I'm sure that at some point in your lifetime, you have either experienced or known someone who received a unit of blood. But have we eve...
I'm sure that at some point in your lifetime, you have either experienced or known someone who received a unit of blood. But have we ever given a second thought to how this integral part of the healthcare system in Nigeria is managed? In this article, I will give the reader a glimpse into this sector due to its importance, and provide some comparison with how it's managed in more advanced countries.
Blood transfusion is a century-old medical practice developed around 1900 by a scientist called Carl Landsteiner, despite several attempts by contemporary scientists before him to devise a means to replace the loss of blood encountered by patients either during surgical operations, accidents, or childbirth.
Landsteiner was able to perfect the art of blood transfusion through the discovery of major blood groups (ABO and Rhesus), which played a role in matching donors and recipients. Since then, there has been continued effort toward safe blood transfusion services across the globe, which has massively led to a decline in the mortality rate associated with decreased blood supply in the body.
In Nigeria, blood transfusion services have been practiced since the colonial and post-colonial periods, mostly starting in Lagos and other major urban centers. The major breakthrough came when the National Blood Transfusion Service was established in 2005 during President Obasanjo's administration. The National Health Act of 2014 led to the passage of the National Blood Service Agency Bill on 29th July 2021.
According to the NBSA (www.nbsc.gov.ng) website, there are 17 voluntary blood donation centers across the six geopolitical zones of Nigeria, including separate centers in the Federal Capital Territory, Abuja, and other centers within the Armed Forces/Military hospitals. National Blood Donation Day is celebrated every 8th of December, and World Blood Donor Day is celebrated every 14th of June.
Nigeria has a population of over 200 million people, and without saying, our demand for blood donation is staggering—considering the number of road traffic accidents, obstetric patients, major surgical procedures, and under-5 malaria and schistosomiasis infections. This is apart from anemic conditions due to malnutrition (iron deficiency), other tropical diseases, chronic kidney disease, abnormal menstruation, and burns.
With all the above-mentioned reasons, our data regarding blood transfusion services is reprehensible.
Several factors have led to this, including community neglect, lack of government intervention, lack of standard private practices, cultural influences, poor funding, and the almighty mismanagement of resources.
About 1,230,000 (one million, two hundred and thirty thousand) units/pints of blood are collected annually across Nigerian healthcare facilities, but unfortunately, about 90% of these donations are paid/commercial. Only 25,000 units are donated by volunteers, which are made available to 3,400 hospitals in urgent cases! This simply shows that less than 5% of blood donation in Nigeria is voluntary.
Let me highlight four different forms of donation practiced worldwide:
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Voluntary donation: Individuals donate purely for the sake of humanity, with no ulterior motive.
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Direct/replacement donation: Usually done by relatives of a patient who are called in times of emergency. This is widely practiced in Nigeria, accounting for about 75% in public hospitals.
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Paid commercial donation: Donors give blood and receive money for it. This practice constitutes about 25% in public hospitals and about 75% in some private clinics. It carries a major risk of transmitting transfusion-transmitted infections like HIV, Hepatitis B, and C.
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Autologous transfusion: An individual donates their own blood prior to a surgical operation, which is then stored and later transfused back to them. This procedure carries the least risk of infection or transfusion reaction.
Among the four blood transfusion methods, the two most widely practiced in Nigeria are the replacement and the paid commercial types. People only care to donate blood when they know their relatives are in need. This practice is common in our society—from the villages to the urban areas. You could donate as soon as you know it's your parent, wife, son, sister, brother, or friend. Any other person can go to hell!
The worst form of practice is the commercial one, where people, either out of ignorance or artificial poverty, donate only if they are going to be paid. This business triggers every form of atrocity, where donors sometimes give blood multiple times within a short period (the standard is at least an interval of 4–6 months, depending on age, gender, and social status).
The paid donors carry the highest risk of transmitting infections and other abnormalities, either to themselves or to the recipients. So, this practice needs to be discouraged by healthcare personnel and the government.
As an insider, and with my little period of practice, I have come to realize some of the difficulties blood transfusion services encounter in our healthcare facilities.
Shortage of Blood Units
There is a chronic shortage of blood supply. This is evident from how doctors and lab personnel always advise patients' relatives to go home and mobilize their kinsmen when a patient is in need of blood. This happens as if it were the standard thing to do. The ideal scenario is for a patient to be transfused from a pool of blood in the blood bank, regardless of whether a replacement is brought. But this can only happen if there are enough units stored—and in most cases, there are none.
I have personally witnessed several cases where a patient nearly lost their life because donors had to travel many kilometers, only to be rejected due to mismatch. Imagine the money and time wasted!
The blame is not on the healthcare personnel, nor the government alone—the blame is on the system and our society at large. We are lacking altruism.
This problem can be attributed to the lack of a decentralized system of blood banking in Nigeria.
Nigeria has a single national blood donation system. Meanwhile, in places like the U.S., blood procurement is majorly met by volunteers. They have pluralistic blood collection programs by the Red Cross, independent community blood centers, and hospitals.
In the U.S., 15 million units of blood are collected from 10 million donors annually. Only 7% are collected in hospitals, and 93% in regional centers—unlike Nigeria, where most collections are done in hospitals.
In the U.S., blood collection, processing, testing, and preservation are regulated by the FDA. They operate a sharing system whereby blood units can be transferred from regions with lower demand and higher collection to regions with higher demand.
Blood Transfusion Data
Nigeria has a blood collection data problem. Many hospitals, especially in rural areas, cannot consistently keep records for even a year. This is due to the manual (pen and paper) system of health records still widely used in Nigeria, which is subject to errors, loss, or manipulation. Without proper blood collection data, it will be difficult to address shortages or implement corrective policies.
Lack of Awareness
Recent data has shown that blood donation is directly proportional to development. In developed countries, 50 units of blood are donated per 1,000 population. In developing countries, 15 units are donated per 1,000, while in underdeveloped countries, only 5 units are donated per 1,000 population.
In underdeveloped and developing countries, limited storage facilities, lack of incentives, malnutrition, poor personal health, and lack of knowledge contribute to low voluntary blood donation. It is more likely for a high-income university graduate to donate blood voluntarily than a less educated poor laborer. The former might be healthier, more mentally stable, and more aware of the need to donate.
Expertise and Procurement Facilities
The current improvements in blood donation services—especially in the tropics—can be attributed to benevolent funding from the U.S. through USAID and the President’s Emergency Plan for AIDS Relief (PEPFAR). Since 2000, there has been increased efficiency in transfusion services in Nigeria, thanks to these agencies.
Despite this improvement, there are still problems with procedures, staff proficiency, specific testing, and the preparation of separate blood components (like plasma derivatives, platelets, and white blood cells).
Our screening methods are still based on qualitative immunophenotyping. We are using 4th-generation ELISA (Enzyme-Linked Immunosorbent Assay) and have not yet adopted Nucleic Acid Testing (NAT).
In 2018, I attended a two-week training in Abuja organized by experts from the University of Maryland, under the supervision of the Federal Ministry of Health (FMoH). We were trained in standard serological techniques for retroviral screening (RVS), Hepatitis, and VDRL. This was in preparation for a six-month extensive survey we conducted across Nigeria on the impact of HIV screening and therapy over the last three decades, called the Nigeria AIDS Indicator and Impact Survey (NAIIS 2018). The training was an eye-opener for me on the need to standardize our screening methods.
The Way Forward
To attain the blood transfusion safety target, there is a need for more voluntary donation campaigns through mass media, schools, churches, and mosques.
Factors preventing voluntary donations should be addressed—such as the establishment of more independent blood donation centers, provision of incentives, availability of storage facilities, and free donation services.
Nigeria should have a centralized registry of people with blood group O Rhesus D negative, and such rare blood units should be made available across the country through a systematic sharing arrangement.
There is a need for communities and philanthropists to create more non-governmental organizations (NGOs) to address the shortage of blood and to complement government efforts, as the government cannot carry out this duty alone.
Saifullahi Attahir is the President of the National Association of Jigawa State Medical Students (NAJIMS) National Body. He wrote this piece from Federal University Dutse, and can be reached at: saifullahiattahir93@gmail.com
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