200 years on from the first successful human-to-human blood transfusion, this procedure has revolutionised patient care. However, there is still work to be done in sub-Saharan Africa, as Professor Kathryn Maitland explains.
Each year, around 2.5 million units of blood are transfused in the UK – that’s enough to fill two Olympic sized swimming pools! Since James Blundell performed the first successful human blood transfusion in 1818, this life-saving medical intervention has made many advances to ensure its accessed throughout the world. An important part of this is ensuring that any health system has adequate supplies of quality-assured and safe blood for transfusion through national and regional blood transfusion services (BTS).
Challenges of achieving safe blood for all
1975 was a milestone year when the World Health Organization (WHO) published a resolution, recognising the importance of BTS and suggested for governments that it was imperative to “promote national blood transfusion services, based on voluntary non-remunerated donations, and to promulgate laws to govern their operation” (1). Nevertheless, more than 40 years later the issues of blood safety, adequate supply, equitable access and rational use still remain major challenges throughout the world. The greatest concern is in low-income countries – the majority of which are in sub-Saharan Africa – which have struggled to achieve the four key goals of an integrated strategy for blood safety.
In sub-Saharan Africa women and young children are chief recipients of blood transfusions, accounting for nearly three-quarters of the blood transfusion requirements in some countries. Most blood transfusions are given as emergency interventions for severe anaemia in children (largely due to infection) and bleeding in pregnancy. The demands for blood are highly unpredictable and challenging for BTS planning. Indeed, there are numerous challenges that face the BTS – with lack of donor blood supplies being a major one.
Blood shortage woes
The WHO has estimated that on the continent the blood requirement for countries should be in the order of 10 to 20 units collected or donated per 1000 population per year (2). The actual blood requirements for each country are not known but based on data from the region in 2013 many sub-Saharan Africa countries still collect < 5 units/1000 population annually (3). The magnitude of the shortage of blood for transfusion in this part of Africa is not certain but the patient groups that suffer the greatest impact of blood shortages are much easier to identify. Young children often die awaiting transfusions.
An Imperial’s Centre for African Research and Engagement (ICCARE) research study in Africa we have found that in children hospitalized with severe and life-threatening anaemia (defined as haemoglobin less than 5g/dl) and were not able to receive a blood transfusion immediately, 52% died by 8 hours with 90% of these deaths occurring within 2.5 hours of hospital admission. Only 4% of children who received a transfusion within 8 hours died, emphasising the importance of the availability of blood transfusion as a life-saving intervention (4).
Safe blood for saving mothers
Women of reproductive age are also major users of blood transfusions in low-income countries. Of the 20 countries worldwide with the highest maternal death rates, 19 are in sub-Saharan Africa where the risk of maternal death is close to 1 in 16, compared with 1 in 2800 in high-income countries. In Africa the most common cause of these maternal deaths is severe bleeding, which contributes to over 40% of maternal deaths. It has been estimated that a quarter of these women die because of blood shortages (5).
Clinical trials key to safeguarding transfusion resources
In order to protect scarce transfusion resources the WHO encourage the rational use of blood transfusion for children – the key users of blood transfusion – restricting routine transfusion for those with a haemoglobin less than 4 g/dl, or 4-5g/dl if they have additional signs of severity (6). However in practice, these guidelines are generally not followed by clinicians as they are not based on clinical trials, meaning the demand outstrips supply. The only way to inform policy and guidelines are large-scale randomised clinical trials to determine which children need a transfusion and which children with severe anaemia can safely be treated with other supportive therapies.
These questions are currently being examined in a randomised controlled trial led by Imperial. TRACT trial involves nearly 4000 children admitted to hospital with severe anaemia in Uganda and Malawi (7). The overarching aim of the trial is to provide the evidence to inform or refine current recommendations for the rational use of paediatric blood transfusion. The trial is currently underway and the results should be available in early 2019.
The provision of safe and adequate blood transfusion is a medical procedure that many in developed nations take for granted. This outlook is sub-Saharan Africa is different and remains an important public health concern. Through the combined efforts of scientific research and international aid organisations, I am optimistic for a future where many more can benefit from the lifesaving potential of blood transfusion.
- Utilization and supply of human blood and blood products Geneva: World Health Organization; 1975.
- Tapko JB, Sam O, Diarra-Nama AJ. Status of blood safety in the WHO African Region: report of the 2004 survey. Brazzaville: WHO Regional Office for Africa; 2007.
- Global status report on blood safety and availability 2016. Geneva: World Health Organization;: World Health Organization; 2017.
- Kiguli S, Maitland K, George EC, et al. Anaemia and blood transfusion in African children presenting to hospital with severe febrile illness. BMC medicine 2015;13:21.
- Bates I, Chapotera GK, McKew S, van den Broek N. Maternal mortality in sub-Saharan Africa: the contribution of ineffective blood transfusion services. BJOG 2008;115:1331-9.
- Pocket book of hospital care for children: Second edition Guidelines for the management of common childhood illnesses. Geneva: World Health Organization; 2013.
- Mpoya A, Kiguli S, Olupot-Olupot P, et al. Transfusion and Treatment of severe anaemia in African children (TRACT): a study protocol for a randomised controlled trial. Trials 2015;16:593.