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BLOOD TRANSFUSION & THE TRAVELLER
 The
reference for this article is:
Thomas MJG. Emergency Transfusion and the
Traveller. Documentation for the European School of Transfusion
Medicine on Blood Transfusion in War, Disasters and Emergencies.
Pesscara, Italy June 1998
If you are travelling overseas on business, or are taking a well-earned
holiday, and you are involved in an accident, the treatment of which
requires a blood transfusion, would you know whether the blood provided
in that particular country met the standards of your national transfusion
service?
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 many countries there is always an acute shortage of blood, far
worse than anything we ever have to face in Europe. One way in which
some countries solve this problem is to require relatives to come
forward and donate blood. It is unlikely that sufficient members
of your family, who also have the correct blood group, to cover
your needs, will accompany you. In addition, when there are such
acute shortages, there is also the 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 100
times higher than in the UK. This means that a donated unit of blood
is much more likely to be infected. As the incidence is higher,
the chances that an individual is in the early stage of a particular
disease are increased. In such a situation the donor is in, what
is commonly known as, the "Window Period". In simple terms,
this means that, although the screening test has yet to become positive,
the unit of blood is infected and would transmit the disease to
a recipient.
In addition, in some parts of the world there
are prevalent diseases which do not occur in Europe, but which can
be transmitted by blood transfusion. 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.
Although the incidence of these problems will
vary as to whether you are an expatriate, a business traveller or
a tourist, the basic precautions are common to all.
Basic Points
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 suffer from a coagulation disorder, such
as haemophilia or Von Willebrand's Disease, or you are not properly
stabilised on anti-coagulant medication.
- You have a medical condition, which commonly
requires transfusion, such as chronic peptic ulceration or oesophageal
varicies.
- 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.
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
of the road from that which is correct in your own country. Always
wear seatbelts, don't drive in the dark, don't drive too fast, and
never drink and drive. This is especially true when you are holiday,
as there is always a temptation to go out to a restaurant or a bar.
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.
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.
Hazardous sports
Avoid hazardous sports, especially if you are not being properly
supervised. Take care when going off on mountain walks or hill climbing.
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 area where malaria is
endemic, 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.
- 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.
- Sterile Needles
and Syringes. It is
wise to take a supply of sterile needles and syringes, as these
may not be readily available in the countries to which you are
going. Most travel clinics can provide packs especially designed
for travellers.
- Intravenous
Fluids. It is possible to take plasma substitutes
and/or crystalloid solutions for use in an emergency, though
such products require skill to use, and an adequate supply is
bulky and heavy. In an emergency, supplies can sometimes be
obtained from embassies. Sterile transfusion equipment (giving
sets and cannulae) may be difficult to obtain. Large expeditions
with trained medical officers may find it valuable to travel
with such resources, but these are impractical for the majority
of travellers. If you do take such supplies with you, do not
attempt to insert an intravenous line unless you are skilled
transfusion techniques. Failed attempts may ruin the only good
venous access available and make it much more difficult for
a doctor to eventually set up a transfusion.
- 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.
- Blood Cover.
It is also advisable to obtain cover from an institution, which
can provide screened blood, see below.
Solutions
One solution that used to be favoured by expatriates living in a
small community was to set up and maintain a so-called “Walking
Blood Bank”. A Walking Blood Bank is comprised of a group of
people, living within a particular community, who are prepared to
be called upon to donate blood to meet a particular emergency.
However there are numerous problems associated
with such a venture including:
- The number of people involved is so small that
there is always a significant chance that sufficient blood of
the required group will not be available.
- As the members of the Blood bank live locally,
they will be liable to carry the diseases endemic to that area.
- As all the members probably know each other,
it is much more difficult for someone to defer from donation if
his social behaviour has put him or her at risk.
- It is very difficult to adequately quality
control such a small venture and the problems of product liability
now make such blood banks non-viable.
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 will ensure a
high degree of quality assurance, and the large turnover will provide
a much greater likelihood of the rapid provision of the requested
number of units of suitable blood. This is especially true with
patients having rare groups or having complicated antibody profiles.
In response to the difficulties in locating reliable
sources of blood, and with the active encouragement of the expatriate
medical and residential communities in Nigeria, a blood bank was
established in Lagos in 1989 as a pilot exercise. The experience
gained in setting up and operating, on an international basis, effective
procedures for the handling, transportation, importation and storage
of blood, resuscitation fluids and sterile equipment led, in 1991,
to the establishment of the Blood Care Foundation.
The Blood Care Foundation is a charitable organisation
registered in England, dedicated to provide, in emergency, screened
blood, obtained from internationally recognised sources in Western
Europe, 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 whole blood, by courier service,
to almost any location in the world within 12 hours, subject to
the availability of scheduled air services.
It is now well recognised that one's heart works
most efficiently when your haemoglobin is around 100g/l. Most people
in the UK have a level of between 140 and 160 g/l. Because we all
have this spare capacity, people rarely die from the anaemia caused
by loosing blood. People die from the lack of fluid volume, which
is medically termed “shock”. In emergencies, therefore,
resuscitation fluids are normally required and will support the
patient until blood can be provided. To ensure these are readily
available, the Foundation has set up an integrated network of Regional
Supply Points (RSPs) throughout the world, which hold stocks of
resuscitation fluids, including plasma expanders, and the sterile
equipment needed for transfusion purposes.
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. The couriers are doctors or
paramedics, trained in cardio-pulmonary resuscitation, and are capable
of putting up a transfusion, even in the shocked 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.
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