Healthcare Landscape in Pakistan – Blood(y) Business – Asrar Qureshi’s Blog Post 984

Healthcare Landscape in Pakistan – Blood(y) Business – Asrar Qureshi’s Blog Post 984

Dear Colleagues! This is Asrar Qureshi’s Blog Post 984 for Pharma Veterans. Pharma Veterans Blogs are published by Asrar Qureshi on its dedicated site https://pharmaveterans.com. Please email to aq.pharmaveterans@gmail.com for publishing your contributions here.

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‘Blood is the lifeline’ is as old an adage as may be traced in history. ‘Blood loss must be replaced with blood’ had been in practice for decades but the situation changed somewhat after the introduction and intense promotion of plasma substitutes which could at least make up the volume. Blood transfusion remains essential in conditions like severe anemia particularly in pregnant women, extreme blood loss in serious injuries, prolonged surgical procedures, and blood disorders like Thalassemia, Hemophilia, blood and bone marrow disorders etc.

Demand for blood and blood products continues to grow due to factors like population growth, aging population, and the access to increasingly sophisticated medical and surgical procedures. Blood collection practices, screening of collected blood, and transfusion have undergone major changes as new information and technology became available. However, despite the availability of effective measures to ensure the quality and safety of blood and blood products, there is still significant risk associated with their clinical use, including adverse reactions and transmission of transfusion-transmitted infections – TTI.

Blood Supply Line

Not too long ago, addicts lurked around main hospitals in major cities, trying to sell their blood for a small money. They were willing to give blood every day, if needed. The quality of their blood was often questioned by the doctors, but other options were not available. The risk of Hepatitis and HIV was not recognized till then; therefore, no screening was done; only blood group was matched. Blood bank services were still emerging, and relatives were not forthcoming to donate blood for their own kin. 

Blood donation and transfusion practices in Pakistan are still way behind compared to global practices. There are estimated 170 public and 450 private blood banks in the country that are mostly hospital-based. Still, there is a considerable shortage of blood, even in large cities. Voluntary Blood Donors are the vital source for providing safe and quality blood. World Health Organization set the target that by 2020, all countries should aim to have 100% of blood donations from voluntary, non-paid donors. Presently, the practice of voluntary blood donation in Pakistan is highly unsatisfactory as only 10% people donate voluntarily while 90% is by family and friends as replacement donation or paid donors. The major reasons for such low voluntary donations are lack of awareness, misconceptions, and lack of motivation.

Punjab Blood Transfusion Authority (we are extremely fond of making authorities) on its website is showing list of private and public blood banks updated till 2018. Six-years old data shows 60 private and 56 public blood banks in Punjab. It is a pity that the site has not been updated for so long, and it may also be seen as a reflection of the working of PBTA. PBTA also has a Licensing Board which is to decide on the issuance of licenses to blood establishments, blood centers, hospital blood banks, and specialized transfusion services.

The following data is taken from a presentation by Dr. Saba Jamal, Director Blood Transfusion Services & Clinical Laboratories, Indus Hospital and Health Network.

• In 2017, estimated 2.75 million blood donations were collected across Pakistan

• Over 95% were based on replacement donations

• Almost all blood banks in public sector, and most in private sector are using rapid testing device for screening, which is not recommended anymore

• Incomplete blood grouping is done, and cross-matching is not done in routine

• Staff is mostly untrained and in short supply

• An estimated 25% of the annual blood collection is transfused to Thalassemia patients

Thalassemia

Thalassemia is a genetic disorder which affects the production of hemoglobin, the protein in our red cells that carries oxygen. When there is not enough hemoglobin, the red cells don’t function properly, and they last for shorter time. Thalassemia patients, therefore, require constant blood transfusions; the frequency varies with the condition.

Patients suffering from Thalassemia minor may not have any symptom at all, intermedia may have mild anemia, and major may have severe symptoms with need for regular transfusion. Thalassemia runs in families and is perpetuated through cousin marriages which are highly favored in Pakistan. People from Mediterranean countries like Greece and Turkey, and people from Asia, Africa, and Middle East are at higher risk.

In Pakistan, Thalassemia major frequency ranges between 5 – 7%, thus there are over 10 million carriers in the country. When two such people marry, the risk of having Thalassemic children is much higher. Blood transfusion remains the mainstay of management. Most of these families come from lower socioeconomic strata, with large family units, who cannot afford management cost. Charitable organizations like Fatimid Foundation, Sundas Foundation are more well-known publicly, but actually there are over 100 small and large centers offering free/ low-cost blood transfusions to these patients. These institutions are unregulated and there are several grey areas in their working. 

WHO Strategic Framework for Blood Safety and Availability 2016 – 2025 

It is long document prepared by WHO Eastern Mediterranean Region; Pakistan is included in the 22 countries falling under EMR. 

Premises

The safety and availability of blood transfusion depends on the:

• availability of a well-organized and adequately funded nationally coordinated blood transfusion service, with an effective blood component program under well-defined regulatory oversight.

• collection of blood and blood components from voluntary, non-remunerated and regular blood donors from low-risk populations.

• quality-assured testing of all donated blood, including screening for TTIs, ABO and Rhesus D grouping, and compatibility testing.

• reduction in unnecessary transfusions through appropriate clinical use and safe administration of blood and blood products.

• implementation of effective quality systems in all areas, including quality management, development and implementation of quality standards, effective documentation systems, training of all staff and regular quality assessment, including hemovigilance, based on a national quality policy and strategy

The strategic framework is intended to guide countries in developing and strengthening national blood systems to ensure the continuity, sufficiency, sustainability, and security of national supplies of safe and efficacious blood and blood components.

Strategy Framework

The framework for action outlines the priority interventions and actions needed from countries to achieve the following targets by 2025.

1. All countries will have developed or reviewed and implemented a national blood policy and strategic plan for a nationally coordinated blood transfusion service.

2. All countries will have developed and implemented an appropriate framework for regulatory mechanisms for the registration, licensing, operation and inspection of blood transfusion services.

3. All countries will have achieved 100% voluntary non-remunerated donations from low-risk populations.

4. All countries will have achieved or maintained 100% quality-assured testing of donated blood for TTIs.

5. All countries will have processed at least 75% of whole blood collected into components within a quality system.

6. All countries will have developed and implemented national guidelines on the clinical use of blood.

7. All countries will have a functioning and sustainable hospital transfusion committee in at least 80% of hospitals.

8. All countries will have implemented national quality management systems at all levels of the blood services.

9. All countries will have established a national hemovigilance system.

Sum Up

Blood collection, supply, screening, fractionation, and transfusion are big bloody businesses in Pakistan. There are serious holes and gaps because the regulatory oversight is absent or lacking. This is leading to spread of Hepatitis and HIV, besides other clinical complications. Pakistan is already endemic for Hep C and Hep B. The governments do not recognize the incidence of HIV, however, an article in The Lancet, December 2022, puts the figure at 210,000. Unsafe blood transfusion is a cause among other reasons.

There is an urgent need to focus on this area and take all necessary measures. 

Concluded.

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For most blogs, I research from several sources which are open to public. Their links are mentioned under references. There is no intention to infringe upon anyone’s copyrights. If, however, it happens unintentionally, I offer my sincere regrets.

References: 

https://cdn.who.int/media/docs/default-source/blood-transfusion-safety/emropub-2017-en-19608.pdf?sfvrsn=3a119965_2&download=true 

https://jimdc.org.pk/jimdc/Volumes/5-1/Voluntary%20Blood%20Donation-Editorial.pdf 

https://pjmhsonline.com/2017/april_june/pdf/781.pdf

https://pbta.punjab.gov.pk/licensed_blood_banks

https://tfp.org.pk/wp-content/uploads/2018/12/Safe-Blood-Where-We-Are-and-The-Way-Forward.pdf

https://www.cdc.gov/thalassemia/about/index.html