Facts About Blood and Blood Banking
Donor Screening and Deferral
Whole Blood and Blood Components
Autologous Blood
Testing of Donor Blood for Infectious Diseases
Transfusion-Transmitted Diseases
West Nile virus
Creutzfeldt-Jakob Disease (CJD)
SARS
Smallpox
Highlights of Transfusion Medicine History
FACTS ABOUT BLOOD AND BLOOD
BANKING
How much blood is donated each year?
AABB estimates that eight million volunteers donate blood each year.
According to the National Blood Data Resource Center (NBDRC) about 15 million units of whole blood
and red blood cells were donated in the United States in 2001.
Typically, each donated unit of blood, referred to as whole blood, is
separated into multiple components, such as red blood cells, plasma, platelets,
and cryoprecipitated AHF (antihemophilic factor). Each component generally is
transfused to a different individual, each with different needs.
Who needs blood?
The need for blood is great on any given day, an average of
38,000 units of red blood cells are needed. Blood transfusions often are needed
for trauma victims due to accidents and burns heart surgery,
organ transplants, and patients receiving treatment for leukemia, cancer or
other diseases, such as sickle cell disease and thalassemia. NBDRC reports that
in 2001, nearly 29 million units of blood components were transfused. And with
an aging population and advances in medical treatments and procedures requiring
blood transfusions, the demand for blood continues to increase.
Who donates blood?
Fewer than 5 percent of healthy Americans eligible to donate blood
actually donate each year. According to studies, the average donor is a
college-educated white male, between the ages of 30 and 50, who is married and
has an above-average income. However, a broad cross-section of the population
donates every day. Furthermore, these average statistics are
changing, and women and minority groups are volunteering in increasing numbers
to donate. Persons 69 years and older account for approximately 10 percent of
the population, but they require 50 percent of all whole blood and red blood
cells transfused, according to NBDRC. Using current screening and donation
procedures, a growing number of blood banks have found blood donation by
seniors to be safe and practical.
Patients scheduled for surgery may be eligible to donate blood for
themselves, a process known as autologous blood donation. In
the weeks before non-emergency surgery, an autologous donor may be able to
donate blood that will be stored until the surgical procedure.
What are the criteria for blood donation?
To be eligible to donate blood, a person must be in good health and
generally must be at least 17 years of age (although some
states permit younger people, with parental consent, to donate). Minimum weight
requirements may vary among facilities, but generally, donors must weigh
at least 110 pounds. Most blood banks have no upper age limit.
All donors must pass the physical and health history examinations given prior
to donation.
Volunteer donors provide nearly all blood used for transfusion in the
United States. The donor's body replenishes the fluid lost from donation in 24
hours. It may take up to two months to replace the lost red blood cells.
Whole blood can be donated once every eight weeks (56 days).
Two units of red blood cells can be donated at one time, using a process known
as red cell apheresis. This type of donation can be made every 16 weeks.
Who should not donate blood?
- Anyone who has ever used intravenous drugs (illegal IV drugs)
- Men who have had sexual contact with other men since 1977
- Anyone who has ever received clotting factor concentrates
- Anyone with a positive antibody test for HIV (AIDS virus)
- Men and women who have engaged in sex for money or drugs since 1977
- Anyone who has had hepatitis since his or her eleventh birthday
- Anyone who has had babesiosis or Chagas disease
- Anyone who has taken Tegison for psoriasis
- Anyone who has risk factors for Crueutzfeldt-Jakob disease (CJD) or
who has an immediate family member with CJD
- Anyone who has risk factors for vCJD
- Anyone who spent three months or more in the United Kingdom from 1980
through 1996
- Anyone who has spent five years in Europe from 1980 to the
present.
Where is blood donated?
There are many places where blood donations can be made. Bloodmobiles
(mobile blood drives on specially constructed buses) travel to high schools,
colleges, churches, and community organizations. People can also donate at
community blood centers and hospital-based donor centers. Many people donate at
blood drives at their places of work. You may use the online
Locator or consult the
yellow pages to locate a nearby blood center or hospital to donate.
What is Apheresis?
Apheresis, an increasingly common procedure, is the
process of removing a specific component of the blood, such as platelets, and
returning the remaining components, such as red blood cells and plasma, to the
donor. This process allows more of one particular part of the blood to be
collected than could be separated from a unit of whole blood. Apheresis is also
performed to collect red blood cells, plasma (liquid part of the blood), and
granulocytes (white blood cells).
The apheresis donation procedure takes longer than that for whole blood
donation. A whole blood donation takes about 1020 minutes to collect the
blood, while an apheresis donation may take about one to two hours.
What is the most common blood type?
The approximate distribution of blood types in the US population is as
follows. Distribution may be different for specific racial and ethnic
groups:
O Rh-positive |
--- |
38 percent |
O Rh-negative |
--- |
7 percent |
A Rh-positive |
--- |
34 percent |
A Rh-negative |
--- |
6 percent |
B Rh-positive |
--- |
9 percent |
B Rh-negative |
--- |
2 percent |
AB Rh-positive |
--- |
3 percent |
AB Rh-negative |
--- |
1 percent |
In an emergency, anyone can receive type O red blood cells, and type AB
individuals can receive red blood cells of any ABO type. Therefore, people with
type O blood are known as universal donors, and those with type AB
blood are known as universal recipients. In addition, AB plasma
donors can give to all blood types.
What tests are performed on donated blood?
After blood has been drawn, it is tested for ABO group (blood type) and
Rh type (positive or negative), as well as for any unexpected red blood cell
antibodies that may cause problems in a recipient. Screening tests also are
performed for evidence of donor infection with hepatitis B and C viruses, human
immunodeficiency viruses HIV-1 and HIV-2, human T-lymphotropic viruses HTLV-I
and HTLV-II, and syphilis. The FDA is allowing national deployment of
investigational nucleic acid amplification tests (NAT) to screen blood for West
Nile virus (WNV) genetic material -- an approach similar to that taken for NAT
to detect HIV and HCV.
The specific tests currently performed are listed below:
- Hepatitis B surface antigen (HBsAg)
- Hepatitis B core antibody (anti-HBc)
- Hepatitis C virus antibody (anti-HCV)
- HIV-1 and HIV-2 antibody (anti-HIV-1 and anti-HIV-2)
- HTLV-I and HTLV-II antibody (anti-HTLV-I and anti-HTLV-II)
- Serologic test for syphilis
- Nucleic acid amplification testing (NAT) for HIV-1 and HCV
- NAT for WNV
How is blood stored and used?
Each unit of whole blood normally is separated into several components.
Red blood cells may be stored under refrigeration for a
maximum of 42 days, or they may be frozen for up to 10 years. Red cells carry
oxygen and are used to treat anemia. Platelets are important
in the control of bleeding and are generally used in patients with leukemia and
other forms of cancer. Platelets are stored at room temperature and may be kept
for a maximum of five days. Fresh frozen plasma, used to
control bleeding due to low levels of some clotting factors, is kept in a
frozen state for usually up to one year. Cryoprecipitated AHF,
which contains only a few specific clotting factors, is made from fresh frozen
plasma and may be stored frozen for up to one year.
Granulocytes are sometimes used to fight infections, although
their efficacy is not well established. They must be transfused within 24 hours
of donation.
Other products manufactured from blood include albumin, immune
globulin, specific immune globulins, and clotting factor concentrates.
Commercial manufacturers commonly produce these blood products.
What fees are associated with blood?
While donated blood is free, there are significant costs associated
with collecting, testing, preparing components, labeling, storing and shipping
blood; recruiting and educating donors; and quality assurance. As a result,
processing fees are charged to recover costs. Processing fees for individual
blood components vary considerably. Processing fees for one specific component
also may vary in different geographic regions. Hospitals charge for any
additional testing that may be required, such as the crossmatch, as well as for
the administration of the blood.
What is the availability of blood?
The blood supply level fluctuates throughout the year. For example,
after the Sept. 11 attacks, the blood supply swelled to very high levels, due
to the overwhelming response of donors. During holidays and in the summer,
levels tend to fall because donations decline, but demand remains stable or
even increases. In addition, policies recommended by the Food and Drug
Administration can eliminate, or defer, donors who may be at risk for variant
Cruetzfeldt-Jacob disease (vCJD), the human variety of the disease that is
commonly known as mad-cow disease. Also, FDA can recommend that a
potential donor who may be at risk for a transfusion-transmissible disease such
as West Nile virus be deferred. These policies reduce the number of people who
are eligible to donate.
What can you do if you arent eligible to donate?
While a given individual may be unable to donate, he or she may be able
to recruit a suitable donor. Blood banks are always in need of volunteers to
assist at blood draws or to organize mobile blood drives. In addition, monetary
donations are always welcome to help ensure that blood banks can continue to
provide safe blood to those in need.
*United States Census 2000
01/04
Top
DONOR SCREENING AND DEFERRAL
The Donation Process
Education
When prospective donors enter a blood bank, they are asked to
read educational materials such as the AABB pamphlet titled “An
Important Message to All Blood Donors.” These materials
contain information on the risks of infectious diseases transmitted
by blood transfusion, including the signs and symptoms of AIDS.
Prospective donors are asked to acknowledge in writing that they
have read and understood these materials, have been given the
opportunity to ask questions, and have provided accurate information.
The prospective donors can elect to leave at this point without
donating. (Self-deferral can occur at any point in the donation
process when a donor voluntarily chooses not to complete the process.)
Health History
Prospective donors who do not self-defer proceed to the next
step: giving a detailed health history. The history is designed
to ask questions that protect the health of both the donor and
the recipient. To ensure that every donor is asked the same questions,
the AABB recommends use of a uniform donor history questionnaire.
However, donor centers often create their own questionnaires,
using the same general guidelines. In addition to questions about
transfusion-transmissible diseases, prospective donors are asked
questions to determine whether donating blood might endanger their
health. If a prospective donor responds positively to any of these
questions, he or she will be “deferred” or asked not
to donate blood. The health history also is used to identify prospective
donors who have been exposed to or who may have diseases, such
as human immunodeficiency virus (HIV), hepatitis or malaria. These
individuals are further evaluated and those at high risk of disease
are deferred.
Physical Examination
The next step in the donation process is an abbreviated physical
examination that includes checking the blood pressure, pulse,
and temperature. A few drops of blood are taken from a finger
and tested to ensure that anemia is not present. An abnormality
found in any part of the physical examination may be a cause for
deferral. Donors also must meet the weight requirement of 110
pounds.
The Actual Donation
A prospective donor who passes successfully through these steps
proceeds to the actual whole blood donation process, which takes
about 20 minutes. The donor lies down or sits in a reclining chair.
The skin covering the inner part of the elbow joint is cleansed.
A new, sterile needle connected to plastic tubing and a blood
bag is inserted into an arm vein. The donor is asked to squeeze
repeatedly his or her hand to help blood flow from the vein into
the blood bag. Typically, one unit of blood, roughly equivalent
to a pint, is collected. After the blood is collected, it is sent
to the laboratory for testing and component preparation. The donor
is escorted to an observation area for light refreshments and
a brief rest period.
Adult males have about 12 pints of blood in their circulation
and adult females have about nine pints. The donor's body replenishes
the fluid lost from donation in about 24 hours. The red blood
cells that are lost are generally replaced in a few weeks. Whole
blood can be donated once every eight weeks.
The Deferral Process
Individuals disqualified from donating blood are known as “deferred”
donors. A prospective donor may be deferred at any point during
the collection and testing process. Whether or not a person is
deferred temporarily or permanently will depend on the specific
reason for disqualification (e.g., a person may be deferred temporarily
because of anemia, a condition that is usually reversible). If
a person is to be deferred, his or her name is entered into a
list of deferred donors maintained by the blood center, often
known as the “deferral registry.” If a deferred donor
attempts to give blood before the end of the deferral period,
the donor will not be accepted for donation. Once the reason for
the deferral no longer exists and the temporary deferral period
has lapsed, the donor may return to the blood bank and be re-entered
into the system.
05/03
Top
WHOLE BLOOD AND BLOOD COMPONENTS
Background
Blood may be transfused as whole blood or as one of its components.
Because patients seldom require all of the components of whole
blood, it makes sense to transfuse only that portion needed by
the patient for a specific condition or disease. This treatment,
referred to as “blood component therapy,” allows several
patients to benefit from one unit of donated whole blood. Blood
components include red blood cells, plasma, platelets, and cryoprecipitated
antihemophilic factor (AHF). Up to four components may be derived
from one unit of blood.
Whole blood is a living tissue that
circulates through the heart, arteries, veins, and capillaries
carrying nourishment, electrolytes, hormones, vitamins, antibodies,
heat, and oxygen to the body's tissues. Whole blood contains red
blood cells, white blood cells, and platelets suspended in a fluid
called plasma.
If blood is treated to prevent clotting and permitted to stand
in a container, the red blood cells, which weigh more than the
other components, will settle to the bottom; the plasma will stay
on top; and the white blood cells and platelets will remain suspended
between the plasma and the red blood cells. A centrifuge may be
used to hasten this separation process. The platelet-rich plasma
is then removed and placed into a sterile bag, and it can be used
to prepare platelets and plasma or cryoprecipitated AHF. To obtain
platelets, the platelet-rich plasma is centrifuged, causing the
platelets to settle at the bottom of the bag. Plasma and platelets
are then separated and made available for transfusion. The plasma
also may be pooled with plasma from other donors and further processed,
or fractionated, to provide purified plasma proteins such as albumin,
immunoglobulin (IVIG), and clotting factors.
Red blood cells are perhaps the most
recognizable component of whole blood. Red blood cells contain
hemoglobin, a complex iron-containing protein that carries oxygen
throughout the body and gives blood its red color. The percentage
of blood volume composed of red blood cells is called the “hematocrit.”
The average hematocrit in an adult male is 47 percent. There are
about one billion red blood cells in two to three drops of blood,
and, for every 600 red blood cells, there are about 40 platelets
and one white cell. Manufactured in the bone marrow, red blood
cells are continuously being produced and broken down. They live
for approximately 120 days in the circulatory system and are eventually
removed by the spleen.
Red blood cells are prepared from whole blood by removing the
plasma, or the liquid portion of the blood. They can raise the
patient's hematocrit and hemoglobin levels while minimizing an
increase in volume.
Patients who benefit most from transfusions of red blood cells
include those with chronic anemia resulting from disorders such
as kidney failure, malignancy, or gastrointestinal bleeding and
those with acute blood loss resulting from trauma or surgery.
Since red blood cells have reduced amounts of plasma, they are
well suited for treating anemia patients who have congestive heart
failure or who are elderly or debilitated; these patients might
not tolerate the increased volume provided by whole blood.
Improvements in cell preservative solutions over the last 15
years have increased the shelf life of red blood cells from 21
to 42 days. Red blood cells may be treated and frozen for extended
storage (up to 10 years).
Plasma is the liquid portion of the
blood — a protein-salt solution in which red and white blood
cells and platelets are suspended. Plasma, which is 90 percent
water, constitutes about 55 percent of blood volume. Plasma contains
albumin (the chief protein constituent), fibrinogen
(responsible, in part, for the clotting of blood), globulins
(including antibodies), and other clotting proteins.
Plasma serves a variety of functions, from maintaining a satisfactory
blood pressure and volume to supplying critical proteins for blood
clotting and immunity. It also serves as the medium of exchange
for vital minerals such as sodium and potassium, thus helping
maintain a proper balance in the body, which is critical to cell
function. Plasma is obtained by separating the liquid portion
of blood from the cells. Plasma is usually not used for transfusion
purpose but is fractionated (separated) into specific products
such as albumin, specific clotting factor concentrates and IVIG
(intravenous immune globulin).
Fresh frozen plasma is plasma frozen within hours after donation
in order to preserve clotting factors, stored for one to seven
years, and thawed before it is transfused. It is most often used
to treat certain bleeding disorders, when a clotting factor or
multiple factors are deficient and no factor-specific concentrate
is available. It also can be used for plasma replacement via a
process called plasma exchange.
Cryoprecipitated AHF is the portion
of plasma that is rich in certain clotting factors, including
Factor VIII, fibrinogen, von Willebrand factor, and Factor XIII.
Cryoprecipitated AHF is removed from plasma by freezing and then
slowly thawing the plasma. It is used to prevent or control bleeding
in individuals with hemophilia and von Willebrand’s disease,
which are common, inherited major coagulation abnormalities. Its
use in these conditions is reserved for times when viral-inactivated
concentrates containing Factor VIII and von Willebrand factor
are unavailable and plasma components must be used. It may also
be used as hemostatic preparation [fibrin sealant or fibrin glue]
in surgery.
Platelets (or thrombocytes) are very
small cellular components of blood that help the clotting process
by sticking to the lining of blood vessels. Platelets are made
in the bone marrow and survive in the circulatory system for an
average of 9–10 days before being removed from the body
by the spleen. The platelet is vital to life, because it helps
prevent massive blood loss resulting from trauma, as well as blood
vessel leakage that would otherwise occur in the course of normal,
day-to-day activity. Units of platelets are prepared by using
a centrifuge to separate the platelet-rich plasma from the donated
unit of whole blood. The platelet-rich plasma is then centrifuged
again to concentrate the platelets further.
Platelets also may be obtained from a donor by a process known
as apheresis, or plateletpheresis. In this process, blood is drawn
from the donor into an apheresis instrument, which, using centrifugation,
separates the blood into its components, retains the platelets,
and returns the remainder of the blood to the donor. The resulting
component contains about six times as many platelets as a unit
of platelets obtained from whole blood. Platelets are used to
treat a condition called thrombocytopenia, in which there is a
shortage of platelets, and in patients with abnormal platelet
function. Platelets are stored at room temperature for up to five
days.
White blood cells are responsible
for protecting the body from invasion by foreign substances such
as bacteria, fungi, and viruses. The majority of white blood cells
are produced in the bone marrow, where they outnumber red blood
cells by two to one. However, in the blood stream, there are about
600 red blood cells for every white blood cell. There are several
types of white blood cells; Granulocytes and macrophages protect
against infection by surrounding and destroying invading bacteria
and viruses, and lymphocytes aid in immune defense.
Granulocytes can be collected by apheresis or by centrifugation
of whole blood. They are transfused within 24 hours after collection
and are used for infections that are unresponsive to antibiotic
therapy. The effectiveness of white blood cell transfusion is
still being investigated.
Plasma derivatives are concentrates
of specific plasma proteins that are prepared from pools (many
units) of plasma. Plasma derivatives are obtained through a process,
known as fractionation, developed during World War II, and are
heat-treated and/or solvent detergent-treated to kill certain
viruses, including HIV and hepatitis B and C. Plasma derivatives
include:
- Factor VIII Concentrate
- Factor IX Concentrate
- Anti-Inhibitor Coagulation Complex (AICC)
- Albumin
- Immune Globulins, including Rh Immune Globulin
- Anti-Thrombin III Concentrate
- Alpha 1-Proteinase Inhibitor Concentrate
05/03
Top
AUTOLOGOUS (self-donated) BLOOD
AS AN ALTERNATIVE
TO ALLOGENEIC (donor-donated) BLOOD TRANSFUSION
“Autologous” transfusions refer
to those transfusions in which the blood donor and transfusion
recipient are the same.
“Allogeneic” transfusions refer
to blood transfused to someone other than the donor.
Preoperative Donation
The most common autologous donation is the preoperative donation
of blood for possible transfusion back to the donor during elective
surgery. For example, a person might give one unit of blood each
week for up to six weeks before surgery, because blood can be
stored in its liquid form for up to 42 days. Patients can make
autologous donations up until 72 hours prior to their surgery.
This is to allow the body enough time to replenish its blood supply
before the surgical procedure.
A significant amount of iron is removed with each autologous
donation. When appropriate, iron supplements are prescribed for
patients making autologous donations in order to help increase
red blood cell count.
Autologous donation is most often employed in surgery on bones,
blood vessels, the urinary tract, and the heart, when the likelihood
of transfusion is high. According to the National Blood Data Resource
Center, autologous blood accounted for 4.7 percent of all donated
blood in 1999. Potential autologous blood donors are medically
stable patients who are free of infection. There is no age limitation
for autologous donation. Many children and elderly patients have
successfully completed autologous donations; however, some patients
may not be good candidates. The physician and patient should make
the decision regarding autologous donation and transfusion jointly.
The process of donating autologous blood stimulates the bone
marrow to produce new blood cells. Given adequate time for recovery,
the collected cells may be wholly or partially replaced prior
to surgery.
If blood loss during surgery is less than anticipated, transfusion
of autologous blood may not be medically necessary. Although the
risk of a complication from autologous blood is low, some residual
risk persists, making automatic transfusion of autologous units
unwise. Forty-four percent of autologous donations are unused
by the autologous donor. These units generally are discarded because
current standards do not allow transfusion of these units to another
patient for safety reasons. In emergency situations, however,
these units may be used for another patient provided there is
medical approval for the crossover and the unit has been fully
screened. Due to the special handling and separate storage requirements,
autologous donations cost more to process.
Blood Dilution (Hemodilution)
Blood dilution, or hemodilution, is the removal of one or more
units of blood just before surgery for transfusion to the patient
during or at the end of the operation. Hemodilution is used to
decrease the loss of red blood cells during surgery. In this procedure,
blood is drawn from a patient prior to surgery, and the patient
is immediately given intravenous fluids to compensate for the
amount of blood removed. Since the number of red blood cells in
the person's circulatory system will have been diluted, fewer
red blood cells will be lost from bleeding during the operation.
After surgery, the patient’s own blood is reinfused. However,
the patient must be able to accommodate the anemia that the procedure
causes.
Perioperative Blood Collection
In perioperative blood collection, blood lost by the patient
during surgery is recovered and recycled throughout the surgery.
Most perioperative blood collection programs use machines in which
shed blood is collected and the red blood cells are concentrated
and washed prior to transfusion. This procedure is widely used
for surgical procedures, such as cardiac, vascular, orthopedic,
urologic, trauma, gynecologic, and transplant surgery, in which
the anticipated blood loss is 20 percent or more of the patient's
estimated blood volume and there is no contamination of the area
by bacteria or cancer cells. This procedure is generally not used
in cancer surgery or surgery of the lower gastrointestinal tract.
Postoperative Blood Collection
In postoperative blood collection, blood that is lost in the
early postoperative period is collected from a drainage tube at
the surgical site and transfused to the patient, either washed
or unwashed. Postoperative collection is used primarily in cardiac
and orthopedic surgery. In most cases, though, the volume of salvaged
red cells is small.
05/03
Top
TESTING OF DONOR BLOOD FOR INFECTIOUS
DISEASE
The AABB and its members are committed to ensuring a safe blood
supply for everyone who may need transfusions. An important step
in ensuring safety is the screening of donated blood for infectious
diseases. Today, nine tests for infectious diseases are conducted
on each unit of donated blood. Tests for hepatitis B and syphilis
were in place before 1985. Since then, tests for human immunodeficiency
virus (HIV-1 and HIV-2), human T-lymphotropic virus (HTLV-I and
-II) and the hepatitis C virus (HCV) have been added. The following
tests are performed on each unit of blood:
Hepatitis B Surface Antigen (HBsAg)
The hepatitis B virus, which mainly infects the liver, has an
inner core and an outer envelope (the surface). The HBsAg test
detects the outer envelope, identifying an individual infected
with the hepatitis B virus. Hepatitis B can cause inflammation
of the liver, and in the earliest stage of the disease, infected
people may feel ill or even have yellow discoloration of the skin
or eyes, a condition known as jaundice.
Fortunately, most patients recover completely and test negative
for HBsAg within a few months after the illness. A small percentage
of people become chronic carriers of the virus, and in these cases,
the test may remain positive for years. Chronically infected people
can develop severe liver disease as time passes, and need to be
followed carefully by an experienced doctor.
Antibodies to the Hepatitis B Core (Anti-HBc)
The anti-HBc test detects an antibody to the hepatitis B virus
that is produced during and after infection. If an individual
has a positive anti-HBc test, but the HBsAg test is negative,
it may mean that the person once had hepatitis B, but has recovered
from the infection. Of the individuals with a positive test for
anti-HBc, many have not been exposed to the hepatitis B virus.
This kind of test result is called a false positive,
and although the individual may be permanently deferred from donating
blood, it is unlikely that the person’s health will be negatively
affected. (Note: This antibody is not produced following vaccination
against hepatitis B. Hepatitis B vaccination, by itself, will
rarely cause the HbsAg test to be positive for a few days after
the shots.)
Antibodies to the Hepatitis C Virus (Anti-HCV)
This test is used to screen donors for the hepatitis C virus
(HCV). It works by detecting antibodies manufactured by the body
in reaction to portions of the virus called antigens.
HCV causes inflammation of the liver, and up to 80 percent of
those exposed to the virus develop chronic infection. Eventually,
up to 20 percent of people with HCV may develop cirrhosis of the
liver or other severe liver diseases. As in other forms of hepatitis,
individuals may be infected with the virus, but may not realize
they are carriers since they do not have any symptoms. Because
of the risk of serious illness, people with HCV need to be followed
closely by a physician with experience evaluating this infection.
Antibodies to the Human Immunodeficiency Virus, Types
1 and 2 (Anti-HIV-1, -2)
This test is designed to detect antibodies directed against
antigens of the HIV-1 or HIV-2 viruses. HIV-1 is much more common
in the United States, while HIV-2 is prevalent in Western Africa.
Donors are tested for both viruses because both are transmitted
by infected blood, and a few cases of HIV-2 have been identified
in US residents. Both of these viruses can cause acquired immunodeficiency
syndrome, or AIDS.
Antibodies to Human T-Lymphotropic Virus, Types I and
II (Anti-HTLV-I, -II)
This test screens for antibodies directed against portions of
the HTLV-I and HTLV-II viruses. Both of these viruses are relatively
uncommon in the United States, but do occur more frequently in
certain populations. HTLV-I is more common in Japan and the Caribbean.
The infection can persist for a lifetime, but rarely causes major
illnesses in most people who are infected. In rare instances,
the virus may, after many years of infection, cause nervous system
disease or an unusual type of leukemia. HTLV-II infections are
usually associated with intravenous drug usage, especially among
people who share needles or syringes. Disease associations with
HTLV-II have been hard to confirm, but the virus may cause subtle
abnormalities of immunity that lead to frequent infections, or
rare cases of neurological disease.
Syphilis
This test is done to detect evidence of infection with the spirochete
that causes syphilis. Blood centers began testing for this shortly
after World War II, when syphilis rates in the general population
were much higher. The risk of transmitting syphilis through a
blood transfusion is exceedingly small (no cases have been recognized
in this country for many years) because the infection is very
rare in blood donors, and because the spirochete is fragile and
unlikely to survive blood storage conditions.
Nucleic Acid Amplification Testing (NAT)
NAT employs testing technology that directly detects the genetic
material of viruses. Because NAT detects a virus’s genetic
material — instead of waiting for the body’s response,
the formation of antibodies, as with many current tests —
it offers the opportunity to reduce the window period during which
an infecting agent is undetectable by traditional tests, thus
further improving blood safety.
NAT is being used to detect HIV-1 and HCV, and this technology
is under investigation for detecting other infectious disease
agents.
Confirmatory Testing
All of the above tests are referred to as screening
tests, and are designed to detect as many infections
as possible. Because these tests are so sensitive, some donors
may have a false positive result, even when the donor was never
exposed to the particular infection. In order to sort out true
infections from false positive test results, screening tests that
are reactive may be followed up with more specific tests called
confirmatory tests. Thus, confirmatory
tests help determine whether a donor is truly infected.
If the test result from a donated unit of blood is abnormal
for any of these disease markers, the unit is discarded and the
donor is notified. The donor’s name is then added to a donor
deferral list and is prohibited from donating blood indefinitely.
05/03
Top
TRANSFUSION-TRANSMITTED DISEASES
Viruses
Cytomegalovirus (CMV)
Cytomegalovirus (CMV) is a virus belonging to the herpes group
that is rarely transmitted by blood transfusion. According to
the Centers for Disease Control and Prevention (CDC), about 50
to 85 percent of adults in the United States are infected with
CMV by the age of 40. CMV infection is usually mild, but it may
be serious or fatal in those who are immunocompromised. Particularly
at risk are low-birth weight infants and bone marrow and organ
transplant patients. If a patient is at high risk of getting CMV
diseases, blood that tests negative for CMV can be transfused.
Alternatively, blood that has been filtered to decrease the number
of white blood cells — the cells that carry CMV —
will protect patients from getting a CMV infection from transfusion.
Hepatitis
Hepatitis was the first documented transfusion-transmitted disease.
Many of the current practices for diminishing risk in transfusion
medicine are based on the experiences of controlling the transmission
of hepatitis.
Hepatitis viruses, which infect the liver, fall primarily into
two groups: viruses with a chronic course that can readily be
transmitted by blood transfusion (hepatitis B and C) and viruses
that cause only acute disease and are rarely transmitted by transfusion
(hepatitis A and E).
Hepatitis A Virus (HAV)
Hepatitis A (HAV) infection is rarely transmitted through blood
transfusion; it is usually spread by contaminated food and water.
About 23,000 cases are reported annually in the US, but epidemiologists
estimate that the virus infects 150,000 Americans each year. Hepatitis
A is very prevalent in the developing world, including Mexico
and parts of the Caribbean. Because HAV antibodies are present
in approximately 20 percent of the population, many with no history
of hepatitis, it is assumed that many people experience unrecognized
infection. There have been occasional reports in the US of transfusion-transmitted
HAV, but little can be done to prevent this rare occurrence. A
vaccine recently developed for HAV has replaced immune globulin
as a pre-exposure prophylactic measure for people at a high risk
for acquiring this infection, although the latter remains useful
after exposure.
Hepatitis B Virus (HBV)
Transmission of hepatitis B virus (HBV) is rare because of routine
testing of blood for the HBsAg and hepatitis B core antibody,
donor screening and deferral for risk of HBV infection, and the
use of only altruistic volunteer blood donors. HBV is a major
cause of acute and chronic hepatitis. Each year in the US, an
estimated 300,000 persons are infected with HBV. More than 10,000
patients require hospitalization, and an average of 350 die from
the disease. There is an estimated pool of 750,000–1,000,000
chronically infected HBV carriers in the US. Approximately 25
percent of carriers have active hepatitis that can progress to
cirrhosis of the liver. An estimated 4,000 people die each year
from hepatitis B-related cirrhosis, and more than 800 die from
hepatitis B-related liver cancer. The number of HBV infections
in the US is falling because hepatitis B vaccinations of health
care professionals and school-age children has become nearly universal.
Screening blood donors for HBV began in 1969 and became mandatory
in 1972. By the mid-1970s, testing and an all-volunteer blood
donor supply reduced the rate of post-transfusion hepatitis B
to between 0.3 and 0.9 percent. From 1982 to 1985, an average
of 3.0 percent of hepatitis B cases in the US were related to
blood transfusion. During the period from 1986 to 1988, the percentage
of reported cases related to blood transfusion declined to 1.0
percent, possibly as a consequence of the donor screening questions
that were instituted to identify persons at increased risk for
HIV infection. In 2000, the frequency of post-transfusion hepatitis
B developing after a blood transfusion was estimated at perhaps
1 in 137,000 screened units of blood.
Hepatitis C Virus (HCV)
Hepatitis C, formerly known as non-A, non-B hepatitis, was discovered
in the late 1980s, and all blood donations have been screened
for it since 1990. Acute hepatitis C virus (HCV) is a relatively
mild infection, and most people are unaware they have become infected;
however, HCV becomes chronic in 80 percent of those infected.
In the general population, 1.8 percent of the population has some
evidence of HCV-infection. While the rate of new HCV infections
is falling rapidly due to behavior changes and blood screening,
HCV is an important source of serious chronic liver disease, which
often develops decades after the initial exposure to the virus.
Antibody screening was started in 1990, and the test has undergone
significant improvement since. In 1999, NAT testing was added
in the US. After more than 10 years of testing for HCV, the risk
of HCV transmission through transfusion is less than 1 per 1,000,000-screened
units of blood.
HIV (Human Immunodeficiency Virus)
Transfusion transmission of HIV, the virus that causes AIDS,
has been almost completely eradicated, since blood banks began
interviewing donors about at-risk behaviors and a blood test became
available in early 1985. The HIV antibody tests, used on every
blood donation since then, have undergone continuous improvement.
Starting in 1999 nucleic acid amplification testing (NAT) has
been used to directly detect the genetic material of the HIV virus
in blood, and current estimates are that fewer than 1 in 1,900,000
blood components is capable of transmitting HIV. Transfusion medicine
specialists are continually researching new technologies to further
reduce the transmission of HIV. Examples of technologies on the
horizon include methods to kill viruses in donated blood (called
viral inactivation) and blood component substitutes.
Human T Lymphotropic Virus I, -II (HTLV-I, -II)
HTLV-I and -II are viruses that are not related to HIV. HTLV-I
is found mainly in Southwestern Japan and Caribbean islands. The
viruses can cause blood or nervous system diseases in a small
number of infected people (less than 5 percent lifetime risk).
HTLV-II is endemic in the Americas (including the US), and also
may infrequently cause slightly increased susceptibility to infections.
Both of these viruses, although rare, were found in the US blood
donor population in the 1980s. Few people have gotten HTLV as
a result of transfusion, but because of the small transfusion
risk that existed in the 1980s, tests to detect HTLV-I antibodies
were developed and quickly implemented; these tests also detected
many, but not all, HTLV-II infections. Tests specifically designed
to detect both viruses are now available and are used by blood
centers to screen every donation.
West Nile virus (WNV)
West Nile virus (WNV) is spread by the bite of an infected mosquito.
The virus can infect people, horses, many types of birds, and
some other animals.
WNV was first detected in the United States in 1999 and has
since been detected in many parts of the US. The first documented
cases of WNV transmission through organ transplantation and transfusion
were noted in 2002. The most common symptoms of transfusion-transmitted
cases of WNV were fever and headache.
The preclinical incubation period is thought to range from 2
to14 days following a bite from an infected mosquito. Approximately
80% of people infected with WNV remain without symptoms, while
20% develop mild symptoms, including fever, headache, eye pain,
body aches, gastrointestinal complaints, and occasionally a generalized
rash or swollen lymph nodes. One in 150 to 200 persons infected
with WNV develops a more severe form of the disease that may be
fatal.
FDA is allowing national deployment of investigational nucleic
acid tests (NAT) to screen blood for West Nile virus (WNV), until
FDA-licensed tests become available. Blood centers have implemented
precautionary measures to protect the blood supply from WNV, including
stockpiling frozen blood components before the start of mosquito
season.
Because WNV can be transmitted through a blood transfusion,
potential donors will be asked orally or in writing about history
of fever and headache. A blood collection facility must implement
the questioning of all donors by June 1 of each year and continue
until November 30, or until there have been two consecutive weeks
without any report of human WNV infection in the state in which
the facility is located. Blood centers may decide to begin questioning
earlier than June 1 in areas where they are aware of reports of
epizootic (epidemic among wild animals) activity or human transmission
of WNV. Depending on an individual’s response to questioning,
that individual may be requested not to donate blood for an interval
of time called a deferral period. That person is said to be “deferred.”
Although there are limited data on the natural course of WNV
infection, the deferral periods recommended are based on the longest
known viremic period (the length of time a virus remains in the
blood stream), with an extra safety margin added.
Who will be deferred?
- A potential donor who has been diagnosed with WNV infection
(including diagnoses based on symptoms and laboratory results)
will be deferred for 28 days from the onset of symptoms or until
the patient has been without symptoms for 14 days.
- A potential donor who responds positively to the question:
“In the past week, have you had a fever with headache?”
will be deferred for 28 days.
- A donor whose blood or components potentially were associated
with a transfusion-related WNV transmission will be deferred
28 days from the date of the implicated donation.
Donors are encouraged to report unexplained post-donation febrile
illness with headache or other symptoms suggestive of WNV infection
that occur within one week after blood donation.
The following CDC Web site may be helpful: www.cdc.gov/ncidod/dvbid/westnile/city_states.htm.
Parasitic Infections
Babesiosis
Babesiosis is a parasitic infection carried by
the white-footed mouse and transmitted by tick bites. It appears
primarily in the northeastern US, in coastal areas that are home
to the white-footed mouse. Cases also have been identified in
the Upper Midwest and Pacific Northwest. About 30 transfusion-associated
cases have been reported in the US. While babesiosis is often
quite mild, some patients, including those without a spleen, the
elderly, or the immunocompromised, may be at risk of serious illness.
There are no useful tests available for screening blood donors,
although testing strategies are being developed and discussed.
The AABB requires that all donors be asked if they have a history
of babesiosis. Those individuals with a history of the disease
are permanently deferred from donating blood.
Chagas’ Disease
A Brazilian doctor, Carlos Chagas, discovered Chagas’
disease almost 100 years ago. This disease is caused by a parasite
that infects as many as 18 million people worldwide. Once infection
is established, it is life-long. Each year, several thousand South
and Central Americans die of heart and digestive problems caused
by the disease. Up to 20 percent of infected people never exhibit
symptoms. This infection is rare in the US, but because of recent
global population shifts, individuals from countries where this
disease is common now reside in the US. To date, there have been
only five cases of transfusion-transmitted Chagas’ disease
reported in North America. The AABB requires that blood centers
permanently prohibit blood donation from anyone who has had Chagas’
disease, and tests are being developed and screening strategies
discussed.
Lyme Disease
Although transfusion-related cases have not been
reported, public health agencies and the AABB are monitoring this
disease because of the remote chance that it could affect transfusion
safety. Lyme disease is associated with the bite of certain species
of the deer tick, and can cause an illness that affects many systems
within the body. Donors with a history of Lyme disease can donate,
provided they have undergone a full course of antibiotic treatment
and no longer have any symptoms.
Malaria
Between 1958 and 1998, the CDC recorded 103 cases
of transfusion-transmitted malaria. These cases were most likely
caused by donations from people who felt well and were not aware
that they were carrying malaria. Although exceedingly rare in
the US, malaria can cause serious consequences, including fatalities.
There is no practical test available to screen donors so AABB
requires blood centers to temporarily defer blood donations from
people who have visited malarial areas in the past year or who
emigrated from a malarial area within the past three years.
05/03
CREUTZFELDT-JAKOB DISEASE (CJD)
CJD is a rare degenerative and fatal nervous system disorder.
It is diagnosed in about one person per million per year in the
US and worldwide. There are three forms of CJD that can affect
humans: sporadic CJD has no known risk factors and accounts for
85 percent of CJD cases; hereditary CJD occurs only in individuals
with a family history of the disease and/or tests positive for
specific genetic mutations; and acquired CJD is transmitted by
exposure to brain or nervous system tissue. Acquired CJD accounts
for less than 1 percent of CJD cases and can occur in individuals
who have received injections of human pituitary gland growth hormone,
or who have had their brain’s outer lining (dura mater)
repaired with dura mater from someone else who had CJD.
Individuals who will develop CJD can remain without symptoms
for decades and then progress rapidly to dementia, severe loss
of coordination and death. Scientists believe abnormal brain proteins
that have undergone a peculiar shape change can cause other brain
proteins to do the same and cause CJD.
Currently, there is no screening test for the disease, and while
blood transfusions have never been shown to transmit any form
of the disease, as a precaution the Food and Drug Administration
(FDA) prohibits blood donation by individuals who may be at risk.
These include potential donors who have received injections of
human-derived pituitary hormone, those with a family history of
CJD, or those who have had surgeries that involved transplanted
dura mater.
variant Creutzfeldt-Jakob disease (vCJD)
Similar to CJD, vCJD, commonly known as the human form of “mad
cow” disease, is a rare degenerative and fatal nervous system
disorder. There is reason to believe that vCJD occurs when humans
eat beef contaminated with bovine spongiform encephalopathy (BSE
or “mad cow”). This new form of CJD has appeared in
residents of the United Kingdom, France, and a single individual
in Hong Kong. There have been no cases of vCJD infection in humans
in the US. Currently, there is no screening
test in humans for the disease.
Even though there is no evidence that vCJD has ever been transmitted
through a blood transfusion, the FDA requires donor deferral policies
for anyone who potentially could have been exposed to the disease,
by eating contaminated beef products in areas of the world where
BSE has been found. These policies are changing as we learn more
about vCJD and BSE.
The FDA recommends that the following donors be deferred
indefinitely due to vCJD risk:
- Donors who spent a total of three months or more in the United
Kingdom (UK) from the beginning of 1980 through the end of 1996;
- Donors who have spent a total of five years or more in France
from 1980 to the present;
- Current or former US military personnel, civilian military
employees and their dependents who resided at US military bases
in Northern Europe (Germany, UK, Belgium, and the Netherlands)
for a total of six months or more from 1980 through 1990, or
elsewhere in Europe (Greece, Turkey, Spain, Portugal, and Italy)
from 1980 through 1996.
- Donors who have received any blood or blood component transfusions
in the UK between 1980 and the present;
- Whole blood, but not source plasma, donors, who have lived
cumulatively for five years or more in Europe from 1980 to the
present, (which includes the aforementioned deferral periods
applied to the UK and France). Unless deemed unsuitable for
other reasons, these donors, although deferred from whole blood
collection, remain eligible to serve as source plasma donors;
- Donors who have injected bovine insulin since 1980, unless
it is possible to obtain confirmation that the product was not
manufactured after 1980 from cattle in the UK.
Other organizations have slightly different policies
summarized here:
Department of Defense (DoD)
The DoD implemented its set of donor deferral rules in October
2001. All active-duty military personnel, civil service employees,
and these two groups’ family members will be deferred indefinitely
due to vCJD risk if they are:
- Donors who traveled or resided in the UK for a cumulative
total of three months or more at any time from 1980 through
the end of 1996;
- Donors who have received a blood transfusion in the UK at
any time from 1980 to the present;
- Donors who have traveled to or resided anywhere in Europe
for a cumulative total of six months or more at any time from
1980 through the end of 1996;
- Donors who traveled to or resided anywhere in Europe for
a cumulative total of five years or more at any time from Jan.
1, 1997, to the present.
American Red Cross (ARC)
The ARC implemented its set of donor deferral rules in September
2001. Donors will be indefinitely deferred if, since 1980 they
:
- Spent a total time of three months or more in any of these
countries: England, Scotland, Wales, Northern Ireland, Isle
of Man, Falkland Islands, Gibraltar, Channel Islands, or
- Spent a total time of six months or more in any combination
of these countries: Albania, Andorra, Austria, Azores, Belarus,
Belgium, Boznia/Herzegovina, Bulgaria, Channel Islands, Croatia,
Czech Republic, Denmark, England, Estonia, Falkland Islands,
Faroe Island, Finland, France, Germany, Gibraltar, Greece, Greenland,
Hungary, Iceland, Ireland (Republic of), Isle of Man, Italy,
Latvia, Liechtenstein, Lithuania, Luxembourg, Macedonia, Madeira
Islands, Malta, Moldova, Monaco, Netherlands (Holland), Northern
Ireland, Norway, Oman, Poland, Portugal, Romania, San Marino,
Scotland, Slovak Republic (Slovakia), Slovenia, Spain, Svalbard,
Sweden, Switzerland, Turkey, Ukraine, Vatican City, Wales, Yugoslavia
(includes Kosovo, Montenegro and Serbia)
- Received blood transfusions in the UK.
SARS (SEVERE ACUTE RESPIRATORY SYNDROME)
Severe acute respiratory syndrome — or SARS — is
a respiratory infection that can develop serious complications.
Most of the cases identified have been in Asia, but there have
been cases in other countries, including the United States and
Canada.
There has been no evidence this infection is transmitted from
blood donors to transfusion recipients, but the virus associated
with SARS is present in the blood of people who are sick, and
it is possible that the virus could be present in blood immediately
before a person gets sick, so that an individual with infection
but no symptoms possibly could transmit SARS through a blood donation.
To help determine whether or not an individual might be infected
with SARS, a blood collection facility will ask a potential donor
orally or in writing about any travel to a SARS-affected country
or a history of SARS or possible exposure to SARS.
Because the risk of contracting SARS through a blood transfusion
theoretically exists, anyone who might be at risk of being infected
with SARS is requested not to donate blood for an interval of
time called a deferral period. The individual is said to be “deferred.”
Who will be deferred?
- Anyone who has traveled or lived in a SARS-affected area*,
will be deferred from making a donation for a period of 14 days
after arrival in the United States.
- Anyone who has had close contact with a person with SARS
or suspected SARS, will be deferred for 14 days after the last
exposure to that individual. Close contact is defined as having
cared for, having lived with, or having had direct contact with
respiratory secretions and/or body fluids of a person known
to have, or to have had, SARS or suspected of having, or having
had, the illness.
- Anyone who has been ill with SARS or suspected SARS, will
be deferred for 28 days from the last date of treatment AND
the last date that the individual had symptoms.
Please note that as long as a donor is and remains well, no
other measures are necessary. If a donor becomes ill with fever
of 100.4o F accompanied by cough or trouble breathing,
that person should see a doctor. Also, any donor who develops
a fever in the 14 days after making a donation should call the
blood center.
- Information about the definition of SARS cases and the
identification of SARS-affected areas are updated regularly.
This information is posted on the CDC web site http://www.cdc.gov/ncidod/sars/casedefinition.htm
or may be obtained by calling the CDC at (888)246-2675, 8 am
–11 pm weekdays, 10 am – 8 pm weekends. Information is also posted in the AABB “Pressroom.”
SMALLPOX
Due to concern that terrorists may have access to the smallpox
virus and attempt to use it against the American public, the U.S.
Department of Health and Human Services (HHS) has been working,
in cooperation with state and local governments, to strengthen
our preparedness for bioterror attacks, by expanding the national
stockpile of smallpox vaccine. The vaccine, which was routinely
administered to Americans until 1972, is a highly effective protection
against smallpox when given before or shortly after exposure to
the virus. Vaccinia is the live virus used in smallpox vaccinations.
It is possible that until the vaccination scab spontaneously
separates from the skin, recipients of the vaccinia virus could
inadvertently infect close contacts who touch the vaccination
site or dressing. The scabs themselves contain infectious virus.
In an effort to ensure that the virus is not transmitted through
a blood donation, potential donors will be asked by blood collection
facilities about history of vaccination or close contact with
anyone who has been vaccinated. A vaccine recipient who has had
no complications may donate after the vaccination scab has spontaneously
separated, or 21 days after vaccination, whichever is the later
date. Some individuals who have received a smallpox vaccination
may be requested not to donate for an interval of time called
a deferral period. Those persons are said to be “deferred.”
Who will be deferred:
- A vaccine recipient whose scab was pulled off or knocked off,
and did not spontaneously separate, will be deferred for two
months after the date of vaccination.
- A vaccine recipient who has experienced complications will
be deferred for 14 days after all vaccine complications are
completely gone.
- If a potential donor has had close contact (defined as physical
intimacy, touching the vaccination site, touching the bandages
or covering of the vaccination site, or handling bedding or
clothing that had been in contact with an unbandaged vaccination
site) with a vaccine recipient and has developed localized skin
lesions without any other symptoms or complications, blood collection
facility personnel will visually verify the absence of a scab.
- If a scab spontaneously separated and is no longer present,
there will be no deferral.
- If a scab was otherwise removed, the donor will be deferred
for three months from the date when the contact (that is
the vaccine recipient) was vaccinated.
- If the date when the contact received the vaccination is
unknown, the potential donor will be deferred for two months
from the time of the interview.
- If a potential donor has had contact with a vaccine recipient
who has had complications, the donor will be deferred for 14
days from the time that all vaccine complications are gone.
- If a potential donor has had contact with a vaccine recipient
who has had no symptoms, the donor will not be deferred and
may make a donation.
The primary concern with the vaccination scab is to ensure that
it is healed, not necessarily how it came off. It is possible
to contract smallpox from the vaccination site until the scab
is fully healed, which generally occurs when the scab spontaneously
separates, or drops off, the skin, usually before 21 days have
elapsed. Healing is considered complete when there is no scab,
oozing or discharge, bleeding, or opening. Healing is evidenced
by pink, uninterrupted skin at the inoculation site.
An individual who wants to receive a smallpox vaccination and
who also wishes to donate blood may want to consider scheduling
the blood donation before the vaccination.
01/04
Top
HIGHLIGHTS OF TRANSFUSION MEDICINE
HISTORY
1628 English physician William Harvey discovers
the circulation of blood. Shortly afterward, the earliest known
blood transfusion is attempted.
1665 The first recorded successful blood transfusion
occurs in England: Physician Richard Lower keeps dogs alive by
transfusion of blood from other dogs.
1667 Jean-Baptiste Denis in France and Richard
Lower in England separately report successful transfusions from
lambs to humans. Within 10 years, transfusing the blood of animals
to humans becomes prohibited by law because of reactions.
1795 In Philadelphia, American physician Philip
Syng Physick, performs the first human blood transfusion, although
he does not publish this information.
1818 James Blundell, a British obstetrician,
performs the first successful transfusion of human blood to a
patient for the treatment of postpartum hemorrhage. Using the
patient's husband as a donor, he extracts approximately four ounces
of blood from the husband's arm and, using a syringe, successfully
transfuses the wife. Between 1825 and 1830, he performs 10 transfusions,
five of which prove beneficial to his patients, and publishes
these results. He also devises various instruments for performing
transfusions and proposed rational indications.
1840 At St. George's School in London, Samuel
Armstrong Lane, aided by consultant Dr. Blundell, performs the
first successful whole blood transfusion to treat hemophilia.
1867 English surgeon Joseph Lister uses antiseptics
to control infection during transfusions.
1873-1880 US physicians transfuse milk (from
cows, goats, and humans).
1884 Saline infusion replaces milk as a “blood
substitute” due to the increased frequency of adverse reactions
to milk.
1900 Karl Landsteiner, an Austrian physician,
discovers the first three human blood groups, A, B, and C. Blood
type C was later changed to O. His colleagues Alfred Decastello
and Adriano Sturli add AB, the fourth type, in 1902. Landsteiner
receives the Nobel Prize for Medicine for this discovery in 1930.
1907 Hektoen suggests that the safety of transfusion
might be improved by crossmatching blood between donors and patients
to exclude incompatible mixtures. Reuben Ottenberg performs the
first blood transfusion using blood typing and crossmatching in
New York. Ottenberg also observed the mendelian inheritance of
blood groups and recognized the “universal” utility
of group O donors.
1908 French surgeon Alexis Carrel devises a
way to prevent clotting by sewing the vein of the recipient directly
to the artery of the donor. This vein-to-vein or direct method,
known as anastomosis, is practiced by a number of physicians,
among them J.B. Murphy in Chicago and George Crile in Cleveland.
The procedure proves unfeasible for blood transfusions, but paves
the way for successful organ transplantation, for which Carrel
receives the Nobel Prize in 1912.
1908 Moreschi describes the antiglobulin reaction.
The antiglobulin is a direct way of visualizing an antigen-antibody
reaction that has taken place but is not directly visible. The
antigen and antibody react with each other, then, after washing
to remove any unbound antibody, the antiglobulin reagent is added
and binds between the antibody molecules that are stuck onto the
antigen. This makes the complex big enough to see.
1912 Roger Lee, a visiting physician at the
Massachusetts General Hospital, along with Paul Dudley White,
develops the Lee-White clotting time. Adding another important
discovery to the growing body of knowledge of transfusion medicine,
Lee demonstrates that it is safe to give group O blood to patients
of any blood group, and that blood from all groups can be given
to group AB patients. The terms "universal donor" and
"universal recipient" are coined.
1914 Long-term anticoagulants, among them sodium
citrate, are developed, allowing longer preservation of blood.
1915 At Mt. Sinai Hospital in New York, Richard
Lewisohn uses sodium citrate as an anticoagulant to transform
the transfusion procedure from direct to indirect. In addition,
Richard Weil demonstrates the feasibility of refrigerated storage
of such anticoagulated blood. Although this is a great advance
in transfusion medicine, it takes 10 years for sodium citrate
use to be accepted.
1916 Francis Rous and J.R.Turner introduce
a citrate-glucose solution that permits storage of blood for several
days after collection. Allowing for blood to be stored in containers
for later transfusion aids the transition from the vein-to-vein
method to indirect transfusion. This discovery also allows for
the establishment of the first blood depot by the British during
World War I. Oswald Robertson, an American Army officer, is credited
with creating the blood depots. Robertson received the AABB Landsteiner
Award in 1958 as developer of the first blood bank.
1927-1947 The MNSs and P systems are discovered.
MNSs and P are two more blood group antigen systems — just
as ABO is one system and Rh is another.
1932 The first blood bank is established in
a Leningrad hospital.
1937 Bernard Fantus, director of therapeutics
at the Cook County Hospital in Chicago, establishes the first
hospital blood bank in the United States. In creating a hospital
laboratory that can preserve and store donor blood, Fantus originates
the term "blood bank." Within a few years, hospital
and community blood banks begin to be established across the United
States. Some of the earliest are in San Francisco, New York, Miami,
and Cincinnati.
1939/40 The Rh blood group system is discovered
by Karl Landsteiner, Alex Wiener, Philip Levine, and R.E. Stetson
and is soon recognized as the cause of the majority of transfusion
reactions. Identification of the Rh factor takes its place next
to the discovery of ABO as one of the most important breakthroughs
in the field of blood banking.
1940 Edwin Cohn, a professor of biological
chemistry at Harvard Medical School, develops cold ethanol fractionation,
the process of breaking down plasma into components and products.
Albumin, a protein with powerful osmotic properties, plus gamma
globulin and fibrinogen are isolated and become available for
clinical use. John Elliott develops the first blood container,
a vacuum bottle extensively used by the Red Cross.
1940 The United States government establishes
a nationwide program for the collection of blood. Charles R. Drew
develops the “Plasma for Britain” program —
a pilot project to collect blood for shipment to the British Isles.
The American Red Cross participates, collecting 13 million units
of blood by the end of World War II.
1941 Isodor Ravdin, a prominent surgeon from
Philadelphia, effectively treats victims of the Pearl Harbor attack
with Cohn's albumin for shock. Injected into the blood stream,
albumin absorbs liquid from surrounding tissues, preventing blood
vessels from collapsing, a finding associated with shock.
1943 The introduction by J.F. Loutit and Patrick
L. Mollison of acid citrate dextrose (ACD) solution, which reduces
the volume of anticoagulant, permits transfusions of greater volumes
of blood and permits longer term storage.
1943 P. Beeson publishes the classic description
of transfusion-transmitted hepatitis.
1945 Coombs, Mourant, and Race describe the
use of antihuman globulin (later known as the “Coombs Test”)
to identify “incomplete” antibodies.
1947 The American Association of Blood Banks
(AABB) is formed to promote common goals among blood banking practitioners
and the blood donating public.
1949-1950 The US blood collection system includes
1,500 hospital blood banks, 46 community blood centers, and 31
American Red Cross regional blood centers.
1950 Audrey Smith reports the use of glycerol
cryoprotectant for freezing red blood cells.
1950 In one of the single most influential
technical developments in blood banking, Carl Walter and W.P.
Murphy, Jr., introduce the plastic bag for blood collection. Replacing
breakable glass bottles with durable plastic bags allows for the
evolution of a collection system capable of safe and easy preparation
of multiple blood components from a single unit of whole blood.
Development of the refrigerated centrifuge in 1953 further expedites
blood component therapy.
1953 The AABB Clearinghouse is established,
providing a centralized system for exchanging blood among blood
banks. Today, the Clearinghouse is called the National Blood Exchange.
Mid-1950s In response to the heightened demand
created by open-heart surgery and advances in trauma care patients,
blood use enters its most explosive growth period.
1957 The AABB forms its committee on Inspection
and Accreditation to monitor the implementation of standards for
blood banking.
1958 The AABB publishes its first edition of
Standards for a Blood Transfusion Service (now titled Standards
for Blood Banks and Transfusion Services).
1959 Max Perutz of Cambridge University deciphers
the molecular structure of hemoglobin, the molecule that transports
oxygen and gives red blood cells their color.
1960 The AABB begins publication of TRANSFUSION,
the first American journal wholly devoted to the science of blood
banking and transfusion technology. In this same year, A. Solomon
and J.L. Fahey report the first therapeutic plasmapheresis procedure
— a procedure that separates whole blood into plasma and
red blood cells.
1961 The role of platelet concentrates in reducing
mortality from hemorrhage in cancer patients is recognized.
1962 The first antihemophilic factor (AHF)
concentrate to treat coagulation disorders in hemophilia patients
is developed through fractionation.
1962 In the US, there were 4,400 hospital blood
banks, 123 community blood centers and 55 American Red Cross blood
centers, collecting a total of five to six million units of blood
per year.
1964 Plasmapheresis is introduced as a means
of collecting plasma for fractionation.
1965 Judith G. Pool and Angela E. Shannon report a method for
producing Cryoprecipitated AHF for treatment of hemophilia.
1967 Rh immune globulin is commercially introduced
to prevent Rh disease in the newborns of Rh-negative women.
1969 S. Murphy and F. Gardner demonstrate the
feasibility of storing Platelets at room temperature, revolutionizing
platelet transfusion therapy.
1970 Blood banks move toward an all-volunteer
blood donor system.
1971 Hepatitis B surface antigen (HBsAg) testing
of donated blood begins.
1972 Apheresis is used to extract one cellular
component, returning the rest of the blood to the donor.
1979 A new anticoagulant preservative, CPDA-1,
extends the shelf life of whole blood and red blood cells to 35
days, increasing the blood supply and facilitating resource sharing
among blood banks.
Early 1980s With the growth of component therapy,
products for coagulation disorders, and plasma exchange for the
treatment of autoimmune disorders, hospital and community blood
banks enter the era of transfusion medicine, in which doctors
trained specifically in blood transfusion actively participate
in patient care.
1981 First Acquired Immune Deficiency Syndrome
(AIDS) case reported.
1983 Additive solutions extend the shelf life
of red blood cells to 42 days.
1984 Human Immunodeficiency Virus (HIV) identified
as cause of AIDS
1985 The first blood-screening test to detect
HIV is licensed and quickly implemented by blood banks to protect
the blood supply.
1987 Two tests that screen for indirect evidence
of hepatitis are developed and implemented, hepatitis B core antibody
(anti-HBc) and the alanine aminotransferase test (ALT).
1989 Human-T-Lymphotropic-Virus-I-antibody
(anti-HTLV-I) testing of donated blood begins.
1990 Introduction of first specific test for
hepatitis C, the major cause of “non-A, non-B” hepatitis.
1992 Testing of donor blood for HIV-1 and HIV-2
antibodies (anti-HIV-1 and anti-HIV-2) is implemented.
1996 HIV p24 antigen testing of donated blood
begins. Although the test does not completely close the HIV window,
it shortens the window period.
1997 U.S. Government issues two reports suggesting
ways to improve blood safety, including regulatory reform.
National Blood Data Resource Center founded by AABB to collect,
analyze and distribute data on all aspects of blood banking and
transfusion medicine.
1998 HCV lookback campaign — a public
health effort to alert anyone who may have been exposed to the
hepatitis C virus (HCV) through blood transfusions before July
1992 so they can receive medical counseling and treatment if needed.
1999 Blood community begins implementation
of Nucleic Acid Amplification Testing (NAT) under the FDA’s
Investigational New Drug (IND) application process. NAT employs
a testing technology that directly detects the genetic materials
of viruses like HCV and HIV.
2002 West Nile virus identified as transfusion
transmissible.
2002 Nucleic acid amplification test (NAT)
for HIV and HCV was licensed by the Food and Drug Administration.
|