The Nakasero Blood Bank
by Dr E.J. WATSON-WILLIAMS
In the last edition of The Courier, we published a dossier on
AIDS, in which we traced the spread of the disease and focused on its tragic
social and economic consequences in ACP countries. This article is not about
AIDS but about blood transfusion, and in particular the successful
rehabilitation, with European Community assistance, of Ugandas main blood
hank and donor centre.
Blood transfusion is an important medical technique which
offers, in certain cases, the only known way of saving patients lives. A
IDS has brought added problems for those who work in blood transfusion services,
but as Dr Watson-Williams shows in the following article, it is possible to
overcome these and other difficulties, and to ensure a, regular supply of
healthy blood for people whose lives depend on it.
In May 1987, the Republic of Uganda, with the assistance of the
Global Programme on Aids (GPA) of the World Health Organisation, held a
donors meeting in Kampala. As a result, the Uganda Aids Control Programme
(ACP) was formed. A major contribution was the pledge by the European
Commission, through its Aids Task Force, of ECU 1.5 million to rehabilitate the
central blood bank at Nakasero. A study by Dr Fransen, Director of the ATF had
recommended complete renovation and the provision of funding for the collection,
processing and distribution of 10 000 units of whole blood annually for two
years. This article describes the initial year of operation following the
recruitment of the first blood donors in November 1988.
The Ugandan Blood Transfusion Service started at Nakasero in
1957. During the next 20 years, it was increasingly successful and, at its peak,
it was collecting blood from 10 000 volunteers a year. Thereafter, however,
serious civil disturbances and outright war resulted in supply shortages and
inadequate maintenance of equipment. The Uganda Red Cross Society, which had
been responsible for blood donor recruitment from the outset had to curtail its
activity because of lack of funds and staff. Telephone, water and electricity
services were unreliable and road and rail transport networks had been severely
damaged. The blood bank finally ceased operating in 1984.
Acquired immune deficiency syndrome (AIDS) was recognised in
Uganda in 1985 and by 1987, the incidence of HIV- I seropositivity had reached
20% among young adults in Kampala. At this time, hospitals in the capital and
elsewhere recruited blood donors from patients relatives and used the
blood as soon as, or in some case before it was found to be negative for HIV-I.
Some 5000 units of blood were collected in 1987 by the four major hospitals in
Kampala. Because it was collected for particular patients, those who had no
relatives or who were in too critical a condition to wait for donors and
blood-testing were often denied transfusion.
As regards donor recruitment, senior school students have always
been the principal source of blood donations and the Uganda Red Cross Society
already had a good established relationship with the school authorities. This
well-educated section of the community can best understand the necessity for
excluding, as blood donors, those who have exposed themselves to risk of HIV
The process begins when a recruiter visits a school to deliver
an informative talk about the need for blood and the tests that are done to
ensure that it is free from risk. Students are asked to volunteer when the blood
bank visits the school about a week later. Those who wish to know the results of
their HIV test are seen by appointment a few days after the session. At this
confidential interview, they are reminded about the consequences of HIV and
asked if they really wish to know the result. If the initial test was positive,
a repeat sample is taken for confirmation. Similar programmes are organised for
office staff, factory workers and religious and other groups.
In addition to voluntary, altruistic donors, the hospitals
continue to encourage relatives to replace blood used. In March 1989, the
Nakasero Blood Bank accepted responsibility for screening blood from these
Blood which has been donated is carefully tested using modern
equipment. The blood group and rhesus type must, of course, be identified and
the donations are also screened for the HIV-I antibody and the Hepatitis E
surface antigen. The blood is stored at 2°-6° C in plastic bags
containing an anticoagulant and is discarded if not used within 30 days.
Concentrated red cells are prepared from blood taken into double or quadruple
bags. After 48 hours sedimentation, the plasma is expressed. Quadruple bags are
used to divide the 240 ml of red cells into three equal portions. These are used
for the transfusion of infants.
Information is stored on a data base. For identification
purposes, the donor gives his date and place of birth, and his mothers
first name (the actual name is not used to help overcome any fears about a lack
of confidentiality). The computer is set up in such a way that the blood bag
label can only be printed if the results of the HIV and Hepatitis tests are
negative. Information about the final use made of the blood is obtained from an
accompanying form which is completed by the hospital laboratory and returned to
the blood bank.
Facilities and equipment
During the reconstruction of the blood bank, a temporary
laboratory was made available by Makerere University Department of Public
Health. This was equipped with basic instruments by the European Community.
Water was brought in by bucket and during the frequent power cuts, work either
stopped or, if the power was not restored in 12 hours, was continued in the New
Mulago Hospital Laboratory which had emergency power.
In May 1990, President Museveni opened the rehabilitated
headquarters of the UBTS at Nakasero. This facility is responsible for the
processing of up to 17 000 units of blood a year and for distribution- to 30
hospitals in the area within 240 kms of Kampala. The headquarters is also
training staff for the four regional blood centres which are due to open in
Nakasero Blood Bank: quarterly
statistics, 1989 and 1990
As regards the financing of the project, in addition to the
major funding supplied by the European Community, assistance has also been given
by the AIDS control programme of Uganda (WHO), the First Health Project of the
International Development Agency, the Mitterrand Foundation of France and the
Carnegie Foundation of New York.
The blood collections and the rate of discard for HIV and
Hepatitis are shown by quarter in the table. It should be noted that the initial
aim of 10 000 usable units of blood per annum has been achieved. While the
central purpose of the UBTS is to maintain a safe and regular supply of blood
for transfusion purposes, the stringent procedures applied in collecting from
donors can also fulfil an educational function. It is noteworthy that among
students at schools which have been visited by the Service at least twice in the
last two years, the rate of HIV infection is down to 2%. Clearly, however, a
major and continuing education effort is needed to reduce infection rates among
the wider population.
As regards the utilisation of the blood, the information
gathered by the UBTS is based on returns of disposition forms accompanying blood
issued to hospitals. While the data are not complete, the indications are that
most units are used as single transfusions. Generally, blood appears only to be
used when a life is in the balance and the volume transfused is restricted to
the minimum essential. The major users of blood are children with severe
Looking to the future
It is clear that the Nakasero blood bank is now achieving its
target of 10 000 usable units of blood per annum. However, when schools are
closed, recruitment is more difficult and the frequency of HIV-positive
donations increases. The future will bring new challenges as the blood
transfusion service expands to meet the needs of people in the regions of
Uganda. With the opening of four regional blood centres during 1991, the aim is
for all hospitals to obtain their blood from the UBTS. Except in emergencies,
when blood may sometimes have to be collected, tested and used by the hospitals
themselves, the intention is for all blood to be tested at a blood centre and
distributed where needed.
For the foreseeable future, regular and repeating volunteer
donors (three times a year) will be a major source of blood. This is something
which is necessary, both for reasons of safety and of economy. Finally,
international funding and technical support will continue to be required. The
Nakasero project has, in its first two years, fulfilled and perhaps even
exceeded expectations but blood transfusion, by its very nature, is a task which
never ceases. Uganda is a country where health problems, and particularly AIDS,
have created a surfeit of human misery. Reliable and efficient blood transfusion
can make a significant contribution to reducing this surfeit.