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External Financial Aid to Blood Transfusion Services in Sub-Saharan Africa: A Need for Reflection

  • Fereydoun Ala,

    Affiliation: London, United Kingdom

    X
  • Jean-Pierre Allain mail,

    jpa1000@cam.ac.uk

    Affiliation: University of Cambridge, Cambridge, United Kingdom

    X
  • Imelda Bates,

    Affiliation: Liverpool School of Tropical Medicine, Liverpool, United Kingdom

    X
  • Kamel Boukef,

    Affiliation: University of Monastir, Monastir, Tunisia

    X
  • Frank Boulton,

    Affiliation: University of Southampton, London, United Kingdom

    X
  • James Brandful,

    Affiliation: Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana

    X
  • Elizabeth M. Dax,

    Affiliation: Fitzroy, Australia

    X
  • Magdy El Ekiaby,

    Affiliation: Shabrawishi Hospital, Giza, Egypt

    X
  • Albert Farrugia,

    Affiliation: University of Western Australia, Crawley, Australia

    X
  • Jed Gorlin,

    Affiliation: Memorial Blood Centers, St Paul, Minnesota, United States of America

    X
  • Oliver Hassall,

    Affiliations: Liverpool School of Tropical Medicine, Liverpool, United Kingdom, University of Oxford, Oxford, United Kingdom

    X
  • Helen Lee,

    Affiliation: University of Cambridge, Cambridge, United Kingdom

    X
  • André Loua,

    Affiliation: University of Guinée, Conakry, Guinea

    X
  • Kathryn Maitland,

    Affiliation: Imperial College London, London, United Kingdom

    X
  • Dora Mbanya,

    Affiliation: University of Yaoundé, Yaoundé, Cameroon

    X
  • Zainab Mukhtar,

    Affiliation: Transfusion Medicine, Karachi, Pakistan

    X
  • William Murphy,

    Affiliation: University College, Dublin, Ireland

    X
  • Ohene Opare-Sem,

    Affiliation: University of Science & Technology, Kumasi, Ghana

    X
  • Shirley Owusu-Ofori,

    Affiliation: Komfo Anokye Teaching Hospital, Kumasi, Ghana

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  • Henk Reesink,

    Affiliation: Academic Medical Center, Amsterdam, The Netherlands

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  • David Roberts,

    Affiliations: University of Oxford, Oxford, United Kingdom, NHS Blood and Transplant, Watford, United Kingdom

    X
  • Oscar Torres,

    Affiliation: Hospital Materno-Infantil Ramón Sardá, Buenos Aires, Argentina

    X
  • Grace Totoe,

    Affiliation: Community Blood Center, Duluth, Minnesota, United States of America

    X
  • Henrik Ullum,

    Affiliation: Rigshospitalet, Copenhagen, Denmark

    X
  • Silvano Wendel

    Affiliation: Sirio Libanes Hospital, Sao Paulo, Brazil

    X
  • Published: September 11, 2012
  • DOI: 10.1371/journal.pmed.1001309

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Response to “External Financial Aid to Blood Transfusion Services in Sub-Saharan Africa: A Need for Reflection”

Posted by amarfin on 15 Apr 2013 at 18:11 GMT

Recently PLoS Medicine published an editorial by Ala et al. titled, “External Financial Aid to Blood Transfusion Services in Sub-Saharan Africa: A Need for Reflection.” [1] The article presented a description of common problems with current transfusion practices in the African region, as well as the authors’ perspectives on solutions. The authors stated that, in their opinion, current WHO strategies to improve donor recruitment, promote coordination through national blood transfusion services, and increase the availability of blood components are misdirected in sub-Saharan Africa, and that externally funded blood safety projects based on these strategies have resulted in serious, negative outcomes in the region. The authors suggest a new paradigm of “sustainable” support for the development of blood transfusion services in sub-Saharan Africa.

Ala et al. state that the “policies and practices from funding countries, particularly exclusive use of volunteer non-remunerated donors, centralisation, and systematic preparation of blood components are not necessarily appropriate for sub-Saharan Africa.” However, these policies and practices, and many WHO recommendations regarding blood safety, stem from an evidence base spanning nearly three decades. The data document an unacceptably high risk of transfusion-transmitted HIV infections resulting from an over-reliance on inadequately stocked hospital-based blood services and on collections from family and replacement donors (FRD) [2-7]. There are three data-driven points also worthy of reflection.
First, published studies have historically described severe inadequacies related to laboratory practices in hospital-based blood banks that were plagued by poor stock management, poor staff training, recording and reporting inaccuracies, and an unreliable procurement infrastructure for blood collection and testing commodities [2,3].

Second, contrary to the suggestion by Ala et al. that voluntary, non-remunerated donors (VNRD) are not safer than FRD, the results of the cited study by Kimani et al. show evidence of superior safety of VNRD compared with FRD [8]. These findings include a higher HIV prevalence and a higher likelihood of multiple sex partners among FRD compared to VNRD recipients in Kenya’s nationally representative, population-based AIDS Indicator Survey [8].

Third, regarding the recommendations for centralized blood services, a CDC-supported 2009 study documented an association between the adoption of WHO recommendations for blood services and the reduction of the risk of transfusion-transmitted HIV in Kenya to 0.0% [9]. This was a significant improvement over the findings of a 1994 residual risk study in Kenya where Moore et al. estimated that 2% of transfusions transmitted HIV [2].

Recent investments by many African countries and large external donors that follow WHO recommendations have markedly improved the availability and safety of blood and blood products. CDC has documented steep declines in HIV prevalence among collected blood units and increases in total and per capita blood collections in countries that have received support from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) to strengthen centralized blood services and collections from only VNRD [10]. In short, improved safety and blood supply adequacy can be simultaneously achieved.

We agree with Ala et al. that further reflection is warranted regarding recommendations for future investments in the region, including the expansion of component therapy and development of sustainable strategies regarding their use. Ala et al. also suggest that whole blood transfusions are superior to packed red blood cell for the treatment of severe malarial anemia is not supported in the scientific literature. However, clinical trials comparing the efficacy of packed red blood cells versus whole blood in severe malaria have not been conducted, and there is little reason to think that anemia due to hemolysis would not be reversed with packed red blood cells alone (Dr. WH Dzik, personal communication, 2012). While whole blood may have some benefit over component therapy in trauma and/or post-partum hemorrhage, further study is warranted before widespread adoption.

Finally, we agree with the authors’ statement that “timely access to blood transfusion has a clear role to play in achieving two of the Millennium Development Goals—reducing death rates by two-thirds in children under-five and by three-quarters in mothers.” We also agree that a blood delivery system should be sustainable as well as culturally and economically appropriate. Mortality attributable to maternal hemorrhage and pediatric malaria can be greatly ameliorated by the availability of safe and adequate blood supplies. Yet, these two clinical indications continue to claim unacceptably high numbers of lives in sub-Saharan Africa [11]. In 2010, 91% of the world’s malaria deaths, an estimated 596,000 deaths, occurred in Africa. Over 90% of the malaria deaths in sub-Saharan Africa occurred in children under five years of age. Maternal hemorrhage accounted for up to 40% of maternal mortality in the region, a statistic that has changed little since 1990. In 2010, of the 40 countries with the world’s highest maternal mortality rate (MMR), 37 (93%) were in sub-Saharan Africa.

To combat these unacceptably high mortality rates, Ala et al. argue for the preservation of decentralized blood banks, continued reliance on family replacement donors, and the exclusive use of whole blood. This argument is based on the notion that these are culturally acceptable and affordable models that have evolved and are embedded in healthcare systems throughout Africa. However, in a review of the public health literature, no studies were found that supported the authors’ claims that decentralization or continued use of whole blood increased the availability of blood. A review of the history of transfusion in Africa has shown that decentralization of transfusion services actually lowered the general availability of blood [12].

As correctly noted by Ala et al., clinicians may have as little as an hour between the moment of diagnosis and the death of a patient suffering from severe hemorrhage or malaria-associated anemia. This leaves little time for identification, notification, and mobilization of a family replacement donor, and subsequent collection, testing, processing, and delivery of blood. By contrast, investing in systems that allow immediate access to safe blood that has been screened for blood-borne pathogens may improve clinical outcomes. To improve access to safe blood at the facility level, we propose that national blood transfusion services develop systems that improve inventory management and long-term component storage and specifically link to hospitals and comprehensive emergency obstetric and neonatal care services, especially outside of urban areas.

In conclusion, the authors’ call for “reflection” is a welcome addition to the global debate on sustainable strategies for global health. Much work remains to be done to help recipient countries in sub-Saharan Africa meet their commitments to increase domestic health funding under the 2000 Abuja Declaration, and to enforce the commitments made by donors under the 2005 Paris Declaration on Aid Effectiveness [13]. Ensuring that these global initiatives support a sustainable future for high-quality and innovative blood transfusion services is a better approach to address long-term blood safety challenges in resource-constrained settings.

Sridhar V. Basavaraju, John P. Pitman, Bakary Drammeh, Naomi Bock, Jan Moore, Anthony A. Marfin

HIV Prevention Branch, Division of Global HIV/AIDS, Center for Global Health, U.S. Centers for Disease Control and Prevention.

Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the U.S. Centers for Disease Control and Prevention.

References:
1. Ala F, Allain JP, Bates I, Boukef K, Boulton F, et al. (2012) External financial aid to blood transfusion services in sub-saharan Africa: a need for reflection. PLoS Med 9: e1001309.
2. Moore A, Herrera G, Nyamongo J, Lackritz E, Granade T, et al. (2001) Estimated risk of HIV transmission by blood transfusion in Kenya. Lancet 358: 657-660.
3. Lackritz EM, Ruebush TK, Zucker JR, Adungosi JE, Were JBO, et al. (1993) Blood transfusion practices and blood-banking services in a Kenyan hospital. AIDS 7: 995-999.
4. McFarland W, Mvere D, Katzenstein D (1997) Risk factors for prevalent and incident HIV infection in a cohort of volunteer blood donors in Harare, Zimbabwe: implications for blood safety. AIDS 11 Suppl 1: S97-102.
5. McFarland W, Mvere D, Shandera W, Reingold A (1997) Epidemiology and prevention of transfusion-associated human immunodeficiency virus transmission in sub-Saharan Africa. Vox Sang 72: 85-92.
6. Jacobs B, Berege ZA, Schalula PJ, Klokke AH (1994) Secondary school students: a safer blood donor population in an urban with high HIV prevalence in east Africa. East Afr Med J 71: 720-723.
7. Diarra A, Kouriba B, Baby M, Murphy E, Lefrere JJ (2009) HIV, HCV, HBV and syphilis rate of positive donations among blood donations in Mali: lower rates among volunteer blood donors. Transfus Clin Biol 16: 444-447.
8. Kimani D, Mwangi J, Mwangi M, Bunnell R, Kellogg TA, et al. (2011) Blood donors in Kenya: a comparison of voluntary and family replacement donors based on a population-based survey. Vox Sang 100: 212-218.
9. Basavaraju SV, Mwangi J, Nyamongo J, Zeh C, Kimani D, et al. (2010) Reduced risk of transfusion-transmitted HIV in Kenya through centrally co-ordinated blood centres, stringent donor selection and effective p24 antigen-HIV antibody screening. Vox Sang 99: 212-219.
10. CDC (2011) Progress toward strengthening national blood transfusion services --- 14 countries, 2008--2010. MMWR Morb Mortal Wkly Rep 60: 1578-1582.
11. United Nations (2012). Millennium Development Goals Report 2012.
12. Schneider WH (2013). History of blood transfusion in sub-saharan Africa. Transfus Med Rev. 2013 Jan;27(1):21-8.
13. OECD (2005) Paris declaration on aid effectiveness. OECD.

No competing interests declared.

RE: Response to “External Financial Aid to Blood Transfusion Services in Sub-Saharan Africa: A Need for Reflection”

jpa1000 replied to amarfin on 09 May 2013 at 09:39 GMT

We welcome the contribution of the group affiliated with CDC in Kenya (1) to the dialogue and reflection resulting from our article (2) about the critical subject of development of blood transfusion services in sub-Saharan Africa (SSA). We do acknowledge that external help has been useful in improving many aspects of transfusion services (3). However, the arguments we present in our article, which are backed up by published evidence, suggest that the indiscriminate application of principles of transfusion practice used in wealthy countries to poorer countries may have unintended consequences which may be detrimental. Basavaraju et al (1) comment on three aspects of transfusion services discussed in our article: exclusive use of voluntary non-remunerated donors (VNRD), centralisation and systematic preparation of blood components - we consider each of these below.

In our article we provided evidence that family donors (also known as replacement donors) in SSA are as safe as VNRD. Basavaraju et al cite five articles or abstracts published between 1993 and 2001, which focused on data concerning HIV infection only, in order to contend that family donors are less safe than VNRD. In some cases, the results in these studies are based on unreliable testing without confirmation or adjustment according to age or gender. VNRD have significantly different age and gender profiles to family donors, so a crude comparison without appropriate adjustments will lead to unreliable conclusions about their comparative safety (4). For example, one study (5) quoted by Basavaraju et al indicates that HIV infection is lower in VNRD aged less than 25 years compared with older donors and that first-time VNRD have a higher prevalence of infection than family donors; thus supporting our plea for epidemiologic adjustments of prevalence. Another study reported data from 1994 and indicated that the VNRD were younger than the family donors but again they did not adjust the HIV infection prevalence for age, gender or repeat donations (6). A more recent study quoted by Basavaraju et al did not directly compare the two populations of well-identified blood donors as it was a household cluster sampled survey (7). In our article we presented data published in 2010 from three different countries showing that there was no difference in prevalence of three different viral markers and between two epidemiologically comparable types of donors: family and first-time VNRD (2).

Regarding centralisation, Basavaraju et al use articles comparing data from 1994 and 2007 to illustrate that increasing centralisation has been responsible for a substantial improvement in HIV blood safety. However this causal link has been disputed because centralisation programmes in transfusion services in SSA have generally been accompanied by very substantial external financial support largely aimed at reducing HIV prevalence (8). We acknowledge that the considerable financial support that PEPFAR programme has devoted to blood transfusion has increased the number of VNRD in several SSA countries. However we also note that, except for the relatively affluent Botswana, none of these countries, including Kenya (9) has come close to reaching the target of 10 units/1000 inhabitants which is widely touted (but not supported by evidence) as an adequate supply. There is evidence from Ghana and from Trinidad and Tobago that this target can be attained and sustained by supplementing VNRD with family donors (10, 11). The article by Schneider (3) quoted by Basavaraju et al does not indicate that decentralisation following independence of SSA countries reduced the availability of blood. However, it does recognise that centralisation is logistically difficult because of high costs and transport issues. Furthermore, centralisation may be of no use when much of the blood is needed for emergency transfusion in geographically remote locations without practical cold chain between centralised collection or testing sites and patient care (12)

We do agree with Basavaraju et al that hospital-based blood banks have often produced poor products because they have been inadequately managed or supervised by the central organisations that did not fulfil their responsibilities to ensure adequate national standards or test distribution, education and quality assurance plans (13). In our article we did not indicate that whole blood was superior to red cell concentrate as asserted by Basavaraju et al. For clarification, approximately 50% of transfusions in SSA are emergencies, predominantly associated with bleeding. In these circumstances whole blood is adequate and used in most of the countries in SSA that are not supported by external funding. Most of them do not have funds or equipment to prepare components. The point being, with extreme limitations of resources, recruiting of return donors and quality systems and testing may be of higher priority than expensive centrifuges in settings with unreliable power supplies and limited access to appropriate preventative maintenance and repair services.

We strongly urge all those involved in supporting transfusion services in SSA to utilise available, locally appropriate, evidence to guide their interventions. Evidence concerning many non-HIV aspects of transfusion services in SSA is extremely weak. It is therefore incumbent upon development agencies to encourage researchers in SSA to generate their own research to fill these knowledge gaps rather than importing potentially inappropriate transfusion service models from wealthy countries.

1. Basavaraju SV, Pitman JP, Drammeh B, Bock N, Moore J, Marfin AA. (2013) Response to “External Financial Aid to Blood Transfusion Services in Sub-Saharan Africa: A Need for Reflection”. PLOs Medicine
2. Ala F, Allain JP, Bates I, Boukef K, Boulton F, et al. (2012) External financial aid to blood transfusion services in sub-saharan Africa: a need for reflection. PLoS Med 9: e1001309.
3. Schneider WH. (2013) History of blood transfusion in sub-saharan Africa. Transfus Med Rev 27:21-28.
4. Allain JP. (2011) Moving on from voluntary non-remunerated donors: who is the best donor? Brit J Haematol; 154, 763-769.
5. McFarland W, Mvere D, Shandera W, Reingold A. (1997) Epidemiology and prevention of transfusion-associated human immunodeficiency virus transmission in sub-Saharan Africa. Vox Sang 72: 85-92.
6. Moore A, Herrera G, Nyamongo J, Lackritz E, Granade T, et al. (2001) Estimated risk of HIV transmission by blood transfusion in Kenya. Lancet 358: 657-660.
7. Kimani D, Mwangi J, Mwangi M, Bunnell R, Kellogg TA, et al. (2011) Blood donors in Kenya: a comparison of voluntary and family replacement donors based on a population-based survey. Vox Sang 100: 212-218.
8. Allain JP. (2010) Volunteer safer than replacement donor blood: a myth revealed by evidence. Vox Sanguinis; ISBT Science Series 5: 169-175.
9. Basavaraju SV, Mwangi J, Nyamongo J, Zeh C, Kimani D, et al. (2010) Reduced risk of transfusion-transmitted HIV in Kenya through centrally co-ordinated blood centres, stringent donor selection and effective p24 antigen-HIV antibody screening. Vox Sang 99: 212-219.
10. Asenso-Mensah K, Achina G, Appiah R, Owusu-Ofori S, Allain JP. Can family/replacement blood donors become regular volunteer donors? Transfusion 2013 epub.
11. Allain JP, Farrugia A, Sarkodie F. (2011) HIV safety in sub-Saharan Africa. Vox Sang 100:434-435
12. Gorlin JB. (2005) Predonation testing of potential blood donors in resource-restricted settings. JB Gorlin Transfusion 45:1541-1542.
13. Nébié K, Ouattara S, Sanou M, Kientega Y, Dahourou H, et al. (2011) Poor procedures and quality control among nonaffiliated blood centers in Burkina Faso: an argument for expanding the reach of the national blood transfusion center. Transfusion 51: 1613-1618.


Jean-Pierre Allain University of Cambridge, Cambridge, UK
Imelda Bates, Liverpool School of Tropical Medicine and Hygiene, Liverpool, UK
Elisabeth Dax, Fitzroy, Australia
Albert Farrugia, University of West Australia, Perth, Australia
Jed Gorlin, Memorial Blood Centre, St Paul, MN, USA
Oliver Hassalll, University of Oxford, Oxford, UK
Kathryn Maitland, Imperial College London, London, UK
Dora Mbanya, University Hospital, Yaoundé, Cameroon
Ohene Opare-Sem, Komfo Anokye Teaching Hospital, Kumasi, Ghana
Oscar Torres, Children Hospital Ramon Sarda, Buenos Aires, Argentina
On behalf of the whole group.

No competing interests declared.