677
family planning (FP) programme a success through voluntary Understanding the grave situation arising out of illegal abortions, the Shantilal Shah Committee was appointed by the Government in 1964 to study and report on the problem. On the efforts.
basis of that committees’ report, submitted in 1966, the Indian Parliament approved the Medical Termination of Pregnancy (MTP) Act 1971 with the sole purpose of discontinuation of billions of future pregnancies. Today, we have more than 7000 institutions, including primary health centres, providing abortions free of cost under the supervision of a trained doctor or other staff. The legislation reduced the death rate of women during abortion. Irrespective of all efforts made by the Government and voluntary organisation, the illegal abortion rate, especially in rural areas of some provinces, is very high-13-3 per 1000 vs 6-6 per 1000
pregnancies.2 Doherty’s opinion that people should be educated for the benefit of society as a whole is true. A tiny province on the south-west coast, Kerala State, is to achieve complete literacy soon, where the family planning programme has been highly successful, and abortion has been the choice for many. However, as Dr Joyce Poole (May 30, p 1340) implied, uneducated societies like those in many of our villages should not be deprived of facilities. The emphasis for the success of the policy lies in how quickly we make our citizens aware of the existence of safe and free abortion under the protection of the law. Department of Physiology, M. P Shah Medical College, Jamnagar 361 008, India
K. P. SKANDHAN
1. Park JE, Park K. Textbook of preventive and social medicine, 12th ed. Jabalpur: Banarsidas Bhanot Publishers, 1989. 2. Indian Council of Medical Research. Illegal abortions in rural areas. New Delhi:
ICMR, 1990
Blood donation SIR,-Dr Leikola (July 4, p 57) states his view that selfsufficiency in plasma derivatives based on voluntary (nonremunerated) blood or plasma donation is a realistic goal. It is noteworthy that more than half the world’s supply of plasma derivatives arises from the use of source material obtained from donors who are compensated for their commitment of time and dedication to participation in plasmapheresis programmes; the ability to obtain sufficient quantities of source material solely from non-compensated donors has not been shown. Participation in blood programmes by non-remunerated donors might even decline in the future because of increased emphasis on autologous donations and the use of haemoglobin substitutes. Potential additional benefits of albumin solutions over and above use in the management of hypovolaemia-eg, as additives to total parental nutrition and in conjunction with bone marrow transplants-are being evaluated and may well lead to even greater application. Intravenous immunoglobulin is gaining wider acceptance as data documenting its efficacy in additional indications are generated; also, virtually all hyperimmune globulin programmes depend on the use of immunised compensated donors. The cost of recombinant coagulation factor VIII to prescribers and institutions may preclude complete adoption as a replacement for plasma-derived concentrates now shown to be safe with respect to transmission of viral agents. All these issues call into question mandating exclusive use of non-compensated donors, and the negative impact such a policy would have on the continued availability of adequate supplies of plasma derivatives needed for optimum patient care. Leikola also states that the use of voluntary, unpaid donors adds to the safety of plasma derivatives. In 1978, the US Food and Drug Administration stated: "... no available data demonstrate that final plasma derivative products derived from volunteer donor plasma carry a lower risk of transmitting hepatitis to recipients than do similar products manufactured from paid donor plasma.1" Data resulting from the evaluation of reagents used in the detection of anti-HCV in haemophiliacs show that the frequency of this marker is similar in many countries, even those with little or no use of imported coagulation factor concentrates. Recent data reported by several facilities obtaining plasma from remunerated donors in the
USA show a frequency of anti-HCV averaging 0-35% by second generation ELISA testing; I note that des Roziers and Nasr2 report that 0-6% of volunteer blood donors tested were repeatedly positive for this marker. The unfortunate transmission of AIDS has also been seen in countries relying solely on concentrates derived from domestic non-remunerated donors. Plasma derivatives produced from pooled donations have been associated with viral transmission irrespective of donor status. Data obtained shortly after the initial implementation of anti-HIV-1testing in the USA showed a closely similar frequency of this marker in units of plasma obtained from remunerated donors and units of blood obtained from nonremunerated donors. Concerns about provision of source material by compensated donors can be alleviated by controls under a competent health authority. Safe and effective plasma derivatives as well as compensation of donors can be achieved. American Blood Resources Association, PO Box 669, Annapolis, Maryland 21404, USA
MICHAEL B. RODELL
1. Federal Register. 1978, Jan 13, (43 FR 2142). 2. des Roziers NB, Nasr O. Second-generation anti-HCV tests and surrogate markers in volunteer blood donors. Transfusion 1992, 32: 492.
Selection for audit SIR,-In your Aug 15 editorial you commend a system by which anaesthetists can select for detailed examination cases falling outside predetermined boundaries and suggest that it might even be applied to internal medicine. The idea is, in principle, straightforward. Patients should be classified in terms of their risk of an adverse outcome, their actual outcome should be recorded, and the expected compared with the observed outcome. In practice the situation is made somewhat difficult, largely because of our failure to measure routinely severity of illness and outcome. Hannan et aP have demonstrated what can be achieved with quite simple measures. In comparison with records of patients randomly selected from among those dying in hospital, records of patients with conditions falling into diagnostic-related groups with an expected mortality rate of less than 0-5% were five times as likely to show departure from professionally recognised standards or evidence of care that caused or contributed to death.’ In 1988 Ellwood2 called for the large-scale collection of data linking severity of illness and outcome. Validated measures of severity, some of which use routine hospital data,3 are available, as are generic and disease-specific measures of outcome.4 What seems to be lacking is the will to use them. Public Health and Policy, Health Services Research Unit, London School of Hygiene and Tropical Medicine, London WC1 E 7HT, UK
Department of
MARTIN MCKEE
EL, Bernard HR, O’Donnell JF, Kilburn H. A methodology for targeting hopsital cases for quality of care record reviews Am J Publ Health 1989; 79: 430-36. 2. Ellwood PM. Shattuck lecture: outcomes management. N Engl J Med 1988; 318: 1 Hannan
1549-56 3 Gonnella JS, Hombrook MC, Louis DZ. Staging of disease
a case-mix
measurement.
JAMA 1984; 251: 637-44. 4. Patrick DL, Deyo RA. Generic and disease specific measures in assessing health status and quality of life. Med Care 1989, 27: S217-S382.
Distribution of scientific information in
Spanish SIR,-Elford and colleagues’ reported a search of the MEDLINE database on CD-ROM (compact disc read-only memory) which showed that between 1981 and 1990 more than 30 000 papers were indexed under AIDS or HIV. In a Lancet note on AIDS research (Feb 22, p 485) you say that "English was the language of the overwhelming majority (82%) of papers on AIDS. Since many cases of AIDS occur in countries where English is not the first language ... this finding raises questions about the accessibility of published research in these countries". You go on, "because of its origin in the USA, MEDLINE may be biased towards English-language publications, and the database does not index all journals that deal with AIDS and HIV". We agree with
family planning (FP) programme a success through voluntary Understanding the grave situation arising out of illegal abortions, the Shantilal Shah Committee was appointed by the Government in 1964 to study and report on the problem. On the efforts.
basis of that committees’ report, submitted in 1966, the Indian Parliament approved the Medical Termination of Pregnancy (MTP) Act 1971 with the sole purpose of discontinuation of billions of future pregnancies. Today, we have more than 7000 institutions, including primary health centres, providing abortions free of cost under the supervision of a trained doctor or other staff. The legislation reduced the death rate of women during abortion. Irrespective of all efforts made by the Government and voluntary organisation, the illegal abortion rate, especially in rural areas of some provinces, is very high-13-3 per 1000 vs 6-6 per 1000
pregnancies.2 Doherty’s opinion that people should be educated for the benefit of society as a whole is true. A tiny province on the south-west coast, Kerala State, is to achieve complete literacy soon, where the family planning programme has been highly successful, and abortion has been the choice for many. However, as Dr Joyce Poole (May 30, p 1340) implied, uneducated societies like those in many of our villages should not be deprived of facilities. The emphasis for the success of the policy lies in how quickly we make our citizens aware of the existence of safe and free abortion under the protection of the law. Department of Physiology, M. P Shah Medical College, Jamnagar 361 008, India
K. P. SKANDHAN
1. Park JE, Park K. Textbook of preventive and social medicine, 12th ed. Jabalpur: Banarsidas Bhanot Publishers, 1989. 2. Indian Council of Medical Research. Illegal abortions in rural areas. New Delhi:
ICMR, 1990
Blood donation SIR,-Dr Leikola (July 4, p 57) states his view that selfsufficiency in plasma derivatives based on voluntary (nonremunerated) blood or plasma donation is a realistic goal. It is noteworthy that more than half the world’s supply of plasma derivatives arises from the use of source material obtained from donors who are compensated for their commitment of time and dedication to participation in plasmapheresis programmes; the ability to obtain sufficient quantities of source material solely from non-compensated donors has not been shown. Participation in blood programmes by non-remunerated donors might even decline in the future because of increased emphasis on autologous donations and the use of haemoglobin substitutes. Potential additional benefits of albumin solutions over and above use in the management of hypovolaemia-eg, as additives to total parental nutrition and in conjunction with bone marrow transplants-are being evaluated and may well lead to even greater application. Intravenous immunoglobulin is gaining wider acceptance as data documenting its efficacy in additional indications are generated; also, virtually all hyperimmune globulin programmes depend on the use of immunised compensated donors. The cost of recombinant coagulation factor VIII to prescribers and institutions may preclude complete adoption as a replacement for plasma-derived concentrates now shown to be safe with respect to transmission of viral agents. All these issues call into question mandating exclusive use of non-compensated donors, and the negative impact such a policy would have on the continued availability of adequate supplies of plasma derivatives needed for optimum patient care. Leikola also states that the use of voluntary, unpaid donors adds to the safety of plasma derivatives. In 1978, the US Food and Drug Administration stated: "... no available data demonstrate that final plasma derivative products derived from volunteer donor plasma carry a lower risk of transmitting hepatitis to recipients than do similar products manufactured from paid donor plasma.1" Data resulting from the evaluation of reagents used in the detection of anti-HCV in haemophiliacs show that the frequency of this marker is similar in many countries, even those with little or no use of imported coagulation factor concentrates. Recent data reported by several facilities obtaining plasma from remunerated donors in the
USA show a frequency of anti-HCV averaging 0-35% by second generation ELISA testing; I note that des Roziers and Nasr2 report that 0-6% of volunteer blood donors tested were repeatedly positive for this marker. The unfortunate transmission of AIDS has also been seen in countries relying solely on concentrates derived from domestic non-remunerated donors. Plasma derivatives produced from pooled donations have been associated with viral transmission irrespective of donor status. Data obtained shortly after the initial implementation of anti-HIV-1testing in the USA showed a closely similar frequency of this marker in units of plasma obtained from remunerated donors and units of blood obtained from nonremunerated donors. Concerns about provision of source material by compensated donors can be alleviated by controls under a competent health authority. Safe and effective plasma derivatives as well as compensation of donors can be achieved. American Blood Resources Association, PO Box 669, Annapolis, Maryland 21404, USA
MICHAEL B. RODELL
1. Federal Register. 1978, Jan 13, (43 FR 2142). 2. des Roziers NB, Nasr O. Second-generation anti-HCV tests and surrogate markers in volunteer blood donors. Transfusion 1992, 32: 492.
Selection for audit SIR,-In your Aug 15 editorial you commend a system by which anaesthetists can select for detailed examination cases falling outside predetermined boundaries and suggest that it might even be applied to internal medicine. The idea is, in principle, straightforward. Patients should be classified in terms of their risk of an adverse outcome, their actual outcome should be recorded, and the expected compared with the observed outcome. In practice the situation is made somewhat difficult, largely because of our failure to measure routinely severity of illness and outcome. Hannan et aP have demonstrated what can be achieved with quite simple measures. In comparison with records of patients randomly selected from among those dying in hospital, records of patients with conditions falling into diagnostic-related groups with an expected mortality rate of less than 0-5% were five times as likely to show departure from professionally recognised standards or evidence of care that caused or contributed to death.’ In 1988 Ellwood2 called for the large-scale collection of data linking severity of illness and outcome. Validated measures of severity, some of which use routine hospital data,3 are available, as are generic and disease-specific measures of outcome.4 What seems to be lacking is the will to use them. Public Health and Policy, Health Services Research Unit, London School of Hygiene and Tropical Medicine, London WC1 E 7HT, UK
Department of
MARTIN MCKEE
EL, Bernard HR, O’Donnell JF, Kilburn H. A methodology for targeting hopsital cases for quality of care record reviews Am J Publ Health 1989; 79: 430-36. 2. Ellwood PM. Shattuck lecture: outcomes management. N Engl J Med 1988; 318: 1 Hannan
1549-56 3 Gonnella JS, Hombrook MC, Louis DZ. Staging of disease
a case-mix
measurement.
JAMA 1984; 251: 637-44. 4. Patrick DL, Deyo RA. Generic and disease specific measures in assessing health status and quality of life. Med Care 1989, 27: S217-S382.
Distribution of scientific information in
Spanish SIR,-Elford and colleagues’ reported a search of the MEDLINE database on CD-ROM (compact disc read-only memory) which showed that between 1981 and 1990 more than 30 000 papers were indexed under AIDS or HIV. In a Lancet note on AIDS research (Feb 22, p 485) you say that "English was the language of the overwhelming majority (82%) of papers on AIDS. Since many cases of AIDS occur in countries where English is not the first language ... this finding raises questions about the accessibility of published research in these countries". You go on, "because of its origin in the USA, MEDLINE may be biased towards English-language publications, and the database does not index all journals that deal with AIDS and HIV". We agree with
![[Blood donation, iron donation].](/assets/img/hold.png)
