Blood Transfusion Service in Nepal

Blood Transfusion Service Center (BTSC) of Nepal Red Cross Society (NRCS) was established in 1966, three years after the formation of NRCS. The NRCS has 108 blood transfusion centers across the country through which it makes 24-hour availability of safe blood for transfusion to the needy.
The revised national guidelines on the management of blood transfusion services was prepared in 2015. NRCS provides its services based on the national guidelines that follow the national blood transfusion policy. The national policy on blood transfusion service (BTS) was formulated in 1993. It was revised and updated in 2006 and 2012. The revised blood policy mandates the screening of all blood donations for HIV, hepatitis B (HBV), hepatitis C (HCV), and Syphilis for the provision of safe blood and blood components.
NRCS follows other manuals and guidelines on transfusion-transmissible infections (TTIs), and biosafety and waste management while providing blood transfusion service.
“Our national blood transfusion policy follows the basic guidelines of World Health Organization (WHO), which has set a minimum standard for the developing countries. It is not a very high standard. Our standard is still being developed. We have recently proposed a new standard to the Ministry of Health and Population and are waiting for its approval,” says Dr. Manita Rajkarnikar, Director, Central Blood Transfusion Service (BTS) Center. The National Bureau for Blood Transfusion Service at Nepal Public Health Laboratory (NPHL) is the governing body that monitors, controls, provides license, and registers all blood transfusion centers throughout the country, she informs.
The government had mandated NRCS as the sole agency to conduct blood programs in 1991. Until recently, it was the only organization responsible for monitoring, supervising, and supplying blood to all the hospital units across the country. There are a few hospital-based blood banks now. The main responsibilities of NRCS are counseling blood donors, blood collection, screening, and supply of safe blood to the needy.

Demand and supply
There is no exact data on how much the demand is. “We have tried to set a target for blood collection, but have not been able to meet it. If the hospitals were to provide an estimate on how much their yearly blood requirement is, then maybe we could set our target on that basis. As per the current trend, the blood demand has gone up by 12-15 percent,” Dr. Rajkarnikar informs.
There is amassive demand of blood during emergencies, and for liver transplants, dialysis, and open-heart and other surgeries. “We need a minimum of 16 units of blood for one patient, and up to 70 units of blood for a liver transplant,” she says. “We are currently facing shortages for platelets concentrate (PRP), and platelet-free plasma, as they can only be stored up to three days. We usually prepare and supply them as per the demand, but it is a bit difficult to manage when it is needed urgently.”
Red blood cells (RBCs) have a long lifespan, so there are usually no problems. But, there has been a steep rise in the number of dialysis cases, which requires packed RBCs (PRBCs) that can be stored up to 42 days. The problem arises when we have to immediately prepare the blood products with short lifespans,” says Dr. Prakash Yadav, Deputy Director, Central Blood Transfusion Service (BTS) Center. According to him, there is a challenge to meet the demand for the rarest blood types. The common blood groups like A and O are easily available. “But, we have problems with negative blood groups. Negative blood groups constitute about 3 percent of the total blood collected at NRCS, of which, AB negative is the rarest. Usually, the donors of rare blood groups are registered with us, and we call them when we need their blood,” he informs.

Is there any deviation between the world’s best practices in TTIs and our practice?
WHO has made it mandatory for developing countries to test all donated blood against transfusion-transmissible infections (TTIs), including HIV, hepatitis B, hepatitis C, and syphilis. “Mandatory testing is done for all the donated blood. We use aseptic method during blood collection, and safety measures are taken throughout the process, from the vein of the donors to the vein of the recipients. We use Rapid Kit for emergency testing, and ELISA when collecting blood in big camps,” says Dr. Rajkarnikar, adding, “We cross-match blood for hospitals that don’t have cross-matching facilities, and we don’t cross-match blood if they have such facilities.”
According to Dr. Yadav,the Australian National Reference Laboratory sends them 10-20 samples every year for external quality assessment (EQA), and based on the NAT test report from their lab, there was not much difference in the result. “Wehave recently sent one report with 98 percent achievement. The records on HIV were almost 100 percent. They send us such samples twice every year. Every sample has a certain time frame within which we have to send them the reports. Then they will send us a comparative report,” he discloses. He also says that they use CE-certified companies, and sometimes the local level government suggests some of the different kinds of kits for HIV tests. Since NAT testing is done for the entire negative sample with the screening test, hence it is not very surprising to achieve 98-100% in such samples, the safety standard rises when false negative bags are not released. Reverse EQA would be beneficial as our negative samples are tested with NAT to find out the false negativity.

Areas where we lack the most
According to the national guidelines, the outdoor collection space should be shaded, well ventilated, well lighted, clean, and some distance away from the main road. In developed countries, they even use mobile buses to collect blood in public places. “But, when we collect blood in outdoor camps, we usually have problems with dust and crowd. We lack space for pre-donation counseling. There is no confidential and separate screening space to interview donors. We also haven’t been able to check the donors’ hemoglobin due to limited manpower,” says Dr. Rajkarnikar.
Dr. Yadav says that, in developed countries, interviews are taken seriously, and depending on the interview and the impression of donors, they are accepted or rejected. “We haven’t been able to conduct interviews and counseling with the donors in the way it should be done. We can minimize a lot of risks at this stage if we could collect blood from healthy donors. Almost 80 percent blood can be filtered out during this stage.”
There is also lack of doctors during the interview and selection of donors. “As per the international guidelines, the presence of a doctor is a must during this procedure, but it is not possible in every place in our context. We also don’t have sufficient doctors and staff nurses during blood transfusion services. But, we have trained staff. In the districts, doctors from the blood transfusion committee will be on call to provide guidance to the staff while providing the services,” says Dr. Rajkarnikar.

Component separation
After the blood donation is made, various blood components: packed red blood cells (PRBC), platelet concentrates, plasma, and cryoprecipitate can be harvested from the whole blood. The products from a single donation can benefit multiple patients. Each blood component can be used for a different indication.
“In developed countries, they do plasma fractionalisation to extract therapeutic products. They further separate albumin and protein products from the unused plasma in pharmaceutical manufacturing companies. People can provide raw materials to such companies through contract basis. But we don’t have a supporting legal system to open such companies in Nepal. Here, the plasma mostly goes to waste. If the patient needs it, we use it, otherwise it becomes useless in a year’s time.”

Disposal of unused blood and blood products
NRCS disinfects both infected and date-expired blood with hypochlorite solution, before discharging into the sewer. “Last time, we decided to dig the ground to dispose the unused blood products, but the locals were against it, so we had to drop the idea. It is one of the oldest methods of medical science.”
Dr. Yadav says that discharging blood products into the drainage is not the proper way, but due to lack of any other alternative, they are still using this method. “The right way would be to use an autoclave or a grinder. Incineration is another way, but it produces smoke during the burning process. Autoclaving would be the best, since it also grinds the blood bags into fine particles. It is a bit expensive, but we are making plans for obtaining it in the near future.”

What Nepal needs: quality or quantity?
“We should never compromise on the quality. One might say quality is expensive, but it is not. There are risks of transmission if we only focused on the quantity, further deteriorating a patient’s condition. Even WHO has said that blood is not the first priority for treatment; it is required in life-threatening emergency situations. But, that is a different scenario, where we might even have to transfuse blood without cross-matching,” says Dr. Rajkarnikar.
Dr. Yadav says that, as a clinician in a hospital, quality blood products are the most important. But, from a manager’s point of view, the need of public demands must be considered, as well. Nevertheless, quality can’t be compromised.

Can quality and quantity go hand-in-hand?
“It is not that difficult to achieve both. But, since NRCS is a humanitarian organization, there are some challenges to achieve this goal. The quality has been compromised due to lack of financial approaches, as it is a non-profit organization. But, if it were to be run like a business, there would be no problem. If people are ready to spend millions of rupees for a life-saving treatment, they will spend whatever cost is involved for a quality blood product, too,” says Dr. Yadav.
WHO has been emphasizing on the total quality system in blood transfusion for 10 South Asian countries, including Nepal, since 2000. In Nepal, the main barrier is costing. Says the doctor, “We want to run on a cost-recovery basis; Australia follows the same cost-recovery system. They charge 200 dollars for one unit of blood. The government covers that cost through insurance. The individual doesn’t feel any burden. It is incorporated in the system.”

Safety concerns
Dr. Yadav says that doctors should recommend blood products according to the need of patients. As transfusion itself is a risky process, they should focus on minimizing the risk when demanding the products, and put blood transfusion on the least priority list, only when there are no other alternatives. All blood products should be properly labeled and transfused to the specified patients, so the risk is minimized. In transfusion system, cold chain management is the most important logistic support.
Dr. Rajkarnikar says that the focus should be on education, motivation of donors, laboratory facilities, HR, and appropriate use of blood and blood products, without burdening the individual patients.

Blood and Beyond

Since 2016, Non-resident Nepali Association Blood Transfusion System Technology Transfer (NRNA BTS TT), under NRNA, has been conducting a webinar series, “Blood and Beyond”, every month to sort out problems concerned with blood transfusion and blood supply, and to make a more efficient system in Nepal. They are also committed to maintaining qualitative service of blood in Nepal with collaboration of stakeholders of Nepal. Recently, they have been working with Ministry of Health and Population of Nepal, Nepal Red Cross Society, and Sanquin Blood Supply System.

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