Progress Toward Strengthening National Blood Transfusion Services — 14 Countries, 2008–2010

Progress Toward Strengthening National Blood Transfusion Services — 14 Countries, 2008–2010Weekly
November 25, 2011 / 60(46);1578-1582

In sub-Saharan Africa, transfusion-transmitted human immunodeficiency virus (HIV) infection persists, particularly among women and children, who receive most blood transfusions (1). Providing technical and financial assistance to national blood transfusion services to increase the adequacy of blood collections and to prevent transfusion-transmitted HIV infection continues to be a priority under the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). Since 2004, PEPFAR has provided support (including policy guidance, strengthening laboratory capacity, and enhancing recruitment and retention of safe blood donors) to national blood transfusion services in 14 countries* heavily impacted by HIV. CDC previously has described progress made by these countries during 2003--2007 (2). This report summarizes the results of updated analyses of data collected by national blood transfusion services during 2008--2010 and reported to CDC, which indicated that, since 2007 1) legislative frameworks supporting a national blood policy were established in two countries, are under development in two countries, and are being updated in one country; 2) the number of whole blood units collected had increased in 11 countries; 3) the percentage of collections from voluntary nonremunerated donors† had increased in five countries; and 4) the proportion of collected units reactive for HIV§ had decreased in 12 countries. Countries supported by PEPFAR continue to make progress toward improving safe and adequate supplies of blood. Continued government commitment is critical for ensuring quality, safety, and adequacy of the blood supply and sustaining the national blood transfusion service after eventual transition from PEPFAR support.

In 2008, the most recent year for which global data are available, approximately 92 million blood units were donated worldwide (3). An estimated 4 million (4.3%) of those units were donated in sub-Saharan Africa (3), which has approximately 12% of the global population¶ and is where blood collections historically have been inadequate to meet clinical demand (4) and inappropriate clinical use of blood further contributes to supply inadequacy (5). Historically, laboratory screening for HIV infection in sub-Saharan Africa also was inconsistent and not performed in a standardized, quality-assured format (6). Collections were primarily from hospital-based services that relied on family members or paid donors, who typically are at greater risk for HIV infection than voluntary nonremunerated donors and, because of external pressures to donate, might not reveal behavioral risks for HIV during donor selection (7).

To overcome these challenges, the World Health Organization (WHO) has emphasized the need to maintain an adequate supply of safe blood. WHO estimates that resource-limited countries will begin to meet clinical demand if at least 10 whole blood units per 1,000 population are collected annually (8). Furthermore, to improve adequacy of supply and reduce the risk for transfusion-transmitted HIV infection, WHO has recommended that resource-limited countries adopt comprehensive national policies for national blood transfusion services (3). In 2010, WHO revised these recommendations to include a quality systems approach as a fifth key element in addition to the existing four (3).** PEPFAR-supported blood safety initiatives are based on these WHO recommendations and have been demonstrated to reduce the risk for transfusion-transmitted HIV while increasing the supply of safe blood (2,9).

Since 2007, CDC has collected and maintained data to support routine monitoring and evaluation of PEPFAR-funded blood safety projects. The resulting blood safety database contains 80 variables related to safety, supply adequacy, and clinical utilization. Data are derived from routine operations at individual centers throughout a country where collection, processing, testing, and distribution occur, and which collectively constitute the national blood transfusion service. Periodically, data are transferred to the national blood transfusion service headquarters in each country. Data are then aggregated annually and shared with CDC, where they are analyzed for ongoing programmatic evaluation.

This report presents a descriptive analysis of data reported by the 14 countries for the period January 2008--December 2010. The four variables selected for analysis and included in this report represent key elements that address blood supply adequacy and transfusion safety outlined by WHO. The variables are 1) the status of a national blood policy and legislative authority for a national blood transfusion service; 2) the percentage of total national blood service whole blood collections from voluntary nonremunerated donors; 3) the total number of national blood service whole blood unit collections and the number of whole blood unit collections per 1000 population based on the 2010 revision of the United Nations Population Division census estimates for 2000--2010††; and 4) the percentage of collected whole blood units reactive for HIV. Also included are the Joint United Nations Programme on HIV/AIDS population prevalence estimates among persons aged 15--49 years, who account for the majority of donations in these countries (3) for 2001, 2007, and 2009. In all 14 countries, algorithms for screening donor blood for HIV dictate that units with a reactive HIV test result be discarded and donors be permanently deferred from future donation. Additional testing to confirm HIV infection status for HIV-reactive units is not performed routinely in all countries, although donors are referred for further testing elsewhere.

By 2007, in addition to six countries with existing national blood policies, such policies were established in six additional countries and were in development in one country. In 2010, 12 countries continued to report the presence of a national blood policy, including one country that was revising its existing policy. Since the most recent reporting in 2007, a legislative framework supporting the national blood policy had been enacted in two additional countries.§§ By 2010, 11 countries had increased total whole blood unit collections relative to 2007, and national blood services in all countries reported increased collections relative to 2003¶¶ (Table 1). South Africa had already achieved 17.4 whole blood units collected per 1,000 population per year in 2003, and Botswana reached 11 units per 1,000 population in 2005. In both countries, whole blood collections continued to be >10 units per 1,000 population per year through 2010. In 2009, collections by the national blood service in Guyana (10.2 units per 1,000 population) had crossed this threshold, with Namibia (9.7 units per 1,000 population) close to this threshold. Six other countries had increased collection rates per 1,000 population since 2007. In 2010, 11 of the 14 PEPFAR-supported countries continued to have either 100% of collections by national blood services from voluntary non-remunerated donors or an increase in the percentage of collections from these persons in comparison with 2007, including Haiti, despite structural losses from the 2010 earthquake (Table 2). Since 2007, the national blood services in 12 countries have reported an overall decrease in the percentage of collected blood units reactive for HIV, despite persistently high HIV population prevalence as estimated by the United Nations (Table 2).

Reported by
Jerry A. Holmberg, PhD, Office of the Assistant Secretary for Health, US Dept of Health and Human Svcs; Sridhar Basavaraju, MD, Christie Reed, MD, Bakary Drammeh, DrPH, Michael Qualls, MPH, Div of Global HIV/AIDS, Center for Global Health, CDC. Corresponding contributor: Sridhar Basavaraju, sbasavaraju@cdc.gov, 404-639-8011.

Editorial Note
During the first phase of PEPFAR (2004--2007), the 14 PEPFAR-supported countries made rapid progress in blood safety and adequacy (2). During 2008--2010, incremental progress continued as the second phase of PEPFAR emphasized sustainability and transition to country ownership. Government commitment is critical to reaching the WHO recommendations for quality, safety, and adequacy of the blood supply and sustaining the national blood service after eventual transition from PEPFAR support. Blood services have been encouraged to supplement external donor support by blending public financing and cost-recovery mechanisms to form a template for long-term sustainability.

Under the second phase of PEPFAR, in addition to previously established activities, additional emphasis for enhancing sustainability includes retention of safe blood donors, enhancement of data management, and building quality systems. Currently, the majority of blood donations in many of the countries are from first-time rather than repeat donors (S. Basavaraju and C. Reed; Division of Global HIV/AIDS, Center for Global Health, CDC; personal communication; 2011). The high rates of HIV in these countries continue to present a substantial challenge for blood services in recruiting and retaining safe blood donors. Substantial burdens of anemia, malnutrition, and viral hepatitis further reduce the potential donor pool and increase the costs of continually identifying additional eligible donors (4). Additionally, data suggest that repeat, voluntary, non-remunerated donors have lower rates of HIV infection than first-time donors, resulting in fewer discards of collected units (10). Blood services are investigating, modifying, or installing upgrades to their existing data management systems to facilitate identification and contact of previous blood donors to encourage repeat donation. These data management systems also will enhance internal monitoring and evaluation capacity to inform evidence-based operational decisions using local data. The development of quality systems to establish procedures, guidelines, and oversight for the entire transfusion process is a sustainability priority. To support quality systems, initiatives include preparing blood services for regional and international accreditation, improvement of national HIV screening algorithms, and coordinated procurement systems.

The findings in this report are subject to at least two limitations. First, the total whole-blood unit collections described in this report do not reflect collections from facilities such as government, private, faith-based, or military hospitals that currently are not incorporated into the national blood service. Consequently, the total and per 1,000 population whole blood unit collections might have been underestimated. Exclusion of collections outside of the national blood service also might have resulted in an overestimate of the proportion of voluntary nonremunerated donors in a country because these facilities might rely on family and replacement donors. Second, national blood services might differ in their level of quality systems implementation, affecting testing proficiency and blood screening algorithms. The sensitivity and specificity of different HIV testing methodologies might have resulted in higher or lower percentages of HIV reactivity among collected units.

However, the impact of test characteristics on the results described in this report likely is minimal.
In 2010, PEPFAR blood safety support was reconfigured to include 16 additional countries.*** In addition to sustainability and quality systems indicators, future reports will focus on progress by these countries.


Acknowledgments
National blood transfusion services in Botswana, Côte d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambia, with support from their respective CDC country offices.


References
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2.CDC. Progress toward strengthening blood transfusion services---14 countries, 2003--2007. MMWR 2008;57:1273--7.
3.World Health Organization. Blood safety key global facts and figures in 2011. Geneva, Switzerland: World Health Organization; 2011. Available at http://www.who.int/worldblooddonorday/media/who_blood_safety_factsheet_2011.pdf . Accessed November 15, 2011.
4.World Health Organization. Status of blood safety in the WHO African Region: report of the 2006 survey. Brazzaville, Republic of Congo: World Health Organization; 2006. Available at http://www.afro.who.int/en/divisions-a-programmes/dsd/health-technologies-a-laboratories.html. Accessed November 15, 2011.
5.Lackritz EM, Ruebush TK, Zucker JR, et al. Blood transfusion practices and blood-banking services in a Kenyan hospital. AIDS 1993;7:995--9.
6.Moore A, Herrera G, Nyamongo J, et al. Estimated risk of HIV transmission by blood transfusion in Kenya. Lancet 2001;358:657--60.
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8.World Health Organization. Blood safety and availability: facts and figures from the 2007 Blood Safety Survey. Geneva, Switzerland: World Health Organization; 2009. Available at http://www.who.int/mediacentre/factsheets/fs279/en/index.html. Accessed November 15, 2011.
9.Basavaraju SV, Mwangi J, Nyamongo J, et al. Reduced risk of transfusion-transmitted HIV in Kenya through centrally co-ordinated blood centres, stringent donor selection and effective p24 antigen-HIV antibody screening. Vox Sang 2010;99:212--9.
10.Allain JP. Moving on from voluntary non-remunerated donors: who is the best blood donor? Br J Haematol 2011 [Epub ahead of print].

* Botswana, Côte d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambia (2009 Joint United Nations Programme on HIV/AIDS HIV population prevalence estimates among persons aged 15--49 years ranged from 1.2% to 24.8%; additional information available at http://www.aidsinfoonline.org/). PEPFAR has directly funded national blood transfusion service activities in all 14 countries through CDC cooperative agreements.

† Persons who donate blood solely for altruistic reasons and who receive no compensation. Designation of voluntary nonremunerated status is determined by blood center staff members based on national blood policy.

§ National blood transfusion services screen donated blood for markers of HIV infection, which include HIV antibody, and in many countries, p24 antigen. Blood units collected by blood services in South Africa and Namibia are additionally subjected to individual HIV nucleic acid testing. For the purposes of transfusion safety, a reactive result on a screening test excludes a unit from transfusion. For this report, the term "reactive" is used because the additional testing required to confirm a result as positive is not routinely performed by all blood services.

¶ Based on the 2010 revision of the United Nations Population Division census estimates. Available at http://esa.un.org/unpd/wpp/unpp/panel_profiles.htm.

** The five key elements of WHO recommendations are: 1) establishment of a nationally coordinated blood transfusion service supported by a legislative framework; 2) collection of blood exclusively from voluntary nonremunerated donors; 3) implementation of universal, quality-assured HIV, hepatitis B and C, and syphilis screening of donor blood; 4) promotion of safe and appropriate use of blood and reduction of unnecessary transfusions; and 5) adoption of quality systems covering the entire transfusion process from donor recruitment to follow-up of recipients. A quality system covers all aspects of blood transfusion, from the recruitment and selection of blood donors to the transfusion of blood and blood products to patients. Key elements include organizational management, standards, documentation, training, and assessment. Additional information available at http://www.who.int/bloodsafety/quality.

†† The revised United Nations Population Division census estimates result in slight variations in whole blood unit collections per 1,000 population per year for 2003--2007 from the previous 2008 MMWR report (2).

§§ Data on establishment of a national blood policy and enactment of legislative framework supporting the national blood policy in each of the 14 countries are available at http://www.cdc.gov/globalaids/mmwr.

¶¶ Tanzania and Nigeria established a national blood transfusion service in 2004. The first year for which 12 complete months of data were available was 2005.

*** Angola, Cambodia, Cameroon, Dominican Republic, Democratic Republic of Congo, Ghana, Kazakhstan, Kyrgyzstan, Lesotho, Mali, Malawi, Swaziland, Tajikistan, Ukraine, Uzbekistan, and Zimbabwe.

full-text:
Progress Toward Strengthening National Blood Transfusion Services — 14 Countries, 2008–2010