P., within CINTESIS, R&D Unit (reference UIDP/4255/2020).

Transfusion and Mortality in Acute Care Surgical Patients in Malawi: A Propensity-Matched Analysis

INTRODUCTION

Information on transfusion-associated outcomes is limited in sub-Saharan Africa. We sought to characterize predictors of mortality in transfused patients with acute care surgical conditions in Malawi.

METHODS

We performed a retrospective propensity-matched analysis of patients with acute care surgical conditions at Kamuzu Central Hospital in Malawi from 2013 to 2021. We compared outcomes between patients who did and did not receive transfusions.

RESULTS

A total of 7395 patients were included. Transfused patients (n = 1086) were older (median 43 y with interquartile range 30-59, versus 39 y [interquartile range 27-53] in the nontransfused group, P < 0.01), had a higher proportion of females (41% versus 27%, P < 0.01), presented earlier to the hospital (median 2.9 versus 3.7 d, P = 0.02), and with lower hemoglobin levels (27% versus 1% < 7 g/dL, P < 0.01). They had a lower rate of surgical intervention (48% versus 59%, P < 0.01) but a higher rate of complications (62% versus 33%, P < 0.01). Crude in-hospital mortality was 25.5% for the transfused group and 12.8% for the nontransfused group (P < 0.01). After propensity matching, transfused patients had three times the odds of mortality compared to nontransfused patients (odds ratio 3.3, 95% confidence interval 2.3, 4.8).

CONCLUSIONS

In this propensity-matched study, transfused surgical patients were more likely to experience in-hospital mortality. These results suggest that the transfusion requirement reflects critical illness and warrants further investigation in this low-resource setting.

Ultra-restrictive red blood cell transfusion strategies in extensively burned patients

In recent years, due to the shortage of blood products, some extensive burn patients were forced to adopt an "ultra-restrictive" transfusion strategy, in which the hemoglobin levels of RBC transfusion thresholds were < 7 g/dl or even < 6 g/dl. This study investigated the prognostic impacts of ultra-restrictive RBC transfusion in extensive burn patients. This retrospective multicenter cohort study recruited extensive burns (total body surface area ≥ 50%) from three hospitals in Eastern China between 1 January 2016 and 30 June 2022. Patients were divided into an ultra-restrictive transfusion group and a restrictive transfusion group depending on whether they received timely RBC transfusion at a hemoglobin level < 7 g/dl. 1:1 ratio propensity score matching (PSM) was performed to balance selection bias. Modified Poisson regression and linear regression were conducted for sensitive analysis. Subsequently, according to whether they received timely RBC transfusion at a hemoglobin level < 6 g/dl, patients in the ultra-restrictive transfusion group were divided into < 6 g/dl group and 6-7 g/dl group to further compare the prognostic outcomes. 271 eligible patients with extensive burns were included, of whom 107 patients were in the ultra-restrictive transfusion group and 164 patients were in the restrictive transfusion group. The ultra-restrictive transfusion group had a significantly lower RBC transfusion volume than the restrictive transfusion group (11.5 [5.5, 21.5] vs 17.3 [9.0, 32.5] units, p = 0.004). There were no significant differences between the two groups in terms of in-hospital mortality, risk of infection, hospital length of stay, and wound healing time after PSM or multivariate adjustment (p > 0.05). Among the ultra-restrictive transfusion group, patients with RBC transfusion threshold < 6 g/dl had a significantly higher hospital mortality than 6-7 g/dl (53.1% vs 21.3%, p = 0.001). For extensive burn patients, no significant adverse effects of ultra-restrictive RBC transfusion were found in this study. When the blood supply is tight, it is acceptable to adopt an RBC transfusion threshold of < 7 g/dL but not < 6 g/dL.

Blood bank programs and transfusion sustainability. A serial mediating model

INTRODUCTION

Researchers establish that the current challenges of blood safety and shortage are based on relationship between master production scheduling and blood transfusion sustainability of blood banks.

OBJECTIVE

The objective of this study is to evaluate program relationship between master production scheduling and blood transfusion sustainability through total quality management and blood production.

METHODS

A survey questionnaire was adopted with staff from regional and government university teaching hospital blood banks. Simple random sampling was used to collect data from respondents. Preliminary and main data analysis was done using SPSS AMOS23.

RESULTS

The results revealed that master production scheduling influence blood transfusion sustainability when serially mediated by total quality management and blood production with 34% variation change at 95% confidence interval. Again, the results obtained show that master production scheduling influence total quality management significantly. Furthermore, total quality management influence blood production significantly. Finally, blood production influence blood transfusion sustainability significantly.

CONCLUSION AND RECOMMENDATIONS

Master production scheduling program actions has a positive significant relationship with blood transfusion sustainability through total quality management and blood production programs as serial mediators. This research contributes to the management of blood banks and suggests to have a greater relational management of total quality management, blood production and master production scheduling program actions in order to achieve high levels of blood transfusion sustainability, and in general, a greater benefit for society.

Gynaecologic oncology surgical cancellations in Zambia

Introduction

Cancellations of elective surgery in low-and middle-income countries (LMIC) are common and a major hindrance for patients who are in need of surgical therapeutic modalities. This is especially important in the context of scaling up needed surgical interventions for gynaecological cancer care. There is a knowledge gap in the literature related to cancellation of gynaecologic oncology surgeries in LMIC, where there is enormous need for this specific cancer surgical capacity. We report in an observational descriptive fashion, our experience at the UTH/CDH in Lusaka, Zambia, on the causes of surgical cancellations in gynaecologic oncology.

Methods

From January 1, 2021 through June 31, 2023, we retrospectively evaluated the surgical registry for gynaecologic oncology at the UTH/CDH in Lusaka, Zambia to assess the number and causes of surgical cancellations.

Results

There were a total of 66 (16.96%) surgical cancellations out of 389 scheduled gynaecologic oncology cases. Lack of available blood and/or low haemoglobin was the most frequent cause of surgical cancellations, 27 cases (40.90%).

Conclusion

We highlight in our series that the lack of blood, leading to surgical cancellations was the most frequent impediment related to performing scheduled gynaecologic oncology surgical procedures. As gynaecologic oncology services scale up in LMIC, given the radical nature of surgery and its association with blood loss, it is incumbent on the entire clinical ecosystem to address this issue and to develop mitigating strategies, specific to their respective resource setting.

Survey of blood collection and transfusion practices among institutions in Africa

INTRODUCTION

Dramatic improvements in blood transfusion have occurred during the last two decades. Transfusion medicine services and practices in Africa remain underexplored.

METHODS

A survey of blood bank/transfusion medicine (BBTM) practices, available blood products, blood product source(s), pre-transfusion testing, and blood donor infectious disease testing methodologies across Africa was performed using the American Society for Clinical Pathology (ASCP) listserv. Survey recipients included hospital-based laboratories/blood banks, national transfusion medicine services, and free-standing laboratories (collectively referred to as institutions).

RESULTS

Responses from a total of 81 institutions across 22 countries were analyzed. All 81 institutions provide at least one type of blood product-whole blood, red blood cells (RBCs), platelets, plasma, and cryoprecipitate, with whole blood (90.1%, 73 of 81) and RBCs (79.0%, 64 of 81) most common, while cryoprecipitate is least common (12.4%, 10 of 81). Only five countries had a responding institution that provides all types of products. Among institutions that collect blood onsite, the most common sources of blood products are patients' family members (94.1%, 48 of 51) and pre-screened on-demand volunteer donors (82.4%, 42 of 51). The most commonly screened infectious agents are HIV and hepatitis B virus (both 81.5%), while 70.4% (57 of 81) test for hepatitis C virus (HCV) and Treponema pallidum.

DISCUSSION

This study highlights significant variability and restrictions in blood product availability, pre-transfusion testing, and blood donor infectious disease testing across Africa. Further studies are needed to ascertain barriers to improving blood donor availability, blood product safety, and infectious disease testing.

The Quality of Blood Donation Services and Its Association with Blood Donors' Trust and Loyalty at Makkah Blood Donation Centers in Saudi Arabia: A Cross-Sectional Study

The current cross-sectional study was conducted to determine the quality of blood donation services and its association with blood donors' trust and loyalty at Makkah blood donation centers in Saudi Arabia. A total of 373 healthy blood donors aged ≥18 years who visited blood donation centers in Makkah, Saudi Arabia, between 1st and 28th February 2023 were recruited using a census sampling method. A pre-tested and validated Arabic language questionnaire was employed. The study survey included a checklist of sociodemographic variables (seven items), as well as seven-point Likert-scale questions on the quality of blood donation services (21 items), questions to assess the participant's level of trust in blood donation centers (4 items), and questions to evaluate the level of loyalty to blood donations (4 items). SPSS (version 24) was used for data analysis. A total of 373 blood donors were included in this study. Of them, 240 (64.3%) were males and 133 (35.7%) were females. The vast majority of the study participants, 330 (88.5%), had a high educational level. The overall average agreement score for the quality of blood donation services was 71.7%. Furthermore, the overall average item agreement score for trust in blood donation centers and places was 83.0%, while the overall average item agreement score for loyalty to blood donation was 72.1%. Moreover, after adjustment for potential confounding factors, high levels of quality in blood donation services were associated with high levels of trust and loyalty among the blood donors (OR: 1.518, CI 95%: 0.321-0.864 and OR: 2.466, CI 95%: 0.285-0.763, respectively) (p-value < 0.05 for all). The overall quality of, trust in, and loyalty to blood donation services were 71.7%, 83.0%, and 72.1%, respectively. In addition, high levels of quality in blood donation services could improve blood donors' trust and loyalty levels at Makkah blood donation centers in Saudi Arabia.

Red blood cell alloantibodies in paediatric transfusion in sub-Saharan Africa: A new cohort and literature review

Blood transfusion support predisposes transfused children to the risk of erythrocyte alloimmunization in Sub-Saharan Africa. A cohort of 100 children receiving one to five blood transfusions were recruited for screening and identification of irregular antibodies using gel filtration technique. The mean age was 8 years and the sex-ratio at 1.2. The retrieved pathologies were: major sickle cell anaemia (46%), severe malaria (20%), haemolytic anaemia (4%), severe acute malnutrition (6%), acute gastroenteritis (5%), chronic infectious syndrome (12%) and congenital heart disease (7%). The children presented with haemoglobin levels ≤6 g/dl, and 16% of them presented positive irregular antibodies directed against the Rhesus (30.76%) and Kell (69.24%) blood group systems. A literature review shows that irregular antibody screenings vary from 17% to 30% of transfused paediatric patients in Sub-Saharan Africa. These alloantibodies are in particular directed against the Rhesus, Kell, Duffy, Kidd and MNS blood group and generally found in sickle cell disease and malaria. This study highlights the urgent need of extended red blood cell phenotyping including typing for C/c, E/e, K/k, and Fya/Fyb, and if possible Jka/Jkb, M/N, and S/s for children before transfusion in Sub-Saharan Africa.

Genetic diversity of the human immunodeficiency virus of type 1 in Gabonese transfusional settings

BACKGROUND

The high endemicity of transfusion-transmissible infections (TTIs) in sub-Saharan Africa is a real public health problem. To reduce the risk of HIV transmission through blood donation, the NBTC of Gabon has launched in recent years a reorganization of its blood transfusion system. This study aims to characterize the molecular strains of HIV-1 circulating in donors and to estimate the risk of viral transmission.

MATERIALS AND METHODS

A cross-sectional study was carried out during the period from August 2020 to August 2021 among 381 donors who had agreed to donate blood at the National Blood Transfusion Center (NBTC). Viral load was determined by Abbott Real-Time (Abbott m2000®, Abbott) and sequencing by the Sanger method (ABI 3500 Hitachi®). The phylogenetic tree was constructed by MEGA X software. Data were checked, entered, and analyzed using SPSS version 21.0 software, with p ≤ 0.05 considered statistically significant.

RESULTS

A total of 381 donors were enrolled in the study. Among the 359 seronegative donors, five (5) seronegative donors were detected positive for HIV-1 using Real-Time PCR. The residual risk was 648 per 1,000,000 donations. The prevalence of residual infection was 1.4% [0,01; 0,03]. Sixteen (16) samples were sequenced. The strains obtained were CRF02_AG (50%), subtype A1 (18.8%), subtype G (12.5%), CRF45_cpx (12.5%) and subtype F2 (6.2%). Six sequences clustered with A1, G, CRF02_AG, and CRF45_cpx subtypes.

CONCLUSION

The residual risk of HIV-1 transmission by blood transfusion remains a concern in the Gabonese transfusional settings. A policy based on improving the current screening strategy would involve the implementation of the nucleic acid test (NAT) in order to optimize the safety of the donation by detecting the HIV-1 subtypes in circulation in the donors.

Prevalence and specificity of red blood cell antibodies in patients transfused in tertiary hospitals in Burkina Faso

BACKGROUND

Sub-Saharan African countries face the challenge of immunological transfusion safety that puts many patients at risk of post-transfusion hemolytic reactions. This is because pre-transfusion testing for irregular/unexpected antibodies that helps to prevent these risks are neither universally available nor accessible. The aim of our study was to determine the prevalence of red blood cell alloantibodies and their specificity in patients transfused in Burkina Faso.

MATERIALS AND METHODS

This was a cross-sectional study including patients who had received at least one blood transfusion. Indirect antiglobulin testing using LISS-enhanced medium gel column agglutination technique was used for antibodies screening and identification. Enzymatic technique with papain-treated red cell reagent was performed in attempt to solve some difficulties if necessary as well as auto-control test and RH-KEL phenotyping when possible to help antibodies identification.

RESULTS

A total of 832 patients were included, 51.6% of whom were female, and the median (IQR) age was 34 (20-49) years. Of these, 43.7% had chronic kidney disease and 20.4% were sickle cell patients. The median (IQR) number of immunisation episodes (blood transfusion and pregnancies) was 3 (2-6) with the median (IQR) number of blood units received per patient of 2 (1-5). The proportion of patients with RBCs antibodies was 6.4% (53/832), with mainly anti-Rh antibodies. A combination of 2 antibodies was found in 7 patients and a combination of 3 antibodies in one patient. Antibodies of unknown specificity (AUS) were encountered in 29%. Independent factors associated with antibody positivity were age (OR = 1.02; p = 0.026), sickle cell disease (OR = 3.23; p = 0.017) and receiving more than 10 blood units (OR = 7.33; p = 0.01).

CONCLUSION

In this study, the proportion of patients with RBC antibodies was quite similar to that observed in Sub-Saharan African countries. However, the availability and accessibility of pre-transfusion compatibility tests as well as the quality of methods used should be improved to ensure the safety of blood transfusions.

Bleeding, Hemorrhagic Shock, and the Global Blood Supply

Hemorrhage is responsible for at least 40% of deaths after trauma and 27% of maternal deaths worldwide. Patients with hemorrhagic shock require attentive critical care and transfusion of blood products. Access to a safe and affordable blood supply is critical to providing safe surgical care. Traumatic injury, obstetric hemorrhage, and upper gastrointestinal bleed are the main causes of severe bleeding requiring transfusion. This article discusses the presentation and management of these causes across the world and provides a brief overview of the current challenges in maintaining a global blood supply.

Red blood cell alloimmunisation in multi-transfused patients with chronic renal failure undergoing haemodialysis in Ouagadougou, Burkina Faso, 2018

Background

In Burkina Faso, red blood cell (RBC) transfusion remains the crucial anaemia treatment following chronic renal failure (CRF) as erythropoietin and its analogues are unavailable. However, blood group matching beyond the ABO and Rhesus is not common in Burkina Faso. Thus, alloimmunisation is a potential issue for transfused patients.

Objective

Our study aimed to identify anti-erythrocyte antibodies in multi-transfused CRF patients at the Yalgado Ouedraogo Teaching Hospital, Ouagadougou, Burkina Faso.

Methods

This cross-sectional study, conducted from October 2018 to November 2019, included CRF patients who had received at least two RBC units. We screened patients for the presence of RBC antibodies using three commercial Cells panels and identified antibody specificities for positive screenings using 11 Cells panels for an indirect antiglobulin test (IAT) in a low ionic strength microcolumn gel-card system.

Results

Two hundred and thirty-five patients (45.1% female; average age: 41.5 years) were included. The median number of blood units received per patient was 10 (interquartile range: 5–20). The overall alloimmunisation rate was 5.9% (14/235). Antibodies identified included: anti-D (1 case), anti-C (1 case), anti-D+C (4 cases), anti-C^W (1 case), anti-E (1 case), anti-S (1 case) and anti-Le^a (1 case). In four positive patients, the specificity of the antibodies was indeterminate. No risk factors were associated with alloimmunisation.

Conclusion

In Burkina Faso, screening for RBC alloantibodies should be mandated for patients at risk. The high rate of indeterminate antibodies suggests the need to develop a local RBC antibody panel adapted to the local population.

Status of hospital-based blood transfusion services in low-income and middle-income countries: a cross-sectional international survey

OBJECTIVES

Blood transfusion is life-saving for patients experiencing acute blood loss and severe anaemia. In low-income and middle-income countries (LMICs), low blood donation rates and unavailability of whole blood and blood components (blood products) impairs timely blood transfusion. To fulfil patient-specific blood orders, a hospital blood transfusion service (HBTS) receives orders from a prescriber for blood transfusion, tests and prepares blood products for the patient. This study sought to describe the current state of LMIC HBTS.

DESIGN

A cross-sectional survey explored LMIC HBTS access to blood products, testing methods, policies and structure. Surveys were administered in English, Spanish, French and Russian, followed by a mixed-methods analysis.

SETTING

HBTS within LMICs.

PARTICIPANTS

From among 124 public and private facilities invited to participate, we received 71 (57%) responses. Of these responses, 50 HBTS from 27 LMICs performed on-site blood transfusions.

RESULTS

Most LMIC HBTS perform blood collection to generate blood products for their patients (36/47, 77%); few relied exclusively on an external supply of blood products (11/47, 23%). The primary reason for blood transfusion was adult anaemia for non-malignant conditions (17/112, 15%). Testing methods varied by gross national income per capita. Blood transfusion delays to patients were common (17/30, 57%) attributed to inadequate blood inventories (13/29, 45%). Other barriers included lack of regular clinician education about transfusion (8/29, 28%) and sustainable financial models for the HBTS (4/29, 14%).

CONCLUSION

This survey describes the status of HBTS in diverse LMICs, illustrating that the availability of blood products remains a principal problem, requiring HBTS to generate its own facility's blood supply. Currently, blood shortages are not reported as a patient-specific adverse event making systematic tracking of delays in transfusion difficult. These findings highlight areas for further exploration related to the lack of available blood inventories for transfusions at HBTS in LMICs.

Barriers and drivers of voluntary blood donation in northern and Western Tanzania

Introduction: Every second, someone in the world needs blood due to surgery, trauma, severe anemia or pregnancy complications. There is a shortage of blood for transfusion worldwide, with the heaviest burden faced by sub–Saharan Africa. In countries like Tanzania, the major source of blood is voluntary blood donation, making its supply one of the most challenging in the health care system. This study assessed the magnitude of the deficit of blood in blood banks, and explored views of key stakeholders on the need, availability and opportunities for improving blood donations in northern and Western Tanzania. Methods: This was an explanatory sequential mixed method study done in the Mpanda and Moshi districts in the Katavi and Kilimanjaro regions. A quantitative component involved a questionnaire survey with 253 community members from the two districts and 24 months blood bank records. The survey explored awareness and perceptions of voluntary blood donation. A qualitative component involved four focus group discussions with registered voluntary blood donors and health care providers from the National Blood Transfusion Service in the two districts. Results: Blood bank records indicated that more blood was collected in Katavi compared to the Kilimanjaro region. Only 26% of the survey respondents had ever donated blood in their lifetime, three quarters of these were from Mpanda district. There was no significant association between socio-demographic factors and likelihood of blood donation. However, being male, older (51 years and above), having higher household income and secondary school education were significantly associated with higher awareness of voluntary blood donation. Community sensitization, education, incentives and availability of blood donation centers near communities were among the most important factors listed to improve blood donation. Conclusions: Significant efforts need to be placed on sensitization and improving knowledge and awareness of voluntary blood donations in order to improve its uptake.

Implementation and performance of haemovigilance systems in 10 sub-saharan African countries is sub-optimal

Background

Haemovigilance is an important element of blood regulation. It includes collecting and evaluating the information on adverse events resulting from the use of blood and blood components with the aim to improve donor and patient safety. We describe the results of the pilot of the integrated GBT+ Blood for the haemovigilance function in 10 sub-Saharan African countries.

Methods

We piloted the integrated WHO Global Benchmarking Tool plus Blood (GBT+ Blood) to assess the haemovigilance function of national regulatory authorities (NRAs) in Ethiopia, Kenya, Malawi, Nigeria, Liberia, Rwanda, South Africa, Tanzania, Uganda, and Zimbabwe. Data obtained from documents and face to face interviews were used to determine the status of implementation and performance of the following six indicators; legal provisions regulations and guidelines, organisation and governance, human resources, regulatory processes, transparency and accountability and finally, monitoring progress and assessing impact, by estimating median scores across 20 sub-indicators. In addition, a cluster analysis was performed.

Results

The countries showed inter-organisation variability in implementation and performance of the haemovigilance function. The overall median score (all sub-indicators) was 44 % (range: 7.5 % - 70 %). The lowest average performance scores were for the arrangement for effective organisation and coordination (35 %) and human resources (35 %) indicators. The highest average scores were observed for the mechanism to promote transparency and mechanism to monitor regulatory performance indicators (50 % and 60 %, respectively). We identified clusters of best-implemented sub-indicators from the procedures for haemovigilance and poorly implemented sub-indicators from the legal provisions, regulations and guidelines for haemovigilance and human resources.

Conclusions

Implementation of sub-indicators and performance of haemovigilance systems varied greatly for all countries with a few countries performing reasonably well in the implementation of some sub-indicators under procedures for haemovigilance. Most countries were poorly implementing sub-indicators in the legal provisions, arrangement for effective organisation and human resources indicators. The legislative provisions in most countries were at a nascent stage. There is a need to set up targeted and customised technical support coupled with prioritised interventions to strengthen the capacities of NRAs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07235-0.

Cost-effectiveness and budget impact of whole blood pathogen reduction in Ghana

BACKGROUND

Despite the promise of pathogen reduction for reducing transfusion-associated adverse events in sub-Saharan Africa, no health-economic assessment is publicly available.

STUDY DESIGN AND METHODS

We developed a mathematical risk reduction model to estimate the impact of nationwide whole blood pathogen reduction in Ghana on the incidence of six infectious and one non-infectious transfusion-associated adverse events. We estimated the lifetime direct healthcare costs and disability-adjusted life years lost for each adverse event. For HIV, HCV, and HBV, we simulated disease progression using Markov models, accounting for the likelihood and timing of clinical detection and treatment. We performed probabilistic and univariate sensitivity analysis.

RESULTS

Adding whole blood pathogen reduction to Ghana's blood safety portfolio would avert an estimated 19,898 (11,948-27,353) adverse events and 38,491 (16,444-67,118) disability-adjusted life years annually, primarily by averting sepsis (49%) and malaria (31%) infections. One year of pathogen reduction would cost an estimated $8,037,191 ($6,381,946-$9,880,760) and eliminate $8,656,389 ($4,462,614-$13,469,448) in direct healthcare spending on transfusion-associated adverse events. We estimate a 58% probability that the addition of pathogen reduction would reduce overall direct healthcare spending. Findings were most sensitive to uncertainty in the probability that a bacterially contaminated blood donation causes sepsis.

CONCLUSION

Whole blood pathogen reduction would substantially reduce the burden of known transfusion-associated adverse events in Ghana and may reduce overall healthcare spending. Additional benefits not captured by this analysis may include averting secondary transmission of infectious diseases, reducing non-medical costs, and averting new or re-emerging transfusion-transmitted infections.

Rapidly freeze-dried human red blood cells for pre-transfusion alloantibody testing reagents

Prior to transfusion of red blood cells (RBCs), recipients must be tested for the presence of alloantibodies to avoid immune complications. Liquid-preserved reagent RBCs with known blood group antigen phenotypes are used for testing. However, these reagents have practical constraints, including limited shelf-life and require constant refrigeration. To address these issues, we explore the effects of rapid freeze-drying conditions with trehalose cryoprotectant (0.1-1 M concentrations) on human RBCs and storage of freeze-dried RBCs (FDRBCs) at room temperature (RT) for up to 12 months. We report that rapid freeze-drying of RBCs for 2.5 hr with 0.5 M trehalose achieves recoverable cells with near-normal morphological shape, although size-reduced. The FDRBCs are metabolically active and functional in antibody-agglutination tests by the column agglutination test (CAT) for ABO and Rhesus-D blood group antigens. Expression of the Duffy blood group protein (CD234) decreases by 50% after freeze-drying RBCs. The initial recovery rate is ≤25%; however, 43% of these FDRBCs are still recoverable after RT storage for 12 months. In this proof-of-principle study, we show that rapid freeze-drying can stabilize RBCs. Further refinements to improve the recovery rate and preservation of antigenic epitopes will make FDRBCs a practical alternative source of reagent RBCs for pre-transfusion alloantibody identification.

Cochrane corner: convalescent plasma or hyperimmune immunoglobulin for people with COVID-19

As the novel coronavirus continues to spread globally and across Africa, efforts are being accelerated to identify effective preventive and therapeutic measures to mitigate its burden. Convalescent plasma and hyperimmune immunoglobulin are being considered as potential therapeutic options for the coronavirus disease 2019 (COVID-19). We highlight and contextualize the findings of a recent Cochrane rapid review that evaluated the effectiveness and safety of convalescent plasma or hyperimmune immunoglobulin transfusion in the treatment of people with COVID-19. From the eight studies it included, the review found limited and low-certainty evidence on the effectiveness and safety of convalescent plasma therapy in patients with COVID-19. The evidence was limited by the small number of participants and low-quality of included studies, as well as the inconsistency of outcome measures and reporting across studies. As African countries brace for the further spread of the virus, while exploring potential therapeutic options to mitigate its morbidity and mortality at peak, convalescent plasma transfusion may offer a therapeutic ray of hope for the continent. Considering the limited evidence of the effectiveness and safety in the treatment of COVID-19, it is imperative for this therapy to be investigated within African contexts to ascertain not only its effectiveness and safety, but also its practical implications within the capacity of national blood transfusion services and health systems in the region.

Primary healthcare practitioners and patient blood management in Africa in the time of coronavirus disease 2019: Safeguarding the blood supply

The coronavirus disease 2019 (COVID-19) pandemic has highlighted various weaknesses in global healthcare services. The blood supply in Africa is a critical element of the healthcare service that may be significantly affected by the pandemic. By implementing principles of patient blood management, primary healthcare practitioners may play an important role in the resilience of the blood supply during the COVID-19 pandemic.

Barriers to Effective Transfusion Practices in Limited-Resource Settings: From Infrastructure to Cultural Beliefs

Background

Surgery and anesthesia are indivisible parts of health care, but safe and timely care requires more than operating rooms and skilled providers. One vital component of a functional surgical system is reliable blood transfusion. While almost half of all blood is donated in high-income countries (HICs), over eighty percent of the global population lives outside of these countries. High-income countries have on average 30 donations per 1000 people, and the average age of transfusion recipient is over 65. Most low-income countries (LICs) have fewer than five donations per 1000 people, where maternal hemorrhage and childhood anemia are the most common indications for transfusion. In LICs, greater than 50% of blood is administered to children under 5 years of age. This study aims to snapshot, by survey, available resources for transfusion and then discusses the infrastructure and cultural barriers to optimal transfusion practice.

Methods

In January 2019, a 10-question survey was sent electronically to physician anesthesiologists working in low- and middle-income countries to examine resources and practice patterns for blood transfusion. Subsequent discussions illustrate obstacles contributing to low availability of blood products and illuminate infrastructure and cultural barriers preventing optimal transfusion practices.

Survey Results

Acquiring whole blood takes hours. Clinicians wait days to receive packed red blood cells or platelets. Fresh frozen plasma is available but untimely. For many, protocols for massive transfusion are rare, and for transfusion, ratios are nonexistent. Complete blood counts take hours, and coagulation profiles are severely delayed.

Discussion of Infrastructure and Cultural Barriers

With few voluntary, unpaid, donors and inconsistent supply of testing kits, donated blood is unsafe. Donors are seasonal for farming communities, endemic malaria areas, and student donors recruited through schools. Cultural beliefs fuel distrust. Transfusion specialists, concentrated in urban areas, see rural patients presenting late. Inadequate triaging and supervision jeopardize patients to shock. Inadequate blood storage leads to waste. Modeling systems from HICs fail to overcome hurdles faced by clinicians working with distinctive belief systems and unique patient populations.

Translation of Cryobiological Techniques to Socially Economically Deprived Populations—Part 1: Cryogenic Preservation Strategies

Use of cold for preservation of biological materials, avoidance of food spoilage and to manage a variety of medical conditions has been known for centuries. The cryobiological science justified these applications in the 1960s increasing their use in expanding global activities. However, the engineering and technological aspects associated with cryobiology can be expensive and this raises questions about the abilities of resource-restricted low and middle income countries (LMICs) to benefit from the advances. This review was undertaken to understand where or how access to cryobiological advances currently exist and the constraints on their usage. The subject areas investigated were based on themes which commonly appear in the journal Cryobiology. This led in the final analysis for separating the review into two parts, with the first part dealing with cold applied for biopreservation of living cells and tissues in science, health care and agriculture, and the second part dealing with cold destruction of tissues in medicine. The limitations of the approaches used are recognized, but as a first attempt to address these topics surrounding access to cryobiology in LMICs, the review should pave the way for future more subject-specific assessments of the true global uptake of the benefits of cryobiology.

The long and winding road to pathogen reduction of platelets, red blood cells and whole blood

Pathogen reduction technologies (PRTs) have been developed to further reduce the current very low risks of acquiring transfusion-transmitted infections and promptly respond to emerging infectious threats. An entire portfolio of PRTs suitable for all blood components is not available, but the field is steadily progressing. While PRTs for plasma have been used for many years, PRTs for platelets, red blood cells (RBC) and whole blood (WB) were developed more slowly, due to difficulties in preserving cell functions during storage. Two commercial platelet PRTs use ultra violet (UV) A and UVB light in the presence of amotosalen or riboflavin to inactivate pathogens' nucleic acids, while a third experimental PRT uses UVC light only. Two PRTs for WB and RBC have been tested in experimental clinical trials with storage limited to 21 or 35 days, due to unacceptably high RBC storage lesion beyond these time limits. This review summarizes pre-clinical investigations and selected outcomes from clinical trials using the above PRTs. Further studies are warranted to decrease cell storage lesions after PRT treatment and to test PRTs in different medical and surgical conditions. Affordability remains a major administrative obstacle to PRT use, particularly so in geographical regions with higher risks of transfusion-transmissible infections.

Red Blood Cell Alloimmunization in Transfused Patients With Sickle Cell Disease in Sub-Saharan Africa; a Systematic Review and Meta-Analysis

Sickle cell disease (SCD) is the most common monogenic disorder in sub-Saharan Africa (SSA). Blood transfusion to increase the oxygen carrying capacity of blood is vital in the management of many patients with SCD. However, red blood cell (RBC) alloimmunization is a major challenge to transfusions in these patients. Commonly in SSA, pretransfusion tests only involve ABO D grouping and compatibility without RBC antibody testing. Data on the frequency of RBC alloimmunization in patients with SCD in SSA are limited. We performed a systematic review and meta-analysis on available data on alloimmunization in transfused patients with SCD to determine the published prevalence of RBC alloimmunization in SCD patients in SSA. Six databases were systematically searched to identify relevant studies, without year or language restrictions. In all, 249 articles were identified and 15 met our selection criteria. The overall proportion of alloimmunization was 7.4 (95% confidence interval: 5.1-10.0) per 100 transfused patients. Antibodies against E, D, C, and K antigens accounted for almost half of antibody specificities, and antibodies to low- and high-frequency antigens were also common and represented almost 30% (20% to low-frequency antigens and 9% to high-frequency antigens) of specificities. Heterogeneity between studies was moderate, and meta-analysis found region of Africa as the major contributor to the heterogeneity. We also observed inconsistencies across studies in reporting of factors that may influence alloimmunization. This review provides an overview of the extent of the alloimmunization problem in SSA and provides a baseline against which to compare the effect of any interventions to reduce the alloimmunization risk.