A study of blood transfusion services at a district hospital in Malawi.

BACKGROUND AND OBJECTIVES: Severe anaemia is an important cause of mortality in developing countries. However, few studies have explored the use of and possibilities for blood transfusion services. The aims of this study are to explore the use of blood transfusion services at a hospital in sub-Saharan Africa and to assess the quality of the transfusion services according to WHO guidelines. MATERIALS AND METHODS: Patient age, gender, haemoglobin (Hb) level, diagnosis, hospital department and replacement donations were recorded for all blood transfusions administered at a district hospital in Malawi in January 2010. The laboratory equipment and procedures were scored according to WHO guidelines. RESULTS: The mean Hb of transfused patients was 4·8 g/dl. Fifty-seven per cent (59/104) of the transfusions were given to children diagnosed with malaria, and 17% (18/104) were given to pregnant women. During the study period, blood was in stock and available for transfusion within 1 h of requisition. The equipment and procedures at this hospital met the main criteria for an adequate WHO stage of development. CONCLUSION: In contrast to the advanced transfusion medicine in developed nations, our findings highlight the persistent and urgent need for life-saving blood transfusions in especially young children and pregnant women in Africa. The results indicate that blood transfusion services adapted to local conditions may be a realistic solution for providing safe blood products in developing countries. Serious challenges, such as HIV transmission and sustainable organization of low-risk blood donations should be addressed to assure access to safe blood products.

Gender differences in presentation rates, deferrals and return behaviour among Norwegian blood donors.

BACKGROUND AND OBJECTIVES: Women are under-represented among long-term blood donors. Reasons for this were sought in the donor pool of the Blood Bank of Oslo, Norway, which comprises only voluntary, non-remunerated donors and has a high degree of stability. METHODS: Three sources of data were analyzed: (1) the subsequent six-year donation patterns of 17 812 donors who donated at least once in 1999; (2) reasons for pre-donation deferral of 484 prospect donors in 2004; (3) reasons for deferrals and absence during a 6.5-year period, retrieved from a follow-up study of 1029 donors who took part in a questionnaire study on motivation for blood donation in 2000. RESULTS: Women were over-represented among first-time donors and under-represented among regular donors. Women below the age of 45 years in 1999 were less likely than men to donate regularly throughout the 6-year study period, whereas the donation behaviour of women and men above 45 years of age was similar. Young (18-29 years) female prospect donors were more frequently deferred at first-time donation than males. In the 6.5-year follow-up study, pregnancy was the most frequently reported cause of absence from or termination of donation, and was reported by 32% of the female respondents that were 45 years or younger. Among the donors that reported having been pregnant, 42% stated to have resumed donation and < 4% stated that they no longer were blood donors. Reported termination of donation by female donors was associated with reported practical obstacles and discomfort related to donation, but not with loss of motivation. CONCLUSION: Most of the gender differences in donation patterns could be ascribed to absence because of pregnancy and lactation. Practical problems and discomfort during donation were important reasons why women reported to have stopped donation. Current deferral criteria pose problems for the recruitment and retention especially of young women.

Seroepidemiological study after a long-distance industrial outbreak of legionnaires' disease.

Following a long-distance outbreak of Legionnaires' disease from an industrial air scrubber in Norway in 2005, a seroepidemiological study measuring levels of immunoglobulin G (IgG) and IgM antibodies to Legionella pneumophila was performed with a polyvalent enzyme-linked immunosorbent assay. One year after the outbreak, IgG levels in employees (n = 213) at the industrial plant harboring the scrubber and in blood donors (n = 398) from the outbreak county were low but significantly higher (P < or = 0.002) than those in blood donors (n = 406) from a nonexposed county. No differences in IgM levels among the three groups were found after adjustment for gender and age. Home addresses of the seroresponders in the exposed county clustered to the city of the outbreak, in contrast to the scattering of addresses of the seroresponding donors in the nonexposed county. Factory employees who operated at an open biological treatment plant had significantly higher IgG and IgM levels (P < or = 0.034) than those working >200 m away. Most of the healthy seroresponders among the factory employees worked near this exposure source. Immunoblotting showed that IgG and IgM antibodies in 82.1% of all seroresponders were directed to the lipopolysaccharide of the L. pneumophila serogroup 1 outbreak strain. In conclusion, 1 year after the long-distance industrial outbreak a small increase in IgG levels of the exposed population was observed. The open biological treatment plant within the industrial premises, however, constituted a short-distance exposure source of L. pneumophila for factory employees working nearby.

Recruiting and retaining young people as voluntary blood donors.

OBJECTIVES: Reasons for predonation deferral of young potential donors and prospects of recruiting and retaining young people (age 18-29) as voluntary blood donors were studied. STUDY DESIGN AND METHODS: Three different sources of data were analysed: (i) the subsequent donation history of 2057 donors who started their donation career at the Blood Bank of Oslo (BBO) in 1999, age and gender of all new donors accepted for donation at BBO in 2004 was retrieved from electronic data files; (ii) data on reasons for predonation deferral, age and gender of all deferred prospect donors at BBO in 2004 was obtained from original screening questionnaires; and (iii) results from a national telephone survey of the general population's attitudes regarding blood donation, conducted in 2005. RESULTS: Twenty-five per cent of the first-time donors recruited in 1999 remained active in 2005, but the percentage was higher among older than younger donors. Change of residency was the most frequent reason for termination of donation among young donors. Young prospect donors were more frequently than older ones deferred for lifestyle-related reasons. Prospect donors older than 30 years were more frequently deferred for health-related reasons. A large proportion (57.7%) of young adults reported a favourable attitude towards becoming blood donors. Lack of a personal request (not being asked) was the most frequently reported reason for not giving blood among young people with no donation record. Only a minor proportion of young non-donors considered themselves disqualified from donating blood due to health status. CONCLUSIONS: Lifestyle-related eligibility criteria and changes of residency pose problems for recruitment and retention of young donors. However, a large proportion of young adults state that they are able and willing to donate blood; therefore, the prospects of recruiting young people as voluntary blood donors seem generally positive.

Transfusion vs. alternative treatment modalities in acute bleeding: a systematic review.

BACKGROUND AND METHODS: The practice of transfusion varies a great deal between countries and hospitals. Therefore, a systematic literature review was performed to evaluate the evidence underlying practice of transfusion and alternative treatment modalities in acute bleeding. After a stepwise evaluation, 79 out of 2438 abstracts were approved as the evidence base. RESULTS: Albumin for volume therapy is not better than artificial colloids or crystalloids and may be detrimental in trauma patients. No outcome difference has been proved between artificial colloids and crystalloids. Use of hypertonic solutions remains controversial, as do the concepts of delayed and hypotensive resuscitation. Healthy individuals tolerate acute, normovolaemic anaemia at 5 g haemoglobin/dl, but pre-operative haemoglobin < 6 g/dl gives increased mortality from surgical interventions. Keeping haemoglobin higher than 8-9 g/dl has not been associated with any positive effect on mortality or morbidity, even in patients with cardiovascular disease. The changes induced in erythrocytes by storage may be clinically insignificant. No alternative to erythrocyte transfusion was established. Evidence underlying the practice of thrombocyte and plasma transfusion is scarce. Available evidence on recombinant coagulation factor VIIa is insufficient to define its future role in acute bleedings. Antifibrinolytic drugs in general seem to reduce the need for transfusion. CONCLUSIONS: Intravenous volume replacement and transfusion policies seem largely based on local tradition and expert opinions. As a result of the difficulties in performing controlled studies in patients with acute bleeding and the large number of patients needed to prove effects, other scientific evidence should be sought to better define best practice in this important field.

Motivation, recruitment and retention of voluntary non-remunerated blood donors: a survey-based questionnaire study.

BACKGROUND AND OBJECTIVES: The aim of this study was to establish which motivational and socio-demographic factors are important for the development of a long-term commitment as a voluntary, non-remunerated blood donor. STUDY DESIGN AND METHODS: A cross-sectional sample survey of active blood donors in Oslo, Norway, was conducted. Donors filled in a self-administered questionnaire during donation. Data on motivation were analysed using factor analysis. RESULTS: The blood donors' socio-demographic characteristics were found to be similar to those of the population as a whole. The single, most important, recruitment channel was the influence of active blood donors. Five dimensions of blood-donor motivation were identified with factor analysis. These were: altruism and empathy; social reasons (such as the influence of friends and family); strengthening of one's self-esteem; positive experiences associated with donation; and a moral obligation to donate. Support for statements on altruistic motives for donation was strong and similar in long-time and short-time donors. In contrast, short-time donors were more likely to be motivated by factors related to self-esteem than were long-term donors. CONCLUSION: The 'good habit' of continued blood donation seems not to be exclusively linked to a high degree of reported other-regarding ('altruistic') reasons, but also to a combination of motives, including some modestly self-regarding motives.

Risk behavior in Norwegian blood donors.

BACKGROUND: Blood banks ensure the safety of blood components by testing them for a set of known infectious agents and by careful selection of donors based on a self-administered questionnaire and an interview. The purpose of this study is to describe the risk behavior for sexually transmitted diseases in Norwegian blood donors. STUDY DESIGN AND METHODS: A survey of the sexual habits of 5,859 blood donors in the capital of Norway was performed by using anonymous questionnaires. The results were compared with a previous survey of 10,000 randomly selected Norwegian subjects aged 18 to 60 years. The response rates were 70.3 percent and 48.4 percent, respectively. RESULTS: Blood donors had considerably more education than the general population. Their general sexual behavior was similar to that of the rest of the population, although the blood donors had later sexual debut, fewer new partners per year, and a lower frequency of intercourse. In addition, homosexual experience among males was much lower in the donor group. Blood donors were less likely to engage in risk behavior for sexually transmitted diseases than were the general population. Nevertheless, 1.5 percent of the donors reported behavior that would have led to deferral had the behavior been disclosed at the predonation interview. Deferrable donors were more likely to be male and young and to have had many partners. CONCLUSION: Anonymous questionnaires reveal information that is not given at the time of blood donation.

The clinical expression of hemochromatosis in Oslo, Norway. Excessive oral iron intake may lead to secondary hemochromatosis even in HFE C282Y mutation negative subjects.

BACKGROUND: The prevalence of hereditary hemochromatosis in Norway is one of the highest reported in the world. However, the clinical presentation in patients with hemochromatosis in Norway seems to be different compared with recent studies elsewhere. The aim of this study was to investigate patients with hemochromatosis in one community hospital in Norway and to study the prevalence of the C282Y mutation. METHODS: One hundred and twenty patients were consecutively admitted to one medical department in Oslo. Serum transferrin and ferritin concentrations were measured in all patients, and a percutaneous liver biopsy was obtained in 108 of 120 (90%) patients. Stainable iron (Perls stain) in hepatocytes was graded from 0 to 4+ and fibrosis from 1 to 4. Genotyping for the C282Y and H63D mutation in the HFE gene was performed by PCR-RFLP. RESULTS: Forty-eight (40%) of the patients suffered from tiredness and astenia and 29 (24%) had typical arthropathy. Only 5 of 105 (4.5%) had biopsy confirmed cirrhosis and 5 had diabetes mellitus. Patients referred from a blood bank had significantly less symptoms and signs compared with other patients. Twenty-one of 120 (17.5%) patients were C282Y mutation negative. Seventeen (81%) of these patients (16 women and 1 man) had a history of extensive oral iron intake lasting from 5 to 50 years. When excluding those with extensive oral iron intake (n = 17), 92 of 103 (89%) were homozygous for the C282Y mutation, 7 (7%) were heterozygous including 3 compound heterozygous and 4 (4%) were mutation negative. CONCLUSIONS: Only a minority of our patients with hemochromatosis had a far advanced disease at the time of diagnosis (less than 5% had cirrhosis) and hemochromatosis in a majority of the C282Y mutation negative patients was associated with excessive oral iron intake for several years.

Different genotypes causing indiscernible patterns of A expression on A(el) red blood cells as visualized by scanning immunogold electron microscopy.

BACKGROUND AND OBJECTIVES: The published sequence of the weak. A subgroup Ael gene from Swedish individuals showed a G insertion in exon VII, causing a frameshift at codon 268 (the A1 gene has 353 codons). We wished to sequence exons VI and VII of two Norwegian Ael individuals and compare the expression of A substance on RBC from different Ael individuals. MATERIALS AND METHODS: Exon VI and VII were amplified by PCR, cloned in M13 and sequenced. A structure expression on Ael RBC was studied by the immunogold technique. RESULTS: In contrast to the Swedish Ael individuals, the two Norwegians had consensus A1 sequences in exon VI and VII. However, the patterns of A expression were indiscernible from the Swedish cases as visualized by immunogold labeling in SEM. In both cases, a few (1-2%) RBC were very strongly labeled, some were weakly labeled and the majority (95%) were unlabeled. CONCLUSION: Although some Ael individuals have an inserted nucleotide in exon VII of the ABO gene, others have consensus A1 sequence in exon VI and VII. However, we could not find any differences in phenotype by immunogold labeling in SEM.

[How soon will we have artificial blood?]. / Får vi snart kunstig blod?

The development of red cell substitute oxygen-carriers has reached a stage where stroma-free haemoglobin solutions (SFHSs) and perfluorocarbon-based substitutes are undergoing clinical trials. However, there is no evidence to suggest that such products will become available, other than for restricted, well-defined indications. Where SFHSs are concerned, the supply of haemoglobin, the strictly limited shelf-life, and the short intravascular half-life are the most important problems to be solved, whereas the use of perfluorocarbons is limited, in particular due to the need of positive pressure ventilation to maintain high oxygen tension. Red cell substitutes for general use will remain a dream in the foreseeable future. Measures to enhance blood preservation and to promote the optimal use of blood products will be the most important areas of transfusion research in the immediate future.

[Genetic diagnostic test for hemochromatosis]. / Genetisk diagnostisk test for hemokromatose.

Haemochromatosis is an inherited, recessive trait and is among the most common genetic diseases in Norway. It is caused by a pathological increase in the absorption of iron from the intestine. This in turn leads to excessive deposits of iron in the organs of the body, e.g. in the liver and pancreas, with concomitant symptoms and frequently organ failure. The mutated gene (HFE), which causes the vast majority of cases of haemochromatosis, has recently been described in a study from the U.S. Based upon this finding, we have established a genotyping protocol for this mutation. We discuss our preliminary experiences using this test as a diagnostic tool, as well as the implications of how it will affect diagnosis. The test is of considerable value, and we suggest that its use should be mandatory in the diagnosis of haemochromatosis.

Prevalence of hemochromatosis among first-time and repeat blood donors in Norway.

BACKGROUND/AIMS: The observed prevalence of hemochromatosis has ranged considerably from 0.05 to 0.37% in studies requiring liver biopsy. We aimed to study the prevalence of genetic hemochromatosis among Norwegian blood donors. METHODS: We studied 10,552 healthy blood donors (5312 women and 5240 men) using serum ferritin as a screening parameter. If serum ferritin concentration was > or = 100 micrograms/l in women and > or = 200 micrograms/l in men, serum iron and transferrin (measured as total iron binding capacity = TIBC) were measured. Blood donors who repeatedly had a transferrin saturation above 40% and a ferritin concentration above these limits were referred to a hepatologist (H.B.). RESULTS: Serum ferritin was > or = 100 micrograms/l in 94/5312 (1.8%) women and > or = 200 microliters in 79/5240 (1.5%) men. Of these, 37 persons had a serum ferritin concentration above 100 micrograms/l (females) or above 200 micrograms/l (males) and a transferrin saturation above 40%. Nineteen of them (13 men and 6 women, median age 36 years, range 28-68) were identified as having hemochromatosis on the basis of increased hepatic iron index. Serum ferritin ranged from 111 to 1980 micrograms/l (median 357 micrograms/l and transferrin saturation from 50 to 100% (median 92%), hepatic iron from 48 to 471 mumol/g dry weight (median 118 mumol/g) and hepatic iron index from 1.5 to 12.1 (median 3.0). One person had cirrhosis and none had diabetes. The prevalence of hemochromatosis was significantly higher among first-time blood donors (12 out of 3500 [3.4/1000]) compared with repeat donors (7 out of 7052 [1/1000]), p < 0.005. CONCLUSIONS: The observed prevalence of hemochromatosis in Norwegian first-time blood donors of 0.34% is comparable to recently observed prevalences in other studies. However, the use of serum ferritin as a first-step screening tool may have failed to detect hemochromatosis in the early stage where iron overload has not yet occurred.

[Quality adjusted life years in assessment of preventive measures. Should blood donors be tested for HTLV-I/II infections?]. / Kvalitetsjusterte leveår i vurderingen av forebyggende helsearbeid. Bør blodgivere testes for HTLV-I/II-infeksjon?

In planning preventive health measures, quality adjusted life-years (QALYs) are useful as a measure of benefit. As an example, the question of whether blood donors should be routinely tested for antibodies to the Human T-lymphotropic viruses I and II (HTLV I/II) is analysed. A mathematical model was set up to describe the consequences, in terms of lost life-years and years with disease due to transfusion-mediated infection (if testing is not performed) or years with reduced quality of life (in the case of testing). These future outcomes were discounted and converted to QALYs. The cost per QALY is about NOK 2.33 million when the prevalence is 1 per 50,000 blood donors, and is reduced to 190,000 per QALY when the prevalence is 10 per 50,000. Using QALYs in evaluation of preventive medicine can be complicated, and calls for cooperation between epidemiologists and health economists.