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Collection of blood from regular voluntary non-­remunerated blood donors is one of the key strategies for blood safety promoted by the World Health Organization (WHO).[1] The Malawi Ministry of Health adopted this strategy and established the Malawi Blood Trans­fusion Service (MBTS) in 2004 as an independent nationally coordinated blood transfusion service based on voluntary non-remunerated blood donation.[2] Blood collections have increased 12 fold in 12 years from 5000 in 2004 to 60,000 in 2016 (Figure 1). This is commendable progress considering that promoting voluntary unpaid blood donation started during a time when Malawi was awash with myths and rumours of blood suckers. However, these collections still fall short of the 120,000 national blood collections needed by about half and consti­tute about 64% of all blood that is collected nationally, highlighting a chronic national blood shortage.[3] The remaining 36% of blood trans­fusions are emergency donations in hospitals.
This article aims to share the Ma­lawi experience in supplying safe blood. It describes the country, the Malawi Blood Transfusion Service, some successes, and the challenges that still remain.

Malawi is a densely populated Southern African country with a 2016 estimated population of 17.1 million, 84% of whom live in rural areas.[4] Life expectancy at birth was estimated at 63.9 for both sexes in 2017].[5] Malawi’s 2015 Gross Do­mestic Product (GDP) was USD 381.40 per capita.[6] The economy is predomi­nantly agro-based.[7] In 2016, the mater­nal mortality ratio was 439/100,000 live births and the under-five mortality rate was 63/1000. HIV prevalence was 8.8% in men and women aged 15-49 years while the national prevalence of hepa­titis B and hepatitis C is unknown.[8]

The Government of Malawi (GoM) pro­vides healthcare to 70% of the popula­tion, the Christian Health Association of Malawi (CHAM) to 29%, and the re­mainder is provided by private hospitals and non-governmental organizations (NGOs).[9] Services provided by GoM in­stitutions do not charge user fees while CHAM and NGOs charge subsidized fees and private facilities charge market-­based fees. There are four tiers of health service provision, namely those respon­sible for provision of community, pri­mary level, secondary level, and tertiary level services. Blood transfusion services are provided at secondary and tertiary level health care facilities. In total, there are 88 such facilities nationally.[9]

Establishment of the malawi blood transfusion service

The Malawi Blood Transfusion Service (MBTS) was established by the Min­istry of Health in 2004 as an inde­pendent nationally coordinated blood transfusion service based on voluntary non-remunerated blood donation. It is registered as a welfare trust with a board of trustees that is appointed by the Minister of Health of Malawi. Of its four centres, two are located in the southern region and one each in the central and northern regions. The headquarters is in Blantyre, Southern Region. All centres are responsible for blood collection and blood distribu­tion. Three of the four centres also make blood components as follows: adult and paediatric red cell suspen­sions, fresh frozen plasma, cryopre­cipitate, and platelet concentrates. Some blood is issued as whole blood.

Screening

Donated blood is screened for HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), syphilis and malaria. The following markers are screened for using enzyme immunoassays: HIV (an­tibodies to HIV I & II and p24 antigen); HBV (HBsAg); HCV (anti-HCV antibod­ies). The Treponema Pallidum Hae­magglutination Assay (TPHA) is used for syphilis screening while thick film microscopy is used for malaria screen­ing. The seroprevalence for HIV, HBV, HCV and syphilis in the blood donor population has decreased between 2011 and 2015 (where comprehensive data is available). The seroprevalence for 2011 and 2015, respectively, was: HIV 3.5% and 1.9%; HBV 4.7% and 3.5%; HCV 2.4% and 1%, syphilis 3.2% and 2.3%.[10]

The prevalence of malaria in 2015 was 0.9% (unknown for 2011). The test kits and algorithm remained the same over this period. Testing is centralized and takes place at the headquarters in Blantyre (Figure 2).

Collection of blood

Blood is collected from all communities across Malawi, which include schools, colleges, workplaces, places of worship and markets. Since 2015, a new initiative was introduced to target the large rural population by collecting blood from villages (Figure 3). In all these com­munities, blood donation is preceded by a motivational talk which educates blood donors about blood donation but also motivates them to become blood donors. There are also radio and televi­sion adverts and programs on blood donation. Regular blood donors are recognized with milestone awards such as T-shirts, head caps, certificates and golf shirts depending on the number of donations made, with golf shirts being given to those who have made at least 25 blood donations. There is also the Blood Donor Association of Malawi (BDAM) and its youth wing the Malawi Club 25. The Chairperson of BDAM is an ex-officio member of the Board of Trustees of the MBTS. Club 25 members are enrolled when they are between 16 and 25 years old. They pledge to donate at least 25 blood units in their lifetime.

Figure 1 Number of blood collections since establishment of the MBTS
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On average, about 40,000 [2011-2015 range of 37,111-41,728] people donate blood each year. The blood donor population is young [median age of 19 years; range 16-65 years], and 80% are 25 years or younger. Amongst all blood donors, 72% are stu­dents, 87% are not married and 80% are male.[10] Young males in Malawi have the lowest prev­alence of HIV (1% for males aged 15-24 years compared to 4.9% for girls of the same age group and a national average of 8.8% for adults 15-49 years old).[11] Repeat blood donation rates have been declining from 58% in 2011 to 51% in 2015. The reason for this is unclear.[10] The low number of people donating blood, the declining propor­tion of repeat blood donors, and the reli­ance on young student blood donors are some of the challenges that contribute to not meeting annual blood needs and severe blood shortages during school holidays. Female blood donors have half the hepatitis B risk of male blood donors (adjusted odds ratio 0.51, CI 0.43-0.60); for males, traditional circumcision and shaving in barbershops are thought to possibly play a role here.[10] As hepatitis B has the highest prevalence in the blood donor population of all diseases screened for, understanding the factors responsible for the high risk of hepatitis B in males can help devise interventions that protect the predominantly young male blood donor population from ac­quiring hepatitis B and thereby help sus­tain increased blood donation levels in this population. Hopefully, the universal vaccination for HBV that started in 2005 will have a major impact over time.

HOTLINE 0888 206 931
MALAWI BLOOD TRANSFUSION SERVICE
THE O’DALA CENTRE
Give Blood. Save Lives
Cell: 0888 206 931 Tel: 01 879 522 / 669
FUNDED BY EUROPEAN DEVELOPMENT FUND

Funding

The MBTS was initially established with a 9.36 million euro grant from the European Union. This grant came to an end in 2006. Unlike other cases where projects were not sustained beyond project funding, MBTS continued to not only exist after this funding stopped but actually expanded its operations from collecting about 24,000 units of blood in 2006 to more than double that amount within 10 years. Further funding comes from the Global Fund to Fight Tuberculosis, AIDS and Malaria (GFTAM), the Presi­dential Emergency Plan for AIDS Relief (PEPFAR) through the Centres for Disease Control and Prevention (CDC), and from a cost recovery mechanism where hospitals are billed for blood units supplied. Cost recovery in the health sector started in 2007 with private hospitals only and was later expanded to cover all hospitals from 2009. By 2016, cost recovery was fund­ing 54% of the USD 3.14 million MTBS annual budget, while the contribution by PEPFAR was 29% and GFTAM 17%. The dependence on external support is still significant and poses a risk to the sustainability of the blood services.

Conclusion

It is possible to improve the micro­biological safety of the national blood supply and to provide blood through a centralized national blood service in a developing country. A high burden of hepatitis in the young male population who seem to have selected themselves for blood donation based on their low risk for HIV needs to be addressed. Reliance on external funding, a young blood donor population, and low blood donation per capita remain challenges that need to be addressed to improve accessibility to safe blood supplies.

References

  1. World Health Organization; Blood Safety Aide-Memoire for National Health Programmes [accessed on 1 July 2016] available from www.who.int/bloodsafety/transfusion_services/en/Blood_Safety_Eng.pdf
  2. Ministry of Health, the National Blood Policy, Lilongwe, Malawi, 2012.
  3. Njolomole S.E, M’baya B, Ndhlovu D, Mfune T, Yonamu F, Phiri P, Kalonjeka B (2017). Post baseline situational analysis of blood safety in Malawi (accessed on 1 November 2017) from www.mbtsmalawi.com.
  4. National Statistical Office. Popula­tion Projections. Malawi, 2016.
  5. United Nations Development Program. Hu­man development Report 2016. [Accessed on on 1 November 1, 2017] from hdr.undp.org/sites/default/files/2016_human_development_report.pdf
  6. Audit Report – Global Fund Grants for Malawi, October 2016.
  7. National Accounts and Balance of Payments Technical Committee, Ministry of Finance, Economic Planning and Development and Na­tional Statistics Office, September 2016.
  8. World Health Organization. Global Bur­den of Disease Geneva, 2013.
  9. Government of the Republic of Malawi. Health Sec­tor Strategic Plan II 2017-2022: Towards Univer­sal Health Coverage. Lilongwe, Malawi, 2017.
  10. M’baya B, Jumbe V, Samuel V, M’bwana R, Mangani R. (2017). Seroprevalence and trends in transfu­sion transmissible infections among voluntary non-remunerated blood donors at the Malawi Blood Transfusion Service (unpublished data).
  11. National Statistical Office (NSO) and ICF. Malawi Demographic and Health Survey 2015-16. Zomba, Malawi, and Rockville, Maryland, USA, 2017.