The challenge of blood collection in the face of Covid-19

By Dr Andrew Byamungu

Even without a single mortality of COVID 19 reported in Uganda the shock waves created by the virus have been felt in any part and any aspect of life in Uganda. The president's orders on containing the spread of COVID 19 could therefore not have come at a better time since it appears that it is no longer a question of if but when we shall face the full effect of the virus.

Uganda Blood Transfusion Service (UBTS) which is mandated to collect, store, process and issue blood to transfusing health facilities may face the impact of COVID 19 probably more than any other department in MOH because of the way it conducts its business. The model on which blood collection is done is mainly shaped by the effort to reduce blood with transfusion transmissible infections (HIV, Hepatitis B and C and syphilis) and ensure sustainability of blood collection with minimum monitory input.

Worldwide, blood for human therapeutic transfusion is collected from health human beings (blood donors) who fall in three categories namely: family replacement donors, paid commercial or professional donors and voluntary non-remunerated (unpaid) donors. In Uganda blood is got from voluntary non-remunerated blood donors. These are people who donate blood by their own free will and receive no money or any other payment which could be construed to be a substitute for money.

The advantage of such donors is that they are not under any pressure to donate blood and are therefore more likely to meet the national criteria of low risk donors, are more likely to donate regularly, are more likely to be free from transfusion transmissible infections (HIV, Hepatitis B and C and syphilis) and are also more likely to respond to appeals for blood donation during emergencies.

For one to appreciate how COVID 19 pandemic is going to affect blood collection, one has to understand how blood is currently collected in Uganda. The bulk of the blood (70% - 80%) is collected from students in learning institutions. The advantage of this model is that it is easy to organize, easy to collect blood since students are in one place and the blood is of higher quality compared to that from other communities since the prevalence of transfusion transmissible infections is generally low among students.

The second way of collecting blood is through conducting blood drives. This is common in urban areas where blood collection teams camp at one place and mobilize people to come and donate blood. This method which is sometimes supported by cooperate organizations is normally done when students have gone for holidays.

The third method is collecting blood from communities using blood donor clubs. With support from Red Cross, communities have been organized into different clubs with the overall objective of donating blood at regular intervals. The clubs have leaders who are also referred to as community resource persons (CRPs) who mobilize their club members to donate blood whenever they are called upon.

Blood is collected from schools, blood drives or donor clubs by teams through normal daily sessions (they collect blood and go back on the same day), or camps (where they stay in communities for two or three days) as they collect blood.

Blood is collection by teams which move in groups of ten people including a driver, phlebotomists, donor clerks and counselors. Currently not more than three people should move in one vehicle

The common denominator for all the above blood collection methods is that people congregate at one point and donate blood - something disallowed during the current efforts to curtail the spread of COVID 19.

COVID 19 is a new disease and there is little knowledge about it pathogenesis. While some general knowledge about its infectiousness, mode of spread, morbidity and mortality is known, this knowledge is mainly based on the experience from China, Europe and North America. The disease dynamics in Africa may be different because of co-infection with other viruses (including HIV), high prevalence of malnutrition and presence of both neglected and non-neglected tropical diseases. While it is known that about 5% of people who develop COVID 19 progress to the severe form which may lead to respiratory and /or multi organ failure, in Africa it is difficult to predict what may happen. Should the virus affect us in such a way that it necessitates transfusion of blood or blood products as part of its management regimen, then more blood may be needed - a situation that may compound the problem of anticipated blood shortage

Since people congregating at one point to donate blood is not allowed and not more than three health workers should move in one vehicle, there is a need for a paradigm shift on how we have been collecting blood.

Can we go back to family replacement donors? In this case a patient who requires blood will get it from either family members or relatives and friends. This method is helpful when voluntary non-remunerated blood donors may not be available and the patient is in dire need of blood. However, the disadvantage is when a patient needs blood when he/she is far from his/her relatives. Another disadvantage is that the criteria for identifying low risk donors may not be followed hence increased risk of transfusion transmissible infections

Can we use paid or professional blood donors? This form of blood collection is a sure way to get blood by patients who can afford or when government is willing to foot the bill. Its biggest disadvantage is that for people who can't afford to pay will surely die. Even if government pays, the venture will not be sustainable and will totally kill the WHO recommended model of voluntary non-remunerated blood donors even after the COVID 19 epidemic has passed

Can we collect blood by moving from house to house after identifying homesteads with potential donors? In this case blood collection teams can go and collect blood from a homestead and then move on to the next homestead. This is a cumbersome exercise where teams have to pitch camp from home to home. Other than being exhaustive and disruptive, at any given time, few units are likely to be collected and a lot of resources are likely to be used.

Is it possible to organize small groups (of less than 10 donors) at designated places where teams can collect blood at none crowded areas. Community Resource Persons could be used to mobilize them. This is possible but a lot of money will be required to facilitate CRPs if this becomes the single most used method of blood collection.

The way forward therefore is to limit use of blood in hospitals by ensuring that priority is given to hot cases (those who acutely need blood such as accident victims, bleeding mothers, anaemic children etc) and defer elective cases (where transfusion can also be delayed). Other suggested reforms that should be adopted during this epidemic include:

The Ministry of Health should take keen interest in management of the blood service and monitor the blood stock levels during the epidemic so that any looming blood shortage can be detected early enough. The ministry should assist UBTS to address the bottle necks that hinder collection of blood during the epidemic and where possible exceptions should be made having put into context the peculiarities of collecting blood during the epidemic period.

Uganda Blood Transfusion Service should design a communication strategy to assure donor of their safety during blood donation. This will address the anxiety of potential donors which stems from misinformation and lack of awareness or fear of getting infected with the virus during blood donation.

The public should be made aware of the importance of maintaining steady supplies of blood and safety of blood donation process for both the donor and the one collecting blood.

There should be undisrupted supply of critical materials and equipment especially protective gear for health workers and infra-red thermometers which build confidence in public hence encouraging more donors to donate blood.

Whichever mode we adopt, there is need for meticulous planning, serious community sensitization and mobilization and allocation of resources.

The writer is the Principal Medical Officer in charge of Mbarara Regional Blood Bank