Blood supply management: experience and recommendations from the Netherlands

Sanquin Blood Supply is the only organization mandated to supply and deliver allogeneic blood products to all hospitals as requested. In the Netherlands two main responsible organizations can be distinguished, the blood establishment (Sanquin) and the hospitals. Sanquin monitors yearly the hospital demand for next years budget, the basis for the yearly collection plan with weekly steering based on the actual inventory levels. Blood supply management was developed recently to understand how nationally organized blood supply organizations have blood available for patients in need. An update was done of an analysis as recommended by the Council of Europe working party of the strength and weaknesses, opportunities and threats of the blood supply organisation in the Netherlands as described previously [ http://dx.doi.org/10·1111/j.1423-0410·2009·1252.x ]. The strengths are first the long standing commitment of voluntary blood donors. Donor commitment is high and research to understand motivation and retention to predict trends and developments in availability is important. This research has contributed to the EU co-funded DOMAINE project (Donor MAnagement IN Europe). The second strength is inventory management on a National level. The cooperation between blood supply and hospital transfusion laboratories is a third strength. A fourth strength is the national consensus on Blood Transfusion from experts in the whole transfusion chain that serves as national guideline. The transfusion trigger in the consensus resulted in a low 2011 transfusion rate of 31/1000 inhabitants as quality marker. Weaknesses are limited business hours for collection as result of efficiency aggravated by an ongoing decrease in demand. Further, inventory management has focused on minimizing the discard and less excess collection asks for flexible steering. Especially for Fresh Frozen Plasma steering effects are delayed by the 6 months quarantine period with risk of shortages by sudden increased demand or decreased collection levels. Another weakness is the challenge to get detailed clinical demand information. Opportunities of one virtual national inventory are the development of mathematical tools to support optimal inventory management. The increasing donor selection criteria may lead to less donor availability as a threat to the system. In the Netherlands the blood supply was centralized and with a national inventory availability is maintained and discard minimized. A national blood collection plan with weekly inventory review for RBC per blood type drives the operations. Mathematical models are used to optimize inventory management of platelets and developed for RBC. The EU co-funded DOMAINE manual describes donor management, while strict transfusion triggers resulted in moderate demand. This integrated system of donor and inventory management with moderate clinical use resulted in a reliable supply. Challenges encountered are delayed steering effect on fresh frozen plasma inventory levels, while safety measures and demographic changes can become a threat.     

Plasma fractionation in Asia–Pacific: challenges and perspectives

Patients in every country should have access to quality blood products. National health authorities play a critical role in ensuring that patients’ needs are met with safe and cost-effective products. Fractionated plasma products, as other blood products, are essential therapeutics used in the prevention, management, and treatment of life-threatening conditions resulting from trauma, metabolic congenital deficiencies, immunological disorders or infections. A few high development index (HDI) countries in the region have sufficient access to a broad portfolio of plasma products (coagulation factors, immunoglobulin, albumin) through domestic (e.g. Australia, Japan, Korea) or contract (e.g. Singapore, New Zealand) plasma fractionation programmes. China is gradually establishing a modern plasma fractionation industry. Other countries face plasma product shortages leading to inappropriate clinical use of plasma for transfusion and of non-virally inactivated cryoprecipitate, and ultimately to inappropriate treatment of patients. The volume of plasma fractionated in the region is too low to meet the needs. The volume (about 6 million l) represents 20% of the total volume fractionated worldwide for 60% of the world population. There is a rationale to encourage plasma contract fractionation programmes or operation of domestic facilities (when justified) to use local resources. However, many challenges are being faced as national plasma fractionation programmes require a mature blood collection infrastructure. Unfortunately, several LDI countries lack a mature national blood programme and a legislative framework on national policies and legislation on blood donations. They lack a safe blood donor base and a well-organized, nationally coordinated blood transfusion services; their blood collection system is scattered among different entities, resulting in non-uniform screening and testing procedures. Financial and human resources are lacking. Still, a few countries (e.g. Hong Kong, Malaysia, Singapore, Taiwan) have strengthened the national blood programmes, national blood policies have been implemented and the management of the blood transfusion service improved, allowing to implement contract plasma fractionation programme with established fractionators. Others are considering initiating (Indonesia and Malaysia) or enhancing (Thailand) domestic fractionation. Plasma fractionation programmes require good awareness and understanding by national regulatory authorities on quality criteria of plasma products. Local plasma product market and potential trends should be evaluated to determine plasma needs and the capacity to implement collection of plasma by apheresis from volunteer dedicated donors to supplement recovered plasma as a source material for fractionation. Appropriate choice of a contract fractionation partner should be made and contract terms discussed carefully. The fractionation technology and product portfolio should be evaluated to make sure that intended products can meet domestic needs (e.g. range, potency and formulation). A reimbursement policy (in particular for IVIG) for a range of proven indications should be established, as approved in the marketing authorization dossier. Confidence of clinicians and patients in the quality and safety of domestic vs. imported products should be built. With the economical development of the region and the ageing population trends, the needs for plasma products are expected to increase, justifying efforts to fractionate domestic plasma (e.g. initially through contract fractionation) and increase guarantee of supply in quality plasma products.     

Regulation of blood services in Africa

Blood and blood products save lives and are a part of the WHO Essential Medicines List. Access to safe and quality-assured blood and blood products are essential for health systems strengthening and it is a global concern. Their use is associated with infectious and immunologic risks. At global level, many resolutions have been adopted by the World Health Assembly that urged Member States to ensure regulatory control of access to quality-assured blood and blood products along the entire transfusion chain. The WHO has also developed an action framework to advance universal access to blood. As part of the implementation of these resolutions and guidelines, the WHO Regional Office for Africa and some partners provided support to countries in the region to strengthen their capacity to establish an effective blood regulatory system through organization of regional training workshops on blood regulation, benchmarking of blood regulatory systems, internship at Paul Ehrlich Institut and establishment of the African Blood Regulators Forum. The current status of blood regulation reveals that there are weak transfusion legislation and blood regulatory systems in most African countries, since many national blood transfusion services still rely on self-regulation. However, the national regulatory authorities have reached the maturity level 3 in two countries (Ghana and Tanzania), but only the experience from Ghana has been described in this paper. Like in other low- and middle-income countries, the regulatory systems for associated substances and medical devices including IVDs are not well established in the African region. Misunderstanding by different stakeholders, lack of legislation that provides legal basis, weak capacity and insufficiency of resources are main challenges facing countries to establish an effective national blood regulatory system. To address these challenges, strong advocacy with governments and collaboration with partners are needed to strengthen national blood regulatory systems.     

Ethics in transfusion medicine: Are the intricate layers of ethics all universal? A global view

Ethical principles have been considered, and in several respects regulated, along the entire blood procurement chain from donor motivation to transfusion to the patient. Consent of donors and voluntary non-remunerated donation are fields which have been addressed by codes of ethics and legislation. Caring for donor health is an area of further development of ethical standards. In part, blood products have also become a market, where commercial principles may synergize, but also creating issues in equality and maintaining human dignity that challenge societal solutions. At the bedside, the main global challenge remains to procure enough blood products for each patient in medical need. Allocation of rare blood, ethical evaluation of transfusion triggers, attitudes towards refusing blood transfusion and provision of blood products to remote settings are areas which should receive consideration.     

Disease transmission by blood products: past,present and future

Transfusion of blood and blood products has been associated with transmission of infectious agents. However, it is probable that blood products are currently very safe and that pooled virus-inactivated products from remunerated donors are now safer than untreated single voluntary donor components. Although the transmission events of the past and the present are reasonably well understood, reliance on a linear approach to predict safety in the future is open to criticism. Indeed, it was not possible to predict the extent or consequences of the AIDS epidemic or of hepatitis C transmission. Moreover, although variant Creutzfeldt-Jakob disease (vCJD) may not be transmitted to any large extent by transfusion of manufactured blood products, this will be due more to good fortune than good judgement - this agent could have escaped the screening, testing and eradication methods on which current confidence in blood product safety depends. Similarly, the emergence of a highly resistant non-enveloped virus, or even of another previously unrecognised disease-causing agent, could result in new threats from transfusion of blood components and products. The ecology of blood transfusion is exquisitely sensitive to variations in starting conditions, a situation typical of a chaotic rather than a linear system. Seemingly trivial events, often apparently unrelated to blood transfusion, have had enormous consequences in this field. Whatever the events that introduced simian immunodeficiency virus to humans or scrapie to cattle, they were a long way from those involved in the manufacture of blood products. In such a setting, reliance on methods that deal effectively with known threats (such as encapsulated viruses and bacteria) without adequate investigation and management of the intrinsic sensitivity to unpredictable events, leaves open the possibility of further infections emerging in the future. It is this reality that will ultimately result in the eradication of the transfusion of donor-derived blood and blood products in the developed world. In addition, all infections with a long disease-free incubation period in the host that can be transmitted in blood will eventually be over-expressed in groups that are exposed to blood either recreationally or professionally. As in the past, this could have occurred before testing or decontamination processes have been developed for emerging pathogens. Failure to be able to rely on completely risk-free donors, in both the voluntary and non-voluntary sides of the blood industry, continues to offer the potential for the transmission of infectious diseases in the future.     

Transfusion emergency preparedness for mass casualty events

Transfusion emergency preparedness is increasingly being recognized as an important element in the healthcare response to mass casualty events (MCE). Planning should be designed to support an integrated response between the blood services and hospitals. The lessons identified from the Manchester Arena bombing in 2017 and recent incidents in London have led to new guidance. Demand planning has been informed by the global experience of civilian MCEs and the changing trends in trauma care. Past evidence suggests that only a modest number of hospitalized patients following MCEs require transfusion. The mean blood use per patient admitted is consistently calculated at 2–3 red cell units. Most blood is used within the first 6 h. However, a small number of critically injured with multi‐trauma may require massive transfusion and ongoing support. Many blood services have reported meeting the initial overall demand for blood from stock. However, universal components may be in short supply. The demand can be managed by pre‐agreed substitutions. Early transfusion triage enables the best use of hospital laboratory and blood service support. Careful communication with donor communities is essential to manage a controlled replenishment of stocks. Future challenges for the transfusion community include the trend towards lower red cell stock holdings and the changing trends in weapon use and tactics. A standardized approach to transfusion data collection is required to support future planning. The transfusion community is encouraged to plan for MCEs, contribute to ‘after action reviews’ and work together for safe and sustainable transfusion support.     

The impact of COVID-19 pandemic on blood supplies and transfusion services in Eastern Mediterranean Region

BackgroundSevere Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has spurred a global health crisis. The safety and supply of blood during this pandemic has been a concern of blood banks and transfusion services as it is expected to adversely affect blood system activities. We aim to assess the situation in the Eastern Mediterranean Region (EMR) during the first months of the pandemic.Materials and methodsA survey was designed to address blood supply, transfusion demand, and donor management during the coronavirus disease-19 (COVID-19) pandemic. Medical directors of different blood banks were invited to participate.ResultsA total of 16 centers participated with representation from 15/19 countries in the region. In total, 75% were from national blood banks. Most centres had a decrease in the blood supply, ranging from 26–50%. Representatives from 14 countries (93.3%) believed that public fear has contributed to a decrease in donations. Most centres (n = 12, 75%) had a reduction in transfusion demand, while those who did not, reported heavy involvement in treating patients with underlying haemoglobinopathies and haematological malignancies. Half of the centres activated their contingency plans. Four centres had to alter the blood donor eligibility criteria to meet demands. All centres implemented donor deferral criteria in relation to SARS-CoV-2, but were variable in measures to mitigate the risk of donor and staff exposure.ConclusionBlood services in the region faced variable degrees of blood shortages. We summarize lessons learnt during this pandemic for the blood banks to consider to plan, assess, and respond proportionately to future similar pandemics.     

Training, skill and competences' follow-up]

Blood transfusion safety is a public health requirement, which is claimed by public health authorities and blood users too. In order to comply with transfusion safety, available national regulatory requirements must be strictly followed (or applied) by blood transfusion workers, caring nurses and physicians. Transfusion's good practices are based on knowledge of the process and the skill in blood transfusion fields. Quality systems, risks management, audits, inspections and certification programs implemented by blood establishments and patients' care services should lead to efficiency. All professionals involved in blood banking and transfusion processes (blood donation, preparation and storage of blood products, transfusion therapy...) must be qualified. They have to follow a program of continued training education. Their competence or ability must also be periodically assessed and documented to let continue and perform tasks safely.     

Globalization and blood safety

Globalization may be viewed as the growing interdependence of countries worldwide through the increasing volume and variety of cross‐border transactions in goods and services, and also through the more rapid and widespread diffusion of technology. Globalization is not just an economic phenomenon, although it is frequently described as such, but includes commerce, disease and travel, and immigration, and as such it affects blood safety and supply in various ways. The relatively short travel times offered by modern aviation can result in the rapid spread of blood‐borne pathogens before measures to counteract transmission can be put in place; this would have happened with SARS if the basic life cycle of the SARS virus did not include an asymptomatic viraemia. This risk can be amplified by ecological factors which effect the spread of these pathogens once they are transferred to a naïve ecosystem, as happened with West Nile virus (WNV) in North America. The rationalization and contraction of the plasma products industry may be viewed as one aspect of globalization imposed by the remorseless inevitability of the market; the effect of this development on the safety and supply of products has yet to be seen, but the oversight and assurance of a shrinking number of players will present particular challenges. Similarly, the monopolization of technology, through patent enforcement which puts access beyond the reach of developing countries, can have an effect on blood safety. The challenges presented to blood safety by globalization are heightening the tensions between the traditional focus on the product safety – zero‐risk paradigm and the need to view the delivery of safe blood as an integrated process. As an illustration of this tension, donor deferral measures imposed by globalization‐induced risks such as vCJD and WNV have resulted in the loss of the safest and most committed portion of the blood donor population in many Western countries, leading to an increased risk to safety and supply. It is only through an appreciation of the basic needs of transfusion medicine, including the enunciation of appropriate principles to manage, rather than eliminate, risks, that the challenges imposed by globalization may be overcome.     

The utilization of rare blood donors

When transfusion is needed for a patient with a rare blood type and the corresponding antibody, it can be challenging and lead to delays in transfusion. Sometimes, the blood cannot be found. Globally, the community of rare donor facilities is extremely collaborative and is quickly engaged in locating and delivering blood to the patients in need of rare blood types. Identifying the rare donor is a resource‐intensive activity in every country especially in times of shrinking human and reagent resources. This paper will discuss the process flow for obtaining blood for patient's requiring rare types and the critical steps for each facility in the supply chain. The local facility plays a vital role in the knowledge of patient need and interaction with the patient's physician. The national facility that coordinates obtaining rare blood internationally also plays a vital role. The International Blood Group Reference Laboratory in Bristol as one of its roles, maintains the International Rare Donor Panel and also plays a vital role. These three roles hold the responsibility for collaboration to identify and obtain blood for patients in need. While there are differences in each country's definition of rare blood types, all are in agreement to assist when a country needs blood products. The International Society Blood Transfusion working party for rare donors plays a critical, collaborative role in developing processes between countries to further rare blood transfers between countries and providing expertise when needed. Outcome data are difficult to obtain, therefore success and ultimate improvement is a challenge. This challenge is one that the needs to be met to improve patient outcomes in cases where rare blood is needed throughout the world.     

The impact of training in transfusion medicine

Background Basic training skills and program for all health care providers working in the blood transfusion services is important and essential. All blood transfusion staff should have active participation in a training program that includes teaching all national and international regulations related to blood transfusion administration and guidelines of safe blood and blood products. The blood bank staff (physicians, medical technologists and nurses) should pass proper assessment procedures in order to work in this vita health related services. All staff working in blood transfusion services should receive a proper education and learning skills in this field of medicine. Awareness of blood safety and Good Manufacturing Practice (GMP) in blood transfusion should be greatly increased among them. Methods and Results Sustainable national and international education and training in blood transfusion services are needed and should be considered as a priority. Methods of teaching and training may include courses or workshops consist of a series of lectures, practical sessions, problem based learning and computer based distance learning programs. A proper training and continuous medical education in blood transfusion services have played an important role in minimizing the risk of transfusion related complications in many countries. Conclusions Creating an effective learning and training environment is a real challenge for most developing countries. Transfusion medicine is a branch of medicine which has a great link with almost all medical and surgical specialties. Blood transfusion safety plays an important and significant role in the patient's management. Proper qualified training personnel are the key of delivering safe blood components and the Good Manufacturing Practice (GMP) in blood transfusion services.     

Systems for accreditation in blood transfusion services

Accreditation is a non-governmental, voluntary process that evaluates institutions, agencies, and educational programs. It is defined as the process whereby an agency or association grants public recognition to Institutes or Blood Banks for having met certain established standards as determined through initial and periodic evaluations that usually involve submitting a self-evaluation report, site inspection by a team of experts, and evaluation by an independent board or commission. To be accredited Institution and or Blood Transfusion Services should establish and maintain quality systems involving all activities that determine the quality policy objectives & responsibilities taking into account the principles of good manufacturing practice (GMP). There are many Established systems for accreditation which can help any institution to know its strengths, weaknesses and opportunities through an informed review process. Any assessment and subsequent accreditation is made with reference to a set of standards so that the standing of an institution can be compared with that of other similar institutions. In summery the accreditation is a continuous process for improvement of quality and safety of participating institutes or facilities and we should encourage all health institutes to be involved in one or another system for accreditation. There is a need for a local or regional accreditation system for health institutes especially for blood transfusion services to help in the development and improvement of the quality of their services.     

The New Zealand national haemovigilance programme: the first step is the hardest

Blood transfusion is an important component of modern day medicine. As doctors our first consideration must always be the interests and safety of our patients. Haemovigilance programmes collect and analyse data on untoward events associated with transfusion. The information collated should be shared with health professionals who prescribe and administer blood products so that they can continue to deliver the good without unintended negative consequences. The European Directorate for the Quality of Medicines and Healthcare (EQDM) defines the standards for haemovigilance and acknowledges that it is a shared responsibility of the professionals in the field and the competent national authorities for blood safety. It includes the surveillance of donor-related events, epidemiological assessment of infections in donors, full traceability of blood components, device defects and reporting of post-transfusion infections. Implementation of a national haemovigilance system is a complex task and usually takes months of planning. Apart from the multiple resources it requires, a number of issues need to be considered: what is to be reported, how will it be reported and who will do the reporting. In addition, information and training needs to be provided to the key stakeholders. In order for a haemovigilance programme to be effective the data need to be collated, analysed and relayed back to the hospitals. Comprehensive annual haemovigilance reports that are readily accessible can include recommendations to promote strategies to reduce transfusion-related risks. In New Zealand the National Haemovigilance Programme was established in 2005. The population of New Zealand is 4·1 million. Reporting is voluntary and usually mediated via the hospital blood banks. The larger hospitals have Transfusion Nurse Specialists (TNSs) who provide education and assist with reporting adverse events. New Zealand is a country member of the Internal Haemovigilance Network (IHN) and utilizes the definitions of reporting categories agreed upon by the IHN. The majority of reports involve reactions that are mild. The overall rate of an adverse event is approximately 1 in 300 units transfused. Platelet concentrates are more frequently associated with reactions compared with other blood components and reactions are predominantly of the allergic type. The Haemovigilance Programme has demonstrated a reduction in the reported rate of transfusion-related acute lung injury (TRALI) since the introduction of male donor fresh frozen plasma (FFP) 3 years ago. The programme has also identified that bacterial contamination of blood components, incorrect blood component transfused (IBCT), wrong blood in tube (WBIT) and acute haemolytic transfusion reactions due to transfusion of passive haemolysin are risks that require further attention. Complications associated with blood donation are also included in the annual haemovigilance reports. Vasovagal reactions are the most frequently occurring donation-associated event and are higher in donors under the age of 20 years. Ongoing surveillance and review of untoward events associated with transfusion is vital so that we can continue to minimize risks related to blood products.     

Building capacities in research for blood services in Africa

BackgroundCapacity building of African based blood services researchers has been identified as key in developing a sustainable programme of generation local evidence to support sound decision making. There are a number of research training programmes that have been instituted targeted at blood services in Africa. The article shares programme experiences of building research capacities for blood services in Africa.MethodologyThe Francophone Africa Transfusion Medicine Research Training network, the NIH REDS-III and NIH Fogarty South Africa programmes and T-REC (Building transfusion research capacity in Africa) have been the key research capacity programmes targeting blood services in Africa over the last decade. To understand their experiences on the implementation of the capacity building programmes, data were drawn from research outputs, publications and end of programme reports. The success, challenges and the main research outputs from their initiatives were highlighted.ResultsThe Francophone research network achievements included more than 135 trainees and in excess of 30 publications. The NIH REDS study the achievements included more than 12 research publications with South Africa junior investigators as lead authors. The NIH Fogarty program currently includes 56 short course trainees, 5 Masters and 6 PhD candidates. The four year (2011-2015, funding period) T-REC programme produced more than 20 publications, 4 PhDs, 42 in-service Diploma in Project Design and Management (DPDM), and supported bursaries for 60 Masters/undergraduate research. The main common challenges in the running of the research programmes include shortages of in-country mentoring and identified needs in high quality research grants writing.Discussion and conclusionThe key achievements for the blood services research capacity building include a mix of short courses, medium-term (epidemiology & biostats) and MS/PhD degree training. Also, having a "train the trainers' programme to develop in-country mentors has been instrumental. Overall, the key recommendations for blood services research capacity building include the need for research collaborations with high-income countries which can jump-start research,and for more in-country grant-writing capacity building, which would help sustainability.     

Quality systems management and overview Quality Management, 20 November 2011

A generic definition of quality system describes the organizational structure, responsibilities, processes, procedures and resources required to maintain high quality products and/or services. In blood transfusion chain setting, a quality system provides a framework in a supply chain setting from a donor’s vein to a patient’s vein through the collection, processing, testing, distribution and administration of high quality, safe and effective blood and blood products.     

Transfusion-related acute lung injury: past, present, and future

Noncardiogenic pulmonary edema caused by transfusion has been observed for almost 60 years. Today, we know this entity as transfusion-related acute lung injury (TRALI). TRALI is an uncommon but potentially fatal adverse reaction to transfusion of plasma-containing blood components. It is typified by dyspnea, cough, hypoxemia, and pulmonary edema within 6 hours of transfusion. Most commonly, it is caused by donor HLA antibodies that react with recipient antigens. It may also be caused by biologically active compounds accumulated during storage of blood products, which are capable of priming neutrophils. Without a "gold standard," the diagnosis of TRALI relies on a high index of suspicion and on excluding other types of transfusion reactions. Although current definitions of TRALI depend on symptoms, laboratory parameters can aid in the diagnosis and frequently identify the causative donor unit. As our understanding of TRALI deepens, risk reduction or prevention may become possible.     

Comparison of HIV-1 detection in plasma specimens and dried blood spots using the Roche COBAS Ampliscreen HIV-1 test in Kisumu, Kenya

The World Health Organization recommends screening donor blood for HIV in centralized laboratories. This recommendation contributes to quality, but presents specimen transport challenges for resource-limited settings which may be relieved by using dried blood spots (DBS). In sub-Saharan Africa, most countries screen donor blood with serologic assays only. Interest in window period reduction has led blood services to consider adding HIV nucleic acid testing (NAT). The U.S. Food and Drug Administration (FDA) mandates that HIV-1 NAT blood screening assays have a 95% detection limit at or below 100 copies/ml and 5000 copies/ml for pooled and individual donations, respectively. The Roche COBAS Ampliscreen HIV-1 test, version 1.5, used for screening whole blood or components for transfusion, has not been tested with DBS. We compared COBAS Ampliscreen HIV-1 RNA detection limits in DBS and plasma. An AIDS Clinical Trials Group, Viral Quality Assurance laboratory HIV-1 standard with a known viral load was used to create paired plasma and DBS standard nine member dilution series. Each was tested in 24 replicates with the COBAS Ampliscreen. A probit analysis was conducted to calculate 95% detection limits for plasma and DBS, which were 23.8 copies/ml (95% CI 15.1-51.0) for plasma and 106.7 copies/ml (95% CI 73.8-207.9) for DBS. The COBAS Ampliscreen detection threshold with DBS suggests acceptability for individual donations, but optimization may be required for pooled specimens.     

AIDS and transfusion practice.

AIDS has reached epidemic proportions in many regions of the world and is rapidly spreading. Among other modes of transmission, HIV may be transmitted through the transfusion of blood and blood products. The potential for such transmission warrants and has sparked the screening of donor blood and blood products for antibodies to HIV. Safe practices for transfusion services would include promoting voluntary donors, motivating and recruiting donors from low-risk groups, encouraging high-risk donors to exclude themselves from the donor pool, obtaining trained donor pool, obtaining trained donor recruiters, and linking programs with AIDS education campaigns. Further, the Blood Safety Initiative of the World Health Organization stresses the importance of transfusing blood and its products only when required to prevent mortality or major morbidity. 4082 of 589,824 individuals screened in India over the period 1985-90 were identified as HIV-seropositive. Of these individuals, 2068 were heterosexually promiscuous, 6 were homosexual, 600 sold blood professionally, 64 were recipients of blood and blood products, and 861 were IV drug users. To help control the spread of HIV, known seropositive donors should be told of their status and permanently barred from giving blood. Since HIV seroprevalence in samples of professional blood sellers has been shown to be comparatively higher than that among voluntary donors, the professional sale of blood should be discouraged in favor of increased the voluntary supplies. ELISA and Western blot tests are used to screen blood for antibodies to HIV, while serum neopterin estimation is also helpful. Viricidal techniques for blood parasites plasma include the application of dry heat of 600 degrees Celsius for 24 hours, heptane, or treatment with solvent-detergents. Viricidal techniques for cellular components of blood remain experimental.     

Transfusion in limited infrastructure locations – where to go decades after safe blood initiative by World Health Organization?

Transfusion demand in sub‐Saharan Africa is increasing. Establishment of large national blood services seems to be challenging. Hospital blood services maintain the basic supply. However, they lack effective communication networks. Cell phones/internet provides the infrastructure for establishing such networks and could help in establishing haemovigilance systems. Voluntary non‐remunerated donors are the minority of donors (<20%). It seems more appropriate to develop strategies to increase the safety of replacement donor blood instead of insisting on copying Western‐world models. Red cell serology is usually restricted to ABO/Rh‐D and at best Coombs crossmatch. Introduction of antibody differentiation and additional typing for C,c,E,e and K would prevent 60–70% of delayed haemolytic transfusion reactions. One of the most frequent indications for blood transfusion is major haemorrhage. Why is component therapy still recommended for resource‐limited regions, while whole blood is reintroduced in Europe/US for exactly the same indications? Plasma thawed due to electricity failures is usually discarded anyway. Leuco‐depleted products would be beneficial (multitransfused sickle‐cell patients/neonates/AIDS). An ideal blood product could be whole blood, in‐line leuco reduced by gravity filtration, treated by user‐friendly pathogen‐reduction not requiring irradiation/illumination. The transfusion medicine community should form an alliance to develop an affordable, pathogen‐reduced blood product, to train regional auditors and to bring in external expertise to aid knowledge transfer. However, standards to be reached should be defined by the respective national experts who understand the culture and needs of their country. In respectful collaboration, we could learn from each other to finally improve transfusion in resource‐limited regions.