The first confirmed case of Covid-19 in India was reported on 27th January 2020 in Thrissur,Kerala9.The country was in a complete state of Lockdown from March-June 2020.Since July2020 there was an exponential rise in daily notified cases with declining trends seen from Nov 2020.The nation witnessed its worst catastrophe again when the second wave hit us affecting almost over 2million people10.With this mammoth population affected and infected, the Blood Transfusion services suffered a significant drop in Blood stores.
While considering the broader issues for blood supply planning during the pandemic, a key consideration for transfusion services is to maintain the balance between supply and demand11.With disruption in this cycle from many issues worldwide, we complied, reviewed and analyzed the blood collection demand, supply, the discarded units at our Blood Bank. Although there have been a number of reports on the impact on blood donations worldwide, there is till date a paucity of information on the transfusion needs of COVID inpatients and the overall blood component requirements during the COVID pandemic12.
The whole blood (WB) collected in phase I, phase II, Phase III and Phase IV were 5517 5379, 6096 and 2076 units respectively. The average In-house donations in phase I was 33.6% as compared to only 12% in Phase II. Similarly in phase III, due to fear and anxiety of contracting Covid-19 from the hospital, the average In house donations was further decreased to 5.75%.With sharp ascend in cases from the second wave in Phase IV, the In house donations was barely 5.1% leading to further depletion in blood stores.
Apart from replacement donations and voluntary blood camps, there is no other way to maintain the blood stocks. We observed that in pre pandemic Phase I 27 VBDC collected almost 1153units (58%) contributing to the blood stock. With restrictions on mass gatherings, VBD camps could not conducted which resulted in further decline of our blood stores. In Phase II only 93units (6.5%) were collected .With government guidelines on resuming voluntary blood camps again, 8 camps collected 236units (12%) in the declining phase. With the wrath of the deadly second wave, only 76 units (2.2%) were collected to contribute to the blood stores.
The phenomenon of decrease in voluntary donation has been seen in many countries globally. In a study conducted by Yahia et al from King Abdullah Hospital, Bisha, Saudi Arabia, published their eight months experience ie (from September 2019 to May 2020) with blood supply and demand. They noted a significant drop of 39.5% in blood bank-based in house collections. At the same time, they also noted a drop in blood demand by 21.7% 13. Wang et al. also reported a similar experience from The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China 14
The average issue of PRBC Units was high with the average of 1180 units during the pre pandemic Phase I. With halt in almost all elective surgeries and non urgent medical procedures, the average PRBC issued in Phase II was only 681units.With return to normalcy and increase in IPD services, the PRBC issued in Phase III again increased to 1108units.With the upsurge of Covid-19 cases again, the number of PRBC units issued was only 866units. However in Phase IV, the major requirement of PRBC units was anemia (non bleeding), being the major reason for transfusion. This was a concurrent finding from a study in Italy where 39% of the admitted patients required PRBC transfusion for the indication of anemia (non bleeding) in first 15days of hospital admission15.
The majority of demand of platelet (PLT) units generally comes from oncology and surgical wards. While wards were functional in full capacity in Phase I, the average platelet demand 15% which declined to 13% in Phase II. With start of OPD’s and non Covid admissions, the average demand of PLT in Phase III further increased to 19%.With the start of second wave towards the end of March, all non urgent admissions were deferred to reserve Blood components for Covid-19 patients. An increase in demand in PLT supply is seen due to thrombocytopenia and widespread use of anticoagulants in ICU and HDU (High Dependency Units) 8.But our PLT demand was only 4.65% in Phase IV. This result was not in-concurrence from the other studies. Although the association of thrombocytopenia is seen as a marker of poor outcome in patients of Covid1916.
While assessing the demands of FFP (Fresh Frozen Plasma), Phase I being the Pre Pandemic Phase showed the average of almost 1248 units(62%) while the Pandemic phase II showed a decline with demand of just 514 units (36%) .The phase III again showed increase in the rise of demands of FFP amounting to 1164 units(58%).
A typical and distinct pattern of coagulation disturbance, including raised D-dimer concentration, has been seen as a poor prognostic marker in Covid 19 patients.17.Inspite tests suggests hypercoagulability, onset of acute disseminated intravascular coagulation is not seen in patients of Covid-1918. Apart from this, patients with COVID-19 also show elevated levels of fibrinogen, normal platelet counts, often normal prothrombin time(PT) and activated partial thromboplastin time(APTT).19The demand of FFP in Phase IV was an average of 966 Units (29%). A study conducted in France showed 64(43%) patients out of 150 presented with thrombotic complications,but only 3% patients presented with bleeding complications.20 Till date, however bleeding complications that could increase blood component requirements have not been frequently seen in patients of Covid-19.21
In the 1890’s, passive immunization therapy has been successfully used to treat infectious diseases. Following identification of those with high titers of neutralizing antibody, convalescent plasma (CP) containing these neutralizing antibodies can be administered in individuals with a specified clinical disease to reduce symptoms and mortality.22
A general principle of passive antibody therapy is that it is more effective when used for prophylaxis than for treatment of disease23.The antibody works by modifying the inflammatory response, which is also more easily achieved during the initial immune response, a stage that may be asymptomatic24
With keeping in mind the early benefits from plasma therapy in Covid-19 patients, we administered a total of 181 units of Convalescent plasma in three phases of the pandemic.69units were transfused in the pandemic phase, 34units in the declining phase and 78units in the second wave of the pandemic.
Lastly we also kept a record of the outdated units beyond expiry (OBDE) as well. In phase I, the OBDE units were 218(11%) of the total collection. With the pandemic phase and no elective surgeries being conducted, the number of ODBE units increased to 301units (21%).This was due to unused blood components. In Phase III, with good utilization and increase in In-house donations, the number of OBDE was reduced to 201units (10%).With less donations and less components prepared, the number of OBDE units in phase IV was only 114units (3.4%).The older units that are discarded does not amount to wastage per se, qualitatively it is not considered as “good transfusion practices”.
An emergency preparedness plan is necessary for all healthcare setups to face a pandemic like COVID 19.25 There is a dire need of an action plan to mitigate and attenuate the potential shortage of blood supply and manage the blood transfusion services efficiently. Apart from protocols laid down by WHO (World Health Organization) and NBTC (National Blood Transfusion Council) to ensure smooth and safe blood transfusion services26, many proactive measures like contacting with NGO’s, military/Police services, religious/cultural associations will also help in mobilizing a large number of donors in short time. Lastly Educating people and creating awareness about the availability of safe (in accordance with safety guidelines of Covid-19) and accessible options of blood donations will encourage more people to donate blood.