|REVIEW ARTICLE - AATM GUIDELINES ON DISASTER AND EMERGENCY PREPAREDNESS FOR ASIA
|Year : 2022 | Volume
| Issue : 2 | Page : 109-114
Disaster and Emergency Preparedness: Role of the Blood Establishment and Hospital Transfusion Service in the Management
Cees Theodoor Smit Sibinga1, Sangeeta Pahuja2, Mujtaba Al-Lawati3, Shabneez Hussain4
1 Faculty of Medicine, University of Groningen and Director IQM Consulting, Zuidshorn, Netherlands
2 Department of Immunohaematology and Blood Transfusion, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India
3 Department of Medical Laboratory Science, Oman College of Health Sciences, Wattayah, Muscat, Oman
4 Head, Blood Transfusion Services, Indus Hospital and Health Network, Karachi, Pakistan
|Date of Submission||22-Jul-2022|
|Date of Decision||19-Aug-2022|
|Date of Acceptance||30-Aug-2022|
|Date of Web Publication||5-Nov-2022|
Cees Theodoor Smit Sibinga
Faculty of Medicine, University of Groningen and Director IQM Consulting, Zuidshorn
Source of Support: None, Conflict of Interest: None
Disasters and emergencies do happen all over the world, both natural and human-made. It is important to carry out a gap analysis and a risk assessment before making plans for disaster and emergency preparedness at national, regional, and local levels. It is equally important to decide in advance what to do and how to react to such situation to restore the “business as usual.” The blood system is an integral part of the health-care system and should be ready to act when necessary – donor mobilization, triage, personnel, stock management, and distribution. In the hospital, one should have a plan and be prepared in advance to introduce priority setting, stock management, restricted transfusion practice, and communication. The article provides a list of recommendations to prepare for such expected and unexpected situation to mitigate as much as possible the deleterious consequences.
Keywords: Blood supply, disaster, emergency preparedness, emergency response, risk assessment
|How to cite this article:|
Smit Sibinga CT, Pahuja S, Al-Lawati M, Hussain S. Disaster and Emergency Preparedness: Role of the Blood Establishment and Hospital Transfusion Service in the Management. Glob J Transfus Med 2022;7:109-14
|How to cite this URL:|
Smit Sibinga CT, Pahuja S, Al-Lawati M, Hussain S. Disaster and Emergency Preparedness: Role of the Blood Establishment and Hospital Transfusion Service in the Management. Glob J Transfus Med [serial online] 2022 [cited 2023 Mar 30];7:109-14. Available from: https://www.gjtmonline.com/text.asp?2022/7/2/109/360490
| Introduction|| |
The archetype of a hazard, disaster, and humanitarian emergency is in the biblical myth of Adam and Eve. There was the hazard of eating from a forbidden apple, which happened and caused the irreversible disaster of being expelled from paradise. When their sons Cain and Abel argued and got trapped in a conflict, Cain attacked Abel and hit him with a primitive though effective weapon on the skull, causing Abel's death – the first humanitarian armed conflict or emergency.
Disasters and emergencies may be due to the force of nature or factors influenced by human beings, or directly caused by humans (humanitarian emergencies). A disaster is a sudden event causing great damage, loss, or destruction. Conventionally, disaster risk is envisaged as the adverse effects resulting from the interaction between hazards with vulnerability, exposure, and adaptive capacity. This may result in damage and destruction of blood supply facilities as well as transport problems (potential donors and supplies) due to environmental disarrangements, for example, roads, bridges, and access to fuel. An emergency is an unforeseen occurrence or combination of circumstances that is potentially dangerous and calls for immediate action. In emergency situations, it is vital to ensure a safe and adequate blood supply for all essential transfusions. The need for emergency and contingency planning has been clearly demonstrated by the COVID-19 pandemic.
| Blood Systems Vary Widely Globally|| |
Centralized or decentralized; managed through the public sector, supranational, nongovernmental, private, or military operators; numerous different blood policies and legal frameworks. Consequently, a diversity of contingency and emergency measures, structured, and ad hoc, currently exists globally. A harmonized approach for emergency preparedness and contingency could be beneficial in facilitating design, coordination, and collaboration. To support countries to ensure the continuity of blood and blood components, a disaster/emergency preparedness and contingency plan for the available blood supply needs to be developed, meeting ethical and legislative standards. Disaster and emergency preparedness is needed in anticipation of disasters and emergencies, where the contingency part focuses on response, backup operations, availability of critical resources, and postdisaster recovery, as well as to ensure the continuity of operations in the “business as usual” manner.
| Gap Analysis and Risk Assessment|| |
South Asia is home to 1.8 billion people, of whom more than 70% live in poverty. Since 1970, Asia and the Pacific has accounted for 57% of global fatalities from disasters and 87 per cent of the global population that has been affected by natural hazards.,
South Asian countries are highly prone to hydrometeorological and geological hazards such as flood, landslide, drought, cyclone, earthquake, and tsunami. 64% of the global population exposed to floods resides in South Asia.,,,, Geographic and climatic conditions make this area vulnerable to natural hazards. Convergence of natural hazards with biological hazards (e.g., COVID-19 pandemic) along with climate change has a cascading effect on disaster risk.,,,
Population growth, economic expansion, urbanization, environmental degradation, and mismanaged development are important drivers of vulnerability to disasters in South Asia. Political instability, border disputes, ineffective regional networks, and climate change in these countries further exacerbate the risk of disasters.,
In the past five decades, natural hazards in Asia and the Pacific have affected 6.9 billion people and killed more than 2 million (average of 41,373 lives lost per year). Dedicated government efforts and disaster risk reduction (DRR) strategies have led to a fall in the average loss of life per year, to around 6200 people in 2019 and 2020; however, number of affected people is still huge (average: 122 million/year). The World Disasters Report reveals that this region has the highest affect to the mortality ratio in the world.
In the past few decades, there has been a strategic shift in disaster management practices toward an integrated DRR approach, which includes incorporating DRR planning in the development process of countries and regions. Sendai Framework for DRR 2015–2030, which rather than managing disasters, put more emphasis on managing risk, underlined the importance of involving many stakeholders at local, national, regional, and global levels., It also broadened the scope of DRR to focus on both natural and human-made hazards and the related environmental, technological, and biological hazards and risks.
Most of the countries of South Asia have developed a regional roadmap for DRR and have incorporated this into development plans. However, the blood system is not adequately addressed in the same. In India, the National Disaster Management Authority, established through the Disaster Management Act, is an apex body to coordinate response to natural or human-made disasters. Bangladesh has a National Disaster Management Council. Although legislative framework is available in most of the South Asian countries, institutional capacities vary across countries.,,
The role of the blood system across total health-care management in disasters is not clearly defined. Adequate and sufficient supply of blood components is an important part of emergency and disaster preparedness for such situations. Some emergencies like terrorist events, wars, etc., can lead to sudden significant increase in blood requirement; whereas events like earthquakes, floods, etc., may damage infrastructure, transportation, communication channels, and may affect the supply of safe blood. Biological disasters, like the COVID-19 pandemic, together with mass vaccination of the affected population, may dry up the blood supply by affecting a large number of the donor population. However, blood management response in most of these countries is fragmented, insufficient, and delayed. Lack of coordination among different agencies leads to duplication of efforts and wastage of resources. Although there are disaster management initiatives, sustainable capacity building has not yet been achieved.
| Emergency Preparedness Planning|| |
Globally, the number of people affected by disaster and emergency situations, including infectious disease outbreaks, natural disasters, and humanitarian crises, is increasing. Disasters and emergencies may show an increased need for blood and blood components. Consequently, maintaining sufficient supplies of safe blood and blood components to treat those affected is critical. However, ensuring sufficient supplies of safe blood may prove to be challenging.
Emergency preparedness and contingency planning are key elements of a blood system and its quality system management. It is essential to ensure that when faced with emergencies or disasters, a safe and adequate supply of blood and blood components can be maintained and made available for all essential transfusions.
Establishing, implementing, and maintaining such plans, in which key stakeholders and their expected actions are defined for different key risk scenarios, allows effective mitigation strategies that lay the foundations for blood supply continuity in emergency and disaster situations to be put into place.
During emergency and disaster situations, important risk events may be prioritized, based on proper risk assessment and gap analysis of the blood system and its routine blood supply. One should consider the complexity of the necessary governance, management structure, and infrastructure, such as communication, transportation, and cold chain, to secure minimum risk and limited gaps to exist and to command. However, situations may substantially differ from event to event, from country to country, and from region to region. In 2021, the Council of Europe launched a survey among 27 European countries aiming to contribute to strengthening national and EU-level plans to ensure the continuity of the blood supply. Recommendations and model preparedness plan(s) were published, and strategies to support European countries in this regard were developed. An important outcome, reported on self-assessment on the need for legislation related to emergency preparedness and contingency plans, shows a decline in interest compared to the current situation: 63% of countries currently have legislation, but only 52% think legislation is needed. Five countries which currently have legislation are uncertain or think legislation or additional legislation is not needed. Only one country that does not currently have legislation believes that it is needed. The percentage of countries experiencing a need for guidelines related to emergency preparedness and contingency plans is like current countries with guidelines, 70%. However, only 12 of the 19 countries that currently have guidelines think they are a necessity. It was suggested that guidelines should include surveillance tools for monitoring the blood stock, situation risk analysis instruments, and model preparedness plans (including geographically sensitive areas). One national competent authority respondent emphasized that guidelines should be issued after any new regulation. This illustrates the importance of a proper legislative and guidance fundament to cope with disasters and emergencies at a national level.
The key objectives of this Council of Europe's Blood Supply Contingency and Emergency Plan survey are captured in [Table 1].
|Table 1: Objectives of the Council of Europe emergency preparedness and contingency survey|
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In 2022, the survey resulted in a model preparedness plan published by the European Directorate for the Quality of Medicines and Health Care, which contains a series of recommendations to all categories of stakeholders. The recommendations focused on regulatory oversight bodies (inspectorates); blood establishments and hospital blood banks provide excellent guidance and advice. However, when creating an emergency preparedness and disaster plan, several key issues need to be identified and defined [Table 2].
Besides a competent emergency preparedness plan, there should be a contingency plan to assure that the blood system not only continues to deliver blood and its components but also the associated services are maintained in a “business-as-usual” way.
| Contingency Planning–Response and Recovery|| |
Disasters or mass casualty events (MCE) can either affect the community alone or the hospital and health delivery system or both. MCEs such as terrorist attacks and wars produce a large number of injured bleeding patients requiring surgical attention and blood transfusions. The sudden influx of even five bleeding patients together in a small hospital, ill-equipped to handle, may constitute a disaster. Fire hazards are another major disaster that are of concern in hospitals today. Fire within a hospital may be even more disastrous affecting patients, staff, or both. Many disasters like floods, earthquakes, etc., may additionally affect hospitals (e.g., structural damages, loss of electricity supply, and inundation) by disrupting the continuity of services.
For long, the blood system has not been a part of hospital MCE response. However, early and prompt blood transfusion is one of the central pillars of damage control resuscitation in severely bleeding patients. It has been seen that deaths occur very fast in massive hemorrhages, mostly within the first 2 h of hospital admission. Hence, it is important to ensure that the blood system is prepared to deal with disaster events. Hospital transfusion plans should be integrated within wider health-care plans to ensure a holistic patient care.
The blood system should have a preprepared and prerehearsed plan for managing the services in the face of MCEs. A memorandum of understanding for sourcing blood from nearby blood centers and a team to call registered donors may help, once the immediate bleeding is controlled. Plans should aim at maintaining delivery of key services and recovery, within the framework of legislative and regulatory requirements, which should include alternate sources of blood, alternate infrastructure for blood donation, availability of reagents and consumables, and staff to handle the additional workload. Regular staff training is crucial and should include authority structure, communication methods, and staff responsibilities. Testing of the plan (e.g., walk-through or desktop exercises and real or simulated drills) needs to be done, and gaps need to be identified and closed.,,,
Response involves action taken at the time of the actual disaster, i.e., putting a plan into action. The hospital blood service should get prior information that should include place, time, type of event, expected number of casualties, type of injuries, etc., Blood center should have a standard operating procedure by which it abides whenever notification of MCE is received. As soon as there is an alert about MCEs, transfusion services should start operating, relating to activation of the emergency network, positioning of personnel, evaluation of existing supplies (blood and blood components and raw material), assessing expected demand, arranging for more supplies, preparation of emergency containers, etc.,,
International organizations have given guidelines on the issue of blood in MCEs and disasters.,, Ideally, patients should be triaged as P1, P2, and P3, and demand (expected requirement in the first 24 h) of blood and blood components should be calculated. The UK NHS estimates that P1 patients would require 8 units of red cells, 8 units of FFP, 2 adult therapeutic dose platelets, and 2 pools of cryoprecipitate. P2 patients would require 2–4 units of red cells and equivalent amounts of components.
However, triage is not always possible in chaotic settings of MCEs. Association for the Advancement of Blood & Biotherapies (AABB) advices 3 units of red cells per patient admitted to the hospital. The AABB task force on disasters emphasizes that facilities should maintain at least 7 days' supply of combined inventories (of suppliers and hospitals) at all times. It is, however, common knowledge that most hospital-based blood centers in Asia, which are the first point of contact in a disaster, have barely enough blood for a day. In this scenario, how should they plan for a disaster?
Prompt blood-based resuscitation is extremely significant in massively bleeding patients. In significantly bleeding patients, delay of every minute after massive transfusion protocol (MTP) has been activated increases mortality by 5%. There should be clear guidance on issue of blood and blood components in emergencies. Universal components (group O rhesus D-negative red cells, plasma, and platelets in universal containers) should be available as soon as the patient reaches the emergency department. However, storage of blood in the emergency room is not permitted by law in many countries of the Indian subcontinent. This is needed not only during disasters but also in massively bleeding trauma patients. Regulations need to be modified to ensure early delivery of blood/components. One should shift to group-specific components and type and screen or cross-matched components as soon as the time and clinical situation of the patient permit.
There should be very clear guidelines on activation and use of MTPs, and staff should be well trained in the institutional MTP in place. Patients should be shifted from empiric/formula-based transfusions to goal-directed therapy as soon as possible.
There has been an increasing interest in the use of cold-stored platelets as they have been shown to be hemostatically superior to room temperature-stored platelets, albeit they have a shorter circulation time., AABB has given approval for the use of cold-stored platelets in actively bleeding patients. However, this component is neither licensed nor available in any of the low- and middle- income countries. Use of thawed plasma (that can be used up to 5 days of thawing if stored at 2°C–6°C) and group A plasma (in view of the short supply of group AB plasma) has also been suggested. Recently, there has been an interest in the use of low-titer O rhesus D-negative whole blood (cold-stored, <14 days old) as initial resuscitative fluid in MCEs. Whole blood is not easily available, and storing it only for emergencies may have logistic issues. Appropriate modifications in regulations and guidelines need to be made to ensure the availability of safe and adequate hemostatic resuscitation in disaster scenarios.
| Conclusions and Recommendations|| |
Ensuring “an adequate and safe blood supply during emergency situations,” such as infectious disease outbreaks, natural disasters, and humanitarian emergencies is one of the high-level outcomes stated by the WHO Action Framework, 2020, to advance universal access to safe, effective, and quality-assured blood products. Countries should prepare for such situations and mitigate the disruption of health care and the blood system.
It is recommended that there shall be:
- An health-care integrated national contingency plan
- A disaster and emergency preparedness plan at national, regional, and local levels
- A disaster and emergency committee led by a designated disaster and emergency manager
- Integration of transfusion services in total health-care plans for disasters and humanitarian emergencies
- Nationally coordinated and structured blood system
- Awareness of possible disasters and humanitarian emergencies
- A disaster and emergency-focused stock management in both blood establishments and hospital transfusion services
- A carefully balanced priority setting and transfusion selection
- A strictly restricted transfusion practice
- Good communication and documentation
- Careful evaluation postdisaster and emergency.
The authors would like to acknowledge the contribution of Dr. C. Shivaram in designing the concept, bringing the team together, and providing critical inputs. We acknowledge the contribution of Dr. Shadhiya Al Khan for providing information on the scenario in the Sultanate of Oman.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]