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BLOOD TRANSFUSION AND THE TRAVELLERby Colonel Michael JG Thomas, MA, MB, FRCP (Edin), DTM&H If you are travelling overseas on business, or are taking a well-earned
holiday, and you are involved in an accident, the treatment of which requires a
blood transfusion, would you know whether the blood provided in that particular
country met the standards of your national transfusion service? Problems The problems with having a transfusion overseas fall into three groups.
These are availability, transfusion transmitted diseases and testing of blood
donations. Availability In many countries there is always an acute shortage of blood, far worse
than anything we ever have to face in Europe. One way in which some countries
solve this problem is to require relatives to come forward and donate blood. It
is unlikely that sufficient members of your family, who also have the correct
blood group, to cover your needs, will accompany you. In addition, when there
are such acute shortages, there is also the ethical problem as to whether it is
right for a relatively affluent traveller, who has other options for obtaining
blood, to use up a local resource, thereby depriving a local resident whose
need may be greater. Transfusion transmitted diseases In many parts of the world the incidence of the common transfusion
transmitted diseases, such as HIV and hepatitis, is as much as 100 times higher
than in the UK. This means that a donated unit of blood is much more likely to
be infected. As the incidence is higher, the chances that an individual is in
the early stage of a particular disease are increased. In such a situation the
donor is in, what is commonly known as, the "Window Period". In
simple terms, this means that, although the screening test has yet to become
positive, the unit of blood is infected and would transmit the disease to a
recipient. In addition, in some parts of the world there are prevalent diseases which
do not occur in Europe, but which can be transmitted by blood transfusion.
Examples of such diseases are malaria, Leishmaniasis, Chagar's disease and
filariasis. Testing In many countries, the health budget is insufficient to allow units of
donated blood to be fully tested. If they are tested, frequently the test kits
used are of a lesser quality than those we would use in the UK. Although the
incidence of these problems will vary as to whether you are an expatriate, a
business traveller or a tourist, the basic precautions are common to all. Basic Points
Avoidance There is an old saying that "The best blood transfusion is no blood
transfusion". This is very true so travellers should always be on their
guard. Medical. Don't travel to countries where the transfusion facilities may be
inadequate if: - You suffer from a coagulation disorder, such as haemophilia or Von
Willebrand's Disease, or you are not properly stabilised on anti-coagulant
medication.
- You have a medical condition, which commonly requires transfusion, such as
chronic peptic ulceration or oesophageal varicies.
- You are pregnant.
Behaviour Being involved in an accident is the commonest reason for a traveller to
require a blood transfusion. The avoidance of accidents is, therefore, the most
effective way of avoiding a transfusion. - Driving on the road. If you are driving in a foreign country take
extra precautions, always remembering that you may have to drive on the
opposite side of the road from that which is correct in your own country.
Always wear seatbelts, don't drive in the dark, don't drive too fast, and never
drink and drive. This is especially true when you are holiday, as there is
always a temptation to go out to a restaurant or a bar. In many countries
holidaymakers are encouraged to hire mopeds. If you do, always wear a crash
helmet and protective clothing. Peace Corps volunteers have recently been
banned from driving mopeds or motorcycles, and there has been a dramatic
reduction in their injury rate.
- Exploring on foot. One of the commonest causes of road accidents
amongst travellers is looking the wrong way when crossing the road. If the
traffic drives on the opposite side of the road to that to which you are
accustomed, take great care as your natural instinct is to look in the wrong
direction and then step off in front of oncoming traffic. As you will be
unfamiliar with the surrounding area, keep to well-lit streets where there are
plenty of other people. Do not venture into areas where you are likely to be
attacked.
- Hazardous sports. Avoid hazardous sports, especially if you are not
being properly supervised. Take care when going off on mountain walks or hill
climbing.
- Disease. Ensure that you avoid catching any disease that might
require a blood transfusion as part of the treatment. The most common such
disease is malaria, so when you are in an area where malaria is endemic, take
adequate malarial prophylaxis, wear long sleeved shirts and long trousers after
dark and always sleep under a properly impregnated mosquito net.
Be prepared Before leaving home, there are a number of things that you can do to
minimise any risks whilst you are abroad. - Blood Group. Have your blood grouped and make sure you take a copy
of the laboratory report with you. Knowing your blood group in advance will
allow appropriate blood to be more quickly obtained in an emergency.
- Sterile Needles and Syringes. It is wise to take a supply of
sterile needles and syringes, as these may not be readily available in the
countries to which you are going. Most travel clinics can provide packs
especially designed for travellers.
- Intravenous Fluids. It is possible to take plasma substitutes
and/or crystalloid solutions for use in an emergency, though such products
require skill to use, and an adequate supply is bulky and heavy. In an
emergency, supplies can sometimes be obtained from embassies. Sterile
transfusion equipment (giving sets and cannulae) may be difficult to obtain.
Large expeditions with trained medical officers may find it valuable to travel
with such resources, but these are impractical for the majority of travellers.
If you do take such supplies with you, do not attempt to insert an intravenous
line unless you are skilled transfusion techniques. Failed attempts may ruin
the only good venous access available and make it much more difficult for a
doctor to eventually set up a transfusion.
- Medical Assistance. It is vital that you take out adequate health
insurance, which includes telephone support as well as emergency evacuation by
air ambulance if indicated.
- Blood Cover. It is also advisable to obtain cover from an
institution, which can provide screened blood, see below.
Solutions One solution that used to be favoured by expatriates living in a small
community was to set up and maintain a so-called "Walking Blood
Bank". A Walking Blood Bank is comprised of a group of people, living
within a particular community, who are prepared to be called upon to donate
blood to meet a particular emergency. However there are numerous problems
associated with such a venture including: - The number of people involved is so small that there is always a
significant chance that sufficient blood of the required group will not be
available.
- As the members of the Blood bank live locally, they will be liable to
carry the diseases endemic to that area.
- As all the members probably know each other, it is much more difficult for
someone to defer from donation if his social behaviour has put him or her at
risk.
- It is very difficult to adequately quality control such a small venture
and the problems of product liability now make such blood banks non-viable.
For the above reasons, Walking Blood Banks are now no longer clinically
acceptable within the international transfusion medical community(1). Blood, whenever practically possible, should be provided
from a major licensed blood bank. This will ensure a high degree of quality
assurance, and the large turnover will provide a much greater likelihood of the
rapid provision of the requested number of units of suitable blood. This is
especially true with patients having rare groups or having complicated antibody
profiles. In response to the difficulties in locating reliable sources of blood, and
with the active encouragement of the expatriate medical and residential
communities in Nigeria, a blood bank was established in Lagos in 1989 as a
pilot exercise. The experience gained in setting up and operating, on an
international basis, effective procedures for the handling, transportation,
importation and storage of blood, resuscitation fluids and sterile equipment
led, in 1991, to the establishment of the Blood Care Foundation. The Blood Care Foundation is a charitable organisation registered in
England, dedicated to provide, in emergency, screened blood, obtained from
internationally recognised sources in Western Europe, resuscitation fluids and
sterile transfusion equipment to its members in countries where these are not
readily available. Today the Foundation operates a global network of blood banks, enabling it
to provide whole blood, by courier service, to almost any location in the world
within 12 hours, subject to the availability of scheduled air services. It is now well recognised that one's heart works most efficiently when your
haemoglobin is around 100g/l. Most people in the UK have a level of between 140
and 160 g/l. Because we all have this spare capacity, people rarely die from
the anaemia caused by loosing blood. People die from the lack of fluid volume,
which is medically termed "shock". In emergencies, therefore,
resuscitation fluids are normally required and will support the patient until
blood can be provided. To ensure these are readily available, the Foundation
has set up an integrated network of Regional Supply Points (RSPs) throughout
the world, which hold stocks of resuscitation fluids, including plasma
expanders, and the sterile equipment needed for transfusion purposes. Should an emergency occur, one of the Foundation's alarm centres is
contacted. The Duty Medical Officer (DMO) in the alarm centre will contact the
doctor in charge of the case to identify the transfusion requirements. If
required, the DMO will arrange for the provision of resuscitation fluids from
an RSP and for a courier to take blood to the patient. The couriers are doctors
or paramedics, trained in cardio-pulmonary resuscitation, and are capable of
putting up a transfusion, even in the shocked patient. References. 1. Neo-natal and obstetric practice. In:
Walker RH ed. Technical Manual. 11th ed. Bethesda, Maryland: American
Association of Blood Banks, 1993:448. ISBN 1-56395-019-7. © The Blood Care Foundation |
