The blood supply chain, from donor to patient: a call for greater understanding leading to more effective strategies for managing the blood supply

O ver the past 2 years, we witnessed massive disruption and displacement of our nation’s base of blood donors, resulting in unprecedented fluctuations in blood donations and blood supply. The two major causes of this disruption were the recent FDA extended blood donor restrictions related to variant CJD (vCJD)1 and the blood donor response after the terrorist attacks of September 11. Although it is difficult to quantify the overall impact of the September 11 attacks on the blood supply, few would argue that, despite the overwhelming initial blood donation response and the outpouring of first-time blood donors, the overall impact on blood donations over the year following September 11 has been negative.2 The public reaction to massive outdating of RBCs and general public lack of understanding of the perishable nature of blood led to months of lower than expected blood donations in many parts of the country. For example, New York area blood donations took almost an entire year to return to the levels seen before September 11 and have yet to return to expected levels. Conversely, there have been reports from other parts of the country where September 11 donors have returned to become repeat donors.3,4 As well, many blood collection programs have found that the overall impact of vCJD guidance has been unexpectedly greater than the 5 to 10 percent loss of blood donors predicted by donor surveys done before guidance. In the wake of vCJD guidance implementation, blood donations over the past summer were well below the donations necessary to support growth of the overall blood supply and contributed to serious regional blood shortages. These events also had a disproportionate impact on specific regions of the United States, such as the New York, Washington and other coastal metropolitan areas. Areas that depend heavily on military collections were also hard hit. As such, they not only tested the limits of elasticity of the blood supply (ability to expand to compensate for sudden contraction), but also tested the limits of fluidity of the supply (ability of centers to move products to areas experiencing either disproportionate reduction in supply or extraordinary demand). The events of the past year occurred in the context of steady and perilous narrowing of the margin between blood collections and blood transfusions in the decade preceding 2000.5 This picture raises serious questions about the stability of the “system” of blood donations and supply; our understanding of the complexity and fragility of the supply chain that connects blood donors to patients; and the potential for blood donations and blood supply to adapt under these kinds of challenges. Three reports in the January issue of TRANSFUSION6-8 deal with aspects of donor suitability and donor motivation, both critical determinants in creating our blood supply. One study from Canada concluded that the incremental risk of changing to a 12-month deferral criterion for male sex with males would be very low (although not zero) while the donations would rise by 1.3 percent.6 Another report indicated that whole-blood donor retention and frequency in general are low, that older donors are more loyal than younger donors, that nonHispanic white people donate far more blood proportionally than other ethnic or racial groups, and that donations from lapsed blood donors are safer than donations from first-time donors.7 The third report indicated a significant positive impact that results from offering credits and health screening as incentives to donate.8 These studies and the Retrovirus Epidemiology Donor Study (REDS) offer unique and important insights into an increasingly complex and difficult responsibility: how to find the numbers of blood donors and donations necessary for our everyday task of fulfiling the demand for transfusion. They point out an increasingly urgent need to have a much more comprehensive and sophisticated understanding of how blood donors are motivated and how best we can maximize the relationship between blood donors and the organizations that collect and manage their gift of life. Increasingly, it seems that altruism, the cornerstone of the all-volunteer blood supply, is not sufficient to acquire and maintain an adequate number of donations. In this issue of TRANSFUSION, Simon9 argues that it might be time to consider paying donors to solve some of the critical type-specific needs for whole blood and platelets. Also, new FDA clarification on blood donor incentives may have changed the set point that determines the difference between paid and nonpaid donors.10 The perception of looser standards may have precipitated an escaTRANSFUSION 2003;43:132–134.