Blood Beyond Borders
SPOTLIGHT units from volunteer donors who gave regularly , which represented 34.9 % of voluntary donations , according to a report from PAHO . 4
Some countries have been able to transition to a voluntary donor system relatively quickly . In Nicaragua , for example , the rate of blood collection was 106.6 units per 10,000 people in 2007 , with a voluntary donation rate of 39 %. Health authorities there took aggressive action to pursue “ self-sufficiency ” by eliminating replacement donation , consolidating blood processing to two centers , recruiting and educating regular blood donors , and expanding mobile blood collection . Replacement donation ended in 2009 and , by 2010 , the country had achieved 100 % voluntary donation . Collection rates improved at the same time , increasing to 125.9 units per 10,000 people in 2011 . 5
The combination of terminating family / replacement donation and educating donors was key to the success in Nicaragua , Dr . Cruz explained . “ People trust the system ,” he said . “ Patients don ’ t pay for blood and blood is provided to everyone .”
He added that it is important for countries in Latin America and elsewhere to consider the nonclinical challenges related to voluntary blood donation . In rural areas , for instance , transporting patients to the hospital can take two to three days . In those cases , the introduction of mobile blood units is essential .
High rates of donor deferral ( when individuals do not meet the criteria used to protect the health and safety of both the donors and recipient ), also can erode trust among potential donors , Dr . Cruz said . In 2015 , deferrals for voluntary blood donors were about 15 % to 25 % for replacement donors in Ibero-American countries . Hospitals deferred donors for unjustified reasons such as lipemic plasma , inappropriate veins , recent food intake , menstruation , and over-stocked blood type . 6
Dr . Cruz stressed that the best way to maintain an adequate blood supply with voluntary , unpaid donors is to forge a relationship with the donors and encourage them to donate every six months . This option is more practical than trying to increase the number of sporadic donors and storing that blood , which expires . But cultivating the donor base requires building relationships with individual donors and having the necessary facilities to collect those donations , he said .
“ Keeping the donors involved is important ,” Dr . Cruz said . “ I feel good when I go to give blood and people thank me .”
PEPFAR Funding Loss A significant portion of blood donation in sub- Saharan Africa is still from family / replacement donors , but some countries have achieved or are close to achieving 100 % voluntary donation , according to Christine Bales , vice president for consulting and global services at AABB ’ s Division of Global Services .
Dr . Odame notes that implementing voluntary blood donation “ has been an age-old problem .” High- and middle-income countries have been able to tackle this issue , but it is a longterm challenge in low-income countries . “ People [ in low-income countries ] don ’ t consider themselves healthy enough to be able to donate blood and there is suspicion of the system ,” he said . “ Culturally , giving blood is not something that many of these countries established . Replacement donatiodn has been the main approach they have taken to meet the demands .”
The national blood services in sub-Saharan African nations have been making some progress , but those gains require financial support , Ms . Bales said .
“ [ Increasing hydroxyurea access ] is a fundamental way to reduce the demand for blood transfusions , which is obviously a challenge in many countries .”
— Isaac Odame , MBChB , MRCP
For example , Lesotho , a small country surrounded by South Africa , had almost achieved full voluntary donation when international funding to the country was cut in 2019 . 7 The main source of funding for blood safety in Africa has come through the U . S . President ’ s Emergency Plan for AIDS Relief ( PEPFAR ). The program has provided millions of dollars in funding to national blood services in Africa to ensure the safety of its blood supply as part of its focus on HIV prevention .
While the hope was that countries would become self-sufficient in managing their blood supply , the reality is that they had not dedicated funds to that purpose . When the international assistance disappeared , those services were no longer funded .
Since the grants have ended , Lesotho is back to 70 % to 80 % family replacement donations , Ms . Bales explained . “ It ’ s very difficult ; the blood supply is always a fragile commodity ,” she said . “ We had made improvements , but were we done ? No , not by far .”
“ Blood centers in Africa were already stretched thin prior to COVID-19 , which has been compounded by the loss of PEPFAR funding – not just in Uganda , but throughout Africa ,” said Aaron Tobian , MD , PhD , director of transfusion medicine at The Johns Hopkins University School of Medicine , who is conducting a clinical trial in Uganda to test whole blood pathogen technology to prevent transfusion-transmitted infections . “ With PEP- FAR pulling out , there were times when many blood systems throughout Africa did not have the money for all their screening for hepatitis B , hepatitis C , and HIV . It really created a conundrum of what to do in that situation .”
Blood systems in Africa are now prioritizing maintaining the standards that were set five to 10 years ago , he said .
Strategies for Blood Sufficiency One possible approach to dealing with a shrinking blood supply is to reduce the demand for blood , Dr . Odame said . For example , in Africa , putting patients with SCD on disease-modifying therapy , like hydroxyurea , has the potential to significantly reduce their need for transfusion .
He cited the REACH trial , which enrolled more than 600 young children with SCD in Angola , the Democratic Republic of Congo , Kenya , and Uganda . Children received a fixed dose of hydroxyurea daily for six months , followed by dose escalation for several years . The trial demonstrated that therapy could significantly increase levels of both hemoglobin and fetal hemoglobin , lowering the need for transfusion . 8
“ I , and others , have been making the case that if ever there was a time to make hydroxyurea accessible to patients living with sickle cell disease in Africa , it is now , because it is a fundamental way to reduce the demand for blood transfusions , which is obviously a challenge in many countries ,” Dr . Odame said .
While the efficacy of hydroxyurea has been proven in clinical trials , implementing it as a standard of care in Africa is a more substantial undertaking , he noted , which involves educating clinicians , health systems officials , and the public on disease-modifying treatments as a cost-effective strategy in SCD .
“ Meeting this challenge , said Dr . Odame , “ requires many multi-sectorial partnerships to strengthen these health systems , train and educate providers at all levels of care , and be able to set up systems to make hydroxyurea accessible and affordable .” — By Mary Ellen Schneider
References
1 . WHO . Blood safety and availability . Accessed February 7 , 2021 , from https :// www . who . int / news-room / fact-sheets / detail / blood-safety-and-availability .
2 . WHO . WHA28.72 Utilization and supply of human blood and blood products . Accessed February 7 , 2021 , from https :// www . who . int / bloodsafety / en / WHA28.72 . pdf .
3 . WHO and International Federation of Red Cross and Red Crescent Societies . Towards 100 % voluntary blood donation : a global framework for action . Accessed February 7 , 2021 , from https :// apps . who . int / iris / handle / 10665 / 44359 .
4 . Pan American Health Organization . Supply of Blood for Transfusion in Latin America and Caribbean Countries 2016-2017 . Accessed February 7 , 2021 , from https :// iris . paho . org / handle / 10665.2 / 52966 .
5 . Berrios R , Gonzalez A , Cruz JR . Achieving self-sufficiency of red blood cells based on universal voluntary blood donation in Latin America . The case of Nicaragua . Transfus Apher Sci . 2013 ; 49 ( 3 ): 387-396 .
6 . Cruz JR . Transfusion safety : lessons learned in Ibero-America and considerations for their global applicability . Intl J Clin Transfus Med . 2019 ; 7:23-37 .
7 . Kaiser Family Foundation . The U . S . President ’ s Emergency Plan for AIDS Relief . Accessed February 7 , 2021 , from https :// www . kff . org / global-health-policy / fact-sheet / the-u-s-presidents-emergency-plan-for-aids-relief-pepfar /. 8 . Tshilolo L , Tomlinson G , Williams TN , et al . Hydroxyurea for children with sickle cell anemia in sub-Saharan Africa . N Engl J Med . 2019 ; 380 ( 2 ): 121-131 .
24 ASH Clinical News March 2021