Blood: A Transfusion of Confusion : Much of the Uncertainty Is Traceable to the AIDS Scare

The nation’s blood supply enters its traditional holiday doldrums facing an array of technical and political challenges that may haunt consumers for months or years to come.

Near term, local and national blood program officials agree that new tests to detect a type of hepatitis previously undiscoverable in donor blood may force area banks to discard 6% of what they collect. Some officials fear as much as 10% of blood may have to be thrown out because of the tests--whose proportion of erroneous results is considered extremely high.

Tests Being Upgraded

Blood bankers hope the shortfall will be short-lived--perhaps no more than six months. The tests, to detect what is known as non-A, non-B hepatitis, are being upgraded and improvement is likely.

But the short-term problem may be just the start of a period of intense confusion and uncertainty for blood banks. Officials agree an array of different types of blood donation--some of them aggressively marketed to play on public fear of AIDS--may perplex consumers and make giving blood as confusing as selecting a telephone service or a new mortgage.

Among the burgeoning practices that are causing concern are:

- Freezing and storing of blood for eventual use, if needed, by the donor.

- Solicitation of blood donations for use of a specific person in which friends, co-workers, relatives and even strangers donate with the blood earmarked for a single patient.

Much of the uncertainty in the blood program--and heavily promoted alternatives to the traditional community donor concept--is directly traceable to the AIDS scare. Blood program operators agree, though, that there is a certain irony in this because, of all theoretical and real dangers of the community blood supply, AIDS today is the least significant.

An Old Principle

They also say the confusion may prompt both blood donors and transfusion recipients to ignore an old principle that is as valid now as ever: The most effective way to avoid transfusion-related complications is for ever greater numbers of people with disease-free blood to donate as often as they can to the community supply.

“What I’ve been saying,” observed Dr. S. Gerald Sandler, Washington-based head of the American Red Cross blood program, “is that, if you want a safe and adequate blood supply, it’s more up to you (lay people) than it is to me.

“Give blood tomorrow. If you leave it up to me to introduce more tests and more policies, you are never going to get there.”

And while in the Los Angeles-Orange County area, at least, donations have recovered to normal or even above-normal levels since the AIDS-blood scare apparently peaked here in mid to late 1985, the proliferation of blood donation practices virtually assures confusion among donors and blood recipients and questions about whether the young and affluent benefit from a blood system far different from the old and poor.

The stakes are enormous. Nationally, the Red Cross collects nearly 6.2 million pints a year, half the nation’s total. In Los Angeles and Orange counties, the Red Cross program has an annual goal of 404,000 units. In 1985, it only got 396,444 units--a shortfall blamed on the AIDS scare.

Red Cross officials said October, 1986, was the best October the local program ever had, with 35,355 units collected--up from 32,179 in 1985. November figures aren’t available yet.

Nationally, Red Cross officials say the improved 1986 fortunes result from both public education programs convincing people reliable tests now exist to detect AIDS-tainted blood and improved donor recruiting nationwide.

But blood discarded because of the new hepatitis test may offset much of the progress. Keeping this blood is not a realistic alternative since non-A, non-B hepatitis represents the most threatening source of infection in today’s community blood supply. Non-A, non-B is rarely fatal but the severity of its symptoms can vary markedly and it often becomes a long-term problem.

While there have always been different types of donation, public attention has focused until recently on just the most common variety--the so-called homologous donation, in which a donor gives a unit of blood for any use blood bankers decide. Homologous donations always have been and probably always will be the backbone of blood programs.

But from the consumer perspective, the most news has been made in the last few weeks by publicity over what is called autologous blood donation--in which an individual puts blood aside for his or her own later use. Last month, the American Medical Assn. Council on Scientific Affairs released a report concluding that the safest blood you can get in a transfusion is what you donate for yourself.

Autologous Donations

Autologous donations can be stored either in liquid or frozen form. The former is a universally accepted and longstanding part of blood programs. Liquid autologous donations can be kept up to 42 days for use--usually in planned surgery. (Frozen blood lasts three years.)

Virtually every hospital blood bank accepts liquid autologous donations and, today, they account for 1% to 2% of all transfused blood, with many experts believing they could increase to 5%. To make an autologous donation, a person generally must be referred by a physician. In the time liquid blood may be stored, a person can give as many as four autologous units--spacing the donations closer together than the two months that must elapse between donations to the community blood supply.

Some rules that would disqualify a person from donating to the community pool--like a history of having once had hepatitis--are waived since a person’s own blood will not reintroduce the infection. Liquid autologous is virtually without detractors in the blood-banking industry.

Frozen autologous blood, however is the subject of an intense ethical and marketing controversy. Its proponents, which in the last three months have come to include the Cedars-Sinai Medical Center, the county’s second busiest after the Red Cross, say frozen autologous blood is important insurance for unknown, future blood needs. The concept has also been aggressively promoted by a for-profit company called HemaCare which has sought to sell frozen blood services countywide.

Detractors, including the Red Cross and most other hospital blood banks in the area, contend that frozen autologous blood represents, said Dr. Carroll Spurling, medical director of the Los Angeles-Orange County Red Cross program, “about as lousy a form of insurance as I can think of.” There is no way, opponents of the frozen blood programs contend, that blood (actually separated red cells) kept in a freezer in one location can reliably be thawed, processed and transported where it will be needed in in time for an emergency.

To blood bankers, though, autologous blood--even the frozen kind--pales as a subject of controversy in comparison to directed donations. Long a part of the blood system, directed donations occur when someone agrees to give blood--but only for a specific patient, often a relative, close friend or co-worker. There is no requirement the donor know the recipient and often directed donors aren’t known to the person getting the blood. California law has recently been amended to require hospitals to permit parents to give directed donations for their children--but not vice versa.

If more directed donor blood is collected than the patient requires, it often is transferred to the community blood supply.

Many officials fear that in the long term--five or 10 years from now, in Spurling’s opinion--directed donations could cause a shortage in the unrestricted community blood pool if many donors hold back, giving blood only for specific people.

Those who oppose greater use of directed donor blood contend such blood may be less safe than community blood supplies since pressures on relatives and friends to donate may prompt them to conceal their health histories in ways anonymous community donors would not.

Nationally, the Red Cross opposes directed donor programs--just as it opposes frozen autologous blood banking except in situations where a patient has an extremely rare blood. The Red Cross permits its 57 regional blood centers to deviate from the national policy if they wish and, Sandler said, a handful--including San Jose--have done so.

The Red Cross has even begun running national television spots to discourage the practice. In one commercial being broadcast in Southern California, a father is depicted in panhandler fashion asking passers by to donate blood for his son. The point of the ad, a Red Cross spokesperson said, is to underscore that a strong community blood supply system should make such pleas unnecessary.

Proponents of increased reliance on directed donations--led by Dr. Dennis Goldfinger, head of the Cedars-Sinai blood program--contend the fears about directed donor blood are unfounded. They argue such programs actually help blood banks to recruit donors who give with no strings attached.

Question of Safety

The basis of the rejuvenated interest in directed donor blood, agreed Spurling, Goldfinger and other experts, is an assumption by participants that it is somehow less likely to carry the threat of AIDS, hepatitis or other infections than the community supply. Recent studies show there is no reason to assume directed donor blood is safer than other blood--but not any less safe, either.

At the Irwin Memorial Blood Center in San Francisco, a non-Red Cross program that is the major blood supplier for the Bay Area, officials recognized two years ago that the city’s unique role in AIDS necessitated embracing the directed donor concept to restore public faith in the blood supply. The experience has given Irwin Memorial the largest cross section of directed (also known as designated) donations in the country.

Vincent Yalon, blood product manager at Irwin Memorial, said 8% to 10% of the San Francisco blood supply is now directed donor. Between June, 1984, and December, 1985, researchers monitored 11,916 donors or would-be donors and compared the disqualification rates for first-time community donors, experienced community donors and designated donors. There were no significant differences, he said.

Cedars-Sinai’s Goldfinger said that in studies in 1985 and 1986, 11.5% of would-be directed donors were rejected by the blood center, compared with 10.4% of community volunteer donors. He said the difference was not statistically significant. He said Cedars-Sinai also monitored how blood fared in laboratory tests after it was collected and that there was no difference in results of tests for AIDS virus exposure, hepatitis B or sexually transmitted disease in the blood of 3,000 directed donors and 4,500 community donors. Goldfinger asserted that there is little chance in well-run blood banks of a directed or autologous donation being given to the wrong patient.

Other studies established that 27% of directed donors at Cedars-Sinai returned to donate again as nonrestricted community donors and that only 1.5% of a sample of 130 volunteer donors indicated they had considered switching to directed donations for their friends and relatives and dropping out of the unrestricted program.

Just Getting Under Way

The focus on both directed donor and frozen autologous blood programs has given Cedars-Sinai one of the most evenly diversified cross sections of blood sources in the country. At the moment, though the frozen autologous program is just getting under way, Goldfinger said Cedars-Sinai’s own collection of about 800 units a month includes about 50% unrestricted community blood, 250 to 350 directed donations and 100 to 150 autologous units of both major types. But Cedars-Sinai, the biggest blood bank aside from the Red Cross, still relies on the Red Cross for about half its blood--a situation Goldfinger said is unlikely to change.

“I am convinced that directed donor has potential medical benefits,” Goldfinger said. But for blood bankers, he contended, “change is frightening. The most difficult thing to get a person to do is to change the way he operates and to work harder.

“If you have a system that is really outstanding--and blood transfusion in this country is really outstanding--you have to be very concerned that making changes could do more harm than good. But blood (recipients) are concerned (about safety) and we need to (make changes) in such a way that we don’t disrupt the blood supply of the nation.”

Fragmented Supply Feared

Other blood bankers are not so certain. Starting with Spurling of the Red Cross, they argue that a trend toward increased reliance on directed donation (and frozen autologous, for that matter) could fragment the blood supply, leaving people who need blood but can’t afford special fees imposed for such programs unable to get transfusions. (Cedars-Sinai charges $200 a unit to freeze blood, for instance, and a $45 premium for a directed donor unit.)

Opponents also worry about how practical it may be to expect many older people to find and recruit others to donate in their names.

“I’m much more concerned about directed donor programs than frozen autologous,” Spurling said. “What bothers me is the idea that is created in the eyes of the public of two different types of blood. One is (what would be perceived as) very good directed donor blood and the other is the second-rate community stuff.

Other Objections

“I sincerely believe that, unchecked, this will destroy the whole philosophy and approach we’ve used for supplying our blood needs. Eventually. Ten years from now. Not tomorrow.”

There are other objections, too. Dr. Klaus Mayer, director of the blood bank at Memorial Hospital in New York (which serves Memorial Sloan-Kettering Cancer Center), noted that in patients suffering from some cancers--most notably leukemia--directed donations timed incorrectly may actually threaten the success of therapy with platelets, a blood component, that can be transfused to leukemia victims. The best platelet suppliers are close relatives, Mayer said, but if a relative had given a directed donation before platelets were needed, the patient might have built up an irreversible sensitivity to them.

“Directed donations,” said Dr. Carol Bell, director of the blood bank at Brotman Medical Center in Culver City, “imply promises to people who are getting them that there is more safety in it than there really is.

“My own feeling--and I don’t think I’m alone in this--is that I don’t trust those units. (Besides), it’s going to leave a certain elite who can have blood.”