|The Courier N° 127 May - June 1991- Dossier 'New' ACP Export Products - Country Reports Cape Verde - Namibia (EC Courier, 1991, 104 p.)|
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 infection.
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 donors.
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 1991.
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 anaemia.
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.