Donor awareness : key to successful voluntary blood donation

The current regulatory requirements for donor eligibility pose a Context: challenge to blood centers in recruitment of voluntary blood donors, particularly in a developing country like India where awareness of the general population is low and myths about blood donation are prevalent. This study evaluates the reasons and rates of donor deferral in a tertiary hospital-based blood bank in western India. To find rates and reasons for deferral of voluntary blood donors in a city in Aim: western India. Settings and design: A retrospective study was done on blood donors during a 3-month period. Data collection was done by electronic records of blood donors. The study was conducted retrospectively at a tertiary Materials and Methods: care hospital in western India. All those who donated whole blood between 1st January 2011 and 31st March 2011 were included in the study. Data was collected using local blood bank software. Statistical analysis used: No statistical technique used as it is a data article. 60.5% of donors were young, below 30 years of age. Donors were Results: predominantly male (91.6%). Voluntary donors comprised 88% of the donors. Total deferral rate was 22.36%, with 17.29% permanent deferrals and 82.71% temporary deferrals. Main reasons for deferral were anemia 39.42%, low body weight 14.29%, hypertension 10.73%, age below 18 years 10.73% and history of medication 6.09%. The common causes of deferral between our study and other similar studies are the same. We concluded that majority of the donor population belongs to Conclusion: 18–30-year-old age group. This is encouraging with a voluntary blood donation initiative. Donor self exclusion and strict donor selection criteria application should be addressed by more proactive measures to make blood donation a safe and pleasurable experience. 1 1


Introduction
Blood donor selection criteria according to the guidelines of the National AIDS Control Organization are based on science, informed medical opinion and regulatory rules, its statistics show that annual rate of blood donation in India is about 7.4 million units, against requirement of 10 million units 1 .According to the Drugs and Cosmetics Act, not every person who walks into a camp/blood bank for blood donation is a donor.Donor by definition is a person who, after complete medical examination by the doctor, is declared fit for donation of blood.To make blood donation safe and increase the confidence of the masses in voluntary blood donation, many safety measures are implemented by the blood transfusion community.
The most important of all safety measures is donor selection.Stringent, meticulous and serious donor screening is necessary to afford protection to blood donors and recipients 2 .The rates and reasons for donor deferral vary from region to region and from one center to another 3 .

Subjects and methods
We obtained full ethics approval for this study from the Ethics Committee of the Santokba Durlabji Memorial Hospital and Research Center, and the study was conducted in our blood bank from 1 st January to 31 st March 2011.We included all individuals coming for whole blood donation in blood bank and camps.There were a total of 8700 individuals during the three-month study period, comprising 7970 (91.6%) males and 730 (8.4%) females.(Table 1) 90% of the donors was voluntary.Most of the donors were residents of our city or within 100 km radius.The volume of whole blood collected was according to donor weight: 50-60 kg -350 ml and > 60 kg -450 ml.
Each donor was selected by the medical officer after taking detailed medical history and general physical examination, which included body weight, temperature, pulse rate and regularity and blood pressure.Deferred donors were classified as temporary deferral or permanent deferral.We followed deferral criteria laid down in the Drugs and Cosmetics Act 1940 (the rules there under) and Technical manual -Director General Health Services and Drug Controller of India.Standard operating procedures based on national guidelines were used for donor selection and deferral.The cut off for hemoglobin was 12.5 gm/dl by fingerpick method.All donors were screened for Hemoglobin values using CuSO 4 specific gravity method.Doubtful Hemoglobin values were confirmed by Hemocue 201+.In case of indoor donors, i.e. in blood bank, hemoglobin was estimated by Sysmex Kx21, fully automated complete blood count (CBC) counter.

Editorial note:
Please note that the refereeing status of this article was changed from "indexed" to "[v1; ref status: approved with reservations 2]".
When this article was first published, F1000Research was still in its beta phase; during this period articles that received any two of "Approved" or "Approved with Reservations" statuses from the reviewers were labelled as "indexed".When the journal was formally launched in January 2013, the requirements for indexing were tightened, and only articles that are given either two "Approved" or one "Approved" plus two "Approved with Reservations" statuses by the reviewers are labelled "indexed".
The new criteria for "indexing" can still be met in the future if a new revised version receives the necessary approval status from the reviewers.

Discussion
This study attempts to analyze the pattern of blood donation in a tertiary care hospital between Jan 1 st 2011 to 31 st March, 2011, in an emerging metropolitan city of western India.
Donor rejection or deferral leaves a person with negative feeling about themselves as well as the blood banking system.However, there are definite advantages of elimination of donors in order to ensure the safety of blood donors as well as recipients of blood/ blood products.Deferring donors also protects donors from possible adverse reactions and avoids consequent negative impact on donor motivation.
In our study the deferral rate was found to be 22.22% (1938).
The lowest rejection rate was reported by Talonic 6 (4%) in Papua New Guinea while Chaudhry 7 , Lim 2 , and Ranveet 8 , Unikrishnan 9 , Sunder 10 reported 8-15% deferral rates in their studies.The comparatively higher deferral rate in our study was due to the stringent donor selection criteria, strict adherence to guidelines of the National Aids Control Organization and National Accreditation Board for Hospitals & Healthcare Providers.Women had a very high deferral rate in comparison to men reflecting the poor nutritional status of female population in our country.Similar observations were reported in studies in Manipal 9 , Delhi 11 and Banglaru 10 .
As reiterated in the national health policy of achieving 100% voluntary donation, our blood bank received 88% of its donors as voluntary donors in comparison to 12% replacement donors, which is way above the national average of 39.3% 11 .Voluntary donation adds to the quality and safety to blood donors and as there is no peer pressure on either the donor or the medical officer; evaluation of donors is purely on the basis of donor selection criteria.There were 335 (17.29%) permanent deferrals as against 1603 (82.71%) temporary deferrals.In a similar study, Custer et al. 5 reported 68.5% temporary and 31.5% permanent deferrals.The lower numbers of permanent deferrals in our study are due to the majority of young donors.A total of 5263 (60.5%) donors were below 30 years of age (Table 2).It is due to active blood donation motivational activities and programs carried out by blood banks in educational institutes through lectures, presentations, posters and pamphlets that large number of young individuals are recruited, thereby strengthening long-term voluntary blood donation belts.In Shaz's study 12 , donors aged more than 60 years were allowed to donate, but in India, individuals above 60 years of age are not permitted to donate blood, but we received 913 (10.5%) donors who were between 50-60 years of age.
The minimum hemoglobin for blood donation is 12.5 mg/dl.Despite all efforts by the government towards reducing nutritional anemia, it is still very common in our country.This is evident from the finding that the most common cause of deferral in our study was low hemoglobin in 764 (39.42%) donors.Low hemoglobin was the commonest cause of deferral in most of studies by Sunder et al. 11 , Charles et al. 13 and Agnihotri N 14 .The minimum cut-off hemoglobin level for blood donation is >12.5 gm% irrespective of sex.The second most common cause for deferral was body weight below 50 Kilograms 277 (15.48%), followed by under age 151 (7.79%).Body weight is related to poor health status of the general population and poor nutrition being common in low socio economic groups.Under-aged potential donors were unaware of basic requirements for blood donation, i.e. age, weight and hemoglobin percentage, indicating the importance of public awareness and education for successful voluntary blood donation.We mostly received voluntary donors, the majority of them in camps.Perhaps the organizations involved in recruiting donors are more enthusiastic in gathering people and pay less emphasis on the eligibility criteria, which adds to the large number of under-aged (151 [7.79%]) and underweight (277 [15.48%]) donors, thus resulting in deferrals.It is of utmost importance for organizations hosting blood donation camps to understand that blood donation is a science and meticulous donor screening is essential.The eligibility criteria for blood donation should be followed stringently; unnecessary gathering of people causes wastage of resources.Self exclusion by donors themselves is the answer to these problems.Self deferral by donors is only possible when our population is educated about selection criteria for blood donation.
Hypertension was the most common cause for permanent deferral 208 (10.73%).Hypertension was noted as common cause of deferral in a similar study by Bahadur et al. [11][12][13] .It was surprising that hypertension, along with cardiac problems, was roughly equally distributed in various age groups.In younger age groups, this might be due to apprehension and anxiety for donation, induced by fear of phlebotomy or fear of the sight of blood.Hypertension is a growing, undiagnosed, epidemic in our country, where people seek medical advice on appearance of signs and symptoms, and seldom go for annual checkups.Additionally, use of electronic blood pressure equipment, with more objective readings could have picked up more hypertensive donors.The use of drugs, particularly antibiotics, antihypertensive and analgesics, was a significant reason accounting for 118 (6.81%) of deferrals (Table 3).
Indian studies from Chandigarh 8 and Lucknow 7 report jaundice as the most common cause of deferral.In a study by Halperin et al. 15 the three most common causes of temporary deferral were low hemoglobin, cold/sore throat and fever, whereas in a study by Ranveet et al. 8 , underweight, underage and low hemoglobin level were the most common causes.Hence, donor deferral studies indicate that in each region there are unique sets of reasons for deferral.
The objective during donor selection should be blood collection as well as donor safety.Safety of donors is important as it helps in gaining confidence and winning the trust of future donors as well.
Donor selection should be done with care, caution, sincerity and ethically, failing which we would be compromising donor safety and defeating the ultimate goal of 100% voluntary blood donation.In our country, where there are myths and social stigma attached with blood donation, we need to be very cautious in donor selection, as any harm to a donor would send the wrong message to the masses.Dorothy et al. 16 supported the view that medical examination may actually serve as an incentive for future repeated donations.
Anemia is the major cause of deferral.Referring such cases to physician for evaluation and treatment of anemia and asking them to donate at a later date is pivotal in ensuring donor recruitment and retention.

Conclusion
The study showed that most of the donors were between 18-to 30-years old.This is encouraging, as they could be motivated to become regular voluntary donors.Temporary deferral has a negative impact on blood donor return rate and subsequent donations 7 .It is necessary to follow strict donor selection criteria to make blood donation safe and win the trust of future donors.To strike a balance between donor selection and deferral, self exclusion by the donor is the key.This can be achieved by advertising campaigns, brochures, lectures, presentations, donor awareness programs and interaction with donors.The entire blood bank staff, especially medical officers, should share the responsibility of winning the confidence of donors and making blood donation a safe and pleasurable experience which will eventually increase voluntary blood donation, giving a permanent remedy to the shortage of blood in the country.

Open Peer Review
Current Referee Status: The study concluded that the deferral rate was 22.36% with a 17.29% permanent deferral rate for donors.Hypertension was the most common cause for a permanent deferral, and anemia was the most common cause for temporary deferral.Of interest, the paper concluded that the majority of donors were between 18-30 years of age.The limitations of this study are that it does not address issues of donor awareness and details about the recruitment process for these donors.Information is unavailable if these donors would in fact be return donors.Additional data, such as a survey given to donors, would be needed to understand the motivation of a regular voluntary donor and the impact of a temporary deferral.While this paper does give interesting information about deferral statistics, and meets the stated aim of the study, the results and conclusions do not really address donor awareness, and therefore conclusions are limited to assess the real impact on donor return rates in a voluntary donor program in India.
I have read this submission.I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
No competing interests were disclosed.The study itself seems to focus more on the reasons for deferral and not so much on awareness as stated in the title.Furthermore, there is no indication of the contents of an assumed awareness.

Competing Interests:
Blood Bank and Transfusion Medicine Department, Children's Hospital of Philadelphia, Philadelphia, PA, USA This article focuses on the challenges of blood donation in a tertiary care hospital in western India and presents a retrospective study of blood donor deferrals from a 3-month period from Jan 2011-March 2011.
Faculty of Medical Sciences, University of Groningen, Groningen, Netherlands Upon review, the title of the article and the actual research in the paper show a considerable discrepancy.

Table 1 . Distribution of Male and Female whole blood donors.
The table indicates the total of 8700 individuals for blood donation.It represents the percentage of male and female donor's selection, and indicates which percentage were deferred donors.

Table 3 .
Age profile of donors.The table indicates the age distribution of the donors, and highlights that the majority of them are young.

Table 4 . Deferral reasons among whole blood donors.
The table highlights the permanent and the temporary deferral explanations amongst the donors.
* Include Influence of alcohol, recent surgery, recent ear piercing, fever, recent tattooing, dental extraction, breast feeding and history of transfusion of blood/blood components.