Prioritising health equity alongside donation safety

Abstract

I read with interest the Review by Nina Worel and colleagues in The Lancet Haematology.1Worel N Aljurf M Anthias C et al.Suitability of haematopoietic cell donors: updated consensus recommendations from the WBMT standing committee on donor issues.Lancet Haematol. 2022; 9: e605-e614Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar Their paper is an important synthesis of the literature and update of consensus recommendations regarding haematopoietic cell donor suitability, with the goal of supporting decision making to minimise medical risk to donors and protect recipients from transmissible diseases. The authors invite recruitment and collection centre staff to consider behavioural risk factors for infections at multiple points in the donor journey, including at recruitment or registration (emphasising behaviours with “clear donor risk or unacceptable recipient risk and that are relatively easy to assess”) and at donor selection and evaluation. They highlight that risk of communicable infectious diseases can be assessed using standardised questionnaires, among those a 2019 questionnaire developed by a multi-organisational Task Force. However, this questionnaire includes multiple stigmatising questions—examples of which can be found in the appendix (p 1)—that are barriers to inclusion for marginalised and disenfranchised donor groups, including gay, bisexual, and other men who have sex with men, and people of African heritage. Screening questions assessing for high-risk sexual behaviour should be gender neutral (see example in the appendix p 2) to avoid further contributing to stigma against donation from men who have sex with men, an eligible but largely untapped donor pool.2Fingrut W DeGurse N Hrycyshyn A et al.Towards a more inclusive unrelated donor registry.Bone Marrow Transplant. 2022; 57: 688-690Crossref PubMed Scopus (5) Google Scholar, 3Hatkar R Sano L DeGurse N et al.Saving lives with Pride: development and evaluation of multimedia resources to engage gay, bisexual, and queer men in Canada as stem cell donors.Blood. 2021; 138 (abstr).3017Google Scholar, 4Rosenfeld A Baribeau O Berscheid K et al.“Building a more inclusive blood system in Canada”: a mixed-methods evaluation of a workshop to guide medical students to develop as health advocates through advancing health equity in blood product donation for gay, bisexual, and queer men.Blood. 2021; 138 (abstr).2975Google Scholar Additionally, asking donors if they have any associations with the continent of Africa, or if their sexual contacts have African heritage, is discriminatory, contributes to systemic racism, exacerbates historic mistrust between African ancestry populations and health-care systems, and interferes with efforts to address racial disparity in access to unrelated donors for patients with African ancestry.5Fingrut W Gyurkocza B Davis E et al.Racial disparities persist in the era of “Donors for All”.Blood Advances. 2022; (published online June 8.)https://doi.org/10.1182/bloodadvances.2022007814Crossref PubMed Scopus (2) Google Scholar Screening for risk factors for transmissible diseases is warranted pre-transplantation; although donors undergo a battery of pre-transplantation infectious disease tests, they can still contract window-period infections. Nevertheless, such screening is of restricted value at the time of recruitment as behavioural risk factors change over time. Moreover, these questions are not a substitute for detailed medical, sexual, and social histories obtained by the transplantation physician at the time of donor selection and evaluation. Similarly, screening questions about incarceration and sex work do not contribute substantially over and above this detailed history, are needlessly stigmatising, and disproportionately affect specific minority populations who are needed as donors. Overall, health equity needs to be prioritised alongside donation safety. Recommendations and screening questions should protect donors and patients, while also minimising stigma, bias, and discrimination against donors from marginalised groups. Applying an equity lens to the development of future donor suitability recommendations will help to build a more inclusive transplantation system. I declare no competing interests. Download .pdf (.14 MB) Help with pdf files Supplementary appendix Suitability of haematopoietic cell donors: updated consensus recommendations from the WBMT standing committee on donor issuesThe contribution of related donors to the globally rising number of allogeneic haematopoietic stem cell transplantations (HSCT) remains increasingly important, particularly because of the growing use of haploidentical HSCT. Compared with the strict recommendations on the suitability for unrelated donors, criteria for related donors allow for more discretion and vary between centres. In 2015, the donor outcome committee of the Worldwide Network for Blood and Marrow Transplantation (WBMT) proposed consensus recommendations of suitability criteria for paediatric and adult related donors. Full-Text PDF