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LETTER

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2003 Blackwell Publishing

Blackwell Publishing Ltd.Oxford, UKVOXVox Sanguinis1423-04102003 Blackwell Publishing Ltd85Letter to the EditorLetterLetterLETTER

Author’s reply

C. L. van der Poel,

1

E. Seifried

2

& W. Schaasberg

3

1

Sanquin Blood Supply, Medical Affairs, Amsterdam, the Netherlands

2

Red Cross Blood Donor Service, Frankfurt, Germany

3

Statistics Netherlands, Voorburg, the Netherlands

Drs Offergeld and Burger stress the present high safety ofblood components and plasma products. This is not disputedin our paper. We acknowledged that ‘the preparation, purifi-cation and viral inactivation procedures employed in theproduction of derivatives of pooled human plasma mayrender the difference between the safety of paid and unpaiddonors for plasma products irrelevant’ [1]. Mr Bult cites astatement about the safety of plasma products by EMEA, astatement however, that continues with: ‘The question ofwhether or not non-remuneration is important for the safetyof blood and blood components for transfusion is a separateissue outside the scope of this document.’ [2]

An assessment on the reasons why unpaid donors aresafer than paid ones was not the scope of our review, thereader is referred to other papers such as one by Sanchezwhich found that donors attracted by cash were 60% morelikely to have a risk for transfusion-transmissible infections[3]. As for the methodology of our paper, it was neverintended as a meta-analysis, and the raw data were notpooled. A similar analysis could address whether tomatoesover time are relatively more expensive than potatoes,without adressing price mechanisms and different currencieswithin comparisons. We merely question a statement bythe European Commission [4], apparently supported byMr Bult, that the difference in risk between paid donorsand unpaid donors is an issue of the past only [4]. Thisstatement occurred in the light of a draft Directive onblood components, the safety of which is related to thewindow period, and also the infectious disease incidenceamong the donors [5]. We can only conclude that the rela-tive risks in the published literature do not support thatstatement.

Offergeld and Burger cite a recent review as an exampleof paid donors with a lower infectious disease marker rate[6]. However, comparisons presented by Strauss were earliercriticized by Fiedler as being of flawed methodology [7].In response, Strauss later presents additional information.Unfortunately the comments by Fiedler in 1995 were nottaken into account by Strauss in his 2001 paper [6]. Thereported paid cytapheresis donors donated about five times

more often per year, i.e. the

incidence

in paid donors wouldbe five times higher than suggested from the presentation ofthe data [6]. In our paper, we addressed the limitations of thedata sets, and by review one cannot escape the impressionthat the difference between unpaid and paid donors mayhave been larger if bias could have been controlled for. Giventhe limitations of other data sets, it seems fair to includeSrauss’s findings in our assessment.

Bult’s vision on arthropod-borne viruses (such as West NileVirus) as compared to blood-borne viruses (such as HepatitisC Virus) is interesting. Blood-borne infections by definitionare predominantly transmitted by blood–blood contact, andsuch viruses are more frequent among drug users [8]. Indeed,an increased incidence among drug users is not likely foragents that are predominantly transmitted by other routes,such as vCJD. It remains to be seen what the predominantroutes of infection are for emerging small DNA viruses [9,10].Bult refers to tables from WHO, reporting 0–5 AIDS casesassociated with transfusion pro annum in the Netherlands[11]. These data have some caveats, mentioned in the sametable [11]. They represent HIV infections in the past, andalthough indeed all blood and plasma donors in the Nether-lands are non-remunerated, not all plasma products transfusedin the past were from Dutch donors [12].

Questioned by Offergeld and Burger about the remunera-tion of donors in relation to the German NAT data, we mayrefer to Legler mentioning 52 DM in the methods, andcomments by Roth [13,14]. Roth takes into account that theGerman unpaid donors may have been more often donorsfrom rural areas with lower incidence rates, and the possibilityof geographical bias was addressed in our paper. As stated byOffergeld and Burger, a nationwide surveillance of relevantinfections has been established in Germany. It would not betoo difficult to compare the infectious disease marker rates ofthe blood collection centres in the city areas for both the paidand unpaid blood donors, or reimbursing vs. non-reimbursingsystems. A detailed epidemiological analysis of the Germandata is indeed welcomed, the independence of which caneasily be adressed by publication in a peer-reviewed inter-national scientific journal.

References

1 Van der Poel CL, Seifried E, Shaasberg WP: Paying for blooddonations: still a risk?

Vox Sanguinis

2002;

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:285–2932 CPMP: Position Statement. Non-Remunerated and Remunerated

Donors: Safety and Supply of Plasma Derived MedicinalProducts 30th May 2002. EMEA/CPMP/BWP, /1818/02/Final.

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3 Sanchez AM, Ameti DI, Schreiber GB, Thomson RA, Lo A,Bethel J, Williams AE, Retrovirus Epidemiology Donor Study:The potential impact of incentives on future blood donationbehaviour.

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Press Release Commissioner Byrne November15th 2001.

http://www.europa.eu.International/rapidstart/cgi/guesten.ksh?, p. _action.gettxt=gt…/374|0|RAPID & lg=EN.pdf

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compared?

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transmission and prevention. In: Reesink HW, ed.

Hepatitis CVirus. Current Studies in Hematology and Blood Transfusion

.Basel: Karger 1998:208–223

9 Schroter M, Laufs R, Zollner B, Knodler B, Schafer P, Sterneck M,Fischer L, Feucht HH: Prevalence of SENV-H viremia amonghealthy subjects and individuals at risk for parenterallytransmitted diseases in Germany.

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(TTV), TTV-like minivirus and related viruses in humans andnonhuman primates.

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Epidemiological Fact Sheet on HIV/AIDS and Sexually Trans-mitted Infections. 2002 Update: http://www.who.int/emc-hiv/fact_sheets/pdf/Netherlands_EN.pdf

12 Mauser-Bunschoten EP: Complications in hemophilia care.Thesis, University Utrecht, 1995

13 Legler TJ, Riggert J, Simson G, Wolf C, Humpe A, Munzel U,Uy A, Kohler M, Heermann KH: Testing of individual blooddonations for HCV RNA reduces the residual risk of transfusion-transmitted HCV infection.

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:1192–119714 Roth WK, Seifried E: Reducing the residual riks of transfusion-

transmitted viruses: mini-pool or single-donation NAT?

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Received: 2 April 2003,accepted: 8 April 2003

C. L. van der PoelSanquin Blood Supply Foundation, Medical Affairs,Plesmanlaan 1251066 CX Amsterdam, the NetherlandsE-mail: c.vanderpoel@sanquin.nl