Regional
Enhancing Blood Transfusion Services on the Remote Islands of Japan
As of April 2024, Japan has 14,125 remote islands, excluding the main islands of Hokkaido, Honshu, Shikoku, Kyushu, and Okinawa. Laws promoting the development of remote islands target 306 inhabited islands, which have a combined population of approximately 570,000 people. As of 2020, these islands have 969 medical facilities, each with varying facilities and medical practices due to differences in population and geographical conditions.
Medical facilities on remote islands, especially core institutions that regularly perform transfusion therapy, face unique challenges due to their geographical conditions. These facilities tend to maintain excessive inventories, leading to consistently high discarding rates. Additionally, emergency deliveries are limited by weather conditions. Similar to on the mainland, the Japanese Red Cross (JRC) Blood Service (BS) manages the supply of blood products for transfusion at these facilities.
To address the unique challenges of managing blood products on remote islands, initiatives have been undertaken to use portable blood product refrigerators (active transport refrigerators, ATR). In Japan, the primary models used are ATR700-RC05 and ATR705-RC05 (Toho Pharmaceuticals, Tokyo)2). These devices have proven to be highly effective in maintaining blood product quality by employing electronic cooling mechanisms with Peltier elements to transport and store blood products at appropriate temperatures, maintain a constant internal temperature regardless of external conditions, and enable long-duration transport. They continuously log temperature changes and notify users of any abnormalities, thereby providing a reliable solution for managing blood products on remote islands.
Figure 1. Geographic locations of the Ogasawara Islands, Amami Oshima, Sado Island, and the Goto Islands.
The numerical values representing distances in the figure are the one-way distances.
Attempts have been made to implement blood rotation (BR) using these devices in various remote Japanese island regions (Figure 1). This involves transporting red blood cell (RBC) products to remote medical facilities, storing them for a set period of time, and then returning the unused products to BS for redistribution to mainland medical facilities. The initiative began with a clinic on Chichi-jima in the Ogasawara Islands, which is approximately 1,000 km from Tokyo and requires a 24-hour one-way ferry trip (Figure 2). Since 2014, two bags of type O RBC products have been transported to the Chichi-jima clinic via ATR and returned to the mainland after 1 week for use in Tokyo Metropolitan Hospitals. This practice has successfully supported emergency transfusions at the Chichi-jima clinic, saving patient lives3). From its inception to the end of 2023, 868 bags of RBC were managed in this manner, with 867 bags being used.
Previously, unused bags in remote clinics were discarded. Similar initiatives have been attempted in Amami Oshima in Kagoshima Prefecture, Sado Island in Niigata Prefecture, and the Goto Islands in Nagasaki Prefecture4-6) (Figure 1). In all cases, the temperature management of the bags was confirmed to be appropriate, with a 100% redistribution rate. The Goto Islands had one receiving medical facility for redistributed RBC bags, while Sado Island and Amami Oshima had 18 and 4 facilities, respectively. The utilisation rate of RBC bags managed under BR ranged from 95.4 to 100%. In addition, the study indicated a reduction in discard rates at facilities on Amami Oshima and Goto Islands, which maintained constant inventories outside BR.
These results suggest that BR offers significant advantages for transfusion medicine on remote islands, ensuring a stable supply of RBC products to meet sudden increases in demand and efficiently using these products through returns and redistribution. However, whether BR can adequately address critical bleeding emergencies in remote medical facilities remains to be determined. Further studies are required to determine the optimal quantity of RBC products and blood type distribution for BR operations. Additionally, the ATR system only addresses RBC products; there is a need to consider the management of plasma and platelet products essential for hemostatic strategies in critical bleeding scenarios.
Furthermore, BR remains a limited-term initiative, except for Tokyo's current implementation. This limitation stems from the need for consensus on the process's robust and sustainable management, given that the re-entry and redistribution of JRC-supplied blood products have not been traditionally practiced. In Japan, blood products are regulated by the Pharmaceutical and Medical Device Act as specific biological products that require meticulous quality control, proper usage, and safety management.
Therefore, it is crucial to establish a comprehensive operational system that can maintain quality while ensuring proper management. To address these challenges, ongoing discussions are needed among all stakeholders, including blood suppliers, government authorities, and medical facilities on remote islands and the mainland, in order to develop criteria to select target medical facilities, appropriate management procedures, and a cost-benefit balance. Additionally, clinical outcomes must be evaluated to verify the system’s effectiveness, including its impact on emergency transfusions and inventory management on remote islands. A nationwide research project is currently underway in Japan to address these issues; the results are expected to facilitate the social implementation of BR in combination with other possible modalities, instilling confidence in the future of blood transfusion services on remote islands.
Figure 2. Overview of the blood rotation system
Blue arrow: Red blood cell (RBC) products are stored in an active transport refrigerator (ATR) and supplied from the Japan Red Cross Blood Service (JRCBS) to a hospital on a remote island, Yellow arrow: RBC products in the ATR are reserved for a set period of time (e.g., one week), and used in cases of emergencies or shortages of other blood type products, Red arrow: After a set storage period, the unused RBC products are returned to the JRCBS in the ATR, Green arrow: If the shipping criteria are met, the recovered RBC products are reissued and used in hospitals on the mainland.
These results suggest that BR offers significant advantages for transfusion medicine on remote islands, ensuring a stable supply of RBC products to meet sudden increases in demand and efficiently using these products through returns and redistribution. However, whether BR can adequately address critical bleeding emergencies in remote medical facilities remains to be determined. Further studies are required to determine the optimal quantity of RBC products and blood type distribution for BR operations. Additionally, the ATR system only addresses RBC products; there is a need to consider the management of plasma and platelet products essential for hemostatic strategies in critical bleeding scenarios. Furthermore, BR remains a limited-term initiative, except for Tokyo's current implementation. This limitation stems from the need for consensus on the process's robust and sustainable management, given that the re-entry and redistribution of JRC-supplied blood products have not been traditionally practiced. In Japan, blood products are regulated by the Pharmaceutical and Medical Device Act as specific biological products that require meticulous quality control, proper usage, and safety management.
Therefore, it is crucial to establish a comprehensive operational system that can maintain quality while ensuring proper management. To address these challenges, ongoing discussions are needed among all stakeholders, including blood suppliers, government authorities, and medical facilities on remote islands and the mainland, in order to develop criteria to select target medical facilities, appropriate management procedures, and a cost-benefit balance. Additionally, clinical outcomes must be evaluated to verify the system’s effectiveness, including its impact on emergency transfusions and inventory management on remote islands. A nationwide research project is currently underway in Japan to address these issues; the results are expected to facilitate the social implementation of BR in combination with other possible modalities, instilling confidence in the future of blood transfusion services on remote islands.
References
1. Ministry of Land Infrastructure Transport and Tourism of Japan. Composition of islands in Japan. [in Japanese] Available from: https://www.mlit.go.jp/kokudoseisaku/chirit/content/001477518.pdf Last accessed 23 Jul 2024.
2. Toho Pharmaceutical Co. Ltd. The ATR700-RC05/ATR705-RC05 Mobile Red Blood Cell Refrigerator. [in Japanese] Available from: https://www.tohoyk.co.jp/medical-total-support/transport/ Last accessed 23 Jul 2024.
3. Igarashi T, Fujita H, Asaka H, Takada Y, Ametani R, Naya I, et al. Patient rescue and blood utilization in the Ogasawara blood rotation system. Transfusion 2018;58:788-794.
4. Oki H, Furukawa Y, Takehara A, Nishisako H, Miyashita K, TeranoT, et al. Amami blood rotation: approaches for efficient blood product use at a core hospital on a remote island with support from several collaborative medical institutions. Japanese Journal of Transfusion and Cell Therapy 2021;67:414-424. [in Japanese].
5. Seki Y, Sato K, Abe T, Komata T, Fuse I. A research on the effective use of blood products in Niigata prefecture through wide-area blood rotation using the ATR blood transport system. Japanese Journal of Transfusion and Cell Therapy 2022;68:496-501. [in Japanese]5.
6. Nagai K, Tomari N, Egawa S, Koga Y, Itonaga H, Imanishi D, et al. Feasibility evaluation of a blood rotation system for efficient blood product utilization in remote island settings. Vox Sang 2024;119:548-555
