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7 Fact Sheet Blood Collection and Use Hong Kong Red Cross Blood Transfusion Service The Hong Kong Red Cross began its voluntary, nonremunerated blood donation programme to supply blood to all hospitals in Hong Kong since The programme has been managed by the Hospital Authority since December 1991 and the Hong Kong Red Cross Blood Transfusion Service (BTS) is the only public institution to supply blood in Hong Kong nowadays. Besides ensuring adequate and safe blood supply to local hospitals in Hong Kong, the BTS is also responsible for the one and only local public Cord Blood Bank and the Bone Marrow Donors Registry to provide unrelated haematopoietic stem cells for patients who needed transplant. Blood Safety: The voluntary, non-remunerated blood donation is one of the fundamentals to safeguard blood safety. The BTS upholds this principle in recruiting eligible citizens for blood donation. In order to achieve zero blood risk, stringent screening criteria are implemented to ensure health of donors and blood safety. In addition, all donated blood are subjected to a number of infectious disease screening using sophisticated equipment. These include Human Immunodeficiency Virus (HIV) antibodies and antigen, Hepatitis B Virus (HBV) surface antigen and nucleic acid, Hepatitis C Virus (HCV) antibodies and nucleic acid, Human T-lymphotropic Virus and Syphillis antibodies detection. Furthermore, bacterial culture test is conducted in all platelet products. The blood collected has to pass all the above tests before distributing to hospitals for clinical use. within the Hong Kong health care sector to have implemented ISO 9000 and to have received certification for the entire organization. Later on, the BTS succeeded in a compliance certification audit conducting by the Australian Therapeutic Goods Administration and attained the cgmp accreditation with respect to its blood and components production. The major benefit of incorporating cgmp into the quality management system is to ensure the total process control and that, in turn, further enhances consistency in terms of blood safety and quality. This is an important step towards attaining international benchmarking within the blood industry. At present, the BTS has implemented ISO9000, ISO14000, OHSAS18000, ISO15189 and cgmp in which it establishes a fully integrated Quality Environmental Occupational Health and Safety Management System to enhance the quality of all production and operation processes whilst improving safety and environmental standards. In April 2016, the BTS acquired the American Association of Blood Banks (AABB) accreditation in recognition of institution s continuous effort in quality improvement. In 2017, the BTS starts to update the standard of ISO9000 and quality management standard to its 2015 version to maintain high efficiency and quality service. Quality Accreditation: The BTS strives for service and blood products excellence to safeguard the safety and satisfaction of both blood donors and recipients. These would be relied on the implementation of a reliable and comprehensive quality management system which has proved to cover all aspects of the process from donation to transfusion, from vein to vein. In the 1990s, the BTS sought to qualify for the code of Good Manufacturing Practice (cgmp) certification and was followed by a programme to implement the ISO9000 quality system. The BTS was one of the pioneer group of blood centres worldwide, the first blood centre in China and the first institution

8 Blood Collection Service: The BTS operates nine donor centres, two university campus donor centres, four mobile blood collection teams and one medicoach. The donor centres are distributed over various districts in Hong Kong, Kowloon and the New Territories, including Causeway Bay, Central District, Mong Kok, Kwun Tong, King s Park (Headquarters), West Kowloon, Tsuen Wan, Sha Tin and Yuen Long. The two university campus donor centres are situated in The University of Hong Kong and the Polytechnic University of Hong Kong. The mobile teams provide service for secondary schools, tertiary institutions, industrial and commercial organisations, government departments and community groups. The medicoach parks outside Fanling MTR Station or Tai Po Civic Centre from time to time. Blood Collection: In 2016, the total attendances for blood donation were 328,318 with a successful collection of 250,554 units of whole blood and 7,668 units of apheresis blood products, namely plasma and platelet (Refer to Figure 1) (Figure 1) Units of Blood Collection Units of Blood Collection Blood Product Supply: Apheresis Products Whole Blood Most of the whole blood collected will be further processed into different blood components, including red blood cells, platelet concentrates, frozen plasma, cryoprecipitate and buffy coat, etc. to meet the different requirements in patient management. The BTS also supplies apheresis platelet to patients for clinical use. In 2016, the BTS has distributed 242,379 units of red blood cell and 251,108 units of other blood components to local public and private hospitals (Refer to Figure 2). In addition, a portion of frozen plasmas was processed into various plasma products, namely albumin, immunoglobulin and factor VIII and IX concentrate. (Figure 2) Supply of Clinical Blood Products Supply of Clinical Blood Products Clinical Use of Blood: Other Blood Components Red Blood Cell As public hospitals managed by the Hospital Authority (HA) provide about 90 percent of in-patient service in Hong Kong, a majority of blood is used in public hospitals. According to the BTS records in 2016, about 91.4% of blood was supplied to public hospitals. The percentage of blood used by private hospitals from 2014 to 2016 were 8.9%, 9.0% and 8.6% respectively. As treatment with blood transfusion is conducted in accordance to clinical needs of patients, the hospital blood banks are responsible for distributing blood to clinical departments and monitoring of the entire process in patient blood management. According to the Hospital Authority statistics in 2016, patients in public hospitals have used 217,819 units of red blood cells, 130,657 units of platelets and 67,053 units of plasma. For red blood cell, more than 80% were used by Medical & Geriatric Department, Surgery Department and Orthopaedics & Traumatology Department. For platelet, more than 80% were used by Medical & Geriatric Department, Surgery Department and Intensive Care Unit. For plasma, more than 70% were used by Medical & Geriatric Department and Surgery Department. (Refer

9 to Diagrams 3, 4, 5 respectively). To analyze by age, 62.9% of red blood cells were used by patients over the age of 60 and 28.2% over the age of 80. (Diagram 3) Use of Red Blood Cells by Specialties (2016 Statistics from the Hospital Authority) (Diagram 5) Use of Plasma by Specialties (2016 Statistics from the Hospital Authority) Obstetrics, 1.2% Gynecology, 1.0% Gynecology, 4.1% Obstetrics, 1.5% Surgery, 22.8% Emergency A & E Department 0.1% 0.1% Surgery, 36.2% O&T, 3.5% ICU, 3.7% M&G, 36.7% Paediatrics, 4.2% O&T, 8.1% M&G, 51.5% Oncology, 2.1% ICU, 3.7% Oncology, 4.3% Paediatrics, 3.8% (Diagram 4) Use of Platelet by Specialties (2016 Statistics from the Hospital Authority) Obstetrics, 0.7% Surgery, 17.0% Gynecology, 0.6% O&T, 2.0% ICU, 9.4% M&G, 58.3% Oncology, 5.1% Paediatrics, 6.6% The Challenges of Blood Collection in Hong Kong: In view of the societal changes, increase in population and ageing issues, Hong Kong is facing various challenges in blood collection: (1) Continuous increase in Hong Kong population leads to substantial increase in blood demand: From 2006 to 2016, the demand for red blood cell has increased from 180,754 to 242,379, which represents a rise in 34%. There has been a continued increase in blood demand for all age groups (the elderly in particular). Based on the 2016 statistics, the amount of blood use (1,000 person/ annum) of age groups 0-14, 15-64, 65-74, and 85 and above were 8.0, 17.5, 58.4, and respectively. According to the data from the Census and Statistics Department (yearly data and trends), there will be a structural change in the population of Hong Kong. In the future decades, except for the age group of 65 and above, the population of all other age groups from 0 to 64 will be decreasing, of which the drop of age group would be the most significant (refer to Diagram 6). Using the data of age group in 2011 as the baseline for comparison, by 2016, it has been reduced by 13%. Forecast information revealed that there will be a decrease by 24% and 29% in 2020 and 2023 respectively.

10 (Diagram 6) Population Census and Forecast (Statistics from the Census and Statistics Department) Population x1,000 (Diagram 7) New Blood Donor by Age New Blood Donor by Age All age Age 25~64 Age 65 up Age 0~ ' 2012' 2013' 2014' 2015' 2016' Age Age Age Age Age Age Age 15~ ' 1965' 1969' 1973' 1977' 1981' 1985' 1989' 1993' 1997' 2001' 2005' 2009' 2013' 2017' 2021' 2025' 2029' 2033' 2037' 2041' Year (2) Change in academic structure: Since 2012, the academic structure of local university education has been changed to four years, which resulted in a continuous decrease of number of students in secondary schools. In addition, as secondary six students have to attend supplementary classes and leave school early in the second term to prepare for the Hong Kong Diploma of Secondary Education Examination (HKDSE), the number of secondary school students who could participate in blood donation has decreased dramatically. Referring to the statistics from 2011 to 2016, the total amount of blood collected in the secondary school mobile blood drives was substantially reduced by 45%. The number of successful donation decreased from 34,207 in 2011 to 18,695 in Although the number of donors in universities was recorded a slight increase from 4,669 to 6,159, it was far from compensating the decline in secondary schools. At the same time, the number of first-time blood donors has also decreased. From 2011 to 2016, the number of first-time blood donors dropped from 44,494 to 36,651, representing a decrease of about 18% (refer to Diagram 7). Although the number of age 16 youngsters participating in blood donation in 2016 has increased a bit (from 7,323 to 7,908, 8%), there was still a remarkable drop of 29% in comparison to 2011 (11,023). (3) High number of deferral: The BTS has observed an excessively high, 21.4%, deferral rate in 2016, in which 12.3% deferrals of all donation was due to low haemoglobin level. In the past few years, the BTS has launched various activities to promote iron-rich and nutritious diet and implemented an Iron Supplement Programme for blood donors. However, the proportion of deferrals has not been showing any impressive reduction. Most of the deferred donors are females and firsttime donors. The BTS hopes that blood donors could be well prepared at all times by staying on a healthy iron-rich diet and watch out for any eating habits that would affect iron absorption of their body. Citizens should also stay alert for any stomach unwell or bleeding disorders, and females should be aware of iron loss during menstruation cycle. (4) Risk of infectious diseases: Since there is no routine blood donation screening tests for many infectious diseases, the BTS has to resort to implement stringent eligibility screening for blood donors to safeguard blood safety. Taking 2016 as an example, the outbreak of Zika virus has affected many popular travel destinations of Hong Kong people. As a result, the BTS was deferring all blood donors from donation for 28 days after their returning from those areas, which has significantly hampered the blood supply. Moreover, the prolonged duration of seasonal influenza surge has further deferred more donations.

11 Our Responses to the Challenges Ahead in Proactive Manners: (1) Stabilize the number of first-time donors: With the gradual leaving of senior donors from the donor pool, Hong Kong needs to recruit at least 40,000 first-time blood donors every year to maintain stable blood supply. Young and healthy donors are the obvious target. The BTS will continue to enhance education, recruitment and publicity in various directions. (2) Encourage first-time blood donors to become repeated blood donor in 12 months after their first donation: In the past five years, about 30% of first-time blood donors would give blood again in 12 months after their first donation. The continuous participation of blood donation in new donors could help ensure a stable blood supply. The BTS will keep on reinforcing and encouraging first-time donor to carry out the live-saving mission. (3) Encourage existing blood donors to donate regularly: With the continuous high blood demand, Hong Kong relies greatly on the regular participation of existing donors in maintaining a stable blood supply. The BTS records showed that the units of blood collected from repeated donors increased from 189,616 in 2011 to 222,434 in 2016, representing an increase of 17.3% (Refer to Diagram 8). Therefore, one of the key priorities of the BTS is to cultivate all donors about the importance of regular blood donation. (Diagram 8) Blood Collected from Repeated Donors Blood Collected from Repeated Donors Increased 17.3% 4) Organize tailor-made promotional activities to encourage public to participate in blood donation: The BTS has observed that female in general are more willing to donate blood than male. From 2011 to 2016, the number of female blood donors has increased by 5% whilst the number of male blood donors remains similar (refer to Diagram 9). (Diagram 9) Number of Blood Donors from 2011 to 2016 (figures by gender) 90,000 88,000 86,000 84,000 82,000 80,000 78,000 76,000 74,000 72,000 Number of Blood Donors from 2011 to ,805 78, ' 2012' 2013' 2014' 2015' 2016' Female donor Male donor Referring to the statistics in 2016, more than 80,000 females were donating blood for one to two times in a year. However, only about 60,000 males made one to two donations in the same year. (refer to Diagram 10). Theoretically, blood donation habit and the quality of blood do not differentiate between backgrounds of donors. The BTS can adopt different publicity strategies to organize people with different background to donate blood at their most convenient locations and time ' 2013' 2014' 2015' 2016'

12 (Diagram 10) Number of Blood Donations in 2016 (figures by gender) Number of Blood Donations in Female donor Male donor Conclusion: Blood has no substitutes but limited shelf life, Hong Kong urges to recruit 1,100 donors each day in order to maintain a stable blood supply. The BTS hopes all needed patients receive timely, safe blood to save their lives. (5) Encourage first-time donation and recall those who have not donated for a long time back to the donor pool: Lastly, citizens should have realized that only 3.2% of eligible donors are participating in blood donation in Hong Kong in 2016 (refer to Diagram 11). That means there is still huge room for improvement in the participation rate of blood donation. Therefore, the BTS is eagerly waiting for all eligible citizens to take their first step to donate blood. On the other hand, for citizens who have not donated for a long period of time, they are welcome to reintegrate to the blood donation pool in order to help ensure a sustainable, self-sufficient blood supply in our society. (Diagram 11) Age 16 to 65 Population Percentage of Participation in Blood Donation in 2016 Age 16 to 65 Population Percentage of Participation in Blood Donation in 2016 Blood Donor 168,593 Non-Blood Donor 5,178,707 Hong Kong Red Cross Blood Transfusion Service website: April