clinical indices of severe anaemia requiring … · enfants de bas âge dans les zones à...

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December 2008, Volume 11, no. 2Africa Sanguine

RÉSUMÉ

Pour établir des critères cliniques pour la transfusion des enfants de bas âge dans les zones à ressources limitées, des enfants pour qui la transfusion sanguine avait été prescrite uniquement sur la base des signes cliniques, dans une unité pédiatrique d’urgence, ont été comparés selon l’âge avec des enfants n’ayant besoin d’aucune transfusion dans la même unité. Des interrogatoires médicaux et des examens cliniques ont été effectués sur chaque enfant et des échantillons de sang ont été prélevés pour l’hémoglobine et l’hématocrite ainsi que pour l’électrophorèse. Sur la base des résultats cliniques obtenus entre les groupes malades et de contrôle, un algorithme a été établi comme guide clinique utile à la prescription de la transfusion sanguine au niveau des soins e santé primaires dans les zones à ressources limitées, là où une infi rmière ou une aide de soins est habituellement responsable de la prise en charge.

Mots-clés : Transfusion, indice clinique, enfants, anémie, zones à ressources limitées

SUMMARY

In order to establish clinical criteria for transfusing young children in resource-limited settings, children for whom blood transfusion had been prescribed on clinical grounds only, in a paediatric emergency unit, were matched for age with children requiring no transfusion in the same unit. Complete medical interviews and clinical examinations were performed on each child and blood samples were collected for haemoglobin and packed cell volume measurements as well as for haemoglobin electrophoresis. Based on the clinical findings obtained between the study and control groups, a flow chart has been established as a useful clinical guide to prescribing blood transfusion therapy at primary health care levels in resource-limited settings, where a nurse or nursing aid is usually in charge.

Keywords: Transfusion; clinical indices, children, anaemia; resource-limited settings

CLINICAL INDICES OF SEVERE ANAEMIA REQUIRING TRANSFUSION IN YOUNG CHILDREN AGED 0-5 YEARS:

Guidelines for resource-limited settings

INDICES CLINIQUES DE L’ANÉMIE GRAVE EXIGEANT LA TRANSFUSION CHEZ LES ENFANTS AGES DE 0 à 5 ANS :

Directives pour les pays a ressources limitees

Mbanya DN1,2, Tayou Tagny C2, Mboka C3 and Tetanye E3

Departments of Haematology1 and Paediatrics3; Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Haematology and Transfusion Service2, Centre Hospitalier et Universitaire, Yaoundé, Cameroon

Correspondence:Prof. Mbanya DNFaculty of Medicine and Biomedical SciencesUniversity of Yaoundé IB.P. 8046, Yaoundé, CameroonTel: +237 7760 7037Fax: +237 2231 40 39Email: [email protected]

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INTRODUCTION

In 1985, a review by DeMaeyer and Aldiels-Tegman1 on the prevalence of anaemias in the world suggested that some 1300 million people were affected by anaemia, especially in developing countries where infants, children and pregnant women are most attained. Children aged under - fi ve years tend to be more severely affected by anaemia, especially in malarial regions2,3. The major aetiological factors of anaemia in developing countries include nutritional defi ciencies of which iron defi ciency is the commonest4,5. Parasitic infections including hookworm and falciparum malarial anaemias6,7 as well as genetic disorders all contribute tremendously to infant mortality and morbidity from anaemia. In recent years, with the advent of HIV/AIDS, more and more children get anaemic from the effects of the HIV infection.

Nevertheless, and, irrespective of aetiology, basic facilities for investigating anaemias are lacking in most health institutions in many developing countries, and when these are available the cost of such investigations is usually the responsibility of the patient/family. More often than not, they either cannot afford it or eventually afford it at a slow, life-threatening pace for the patient. These handicaps, coupled with ignorance on the part of some parents, and the fact that most families usually find it cheaper to consult with witch doctors and traditional healers before a medical institution (as a last resort), all contribute to the emergency transfusions prescribed in the paediatric unit. Previous studies in the same institution in Cameroon8 report that the Paediatric Unit consumed more than 50% of all blood transfused within that hospital. In most centres, facilities for even basic emergency packed cell volume (PCV) estimates prior to transfusion are lacking. Thus, transfusions are usually entirely based on the clinical judgement of the prescribers8.

In the very remote rural regions, health care provision usually consists of health centres or dispensaries with only a nursing staff or nursing aid as the responsible offi cer. Thus, prescribed transfusions are not always justifi able. With all the risks involved in blood transfusions and especially with the increasing prevalence of AIDS, hepatitis B and C, and other non-curable transfusion transmissible diseases, even an occasional unjustifi able transfusion should be avoided since the consequences could be fatal. Establishing simple criteria for determining which children should be transfused could serve as a very useful tool, not only in some urban settings, but more so at the primary health care level (rural health centres and dispensaries). Such criteria will be applicable to medical students, young doctors and paramedical staff.

The aim of this study was, therefore, to establish simple standardized clinical indices for selecting anaemic children requiring blood transfusion with the hope of reducing the number of unnecessary transfusions prescribed and at the same time being able to save life in remote, rural, resource-limited areas.

PATIENTS AND METHODS

A random sample of 69 severely anaemic children (aged 0 - 5 years) for whom blood transfusions were prescribed based on clinical judgement alone was included in the study. A control group of 69 randomly selected age-matched children requiring no transfusion in the same paediatric unit was also included. Informed parental consent was obtained in all cases.

A complete medical interview and thorough physical examination was carried out for each child. Questionnaires designed to obtain information on each patient’s identity, age, sex, past and present medical history pertaining to the present health condition as well as clinical fi ndings were completed for each child. Cases suspected on clinical grounds, or known to be sickle cell anaemia sufferers were excluded from the study.

A 2.5 ml of venous blood sample was collected from each child into a tube containing Ethylene Diamine Tetra Acetate (EDTA) and another 2.5 ml into a 3.8% citrated tube. These samples were used within 24 hours. Haemoglobin (Hb) and the packed cell volume levels were obtained from the EDTA samples using an electronic particle counter (CBC 5, Coulter Electronics Ltd). The citrated samples were used for haemoglobin electrophoresis. Briefly, a haemolysate was prepared from the red cells and electrophoresis was performed on a cellulose acetate band using tris-glycine buffer at pH 9.0 and Hb mobility examined after 30 minutes at 200 Volts.

Statistical analyses were done using the x2 test and the Student’s t tests. P values <0.05 were considered statistically signifi cant.

RESULTS

Of the 138 children, 69 constituted the study group (42 boys and 27 girls) while 69 were controls (40 boys and 29 girls). There was no statistical difference in the sex distribution of the two groups and their ages were from 6 months to 5 years in each group (22 aged 6-11 months, 37 aged 12-25 months and 10 aged 36-60 months respectively). Statistically, the age group distribution, sex repartition, body weight and temperatures were similar between the two groups.

Table I shows the major clinical fi ndings noted in the children. These included generalised pallor, shortness of breath (dyspnoea), and jaundice reported respectively in 100%, 33.33% and 24.63% of the study group, compared to 1.45%, 1.45% and 0% respectively in the control group. Although tachycardia (high mean pulse rate) was observed in both groups of children, the values were signifi cantly higher in the study group (Table 1). The mean pulse rate in the study group was 120.02 ± 11.56 (range 98-138/minute) compared to 90.05 ± 13.45 (range 66-110/minute) in the control group of children. Splenic and liver enlargement was signifi cantly present in the study group (Table 1).

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The mean haemoglobin and PCV levels for the study group were 5.83 ± 1.46 g/dl and 15.39 ± 4.51 l/l respectively, compared to 11.42 ± 1.52 and 34.31 ± 5.60 l/l in the control group, differences that were statistically signifi cant (p<0.05). Hb electrophoresis showed that only one child in the study group requiring transfusion (1.45%) was HbSS compared to 9 (13.04%) in the control group. All the rest were HbAA.

DISCUSSIONS

Anaemia remains a major public health problem through out the world and more so in developing countries of sub-Saharan Africa, where poverty, ignorance compounded with parasitic infections such as malaria and hookworm infections3,6,7,9 and poor nutrition (example, iron defi ciency anaemia) aggravate the situation. Some studies have shown that morbidity in young children in some of these countries are frequently related to anaemia3,10,11,12 . Others studies have also shown that blood transfusion in our communities is most commonly used in paediatric cases, and are not necessarily properly indicated8,13. In the present study, anaemia requiring transfusion was diagnosed on clinical grounds because most patients have to pay for every test, and would usually not afford a simple PCV fee of approximately US$ 2, or will be able to raise the money at a life-threatening pace. Furthermore, the patient, for each unit of blood transfused makes a contribution of the equivalent of about 25-30 US$. These factors contribute to late arrivals for consultations at the hospitals, leaving the attending physician or health care provider with very little time to waste. In other instances, and especially where there is no physician or appropriately trained medical personnel (mainly very rural health centres, which serve a signifi cant proportion of the general population), the personnel transfuses every case received, on ground of such fi ndings as fatigue, tiredness or pallor (unpublished data).

Our fi ndings show that while pallor was present in all cases in the study group (confi rmed to be severely anaemic by Hb and PCV levels), other signifi cant fi ndings should accompany such clinical basis for a decision for blood transfusion. Dyspnoea, tachycardia, jaundice, splenomegaly and hepatomegaly were signifi cant fi ndings in this study. Dyspnoea and tachycardia are signs of severe anaemia, whose presence should not be down-played. Although both groups of children had mean febrile temperatures, there was no significant difference between them (Table 1). While pulse rate is known to rise with increasing temperature, however, the signifi cantly higher pulse rate noted in the study group was probably related to the severe anaemia in these children.

Jaundice and splenomegaly, being some of the “markers” of haemolysis, may suggest such a mechanism in some of the children. Haemolysis with hepatomegaly and splenomegaly may result from haemoglobinopathies. In Cameroon, about 2% of the population were described as homozygous for Hb SS14. However, only 1.45% of the study population here had HbSS, suggesting that this was not the major cause of haemolysis in our study. Cameroon is an endemic region for Plasmodium falciparum malaria15,16 and a haemolytic mechanism is believed to occur through non-immune destruction of infected erythrocyte by the reticulo-endothelial system. Earlier findings suggested the possibility of an immune-mediated mechanism17,18.

Reports of high rates of morbidity and mortality in children under fi ve years of age as a result of severe anaemia have been reported. Thus, particular attention in malaria prevention and early management in these children is essential.

The haematological fi ndings of very low mean Hb and PCV respectively in the study group (5.83 ± 1.46 g/dl and 15.39 ± 4.51%) confi rm severe anaemia in this group, and justify the indication for blood transfusion, hence validating the clinical criteria considered in the present study.

Thus, from the fl ow chart shown in Figure 1, generalized pallor will be present in an anemic child. However, pallor is not always indicative of anaemia, and all other manifestations must be taken into account. Dyspnoea and severe tachycardia must be considered seriously. These three manifestations (generalized pallor, dyspnoea and tachycardia between 110-120 beats/minute) in very young children may be suffi cient reason to consider transfusion of appropriate volumes of packed red cells. The presence of jaundice and splenic and/or liver enlargement are further suggestive of haemolytic mechanisms commonly due to malaria parasites present in severely anaemic children in malaria-endemic regions8,19 and responsible for the severe anaemia in them. In fact reports from Mbanya and Kaptue3, and Mbanya et al13 confi rmed that most transfusions in children in hospital settings of Yaoundé, Cameroon were due to anaemia caused by malaria. Given the dangers and complications associated with blood transfusion especially in our communities, it is recommended that where there is pallor with none of the other clinical manifestations, it would be safer to manage symptomatically (treat malaria in the malarial context, or give nutritional blood tonics) while pursuing appropriate further laboratory investigations to exclude other underlying disorders as the case may be (Figure 1). In case of improvement in the child, observe and discharge or where the symptoms persist, refer to a higher centre as required.

Blood safety remains an issue of major concern in our community and the unmonitored and “disorderly” prescription of blood to patients and especially very young children should be guided. Medical personnel faced with the dilemma of therapeutic decisions in very limited resources may source from these guidelines for the prescription of blood transfusion.

REFERENCES

1. DeMaeyer E, Adiels-Tegman M. The prevalence of anaemia in the World. World Health Statistics 1985; 38:302-16.2. Jourdan PM, Laoussou P, Lybie A, Kjetland EF. Indicators of anaemia in under-fi ves with malaria at a hospital in northern Cameroon. West Afr J Med. 2008; 27:7-12. 3. Mbanya DNS, Mboka C, Monny Lobe M, Tetanye E. Severe anaemia in children aged 6 months to 5 years in a malaria endemic region: experience from a paediatric unit in Yaoundé, Cameroon. Bull Liais Doc OCEAC 2002; 35:23 - 27.4. Stoltzfus RJ. Iron defi ciency: global prevalence and consequences. Food Nutr Bull. 2003;24:99-103.

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5. UNICEF/UNU/WHO. Iron defi ciency anaemia: assessment, prevention, and control. Genève, Organisation mondiale de la Santé, 2001.6. Eliades MJ, Wolkon A, Morgah K, Crawford SB, Dorkenoo A, Sodahlon Y, Hawley WA, Hightower AW, Kuile FO, Terlouw DJ. Burden of malaria at community level in children less than 5 years of age in Togo. Am J Trop Med Hyg. 2006; 75:622-9.7. Nkuo-Akenji TK, Chi PC, Cho JF, Ndamukong KK, Sumbele I. Malaria and helminth co-infection in children living in a malaria endemic setting of mount Cameroon and predictors of anemia. J Parasitol. 2006; 92:1191-5.8. Mbanya DNS et Kaptue LN. L’analyse de la prescription sanguine: l’expérience d’un hôpital de Yaoundé, Cameroun. Sem Hôp (Paris) 1995; 71: 873 - 876.9. Ronald LA, Kenny SL, Klinkenberg E, Akoto AO, Boakye I, Barnish G, Donnelly MJ. Malaria and anaemia among children in two communities of Kumasi, Ghana: a cross-sectional survey. Malar J. 2006; 5:105-109.10. Bryce J, Boschi-Pinto C, Shibuya K, Black RE; WHO Child Health Epidemiology Reference Group. WHO estimates of the causes of death in children. Lancet. 2005; 365:1114-6.11. El Ati J, Gaigi S, Beji C, Haddad S, Cherif S, Farhat A, Fattoum S, Ben Abdeladhim A.Prevalence and causal factors of anemia in children in Tunisia Tunis Med. 2005; 83:511-8. 12. Campbell JD, Sow SO, Levine MM, Kotloff KL. The causes of hospital admission and death among children in Bamako, Mali. J Trop Pediatr. 2004;50(3):158-63. 13. Mbanya D, Binam F, Kaptue L. Transfusion outcome in a resource-limited setting of Cameroon: a fi ve-year evaluation. International Journal of Infectious Diseases 2001;5:70 -3.14. Bernstein SC, Bowman JE, Kaptue Noche L. Population studies in Cameroon: hemoglobin S, glucose-6- phosphate dehydrogenase defi ciency and falciparum malaria. Hum Hered. 1980; 30:251- 8.15. van der Kolk M, Tebo AE, Nimpaye H, Ndombol DN, Sauerwein RW, Eling WM. Transmission of Plasmodium falciparum in urban Yaoundé, Cameroon, is seasonal and age-dependent. Trans R Soc Trop Med Hyg. 2003; 97:375-9.16. Quakyi IA, Leke RG, Befi di-Mengue R, Tsafack M, Bomba-Nkolo D, Manga L, Tchinda V, Njeungue E, Kouontchou S, Fogako J, Nyonglema P, Harun LT, Djokam R, Sama G, Eno A, Megnekou R, Metenou S, Ndountse L, Same-Ekobo A, Alake G, Meli J, Ngu J, Tietche F, Lohoue J, Mvondo JL, Wansi E, Leke R, Folefack A, Bigoga J, Bomba-Nkolo C, Titanji V, Walker-Abbey A, Hickey MA, Johnson AH, Taylor DW. The epidemiology of Plasmodium falciparum malaria in two Cameroonian villages: Simbok and Etoa. Am J Trop Med Hyg .2000; 63:222-30. 17. Greenwood B, Stratton D and Williamson W. A study of the role of immunological factors intake pathogenesis of the anaemia of acute malaria. Trans Roy Soc Trop Med Hyg 1978; 72: 378 - 385.18. Abdalla S and Weatherall D. The direct antiglobulin test in P. falciparum malaria. Br J Haematol 1982; 51: 415 - 425.19. Chiabi A, Tchokoteu PF, Toupouri A, Mbeng TB, Wefuan J. The clinical spectrum of severe malaria in children in the east provincial hospital of Bertoua, Cameroon. Bull Soc Pathol Exot.2004; 97:239-43.

Table 1: Major clinical fi ndings of the study (study vs. control groups).

Results are expressed as means ± 1SD. NS* = Not Signifi cant; S = Signifi cant

Figure 1: Flow chart of major clinical indices for transfusion

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INTRODUCTION

1. Overview of Blood Safety in Developing Countries:Blood safety initiative as a global agenda passed in 1975 when World Health Assembly Resolution WHA 28.72 was passed which urged all member states to develop comprehensive and well-coordinated blood transfusion services based on voluntary, non-remunerated blood donation. In developing countries where the biggest burden of infectious diseases and maternal/infant mortality/morbidity is carried, implementing blood safety has been a slow process.Before late 90s most of developing countries were depending on replacement blood donors such as relatives, friends or paid donors as a source of blood. This resulted in the lack of

readily available blood to meet the demand for emergencies in obstetrics, accidents, disasters etc. Safety of blood was at jeopardy due to dependence on replacement donors from high risk populations; lack of standardized blood donor recruitment, TTI testing, blood storage and transportation. In Tanzania despite knowing the inherent danger of transmitting HIV, HBV, HCV and Syphilis from family replacement donors1, implementation of blood safety effectively started in 2005 through PEPFAR support. The start of a centralized blood service was an eye opener on the existing problem of prevalent TTIs among the donors from the community (Figure-1)2.

RÉSUMÉ

Le sang sûr provenant d’un donneur volontaire de sang non rémunéré est une initiative qui a été prise en 1975 en conformité avec la résolution WHA 28.72 de l’Assemblée mondiale de la santé. Cette résolution a été adoptée globalement par beaucoup de pays ; les pays riches et les pays pauvres comprenant les 15 soutenus par le PEPFAR. A travers cette initiative, il est supposé que beaucoup de pays en voie de développement bénéfi cieront d’appui pour sauver des patients qui ont besoin du sang comme en obstétrique, pédiatrie, traumatologie, et chez les patients atteints de cancer. De plus, la préparation et la gestion dans les situations d’urgence et de désastre seront renforcées dans ces pays. Au Malawi il a été démontré que le taux de mortalité maternel a chuté de moitié après l’introduction de la sécurité transfusionnelle. L’amélioration de la disponibilité du sang sûr augmente l’effort de réduction de la mortalité maternelle et l’accomplissement de ce but sera réalisé si l’engagement politique, le professionnalisme et la motivation des obstétriceiens sont en place.

ABSTRACT

Safe blood through voluntary non-remunerated blood donation is an initiative which as a global agenda was passed in 1975 in line with World Health Assembly Resolution WHA 28.72. This resolution has been adopted by many countries globally; the rich and the poor including the 15 PEPFAR supported countries.Through this initiative it is assumed that many developing countries will benefit by saving many patients who need blood such as obstetric, paediatrics, trauma, and cancer patients. In additional emergency preparedness and disaster management will be strengthened in these countries. In Malawi it has been shown that Maternal Mortality Ratio has dropped by half after the introduction of blood safety. Improved availability of safe blood adds to the effort to reduce maternal mortality and achievement of this goal will be realized if political commitment, midwifery professionalism and motivation are in place.

MATERNAL MORTALITY: A CONSIDERATION FOR DEVELOPING COUNTRIES AND EMERGENCY PREPAREDNESS BLOOD SAFETY PLAN

MORTALITÉ MATERNELLE : UNE CONSIDÉRATION POUR LES PAYS EN VOIE DE

DÉVELOPPEMENT ET PREPARATION D’UN PLAN D’URGENCE POUR LA SECURITE TRANSFUSIONNELLE

Ahmad M. Makuwani, Operations Offi cer NBTS Tanzania; Terri Konstenius, AABB; Faustine E. Ndugulile, Programme Manager NBTS Tanzania; Kenra Ford, AABB.

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Figure 1: Comparison of TTIs distribution among voluntary blood donors (N = 6183) and

relative blood donors (N = 1941)

TTIs Seroprevalence VNRBD vs Relatives Mwanza BC July Sept 06

Global imbalance in provision of safe bloodWHO in 2004 showed that there is a major imbalance between developing and industrialized countries in accessing safe blood. The report noted that only 45% of the global blood supply is collected in developing countries, which is a home to over 80% of the world’s population. The blood donation rate in this region is less than 1% of the total population against the recommended 1-3% of the population3. Partly this scenario is compounded by many competing socio-economic priorities in these countries. The evidence to this observation is given by Cruz and Rosales in a report of 2003 which shows that there is a direct correlation between the availability of safe blood and GNP per capita income of the country3.

Disaster management, speeding the formation of blood safetyOn August 7, 1998, there were twin bombings of US embassies in Nairobi and Dar es Salaam. To add more, on September 11, 2001, there was another deadly terrorist attack of the New York World Trade Centre. On June 24, 2002, Tanzania suffered a major train accident which crashed with over 1 200 passengers on board. All these disaster required readily available safe blood4, 5. These disasters brought new energy towards addressing the need for emergency preparedness and disaster management. It is felt that the emerging disasters, HIV/AIDS pandemic and associated problems, brought a new thrust in engaging new tools towards health sector coordination6. PEPFAR support in blood safety is anchored or based on these realities.

2. Safe Motherhood:World Declaration Infl uencing Maternal HealthAlthough Maternal Mortality has consistently remained high in developing countries, several declarations have been put forward to acknowledge this problem as of public health importance. Some of the recorded declarations addressing safe motherhood include; 1978 Declaration of Alma Ata which expressed the need for urgent action by all governments, all health workers, and the world community to protect and promote the health of all the people of the world, 1987, Safe motherhood initiative, Nairobi Kenya which issued an international call to reduce maternal mortality and morbidity by one half by the year two thousand, 1995, Women Congress Beijing Declaration to ensure equal access and treatment of women and men in education and health care and to enhance women’s sexual and reproductive health as well as education and the 2005, Millennium Development Goals (MDGs) No. 4 and 5 which requires the reduction by two-thirds of the mortality rate among children under fi ve and by three-quarters the maternal mortality ratio.

Global perspective of maternal deaths:Globally it is estimated that 500 000 women die each year during pregnancy, delivery, or postpartum. Almost 99% of these maternal deaths occur in developing countries7. Estimates show that 25% of these deaths are caused by severe bleeding. The contribution of maternal death due to bleeding related complications globally varies from 21% to 40% (fi gure 2).

Figure 2: Regional Distribution: contribution of severe bleeding leading to maternal death

Causes of maternal deathsResearch has shown that 80% of the world maternal deaths are due to preventable direct obstetric complications which include haemorrhage, infections, unsafe abortion, eclampsia, obstructed labour, and other direct causes. Nepal has shown that over 67.4% of maternal deaths occurred at home8. Globally, 61% of these maternal deaths occur during postpartum9, and 15-20% of all pregnancies develop sudden obstetric complications which cannot be predicted. It is also important to note that domestic violence has also been reported to be related to maternal death10.

Basic causes of maternal mortalityMaternal mortality in developing countries have failed to decline because of low level political commitment, low level of midwifery skills and demoralized health workers. Maternal mortality in Sweden at the beginning 20th century was 230 per 100 000 live births compared with over 500 per 100 000 in the mid-1880s, this decline was possible by addressing the three issues above11. Sri Lanka using similar approach witnessed a decline of maternal mortality from over 1056 per 100 000 live births in 1947 to 20 per 100 000 in 1996 (fi gure 3)12.

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Figure 3: Political commitment, increased skills and motivation leading to reduced MDR in Sri Lanka

Sri Lanka: Maternal Mortality Reduction from 1945 - 1996

It is worth mentioning that midwifery skills remains an important weapon for decreasing maternal death as emphasized in the following words of wisdom; “To begin with, the midwife in Scandinavia is not regarded as pariah... One sees, therefore, in the training schools for midwives, bright, healthy looking, intelligent young women of the type from whom our best class of trained nurses would be recruited in this country, who are proud of being associated with an important community work, and whose profession is recognized by medical men as an important factor in the art of obstetrics, with which they have no quarrel” (George W. Kosmak Addressing AMA 1926)13.

Maternal mortality is a function of low socioeconomic statusOlenick in 1998 in Pakistan reported that women from low socioeconomic settings are more likely to die from maternal causes than others14. Ezechi et al in 2000 in Nigeria reported that fi nancial constraints and poor access to hospital transportation were the causes of delay contributing to maternal death15. On the other hand, attaining community level education is strongly correlated with lower maternal mortality rates16.

3. Role of blood safety in addressing maternal mortalityTo show the importance of availability of safe blood, in reducing maternal mortality Safe Blood for Safe Motherhood was the theme for World Blood Donor Day 2007. The new WHO initiative was introduced to improve available safe blood in health facilities providing Emergency Obstetric Care (EmOC), particularly in countries with high maternal mortality, and to implement appropriate use of blood 17. Timely available safe blood or blood components is a cornerstone to EmOC in developing countries. Makuwani et al 2003 at Mkuranga District Hospital reported that one of the signal functions of comprehensive EmOC was to work out the diffi culty of ensuring readily available safe blood18.Pregnancy related bleeding complications in developing countries remains a main cause of immediate sudden death. Thononnen et al in 1996 in Ivory Coast reported that 2/3 of women with pregnancy related complications died within

24 hours of hospital admission due to delays with mainly pregnancy bleeding complications19. This tallies with a 2005 report by Sombie et al which showed that 58.8% of pregnant mothers suffer three levels of delays and in particular delay at the district hospital during mobilizing safe blood for transfusion20. To show its importance available safe blood to safe motherhood, provision of transfusion of safe blood is among of the key indicator of comprehensive EmOC.

What about skills of workers in EmOC?Available skilled health workers are the pillar to a safe outcome of any pregnancy and this emphasizes the success many countries have had in reducing maternal morbidity and mortality by simply improving the skills of birth attendants. This is a big gap in developing countries. In Tanzania home delivery conducted by unskilled birth attendants accounts for almost 50% of all deliveries contrary to 98% of antenatal visit21. Makuwani et al in Tanzania reported that by simply improving skills, equipping the EmOC facility and ensuring availability of supplies managed to increase the number of deliveries in the facility by three to four folds at Mkuranga District Hospital18.

Will maternal death decrease if the blood is available in time?Blood safety addresses UN MDGs no. 4 Reduce by two thirds the mortality rate among children under fi ve, no.5 Reduce by three quarters the maternal mortality ratio, and no. 6 Halt and begin to reverse the spread of HIV/AIDS and the incidence of malaria and other major diseases. Blood safety cuts across to all these three MDGs.

It has been pointed out that bleeding pregnancy related complication contributes to over 21-40% of all maternal death worldwide7. Indra and Hari in 2006 in Nepal’s reported that nearly half of maternal deaths were due to post-partum haemorrhage which accounted for almost 46% of maternal deaths per annum22.

In Tanzania a National Blood Service programme has been operational for almost three years, and reports indicate that shortages of safe blood have been contained to some degree. This tallies with a 2005 report from Malawi after two years of blood safety operation showing the decline of maternal mortality rate due to severe blood loss by more than 50 per cent23.

In developing countries chronic anaemia as a result of malnutrition, malaria and worm infestation is not uncommon. Massawe et al in 2002 reported the prevalence of anaemia and severe anaemia in pregnant women as 60% and 3.8%, respectively24. Such anaemia’s and others pregnant related blood complications (e.g. HELLP syndrome, abruption placenta) require the availability of blood components.

Blood safety through collaboration has to provide skills for the appropriate use of blood and blood components e.g. packed red blood cells (RBC), platelets, plasma, Fresh Frozen Plasma (FFP), to ensure safe transfusion etc.

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The thinking of maternal death may decline with improved access to safe blood assumes that every variable determining the care of pregnant mother such as available skilled health personnel, provisional of evidence based good antenatal care, availability of supplies alternatives to blood, uterotonic drugs, best practices of EmOC, readily available safe blood and blood components, reduced delay at each stage of seeking care and others are in place. In developing countries such situations may sound to be ideal than real.

Inappropriate use of blood and blood components is another area which carries an obvious danger in obstetric practice. Amin et al in Canada 2004 reported that around 93% and 67% of doctors indicated increased confi dence and changed prescription pattern respectively of blood and blood components following an improved quality blood and blood products25.

CONCLUSION

Blood safety will add value to reduction of maternal mortality when there is a good political commitment, adequate and motivated skilled health workers. The country needs to link with other institutions such as department of reproductive health, Prevention of Mother To Child Transmission of HIV and other sectors addressing safe motherhood to have the additive effect of there efforts. With empowered decision making at community level during seeking and improved transportation system, delays may be reduced to minimum. However it is true that maternal mortality is a disaster in developing country that needs emergency preparedness including readily available safe blood.

REFERENCES:

1. Matee MIN, Magesa PM, Lyamuya EF; Seroprevalence of human immunodefi ciency virus, hepatitis B and C viruses and syphilis infections among blood donors at the Muhimbili National Hospital in Dar Es Salaam, Tanzania; BMC Public Health 2006, 6:21.2. Ministry of Health and Social Welfare, National Blood Transfusion Service Database 2005-7.3. Cruz JR, Pérez-Rosales MD: Availability, safety and quality of blood for transfusion in the Americas. World Hosp Health Serv. 2005; 41(1):25, 27-31.4. Blood Support for Kenya & Tanzania Embassy Bombings, ASBP June 7th, 1998.5. Siringi S; Tanzania rail crash highlights lack of medical resources for disasters. Lancet. 2002 6; 360(9326):65.6. Bradt DA, Drummond CM; From Complex Emergencies to Terrorism -New Tools for Health-Sector Coordination in Confl ict-Associated Disasters; Prehosp Disast Med 2003; 18(3):263-271. 7. The World Health Report, 2005. Make every mother and child count. Geneva, World Health Organization, 2005. 8. Maternal Mortality & Morbidity Study, His Majesty’s Government of Nepal, 1998.

9. Maternal Health around the World (Wall-chart), WHO, Geneva, 1997. 10. Ganatra BR, Coyaji KJ, Rao VN; Community-cum-hospital-based case control study on maternal mortality, KEM Hospital Research Centre, Pune, December 1996. 11. Högberg U, Wall S, Brostrom G. The impact of early medical technology on maternal mortality in late 19th century Sweden. International journal of gynaecology and obstetrics, 1986, 24(4):251-261. 12. Improve maternal health: Millennium Development Goals Country Report 2005 - Sri Lanka. 13. Högberg U; The Decline in Maternal Mortality in Sweden: The role of community midwifery; Am J Public Health. 2004; 94(8): 1312-1320. 14. Olenick I; Poor socioeconomic status is linked to high maternal mortality in rural Pakistan; International Family Planning Perspectives, Jun 1998. 15. Ezechi OC.; Fasubaa OB.; Dare FO; Socioeconomic barriers to safe motherhood among booked patients in rural Nigerian communities. J Obstet Gynaecol. 2000; 20(1):32-4.16. Mbizvo MT, Fawcus S, Lindmark G, Nyström L; Operational factors of maternal mortality in Zimbabwe Health Policy and Planning; 1993, 8(4): 369-378).17. World Health Organization (WHO). World Blood Donor Day Announcement 2007. 18. Makuwani AM, Massawe SN, Lema RSM, Mpembeni R, Shekimweri A, Mrema G, Mussa H; Setting an EmOC (EmOC) unit local initiatives, availability of resources and good will are the main ingredients of success: a lesson from Mkuranga District Hospital (unpublished) 2005.19. Thonneau P, Djanhan Y, Tran M, Welfens-Ekra C, Bohoussou M, Papiernik E; The Persistence of a High maternal Mortality Rate in the Ivory Coast, Am J Public Health. 1996 October; 86(10): 1478-1479. 20. Sombie I, Meda N, Ky-Zerbo O, Dramaix-Wilmet M, Cousens S; A theme issue by, for, and about Africa: Maternal mortality in rural Burkina Faso; BMJ. 2005 October 1; 331(7519): 779. 21. National Bureau of statistics (Tanzania) and Measure international Inc. Tanzania demographic and health survey.2005. 22. Adhikari I, Adhikari H; World Disasters Report-2006 Highlights Nepal’s Maternal Mortality; Nepal’s Red Cross Society; Sept 2006. 23. Safe Blood Donation Key to Maternal and Child Health, UN Agency Says; Realtime News Blaze, Daily News 2007. 24. Massawe SN; Anaemia in women of reproductive age in Tanzania: A study in Dar es Salaam. Uppsala University, Medicinska vetenskapsområdet, Faculty of Medicine, Department of Women’s and Children’s Health; Doctoral thesis 2002). 25. Amin M, Wilson K, Tinmouth A, Hébert P; Does a perception of increased blood safety mean increased blood transfusion? An assessment of the risk compensation theory in Canada; BMC Public Health 2004, 4:20.

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SUMMARY

The aim of the workshop was for key stakeholders in blood transfusion services in sub-Saharan Africa to develop an agreed research agenda to fi ll gaps in the evidence needed to improve the supply and safety of blood for transfusion. The research agenda focuses primarily on obtaining high quality information about existing services and their effectiveness in order to be able to target areas where interventions will have maximum impact. Participants confi rmed that there is limited and uncoordinated research expertise within the transfusion services in sub-Saharan Africa and this defi cit will need to be addressed urgently as the research agenda is translated into action.

BACKGROUND

Improving the supply of safe blood is a key intervention in reducing mortality and morbidity in sub-Saharan Africa (SSA) especially in young children and pregnant women. The purpose of this workshop was to bring together transfusion service providers, users and researchers to define and prioritise research to fi ll gaps in the evidence supporting improvements in the safety, adequacy and equity of the supply of blood for transfusion in SSA, and to identify and disseminate examples of best practice. The three day workshop was funded by the Wellcome Trust and co-hosted by the Kenya Chapter of the Africa Society for Blood Transfusion (AfSBT), the Regional Blood Transfusion Centre in Mombasa and the Kenya Medical Research Institute (Kilifi ), with assistance from Oliver Hassall (OH; Kilifi , Kenya), Julie Makani (JM; Dar es Salaam, Tanzania) and Imelda Bates (IB; Liverpool, UK). The 36 participants were from 13 countries and included transfusion researchers, transfusion service directors and funders, and representatives of transfusion users including senior obstetricians, anaesthetists and paediatricians.

RESUME

Le but de l’atelier était, pour les principaux décideurs dans des services de transfusion sanguine en Afrique au Sub-Saharienne, de développer un programme acceptable de recherches pour combler les lacunes dans l’évidence requise d’améliorer l’approvisionnement en sang sécurisé pour la transfusion. Le programme de recherches se concentre principalement sur l’obtention des informations de haute qualité sur des services existants et leur effi cacité afi n de pouvoir viser des secteurs où les interventions auront un impact maximum. Les participants ont confi rmé qu’il y a une expertise limitée et non coordonnée de recherches dans les services de transfusion en Afrique sub-Saharienne et ce défi cit devra être redressée urgemment lorsque le programme de recherches est traduit en action.

CONTEXTE

L’amélioration de l’approvisionnement en sang sécurisé est une intervention principale réduisant la mortalité et la morbidité en Afrique Sub-Saharienne (ASS) particulièrement chez les enfants de bas âge et les femmes enceintes. Le but de cet atelier était de rassembler des fournisseurs, des utilisateurs et des chercheurs de services de transfusion pour défi nir et donner la priorité à la recherche pour combler les lacunes dans les améliorations de l’évidence de la sécurité du sang, de l’adéquation et des capitaux appropriés pour l’approvisionnement en sang pour la transfusion en ASS, et pour identifi er et diffuser des exemples de meilleures pratiques. L’atelier de trois jours a été financé Wellcome. Il était co-organisé par la section Kenyane de la société africaine de transfusion sanguine (AfSBT), le centre régional de transfusion sanguine de Mombasa et l’institut de recherche médicale du Kenya (Kilifi ), avec l’aide d’Oliver Hassall (Kilifi , Kenya), Julie Makani (Dar Es Salaam, Tanzanie) et Confi ts d’Imelda (ILiverpool, Royaume-Uni). Les 36 participants provenaient de 13 pays et étaient chercheurs en transfusion, des directeurs et bailleurs de fonds de services de transfusion, et représentants des utilisateurs de transfusion comprenant les obstétriciens, les anesthésistes et les pédiatres.

PROCEEDINGS OF BLOOD TRANSFUSION RESEARCH WORKSHOPMOMBASA, KENYA: 23-25 SEPTEMBER 2008

THEME: How can research contribute to improving safe blood supplies for emergency transfusions in sub-Saharan Africa?

WORKSHOP SUMMARY REPORT (taken from ORIGINAL REPORT: OLIVER HASSALL, IMELDA BATES, 26 Sept 2008)

ATELIER SUR LA RECHERCHE EN TRANSFUSION SANGUINEMOMBASA, KENYA: 23-25 SEPTEMBRE 2008

THÈME : Comment la recherche peut-elle contribuer à améliorer les approvisionnements de sang sûrs pour les transfusions d’urgence en Afrique Sub-Saharienne ?

RAPPORT SUCCINCT DE L’ATELIER (tiré DU RAPPORT ORIGINAL : OLIVER HASSALL, CONFITS D’IMELDA, 26 Septembre 2008)

T. MapakoWebmaster and Research Coordinator, AfSBTNational Blood Service, ZimbabweTel: +263-4-707801/4 Fax: +263-4-707820 Emails: [email protected]; [email protected]

10


WORKSHOP OUTLINE

The workshop addressed fi ve main research areas which covered all aspects of transfusion practice. All participants were invited to make a presentation and fi nal speakers were selected by the organisers to represent a range of topics, backgrounds and countries. A half-day session was devoted to each theme and each session consisted of four 10-minute thought-provoking presentations to highlight key areas of the theme. For the rest of the session participants were split into groups of six and they discussed around the topic to identify key evidence gaps and devise research questions to address these gaps. At the end of each session the groups’ deliberations were discussed by all participants and consensus reached about the priority topics and research emphases. The consensus results were presented back to all participants in the sixth (fi nal) session for refi ning and fi nal agreement. All participants contributed to discussions about mechanisms for implementing, funding and disseminating the agreed blood transfusion research agenda.

PROCEEDINGS AND OUTCOMES OF WORKSHOP

Research Priority AreasThe research priority areas identified to inform better transfusion practice in SSA are listed below and are then described in detail.

1. Reducing transfusion-transmitted infections2. Increasing recruitment and retention of safe donors3. Promoting appropriate use of blood transfusion4. Managing supply, stocks and equitable distribution5. Transfusion service models - cost, effectiveness and sustainability

REDUCING TRANSFUSION-TRANSMITTED INFECTIONSThe variable prevalence rates, infection risk and screening methods for HBV and to a lesser extent, HCV and syphilis, mean that it is diffi cult for hospitals and transfusion services to make rational decisions about the risks, benefits and costs of different strategies for screening blood based on evidence from outside Africa. The morbidity/mortality due to transfusion-transmitted malaria and the benefi ts and feasibility of screening for malaria are unknown. In SSA children are major users of blood. Because paediatric packs are expensive adult units are split into smaller aliquots with the risk of bacterial contamination. Evidence is needed to ensure transfusion services cater adequately for children as well as adults.

Research Questions / Topics1. Can a model be developed that enables variables such as prevalence, test cost etc to be inputted to provide information about cost effectiveness of screening/not screening for TTIs (e.g. HBV, HCV, syphilis). The model should incorporate the variable effectiveness different screening strategies (e.g. pre- or post-donation testing, NAT testing) with differing prevalence rates.2. What are the factors that contribute to the prevalence and epidemiology of TTIs. Simple IT systems are needed to enable rigorous inter-country comparative studies of TTIs using ‘look back’, and recipient tracing

3. Can a centralised service be established to advise on validated test kits for TTIs? What robust, practical systems can be used to ensure test quality particularly in hospital based systems? Does HIV infection interfere with grouping/cross-matching?4. Should malaria screening be carried out? Are there appropriate tools and what alternative strategies (e.g. treating recipients with anti-malarials) more appropriate/ cost-effective? Would giving ITNs to donors reduce transfusion-malaria risk?5. Is there clinically signifi cant bacterial contamination of blood packs? Is it restricted to packs split for paediatric use and how can contamination be reduced? How could the cost of paediatric bags be reduced?

INCREASING RECRUITMENT AND RETENTION OF SAFE DONORSAbout 80% of the blood in SSA comes from replacement donors. A large proportion of voluntary donors are secondary school children. There is very little published information about what motivates and deters blood donors/non-donors in SSA. Without this information, meaningful recruitment and retention strategies cannot be implemented and tested. There are no mechanisms to measure the impact and cost-effectiveness of locally appropriate donor strategies. Donor care (post-test counselling, referral and treatment) is an important transfusion service responsibility with implications for donor recruitment and retention and wider public health, but practice is not standardised or evidence-based.

Research Questions / Topics1. What evidence exists about donor motivation and retention in SSA? How can this be disseminated and used to develop appropriate and cost-effective education and marketing strategies? Does the private sector have a role in donor recruitment and/or screening? What incentives are acceptable? How can the safety and supply of replacement donations be improved? Are SMS and other technologies useful?2. What are existing practices for referring donors for management of TTIs and anaemia? Evidence is needed to inform an effective but practical donor care strategy. What is the impact of regular donation on haematinic balance in donors in SSA? Should donors be offered HBV vaccination and could donors who clear HBV and syphilis infections be re-recruited instead of deferred for life?3. What are the lessons and costs of different donor recruitment models, including databases, lookback systems, testing algorithms and donor counselling? Could donor screening be integrated with VCT/HIV services?

PROMOTING APPROPRIATE USE OF BLOOD TRANSFUSIONThere is signifi cant inappropriate use of blood and blood products in SSA coexisting with lack of supply. The problem is compounded by lack of knowledge about use of blood/component transfusions and poor/unknown quality of haemoglobin measurements which are critical to guide decisions to transfuse and for monitoring transfusion effectiveness. There is little evidence available to guide hospital management of children with uncomplicated severe anaemia (Hb 4-6g/dl) and the evidence underpinning

11


transfusion guidelines for adults and children is weak. There is almost no information about the prevalence and patterns of transfusion reactions in SSA and no system for detecting and reporting these reactions; patterns are likely to be different from those in other regions. There is mistrust between hospital staff and transfusion services which hampers effective use of blood. Blood transfusion committees may be one mechanism to bridge this gap in larger hospitals but they are diffi cult to establish and maintain.

Research Questions / Topics1. What is the evidence to guide emergency pre-transfusion management of adults and children with severe anaemia and for prescribing transfusions including those to stable children with Hb 4-6 g/dl. How can accurate, rapid haemoglobin measurements always be available to inform transfusion practice?2. How can clinicians ensure that guidelines for appropriate use of blood/products are adhered to at all health service tiers in SSA, and how can the impact of adherence by evaluated? What are the alternatives to transfusion in SSA (e.g. iron, autologous transfusion, anti-fi brinolytics) and how should they be used? In what circumstances would outpatient rather than inpatient transfusions be cost-effective?3. What are the patterns and prevalence of transfusion reactions in different settings in SSA including alloimmunisation in multiply-transfused patients, and incidence of detect delayed reactions and infections. How can severe reactions be effectively confirmed, communicated and lessons learnt and disseminated?4. What factors hinder good collaborations between hospital and transfusion service staff? Would a haemovigilance offi cer and/or blood transfusion committee peer review of blood utilisation practices facilitate better blood use?

MANAGING SUPPLY, STOCKS AND EQUITABLE DISTRIBUTIONIn contrast to wealthy countries, the majority of transfusions in SSA are emergencies. Most deaths from lack of blood occur in the community and/or primary health facilities so efforts should focus on improving blood supply in the periphery. The need for blood in SSA is unknown. Tools are needed to provide reliable estimates of units needed/capita so that adequacy of supply at all health services tiers can be assessed. Transfusion services have no mechanisms for predicting changes in trends in blood/component usage (e.g. due to impact of ACTs, ITNs and ARVs). There is inequitable distribution with those living close to a central BTS having better access but the degree of inequity needs to be quantifi ed and mapped. Inequity is exacerbated by poor distribution and management of existing blood stocks and lack of evidence to guide discard policies (e.g. 30 minute ‘out of fridge’ rule). There is no system in the region for utilising excess plasma produced by centres which prepare blood components.

Research Questions / Topics1. How much blood do the countries of SSA need? What tools and what models can be developed to estimate this need, to document unmet need and to prioritise facilities with the greatest gap in supply? What factors contribute to unmet need, what is the impact of unmet need on morbidity and mortality and how can this be measured, addressed and monitored?

2. How much does mismanagement of stocks within facilities contribute to inadequate supply (e.g. ordering, stock management, inappropriate transfusions)? What is the evidence to guide discard policies in SSA including the effect of using domestic refrigerators for storage and the ‘30 minute rule’? Could Maximum Blood Ordering Schedules work in SSA? How can changing trends in transfusion needs for HIV and malaria patients be predicted and catered for in different transfusion systems?3. What is the distribution policy in centralised systems? What is the degree of inequity in access to blood supply in all systems? What factors contribute to this inequity and what mechanisms can be used to improve existing hospital-based systems? What is the true cost of blood to families in different countries/systems (including hidden costs such as donor recruitment)? How do hospitals make rational choices about transfusion recipients when supplies are inadequate? What interventions can improve equitable access to blood?4. What are the options in SSA for contract fractionation that would be ethical and acceptable to donors and what evidence-based recommendations can be made?

TRANSFUSION SERVICE MODELS - COST, EFFECTIVENESS AND SUSTAINABILITYThe hospital-based system provides 80% of blood in SSA. It is sustainable and based predominantly on replacement donors but it cannot meet all demand and it is diffi cult to ensure quality. Centralised systems are more controllable, predictable and produce safer blood from voluntary donors but there is no evidence that they reliably reach the most peripheral communities. Hybrids of these two models exist in several countries. Rigorous evidence is lacking regarding the effectiveness and sustainability of different transfusion systems in SSA (ie. centralised/zonal, hospital-based, hybrids) and there is virtually no public information about the economics of these systems including the proportion spent on donor recruitment and care. There is a lack of skilled and knowledgeable staff in all disciplines within the transfusion service and diffi culty in attracting and retaining high calibre staff.

Research Questions / Topics1. What structures within each type of system are effective/ ineffective in meeting supply and safety needs, and impacting on clinical outcomes in SSA, and what are the reasons for success/failure? What indicators can be used to compare equitability, effectiveness and sustainability of different systems?2. What is the full economic cost of ‘donor vein’ to ‘recipient vein’ blood, and associated pre-and post-vein activities, from different perspectives (e.g. health provider, recipients) in different systems? What is the cost-effectiveness of different models of transfusion services taking account of societal costs, willingness to pay, level of automation, morbidity and mortality (e.g. at 2 years). What are the DALYS for various conditions (especially those relating to maternal and child health), and how do they vary with context in SSA? Can this information be used to derive societal costs of the lack of blood? 3. How will cost-effectiveness of each type of system change if, for example, the appropriateness of blood usage improves, workload increases or local quality reagents are available? What is the gap between government funding and the full cost of producing a safe unit of blood

12


in different systems and are there models for how this gap can be fi lled (e.g. cost-recovery)? Can comparative inter-country case studies of models that are successful/ unsuccessful be synthesized, particularly from countries that no longer have donor funding?4. What attracts, motivates and retains professional transfusion staff? What career development structures are needed? What human resource skills are needed in the different systems? What educational methods should be used and how can they be evaluated?

DISSEMINATION STRATEGY

In order to promote the implementation of the proposed research priority areas there was consensus to formulate a dissemination strategy. The identified strategies are detailed below, relating to target audience, activities and responsibilities. World Health Organization (WHO) Summary of report sent to WHO-AFRO and WHO-HQ: Dr. I. Bates / Dr. O. Hassall

Africa Society for Blood Transfusion (AfSBT) Circulate report: Website, e-mails, Africa Sanguine journal Prepare abstract for AfSBT meeting: June 2009 (Nairobi): David Mvere

International Society of Blood Transfusion (ISBT) Report in the Transfusion Today journal Prepare Abstract for ISBT meeting: March 2009 (Cairo): Prof. Marcela Contreras

Centre for Diseases Control (CDC) Disseminate report fi ndings: Dr. Jane Mwangi

AABB Disseminate report fi ndings: Dr. Jane Mwangi

Ministry of Health (MoH) / Policy Makers Disseminate report fi ndings Prepare for African Summit on Universal Access to Blood in October 2009: (Use research evidence as advocacy tool): All participants

Associations Disseminate report fi ndings to other Associations such as Association of Pathologists (Oct 2008 meeting): All participants

USA Presidential Emergency Plan For HIV/AIDS Relief (PEPFAR) Disseminate report fi ndings: Dr. Lawrence Marum

Global Collaboration for Blood Safety (GCBS) Disseminate report fi ndings at GCBS meeting: Geneva, Nov 2008: GCBS member participants

Wellcome Trust Disseminate report fi ndings: Dr. I. Bates / Dr. O. Hassall

Other Disseminate report findings to all workshop invitees including those who could not attend and participants’ respective institutes: All participants

ENHANCING BTS RESEARCH CAPACITY

The major challenge to implementing the research agenda is that there is limited research capacity within the transfusion services in SSA. The implementation strategy therefore focuses on different approaches to building up capacity for research and rigorous monitoring and evaluation of transfusion services. Suggested approaches to build research capacity included the following, according to strategy, action/key issues and responsibilities: Create a research Network Platform Establishing a network to exchange ideas about research Put this as an Agenda for AfSBT council meeting Mr. David Mvere

Local Research Collaboration Establish link with local academic institutions for research mentoring and for BTS to host student projects: All participants

PEPFAR Technical Assistance links To be used as research resource persons: All participants

Appointment of dedicated Research and Data Offi cer Dedicated Research and Data Offi cer could be appointed (e.g. Zimbabwe model) to manage data, policies and protocols: All participants

Promote and facilitate research BTS leaders need to promote and facilitate research and evidence-based practice: All participants

International collaborative research work Generic proposals for research need to be developed by academics and then implemented in different countries by BTS staff Dr. I. Bates / Dr. O. Hassall

Support for abstract Writing Assist BTS staff to write and submit abstracts for the AfSBT meeting and the Africa summit on blood transfusion in 2009 (PEPFAR to support?): All participants

Capacity building for research Research should be implemented as part of a research skills development course for BTS staff modelled on Pan African Thoracic Society research network initiative (to discuss fi nding with Wellcome): Dr. I. Bates / Dr. O. Hassall

13


FUNDING STRATEGIES

It was noted that for research work to be undertaken there is need for funding opportunities to be identifi ed. Whilst there may be several potential funders the workshop noted that the PEPFAR grant currently allows monitoring and evaluation fi nancial support in countries under PEPFAR. The Wellcome Trust will be approached to facilitate support for research activities and research capacity building. A summary of possible funding agencies follows, together with action/key issues and responsibilities.

PEPFARMonitoring and evaluation aspects: PEPFAR already has networks with BTS across several SSA countries and data that will allow inter-country comparisons. They are able to fund monitoring and evaluation activities but not research and will build the aspects form the research agenda that fi t into the M&E category into this strategy and budgets: Dr. Lawrence Marum

Wellcome TrustPrimary research and research capacity building: Aspects of the research agenda that are primary research, and therefore not eligible for funding by PEPFAR, will be synthesized and submitted to the Wellcome Trust as well as a proposal for a formal research capacity building programme for transfusion services in SSA: Dr. I. Bates / Dr. O. Hassall

VIEWS FROM AfSBT COUNCIL

The AfSBT welcomes the deliberations from this workshop and has embraced the workshop recommendation that it spearheads the implementation of the report. The society has since approved this role and has identifi ed a Webmaster and Research Coordinator (Mr. Tonderai Mapako, Zimbabwe) to facilitate on this important task. Currently the Society is making arrangement that the report be posted on the Society website and shall in the near future making a follow-up on the implementation of the report by various institutions. It is the Society sincere hope that all members will cooperate with the Society to make this objective a reality. The society welcomes your ideas through the Webmaster and Research Coordinator on issues arising from this article.

Views from AfSBT Webmaster and Research Coordinator (T. Mapako) It is with great pleasure to be given the honour to facilitate these great responsibilities for the society. I shall use this report as a basis for all future work so please take time to read and understand issues that have been raised in this report. The full report and this summary article shall be posted on the website for all members to read and act! Your contributions shall be solicited in future and reports on your organisation status quo as far as issues raised in this report are concerned will be greatly appreciated and published for all members’ benefi ts. To facilitate networking, contact details of participants to the BTS workshop are available from the author of this article.

CONCLUSION

The AfSBT is hopeful that all responsible persons will follow-up on the areas of their responsibilities. The value of scientifi c research cannot be under-estimated for BTSs and this is a great opportunity to strengthen their contributions to research.

14


COUNTRY FEATURES

SUMMARY

As there were no reliable data for the prevalence of red cell alloantibodies or antigens in the population of Malawi, a study was conducted to screen 1 000 patients for the presence of antibodies and to type them for ABO, RhD, C, c, E, e and K antigens. Five hundred donors were also tested for these antigens plus Fya, Fyb, Jka, Jkb, S, s.

Red cell antibodies were identifi ed in 11 patients [1.1%]; 2 were anti-D, 2 anti-S, 1 anti-Lea+b and 6 anti-M, 4 of which were found in non-transfused males suggesting they might be naturally acquired.

The antigen frequencies found were similar to those in literature but with 97.2% of donors being Fy(a-b-). All patients tested were K negative and only 3 donors were found to be K positive, one being Caucasian. Approximately 3.5% of Malawians are RhD negative, lower than the usual 8% quoted for Black Africans. The incidence of the R1 gene is also lower than reported fi gures.

The frequencies found show a high level of red cell antigen homogeneity among Malawians except for the S, RhE and RhC antigens.

These data confi rm the assumption made that pre-transfusion and antenatal antibody screening is not necessary. As haemolytic disease of the newborn (HDN) is rare in Malawi, more work is needed to find the real incidence of this condition.

RÉSUMÉ

Du fait q’il n’y avait aucune donnée fi able pour la prévalence des antigènes et des allo anticorps des globules rouges dans la population du Malawi, une étude a été entreprise pour examiner 1000 patients pour rechercher des anticorps et pour décrire les antigènes ABO, RhD, C, c, E, e et K correspondants. Cinq cents donneurs ont été également examinés pour ces antigènes plus Fya, Fyb, Jka, Jkb, S, s.

Des anticorps anti-érythrocytaires ont été identifi és chez 11 patients [1.1%] ; 2 étaient anti-D, 2 anti-S, 1 anti-Lea+b et 6 l’anti-M dont 4 ont été trouvés chez des mâles non transfusés suggérant qu’ils pourraient être naturellement acquis.

Les fréquences d’antigène trouvées étaient semblables à ceux de la littérature mais avec 97.2% de donneurs Fy(a-b -). Tous les patients examinés étaient K négatif et seulement 3 donneurs se sont avérés K positifs, un étant caucasien. Approximativement 3.5% de Malawites sont RhD négatifs, inférieur au 8% habituellement retrouvés chez les Africains noirs. L’incidence du gène R1 est également inférieure aux données rapportées.

Les fréquences trouvées montrent un niveau élevé d’homogénéité d’antigènes des globules rouges ‘antigènes parmi les Malawites excepté les antigènes S, de RhE et RhC.

Ces données confi rment que la recherche pré transfusionnelle et pré natale d’anticorps ne sont pas nécessaires. Aussi, la maladie hémolytique du nouveau-né (HDN) est rare au Malawi, une étude plus approfondie est nécessaire pour obtenir la vraie incidence de cette condition.

THE PREVALENCE OF RED CELL ANTIGENS AND ANTIBODIES IN THE MALAWI POPULATION

PRÉVALENCE DES ANTIGÈNES ET DES ANTICORPS DES GLOBULES ROUGES DANS LA POPULATION

DU MALAWI

M’baya B*, Mfune T*, Mogombo E*, Mphalalo A*,Ndhlovu D*, Knight R C***Malawi Blood Transfusion Service, PO Box 2681, Blantyre, Malawi**National Blood Service, Colindale Avenue, London, England

15


BACKGROUND

The prevalence of red cell alloantibodies varies greatly from population to population and is dependent on many factors such as the blood group heterogeneity of the population, the presence of different ethnic groups with different blood group frequencies and the number of patients needing multiple transfusions.

Except for ABO and RhD, there are no recent data on the frequency of other red cell antigens in the Malawi population. Current developments in the health sector in the country mean that the absence of this data can no longer be ignored. Until 2004, when the Malawi Blood Transfusion Service (MBTS) was established, all the blood used for transfusion in the country was from family replacement blood donors with severe blood shortages at most times of the year. Since its establishment, the MBTS has made blood from voluntary non-remunerated blood donors more readily available.

The majority of transfusions in Malawi are for children who become anaemic as a result of malaria. As most of them are being saved, some will require further transfusions in their lifetime. Due to the improved availability of blood, patients requiring multiple transfusions are receiving them and living longer. Furthermore, there are advanced plans to establish a cancer centre in the country that will increase the number of patients requiring multiple blood transfusions as part of their care. These trends mean that red cell antibody formation may become a problem depending on the red cell heterogeneity of the Malawi population.

Pre-transfusion testing in most hospital blood banks is still limited to a saline major crossmatch and not the recommended indirect antiglobulin testing (IAT). Clinically signifi cant IgG antibodies will not be detected using only the saline crossmatch method.

Therefore, it was thought necessary to establish the baseline prevalence of red cell alloantibodies and the frequency of the major blood group antigens in patients in hospitals in Malawi and among blood donors. This would enable the MBTS to plan its strategy for blood collection and testing, as well as for giving expert support to Hospital Blood Banks. This was well demonstrated by Lin-Chu et al in Taiwan1 where, having done such studies, they decided on a simple, cost effective compatibility testing strategy rather than following established North American or European standards.

METHODS

To establish the prevalence of red cell alloantibodies, 1 000 adult patients, including antenatal women, were enrolled from hospitals across the country. They were tested for the presence of alloantibodies using DiaMed gel technology. Those samples found to be screen positive were further tested to establish the specifi city of the antibodies involved.

To establish the frequency of the Rh and K antigens in Malawians the same 1 000 patient samples used to test for antibodies were typed for the Rh C, c, E, e, and K antigens in addition to ABO and RhD.

In addition 500 donors attending MBTS sessions from different parts of Malawi were tested to establish the frequency of ABO, RhD, C, c, E, e, K, Fya, Fyb, S, s, Jka, and Jkb antigens.

The study was approved by the National Health Sciences Research Council of Malawi. Only patients who gave informed consent were enrolled into the study.

Each patient sample was identifi ed by, as a minimum, name, age, gender and date of collection. Each sample was then given a laboratory ID number; the data stored electronically was ID number, age and gender and, where applicable, previous transfusion and pregnancy data. All patient and donor data remains confi dential.

Although any fi ndings in this study would not have any direct health consequences for the patient, it was agreed that patients who wished to know their test results be informed and that those who had alloantibodies be given an ‘antibody card’.

No additional consent was required from donors as they had already consented to their blood being tested for blood groups.

The testing was performed using DiaMed gel-card technology in accordance with the manufacturer’s protocols. Reagent red cells for antibody screening [2-cell screen] and a 10-cell antibody identifi cation panel, suitable for use in the DiaMed system were supplied by the National Blood Service, UK. Each batch of tests was validated using standard positive and negative controls. Where possible, samples were tested within 7 days of collection.

DiaMed gel-card technology is simple to use and although more expensive than the reagents required for tube techniques, it proved well suited to the type of testing needed for this project.

The laboratory work and data handling were performed by two senior technicians from the MBTS Blantyre laboratories having been trained to use the DiaMed technology.

RESULTS

1 000 patients were enrolled in the study and 500 blood donor specimens were analysed. The general characteristics of the patients in the study are given in table 1.

Table 1: General Characteristics of Patients in the Study

All the test data were considered acceptable except for one batch of 12 samples for anti-S, -s and anti-Jka, -Jkb testing where, at the beginning of the project some technical diffi culties were encountered.

Previous Transfusions

1000

Range 15-81

Mean

30±10.7

M

292

F

708

Range

0-16

Mean

3±2.3

M:F ratio

1:2.4

No.

101

Range

1-16

Mean no. of transfusions

1.8±1.0

Parity (female patients)

SexAgeNo. ofSubjects

16


The results obtained from 500 donors tested for ABO, RhD, C, c, E, e; K, Fya, Fyb, Jka, Jkb, S and s antigens are given in tables 2 and 3.

The results obtained from testing 1 000 patients for ABO, RhD, C, c, E, e and K antigens are given in table 3.

The tables show the frequency of the various antigens in the donor and patient populations of Malawi. For easy comparison, the last two columns of tables 2 and 3 show the frequencies of these antigens as reported in literature.

Table 2: ABO and RhD antigen frequencies (%)

Blood Patients US US Donors (%) (%) Blacks (%)* Caucasian (%)*

A 20.8 28.5 27 40

AB 4.0 4.1 4 4

B 20.2 18.5 20 11

O 54.6 48.9 49 45

RhD positive 95.2 97.4 92.5 85

*US Black & Caucasian fi gures from Reid ME & Lomas-Francis C2

Table 3: Antigen frequencies of donors and patients (%)

Antigen Donors (%) Patients (%) US Blacks (%)* US Caucasian (%)*D 95.2 97.4 92 85

C 13.4 15.0 27 68

c 99.2 99.8 96 80

E 14.0 17.4 22 29

e 99.6 99.0 98 98

K 0.6 0 2 9

Fya 2.4 Not tested 10 66

Fyb 1.0 23 83

Fy(a+b-) 0.8 9 17

Fy(a+b+) 0.4 1 49

Fy(a-b+) 0.6 22 34

Fy(a-b-) 97.2 68 0

Jka 93.4 Not tested 92 77

Jkb 40.5 49 74

S 36.6 Not tested 30.5 55

s 90.0 94 89

S-s- 0.8 1 0

* US Black & Caucasian fi gures from Reid ME & Lomas-Francis C2

Table 4 gives the probable Rh genotype based on the test results.

Table 4: Probable Rh genotypes

Rh type Donors Patients US Blacks* US Caucasian*Ro 70.8 66.3 42.2 3.2

R1r / R1Ro 10.2 12.8 25.6 34.7

R2r / R2Ro 12.4 15.8 15.4 11.5

R1 R2 1.0 0.9 13.2 4.2

R1 R1 0.6 0.2 3.6 19.3

R2R2 0.4 1.0 1.2 0.3

rr 3.2 1.7 6.8 13.7

rlr 1.2 0.6 0.5 0.7

Rllr 0.2 - 0.1 0.3

* fi gures from Mourant et al3. The distribution of the human blood groups.

Of the 1 000 patient samples screened for antibodies, 13 [1.3%] were found to be positive. Antibody specifi city was determined in 11 samples. There were two examples of anti-D, one only weakly reactive; six examples of anti-M, two anti-S, and one anti-Lea+b. In the other two samples no specifi city was determined. Details are given in table 5.

Table 5: Patients with alloantibodies

Antibody Gender Age Transfusions Parity1 Anti-D [weak] F 20 0 2

2 Anti-D F 44 0 4

3 Anti-S F 32 1 2

4 Anti-S F 42 0 6

5 Anti-M M 28 0 N/A

6 Anti-M M 22 0 N/A

7 Anti-M M 25 0 N/A

8 Anti-M M 39 0 N/A

9 Anti-M F 32 0 3

10 Anti-M F 43 0 5

11 Anti-Lea+b F 21 0 2

17


DISCUSSION

AntibodiesThe patient population is young (mean age 30) and this refl ects the young Malawi population as the life expectancy is only 36 years. The frequency of alloantibodies in this study is low, 1.1%. Considering that 10% of the patients in the study had been previously transfused and many had multiple pregnancies (refer to table 1), the alloimmunisation rate seems low. This is probably due to the red cell homogeneity of the population. In countries with a more diverse ethnically mixed population, alloimmunisation rates are higher.

The predominant antibody found was anti-M [six examples]; however the DiaMed technology used does have a propensity for detecting anti-M. Antibodies of this specifi city often are a mixture of IgM and IgG antibodies and many do not react in standard IAT tube methods and are therefore considered to be clinically non-signifi cant [Redman & Malde]4. Four of these antibodies were found in un-transfused males aged 22 to 39 years and therefore might be naturally acquired. Two examples were found in females neither of whom had been transfused but both had been pregnant. As DiaMed gels are not used in hospitals in Malawi for compatibility testing it is unlikely that anti-M will cause any signifi cant problems. Because of the benign nature of anti-M and anti-N antibodies, typing for these two antigens was not included in the initial study although it is now planned to test a small cohort of donors for M and N antigens.

With the incidence of RhD negative individuals being so low, approximately 3.5%, it is perhaps not too surprising that anti-D was only found in two patients, one example of which was only weakly reactive. Both patients were female, one had had 2 pregnancies the other 4 pregnancies but neither had been transfused. Anecdotal evidence is that HDN is very rare or not recognised as there are many other causes of neonatal anaemia and jaundice.

The other clinically signifi cant antibody found was anti-S, two examples. The S antigen is found in 36.6%. As such, the chances that someone who is S negative may be exposed to the S antigen as a result of pregnancy or transfusion are quite high. In Malawi, pre-transfusion antibody screening is not performed, and indeed not all hospital laboratories yet use an IAT in their crossmatch let alone being able to identify antibody specifi city. However, if a serological incompatibility was caused by anti-S, finding a suitable compatible unit would not be too diffi cult by crossmatching more units of blood by an IAT.

One example of anti-Lea+b was identifi ed in a 21 year old female in a surgical ward; she had not been transfused but had had two pregnancies. The frequency of Lewis antigens was not determined in this study as the antibodies are considered to be mostly not clinically signifi cant but reported frequencies for Le(a-b-) individuals in the US Black population is 23%.

AntigensThere is some variation between the data for donors and patients but the donors are a self selected group and will include some non-Black Africans whereas the patient cohort was all local Malawians. Samples from both cohorts were taken across the country to reduce any regional bias and data analysed from each of the three regions showed little difference.

Blood group antigen frequencies quoted for Africans are often based on data from Afro-Caribbean populations in the USA that do not refl ect the regional differences found throughout the continent of Africa. Other data are now quite old and often done on small groups or tribes mainly for anthropological studies.

The incidence of Ro [RoRo] at approximately 66% is higher

than the 42.2% reported for US Blacks and the 41.8% found among the UK Black population. The R1 gene is less common than generally reported but the R2 gene appears to be similar to that normally quoted for black populations.

All the 1 000 patients tested were K negative and only three of the donors were positive; one was Caucasian while the other two Black African. The family history of these two individuals is unknown but there could have been some Caucasian blood in their lineage or from one of the Black African groups in which a higher incidence of K+ has been reported; 10.3% in a small sample of 106 Bantus and 5.2% among 201 Hottentots were K+ [quoted by Mourant et al]3. The 100% K negative fi gure for patients is in agreement with a report from Ghana [Narter-Olaga]6 in which 1 000 donors tested were all K negative.

Because the incidence of the K antigen is so very low the likelihood of anti-K being found in the general hospital population in Malawi is very small whereas in the UK, anti-K is the commonest antibody found after anti-E. [Redman et al]5

The incidence of Fy(a-b-) at 97.6% is higher than the 68% usually quoted for Black Africans and the 66.4% found in the black population in London, but similar to earlier reported frequencies in Tanzania and Zambia quoted by Mourant et al.3

The Duffy antigen on red cells acts as the receptor for Plasmodium vivax so the absence of the Duffy carrier protein in Fy(a-b-) make these cells resistant to invasion by this parasite. Data from the local Malaria Research Project shows that P. vivax is very rarely found in Malawi whereas P. falciparium is one of the major causes of fatality in children. In 3 000 cases of malaria studied during January to July 2008 in Malawi, only one case caused by P. vivax was found [Heyderman personal communication]7.

The incidence of S and s antigens and for the phenotype S-s- [0.8%] is not too dissimilar to other published data for Black Africans. Most individuals who are S-s- are also negative for the U antigen but the frequency of U- is variable within Black African populations varying from 0.17% to 1.4%, averaging at about 1%.

The Jk types are consistent with other data on Black African populations.

18


CONCLUSION

The frequency of blood group antibodies and antigens found in this study will help with future planning of the blood transfusion services in Malawi.

This study confirms the assertion that the prevalence of alloantibodies in the current population of Malawi is low. As such, there should not be many problems in finding compatible blood.

Apart from the S, RhE and RhC, there is a high level of homogeneity in the red cell antigen distribution among the rest of the antigens tested for in this study. Considering the low antigenicity of the three red cell antigens where there is a high degree of heterogeneity, it is anticipated that red cell alloimmunisation will not be a major problem for Malawi, in the near future. At the same time, it also means that should a patient develop antibodies against antigens found in the majority of the population [eg anti-U], it will be diffi cult to fi nd a suitable blood donor for such patients.

At present, because of this low incidence of significant antibodies in patients, any further typing of donors for antigens other than ABO and RhD is not necessary.

These data also suggest that pre-transfusion antibody screening is not required but red cells for transfusion should be crossmatched by IAT. If an incompatibility is found then the pragmatic approach of crossmatching further units to fi nd suffi cient compatible blood is acceptable. Samples can subsequently be referred to the central MBTS laboratory for antibody identifi cation but transfusion should not be withheld awaiting these results.

The low RhD negative rate, (about 3.5%) mean that it is diffi cult to have suffi cient amounts of RhD negative blood for all RhD negative patients. It also means that most RhD negative women will have RhD positive partners and HDN may be a big problem for these women. Anti-D immunoglobulins are not available in hospitals in Malawi. There is need for further research on RhD and HDN in the country.

To help improve transfusion practice in Malawi there is an active training programme, led by MBTS, to assist hospital blood banks in good transfusion laboratory practice that will underpin this approach to providing safe and compatible blood. This training is supported by a grant from Centres for Disease Control and Prevention (CDC) of the USA through its Malawi Offi ce.

ACKNOWLEDGEMENTS

Thanks to Mr Alan Lawson, DiaMed-GB Ltd. for kindly supplying the reagents used for this project. Thanks also to all hospital nurses and laboratory technicians who worked as research assistants in this study.

REFERENCES

1. Lin-Chu M, Broadberry RE, Chang FJ. The distribution of blood group antigens and alloantibodies among Chinese in Taiwan. Transfusion 1988; 28: 350-3522. Reid ME, Lomas-Francis C. The blood group antigen Facts Book. 2nd Edition, 2004; Elsevier Ltd3. Mourant AE, Kopec AC, Domaniewska-Sobczak K. The distribution of the human blood groups and other polymorphisms. 1976, Oxford University Press 4. Redman M, Malde R. Personal communication5. Redman R, Regan F, Contreras C. A prospective study of the incidence of red cell allo-immunisation following transfusion. Vox Sang 1996; 71: 216-220 6. Narter-Olaga E. Personal communication 7. Heyderman R personal communication

19


INTRODUCTION

The Western Province Blood Transfusion Service (WPBTS) collects approximately 130 000 whole blood donations per annum in the greater Western Cape Region of South Africa.

Of these approximately 600 are donated by therapeutic donors i.e. those who are required to be venesectioned to treat iron overload or erythrocytosis / polycythaemia and the numbers are increasing annually.

BACKGROUND

South Africa has a high prevalence of hereditary haemochromatosis with up to 1 in 6 Caucasians being carriers and up to 1 in 115 having the potential to be affected. Additionally the number of donors affected by primary or secondary polycythaemia has created the need for therapeutic phlebotomy services.

Increasingly the public have turned to the transfusion service for these services which has resulted in the development of a dedicated therapeutic phlebotomy clinic managed by a WPBTS medical offi cer and run by trained professional nurses.

Until 1999 all therapeutic units were discarded as they were not considered entirely voluntary donations and were perceived as possibly having a different risk profi le in terms of transfusion transmissible infections. The disposition of the blood is now evaluated individually by the medical offi cer based on the donor’s diagnosis and donor acceptance criteria of WPBTS.

INTRODUCTION

Le service de transfusion sanguine de la province ouest (WPBTS) collecte approximativement 130 000 dons de sang total par an dans la région occidentale la plus grande du Cap en l’Afrique du Sud.

De ces dons, approximativement 600 sont donnés par les donneurs thérapeutiques par exemple ceux qui sont requis pour la saignée pour traiter la surcharge en fer ou l’érythrocytose (polycythémie) et leurs nombres augmentent annuellement.

CONTEXTE

L’Afrique du Sud a une forte prévalence d’hémochromatose héréditaire avec jusqu’à 1chez 6 Caucasiens porteurs et plus de 1chez 115 affectés potentiels. En plus le nombre de donneurs affectés par polycythémie primaire ou secondaire a créé le besoin de services de phlébotomie thérapeutique. De plus en plus le public se tourne vers le service de transfusion pour ces services ce qui a eu comme conséquence le développement d’une clinique de phlébotomie thérapeutique dirigé par un médecin et fonctionnant avec des infi rmières professionnelles qualifi ées.

Jusque à 1999 toutes les unités thérapeutiques ont été jetées car elles n’ont pas été considérées comme des dons entièrement volontaires et ont été perçues comme ayant probablement un profi l différent de risque en termes d’infections transmissible par transfusion. Le devenir du sang est maintenant évalué individuellement par le médecin sur la base du diagnostic du donneur et des critères d’acceptation du don du WPBTS.

THERAPEUTIC PHLEBOTOMY EXPERIENCE IN SOUTH AFRICA BY WESTERN PROVINCE BLOOD TRANSFUSION SERVICE

Reprinted with permission (Poster presentation ISBT congress, Macao, June 2008)

EXPÉRIENCE DE PHLEBOTOMIE THÉRAPEUTIQUE en AFRIQUE DU SUD PAR LE SERVICE DE TRANSFUSION SANGUINE DE LA

PROVINCE DE L’OUESTRéimprimé avec permission (Présentation Poster congrès ISBT, Macao, juin 2008)

Rees J, Bellairs G Western Province Blood Transfusion Service, South Africa

20


STRATEGY OF THERAPEUTIC PHLEBOTOMY CLINIC

WPBTS has adopted a multi-level strategy with emphasis on communication and teamwork between participants in order to ensure both the safety of the blood supply and the effective treatment of donors. Therapeutic donors are referred by their own physician after undergoing full medical evaluation and blood tests to support their diagnosis. Medical management and setting of bleeding intervals is the responsibility of the donor’s physician. Donors are individually interviewed by clinic staff prior to donating and complete WPBTS’s confi dential health questionnaire and therapeutic phlebotomy consent form to ensure they meet regular donor acceptance criteria. Particular attention is focused on risk factors that could impact on the safety of the blood supply. Phlebotomy is performed by clinic staff and a full blood count is taken. Each donor is given a unique computer code to indicate the disposition of their blood. Results of full blood counts and / or iron studies are reviewed by WPBTS Medical offi cer after each donation and forwarded to the donor’s physician to help guide treatment decisions. Donors are educated to help them understand their diagnosis and are actively encouraged to have regular medical monitoring so that their bleeding intervals are set appropriately. Information particularly on haemochromatosis is shared to help raise awareness in affected families sometimes resulting in earlier detection and treatment of previously undiagnosed family members.

AIDS TO A SMOOTH ENROLMENT

In 2007 WPBTS designed and distributed a therapeutic phlebotomy pamphlet to enhance communication between clinicians, donors and WPBTS. It has proved to be highly effective in facilitating the smooth enrolment of eligible donors.This pamphlet summarises:· The role and responsibilities of all participants. · Includes relevant educational material. · Has tear-off doctor referral and donor consent forms.

GENERAL OVERVIEW OF DONORS

People of all ages and population groups are bled on the therapeutic panel.Donors referred to WPBTS with haemochromatosis are predominantly Caucasian males diagnosed in the 40 to 60 year old age groups when their iron overload becomes symptomatic.

Figure 1: Gender of Donors with Haemochromatosis 1997 - 2007 (WPBTS)

GROWTH OF THERAPEUTIC PHLEBOTOMY CLINIC

From embryonic beginnings in the late 1990s the number of donors has grown steadily. The clinic has correspondingly increased its facilities at Headquarters and in addition donors are now being bled at the Regional Offi ces.

CONCLUSION

Teamwork and a good relationship between donors, physicians and clinic staff has led to a mutually beneficial program for all parties.Donors normalise their blood counts and iron stores, physicians are assisted in treating their patients and WPBTS obtains safe blood on a regular basis from well informed and medically monitored donors.

Figure 2: Therapeutic Donors 1997 - 2007 (WPBTS)

Figure 3: Units Donated by Haemochromatosis Donors 1997 - 2007 (WPBTS)

Figure 4: Units Donated by Secondary PolycythaemiaDonors 1997 - 2007 (WPBTS)

21


QUALITY IN BLOOD TRANSFUSION

BACKGROUND

Accreditation of blood transfusion services in South Africa has been performed by the national accreditation body, SANAS, for the past seven years. To achieve accreditation, each service maintains a Quality Management System which includes an internal audit programme.

The internal audit programme at WPBTS was operating successfully but the writing of reports, together with the generating of corrective action forms, was often taking more time than performing the audits. Something needed to be done to streamline the audit system and reduce the paperwork. Our aim was also to introduce a fresh new look to the audit checklists and to rekindle staff interest in the programme.

CONTEXTE

L’accréditation des services de transfusion sanguine en Afrique du Sud a été effectuée par le l’organisme national d’accréditation, SANAS, pendant les sept dernières années. Pour réaliser l’accréditation, chaque service maintient un système de gestion de qualité qui inclut un programme d’audit interne.

Le programme d’audit interne à la WPBTS fonctionnait avec succès mais la rédaction des rapports, ainsi que la prise des actions correctives, prenait souvent plus de temps que l’exécution des audits. Quelque chose a dû être faite pour améliorer le système d’audit et pour réduire les la rédaction des rapports. Notre but était également présenter un nouveau regard sur le questionnaire d’audit et de renforcer l’intérêt du personnel pour le programme.

ACCREDITATION MODEL

The South African model for assessment of blood transfusion services consists of three parts all of which have been included in the internal audit system:

The Quality Management System section incorporates the principles of ISO 9000 and includes the following parameters: Organisation Resources Quality system Document control Records Computer system Internal audits

Process control External supplies and services Non-conformances Corrective and preventive action Resolution of complaints Customer services Premises and equipment Health and safety.

The Technical section incorporates specifi cations from the South African Standards of Practice for Blood Transfusion (with reference to the European, American, Canadian and Australian guides) and includes the following: Blood donor criteria Apheresis donor criteria Blood collection Processing of blood components Testing and disposition of blood components Blood product specifi cations Compatibility testing and transfusion Autologous and designated donation procedures.

A FRESH APPROACH TO QUALITY AUDIT SYSTEMSReprinted with permission (Poster presentation ISBT congress, Macao, June 2008)

UNE FRAICHE APPROCHE AUX SYSTÈMES D’AUDIT QUALITÉRéimprimé avec la permission (Présentation de poster, congrès ISBT, Macao, juin 2008)

Lesley Bust, Quality Assurance ManagerWestern Province Blood Transfusion Service (WPBTS)Cape Town, South Africa

22


The Laboratory section incorporates parameters from both ISO 17025 and ISO 15189 such as: Sample requisition and collection Storage and handling of samples Test procedures Quality control and quality assurance procedures Reporting of results Equipment Quality control on equipment Reagents, controls and standards.

AUDIT TECHNIQUES

At WPBTS the techniques used for internal auditing combine three activities. The fi rst is direct questioning where auditors ask staff questions from the checklist and check their responses together with related documents and forms. The second technique is witnessing which involves observing staff members carrying out specific tasks to determine whether they are following procedures and can be deemed competent.

The third auditing technique is the performance of a vertical assessment which begins by selecting a specifi c outcome which can be either a donation, a test result or a blood product, and checking all parameters relating to that outcome. This includes checking the equipment used plus the validation, calibration and maintenance thereof. It also includes checking the methods used and the selection, validation and verifi cation thereof. The documentation used, both procedures and

worksheets, will also be checked as will personnel records such as organograms, job descriptions, training records and competency assessments.

Previously, witnessing and vertical assessments were recorded on separate forms but now these have been incorporated into the audit checklists.

AUDIT CHECKLISTS

Rather than having one long audit checklist, customized checklists were drawn up for the fi ve different operations within blood transfusion viz. Clinics, Processing, Testing, Blood Banking and Quality Management System administration. The relevant ISO elements for that department or area, plus the required technical specifi cations, were included omitting those parts that do not apply.

The checklists have been designed with demarcated blocks for recording specifi c data in an abbreviated format rather than expecting auditors to write sentences verifying what they observed. As a result, audit reports are now produced in a shorter time. The new checklists have achieved our aim of being more user-friendly and can easily be adapted for use in other transfusion services in both first-world and developing countries.

A short extract from a clinic checklist is included but please contact the author at [email protected] should you require full copies of any of the checklists or additional information.

Table 1: Extract Only: Internal Audit Checklist (Blood Collection)

CompliesCompliesComplies

CompliesComplies

Complies

CompliesComplies

Complies

CompliesComplies

Complies

CompliesCompliesComplies

CLN-W07 (12/07/2007).Sr ____ deemed competent.Confi dential questionnaire.Sister in charge checks medication. List available in Work Instruction CLN-W19 (dated 11/02/2008).CLN-W19 (11/02/2008).Donor given card with information on it. Donor can contact the Service to withdraw unit after donation - form CLN35 checked. CLN-W08 (01/03/2007)._____.

Female donor (12,9 g/dl) and male donor (14,0 g/dl) observed being tested.

CLN-W09 (28/06/2004).Sr_____.

Pulse - normal.BP - 140/80.Recorded on questionnaire. CLN-W10 (27/02/2008).Sr _____.Observed cleaning and preparation of arm.

DONOR SCREENINGProcedure no. for screening and issue dateStaff observedScreening includes verbal/written questions on HIV/ AIDS.Registered nurse or medical practitioner evaluates donor medicationsProcedure no. for deferrals and date last updatedSystem for donor to request discard of unit

HAEMOGLOBIN CHECKProcedure no. and issue dateStaff observedEach donor screened for Hb/ Hct: - Method acceptable - Hb > 12,5 g/dl or Hct > 0,38 l/l PHYSICAL DONOR CHECKSProcedure no.Staff observedEach donor pulse, blood pressure checked: - Pulse 50-100 beats/min (except athletes) - Systolic BP < 180 mm Hg - Diastolic BP < 100 mm Hg VENEPUNCTUREProcedure no. and issue dateStaff observedSkin free of lesions and preparation of venepuncture site acceptable

DEPARTMENT: Donor Division DATE: 20 May 2008AREA: _____ Donor Clinic AUDITOR: _____(QMS section), _____(Technical)

23


EDUCATION AND TRAINING

GENERAL

The blood systems of the developed countries cannot easily be transplanted to and be implemented, and usually are not appropriate and too expensive for blood services in Africa. Education and continuing professional development of staff and the identifi cation, mentoring and development of leaders may be the most effective tools to support blood services in Africa. Thus sustainable and appropriate operational structures could be established to effectively address the challenges posed by HIV/AIDS, malaria, other transfusion-transmitted infections, and the shortage of suffi cient safe blood collected from voluntary non-remunerated blood donors. External training programmes must take into account the language diversity of the African countries. The continent has been divided into Luso, Franco- and Anglophone regions. This is practical, but makes effective communication costly and diffi cult.

This review will focus on three organisations that have recently committed to address the issue: Africa Society for Blood Transfusion (AfSBT), Africa Institute for Transfusion Medicine (AITM) and the South African National Blood Service (SANBS). I will not discuss the established and most important roles of the WHO and other organisations and countries which have for many decades been involved in training and education in Africa.

GÉNÉRALITÉS

Les systèmes de transfusion sanguine des pays développés ne peuvent pas être facilement transplantés et être mis en application ; ils ne sont pas habituellement appropriés et sont trop chers pour des services de transfusion sanguine en Afrique. La formation, l’identification et le développement professionnel continu du personnel, le tutorat et le renforcement des responsables peuvent être des outils les plus effi caces pour soutenir des services de transfusion sanguine en Afrique. Ainsi des structures opérationnelles soutenables et appropriées ont pu être établies pour résoudre effi cacement les défi s posés par le VIH/SIDA, la malaria, et d’autres infections transmises par transfusion, et le manque de sang sûr suffi sant collecté à partir de donneurs de sang volontaires non rémunérés. Les programmes de formation externes doivent tenir compte de la diversité de langue des pays africains. Le continent a été divisé en régions Lusophone, Francophone et anglophones. Ceci est pratique et efficace, mais de marques coûteuse et difficile. Cette revue se concentrera sur trois organismes qui ont récemment investi pour assurer cette mission : la Société Africaine de Transfusion Sanguine (AfSBT), l’Institut Africain pour la Médecine Transfusionnelle (AITM) et le Service National Sang Sud-Africain (SANBS). Je ne discuterai pas les rôles établis et importants de l’OMS et d’autres organismes et la plupart des pays qui pendant beaucoup de décennies ont été impliqués dans la formation et l’éducation en Afrique.

TRAINING AND EDUCATION PROGRAMMES IN AFRICA:Role of the Africa Institute for Transfusion Medicine,

the Africa Society for Blood Transfusion and the South African National Blood Service

Published in Transfusion Today No. 77: Regional No. 4: December 2008Published also in Africa Sanguine Vol. 11 no. 2 December 2008, with permission

PROGRAMMES DE FORMATION ET D’ÉDUCATION EN AFRIQUE :Rôle de l’institut africain de médecine de transfusionnelle,

de société africaine de transfusion sanguine et le service national du sang sud-africain

Édité dans le numéro 77 de Transfusion Today : Numéro Régional 4 : Décembre 2008 Édité également dans le numéro 2 décembre 2008 de Africa Sanguine vol. 11, avec permission

Anthon Heyns MD, DSc President, Africa Society for Blood TransfusionChairman, Africa Institute for Transfusion MedicineProgramme Director, SANBS PEPFAR HIV Safe Blood Programme

24


AFRICA SOCIETY FOR BLOOD TRANSFUSION

The AfSBT has embarked on a programme that will broaden its scope and offer the AfSBT members opportunities to access training and education programmes. The AfSBT will do this by acting as a coordinator of the education and training activities that are offered by institutions and organisations to African countries. The AfSBT will also play a more direct role by developing its website and using this as a tool to make available appropriate distance learning training materials to blood transfusion professionals in Africa. This platform could be an effective tool to identify, mobilise, share and discuss educational resources that are made available to African blood services. The blood transfusion journal of the AfSBT, Africa Sanguine, will also in the near future be published electronically and distributed via the website.

This is an ambitious project and it is gratifying that the AABB and the ISBT have already offered to assist the AfSBT in this venture.

A highlight of the AfSBT activities will be a Workshop on Education and Training in Blood Transfusion in Africa that will be part of the 5th Conference in Blood Transfusion to be held in Nairobi, Kenya from 24 to 27 June 2009. It is hoped that the outcome of the workshop that will include all stakeholders, will be the development of a process to establish regional transfusion medicine training centres in Africa. Central to the proposal is that the internet and distance and e-learning could be powerful tools that will make it possible to reach the maximum number of blood transfusion professionals in Africa and to share resources that have been developed by professionals in other countries.

The model to establish such training centres could be based on obtaining the support of regional intergovernmental organisations that promote, amongst others, regional activities in the economic and health spheres. The latter could include the Southern African Development Community (SADC), the Economic Community of West African States (ECOWAS), the East African Community (EAC) and the African Science and Technology Community (AS&T). The initiative would be strengthened by also involving the AABB, ISBT, the Centers for Disease Control and Prevention, the World Health Organization, Safe Blood for Africa and Sanquin. Preliminary discussions with these organisations have been promising and the concept has been enthusiastically received.

AFRICA INSTITUTE FOR TRANSFUSION MEDICINE

Twenty eminent leaders in the fi eld of Transfusion Medicine in February 2007 met in Johannesburg to discuss the feasibility of establishing a transfusion medicine institute in Africa. The role of the institute would be to provide education, training and leadership development for the blood services in Africa. The outcome of this meeting was the establishment of the Africa Institute for Transfusion Medicine. This organisation was formally established in Geneva in November 2008. A Board of Directors, chaired by Professor Anthon Heyns with Dr Loyiso Mpuntsha, the CEO of the South African National Blood Service as deputy chairman, was constituted. Dr. James van Hasselt is the Secretary and Administrator of the organisation and Dr Jean Emmanuel is the other member of the executive committee. This committee will be

responsible for the day to day activities of the organisation. The governance structure of AITM has been established and the organisation is now ready to embark on activities that will fulfi l its aims. The AITM has been registered as a not-for-profi t organisation. Funding is obviously a major issue. The Safe Blood for Africa Foundation has offered to raise and provide funds for the AITM until the organisation can raise its own funds and has established itself as a sustainable and viable organisation.

The aim of AITM will be to promote education and training on several levels: to offer its own training or educational courses; to offer scholarships for students to attend courses offered by other institutions; to fi nancially assist other training institutions to develop and offer courses in transfusion medicine; and to offer training in collaboration with other institutions.

An example of such an initiative could be AITM scholarships for students to attend the Masters Degree in Management in Transfusion Medicine offered by the Academic Institute for International Development in Transfusion Medicine in the Faculty of Medicine at the University of Groningen, The Netherlands. The AITM is also discussed with Professor Vernon Louw and Dr Teresa Nel of the Department of Haematology of the University of the Free State in South Africa, AITM scholarships for students from Africa who have enrolled for the Diploma in Clinical Transfusion Medicine.

SOUTH AFRICAN NATIONAL BLOOD SERVICE

One of the most exciting projects funded by the SANBS PEPFAR Safe Blood Cooperative Agreement is to establish a Transfusion Medicine Training Centre (TMTC) in Johannesburg. The TMTC is a joint initiative of SANBS and the Western Province Blood Transfusion Service, the other blood service in South Africa. The TMTC will offer not only training and professional development for blood transfusion staff, but also for other health care professionals that prescribe and use blood products for the treatment of their patients. This external training will address some of the key elements of blood transfusion practice: the appropriate use of blood, assessing blood needs, minimising complications of blood transfusion, haemovigilance, monitoring the outcome of transfusion, and assessing the risk-benefit of a blood transfusion. This continued professional development is important because few healthcare providers receive advance and ongoing training in transfusion medicine during and after their formal medical or nursing school education.

SANBS also recognises that it can play a key role in strengthening blood services in Southern Africa. Under the leadership of Dr Loyiso Mpuntsha, the CEO and Dr Sam Gulube, the SANBS Medical Director, SANBS will offer the TMTC facilities and training materials developed under the Distance Learning Initiative to the member states of the Southern African Development Community.

The key to the success of the TMTC will be to develop affordable distance learning materials. Such materials should be appropriate not only for South Africa but should also be in a format that could be adapted by blood services in the Southern African region. The programme takes into account that education and training should address not only medical

25


and scientifi c endeavours. It will also target other areas such as nursing, behavioural and cultural behaviour. This will have an impact on blood donation and donor education and the knowledge of the epidemiology of transfusion transmitted infectious disease and the management of risk associated with blood transfusion. Training will also be provided in information technology systems in blood transfusion, fi nancial and human resource management, leadership development, and the general business management of a blood service.

The project has already made great strides towards achieving its goals. The AABB has assisted in evaluating the teaching materials available in SANBS. The training centre has been constructed. This includes appropriate video conferencing facilities that link with the SANBS zones and training laboratories. The content and evaluation of all the courses on offer will be developed according to a structured curricula framework.

Picture 1: Training in Technical Aspects of Transfusion Medicine. Course leader: Alan Kitchen

An important facet of such training programmes is to ensure that the courses are accredited and certifi ed. The process to ensure this has been done with the help of external consultants. All attendance and in-depth formal courses will thus be accredited with the appropriate South African educational authority.

IN SUMMARY

The project to develop the human resource capacity and leadership potential of the staff of the African blood transfusion services is a most important initiative. If this ambitious initiative is successful it will have a major positive effect on the quality of blood transfusion services in Africa. No doubt this will further the aims to make available suffi cient safe blood to the patients of Africa. The most gratifying aspect of this programme has been the enthusiasm and the support that has been offered by other established organisations and individuals. The cooperation of all these role players and their offer to share experience, expertise, information and materials, augurs well for the future.

Picture 2: Course in donor recruitment and education. Course leader: Diane de Coning

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UPCOMING EVENTS

ATTENDEESThe meeting, to be held on 24 June 2009, will be open only to invited participants. The outcomes of the meeting will be reported to the registered attendees of the AfSBT Congress held immediately after the Workshop, at the same venue in Nairobi, from 25 to 27 June.

AIMS OF THE MEETINGRecognizing that human capacity building and a skilled workforce are the pillars of a successful and sustainable blood service system, the aim is to organize a one-day pre-congress workshop of all stakeholders interested in establishing sustainable training and education systems in the disciplines of blood transfusion in Africa, on a regional basis, and to discuss how best this goal may be achieved.

BACKGROUND

The discipline of blood transfusion in Africa faces unique challenges. HIV/AIDS and malaria, and other transfusion transmissible infections, impact negatively on blood safety and the availability of healthy blood donors. Despite the efforts of international organizations such as the WHO and the support of programmes such as PEPFAR, donor recruitment in many countries is still based on paid and family-replacement donors. Blood screening systems for transfusion transmissible infections are not optimal or complete; systems for the preparation of blood components are not appropriate, and the structures for monitoring and evaluation of blood systems and haemovigilance are largely non-existent. The blood systems are often not sustainable because of the lack of fi nancial and trained human resources. Government support and the absence of effective policy making and

an appropriate regulatory framework are lacking in many countries. The blood systems of developed countries cannot easily be transplanted to and implemented, and often are not appropriate and too expensive for blood services in Africa. The language diversity in practice has been addressed by dividing the continent into Luso, Franco- and Anglophone regions, but this makes effective communication costly and diffi cult.

The result of these compounding factors is that there is a need to assess the current status of blood systems in Africa, to design systems to measure and evaluate blood systems, and to use this information to develop appropriate generic models that will make it possible for all countries to establish sustainable quality blood services. This proposal is based on the premise that the most suitable tool to assist and strengthen blood services in Africa, in order to strengthen the human resource capacity of the transfusion services, is to establish regional blood service training and education centres. This could be realized by utilizing the AfSBT as the coordinating body and regional intergovernmental organizations that coordinate and promote, amongst others, regional activities in the economic and health spheres. The latter could include the Southern African Development Community (SADC), the Economic Community of West African States (ECOWAS), the East African Community (EAC) and the African Science and Technology Community (AS&T). PEPFAR, and particularly the technical support teams of the blood services could also assist in the development of such regional training centres. Central to the proposal is that the Internet and distance learning could be powerful tools that will make it possible to reach the maximum number of blood transfusion professionals in Africa and to share resources that are available in other countries.

5th INTERNATIONAL CONGRESS of the AfSBT, Nairobi, Kenya 24-27 June 2009 IN COLLABORATION WITH INTERNATIONAL PARTNERS

THEME: MEETING THE NEEDS FOR SAFE BLOOD IN AFRICA

VENUE: Laico Regency Hotel, Nairobi

CONGRESS DATES: 24 June 2009: Pre-conference Education and Training Symposium (by invitation) 25-27 June 2009: AfSBT congress in parallel with Club 25 and Health Promotion Symposium 27 June 2009 (p.m.): General Assembly of the AfSBT

PRE-CONFERENCE EDUCATION AND TRAINING SYMPOSIUM

28


STAKEHOLDERS

International and regional organizations such as the technical support teams of the PEPFAR supported countries (WHO, AABB, Safe Blood for Africa, Sanquin, African Institute for Transfusion Medicine), and the AfSBT.

The leadership and regulatory authorities (Ministry of Health and divisions of Finance, Legal/regulatory and administration) responsible for developing, implementing and sustaining national blood services.

Regional intergovernmental organizations such as SADC, ECOWAS, EAC, and AS&T.

Commercial corporations with an interest to promote sustainable blood services in Africa.

Funders and donors (e.g. European Union).

AGENDA

The agenda, still to be fi nalised, could include topics such as: Current status of training establishments and systems in (selected) African countries. This could be presentations by the Technical Support teams of the PEPFAR programme: WHO, AABB, Safe Blood for Africa, Sanquin and selected African blood services such as the South African National Blood Service.

The role of regional intergovernmental organizations and how this can be mobilised and coordinated.

How can these efforts to establish blood systems be coordinated? The role of the AfSBT, that should be considered central to the initiative.

The perspective of the AfSBT as a coordinating body.

Need analysis: available information and how to achieve this.

Lessons learnt, barriers and opportunities (success stories and barriers encountered).

Proposal(s) of appropriate workable models.

Web-based training and education.

Distance learning.

Accreditation and certifi cation of courses.

How can such models be evaluated and progress measured?

Roles of all stakeholders.

CLUB 25 AND HEALTH PROMOTION SYMPOSIUM

A parallel symposium supported by the International Federation of Red Cross and Red Crescent Societies, will be held with particular reference to Club 25 and Health Promotion amongst young blood donors, from 25 to 27 June 2009, also at the Laico Regency Hotel in Nairobi. CLUB 25 AND THE SOCIAL DETERMINANTS OF HEALTH

How Club 25 programmes are improving health and well-being of young people by providing opportunities for: · Skill-building and leadership

· Networking and creating a sense of belonging

· Personal development

· Social cohesion and community solidarity

How Club 25 programmes are helping (or could help) in the wider arena of public health education and promotion:· HIV/AIDS peer education, infectious disease control

· Food, exercise and good health

· Environment and health issues

· Occupational health and road safety

· Oral health, mental health, perinatal/child health and rural health

WHY NAIROBI, KENYA?

Kenya is a rapidly growing country with a substantial professional middle class. It has one of the highest numbers of trained professionals in the African continent. This includes professionals in the health fi eld.

Kenya is served by a network of 300 hospitals spread across the country. There are four national referral and teaching hospitals providing a range of sophisticated health services. All these are provided with staff from four public and two private medical schools offering both undergraduate and graduate programmes in various specialities of medicine.

The country has a young but rapidly growing National Blood Transfusion Service which has established a network of six Regional Blood centres across the country. The service, with support from the AABB has trained over 100 middle level cadres in blood banking. In addition the service has provided support to train university lecturers in Blood Banking. These have provided the necessary linkage between the Service and the universities. There are also several medical specialists in haematology and blood transfusion.

Kenya is one of Africa’s most popular destinations with good reason. Besides being one of the most popular safari destinations in the world - famous for its “Out of Africa” scenic beauty, diverse cultures and abundant wildlife, Kenya has over the last few years hosted a number of internal conferences.

29


AfSBT KENYA CHAPTER

This is the fi rst national chapter of AfSBT. With the support of the parent organization (AfSBT), the Kenya chapter has the overall role of hosting this conference. They anticipate that this will provide an incentive to other African countries to form such chapters and lead to the rapid growth and recognition of blood transfusion medicine in Africa.

OFFICE BEARERS IN NAIROBI

Dr. Jack Nyamongo: Chair (AfSBT)Mr. Joseph Wangendo: Vice-Chair (Bloodlink)Ms. Mary Kariithi: Secretary (AfSBT)Dr. Grace Kitonyi: Treasurer (University of Nairobi)Ms. Jane Thirikwa: Congress Liaison Offi cer (AfSBT) The AfSBT Kenya Chapter was constituted to focus on harnessing development and skills in blood transfusion in Kenya. The Chapter’s mission and objectives are in line with the mission and objectives of the AfSBT. The chapter is involved in contributing to the advancement of knowledge in the fi eld of blood transfusion in Kenya and facilitating the exchange of information relating to blood transfusion and related disciplines. The Kenya Chapter also encourages regional collaborative programmes dealing with manpower development, donor recruitment, safety in donor screening and general transfusion practice.

AfSBT Congress topics will include: New initiatives in education and training PEPFAR: progress and topical issues Organization and management of BTS Blood donation and donor care Blood serology and immunohaematology Donation testing strategies Blood use and estimating needs Blood processing, storage and inventory management Quality assurance systems Club 25 and Health Promotion

Delegates to the Nairobi congress will include: Policy formulators and decision makers Medical (specialists, doctors, scientists, laboratory technologists and nurses) Young professionals and students, including Blood Donor Recruiters Vendors and supplies of equipment, reagents and consumables

The meeting will be recognized for CPD / CME credits by: Kenya Medical Practitioners and Dentists Board Kenya Medical laboratory technicians and technologists Board Kenya Nursing Council

REGISTRATION AND ABSTRACT SUBMISSION

Registration will be done via the AfSBT website: www.afsbt.org Abstracts must be submitted via the website by 31 March 2009

CONTACTS

Congress organizer: Dazzle Events Ms Helen Hansen: [email protected] Ms Jessica Martin: [email protected]

Education and Training Symposium Dr Sam Gulube: [email protected]

Club 25 and Health Promotion Symposium Mrs Sylvia Khamati: [email protected]

AfSBT Congress Liaison Offi cer Ms Jane Thirikwa: [email protected]

Abstracts and scientifi c programme Ms Beryl Armstrong: [email protected]

30


The website for the Africa Society for Blood Transfusion should be operational by the time you get this journal. Its development has taken place under the guidance of our President, Prof Anthon Heyns. Once the website is operational, it is planned to use it extensively to improve communication with AfSBT members, and to present the Society to the community at large.

It is envisaged that a page on the web will be devoted to the Africa Sanguine journal. Information on this page will include the following information: Contents of the current issue Contact details of the Scientifi c and Publications committee Special requests for contributions Availability of archival editions Electronic publication of the journal, in time.

An important page and sub-pages of the website will be devoted to the 5th Africa Society for Blood Transfusion Congress to be held in Nairobi, Kenya from 25 to 27 June 2009. The International Federation of Red Cross and Red Crescent Societies will collaborate with the AfSBT and hold their International Forum: Club 25 and Health Promotion at the same time and venue. The Congress will also include sessions devoted to the outcomes and challenges experienced by PEPFAR Blood Safety Cooperative Programmes in African countries.

There will also be a page with information on the Workshop on Education and Training in Blood Transfusion in Africa to be held in Nairobi on 24 June 2009. This workshop is by invitation only and is organized by Dr Sam Gulube of the South African National Blood Service.

Current state of development of the website:· The go-live date is December 2008 · Thereafter, the website will be continuously improved · Although it was originally hoped that Dr Peter Kataha (retired director, Blood Transfusion Service, Uganda) was to be the web-master, he is now unable to take up this responsibility. · Mr Tonderai Mapako (Executive Officer - Research, Development and Data Management, National Blood Service Zimbabwe) has now been appointed web-master and is responsible for content and maintenance.

Members are invited to contact the web-master at [email protected] with suggestions of content that they would like to see on the website.

Le site Web de la Société Africaine de Transfusion Sanguine (AfSBT) devrait être opérationnel avant que ce journal soit édité. Son développement a eu lieu grâce aux conseils de notre président, le Professeur Anthon Heyns. Une fois que le site Web est opérationnel, il est projeté de l’employer intensivement pour améliorer la communication avec des membres de la AfSBT, et pour présenter la société à la communauté dans son ensemble.

On envisage qu’une page sur l’animation sera consacrée au journal Africa Sanguine. L’information dans cette page inclura: Contenu de la question actuelle Petits groupes de contact du comité scientifi que et de publications Demandes spéciales des contributions Disponibilité des éditions archivistiques Publication électronique du journal, à temps.

Une page importante et des page secondaire du site Web seront consacrées au 5ème congrès de la société africaine prévu à Nairobi, Kenya du 25 au 27 juin 2009. La fédération internationale de la croix rouge et des sociétés de croissant rouge collaborera avec l’AfSBT et tiendra un forum international : Club 25 et promotion de santé en même temps. Le congrès inclura également des sessions consacrées aux résultats et aux défis éprouvés par des programmes coopératifs de sécurité transfusionnelle du PEPFAR dans les pays africains.

Il y aura également une page avec l’information sur l’atelier sur l’éducation et la formation en transfusion sanguine en Afrique à tenir à Nairobi 24 juin 2009. Cet atelier sera organisé par Dr Sam Gulube du service national sud-africain de sang.

État actuel du développement du site Web : · La date de démarrage est décembre 2008 · Ensuite, le site Web sera sans interruption amélioré · Bien qu’on ait espéré à l’origine que le Dr Peter Kataha (ancien directeur à la retraite du service de transfusion sanguine de l’Ouganda) devait être l’animateur maître du site, il ne pourra pas maintenant prendre cette responsabilité. · M. Tonderai Mapako (cadre dirigeant - recherche, développement et gestion des données, service national du sang du Zimbabwe) a été maintenant nommé animateur maître et est responsable du contenu et de l’entretien.

Des membres sont invités à entrer en contact avec l’animateur maître à son adresse yahoo : [email protected] avec les suggestions du contenu qu’ils voudraient voir sur le site Web.

WEBSITE NEWSNOUVELLES DU SITE WEB

Beryl ArmstrongEditorAfrica Sanguine

31


AFRICA SOCIETY FOR BLOOD TRANSFUSIONGENERAL INFORMATION

NEW MEMBERS

Individual members:Ms Rita O’Brien (USA)Dr Christopher J Gresens (USA)

Corporate member: AABB (Contact person:Mr James Reilly: USA)

COUNCIL MEMBERS

President: Prof. Anthon du P Heyns (South Africa)Past President: Prof. Kamel Boukef (Tunisia)President Elect: Dr Seidou Konate (Côte d’Ivoire)

Vice President (Francophone)Dr André Loua (Guinea)

Vice President (Anglophone)Dr Jane Mwangi (Kenya)

Treasurer: Mrs S Zondi (South Africa)Secretary General: Mr D Mvere (Zimbabwe)

COUNCILLORSMrs Beryl Armstrong (South Africa)Mr David Chama (Zambia)Dr Joel Gudo (Mozambique)Ms Mary Karithi (Kenya)Dr Kaba Kourouma (Guinea)Dr Simon Njoku (Nigeria)Dr J Sonoo (Mauritius)

ISBT Africa RepresentativeMr Ravi Reddy (South Africa)

Scientifi c and Publications committeeMrs Beryl Armstrong (Chairman and Editor Africa Sanguine)Mrs Leesha Raman (Sub Editor, Africa Sanguine)Mrs Elizabeth Smart (South Africa)Mr David Mvere (Zimbabwe)Dr Arthur Bird (South Africa)Mr Duncan Armstrong (South Africa)Dr Jean-Baptiste Tapko (Cameroon)Mr David Chama (Zambia)Prof Banji Adewuyi (Nigeria)Dr Justina Ansah (Ghana)Dr André Loua (Guinea)

Blood Safety committeeDr Jane Mwangi (Chairman)Mr Ravi ReddyDr P Kataha

Other Committees as indicated in the AfSBT Statutes · These play a reactive role if and when issues arise.· Ethics as related to publications is now part of the Scientifi c and Publications committee.

Circulation of the journal· Individual members· Corporate members· Support organizations

Complimentary Copies - Global AABBAustralian and New Zealand Society of Blood TransfusionBritish Blood Transfusion SocietyEditor, Transfusion TodayEuropean UnionInternational Consortium for Blood SafetyInternational Federation of Red Cross and Red Crescent SocietiesInternational Plasma Fractionation AssociationInternational Society of Blood TransfusionInternational Society of HaematologyWorld Federation of HaemophiliaWorld Health Organization, HQ Geneva

Complimentary Copies - AfricaBlood Transfusion Safety Focal Points in Africa, through World Health Organization Country Offi ces

ACKNOWLEDGEMENTS:

AfSBT acknowledges with gratitude the support of the following:

National Bioproducts Institute: Formatting, printing and distribution of Africa Sanguine

Dr André Loua: French translation of articles published in Africa Sanguine

32


CONTRIBUTION GUIDELINES: INSTRUCTIONS TO AUTHORS

All articles must include a summary or abstract of not more than 200 words. Scientifi c articles must include an introduction, study design and methods, results, discussion, conclusion, acknowledgements and references.

Evidence should be provided that tests carried out, or research fi ndings presented, have met the standards set, and that they have received approval by, the authorized ethics committee of the institution, country or region. When reporting research on human subjects, the work must comply with the principles of the Declaration of Helsinki (1964), and authors should indicate that ethical approval of the study was granted, and, where appropriate, that informed consent was given. The Editors reserve the right to reject a paper with questionable ethical justifi cation1.

· Authors should provide their full contact details.

· An appropriate member of the Scientifi c and Publications Committee may be asked to review articles received and the Editor’s decision to publish will be fi nal.

· Authors should keep a copy of their submission for reference.

· References should be given at the end, with the names of all authors, titles of journals, issue numbers and fi rst and last page numbers.

· The title must be as brief and to the point as possible.

· Authors’ names must be stated, together with the name of the institution.

· The fi rst time that a statement to be abbreviated appears in the text, it must be written in full, followed by the abbreviation in parenthesis: e.g. National Blood Transfusion Service (NBTS). There must be no full stops between letters.

· Standard units of measurement must be used.

ELECTRONIC MAIL / COMPUTER DISKETTES

Microsoft compatible formats are required. Basic text should be used, and complex formatting avoided. Submissions should be sent to the Editor as attachments to e-mail.

LETTERS AND SHORT REPORTS

These do not require abstracts. Letters and short reports are welcomed, and will be published at the discretion of the Editor.

CORRESPONDENCE

All correspondence must be sent to the Editor, by email.

Editor, Africa SanguineMrs Beryl Armstrong c/o National Bioproducts InstitutePrivate Bag X9043Pinetown 3600South Africa

Email address: [email protected]

Telephone: +27 31 262 8142Fax number: +27 31 262 9972

REFERENCE

1. Instructions for authors: Vox Sanguinis (ISBT) Blackwell Publishing

Type of application (check applicable block): New Renewal Update of details (no charge)

PERSONAL INFORMATION

Family name (surname)………………………………………… Initials……………………………. Mr / Mrs / Ms / Prof

First name (calling name)……………………………………… Title………………………..………………..M / F

Nationality……………………………………………………………………………………………Year of birth

Organization ………………………………………………………………………………………………………………………

Address…………………………………………………………………………………………………………………………….

Postal code……………….. City ………………………… Country……………………………………………………..

Telephone + dialling codes ……………………………… Fax: ………………………………………………………..

Email ………………………………………………… AfSBT membership number (for renewals, updates)………………

Contact details (if different from above) ………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………

Academic and professional qualifi cations…………….………………………………………………………………………..

………………………………………………………………………………………………………………………………………

Professional title / position in organization ............……………………………………………………………………………

Areas of expertise and interest ........……………………………………………………………………………………………

……………………………………………………...........…………………………………………………………………………

Duration of active work in fi eld of blood transfusion / transfusion medicine ………………………………………………..

I grant permission for my contact details to be given to third parties YES NO

PAYMENT (per annum)

Individual Membership US$ 25.00 (or US$ 100.00 for 5 years)

Corporate Membership US$ 100.00

Support Organisation Membership US$ 500.00

The undersigned declares to pay the total amount in US$ or equivalent SA Rand by bank transfer, and to fax, scan and email, or post application and proof of deposit for attention of AfSBT assistant (contact details above):

Signature……………………………………………....….. Date……...........……………………....(dd / mm / yyyy)

Banking Details:

Account Name: The Africa Society for Blood Transfusion. Bankers: First National BankBranch Name: Pinetown, South Africa Account Number: 62021117917 Branch Code: 221626 Swift Code: FIRNZAJJ - 659

AFRICA SOCIETY FOR BLOOD TRANSFUSIONMEMBERSHIP APPLICATION / RENEWAL / UPDATE FORM

To be sent to AfSBT Assistant: Ms Conilynn VenterPrivate Bag X9043 Pinetown 3600 South Africa

Fax: +27 31 708 5614Email: [email protected]

Type d’application (cocher la case): Nouveau Renouvellement Mise à jour des données (aucune charge)

INFORMATION PERSONNELLE

Nom de famille………………………………….. Titre ……………………………. Mr / Mrs / Ms / Pr

First name (calling name)………………………………… Sexe………………………..……………….. M / F

Prénom…………………………………………………………………………………… Année de naissance

Nationalité …...……………………………………………………………………………………………………………………

Service ……………………………………………………………………………………………………………………….......

Addresse ………………………………………………………………………………………………………………………….

Code postal……………….. Ville ………………………… Pays ...……………………………………………………..

Téléphone + code indicatif ……………………………… Fax: ………………………………………………………..

Email ……........……………………………………………

Numéro de membre de l’AfSBT (pour les renouvellements, mise à jour) ………………………………...........………….

Adresse de contact (si différente de l’adresse ci-dessus) ……………………………………………………………………

………………………………………………………………………………………………………………………………………

Qualifi cations académiques et professionnelles …………….………………………………………………………………..

………………………………………………………………………………………………………………………………………

Titre professionnel / position dans le service ............……………………………………………………………………..…

Domaine d’expertise et d’intérêt ........………………………………………………………………………………………….

Durée de travail actif dans le domaine de la transfusion sanguine / médecine transfusionnelle ……………………….

………………………………………………………………………………………………………………………………………

Je donne la permission pour que mon adresse de contact soit donnée à tierces parties OUI NON

PAYEMENT (par an)

Adhésion individuelle US$ 25.00 (ou US$ 100.00 pour 5 ans)

Adhésion corporative US$ 100.00

Organisme de soutien US$ 500.00

Le sous signé s’engage à payer le montant en US$ ou l’équivalent en Rand Sud Africaine par transfert bancaire et envoyer par Fax ou email, ou par la poste et preuve de dépôt à l’attention de l’assistante de l’AfSBT (contact ci-dessus):

Signature……………………………………………....….. Date……...........……………………....(jj / mm / aaaa)

Relevé d’Identité Bancaire :

Intitulé du compte: The Africa Society for Blood Transfusion Banque: First National BankNom de l’agence: Pinetown, South Africa Numéro de compte: 62021117917 Code agence : 221626 Code Swift : FIRNZAJJ - 659

SOCIETE AFRICAINE DE TRANSFUSION SANGUINE

NOUVELLE D’ADHESION / RENOUVELLEMENT / MISE À JOUR

A envoyer à l’Assistant de l’AfSBT: Mme Conilynn VenterPrivate Bag X9043 Pinetown 3600 South Africa

Fax: +27 31 708 5614Email: [email protected]

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