National Blood Service (NBS), a branch of National Health Service (NHS) collects and distributes blood and its components in England and North Wales. It was established in 1946 as National Transfusion Service and started partnership with NHS in 1948 (National Blood Service). The transfusion of blood and its products are widely used to replace blood loss due to anaemia, surgery or any other type of severe blood loss in the patients. Blood should be transfused in a correct way to the right patient avoiding the risk of any infections. Efficient transfusion can only be obtained if the supply of harmless blood is sufficient and high-quality clinical practice is implemented (Murphy et al., 2011). However there is always a possibility of certain types of risk which may affect the patient's health (Overfield et al., 2008). NBS relies on the voluntary donations of blood from the public and there are many blood centres throughout the UK from where NBS collects blood. It supplies laboratories for screening blood components and provides training to the transfusion specialists and other staffs who work for the transfusion units (National Blood Service).
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In the past, people did not have much information about the infections caused due to blood transfusion so there was more chance of getting infected by blood related diseases. But with the development in science and technology, today people are more concerned about the infection acquired through blood transfusion. NBS plays a great role in improving the quality of transfusion service in England and North Wales. Hence the risk of transfusion acquired infection is decreasing every year (Taylor et al., 2008). Serious Hazards of Transfusion (SHOT) scheme was introduced first in the UK in 1996. It is a haemovigilance scheme and its main purpose is to anonymously collect and analyse any adverse reactions in transfusion from all healthcare organisation in the UK that deals with transfusion (Serious Hazards of Transfusion). Deaths of 105 patients and morbidity in 296 patients due to transfusion between 1996 and 2005 have been reported by the SHOT. From the study by Taylor et al, improvements in the safe transfusion practice are found to be made by NBS however not all hospitals have showed improvement (Taylor et al., 2008).
In recent years, NBS has shown much improvement in the infrastructure of blood transfusion and is working hard to minimise the transfusion acquired infections. Before 1975 NBS used glass bottles to collect blood but in 1975 NBS replaced the glass bottles with the plastic blood bags. This would allow a much wider utilisation of blood components (National Blood Service). NBS also introduced HIV testing in 1986 and hepatitis C screening in 1991. Similarly in 1999, it introduced the Nucleic acid Amplification Technology (NAT) which is used to identify viruses in their premature stages. The use of NAT ensures the transfusion to be much safer (National Blood Service). Blood is usually separated to different components such as red cells, plasma, and platelets before transfusion. Different components are used in different treatments for example, red cells are used to treat anaemia, plasma (fresh frozen) is used during cardiac treatment and platelets are used in leukaemia treatment (National Blood Service). Transfusion of white blood cells filtered blood has a lower mortality rate (Watering et al., 1998). Patients are transfused with the whole blood in very rare cases for instance if the patient is undergoing severe blood loss (National Blood Service).
There are many general precautions followed by NBS while making selections of the donors, handling and storing blood to minimise the risk of infection. The blood products should be treated before the transfusion to minimise the risk of getting infection and the right blood component should be selected for the right patient. In the UK, to be eligible to donate blood, the donor must be of age 17 to 65 and healthy (National Blood Service). The donors should provide their details like their names, address and date of birth and they are made to complete a questionnaire to find out any harm that may be caused to the recipients. Different criteria such as the donor's lifestyle, recent travel to foreign country, previous transfusion, family history of diseases, current health conditions are assessed before making selection of donor (McCullough, 2005). NBS emphasises on any medications taken by the donor as this may affect the blood for instance if the donor is taking aspirin then it badly affects the platelet quality (Overfield et al., 2008). The most important step in transfusion process is to identify the right donor for the right patient as blood transfusion to wrong patient leads to serious hazard or even death (Murphy et al., 2011). In 2005, SHOT reported that 18% of the patients were transfused with the wrong blood components due to misidentification of the right donor (Overfield et al., 2008).
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Before any transfusion, the ABO and RhD blood group of the patient and the donor should be identified because administration of incompatible blood is the most frequent cause of fatal transfusion reaction (Taylor et al., 2008). The red cells should be tested atleast twice for ABO and RhD to confirm the blood group. Also HLA typing is performed to find any harmful effect that may result after transfusion. NBS also ensures that all the blood samples are mandatorily tested for HIV-I and 2, human hepatitis B and C, and human T cell leukemia virus (HTLV) before using for transfusion (Mc Cullough, 2005). HIV test for the blood donors in the UK was introduced in 1985 and has been a compulsory screening since then. The study carried out by Perry et al in 2008 demonstrated that the performance of HIV screening kits in the UK has been enhanced over time and thus safety of transfusion has been improved (Perry et al., 2008). Variant Creutzfeldt - Jakob disease (vCJD) is also one of the transfusion acquired infections and people with an increased risk of vCJD are disqualified to donate blood (Dobra and Bennett, 2006).
The collection of blood is also a major part where transmission of infection is likely to occur. Therefore the blood is collected in such a way that the maximum sterility as possible is achieved. Antiseptic cleansing is normally used to cleanse the venepuncture site in the skin however there may be some possibility of airborne pathogens to enter (Overfield et al., 2008). It is also very important to label all the cointainers correctly and they should be sterile. In addition the blood components should be stored within the specific temperature; normally red cells are cooled within the range of 4oC Â± 2oC (James, 2005). Even during processing the blood components bacteria may enter and therefore the blood should be handled with great care following aseptic technique (Mc Cullough, 2005). To separate the different blood components in the transfusion centres, hermetically sealed transfer bags are used. Once those bags are taken to the hospital transfusion units, they are opened and the leucocyte depletion filters are attached to those bags. Besides there should be right conditions for storage after opening the bags to minimise the risk of propagation of bacteria and the storage time should be strictly controlled. Anticoagulant must be used while storing the blood to avoid the coagulation of blood (Overfield et al., 2008).
In the early 1980s, HIV affected a large community of homosexual men and from that time NBS has been excluding blood from men that have sex with other men which is now a legal requirement (National Blood service). A study was carried out in 2003 to find whether exclusion of homosexual men contributes to the safety of the blood which demonstrated a positive result. In particular, HIV transmission was found to be prevented by excluding homosexual men for transfusion (Soldan and Sinka, 2003). NBS set up a "transfusion- related acute lung injury" (TRALI) risk reduction group in March 2003 to find out if this risk can be reduced. The risk of TRALI was found to be higher after transfusing platelets or fresh frozen plasma (FFP) compared to the red cells. One of the approaches to reduce this risk was to discard the plasma from the female donors as the plasma from females has a higher risk of TRALI. After the exclusion was implemented, there was a reduction in TRALI. The data from NBS shows that 90% of the plasma in 2007 was from the male donors (Chapman and Williamson, 2008).
It can be concluded that several improvements have been made over time in the policies implemented by National Blood Service to ensure that the infections due to transfusion are prevented. However there is always some chance of getting infections, therefore the quality of the transfusion can be maintained or improved by training the staffs and monitoring the transfusion units frequently. In addition electronic system can be implemented in all the hospitals as it helps to identify the correct patient. There are also various sources of infections present in hospitals other than transfusion. Therefore the transfusion scientist must be aware of the different sources of infections in the hospital and also consider the infections that may occur after transfusion. The risks of transfusion acquired infections can only be prevented if all the bodies related to the blood transfusion including hospitals; transfusion centres and laboratories work together to provide a qualitative service. The transfusion unit should be reported in case of any undesirable reaction during or after transfusion. In case of any other infections such as viral infection due to transfusion, it should also be informed to the related authority. Thus precautions must be taken in each stage of transfusion from the selection of the donor and collection of blood through to the screening of blood and the correct identification of the donor.
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