“One small step for a man, a giant leap for mankind; - But the step is still to be taken" - The challenges of building a safe repeat donor pool

•Dr C. Shivaram•Chief-Transfusion services •Manipal Hospital Bangalore

20 July 1969 1900s

Some questions with No answers

After 65 years of independence One-third of Indians : Do not have access to safe

drinking waterFood to eat House to live in.We as Indians, Traditionally do not believe in Punctuality,

standing in que or keeping our surrounding clean.In this scenario, establishing a Safe donor pool seems all

the more difficult.

VOLUNTARY DONOR

AltruisticCaring and givingMotivatedUnderstands the

implications of donation

Have Reduced risk of HIV or Hepatitis

WHO/NACO

Voluntary non-remunerated blood donors are the foundation of a safe, sustainable blood supply. Without a system based on voluntary unpaid blood donation, particularly regular voluntary donation, no country can provide sufficient blood for all patients who require transfusion.

Moving on from voluntary non-remunerated donors: who is the best blood donor?

Allain JP. Source Division of Transfusion Medicine, Department of Haematology, University of Cambridge, Cambridge, UK. Abstract Blood transfusion safety in sub-Saharan Africa (SSA) is marred by the high prevalence of infectious agents, chronic blood

shortage and lack of resources. However, considerable pressure is applied by richer countries and international transfusion bodies to establish voluntary, non-remunerated blood donors (VNRD) as the only source of blood, excluding the traditional family/replacement donors on the grounds of a higher level of safety. Such a policy increases the cost of a unit of blood by two to fivefold and exacerbates the pre-existing blood shortage. This review provides compelling evidence that first-time VNRD are no safer than family/replacement donors and that only repeat donation provides improved blood safety. In order to limit blood shortage and maintain affordability of the blood supply in SSA, both types of donors should be accepted and both should be encouraged to donate regularly.

Challenges of Building a Safe donor PoolIntense competition between blood banks in

a Fragmented BTS.Blood comes with a price for testing. Donor

perceives this as sale of blood.No incentives for donating blood .Blood Banks have no mechanism in place to

identify and recall blood donors.Blood banks have no counselors.Blood banks have the dual responsibility of

ensuring Safe blood and Safe donor.

Current Scenario SEAR Countries All countries except Thailand depend heavily on replacement

donors. Lack of resources, lack of professional management, myths

and misconceptions form a barrier to blood donation. Besides recruitment, the donor screening and donor

management are also not well addressed. The donors are mainly males of 20-35 years who come from

the middle class of the society. Only 3-6 % of females donate blood.

Most of the donors donate once in a lifetime as there is no emphasis on retention programmes.

Only 5-10 % are repeat donors. The prevalence of transfusion-transmissible infections in the

region is variable; HIV 0-1.6 %, HBV 0.06-8.5 %, HCV 1.2-3 %.

Bharucha ZS.Dev Biol (Basel). 2005;120:145-53.

Need for Safe Repeat donors

First time donors were less motivated by the cause of

humanity (56.21%) and volunteered because of peer

pressure (26.03%).

Regular donors came forward to donate blood for the

cause of humanity (80.6%) and the sense of pride

(27.79%). Among altruistic blood donors. About 96.6% donors

want to become repeat donors.

Majority of the donors had good knowledge about

routes of HIV transmission

Shah R, Tiwari AK, Shah P, Tulsiani S, Harimoorthy V, Choudhury N.Indian J Pathol Microbiol. 2007 Oct;50(4):896-900.

We have no definition of a Repeat donor

Voluntary non-remunerated donation: donation given by an altruistic donor who gives blood freely and voluntarily without receiving money or any other form of payment.

Family/replacement donation: donation given by an individual who gives blood when it is required by a member of the patient’s family or community.

In Asian countries like India Family donors are classified under Voluntary donors.

http://www.who.int/bloodsafety/global_database/bloodsafetyindicators2010example_en.pdf.

Blood Safety Indicators 2010/Global Database on Blood Safety

ISBT Code of Ethics

Council of Europe

Building Donor databaseOne who has donated blood atleast once

in the last one year( Not necessarily at our blood bank).

Apheresis donor Pool (Manipal hosp BB): 178

Voluntary donor base of 8000+ donorsRepeat WB donor data base of 1396.Imagine how big this number would be if

all major blood banks networked together.

Need for Blood donor Mobilization1200 million people.1% of this =12 million units .Annual collection in India = 8 million units

and of this about one-half is from Voluntary donors.

How do we mobilize another 4 million people?

How do we convert the 50% of replacement donors to become repeat Voluntary donors.

Converting Replacement donors To VNRD and then to Repeat Voluntary.

Family donors might be either directed or replacement.

Difficult task to encourage these people to become VNRBD.

Many benefits if this can be achieved.

Family replacement donation is prevalent in many countries across the globe.

Main reasons to convert toVNRBD ensure safer resources long term sustainability reduced cost and a stable supply Build a pool of safe donors.

Patient’s relatives feel that replacement donation is safer.

Medical professionals believe it is easier.

Society at large finds replacement donation acceptable.

Benefits of building a Repeat donor data base.Every businessman knows that it costs twice as

much to get a new customer as to retain an old customer.

Retaining blood donors is economical and adds to quality.

Searching for donors from a pool is also easier than searching blindly in the community.

Extended phenotyping of a group of donors will help in searching for antigen negative blood.

Building a Safe Repeat donor Pool –Primary Steps

1. Build a Community committed to Volunteerism -uniform cost/quality/benefits2. Build a BTS committed to safe blood. Accreditation and not legislation is the key3. Conducive Govt Policies- Who can hold camps? Treat blood as an essential drug4. Networking of BTS with Government and Industry

and Educational institutes. -Make blood donation drives compulsory-twice a year. Sops-Tax benefits or surcharge.5. Segregate Blood donor organizations form blood

centers/blood bank.

Complementary StepsSustained motivation & Recruitment-Electronic

mediaIncentives for Repeat donation that can be used

across Indian BTS.Unlock barriers (i.e. the non-functioning systems

of donor identification, registration and recall) to repeat donation.

This would multiply the blood supply from the current donor pool by two-threefold.

Conducting camps under a neutral banner/not an institutional banner.

Where do we begin?• If our aim is 100% VBD then we need 100% camps.• Separate Blood donor organization body to arrange

for camps.1.Government Policy

• Blood Banks sell blood:• Uniform dynamic pricing

mechanism based on quality and type of component X Cost of living

2.Change Community Perception

•Guidelines for networking.•Institutional Factors should not be an impediment

3.Networking of Fragmented BTS

• Define “Repeat donor”• Selection of donors based on pre-

determined guidelines. 4. Official Data

base of VBD

Action At Blood Bank LevelEnsure good treatment of blood donors.Start Building a pool of Repeat donors.Avoid smear campaigns.Prepare for data sharing.Reach out to the community in as many ways as

possible and explain why blood comes with a cost.Track donor recall and remember them even when

you don’t need their blood.

Arguments against a data base

I have built my database with difficulty why should I share it with others?-Donor is not our property

This will be misused by some.-Let’s network with like minded people.

My donor will be called by another blood bank- You can also call their donor.

I will upload what about others? –Haemovigilance and updating repeat donor data should be a part of the CMIS report that we send to NACO/SACS

Identifying a Repeat donor Donor ID- No value add-not retained by donor. Pan card: Less than 1% of people have Pan cards. Adhar Number- Still far away. Even if a donor ID is given and retained the IT systems of

two blood banks do not network with each other. Food for Thought What we need are donor identifiers which the donor cannot

leave behind or forget- Thumb scan/Retinal scan. What we need are IT systems that are India specific not

institutional specific. Let’s begin with a regional database of Voluntary donors

with last date of donation on a central server connected Via the internet which can network with a national database.

Conclusion Safe donor Pool is a necessary pre-requisite for

safe blood.Safe donor pool cannot be achieved by

sporadic/cosmetic efforts overnight.Radical reforms in Blood banking-

◦Relook at who can conduct camps◦ Awakening corporate social responsibility

Evolving a dynamic but uniform pricing mechanism will help sustain VBD movement.

Building a Safe donor Pool.

“One small step for a man, a giant leap for mankind; - But the step is still to be taken”

Blood transfusion is a lot like marriage.

It should not be entered upon lightly, unadvisedly or wantonly, or more often than is absolutely necessary” - Beal

THANK YOUSHIVARAM@MANIPALHOSPITALS.com