PONE-D-21-22354Demand and supply dichotomy of blood and components: A National level estimation study in IndiaPLOS ONE

Dear Dr. Mammen,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. The manuscript presents interesting data and is of great interest given the scale of the analysis. However, there are several important limitations that preclude to accept the manuscript in its current form. We invite you to submit a revised version of the manuscript that addresses the points below:

Please keep special attention to the very useful Reviewers' suggestions, including:

1. Need to revision of the manuscript and rephrasing for clarity.

2. Preparation of a flow chart to describe the sampling strategy. Please describe not only general logic of sampling, but also provide the exact numbers of different facilities (private, public, tertiary, etc) considered during the sampling, and the exact numbers of finally selected facilities.

3. Need to a clear distinction between blood and components.

4. More details on how is the diagnosis and transfusion related information have been documented.

Additionally, I suggest to:

1. Please provide the reference to the the National Health Profile (2017).

2. The demand is one of the core concepts of the manuscript, and much more details on its calculation should be presented. The phrase "We computed the demand for whole blood or components by extrapolating the sum of whole blood or components demanded by each institution." is not clear. Please provide more details also on statistical methods (first of all about BOR adjustment).

3. Please provide in the footnote of all tables the definitions of abbreviations used.

4. In the Table 2, please use the same digit capacity for the "Clinical demand in whole blood units" for the columns related to study data and national estimates.

5. In the Table 3, please introduce a column with "demand per bed before adjustment" data.

6. The number of blood transfusions for the Nutritional Anemia is impressive. Could you please comment in the Discussion which haemoglobin level is the indication of blood transfusion for this population?

7. The second most prevalent category requiring blood transfusion is patients with End-stage renal disease. Could you please comment in the Discussion about availability of erythropoetin and parenteral iron medications in India, as well as which haemoglobin level is the indication of blood transfusion in this particular disease? You provided separate estimates for "End-stage renal disease" and "Chronic Kidney Disease" - could you please comment on it?

8. In the Table 3 the "Sepsis" and "Disseminated Intravascular Coagulation" are 2 separate categories for adults, but one merged category for pediatric care. Please could you explain why the same questionnaires applied have led to different categories?

9. In the tables, please use "in thousands" instead of "(in ‘000)".

10. It would be better to use "general medicine" instead of "medical specialty", where appropriate..

11. While only 30-40% of considered facilities have their own blood bank, could you please describe some details on how the blood or components are distributing from facilities with to those without blood bank? It would be also interesting to know more about blood donation in India - whether donors have some incentives, are there any cultural or religious patterns of blood donation, etc.

12. Please indicate the volume for the whole blood and components used. Even if their volume per unit is standard, the clear definition is always a good choice.

13. Please avoid abbreviations in the references where possible. Please control for the references completeness, for example "IIPS. National Family Health Survey-2017 (NFHS-4) New Delhi: International Institute for Population Sciences, Ministry of Health and Family Welfare, 2017" would be better to supply with ISBN or web-link.

14. It is up to your choice, but it would be useful to share the questionnaire in the supplement, to give the opportunity to reproduce the study for other LMICs research groups.

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Boris Bikbov

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: It’s my opinion that the manuscript is fairly good and well written. The information supplied is also relevant and timely. I have a few questions and some minor concerns. First, the authors should consider the use of a flow chart to describe the sampling strategy. The current approach appears to be long-winded, hence difficult to follow. Further, the authors should have incorporated more references on blood demand from other jurisdictions e.g. regional studies within India or Asia. Although these studies are rare, I’m sure a sufficient number or papers can be found in existing digital repositories. In addition, reference 17 and 22 are similar.

Reviewer #2: An important topic chosen by a group of authors from different fields, kudos to them. I have few observations which I feel you will be able to answer and further improve the article.

1. Introduction

a) Para 1 last line needs rephrasing

b) para 2 what programmes are being talked about

c) para 3 there is repetition and explanation of the same words, avoid semantics and reduce unnecessary words

2.The aim of the study in the abstract and main body is different, please explain.

3. The study used data from various different institutes, was the ethic clearance from each participating institute taken.

4. Table one says beds <30, 31-200 etc while text in methods says beds <50 as primary in pvt sector, please justify.

5. Table 4 needs to be made more reader friendly by reducing unnecessary rows.

6. Please explain 'Discussion " para 2 initial 4 lines

7. Discussion

a) Demand for blood components - has been written and appears out of context. a comment about the clinician's know;edge regarding components was not surveyed and should not be commented upon.

b) The discussion needs to be more specific and needs rewriting all over.

8. Please remove all the unnecessary comments from the conclusion which were not part of the aim & objectives. Please stick to the study per se and not the general comments

Thanks

Reviewer #3: Reviewer´s comments

Ms. No. PONE-D-21-22354

Ms. Title Demand and supply dichotomy of blood and components: A national level estimation study in India

Authors: Mamman J et al

The aim of this study, with authors representing health authorities in India, was to estimate clinical demand, supply and utilization of (whole?) blood and blood components, based on data from randomly selected facilities and then by extrapolating the study data, give estimates for the whole country.

General comments

The aim to estimate the supply and need of blood is ambitious and important, and it is a challenge, especially in a country like India, with a very large population and different levels of health care.

The effort and work are impressive, and it is an interesting descriptive report of the blood supply and usage, but the final estimations are based on many uncertain assumptions. It is not convincingly shown that the selected facilities are representative, the indications for blood transfusions varies and are in many parts not appropriate, according to guidelines in developed countries. The authors make reservations in the discussion and discuss the limitations of the study, but this could be further emphasized.

Specific comments

Title

I do not fully understand the title: Blood and components? The availability and use of blood components vs whole blood and the demand of different blood components are not analysed.

Something like “The blood supply in India-An estimation of available donors and demand and usage of blood transfusions on a national level”………?

Abstract

line 31 blood and components? Do you mean whole blood and blood components?

Line 35-36 are the regions, states and facilities all randomly selected? Not chosen as representative for different parts of the country and health care level?

Line 42-44 The study data, from where the national estimations are calculated should be presented.

Line 50-53 The conclusion should be more specific. What is the main message? Some of the findings discussed on page 15, line 282-306 and page 19 line 390-395?

Introduction

The introduction is informative, describing 2760 blood banks, public or private, often attached to hospitals, component preparation of 53% of the collected blood.

To interpret the data and results a short paragraph is requested of costs in the health care; is the health care free or paid for in public facilities? In private facilities? Are blood transfusions free or paid for? Are blood donors non-remunerated or compensated? Are relatives asked to donate?

Methods

Line 92-98. It would be nice with a map of India where you marked the regions and states and the selected facilities.

Line 98-100 how was the facilities randomly selected?

Line 98-99 define primary, secondary and tertiary health care facilities, with respect to blood transfusions/blood donations? It is partly explained later in line 108, “based on expert´s consensus”? Do you have a reference, documentation or is it an assumption?

Data collection

Line 133-134 How is the diagnosis and transfusion related information documented? Is it similarly documented in the different facilities?

Line 136-138 Please describe how you retrieved the data from the systems? Electronically or manually? Do all centers have electronic hospital and blood bank records?

Line 138 How was the data validated?

Data analysis and computation of clinical demand

Line 140 How was data entered in SPSS?

Line 157-158 Are the indications for whole blood and components different or is it a matter of tradition and availability?

Results

Line 219 Is nutritional anemia an appropriate indication for blood transfusion?

Discussion

The discussion includes many interesting aspects. Will the need of blood transfusions increase or decrease in India, referring to international trends? Are blood transfusions used on appropriate indications or is education primary needed?

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Reviewer #1: No

Reviewer #2: Yes: DR SUSHIL CHAWLA

Reviewer #3: No

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The clinical demand and supply blood in India: A National level estimation study

PONE-D-21-22354R1

Dear Dr. Mammen,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Boris Bikbov

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #3: I find that that the authors have addressed the comments and objections appropriately. They have clarified the issues with inclusion of centers, indication for blood transfusions, calculations, etc. I think the manuscript gives interesting information of blood supply and demand in India, and the information may also be representative for other countries. I appreciate the added limitations of the study, and requirement of education and implementation of other treatment strategies in nutritional anemia.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #3: Yes: Agneta Wikman, Professor, Senior Consultant, Transfusion Medicin, Karolinska Institutet