Transfusion safety in francophone African countries: An analysis of strategies for the medical selection of blood donors

Transfusion safety is one of the main challenges faced by blood transfusion centers in Africa due to the high prevalence of transfusion-transmissible infections (TTIs) and the high residual risk of transfusion contamination by these agents.1 This issue has been raised by numerous local and multicenter studies conducted in francophone African countries.2–7 An estimated 25% of blood units collected in sub-Saharan francophone Africa are contaminated by viral agents (human immunodeficiency virus [HIV], hepatitis B virus [HBV], hepatitis C virus [HCV], parasites [Plasmodium spp., microfilaria], and bacteria). Despite safety strategies recommended by the World Health Organization (WHO)8 and the support of international organizations participating in the transfusion safety of sub-Saharan Africa, the risk of TTIs is still high. Recent multicenter studies have shown that the risk of HIV transmission by transfusion ranges between 1 in 25,600 and 1 in 90,200, which is much higher than in industrialized countries.9 To increase the safety of blood products transfused in Africa, three strategies need to be considered: more effective medical selection of blood donors, better detection of TTIs, and physical and chemical treatment of blood products. Detection of TTIs has greatly improved in past years in Africa. Many studies have revealed that quick screening tests, validated through quality assurance, have reduced transfusion risks as was achieved by fourth-generation serologic tests.10,11 Viral detection through nucleic acid testing would certainly be most beneficial but it is still not feasible in most African countries due to financial and technical reasons.12 In addition, the efficacy of this biologic screening is limited by many factors such as genetic variation (e.g., HIV),13 test conditions, absence of quality assurance in many centers, and the inability to detect recently infected subjects.14 Physical and/or chemical treatment of blood products is still only feasible for platelet concentrates and plasma.15 However, blood products as a whole and red blood cells are the main blood-derived products used by a vast majority of sub-Saharan African countries. Furthermore, these countries cannot currently afford the cost of this type of physical and chemical blood treatment. It appears that the most efficient way to improve transfusion safety in Africa at this time is to improve the medical selection process to exclude subjects at high risks of transmitting blood-borne infectious pathogens from blood donation. The medical selection step comes first in the overall process of collecting safe blood products. The identification and exclusion of donors with high-risk behaviors leads to a significant yet poorly quantified reduction in the risk of infections for the blood recipients and ensures donor safety as well.16 With the high TTI risk being associated with having multiple sex partners, sexual relationships between men, tattoos, or injection drug use, complementary strategies need to be used to exclude high-risk subjects in the selection of blood donors. Such strategies are: 1) predonation counseling, where the goal is to inform donor candidates on behaviors that are considered at risk, on the actual blood donation procedure, and the possibility of self-exclusion; 2) reviewing the donor candidate’s medical history with a physician to ensure the absence of symptoms (past or current) that may carry a risk for the donor or recipient; 3) physical examination, as certain physical signs and symptoms may contraindicate blood donation; and 4) infectious disease (ID) marker testing to identify infections.17,18 Maintaining a high level of vigilance after a blood donation is essential as the donor’s initial interview is audited in the hours or days after the donation. In developing countries, where resources are limited, the medical selection process is all the more critical as other strategies of ensuring safety of the blood products are difficult to achieve or insufficient on their own. This method is easy to achieve and does not require any specific equipment. The authors investigated the variability and the conditions in which this medical selection process was completed in various francophone African countries. The results of this study identify hurdles that need to be overcome and establish a baseline for the transfusion centers in Africa that would like to improve their current strategies in preventing ID.