Transfusion and Apheresis Science 41 (2009) 145–149

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Transfusion and Apheresis Science

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Platelet utilization in the developing world: Strategies to optimizeplatelet transfusion practices

Anupam Verma *, Prashant AgarwalTransfusion Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, India

a r t i c l e i n f o

Keywords:Platelet transfusion

Developing worldAppropriatenessStrategiesBlood transfusion services

1473-0502/$ - see front matter � 2009 Elsevier Ltddoi:10.1016/j.transci.2009.07.005

* Corresponding author.E-mail address: aver@sgpgi.ac.in (A. Verma).

a b s t r a c t

There is perennial shortage of blood and blood components in most of the developingworld. The resources are inadequate in terms of meeting the ever growing demand of bloodcomponents especially platelets. A poor health care system has led to underdevelopment ofblood transfusion services which ultimately affect the transfusion practices. There is a pau-city of comprehensive data on the platelet usage from the developing countries which isreflective of their modest development in blood component therapy. This is in sharp con-trast to the fast pace of development in platelet transfusion practice in developed worldwhere platelet substitutes are to become a reality for clinical use in near future. In devel-oping world a considerable heterogeneity exists for platelet transfusion practices betweencountries, and even within countries in hospitals where this precious resource is available.This variation in existing practices can partly be explained by factors like individual pref-erences, lack of any hospital transfusion policy with regard to platelet transfusion, prob-lems of platelet availability, etc. There is a need to implement best platelet transfusionpractices as platelet products are scarcely available and expensive. Few interventions areemphasized in this article in the context of improving the status of platelet utilization indeveloping countries.

� 2009 Elsevier Ltd. All rights reserved.

1. Introduction

Platelet transfusions are administered to patients acrossall age groups to prevent or treat bleeding in patients withquantitative or qualitative defects of platelets [1]. Theplatelet products are one of the most expensive blood com-ponents and also, among the most misused blood productseven in developed world [2]. In developing world there islimited availability of platelet products as only few bloodcenters have component separation facility and thus a lim-ited data is available on this topic. This paper attempts toassess the platelet usage patterns and platelet transfusionpolicies in resource limited nations and provide sugges-tions for its optimum use and future development.

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The platelet utilization for that matter usage pattern ofany other blood component is determined by severalinterlinked factors, viz., local circumstances in terms ofpatient populations served, level and standard of health-care services available, availability of adequate bloodcomponents, level of education and training in transfusionmedicine etc. A glimpse into various blood transfusionservices operating in different countries in the developingworld is presented here, which has direct relevance withvaried platelet transfusion practices observed in resourcelimited countries.

2. Blood transfusion services and policies in thedeveloping world

The developing world with low human development in-dex has limited access to the resources, be it financial,technical or others. As per World Health Organization

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(WHO), developed world with 20% population is using 55–65% blood supply of the world annually [3] whereas, devel-oping world has limited access to hemotherapy support.Moreover there is ineffective use of available resourceswith low productivity in resource limited countries [4].Sri Lanka has better organized blood transfusion services(BTS) compared to most of other developing countries inAsia, for example, India, Pakistan, and Bangladesh whichhave fragmented BTS. In India 2530 blood banks are oper-ating in public and private sectors [5]. National AIDS Con-trol Organization (NACO) is supporting modernization ofall major blood banks at state and district levels. As perthe action plan for blood safety under National AIDS Con-trol Program phase III (NACP-III for year 2007–12) thepercentage increase of blood being processed into com-ponents from 20% to 50% is envisaged [6]. In India, espe-cially in large cities, the hospital based blood banks havemade some appreciable progress in the field of transfusionmedicine, as they cater to the hospital blood needs, so theirresources are allocated and managed accordingly. Addi-tionally, hospital blood banks in government and privatesectors are able to respond quickly to the changing needsas per the pace of development in clinical departments toprovide better hemotherapy to their patients. Approxi-mately nine million whole blood units are collected annu-ally as against estimated requirement of about 15 millionunits in South East Asian Region [7]. These countries alsopresent with marked variation in percentage of voluntaryblood donors which are crucial for any successful bloodprogram. The blood and component cost recovery is notuniform in majority of developing world, notably in mostof the South East Asian countries. In China, all blood ser-vices and blood banks (over 300 blood services and morethan 100 blood banks) are established by governmentand health authorities [8]. BTS consist of 32 blood centersat provincial levels and remaining are regional blood ser-vices at prefecture levels. In 2005, the rate of componentpreparation was 88% with some areas having more than99% component separation [8]. The component therapy isan indicator of hospital performance assessment in China.In the Middle East region, Iran has one of the most compre-hensive blood transfusion systems with self sufficiency inblood and blood components. However, due to absence ofa national protocol for use of blood and blood componentsand availability of these products free of charge, inappro-priate use of blood products including platelets is the ma-jor challenge in Iran [9]. Similarly countries in LatinAmerica also have fragmented BTS. Blood transfusion-re-lated activities are government regulated, while imple-mentation of activities is the responsibility of agovernment central blood bank, hospital blood banks,non-government institutions, or a combination of all ofthe above [10].

Thus there is no uniformity in the organizational struc-ture of blood banks in the resource limited countries.Majority have fragmented BTS with some of the bloodbanks operating in government and some in private ornon government organization sectors. Moreover, thereare differences within the same hospital and among vari-ous user departments as regard to blood transfusion prac-tices as there are no national guidelines on appropriate

usage of blood components and limited awareness of clini-cians to transfusion medicine. Most clinicians are notaware of the ‘‘platelet transfusion triggers” and have noknowledge about transfusion guidelines and thus platelettransfusion practices are bound to vary. The modern bloodbanking is in transition phase at most centers in resourcelimited countries. The initial focus on enhancing voluntaryblood donor base and blood safety is slowly paving way forcreating more component separation facilities which is anappropriate step as only after attaining acceptable bloodsafety, provision for blood component facility seemsprudent.

3. Platelet usage in developing vs. developed world

The readily availability of platelet concentrates haschanged the way the modern clinical medicine is practisedin the developed world whereas the developing world haslimited availability of this precious resource. In developingworld even those blood centers which have blood compo-nent facility, the production and utilization of platelets dif-fer. Few differences related to platelets and theirtransfusion between developed and developing world isshown in Table 1. In general the scenario is almost similarto transfusion practices of other blood component(s) asmost resource restricted countries have financial, organi-zational, technical and operational deficits.

4. Platelet usage pattern in some of the countries fromthe developing world

A retrospective study from Sri Lanka [11] to estimateplatelet transfusion appropriateness involving 515 requestforms for one year duration was carried out. Nearly 41%random donor platelets (RDP) transfusions from medicalwards (general medical and hematology wards) and 49%of transfusions from surgical wards (general surgery,obstetrics and gynecology and cardiothoracic surgery)were found out to be inappropriate using British commit-tee for standards in haematology (BCSH) guidelines. Mostinappropriate transfusions (50%) were reported from car-diovascular and thoracic surgery (CVTS) (largest consumerof platelets) in prophylactic category and from generalhematology department [11]. A six month retrospectiveplatelet audit from a tertiary care hospital of India revealedthat majority of platelets prepared were RDP (98.5%) andremaining 1.5% platelets were single donor platelets(SDP) [12]. The majority of RDP were prepared by plateletrich plasma platelet concentrate (PRP-PC) method (69%).Out of total 5444 RDP transfused to 814 patients the threemain user specialties were adult hemato-oncology (28%)followed closely by pediatrics (27%) and pediatric hemat-o-oncology (11%). Similarly for SDP, first three major con-sumers were adult hemato-oncology specialty (84%)followed by CVTS (6%) and pediatric hemato-oncology(4%). Mean ABO group specific RDP utilization per patientwas 4.94 units. However the average RDP dosage per trans-fusion episode was less than 2 (range 1–5 units). Overallabout 71% RDP were utilized as against 100% utilizationfor SDP. Approximately 21% RDP units expired and the rest

Table 1Some of the differences related to platelets and their transfusion between developed and developing world.a

Developed world Developing world

Platelets are readily available from whole blood donors and apheresis donors Either not available or limited availability of platelets; lesser SDP usage dueto high cost and lack of technological advances

BC-PLTb used in Europe and PRPc in USA Mixed (PRP > BC-PLT)Leukodepleted platelets are generally used as inline whole blood

leukodepletion filters or separate platelet filters are usedFilters for leukodepletion are not available due to high cost, only used insome cases

Availability of national guidelines or locally approved preset criteria forplatelet transfusion, thus less heterogeneity in platelet transfusionpractices

No national transfusion guidelines. Individual preferences thus nouniformity in platelet transfusion practices

Adequate dose; pool of 5–6 RDP given Many patients receive inadequate dose; individual units of RDP aretransfused

Quality control of platelets done including use of automated culture systemfor bacterial contamination

No quality control checks including for bacterial contamination

Pathogen inactivation system for platelets are in use in Europe for microbes Too costly, other issues take priorityConsideration of ABO and Rh matching for RDP No regard to ABO and Rh group for RDP at most places however group

matched SDP are usedCross-matched platelets, HLA matched platelets are available for

alloimmunized refractory patientsNo such facility available for refractory patients

SDP now constitute bulk of platelet transfusion needs RDP constitute bulk of platelet products transfusedJustification for platelet transfusion is documented in most of the request

formsDocumentation is given less importance

Monitoring for efficacy is done routinely including corrected countincrement

Hardly any monitoring for efficacy other than clinical observation and/orplatelet count

Platelet outdating is main reason for discarding of platelets Less outdating as most centers transfuse platelets across ABO barrier and atsome places platelets only prepared on as and when required basis

Extended storage of SDP till 7 days has been disapproved hence currently allplatelets are being stored for 5 days

Five-day storage (3 days at some places depending on type of storage bag)

Specialized products like irradiated platelets, hyper-concentrated platelets,etc. are readily available at major centers

Only rare centers have such products

a These are the general statements; these may not be applicable to some of the centers.b Buffy coat removed platelets.c Platelet rich plasma.

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were discarded due to various other reasons. About 74%RDP were transfused therapeutically whereas remaining26% were utilized prophylactically. In contrast only 22%of SDP were used for therapeutic reasons. Of the patientswho received RDP majority received ABO matched RDPunits with only 5% RDP given across ABO barrier whereascent percent ABO and Rh matched SDP were transfused.In this study, the inappropriate prophylactic platelet trans-fusion rate was 12% which was reported from CVTSspecialty using BCSH guidelines. However the inappropri-ateness was not discussed under prophylactic and thera-peutic categories for other specialties [12]. Similarly aprospective study from another teaching referral hospitalin North India reported specialty wise usage pattern ofplatelet concentrates over a period of 2 months [13]. Herea total of 1746 RDP from 2592 whole blood donations, allof which prepared by buffy coat removal (BC-PC) methodand 48 SDP from same number of apheresis donors wereprepared. A total of 1101 RDP (66%) were transfused pro-phylactically against 221 requests (64.4%) while, 571 RDPwere transfused for therapeutic (35.6% requests) reasons.Twenty-three percent of prophylactic requests and 15% ofthe therapeutic requisitions were not justified. Theunavailability of pre-transfusion platelet count was foundto be the most common reason for unjustified prophylactictransfusions [13].

Over all, 4.87 RDP units were transfused per episode.This was closer to optimum adult platelet dose (1 unitof RDP/10 kg body weight) as majority of patient popula-tion studied were adults unlike earlier study from India

where patients received less than 2 units of RDP, whichmay be due to preponderance of pediatric patient popula-tion in that study [12]. Another difference in platelettransfusion practice at this center was that the RDP weregiven without consideration to ABO and Rh compatibility[13]. The platelet expiry rate was relatively very low com-pared to the study by Saluja et al. [12] which revealed ahigh wastage rate which can partly be explained by useof ABO matched platelets in latter study. An interestingobservation came from this study where the authorsfound occurrence of increased requisitions received dur-ing weekends for platelet products in view of anticipatedshortage of platelets. This led to increased production ofRDP to meet the demand during such times [13]. A retro-spective study from the same hospital reported 21.5%inappropriate platelet transfusions in year 2003 dengueepidemic [14]. A total of 826 RDP were transfused to245 patients affected with various categories of dengueinfection (3.4 units/patient). Similarly widespread misuseof platelets had been observed in dengue epidemics inSouth East Asia as many of these thrombocytopenic pa-tients were transfused without any signs of bleeding[15–17].

A prospective audit from a pediatric hospital in KualaLumpur, Malaysia was performed during one month periodwhile a retrospective collection of data was carried out forthe previous month for comparison [18]. Based on locallyapproved criteria, it was found that in 18.5% (22 of 119)of the cases, the indications for platelet transfusions werenot justified. The major users were patients admitted in

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hematology and oncology specialties which accounted formajority (53.4%) of the total number of requests. Besidesthere were 37 (29%) requests for platelets for patients withdengue hemorrhagic fever. It was also observed in thisstudy as a part of quality indicators for platelet transfusionpractice that about 6% cases received their platelet transfu-sions more than 6 h (cut off time for optimum turnaroundtime) after the requests were made [18]. A study from Ven-ezuelan hospital showed 70% prevalence of appropriateuse of platelets in adult patients according to criteria setby NIH Consensus Conference for platelets in departmentsof medicine, surgery, obstetrics and emergency [19]. Mainindication was prophylactic use in patients with bone mar-row failure. Information regarding platelet dose and othertransfusion details was lacking.

There are number of limitations that need to be consid-ered when interpreting these data. First, patients/depart-ments who were the main users of platelets might havebeen disproportionately represented in some of the stud-ies. Patient characteristics including diagnosis, procedures,and severity of illness might have contributed to the likeli-hood of specific patient groups receiving platelet transfu-sion more than the others, for example, aplastic anemiapatients, neonates admitted in intensive care units whichrequire repeated dosing whereas one episode of platelettransfusion is sufficient in most cases of cardiac surgerypatients. Second, there are no studies except one [13]which has discussed the misuse of platelet transfusion un-der both therapeutic as well as prophylactic categories,majority of the studies have elaborated either on the ther-apeutic or on the prophylactic misuse only. However, thisdata provide a baseline regarding the overall platelet trans-fusion practices, including method of preparation, utiliza-tion pattern in different specialties, wastage rate and rateof overall appropriateness. It provides us an opportunityto use interventions aimed at promoting appropriate useof platelets.

5. Key points

� Limited availability of platelet products. In centerswhere platelets were used, only few selected centersprocessed up to 60–70% of whole blood donations intoplatelets.

� Platelet transfusion patterns were marked by heteroge-neity in all areas of transfusion practices, including doseof platelets transfused, methods of preparation of plate-lets, concern about ABO and Rh matching, proportion ofplatelet transfusions given for treatment of bleeding orfor prophylaxis and outdating rate.

� In most of the studies the difference in appropriatetransfusions may be due to difference in patient popula-tion or use of different guidelines for assessment ofappropriateness. The misuse of platelet transfusion ran-ged from 12% to 49% for prophylactic purpose in differ-ent studies. This highest and lowest percentage ofmisuse occurred in cardiac surgery patients whereplatelet counts were normal and no evidence of bleedingrelated to platelets was present. In therapeutic category,inappropriate use was 15%.

� Appraisal of transfusion practices revealed that inappro-priate transfusions were more when platelets weretransfused for prophylactic reasons. Hemato-oncology,cardiac surgery patients and dengue patients (duringepidemic) were the main users of platelet products.

� Most of these studies did not comment on the qualityindicators in platelet transfusion practices viz appropri-ate amount of platelets requested adequate dose issuedand transfused; turnaround time; post-transfusionefficacy.

6. Strategies for improving the status of platelettransfusion practices

To become successful, a sound and realistic strategyshould be employed, starting from the identification ofkey problems being faced by a hospital as regard to bloodtransfusion. ‘‘One size fits all” policy does not work here.The strategies which can be applied to improve plateletusage and overall platelet transfusion practices in the re-source limited countries are:

General strategies:� Formulation of a national blood policy and development

of a national blood program. Help may be taken fromWHO documents [20].

� The concerned governments have to take up the respon-sibility to create facility for adequate number of bloodcomponent separation units.

� An effective safe, voluntary blood donor base.� Human resource development for trained manpower

especially training of all hospital staff involved intransfusion.

� Setting up of hospital transfusion committees toimprove overall transfusion practices including hemo-vigilance and audit.

� Locally available transfusion guidelines for rational useof platelets.

� Networking with other blood centers and setting upsatellite centers having platelet storage facility.

� Interaction between clinicians and transfusion medicinespecialists. Understanding the blood center’s limitationswill enable the clinicians to prioritize and make optimaluse of platelet units that are important to the treatmentof a patient.

Specific strategies:� Reducing outdating of platelet component (RDP) units by

allowing platelet transfusions across ABO and Rh barrier.� Increasing platelet inventory by maximizing component

separation from whole blood donations and increasingplateletpheresis procedures.

� Standard blood request form can provide informationabout platelet transfusion triggers which can guide theclinicians in making the decision for transfusion.

� Monitoring of requests for platelet transfusions.� Prophylactic use of platelet transfusion need to be fur-

ther evaluated and grey areas need to be discussed byclinicians and transfusion specialist.

� Efficacy after platelet transfusion should be monitoredalso by corrected count increment.

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7. Conclusions

Platelet transfusion therapy has steadily increasedworldwide over the years but the progress made so farin the developing world is not up to the mark. Inappropri-ate use of blood component leads to extra financial burdenon existing health care expenses apart from compromis-ing patient safety. It is not difficult to ascertain the causesfor the poor standards of platelet transfusion practices inresource limited countries. Considerable effort has to bedirected towards improving platelet utilization practices.Monitoring platelet transfusion practices, would be bene-ficial for improving efficacy and limiting costs. Presentlythere are no established alternatives for human derivedplatelets. The platelets should be used judiciously moreso, when it is an expensive product and not readily avail-able. Finally there is need for increasing the voluntaryblood donation with more availability of blood compo-nent separation facility, increasing the percentage of com-ponent preparation, increasing pool of plateletpheresisdonors, conducting transfusion audits, decreasing wast-age due to expiry, having better transfusion policiesincluding minimizing needless platelet transfusions andconsidering use of appropriate pharmacotherapy in spe-cific situations.

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