Thousands of potential donors in Switzerland cannot give blood. Now faced with a potential shortage, specialists are questioning certain exclusionary measures.
Apr 07, 2015
Homosexual men may soon be allowed to donate their blood in the United States if they have not had sexual relations for one year. The US Food and Drug Administration (FDA) has been discussing the issue since December and will release a recommendation this year. The current lifetime ban on blood donations from homosexuals and bisexuals has been in force since 1983 in the United States and since 1977 in Switzerland, where the ban remains enforceable.
Jul 16, 2014
Blood cell culture from stem cells is progressing. Professor Marc Turner from the University of Edinburgh used the process to manufacture type O artificial blood that can be transfused to patients. A clinical trial is planned for 2016.
In 2011, Professor Luc Douay led a similar clinical trial at Pierre-and-Marie-Curie University in Paris but for self-transfusion.
Every year Switzerland fears a blood shortage,” says Rudolf Schwabe, director of the Swiss Red Cross’s (CRS) Blood Transfusion Service. His message is clear. Overall the country is self-sufficient, but several cantons such as Geneva, Basel and Vaud regularly have to call upon other Swiss transfusion centres to obtain a sufficient amount of blood bags.
“We import 10% of our requirements every year, i.e. about 3,000 bags of the 30,000 required in the Vaud canton,” says Jean-Daniel Tissot, chief of the Blood Transfusion Centre at the Lausanne University Hospital (CHUV). “And these requirements are increasing with new technological advances in medical care, which are making it possible to treat older patients.”
Red blood cells, platelets and plasma are drawn when a donor gives blood. These three components are used mainly by doctors from onco-haematology and transfusion surgery services. “Unfortunately when we call for blood donations, we are sending a contradictory message,” continues Jean-Daniel Tissot. “We are looking for more and more donors, and at the same time we are refusing more and more volunteers, since the precautionary measures are so restrictive.” To be able to give blood, volunteers must meet very precise criteria. Those who do not meet the criteria may be excluded from giving blood temporarily, or even definitively. Below is an overview of the main obstacles to giving blood.
Men who have had sexual relations with partners of the same sex any time after 1977 – when the first human retrovirus linked to AIDS was discovered – are excluded from giving blood for life, as are people who take drugs or engage in commercial sex acts. “It has been shown that, every eight years, one bag in three million is contaminated,” says Emmanuel Rigal, chief of the Blood Transfusion Centre at the Geneva University Hospitals (HUG) in Geneva. “By relaxing this measure, the risk incurred would be an additional three to four people contaminated per year in Europe. In relative terms, that’s still very low. But what is society’s threshold of acceptability for the additional risk, even minimal, of HIV transmission? It’s more a social issue than a medical one.” According to Jean-Daniel Tissot, “no one has the courage to make this decision, but the discussion will resume as new medical techniques are studied”. Moreover, in 2012, the Swissmedic supervisory authority refused to get involved after a year of Parliamentary debate on this precautionary measure. “Any ascertained, or even suspected, risk for recipients must be avoided,” says Hans-Beat Jenny, Swissmedic’s deputy director.
The period of time a person must wait, after changing partners, before they are allowed to give blood was previously set at 12 months. In January 2012, the period was reduced to four months. But for the chief of transfusions at the CHUV, this criterion may be reconsidered, especially bearing in mind protected sex and the value of tests that can offset the risk of infection: “With this measure, we’re forced to refuse no less than 30 to 40% of young donors.” At the CRS, Rudolf Schwabe also objects to this restriction: “The population of young donors is large, so we are hoping to reduce this waiting period to three months.”
Malaria, chikungunya and chagas are emerging viral and parasite-borne diseases which temporarily prevent donors from giving blood in Switzerland. But there is no prospect of this principle being called into question. “The risk of transmission of an unknown pathogen is still too high,” says Jean-Daniel Tissot. In 2013, it was West Nile fever that paralysed blood donation centres: travellers returning from the United States and Canada, among others, had to observe one month’s quarantine. This phenomenon affects Geneva in particular, where the population is very mobile – Geneva is among the cantons most affected by blood shortages.
Any individual who spent at least six months in England between 1980 and 1996 is not permitted to give blood. Creutzfeldt-Jakob disease, a virus which appeared during this period in Great Britain, has a very long incubation period, and tests are not always able to detect it. In 2004, a variant of this disease, “mad cow disease”, banned anyone who received a blood transfusion after 1980 from giving blood. “Because of this measure, we lost 11% of our most loyal donors,” says Jean-Daniel Tissot. “This rule should be re-examined or even abolished. As for Creutzfeldt-Jakob disease, no case has been observed in Switzerland, and the measure is no longer relevant.”
While the minimum age for giving blood in the US is 16, donors must be at least 18 years old in Switzerland. This measure is accepted by specialists, who cite medicolegal reasons and the need to allow patients time to grow up. As regards the minimum weight of 50 kilos, there should be no change there either. “We draw 450 ml of blood, which is quite a bit as concerns the donor’s health,” says Jean-Daniel Tissot. “And if we drew less blood from a person weighing under 50 kilos, the quality of the blood would no longer be optimum.”
In Switzerland, female volunteers can give blood at most twice a year, while males can give up to three times (compared with four and six times respectively in France). “Drawing more blood would expose donors to risks and reduce their iron reserves, causing anaemia and chronic fatigue, especially in women,” says Emmanuel Rigal, who considers the rule satisfactory. Jean-Daniel Tissot finds even this criterion to be excessively permissive: “We already draw too much blood from the same people in Switzerland. I would prefer increasing the number of donors by one and a half times and decreasing the number of donations from each volunteer by one and a half times.”
1. Purify the blood
Switzerland is a pioneer in the “pathogen inactivation” procedure, which consists of destroying all the bacteria that might be present in the blood, thus ensuring a more pure blood. This technique is already carried out on platelets and plasma, two blood components which permit coagulation. And research is in progress for the total elimination of these harmful agents in red cells. “Once we’re able to destroy pathogens in red cells too, infection risks will be under control,” says Jean-Daniel Tissot. “All the restriction criteria will have to be revised.”
2. Produce artificial blood
To date there is still no blood substitute, and the research being conducted on the manufacture of synthetic blood has for the moment been interrupted following health complications, such as increased risk of infarction, as shown by a study published in the Journal of the American Medical Association in 2008. On the other hand, the development of red cells from embryonic stem cells is close to becoming a reality. Professor Luc Douay, chief of the Haematology Service at Hôpital Saint-Antoine in Paris, conducted a first successful clinical study in 2011 and is pinning his hopes on a new cell discovered in 2007 called the “induced pluripotent” cell, which can produce an unlimited number of red cells. “The greatest challenge is adapting laboratory culture conditions to production on an industrial scale,” he says. “I hope to see the first results within four years.”
3. Reduce blood transfusions
Though giving blood will always be necessary in cases of blood-loss emergencies, blood transfusions are not indispensable in all situations. “By conducting work upstream in hospital services, the need for blood donations can be reduced by at least half,” says Donat Spahn, chief of the Anaesthesiology Service at Zurich University Hospital. He thought up a concept called “Patient Blood Management”, which has three objectives: to increase medical examinations of patients and treat them for any possible anaemia before hospitalisation; to reduce blood loss during an operation by reviewing certain surgical techniques; and finally to forestall the need for post-operative transfusion by treating patients with sufficient iron and erythropoietin, a hormone that boosts red cell production. A pilot programme has already been set up in Australia for orthopaedic surgery.