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How sharp practices, insufficient banks, ill-equipped facilities threaten safe blood transfusion in Nigeria

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A person donating blood

Photo The Independent


Mrs. BASIRAT Adeyanju came back from her business one evening and found her teenage son in a pool of blood at home, after trying to commit suicide by stabbing himself with a knife.It was learnt that the incident took place during the Muslim 30 days fast, as the teenager (name withheld) was depressed due to reasons best known to the family alone, according to his mother.

Adeyanju said her son was rushed to the hospital where the doctor said he had lost blood and would require three pints of blood in order to live again. The teenager has since received donated blood but is still in the hospital on observation.Anthony Ebi-John took a relative, who was pregnant and due for delivery to the hospital early this year. He was asked to get a pint of blood for her after delivery, but her blood group was a rare type.

“My relative wanted to deliver sometimes early this year and so they said we should give blood, just one pint of blood and we had to pay then about N7, 000, “ he explained.He said with the suffering undergone then, looking for her blood type, he had vowed to donate blood as a selfless humanitarian service to ensure Nigerians who need blood get it easily.

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Jaiyeoba Olalekan, 34, is a civil servant, who started voluntary blood donation at the Lagos University Teaching Hospital (LUTH) in 2017. He donates blood four times in a year, that is, every three months and was seen donating blood to help fill the hospital’s blood bank.

He has positive Rhesus factor and belongs to blood group ‘O ‘. He has donated a total of nine units of blood. Olalekan, who spoke to The Guardian said: “I started donating blood because I believe by donating at least a pint of blood you are saving a life.”

Anabe Addullaziz, 48, a butcher and trader, who has a rare blood group, rhesus ‘O -” has donated a total volume of five units of blood, while Ugochukwu Nwaruocha, who is into real estate, donates blood three times a year and has so far donated a total of eight units of blood since 2017.

Adeboye Oluwaseun, who also does voluntary blood donation, four times a year, since 2015, said: “Anytime I donate I feel lighter, refreshed and feel like the blood is going to save a life, which is the main essence of me becoming a voluntary donor.”
Olalekan, Addulllaziz, Oluwaseun represent few Nigerians who voluntarily donate blood.

Why donate blood?
According to haematologists, people that need blood transfusion are mostly road traffic accident victims with acute haemorrhage at the emergency room, obstetric (pregnant) women, with antepartum/postpartum haemorrhage and under-five children, presenting with anaemic heart failure. They said prompt administration of appropriate and adequate units of blood could help avoid their demise.

The risk of transmission of serious infections, including Human Immuno-deficiency Virus (HIV) and hepatitis, through unsafe blood and chronic blood shortages brought global attention to the importance of blood safety and availability.

According to studies, ineffective blood transfusion services in Nigeria, has been seen as another major contributor to the high rate of maternal and infant mortality, which is estimated at 800 deaths/100,000 live births, as well as the poor health indices.
Also, several studies have demonstrated how continuous donation increases life span, prevents cancer, sudden death and stroke.

However, these critical health conditions may worsen with millions of deaths recorded yearly if Nigeria does not attain the required blood transfusion safety and practice, which remains a cumbersome task due to a number of factors, ranging from shortage of blood, equipment and infrastructural deficits, poor implementation of blood transfusion guidelines to high prevalence of Transfusion-Transmissible Infections (TTIs).

Little wonder the World Health Organisation (WHO) has been pushing efforts to establish safe, available, and affordable blood transfusion services in Africa through encouraging adequate blood donor recruitment, donor blood testing, and collection as well developing strategies for the rational use of blood.Haematologists are of the view that creating more awareness on regular blood donation would help save lives and reduce the risk factors to sudden deaths.

On the benefits of regular blood donation to individual’s life and the society, a Consultant Haematologist, Department of Haematology and Blood Transfusion, LUTH, Dr. Deborah Edewor-Okiyo, said it helps in reproducing more blood cells in the bone marrows, enhance youthfulness, increases lifespan, reduces the risk of hypertension as it lowers the cholesterol level in blood, as well as reduces the risk of stroke in people who are already or have never been hypertensive.

She noted that one of the most important benefits of blood donation is the reduction of the risk of various kinds of cancers.
“There are various types of cancer – tissue cancer, blood cancer, like the Polycythemia vera, that has to do with excessive proliferation of red blood cells and it is cancerous and cannot be controlled. Another is cancer of the white blood cell, which is called leukemia. Acute cancers are curable when they are detected on time and continuous blood donation helps in early detection of illnesses. For someone who is into blood donation regularly, before the individual will get to that level and come down with those illnesses, he would have averted it,” she explained.

The Consultant haematologist explained that every one unit of blood can save three lives with the improved medical technology, where blood components are separated into the red blood cells, for road accident victims, white blood cells, platelets for those who have bleeding conditions/disorders in their nose, mouth and underneath their skin as it arrests the medical conditions, as well as the plasma, which is frozen to help arrest bleeding.

Consequently, Nigeria, on Friday, June 14, joined the rest of the world to commemorate the 2019 World Blood Donor’s Day. The Day is set aside to thank voluntary, unpaid blood donors for their life-saving gifts of blood and also to raise awareness of the need for regular blood donations to ensure that all individuals and communities have access to affordable and timely supplies of safe and quality-assured blood and blood products, as an integral part of the Universal Health Coverage (UHC) and a key component of effective health systems.

Indeed, Nigerians did not relent in volunteering their blood as a good number were seen donating their bloods at the hospitals, work places and venues set aside by non-governmental organisations and social groups to help save lives.
Challenges

The Guardian investigation revealed that blood is usually obtained on an emergency basis. The typical scenario is that patients with an urgent need of a blood transfusion task his or her relatives to provide blood. The relatives donate blood or procure blood from private laboratories and blood banks. They may also enlist the services of commercial blood donors.

A poor blood donation culture exists in sub-Saharan Africa and several studies have shown that this is fuelled by religious, spiritual and superstitious beliefs.

Professor of Haematology and Transfusion Medicine, College of Medicine University of Lagos (CMUL)/ Lagos University Teaching Hospital (LUTH), Sulaimon Akanmu, said Nigerians attitude towards blood transfusion medicine in general, still remains ‘appalling’ with respect to several factors, which include the type of donors who present themselves to donate blood, poor infrastructure and facilities for blood collection, equipment to fractionate blood, as well as storage and manpower for donor care, which he said is important in the process.

He explained that there are three main classifications of blood donors in Nigeria; the voluntary returning donors, who are the altruistic individuals that donate blood with the sole aim of saving lives without regard to any form of inducement; family replacements donors, those who donate for a hospitalised family member, friend, or associate and the commercial, that is paid donors, people who leverage on blood shortages, coupled with increased poverty to give their blood solely for financial purposes.

According to the WHO, a stable base of regular, voluntary, can assure unpaid blood donors an adequate and reliable supply of safe blood. These donors are also the safest group of donors as the prevalence of blood-borne infections is lowest among this group. World Health Assembly resolution WHA63.12 urges all Member States to develop national blood systems based on voluntary unpaid donations and to work towards the goal of self-sufficiency.

Akanmu endorsed the WHO’s position on blood sourcing from voluntary regular blood donors, due to their reduced chances of harbouring and transferring TTIs, such as HIV, Hepatitis B and C and syphilis among other common deadly diseases. He noted that the other two categories of blood donors face the risk of having the TTIs.

Akanmu, who is also the Head, Department of Haematology and Blood Transfusion, stressed that the present pool of mainly family replacement and commercial blood donors cannot bridge the nation’s blood supply chain deficits, which is the key hindrance to the smooth operations of the National Blood Transfusion Policy, aimed towards boosting transfusion safety in the country.
“Nigeria lacks insufficient blood transfusion facilities to care for donors in terms of manpower, to give the donors the kind of counselling they will need. We don’t have sufficient people; our facilities are not good enough to give a welcoming environment to our patients. The emptiness of our shelves is worrisome, no equipment or materials, no gloves, no blood bags, no reagents for screening, lack of repair of faulty equipment or purchase of new modernised ones among other issues.

“The most important thing we are lacking in the transfusion medicine practice in Nigeria, in terms of making the best use of a pint of blood donated, is the facility to fractionate blood into its different components, such that three to four people can benefit from a donated unit of blood. If we have the facilities in place everywhere, we must be able to fractionate blood into components,” he stressed.

The professor of haematology stressed that, with the WHO categorisation of countries based on their source of blood, ranging from categories A and B, with 80 per cent and 50 per cent contribution from the ‘volunteer returning blood’ donor, respectively to category C with less than 50 percent, Nigeria does not meet any of the categories because of her poor blood supply chain.
“ Nigeria is not on the map of people that have organised transfusion medicine practice. If we don’t have a system in place, we cannot even be categorised.

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“It is countries that have organised transfusion medicine practice that collects data from all transfusion facilities in the country and have what we call a ‘Desk Officer’ in the Federal Ministry of Health that collects all the data, which is being updated every week, month and at the end of the year. Then you have information concerning transfusion medicine from the entire country and share the data with the WHO, because the international agency does not deal with facilities, nor directly with hospitals, they deal with nations federal ministry of health,” he added.

Akanmu lamented that Nigeria does not have blood sufficiency in her blood bank due to the poor donation culture of citizens.
He said the WHO gave a formula for each country to use and determine the number of blood that must be collected per annum in order to meet the transfusion requirement, which states that at least five per cent of the population in that community must donate blood once in a year.

“If you say in Nigeria there are about 200 million people, what we are saying indirectly is that five per cent of the 200 million should donate blood once in a year, then we will be able to meet the transfusion requirement of Nigeria, which means in Nigeria, we must be able to collect nothing less than four million units of blood,” he explained.

According to the professor of haematology, the required amount of blood collected from an individual should be between 420 -450ml with the use of an ‘automated blood volume collector’, which he said would ease collection process, adding that it is not available in any hospital setting in Nigeria.

Akanmu said the last assessment of the total volume of blood that was ever collected in Nigeria, a document of the federal ministry of health, was 1.2 million, which he lamented is a far cry from the total volume that is expected to be sufficient for transfusion requirement in Nigeria, saying: “That is why the group of people in Nigeria that requires blood die like chicken due to insufficient blood supply.”

He said for the obstetric women, though, 90 per cent of women give birth without complications, the few remaining number could likely bleed to death if her placenta is not located on time and blood not available in the bank to replace the lost ones, noting that about 15 pints of blood is needed by the obstetric woman to survive.

“If the blood bank does not have or the blood bank is not stocked with blood from the volunteer returning blood donors, she will die and we are losing our women like that in the villages and the urban centers because of the emptiness of the shelve. You open your blood bank and the refrigerator is empty, no blood!” he lamented.

He also noted that many of the mass casualties of road accidents, when been rushed to the hospital’s emergency unit die at the spot because of blood supply deficit in the bank, adding that with the WHO’s estimated transfusion requirement of five percent in every country, Nigeria would need more than four million units of blood for its growing population to survive.He said the United State of America at present, collects about 12 million units of blood yearly, yet they are barely able to meet transfusion requirement of their country.

Akanmu said globally, about 117 million units of blood are collected yearly, as 50 per cent are from the developed countries that contribute about 16 per cent of the world’s total population. Akanmu told The Guardian that despite the fact that the practice prevents depression and heart diseases, less than one per cent of the Nigerian population is voluntarily donating blood.

Edewor-Okiyo, stressed that the awareness level of blood donation is low as people are not aware of the benefit to themselves and even to the society.She said the rate of emergency cases coming into the hospital every minute is alarming, ranging from excessive bleeding as a result of road traffic accident to postpartum hemorrhage, during pregnancy and childbirth as well as other surgical issues.

Edewor-Okiyo noted that with blood deficit in the blood bank, these set of individuals would bleed to death without replacement of the lost blood.

Paying for donated blood
While Ebi-John and other relatives of blood recipients claim that they purchase a pint of blood for about N7000 or more, Edewor-Okiyo said the money is not for the blood, but for the test kits used for screening the blood for any type of transfusion-transmissible infections, HIV, Hepatitis B and C and syphilis among other common deadly diseases.

“Because blood is scarce commodity, the money paid by recipient is not for the purchase of the blood, but for the test kits used for screening microorganisms and separating components. What we do in the hospital is that they are allowed to pay for screening because someone has donated it for free. We need to know the blood group of the blood sample we collected and we require test kits to do that and these are expensive,” she explained.

She further said the blood is subjected to haemovigilance, which is ensuring quality control of blood, right from the time of collecting the blood from the donor to the storage and processing, up to the recipient receiving the blood, lamenting that Nigeria is yet to have National Haemovigillance.

“Haemovigilance also include follow up of the recipient, if there would be any complications following the blood transfusion and if there is the issue would be arrested immediately. In Nigeria we don’t have the National Haemovigillance, how the society sees blood donation,” she stressed.

Recommendations
The consultant haematologist, however, advocated for intensive blood donation awareness by engaging the people in communities on awareness programmes, which she said will change their perception of blood donation, as well as having policies that will drive safe blood transfusion practice in Nigeria.

Several studies have shown that blood transfusion saves lives and improves health, but many patients requiring transfusion do not have timely access to safe blood. Experts insist that providing safe and adequate blood should be an integral part of every country’s national health care policy and infrastructure.

A study titled published in Journal of Education and Practice recommends among others that the federal government, state government, private hospitals and concerned Nigerians should encourage mass media campaigns continuously on the need for safe blood donations to save lives. It also upholds that the federal and state governments should establish more blood banks in their health facilities, in order to spur the people, who would become aware through the mass media, to access same for safe blood donations.

The WHO has been at the forefront to improve blood safety and availability, and recommends the following integrated strategy for blood safety and availability:Establishment of a national blood system with well-organized and coordinated blood transfusion services, effective evidence-based and ethical national blood policies, and legislation and regulation, that can provide sufficient and timely supplies of safe blood and blood products to meet the transfusion needs of all patients.

Collection of blood, plasma and other blood components from low-risk, regular, voluntary unpaid donors through the strengthening of donation systems, and effective donor management including care and counselling.Quality-assured screening of all donated blood for transfusion-transmissible infections, including HIV, hepatitis B, hepatitis C and syphilis, confirmatory testing of the results of all donors screen-reactive for infection markers, blood grouping and compatibility testing, and systems for processing blood into blood products (blood components for transfusion and plasma derived-medicinal products), as appropriate, to meet health care needs.

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Rational use of blood and blood products to reduce unnecessary transfusions and minimize the risks associated with transfusion, the use of alternatives to transfusion where possible, and safe and good clinical transfusion practices, including patient blood management.

Step-wise implementation of effective quality systems, including quality management, standards, good manufacturing practices, documentation, training of all staff, and quality assessment.Through its Blood and Transfusion Safety programme, WHO supports countries in developing national blood systems to ensure timely access to safe and sufficient supplies of blood and blood products and good transfusion practices to meet the patients’ needs. The programme provides policy guidance and technical assistance to countries for ensuring universal access to safe blood and blood products and work towards self-sufficiency in safe blood and blood products based on voluntary unpaid blood donation to achieve universal health coverage.

Meanwhile, to ensure more people donate blood voluntarily, the WHO in collaboration with IFRC, last year, developed a global framework to achieve 100 per cent voluntary blood donation. The framework is designed to provide guidance and support to countries seeking to establish effective voluntary blood donor programmes to phase out family or replacement blood donation and eliminate paid donation.

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