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Paying for plasma – Canada’s double standard?


Sandra Duvlock was 58 when she was diagnosed with dermatomyositis. The gradual inflammation of her muscles had gotten to the point where she was unable to walk, clean or feed herself. When this relatively rare disease was diagnosed, Duvlock was prescribed intravenous immunoglobulin (IVIG) treatment and long-term physical rehabilitation.

IVIG is a blood product that uses plasma proteins to boost the immune system of patients like Duvlock. Plasma is the liquid component of blood that holds red blood cells in suspension.

At 66, Duvlock’s dermatomyositis is finally under control and she is back to her daily routine with one caveat: regular IVIG treatments once a month.

Canadian Blood Services purchases plasma protein products (PPPs) like IVIG, albumin and various coagulation factors from the United States and Europe. This is because Canada uses a volunteer-only donation system and does not have the donor base to support demand. Canadian Blood Services, and its Québec counterpart Héma-Québec, are non-governmental bodies tasked with safety, procurement and distribution of blood products.

Duvlock’s IVIG costs $480 a month. The total cost over eight years of treatment is around $46,000.

Canada has seen a rise in IVIG use, with requirements going up six to eight per cent each year in the last decade. Last year alone, Canadian Blood Services and Héma-Québec purchased $670 million dollars of plasma protein products from the US and Europe, an increase from $630 million spent in 2012. Canada is the largest per capita user of IVIG in the world.

Most of the plasma protein products are purchased from countries that allow paid plasma donations. In March 2014, a new private enterprise tried to open its doors in Ontario – Canadian Plasma Resources – a for-profit clinic aimed at collecting plasma by paying donors.

While this private clinic would not have broken any existing laws, Ontario quickly drew up The Volunteer Blood Donations Act legislation (currently under review) in response.  This was done to prevent the company from operating, citing safety reasons and concerns that paying donors will decrease the number of individuals who voluntarily donate blood.

Why does Canada buy plasma?

Canadians need plasma for two main purposes:

1. Transfusion, requiring 50,000 litres of donated plasma a year.

2. Manufacturing plasma protein products, requiring 1.1 million litres of plasma a year.

Canada is a volunteer blood donor only country, and collects 190,000 litres of plasma a year, more than enough to cover transfusion needs, but not enough for plasma protein products.

Canadian Blood Services sends some of the plasma collected to pharmaceutical companies to be manufactured into plasma protein products. However to meet Canadians’ needs, about 885,000 litres of plasma protein products are bought annually from US or European companies.

Canadian Plasma Resources plans to open three clinics, two in Toronto and one in Hamilton, for the sole purpose of collecting plasma for plasma protein products manufacturing.

“Before the end of the decade, we will be spending over a billion dollars a year on plasma protein products as a country,” says CEO of Canadian Plasma Resources Bazrin Bahardoust. “This money will all go outside the country.”

Why is collecting plasma so costly?

There are two ways to donate and collect plasma.

The first is whole blood donation where blood is separated into red blood cells and other products, including plasma. This is what most Canadians do when they give blood.

The second is plasmapheresis, in which blood components are separated and only the plasma is collected, while other cells recirculate back to the donor.

The advantage of plasmapheresis is that plasma can be collected more frequently and in greater quantities in one sitting. In the US, donors can donate plasma using plasmapheresis up to twice a week, compared with once every 56 days for whole blood donation.

Below is a video shot by Jerry Aulenbach while underdoing plasmapheresis. Aulenbach is a regular blood and plasma donor in Edmonton.

The disadvantage of plasmapheresis is the high cost of the machines and technology. One unit of plasma collected through whole blood donation costs $135, while plasma collected through plasmapheresis costs $719. Most of the plasma collected through Canadian Blood Services is from whole blood.

Plasmapheresis to manufacture plasma protein products has become a private enterprise.

Bahardoust, says that each plasma collection centre has to collect 30,000 to 40,000 liters of plasma annually to make the operation economically viable. Canada’s last plasmapharesis collection clinic, which recently closed in Thunder Bay, was only hitting a threshold of 15,000 litres a year.

According to Canadian Blood Services, to be able to manufacture our own plasma protein products we would need to collect 700,000 litres of plasma.

In comparison, private US clinics collect over 20 million liters a year from over 40 million donors.

With only about 3% of eligible Canadians donating blood publicly, amassing a sufficient volunteer donation base is a challenge.

“We can’t compete with the US” says Graham Sher, CEO of Canadian Blood Services. “We would need to quadruple the amount of plasma we already collect. It’s just more economical to buy it from the international market.”

Health Canada conducted a roundtable discussion on the views of Canadians about paying donors for plasma in March 2013. At this discussion, a joint presentation between Health Canada and Canadian Blood Services stated that “no country in the world [including Canada] has been able to meet their need for plasma with a solely volunteer model.”

However, in June 2013, Health Canada went on to say that “provinces and territories have the authority to allow or disallow the payment of plasma donors.”

Canada’s mixed history of blood safety

The Canadian public has had mixed reactions towards paying donors for blood products.

During the 1970s and 1980s thousands of Canadian transfusion-requiring hemophiliacs were infected with HIV and hepatitis C, in part because of plasma that was purchased and imported from high-risk prison populations in the US. This became known as The Tainted Blood Scandal.

A federal commission led by Justice Krever on the Tainted Blood Scandal found major safety gaps in Canada’s blood system at that time, and made recommendations which have shaped our current system.

Michael McCarthy, past vice-president of the Canadian Hemophilia  Society and Tainted Blood Scandal victim warns in a recent Toronto Star op-ed that “we cannot be so trusting again.” He says “all it takes is a shortage of blood, a bad economic environment or new virus to trigger the next tainted blood scandal.”

However, groups like the Canadian Organization for Rare Disorders have emphatically stated the important need that plasma protein products fill for many Canadian patients.

The Ontario government stance on pay-for-plasma clinics echoes that of the 1997 Krever Commission which recommended that donors not be paid except in rare circumstances. Minister Matthew’s stated concerns are that

  1. Paying people for blood or plasma is a safety issue
  2. Compensation risks depleting the existing voluntary donor pool
  3. There is a risk it will exploit impoverished and low-income Canadians

Matthews has written to her counterparts in other provinces, encouraging them to introduce legislation along the lines of Ontario’s recent Voluntary Blood Donations Act.

The following sections will explore Ontario’s stated concerns.

Concern 1: Safety in volunteer versus paid donation

Kate Chipperfield, Regional Medical Leader of Transfusion Medicine at Vancouver Coastal health, says the advantage of a volunteer system is that it lends itself to more honest screening.

“The problem with paid donors is that they have an ulterior motive for donation,” says Chipperfield. “And no matter how much you test that sample for risk, it can never be as low as when you donate out of the goodness of your heart.”

She goes on to explain that testing of viruses is never perfect. “There are limitations of tests, human error, emerging new pathogens. In the 60’s, no one knew about HIV or Hepatitis B. Lowering the pre-test probability [of blood-borne infection] is one of the safeguards we have against transmission,” she says.

McCarthy agrees. “What happens when blood is purchased from populations with an increased incidence of transmittable disease, including those for which we may have no tests?”

2009 study found that only one-third of injected drug users who reported selling their plasma in our study were potentially deferred as high risk donors the last time they sold their plasma.”

However, private companies that pay donors for plasma say they have an extensive screening process. “All of our donors are pre-screened,” says a spokesperson for Biolife Plasma Services, a US company. “They [donors] get annual physicals and periodic blood tests for syphilis, hepatitis and other infections. After an initial donation, their plasma is held for 60 days until it can be verified for safety.”

There is also a National Donor Registry in the US, where previously exempted donors are recorded.

Sher of Canadian Blood Services says “plasma protein products go through a different, more extensive filtering process than plasma intended for transfusion,” he says. “There hasn’t been viral transmission in plasma protein products in 25 years of using paid donors and studies have shown it is extremely safe.”

However, because Canada has not previously had a pay-for donation system, it does not have all of these safeguards in place should private plasma collection centres open.

Concern 2: Depleting the donor pool by paying people

In 2013, Health Canada examined the idea of paid donors depleting the voluntary pool and stated it was not a threat.

Bahardoust agrees, arguing that the whole blood donation population is different than paid-donors. “One population donates a few times a year, minimally intrusive into a life,” he says. “But the other is going once a week. Partly to feel good and partly for their own gain; you won’t get that kind of commitment out of altruism.”

Canadian Blood Services emphasized in a 2013 report that they will be monitoring the impacts of new donor-paid facilities on the voluntary donor supply, but that given the experience of implementing parallel systems in jurisdictions in both Europe and the United States, they do not expect it to be an issue.

In fact, most countries with parallel system actually have higher volunteer donations per capita than Canada.

Concern 3: Exploiting low-income Canadians

Canadian Plasma Resources plans to pay donors $20-30 per sitting, which takes between one to two hours. This is done through either a charitable tax receipt after making a donation to the Sick Kids Foundation on behalf of the donor, or a gift card with their name. This is in keeping with the existing FDA and WHO guidelines for paid and voluntary donations.

The motivations for donors have been studied extensively and while monetary donation is important, studies show that factors like convenience and altruism are equally important.

However, McCarthy disagrees. He points out that “the location of this Toronto clinic being proposed next to a homeless shelter — it will be the homeless, the economically challenged and students who will find the $20 fee an attractive incentive…”

The evidence and the optics

Many Canadians find the idea of paying for body fluids, which is often mixed in with ideas like payment for organ donation, distasteful.

Scott Klarenbach, an Edmonton nephrologist and health economist at the University of Alberta has done extensive research looking at financial incentives for living kidney donation. He says the emotional response to paid donation isn’t consistent with established safety data.

“Some of the Krever comments in the commission are extraordinarily conservative and are from a different era,” Klarenbach says. “Risk of disease is much lower than it was in the 1990’s given the technology we now have.”

He suggests it may be time for new guidelines for blood donation. “You really need to do the research to show that it will affect safety or the existing donor pool. I am struck by the aversion to paying. If we expect people to come forward and donate out of altruism, it might be a bit naïve.”

Klarenbach goes on to say that it may be a bit hypocritical to be against paying people in Canada for plasma but then buy from those who are paid in other countries.

Canadian Blood Services says that there is no evidence that a safety issue exists, and at the end of the day, the lives of patients depend on these treatments.

“If any government in this country wants to pass a public policy saying that we shouldn’t pay citizens, that is their right but that is not my job,” says Sher. “When lives are at risk, that’s simply not an option. Our job is to worry about safety and supply.”

But McCarthy says that with $1 billion in annual funding, there has to be an effective way for Canadian Blood Services to increase the supply through volunteer donation.

Ultimately, safety concerns need to be balanced with the heavy use of plasma protein products by Canadian patients, taking into account the best current estimates of the risks of paid donation, and recognizing that donors from other countries are paid.

Is it time for a revision to current policies around paying Canadians for plasma, or should they remain the same?

Should paying for plasma be allowed in Canada?

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22 comments

  1. Jeremy Petch

    One thing that struck me when reading this was the domestic demand issue – why is Canada such a high per capita user of plasma products? Do Canadians suffer from a higher prevalence of diseases requiring these products or are we using these products less judiciously than other jurisdictions?

      • Tom Feasby

        Andreas and Bakul, we have evidence of a lot of inappropriate IVIG use in Canada (Feasby, TE, Quan, H, Tubman, M, Pi, D, So, L, Tinmouth, A, Ghali, WA (2012) Utilization controls and the appropriateness of intravenous immunoglobulin. Open Medicine 2012;6(1)e30 http://www.openmedicine.ca/article/view/480), but there is not much evidence from other countries.

  2. Tom Closson

    Then let’s focus on appropriate use. Apropriateness does not receive adequate attention with most medical therapies and diagnostics in Canada.

  3. Tom Feasby

    Thanks for this well-reasoned article on the important topic of paying for blood/plasma donations. It’s hypocritical of Canadians to be the largest per capita users of IVIG and yet we are amongst the lowest donators. Our reasoning is clearly coloured by tainted blood scandal but I think it’s time for a serious rethink. We seem convinced that the plasma products we import are safe, despite their acquisition from paid donors elsewhere, yet we think that to acquire the product from paid Canadian donors would somehow be unsafe. It doesn’t add up.
    We need more leadership on this issue from the CBS and our ministers of health. Let’s move on from the burden of the Krever Inquiry and make policy decisions based on today’s evidence.

  4. David

    Agreed – particularly when the HIV prevalence in Canada is half that of the United States. I would think that would have the largest influence on pre-test probability of infected donation.

  5. plas donor

    most donations come from poor homeless drug addicts tho some donate to supplement thier income the usually pay $40-$60 a week for two donations and the employees are trained there high school or equivilant and they profit well for the product

  6. Rick Janson

    “There hasn’t been viral transmission in plasma protein products in 25 years of using paid donors and studies have shown it is extremely safe.” Except for the 2007 recall of Chinese-manufactured IvIG which carried Hep C to its recipients. A quick look at the U.S. FDA site will show that IvIG batches are regularly recalled for safety reasons.

    One of the reasons why we cannot reach our targets around voluntary donation is that we don’t even try. Where were these patients groups who are so concerned about supply when CBS closed down its Thunder Bay dedicated plasma collection centre in 2012? That was the last of its kind. More than 40 countries around the world are self-sufficient in collection of plasma for use in plasma-based products like IvIG. Why aren’t we?

    Further, its a myth that only Canada operates a system that relies on voluntary donation. According to the World Health Organization, 71 countries collected over 90 per cent of their blood supply from voluntary unpaid blood donors, and 60 of those countries collected 100 per cent of their supply voluntarily.

    There is no guarantee that Canadian Plasma Resources will end up selling any of its product in Canada. Should a real shortage ever take place (unlike the imaginary shortages some of these big-pharma backed patient groups like to talk about) supply will go to the highest bidder. At present there is no fractionation plant even operating in Canada.

    The last time we did have a shortage was following the U.S. FDA’s clampdown on the quality of the manufacturing process for IvIG (that’s supposed to be safe) in the late 1990s. The provincial deputy ministers of health vowed to increase Canadian content in plasma-base products. When U.S. availability rebounded, they forgot all about it.

    To say we have been making an effort for 15 years is nonsense.

    Both CPR and CBS have previously admitted that it will impact voluntary donations. Both of them appear now to be changing their story. That should raise some flags all by itself.

    The Cangene example is completely misleading. Its exactly what Krever was talking about — a rare exception based on donation needed from individuals with rare blood types.

    What CPR is visioning is on a scale that will completely dwarf CBS’ collection efforts for both whole blood and plasma.

    And all this faith in the FDA to protect us? Let’s not forget the tainted blood scandal was an international public health disaster caused in part by FDA approval — for export only — of tainted plasma. They knew enough not to approve it for domestic use, but for others… well, you pay your money to takes your chances.

    This is hardly good policy, yet we continue to see misinformation continually parrotted on this issue.

    CPR has hired two lobby firms to work this issue both at Queen’s Park and in the public sphere.
    It’s there for anybody to see in the public lobby registry.

    If Krever is so out of date, why did the WHO renew its commitment to voluntary donation and self-sufficiency in 2012?

  7. Claude C

    obviously there is lots of people who don’t have the right information
    a) IVIG is only a $7bn world market and people have been using this product for more than 20 years
    b) Canada is buying IVIG from US paid donors
    c) more than 70% of plasma collected is produced from paid donors in the US
    d) IVIG is approved in more than 40 indications
    e) IVIG is used in more than 200 countries and we never heard of problems like other drugs
    f) IVIG is in many cases cheaper and better efficacious than other treatments, I can provide tons of article to support

  8. Ben

    Where can I find a source for the claims of Spending and purchasing of Plasma from other countries?

  9. Robert Coker

    Most people I know would give if they were paid. We no longer have the society of giving out of kindness. We have been hammered from all organizations to give. Majority of people are what about me. We see other countries paying people for what we give for free. Its why people do not donate anymore.

  10. Maggie

    More people would give blood if they were paid, and it would be Canadian blood, not from other countries that we have to pay for. Clearly Canada is already paying for blood, so why not pay your own citizens?

    • Stephen

      I agree Maggie,wish it had been done long ago,I have over 300 donations

  11. John Rose

    Its a Donation give a tax receipt. the low income can help as well as the rich

    • FabioF79

      Exactly! It’s like for charity givers, we could use this to lower (just a bit) annual taxes!

  12. Bill

    I can’t believe we expect people to give blood for free. It shows a total lack of thankfulness to those that contribute blood. And we are also taking all incentive away for people to give blood, altruism may be nice, but in reality a sustainable viable system has to be based on a win – win logic. It has to be a win for the hospitals and it has to be a win for the giver of blood, since hospitals are government owned there is really a way of compensating blood donors without paying them. If it is a true donation, let’s give them a donation tax credit of let’s say $200 per blood donation. I’m cool with that. It’s probably better than paying them, because this way it is still a donation, and it will not be the poor that will be attracted if that is the concern but the wealthy. Because the wealthy benefit from tax breaks more than the poor. This would counter the argument that paying for blood would attract poor quality blood from poor neighborhoods, which by the way I don’t buy. The rich do drugs and get sick as well. But assuming we do not want to exploit the poor and have them donate blood, guess what give tax breaks and then the wealthy will be enticed into giving blood. I for one would never donate blood, simply because I would be enabling a system that is fundamentally flawed and ethically wrong. Every deal has to be win win or no deal, and right now it is a win lose situation that is not long term sustainable. If we do not compensate blood givers and do not recognize them at all, we won’t have them for long.

  13. Marek Gala

    I am regular blood donor . We spend to much time in a lineups at blood clinics .Some cities in Poland offer free transit free passes for honorable blood donors that’s how they call regular blood donors.

  14. Jennelle

    Two days from now I will give blood for the first time. Until this point I hadn’t really given it much thought or consideration, and that’s possibly because I haven’t been personally touched by the need for it, since so far there have been no medical issues or emergencies in the lives of anyone close to me that required donor blood. I had no idea that plasma, en masse, was donated separately, and that it was equally important and in such high demand. Nor that it was outsourced.

    My basic 5 cents (because 2 cents aint worth spit now):
    Seems that if we are paying another country for their PAID donor plasma, we should be able to put together a similarly safe, functional, regulated system (perhaps taking notes from other well established ones..) to purchase plasma from our own citizens, keeping (at least some of) the money within our own country.
    I’m fairly certain that if the effort was put in to create guardrails within the system, protecting those it could potentially take advantage of, (or the flip side, protecting the system from being taken adventage of) then that argument would become invalid, or at the very least weak-kneed. Why wouldn’t the present volunteer system model work? Keep records and set limits on how often people can donate. Simple. No? Why not.
    Of course people of lower income or students or the impoverished would try to get in on it. When I was a student I most certainly would have.
    Here’s my counter argument: If the same screening process applied, and restrictions set on how often plasma could be given, why then is it considered unethical? It might be a little obvious if you plopped a center down in the lowest income neighborhood, but then again, so what? It is not a parasitic relationship, both sides gain, and neither are hiding insidious motives. Except maybe that 19 yr old university student who just wants another supply of natures exam-anxiety medicine. Oh the horror.

    Or, if dead set against the idea of up-front paying canadians for their natural resource, I liked the idea stated earlier that perhaps it should be regarded for what it is, a donation, and perhaps by meeting a certain number of donations annually one could qualify for a tax deduction, or some other incentive?

    Of course more people will sign up to contribute if there is incentive, because surprise surprise not everyone is run by altruism. Not everyone holds the exact same values, and we live in a culture of Me, not We. Many if not most people want something, anything, in return. Call it what you like. That’s reality.

    Is it fair to expect every individual to be willing to give their most precious resource away, with no incentive? As someone else already pointed out, that’s exceedingly nieve. In a different society, possibly. But not this one. Think the states would get enough plasma donors to be able to sell off the surplus to us without paying them? No way Jose.
    I think it’s pessimistic to assume the volunteer donor population will diminish if pay-for-plasma systems are put in. I think if people are already donating their blood for honest altruistic reasons it’s almost a safe bet they’ll continue to do so.
    It might even stimulate more altruistic donors. Maybe someone decides to donate their plasma because of the incentive, then decides they’re going to donate some whole blood too because hey, surprise surprise, maybe they like the feeling of doing some good. Our psychology is a funny, flip-floppy thing.

  15. Johnny Vanderburgh

    Of course we should pay for Plasma donations here in Canada the exchange rate is almost $.50 on every dollar
    we are already bleeding to the U.S. for plasma.

  16. Sean

    http://www.cbc.ca/news/health/paid-plasma-blood-donations-canada-1.3480763 this story will address some of peoples questions.

    There is a misconception on need and shortage, as well as what is purchased by Canadian Blood Services.

    One needs to ask if there is such a need, why isn’t CBS being tasked with collecting and processing the finished product, rather than spend $500 million on purchasing finished material.

    Cut out the middle man and save tax payers $

  17. Margaret Angel

    1. How is this patient’s IVIG only costing $480 per month, when IVIG costs $55 per gram and is dosed at 0.4 to 2g/kg per month? $480 (in the case example) is only 9 grams of IVIG, and if this is her monthly use, she weighs somewhere between 4.5 to 23 kg (10 to 51 pounds). With all due respect to the brave patient for sharing her story, the expression of concern on the macroenconomics of IVIG use may be more potent if using a “representative example” by chronicity AND weight. People need to realize that a 70kg (“average-size”) adult taking 0.4 – 2 g/kg per month is consuming $1,540 to 7,700 in each of those IVIG infusion-installments (over 1-5 days in a given treatment cycle), which then adds up to / nearly $100,000 per year.
    2. Why are we over-using? Drugs are not available in a nationalized pharmacare scheme, but blood products are, so these are always easier to reach for. The needle will always (literally and figuratively) flip over to the blood product when pitted against the pharmaceutical alternative (and we see this with RBC transfusion instead of IV iron in iron deficient anemic women, and IVIG instead of limited access targeted/biologic immunomodulating biologic therapies).
    3. What does CPR “pay” in the cost of obtaining each donor’s plasma unit, against what it (or CBS) makes from selling that bag? (In other words: What do the fractionators pay for a Canadian bag of plasma?) I see a 60-90-fold mark-up on the charged value of a plasma unit for the albumin, IgG, PCC, fibrinogen, and vWF/FVIII that it contains, based on unit pricings of each derivative (and the expected levels of constituents in a given donated volume), versus the $25 reimbursement given to a paid donor. No matter who is collecting and dealing, the top-dog refiner will still make away with the greatest profit. This argument cannot go far without greater transparency on every transaction at each stage (collection costs, pre-processing handover compensations by industry to collectors [be they public or private], and then charges invoiced by industry after the products are finished and bought back by CBS). We need to see how this money flows alongside the high-carbon-footprint tsunamis of plasma trading.

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