CLINICAL FEATURE

The Growing Need for

Diverse Blood Donors
Downloaded from https://journals.lww.com/ajnonline by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3OlGIyw74G1+Tyylwmx/NjJnmMutUikutLkYI5f/XIV6H7Y7wW0xR/A== on 01/08/2019

Nurses are in a powerful position to help ensure a consistent blood supply.

ABSTRACT: Research shows that phenotype matching can improve the outcomes of people who receive
repeated transfusions. In addition, the demographics of the United States are shifting, and more ethnically
and racially diverse donors are needed. These factors have health implications and require ongoing efforts
to ensure a safe and adequate U.S. blood supply. Nurses can help to develop and implement strategies to
increase the number and diversity of blood donors, ensuring donations better match the needs of transfu-
sion recipients daily and in the event of a public health emergency.

Keywords: blood donation, blood donor, sickle cell disease, transfusion

A
pproximately 36,000 units of red blood cells
are needed every day in the United States.1 It’s
estimated that almost 21 million blood com-
ponents were transfused in 2011.1 The American
Red Cross provides about 40% of this blood sup-
ply.2 The safety of the U.S. blood supply is ensured
by the U.S. Food and Drug Administration (FDA),
which regulates blood centers, and the Centers for
Disease Control and Prevention, which conducts in-
vestigations and surveillance.
When blood is phenotypically matched (a close
blood type match between donor and recipient), the
person receiving the donation is at a lower risk for
antibody formation and subsequent complications of
transfusion therapy.3 Research indicates that the eth-
nicity of the blood donor and recipient are important
factors in achieving a close phenotypical match.4 A
consistent supply of blood from ethnically and racially
diverse donors is necessary for phenotype matching
in order to reduce the risk of adverse effects and com-
plications in people who require chronic blood trans-
fusions.4
Harvey and colleagues reported that “severe, life-
threatening, or fatal” reactions accounted for nearly
8% of the reactions to blood transfusions in a U.S.
study they conducted from 2010 to 2012.5 According
to the FDA, deaths due to transfusion reactions ranged
from 41 to 65 per year between 2011 and 2015.6
The top three fatal complications of blood transfu-
sions during that period were transfusion-­related acute
lung injury (TRALI), transfusion-­associated circula-
tory overload (TACO), and hemolytic transfusion re-
actions.6 Acute hemolytic transfusion reactions involve
the rapid destruction of red blood cells within 24 hours
of a transfusion due to an incompatible transfusion.
Symptoms may include fever, pain, and, in some cases,
kidney failure. According to Gardner and colleagues,
who studied the treatment of delayed hemolytic trans-
fusion reactions in patients with sickle cell disease,
these reactions typically occur 24 hours to 21 days
after transfusion, with symptoms ranging from mild
to more severe.7
Primary pulmonary transfusion reactions in-
clude those with predominant pulmonary injury
and respiratory distress.8 Secondary pulmonary re­
actions occur following another reaction and in-
clude transfusion-related hypotension, anaphylaxis,
and bacterial infections.8 Healthy people usually
tolerate the increased volume of a blood transfu-
sion; however, those who are elderly, young, or
have congestive heart failure or renal failure have
­decreased volume tolerance and are at a greater risk
for TACO. Circulatory overload causes increased
central venous pressure and increased volume in

44 AJN ▼ July 2017 ▼ Vol. 117, No. 7 ajnonline.com

 By Linda M. MacIntyre, PhD, RN

pulmonary vessels, leading to lung edema.8 Respira-

tory distress related to TACO usually occurs within
one to two hours of transfusion, and common com-
plaints include chest tightness, headache, and a dry
cough.8 According to Bux and Sachs, TACO should
be considered if any four of the following criteria oc-
cur within six hours of transfusion: “acute respira-
tory distress, tachycardia, increased blood pressure,
acute or worsening pulmonary edema, and evidence
of positive fluid balance.”8
The FDA has reported that the greatest number
of transfusion-associated deaths between 2011 and
2015 were attributable to TRALI (38%).6 Clinical
symptoms of TRALI usually occur within the first
six hours of initiating a blood transfusion and in-
clude respiratory distress, hypotension, fever, and
cyanosis.8 Hypoxemia (a sudden drop in arterial ox-
ygen) and frothy edema from the endotracheal tube
are clinical signs of TRALI.8

Photo by Jody Lane / American Red Cross.

CHANGING DEMOGRAPHICS AND BLOOD DONATION
Demographics are shifting in the United States, with
the population expected to become more diverse in
terms of both race and ethnicity.9 In 2012, minorities
represented 36.6% of the U.S. population, and, for
the first time, more than half of children born in the
United States were minorities.10 In March 2015, the
U.S. Census Bureau released a report projecting that
the United States would be a “majority-minority”
country by 2060, with 56% of the population con-
sisting of minorities.9
These population changes have implications for
blood donation and safe transfusion practices. Ethnic
groups have varying frequency of certain blood types,
and the risk of complications can be reduced, even in
people who have the same blood type, if the donor
and recipient have the same ethnic background.4 Di-
versity in blood donors is needed to ensure that the
right match is available for recipients.
ANTIGENS, PHENOTYPES, AND ALLOIMMUNIZATION
All people have one of four blood types within the
ABO blood group system, in addition to the presence
(Rh positive) or absence (Rh negative) of antigen D,
referred to as the Rh factor.11 Type O negative blood is
considered the universal blood type, because it’s com-
patible with any other blood type and is often used for
emergency transfusions. Therefore, there is consid-
erable need for—and sometimes a shortage of—this
type of blood. An analysis by Garratty and colleagues
of data from 3.1 million U.S. blood donors found the
highest percentage of type O blood among people in
the following ethnic groups: Hispanic (56.5%), North
American Indian (54.6%), and black non-Hispanic
(50.2%).12 Increasing the number of donors from these
ethnic groups would help to meet the demand for type
O blood.
Some patients require closer blood-type matching
beyond ABO and Rh. In addition to ABO, there are
many red-cell antigens that are important factors.13 If
a person receives a transfusion with foreign antigens,
she or he can develop antibodies to the antigen. Once
a person has made antibodies to a red-cell antigen, she
or he must receive transfusions from donors who lack
that antigen. Alloimmunization refers to an immune
response that is triggered when a foreign antigen is in-
troduced into the body.14 Antigens are found on red
blood cells, antibodies are found in blood plasma, and
agglutination (clumping) occurs when antigens and
antibodies bind.15 For example, a person with type O
blood does not have A or B antigens on red cells but
has A and B antibodies in plasma and would have an
adverse reaction if transfused with blood that has A
or B antigens.15 People who receive transfusions regu-
larly require closer phenotyping to reduce the risk of
alloimmunization.16
U-negative and Duffy-negative blood types are
found in people of African descent, and people in the
United States who have these blood types and sickle
cell disease rely on transfusions of blood donated by

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 volunteers of the same ancestry.17, 18 Other rare blood
types found in different ethnic groups include: Kp(b-)
and Vel- in Caucasians; Dr(a-) in those of Eastern Eu-
ropean and Russian Jewish ancestry; Di(b-) in Hispan-
ics; RzRz in Native Americans and Alaskan Natives;
and Jk (a-b-) in Pacific Islanders and Asians.18
FACTORS INFLUENCING BLOOD DONATION
The World Health Organization recommends that
to ensure a safe and consistent blood supply, blood
donors should be volunteers (unpaid); the organiza-
tion maintains that “the prevalence of bloodborne
infections is lowest among this group.”19 In 2012,
more than 90% of the blood collected in 73 low-
and middle-income countries came from volunteer
donors, whereas approximately 50% of the blood
collected in another 72 low- and middle-income
countries came from paid donors or family and re-
placement donations.20 In the United States, the FDA
doesn’t require that donated blood used for transfu-
sion come from volunteer donors.21 However, accord-
ing to Catherine Mazzei, MD, medical director, Red
Cross Northern California Blood Services Region (per-
sonal communication, March 31, 2017), “No hospi-
tal will use, nor will patients agree to accept, blood
not labeled ‘Volunteer Donor.’ Plasma donors are
paid if their plasma is manufactured into albumin,
etc., and hospitals and patients are okay with that
because the plasma is processed, which removes in-
fectious disease risk.”
The FDA determines donor eligibility, although
collection centers may have additional criteria.22 Being
infected with HIV, hepatitis B, or hepatitis C results in
permanent deferral from donating blood. Receiving
tattoos or piercings in unlicensed facilities results in a
12-month deferral period by the Red Cross.2 Being
diagnosed with certain types of cancer, such as leuke-
mia or lymphoma, leads to permanent deferral. Peo-
ple who have been successfully treated for other types
of cancer may not be subject to permanent deferral.23
It’s estimated that 38% of the U.S. population
is eligible to donate blood, and yet less than 10%
do so annually.1, 24 In a study of blood donor eligi-
bility among people 18 to 69 years of age, James
and colleagues found that 122 million people—­
approximately 41% of the U.S. population—were
­eligible blood donors.16 Eligibility rates differed ac-
cording to race and ethnicity, sex, and age: 36.5% of
African Americans, according to the researchers, were
eligible to donate compared with 46.4% of whites
and 40.7% of Hispanics. The top three reasons for
donor deferral also varied: among African Ameri-
cans, deferral was due to low hemoglobin levels,
hepatitis B virus infection, and tattoos; whites re-
ceived deferrals if they had cancer, tattoos, and low
hemoglobin levels; and Hispanics were deferred for
tattoos, low hemoglobin levels, and pregnancy. More
men (45.4%) than women (42.7%) were eligible to
46 AJN ▼ July 2017 ▼ Vol. 117, No. 7 ajnonline.com
donate blood. Generally, people are less likely to be
eligible as they age.16 In the United States, there is
no upper age limit for blood donors, and people as
young as 17, or 16 with parental consent in some
states, may donate if they meet eligibility criteria.
It is important for nurses and other health profes-
sionals who promote blood donation to understand
the factors that influence it. Reasons for blood dona-
tion include altruism, personal satisfaction, and the
need of a family member or friend.25 In addition,
there are many reasons cited by those who don’t do-
nate. They may be unaware of the need for donated
blood, for example, or they do not understand the
process (for more information, see The Blood Dona-
tion Process 24, 26-28). Other reasons for not donating
blood include perceived or actual ineligibility, a previ-
ous deferral or negative experience, fear of needles,
religious reasons, and mistrust.16, 29 Factors known to
influence decreased donation rates in the black com-
munity specifically, according to Shaz and Hillyer, in-
clude increased deferral and ineligibility rates, fear
and mistrust, and inadequate marketing and educa-
tion programs.30 Temporary deferral, regardless of
the duration, can result in never attempting to donate
blood again.31
STRATEGIES FOR ADDRESSING DIVERSE BLOOD NEEDS
Because of changing demographics and the growing
need for closer phenotype matching for people who re-
quire frequent blood transfusions, efforts are needed
to increase the number and diversity of blood donors
so that donations better match the needs of transfu-
sion recipients. More blood donors of African descent,
for example, are needed to provide better phenotype
matching for those who have sickle cell disease and
receive frequent transfusions.17, 30
Marketing campaigns to recruit African American
volunteers, according to Shaz and Hillyer, have had
limited success.30 Shaz and colleagues reported that
among 928 African American church attendees who
were asked in which situations they’d be more likely
to donate blood, 79% said if asked by a religious,
social, or civic group; 77%, if asked by friends or
family; 72%, after hearing about or seeing a need
for blood; 67%, if asked by a coworker; 63%, in re-
sponse to calls or e-mails; and 58%, if they received
a letter.32 In another study, researchers reported that
white and African American blood donors agreed that
free health screenings and reminder mailings helped to
encourage donation; however, the African American
donors also cited race-specific marketing campaigns
and Red Cross community involvement as important
motivators of blood donation.33
Vincent Edwards, national director of diversity,
Red Cross Biomedical Services, who oversees bio-
medical diversity initiatives, explained in a personal
communication (May 6, 2016): “Some African Ameri-
can community members have been taught not to trust
the process of donating blood due to historical facts,
such as Tuskegee, and community education [around
blood donation] isn’t needed as much in Caucasian
communities. Issues and conversations of trust do not
have to be addressed in the same way in Caucasian
communities.” As background information, Edwards
further noted, “The exploitation of African American
men during Tuskegee experiments—in which gov-
ernment researchers for 40 years observed but didn’t
treat African American men who had syphilis, some
of whom were told they were receiving treatment and
none of whom provided informed consent—was re-
vealed in the early 1970s. The resulting mistrust of the
medical profession by some African Americans has
had far-reaching effects, including the dissuasion of
potential donors from giving blood. In order to en-
courage more African American volunteers to donate
regularly, we need to understand the origins of and
address feelings of mistrust that are unique to mem-
bers of this community.”
Further studies are needed to identify effective strat-
egies for blood donation in additional ethnic groups
and geographic locations.
HOW NURSES CAN RESPOND
To increase awareness of this issue, Red Cross nurses
who are also members of the National Black Nurses
Association (NBNA) have presented interactive ses-
sions at NBNA annual conferences for the past few
years and plan to do so again this year. In these ses-
sions, facts about blood donation and information
about factors that hinder or promote it are presented.
Participants then meet in small groups to discuss their
awareness of blood donation and to identify strategies
to effectively increase blood donation in their com-
munities. Mistrust and fear related to the Tuskegee
syphilis study have been openly discussed along with
potential solutions for building trust among prospec-
tive black donors. These solutions include having a
trusted member of the community advocate for blood
donation, with the aim of improving the health out-
comes of people in the community receiving blood
transfusions.
When I was a hemodialysis nurse, I was privileged
to observe, within a few hours, the positive effects
of blood transfusions in people treated with dialy-
sis. Understanding the challenges of obtaining a match
for people who require multiple blood transfusions
has led to my increased appreciation for all blood
donors. Nurses have the skills and opportunities to
engage in strategies that will help ensure the nation
has a safe and adequate blood supply. Ranked for
the 15th year in a row as the professionals the public
trusts most,34 nurses are well positioned to help in-
crease awareness of the need for diverse blood do-
nors, share facts about blood donation, and educate
prospective donors on the process of donation as well
as temporary deferrals and ways to address these.
ajn@wolterskluwer.com
The Blood Donation Process
Red blood cells have a shelf life of 42 days, and platelets must be
used within five days of donation.24 Because of the short shelf life
of these blood products and the need for blood to be collected,
tested, and available prior to an emergency, ongoing collection is
essential.26
The blood collection process is designed to ensure safety for both
the donor and transfusion recipients.27 The entire process takes ap-
proximately an hour and involves presenting identification (a driver’s
license or another acceptable form of primary identification, or two
other forms of identification) and completing a registration form,
health history, and miniphysical.24 Blood donors should be in good
health and weigh at least 110 lb.27 Blood pressure and hemoglobin
levels, in addition to temperature and pulse, are checked to help en-
sure the safety of the donor.24
The actual time it takes to donate whole blood is only eight to
10 minutes; it takes about one-and-a-half to two hours to donate
platelets.28 The donor is monitored, asked to wait 10 to 15 minutes
after the donation is finished, and offered fluids and snacks to en-
sure she or he has adjusted to the change in fluid volume. All com-
ponents of the whole blood donation are used and transfused as
one of various blood products—red cells, platelets, plasma, and
cryoprecipitate—that can be used to help more than one person.24
Eligible donors can give whole blood every 56 days; double red cells
every 112 days; and platelets every seven days, up to 24 times per
year. For more information and to make an appointment, visit www.
redcrossblood.org.
Helping prospective donors understand the differ-
ence between temporary and permanent deferrals
could mitigate some barriers to blood donation.
Nurses are skilled in assessing a person’s receptive-
ness to information and can provide health informa-
tion clearly and effectively. Additionally, nurses can
work collaboratively with other health professionals
to increase public awareness of the need for blood do-
nation from diverse groups. Actions that nurses and
other health professionals can take to help ensure that
the blood supply meets patient needs include becom-
ing knowledgeable about blood donation, ways to
mitigate temporary deferrals, specific needs related to
diagnoses such as sickle cell disease, and culturally ef-
fective strategies to promote blood donation. Under-
standing that donors may differ in how they want to
be asked to donate—and in the ways in which they
schedule donations—can lead to improved donor re-
cruitment strategies. For example, some donors say
they prefer to use the Red Cross Blood Donor App
(www.redcrossblood.org/bloodapp) to schedule do-
nations and receive updates.
Nurses are also encouraged to donate blood
if they’re eligible. Nurses who can’t donate can
­encourage a friend or family member to donate, or
volunteer to set up or participate in a blood drive.
AJN ▼ July 2017 ▼ Vol. 117, No. 7 47
 They can educate individuals and groups on the on-
going need for blood donation from diverse blood
donors to improve health outcomes for people who
require frequent transfusions. Additionally, nurses
can promote blood donation throughout the year
to diverse groups, and encourage eligible donors to
give regularly. To learn more about donation eligi-
bility requirements, visit www.redcrossblood.org/
donating-blood/eligibility-requirements. Nurses can
also volunteer for organizations that collect and dis-
tribute lifesaving blood. To find out more about vol-
unteering in your community, visit www.redcross.
org/support/volunteer/opportunities#step1. ▼
Linda M. MacIntyre is the chief nurse of the American Red Cross,
Washington, DC. Contact author: linda.macintyre@redcross.org.
The author is grateful to Catherine Mazzei, MD, medical director,
Northern California Blood Services Region, and Mary O’Neill,
MD, interim chief medical officer, Medical Office, both of the
American Red Cross, for their review of this article. The author
has disclosed no potential conflicts of interest, financial or other-
wise.
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