Report 3 (of 5): Blood Safe - Uganda

Introduction

The supply of safe blood is the responsibility of governments and public health services in developing as well as developed countries. If the supply of blood is unsafe, doctors are faced with a cruel ethical dilemma - whether or not to give blood that might save a life or that might kill. It also creates a high risk for individual patients who are in need of blood or blood products.

In countries where no proper blood transfusion service is organised, blood transfusions are still given but can do more harm than good. The most serious characteristic of HIV infection by blood transfusion is that it is almost 100 per cent effective in each case. In countries in the South, between 5 and 10 per cent of HIV infections are due to transfusions of HIV contaminated blood.

Special Characteristics of the Health and Blood Supply in Africa

• In several countries throughout the African continent, much of the health infrastructure has been destroyed by civil war and civil strife.
• Some regions of Africa have a high rate of HIV infection in the general population leading to a basic probability that the blood supply will also be heavily contaminated unless stringent precautions are taken.
• Blood is frequently given by doctors in Africa in cases where blood transfusion could be replaced by other measures.
• African economies are generally too poor to import "safe" blood supplies or blood products from abroad.
• African health budgets are generally tiny when expressed in terms of per head of population so, a full scale safe blood service is often considered quite beyond their means.
• Africa has professional paid blood donors who make their living out of giving blood. These people and their behaviour are hard to keep track of, and they tend to have abnormally high rates of HIV infection.
• Most donations of blood are given directly to the individual hospital which makes it hard to enforce consistent standards over the many scattered sites. Personnel trained and skilled in blood transfusion are thinly spread.
• In the absence of a national or regional safe blood policy and blood transfusion service, relatives of the sick and injured give their blood to be used there and then. There is often no time or facilities to test the blood for HIV or anything else. As a consequence, the well meaning attempt to help, may end in an even worse outcome.

The Uganda Blood Transfusion Service (UBTS)

Despite having suffered fifteen years of alternating civil war and neglect, Uganda has emerged from the ruins with a national blood transfusion service. Less than a decade after being established, the Uganda Blood Transfusion Service (UBTS) is supplying almost all the hospitals in Uganda - over 90 of them - with almost all the supplies they

need of safe, - over 90 of them - with almost all the supplies they need of safe, screened blood that is free of the HIV virus and hepatitis. Even where there are continuing security problems in the north of the country which make direct supplies too dangerous to deliver, there are local arrangements for blood screening.

The UBTS has its central laboratory at the Nakasero Blood Bank in Kampala, with four regional blood banks in Gulu, Mbale, Mbarara and Fort Portal. There is one blood donor recruiter at each of the regional blood banks, and at the Nakasero Blood Bank, there are six donor recruiters. All of them have received additional training in blood donor recruitment.

The UBTS and its 100 or so staff, now supply nearly 40,000 units of blood a year to Ugandan hospitals which is enough for today’s needs. Even in cold storage, blood only lasts for about 35 days so the UBTS has to keep up a continuous supply of new blood.

The European Commission in Brussels is the main technical and financial supporter of the Uganda safe blood project. In the context of Uganda’s own HIV/AIDS campaign, the safe blood programme has a significance far wider than simply the screening of blood for hospitals. The diverse collection of activities that go into making a fully fledged safe blood programme is one of the most efficient, measurable and cost effective mass interventions yet devised against the HIV epidemic.

The Wider Contribution of the UBTS

• The UBTS has prevented many thousands of HIV infections that might have been caused by use of HIV-contaminated blood in hospitals.
• The UBTS has enabled many thousands of Ugandans to visit the AIDS Information Centres in Kampala and elsewhere, to know their HIV status accurately and so make informed decisions about their lives, partners, habits and responsibilities.
• During the UBTS’s campaigns to recruit reliable blood donors, many thousands of people, particularly among the young in schools, colleges and churches, have been educated about the HIV epidemic and its patterns of spread.

The Uganda Blood Transfusion Service has been one of the major instruments of AIDS control in the country. The UBTS has saved countless lives, not only among those who need blood transfusions but among those who as potential blood donors, have received AIDS education and among those who have sought a blood test so as to know their HIV status and avoid passing on the infection to others.

Operations of the Uganda Blood Transfusion Service (UBTS)

• Recruitment of a core group of unpaid, volunteer, repeating blood donors, that is, people who can be relied upon to give blood regularly that is HIV free. This cuts down the wastage (contaminated blood has to be destroyed), the risks to hospital patients and the costs.
• Systematic training of staff so that public trust in the blood test results is high.
• A central coordinating organisation so that minimum standards and quality control can be defined and enforced, and scarce skills can be utilised in the best ways.
• A complex web of transport arrangements, involving the UBTS’s own road transport, public bus and taxi services, post office vans and local air services to overcome both poor local roads and security problems.
• Development of other sources of income, in addition to the EC’s external funding, so that the UBTS has some degree of financial independence.
• The extensive HIV education efforts that accompany the recruitment of blood donors.
• The training of clinical staff in the appropriate use of blood, that is, to teach them when blood transfusion is essential and when it is not at all necessary.

Recruiting Blood Donors

In the past, it was acceptable to take blood from any donor. The current situation, as set out by UBTS, 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 for the amount of blood transfusions being carried out by identifying them through a programme of voluntary recruitment.

A group of potential donors, such as, students, church congregations or office workers is selected and then visited by the blood bank recruiter. Leaflets are distributed and a meeting held which lasts for about 30-45 minutes. The potential donors are reassured about anonymity, safety, confidentiality and other fears that they may have. If a sufficient number (20 or more) is interested, a date is set for the bleeding session where every potential donor has a sample of blood taken and confidential individual questioning takes place.

Counselling sessions are given to potential donors which provide facts concerning the need for blood transfusion. In keeping with blood bank policy, the first time donor uses a surrogate name, usually mother’s first name, giving for verification date and place of birth. After two weeks, the counsellor returns to discuss results. The donor needs to show the receipt and give the correct date and place of birth and surrogate name before any discussion can take place.

About 97 per cent of the blood that arrives at the blood transfusion service tests HIV negative and 99 per cent of the blood taken from the donor clubs is also HIV negative. If the result is negative, the donor is given a suggested time to give more blood and counselled on methods of ensuring a risk-free life. Condoms are available for donors if desired. However, if the HIV result is positive, the best possible arrangements for follow up are made.

Since the scheme began, 40 donor clubs have been set up throughout Uganda and the blood is being distributed to hospitals nationwide. For the programme to remain successful, it must retain the volunteers. Encouraging donors to return is vital because they have already been identified as HIV and hepatitis free, and have attended the health education talks several times previously.

Key factors in the creation of an effective blood transfusion service

• Acceptance of transfusion medicine as a distinct sector in the health care system.
• Establishment of a national blood policy.
• Well trained and dedicated professionals.
• Broadly based national advisory bodies.

Transfusion medicine is not only the collecting and testing of blood. It also requires:

• Recruitment and retention of blood donors.
• Blood collection.
• Laboratory testing.
• Blood processing and storage.
• Training of physicians in appropriate use of blood.

The Organisation of a Blood Transfusion Service

A centralised national/regional blood transfusion service can give better guarantees of blood safety than a hospital based service by offering:

• Recruitment of a network of voluntary, non-renumerated blood donors that is less subject to local variations or emergencies.
• A regular blood supply - a centralised system is able to sustain, manage and guarantee an adequate stock more effectively.
• Techniques that observe minimum safety standards, such as blood grouping, compatibility testing, screening for infectious diseases, record keeping and quality control.
• Better training of personnel, economies of scale by bulk purchasing and automation.

Coordination 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 and support of research are easier to arrange.

For further information, please contact:

Intermediate Technology would like to thank the European Commission for providing the original material on safe blood transfusions. This information sheet has been compiled using extracts from the book ‘Safe Blood in Developing Countries - The lessons from Uganda’ edited by Rex Winsbury (ISBN 92-827-5281-X).

Further reading available from ITDG Development Bookshop

Blood Collection, Fractionation and Storage Methods
Yvonne J. Brouard, Jenefer Blackwell and Paul E. M. Fine
Written for those working in developing countries, this book reviews the procedures for blood collection and the associated problems of handling. It gives guidelines and makes suggestions for overcoming these problems and well as looking at new techniques and equipment suitable for reducing the hazards in field study situations.
£5.50, (London School of Hygiene and Tropical Medicine), 50pp, 1989, ISBN 0 90099 520 3

TVE/ Practical Action gratefully acknowledge support for the HANDS ON programmes from the UK's Department for International Development (DFID), the European Commission (EC), the UN Foundation and UNDP/The Equator Initiative in collaboration with the Government of Canada, IDRC, IUCN, BrasilConnects and the Nature Conservancy.