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HEALTH POLICY AND PLANNING; 14(4): 354362 Oxford University Press 1999
The demand for blood transfusion is high in sub-Saharan Africa because of the high prevalence of anaemia
and pregnancy related complications, but the practice is estimated to account for 10% of HIV infections in
some regions. The main response to this problem by the international donor community is to establish
vertically implemented blood transfusion services producing suitable (safe) blood at a cost of US$2540 per
unit. However, the economic sustainability of such interventions is questionable and it is argued here that
hospital-based blood transfusion services operating at a basic adequate level are sufficient for low-income
African countries. The results of a project aimed at improving such services in Tanzania are presented. The
main findings are: (1) the cost per suitable blood unit produced was US$12.4; (2) at an HIV test sensitivity of
93.5% during the study period, discounted financial benefits of the interventions exceeded costs by a factor
of between 17.2 and 37.1; (3) the cost per undiscounted year of life saved by use of these interventions was
US$2.72.8; and (4) safe blood transfusion practices can be assured at an annual cost of US$0.07 per capita.
Recommendations are made to ensure safe blood transfusion practices at hospital-based blood banks in
Tanzania.
economic, as the costs far exceed those of integrated pro- Table 1. Bugando Medical Centre
grammes in which the cost of logistics, training and super-
vision can be shared. The high price of blood units in relation Type of hospital regional/referral
to national public health expenditure further inhibits sustain- Number of beds 820
ability. The poorer the country and the lower the level of Blood transfusions/month1 250
health spending, the more the governments capacity for new HIV-prevalence among blood donors1 12%
Inpatients/year1 17 885
investments is restricted. Even when the national budget is
Bed occupancy rate 79%
able to absorb the recurrent costs, it is most likely that Regional population 2 351 2332
resources for other programmes would be depleted, resulting BTS semi-autonomous;
in a redistribution of underfinancing (Prost and de Ferranti employing 6 people
1985). Voluntary blood donors less than 10% of all
donors
For low-income African countries, pattern II hospital-based
blood banks may be the best solution on economic grounds, 1 1991 data.
2 1995 estimates.
although there are disadvantages: competing with other
departments for resources; potential problems with the
supply of consumables, such as HIV-test kits; difficulties in
establishing a voluntary blood donor panel because willing- screening of all donated blood for HIV and syphilis;
ness to donate is affected by the quality of services provided increasing blood collection among voluntary donors;
by a hospital; and the fact that the in-charge of the blood bank use of autologous blood transfusion for eligible patients;
often has limited knowledge of BTS. The advantages are that reducing the use of blood transfusion for life saving situ-
the programme is integrated into the existing health care ations only;
delivery system and that less capital costs will be required as improving the laboratory aspects of blood transfusion.
the majority of the equipment needed will already be present.
Blood collection procedure
The implementation of interventions that will reduce trans-
fusion-related HIV-transmission has been described else- According to the NGSBT only men and women that do not
where (Jacobs 1997). Here, an economic evaluation of the belong to a population group at increased risk for HIV infec-
feasibility of hospital-based blood banking is reported with tion, who are aged 18 years or more, weighing at least 50 kg,
recommendations for important support measures. and with haemoglobin (Hb) levels of 13.5 g/dl and 12.5 g/dl,
respectively, are allowed to donate blood. With the approval
of the Ministry of Health the Hb thresholds were lowered to
Methods
12.5 g/dl and 11.5 g/dl for males and females, respectively.
Adhering to the recommended thresholds would have
Background
resulted in too many potential blood donors being deferred,
The project on which this study is based started in 1992 in due to the low Hb level among the general population. On the
Mwanza region, Tanzania. The region is situated on the other hand, collecting blood from individuals with an Hb
southern shores of Lake Victoria and covers an area of 19 683 below the recommended thresholds increases the risk for
km2. Its population was estimated at 2 351 233 in 1995 (Min- adverse blood-donation reactions such as hypovolaemia.
istry of Health 1995). A National Blood Transfusion Advis- Therefore, smaller blood collection bags of 250 ml 10%
ory Committee was established in 1990 which formulated instead of 450 ml 10% are used for such individuals. Indi-
comprehensive National Guidelines for Safe Blood Trans- viduals weighing 5055 kg are also at increased risk for
fusion (NGSBT), covering all aspects from collection to adverse donation reactions and are, therefore, bled using the
transfusion (Ministry of Health 1990). Additionally, consen- smaller blood collection bags. A quarter of the people offer-
sus guidelines for the prescription of blood transfusion were ing to donate blood have to be deferred because of their Hb
introduced in 1991 (Gumodoka et al. 1993). Screening of level and/or body weight.
donated blood for HIV antibodies was introduced nation-
wide by the end of 1989 (Lyamula et al. 1996). The sensitivity The cost of single blood collection bags, whether 250 or 450
of the screening test (ELISA) used in Mwanza region at the ml, is the same. For multiple blood collection bags, costs cor-
start of the project was 93.5% (Velema et al. 1992). The HIV relate directly with the number of individual bags rather than
incidence rate in rural Mwanza region was 1% for the period with the total volume. Multiple bags are used for producing
199194 (Grosskurth et al. 1995). packed cells by depleting the plasma, after centrifugation or
48 hours sedimentation of the whole blood. Packed cells are
Although the project took place in five hospitals, only the used to treat patients with severe anaemia that have a subse-
results from Bugando Medical Centre (BMC), an urban quent risk of circulatory overload when treated with whole
referral hospital with a semi-autonomous BTS, are discussed blood. A double blood collection bag contains one unit for
here. Table 1 displays relevant data for this hospital. packed cells and one unit for derived plasma, while a triple
bag contains two units for packed cells and one unit for
The aim of the project was to implement the interventions derived plasma. Because of the higher cost of multiple blood
required to assure safe blood-transfusion practices, as formu- collection bags, they were only used among voluntary blood
lated by the Tanzanian Ministry of Health: donors as they are at significantly lower risk of transfusion
06 Jacobs (jl/d) 20/10/99 8:30 am Page 356
transmittable infections and their units of blood are less likely Costbenefit analysis
to be discarded. The derived plasma was never used for
Prior to full implementation of the interventions at the end of
medical purposes.
1992, 12% of blood donors were HIV-positive and there were
3000 annual transfusions. If blood had not been tested, on a
All blood collected in the study period, 199394, was tested
crude calculation, approximately 360 transfusions would have
for HIV-antibodies the following morning by use of ELISA.
been HIV-infected. As a result of the intervention, the annual
Units found to be positive were destroyed immediately.
number of blood transfusions was reduced to 1200. If HIV
prevalence among donors had remained at 12%, a crude
Study methods calculation gives the number of HIV-infected transfusions as
144, in which case, reducing transfusions prevented about 216
Cost-minimization is based on the cost per suitable (safe)
HIV infections. However, overall HIV prevalence fell to 7%
blood unit. To determine the price of a suitable blood
because more blood came from voluntary donors. The crude
unit, the format for cost data reporting from Beal et al.
estimate of HIV-infected transfusions would be 84, so that
(1992) is used. Pricing suitable blood units also allows
reducing prevalence prevented 60 HIV infections.
comparison with centrally coordinated, national blood pro-
grammes.
In calculating the benefits of the intervention here, we con-
sider that screening prevented the transfusion of blood from
A cost-benefit analysis was conducted to consider benefits
donors who tested HIV-positive. However, we also take into
achieved at BMC by (1) reducing the number of unnecessary
account that the other interventions prevented the trans-
blood transfusions; (2) lowering the HIV-prevalence among
fusion of blood from those who tested falsely negative. Table
blood donors to reduce the number of units testing falsely
2 shows the number of potentially HIV-infected units (PHIU)
negative; and (3) avoiding homologous blood transfusion by
by donor HIV-prevalence (2, 7 and 12%) and test-sensitivity
use of autologous blood transfusion. The cost-benefit of
(93.5 and 99%), assuming an annual incidence rate of HIV
screening the blood for HIV prior to transfusion has been
infection of 1% among the blood donors, in line with the
demonstrated by Foster and Buv (1995) and will be calcu-
regional HIV-incidence during the study period. If test sensi-
lated separately here for comparison.
tivity was 93.5% and HIV prevalence was 7%, an estimated
4.9 per 1000 transfused units would have come from donors
The cost-benefit analysis uses the human capital approach,
who tested falsely negative. In addition, an estimated 1.5 per
although this is controversial. Alternatives, such as peoples
1000 units would have come from donors who tested negative
observed or stated preference are usually based on peoples
because they had no antibodies in the window period. Con-
willingness to pay. These are not applied in this study because
sequently, 7.7 (6.4 per 1000) potentially HIV-infected units
of the lack of information in developing countries.
would be transfused to 1200 recipients. In comparison, before
the intervention, 29.4 (9.8 per 1000) units were transfused to
For a cost-effectiveness analysis, the number of years of life
3000 recipients from donors who would test falsely negative:
saved was calculated using a life table. The most recent avail-
i.e. the interventions other than screening prevented trans-
able for Tanzania is for 1967 (Cond et al. 1980). Calculations
fusion of about 22 units of HIV-infected blood in 1 year.
were also done using a more recent life table for 1980 from
neighbouring Zambia for which the mortality level closely
Some transfused patients receive more than one blood unit,
matches that of Tanzania (United Nations 1995).
some less. For the costbenefit analysis, therefore, it is neces-
sary to convert prevention of infected units into HIV infec-
Results tions prevented (Table 3). A significant number of the patients
After the creation of a hospital blood transfusion committee
at BMC and following acceptance and modification of the Table 2. Risk of transfusing potentially HIV-infected blood units
consensus guidelines to BMC Guidelines for Safe Blood (false negatives and window period negatives): by test-sensitivity and
Transfusion, the average number of monthly transfusions blood donor prevalence with a 1% annual incidence
dropped from 250 in 1991 to 100 in 199394. The proportion
of donors who were voluntary increased to 23.8% (339/1423) HIV-prevalence PHIU1 (per 1000) by test sensitivity
in 199394, compared with less than 10% prior to the start of among blood donors
93.5% 99%
the project. HIV prevalence among voluntary donors was
1.8% (6/339) compared with 8.7% (94/1084) among relatives
donating blood. Due to the use of triple and quadruple blood 2% 2.9 1.7
bags and because of the lower HIV-prevalence among volun- 7% 6.4 2.2
12% 9.8 2.7
tary donors, this group accounted for 30.5% of all suitable
blood units produced (433/1421).
1 PHIU = potentially HIV-infected blood units. For example, at 7%
The cost per suitable blood unit produced in BMC was HIV-prevalence and 93.5% sensitivity: Number with antibodies
testing falsely HIV-negative (20/0.935 20) = 4.9. Number without
US$12.4 (Annex 1). Capital costs were 24% of the total antibodies testing HIV-negative in the window period = 1.5. (Calcu-
annual expenditure in BMC and personnel accounted for lated using the formula from Savarit et al. 1992: the risk of a blood
10.4%. The marginal cost per suitable blood unit was US$5.1 donor donating in the window period, RW = Incidence 3 56/365 =
for relative donors and US$5.8 for voluntary donors. 0.01 3 0.15, i.e. 1.5 per 1000).
06 Jacobs (jl/d) 20/10/99 8:30 am Page 357
though not ascertained, number of anaemic children, one blood unit is shared by different compatible children due to the small volume of
blood they require which is often well below one blood unit.
4 Excludes transfusion recipients already HIV-infected (e.g. children 04 years: 17.6 3 0.957 = 16.8).
receiving a blood transfusion are already HIV-infected, so it is was estimated at US$24625316 in Tanzania in the year
necessary to subtract them from the total number of HIV 198788 (Over et al. 1988). This converts to US$29786430 in
infections prevented. A 3-year sentinel surveillance among 1992 US dollars2, and a total cost for 22 people of US$65
antenatal clinic attenders in Mwanza found an overall HIV- 516141 460. The benefitcost ratio is, therefore, between
prevalence of 12% (Kigadye et al. 1993). However, another 3.7:1 and 8.0:1, but as most benefits will occur in the future,
study indicated that data obtained from this group underesti- they should be discounted. Assuming seven years elapse
mated the population HIV-prevalence. It suggested that blood between infection and disease progression, and using a 5%
donors who donate blood for a friend or relative are represen- discount rate, the resulting discounted benefitcost ratio is
tative only if the prevalence rate is standardized for age and 3.1:1 to 6.6:1.
sex (Borgdorff et al. 1993).
Screening the blood for HIV-antibodies detected 100
HIV-prevalence among female relative donors aged 1539 seropositive blood donors, thereby avoiding an additional 119
years was 14.3% (20/140), which is taken here as the HIV- HIV infections, not allowing for any use of multiple blood
prevalence for pregnant women receiving transfusions. Chil- bags.3 Assuming the same mortality rate among transfusion
dren aged under five years are assumed to have been recipients as above (15%), the number of HIV infections pre-
perinatally infected and the perinatal transmission rate for vented by use of HIV screening was 101. All interventions
HIV is 2040% in Uganda and Zaire (Preble 1990). A rate of combined, therefore, avoided 123 HIV infections and the
30% has been used here, so HIV prevalence among blood associated costs of US$366 294790 890, a benefitcost ratio
transfusion recipients in this age group is estimated at 4.3%. of 20.7:1 to 44.8:1. The discounted benefitcost ratios were
For children aged 5 years and over, prevalence of 1% is used 15.8:1 to 37.0:1.4
in line with the findings of Killewo et al. (1993) in neighbour-
ing Bukoba region. For operated patients, the overall HIV- BMC provides blood for all hospitals in the town which had
prevalence of 12% among adults in Mwanza is used (Barongo an estimated population of 250 000 in 1988. Because the
et al. 1992). On the basis of the study by Borgdorff et al. whole population, excluding the referred rural patients, is
(1993) in Mwanza, an HIV-prevalence of 24% is used for potentially at risk to receive a blood transfusion, the ad-
anaemic adults receiving transfusions. ditional annual costs of assuring safer blood-transfusion prac-
tices are therefore US$0.07 per capita (1992 US$).
Assuming the above HIV-prevalence rates, a total of 26 HIV
infections would be prevented (Table 3). However, this esti-
Cost-effectiveness analysis
mate needs to be reduced because some transfused patients
die. Research in Kenya found a mortality rate of 13.5% Table 4 shows the calculation for the number of years of life
among transfused children and 9.1% among transfused saved by the interventions other than screening the blood for
women (Lackritz et al. 1993; Zucker et al. 1994). Mortality HIV. The cost per year of life saved by use of these interven-
rates have yet to be ascertained at BMC, but conservatively tions was US$15.315.8. When considering all interventions,
allowing for a slightly higher mortality rate of 15% among 62396463 years of life were saved at a cost of US$2.72.8 per
blood transfusion recipients, the total number of HIV-infec- year. Screening the blood for HIV is the most important of
tions prevented is reduced to 22. the interventions for avoiding transfusion-related HIV-infec-
tion, as it contributed 82% of the total number of years of life
The cost of preventing these 22 HIV infections is US$17 655 saved and accounted only for 8% of the total cost per suitable
(Annex 1). The total cost incurred for an HIV-infected person unit.
06 Jacobs (jl/d) 20/10/99 8:30 am Page 358
Patient group Infections Mean age Sex ratio Years of Total Years of Total
prevented of patients M:F life saved years of life saved years of
excluding in years per person2 life saved2 per person3 life saved3
recipients M; F M; F M; F
who died
Discussion was achieved during the study period, with no other inter-
ventions, the number of potentially HIV-infected units
Hospital-based blood banking has the important advantage (PHIU) being transfused would have been 8.1 instead of 29.4
of incurring lower costs than a centralized approach. The cost (Table 2). The effect of the other two measures, reducing the
of a suitable blood unit produced at BMC was US$12.4, con- number of avoidable blood transfusions and lowering the
siderably less than the cost of a suitable blood unit under a HIV-prevalence among blood donors, would be to reduce the
centralized approach in other African countries (US$2540). number of PHIU from 8.1 per year to 2.6. Only 132137 years
Such a difference is particularly important as many African of life would be saved at a cost of US$129134 for each year.
countries have a very limited budget for health care. However, as a result of lowering the HIV prevalence among
blood donors, there were substantial savings since fewer units
The cost per year of life saved through additional measures had to be discarded. There were direct savings of between
other than screening the blood for HIV was US$15.315.8. US$918010 440 (1800 fewer units were used at a marginal
This compares favourably with other health interventions cost per unit of US$5.1 for relative donors and US$5.8 for
such as measles immunization, estimated to cost US$13.5 per voluntary donors). However, risks involved in blood trans-
year of healthy life added in the Ivory Coast and US$16.2 in fusion are not confined to transmission of HIV. They include
Zambia (1992 US$) (Prost and Prescot 1984). However, for hepatitis B, C and D, syphilis, HTLV and alloimmunization to
the combination of HIV screening with other interventions, red blood cells, which is further reason for seeking to mini-
the cost per year of life saved is reduced to US$2.72.8. Con- mize the use of blood.
sidering only the cost of screening at BMC, the cost per year
of life saved would be US$0.2. The cost of a hospital-based BTS to operate at basic-adequate
level, assuring adherence to measures aimed at reducing
These costs compare favourably with the findings of Foster transfusion-related HIV transmission, is only US$0.07 per
and Buv (1995) who calculated that screening blood for HIV head of population. This figure would have been substantially
in neighbouring Zambia resulted in a cost per year of life higher if the BMC guidelines for blood transfusion had not
saved of US$1.3. Their higher costs per year of life saved been followed. These guidelines should be implemented
would be partly due to their assumption of 50% mortality nationally and legislation is required to enforce adherence
among blood recipients and also because two-thirds of the because compliance is poor in Tanzania (Vos et al. 1994). The
blood was screened using more expensive rapid essays. Their financial savings on direct costs would be substantial if the
discounted benefitcost ratio of screening the blood for HIV guidelines were generally adhered to.
was 2.7:1 to 3.0:1, compared with 15.8:1 to 37.0:1 in this study,
which is due to the substantial difference in the cost per HIV In order to make such legislation and other transfusion prac-
infection used for the calculations. The providers cost per tices effective, a control system should be established, ideally
HIV-infection prevented in Zambia was US$110.6 compared implemented by the National AIDS Control Programme
with US$29796432 (1992 US$) in Tanzania. However, the (NACP). Currently each region has a Regional AIDS Control
latter included social costs. Manager, but this person is unable to perform the required
tasks due to shortage of funds (Dodd 1995). Donors should,
The benefits of the interventions other than screening the therefore, provide more support to the NACP instead of
blood for HIV depend mainly on the sensitivity of the HIV- diverting funds to NGOs. If donors continue to support
screening test, which was 93.5% during the study period. NGOs instead of the NACP, an alternative structure for
However, this may now have risen to about 99% due to the coordination among them needs to be established. This struc-
development of better tests, improved supervision and an ture should control resource allocation to avoid wastage of
adequate quality control scheme. If a test sensitivity of 99% funds on parallel intervention systems.
06 Jacobs (jl/d) 20/10/99 8:30 am Page 359
Several other measures would help to improve the effective- Efforts to limit the demand for transfusions due to severe
ness of a hospital-based BTS and to minimize HIV trans- anaemia are constrained by the lack of capacity to perform
mission through transfused blood. Firstly, it is important to Hb tests in all dispensaries (Massawe et al. 1995). For chil-
improve the laboratory diagnosis of HIV infection among dren with an Hb of 58 g/dl, the need for blood transfusion
blood donors to lower the risk of transfusing PHIUs. It is esti- can be averted by treating the underlying condition of
mated that only 80% of all blood for transfusion in Tanzania anaemia. However, using clinical signs for diagnosis of
is screened for HIV (World Bank 1992). The main reason anaemia at this Hb level had only a 66% sensitivity, and a
given is that it can not be done in emergencies. The annual cheap and reliable method for Hb screening still does not
report of Rubya Hospital in Bukoba illustrates the logistical exist (Luby et al. 1995). A study from Malawi indicates that
problems of distribution of test kits and the regrettable con- the use of clinical signs to diagnose anaemia in children by
sequences of a failing logistical system (anonymous 1994). Of non-physician health workers has a sensitivity of 93% for
the 371 blood donations tested, 30% were HIV-positive. Due severe anaemia (Hb <5 g/dl) (Luby et al. 1995) Unfortu-
to an unreliable test kit supply, the other 782 blood trans- nately, the Hb is then at such a low level that a blood trans-
fusions could not be screened, so potentially 235 transfusion fusion is almost mandatory. In view of this, preventive and
recipients could have been HIV-infected. It is a top priority to curative measures to control malaria may be a more feasible
strengthen the distribution of HIV-test kits to allow all blood approach to reducing the demand for blood transfusion due
to be screened. to severe anaemia.
Currently, it is the task of the NACP to manage distribution In order to lower costs associated with BTSs, it is also import-
of test kits. Collaboration with the expanded programme on ant to improve collaboration between government and
immunization would be beneficial as it has a proper network mission hospitals. The latter are a valuable health sector
for distribution of vaccines by cold chain. In addition to resource in Tanzania as they manage about half of all health
ensuring that testing can be done, maintenance of a stock of services (Gilson et al. 1994). In Mwanza, all the hospitals con-
blood is a prerequisite for proper and timely HIV-testing. A ducting more than 50 blood transfusions a month were
voluntary blood donor panel allows this and should also be mission hospitals, while those of the government transfused
continued on ethical grounds to reduce wastage of blood col- 20 or less units a month. The main reason for this difference
lection units, tests and sera because of high HIV-prevalence is patient attendance, which is likely to be higher at mission
among relative donors. hospitals because of an increased likelihood of drugs being
available. Additionally, mission hospitals usually have access
It is particularly important for HIV-testing to be monitored, to external funding, which Laleman et al. (1992) identified as
although quality control is required for all hospital-based an important determinant for successful transfusion practices
blood banks. Samples of known but undisclosed content can at rural hospitals.
be sent from an organizing laboratory to a testing laboratory
and the results reported back. This serves three purposes: (1) Mission hospitals were also found to have better laboratories
to allow the national health authorities to gain insight into the than government hospitals (Gilson et al. 1995) so they could
general level of proficiency in the laboratory testing; (2) to provide HIV-tested and ABO,D grouped blood to govern-
allow participants to gain an insight into their own level of ment hospitals. The latter could collect blood among groups
performance and to take action to remedy any problems at lower risk for HIV-infection at their location and replace
revealed; and (3) to allow organizers to identify participants the units received from mission hospitals. With such an
whose long-term performance is poor, in order to offer them exchange system, blood can be tested for HIV by use of the
help and advice in resolving their problems (Emmanuel cheaper and more sensitive ELISA instead of rapid essays.
1992). Because of the countrys size and malfunctioning com- However, for such collaboration to happen at district level,
munications, organizing laboratories should ideally be estab- District Medical Officers (DMOs) need to be more involved
lished at regional level. Such a quality control system was with the coordination of mission hospitals. Gilson et al.
established in Mwanza Region by the TanzanianNether- reported that these remained largely outside the DMOs
lands Research on AIDS project and should be introduced in influence and that most contacts occurred through the deliv-
all regions. ery of immunization supplies (Gilson et al. 1994).
A further requirement is to ensure frequent supervisory visits Development of BTSs and the level at which they operate
for monitoring HIV-testing. A study conducted in neighbour- needs to be compatible with the overall national health care
ing Zambia found that six out of 42 trained laboratory tech- structure. The national health care plan and socioeconomic
nicians were no longer present in their respective hospital circumstances need to be taken into account to ensure sus-
after 1 year. Of 19 hospitals that were using ELISA for HIV tainability. A BTS which operates at a higher level than the
screening, eight already had malfunctioning equipment after overall health care structure does so by diverting resources
1 year (Chipuka et al. 1993). In Zaire, supervisory visits sig- from other much needed interventions. For a low-income
nificantly improved transfusion procedures, including HIV- country like Tanzania, provision of safe blood transfusion ser-
testing (Laleman et al. 1992). vices through a hospital-based blood banking system is a feas-
ible horizontal alternative to the more costly vertical
The demand for blood transfusion is significantly affected by approach. Such an intervention will be more effective in pre-
malaria, which accounts for 31% of episodes of sickness and venting HIV transmission through blood transfusion if the
much of the anaemia in Tanzania (Ministry of Health 1995). above support measures are also introduced.
06 Jacobs (jl/d) 20/10/99 8:30 am Page 360
Capital costs
Recurrent costs
Salaries
Administrative staff 135
Blood collection staff 310
Laboratory staff 135
Blood donor recruiter 535
Attendant 80
Pension fund 135
On call allowance 510
Transport
Total cost for one year 711.8
Consumables2
Disposable lancets 115
Blood collection containers3 5102
Reagents for blood grouping4 1254
Compatibility testing5 503.5
06 Jacobs (jl/d) 20/10/99 8:30 am Page 362
Notes
1 The building is estimated to last 20 years; the refrigerator, voltage stabilizer and vehicle, 10 years; and the remainder, 5 years. For the vehicle
tive donors).
3 Relative donors were bled using single blood bags (US$2.94). For 100 voluntary donors, 80 double, 10 triple, and 10 quadruple blood bags
3 10 ml.
5 15 3 10 ml was used at a cost of US$503.5.
6 339 voluntary donors were bled (HIV-prevalence 1.8%) and 1084 relative donors (HIV-prevalence 8.7%). This provided 990 suitable units
from 990 HIV-negative relative donors and 431 suitable units from 333 HIV-negative voluntary donors (266 double blood collection bags with
266 units; 33 triple bags with 66 units; 33 quadruple bags with 99 units).
7 Calculated per 100 donors being bled: 100 relative donors produced 91 suitable units (990/1084 3 100); 100 voluntary donors produced 127