AABB23: The Potential Benefits of Civilian Walking Blood Banks

When blood isn’t available, such as in developing regions lacking blood banks or during times of crisis, how can patients’ blood needs be met? Sunday afternoon’s session, “Civilian Walking Blood Banks: Considerations for Crisis Readiness and Settings Where Banked Blood is Unavailable,” explored the innovative concept of a walking blood bank, its potential need in resource-constrained areas and in crisis scenarios, variations in its implementation and the latest relevant research and technology developments in this arena.

A traditional blood bank involves all transfusion indications, uses voluntary community donors, processes components or whole blood, tests at a centralized laboratory and has a timeline running from days to weeks. In comparison, a walking blood bank (WBB) is a transfusion strategy in which blood donors are summoned in times of emergency or urgency, family replacement donors and a voluntary donor registry (often consisting of blood from healthcare workers) are the primary blood sources, only fresh whole blood is processed, testing is in the form of rapid diagnostic tests (RTDs) with pre-screening and the timeline runs from minutes to hours. Essentially, as Linda S. Barnes, DrPH, MHA, RAC, CABP(H), explained, “the primary differentiator here, in terms of blood availability and fulfillment is through speed. Speed and timely access to blood, particularly if there is no banked blood available.”

Emergency Transfusion Kit

Barnes explained that three case studies would be covered in the session and the characteristics between the three settings would be compared.

The first case study setting was Angola in southern Africa, where the civilian WBB (CWBB) was performed in a clinic with no central lab or blood bank. Blood transfusion was primarily applied due to severe pediatric anemia secondary to malaria. The transfusion protocol was implemented by the treating physician.

Barnes mused, “I came to this setting experiencing irony about how an essential medicine that exists inside all people—and I look out in the audience here and I see blood donors—is so unavailable when it is needed.” She then talked about a young Angolan patient, Martinho, who was severely ill from malarian-induced severe anemia. The emergency transfusion kit protocol was activated and fresh whole blood was collected from a compatible tested donor and directly transfused to Martinho. Soon afterward, the boy was eating and walking. He was discharged the next day.

The emergency transfusion kit included a blood type test, RTDs for infectious disease, supplies to collect and give blood units and guidelines and flowcharts for instruction. The kit was capable of providing six transfusions and contained one entire adult blood volume.

This kit, she explained, is a just-in-time kit for emergencies, meant to be complementary to existing blood supply systems, or for use in very remote, hard-to-reach areas where stocking blood isn’t feasible. She then discussed a four-month initiation period as part of a pilot in rural Angola. The pilot included 12 patients, including 10 severe pediatric anemia patients, all of whom survived.

Emergency Transfusion Protocol

Nakul P. Raykar, MD, MPH, spoke on behalf of the LIFE-BLOOD (Local Initiative For Emergency Blood) Study Team about the second case study in Kenya. The setting was a hospital setting where a blood bank was present and a CWBB was implemented when no blood was available in the blood bank. The indications were for emergency transfusion in a dire setting. The transfusion protocol was implemented through a multidisciplinary decision.

The setting was Lodwar County Referral Hospital (LCRH) in Turkana, one of Kenya’s poorest counties. Meant to serve 100,000 citizens, its catchment population actually exceeds 1.3 million people and includes Uganda and South Sudan. It does not have testing authority and has to send its blood samples to a regional blood transfusion center for testing of transfusion-transmissible illnesses—a process that can take 3-14 days.

An increasing need for blood at LCRH has led to shortages. During the pilot period, there was not enough compatible blood 40 out of 126 days. A qualitative study was conducted to find out what happens when screened blood was unavailable. Results showed that RDTs were essential in the most dire situations. However, RDTs had not been sanctioned for use because despite their sensitivity in the laboratory; they do not perform well in the hot, desert Turkana environment where there are frequent power outages. Given these risks, the decision to authorize emergency RDT transfusion measures became a shared decision among clinicians, patients, family members, blood bank staff and hospital administrators to mitigate medicolegal risks.

RTD risk was studied, and it was decided that RTDs are an acceptable strategy to screen blood in Lodwar. “RTDs are sometimes necessary and, in many circumstances, already used but there is uncertainty over their efficacy and when we tested the performance of the RTDs in Lodwar, they performed very, very well,” Raykar said. “The general consensus was that a walking blood bank is needed and it’s feasible in the low-resource civilian context when screened blood is unavailable.”

The LIFE-BLOOD Study’s Phase 1 aims were threefold: understand blood usage, understand perspectives and understand RTD performance. Raykar said that the study team is hoping to secure funding for phase 2 of the study, which would work on crystallizing this emergency protocol and developing a system through which it is implemented, and then studying it as well as looking its adaptability to other contexts within Turkana.

Field-Forward Setting

The final case study setting was a military representation in a field-forward setting—not a typical facility. The indications were primarily traumatic hemorrhage and were implemented through formalized protocols.

Col. Andrew P. Cap, MD, PhD, explained how, when US forces entered World War II, the military had, in attempt to seem modern, relegated whole blood to the sidelines, for only the most dire of emergencies. Plasma was the primary resuscitation plan and no equipment or testing support for walking blood banks were provided. Poor outcomes eventually led the US military blood system to be completely dismantled and forgotten by the time the Korean conflict began. At this point, plasma became a bridge to whole blood.

Cap remarked, “The walking blood bank really saved us after the initial experience in north Africa, especially in the Italian campaign, and even through the early phases of Operation Overlord and the invasion of northern Europe. In fact, we did not have a stored Whole Blood program fully operational supplying US troops until the end of 1944. So for all of that time, we essentially used the walking blood bank or got blood from our British colleagues.”

Throughout the past 20 years, including the conflicts in Iraq and Afghanistan, it was increasingly shown that higher-dose warm fresh whole blood provided better outcomes.

“I think the civilian walking blood bank program certainly offers some possibilities in resolving challenges,” Cap said. “The THOR and AABB Working Party did an analysis of US cities in mass casualty-type settings and the result of that modeling exercise and studying of inventory was that we’re not really prepared. We have very, very minimal excess capacity in the system that could easily be overcome by events. We’ve been lucky in some recent mass casualty events because of the availability of transport assets to move blood around in a timely manner. But the weather doesn’t always cooperate and sometimes ‘the enemy gets a vote,’ as we say in the military, so we need better preparedness.”