Public Health: Maintaining an Adequate Blood Supply Is Key to Emergency Preparedness
Published: 2002-09-10T00:00:00

Fast Facts:

Highlights:
section_title: What GAO Found
paragraphs: The terrorist attacks of September 11 underscored the critical importance of a safe and adequate supply of blood for transfusions. In recent years, an average of 8 million volunteers have donated more than 14 million units of blood annually, and 4.5 million patients per year have received life-saving blood transfusions, according to the American Association of Blood Banks. Ninety percent of the U.S. blood supply is collected by two blood suppliers, the American National Red Cross and the independent blood banks affiliated with America's Blood Centers. Within the federal government, the Food and Drug Administration is responsible for overseeing the safety of the nation's blood supply. The surge in donations after the terrorist attacks added an estimated 500,000 units to annual collections in 2001. The experience illustrated that large numbers of Americans are willing to donate blood in response to disasters. However, because very few of the units donated immediately after September 11 were needed by the survivors, this experience has also raised concerns among blood suppliers and within the government about how best to manage and prepare the blood supply for emergencies. Data indicate that the blood supply has increased in the past 5 years and that it remains generally adequate. Blood collections increased 21 percent from 1997 to 2001, and collections in the first half of 2002 appear to have been roughly equivalent to the same period in 2001. Blood suppliers and the federal government have begun to reevaluate how blood is collected during and after disasters to avoid repeating this experience and also to ensure that enough blood is available during emergencies. A task force, including members from federal agencies and blood suppliers, has been formed to coordinate the response in future emergencies to the need for blood. Insights from the experiences of September 11 and other disasters have led the task force to conclude that the need for blood in most emergencies can be best met by maintaining an adequate blood inventory at all times, rather than increasing blood collections following a disaster.

section_title: Letter
paragraphs: I am pleased to have the opportunity to testify as the Subcommittee  considers the blood supply and its adequacy to meet the nation’s  emergency needs. The terrorist attacks of September 11, 2001, reminded  the nation of the critical importance of a safe and adequate supply of blood  for transfusions. In recent years, an average of about 8 million volunteers  have donated more than 14 million units of blood annually, and  approximately 4.5 million patients per year have received life-saving blood  transfusions, according to the American Association of Blood Banks  (AABB). About 90 percent of the U.S. blood supply is collected by two  blood suppliers, the American National Red Cross and independent blood  banks affiliated with America’s Blood Centers (ABC). Within the federal  government, the Food and Drug Administration (FDA) is responsible for  overseeing the safety of the nation’s blood supply. The surge in donations  after the terrorist attacks added an estimated 500,000 units to annual  collections in 2001. The experience illustrated that large numbers of  Americans are willing to donate blood in response to disasters. However,  because very few of the units donated immediately after September 11  were needed by the survivors, this experience has also raised concerns  among blood suppliers and within the government about how best to  manage and prepare the blood supply for emergencies.
Today we are releasing a report that summarizes several issues regarding  blood safety and availability. My comments will focus on three of the  topics addressed in our report: the adequacy of the blood supply, the  response of the blood suppliers to the September 11 attacks, and their  planning for future emergencies. Our report also describes recent changes  in the price of blood and evaluates the potential impact of the new  guidance from FDA that is aimed at reducing the risk of transmitting  variant Creutzfeldt-Jakob disease, the human form of “mad cow” disease,  through blood transfusions.
In brief, available data indicate that the blood supply has increased in the  past 5 years and that it remains generally adequate. Blood collections  increased 21 percent from 1997 to 2001, and collections in the first half of  2002 appear to have been roughly equivalent to the same period in 2001.  There has been a corresponding rise in the number of transfusions from  1997 to 2001. Although local and temporary blood shortages occur from  time to time, the inventory of blood in America’s hospitals was at  historically high levels before September 11 and has generally remained  adequate through the first 8 months of 2002. In the weeks immediately  following September 11, blood collections increased nearly 40 percent over  collections earlier in 2001. Because only a small amount of blood was  needed to treat survivors of the attacks, a nationwide surplus developed,  which stressed the collection system. We estimate that about five times the  usual proportion of units of blood became outdated and had to be  discarded in the months following September 11. Monthly blood  collections returned to preattack levels by November, following the pattern  of collections after earlier emergencies. Blood suppliers and the federal  government have begun to reevaluate how blood is collected during and  after disasters to avoid repeating this experience and also to ensure that  enough blood is available during emergencies. A task force including  members from federal agencies and blood suppliers has been formed to  coordinate the response in future emergencies to the need for blood.  Insights from the experiences of September 11 and other disasters have led  the task force to conclude that the need for blood in most emergencies can  be best met by maintaining an adequate blood inventory at all times, rather  than by increasing blood collections following a disaster.
subsections: section_title: Background
paragraphs: Sixty percent of the U.S. population is eligible to donate blood, but in any  given year only about 5 percent of those who are eligible actually do so.  Eighty percent of donors are repeat donors. A typical donor gives blood  approximately 1.6 times per year, but donors may give 6 times per year, or  every 8 weeks, which is the period the body needs to replenish red blood  cells.
The two largest blood suppliers, the Red Cross and ABC, each collect about  45 percent of the nation’s blood supply, and roughly 10 percent is supplied  by other independent blood centers, the Department of Defense, and  hospitals that have their own blood banks. Suppliers test, process, and  store the blood they collect, and ultimately sell it to health care providers.   Liquid red blood cells have a shelf life of 42 days, and a small proportion of  the blood collected is not used during that period and is discarded. Most  hospital transfusion services purchase blood and blood components under  a contract with a local supplier, which describes the price and quantity of  blood to be delivered. Blood suppliers use resource-sharing programs to  help distribute blood from low-demand to high-demand areas. Taken  together, the Red Cross, ABC, and AABB’s National Blood Exchange  redistributed about 1.4 million units of blood—over 10 percent of the  nation’s supply—among blood banks in 2000. In addition, the Red Cross  has a nationwide inventory control system to facilitate the movement of its  surplus blood.
Under the Public Health Service Act and the Federal Food, Drug and  Cosmetic Act, FDA regulates and licenses blood and blood products to  ensure that they are safe. FDA has no authority to determine the amount of  blood that should be collected or to compel suppliers to make products  available. However, it can make recommendations related to the  availability of blood during public health emergencies. For example, after  the September 11 attacks, FDA issued emergency guidelines to speed the  delivery of blood to areas affected by the attacks. Also within the  Department of Health and Human Services (HHS), the Advisory Committee  on Blood Safety and Availability provides advice to the Secretary of HHS  and to the Assistant Secretary for Health on various issues involving the  blood supply, including economic factors affecting cost and supply, as well  as public health, ethical, and legal issues related to blood safety.
section_title: The Blood Supply Has Increased and Remains Generally Adequate
paragraphs: Available data indicate that the nation’s blood supply has increased and  remains generally adequate. Although local and temporary blood shortages  occur from time to time, the inventory of blood in America’s hospitals was  at historically high levels before September 11 and has remained adequate  through the first 8 months of 2002.
Although no one data source has comprehensively tracked the nation’s  blood supply in the past, all of the sources we identified indicated that the  national supply has grown in recent years and was at historically high  levels before the surge in donations that occurred after September 11.  Annual blood collections have increased substantially—21 percent—since  1997, according to National Blood Data Resource Center (NBDRC)  measurements and estimates of annual blood collections by all blood  centers.  (See fig. 1.)  The number of units of blood collected annually  increased from 12.4 million in 1997 to an estimated 15 million in 2001.  (NBDRC estimated that 2001 collections would have reached 14.5 million  units, 17 percent higher than in 1997, without the post-September 11 surge.)
The increase in the blood supply has been echoed by a corresponding  increase in the amount of blood transfused. (See fig. 1.) For example,  NBDRC data indicate that the number of red blood cell units transfused  rose 17 percent from 1997 to 2001, from 11.5 million to 13.5 million units.
The annual number of units that were available but not transfused  remained at about 1 million units.
Blood inventories were generally adequate just prior to the September 11  attacks. The Red Cross reported that its total red blood cell inventory was  33 percent higher in August 2001 than it was in August 2000 and that its  type O inventory was 83 percent higher than it was in August 2000.  The  New York Blood Center (NYBC) reported that it had a 4- to 5-day supply of  blood on hand in early September 2001. On September 10, 2001, the median  inventory for the hospitals in HHS’s Blood Sentinel Surveillance System for  all blood types stood at approximately 7 days, and for type O Rh-negative  blood, at 6 days.
The limited information available to us indicates that blood collections to  date in 2002 have been roughly comparable to the levels immediately prior  to September 11.  According to NBDRC data, collections for the first half of  2002 have been similar to the same period in 2001.  The hospital inventories  measured by HHS’s Blood Sentinel Surveillance System in mid-August 2002  were similar to those levels measured just prior to September 11, 2001.
section_title: Blood Collected in Response to September 11 Stressed Collection System and Resulted in Surplus
paragraphs: The high volume of blood donations by volunteers immediately after  September 11 stressed the collection system and resulted in a national  surplus. Monthly blood collections increased nearly 40 percent over  collections earlier in 2001 in the weeks immediately following September  11, but there was little additional need of blood for transfusions. The  nationwide blood supply was substantially greater than needed for  transfusions.  Consequently, the proportion of units that expired and were  discarded in October and November 2001 was five times higher than the  proportion that expired in an average 2-month period earlier in 2001.
America’s blood banks collected an unprecedented amount of blood in a  short period after the September 11 attacks. In response to the perception  that blood would be needed to treat victims, Americans formed lines to  give blood at hospitals and blood banks even before a call for blood went  out. HHS, ABC, and the Red Cross all issued requests for blood donations,  although HHS and ABC quickly stopped issuing requests when it became  clear that there were few survivors of the attacks and therefore little need  for additional blood for transfusions. Many blood suppliers were reluctant  to turn away potential donors, however, and some hospitals that did not  have their own blood banks responded to the surge in volunteers by  collecting blood anyway.  NBDRC estimated that total blood collections in  the United States were 38 percent higher in September 2001 than average  monthly collections earlier in 2001. The Red Cross reported that its  national blood collections during the week of September 11 more than  doubled compared with the preceding weeks. Estimates of the number of  additional units collected nationwide in September and October 2001 in  response to the September 11 attacks range from 475,000 to 572,000.  Following the pattern of responses to previous disasters, the sharp  increase in blood collections did not last. While higher than usual blood  collections continued for several weeks after September 11, the number of  units collected had returned to the baseline level or slightly below it by the  beginning of November. (See fig. 2.)
This surge of donors stressed the collection system. Shortages in blood  collecting supplies, phlebotomists (technicians trained to collect blood),  and storage capacity occurred as more potential donors arrived. Long  waiting lines developed because there was insufficient staff to draw blood.  Increased errors in the collection process at some blood banks  accompanied the surge in donations. As much as 20 percent of some blood  banks’ donations was collected improperly and had to be discarded,  primarily because individuals had not completed the donor questionnaire  correctly.
Far more blood was collected immediately after September 11 than was  needed by survivors or than ultimately could be absorbed by the nation’s  blood banks.  Fewer than 260 units were used to treat victims of the  attacks. A portion of the surplus went unused, expired, and was discarded.  NBDRC surveyed a nationally representative sample of 26 blood suppliers  and found that about 10 percent of the units collected in September and  October 2001 by the suppliers it surveyed expired and were discarded. This  was nearly a fivefold increase in the proportion of units these suppliers  discarded because they had expired in the first 8 months of 2001. Of the  roughly 572,000 additional units collected in response to September 11, we  estimate that about 364,000 units, or about two-thirds, entered the nation’s  blood inventory and that approximately 208,000 units, or about one-third,  expired and were discarded.  All of these figures underestimate the total  number of expired units because they represent expirations at blood  suppliers only and do not capture units that expired in hospital inventories.
Some blood banks also suffered serious financial losses, as they incurred  the costs of collecting and processing units of blood they could not sell. For  example, the New York Blood Center claimed it lost from $4 million to $5  million and suffered a nearly threefold increase in the number of units it  had to discard when blood donated in response to the attack expired.
section_title: Blood Suppliers Are Focusing Emergency Planning on Maintaining Adequate Inventory
paragraphs: Incorporating the lessons learned from past disasters, blood suppliers and  the federal government are reevaluating how blood is collected during and  after disasters and are focusing on maintaining a consistently adequate  inventory in local blood banks in preparation for disasters and not  collecting more blood after a disaster than is medically necessary.
Since September 11, federal public health agencies and blood suppliers  have been critical of their responses to prior disasters and have begun to  plan for a more effective response to future emergencies. Through an  interorganizational task force organized by AABB in late 2001, the focus  has begun to shift away from increasing blood collections in an emergency  to maintaining an adequate inventory of blood at all times. This shift was  prompted by the realization that a surge in blood collections following a  disaster does not help victims because disaster victims rarely require many  units of blood and because newly collected blood cannot be used immediately. For example, as with September 11, only a small percentage  of the additional blood collected after the Oklahoma City bombing was  transfused into victims (131 units of more than 9,000 units collected).   Moreover, the units used to treat victims in the hours after a disaster are  those already on hand at the treating hospital or local blood bank. It takes  2 days to completely process and test a unit of newly donated blood, so  existing stores of blood must be used to treat disaster casualties. Finally,  military experts and blood industry officials told us that it is unlikely a  discrete disaster would require more blood than is normally stored in the  nation’s blood inventory. They noted that large amounts of blood have not  been needed in building collapses (like the September 11 attacks and the  Oklahoma City bombing), nor would blood transfusions be a likely  treatment for illnesses caused by a bioterrorism attack. Nonetheless,  disaster scenarios that have not yet been identified may require more blood  than is currently envisioned.
A report by the AABB task force made recommendations for the  emergency preparedness of the blood supply that were adopted by the HHS  Advisory Committee on Blood Safety and Availability. The  recommendations are aimed at having federal and other organizations that  are involved in the collection or use of blood coordinate their actions in an  emergency. For example, the task force recommended that all blood  banks—not just the Red Cross as is now the case—be designated as  suppliers of blood in an emergency and that the Assistant Secretary for  Health serve as the spokesperson for all organizations involved in  managing and transporting blood in an emergency. Recognizing that an  adequate blood inventory in an affected area is the most important factor in  the initial response to a disaster, the task force also recommended that  blood banks maintain a 7-day supply of all blood types at all times.
Both the Red Cross and ABC are independently pursuing their own plans to  meet emergency and long-term needs. The Red Cross expects to increase  annual collections by 9 percent during each of the next 5 years. The Red  Cross also plans to implement a “strategic blood reserve” within the next 5  years using preregistered donors and a limited stock of frozen blood cells.
ABC has established a “national strategic donor reserve” through which it  can call on the donors it has registered, if needed.
section_title: Concluding Observations
paragraphs: Although local and temporary blood shortages occur from time to time,  America’s blood supply is generally adequate. The blood community’s  response to disasters can be improved, and the community is beginning to  take the necessary steps to learn from past experiences. The  interorganizational task force organized by AABB has involved the blood  community in efforts to more effectively plan for future disasters.  In  addition, the Red Cross and ABC are independently taking steps to meet  emergency requirements.
Mr. Chairman, this concludes my prepared statement. I would be happy to  respond to any questions you or other Members of the Subcommittee may  have at this time.
subsections: section_title: Contact and Acknowledgments
paragraphs: For further information about this testimony, please contact me at (202)  512-7119. Martin T. Gahart, Sharif Idris, and Roseanne Price also made key  contributions to this statement.