Sunday, September 18, 2011

Platelets in Developing Countries

Blood saves lives BUT wrong responses to blood needs are horribly wasteful, even criminally wasteful, and especially so in developing nations where the tech may not even work.

My present concern was ignited by a recent bit of news from Pakistan that the government was responding to the #DENGUE crisis (an epidemic affecting many thousands) in populous Lahore.  Like many viruses that cause bleeding, dengue can be most deadly in its hemorrhagic form, and the main cause of bleeding comes down to dropping platelet counts - and platelets are blood components that are the body's first line of defense against bleeds. The government proposes tossing out 40,000,000 (40 million!) rupees to purchase top-of-the-line blood cell separators as the cries for platelets from dengue sufferers have grown to a crescendo.

Sounds good, doesn't it! People desperately need platelets, so the government immediately jumps into action to meet that need... Well, unfortunately that's all it does is to 'sound' good!

And thats how complicated the 10k apheresis kit is!
In the first place, the machines themselves are very expensive. Perhaps the government will be able to buy a couple dozen machines for that money. But what's really very sad, such machines do not work at all on their own. You need to use 1 disposable kit for each donation. EACH platelet concentrate from one donor (single donor platelets or SDP) requires a (single use) kit and EACH kit costs anywhere from 10,000 to 20,000 Pak Rupees.

And that my friends, means that only the richest patients will be able to afford this treatment. In short, eventually, the government would have spent your public's tax money on a bunch of utterly useless machinery.

Being a blood banker, I also know that the time to implementation for blood cell separator tech is approximately a minimum of 3 months, so even supposing the government does something really brave, like subsidizing the cost of the kits, the whole setup will only go into action after the dengue is  long gone...
After 1 spin PRP above RBC

Of course, the spin-doctors might leave the public admiring the government's caring responsiveness, but ultimately the same thousands WILL DIE for lack of platelets.

Oh, I am not even going to harp much on the fact that properly using these machines requires a LOT of training, with a heck of a lot of infrastructure. These machines will not function safely on generators, and so will need large UPS backup. Then, doctors need to be trained in how to prescribe these SDP, which is a whole lot different from using the commonly available (random donor) platelet concentrate! And then there's the little practicalities like maintaining and servicing some very sophisticated machinery. In my experience, when asked to do after sales service, the sellers/manufacturers/agents found in 3rd world nations are so often adept at playing hard to get!

In other words, stuff like this is simply not appropriate for 3rd world economies. It is a simple thing to have blood cell separators (US 'apheresis' machines) as standard equipment for any US/European/Japanese blood transfusion service, but in those economies our 10,000 rupees is just $110, what an American might spend dining out just once, while to a Pakistani or an Indian that's one month's wages, and for just 1 day's treatment with SDP.

harvesting the platelet rich plasma
I also hardly need to remind folks that in all the 'fancy' countries there's insurance cover, or the governments there treat even their citizens' tertiary health problems with nationalized free treatment - and which developing nations can afford to do either of those things???

Now, I can't altogether blame the government for this fiasco. But then I can! It is typically the health ministry's responsibility to get proper advice from genuine experts and find workable and effective solutions to emergencies like the present dengue/platelet crisis. Solutions do so often exist; workable solutions, and much less expensive ones!

What would have been a more effective solution in Lahore? Encourage the existing network of blood banks in Pakistan to coordinate the supply of 'ordinary' platelet concentrates. Here, the technology is simple. Many blood banks will already have the centrifuges, and "triple bag" kits are readily available at very reasonable prices. It's also easy to train the technicians to make 'ordinary' platelet concentrate. Best of all, the end user cost is only a mere Rs 300/- to 500/- per platelet concentrate, of which a doctor may need to use just 1 or 2 every 12 hours to maintain the platelet count in a safe range, i.e. a cost to the patient of Rs 1,000 to 2,000 per day, (that's still expensive) to stay safely alive until the self-limiting dengue virus hopefully makes a quiet exit.

We, in third world countries, are often witness to much of such government over-enthusiasm. And it often enough isn't the result of stupidity, is it?  So very often we find that some extra-smart 'expert' government adviser somewhere has quietly pocketed a hefty commission (kickback/baksheesh) for suggesting a brilliant but useless scheme!

But, at what cost to the nation, and particularly at the cost of how many lives?

And so, to end the sermon, do try to work with locally effective technology rather than doing stuff that will only be a donation to some foreign manufacturer of completely useless-to-you white elephants. Think about it.

In the meantime, I would also urge all blood bankers to really, really, switch to blood components. Of course, you will not be able to do that unless physicians and surgeons start insisting on using only blood components! Coordinate - Educate!

So called 'whole' blood is a killer when used to treat drops in platelet counts. Whole blood can dangerously load the circulation as you are putting in an extra 350 mL of blood (and completely unneeded red cells lead to hemoconcentration) to get an effect equal to the platelets found in just 50 to 70 mL of platelet concentrate.
I've personally witnessed volume overloads  and very high hematocrits resulting from such whole blood mistransfusions that literally killed patients!

I would simultaneously urge all blood donors to request their blood banks to collect blood in multiple bags so that blood component processing becomes simple and safe. If you see just a single bag without 'satellite bags' attached, go ahead and donate, but then go and meet the blood bank director and tell that person that you will feel much more motivated to be a regular donor if they quickly move to blood components - BECAUSE, your one blood donation (made into components) can serve 3 to 4 patients, and is in any case always safer and more effective than 'whole' blood!

Wouldn't you want to save many precious lives each time you donate your precious blood? I certainly do...

P.S. Blood Components : From 1 unit (450 mL) of 'whole' blood = Red Cells (180 mL) + Fresh Frozen Plasma (200 mL) + Platelet Concentrate (max 70 mL). Sometimes the plasma can further be split to provide clotting factor VIII concentrate and plain plasma (without this clotting factor). So, 1 blood donation made into it's components can help save at least 3 lives or even more!

The platelets in 'whole' blood get killed when the blood temperature drops below +20 C. Whole blood is typically stored at +4 C. So unless the 'whole' blood is fresh and uncooled, it's totally useless for platelets anyway! However, once platelet concentrate is made from fresh warm blood, it is good for at least 5 days at +22 C, so can also be transported to from central processing units to wherever the demand exists. Platelets need to be maintained at this temperature of +22 C and be gently agitated.

Should have a healthy platelet count. Should not have any bleeding disorder. Should not have smoked, taken aspirin or Aggrenox for at least 48 hours, or any antiplatelet meds like Plavix (clopidogrel) for 10 days before donation and of course should meet the other general requirements for blood donation (minimum height-weight etc.).

* Pics on the left show parts of the 'low' tech processing of blood manually to get the blood components safely out and this is all done within a closed sterile blood bag system. The triple bag is most commonly used to provide the 3 main blood components.


Ilmana Fasih said...

I understand what you are talking of is the difference between the automated apheresis at the time of collection and the manual separation of buffy coat/ centrifuge of the platelets from the whole blood donation. I agree the earlier method is extremely expensive and the other, more appropriate for the situation in Pakistan. But then should you also not be mentioning the relative advantages and disadvantages of the two...the latter requires several donors to get one pack of platelets, and more difficult to check for infections.

And yes I wholly agree that it should be emphasized to not transfuse WHOLE BLOOD, which I presume is basic knowledge. But then a lot of medics and small hospitals, may be ignorant too.

Ilmana Fasih said...

My blog on persuasion for blood donation:

Unknown said...

Thank you doctor for your encouragement. Yours is a lovely article encouraging blood donation - so clear!

Yes, I should probably have compared the 2 more objectively. The advantage of single donor platelets are that the patient is exposed to fewer antigens and so the risk of immune responses being triggered is less.

Apart from that, on every count the two products perform exactly the same. 1 SDP can be the equivalent of 5-6 ordinary PLT Concentrates, but then few patients actually need to have so much infused at once, so the flexibility of the physician to just maintain an adequate platelet count is actually better when using the 'ordinary' PLT Concentrate.

Unknown said...

There's now a dengue epidemic in India's Bengal, so the issue has come home to roost! I'm linking this post to a Linkedin discussion at my group "Blood Components" in hopes to get the issue discussed more thoroughly and hopefully have viable platelets available for the thousands of affected patients.


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