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The Red Cross blood donation reserves are below the minimum threshold. The situation is serious, explains Dr Anne Schuhmacher, medical director of the blood transfusion centre. It seems to be the right time to announce that more people can donate as of now.
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Lëtzebuerger Journal: Has any progress been made in the discussion of blood donation by men who have had a sexual relationship with another man?
Dr Anne Schuhmacher: Before January 2021 we did not accept male or female donors who had sex with men who had sex with men, the so-called MSM (men who have sex with men). Since January, we accept all donors, without discrimination as to their sexual orientation. They are no longer asked about their lifelong sexual practices. They are only asked about their sexual practices in the twelve months prior to the donation.
That is to say, if a person has had a sexual relationship with an MSM in the twelve months prior to the donation, they will not be able to give blood?
If the donor – man or woman – had sexual intercourse with an MSM in the twelve months preceding the donation, he or she will be offered to donate plasma immediately. On the other hand, if they did not have sexual intercourse with an MSM in the twelve months preceding the donation – regardless of their sexual orientation – they will be able to donate full blood or blood plates.
How do you justify this regulation?
We base it on statistics. In the Grand Duchy, there is an AIDS surveillance committee. Its latest report published in 2019 clearly shows – over several years – that there are more new contaminations in the homosexual population, if you consider the size of the population.
Do you have any percentages to show how much more at risk gay men are of transmitting diseases through sex?
I can give you the figures from the Aids Committee's monitoring committee. It's difficult, because I don't know the size of the homo- or bisexual population in Luxembourg. In 2019, we had 96 new patients affected by HIV. Of these 96, there were 46 homosexuals and 42 heterosexuals. Although the figures are almost the same in absolute terms, there are not as many homosexual men as heterosexual men in the total male population: the percentage of the former is lower than that of the latter. This means that the incidence of HIV in the homosexual population is higher. It is true that HIV is not so common anymore… but it's not the only disease. For example, there is a recrudescence of syphilis among people who engage in risky sexual behaviour. These are the figures that have prompted us to be cautious. Moreover, regardless of the sexual orientation of the donor, if he has had a new partner in the four months preceding the donation, he will not be allowed to give blood.
Dr Anne Schuhmacher
You took the example of neighbouring countries to decide on this shift. How did you proceed?
We actually looked at what was being done in other countries. We were in favour of not discriminating, but we still wanted to ensure the safety of the recipients. What bothered us in how neighbouring countries handled the issue was that donors were always required to be abstinent. All European countries apply a period of abstinence – some for twelve months, six months, four months in France and three months in England. We based our model on Canada, which allows plasma donation without abstinence, provided the donor answers the other questions in the form correctly, particularly in relation to risky behaviour. In Canada, they allow whole blood donation after four months – here it's twelve months.
In other words, the twelve-month regulation is still an abstinence regulation …
No. There is no abstinence insofar as the person can still make a form of donation. If there has been no abstinence in the twelve months preceding the donation, we will say "ok, you can donate your plasma right away".
On the person
Dr Anne Schuhmacher is a medical biologist who joined the Red Cross in 2015 to head the blood products distribution service. Two years later she took over the management of the laboratory. For the past three years she has been the medical director of the transfusion centre.
Isn't every donation tested before another person receives it?
Yes, all blood donations are tested for HIV, hepatitis C, hepatitis B and syphilis. These are called serologies – we look for antibodies to the virus. To this we add molecular biology tests, which consist of looking for the virus genome. This is done for hepatitis A, B, C, HIV, parvovirus B-19 and in some cases hepatitis E.
So if the blood is tested after donation – why is this regulation necessary?
Because there is still the problem of what is called the serological window. This is the time between contamination and the appearance of antibodies in the blood. During this period we cannot detect the presence of the virus. In the case of molecular biology, we don't talk about a serological window but it depends on the viral load. People who are infected have a higher or lower viral load. The viral load must be high enough to be detected. Because of this, you have to be careful. And not all sexually transmitted diseases are tested.
"We were in favour of not discriminating, but we still wanted to ensure the safety of the recipients."
Dr Anne Schuhmacher
And other sexually transmitted diseases are also more prevalent in the gay male community?
Yes, to take the example of syphilis, there is a very clear resurgence in the homosexual population. I'm not making a judgement, it's based on statistical observations. We are also there to ensure the safety of the recipients.
HIV infection can be excluded by a common antibody test after six weeks. This seems to me the only logical period of abstinence. Since a year without sexual intercourse is really a lot. To come back to this: Why the twelve months?
An HIV infection can be excluded after one to five weeks. But there are longer windows of time, for example for hepatitis B, which is also a sexually transmitted disease and can only be excluded after one month. The window period for hepatitis C is 70 days and two to four weeks for syphilis. The times vary according to the type of test and the patient. The twelve months are to protect against other diseases that we are not looking for. We have drawn a lot of inspiration from what is done in other countries. And it's a first step.
So if everything goes well in France with the four months of abstinence, this would be a prospect for Luxembourg too?
Could you explain the different forms of donation?
Whole blood donation is the most common and lasts about ten minutes, and if you count the arrival, the donation and then the break that is offered to the donors, it takes 30 minutes. Plasma donation or platelet donation lasts an hour on average. It is done on an automatic sampling machine which consists of taking the donor's whole blood in small volumes, sorting the cells and recovering only what we want to keep in the bag and re-injecting the other cells back into the donor. If plasma is donated, red blood cells and platelets are reinjected into the donor during the donation. At the end of the donation, the donor will be much less tired and will be able to donate his plasma more often.
Dr Anne Schuhmacher on not wanting to discriminate against anyone
What is plasma used for?
There is a real shortage of plasma in the world. It is used to make fresh frozen plasma, which is used in cases of massive haemorrhage or for burn victims. But it is also used to manufacture medicines such as immunoglobulins and albumin. These are drugs that are very often prescribed and there is a worldwide shortage. We must therefore make an effort to collect plasma. We must make this type of donation known and make people understand that it is as important to give plasma as to give whole blood.
To come back to what you said at the beginning: A man or a woman who has had sexual relations with an MSM gives his plasma. When will it be used?
The advantage of plasma is that it is frozen and can be kept for a year. If the person comes back four months after this first donation, we will repeat all the tests. If the tests are still negative, the plasma will be used. The four-month rule is essential because it takes four months to detect most viruses. With the four months, we are sure not to miss the viruses we are looking for.
You keep saying that you don't make a difference between homosexual men and heterosexual people, yet there is a difference.
I make a difference based on statistical risk. I'm not being judgmental. What used to be shocking was the question of whether the potential donor had had a homosexual relationship in his life. Even if it was forty years ago, he was excluded from giving blood. I was convinced that we had to change this. Now, the only thing that interests us is whether there is a risk for the sample we want to collect today. I don't care about the rest. That's the big change.
What bothers me is that heterosexual people are not immune to AIDS or other sexually transmitted diseases.
We have questions about sex with sex workers. We know that this is a risky activity. And so we're going to issue eviction criteria in relation to blood donation. If someone has earned his living by prostituting himself, for example, it is not a value judgment in relation to his behaviour but because we know that there is a risk of catching a sexually transmitted disease. We have an obligation to guarantee the safety of the bags we transfuse and from the moment there is a doubt that persists – without any prejudice – we are obliged to take it into account.
So this new regulation has been effective since January 2021. Did you announce it? Because I haven't seen or read anything.
No, we didn't advertise it because this year has been so disrupted by Covid … We worked on this project throughout 2020. It was a real desire to turn the page and move on.
In the last five months, have you ever had a case where a gay man was able to give blood?
No, I think that the information has to be made public before people come to us and are no longer afraid. I think that those concerned always experienced it as a judgment. And now for me there is no more judgment. It is the sexual practices that we are interested in, not the sexual orientation. But for example, people from England are also very unhappy to be excluded.
So what happened between 1980 and 1996 in Britain? Because people who lived there for more than twelve months in that period are excluded from donating too.
There was the mad cow disease epidemic, which had a huge impact on the UK. The agent of this disease is transmitted to humans by eating contaminated beef. And humans can get Creutzfeldt-Jakob disease which is a form of dementia from which many people have died. Because England was much more affected, other countries did not accept donors who lived in the UK during that period. This rule is still applied because there are studies that show that the incubation period can be up to 40 years.
A fortnight ago the Red Cross issued a statement that your supplies are running out. During the first lockdown it was the opposite. Is the initial solidarity of the pandemic fading? Or what could be the reason for this evolution?
No, the solidarity still exists. It is true that at the beginning of 2020 we started with an excellent supply. There was the lockdown in the spring, during which donors reacted – without being asked – out of a sense of solidarity. So the stock was even better. It is true that hospitals have reduced their consumption a little because they have had to postpone operations. But we can't put a figure on this drop because every year since 2017 we have seen a drop in the consumption of red blood cells. There was a drop in 2020 compared to 2019, but we can't say it's because of Covid.
Dr Anne Schuhmacher on the blood shortage
So it's not the donors' fault?
No, the donors keep coming. Our blood donations are similar to last year's and the year before that. But what has happened since February 2021 is that there has been a significant increase in demand in the hospitals that cannot be explained. In January we had the same consumption as in January 2019. In February we had an increase of 11%, in March an increase of 29%, in April 20% and in May 26% compared to the previous year. This may be a carry-over from last years operations, but also other things, such as an operation or a patient who needs a lot of blood bags.
How serious is the situation?
Very serious. We have a stock that is below our minimum threshold. We have already made two media appeals and donors have responded. Although this week is the holiday week, we still have many donors coming in. There is nothing to complain about. The challenge now is to keep the momentum going for several weeks to build up our stocks – and not let them fall back afterwards.
What was the average number of people who donated whole blood per day in May? I remember that in October 2020 it was 80 people per day. And the ideal is between 80 and 100 people a day.
In May 2021 on average we had 97 donors who came per collection day. To replenish stocks and keep up with rising demand, in fact, we would have to be between 100 and 120.
What happens if the reserves are completely exhausted?
We have agreements with the three border countries – France, Belgium and Germany – that say we can call on their help in the event of a national disaster. These agreements were put in place after a train accident in 2006. If there is ever a disaster, it is certain that we will not be able to keep up and we can call on their help. This has already happened occasionally. It even happened last year that we handed over 20 bags to Germany. We were proud.
How long is a person who has had Covid-19 excluded from giving blood?
A person who has had Covid cannot come for four weeks.
The questionnaire also says: "Have you been vaccinated or had another injection in the last four weeks? "This is a question that the majority of the population is likely to answer in the affirmative in the coming weeks. What does this mean to you?
Whatever the type of Covid-vaccination, you can't come and give for a week. Overall, neither that nor the number of people infected has much impact on our supplies because there will be a smoothing effect. A Covid patient won't be able to come for four weeks but he will come afterwards. A vaccinated person won't be able to come for a week but will come afterwards. Moreover, we have put this new information on our website dondusang.lu, so our donors can inform themselves and prepare accordingly. So it doesn't have an effect on our stocks.
If you are vaccinated and then you give blood – will the person who gets the blood be immune?
It's quite logical to think like that. There are countries that have set up plasma banks of Covid patients. Patients who have had Covid will develop antibodies and those who have a high level of antibodies can be interesting because their plasma can be harvested to give to patients in desperate situations.
Is this done in Luxembourg?
In Luxembourg we have thought about this possibility. The transfusion centre in partnership with the CHL and the LIH has the possibility of creating a plasma bank of Covid patients. We put together a file, submitted it to the Ministry of Health and we are still waiting for an answer … The fact is that not all plasma can be given to all patients. It's like blood types. There are incompatibilities. So to manage to have a plasma bank for Covid patients, it is complicated in such a small country to manage to have a sufficient – and useful – stock.