Dr C. Shivaram Chief-Transfusion services Manipal Hospital Bangalore

1. “One small step for a man, a giant leap for mankind; - But the step is still to be taken" - The challenges of building a safe repeat donor pool Dr C. Shivaram Chief-Transfusion services Manipal Hospital Bangalore 20 July 1969 1900s

2. After 65 years of independence • One-third of Indians : Do not have access to safe drinking water • Food to eat • House to live in. • We as Indians, Traditionally do not believe in Punctuality, standing in que or keeping our surrounding clean. • In this scenario, establishing a Safe donor pool seems all the more difficult. Some questions with No answers

3. Altruistic Caring and giving Motivated Understands the implications of donation Have Reduced risk of HIV or Hepatitis VOLUNTARY DONOR

4. Voluntary non-remunerated blood donors are the foundation of a safe, sustainable blood supply. Without a system based on voluntary unpaid blood donation, particularly regular voluntary donation, no country can provide sufficient blood for all patients who require transfusion. WHO/NACO

5. Moving on from voluntary non-remunerated donors: who is the best blood donor? • Allain JP. • Source • Division of Transfusion Medicine, Department of Haematology, University of Cambridge, Cambridge, UK. • Abstract • Blood transfusion safety in sub-Saharan Africa (SSA) is marred by the high prevalence of infectious agents, chronic blood shortage and lack of resources. However, considerable pressure is applied by richer countries and international transfusion bodies to establish voluntary, non-remunerated blood donors (VNRD) as the only source of blood, excluding the traditional family/replacement donors on the grounds of a higher level of safety. Such a policy increases the cost of a unit of blood by two to fivefold and exacerbates the pre-existing blood shortage. This review provides compelling evidence that first-time VNRD are no safer than family/replacement donors and that only repeat donation provides improved blood safety. In order to limit blood shortage and maintain affordability of the blood supply in SSA, both types of donors should be accepted and both should be encouraged to donate regularly.

6. Intense competition between blood banks in a Fragmented BTS. • Blood comes with a price for testing. Donor perceives this as sale of blood. • No incentives for donating blood . • Blood Banks have no mechanism in place to identify and recall blood donors. • Blood banks have no counselors. • Blood banks have the dual responsibility of ensuring Safe blood and Safe donor. Challenges of Building a Safe donor Pool

7. All countries except Thailand depend heavily on replacement donors. • Lack of resources, lack of professional management, myths and misconceptions form a barrier to blood donation. • Besides recruitment, the donor screening and donor management are also not well addressed. • The donors are mainly males of 20-35 years who come from the middle class of the society. Only 3-6 % of females donate blood. • Most of the donors donate once in a lifetime as there is no emphasis on retention programmes. • Only 5-10 % are repeat donors. • The prevalence of transfusion-transmissible infections in the region is variable; HIV 0-1.6 %, HBV 0.06-8.5 %, HCV 1.2-3 %. Current Scenario SEAR Countries Bharucha ZS. DevBiol (Basel). 2005;120:145-53.

8. First time donors were less motivated by the cause of humanity (56.21%) and volunteered because of peer pressure (26.03%). • Regular donors came forward to donate blood for the cause of humanity (80.6%) and the sense of pride (27.79%). • Among altruistic blood donors. About 96.6% donors want to become repeat donors. • Majority of the donors had good knowledge about routes of HIV transmission Need for Safe Repeat donors Shah R, Tiwari AK, Shah P, Tulsiani S, Harimoorthy V, Choudhury N. Indian J PatholMicrobiol. 2007 Oct;50(4):896-900.

9. ISBT Code of Ethics Council of Europe • Voluntary non-remunerated donation: donation given by an altruistic donor who gives blood freely and voluntarily without receiving money or any other form of payment. • Family/replacement donation: donation given by an individual who gives blood when it is required by a member of the patient’s family or community. • In Asian countries like India Family donors are classified under Voluntary donors. • http://www.who.int/bloodsafety/global_database/bloodsafetyindicators2010example_en.pdf. • Blood Safety Indicators 2010/Global Database on Blood Safety We have no definition of a Repeat donor

10. One who has donated blood atleast once in the last one year( Not necessarily at our blood bank). • Apheresis donor Pool (Manipal hosp BB): 178 • Voluntary donor base of 8000+ donors • Repeat WB donor data base of 1396. • Imagine how big this number would be if all major blood banks networked together. Building Donor database

11. 1200 million people. • 1% of this =12 million units . • Annual collection in India = 8 million units and of this about one-half is from Voluntary donors. • How do we mobilize another 4 million people? • How do we convert the 50% of replacement donors to become repeat Voluntary donors. Need for Blood donor Mobilization

12. Family donors might be either directed or replacement. Difficult task to encourage these people to become VNRBD. Many benefits if this can be achieved. Family replacement donation is prevalent in many countries across the globe. Main reasons to convert to VNRBD ensure safer resources long term sustainability reduced cost and a stable supply Build a pool of safe donors. Patient’s relatives feel that replacement donation is safer. Medical professionals believe it is easier. Society at large finds replacement donation acceptable. Converting Replacement donors To VNRD and then to Repeat Voluntary.

13. Every businessman knows that it costs twice as much to get a new customer as to retain an old customer. • Retaining blood donors is economical and adds to quality. • Searching for donors from a pool is also easier than searching blindly in the community. • Extended phenotyping of a group of donors will help in searching for antigen negative blood. Benefits of building a Repeat donor data base.

14. 1. Build a Community committed to Volunteerism -uniform cost/quality/benefits 2. Build a BTS committed to safe blood. Accreditation and not legislation is the key 3. Conducive Govt Policies- Who can hold camps? Treat blood as an essential drug 4. Networking of BTS with Government and Industry and Educational institutes. -Make blood donation drives compulsory-twice a year. Sops-Tax benefits or surcharge. 5. Segregate Blood donor organizations form blood centers/blood bank. Building a Safe Repeat donor Pool –Primary Steps

15. Sustained motivation & Recruitment-Electronic media • Incentives for Repeat donation that can be used across Indian BTS. • Unlock barriers (i.e. the non-functioning systems of donor identification, registration and recall) to repeat donation. • This would multiply the blood supply from the current donor pool by two-threefold. • Conducting camps under a neutral banner/not an institutional banner. Complementary Steps

16. Where do we begin?

17. Ensure good treatment of blood donors. • Start Building a pool of Repeat donors. • Avoid smear campaigns. • Prepare for data sharing. • Reach out to the community in as many ways as possible and explain why blood comes with a cost. • Track donor recall and remember them even when you don’t need their blood. Action At Blood Bank Level

18. I have built my database with difficulty why should I share it with others?-Donor is not our property • This will be misused by some.-Let’s network with like minded people. • My donor will be called by another blood bank- You can also call their donor. • I will upload what about others? –Haemovigilance and updating repeat donor data should be a part of the CMIS report that we send to NACO/SACS Arguments against a data base

19. Donor ID- No value add-not retained by donor. • Pan card: Less than 1% of people have Pan cards. • Adhar Number- Still far away. • Even if a donor ID is given and retained the IT systems of two blood banks do not network with each other. Food for Thought • What we need are donor identifiers which the donor cannot leave behind or forget- Thumb scan/Retinal scan. • What we need are IT systems that are India specific not institutional specific. • Let’s begin with a regional database of Voluntary donors with last date of donation on a central server connected Via the internet which can network with a national database. Identifying a Repeat donor

20. Safe donor Pool is a necessary pre-requisite for safe blood. • Safe donor pool cannot be achieved by sporadic/cosmetic efforts overnight. • Radical reforms in Blood banking- • Relook at who can conduct camps • Awakening corporate social responsibility • Evolving a dynamic but uniform pricing mechanism will help sustain VBD movement. Conclusion Building a Safe donor Pool.

21. Blood transfusion is a lot like marriage. It should not be entered upon lightly, unadvisedly or wantonly, or more often than is absolutely necessary” - Beal THANK YOU SHIVARAM@MANIPALHOSPITALS.com