Blood Transfusions: How Safe

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“”Even 30 years ago, pathologists and blood-bank personnel were advised: Blood is dynamite!

—a 64-year-old quote that JW.org thinks is relevant to today

The following is a side-by-side rebuttal to the JW.org (the official Jehovah's Witnesses website) document "Blood Transfusions: How Safe?", which exists to provide a health-based defence for the Witnesses' disavowal of blood transfusions. "How Safe" alleges that blood transfusions pose several serious health risks, but uses many outdated publications that are no longer relevant in the slightest. Moreover, the article presents many "scary" truths in order to frighten people from transfusions - without even mentioning the comparable risks of refusing blood transfusions.

Although the document was originally published in the 1990s, JW.org keeps the publication online and presents it without noting that its contents are hopelessly out-of-date. This becomes unmistakably obvious when the actual text keeps using a present tense (and tone) when citing studies from the years 1987-1990. "Radically tubular!", as the kids of today would put it. And just in case you've repressed how much of life's journey you've already zoned out through, please realise that 1987 was 37 years ago. These aren't exactly studies from yesterday; the spring-chicken college sophomores who conducted said studies are likely retired by now.

Overall, the document is a pseudoscientific defense of a religious dogma. On the positive side, it does mean that the Jehovah's Witnesses serve as a useful set of test subjects for synthetic blood substitutes.

RationalWiki Introduction

The 22 May 1994 cover of Awake, an official JW publication. The first 15 pages detail the life stories of all 26 children pictured here and how each consciously chose to die, merely because they would not allow a blood transfusion.

According to JW.org, Jehovah's Witnesses (JW) cannot get blood transfusion without violating the tenets of their official church doctrine. This doctrine has resulted in unnecessary injury and death. How can the harms of this belief be quantified? First, we must examine the harms of blood transfusion.

Federal data

Fortunately for comparative health purposes, federal law requires that blood-related fatalities be reported (bold added):

Section 606.170(b) of Title 21, Code of Federal Regulations (21 CFR 606.170(b)), requires that facilities notify the Food and Drug Administration (FDA), Center for Biologics Evaluation and Research (CBER), Office of Compliance and Biologics Quality (OCBQ), as soon as possible after confirming a complication of blood collection or transfusion to be fatal. The collecting facility is to report donor fatalities, and the compatibility testing facility is to report recipient fatalities. The regulation also requires the reporting facility to submit a report of the investigation within 7 days after the fatality.

The HHS does note that "[t]he actual rate of adverse reactions is likely to be more than what was reported to the transfusion service." However, these numbers includes both fatalities where "transfusion could not be ruled out as the cause" and where "while there was a temporal link, there was no evidence to support a causal relationship". In other words, these estimates are essentially the maximum possible fatality rate that we know about:

Year	FDA: Transfusion fatalities	FDA: Post-donation fatalities	FDA: Total fatalities	HHS: Total transfusions	Fatality rate (FDA / HHS): deaths per million transfusions
2014	56	7	63	(assumed to be the same as 2011)	3.0096
2013	59	5	64	(assumed to be the same as 2011)	3.0574
2012	65	11	76	(assumed to be the same as 2011)	3.6306
2011	58	8	66	20,933,000	3.1529
2010	64	4	68	(assumed to be the same as 2008)	2.8731
2009	66	4	70	(assumed to be the same as 2008)	2.9576
2008	54	10	64	23,668,000	2.7041
2007	63	15	78	(assumed to be the same as 2006)	2.5962
2006	73	14	87	30,044,000	2.8958
2005	76	8	84	(assumed to be the same as 2004)	2.8928
2004	n/a	n/a	n/a	29,038,000	n/a
Average	63.4	8.6	72	24386200	2.9525

If we assume that the average death rate for blood transfusions is 8 per million (which is far beyond any upper reported estimate), then if every single one of the (upper estimate) 8.2 million Jehovah's Witnesseses had a blood transfusion, then at most about 66 people' would die. (Realistically, only about 1.5% of people need a blood transfusion, and the true death rate is less than half of the above, making this estimate at least orders of magnitude too high.)

Data on harms on lack of blood transfusions

In comparison, the May 1994 cover (see above) of Jehovah's Witness publication Awake! lists 26 children (children! no adults!) who died rather than get a blood transfusion.

One (pro-blood-transfusion) Jehovah's Witness source puts the annual death toll from lack of blood transfusions during surgery alone at 900 deaths per year, based on the results of Kitchens 93.

Rates comparison

To summarize:

Jehovah's Witnesses: Die at about 1% higher rates from complications due to bloodless surgery.

Non-JWs: Die at 0.0008% higher rates (8 per million; twice the realistic upper bound) from transfusion complications. Get potentially-lethal Hepatitis B at 0.000488% higher rates (1 in 205,000; upper bound). Get potentially-lethal Hepatitis C at 0.0000625% higher rates (1 in 1.6 million; upper bound). Get HIV at 0.00005% higher rates (1 in 2 million; upper bound).

Let's assume that every single infection of Hepatitis B and C and HIV are fatal. Even in this worst-case scenario, only 0.0014005% of blood transfusions recipients die. In other words, even in the best possible light, Jehovah's Witnesses face perhaps 700 times as much risk as non-JWs do.

Jehovah's Witnesses also face vastly increased risks during childbirth -- on the order of 70 times greater. However, the increased deaths from surgery alone are sufficient to prove that refusing blood is far, far more dangerous than accepting it.

Side-by-side rebuttal

Jehovah's Witnesses

RationalWiki

Intro

Before submitting to any serious medical procedure, a thinking person will learn the possible benefits and the risks. What about blood transfusions? They are now a prime tool in medicine. Many physicians who are genuinely interested in their patients may have little hesitation about giving blood. It has been called the gift of life.

Distracting Truth #1: Indeed, you should try to learn more about what doctors are doing to your body. However, the Jehovah's Witnesses page neglects to mention any of the "possible benefits" and seems obsessed with the "risks".

Millions have donated blood or have accepted it. For 1986-87 Canada had 1.3 million donors in a population of 25 million. "[In] the most recent year for which figures are available, between 12 million and 14 million units of blood were used in transfusions in the United States alone."—The New York Times, February 18, 1990.

Distracting Truth #2: Indeed, lots of people get blood. However, the JW document fails to note how many of those people's lives were saved.

"Magical quality"

"Blood has always enjoyed a 'magical' quality," notes Dr. Louise J. Keating. "For its first 46 years, the blood supply was perceived as being safer than it actually was by both physicians and the public." (Cleveland Clinic Journal of Medicine, May 1989) What was the situation then, and what is it now?

Outdated Evidence #1: Moreover, given that blood transfusion's "first 46 years" could be as early as 1830-1876, this says almost nothing and is almost entirely irrelevant to now.) Quote Mine #1: In said article, Dr. Keating goes on to say During the past four years, however, since the AIDS epidemic has been recognized as a serious threat to the nation's health, the blood supply has been perceived as far less safe than it actually is. Blood is and will continue to be an invaluable therapeutic modality, without which physicians could not perform many therapeutic procedures such as heart and vascular surgery, cancer chemotherapy, joint replacement, trauma, and transplantation. (emphasis added)

General problems

Even 30 years ago, pathologists and blood-bank personnel were advised: "Blood is dynamite! It can do a great deal of good or a great deal of harm. The mortality from blood transfusion equals that from ether anesthesia or appendectomy. There is said to be approximately one death in 1,000 to 3,000 or possibly 5,000 transfusions. In the London area there has been reported one death for every 13,000 bottles of blood transfused."—New York State Journal of Medicine, January 15, 1960. Have the dangers since been eliminated so that transfusions are now safe? Frankly, each year hundreds of thousands have adverse reactions to blood, and many die. In view of the preceding comments, what may come to your mind are blood-borne diseases. Before examining this aspect, consider some risks that are less well-known.

Outdated Evidence #2: This is really old data, and it matters. In 2012, the Food and Drug Administration noted that transfusions are continually improving: [T]he blood supply is safer today than at any time in history. Due to advances in donor screening, improved testing, automated data systems, and changes in transfusion medicine practices, the risks associated with blood transfusion continue to decrease. The most recent data from the FDA (see top of article) suggests a rate of about 3 deaths per million, as compared to deaths per thousand reported here.

Hemolytic Transfusion Reactions

Early in the 20th century, scientists deepened man's understanding of the marvelous complexity of blood. They learned that there are different blood types. Matching a donor's blood and a patient's blood is critical in transfusions. If someone with type A blood receives type B, he may have a severe hemolytic reaction. This can destroy many of his red cells and quickly kill him. While blood-typing and cross matching are now routine, errors do occur. Every year people die of hemolytic reactions.

Outdated Evidence #3: Hemolytic reactions DO occur. However, the FDA's most recent data (2014) reports a mere eight fatal Hemolytic Transfusion Reactions (HTR). In 2013 there were six; 2012, eight; 2011, nine. Compare this with 2011's 20.933 million blood transfusions. (For an average rate of 0.37081 deaths per million.) Notably, these rates appear to be going down — see the chart below. Is there a risk? Yes. Is it significant? No.

Fatal incidents of Hemolytic Transfusion Reactions (HTR) are low and have been going down. Remember, that number on the left is the actual number -- 0-30 people, not percent or thousand or million.

The facts show that the issue of incompatibility goes far beyond the relatively few blood types that hospitals seek to match. Why? Well, in his article "Blood Transfusion: Uses, Abuses, and Hazards," Dr. Douglas H. Posey, Jr., writes: "Nearly 30 years ago Sampson described blood transfusion as a relatively dangerous procedure… [Since then] at least 400 additional red cell antigens have been identified and characterized. There is no doubt the number will continue to increase because the red cell membrane is enormously complex."—Journal of the National Medical Association, July 1989.

Distracting Truth #3: Indeed, Scientists keep studying how blood works... and this is bad? Part of the reason that scientists study antigens is so that they can figure out how to negate them and make transfusions even safer -- as the data above proves that they are doing so.

"Approximately 1 in 100 transfusions are accompanied by fever, chills, or urticaria [hives]… . Approximately 1 in 6,000 red cell transfusions results in a hemolytic transfusion reaction. This is a severe immunologic reaction that may occur acutely or in a delayed fashion some days after the transfusion; it may result in acute [kidney] failure, shock, intravascular coagulation, and even death."—National Institutes of Health (NIH) conference, 1988.

Outdated Evidence #5: See the responses to high death rates at the top of this section. Furthermore, searches for this (supposed) NIH document returned no non-JW online results.

Immune system

Scientists are now studying the effect of transfused blood on the body's defense, or immune, system. What might that mean for you or for a relative who needs surgery? When doctors transplant a heart, a liver, or another organ, the recipient's immune system may sense the foreign tissue and reject it. Yet, a transfusion is a tissue transplant. Even blood that has been "properly" cross matched can suppress the immune system. At a conference of pathologists, the point was made that hundreds of medical papers "have linked blood transfusions to immunologic responses."—"Case Builds Against Transfusions," Medical World News, December 11, 1989.

Distracting Truth: It is true that blood transfusions can . However, this fact draws attention away from the fact to compare blood loss poses a far more significant risk. Not only does insufficient blood lead to a weakening of the body and thus of the immune system, but it often poses a legitimate threat to a patient's life. Unfortunately, the article "Case Builds Against Transfusions" does not appear to be freely available online, and so it is unclear if this is a quotemine or accurate representation of the article.

Cancer

A prime task of your immune system is detecting and destroying malignant (cancer) cells. Could suppressed immunity lead to cancer and death? Note two reports.

There are several issues with the argument that "transfusions cause cancer". First and foremost, cancer patients often get transfusions because they are already in severe condition — and this may explain why they do worse than the patients who did not need transfusion and thus did not get it. Second, cancer is itself often the reason that people get transfusions. The American Cancer Society notes that cancers which cause internal bleeding, which harm the blood-producing bone marrow, or which harm the blood-regulating kidneys or spleen may cause anemia, which is pretty damn bad. Similarly, surgery, chemotherapy, radiation therapy, and organ transplants all affect blood and may require blood transplants.

The journal Cancer (February 15, 1987) gave the results of a study done in the Netherlands: "In the patients with colon cancer, a significant adverse effect of transfusion on long-term survival was seen. In this group there was a cumulative 5-year overall survival of 48% for the transfused and 74% for the nontransfused patients."

The author creates a quotemine by failing to quote the next two sentences: Perioperative blood transfusion was associated with a relative risk of 3.42 for all deaths (P = 0.005) and 4.25 for death due to cancer (P = 0.03), after adjustment for other important variables such as age, sex, stage, location of tumor, surgical procedure, and preoperative hemoglobin level. In contrast, in our study group of patients with breast cancers, who all underwent a modified radical mastectomy, no effect of bloodtransfusion on long-term survival was seen. The study reports that, while blood transfusions seemed to have hurt colon cancer patients and had insignificant but slightly positive effects for breast cancer recipients. More importantly, this study is 29 years old, and both transfusion methods and cancer procedures have changed. Most importantly, this study applies only to people who already have cancer. It does not apply to most members of the general population, and it is disingenuous to equate "transfusion can exacerbate cancer" with the entirely different "transfusion can cause cancer".

Physicians at the University of Southern California followed up on a hundred patients who underwent cancer surgery. "The recurrence rate for all cancers of the larynx was 14% for those who did not receive blood and 65% for those who did. For cancer of the oral cavity, pharynx, and nose or sinus, the recurrence rate was 31% without transfusions and 71% with transfusions."—Annals of Otology, Rhinology & Laryngology, March 1989. [....] What do such studies suggest regarding transfusions? In his article "Blood Transfusions and Surgery for Cancer," Dr. John S. Spratt concluded: "The cancer surgeon may need to become a bloodless surgeon."—The American Journal of Surgery, September 1986.

Indeed, surgeons are trying to find ways to reduce blood loss during surgery. Why make the patient bleed — and risk death or an emergency transfusion — when you don't need to? However, this does not mean that bloodless surgeries are equally safe. Kitchens 93 (admittedly an old study) reported that, for "patients of the Jehovah's Witness faith who were not given transfusion for operations during which transfusion is typically given", "approximately 0.5% to 1.5% of such operations are complicated by anemia resulting in death". Yes, the option is available. No, the option is not equally good.

"Fingerprints"

Danish scientist Niels Jerne shared the 1984 Nobel Prize for Medicine. When asked why he refused a blood transfusion, he said: "A person's blood is like his fingerprints—there are no two types of blood that are exactly alike."

First, again: an internet search for this quote return no non-JW results. Second, it's not clear what this quote is supposed to mean. Yes, blood is different between individuals, and so are all organs. Nevertheless, they're all transplantable.

Infection

Another primary task of your immune system is to defend against infection. So it is understandable that some studies show that patients receiving blood are more prone to infection. Dr. P. I. Tartter did a study of colorectal surgery. Of patients given transfusions, 25 percent developed infections, compared with 4 percent of those who received no transfusions. He reports: "Blood transfusions were associated with infectious complications when given pre-, intra-, or postoperatively … The risk of postoperative infection increased progressively with the number of units of blood given." (The British Journal of Surgery, August 1988) Those attending a 1989 meeting of the American Association of Blood Banks learned this: Whereas 23 percent of those who received donor blood during hip-replacement surgery developed infections, those given no blood had no infections at all. Dr. John A. Collins wrote concerning this effect of blood transfusions: "It would be ironic indeed if a 'treatment' which has very little evidence of accomplishing anything worthwhile should subsequently be found to intensify one of the main problems faced by such patients."—World Journal of Surgery, February 1987.

The same problems apply to this study as to the Netherlands study above — namely that the study applies only to people who already have cancer and is 30 years old.

Blood-borne disease worries conscientious physicians and many patients. Which disease? Frankly, you cannot limit it just to one; there are indeed many.

Physicians truly worry about blood-borne disease. They also worry about patients who risk death from lack of transfusion.

After discussing the more well-known diseases, Techniques of Blood Transfusion (1982) addresses "other transfusion-associated infectious diseases," such as syphilis, cytomegalovirus infection, and malaria. It then says: "Several other diseases have also been reported to be transmitted by blood transfusion, including herpes virus infections, infectious mononucleosis (Epstein-Barr virus), toxoplasmosis, trypanosomiasis [African sleeping sickness and Chagas' disease], leishmaniasis, brucellosis [undulant fever], typhus, filariasis, measles, salmonellosis, and Colorado tick fever."

Lyme disease

Actually, the list of such diseases is growing. You may have read headlines such as "Lyme Disease From a Transfusion? It's Unlikely, but Experts Are Wary." How safe is blood from someone testing positive for Lyme disease? A panel of health officials were asked if they would accept such blood. "All of them answered no, although no one recommended discarding blood from such donors." How should the public feel about banked blood that experts themselves would not accept?—The New York Times, July 18, 1989.

Distracting truth: Lyme disease can pass through blood, but this isn't a realistic threat. The CDC notes that this has never been observed, despite hundreds of millions of transfusions over decades: Although no cases of Lyme disease have been linked to blood transfusion, scientists have found that the Lyme disease bacteria can live in blood from a person with an active infection that is stored for donation. Individuals being treated for Lyme disease with an antibiotic should not donate blood. Individuals who have completed antibiotic treatment for Lyme disease may be considered as potential blood donors. Although blood is not screened for Lyme disease after donation, donors who were diagnosed with Lyme disease or who exhibit signs of Lyme disease are promptly turned away. To study whether this poses a risk, Gerber et. al 1994 studied a sample of 155 patients (who received 601 units of blood cells and 155 units of blood platelets) and found: No patient developed clinical or serologic evidence of Lyme disease; 1 (who received 5 units of PRBC) developed clinical and serologic evidence of babesiosis. The risk of acquiring Lyme disease from a transfused unit of PRBC was 0 (95% confidence interval [CI], 0-0.5%) and from a transfused unit of platelets was 0 (95% CI, 0-0.8%); the same risks for babesiosis were 0.17% (95% CI, 0.004%-0.9%) and 0 (95% CI, 0-0.8%), respectively. The risk of acquiring either Lyme disease or babesiosis from a blood transfusion in Connecticut is very low. Although the chance for infection by Lyme disease through blood donation exists, it seems to be extremely low. Quote Mine: The cited New York Times article also writes: Although data are limited, Dr. Sandler said, it is thought that if the microbe can be spread in a transfusion, it can occur only in the initial stages of the disease. In cases where the spirochete has been isolated from the blood of patients, the individual has felt ill, making it unlikely that such a person would feel well enough to donate blood, Dr. Sandler said. To reduce the risk from a Lyme-infected donor who may not feel ill, the Red Cross has instructed blood-bank workers to examine each donor for the Lyme rash. Outdated Evidence: The cited New York Times article is 35 years old -- before relevant testing had been done -- and raised a valid point in an area of scientific uncertainty. For example, Aoki et. al 1989 noted that "Routine blood cultures will rarely document bacteremia and serologic testing is not yet reliable". However, Gerber et. al 1994 post-dates both of these articles, used serologic testing successfully, and put many Lyme-related concerns to rest.

Migrant blood

A second reason for concern is that blood collected in one land where a certain disease abounds may be used far away, where neither the public nor the physicians are alert to the danger. With today's increase in travel, including refugees and immigrants, the risk is growing that a strange disease may be in a blood product.

Distracting truth: Watchtower fails to include even a single source to back up this assertion. Yes, changing demographics make blood transfusion somewhat riskier. No, this is not an insurmountable risk. Yes, these issues are being looked at.

Hepatitis

"Ironically, blood-borne AIDS … has never been as great a threat as other diseases—hepatitis, for instance," explained the Washington Post. Yes, vast numbers have got very sick and have died from such hepatitis, which has no specific treatment. According to U.S.News & World Report (May 1, 1989), about 5 percent of those given blood in the United States get hepatitis—175,000 people a year. About half become chronic carriers, and at least 1 in 5 develop cirrhosis or cancer of the liver. It is estimated that 4,000 die. Imagine the headlines you would read if a jumbo jet crashed, killing all aboard. But 4,000 deaths amount to a full jumbo jet crashing every month! Physicians had long known that a milder hepatitis (type A) was spread through unclean food or water. Then they saw that a more serious form was spreading through blood, and they had no way to screen blood for it. Eventually, brilliant scientists learned how to detect "footprints" of this virus (type B). By the early 1970's, blood was being screened in some lands. The blood supply appeared safe and the future for blood bright! Or was it? Before long it was clear that thousands who were given screened blood still developed hepatitis. Many, after debilitating illness, learned that their livers were ruined. But if the blood had been tested, why was this happening? The blood contained another form, called non-A, non-B hepatitis (NANB). For a decade it plagued transfusions—between 8 and 17 percent of those transfused in Israel, Italy, Japan, Spain, Sweden, and the United States contracted it. Then came headlines such as "Mysterious Hepatitis Non-A, Non-B Virus Isolated at Last"; "Breaking a Fever in the Blood." Again, the message was, 'The elusive agent is found!' In April 1989, the public was told that a test was available for NANB, now being called hepatitis C. You might wonder if this relief is premature. In fact, Italian researchers have reported another hepatitis virus, a mutant, which might be responsible for a third of the cases. "Some authorities," the Harvard Medical School Health Letter (November 1989) observed, "worry that A, B, C, and D are not the whole alphabet of hepatitis viruses; yet others may emerge." The New York Times (February 13, 1990) stated: "Experts strongly suspect that other viruses can cause hepatitis; if discovered, they will be designated hepatitis E and so on." Are blood banks faced with more long searches for tests to make blood safe? Citing the problem of cost, a director of the American Red Cross made this disturbing comment: "We can't just keep adding test after test for each infectious agent that might be spread."—Medical World News, May 8, 1989. Even the test for hepatitis B is fallible; many still contract it from blood. Moreover, will people be satisfied with the announced test for hepatitis C? The Journal of the American Medical Association (January 5, 1990) showed that a year can pass before antibodies of the disease are detectable by the test. Meanwhile, people transfused with the blood may face ruined livers—and death.

First: This is a textbook case of science was wrong before. If doctors messed up in the past, that doesn't mean that they can't get it right in the future. This is especially true given that all data presented is from 1990 or earlier -- at least 34 years old. Second: As JW.org notes, blood is tested for presence of hepatitis. This has vastly reduced the risk of bloodborne viral infections. Modern sources say that the risk of contracting Hepatitis through transfusion in the United States is: B: 1 in 205,000 (according to the NIH), 1 in 800,000 (according to the ACS) C: 1 in 1.6 million (ACS), 1 in 2 million (NIH) According to the National Health Service, there hasn't been a reported case of viral infections from transfusion in Britain since 2005. As such, the JW.org evidence is clearly outdated and irrelevant to a modern conversation on blood transfusion. Also, see the "Rates comparison" section.

Previously considered non-infectious

Moreover, a specialist in infectious diseases warned: "The blood supply may have to be screened to prevent transmission of several disorders that were not previously considered infectious, including leukemia, lymphoma, and dementia [or Alzheimer's disease]."—Transfusion Medicine Reviews, January 1989. Chilling as these risks are, others have created much wider fear.

As of 2016, leukemia, lymphoma, and dementia remain apparently noninfectious.

AIDS

"AIDS has changed forever the way doctors and patients think about blood. And that's not a bad idea, said the doctors gathered at the National Institutes of Health for a conference on blood transfusion."—Washington Post, July 5, 1988. The AIDS (acquired immunodeficiency syndrome) pandemic has, with a vengeance, awakened people to the danger of acquiring infectious diseases from blood. Millions are now infected. It is spreading out of control. And its death rate is virtually 100 percent. AIDS is caused by the human immunodeficiency virus (HIV), which can be spread by blood. The modern plague of AIDS came to light in 1981. The very next year, health experts learned that the virus could probably be passed on in blood products. It is now admitted that the blood industry was slow to respond, even after tests were available to identify blood containing HIV antibodies. Testing of donor blood finally began in 1985,* but even then it was not applied to blood products that were already on the shelf.

Modern sources say that the risk of contracting HIV through transfusion in the United States is 1 in 2 million. Indeed, the NIH notes: "Your risk of getting HIV from a blood transfusion is lower than your risk of getting killed by lightning."

Video summary

Goes through the 1994 Awake magazine:

External links

• Keeping Blood Transfusions Safe: FDA's Multi-layered Protections for Donated Blood, FDA.gov