|Year : 2016 | Volume
| Issue : 1 | Page : 3-6
Let us take small incremental steps at our blood center, for a giant leap in blood safety
From the Consultant and Head, Department of Transfusion Medicine, Manipal Hospital, Bengaluru, Karnataka, India
|Date of Web Publication||3-Mar-2016|
From the Consultant and Head, Department of Transfusion Medicine, Manipal Hospital, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chandrashekar S. Let us take small incremental steps at our blood center, for a giant leap in blood safety. Glob J Transfus Med 2016;1:3-6
|How to cite this URL:|
Chandrashekar S. Let us take small incremental steps at our blood center, for a giant leap in blood safety. Glob J Transfus Med [serial online] 2016 [cited 2018 Jan 20];1:3-6. Available from: http://www.gjtmonline.com/text.asp?2016/1/1/3/177999
Blood transfusions are considered so safe today, that your risk of contracting human immunodeficiency virus (HIV) from a blood transfusion, is lower than your risk of getting killed by lightning. Technological advancements such as nucleic acid amplification (NAT) testing, brought down the risk of HIV over a 10 years period, to as low as 1 in 2 million in the United States. Implementation of technologies like NAT is saving thousands of lives per year in India  and the neighboring countries.
| Blood Safety in Asian Countries|| |
Asian Association of Transfusion Medicine (AATM) countries, such as the rest of the world have made great strides in blood safety. By AATM countries, I am referring to Asian and some Middle East countries which are members of our association, the AATM, comprising of Afghanistan, Bangladesh, Bhutan, India, Iran, Maldives, Mongolia, Nepal, Srilanka, Pakistan, and Turkey. Many advanced centers in this region have fully exploited the benefits of advanced technologies, be it NAT tests for infectious disease testing or column agglutination or microplate in immunohematology. So far, the prevalence of transfusion-transmissible infections (TTIs) in the blood supply is higher in low- and middle-income countries resulting in increased transfusion risks. Persons living in developing countries are commonly anemic, and are at high risk for traumatic injuries and obstetric complications. Hence, availability of safe blood is all the more important in these countries.
| Global Blood Supply|| |
There are wide disparities in the availability and quality of blood across continents and countries. The world collected 108 million units of blood, using the services of 10,000 blood centers in the year 2014. While, 50% of blood was collected in the high-income countries that account for 18% of the global population, the other 50% was collected in the medium- and low-income countries that house more than 80% of the world population, a clear indicator of the disparities in the availability of blood across different regions of the world.
| National Blood Policy|| |
Efforts of transfusion medicine professionals in our member countries have paid off, and nearly all countries  in the AATM region including Bhutan, India, Maldives, Myanmar, Nepal, Sri Lanka Thailand, Iran, and Turkey have a National Blood Policy, conforming to WHO requirements which ensures government commitment. Many countries such as India, Bhutan, and Maldives have had this policy since 2007. Although most AATM countries have a National Blood Policy in place, efficient coordination and regulation of blood services nationwide seem to be lacking.
| Fragmented Blood Transfusion Service|| |
India, the largest country in the AATM region with a population of 1.25 billion, has the maximum number of 2760 blood centers. Although they are centrally coordinated by the National Blood Transfusion council through the Regional Blood Transfusion Centres, laws in the country preclude centralized TTI testing, and new blood centers continue to come up despite best efforts at consolidation. The same is the case with many other countries in the region. Srilankan blood transfusion service (BTS) is divided into 19 clusters with each cluster supervising blood centers in its region. In all, this Island state has 77 peripheral blood centers  and is moving toward centralization. Iran in the Middle East with a population of 74 million has 30 regional blood centers with over 200 blood donation sites. In this scenario of having to deal with a fragmented transfusion service, how can we make our blood supply safer? How can we aim to make our blood supply as safe as in the west? Let us examine the problems plaguing our BTSs and ways of addressing them. I propose some simple steps that all of us can take which will greatly improve the quality of our blood supply and our blood transfusions and permit fairer comparisons. Not that these are new, but these are steps which are easily doable, but we continue to neglect them in our quest for state of the art technology.
| Safe Donor Is The first Step to Blood Safety|| |
Iran has abolished family donors and achieved 100% voluntary blood donation. Srilanka has achieved 100% voluntary blood donation according to National Blood Transfusion Council report of Srilanka. India still continues to have a significant chunk of donors labeled voluntary-family donors, who are in fact replacement donors. According to blood banks that reported in the computerized management Information System of National AIDS Control Organization in 2012–2013, the percentage of voluntary donors was 73% and 27% was from replacement donations in blood banks. Still other countries continue to have problems of paid donation. While it is good to have all blood coming from voluntary non-remunerated donors, the term itself is interpreted differently in different countries. To avoid biases in the classification of donors due to varying definitions, can we have a better way of assessing safety of blood donors? Can't we find a more objective way of comparing the quality of donors at a blood center, region, or country or within the same center over a period of time?
Improving blood donor quality through counseling
Counseling provides an opportunity for the BTS to assist donors, helping donors to understand the donation process, the risks to recipients if they do not give a truthful history and then provide an informed consent for blood donation or defer themselves from the donation. Counseling reduces donation of blood by unsuitable donors, that subsequently has to be discarded, thereby decreasing the wastage of resources, including donor and staff time, consumables and screening tests. When properly done, blood donor counseling contributes to blood safety by reducing the prevalence of TTI in donated blood. Benefits of blood donor counseling surpass the benefits of modern day technology and should be the most important tool for blood safety, especially in resource-constrained countries. It has been our experience at our center, that the number of donors admitting to high-risk sexual behavior during counseling is far more than the NAT yield. NAT yield is the number of donors who are seronegative but NAT-positive for one or more infectious markers.
In India, National Accreditation Board of Hospitals (NABH)-Blood Bank accreditation requirements specify that donors should be counseled with respect to the following to ensure blood safety. Four simple steps that all blood centers can adapt easily.
- Modes of spread of HIV/AIDS
- Need for honest answers during questioning
- Confidentiality of test results
- Information regarding alternative testing sites, so that blood centers are not used as free testing centers by blood donors.
Hence, appointing a dedicated blood counselor should be the first step towards blood safety; advanced technologies come much later.
Comparing quality of donors by using the transfusion-transmissible infection index
For a long time, we have given a lot of importance to the terms voluntary and replacement donors as indicators of blood safety. Perhaps it is time to give up on this classification of blood donors as a guide to blood safety. Often, this data provided by blood centers or countries is difficult to verify, due to the variations in definition or their understanding. Why not use the cumulative TTI rate (HIV/hepatitis B virus (HBV)/hepatitis C virus (HCV)/syphilis/malaria) expressed as a percentage in blood donors, as an indicator of donor quality? We may call this the TTI index and use this objective figure to compare blood centers or countries instead of depending on varying donor definitions. To do this we need to ensure that our donors by whatever name we call them, are well informed about blood donation, blood transfusion, and its risks. They should be offered counseling by a trained counselor so that we start with a safe donor who is given the option of self-deferral.
Improving quality (sterility) of donated blood
To a great extent good testing for viral markers will reduce TTI incidence but what about transfusion-transmissible bacterial infection (TTBI)? The American Association of Blood Banks (AABB) in 2008 reported that the second most common problem faced by blood services in the United States is the bacterial contamination of blood products. If that's a problem in the United States, it must be even bigger in resource-constrained countries. Of the 735 adverse recipient reactions reported to National Institute Biologicals that monitors National Haemovigilance Program of India, between February and November 2013, nine (9) cases were that of TTBI. More data is likely with this voluntary program being made mandatory in future. McDonald reported that excluding the first 20 ml of the initial collection was an effective way of reducing the risks of bacterial contamination in blood products. Use of bags with diversion pouches together with improved donor arm disinfection, has shown to improve the percentage of reduction in contamination from 47% to 77%.
Simple ways to ensure sterility of the blood
Based on available data, the following simple steps will add greatly toward reducing TTBI at a low cost.
- Replacing the conventional two-step phlebotomy asepsis procedure, consisting of 70% isopropyl alcohol followed by tincture of iodine, with a single step procedure comprising of a combination of 2% chlorhexidine gluconate and 70% isopropyl alcohol 
- Replacing unsterile cotton with sterile gauze for cleaning
- Use of blood bags with diversion pouches and diverting the first 20 ml of blood.
Together all these constitute an effective, low-cost strategy to reduce TTBI. Let us focus on bacterial prevention. Routine testing for bacteria by expensive time-consuming tests can come much later.
Better testing techniques for better blood
The focus of blood safety in resource-constrained countries is mainly aimed at how to make blood free from viral markers (HIV/HBV/HCV), syphilis and malaria, ignoring simpler things such as wrong blood grouping, wrong blood in tubes (WBIT), and incorrect blood component transfusion (IBCT)that kill more patients than TTIs. Good patient identification procedures coupled with use of advanced serological techniques like column agglutination by gel or bead or the microplate techniques score over the traditional tube tests as they have more sensitivity, and results are stable for later verification. Good immune-hematology techniques for blood grouping/Rh typing, antibody screening, and crossmatch needs to be in place before we think of extended phenotyping.
Similarly, for any blood center, plotting a Levy-Jennings chart for TTI markers and applying a few simple Westgard rules, while testing by serology should be the first step to improving TTI testing. They should precede implementation of pooled NAT, individual NAT (ID-NAT) or Pathogen reduction. Further, use of blood bags with a buffy coat which gives Log 1 leukoreduction should precede any discussion on universal leukoreduction.
Better storage, better transport and better modes of blood delivery
The best technology and the best of resources are rendered ineffective, if safely tested blood is not appropriately stored. Fresh frozen plasma prepared by a blood center may be of good quality, but if not appropriately stored the cryoprecipitate prepared from it may be rendered ineffective. Currently, monitoring multiple storage devices is easy thanks to central monitoring systems, that warn the user whenever the temperature is breached. Various temperature indicators for individual bags or their containers are available to monitor blood in transit. However, what is not implemented routinely are methods for safe delivery of blood to bedside. IBCT, or wrong blood transfusion, remains the most frequent transfusion hazard and is preventable. Boxes with number locks that can only be opened with a unique ID number on patient wrist band are available. These will go a long way in preventing IBCTs.
Participation in external quality assessment schemes and accreditation
Nearly, 97% of blood screening laboratories in high-income countries are monitored through external quality assessment schemes (EQAS), as compared to 33% in middle-income countries and 16% in low-income countries. EQAS and accreditation are novel but fast spreading concepts in Asia composed of predominantly middle- and low-income countries. The Quality Council of India set up by the Government runs an accreditation program specific to blood banks. NABH, which runs this program, is a part of the International Society for Quality in Healthcare. The NABH-Accreditation Program for Blood Centres is growing day by day and is also offered to neighboring countries. The AABB also offers accreditation programs to blood centers in other countries. Before embarking on this, it is prudent to have a good internal quality control (QC) program, which is the cornerstone of quality and begin participation in external quality assurance schemes provided by certified providers. AATM has been offering external quality assessment programs to many blood centers in the AATM countries.
Better transfusion practices
AABB guidelines and Cochrane recommendations recognize that at least 40% of all transfusion is avoidable, and nearly 50% of a surgical transfusion could be avoided by treating preoperative anemia or using autologous transfusion (own patient blood). While all of this may not be applicable to the same extent in all countries, there is no doubt that restrictive regimes, preoperative medication, and autologous blood will help to save a lot of blood in all countries. How do we apply this in our region, our center? We can cut down on our blood usage by these three simple steps to be adopted by blood centers:
- First, blood centers must begin insisting on capturing indications for transfusion and asking clinicians to fill up justification forms when the transfusions seem inappropriate.
- Second, ensure that the desired component is given in the right dose, discouraging whole blood which will again lead to saving of blood.
- Last, blood centers must ensure that the blood issued is used within a stipulated time, or the unused blood returned to blood center to be used for another patient.
Hospital hemovigilance programs must be designed keeping the country's hemovigilance program in mind which are mostly in line with the International Hemovigilance Network. Hospital hemovigilance must set down the procedure for positive patient identification to avoid WBIT and IBCT. The blood centers in coordination with the Hospital Transfusion Committee must lay down guidelines for meeting emergency transfusions, and every hospital must have a massive transfusion protocol to deal with trauma and obstetrical emergencies. Hospital hemovigilance must include both donor and recipient hemovigilance with particular reference to root cause analysis, corrective and preventive action, wherever possible. A whole lot of quality indicators may be addressed based on need.
Quality of blood center staff
The quality of blood cannot be improved without improving the quality of staff. While it is heartening to note that Masters Degree in Transfusion Medicine is now a separate 3 years course distinct from pathology, in India the medical technologists still study laboratory medicine and not transfusion medicine. Postgraduate courses in transfusion medicine for medical laboratory technologists are few in India. Most blood centers in India/Asia depend on training medical laboratory technologist on the job, which can compromise safety. Postgraduate course in transfusion medicine for lab technologists is the crying need of the hour, just as we have for doctors.
Centralized transfusion-transmissible infection screening for standardizing blood centers in Asia
Blood centers in developing Asian countries are primarily of two types. Technologically the most advanced blood centers, that offer everything possible, from NAT testing to antibody screening to leukoreduction and irradiation. These are housed in large private hospitals and cater to select population. Then we have the nongovernment organization (NGO) run blood banks and government blood banks, not all of whom are financially sound enough to invest in technology and good manpower, and focus on voluntary blood donation as the main mode of blood safety. They serve the large majority of patients admitted to small hospitals which lack their own blood bank. Many NGOs and governments like state Government of Karnataka (India) have added NAT testing into their armamentarium, to improve the safety of blood given to poor patients admitted to government hospitals, which is a welcome step. Despite all this, such advanced facilities are not widely available, and the small size of blood banks is a deterrent to quality. Hence, we need to change our laws to allow centralized TTI testing be it serology or molecular (NAT) testing. This will bring in standardization in the way we screen for infections and may pave the way toward centralization of our BTS in the years to come.
| Conclusion|| |
Focusing on donor counseling will bring down TTI rates regardless of the type of donors we have. Having a trained donor counselor is, therefore, a mandate. Introducing TTI index for comparisons of blood safety will remove the anomalies that exist in the classification of blood donors. Focusing on donor arm disinfection along with use of blood bags with diversion pouches will reduce the risk of TTBI. Having a centralized accredited testing facility for TTI markers, be it serology or NAT will bring in standardization, greatly improve the quality of testing and also make it more economical. Until that happens, it is important for individual blood centers to remember that good serological testing with QC samples plotted on a Levy-Jennings chart comes before pooled NAT or ID-NAT. Blood centers and testing laboratories must participate in EQAS programs and enroll for accreditation programs so as to improve our community confidence. We need to build staff capacity in transfusion medicine through regular training programs. We must ensure not only better storage and better transport, but also better delivery of blood to the bedside so as to eliminate clerical errors and wrong transfusions. Our transfusion practices at the hospital/blood center level must focus on increased usage of blood components, discourage inappropriate usage and provide an option to return unused blood within a stipulated time to avoid wastage. Hospital hemovigilance must track donor and recipient reactions and offer a prompt remedy to minimize the adverse effects of donation or transfusion. The laws in the country must complement the working of the blood centers, inspections must facilitate quality improvements, and the laws must be frequently updated to include evolving technologies such as NAT, leukoreduction, irradiation, or pathogen reduction. Obviously, this is not in the hands of the blood banker. Let us focus on the remaining steps that we can do at our level, at our blood center; our country and our region will take a giant leap in blood safety. Launch of Global Journal of Transfusion Medicine is one small step, but hopefully a significant step in this direction.
| References|| |
Zou S, Dorsey KA, Notari EP, Foster GA, Krysztof DE, Musavi F, et al.
Prevalence, incidence, and residual risk of human immunodeficiency virus and hepatitis C virus infections among United States blood donors since the introduction of nucleic acid testing. Transfusion 2010;50:1495-504.
Chandrashekar S. Half a decade of mini-pool nucleic acid testing: Cost-effective way for improving blood safety in India. Asian J Transfus Sci 2014;8:35-8.
Kralievits KE, Raykar NP, Greenberg SL, Meara JG. The global blood supply: A literature review. Lancet 2015;385 Suppl 2:S28.
DeMaeyer E, Adiels-Tegman M. The prevalence of anaemia in the world. World Health Stat Q 1985;38:302-16.
Choudhury N. Blood transfusion in borderless South Asia. Asian J Transfus Sci 2011;5:117-20.
Cheraghali A. Overview of blood transfusion system of Iran: 2002-2011. Iran J Public Health 2012;41:89-93.
Nair SC, Mammen JJ. Repeat voluntary non-remunerated blood donor is the best quality indicator for blood safety. Indian J Med Res 2015;141:749-52.
Bethesda MD. Bacterial contamination of blood components. Association Bulletin 96-6. American Association of Blood Banks; 1996.
Boparai JK, Singh S. Hemovigilance: A new beginning in India. Int J Appl Basic Med Res 2015;5:200-2.
McDonald CP. Interventions implemented to reduce the risk of transmission of bacteria by transfusion in the English national blood service. Transfus Med Hemother 2011;38:255-8.
McDonald CP. Bacterial risk reduction by improved donor arm disinfection, diversion and bacterial screening. Transfus Med 2006;16:381-96.