The status of blood safety in ECO member states

Abstract

Background

Access to the information concerning blood safety is essential for managing problems and overcoming the challenges that are faced in any given region. Information on the availability and safety of blood in countries of the Economic Cooperation Organisation (ECO) is largely lacking. To address this problem, the Iranian Blood Transfusion Organisation, in collaboration with other ECO member states, initiated a research project in 2009 to collect, analyse and compare statistics on blood safety in the region.

Materials and methods

A modified and summarised version of the Global Database on Blood Safety (GDBS) questionnaire was used to collect data. The questionnaire was sent to all ten countries in the ECO region. The heads of the national transfusion services or focal points were requested to complete the form. Related literature and websites were also reviewed.

Results

Only three countries (Afghanistan, Iran and Turkey) completed the questionnaire, while other countries provided their available data on some parts of the questionnaire. The number of donations per year varied from 5 to 27/1,000 population. The rate of donors positive for human immunodeficiency virus ranged from 0.003% to 0.2%. The rate of donors positive for hepatitis C virus antibody varied from 0.05% to 3.9% while that of hepatitis B virus surface antigen ranged from 0.15% to 3.91% respectively.

Discussion

There is very clear diversity in blood transfusion services among ECO member states. Most countries in the region do not have a data-recording system. It is generally estimated that the need for blood is much higher than the supply in this region. Deficiencies in donor screening and a high prevalence of transfusion-transmitted infections are other important challenges.

Introduction

The safety of blood and blood products remains a continuing cause for concern, particularly in developing countries¹. A safe and adequate blood supply is a necessary prerequisite to enable health systems to respond to demands and contribute to improving public health. Access to blood safety information is essential to overcome the challenges and solve problems in any region. It is also a key for analysing trends of changes and developments in the field, improving management and policy making and assuring a safe blood supply. Information on the availability and safety of blood services in the countries of central and southwest Asia is generally lacking.

To communicate with key stakeholders, in particular, with policy makers, on the need for blood safety in this region, the Iranian Blood Transfusion Organisation (IBTO) proposed hosting the First Meeting of the Heads of Blood Transfusion of Economic Cooperation Organization (ECO)^* member states in June 2008 in Tehran, Iran. In this meeting participants were urged to formulate a regional network of cooperation on data banking, training, education and exchange of expertise on transfusion medicine². At the end of 2008, the IBTO proposed establishing an “ECO Blood Safety Network”. In April 2010, the IBTO and ECO signed an agreement to set up the network. Networking is one of the most recommended tools for the optimisation of resource use among countries with limited resources in the public health sector³.

The aims of the first phase of the project were to collect, analyse, compare and update statistics on blood safety and establish a regional information network (e-network) in ECO member states in order to identify the shortcomings at regional level and to suggest recommendations for improvement. In order to collect related data, a special questionnaire was designed and sent to focal points or other related authorities of all member states several times. Finally, in 2014, a comprehensive and analytical report on blood safety status in member states was published after necessary revisions by the countries.

The report provides an overview on the general status of blood safety in this region. It enables each country to assess its own situation and monitor its progress in relation to other countries and to regional trends as well as assisting them in the planning of research and in developing appropriate strategies to address their needs.

Materials and methods

A modified version of Global Database on Blood Safety (GDBS) questionnaire was used to collect data. The ECO Blood Safety Network questionnaire consists of six sections: (i) organisation and management of national blood transfusion services, (ii) blood donation and availability, (iii) blood screening, (iv) processing, storage and distribution of blood and blood products, (v) clinical and other uses of blood, and (vi) quality management and training.

The questionnaire was sent to all ten countries in the ECO region through the ECO Secretariat. An online version of the questionnaire was also designed and has been available at www.ecobsn.com website since July 2012. The heads of the national transfusion services or designated focal points were requested to complete the form. The related literature was reviewed and relevant and useful websites searched in order to complete the data as much as possible. The national reports presented at three meetings of the Heads of Blood Transfusion of ECO member states were also reviewed. By the end of 2014, only three countries (Afghanistan, Iran and Turkey) had completed the questionnaire and returned it for further actions. The focal points of seven member states (Azerbaijan, Pakistan, Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan) have not yet returned their questionnaires. The latest version of Microsoft Excel Worksheets was used to prepare tables and graphs.

Results

The results are extracted from the received questionnaires and the latest data available. Information from some countries is omitted in some parts of the results because of the lack of reliable data in the related sections.

Organisation and management of national blood transfusion services

In most countries, government is not the only body responsible for blood services. In some countries private institutions exist, but the degree of involvement of the private sector varies from one country to another. Generally, there are three kinds of Blood Transfusion Service (BTS) in the region:

• - nationally and governmentally organised BTS (Iran);

• - combination of national BTS and independent hospital-based blood banks (Afghanistan and Turkey)⁴;

• - combination of governmentally run BTS (Republican blood centres) plus hospital and privately-based BTS (mostly in Central Asian countries, namely Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan) (Table I).

Table I.

General blood transfusion information among ECO member states.

Country	Nationally coordinated BTS	Governmentally-run BTS	Blood policy developed	Independent hospital blood banks	Private sector	Adequate trained staff
Azerbaijan	Yes	Yes	Not available	Yes	Not available	Yes
Afghanistan	Yes	Yes	Under development	Yes	Yes	Yes
Iran	Yes	Yes	Yes	No	No	Yes
Kazakhstan	No	Yes	No	Yes	Yes	No
Kyrgyzstan	Yes	Yes	No	Yes	Yes	No
Pakistan	No	Yes	Under development	Yes	Yes	Yes
Tajikistan	No	Yes	No	Yes	Yes	No
Turkey	Yes	Yes	No	Yes	No	Yes
Turkmenistan	Yes	Yes	No	Yes	Yes	No
Uzbekistan	No	Not available	No	Yes	Yes	No

ECO: Economic Cooperation Organization; BTS: Blood Transfusion Service.

In six countries, a nationally coordinated blood service has been established; however, not all related activities have been centralised yet in some of them. These services usually cover the whole range of activities of both a blood establishment and a blood bank (donations, processing, testing and storage of blood and blood components as well as pre-transfusion testing and release of blood components to the hospitals).

It seems that most services are suffering from inadequate numbers of competent staff. Skill levels are often low, training is inappropriate, and poor salaries do not attract highly qualified staff.

Blood donation and availability

The number of blood donors in ECO countries differs widely. However, most countries in the region do not have a reliable source to estimate their annual blood collection (Figure 1).

Figure 1.

Donations per 1,000 population.

• - The number of donations per year varied from 5/1,000 population (Tajikistan)⁵ to 27/1,000 (Iran and Turkey).

• - Azerbaijan had the second lowest rate of donations per 1,000 population⁶.

• - Iran was the only country in the region which reached 100% voluntary non-remunerated blood donation in 2007⁷.

• - Turkey had the highest rate of voluntary blood donations among the countries surveyed (in Turkey, the Red Crescent collects 100% of blood from voluntary blood donors but other centres are still dependent on replacement blood donation).

• - The highest figure of replacement blood donation was in Pakistan (85%)⁸.

• - Some countries such as Kyrgyzstan, Kazakhstan, Uzbekistan and Pakistan still have paid donation (Figure 2).

Figure 2.

Percentages of types of blood donation.

Prevalence of donors positive for markers of infection

The data are based on confirmatory tests in the three countries which filled in the questionnaire. The types of tests in other countries are not known.

• - The rate of donors positive for human immunodeficiency virus (HIV) in the ECO region ranged from 0.003% to 0.2%; for rate of hepatitis B virus surface antigen (HBsAg) ranged from 0.1% to 3.91% and that of hepatitis C virus (HCV) from 0.05% to 3.9%.

• - Iran had the lowest rate of test-positive donors in the region; Afghanistan had the highest rate of donors positive for HBsAg.

• - Pakistan had the highest rate of HCV-positive donors⁹.

• - Central Asian countries (cumulative data) had the highest rate of HIV-positive blood donors¹⁰ (Figures 3 and 4).

Figure 3.

Prevalence (%) of HCV- and HBsAg-positive blood donors.

HCV: hepatitis C virus; HBsAg: hepatitis B virus surface antigen.

Figure 4.

Prevalence (%) of HIV-positive blood donors.

HIV: human immunodeficiency virus.

Discussion

There is very clear diversity in BTS among ECO member states. Some countries such as Iran have a centralised public blood transfusion organisation while transfusion services in some other member countries e.g. those in Central Asia are totally regional and fragmented.

Most countries in the region except Iran and Turkey do not have an organised data-recording system. This was the most important challenge in this project, which led some countries not to answer the questions despite several appeals. Another challenge was the language barrier, as Russian is spoken in most countries in central Asia and there is not enough familiarity with English.

It is generally estimated that the need for blood is much higher than the supply in this region. The population of the ECO region exceed 433 million in 2011, accounting for 6.23% of the world’s total population¹¹. Our findings show at least three countries in the region collected fewer than 10 donations per 1,000 population, the level recommended by the World Health Organization in order to meet national needs for blood transfusion, and suffer from severe shortfalls in blood supply. These shortfalls have been exacerbated since the Soviet Union collapsed in 1985. For example, according to the report presented during the 3^rd meeting of ECO, Azerbaijan used to collect 160,000 blood units (24.4 per 1,000 population) in 1985 but this rate dropped drastically to 10,000 (1.4 per 1,000 population) in 2001 and only increased gradually up to 60,000 (6.4 per 1,000 population) in 2012⁶. Another reason for the shortfalls may the results of the general fear of contracting HIV through blood donation which is generally pandemic in central Asia¹⁰.

The majority of countries in this region are still dependent on replacement donations and some on paid donations. Reliance on paid blood donors is very common in Central Asia. This may due to the lack of effective national donor programmes, deficiencies in national donor recruitment schemes and the absence of a culture of voluntary blood donation¹⁰. As the countries in this region have common cultural and religious backgrounds, exchanging experiences on recruitment of voluntary blood donors through the ECO Blood Safety Network would help to face this challenge.

The currently fragmented, mainly hospital-based blood services under the legal and financial responsibility of various entities must be reformed, with the support of a proper legal and regulatory framework, into a nationally coordinated service.

Although some countries have made improvements, establishing a quality system, available data indicate that most countries, especially those in Central Asia, do not have all the elements of a national quality system fully in place. There is an urgent need to train blood donor recruiters, blood donor counsellors, quality managers, prescribers of blood and nurses involved in the administration of blood and blood products.

There is a huge discrepancy in blood safety between the countries in the region; while in some countries the rates of donors positive for infectious markers are much lower than in general population, the rates in some other countries are almost equal to those in the general population. The latter countries must pay more attention to recruiting voluntary donors from low-risk populations.

Another common challenge in the region is irrational clinical blood use. A local study found that there is a tendency among clinicians to order more units of blood and blood components than actually required¹³. Arrangements for optimisation of blood usage have not been developed in most countries. Iran and Turkey have established haemovigilance systems in some hospitals but not throughout the country. None of the surveyed countries has an organised system to record clinical blood use. There are no updated national guidelines for the clinical use of blood and the concept of patient blood management and practice of autologous blood transfusion are unfamiliar in this region.

Conclusions

The aim of the ECO Blood Safety Network is to promote collaboration among national blood services on availability and safety of blood in the region. So far, three meetings and two workshops have been held among high-level authorities and experts to address common challenges and find the best practices¹². With continuous collaboration through the network, organisations and individuals can benefit from others’ experiences by conducting more training workshops and providing technical advice.