Status of hospital-based blood transfusion services in low-income and middle-income countries: a cross-sectional international survey

Abstract

Objectives: Blood transfusion is life-saving for patients experiencing acute blood loss and severe anaemia. In low-income and middle-income countries (LMICs), low blood donation rates and unavailability of whole blood and blood components (blood products) impairs timely blood transfusion. To fulfil patient-specific blood orders, a hospital blood transfusion service (HBTS) receives orders from a prescriber for blood transfusion, tests and prepares blood products for the patient. This study sought to describe the current state of LMIC HBTS.

Design: A cross-sectional survey explored LMIC HBTS access to blood products, testing methods, policies and structure. Surveys were administered in English, Spanish, French and Russian, followed by a mixed-methods analysis.

Setting: HBTS within LMICs.

Participants: From among 124 public and private facilities invited to participate, we received 71 (57%) responses. Of these responses, 50 HBTS from 27 LMICs performed on-site blood transfusions.

Results: Most LMIC HBTS perform blood collection to generate blood products for their patients (36/47, 77%); few relied exclusively on an external supply of blood products (11/47, 23%). The primary reason for blood transfusion was adult anaemia for non-malignant conditions (17/112, 15%). Testing methods varied by gross national income per capita. Blood transfusion delays to patients were common (17/30, 57%) attributed to inadequate blood inventories (13/29, 45%). Other barriers included lack of regular clinician education about transfusion (8/29, 28%) and sustainable financial models for the HBTS (4/29, 14%).

Conclusion: This survey describes the status of HBTS in diverse LMICs, illustrating that the availability of blood products remains a principal problem, requiring HBTS to generate its own facility's blood supply. Currently, blood shortages are not reported as a patient-specific adverse event making systematic tracking of delays in transfusion difficult. These findings highlight areas for further exploration related to the lack of available blood inventories for transfusions at HBTS in LMICs.

Keywords: blood bank & transfusion medicine; health policy; health services administration & management; organisation of health services; public health.

Figure 1

All testing uses agglutination. Blood typing (ABO/Rh using the ABO system: O, A, B, and AB and Rhesus [Rh] factor) determines the major blood type for red blood cell (RBC) antigens A, B and rhesus (Rh) factor. RBC antibody screening is a serological test for detection of antibodies directed against RBC antigens other than A and B antigens. RBC antibody identification finds the specific RBC antibody or antibodies present to inform clinical significance. Cross-matching or compatibility testing consists of the cumulative examination of donor and patient major ABO incompatibilities and clinically significant antibodies. Slide or Tile agglutination testing will only detect incompatibility caused by IgM, while tube, gel or solid phase may also detect incompatibility caused by IgG antibodies. The ‘other’ category included computer cross-match or solid phase capture. Country classification based on world bank atlas method categories (2019).

Figure 2

Adult anaemia, non-malignant, includes chronic loss or decreased production of erythrocytes (RBCs) associated with pathophysiological conditions other than cancer. Adult cancer and associated myelosuppressive treatments may decrease RBC production, leading to anaemia, thrombocytopaenia (low platelets) or leucopaenia (low white blood cells). Surgery patients (elective, trauma resuscitation and cardiac, orthopaedic, obstetrical) may require blood transfusion related to acute blood loss, however, underlying anaemia may hasten the need for blood transfusion. RBC, red blood cell.

Figure 3

Themes were distilled qualitatively from free-text comments and multiselect options describing the barriers and facilitators encountered by LMIC HBTS for timely and appropriate blood transfusion. The size of the box indicates the relative frequency of mention in responses, the bolded boxes illustrate dominant themes. HBTS, hospital blood transfusion service; LMIC, low-income and middle-income country.