Blood supply management during an influenza pandemic

The word pandemic is derived from the Greek words 'all' and 'people'. Pandemics occur when a pathogen emerges to which the majority of human population has little or no immunity, resulting in rapid spread worldwide. If the pathogen is highly virulent, widespread morbidity and mortality occurs with enormous disruption in global infrastructure and systems. Although the term pandemic is most often used in modern times in relation to influenza, other pandemics would include the HIV pandemic as well as historical instances of smallpox, cholera and tuberculosis pandemics. The 20th Century was marked by three major influenza pandemics involving significant mortality. The 'Spanish flu' of 1918–1919 was associated with at least 50 million deaths, the 'Asian flu' of 1957–1958 with two million deaths and the 'Hong Kong flu' of 1968–1969 with one million deaths. Much of the assumptions upon which subsequent pandemic plans were developed are based on historical data from these three pandemics. In 2003, the emergence of SARS in Asia gave a deadly reminder of the speed and efficiency with which a new virus could spread in the modern era of air travel and globalization. Fortunately, SARS did not evolve into a pandemic. But the magnitude of its impact on the social and economic fabric in affected countries spurred greater focus on pandemic influenza planning. The many lessons learnt from the impact of SARS on blood supply and blood services also resulted in wider consciousness of the importance of contingency planning in the blood community. It was widely anticipated that the H5N1 avian influenza virus or a virus similar to this would be the source of the next pandemic in this century. Unexpectedly, the H1N1 virus emerged and unraveled many fixed assumptions upon which health authorities and international agencies had based their plans. It is a sharp reminder that every influenza outbreak or pandemic is unique, and that scenario plans need to be sufficiently flexible to adjust quickly to new situations. At the time of writing, the H1N1 virus still exhibits rapid infectivity but relatively low virulence. Time will tell if the virus will progress to increased virulence, or fade away to become yet another seasonal strain. Influenza viruses spread in general through the respiratory route and there are no documented cases of spread through blood transfusion. However, although there is little evidence at present to indicate that seasonal influenza virus is transfusion transmissible, this cannot be assumed with certainty in the case of a novel virus. Because current blood donor selection screens out those who are ill, the blood donor would have to be asymptomatic and viraemic in order for the influenza virus to be transmitted through transfusion. As viraemia has been described a day or two before illness in seasonal influenza, there is a theoretical risk that infected donors presenting just before symptoms may transmit virus. Experience during the SARS epidemic has shown that the most significant impact on the blood supply during a pandemic is likely to be a dramatic reduction in blood donors. Blood collection will be adversely affected as blood donors become ill or have less time to donate because of work commitments or the need to care for others. Donors will also be reluctant to attend blood donation sessions for fear of being infected. Organizations may be reluctant to or discouraged from organizing blood drives as part of measures to prevent congregation of people and virus transmission in the community. During the peak of the SARS epidemic in Singapore, a decrease of 60% was seen in donors coming forward to donate blood. Various planning scenarios estimate that up to 30–40% of the population may be infected during the peak of an influenza pandemic, and that donor loss of 10–30% may occur. Additional donor selection criteria can also be expected to contribute to the decrease in collections. In Singapore, an additional 4% of potential donors were deferred during the SARS epidemic as a result of risk reduction measures. During an influenza pandemic, it is also likely that more donors will be deferred because they have recently taken antibiotics or antivirals as part of prevention/treatment protocols. In countries where vaccinations are made widely available – whether seasonal influenza vaccine or a newly developed vaccine to the pandemic strain – donors who have been recently vaccinated may also need to be temporarily deferred. Influenza and its complications are not generally associated with the need for blood transfusions, and an increased need for blood and blood components during a pandemic is unlikely. Conversely, there may be a decrease in demand as healthcare capacity is shifted towards the need to provide basic healthcare support, and elective surgery and non-urgent clinical interventions are deferred. These changes in demand will affect the different types of blood components differently. It is estimated that demand for red cells will decrease by 5–25%, and frozen and fractionated products by 0–10%, with little or no change in platelet demands. At the peak of a pandemic, it is estimated that employee absenteeism may be as high as 35–50% as a result of illness, the need to care for ill family members, and concern about infection. Where small specialized teams are affected, e.g. laboratory staff performing nucleic acid amplification testing, the impact may be greater. During a pandemic, it is also less likely that temporary or contract workers can be sourced to help meet operational needs. Staff unavailability being a universal problem, this will translate into disruptions in other areas of operations, such as consumables and supply chains, equipment maintenance, transportation and infrastructure. Widespread disruptions to key services in the community may also occur, leading to disruptions in water, electricity, sewage and other services. In order to maintain a safe and adequate blood supply during a pandemic, blood services must plan and prepare so that appropriate actions can be taken as the situation unfolds. Experience with the recent H1N1 outbreaks has shown how rapidly a novel influenza virus spreads globally and even countries far from the epicentre experienced spread within weeks of warning. The key elements that should be considered in a pandemic response plan are listed in Table 1. During planning, it is important to bear in mind that the influenza virus is unpredictable, and that it will be impossible to predict with certainty the severity and impact of any pandemic until it actually occurs. There will also be uncertainty as to whether the virus will mutate towards higher or lower virulence and transmissibility as the pandemic progresses. Contingency plans should therefore be developed with sufficient flexibility to allow them to be adapted to the different situations that may emerge as the pandemic unfolds. The most useful approach is to develop a range of strategies and measures that can be taken, and to select the most appropriate combinations to meet different situations. This approach requires a clear command and control structure so that timely decisions can be made on the measures to be deployed. A system for intelligence gathering, decision making and deployment, and outcome assessment should also be in place so that challenges can be effectively managed as they arise. The blood service must be nimble enough to take appropriate actions in anticipation of impact, as it may often be too late once the impact occurs. Systems should be tested during routine exercises, which can be conducted as desktop exercises, functional drills or full-scale exercises. The measures taken to protect the integrity of the blood supply should be effectively coordinated with all stakeholders. The timing and scope of these measures should be guided by national pandemic influenza plans and national health and safety guidelines. For example, in Singapore, the national Disease Outbreak Response System is based on different alert levels (green, yellow, orange, red and black) and allows a risk management approach appropriate to the transmissibility and virulence of the virus. The pandemic plans for the blood supply are developed in alignment to this system so that whatever measures are deployed will be consistent with overall national level measures. The blood service must also make sure that it is recognized by local, state and government authorities as a critical healthcare agency, and that contingency plans for the blood supply are included as part of national contingency plans. National coordination is particularly important in areas such as donor deferral criteria, infection control measures, blood shortage management and media messaging. Careful risk assessment should be conducted before any changes are made to policies, practises or procedures. Any adverse effects that may arise and lead to unexpected and undesirable consequences should be identified and addressed. One important point that must be considered if changes are made to quality or safety standards is the outcome of blood collected under these different standards when the pandemic is over. Regulatory agencies should obviously be kept informed of any such changes, including its effects on products in available inventory, on donors, and on operations. Current donor selection criteria should already exclude donors with signs and symptoms of influenza or other illness. It is also common practice to screen out those who may have had recent contact with ill persons. As the incubation period for human influenza viruses in general is short, i.e. 2–3 days (range 1–7 days), this often involves temporarily deferring the donor for that duration. Whatever the criteria that is introduced, it must be developed based on reliable information and reviewed regularly with further knowledge about the pandemic and disease characteristics. The effect of influenza prevention and treatment protocols on the safety of blood collected from donors who have been on such protocols should also be carefully evaluated. Such protocols include antibiotics, antivirals and influenza vaccines, and appropriate deferral policies must be developed taking into account the relevant pharmacological and clinical data. Throughout the course of the pandemic, donor selection criteria should be regularly reviewed and adapted if necessary to meet the changing situation. For example, during the early stages of disease outbreak, there may be some usefulness for blood services in unaffected areas to defer donors who have recently travelled to affected countries. As the pandemic spreads to the local population, this strategy becomes ineffective and should then be discontinued in order to reduce unnecessary donor loss. Look-back studies will allow the blood service to assess the risk of transfusion transmissibility of the virus, which will help to guide rational blood safety policies. A system of donor and patient look-back should therefore be established with hospitals and health authorities so that comprehensive monitoring and full audit trails are achieved. Where available, archived donation samples are invaluable tools in establishing transmission. Stringent measures should be taken to ensure that influenza is not spread through blood service activities. It is particularly important that the environment for blood donation is safe, and that donors also perceive it to be safe to donate blood. The aim is to maintain donor and staff confidence that the likelihood of acquiring influenza during blood donation or blood service activities is low. Influenza viruses spread from human to human mostly through coughing and sneezing by large droplet secretions, and close contact within 2 m with someone ill with influenza carries a higher risk of infection. The virus can also be spread by indirect means through contact with a surface with viruses on it. Additional infection control measures are thus an effective means to reduce infection risk. Potential donors who are ill should be screened off at the earliest opportunity. Information posters on who should and should not donate blood should be posted outside blood collection sessions. It is also useful to provide information on hand-washing and respiratory hygiene. Our experience is that, most donors (and friends and family accompanying them) appreciate the opportunity to learn how to wear a mask and wash their hands correctly. Such information can also be uploaded on the blood service websites so that donors can obtain the information without needing to come down to the blood centre or donation session first. Triage stations situated outside the session to screen donors for fever and signs/symptoms of influenza will reduce the risk of an infected donor entering the blood donation area. All persons entering the session should go through the triage, including visitors and contract workers. Donors may be provided with face masks and hand disinfectants before they enter the blood collection areas. The measures deployed by the blood centre should preferably follow national infection control measures practised in other health facilities so that there is consistency with overall practice. Greater segregation and distancing between donors may be introduced in the blood donation area to reduce the risk of transmission. This will require limiting the number of donors per session or increasing the space needed at mobile sessions, and may therefore reduce the number of organizations who are able or willing to host blood drives. Distancing may also be introduced in the laboratories and other work areas of the blood centre to minimize spread of infection between staff. In the early stages of the pandemic, it may be possible to physically segregate staff into two or more functional teams based at different locations. This strategy limits the number of staff exposed to infection or subject to quarantine if one person falls ill. However, it would not be feasible once the pandemic spreads through the population. Where it is available, remote working arrangements should be considered for staff who do not need to be physically present in the facility. Reduced entry and exit points to the facility with triage stations at these points will help to exclude symptomatic persons from entering the facility. Temperature monitoring of staff may be useful in some circumstances, and staff should also be informed not to report for work if they are ill. Greater use of personal protective equipment by staff is advisable in areas with higher risk of infection, and staff in the blood collection areas may be provided with face masks, disposable gowns and gloves to reduce the potential for cross-infection. Strengthening hygiene measures also includes introducing more hand-washing stations and intensive facility cleaning regimes. The scope of expected donor loss must be determined so that blood shortages can be anticipated and managed. Communication is key to minimizing donor loss and managing blood shortage. Donor loss from illness can often be mitigated by providing information to the donor about when he/she can return to donate again, and encouraging them to do so when they recover. The ability to maintain donor confidence in the safety of the blood donation environment and donor awareness of the need to continue donating blood is important in retaining donors who might otherwise stay away from blood collection because of fears of contracting infection at the donation session. Measures necessary to ensure a safe environment have been described earlier. It is equally important to communicate information regarding these measures to the blood-donating public, and to do so even before donor attendance has dropped. In Singapore, messages about the importance of continuing to donate blood and the stringent measures taken to assure safety during blood donation sessions were communicated to the public early during the H1N1 pandemic using website updates and media releases. By initiating these messages early and providing the public with the necessary information to address their fears, donors continued to come forward to donate blood even after higher alert levels were announced. During a pandemic, the traditional sources of blood donors, e.g. schools, universities, community groups, are often disproportionately affected. Having a resilient panel of donors and broad base of mobile blood drive partners will help to overcome the loss of donors from these groups. During the SARS outbreak, a major cause of drop in blood donations was the closure of schools during a period traditionally set aside for school drives. Fortunately, the blood service was able to tap on other partners such as religious groups to organize mobile blood drives. Having a wide range of donor recruitment strategies and access to many different communication channels will enable the blood service to tap on different segments of the population when needed. During the early stages of the pandemic when the population is still relatively unaffected, it may be useful to boost blood stocks in anticipation of shortage later on. This is particularly useful for longer shelf life components such as fresh frozen plasma and cryoprecipitate. Blood services with frozen blood programmes may start building up frozen red cell inventories with an appropriate balance of blood groups. Establishing sufficient stockpiles of red cells and plasma when collections are still stable allows the blood service to concentrate on collecting short shelf life products like platelets when less donors are available. Most national contingency plans will include plans to vaccinate the population when a vaccine against the pandemic strain becomes available. If this involves a large section of donating public, blood collection will be significantly affected as recently vaccinated donors will have to be deferred for a period of time depending on the type of vaccine. To pre-empt this, the blood service needs to work with the health authorities to determine the schedules for vaccination and hopefully be able to collect blood from potential donors before they are vaccinated. A close liaison with clinicians and hospitals is important to determine the clinical situation and identify clinical needs more accurately. Regular dialogue with Hospital Transfusion Committees should be maintained to update blood supply situations and to introduce appropriate blood conservation measures to maximize the blood supply during blood shortages. Lines of communication should be established as early as possible, and most clinicians and hospital staff are usually willing to cooperate with the blood centre to make optimal use of limited blood supplies. Close monitoring of collection and inventory levels with daily review of planned donation sessions is of course critical during blood shortage. Regular planning sessions among the donation, production, inventory management and clinical teams will enable the recruitment strategy to be adjusted to best meet the situation as it unfolds and the blood supply to be maximized. Efficient blood stock inventory management, with effective stock rotation and coordinated distribution will optimize utilization and minimize outdates. During a severe pandemic, it is likely that the blood service will have to operate in an environment of tremendous resource limitation, whether in staffing, consumables, infrastructure or support. If this should lead to failure to meet the need for blood/blood components or if transmission of influenza should occur through its activities, then the reputation and public image of the blood service will be badly affected. Critical functions or activities within the blood service that affect its ability to assure safe and sufficient supply of blood must therefore be identified so that limited resources can be diverted to the most essential services. During the initial stages when the shortage of staff is relatively moderate, work schedules and tasks can be adjusted based on priority of needs. It is useful to classify which activities are time-sensitive and which can be postponed or delayed, so that staff can be deployed more efficiently. When staff shortages become more acute, non-essential activities may have to be suspended and existing staff re-deployed to perform essential functions. Contingency plans must anticipate this and include the necessary training programmes for staff to acquire skills at multiple tasks and be competent in cross-departmental functions. This should be accompanied by the development of appropriate policies to address staffing issues such as salary continuation, benefits, compensations. Employees may also need psychological assistance during pandemics and crisis counsellors should be on hand to help them to cope with the increased psychological stress. Critical consumables are defined as one without which the blood supply will cease and for which there is no readily available alternative. Arrangements must be made in advance with suppliers of critical consumables to ensure continuity of supply or stockpiling of reserves if this cannot be assured. Just-in-time inventories may not be compatible for pandemic situations. Items such as face masks, gowns and gloves will be in great demand during a pandemic, and particular attention must be taken to make sufficient supplies available. Needless to say, the blood service needs to track its consumables inventory very carefully. Effective and timely communications with all stakeholders is a key area that must never be underestimated or overlooked during a pandemic. Stakeholders include the public, blood donors, staff, hospitals, clinicians, health response coordination agencies and other blood services. It is important to have communication in place among key stakeholders to timely of messages and partners who may not be or with the about blood donation and the blood supply must be consistent with national communication plans. As far as possible, key messages should be developed in advance and it is useful to have a set of available, which can be for different stages of the pandemic or different situations. messages regarding the blood supply should also be into the overall national pandemic in such messages are usually more e.g. blood to or not donate blood if are The is a useful guide to follow when public messages in a The media is a very means of public communication as it is often the source of information for the public and thus able to a on their and There are many of media – media media and media It is important to to the different of media and to communications and messages should be identified within the and with the skills to communicate effectively with the During a pandemic, risk communication becomes of importance in impact on the blood The blood service must communicate with the public in a that and and the pandemic and This requires and and communication that is and communication is a and the and knowledge about should be Information should be provided about measures are being taken to ensure donor any new deferral policies or changes to and and to when they come forward to By providing the donating public with information about they can do to make and how they can their part to help during the pandemic, they are able to in a and a in blood supply There is a similar need to maintain communications within the blood communications is critical in staff and and fear and uncertainty to staff Staff must be informed and about the pandemic and changes in policies, work and and the for the A and work will be more for challenges and able to when they are to work or are re-deployed to different like the Asia Blood and the Blood and international organizations like the and are effective for of information and knowledge about the pandemic. have a to in strategies for donor management and blood supply safety and For example, of donor management policies among during the H1N1 pandemic blood services to and their deferral policies for infected donors. The recently an and comprehensive on pandemic influenza to blood organizations in their planning. A pandemic influenza will have a major impact on the blood Blood services must develop appropriate plans to prepare for and the blood supply during a pandemic. Measures must be developed to ensure ensure donor and staff blood supply ensure operational effective communications and with other blood services.