Student Butra Sary gives blood at a mobile blood bank. Student donors are sought after for their low HIV risk.

With the threat of a critical blood shortage no longer looming large, the Ministry

of Health (MoH) says it can now afford to exercise more discretion over who makes

deposits at the country's national blood bank.

Eight years ago the national blood supply was in such dire state that a World Health

Organization official predicted if the number of blood donors continued to decline,

"there would not be enough blood available to supply the medical needs of the

country."

Suffice to say, blood transfusions are a vital component in a functioning hospital.

In Cambodia, the most common reasons for transfusions are patients in intensive medical

care units (33 percent), surgery patients and victims of accidents (28 percent),

women with hemorrhagic complications during childbirth (22 percent) and children

with dengue fever, hemorrhagic fever and complicated malaria (13 percent).

It has taken a concerted effort from NGOs and the Government, but the downward trend

in donations has now been reversed - so much in fact that policies on the future

of blood donations are focusing no longer on just attracting donors, but rather on

attracting the right type of donors.

The government's National Blood Transfusion Centre (NBTC), in collaboration with

the Cambodian Red Cross, has been campaigning with some success to boost the number

of volunteer donors in Cambodia to 100 percent, while simultaneously reducing the

number of replacement donors to zero.

The difference is as follows: International standards define two types of blood donor

- voluntary and replacement. Voluntary donors are those who give blood willingly,

and in Cambodia can be subdivided into two groups. 'External donors', who donate

blood to mobile teams in areas such as universities and high schools, and 'spontaneous

donors', who come to donate blood at transfusion centers.

Replacement donors on the other hand, are those from the family of a patient requiring

the transfusion. They are expected to contribute to the general blood supply an equal

amount of blood to that used by the patient, though this can be waived if there is

no next-of-kin.

Blood money

Unfortunately, poor education about blood has spawned a Cambodian subcategory in

this type of donation as well: 'Professional donors' are those paid by the family

of the patient to give blood on the family's behalf, often because the family is

wary or misinformed about donation. These paid donors and their intermediaries can

receive anywhere between $5 and $40 for their troubles.

Dr Hok Kim Cheng, chief of administration at NBTC, refers to this as the corruption

of blood. "These people are not volunteers. Rather, they need the money. In

their own opinion they don't want to give blood voluntarily," he says.

The NBTC does not give money to donors for their blood, and services provided for

blood supply to public hospitals are also free of charge. Despite this, there are

still some reports of families paying to receive blood, even though they shouldn't.

Replacement donors, and especially professional donors, are also at higher risk of

passing on Transfusion Transmissible Infections (TTI) such as HIV or hepatitis. Figures

for 2002 showed HIV was prevalent in 2.9 percent of replacement donors, compared

to only 0.2 percent of external donors, and nil in spontaneous donors.

Dr Kim Cheng explains this is because replacement donors come from across the population.

"But when we collect blood from external donors, we look for low HIV risk donors.

Most often it is students, as they have usually not been opened to sexual life,"

he said.

Regardless of the donor it comes from, all blood is systematically screened for hepatitis

B and C, HIV, syphilis and malaria - if the donor is suspected of coming from a malaria

zone.

But if the risk that blood being unusable can be reduced, so too will the amount

of precious resources wasted on processing and then discarding it. "This is

why we say we do not have enough blood. We want to phase out replacement donors.

This is also the international aim," says Dr Kim Cheng.

Cambodia is still well short of 100 percent volunteer donations, but definite progress

is being made. According to a WHO survey in 2003 on Cambodian attitudes to blood

donation, between 1997 and 1998, spontaneous voluntary donors "almost disappeared"

while the number of replacement donors jumped from 66 percent up to 90 percent of

total blood donations. As further proof of the risk of replacement donors, the prevalence

of positive HIV tests in collected blood increased from 3.5 percent to 5.6 percent

during the same time.

In response to the figures, in 1998 the NBTC started a strong campaign utilizing

blood drives to increase voluntary donations. At the start of the campaign, voluntary

donations were barely 10 percent. Now they are between 27 and 30 percent.

To consolidate the progress made, in 2002 the NBTC in collaboration with the Cambodian

Red Cross started a pilot project on Blood Donor Recruitment. Though currently restricted

to Phnom Penh and Battambang, the eventual goal of the project is to set up a well-functioning

blood donor recruitment system across Cambodia. The Korean Red Cross is providing

financial and technical support until 2005.

Dr Uy Sam Onn is the project manager at the Cambodian Red Cross. "We are doing

this project to change the behavior of people towards blood donor activities,"

he said. According to the WHO survey, lack of understanding about blood donation

was behind 50 percent of refusals to donate, followed by 33 percent of people who

said they simply "lacked interest".

Therefore, crucial to the success of the campaign is demystifying and educating about

blood donation as well as dispelling the common myths. "Some people believe

that if they donate blood, it will not be replenished within their body," says

Dr Sam Onn.

The role of the CRC in the project is in promoting the benefits and educating the

public about blood donation. A significant part of this is achieved through organization

of blood donation days. Last year in Phnom Penh they visited 15 high schools, 10

universities and numerous religious schools and NGOs including UNICEF, World Vision

and Medecins Sans Frontieres. This year they hope to visit each place twice.

In addition to blood drives, the project has organized educational advertisements

on a sports program on television this March, and currently has billboards over the

Central and Deoumkor markets.

Blood donor recruitment has so far had significant success. Dr Sam Onn said the prevalence

of HIV in blood in 2002 was 62.5 percent lower than that recorded in 1998.

Rational use

Surprisingly, it is not only potential donors in need of education on blood for the

target to be reached. Dr Oscar Barreneche, a medical officer at the WHO, says progress

towards the target also depends on the education of doctors and medical staff about

blood and blood use.

"To reach the point of 100 percent voluntary donations, we need to make sure

blood is rationally used. If there is a misuse of blood, there will never be enough,"

said Dr Barreneche.

"The idea is that you only transfuse the blood component the patient needs.

Instead of transferring the blood as a whole, you can separate it into red or white

blood cells, plasma and platelets."

In 1998, 80 percent of blood transfusions in Cambodia involved whole blood. In 2002

the figure was only marginally improved. By comparison, less than one percent of

transfusions in countries such as New Zealand and Australia used whole blood.

According to a WHO booklet on blood safety the demand for whole blood and blood products

is a good indicator of the rational use of blood by prescribing clinicians. The more

developed the health care service, the more blood component orientated transfusions

are performed, resulting in less whole blood being requested.

Barreneche said that the utilization of blood was improving. Although many doctors

in Cambodia had received very little training in the field of blood, the WHO has

worked closely with the NBTC to develop clinical guidelines on the use of blood in

referral hospitals as well as conducting training sessions.

The percentage of blood from replacement donors is currently hovering around 70 percent.

This 20 percent decrease from 1998 levels is predominately attributable to a decline

in professional donors, says Barreneche.

Importantly, the overall number of blood donors is simultaneously increasing. This

is a reflection of the developing health sector that has enabled more hospitals to

perform surgery, stimulating a greater demand for blood. The blood recruitment project

has ensured that the blood donated is of higher quality.

As for the future of project after 2005, Dr Sam Onn is unsure what will happen. If

the generosity of the Korean Red Cross continues, it is possible the project could

be extended out of the cities.

"People in rural areas do not care about blood transfusion, they know nothing

about blood," he said. "But we can't target them because we don't have

the funding."