In the Land of the Pharoes
Safe blood transfusion in developing countries
Von Dr. Denham Pole MD / Schweizerisches Rotes Kreuz SRK
Production of blood is a highly technological process which is dependent on the basic infrastructure of the country (power and water supply, transport, education...). Throughout the whole length of the chain there are people involved – from the donors to the laboratory staff to the doctors and nurses – where there is a need for outstanding human values and skills; on the one hand humanitarian and philanthropic, on the other hand dedication and professionalism. It should be clear therefore, that blood safety goes hand-in-hand with general development, be it social, political or economic.
The Swiss Red Cross was mandated three years ago by the Swiss Government to assist in the planning and to accompany a project to rehabilitate the blood transfusion service of Egypt. When we investigated the situation in the country, we found that there were over a thousand small, mostly inefficient blood banks acting completely independently with almost no standardization. Almost all blood was collected by the family replacement system of coerced or paid donors and the clinical use of blood was not up to international standards with many doctors, even senior ones, prescribing "fresh, whole blood". Staff of the laboratories were lacking professional training and there was no system of quality control.
A project was therefore planned to establish a national center to act as a reference laboratory and a network of eight large regional centers to cover the entire country, to equip them with large, high-throughput laboratory equipment and to centralize blood testing in these centers. A further 30 collection and distribution centers were chosen to provide every hospital with adequate supplies of blood, but where the laboratory testing would be done at the regional center. By concentrating training resources on large regional centers, it was planned to improve blood safety and to increase the quantity of blood available. It was also planned to improve the clinical prescribing of blood through the project and to encourage the use of components. Part of the effort of the project was to set up a blood donor recruitment program, and in this respect we cooperated with a project funded by USAID. Details of the project may be seen on the Internet at www.nbtsegypt.org
Clearly such an ambitious project was a risky undertaking, particularly in such a large and heavily-populated country like Egypt. In the case of blood donor recruitment we discovered that the practice of "family replacement" was so established that it proved difficult to change. Blood center staff had for many years so designed their working procedures around family replacement, that to relinquish their passive role and to look actively for donors meant a big change in thinking. However there is now a trend towards recruitment of voluntary blood donors with the center in Alexandria collecting 50% of their donors in this way and the National Center 100%. Other centers also increased the proportion of voluntary donors to a smaller extent.
In the case of laboratory screening, the lack of a standard training course in Egypt for laboratory technicians, who get no experience on high-tech equipment after graduation, meant that many of the staff were lacking the basic skills needed to carry out precise detailed laboratory work to the accuracy needed. The training initially planned at a high professional level had to be changed to basic training as it proved necessary to concentrate on basic understanding of the processes involved rather than to teach more advanced techniques.
In the case of doctors in the hospitals, it became clear that outmoded ideas and practices were widespread, even in the case of senior physicians and surgeons. A series of training programs, workshops and seminars were carried out, the messages of modern transfusion medicine were gradually introduced, and it was gratifying to notice increased enthusiasm of blood center and clinical staff after these sessions.
Although considerable progress was made in the 3 years of the project, we have not yet succeeded in having the district blood banks send their samples for testing to the regional centers nor to reduce the number of testing centers. However some hospitals which previously tested blood are now obtaining it from the national center.
Conclusions drawn from our Egyptian experience
It takes at least 10 years to establish a good blood transfusion service in any country. Each project should have a policy/planning phase lasting at least one year. During this time, the plan for the project should take shape as well as an overall plan for the establishment of a national blood transfusion service to take over after the project ends. The project plan should include an overall concept for blood testing (centralization or regionalization), the location of centers (testing & distribution centers, hospitals to be served) and the type of equipment to be ordered and the degree of automation.
The next steps of the project should consist of tendering, selection of supplier, contract negotiation and building – a process which could well last a further year. This is followed by delivery, installation, supplier training and professional training (at least 6 months per center).
By this stage the activities of the blood banks themselves can start with a well designed blood donor recruitment program, the establishment and supervision of the laboratory work, and for hospitals, clinical guidelines and hospital committees on blood. Of vital importance is adequate staff, all properly trained.
Can we aim for the same level of quality of blood as in industrial countries?
Even though there are high levels of infectious disease in developing countries (hepatitis-C in Egypt, AIDS in sub-Saharan Africa), it is possible using modern blood safety practice, to exclude blood transfusion as an important source of cross-infection. Careful selection of donors, good laboratory practice and a cautious clinical approach of avoiding blood transfusion whenever possible could result in transfusion becoming as safe in developing countries as elsewhere.
The supply of safe blood is an exercise in good management and organization. The knowledge is available on how to obtain, process, test, store, distribute and administer safe blood. Management of the blood transfusion service obeys the same principles as in any other sector, be it education, agriculture, banking or transport. In all these cases, the solution is the same; better management training, attention to detail in organization and the use of know-how from other countries and international aid organizations.
How can a developing country get the best system it can afford?
It is obvious that when resources are limited, they must be spent on the most essential items. Clearly, if there is almost no money to run the health services, a country might be better off to avoid blood transfusion at all and to concentrate resources on more cost-effective aspects of healthcare – immunization, treatment of common infections, early detection of obstetrical complications. If there are limited resources available for blood transfusion, the best strategy is to reduce the number of blood testing centers to an absolute minimum so that quality of production and testing can be assured and safe blood distributed to the major hospitals.
The over-riding consideration in any country is to spend on all aspects of blood safety equally. It is unwise to overspend on high-tech lab equipment and to have no resources for a blood donor campaign, or to employ a large number of staff but to have little left over to train them. A full cost-analysis of the entire system must be made and each aspect of the system must be allotted an appropriate share of the budget.
*Since 1994, Dr. Denham Pole MD has worked for the Swiss Red Cross, Department of International Cooperation, as a manager of Swiss Government healthcare projects in Asia and Europe. For the past 4 years he has been the Swiss project leader for the Rehabilitation of the Blood Transfusion Service in Egypt.