|Year : 2018 | Volume
| Issue : 1 | Page : 6-12
Blood donor notification: Boon for the community, bane for blood donors, and blood centers?
Shivaram Chandrashekar, Ambuja Kantharaj
Department of Transfusion Medicine, Manipal Hospital, Bengaluru, Karnataka, India
|Date of Web Publication||5-Apr-2018|
Dr. Shivaram Chandrashekar
Department of Transfusion Medicine, Manipal Hospital, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Altruism, warm glove, kinship and a sense of duty are the primary driving forces behind blood donation. The concept of donor cycle starts with donor recruitment and ends with donor retention and recall or with notification of sero-reactive donors. Donor Selection criteria vary from country to country and from region to region. Blood donor counseling is a confidential dialogue between the donor and a trained counselor aimed at ensuring the safety of donors and health of recipients. Predonation counseling covers modes of transmission of HIV, tests carried out on donated blood, confidentiality of test results, information on alternate testing sites and confidential self exclusion. Counseling during donation helps allay fears and is likely to reduce the incidence of adverse reactions in the donor. Post donation counselling aims at educating the donors on the interval between donations, care of the phlebotomy site, special instructions in case of adverse events and specific instructions depending on their job, besides nutritional /medical advice to deferred donors. Posttest counseling and notification of reactive donors is essential for the health of the donor and his family, prevention of diseases, improving blood bank economy by avoiding wastage of blood, and reducing exposure to healthcare workers. Problems in notification are diverse. It creates donor anxiety and suicidal tendencies in some. The kits used in a blood centre may give false positive results. NAT reactivity, with sero-negativity further compounds the problem. Response rate to notification is often poor. All these have made donor notification a boon for the community, but a bane for blood donors and blood centers. Every country must evolve specific guidelines for donor notification. This paper discusses Indian Guidelines for Blood donor counseling and sero-reactive Donor Notification.
Keywords: Donor counseling, donor cycle, donor notification, transfusion transmitted
|How to cite this article:|
Chandrashekar S, Kantharaj A. Blood donor notification: Boon for the community, bane for blood donors, and blood centers?. Glob J Transfus Med 2018;3:6-12
|How to cite this URL:|
Chandrashekar S, Kantharaj A. Blood donor notification: Boon for the community, bane for blood donors, and blood centers?. Glob J Transfus Med [serial online] 2018 [cited 2018 Aug 17];3:6-12. Available from: http://www.gjtmonline.com/text.asp?2018/3/1/6/229327
| Introduction|| |
| Why Do People Donate Blood?|| |
Before we address the issue of donor notification let us understand why people donate blood and what are the components of the donor cycle.
Altruism is the common reason why people donate blood. Altruism is an unselfish concern for other people's happiness and welfare. Altruistic people are willing to do things that bring advantages to others, even if it results in disadvantage for self.
Pure altruism is believed to be the archetypal motivation for blood donation. Ferguson et al. have shown that warm glow is also a predictor for blood donation. Warm glow is the positive emotional feeling people get from helping others. Warm glow is the driving force for all types of charities that people engage in.
Kin selection suggests that individuals show preferential helping toward family members. Kinship, although reported by blood donors as a motive, is also unlikely to sustain donation because blood cannot be donated directly to the relatives. The typical small rewards (e.g., tea and biscuits) may be insufficient to outweigh the high costs of donation.
The sense of duty and reluctant altruism are other reasons for donating blood. Reluctant altruism is more likely to be driven by a sense of frustration with others inaction, whereas duty is likely to be aimed at pleasing others by doing the right thing.
The most common reason reported for not donating blood is not being asked to donate. According to another study, the most common obstacle to becoming a regular blood donor was “laziness” (19.1%) followed by “fear of needles” (10.5%).
| Donor Cycle|| |
The concept of donor cycle [Figure 1] as explained by the DOMAINE study  includes donor recruitment, donor invitation, donor selection, donation procedures, and donor retention.
To this, we may add donor notification, when the donor tests reactive for one of the transfusion-transmitted infections (TTIs).
| Donor Recruitment|| |
Donor recruitment  is done from a potential donor pool consisting of prospective donors which could be the student population, the business community, the office goers, or religious communities. Virtually every group of people sans prisoners in jail qualify as a potential donor. Every blood center needs to identify and target their potential pool of prospective blood donors.
Donor recruitment can be done by way of letters, telephonic messages, E-mails, media announcements, or by direct one-to-one requests either directly by blood center or through friends of donors or relatives of patients.
| Donor Invitation|| |
Donor invitation is the first step in donor recruitment. Blood establishments send invitations to registered and eligible donors requesting them to make a donation.
Further blood centers can also send invitations to those donors who might have been ineligible in the past but may be eligible currently as they have shown their intention to donate.
Temporary donor deferral registries can be an important source for donor recruitment. A donor who could not donate blood a month ago as he had fever or was on treatment may be eligible and willing to donate today. Temporary deferral can result in substantial donor attrition because it dampens the enthusiasm of the donor or arouse their confusion and anger, thereby reducing the chance of returning for a subsequent blood donation.
A study in China  showed that after the implementation of donor invitation, repeat donors increased from 27.5% in 2010 to 48.6% in 2011.
| Donor Selection|| |
Donors are selected based on well-defined criteria which vary from country to country and sometimes region to region within the same country [Table 1]. Donor selection should ideally be preceded by one–one predonation counseling and testing, followed by postdonation advice. It is a good practice to give sufficient educational material to ensure both donor safety and freedom from diseases. Counseling of donors by dedicated donors seldom happens consistently in many Asian countries which compromises blood safety. No test or processing technology can be a substitute for good donor counseling.
| Blood Donor Counseling|| |
Blood donor counseling is a confidential dialog between a blood donor and a trained counselor  regarding issues related to the donor's health and the donation process; it may be provided before, during, and after blood donation. Generally, counseling needs to be done at least twice during the donation process, once before donation and again after donation [Figure 2].
Predonation counseling  is a broad topic. In a nutshell, this aims to allay fears concerning blood donation, clear myths relating to blood donation, explain and ascertain risk factors associated with the donor to ensure blood safety, and stress on the importance of giving a truthful history in the interest of patient safety.
Predonation screening is necessary to determine donor eligibility as a part of the donor selection process. In most countries, elements of predonation counseling are specified by the respective blood Transfusion authorities or in some cases by the accreditation agencies. For instance, NABH standards  in India, requires that predonation counseling address the following points in line with NACO guidelines [Table 2]. This should cover the following: modes of transmission of HIV, tests carried out on donated blood, confidentiality of test results, information on alternate testing sites, and confidential self-exclusion. Information on alternative testing site ensures that the blood center is not used by potential donor as center for free HIV testing. Confidential unit exclusion wherein the donor informs the blood center that his blood may not be safe but could not disclose the same during the donation process gives a final opportunity for both the donor and blood center to ensure safety.
Counseling during donation helps allay fears and is likely to reduce the incidence of adverse reactions in the donor.
This is aimed at educating the donors on the interval between donations, care of the phlebotomy site, special instructions if the donation was associated with an adverse reaction, and specific instructions depending on their job (pilots/construction workers). Nutritional advice to deferred donors and at a later stage notification of TTI reactive donors also form a part of postdonation counseling [Table 3].
Deferred donor and TTI Reactive donor counseling: deferred donors constitute an important pool of potential donors for recruitment in the future and if appropriately counseled (e.g., nutritional advice for anemia), are more likely to return for donation. TTI reactive donor counseling is perhaps the most difficult. Notification of a blood donor about abnormal TTI results is a very sensitive and crucial aspect of postdonation counseling as it has psychological and social impacts. Each donor reacts in a different manner, some people faint, some get angry, others start weeping, and a few others remain apparently calm; although, they can present with nervous breakdown, emotional disturbances, and suicidal tendencies later.
| Donation Procedure|| |
Donation Procedures are varied today. We have whole blood donations and we have apheresis donations comprising platelets, plasma, double red cells, and multicomponent apheresis, all with their differing requirements in different countries. Irrespective of where they donate, donor psychology is complex, and the only unifying factor is the treatment meted out to blood donors and donor perception of how their blood will be used, that probably determines whether they will return for donation or not.
| Donor Retention|| |
Social marketing campaigns for recruitment/retention of donors should focus on identified motivators.
A study  identified the most frequently cited motivators for male blood donation were as follows: altruism; positive attitude toward incentives; health check(s); subjective norms. Altruism was less pronounced among males compared with females and was combined with a warm glow (impure altruism). Perceived health benefits and incentives (e.g., health checks and coffee mugs) were stronger motivators in males than females.
| Donor Recall|| |
To ensure that donors can be recalled and converted to regular repeat donors it is important to make donor experience during the first donation a pleasant one. Donors should be encouraged to speak and should be heard. Given an opportunity, donors can voice their concerns or give ideas and suggestions for the betterment of the process. Creation of donor membership programs, offering incentives like free parking, access to events like cultural events may be helpful. Blood centers should identify the opportunities for interaction with donors more often. Hosting a dinner, felicitating donors all help to bring donors under one roof and help in bonding with the cause of blood donation. Donors can also be offered other volunteering options that target donor's interests and skills such as making paintings/drawings about blood donation and writing poems/literary work relating to blood donor motivation. Storytelling with sharing of success stories regarding how their contribution was useful is a great way to arouse emotions and help them understand the importance of their deeds.
| Donor Notification: Is it Essential to Inform the Positive Donor?|| |
A study from Chennai, India best answers this question. Of 22573 donors, 355 (1.7%) were found to be positive in the screening tests. Letters of calling were sent to 310 (87.04%) donors. Of these 218 (70%) donors with 7 HIV, 199 hepatitis B surface antigen (HBsAg), and 12 HCV positivity responded. None of the responded donors knew their status earlier. More importantly, this study showed that 82 (35%) of them were repeat donors with 201 earlier donations at various blood banks showing the importance of donor notification.
Posttest counseling and notification of positive donors is essential for the health of the donor and his family, prevention of diseases, improving blood bank economy by avoiding wastage of blood, and reducing exposure to health-care workers.
Blood center kits have a high sensitivity and are prone to give false positive results. A study  has shown that the false positivity for HBsAg showed a mean false positivity of 2.2% with the highest false positivity being 4.4%, for HCV the mean false positivity was 2.8% with the highest being 8.7%, and for HIV the mean false positivity was 11.1% with the highest being 28%. Whereas blood banks kits are designed to protect patients, the same can create unnecessary anxiety, stress, and suicidal tendencies in blood donors as was evident in a case in North Eastern India. The blood donors should be made to understand that blood centers are not diagnostic centers.
According to the media reports, donor apparently tried to commit suicide even after being told that these tests need more detailed investigation and referral to an Integrated Counseling and Treatment Center (ICTC). This is, especially true for a high proportion of blood donors labeled as anti-HCV antibody positive based on low antibody titers. These donors may not be at increased risk of carrying HCV. Labeling would result in creating unnecessary anxiety among blood donors. Not conveying the same to them could also lead to litigation for failure to communicate the results and advice follow-up. It may, therefore, be wise to confirm the results using better tests such as RIBA, polymerase chain reaction, if facilities are available and communicate the results with proper counseling, and documentation.
Another important problem of late is about donors who are notified due to NAT reactive/enzyme-linked immunosorbent assay (ELISA) nonreactive status. These donors have their tests repeated by their personal physicians and return with discrepant results as most of the laboratories again screen samples by ELISA. These donors usually reveal an angry behavior in blood bank and question the accuracy of screening performed in the blood bank.
Donor notification, once nonexistent is the hot topic of the day in India, thanks to the print and electronic media highlighting the demerits of not notifying donors. Nonnotified donors not only pose a risk to themselves and their family but also continue to donate blood leading to wastage or breach of patient safety if they get inadvertently transfused. Donor anxiety is perhaps a small price to compensate for larger patient and community safety.
Newspaper reports  in India, erroneously highlighted that more than 20,500 had become HIV positive over 11 years due to nonnotification of reactive donors by blood centers. In reality, this data were collected based on a history of blood transfusion given by people coming to ICTCs and not based on donor look back. Experts opine that such reports could be misleading as patients tend to give blood transfusion as a reason to hide unsafe sex and such reports are invalid without a proper donor look-back mechanism.
| National Blood Transfusion Council Guidelines for Blood Donor Counseling and Transfusion Transmitted Infection Reactive Donor Notification|| |
TTI-reactive donor notification is essential for early clinical intervention to minimize disease in the donor and the risk to the partners/close contacts. As per the present protocol, each reactive donor is informed about the abnormal test results, counseled, and referred for further confirmation and management to the concerned specialty.
The National Blood Transfusion Council has come out with a specific circular  titled “Guidelines for Blood Donor Selection and Blood donor deferral” in 2017. The policy recommends information and referral of HIV-reactive donors to the ICTC/HTS (HIV testing center) for further management and referral of HBV-reactive and HCV-reactive donors to the gastroenterologist. Malaria positive donors are referred to physician and syphilis positive donors to STD centers. The present policy clearly delineates action to be taken by the blood bank and action to be taken by ICTC/HTS [Figure 3] and [Figure 4].
|Figure 3: Transfusion transmitted infection reactive donor notification. STD= Sexually Transmitted Disease ICTC : Integrated Counseling and Testing center; HTS=HIV testing center; GE=Gastroenterology|
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|Figure 4: Recall and referral mechanism for seroreactive blood donors. NBTC=National Blood Transfusion Council ; ART=Anti Retroviral Treatment|
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| Response Rates for Donor Notification|| |
Despite a lot of efforts by many blood centers, the results are not encouraging. The response rate for donor notification is poor as can be seen from the [Table 4]. In a study by Sachdev et al., only 167 people responded out of 787 people notified; in another study by Suman et al. and Chaurasia et al., the response rate was 218 out of 310 and 373 out of 652 notified.
| Conclusion|| |
Donor notification beyond doubt helps to track reactive donors and provide appropriate treatment so that their spouses, their family, and the community, in general, do not acquire these infections through high-risk sexual behavior or through blood transfusion. While it is no doubt a boon for the community, the intricacies involved such as donor anxiety and the difficulties in communicating and referring the donor to higher centers for counseling and management make it a bane for blood donors and blood centers alike. However considering the importance of donor notification, it is imperative that all blood countries evolve guidelines for donor notification and implement the same in the long-term interest of our nations. The authorities should also widely publicize the fact the blood centers are not diagnostic centers and are doing donor notification only as a community service with the limited resources they have. This will help to minimize social distrust between the blood centers and blood donors and pave the way for a healthy voluntary blood donor program.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]