Barriers to Effective Transfusion Practices in Limited‐Resource Settings: From Infrastructure to Cultural Beliefs

Abstract

Background Surgery and anesthesia are indivisible parts of health care, but safe and timely care requires more than operating rooms and skilled providers. One vital component of a functional surgical system is reliable blood transfusion. While almost half of all blood is donated in high-income countries (HICs), over eighty percent of the global population lives outside of these countries. High-income countries have on average 30 donations per 1000 people, and the average age of transfusion recipient is over 65. Most low-income countries (LICs) have fewer than five donations per 1000 people, where maternal hemorrhage and childhood anemia are the most common indications for transfusion. In LICs, greater than 50% of blood is administered to children under 5 years of age. This study aims to snapshot, by survey, available resources for transfusion and then discusses the infrastructure and cultural barriers to optimal transfusion practice. Methods In January 2019, a 10-question survey was sent electronically to physician anesthesiologists working in low-and middle-income countries to examine resources and practice patterns for blood transfusion. Subsequent discussions illustrate obstacles contributing to low availability of blood products and illuminate infrastructure and cultural barriers preventing optimal transfusion practices. Survey Results Acquiring whole blood takes hours. Clinicians wait days to receive packed red blood cells or platelets. Fresh frozen plasma is available but untimely. For many, protocols for massive transfusion are rare, and for transfusion, ratios are nonexistent. Complete blood counts take hours, and coagulation profiles are severely delayed. Discussion of Infrastructure and Cultural Barriers With few voluntary, unpaid, donors and inconsistent supply of testing kits, donated blood is unsafe. Donors are seasonal for farming communities, endemic malaria areas, and student donors recruited through schools. Cultural beliefs fuel distrust. Transfusion specialists, concentrated in urban areas, see rural patients presenting late. Inadequate triaging and supervision jeopardize patients to shock. Inadequate blood storage leads to waste. Modeling systems from HICs fail to overcome hurdles faced by clinicians working with distinctive belief systems and unique patient populations.

Status of hospital-based blood transfusion services in low-income and middle-income countries: a cross-sectional international survey

“…Our study substantiated difficulties ensuring adequate blood products for patients at the hospital level 5 16 21 24. Respondents described that insufficient blood inventories contributed to delays in treatment for patients.…”

“…Much of the published literature about blood transfusion in LMICs focuses on the safety of the blood supply and the risk of transfusion-transmitted diseases 2 4 9. While these topics are critically important, hospital-based transfusion practices and resources at the local level are essential determinants impacting patient care and outcomes 18 21 23. The HBTS provides a vital service to ensure enough blood for patients at the facility and that the blood is used safely and efficiently.…”

“…In high-income countries, the HBTS usually obtains their blood supply from accredited external blood collection agencies (nationalised or not-for-profit organisations) using standardised blood donation programmes, and sensitive and specific laboratory tests to prevent transfusion-transmitted diseases 25 26. In LMIC, the HBTS must collect blood when there is no such external blood supplier, or the external supplier cannot provide sufficient blood to meet clinical demand 9 21 26. However, the contribution of HBTS blood collection activities in this context is poorly documented in the literature.…”

“…Understanding the diverse abilities and needs could highlight areas for improvement and protect against the lack of blood transfusion leading to preventable outcomes 5 6 19. This study sought to describe the current state of HBTS in LMICs, including the facility and blood supply characteristics, leadership oversight, testing capabilities, patient care factors and challenges in settings that generally have few resources with the purpose of identifying opportunities for improvement and further investigation 10 19 21…”

Prophylactic blood transfusion prior to elective invasive procedures

“…In both developed and developing countries, inappropriate prescription of blood components occurs in up to 36% of cases 2 . The rational prescription of transfusion therapies is essential due to limited resources and growing demand 3 . Moreover, several studies have shown that aggressive correction of anemia, thrombocytopenia, and coagulopathies does not necessarily result in better clinical outcomes 4 .…”