Transfusion Practice in a Resource-poor Setting: Ugandan Experience

Aggrey Dhabangi (MD, M.MED) Makerere University College of Health Sciences, Kampala,

Uganda

2019-09-21

Aim

• Share experiences; Transfusion services and testing in a resource-poor setting

• Discussion: Suggestions of feasible, high impact Laboratory/testing approaches for improvement

Presentation outline • Uganda: The Geography, Population, Health and

Demography – Stats • Health System in Uganda; the structure and

organization • National Blood Services: History, Organization

and current stats • Transfusion practice: Clinical & Laboratory • Discussion: What, where & how to improve

Uganda - Location

Btw: 10 29’ S & 40 12’ N latitude, 290

34 E & 3500’ E longitude

Uganda; the Pearl of Africa

Key population, demographic and health data (National Population and Housing Census 2014)

Variable National Statistics

a) Basic Population data

Total Population (2018 estimate) 40 million persons

(grow rate: 3.03% )

Surface area (square kilometers) 241,550.7

Population density (persons per Sq Km) 173

Population of under 5 years 17.7 %

Population of under 18 years 55.1 %

Population of 60+ years 3.7 %

UDHS - 2016 Variable National Statistics

b) Health data

Maternal mortality rate (per 100,000 live birth) 336

Infant mortality rate (per 1,000 live births) 43

Under 5 mortality rate (per 1,000 live births) 64

Under 5 Prevalence of severe anemia (Hb<7.0 g/dL) 2.3%

Life expectance at birth (years) 63.3

The Health Structure • Total of 5,117 health facilities

• 2,932 (60 %) are public, including

• 2 national referral hospitals,

• 11 regional referrals, 3 city referral hospitals

• Several general hospitals, & H/centers (IV, III and II)

The Private Health sector (40% of H/facilities):

• 15-20 Private hospital in Kampala capital city

• Each of the 11 regions with 1-2 PNPF hospitals

• Several Medical centers and Clinics

HSD

District Health Services HQ

National Referral HOSP

Referral Facility (Public or NGO)

(HC IV or HOSPITAL)

HC II HC II

HOUSEHOLDS / COMMUNITIES / VILLAGES

Regional Referral

HOSPITALS

HC II HC II HC II

HC III HC III HC III

MOH Headquarters

District Health Services

Functional structure - Public

Target pop; 35,000,000

Target pop; 2,000,000

Target pop; 500,000

pop;20,000

Mulago National Referral Hospital, Kampala

Serves Kampala city (1.5 Million), Surrounding suburbs (2 million)

And referrals from Regional and Private Hospitals

History of Blood Transfusion in Uganda

First Blood grouping in Kampala = 1931

Year Kenya Uganda Tanganyika Nigeria

1949 323 720 140 --

1950 421 720 -- --

1951 500 648 -- --

1952 -- -- -- --

1953 550 558 268 1,168

1954 -- 556 162 250

1955 840 664 288 540

1956 -- 1,269 -- 1,603

1957 1884 1,409 652 6,057

1958 -- 2,726 664 7,361

1959 5,146 3,874 1,031 --

1960 -- 5,500 896 --

1961 -- 8,533 1,109 --

1962 11,282 9,000 -- --

Blood Transfusions Between W.W.2 and Independence

Schneider WH. History of blood transfusion in sub-Saharan Africa. Transfus Med Rev. 2013, 27(1):21-28.

Uganda Blood Transfusion Services (UBTS)

• Established In 1989

• Prior: Mix; Regional & Hospital based blood banks

UBTS: National Network

• 1 H/Quarter

(Blood Center)

• 6 Regional

(Blood Centers)

• 9 Regional

(Collection & Distributn)

• 25 Mobile teams

(Affiliated to all above)

Blood Policies and operation • Donors: Exclusively VNRBDs • Donor testing: Eligibility Screening ABO & Rh Serology: HIV, HBV, HCV, & Syphilis NAT; still unavailable

• Funding: Government of Uganda (PEPFAR, previous support) • Quality Management Department x 1 yr now • Accreditation: AfSBT

Blood Products

1. Whole blood (60%)

2. Red cell concentrates

(Largely for Pediatrics)

3. Platelets concentrates (single donor)

….All (WB, RCC & PLT); NOT Leukoreduced

4. FP

5. Cryoprecipitates (On order)

Trends in Blood Collection: 2003-2013

0

50,000

100,000

150,000

200,000

250,000

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Units of Blood Collected Per Year (2003 to 2013)

•100% VNRBDs

•Collection doubled since 2003

• Increased capacity over the years

•PEPFAR role

17

Current performance

Parameter FY: 2015Jul -

2016Jun

FY: 2016Jul-

2017Jun

No. of Sessions 9,071 8,607

Total Collections 247,711 239,260

TTIs (prevalence) (%) (%)

HBV 2.24 2.27

HCV 1.54 1.40

HIV 0.87 0.67

SYP 0.23 0.27

Average % issued 94%

Challenges

When the little is unsafe!

Transfusion Practice • Blood orders;

Blood Utilization 45% of blood treats children under 5,

most with severe anaemia from malaria

30% of blood treats women, during

childbirth

• 250 transfusing

healthcare facilities

Blood Utilization; Studies Item Assessed National Referral Hosp

(Butler EK et al 2015)

Regional Referral Hosp

(Natukunda B et al 2010)

Sample size, n (Patients) 3,662 1,674

Blood Products WB-69%, RCC-32%,

PLT-6%, FP-2%

WB-58%, RCC-41%,

PLT-0.2%, FP- ?

Blood units per patient ratio 1.7 1.7

Pre-Transfusion Hb, Median (IQR) 56 (40-72) ??

Disease Categories Transfused Proportion (%) Proportion (%)

a) Malaria 2 33

a) Sickle cell Anemia 7 1

a) Obstetric Hemorrhage 12 9 *(Other bleeding= 20)

a) Cancer 33 8

a) Trauma & Surgery 12 4

a) Anemia –Unknown, Other

infections

14 19

Pre-transfusion testing in Uganda

• Current practice is limited to:

ABO typing (forward only)

Rh (D) typing

Method = Tile (slide)

RT saline cross-match

Orders:

Type & cross-match - Majority

Patient sample kept for 7 days

Shortcomings - Laboratory

Donor cells (segments), NOT kept

Patient identification: Weak system

No screening for RBC allo-antibodies

No AHG cross-matches.

Do not detect clinically significant RBC antibodies

(of the IgG iso-type, reactive at 37˚C)

Puts allo-immunized blood recipients and pregnant women at risk of HTRs/STRs and HDFN respectively.

The Consequences

• Prev. of Alloimmunization in SCA; 6.1%

• 80% of immunized, had had >10 transfusions

• 67% of alloantibodies belong to Rh blood group.

(Natukunda B et al. 2010)

ATRs • Prevalence of ATRS; 9.6%

• FNHTR – 50% of all ATRs (Waiswa MK et al. 2014)

• Frequency BC in PLTs: 2% (Hume HA et al. 2016)

Discussions Areas that need urgent improvement

• Which tests? • The priorities • The resources • Quality systems • Blood safety • Training of staff • ? More evidence

Thank you