Global Journal of Transfusion Medicine

EDITORIAL
Year
: 2022  |  Volume : 7  |  Issue : 1  |  Page : 1--2

Changing transfusion policies and perspectives with changing times


Shivaram Chandrashekar 
 Manipal Hospitals, Bengaluru, Karnataka, India

Correspondence Address:
Dr. Shivaram Chandrashekar
Manipal Hospitals, Bengaluru, Karnataka
India




How to cite this article:
Chandrashekar S. Changing transfusion policies and perspectives with changing times.Glob J Transfus Med 2022;7:1-2


How to cite this URL:
Chandrashekar S. Changing transfusion policies and perspectives with changing times. Glob J Transfus Med [serial online] 2022 [cited 2022 Jul 1 ];7:1-2
Available from: https://www.gjtmonline.com/text.asp?2022/7/1/1/317182


Full Text

The WHO recommends a national blood transfusion service (BTS) based on voluntary nonremunerated donation (VNRD) of blood and blood components.[1] We believe that VNRD is the best index of blood safety. This might be true in the West where everyone is well fed, with basic necessities fulfilled and motivated to donate by people trained to do just that. However, the same may not be applicable to low- and middle-income countries (LMICs) plagued with multiple problems.[2] First, the access to blood as well as blood donors is not uniform across the country and hence the concept of a large blood center catering to large populations may not necessarily be helpful in LMICs where donors are sparse and spread across the country.[3] LMICS of late neither have a centralized BTS nor a fragmented BTS but have an intermediate one controlled by both National and regional bodies. The guidelines are laid down by a national body but implemented differently in different regions (states) as health is a state subject. For instance, in India, the Drugs and Cosmetics Act, 1940 permits nearly all blood centers to go out for blood donation drives (camps) and solicit donors, but some states still insist on “their permission” for something that is already gazetted (legal).

 Changing Our Perspective on Voluntary Nonremunerated Donation



We give huge importance to voluntary blood donation, but variations in donor nomenclature have probably rendered a classification of blood donors into voluntary donors, replacement/family donors, and paid donors redundant. Motivated or coaxed by the blood center, families often bring donors to donate blood. The margin between motivation and persuasion to donate is very thin. This, however, is the only opportunity for the blood center to impress upon the need for blood donation on the families they helped with blood needed for their patient. What should we call such family donors who after being convinced of the need for blood donation donate voluntarily for the blood center that helped them? Do we label them family/replacement or voluntary donor? Does it really matter? Although the figures for voluntary blood donation in many LMICs are impressive and growing, in reality, we do not know how much of this is real and how much is due to variations in donor labeling. While VNRD is definitely a patient-friendly measure, it cannot be regarded as the best index of blood safety.

It is foolhardy to think that in most LMICs plagued with problems of poverty, illiteracy, lack of nutrition, iron-deficiency anemia, etc., changes will happen overnight and we will have 100% VNRD and a centralized BTS very soon. With time, we have realized that while VNRD and centralization of BTS may be good for the West, it is not necessarily so for LMICs. Transitioning from a mixed system of voluntary and replacement donation to 100% VNRD is easier said than done. For voluntary donation to increase, many factors such as hunger, poverty, illiteracy, nutritional levels, and access to health care need to be addressed first. Poverty and hunger lead to poor nutrition and poor health, reducing numbers of eligible donors. Geographic lack of access to health care leads to poor health status and fewer eligible donors. This coupled with ignorance and illiteracy keeps blood donors away from blood centers in the LMICs. Small day-to-day problems are plenty in LMICs. When the stomach is empty and mind is occupied with these problems, it is difficult for even the most altruistic person to think of blood donation.

 How about a Better Blood Safety Indicator?



In this context of varying donor nomenclature, are we justified in the importance we give to VNRD? Is it time to look at a more objective indicator such as Transfusion Transmissible Index (TTI) rate? If the purpose of increasing VNRD is to reduce the TTI rate, why we do not use the TTI rate itself to assess our progress or compare nations or blood centers? Good counseling is essential for blood safety, more important than the label affixed on the donor.

 Inappropriate Donor Deferrals



On one hand, we want more donors, but on the other hand, our policies are designed to deter many donors. Today, we know that all good enzyme-linked immunosorbent assay/chemiluminescence immunoassay kits can detect an infection as early as 2–6 weeks and definitely within 90 days and by NAT even faster in a few days.[4],[5] This being the case do we need a 6-month deferral after tattooing, dental procedure, or minor surgery? Should we not have exceptions to such criteria left to the discretion of the transfusion physicians? Again, rabies is strictly an intraneuronal virus, but we have a 1-year deferral period after dog bite or rabies vaccination. Women with rare blood groups may need autologous blood deposits. However, blood donation in pregnancy is illegal in many countries. A woman in lactation may need to donate a small quantity of platelets for her baby with neonatal alloimmune thrombocytopenia. While Association for Advancement of Blood and Biotherapies (AABB) makes exceptions to such polices, many LMICs, for instance, the Indian Food and Drug Administration (FDA), make no such exceptions.

 Processing Charges and Financial Audits



There can be no doubt that blood donated by a donor is priceless and there should be no profiteering by blood centers. However, who will fund the free blood issues to thalassemics, hemophiliacs, and the growing list of inclusions to this? Many governments in LMICs fix a price for blood called the processing charges. Does costing of blood mean only the reagent costs and staff salaries? What about cost of quality, wastage, and research? What about the costs of infrastructure, electricity (storage), equipment purchase, depreciation, maintenance, calibration, and replacement? Having fixed the price of blood, is there a need to do financial audits of blood centers by health-care services? If after following the fixed prices, blood centers by virtue of their workload or prudent handling of resources are able to break even or save some money, does that amount to profiteering? Do we go after surgeons and other physicians in the same manner as we go after transfusion physicians?

 Manual versus Electronic Records



Thanks to COVID, many countries like India have gone completely digital – be it education, yoga and exercise, financial transactions, and accessing your vehicle or property documents – everything is digital today. You can go round India today with just your mobile phone which has your identity documents, vehicle papers/bus/train/air tickets, hotel booking and the numerous apps on your phone enable you to stay connected with family and friends and also to make payments for anything simply by scanning QR Code (barcode). They are accepted by street vendors or a 5-star hotel alike.

However, even in such a country, blood centers are required to maintain hardcopies of all their documents. What is better – a register which can be torn and rewritten or a software which tracks all changes with date, time, and name of the person effecting the change? If financial institutions and governments can carry out huge financial transactions without use of paper, why cannot blood centers have the same liberty? Which is supreme – the Drugs and Cosmetic act that insists on hard copies or the Information Technology Act, 2000 that supersedes other acts and permits digital signatures and softcopies? It is time for all blood centers in LMICs to move toward electronic data capturing and maintenance.

 Disparity/Inconsistency in Guidelines



Platelet shelf life in most LMICs is 5 days. However, there are some inconsistencies about how to count. For instance, day of collection worldwide is counted as day 0 and so does the National Guidelines of India and the accreditation guidelines given by NABH-India.[6],[7] However, some Indian FDA authorities have interpreted the day of collection as day 1, leading to confusion and confrontations.

Another such glaring inconsistency is the deferral period for single-donor platelet (SDP) donation after whole-blood donation. As per the Indian Drugs and Cosmetics Act following whole-blood donation, one can donate SDP after 28 days, but following an SDP donation, if reinfusion of red cells is not possible, the deferral period is 90 days.[8] Such inconsistencies are not unique to India and it will be good to compile and come out with a comprehensive document for revamping transfusion services in LMICs and also for making exceptions to laid down policies for an emergency. Minimum governance and maximum liberty is essential for growth of transfusion medicine or for that matter modern medicine as a whole.

References

1WHO. Towards 100% Voluntary Blood Donation: A Global Framework for Action. WHO. Available from: https://apps.who.int/iris/handle/10665/44359. [Last acessed on 2022 Apr 11].
2Field SP, Allain JP. Transfusion in sub-Saharan Africa: Does a Western model fit? J Clin Pathol 2007;60:1073-5.
3Jenny HE, Saluja S, Sood R, Raykar N, Kataria R, Tongaonkar R, et al. Access to safe blood in low-income and middle-income countries: Lessons from India. BMJ Glob Health 2017;2:e000167.
4Aidsmap. Available from: https://www.aidsmap.com/about-hiv/what-window-period-hiv-testing. [Last accessed on 2022 Apr 11].
5Contreras AM, Reta CB, Torres O, Celis A, Domínguez J. Safe blood in the absence of viral infections due to HBV, HCV and HIV in serological window period in donors. Salud Publica Mex 2011;53 Suppl 1:S13-8.
6Standards for Blood Banks. NACO NBTC; 2017. Available from: http://nbtc.naco.gov.in/page/bloodbankstandard/. [Last accessed on 2022 Apr 11].
7Accreditation Standards on Blood banks/Blood Centres and Transfusion Services. 3rd ed. NABH, Government of India Publication; 2016.
8Drugs and Cosmetic Act 1940 Amended in 2020. Available from: https://cdsco.gov.in/opencms/opencms/system/modules/CDSCO.WEB/elements/download_file_division.jsp?num_id=Njc3NA==/. [Last accessed on 2022 Apr 11].