DrAmar Nathgiri

Blood safety and availability

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Key facts

• Of the 107 million blood donations collected globally, approximately half of these are collected in the high-income countries, home to 15% of the world’s population. This shows an increase of almost 25% from 80 million donations collected in 2004.
• In low-income countries, up to 65% of blood transfusions are given to children under five years of age; whereas in high-income countries, the most frequently transfused patient group is over 65 years of age, accounting for up to 76% of all transfusions.
• Blood donation rate in high-income countries is 39.2 donations per 1000 population; 12.6 donations in middle-income and 4.0 donations in low-income countries.
• An increase of 7.70 million blood donations from voluntary unpaid donors from 2004 to 2011. 71 countries collect over 90% of their blood supply from voluntary unpaid blood donors; however, 73 countries collect more than 50% of their blood supply from family/replacement or paid donors.
• Only 41 of 151 countries produce plasma-derived medicinal products (PDMPs) through the fractionation of plasma collected in the country, whereas the other 110 countries import PDMPs from abroad.

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National blood policy and organization

Blood transfusion saves lives and improves health, but many patients requiring transfusion do not have timely access to safe blood. Providing safe and adequate blood should be an integral part of every country’s national health care policy and infrastructure. WHO recommends that all activities related to blood collection, testing, processing, storage and distribution be coordinated at the national level through effective organization and a national blood policy. This should be supported by appropriate legislation to promote uniform implementation of standards and consistency in the quality and safety of blood and blood products.
In 2011, 68% of countries had a national blood policy, compared with 60% of countries in 2004. Overall, 62% of countries have specific legislation covering the safety and quality of blood transfusion:

• 81% of high-income countries
• 60% of middle-income countries
• 44% of low-income countries.

Blood supply

About 107 million blood donations are collected worldwide. Almost half of these are collected in high-income countries, home to 15% of the world’s population.
About 10 000 blood centres in 168 countries report collecting a total of 83 million donations. Collections at blood centres vary according to income group. The median annual donations per blood centre is 3100 in the low- and middle-income countries, as compared to 15 000 in the high-income countries.
There is a marked difference in the level of access to safe blood between low- and high-income countries. The whole blood donation rate is an indicator for the general availability of blood in a country. The median blood donation rate in high-income countries is 39.2 donations per 1000 population. This compares with 12.6 donations in middle-income countries and 4.0 donations in low-income countries (see Figure 1).
75 countries report collecting fewer than 10 donations per 1 000 population. Of these, 38 countries are in WHO’s African Region, 6 in the Americas, 8 in the Eastern Mediterranean Region, 6 in Europe, 7 in South-Eastern Asian and 10 in the Western Pacific. All are low- or middle-income countries.

Figure 1: Whole blood donations per 1000 population

Blood donors

Age and gender of blood donors

Data about the gender profile of blood donors show that globally, 30% of blood donations are given by women, although this ranges widely. In 18 of the 104 reporting countries, less than 10% donations are given by female donors. The age profile of blood donors shows that overall 6% of donors come from the under-18 age group, 27% from people aged 18–24, 38% from the 25–44 group, 26% from 45–64 group and 3% from those over 65. In low- and middle-income countries, proportionally more young people donate blood than in high-income countries (see Figure 2). Demographic information of blood donors is important for formulating and monitoring recruitment strategies.

Types of blood donors

There are three types of blood donors:

• voluntary unpaid
• family/replacement
• paid.

An adequate and reliable supply of safe blood can be assured by a stable base of regular, voluntary, unpaid blood donors. These donors are also the safest group of donors as the prevalence of bloodborne infections is lowest among this group. World Health Assembly resolution (WHA63.12) urges all Member States to develop national blood systems based on voluntary non-remunerated blood donation¹ and work towards the goal of self-sufficiency.
Data reported to WHO shows significant increases of voluntary unpaid blood donations in low- and middle-income countries:

• An increase of 7.70 million blood donations from voluntary unpaid donors from 2004 to 2011 has been reported by 156 countries. The highest increase of voluntary unpaid blood donations was observed in the South-East Asia (65%) and African (48%) Regions. The maximum increase in absolute numbers was reported in the Western Pacific Region.
• 71 countries collect more than 90% of their blood supply from voluntary unpaid blood donations, including 60 countries with 100% (or more than 99%) of their blood supply from voluntary unpaid blood donors (38 are high-income countries, 22 middle-income countries and 11 low-income countries) (see Figure 3).
• 15 countries of these 60 countries have achieved 100% (or more than 99%) voluntary unpaid donation in 2011 from a lower percentage reported in 2004; six of these 15 countries have achieved this target from a percentage lower than 75% reported in 2004: Cook Islands (from 40% to 100%), Kenya (from 53% to 100%), Nicaragua (from 41% to 100%), Turkey (from 40% to 100%), United Arab Emirates (from 59% to 100%) and Zambia (from 72% to 100%).
• In 73 countries, more than 50% of the blood supply is still dependent on family/replacement and paid blood donors (8 are high-income countries, 45 are middle-income countries and 20 are low-income countries).
• 22 countries still report collecting paid donations in 2011, around 800 000 donations in total. 58% of paid donations reported are apheresis donations.

Figure 3: Percentage of voluntary unpaid blood donations

Blood screening

WHO recommends that all blood donations should be screened for infection prior to use. Screening should be mandatory for HIV, hepatitis B, hepatitis C and syphilis.

• 25 countries are not able to screen all donated blood for one or more of the above infections.
• Irregular supply of test kits is one of the most commonly reported barriers to screening.
• 24% blood donations in low-income countries are not screened following basic quality procedures which include documented standard operating procedures and participation in an external quality assurance scheme.
• The prevalence of transfusion-transmissible infections (TTIs) in blood donations in high-income countries is considerably lower than in low- and middle-income countries. The prevalence of HIV in blood donations in high-income countries is 0.003% (median), in comparison with 0.1% and 0.6% in middle- and low-income countries respectively. This difference reflects the variable prevalence amongst members of the population who are eligible to donate blood, the type of donors (such as voluntary unpaid blood donors from population at lower risk) and the effectiveness of the system of educating and selecting donors.

Blood processing

Blood collected in an anticoagulant can be stored and transfused to a patient in an unmodified state. This is known as ‘whole blood’ transfusion. However, blood can be used more effectively if it is separated into components, such as red cell concentrates, plasma, and cryoprecipitate and platelet concentrates. In this way, it can meet the needs of more than one patient. The capacity to provide patients with the different blood components they require is still limited in low-income countries: 40% of the blood collected in low-income countries is separated into components, 78% in middle-income countries and 97% in high-income countries.

Supply of plasma-derived medicinal products (PDMPs)

World Health Assembly resolution (WHA63.12) urges Member States to establish, implement and support nationally-coordinated, efficiently-managed and sustainable blood and plasma programmes according to the availability of resources, with the aim of achieving self-sufficiency. It is the responsibility of individual governments to ensure sufficient and equitable supply of plasma-derived medicinal products namely immunoglobulins and coagulation factors, which are needed to prevent and treat a variety of serious conditions that occur worldwide.
41 countries (20 high-income, 19 middle-income, 2 low-income) of the 151 reporting countries, reported producing all or part of the PDMPs through the fractionation (e.g. domestic or/and contract fractionation) of plasma collected in the country.

• 32 of the 41 countries report plasma fractionation carried out within the country.
• 9 of the 41 countries report plasma sent for contract fractionation in another country.

The other 110 countries report that all PDMPs are imported.
Around 10 million litres plasma from 33 reporting countries (including 17 high-income countries, 15 middle-income countries and 1 low-income countries, covering a population of 2.6 billion) was fractionated for the production of PDMPs during the year. This includes around 50% plasma recovered from the whole blood donations.

Clinical use of blood

Unnecessary transfusions and unsafe transfusion practices expose patients to the risk of serious adverse transfusion reactions and TTIs. Unnecessary transfusions also reduce the availability of blood products for patients who are in need.
WHO recommends that all countries have transfusion committees to implement national policy and guidelines on rational use of blood in hospitals and a national haemovigilance system to monitor and improve the safety of the transfusion process.

• 109 countries have national guidelines on the appropriate clinical use of blood.
• 86% high-income countries have a national haemovigilance system, compared to only 34% of low- and middle-income countries.
• Ttransfusion committees are present in 79% of the hospitals performing transfusions in high-income countries and in about half of the hospitals in low- and middle-income countries.
• Clinical audit are conducted in 91% of hospitals performing transfusion in the high-income countries and in 58% of hospitals in the low- and middle-income countries
• Systems for reporting adverse transfusion events are present in 93% of hospitals performing transfusion in high-income countries and 76% in low- and middle-income countries.

Blood transfusions

There are great variations between countries in the age distribution of transfused patients. For example, in the high-income countries, the most frequently transfused patient group is over 65 years, which accounts for up to 76% of all transfusions. In the low-income countries, up to 65% of transfusions are for children under the age of five years.
In high-income countries, transfusion is most commonly used for supportive care in cardiovascular surgery, transplant surgery, massive trauma, and therapy for solid and haematological malignancies. In low- and middle-income countries it is used more often to manage pregnancy-related complications and severe childhood anaemia.

WHO response

The WHO strategy for blood safety and availability addresses five key areas:

• the establishment of well-organized, nationally-coordinated blood transfusion services to ensure the timely availability of safe blood and blood products for all patients requiring transfusion.
• the collection of blood from voluntary unpaid blood donors from low-risk populations.
• quality-assured testing for transfusion-transmissible infections, blood grouping and compatibility testing.
• the safe and appropriate use of blood and a reduction in unnecessary transfusions.
• quality systems covering the entire transfusion process, from donor recruitment to the follow-up of the recipients of transfusion.

Through its Blood Transfusion Safety Programme, WHO supports countries in developing national blood systems to ensure timely access to safe and sufficient supplies of blood and blood products and good transfusion practices to meet the patients’ needs. The programme provides policy guidance and technical assistance to countries for ensuring universal access to safe blood and blood products and work towards self-sufficiency in safe blood and blood products based on voluntary unpaid blood donation to achieve universal health coverage.

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¹Voluntary non-remunerated blood donation also includes the donation of plasma and cellular blood components.
Data source: This fact sheet is based on the data obtained through the WHO Global Database on Blood Safety (GDBS) for the year 2011 which were reported by 163 countries. To give a more complete overview of the global situation, data for the year 2010 have been used from 14 countries, where 2011 data are not available. Overall, responses received from 177 countries cover 98% of the world’s population