Safe Blood Transfusion: A Challenge

Blood Transfusion is an integral part of our healthcare system and many times it is essential to save lives of patients. Some of the clinical conditions that require transfusion of blood are complex surgical procedures, severe anaemia, trauma and pregnancy-related complications like obstetric emergencies. While conditions like sickle cell anaemia and dengue may require transfusions occasionally, thalassemics and patients suffering from cancers like acute myeloid leukaemia and lymphoma require blood more frequently.

Unsafe Blood Can Cost a Life

In a shocking incident, a 9-year-old child suffering from Leukemia contracted HIV after blood transfusion in a reputed cancer hospital in Trivandrum. In another incident, a lady in Bangalore claimed that she contracted HIV through transfusion from one of the top hospitals in the city. There was also a case where 32 thalassemic children contracted the disease after transfusion in a leading hospital in Junagadh, Gujarat. Similar incidents have surfaced time and again in various parts of the country. In fact, according to a report published by a leading newspaper, over 20,500 patients contracted HIV in the last 11 years, through unsafe transfusion of blood. These numbers only talk about HIV infections through unsafe blood. If we add the cases of Hepatitis B and Hepatitis C infections, this number will skyrocket to a few lakhs ! So while blood is a life saver and needs to be transfused, the bitter truth is that not all the blood issued by blood banks is safe.

How can this problem be tackled?

In terms of volume, India collects between 11 and 12 million blood units a year, which is a large number. Unlike most developed countries which follow a centralized blood banking model, India has a fragmented blood transfusion system with over 2900 blood banks. There are also various formats of blood banks in India like – Government blood banks, hospital based blood banks, stand-alone blood banks etc., which makes it a difficult task to come up with a uniform strategy for ensuring safe blood for all. The challenge is not just with fragmentation or the number of blood banks, it is also with the lack of regular, repeat voluntary blood donations and screening techniques that are used to test donated blood before transfusion.

The National Blood Policy (based on a Supreme court judgement that put the onus of providing ‘safe blood’ on the Government) states that every unit of blood that is donated at a blood bank should be thoroughly checked and tested to ensure that the blood does not contain deadly viruses such as HIV, Hepatitis B and Hepatitis C. The last two decades have had significant upgradation of blood banks through policies and programs of NACO and NBTC in India including licensing based on strict guidelines, screening of all collected units, quality systems, etc. However, the rising number of cases of patients getting infected with transfusion transmitted infections shows that we need to do more. One of the latest and most effective innovations that got introduced in the field of Transfusion Medicine is the Nucleic Acid Amplification Test (NAT) method for screening of blood.

What is NAT?

NAT (Nucleic Acid Amplification Test) is an advanced molecular blood screening technique which has a higher sensitivity than the serology testing technique (Rapid/ELISA/ Chemiluminescence) which is used conventionally at most of the blood banks and hospitals in India. Unlike serology, NAT directly detects the genetic material of the virus, instead of waiting for the body’s immune response. This makes NAT a highly sensitive technique which considerably reduces the window period for infection. This feature helps NAT detect early stage infections as well as Occult Hepatitis B virus infections, which may otherwise get missed by conventional serology, thereby decreasing the possibility of transmission of infection via transfusion.

Globally, there are two technologies used in NAT screening namely Transcription Mediated Amplification (TMA) and Polymerase Chain Reaction (PCR). While both are similar technologies, TMA seems to be more optimized for the detection of lower concentration of viruses and high throughput situations with quick turnaround times. The process of TMA is isothermal and the entire process is performed in a single tube.

NAT is performed in two formats- Individual Donor NAT (ID-NAT) and Minipool NAT (MP-NAT). In ID-NAT, each donor sample is tested individually, thus ensuring that each and every blood unit is screened safely. In case of MP-NAT, samples of 6 or more donors are mixed together in small amounts and then tested. Pooled testing may compromise the results due to viral load dilution and resultant reduction in screening sensitivity. Countries with high prevalence of HIV and Hepatitis have chosen ID-NAT as it ensures better safety for their patients. Some countries which use ID-NAT include, Japan, Korea, Australia, France, Italy, Switzerland, South Africa, Thailand, Singapore, Hong Kong, Malaysia, Indonesia, Sri Lanka, Denmark, New Zealand etc.

Dr Dhinesh Kumar, Senior Specialist- Transfusion Medicine, Aster Medcity, Kochi believes that “ID-NAT is a direct and effective way of testing; which is proven to be more sensitive in identifying the infected units. Using ID-NAT, we ensure that every blood unit which gets transfused is made as safe as possible.”

Adoption of NAT in India

The first hospital to adopt NAT in India was Indraprastha Apollo Hospital, Delhi. They implemented NAT in their routine screening in 2006. Karnataka Government was the first in India to make ID-NAT mandatory in all government supported blood banks in 2012. Currently, around 100 blood banks, including AIIMS (Delhi, Jodhpur & Rishikesh), PGI (Chandigarh), Christian Medical College (Vellore,) HN & Hinduja Hospital, KDAH (Mumbai) Medanta-The Medicity (Gurgaon) Narayana Hrudayalaya (Bangalore & Kolkata), Gangaram, Fortis, RML & AFTC (Delhi), Aster & Amrita (Kerala), are using ID-NAT, while 40 blood banks are using MP-NAT, which because of mixing donor samples, costs less.

Although NAT is widely used in other countries, its adoption in India is abysmally low. Just about 10 percent of the blood that is issued in our country is NAT tested! In spite of so many reports of innocent people getting infected through unsafe blood, the uniform adoption across centres has been a constant challenge for the Government and other private institutions.

About Author: Mr Sumit Bagaria is the Managing Director and CEO of Hemogenomics, Bangalore. He is also the Founder of the Indian Foundation for Safe Blood- He was awarded by the Armed Forces Transfusion Centre, New Delhi for “Exemplary Contribution” towards promoting blood safety. Having more than 10 years of experience in the field of transfusion medicine, he aims to bring about a renaissance in the blood safety standards India.