Introduction
Blood transfusion is a vital treatment approach that saves millions of lives annually. So far, despite some efforts, no successful, alternative transfusion substance, such as a blood substitute, has been discovered (
Van Veen and Hunt, 2015). Blood and blood components remain the only available treatment for trauma and surgery patients, as well as those with thalassemia, hemophilia, cancer and anemia. Due to the rising global rate of both advanced and elective surgeries, the need for blood and its components is increasing, while advancements in the donor selection process and serological tests now result in a higher rate of donor deferment (
Belayneh et al., 2013). The number of deferred Iranian donors, for example, increased from 14 percent in 2001 to 22 percent in 2011(Cheraghalli, 2012;
Razjou et al., 2012). To achieve a sufficient blood supply, the organization of mobile blood collection sessions may represent a useful strategy in overcoming current barriers to further donor recruitment and retention, such as a lack of convenient access to blood donation centers, seen especially in rural areas. Mobile sites are generally donor rooms located at a variety of relatively populous locations including military installations, schools, hospitals etc. (
Rose et al., 2011;
James et al., 2014). Such locations are chosen for their convenience and proximity to public, gathering areas in order to enhance donor recruitment (
Abhishekh and Usha, 2013).
The Iranian Blood Transfusion Organization (IBTO), established in 1974, is a national organization of blood centers throughout Iran with the mission of providing a sufficient supply of safe blood products. As IBTO relies entirely on government funding it is worth mentioning that since 2007, blood donation has become entirely voluntary and non-remunerated all over the country (
Gharehbaghian, 2012). The annual donation index in Iran is 26.2/1000, meaning that in 2011 about 2 million units of blood were collected by the IBTO. Currently 283 fixed blood donation sites are accessible in the country from which 80% of all donated blood is collected, while mobile teams collect the remaining 20% (
Cheraghali, 2012).
The selection, however, of safe, healthy donors, the prevalence of transfusion transmissible infections (TTIs), including, most notably, hepatitis B, C and HIV and the need for “zero risk blood transfusion” remain major concerns for blood transfusion organizations throughout the world . Although the mobile teams provide a relatively high proportion of blood supplies, there are only a few studies concerned with the safety of collected blood from mobile sites as compared to fixed ones.
The aim of this study, therefore, was to investigate the mobile blood collection sites and their roles in providing safe and adequate supplies to the Khuzestan blood transfusion organization (KHBTO) from 2007 to 2012, in comparison with fixed centers. The results of this study are of great importance to the future establishment of both fixed and mobile collection sites; first with regards to their organizational management strategies and, additionally, in providing a framework from which to consider influential factors surrounding blood safety and donor numbers. It was found, to cite one example, that the creation of new collection centers in high-risk population areas should be avoided.
Materials and methods
Study population
This retrospective study was performed using collected data from donors referred to the Khuzestan Blood Transfusion Organization (KHBTO) between 2007 and 2012. The study included all healthy blood donors eligible to give blood but did not include the self-confidential exclusion donations. Khuzestan province is located in the south-west of Iran, neighboring Iraq and the countries bordering the Persian Gulf. The province has a population of about 4346000 (Census 2011), and is one of the largest economic hub provinces in Iran. Khuzestan province is located on the Thalassemia belt and has many transfusion-dependent patients. To estimate the index of blood donation in the province, the donation index was calculated by dividing the number of donations by the total population. The final index was reported per 1000 people.
Screening tests
All donated blood was screened for HIV, HBV and HCV infections with the approved kits and according to the manufacturer's instructions (Table 1). Donors who returned a positive screening test were considered as initially reactive individuals and the screening tests were performed again. Donors who were repeatedly reactive were considered to be seropositive for that infection and confirmatory tests were carried out (Table 1). The evaluation of TTI prevalence was conducted based on the results of the confirmatory tests.
According to the IBTO's standards, donated blood which initially tested positive was discarded and the positive donors were deferred permanently. For the donors whose screening tests were confirmed, consultation and further follow-up actions were organized. Moreover, it was suggested to the family members of the HBV positive donors that they be vaccinated.
Definitions
A first time blood donor was identified as a donor who donated for the first time. A regular donor was defined as a donor who had donated more than once during a 1 year period. A lapsed donor was defined as any donor who had a history of one or more previous donations but for whom the interval between two donations had been more than 1 year.
Statistical analysis
Statistical analyses were performed using SPSS version 16.0 and P<0.05 was considered to be statistically significant. The prevalence of TTIs was reported per 100,000 donations. To evaluate the difference between the prevalence of TTIs' in the collected blood from the fixed sites and in that of the mobile sites, Chi-square analysis was performed.
Results
During the 2007-2012 period, 621117 blood units were assessed by the fixed (85.57%) and mobile centers (14.43%). The median index of blood donation in Khuzestan province was 23.8 per 1000 persons. Fig. 1 shows the trend of blood donation from 2007 to 2012 according to the status of donations. As shown in the figure, the highest and lowest blood numbers were received in 2010 and 2007, respectively. Most notably, in 2010 the mobile teams collected the lowest number of units (10.56%), whereas the highest (20.93%) was collected in 2009 (Fig. 2).
In the years analyzed, the mean value of HBV, HCV, HIV prevalence in fixed centers was 214(range from 97 to 372), 104.83(range from 53 to 150), and 5.32(range from 0 to 12), respectively. On the other hand, the mean value of HBV, HCV, HIV prevalence in mobile centers was 320.34 (range from 90 to 563), 117.4 (range from 36 to 178), and 5.31 (range 0 to 17), respectively.
The prevalence of HBV in the blood units collected at the fixed centers decreased from 372.42 per 100000 in 2007 to 97.19 in 2012. A similar trend was observed for the blood units collected by the mobile teams: 419.6 in 2007 and 90.28 in 2012.
The HCV prevalence in the units collected by the mobile centers decreased from 150.04 in 2007 to 53.1 in 2012, whereas it was 164.84 and 73.86 in units collected by the fixed centers in 2007 and 2012, respectively. Fluctuation was observed in the trend of HCV prevalence in both groups; the prevalence slope of HCV declined at a gradually slower rate than that of HBV. A similar fluctuation was seen in HIV prevalence which in blood units collected by the fixed centers increased from 0 in 2007 to 12.63 in 2009 and then dropped to 5.01 in 2012. Meanwhile, in the units collected by the mobile teams the fluctuations in HIV prevalence were notably high (Figs. 3, 4).
In Table 2, the annual prevalence of TTIs in the units collected at the fixed or mobile centers is compared. As shown in the table, a higher prevalence of HBV is observed in blood collected by the mobile teams and this difference is statistically significant (p = 0.014). Although the prevalence of HCV and HIV was higher in units collected by the mobile teams than in those collected at the fixed centers, statistically no significant differences were observed. The differences between HBV and HCV prevalence in the beginning and at the end of the study, however, were significant in both fixed and mobile blood collections.
Discussion
The results of our study showed that the blood donation index in Khuzestan province was 23.8 per 1000 people. Maghsudlu et al. reported that the blood donation index in Iran ranges from 13 in the North-west region to 39 in the Central region, with a mean rate of 24.2 per 1000 persons (
Maghsudlu et al., 2009). A WHO report stated that the blood donation rate in middle income countries is 11.7 per 1000 population (
http://www.who.int/mediacentre/factsheets/fs279/en/). Hence the results of this study revealed that the index of blood donation in Khuzestan province is close to the national average but nearly two times higher than that of countries of a similar economic level and also higher than that of neighboring countries (
http://www.searo.who.int/thailand/factsheets/fs0029/en/). The blood donation index is lower due to severe climate conditions and other factors which act as blood donation barriers, causing difficulties in accessing collection centers, such as a low number of mobile sites for blood collection.
Of all the blood resources provided by the KHBTO, 14.43% were provided by the mobile teams, whereas the median range of blood units collected by mobile teams in the whole country was reported to be 20%. (
Pourfathollah et al.,2015). Studies on the allotment of blood units collected by mobile centers were sporadic. Carey et al. showed that in the United States, two-thirds of whole blood donations (67.9%) were given at mobile centers (
Carey et al., 2012). Shi et al. also stated that most whole blood units were collected by mobile centers but they did not report the exact number (
Shi et al., 2014). Based on this limited data it could be suggested that the number of donations at the mobile sites of KHBTO was lower than the national average and much lower than that of developed countries. Therefore, better design and planning could provide a safe and adequate blood supply to mobile teams and needs to be considered before their establishment.
It has been reported that altruistic and religious reasons are the main motives for blood donation among Iranian donors (
Maghsudlu and Nasizadeh, 2011). For example, a positive deviation in blood donations is observed during the religious month of Muharram (Prophet’s grandson, Imam Hussein) (
Gharehbaghian,2012). Furthermore, the eight-year war between Iran and Iraq also had a profound impact on voluntary, non-remunerated blood donation in Iran. Khuzestan province is known as one of the most religious provinces in Iran and was also the main front of the war, two factors which, seemingly, provide it with the greatest potential for the recruitment and retention of blood donors. In addition, about one-third of the Khuzestani population lives in rural areas and, as such, utilizing mobile blood centers could be the best way of collecting blood ; the mobile teams can play a crucial role in providing blood supplies to the province.
During this five-year period, the number of donations underwent many fluctuations, and a sudden increase was observed in 2008 (Fig. 1) which, most likely, was due to the fact that satellite organizations joined the central KHBTO at that time. Blood donation continued its upward trend until 2010, when a sudden declining trend was observed due to the relocation of some of the blood transfusion services to adjoining neighboring provinces as well as the closure of others which failed to meet IBTO standards in 2011 (Table 2).
Additionally, a declining trend was observed in the number of first-time donors in contrast to an increasing trend in regular and repeat donors. Based on this finding it could be concluded that the return rate of first-time donors to the KHBTO is high; this reflects the success of the IBTO recruitment strategy and satisfaction of blood donors. In addition, several studies have reported that blood units collected from regular and repeat donors have a lower prevalence of TTIs (Al Shaer et al., 2012;
Song et al., 2014). Thus, the safety of the Khuzestan blood supplies may be enhanced by this change in the pattern of blood donation.
The mean value of HBV prevalence in the blood units collected by the mobile teams and fixed centers was 320.34 and 214.72 per 100000 donations, respectively; for both groups, we observed a significant decrease of HBV prevalence during the study period.
This finding was in accordance with other studies in the country. Pourfathollah et al. reported a decreased HBV prevalence from 610 per 100000 donations in 2005 to 136 in 2013 (
Pourfathollah et al., 2015). Keshvari et al. found a pattern of decrease in the HBV prevalence in the Tehran blood transfusion service from 423 to 153 per 100000 donors during the five-year period from 2008 to 2013(
Keshvari et al., 2015). A similar decline has also been found in most other regions of the world, according to Adouani et al. in Morocco, Singh et al. in India and Chiamchanya et al. in Thailand (
Singh et al., 2009;
Adouani et al., 2013;
Chiamchanya, 2014). In light of the fact that the 21 to 25 year old age group represents the largest number of blood donors in Iran, and given that a national vaccination program has been in place for all infants since 1993, HBV vaccination is likely the main reason for the declining pattern of HBV prevalence (
Maghsudlu et al., 2009;
Mirrezaie et al., 2014).
The mean value of HCV prevalence in the blood units collected by the mobile teams and fixed centers was 117.4 and 104.83 per 100000 donations, respectively; for both groups, we observed a slow decrease of HCV prevalence during the study period in agreement with another wide Iranian study carried out by
Khodabandehloo et al. (2013). Similar data has been reported in studies carried out in other countries, namely in China (
Gao et al., 2011), Argentina (
Lucky et al., 2013), and Australia (
Flichman et al., 2014). By contrast, increasing trends have been reported in India (
Meena et al., 2011) and Turkey (
Uzun et al., 2013). This decreasing trend of HCV infection in Iran reveals that sites have been successful in following IBTO standards: systematic screening of all donated blood, permanent exclusion of donors with a positive HCV result, training programs in relation to TTI transmission throughout the country, implementing confidential unit exclusion, and increasing the number of repeat and regular donations.
The mean value of HIV prevalence in the blood units collected by the mobile teams and fixed centers was 5.31 and 5.32 per 100000 donations, for the mobile teams and fixed centers, respectively. Although the prevalence trend showed some fluctuations, it generally increased in accordance with the findings of Mohammadali et al. in Tehran province, Iran (
Mohammadali and Pourfathollah, 2014) contrary to the previous findings of Kasraian of (Shiraz, Iran), Pourfathollah (Iran) and Al Shaer (UAE). (Kasrian, 2010; Al Shaer et al., 2012;
Pourfathollah et al., 2015). Hong et al. (China), Rudowska (Poland) and Suligoli (Italy) all reported an incremental increase in HIV prevalence among blood donors(
Suligoi et al., 2010;
Rudowska et al., 2011;
Hong et al., 2012). Likatavicius reported a different pattern of HIV prevalence in Europe, which includes an incremental increase in Eastern Europe, stability in Central Europe and a decrease in the West (
Likatavicius et al., 2007). The current prevalence of HIV in the general Iranian population is 34.91 per 100000(based on the registered records of the Iranian Ministry of Health) which is more significant compared with that which was found in the donations analyzed by this study. Moreover, the trend of HIV transmission by blood donation decreased from 0.9% in 1986 to 0 in 2012(Iran Ministry of Health, 2011). Because the trend of HIV prevalence in the national studies is decreasing (whereas it is increasing in the regional studies), we assumed that HIV has a different prevalence in different parts of the country. Therefore, regional studies and locally-oriented training would be helpful to identify the high-risk areas in Iran. Media propaganda, especially surrounding World AIDS Day and training programs concerned with HIV, is one of the motivators driving high risk blood donors to refer to blood transfusion organizations to check their HIV status. Establishing dedicated centers to carry out HIV tests for free of charge could decrease the high risk individuals visiting donation sites.
Briefly, TTI prevalence in the blood units collected by the mobile teams was higher than that of the blood units collected in the fixed centers. Although HBV prevalence was significantly different in both groups, insignificant differences were seen in the prevalence of HCV and HIV (Table 2). In contrast to our findings, Abhikhesh et al. reported a higher incidence of TTIs among donors at the fixed centers than among those at the mobile centers (
Abhishekh and Usha, 2013). Nearly 50% of the blood units at the mobile centers were obtained from first-time donors, whereas this figure was 29% at the fixed centers (Table 2). As the prevalence of TTIs is higher for first-time donors, the difference between the prevalence in the two groups is logical (
Mohammadali and Pourfathollah, 2014). The increased TTI prevalence in donations collected by mobile centers can be due to a lack of an appropriate strategy of recruitment of regular and lapsed donors.
Conclusions and recommendations
Although Khuzestan province has a high potential for the recruitment of more donors through mobile teams, the number of blood units collected by the mobile teams was lower than the national average. However, the findings of this study showed that the number of blood donations in Khuzestan province is comparable with the number of blood donations in the rest of the country. In addition, TTI prevalence in the blood units collected through drives at the mobile centers was higher than that of blood collected at the fixed centers. This may be due to inadequate programs pertaining to the use of mobile centers and insufficient privacy between donors and physicians during donor interviews in some situations. The vast survey on blood donation in Khuzestan province and the comparison of the TTI prevalence in mobile and fixed collection centers were the main advantages of this study. On the other hand, the demographic information of the donors was not evaluated and the circumstances of blood donation in different areas of the province were not examined; these are acknowledged limitations of the study.
Throughout the country, donor recruitment and the safety of blood resources can be improved through the implementation of the following recommendations:
• Increasing the number of mobile teams and their establishment in rural areas, religious places and educational centers
• Implementing educational programs on blood donation, blood safety and TTI transmission pathways in order to increase awareness in the general population
• Conducting regional studies to assess blood donation and the prevalence of TTIs across the country in order to implement strategic programs and provide adequate supplies of safe blood.
Higher Education Press and Springer-Verlag GmbH Germany, part of Springer Nature
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