Challenges of Blood Transfusion in a Developing Country and the Ways Forward

the ABSTRACT Unsafe BT is a major public health problem in sub-Saharan Africa due to high patronage on commercial blood donation as against the WHO recommended voluntary non-remunerated blood donation. According to WHO blood safety report in Africa, 250-500 people are infected with HIV daily as a result of unsafe blood transfusion. Unsafe blood transfusion practice is a major contributor to morbidity and mortality in a developing country such as Nigeria. This review study gives insight into the challenges of BT in Nigeria and the strategic leadership approaches to attain blood safety and curb the morbidity and mortality attributable to unsafe BT practices in the region.

crude, unsafe manual (analogue) mode of administering blood while the CBT is the current, safer automated (digital) method of blood administration. It is actually the CBT that qualifies blood as a gift of life. Blood can only be a gift for life when it is safe for transfusion.

1) ABO-Rh blood grouping and cross-matching before
transfusion. Group-specific blood transfusion is the topmost priority of SBT in this criterion.
2) Screening test: Donor blood is subjected to screening tests against infectious agents.
3) Blood Storage: the suitability of anticoagulant-containing blood container is a vital component of SBTP.

4) Tests to handle complications of BTR (Rhesus-ABO
antibodies test) as in ABO-Rh or inter-donor incompatibilities.
In Safe BTP, CBT is the rule-only deficient blood component in a recipient is replaced with the donor's blood. This mechanism saves blood wastage as one unit of blood can provide several BPs.
Safe BT is a palliative intervention as it can improve the QOL of the severely anemic dying patient.In order to sustain Safe BTP, VNRBD pool is recognized globally as the safest source of blood. The WHO recognized VNRBD as the foundation for safe, sustainable, sufficient and secured blood [5][6]. 6) WHO Global Blood Safety Network [12] These WHA resolutions are needed in order to ensure security, safety and sufficiency of blood to all patients.

Epidemiology
The WHO recommends blood donation by 1% of any given population as the minimum requirement needed to meet the nation's most basic needs in order to ensure sustainable sufficiency in safe blood. About 112.5 million blood donations of blood are collected globally annually out of which 50% occur in HICs of the world. About 57 countries have achieved 100% in VNRBD. The

average blood donation in LICs is fifteen times lower than their
HICs counterparts as in 2006 [13]. Globally, more than seventy countries have a blood donation rate < 1% (10 per 1000 persons).
In Africa only 40% (3.2 million as against 8.0 million) of the minimum requirement of BD was met in 2006. In Nigeria, 33.3% (0.5 million as against 1.5 million) of the minimum requirement of blood was met in 2006 [14]. The 3 Forms of Blood Donation

according to definitions on blood safety endorsed by WHO Expert
Groups include: VNRBD -( altruistic giving, non-remunerated, for life-saving);Family/Friend Replacement Donation (FRD), which is a donation on goodwill, to save cost and Commercial (Paid) Donation (CD)-which is majorly for financial gratification [15]. In Nigeria public healthcare sectors, 75% of blood donations are FRD while 25% are sourced commercially. The reverse is the case in private sectors where CD (75%) is the major source of blood donation while 25% are contributed by FRD. The VNRBD contribution to blood pool in Nigeria is negligible [14]. ix. Poor quality control system.

SWOT Analysis of BT in Nigeria
x.
No emergency preparedness response plan.

Challenges due to choice of Blood Donation:
The CD and FRD are predominant sources of blood in Nigeria as against VNRBD which is predominant in developed countries. CD is illegal, lacks documentation and predisposed to TTI [1,3,14,16].

Challenges due to High Prevalence of TTIs:
The high prevalence of TTIs in the general/donor population is a strong set-back to achieving SBT. This is not usually the case with routine VNRBD.

Blood Supply Deficit:
There is a need to invest more money in transfusion medicine in LICs to achieve the minimum requirement of sustainability, security, safety and sufficiency in blood transfusion.   The current global framework on SBT is geared towards 100% VNRBD. This framework has four goals and twenty strategies viz:

1) Goal A: Create Enabling Environment for VNRBD -This
goal has 3 strategies for its implementation.

2) Goal B:
Foster culture of VBD -This goal has 7 strategies for its implementation.
3) Goal C: Build and maintain safe sustainable VBD Base -This goal has 6 strategies for its implementation.

4) Goal D: Provide Quality Donor Services and Care -This
goal has 5 strategies for its implementation.
In addition to the above framework, other strategic approaches to improve the scorecard of SBT in a developing country such as Nigeria are to:

1) Revive the NBTS:
There is a need to revive the NBTS through funding and legislative backing to become fully recognized institution.
2) Embark on VNR Blood Drive: Did I hear ''One million safe blood unit initiative'' by the NBTS national co-ordinator?

3) Improve leadership style-(Government Commitment):
Good health governance from top-down.

5) Safe Blood Transfusion-COVID-19 Era:
There is a need for emergency response readiness in the COVID-19 era as regards to sustainability of safe Blood. Efforts must be made to enhance donor safety through social distancing, infection control (hand hygiene, temperature check and use of face mask). Ensure staff health and safety by implementing CDC guidelines on COVID-19 for blood and plasma collection [17].

Conclusion
Unsafe BT is a major public health challenge in a developing country such as Nigeria. I think it is time to change the narrative.
It is time to change the crude unsafe choice of CD to safe VNRBD.
It is time to change the age-long simple (whole blood) method of blood transfusion to the current CBT. It is time to re-structure our infrastructures in TM. This will be in the interest of our current and future generations. It will also be in the interest of accountability, transparency, and high evidence-based research studies in transfusion and forensic medicine.