Indian blood bankers soaking up U.S. know-how

February 2007
Feature Story

Anne Ford

During his trips to India, where he has given several blood banking talks and workshops for health professionals over the past 15 months, Jim Perkins, MD, refuses to assume a preachy attitude. “I didn’t want to go someplace and say, ‘You should be doing this—that’s the way we do it,’” he says. “Because who am I to say, ‘This is an appropriate health priority at your stage of development’?” Dr. Perkins is director of Evanston Northwestern Healthcare Blood Banks, headquartered in Evanston, Ill., and assistant professor of pathology at Northwestern University’s Feinberg School of Medicine, Chicago.

As it turns out, however, he and the medical professionals he has met there share one of the same priorities: to improve the safety of the Indian blood supply, particularly in regard to blood group antibody testing, which few blood centers there perform. “The typical pretransfusion testing sequence in India is an ABO and Rh type on the donor and recipient, and then a crossmatch,” he says. “If they have a positive crossmatch, most places just simply keep crossmatching additional units, without identifying the cause of the positive crossmatch, and that’s a limited approach. They can’t deal with autoantibodies. If your crossmatches are positive with everyone, you don’t know, ‘Is this a clinically significant antibody against other people, or is this an antibody against the person themselves that can be ignored?’ This is a blood safety issue that needs to be addressed.”

Trends in Indian medicine, he adds, have made the issue even more important. “They’re seeing more and more medical tourists who are coming there for heart operations,” he says. “They’re seeing more and more patients who are multiply transfused and therefore have blood group antibodies. More and more of their population has access to sophisticated health care, so it is likely a growing need.”

He continues, “What was particularly gratifying when I went on that first trip to India was, everyone knew they wanted to do this. When a technologist sits in a laboratory and is getting positive crossmatches and has to issue incompatible blood, that’s a terrible thing. They’re afraid for the patient. And that provides a tremendous incentive for them to want to be able to solve these problems. So we have had a tremendously positive reception everywhere we’ve gone.”

Dr. Perkins’ interest in the topic stems from a visit to Pakistan in January 2004. During the trip, he and his blood banking colleagues Mohammed Pothiawala, MS, MT (ASCP) SBB, technical director of the blood bank at the University of Chicago Hospitals, and Syed Arif Azeem, MT(ASCP)SBB, administrator of radiation oncology at Edward Hines Jr. VA Hospital, Hines, Ill., who had arranged the trip, gave lectures to health professionals in the city of Karachi. “We talked about everything from antibodies to transfusion reactions, hemolytic disease of the newborn, and indications for transfusion,” Dr. Perkins says. “We stood up on the dais and gave a lot of talks about what could be done and what should be done, but it was clear in that context that you weren’t going to bring about change by standing on a dais and talking. So right away, I wanted to set up a situation where I could go back and do wet workshops on group antibody identification.”

Plans for a second Pakistan trip were thwarted by the massive earthquake there in October 2005. But Anil Singhvi, MD, a young Indian oncologist and hematologist who had met Dr. Perkins earlier that year while on fellowship at Evanston Hospital and who now consults at Choithram and Geeta Bhawan hospitals in Indore, India, offered to help arrange a similar trip to India. The result: a 17-day visit in November and December 2005, during which Dr. Perkins gave talks at the Indian Society of Blood Transfusion and Immunohematology meeting in the city of Udaipur, the Prathama Blood Centre in Ahmedabad, the Choithram Hospital in Indore, and (in the neighboring country of Nepal) the South Asian Association of Transfusion Medicine meeting in Kathmandu.

“As in Pakistan, I talked about everything,” Dr. Perkins says. “My primary talk at the ISBTI meeting was on setting up a peripheral blood stem cell transplant program. In Ahmedabad I talked about transfusion reactions, in Kathmandu I did case studies—i.e., told stories—and talked about antibodies, and in Indore I talked about antibodies, HDN, and indications for red blood cell transfusion.”

“His visit was a grand success,” Dr. Singhvi says. “I can still remember how he singlehandedly gave a nonstop three-hour talk at a symposium on blood banking and blood group antibodies that I had arranged at my institution. All my colleagues here were literally glued to their seats during that presentation. I can assert that Jim is one of the best things to have happened on the Indian blood banking scene lately.”

As a result of the contacts he made on that visit, Dr. Perkins was able to arrange a second India trip last November, during which he was finally able to achieve his wet-workshop goal. The trip was funded by the Wilmette-Kenilworth (Ill.) Rotary Club, of which Dr. Perkins is a member; the medical staff of Evanston Northwestern Healthcare; and Dr. Perkins himself.

He was joined by Susan T. Johnson, MSTM, MT(ASCP)SBB, manager of the immunohematology reference laboratory at the Blood Center of Wisconsin, Milwaukee, and Graeme Woodfield, MB, ChB(NZ), PhD, clinical associate professor in the Department of Molecular Medicine and Pathology at the University of Auckland, New Zealand. The three led a three-day preconference wet workshop before the Indian Society of Blood Transfusion and Immunohematology annual meeting in Ahmedabad. Johnson and Dr. Perkins also spoke at the meeting itself—Johnson about the direct antiglobulin test, and Dr. Perkins about preparing in-house red cell reagents for detecting and identifying antibodies.

ImmucorGamma and Cardinal Health donated reagents and equipment for the preconference workshop. “They donated timers and test tube racks and disposable pipettes and all this stuff,” Dr. Perkins says. “I carried six big suitcases, all of which were overweight.” The workshop drew 18 physicians and six laboratory technologists. “We started out just grading reactions in the test tube on a titration,” Dr. Perkins says. “And then we moved into progressively more complicated problems, finishing with an autoantibody problem.” He and Johnson had brought some blood group antibodies from blood donors, and LifeSource, a blood center in Chicago, donated some as well.

The team encountered one major limitation: “The blood cell reagents that we use are derived from European populations,” Dr. Perkins says. “I’m talking about antibody screening cells and antibody panel cells. In this country, we do a so-called type and screen, and if the antibody screen portion of that is negative, we typically do abbreviated crossmatches, or electronic crossmatches, which only are designed to detect ABO errors—mostly clerical ABO errors—and that’s validated.

“We cannot make that assumption in another population,” he continues. “One of our distinguished colleagues in India, one of the board members of ISBTI, did a small study recently where he was identifying antibodies, and 14 percent of the alloantibodies that he detected with positive crossmatches could not be identified using Swiss cell panels. So there is evidence that this is a problem. If you’re telling people, ‘Consider adopting the type and screen type of algorithm that we use,’ in order to do that, they’re also going to have to have the appropriate infrastructure in the form of antibody screening and panel cells, reagents that are created locally. So coming out of this workshop, we are attempting to facilitate their drawing their own regular donors and producing those cells locally.”

Another, larger goal is to help create a countrywide immunohematology infrastructure similar to that in the United States. At his own hospital, Dr. Perkins says, “we identify most of our own antibodies. But if we’re stumped, we have all these centers that we can send our specimens to and get them analyzed. There’s no such infrastructure in India.” He hopes to work with Indian blood centers such as those in Ahmedabad, Delhi, and Bombay, to develop their capabilities, “and one aspect of that is to create their own panels of donor cells and begin to manufacture their own screening cells.” In addition, “we hope to bring blood bankers from India here to work in reference laboratories—in particular if we can find situations where they can stay for free in the homes of Rotary members or other volunteers—to learn these skills of setting up immunohematology reference laboratories.”

As of CAP TODAY press time, Dr. Perkins was planning a third India trip for January. Accompanied by Marilyn Moulds, MT (ASCP)SBB, recently retired as vice president of reference and education services at ImmucorGamma, he aimed to hold a five-day workshop at Jeevan Blood Bank in the southern Indian city of Chennai (previously known as Madras). The trip will again be partly funded by Rotary, Dr. Perkins’ colleagues at Evanston, and Dr. Perkins himself, and ImmucorGamma and Cardinal Health will again donate supplies. (“We could not do it without them,” he says.) He plans to return later this year to do another workshop at the ISBTI annual meeting in the city of Bhopal.

The trips have given Dr. Perkins tremendous enthusiasm for India, which he had never visited before. (“I always tell people, ‘Oh, I’m just here for the food,’” he jokes.) Then, too, the response his talks and workshops have received from the medical community there have only fueled that enthusiasm. “People are coming to us wanting to know, wanting to further develop their skills, further develop their laboratories,” he says. “It is so gratifying to teach people who want to know what you have to offer.”