Public education and health screening

Another element in the first-line defense system is effective public education and health screening. In the United States, it is estimated that each year less than 5 percent of individuals eligible to donate blood actually do so. A donor must be in good health, weigh at least 110 pounds, and be at least 17 years of age (some states permit donors under the age of 17 with parental approval). Most blood banks have no upper age limit, and an increasing number of seniors give blood. Getting more voluntary donors requires appealing to both individual self-interest and community spirit. The American Red Cross public education message points out that most of us will "face a time of great vulnerability in which we will need blood. And that time is all too often unexpected" (American Red Cross, 2006a).

An effective public media campaign also involves educating individuals about the need for voluntary exclusion, so that people in a high-risk group or in poor health do not try to donate blood. At present in the United States, guidelines for ineligibility include (Food and Drug Administration, 2002):

• a prior history of illegal intravenous drug use

• a man who has had sexual contact with another man (MSM) since 1977; however, this is currently being reconsidered, the proposal being to accept MSM only if there has been no MSM activity in the last year

• any history of receiving clotting-factor concentrates

• a history of engaging in sex for money or drugs since 1977

• a history of hepatitis since age 11

• a history of babesiosis or Chagas' disease

• ever having taken Tegison for psoriasis

• risk factors for Crueutzfeldt-Jakob disease (CJD), which include a family member with CJD, receipt of a dura mater transplant or administration of human pituitary derived growth hormone, and/or transmission via reusable instruments employed during brain surgery

• risk factors for variant Creutzfeldt-Jacob Disease or vCJD, which include three months or more spent in the United Kingdom from 1980 through 1996, or five years spent in Europe from 1980 to the present.

Public health prevention also includes identifying and refraining from collecting blood at high-risk locations, such as prisons and mental health facilities, where there is a high-risk for hepatitis; and, even though there is an effective test for HIV contamination, avoiding community settings with a relatively high concentration of men who have sex with men, because of the risk of HIV infection. To some, this policy is controversial.

Educational materials provided in advance contain clear and specific instructions that list the exclusions for giving blood, such as recent travel to a geographic location where malaria is endemic, or residence in Europe where variant Creutzfeldt-Jacob Disease (vCJD) is present (see below). Upon entering the blood collection center, prospective donors are given written materials with information on the risks and symptoms associated with infectious diseases transmitted by blood transfusion. They are asked questions and then given a form to sign indicating they have read and understood the material, and have provided accurate personal information. Questions also are asked about donor safety, such as a medical history of heart disease, current fever, or other sign of infectious disease. At that point, they can elect to leave without giving blood.

Donors then are asked clear and specific questions about behaviors that increase the risk of carrying an infectious agent that can be transmitted by transfusion, such as injecting drugs, sexual activity, recent tattooing, and travel. These questions are updated as needed to account for changing infectious disease epidemiology. For example, in response to the newly emerging AIDS epidemic of the early 1980s, blood collection centers began asking men about sexual contact with other men. Even though a virus had not yet been isolated and determined to cause AIDS, population-based data were showing the new disease to be behaving like hepatitis B, which already was well known to be caused by a virus and spread by sexual activity, by sharing intravenous needles during recreational drug use, and by blood transfusion. In general, the public health approach is to continue an effective screening measure until population-based data points conclusively in another direction. It is rare to discontinue the strict application of a screening protocol until there is convincing data over a sustained period of time. Thus, it was several years before Haitians in the United States stopped being considered a separate risk group for HIV.

In the United States, the policy generally is to screen for individual behavior, not group ethnicity. The first instructions for identifying AIDS were promulgated in January 1983. In March 1985, a laboratory test became available to screen for HIV in donated blood. The test was developed within a year, and was made available for donor screening prior to large-scale experience with the screening test and its confirmatory test, the Western Blot. Accordingly, as experience developed, with millions of blood donations being tested, information regarding the false-positive rate became available and the test was modified over the next few years to improve its specificity. Still, the screening questions were not changed until solid epidemiological information became available. To do this, donors with positive test results were interviewed and specific criteria for Western Blot positivity began to be developed by looking at individuals who had been considered Western Blot-positive but had no risk factors for disease. Then the exclusion policy was revised to ask donors specific questions about behavior. Guidelines recently were revised for tattooing, now done on a state-by-state basis based on each state's own regulation of tattooing facilities.

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