Trying To Keep The Blood Flowing

March 1, 2005 by Natalie Salat

ILLUSTRATION: BARBARA SPURLL

ILLUSTRATION: BARBARA SPURLL

Ron Morrow is sitting in a red leather armchair, looking pretty relaxed for someone who has a needle and long, thin tube coming out of his right arm. One unit—450 millilitres—of his blood is making its way into a plastic bag at the other end of the apparatus. Needles might make some squeamish, but the retired teacher, a slender man with silver hair and spectacles, is a seasoned blood donor.

On this blustery December day, Morrow has made the hour’s journey into Ottawa from Perth, Ont., to give blood for the 80th time at the Canadian Blood Services’ permanent donor clinic. “I come every 56 days,” says the 67-year-old. “My father died at 49 of a blood problem—he had a duodenal ulcer, and massive losses of blood. He wouldn’t have lived as long as he had, back then, if his friends hadn’t donated. That stuck with me.”

Unfortunately, the CBS—the agency that, together with Quebec’s blood operator Héma-Québec, is responsible for supplying Canadian health facilities with blood—is about to lose Morrow as a donor for six months due to new restrictions. “I’m going to the Dominican Republic,” he explains. In December, the CBS expanded its measures to prevent the transmission of malaria, adding the popular holiday destination to its list of risk areas. On Morrow’s return, he will have to wait half a year before donating again.

The good news is that Morrow will no longer have to stop giving blood when he turns 71, because the CBS also removed the upper age limit for donation in December. (The lower limit remains 17.) Dr. Graham Sher, the blood services’ chief executive officer and a hematologist, explains that the restriction had been in place to protect donors, but recent research showed no reason why an otherwise healthy person at 72 would be any less safe to donate than at 71. “We were finding a lot of very annoyed 72-year-olds,” he observes, adding, “If you’ve got a long-time donor who doesn’t have risk factors, you don’t want to lose them.” Morrow’s fellow donor, Françoise Malboeuf, 66, a retired Statistics Canada employee, says she will keep giving blood into her 70s. “As long as they’ll take it, why not?”

The shiny new clinic in Ottawa is a hive of activity, but this scene tells just part of the story. Recruiting and retaining donors is a constant struggle. Only 3.6 per cent of Canada’s eligible population of 12 million, excluding Héma-Québec, are coming forward to provide this life-giving tissue. And both blood operators are having to re-evaluate their eligibility requirements in response to new science and threats, such as the emergence of West Nile Virus and variant Creutzfeldt Jakob Disease (vCJD), the human form of mad cow disease.

Asked why such a low percentage of Canadians is donating, Sher replies, “We came through a tainted blood scandal in this country. Prior to that, going back to the early 1980s, fully seven or eight per cent of the population was donating. We’ve done it before—part of it is overcoming the legacy. Giving blood today is (also) much stricter than it was 10 or 20 years ago—much more personal.” Every time a person donates, they must fill in a detailed health questionnaire, including questions about sexual activity, drug use and anything that could be considered high-risk behaviour. “All of that is in the name of safety, but it means you as a blood donor have got to give up more time from your busy life.” (The process itself takes between 45-60 minutes.)

When the tainted blood scandal occurred—in which a thousand Canadians were infected with the AIDS virus and tens of thousands with Hepatitis C through transfusions—the blood system was managed by the Canadian Red Cross. The Krever Commission, a very public inquiry chaired by Justice Horace Krever from 1993-97, delved through the wreckage and came up with 50 recommendations for overhauling Canada’s blood system. The new Canadian and Québécois blood operators that emerged in 1998 have since had an uphill slog to restore public confidence and boost their collection of blood, which had plummeted in the scandal’s wake.

Both the CBS and Héma-Québec are waging campaigns on several fronts to increase donorship, including marketing campaigns, a national call centre, school programs and 15,500 clinics a year. “We are working with the broadest population to help Canadians understand they have a commitment to make,” asserts Sher. Elaine Senack, the CBS’ regional director for north/ east Ontario and Nunavut, adds, “Blood is for everyone. Every one of us, at one time in our life, if we won’t need it, then one of our family members will need it.”

* * *

“Blood is the soul of who we are. The history of it as much as the biology is fascinating,” says Sher. Although it is now common knowledge that blood transports oxygen and nutrients around the body, carries away waste products and plays a key role in the immune system, its nature and purpose remained a mystery until not too long ago.

In 1628, Englishman William Harvey uncovered the workings of the circulatory system. Nearly 40 years later, Frenchman Jean-Baptiste Denis conducted the first documented blood transfusions on humans —unfortunately not all of which worked. It wasn’t until German scientist Dr. Karl Landsteiner made the crucial discovery of blood types at the turn of the 20th century that it became clear why so many transfusions since the 1660s had proved fatal.

Each of us belongs to one of four blood groups, A,B, AB and O, depending on the presence of antigens (proteins that can elicit an immune response) on the surface of our blood cells and antibodies in plasma. Blood is further classified as Rh negative or Rh positive, depending on the presence of a specific type of protein that humans have in common with Rhesus monkeys—our DNA neighbours. Not all blood types are compatible. In fact, giving someone the wrong variety can kill them. The only blood that can be given universally is O Rh negative.

Though some blood transfusion occurred during World War I, it wasn’t until WW II that organized blood supply systems, including Canada’s, came into being thanks to the International Red Cross. By this point, the science had evolved to make life-saving transfusions possible near the front lines. At a time when Canada’s population was barely 14 million compared with today’s 31-million plus, the Canadian Red Cross collected two million donations in wartime. “We’re trying to get (that) back up again,” says Senack. “If you think of the population today compared with the 1940s—big difference.”

* * *

Public confidence in the blood services is returning, and observers from agencies such as the World Health Organization and the Canadian Hemophilia Society give Canada’s revamped system high marks. “People should feel a great level of safety with regard to things we used to think were risks (such as HIV and Hepatitis),” notes David Page, blood safety co-ordinator for the Canadian Hemophilia Society. Page developed an interest in blood safety as a result of having the blood-clotting disorder. He points to the quick reaction of the blood operators and Health Canada to the emergence of West Nile Virus—a test was developed and in use within six months—as an example of the “huge effort on the part of the blood services, Health Canada and patient groups like ours to look for emerging threats.”

Nonetheless, public confidence needs to translate into more donors. Sher says the CBS is aiming to collect blood from five per cent or greater of the eligible population, which some Scandinavian countries, Taiwan and the UK do. He notes that last year’s total of 842,366 donations is the highest in the blood services’ five-year history. “We have managed to increase collection of red blood cells in Canada by almost 25 per cent, to the point today where we meet almost 100 per cent of hospital needs on a day-to-day basis.” The CBS supplies blood to some 732 health facilities across Canada, using courier and air services. Its report for 2003-04 indicates that the organization—funded by the provinces (except Quebec) and territories—exceeded its target of 95 per cent for meeting hospitals’ needs for red blood cell units.

“If we have shortages, and we do unfortunately have shortages of particular blood groups,” explains Senack, “we have a national inventory, so every day our managers are on a conference call to see what needs to be where. What we try to do across the country is keep a four-day inventory—that’s the ideal. If it drops below two days, we get a bit nervous.”

On the plus side, one unit of blood can save three lives. At the CBS’ 11 labs across Canada, blood is spun down in a centrifuge into three components: red blood cells, platelets (the cells necessary for clotting) and plasma (the clear liquid component). On the down side, fresh components have a limited shelf life: 42 days for red blood cells, 35 days for whole blood, five days for platelets and one year for fresh frozen plasma.

And Canada’s needs are increasing. As the baby boomers age and medicine progresses, the number of surgeries and blood-intensive treatments is going up. The demand for red blood cells is rising by four to five per cent a year and for platelets by six to seven per cent. An operation on the cardiovascular system requires up to 25 units of red blood cells, trauma such as a car accident might take 50 units, and a liver transplant can use up to 100. Leukemia patients need up to eight units of platelets a week.

“We can meet the growing demand, but it’s a challenge,” acknowledges Sher. “We’ve shown we can increase collections, but we’re doing much more. We’ve built an infrastructure using systems developed in other businesses. We have a national call centre (from which) we contact our donors to book appointments. We use state of the art call centre technology to build on our relationship with our donors (and) we’re scheduling appointments in locations that meet donors’ needs, whether that’s in a mall or office. The other thing is we’re working with the tapestry of the Canadian population to recruit donors.”

Senack adds that the CBS partners with organizations such as The Royal Canadian Legion. “When I first started (with the Red Cross), we always went to the Legion hall in the local community. The Legion is one of our big supporters. We also have a program called What’s Your Type. We use this in high schools because it’s important for us to get new and young donors.” Staff members visit schools and malls to tell youth about what the blood services do, help them discover their blood type and encourage older students to make an appointment.

Then there’s advertising as well as marketing campaigns tied to popular culture. For instance, when the DVD for vampire movie Van Helsing came out in October, the CBS joined forces with Universal Studios to insert customized ads onto 500,000 discs.

Attracting a fresh supply of donors is important due to a revolving door of restrictions. Since the Krever inquiry, CBS and Héma-Québec have been leaning heavily on the side of caution. For instance, both implemented restrictions against variant CJD (the human form of bovine spongiform encephalopathy, or mad cow disease) that exceeded regulator Health Canada’s recommendations and cut their donorship levels by several per cent. Now, however, they are moving to ease those restrictions.

The mad cow scare erupted in the U.K. in 1996; some 147 people have died of the human form of the brain-wasting disease after consuming infected beef. When the theoretical risk of transmission through blood transfusions was identified, Health Canada recommended that anyone who spent more than three months cumulatively in the U.K. or in France between 1980 and 1996 be deferred from giving blood, or that anyone who has spent more than five years in Western Europe or received a blood transfusion in the U.K. from 1980 onward also be barred.

The CBS and Héma-Québec went further. The CBS’ restrictions, implemented in 2001, said that anyone who spent more than three months in the U.K. or in France from 1980 onwards would be deferred from giving blood. Héma-Québec set the U.K. limit to one month.

Some denied donors say these restrictions have gone too far. Katie Castleton, 31, who works for the government in Ottawa and has travelled extensively, says, “It’s quite frustrating as I would like to donate. I have no health problems that would stop me other than that rule.”

Castleton may soon get to do her part. Dr. Peter Ganz, the director of Health Canada’s centre for biologics evaluation, says both blood operators are “looking to relax the (vCJD) requirement so that the time spent in the U.K. or France is not cumulative to the present, but to 1996.” This would be a return to Health Canada’s recommendations.

Sher justifies the CBS’ caution. “You have to appreciate there was no test for (vCJD). Absent proof it couldn’t be spread through blood, we—not just in Canada, but other countries (like the United States)—took precautionary steps.” The change in policy, likely to be approved by Health Canada this year, comes as a result of further evidence indicating the greatest risk for acquiring vCJD was through food exposure in the U.K. and France. André Roch, Héma-Québec’s vice-president of public affairs, comments, “We (may) overdo the safety aspect, but I don’t think we can be safe enough.”

Ganz concludes, “We’re really world leaders in blood safety right now, which we have worked hard to become.” He notes there is greater transparency in Canada’s blood supply system since Krever, including the clear division of roles and a new, proactive approach. “We’re not sitting back waiting for a crisis to happen.” He praises both the CBS and Héma-Québec for making strides in recruitment. “Worldwide, we’re struggling with a very large demand and at the same time a diminishing response from the public in being able to provide all the blood needed.” Until an artificial substitute is found, the world’s blood systems are having to appeal to altruism.

Rakesh Vasishtha of the National Blood Services in England and North Wales says busy lives and squeamishness are two factors the NBS tries to counter by focusing on the message that giving blood saves lives. “The challenge is never-ending, because as we get new donors some are being retired. You’re on a constant treadmill.”

And, as Ganz notes, the Canadian Red Cross had 50 years to build up a solid donor base. “The CBS and Héma-Québec are relatively young (and) it does take time to develop a loyalty. Perhaps the public is still a bit weary.”

Not everyone. Sitting across from Morrow at the Ottawa clinic, Ken Brennan of Kinburn, Ont., is giving his 27th unit of blood. He started donating five years ago. “I just thought it was a good thing to do. I keep hearing the advertising, so they must need it.”

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