Paid-versus-volunteer blood donation in the United States: a historical review

The Evolution of the Safety of Plasma Products from Pathogen Transmission-A Continuing Narrative

Chronic recipients of plasma products are at risk of infection from blood-borne pathogens as a result of their inevitable exposure to agents which will contaminate a plasma manufacturing pool made up of thousands of individual donations. The generation of such a pool is an essential part of the large-scale manufacture of these products and is required for good manufacturing practice (GMP). Early observations of the transmission of hepatitis by pooled plasma and serum led to the incorporation of heat treatment of the albumin solution produced by industrial Cohn fractionation of plasma. This led to an absence of pathogen transmission by albumin over decades, during which hepatitis continued to be transmitted by other early plasma fractions, as well as through mainstream blood transfusions. This risk was decreased greatly over the 1960s as an understanding of the epidemiology and viral aetiology of transfusion-transmitted hepatitis led to the exclusion of high-risk groups from the donor population and the development of a blood screening test for hepatitis B. Despite these measures, the first plasma concentrates to treat haemophilia transmitted hepatitis B and other, poorly understood, forms of parenterally transmitted hepatitis. These risks were considered to be acceptable given the life-saving nature of the haemophilia treatment products. The emergence of the human immunodeficiency virus (HIV) as a transfusion-transmitted infection in the early 1980s shifted the focus of attention to this virus, which proved to be vulnerable to a number of inactivation methods introduced during manufacture. Further developments in the field obviated the risk of hepatitis C virus (HCV) which had also infected chronic recipients of plasma products, including haemophilia patients and immunodeficient patients receiving immunoglobulin. The convergence of appropriate donor selection driven by knowledge of viral epidemiology, the development of blood screening now based on molecular diagnostics, and the incorporation of viral inactivation techniques in the manufacturing process are now recognised as constituting a "safety tripod" of measures contributing to safety from pathogen transmission. Of these three components, viral inactivation during manufacture is the major contributor and has proven to be the bulwark securing the safety of plasma derivatives over the past thirty years. Concurrently, the safety of banked blood and components continues to depend on donor selection and screening, in the absence of universally adopted pathogen reduction technology. This has resulted in an inversion in the relative safety of the products of blood banking compared to plasma products. Overall, the experience gained in the past decades has resulted in an absence of pathogen transmission from the current generation of plasma derivatives, but maintaining vigilance, and the surveillance of the emergence of infectious agents, is vital to ensure the continued efficacy of the measures in place and the development of further interventions aimed at obviating safety threats.

The effect of motivational strategy on voluntary plasma donation, a field trial

BACKGROUND

Plasma protein therapies (PPTs) are a group of medicines extracted from human plasma through fractionation. The manufacture of adequate amounts of PPTs requires a large volume of human plasma. WHO emphasized that whole blood and blood component donations should be voluntary and non-remunerated. So, motivating people to donate plasma is crucial. In this study, we evaluated the impact of social media on motivating blood donors to donate plasma without any compensation and the moderating effects of blood donation history on plasma donation.

METHODS AND MATERIALS

we allocated blood donors (n = 501) to intervention and control groups randomly. Participants in the intervention group got educational and motivational messages through a WhatsApp channel. Then, we followed up all participants for six months and registered the information of the plasma donation during this period.

RESULT

In the intervention group, 6.8% had returned to donate plasma, while this was 2% in the control group (p = 0.016, OR:3.59, 95%CI:1.3-9.89). Among regular blood donors in the intervention group, 17.86% had returned to donate plasma but, no regular donor returned to donate plasma in the control group (p = 0.055). In addition, 10.8% of donors who had academic education in the intervention group returned to donate plasma, although this was 2.54% in the control group (P = 0.0485).

CONCLUSION

Our findings suggest that the educational interventions have more effects on academically educated donors to motivate them to donate plasma.

Use of an HBV-DNA Hybridization Assay in the Evaluation of Equivocal Hepatitis B Virus Tests in Solid Organ Donors

Context

Serological markers for the hepatitis B virus are routinely used in the evaluation of potential organ donors. However, serological tests can be associated with significant false or equivocal results and may not be indicative of the true risk of hepatitis B infection. Studies have recently questioned the significance of an isolated hepatitis B core antibody test in evaluating the suitability of solid organs for transplantation. The ability to detect hepatitis B virus DNA may prove useful when the diagnosis of hepatitis B infection is in doubt.

Design

Serum samples from 16 donors with equivocal or positive hepatitis B core antibody and/or hepatitis B surface antigen serological screening tests were retrospectively tested for the presence of hepatitis B DNA. Any available follow-up data on the placement of organs from these donors was obtained.

Results

One of the 16 (6.3%) donors tested positive for the presence of hepatitis B DNA, but organs from this donor were not recovered or transplanted. Follow-up on 14 organs recovered and transplanted from 6 donors in this group did not show clinical and/or laboratory evidence of hepatitis B infection in the recipients.

Conclusions

In our donor population, there was a low incidence (6.3%) of donors with equivocal or positive hepatitis B core antibody and/or hepatitis B surface antigen serological screening tests who subsequently demonstrated the presence of detectable hepatitis B DNA. Posttransplantation follow-up of the recipients of 14 recovered organs failed to demonstrate any cases of posttransplant hepatitis B infection.

Blood donor selection and deferral pattern as an important tool for blood safety in a tertiary care hospital

CONTEXT

Blood donor selection criteria based on science and regulatory rules influence donor as well recipient safety and demographics.

AIM

To evaluate and analyze the blood donor deferral pattern and its causes among blood donors in a tertiary care hospital blood bank and to review its influence on blood safety.

SETTINGS AND DESIGN

Hospital based blood bank, retrospective analysis.

SUBJECTS AND METHODS

The data available as donor deferral record over a period of 13 years from 2001 to 2013 was analyzed.

RESULTS

The blood donor deferral rate was 11.5%, the deferral rate in various categories was 4.8%, 4.7%, 1.6%, and 0.3% in Category 1, Category 2, Category 3, and Category 4, respectively. The majority of deferrals were temporary deferrals (62.8%) of young donors. The maximum number of donors deferred (28.2%) due to a history of jaundice (permanent) followed by 19.4% due to low hemoglobin (temporary). History of malaria, intake of medicines, infections, underweight, last blood donation within 3 months (temporary deferral), and history of heart and lung diseases, diabetes, and with suspicious identity (permanent deferral) were other major causes identified.

CONCLUSION

The pattern of donor deferral identified is an important tool for blood safety and also provides key areas to focus on a region or policy formulation nationally for donor selection as well ensure donor safety. The value of determining donor deferral pattern by the categories described is in calling back donors deferred due to temporary reasons and can help retain pool of motivated blood donors.

Current testing strategies for hepatitis C virus infection in blood donors and the way forward

Screening tests for blood donations are based upon sensitivity, cost-effectiveness and their suitability for high-throughput testing. Enzyme immunoassay (EIAs) for hepatitis C virus (HCV) antibodies were the initial screening tests introduced. The ”first generation“ antibody EIAs detected seroconversion after unduly long infectious window period. Improved HCV antibody assays still had an infectious window period around 66 d. HCV core antigen EIAs shortened the window period considerably, but high costs did not lead to widespread acceptance. A fourth-generation HCV antigen and antibody assay (combination EIA) is more convenient as two infectious markers of HCV are detected in the same assay. Molecular testing for HCV-RNA utilizing nucleic acid amplification technology (NAT) is the most sensitive assay and shortens the window period to only 4 d. Implementation of NAT in many developed countries around the world has resulted in dramatic reductions in transfusion transmissible HCV and relative risk is now < 1 per million donations. However, HCV serology still continues to be retained as some donations are serology positive but NAT negative. In resource constrained countries HCV screening is highly variable, depending upon infrastructure, trained manpower and financial resource. Rapid tests which do not require instrumentation and are simple to perform are used in many small and remotely located blood centres. The sensitivity as compared to EIAs is less and wherever feasible HCV antibody EIAs are most frequently used screening assays. Efforts have been made to implement combined antigen-antibody assays and even NAT in some of these countries.

Incentivizing blood donation: systematic review and meta-analysis to test Titmuss' hypotheses

OBJECTIVES

Titmuss hypothesized that paying blood donors would reduce the quality of the blood donated and would be economically inefficient. We report here the first systematic review to test these hypotheses, reporting on both financial and nonfinancial incentives.

METHOD

Studies deemed eligible for inclusion were peer-reviewed, experimental studies that presented data on the quantity (as a proxy for efficiency) and quality of blood donated in at least two groups: those donating blood when offered an incentive, and those donating blood with no offer of an incentive. The following were searched: MEDLINE, EMBASE and PsycINFO using OVID SP, CINAHL via EBSCO and CENTRAL, the Cochrane Library, Econlit via EBSCO, JSTOR Health and General Science Collection, and Google.

RESULTS

The initial search yielded 1100 abstracts, which resulted in 89 full papers being assessed for eligibility, of which seven studies, reported in six papers, met the inclusion criteria. The included studies involved 93,328 participants. Incentives had no impact on the likelihood of donation (OR = 1.22 CI 95% 0.91-1.63; p = .19). There was no difference between financial and nonfinancial incentives in the quantity of blood donated. Of the two studies that assessed quality of blood, one found no effect and the other found an adverse effect from the offer of a free cholesterol test (β = 0.011 p < .05).

CONCLUSION

The limited evidence suggests that Titmuss' hypothesis of the economic inefficiency of incentives is correct. There is insufficient evidence to assess their likely impact on the quality of the blood provided.

Toward a more stable blood supply: charitable incentives, donation rates, and the experience of September 11

Although excess blood collection has characterized U.S. national disasters, most dramatically in the case of September 11, periodic shortages of blood have recurred for decades. In response, I propose a new model of medical philanthropy, one that specifically uses charitable contributions to health care as blood donation incentives. I explain how the surge in blood donations following 9/11 was both transient and disaster-specific, failing to foster a greater continuing commitment to donate blood. This underscores the importance of considering blood donation incentives. I defend charitable incentives as an alternative to financial incentives, which I contend would further extend neoliberal market values into health care. I explain my model's potential appeal to private foundations or public-private partnerships as a means for expanding both the pool of blood donors and the prosocial benefit of each act of blood donation. Finally I link my analysis to the empirical literature on blood donation incentives.

Blood donors' attitudes towards incentives: influence on motivation to donate

BACKGROUND

Understanding the factors that motivate donors to donate will facilitate improvements in recruitment programmes. Donation incentives are often used to improve the effect of recruitment programmes. This cross-sectional study was designed to understand donors' attitudes toward incentives.

MATERIAL AND METHODS

Participants (n=421) were recruited among volunteer donors at the Shiraz Blood Transfusion Centre when they registered for blood donation. They completed a questionnaire with items regarding demographic characteristics, donation status (first-time donor or regular donor), and their motivation for donating, their attitude towards incentives, and the best type of incentives. Multiple logistic regression and chi-squared tests were used to analyse the data with Statistical Package for the Social Sciences (SPSS) software.

RESULTS

The majority of donors (85.6%) donated blood for altruistic reasons. One quarter of the donors (25.3%) believed that incentives should be offered to encourage them to donate. Most donors (84.5%) believed that the most effective incentive was offering specific blood tests. Donors who had donated for non-altruistic reasons were more interested in receiving incentives. The desire to receive incentives was more widespread among younger, married, first-time donors, donors with a lower educational level and donors with a history of more than five donations. The desire to receive incentives decreased as age increased.

DISCUSSION

Most of the donors (74.7%) had no desire to receive incentives, and this was even more apparent among donors who donated for altruistic reasons. Non-monetary incentives may be effective in attracting younger, married, first-time donors, donors with a lower educational level and donors with a history of more than five donations.

Étude des connaissances, attitudes et pratiques en matière de don de sang. Enquête sociologique dans la population de Lomé (Togo)

GOALS

1) analyse the knowledge, attitudes and practices of Lome population about blood donation; 2) identify obstacles to blood donation among the population of Lome; 3) suggest some solutions to improve the performance of the National Blood Transfusion Centre (CNTS).

METHODOLOGY

We have conducted a sample survey among the population of Lome from the 6th to 21st October 2003. Three hundred persons filled a questionnaire.

RESULTS

In the sample, 183 (61%) were males. Their age ranged from 18 to 67 years with 2/3 of young peoples between 18 and 37 years. Pupils/students were 24,33%, wage-earners, 55% and the unemployed, 17,67%. More than the half of the investigated persons (54,67%) were unmarried and 96, 33% persons were literate. Nearly all the people (96,33%) knew about blood donation in Lome and they have received information mainly from friends, media and sensitization by the CNTS. Sixty-one percent of the investigated knew where blood is donated. All the investigated were unanimous about the vital role of blood. Whatever their religion, they recognized its sacred nature. The majority of the investigated (85%) were willing to donate blood. Only 95 people were donors. The reasons for non-donation were mainly related to the fear of catching diseases (31,71%) especially the HIV (9,76%), the lack of information (25,37%), the religious beliefs (19,51%) and the fear of knowing the result of one's HIV test. 277 people (92,33%) said that blood should be donated without remuneration.

CONCLUSION

There is a growing interest in the blood donation among the population of Lome but new strategies must be elaborated to inform the population and motivate blood donors.

Prevalence of hepatitis C, HIV, and risk behaviors for blood-borne infections: a population-based survey of the adult population of T'bilisi, Republic of Georgia

Injection drug use and associated hepatitis C virus (HCV) and HIV infections are on the rise in Russia and the republics of the former Soviet Union. While small targeted studies have found widespread drug use and disease among at-risk populations, there have been few attempts to comprehensively evaluate the extent of these epidemics in general post-Soviet societies. We conducted a two-stage cluster randomized survey of the entire adult population of T'bilisi, Republic of Georgia and assessed the burden of HCV, HIV, and risk behaviors for blood-borne infections in 2,000 study participants. Of the 2,000 surveyed individuals, 162 (8.1%) had injected illicit drugs during their lifetimes. Of the individuals who had injected illicit drugs, 138 (85.2%) reported sharing needles with injection partners. HCV was found in 134 (6.7%) of the total surveyed population, but in 114 (70.4%) of those who had injected illicit drugs. We found HIV in only three (0.2%) individuals, all of whom had injected illicit drugs. Injection drug use and high-risk injection practices are very common in Georgia and may be harbingers of a large burden of HCV-associated liver diseases and a potentially serious HIV epidemic in the years to come.

Knowledge, attitude and practice survey regarding blood donation in a Northwestern Chinese city

Recruitment of low-risk blood donors in developing countries is challenging. We studied the attitudes towards blood donation in several populations in a city in Western China. A survey of knowledge, attitude and practice was performed including 1280 individuals from eight distinct populations in Urumqi, Xinjiang Uyghur Autonomous Region, China. Included were Han Chinese and Uyghur populations of blood donors, non-donors, injection drug users, students and factory workers. Knowledge about blood donation varied between the groups. Factors motivating blood donation included social pressure, desire to know screening results and altruism. Inhibiting factors included fear of contracting an infection and other adverse health effects, including loss of vitality. Misconceptions about the effects of blood donation are widespread, even among educated persons in Urumqi. Fear of acquiring a serious infection may have been increased by the reports of HIV acquisition during plasma donations in China.

Risks of blood transfusion

This article discusses advances in blood safety during the last 20 years, particularly for prevention of transfusion-transmitted viral infections. Although the most serious known risks from blood transfusion are administrative errors, transfusion-related acute lung injury, and bacterial contamination in platelet products, infection from emerging pathogens such as West Nile virus emphasizes the need for implementing proactive strategies. Pathogen inactivation technologies and reactive strategies such as nucleic acid testing ensure continued advances in blood safety.

Risks of blood transfusion

OBJECTIVE

To review the current status of risks of blood transfusion.

DATA SOURCES, EXTRACTIONS, AND SYNTHESIS

English-speaking literature, literature search using key works, human data, and follow-up with key bibliographic citations.

CONCLUSIONS

Substantial advances have been achieved in blood safety during the last 20 yrs, particularly for transfusion-transmitted viral infections. Currently, the most serious known risks from blood transfusion are administrative error (leading to ABO-incompatible blood transfusion), transfusion-related acute lung injury, and bacterial contamination in platelet products. Emerging pathogens, such as West Nile virus infection emphasize the need for implementation of proactive strategies, such as pathogen inactivation technologies, as well as reactive strategies, such as nucleic acid testing, to ensure continued advances in blood safety.

Attitudes toward blood donation incentives in the United States: implications for donor recruitment

BACKGROUND

The potential effectiveness of various donation incentive programs may vary by demographics, first-time or repeat status, and collection site.

STUDY DESIGN AND METHODS

Attitudes toward future incentives were obtained from a 1998 anonymous survey sent to 92,581 US blood donors. Responses (encouraged, discouraged, no difference) to incentives were compared within demographic groups, donations sites, and between first-time and repeat community whole-blood (WB) donors using chi-square tests and logistic regressions adjusted for sample design.

RESULTS

Incentives most likely to encourage donation return among all 45,588 WB respondents were blood credits (61%), cholesterol screening (61%), and prostate-specific antigen (PSA) screening (73% of men). Younger donors (< or = 25 years old) were 4 to 5 times more likely to be encouraged to donate if offered compensatory incentives (tickets to events, discounts or lottery and/or raffle tickets), gifts, or a token of appreciation than were those donors older than 55. This age effect influenced positive attitudes toward incentives in first-time donors and in donors giving at schools, universities, or military sites. Among all donors, up to 7 to 9 percent reported they would be discouraged to return if offered compensatory incentives.

CONCLUSIONS

Blood credits and cholesterol and PSA screening would be well received at all donation sites. Gifts, compensatory incentives, and tokens of appreciation appeal more to younger donors. These data may allow blood centers to optimize recruitment by tailoring limited incentive resources more effectively.

Paying for blood donations: still a risk?

It is presently disputed whether studies indicating a higher risk of infectious diseases among paid blood donors are lessons of the past, or still hold relevance. Comparative studies published between 1968 and 2001 were assessed for a possible trend of change in the relative risk for infectious disease markers between paid and unpaid blood or plasma donors. Studies reporting that paid donors had lower risk were found, but most studies, including recent ones, continued to report that paid donors have higher rates of infectious disease markers than unpaid donors. By log-linear regression analysis of the relative risk estimates for infectious disease markers among paid and unpaid donors from 28 published data sets, evidence was not found to indicate that the difference in risk for infectious disease markers between paid donors and unpaid donors had diminished over time (P = 0.128, not significant). Paid donors are still more likely than unpaid donors to donate blood in the period during which infectious donations escape detection by blood-screening tests (the "window-period"). Therefore, paid donations have a higher risk that labile blood components (such as red blood cells and platelets) are infected. Additional safety measures for handling plasma donations, and the preparation, purification and viral-inactivation steps employed for the production of plasma derivatives, may render the difference in infectious disease marker rates in donors irrelevant for plasma products. However, not all viruses are inactivated and paid donors were repeatedly found to have higher frequencies of markers for emerging agents. In a quality system, critical steps of the process should be addressed, and selection of the donor population is one of the first steps in this process. It is advised that blood establishments present yearly reports (with complete and raw data) to authorities on the incidence and prevalence of infectious disease markers among their donors as an ongoing surveillance on the "quality" of their donor populations. Paid blood or plasma donors still have higher rates for infectious disease markers than unpaid donors.

Preserving the national blood supply

This paper examines the current state of the blood supply in the US and focuses on the potential for augmenting blood availability by attention to the iron status of donors. Increasing demands are being made upon the national blood supply as rates of blood donation are declining, in part because of the loss of blood donors as a result of enhanced screening and testing procedures. Iron-related means of expanding the blood supply include the use of blood from individuals undergoing therapeutic phlebotomy for hereditary hemochromatosis and enhancing the retention and commitment of women of childbearing age as donors by using iron supplementation to prevent iron deficiency. In Section I, Dr. Klein discuss the circumstances responsible for a decline in the population of eligible donors, including public attitudes toward donation, factors influencing the retention of donors by blood centers, and the effects of increased screening and testing to maintain the safety of the blood supply. In Section II, Drs. Kushner and Ajioka focus on the consequences of the decision by the US Food and Drug Administration (FDA) to develop recommendations to permit blood centers to collect blood from patients with hereditary hemochromatosis and to distribute this blood obtained without disease labeling if all other screening and testing procedures are passed. After summarizing the pathophysiology of hereditary hemochromatosis, the use by blood centers of blood obtained from heterozygotes and homozygotes for hereditary hemochromatosis is considered. In Section III, Dr. Brittenham reviews the use of low dose, short-term carbonyl iron supplementation for women donors of childbearing age. Replacing the iron lost at donation can help prevent iron deficiency in women of childbearing age and, by decreasing deferral, enhance the retention and commitment of women who give blood regularly. He emphasizes the use by blood centers of iron-related means to enhance recruitment and retention of blood donors.

The disappearance of transfusion-transmitted hepatitis C virus infections in the United States

Because of anti-HCV testing, rates of transfusion-transmitted HCV infections have dropped from a high level (approximately 1 per 200 units, even using volunteer, repeat donors) to an extremely low one (approximately 1 per 125,000 units). Moreover, preliminary data indicate that pooled- (and perhaps, eventually, single-) specimen NAT for HCV-RNA or EIA for HCV core antigen may reduce this risk even further. It is anticipated that implementation of one or more of these methods, coupled with one or more pathogen-inactivation steps, may functionally eliminate the risk of transmitting HCV by transfusions.

Use of an HBV-DNA hybridization assay in the evaluation of equivocal hepatitis B virus tests in solid organ donors

CONTEXT

Serological markers for the hepatitis B virus are routinely used in the evaluation of potential organ donors. However, serological tests can be associated with significant false or equivocal results and may not be indicative of the true risk of hepatitis B infection. Studies have recently questioned the significance of an isolated hepatitis B core antibody test in evaluating the suitability of solid organs for transplantation. The ability to detect hepatitis B virus DNA may prove useful when the diagnosis of hepatitis B infection is in doubt.

DESIGN

Serum samples from 16 donors with equivocal or positive hepatitis B core antibody and/or hepatitis B surface antigen serological screening tests were retrospectively tested for the presence of hepatitis B DNA. Any available follow-up data on the placement of organs from these donors was obtained.

RESULTS

One of the 16 (6.3%) donors tested positive for the presence of hepatitis B DNA, but organs from this donor were not recovered or transplanted. Follow-up on 14 organs recovered and transplanted from 6 donors in this group did not show clinical and/or laboratory evidence of hepatitis B infection in the recipients.

CONCLUSIONS

In our donor population, there was a low incidence (6.3%) of donors with equivocal or positive hepatitis B core antibody and/or hepatitis B surface antigen serological screening tests who subsequently demonstrated the presence of detectable hepatitis B DNA. Posttransplantation follow-up of the recipients of 14 recovered organs failed to demonstrate any cases of posttransplant hepatitis B infection.

An examination of ethical issues raised in the pretreatment of normal volunteer granulocyte donors with granulocyte colony-stimulating factor

OBJECTIVE

To explore some of the ethical issues surrounding the administration of granulocyte colony-stimulating factor (G-CSF) to healthy individuals for the purpose of retrieval of granulocytes.

DESIGN

Review of the historical precedent of drug administration to normal blood donors and review of the literature concerning the side effects of G-CSF administration to healthy individuals, particularly as related to granulocyte collection. We identify and discuss some of the ethical questions regarding this issue.

RESULTS

Although the short-term side effects of G-CSF use in normal donors are generally felt to be benign, little is known about the long-term side effects. Ethical questions regarding the administration of this drug to normal donors for the purpose of collecting large numbers of granulocytes include the following: Does the potential benefit to a patient/recipient justify the unknown risks to the medicated granulocyte donor? Who should act as an advocate for donors so that their best interests are protected? What is the role and quality of informed consent for donors undergoing G-CSF administration? Is monetary compensation appropriate for donors administered G-CSF as part of a research protocol?

CONCLUSIONS

We recommend the establishment of a donor registry to collect the needed data on the side effects of G-CSF on normal donors. Until adequate data are collected, the use of G-CSF and similar agents in normal donors should be regarded as experimental and subject to review by institutional review boards.

A survey of phlebotomy among persons with hemochromatosis

BACKGROUND

One in 10 whites in the United States is a carrier for hemochromatosis and an estimated 1 in 200 is clinically affected. Early treatment with therapeutic phlebotomy to remove excess iron can prevent associated chronic diseases. However, little information is available on the amount of blood withdrawn or the rates of withdrawal from hemochromatosis patients. The patterns of therapeutic phlebotomy and the magnitude of charges in persons with hemochromatosis were surveyed.

STUDY DESIGN AND METHODS

Surveys were mailed to persons with hemochromatosis identified by health care providers, blood centers, patient advocacy groups, and the Internet. There were 2362 respondents to the survey from the United States.

RESULTS

Thirty-seven percent of respondents reported being voluntary blood donors prior to diagnosis. The mean rate of therapeutic phlebotomy for iron depletion was 2.6 units per month (mean duration, 13 months). The mean rate of maintenance phlebotomy was 0.5 units per month. Therapeutic phlebotomy rates varied by sex, age, reason for diagnosis, and severity of symptoms. Seventy-six percent of respondents reported full or partial insurance coverage of therapeutic phlebotomy charges. Seventy-six percent received therapeutic phlebotomy services in a hospital or physician's office and 30 percent in a blood center. Charges for therapeutic phlebotomy varied by site, with a mean cost of $90 in hospitals and $52 in blood centers. Fifty-four percent of respondents attempted to donate blood after their diagnosis but were excluded.

CONCLUSION

The amount of blood withdrawn from persons with hemochromatosis is substantial. The location where patients received phlebotomy services appears to be influenced by charges and time since diagnosis.

Infectious disease testing related to organ and tissue transplantation: results from a national laboratory survey

BACKGROUND

The purpose of this national survey in the United States was to determine laboratory practices and policies related to infectious disease testing of tissue and organ donors.

METHODS

Supplementary questions were asked of the laboratories that subscribe to the College of American Pathologists' 1996 Donor Center (DC-B) and Viral Markers (W1-B and W2-B) surveys. Only the laboratories that perform infectious disease testing for the purposes of organ and tissue transplantation were asked to respond to the survey.

RESULTS

A total of 1563 laboratories participated in the 1996 DC-B, W1-B, and W2-B surveys. A total of 203 (13.0%) laboratories indicated that infectious disease testing was performed for purposes of tissue and organ transplantation. The majority (81. 1%) of respondents were hospital-based laboratories or regional blood centers. Variances existed in policies regarding type of testing, turnaround times, maintenance of frozen samples, confirmatory testing of positive screening tests, and the reporting of results.

CONCLUSIONS

Various policies and procedures are practiced by laboratories that perform infectious disease testing related to transplantation, and standard guidelines do not currently exist. More data is needed to assess the variability of infectious disease testing of organ donors, as well as the need for standard guidelines.

Donor selection: the exclusion of high risk donors?

Selection of donors is an important means to improve the overall safety of the blood supply. Since the AIDS epidemic emerged and after the introduction of sensitive screening tests for HIV, it became clear that blood donations given in the infectious 'window' period, formed the most important risk for recipients of blood products. Therefore, selection criteria became more and more stringent to exclude these high risk donors. Means to exclude high risk donors are non-remuneration, including a clear policy to provide no incentives which can be readily converted to cash, the avoidance of replacement donations, the discouragement of 'HIV test seeking' donors, education and information of donors about HIV and other blood-borne infectious diseases and the in depth questioning about risk behaviour, orally as well as by questionnaires. Although this policy of donor selection is recognized by most blood centers in the world, the efficacy of this selection has not been well documented. Therefore in future, studies should be performed to base these selection criteria on evidence.

Post-transfusion hepatitis: current risks and causes

Viral hepatitis which follows transfusions (post-transfusion hepatitis) may be due to those transfusions, i.e., transfusion-transmitted hepatitis (TTH), or may be incident to the reason for the transfusion and, thus, may be transfusion-associated, but not transfusion-transmitted. The current risks of TTH, today, are extremely small, but are still due, primarily, to the hepatitis B virus (HBV) and the hepatitis C virus (HCV), the latter, formerly being known as "non-A, non-B hepatitis." The residual, now, of TTH which is non-A, non-B, and non-C is extremely small and may be due to a variety of agents. Using volunteer (unpaid), repeat, blood donors, who are carefully screened for hepatitis risk factors and then tested for evidence of HBV infection, the risk of HBV being transmitted by a transfusion today is in the order of 1 per 63,000 units of blood. For transfusion-transmitted HCV, with the same repeat, volunteer (unpaid) donors, careful screening and a sensitive assay for anti-HCV, the risk is in the order of 1 in 125,000 units. These risks of HBV and HCV due to transfusions are so small that other means of acquiring these viruses should be sought when patients develop hepatitis following blood transfusions. However, efforts to further reduce the current risks of HBV and HCV transmission by transfusions should continue; these include restricting transfusions to those which are necessary or appropriate, utilizing alternatives to transfusion, employing novel assays to detect viral nucleic acids, and, finally, implementing various microbial inactivation techniques on blood, blood components and plasma derivatives.

Current risks of viral hepatitis from blood transfusions

The incidence of transfusion-associated hepatitis in the United States has fallen dramatically since the late 1960s. Where once the risks were so great that as many as one in three transfused patients contracted hepatitis, now they are infinitesimal. Many factors share responsibility for this accomplishment; however, two stand above the rest: (i) improved donor selection and screening criteria, especially elimination of paid blood donations; and (ii) major advances in testing for viral hepatitis carriers. Currently, four tests are used for the prevention of transfusion-associated hepatitis: (i) hepatitis B surface antigen; (ii) hepatitis C virus antibody; (iii) hepatitis B core antibody; and (iv) alanine aminotransferase. The first two tests are largely responsible for the current low risks of transfusion-associated hepatitis due to hepatitis B virus and hepatitis C virus of 1 in 63,000 and 1 in 125,000, per unit, respectively. To further reduce the risks of transfusion-associated hepatitis will require the enhanced sensitivity provided by nucleic acid amplification techniques (e.g. polymerase chain reaction). Currently, however, no such tests are licensed and practical, automated, or inexpensive enough for individual blood donor screening. We have made such great strides in the prevention of transfusion-transmitted hepatitis that background rates of viral hepatitis now greatly exceed the risk of transmission via transfusion. For this reason, while it may still be reasonable to consider a transfusion as a possible cause for hepatitis, it is imperative that many other possibilities (e.g., iatrogenic and other risk factors) be ruled out.

History of posttransfusion hepatitis

The risk of hepatitis virus transmission from transfusions has declined dramatically from that of the 1940s when posttransfusion hepatitis (PTH) was first appreciated. Introduction of hepatitis B surface antigen screening and conversion to volunteer donors for whole-blood donations in the late 1960s and early 1970s led to substantial reduction in PTH cases. However, up to 10% of the recipients continued to develop PTH, most cases of which were attributed to an unknown non-A, non-B viral agent. Implementation of surrogate marker testing (i.e., alanine aminotransferase and anti-hepatitis B virus core antigen) for residual non-A, non-B hepatitis in the late 1980s reduced the per unit risk of PTH from 1 in 200 to about 1 in 400. Hepatitis C virus was discovered in 1989 and quickly was established as the causative agent of &gt;90% of non-A, non-B PTH. Introduction of progressively improved antibody assays in the early 1990s reduced the risk of PTH due to hepatitis C virus to about 1 in 100 000. Although additional hepatitis viruses exist (e.g., hepatitis G virus), these appear to be minor contributors to clinical PTH, which has been virtually eradicated.

Results of a survey of infectious disease testing practices by organ procurement organizations in the United States

BACKGROUND

Information related to infectious disease testing policies and practices of organ procurement organizations in the United States does not currently exist.

METHODS

A total of 63 organ procurement organizations in the United States were surveyed during May 1996. Participants responded to a detailed questionnaire concerning infectious disease tests performed for tissue and solid organ donors and policies related to the reporting and notification of positive test results.

RESULTS

The response rate was 77.8%. The majority of testing is performed by hospital laboratories with an expected turnaround time of 5 hr or less by 71% of organ procurement organizations. Almost all routinely perform screening tests for human immunodeficiency virus, hepatitis C virus, cytomegalovirus, syphilis, human T lymphocyte virus I, and hepatitis B surface antigen. Other tests are performed with greater variability. Although the majority of organ procurement organizations perform confirmatory tests when screening tests are positive, 35% do not perform confirmatory testing or do so only sporadically. There are a wide range of policies concerning the subsequent reporting of positive infectious disease tests and to whom results should be reported.

CONCLUSIONS

Infectious disease testing policies of organ procurement organizations, particularly for solid organs, demonstrate variability in interpretation and perceived significance of positive test results, the initiation or need for reflex and confirmatory testing, the reporting of positive results, and to whom positive test results should be reported. There is a need for a consistent national policy for appropriate infectious disease testing and reporting of results.