Trends and Gaps in National Blood Transfusion Services - 14 Sub-Saharan African Countries, 2014-2016

Transfusion transmissible infections among blood donors in Ghana: A 3-year multicentered health facility-based retrospective study

Transfusion transmissible infections (TTIs) remain a major health challenge particularly in developing countries. Here, we present a multicentered hospital-based retrospective study on the prevalence, distribution, and risk factors of TTIs in Ghana. Data on blood donors from four health facilities, namely Nkwanta South Municipal Hospital (Oti region), Weija-Gbawe Municipal Hospital (Greater Accra region), SDA Hospital (Northern region) and Wa Municipal Hospital (Upper West region) were extracted and analyzed. Descriptive statistics and multinomial logistic regression were applied to compare sociodemographic data with TTI status. A total of 6094 blood donors were included in this study, and 2% were females. The overall prevalence of TTIs was 21.0% (1232/5868). Specifically, the prevalence of HBV, HCV, HIV, and Syphilis was 6.6% (385/5868), 4.9% (286/5830), 2.9% (168/5867), and 6.8% (393/5739), respectively. Wa dominated in all the viral agents considered in this study, while the Oti region recorded the highest prevalence in T. pallidum. The odds of HBV infection was 3.1 (p = 0.008) among first-time donors, while that for HCV was 2.8 (p = 0.042). For rural dwellers, donors significantly had T. pallidum (p < 0.001; OR = 2.8), HCV (p < 0.001; OR = 2.9), and HIV (p = 0.028; OR = 1.5) infections. Generally, the recipients of transfused blood were predominantly pregnant mothers, followed by children and accident victims. This study has revealed significant disparities and relatively high prevalence of TTIs in Ghana, specifically HBV, HCV, HIV and T. pallidum infections. The variations suggest the presence of unique health challenges per study area, hence the need for a tailored intervention for each study site.

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.

Nucleic acid testing identifies high prevalence of blood borne viruses among approved blood donors in Mozambique

Background

Although blood transfusion is an intervention that saves lives, it poses significant risks to the blood receivers, including the transmission of bloodborne pathogens. We aimed at determining the prevalence of Human Immunodeficiency Virus (HIV), Hepatitis B virus (HBV), and Hepatitis C virus (HCV) in candidates approved for blood donation, and in samples considered to be negative in reference blood banks in Mozambique.

Methods

A cross-sectional study was performed between November 2014 and October 2015 in Maputo and Beira cities. Demographic information was obtained from all consenting blood donors using a structured questionnaire. Plasma samples were screened for HIVAb/Ag combinations, HBsAg and Anti-HCV. Blood donors considered to be negative by serological testing were re-tested in pools of six plasma samples using nucleic acid testing (NAT).

Results

Most blood donors were male 2,320 (83.4%) with an age range of 18 to 34 years. The overall seroprevalence of HIV, HBV and HCV infections among blood donors approved for donation was 4.6% (127; 95% CI 3.8–5.4), 4.5% (124; 95% CI 3.7–5.3) and 0.4% (11; 95% CI 0.2–0.7), respectively. The overall frequency by NAT of HIV RNA, HBV DNA, and HCV RNA in serologically negative blood donor samples was 2.6 per 1000 blood donors (7; 95% CI 1.1–5.4); 12.5 per 1000 blood donors (33; 95% CI 8.6–17.5) and 2.6 per 1000 blood donors (6; 95% CI 1.0–5.7), respectively.

Conclusion

Our results show high seroprevalence of HIV and HBV infections in blood donors approved for donation, and high frequency of molecular biomarkers of HIV, HBV, and HCV in blood considered to be safe. These results suggest the need for a new blood screening policy in Mozambique, including the use of NAT to detect infectious blood donations during the immunologically negative window.

Baseline assessment findings of the Africa Society for Blood Transfusion Step-Wise Accreditation Programme in 10 sub-Saharan African countries, 2016-2018

BACKGROUND AND OBJECTIVES

The accreditation of blood services promotes continuous quality improvement in blood and transfusion services. The Africa Society for Blood Transfusion (AfSBT) conducted 20 baseline assessments of National Blood Transfusion Services (NBTS) or blood banks as part of the Step-Wise Accreditation Programme (SWAP) in 10 sub-Saharan African (SSA) countries from 2016 to 2018. This paper aims to elucidate the process and findings of the baseline assessments.

MATERIALS AND METHODS

This is a descriptive study of 20 baseline assessments of NBTS. Eleven sections of the AfSBT assessment were reviewed, and 48 out of 68 standards and 356 out of 466 criteria were assessed. Each standard was assigned a value of 1 if it was fully achieved, 0.5 if partially achieved and 0 if not achieved. We defined average section scores >75% as having 'met AfSBT Standards', ≤25% as not meeting standards, 26%-50% as needs major improvement, and 51%-75% as needs some improvement and >75% as meets standards.

RESULTS

The AfSBT SWAP standards were met in 4 out of the 11 sections: donor management, blood collection, component production and compatibility testing. Three sections were determined to need some improvement (quality system; handling, transport and storage and testing of donated blood), and three sections were determined to need major improvement (haemovigilance, blood administration and national blood service accreditation). One section (receipt, ordering, and issuing of blood) did not meet standards.

CONCLUSION

Despite improvements in the quality of blood services in SSA over the past two decades, governments may consider the importance of prioritizing investments in NBTS, ensuring these institutions meet international accreditation standards that are aligned with safe blood transfusion services.

Safe blood supply in sub-Saharan Africa: challenges and opportunities

The low recruitment and retention of blood donors in sub-Saharan Africa is a grave concern for blood transfusion services in the region. This problem is exacerbated by factors such as a high prevalence of transfusion-transmissible infections and anaemia, over-reliance on family replacement donors, resource constraints, and poor communication with the public. To improve blood safety and availability, innovative intervention strategies must be developed and implemented. The primary objective of this Series paper is to discuss the available evidence in the region and to provide recommendations on how to improve safe blood supply in sub-Saharan Africa. These recommendations include a call for renewed attention to donor recruitment in blood transfusion centres, a consistent and structured educational intervention, the development and adherence to national policies on blood donor selection with focus on voluntary donations, and comprehensive screening of donations for transfusion-transmissible infections. TRANSLATION: For the French translation of the abstract see Supplementary Materials section.

Association between volume resuscitation & mortality among injured patients at a tertiary care hospital in Kigali, Rwanda

BACKGROUND

Injuries cause significant morbidity and mortality in sub-Saharan African countries such as Rwanda. These burdens may be compounded by limited access to intravenous (IV) resuscitation fluids such as crystalloids and blood products. This study evaluates the association between emergency department (ED) intravenous volume resuscitation and mortality outcomes in adult trauma patients treated at the University Teaching Hospital-Kigali (UTH- K).

METHODS

Data were abstracted using a structured protocol for a random sample of ED patients treated during periods from 2012 to 2016. Patients under 15 years of age were excluded. Data collected included demographics, clinical aspects, types of IV fluid resuscitation provided and outcomes. The primary outcome was facility-based mortality. Descriptive statistics were used to explore characteristics of the population. Kampala Trauma Scores (KTS) were used to control for injury severity. Magnitudes of effects were quantified using multivariable regression models adjusted for gender, KTS, time period, clinical interventions, presence of head injury and transfer to a tertiary care centre to yield adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

From the random sample of 3609 cases, 991 trauma patients were analysed. The median age was 32 [IQR 26, 46] years and 74.3% were male. ED volume resuscitation was given to 50.1% of patients with 43.5% receiving crystalloid and 6.4% receiving crystalloid and packed red blood cell (PRBC) transfusions. The median KTS score was 13 [IQR 12, 13]. In multivariable regression, mortality likelihood was increased in those who received crystalloid (aOR = 4.31, 95%CI 1.24, 15.05, p = 0.022) and PRBC plus crystalloid (aOR = 9.97, 95%CI 2.15,46.17, p = 0.003) as compared to trauma patients not treated with IV resuscitation fluids.

CONCLUSIONS

Injured ED patients treated with volume resuscitation had higher mortality, which may be due to unmeasured confounding or therapies provided. Further studies on fluid resuscitation in trauma populations in resource-limited settings are needed.

Motivations and deterrents toward blood donation in Kampala, Uganda

Severe malaria, hemorrhage during childbirth, sickle cell anemia, injury from road accidents, and other medical conditions that necessitate blood transfusions affect thousands of Ugandans every year. However, only 0.3-0.5% of the population donates blood, which is less than half of the proportion recommended by the World Health Organization to maintain a sufficient supply in blood banks and health facilities. In January 2018, Uganda faced crisis level blood shortages, increasing preventable deaths in the country as patients lacked access to life-saving transfusions. To understand the factors that impact a person's decision to give blood and to inform public health campaigns that seek to promote donation, researchers collaborated with Uganda Blood Transfusion Services (UBTS) and the Uganda Red Cross Society (URCS), the primary actors in blood donation in Uganda, to conduct 50 semi-structured in-depth interviews with blood donors and non-donors and 22 key informant interviews with UBTS and URCS staff members. Through qualitative data analysis using Dedoose software, this study identified several key motivations that promote donation, including altruism, civic duty, and opportunities for disease testing, as well as important deterrents, including fear of needles and blood and lack of awareness of or access to blood donation drives. Results have been shared with blood collection agencies to inform public health campaigns that seek to dispel fears and promote motivations toward donation to increase the blood supply and decrease preventable deaths in Uganda.

New HIV infections from blood transfusions averted in 28 countries supported by PEPFAR blood safety programs, 2004-2015

BACKGROUND

To quantify the impact of the US President's Emergency Plan for AIDS Relief (PEPFAR) on the risk of HIV transmission through infected blood donations in countries supported by PEPFAR blood safety programs.

METHODS

Data reported to the World Health Organization Global Database on Blood Safety were analyzed from 28 countries in sub-Saharan Africa (SSA), Asia, and the Caribbean during 2004-2015. We used the Goals model of Spectrum Spectrum System Software, version 5.53, to perform the modeling, assuming laboratory quality for HIV testing had 91.9% sensitivity and 97.7% specificity irrespective of testing method based on results of two external quality assurance and proficiency testing studies of transfusion screening for HIV in SSA blood centers. We calculated the number of new HIV infections from the number of transfusions and the prevalence of HIV infection acquired from blood transfusions with infected blood donations. We determined the impact of laboratory testing programs by estimating the number of new HIV infections averted since PEPFAR implementation.

RESULTS

Assuming that HIV testing would not be performed in any of these countries without PEPFAR funding, the number of new HIV infections acquired from blood transfusions averted by laboratory testing increased over time in all 28 countries. The total number of HIV infections averted was estimated at 229 278 out of 20 428 373 blood transfusions during 2004-2015.

CONCLUSION

Our mathematical modeling suggests a positive impact achieved over 12 years of PEPFAR support for blood safety. Standardized HIV testing of donated blood has reduced the risk of HIV transmission through blood transfusions in SSA, Asia, and the Caribbean.

Demographical Pattern of Blood Donors and Pre-Donation Deferral Causes in Dhahran, Saudi Arabia

Background

Understanding the demographic features of blood donors is important for identifying the donor structure and guiding the recruitment and retention strategies of donors. This study was aimed to determine the demographic characteristics of blood donors, the types of donation drives, and the frequency and reasons for pre-donation deferral in our population.

Methods

This cross-sectional study included data analysis of all prospective blood donors presenting themselves for donation at the Blood Bank of the King Fahad Military Medical Complex, Dhahran, Saudi Arabia between January 2010 and December 2018. Eligibility of blood donation was assessed using a standardized history questionnaire, physical examination, hemoglobin estimation, pulse rate, blood pressure, and temperature. The questionnaire included the demographic features of the donor such as age, gender, and the reason for donation and other specific risk factors that potentially affect the safety of the donor or the recipient. Data analyzed using the analysis of SPSS version 20 (SPSS Inc., Chicago, IL, USA) were used to calculate the unadjusted odds ratios (OR) and the respective 95% confidence interval for the association between the various demographic parameters.

Results

A total of 28,189 potential donations were recorded during the study period; of these, 77.4% were family replacements with females accounting for only 1.8% of all donations. Most of the donors were Saudi nationals (92.1%) of whom donors between 18 and 34 years old constituted 87.9%, while those over 40 years old represented only 7.9% of the donations. Pre-donation temporary deferral occurred in 3300 (11.7%) of all potential donation attempts. The most common causes being the recent intake of medication (24.4%) followed by low hemoglobin (14.8%), low or high blood pressure (14.6%), low or high pulse rate (13.6%), and low weight (11.6%).

Conclusion

A profile of blood donors consisting mainly of young male citizens who mostly donated for family replacement was detected. Deferral rate was found to be average when compared to other countries; the causes being similar to those detected in other developed countries. Simple descriptive statistics has shown no marked difference was noted over the 9 years of the study in neither the profile of blood donors nor the cause for temporary deferral of prospective blood donors.

Transfusion, mortality and hemoglobin level: Associations among emergency department patients in Kigali, Rwanda

BACKGROUND

Studies from high-income countries (HIC) support restrictive blood transfusion thresholds in medical patients. In low- and middle-income countries (LMIC), the etiologies of anemia and baseline health states differ greatly; optimal transfusion thresholds are unknown. This study evaluated the association of packed red blood cell (PRBC) transfusion with mortality outcomes across hemoglobin levels amongst emergency center (EC) patients presenting with medical pathology in Kigali, Rwanda.

METHODS

This retrospective cohort study was performed using a random sample of patients presenting to the EC at the University Teaching Hospital of Kigali. Patients ≥15 years of age, treated for medical emergencies during 2013-16, with EC hemoglobin measurements were included. The relationship between EC PRBC transfusion and patient mortality was evaluated using logistic regression, with stratified analyses performed at hemoglobin levels of 7 mg/dL and 5 mg/dL.

RESULTS

Of 3609 cases sampled, 1116 met inclusion. The median age was 42 years (IQR 29, 60) and 45.2% were female. Transfusion occurred in 12.1% of patients. Hematologic (24.4%) and gastrointestinal pathologies (20.7%) were the primary diagnoses of those transfused. Proportional mortality was higher amongst those receiving transfusions, although not statistically significant (23.7% vs 17.0%, p = 0.06). No significant difference in adjusted odds of overall mortality by PRBC transfusion was found. In stratified analysis, patients receiving EC transfusions with a hemoglobin >5.0 mg/dL, had 2.21 times the odds of mortality (95% CI 1.51-3.21) as compared to those ≤5.0 mg/dL.

CONCLUSIONS

No association between PRBC transfusion and odds of mortality was observed amongst EC patients in this LMIC setting. An increased mortality association was found for patients receiving PRBC transfusions with an initial hemoglobin >5 mg/dL. Results suggest benefits from PRBC transfusion are limited as compared to HIC. Further research evaluating emergent transfusion thresholds for medical pathologies should be performed in LMICs to guide practice.

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.