The evolving profile
of CBS blood donors
Mark Bigham
BC Yukon Centre
Transfusion Medicine Rounds
15 May 2009
1
Acknowledgment
• Mr Tony Steed
– CBS, Dir, Market Knowledge and Donor Insights
• Mr Steve Harding
– CBS, Exec Dir, Marketing and Communications
• Dr Mindy Goldman
– CBS, Exec Med Dir, Donor and Transplantation Svces
• Dr Margaret Fearon
– CBS, Exec Med Dir, Med Micro
• Mr Vito Scalia
– CBS, Dir, Nat’l Testing Laboratory
• Dr Sheila O’Brien
– CBS, Dir, Nat’l Epidemiology and Surveillance
2
Alert Clauses
• Potential threats to objectivity
–
–
–
–
–
H.sapiens
Male
Boomer
CBS medical consultant
Public health lens
• Some personal views expressed
– although others may hold privately or express publicly
3
Determinants of CBS Donor Profile
Donor Profile is influenced and shaped by
– Population Characteristics
• Demographic, health characteristics, exposure risk, socioeconomic
cultural factors
– Donor (self)-selection determinants of donation
– CBS Donor Marketing and Recruitment Strategy
– Government (Regulator) standards and regulations and
Professional practices, guidelines and recommendations;
and
– CBS scientific review, business decisions, policies and
procedures
4
Blood demand-supply alignment
5
the challenge… increasing demand
need to grow active donor base by 7% over the next 4 years
recent growth rates ~ 0.7%/yr
W h o le B lo o d T a rg e ts & R e q u ire d D o n o r B a s e
475
1000
956
450
950
939
450
445
922
443
438
435
901
425
431
900
427
417
400
850
2 0 0 8 -0 9
2 0 0 9 -1 0
@ 2 .1 6
6
2 0 1 0 -1 1
W ith D o u b le R e d s
2 0 1 1 -1 2
2 0 1 2 -1 3
W B T a rg e ts
W h o le B lo o d U n its (th o u s a n d s )
D o n o rs R e q u ire d (th o u s a n d s )
973
Slower increase in blood supply +
flat-lined total active donor base
Whole Blood - Donation Frequency, Units and Donors
Trailing 12 months
1,000,000
2.3
849,932
842,356
871,815
875,113
872,505
809,913
803,551
Number of Donors & Units
2.2
2.18
2.16
2.11
600,000
2.1
2.09
403,685
400,000
2.18
2.16
388,290
399,919
390,472
403,247
405,044
400,596
2
1.99
200,000
1.9
-
1.8
MAR '02
MAR '03
MAR '04
MAR '05
MAR '06
MAR '07
Fiscal End
Distinct Donors
7
Whole Blood Units
Whole Blood Avg Donation Frequency
MAR '08
Annual WB Donations per Donor
800,000
Donor Base Dynamics
Total CBS donor-eligible population ~ 13 million
~3% Participation Rate
Number
Donations
Whole Blood Donors
Fiscal 2007/08
1x
184,157
46.0%
2x
88,907
22.2%
3x
53,995
13.5%
4x
35,588
8.9%
5x
23,054
5.8%
6x
13,337
3.3%
7x
1,558
0.4%
Avg 2.18/year
(+0.02)
400,596 Active Whole
Donors (-1.1%)
136,167 lapsed
donors/year (+2.9%)
(~30% of donor base)
8
73,650 new
donors/year (-6.0%)
(12.6% of collections)
75,907 reinstated
donors/year (+9.2%)
(13.0 % of collections)
~251,039 repeat
donors/year (-1.4%)
(74.4 % of collections)
800,000 lapsed donors in
database
Donor Profile
Population Determinants
• demographics
–
–
–
–
population growth
ethnic diversity
urbanization
age
• Health characteristics
• exposure risk
– e.g. no geographic vCJD deferral for
RBC/plts in UK
– No geographic deferral for Babesiosis in
Canada
• Socioeconomic, cultural issues
– language, societal values (community
cohesion, volunteerism)
– priority of donation among volunteer
opportunities
9
Projected ↓ rate population growth
growth driven by new Canadians
500
As natural population growth falls, immigration becomes the sole
source of growth
400
300
Natural
Increase
200
100
-200
Years
Source: Environics-Analytics
10 - Demographic Trends: Results from the 2006 Census
Source: Statistics Canada, Population Projections Cat No. 91-520 (scenario 3 Immigration average 260,000)
51
0
2
46
2
0
41
2
0
36
0
2
31
0
2
26
0
2
21
2
0
16
0
2
11
0
2
06
0
2
01
0
2
96
9
1
91
9
1
86
9
1
9
1
9
1
-100
81
0
76
Thousands of persons
Net Migration
↑urbanization
11
12
and ↑ diversity
Top 5 recent (1991-2001) immigrant groups
Toronto
Chinese
Indian
Pakistani
Filipino
Sri Lankan
Montreal
Algerian
Chinese
French
Haitian
Moroccan
Vancouver
Chinese
Taiwan
Hong Kong
Indian
Filipino
OttawaGatineau
Chinese
Indian
Iranian
Somali
Yugoslav
Calgary
Chinese
Indian
Filipino
Pakistani
British
Edmonton
Indian
Filipino
Chinese
Winnipeg
Filipino
Indian
Hamilton
Yugoslav
Chinese
Bosnian
Iraqi
Indian
Source: Citizenship and Immigration Canada, Mar 2009 At:
http://www.cic.gc.ca/EnGLIsh/resources/research/ethnic-segregation/settlement.as
13
By 2017, 20% of Canadians a visible minority
8
25
20
6
5
15
Millions
Percent
4
10
3
2
5
1
0
0
1981
1986
14
1991
1996
2001
2006
2011
2017
Percent of population
Millions of Persons
7
Evolution of visible minorities in Canada
Japanese
Korean
2017
West Asian
2001
Arab
South-east Asian
Latin American
Filipino
Black
South Asian
Chinese
0
200
400
600
800
1000
Thousands of persons
15
1200
1400
1600
1800
2000
speaking “non-official” languages…
Source: Gov’t of BC,Multiculturalism and Immigration Branch, Feb 2008 At: www.welcomebc.ca
16
The top five non-”official” languages spoken
at home in Canada
• Chinese
– comprising 8 language categories including Mandarin
and Cantones
•
•
•
•
•
Italian
German
Punjabi
Spanish, in that order.
strong growth in recent years in Urdu, Arabic
and Tagalog (Philippines).
Source: Council of Europe/ERICarts, "Compendium of Cultural Policies and Trends in Europe, 10th
edition", 2009
17
..older
Donor Age Distribution vs. Canadian Population
by Donation Type
4.50%
4.00%
3.50%
3.00%
2.50%
2.00%
1.50%
1.00%
0.50%
WHOLE BLOOD
18
PLASMA
PLATELETS
Canadian Population (2006 Projection)
75
73
71
69
67
65
63
61
59
57
55
53
51
49
47
45
43
41
39
37
35
33
31
29
27
25
23
21
19
17
0.00%
…and not getting younger
A g e D is trib u tio n o f B lo o d D o n o rs
2 0 0 1 to 2 0 1 5
30%
25%
Median Age:
2001
38.9
2007
41.6
2015
42.5
20%
15%
10%
5%
In 2007 donors aged 50+ accounted for 30% of
our whole blood donors and 37% of
donations, up from 22% and 27% respectively
in 2001. At current participation rates, 35% of
our donors will be 50+ by 2015
0%
L e ss
Than 20
2001
19
20 - 29
30 - 39
2007
40 - 49
50 - 59
60 - 69
70 or
o ld e r
2 0 1 5 (a t c u rre n t p a rtic ip a tio n ra te s )
CBS’s response – Growth-oriented donor marketing and
recruitment/retention strategy
Marketing Efficiency
Data
Access
Foundation
Reporting,
Profiling
Informed
decision
making
Current
Value
Differentiate
donors
according to
their
contribution
Segmentation
Differentiate
donors
according to
behavior,
attitudes, or
neighborhood
characteristics
Relationship Building
20
Predictive
Modeling
Potential
Value
Highest level of
Interact directly Customization.
Potential Value
with donors
calculated for
with highest
each donor
likelihood to
respond
Population Health/Chronic Disease Trends
e.g. Diabetes
Canada,
Prevalence
1995 -2005
Source: Lipscombe,Hux. Trends in diabetes prevalence, incidence, and mortality in Ontario, Canada 1995–2005: a populationbased study. Lancet 2007
21
All-cancer, Canada, 1992-2005, Age Standardized
Incidence per 100,000 (Canada, 1991)
50-54
55-59
60-64
Source: Publ Hlth Agency of Canada, Cancer Surveillance On-line. Accessed 13 May 2009
22
Obesity (BMI >30), Canada, 1994-2007,
Prevalence, 45-64 yr olds
23
Donor Profile …
Determinants of donor self-selection
for giving blood
24
…a theoretical framework
25
Determinants of Donation – interface with CBS Marketing
and Recruitment Strategy
Cause Awareness
Understanding Importance of Blood Donation
Brand Awareness
Personal Relevance
Intent to donate – 22%
Whats YourType?
Partners for Life
media
Direct Mail
conversion
Operation Lifeblood
Donation – 3.2%
26
Donor profile…
Regulatory, Professional and CBS impacts
– Regulatory Standards
• CSA Z902-04 Blood and Blood Products
• Health Canada
– Biologics and Genetic Therapies Directorate
• The long shadow of FDA (and Council of Europe)
– Transfusion Medicine Professional Practices, Guidelines,
Recommendations
• AABB
– Technical Manual
• CSTM
– CBS scientific review and business decisions
• Policies and Procedures
27
Preface to Donor Criteria Manual,
CRCS BTS, 1st edition, 1979
“…regarding deferrals….unfortunately, with
a very few exceptions, there are no
scientific data available to support some of
these decisions, and it would require
studies of great magnitude and
questionable value to determine the
significance of every pathological condition
in relation to blood donation and blood
transfusion…”
28
1983
29
2009
30
31
…views of donor screening related to blood safety
Evidence-based
clinical, lab, epidemiologic factors, risk assessment
Precautionary principle
donor, recipient & societal views/values
of blood safety, risk perception, risk
tolerance
32
Donor eligibility criteria
– Medical discretion
• External Medical Enquiries
– Donor eligibility criteria change process
•
•
•
•
CBS internal or external driver
CBS Donor Selection Criteria Working Group
CBS Regulatory Affairs
Health Canada
33
Donor Eligibility Controversies
MSM
McLaughlin Centre for Pop Hlth Risk Assessment report, 2007
• Donor view: human right/discriminatory deferral criteria
• Recipient view: asymmetry of inherent risk of blood tx
• Scientific view: HIV risk
34
Generic Donor Criteria
•
•
•
•
•
•
non-human primate a no-no
Age
Weight
Donation frequency
Vitals
Hb/Hct
35
Bugs we ask about directly or indirectly
(e.g. birth, residence, travel) which are
transfusion-transmissible
• HIV (+birth/residence >6/12 W. Africa re: Gp N HIV)
• Hepatitis
– HCV – whether or not natural viral clearance or Rx SVR (+ jail)
– HBV – even if acute resolved infection and “protective” titer anti-HBs
– HAV
•
•
•
•
•
Malaria (adapted USCDC criteria for birth, residence, travel)
Babesiosis
Chagas (+birth, residence, travel > 6/12 Mexico, Cent/S.Am)
Leishmaniasis
vCJD (UK, France, W. Europe, 1980-96) (or if immediate
blood relative had CJD)
• syphilis
36
Meds/Rx we ask about (directly or indirectly)
which are transfusion-transmissible
• In utero teratogenicity
– Vit A/retinoid derivatives (e.g. acutane)
– Antimetabolites (e.g. MTX)
– Hormonal effectors (e.g. anti-androgen finasteride or
pro-androgen danazol)
37
Bugs we ask about which may be
transfusion-transmissible
• Live attenuated vaccinations
– chicken pox vaccine 3/12
– MMR 12 wks
– HB 28 days (HBsAg assay interference)
38
Bugs/diseases we ask about which are
unlikely or not transfusion-transmissible but
donors deferred anyways
• CJD – dura mater graft, human pituitary
GH/gonadotropin
• All cancer except basal, squamous, cervical in situ
• Gonorrhea
• Simian Foamy virus through occupational monkey
contact
• Crohn’s
39
Bugs we don’t ask about or test for,
which are transfusion-transmissible
•
•
•
•
•
Dengue – 3/12
Erlichiosis – would be permanent
HHV-8 (Kaposi) – no deferral
Parvo B19 – if feeling well
HGB virus – no deferral
… or may be transfusion-transmissible
• H. simplex – 1 yr post-primary episode
• EBV – 6/12
• H. zoster (chicken pox) – 3 wks
40
Bugs/diseases we don’t ask about which are
unlikely or not transfusion-transmissible but
are deferred anyways
•
•
•
•
•
Multiple Sclerosis
Ankylosing Spondylitis
SLE
Fibromyalgia (if on meds)
Lyme (tick bite) – 6 months
41
in-your-face Questions
• Blood and sexual contact
– MSM or female partner of MSM since 1977
– Sex trade worker or sex for $/drugs
– IDU
– Sex with W. African, person with HIV,
hepatitis, “whose sexual background you
don’t know”
– Blood tx in UK, France, W. Europe or W.
Africa
42
Donor safety Deferrals
•
•
•
•
Anemia/bleeding disorders
Heart disease
Repeated syncopal episodes
Epilepsy
43
…in case you were wondering….
•
•
•
•
•
•
•
Hemochromatosis …the “motive” question
Anemic males
Transgendered
Transvestites
Lesbians
doctors
“odd” persons – behaviour, comprehension,
accuracy and reliability of hx, informed consent
44
How much risk reduction (RR) is attributable
to donor screening?
• Attributable RR of Questionnaire (direct/indirect-incl donor
self exclusion)
– ~20% deferral rate, mostly 1st time donors
– Population prevalence - 1st time donor test prevalence
• Attributable RR of Repeated TD testing (i.e. repeat donors)
– reactive test prevalence in 1st time donor– reactive test prevalence in
repeat donor
• Recipient Residual Risk
– weighted false-negative test prevalence in test-negative 1st time and
repeat donors
45
HIV prevalence per 100,000 CBS donations, 1990-2006
Prevalence per 100,000 Donations
30
First Time
Repeat
25
20
15
10
5
0
1990
1992
1994
1996
1998
Year
46
2000
2002
2004
2006
HCV prevalence per 100,000 CBS donations, 1990-2006
Prevalence per 100,000 Donations
400
First Time
Repeat
300
200
100
0
1990
1992
1994
1996
1998
Year
47
2000
2002
2004
2006
Pathogen Inactivation
The future direction of allogeneic blood safety
www.hc-sc.gc.ca48
Thank you
49
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