Colonel (Retd) Michael JG Thomas MA, MB, BChir, FRCP Edin, LMSSA, DTM&H
If you are attending an overseas medical conference, or taking a well-earned holiday, and you are involved in an accident, or have a medical emergency that requires a blood transfusion, would you know whether the blood provided in that country meets the standards of our national transfusion services?
The problems with having a transfusion overseas fall into three groups: availability, transfusion transmitted diseases, and testing of blood donations.
In certain parts of the world, the local genetic makeup means that certain blood groups are very uncommon. This is especially true for the rhesus negative groups, as these groups are virtually confined to the Mediterranean and Northern European races. In many countries there is always an acute shortage of blood, far worse than anything we ever have to face in Europe. This presents us with the ethical problem of whether it is right for a relatively affluent traveller, who has other options for obtaining blood, to use up a local resource, thereby depriving a locals whose need may be greater.
Transfusion Transmitted Diseases
In many parts of the world, the incidence of the common transfusion transmitted diseases, such as HIV and hepatitis, is as much as 1,000 times higher than in the UK. This means a donated unit of blood is much more likely to be infectious, as an individual is much more likely to be in the ‘window period’. This means that, although the screening test does not show positive, the unit of blood would transmit the disease to a recipient.
In some parts of the world there are endemic diseases, which can be transmitted by blood transfusion, but for which a screening test is not available or is unreliable; such as malaria, Leishmaniasis, Chagar's disease and filariasis.
In many countries, the health budget is insufficient to allow units of donated blood to be fully tested. If they are tested, frequently the test kits used are of a lesser quality than those we would use in the UK.
There is an old saying that: "The best blood transfusion is no blood transfusion". This is very true, so travellers should always be on their guard.
Do not travel to countries where the transfusion facilities may be inadequate if you have a coagulation disorder, a medical condition that commonly requires transfusion, or you are pregnant.
Being involved in an accident is the commonest reason for a blood transfusion. The avoidance of accidents is, therefore, the most effective way of avoiding a transfusion.
1 Driving on the road. If you are driving in a foreign country take extra precautions. Remembering you may have to drive on the opposite side from what you are used. Always wear seatbelts, do not drive in the dark, do not drive too fast, and never drink and drive. If you hire a moped, always wear a crash helmet and protective clothing. Peace Corps volunteers have been banned from driving mopeds or motorcycles, and there has been a dramatic reduction in their injury rate.
2 Exploring on foot. One of the commonest causes of road accidents among travellers is looking the wrong way when crossing the road. If the traffic drives on the opposite side of the road from what you are used to, take great care as your natural instinct is to look the wrong way. As you will be unfamiliar with the surrounding area, keep to well-lit streets where there are plenty of other people. Do not venture into areas where you are likely to be attacked.
3 Hazardous sports. Avoid them, especially if you are not being properly supervised. Take care when going off on mountain walks or hill climbing.
4 Disease. Ensure you avoid catching any disease that might require a blood transfusion. The most common is malaria, so when you are in an endemic area, take adequate malarial prophylaxis, wear long sleeved shirts and long trousers after dark and always sleep under a properly impregnated mosquito net.
Before leaving home, there are several things you can do to minimise risks while abroad.
1 Blood Group. Have your blood grouped and ensure you take a copy of the laboratory report with you. Knowing your group in advance will allow appropriate blood to be obtained faster in an emergency.
2 Sterile Needles and Syringes. It is wise to take your own supply.
3 Intravenous Fluids. Unless you have someone in the party who is competent at putting up intravenous infusions, it is not worth taking these fluids. Only a skilled person should attempt to insert an intravenous line, as failed attempts may ruin the only good venous access.
4 Medical Assistance. It is vital to take out adequate health insurance, which includes telephone support as well as emergency evacuation by air ambulance if indicated.
5 Blood Cover. It is also advisable to obtain cover from an institution, which can provide screened blood (see below).
For large groups, and expatriates living in a small community, one method of providing blood cover has been to set up a so-called ‘walking blood bank’, whose participants are prepared to donate blood to meet an emergency. The American Association of Blood Banks considers this practice "a relic of less sophisticated times" and, in its technical manual1, mentions it only to identify the hazards.
Problems with a Walking Blood Bank
These are explained on the page Walking Blood Bank
The Blood Care Foundation is a British charity, which provides, in emergency, screened blood, obtained from internationally recognised sources in Western Europe and the USA, resuscitation fluids and sterile transfusion equipment to its members in countries where these are not readily available.
Today the Foundation operates a global network of blood banks, enabling it to provide blood, hand-carried by a consultant anaesthetist or skilled paramedic, to almost any location in the world within 12 hours; subject to the availability of scheduled air services. To combat the problem of the availability of rhesus negative blood in Asia, the Foundation has recently established a rhesus negative bank in Hong Kong and will establish another in South-East Asia in the near future.
Should an emergency occur, one of the Foundation's alarm centres is contacted. The Duty Medical Officer (DMO) in the alarm centre will contact the doctor in charge of the case to identify the transfusion requirements.
1. Neo-natal and obstetric practice. In: Walker RH ed. Technical Manual. 11th ed. Bethesda, Maryland: American Association of Blood, 1993:448. ISBN 1-56395-019-7.