Case

W16617

MODEL BLOOD BANK, INDORE: SUPPLY CHAIN MANAGEMENT

Harshal Lowalekar, T. S. Raghu, and Ajay Vinze wrote this case solely to provide material for class discussion. The authors do not intend to illustrate either effective or ineffective handling of a managerial situation. The authors may have disguised certain names and other identifying information to protect confidentiality. This publication may not be transmitted, photocopied, digitized or otherwise reproduced in any form or by any means without the permission of the copyright holder. Reproduction of this material is not covered under authorization by any reproduction rights organization. To order copies or request permission to reproduce materials, contact Ivey Publishing, Ivey Business School, Western University, London, Ontario, Canada, N6G 0N1; (t) 519.661.3208; (e) [email protected]; www.iveycases.com. Copyright © 2016, Richard Ivey School of Business Foundation Version: 2016-09-29

It was May 1, 2015, and Dr. Anil Joshi, the in-charge and associate transfusion officer at the Model Blood Bank (MBB), the largest blood bank in Indore, was reviewing the monthly numbers. Although the report on collected and issued blood units (see Exhibit 1) seemed to indicate no crisis in demand and supply, Dr. Joshi knew that the situation was worse than what the report indicated. Due to complicated requirements on blood products, demand for specific products was frequently not met and shortages in specific blood products persisted despite improvements in number of blood units collected.. What worried him was that the problem of blood shortage would likely only worsen in the months of May, June, and July, when the majority of educational institutions in India, which constituted a significant source of blood donation for the MBB, would be closed due to vacations. The implications of a shortage of blood products were very serious. A shortage would mean some surgeries would need to be postponed; in situations such as accidents or a pandemic, the unavailability of blood could even result in the loss of lives. Joshi needed to decide on the optimal frequency and quantity of blood collection over the next few months to minimize the shortage and wastage of blood products at the MBB. He was considering two options: (1) increase the collection quantity at the blood donation camps,1 or (2) increase the frequency of blood collection camps. The business objective was to minimize the total shortage and wastage costs at the bank. THE BLOOD BANKING SCENARIO IN LOW-INCOME COUNTRIES According to the World Health Organization (WHO), blood donation by approximately 1 per cent of a country’s total population was sufficient to meet the nation’s annual demand.2 But approximately 40 per cent of the world’s nations were unable to meet this requirement.3 The average blood collection in low- income nations (0.4 per cent) was less than in medium- (1.17 per cent) and high-income nations (3.7 per cent).4 This meant that low-income countries struggled with a blood shortage rate of 60 per cent. The problem of blood shortage was further amplified in low-income countries because only a low percentage of whole blood (45 per cent) was fractionated into components.5 Many blood banks in low- income countries were not equipped to prepare and store components such as red blood cells, platelets, and plasma. Such blood banks stored all collected units as whole blood (i.e., blood that was not separated into

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This document is authorized for use only by Prashath Sivaganeshan in 620 winter 2021 (2) taught by Mahmood Kotb, University Canada West from Feb 2021 to Aug 2021.

Page 2 9B16D018 components) and issued the whole blood in place of the desired components. This approach affected the overall blood supply since transfusing one unit of whole blood when a patient required just one component wasted the other two components present in the blood. The transfusion of whole blood, instead of only the desired component, also led to some side effects in the recipient’s body. Therefore, componentization was a beneficial process that both reduced the overall risks associated with transfusing whole blood and increased the overall blood supply by making one unit of whole blood available to three potential recipients. To increase the overall safety in blood transfusion, the WHO recommended blood collection only from non-remunerated voluntary donors.6 Blood-borne diseases and infections were found to be less prevalent among voluntary donors than paid and replacement donors,7 who often donated blood not willingly, but out of necessity.8 Although the percentage of voluntary donations had increased around the world, nearly half of all nations (mostly the low- and medium-income countries) still depended on replacement and paid donations for more than 50 per cent of their blood supply.9 The prevalence of transfusion-related infections was significantly higher in low- and medium-income countries than in high-income countries. The combined rate of prevalence of the human immunodeficiency virus (HIV), the hepatitis B virus (HBV), and the hepatitis C virus (HCV) observed in low-income countries was 5.51 per cent, as opposed to 1.13 per cent in middle-income countries and 0.04 per cent in high-income countries.10 THE BLOOD BANKING SCENARIO IN INDIA India, like several other low-income countries, faced a huge shortage of blood products. The total blood supply in India in the fiscal year 2009/10 was less than 70 per cent of the annual demand (see Exhibit 2). Most of the states in India experienced an extreme shortage; some states such as Bihar faced a shortage as great as 90 per cent of the demand. Only a few states—such as Gujarat, Maharashtra, Mizoram, Punjab, and Kerala—collected enough units of blood to meet the demand in their states. Voluntary, non- remunerated donations constituted nearly half of the blood supply in India; the remaining supply came from replacement and paid donations.11 The problem of blood shortage in India could be mainly attributed to a poor overall organization of blood services. Most of the collection and transfusion services in India were performed by various licensed,12 central, and state government-owned blood banks; voluntary blood banks; and privately owned hospital and commercial blood banks. Railways, municipalities, defence forces, and independent trusts were also involved in the blood collection process.13 There was minimal coordination among the activities of this fragmented mix of agencies; as a result, the agencies often competed among themselves for blood collection.14 Since there was no coordination of blood services, most of the Indian blood banks managed their operations in a decentralized mode. Many medium to large blood banks organized their own blood collection camps. Some small, hospital-associated blood banks that could not collect blood themselves met their requirements by ordering blood from large blood banks at regular intervals. The inventory of blood products was managed at the level of the individual blood banks; collecting blood in large quantities was considered a measure of success. Since the number of voluntary donors was limited, there was intense competition among blood banks for donations. Because they were unable to collect sufficient units in blood collection camps, Indian blood banks often faced a shortage of blood products. The fear of facing a shortage often led blood banks to set up huge blood donation camps where blood was collected in large quantities. Compounding the problem, blood component therapies were not popular in the general population, and those opposed to the therapies weren’t willing to contribute.15

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This document is authorized for use only by Prashath Sivaganeshan in 620 winter 2021 (2) taught by Mahmood Kotb, University Canada West from Feb 2021 to Aug 2021.

Page 3 9B16D018 HISTORY AND ORGANIZATION OF THE MODEL BLOOD BANK, INDORE The Model Blood Bank (MBB) was the largest blood bank operating in the city of Indore,16 the industrial capital of the state of Madhya Pradesh. The MBB was set up in 1955 as a non-profit blood bank within the government-owned Maharaja Yeshwant Rao Hospital (commonly known as “MY Hospital”). The blood bank was run jointly by the hospital and the Mahatma Gandhi Memorial Medical College, Indore. Funding for the blood bank’s operations was provided by the state government of Madhya Pradesh and the National AIDS Control Organization. The team at the MBB consisted of 35 people with Joshi in charge (see Exhibit 3). The blood bank operated 24 hours a day, seven days a week, supplying quality blood products to various hospitals in the city. Since its inception, the MBB had worked with both voluntary and replacement donors. The percentage of replacement donations had gradually decreased; almost 91 per cent of collections came from voluntary sources.17 Blood collection camps were organized in different parts of Indore, and the collected blood units were tested for infectious diseases to ensure patient safety. The MBB had successfully conducted 842 blood donation camps from 2005 to 2014. The MBB was one of the few blood banks in Indore equipped to separate blood components. With its state- of-the-art equipment and component separation facility, the MBB was able to manufacture, store, and supply major blood components such as red blood cells, platelets, and plasma. It was not permitted to manufacture advanced products (predominantly drugs) using the collected blood units. Approximately 70 to 80 per cent of the whole blood collected at the MBB was broken into components. Being a charitable organization, the blood bank charged a very nominal rate of ₹7018 (approximately US$1) for one unit of whole blood or a component. Approximately 70 per cent of the blood was given away free of charge to prenatal, neonatal, and postnatal patients; patients who had cancer, HIV, thalassemia, or aplastic anemia; and patients living below the poverty line. The blood bank was regulated by the Madhya Pradesh’s Food and Drugs Administration; under its regulations, the blood bank could prepare only packed cells, platelets, plasma, and cryoprecipitate. THE BLOOD SUPPLY CHAIN AT THE MODEL BLOOD BANK The blood supply chain at the MBB included five major steps: collection, separation into components, testing and determination of blood type, storage, and issuing. Collection The major supply (approximately 90 per cent) of the total blood collection at the MBB came through voluntary non-remunerated donations collected at blood donation camps. Replacement donations constituted approximately 10 per cent of the total blood supply. The remaining supply was from those donors who came to the MBB to donate blood. The annual average blood collection at the MBB was approximately 24,000 units. The frequency of organized blood donation camps differed according to the month of the year (see Exhibit 1). The MBB had organized a total of 165 blood donation camps in 2014. Blood was collected in specially designed plastic bags that had an anticoagulant solution (see Exhibit 4). The type of bag used for blood collection depended on the number of components to be produced from the collected unit. Single bags were used to store whole blood, while triple bags were used to store components such as red blood cells, platelets, and plasma. As a standard practice, blood from donors who were in

For the exclusive use of P. Sivaganeshan, 2021.

This document is authorized for use only by Prashath Sivaganeshan in 620 winter 2021 (2) taught by Mahmood Kotb, University Canada West from Feb 2021 to Aug 2021.

Page 4 9B16D018 excellent physical health was collected in 450-millilitre (ml) triple bags, while blood from other donors was collected in 350-ml single bags with a closed system. It typically took 7–10 minutes to collect blood from a donor at the blood donation camp. Donors received refreshments and a donation certificate after the donation process was completed. No incentives in the form of cash or gifts were given to donors for donating blood. The MBB, like other blood banks in India, followed a policy of collecting blood from all medically fit donors who arrived at the blood donation camp. This policy was due to the perennial shortage of blood products in India. Also, since the blood demand was highly variable, it was difficult for blood banks such as the MBB to predict future demand with reasonable accuracy. Moreover, turning away donors could make them less motivated to donate blood in the future. It was usually very difficult to predict the number of donors who would arrive at a given blood donation camp (see Exhibit 5). This unpredictability posed significant challenges for planning blood collection. When the blood bank did not receive the number of units it needed by the end of a blood donation camp, the blood bank faced a potential shortage. On the other hand, if the number of donors was larger than expected, the blood bank collected more than it needed; because blood products were perishable, over- collection increased the level of wastage. The disposal of medical waste from blood banks (such as discarded blood bags, needles, and chemicals) posed significant environmental challenges. Nonetheless, in the world of blood banking, wastage, even though a serious problem, was preferred over shortage. Separation into Components When the blood donation camp was complete, collected blood units were brought to the blood bank laboratory. Triple bags were centrifuged at high speed. Due to the difference in their densities, the three components separated out in the triple-bag system: plasma in the top layer, platelets in the middle, and red blood cells in the bottom (see Exhibit 6).19 The components were then drained out into three bags, sealed, and sent for storage in appropriate conditions. Approximately 70 to 80 per cent of the total blood collected at the MBB was separated into components.   Testing and Determination of Blood Type All units collected from donors at the blood donation camps were tested in the laboratory to determine whether they were safe for transfusion. Blood samples were tested for diseases such as HIV, HCV, HBV, malaria, and syphilis, which could be transmitted from the donor blood to the recipient through transfusion. The units that failed the screening tests were discarded; the failed units accounted for approximately 2 per cent of the total blood collection. The blood type of collected units was also determined (see Exhibit 7).20 Storage Blood units deemed safe for transfusion were stored in appropriate conditions at the blood bank. Whole blood and red blood cells were stored at 2–6 degrees Celsius (ºC) in blood bank refrigerators for a maximum duration of 35 days.21 Platelets were stored at room temperature (21–22ºC) in special storage units for a maximum duration of five days. Plasma was stored in a frozen state at −25ºC for up to one year, and at −18ºC for up to one and a half years. As recommended by the WHO, the process of testing, componentization, typing, and

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Page 5 9B16D018 storage was completed within six hours of collection to ensure the viability of the blood components (especially the platelets).22 Issuing The MBB supplied blood and its components to several hospital blood banks in the city as well as directly to patients who were in need of blood. Units were issued for patients against a signed requisition from their doctors that specified the type and quantity of the blood component required.23 Red blood cells were given to patients who had anemia (i.e., insufficient red blood cells), which was often the result of internal bleeding or kidney failure.24 Platelets were commonly given to patients who had bleeding disorders and those undergoing open-heart surgery and cancer therapy.25 Patients who had clotting disorders, those who had experienced burns, and trauma victims required plasma transfusions.26 In the absence of the required blood component, one unit of whole blood of the patient’s blood type was given to the patient. Whole blood and red blood cells that were the same blood type as the recipient were usually considered to be perfectly substitutable. For example, in the absence of a demanded product (e.g., whole blood or red blood cells), a recipient would be given the other product in the same blood type. Except in extraordinary circumstances, it was common practice to transfuse the recipient with whole blood or red blood cells that matched the recipient’s blood type. Platelets, however, were not specific to blood type so could be given to recipients of any blood type (see Exhibit 8).27 Plasma was the least required component for transfusions because plasma transfusions could cause many adverse transfusion-related reactions and circulatory overload in a recipient’s body.28 Excess plasma at the blood bank was discarded; the state laws did not permit banks to sell blood units for commercial reasons. Blood banks in other states were able to sell their excess plasma at a good price to pharmaceutical companies that used the plasma to prepare globulins and albumin.29 THE BLOOD SHORTAGE PROBLEM Despite its continuous efforts to increase blood collection, the MBB struggled with the increasing rate of shortage of various blood products. The shortage figures from April 2015 increased Joshi’s worry. In that month, the MBB was short an average of more than 10 per cent of various blood products in April. The MBB also experienced wastage of precious negative blood types due to lack of demand during the month (see Exhibit 8). Also, at the prevailing rate of componentizing, almost all of the plasma needed to be discarded due to a very low demand for plasma. April 2015 was also notable for a major earthquake that occurred in Nepal. Even though the MBB did not experience any noticeable increase in demand due to the Nepal calamity, such incidents posed a major challenge to blood banks. It was impossible for any blood bank to predict the occurrence of calamities, outbreaks, and major accidents, and the resulting demand they created. The MBB ensured a minimum stock of approximately 200 blood units at any time to meet urgent requirements arising from such events, but keeping a very large stock of blood was not a viable solution since it resulted in the wastage of precious blood units. The MBB had attempted to mitigate the risk of potential shortages by maintaining a comprehensive list of contacts at the agencies and institutions that hosted blood donation camps, and of all donors from previous blood donation camps. Joshi expected that the overall blood supply would drop by approximately 10 per cent during the months of May, June, and July 2015. He was also well aware that during blood supply shortages, hospital blood banks

For the exclusive use of P. Sivaganeshan, 2021.

This document is authorized for use only by Prashath Sivaganeshan in 620 winter 2021 (2) taught by Mahmood Kotb, University Canada West from Feb 2021 to Aug 2021.

Page 6 9B16D018 tended to inflate their order sizes in an attempt to compensate for the effects of rationing. Often in the months of lean supply, the hospital blood banks ordered two to five times the desired number of units. Moreover, since the demand forecasts at the hospital blood banks were either not available or extremely erratic, inflations in order sizes resulted in simultaneous shortage and wastage at different hospital blood banks. Joshi needed to find a way to ensure that hospital blood banks did not over-inflate their orders. He also needed to ensure that the overall supply of blood at the MBB increased in order to compensate for the ever- mounting blood shortage problem. He was considering two main options: increase the collection quantity at the blood donation camps or increase the frequency of the blood donation camps. Increase the Collection Quantity at the Blood Donation Camps Increasing the quantity of blood collected would be achieved by organizing extra-large blood collection camps at large private organizations such as information technology and manufacturing companies in and around Indore. The MBB would need to advertise heavily in newspapers, magazines, and other media, and organize donor motivation seminars to increase the donor turnout at the blood donation camps. Increasing the collection quantity could alleviate the shortage problem to a large extent, but it could also increase inventory costs at the blood bank. This increased cost was not necessarily a bad thing according to Joshi, who believed that a larger inventory gave the MBB a better chance of dealing with a potential blood shortage. However, a larger inventory would also increase the rate of wastage for blood products, but as Joshi put it, “Wastage is preferred over shortage any day.” Increase the Frequency of the Blood Donation Camps The other, relatively less popular, option was to increase the number of times the MBB set up blood donation camps. Increasing the blood collection frequency could alleviate the shortage problem but it could also increase the collection costs associated with setting up the blood donation camps. The overall inventory of blood products would be reduced under this option but Joshi was not sure whether wastage would reduce significantly. A major benefit of this option was that the MBB could set up blood donation camps at even those sites where it normally would not (e.g., housing societies, bus terminals, and railway stations). These sites had low potential for collection without requiring additional advertising. The overall blood donation camp duration would be shorter, and the MBB could manage collection with fewer personnel and less equipment.

Harshal Lowalekar is an Assistant Professor in the area of Operations Management and Quantitative Techniques at the Indian Institute of Management Indore, India. T. S. Raghu is the Department Chair of Information Systems at W. P. Carey School of Business, Arizona State University, United States. Ajay Vinze is the Earl and Gladys Davis Distinguished Professor in Information Systems at W. P. Carey School of Business, Arizona State University, United States.

For the exclusive use of P. Sivaganeshan, 2021.

This document is authorized for use only by Prashath Sivaganeshan in 620 winter 2021 (2) taught by Mahmood Kotb, University Canada West from Feb 2021 to Aug 2021.

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For the exclusive use of P. Sivaganeshan, 2021.

This document is authorized for use only by Prashath Sivaganeshan in 620 winter 2021 (2) taught by Mahmood Kotb, University Canada West from Feb 2021 to Aug 2021.

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This document is authorized for use only by Prashath Sivaganeshan in 620 winter 2021 (2) taught by Mahmood Kotb, University Canada West from Feb 2021 to Aug 2021.

Page 9 9B16D018

EXHIBIT 3: THE TEAM AT THE MODEL BLOOD BANK

Designation Number of Staff

In-Charge and Associate Transfusion Officer (Dr. Anil Joshi)

1

Medical Officers 6

Technical Supervisor 1

Technical Assistant 1

Medico Social Worker 1

Counsellor 1

Lab Technicians 8

Lab Assistants 2

Lab Attendants 3

Staff Nurse 3

Store Keeper 1

Class IV 7

  Source: “Pathology,” Mahatma Gandhi Memorial Medical College, accessed June 2, 2016, www.mgmmcindore.org /pathology.html.

EXHIBIT 4: BLOOD TRANSFUSION BAG

Source: Photograph taken by case authors with permission from the Model Blood Bank.

For the exclusive use of P. Sivaganeshan, 2021.

This document is authorized for use only by Prashath Sivaganeshan in 620 winter 2021 (2) taught by Mahmood Kotb, University Canada West from Feb 2021 to Aug 2021.

Page 10 9B16D018

EXHIBIT 5: UNITS OF BLOOD COLLECTED IN BLOOD DONATION CAMPS HELD BY THE MODEL BLOOD BANK

Source: Prepared by case authors using data from the Model Blood Bank, with permission; Harashal Lowalekar, T. S. Raghu, and Agay Vinze, Model Blood Bank, Indore: Supply Chain Management—Student Spreadsheet (London, ON: Ivey Publishing). Available from Ivey Publishing, product no. 7B16D018.

0

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8

10

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14

16

18

F re

q u e

n c y

Blood Collection in Camps

Frequency

For the exclusive use of P. Sivaganeshan, 2021.

This document is authorized for use only by Prashath Sivaganeshan in 620 winter 2021 (2) taught by Mahmood Kotb, University Canada West from Feb 2021 to Aug 2021.

Page 11 9B16D018

EXHIBIT 6: THE BLOOD COMPONENT SEPARATION PROCESS

Note: RBC = red blood cells. Source: Prepared by case authors using information from company documents.

EXHIBIT 7: COMPOSITION OF BLOOD GROUPS AT THE MODEL BLOOD BANK, BY PERCENTAGE

Blood Type O+ O− A+ A− B+ B− AB+ AB−

Distribution 39.0% 1.0% 27.0% 0.5% 25.0% 0.4% 7.0% 0.1% Source: Prepared by case authors using data from company documents. .

Platelet-Rich Plasma Packed Cells

(RBC)

Fresh Whole Blood

Spin before 2 hours at 1,200–1,400 RPM and 22°C for 30 minutes

Factor-Rich Plasma Packed Cells

(RBC)

Spin before 6 hours at 1,200–1,400 RPM and 4–6°C for 30 minutes

Spin at 2,400–2,600 RPM and 22°C for 30 minutes

Platelet Concentrate Platelet-Poor Plasma

Spin at 1,400–1,600 RPM for 30 minutes

Cryoprecipitate Cryo-Poor Plasma

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This document is authorized for use only by Prashath Sivaganeshan in 620 winter 2021 (2) taught by Mahmood Kotb, University Canada West from Feb 2021 to Aug 2021.

Page 12 9B16D018

EXHIBIT 8: UNITS OF RED BLOOD CELLS AND PLATELETS REQUISITIONED FROM THE MODEL BLOOD BANK, APRIL 2015

Date Red Blood Cells (Units)

Platelets (Units)

O+ O− A+ A− B+ B AB+ AB− (All Groups)

April 1, 2015 39 0 18 1 20 0 6 0 22

April 2, 2015 17 1 15 0 18 0 6 0 32

April 3, 2015 30 0 10 0 8 0 7 0 24

April 4, 2015 39 0 24 0 10 0 2 0 24

April 5, 2015 29 2 16 0 23 0 4 0 38

April 6, 2015 24 1 17 1 15 0 8 0 30

April 7, 2015 31 1 17 1 21 0 3 0 32

April 8, 2015 36 1 14 0 21 0 4 0 30

April 9, 2015 23 3 18 0 14 0 4 0 31

April 10, 2015 29 0 18 1 22 0 3 0 25

April 11, 2015 25 0 25 2 12 0 2 0 24

April 12, 2015 36 0 21 0 14 0 7 0 23

April 13, 2015 20 3 12 1 11 0 3 1 27

April 14, 2015 24 0 18 0 24 0 3 0 34

April 15, 2015 37 1 26 1 23 1 5 0 24

April 16, 2015 46 0 27 0 11 1 6 0 29

April 17, 2015 31 2 21 0 14 0 4 0 27

April 18, 2015 32 1 14 0 14 0 3 0 19

April 19, 2015 33 1 12 0 19 0 3 0 27

April 20, 2015 29 0 15 0 17 0 6 1 27

April 21, 2015 23 1 13 1 17 0 3 0 33

April 22, 2015 27 2 13 0 20 0 6 0 26

April 23, 2015 35 0 21 1 15 0 3 0 39

April 24, 2015 26 2 22 0 25 0 2 0 28

April 25, 2015 29 0 31 0 14 0 9 0 34

April 26, 2015 27 2 17 1 15 0 4 2 27

April 27, 2015 29 1 17 1 19 0 4 0 24

April 28, 2015 31 1 21 0 16 0 11 0 20

April 29, 2015 32 1 8 1 30 0 4 0 33

April 30, 2015 31 2 13 0 25 0 3 0 23

Source: Prepared by case authors using data from company documents.

For the exclusive use of P. Sivaganeshan, 2021.

This document is authorized for use only by Prashath Sivaganeshan in 620 winter 2021 (2) taught by Mahmood Kotb, University Canada West from Feb 2021 to Aug 2021.

Page 13 9B16D018

ENDNOTES

1 Blood donation camps (also known as blood donation drives) generally referred to events where a large number of voluntary donors donated blood. Blood donation camps were often organized at schools, colleges, institutions, and corporations. 2 World Health Organization, Blood Safety and Availability, Fact Sheet no. 279, June 2015, accessed March 16, 2016, www.who.int/mediacentre/factsheets/fs279/en. 3 N. Dhingra, “International Challenges of Self-Sufficiency in Blood Products,” Transfusion Clinique et Biologique 20, no. 2 (2013): 148–152, accessed March 17, 2016, doi:10.1016/j.tracli.2013.03.003. 4 World Health Organization, op. cit. 5 Ibid. 6 N. Dhingra, op. cit. 7 Blood banks sometimes asked the family members of the recipient to donate (or make donation arrangements for) the same number of units as transfused to the recipient. Such donations were known as replacement donations. 8 World Health Organization, op. cit. 9 Ibid. 10 Ibid. 11 “State-wise Blood Units Collected through Voluntary and Replacement Donations in India (2001 to 2003 and 2005),” Indiastat, 2012, accessed September 26, 2012, www.indiastat.com/table/health/16/others/17873/338537/data.aspx. 12 The licensing of blood banks was under the authority of the Drug Controller General of India, Central Drugs Standard Control Organization. 13 Tim J. Bray and K. Prabhakar, “Editorial: Blood Policy and Transfusion Practice–India,” Tropical Medicine & International Health 7, no. 6 (2002): 477–478, accessed March 16, 2016, doi:10.1046/j.1365-3156.2002.00895.x. 14 Ibid.; A. Nanu, “Blood Transfusion Services: Organization Is Integral to Safety,” National Medical Journal of India 14, no. 4 (2001): 237–240, accessed March 16, 2016, http://europepmc.org/abstract/med/11547532. 15 K. V. Ramani, Dileep V. Mavalankar, and Dipti Govil, “Study of Blood-Transfusion Services in Maharashtra and Gujarat States, India,” Journal of Health, Population and Nutrition 27, no. 2 (2009): 259–270. 16 Indore was the largest city in the state of Madhya Pradesh with a population of nearly 2 million. Source: Census Organization of India, “Indore City Census 2011 Data,” Population Census 2011, 2015, accessed March 16, 2016, www.census2011.co.in/census/city/299-indore.html. 17 The percentage of replacement donations at the MBB decreased from approximately 72 per cent in 2004 to 9 per cent in 2015. 18 All currency amounts are in INR (₹) unless otherwise specified. ₹67.43 = US$1 on May 1, 2015. 19 Cornell University College of Veterinary Medicine, “Blood Components,” eClinpath, accessed June 1, 2016, www.eclinpath.com/hemostasis/transfusion-medicine/components. 20 Human blood was categorized into four major blood groups (O, A, B, and AB), each of which was subdivided into two types reflecting the presence (positive) or absence (negative) of an antigen known as the rhesus (Rh) factor. The result was eight blood types: O positive, O negative, B positive, B negative, A positive, A negative, AB positive, and AB negative. The negative blood types were rare, occurring in less than 5 per cent of the human population. 21 The life of red blood cells could be extended to 42 days by using special bags that had a solution of citrate-phosphate dextrose instead of using regular bags that had a solution of acid-citrate dextrose in which blood could be stored for 35 days. 22 World Health Organization, The Clinical Use of Blood: Handbook (Geneva: World Health Organization, 2002), accessed March 16, 2016, www.who.int/bloodsafety/clinical_use/en/Handbook_EN.pdf. 23 “The Apheresis Donation Process,” Five Points of Life Foundation, accessed June 1, 2016, www.fivepointsoflife.com /teach-learn/what-are-the-five-points/apheresis-donation. 24 World Health Organization, The Clinical Use of Blood: Handbook, op. cit.; Ibid. 25 Ibid. 26 Ibid. 27 Harshal Lowalekar and N. Ravichandran, “Inventory Management in Blood Banks” in Case Studies in Operations Research, vol. 212 of International Series in Operations Research and Management Science (New York: Springer, 2015): 431–464, accessed June 6, 2016, http://link.springer.com/chapter/10.1007/978-1-4939-1007-6_18. 28 Suchitra Pandey and Girish N. Vyas, “Adverse Effects of Plasma Transfusion,” Transfusion 52, no. S1 (2012): 65S– 79S, doi:10.1111/j.1537-2995.2012.03663.x/full. 29 Globulins and albumin were proteins mainly used to treat conditions and diseases involving the immune system.

For the exclusive use of P. Sivaganeshan, 2021.

This document is authorized for use only by Prashath Sivaganeshan in 620 winter 2021 (2) taught by Mahmood Kotb, University Canada West from Feb 2021 to Aug 2021.