External Financial Aid to Blood Transfusion Services in Sub-Saharan Africa: A Need for Reflection

Ala, F.; Allain, Jean Pierre; Bates, Imelda; Boukef, K.; Boulton, Frank; Brandful, James; Dax, Elizabeth M.; Ekiaby, Magdy El; Farrugia, Albert; Gorlin, Jed B.; Hassall, Oliver; Lee, Helen; Loua, André; Maitland, Kathryn; Mbanya, Dora; Mukhtar, Zainab; Murphy, William G.; Opare-Sem, Ohene; Owusu‐Ofori, Shirley; Reesink, H. W.; Roberts, David J.; Torres, Oscar Andrés Gamarra; Totoe, Grace; Ullum, Henrik; Wendel, Silvano

doi:10.1371/journal.pmed.1001309

Cited by 70 publications

(83 citation statements)

References 29 publications

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“…The absence of adverse events related to volume overload provides reassuring endorsement of the relative safety of whole blood for pediatric transfusions in severely ill African children. Our study challenges the strong United States President’s Emergency Plan for AIDS Relief (PEPFAR) recommendation (made on the basis of patient safety) for component preparation, including packed cells [3]. It also supports the recent questions around implementation of these specific PEPFAR requirements for transfusion services, which are both costly and not evidence-based.…”

Section: Discussionsupporting

confidence: 75%

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Phase II trial of standard versus increased transfusion volume in Ugandan children with acute severe anemia

Engoru

Thompson

Nteziyaremye

et al. 2014

BMC Med

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BackgroundSevere anemia (SA, hemoglobin <6 g/dl) is a leading cause of pediatric hospital admission in Africa, with significant in-hospital mortality. The underlying etiology is often infectious, but specific pathogens are rarely identified. Guidelines developed to encourage rational blood use recommend a standard volume of whole blood (20 ml/kg) for transfusion, but this is commonly associated with a frequent need for repeat transfusion and poor outcome. Evidence is lacking on what hemoglobin threshold criteria for intervention and volume are associated with the optimal survival outcomes.MethodsWe evaluated the safety and efficacy of a higher volume of whole blood (30 ml/kg; Tx30: n = 78) against the standard volume (20 ml/kg; Tx20: n = 82) in Ugandan children (median age 36 months (interquartile range (IQR) 13 to 53)) for 24-hour anemia correction (hemoglobin >6 g/dl: primary outcome) and 28-day survival.ResultsMedian admission hemoglobin was 4.2 g/dl (IQR 3.1 to 4.9). Initial volume received followed the randomization strategy in 155 (97%) patients. By 24-hours, 70 (90%) children in the Tx30 arm had corrected SA compared to 61 (74%) in the Tx20 arm; cause-specific hazard ratio = 1.54 (95% confidence interval 1.09 to 2.18, P = 0.01). From admission to day 28 there was a greater hemoglobin increase from enrollment in Tx30 (global P <0.0001). Serious adverse events included one non-fatal allergic reaction and one death in the Tx30 arm. There were six deaths in the Tx20 arm (P = 0.12); three deaths were adjudicated as possibly related to transfusion, but none secondary to volume overload.ConclusionA higher initial transfusion volume prescribed at hospital admission was safe and resulted in an accelerated hematological recovery in Ugandan children with SA. Future testing in a large, pragmatic clinical trial to establish the effect on short and longer-term survival is warranted.Trial registrationClinicalTrials.Gov identifier: NCT01461590 registered 26 October 2011.Please see related commentary article http://www.biomedcentral.com/1741-7015/12/68/abstract.

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Section: Discussionsupporting

confidence: 75%

“…Young children and women account for more than three quarters of the blood transfusions in sub-Saharan Africa - most given as emergency life-saving treatments [3]. Despite high demand, blood supply is inadequate to meet the needs.…”

Section: Introductionmentioning

confidence: 99%

Phase II trial of standard versus increased transfusion volume in Ugandan children with acute severe anemia

Engoru

Thompson

Nteziyaremye

et al. 2014

BMC Med

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“…As in the case of other more sophisticated POC devices cost and unavailability of supplies at local level are likely to represent major barriers to their utilization. As far as the management of coagulopaties is concerned, it is important to remember that in most peripheral hospitals in Sub-Saharan Africa whole blood is the only available blood product [42]. Fresh whole blood units, if available in sufficient number, are indeed an effective therapy in case of dilutional and consumption coagulopathy that follows severe acute bleeding and trauma since it rapidly restores simultaneously red blood cells, active clotting factors and platelets [43].…”

Section: Hemostasismentioning

confidence: 99%

Point of Care Testing and Transfusion Safety in Resource Limited Settings: A Review

Musi¹

2015

J Blood Disord Transfus

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Worldwide, one of the fastest growing aspects of clinical laboratory testing is point of care testing (POCT). Decentralized patient care and access to testing in under-served areas are key elements in the evolving expansion of POCT. Several available POCT devices can potentially contribute to safer transfusion practices in resourcelimited settings. Only "rapid diagnostic tests" and some simple hemoglobinometers are normally encountered in the peripheral hospitals of low income countries. Strengths, weaknesses and barriers of large scale utilization of POCT in transfusion medicine are discussed.

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“…In LIC such as sub-Saharan Africa, centralized systems initially introduced by the colonial powers were replaced by decentralized services delivering good transfusion outcomes at lower costs 89–91. Subsequently, economic pressures leading to the need for external aid have resulted in a surge toward centralizing blood systems as a condition of such aid 51. This pressure is often premised on the minimization of human immunodeficiency virus and other infectious disease transmission through such centralization.…”

Section: The Blood Center In the New Paradigmmentioning

confidence: 99%

Toward a patient-based paradigm for blood transfusion

Farrugia¹,

Vamvakas²

2014

JBM

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The current “manufacturing paradigm” of transfusion practice has detached transfusion from the clinical environment. As an example, fresh whole blood in large-volume hemorrhage may be superior to whole blood reconstituted from multiple components. Multicomponent apheresis can overcome logistical difficulties in matching patient needs with fresh component availability and can deliver the benefits of fresh whole blood. Because of the different transfusion needs of patients in emerging economies and the vulnerability of these blood systems to emerging infections, fresh whole blood and multicomponent apheresis can better meet patient needs when compared with transplants of the “manufacturing paradigm”. We propose that patient blood management, along with panels of repeat, paid, accredited apheresis and fresh whole-blood donors can be used in emerging economies to support decentralized blood services. This alternative transfusion–medicine paradigm could eventually also be adopted by established economies to focus transfusion medicine on local patient needs and to alleviate the problem of the aging volunteer donor base.

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External Financial Aid to Blood Transfusion Services in Sub-Saharan Africa: A Need for Reflection

Abstract: Jean-Pierre Allain and colleagues argue that, while unintended, the foreign aid provided for blood transfusion services in sub-Saharan Africa has resulted in serious negative outcomes, which requires reflection and rethinking.

Cited by 70 publications

References 29 publications

Phase II trial of standard versus increased transfusion volume in Ugandan children with acute severe anemia

Phase II trial of standard versus increased transfusion volume in Ugandan children with acute severe anemia

Point of Care Testing and Transfusion Safety in Resource Limited Settings: A Review

Toward a patient-based paradigm for blood transfusion

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