Types of Blood Donors and Blood Safety in Developing Countries 2011/03_ Mbanya.pdf · 1953 Nigeria,...

Types of Blood Donors and Blood Safety in Developing

CountriesDORA MBANYA DORA MBANYA FMBS FMBS –– UYI/CHUUYI/CHU

YAOUNDE YAOUNDE -- CAMEROONCAMEROON

Developing countries - hmmmm

AFRICAAFRICA

Presentation OutlinePresentation Outline

Introduction Introduction

History & evolution of transfusion in SubHistory & evolution of transfusion in Sub--Saharan Saharan

Africa (SSA)Africa (SSA)

Types of blood donors in SSA & impactTypes of blood donors in SSA & impact

Any hope?Any hope?

ConclusionsConclusions


Blood safety continues to represent a big challenge in

developing countries, especially of SSA

According to a review by Tayou et al (2008) it is

multifactorial:

Related issues include the absence of policies and

legislation that organize and coordinate transfusion

practice, and their implementation


Blood donors and donor programmes are

inexistent

High prevalence Transfusion Transmissible

Infections (TTI) & inappropriate screening

Cold chain disruptions and storage problems

Distribution and rational use issues

IntroductionIntroduction

Blood donation remains Blood donation remains a key element a key element in blood in blood

safetysafety

In these settings, blood donors tend to be mainly In these settings, blood donors tend to be mainly

family or replacement donorsfamily or replacement donors

However, according to WHO (1997), these are very However, according to WHO (1997), these are very

risky donorsrisky donors. .

First Reports of Blood Transfusion (service or systematic First Reports of Blood Transfusion (service or systematic treatment) in subtreatment) in sub--Saharan Africa, 1924Saharan Africa, 1924--19551955

19241924 Belgian Congo (Zaire)

19431943 Senegal

19481948 Kenya, Uganda, Tanganyika

19501950 Angola, Cameroon, Dahomey (Benin), Ivory Coast, Guinea, Mali, Mozambique, Niger, Northern Rhodesia, Togo, Upper Volta (Burkina Faso)

19511951 Southern Rhodesia (1926 for Europeans only)

19531953 Nigeria, Gold Coast (Ghana)

19551955 Tchad, French Congo, Gabon

History

Courtesy Dr. William SchneiderCourtesy Dr. William Schneider

Who gave blood?Who gave blood?Blood banksBlood banks–– ““voluntaryvoluntary”” donorsdonors

SchoolsSchoolsSoldiersSoldiersGovGov’’t private officest private officesPrisonersPrisoners

Blood donation, Hôpital Principal Dakar, 1950s

Donation in Uganda

Mengo Hosp 1949

Schoolboys 1951

Rural Uganda 1953

History


Daily Nation (Kenya), 1962

Press coverage of blood transfusion near the time of independence in Kenya

Supplying oneSupplying one’’s own donors existed right s own donors existed right after independenceafter independence

History


WHO Intervention in blood safetyWHO Intervention in blood safety

During the 28During the 28thth WHO WHA of WHO WHA of May 1975May 1975, ,

Resolution WHA 28.72 called on member states to :Resolution WHA 28.72 called on member states to :

Promote the creation of Promote the creation of National Blood Transfusion National Blood Transfusion

ServicesServices (NBTS) based on voluntary non(NBTS) based on voluntary non--

remunerated blood donors (remunerated blood donors (VNRBDVNRBD))

Promote the Promote the promulgation of laws promulgation of laws that govern that govern

transfusion practicetransfusion practice

History of blood transfusion in subHistory of blood transfusion in sub--Saharan Saharan Africa: 1975 to presentAfrica: 1975 to present

Example of Burundi assistance from Swiss Red CrossExample of Burundi assistance from Swiss Red Cross–– Donor Recruitment and mobile unit Donor Recruitment and mobile unit


Types of donorsTypes of donors

3 categories of donors can be identified:3 categories of donors can be identified:

Volunteer nonVolunteer non--remunerated blood donor (VNBD): remunerated blood donor (VNBD): ““person person

gives blood of his/her own free will and receives no gives blood of his/her own free will and receives no

payment for it, either in the form of cash, or in kind which payment for it, either in the form of cash, or in kind which

could be considered a substitute for moneycould be considered a substitute for money””

Courtesy Prof. JP AllainCourtesy Prof. JP Allain

Types of donorsTypes of donors

Family/Replacement donor (F/R donor)Family/Replacement donor (F/R donor)

““Individuals who are generally relatives or friends of patients Individuals who are generally relatives or friends of patients

who require blood transfusionwho require blood transfusion””

Paid donors:Paid donors:

““Persons who receive monetary payment from the family of a Persons who receive monetary payment from the family of a

patient to substitute for unavailable patient to substitute for unavailable ‘‘replacementreplacement’’ donors donors

within the family circlewithin the family circle”” Courtesy Prof. JP AllainCourtesy Prof. JP Allain

Characteristics of Blood Characteristics of Blood donations in SSAdonations in SSA

Variation in transfusion servicesVariation in transfusion services::

–– HospitalHospital--based systemsbased systems

–– Centralized BTS Centralized BTS

–– Hybrid of both systems; is predominant Hybrid of both systems; is predominant (Bates et al, (Bates et al,

2007), where a few centralized functions (transfusion 2007), where a few centralized functions (transfusion

guidelines; collection from voluntary donors) are guidelines; collection from voluntary donors) are

incoorporated into the hospitalincoorporated into the hospital--based blood banking based blood banking

Characteristics of Blood donors in SSACharacteristics of Blood donors in SSA

Mainly Family/Replacement in 70 Mainly Family/Replacement in 70 –– 100% cases100% cases

R/FR/F donors are donors are readily available readily available and and cheapercheaper to obtain than to obtain than

VNRBD (Hensher& Jefferys, 2000; VNRBD (Hensher& Jefferys, 2000; Allain et al.,Allain et al.,2004; Lara 2004; Lara

et al., 2007).et al., 2007).

Mainly firstMainly first--time time donors donors

About About >75% aged <30 yrs >75% aged <30 yrs (Rajab, Nigeria; Nebie, (Rajab, Nigeria; Nebie,

Burkina;Tayou et al (Multicentric study)Burkina;Tayou et al (Multicentric study)

Type and age distribution of blood donors in Type and age distribution of blood donors in Kumasi, GhanaKumasi, Ghana

0

10

20

30

40

50

60

70

<20 20-24 25-29 30-34 35-39 40 -44 45-49 >50

Age groups

% o

f tot

al

Replacement donorsVolunteer donors

0

10

20

30

40

50

60

70

<20 20-24 25-29 30-34 35-39 40 -44 45-49 >50Age groups

% o

f tot

al

Replacement donors

Volunteer donors

0

10

20

30

40

50

60

70

<20 20-24 25-29 30-34 35-39 40 -44 45-49 >50

Age groups

% o

f tot

al

Replacement donorsVolunteer donors

0

10

20

30

40

50

60

70

<20 20-24 25-29 30-34 35-39 40 -44 45-49 >50Age groups

% o

f tot

al

Replacement donors

Volunteer donors

Allain JP, ISBT Science Series,2010, 5: Allain JP, ISBT Science Series,2010, 5: 169169--175175


Contrast with Europe: Contrast with Europe:

ExEx. Lefrere & Rouger, 2006 reported:. Lefrere & Rouger, 2006 reported:

–– <50% aged under 35 years <50% aged under 35 years in some European countriesin some European countries

Male predominance Male predominance in most African reports ranging in most African reports ranging

6060--90% 90% (Agbovi et al, Togo; Nebie et al, Burkina F; (Agbovi et al, Togo; Nebie et al, Burkina F;

Allain et al, Ghana; Tayou et al (Multicentric study)Allain et al, Ghana; Tayou et al (Multicentric study)


High TTI prevalence High TTI prevalence (HBV,HIV, HCV, Syphilis, (HBV,HIV, HCV, Syphilis,

Malaria, FilariaMalaria, Filaria……))

According to WHO at least 5% TTI transmitted According to WHO at least 5% TTI transmitted

through blood transfusion in Africathrough blood transfusion in Africa

TTI in 1TTI in 1stst time donors Cameroon compared to some time donors Cameroon compared to some African countries (Mbanya et African countries (Mbanya et al, Transfusion Medicine

2003; 13(5): 267 – 73)Type of infection Number cases detected

(n=252)

Percentage

(Cameroon, 2003)

Other African Prevalences

among donors (%)

Reference

HBV 27 10.7 11 (Tanzania)

20.3 (Mauritania)

Matee et al, 1999

Lo et al, 1999

Syphilis 23 9.1 12.7 (Tanzania)

13.5 (Ghana)

14.4 (Cameroon)

Matee et al, 1999

Ampofo et al, 2002

Mbanya et al, 2002

HIV 20 7.9 3.0 (Kenya)

8.7 (Tanzania)

Mwangi, 1999

Matee et al, 1999

HCV 12 4.8 8.0 (Tanzania)

HTLV-1 4 1.6 0.0: (Tanzania)

0.7 (Ghana)

7.1 (Cameroon)

Matee et al. 1999

Ampofo et al, 2002

Mbanya et al, 2002

Total 66 26.2 - -

Serological findings among blood donors Serological findings among blood donors ((FTD = First time donors; RD= Regular donors; FD=Family donors; BFTD = First time donors; RD= Regular donors; FD=Family donors; BD=Benevolent donorsD=Benevolent donors))

No.

Positive

% No. FTD

Positive(%)

No. RD

positive (%)

No. FD

(%)

No. BD

(%)

HBsAg 21 10.3 18 (85.7) 3 (14.3) 20 (95.2) 1 (4.8)

HIV 6 2.9 5 (83.3) 1 (16.7) 6 (100) 0 (0.0)

HCV 8 3.9 7 (87.5) 1 (12.5) 7 (87.5) 1 (12.5)

Mbanya et al, Transfusion Medicine, Mbanya et al, Transfusion Medicine, 2005, 15, 3952005, 15, 395––399399

Viral markers in the donors in Nigeria (Ahmed et al, 2007)

))Marker VNRBD (%) F/R donors (%) Paid donors (%)

HIV 4.1 4.6 8.1*

HBsAg 13.5 14.1 20.5*

HCV 1.4 1.8 2.8*

* Statistically significantly higher difference for all markers in paid donors

Comparison of viral infection markers Comparison of viral infection markers between SSA firstbetween SSA first--time VNRBD & time VNRBD &

Replacement donorsReplacement donorsCountry Viral marker 1st-time VNRD

(%)

1st time F/R

donors (%)

P value

Ghana Anti-HIV 69/6640 (1.0) 50/4360 (1.1) 0.87

(Allain et al, 2010) HBsAg 919/6640 (13.8) 649/4360 (14.9) 0.13

Guinea Anti-HIV 26/1784 (1.5) 42/8956 (0.5) <0.001

(Loua &Nze Nkoure,

2010)HBsAg 259/1784 (14.5) 1142/8956(12.8) 0.047

Cameroon Anti-HIV 11/272 (4.0) 114/3053 (3.7) 0.9

(Mbanya et al, 2010) HBsAg 49/272 (18.00) 233/3053 (7.6) <0.001

Courtesy Prof. JP AllainCourtesy Prof. JP Allain

ImpactImpact

Impact on blood supplyImpact on blood supply

Analysis of blood donation patterns ( WHO, 2004): Analysis of blood donation patterns ( WHO, 2004):

A A significant difference in blood donations between low, medium ansignificant difference in blood donations between low, medium and d

high HDI countries:high HDI countries:

–– 61% of the global blood supply 61% of the global blood supply was donated in was donated in

developed (high HDI) countries. developed (high HDI) countries.

–– 39% 39% was was donated in developing donated in developing (low and medium HDI)(low and medium HDI)

Thus, there is acute shortage Thus, there is acute shortage of blood in this regionof blood in this region

Donation per 1000 population in the African Donation per 1000 population in the African RegionRegion

Courtesy BLS/AFROCourtesy BLS/AFRO

Total units collected 1999Total units collected 1999--20082008


AFRO Strategy for Blood Safety AFRO Strategy for Blood Safety Resolution AFR/RC51/R2Resolution AFR/RC51/R2 (Aug 2001)(Aug 2001)

Main objectivesMain objectives–– TTo assist the countries to o assist the countries to

set up an effective set up an effective system system of of recruitmentrecruitment of lowof low--risk risk blood donorsblood donors;;

–– To To improve the safetyimprove the safety of of blood and blood productsblood and blood products

–– To promote the To promote the appropriate useappropriate use of blood of blood and blood products by and blood products by clinicians;clinicians;

Targets for 2012Targets for 2012–– Situation analysis done by Situation analysis done by

all countriesall countries–– National Policy National Policy

implemented in at least implemented in at least 75% of countries75% of countries

–– At least 80% of blood At least 80% of blood collected from VNRBDcollected from VNRBD

–– 100% of blood screened 100% of blood screened for for all major TTIsall major TTIs


Percentage of VNRBD in countries of the Percentage of VNRBD in countries of the African Region 2006African Region 2006


Voluntary donation on AFRO Voluntary donation on AFRO targetstargets

21

5

20

0 5 10 15 20 25

Number of Countries

<50%

50 to 79

80 to 100

Perc

enta

ge o

f Tot

al

dona

tions

AFRO TARGET - 80% voluntary donation by 2012Courtesy BLS/AFROCourtesy BLS/AFRO

Any hope?Any hope?

Nearly four decades Nearly four decades after the 28after the 28thth WHO WHA of May 1975, WHO WHA of May 1975,

Resolution WHA 28.72 called on member states to promote Resolution WHA 28.72 called on member states to promote

the creation of national BTS based on VNRBD, and the the creation of national BTS based on VNRBD, and the

promulgation of laws that govern transfusion practice:promulgation of laws that govern transfusion practice:

BLOOD DONATION, SUPPLY & SAFETY on the whole, in BLOOD DONATION, SUPPLY & SAFETY on the whole, in

SSA is still very challengingSSA is still very challenging..

Any hope? Any hope?

It is 2011:It is 2011:

7070--80% donations continue to be F/R 80% donations continue to be F/R

Most are firstMost are first--time donorstime donors

Hence donor retention remains a major issue.Hence donor retention remains a major issue.

Hope? : Yes, Hope? : Yes, May 2005May 2005 WHA Resolution 57.13:WHA Resolution 57.13:

–– Established the WBDD to be celebrated on 14Established the WBDD to be celebrated on 14thth of June of June

Celebration of the WBDDCelebration of the WBDD

Courtesy BLS/AFRO

World Blood Donor Day 2010: World Blood Donor Day 2010: CameroonCameroon

Club 25Club 25

Initiated in Zimbabwe (1989)Initiated in Zimbabwe (1989)

–– Pledge by youths to donate at least 25 times Pledge by youths to donate at least 25 times

Spread to many other countries of Africa & the Spread to many other countries of Africa & the

developing worlddeveloping world

Significant role in blood supply where it worksSignificant role in blood supply where it works


Blood transfusion Blood transfusion safety in sub-Saharan Africa (SSA) is still

plagued amongst other issues by:

– High prevalence of infectious agents,

– Donor selection issues and chronic blood shortage

– Compounded by the lack of resources etc. etc.

This implies that international norms in transfusion safety

are not implemented/implementable in most of SSA


Hence the dilemma remains:Hence the dilemma remains:

What would work best What would work best for these resourcefor these resource--limited limited

developing countries?:developing countries?:

– Supply???

– Safety???

Blood safetyBlood supply

25-50% of deathsdue to

lack of blood

High prevalence of transfusion-transmitted

infections in Africa

Conclusions

Courtesy Dr. Imelda BatesCourtesy Dr. Imelda Bates

What would strike the balance between blood supply and safety?


So, what would work?So, what would work?A centralized system (A centralized system (100% VNRBD100% VNRBD) )

OR OR

A local system (A local system (tolerance of F/R donorstolerance of F/R donors))

Cost/unit of bloodCost/unit of bloodCentralised and local systemsCentralised and local systems

LocalCentralised (excl. capital costs)

$16

Donor recruitment

Blood distribution

Quality processes

$60

Medina Lara et al J. Clin. Pathol., 2007; 60:1117-1120

Patients bear donor costs

No distribution costs

Quality?

Conclusions


SolutionSolution: Strategies to increase repeat donations: Strategies to increase repeat donations

Both types of 1stBoth types of 1st--time donors (VNRBD & F/R) are equally time donors (VNRBD & F/R) are equally

acceptableacceptable

Improved blood safety relies on repeat donations Improved blood safety relies on repeat donations

Hence that should be a target in our settingsHence that should be a target in our settings

““Winning isn't everything, but wanting to win isWinning isn't everything, but wanting to win is””

Following a train wreck in October 1957

AcknowledgementAcknowledgement

For kindly authorizing me to use their slides, I wish to For kindly authorizing me to use their slides, I wish to thank:thank:

Prof. JP AllainProf. JP AllainDr. W. SchneiderDr. W. SchneiderDr. I. BatesDr. I. BatesDr. JB TapkoDr. JB Tapko

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