Life-giving blood

Dr. Erdenebayar Namjil, M.D., Ph.D., Associate professor of Mongolian National University of Medical Sciences, General Director of National Center for Transfusion Medicine talks with The Mongolian Observer about the quality and availability of blood, an agency that is involved in a life-saving mission.

    Every year, on 14 June, countries around the world celebrate World Blood Donor Day – WBDD. The event serves to raise awareness of the need for safe blood and blood products and to thank blood donors for their life-saving gifts of blood. How was this day celebrated in Mongolia?
In Mongolia, we have been observing the WBDD since 2003 and World Health Organization (WHO) has been celebrating the Day under different watchwords every year. Giving high importance to WBDD, we also try to organize an encompassing and productive Day as we believe that the Day can be used as a tool for raising awareness of the Government to the issue of blood donor.
Let me give you an example. More than two thirds of Mongolia’s population live in and all the central hospitals and special medical centers are all located in Ulaanbaatar, putting a heavy burden on medical services including increased demand for blood as the country is undertaking liver and bone marrow transplant. In other words, we are able to meet the growing demand for blood for different patients, we are able to meet the demand only by taking blood from as many donors as possible. In view of this, we do not celebrate the World Blood Donor Day as a one-time event but rather we feel it more important to raise awareness among the public for intensifying the donor movement and accordingly, we must plan different activities. We have special blood donor promotion events and together with the Ulaanbaatar City Municipality we have a regular blood donor on the 3rd of every month. On this day this year, the Ulaanbaatar City Mayor and Governor S. Batbold donated blood and made an appeal to blood donors.

    You just mentioned that your Center has announced every 3rd of the month as “Blood Door Day.” What has been the reaction of the residents of Ulaanbaatar?
Blood Donor Day was first launched in April 2014 when the Ministry of Health passed a relevant order, as part of which our Center we have been regularly carrying our training for donors and media campaigns involving organizations, businesses, NGOs and government agencies in an effort to increase the number and ranks of blood donors.
Why we have chosen the 3rd of every month is quite significant too. Mongolians regard number 3 as a lucky number, which symbolically also implies the past, present and future and the message is that if you donate your blood you can save 3 lives. Most importantly, the objective behind such a monthly campaign is to increase the number of blood donors. A person who is giving his or her blood for the first time is considered a blood donor but those who donate blood two or more times in a year are regular donors, and the higher the number of the latter, that better can we ensure blood safety. This action is also designed at increasing awareness and knowledge about blood donation.

    How did you observe this year’s World Blood Donor Day?
The host country for the global event of World Blood Donor Day 2017 was Vietnam and we celebrated WBDD on the same day on 14 June, and the highlight of the event was that it was simultaneously celebrated in all the aimags of the country and not only in the capital city of Ulaanbaatar. This year our focus was on response to emergency and globally all countries are giving priority to ensuring sufficient stocking of blood and blood products.

World Blood Donor Day 2017. Dr. Erdenebayar, General Director of NCTM awarding Mr. Bum-Erdene with the First Top 200+ Donor for donating blood more than 200 times

In Ulaanbaatar, this year’s WBDD was organized at the National Park where we publicly recognized our regular donors with the medal “Honorary Donor,” and we have a special event celebrating a donor Bum-Erdene who is the first Mongolian to donate blood more than 200 times.
Your center certainly would have a data bank for research and statistics purposes. How many regular blood donors are there in Mongolia and how does Mongolia compare in this indicator with the rest of the world?
An important indicator is how many blood donors are there per 1000 of the population. In this sense Mongolia does not hold a high place. WHO recommends that if this indicator is 1.5% for a developing country like Mongolia, then it’s fine. In 2012 every 7 out of 1000 people used to donate blood, and five years later today the figure has risen to 11 out of 1000, which is not a bad showing. In Ulaanbaatar, in particular, this figure is 18 per 1000 of the population, meaning that the requirements for blood are being fully met. However, in the rural areas, this figure is small, it’s 5 out of every 1000, and this is because the scale and scope of medical services in the rural areas are relatively small and subsequently the requirements for blood and products are small too.
On the other hand, worldwide rational use of donor blood and blood products is a priority. In Mongolia today, the number of medical facilities requiring blood is growing. We supply blood on a contractual basis. And we urge the medical facilities and doctors to promote rational use of blood, asking them not to use blood for patients who really do not need blood. In recent years use of blood in the industrialized European countries is becoming lower simply because of rational utilization and also, because of broader application of alternative medical treatment methods as well as rational use of donor blood. Today in Mongolia we are seeing an increase in the number of blood donors because of the growing number of cancer and blood disease patients and growing incidence of accidents and trauma, frost-bite, burns and complications during birth.
At present, we do not see any tendency that shows the requirement for blood will decline, on the contrary, the demand will grow. Proceeding from this premise we believe that we need to give priority attention to increasing the reserve of donor blood.
There is an increasing number private hospitals and medical centers. How does your center regulate blood supply to both private and public hospitals?
Mongolia has a Law on Blood Donor, adopted in 2002, which was amended in 2012. It will be renewed and updated this year where we plan to include provisions on management of blood donation and celebration of blood donors.
Under the law, as well as an order of the Health Ministry, our center is obliged to provide our services to hospitals and medical irrespective of their affinity, whether they are public or private, but at the same time they must equally comply with some of our requirements. For instance, both public and private medical centers must have proper containers for transporting, storing blood and blood products, and dedicated doctors and medical experts to handle them.
Our center produces almost 82 percent of all blood and blood products of the country, more than 30 percent of which is used by the Central Polyclinic Hospital Number One in Ulaanbaatar. At present, the number of private hospitals with high requirement for blood and blood products is not that numerous. Primarily public hospitals and third grade medical center have the highest requirements.

Source: WHO

    Do you have branches in the rural areas?
Blood transfusion was first introduced in the country in 1938 and it was done by Russian doctors and in those years, there used to be quite a high requirement for blood because of the numerous and regular border disputes and skirmishes. Our Center was first created in 1956 and then it had only one doctor and two nurses and in 2007 it was officially expanded as a National Center with the status of tertiary-level specialized medical center.
All the 21 aimags (province) of the country have central hospitals and they have a blood section. Our center provides professional and methodological guidance and management to these blood sections. The two remote districts of Ulaanbaatar – Nalaikh and Baganuur small blood centers, and in total we have 27 blood sections across the country.
Blood sections in the aimags are responsible for blood supply in their territory of jurisdiction. Given the vastness of our territory, soums and districts are located at great distance from the given aimag centers and when they require blood for an emergency, the soums have the data for blood donors, so the situation is taken care of relatively quickly. In most cases blood and blood products required at the soums are supplied from the aimag, but on the whole, the blood requirement in the soums is small. There are less than a dozen incidents in a year when the soums require blood.
In aimags too in recent years specialized private medical centers are being established in quite many numbers which are providing surgical services, which means that their requirement for blood is likely to surge.
The key mission and goal of our center is to provide safe and quality blood and blood products regularly and insufficient quantity.

    You have moved to a brand new facility, which means your center now has the latest in safe and quality blood collecting and distributing technology and system?

Haemonetics MCS®+, multicomponent collection system is dedicated to blood component collection including platelets, plasma, and red blood cells, and also performs therapeutic procedures

As I mentioned earlier about the law on blood donor, the Parliament in 2007 adopted a State Policy on Guaranteeing Supply of Safe Blood. A year later in 2008, the Government adopted a plan of action for the implementation of this state policy up to the year 2015 which included 41 action points for strengthening the national blood service. The Action Plan was fully implemented which was a major accomplishment for our health sector because the safety and quality of blood are not only our Center’s responsibility but also a priority cross-sectoral concern and that of the Government. Within its framework, more than 40 years later our new center was built. Alongside this all the blood sections in the rural areas were renovated and now we can say that we have close very close to international standards in terms of safe and quality blood.
People have a very simple notion about our center – they think we simply collect blood from donors and distribute them without realizing that it’s much more complicated than that. And we try to improve their knowledge and awareness, as mentioned earlier that we collect blood, put them to strict lab tests, produce and store them, quite a lengthy and complicated process.
The Mongolian Government and the Asian Development Bank implemented the “Health Development Program 5” under which our center and its branch sections were equipped with state-of-the-art world standard equipment for collecting, testing, producing, storing and transporting blood and blood products. In the past, we were not using special-purpose refrigerators for storing blood, which meant that the quality of our products was at risk. This has changed now and today we can store plasma products at minus 80 degrees Celsius, which means we can store it up to 5 years.

The INTERCEPT™ Blood System is a pathogen inactivation system proactive approach to transfusion-transmitted infectious risk reduction and provides continued protection through broad spectrum inactivation of viruses, bacteria, parasites and T-cells

    Can we understand that with technological renovation, data and information gather and registration have also become simpler?
In the last few years our center introduced 15 to 16 new technologies and their impact is already being felt. Electronic information system has been introduced in donor blood collection, meaning that a data recorder nurse is no longer required to manually input data regarding the donor and the donor blood. We also have applied new technology in blood collection, which is very important for the quality and safety of blood. In the past, we could store Red Cell for only 21 to 35 days, but with the introduction of a new type of solution, we can store it up to 42 days. Rare type blood is frozen using a special technology, making it possible to store it up to 10 years.
We have also been able to solve in a complex manner the cold chain technology including walk-in-cold room, +4 and -30 cold rooms, special-purpose refrigerators and freezers and ice boxes and they are all computer controlled.
We used to spend hours to freeze plasma products using old traditional technology, but now we have a rapid freezer that can deep freeze 18-20 plasma products at one time in just 15 minutes, which is important for the quality of the products. Also, frozen products were earlier put in warm bath for defrosting, but now we have special purpose defrosters.
We have introduced, for the first time in Mongolia, x-ray irradiation technology which can prevent adverse reaction and complications especially among patients who have had several blood transfusions, including children, and patients suffering from immunity deficiency and cancer. In 2003, we also introduced a latest technology called pathogen inactivation, which can inactivate different kinds of bacteria and viruses, which means the blood product is guaranteed 100 percent sterile. This technology is being used mainly in highly industrialized countries.
The capacity of our laboratory has also been significantly upgraded. In 2012, we introduced polymerase chain reaction bringing our standard to international level. Our center is involved in applying MEQAS or Mongolian External Quality Assurance System (EQAS) as well as EQAS – External Quality Assurance System. In 2015 our laboratory was successfully accredited under ISO MNS 15189 standard and by 2018 we are working for ISO 9001:2015 quality management system, which will make our laboratory the first in the health sector to introduce the system.

    In this connection, I have a question regarding blood analysis?
This is very important. The WHO makes it mandatory for screening and testing blood for Hepatitis B, Hepatitis C (HBV, HCV), HIV, Syphilis and I must say we are strictly following these recommendations as all the tests are being carried out in 100 percent of donor blood. As I already said, we have introduced ELISA and PCR methods. The Health Minister has passed a directive for blood transportation and we have been working on the accreditation of blood quality at the aimag level since last year and our goal is to apply PCR method for total accreditation of blood samples.

    How many donors are there in Mongolia and what kind of blood donors do we have? I understand that there are typically 3 types of blood donors: voluntary unpaid; family/replacement, and paid.
In the half century of our service, nation-wide we have more than 140 thousand donors registered, of whom there are over 1,200 Honorary Donors aged 35 and above. Through the history of blood donation, we have had all three kinds of donors, but in the last 20 years there have been many more voluntary, unpaid donors. In 1975 WHO assembly urged member states to promote the development of national blood services on voluntary non-remunerated donation of blood and within its framework, our senior donors had launched specific actions. At one time we used to have paid donors and in 1994 we started to promote voluntary unpaid blood donation and this effort was regulated through a Health Minister order in 2000.

Haemonetics MCS®+, multicomponent collection system is dedicated to blood component collection including platelets, plasma, and red blood cells, and also performs therapeutic procedures.

    What is the advantage of voluntary, unpaid donor?
There are typically 3 types of blood donors: voluntary unpaid; family/replacement, and paid. Each of them have their own advantage and associated risks too. The entire world is focused on promoting voluntary, unpaid blood donor movement. In our country, according to last 5 year’s statistics, 2-4 percent of all blood donors are family or replacement donors, as the help of family members is sought when there is a shortage of blood.
As of 2016, Mongolia became a 100 percent voluntary, unpaid blood donor country, which is a great accomplishment.

    How are blood donors awarded and honored?
Since 2015 we have been events to celebrate donors who have donated blood many times. We have several awards, such as the “Bronze Donor” for those donors who have donated blood 70 to 100 times, “Silver Donor” award for those who have given blood 100 to 150 times and “Gold Donor” who have donated blood more than 150 times. According to the Blood Donor Law, any donor who has donated blood more than 35 times is given a free 10-day voucher to a holiday center, and under a Health Ministry decree such a donor is provided free medical laboratory test. And, Honorary Donors have access to free public transport service. We also have special awards for 5, 10, 20, 30 donations in the shape of a heart and number of donations inscribed.
Some 135 people are working in the blood service, 70 of whom work at our center and the remaining in the rural areas. We also have a new non-governmental organization created by senior voluntary donors, some of whom are 80 years of age and we are working closely with them.
We also work closely with the Mongolian Red Cross Society, which under law, is responsible also for the training and advocacy of blood donors. I am member of the Steering Council of the Red Cross Society and I am trying my best to increase the Society and its volunteers’ involvement in the blood donation movement.

    Finally, how does Mongolia cope with a situation should there be shortage of blood, which tends to happen, judging by the experience of other countries?
Our center works 24 hours a day, 7 days a week attending the orders for blood and blood products from the hospitals. In our country, we have observed that certain types of blood tend to become short especially in late July and August, and during the New Year and the Mongolian Lunar new year of Tsagaan Sar. From practice we have seen that in the last 5 years the demand for Group O blood increases in July and August. Today more than 40 percent of Mongolians have Group O blood, 32 percent have Group B blood, 23 percent – Group A and only 7 to 8 percent have Group AB blood. Although every month we collect blood equivalent to the above ratio of blood groups, but it’s interesting why Blood Group A and B blood is in high demand in July and August? In summer normally Mongolians go on their annual vacations, students from the rural areas go back to their homes and owing to this and perhaps some other factors the number of donors from a particular blood group may decline and so this is one issue we need to pay attention to.
Alongside this, starting this year we are paying more attention to the rational use of blood and blood products by hospitals. Doctors have less experience in terms of blood study and so we need to focus on building up their capacity and knowledge in blood. We are also conducting planned training at all hospitals on clinical haemotology. We are hopeful the trainings will be productive and unnecessary transfusion of blood will decline.

Blood donors at the National Center for Transfusion Medicine. Photos courtesy of NCTM

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