Blood donation in South Africa

 

In South Africa, blood transfusion was first undertaken a few years after the early techniques of blood extraction, typing and transfusing had been developed, with the national centre for such activities being Johannesburg. At that time, most blood providers were either relatives of a patient or paid donors, although the services of voluntary, unpaid donors were also used relied upon. In 1937, the first full-time blood service in the country, the Rand Blood Transfusion Service, was established on the basis of a system whose structure had been laid the previous year by the student run blood donation service that operated at the University of the Witwatersrand.

 

During 1940, the blood service was to establish one of the first formally constituted blood banks in the world, which allowed for blood to be stored for emergency use without having to call on donors at short notice, while avoiding any need for direct contact to take place between the donor and recipient (which could be an uncomfortable experience). In 1942, the South African Blood Transfusion Service (SABTS) superseded the Rand Blood Transfusion Service along with associated branches that operating in areas like Cape Town and Durban. During World War 2, in addition to meeting local blood requirements, blood was also supplied to the national military services as well as to the Red Army as a form of military assistance. While the SABTS was, in 1943, to introduce policies so that South Africa was to become the first country in the world in which all blood was declared to be given for no financial gain, in this year, it was also to experience its first blood shortage, when the annual demand for blood (323 units) exceeded the number of transfusion performed (303 units) [1].

 

In the years immediately after World War, the coastal branches of the SABTS were to break away and form independent regional blood banks. Consequently, while the SABTS was to collect blood from donors in most of the then Transvaal and Orange Free State, bodies such as the Western Province Blood Transfusion Service and Natal Blood Transfusion Service were involved in collecting blood from unpaid volunteers in the rest of the country. In subsequent years, each blood bank was to gradually expand in profile. While new blood products were introduced into local use, increasing numbers of donors were recruited to meet the rising annual blood demand, with the number of local branches being expanded as donors in the smaller towns were recruited to aid in meeting the national desire to attain self-sufficiency in blood supply.

 

Since the 1990s, a process of rationalisation in this sector has been taking place though. In 1998, the Department of Health accepted the proposals of a document known as the National Blood Policy, that were drafted, to a large degree, in accordance with the wishes of the national blood banks. In terms of this document, non-remunerated blood donation was to remain the cornerstone of national blood collection policy, with the different blood banks agreeing to be amalgamated into a single national blood service, thereby enabling the Department of Heath to issue a single license to collect blood in this country. Although they were to continue to retain a degree of separate regional identity, from 1 April 2001, all blood banks in the country were merged into a national body known as the South African National Blood Service (SANBS).

 

While the government plays a regulatory role in the blood sector, in accordance with the Human Tissues Act of 1983, it is not actively involved in the collection of blood or administration of the blood services. Rather, these bodies are NGOs that operate independently of the state sector, since they are non-profit associations that “belong” to the members who constitute their blood donor pools, with decisions of an administrative nature being taken jointly by the professional medical directors and the elected donor committees that represent donors (although other relevant parties, such as the state, are allowed some degree of representation on their boards as well).

 

In Table 4, a summary of the blood collection figures of the SABTS over the past decade is supplied. While there were other blood banks in the country during this period of investigation, the SABTS was the largest and, arguably, most efficient of the national blood services, with approximately 55% of the national blood supply being drawn from its donors each year. Thus, if we wish to get an idea of what overall blood collection trends in the country during this period were, all that would be required would be to literally double the figure provided for SABTS collections to get an approximate national total. For example, given that just over 500,000 units were collected by the SABTS in 2000, we can estimate that in this year, about 1,000,000 units were donated by donors around the country.

 

Table 4 Blood donation in South Africa (1991-2000) [2]

Year	Active  blood donors	Change on previous year	Units procured	Change on previous year	Average donations
2000	225,249	4,672 (2.1%)	531,974	-54,115 (-9.2%)	2.4
1999	220,577	-55,026 (-20%)	586,089	17,013 (3%)	2.7
1998	275,603	17,139 (6.6%)	569,076	26,351 (4.9%)	2.1
1997	258,464	-2,386 (-0.9%)	542,725	31,530 (6.2%)	2.1
1996	260,850	24,939 (10.6%)	511,195	-17,221 (-3.3%)	2.0
1995	235,911	-13,093 (-5.3%)	528,416	17,153 (3.4%)	2.2
1994	249,004	-15,482 (-5.9%)	511,263	6.636 (1.3%)	2.1
1993	264,486	-7,739 (-2.8%)	504,627	22,986 (4.8%)	1.9
1992	272,225	13,249 (5.1%)	481,641	41,301 (9.4%)	1.8
1991	258,976		440,340		1.7

 

From these figures, we can see that the absolute quantity of blood collected over the past decade has increased by about 20%, even though the respective number of active donors decreased by 10%. This rise in blood provision has been accomplished primarily through an increase in the average number of units provided by donors per annum – while only 1.7 units were collected per donor in 1991, by 2000, each donor gave 2.4 units of blood annually. In most years, the marginal increase in units collected was greater than the equivalent change in the number of active donors, which suggests that the SABTS was quite efficient in making use of the donors that it had, as each new donor gave more than one unit of blood in the course of a year. What is not reflected in these figures though is that there were major variations in the number of units of blood collected by different branches of this organisation – for example, while slightly more than 2 units of blood were collected from each member of the large Johannesburg branch in 2000, in the mining town of Ermelo, each donor gave about 4.5 units of blood during the equivalent period.

 

Although the total figures are impressive, they hide the fact that in 2000, the SABTS suffered a major decrease in blood donations compared to the previous year, with the marginal change in units procured being -9.2% even though there was a 2.1% increase in the number of donors compared to 1999. While it would be impossible to state whether this is simply an aberration in the general trend of rising annual supply, what is very worrying is that the loss in collection momentum was fairly substantial, with the total quantity of blood collected being at its lowest level in 4 years (and on a similar level as the quantity collected in 1995). This suggests that while the SABTS may have been efficient in getting blood out of its current donor pool, it would be facing growing and possibly insurmountable problems in getting marginally greater increments of blood from them due to the already high quantity of blood collected by these donors [3].

 

Provided in Table 5 is a breakdown of the number of units of blood donated in the 1998-1999 financial year by donors according to race and gender [4]. From this, we can to see that while white males have lost their influence in many sectors of South African society, when it comes to the provision of blood, they play a dominant role, with approximately 60% of the blood that was collected during the year under review being provided by them, with white women coming second by donating about 30% of the blood collected by the SABTS [5]. In a general racial sense, it is clear that whites donate blood out of all proportion to their representation in the national population, for in 1999, they provided about 90% of all the collected blood against a figure of 10% for non-whites. This meant there was a largely inverse relationship between the representation of whites on the national population register and in the blood donor pool, for if they were to donate blood in strict accordance with their racial presence in the country, they would only provide about 15% of all the blood collected by the SABTS. On a gender basis, it is apparent that amongst all racial groups, males donate substantially more blood than females. This is only to be expected, as not only are women more likely to be excluded from donating blood because they are pregnant (an obvious excluding factor), but they also have a greater likelihood of falling below the minimum body mass required for consideration as donors.

 

Table 5 Characteristics of the blood donor pool [6]

Features	White	Black	Coloured	Asian	Total Gender
Male	325,013	28,074	9,988	7,680	370,755
Female	187,223	16,717	8,160	3,234	215,334
Total Race	512,236	44,791	18,148	10,914	586,089

 

An extremely important factor in the maintenance of these high collection rates has been the relatively large volume of blood donated by repeat donors, who provide blood on a regular basis to the blood bank. In the case of the SABTS, over 80% of its blood supply is derived from these donors [7], with the remaining blood being provided by less desirable infrequent donors. Various programmes have been introduced to ensure that members donate blood regularly, with donors receiving special recognition for giving blood either 4 or the maximum of 6 times in one year – in 1999, about 65,000 people gave 4 units of blood and just over 14,000 donated 6 units in that year [8]. In addition to these awards, there are also commendations for people who have given a set total number of units of blood in their lives, with 2 donors, each of whom has donated over 300 units of blood, presently competing for the title of the most prolific (unpaid) blood donor in the world.

 

The prime motivation behind the behaviour of blood donors in South Africa is said to be an altruistic desire to help others, although it is highly likely that other factors may contribute to the decision to donate blood (and which may thus shed light on why there are large numbers of irregular blood donors). In cases where donors are recruited at their place of work, it is possible that some workers may feel exposed to some degree of coercion into giving blood by their employers or fellow co-workers, while in instances where blood donation occurs at schools, students may face some peer pressure or have a personal desire to emulate the activities of their peer group that makes them give blood. In such cases, these local blood donors may be classified as being captive donors according to our donor typology. There may also be cases where donors, especially those who are employed, give blood in order to take time off work or receive some other indirect benefit, in which case donation takes place in return for the provision of fringe benefits (even if these benefits are not actually provided by the blood bank). An issue that has been discussed amongst local blood banks has been the provision of indirect benefits to donors should they themselves need blood. While the standard SABTS procedure in this case is to usually bill the donor’s medical scheme (or respective state hospital) for the costs associated with the donor’s blood use, provisions are made for any blood costs that are privately borne by the donor to be refunded, so long as he or she had previously donated certain quantities of blood within predefined periods [9]. In this situation, we may then find that some people are credit donors, who give blood in the expectation of receiving the perk of not having to repay their own blood use should the need for them to receive a blood transfusion arise some time in the future. While blood banks may negate the value of such benefits in recruiting donors (and may not openly discuss the availability of such benefits with donors), their value in the recruitment and subsequent retention of people in the blood donor pool may be substantially greater than is realised.

 

At present, no payment is provided locally for blood, as this would be in contravention of the regulations contained within the Human Tissues Act. While the SABTS claims that “South Africa became the first country in which donors gave their blood purely for altruistic reasons, with no monetary gain” [10], there was one important exception to this general rule of non-remuneration of blood donors that is worth mentioning. For many years, the South African Institute for Medical Research (SAIMR) was involved in the purchase of blood from paid donors in order to meet the medical requirements of the independent hospitals erected by the major Transvaal gold mines. Here, blood was purchased for use in mineworkers who were in need of transfusion after falling ill or being involved in an accident, which was a relatively common occurrence due to the high risks associated with their occupation. In keeping with the general laws of the country at the time, all blood (regardless of source or donor motivation) was divided according to the racial category of the donor [11], with paid donors also being segregated when it came to the payment that they received – while whites earned R4 per unit of blood sold, non-whites received only R1 per unit [12]. Currently, payment for blood no longer takes place, as the SAIMR withdrew from the provision of blood to the mines a couple of decades ago, from whence blood was instead obtained from the normal blood banks using their voluntary donation principles.

 

A significant concern for any blood bank involves the possible contamination of blood products by transmissible diseases. To counter these threats, the SABTS conducts an intensive series of tests on all donated blood that screen for most of the diseases that were previously examined, with the test standards being set at amongst the highest quality levels in the world. For example, in the area of HIV detection, South Africa is the only country in the world other than the USA to use what is known as the p24 test, which is a highly sensitive test that has reduced the window period in which contaminated blood could be collected to only about 16 days [13]. In addition to direct tests, the SABTS utilises risk management techniques to ensure that the probability of obtaining tainted blood is minimised, with blood donors being classified into 4 basic risk levels that represent how likely they are to be carriers of disease [14]. In the most recent collection year, 621 donations were registered, according to the screening tests, as being HIV positive, although the difference in infection rates between members of different groups was substantial. Repeat donors, who fall into the safest risk category, were found to have given blood that appeared HIV positive 0.0079% of the time (i.e. in 32 out of over 400,000 donations), while donors who had the highest category risk profile had blood that appeared HIV positive in 4.29% of the units donated [15]. Such a remarkable safety record and attention to detail when it comes to safeguarding the interests of recipients is not copied throughout the country though, as the smallest blood bank in South Africa, Medimatch, was temporarily suspended by the Department of Health in 2000 for working according to sub-standard operating procedures. Here, it was found that the laboratory of this organisation was simply a kitchen in a residential home, with poor safety standards being applied in a similar fashion to the storage and disposal of donated blood products [16].

 

No record exists of how many people in South Africa acquired transfusion related HIV, although the SABTS asserts that this number is minimal, with any haemophiliacs and blood recipients that did become HIV positive likely to have been infected through the use of imported blood products rather than local blood products [17]. Several factors make this statement concerning the absolute safety of locally acquired blood in transmitting disease highly questionable. First, press reports occasionally surface where local individuals state that they became HIV positive after a medical procedure, with blood transfusion being viewed as their only possible vector for acquiring this disease [18]. Second, when HIV testing was finally introduced by the SABTS in November 1985, the first case of an infected donation was reported within less than a month of full-scale use of this test. This suggests that even at this early stage of the national HIV epidemic, there may have been some infected donors who could have unwittingly passed their disease on to recipients, with such a possibility being particularly unfavourable to blood recipients since these early tests were not as sensitive in detecting infection at the early window stage as the later blood tests. Third, as the discussion on risk groups revealed, positive test results continue to appear amongst blood donations, even for the apparently very safe, repeat blood donors. As such, while the probability of an infection escaping detection during the window period is extremely low, it can never be defined as being zero, in which case provision must be made that some blood recipients may get HIV. With respect to hepatitis, a similar possibility of donors passing infected blood on to patients must be considered, with South Africa too being affected by the fact that HCV, for example, could only be detected locally following the introduction of the appropriate test in 1992. Thus, prior to this period, there must have been cases where patients were infected with this disease that were not properly accounted for in the available data [19].

 

In Table 6, a summary of the main blood products that are transfused into patients is provided. As we can see, the most important category of blood products to be used in this country are red cell products, with almost 400,000 units being transfused in 2000, representing an increase of about 30% in demand for this class in a decade. Frozen blood products, which are essentially derived from fresh frozen plasma, make up the next highest category of transfused product, although their respective rate of increase in demand is lower than that of the red blood cells products. The amount of albumin and dried blood products obtained from the stock of donated SABTS blood has decreased substantially in the past few years and is now zero, with a significant decrease also being registered in the quantity of platelet units issued. These falls in consumption do not actually mean that there has been a decrease in the demand for these important products. Rather, what has happened is that the SABTS no longer manufactures such products using its own facilities, but has instead contracted to send basic raw materials to the largest national blood processing agency, the Natal Bioproducts Institute, where greater economies of scale allow them to more efficiently synthesise these products [20]. In addition, while the amount of blood provided by local donors may make South Africa self sufficient in most aspects of blood transfusion, there is always a possibility that some local patients may require specialised blood products that can only be imported due to a lack of local market demand or production ability.

   

Table 6 Blood usage (1991-2000) [21]

Year	Red blood cell products	Frozen blood products	Dried blood products	Albumin	Platelets
2000	398,443	76,404	166	172	29,899
1999	395,276	78,485	1,098	197	66,242
1998	414,055	79,968	1,564	5,977	71,900
1997	397,511	79,881	1,714	7,179	63,809
1996	383,447	75,428	4,336	4,561	61,469
1995	367,441	70,574	3,887	10,607	56,012
1994	343,545	72,513	7,647	15,307	49,739
1993	351,418	69,287	9,275	12,157	51,217
1992	333,798	N.A.	N.A.	N.A.	N.A.
1991	306,634	N.A.	N.A.	N.A.	N.A.

 

Unfortunately, there is no comprehensive data dealing with the amount of blood collected by the SABTS that ends up being wasted, which therefore makes any assessment of the general efficiency with which it handles its blood stocks highly speculative [22]. However, from a cursory examination of the available data, about 0.25-0.50% of all donated blood must be destroyed immediately after collection due to the possible presence of transmissible diseases. Given that the SABTS operates according to world-class standards of quality control, it is highly unlikely that there would be much technical waste involving the contamination of blood products by bacteria and other foreign agents. It is also difficult to ascertain the amount of administrative waste and waste attributable to defensive medical procedures in South Africa as local blood banks do not account for what happens to blood once it is out of their control. There is, however, some anecdotal information on the amount of blood that is wasted due to expiration before use. Here, it seems that very little SABTS blood reaches its final date of use before it can be transfused, although this may have less to do with the overall efficiency of the SABTS in handling its blood supplies than with the fact that it has great difficulty in acquiring sufficient stocks for blood to even have the opportunity to go to waste. This is since the average available quantity of blood stored in the blood banks is rarely enough to cover blood demand for more than a few days, with donated blood usually being processed and issued for use within a few days of collection [23]. The only exception to this general rule may concern blood of more common groups, such as type A+ blood, where there appears to be an excess number of donors, as well as with some less needed plasma by-products that are obtained when plasma is processed into different products. In these cases, what may happen though is that instead of destroying such surplus products, blood banks will export them for use in countries where a greater need is expressed for them, with compensation taking place either as cash payments or through the receipt of blood products or equipment that local blood banks need.

 

Occasionally, shortages of blood are experienced, when a blood bank is unable to meet all the blood needs of hospitals in a rapid manner. In such a case, a request would be made by the affected blood bank to its counterparts in other parts of the country to assist it in meeting the requirements of local medical institutions until sufficient supplies could be acquired. For example, if the Western Province Blood Transfusion Service were to run out of blood, in addition to launching an appeal to the public to come forward and donate blood, it would also turn to bodies such as the SABTS to ship blood to it, and vice versa. While shortages of blood are not common in South Africa, they are also not unheard of – in 2000, for example, the Natal Blood Transfusion Service twice ran out of enough blood to meet overall demand [24]. When this happened, non-essential surgery had to be cancelled until a later date, when blood stocks had been replenished, with transfusions only being allowed to take place in emergency operations. Similar problems regarding blood shortages have also been expressed by the SABTS though, which was forced to consider issuing blood in emergency situations to patients as well, due to the fact that it often had a maximum of 2 days worth of blood supplies [25].

 

There are a couple of important issues that have been raised concerning blood donation in South Africa. The greatest threat to the blood transfusion system in this country is posed by the infectious disease epidemics such as HIV and hepatitis. In addition to the obvious threat of infecting recipients through contaminated blood donations, these diseases may also have a less noticeable but just as important effect of reducing the total amount of blood that can be collected by the blood banks. In 1999, there were at least 4.4 million HIV positive people in this country [26], with the fact that at least 1,000 new cases are reported daily of people being infected with this disease, meaning that the number of cases is by now close to 6 million carriers. In addition, South Africa is said to be a high-risk area for the contraction of the more fatal strains of hepatitis (hepatitis-B and hepatitis-C), with at least 2 million carriers of this disease being in the country at present.

 

While there may be some double-counting if people are infected by both diseases, the impact on the blood banks of such high infection rates is significant, as they will have lost a fair number of potential donors who would have been able to help them maintain the supply of blood in the country. This can be seen with the following mathematical estimate. Apart from, at most, 100,000 infants and adolescents, most people with HIV in this country are over the age of 16 years, which is to be expected, given that this disease is spread primarily by the sexually active sector of the population in this country. Now, about half of the approximately 42 million people in this country are said to be over the age of 16 years, which means that there are, at the outset, about 21 million adults in this country who would be legally eligible to give blood. If we assume that half of those individuals with hepatitis also have HIV and the other half hepatitis only (thereby avoiding a double-count), then about 5.5 million people in the country would be infected with a blood transmissible disease. Almost immediately, the size of the possible national donor pool would shrink by 25% due simply to disease infection, before other factors that often impede donation are accounted for [27]. The problem for the blood banks is that their current pool of good donors, made up mainly of middle-aged and elderly donors, is aging [28]. Here, replacing them will be made increasingly difficult if large numbers of potential donors are prevented from donating blood if they have these diseases, with the increasing number of cases reported daily only leading to even greater problems in the collection of blood [29]. Furthermore, prospects of relying on those who are younger than 16 to make up any shortfall in collections is limited, as popular belief has it that up to one-third of these individuals may eventually contract HIV over time.

 

The other topic of concern relates to the fact that major work needs to be carried out by the blood banks in order to increase the number of black blood donors in this country. As the analysis of the racial classification of donors clearly demonstrated, they constitute a minority of the donor pool even though, as the major racial group in South Africa, they are likely to have the greatest total blood demand in the country. This imbalance between blood contributions and requirements is neither desirable nor sustainable in the long run, and can only result in severe supply problems when current donor sources are no longer available in as great numbers as they were in the past. In a study conducted in Natal in the 1960s, it was found that “the image held by some Bantu adults of the Blood Transfusion Service was a negative one in that it was seen as a governmental organization and ‘White’” [30]. While the political situation in this country has changed dramatically since then, perceptions may prove to be significantly harder to alter than facts. Here, it appears that many black people may possibly still see blood donation as being something that is only of relevance and interest to whites, even though they too can benefit from the medical outcome of blood transfusion.

 

Returning to the aforementioned 1960 study, it was stated that “the concepts of blood held by the average manual worker Bantu closely link blood with health and are unfavourable to blood donation” [31]. Now, while Westernisation may change the lifestyle habits of black people in this country, especially those in urban areas, it is still possible that many people may retain strong cultural beliefs about the role of blood that may be very hard to dispel. Consequently, regardless of the provision of any public information aimed at clearing up their misconceptions on this topic, efforts at recruiting new donors among the black community may fail. In many cases though, it is possible that the low blood donation rate amongst blacks may not necessarily indicate the lack of an altruistic desire to help others or a predominance of selfishness. Rather, some blacks may be prevented from becoming blood donors due to being in a poor state of general health. Here, we might find that poverty, and an accompanying lack of nourishment, means that many black people may not meet the minimum body mass or iron count requirements needed to give blood even if they so desire, in which case blood collection does not take place simply due to factors outside the control of these individuals.

 

In this section, it has been clearly demonstrated that given the particular constraints it faces, the SABTS has managed to run an impressive blood collection system. However, it has also been seen that there are various factors that may prevent the new national blood service from carrying out its activities as efficiently as it may desire, in which case, shortages of blood are likely to occur more often in South Africa than has been case so far. Under such circumstances, there may be no option other than to consider adopting alternative measures in order to ensure that a safe blood supply continues to be provided in this country. In the following sections, we examine various ways in which non-market methods of acquiring and using blood in a more efficient manner can be introduced into the country.

 

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