We read with interest the recent article on blood donation in resource-poor Sub-Saharan Africa (SSA) (Allain, 2011). On the grounds that first time voluntary non-remunerated blood donors (VNRD) are no safer than replacement family donors (R/F) and the cost of a unit of blood from VNRD is considerably greater than one from R/F, the author recommends the retention of both R/F and VNRD. We chronicle the development of blood transfusion services in Trinidad and Tobago (TRT) to offer another perspective on the relative cost and safety, the feasibility of accepting both types of donor and to propose an alternative strategy for blood safety, affordability and adequacy in developing countries.
Trinidad and Tobago is a two-island state of population 1·3 million, adult literacy rate 99% and gross domestic product (GDP) per capita of US$ 15 781·50 (http://data.un.org/CountryProfile.aspx?crName=Trinidad+and+Tobago) for which its petroleum industry is largely responsible. The 2010 United Nations General Assembly Special Session on human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) reported a HIV prevalence of 1·5% in TRT (http://data.unaids.org/pub/Report/2010/trinidadandtobago_2010_country_progress_report_en.pdf) compared to between 2% and 25·9% for countries in SSA, as reported by the United Nations Joint Programme on AIDS (www.scribd.com/doc/51567072/UNAIDS-Fact-Sheet-Sub-Saharan-Africa-2010). The islands were amalgamated as a British colony in 1889 until independence in 1962 and became a member state of the Pan American Health Organization/World Health Organization (PAHO/WHO) region of the Americas in 1964. Despite the inception of a voluntary blood donor service in London in 1921 (Bird, 1992), this does not appear to have been implemented in the colony where blood transfusion was first recorded in 1951 (Messiah, 1978). Early blood donation was supported by the Red Cross and foreigners employed in the oil industry. As hospitals developed and the demand for blood increased, hospital-based R/F emerged by default to become the main source of blood. A totally state-funded National Blood Transfusion Service with predominantly (>85%) hospital-based R/F and a smaller amount of VNRD was established in 1986. To date, there are no charges to patients, insurance companies or hospitals.
By the time the PAHO adopted its resolution to improve blood transfusion services in the region of the Americas (Pan American Health Organization, World Health Organization, 1999), the spectrum of medical conditions and services in TRT resembled those of a developed country. In addition to voluntary, repeated blood donation, the resolution recommended quality assurance, allocation of resources for infrastructure development and the appropriate use of blood components to avoid unnecessary transfusions. Whereas TRT now provided chemotherapy for haematology and oncology, cardiac surgery, organ transplantation, dialysis, trauma services and chronic transfusion programmes for thalassaemia major and sickle cell disease, its blood donor pool had remained restricted to the contacts of hospitalized patients. Its annual donation rate remained closer to that required for the provision of basic medical services. The mismatch between annual donation rate and demand continues despite further medical advances (Pan American Health Organization, World Health Organization, 2010).This is because citizens, rather than donating regularly, save their donations until needed by a relative or friend. Furthermore, such R/F donations are reserved for specific patients. R/F donation is historically well established and entrenched in the community and among health professionals. VNRDs have to be given the right to claim their own donations to protect themselves and their families, effectively making them remunerated donors. Thus, although TRT has been cited as an example of a country where sufficient supply is achievable with R/F alone (Allain, 2010), the units collected are inadequate for the clinical activities undertaken and all assigned to specific individuals rather than freely available for general use. Chronic and acute blood shortages create a demand for professional donors who, paid by patients or relatives, could masquerade as either R/F or VNRD. They are then not readily identifiable but seem to be more prevalent in TRT than reported for SSA. The R/F system places stress on patients and families to locate their own blood donors which may then be transferred to clinicians as pressure to transfuse. Society bears the cost of lost productivity, morbidity and mortality from undertransfusion, delayed transfusions, surgical cancellations and attenuated chemotherapy. Unsuitable individuals driven by social, family or financial pressure to donate contribute to high deferral rates, reduced efficiency and increased cost at donation centres (Charles et al, 2010). Paradoxically, a lack of confidence in the supply encourages excessive cautionary requesting and wastage from expiration and discard.
Table 1 depicts the percentage of VNRDs, annual donation rate and prevalence of reactive markers in blood donors for TRT and Curacao in 2009 (Pan American Health Organization, World Health Organization, 2010). The West Indian island of Curacao is a previous Dutch colony that remains a country within the kingdom of the Netherlands. Its GDP per capita is comparable to that of TRT. Voluntary blood donation in Curacao was established during the colonial period and has continued in keeping with European legislation. Estimating the risk of transfusion-transmitted infection (TTI) in any setting requires prospective follow up of patients who have received transfusions or determination of the incidence of TTI among the donor pool. Like most countries in the region of the Americas, neither is possible for TRT because of majority collection from replacement sporadic or first-time donors and the lack of systematic follow up of patients who receive blood (Cruz et al, 2005). However, the annual cost of discarding seropositive units probably exceeds that of staff, equipment and advertisement required for a voluntary service.
|Country||VNRD (%)||Donation rate per 10 000 population||HIV (%)||HbsAg (%)||HCV (%)||Syphilis (%)||HTLVI/II (%)||Total TTI (%)|
Lack of awareness is a major contributor to the persistence of R/F donation in TRT (Sampath et al, 2007). A voluntary blood donor organization has been started in the Faculty of Medical Sciences at the University of the West Indies, Trinidad and Tobago to raise awareness in the community and among health professionals. The objective is to form voluntary donor panels that will convert rather than exclude previous R/F and accept new members only after initial screening as is done in Curacao. Clinical use of blood will be emphasized in the training of health professionals. We are hoping that support for this initiative will not be stymied by misinterpretation of Allain's article (Allain, 2011) as justification for R/F systems as a substitute for proper organization in countries with sufficient resources.