Transfusion and Apheresis Science 51 (2014) 6–7

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Transfusion and Apheresis Science j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / t r a n s c i

Guest Editorial

Transfusion Education and Practice in South Africa The transfusion of blood and blood products in South Africa has a long and interesting history. It is the winding course of this long road of developments since the time when blood was provided in glass bottles in the suburbs of Johannesburg with a single person manning the “blood bank”, sleeping on a single bed besides a non-mobile telephone, to ensure an immediate response to requests for blood. Over the years, the South African Blood Transfusion Services have grown this dedication shown by its pioneers and developed the blood services into world-class institutions, with safety procedures and screening methods in place that can compete with the best in the world. Despite being faced with the largest HIV epidemic in the world, the transmission of HIV through blood products is estimated at less than 1 per million units of blood transfused. This was made possible through an excellent donor recruitment strategy, making use of voluntary, non-remunerated, low-risk blood donors only, very stringent screening of donors and the use of comprehensive screening of donated units for a range of infections, including nucleic acid testing (NAT) for the detection of HIV and hepatitis viruses. Thus, blood safety in South Africa is not usually considered a great problem. What is a challenge though is the need for this scarce and expensive resource to be used more appropriately. The HIV epidemic has been accompanied by an explosion of HIVrelated diseases and conditions for which blood transfusion is required, and it became apparent very quickly that HIV and its related conditions were increased drivers of blood use, which not only put pressure on the limited blood supply, but also increased the costs of blood and blood products to health services dramatically. A second challenge is the limited training that medical students and doctors receive in the use of blood and blood products. With an increasing number of students, packed medical curricula in an era where one sees an explosion of new knowledge, coupled with an exodus of medical doctors and specialists to other countries and the lack of blood transfusion specialists inside the country, the time spent on blood transfusion education is not enough. With the above in mind, it was recognised that a postgraduate programme in transfusion medicine was required that could fill this gap in knowledge amongst medical doctors, while simultaneously increasing the collective pool of expertise in terms of blood transfusion in http://dx.doi.org/10.1016/j.transci.2014.10.015 1473-0502/© 2014 Elsevier Ltd. All rights reserved.

South Africa. Thus, a postgraduate diploma in Transfusion Medicine was established at the University of the Free State in Bloemfontein, South Africa, as a part-time programme that is run over 2 years. The success of the programme led to the development of a research master’s degree which is open to graduates of the diploma or people with an equivalent qualification. A third challenge is that of obtaining informed consent from patients with hugely diverse cultural backgrounds in a country with 11 official languages and a very high illiteracy rate. Ensuring that the patient understands the indications and risks, often making use of an interpreter, can be challenging. Similarly, ensuring that informed refusal has taken place when blood transfusion is declined, is not always a given. In this edition of the journal an attempt is made to address a number of these challenges. This is done under the broader theme of Transfusion Education and Practice in South Africa. Sadly, Professor Peter Jacobs, the original editor of this theme and one of the doyens of haematology and bone marrow transplantation in South Africa, and a longstanding member of the editorial team at Transfusion and Apheresis Science, passed away on the 18th of November 2013. With the assistance of the editorial team at Transfusion and Apheresis Science, we have completed this task, with fond memories of his contributions during the early phases of planning and development and his continued support, even in the time of his illness. Dr. Karin van den Berg et al. address the impact of HIVassociated anaemia on the incidence of red cell transfusion and discuss the implications for blood services in HIVendemic countries. This article provides a bird’s eye view of the causes of HIV-related anaemia and how this increases blood use. The information should be of great value to blood services and clinicians alike, not only in terms of planning for changing patterns of blood utilisation, but also in terms of identifying the underlying aetiology of HIVrelated anaemia, as many of these causes, if left untreated, will render patients transfusion-dependent in the long-term. Dr. Petronella Sonnekus et al. address the issue of appropriate blood use by looking at the use of platelet transfusions in a large academic hospital, confirming that there are multiple challenges in terms of the

Guest Editorial/Transfusion and Apheresis Science 51 (2014) 6–7

appropriateness of platelet transfusions, thresholds for platelet transfusion and the associated cost implications. She makes a strong case for the development of educational programmes in transfusion medicine aimed at medical doctors, that could help in closing the gap in knowledge and skills in the field, which would contribute in ensuring costeffective and appropriate use of blood and in this case, platelets. Important recommendations are made that could contribute to better alignment of clinical practice with clinical guidelines. Dr. Jaco Joubert et al. also performed an audit on blood use but focused on red cell transfusions, concentrating on appropriate usage, as well as investigating the underlying causes of anaemia, the achievement of certain haemoglobin thresholds, wastage and informed consent. This was done by doing a baseline retrospective audit, followed by a training intervention which addressed some of the shortcomings found in the audit. Thereafter, a prospective audit was done to determine whether training had an impact. The effects of training are limited by sample size, but valuable observations are made that could inform future studies of larger size. It was notable that clinical practice in this hospital was consistent with clinical guidelines with very high standards of transfusion practice at baseline, another factor that may have made it difficult to show a significant improvement after training. In the two articles related to the development of a postgraduate diploma in Transfusion Medicine, I discuss some of the results from my own studies during the development of the programme that tried to provide a scientific basis for the curriculum content, which included the development of outcomes for such a training programme. In my second article, I attempted to establish the difference in terms of the scope of practice of a medical doctor who wants to improve their knowledge of transfusion for day-to-day clinical practice as opposed to that of the specialist in transfusion medicine, who works in the field full-time. These articles should be of use to anyone who wants to design a similar programme and could serve to inform such a venture.

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Finally, in terms of dealing with challenges related to informed consent, Dr. Barrett et al. studied the recall and perceptions of patients with regards to the informed consent process in a tertiary level academic hospital. This was a project done with a group of medical students and makes an effort to address some of the culturally unique aspects of obtaining informed consent, and also points out some of the weaknesses that should be addressed. Taking the patient’s needs into account in terms of what is culturally appropriate, and ensuring understanding of the consent process and documenting such consent are highlights of this article. In conclusion, all of the articles in this theme show that a large gap exists in terms of physicians’ knowledge on the indications for and use of blood and blood products. Universally appropriate, cost-effective use of blood is the holy grail that one aims for, and it is our belief that education in the use of blood is sorely needed as part of any strategy that endeavours to address this challenge head-on. It is hoped that the humble contribution made may, at the very least, stimulate ideas and encourage similar, larger studies in other developing countries and beyond. We are proud to say that Dr. Karin Van den Berg, Dr. Claire Barrett and Dr. Jaco Joubert and one of the co-authors, Dr. Sunette Joubert, have all successfully graduated from the Postgraduate Diploma in Transfusion Medicine. Dr. Van den Berg was also the first graduate from the Master’s Degree in Transfusion Medicine, and these projects are all products of the seeds that were sown in them during their time of study. Vernon J Louw Professor and Head Department of Internal Medicine, Chair Postgraduate Diploma and Master’s Degree Programmes in Transfusion Medicine, School of Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa Tel.: +27 51 405 2907. Email address: [email protected]

Transfusion education and practice in South Africa.

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