India has come a long way in making safe blood available throughout the year, but much remains to be done before we reach the cherished goal of 100 per cent voluntary donation and the availability of safe blood across the country at all times. This is food for thought, especially on World Blood Donor Day which is observed every year or June 14.
Here is why. Voluntary donors from low-risk populations form the cornerstone of a programme of safe and adequate blood supply. Yet, voluntary donation comprises only about 70 per cent of the demand in India, with the rest being met by replacement donation.
Replacement donors are friends and relatives of a patient who donate blood as replacement for the blood given to the patient. Though paid blood donation was banned in January 1998 after the Supreme Court’s directive, replacement donation now ensures that professional donation continues to operate in the form of relatives/friends.
That professional donors pass off as replacement donors at blood banks and hospitals is rather a norm in the case of patients who have been admitted to tertiary care hospitals in a new city.
Risks with replacement donation
At times, these replacement donors (friends and relatives) are more likely to harm the recipients by hiding or overlooking the many don’ts of donation. Compounding this is the fact that many hospitals and banks often never care to study their elaborate medical history and carry out behavioural screening.
Though voluntary self-deferral to donate without citing reasons is widely accepted, replacement donors rarely resort to it either to hide their high-risk behaviour or due to pressure to meet the immediate demand for certain units of blood. As a result, the prevalence of HIV, hepatitis B, and hepatitis C is much higher among family donors when compared to voluntary donors, as a 2012 study published in the Asian Journal of Transfusion Science found.
Though donated blood is screened for transfusion transmitted infections (TTI) such as HIV, hepatitis B, hepatitis C, syphilis and malaria, the tests fail to detect the diseases in the window period of infection.
In the case of HIV, the window period (time between exposure to infection and the point when the test reflects accurate results) varies depending on the sensitivity and specificity of the assay used. Further, the risk of replacement donors having TTIs is 1.5-2.5 times higher than for voluntary donors, a September 2015 study in The Indian Journal of Medical Research notes.
Need for awareness
Donating safe blood can become a reality only when replacement donors are phased out and the focus is shifted to increasing blood collection through voluntary donations to meet ‘over 95 per cent of blood requirement’. This can be done through increased awareness, providing appropriate facilities for people to donate blood, and improved donor retention.
The concerted efforts by the government, blood banks and others have resulted in a progressive increase in voluntary blood donation. From about 54.5 per cent in 2006, the amount of blood collected from voluntary donors rose to 84 per cent in 2013-2014 in National AIDS Control Organisation (NACO)-supported blood banks. The total annual amount of units collected has also shown an absolute increase in over 10 years — from 4.4 million blood units in 2007 to 10 million units on average in the last three years. A study to estimate requirements is now under way.
The 1,161 NACO-supported blood banks alone accounted for over 5.7 million blood units collected during 2013-2014. Tamil Nadu and Arunachal Pradesh recorded 100 per cent voluntary donation in NACO-supported banks. Maharashtra comes close with 97 per cent voluntary donation. But when compared with Tamil Nadu, where only 0.34 million units were collected, Maharashtra collected 0.7 million in 2013-2014. Delhi had only 57 per cent voluntary donation — the least in the country. The absolute collection was 0.3 million units. This is primarily due to greater reliance on replacement donors and the more number of private sector blood banks.
The high percentage of voluntary donations recorded in NACO-supported blood banks is partly because it included family donors under the ambit of voluntary donation. In was only in June 2014 that the definition of voluntary blood donation was modified in accordance to the WHO definition.
The percentage of voluntary donations during 2015-2016, after excluding for family donors, was 79 per cent, says Dr. Shobini Rajan, Assistant Director General (Blood Safety) of NACO.
Incidentally, most voluntary donors are first-time donors, with repeat donation accounting for close to 20 per cent in NACO-supported banks. At the Chennai-based Jeevan Blood Bank, repeat donation accounts for 5-7 per cent.
In order to phase out replacement donation “in a time bound programme”, the National Blood Policy of 2007 was formulated to shift the onus on institutions that prescribe blood for transfusions to procure blood for their patients from licensed banks. But this didn’t happen, as the 2015 paper in the Indian Journal of Medical Research reveals. Nearly 97 per cent of donations made (2005-2013) at the Indraprastha Apollo Hospitals, Delhi, came from replacement donors, the study says.
There is now a more viable alternative. In August 2015, the National Blood Transfusion Council decided to allow even hospital-based private blood banks to conduct donation camps. However, the Drugs and Cosmetics Act 1940 and Rules 1946 would have to be amended and notified before the change can be effected.
While the bulk transfer of blood and blood components between blood banks even across States was permitted in August last year, there are still 82 districts in the country without even one blood bank, including private ones, says Dr. Rajan.
Finally, the immediate goal will be to meet the National AIDS Control Programme IV (2012-2017) plan of having in place over 50 per cent of all the blood banks that are NACO-supported and collect 90 per cent of the blood in the country, with 95 per cent of the donation from voluntary donors. Achieving this goal is important as 2020 is the target year for all countries to obtain 100 per cent of blood supplies from voluntary unpaid donors.
The World Health Organisation’s theme of this year’s World Blood Donor Day on June 14 is “Blood connects us all” highlighting the common bond that all people share in their blood. The slogan, “Share life, give blood”, draws attention to the role that voluntary donation systems play in encouraging people to care for one another and promoting community cohesion, the WHO says.