Access to safe blood is essential for patients to prevent them from acquiring transfusion-transmitted infections (TTIs) like HIV, Hepatitis B (HBV), and Hepatitis C (HCV).
Globally every year around 92 million blood units are collected. In India there are around 4150 licensed blood banks collecting approximately 13 – 14 million blood donations every year.
- Background on NAT: Nucleic acid testing (NAT) is a crucial method for screening blood donations to detect transfusion-transmitted infections (TTIs) like HIV, HCV, and HBV at an early stage. Traditional antibody tests sometimes miss infections that NAT can detect, significantly reducing the risk of transmission. Although NAT is widely adopted in high-prevalence areas, its mandatory implementation in India remains absent due to cost concerns, meaning not all citizens can access the safest blood possible.
NAT screening has been adopted all over the world in the last 3 decades. While 100% of the blood in developed countries (including USA, Australia, Japan, Korea, UK, France, Germany etc.), and others like South Africa, Malaysia, Brazil, UAE, Indonesia and even Vietnam and Thailand are tested for NAT. Since NAT is not a mandatory test in India, only about 8-10% of our blood is tested by NAT.
Since NAT is not a mandatory test in India, only about 8-10% of our blood is tested by NAT.
- NAT Testing Types:
- ID-NAT (Individual Donor NAT): Each donation is tested individually, offering higher sensitivity, especially beneficial in high-prevalence areas. Many top blood centres in India, like AIIMS and CMC Vellore, use ID-NAT despite the higher costs to ensure safety.
- MP-NAT (Minipool NAT): Here, samples are pooled (typically 6-24) before testing, which lowers the per-sample cost but has a lower sensitivity. MP-NAT may miss certain early-stage infections that ID-NAT would catch.
There are multiple publications and reports from various countries about higher sensitivity ID-NAT, that will detect more infected samples missed by Antibody/ELISA or other serological tests.
On the other hand, pooling is essentially cheaper because it allows spreading fixed costs over multiple samples and significantly reduces the variable costs related to reagents and operational throughput.
However, it’s important to balance cost savings with potential drawbacks like reduced sensitivity.
Choosing the right methodology is very important for NAT implementation. The decision to do NAT is based primarily on prevalence. Most Asian countries have not only made NAT testing mandatory, and because of the high prevalence of Hepatitis B, have implemented ID-NAT. USA and some countries in Europe with low prevalence and voluntary donors do MP-NAT. India not only has a high rate of prevalence of Hepatitis B in the general population, but because of replacement donors (not regular repeat voluntary donors which ensures safer blood), our prevalence of even HIV and Hepatitis C in blood donors is amongst the highest in Asia.
Blood centre at Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum implemented ID-NAT to ensure the safest blood for our patients. Both the two globally approved technologies – TMA (Grifols) and PCR (Roche) are available in ID-NAT format in India.
Though I believe that whatever technology a Blood Centre adopts, it is better than not doing any NAT. I sometimes give an analogy that though airbags and seatbelts are essential for safety in cars, just seat belts are better than nothing. Some Blood centres in India are doing either ID-NAT or MP-NAT. As per my understanding for testing a pool of 6 blood donations, MP-NAT requires only 1 test for all 6 samples as compared to 6 tests required for ID-NAT. So there is definitely a cost advantage with Minipool testing. But is this saving being passed on to the patient?
- Cost Comparison and Challenges:
The Government of India is very clear that hospitals and blood centres should not profit from providing blood to patients (it is meant to be donated voluntarily) and should recover the actual costs of processing - blood collection (blood bags etc.), blood separation (into Red Blood Cells or RBCs, Platelets and Plasma), testing (serology, NAT, immunohematology etc.) and other overheads and costs.
In order to combat the practice of overcharging for blood in hospitals and private blood centres, the central government had decided to waive all fees, except processing charges. The choice was made in light of the perspective that “blood is not meant for sale", leading to the issuance of an advisory to all blood centres throughout India.
In order to combat the practice of overcharging for blood in hospitals and private blood centres, the central government had decided to waive all fees, except processing charges.
The National Blood Transfusion Council (NBTC) caps the charge for NAT testing at Rs. 1200. I would presume that this was based on the more sensitive ID-NAT testing, given that ID-NAT requires individual testing, the per-sample cost aligns closely with this cap. For MP-NAT, when testing in pools of six, theoretically it should cost 1/6th of ID-NAT, or Rs. 200 given that a single test can cover six samples. Even if there are some other costs, like that of equipment etc., the cost could not be higher than Rs. 300/400 per sample tested.
Given India’s high TTI prevalence, making NAT more accessible is essential to safeguarding every citizen’s health. The 3 main components of Whole blood which are transfused to patients - RBCs (Red Blood Cells - which are the main blood product used in surgeries, accidents and for thalassemia etc.), Fresh Frozen Plasma and RDPs (Random Donor Platelets - needed especially during Dengue).
I strongly believe the cost of NAT can be charged by a blood centre, if set at Rs. 1200 for ID-NAT, i.e. about Rs. 400 for each of the 3 blood components. Testing with MP-NAT will be much lower than ID-NAT i.e. Rs.100-150 per component. Charges should be based on costs and efficacy.
Safe blood is a fundamental right and critical for patient health during transfusions. I am a strong advocate of ID-NAT, but if some blood banks are going to do MP-NAT, the lower cost should be passed on to the patient, reducing the amount they pay for the processing charges.
Given India’s high TTI prevalence, making NAT more accessible is essential to safeguarding every citizen’s health.
Dr. Debashish Gupta
- HOD - Department of Transfusion Medicine, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum
- President of the Indian Society of Transfusion Medicine (ISTM)
Note:
- The current NBTC guidelines do not differentiate between the processing charges allowed to be collected by a blood bank, whether they do ID-NAT or MP-NAT. Therefore a blood bank can charge up to Rs. 1200 irrespective of whether they do ID-NAT or MP-NAT. Close to 1 lakh blood samples are being tested annually by MP-NAT.
- The thoughts expressed are personal and do not represent the view of any agencies.
Dr. Debashish Gupta leads the Indian Society of Transfusion Medicine while heading Transfusion Medicine at Sree Chitra Tirunal Institute. His career spans national policy work with NACO and international experience with CDC in Kenya, advancing blood safety standards worldwide.
Disclaimer - Content Partner Article: The following piece has been submitted by Sree Chitra Tirunal Institute for Medical Sciences and Technology. Our editorial team was not involved in its creation.
