Transfusion and Apheresis Science xxx (xxxx) xxx–xxx

Contents lists available at ScienceDirect

Transfusion and Apheresis Science

journal homepage: www.elsevier.com/locate/transci

A university – Led initiative to promote voluntary non-remunerated blood

donation in a developing country
⁎
Kenneth S. Charlesa,b,c, , Melissa Fridayb,c, Deepak Lallc, Kasturi Harrichanc, Melina De Fourc,d,
Kendra Guyc,d, Andre Earlec,d, Delia Rawlinse, Andrew D. Chantryf
a
Department of Paraclinical Sciences, Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
b
Department of Medicine, North Central Regional Health Authority, Eric Williams Medical Sciences Complex, Uriah Butler Highway, Trinidad and Tobago
c
The University of the West Indies Blood Donor Foundation, Department of Paraclinical Sciences, Faculty of Medical Sciences, The University of the West Indies, St.
Augustine, Trinidad and Tobago
d
Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
e
National Blood Transfusion Service, Charlotte Street, Port of Spain, Trinidad and Tobago
f
University of Sheffield Medical School, Department of Oncology & Metabolism, Beech Hill Road, Sheffield, S10 2RX, England, United Kingdom

A R T I C LE I N FO A B S T R A C T

Keywords: Objective: To describe the process, challenges and impact of developing a voluntary non-remunerated blood
Voluntary donor programme in a replacement- based blood donation system.
Non-remunerated Background: Trinidad and Tobago is a developing country whose blood transfusion service is based on re-
Replacement placement and remunerated donors. The University of the West Indies Blood Donor Foundation was formed to
Donation
promote voluntary non-remunerated donation through education, research and example.
Methods/materials: The process of establishing the Blood Donor Foundation was documented. Age, gender,
number, history (first-time or repeat) and serological tests of donors attending 12 consecutive sessions between
2015 and 2018 were analyzed. Comparisons were made to published PAHO data for TTO’s replacement blood
donor system and the programme’s impact on national policy described. Chi square analysis was used to measure
significance of associations and p < 0.05 to assign statistical significance.
Results: After research and sensitization, 951 units of blood were collected, 50% from people in the 17–25 age
group, 54% from females and 55% from repeat donors. Deferrals were < 10% and initially reactive serological
tests 1.2% compared to 43.6% and 3.04% respectively (p < 0.05 for both) for the national donor pool. The
model was accepted for application nationally.
Conclusion: A voluntary non-remunerated blood donation programme was successfully established within a
replacement-based system providing a model for national adoption.

1. Introduction
1.1. Country information
Trinidad and Tobago (Pan American Health Organization (PAHO)
designation TTO) is a developing Caribbean country in the PAHO
Region of the Americas. The population is estimated to be 1 245 773
persons and approximately 21.000 units of blood are collected yearly
giving an annual donation rate of 17 per 1000 population. As much as
25% of the population is below age 25 and 50% are female [1]. The
Gross Domestic Product per capita of US $ 15, 350.90 [2], the adult
literacy rate of 98% and Human Development Index (HDI) of 0.78 place
it in the high development category [3].
1.2. Arrangement of the TTO National Blood Transfusion Service
The National Blood Transfusion Service (NBTS) has headquarters in
Port of Spain, the capital city and six fixed blood donation centres in

Abbreviations: EWMSC, Eric Williams Medical Sciences Complex; FBBA, Friends of the Blood Bank Association; FMS, Faculty of Medical Sciences; F/R, Family
replacement; MOH, Ministry of Health; NBTS, National Blood Transfusion Service; NCRHA, North Central Regional Health Authority; PAHO, Pan American Health
Organization; RHA, Regional Health Authority; TTO, Trinidad and Tobago; UWI, The University of the West Indies; UWIBDF, University of the West Indies Blood
Donor Foundation; VNRD, Voluntary Non-Remunerated Donor
⁎
Corresponding author at: Department of Paraclinical Sciences, Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago.
E-mail address: kenneth.charles@sta.uwi.edu (K.S. Charles).

https://doi.org/10.1016/j.transci.2019.07.008
Received 16 March 2019; Received in revised form 6 July 2019; Accepted 6 July 2019
1473-0502/ © 2019 Published by Elsevier Ltd.

Please cite this article as: Kenneth S. Charles, et al., Transfusion and Apheresis Science, https://doi.org/10.1016/j.transci.2019.07.008
K.S. Charles, et al. Transfusion and Apheresis Science xxx (xxxx) xxx–xxx

public hospitals throughout the country. Each donation centres is Table 2

managed by a Regional Health Authority (RHA) in accordance with Supply of blood for transfusion in TTO.
standards and policy set by the Ministry of Health (MOH). A mobile (adapted from [14]).
collection service is operated by a non- governmental organization, the Year 2014 2015
Friends of the Blood Bank Association (FBBA).
Most (> 80%) of blood is collected from family replacement donors Total collections 21,249 21,121
Donations per 1000 inhabitants 15.8 15.7
(F/R) at the hospital-based donation centres. F/R donors receive a ‘chit’
Voluntary donations % 17.7 18.4
as proof of donation which is used to claim a unit of blood component Replacement donations % 82.3 81.6
for a named beneficiary. A smaller number, mostly on the mobile ser- Voluntary deferrals % 27.8 27.6
vice, donate blood for no specific person but receive a ‘credit’ for each Replacement deferrals % 42.8 46.2
donation which could be converted to a ‘chit’ for a named beneficiary at
a later date. Although these are considered voluntary donors locally the
option to reclaim their donation makes them remunerated donors by 1.5. The University of the West Indies Blood Donor Foundation (UWIBDF)
PAHO’s definition [4].
The University of the West Indies Blood Donor Foundation
(UWIBDF) was established in the Faculty of Medical Sciences (FMS) of
1.3. Problems with involuntary blood donation the St. Augustine, TTO campus in 2011 to conduct research and edu-
cation that would help blood collection agencies by promoting volun-
The annual rate of donations is low in all socio-demographic groups tary non-remunerated blood donation [15].
and lowest in persons under age 25 years and among students. Lack of The aims of this study were to describe the complexity of actions
information and poor access are major contributors to poor donation needed to comply with PAHO blood safety resolutions, examine the
behaviour [5]. Using PAHO’s eligibility criteria for blood donors of age generic feasibility of a UWIBDF-led voluntary non-remunerated blood
18–25 (lower limit 17 with parental consent), weight 110 pounds, donation programme and assess its impact on national policy.
haemoglobin concentration 12.5 g/dl for women and 13.5 g/dl for men
with minimum donation intervals of 3 months and a maximum fre- 2. Materials and methods
quency of 2 donations per year for women, 3 for men for men, donor
deferrals are high [6]. Women donate far less frequently than men 2.1. Creation of the UWIBDF
(ratio 1: 2.5) and are more likely to be deferred [7]. Chronic blood
shortage, transfusion- transmitted infections and overall inefficiency Religious and voluntary organizations to which FMS students be-
[8,9] have plagued the service and often attracted adverse media cov- longed were targeted to form the core membership. These included
erage that erodes public confidence. Table 1 illustrates published PAHO Share Goodness, the Hindu Students’ Council, Intervarsity Christian
data for TTO showing an annual donation rate of 17 per 1000, > 85% Fellowship, Mount Hope Islamic Society, the Movement for
F/R donations and total donor TTIs 3% for the years 2008 and 2009 Empowerment of Dharmic Services, the Trinidad and Tobago Medical
[10]. Students Association, the Leadership Council and the Rotaract Club.

2.2. Patron
1.4. Failed attempt to institute exclusive VNRD in TTO
Patronage of the UWIBDF was granted by a former Chancellor of
Restructuring the National Blood Transfusion Service in accordance The UWI who had served as Director of PAHO from 1993 to 2002.
with PAHO’s resolutions [11,12] resulted in a marked fall in blood During this period, there was strong advocacy for a Public Health ap-
donations when ‘chits’ and ‘credits’ were discontinued at the end of proach to the promotion of voluntary non-remunerated blood donation
2010. Intense and sensational media coverage of the resulting acute in the Caribbean region [16].
blood shortage preceded a MOH decision to revert to ‘chits’ and ‘credits’
within four months of their discontinuation [13]. The conditions that 2.3. Collaborations
prevailed before 2010 returned and, with them, a resumption of ad-
verse media reports. Published PAHO data for 2014 and 2015 are Within The UWI, the UWIBDF collaborated with the Departments of
summarized in Table 2 showing annual donations of 16 per 1000 with History, Social Sciences, Preclinical Medical Sciences, Paraclinical
deferral rates of 27% for voluntary and > 40% for F/R donors [14]. Medical Sciences, Clinical Medical Sciences and Clinical Surgical
Sciences to conduct research into knowledge, attitudes and practice
(KAP) related to blood donation.
Table 1
Supply of blood for transfusion in TTO. 2.4. Outreach
(adapted from [10]).
Year 2008 2009 UWIBDF representatives visited schools, military institutions, places
of worship and shared information at meetings of the Society of
Number of units collected 22,011 22,368 Surgeons, the Obstetric Society of Trinidad and Tobago, the Caribbean
Donations per 1000 population 16.9 17.2
Association of Haematologists and Oncologists, the Trinidad and
Percent type of allogeneic donors
Voluntary 12 13
Tobago Defence Force, the National AIDS Coordinating Committee, the
Family Replacement 88 87 Trinidad and Tobago Medical Association and the Caribbean
Percent of units reactive/positive
Association of Medical Technologists.
HIV 0.21 0.22
HBsAg 0.35 0.31 2.5. Blood donation activities
HCV 0.15 0.21
Syphilis 1.49 1.36
From 2015, the UWIBDF collaborated with the NCRHA to establish
HTLV I/II 0.72 0.94
Total 2.92 3.04 a voluntary non-remunerated blood donation programme at the
EWMSC blood donation centre. Blood drives were held on a Saturday

2
K.S. Charles, et al.
every three-months. Specific nurse phlebotomist training was con-
ducted by the UWIBDF. The NCRHA provided the venue, personnel,
security and laboratory services and UWIBDF recruited donors, made
appointments and issued donor information including eligibility criteria
via its website. Pre- event publicity was generated using flyers, posters,
social media (Facebook, Instagram, Twitter), WhatsApp and e mail
messages. WhatsApp and text messages as well as mobile phone calls
were used to coordinate activities on blood drive days. UWIBDF vo-
lunteers, including schoolchildren, university students, patients and
well-wishers assisted with data collection, serving refreshments, pro-
viding information and general donor hospitality. Donors received no
chits or credits and all donations were screened for transfusion trans-
missible infections – Hepatitis B, Hepatitis C, Human Immunodeficiency
Virus, Syphilis, Human T Lymphotropic Virus I/II, Syphilis and Chagas’
Disease – by Enzyme Linked Assay (ELISA) at the NBTS Headquarters in
Port of Spain.
Blood donors’ data and comments were collected manually on the
centre’s NBTS donor card, a UWIBDF donor card and Microsoft Excel
spreadsheets. After – event feedback including units collected, re-
sponses to comments and a date for the next blood drive was provided
online.
2.6. Statistical analysis
Data analysis was performed using SPSS statistical software and
Minitab 17. Chi-square was used to assign significance and logistic re-
gression to analyse correlation between variables. p < 0.05 was used to
define statistical significance.
3. Results
3.1. Heightened international awareness
Conference presentations and publications highlighted the historical
basis for current challenges facing blood transfusion systems in TTO
and the Caribbean [15,17].
3.2. Increased blood donation awareness in the medical school
Blood donation was introduced into the first year of the medical
curriculum. Medical students produced educational material and pre-
sented topics related to voluntary non-remunerated blood donation
before peers and regional audiences (Fig. 1).
3.3. Research projects and publications
Collaborative research projects generated publications examining
current knowledge, attitudes and practices (KAP) and consequences of
failure of uptake of VNRD [18–21], inspiring similar research regionally
and internationally [22,23].
3.4. Blood donation events
Following sensitization, 951 units of blood were collected at twelve
VNRD blood drives in four years (Fig. 2). This represented 1.1% of units
collected nationally over the period. Annual donations increased for the
first three years then plateaued as they reached the capacity of the
donation centre's infrastructure (Fig. 3) The largest proportion (476 or
50%) of donations were made by persons aged 18–25 (Fig. 4) and fe-
males (518 or 54%, Fig. 5). Repeat donors (527 or 55%) outnumbered
first time donors (FTD) (Fig. 6). Donor deferrals and initially reactive
tests were lower than those most recently by PAHO for F/R and re-
munerated donors in the national blood system (8% vs 43.6%,
p < 0.0001 and 1.2% vs 3.04%, p < 0.05 respectively) [14]. Donor
deferrals were mostly due to recent viral infections, antibiotic therapy,
recent travel, tattoos and anaemia and a report is in preparation. Out of
3
Transfusion and Apheresis Science xxx (xxxx) xxx–xxx
12 initially reactive tests over 12 UWIBDF VNRD events, four were for
anti-HCV, three for Syphilis, two HTLV I/II and three Chagas’ Disease.
3.5. Impact
The UWIBDF/NCRHA collaborative events increased the percentage
of VNRD-sourced blood donations in TTO from 0% in 2014 to 1. 4% in
2018. Although the numerical impact of this increase was incon-
sequential its societal and political impact was much greater. Between
2016 1nd 2018, the MOH and two visiting PAHO missions examined
the UWIBDF/NCRHA model and accepted it for national adoption. In
2018, the MOH announced its decision to phase out ‘chits’ and ‘credits’
over a 3–5 year period by introducing the model at all fixed donation
centres and utilizing a newly acquired mobile unit to collect VNRD
blood outside the hospital setting. A National Blood Transfusion
Committee with representatives from the MOH, RHAs, FBBA and
UWIBDF has been appointed to manage the transition to 100% VNRD
with a Communications Sub-Committee to coordinate messaging with
the national media.
4. Discussion
The UWIBDF has demonstrated the feasibility of voluntary non-re-
munerated blood donation programme in TTO. As in other developing
countries, its KAP surveys have provided information for use devising
communication and donor mobilization strategies in converting to
100% VNRD at the national level [24].
4.1. High blood donation among young persons aged 18–25 years old
Direct targeting, involvement of medical students as young, cred-
ible, respected community members, providing information and a
convenient setting appealed to young donors. Voluntary and religious
groups served as validating organizations with established social net-
works. Information technology and social media provided a rapid, in-
expensive, far-reaching and enjoyable method of communicating in-
formation.
4.2. Blood donation among women
The UWIBDF VNRD programme appealed to women who have been
shown to be more willing than men to participate in altruistic than
transactional blood donation [25]. As a result, the proportion of female
donors was closer to that seen in developed countries with 100% VNRD
[26,27] than in developing countries with predominant replacement
donation [28,29].
4.3. First- time and repeat donors
The UWIBDF programme has not shared the experience of Brazil,
where community first-time VNRDs had a higher prevalence of HIV
than replacement blood donors [30]. However, the high percentage of
FTDs accounts for the higher total TTI rate compared to the established
programme in Curacao that recruits repeat VNRDs only [10,14]. Donor-
friendly arrangements, personal contact, prompt feedback and donor
satisfaction have encouraged repeat donation which improves blood
safety [31].
4.4. Donor deferrals
Comparatively low donor deferral rate (8%) is attributable to the
younger, healthier donor population. The absence of a material reward
for donating and prior notification of eligibility criteria allowed self-
exclusion and reduction of unnecessary deferrals, reducing cost and
enhancing efficiency [6].
K.S. Charles, et al. Transfusion and Apheresis Science xxx (xxxx) xxx–xxx

Fig. 1. Medical student blood donation activities.

Footnote: a, b, c – Posters from blood donation practicums in Year 1 d. Community Health research group and poster in Year 2 e. Group leader receiving challenge
trophy for best blood donation project in Year 3.

Fig. 2. Units donated at twelve (12) UWIBDF events between 2015 and
2018.
Footnote: Blood donor eligibility criteria were circulated to donors in the week
before events after Event #2. Events #7 and #11coincided with medical stu-
dent examinations.
Fig. 4. Blood donations in different age groups.

Fig. 3. Annual donations at UWIBDF event.2015–2018.

Fig. 5. Blood donations by gender.

4.5. Challenges faced

Events had to be planned to avoid examination and vacation periods organizational challenges that faced PAHO in aiming for 50% VNRD
when many young donors are unavailable. The ongoing parallel system [10]. The growing number of VNRDs has outstripped the capacity of a
of mandatory replacement donation posed the ethical and single donation centre and the charitably-derived resources of the

4
K.S. Charles, et al.
Fig. 6. First time and repeat donors.
Footnote: Individuals who had previously donated blood were considered re-
peat donors.
UWIBDF. Increased financial and technical support are needed to in-
crease staffing, infrastructure, the frequency of events and to institute
extramural collections.
5. The future
Achieving 100% VNRD requires a separate programme to convert
the existing pool of F/R donors to VNRD. This programme will follow
the approach used at the Komfo Anokya Teaching Hospital in Ghana of
converting F/R donors to family donors (FD) who donate blood without
coercion to the hospital’s supply rather than a specific beneficiary. FDs
are equivalent to VNRDs. However, they are more directly motivated,
having had the experience of a family member in need and display a
high propensity to repeat donation [32]. They therefore represent a
legitimate and readily available source of new VNRDs during transi-
tioning [33]. Interventions used to achieve 100% VNRD over a three
year period in Nicaragua, a low-income country in PAHO’s Region of
the Americas, will be followed, using the model that was provided for
the region in 2013. These include intense donor education and re-
cruitment in work places, schools, universities, neighbourhood groups,
social clubs and places of worship, training of administrative, medical/
technical personnel and the general public as well as revision of legal
and regulatory pathways to facilitate VNRDs [34]. This will be a na-
tional effort that depends on continued support from the MOH and
PAHO/WHO for success. A study of TTI prevalence in first time and
repeat VNRDs compared to first time and repeat F/R donors is ongoing,
now that a pool of VNRDs is available for the first time.
6. Conclusion
A university-led initiative to provide has produced a successful
VNRD programme within an F/R-based blood system. As has been done
previously, it used education, example and a donor-friendly environ-
ment to generate a new pool of spontaneously repeating VNRDs at little
additional expense to the donation centre [35]. This achievement has
demonstrated the feasibility of voluntary non-remunerated blood do-
nation and provided an incentive for collecting VNRD blood at all blood
donation centres and extramurally in TTO.
Funding
No funding was received for this study.
Acknowledgements
Charles, KS – wrote the paper, analyzed data; Friday, M - collected
data; Lall, D - collected data; De Four, M - collected data; Earle, A -
collected data; Harricharan, K – collected data; Rawlins, D – collected
5
Transfusion and Apheresis Science xxx (xxxx) xxx–xxx
data; Chantry AD – helped conceptualize the report, reviewed manu-
script.
References
[1] Central Statistical Office. Trinidad and Tobago 2011 housing and population census.
2019 . Accessed 23rd February 2019 http://cso.gov.tt/census/2011-census-data/.
[2] Trading Economics. Trinidad and Tobago GDP. 2019 Accessed 23rd February 2019
https://tradingeconomics.com/trinidad-and-tobago/gdp.
[3] United Nations Development Programme. UNDP human development report 2016:
human development for everyone. Trinidad and Tobago 2017 Accessed 24th
February 2019 http://www.tt.undp.org/content/trinidad_tobago/en/home/
library/humandevelopment/human-development-report-2016.html.
[4] Pan American Health Organization, World Health Organization. Annex: instructions
to complete the form “National Blood Program”. Transfusion medicine in the
Caribbean and Latin American countries, 2000–2003. Washington, D.C: PAHO;
2005. p. 76–7.
[5] Sampath S, Ramsaran V, Parasram S, Mohammed S, Latchman S, Khunja R, et al.
Attitudes towards blood donation in Trinidad and Tobago. Transfus Med
2007;17:83–7.
[6] Pan American Health Organization, World Health Organization. Eligibility for blood
donation: recommendations for education and selection of prospective blood do-
nors. Washington, DC: PAHO; 2009.
[7] Charles KS, Hughes P, Gadd R, Bodkyn CJ, Rodriguez M. Evaluation of blood donor
deferral causes in the Trinidad and Tobago National Blood Transfusion Service.
Transfus Med 2010;20:11–4.
[8] Monteil M, Naraynsingh V. Blood utilization for elective general surgery at the Port
of Spain General Hospital. West Indian Med J 1986;35:293–4.
[9] Charles KS, Persad R, Ramnarine L, Seepersad S, Ratiram C. Blood transfusion in a
developing society: who is the best blood donor? Br J Haematol 2012;158:548–58.
[10] Pan American Health Organization WHO. Supply of blood for transfusion in the
Caribbean and Latin American countries 2006, 2007, 2008 and 2009. Progress since
2005 of the Regional Plan of Action for Transfusion Safety. Washington, DC: PAHO;
2010.
[11] Pan American Health Organization, World Health Organization. 46th directing
council, 57th session of the regional committee. Progress report on the regional
initiative for blood safety and pan for action for 2006–2010. Resolution CD 46/16.
2005.
[12] Pan American Health Organization, World Health Organization. 48th directing
council. Improving blood availability and transfusion safety in the Americas. CD
48/11. 2008.
[13] Parmasad V. “She is my blood”. Donation and reciprocity in Trinidad. In:
Chardonneau J, Smith A, editors. Giving blood: the institutional making of altruism
London: Taylor and Francis Group; 2015. p. 199–218. https://doi.org/10.4324/
9781315689579.
[14] Pan American Health Organization, World Health Organization. Supply of blood for
transfusion in Latin American and Caribbean countries 2014 and 2015.
Washington: PAHO; 2017. DC. ISBN: 978-92-75- 31958-1.
[15] Charles KS. Blood transfusion in the Caribbean: a case study of Trinidad and
Tobago. Transfus Med 2017;27:3–9.
[16] Alleyne GAO. Ensuring safe blood in the Americas. Rev Panam Salud Publ
2003;13:65–7.
[17] Charles KS, Cateau H, McCollin D, Lall D, Persad R. Exploring the dichotomy be-
tween blood transfusion services in England and a former British colony: indolence,
indifference or ignorance? Br J Haematol 2014;65. 97-7.
[18] Charles KS, Chisholm K, Gabourel K, Philip K, Ramdath S, Abdul-Hakeem, et al. A
follow up survey of knowledge, attitudes and practices surrounding blood donation
in Trinidad and Tobago. ISBT Sci Ser 2017;12:349–56.
[19] Charles KS, Poon King AP, Ramai A, Rajnath K, Ramkissoon D, Ramkissoon S, et al.
Blood donors’ attitudes towards voluntary non-remunerated donation in Trinidad
and Tobago. Transfus Med 2017;27:249–55.
[20] Charles KS, Metivier KS, Sammy S, Labban M, Rudder M, Singh S, et al. Attitudes,
knowledge and risk perception surrounding receiving blood transfusion in Trinidad
and Tobago. ISBT Sci Ser 2018;14:201–7. https://doi.org/10.1111/voxs.12434.
[21] Charles KS, De Freitas L, Ramoutar R, Goolam R, Murray D, Juman S, et al. Blood
utilization in a developing society – what is the best index of efficiency? Transfus
Med 2018;28:413–9.
[22] Atherley AE, Taylor CGJr, Whittington A, Jonker C. Knowledge, attitudes and
practices towards blood donation in Barbados. Transfus Med 2016;26:415–21.
[23] Charles KS, Bhagwansingh S. Comparative knowledge, attitudes and practice sur-
veys in two multi-ethnic communities. ISBT Sci Ser 2018;14:248–50. https://doi.
org/10.1111/voxs.12462.
[24] Lownik E, Riley E, Konstenius T, Riley W, McCullough J. Knowledge, attitudes and
practices surveys of blood donation in developing countries. Vox Sang
2012;103:64–74.
[25] Lightman ES. Women and voluntary blood donation. J Sociol Soc Welf 1982
Accessed 18th October 2018 https://scholarworks.wmich.edu/jssw/vol9/iss4/5.
[26] Bani M, Giussani B. Gender differences in giving blood: a review of the literature.
Blood Transfus 2010;8:278–87. https://doi.org/10.2450/2010.0156-09.
[27] Shaz BH, James AB, Hillyer KL, Schreiber GB, Hillyer CD. Demographic variations
in blood donor deferrals in a major metropolitan area. Transfusion 2010;50:881–7.
[28] Shahshahani HJ. Why don’t women volunteer to give blood? A study of knowledge,
attitude and practice of women about blood donation, Yazd, Iran, 2005. Transfus
Med 2007;17:451–4.
K.S. Charles, et al.
[29] Nwogoh B, Aigberadion U, Nwannadi AI. Knowledge, attitude, and practice of
voluntary blood donation among healthcare workers at the university of benin
teaching hospital, Benin City, Nigeria. J Blood Transfus 2013;2013. https://doi.
org/10.1155/2013/797830. 797830.
[30] Barreto CC, Sabino EC, Goncalez TT, Laycock ME, Pappalardo BL, Salles NA, et al.
Prevalence, incidence, and residual risk of human immunodeficiency virus among
community and replacement first-time blood donors in Sao Paulo, Brazil.
Transfusion 2005;45:1709–14.
[31] Allain JP, Sarkodie F, Asenso-Mensa K, Owusu-Ofosi S. Relative safety of first-time
volunteer and replacement donors in West Africa. Transfusion 2010;50:340–3.
[32] Asenso-Mensah K, Achina G, Appiah R, Owusu-Ofori S, Allain JP. Can family or
Transfusion and Apheresis Science xxx (xxxx) xxx–xxx
replacement blood donors become regular volunteer donors? Transfusion
2014;54:797–804.
[33] Allain J-P, Sibinga CTS. Family donors are critical and legitimate in developing
countries. Asian J Transfus Sci 2016;10(1):5–11.
[34] Berrios R, Gonzalez A, Cruz JR. Achieving self-sufficiency of red blood cells based
on universal voluntary blood donation in Latin America. The case of Nicaragua.
Transfus Apher Sci 2013;49:387–9.
[35] Allain JP, Sarkodie F, Boateng P, Asenso K, Kyeremateng E, Owusu-Ofori S. A pool
of repeat blood donors can be generated with little expense to the blood center in
sub-Saharan Africa. Transfusion 2008;48:735–41.