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Jayaram A; Pendleton A, Dutta R; Roy N, Raykar N. Necessity is the mother of invention: advocating for alternatives to banked blood. HPHR. 2021;32.
DOI:10.54111/0001/FF1
Safe blood is a scarce resource, especially in low- and middle-income countries. Over 50% of blood is donated and utilized in high-income countries such as the United States, Canada, Europe and Australia. Although the number of hemorrhage-related deaths each year is unknown, at least 5 million people annually die from trauma-related injuries, overwhelmingly due to hemorrhage. While all blood transfusions carry the potential risk of a transfusion transmissible infection, the unavailability of blood in hemorrhagic emergencies results in almost certain death. Here, we outline three potential domains for interventions: enhancing delivery systems, increasing salvage of blood in operating rooms, and walking blood banks. To truly scale surgical systems and meet the needs of the patients in those systems, it is imperative that we increase access to safe blood now.
Access to a safe and affordable blood supply is critical to the provision of safe surgical and anesthesia care. However, safe blood is a scarce resource, especially in low- and middle-income countries (LMICs). Over 50% of the world’s blood supply exists in the United States, Canada, Europe and Australia. Conversely, every single country in South Asia, Oceania, and Sub-Saharan Africa are in blood shortage. Meanwhile, hemorrhage from trauma, obstetrics, pediatric anemias, and gastrointestinal hemorrhage kill millions who live in the world’s poorest settings.1 At least 5 million people worldwide die from trauma-related injuries annually, overwhelmingly due to hemorrhage.2 One-fourth of maternal deaths in Africa are attributed to hemorrhage.3 An estimated 50-80% of sickle-cell patients in sub-Saharan Africa will die before the age of five, many in need of blood transfusion.4
Our team works in India, where the blood donation rate is 4 units per 1000 people, well below the WHO recommended minimum of 10 units per 1,000 population.5 Sadly, this low national average actually overstates blood available to much of the Indian population. Bihar is one of India’s poorest states with a population of over 100 million. 89% of Bihar’s population is rural, but most blood banks are located in urban settings. In fact, seventy percent of first-referral units (FRUs) in Bihar—facilities that serve as the point-of-entry for advanced maternal care including cesarean delivery—do not have an on-site blood bank. This means that over 100,000 deliveries, including 1,700 cesarean deliveries, occur at FRUs without blood available onsite.6-8 In cases of obstetric hemorrhage, patients’ families are asked to procure blood from government or private blood banks. Without timely access to banked blood, clinicians in these centers are forced to refer patients to higher centers, with travel times in the hours and at significant cost to the patient.9
The unavailability of blood in the case of hemorrhagic emergency results in almost certain death. And while governments, health systems, and the transfusion medicine community work diligently to optimize blood banking systems and availability, this leaves out the hundreds of millions who live outside the reach of a blood bank. Here, we outline three potential strategies to end the blood drought in the world’s poorest settings: civilian walking blood banks, enhanced delivery systems, and increased salvage of blood in the operating room.
Drone-based delivery is an innovation that increases the catchment area of existing blood banks. Especially important in areas poorly accessible by roads that ambulances or cars cannot easily traverse, unmanned aerial vehicles allow for urgent and emergent blood delivery. One company working in Rwanda has developed drones capable of travelling distances up to 99 miles with up to four units of blood (10). These systems have also been used successfully in conjunction with cell phone-based ordering and could be leveraged as part of a system to increase the catchment area of timely blood delivery, especially in areas with mountainous or inaccessible terrain.10 Further geospatial analysis and investment are needed to identify drone delivery feasibility and cost-effectiveness compared to other modes of transportation in a variety of settings. However, while this can extend the reach of blood accessibility in an emergency, it does not address the supply challenges of low donorship, blood collection, and underlying blood availability.
Intraoperative autotransfusion (IAT) is another alternative to banked blood, in which the patient’s blood is collected, filtered, and then transfused back to them in the operating room. Used for decades in cardiac surgery in high-income settings, this technique can decrease the strain on the system for additional blood for elective surgery – and potentially for emergency surgery, while limiting the risks of TTI. One study interviewed surgeons and anesthesiologists familiar with IAT in low-resource settings and found barriers to more widespread use of IAT were a lack of knowledge and a lack of formal guidelines and affordable equipment. Most of the efforts in this arena have been through self-made devices, as there has been a lack of affordable commercial devices.11 The Hemafuse, an IAT system designed for low-resource settings, is an example of a product developed specifically for the low-resource setting though it does not replicate the cell-washing capabilities of more advanced systems and it has yet to be tested on a large scale.12 Additionally, while it may decrease demand for blood donation for intraoperative needs, it will not address the broader aspects of blood access or availability.
Without access to blood banks, Indian surgeons taking care of the rural poor in the 1980s and 1990s developed their own. In a system they called “Unbanked, Directed Blood Transfusion”– and what is now known as a “Walking Blood Bank.”13 Here, rural surgeons collected whole blood from a consenting donor (such as a member of the patient’s family, the local community, or the healthcare staff) on-demand, tested the blood for infection with rapid testing kits for HIV and hepatitis, performed a cross-match, and transfused the patient. While effective, these practices were banned by the Central government amidst concerns over potential HIV transmission in the blood supply. At the time, rapid testing kits had lower sensitivity for HIV and hepatitis compared to testing available in blood banks.14 Though outlawed in India, the life-saving potential of UDBT has been successfully leveraged in emergencies within other low-resource settings. Since, advances in diagnostic testing have produced rapid testing kits for HIV, HBV, and HCV with equivalent sensitivity and specificity to blood-bank based ELISA testing systems Additionally, these tests are low-cost, fast (approximately 10 minutes for results), do not require a cold-chain, and meet WHO sensitivity/specificity guidelines.15 Militaries across the world have refined the use of walking blood banks in combat zones and for its soldiers in overseas deployments in peacetime, there has been at least one documented instance of activation of a civilian walking blood bank in Norway, and guidelines have been developed for walking blood banks for the disaster setting.16 The United States military has transfused over 3000 individuals successfully with minimal adverse events.17 Social media and the widespread ownership of mobile phones in LMICs could be used to leverage just-in-time donation, as evidenced by organizations such as Blooders in Mexico, which have started to operate at the intersection of education, communication, and blood donation and management.18 Walking blood banks are particularly interesting because they address the entire continuum of transfusion, from donation and blood collection to testing and transfusion. It increases the blood supply in remote settings, where it is employed.
While ministries of health should continue to prioritize investment in and optimization of the entire continuum of blood transfusion from blood donation to testing to banking and transfusion, they must also recognize the plight of the millions who will be outside of the reach of a blood bank for the near future. The interventions outlined here all demonstrate promise in providing more immediate relief for the blood drought but have yet to be tested systematically. To identify contextually appropriate alternatives for blood transfusion in the absence of banked blood, we must start with identifying rate-limiting steps in blood donation and delivery across different contexts. What is the actual transfusion needed at remote, rural hospitals in different parts of the world? Is it cost-effective to establish a blood bank in these settings or cheaper to fly blood there in times of immediate need? What is the local prevalence of HIV, HBV, and HCV and what would be the optimal testing strategy for a walking blood bank? Is the operative volume high enough to warrant a focus on intraoperative autotransfusion?
To answer these questions and many others, there is a pressing need for high-quality cross-sectional studies that employ a blend of quantitative, geospatial, modelling and qualitative analysis methods to understand community blood needs and the feasibility of strategies to make blood transfusion in rural and low-resource communities that need it the most. Blood transfusion is critical to preserving life in settings of hemorrhage or life-threatening anemia. There has been insufficient focus on blood needs in the world’s most rural and poorest communities. There is an urgent need to scale blood systems using traditional and novel approaches to leverage the latest in transportation, low-cost innovation, and communication technology.
Anusha Jayaram is a Class of 2022 MD/MBA candidate at Tufts University School of Medicine pursuing general surgery residency. After graduating from NYU with a degree in Anthropology, she worked in clinical surgical research at Mount Sinai. She currently serves as the National Co-Chair for the Global Surgery Student Alliance, where she has engaged in global surgery research, advocacy, and education for and with students and trainees. She recently was a Paul Farmer Global Surgery Research Associate at the Program for Global Surgery and Social Change for the 2020-21 academic year, where she worked with Team India on projects related to trauma, access to blood, and financial risk protection.
Alaska Pendleton, MD, MPH is with the Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, at Harvard Medical School, and the Department of Vascular and Endovascular Surgery, Massachusetts General Hospital, in Boston, MA.
Rohini Dutta is with Christian Medical College and Hospital, Ludhiana, India, and the World Health Organization Collaborating Center for Research in Surgical Care Delivery in Low-and-Middle Income Countries, in Mumbai, India.
Nobhojit Roy, MD, PhD is with the World Health Organization Collaborating Center for Research in Surgical Care Delivery in Low-and-Middle Income Countries, in Mumbai, India.
Nakul P. Raykar, MD, MPH is Fellowship Director at the Program in Global Surgery and Social Change at Harvard Medical School and a trauma surgeon at Brigham and Women’s Hospital in Boston, MA. He was part of the core author for The Lancet Commission on Global Surgery and his research focus is on expanding access to blood transfusion in low-resource settings. He can be reached at nraykar@bwh.harvard.edu for further inquiries related to this article.
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