Correspondence
Blood and Disaster
N Engl J Med 2002; 347:68-69July 4, 2002
- Article
To the Editor:
Dr. Schmidt (Feb. 21 issue)1 appears not to appreciate the powerful need people have to give blood when a tragedy strikes or the potent symbolism involved. When America's Blood Centers, whose community-based network provides nearly half of the nation's blood supply, learned that there was little need for blood after the September 11, 2001, terrorist attacks, we asked the public on September 12 to donate blood in the weeks ahead. Many, although not all, were satisfied to schedule memorial donations, but most of our centers collected little blood that was not transfused into patients.
Schmidt notes that in one instance, up to 40 percent of new donors responding to a disaster gave blood again within six months, although his conclusion was based on the conduct of donors in the disaster area. Recent widespread blood shortages are reminders that September 11 did not create a sustained motivation for blood donation.
1 ReferencesLouis Katz, M.D.
America's Blood Centers, Washington, DC 200051
Schmidt PJ . Blood and disaster -- supply and demand. N Engl J Med 2002;346:617-620
Full Text | Web of Science | Medline
To the Editor:
Schmidt's Sounding Board commentary reminds us that mass appeals for blood can be inefficient and unsafe. However, the impulse to bolster blood supplies in the hours that followed the disasters on September 11 was understandable and reasonable. The initial appeals came from the affected areas and were based on the predictions by hospitals in New York and New Jersey that there would be between 5000 and 10,000 casualties.1 Even when the number of casualties turned out to be far smaller, no one could predict what acts of terror might occur in other areas during the succeeding days. Transport of blood nationwide had been curtailed in a way that no contingency plan had anticipated. Prudence dictated preparing for the worst.
One positive outcome of the confusion surrounding the need for blood was the formation of a task force to improve the national response to the need for blood during domestic disasters and acts of terrorism. Under the auspices of the American Association of Blood Banks, more than 15 governmental, not-for-profit, and commercial organizations prepared a plan that designates a single coordinating center for national emergencies and provides for local assessments of the need for blood, transportation, and communication with the public. The Advisory Committee on Blood Safety and Availability of the Department of Health and Human Services endorsed this plan at its meeting in February.
Finally, Schmidt's contention that “none of the reports” credited the blood contributed before the disaster with saving lives is incorrect. In fact, the commentary by the American Association of Blood Banks that he cites states that “blood for today's tragedy is taken from yesterday's inventory. . . . The question is not whether to donate but when to donate,” and it calls for a sustained national blood program.2 That message was reiterated in the September 12 press release issued by the association, which reported that inventory levels were meeting hospital needs,3 and this was and remains the stated position of the American Association of Blood Banks.
Schmidt's central thesis is that the best preparation for the next disaster is to ensure that sufficient blood is “on the shelf.” The message is not new, but it cannot be repeated often enough.
3 ReferencesHarvey G. Klein, M.D.
Karen Shoos Lipton, J.D.
American Association of Blood Banks, Bethesda, MD 20814-27491
AABB responds to needs for blood. Press release of the American Association of Blood Banks, Bethesda, Md., September 11, 2001.
2
Klein HG . Earthquake in America. Transfusion 2001;41:1179-1180
CrossRef | Web of Science | Medline3
AABB applauds Americans' spirit to help. Press release of the American Association of Blood Banks, Bethesda, Md., September 12, 2001.
To the Editor:
Schmidt's statement that “medical facilities usually have a three-day supply of blood on hand” is clearly wrong, given that shortages and blood emergencies are declared frequently. The summer of 2001 witnessed one of the worst shortages in 20 years, and more recently, early this year in New York City, supplies were again limited and another shortage was declared. Had the terrorist attack occurred a few weeks earlier, even the limited demand would clearly have outstripped the supply.
The use of data on supply and demand from disasters that are smaller by an order of magnitude than the September 11 attacks is of dubious value. This disaster was unique in that the ratio of the number of persons injured to the number killed was dramatically skewed, with few crush injuries and amputations, as well as in that the emergency transportation system remained intact. A ratio of the number injured to the number killed of less than 1:20 makes this event unlike those Schmidt lists in his Table 1. Similar figures for transfusion demands from the recent earthquakes in Japan and Turkey would have had greater validity for comparison, had such data been available.
What was lost in the aftermath of September 11 was the opportunity to break the monopolistic hold on the blood supply of the American Red Cross and the regional blood centers. Claims of excessive costs to freeze units of blood are really just excuses to perpetuate the status quo. If the federal government could establish a strategic reserve of 100,000 units, the monopoly on blood would be broken. There is minimal competition within regions, and the price of blood has climbed by 20 percent since September 11.
The concept that local supplies will always suffice is clearly too optimistic for the realities of asymmetric warfare. Had the terrorists released persistent agents or hit a nuclear facility in the vicinity of the attack, the transport system would not have functioned. Unfortunately, in planning to fight asymmetric warfare, repeatedly making conventional and outmoded assumptions is a recipe for disaster. Large supplies of frozen blood, as well as other medical supplies, need to be positioned in advance. These blood reserves would also have the immediate economic advantage of constraining future price increases.
Clifford Gevirtz, M.D., M.P.H.
Mt. Sinai School of Medicine, New York, NY 10029
clifford.gevirtz@med. va. gov Author/Editor Response
Dr. Schmidt replies:
To the Editor: Katz properly cites the symbolism of blood donation. A half-million people gave blood after September 11 because they had been conditioned to respond in this way to tragedy. The less than 300 units actually transfused into the victims were donated before September 11 in regular volunteer programs. Such disparities are expected by those involved with blood banks but not by the general public.
Gevirtz proposes that we build a strategic reserve of frozen blood for disasters. With the current technology, three hours are required to process each unit of thawed red cells, one by one in its own machine. Transfusions for 50 disaster victims would require a waiting battery of sterile machines and trained operators. Transfusions for 1000 victims would require systems that are not yet available.
Frozen stored red cells are discarded whenever blood banks are required to obtain a new type of information about the donor's history. Despite its 10-year shelf life, blood frozen after September 11 should not be used after May 31, 2002, the effective date of the call by the Food and Drug Administration for the rejection — because of the risk of “mad cow disease” — of blood donors who have lived in the United Kingdom for three months or in France for five years since 1980.1 New requirements are always under review. Using up stored blood just before the implementation of new requirements would be unethical. When the AIDS crisis began, such a decision in France led to charges of involuntary manslaughter against the minister of health and the prime minister, and the head of the national blood service was sent to prison.2 Constant turnover of a stockpile would double the cost of blood to hospitals.
What is required now is not the stockpiling of frozen blood but the proper encouragement of the walking blood reserves that exist in every community. Like politics, all blood donation is local, and Klein and Lipton are correct in calling for local assessments of the system. More is needed. A single, local voice must be established for blood emergencies in every community. That voice must be recognized as speaking for the disparate interests of donors, recipients, and collectors and to the demands of competing hospitals. The supply and demand of blood for disasters must be controlled by the authority in charge of emergency preparedness in each community, under commitments like those obtained from the competing fire, rescue, and police departments. Local cooperation regarding the collection and use of blood donations must be forged now, while the lessons from September 11 are fresh.
2 ReferencesPaul J. Schmidt, M.D.
University of South Florida, Tampa, FL 33620
pauljschmidt@aol.com 1
Guidance for industry: revised preventive measures to reduce the possible risk of transmission of Creutzfeldt-Jakob disease (CJD) and variant Creutzfeldt-Jakob disease (vCJD) by blood and blood products. Rockville, Md.: Food and Drug Administration, Center for Biologics Evaluation and Research, January 2002.
2
Steffen M. The nation's blood: medicine, justice, and the state in France. In: Feldman EA, Bayer R, eds. Blood feuds: AIDS, blood, and the politics of medical disaster. New York: Oxford University Press, 1999:95-126.
