(introduction...)

By Dr Peter Kataaha, Director of the Uganda Blood Transfusion Service, and Dr John Watson-Williams, former Technical Assistant to the UBTS

Blood donor recruitment as we know it today is new to the Uganda Blood Transfusion Service. Whereas in the past it was acceptable to take blood from any donor, the current situation entails the notion of a 'safe donor', bearing in mind HIV, hepatitis and other infections. The main objective is to recruit enough safe blood donors. So the programme is designed to identify these 'safe blood donors'. It includes, as a key item, recruitment of voluntary, altruistic donors.

Such individuals should be at low risk for HIV infection. The process involves educating blood donors before they make up their minds to donate blood (pre-donation counselling). During these sessions the would-be blood donor is given facts concerning the need for blood transfusion and the reasons why people should give blood to save lives. This education should enable them to identify risk factors in their lives, if any, and help them make a decision whether to withdraw from blood donation or not. Encouragement of repeating donors is of vital importance. Repeating donors are those who have been identified as HIV and hepatitis free, have attended health education talks several times, are highly motivated to keep donating blood, and value the responsibility they have chosen for the sake of their communities.

There are four regional and one subsidiary blood banks in the country, and at each one of these there is a blood donor recruiter. There are six donor recruiters at the Nakasero Blood Bank. Six of the donor recruiters are employed by the Uganda Red Cross while the rest are employed by the Blood Transfusion project itself. Two of the eleven are medical assistants while the rest are university graduates in social services. They have all received additional training in blood donor recruitment at the Nakasero Blood Bank and some have been to Harare, Zimbabwe, for further training.

Seroprevalence trends in donor recruitment

The numbers of blood units obtained from these voluntary donors has continued to go up. In 1993, out of a total collection of 30,217 units of blood, 17,127 were obtained from voluntary donors who were recruited by this programme. The number of such units rose to 18,139 in 1994.

The HIV seroprevalence rate among these donors was 5.3 per cent in 1993, and came down to 3.9 per cent in 1994. This downward trend in the HIV seroprevalence has been going on since the inception of this programme in 1989, when it stood at 14 per cent among the volunteer blood donors used at that time.

HIV seroprevalence among replacement/relative donors has also been going down. In 1993 it was 13.1 per cent and in 1994 10.1 per cent. In 1989 the seroprevalence in relative donors was 24 per cent. But the important point is that the comparison of the HIV seroprevalence rate among voluntary donors as against relatives who give blood i.e. 3.9 per cent versus 10.1 per cent, clearly demonstrates the value of active blood donor recruitment.

The trend in HBsAg seroprevalence has shown a similar pattern. HBsAg among volunteer donors is lower than among relatives who become blood donors, again demonstrating the relative safety associated with recruited volunteer blood donors.

A further advantage of volunteer donor recruitment is the availability of a pool of donors whose HIV status is fairly predictable. From this pool, blood can be taken into quadruple bags which, after screening, can be divided into smaller bags for paediatric transfusions. From the same group blood can be taken for the preparation of platelets.

Also, during an emergency or when blood from a rare blood group e.g. Rhesus negative, is needed, donors from this pool can be called upon at short notice to donate.

Costs of relatives versus volunteers

Initially, a unit of blood obtained from a relative blood donor is slightly cheaper than a unit from a volunteer donor, but after tests are done and blood infected by HIV or hepatitis is discarded, then blood from relative donors becomes more expensive due to the wastage.

A blood donor gives blood at the Nakasero blood bank.

Moreover, one can obtain more than one component from blood taken from volunteer donors, which makes it good value for the money used to recruit these donors. Figures for 1994, for example, show that of all the blood discarded, 64.4 per cent was from relative donors (see table again).

Table. Characteristics of blood units obtained from volunteer (V) and relative (R) donors, 1993 and 1994.

Year	Numbers		HIV		Hep		Discard
	V	R	V(%)	R(%)	V(%)	R(%)	V(%)	R(%)
1993	17,127	13,090	5.3	13.1	4.9	7.0	13.9	20.8
1994	18,139	19,828	3.9	10.1	5.7	7.7	11.1	18.4

Future strategies: Donor clubs

In a pilot project in 1993, individuals who had donated more than three consecutive times were organised in blood donor clubs. Individuals in these clubs had undertaken to donate blood at least twice a year and made a pledge to stay HIV negative. Over a period of 2 years, 3,731 units were collected from 913 donors in 13 clubs representing an average of two donations per year per person. This project cost about US$ 1.90 per unit of blood, for recruitment alone.

But the most significant point here is that the HIV seroprevalence was under 0.1 per cent. In spite of the problems that could be associated with the 'window period' in this group, the level of HIV infection demonstrates that with extra effort blood for transfusion in Uganda can be made virtually safe. The discard rate was minimal. Moreover, club members were always available whenever needed.

The UBTS therefore plans to extend this pilot project gradually and hopes that at least 25 per cent of all the blood is obtained from this group in 1995, increasing to 75 per cent in three years time.

Donating blood. (1)

Donating blood. (2)

How are blood donors recruited?

At the beginning it was difficult to overcome commonly held fears among potential blood donors, such as these:

- donating blood is unsafe because of the reuse of needles

- all donors would be tested for HIV infection and the results reported to the government, the press and employers

- blood would be sold to patients in order to enrich the health care workers

- there was no chance of confidentiality

- the real purpose was to do research on their blood

- blood is life and its loss is permanent

- an inadequate diet, because of poverty, would hinder blood replacement

- weakness following donation would result in impaired social and work activities.

Most of these fears required only intensive and time-consuming reassurance to allay. So the system we arrived at was this. A group of potential donors, students, office or factory workers, church congregations etc., is selected. A responsible person in the organisation is visited by the blood bank recruiter and asked to provide an opportunity for the blood bank to present its programme and its needs. Leaflets are distributed and a meeting held. This usually lasts 30-45 minutes and reassures potential donors about anonymity, safety, confidentiality, and any of the other fears they held.

If a sufficient number (20 or more) is interested, we set a date for the blood collecting team to visit. At the bleeding session, every potential donor is asked to read a leaflet reiterating the type of personal history that carries risk of HIV infection and other conditions that would make giving blood undesirable, and asked to continue only if they were confident of being safe. Individual questioning follows, in as confidential a setting as possible, and then the donor without known risk has a haemoglobin screen and gives 450 ml of blood.

The donor is given a receipt with the same number as the blood bag and test sample. After two weeks, another appointment is made and the counsellor returns to the site of the bleeding session to discuss results, in a confidential environment, with all those who wished to know. In keeping with blood bank policy, the first time donor uses a surrogate name, usually mother's first name, and gives for verification his/her own date and place of birth. When the results are to be given the donor has to show the receipt and give the correct date and place of birth and mother's first name before any discussion takes place.

If the HIV result is positive, the best possible arrangements for follow-up are made. If the result is negative, the donor is given a suggested time to make the next donation and counselled on methods of ensuring a risk-free life. Condoms are available if desired. All positive results are confirmed with a second sample if the donor wishes.

Nowadays, donors who are acceptable as repeat donors are also given information to reinforce their ability to keep clear of HIV infection risk, condoms if desired, and enrolled in a safe donor club. On their second donation they use their real name and rely on the blood bank to inform them if there is a need to return for further counselling.

Many suggestions were made to reward blood donors with travel allowances, food parcels, or priority for hospital care if needed. But all of these ideas were reluctantly but firmly rejected. But the donor clubs, once formed, are supported by refreshments for their meetings and sometimes their members are given T shirts or other items with blood bank identification. This system of blood donor clubs was initiated with a grant of CAN$10,000 from the Canadian aid agency, CIDA.

(introduction...)

There has been much debate about the relative merits of a centrally organised blood transfusion service, as adopted in Uganda in comparison to a more decentralised structure such as that adopted by, for example, Zambia, where the EC is also providing support. The current wave of reform in public health does not always take into account the specific needs of safe blood. This is a pity, because by better organisation of blood transfusion, better results could be achieved. Key factors in the creation of an effective blood transfusion service are:

a) acceptance of transfusion medicine as a distinct sector in the health care system
b) establishment of a national blood policy
c) well trained and dedicated professionals
d) broadly-based national advisory bodies.

Transfusion medicine is not only the collecting and testing of blood. It is also a major therapeutic art requiring:

a) recruitment and retention of blood donors
b) blood collection
c) laboratory testing
d) blood processing and storage
e) training of physicians in appropriate use of blood.

A discipline of such diversity must be recognised as a distinct entity within the health system. It is often the lack of this recognition that contributes to poor organisation of the blood transfusion service.

The type of organisation and level of development of the blood service should be specified in the national health plan. The government bears the ultimate responsibility for organising and backing up the blood transfusion service, regardless of who is operating it. A safe blood policy implies that this operating responsibility is either assumed by national health authorities or partially delegated to a parastatal agency or NGO, such as the Red Cross or Red Crescent. Research carried out by the World Health Organisation showed that, among nations which responded to its enquiries, a national blood policy had been adopted in 81 per cent of developed countries, but in only 64 per cent of developing and 60 per cent of least developed countries. Since many nations did not respond to the WHO, it is likely that in reality even fewer countries in the developing world have a national blood policy. In nearly half the developing and least developed countries that did respond, the blood transfusion services are hospital-based, which usually implies a lack of national co-ordination. So what exactly is the choice of organisation? In broad terms, the choice lies between a centralised, a regionalised and a hospital-based organisation, with a mixture as the fourth option.

1. A centralised organisation

This usually consists of one national blood transfusion centre which operates the service for the whole country, with or without regional centres. This plan is more feasible in smaller countries. A centralised national blood transfusion service can give better guarantees of blood safety than a hospital-based service by offering:

a) recruitment of voluntary, non-remunerated blood donors that is less subject to local variations or emergencies

b) a regular blood supply, because a centralised system is better able to sustain, manage and guarantee an adequate stock

c) techniques that observe minimum safety standards, such as blood grouping, compatibility testing, screening for infectious diseases, record keeping and quality control

d) better training of personnel, economies of scale by bulk purchasing, and automation.

Co-ordination at national level becomes easier, and this can make the service more cost-effective. It also increases capacity to provide blood in emergencies, and makes possible a uniform standard of quality assurance and training.

National reference laboratories for transfusion medicine (e.g. blood group serology, haematology, tissue typing, coagulation) and support of scientific research are easier to arrange.

A national system also makes it easier to develop a high profile among the medical establishment, as well as in the community at large. This is important both for recruitment of blood donors and for creating trust and confidence in the service.

There are however potential disadvantages in a centralised system. It does depend on good communications (e.g. telephone and fax for laboratory results) and on a good transport system (e.g. for laboratory samples and blood products). These preconditions may not exist in some countries. Also, there may be delays in providing laboratory results and blood components, if these are organised centrally. Lastly, the physical distance between a national blood centre and the hospitals and blood donors may create difficulties in relations with both the users and givers of blood.

Blood bags stored in a refrigerator.

2. A regional system

In this model, the country is divided into regions, with varying degrees of autonomy for each region and with varying mechanisms for ensuring national control and co-ordination. Even in a regional model, the regulations and policy co-ordination should be done at national level, with input from the regions. A regional system is often preferred in larger countries, where the size of any one region may allow the creation of a blood transfusion service which corresponds to a national service in a smaller country. The advantages and disadvantages of the regional approach have to be weighed up in the light of that country's special conditions and political realities.

3. A hospital-based system

Here, each hospital runs its own blood transfusion service, with or without national co-ordination. This system can cause problems, and even in developed, industrialised countries national co-ordination has proved difficult. For this reason, experts are generally against leaving the responsibility for blood transfusion totally to the individual hospitals. But blood banks integrated into hospitals can have some (possibly minor) advantages:

a) hospitals have a close relationship with patients, and analyses can be performed for donors and for patients in the same laboratory

b) hospital blood banks are closer to those prescribing blood, which makes it easier to discuss the pros and cons

Photo

4. A mixed system

Combinations of hospital-based and national/regional blood centres exist in about a quarter of the countries that reported to the WHO. Usually, there is a national blood transfusion service, but many hospitals find its coverage less than satisfactory and so run their own blood bank. Sometimes the local blood centre in the capital city carries the word 'national' in its title, somewhat misleadingly. This type of organisation is often not very efficient and is usually more costly than a national or regional blood transfusion service.

(for a fuller discussion of this question, please see the EC's companion volume Safe Blood in Developing Countries: Principles and Organisation)

The Zambian solution

With the encouragement of the World Bank and other donors such as the Danish agency Danida, Zambia is carrying out a far-reaching reform of its health system, by decentralising management, and therefore responsibility for decision-making and spending, down to the districts. Such radical decentralisation is new to Africa.

In that circumstance, the Zambian government decided against the idea of a centralised blood transfusion service on the lines of Uganda, even though this was the initial recommendation from Dr Watson-Williams, who was asked by the EC to go to Zambia after finishing his assignment in Uganda. As in Uganda, the EC is the main external funder of the Zambian blood transfusion service.

The proposal to strengthen the Zambian blood programme originated at about the same time as the Uganda project. But it took longer to get started, partly because of a change of government, partly because of the lengthy discussions about what would be the right structure for Zambia. The Zambian Ministry of Health came to the view that, at a time when it was trying to decentralise many central activities and reduce staff at the centre, it could not accept a new central unit of the size of a blood transfusion service.

On the other hand, with complete decentralisation, there could be problems with quality control, training, and setting minimum standards (for example, on the right choice of blood bags to buy in). So could there be a mixed solution?

Zambia has a number of heavily populated areas, for example, the capital Lusaka and the so-called 'copper belt' where the famous copper mines are. It was decided that these areas should have a centralised blood transfusion service, in which the major hospitals would be supplied centrally. But the remoter provinces and hospitals would each recruit their own blood donors and test the blood themselves. In other words, it was a compromise, but a compromise that corresponds to the population distribution of Zambia.

Similarly, in Cote d'Ivoire, there are one central and two regional blood centres, and the plan had been that these three would divide the country between them in terms of blood supply to the interior of the country. But the difficulties of distribution in Cote d'Ivoire have meant that the central blood bank still supplies much of the interior, and some hospitals still have to do their own recruitment and testing.

So Uganda is unique in Africa in the degree of central organisation that it has achieved. The EC believes that the basic principles are that

a) there must be a strong central agency to formulate a national policy and strategy, advise the Ministry of Health, lay down standards and procedures for obtaining safe blood, set guidelines on the use of blood, promote training of BTS and health staff on how to obtain safe blood, and act as the central 'quality control' for blood transfusion. But

b) the methods for recruiting blood donors and testing blood can and do vary between countries, according to local circumstances.

(introduction...)

The EC publication Safe Blood in Developing Countries: Principles and Organisation emphasises that:

'Successful implementation [of a safe, accessible and adequate blood supply] will largely depend on the knowledge, skills and commitment of the people working in every blood transfusion service and hospital blood bank. Training will obviously play an important part in this process of improving the quality and safety of blood supply.'

So how did the Uganda Blood Transfusion Service, starting almost from scratch but picking up what pieces were left from the old blood transfusion service, set about the task of training its people?

Dr John Watson-Williams contributes the following account, which illustrates the complex training needs of a properly organised blood transfusion service.

A. Training of Nakasero staff

Thirty-six members of the old Nakasero Blood Bank staff reported for training on September 25, 1988. There were eight technicians, who had completed the three years of training of the school for medical laboratory assistants at Jinja; eleven laboratory and donor attendants, who had completed high school with O level certification and had been trained on the job at Nakasero; five clerks, eight cleaners, two yardmen, one driver and four 'ascaris' or security guards. The technicians had many years experience of blood typing and the attendants had experience of taking blood, whilst most of the cleaners had been working with the cleaning and assembly of blood collecting and giving sets. With the three professional staff, Dr. Kataaha. Dr. Kyeyune and Mr. Senyonga, we worked out a training schedule, which would last six weeks, to bring all staff up to date and to explain how we conceived that the project would be developed. None of the staff had received pay for at least six months, but the EC Delegate agreed to provide an allowance while they were being trained. All staff had to walk at least two miles to work as there was no public transport to Nakasero. The main rooms of the blood bank building had a sound roof and floor and it was there that we held classes. Surprisingly, enough chairs, stools and benches were found for everyone to sit down around tables. All staff attended lectures at 8.30 am and at 2 pm, and after the lectures the laboratory and donor staff had practical training using the limited resources available. There was neither electricity nor water.

Detailed lecture notes were written to cover the subjects of HIV infection, viral hepatitis and other diseases transmissible by blood, the blood groups, IgM and IgG antibodies, compatibility testing, transfusion reaction, donor motivation and health criteria, the collection and storage of blood, record keeping, and quality assurance. These notes later formed the basis of all teaching courses given by the UBTS. Lectures, given in English, were translated into Luganda for the few non-English-speakers.

The lectures were designed to give everyone sufficient knowledge about the life-saving qualities of blood and the risks of blood transfusion for them to be able to discuss the subject and answer the questions of their peers. These classes also helped everyone to understand what other staff did in the blood bank and thus strengthened team spirit. Even at this stage in the project the idea of a national programme was discussed.

The practical classes gave an opportunity not only to reinforce lecture material but also to select those with the better skills who would be able to fill critical positions.

B. Training of hospital staff

During visits to hospitals other than those in the Kampala area, many errors in blood banking technique had been observed. Blood collections were improperly made and skin cleansing was inadequate. Incomplete filling of blood bag, sometimes purposely on a doctor's order, or clotting of the contents, were common. After removing the needle, air was allowed to enter the tubing, and sometimes the bag, and labelling of sample and primary bag, were unreliable. Blood typing, both of donor and patient, was done on reused tiles that often were inadequate and not safely cleaned.

Compatibility testing was almost always by a saline suspension of red cells mixed with serum on a microscope slide and spread with the tip of a Pasteur pipette. Blood donor HIV test results (when they were tested) were not kept in a way that preserved confidentiality, but at the same time donors were not given their results.

Therefore, before any hospital was added to the list supplied by the Nakasero Blood Bank or one of the regional blood banks, it was required that a laboratory technician should spend five days at the blood bank. We tried to arrange for three or four hospitals to send staff at the same time. This period of secondment was necessary to explain procedures, record keeping, and methods of blood collection and laboratory testing.

During this five day training the technicians attended lectures on HIV and other diseases transmitted by blood, donor selection criteria and care, and record keeping and quality assurance. Practical instruction concentrated on correct blood collection methods and compatibility testing using the one-tube technique for saline and anti-human globulin procedures controlled by adding coated cells to the negative AHG test.

The technician took back to the hospital a copy of the laboratory manual and all standard operating procedures. Follow-up contact with hospitals was necessary to make sure that these procedures were explained and taught to all personnel involved in blood transfusion. It was reported that these changes resulted in a marked reduction in the number of transfusion reactions.

Photo

After technician training, all blood units collected at each hospital were sent to the UBTS laboratory for testing and adding to inventory if found to be satisfactory. Monitoring these blood units was valuable to indicate when there was a need for refresher training at that hospital.

C. Residential courses for hospital staff

The development of safe blood transfusion practice requires three elements; the recruitment and screening of donors with low-risk, the reliable laboratory screening of blood before it is transfused, and the use of blood only when it is indicated to reduce morbidity and mortality for the patient. To address these issues it was decided to invite a team of three, a doctor, technician and nurse, to a five day course at one of the regional centres. Courses were held twice at Mbarara and twice at Mbale in 1992 and once at Kampala in 1993, with funding by the National AIDS Control Programme (NACP). Two hundred and sixty participants came from 88 hospitals.

These courses were designed to emphasise that blood transfusion is not a responsibility solely of laboratory staff. The subjects of the lectures, four daily, were similar to those of the original Nakasero training, and the rest of each day was devoted to smaller group training for each of the three professional groups.

- the doctors discussed the indications for blood transfusion, which had been widely distributed in a NACP publication (Guidelines for appropriate use of blood in Uganda 1989), and criteria of donor selection

- the nurses learned about taking a history from a prospective donor, procedures for checking blood before, and checking the patient during, a transfusion, and the possible causes and appropriate responses to reaction during or after the transfusion

- the technologists had a wet laboratory class to learn the UBTS blood typing and compatibility testing methods.

On completion of the course, the three persons returned to their base to form a hospital transfusion committee. Although a formal evaluation of the impact of this training has not been made, two benefits occurred; one was an increase in the hospital collection of blood with a reduced number of units found to be HIV positive, and the other was a reduction in the overall use of blood by the hospital.

D. Training at schools for medical assistants

Uganda has two medical schools, at the University of Makerere and at Mbarara University, and three schools for medical assistants, Fort Portal, Mbale and Gulu. Eighty doctors and one hundred and fifty medical assistants graduate annually. Although at this time only doctors can order blood transfusions, this is likely to change very soon, and in any event it is often the medical assistant who first identifies the need for a transfusion.

In 1994 the UBTS developed a five-day course in blood transfusion medicine and, with NACP funding, gave it for sixty final year students at Fort Portal and repeated it for another sixty at Mbale. It is intended to make such courses a regular offering and taught predominantly by the schools' own staffs, at the schools of medicine and the medical assistants schools. The course is clinically orientated with discussion groups and case discussion presented in an interactive fashion.

E. Training of senior professional staff

1. Doctors

Doctors in medical charge of regional and national blood banks must be offered the chance of a career with possible eventual recognition as a specialist in blood transfusion medicine. In the UBTS there are five blood banks with doctors in charge. Each of the four regional directors had at least two years postgraduate experience and completed three months of full time instruction at Nakasero followed by six months of closely supervised experience whilst establishing the blood bank.

These and the second doctor at Nakasero are, at the time of writing, to be given six months training and experience in a European blood transfusion service and the opportunity to become certified in blood transfusion medicine by the Royal College of Physicians of Edinburgh, or an equivalent body. This, together with obtaining the diploma of Master in Medical Sciences of University of Makerere (a three year programme), should be sufficient for recognition as a specialist. The director of the UBTS must have additional training and experience in related subjects such as haematology or immunology.

2. Technologists

UBTS staff include one chief technologist and five technologists at Nakasero and one technologist in each of the four regional blood banks. These have all completed the five years of training at the school of medical laboratory technology at Mulago hospital. There is, at present, no internationally recognised diploma in the speciality of blood transfusion for which graduates of the Mulago school are eligible, but it is important that technologists should get specialist training in a blood bank other than UBTS. When this has been accomplished, it is expected that the trained technologists will be able to develop an appropriate curriculum and certification in Uganda to provide for continuity of blood transfusion as a medical laboratory speciality.

3. Administrators

A national blood transfusion service with a multi-profession staff and responsibility for central purchasing and distribution, for development of national guidelines, and for quality assurance and research, is a complex organisation. Appropriate personnel and remuneration policies, continued training, security measures and the maintenance of respect and a high profile among the public - all these matters require competent administration. The UBTS administrator is, at the time of writing, being supported in his studies to acquire a master's degree in business administration.

4. Blood donor recruiters

Continued support of the blood bank by dedicated voluntary blood donors is essential. Because of the high frequency of virus infections transmissible by blood, it is necessary to place even more emphasis on donor recruitment and support in Uganda than in, say, a developed European country. Thus blood donor recruiters must be given the skills and recognition necessary to encourage skilled professionals to take on these jobs and to feel satisfied with their career.

5. Nurses

Although it has been customary for blood donors to be bled and given care by laboratory staff, it is more appropriate and more effective that this be done by nurses. The UBTS expects to develop an education and certification programme for nurses in blood transfusion.

(introduction...)

by Dr John Watson-Williams

1. Which diseases are screened against - and which are not? and why not?

The safe blood programme in Uganda screens blood for the HIV virus, and for Hepatitis B - but not for Hepatitis C, HTLV-1 or syphilis. Why those two infections, and not the others?

Every country has to decide, in the light of the local pattern and incidence of diseases, what infections to screen its blood against. In the case of Uganda, the entire rationale for the EC rehabilitation of the Nakasero Blood Bank was the high rate of HIV infection in the Ugandan donor population. HIV was therefore the first priority. Hepatitis B was the next priority. This could not be screened by donor history, except that those who had recently been ill could be excluded. But 6 per cent of the donor population are Hepatitis B surface antigen positive and therefore presumed to be carriers of this virus.

Consideration was then given, from 1991 onwards, to screening for Hepatitis C carriers, at least on a pilot basis. A preliminary survey found that only 0.5 per cent of donors were positive when tested for anti Hepatitis C and presumably less than this number would be confirmed carriers. As the cost of testing became less, and the sensitivity and specificity of the tests improved, the cost effectiveness of screening for Hepatitis C did improve. Even so, by December 1993 it was calculated that only 56 cases of chronic Hepatitis C could be prevented by screening 37,000 blood units at a cost of 3,300 ECU per case - far above the cost of each AIDS case or Hepatitis B case prevented. Prevention of transmission of HTLV-1 infection would probably have been even less cost-effective. Therefore these two screenings, Hepatitis C and HTLV-1, have not been performed in Uganda.

Photo

There is a case for testing all donations for evidence of T pallidum (syphilis). This is not however based on reducing risk of transmission of syphilis, because the organism is destroyed in blood stored at 4 degrees celcius. Rather, the argument is that a positive syphilis test indicates the probable presence of sexual transmitted diseases, and thus an increased risk of being infected with HIV, even if the HIV test is negative (i.e. syphilis testing could be used to reduce the risk of the so-called 'window period', the period before HIV infection shows up in the tests). However, this test is not used for blood donor screening in Uganda.

2. The special problem of malaria

One of the major concerns must be the risk of transmitting malaria by blood transfusion, either P. falciparum or P. malariae. In Uganda malaria is endemic throughout the country, and is one of the major causes of infant mortality. There is evidence that some strains of P. falciparum are resistant to treatment with 4-amino-quinilone drugs (e.g. Chloroquine). Screening of potential donors by microscopic examination of a stained blood smear has been suggested, at least to exclude transfusion of blood carrying more than a certain level of malaria parasites. This would add about 15 minutes of technician time and cost 0.1 ECU for each unit of blood.

Mr. Paul Senyonga, chief technologist at Nakasero, at his computer terminal

The strongest argument against malaria testing is that it carries a risk of breaking glass and subsequent HIV infection of the laboratory staff, and has very little gain in improved patient care. However, all transfused patients must be assumed to have received at least some plasmodia from every unit of blood and are candidates for anti-malaria therapy if fever occurs.

3. Adapting laboratory methods

Both the temporary laboratory and the laboratory in the new Nakasero building were very confined (14 square metres and 60 square metres respectively). It was important to use methods that required as little bench space as possible. A decision was made to use disposable plastics instead of glass to reduce time and space and the danger associated with washing. This had the additional advantage of marked reduction in the risk of contamination from one sample to another.

Staff training emphasised the importance of orderly work and a neat bench. Methods of blood grouping and crossmatching were standardised for use in every hospital. This made it possible to standardise supplies of reagents and disposable test tubes. Microscopes would not be used for crossmatching, for safety reasons. Instead, the standard saline and Anti Human Globulin methods were developed to give the greatest sensitivity.

Dr Peter Kataaha, director of the Uganda Blood Transfusion Service, at his portable computer

4. The start-up equipment - and computer

The grant from the Carnegie Foundation paid for a heavy duty microtitre plate centrifuge and an incubator. All we then needed to get started again, from the EC funding, was Elisa washers and readers supplied both from Abbott and from Organon Tecnika as part of the Elisa kit order, and domestic refrigerators and one chest freezer shipped by air to arrive in January 1989. An Amstrad computer and a dot matrix printer and three simple portable typewriters completed the emergency equipment purchase.

The computer was used to generate sets of six unique six-figure numbers on adhesive labels. It linked these numbers to the donor identification and, after complete processing, printed larger adhesive labels as blood bag labels with the blood group and HIV (and later Hepatitis B) results. These labels were colour coded by use of crayons (O = blue, A = yellow, B = pink, AB = black, and Rhesus negative = crimson). The computer was also programmed to assist quality control, to make lists of donors by place collected and to prepare confidential results for the counsellor to take to counselling sessions.

5. Transport, for people, supplies, and blood

Transport can be an overlooked item. But it is important, for various reasons. In Kampala, the New Mulago Hospital was well served by public transport and staff could get to and from work. But when the Blood Bank moved back to Nakasero it could have been an impossible situation. The blood bank building is at the top of a high hill and at least one mile from any bus route. So the director of the AIDS Control Programme made a temporary assignment of one Isuzu pick-up truck, for this and other uses.

All goods arriving at Entebbe airport had to be collected by blood bank transport. The goods were consigned to the Ministry of Health (thus avoiding duty) and their staff were of great help in processing clearance rapidly. But the MoH never had a vehicle to carry the goods 50 km from Entebbe airport to the Institute. The contract to supply had no provision to pay for this transport and the suppliers' responsibility ended when the MoH accepted goods at the airport. In July 1989 two more Land Rovers and a Volkswagen Jetta saloon were delivered and later on more transport was acquired.

So by 1991 the blood bank had four vehicles, and later received more. But transport costs were a major and increasing expense, due to maintenance of older vehicles and rapidly rising cost of fuel. Priority was given to donor recruitment and blood collection activities. UBTS transport was not used for the delivery of blood except when visiting hospitals for other purposes and for a daily run to all Kampala hospitals and to the public bus transport station.

Transport of blood to hospitals outside of Kampala and to and from the regional blood banks was generally by the public bus service (see also interview with Dr Peter Kataaha). We used four gallon insulated containers, packed with ice which was insulated from the blood bags by corrugated paper. Until 1993, when the public bus service went bankrupt, the system worked well.

For the most remote hospitals we were able to use the Mission Aviation Fellowship (MAF) services out of Kampala via Entebbe airport (see box on MAF). Even with this however, there were times when some hospitals, due to security problems, lack of flights or other reasons, could not rely on receiving blood quickly. For this reason every hospital was supplied with blood bags and other consumables and test kits and systems for emergency HIV testing.

6. Voice and data communications - or lack of

Communications with hospitals and between regional blood banks have been a major and, as yet, unsolved problem. Until 1992 the NBB rarely had a telephone service. The MoH radio link could sometimes be used for brief messages and occasionally the Uganda Broadcasting Service would deliver messages. But the only real solution will be the expected improvement in the national telephone system, to a level that will allow computer communication via modem.

7. Funding staff salaries in a time of inflation

To begin with the entire staff was very happy. They were doing an important job and were doing it well. They were much better rewarded than they had been before. Each person was provided with two sets of uniform, or clothing, including one pair of shoes. It was uneconomic to allow staff to leave for a midday break (they would never return in the afternoon) so meals were provided locally.

Photo

But there was one big problem which loomed very soon. The staff establishment for the Nakasero Blood Bank was inappropriate, having been unchanged since 1976. No additions were expected and the staff was stable, so no promotion was likely. The cost of living rose steadily, and the allowances initially agreed became insufficient for staff to survive even at the lowest level and, for the senior staff, pitiable compared to potential earnings in non-government service. Every six months the EC Delegate and Ministry reluctantly agreed to make small increases. This situation is integral to any government service in countries with a declining economy and mounting problems. Management has to take every opportunity to provide more remuneration for sustained loyal and excellent service (see also interview with Dr Peter Kataaha).

8. Keeping records, or trying to

Blood bank records are computer-based but always supported by manual records. The donor record file on the computer allows storage of all relevant information about the donor, the results of testing the blood, the distribution to hospitals, and the name and place of the patient who received the blood. With each unit of blood a utilisation form is sent, to be completed at the hospital, with details of use by patients of every unit of blood, and then returned to the NBB for entry into the blood unit record file. This system was successful only when a senior staff member made continuing efforts to receive correctly completed forms. This problem is not amenable to easy solution until the telephone service is reliable.

9. All or only some hospitals?

The original project document stated that the NBB would, by the end of three years, be processing 10,000 blood donations annually and that this should be sufficient to meet the needs of hospitals within 100 km of Kampala. Did this remit mean only government hospitals or should it include all mission, military and private hospitals?

The decision was taken to be inclusive and not exclusive. This made logistical planning much easier and ensured that there would be uniformity of blood bank arrangements throughout the area. This was the critical decision that led to a national blood transfusion service. As the success of the NBB grew, and each new hospital was offered and accepted service, it was with the concept of total service.

Eventually all blood collections and processing would be the responsibility of the NBB. NBB would supply all consumables and reagents, would establish policies for donor recruitment and laboratory testing, and would determine guidelines for the use of blood and also for the counselling and follow-up of blood donors. In making these policies the NBB was acting for the Ministry of Health. The policies became Ministry of Health policies but were never supported by legislation or regulation.

It followed that the NBB was in a position to know the total blood transfusion activity in the country and also to collect statistics about the use of blood from every hospital. This latter task was very demanding in staff time and only partially successful. But enough data was collected to make it fair to assume that it was representative of the whole country for the purposes of planning policy.

The editor adds:

There are also other issues, for example, security, electrical and water supplies, environmental concerns, and legal and ethical principles.

On security, Dr Watson-Williams is too modest to mention that there was and is also a personal risk. His report to the EC for 1990 mentions that:

'On April 6 armed men robbed me of 2,000,000 Uganda shillings on the way back from the bank... From April 10 the Uganda police has supplied two armed men, every twelve hours, for round the clock security... one of these will accompany all bank trips.'

Dr Peter Kataaha, director of the UBTS, was on another occasion kidnapped and feared for his life.

On electricity and water, the need for continuous and reliable supplies is obvious enough. But in Uganda, as in other poor countries, they cannot always be guaranteed. So what fall-back arrangements can be made?

On environmental concerns, the 1992 proposal for continued EC funding of the UBTS points out that:

'A blood transfusion project handles a large amount of infected human blood. Some of the risks are known and measures to protect both the staff and the public must be developed and utilised with effective monitoring. This is much easier in a central facility [see arguments about central organisation - Ed.] than in widely scattered hospitals. The preferred method of handling contaminated disposable items in Uganda today is high temperature incineration. This necessitates a purpose built incinerator and this must be carefully managed to prevent toxic smoke and fumes in the local atmosphere.'

The legal and ethical rules that should govern blood transfusion, along with many other specialist aspects, are dealt with in the publication Safe Blood in Developing Countries: Principles and Organisation, issued by the EC.