- Email: [email protected]
Blood transfusion service in disasters
ARTICLE IN PRESS Transfusion and Apheresis Science ■■ (2016) ■■–■■
Contents lists available at ScienceDirect
Transfusion and Apheresis Science j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / t r a n s c i
Review
Blood transfusion service in disasters Hasan Abbas Zaheer *, Usman Waheed Safe Blood Transfusion Programme, Ministry of National Health Services, Government of Pakistan, Pakistan
Contents 1.
2. 3. 4. 5. 6.
Types of disasters and its impact on BTS ....................................................................................................................................................................... 1.1. Earthquake ................................................................................................................................................................................................................... 1.2. Floods ............................................................................................................................................................................................................................. 1.3. Terrorism ...................................................................................................................................................................................................................... 1.4. Biological event .......................................................................................................................................................................................................... Response plan ........................................................................................................................................................................................................................... Staff capacity building ........................................................................................................................................................................................................... Managing voluntary donors during disasters ............................................................................................................................................................... Consolidation of blood transfusion services in Pakistan after the 2005 Earthquake ...................................................................................... Role of media in blood management during disasters .............................................................................................................................................. References ..................................................................................................................................................................................................................................
National response to disasters is managed well in countries with a developed healthcare system and a centrally coordinated blood transfusion system. However, in countries without an integrated healthcare system and a fragmented blood transfusion system, the national response to blood management in disasters is patchy, insufficient and lacks proper coordination [1]. Blood banking plays a crucial role in providing health care services in disasters. It is, however, vital to note that natural disasters normally may not generate an urgent need for blood [2]. Floods and earthquakes disrupt the transportation system and damage the healthcare infrastructure. The refugees are housed in temporary camps with inadequate healthcare facilities and burden the existing local healthcare infrastructure. Transfusion needs in such settings generally remain neglected and unmet and especially pose risks to safe motherhood. It is very crucial to sensitize and familiarize both health authorities and blood bank personnel to their
* Corresponding author. Safe Blood Transfusion Programme, Ministry of National Health Services, Government of Pakistan, Pakistan. Fax: 0092 51 9263238. E-mail address: [email protected] (H.A. Zaheer).
2 2 2 2 2 2 3 4 4 4 5
roles and duties in disaster situations. The single greatest risk of disasters is the disruption of delivery system and not the actual shortage of blood. The critical aspect is to ensure that policies and procedures for emergency and extraordinary release are present and can be put into practice whenever required to meet the urgent demand of blood. Wastage of blood often occurs during disasters [3]. However, the real challenge in disasters especially in developing countries occurs due to disruption of articulations related to the following areas: – – – –
Health infrastructure Transportation system Overall available blood stocks in blood bank or hospitals Determination of the magnitude and exact nature of the calamity – Expected number of emergency hospital admissions In the context of blood supply, the term ‘disaster’ refers to special characteristic events leading to the below mentioned needs [4]. – Suddenly requiring a much larger quantities of blood than usual.
http://dx.doi.org/10.1016/j.transci.2016.09.007 1473-0502/© 2016 Published by Elsevier Ltd.
Please cite this article in press as: Hasan Abbas Zaheer, Usman Waheed, Blood transfusion service in disasters, Transfusion and Apheresis Science (2016), doi: 10.1016/j.transci.2016.09.007
ARTICLE IN PRESS H.A. Zaheer, U. Waheed / Transfusion and Apheresis Science ■■ (2016) ■■–■■
2
– Temporarily restricting or seriously affecting a blood bank’s ability to collect, test, process, and distribute blood. – Temporarily restricting or preventing the local population from donating blood, or restricting or preventing the use of the available inventory of blood products; this situation requires immediate replacement or resupply of the region’s blood inventory from another region. – An unexpected influx of donors, requiring accelerated drawing of blood to meet an emergent need elsewhere [5]. Heavy workload, collapsed infrastructure, failure of basic amenities and loss of technical human resources make relief efforts, including blood transfusion services, a gargantuan task. Most of the times, the disasters are inherently local and need urgent delivery of blood and blood products from blood banks or blood collection sites having proper logistic support to transport blood to the affected area. In a disaster, the coordination between the hospitals and blood banks in the affected area should be optimal. The assessment of immediate (i.e., within the first 24 hours) and short term need for blood is the responsibility of the hospital which then communicate that information to the affected blood bank. Assessing the actual blood transfusion needs is a prerequisite and a very crucial step. Initial estimates of blood requirements in an earthquake are often exaggerated [6]. The requirements for blood in large disasters are mainly calculated from the number of people injured who survived long enough to be presented for care and the amount of blood used in providing that care [7]. A complete list of all consumable materials and vendors who can supply them should be readily available.
1. Types of disasters and its impact on BTS
1.3. Terrorism A huge blast from an accidental industrial explosion, military or flammable-material source or an intentional terrorist or criminal bomb can cause high immediate mortality. Survivors would require revival and surgery with associated transfusion support. Local inventories of blood components would need assessment for adequacy and augmentation. Large influx of blood donors are often witnessed after such unpleasant events and coordinated public announcements about the blood supply are helpful to achieve the appropriate balance between supply and demand [4]. 1.4. Biological event The use of a biological agent poses the greatest threat to the collection of blood products. Depending on the type of agent involved in the event, staff, volunteers, and blood donors may be infected; facilities and vehicles may be contaminated; donors may have to be deferred. In recent years, the world has experienced the ‘sarin gas’ attack in Japan [8] and the multiple anthrax incidents in the United States [9], and the effects of those attacks, including use of prophylaxes, public fear, and long-term decontamination of facilities. Disasters can also affect donor eligibility criteria, particularly emergencies involving any potential infectious diseases or hazardous chemicals. The causative agent should be identified and measures taken to prevent its 1) transmission through blood transfusion, 2) potential to harm recipients, and 3) any asymptomatic period after exposure and before or after the actual disease period when the donor may be infectious. If any agent is considered to be transmissible, a deferral period that ensures an adequate safety period from infectivity or adverse effect must be determined, and donors must be deferred appropriately [10].
1.1. Earthquake
2. Response plan
Earthquakes directly affect the blood supply. Blood usage may not be much initially, but the event could significantly obstruct transportation activities if a huge area is inaccessible. Hospitals should provisionally postpone elective surgeries, followed by a spike in such surgeries once all processes are back to normal. To guarantee quick progress in normalizing the situation, the blood establishments should form special preparations (supplies, power supply, staff, transportation, etc.). The maintenance of cold chain is also essential.
The response plan is dependent on the blood bank in the affected area where it could act like the main medium for information flow and communication. The affected blood bank’s role is to assess the local medical requirements of blood and to communicate this need to the national/local health authority which will then recommend an action strategy including the coordination and dissemination of a message to the National Blood Programmes and Blood Donor Organizations. In a response to disaster situation, it is important that blood bank should ensure the following measures:
1.2. Floods
– Blood bank staff must be familiar with the hospital/ center disaster plan. – SOPs related to hospital disaster plan are developed. – Adequate facilities to keep and maintain 3-day supply of blood products, which may need to be expanded up to a 7-day supply. – After a disaster, the public usually responds by volunteering to donate large quantities of blood than needed, so there must be guidelines to smoothly entertain the increased donor influx.
In a flooded area, the impact may be undersized, but can also be destructive. The blood delivery may experience small or no impact unless the blood establishment or its hospitals themselves are flooded. Citizens may volunteer in large numbers to donate to help the victims, which may result in a donor rush. If the blood center is flooded, emergency evacuation should be carried out to guarantee the protection of staff and the blood components.
Please cite this article in press as: Hasan Abbas Zaheer, Usman Waheed, Blood transfusion service in disasters, Transfusion and Apheresis Science (2016), doi: 10.1016/j.transci.2016.09.007
ARTICLE IN PRESS H.A. Zaheer, U. Waheed / Transfusion and Apheresis Science ■■ (2016) ■■–■■
– Increased resources (personnel, equipment, and supplies) are sometimes allocated for collecting and processing blood which may not be required and center may be unable to process and distribute available and urgently needed products to centers which require them. – There should be separate slot of trained, educated and skilled blood bank professionals within treating facilities to handle such situation. Historically, most disasters require relatively few units of blood for transfusions; however, the public response to disasters has traditionally resulted in abrupt increase in blood donations regardless of the true medical need for transfusions. Therefore, quality and safety of blood products are other vital topics of concern in the disaster affected area. In emergency situations, blood banks are sometimes more concerned with the quantities rather than the safety of the procedure. This happens because emergency management personnel are often unaware of issues related to the collection, processing, storage, and distribution of blood and blood components. As blood collected in response to the disaster takes more time to process, it is crucial for the local blood supply to remain at sufficient levels to treat victims of potential hazards as defined in the organizational risk assessment. Attempts should be made to determine the true medical need for blood during a disaster and to convey this need to organizations within the blood community (BDOs), to blood donors, and to the public through a clear and consistent communication strategy [2,7,11]. The personnel or authority who is authorized to make public appeals for blood donation should be identified and must coordinate with people in the field who are involved in making the needs assessment. The AABB Disaster Task Force recommends maintaining a 5- to 7-day supply [combined inventory at the blood collector and hospital(s) it serves] to cope with potential disasters [5]. Blood transfusion is an important factor in reducing the number of casualties in disasters. Strong community response to disaster is triggered by socially embedded, disaster related altruism and sympathy in the general population. For instance, the publicity given to the volunteer blood donation and transfusion during World War II helped a lot to create a strong link in the public mind between the individual act of donating blood and the care of victims of war and disaster [7]. The blood banks should ensure that: – Facilities maintain inventories for disasters at all times in all locations. – Control collections made in response to a disaster are not in excess of actual need. – Clear message is sent to the community, donors, and the public regarding the collection of the blood supply (both locally and nationally) during a disaster. – Continuous disaster planning, including participation in disaster drills and close coordination with local, state, and federal response agencies is conducted. – Overall inventory management within the country, including a unified approach to communication among
3
blood facilities and transportation of blood and blood components during a disaster is entailed. Each blood establishment should plan, prepare and remain prepared for a disaster situation. The process of emergency management involves four phases: mitigation, preparedness, response, and recovery. In all four phases, the following key issues must be covered properly: – Leadership (including command, control and management structure) – Prioritization of activities – Communication – Maximizing and managing the available supply (including shortage management) – Donor safety and availability – Recipient safety and donor deferral – Financial resources assurance – Human resource safety and availability – Consumables and supply chain resilience – Equipment and infrastructure
3. Staff capacity building Continuous education and training of the blood establishment staff on the disaster plan, as well as active drills are necessary to ensure that planned response will run smoothly and will be managed properly. Upon hiring, and, at least, annually thereafter, each employee must be made aware of and trained in measures required to implement key elements of the national and internal disaster plan. The exercises should be followed by regular written knowledge assessments to ensure competency and to evaluate the course. The institution should schedule annual refresher training courses for all staff, along with regular disaster drills that include resource-sharing groups. The response plan should be centered at the blood bank/ establishment in the potential affected area that acts as a main medium for information sharing and communication [5]. The activation of the response plan is a step-bystep process. The affected blood establishment’s role is to evaluate the local medical needs of blood and to communicate this need to the blood supply coordination authority. This authority will then consider the magnitude of needed response and recommend an action strategy including, but not limited to the delivery of blood to the affected blood collector and the management and dissemination of a message to the national blood community and donors. The blood supply coordination authority facilitates coordination among national blood organizations, blood regularity authority, and regional, state, and local government bodies. This is necessary to decide the medical needs for blood, facilitate transportation of blood from one facility to another, and to communicate a common message to the national blood community and the public about the status of the blood supply in the disaster-affected area and the nation. Immediate shipment of required blood products will be from blood establishments with access to the most rapid means of transportation to the affected area. The
Please cite this article in press as: Hasan Abbas Zaheer, Usman Waheed, Blood transfusion service in disasters, Transfusion and Apheresis Science (2016), doi: 10.1016/j.transci.2016.09.007
ARTICLE IN PRESS 4
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blood supply coordination authority will reassess the needs 24 hours after the event (and daily as necessary) and may alter the strategy for meeting blood needs, depending on the circumstances [5]. Response to disasters has to be managed in phases. The following blood products are the most likely to be needed in each of the following phase of a disaster: – First 24 hours: Type O red blood cells (RBCs) – 1–10 days: RBCs (all ABO/Rh types) and platelets (Plts) – 11–30 days: RBCs, Plts, and (for radiologic incidents) stem cells and bone marrow
4. Managing voluntary donors during disasters In many developing countries including Pakistan, the national response to blood management in disasters often lacks proper coordination, e.g. in contrast to normal times, the response of the public toward voluntary blood donation is overwhelming when calamities strike. But in the absence of a proper donor management system, the true potential of the enthusiastic public response during crisis has not been harnessed to make the system safer and better prepared for disasters. Pakistan is a country still dependent on blood donations by the patient’s relatives. An increase in voluntary donors during disasters help to shift the responsibility for blood provision from patient’s relatives to the health care system itself and also discourage people from selling their blood. The origins of this family donation system may be found in cultural and ethnic backgrounds of groups of people who were used to see and care for – the health of – their own primary circle of families and friends. Blood safety depends on the quality of donors and their blood. The quality of the blood donors and their blood is directly dependent on the well informed donors who themselves take the decision to donate or not against a background of their knowledge about their behavior and their health. In case of disasters, people donate voluntarily and in high numbers. These donors present a high potential of becoming regular voluntary non-remunerated blood donors. Therefore, one of the national management strategies for these donors include converting them into regular voluntary nonremunerated donors and recruiting them for regular donations in the future. It is advisable that once a disaster has taken place, blood centers should stimulate strategies to manage donors and volunteers. The messages to the blood donors and local community through local media should be coordinated and assessed by the blood supply coordination authority. It is very vital to maintain frequent communication with waiting donors. Ensure that sufficient water, food, HVAC (heating, ventilation, air conditioning), and restroom facilities are available. Blood establishments, with appropriate and carefully prepared messages, should refrain blood donors from visiting blood centers in large numbers until there is a need assessment. However, they should be prepared to manage large crowds of blood donors as well as to react if blood donor shortage appears.
5. Consolidation of blood transfusion services in Pakistan after the 2005 Earthquake The frequency and gravity of disasters are steadily increasing and their characteristics are becoming multifaceted, rendering prevention and response more difficult. Because of the varying degree of each disaster, there are different mitigation strategies for each. Presently, Pakistan has been confronted with natural disasters such as earthquakes, floods, windstorms, droughts and cyclones. Disasters are not going to go away and there is no alternative but to focus on disaster risk reduction framework as a holistic approach. Therefore, during the last decade, the Government has accorded priority to disaster risk reduction. Emergencies and disaster situations require a rapid and timely response from the health services. Since the 2005 earthquake, the Government of Pakistan has promoted the development of activities to reduce vulnerability of the health sector to disasters and to strengthen emergency and disaster preparedness plans. Likewise, the disasters have underscored the importance of including the activities of blood transfusion services in the health sector’s emergency plans. In Pakistan, the National Disaster Management Commission was established at the Prime Minister Secretariat under the stewardship of the Prime Minister, and its executive arm is the National Disaster Management Authority [12]. Another body named National Health Emergency Preparedness and Response Network was established in 2010. It functions under the Cabinet Division and coordinates the national health response, including blood transfusion response to a disaster [1]. The Government of Pakistan initiated the blood safety system reforms on the internationally recommended model. A nationally coordinated blood transfusion service was introduced through support from the German government [13,14]. A network of regional blood centers and attached hospital blood banks has been established in the phase-I (completed in 2015). The phase-II (2016–2020) envisages consolidation and extension of services to cover regions not covered under phase-I. Recently, the Ministry of National Health Services, through the Safe Blood Transfusion Programme, revised the National Blood Policy and Strategic Framework (2014–20) which has identified Disaster Management as a priority area [15]. The Strategic Framework proposes to ‘formulate a disaster management team consisting of blood bank doctors and technicians at national, provincial level to ensure sufficient and timely supply of reagents /blood bags, etc. in emergency areas for safe supply of blood for transfusion during catastrophes’. 6. Role of media in blood management during disasters Globally, media has the opportunity of educating the people about disasters. They are supportive in the warning of hazards, and collecting, organizing and disseminating information about the areas affected. Media informs government and relief organizations about specific needs and facilitates response and management. The government officials, medical community and relief organizations need to coordinate with the media to
Please cite this article in press as: Hasan Abbas Zaheer, Usman Waheed, Blood transfusion service in disasters, Transfusion and Apheresis Science (2016), doi: 10.1016/j.transci.2016.09.007
ARTICLE IN PRESS H.A. Zaheer, U. Waheed / Transfusion and Apheresis Science ■■ (2016) ■■–■■
increase the effectiveness of relief efforts. In case a disaster has taken place, it is very important that the real need for blood is communicated to the general public. To communicate these needs to the existing donor base and potential new donors, blood banks should contact print and electronic reporters (if reporters are not already calling the blood bank) to provide them with an accurate, concise information. However, before talking to the media, blood banks should speak to and cooperate with the blood supply coordination authority to ensure that a consistent message is being delivered. Blood banks should have updated local media inventory (TV, newspapers, radio stations), delegate the spokesperson(s) and prepare drafts of press releases. A survey [4] showed that various media tools that are employed for donor recruitment and retention are: – Commercials on national and local television and radio – Advertising in national and local newspapers and magazines – Advertising on websites Altogether, 80% of the blood banks employ websites, local radio and local newspapers. More than half of the blood banks use national media channels and 40% use advertisements in magazines. The two relatively new methods are: – Collaboration with mobile phone companies for advertising; – Phoning people who have indicated their interest in donation by filling in a relevant Internet survey. 7. Conclusion Adequate and sufficient supply of blood components is an important part of emergency preparedness for disaster situations. It requires a robust and well developed blood supply system, trained workers and well-equipped storage facilities, combined with thoughtful, flexible, evidencebased, emergency planning and efficient cooperation between blood banks and civilian/military authorities. Managing donors, volunteers and crowds as well as working with the media are vital parts of the blood supply chain that
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should be especially carefully planned and enacted during disaster situations. As already discussed in previous sections, disasters are of many types and each specific disaster event can have different potential impacts on the blood supply. It is necessary, therefore, to create specific Disaster Operation Plans for some common hazards in the relevant region. It is therefore essential to create a paradigm shift from reactive approach of responding and calamity relief after the disaster to proactive approach of disaster prevention, preparedness, and mitigation. References [1] Zaheer HA. Blood management in disaster situations in Pakistan. ISBT Sci Ser 2012;7:1–5. [2] Schmidt PJ. Blood and disaster – supply and demand. N Engl J Med 2002;346:617–20. [3] Sönmezoglu M, Kocak N, Oncul O, Ozbayburtlu S, Hepgul Z, Kosan E, et al. Effects of a major earthquake on blood donor types and infectious diseases marker rates. Transfus Med 2005;15(2):93–7. [4] de Kort W, Veldhuizen I. Donor management manual. 2010. ISBN 978-90-815585-1-8. [5] The American Association of Blood Banks. Disaster operations handbook: coordinating the nation’s blood supply during disasters and biological events. Bethesda, MD: AABB; 2003. [6] Mujeeb SA, Jaffery SH. Emergency blood transfusion services after the 2005 earthquake in Pakistan. Emerg Med J 2007;24(1):22–4. [7] Hess JR, Thomas MJG. Blood use in war and disaster: lessons from the past century. Transfusion 2003;43:1622–33. [8] Okumura T, Suzuki K, Fukuda A, Kohama A, Takasu N, Ishimatsu S, et al. The Tokyo subway sarin attack: disaster management, Part 1: Community emergency response. Acad Emerg Med 1998;5(6):613–7. [9] U.S. Federal Bureau of Investigation. Amerithrax or Anthrax Investigation. [10] American Association of Blood Banks. Technical Manual. 17th ed. Bethesda, MD: American Association of Blood Banks (AABB); 2011 [Chapter 4]. ISBN 978-1563953156. [11] Linden JV, Davey RJ, Burch JW. The September 11, 2001 disaster and the New York blood supply. Transfusion 2002;42:1385–7. [12] National Disaster Management Authority, Pakistan. http:// www.ndma.gov.pk/ [accessed 24.01.16]. [13] Zaheer HA, Waheed U. Blood safety system reforms in Pakistan. Blood Transfus 2014;12(4):452–7. [14] Zaheer HA, Waheed U. Legislative reforms of the blood transfusion system in Pakistan. Transfus Med 2014;24(2):117–9. [15] National Blood Policy & Strategic Framework (2014-20). Safe Blood Transfusion Programme, Government of Pakistan.
Please cite this article in press as: Hasan Abbas Zaheer, Usman Waheed, Blood transfusion service in disasters, Transfusion and Apheresis Science (2016), doi: 10.1016/j.transci.2016.09.007
Contents lists available at ScienceDirect
Transfusion and Apheresis Science j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / t r a n s c i
Review
Blood transfusion service in disasters Hasan Abbas Zaheer *, Usman Waheed Safe Blood Transfusion Programme, Ministry of National Health Services, Government of Pakistan, Pakistan
Contents 1.
2. 3. 4. 5. 6.
Types of disasters and its impact on BTS ....................................................................................................................................................................... 1.1. Earthquake ................................................................................................................................................................................................................... 1.2. Floods ............................................................................................................................................................................................................................. 1.3. Terrorism ...................................................................................................................................................................................................................... 1.4. Biological event .......................................................................................................................................................................................................... Response plan ........................................................................................................................................................................................................................... Staff capacity building ........................................................................................................................................................................................................... Managing voluntary donors during disasters ............................................................................................................................................................... Consolidation of blood transfusion services in Pakistan after the 2005 Earthquake ...................................................................................... Role of media in blood management during disasters .............................................................................................................................................. References ..................................................................................................................................................................................................................................
National response to disasters is managed well in countries with a developed healthcare system and a centrally coordinated blood transfusion system. However, in countries without an integrated healthcare system and a fragmented blood transfusion system, the national response to blood management in disasters is patchy, insufficient and lacks proper coordination [1]. Blood banking plays a crucial role in providing health care services in disasters. It is, however, vital to note that natural disasters normally may not generate an urgent need for blood [2]. Floods and earthquakes disrupt the transportation system and damage the healthcare infrastructure. The refugees are housed in temporary camps with inadequate healthcare facilities and burden the existing local healthcare infrastructure. Transfusion needs in such settings generally remain neglected and unmet and especially pose risks to safe motherhood. It is very crucial to sensitize and familiarize both health authorities and blood bank personnel to their
* Corresponding author. Safe Blood Transfusion Programme, Ministry of National Health Services, Government of Pakistan, Pakistan. Fax: 0092 51 9263238. E-mail address: [email protected] (H.A. Zaheer).
2 2 2 2 2 2 3 4 4 4 5
roles and duties in disaster situations. The single greatest risk of disasters is the disruption of delivery system and not the actual shortage of blood. The critical aspect is to ensure that policies and procedures for emergency and extraordinary release are present and can be put into practice whenever required to meet the urgent demand of blood. Wastage of blood often occurs during disasters [3]. However, the real challenge in disasters especially in developing countries occurs due to disruption of articulations related to the following areas: – – – –
Health infrastructure Transportation system Overall available blood stocks in blood bank or hospitals Determination of the magnitude and exact nature of the calamity – Expected number of emergency hospital admissions In the context of blood supply, the term ‘disaster’ refers to special characteristic events leading to the below mentioned needs [4]. – Suddenly requiring a much larger quantities of blood than usual.
http://dx.doi.org/10.1016/j.transci.2016.09.007 1473-0502/© 2016 Published by Elsevier Ltd.
Please cite this article in press as: Hasan Abbas Zaheer, Usman Waheed, Blood transfusion service in disasters, Transfusion and Apheresis Science (2016), doi: 10.1016/j.transci.2016.09.007
ARTICLE IN PRESS H.A. Zaheer, U. Waheed / Transfusion and Apheresis Science ■■ (2016) ■■–■■
2
– Temporarily restricting or seriously affecting a blood bank’s ability to collect, test, process, and distribute blood. – Temporarily restricting or preventing the local population from donating blood, or restricting or preventing the use of the available inventory of blood products; this situation requires immediate replacement or resupply of the region’s blood inventory from another region. – An unexpected influx of donors, requiring accelerated drawing of blood to meet an emergent need elsewhere [5]. Heavy workload, collapsed infrastructure, failure of basic amenities and loss of technical human resources make relief efforts, including blood transfusion services, a gargantuan task. Most of the times, the disasters are inherently local and need urgent delivery of blood and blood products from blood banks or blood collection sites having proper logistic support to transport blood to the affected area. In a disaster, the coordination between the hospitals and blood banks in the affected area should be optimal. The assessment of immediate (i.e., within the first 24 hours) and short term need for blood is the responsibility of the hospital which then communicate that information to the affected blood bank. Assessing the actual blood transfusion needs is a prerequisite and a very crucial step. Initial estimates of blood requirements in an earthquake are often exaggerated [6]. The requirements for blood in large disasters are mainly calculated from the number of people injured who survived long enough to be presented for care and the amount of blood used in providing that care [7]. A complete list of all consumable materials and vendors who can supply them should be readily available.
1. Types of disasters and its impact on BTS
1.3. Terrorism A huge blast from an accidental industrial explosion, military or flammable-material source or an intentional terrorist or criminal bomb can cause high immediate mortality. Survivors would require revival and surgery with associated transfusion support. Local inventories of blood components would need assessment for adequacy and augmentation. Large influx of blood donors are often witnessed after such unpleasant events and coordinated public announcements about the blood supply are helpful to achieve the appropriate balance between supply and demand [4]. 1.4. Biological event The use of a biological agent poses the greatest threat to the collection of blood products. Depending on the type of agent involved in the event, staff, volunteers, and blood donors may be infected; facilities and vehicles may be contaminated; donors may have to be deferred. In recent years, the world has experienced the ‘sarin gas’ attack in Japan [8] and the multiple anthrax incidents in the United States [9], and the effects of those attacks, including use of prophylaxes, public fear, and long-term decontamination of facilities. Disasters can also affect donor eligibility criteria, particularly emergencies involving any potential infectious diseases or hazardous chemicals. The causative agent should be identified and measures taken to prevent its 1) transmission through blood transfusion, 2) potential to harm recipients, and 3) any asymptomatic period after exposure and before or after the actual disease period when the donor may be infectious. If any agent is considered to be transmissible, a deferral period that ensures an adequate safety period from infectivity or adverse effect must be determined, and donors must be deferred appropriately [10].
1.1. Earthquake
2. Response plan
Earthquakes directly affect the blood supply. Blood usage may not be much initially, but the event could significantly obstruct transportation activities if a huge area is inaccessible. Hospitals should provisionally postpone elective surgeries, followed by a spike in such surgeries once all processes are back to normal. To guarantee quick progress in normalizing the situation, the blood establishments should form special preparations (supplies, power supply, staff, transportation, etc.). The maintenance of cold chain is also essential.
The response plan is dependent on the blood bank in the affected area where it could act like the main medium for information flow and communication. The affected blood bank’s role is to assess the local medical requirements of blood and to communicate this need to the national/local health authority which will then recommend an action strategy including the coordination and dissemination of a message to the National Blood Programmes and Blood Donor Organizations. In a response to disaster situation, it is important that blood bank should ensure the following measures:
1.2. Floods
– Blood bank staff must be familiar with the hospital/ center disaster plan. – SOPs related to hospital disaster plan are developed. – Adequate facilities to keep and maintain 3-day supply of blood products, which may need to be expanded up to a 7-day supply. – After a disaster, the public usually responds by volunteering to donate large quantities of blood than needed, so there must be guidelines to smoothly entertain the increased donor influx.
In a flooded area, the impact may be undersized, but can also be destructive. The blood delivery may experience small or no impact unless the blood establishment or its hospitals themselves are flooded. Citizens may volunteer in large numbers to donate to help the victims, which may result in a donor rush. If the blood center is flooded, emergency evacuation should be carried out to guarantee the protection of staff and the blood components.
Please cite this article in press as: Hasan Abbas Zaheer, Usman Waheed, Blood transfusion service in disasters, Transfusion and Apheresis Science (2016), doi: 10.1016/j.transci.2016.09.007
ARTICLE IN PRESS H.A. Zaheer, U. Waheed / Transfusion and Apheresis Science ■■ (2016) ■■–■■
– Increased resources (personnel, equipment, and supplies) are sometimes allocated for collecting and processing blood which may not be required and center may be unable to process and distribute available and urgently needed products to centers which require them. – There should be separate slot of trained, educated and skilled blood bank professionals within treating facilities to handle such situation. Historically, most disasters require relatively few units of blood for transfusions; however, the public response to disasters has traditionally resulted in abrupt increase in blood donations regardless of the true medical need for transfusions. Therefore, quality and safety of blood products are other vital topics of concern in the disaster affected area. In emergency situations, blood banks are sometimes more concerned with the quantities rather than the safety of the procedure. This happens because emergency management personnel are often unaware of issues related to the collection, processing, storage, and distribution of blood and blood components. As blood collected in response to the disaster takes more time to process, it is crucial for the local blood supply to remain at sufficient levels to treat victims of potential hazards as defined in the organizational risk assessment. Attempts should be made to determine the true medical need for blood during a disaster and to convey this need to organizations within the blood community (BDOs), to blood donors, and to the public through a clear and consistent communication strategy [2,7,11]. The personnel or authority who is authorized to make public appeals for blood donation should be identified and must coordinate with people in the field who are involved in making the needs assessment. The AABB Disaster Task Force recommends maintaining a 5- to 7-day supply [combined inventory at the blood collector and hospital(s) it serves] to cope with potential disasters [5]. Blood transfusion is an important factor in reducing the number of casualties in disasters. Strong community response to disaster is triggered by socially embedded, disaster related altruism and sympathy in the general population. For instance, the publicity given to the volunteer blood donation and transfusion during World War II helped a lot to create a strong link in the public mind between the individual act of donating blood and the care of victims of war and disaster [7]. The blood banks should ensure that: – Facilities maintain inventories for disasters at all times in all locations. – Control collections made in response to a disaster are not in excess of actual need. – Clear message is sent to the community, donors, and the public regarding the collection of the blood supply (both locally and nationally) during a disaster. – Continuous disaster planning, including participation in disaster drills and close coordination with local, state, and federal response agencies is conducted. – Overall inventory management within the country, including a unified approach to communication among
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blood facilities and transportation of blood and blood components during a disaster is entailed. Each blood establishment should plan, prepare and remain prepared for a disaster situation. The process of emergency management involves four phases: mitigation, preparedness, response, and recovery. In all four phases, the following key issues must be covered properly: – Leadership (including command, control and management structure) – Prioritization of activities – Communication – Maximizing and managing the available supply (including shortage management) – Donor safety and availability – Recipient safety and donor deferral – Financial resources assurance – Human resource safety and availability – Consumables and supply chain resilience – Equipment and infrastructure
3. Staff capacity building Continuous education and training of the blood establishment staff on the disaster plan, as well as active drills are necessary to ensure that planned response will run smoothly and will be managed properly. Upon hiring, and, at least, annually thereafter, each employee must be made aware of and trained in measures required to implement key elements of the national and internal disaster plan. The exercises should be followed by regular written knowledge assessments to ensure competency and to evaluate the course. The institution should schedule annual refresher training courses for all staff, along with regular disaster drills that include resource-sharing groups. The response plan should be centered at the blood bank/ establishment in the potential affected area that acts as a main medium for information sharing and communication [5]. The activation of the response plan is a step-bystep process. The affected blood establishment’s role is to evaluate the local medical needs of blood and to communicate this need to the blood supply coordination authority. This authority will then consider the magnitude of needed response and recommend an action strategy including, but not limited to the delivery of blood to the affected blood collector and the management and dissemination of a message to the national blood community and donors. The blood supply coordination authority facilitates coordination among national blood organizations, blood regularity authority, and regional, state, and local government bodies. This is necessary to decide the medical needs for blood, facilitate transportation of blood from one facility to another, and to communicate a common message to the national blood community and the public about the status of the blood supply in the disaster-affected area and the nation. Immediate shipment of required blood products will be from blood establishments with access to the most rapid means of transportation to the affected area. The
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blood supply coordination authority will reassess the needs 24 hours after the event (and daily as necessary) and may alter the strategy for meeting blood needs, depending on the circumstances [5]. Response to disasters has to be managed in phases. The following blood products are the most likely to be needed in each of the following phase of a disaster: – First 24 hours: Type O red blood cells (RBCs) – 1–10 days: RBCs (all ABO/Rh types) and platelets (Plts) – 11–30 days: RBCs, Plts, and (for radiologic incidents) stem cells and bone marrow
4. Managing voluntary donors during disasters In many developing countries including Pakistan, the national response to blood management in disasters often lacks proper coordination, e.g. in contrast to normal times, the response of the public toward voluntary blood donation is overwhelming when calamities strike. But in the absence of a proper donor management system, the true potential of the enthusiastic public response during crisis has not been harnessed to make the system safer and better prepared for disasters. Pakistan is a country still dependent on blood donations by the patient’s relatives. An increase in voluntary donors during disasters help to shift the responsibility for blood provision from patient’s relatives to the health care system itself and also discourage people from selling their blood. The origins of this family donation system may be found in cultural and ethnic backgrounds of groups of people who were used to see and care for – the health of – their own primary circle of families and friends. Blood safety depends on the quality of donors and their blood. The quality of the blood donors and their blood is directly dependent on the well informed donors who themselves take the decision to donate or not against a background of their knowledge about their behavior and their health. In case of disasters, people donate voluntarily and in high numbers. These donors present a high potential of becoming regular voluntary non-remunerated blood donors. Therefore, one of the national management strategies for these donors include converting them into regular voluntary nonremunerated donors and recruiting them for regular donations in the future. It is advisable that once a disaster has taken place, blood centers should stimulate strategies to manage donors and volunteers. The messages to the blood donors and local community through local media should be coordinated and assessed by the blood supply coordination authority. It is very vital to maintain frequent communication with waiting donors. Ensure that sufficient water, food, HVAC (heating, ventilation, air conditioning), and restroom facilities are available. Blood establishments, with appropriate and carefully prepared messages, should refrain blood donors from visiting blood centers in large numbers until there is a need assessment. However, they should be prepared to manage large crowds of blood donors as well as to react if blood donor shortage appears.
5. Consolidation of blood transfusion services in Pakistan after the 2005 Earthquake The frequency and gravity of disasters are steadily increasing and their characteristics are becoming multifaceted, rendering prevention and response more difficult. Because of the varying degree of each disaster, there are different mitigation strategies for each. Presently, Pakistan has been confronted with natural disasters such as earthquakes, floods, windstorms, droughts and cyclones. Disasters are not going to go away and there is no alternative but to focus on disaster risk reduction framework as a holistic approach. Therefore, during the last decade, the Government has accorded priority to disaster risk reduction. Emergencies and disaster situations require a rapid and timely response from the health services. Since the 2005 earthquake, the Government of Pakistan has promoted the development of activities to reduce vulnerability of the health sector to disasters and to strengthen emergency and disaster preparedness plans. Likewise, the disasters have underscored the importance of including the activities of blood transfusion services in the health sector’s emergency plans. In Pakistan, the National Disaster Management Commission was established at the Prime Minister Secretariat under the stewardship of the Prime Minister, and its executive arm is the National Disaster Management Authority [12]. Another body named National Health Emergency Preparedness and Response Network was established in 2010. It functions under the Cabinet Division and coordinates the national health response, including blood transfusion response to a disaster [1]. The Government of Pakistan initiated the blood safety system reforms on the internationally recommended model. A nationally coordinated blood transfusion service was introduced through support from the German government [13,14]. A network of regional blood centers and attached hospital blood banks has been established in the phase-I (completed in 2015). The phase-II (2016–2020) envisages consolidation and extension of services to cover regions not covered under phase-I. Recently, the Ministry of National Health Services, through the Safe Blood Transfusion Programme, revised the National Blood Policy and Strategic Framework (2014–20) which has identified Disaster Management as a priority area [15]. The Strategic Framework proposes to ‘formulate a disaster management team consisting of blood bank doctors and technicians at national, provincial level to ensure sufficient and timely supply of reagents /blood bags, etc. in emergency areas for safe supply of blood for transfusion during catastrophes’. 6. Role of media in blood management during disasters Globally, media has the opportunity of educating the people about disasters. They are supportive in the warning of hazards, and collecting, organizing and disseminating information about the areas affected. Media informs government and relief organizations about specific needs and facilitates response and management. The government officials, medical community and relief organizations need to coordinate with the media to
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increase the effectiveness of relief efforts. In case a disaster has taken place, it is very important that the real need for blood is communicated to the general public. To communicate these needs to the existing donor base and potential new donors, blood banks should contact print and electronic reporters (if reporters are not already calling the blood bank) to provide them with an accurate, concise information. However, before talking to the media, blood banks should speak to and cooperate with the blood supply coordination authority to ensure that a consistent message is being delivered. Blood banks should have updated local media inventory (TV, newspapers, radio stations), delegate the spokesperson(s) and prepare drafts of press releases. A survey [4] showed that various media tools that are employed for donor recruitment and retention are: – Commercials on national and local television and radio – Advertising in national and local newspapers and magazines – Advertising on websites Altogether, 80% of the blood banks employ websites, local radio and local newspapers. More than half of the blood banks use national media channels and 40% use advertisements in magazines. The two relatively new methods are: – Collaboration with mobile phone companies for advertising; – Phoning people who have indicated their interest in donation by filling in a relevant Internet survey. 7. Conclusion Adequate and sufficient supply of blood components is an important part of emergency preparedness for disaster situations. It requires a robust and well developed blood supply system, trained workers and well-equipped storage facilities, combined with thoughtful, flexible, evidencebased, emergency planning and efficient cooperation between blood banks and civilian/military authorities. Managing donors, volunteers and crowds as well as working with the media are vital parts of the blood supply chain that
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should be especially carefully planned and enacted during disaster situations. As already discussed in previous sections, disasters are of many types and each specific disaster event can have different potential impacts on the blood supply. It is necessary, therefore, to create specific Disaster Operation Plans for some common hazards in the relevant region. It is therefore essential to create a paradigm shift from reactive approach of responding and calamity relief after the disaster to proactive approach of disaster prevention, preparedness, and mitigation. References [1] Zaheer HA. Blood management in disaster situations in Pakistan. ISBT Sci Ser 2012;7:1–5. [2] Schmidt PJ. Blood and disaster – supply and demand. N Engl J Med 2002;346:617–20. [3] Sönmezoglu M, Kocak N, Oncul O, Ozbayburtlu S, Hepgul Z, Kosan E, et al. Effects of a major earthquake on blood donor types and infectious diseases marker rates. Transfus Med 2005;15(2):93–7. [4] de Kort W, Veldhuizen I. Donor management manual. 2010. ISBN 978-90-815585-1-8. [5] The American Association of Blood Banks. Disaster operations handbook: coordinating the nation’s blood supply during disasters and biological events. Bethesda, MD: AABB; 2003. [6] Mujeeb SA, Jaffery SH. Emergency blood transfusion services after the 2005 earthquake in Pakistan. Emerg Med J 2007;24(1):22–4. [7] Hess JR, Thomas MJG. Blood use in war and disaster: lessons from the past century. Transfusion 2003;43:1622–33. [8] Okumura T, Suzuki K, Fukuda A, Kohama A, Takasu N, Ishimatsu S, et al. The Tokyo subway sarin attack: disaster management, Part 1: Community emergency response. Acad Emerg Med 1998;5(6):613–7. [9] U.S. Federal Bureau of Investigation. Amerithrax or Anthrax Investigation. [10] American Association of Blood Banks. Technical Manual. 17th ed. Bethesda, MD: American Association of Blood Banks (AABB); 2011 [Chapter 4]. ISBN 978-1563953156. [11] Linden JV, Davey RJ, Burch JW. The September 11, 2001 disaster and the New York blood supply. Transfusion 2002;42:1385–7. [12] National Disaster Management Authority, Pakistan. http:// www.ndma.gov.pk/ [accessed 24.01.16]. [13] Zaheer HA, Waheed U. Blood safety system reforms in Pakistan. Blood Transfus 2014;12(4):452–7. [14] Zaheer HA, Waheed U. Legislative reforms of the blood transfusion system in Pakistan. Transfus Med 2014;24(2):117–9. [15] National Blood Policy & Strategic Framework (2014-20). Safe Blood Transfusion Programme, Government of Pakistan.
Please cite this article in press as: Hasan Abbas Zaheer, Usman Waheed, Blood transfusion service in disasters, Transfusion and Apheresis Science (2016), doi: 10.1016/j.transci.2016.09.007