Blood transfusion is an indispensable component of health care. It contributes to saving millions of lives each year in both routine and emergency situations, permits increasingly complex medical and surgical interventions and dramatically improves the life expectancy and quality of life of patients with a variety of acute and chronic conditions.
Patients who require transfusion as part of their clinical management have the right to expect that sufficient blood will be available to meet their needs and to receive the safest blood possible. However, many patients still die or suffer unnecessarily because they do not have access to safe blood transfusion. The timely availability of safe blood and blood products is essential in all health facilities in which transfusion is performed, but in many developing and transitional countries there is a widespread shortfall between blood requirements and blood supplies.
Blood transfusion in health care
Many medical advances that have improved the treatment of serious illness and injuries have increased the need for blood transfusion for patients’ survival, to support them through recovery or to maintain their health. Surgery, trauma and cancers, for all of which there is a high probability of the need for blood transfusion, are replacing communicable diseases as leading causes of death. About 234 million major operations are performed worldwide every year, with 63 million people undergoing surgery for traumatic injuries, 31 million more for treating cancers and another 10 million for pregnancy-related complications.7-8
National requirements for blood are, in part, determined by the capacity of the country’s health care system and its coverage of the population. In developed countries with advanced health systems, the demand for blood continues to rise to support increasingly sophisticated medical and surgical procedures, trauma care and the management of blood disorders. An increase in ageing populations requiring more medical care has also led to increased requirements for blood.
In countries where diagnostic facilities and treatment options are more limited, the majority of transfusions are prescribed for the treatment of complications during pregnancy and childbirth, severe childhood anaemia, trauma and the management of congenital blood disorders. Haemorrhage, for example, accounts for over 25% of the 530 000 maternal deaths each year; 99% of these are in the developing world. Access to safe blood could help to prevent up to one quarter of maternal deaths each year and blood transfusion has been identified as one of the eight life-saving functions that should be available in a first-referral level healthcare facility providing comprehensive emergency obstetric and newborn care.9
Children are particularly vulnerable to shortages of blood in malarious areas because of their high requirement for transfusion arising from severe life-threatening anaemia resulting from malaria, often exacerbated by malnutrition. In 2008, 109 countries were endemic for malaria, 45 within the WHO African region. In 2006, there were an estimated 247 million malaria cases among 3.3 billion people at risk, causing nearly a million deaths; 91% of malaria deaths were in Africa and 85% were of children under five years of age.10
Road traffic accidents kill 1.2 million people and injure or disable between 20 million and 50 million more a year, a large proportion of whom require transfusion during the first 24 hours of treatment; 90% of deaths occur in developing and transitional countries. Road traffic injuries are predicted to become the third largest contributor to the global burden of disease by 2020, with an anticipated increase of 65% in road traffic deaths globally and 80% in low and medium HDI countries.11 The timely availability of blood at emergency health care facilities is one of the determinants of patient survival.
About 300 000 infants are born each year with thalassaemia and sickle-cell disease and need regular blood transfusion.12 While the prevalence of these disorders of haemoglobin is unknown, there is a high requirement for regular transfusion in affected regions, particularly the Mediterranean region, Asia and north Africa.
Sufficiency and security of national blood supplies
Blood transfusion services face a dual challenge of ensuring both a sufficient supply and the quality and safety of blood and blood products for patients whose lives or wellbeing depend on blood transfusion. Blood supplies need to be constantly replenished since whole blood and blood components have a limited shelf-life. Most countries battle to meet current requirements while at the same time responding to increasing clinical demands for blood.
Developed countries with well-structured health systems and blood transfusion services based on voluntary blood donation are generally able to meet the demand for blood and blood products. They must constantly strive to maintain adequate blood stocks in the face of rising clinical demands, increasingly stringent donor selection criteria and the loss of older donors who are no longer eligible to give blood. Nevertheless, even though there may be periodic or seasonal shortages, access to safe blood for all patients requiring transfusion can generally be taken for granted. Overall, developed countries are likely to have effective blood donor programmes, more voluntary donors, higher donation rates and more available blood.
In contrast, in developing and transitional countries, chronic blood shortages are common. Sophisticated health care provision may be available in major urban centres, but large sectors of the population, particularly those in rural areas, often have access only to more limited health services in which blood transfusion may be unsafe or not available at all.
WHO estimates that blood donation by 1% of the population is generally the minimum needed to meet a nation’s most basic requirements for blood; the requirements are higher in countries with more advanced health care systems. However, the average donation rate is 15 times lower in developing countries than in developed countries. Globally, more than 70 countries had a blood donation rate of less than 1% (10 donations per 1000 population) in 2006.5 In the WHO African region, blood requirements were estimated at about 8 million units in 2006, but only 3.2 million units were collected – about 41.5% of the demand.13 South-East Asia accounts for about 25% of the world’s population, but collects only 9% of the world’s blood supply – 7 million units a year compared with an estimated requirement for total of 15 million units.14 Ageing populations and more strict donor selection criteria are further reducing the pool of eligible blood donors. Globally, over 81 million donations of blood are collected annually, but only 45% of these are donated in developed and transitional countries, where 81% of the world’s population live.5
Most countries with low rates of blood donation are largely dependent on blood provided by the families or friends of patients who require transfusion – and even on paid donation. They generally do not have structured blood donor programmes and cannot attract sufficient numbers of donors to meet the need for blood in emergencies, planned surgery and regular transfusion for conditions such as thalassaemia.
Paradoxically, despite a markedly inadequate blood supply in many countries, unnecessary transfusions are often given when the availability and use of simpler, less expensive treatments would provide equal or greater benefit. Not only does this expose patients needlessly to the risk of potentially fatal transfusion reactions, it also widens the gap between supply and demand and contributes to shortages of blood and blood products for patients who really need them.
Safety of blood and blood products
The HIV/AIDS pandemic focused the world’s attention on blood transfusion as a significant route of transmission of HIV/AIDS. It is estimated that blood transfusion accounted for 5-10% of HIV infections in the 1980s and it still contributes to a significant proportion of new infections, particularly in high prevalence countries.
The risk of HIV infection through unsafe blood and blood products is exceptionally high (95–100%) compared to other common routes of HIV exposure: for example, 11–32% for mother-to-child transmission and 0.1%–10% for sexual contact.15 Sub-Saharan Africa has a particularly high level of transfusion-associated HIV compared with other regions due to a higher risk of infected blood being transfused. In some regions of the world, hepatitis B, hepatitis C and other bloodborne infections such as Chagas disease pose an even greater threat to national blood supplies. In developing countries, pregnant women and children account for a disproportionate number of HIV and hepatitis viral infections through unsafe blood and blood products because they are the main groups of patients requiring transfusion.
Preventing the transmission of infection through unsafe transfusion is one of the core strategies for HIV/AIDS prevention – and is, in fact, the only approach to HIV prevention that is almost 100% effective. In most developed countries, the risk of HIV transmission is very low because of the adoption of an integrated approach based on voluntary blood donation, stringent donor selection procedures, the screening of all donated blood for transfusion-transmissible infections and the use of transfusion only when no suitable alternatives are available. However, varying degrees of risk remain in many parts of the world. The transmission of hepatitis and other bloodborne infections is equally preventable.
The prevalence of infectious markers among donated blood units is not only an indicator of the relative risk of transfusion-transmitted infection, but also directly affects the actual availability of blood. In Latin America and the Caribbean, for example, around 240 000 units of blood were discarded in 2005 because laboratory screening tests showed evidence of infection. At an estimated cost of basic supplies of US$ 56 per unit, this represented a loss of US$ 13.4 million.16
Why voluntary blood donation?
Blood and blood products are a unique and precious national resource because they are obtainable only from individuals who donate blood or its components. Most countries urgently need a substantial increase in the number of people who are willing and eligible to donate blood in order to ensure a stable supply of safe blood and blood products that is sufficient to meet national requirements.
WHO, the IFRC, the Council of Europe, the International Society of Blood Transfusion, the International Federation of Blood Donor Organizations and a number of other international and national organizations have defined voluntary non-remunerated blood donation as a founding and guiding principle. They recommend that all blood donation should be voluntary and non-remunerated and that no coercion should be brought to bear upon the donor to donate.
A voluntary non-remunerated blood
donor gives blood, plasma or cellular components of his or her own free will and receives no payment, either in the form of cash or in kind which could be considered a substitute for money. This would include time off work other than that reasonably needed for the donation and travel. Small tokens, refreshments and reimbursements of direct travel costs are compatible with voluntary, non-remunerated donation.
Family/replacement donors are those who give blood when it is required by a member of their own family or community. In most cases, the patient’s relatives are requested by hospital staff to donate blood, but in some settings it is compulsory for every patient who requires transfusion to provide a specified number of replacement donors on emergency admission to hospital or before planned surgery. Although donors are not paid by the blood transfusion service or hospital, there may be a hidden paid donation system in which money or other forms of payment are actually provided by patients’ families.
In some countries, patients may prefer direct donation by family members or friends rather than “strangers” because they believe this will eliminate the risk of transfusion-transmissible infection.17 However, prevalence rates of transfusion-transmissible infections are generally found to be higher among family/replacement donors than voluntary donors.4,5,18-22
Paid or commercial donors give blood in return for payment or other benefits that satisfy a basic need or can be sold, converted into cash or transferred to another person. They often give blood regularly and may even have a contract with a blood bank to supply blood for an agreed fee. Alternatively, they may sell their blood to more than one blood bank or approach patients’ families and try to sell their services by posing as family/replacement donors.
National blood transfusion services based on voluntary blood donations
In 1975, the Twenty-eighth World Health Assembly in resolution WHA28.7223 called for the development of national blood transfusion services based on voluntary blood donation to ensure safe, adequate and sustainable blood supplies and to protect the health of blood donors and recipients. Thirty years later, this resolution was endorsed in resolution in WHA58.131 which reflected evidence in transfusion medicine and science and consideration of economic, ethical and social factors. The resolution urged countries to establish or strengthen systems for the recruitment and retention of voluntary, non-remunerated blood donors in order to ensure safe and adequate blood supplies and equitable access to safe blood and blood products.
Voluntary blood donation and sufficient, sustainable blood supplies
Countries provide annual data on blood safety and availability to the WHO Global Database on Blood Safety (GCBS).4,5 These data show that 54 out of 193 countries have achieved 100% voluntary blood donation; the majority of these (68%) are developed countries, while transitional and developing countries account for 23% and 9% respectively. The average donation rate in the countries with 100% voluntary blood donation is 31 per 1000 population compared to countries with 50% or less voluntary blood donations, which have an average donation rate of 9 per 1000 population.5
Analysis shows that countries with 100% voluntary blood donation have a higher proportion of regular blood donors and that this has been maintained over a number of years. Further, in countries where the percentage of voluntary blood donations has risen, there has also been an upward trend in the percentage of regular blood donations. This shows that voluntary blood donors are more likely to donate on a regular basis than other types of donor. A panel of safe voluntary donors who donate blood regularly enables blood collection to be planned systematically to meet the requirements for blood, by blood groups and components. This enables the blood transfusion service to maintain a constant and reliable supply of safe blood when required in every clinical setting practising transfusion. Building a pool of regular voluntary blood donors is also more cost-effective than recruiting new donors.
In systems based on voluntary blood donation, patients have improved access to safe blood transfusion in routine and emergency situations, without which their survival or quality of life might be threatened. The blood and blood products they receive carry a low risk of infection that might further compromise their health. They are not placed under pressure to find blood donors in order to receive treatment and feel a sense of being cared for by others whom they will never meet. In turn, this may motivate a spirit of generosity and a desire for reciprocal volunteering in the future.
In a well-organized voluntary donor programme, the need for blood in disaster and emergency situations can usually be met through its established donor base. Regular donors tend to be particularly responsive to appeals for donors during periods of blood shortage or in emergency situations because they have already expressed a commitment to voluntary blood donation.
Family/replacement donors cannot meet a community’s requirements for blood and blood products because they provide blood only for individual patients when requested. The blood given to patients will not necessarily be replaced by blood group or quantity. Hospitals that are dependent on replacement donors are rarely able to maintain a sufficient stock of blood to meet the transfusion needs of all their patients, particularly in emergency situations or for regular transfusions, or to share their blood supplies with other hospitals.
Paying people to give blood undermines the principle of voluntary non-remunerated blood donation. Where systems of paid and voluntary blood donation co-exist, people who might otherwise donate voluntarily may opt to receive payment for their blood, thus weakening the voluntary blood donor programmes.
Voluntary blood donation and the safety of blood and blood products
Voluntary blood donors, particularly regular donors, are the first line of defence in preventing the transmission of HIV, hepatitis viruses and other bloodborne infections through the route of transfusion. A number of studies have reported significantly lower prevalence of transfusion-transmissible infection markers among voluntary donors compared with other types of donors, with the lowest rates among regular donors.5,16
Voluntary donors are recognized to be the safest donors because they are motivated by altruism and the desire to help others and by a sense of moral duty or social responsibility. They have no reasons to withhold information about their lifestyles or medical conditions that may make them unsuitable to donate blood. They are not placed under any pressure by hospital staff, family members or the community to donate blood and they entrust their blood donations to be used as needed, rather than for specific patients. The only reward they receive is personal satisfaction, self-esteem and pride. In a well-organized blood donor programme, voluntary donors, in particular regular donors, are well-informed about donor selection criteria and are more likely to self-defer if they are no longer eligible to donate, thus reducing the need for temporary or permanent deferrals. This also leads to less wastage of donated blood, with all its associated costs, because fewer blood units test positive for infection and need to be discarded.
Family/replacement donors are usually not informed about conditions that may make them unsuitable to donate blood. Even if there is a donor selection process to assess their eligibility to donate, they may be unaware of the significance of some of the questions in the donor interview. In their eagerness to donate blood to save the life of a loved one or their fear of distressing or displeasing their family, replacement donors may conceal information about their health status or lifestyle behaviour. This poses an increased risk of the transmission of infection, often resulting in a higher volume of donated blood that has to be destroyed because of evidence of infectious disease markers.18-22
Paid donors often lead lifestyles that expose them to the risk of HIV and other infections that could be transmitted through their blood. The highest prevalence of transfusion-transmissible infections is generally found among paid or commercial donors.24-29 People who accept payment for their blood are primarily motivated by the prospect of monetary gain rather than a desire to help save lives. The need to protect their income from blood “donation” compromises issues of honesty in the donor interview and they are highly unlikely to reveal reasons why they may be unsuitable to donate blood. Further, they are often undernourished and in poor health and may give blood more frequently than is recommended, resulting in harmful effects on their own health.
Voluntary blood donation and ethical, economic and social concerns
Meeting the nation’s need for safe blood and blood products through the donation of human blood should be based on ethical principles including respect for the individual and his or her worth, the protection of the individual’s rights and wellbeing, the avoidance of exploitation and the Hippocratic principle of “primum non nocere” – first do no harm.
Paid donors are vulnerable to exploitation and commercialization of the human body as they usually come from the poorer sectors of society and become paid blood donors due to economic difficulties. Any form of exploitation of blood donors, including payment for blood, coercion and the collection of blood from institutionalized or marginalized communities such as prisoners diminishes the true value of blood donation. A blood donation is a “gift of life” that cannot be valued in monetary terms. The commercialization of blood donation is in breach of the fundamental principle of altruism which voluntary blood donation enshrines.
In systems based on family/replacement donation, the onus of providing blood is placed on the patient’s family and friends rather than on the health system. Patients and their families are placed under considerable pressure to find blood donors at a time when they are already stressed because of the patient’s illness. Relatives who are unwilling or ineligible to donate blood and who cannot find other suitable replacement donors may resort to paying others to donate, even if this practice is forbidden by the country’s legislation. The problem is particularly acute when patients require regular transfusion for conditions such as thalassemia and blood is required every month or even more frequently. Patients are also disadvantaged if they have been referred from distant health facilities and have not been accompanied by relatives or friends.
Out-of-pocket payments for health care, including paying blood donors for giving blood, may contribute to households incurring catastrophic expenditure which can help to push them into poverty. The need to pay out-of-pocket may also mean that patients do not seek care when they need it. Ensuring that a safe and sufficient national blood supply is provided through voluntary blood donation effectively removes one of the main barriers to universal and equitable access to blood transfusion.
The donation of blood on a replacement basis also has an impact on its subsequent use. Patients and their families who have provided blood donors expect that transfusion will be given, even if it is no longer needed because of changes in the patient’s clinical condition. Physicians are placed under pressure to transfuse the number of units provided as replacement by their relatives, irrespective of the clinical need and possible risks associated with transfusion.
Voluntary blood donors themselves benefit from health education and encouragement to maintain healthy lifestyles as well as regular health checks and referral for medical care, if needed. Provided that they receive good donor care when they donate blood, they feel personal satisfaction and self-esteem which provides a sense of social engagement and belonging that is recognized and valued by the community. Voluntary blood donors serve as effective donor educators, recruiters and health promoters. Studies have shown that the influence of active blood donors is one of the most effective strategies for donor recruitment.30 Voluntary donors also play a valuable role as active agents in health promotion; in addition to practising healthy lifestyles themselves, they help to build healthy communities through their influence among their peers and families. Even donors who are no longer able to donate due to age or medical conditions can still play an important role in promoting voluntary blood donation in their families, workplaces and communities.
Challenges in achieving 100% voluntary blood donation
Information reported by national health authorities to the WHO Global Database on Blood Safety reveals interesting patterns and some striking differences between countries that have entirely voluntary systems of blood donation and high donation rates and those that still remain a long way from achieving 100% voluntary blood donation.
In 1998–1999, when the first GDBS data were collected, only 26 countries reported that they collected all blood donations from voluntary blood donors.31 Most of these were countries that had always had a history of voluntary blood donation. However, the number rose to 39 by 2001–2002 and to 50 by 2004–2005.4 In 2006, an additional four countries achieved 100% voluntary blood donation.5
GDBS data help to identify the challenges that urgently need to be addressed in countries with low rates of voluntary blood donation. These are outlined below. Likewise, the achievements of countries with successful voluntary donor programmes point to strategies that have been effective in shifting from a dependence on family/replacement and paid donation to truly voluntary systems, even in resource-limited countries.
Government commitment and support
The commitment and support of the government to an effective national blood programme is a prerequisite for the achievement of 100% voluntary blood donation. Without concrete recognition of blood transfusion as an integral part of the health care system, the infrastructure and the human and financial resources needed to ensure the availability of sufficient supplies of safe blood and blood products are unlikely to be provided.
The development of a national blood policy, as part of the overall national health policy, does not necessarily reflect the extent or quality of implementation, but can often be a prerequisite for effective programme action. Effective plans are needed to demonstrate the direction and steps that the government will take to achieve 100% voluntary blood donation. Countries will not be able to achieve this goal until and unless government commitment and support are demonstrable by the development and implementation of a national blood policy and plan with the allocation of resources for infrastructure strengthening, and human and financial resources.
Blood donor programme
Fragmented systems for blood banking that lack coordination, particularly in developing countries, rarely have the capacity or resources needed to build effective donor education programmes; without donor education, there are limited opportunities to attract adequate and consistent numbers of voluntary donors to reduce the reliance of the health care system on family/replacement donation. Such fragmented systems also lack the wider infrastructure that enables blood and blood products to be exchanged between hospitals or moved to parts of the country where there are shortages. Studies in 15 countries in the Americas region indicate that poor blood bank infrastructures and operations and poor donor care are major hurdles to both voluntary donation and donor retention.32
Financial resources
Like every other element of the healthcare system, the blood transfusion service cannot function effectively without adequate, stable financing. Blood donor programmes are often perceived to incur minimal costs, apart from expenditure on blood collection bags, because blood is donated free of charge by donors. As a result, they often receive lower priority in the allocation of funds than areas such as blood screening. Yet without an identifiable budget, the programme cannot reach out to blood donors. All too often, blood donor programmes report that they do not have sufficient funds for donor recall or to maintain vehicles and operate mobile donor sessions.
Trained staff
When blood is collected from family/replacement donors in small hospital blood banks, it is not uncommon to find that the venepuncture procedure is performed by a laboratory technician, often because no other staff are available. In order to protect donors and donated blood, blood should not be collected in settings where there are insufficient staff with the required qualifications, training and experience to perform the procedure safely.
A wider problem is the lack of specialist staff with particular skills in marketing and communications that are needed for successful donor information, education and motivation. Donor session nurses may be experienced in giving public talks, but rarely have the time or expertise to design effective posters and leaflets or organize media campaigns. Similarly, donor notification and counselling, particularly for donors who are found to have HIV or hepatitis infections, requires qualified and trained staff with excellent interpersonal communication skills and an ability to provide empathetic support and care.
Donor communication strategies
The issue of effective donor communication strategies and educational materials is closely linked to the issues of budgets and staffing. Even if a blood centre is attractive and well-located, only the most dedicated donors will attend unless they are encouraged to do so. This requires time and money.
Without information, most people will simply remain unaware of the blood transfusion service and the need for blood donation. Without education and motivational activities, few will be sufficiently self-motivated to find out how they can donate their blood. Communication is at the core of a successful and sustainable voluntary blood donor programme. It transcends all areas, not only donor information and education, including advocacy and relationships with stakeholders.
Communication is often regarded as simply sending messages but is really more related to the giving of meaning to things; for this reason the importance of the message lies not so much in what is sent but how the message is perceived by the receivers. This is why communication requires greater recognition within blood transfusion services as a professional discipline, requiring a dedicated budget and specialist staff to undertake research, planning, donor information and education, and evaluation.
Public trust in the blood transfusion service
The community must have confidence in its blood transfusion service. Without trust in its integrity and efficiency and the safety of its procedures, few people would choose to donate their blood. This trust is earned over a long period of time but can be undermined very quickly, resulting in a negative effect on the loyalty and continuing support of individual blood donors, the community and partner organizations.
Even when unjustified, negative public perceptions can result in an inability to attract voluntary donors and, in extreme cases, the rapid loss of donors. A number of countries have had to cope with potentially damaging public responses to issues ranging from the actions of a single member of staff to faulty blood collection bags, unpopular policies or new donor selection criteria. The media are usually good friends to blood transfusion services, but their involvement in negative situations can have a major impact, particularly if the service is perceived to compromise the health of its donors or has been responsible for the transmission of infection.
