Abstract

The article aims to discuss the consequences of social distancing measures on the availability of blood and organization of blood therapy services at the beginning of the Covid-19 pandemic in Brazil. News published in April 2020 on the websites of the country’s state Blood Service Networks were consulted and organized in an Excel spreadsheet, presented in summary charts, and descriptions of results were prepared. A critical situation of blood supply, especially of some blood types, has been observed in many states. This situation is influenced by the circulation of the new coronavirus. The adoption of social distancing measures associated with unchanged transfusion demands for outpatient, urgency and emergency care required the implementation of strategies and actions for the reorganization of the services. Protection measures were incorporated, flows were changed and new routines were established. This study shows the extent to which the epidemiological situation of Covid-19 and the necessary measures for its control influenced the stocks and availability of blood. Changes in the organization of blood therapy services were fundamental in order to ensure protection, mitigate the risks of spreading the virus, and ensure the blood supply to meet the needs of the health system.

Key words:
Coronavirus infections; Brazil; Blood Therapy Service; Organization and administration

Introduction

Studies show that the spread of the SARS-Cov-2 virus, the etiological agent of the disease known as Covid-19, has had an impact on the number of blood donations and, therefore, on the supply of blood products to health services. Furthermore, it heated up the discussion on blood safety and surveillance measures, even though there is no confirmed scientific evidence of transmission of the virus by transfusions¹1 Cai X, Ren H, Chen F, Li L, Lei H, Wang X. Blood transfusion during the Covid-19 out break. Blood Transfus 2020; 18(2):79-82.

2 Franchini M, Farrugia A, Velati C, Zanetti A, Romanò L, Grazzini G, Lopez N, Pati I, Marano G, Pupella S, Liumbruno GM. The impact of the SARS-Cov-2 outbreak on the safety and availability of blood transfusions in Italy. Vox Sang 2020; 10.1111/vox.12928.
https://doi.org/10.1111/vox.12928... ^-33 Kwon SY, Kim EJ, Jung YS, Jang JS, Cho NS. Post-Donation Covid-19 Identification in Blood Donors. Vox Sang 2020; 10.1111/vox.12925.
https://doi.org/10.1111/vox.12925.... .

The increase in the number of confirmed cases of SARS-Cov-2 has led governments to decide to adopt measures of social distancing, with interruption of activities in the community, due to the need to flatten the curve. This posed challenges to health services, including for blood therapy services, whose offer of therapeutic resource depends on the availability and willingness of donors. Added to this, blood products are perishable⁴4 Shander A, Goobie SM, Warne MA, Aapro M, Bisbe E, Perez-Calatayud AA, Callum J, Cushing MM, Dyer WB, Erhard J, Faraoni D, Farmer S, Fedorova T, Frank SM, Froessler B, Gombotz H, Gross I, Guinn NR, Haas T, Hamdorf J, Isbister JP, Javidroozi M, Ji H, Kim YW, Kor DJ, Kurz J, Lasocki S, Leahy MF, Lee CK, Lee JJ, Louw V, Meier J, Mezzacasa A, Munoz M, Ozawa S, Pavesi M, Shander N, Spahn DR, Spiess BD, Thomson J, Trentino K, Zenger C, Hofmann A, International Foundation of Patient Blood Management (IFPBM) and Society for the Advancement of Blood Management (SABM) Work Group. The essential role of patient blood management in a pandemic: a call for action. Anesth Analg 2020; 131(1):74-85. and require constant replenishment⁵5 Raturi M, Kusum A. The active role of a blood center in out pacing the transfusion transmission of Covid-19. Transfus Clin Biol 2020; 27(2):96-97..

The adoption of social distancing measures aims to reduce interactions in a community, considering that people can be infected and not yet identified nor isolated. In this sense, reducing circulation and avoiding agglomeration of people reduce the transmission of diseases whose contagion requires physical proximity between people⁶6 Wilder-Smith A, Freedman DO. Isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus (2019-nCoV) outbreak. J Travel Med 2020; 27(2):taaa020..

Examples of measures that aim at social distancing are the closing of schools and workplaces, the suspension of some types of commerce activities and the cancellation of events/meetings to avoid crowding⁶6 Wilder-Smith A, Freedman DO. Isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus (2019-nCoV) outbreak. J Travel Med 2020; 27(2):taaa020.. Such initiatives have had an impact on the supply of “priceless resources” to health, so that the emergence of the pandemic led to the interruption of activities in the community, including the closure of donation centers/units in many areas around the world, reaching the point in which the demand exceeded the supply⁴4 Shander A, Goobie SM, Warne MA, Aapro M, Bisbe E, Perez-Calatayud AA, Callum J, Cushing MM, Dyer WB, Erhard J, Faraoni D, Farmer S, Fedorova T, Frank SM, Froessler B, Gombotz H, Gross I, Guinn NR, Haas T, Hamdorf J, Isbister JP, Javidroozi M, Ji H, Kim YW, Kor DJ, Kurz J, Lasocki S, Leahy MF, Lee CK, Lee JJ, Louw V, Meier J, Mezzacasa A, Munoz M, Ozawa S, Pavesi M, Shander N, Spahn DR, Spiess BD, Thomson J, Trentino K, Zenger C, Hofmann A, International Foundation of Patient Blood Management (IFPBM) and Society for the Advancement of Blood Management (SABM) Work Group. The essential role of patient blood management in a pandemic: a call for action. Anesth Analg 2020; 131(1):74-85..

Measures to prevent the spread of the virus were adopted by many countries in the world threatens the blood supply, for example, precautionary, quarantine or confinement exclusions and fears of causing self-exclusions⁴4 Shander A, Goobie SM, Warne MA, Aapro M, Bisbe E, Perez-Calatayud AA, Callum J, Cushing MM, Dyer WB, Erhard J, Faraoni D, Farmer S, Fedorova T, Frank SM, Froessler B, Gombotz H, Gross I, Guinn NR, Haas T, Hamdorf J, Isbister JP, Javidroozi M, Ji H, Kim YW, Kor DJ, Kurz J, Lasocki S, Leahy MF, Lee CK, Lee JJ, Louw V, Meier J, Mezzacasa A, Munoz M, Ozawa S, Pavesi M, Shander N, Spahn DR, Spiess BD, Thomson J, Trentino K, Zenger C, Hofmann A, International Foundation of Patient Blood Management (IFPBM) and Society for the Advancement of Blood Management (SABM) Work Group. The essential role of patient blood management in a pandemic: a call for action. Anesth Analg 2020; 131(1):74-85.^,77 Garraud O. Covid-19: is a paradigm change to be expected in health care and transfusion medicine? Transfus Clin Biol 2020; 27(2):59-60.. Still, the uncertainty, fear, assumptions existing in the mind of donors and their reluctance to go to services to donate blood imply a significant reduction in the amount of blood collected worldwide⁸8 Raturi M. A Quick "Can I Donate Blood" Self-Assessment Tool Amid the Covid-19 Outbreak. Transfus Clin Biol 2020; 27(2):169-170..

In a recent publication, heads of blood banks and transfusion departments in hospitals in 12 countries around the world, including Australia, Brazil, Canada, Denmark, Iran, Israel, Italy, Japan, Korea, Spain, the United Kingdom and the United States, reported on the different expectations and deadlines for blood shortage considering the levels of the pandemic in their countries until the penultimate week of April. Israeli, Spanish, Danish, British and Korean respondents did not expect a shortage of blood as a result of this pandemic, while the others expected shortages in the short, medium or long term⁹9 Yazer MH, Jackson B, Pagano M, Rahimi-Levene N, Pares V, Bueno JL, Jackson RP, Shan H, Amorim-Filho L, Lopes M-E, Boquimpani C, Sprogøe U, Bruun MT, Titlestad K, Rushford K, Wood EM, McQuilten ZK, Angelis V, Donne MD, Murphy M, Staves J, Cho D, Nakamura F, Hangaishi A, Callum J, Lin Y, Mogaddam M, Gharehbaghian A, Lozano M, Vox Sanguinis International Forum on Transfusion Services About Response to Covid-19. Vox Sang 2020; 115(6):536-542..

The pandemic and the adoption of measures such as physical distancing and closing and looking cities, provinces or countries in the attempt to contain the spread of the infection can result in a great decline in blood supply and in a generalized scarcity of blood products¹⁰10 Fan BE, Ong KH, Chan SSW, Young BE, Chong VCL, Chen SPC, Lim SP, Lim GP, Kuperan P. Blood and blood product use during covid-19 infection. Am J Hematol 2020; 95(7):E158-E160.. It is important to note that patients suffering from cancer, hematological disorders, and also surgery, urgency and emergency services need blood components for provision and prescription to patients.

This article aims to discuss the consequences of social distancing measures on the availability of blood and the organization of blood therapy services at the beginning of the Covid-19 pandemic in Brazil.

Methodology

In order to monitor the consequences of the pandemic and the strategies adopted by blood therapy services to ensure the availability of blood to meet the demands of health services, a bank was builtin the Excel software with news from the websites of state Blood Service Networks in Brazil. The first synthesis produced based on such news was published on the Observatory of Political Analysis in Health (https://www.analisepoliticaemsaude.org/oaps/)¹¹11 Souza MKB, Lima YOR, Cavalcante LLR. (Des)Abastecimento do estoque de sangue e estratégias para o aumento da doação em tempos de Covid-19 [Internet]. 2020 [acessado 2020 Abr 18]. Disponível em: https://www.analisepoliticaemsaude.org/oaps/pensamentos/551b2b2b673ef8efe72170ac42f1e8ba/7/
https://www.analisepoliticaemsaude.org/o... , considering the period from February 26 (date of notification of the first case confirmed in Brazil, in the state of São Paulo) until March 31, 2020.

On March 31, 2020, there were 5,824 confirmed cases of Covid-19 in Brazil, and that number went to 87,126 on April 30, 2020 (https://painel.covid19br.org/). In this sense, this study presents the following question: how did the social distancing measures adopted influence blood stocks and the organization and functioning of blood therapy services in the first months of the Covid-19 pandemic in Brazil?

The news published on the websites of the state Blood Service Networks of Brazil and used for discussion in this article include publications of the month of April 2020 and are summarized in two charts.

The discussion of the results is collated with the synthesis of experiences and publications from other countries found in a survey in PubMed (using the descriptors: Covid-19 or new coronavirus or coronavirus disease 2019 and blood transfusion or blood donors or blood supply or blood bank or blood donation or transfusion medicine), as one of the activities developed by the author at Rede CoVida - Science, Information and Solidarity, which is characterized as a scientific and multidisciplinary collaboration project focused on the Covid-19 pandemic resulting from the partnership between the Center for Data Integration and Knowledge for Health (Cidacs/Fiocruz Bahia) and the Federal University of Bahia (UFBA) (https://covid19br.org/).

Results

The records showed that the Covid-19 pandemic caused changes in the organization and functioning of blood therapy services, including a reduction in the levels of blood stocks due to the mandatory social distancing measures adopted to control the spread and transmission of the virus. Chart 1 summarizes these results.

According to the news published on the websites of the state Blood Service Networks in April 2020, there was a “critical situation” in the supply, especially for blood types with negative RH factor, O+ and platelets. In some states, at the beginning of the month, the records showed a reduction of 30% in the number of daily donations (Hematology and Blood Therapy Center of Alagoas - Hemoal, 07.04.20),or 35% in the total number of donors (Arthur de Siqueira Cavalcanti State Institute of Hematology of Rio de Janeiro - Hemorio, 07.04.20) and even 60% of donors (Hematology and Blood Therapy Center of Amazonas - Hemoam, 01.04.20).

This situation presented on the websites remains justified/compromised by the “new coronavirus pandemic (Covid-19)” (Hematology and Blood Therapy Center of Maranhão -Hemomar, 03 and 08.04.20; Hematology and Blood Therapy Foundation of Rondônia - Fhemeron, 24.04.20) and because of the growth in the number of cases in Brazil, according to news from the Hospital Foundation of Hematology and Blood therapy of Amazonas (Hemoam).

According to statements identified on the websites, directors and those responsible for blood collection and other departments of the blood cycle revealed their concern with the situation. About this, the director of the Hemoam Foundation pointed out that “despite adopting measures to avoid crowding of people, scheduling, changing the layout of waiting rooms to maintain a minimum distance between donors, and placing alcohol gel dispensers at will with in the blood center, donations are increasingly reduced” and, he added that “the pandemic slowed everything down”, calling attention to the fact that “the consumption of blood products is still high”(Hemoam, 01.04.20).

Information from the website of the Hematology and Blood Therapy Center of Maranhão (Hemomar) highlights that “due to the social isolation measures adopted to combat the Covid-19 pandemic, blood donations dropped and the stock of bags was at a critical level” (Hemomar, 08.04.20). About this, the website of the Hematology and Blood Therapy Foundation Center of Minas Gerais reaffirmed that in this moment of social isolation, “reflexes can be observed in the flow of donors” (Hematology and Blood Therapy Foundation Center of Minas Gerais - Hemominas, 15.04.20).

It was also emphasized in some publications that there is still a need for blood, such as in cases of patients with sickle cell anemia and thalassemia (Fhemeron, 02.04.20). The need for blood and blood components for such services was also mentioned by the director of the Hematology and Blood therapy Foundation of Bahia, who made reference to patients with dengue (Hematology and Blood Therapy Foundation of Bahia - Hemoba, 29.04.20). The coordinator of the Hematology and Blood Therapy Foundation of Rondônia also “clarified that the Covid‐19 does not dictate the demand for blood types O+ and O‐ in the bank, nor reduction in the number of surgeries and accidents during the quarantine”. She stressed that “these types are the most transfused” and highlighted the need to meet the urgent needs of cancer patients (Fhemeron, 30.04.20).

Other statements identified on the websites showed that the reduction in the service capacity of mobile units (Blood Therapy and Hematology Center of Goiás - Hemogo, 24.04.20) due to the adoption of measures to ensure greater safety for donors extended the waiting time and some people have no patience or cannot wait (Hemomar, 08.04.20), and this also influences the blood stock levels.

Demands and changes in the organization and functioning of blood therapy services

The context of the pandemic had an impact on blood stock levels, so that strategies for organization, functioning and routine of the services needed to be implemented. This study revealed that such strategies were related to safety, precaution and risk reduction measures for the spread of the virus in services, incorporation of new technologies, among others (Chart 2).

Protection and precautionary measures against the transmission of the virus were implemented in the month of April, including intensified hygiene of areas and surfaces (Hemoba, 13.04.20; Blood Center Foundation of Brasília - FHB, 08.04.20); use of masks by patients and donors (Hemoba, 29.04.20); respect for a minimum distance between donors; expansion of the quantity of alcohol gel dispensers; use of safety equipment (Hemoba, 29.04.20; FHB, 08.04.20; Hematology and Blood Therapy Center of Pará - Hemopa, 13.04.20; Pró-Sangue Blood Center Foundation of São Paulo - Pró-Sangue, 27.04.20).

New measures to protect people, patients and candidates for donation have been incorporated, for example, “to measure the body temperature of all patients arriving at the institution” (Hemopa, 13.04.20), thus requiring a referral flow, so that “in case of fever or other symptoms of Covid-19, people are referred to other public health units, and they are temporary impeded to donate” (Hemoam, 03.04.20). As a protective measure, other flows were changed and routines were established, for example, at the Hemopa, emergency cases are priority in medical consultations, in case of patients who need to receive transfusions, platelets and Factor. Also, in the case of patient with aplastic anemia, consultations for physical therapy and scheduling to retrieve medications aresuspended (Hemopa, 13.04.20).

The expansion of donation points/locations was reported on the websites. The Hematology and Blood Therapy Center of Ceará decided to provide new places for donation in strategic points of the state to continue receiving volunteers during the pandemic (Hemoce 23.04.20), although in many realities the implantation of external tents (Hemomar, 08.04.20) as a measure to reduce agglomerations (FHB, 22.04.20) has reduced the collection capacity of such collection units (Hemogo, 03.04.20; Hemogo, 24.04.20). In this sense, other strategies used are the scheduling of the donation (Hemoba, 13.04.20; FHB, 20.04.20; Hemogo, 03.04.20; Hemogo, 24.04.20; Pró-Sangue, 27.04.20; Hematology and Blood Therapy Center of Sergipe - Hemose, 27.04.20), the pre-scheduled donation (Hematology and Blood Therapy Center of Mato Grosso do Sul - Hemosul, 30.04.20) of groups of up to ten people (Hemose, 20.04.20; Hematology and Blood Therapy Center of Tocantins - Hemoto, 24.04.20) and the call of healthy people (Hemoba, 29.04.20; FHB, 02.04.20).

The context of the pandemic influenced the routines of the services, with extended opening hours, and opening on Saturdays and/or holidays (FHB, 22.04.20; Hemosul, 30.04.20; Hemominas, 15.04.20; Hematology and Blood Therapy Center of Santa Catarina - Hemosc, 01.04.20; Hemoto, 24.04.20). Some blood centers included in their routine, in April, the validation, offer and realization of diagnostic tests for Covid-19. For example, the Hematology and Blood Therapy Center of Ceará validated the effectiveness of rapid tests for Covid-19 (Hemoce, 15.04.20) and is qualified to perform the laboratory diagnosis of coronavirus, sending the material to be analyzed at the Molecular Biology Laboratory of the Hemoce (Hemoce, 14.04.20). Also, since the beginning of April, the Hemominas Foundation joined the Redelab Covid-19 and has contributed to the increase in the capacity of testing in SUS (Hemominas, 22.04.20).

Information technologies have been incorporated in order to streamline services and qualify the experience of donors in blood centers. The Pró-Sangue Foundation in São Paulo established a partnership with a specialized company that uses Artificial Intelligence in order to facilitate the search for information and clarify doubts of donors (Pró-Sangue, 01.04.20) and modernized its scheduling system through a partnership with a Brazilian startup company, giving the candidates greater agility and autonomy when scheduling or canceling their donations (Pró-Sangue, 13.04.20).

The maintenance of old strategies such as partnerships to encourage donation was mentioned on the websites visited, however, new partners and new strategies were also highlighted. A sanitation process to sanitize and eliminate agents that cause various infections was mentioned in Pará, through a partnership with the city halls of two municipalities (Hemopa, 30.04.20). In Bahia, a partnership was established with a transport service to disseminate information and a message was posted to encourage donation (Hemoba, 27.04.20). External collection in condominiums was adopted by Hemorio and this initiative has been expanded to other states. Many states have established partnerships with transportation applications to help in the travel to collection units (Hemoam, 14.04.20; Hemoce, 04.04.20; Hematology and Blood Therapy Center of Piauí - Hemopi, 06.04.20; Hemorio, 07.04.20; Hematology and Blood Therapy Center of Rio Grande do Norte - Hemonorte, 20.04.20; Pró-Sangue, 27.04.20) and/or free transportation for the round trip with a limited number of people inside the vehicle (FHB, 08.04.20; FHB, 20.04.20; Hemomar, 03.04.20; Hemogo, 29.04.20). Also, according to the initiative of the Court of Justice and the Secretariat of Public Security, the blood service network of the state of Goiás expects an increase in the number of donations, under Ordinance 01/2020 of the Court of Execution of Penalties and Alternative Measures, which determines that blood donation held from March to June 2020 will be equivalent to 35 hours of provision of services to the community by convicts (Hemogo, 01.04.20).

Blood centers have also promoted, in some cases articulated with other institutions, qualification and training related to the demands of facing the pandemic. The training includes updating of the screening criteria, rational use of personal protective equipment (PPE) to guide on proper use (Hemoam, 03.04.20); security protocols (Hemogo, 03.04.20; Hemogo, 24.04.20); protocols and adjustments in teams (Hemominas, 22.04.20).

Discussion

Before the Covid-19 epidemic, blood stocks varied between states in Brazil, however, as of mid-March, some Blood Service Networks announced blood stocks, especially of the O and AB groups, positive and negative, were in critical levels, for example, in the states of Alagoas, Bahia, Mato Grosso do Sul, Espírito Santo, Maranhão, Rio Grande do Norte, Rondônia, Minas Gerais, Rio de Janeiro and São Paulo¹¹11 Souza MKB, Lima YOR, Cavalcante LLR. (Des)Abastecimento do estoque de sangue e estratégias para o aumento da doação em tempos de Covid-19 [Internet]. 2020 [acessado 2020 Abr 18]. Disponível em: https://www.analisepoliticaemsaude.org/oaps/pensamentos/551b2b2b673ef8efe72170ac42f1e8ba/7/
https://www.analisepoliticaemsaude.org/o... . The supply and destocking situation continued in Blood centers in Brazil during the month of April, as shown here, justified by the adoption of the necessary social distancing measures to contain the spread of the SARS-Cov-2 virus.

Social distancing measures⁶6 Wilder-Smith A, Freedman DO. Isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus (2019-nCoV) outbreak. J Travel Med 2020; 27(2):taaa020. included the interruption of activities in the community and specifically the closure of donation centers/units in many areas around the world, causing an impact on the offer of “priceless resources” to health⁴4 Shander A, Goobie SM, Warne MA, Aapro M, Bisbe E, Perez-Calatayud AA, Callum J, Cushing MM, Dyer WB, Erhard J, Faraoni D, Farmer S, Fedorova T, Frank SM, Froessler B, Gombotz H, Gross I, Guinn NR, Haas T, Hamdorf J, Isbister JP, Javidroozi M, Ji H, Kim YW, Kor DJ, Kurz J, Lasocki S, Leahy MF, Lee CK, Lee JJ, Louw V, Meier J, Mezzacasa A, Munoz M, Ozawa S, Pavesi M, Shander N, Spahn DR, Spiess BD, Thomson J, Trentino K, Zenger C, Hofmann A, International Foundation of Patient Blood Management (IFPBM) and Society for the Advancement of Blood Management (SABM) Work Group. The essential role of patient blood management in a pandemic: a call for action. Anesth Analg 2020; 131(1):74-85.. Therefore, the significant reduction in the number of blood donations is confirmed as a repercussion of the social restrictions made by governments to combat the spread of Covid-19¹²12 Baron DM, Franchini M, Goobie SM, Javidroozi M, Klein AA, Lasocki S, Liumbruno GM, Muñoz M, Shander A, Spahn DR, Zacharowski K, Meybohm P. Patient Blood Management during the Covid-19 Pandemic - A Narrative Review. Anaesthesia 2020; 75(8):1105-1113.. For example, in New York City there was a significant reduction in blood supply during the week of March 16, 2020, when schools, businesses and religious institutions were closed due to the coronavirus outbreak⁴4 Shander A, Goobie SM, Warne MA, Aapro M, Bisbe E, Perez-Calatayud AA, Callum J, Cushing MM, Dyer WB, Erhard J, Faraoni D, Farmer S, Fedorova T, Frank SM, Froessler B, Gombotz H, Gross I, Guinn NR, Haas T, Hamdorf J, Isbister JP, Javidroozi M, Ji H, Kim YW, Kor DJ, Kurz J, Lasocki S, Leahy MF, Lee CK, Lee JJ, Louw V, Meier J, Mezzacasa A, Munoz M, Ozawa S, Pavesi M, Shander N, Spahn DR, Spiess BD, Thomson J, Trentino K, Zenger C, Hofmann A, International Foundation of Patient Blood Management (IFPBM) and Society for the Advancement of Blood Management (SABM) Work Group. The essential role of patient blood management in a pandemic: a call for action. Anesth Analg 2020; 131(1):74-85..

In China, the first country to record SARS-Cov-2 cases, strict social distancing measures effectively contained the virus; however, the mobility restrictions implemented also had a profound impact on the health system, including a reduction in blood donation in many areas of the country, requiring initiatives and strategies to ensure blood supply¹1 Cai X, Ren H, Chen F, Li L, Lei H, Wang X. Blood transfusion during the Covid-19 out break. Blood Transfus 2020; 18(2):79-82..

In this sense, it should be noted that social distance and its consequence on blood stocks brought the need to reorganize blood therapy services and include new strategies and actions to ensure blood supply in several countries, including Brazil, as the present study revealed. Thus, safety and precautionary measures for donation candidates, patients and workers, as well as new routines, flows and technologies were incorporated in the services, including the adoption of protocols, information and communication technologies, offering diagnostic tests to Covid- 19, and actions to encourage donation were intensified along with old and new partners.

Since the beginning of the first cases of Covid-19 in Brazil, blood centers have incorporated routine donations to ensure the blood supply and avoid crowding in services, the provision of transportation services for commuting, the expansion of waiting room environments, protocols with guidelines for the disposition of chairs in the waiting room and in the donation room, use of PPE and intensification of cleaning¹¹11 Souza MKB, Lima YOR, Cavalcante LLR. (Des)Abastecimento do estoque de sangue e estratégias para o aumento da doação em tempos de Covid-19 [Internet]. 2020 [acessado 2020 Abr 18]. Disponível em: https://www.analisepoliticaemsaude.org/oaps/pensamentos/551b2b2b673ef8efe72170ac42f1e8ba/7/
https://www.analisepoliticaemsaude.org/o... . In addition, the epidemic also added a new profile of users entering the collection room, which should be screened according to new criteria established and subject to updating according to the behavior of the pandemic. During this period, donor and worker safety must remain a priority for any collection and transfusion service, which implies the adoption of a set of measures⁸8 Raturi M. A Quick "Can I Donate Blood" Self-Assessment Tool Amid the Covid-19 Outbreak. Transfus Clin Biol 2020; 27(2):169-170., including the provision of training on the proper use of PPE and application universal precautions for the safety of workers⁹9 Yazer MH, Jackson B, Pagano M, Rahimi-Levene N, Pares V, Bueno JL, Jackson RP, Shan H, Amorim-Filho L, Lopes M-E, Boquimpani C, Sprogøe U, Bruun MT, Titlestad K, Rushford K, Wood EM, McQuilten ZK, Angelis V, Donne MD, Murphy M, Staves J, Cho D, Nakamura F, Hangaishi A, Callum J, Lin Y, Mogaddam M, Gharehbaghian A, Lozano M, Vox Sanguinis International Forum on Transfusion Services About Response to Covid-19. Vox Sang 2020; 115(6):536-542..

Studies report the experiences of several countries in the world in the pandemic and the measures adopted to maintain and ensure the blood collection and supply system. Actions range from raising awareness to stimulating donations through information resources, media and communication¹1 Cai X, Ren H, Chen F, Li L, Lei H, Wang X. Blood transfusion during the Covid-19 out break. Blood Transfus 2020; 18(2):79-82.^,22 Franchini M, Farrugia A, Velati C, Zanetti A, Romanò L, Grazzini G, Lopez N, Pati I, Marano G, Pupella S, Liumbruno GM. The impact of the SARS-Cov-2 outbreak on the safety and availability of blood transfusions in Italy. Vox Sang 2020; 10.1111/vox.12928.
https://doi.org/10.1111/vox.12928... ^,55 Raturi M, Kusum A. The active role of a blood center in out pacing the transfusion transmission of Covid-19. Transfus Clin Biol 2020; 27(2):96-97. to the adoption of new protocols, flows and routines, such as screening blood donors⁵5 Raturi M, Kusum A. The active role of a blood center in out pacing the transfusion transmission of Covid-19. Transfus Clin Biol 2020; 27(2):96-97., implementing protocols of no shows and review of transfusion requests¹³13 Pagano MB, Hess JR, Tsang HC, Staley E, Gernsheimer T, Sen N, Clark C, Nester T, Bailey C, Alcorn K. Prepare to adapt: blood supply and transfusion support during the first 2 weeks of the 2019 novel coronavirus (COVID-19) pandemic affecting Washington state. Transfusion 2020; 60(5):908-911., adoption of a patient’s blood management program (PBM) using information systems²2 Franchini M, Farrugia A, Velati C, Zanetti A, Romanò L, Grazzini G, Lopez N, Pati I, Marano G, Pupella S, Liumbruno GM. The impact of the SARS-Cov-2 outbreak on the safety and availability of blood transfusions in Italy. Vox Sang 2020; 10.1111/vox.12928.
https://doi.org/10.1111/vox.12928... ^,1414 Mascaretti L, De Angelis V, Berti P. The severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) pandemic and transfusion medicine: reflections from Italy. Blood Transfus 2020; 18(2):77-78., patient-centered approach, application of good practice consensus¹²12 Baron DM, Franchini M, Goobie SM, Javidroozi M, Klein AA, Lasocki S, Liumbruno GM, Muñoz M, Shander A, Spahn DR, Zacharowski K, Meybohm P. Patient Blood Management during the Covid-19 Pandemic - A Narrative Review. Anaesthesia 2020; 75(8):1105-1113., change in the dynamics of hospital activities that change routine operations into pandemic and urgent operations¹³13 Pagano MB, Hess JR, Tsang HC, Staley E, Gernsheimer T, Sen N, Clark C, Nester T, Bailey C, Alcorn K. Prepare to adapt: blood supply and transfusion support during the first 2 weeks of the 2019 novel coronavirus (COVID-19) pandemic affecting Washington state. Transfusion 2020; 60(5):908-911., among others.

Also in the set of strategies to mitigate blood shortages, medical information campaigns on the appropriate thresholds for transfusion and appropriate use of pharmaceutical products⁹9 Yazer MH, Jackson B, Pagano M, Rahimi-Levene N, Pares V, Bueno JL, Jackson RP, Shan H, Amorim-Filho L, Lopes M-E, Boquimpani C, Sprogøe U, Bruun MT, Titlestad K, Rushford K, Wood EM, McQuilten ZK, Angelis V, Donne MD, Murphy M, Staves J, Cho D, Nakamura F, Hangaishi A, Callum J, Lin Y, Mogaddam M, Gharehbaghian A, Lozano M, Vox Sanguinis International Forum on Transfusion Services About Response to Covid-19. Vox Sang 2020; 115(6):536-542. have gained attention and have been incorporated into the routine of services as well as the organization in the provision of care and dispensing of blood products to patients who depend on them as therapeutic resource in several countries. For example, in the United Kingdom, national expert advice from a Covid-19 working group has been implemented for medical updating, with practical guidance and counseling for the optimal use of blood products and methods to mitigate the use of blood in patients with hemoglobin diseases¹⁵15 Roy NBA, Telfer P, Eleftheriou P, De la Fuente J, Drasar E, Farrukh S, Roberts D, Atoyebi W, Trompeter S, Layton DM, Lugthart S, Stuart-Smith S, Chakravorty S, Wright J, Porter J, Inusa B, Howard J, National Haemoglobinopathy Panel. Protecting Vulnerable Patients With Inherited Anaemias From Unnecessary Death During The Covid-19 Pandemic. Br J Haematol 2020; 189(4):635-639..

A Technical Note published by Rede CoVida in Brazil presented a review of recommendations for the planning and organization of blood therapy services, with a view to guaranteeing the blood supply to the needs of the health system and the supply of convalescent plasma for the tests in the treatment of Covid-19¹⁶16 Souza MKB. Nota Técnica 05/2020. Revisão sobre recomendações para o planejamento e a organização dos serviços hemoterápicos durante a pandemia pelo SARS-COV-2 [Internet]. [acessado 2020 Maio 25]. Disponível em: https://covid19br.org/main-site-covida/wp-content/uploads/2020/05/Nota-Tecnica-05-hemoterapicos.pdf
https://covid19br.org/main-site-covida/w... . The importance of planning and organizing services to respond to events was pointed out as “lessons learned from this pandemic” by representatives of banks and transfusion departments from different countries around the world⁹9 Yazer MH, Jackson B, Pagano M, Rahimi-Levene N, Pares V, Bueno JL, Jackson RP, Shan H, Amorim-Filho L, Lopes M-E, Boquimpani C, Sprogøe U, Bruun MT, Titlestad K, Rushford K, Wood EM, McQuilten ZK, Angelis V, Donne MD, Murphy M, Staves J, Cho D, Nakamura F, Hangaishi A, Callum J, Lin Y, Mogaddam M, Gharehbaghian A, Lozano M, Vox Sanguinis International Forum on Transfusion Services About Response to Covid-19. Vox Sang 2020; 115(6):536-542..

For the discussion, it is important to note that the dissemination of the new coronavirus also produced an intense debate on blood safety, including the issuance of recommendations by health authorities, emphasizing the lack of scientifically documented evidence of transmission by blood transfusions¹²12 Baron DM, Franchini M, Goobie SM, Javidroozi M, Klein AA, Lasocki S, Liumbruno GM, Muñoz M, Shander A, Spahn DR, Zacharowski K, Meybohm P. Patient Blood Management during the Covid-19 Pandemic - A Narrative Review. Anaesthesia 2020; 75(8):1105-1113.. For example, in Italy, recommendations with preventive measures for the transmission of SARS-CoV-2 were published and updated in several versions/decrees²2 Franchini M, Farrugia A, Velati C, Zanetti A, Romanò L, Grazzini G, Lopez N, Pati I, Marano G, Pupella S, Liumbruno GM. The impact of the SARS-Cov-2 outbreak on the safety and availability of blood transfusions in Italy. Vox Sang 2020; 10.1111/vox.12928.
https://doi.org/10.1111/vox.12928... . In Brazil, technical notes were also published informing the criteria for clinical screening for dengue (DENV), chikungunya (CHIKV), zika (ZIKV) and coronavirus (SARS, MERS, 2019-nCoV) in blood donation candidates¹⁷17 Brasil. Ministério da Saúde (MS). Nota técnica nº 5/2020-CGSH/DAET/SAES/MS. Atualização dos critérios técnicos para triagem clínica de dengue (DENV), chikungunya (CHIKV), zika (ZIKV) e coronavírus (SARS, MERS, 2019-nCov) nos candidatos à doação de sangue [Internet]. 2020 [acessado 2020 Mar 28]. Disponível em: https://www.saude.gov.br/images/pdf/2020/fevereiro/21/SEI-MS---0013484477---Nota-T--cnica.pdf and the criteria related to the risk of infection by SARS-CoV-2 are updated¹⁸18 Brasil. Ministério da Saúde (MS). Secretaria de Atenção Especializada à Saúde. Departamento de Atenção Especializada e Temática Coordenação-Geral de Sangue e Hemoderivados. Nota Técnica Nº 13/2020-CGSH/DAET/SAES/MS. Atualização dos critérios técnicos contidos na Nota Técnica Nº 5/2020-CGSH/DAET/SAES/MS para triagem clínica dos candidatos à doação de sangue relacionados ao risco de infecção pelo SARS-CoV-2 [Internet]. 2020 [acessado 2020 Abr 26]. Disponível em: https://www.saude.gov.br/images/pdf/2020/marco/27/SEI-MS---0014052636---Nota-T--cnica---n---13-2020.pdf
https://www.saude.gov.br/images/pdf/2020... . These notes clarify criteria that generate temporary disqualification for donation, which in the case of Brazil the danger of returning to epidemics due to arboviruses needs to be taken into account¹⁹19 Cioffi JGM. Viroses, transfusões de sangue e doações voluntárias [Internet]. 2016 [acessado 2020 Mar 26]. Disponível em: http://blog.saude.mg.gov.br/2016/06/06/artigo-viroses-transfusoes-de-sangue-e-doacoes-voluntarias/
http://blog.saude.mg.gov.br/2016/06/06/a... and presents general guidelines for the functioning of blood therapy services to prevent the spread of the virus and protect the health of patients, donors and workers, which to some extent affects the number of donations and stock conditions.

Finally, this study showed that the adoption of social distancing measures required changes in the routine and organization of the blood collection and supply system, but such necessary and effective measures - in the context of a pandemic with rising growth in Brazil, with registration of 431.609 confirmed cases on May 28, 2020 (https://painel.covid19br.org/) - should take into account, for the sake of flexibility, the monitoring of the epidemiological situation, the speed of transmission of the epidemic and the number of cases²⁰20 Aquino EML, Silveira IH, Pescarini JM, Aquino R, Souza-Filho JÁ, Rocha AS, Ferreira A, Victor A, Teixeira C, Machado DB, Paixão E, Alves FJO, Pileco F, Menezes G, Gabrielli L, Leite L, Almeida MCC, Ortelan N, Fernandes QHRF, Ortiz RJF, Palmeira RN, Pinto Junior EP, Aragão E, Souza LEPF, Barral Netto M, Teixeira MG, Barreto ML, Ichihara MY, Lima RTRS. Medidas de distanciamento social no controle da pandemia de COVID-19: potenciais impactos e desafios no Brasil. Cien Saude Colet 2020; 25(Supl. 1):2423-2446.. Thus, in order to meet the demands of health services with regard to blood products, the dissemination, sharing and incorporation of strategies, practices and routines by Blood Centers should be fully active in this context of a pandemic.

Final considerations

This study showed that the epidemiological situation and the necessary measures for its control influenced blood stocks conditions and availability and, consequently, demanded changes in the organization of blood therapy services.

As in other countries, in the Brazilian reality, the adoption of distancing measures has required a reorganization of blood therapy services. Strategies, actions and routines have been incorporated and/or intensified to ensure protection, mitigate the risks of spreading the virus, and guarantee the supply of blood and blood components to meet the needs of the health system.

Therefore, the strategies and new routines incorporated by services, discussed in this article in the light of experiences in other countries, are important and must be maintained and implemented in order to contain the epidemiological situation of the Covi-19 pandemic and mitigate the health risks of population.

Acknowledgements

I am grateful for the support in the collection and updating of the matrix of news from the Blood Service Networks through the Observatory of Political Analysis in Health of the Institute of Collective Health (OAPS/ISC/UFBA) and the scientific support of the CoVida - Science, Information and Solidarity Network (Cidacs/Fiocruz and UFBA).

References

Publication Dates

History