The global health community needs to rethink its estimation of how much blood a country needs to match demand, according to a study published today in The Lancet Haematology. For India, there is much to take away from the findings which, for the first time, estimate the gap between blood supply and demand worldwide.
“An adequate blood transfusion supply is essential for a functioning health-care system,” the study reads. “Although blood and its components were recently added to the WHO [World Health Organization] Model List of Essential Medicines, insufficient blood inventories in many low-income and middle-income countries still lead to preventable mortality and morbidity.”
“Essential blood medicines,” expands Professor Thierry Burnouf, Professor at the Graduate Institute of Biomedical Materials and Tissue Engineering at the College of Biomedical Engineering, Taipei Medical University in Taiwan in a linked Comment, “as defined by [the] WHO, include whole blood, cellular components (red blood cell concentrates and platelet concentrates), fresh frozen plasma, and various plasma protein derivatives such as clotting factor concentrates for substitutive therapy of haemophilia and preparations of γ globulins to treat immunodeficiencies, exposure to tetanus and rabies, or to prevent haemolytic disease in newborns.”
Out of 195 countries and territories, 119 lack a sufficient blood supply to cope with their demand. India is one of those 119 countries. In fact, as the study notes, “India had the greatest absolute unmet blood unit need.”“Based on our study, we estimate that India has a gap of over forty million blood units between its need and supply,” study author Dr Meghan Delaney, Chief of Pathology and Lab Medicine, Children’s National Hospital in Washington, D.C., told Health Issues India. This deficit translates to “the greatest in the world by unit number.” To match demand, she adds, “donation levels need to be tripled to meet the blood need of the country” as “our model predicts that India has donations at a rate of only 8.2 donations per 1,000 people.”
“The donation targets for India, as estimated by the model are 40,964,075 units per year,” Delaney explains. “This need is equal to 25.4 donations per 1,000 people…This estimate is based on the number of people with prevalent diseases that are treated with blood transfusion in the country and then subtracting out the number of blood units reported to WHO that were collected. The study made the estimates based on an assumption that the level of care was adequate to provide the blood transfusions.”
The study notes that WHO targets may need to be adjusted in order to realise “safe and accessible blood transfusion”, which Delaney describes as “a cornerstone of the WHO’s approach to improving blood transfusion infrastructure.”
The WHO recommends donation rates of ten to twenty for every thousand people. While the optimal donation rate for India of 25.4 for every thousand is “only slightly higher than the WHO recommendations”, as Delaney points out, the study does note that its target represents “an underestimate for many countries.”
The study notes that “ensuring enough blood is available for transfusions involves an understanding of the local epidemiological and demographic structure, and the capacity for component preparation from whole blood.” In India, there are many challenges.“India…has a unique disease burden profile,” says Delaney. “India has especially high rates of nutritional deficiencies, hemoglobinopathies and hemolytic anemia, and respiratory infections and tuberculosis, which are all diseases that require significant amounts of blood transfusions.” In addition, “only sixty percent of whole blood donations in India are separated into its different components.”
Separation of blood products “enhances the utilization of individual donations and decreases the need for blood donors. Transfusing the appropriate combination of blood products effectively provides for the clinical needs of patients and best utilises the donated blood,” noted a 2017 study. Indeed, Burnouf tells Health Issues India “using whole blood results in an under-valorization of the donated blood, which leads to an actual wastage of the plasma that could be otherwise be used clinically to treat patients with complex bleeding disorders.”
The reasons behind this are manifold. “Not dividing blood into its main parts can be due to various reasons, including lack of infrastructure, resulting in excessive whole blood therapy in India (which can lead to more risk of side-effects in blood recipients),” adds Burnouf. “It can be argued that Indian efforts to improve the effectiveness of the use of blood units donated and mitigate the shortfall ought to increase the rate of whole blood donations being separated into different components, to optimise the treatment of those who require transfusions and to take full advantage of blood collected.”
Burnouf emphasises the importance of plasma. He says, “this plasma, if available, could also be fractionated into vital therapeutic products for the treatment of specific deficiencies in coagulation factors, and various types of infections due to immunological deficits associated with deficiencies in antibodies…Availability of plasma for fractionation would be highly beneficial as India is still experiencing severe shortages in fractionated plasma products.”
The public health needs of taking steps to increase India’s blood supply are patent. “When there is not enough access to blood transfusion,” explains Delaney, “the result can impact the patient with increased morbidity or mortality.” Indeed, the blood units India missed out on in the 2016-17 period “could have aided more than 320,000 heart surgeries or 49,000 organ transplants.”The reasons behind such shortages are manifold. “In general,” notes Delaney, “an adequate blood inventory to support the population requires government and fiscal support for the blood supply….Increasing the number of donations and the capacity to split whole blood donations into components will decrease the gap between blood supply available for transfusion and transfusion need.”
Furthermore, Delaney adds that “[the] WHO advocates for having a national blood policy and national level coordination of blood transfusion system. Increasing the number of blood donors and the availability of laboratories that test and process blood units as well as the infrastructure to support the storage and transport of blood is critical to increase access to a safe blood supply.”
“The harmonization of blood collection practices at the national level should be supported,” adds Burnouf. “Development of larger and more efficient blood establishments operating under good manufacturing practices and with enough financial resources should continue. Such an evolution is essential to ensure optimal usage of blood resources and to improve blood collection quality, safety, and efficiency.”
This is not to say that India has not taken strides towards improving blood supply. “India has accomplished substantial efforts to collect a higher proportion (about 85 percent) of blood from voluntary non-remunerated donors (thereby decreasing the ratio of blood from family/replacement donors),” Burnouf concludes. “It should now stimulate episodic donors from low-risk populations to become regular donors since this allows the blood establishment to build up medical history records ensuring optimal blood product safety to the Indian patients.”
“The global need and availability of blood products: a modelling study”, published in The Lancet, can be accessed here.