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1.  Health system capacity: maternal health policy implementation in the state of Gujarat, India 
Global Health Action  2013;6:10.3402/gha.v6i0.19629.
The Government of Gujarat has for the past couple of decades continuously initiated several interventions to improve access to care for pregnant and delivering women within the state. Data from the last District Family Heath survey in Gujarat in 2007–2008 show that 56.4% of women had institutional deliveries and 71.5% had at least one antenatal check-up, indicating that challenges remain in increasing use of and access to maternal health care services.
To explore the perceptions of high-level stakeholders on the process of implementing maternal health interventions in Gujarat.
Using the policy triangle framework developed by Walt and Gilson, the process of implementation was approached using in-depth interviews and qualitative content analysis.
Based on the analysis, three themes were developed: lack of continuity; the complexity of coordination; and lack of confidence and underutilization of the monitoring system. The findings suggest that decisions made and actions advocated and taken are more dependent on individual actors than on sustainable structures. The findings also indicate that the context in which interventions are implemented is challenged in terms of weak coordination and monitoring systems that are not used to evaluate and develop interventions on maternal health.
The implementation of interventions on maternal health is dependent on the capacity of the health system to implement evidence-based policies. The capacity of the health system in Gujarat to facilitate implementation of maternal health interventions needs to be improved, both in terms of the role of actors and in terms of structures and processes.
PMCID: PMC3606923  PMID: 23522352
maternal health; policy; implementation; India; Gujarat; health system capacity
2.  Study of Blood-transfusion Services in Maharashtra and Gujarat States, India 
Blood-transfusion services are vital to maternal health because haemorrhage and anaemia are major causes of maternal death in South Asia. Unfortunately, due to continued governmental negligence, blood-transfusion services in India are a highly-fragmented mix of competing independent and hospital-based blood-banks, serving the needs of urban populations. This paper aims to understand the existing systems of blood-transfusion services in India focusing on Maharashtra and Gujarat states. A mix of methodologies, including literature review (including government documents), analysis of management information system data, and interviews with key officials was used. Results of analysis showed that there are many managerial challenges in blood-transfusion services, which calls for strengthening the planning and monitoring of these services. Maharashtra provides a good model for improvement. Unless this is done, access to blood in rural areas may remain poor.
PMCID: PMC2761785  PMID: 19489420
Blood-banks; Blood-storage centres; Blood transfusion; Emergency obstetric care; India
3.  Third Angle of RSBY: Service Providers’ Perspective to RSBY-operational Issues in Gujarat 
Government of India in 2008, launched its flagship health insurance scheme for the poor. The Rashtriya Swasthya Bima Yojana (RSBY) combines cutting edge technology with an unusual reliance on incentives to provide inpatient insurance coverage. The scheme allows for cashless hospitalization services at any of the empaneled hospitals. Stakeholders in RSBY include members of the community, Insurance Company and the service provider.
The study manuscript is an attempt to get an insight to understand the bottle necks in faced by the service providers with an overall goal to understand issues in complete roll out of RSBY and its successful implementation across country. It was conducted to undertake the stakeholder analysis and understand the service providers’ perspective to RSBY.
Setting and Design:
The present study was conducted in the Patan district of Gujarat state. Qualitative tool mainly in-depth interview of service providers of RSBY in Patan district of Gujarat state was utilized for the data collection.
Results and Conclusion:
Service providers opined an ineffective IEC around the utility of the RSBY service in the community. In spite of the claim that scheme relies heavily on technology to ensure paperless cashless services, on field, it was observed in the present study that the claim settlements are done through physical documents. The service providers had a perceived threat of being suspended from the list/de-empanelment of the provider by the insurance company. There is an urgent need for improved and effective IEC for the service and possibilities of an arrangement for to settle the case of grievances around suspensions ao that genuine hospitals can have fair deal as well. There definitely remains a greater and more serious role of government, which ranges from ownership to larger issue of governance.
PMCID: PMC3894038  PMID: 24479073
BPL community; insurance companies; Rashtriya Swasthya Bima Yojana; service provider
4.  The State-Led Large Scale Public Private Partnership ‘Chiranjeevi Program’ to Increase Access to Institutional Delivery among Poor Women in Gujarat, India: How Has It Done? What Can We Learn? 
PLoS ONE  2014;9(5):e95704.
Many low-middle income countries have focused on improving access to and quality of obstetric care, as part of promoting a facility based intra-partum care strategy to reduce maternal mortality. The state of Gujarat in India, implements a facility based intra-partum care program through its large for-profit private obstetric sector, under a state-led public-private-partnership, the Chiranjeevi Yojana (CY), under which the state pays accredited private obstetricians to perform deliveries for poor/tribal women. We examine CY performance, its contribution to overall trends in institutional deliveries in Gujarat over the last decade and its effect on private and public sector deliveries there.
District level institutional delivery data (public, private, CY), national surveys, poverty estimates, census data were used. Institutional delivery trends in Gujarat 2000–2010 are presented; including contributions of different sectors and CY. Piece-wise regression was used to study the influence of the CY program on public and private sector institutional delivery.
Institutional delivery rose from 40.7% (2001) to 89.3% (2010), driven by sharp increases in private sector deliveries. Public sector and CY contributed 25–29% and 13–16% respectively of all deliveries each year. In 2007, 860 of 2000 private obstetricians participated in CY. Since 2007, >600,000 CY deliveries occurred i.e. one-third of births in the target population. Caesareans under CY were 6%, higher than the 2% reported among poor women by the DLHS survey just before CY. CY did not influence the already rising proportion of private sector deliveries in Gujarat.
This paper reports a state-led, fully state-funded, large-scale public-private partnership to improve poor women’s access to institutional delivery - there have been >600,000 beneficiaries. While caesarean proportions are higher under CY than before, it is uncertain if all beneficiaries who require sections receive these. Other issues to explore include quality of care, provider attrition and the relatively low coverage.
PMCID: PMC4006779  PMID: 24787692
5.  Inequity in maternal health care service utilization in Gujarat: analyses of district-level health survey data 
Global Health Action  2013;6:10.3402/gha.v6i0.19652.
Two decades after the launch of the Safe Motherhood campaign, India still accounts for at least a quarter of maternal death globally. Gujarat is one of the most economically developed states of India, but progress in the social sector has not been commensurate with economic growth. The purpose of this study was to use district-level data to gain a better understanding of equity in access to maternal health care and to draw the attention of the policy planers to monitor equity in maternal care.
Secondary data analyses were performed among 7,534 ever-married women who delivered since January 2004 in the District Level Household and Facility Survey (DLHS-3) carried out during 2007–2008 in Gujarat, India. Based on the conceptual framework designed by the Commission on the Social Determinants of Health, associations were assessed between three outcomes – Institutional delivery, antenatal care (ANC), and use of modern contraception – and selected intermediary and structural determinants of health using multiple logistic regression.
Inequities in maternal health care utilization persist in Gujarat. Structural determinants like caste group, wealth, and education were all significantly associated with access to the minimum three antenatal care visits, institutional deliveries, and use of any modern method of contraceptive. There is a significant relationship between being poor and access to less utilization of ANC services independent of caste category or residence.
Discussion and conclusions
Poverty is the most important determinant of non-use of maternal health services in Gujarat. In addition, social position (i.e. caste) has a strong independent effect on maternal health service use. More focused and targeted efforts towards these disadvantaged groups needs to be taken at policy level in order to achieve targets and goals laid out as per the MDGs. In particular, the Government of Gujarat should invest more in basic education and infrastructural development to begin to remove the structural causes of non-use of maternal health services.
PMCID: PMC3591509  PMID: 23469890
maternal health; health care utilization; inequity; antenatal care; skilled birth attendance; Gujarat
6.  Infection control in delivery care units, Gujarat state, India: A needs assessment 
Increasingly, women in India attend health facilities for childbirth, partly due to incentives paid under government programs. Increased use of health facilities can alleviate the risks of infections contracted in unhygienic home deliveries, but poor infection control practices in labour and delivery units also cause puerperal sepsis and other infections of childbirth. A needs assessment was conducted to provide information on procedures and practices related to infection control in labour and delivery units in Gujarat state, India.
Twenty health care facilities, including private and public primary health centres and referral hospitals, were sampled from two districts in Gujarat state, India. Three pre-tested tools for interviewing and for observation were used. Data collection was based on existing infection control guidelines for clean practices, clean equipment, clean environment and availability of diagnostics and treatment. The study was carried out from April to May 2009.
Seventy percent of respondents said that standard infection control procedures were followed, but a written procedure was only available in 5% of facilities. Alcohol rubs were not used for hand cleaning and surgical gloves were reused in over 70% of facilities, especially for vaginal examinations in the labour room. Most types of equipment and supplies were available but a third of facilities did not have wash basins with "hands-free" taps. Only 15% of facilities reported that wiping of surfaces was done immediately after each delivery in labour rooms. Blood culture services were available in 25% of facilities and antibiotics are widely given to women after normal delivery. A few facilities had data on infections and reported rates of 3% to 5%.
This study of current infection control procedures and practices during labour and delivery in health facilities in Gujarat revealed a need for improved information systems, protocols and procedures, and for training and research. Simply incentivizing the behaviour of women to use health facilities for childbirth via government schemes may not guarantee safe delivery.
PMCID: PMC3115920  PMID: 21599924
7.  Transfusion Practices Committee of a public blood bank network in Minas Gerais, Brazil 
This study aimed to verify the performance of blood transfusion committees in transfusion services linked to the public blood bank network of the state of Minas Gerais.
A cross-sectional observational study was conducted between 2007 and 2008 using questionnaires and proficiency tests to evaluate the reporting and investigation of transfusion reactions comparing transfusion services with and without transfusion committees in the public transfusion services of the state of Minas Gerais.
Nineteen of Hemominas own transfusion services and 207 that contracted the services of the foundation located in 178 municipalities were visited between 2007 and 2008. Established transfusion committees were present in 63.4% of the services visited. Transfusion incidents were reported by 53 (36.8%) transfusion services with transfusion committees and by eight (9.6%) without transfusion committees (p < 0.001) with 543 (97.5%) and 14 (2.5%) notifications, respectively. Of the reported transfusion incidents, 40 (75.5%) transfusion services with transfusion committees and only two (25%) of those without transfusion committees investigated the causes.
The incidence of notification and investigation of the causes of transfusion reactions was higher in transfusion services where a transfusion committee was present. Despite these results, the performance of these committees was found to be incipient and a better organization and more effective operation are required.
PMCID: PMC3545427  PMID: 23323064
Blood transfusion; Blood safety; Professional staff committees; Blood banks
8.  An evaluation of two large scale demand side financing programs for maternal health in India: the MATIND study protocol 
BMC Public Health  2012;12:699.
High maternal mortality in India is a serious public health challenge. Demand side financing interventions have emerged as a strategy to promote access to emergency obstetric care. Two such state run programs, Janani Suraksha Yojana (JSY)and Chiranjeevi Yojana (CY), were designed and implemented to reduce financial access barriers that preclude women from obtaining emergency obstetric care. JSY, a conditional cash transfer, awards money directly to a woman who delivers in a public health facility. This will be studied in Madhya Pradesh province. CY, a voucher based program, empanels private obstetricians in Gujarat province, who are reimbursed by the government to perform deliveries of socioeconomically disadvantaged women. The programs have been in operation for the last seven years.
The study outlined in this protocol will assess and compare the influence of the two programs on various aspects of maternal health care including trends in program uptake, institutional delivery rates, maternal and neonatal outcomes, quality of care, experiences of service providers and users, and cost effectiveness. The study will collect primary data using a combination of qualitative and quantitative methods, including facility level questionnaires, observations, a population based survey, in-depth interviews, and focus group discussions. Primary data will be collected in three districts of each province. The research will take place at three levels: the state health departments, obstetric facilities in the districts and among recently delivered mothers in the community.
The protocol is a comprehensive assessment of the performance and impact of the programs and an economic analysis. It will fill existing evidence gaps in the scientific literature including access and quality to services, utilization, coverage and impact. The implementation of the protocol will also generate evidence to facilitate decision making among policy makers and program managers who currently work with or are planning similar programs in different contexts.
PMCID: PMC3488490  PMID: 22925407
India; Demand side financing; Maternal morality; Chiranjeevi yojana; Janani suraksha yojana
9.  Estimation of the prevalence and rate of acute transfusion reactions occurring in Windhoek, Namibia 
Blood Transfusion  2014;12(3):352-361.
Acute transfusion reactions are probably common in sub-Saharan Africa, but transfusion reaction surveillance systems have not been widely established. In 2008, the Blood Transfusion Service of Namibia implemented a national acute transfusion reaction surveillance system, but substantial under-reporting was suspected. We estimated the actual prevalence and rate of acute transfusion reactions occurring in Windhoek, Namibia.
The percentage of transfusion events resulting in a reported acute transfusion reaction was calculated. Actual percentage and rates of acute transfusion reactions per 1,000 transfused units were estimated by reviewing patients’ records from six hospitals, which transfuse >99% of all blood in Windhoek. Patients’ records for 1,162 transfusion events occurring between 1st January – 31st December 2011 were randomly selected. Clinical and demographic information were abstracted and Centers for Disease Control and Prevention National Healthcare Safety Network criteria were applied to categorize acute transfusion reactions1.
From January 1 – December 31, 2011, there were 3,697 transfusion events (involving 10,338 blood units) in the selected hospitals. Eight (0.2%) acute transfusion reactions were reported to the surveillance system. Of the 1,162 transfusion events selected, medical records for 785 transfusion events were analysed, and 28 acute transfusion reactions were detected, of which only one had also been reported to the surveillance system. An estimated 3.4% (95% confidence interval [CI]: 2.3–4.4) of transfusion events in Windhoek resulted in an acute transfusion reaction, with an estimated rate of 11.5 (95% CI: 7.6–14.5) acute transfusion reactions per 1,000 transfused units.
The estimated actual rate of acute transfusion reactions is higher than the rate reported to the national haemovigilance system. Improved surveillance and interventions to reduce transfusion-related morbidity and mortality are required in Namibia.
PMCID: PMC4111817  PMID: 24333079
blood safety; blood transfusion; blood transfusion/adverse effects; surveillance; Namibia
10.  Maternal Health in Gujarat, India: A Case Study 
Gujarat state of India has come a long way in improving the health indicators since independence, but progress in reducing maternal mortality has been slow and largely unmeasured or documented. This case study identified several challenges for reducing the maternal mortality ratio, including lack of the managerial capacity, shortage of skilled human resources, non-availability of blood in rural areas, and infrastructural and supply bottlenecks. The Gujarat Government has taken several initiatives to improve maternal health services, such as partnership with private obstetricians to provide delivery care to poor women, a relatively-short training of medical officers and nurses to provide emergency obstetric care (EmOC), and an improved emergency transport system. However, several challenges still remain. Recommendations are made for expanding the management capacity for maternal health, operationalization of health facilities, and ensuring EmOC on 24/7 (24 hours a day, seven days a week) basis by posting nurse-midwives and trained medical officers for skilled care, ensuring availability of blood, and improving the registration and auditing of all maternal deaths. However, all these interventions can only take place if there are substantially-increased political will and social awareness.
PMCID: PMC2761782  PMID: 19489418
Health services; Management capacity; Maternal health; Maternal mortality; Morbidity; India
11.  Red Blood Cell Transfusion and Mortality in Trauma Patients: Risk-Stratified Analysis of an Observational Study 
PLoS Medicine  2014;11(6):e1001664.
Using a large multicentre cohort, Pablo Perel and colleagues evaluate the association of red blood cell transfusion with mortality according to the predicted risk of death for trauma patients.
Please see later in the article for the Editors' Summary
Haemorrhage is a common cause of death in trauma patients. Although transfusions are extensively used in the care of bleeding trauma patients, there is uncertainty about the balance of risks and benefits and how this balance depends on the baseline risk of death. Our objective was to evaluate the association of red blood cell (RBC) transfusion with mortality according to the predicted risk of death.
Methods and Findings
A secondary analysis of the CRASH-2 trial (which originally evaluated the effect of tranexamic acid on mortality in trauma patients) was conducted. The trial included 20,127 trauma patients with significant bleeding from 274 hospitals in 40 countries. We evaluated the association of RBC transfusion with mortality in four strata of predicted risk of death: <6%, 6%–20%, 21%–50%, and >50%. For this analysis the exposure considered was RBC transfusion, and the main outcome was death from all causes at 28 days. A total of 10,227 patients (50.8%) received at least one transfusion. We found strong evidence that the association of transfusion with all-cause mortality varied according to the predicted risk of death (p-value for interaction <0.0001). Transfusion was associated with an increase in all-cause mortality among patients with <6% and 6%–20% predicted risk of death (odds ratio [OR] 5.40, 95% CI 4.08–7.13, p<0.0001, and OR 2.31, 95% CI 1.96–2.73, p<0.0001, respectively), but with a decrease in all-cause mortality in patients with >50% predicted risk of death (OR 0.59, 95% CI 0.47–0.74, p<0.0001). Transfusion was associated with an increase in fatal and non-fatal vascular events (OR 2.58, 95% CI 2.05–3.24, p<0.0001). The risk associated with RBC transfusion was significantly increased for all the predicted risk of death categories, but the relative increase was higher for those with the lowest (<6%) predicted risk of death (p-value for interaction <0.0001). As this was an observational study, the results could have been affected by different types of confounding. In addition, we could not consider haemoglobin in our analysis. In sensitivity analyses, excluding patients who died early; conducting propensity score analysis adjusting by use of platelets, fresh frozen plasma, and cryoprecipitate; and adjusting for country produced results that were similar.
The association of transfusion with all-cause mortality appears to vary according to the predicted risk of death. Transfusion may reduce mortality in patients at high risk of death but increase mortality in those at low risk. The effect of transfusion in low-risk patients should be further tested in a randomised trial.
Trial registration NCT01746953
Please see later in the article for the Editors' Summary
Editors' Summary
Trauma—a serious injury to the body caused by violence or an accident—is a major global health problem. Every year, injuries caused by traffic collisions, falls, blows, and other traumatic events kill more than 5 million people (9% of annual global deaths). Indeed, for people between the ages of 5 and 44 years, injuries are among the top three causes of death in many countries. Trauma sometimes kills people through physical damage to the brain and other internal organs, but hemorrhage (serious uncontrolled bleeding) is responsible for 30%–40% of trauma-related deaths. Consequently, early trauma care focuses on minimizing hemorrhage (for example, by using compression to stop bleeding) and on restoring blood circulation after blood loss (health-care professionals refer to this as resuscitation). Red blood cell (RBC) transfusion is often used for the management of patients with trauma who are bleeding; other resuscitation products include isotonic saline and solutions of human blood proteins.
Why Was This Study Done?
Although RBC transfusion can save the lives of patients with trauma who are bleeding, there is considerable uncertainty regarding the balance of risks and benefits associated with this procedure. RBC transfusion, which is an expensive intervention, is associated with several potential adverse effects, including allergic reactions and infections. Moreover, blood supplies are limited, and the risks from transfusion are high in low- and middle-income countries, where most trauma-related deaths occur. In this study, which is a secondary analysis of data from a trial (CRASH-2) that evaluated the effect of tranexamic acid (which stops excessive bleeding) in patients with trauma, the researchers test the hypothesis that RBC transfusion may have a beneficial effect among patients at high risk of death following trauma but a harmful effect among those at low risk of death.
What Did the Researchers Do and Find?
The CRASH-2 trail included 20,127 patients with trauma and major bleeding treated in 274 hospitals in 40 countries. In their risk-stratified analysis, the researchers investigated the effect of RBC transfusion on CRASH-2 participants with a predicted risk of death (estimated using a validated model that included clinical variables such as heart rate and blood pressure) on admission to hospital of less than 6%, 6%–20%, 21%–50%, or more than 50%. That is, the researchers compared death rates among patients in each stratum of predicted risk of death who received a RBC transfusion with death rates among patients who did not receive a transfusion. Half the patients received at least one transfusion. Transfusion was associated with an increase in all-cause mortality at 28 days after trauma among patients with a predicted risk of death of less than 6% or of 6%–20%, but with a decrease in all-cause mortality among patients with a predicted risk of death of more than 50%. In absolute figures, compared to no transfusion, RBC transfusion was associated with 5.1 more deaths per 100 patients in the patient group with the lowest predicted risk of death but with 11.9 fewer deaths per 100 patients in the group with the highest predicted risk of death.
What Do These Findings Mean?
These findings show that RBC transfusion is associated with an increase in all-cause deaths among patients with trauma and major bleeding with a low predicted risk of death, but with a reduction in all-cause deaths among patients with a high predicted risk of death. In other words, these findings suggest that the effect of RBC transfusion on all-cause mortality may vary according to whether a patient with trauma has a high or low predicted risk of death. However, because the participants in the CRASH-2 trial were not randomly assigned to receive a RBC transfusion, it is not possible to conclude that receiving a RBC transfusion actually increased the death rate among patients with a low predicted risk of death. It might be that the patients with this level of predicted risk of death who received a transfusion shared other unknown characteristics (confounders) that were actually responsible for their increased death rate. Thus, to provide better guidance for clinicians caring for patients with trauma and hemorrhage, the hypothesis that RBC transfusion could be harmful among patients with trauma with a low predicted risk of death should be prospectively evaluated in a randomised controlled trial.
Additional Information
Please access these websites via the online version of this summary at
This study is further discussed in a PLOS Medicine Perspective by Druin Burch
The World Health Organization provides information on injuries and on violence and injury prevention (in several languages)
The US Centers for Disease Control and Prevention has information on injury and violence prevention and control
The National Trauma Institute, a US-based non-profit organization, provides information about hemorrhage after trauma and personal stories about surviving trauma
The UK National Health Service Choices website provides information about blood transfusion, including a personal story about transfusion after a serious road accident
The US National Heart, Lung, and Blood Institute also provides detailed information about blood transfusions
MedlinePlus provides links to further resources on injuries, bleeding, and blood transfusion (in English and Spanish)
More information in available about CRASH-2 (in several languages)
PMCID: PMC4060995  PMID: 24937305
12.  Current perspectives in transfusion-transmitted infectious diseases: emerging and re-emerging infections 
Isbt Science Series  2014;9(1):30-36.
In August 2009, a group from the AABB (Stramer et al., Transfusion 2009;99:1S–29S, Emerging Infectious Disease Agents and their Potential Threat to Transfusion Safety; published a Supplement to Transfusion that reviewed emerging infectious disease (EID) agents that pose a real or theoretical threat to transfusion safety, but for which an existing effective intervention is lacking. The necessary attributes for transfusion transmission were outlined including: presence of the agent in blood during the donor's asymptomatic phase, the agent's survival/persistence in blood during processing/storage, and lastly that the agent must be recognized as responsible for a clinically apparent outcome in at least a proportion of recipients who become infected. Without these attributes, agents are not considered as a transfusion-transmission threat and were excluded. Sixty-eight such agents were identified with enough evidence/likelihood of transfusion transmission (e.g., blood phase) and potential for clinical disease to warrant further consideration. In the Supplement, Fact Sheets (FS) were published providing information on: agent classification; disease agent's importance; clinical syndromes/diseases caused; transmission modes (including vectors/reservoirs); likelihood of transfusion transmission, and if proven to be transfusion-transmitted, information on known cases; the feasibility/predicted success of interventions for donor screening (questioning) and tests available for diagnostics/ adapted for donor screening; and finally, the efficacy, if known, of inactivation methods for plasma-derived products. The Supplement included a separate section on pathogen reduction using published data. Agents were prioritized relative to their scientific/epidemiologic threat and their perceived threat to the community including concerns expressed by the regulators of blood. Agents given the highest priority due to a known transfusion-transmission threat and severe/fatal disease in recipients were the vCJD prion, dengue viruses and the obligate red-cell parasite that causes babesiosis (B. microti and related Babesia). Although the focus of the Supplement was towards the United States and Canada, many of the agents (and the process) are applicable worldwide.
Next steps
Since the publication of the Supplement, six new FSs (yellow fever viruses-including vaccine breakthrough infections, miscellaneous arboviruses, XMRV, human parvoviruses/bocaviruses other than B19, and most recently the Middle East respiratory syndrome coronavirus, MERS-CoV) were added and 14 existing FSs updated (Anaplasma, Babesia, Bartonella, Erhlichia, chronic wasting disease-CWD, human prions other than vCJD, vCJD, Coxiella burnetii-the agent of Q fever, dengue viruses, HAV, HEV, Japanese encephalitis-JE complex, tick-borne encephalitis viruses-TBEV, and human parvovirus B19). Also, tables were released outlining pathogen reduction clinical trials/results (published) and availability/commercial routine use of such technologies by country. Of necessity, the list of EID agents is not, and can never be, complete due to the nature of emergence. We recognized that a system of assessing the risk/threat of EIDs for their potential impact on blood safety and availability must include processes for monitoring, identifying, evaluating, estimating severity, assessing risk and developing interventions. Thus, a ‘toolkit’ containing the necessary ‘tools’ from EID monitoring (horizon scanning) to validation/effectiveness evaluations of interventions is being developed. The goal is, to develop a systematic approach to risk assessment and intervention development for the impact of emerging infectious upon blood safety intended to educate and provide advise about risks/interventions in a timely/accurate fashion.
The process and final product (toolkit) including methods to monitor EID agent emergence, identification/recognition of a transfusion-transmission threat, methods for quantitative risk assessments, and the appropriate management of such threats should be considered for implementation by all blood systems.
PMCID: PMC4142007  PMID: 25210533
blood donation testing; epidemiology; transfusion; transmissible infections
13.  A Cost-Effectiveness Analysis of India’s 2008 Prohibition of Smoking in Public Places in Gujarat 
Tobacco smoking and exposure to secondhand tobacco smoke are associated with disability and premature mortality in low and middle-income countries. The aim of this study was to assess the cost-effectiveness of implementing India’s Prohibition of Smoking in Public Places Rules in the state of Gujarat, compared to implementation of a complete smoking ban. Using standard cost-effectiveness analysis methods, the cost of implementing the alternatives was evaluated against the years of life saved and cases of acute myocardial infarction averted by reductions in smoking prevalence and secondhand smoke exposure. After one year, it is estimated that a complete smoking ban in Gujarat would avert 17,000 additional heart attacks and gain 438,000 life years (LY). A complete ban is highly cost-effective when key variables including legislation effectiveness were varied in the sensitivity analyses. Without including medical treatment costs averted, the cost-effectiveness ratio ranges from $2 to $112 per LY gained and $37 to $386 per acute myocardial infarction averted. Implementing a complete smoking ban would be a cost saving alternative to the current partial legislation in terms of reducing tobacco-attributable disease in Gujarat.
PMCID: PMC3108108  PMID: 21655118
cost-effectiveness; public smoking bans; smoke free public places; secondhand smoke; tobacco smoking
14.  Maternal Healthcare Financing: Gujarat's Chiranjeevi Scheme and Its Beneficiaries 
Maternal mortality is an important public-health issue in India, specifically in Gujarat. Contributing factors are the Government's inability to operationalize the First Referral Units and to provide an adequate level of skilled birth attendants, especially to the poor. In response, the Gujarat state has developed a unique public-private partnership called the Chiranjeevi Scheme. This scheme focuses on institutional delivery, specifically emergency obstetric care for the poor. The objective of the study was to explore the targeting of the scheme, its coverage, and socioeconomic profile of the beneficiaries and to assess financial protection offered by the scheme, if any, in Dahod, one of the initial pilot districts of Gujarat. A household-level survey of beneficiaries (n=262) and non-users (n=394) indicated that the scheme is well-targeted to the poor but many poor people do not use the services. The beneficiaries saved more than Rs 3,000 (US$ 75) in delivery-related expenses and were generally satisfied with the scheme. The study provided insights on how to improve the scheme further. Such a financing scheme could be replicated in other states and countries to address the cost barrier, especially in areas where high numbers of private specialists are available.
PMCID: PMC2761781  PMID: 19489419
Chiranjeevi scheme; Delivery; Emergency obstetric care; Maternal mortality; Obstetric care; Private-public relationship; India
15.  Improved traceability and transfusion safety with a new portable computerised system in a hospital with intermediate transfusion activity 
Blood Transfusion  2011;9(2):172-181.
A retrospective study carried out on medical records of transfused patients in our hospital in 2002 revealed that manual identification procedures were insufficient to offer satisfactory traceability. The aim of this study was to assess adequacy of transfusion traceability and compliance with proper identification procedures after introducing an electronic identification system (EIS) for transfusion safety.
Materials and methods.
The chosen EIS (Gricode®) was set up. Traceability was calculated as the percentage of empty blood units used returned to the Transfusion Service, compared to the number of supplied units. Compliance in the Transfusion Service was calculated as the percentage of electronic controls from dispatch of blood components/transfusion request performed, compared to the total number of transfused units. Compliance in the ward was calculated as the percentage of electronic controls from sample collection/transfusion performed, compared to the total number of samples collected.
This retrospective study showed that only 48.0% of the medical records were free of inaccuracies. After the implementation of the EIS (2005–2008), traceability was always above 99%. Percentage of monthly compliance from 2006 to 2008 was always above 93%, showing a significant trend to increase (p<0.05). The mean compliance in this period was higher in the Transfusion Service (97.8±0.7 SD) than in the ward (94.9±2.4 SD; p<0.001). Compliance in the ward was lowest when the system was first implemented (87.9% in April 2006) after which it progressively increased. No errors in ABO transfusions were registered.
After implementation of the EIS, traceability and compliance reached very high levels, linked to an improvement in transfusion safety.
PMCID: PMC3096861  PMID: 21251464
transfusion safety; traceability; patient identification system
16.  Access To Essential Maternal Health Interventions and Human Rights Violations among Vulnerable Communities in Eastern Burma 
PLoS Medicine  2008;5(12):e242.
Health indicators are poor and human rights violations are widespread in eastern Burma. Reproductive and maternal health indicators have not been measured in this setting but are necessary as part of an evaluation of a multi-ethnic pilot project exploring strategies to increase access to essential maternal health interventions. The goal of this study is to estimate coverage of maternal health services prior to this project and associations between exposure to human rights violations and access to such services.
Methods and Findings
Selected communities in the Shan, Mon, Karen, and Karenni regions of eastern Burma that were accessible to community-based organizations operating from Thailand were surveyed to estimate coverage of reproductive, maternal, and family planning services, and to assess exposure to household-level human rights violations within the pilot-project target population. Two-stage cluster sampling surveys among ever-married women of reproductive age (15–45 y) documented access to essential antenatal care interventions, skilled attendance at birth, postnatal care, and family planning services. Mid-upper arm circumference, hemoglobin by color scale, and Plasmodium falciparum parasitemia by rapid diagnostic dipstick were measured. Exposure to human rights violations in the prior 12 mo was recorded. Between September 2006 and January 2007, 2,914 surveys were conducted. Eighty-eight percent of women reported a home delivery for their last pregnancy (within previous 5 y). Skilled attendance at birth (5.1%), any (39.3%) or ≥ 4 (16.7%) antenatal visits, use of an insecticide-treated bed net (21.6%), and receipt of iron supplements (11.8%) were low. At the time of the survey, more than 60% of women had hemoglobin level estimates ≤ 11.0 g/dl and 7.2% were Pf positive. Unmet need for contraceptives exceeded 60%. Violations of rights were widely reported: 32.1% of Karenni households reported forced labor and 10% of Karen households had been forced to move. Among Karen households, odds of anemia were 1.51 (95% confidence interval [CI] 0.95–2.40) times higher among women reporting forced displacement, and 7.47 (95% CI 2.21–25.3) higher among those exposed to food security violations. The odds of receiving no antenatal care services were 5.94 (95% CI 2.23–15.8) times higher among those forcibly displaced.
Coverage of basic maternal health interventions is woefully inadequate in these selected populations and substantially lower than even the national estimates for Burma, among the lowest in the region. Considerable political, financial, and human resources are necessary to improve access to maternal health care in these communities.
Luke Mullany and colleagues examine access to essential maternal health interventions and human rights violations within vulnerable communities in eastern Burma.
Editors' Summary
After decades of military rule, Burma has one of the world's worst health-care systems and high levels of ill health. For example, maternal mortality (deaths among women from pregnancy-related causes) is around 360 per 100,000 live births in Burma, whereas in neighboring Thailand it is only 44 per 100,000 live births. Maternal health is even worse in the Shan, Karenni, Karen and Mon states in eastern Burma where ethnic conflicts and enforced village relocations have internally displaced more than half a million people. Here, maternal mortality is thought to be about 1000 per 100, 000 live births. In an effort to improve access to life-saving maternal health interventions in these states, Burmese community-based health organizations, the Johns Hopkins Center for Public Health and Human Rights and the Global Health Access Program in the USA, and the Mae Tao Clinic (a health-worker training center in Thailand) recently set up the Mobile Obstetric Maternal Health Workers (MOM) Project. In this pilot project, local health workers from 12 communities in eastern Burma received training in antenatal care, emergency obstetrics (the care of women during childbirth), blood transfusion, and family planning at the Mae Tao Clinic. Back in Burma, these maternal health workers trained additional local health workers and traditional birth attendants. All these individuals now provide maternal health care to their communities.
Why Was This Study Done?
The effectiveness of the MOM project can only be evaluated if accurate baseline information on women's access to maternal health-care services is available. This information is also needed to ensure the wise use of scarce health-care resources. However, very little is known about reproductive and maternal health in eastern Burma. In this study, the researchers analyze the information on women's access to reproductive and maternal health-care services that was collected during the initial field implementation stage of the MOM project. In addition, they analyze whether exposure to enforced village relocations and other human rights violations affect access to maternal health-care services.
What Did the Researchers Do and Find?
Trained survey workers asked nearly 3000 ever-married women of reproductive age in the selected communities about their access to antenatal and postnatal care, skilled birth attendants, and family planning. They measured each woman's mid-upper arm circumference (an indicator of nutritional status) and tested them for anemia (iron deficiency) and infection with malaria parasites (a common cause of anemia in tropical countries). Finally, they asked the women about any recent violations of their human rights such as forced labour or relocation. Nearly 90% of the women reported a home delivery for their last baby. A skilled attendant was present at only one in 20 births and only one in three women had any antenatal care. One third of the women received postnatal care and only a third said they had access to effective contraceptives. Few women had received iron supplements or had used insecticide-treated bednets to avoid malaria-carrying mosquitos. Consequently, more than half the women were anemic and 7.2% were infected with malaria parasites. Many women also showed signs of poor nutrition. Finally, human rights violations were widely reported by the women. In Karen, the region containing most of the study communities, forced relocation tripled the risk of women developing anemia and greatly decreased their chances of receiving any antenatal care.
What Do These Findings Mean?
These findings show that access to maternal health-care interventions is extremely limited and that poor nutrition, anemia, and malaria, all of which increase the risk of pregnancy complications, are widespread in the communities in the MOM project. Because these communities had some basic health services and access to training in Thailand before the project started, these results probably underestimate the lack of access to maternal health-care services in eastern Burma. Nevertheless, it is clear that considerable political, financial, and human resources will be needed to improve maternal health in this region. Finally, the findings also reveal a link between human rights violations and reduced access to maternal health-care services. Thus, the scale of human rights violations will need to be considered when evaluating programs designed to improve maternal health in Burma and in other places where there is ongoing conflict.
Additional Information.
Please access these Web sites via the online version of this summary at
This research article is further discussed in a PLoS Medicine Perspective by Macaya Douoguih
The World Health Organization provides information on all aspects of health in Burma (in several languages)
The Mae Tao Clinic also provides general information about Burma and its health services
More information about the MOM project is available in a previous publication by the researchers
The Burma Campaign UK and Human Rights Watch both provide detailed information about human rights violations in Burma
The United Nations Population Fund provides information about safe motherhood and ongoing efforts to save mothers' lives around the world
PMCID: PMC2605890  PMID: 19108601
17.  Using theories of behaviour to understand transfusion prescribing in three clinical contexts in two countries: Development work for an implementation trial 
Blood transfusion is an essential part of healthcare and can improve patient outcomes. However, like most therapies, it is also associated with significant clinical risks. In addition, there is some evidence of overuse. Understanding the potential barriers and enablers to reduced prescribing of blood products will facilitate the selection of intervention components likely to be effective, thereby reducing the number of costly trials evaluating different implementation strategies. Using a theoretical basis to understand behaviours targeted for change will contribute to a 'basic science' relating to determinants of professional behaviour and how these inform the selection of techniques for changing behaviour. However, it is not clear which theories of behaviour are relevant to clinicians' transfusing behaviour. The aim of this study is to use a theoretical domains framework to identify relevant theories, and to use these theories to identify factors that predict the decision to transfuse.
The study involves two steps: interview study and questionnaire study. Using a previously identified framework, we will conduct semi-structured interviews with clinicians to elicit their views about which factors are associated with waiting and further monitoring the patient rather than transfusing red blood cells. Interviews will cover the following theoretical domains: knowledge; skills; social/professional role and identity; beliefs about capabilities; beliefs about consequences; motivation and goals; memory, attention, and decision processes; environmental context and resources; social influences; emotion; behavioural regulation; nature of the behaviour. The interviews will take place independently in Canada and the UK and involve two groups of physicians in each country (UK: adult and neonatal intensive care physicians; Canada: intensive care physicians and orthopaedic surgeons). We will: analyse interview transcript content to select relevant theoretical domains; use consensus processes to map these domains on to theories of behaviour; develop questionnaires based on these theories; and mail them to each group of physicians in the two countries. From our previous work, it is likely that the theories will include: theory of planned behaviour, social cognitive theory and the evidence-based strategy, implementation intention. The questionnaire data will measure predictor variables (theoretical constructs) and outcome variables (intention and clinical decision), and will be analysed using multiple regression analysis. We aim to achieve 150 respondents in each of the four groups for each postal survey.
PMCID: PMC2777847  PMID: 19852832
18.  Effect of a formal education programme on safety of transfusions 
BMJ : British Medical Journal  2001;323(7321):1118-1120.
Failure of correct identification and insufficient monitoring of patients receiving transfusions continue to be appreciable and avoidable causes of morbidity and mortality.
A study by a regional transfusion service and a transfusion nurse specialist of the effects of an education programme based on the current national guidelines on identification and monitoring of patients receiving transfusions.
A large United Kingdom teaching hospital which houses the headquarters of the regional transfusion service.
Key measures for improvement
Improvement in compliance with published national guidelines on the prescription and administration of blood transfusions.
Strategy for change
An audit of current compliance followed by dissemination by a transfusion nurse specialist of a clinical skills package (based on the best practice for transfusion) to all staff involved in giving transfusions. This was supported by trained instructors and the display of standard operating procedures for transfusion in all clinical areas.
Effect of change
An improvement in compliance with the national guidelines to over 95% in six out of seven of the recommendations on best practice was seen 18 months after the initial intervention.
Lessons learnt
The study shows that education of those who prescribe and administer transfusions, as recommended by bodies concerned with the hazards of transfusion, can improve the safety of transfusions.
PMCID: PMC1121603  PMID: 11701582
19.  Risk and crisis management in intraoperative hemorrhage: Human factors in hemorrhagic critical events 
Korean Journal of Anesthesiology  2011;60(3):151-160.
Hemorrhage is the major cause of cardiac arrest developing in the operating room. Many human factors including surgical procedures, transfusion practices, blood supply, and anesthetic management are involved in the process that leads to hemorrhage developing into a critical situation. It is desirable for hospital transfusion committees to prepare hospital regulations on 'actions to be taken to manage critical hemorrhage', and practice the implementation of these regulations by simulated drills. If intraoperative hemorrhage seems to be critical, a state of emergency should immediately be declared to the operating room staff, the blood transfusion service staff, and blood bank staff in order to organize a systematic approach to the ongoing problem and keep all responsible staff working outside the operating room informed of events developing in the operating room. To rapidly deal with critical hemorrhage, not only cooperation between anesthesiologists and surgeons but also linkage of operating rooms with blood transfusion services and a blood bank are important. When time is short, cross-matching tests are omitted, and ABO-identical red blood cells are used. When supplies of ABO-identical red blood cells are not available, ABO-compatible, non-identical red blood cells are used. Because a systematic, not individual, approach is required to prevent and manage critical hemorrhage, whether a hospital can establish a procedure to deal with it or not depends on the overall capability of critical and crisis management of the hospital.
PMCID: PMC3071477  PMID: 21490815
Crisis management; Hemorrhage; Risk management; Transfusion
20.  Institutional authorisation and accreditation of Transfusion Services and Blood Donation Sites: results of a national survey 
Blood Transfusion  2011;9(4):436-454.
The aim of the survey described in this article was to determine decisional and strategic factors useful for redefining minimum structural, technological and organisational requisites for transfusion structures, as well as for the production of guidelines for accreditation of transfusion structures by the National Blood Centre.
Materials and methods
A structured questionnaire containing 65 questions was sent to all Transfusion Services in Italy. The questions covered: management of the quality system, accreditation, conformity with professional standards, structural and technological requisites, as well as potential to supply transfusion medicine-related health care services. All the questionnaires returned underwent statistical analysis.
Replies were received from 64.7% of the Transfusion Services. Thirty-nine percent of these had an ISO 9001 certificate, with marked differences according to geographical location; location-related differences were also present for responses to other questions and were confirmed by multivariate statistical analysis. Over half of the Transfusion Services (53.6%) had blood donation sites run by donor associations. The statistical analysis revealed only one statistically significant difference between these donation sites: those connected to certified Transfusion Services were more likely themselves to have ISO 9001 certification than those connected to services who did not have such certification.
The data collected in this survey are representative of the Italian national transfusion system. A re-definition of the authorisation and accreditation requisites for transfusion activities must take into account European and national legislation when determining these requisites in order to facilitate their effective applicability, promote their efficient fulfilment and enhance the development of homogeneous and transparent quality systems.
PMCID: PMC3200415  PMID: 21839026
authorisation; accreditation; quality system; minimum requisites; transfusion system
21.  Towards the creation of a flexible classification scheme for voluntarily reported transfusion and laboratory safety events 
Transfusion and clinical laboratory services are high-volume activities involving complicated workflows across both ambulatory and inpatient environments. As a result, there are many opportunities for safety lapses, leading to patient harm and increased costs. Organizational techniques such as voluntary safety event reporting are commonly used to identify and prioritize risk areas across care settings. Creation of functional, standardized safety data structures that facilitate effective exploratory examination is therefore essential to drive quality improvement interventions. Unfortunately, voluntarily reported adverse event data can often be unstructured or ambiguously defined.
To address this problem, we sought to create a “best-of-breed” patient safety classification for data contained in the Duke University Health System Safety Reporting System (SRS). Our approach was to implement the internationally recognized World Health Organization International Classification for Patient Safety Framework, supplemented with additional data points relevant to our organization. Data selection and integration into the hierarchical framework is discussed, as well as placement of the classification into the SRS. We evaluated the impact of the new SRS classification on system usage through comparisons of monthly average report rates and completion times before and after implementation. Monthly average inpatient transfusion reports decreased from 102.1 ± 14.3 to 91.6 ± 11.2, with the proportion of transfusion reports in our system remaining consistent before and after implementation. Monthly average transfusion report rates in the outpatient and homecare environments were not significantly different. Significant increases in clinical lab report rates were present across inpatient and outpatient environments, with the proportion of lab reports increasing after implementation. Report completion times increased modestly but not significantly from a practical standpoint.
A common safety vocabulary can facilitate integration of information from disparate systems and processes to permit meaningful measurement and interpretation of data to improve safety within and across organizations. Formation of a “best-of-breed” classification for voluntary reporting necessitates an internal examination of localized data needs and workflow in order to design a product that enables comprehensive data capture. A team of clinical, safety, and information technology experts is necessary to integrate the data structures into the reporting system. We have found that a “best-of-breed” patient safety classification provides a solid, extensible model for adverse event analysis, healthcare leader communication, and intervention identification.
PMCID: PMC3431246  PMID: 22607821
22.  The quest for an Indian blood law as of blood transfusion services regulatory framework 
Blood transfusion services are a vital part of the national health delivery system. The responsibility for ensuring a continuous supply of blood rests with health administrators, who need to galvanize entire communities towards regular and non-remunerated blood donation.
The present study aimed to examine the prevailing global regulations and practices related to blood transfusion and press the case for a dedicated blood law in India.
Materials and Methods:
We attempted a comprehensive, annotated assembly of published studies on blood transfusion services in India.
Data Abstraction and Synthesis:
Laws related to blood transfusion services exist in India as a part of the Drugs and Cosmetics Law. In the developed world, most blood donors are unpaid volunteers who give blood for a community supply. In order to augment safe blood transfusion services in India, we have to develop operational legal guidelines on recruitment and retention of voluntary blood donors to direct related organizations for this imperative activity.
Several factors, such as political will and a professional and ethical approach can help in formulating a common vision, building trust, by providing optimum information towards a social movement for the rational blood transfusion services. We have to come together for a dedicated blood law in order to improve the quality of blood transfusion services in India.
PMCID: PMC3159250  PMID: 21897599
Blood law; India; Drugs and Cosmetics Act India
23.  Blood management in intensive care medicine: CRIT and ABC – what can we learn? 
Critical Care  2004;8(2):89-90.
In 284 US intensive care units the CRIT study (Anemia and blood transfusion in the critically ill – Current clinical practice in the United States) assessed allogeneic red blood cell (RBC) transfusion and outcome in 4892 patients. As in the former European ABC study (Anemia and blood transfusion in the critically ill), the mean pretransfusion hemoglobin was approximately 8.5 g/dl and RBC transfusions were independently associated with an increased mortality. These studies were purely observational and, therefore, despite the finest statistical models indicating that RBC transfusions were independently associated with a higher mortality, it remains possible that this adverse outcome is not due to a harmful effect of RBC transfusion in itself, but merely reflects the fact that transfused patients were sicker to start with. The definitive call is still out, but one mechanism by which RBC transfusion might be harmful now appears less likely; namely, storage lesion. In the CRIT study, mortality was not increased in patients receiving 'old' RBCs (>14 days stored) versus 'fresh' RBCs. The effect of leukoreduction could not be assessed since mainly nonleukoreduced RBCs were transfused. The evidence is mounting, however, that RBC transfusions are efficacious only when oxygen delivery is compromised. What can be done to diminish the use of RBC transfusions, its costs and side effects in intensive care medicine? There are two important options available today: decreasing blood loss for diagnostic purposes using pediatric sampling tubes, and establishing restrictive multidisciplinary transfusion guidelines and implementing them in daily clinical practice.
PMCID: PMC420042  PMID: 15025763
blood transfusion; morbidity; mortality
24.  Error management in blood establishments: results of eight years of experience (2003–2010) at the Croatian Institute of Transfusion Medicine 
Blood Transfusion  2012;10(3):311-320.
Continuous and efficient error management, including procedures from error detection to their resolution and prevention, is an important part of quality management in blood establishments. At the Croatian Institute of Transfusion Medicine (CITM), error management has been systematically performed since 2003.
Materials and methods.
Data derived from error management at the CITM during an 8-year period (2003–2010) formed the basis of this study. Throughout the study period, errors were reported to the Department of Quality Assurance. In addition to surveys and the necessary corrective activities, errors were analysed and classified according to the Medical Event Reporting System for Transfusion Medicine (MERS-TM).
During the study period, a total of 2,068 errors were recorded, including 1,778 (86.0%) in blood bank activities and 290 (14.0%) in blood transfusion services. As many as 1,744 (84.3%) errors were detected before issue of the product or service. Among the 324 errors identified upon release from the CITM, 163 (50.3%) errors were detected by customers and reported as complaints. In only five cases was an error detected after blood product transfusion however without any harmful consequences for the patients. All errors were, therefore, evaluated as “near miss” and “no harm” events. Fifty-two (2.5%) errors were evaluated as high-risk events. With regards to blood bank activities, the highest proportion of errors occurred in the processes of labelling (27.1%) and blood collection (23.7%). With regards to blood transfusion services, errors related to blood product issuing prevailed (24.5%).
This study shows that comprehensive management of errors, including near miss errors, can generate data on the functioning of transfusion services, which is a precondition for implementation of efficient corrective and preventive actions that will ensure further improvement of the quality and safety of transfusion treatment.
PMCID: PMC3417730  PMID: 22395352
errors; quality management; near miss
25.  Seroprevalence of HBV and HCV in blood donors: A study from regional blood transfusion services of Nepal 
Background and Objective:
Hepatitis B and hepatitis C are significant health problems that might involve the late sequel of liver cirrhosis and hepatocellular carcinoma. A high prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) in blood donors poses an increased risk of window period transmission through blood transfusion. The present study aimed to know the seroprevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) among blood donors in regional blood transfusion services of Nepal.
Materials and Methods:
This was a retrospective study conducted among blood donors in Banke (5,211), Morang (5,351), and Kaski (5,995) blood transfusion services. Serum samples were tested for hepatitis B surface antigen (HBsAg) and anti-HCV antibodies using rapid enzyme immunoassays. The donors information was collected via the donor record register through their respective blood transfusion services. The software “Winpepi ver 3.8” was used for statistical analysis.
The seroprevalence rate of HBV was highest in the Banke (1.2%) followed by Biratnagar (0.87%) and Kaski (0.35%) (P < 0.0001). The seroprevalence of HCV was highest in the Morang (0.26%) followed by Kaski (0.16%) and Banke (0.11%) (P > 0.05). The seroprevalence of HBV was significantly higher than HCV in all three blood transfusion services. The burden of HBV as well as HCV seems to be higher in male donors (P > 0.05).
The study revealed that the seroprevalence of HBV was alarmingly higher in two of the three blood transfusion services. Implementation of community-based preventive measures and improved strategies for safe blood supply might prove useful to decrease the seroprevalence.
PMCID: PMC2937303  PMID: 20859506
Blood donors; hepatitis B virus; hepatitis C virus; Nepal; seroprevalence

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