The future of transfusion and Africa

The number of people on Earth is expected to dramatically increase in the next few decades. Based on current trends, world population, which passed 7 billion in 2011, is expected to reach 9 billion in just 25 years and peak at 11 billion in 2050. Nearly all this growth will occur in economically less-developed nations. Fertility rates in wealthy nations are low and life expectancy is high and neither is expected to substantially change; in contrast, life expectancy in disadvantaged nations is expected to increase from current levels (<45 years) to 66 years by midcentury. Regionally, the greatest rate of growth is projected to occur in Africa (Fig. 1). In fact, of the nine countries expected to account for one-half of the increase in world's population, four of them are in Africa: Nigeria, Democratic Republic of the Congo, Uganda, and Ethiopia. World population projections by region according to the United Nations. Because transfusion needs are likely to mirror population expansion as medical sophistication advances worldwide, the greatest growth in transfusion medicine in our century is likely to occur in disadvantaged nations, especially those of sub-Saharan Africa. Accompanying the imperatives of growth in human population are the demands on transfusion therapy dictated by anemia. The current worldwide health impact of anemia is staggering, accounting for nearly 10% of the global burden of all human disability.1 In 2010, the prevalence of anemia was approximately 32% of all humans and reached 60% in sub-Saharan Africa. The greatest burden of anemia falls on children less than 5 years of age, much of this due to malaria and malnutrition. Because anemia due to malaria accounts for up to 70% of pediatric blood transfusions in sub-Saharan Africa,2, 3 efforts to control malaria can favorably affect the demand for blood. Indeed, a national approach to combat malaria, such as Ghana's National Malaria Control Program, has been shown to decrease the rate of pediatric transfusion.4 Today, sub-Saharan Africa struggles with the growing demand placed on transfusion services.5 Although millions of units are transfused each year, current blood product collections fail to meet medical needs. In fact, although sub-Saharan Africa is home to 12% of the world's population, it accounts for only 4% of the world's donated blood supply.6 Blood inventories are outstripped by demand (Fig. 2). Thus, regional population growth combined with increasing demand result in a serious short-fall in the blood supply. Transfusion medicine bears witness each day to preventable deaths that result from insufficient blood availability. Estimates of RBC needs to treat six medical conditions common in sub-Saharan Africa. Note the x-axis is logarithmic. Reproduced from Lund et al.,5 with permission from Elsevier B.V. Nevertheless, there have been serious efforts to improve the supply of blood in sub-Saharan Africa, as is outlined in a report from the US Centers for Disease Control.6 Gradual progress has been made in 14 African nations during the period 2008 to 2010; the amount of blood collected has increased in 11 nations, while the proportion of units reactive for human immunodeficiency virus (HIV) has decreased in 12 nations. Despite these advances, of the 14 nations with reported data, median collection rates were only 4.4 per 1000 population. Much of the activity of blood collection, testing, and transfusion lies entirely at the hospital level with a dependence on replacement blood donors.7, 8 However, efforts to improve blood safety and availability at the national level continue and excellent examples of programs with centralized blood collection and pathogen testing exist.6 The President's Emergency Plan for AIDS Relief (PEPFAR) provides essential support to the development of a safe and sufficient blood supply in selected African nations. PEPFAR has promoted advances in operational systems of blood donor recruitment, processing and testing to improve transfusion safety. In contrast to programs designed to enhance the blood supply, few programs have focused on hospital transfusion services and the bedside practice of transfusion therapy. Notable recent activity includes PEPFAR efforts to establish clinical guidelines and hemovigilance programs, as well as efforts by the African Society for Blood Transfusion (http://www.afsbt.org) to develop standards and accreditation programs. Nevertheless, apart from a few selected publications,9-11 very little is published about transfusion medicine as practiced in hospitals throughout sub-Saharan Africa. In the current issue of TRANSFUSION, readers are offered a glimpse into the world of blood transfusion at the hospital level in Africa. Waiswa and coworkers12 report an observational study of transfusion reactions at the Mulago teaching hospital located in Kampala, Uganda. Mulago Hospital is a 1500-bed national referral center and a busy health care facility (see Fig. 3). Mulago Hospital in Kampala, Uganda. During the 7 weeks of the study, the authors investigated more than 500 RBC transfusions observing patients during and 4 hours after each transfusion. These transfusions represented approximately 20% of the total RBCs transfused (2300 units) during the 7 weeks. They found that reactions were common. Nearly 10% of the RBC transfusions were accompanied by a variety of acute reactions ranging from febrile reactions to the infusion of ABO-incompatible RBCs. The data include internal trends we might expect to find. For example, acute reactions were less common among pediatric recipients and were more common among women with a history of prior pregnancy. Of interest, acute reactions were not associated with the storage age of RBCs. Investigation of the reactions was limited and did not include analyses that are typical in many developed nations, such as a clerical check of patient and product identification, a posttransfusion sample direct antiglobulin test, antibody screen, antiglobulin cross-match, or repeat blood type to ensure ABO compatibility. In addition, common clinical studies, such as chest X-rays, biochemistry testing, and blood gas analysis, were not frequently performed. Thus, the 10% acute reaction rate, which is based on clinical findings alone, is almost certainly an underestimate of the true rate of adverse events. Moreover, the study hospital has more resources and expertise than most community-based health care facilities where it seems plausible that still higher rates of adverse events might occur. Despite the inability to fully investigate suspected transfusion reactions as done in developed nations, the authors present a clear message that regardless of the obstacles, there are substantial opportunities to provide safer transfusions throughout sub-Saharan Africa. For transfusion medicine professionals who live and work outside of Africa, there are many opportunities to join in advancing our shared profession. In particular, three important areas stand out as spring boards for further development: medical technology, clinical trials, and education. Innovations in medical technology—designed for transfusion practice in an African hospital—will have a direct beneficial effect on patient outcomes. For example, a low cost and easy-to-maintain technology for determination of the hemoglobin (Hb) concentration would represent a basic platform for transfusion management, and a method to measure bilirubin might improve the care of neonates with jaundice. To that end are some especially exciting early efforts to measure the concentration of Hb and bilirubin using a smartphone (see http://www.gizmag.com/hemoglobe/23453/ and http://www.abstracts2view.com/pas/view.php?nu=PAS14L1_2160.8). Clinical trials, conducted in Africa, provide essential information regarding proper treatment of the major conditions that require RBC transfusion. Maternal death due to hemorrhage persists as a tragic cause of loss of life in economically disadvantaged nations and, as shown in Fig. 2, represents a leading indication for RBC transfusion. Currently under way is the World Maternal Antifibrinolytic Trial (WOMAN trial, ClinicalTrials.gov NCT00872469)—a large prospective randomized controlled trial designed to assess the benefit of early use of an antifibrinolytic agent (tranexamic acid) to reduce death due to obstetric bleeding. Urgent treatment of life-threatening anemia in children is another leading indication for RBC therapy. Also currently under way is the Transfusion in Severe Anemia with Lactic Acidosis trial (ClinicalTrials.gov NCT01586923) designed to measure, in a cohort of children with profound anemia, oxygen delivery to tissues by either fresh or stored RBCs. Clinical trials such as these provide not only biologic data of direct interest to wealthy nations, but also provide critical information for transfusion policy and treatment protocols in the context of African health care. Continued education in transfusion medicine will remain an essential means of promoting safe transfusion practice. Evidence-based use of blood therapies and principles of blood management are especially important in sub-Saharan Africa where the availability of blood is often marginal. Among the wide variety of medical educational efforts, we are pleased to have offered an educational conference devoted exclusively to transfusion therapy in sub-Saharan Africa, which was held in Uganda on November 5 to 7, 2014. Supported by grants from the International Society of Blood Transfusion, the AABB, and other organizations, the conference and workshop focused on clinical transfusion therapies and will be made available free of charge at the ISBT Academy Web site so that health care workers throughout Africa can learn current state of the art practice. We are proud that two of the authors of the article by Waiswa and coworkers in the current issue of TRANSFUSION were faculty members at this conference. As this editorial goes to press, it is painfully obvious that the spread of Ebola to densely populated urban centers has opened an entirely new and deadly chapter in the history of healthcare in sub-Saharan Africa. Transfusion Medicine will be changed by Ebola in unexpected ways. Indeed, a September 2014 World Health Organization report on potential therapies for Ebola lists transfusion of human plasma obtained from Ebola survivors at the top of the list of “lead experimental therapies”. Plasma transfusion as therapy is expected to scale up by the end of this year and its progress is worth following. In today's interconnected Global village, lessons learned from transfusion activity in sub-Saharan African may suddenly take on enormous relevance for all of us. Clinical transfusion medicine has no national boundaries and the transfusion of blood is a shared worldwide experience of life-saving medical practice and human beneficence. There is much that readers of TRANSFUSION can do to support colleagues in less wealthy nations who seek to achieve their highest potential. We encourage those with emerging interest to get more involved, commend those who have already shared their time and knowledge with others, and urge all to rededicate themselves to the good that each of us can do when working together. The authors have disclosed no conflicts of interest.