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Blood Transfusion in Sub‐Saharan Africa

Article in Transfusion Alternatives in Transfusion Medicine · June 2008

DOI: 10.1111/j.1778-428X.2004.tb00108.x

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TATM 2004;6(1):16-23

Blood Transfusion
in Sub-Saharan Africa

SUMMARY

The population of Sub-Saharan Africa has an average annual income of $400-1000

J EAN -P IERRE A LLAIN , MD , PhD , 1 and cannot afford blood produced according to the standards established by affluent
S HIRLEY O WUSU -O FORI , MD , 2
AND I MELDA B ATES , MD 3 countries. To prepare enough safe blood in a sustainable fashion, African countries
1
DEPARTMENT OF HEMATOLOGY need to optimize use of their own resources and develop ways to produce affordable
UNIVERSITY OF CAMBRIDGE
safe blood appropriate to their own situations. Uncritical adoption of external advice
CAMBRIDGE, UNITED KINGDOM
and models, particularly those from more wealthy countries, may lead to problems
TRANSFUSION MEDICINE UNIT
2
of sustainability unless they are adapted for use in resource-poor environments.
DEPARTMENT OF MEDICINE
KOMFO ANOKYE TEACHING HOSPITAL Sub-Saharan African countries have developed a variety of systems to achieve the objective
KUMASI, GHANA of producing safe blood. These vary from centralized, high volume, modern blood

3
LIVERPOOL SCHOOL OF TROPICAL MEDICINE centers to locally organized donor programs for isolated district health care facilities.
LIVERPOOL, UNITED KINGDOM The wide range of systems to recruit, select and retain blood donors and of availability

of choice of reagents and equipment to screen blood allows flexibility so that the

transfusion process can be adapted to local circumstances and resources.

With variations in the prevalence rate of HIV, HBV and HCV, the cumulative prevalence

is invariably high in Africa and therefore, test sensitivity is critical. Nucleic acid

testing is highly sensitive but is not affordable. New inexpensive and effective testing

technology as well as pathogen inactivation techniques directed towards the needs

• Blood supply
• Safe blood of developing countries should become a major target of external support.

• Blood screening

16 )
Transfusion Alternatives in Transfusion Medicine
( Page VOLUME 6 NUMBER 1 MARCH 2004

‘17% of the global population has access to 60% of the global blood
supply.’1 In 2002, the WHO estimated that among the 46 member
states in the African continent, 14 had a national blood policy
and six had a policy to encourage volunteer donor recruitment.2
Overall over 60% of blood originated from replacement/family
donors. This review also estimated that 25% of the blood was
untested for anti-HIV and that blood transfusion was the origin
of 5-10% of new HIV infections. HBsAg was screened in 50% of
donors or donations and only 19% were screened for anti-HCV.
For the whole continent, the priority problems impeding
progress in transfusion are the inconsistency of supply and high
prices of screening tests, breakage in the cold chain mostly due
to frequent power cuts and poorly trained staff. Most blood is
collected in small hospital-based units often with no dedicated
staff or specifically allocated budget. A number of national blood
centers leading or coordinating national blood transfusion
activities have been established in sub-Saharan Africa with
external support.
This review will expand on some of the issues but focus on
sub-Saharan Africa where the problems are most enormous and
the solutions the most difficult to find.
Organization of Transfusion
Services
in Sub-Saharan Africa
There is marked variability in the organization of transfusion
services in sub-Saharan Africa (Box 1). For many years, WHO
has encouraged governments to develop national blood policies
and create blood center networks. Considerable effort has been
made in developing quality assurance and standard programs to
improve the quality of available blood.3 A few countries (e.g.,
Côte d’Ivoire, Benin, Malawi, Kenya) have invested significant
resources in transfusion services (often with financial support
and advisers from European or North American governments)
and have committed to establishing centralized systems based
on the blood bank model used in wealthy nations (Table 1).
These centers typically collect over 10,000 units a year, use
automated equipment and produce some components. Blood
donor recruitment, and screening and processing of donated
blood, is carried out in specifically designed premises away from
the hospitals where blood is transfused.
At present, most countries in sub-Saharan Africa do not operate
a centralized transfusion service.4 Each hospital recruits donors
for its own patients and processes the blood for local transfusion.
These hospitals often handle less than 1,000 units a year5-7 and
experience difficulties in standardization, quality assurance and
in maintaining supplies of high quality reagents. Recruiting
voluntary donors from the community is complex and expensive
and depends on regular education programs, venesection teams,
vehicles and cold storage. Because of these difficulties, the
Transfusion Alternatives in Transfusion Medicine
Blood Transfusion in Sub-Saharan Africa J E A N -P I E R R E A L L A I N et al.
Box 1. Case Studies – Examples of Blood
Transfusion Systems
Integrated National Blood Service
Côte d’Ivoire blood service was created in 1992 with substantial subsidies
from the European Union that created a National Blood Transfusion Center
located in Abidjan, the capital, and three smaller provincial centers located in
Bouaké, Daloa and Korhogo. In addition, blood depots are located in hospitals
in five other major cities. For a population of 12M, approximately 80,000
units of blood were collected in 2002, mostly from volunteer blood donors
recruited amongst secondary school students (> 60%), of which 24% were
first time donors.
Any hospital in the country has access to the blood supply free of charge
to the hospital and the patients. The government provides the funding. Less
than 20% of the blood is processed into blood components that are mostly
used in the capital. Antibody to HIV and HCV as well as HBsAg are tested by
EIA in the capital. The cost per unit produced is estimated to be $40.
Regional Hospital Blood Service
In a 1200 bed hospital, the current demand for blood products is, in adults,
whole blood for acute anemia or massive hemorrhage and, in children, 200 mL
plasma-depleted red cells for anemia related to malaria, sickle cell disease or
thalassemia. The centrifuge for preparation of blood components has been
awaiting spare parts for several months and only whole blood is currently
available. Approximately 10,000 candidate donors are screened per year and
7,000 blood units are available for clinical use. Ten per cent of this total is
distributed to private hospitals across the 1.2 M inhabitant city, the rest being
used in the main hospital. Patients’ families are asked to pay $14 for a unit
of blood and $7 if the blood is replaced. Volunteer blood (50% of total) is
primarily collected in secondary schools (80% of total volunteer donations).
Anti-HIV, HBsAg and anti-HCV are screened pre-donation with high
performance rapid tests so that blood bags (representing one third of the total
consumable budget) are not wasted. This approach also means that only clinical
grade blood is collected and deferred donors can be identified, informed and
counseled. This procedure has led to a decreasing prevalence of viral markers
in volunteer donors.
Rural, Community Hospital
This 40-bed hospital is too isolated to conveniently order and receive blood
from the regional hospital center and has to rely on its own resources to
produce the 100-200 blood units per year needed. They have procured the
blood bags and the anti-HIV and HBsAg rapid tests from the regional blood
center. Because of the small demand, collecting and keeping a refrigerated
blood stock is neither feasible nor economical. The staff have designed an
alternative strategy called ‘donor club.’ The local population was informed
about transfusion through village meetings and sketches presented by the
local drama group, which illustrated situations involving the need for blood
and blood donors. Volunteers who agreed to join the club were registered and
tested for blood group and HBsAg. HBsAg negative volunteers (80%) constitute
a registry of potential donors who agree to be called upon in case blood is
needed in the hospital. When a patient needs blood, the blood group is
determined and two blood group-matched volunteers are brought to the
hospital and tested for anti-HIV. Blood is then collected from a HIV negative
donor. HBsAg is not re-tested as HBV infection occurs predominantly at birth
(see below). The patients’ family are charged $9 for each unit of blood.
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Blood Transfusion in Sub-Saharan Africa J E A N -P I E R R E A L L A I N et al.

majority of donors in poorer countries are ‘replacement’, not
volunteer, donors. These are family members who are responsible
for providing blood for their relatives in the hospital. Patients in
poorer countries usually present late in the course of their disease
and the delays and lack of stored blood inherent in the
replacement donor system mean that patients may die before a
blood transfusion can be organized.
Improving the Blood Supply
As shown in Table 1, the blood supply in Sub-Saharan Africa
ranges between 1 and 11 units/1000 inhabitants with a median
around 3, compared to a range of 30-60 in developed countries.
Higher level of supply and availability of some components are
found in more wealthy African countries (Botswana, Gabon) or
those that have benefited from considerable external support for
many years (Côte d’Ivoire and Senegal). The poor level of supply
has forced users to utilize trigger values of hemoglobin as low
as 4 or 5 g/dL that are considered life threatening in other
settings. As we will consider later, this situation is further
compromised by an inadequate clinical use of this rare
therapeutic weapon.
In most parts of Africa, replacement donors are the main
resource and account for > 80% of the blood supply in sub-
Saharan Africa (Table 1). They are typically young males in the
high-risk bracket of HIV infection or other sexually transmitted
viruses.8-10 Cultural taboos and lack of education about donating
blood (e.g., ‘men will become impotent if they donate blood’;
‘HIV can be caught from the blood bag needle’) makes relatives
reluctant to donate so they may choose to purchase blood from
‘professional donors.’
As the availability of replacement donors is limited, the most
effective way to improve the availability of blood is to recruit
and retain secondary school students as volunteer donors.10,11
They are younger (age range 16 to 20) and generally less sexually

Table 1.
Some Basic Facts About Blood Transfusion in Some Sub-Saharan African Countries*
Country† Blood system Units/year Units/1000‡ Components % replacement Virus screened§ Cost (USD)
Real To patients
Cameroon Decentralized 25,000 1.6 5% RCC, FFP 88 HIV, HBV 40 6
Rep. Congo Centralized 21,000 7 HIV, HBV
Côte d’Ivoire Centralized 80,000 4.7 20% RCC, FFP, PC < 20 HIV, HBV, HCV 45 No cost
integrated
Gabon Decentralized 15,000 11.3 20% RCC, FFP HIV, HBV, HCV 45 No cost
Guinea Centralized 20,000 2.2 5% RCC, FFP HIV, HBV 40 8
Mali Centralized 25,000 2.2 5% RCC, FFP HIV, HBV 40 8
integrated
Rep. Dem. Centralized 80,000 1.4 < 5% RCC HIV 50-100%
coordinated
Congo
Senegal Centralized 40,000 3.8 20% RCC, FFP, PC HIV, HBV, HCV 45 8
integrated
Botswana Centralized 12,000 7 97% RCC, 50% FFP 0 HIV, HBV, HCV 10 No cost
(supplies)
Ghana Decentralized 60,000 3 5% RCC, FFP 80 HIV, HBV, HCV|| 15 10-14
coordinated
Kenya Decentralized 50,000 1.6 < 5% RCC 60 HIV, HBV
± coordinated
Malawi Decentralized 25,000 2.5 0 90 HIV, HBV 12 No cost
Nigeria Decentralized < 5% RCC 66 HIV, part HBV 20-35 20
Tanzania Decentralized 130,000 3.7 < 5% RCC > 80 HIV, part HBV 12.6-25
Zimbabwe Centralized 0 HIV, HBV, HCV 20-30 insurance
* Most data have been tabulated from abstracts published at the 3rd African congress of Blood Transfusion (Tunis 2002) or the French national congress of Transfusion (St Etienne, France), 2003.
† Côte d’Ivoire, Gabon, Guinea, Mali, Senegal benefited from EU start-up funding for infrastructure, equipment and training. Cameroon, Ghana, and Nigeria did not receive external funding. In all French
speaking countries, government or hospitals heavily subsidize blood production.
‡ Units of blood collected per 1000 inhabitants.
§ Screening is performed with EIA in capital blood centers collecting 10-70,000 units/year and with rapid tests in regional or other types of health care settings.
|| HCV screening started nationwide in 2003.]
¶ For patient families who provide a replacement donor, cost is reduced by 50%.

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Transfusion Alternatives in Transfusion Medicine
( Page VOLUME 6 NUMBER 1 MARCH 2004

active than older donors, have a greater proportion of females
and are 5 to 10 times less likely to be infected with HIV than
replacement donors.
Several strategies have been devised to encourage repeat
voluntary donors in an attempt to further reduce the risk of virus
carriage.12,13 but these recruitment and retention programs require
dedication and funds that are not always available. In Zimbabwe,
Pledge 25 Club, a program using education and incentive to
attracting school students to give blood 25 times, has been largely
successful.14 A less ambitious ‘Club 5’ could also be very effective
in many areas. However, during school recess, alternative
strategies need to be devised. Those include recruiting donors
from faith-based organizations or collaborating with radio stations
to organize and promote blood donations.15
Ultimately, the objective should be that the exclusive source
of blood be repeat volunteer donors as already achieved in
Botswana, Côte d’Ivoire and Zimbabwe, but this will take time,
dedication and funds.
As a novel and accessory source of blood, the feasibility of
using placental blood to transfuse small children in malarious
areas is currently being investigated.16 The placenta containing
this blood is normally discarded after delivery but the high
hematocrit and easy availability may make it suitable for small
volume emergency transfusions.
Blood Safety
An unsafe blood supply is costly in both human and economic
terms. Transfusion of infected blood causes morbidity and
mortality in the recipients, and has an economic and emotional
impact on their families and communities. Those who become
infected through blood transfusion are infectious to others and
contribute to the spread of disease throughout the wider
population. This increases the burden on health services and
reduces productive labor. Investment in safe supplies of blood
is therefore a cost-effective investment for every country, even
those with few resources. WHO has identified four key objectives
of all strategies used to ensure that blood is safe for transfusion
(Box 2).1
WHO stipulates that an effective quality assurance program
should be in place for all aspects of the transfusion process. This
process involves all operation stages: donor recruitment and
selection, infection screening, blood grouping and blood storage,
administration to the patients and clinical monitoring for adverse
reactions. It is the responsibility of governments to develop
policies and legislations that will guarantee that the blood
transfusion process and its associated quality assurance programs
are of international standard. It is well recognized that poor
performance of transfusion processes can significantly reduce
the safety and efficacy of blood transfusions.17,18
Transfusion Alternatives in Transfusion Medicine
Blood Transfusion in Sub-Saharan Africa J E A N -P I E R R E A L L A I N et al.
Box 2. Key Objectives of Strategies
to Ensure Provision of Safe Blood1
• Establish a coordinated blood transfusion service that can provide adequate
and timely supplies of safe blood for all patients in need
• Collect blood only from voluntary non-remunerated blood donors from low-
risk populations and use stringent donor selection procedures
• Screen all blood for transfusion-transmissible infections and have standardized
procedures in place for grouping and compatibility testing
• Reduce unnecessary transfusions through the appropriate clinical use of
blood, including the use of intravenous replacement fluids and other simple
alternatives to transfusion, wherever possible
Epidemiology of Blood Borne
Infections in Sub-Saharan Africa
HIV
The overall prevalence of HIV antibody in sub-Saharan Africa
blood donors ranges between 0.5 and 16% (Table 2). It tends to
remain below 5% in West Africa, below 10% in East and Central
Africa and above 10% in Southern Africa.19
Hepatitis B
Chronic hepatitis B prevalence, indicated by the presence of
circulating HBsAg, ranges between 5 and 25% in both the general
population and in blood donors.20 This high prevalence is due to
the mode of transmission and the virtual absence of national
vaccination programs. HBV infection is acquired predominantly
at birth or horizontally in infancy. By age 10, most of the population
has been in contact with HBV. Infection of adults through other
routes is rare. Prevalence data from blood donors is not entirely
reliable since it depends heavily on the sensitivity of the screening
assays used.20 HBsAg tends to be more prevalent in West Africa
(10-25%) than in East or Central Africa (5-10%); the lowest
prevalence is found in Southern Africa (5% or less) (Table 2).
Hepatitis C
Antibody to HCV is not routinely screened for in many parts
of Africa but the prevalence of this infection ranges between 0.5
and 3% and reaches 10-15% in Egypt21 or in localized areas
suggesting the importance of local factors such as various types
of injections, or past diagnostic or vaccination campaigns
contributing to spread the infection.
Other Infections
Most countries in sub-Saharan Africa do not screen for HTLV
since the prevalence is low (< 2%). In addition, its pathogenicity
post-transfusion has only been demonstrated in immuno-
suppressed patients who are rare in Africa.
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Blood Transfusion in Sub-Saharan Africa J E A N -P I E R R E A L L A I N et al.

Although the risk of acquiring syphilis from infected blood is the situation in the field, particularly in small, remote, hospitals
low, most blood banks in sub-Saharan Africa do screen for where regular supply of reagents remains a major issue. Lack of
Treponema pallidum. Infected fresh blood is potentially infectious quality assurance, poor supervision of operators and inadequate
for syphilis but storage at 4°C can inactivate the bacterium. storage conditions of kits affects considerably the residual risk
Malaria can be transmitted by transfusion and has an incubation of transfusion-related infections.17
period of 7-50 days. In areas of low or no malaria transmission, In many hospitals, HBsAg screening is performed with latex
screening for the parasite is important, as recipients are likely to agglutination or other rapid tests with sensitivity ranging between
have no immunity. In countries where malaria is highly endemic, 50 and 95% compared to enzyme immunoassays (EIA), which
the prevalence of Plasmodium in donor blood is very high (16- detect 0.4 ng/mL of HBsAg.20 WHO has established a systematic
40%), particularly during the rainy season22,23 and a policy of evaluation of both EIA and rapid tests to guide developing
excluding donors with low-grade parasitemia would lead to a countries in their choice of reagents. These evaluations include
significant loss of donors. In these countries much of the blood test costs. Many rapid tests for anti-HIV and HBsAg and fewer
is given to hospitalized children with malaria who are likely to for anti-HCV are available but sensitivity and specificity, ease of
be receiving anti-malarials, or adults who are clinically immune use and cost vary greatly (WHO/BCT/BTS 2001, 2002). Some
to malaria. Preventive treatment of young children receiving of these tests are performed in one single step with results
transfusion with anti-malarial drugs is considerably more cost- obtained in 10-20 minutes using whole blood, plasma or serum
effective than screening blood for malaria parasites.23,24 samples. The best assays have > 98% specificity and sensitivity
similar to EIA for anti-HIV, > 95% for anti-HCV and detect
1 ng/mL of HBsAg.
Screening for Blood-Transmitted New approaches adapted to local situations appear promising.27
Infections – The Reality In small blood banks, the expensive microtiter plate systems
used post-donation can be replaced by cheaper, more cost-
HIV transmission through blood transfusion has clearly effective, high performance rapid tests performed pre- or post
dominated blood safety during the past 15 years and major donation. Pre-donation testing provides the advantages of
progress has been made to eliminate infectious blood. Some reducing material waste and easy, on-site, communication with
studies attributed 5-10% of HIV infections to transfusion and deferred donors who, otherwise, could not be reached.15 To
up to 40% in children.25,26 At present, on the basis of data increase the level of blood safety, governments, hospitals, WHO
provided by the governments of individual countries, WHO and aid agencies need to show flexibility and consider the benefits
consider that 95% of the blood transfused in sub-Saharan Africa of multiple strategies adapted to local needs rather than directly
is screened for antibody to HIV. This does not necessarily reflect importing the Western models designed for totally different
populations, staff or resources (Table 3).
Table 2.
Prevalence of Transfusion-Transmissible Agents in Sub-Saharan African Blood Donors Residual Risk of
Country Year collected Prevalence (%) Transfusion
Anti-HIV HBsAg Anti-HCV HTLV Syphilis Malaria Transmission of Blood
Benin 1998 0.5-3 12 1.4-2.3 0.3-5.4 33.5
Borne Viruses
Botswana 2000 10 5 1
Cameroon 1994-1998 4.1-5.8 10-16 1.6
The present residual risk of viral
Ghana 1998-2002 1.7-3.8 15 1.7-8.4 0.5 13.5
transmission by transfusion has been
Kenya 1995-1998 4.5-3.0 4.2-3.9 1.5-1.8
assessed for HIV. In studies conducted in
Malawi 2000 10.7 8.1 6.8 2.5 3.0
Kenya, Zambia and the Democratic
Nigeria 1992-1998 3.9-5.4 15-20 12.3 0.7 19-41
Republic of the Congo, the risk of HIV
RDC 1998 6.4 9.2 4.3
transmission by transfusion was estimated
RSA* 2001 4.5 5 0.5
between 1 and 3%, related in part to high
Tanzania 1998-2000 4-8.7 11-20 1.2-10.3 0 11-12.7
prevalence but also to poor test
Togo 1995-2000 3.3 1.8
performance, inadequate storage
Uganda 2000 3.9-5.4
conditions and staff training.17,28,29 The
Zambia 1991-1995 8-16 6.5
residual risk of HBV infection remains
Zimbabwe 1997 8.8 2.5-15.4 0.1
substantial because of donations
* Donors of African origin.
containing low level of HBsAg or occult
HBV DNA.20 This risk remains high for

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Transfusion Alternatives in Transfusion Medicine
( Page VOLUME 6 NUMBER 1 MARCH 2004

children below age 10 but is mitigated in older patients by the
very high prevalence of HBV markers indicating immunity (60-
90%). In Ghana we evaluated the residual risk of HIV, HCV and
HBV transmission by genomic screening at 1:2,578, 1:1,450 and
1: 326, respectively when using EIA screening.20,30 These risks
are essentially due to the window period for HIV and HCV and
to occult chronic carriage for HBV (HBsAg negative/DNA
positive).
Cost of Transfusion Services
in Sub-Saharan Africa
Many countries in sub-Saharan Africa have introduced ‘fee-
for-service’ in the health system. In these countries, costs of
transfusion are entirely or partially paid by the patients’ families
who have an average income of $400-1,000/annum. As a result,
the cost of transfusion has to remain very low to be affordable.
This leads to compromises on the quality and safety of blood or
to heavy reliance on external aid thereby threatening
sustainability. The cost of a blood unit should not reach a level
that would discourage patients from its use.
Some countries, particularly in the Central and West African
French speaking countries, have established a government or
hospital-financed system covering blood costs either totally as
in Côte d’Ivoire and Gabon or partially as in Guinea, Burkina-
Faso or Senegal with families paying a fixed price of $7-10/unit
that represents less than 25% of the actual cost (Table 1). This
situation seems to be specific for blood transfusion as it does not
apply to other health costs.
In most English speaking countries with a ‘fee-for-service’
policy, blood is provided at cost (when known) or at a centrally
established price. In most cases, a replacement donor system
rather than one relying on volunteer donors reduces the
processing cost by 50% to $4-8.
When a transfusion service is provided by individual hospitals,
it places an enormous burden on laboratory resources. In a
typical district hospital in Malawi in 1997, 39% of all tests
performed by the laboratory were transfusion-related. The overall
cost of the transfusion service, including consumables,
proportional amounts for capital equipment and depreciation,
staff time and overheads, was 36% of total laboratory costs.
Extrapolating from these figures, each unit of whole blood cost
the laboratory approximately $12 to collect and process.31
The challenge for Africa is that safe blood should be affordable
for health services and individuals with extremely limited
resources. The majority of a blood unit cost originates from
imported goods such as the blood bags and grouping and
screening assays. Staff costs are a relatively small proportion of
the overall costs because salaries are low and because negligible
resources are put into staff training, supervision and auditing
mechanisms. According to published studies, a unit of blood
Transfusion Alternatives in Transfusion Medicine
Blood Transfusion in Sub-Saharan Africa J E A N -P I E R R E A L L A I N et al.
Table 3.
Potential Testing Strategies for Viral Markers in Sub-Saharan Africa*
Strategy 1 Strategy 2 Strategy 3
Units collected/annum† < 10,000 < 10,000 > 10,000
Cumulated prevalence > 10% < 10% 5-25%
of HIV/HBV/HCV
Type of screening tests Rapid Rapid EIA
Confirmation‡ Rapid Rapid EIA
Time of Testing Pre-donation Post-donation Post-donation
Cost of screening/ 3-5 3-5 5-8
donor or unit ($)
Cost/unit for clinical use§ < 15 15-20 20-40
* This Table is based on published data from Sub-Saharan Africa. Rapid test performance
and cost can be found in the WHO website.
† District/private hospital or most regional hospital blood banks collect less than 10,000 units
of blood per annum.
‡ Confirmation of reactive test is performed with alternative screening assays of the same type.
§ Pre-donation screening saves the cost of plastic bags. All units collected are clinically usable.
These potential strategies have all been piloted in various countries and blood banks in West
Africa. Details can be found in references 7, 15, 42-44.
may cost between $10 and 40,32 which is not affordable by most
families in sub-Saharan Africa. Because transfusion is such an
expensive service, the costs are often subsidized by the
government or external agencies making resources for transfusion
services vulnerable to fickle political and non-sustainable
fluctuations.33
Developing systems that rely more on local resources means
that they may be more dynamic, productive and sustainable.34
There are several ways to make effective cost-savings in
transfusion services in sub-Saharan Africa. For example, using
cheap but effective rapid tests that do not require equipment,
diagnostic companies reducing prices for resource-poor countries,
avoiding additional costs to intermediaries and limiting blood
bag waste by pre-donation screening where appropriate.15,35
Confirmatory testing is an expensive process and WHO has
advocated that confirmation of reactive samples with an
alternative screening assay rather than an expensive, highly
specific, confirmatory assay is adequate in regions where
prevalence is high. This approach contributes to cost reduction.
It might also be debated that a test specificity > 99.8% is sufficient
to avoid the need for confirmation. Much more research is
needed comparing the cost-effectiveness of various strategies to
supply safe blood to patients who live in resource-poor settings.
Clinical Use of Blood
In wealthy countries the majority of transfusions are planned
and carried out electively. In contrast, in poorer sub-Saharan
countries, and particularly those where malaria transmission is
high, most transfusions are given for life-threatening emergencies.
In these countries 50-80% of transfusions are administered to
children predominantly for malaria-induced anemia. Transfusion
can significantly reduce the mortality of children with severe
21 )
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Blood Transfusion in Sub-Saharan Africa J E A N -P I E R R E A L L A I N et al.

anemia but it may not have any benefit unless it is given within
The Future of Blood Transfusion
the first two days of hospital admission.36 In areas of high HIV
in Africa
prevalence, young children generally have a relatively low risk
of being infected with HIV and potentially have a long life
The future of transfusion in Sub-Saharan Africa is in increasing
expectancy. However, this is the age group that is predominantly
safe blood supply and reducing unnecessary transfusions.
affected by severe malaria-related anemia and so they are
Increased blood supply depends on the recruitment of volunteer
particularly at risk of transfusion-acquired HIV infection.37
donors and this should become government priority for policy
Pregnant women are the second most common recipients of
development and resource allocation. In addition to making a
blood particularly for hemorrhagic emergencies.38,39 Other
critical therapy more available, this will also improve safety.
specialities that are significant users of blood are surgery, trauma
Laboratory and blood bank management systems also need to
and general medicine.
be improved to ensure regular supply of reagents and protection
of the cold chain. Hospitals and other health facilities could
cooperate to directly purchase cheap, high quality, tests adapted
Guidelines for Transfusion Practice to their needs.
Different settings, different problems, different solutions. Under
Many institutions in sub-Saharan Africa have developed
a coordinating umbrella focusing on training and quality
guidelines to promote rational use of blood transfusions. Such
assurance, multiple strategies with the same objectives of supply
guidelines can reduce unnecessary transfusions. For example,
and quality of blood will succeed if dedicated and competent
strict enforcement of a transfusion protocol in a Malawian
staff are in place and are adequately resourced and supported by
hospital reduced the number of transfusions by 75% without
enforceable legislation.
any adverse effect on mortality.40 The principles underlying most
There is currently a feeling of guarded optimism about the
transfusion guidelines are similar and combine a clinical
future of blood safety in developing countries. The recent increase
assessment of whether the patient is developing complications
in allocation of resources for the prevention and management of
of inadequate oxygenation, with a measurement of the
HIV in Sub-Saharan Africa, including the investment by
hemoglobin level (as a marker of intracellular oxygen
governments of wealthy countries and contributions from
concentration). In sub-Saharan countries, the recommended
international and private agencies, has grown to include
hemoglobin threshold for transfusions is often well below that
transfusion safety. Parallel to the price reduction for anti-viral
which would be accepted in more wealthy countries. In the USA
drugs, the cost of screening tests supplied to developing countries
anesthetists suggest that transfusions are almost always indicated
has also decreased. The high cost of anti-HCV will soon be
when the hemoglobin level is less than 6 g/dL40 whereas in many
reduced when the patent expires. The rapid development of new
African countries transfusions are recommended for children at
technologies such as semi-conductors, microchips, nano-
hemoglobin levels less than 4 g/dL, providing there are no other
technology may provide performance comparable to genomic
clinical complications.
amplification with easier to use, relatively cheap, assays. A leap
Ensuring that transfusion guidelines are implemented is
from rapid tests to semiconductor-based technology bypassing
extremely difficult for resource-poor countries without formal
enzyme immunoassays and classical genomic amplification
monitoring and auditing systems. This is particularly problematic
methods can be envisaged. Methods of pathogen inactivation
if the quality of hemoglobin measurements is not assured. A
applicable to whole blood are being developed that could, in
study from Malawi has shown that if clinicians do not have
one step, reduce or eliminate the risks of viral, bacterial and
confidence in hemoglobin results they will rely entirely on clinical
parasitic infections.
judgment to guide transfusion practice and this can lead to
significant numbers of inappropriate transfusions.18 In a typical
district hospital in Africa the cost of providing a unit of blood is
approximately 40 times the cost of a quality assured hemoglobin
test.31 Investment in improving the low cost hemoglobin testing
therefore has the potential for significant cost saving downstream
in the much more expensive transfusion process as well as
reducing the risk of transfusion-related infections.

22 )
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( Page VOLUME 6 NUMBER 1 MARCH 2004

1. World Health Organisation. Blood Safety for too few. Press release
WHO/25, 7 April 2000.
2. Tapko JB. Blood safety: a strategy for the African region. The 4th
Arab congress and the 3rd African congress of Blood Transfusion.
Tunis, 2002:67-74.
3. Dhingra N, Hafner V, Xueref S. Hemovigilance in countries with
scarce resources—a WHO perspective. TATM 2003;5:277-84.
4. Lackritz EM. Prevention of HIV transmission by blood transfusion
in the developing world: achievements and continuing challenges.
AIDS 1998;12 Suppl A:581-6.
5. Rukundo H, Tumwesigye N, Wakwe VC. Screening for HIV I
through the regional blood transfusion service in southwest Uganda:
the Mbarara experience. Health Transit Rev 1997;7 Suppl:101-4.
6. Nwagbo D, Nwakoby B, Akpala C, et al. Establishing a blood
bank at a small hospital, Anambra State, Nigeria. The Enugu PMM
Team. Int J Gynaecol Obstet 1997;59 Suppl 2:S135-9.
7. Sengeh P, Samai O, Sidique SK, Kebbie A, Fofana P, Stephens
S. Improving blood availability in a district hospital, Bo, Sierra
Leone. The Bo PMM Team. Int J Gynaecol Obstet 1997;59 Suppl
2:S127-34.
8. McFarland W, Mvere D, Shamu R, Katzenstein D. Risk factors for
HIV seropositivity among first-time blood donors in Zimbabwe.
Transfusion 1998;38:279-84.
9. Jacobs B, Mayaud P, Changalucha J. Sexual transmission of
hepatitis B in Mwanza, Tanzania. Sex Transm Dis 1997;24:121-6.
10. Sarkodie F, Adarkwa M, Adu-Sarkodie Y, Candotti D, Acheampong
JW, Allain JP. Screening for viral markers in volunteer and replacement
blood donors in West Africa. Vox Sang 2000;80:142-7.
11. Jacobs B, Berege ZA, Schalula PJ, Klokke AH. Secondary school
students: a safer blood donor population in an urban with high HIV
prevalence in East Africa. East Afr Med J 1994;71:720-3.
12. Schutz R, Savarit D, Kadjo JC. Excluding blood donors at high risk
of HIV infection in a West African city. BMJ 1993;307:1517-9.
13. Savarit D, De Cock KM, Schutz R, Konate S, Lackritz E,
Bondurand A. Risk of HIV infection from transfusion with blood negative
for HIV antibody in a west African city. BMJ 1992;305:498-502.
14. Mvere DA. Evaluation of the pledge 25 club: a youth donor
recruitment programme in Zimbabwe. 27th International Congress
of the ISBT, Vancouver, 2002:A684.
15. Opare-Sem O, Owusu-Ofori S, Allain JP. A novel approach to
blood safety: pre-donation screening of blood donors for viral
markers. Africa Sanguine 2002;5:12-6. Available at:
http://www.scidec.com/afsbt/en_UK/africa_sanguine.asp.
Blood Transfusion in Sub-Saharan Africa
R E F E R E N C E S
16. Hassall O, Bedu-Addo G, Adarkwa M, Danso K, Bates I.
Umbilical-cord blood for transfusion in children with severe anaemia
in under-resourced countries. Lancet 2003;361:678-9.
17. Moore A, Herrera G, Nyamongo J, et al. Estimated risk of HIV
transmission by blood transfusion in Kenya. Lancet 2001;358:657-60.
18. Bates I, Mundy C, Pendame R, Kadewele G, Gilks C, Squire S.
Use of clinical judgement to guide administration of blood transfusions
in Malawi. Trans Royal Soc Trop Med Hyg 2001;95:510-2.
19. UNAIDS/WHO Epidemiological Fact Sheet, 2002 update.
20. Allain JP, Candotti D, Soldan K, et al. The risk of hepatitis B
virus infection by transfusion in Kumasi, Ghana. Blood
2003;101:2419-25.
21. Frank C, Mohammed MK, Strickland GT, et al. The role of
parenteral antischistosomal therapy in the spread of hepatitis C
virus in Egypt. Lancet 2000;355:887-91.
22. Achidi EA, Perlmann H, Berzins K. Asymptomatic malaria
parasitaemia and seroreactivities to Plasmodium falciparum antigens
in blood donors from Ibadan, south-western Nigeria. Ann Trop
Med Parasitol 1995;89:601-10.
23. Ibhanesebhor SE, Otobo ES, Ladipo OA. Prevalence of malaria
parasitaemia in transfused donor blood in Benin City, Nigeria. Ann
Trop Paediatr 1996;16:93-5.
24. Kinde-Gazard J, Oke J, Gnahoui I, Massougbodji A. The risk
of malaria transmission by blood transfusion at Cotonou, Benin.
Sante 2000;10:389-92.
25. Beal RW, Bontick M, Fransen L eds. Safe blood in developing
countries. Brussels: EEC AIDS task force, 1992:11-2.
26. Shaffer N, Hedberg K, Davachi F. Trends and risk factors for
HIV-1 seropositivity among outpatient children, Kinshasa, Zaire.
AIDS 1990;4:1231-6.
27. Magoha GA, Mwanda WO, Afulo OK. Autologous transfusion in
surgical patients at Kenyatta National Hospital, Nairobi. East Afr
Med J 2001;78:564-7.
28. Consten EC, van der Meer JT, de Wolf F, Heij HA, Henny PC,
van Lanschot JJ. Risk of iatrogenic human immunodeficiency
virus infection through transfusion of blood tested by inappropriately
stored or expired rapid antibody assays in a Zambian hospital.
Transfusion 1997;37:930-4.
29. Mbendi-Nlombi C, Longo-Mbenza B, Mbendi-Nsukini S,
Muyembe-Tamfum JJ, Situakibanza-Nanituma H, Vangu-
Ngoma D. Prévalence du VIH et de l'antigène HBs chez les donneurs
de sang. Risque résiduel de contamination chez les receveurs de
sang à Kinshasa-est, République Démocratique du Congo. Med
Trop 2001;61:139-42.
Transfusion Alternatives in Transfusion Medicine
J E A N -P I E R R E A L L A I N et al.
30. Candotti D, Sarkodie F, Allain JP. Residual risk of transfusion
in Ghana. Br J Haematol 2001;113:37-9.
31. Mundy C, Bates I, Nkhoma W, et al. The operation, quality and
costs of a district hospital laboratory service in Malawi. Trans Royal
Soc Trop Med Hyg 2004; in press.
32. Jacobs B, Mercer A. Feasibility of hospital-based blood banking:
a Tanzanian case study. Health Policy Plan 1999;14:354-62.
33. Hensher M, Jefferys E. Financing blood transfusion services in sub-
Saharan Africa: a role for user fees? Health Policy Plan
2000;15:287-95.
34. Nnodu OE, Odunukwe N, Odunubi O, Ekanem E, Njoku OS.
Cost effectiveness of autologous blood transfusion: a developing country
hospital's perspective. West Afr J Med 2003;22:10-2.
35. Mvere D, Constantine NT, Katsawde E, Tobaiwa O, Dambire
S, Corcoran P. Rapid and simple hepatitis assays: encouraging
results from a blood donor population in Zimbabwe. Bull World
Health Organ 1996;74:19-24.
36. Lackritz E, Campbell C, Ruebush T. Effect of blood transfusion
on survival among children in a Kenyan hospital. Lancet
1992;340:524-28.
37. Shaffer N, Hedberg K, Davachi F. Trends and risk factors of HIV-
1 seropositivity among outpatients children, Kinshasa, Zaire. AIDS
1990;4:1231-3.
38. Gerard C, Sondag-Thull D, Watson-Williams EJ,
Fransen L, eds. Safe blood in developing countries. European
Commission: Luxembourg, 1995:95.
39. Zucker J, Lackritz T, Ruebush T. Anaemia, blood transfusion
practices, HIV and mortality among women of reproductive age in
western Kenya. Trans Royal Soc Trop Med Hyg 1994;88:173-6.
40. Craighead J, Knowles J. Prevention of transfusion-associated
HIV transmissions with the use of a transfusion for under 5s.
Tropical Doctor 1993;23:59-61.
41. American Society of Anesthesiologists Task Force. Practice guidelines
of blood component therapy. Anesthesiology 1996;84:732-47.
42. van Hoogstraten MJ, Consten EC, Henny CP, Heij HA, van
Lanschot JJ. Are there simple measures to reduce the risk of HIV
infection through blood transfusion in a Zambian district hospital?
Trop Med Int Health 2000;5:668-73.
43. Bosso J, Siransky-Bogui L, Koffi Abe N, Aisse A, Konate S,
Darret SB. S. Evolution des prélèvements au CNTS d'Abidjan de
1992 à 2002. Transfus Clin Biol 2003;10 Suppl 1:38.
44. Loua A, Magassouba FB, Camara AS, Balde MA. Mise en place
d'un programme de mobilisation sociale en faveur du don de sang
au CNTS de Conakry. Transfus Clin Biol 2003;10 suppl 1: 38.
23 )
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