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ASH VTP Helps Enable Sustainable Growth in Nigerian Blood Transfusion Service

June 29, 2023

July 2023

Khylia Marshall

Khylia Marshall is a freelance journalist based in Tucson, Arizona.

(From left to right) Angela Ugwu, FMCpath; Andreas Greinacher, MD; Dalha Gwarzo, MBBS, FMCpath; and Ted E. Warketin, MD, FRCP(C), FACP, professor of hematology at McMaster University in Hamilton, Canada, take a moment away from training at the University of Greifswald in Germany.
(From left to right) Angela Ugwu, FMCpath; Andreas Greinacher, MD;
Dalha Gwarzo, MBBS, FMCpath; and Ted E. Warketin, MD, FRCP(C), FACP,
professor of hematology at McMaster University in Hamilton, Canada, take
a moment away from training at the University of Greifswald in Germany.

Hematologists are revolutionizing the blood transfusion service at the Aminu Kano Teaching Hospital (AKTH) in northern Nigeria. Using the microtiter plate method (MTP), doctors at AKTH perform extended Rh typing to successfully match blood donors with recipients and reduce potential adverse effects related to alloimmunization, especially in multiply transfused patients. Moreover, the institution has created and implemented standard operating procedures (SOPs) in its laboratories, hosted training conferences on enhancing blood transfusion services for local hospitals, and established a regular virtual training on blood typing. The hospital is rapidly becoming the center for training on transfusion medicine and hemovigilance in Nigeria.

Just five years ago, in 2018, blood transfusion in Nigeria looked a lot different. Nigeria has the highest burden of sickle cell disease (SCD) in the world,1 and a common concern for local hematologists is treating patients who are multiply transfused and transfusion-dependent, including those with SCD, chronic kidney disease, malignancies, anemia due to severe malaria, and obstetric hemorrhages. At the time, to match blood donors with recipients, doctors had the technology and training to test for the ABO blood groups and rhesus D (RhD), but they were unable to test for the other rhesus blood group antigens and thus were unable to match blood consistently and accurately.

In 2016, Angela Ugwu, FMCpath, of the University of Nigeria Nsukka and University of Nigeria Teaching Hospital (UNTH) in Enugu State, took a step to change everything. She applied for the American Society of Hematology (ASH) Visitor Training Program (VTP) to study with Andreas Greinacher, MD, head of the Department of Transfusion Medicine at the University of Greifswald in Germany. Her application proposed training on extended Rh and ABO typing using the MTP method and organization of a quality management system with the intention to ultimately create and manage an efficient hospital-based blood transfusion system. Dr. Ugwu received the ASH VTP award in 2017.

ASH Clinical News spoke with Drs. Ugwu and Greinacher and others about the ASH VTP program to learn about how the program was implemented in Nigeria, the effect it has had on hematology practice in the region, and what the future there may hold.

The Visitor Training Program

The VTP was founded in 2008 to help build hematology capacity in low- and middle-income countries by providing funding for individual hematologists and other hematology professionals to train for up to 12 weeks with an ASH member mentor located anywhere in the world.

Applicants create their own training program based on the specific needs and priorities of their institution and region. Participants are selected by the ASH International Members Committee (IMC) based principally on “the need for the training and the likelihood that the training will be implemented once the awardee returns to their home institution,” said Erin Sheek, international programs manager at ASH. The IMC also considers the strength of the mentor-mentee relationship as a marker of success for the partnership.

(Back row from left to right) Dr. Hauwa Ibrahim, FMCPath, representing the chief medical officer of the Murtala Muhammed Specialist Hospital in Kano who agreed to further support and develop the regional transfusion medicine program; Salisu Kwaru, one of the directors on the board; professor Aisha Kuliya-Gwarzo; Kathleen Selleng, MD; Nasir A Kabo, FMCR, director general of the Hospital Service Management Board of Kano State; Andreas Greinacher, MD; M.D. Shehu, MD, one of the directors on the board; (Front row from left to right) Dalha Gwarzo, MBBS, FMCpath, and Aminu A. Yusuf, MBBS, FMCPath. Photo courtesy of Dr. Greinacher.
(Back row from left to right) Dr. Hauwa Ibrahim, FMCPath, representing
the chief medical officer of the Murtala Muhammed Specialist Hospital in
Kano who agreed to further support and develop the regional transfusion
medicine program; Salisu Kwaru, one of the directors on the board;
professor Aisha Kuliya-Gwarzo; Kathleen Selleng, MD; Nasir A Kabo, FMCR,
director general of the Hospital Service Management Board of Kano State;
Andreas Greinacher, MD; M.D. Shehu, MD, one of the directors on the board; 
(Front row from left to right) Dalha Gwarzo, MBBS, FMCpath, and Aminu A. Yusuf,
MBBS, FMCPath. Photo courtesy of Dr. Greinacher.

A Good Fit

Dr. Ugwu’s application was both needed and implementable in Nigeria.

Training on the less expensive MTP method of typing and obtaining equipment were key components of the program. Dr. Greinacher obtained donations of a centrifuge, reagents, and other equipment necessary to commence extended Rh typing at AKTH. A centrifuge, digital weighing balance, MTP shaker, and MTP reading mirror were also donated to UNTH.

In 2018, Dr. Ugwu successfully completed her training at the University of Greifswald, along with Dalha Gwarzo, MBBS, FMCpath, of AKTH in Kano, Nigeria, 450 miles north of Enugu. Dr. Gwarzo was not affiliated with the ASH VTP, and he and Dr. Ugwu met when Dr. Greinacher introduced them through this partnership.

Upon returning home, Dr. Ugwu was able to implement much of the training she gained in Greifswald. She established a hospital blood transfusion team that meets monthly to manage blood transfusion services at UNTH; she implemented a quality documentation system in which patient information is registered and traceable, so logs can be traced from the donor to the patient; she ensured units of blood are screened and documented properly and then followed up; and she trained her staff so that blood grouping “is done as it should, both forward and in reverse,” Dr. Ugwu said.

Moreover, due to lack of voluntary blood donors, Dr. Ugwu introduced a hospital blood transfusion register with the support of UNTH management. The goal is to encourage voluntary blood donation by UNTH staff, “which will go a long way in sustaining the donor pool in the UNTH blood bank,” Dr. Ugwu said.

Unfortunately, full implementation of the MPT method at UNTH was stalled due to safety concerns and airport closures. While Dr. Ugwu expressed disappointment “that UNTH could not implement the MPT program alongside AKTH,” she and Dr. Gwarzo intend to work more closely in the future. Dr. Ugwu’s hope is to undergo an audit of the transfusion service at UNTH, the results and recommendations of which might then be presented to management for implementation.

“The training I got from Andreas has helped us a lot,” Dr. Ugwu said. “If it was not for ASH’s sponsorship, I don’t think I would have been able to afford … the training; it would not have been possible.”

Angela Ugwu, FMCpath (second from right), and Dalha Gwarzo, MBBS, FMCpath (third from left), take a photo with the blood bank staff in Greifswald, Germany.
Angela Ugwu, FMCpath (second from right), and Dalha Gwarzo, MBBS, FMCpath
(third from left), take a photo with the blood bank staff in Greifswald, Germany.

Making Progress

Although progress was halted at UNTH, efforts to implement the MTP method of blood group typing continued with Dr. Gwarzo at AKTH.

In late August 2019, Dr. Greinacher and colleague Kathleen Selleng, MD, visited AKTH to conduct a baseline audit on Kano’s immunohematology lab and blood donor clinic to identify gaps in the transfusion service. The audit resulted in a number of recommendations, including creating SOPs for blood donor testing; blood storage management; and blood sample arrival, documentation, and rejection criteria.

Dr. Greinacher also conducted a series of academic lectures in Kano for the resident doctors on various hematology topics. Following Dr. Greinacher’s lectures and Dr. Selleng’s audit, real changes started happening at AKTH and in the neighboring blood banks in Kano.

“We started doing the basic things of documentation, improving hygiene, going through our SOPs regarding certain tests that we do in the lab, and trying to improve them based on what we learned in Germany,” Dr. Gwarzo said.

Dr. Gwarzo’s team audited 10 blood banks around Kano. He subsequently organized a five-day training in which resource persons from all over Nigeria from different disciplines were invited to come to Kano and deliver lectures designed to enhance blood transfusion services. Doctors, nurses, laboratory technologists, laboratory technicians, and pathologists from 10 hospitals in Kano attended the trainings in March 2020.

Then, the COVID-19 pandemic created some challenges for the project. Delivery of the centrifuge and reagents was delayed until early 2021, and the follow-up visit planned by Drs. Greinacher and Selleng was canceled. In lieu of an in-person visit, Dr. Greinacher obtained a two-year grant for capacity building that funded the installation of a stable internet connection and video conferencing system in Kano to allow for virtual training sessions.

In 2023, the video conferencing system still allows for regular trainings between Greifswald and AKTH. Real-time conferencing where technologists work alongside each other “is overcoming the uncertainties and hesitations to use new reagents and new technologies because [technologists in Kano] have a mentor beside [them] virtually,” Dr. Greinacher said.

Implementation

Kathleen Selleng, MD (fourth from right), Andreas Greinacher, MD (second from left), professor Aisha Kuliya-Gwarzo (fourth from left) of Bayero University in Kano, and members of the Aminu Kano Teaching Hospital hematology team gain an audience with Mallam Muhammadu Sanusi II (third from left), the 14th Emir of Kano, who granted his political support for the activities to improve blood safety in Kano state. August 2019. Photo courtesy of Dr. Greinacher.
Kathleen Selleng, MD (fourth from right), Andreas Greinacher, MD
(
second from left), professor Aisha Kuliya-Gwarzo (fourth from left)
of Bayero University in Kano, and members of the Aminu Kano
Teaching Hospital hematology team gain an audience with Mallam
Muhammadu Sanusi II (
third from left), the 14th Emir of Kano, who
granted his political support for the activities to improve blood safety
in Kano state. August 2019.
Photo courtesy of Dr. Greinacher 

The centrifuge and equipment for MTP blood group typing arrived at AKTH in early 2021, and practice has been up and running since August 2022, when Drs. Greinacher and Selleng were able to travel again and deliver the final missing parts to the facility.

“We have been doing the extended Rh matching,” Dr. Gwarzo said. “We’ve tested a lot of donors and some of our patients. We’re moving forward.”

Although Dr. Gwarzo and his team have not accumulated enough data to declare the endeavor a success, they have seen a reduction in complaints from clients and physicians. Furthermore, he and his team have gained confidence in using the MTP method. On three separate occasions, they were able to combat reactions to blood transfusions.

“We picked the antigen responsible for the reaction, we gave [patients] the matched blood that they needed, and they improved,” Dr. Gwarzo said.

Dr. Gwarzo plans to report on these patients as a case series to share with other centers in the region for training purposes.

Next Steps

AKTH is the only center in Nigeria that has been able to perform extended Rh typing with the MTP method, and hematologists there want to expand their capabilities to identify the alloantibodies that multiply transfused patients develop.

“Only about 70% of these alloantibodies are produced by Rh antigens; we still have other clinically significant alloantibodies we cannot detect in our center,” said Halima Ismail, MBBS, the senior registrar in the Department of Hematology and Blood Transfusion at AKTH.

Dr. Ismail works alongside Dr. Gwarzo and submitted her application for the ASH VTP in fall 2022. Her application proposed a training on antibody screening and detection with Dr. Greinacher. As AKTH becomes a referral center for neighboring states, Dr. Ismail said her institution must be able to provide safe and compatible blood for all patients. Thus, her proposed training will build on the training Dr. Greinacher gave to Drs. Ugwu and Gwarzo and expand the number of patients that her institution can safely treat.

Dr. Ismail first intends to obtain 100 blood group O samples from the hospital staff to take to Greifswald to characterize the clinically significant red cell antigens using PCR technology, which her institution already has the capacity to support. Ultimately, Dr. Ismail intends to use her stock as test cells to identify more rare antibodies and essentially build her own reagents.

The beauty of the VTP initiative in Nigeria is that it’s affordable for the local teams, Dr. Greinacher said. The program is not dependent on grant money but can continue because the local team can produce their own reagents.

If Dr. Ismail receives the VTP award, she intends to “do a step-down training in [her] institution, and then, when this is well grounded in [her] institution, [they’ll] start also retraining other hospitals within Nigeria, so that people do not have to leave the country to learn this procedure – it’s already available in their home institution.”

Moreover, Dr. Ismail said, “It will open our research field ... to improve the knowledge of blood transfusion medicine.”

Sustainable Growth and Training

The mentor-mentee relationship is key with the ASH VTP, and the program in Nigeria provides a good example of an ongoing relationship. Dr. Greinacher visits Nigeria every year, gives lectures and demonstrations both in person and virtually, advocates to hospital and political leaders in Nigeria, and works to secure grants that will improve the transfusion service in Nigeria. Both Drs. Ugwu and Gwarzo said he has done a lot for not just Kano, but for Nigeria as a whole.

“Now the foundations are laid to build on and go into more specialties,” Dr. Greinacher said. “The idea is to help them develop it [into] a type of center of excellence, at least in West Africa, and then to train others.”

Halima Ismail, MBBS, trains on the microtiter plate method at Aminu Kano Teaching Hospital in August 2022. Photo courtesy of Andreas Greinacher.
Halima Ismail, MBBS, trains on the microtiter plate method at
Aminu Kano Teaching Hospital in August 2022. Photo courtesy
of Andreas Greinacher.

Get Involved

The ASH VTP has funded 209 individuals from 50 countries between its inception in 2014 and when it was temporarily suspended due to the COVID-19 pandemic in 2020.

The VTP has since reopened and anticipates awarding another 15 to 20 grants in July 2023. Applications become available in April each year, and awardees are notified in July of the following year.

To get involved in the VTP or to learn more about the application process, visit hematology.org/awards/career-enhancement-and-training/visitor-training-program.

Reference

Okoroiwu HU, López-Muñoz F, Povedano-Montero FJ. Bibliometric analysis of global sickle cell disease research from 1997 to 2017. Hemat Transf Cell Ther. 2022;44(2):186-196.

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