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Executive summary.

Understanding how communicable diseases spread is key to controlling them. Blood transfusions are a small contributor to communicable disease transmission compared to other well-reported modes, but ensuring the safety of the blood supply in a health system is largely within the purview of national governments.

Until recently, little was known about blood transfusion systems in Central Asia and their contribution to disease transmission. The World Bank and the Central Asian Regional Office of the United States Centers for Disease Control and Prevention (CDC/CAR) collaborated to shed light on the workings of these systems. With the permission and collaboration of the Central Asian countries' Ministries of Health, and under a co-financing arrangement with the World Bank, CDC/CAR re-screened blood samples from 7,500 blood donors in Central Asian countries in 2007. These re-screenings revealed the risk that contaminated blood may be reaching health facilities for administration to unsuspecting patients by unsuspecting doctors. This is alarming given that transfusion of HIV-infected blood is the most efficient means of transmission: about 100 times more efficient than intravenous drug injection with a contaminated syringe (according to available evidence, risk of HIV transmission through blood transfusion is 9,250 per 10,000 exposures to an infected source).

The report discusses inter-related parts of blood transfusions systems, and presents an overview of the parts that need to be strengthened in Central Asia. Numerous parts are in serious need of organizational restructuring, new investment and increased budgetary support for operation and maintenance. This report sets them out such that each can be addressed in turn--and some simultaneously. The report also discusses the health threat posed by alarmingly low levels of blood supplies, fostered by a culture that places little value on donating blood, public fear of being infected by giving blood, and the near absence of donor promotion campaigns.

Evaluating communicable diseases rates in blood donors is essential for monitoring the safety of the blood supply and donor screening effectiveness. This assessment found that the current screening for blood borne pathogens of donated blood in Central Asia may be providing a false sense of security--the risk of receiving an infected blood unit and acquiring a transfusion-transmitted infection in the countries of the region is real. More ominous is the fact that some health facilities in Central Asia do not test blood donations at all. This means that the transmission risks indicated in this study may be conservative estimates, as they are based on a sample that excludes the blood that never reaches the existing screening system.

The blood sample re-testing identified cases of HIV that had been undetected by the blood center laboratories that originally tested these samples. These cases included HIV-infected blood units that reached health facilities; other units found positive for viral hepatitis B and C had been discarded. The re-testing found prevalence of communicable diseases in the blood samples to be 0.20 percent for HIV, 2.7 percent for hepatitis B, 3.0 percent for hepatitis C, and 3.6 percent for syphilis. ALT tests were also performed as back-up check for the potential "window" infection stage (when markers for the disease could not be detected. Elevated ALT is a "red flag for liver dysfunction, generated by viral infections, drug or alcohol abuse). A prevalence of 8.6 percent for ALT elevation was found, signaling potential residual risk of transmission of viral diseases during the window stage. These findings underscore the need to strengthen screening of blood donors on the occasion of each donation and other prevention and control measures to guarantee the safety of the blood supply in the health systems of the Central Asia countries, and reduce the risk of involuntary infection to the unsuspecting population. The information generated by this assessment may serve as an initial baseline for future assessments.

Results disaggregated by country are not presented due to their sensitive nature, but they were conveyed by the CDC/CAR team to high-level authorities of the Ministries of Health in the participating countries as soon as they became available in 2007, as was done in past years with the results of related assessments. The Ministries' early response was to adopt several measures with the support of international organizations, as follows:

* Legal and regulatory measures have been issued and adopted in some countries.

* Blood centers that did not use questionnaires to identify behavioral risk factors among potential donors are now starting to use them.

* New laboratory equipment has been installed in two republican blood centers.

* Blood centers that used re-usable vials have started using disposable bags; they are also using more-reliable test-kits.

* Training workshops have been organized on blood safety for laboratory quality control, blood safety for epidemiologists, and blood banking and use for medical personnel. Also, full courses have been conducted in these countries for epidemiologists and blood service specialists.

* Additionally, national guidelines on the use of blood are now being revised.

Further improvements are recommended in this report, including revising policies and national level coordination of blood services, shifting to 100 percent unpaid blood donors, implementing blood donation campaigns, creating related information systems and standardized databases on blood donors and donated blood, raising budgets for blood transfusion services, improving infrastructure and equipment and related materials, developing centralized procurement systems and guidelines for procurement, ensuring that blood and its products are used rationally, implementing quality assurance and control systems within all parts of the blood transfusion service, and improving communication and collaboration at the regional level.

Controlling blood transmitted communicable diseases and ensuring appropriate blood supplies are key public health issues in Central Asia. Ensuring blood supply safety, however, is a particularly difficult challenge in countries with a low national income level and weak health care systems. As argued here and fully consistent with the health improvement and poverty alleviation objectives of World Bank work in the health sector, efforts to address the systemic deficiency of blood transfusion services in Central Asia should be part of broader health system strengthening programs and activities that need to be supported by national governments and the international community. It is expected therefore that this report will contribute to advance health system reforms in Central Asia and beyond.
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Publication:Blood Services In Central Asian Health Systems: A Clear and Present Danger of Spreading HIV/AIDS and
Date:May 1, 2008
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