PUBLIC HEALTH
Public health
Blood banking in China
Hua Shan, Jing-Xing Wang, Fu-Rong Ren, Yuan-Zhi Zhang, Hai-Yan Zhao, Guo-Jing Gao, Yang Ji, Paul M Ness
While transfusion-transmissible diseases, including AIDS and viral hepatitis, continue to spread especially in developing
countries, the issue of safeguarding the world’s blood supply is of paramount importance. China houses more than 20% of
the earth’s population, and thus its blood supply has the potential to affect the global community. In recent years,
Chinese blood centres have tried to improve the nation’s blood safety. Although substantial progress has already been
made, many daunting difficulties remain. Traditional cultural barriers need to be overcome to successfully mobilise
volunteer blood donors. Gaps in information and technology still need to be closed. Insufficiency of economic resources
also restrict the blood bank industry. Other developing countries face many of the same challenges as China.
In recent years, the HIV epidemic (in this article HIV refers
to HIV-1 and HIV-2) helped to focus the attention of the
Chinese public on the issue of blood safety, and the world’s
attention on these evolving health-care issues in China. The
most recent report from the Chinese Ministry of Health
estimated that there have been 850 000 HIV-infected
people in China, and the number of reported cases in 2001
was at least 40% greater than in 2000.1 The Chinese
National Centre for AIDS Prevention and Control
estimated that more than 97% of people with HIV in China
are unaware of their infection status.2 Viral hepatitis B and
C also pose sizeable threats to blood safety in China.3–6
A critical step in safeguarding blood safety is to recruit
volunteer donors from low-risk populations. Although
volunteer donor recruitment is a challenging proposition
worldwide, it has been especially difficult in China.7
Traditional Chinese culture holds that the loss of even a
small amount of blood has a substantial detrimental effect
on health. Some people also believe that donating blood is a
disloyal act against one’s ancestors. Old cultural beliefs,
combined with inadequate effort to mobilise volunteer
donors, have led to a chronic shortage of blood products,
which in turn has created a market for paid blood donations
and associated illegal practices. Even though the
government has increased its efforts to educate the public
about donation, many parts of China still cannot meet their
needs by donations from volunteer donors alone.
Therefore, many blood centres still accept employerorganised donations, which can involve coercion. A few
less-developed areas continue to collect whole blood from
paid donors. This report will discuss recent changes in
whole-blood donor recruitment as well as other aspects of
blood banking in China.
Lancet 2002; 360: 1770–75
Division of Blood Transfusion, HIV Specialty Testing Laboratory,
Department of Pathology (H Shan MD), and Division of Blood
Transfusion, Department of Pathology (P M Ness MD), Johns
Hopkins Medical Institutions, Baltimore, MD 21287, USA; Institute
of Blood Transfusion, Chinese Academy of Medical Sciences,
Chengdu, Sichuan, China (J-X Wang PhD, Y Ji MD); Beijing Red Cross
Blood Centre, Beijing, China (F-R Ren MS, H-Y Zhao MD, G-J Gao MD);
and Xinjiang Autonomous Regional Centre for Disease Control and
Prevention, Urumqi, Xinjiang, China (Y-Z Zhang MD)
Correspondence to: Dr Hua Shan
(e-mail: hshan@jhmi.edu)
1770
Current practices
Structure of Chinese blood bank system
Whole-blood units for clinical use are collected at blood
centres. There are more than 400 blood centres in
China at three levels: provincial, regional, and county.
Local government health offices oversee the operation of
Chinese blood centres. Additionally, there are more
than 10 000 hospital blood banks. The Ministry of
Health is responsible for establishment of national
policies on health-related issues, whereas the subsidiary
Division of Blood Product Management directly
regulates the country’s blood-bank industry. The
recently expanded Chinese Society of Blood
Transfusion consists of eight committees that include
the Blood Donor Motivation Committee, the Blood
Quality Management Committee, the Blood Products
Committee, and the Clinical Transfusion Committee.
The Chinese Society of Blood Transfusion and the
National Blood Standardisation Committee advise the
Ministry of Health in setting national policies. The State
Drug Administration licenses test kits used in bloodbank testing. The State Council, which oversees both
the Ministry of Health and the State Drug
Administration, is the country’s legislative government
body with the power to establish laws regulating blood
banking. The Chinese Red Cross Society functions
mainly by assisting the government in donor recruitment
and in facilitating cooperation with the International
Red Cross. The Institute of Blood Transfusion (under
the Chinese Academy of Medical Sciences), the
Shanghai Blood Center Research Institute, and the
Institute of Transfusion Medicine (under the Chinese
Academy of Military Medical Sciences) and Beijing Red
Cross Blood Center Research Institute are leaders in
blood-bank research in China.
The Chinese plasma derivatives industry is regulated
separately by the National Institute for the Control of
Pharmaceutical and Biological Products, which is a
division of the State Drug Administration. As a result of
strict criteria in certifying manufacturing facilities in
recent years, the number of licensed manufacturers of
plasma derivatives has fallen from more than 100 to
about 30. There are more than 200 licensed source
plasma collection centres in the country. Yearly, more
than 1 million L of source plasma are collected by
apheresis, mostly from paid donors. China strictly
restricts the importation of blood products.
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PUBLIC HEALTH
Recruitment of whole-blood donors
Because of the shortage of volunteer donors, China has
had to rely on various other methods to motivate donors.
The responsibility of donor recruitment was placed with
local governments. They often assigned donation quotas to
work units such as factories and universities, who then
might have to meet the assigned quota to ensure that
individuals from that group received favourable pricing
and even access to blood products. Because of the general
reluctance to donate blood, employers often pressured
employees into donating, by use of incentives such as small
monetary compensations and time off work. Thus, many
of these donors were not true volunteers. They were also
different from paid donors, because the compensation they
received was relatively small, and as a group their
socioeconomic situation was much better than that of most
paid donors.
When employer-organised donations still could not
meet the demand for blood, a market grew for wholeblood donors to sell blood. Paid donors typically came
from poor rural areas and sold blood to supplement their
income. Until recently most whole-blood units collected in
China were from either employer-organised or paid
donations. This situation has changed gradually since
1998, when the new blood donation law became effective.
This law bans all paid whole-blood donations for clinical
use and encourages all Chinese citizens between the ages
of 18 and 55 years, who meet the health criteria for blood
donation, to donate blood voluntarily.8 The blood-bank
industry started a movement that aimed to shift
responsibility for recruitment from government and
employers to the blood centres. Increasing numbers of
volunteer donors now donate at blood centres or mobile
stations set out by blood centres in strategic locations.
Although this transition will take more time to complete,
initial results are encouraging. At a national blood safety
workshop held in Chengdu, some blood centres—
including those in Shenzhen, Xian, Zhengzhou, and
Qingdao—were reported to have already achieved the goal
of meeting all their regions’ blood needs with volunteer
donations. Table 1 shows data reported by Shenzhen
Blood Centre that show the gradual increase of voluntary
donations. Many other regions still partly rely on
employer-organised donations.
Nationwide, the proportion of blood for clinical use
collected from volunteer donors has steadily increased
from 11% in 1996 to 67% in 2000 (data from Chinese
Society of Blood Transfusion). According to the Chinese
Society of Blood Transfusion, the numbers of whole-blood
units collected in 1996, 1998, and 2000 are about
5·9 million, 7·0 million, and 8·2 million, respectively.
More than 90% of whole-blood units collected in China
are 200 mL units. The small donation volume contributes
to the blood shortage and the high cost of blood products.
Many blood centres have programmes that encourage
Period
1993
1994
1995
1996
1997
1998
1999
2000
2001
The number Increase compared with
of donations previous year
Proportion of all
transfused units
55
249
6202
17 517
34 456
60 175
77 803
92 648
96 320
0·18%
0·64%
18%
41%
64%
86%
100%
100%
100%
353%
2390%
182%
100%
75%
30%
19%
4%
Table 1: Trends in volunteer whole-blood donation from
Shenzhen City
THE LANCET • Vol 360 • November 30, 2002 • www.thelancet.com
donation of larger units. In 1999, 37% of all donors in
Shenzhen City gave donations in units of 400 mL; this
proportion increased to 53% in 2000, and remained around
52% between January and March, 2001.9
Clinical transfusion practices
The degree of service provided by hospital blood banks
varies greatly. Functions of a typical hospital blood bank in
China include blood storage, pretransfusion tests, and
distribution of blood products. Large hospital blood banks
undertake leucoreduction (by filtration) and irradiation of
blood products; for small hospitals, these procedures are
usually done at blood centres on request. In many hospitals
in rural areas, much of the need for red-blood-cell
transfusion is still met by whole blood. To promote
transfusion of components, the Ministry of Health has set
graded goals on the basis of the size of the hospitals. For
large hospitals, at least 70% of all blood products transfused
should be in the form of components. By contrast, small
hospitals can still use whole blood to meet up to 80% of
their transfusion needs. Beijing has increased its use of
components from 35% in 1996 to 84% in January, 2001. In
Shanghai, red-cell concentrates are used in more than 95%
of red-cell transfusions. Nationwide, components were used
in about 40% of transfusions in 2000, compared with 20%
in 1996 (data from Chinese Society of Blood Transfusion).
The old beliefs that created the fear of donating blood
have also been responsible for common requests for
unnecessary transfusions. The notion that a blood
transfusion is always beneficial to health is widespread.
Even though public awareness of diseases that can be
transmitted by transfusion has increased, most transfusion
experts in China that believe that blood is quite frequently
used as a “health booster” in rural areas. Unjustified
transfusion of plasma is also thought to be quite common.
On the other hand, the per-head use of blood products is
still lower than in most developed countries. In Shanghai,
one of the most modern cities in China, use of red blood
cells (or whole blood) is about 25% of that in the USA (data
from Chinese Society of Blood Transfusion). Numbers of
donations in China have risen in correspondence with an
increased need, as advanced medical procedures are
introduced. In 2000, Beijing Red Cross Blood Centre
received about 12 000 donations of platelet products by
apheresis, which was more than 18% more donations than
they received the previous year.
Clinical transfusion specialists are in short supply. Most
medium and small hospitals do not have transfusion
committees and guidelines. Surgeons and other physicians
who order blood products rarely receive feedback or
guidelines, except in large academic hospitals.
Donor testing
The Ministry of Health requires the following tests for all
blood products collected for clinical use: haemoglobin
concentration and packed-cell volume, ABO group,
presence of HBsAg, and hepatitis C virus (HCV) antibody,
alanine aminotransferase concentration, HIV-1 and HIV-2
antibody, and serological test for syphilis. Because of the
very low proportion of Rh-negative individuals in China
(<1%, data from Chinese Society of Blood Transfusion),
Rh typing is not routinely done.
A policy of doing two rounds of screening tests was
developed by the employer-organised recruitment system.
Samples for the first screen are collected during the initial
donor interview, usually several days before the actual
donation. Only those with acceptable results will be called
back to donate blood and undergo the second round of
tests. This policy was developed partly to reduce the high
1771
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PUBLIC HEALTH
collection costs that resulted from the high rate of donor
disqualification. The Ministry of Health requires that
different reagents be used in the second round of screening
to maximise the detection of reactive samples. Another
purpose of this policy was to combat the problem of donor
misrepresentation when surrogate donors were hired by
people who were under pressure but unwilling to donate.
To what extent this double-testing policy has benefited
blood safety in China is unclear. A 1999 national study
examining the effect of this policy questions its importance
in the improvement of blood safety.10
Current testing algorithms vary among blood centres, and
testing policies are being adapted to the shift from
employer-organised to volunteer donors. Most blood
centres still screen all donors twice with all required tests. At
some centres, only employer-organised donors will undergo
the double screening process, while volunteer donors are
allowed to donate after being found negative in a rapid test
for HBsAg. Blood samples collected from volunteer donors
will then be tested either just once or twice with different
reagents in the blood centre for all required tests.
Donors with any abnormal screening test result from
either one or both rounds of screening will be disqualified.
According to data collected from four regions (Xinjiang,
Chengdu, Kunming, and Guangzhu), in 2001, 3·84–9·57%
of donors were disqualified by abnormal test results.
According to data reported to the Chinese Society of Blood
Transfusion, an abnormal alanine aminotransferase
concentration (2–5% of donors) is the most common
reason for disqualification. Some experts feel that the
current cutoff value for alanine aminotransferase (40 IU) is
too stringent, and results in the loss of otherwise qualified
donors. Several workers have examined the value of this
enzyme as a surrogate marker for viral hepatitis.11–14 One
study showed that among donors in Beijing with abnormal
test results for alanine aminotransferase with the current
cut-off value, only 20% (266 of 1347) also had abnormal
results for HBsAg, antibodies against HCV, or both.14 An
active debate continues on the value of inclusion of the
alanine aminotransferase test with the current cutoff in
routine donor screening.
Reactive anti-HIV test results are required to be
confirmed at local public-health-station HIV reference
laboratories certified by the Ministry of Health. Staff from
local public-health stations undertake notification and
consultation of donors. Confirmatory testing for HCV is not
routinely done because of the large number of anti-HCV
reactive donors at screening and the high cost of
confirmatory testing. There is no national standardised
programme by which to notify donors about positive test
results, except for HIV.
Hepatitis B and C
During the past 16 years, the hepatitis B virus (HBV)
immunisation programme for newborns has greatly reduced
the HBsAg-positive rate in Chinese children. Because of the
large number of infected adults—and, perhaps, new
infections acquired by re-use of non-sterile needles for
intravenous injections in hospitals—the rate in the general
Chinese population is still about 9·8%.3 The seropositive
rate for anti-HCV in the general Chinese population is
2·9%.3 In 1999, 3·1% and 1·1% of all whole blood donors
in China were seropositive for HBsAg and anti-HCV,
respectively (data from Chinese Society of Blood
Transfusion).
Several workers have investigated the residual risk of
HCV transmission by seronegative blood products.
Findings of a study from Maanshan showed that 0·9%
(171 of 19 656) of HCV seronegative donor samples tested
positive in their HCV-RNA PCR test.15 Data from a
similar study in Beijing showed that 1·1% (16 of 1522) of
HCV seronegative units were positive for HCV-RNA in a
PCR assay.16 Factors that could contribute to such high
rates include false-negative HCV-antibody test results,
false-positive HCV-RNA PCR results, and true window
phase HCV infections. Nevertheless, such findings suggest
that a significant number of HCV-infected units are not
detected by the HCV antibody test, and this number is
likely to be greater than those in developed countries.
HIV
Most individuals infected with HIV in China are from
rural areas; 81% are between the ages of 20 and 39 years.17
Intravenous drug use remains the leading risk factor, with
72% of infected individuals reporting a history of this
behaviour.17 Numbers of individuals infected through
other routes, including sexual contact and mother-to-child
transmission, have also risen.1,2 Infection of donors during
the collection process has been reported,1,2,18 and is
estimated to contribute to 9·7% of all reported infections.1
The number of people who have contracted HIV by
receiving blood products has not been officially estimated.
Routine testing of donors for HIV has been required by
the Ministry of Health since 1993. Early in 1995, clusters
of HIV-infected donors were found in several provinces in
China.5,19,20 The spread of HIV among donors arose mostly
in underground for-profit plasma collection operations.
The ministry established regulations in 1995 that
outlawed all unlicensed blood collection, and at about the
same time started to enforce nationwide HIV testing for all
blood donors, including those donating plasma.21 The
HIV-seropositive rate is still very low among donors in
Beijing and most large cities, but in areas with higher
frequency of HIV, such as Yunnan, Xinjiang, and
Guangxi, HIV-seropositive donors are often detected.21,22
As one of the least developed regions in China, Xinjiang
has the second highest number of HIV-infected people of
all Chinese provinces.1,2,22 In 1999, 25–64% of all wholeblood donations from nine blood centres in Xinjiang were
from employer-organised donors. The rest were from paid
donors. The existing donor screening process consists of
the tests required by the Ministry of Health and a simple
physical examination. Samples that test positive for HIV-1
or HIV-2 are sent to the regional HIV confirmatory
laboratory for repeat testing by enzyme immunoassay with
reagents from Ortho (Vironostika HIV Uni-Form II PlusO, Ortho HIV/1+2 Ab-capture) and with a domestically
manufactured kit. Western blot testing for HIV is not
Area blood centres
January–March
April–June
July–September
Total
Total
Urumqi
State farm corp
Yili
Changgii
Kashi
Akesu
Bayinguoleng
Kelamayi
Kuche
15 (16)
15 (18)
16 (21)
38 (68)
3 (5)
2 (2)
6 (8)
11 (15)
6 (24)
1 (4)
1 (3)
8 (31)
0 (0)
0 (0)
0 (2)
0 (2)
0 (2)
0 (0)
0 (3)
0 (5)
0 (0)
1 (5)
2 (3)
3 (8)
1 (11)
0 (2)
0 (0)
1 (13)
0 (1)
1 (3)
0 (0)
1 (4)
0 (0)
1 (1)
2 (2)
3 (3)
25 (59)
21 (35)
27 (42)
73 (136)
Total number of whole blood units tested=40 555. Data are number of donors with confirmed reactive HIV-antibody result (number of donors with reactive HIV-antibody
at screening test).
Table 2: HIV test results from whole-blood donors in Xinjiang in 2000
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For personal use. Only reproduce with permission from The Lancet Publishing Group.
PUBLIC HEALTH
Number of HIV-infected donors investigated
Employer-organised donors
History of intravenous drug use
Intravenous drug user as sex partner
Risk information not available
Paid donors
Risk information not available
1999
2000
(January to
September)
60
73
44
1
0
50
2
3
15
18
Table 3: Risk factors associated with HIV infection in wholeblood donors in Xinjiang
routinely used in Xinjiang because it is too expensive.
Data from Xinjiang Regional HIV Confirmatory
Laboratory (table 2) show that, in 1999, the rate of
confirmed HIV seropositive donors was 1·21 per 1000,
and for January to September, 2000, the rate was 1·8 per
1000 donors. Risk factors were assessed by follow-up
interviews for HIV-infected donors (table 3); most
employer-organised donors who were HIV-positive said
they had a history of intravenous drug use. No risk-factor
information was available from paid donors, many of
whom were migrant “professional” donors. Some paid
donors probably acquired HIV infection through previous
donations.
No national studies on the residual risk of HIV through
blood transfusion have been reported. Since prevalence of
HIV varies substantially between regions, residual risk is
also likely to vary. Findings from a county blood centre in
central China at which HIV cross-infection between paid
donors had occurred in the past suggested that the
residual risk of HIV infection by transfusion in this county
was 1 in 2000 to 1 in 20 000 in 1998.23
Transmission of disease between paid donors
Unlicensed centres for collection of source plasma and
whole blood increased in number in many parts of China
in the early 1990s. Some of these centres used unsafe
methods of collection that directly contributed to the
spread of disease in donors. Non-sterile needles were often
reused. Some places pooled blood from donors of the
same ABO type during collection of plasma, before red
cells were returned to donors.24,25 Donors were not tested
for HIV at many sites. If HBV and HCV tests were done,
the quality of the tests was often poor. Additionally, at
about this time, intravenous drug use helped to spread
HIV infection,2 and paid plasma and whole-blood
collection attracted high-risk donors including users of
intravenous drugs.
In the early 1990s, the Chinese Insititute of Blood
Transfusion (in collaboration with the American Red
Cross National Laboratory, sponsored by the World AIDS
Foundation) reported high rates of HIV-seroprevalence
among repeat blood donors, especially plasma donors.19,20
These and other reports helped to uncover the link
between transmission of HIV and other diseases among
blood donors and unsafe blood and plasma collection
practices. Data from a study in Henan in 1997 showed
that 17% (15 of 88) of blood donors were HIVseropositive, compared with 0·2% (2 of 875) of nondonors.24 Hubei and Shandong reported in 1999 that rates
of HIV-seropositivity were substantially higher in donors
(9·2%) than in non-donors (0·6%).25 For donors, the rate
was 25·9% for those who had sold plasma by apheresis,
and 2·6% for those who had only sold whole blood. The
individual’s risk of infection correlated with the number of
donations they had made. Most infected donors had
started selling blood before 1995. Reports of HCV
infection in donors suggest that between 1992 and 1994,
THE LANCET • Vol 360 • November 30, 2002 • www.thelancet.com
more than 500 000 donors were infected with HCV
because of contamination during blood collection, mostly
during collection of plasma in unofficial for-profit
collection facilities.4,6
In 1995, the Chinese government established new
regulations banning all unofficial collection of plasma and
whole blood and enforcing regulations on all blood
collection facilities. Although most transmission of disease
among donors occurred before 1996, this problem
continues to exist because of the persistence of a few illegal
centres. Three illegal plasma collection sites were
discovered in a central China province between 1998 and
1999. When the National Centre for AIDS Prevention
and Control tested 96 paid donors from these sites, 71
were seropositive for HIV.26 At one site, 50% and 100% of
donors tested seropositive for syphilis and HCV,
respectively, and all of 142 samples taken from the
collected plasma bags tested positive for HIV. Equipment
at these sites had been reused without proper
decontamination treatment. This report illustrated the
continuing threat of disease transmission between donors
and contamination of blood products.
Quality of donor testing
Although development of effective quality systems has
been an important aim for many Chinese blood centres in
recent years, available data indicate a need to hasten this
process. When the Institute of Blood Transfusion
developed a quality control programme for testing at all 30
blood centres in Sichuan several years ago, it found that
five of 30 (1998) and one of 30 (1999) of these centres
made errors in testing samples for HIV, including serious
mistakes in four centres. Most errors were due to noncompliance with standard operating procedures and
inadequate quality control processes. Quality control
results from 32 blood centres in Guangdong also showed
problems in donor testing.27 This study found more
erroneous results with tests for HIV-antibody and syphilis
than with those for HBsAg and HCV-antibody. At Beijing
Red Cross Blood Center in 2000, 146 879 whole-blood
donors who had passed the first round of screening tests
were tested again with different test kits, and 1·3% (1905)
were found to have at least one abnormal test result.
Differences between licensed testing kits are generally
thought to account for most of the discrepancies in results,
but human error is also implicated.
Future directions
To meet the nation’s increasing need for blood while
protecting the integrity of its blood supply, much work lies
ahead for the Chinese blood-bank industry.28,29 The extent
of development in blood banks varies substantially
between regions of China. The largest blood centres
already employ well trained professional staff and
advanced equipment, but most places still have little
access to modern information and technology. Recent
years have been a challenging yet exciting time; although
many changes have already occurred, opportunities to
improve are still plentiful. The greatest needs are for
effective regulatory policies, staff training, and systems to
record and share information.
All-volunteer whole-blood donation system
To improve blood availability and safety, an all-volunteer
donation system for whole-blood collection should be the
most important goal for the Chinese blood-bank industry.
Old cultural beliefs still contribute to reluctance to donate
blood voluntarily. The blood centres that have been most
successful in mobilising volunteer donors are not
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PUBLIC HEALTH
necessarily those with the most staff and the most
advanced technology. Innovative programmes for donor
education and motivation, as well as strong resource
commitment from the government, will be important in
the recruitment of volunteer donors, as the successful
experiences of blood centres from Shenzhen and Xian have
shown. Recruitment of volunteer donors is still especially
challenging in rural areas, where traditional cultural
influences remain strong.
National standards and quality control systems
Standardisation of criteria for donor qualification and
exclusion, donor-screening procedures, and donor
notification programmes are all priorities. Standards from
developed countries can serve as a valuable source of
information, yet unique characteristics of the situation in
China must be considered. Some existing policies were
developed on the basis of outdated information; for
example, the current Blood Donation Law allows an
individual to donate whole blood only twice a year. Such
measures restrict the availability of blood and convey
incorrect messages to the public about the safety of
donation. To help ensure that the best policies are
established, improvement of the existing policy-making
system will be important. Effectively designed and
enforced national quality control programmes will speed
the pace of modernisation.
Quality of donor testing
Evaluation and improvement of the quality of licensed test
kits should be a priority. For example, more than 20 test
kits for HCV antibody detection are licensed for donors
testing in China, and a system is urgently needed to further
evaluate these kits and guide blood centres in selection of
test systems. Improved staff training and increased
automation should reduce the rate of human error.
Development of inexpensive, reliable, easy methods of
testing should be helpful, especially to poor, remote
regions.
Hospital transfusion practice
Training of clinical transfusion specialists, development of
transfusion committees and guidelines, and education of
general physicians are all necessary measures. Practices
that need continued improvement are: reduced use of
whole blood and unnecessary transfusions; increased
appropriate use of specialised blood components (such as
leucoreduced and irradiated products) for special patient
populations; and increased use of alternative transfusion
practices such as autologous transfusions and intraoperative blood salvage systems.
Research
Research efforts should focus on areas that seem likely to
provide improvement most cost-effectively. We should
update our understanding of the Chinese public’s attitude
to blood donation; search for effective strategies to
encourage volunteer donors; design effective donor
questionnaires; obtain data about transfusion reactions,
especially haemolytic and septic reactions; and investigate
effective methods of pathogen inactivation. Calculation of
residual risks and high-risk behaviours associated with
disease transmission by transfusion will help in the
development of effective strategies for donor screening.
Conclusion
Improvement of blood safety in China is of global
importance. As the world becomes an increasingly
interconnected community, the spread of infectious
1774
diseases in one part of the world can pose a serious
threat to the rest of the world. Therefore, control of
existing infectious diseases, and surveillance for new
diseases in China have the potential to benefit the entire
global community. Successful programmes developed in
China could serve as models for other developing
countries facing similar economic and social challenges.
Although experiences from developed countries are
helpful, China should aim to find its own effective and
realistic ways to improve the nation’s blood-bank
system. Commitment to resources from the Chinese
government and assistance from foreign and
international organisations will be important to China’s
success in achieving this goal.
Contributors
Hua Shan, Jing-Xing Wang, Fu-Rong Ren, Yuan-Zhi Zhang,
Hai-Yan Zhao, Guojing Gao, and Yang Ji contributed to the collection
of data. Hua Shan, Fu-Rong Ren, Jing-Xing Wang, and Paul Ness
contributed to the analysis and writing/editing of the report.
Conflict of interest statement
None declared.
Acknowledgments
The research, analysis, and writing of this report were partly supported
by a fellowship from Fogarty International Center/USNIH (5D43
Tw00010-AITRP) and a grant from the Johns Hopkins
University/China HIV Prevention Trial Network project (U01
AI48011). The sponsors had no role in study design, data collection,
data analysis, data interpretation, or writing of the report.
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Uses of error
Clinical errors
Henrik Birgens
In 1985, I substituted for the local doctor on one of the
many small inhabited islands around Denmark and
arrived on a very cold late afternoon in November. Half
an hour after my arrival, I was phoned from the only shop
on the island, where they asked me to visit one of their
female employees in her home. They thought she might
have pneumonia. The patient, a 42-year-old woman, had
developed retrosternal pain with radiation to the neck.
The pain was strongly aggravated when she walked from
the job to her home. When I saw her, the pain had
disappeared, but I thought this was ischaemic heart pain. I
wanted to have her transferred to hospital, but this was
only possible by a military helicopter. Before I arranged
this expensive and troublesome transport (it was now dark
and there was no illuminated aerodrome), I decided to
take an electrocardiogram and asked the patient to visit
me in the clinic. I went back in order to arrange the
electrocardiographic machine (which had not been used
for a very long time). When she arrived after almost an
hour, her pain was returned and she had quite
pronounced dyspnoea. The electrocardiogram showed a
large anterior myocardial infarction. I then realised that
she had walked alone in the darkness and in frosty
weather by sandy tracks to the doctor’s house—not a good
combination for a patient with acute myocardial
infarction. We both were lucky. The patient survived my
imprudence and was transferred to hospital, where she
survived her infarction. I learnt to be more careful and
never to leave an ill patient unobserved.
Another error I remember clearly was in the beginning
of my haematological training. I saw a 50-year-old man
with an elevated haematocrit. I felt a large smooth mass
below the left costal margin compatible with a
splenomegaly. I diagnosed polycythaemia vera and treated
him with venesection, but after a few times it was
impossible to find a suitable vein for this purpose. He
therefore was treated with 32P. However, a few months
later, he was admitted in a very bad condition with a
visible weight loss. Chest radiography showed multiple
lung metastases and an ultrasound scan of the abdomen
showed a large tumour in the left kidney. The patient died
a few months later due to a renal carcinoma. What we
thought was an enlarged spleen turned out to be an
erythropoietin-producing renal-cell carcinoma. Although
the patient may not have survived in my case, I never
forget to do an abdominal scan in patients with elevated
haematocrit in order not to miss this rare cause of
polycythaemia.
Department of Haematology L, Herlev Hospital, University of Copenhagen, DK-2730 Herlev, Denmark (H Birgens
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DMSci)
1775
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