Assessment of Transfusion Practices Among Doctors During COVID-19 Pandemic Using Questionnaire-Based Survey.

During COVID-19 pandemic, many doctors were redirected from various disciplines for care of COVID-19 patients. A survey was conducted among doctors involved, to assess transfusion practices during the pandemic. To assess the knowledge, attitude, and practices of blood transfusion among doctors involved in care of COVID-19 patients. A cross-sectional survey using an online questionnaire (Google form) was used to assess knowledge and need of transfusion, attitude towards modifications in transfusion process, and practices during pandemic. Analysis was done among subgroups based on experience (designation), user type (speciality) and frequency of blood usage in parent department. Of 1900 invitations, 437 responses were received from resident doctors and faculty members across various disciplines. Of these, 354(81%) participants were included in analysis. Mean knowledge score was 6.2, majority 297(83.9%) had adequate knowledge scores (≥ 5 of total 12). Knowledge levels were higher among frequent blood users. Positive attitude towards changes in transfusion process was observed in 72.9% participants with similar scores in subgroups. Practice was assessed in 222(62.7%) participants. Mean practice score was 6.9, wherein 57.7% participants had optimal scores (≥ 7 of total 14). Positive correlation was observed between attitude and practice, unlike knowledge and practice. Although most participants had demonstrated adequate transfusion knowledge levels and positive attitude, transfusion practices during pandemic were affected mainly due to shortage of blood components and modifications in transfusion requisition process due to stringent COVID-19 containment measures. Thus, indicating need for improvement in the basic understanding of the transfusion process. Supplementary Information: The online version contains supplementary material available at 10.1007/s12288-022-01613-2.

Incidence of acute haemolysis in cats receiving canine packed red blood cells (xenotransfusions).

OBJECTIVES: The aim of this study was to report the incidence of transfusion reactions in cats, including acute haemolysis (AH), occurring within 24 h of receiving a xenotransfusion. An additional aim was to determine whether cases with AH could be classified as having an acute haemolytic transfusion reaction (AHTR) as per the definition provided by the Association of Veterinary Haematology and Transfusion Medicine's Transfusion Reaction Small Animal Consensus Statement. METHODS: Medical records of cats that received canine packed red blood cells (PRBCs) between July 2018 and September 2020 at a veterinary hospital were reviewed. The incidence of AH, AHTRs, febrile non-haemolytic transfusion reactions (FNHTRs), transfusion-associated circulatory overload and septic transfusion reactions were recorded. RESULTS: The medical records of 53 cats were retrospectively evaluated. Twenty-three (43%) cats had transfusion reactions. Thirteen (25%) cats had AH; however, only four (8%) met the definition of an AHTR. Ten (19%) cats were determined to have FNHTRs. Survival to discharge of cats affected by AH was 50% (25% for cases that met the definition of an AHTR). Survival to discharge of cats not suffering from AHTR was 40%. CONCLUSIONS AND RELEVANCE: This report indicates that a higher proportion of cats undergo AH (25%) when administered canine PRBCs than previously reported, although many could not be classed as having an AHTR due to an apparently adequate packed cell volume rise. Challenges with sourcing feline blood in emergency situations occasionally necessitates the use of xenotransfusion in transfusion medicine. Clinicians should be aware that haemolysis after xenotransfusion can occur within 24 h and that a repeat feline transfusion may be required sooner than anticipated in some cases.

Getting the Most Out of the Evidence for Transfusion Medicine and Lessons from the COVID-19 Pandemic

Evidence-based medicine (EBM) has been described by Sackett et al. as ‘the integration of best research evidence with clinical expertise and patient values'. This chapter discusses core elements of EBM with particular reference to clinical research in transfusion medicine, and provides a practical approach to searching for evidence and critical appraisal, with some considerations of different study designs. It also includes a review of how the evidence base for transfusion medicine was collated in response to the COVID-19 pandemic. One important component of EBM is the critical appraisal of the evidence generated from a study. One important aspect of clinical trial appraisal concerns the understanding of chance variation and sample-size calculation. Appraising the evidence base for transfusion medicine is one part of improving practice;another is the effective dissemination of the evidence to clinicians. © 2022 John Wiley and Sons Ltd.

Early, very high-titre convalescent plasma therapy in clinically vulnerable individuals with mild COVID-19 (COVIC-19): protocol for a randomised, open-label trial.

INTRODUCTION: COVID-19 convalescent plasma (CCP) is a possible treatment option for COVID-19. A comprehensive number of clinical trials on CCP efficacy have already been conducted. However, many aspects of CCP treatment still require investigations: in particular (1) Optimisation of the CCP product, (2) Identification of the patient population in need and most likely to benefit from this treatment approach, (3) Timing of administration and (4) CCP efficacy across viral variants in vivo. We aimed to test whether high-titre CCP, administered early, is efficacious in preventing hospitalisation or death in high-risk patients. METHODS AND ANALYSIS: COVIC-19 is a multicentre, randomised, open-label, adaptive superiority phase III trial comparing CCP with very high neutralising antibody titre administered within 7 days of symptom onset plus standard of care versus standard of care alone. We will enrol patients in two cohorts of vulnerable patients [(1) elderly 70+ years, or younger with comorbidities; (2) immunocompromised patients]. Up to 1020 participants will be enrolled in each cohort (at least 340 with a sample size re-estimation after reaching 102 patients). The primary endpoint is the proportion of participants with (1) Hospitalisation due to progressive COVID-19, or (2) Who died by day 28 after randomisation. Principal analysis will follow the intention-to-treat principle. ETHICS AND DISSEMINATION: Ethical approval has been granted by the University of Ulm ethics committee (#41/22) (lead ethics committee for Germany), Comité de protection des personnes Sud-Est I (CPP Sud-Est I) (#2022-A01307-36) (ethics committee for France), and ErasmusMC ethics committee (#MEC-2022-0365) (ethics committee for the Netherlands). Signed informed consent will be obtained from all included patients. The findings will be published in peer-reviewed journals and presented at relevant stakeholder conferences and meetings. TRIAL REGISTRATION: Clinical Trials.gov (NCT05271929), EudraCT (2021-006621-22).

Cohort profile: a longitudinal regional cohort study to assess COVID-19 seroprevalence in blood donors - baseline characteristics of the SeMaCo study participants.

PURPOSE: The SeMaCo study (Serologische Untersuchungen bei Blutspendern des Großraums Magdeburg auf Antikörper gegen SARS-CoV-2), a prospective, longitudinal cohort study with four survey phases spanning 3-5 months each over a period of 22 months, extends the spectrum of seroepidemiological studies in Germany. We present here a careful characterisation of the initial survey phase of the cohort to provide baseline data on infection incidence and obtained from questionnaires, focussing in particular on the attitude towards COVID-19 vaccinations, the vaccination success and the vaccination acceptance. PARTICIPANTS: A total of 2195 individual blood donors from the donor pool of the blood donation service of the University Hospital Magdeburg were enrolled in the initial survey phase from 20 January 2021 to 30 April 2021. 2138 participants gave sociodemographic/contact data (51.7% male, mean age 44 years) and 2082 participants answered the vaccination questionnaire. FINDINGS TO DATE: Out of 2195 participants with antibody results, 1909 (87.0%) were antibody negative. The remaining 286 subjects (13.0%) were either antibody-positive and vaccinated (160/286; 55.9%) or antibody-positive without vaccination information (17/286; 5.9%) or antibody-positive and unvaccinated (109/286; 38.1%). The latter result reflects the rate of true or highly probable SARS-CoV-2 infections in our initial study cohort. FUTURE PLANS: The study primarily aims to measure the prevalence and long-term kinetics of IgG-antibodies against SARS-CoV-2. Including the baseline, the study foresees four survey periods of 3-4 months each. At each visit, we will assess the blood donors' attitude towards vaccination, the antibody response following vaccination and/or infection, as well as undesired vaccination effects. We aim to test the same participants during the survey periods by repeated invitations for blood donation to ensure a long-term (follow-up) in as many study participants as possible. After the four survey phases, a longitudinal data set will be created that reflects the course of the antibody levels/frequencies as well as the infection and vaccination incidence. TRIAL REGISTRATION NUMBER: DRKS00023263.

Congreso Nacional de la Sociedad Espanola de Transfusion Sanguinea y Terapia Celular - SETS.

The proceedings contain 29 papers. The topics discussed include: pre-exposure prophylaxis for HIV: impact of exclusion criteria on transfusion safety;the Sero-epidemiological study of SARS-COV-2 in Spain (ENE-COVID);and the transfusion medicine of yesterday and tomorrow: a critical reflection on the role of our speciality in modern medicine.

Cohort profile: A Québec-based plasma donor biobank to study COVID-19 immunity (PlasCoV).

PURPOSE: The long-term humoral immunity to COVID-19 is not well understood owing to the continuous emergence of new variants of concern, the evolving vaccine-induced and infection-induced immunity, and the limited duration of follow-up in previous studies. As the sole blood service in Québec (Canada), Héma-Québec established a COVID-19-focused biobank ('PlasCoV') in April 2021. PARTICIPANTS: As of January 2022, the biobank included 86 483 plasma samples from 15 502 regular donors (age range=18-84 years, females=49.7%), for an average of 5.6 donations per donor. Nearly two-thirds (65.6%) of biobank donors made at least two donations, with many donors having provided samples prevaccination and postvaccination (3061 (19.7%)) or preinfection and postinfection (131 (0.8%)), thus allowing for longitudinal studies on vaccine-induced and infection-induced immunity. FINDINGS TO DATE: A study that used PlasCoV samples revealed that previously infected individuals who received a single dose of the BNT162b2 COVID-19 vaccine exhibited the strongest immune response. By contrast, SARS-CoV-2-naïve individuals required two vaccine doses to produce a maximal immune response. Furthermore, the results of a four-phase seroprevalence study indicated that the antinucleocapsid (N) response wanes rapidly, so that up to one-third of previously infected donors were seronegative for anti-N. FUTURE PLANS: Donations from individuals who consented to participate before 1 October 2022 will be collected up until 31 March 2023. This plasma biobank will facilitate the conduct of longitudinal studies on COVID-19 immunity, thus helping to provide valuable insights into the anti-SARS-CoV-2 immune response and its persistence, and the effects of vaccination and variants on the specificity of the anti-SARS-CoV-2 immune response.

Allocating Blood Products During a Time of Remarkable Shortage

The COVID-19 Pandemic adversely impacted the nation's blood supply such that blood suppliers could not fill standing orders. To address the dwindling blood supply, the American Red Cross (ARC) implemented daily thresholds, which distributed red blood cells (RBCs) based on clients' historical blood orders and the ARC's inventory. The threshold system left the blood bank to devise a process to judiciously allocate the reduced RBC supply across our institution. Herein, we describe an internal RBC utilization audit, the data from which we used to devise an algorithm to predict our ability to meet transfusion requirements for operating room (OR) procedures. An OR adjudication committee used our report to prioritize elective surgical cases taking places the following day. Thirtyone non-consecutive days of blood inventory release slips were reviewed across three months of recent transfusions. Weekdays were disproportionally investigated to predict the blood utilization for days with scheduled OR procedures. For all RBCs released, the blood type requested and the final disposition (transfused vs returned to blood bank) of the units were recorded. Average use was calculated as well as interquartile range (IQR) to account for transfusion variability. Utilization data was then used to develop a worksheet-based tool to predict ability to meet RBC requirements. Overall, the hospital transfused an average of 80 RBC units each weekday (IQR: 64-92 units). Approximately 40% of all requested RBC units were released to the OR. In turn, the OR transfused only 39% of the RBCs released to them, which represented 20% of transfusions hospital-wide. The OR requested an average of 41 RBC units each weekday (IQR: 25-57 units). The OR transfused an average of 16 units of RBCs each weekday (IQR: 9-21 units). The outpatient cancer center infusion clinic used less than 15% of total RBCs. The biggest user of RBCs were inpatients, who were transfused 65% of RBCs during the week and 82% of transfusions during the weekend. These percentages and the averageto-third-quartile range were used to devise a blood allocation algorithm to inform the OR if the blood bank could support anticipated use. The data was also used to devise a blood allocation worksheet for the on-call transfusion medicine physicians to predict our ability to provide adequate blood for emergent, non-elective procedures that require transfusion support such as liver transplants and aortic repairs. The audit of RBC disposition informed blood inventory management practices during a time of remarkable shortage. Within the confines of the threshold system, the transfusion medicine service allocated the expected number of units based on historical request and transfusion data to predict whether inventory levels could support scheduled and nonscheduled OR procedures.

E-learning/online education in transfusion medicine: A cross-sectional international survey.

OBJECTIVES: This survey aims to assess the scope of transfusion e-learning courses in blood establishments and transfusion services internationally. BACKGROUND: E-learning/online education is increasingly used in the education of medical professionals. There is limited published data on the use of e-learning for transfusion medicine. MATERIAL AND METHODS: An International survey was designed and distributed to all members of the International Society of Blood Transfusion to assess utilisation of e-learning in their institutions. Descriptive statistics were used to summarise the results. RESULTS: A total of 177 respondents participated, 68 of which had e-learning modules in their institutions. Approximately two-thirds of the courses were developed in-house (66%), and 63% are available to learners from outside the host institutions. In one-third of institutions, these courses were established during the COVID-19 pandemic, while 15% had used e-learning courses for more than 10 years. The courses target different audiences and topics ranging from blood donation to hemovigilance. The most common audiences were physicians (71%), laboratory scientists/technologists (69%) and transfusion practitioners (63%). Formal assessment of learning outcomes is used in 70% of the programs. CONCLUSIONS: The survey demonstrates the widespread use of e-learning courses in transfusion education, with a substantial proportion being developed during the COVID-19 pandemic.

Efficacy of convalescent plasma therapy in the patient with COVID-19: a randomised control trial (COPLA-II trial).

IMPORTANCE: No proven treatment is available for severely ill COVID-19. Therapeutic use of COVID-19 convalescent plasma (COPLA) is under investigation. OBJECTIVE: To compare the efficacy of COPLA with standard medical therapy (SMT) alone in severe COVID-19 patients. DESIGN, SETTING AND PARTICIPANTS: A multicentric, open-labelled, phase-III randomised controlled trial conducted at two treatment centres with COPLA collected at the third dedicated centre in North-India, the coordinating centre during trial from June 2020 to December 2020. The study population comprised 400 participants in the ratio of 1:1 in each treatment group. INTERVENTION: One group received COPLA with SMT (n=200), and another group received SMT only (n=200). MAIN OUTCOME MEASURES: Primary outcome was time to clinical improvement measured by a two-point reduction in the ordinal scale. Secondary outcomes included duration of O2 therapy, the proportion of patients on mechanical ventilation at day-7, mortality, SARS-CoV-2 antibody levels, cytokine levels and incidence of adverse events. RESULTS: The median time to a two-point reduction in the ordinal scale in both groups was 9 days (IQR=7-13) (p=0.328). The median duration of O2 therapy was 8 days (IQR=6-12) in COPLA and 10 days (IQR=6-12) in SMT group (p=0.64). The PaO2/FiO2 ratio showed significant improvement at 7 days in COPLA group(p=0.036). There was no difference in mortality till 28 days in both groups (p=0.62). However, if COPLA was given within 3 days of hospital admission, a significant reduction in ordinal scale was observed (p=0.04). Neutralising antibody titres in COPLA group (80 (IQR 80-80)) were higher than SMT group (0 (IQR 0-80)) at 48 hours (p=0.001). COPLA therapy led to a significant reduction in TNF-α levels at 48 hours (p=0.048) and D-dimer at 7 days (p=0.02). Mild allergic reactions were observed in 3 (1.5%) patients in COPLA group. CONCLUSION AND RELEVANCE: Convalescent plasma with adequate antibody titres should be transfused in COVID-19 patients along with SMT in the initial 3 days of hospitalisation for better clinical outcomes. TRIAL REGISTRATION NUMBER: NCT04425915.

SARS-CoV-2 vaccination, ABO blood group and risk of COVID-19: population-based cohort study.

OBJECTIVE: To compare outcomes between O and non-O blood groups, and by modified RNA (mRNA) and adenovirus-vectored (Ad-V) vaccines. DESIGN: Population-based cohort study. SETTING: All of Ontario, Canada. Linked data sets captured clinical encounters, vaccinations and laboratory testing for SARS-CoV-2. PARTICIPANTS: Individuals aged 12+ years with known ABO blood group and free of SARS-CoV-2 before 15 January 2021. MAIN OUTCOMES MEASURES: The main exposure, first SARS-CoV-2 vaccination, was modelled in a time-varying manner. O and non-O blood group was known prior to vaccination. SARS-CoV-2 infection, and severe COVID-19 (hospitalisation or death), were assessed starting 14 days after vaccination, up to 27 June 2021. RESULTS: 2 472 261 individuals were included. 1 743 916 (70.5%) had at least one vaccination, of which 24.6% were fully vaccinated. Those vaccinated were more likely to be women, older in age, residing in a higher-income area and have higher rates of certain comorbid conditions, like cancer, diabetes and hypertension. Relative to unvaccinated, after receiving their first mRNA (adjusted HR (aHR) 0.46, 95% CI 0.44 to 0.47) or Ad-V (aHR 0.49, 95% CI 0.44 to 0.54) vaccine, the risk of SARS-CoV-2 infection was lower, as was severe COVID-19 (aHR 0.29, 95% CI 0.20 to 0.43 (mRNA); aHR 0.29, 95% CI 0.26 to 0.33 (Ad-V)). Stratifying by blood group produced similar results. For example, after first mRNA vaccination, the aHR of severe COVID-19 was 0.31 (95% CI 0.27 to 0.36) among non-O blood groups, and 0.27 (95% CI 0.22 to 0.32) among O blood groups, relative to unvaccinated. Fully vaccinated individuals had the lowest risk of SARS-CoV-2 and severe COVID-19. CONCLUSIONS: SARS-CoV-2 infection and severe COVID-19 are reduced by vaccination. This effect does not vary by vaccine type or blood group, but is more pronounced among fully, than partially, vaccinated individuals.

BLOOD TRANSFUSION SERVICES IN COVID: SCALING THE UNSCALABLE

Objective: The present manuscript discusses our journey of providing safe BTS during this ongoing COVID-19 pandemic. Methods: It was a single-center, retrospective type of study conducted over a period of 1 year (January 2020-December 2020) in the department of transfusion medicine. The number of donations (replacement and voluntary) was compared during the pre-COVID months with that during the COVID outbreak. The measures included but were not limited to various aspects of staff management, environmental factors, guidelines implementation, and innovative assertions for implementing COVID-19 appropriate behavior. Gradually, provisions were also made for the collection of the COVID convalescent plasma from the recovered donors as a part of the management guidelines issue by the Indian Council of Medical Research. Results: COVID-19 pandemic has had a drastic negative impact on the blood donation but it has also highlighted the potential and the ability of the BTS to withstand such testing times. Conclusion: COVID-19 has left a profound impact on the blood transfusion services. It has highlighted the importance of having a coping strategy in place to withstand such times without compromising the health and the needs of the patients.

Blood component utilization among COVID-19 patients in a small tertiary centre

Background: The first wave of COVID-19 outbreak in Malaysia started with the first case in January 2020 followed by the second wave in February 2020 and the third wave in October 2020. In the early phase, COVID-19 patients were treated in designated Ministry of Health (MOH) hospitals only. However towards the end of 2020, as the crises set in, COVID-19 patients were also being treated in private centres and university hospitals including our centre, Universiti Teknologi MARA (UiTM) Medical Specialist Centre. Aims: To evaluate the utilization of blood components among hospitalized COVID-19 patients. Methods: Retrospective study of blood component transfusions among hospitalized COVID-19 patients from January 2021 to December 2021 was conducted in Transfusion Medicine Unit, UiTM Medical Specialist Centre. The data was retrieved from Blood Bank Information System (BBIS) and transfusion request forms. The type of blood products and the number of blood components transfused to the patients were analysed. Results: Overall, 256 COVID-19 patients were admitted to our centre in 2021. Twenty-eight of the patients received blood product transfusions for an overall transfusion rate of 10.9%. Out of a total of 2438 blood components used by all patients admitted to our centre in 2021, 4.3% of blood components were transfused to COVID-19 patients in which the majority were red blood cells, 56 units (4.2%) followed by platelets 40 units (9.5%) and fresh frozen plasma 9 units (1.8%). Summary/Conclusions: The transfusion rate of blood components among hospitalized COVID-19 patients is lower than other hospitalized non-COVID-19 patients.

Collection of COVID-19 convalescent plasma in institute for transfusion medicine of republic of North Macedonia and evaluation of anti-SARS-CoV-2 antibody concentration in different donors subgroups

Background: Plasma collected from patients that have recovered from an infectious disease has been transfused over many decades for prophylaxis and treatment of various infectious diseases. Taking into consideration the expansion of COVID-19 pandemics, we started the COVID-19 convalescent plasma (CCP) programme. Aims: The aim of our study is to show our experience with collecting the CCP and to evaluate the SARS-CoV-2 antibody concentration in different convalescent plasma donors' subgroups. Methods: This is a prospective study performed in the Institute for Transfusion Medicine of Republic of North Macedonia since 30 April 2020 till July 2021. Antibody testing was performed at the Institute for Immunobiology and Human Genetics in Skopje using CLIA method with Snibe Maglumi SARS-CoV-2 S-RBD IgG (quantitative) with IgG cut-off larger than 5 AU/ml. All potential donor were tested for: negative RTPCR for SARSCoV-2 before donation, anti-SARS-CoV-2 antibodies, anti- HLA antibodies (where applicable), blood count, blood group, TTI and biochemistry. Preferred method for plasma collection was plasmapheresis which was performed with Terumo BCT Trima Accel and donation of whole blood, depending on the donor preference and venous access. All donors signed inform consent for donation and inclusion in the study. Results: There were 1476 potential CCP donors, but only 700(47.9%) donors fulfilled all the criteria and we obtained 793 units of CCP;639 (80.6%) units from whole blood donors and 154 (19.4%) CCP units from 61 plasmapheresis donors, 485 (69.3%) males and 215 (30.7%) females. Mean age of the donors was 40 years (range 18-63). Mean value of SARS-CoV-2 S-RBD IgG concentration was 31.05 AU/ml, (range from 5.1 AU/ml to >100 AU/ml), mean value of SARS-CoV-2 S-RBD IgG in men was 37.6 AU/ml and 28.9 AU/ml in women (p < 0.05). Distribution of CCP donors according to the ABO blood group was: 301 blood group A (43%) with median value of SARS-CoV-2 S-RBD IgG = 27.15 AU/ml, 220 blood group O (31.4%) median value of SARS-CoV-2 S-RBD IgG = 32.1 AU/ml, 116 blood group B (16.6%) median value of SARS-CoV-2 S-RBD IgG = 35.9 AU/ml and 63 donors had blood group AB (9%) median value of SARS-CoV-2 S-RBD IgG = 26.45 AU/ml. There were 69 donors that were previously hospitalized with mean value of SARS-CoV-2 S-RBD IgG = 48.6 AU/ml, and 629 that were treated at home with mean value of SARS-CoV-2 SRBD IgG = 29.1 AU/ml (p < 0.05), of which 578 had symptoms with mean value of SARSCoV- 2 S-RBD IgG = 29.1 AU/ml and 51 were asymptomatic with mean value of SARS-CoV-2 S-RBD IgG = 29.3 AU/ml. The CCP donors had the following distribution according to the age: 125 donors in the 18-29 age group with median value of SARS-CoV-2 S-RBD IgG = 23.0 AU/ml, 200 donors in the 30-39 age group with mean value of SARSCoV-2 S-RBD IgG = 28.2 AU/ml, 217 donors in the 40-49 age group with mean value of SARS-CoV-2 SRBD IgG = 32.9 AU/ml and 156 donors in the 50-63 age group mean value of SARS-CoV-2 S-RBD IgG = 38.3 AU/ml (p < 0.05). Summary/Conclusions: The collection procedures are safe and effective and collected CCP units were with high concentration and quality. The concentration of SARS-CoV-2 S-RBD IgG in CCP obtained from previously hospitalized patients was significantly larger than in ones that were treated at home. The concentration of SARS-CoV-2 S-RBD IgG was higher in men, in advanced age group and in donors with blood group B. The further studies are needed to clarify the impact of different variables on antibodies concentration/ titre in donors.

How we develop and prepare leadership for todays' challenges

The challenges for leadership today are many and in addition to expertise of the whole blood transfusion chain (future) leaders need skills and competences to effectively address a complex and sometimes uncertain environment. Societal trends translate into challenges of the leadership of today, like for instance the importance to attract and retain human capital in an era of diversity, equity and inclusion (DEI) and digital transformation. More recently intensely exemplified by the COVID 19 pandemic and dealing with social media for communication. This requires a personalized learning approach by learners that cooperate and help each other and when possible make use of the workplace context. For blood transfusion WHO has identified leadership as one of the essential prerequisites for a centrally coordinated system. In essence, the leaders should be able to understand the position of the key stakeholders in the blood transfusion chain (governmental authorities, societal and clinical organizations, patients) and communicate tailored to the needs of each target group to build collaboration and trust. Leadership importance is not limited to large centralized blood supply organizations, it is also essential for small scale organizations. The bottom line is understanding the key stakeholders and effective communicate to facilitate collaboration and trust to maximize the beneficial outcome of the blood transfusion chain for patients. The Management of Transfusion Medicine post graduate programme is meant for personal development of professionals that have a senior management position in a centrally coordinated blood supply. Students follow a personalized track to improve their management knowledge and skills to be better geared to face every day challenges. In the end leaders need to act also when confronted with crisis, like the recent pandemic, disasters or even in the event of war, the environment is volatile and asks for decisions based on minimal information. Effective investment in development of leadership skills is key.

Approach to management of cryoprecipitate inventory during pandemic-related shortages

Background: A surprising and disturbing feature of blood shortages in the United States during the COVID-19 pandemic is that they include Cryoprecipitate, a component that was not historically affected by seasonal shortages. Our blood suppliers provide Cryoprecipitate primarily as 5-unit pools. A few individual whole blood-derived units of Cryoprecipitate are also provided for use for infants and young children. The adult dose of Cryoprecipitate, standardized many years ago, has been two pools (10 units). In an average-sized adult, this dose is expected to increase plasma fibrinogen by 50-100 mg/dl. Over the 10-year period 2011- 2020, the number of single units transfused at our 1000 bed tertiary care hospital remained small and relatively stable, but the number of transfused pools increased approximately 60%, from a monthly average of 322-522. During the pandemic, Cryoprecipitate usage at our hospital remained high, possibly because high-use surgeries, such as urgent cardiovascular and liver transplant procedures, were not restricted. In the face of donor- and manufacturing-related shortages, our blood bank has been challenged to maintain an adequate inventory to support these services. Aims: To develop and implement a plan for ensuring sufficient availability of Cryoprecipitate units to meet our patients' needs. Methods: As with other blood components, the shortage of Cryoprecipitate was initially managed through prospective review and modification (if appropriate) of orders by the Transfusion Medicine resident physician, and regular communications with the blood suppliers regarding inventory requirements. Additional steps for Cryoprecipitate were: re-evaluating the standard dose of Cryoprecipitate, and exploring alternatives to the use of Cryoprecipitate pools. Results: Quality control data from our blood suppliers provided evidence that the fibrinogen content of Cryoprecipitate currently averages 524 mg per unit, more than twice the value of 250 mg per unit that is generally used for dosing calculations. These data justified halving the standard adult dose to 1 pool. An explanatory document was distributed to the clinical services, with comparisons of plasma fibrinogen increments expected with two pools versus one pool. An update to the electronic ordering system is in process, to change the default Cryoprecipitate order for adults from two pools to one pool. We increased the stock of single Cryoprecipitate units, whenever these were available, to build a buffer for adult use in case of ongoing shortage. We collaborated with the hospital pharmacy to maintain a reserve of purified fibrinogen concentrate, and develop a dosing and administration protocol for off-label use of this product. So far, there has not been an occasion to use either alternative. The efforts above have been supplemented with frequent, structured communication with the clinical services and hospital leaders regarding inventory levels of blood components, and the measures taken and requested to safeguard this precious resource. Summary/Conclusions: Meeting the challenge of extreme and prolonged blood shortages requires a multi-pronged approach that may include questioning assumptions, considering alternatives, and improving inter-disciplinary communications.

Reasons for deferral of COVID-19 convalescent plasma donors

Background: Taking into consideration historic success of convalescent plasma in prophylaxis and treatment of various infectious diseases over the century and expansion of COVID-19 pandemics, we started the COVID-19 convalescent plasma program in our country. Aims: The aim of our study was to show the reasons for deferral of the COVID-19 convalescent plasma (CCP) donors. Methods: This is a prospective study organized in the Institute for Transfusion Medicine of Republic of North Macedonia since 30 April 2020 till July 2021. CCP donors eligible for donation were donors without a history of blood transfusion, female donors who have never been pregnant, or who have been tested and found negative for anti- HLA antibodies, age 18-65, in good health that fulfil all other criteria for regular blood donors. All potential donor were tested for: negative RT-PCR for SARSCoV-2 before donation, anti-SARS-CoV-2 antibodies, anti-HLA antibodies (where applicable), blood count, blood group, TTI and biochemistry. Antibody testing was performed at the Institute for Immunobiology and Human Genetics in Skopje using CLIA method with Snibe Maglumi SARS-CoV-2 S-RBD IgG with IgG cut-off for CCP donation larger than 5 AU/ml (cut-off for regular positive result was larger than 1 AU/ml). All donors signed inform consent for donation and inclusion in the study. Results: There were 1462 potential CCP donors, of which 762(52.1%) did not fulfil criteria for CCP donation, 424(55.6%) women and 338 (44.4%) men. There were 454(59.6%) potential CCP donors that did not have enough anti-SARS-CoV-2 S-RBD IgG antibodies (Ab), of which 223(49.1%) had Ab concentration less than 1 AU/ml (29.3% of all deferred donors) and 231(50.9%) had Ab concentration between 1 and 5 AU/ml (30.3% of all deferred donors). In this subgroup of deferred donors, there were 227 women (50%) and 227 men (50%), with mean age 37.2 ± 10.1 (range 18-63). There were statistical significant correlation between the gender and the Ab concentration less than 1 AU/ml and from 1 to 5 AU/ml (Pearson Chi-square: 3.88667, df = 1, p = 0.048671). Multiple regression analysis showed that gender is independently connected with the Ab concentration, OR = 1.4495 (95%CI 1.0016-2.0976), i.e. male gender increases the chance for increased Ab concentration for one and a half times. According to the age group, the majority of deferred CCP donors, because of low Ab concentration, are in the age group from 30 till 39(39.6%), followed by age group from 40 till 49(23.8%), and least deferred donors were in 50 and above age group (13.2%). The most of these deferred donors were treated at home, 451(99.3%) and had symptoms 240(52.9%). Distribution according to blood group in CCP donors deferred due to low Ab concentration was: blood group A- 182(40.1%), blood group O-153(33.7%), blood group B-69(15.1%) and blood group AB-42(9.3%). In the whole investigated group, 65 (8.5%) potential donors were deferred because of low haemoglobin level (less than 12.5 g/dl for women and less than 13.5 g/dl for men), 26 (3.4%) were deferred because of positive TTI markers and 102 (13.4%) women of the total number of deferred donors were deferred because of presence of HLA antibodies (i.e. 24% of investigated women). Summary/Conclusions: There is large percentage of deferred CCP donors mostly because of low Ab concentration, presence of HLA antibodies and low haemoglobin level, but starting of COVID-19 convalescent plasma program was a big success for our institution and our country and helped a lot of patients.

Anaemia and blood transfusion in COVID patients

Background: The Severe Acute Respiratory Coronavirus 2 (SARS-CoV- 2) infection manifests itself through a wide range of clinical pictures, from the condition of asymptomatic carrier to severe respiratory insufficiencies and/or severe organ impairments, including a massive release of cytokines, an increase in the coagulation state, haemoglobin damage, dysregulation of iron homeostasis and iron overload. It has also been appreciated a normo/macrocytic anaemia in many patients, typically associated with phlogosis. In effect, the condition of inflammation deeply affects erythropoiesis through different mechanisms, both linked to an altered iron metabolism mediated by an increased production of interleukins, and caused by proinflammatory cytokines such as the interferon-γ, IL-1, IL-33 and the Tumour necrosis factor-α (TNF-α). Inflammatory cytokines, especially IL-6 and IL-1b, increase the production of hepcidin, which, by degrading ferroportin, the cellular exporter of iron, provokes a reduction in serum iron and a sequestration of iron at the macrophage level. This process deprives potential microorganisms of iron, but it can cause a typically macrocytic anaemia, also known as 'anaemia of chronic disorders'. An altered iron metabolism would therefore be expected also in the SARS-CoV-2 infection. Nevertheless, studies on alterations of the iron metabolism in this infection are still quite limited. Aims: Our study is a retrospective analysis aimed at understanding the Covid-related pathogenesis of anaemia through the data examination of patients transfused during the SARS-COV2 infection. Methods: In our Immunohematology and Transfusion Medicine Service, we have analysed the types of anaemia occurred in patients suffering from SARS-CoV-2 who have been subjected to blood transfusion in a period comprised between November 2020 and December 2021. We have evaluated data in relation to 29 patients presenting normo-macrocytic anaemia at the onset, subjected to a transfusion of prefiltered red blood cells. The analysed sample included 15 males and 14 females with an average age of 67 years (range: 40-96). Only 4 patients out of 29 had a haemorrhage at the onset. The other 25 patients did not incur into haemorrhagic episodes. Results: Average pre-transfusion blood counts have highlighted an average haemoglobin value of 7.5 g/dl (range: 6.4-9.2) with an average globular volume of 93 fL (range: 65.3-105). Patients have been transfused on average with 4 units of prefiltered red blood cells (range: 1-24). All patients presented a severe phlogosis documented by average ferritin values of 520 ng/ml (range: 355-1200) and of CRP of 8.7 mg/dl (range: 1.79-25). Summary/Conclusions: Analysed data lead us to think that, as it has been confirmed by the scarce literature on the matter, the majority of cases of anaemia associated with a SARS-CoV-2 infection has an inflammatory pathogenesis. The high values of the serum ferritin and of the CRP strengthen this hypothesis. There is surely an additional etiopathogenetic component of bone marrow inhibition on the erythrocyte maturation associated with an alteration of iron metabolism, as it can be deduced from the increase in the average globular value.

Utilizing digital tools to provide educational programs in Transfusion Medicine

Background: Providing up-to-date educational programs to the healthcare community is essential for ensuring the highest quality of care and safety of patients. Continuing education programs that address current and future challenges impacting transfusion medicine (TM) are purposefully designed to enhance current understanding and educate on these emerging topics. However, the COVID-19 pandemic has forced adaptation to the methods by which these education programs are delivered and necessitated the use of digital tools to continue the delivery of high-quality continuing education. Aims: The aims of the current program were to provide educational programs in TM utilizing digital platforms and to maximize engagement. Methods: Two digital mediums, podcasts and webinars, were utilized to provide educational materials. Podcasts were released on a monthly basis and cover topics on advancement of science and technology that are pertinent to lab professionals and can impact patient care. Webinars consisting of traditional speaker presentations with defined learning objectives that focused on lab procedures and emerging concepts were presented to live attendees and were subsequently offered for on demand attendance. Furthermore, some webinars were accredited through professional agencies in order allow attendees to receive professional continuing educational credits. Metrics were gathered periodically to gauge reach of these materials and ensure continuous engagement. Results: Podcast engagement was measured by total downloads and reach was assessed by analysis of downloads by country. A total of 20 podcasts were released from July 2020 through January 2022. As of January 2022, the podcasts were downloaded over 13,300 times in 97 countries with downloads most frequently occurring in the United States, Canada, and the United Kingdom. To date, the most frequently downloaded podcast involves discussion with a professor from Yale University regarding COVID-19 antibody immunity. A total of eight webinars were offered in 2021 and were attended by over 2500 live attendees and more than 1300 on demand attendees. The most frequent webinar attendees were lab technicians and those in lab management. Summary/Conclusions: Development and implementation of digital platforms for the delivery of continuing education in TM has been received by an international audience. By offering two different digital platforms, continuing education on emerging topics was able to be delivered through an easily digestible platform in podcasts and in more traditional presentations through webinars. Despite the everchanging landscape of in-person activities created by the COVID- 19 pandemic, these digital tools provided an avenue for the continued offering of education materials to TM professionals.

Impact of COVID-19 pandemic on blood utilization in hospital Tengku Ampuan Rahimah Klang, Selangor, Malaysia

Background: Coronavirus are a family of viruses that can cause respiratory illnesses in human. Special features of Coronavirus is the 'crown like spikes' seen on the surface of the virus. Currently, the entire world are aware of the new strains of the coronavirus that was first reported in Wuhan, China in December 2019 named COVID-19. COVID- 19 pandemic has disrupted the transfusion services in Malaysia in terms of blood collection and potential transfusion needs in total. The pandemic has also caused plausible impact on blood utilization in Hospital Tengku Ampuan Rahimah, Klang, which also the only collection centre in the State of Selangor. Aims: We quantified the impact of COVID-19 on blood utilization in year 2019 until the emerging of COVID-19 pandemic, stratified by most utilized blood products and enumerated blood utilization by different departments. We then specifically analysed the blood utilization in hospitalized COVID-19 patients. Methods: This retrospective cross-sectional study was conducted at Transfusion Medicine Department, Hospital Tengku Ampuan Rahimah Klang from January 2019 to December 2021. Data on transfusion records from Quality Assurance database were collected, summarized and analysed. Overall blood utilization were computed on yearly basis, comparison of blood utilization among respective departments, different type of blood product utilized and overall trend of transfusion in COVID-19 patients were estimated. Results: For the past 3 years, a total of 82,056 units of blood product were utilized. 32,271 units in year 2019, 30,172 units in year 2020, and 19,613 units were used in year 2021. There was a significant reduction in blood utilization after the emerging of COVID-19 pandemic at about 6.50% in 2020 and 39.22% in 2021 compared to year 2019. The most utilized blood product during last 3 years were red cells ranging from 10,516-17,882 units, followed by random platelets 3376-6041 units, and fresh frozen plasma 3739-4662 units. However, there were no significant statistical impact of COVID-19 pandemic observed in utilization of different types of blood product. Average reduction in blood utilization in the year 2020 and 2021 compared to year 2019 in Emergency Department were (44.0%). We have observed a reduction in blood utilization for surgical-based departments, namely Orthopaedic Department (25.9%) and General Surgical Department (22.6%). During the early phase of pandemic in year 2020, the trend of COVID-19 cases was still on the rise and escalated in year 2021 and that was consistent with our findings for hospitalized COVID-19 patients as the red cells transfused in 2020 was only 908 units but in 2021 was 3120 units were transfused which comprised of 8.3% and 29.7% of total red cells utilization. Summary/Conclusions: Following notification of Hospital Tengku Ampuan Rahimah as a State referral and COVID-19 Hybrid Hospital, there was an influx of COVID-19 patients and re-direction of other cases to nearby facilities. Declined blood utilization during COVID 19 pandemic was associated with postponements of elective surgical procedures, reduction in trauma cases due to Movement Control Order and judicious transfusion in COVID-19 patients. An ongoing effective pandemic response and efforts made by various departments had good impact in rationale use of blood products at Hospital Tengku Ampuan Rahimah, Klang.