|Blood Safety and HIV: UNAIDS Technical Update (UNAIDS, 1997, 8 p.)|
Create a national blood transfusion service
Creating a national blood transfusion service (NBTS) means making all transfusion centres and blood banks part of a national network, accountable to the government or to a government-appointed nonprofit organization. Such a service should be developed within the framework of the country s health care infrastructure.
There should be a national policy and plan for the NBTS, with the proper legislative and regulatory control and an adequate financial budget. The NBTS should be recognized as a clearly identified unit of the health care system (separate from general laboratory systems) and have its own budget and trained staff. Important steps in setting up a NBTS include the following:
· obtain formal government commitment and support;
· develop a national blood policy and plan;
· identify an appropriate organization for the NBTS;
· appoint an executive committee and a chief medical officer for the NBTS, as well as - where necessary - an advisory committee of medical specialists;
· select and train staff with organizational, management, medical and technical skills;
· draw up a budget, and develop an appropriate financing system to make the blood programme sustainable;
· develop and implement a quality management system;
· develop and implement monitoring and evaluation systems for the service.
The NBTS can be financed either through an annual government allocation or through a cost-recovery fee. The cost-recovery fee is a charge for services to supply blood. It is paid by hospitals and other institutions using blood, and agreed upon in annual negotiations involving the government, hospital administrators and the blood transfusion service. The charge is intended to cover capital and recurrent cost items - such as buildings, salaries and test kits. The blood or blood product itself should always ideally be free for those receiving transfusions, or else paid for through government allocations or a health insurance scheme.
Educate, motivate, recruit and retain low-risk donors
Systems that use family replacement and paid blood donors are more likely to transmit TTIs. As a first step, paid donations should be prohibited and family replacement donors should be phased out. However, it is not always easy to change these practices. Consideration should be given to methods to detect and refuse paid donors, who will often persist in evading rules prohibiting them. Some form of identification system may thus be required.
Good donor selection is an important part of the process of collecting blood. When donors present themselves at blood donation centres they need to be interviewed by trained staff, so that those who appear to have a high risk of being infected, or appear to be paid donors, are excluded. Potential donors whose poor health or nutritional status makes them unsuitable should also be excluded, for the sake of their own health as well as the health of the recipients.
Educating people about the importance and responsibility of being a blood donor is essential so that prospective donors can make the correct decisions to donate, to self-exclude, or to self-defer. Self-exclusion means excluding themselves if they know or think that their blood may be unsafe as a result of risk behaviour, or because of the state of their own health. Self-deferral is postponing blood donation if there are temporary reasons for doing so.
Some donors may be unwilling to self-exclude or self-defer - even if they know that their blood may be unsafe. There may be peer group pressure on them to give blood, and they may not want others to know why they are unwilling to give blood. For this reason, it is important to give all donors an opportunity to tell clinic staff - in the strictest confidence - about their concerns. In cases where the clinic staff feel that a donor is unsuitable, they must have a mechanism to remove and dispose of the unit of blood after donation. This is called confidential unit exclusion (CUE).
Educating the public, motivating and recruiting them, and retaining them as donors who give blood regularly are all necessary. The ability to do these effectively will depend on a well-staffed and well-funded blood donor recruitment unit, trained in dealing with mass media and in communication skills. Among other things, a blood donor recruitment team should do the following:
· write and produce educational materials for blood donors;
· plan and carry out educational campaigns - in workplaces, schools and colleges - to motivate, recruit and retain donors;
· set up a blood donor registry system;
· work out procedures for donor selection and deferral, as well as for donor notification;
· design mechanisms to retain donors (such as donor clubs);
· prepare guidelines and standard operating procedures, including procedures to ensure strict confidentiality for donors;
· train staff in counselling techniques and the ability to select donors;
· set up links with other health facilities to refer donors, where necessary.
Screen all donated blood
It is important that blood transfusion services move as rapidly as possible towards screening all blood. The tests should include at least HIV, HBV and syphilis - and other TTIs as determined according to the prevalence and epidemiological risk. National guidelines should be developed and implemented for screening all blood donations using the most appropriate and effective testing strategies for each type of infection (see UNAIDS Technical Update, HIV Testing Methods). Items to be considered here include:
· the development of standard operating procedures and guidelines for screening, testing strategies, and a quality assurance programme;
· training of NBTS technical staff;
· the purchase, supply, storage and distribution of reagents and other materials used in testing, so as to ensure continuous testing.
Reduce unnecessary blood transfusions
It is important to minimize the number of inappropriate blood transfusions so as to reduce the risk of TTIs as well as other possible adverse reactions from transfusions. The following activities should be considered:
· developing a national standard operating procedure and national guidelines or indicators for giving transfusions;
· training people who prescribe blood to avoid unnecessary or inappropriate transfusions;
· ensuring accessibility and availability of blood substitutes for volume replacement, such as crystalloids and colloids, for use where appropriate; these will not transmit infections and can be obtained at a fraction of the cost of whole blood.
Preventing the causes that lead to individuals requiring blood transfusions will not only save unnecessary transfusions and reduce transmission of TTIs, but will improve health in the long term. Blood transfusions - often given for chronic anaemia - are unnecessary if the underlying condition is treated and the patient given corrective therapy. Preventing diseases such as malaria and worm infestations, and raising health standards generally, are important measures to reduce unnecessary transfusions. Similarly, proper care for women before, during and after delivery, will greatly reduce blood loss and in turn reduce the need for transfusions.
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UNAIDS acknowledges the kind assistance of Dr Jean Emmanuel, Chief of the Blood Safety Unit, and Dr Gaby Vercauteren, Scientist in the Blood Safety Unit, at WHO, in preparing this document.