Unsafe Blood Still Found in Some Developing Countries

November 1, 2002
Charles L. Bennett, MD, PhD

Oncology NEWS International, Oncology NEWS International Vol 11 No 11, Volume 11, Issue 11

During the HIV epidemic in the 1980s, more than half of the hemophiliac patients living in many countries, including the United States, France, Denmark, and Japan, became infected with HIV as a result of blood transfusions with contaminated blood or blood products.[1,2] Since the clotting factor needed to treat hemophiliacs was manufactured by pooling plasma from thousands of donors, even one HIV-infected donor could contaminate the entire supply, infecting hundreds.

During the HIV epidemic in the 1980s, more than half of the hemophiliac patients living in many countries, including the United States, France, Denmark, and Japan, became infected with HIV as a result of blood transfusions with contaminated blood or blood products.[1,2] Since the clotting factor needed to treat hemophiliacs was manufactured by pooling plasma from thousands of donors, even one HIV-infected donor could contaminate the entire supply, infecting hundreds.

Several developed countries faced civil litigation that resulted in the indictment and imprisonment of government officials and industry leaders for their role in the mismanagement of the blood supply.[3] Investigations of these individuals revealed that they delayed the implementation of donor screening policies and/or technologies used to screen donors and blood supplies for HIV.

Fear of future litigation combined with the development and implementation of blood donor screening policies and screening tests in the last 17 years have helped to ensure the safety of the blood supply in developed countries. Many developing countries, however, have been struggling to adopt similar safety measures.

Most developing countries cannot afford, nor do they have the infrastructure required, to implement the effective yet costly methods to ensure safety employed in developed countries. Some 13 million units, or up to 45% of blood donations in developing countries, are never tested for infections transmissible by transfusion.[3,4]

In addition, donors in developing countries are often compensated monetarily, attracting people living in poverty who have a high risk of carrying HIV, hepatitis C virus, or hepatitis B virus. These people often donate frequently without regard to the status of their health and the risk to others.

Thus, 10% of new HIV infections in developing countries are estimated to result from transfusions using infected blood and blood products.[4]

India

India is one example of a developing country that faced catastrophe due to a contaminated blood supply. In 1995, the Bombay blood bank, supported by the Red Cross Society, was closed for supplying HIV-contaminated blood to hospitals from 1992 to 1994. By 1996, nearly 9% of the 2,574 AIDS cases in India were due to the transfusion of HIV-contaminated blood or blood products. Roughly 95% of the blood supply in India was believed to be unsafe.[5,6]

The Indian government responded by mandating HIV screening at all blood banks, banning professional blood donations, strengthening the management of blood banks, and establishing the National and State Blood Transfusion Councils to oversee the blood safety program.[3]

Although the Indian government’s actions may have increased the safety of the blood supply, it also had negative consequences. The ban on professional blood donations, which previously accounted for 50% of India’s blood supply, exacerbated blood shortages and raised the cost of blood in the underground market.

In addition, a national survey of blood bank directors indicated that the screening program had not been instituted effectively, since only 87% of the blood banks screened for hepatitis B, 95% for HIV, and 6% for hepatitis C.[7]

Similarly, HIV testing of donated blood remained infrequent in neighboring Pakistan. Furthermore, the decentralization of blood donation systems in India and Pakistan made quality control difficult to assure. For example, test kits were often in short supply, and laboratory technicians were not all trained to the same high standard.[8]

In other parts of Asia, paid donors account for an even larger portion of blood donors. Paid donors represented 80% of all donors in Vietnam in 1997.[9] Although screened by HIV antibody test, contaminated blood went undetected as donors gave blood during the "window period," the time between infection and seroconversion. According to the Vietnamese director of the Central Hematology and Blood Transfusion Institute, 100 persons contracted HIV through blood transfusion in 1997.[9]

China

China experienced one of the most severe HIV-contaminated blood supply problems since the onset of the epidemic. The Chinese view blood as sacred, and thus paid donors, who receive $250 for one to two units, are the primary source of blood in China.

The demand for blood donations expanded in 1993 when Chen Mingzhan, the minister of health, approved a plan to export blood products. Middlemen sold blood purchased from farmers in the countryside to hospitals, blood banks, and blood-product suppliers. A year later, blood screened from Guan County, near the country’s capital Beijing, indicated for the first time that HIV-infected persons were donating blood.

In 1995, the National People’s Congress passed laws to prohibit selling blood and to establish a voluntary donation system.[10] However, these laws failed to stop professional blood donation, as paid donors continued to supply 60% of China’s blood supply.[11]

Although the Chinese government mandated HIV testing of donated blood, screening was infrequent and often ineffective due to the poor quality of Chinese-made HIV test kits. In 1997, the Chinese health officials certified only five Chinese-made blood-testing kits. The public health officials of the Beijing Municipality found the approved kits comparable to imported kits with low rates of false-negative and false-positive results.[12]

Unfortunately, these kits were utilized only 20% of the time to test blood in Chinese hospitals.[12] Moreover, improper practices during the donation process, including the re-use of needles, pooling of blood products, and reinfusion of contaminated blood to donors in an effort to reduce the time between donations, perpetuated the spread of HIV infection.[10-12]

Success in Africa

Despite the difficulties, some developing countries, such as South Africa, Zimbabwe, and Namibia, have managed to finance and institute programs that resulted in a safe blood supply.

Zimbabwe ensures the safety of its blood supply through a centralized blood collection system. The National Blood Transfusion Service employs mobile teams that collect blood in the community and bring the blood donations to one of two fully equipped testing sites, where trained technicians screen them for transfusion-transmissible infections.[8]

The mobile teams only recruit voluntary, unpaid donors. This selection process depends largely on altruistic motives and greatly reduces the risks associated with collecting blood from paid donors.

Following the testing, the site distributes blood to hospitals around the country. Other developing countries may be able to use these practices as a model to develop and implement measures to safeguard their blood supply.

Developed countries, like the United States, have taken tremendous steps to create one of the safest blood supplies in the world. A few African nations have demonstrated that poor, developing countries can also create a safer blood supply.

While developing countries may not be able to afford some techniques used in developed countries, they can ensure safety by employing cheap and effective measures, such as volunteer donors and national testing sites. With technical and even financial support from their international peers, developing countries can have great success with establishing and maintaining infrastructures for safeguarding their blood supply.I

References:

1. World Health Report 1996—Executive Summary. World Health Organization (WHO), 1996.

2. Grmek MD: History of AIDS: Emergence and Origin of a Modern Pandemic. Princeton, NJ, University Press 1990.

3. Weinberg PD, Hounshell J, Sherman LA, Goodwin J, Ali S, Tomori C, Bennett CL: Legal, financial, and public health consequences of HIV contamination of blood and blood products in the 1980s and 1990s. Ann Intern Med 136:312-319, 2002.

4. Blood Safety . . . For Too Few. WHO. Press release. April 7, 2000.

5. Jayaraman KS: HIV scandal hits Bombay blood centre. Nature 376:285, 1995.

6. The World Bank Group: India’s national AIDS control program. Available at www4.worldbank.org/sprojects/project.asp?pid=P045051. September 1999.

7. Kapoor D, Saxena R, Sood B, Sarin SK: Blood transfusion practices in India: Results of a national survey. Indian J Gastroenterol 19:64-67, 2000.

8. The Panos Institute: Safe blood: An affordable right? Available at http://www.aegis.com/news/panos/1996/PS960601.html. June 10, 1996.

9. Vietnam says dozens of blood donors are HIV positive. Reuters. October 17, 1997.

10. Tomlinson R: Chinese clamp down on blood products. BMJ 314:93, 1997.

11. Pomfret J: The high cost of selling blood: An AIDS crisis looms in China, Official response is lax. Washington Post January 11, 2001.

12. Keeping China’s blood supply free of HIV. U.S. Embassy Beijing sixth of seven reports. Available at http://www.usembassy-china.org.cn/english/sandt/webaids5.htm. April 1997.