Fear of disease leads many to bank their own

THE BALTIMORE EVENING SUN

BLOOD BANK officials say the fear of AIDS and other diseases sometimes acquired through blood transfusions has created a sharp increase in the number of patients banking their own blood before surgery.

Your own blood is often the safest available to you, and most hospitals now actively encourage such "autologous" donations in non-emergency surgical procedures.

But the same fears are also prompting more people to ask close friends and relatives to donate blood for them. And while most area hospitals are willing to cooperate in these "directed" donations, they counsel patients that such blood is no safer than anonymous donations, and may even be riskier.

Friends and relatives urged to donate are thought to be more likely to lie about their medical history and conceal high-risk behaviors, increasing the risk that infected blood will slip by the imperfect screening tests.

"Publicly we all agree directed donations are not a very good idea and should be discouraged," said Dr. Robert Wenk, blood bank director at Sinai Hospital in Baltimore.

Privately, however, hospitals are unwilling to turn away patients or antagonize surgeons who insist on directed donations. "It creates a hostile environment," Wenk said.

?/ So, directed donations, too, are growing. * Blood bank directors insist that blood donated anonymously is 1/8 very safe, perhaps safer than it has ever been. All donated blood is tested routinely for AIDS, hepatitis, syphilis and a still-growing list of other infectious diseases before it is released for use.

But there are no guarantees. Scientists have shown, for example, that the blood of recently infected AIDS victims may test negative in routine blood screening, but would still be capable of infecting the recipient.

An ongoing study by the Johns Hopkins School of Public Health has found that despite the blood screening, an average of one unit of blood in 40,000 given to cardiac surgery patients in Baltimore and Houston would cause those patients to test positive for the AIDS virus following their surgery, said Dr. Paul Ness, blood bank director at Johns Hopkins Hospital and executive director of the Red Cross Chespeake Region blood program.

Wenk called the AIDS risk from transfusions today "infinitesimally small," and blamed the news media for perpetuating needless fears with recent reports of people infected by anonymously donated blood, and of federal criticism of blood bank management at some Red Cross collections centers.

"I think you have a six-times greater chance of being struck by lightning," he said. "There is a much greater chance of dying from your anesthesia or surgery. But people are primarily concerned about catching AIDS, mostly because of what's been in the press. So the risk is less than the perception of it."

"To be sure, there are other risks [from tranfusions], and I don't mean to belittle them," Wenk said. "The chances of catching hepatitis from a blood transfusion is more on the order of 1 in

100, even with screening."

There also are risks from improperly typed and matched blood, bacterial or viral infections, blood clots and other mishaps.

"The best transfusion is no transfusion," he said.

But except for hepatitis, "most everything else is of little clinical consequence or very rare."

Ness also noted that despite the disease's spread, the number of AIDS-positive people who donate is declining. And even the risk of catching hepatitis from a blood transfusion has been "substantially" reduced since a new test for hepatitis C -- the most frequent cause of post-transfusion hepatitis -- was licensed and implemented last May.

*

Groundless or not, the public's fear of being infected by a transfusion from a stranger has prompted more and more Americans to ask to donate blood for themselves in advance of elective surgery. And doctors and hospitals are now encouraging them, despite increased handling costs.

"Autologous donation represents the safest kind of transfusion," said Wenk. Your body will never reject your own blood, and "you cannot transmit disease to yourself." Receiving your own blood may even speed recovery.

Not everyone is healthy enough to donate for themselves. Any blood donation can also become contaminated at the time it is drawn, often from bacteria on the skin.

But for most patients, autologous donations are becoming the blood of first resort.

A survey reported in the New England Journal of Medicine last year by Dr. Douglas M. Surgenor, senior investigator at the Center for Blood Research in Cambridge, Mass., shows autologous donations grew from just 28,000 in 1980 to 397,000 in 1987, the latest data available for the study.

Simultaneously, Surgenor said, new concerns about the safety of the blood supply ended 40 years of steady growth in the total number of blood transfusions ordered by doctors in the United States.

Whole blood and red cell transfusions performed in the United States peaked at 12.2 million units in 1986, Surgenor said. By 1987, they had fallen to a point 15 percent below the number that would have been expected if the growth had continued.

Surgenor said autologous donations could eventually provide up 15 percent of the total blood used by hospitals, limited mostly because they're practical only for non-emergency surgery. They accounted for just 3 percent in 1987.

For procedures like hip and knee replacements, patients in some hospitals are already more likely to receive their own blood than that of a stranger.

"In orthodpedics and urology, two large elective surgery

populations, probably 60 to 70 percent of the blood we use is autologous," said Ness, Johns Hopkins' blood bank director. Hopkins has one of the most aggressive autologous blood programs in the region.

"We've almost reached the limit of where we can go," he said. "Most legitimate candidates are already being approached."

*

The enthusiasm blood bank directors now express abouautologous donations is matched only by their concern about the parallel increase in demand for directed donations, where patients ask close friends or relatives to donate blood for them.

"There is no evidence that directed donors are safer than volunteer donors," said Sinai's Wenk. At the same time, "there is evidence to suggest that volunteer donors are safer."

"I make a concerted effort to counsel people on the telephone that directed donations are not an accepted medical idea," Wenk said.

Ness said hospitals cooperate with directed donations because

they have been forced to by public pressure, fueled again by doubts about the safety of the nation's blood supply.

"In some states there have been laws passed that say a blood center has to provide directed donations if patients ask for it," he said. There is no such law in Maryland.

Some surgeons, too, will pressure hospitals on behalf of their patients to allow directed donations.

"Some of the most angry people I've spoken with are surgeons," said Wenk. "Most of them are ignorant [of the risks]."

A few hospitals even use it as "a marketing strategy . . . 'Come to our hospital for surgery the way you like it,'" Wenk said. Other advocates say families feel more supportive by providing blood, and "the patient feels better if he thinks he's getting safer blood, even if that's not true."

If directed donations aren't used, some hospitals discard the blood; others will use it for other patients.

Statistics on directed donations are elusive. Surgenor estimates they are one-tenth to one-quarter as frequent as autologous donations. Baltimore-area Red Cross and hospital officials report the demand is generally growing.

Elizabeth Hall, the national Red Cross spokeswoman, said directed donations at Red Cross facilities nationally nearly doubled to 36,169 last year, from 19,262 in 1989.

The chief danger with directed donations, blood bank directors say, is that donors enlisted by friends or family members are thought less likely to admit to high-risk behaviors during pre-donation questioning.

An extra-marital affair, a sexual encounter with a prostitute or homosexual, or an experiment with IV drugs puts a potential donor at high risk of donating infected blood.

"When you ask somebody to be a directed donor, you put them under a high level of personal pressure, the dilemma of giving blood or confessing to some alternative lifestyle they have never confessed before," said Ness. Many give their blood and keep their secrets.

Directed blood donations are tested the same as anonymous blood, Wenk said. But the screening tests aren't perfect. Some infected blood gets through. That makes donor honesty during questioning by blood bank officials a critical factor in eliminating high-risk donors before their blood enters the system.

The more people pressured by family and friends to donate, and by a fear of exposure to conceal high-risk behavior, the more bad blood will get through to patients.

Directed donations may also pose risks for spouses and close blood relatives.

A woman transfused with her husband's blood may develop antibodies to his blood proteins. If she later becomes pregnant with his child, her antibodies may attack and kill or damage the fetus, which may share his blood chemistry. Such donations are more acceptable after the woman's child-bearing years.

First-degree relatives -- parents, children and siblings -- are thought to be poor risks for directed donations because of "donor versus host disease," a recently identified and potentially fatal risk that the donor's transfused white blood cells may attack proteins in the recipient's blood. These factors are rarely a worry with unrelated donors and are not tested for in normal blood screening.

When first-degree relatives do make such directed blood donations, their blood is now routinely exposed to radiation to kill the white cells.

Using your own blood

Methods for autologous donations.

* Pre-operative donation -- Patients donate blood three days or more before surgery. The amount of blood drawn and the timing depends on the patient's health and the surgery planned. Blood can be stored for up to seven weeks.

* Pre-operative hemodilution -- At the time of surgery, doctors draw one or two pints of blood, replacing it immediately with other fluids. Patient's remaining blood is diluted, reducing red cell loss during surgical bleeding, but blood volume remains stable. The drawn whole blood is given back to the patient as needed.

* Intra-operative blood salvage -- Patient's blood is collected from wounds during surgery, then filtered, washed and given back as needed. Common now in heart surgery where three or more pints are lost.

* Auto-diffusion -- Patients in good health can be give human gene recombinant erythropoietin, or "hEPO", a genetically engineered substance that stimulates red cell production. It allows larger amounts of blood to be drawn prior to surgery.

Before surgery

If you're awaiting surgery and wish to donate blood in advance for yourself, or to have someone you know donate for you:

* First, consult your doctor. You may not need blood for your surgery, or you may not be healthy enough to donate for yourself. Your doctor can tell you what, if anything, you need to do.

* Next, if your doctor agrees, and doesn't offer to do it for you, contact the blood bank at the hospital where your surgery will take place and arrange for the donation. Most, if not all, area hospitals encourage patients to donate for themselves. The blood can normally be drawn in the hospital's own blood bank. Don't wait. You can't donate closer than three days before surgery.

* If you're asking to have friends or relatives donate blood for you, some hospital blood banks will advise you to reconsider. They will spell out the risks involved and discuss the comparative safety of donating for yourself or accepting anonymous donations from the regular blood supply. If you still insist, some hospitals will draw the blood themselves; others will send your donors to the Red Cross, where the blood is typed, tested and returned to the hospital in time for surgery.

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