Transfus. Sci. 1990; 11: 179-184 09%~3886/90 $3.00+0.00 Printed in Great Britain. All rights reserved Copyright 0 1990 Pergamon Press plc

International Forum Revival of the Ugandan Blood Transfusion System 1989: an

Example of International Cooperation

n 10 yr of civil war in Uganda had destroyed the Blood Transfusion Service when the present government came to power in 1986. AIDS had become recog- nized as a problem of severe proportion. In 1987 the E.E.C. pledged to rehabilitate the central blood bank. This paper des- cribes the first year of operation from December 1988. Over 5000 units of blood, largely from volunteer donors, were delivered to 19 hospitals. The over- all incidence of HIV- 1 seropositivity was 14.6% and Hepatitis B surface antigen was 5.5%. The cost was 21.5 ECU (US $25) for each unit of HIV negative, H.B.s.Ag. negative, blood. n

INTRODUCTION

In May 1987 the Republic of Uganda, with the assistance of the Global Pro- gram on AIDS (G.P.A.) of the World Health Organization [WHO], held a donors’ meeting in Kampala. As a result the Uganda AIDS Control Programme (A.C.P.) was formed; a major contribu- tion was the pledge of the European Economic Commission (E.E.C.), through its AIDS Task Force (A.T.F.), of 11/2 million ECU to rehabilitate the central blood bank at Nakasero. A study by Dr Fransen, director of A.T.F. had recom- mended complete renovation and the provision of funding for the collection, processing and distribution of 10,000 units of whole blood annually for 2 yr.

The provision of one or more technical assistants was considered necessary.’ E. J. W-W. Went to Uganda as American Red Cross delegate in September 1987 and, in October 1988, was appointed as technical assistant for the Nakasero Blood Bank Rehabilitation Project of E.E.C. This report describes the first year of operation following the recruitment of the first blood donors in November 1988.

BACKGROUND

The Ugandan Blood Transfusion Service started at Nakasero in 1957. During the next 20 yr it was increasingly successful and, at its peak, was collecting blood from 10,000 volunteers a year. During the next 10 yr, however, serious civil disturbances and outright war, lack of supplies and inadequate maintenance of equipment led to cessation of the blood bank in 1984. The Uganda Red Cross Society, which had been responsible for blood donor recruitment from the time of the start of the blood bank, had had to curtail this activity because of lack of funds and staff. Telephone, water and electricity services were unreliable and road and rail transport networks had been severely damaged.

Acquired immune deficiency syn- drome was recognized in Uganda in 19852 and by 1987 the incidence of HIV-l seropositivity had reached 20% among young adults in Kampala.3t4 Hospitals in Kampala and elsewhere recruited blood

179

180 Transjus. Sci. Vol. 11, No. 2

donors from patients’ relatives and used the blood as soon, or in some cases before, it was found to be negative for anti HIV- 1. A total of about 5000 units of blood were collected in 1987 by the four major hospitals in Kampala. Because it was collected for particular patients, those who had no relatives, or who were too critical to wait for donors and testing of blood, were often denied transfusion.

METHODS

Donor Recruitment

The Uganda Red Cross Society had estab- lished a good relationship with the school authorities and senior students had always been the major source of blood donors. This well educated section of the community can best understand the necessity for excluding, as blood donors, those who have exposed them- selves to risk of HIV infection. A recrui- ter gives an informative talk about the need for blood and the tests that are done to ensure it is free from risk. Students are asked to volunteer when the blood bank visits the school about a week later. Those who wish to know the results of their HIV test are seen by appointment a few days after the session. At this con- fidential interview they are reminded of the consequences of HIV and asked if they really wish to know the result. If the ELISA test was positive a repeat sample is taken for confirmation. Similar prog- rams are organized for office staff, factory workers, religious and other groups.

In addition to voluntary altruistic donors, the hospitals continue to encour- age relatives to replace blood used. In March 1989 the Nakasero Blood Band accepted responsibility for screening blood from these donors.

Laboratory

Red cells are typed for ABO and Rh D type and serum for A and B antibody by a microtiter technique. Discrepancies and

Rh D negative results are confirmed by tube method. HIV-l antibody and Hepa- titis B surface antigen are screened for with ELISA. During the year kits from Organon, Biochrom and Abbot were used. Blood, in plastic bags with CPD-Al anticoagulant, is maintained at 2-6”C and discarded if not used within 80 days.

Concentrated red cells are prepared from blood taken into double or quad- ruple bags. After 48 h sedimentation the plasma is expressed. Quadruple bags are used to divide the 240 mL of red cells into three equal portions; these are used for the transfusion of infants.

Records

A desk top computer, with hard disc, is used with Q & A, a database program from Symantec. For donor identification the donor gives; -date and place of birth and Mother’s first name, (the actual name is not used because of fear of lack of confidentiality). The blood bag label can be printed only if the results of HIV and Hepatitis B tests are negative. Final use of the blood is obtained from an accom- panying form that is completed by the hospital laboratory and returned to the blood bank.

Facilities and Equipment

During the reconstruction of the blood bank, a temporary laboratory was made available by Makerere University Department of Public Health. This was equipped with basic instruments by E.E.C. Water was brought in by bucket and, during the frequent power cuts, work either stopped or, if the power was not restored in 12 h, was continued in the New Mulago Hospital laboratory which had emergency power.

RESULTS

The number of both voluntary and hospi- tal recruited donors increased steadily to

International Fomm 181

over 1000 a month (Table 1). This was possible because of the gift from E.E.C. of 3 Land Rovers, each of which carried all the supplies and a team of 7 persons needed to collect blood from 50 volun- teers.

Anti HIV-l

See Fig. 1. Overall 14.6% of donors were found to be positive. There is a great variation between donors of different ages and sex. Peak incidence was found in females 20-25 yr and males 2530 yr. The volunteer donors had an overall incidence of 9% compared with 22% of the donors recruited by patients’ rela- tives.

Hepatitis B Surface Antigen

A preliminary survey of serum samples collected during December 1988 showed that 10% were positive for surface anti- gen and 68% had antibody. Routine testing of all samples started in Septem- ber 1989. Antigen is present in 61/2% of volunteer donors and 4Y3% of relatives’ donors. Those positive for anti-HIV-1 have a higher incidence (9.3% ) of hepati- tis B surface antigen.

Counselling

The blood bank staff of physicians and donor recruiters perform first level coun- selling only. Donors found to be positive for anti-HIV-l are referred to The AIDS Support Organization (T.A.S.O.) for con- tinued support. 24% of donors came back to discover their test results.

cost

The cost of the program, excluding sup- port for E.J. W-W., is shown in Table 2. If the capital costs are amortized over 5 yr the annual cost was US $116,678;-US $17.6 for each unit collected or US $21.5 for each usable unit.

Population served

The number of hospitals increased from 5 to 19 (2200

served to 3880

beds]. The area of the country served encompassed Jinja to the east and Mbar- ara to the west, with a population of about 5 million.

Utilization

1189 units were discarded. The most common reason was because of HIV

Table 1. Units of Blood Supplied to Hospitals

Month No. Hodtals Volunteer ReIative TotaI

December 88 January 89 February March April May We July August September October November

4 4 4 4 5 7

: 9

16 18 18

89 171 176 133 134 233 166 311 171 378 530 534

41 11 78

171 239 219 272 251 392 285 446

89 212 187 211 305 472 385 583 422 770 815 980

Total 19 3026 2415 5441

182 Transfus. Sci. Vol. 11, No. 2

PosEive ‘.O

6.0

0.0 Jan. Fe1

40.0

35.0

30.0

% 25.0

Positive 20.0 I

BY Ju intar

IL Jul. Au ‘y Donors

n+u Male Female

Pt. Recruited

n.I Sept. oc

35.0

30.0 I r

I_! Y Jo nors

n ret

Am Sm. Oct. Nov. ited by iatierks

25.0 20.0 15.0 10.0 0.0 5.0

Iv.1950 195KA 1955-59 1960-64 196569 1970.72

Date of Birth Males Only

Figure 1. Nakasero Blood Bank, Uganda. Frequency of HIV-l Antibody-positive Blood Donors, 1989.

Table 2. Costs of First Year of Nakasero Blood Bank Rehabilitation

Item

Capital Major equipment Vehicles

Recurrent Glassware, etc. Reagents (ELISA + An&era) Disposable tubes, etc. Blood bags and giving sets Donor supplies ~Iis&aneous (office, etc.)

Donor refreshment Vehicle running costs Other

ECU U. shs (x 1000)

20,198 56,233

2149 43,470

3590 18,164

1670 2159

11,285 1198 1168 831

Total recurrent 14,482,OOO U.shs at 450/ECU

Total ECU Add l/5 of capital

69,202 14,482 32,190

101,392 15,286

116,678

Cost per unit collected (6630 units) 17.6 Cost per unit delivered (5441 units) 21.5

Intemational Forum 183

Table 3. Patients Transferred at 17 Hospitals September-November 1989

children Adults R&i!3Oll 80 mL Cells 450 mL Blood Ullits Patients Total Units

Hb<3Og/L 168 203 302 Hb < 50 g/L 39 182

if 35 79 280

Hb < 70 g/L 4 29 21 33 5wm 38 126 82 164 Other 4 22 8 26

Total 207 431 305 225 805

(14.6%), followed by Hepatitis B surface antigen (5.5% of those tested). 144 (2.1%) were inadequate collections. Approxi- mately 12% of females and 2% of males were rejected for low hemoglobin level. (Less than 120 and 130g per L respec- tively.)

The indications for transfusion in Uganda have been described by the Ministry of Health.5 In general the pur- pose is to restrict transfusion to the essential minimum necessary to pre- serve life. When transfusion is given the volume is only that considered essential to allow other therapy to be successful. Nearly all transfusions are of one unit or less. Table 3 shows the reasons for trans- fusion during 3 months when particular effort was made to collect this informa- tion.

DISCUSSION

Initially the project presented great chal- lenges. The breakdown of normal servi- ces, the economic depression of the country and the very high incidence of HIV infection were all major obstacles. However, there were some favorable cir- cumstances; the political climate of optimism and a stable government able to attract international support; the peo- ple of Uganda have a high regard for education and had previously supported a successful voluntary blood donor pro- gram. Uganda, moreover, was the first African country to delineate an AIDS strategy and this encouraged the E.E.C. to offer generous financial and technical

support; and the program enjoyed the skills of an experienced and dedicated staff.

Critical to the success obtained was the decision to centralize the laboratory and aggressive recruitment of volunteer donors. A staff of five were employed in recruitment. Because there was only one trained technician it was essential that each member of the staff was trained in one duty only. Adequate supervision of the laboratory staff is the greatest single problem, which will only be successfully overcome when more training is poss- ible.

THE FUTURE

Four regional blood centers are planned to provide for a truly national service. There is an urgent need to redevelop the role of the Uganda Red Cross Society in donor recruitment, support and reten- tion. As the program enlarges its area of operation outside the immediate sur- roundings of Kampala, local community support must be built. Communication systems, telephone and roads services need development and alternative sources of power must be available in every hospital.

In March 1990 the rebuilt Nakasero Blood Bank will be fuctioning. This will enable the Uganda Blood Transfusion Service to develop some component pre- paration, to embark on re-education of laboratory staff and to teach medical students and physicians the essentials of modem transfusion therapy.

184 Trmsfus. Sci. Vol. 11, No. 2

Acknowledgements

We axe grateful to the Government, and particularly the Ministry of Health, of the Republic of Uganda for encour- agement. The AIDS Task Force of the E.E.C. has been unstinting in su port. The Came ‘e Car oration of New York provided &e initial funds g E./. G-W. to make a feasibility study in association with the Uganda Red Cross Society. The project could not have been started without the enthusiastic support of the sta of the blood bank and, of course, the wonderful If vo untary blood donors of Uganda.

1.

REFERENCES

Franzen L: Report to E.E.C. on proposal to rehabilitate the Nakasero Blood Bank. E.E.C. Project Number 5710.94.95.005, 1987.

Nakasero Blood Bank Ministry of Health Uganda, Kampala

Serwadda D, Mugerwa RD, Sewankamto NK, Lwegaba A, Carswell JK, Kirya GB, Baylet AC, Downing RG: Slim disease, a new disease in Uganda and its association with HTLV III infection. Lancet 1985; ii:849-852. World Health Organization: Acquired immunodeficiency syndrome (AIDS) - data as at 31 August 1989. Wkly Epidemiol Ret 1989; 64:265-272. Berkley S, Okware S, Naamara W: Sur- veillance for AIDS in Uganda. AIDS 1989; 3:79-85. AIL% Control Programme. Ministry of Health Uganda; Indications for Blood Transfusion in Uganda, July, 1989.

Edward John Watson-Williams, FRCP, FRC Path

Peter K. Kataaha, MD, PhD