Donated blood suplies: Need for strict control

Inez Nimpuno, Canberra

The news about contaminated blood donations is no surprise. Readers of the Feb. 14 article on tainted donated blood were not jolted or shocked, as public impression about transfusions is drawn from the common knowledge of how unreliable blood donation systems are in developing countries, including Indonesia.

The poor standards of blood transfusion programs is a reflection of the low support provided by the international aid community and Indonesian health development efforts. Still, the revelation of contaminated blood is inevitably worrying to those who depend their lives on regular or emergency blood transfusions, even if the news is not a surprise.

Earlier this week, reports on the outbreak of dengue fever and the increasing death toll filled every major newspaper in Indonesia. As cited in The Jakarta Post, the demand for blood has increased by 200 percent over the last month in Jakarta alone.

The increase was caused by a sudden demand for thrombocyte infusions to prevent further hemorrhaging in dengue patients when they reach a critical stage in the disease. Patients faced with the choice of transfusion or immediate death want to be assured that the donated blood carries no potentially fatal infectious diseases. They do not want to trade an immediate death from dengue fever for the fatal consequences of HIV.

The proportion of Jakarta blood donations contaminated with hepatitis B and C, HIV and syphilis rose from 3 percent in 2002 to 5 percent in 2003. This indicates an increased risk of infection if the blood supply is not effectively screened and the contaminated blood destroyed.

Luckily, the Jakarta supply seems to be screened, but we know that such screening does not take place everywhere in Indonesia. The questions we must ask are, where are blood supplies not screened, and what is the chance that contaminated blood gets through the screening procedures?

A breakdown of the screening process can occur either due to an under-resourced testing system or complexities in data collection. The problems that contribute to transfusion risk include inconsistent refrigeration, data entry errors, equipment failure and lack of quality assurance programs.

No data is available on the number of people who have contracted hepatitis B and C, HIV and syphilis after a transfusion, and this is the most obvious indicator of the problem. In Indonesia, an estimated 130,000 people have been infected with HIV, but fewer than 5,000 have ever been identified through a blood test. The rest are so-called silent victims.

The World Health Organization (WHO) has reported that about 5 to 10 percent of all HIV infections worldwide were acquired through contaminated blood and blood products. Their report asserted that in Indonesia, almost all donated blood is screened for HIV. However, Indonesia is one of the countries that test 50 to 70 percent of blood donations for hepatitis B and 20 to 30 percent for hepatitis C.

It is estimated that the prevalence of HIV among blood donors increased from 0.001 percent to 0.004 percent from 1992 to 1999, to slightly less than 0.01 percent from 1999 to 2000. If the proportion of blood donations contaminated with major infectious diseases, including HIV, is now 5 percent and rising, the WHO evaluation would appear to be seriously out of date.

Industrialized countries assure blood safety by screening donors, deferring high-risk donors and screening all donations for serologic markers of infectious diseases. Here, the Indonesian Red Cross (PMI) manages most blood donations and blood banking. At the provincial level these programs strive to be of high quality, although most doctors will say that the systems "could do better".

At the district level, screening is difficult to implement. Systems are not in place to recruit and retain low-risk donors, and there are virtually no resources for the training and supervision of personnel in infectious-disease testing, record keeping and blood bank management. In many places, no budget even exists for procurement, management and proper distribution of test reagents.

When test kits are provided, laboratory procedures are irregular and subject to human error. Record-keeping is generally substandard, and because of limited resources and infrastructure, no pretense at quality assurance is even made. All these factors compromise the accuracy of testing.

Such talk of testing and screening is of little reassurance to the thousands of patients each year who are told that they or their families must search for blood before a serious operation or in a medical emergency. The stories of frantic husbands driving through the night to find blood of a particular type for their wives who are hemorrhaging after giving birth would seem melodramatic if it were not so common in small towns and even major cities across the country.

Sixty percent of maternal deaths is caused by hemorrhaging. Women require safe blood for postnatal treatment. To talk of reducing maternal mortality means guaranteeing the blood bank system, integrating it into the hospital system and subjecting both to strict quality control. To consider less is omong kosong -- empty rhetoric.

Still, this lip service will not surprise Indonesians. They have had three decades of omong kosong concerning blood banks. It may not be a surprise, but it should be a concern for every voter. The electorate should ensure that candidates fill their rhetoric with solid commitments, clear programs and guaranteed budgets.

The writer is a medical professional who recently completed a Masters Degree in Demography at the Australian National University. She undertook field research on blood supply problems in 2002.