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1.1. BLOOD DONOR COUNSELLING
A blood transfusion service is an essential element of a health-care system and individuals who donate their blood provide a unique contribution to saving lives and improving patient health. To provide a safe and sufficient blood supply, the BTS should build and maintain a pool of safe, voluntary non-remunerated blood donors. Blood donors should be provided with high standards of care and assurance of their health and safety. Counselling is an integral part of the BTS duty of care for all individuals who present themselves for blood donation or are blood donors (1,5).
Blood donor counselling is a confidential dialogue between a blood donor and a trained counsellor about issues related to the donor's health and the donation process; it may be provided before, during and after blood donation. There are benefits for both the BTS and the wider health system in implementing blood donor counselling. It minimizes the unnecessary loss of suitable donors while maximizing the retention of donors, including those who are temporarily deferred.
Counselling provides an opportunity for the BTS to assist donors to provide informed consent for blood donation and to defer unsafe donors; it also aids donors to self-defer if they are aware of having been exposed to any risk of a transfusion-transmissible infection or have a known health condition or have had a treatment that could influence their suitability to donate blood (6). Reducing the donation of blood by unsuitable donors that subsequently has to be discarded will decrease the wastage of resources, including donor and staff time, consumables and screening tests, and also avoid needless discomfort to donors (7). Blood donor counselling contributes to blood safety by reducing the prevalence of TTI in donated blood and assists in maintaining a pool of safe, healthy and reliable voluntary non-remunerated blood donors (8).
The counselling of blood donors is an important means of promoting healthy lifestyles and makes an important contribution to individual and community health (9,10). In addition, counselling contributes to the early diagnosis and treatment of conditions such as anaemia, blood disorders and infections. This offers a crucial early entry point for the treatment and care of donors found to be infected and may contribute to delaying or preventing the development of full-blown disease or complications (11,12). This duty of care extends beyond donors themselves to their families and the general population as these individuals may infect others if they are not aware of their infection status. Donor counselling thus contributes to the continuum of care in the health system, plays an important role in preventing the further transmission of infections, contributes to the containment of epidemics and reduces the disease burden on the national health system.
Counselling may also reduce adverse donor reactions (13), improve donor perceptions of the BTS, encourage donors to recommend blood donation to friends and family and, most importantly, increase the likelihood of returning for future donation (5). This is particularly valuable for BTS in the process of transition from a reliance on first-time or family replacement donors to regular voluntary non-remunerated blood donors (VNRBD) (14).
Information provided by 164 countries to the WHO Global Database on Blood Safety indicates that, worldwide, more than 92 million blood donations are collected annually. Of these, an estimated 1.6 million units are discarded due to the presence of markers for TTI, including HIV, hepatitis B (HBV), hepatitis C (HCV) and syphilis. In addition, at least 13 million prospective donors are deferred from donating blood due to anaemia, existing medical conditions or a risk for infections that could be transmitted through transfusion (15).
The scale of these discards and deferrals underlines the importance of public health information, donor education and counselling to enable prospective donors who may be unsuitable to donate blood to self-defer at any stage in the donation process. It also highlights the need to establish counselling systems for individuals who are not accepted as blood donors or who are found to have unusual or abnormal test results.
However, many national BTS do not recognize that blood donor counselling is essential for providing quality donor service and care and do not have clear national policies on blood donor counselling or the infrastructure and resources required for counselling.
1.2. AIM AND OBJECTIVES
In 1994, Guidelines for blood donor counselling on human immunodeficiency virus (HIV) was published as a collaborative effort of the International Federation of Red Cross and Red Crescent Societies (IFRC), the WHO Global Programme on AIDS, and the United States Centers for Disease Control and Prevention (CDC) (16). These guidelines were developed in response to the specific challenges posed by the need to keep blood supplies free from HIV and provide support for blood donors who tested positive for HIV. There were also concerns that, due to the limited availability of HIV testing sites and the potential stigma associated with HIV, some donors might not disclose sensitive information on behaviours that increased their risk of HIV infection or might donate blood for the purpose of ascertaining their HIV status. These concerns are still true today.
In the intervening years, diagnostic technologies and treatment options have advanced for HIV, as well as for HBV, HCV and other infections, such as malaria and Chagas disease. It is now recognized that the scope of donor counselling should not only address HIV but should also encompass other TTI as well as medical conditions that might compromise donor health. The WHO Blood Transfusion Safety programme, in collaboration with CDC and the IFRC, therefore initiated a process to review and update the guidelines and expand their scope beyond HIV to include other TTI and donor health and safety issues.
The aim of Blood donor counselling: implementation guidelines is to support countries in establishing effective national systems for blood donor counselling where they do not yet exist.
The specific objectives are to provide:
Policy guidance on providing blood donor counselling as an essential component of quality donor service and care and as a requirement for a safe blood supply.
Information and technical guidance on the specific measures and actions needed to promote donor care and the safety of blood donors and transfusion recipients through counselling for:
Prospective donors who have been deferred from blood donation to protect their own health or that of patients receiving transfusion
Blood donors with unusual red cell serology or rare blood groups
Blood donors with abnormal test results for HIV, HBV, HCV, syphilis, Chagas disease or other TTI.
In 2008, the WHO Blood Transfusion Safety programme convened an Expert Consultation on Blood Donor Counselling. The specific objectives of the consultation were to review Guidelines for blood donor counselling on human immunodeficiency virus (HIV) and to define the scope for updating and expanding these guidelines in the context of blood safety and overall public health.
The consultation was convened as a technical working group comprising international experts in the field of blood donation and donor counselling from both developing and developed countries in all WHO regions (see Acknowledgements). The technical working group recommended that updated guidelines should not be confined to counselling on HIV, but should address pre-donation and post-donation counselling on major TTI, including HBV, HCV and syphilis, as well as medical conditions requiring deferral, and donor care. The scope of the revised document was agreed and its structure and content were planned. The technical working group met to prepare, review and revise drafts of the guidelines.
The WHO Blood Transfusion Safety programme established an external review group comprised of members of the WHO Expert Advisory Panel on Blood Transfusion Medicine, experts from WHO Collaborating Centres in Blood Transfusion Medicine, directors of national blood transfusion services and blood programme managers in each WHO region (see Acknowledgements). The composition of the external review group was designed to ensure a wide range of specialist expertise and experience from BTS in all regions at different stages of development. The role of this group was to review the draft guidelines and advise WHO on the relevance and applicability of these guidelines in their countries. An editorial team edited the various document drafts.
In 2011, an external review of an advanced draft to assess the feasibility of the implementation of these guidelines was undertaken by participants in an inter-regional workshop on blood donor selection and donor counselling for priority countries in the African and Eastern Mediterranean regions (17) (see Acknowledgements).
Members of the technical working group searched the literature using PubMed, MedLine, the WHO Library Database (WHOLIS) and regional databases. Particular efforts were made to identify systematic literature reviews and publications related to blood donor counselling in developing countries. Some elements of counselling are not unique to blood donation; thus, general principles of psychosocial and HIV counselling and the evolving methodologies, literature and guidelines on training and the supervision of health care counsellors have been applied to blood donor counselling.
Review and updating of the guidelines
It is anticipated that these guidelines will be reviewed in 2017 in terms of any new developments or feedback on their implementation. The WHO Blood Transfusion Safety programme will be responsible for initiating the review to assess the need for updating.