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Blood Transfusion Abroad

Colonel (Retd) Michael JG Thomas MA, MB, BChir, FRCP Edin, LMSSA, DTM&H
If you are attending an overseas medical conference, or are taking a well-earned holiday, and you are involved in an accident, or have a medical emergency, the treatment of which requires a blood transfusion, would you know whether the blood provided in that particular country met the standards of our national transfusion services?

Problems
The problems with having a transfusion overseas fall into three groups. These are availability, transfusion transmitted diseases and testing of blood donations.

Availability
In certain parts of the world, the genetic makeup of the local population is such that certain blood groups are very uncommon. This is especially true for the Rhesus Negative groups as these groups are virtually confined to the Mediterranean and Northern European races. In many countries there is always an acute shortage of blood, far worse than anything we ever have to face in Europe. When there are such acute shortages, there is an ethical problem as to whether it is right for a relatively affluent traveller, who has other options for obtaining blood, to use up a local resource, thereby depriving a local resident whose need may be greater.

Transfusion Transmitted Diseases
In many parts of the world the incidence of the common transfusion transmitted diseases, such as HIV and hepatitis, is as much as 1,000 times higher than in the UK. This means that a donated unit of blood is much more likely to be infectious as an individual is much more likely to be in the “Window Period”. This means that, although the screening test has yet to become positive, the unit of blood is infectious and would transmit the disease to a recipient.

In some parts of the world there are endemic diseases, which can be transmitted by blood transfusion but for which a screening test is not available or is unreliable. Examples of such diseases are malaria, Leishmaniasis, Chagar’s disease and filariasis.

Testing
In many countries, the health budget is insufficient to allow units of donated blood to be fully tested. If they are tested, frequently the test kits used are of a lesser quality than those we would use in the UK.

Avoidance
There is an old saying that “The best blood transfusion is no blood transfusion”. This is very true, so travellers should always be on their guard.

Medical
Don't travel to countries where the transfusion facilities may be inadequate if you have a coagulation disorder, have a medical condition, which commonly requires transfusion, or you are pregnant.

Behaviour

Being involved in an accident is the commonest reason for a traveller to require a blood transfusion. The avoidance of accidents is, therefore, the most effective way of avoiding a transfusion.

  1. Driving on the road. If you are driving in a foreign country take extra precautions, always remembering that you may have to drive on the opposite side from that to which you are used. Always wear seatbelts, don't drive in the dark, don't drive too fast, and never drink and drive. In many countries holidaymakers are encouraged to hire mopeds. If you do, always wear a crash helmet and protective clothing. Peace Corps volunteers have recently been banned from driving mopeds or motorcycles, and there has been a dramatic reduction in their injury rate.
  2. Exploring on foot. One of the commonest causes of road accidents amongst travellers is looking the wrong way when crossing the road. If the traffic drives on the opposite side of the road to that to which you are accustomed, take great care as your natural instinct is to look in the wrong direction and then step off in front of oncoming traffic. As you will be unfamiliar with the surrounding area, keep to well-lit streets where there are plenty of other people. Do not venture into areas where you are likely to be attacked.
  3. Hazardous sports. Avoid hazardous sports, especially if you are not being properly supervised. Take care when going off on mountain walks or hill climbing.
  4. Disease. Ensure that you avoid catching any disease that might require a blood transfusion as part of the treatment. The most common such disease is malaria, so when you are in an endemic area, take adequate malarial prophylaxis, wear long sleeved shirts and long trousers after dark and always sleep under a properly impregnated mosquito net.
Be Prepared
Before leaving home, there are a number of things that you can do to minimise any risks whilst you are abroad

  1. Blood Group. Have your blood grouped and make sure you take a copy of the laboratory report with you. Knowing your blood group in advance will allow appropriate blood to be more quickly obtained in an emergency.
  2. Sterile Needles and Syringes. It is wise to take a supply of sterile needles and syringes.
  3. Intravenous Fluids. Unless you have someone in the party who is competent at putting up intravenous infusions, it is not worth taking intravenous fluids. Only a skilled person should attempt to insert an intravenous line as failed attempts may ruin the only good venous access.
  4. Medical Assistance. It is vital that you take out adequate health insurance, which includes telephone support as well as emergency evacuation by air ambulance if indicated.
  5. Blood Cover. It is also advisable to obtain cover from an institution, which can provide screened blood, see below.
Large Groups
For large groups and expatriates living in a small community, one method of providing blood cover has been to set up a so-called “Walking Blood Bank”, whose participants are prepared to donate blood to meet a particular emergency. The American Association of Blood Banks considers this practice "a relic of less sophisticated times" and, in their technical manual1, mention it only to identify the hazards.

Problems with a Walking Blood Bank
  • Potential donors are exposed to the local endemic insect-vectored diseases, such as malaria.
  • Embarrassment can arise if certain members are rejected because of their life style. Because of this, there is an increased risk that potential donors will not be entirely truthful as to their risk factors.
  • Blood must be adequately screened, even in an emergency. Therefore the normal screening tests have to be performed on any blood obtained from a “Walking Donor” panel. The performance of these tests will inevitably delay the provision of the blood, probably for a period longer than it would take to deliver the same number of fully screened units from a major blood bank.
  • In an emergency situation, it may be very difficult or even impossible to provide blood of the specific group in the amount required.
  • Because a Walking Blood Bank is, by its very nature, a small enterprise, it is extremely difficult to ensure that an adequate level of quality assurance is maintained.
  • There are numerous administrative tasks to be performed with regard to keeping track of potential donors and recruiting replacements. This makes the exercise an expensive one.
  • All aspects of product liability are vested in the administrators of a Walking Blood Bank whereas, when blood is provided by a major blood bank, product liability remains with them.
For the above reasons, Walking Blood Banks are now no longer clinically acceptable within the international transfusion medical community1. Blood, whenever practically possible, should be provided from a major licensed blood bank. This is especially true with patients having rare groups or having complicated antibody profiles.

The Blood Care Foundation is an English charity, which provides, in emergency, screened blood, obtained from internationally recognised sources in Western Europe and the USA, resuscitation fluids and sterile transfusion equipment to its members in countries where these are not readily available.

Today the Foundation operates a global network of blood banks, enabling it to provide blood, hand carried by a consultant anaesthetist or skilled paramedic, to almost any location in the world within 12 hours, subject to the availability of scheduled air services. To combat the problem of the availability of Rhesus Negative blood in Asia, the Foundation has recently established a Rhesus Negative bank in Hong Kong and will establish another in South-East Asia in the near future.

Should an emergency occur, one of the Foundation's alarm centres is contacted. The Duty Medical Officer (DMO) in the alarm centre will contact the doctor in charge of the case to identify the transfusion requirements. If required, the DMO will arrange for the provision of resuscitation fluids from an RSP and for a courier to take blood to the patient.

References.
1. Neo-natal and obstetric practice. In: Walker RH ed. Technical Manual. 11th ed. Bethesda, Maryland: American Association of Blood Banks,1993:448. ISBN 1-56395-019-7.