CHAPTER VI
Blood Donors and the Technique of Collectionof Blood
REQUIREMENTS FOR BLOOD DONORS
When the Red Cross Blood Donor Service was inaugurated in 1941, there weretwo problems concerning donors to be considered. The first was their recruitment(p. 119). The second was their selection. The second problem had two parts, (1)the collection of useful and usable blood, and (2) the protection of the donorsfrom any mischances and sequelae of their donations. In general, the rules whichwere adopted by the Subcommittee on Blood Procurement, NRC (National ResearchCouncil), at the 18 August 1941 (2) meeting remained the basic rulesthroughout the program, though certain variants were introduced as experiencewas accumulated.
Initial Specifications
Initial requirements for blood donors were as follows:
1. Donors should be between 21 and 60 years of age.
2. Donations should be accepted from both males and femalesand from members of all races.
3. No donor should be accepted from whom a donation of 500 cc.could not be expected.
4. The temperature by mouth should not exceed 99.5? F.(39.5? C.).
5. The blood pressure should not exceed 180/100 mm. Hg.
6. The hemoglobin should be 80 percent or more.
7. The pulse should be recorded andnote made of bradycardia and any irregularity. In practice, donors with anyirregularities were rejected except that no attention was paid to an occasionaldropped beat.
8. Women who were pregnant or who had delivered or miscarriedwithin the preceding 9 months were not accepted.
Diabetics were accepted only on the written permission of their personalphysicians.
Donors were also asked when they had last given blood and were questionedconcerning possible diseases, which are discussed under a separate heading (p.141).
1Unless otherwise indicated, all data in this chapter are from Dr. G. Canby Robinson's final report of the Red Cross Blood Donor Service in July 1946 (1).
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Later Specifications
As time passed, the following alterations were made in the originalspecifications for donors:
1. The age was lowered to 18, with the proviso that donors inthis age group must present signed permission from their parents or guardians.
2. Donors whose temperature was above 98.4? F. (37? C.) werenot accepted.
3. Donors with blood pressures up to 200/100 mm. Hg wereaccepted.
4. A hemoglobin level of 12.3 gm. percent was required, thedetermination to be made by a really precise method (p. 160).
5. Both male and female donors must weigh at least 110 pounds.
6. Donors were instructed not to eat within 4 hours before thedonation, and in the interim to drink no milk. Originally, the requirement wasthat no fatty foods must be eaten within a 4-hour period, since at the end ofthis time, the fat concentration in the blood would be reaching its highestlevel.
7. The following groups of donors were also not accepted:
a. Those who had had tooth extractions within 24 hours.
b. Those who must return to work with heavy machinery within 8 hours.
c. Those who had been treated for rabies within the previous 5 years.
d. Those who were extremely sensitive to horse serum and similar substances, for fear of passive transfer of sensitivity to the recipient, which would later prevent the effective use of sera for tetanus, gas gangrene, and other conditions. Many observers thought that this risk could be ignored because of the large pools of plasma being used.
e. Military and commercial fliers, including crews as well as pilots.
The understanding was that donors who had been receiving sulfonamides shouldbe evaluated individually. This regulation was honored more in the breach thanin the observance. At the 2 June 1944 meeting of the Subcommittee on BloodSubstitutes (3), an instance was reported of transfer of sulfathiazolesensitivity from a donor to a recipient who was receiving the drug. Although itwas thought that such instances might become more frequent, there were no otherreports of the kind.
Even after all the prescribed regulations and restrictions for donors hadbeen met, there were still some questionable cases. In these, the decision foracceptance or rejection was made on an individual basis, by the physician incharge of the center. It was the rule, if any doubt existed after theevaluation, to reject the donor.
Release
Every donor was required to sign a release (fig. 27) stating that he or shewas voluntarily furnishing blood through the American Red Cross to the Army andthe Navy, and that he or she agreed that neither the Red Cross nor anyoneconnected with the Blood Donor Service would be held responsible for any eventthat might follow the donation.
The number of registered donors whose donations were rejected was reportedeach month by each center to the Technical Director of the program. Of14,695,836 persons registered, 1,514,085 (10.3 percent) were rejected,
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chiefly for low hemoglobin levels (p. 158) or high bloodpressure. The breakdown was as follows:
5,026 of 932,927 first-time male donors(0.5 percent).
13,859 of 1,781,481 male re-donors (0.75 percent).
105,432 of 1,043,833 first-time female donors (10 percent).
241,694 of 1,849,860 female re-donors (13 percent).
FIGURE 27.-Release signed by donors before they gave blood at American Red Cross blood
donor centers.
DONORS WITH SPECIAL DISEASES
History-Taking
The problem of disease in volunteer blood donors had twoaspects, (1) the protection of the donor and (2) the protection of the recipientfrom transmissible diseases or diseases thought to be transmissible. At theoutbreak of the war and the beginning of the blood program, very little specificinformation was available as to the transmissibility of diseases if blood weredrawn during an illness or shortly thereafter. As a precaution, however, donorswere not accepted if they had had, or were recently convalescent from, anyinfectious disease or any other disease of known or unknown etiology.
Regulations provided that blood donors should be questionedby the registered nurse or the physician in charge of the center concerningtheir previous history of disease and any current symptoms. On the whole, theseregulations were honored, though it must be admitted that their observancedepended not only upon the care (or carelessness) of center personnel but alsoupon the workload. On D-day, for instance, when the centers were crowded withunscheduled as well as scheduled donors, questioning must have been superficialif it was carried out at all.
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The regulations, however, provided for questioning thewould-be donor on the following matters (4):
1. Any illness within the past month.Particular note was taken of the presence, or expected development, of upperrespiratory infections. The physician in charge was asked to rule inquestionable cases.
2. Sinusitis and hay fever. Donors wereacceptable if they were not having acute attacks and were otherwise in goodhealth.
3. Septic sore throat within the past 3months. The physician in charge made the decision.
4. Undulant fever or clinical tuberculosiswithin the past 5 years. Either disqualified the donor. If he had hadextrapulmonary tuberculosis, the physician in charge made the decision.
5. Cardiovascular disease, as evidenced byshortness of breath, swelling of the feet, a persistent cough, or pain in thechest. A history of cardiovascular disease, or the existence of any of thesesymptoms and signs, disqualified the donor.
6. Jaundice within the past 6 months. Donorswith such a history were immediately disqualified. If there was a family historyof jaundice, the physician in charge made the decision on the basis of thecloseness of contact and the nature of the jaundice. It should be rememberedthat serum hepatitis did not become a problem until the last year of the bloodprogram (p. 674).
7. Fainting spells and convulsions. Thephysician in charge made the decision. Such donors were practically alwaysrejected.
8. Rabies. Volunteers who had had treatmentfor this condition within the past 5 years were rejected.
9. Virus infections such as dengue, yellowfever, atypical pneumonia, and virus exanthemata. These volunteers, who wereusually evaluated individually, were not accepted until 6 months had elapsed.
On the basis of a review of the literature, which containedreports of several cases in which leukemic blood had been transfused, it wasdecided that this disease was not transmissible by this route (5). On thecontrary, there were some reports of the treatment of agranulocytosis byleukemic blood. There was also some evidence that sodium citrate was somewhattoxic for the cells of mice with leukemia.
The risk of serum hepatitis from transfused plasma,unsuspected until late in the war, proved the greatest risk of all (p. 674).Early in the war, the chief concern was with syphilis and malaria.
Syphilis
The "Minimum Requirements for Unfiltered Normal HumanPlasma," issued by the National Institute of Health on 20 February 1941 (p.279), specified that an acceptable serologic test for syphilis must be made in aqualified laboratory on a specimen of blood taken at the time of bleeding andthat the blood should not be used for the production of normal human plasmaunless the result of the test was negative.
At the meeting of the Subcommittee on Blood Substitutes on 13July 1944, the subject was discussed extensively, and it was agreed that theevidence
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showed that the chance of transmitting syphilis bytransfusion was very remote. The life of the spirochete had been demonstrated inlaboratory studies with infected testicular tissue to be less than 92 hours instored blood, and its survival would probably be shorter in organisms occurringnaturally in the bloodstream.
The following recommendations were therefore adopted:
1. A serologic test for syphilis should berequired on each blood intended for processing into plasma, the test to beperformed by a method approved by the Venereal Disease Division of the U.S.Public Health Service.
2. In addition, the Kline exclusion test orthe Kahn presumptive test should be performed on bloods to be used insuspensions of red blood cells.
3. Resuspended red blood cells would beacceptable for use only if they were derived from serologically negative blood.
4. Blood cells to be used for resuspension andtransfusion should be held for 72 hours at 39? F. (4? C.) before reinfusion,in conformity with existing Red Cross regulations.
Malaria
Malarious donors in the Zone of Interior never furnished theproblem that they did in certain oversea theaters (pp. 423 and 597), but theycould not be ignored, one reason being that there were then no criteria for thecomplete cure of malaria (5). It was known that the parasites did notsurvive either freezing or drying, and that frozen or dried plasma processedfrom the blood of malarious donors therefore would not transmit the disease.
The matter first came up at the meeting of the Subcommitteeon Blood Substitutes on 10 March 1942 (6). A number of lines ofinvestigation were suggested, and the Army and the Navy were advised, for thepresent, to use caution in processing liquid plasma in malarious districts.
At the 12 May 1942 meeting of the subcommittee (7),the opinion was expressed that the fear of transmission of malaria throughplasma had perhaps been overemphasized. Studies on fowl malaria at the NavalMedical School had indicated that this variety of Plasmodium does notsurvive in dried plasma. Recent observations in Puerto Rico had included apatient who received 10 cc. of unfiltered plasma obtained from a malarious donorand who had clinical signs of malaria and positive smears 25 days afterinoculation. Subjects who received the same inocula passed through a Seitzfilter did not develop the disease. The plasma used in these experiments wasaspirated from citrated blood that had been refrigerated for 48 hours.
A letter from Dr. Lowell R. Coggeshall read at the 23 June1942 meeting of the Subcommittee on Blood Substitutes (8) expressed hisown opinion that lyophilized plasma infected with malarial parasites was notdangerous and that there would probably be no infections from the transfusion ofliquid plasma over 10 days old if all the red blood cells had been removed.Conclusive laboratory proof of these opinions would be long in forthcoming, butit had already been established that plasma infected with Plasmodium knowlesiwas not infective for Rhesus monkeys, even when fresh, if all the red cells
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had been removed. A report from the Malaria Conference statedits official opinion that there was a real hazard from the transfusion ofinfected plasma, though it was probably safe to use it if all the red cells hadbeen removed by centrifugation.
At the subcommittee meeting on 20 October 1942 (9, 10),Cdr. Lloyd R. Newhouser, MC, USN, reported experiments carried out with Lt.Cdr. Eugene L. Lozner, MC, USN, on 18 patients, none of whom developed malariaafter transfusions of 500 cc. of dried plasma infected with different species,with parasite counts of 150,000 per cc. A preliminary report from Dr. Mark C.Boyd, of the Rockefeller Foundation, concerned the intravenous injection of 35cc. of reliquefied lyophilized plasma prepared from blood with a high density ofparasites secured from patients with Falciparum malaria. None of thesubjects in a completed experiment had developed malaria, and a secondexperiment was sufficiently far advanced to indicate that the results would besimilar.
The question of the transmission of malaria by transfusioncame up again at the 13 July 1944 meeting of the Subcommittee on BloodSubstitutes (5), in connection with the blood donor regulations of theNew York City Department of Health, already discussed in connection with thepossible transmission of syphilis by red blood cell suspensions. It wasgenerally doubted that a physical examination, with reliance upon an enlargedspleen, would identify malarious donors; the Army experience had showed theabsence of this finding in many hundreds of men with malaria. The Board for theCoordination of Malarial Studies considered the search for a palpable spleen"a futile gesture."
At this meeting, Commander Lozner reported studies thatshowed that when only 5-10 cc. of infected blood had been injected after 8 days'storage, infection had followed. If it could be calculated that the parasitesdied at a rate plotted on a logarithmic curve, then they would probably survivein larger quantities of blood for 2-3 weeks. Transmission of malaria had beenreported from donors who had been clinically cured for 15 years.
Dr. Robinson pointed out that the regulation that a donorshould be rejected who had had clinical manifestations of malaria within thepast 15 years had been made for the protection of the donor from activation ofthe infection rather than for the protection of the recipient.2
At the end of this discussion, it was recommended that aparticularly accurate history on possible malarial infection be obtained fromall donors whose blood was intended for preparation of red blood cellsuspensions. Any donor with a history even remotely suggesting the possibilityof malarial infection, however far in the past, should not be accepted. Donorsshould be asked not only whether they had had malaria but whether they had beenin areas in which the disease was known to be endemic.
2At Grady Hospital, Atlanta, Ga., it was not uncommon for patients who had incurred trauma, sustained hemorrhage, or been given inhalation anesthesia to have temperature charts suggestive of tertian or quartan malaria. Blood smears were done routinely on these patients and frequently revealed the plasmodial parasite.
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ROUTINE OF DONATION
In a program of such magnitude as the Red Cross Blood DonorService, an assembly line type of production had to be developed (11). Thiswas necessary not only because of the large quantities of blood handled but alsobecause, when as fragile a biologic product as blood was being dealt with,standardization of the operation was essential. It was also necessary for theprotection of the vast army of donors that all equipment and all technicaldetails of collections be standardized.
Bleeding was carried out by teams, each of which consisted ofa physician, four nurses, a secretary, and one or two shipping clerks. The basisof operation was a unit consisting of two beds and a worktable under thesupervision of one nurse. A trained team could easily handle 100 donors in 4-5hours. The fewer the people who did the bleeding, the less the chances ofcontamination.
No single person was a more essential part of the team thanthe secretary. The handling of records had been planned to require as littletranscription as possible, but all subsequent handling of the blood dependedupon the accuracy of the serial numbering of the medical record, bleedingbottle, and serologic tube. The medicolegal importance of accuracy in thisrespect needs no elaboration.
The routine of a donation was as follows:
1. The prospective individual donor phoned foran appointment, or, less often, came directly to the donor center. If time andspace were available, he was taken at once; otherwise, he was given the earliestpossible appointment.
2. Entry to the center was through a receptionroom, with an adjoining cloakroom. The donor then passed on to a second room, inwhich his appointment was checked, and his name and address were entered on adaily booking sheet (fig. 28). A standard, serially numbered registration card(fig. 29) was prepared for him. It contained the questions each donor was asked,space for the replies and for entering other data, and the release which he waslater asked to sign (fig. 27).
3. In the succeeding room, the blood pressure,temperature, and pulse were taken and recorded. A hemoglobin determination wasmade (fig. 30). The registered nurse who had carried out these procedures alsoasked the necessary questions and recorded the replies. These proceedings wereconducted at separate tables, so that complete privacy was assured. When theywere completed, the donor signed the release. Later, all data connected with thedonation (and subsequent donations) were filed under the donor's name (fig.31).
4. Bleeding was originally conducted inseparate cubicles in the belief that the sight of other donors would be harmful.It was soon found that a common bleeding room (fig. 32), where the donors werein full view of each other, was good psychology and also efficient, in that thephysician in charge could keep close check on all donors while bleeding was inprogress. As many as 36 bleeding tables or cots were set up in a single room,with a small work stand between each pair.
5. When the original regulations were drawn up(2), it was specified that the donor lie recumbent for at least 10minutes after the blood was drawn. If there was any sort of reaction, the periodof recumbency was prolonged or he was moved to a separate room, in which he wasunder the supervision of the physician in charge, a nurse, or a nurse's aide,as his condition indicated.
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FIGURE 29.-Card used by American Red Cross forregistration and history of blood donors.
6. After the rest period, the donor was taken tothe canteen, operated by the Red Cross Canteen Corps, and, seated at a smalltable, was given milk, a soft drink, crackers, or other light refreshment (figs.33 and 34). Whisky was not given.
7. When the donor was ready to leave thecenter, he was presented with a certificate and emblem (p. 128) attesting thedonation, and was also given the opportunity to make an appointment for anotherdonation at the end of 8 weeks.
The reception and treatment of donors at the centers were animportant part of the Blood Donor Service. All personnel recognized theimportance of treating them courteously in every phase of the procedure. Theywere welcomed cordially but not effusively. If a volunteer had to be rejected,the reason for the rejection was made clear by careful explanation by thephysician or nurse, and, if it seemed practical, the suggestion was made that hereapply at a later date.
The spirit of comradeship among the donors in the centers wasnotable, although they represented every social, economic, and educationalbackground. The sights and sounds in the canteen after donations suggestedgroups of old friends rather than persons who shortly before had been completestrangers to each other. The donation of blood without doubt raised the spiritsof the donor who had made it, and the donors themselves repeatedly expressedthis feeling.
TECHNIQUE OF COLLECTION OF BLOOD
General Considerations
The basic requirement that blood be collected under conditionsof absolute asepsis was met by the use of a closed system (4, 12). Standardequipment was used (p. 151). It was decided that gloves, gowns, masks, and capsneed
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FIGURE 30.-Determination of donor'shemoglobin and blood pressure,American Red Cross Blood Donor Center, San Antonio, Tex.
not be used, and that sheets and towels need not besterilized (2). Everything used in the bleeding set, however, wassterilized in an autoclave at 250? F. (121? C.) for 30 minutes. In addition tothe equipment prepared daily at each center for the next day's quota, aconstant supply of equipment had to be sent to the centers from the processinglaboratories, where needles were sharpened, rubber tubing was cleaned, and otherprocedures were carried out.
The greatest care was exercised in all details of theprocedure. A sterile needle was used for each donor, dispensed from anindividual test tube or other container from which it could be removed withoutrisk of contamination from air or from the hands of the operator. The Novocain(procaine hydrochloride) for each day's use was dispensed at the beginning ofthe day, by one nurse, under as nearly aseptic conditions as possible.Diaphragm-stoppered bottles, which permitted multiple withdrawals, were notused.
Details of Technique
Bleeding was usually carried out by a graduate nurse, undersupervision of the physician or medical officer in charge. Any problems whicharose during the procedure were referred by the nurse to him.
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FIGURE 31.-Fileroom, American Red Cross BloodDonor Center, San Antonio, Tex.
The following technique was employed (fig. 35):
1. With the donor recumbent on a padded tableor bed, the arm was bared, and the most suitable site for venipuncture selected.Usually, this was the anterior aspect of the upper forearm.
2. A blood pressure cuff, folded to half itswidth, was applied to the arm, to serve as a tourniquet. Except during the flowof blood into the bottle, the tourniquet was not released unless a clamp wasapplied to seal off the inlet tubing completely. Before the vein was entered,the pressure in the cuff was raised to 40-60 mm. Hg.
3. The selected site was scrubbed mechanicallyover an area 4 by 4 inches with 50-percent solution of green soap followed bythe application of alcohol (70 percent by weight). Iodine (2-percent aqueoussolution U.S.P.) was applied, allowed to dry, and then removed with a sponge wetwith alcohol. If, for any reason, bleeding had to be delayed, the field wascovered with a gauze square soaked in alcohol.
4. Venipuncture was performed without touchingthe prepared area of the forearm. If introduction of the needle was difficult,it was permissible to palpate the site above and below the puncture after theneedle was in situ. If the needle had to be withdrawn after it had penetratedthe skin, a fresh bleeding set was used for the second attempt. Not more thantwo attempts to enter a vein were permitted.
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5. The actual bleeding occupied about 5minutes. Every effort was made to collect 500 cc., and nobleeding was counted as such unless the bottle was filled to the 300-cc. level.If suction was necessary, as it occasionally was, a hand pump was used. Thebottle was not rotated during the collection of the blood.
6. After the needle was withdrawn, the arm waseither kept extended or was elevated; it was never flexed. Pressure wasmaintained over the venipuncture with a gauze square held in place by the nurseor, more often, by the donor himself. Then a small piece of gauze, held in placeby adhesive, was placed over the puncture.
7. While the bleeding was in progress, thebleeding bottle was tagged, as was the serologic tube, with the donor's nameand serial number, and the name on each receptacle was checked with the donor. Adouble card was used for the bleeding bottle.
8. The serology sample was taken at the end ofthe bleeding. The tube was kept below the level of the bottle, to prevent bloodfrom running back into the bottle, while it was collected.
9. A spring clamp was placed on both steelinserts and both tubes in the stopper of the bleeding bottle (fig. 36), so bentas to constrict the rubber tubes at the bases of the inserts. An eighth of aninch of tubing extended above the edges of the steel inserts, so that there wasno danger of their cutting through it. Both inlet tube and airway tube were cutflush with the edge of the stopper.
10. A careful check was made, to be certainthat there were no air leaks about the hub of the needle or at the point atwhich the tubing was connected with the steel tubes. If any leaks were found, orif there was any break in technique in the course of the bleeding, the bleedingtag was marked "P.C.," to indicate potential contamination.
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Postbleeding Disposition of Blood
The bottles of blood were moved at frequent intervals fromthe bleeding room to large refrigerators, the temperature of which was strictlycontrolled. At the end of the day, all the donations were packed in refrigeratorchests (p. 204) by trained blood custodians (fig. 37) and dispatched, by railwayexpress or truck, to a processing laboratory. A daily shipping list, includingeach donor's name and serial number, was made in triplicate and accompaniedeach ship-
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FIGURE 34.-Kitchen attached to canteen,American Red Cross Blood Donor Center, Fort Worth, Tex.
ment. Processing, beginning with serologic testing, started thefollowing morning. The blood was moved on prearranged express schedules, so thateach lot reached the laboratory within 24 hours after it was collected.
REACTIONS TO DONATIONS
The efficiency of the selection of donors by the regulationsoutlined is evidenced in the very few fatalities, and the few really seriousaccidents, which occurred in the course of the program. The accident rate indonor centers, in fact, was far below the accepted accident rate for thepopulation as a whole (11). It was concluded at the end of the war,taking into consideration the millions of people involved, that the donation ofa pint of blood was harmless and that among the same group of people, engaged insuch presumably innocuous occupations as taking baths, using electricalappliances, or going up or down stairs, the percentage of accidents over thesame period was probably much greater.
In April 1943, a member company inquired of the MedicalCommittee of the Industrial Hygiene Foundation whether the giving of bloodaffected production and caused absenteeism. It was the unanimous opinionof the committee that there were no undesirable effects at all (13).
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A sample experience was cited to prove the statement: Onecompany, after an intensive drive among office and shop employees had produced3,348 donations during the visit of a mobile bleeding unit, did not find asingle absence from illness immediately afterward that could be attributed tothe donation. One reason, of course, was that the careful predonation check hadeliminated the donors likely to be adversely affected. The blood was alwaysdrawn after the worker went on the shift, never before. Office workers generallyreturned to work directly, but shop workers waited for 2 hours.
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Other companies also reported that they found no absencesattributable to the donations, no increased incidence of colds or other upperrespiratory infections, and no increase in fatigue. Many reported, on thecontrary, that the donation seemed to have provided a stimulus to greater effortand improved morale.
Incidence of Reactions
In order to obtain information directly from the donorsconcerning the effects of donation, 10,000 postcards were distributed toconsecutive donors at each of four centers, with the request that they befilled in and returned within the week. Replies were received from 27,021 donors(68.2 percent), the number probably including most, though not all, of those whohad experienced any effects.
Of the 27,021 donors who replied, 81.6 percent had nocomplaints. Those with complaints usually had more than one. In all, 8.9 percentreported some general ill effects and 10.1 percent had some trouble in the armfrom which the
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FIGURE 37.-Shipping room at unidentifiedAmerican Red Cross blood donor center.
blood was withdrawn, but only 4.1 percent reported limitationof activity within the week after the donation (the figures are overlapping).The percentage of upper respiratory infections, less than 1 percent, was lowerthan the general incidence of such infections during the period covered by thesurvey. A good proportion of those who complained of some lassitude and weaknessin the 48 hours after the donation were sedentary indoor workers or housewives.The Blood Donor Service was unaware of specific instances of absenteeism, butthere is no doubt that occasional persons took advantage of their donations toremain away from work.
Types of Reactions
Accidents and reactions among donors were analyzed by Dr. (laterMajor, MC) Earl S. Taylor (11) in a presentation to the American MedicalAssociation at its annual meeting in June 1942, by which time 286,197 bleedingshad been carried out, with 10,348 reactions (3.5 percent). Later, with Dr. MaryHeiss Boynton, Major Taylor (14) analyzed the reactions which hadoccurred in the more than 7 million donors who had given blood up to 1 April1944. The significant data of both analyses were as follows:
Fatalities.-Several fatal illnesses had theirinception immediately after donations, the most important being in the group ofdonors with cardiac or
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other circulatory conditions. In all, there were 10 fatalcardiovascular accidents within 3 to 48 hours after the donors had left thecenters, in addition to 1 fatality in a center, caused by a sudden coronaryarterial occlusion. The giving of blood was thought to have had little ornothing to do with these deaths.
There were also eight instances of angina pectoris, coronarythrombosis, or cerebral hemorrhage during, or within 2 hours after, thedonations; all were followed by recovery.
Fainting-In both the 1941 and 1944 surveys, the mostdisturbing reaction was impending faintness, actual faintness, or occasionally,a deeper loss of consciousness. Compilation of reports from all bleeding centersat the end of the war gave the number of donors who "fainted or stayedlonger than usual" after the donation as 490,000 out of more than 13million donors (3.7 percent). About half of this group showed definite syncope,though the loss of consciousness was only momentary. A small number presentednot only loss of consciousness but generalized convulsions, incontinence,cyanosis, and, occasionally, very striking tetany with carpopedal spasm. Allresponded rapidly to symptomatic treatment.
All centers were equipped to treat such conditions, and allmobile units carried with them equipment for intravenous administration ofsaline solution, as well as sedative and other drugs.
The most likely subject for syncope was a young adultweighing between 100 and 110 pounds (later, 110 pounds was the lower limit for adonor). If he was also hypotensive, he was almost certain to have some reaction.Another candidate for syncope was the donor who had worked a long shift at afactory, particularly in warm weather; in such cases, dehydration was also afactor.
Emotional and psychic influences played a major role infainting. Some donors fainted before bleeding was begun or soon after it wasstarted. In a few instances, the wife or the husband fainted while the spousewas being bled.
Weakness.-Few opportunities arose to pass judgmenton donors who complained of limitation of activities because of weakness orlassitude for 7-10 days after the donation. When examinations could be made, nobasis was found for the complaints, which seemed to be chiefly of emotional orpsychogenic origin.
Lacerations and contusions-A few lacerations,contusions, and fractures occurred in association with fainting, most often insubjects who had refused to rest after the donation.
Local reactions-The most frequent local complicationwas extravasation of blood into the tissues at the point of venipuncture. Thearea was discolored, and was sometimes swollen and uncomfortable, for severaldays. There were a few instances of dermatitis about the venipuncture, but norecord of iodine or other burns. There were also about 30 reported instances oflocal infection. It was reported that one donor had developed a staphylococcicsepticemia after the donation, but since he recovered in 5 days, the diagnosiswas considered highly unlikely.
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Other complications-Other complications than thosejust discussed were minor and infrequent. All rumored reports of profound anemiaand prostration were traced to the sources and all were found to be groundless.
REGENERATION OF HEMOGLOBIN
Initial Studies
In June 1941, Dr. Taylor (15) reported an analysis hehad received, in a personal communication from E. M. Katzen, of a carefullycontrolled study of 100 professional male donors of the Blood TransfusionAssociation, New York City. These 100 men had given 3,617 transfusions,averaging 525 cc. each, over periods ranging from 4 to 14 years and averaging 7years. They had given from 16 to 101 times during the period of observation, anaverage of 36 times per donor. They were required to rest 1 week betweentransfusions for each 100 cc. of blood donated. They had hemoglobindeterminations every month they gave blood and a routine checkup every 3 monthsif they had not donated in the interval.
None of these donors showed any significant failure toregenerate hemoglobin when they were studied at the end of their rest period,and over the years there had been little variation from their originalhemoglobin values. This long-term study was taken to indicate that repeatedblood donations at stated intervals had no deleterious effects on healthydonors.
At a meeting of the Subcommittee on Blood Substitutes on 23June 1942 (8), Dr. Taylor pointed out that the immense number of donorsrecruited by the Red Cross Blood Donor Service offered opportunities forinvestigation, particularly studies of hemoglobin regeneration, which should notbe neglected. At the meeting of the subcommittee on 17 November 1943 (16), hereported the studies of Dr. Charles Doan, Ohio State University College ofMedicine, on over 4,000 donors who had given blood from one to five times at theRed Cross donor center at Columbus, Ohio. When blood was given every 8 weeks,about 80 percent of the women donors showed prompt return to their originalhemoglobin values. The remaining 20 percent did not, nor did their values returnto the original levels even when the interval between donations was as long as 4months. In view of these facts, it seemed to Dr. Taylor that a certain number ofdonors would either have to be rejected (and the Tallqvist technique,unfortunately, was difficult to read at the 80-percent level, then the criticallevel for rejection of donors) or would have to be given iron.
Dr. Doan's data confirmed the observations made by Fowlerand Barer (17) at the State University of Iowa College of Medicine on 200donors, who gave blood for 636 transfusions.
The idea of administering iron to donors was not wellreceived by some of the committee members, who thought it a dangerous policy forRed Cross donor centers to practice medicine. Dr. A. M. Fisher, who was presentas a representative of the Canadian National Research Council, said thatdonations in
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Canada were now limited to five a year. Some Canadian donorcenters prescribed iron but others thought it a poor policy to suggest to donorsthat they might not regenerate blood promptly.
The problem of posttransfusion anemia in women donors wasdiscussed at a subsequent meeting of the Subcommittee on Blood Substitutes (18)and at the Blood Donor Conferences held in December 1943 and January 1944 (p.119). Captain Taylor reported at these meetings that several studies carried outby the Red Cross had showed that a certain percentage of female donors developedsome anemia after blood donations, but he did not consider it justified to saythat "medical authorities were becoming worried about possible resultantanemias." At the January 1944 conference, there was general agreement thatthe incidence of posttransfusion anemia was about 15 percent, but there wasopposition to the administration of iron by physicians at the blood donorcenters.
Recommendations of Ad Hoc Committee
An ad hoc committee (Dr. Elmer L. DeGowin, Chairman, CaptainTaylor, Col. Douglas B. Kendrick, MC, Captain Newhouser, Dr. Max M. Strumia)appointed at the 5 January 1944 meeting of the Subcommittee on Blood Substitutesmet on 19 January 1944, with Dr. Doan; Dr. Willis M. Fowler; Dr. Carl V. Moore,Washington University School of Medicine; and Dr. William Thalhimer. It wasagreed:
1. That the Tallqvist test for hemoglobin washighly inaccurate and had not been effective in the selection of donors withoutanemia.
2. That many female donors who should not havegiven blood had been accepted on the basis of this test.
3. That the Red Cross, to preventposttransfusion anemia, must devise other standards for the selection of donors.Changes in the technique of selection had been impractical up to this time,particularly in mobile bleeding units, because there had been no quick,accurate, and simple technique available to determine the hemoglobin level.
The ad hoc committee recommended:
1. That the recently devised Thalhimermodification of the copper sulfate technique of Phillips, Van Slyke et al. (p.257) be used to determine the critical level of hemoglobin for the selection orrejection of donors. This test had the additional advantage of indicatinghypoproteinemia; Dr. Doan's data suggested that some women tend to regenerateplasma proteins after transfusion even more slowly than they regeneratehemoglobin.
2. That over the next 6 weeks, Dr. Doancompare the accuracy of the prescribed method with that of the Evelyncolorimeter in the blood donor center at Columbus, Ohio. Final acceptance of thecopper sulfate method should await his final report.
3. That arrangements be made to procure thesolutions used in the copper sulfate test and to procure photoelectriccolorimeters to use for occasional quantitative determinations of hemoglobin inmultiple donors and for checking the accuracy of the copper sulfate technique.
4. That the minimum level of hemoglobin foracceptable donors of both sexes be tentatively placed at 11.5 gm. percent. Bythis criterion, if Dr. Doan's data were correct, about 25 percent of allfemales and about 20 percent of all males living in conditions similar to thosein Ohio would be rejected. Final action on this point would be taken afterreceipt of further studies by Dr. Doan on multiple donors.
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5. That Drs. Doan and Moore be permitted toprescribe iron at their discretion in the blood donor centers at Columbus andSt. Louis. Dr. Doan wished to give iron only to re-donors who regeneratedhemoglobin slowly. Dr. Moore wished to test its effect on the incidence ofrejections of re-donors. Both physicians were asked to observe the effect of itsprescription on relations of the centers with the local medical profession.
No action would be taken, until additional data wereavailable, on the volume of blood to be collected from female donors; on theincidence of rejection of female donors in the age group 18-21 years; and on anincrease of intervals between donations in women. At the urgent request ofCaptain Taylor, who thought it highly undesirable to question women on thispoint, no recommendations were made concerning donations during menstruation.
In further discussion of iron therapy, it was concluded thatsince medical practice varied in different localities, the local technicalsupervisor was in the best position to judge the repercussions of any givenpolicy on the local medical profession and on the procurement of donors. Therewas general agreement that repeated bleedings undoubtedly producediron-deficiency anemia in some women and that the Red Cross, because of itspublicity concerning the safety of blood donations, was morally if not legallyresponsible for it.
Followup Actions
By 21 April 1944 (19), all blood donor centers hadbeen supplied with materials for the Thalhimer-Phillips-Van Slyke copper sulfatetest. The solutions were adjusted to a hemoglobin concentration of 12.3 gm. forall donors, since it had been found in over a thousand males tested that only 5had hemoglobin levels below 13.5 gm. percent. With a minimum standard of 12.4gm. percent, about 10 percent of prospective female donors had been rejected,the incidence being slightly higher at the Columbus Blood Donor Center than atothers. The correlation between the Evelyn and the copper sulfate techniqueswas reported as good. The solutions were regularly checked for accuracy.
In view of these data, it was recommended that a singlestandard of hemoglobin, 12.3 gm. percent, be used as a minimum for donors ofboth sexes.
Statistics averaged for several centers for May 1944,covering a total of 12,545 prospective women donors, showed a rejection rate of17 percent (3). The rate was 10 percent for 6,000 first-time donors,which was the expected figure arrived at on the basis of a large series ofdeterminations by the photoelectric cell colorimeter. On their initialappearance, only 0.3 percent of male donors were found to have hemoglobin valuesbelow the minimum of 12.3 gm. percent. The male rejection rate on re-donationvaried from 0.2 to 8 percent. The rejection rate in female donors ranged from 12to 55 percent.
No further changes were made in the minimum hemoglobin levelduring the remainder of the war.
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References
1. Robinson, G. C.: American Red Cross Blood Donor ServiceDuring World War II. Its Organization and Operation. Washington: The AmericanRed Cross, 1 July 1946.
2. Minutes, meeting of Subcommittee on Blood Procurement,Division of Medical Sciences, NRC, 18 Aug. 1941.
3. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 2 June 1944.
4. Phalen, J. A.: The Blood Plasma Program. Division ofMedical Sciences, NRC. Washington: Office of Medical Information, 1944.
5. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 13 July 1944.
6. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 10 Mar. 1942.
7. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 12 May 1942.
8. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 23 June 1942.
9. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 20 Oct. 1942.
10. Lozner, E. L., and Newhouser, L. R.: Studies on theTransmissibility of Malaria by Plasma Transfusions. Am. J. M. Sc. 206: 141-146,August 1943.
11. Taylor, E. S.: Procurement of Blood for the Armed Forces.J.A.M.A. 120: 119-123, 12 Sept. 1942.
12. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 18 July 1941.
13. What About Blood Donations by War Workers? A Discussion bythe Medical Committee of Industrial Hygiene Foundation and Other MedicalSpecialists. Pittsburgh: Industrial Hygiene Foundation,April 1943.
14. Boynton, M. H., and Taylor, E. S.: Complications Arisingin Donors in a Mass Blood Procurement Project. Am. J. M. Sc. 209: 421-436, April1945.
15. Taylor, E. S.: Blood Procurement for the Army and Navy.Preliminary Report. J.A.M.A. 117: 2123-2129, 20 Dec. 1941.
16. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 17 Nov. 1943.
17. Fowler, W. M., and Barer, A. P.: Rate of HemoglobinRegeneration in Blood Donors. J.A.M.A. 118: 421-427, 7 Feb. 1942.
18. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 5 Jan. 1944.
19. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 21 Apr. 1944.
