Quality and safety measures in transfusion practice: The experience of eight southern/eastern Mediterranean countries

Transfusion safety: Is there a difference between reported reactions in low-to-middle income and high-income countries?

BACKGROUND AND OBJECTIVES

Transfusion safety may be becoming dependent on the financial resources made available for transfusion structures and may vary between high-income countries (HIC) and low-to-middle-income countries (LMIC). To assess whether there is a difference in the reported TR between these two groups of countries, we examined TR reported in Tunis the capital of Tunisia, a LMIC, and compared their frequency with reported TR in HIC.

MATERIALS AND METHODS

Data of TR were collected from transfusion incident report (TIR) forms declared by healthcare facilities in Tunis between 2015 and 2019. They were analysed and compared to reported TR in France (ANSM) and UK (SHOT).

RESULTS

The incidence of TR was 70.6/100 000 blood components (BP) issued. A third of TR (36.8%) occurred at night. Febrile non-hemolytic transfusion reactions (43.7%) and allergic reactions (35%) were the most reported TR respectively 22.4/100 000 BP and 17.9/100 000 BP. The rate of ABO incompatibilities was 1.96/100 000 red blood cell units (RBC): they were all caused by human error. The rates of TRALI, TACO and bacterial contaminations were respectively 1.26/100 000 BP, 1.4/100 000 RBC and 0.7/100 000 BP.

CONCLUSION

While advanced technologies applied to transfusion have improved transfusion safety, this study shows that their impact has been relatively minor, as reported TR in LMIC are still comparable to those in HIC. ABO-incompatibilities are still higher in LMIC: this should be addressed by reinforcing the training of all healthcare personnel involved in transfusion medicine.

Thirty years of hemovigilance - Achievements and future perspectives

Since its emergence in the early 1990s, hemovigilance has gradually evolved from a blood safety concept focused on surveillance of adverse reactions and events in patients, to a well-defined system that monitors the entire transfusion chain and improves its safety. The importance of hemovigilance has been recognized globally in a relatively short time, but the level of its implementation varies significantly between countries. The cooperation of international organizations has significantly contributed to the promotion, implementation, and education in this field. Thanks to initiatives taken, the safety of transfusion practice has been improved in many segments, primarily related to the risks of adverse events in recipients of blood components. In parallel with changing transfusion practice, the hemovigilance process has also matured. In addition to the reduction of existing risks and the early detection of emerging risks, hemovigilance has also embraced the principles of patient blood management. Research in hemovigilance is more increasingly focused on specific categories of patients, specific blood components and methods of their preparation, rare reactions, and transfusion efficacy and efficiency. A proactive approach and use of big data can play an important role in achieving these goals. Additional and sustained efforts should be made to prevent underreporting of events and to improve data comparability through clear definitions and grading systems. This review provides a historical overview of hemovigilance and its achievements, current challenges, and future plans.

How to improve issuing, transfusion and follow-up of blood components in Southern and Eastern Mediterranean countries? A benchmark assessment

To determine the existence of guidelines regarding the appropriate clinical use of blood and blood components, transfusion requests, and blood issuing/reception documents and procedures. The different bedside transfusion organizations/processes and hemovigilance are also analyzed. The ultimate objective is to identify safe potential options in order to improve blood safety at the lowest cost. Data emanating from eight Arabic eastern/southern Mediterranean countries who responded to five surveys were collected and tabulated. National recommendations for the clinical use of blood components especially for hemoglobinopathies are lacking in some countries. In matter of good practices in the prescription, issuing and reception of BCs, efforts were made either on national or local basis. Procedures regarding patient information and ethical issues are still lacking. Almost all Mediterranean countries apply two blood testing procedures on each patient sample. Only Morocco, Tunisia and Algeria perform bed side blood group testing; Egypt and Lebanon perform antibody screen and antiglobulin cross matching universally. Automation for blood testing is insufficiently implemented in almost all countries and electronic release is almost absent. National hemovigilance policy is implemented in Tunisia, Morocco, and Lebanon but the reporting system remains inoperative. Insufficient resources severely hinders the implementation of expensive procedures and programs; however, the present work identifies safe procedures that might save resources to improve other parts in the transfusion process (e.g. electronic release to improve safety in issuing). Moreover, setting up regulations regarding ethics in transfusing recipients along with local transfusion committees are crucially needed to implement hemovigilance in transfusion practice.

Transfusion of stored autologous blood in patients with low-grade pseudomyxoma peritonei: A retrospective analysis of its safety and outcome

Background

Pseudomyxoma peritonei is a rare disease that presents as a malignant tumor on the peritoneal surface. Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy is the standard treatment for this disease and frequently requires a red blood cell transfusion. However, due to the limited collection and supply of allogeneic blood, surgical treatment may be delayed due to inadequate preparation of allogeneic blood in the course of clinical treatment. This study aimed to evaluate the safety and efficacy of transfusion of stored autologous blood in patients with low-grade pseudomyxoma peritonei.

Methods

Pseudomyxoma peritonei patients who received cytoreductive surgery combined with heat-infused peritoneal chemotherapy were divided into two groups: transfusion of allogeneic blood and transfusion of stored autologous blood. A comparison of the differences in multiple factors between the two groups was performed, including tumor recurrence, survival time, hemoglobin and hematocrit levels, coagulation function (prothrombin time, activated partial thromboplastin time, and fibrinogen), total hospital stay duration, and incidence of serious adverse events after surgery.

Results

Propensity scores matching analysis yielded 34 patients with allogeneic blood transfusion and 34 patients with stored autologous blood transfusion. Comparison analysis did not show statistical differences in several factors, including age, tumor grade, tumor recurrence rate after surgery, etc., between the two groups. The cytoreductive degree was considered an independent risk factor for tumor recurrence. The pseudomyxoma peritonei patients in the autologous transfusion group had a higher 5-year survival rate and a longer survival time. Moreover, transfusion of stored autologous blood did not increase the rate of tumor recurrence, or the total hospital stay duration after surgery, the hemoglobin level and coagulation function were well stabilized within 24 h after surgery, and there was a low incidence of serious adverse events.

Conclusion

The clinical application of transfusion of stored autologous blood in pseudomyxoma peritonei patients is safe and effective.

International collaboration for blood safety: The French-African experience

Blood safety is a non-negotiable issue worldwide, specifies the World Health Organization (WHO). Africa is both an entity and a multiplicity of situations within and cross-borders. Indeed, most African countries have recent borders and political organizations, after gaining independence in the 60's. Many such countries have maintained various types of links and cooperation programs with former European countries of influence, e.g. France and Belgium among others, which is the case for several countries from the francophone Central and West Africa. Besides, borders do not delineate ethnic groups as many of them migrate, with spread North to South and East to West across several countries, each having representations, ethnologically speaking. Transfusion is an essential supportive healthcare that requires medicine, technicity and logistics. Cooperation can be provided to Francophone Africa though at the expense of recruiting donors upon criteria that do not completely overlap with e.g. those put forward in France and other high-income countries, despite WHO claims for the universal model of Voluntary Non-Remunerated Blood Donation system. Next, the patient profile in intertropical Africa-of which the various francophone African countries-stringently differs from the profile now seen in France, with its younger (but strongly social network-connected) populations and the importance of anemia of all causes but frequently infectious in nature. The frequency of antigens defining blood groups also significantly differs from that in France and the rest of Europa. Last, the carriage of blood transmissible infectious pathogens in sick but also apparently healthy populations seriously complicates the build up of suitable blood component inventory. In the present review, we discuss the universality of blood donation, the specificities of inter-continent cooperation and report on experiences of such cooperation. The French Blood Establishment EFS has taken over earlier initiatives of regional blood services and provides technology and scientific transfer and support to many countries for several decades; the National Institute for Blood transfusion, an education and research institute, has set up collaborative research in several domains but mostly in the domain of blood transmissible infections. We next also present a theoretical view of support named ALEASE, that can be pursued, based on collaborative experiences carried out in the Mediterranean Northern and Eastern areas. ALEASE promotes benchmark between participants. If there is general agreement that cooperation between economically wealthy countries and low-income, developing, countries in the domain of blood and blood transfusion safety, promotion of blood donation, blood component manufacturing, transfusion technology, hemovigilance, etc., tools to achieve this goal can be periodically reviewed based on specific needs for countries and professionals. That also comprise of adapted, sometimes specific, education programs.