Addressing Patient Concerns with Blood Transfusion from Donors Vaccinated Against COVID-19

Perioperative specialists, including anesthesiologists, surgeons, and proceduralists, are often the first clinicians to receive these requests and are exceptionally poised to provide guidance to patients in the time leading up to surgery. Consultations in the anesthesiology preoperative evaluation clinic may serve as a well-timed opportunity to discuss patients’ concerns regarding blood transfusion and provide educational materials for their review. However, these requests may also be encountered during nonprocedural healthcare encounters, such as during an inpatient admission. It is therefore essential that all clinicians are informed on this issue and prepared to discuss both the safety of our donor blood supply and the alternatives to transfusion (along with the associated risks and limitations) with patients.

When connecting with patients regarding their concerns, it is critical to first understand why a patient may make this request. Patients present to us with diverse preferences and varying degrees of understanding regarding medical care and general health, and it is our obligation as clinicians to understand these preferences and their drivers. Although there is a history of prejudice affecting requests for specific blood attributes many requests to avoid blood from donors vaccinated against COVID-19 are likely to be related to exposure to unsupported claims of vaccine-related harm associated with blood transfusions that are being disseminated across social media and other platforms. One such example is the incorrect notion that receiving blood from a person who received an mRNA-based COVID-19 vaccine may alter recipient genetics or result in unknown long-term adverse clinical consequences. In the current era of misinformation, including political proposals that threaten the blood supply it is imperative that clinicians convey empathy and provide tailored education and guidance when patients approach us with these concerns.

Conversations should always come from a place of nonjudgment, working collaboratively through a shared decision-making framework to ensure patient-centered care. This framework is based on the patient–clinician relationship such that patients and clinicians work collaboratively to identify the patient’s problematic situation (i.e., reluctance to receive blood transfusion secondary to vaccine-related concerns), understand underlying drivers, find possible ways to address the problematic situation, reconcile conflicts, and formulate a collaborative care plan that makes sense intellectually, practically, and emotionally for both the patient and the clinician. Table 1 presents some strategies to consider when discussing the issue of donor blood vaccinated against COVID-19 with patients and provides specific examples.

During this process, it may be helpful to have a broader discussion about the likelihood of transfusion in the patient’s medical or surgical care. For those unlikely to need transfusion (e.g., no preexisting anemia, undergoing procedures with minimal blood loss), that reassurance may be sufficient for the patient and care team to agree to proceed with surgery, although it will still be necessary to clarify the patient’s blood-related wishes in case of an emergency. Within these discussions, it is important for patients to recognize that specific donor characteristics such as vaccination status, sex, race, sexual orientation, or religion do not impact the safety of blood products and therefore are not required to be recorded, thereby making it impossible in our current blood banking infrastructure to determine which blood products are from donors who have or have not been vaccinated against COVID-19. Furthermore, just as there is no evidence to support the transmission of COVID-19 through blood donation there is no evidence demonstrating transmission of COVID-19 vaccine components through blood donation. However, we must also acknowledge that no studies have explicitly addressed the latter. Importantly, patients should be reassured that vaccines based on mRNA technology provide instructions to build immunity against future infections and do not interact with or alter recipient DNA. The safety of the blood supply should be highlighted, and questions should be answered truthfully and respectfully. Finally, it is important for patients to consider whether, in the event of life-threatening hemorrhage, they would rather face serious harm or death than receive blood products from a donor vaccinated against COVID-19.

If the patient remains steadfast in wanting to avoid blood products from donors vaccinated against COVID-19, remaining options for the patient include not receiving blood products or seeking autologous and/or directed blood donations. However, there are serious risks associated with each of these alternatives and not all options are available for each patient or at each institution. Clear and detailed discussion and documentation of the conversation and patient desires is important to protect patient autonomy, ensure consistency in messaging during transitions in patient care, and for medicolegal reasons. Figure 1 outlines the approach to the patient requesting to avoid blood products from donors vaccinated against COVID-19 through a shared decision-making model along with potential alternative options that may be presented and the associated risks and challenges for each.

Lessons learned from vaccination hesitancy discussions may provide some guidance in conversations regarding vaccine-driven blood concerns. For example, conveying clear messages with language the target audience can understand and framing relative risk was found to be beneficial in discussions regarding COVID-19 vaccination.  Additionally, thinking about interventions at the individual level, interpersonal level, and organization level has proven helpful in communicating with patients about vaccine hesitancy, and a bundled approach applying interventions at all three levels has been shown to be quite effective.

Some of these approaches may help when addressing patient hesitancy surrounding blood transfusions from individuals vaccinated against COVID-19. For example, on an individual level, educating patients on factual information about the dangers of the communicable disease (e.g., measles) has proven much more effective than a focus on debunking vaccination myths.  In the context of blood transfusion safety, this approach could be applied by electing to focus on the potential risks and challenges associated with avoiding blood transfusions from an altruistic donor rather than focusing the discussion on refuting the misconceptions surrounding blood safety from donors potentially vaccinated against COVID-19.

If a patient declines allogeneic blood products despite information-sharing regarding the safety of the blood supply, the patient may receive treatment like other patients who decline blood products. A select group of patients, most notably those of the Jehovah’s Witness faith, choose not to receive blood products based on religious or moral preference, and there is abundant literature supporting successful management of these patients at specialized medical centers when blood is not an option.  Management focuses heavily on preoperative preparation, including clear conversations and documentation about what products and procedures a patient will or will not accept, risks of not transfusing (up to and including death), as well as diagnosis and treatment of anemia to minimize the risk of end-organ ischemia in the setting of acute blood loss. Intraoperative blood conservation techniques, including use of cell salvage, antifibrinolytics, and acute normovolemic hemodilution can further minimize blood loss, and phlebotomy should be minimized throughout the perioperative period. If it is deemed unlikely that surgery can be safely performed without transfusion, one may consider minimally invasive techniques (e.g., robotic or laparoscopic versus open procedures), alternate management (e.g., percutaneous coronary interventions as opposed to coronary artery bypass grafting) or, in the most extreme cases, surgery may be deferred.

Two other potential options include autologous donation and directed blood donation. Autologous blood donation involves a patient donating their own blood for use at a later date, typically for use during an upcoming surgical procedure. Such donations require a medical order from a physician, an adequate hemoglobin concentration, and sufficient time for hemoglobin recovery. Directed donations involve an ABO and RhD-compatible donor, often a family member or friend, providing blood specifically for the patient. These donations are collected and processed by a donor center and transferred for storage at the hospital blood bank until they are requested for transfusion. Directed donations may be medically indicated in situations where the recipient has a rare blood type and has developed antibodies to common blood cell antigens (i.e., antibodies to high-prevalence erythrocyte or platelet antigens). However, both autologous and directed blood donations come with significant risks, costs, and other issues that should be clearly understood and communicated to patients before pursuing either one.

While both autologous and directed donations are potential alternatives to accepting allogeneic blood transfusions from donors who may have received a COVID-19 vaccine, there are substantial costs and logistical concerns regarding blood collection and storage. Costs associated with autologous and directed donations may not be covered by insurance and increase out-of-pocket expenses for patients. Additionally, the number of centers prepared to handle autologous and directed donations has declined significantly since the 1980s when these options were first popularized during the HIV/acquired immunodeficiency syndrome (AIDS) pandemic. Even at the height of directed blood donations four decades ago, there was much debate over this as a potential option. 

Autologous donation should be timed appropriately (ideally more than 4 weeks in advance) to allow the patient’s blood volume and hemoglobin level to recover before surgery. Thus, in a patient presenting for urgent or emergent surgery, the use of autologous preoperatively donated blood is not an option. Other contraindications include preexisting anemia and medical comorbidities that would place the patient at increased risk of harm by donating blood. Finally, many of the collected units ultimately go unused, because blood transfusions are not required for most surgeries and those units cannot be transfused to other patients.

Directed blood donation comes with additional important risks to consider. There is concern that the individual identified as the one “willing” to donate blood for the patient may do so under some element of coercion, whether perceived or not. Consequently, this individual may be less likely to disclose elements of their pertinent medical or social history during the donation process than an altruistic donor, thereby conferring increased risk to the patient. Surveys of first-time directed donors demonstrate higher rates of positive infectious disease testing compared to repeat blood donors, conferring an increased risk of transfusion-transmitted infections from this donor population. 

Additionally, transfusion of blood products from related donors who share human leukocyte antigens increases the risk of transfusion-associated graft versus host disease, a rare but often fatal transfusion-related disease. As a result, most directed donor blood products undergo irradiation to mitigate this risk; however, this treatment comes at the cost of increased potassium and hemoglobin leakage from erythrocytes. These changes in stored, irradiated erythrocytes can be particularly deleterious to patients susceptible to hyperkalemia and has historically created concern in high-risk populations (such as neonates) for increasing the potential for cardiac arrhythmias and cardiac arrest. Finally, exposure to directed blood from related donors increases the risk of human leukocyte antigen alloimmunization that can limit the number of compatible donors for organ transplantation in the future.

Logistically, tracking and storage of autologous and directed donor blood products introduces additional administrative and nonstandard work that is time intensive, costly, and can increase risks of mistransfusion. Donations are time sensitive, because blood products have a limited shelf life; therefore, autologous and directed donor units must be used before their expiration date. Furthermore, the amount of blood collected via autologous or directed donations may not adequately meet transfusion needs in the setting of large volume blood loss.

Autologous and directed donations may also result in unintended consequences to the general blood supply. Significant adoption may reduce blood center resources for processing standard donations thereby reducing inventory. The advent of nonstandard blood suppliers who accommodate specific donor characteristic requests poses an additional concern, which was recently highlighted by the Food and Drug Administration in a statement recommending caution about websites advertising blood and blood components from donors not vaccinated against COVID-19.  Use of blood products from such suppliers would require developing dual inventory systems, adding an additional layer of regulatory complexity and cost to transfusions.

Finally, concerns regarding equity arise when approving directed donations in situations without a medical indication. If requests for directed donations based on vaccination status are approved, would health systems be obligated to honor requests based on other donor criteria such as race or religion? If restrictions are placed on some directed donation requests but not others, then inequity is inevitable. Because most blood centers require an order to collect and process directed donations, physicians must consider the greater ethical consequences of accommodating such requests.

Establishing an institutional policy will ensure a unified approach for clinicians presented with these requests. Paramount to this process is to engage with your hospital’s blood bank physicians and staff and/or patient blood management representatives who have the most knowledge about the local or regional blood supply and the logistics involved in autologous and/or directed blood donation and storage in your area. Importantly, transfusion medicine professionals are likely aware of how often these requests are being received from surgical patients and other patients at higher risk of requiring a transfusion.

A policy should clearly state that blood products cannot be specifically identified or administered or refused based on age, sex, race, religion, or vaccination status of the donor. When an autologous or directed blood donation is requested for reasons other than medical necessity (i.e., rare blood type, antibodies), the policy should provide consistent and clear guidance on how these requests will be handled and what options may be available for care delivery at your institution. This policy should be communicated and distributed to all medical staff and be readily available when patients and/or their family members inquire about options. Patient education materials should be created to support policy development, ensure consistent messaging at the appropriate medical comprehension level, and facilitate shared decision-making. Further, the presence of an institutional policy may help attenuate challenging patient interactions and ensure consistency of responses. To that end, it is critically important to share this messaging with patients in the earliest stages of surgical planning, such that patients do not feel “caught off guard” much further along in their surgical journey.

Patient concerns over the safety of the blood supply because of potential COVID-19 vaccination status of donors is an increasingly encountered clinical dilemma. Requests to avoid blood products from donors vaccinated against COVID-19 present a number of challenges given that it is not possible in our current blood banking infrastructure to distinguish units of blood that have been received from donors vaccinated or not vaccinated against COVID-19. Collaborative, nonhurried, and nonjudgmental conversations using a shared decision-making framework are paramount when working through this concern with patients in the perioperative period. Policy development should be implemented at the institutional level to provide consistent guidance to clinicians, including what options are available for a particular patient.