The voluntary donor system

Voluntary donation continues to be the foundation for maintaining blood safety. To date, only about 40 countries in the world have established systems for fully voluntary blood donation. This includes only about half of the 52 WHO European Member States, with 17 more in the process of developing one (WHO, 2005b). The problem is primarily in Eastern Europe. Africa is less advanced, with only about 15 percent of the 46 Member States in the African Region having a voluntary system, and only 30 percent have plans on the table to institute such a policy. It is estimated that about 60 percent of transfusions come from family donors, who are known to be more likely than voluntary donors to have a transmissible infectious agent (WHO, 2002).

The United States has a fully voluntary system. Most collection centers in the United States stopped paying for blood in the late 1960s, and with that came a clear reduction in transmission of hepatitis by transfusion. In the early 1970s in the United States there was a risk of approximately 6-8 percent of contracting some form of hepatitis from a transfusion. The risk now of becoming infected with hepatitis B is about 1 in 250,000, and the risk of acquiring hepatitis C is less than 1 in 3300 units transfused. This remarkable improvement in reducing post-transfusion hepatitis may be considered a marker for overall blood safety that occurred from the mid-1960s onward with the US national shift to voluntary blood donation. To appreciate the role of voluntary donation in this improvement, it is helpful to note that at about this time Australia Antigen testing (HBsAg Assay) for hepatitis B was introduced. However, the Australian Antigen test does not detect hepatitis C (previously called Non A/Non B), and HCV transmission declined over these years. It seems reasonable to conclude that voluntary donation works. After 1970, only a very few institutions in the United States continued to pay certain blood donors, and the last few stopped the practice in the past 15 years. Since 2004, we believe that all blood components transfused in the US come from volunteer sources.

In summary, the most critical area for change is in the developing world, where well-established voluntary donor systems still do not exist. The consequence is a much higher rate of transfusion-related infection in these countries, due to agents like HIV, hepatitis B and C, and Chagas' disease, where it is found only in the Americas (WHO, 2004). In response to this public health problem, the World Health Organization strongly advocates that "Member States promote national blood transfusion services, based on voluntary non-remunerated donations, and promulgate laws to govern their operation" (see also the May 1975 World Health Assembly resolution WHA 28.72). And the problem is not isolated to Africa. WHO Europe (2006) notes:

The spread of the HIV/AIDS epidemic makes this issue {voluntary donation} of primary concern for many countries of the WHO European Region. The latest data show that in Western Europe, where blood donations are mainly non-remunerated,

HIV prevalence has declined regularly over time to 1.3 per 100,000 donations (2002). In Eastern Europe, where the national blood supplies are mainly based on paid or family replacement donors, HIV prevalence has increased alarmingly during the last years, up to more than 40 times when compared to some Western European countries.

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