Blood transfusion safety

Blood is neither a commercial product nor can it be synthesized artificially. The responsibility for ensuring its continuous supply rests with the health administrators who need to galvanize entire communities towards regular and non-remunerated blood donations.

Blood Transfusion Services in South-East Asia

The blood transfusion services (BTS) in Member Countries of SEAR, are in varying stages of development. Against an estimated annual requirement of 15 million units of blood, around 9.3 million units are collected. Voluntary non-remunerated donations vary from 40-93% in different countries. Paid donors continue to be a source in Bangladesh. Almost three fourth of the collected blood is utilized as whole blood. Quality of screening for major infections such as HIV and hepatitis B & C is a critical issue in SEAR where number of people living with HIV, hepatitis B and hepatitis C is estimated to be 6 million, 85 million and 25 million respectively.

WHO strategy for safe blood

WHO has a global strategy for safe blood which recommends the following integrated strategy to national health authorities:

   Establishment of a well-organized, nationally coordinated blood transfusion service that can provide adequate and timelysupplies of safe blood for all patients in need;

     Collection of blood only from voluntary unpaid blood donors at low risk of acquiring transfusion-transmissible infections, and stringent blood donor selection criteria;

    Testing of all donated blood for transfusion-transmissible infections, blood groups and compatibility;

     Production of blood components to maximize the use of donated blood and enable the provision of therapeutic support for patients with special transfusion requirements;

      Appropriate clinical use of blood and the use of alternatives, where possible, to minimize unnecessary transfusions;

      Safe transfusion practice at the bedside;

     Comprehensive quality system covering the entire transfusion process, from donor recruitment to the follow-up of recipients of transfusion

Infections transmitted through blood

Unfortunately blood is also a potent vehicle for the transmission of various micro-organisms. Use of unscreened blood has the potential for infecting recipients with lethal infection like HIV/AIDS, hepatitis B and C, and from many others. Transfusion transmissible infections (TTI) contribute significantly to the epidemiology of these infections.  Though most of the countries are now screening donated blood for these organisms, yet greater efforts are needed to ensure continuous availability of safe blood to entire population.

Rational use of blood

The rational use of available safe blood also warrants the immediate attention of health administrators, blood transfusion service providers and prescribing physicians. It is well recognized that safety, adequacy, and quality of blood are the essential requisites that any blood transfusion service will have to ensure to derive the maximum benefit from donated blood. WHO has accorded the utmost priority to ensure the safety of blood. Blood safety was also the theme of World Health Day 2000 with a thought-provoking slogan, “Safe blood starts with me: blood saves lives”.

Aide-Memoire on Blood Safety for National Blood Programme

Quality Management Project for safe blood

The availability and safety of blood depends on multiple steps in the transfusion chain. This starts with a healthy and a motivated population, retention of voluntary non-remunerated donors, processing and testing of all donated blood, availability of blood and blood products, rational use of blood and its components and post-transfusion monitoring of the patient. At every step, any lowering of quality will reflect on the class of the final product. Quality management of blood transfusion services is an all-encompassing concept that needs to be integrated into the working of any blood transfusion service to achieve ideal results.

Accordingly, a Quality Management Project (QMP) has been implemented in South-East Asia Region under which 135 quality managers for blood centres have been trained in all the countries of this Region during 2001-2005.

WHO collaborating centre for blood safety

Continued post-training support and networking between various blood banks has been assured through Regional Quality Training Centre at National Blood Centre, Thai Red Cross Society, Bangkok. This institute is also the WHO Collaborating Centre on Training in Blood Transfusion. Realizing that external quality assessment can act as a powerful tool to enhance internal quality control measures, a scheme to undertake this activity has been started with Department of Medical Sciences, Ministry of Public Health, Thailand as the organizer for Regional External Quality Assessment Scheme for blood group serology and TTI. Selected blood banks from all the countries of SEAR are participating in this scheme.

Aide Memoire on Quality in blood transfusion services

Laboratory Services

The World Health Organization has been advocating strengthening of laboratory services as evidenced by WHA Resolution 27.62 (1974) and RC resolution SEA/RC49/R4 (1996)., WHO has been continuously striving to develop, strengthen and expand health laboratory services through the application of appropriate and cost-effective diagnostic and therapeutic procedures that are essential for the provision of quality health care and mitigation of human mortality, morbidity and misery.  Accurate and timely laboratory analysis are critical for identifying, tracking and limiting public health threats. An efficient national network of public health laboratories strengthens the health system and augments its capability to respond effectively to needs of public health. Similarly emerging disease surveillance shall warrant modern computing and communication technologies to transform data into useable information quickly and effectively. Accurate and efficient data transfer with rapid notification of key partners and constituents is critical to effectively address the threats of emerging diseases.

Up-gradation of health laboratories in general, and public health laboratories in particular rrequire considerable strengthening in developing countries to enhance their response capability for various outbreaks notably of SARS, highly pathogenic avian influenza, Nipah virus, rickettsiosis, dengue fever, Japanese encephalitis and leptospirosis. Facilities to diagnose exotic infections e.g. Ebola and most of the agents with bio-terrorism potential are limited. Challenges being faced for  efficient public health laboratories in some developing countries include absence of national policy and allocation of resources to modernize public health laboratories, insufficient infrastructure, non-availability of norms, standards and guidelines, inadequate regulatory mechanism, weak quality management of public health laboratories, improper utilization and maintenance of equipment and non-availability of quality diagnostic kits and reagents on continuous basis.

Laboratory  networks

WHO has been advocating and supporting strengthening of national network of laboratories. The intercountry networks of laboratories are required to provide support for selected parameters and unusual events. Some of the existing networks are:

Influenza: Six of the 11 Member States of SEAR are participating in Global Influenza Laboratories Network (FLUNET) through their respective National Influenza Centres. The countries which do not have national influenza centres are Bhutan, Maldives, Myanmar, Nepal and Timor Leste. Guidelines for establishment of national influenza centres are available.

Drug Resistance in TB:India, Nepal and Thailand are part of Global Network for Surveillance of Drug Resistance in Tuberculosis.

Salmonella Surveillance: 71 laboratories (from health and veterinary sectors) from seven SEAR countries (India-7, Indonesia 6, Maldives 1, Myanmar 4, Nepal 5, Sri Lanka 6 and Thailand 42) are participating in Global Salmonella Surveillance Network. 

Enteroviruses (Poliomyelitis): 16 enteroviruses laboratories with focus on poliomyelitis are members of Global network. These laboratories are from Bangladesh (1), DPR Korea (1), Indonesia (3), India (8), Myanmar (1), Sri Lanka (1) and Thailand (1). The Thailand and Sri Lanka laboratories are also the Regional Reference Laboratories and provide support to Nepal and Maldives respectively. The Enterovirus Research Centre, Mumbai is the Global Specialized laboratory. WHO has been providing considerable support to sustain this network.

Measles: 15 laboratories representing all the Member States of SEAR have been brought together as a measles network. The National Institute of Health, Thailand serves as the Regional Reference Laboratory for this network.

HIV and hepatitis B: The Bureau of Laboratories Quality and Standards, Ministry of Public Health, Thailand coordinates a network of 20 laboratories for strengthening quality of screening for HIV and hepatitis B.

Laboratory Support to HIV/AIDS

 For various issues pertaining to prevention and control of HIV/AIDS, the laboratory support is the most basic and fundamental tool. Monitoring of antiretroviral therapy, diagnosis of HIV and associated infections and evaluation of response to therapy in the individual and various public health interventions cannot be accomplished until reliable laboratory support is available both at clinical and public health areas. Guidelines have been developed to ensure optimal utilization of laboratory support in providing quality care and reliable diagnostic support to various interventions against HIV/AIDS in South-East Asia.

Human organ and tissue transplantation

Transplantation of various human solid organs (especially kidneys), tissues (cornea, bone, skin etc) and cells (stem/haematopoietic cells) has increased worldwide in the recent past with improvements in surgical skills, technology for genetic-matching and availability of safe agents that can bring about immunosuppression. Non-availability of adequate number of donors is a major problem in meeting the demand of donated organs.

WHO developed Guiding Principles on Human Organ Transplantation in 1991, Consequent to international deliberations, WHA passed resolution WHA 57.18 in 2004 which is now the basis of WHO’s work in this area.

No comprehensive and systematically collected data on number of transplantations in SEAR countries are available. Globally, about 35,000 kidney transplantations take place every year.  Estimated numbers of annual kidney transplantations in India and Thailand are around 3000, and 300 respectively. These are performed in around 50 centres in India and 30 centres in Thailand. Almost 50% of kidney donors in SEAR are live unrelated donors. The number of heart and liver transplantations in SEAR is very small. Legal frameworks on transplantation of human organs are available in several countries and Professional societies for Transplantation exist in India, Thailand and Indonesia. Many NGOs are involved in advocacy and public awareness on organ donation.

WHO has been bringing together global experts to develop consensus on ethical, technical and regulatory issues on organ and tissue transplantation.

Xenotransplantation is defined as the transplantation of living cells, tissues or organs of animal origin. It has the potential to supplement the limited supply of human material for transplantation but requires considerable research to overcome the problems of immunorejection and assuring safety of transplantation for the recipient from getting infected with unknown microorganisms or microbes restricted to animals.     

Diagnostic imaging

World Health Organization has been playing an important role in supporting and developing radio diagnostic and radio therapeutic services especially in the developing countries. WHO has been actively involved in providing technical support in radiation medicine through its Collaborating Centres by imparting training, preparing technical guidelines and standards as well as implementation of quality assurance activities. A global network of Secondary Standard Dosimetry Laboratories is operating with large number of laboratories in developing world.