Anne Paxton
August 2022—Blood is a precious resource and shouldn’t be treated as a commodity. That’s the consensus in the blood banking community, in line with a longstanding conviction that volunteer donations should remain at the blood system’s core. But as the worst of the pandemic appears to have passed, discussion of blood shortages has increasingly drawn on the vocabulary of commerce, and the warnings about the blood supply have been rife with references to supply chain problems that go beyond the need for more donations.
Crises in the blood supply are nothing new, and while the health care system strives to stay prepared, the pandemic threw novel commercial and logistical factors into the mix, in some ways jumbling the expected order of a crisis for blood services. Hospitals scrambled to cope with a surge of COVID-19 patients while the spread of infection caused thousands of blood drives to be canceled, so there was a steep drop in supply of blood products, says Pampee Young, MD, PhD, chief medical officer, biomedical services, American Red Cross.
“What saved us was the concurrent order from government and state legislatures to cancel all elective surgeries,” Dr. Young says. That COVID-19 itself did not require a lot of blood brought a concurrent drop in demand. “That prevented an absolutely major crisis,” she says.
So for the blood supply, the initial phases of the pandemic may have been the easier part. Pandemic recovery, however, has brought a more intense set of pressures and threats. At the beginning of this year, reopening the economy amid spread of the omicron variant may have been foremost on people’s minds. But the blood supply had dropped to historic lows.
“In January 2022, we had the most severe blood shortage we’ve had in two decades,” says Alyssa Ziman, MD, medical director for UCLA clinical laboratories and medical director of transfusion medicine at Ronald Reagan UCLA Medical Center. Triaging patients based on availability of blood, negotiating with physicians on whether surgeries could wait, moving blood between hospitals—all were measures the medical center took to manage the critical shortage.
“I think what helped us get through, in hindsight, was that the surgery schedule was curtailed because of the pandemic’s impact on patients and staffing. I also think that people’s behavior must have changed, as our hospital did not have to treat as many severe trauma patients as we have typically seen in December and January. So we managed to get through the severe shortage without a major trauma that required transfusion of 50 or 100 units of blood.”
While shortages have eased to a degree, blood experts interviewed by CAP TODAY describe the ongoing impact of the pandemic on the blood supply and some of the serious challenges that remain.
[dropcap]B[/dropcap]efore the pandemic, blood banks were comfortable if they had five to seven days of inventory on the shelves, says Claudia Cohn, MD, PhD, chief medical officer of the Association for the Advancement of Blood and Biotherapies (AABB). If they dropped below five days, that’s when they became worried, and at three days “they would issue an emergency alert” to recruit donors.
“We then sort of stabilized with maybe two or three days’ worth of blood on the shelves but very few patients. So we were okay,” says Dr. Cohn, who is professor of laboratory medicine and pathology, director of the blood bank laboratory, and associate director of clinical laboratories, University of Minnesota.
Two- or three-day supplies of blood became common. “We stayed there for a while,” she says. “But then the shortage of workers began to have an effect, as it has on every segment of the workforce. Some blood centers took measures to make sure their employees were happy and offered raises, better work hours, and things like that, but other blood centers did not. And so we saw problems with blood collections across the country, and that is still somewhat the case. So we’re still in this chronic shortage, but it has gotten better.”
The worst-case scenario, Dr. Cohn adds, “happened when we were at a one-day supply of blood at many, many centers, and there was a news report that at least one emergency trauma center closed for a few hours because they simply didn’t have the blood on their shelves to accept new patients.” Blood shortages causing delays in care occurred at a lot of hospitals, she says, but nearly all were unwilling to talk about it publicly. “They didn’t want to scare patients and have patients who had a choice go to a different hospital.”
Recovering from pandemic mode also didn’t mean the country started stepping up again to donate. “I suspect it’s probably not the first thing on your mind to come and donate blood for strangers, to get stuck with a needle,” says Kamille West-Mitchell, MD, chief of the Blood Services Section of the National Institutes of Health Clinical Center Department of Transfusion Medicine.
The workforce is a part of the blood system that people don’t often think about, Dr. West-Mitchell says. “They just think the blood magically comes out. But you need dedicated people to screen and recruit donors, test donations, and manufacture components. The workforce is a major element that I don’t think was anticipated in the beginning as part of the shortage.”
Demand also took many hospitals by surprise, Dr. West-Mitchell says. “Demand absolutely went up. It came back before the supply really did. People who had major interventions postponed for a year led to hospitals doing tons of transplants all in one month.” Suddenly there is a situation in which many patients need blood, she says, at a time when blood donation levels are far from recovered.
The pandemic has not exactly made haste to leave. “I’m not sure we’re done with the pandemic, because the pandemic is multiple things going on, not just one thing,” says Patricia Kopko, MD, professor of pathology and director of transfusion medicine, University of California San Diego Medical Center. “First of all, hospitals and blood suppliers in general are experiencing the same supply chain issues that the rest of the world is experiencing.
“Think about it,” she continues. “If you run a big blood center and you have hundreds of vehicles, how many do you have to replace a year? Have you tried to buy a car lately? It’s the same supply chain issues for everything, from not being able to buy blood sample tubes to little things like one of your TVs breaks and your donors like to come in and watch baseball games and you don’t have a TV for them to do that. It’s everything that goes into the supply chain to do what blood centers do.”
On top of that, blood centers still have trouble getting employees. “There are millions of people who are not in the workforce because they’re either sick from COVID, taking care of somebody who’s sick from COVID, retired because they’re afraid of COVID, or they died, or they didn’t have enough money to pay for child care for their kids. A large percentage of people who work drawing blood are women, and many are young women with children not yet in school. So you can’t get employees. But the blood supply still needs to be there.”
Maintaining adequate staffing is especially challenging at blood suppliers like the Red Cross, Dr. Young says. For one thing, shifting staff around is much more difficult than it would be at a hospital. “There is a three-month training program for staff who collect the blood because every step of blood collection is so highly regulated.”
Says Dr. Cohn, “We went from a one-day supply, with everyone scrambling all the time, to now stabilizing, I’d say, at a three-day supply in some cases. But that gives some perspective on how bad it is that a one- to three-day supply is considered the new normal.” Still, there are regional differences. “The Midwest has always done better than the coasts,” she says. When Dr. Cohn was a pathology resident in New York, “We regularly triaged patients for platelets. We would say, ‘If you’re not bleeding and the platelet count is above five, you don’t get platelets.’ In the Midwest, we’re awash in blood, more than most other parts of the country, and so we’re probably at a three- to five-day supply at the center that serves my hospital.” Since blood drives are often hosted by schools and businesses that are continuing in hybrid mode—partly remote and sometimes closed—she believes collection is going to be a regular problem for the foreseeable future.
But without accurate and timely tracking of blood units, shortages could be hard to predict and address. Dr. Cohn saw the need for ongoing updates of blood unit volumes and helped lead the AABB to initiate a platelet and group O red cell survey of blood centers, which launched in May 2021.
“The idea for this survey came about during the beginning of the pandemic when COVID-19 convalescent plasma [CCP] and red blood cell and platelet shortages were a big deal,” Dr. Cohn explains. “So we decided, given the crisis mode, to launch a survey about CCP and the two blood products that are usually in short supply, and there was a wonderful response. And we began to publish weekly how much CCP and blood were being used and how bad the situation was where there were shortages.” Once interest in CCP began to wane, they reworked the survey so that it focused solely on group O red blood cell and platelet collections and usage. “We also purposely built in questions to try to understand shortages,” she adds. The survey is a pet project of hers to try to push forward the idea of a national blood data inventory, she says. “It’s a massive undertaking, probably five to 10 years from fruition, at least. I don’t expect to do it during my career, but if I move it forward a little bit, that’s great.”
Dr. Cohn hopes it will fill the gap left by the CDC. However, “For hospitals, there’s an atmosphere of fear about sharing their information,” because of potential harm to their standing within their communities. “So perhaps we need to make it a point of accreditation that you have to share your information. And we’re trying to be intelligent about this and have data collection fields that are well defined so that the data that’s collected is meaningful. Currently, about 75 percent of blood centers are sharing their data with us to tell us how much is collected and whether they’re losing units because of outdate.”
The blood center community responded enthusiastically to the results of this survey, saying it was a useful source of information, she says. “For hospitals, it’s more difficult because they’re short staffed. They don’t have the data readily available. So we’re only getting data from a small percentage of hospitals, which isn’t great. So I don’t know how representative the numbers really are on the transfusion side of things. On the collection side of things, the numbers are good.”
[dropcap]R[/dropcap]alph Vassallo, MD, chief medical and scientific officer of Vitalant, Scottsdale, Ariz., sees problems other than the pandemic contributing to shortages. He attributes a portion of the woes of the U.S. blood system to the overly competitive environment that can crop up among blood centers. “There are some geographies that are served by several providers where it’s a race to the bottom to offer hospitals the lowest price for a red cell unit, and oftentimes red blood cells are sold below cost. So blood centers do a number of things. They assign some of the lost margin to platelet products or plasma derivatives like cryoprecipitate, or they diversify and provide clinical services like therapeutic apheresis or laboratory work with a small margin, so when they have to replace a bus or offer more competitive salaries, that requires margin from the sum total of products and services. The model is not as rational as it should be.”
Drs. Kopko and Ziman and others, on behalf of University of California transfusion medicine physicians, wrote a commentary last year in which they said, “The commoditization of blood has resulted in an unsustainable model wherein 90% of the US blood supply is provided below cost. The veneer of adequacy hides an increasingly fragmented infrastructure that leaves the nation ill-equipped to face future, unpredictable threats” (Barnhard S, et al. Transfusion. 2021;61[9]:2768–2771).
They wrote that they support the recommendations contained in the Department of Health and Human Services document “Adequacy of the National Blood Supply: Report to Congress 2020,” which are focused around four central themes: investment in data infrastructure; modernization of the current business model for blood collection, innovation, and technological advancement; modernization of the legacy reimbursement system; and expansion of the donor base through a better understanding of donor motivation and better access to donation.
It is the decline in donations—pandemic related or not—that blood experts cite most frequently as a cause for alarm. “We’ve published some of our data and it looks like the rabbit in the anaconda,” Vitalant’s Dr. Vassallo says. “Forty-five-year-olds 20 years ago, then 55-year-olds 10 years ago, and now the 65-year-olds are the ones who donate the most apheresis platelets of any age group.” Can Generation X, millennials, and Generation Z step in to fill the void? Making that happen will be difficult, he says.
Dr. West-Mitchell of the NIH says that something more like a culture change will be needed to bring donations to the level needed. “People tend to think of blood needs as in blood right now, whenever there’s a disaster. But we don’t just need a blood donation. We need a blood donor cohort. That’s incredibly important, and it’s part of the message we want to make sure is very clear. We need donations today. We need donations tomorrow, next week, next month, next year.”
At Northwestern University, blood needs returned to the usual summer levels over the past few months, says Glenn E. Ramsey, MD, chair of the CAP Transfusion, Apheresis, and Cellular Therapy Committee and director of transfusion medicine at Northwestern. “But I think there’s still a lot of thought going on about what happened. We’ve been fortunate that our supply regionally here has been pretty stable. We didn’t have much experience with this type of situation over the last 10 or 15 years.”
Normally only about five percent of red cells are collected in the hospitals, Dr. Ramsey notes. But one early outcome of the pandemic is that Northwestern’s hospital administration became supportive of having blood drives at system hospitals. Now, six months later, “It’s become a regular occurrence. For the first time ever, we have blood drives two days a week in our hospital by our blood supplier. And that was a very helpful margin to offer the supplier during the shortage.”
For now, much uncertainty still surrounds the pandemic in terms of the direction new variants could take, whether vaccines will be up to the task of checking the spread of infection, and whether more blood supply surprises are in store for blood centers and hospitals.
But as blood centers and hospitals look ahead, discussions continue. What if there is another pandemic or a pandemic that hits even harder? Models of pandemics have been part of how the blood system prepares, Dr. Ramsey says, and they helped in the preparations for COVID-19 in some ways. However, “I think we need to be more flexible and more thoughtful in looking ahead,” he says. “What will we do if this happens again, and what if we have a critically severe shortage sustained for a lengthy period of time?” Or could the next crisis be a mass casualty event, for example, where in the face of a severe blood shortage hospitals need many units of blood right away for a particular group? Those are possibilities that keep people in charge of blood services up at night, he says.
“The next thing that comes along is always going to create different problems.”
Anne Paxton is a writer and attorney in Seattle.