According to Professor Hassan Zaheer Abbas, coordinator of the Safe Blood Transfusion Program (SBTP) established in 2010 in collaboration with the German Embassy in Pakistan “Nationally, transfusion medicine has been dominated by a demand oriented incoherent blood transfusion system which is not only hazardous but can also promote unsafe transfusions.” He also added “approximately 3.5 million units of blood are collected every year in Pakistan, of which only 11% are donated by voluntary, unpaid blood donors from low risk populations and that it is necessary for family replacement donations to be substituted by voluntary non-remunerated donors.” He believes “a complete dependence on voluntary blood donation can be achieved if 2-3% of the total population becomes a part of this ‘pool’.”
Voluntary non-remunerated blood donors are the source of safe, sustainable blood supply and organisations such as WHO and the International Federation of Red Cross and Red Crescent Societies are jointly trying to achieve a global framework of action to achieve 100% voluntary non remunerated blood donation. While accurate, Pakistan currently is relatively deficient in a centralised, streamlined blood donation framework to parallel an altruistic blood donor culture system, one that would be similar to developed countries without any hindrances.
“There are sub-optimal standards for donor selection, inadequate practices for manufacturing, laboratory testing storage, transfusion and transport which can compromise the donor and patient safety.” Professor Abbas mentioned in his letter to the editor for the Transfusion Medicine journal in 2014.
A nation-wide cross sectional descriptive study was conducted in 2012 to understand the Knowledge, Attitude and Practices (KAP) of blood donors towards donating in Pakistan. While having its limitations, the study showed that 62% of the 3000 respondents were afraid of contracting blood borne diseases due to process of donation. Much of the negative outlook towards voluntary blood donation stemmed from fear of needles and the procedure. Potential donors also had little confidence in the fate of the blood that they donate and believed that blood banks would sell it for monetary reasons.
However, in man-made or natural disaster stricken situations, the public is very accessible and willing to donate voluntarily – in contrast to routine donations. Yet, there is a lack of a donor management system to accommodate such a large response from altruistic donors.
"Approximately 3.5 million units of blood are collected every year in Pakistan, of which only 11% are donated by voluntary, unpaid blood donors from low-risk populations"
A large turn-out in afflicted circumstances shows a public willing and able to donate, but there are gaps that need to be bridged before voluntary non- remunerated donations become the primary source of blood in Pakistan. Blood banks’ practices often fall below WHO standard guidelines and every country’s national healthcare policy and infrastructure should prioritise providing safe and adequate blood. A standard blood screening procedure occurs for donors worldwide, which includes testing for HIV, Hepatitis B and C, malaria and syphilis. Some private blood centers such as Indus Hospital adhere to these guidelines very stringently but a cohort study conducted on approximately 16,000 donors in Karachi showed that 5.8% of them were reactive for at least one of the screens – meaning that a substantial percentage of the donors provided blood harboring transfusion-transmitted infections.
Another survey of 170 blood banks in Karachi showed that the quality and performance of kits used for screening were often compromised by frequent power cuts and they were not stored at the recommended temperatures. Many of the surveyed blood centers continue to use rapid screen tests despite WHO guidelines discouraging the usage of rapid test kits in blood banks where there are frequent donations.
In addition to less-than-perfect screening facilities, storage and transport facilities are not available in many areas of Pakistan, which poses a higher risk of the blood collected being inadequately utilised. Newly constructed blood regional centres are not fully functional due to a scarcity of skilled professionals and financial bodies. Provincial blood transfusion authorities are not well equipped to carry out regulatory functions, thus hindering adequate safety legislation from being enforced.
The SBTP legislative reforms and framework of action includes spreading awareness, especially through campaigns about voluntary blood donation, blood demand and blood use by involving mass media and educational institutes. It also consists of establishing a blood donor committee and emphasises training for staff in donor education and care. It aims to maintain a well indexed record of voluntary blood donors at a central level with provincial coordination. The implementation includes liasing with educational institutions and acquiring technical support from WHO and IFRC.
Professor Abbas emphasises, “The core foundation of the reforms being undertaken by this program is promotion of the national culture of voluntary, unpaid and regular blood donations and converting family replacement donors to regular voluntary donors.” While these policies are pragmatic in theory, the heterogeneous condition of transfusion medicine could make it a very challenging task to acquire donors and establish a regular non-remunerated voluntary blood donor base. Prior to maximising the number of regular donors, fully equipped blood banks, tracked and recorded vein-to-vein transfusion chains, a standardized infrastructure, databases and overall, a standard practice, will have to be established across the country to ensure an aseptic, structured and efficient process for donors. According to WHO guidelines, in fact, “blood transfusion should be the priority of every nation’s health policy.”
Usually, in developed countries non-profit organisations and/or the government’s health department establishes a regulated centralised blood banking system with numerous collaborations with hospitals and clinics in the city/country. Each hospital is equipped and operational for donation and storage with an exclusive area for these procedures. Since their financial standing is relatively better, their awareness and educational campaigns to advocate for more donors stand on a strong foundation. Such organisations take years to work out the knots in their system and eventually become thoroughly streamlined, which is a continuous and consistent effort to improve the already established system. Therefore, while a top-down approach is certainly the bigger picture, a bottom-up approach is more essential and relatively a more urgent structure to work on in crucial healthcare systems.
An efficient blood donation and transfusion medicine system can not only give an improved healthcare system but also be potentially invaluable to research and development in transfusion medicine and in understanding the molecular mechanism of diseases as well as a range of therapeutic approaches. This can open up many avenues for international collaborations and recognition in health as well as scientific research and education.
The writer is a researcher at the University of Cambridge