C O M M E N TA RY
International variation in volunteer whole blood donor
eligibility criteria
_2392
507..513
Julie K. Karp and Karen E. King
BACKGROUND: This study assesses international
variation in volunteer whole blood donor eligibility
criteria.
STUDY DESIGN AND METHODS: In February 2008,
Web sites of major blood collection organizations in 17
countries were queried for the volume of whole blood
donations and six donor eligibility criteria: allowed donation frequency, donor age, hemoglobin (Hb), weight,
and deferrals for tattoo and pregnancy/breast-feeding.
RESULTS: The allowed frequency of whole blood
donation ranged from 56 to 120 days, some with sexand age-specific limitations. While blood collection
agencies in three countries did not have an upper age
limit for donation, the remainder mandated donor retirement at ages from 60 to 81 years. The minimum Hb
level was 11.5 to 12.5 g/dL for women and 12.5 to
13.5 g/dL for men. Blood collection organizations in only
three countries required a minimum donor weight of
less than 50 kg. Tattoo and pregnancy deferrals ranged
from 4 to 12 months and 6 weeks to 12 months,
respectively. The volume of whole blood donations
ranged from 300 to 500 mL. The percentage of total
blood volume donated, the absolute grams of Hb
expected to be restored per deferral period and per day
of donor deferral, and the concentration of Hb expected
to be restored per deferral period were calculated.
CONCLUSIONS: International volunteer whole blood
donor eligibility criteria demonstrate marked variation.
These differences likely cause international variation in
the prevalence of adverse donor reactions and iron
deficiency anemia. The reasons underlying these dissimilarities are unclear, but may include varying cultural
influences and average donor body habitus.
W
ithin the United States, the practice of volunteer whole blood donation is largely
uniform. However, personal experience has
demonstrated that the international practice of volunteer whole blood donation varies significantly
between countries. The entire process of whole blood
donation is heavily influenced by the country in which it
occurs. These international differences extend from the
donor eligibility criteria to the postdonation refreshments
and beyond. To our knowledge, a comprehensive review of
the international variations in whole blood donation has
not been published to date.
In this study, we assess international variation in
whole blood donor eligibility criteria. We have intentionally limited the scope of this study to include whole blood
donor eligibility criteria only as defined by international
blood collection organizations. Our goal was to emphasize
the international whole blood donor experience and, as
such, we did not assess whole blood donor eligibility criteria as defined by international regulatory agencies. Our
findings provide insight into the potential international
differences in the prevalence of adverse donor reactions,
rate of donor deferral, whole blood donor iron deficiency
anemia, whole blood donor weight requirements as it
relates to the average donor body habitus, and the possible cultural influences on donor eligibility requirements.
MATERIALS AND METHODS
In February 2008, the Web sites of major blood collection
organizations in 17 countries across five continents were
queried for six volunteer whole blood donor eligibility
From the Department of Pathology, Hemapheresis and Transfusion Support, The Johns Hopkins Hospital, Baltimore, Maryland.
Address reprint requests to: Karen E. King, The Johns
Hopkins Hospital, 550 North Broadway, Suite 810, Baltimore,
MD 21205; e-mail: [email protected].
Received for publication January 22, 2009; revision
received July 8, 2009, and accepted July 8, 2009.
doi: 10.1111/j.1537-2995.2009.02392.x
TRANSFUSION 2010;50:507-513.
Volume 50, February 2010
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KARP AND KING
criteria: allowed frequency of whole blood donation,
donor age, hemoglobin (Hb), weight, and tattoo and
pregnancy/breast-feeding deferrals.1-17 The volume of
whole blood donations in each country was also noted.
The blood collection organizations that were queried are
listed in Table 1.
The percentage of total blood volume donated, the
absolute grams of Hb expected to be restored per deferral
period and per day of donor deferral, and the concentration of Hb expected to be restored per deferral period were
calculated for each blood collection organization for both
men and women. These values were calculated only for
blood collection organizations for which whole blood
donation volume, allowed donation frequency, minimum
donor weight, and minimum Hb were available. These
calculations are shown in Fig. 1.
Total blood volume was calculated using the
normal values for blood volume: 66 mL/kg in men
and 60 mL/kg in women.18 The minimum donor weight
for each blood collection organization was used to calculate the total blood volume. The reported whole blood
TABLE 1. International blood collection
organizations queried
American Red Cross (United States)
Canadian Blood Services (Canada)
Cruz Roja Mexicana (Mexico)
National Blood Service (England)
Irish Blood Transfusion Service (Ireland)
Northern Ireland Blood Transfusion Service (Northern Ireland)
Scottish National Blood Transfusion Service (Scotland)
Sanquin (Netherlands)
Deutsches Rotes Kreuz (Germany)
Österreichisches Rotes Kreuz (Austria)
Service de Transfusion Croix Rouge Suisse (Switzerland)
New Zealand Blood Service (New Zealand)
Australian Red Cross Blood Service (Australia)
South African National Blood Service (South Africa)
Health Sciences Authority (Singapore)
Hong Kong Red Cross Blood Transfusion Service (Hong Kong)
Indian Society of Blood Transfusion and Immunohaematology
(India)
Percent of Total Blood Volume Donated =
Minimum Whole Blood Donation Volume (mL)
Total Blood Volume (mL)
Absolute Grams of Hemoglobin Expected to be Restored Per Deferral Period
Following Whole Blood Donation =
Minimum Hemoglobin (g/mL) × Minimum Whole Blood Donation Volume (mL)
Absolute Grams of Hemoglobin Expected to be Restored Per Day of Donor
Deferral Following Whole Blood Donation =
Minimum Hemoglobin (g/mL) × Minimum Whole Blood Donation Volume (mL)
Allowed Donation Frequency (days)
Concentration of Hemoglobin Expected to be Restored Per Deferral Period
Following Whole Blood Donation =
Absolute grams of hemoglobin expected to be restored per deferral period (g)
Total Blood Volume (dL)
Fig. 1. Formulas for calculations.
508 TRANSFUSION
Volume 50, February 2010
donation volume was then divided by the total blood
volume to determine the percentage of total blood volume
donated.
The absolute grams of Hb expected to be restored
per deferral period was calculated by multiplying the
minimum donor Hb (in g/mL) by the minimum volume of
whole blood donation (in mL). The absolute grams of Hb
expected to be restored per day of donor deferral was calculated by simply dividing by the allowed whole blood
donation frequency (in days). The concentration of Hb
expected to be restored per deferral period was calculated
by dividing the absolute grams of Hb expected to be
restored per deferral period by the total blood volume
(in dL).
RESULTS
A total of 106 (89%) of the 119 possible data points were
available. The 13 unavailable data points were spread over
organizations in eight countries. Cruz Roja Mexicana and
Deutsches Rotes Kreuz each had three unavailable data
points (Hb, tattoo, and pregnancy/breast-feeding deferrals). Österreichisches Rotes Kreuz had two unavailable
data points (Hb and weight). Hb was unavailable for blood
collection organizations in seven countries (Mexico,
Ireland, the Netherlands, Germany, Austria, Switzerland,
and South Africa). Interestingly, none of the criteria was
consistent across the blood centers in all countries
(Table 2).
The allowed frequency of whole blood donation
ranged from 56 to 120 days, with some organizations
imposing sex- and age-specific limitations. In addition to
specifying the frequency of whole blood donations, the
number of whole blood donations allowed per calendar
year was limited by blood collectors in 11 countries.
Depending on the organization, women were restricted to
three to four donations per year and men were restricted to
three to six donations.
Whole blood donors were allowed to donate as early
as age 16. However, parental consent was required for 16and/or 17-year-old donors by blood collection organizations in the United States, Australia, Singapore, and Hong
Kong. In nine organizations, first-time donors were
required to be younger than a defined age, ranging from
60 to 66 years. Repeat donors were allowed to donate
beyond this age, but only until the age of mandatory
donor retirement, if defined. In fact, blood collection organizations in 14 countries mandated donor retirement at
ages ranging from 60 to 81 years. Canadian Blood Services
and Service de Transfusion Croix Rouge Suisse required
physician approval for whole blood donors older than 71
and 66 years, respectively. The Netherlands’ Sanquin
required physician approval to be a first-time donor
between the ages of 60 and 65. New Zealand Blood Service
required physician approval for blood donors between the
Volume 50, February 2010
NA
12.5 g/dL women,
13.5 g/dL men
18-65
17-59; ⱖ60 and ⱕ70 if donated
in past 5 years
90 days; ⱕ4¥/year
NA
NA
18-70; first-time donor ⱕ65;
first-time donor ⱖ60 only
with MD approval
18-68; first-time donor ⱕ60
18-65; first-time donor ⱕ60
18-65; ⱖ66 with MD approval
56 days; women,
ⱕ4-5¥/year;
men, ⱕ6¥/year
Women, ⱕ3¥/year;
men, ⱕ4¥/year
16-65; 16-17 with parental
consent
18-60
Women, ⱕ3¥/year;
men, ⱕ4¥/year;
16-17 every
6 months
Women, ⱕ3¥/year;
men, ⱕ4¥/year
45 kg = 350 mL;
ⱖ50 kg = 450 mL
Indian Society of Blood
Transfusion and
Immunohaematology
16-60; 16-17 with parental
consent
84 days; ⱕ4¥/year
300-450 mL
16-65
16-70; 16-17 with parental
consent; ⱖ71 with annual
MD approval; mandatory
retirement at 81
56 days
84 days
84 days; ⱕ4¥/year
56 days; women,
ⱕ4¥/year;
men, ⱕ6¥/year
16-70; first-time donor ⱕ60;
70-75 with MD approval
NA
17-70; first-time donor ⱕ66
84 days; ⱕ3¥/year
Women, 17 weeks,
ⱕ3¥/year; men,
10-11 weeks,
ⱕ5¥/year
12.5 g/dL women,
13.5 g/dL men
17-70; first-time donor ⱕ66
112 days; ⱕ3¥/year
12.5 g/dL
11.5 g/dL women,
13.0 g/dL men
12.5 g/dL
NA
12.5 g/dL women,
13.5 g/dL men
12.5 g/dL women,
13.5 g/dL men
NA
12.5 g/dL women,
13.5 g/dL men
18-67 if donated in past 5 years;
first-time donor ⱕ60
90 days
NA
12.5 g/dL
17-71; first-time donor ⱕ61;
ⱖ71 with annual MD approval
56 days
112 days
Minimum Hb
12.5 g/dL
Donor age (years)
17+; 16 with parental consent
and allowed by state law
Allowed donation
frequency
56 days
Hong Kong Red Cross
Blood Transfusion
Service
450 mL
450 mL
Service de Transfusion
Croix Rouge Suisse
Health Sciences
Authority
450 mL
Österreichisches Rotes
Kreuz
480 mL
500 mL
Deutsches Rotes Kreuz
South African National
Blood Service
500 mL
Sanquin
470 mL
465 mL
Scottish National Blood
Transfusion Service
Australian Red Cross
Blood Service
470 mL
Northern Ireland Blood
Transfusion Service
470 mL
470 mL
Irish Blood Transfusion
Service
New Zealand Blood
Service
435 mL
470 mL
Cruz Roja Mexicana
450 mL
Canadian Blood
Services
National Blood Service
Whole blood
donation volume
1 pint ª 473 mL
Blood collection
organization
American Red Cross
45 kg
41 kg
45 kg
50 kg
45 kg; 50 kg
if 16-17
50 kg
50 kg
NA
50 kg
50 kg
50 kg
50 kg
50 kg
50 kg
50 kg
50 kg
Minimum
weight
110 lbs ª 50 kg
NA
12 months
12 months
6 months
12 months
6 months
6 months
4 months
NA
12 months
12 months
12 months
6 months
6 months
NA
6 months
Tattoo deferral
12 months, unless
applied by state
regulated entity
TABLE 2. Whole blood donor eligibility criteria for international blood collection organizations
Until weaning
6 months
6 weeks or until
weaning
6 months
9 months or
until weaning
9 months;
3 months
after weaning
12 months
6 months
NA
6 months
9 months
9 months
12 months
9 months
NA
6 months
6 weeks
Pregnancy/
breast-feeding
deferral
INTERNATIONAL VARIATION IN DONOR ELIGIBILITY
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KARP AND KING
ages of 70 and 75, while the Australian Red Cross Blood
Service required annual physician approval for all donors
over the age of 71. The American Red Cross was the only
organization with neither restrictions on senior donors
nor an upper age limit for whole blood donation.
Four blood collection organizations required a Hb of
12.5 g/dL for whole blood donation for both sexes. Five
organizations required a Hb of 12.5 g/dL for women and
13.5 g/dL for men. Hong Kong Red Cross Blood Transfusion Service required a Hb of 11.5 g/dL for women and
13.0 g/dL for men. While 12 organizations stipulated a
minimum whole blood donor weight of 50 kg, Hong Kong
Red Cross Blood Transfusion Service required a minimum
donor weight only of 41 kg. Blood collections organizations in India, Singapore, and Australia required a
minimum donor weight of only 45 kg, with the Australian
Red Cross Blood Service mandating that 16- and 17-yearold donors weigh at least 50 kg.
Tattoo and pregnancy deferrals ranged from 4 to 12
months and 6 weeks to 12 months, respectively. Only four
blood collection organizations reported specific deferral
periods for breast-feeding, which ranged from the time of
weaning to 3 months after weaning.
The volume of whole blood donations ranged from
300 to 500 mL. Thirteen organizations reported whole
blood donation volumes between 435 and 480 mL. The
Indian Society of Blood Transfusion and Immunohaematology and Hong Kong Red Cross Blood Transfusion Service
limited the donation volume relative to patient weight,
with volumes as low as 300 mL by the latter organization.
Deutsches Rotes Kreuz and the Netherlands’ Sanquin both
reported whole blood donation volumes of 500 mL.
The percentage of total blood volume donated ranged
from 12.2% to 17.4% for women and 11.1% to 15.8% for
men. The minimum absolute grams of Hb expected to be
restored per deferral period was 36 g per 120-day deferral
period for women and 39 g per 90-day deferral period for
men. The maximum absolute grams of Hb expected to be
restored per deferral period was 59 g per 56-day deferral
period for both women and men. The absolute grams of
Hb expected to be restored per day of donor deferral
ranged from 0.29 to 1 g/day for women and 0.46 to 1 g/day
for men. The concentration of Hb expected to be restored
per deferral period ranged from 2.0 g/dL per 56-day deferral period to 1.4 g/dL per 120-day deferral period for
women and from 1.8 g/dL per 56-day deferral period to
1.9 g/dL per 112-day deferral period for men. These values
are listed in Table 3.
DISCUSSION
The percentage of total blood volume donated showed
some international variation. As expected, regardless of
location, female donors always donated a larger percentage of their total blood volume than their male counter510 TRANSFUSION
Volume 50, February 2010
parts. While the differences in the percentage of total
blood volume donated are not particularly striking,
further research might evaluate the international variation in the incidence of adverse donor reactions relative to
the total blood volume donated. One could hypothesize
that there would be a direct relationship between the percentage of total blood volume donated and the incidence
of adverse donor reactions.
The absolute grams of Hb expected to be restored per
deferral period and per day of donor deferral are devised
calculations with no established clinical equivalent.
However, these calculations do highlight the differences in
international blood collection practices.
With the exception of Singapore’s Health Sciences
Authority, the absolute grams of Hb expected to be
restored per deferral period does not show marked international variation. However, the length of the deferral
period over which the absolute grams of Hb are expected
to be restored does show international variation. A comparison between the American Red Cross and England’s
National Blood Service emphasizes this variation.
Based on our calculations, the absolute grams of Hb
expected to be restored are similar between the two organizations. The American Red Cross expects 59 g of Hb to
be restored for both women and men. The National Blood
Service expects 59 and 63 g of Hb to be restored for
women and men, respectively. Notably, the American Red
Cross has a 56-day deferral period, while the National
Blood Service has a 112-day deferral period. Thus, while
the American Red Cross and the National Blood Service
expect their donors to restore virtually the same absolute
grams of Hb per deferral period, the National Blood
Service requires a deferral period twice as long as their
American counterparts. Similar comparisons can be made
between several of the blood collection organizations.
As a result of the units in which it is expressed, the
concentration of Hb expected to be restored per deferral
period is a calculation that is more readily applied to clinical practice. Nonetheless, this calculation also highlights
the differences between international blood collection
organizations. For example, the American Red Cross
expects the concentration of Hb expected to be restored
per deferral period to be 2.0 g/dL for women and 1.8 g/dL
for men. The National Blood Service expects the concentration of Hb expected to be restored per deferral period to
be 2.0 g/dL for women and 1.9 g/dL for men. These values
are nearly identical, but the deferral period for the
National Blood Service remains double that of the American Red Cross.
The consequences of these findings are likely twofold.
First, blood collection organizations with shorter deferral
periods and higher expectations for Hb restoration likely
have an increased incidence of whole blood donor iron
deficiency anemia. Simply put, if whole blood donors are
not given adequate time to restore their Hb levels between
Women 45 kg, 13%
Women ⱖ50 kg, 15%
Men 45 kg, 11.8%
Men ⱖ50 kg, 13.6%
Women, 17.4%
Men, 15.8%
Australian Red Cross Blood
Service
Indian Society for Blood
Transfusion and
Immunohaematology
Women, 15.7%
Men, 14.2%
New Zealand Blood Service
Women, 12.2%
Men, 11.1%
Women, 15.5%
Men, 14.1%
Scottish National Blood
Transfusion Service
Hong Kong Red Cross
Blood Transfusion Service
Women, 15.7%
Men, 14.2%
Northern Ireland Blood
Transfusion Service
Women, 16.7%
Men, 15.2%
Women, 15.7%
Men, 14.2%
National Blood Service
Health Sciences
Authority (Singapore)
Women, 15%
Men, 13.6%
Percentage of total
blood volume donated
Women, 15.8%
Men, 14.3%
Canadian Blood Services
Blood collection organization
American Red Cross
Women, 44 g per 120-day deferral period
Women, 56 g per 120-day deferral period
Men, 44 g per 90 day deferral period
Men, 56 g per 90 day deferral period
Women, 36 g per 120-day deferral period
Men, 39 g per 90 day deferral period
56 g per 84-day deferral period
Women, 59 g per 84-day deferral period
Men, 63 g per 84-day deferral period
Women, 59 g per 84-day deferral period
Men, 63 g per 84-day deferral period
Women, 58 g per 84-day deferral period
Men, 63 g per 84-day deferral period
Women, 59 g per 112-day deferral period
Men, 63 g per 112-day deferral period
Women, 59 g per 112-day deferral period
Men, 63 g per 112-day deferral period
56 g per 56-day deferral period
Absolute grams of Hb expected
to be restored per donor deferral
period after whole blood donation
59 g per 56-day deferral period
Men, 0.49 g/day
Women, 0.36 g/day
Women, 0.29 g/day
Men, 0.43 g/day
1 g/day
Women, 0.70 g/day
Men, 0.76 g/day
Women, 0.70 g/day
Men, 0.76 g/day
Women, 0.69 g/day
Men, 0.75 g/day
Women, 0.52 g/day
Men, 0.57 g/day
Women, 0.52 g/day
Men, 0.57 g/day
1 g/day
Absolute grams of Hb
expected to be restored
per day of donor deferral
after whole blood donation
1 g/day
Women 45 kg, 1.6 g/dL per 120-day deferral period
Women ⱖ50 kg, 1.9 g/dL per 120-day deferral period
Men 45 kg, 1.5 g/dL per 90 day deferral period
Men ⱖ50 kg, 1.7 g/dL per 90 day deferral period
Women, 1.4 g/dL per 120-day deferral period
Men, 1.4 g/dL per 90 day deferral period
Women, 2.1 g/dL per 84-day deferral period
Men, 1.9 g/dL per 84-day deferral period
Women, 2.8 g/dL per 84-day deferral period
Men, 2.1 g/dL per 84-day deferral period
Women, 2.0 g/dL per 84-day deferral period
Men, 1.9 g/dL per 84-day deferral period
Women, 1.9 g/dL per 84-day deferral period
Men, 1.9 g/dL per 84-day deferral period
Women, 2.0 g/dL per 112-day deferral period
Men, 1.9 g/dL per 112-day deferral period
Women, 2.0 g/dL per 112-day deferral period
Men, 1.9 g/dL per 112-day deferral period
Women, 1.9 g/dL per 56-day deferral period
Men, 1.7 g/dL per 56-day deferral period
Concentration of Hb expected to be restored per
donor deferral period after whole blood donation
Women, 2.0 g/dL per 56-day deferral period
Men, 1.8 g/dL per 56-day deferral period
TABLE 3. Percentage of total blood volume donated, absolute grams of Hb expected to be restored per deferral period and per day of deferral, and Hb
concentration expected to be restored per deferral period
INTERNATIONAL VARIATION IN DONOR ELIGIBILITY
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KARP AND KING
allowed donations, iron deficiency anemia is more likely
to occur. A consequence of a higher incidence of whole
blood donor iron deficiency anemia is increased incidence of whole blood donor deferrals. Increased whole
blood donor deferrals make an already shallow donor pool
that much shallower. Furthermore, a deferred donor may
not return for future donations, only further limiting the
donor pool.
Alternatively, one could argue that blood collection
organizations with longer deferral periods are overly conservative. While longer deferral periods may better protect
donors from iron deficiency anemia, they may also
prevent the blood collection organization from maximally
utilizing the donor pool.
While the deferral periods for whole blood donors
appear rather arbitrary, the international differences in
whole blood donor weight requirements likely accurately
reflect international differences in average donor body
habitus. According to the World Health Organization
Global Database on body mass index, approximately 35%
of the American population has a normal body mass
index, compared to 62% of the Indian population.19 This
information supports the disparate whole blood donor
weight requirements of the American and Indian blood
collection organizations.
The American Red Cross and the Indian blood collection organization required whole blood donor weights of
50 and 45 kg, respectively. With a majority of Americans
having supranormal body mass indices, it is not difficult to
find American blood donors who meet the 50-kg weight
requirement. By contrast, if the Indian weight requirement were also 50 kg, a minority of the population would
meet this requirement. As such, the Indian weight requirement of 45 kg reflects the leaner average donor body
habitus of the Indian population. One should also note
that the whole blood donation volume is lowered to
350 mL in Indian donors weighing between 45 and 50 kg.
Thus, both India’s whole blood donor weight requirement
and its donation volume reflect the distinct physical characteristics of that country’s donor population.
International variation in the remaining whole blood
donor eligibility criteria may reflect international cultural
differences. The minimum age requirement for whole
blood donation ranged from 16 to 18 years, possibly
depending on the country’s legal age of consent. Similarly,
the varying cultural views of sex may influence whether
or not whole blood donor criteria are sex-specific or
sex-neutral. Sex-specific donor criteria may reflect more
traditional sex roles, and sex-neutral limits on donation
frequency may be the result of the cultural influence of sex
equality. That being said, sex-specific donor criteria may
reflect presumed physiologic differences between male
and female donors.
Cultural influences may also be a factor with regard to
the maximum age limits of whole blood donors. As per the
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Volume 50, February 2010
American Red Cross, whole blood donors may continue
donating as long as they meet eligibility criteria and
remain in general good health. Physician approval is not
required and there is no mandatory donor retirement age.
In all other queried organizations, there was some defined
upper age limit for whole blood donation, with or without
physician approval, as well as restrictions on senior firsttime donors. The age at which donors are asked to cease
donating appears, to some extent, culturally defined. With
mandated donor retirement at ages ranging from 60 to 81
years, these criteria have no clear biologic basis. Further
research may provide insights into whether any maximum
age limit should exist for whole blood donors and, if so, at
what age.
Finally, the international variation in tattoo and
pregnancy/breast-feeding deferrals is likely a reflection of
the degree to which tattoo parlors are regulated by government and health agencies, as well as the cultural perception of tattoos. Pregnancy/breast-feeding deferrals may be
a reflection of the cultural perception of pregnancy and
women, as well as the frequency of breast- versus
bottle-feeding.
Our findings beg further investigation. First, blood
collection organization Web sites written in non–Latinbased languages were not queried. These Web sites
should be included in later studies. Second, this study
only incorporated data retrieved from blood collection
organization Web sites. Attempts to contact these organizations and obtain more information regarding the
incidence of iron deficiency anemia and donor deferrals
could be valuable. Finally, our findings raise questions
regarding the reasons underlying donor eligibility criteria. Further research is needed to determine if these criteria are the product of evidence-based medicine or of
social convention.
In conclusion, the dissimilarities in international
whole blood donor eligibility criteria are numerous and
often influenced more by culture rather than science. As
the number of eligible volunteer whole blood donors
grows ever smaller, we must objectively reevaluate donor
eligibility criteria to maximize the donor pool and to minimize the risks associated with donation. International
research and collaboration will be required to optimize
volunteer whole blood donor eligibility criteria.
CONFLICT OF INTEREST
The authors have no conflicts of interest.
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INTERNATIONAL VARIATION IN DONOR ELIGIBILITY
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