The blood drought in context
Authors: Nakul P Raykar, Katherine Kralievits, Sarah L M Greenberg, Rowan D Gillies, Nobhojit Roy, John G Meara
Journal: The Lancet Global Health (2015)

Universal access to safe, affordable surgery when needed depends on a sufficient and safe blood supply. This is not the case in most of the world today. The average donation rate in low-income countries (2·8 donations per 1000 population) is an order of magnitude below that of high-income countries (36·4 donations per 1000 population).1WHOGlobal database on blood safety: summary report 2011.http://www.who.int/bloodsafety/global_database/GDBS_Summary_Report_2011.pdf?ua=1Google Scholar To put these figures into context, take Ethiopia, which has a blood donation rate of 0·6 units per 1000 population or roughly 56 000 units per year.2Tapco JB Toure B Sambo LG Status of blood safety in the WHO African region: report of the 2010 Survey.http://www.afro.who.int/en/downloads/doc_download/9135-status-of-blood-safety-in-the-who-african-region-2010.htmlGoogle Scholar With just over 3 million births per year in Ethiopia, we know that between 66 000 and 230 000 mothers will require a blood transfusion for postpartum haemorrhage.3Calvert C Thomas SL Ronsmans C Wagner KS Adler AJ Filippi V Identifying regional variation in the prevalence of postpartum haemorrhage: a systematic review and meta-analysis.PLoS One. 2012; 7: e41114Crossref PubMed Scopus (119) Google Scholar In the high-income setting, the median transfusion requirement per case of postpartum haemorrhage is three units.4Balki M Dhumme S Kasodekar S Seaward G Carvalho J Blood transfusion for primary postpartum hemorrhage: a tertiary care hospital review.J Obstet Gynaecol Can. 2008; 30: 1002-1007PubMed Scopus (35) Google Scholar In addition to far exceeding the existing blood supply, this leaves nothing for patients with other surgical conditions, trauma, and severe malarial or sickle-cell anaemia.5Lund TC Hume H Allain JP McCullough J Dzik W The blood supply in sub-Saharan Africa: needs, challenges, and solutions.Transfusion Apheresis Sci. 2013; 49: 416-421Summary Full Text Full Text PDF PubMed Scopus (42) Google Scholar To make the situation even worse, these low donation rates are almost certainly overestimates; they include blood that is unsafe for use, infected with organisms that cause transfusion-transmissible infections (TTIs) such as AIDS, hepatitis, malaria, and syphilis.6Jayaraman S Chalabi Z Perel P Guerriero C Roberts I The risk of transfusion-transmitted infections in sub-Saharan Africa.Transfusion. 2010; 50: 433-442Crossref PubMed Scopus (103) Google Scholar In fact, up to 52% of blood collected in Nigeria and 14% of blood collected in Mali could be contaminated with malarial parasites and hepatitis B virus, respectively.7Buyx AM Blood donation, payment, and non-cash incentives: classical questions drawing renewed interest.Transfusion Med Hemother. 2009; 36: 329-339Crossref PubMed Scopus (44) Google Scholar, 8Allain JP Moving on from voluntary non-remunerated donors: who is the best blood donor?.Br J Haematol. 2011; 154: 763-769Crossref PubMed Scopus (64) Google Scholar 19% of blood collected in sub-Saharan Africa is not even tested for hepatitis C virus.2Tapco JB Toure B Sambo LG Status of blood safety in the WHO African region: report of the 2010 Survey.http://www.afro.who.int/en/downloads/doc_download/9135-status-of-blood-safety-in-the-who-african-region-2010.htmlGoogle Scholar In Ethiopia and beyond, patients and providers have few options when in need of a transfusion. One possibility is unbanked direct blood transfusion (UDBT), which involves on-the-spot donation from a family member or volunteer in the community, a screen for TTIs with a rapid testing kit, and a blood type cross-match. UDBT is not ideal: rapid testing kits are not as sensitive as banked blood screening protocols, family and replacement donor blood has a higher prevalence of TTIs, and the potential for coerced donation is high.6Jayaraman S Chalabi Z Perel P Guerriero C Roberts I The risk of transfusion-transmitted infections in sub-Saharan Africa.Transfusion. 2010; 50: 433-442Crossref PubMed Scopus (103) Google Scholar, 7Buyx AM Blood donation, payment, and non-cash incentives: classical questions drawing renewed interest.Transfusion Med Hemother. 2009; 36: 329-339Crossref PubMed Scopus (44) Google Scholar Another option is commercial blood donation, whereby eligible individuals are paid for donation. Unfortunately, in the setting of poverty, payment creates perverse incentives for donation of unsafe quantities at unsafe intervals. Reports exist of commercial donors presenting to hospitals in hypovolaemic shock.8Allain JP Moving on from voluntary non-remunerated donors: who is the best blood donor?.Br J Haematol. 2011; 154: 763-769Crossref PubMed Scopus (64) Google Scholar However, when faced with the untenable option: forego a life-saving operation owing to lack of blood, or operate knowing the patient will die without a transfusion, UDBT or commercial donations become necessary choices. The dependence on UDBT and commercial blood donors will exist as long as reasonable alternatives do not. Rather than disregarding or banning these practices, practical interim measures should be implemented to optimise their safety.8Allain JP Moving on from voluntary non-remunerated donors: who is the best blood donor?.Br J Haematol. 2011; 154: 763-769Crossref PubMed Scopus (64) Google Scholar Offering formal training for providers, developing best practices and formal auditing mechanisms, and ensuring reliable provision of testing kits can be crucial to keeping patients, donors, and providers safe. Interim measures, however, are not nearly enough. A massive expansion of the blood donor pool is needed, but scaling up blood donation in the low-resource world is no easy task. WHO has long advocated a set of interventions to fortify a nation's blood supply,9WHODeveloping a national blood system: aide memoire for ministries of health.http://www.who.int/bloodsafety/publications/am_developing_a_national_blood_system.pdf?ua=1Google Scholar but countries will have difficulty solving these problems on their own. Nations with the lowest donation rates also have high rates of malnutrition, chronic anaemia, and TTIs, severely restricting the donor pool.2Tapco JB Toure B Sambo LG Status of blood safety in the WHO African region: report of the 2010 Survey.http://www.afro.who.int/en/downloads/doc_download/9135-status-of-blood-safety-in-the-who-african-region-2010.htmlGoogle Scholar Blood availability must be addressed as a global priority. Until the international community develops feasible equity-based transnational strategies, billions will continue to lack access to life-saving transfusions. First, we must build a donor pool fit for donation by combating malnutrition as aggressively as TTIs. Next, we must establish well distributed blood bank infrastructure capable of meeting demand. Although these efforts might lack a profit motive, global public–private partnerships have had success in developing drugs for neglected diseases, and should be considered as a structural response to this crisis.10Chatelain E Ioset J-R Drug discovery and development for neglected diseases: the DNDi model.Drug Design Dev Ther. 2011; 5: 175PubMed Google Scholar As these changes lay the foundation for a better donor pool, so too must we change the fear and trepidation that surrounds blood donation in many regions of the world. We must engage local community leaders in concert with clerics in churches, temples, and mosques, both to dispel myths about blood donation and to encourage it as a civic responsibility. We declare no competing interests.