ORIGINAL RESEARCH
Changes in minimum hemoglobin and interdonation interval:
impact on donor hemoglobin and donation frequency
Mindy Goldman,1 Qi-Long Yi,1 Tony Steed,2 and Sheila F O’Brien1
BACKGROUND: To reduce donor iron deficiency in
whole blood donors, we changed our hemoglobin
(Hb) cutoff in males and interdonation interval in females.
STUDY DESIGN AND METHODS: A change in
messaging to females in fall 2016 was followed by
changing the interdonation interval from 56 to 84 days in
the appointment booking system (December 2016) and
actual donation criterion (March 2017). The minimum Hb
for males increased from 125 g/L to 130 g/L (March
2017). We evaluated Hb levels and deferral rates, donor
presentations with a Hb level below 120 g/L, donation
frequency, and donor base size before and after these
changes.
RESULTS: The Hb deferral rate decreased in females
from 13.0% to 9.5%, increased in males from 1.2% to
2.1%, and decreased overall from 6.8% to 5.4% (all
p < 0.001). Mean Hb increased from 135.0 g/L to
136.2 g/L in females and from 149.9 g/L to 150.6 g/L in
males (both p < 0.0001). The percentage of
presentations with Hb below 120 g/L decreased by 27%
in males and females (p < 0.001). Annual donation
frequency decreased by 12% in females and 4% in
males; the donor base was expanded by 5.8%.
CONCLUSIONS: Many positive impacts were seen for
female donors, including a shift in the Hb distribution
curve to the right, and a large reduction in Hb deferrals.
For males, there was an increase in Hb deferrals and a
small increase in mean Hb. Changes were related to
both reduced donation frequency and a shift in
composition of the donor base.
I
ron deficiency is common in certain segments of the
population, such as women of childbearing age. This
problem is compounded by whole blood donation,
since approximately 200 to 250 mg of iron are lost
with each donation.1 Donors who continue to be in negative
iron balance will eventually fall below the minimum hemo-
globin (Hb) cutoff level for blood donation, resulting in
deferral. For blood centers in Canada and the US, deferral
for low Hb is the largest single deferral category, resulting in
deferral of up to 10% of all donors.2,3
Hb cutoff levels ensure that a certain minimum red cell
volume will be present in a red cell unit, and that blood will
not be collected from anemic donors. Minimum interdonation
intervals provide time for donors to replenish lost iron and,
ideally, return to their pre-donation Hb level. However, studies
performed in Canada and other countries demonstrate that
many donors with Hb levels above the cutoff are iron deficient,
and that a short interdonation interval (or high frequency
of donation) is a major risk factor for iron deficiency.3–8 In
the Hemoglobin and Iron Recovery Study (HEIRS), donors
without iron supplementation required considerably more
than 56 days to return to baseline ferritin and Hb levels.4
Until 2016, Canadian Blood Services (CBS) followed
Canadian Standards Association standards for blood and
blood components, which specify a minimum Hb level of
125 g/L and a minimum interdonation interval of 56 days
(8 weeks) for both males and females.9 Based on normal
physiological differences in Hb and iron stores in females
and males, and Canadian and international data on risk fac-
tors for donor iron deficiency, CBS increased the minimum
From the 1Donor & Clinical Services, Canadian Blood Services,
Ottawa, Ontario, Canada; and the 2Donor Relations, Canadian
Blood Services, Ottawa, Ontario, Canada.
Address reprint requests to: Mindy Goldman, Donor and Clini-
cal Services, Canadian Blood Services, 1800 Alta Vista Drive,
Ottawa, ON, Canada K1G 4J5; e-mail: mindy.goldman@blood.ca
Received for publication November 22, 2018; revision received
January 7, 2019, and accepted January 7, 2019.
doi:10.1111/trf.15155
© 2019 AABB
TRANSFUSION 2019;9999;1–8
TRANSFUSION 1
GOLDMAN ET AL
Hb cutoff from 125 g/L to 130 g/L for male donors and the
minimum interdonation interval from 56 days (8 weeks) to
84 days (12 weeks) for female donors in 2016–17.3–8,10,11 We
proactively invested in programs to increase new donor recruit-
ment and encourage lapsed donors to return to donate in order
to ensure the adequacy of the blood supply.
The normal Hb distribution is slightly different in
individuals of African origin, with proposed lower limits of
129 g/L and 127 g/L in males between 20 and 59 and over
60 years of age, respectively, compared to 137 g/L and
132 g/L in males of European origin between 20 and 59 and
over 60 years of age.12 A higher Hb cutoff for males may
therefore disproportionately affect these donors. In our blood
center, donors of African descent are particularly important
to support transfusion needs of sickle cell anemia patients,
and many have been phenotyped for the Duffy blood group
system.
We assessed donor Hb distribution and deferrals in
our whole blood donor population before and after imple-
mentation of these changes. We also evaluated donation
frequency in regular repeat donors, and expansion of our
active donor base to compensate for donation loss due to
the criteria changes. We specifically evaluated the deferral
rate in Fy(a-b-) donors, since this phenotype occurs in
67% of individuals of African descent and less than 1% of
individuals of European or Asian descent. We hope this
information is helpful to blood centers considering both
the donor health and the operational impacts of similar
policy changes.13
MATERIALS AND METHODS
Hb measurement and eligibility criteria
Donor Hb is measured on a fingerstick sample, using a por-
table hemoglobinometer (CompoLab, Fresenius Kabi, Bad
Homburg, Germany); results on all donors, including those
failing their Hb screen, are entered into the blood center
operating system, eProgesa (MAK systems, Paris, France) as
of July 2016. The vast majority of donations are prebooked.
For female donors, messaging about appointment rebook-
ing changed in September 2016. In December 2016, donor
booking software was changed so that female donors could
be rebooked only after an 84-day interval. In March 2017,
the minimum interdonation interval for females and the Hb
cutoff level for males was changed in the criteria manual
and operating system software. Additionally, the deferral
period for females below the Hb cutoff was increased from
56 to 84 days. The Hb cutoff level for females remained at
125 g/L, the minimum interdonation interval for males
remained at 56 days, and the deferral period for males
failing their Hb screen remained at 56 days. No changes
were made in the equipment or methods of determining
donor Hb over the time frame of the study.
2 TRANSFUSION
Donors are provided with information about Hb and
iron in the mandatory pre-donation pamphlet, “What You
Must Know To Give Blood”, and referred to our website
(www.blood.ca) for more information about iron.
As this is a purely observational study of aggregate oper-
ational data, no approval was needed from the CBS Research
and Ethics Board.
Statistical analysis
Donor sex, Hb levels, and red cell phenotype results were
extracted from the National Epidemiology Donor Database
(NEDD). Hb levels in deferred donors were only available elec-
tronically from July 2016 onwards, with implementation of an
automated donor questionnaire. Weekly Hb deferral rates for
whole blood donors were followed from January 1, 2016 to June
30, 2018 for male and female donors. Deferral rates were calcu-
lated from January 1 to September 30, 2016 (Period 1) and July
1, 2017 to June 30, 2018 (Period 2) for all donors. For Fy(a-b-)
donors, since donor numbers were small, longer time periods
were chosen for comparison: November 1, 2015 to March
4, 2017 versus March 5, 2017 to June 30, 2018, although the
changes in messaging and rebooking occurred during the end
of the first period. Hb deferral rates were calculated by dividing
the number of deferrals for low Hb by the total number of visits
for whole blood donation (donations + deferrals for low Hb).
The donor Hb distribution was plotted as a smooth curve
for the periods from July 1 to December 31, 2016, and July 1 to
December 31, 2017, for males and females separately.
Statistical comparisons were made using a t test, Wilcoxon
rank sum test, or Chi-square test. P-values less than 0.05 were
considered significant.
Donation frequency per donor within 1 year was tabu-
lated and compared for donors successfully donating
between October 2015 and September 2016 (period 1) and
October 2016 and September 2017 (period 2).
Donor base composition: Donors are considered new if
they have never donated before at CBS, reinstated if they
returned to donate over 12 months since their last donation,
and repeat if they had donated before at CBS in the last
12 months. The active donor base consists of individuals who
have donated at least once in the last 12 months and was
assessed using the number of donors and donations and the
donor’s status as a first-time, reinstated, or repeat donor.
Phenotyped donors: Known Fy(a-b-) donors were iden-
tified in eProgesa. Deferral rates were calculated for these
donors using the same method as for all donors, as already
described.
RESULTS
Donation frequency and donor base composition
Donation frequency in the previous 12 months decreased
from 1.8 in early 2016 to 1.2 in July 2018 in female donors
(p < 0.001). Most of this decline was seen in late 2016 and

early 2017, with little change in frequency since then (Fig. 1).
Donation frequency declined slightly in male donors, from 2.5
in early 2016 to 2.3 in July 2018 (p = 0.013). Table 1 shows the
donation frequency and number of donations made by repeat
donors in the year before criteria changes (October 2015–
September 2016) and the year including criteria changes
(October 2016–September 2017). There was an increase in
female donors donating between one and three times a year,
and a reduction in females donating four or more times a year.
As we move farther out from March 2017, there will no longer
be any females donating five or more times a year. For males,
there was an increase in males donating from one to three
times a year and a reduction in males donating four or more
times a year, in spite of no change in the minimum interdona-
tion interval. To make up for the donation shortfall from repeat
donors, the number of new and reinstated donors increased.
Comparing calendar 2016 to 2017, donations from new donors
increased from 7,340 per month to 8,459 per month (15%
increase). The number of reinstated donors also increased
from 133,920 to 140,954 annually (5% increase). As a result,
the active donor base increased by 5.8%, to reach 420,699
active donors. Red cell demand decreased by approximately
3% annually during this period.
Distribution of Hb levels
The Hb distribution curves of female (Fig. 2A) and male
(Fig. 2B) presenting donors are shown from July 1 to December
31, 2016 and July 1 to December 31, 2017. For female donors,
both the mean and the median Hb were 135.0 g/L in 2016. In
2017, the mean was 136.2 g/L and the median was 136.0 g/L
(p < 0.001). The number of female donors with a Hb level
below 120 g/L declined from 13,281 (6.7% of female donation
attempts) in 2016 to 8,915 (4.9% of female donations
attempts) in 2017 (p < 0.001). For male donors, the mean
Fig. 1. Whole blood donation frequency in previous 12 months, successful donors January 1, 2016 to June 30, 2018.
HEMOGLOBIN AND INTERDONATION INTERVALS
Hb was 149.9 g/L in 2016 and 150.6 g/L in 2017 (p < 0.001),
while the median Hb remained constant at 150.0 g/L. The
number of male donors with a Hb below 120 g/L declined
slightly from 1,350 (0.60% of male donation attempts) to
1,007 (0.44% of male donation attempts), (p < 0.001).
Hb deferral rates
Weekly Hb deferral rates are shown for female (Fig. 3A) and
male (Fig. 3B) donors from January 1, 2016 to June 30, 2018
(note difference in scale of the y axis in 3A and 3B). Compar-
ing Periods 1 and 2, the deferral rate in females decreased
from 13.0% to 9.5% (p < 0.0001). This decrease began when
donor messaging on our collections sites and website started
in fall 2016, and continued when the rebooking software was
changed to permit a minimum interdonation interval of
84 days in early December 2016. Since the implementation
of the actual change in criteria in March 2017 the rate has
stabilized at approximately 8% to 10%, with some expected
seasonal variation.
For male donors, no gradual implementation was possi-
ble, and the deferral rate increased abruptly with the change
in criteria in March 2017 from 1.2% in Period 1 to 2.1 in
Period 2 (p < 0.001). With some expected seasonal variation,
the rate has stabilized at approximately 1.6 to 2.4%.
Fy(a-b-) donors
Donors known to be Fy(a-b-) who donated during the study
observation period had higher Hb deferral rates in both
females and males than all whole blood donors but experi-
enced the same trends, with a decline in deferral rate from
18.6% to 13.8% in female donors (p = 0.031), an increase in
deferral rate from 3.2% to 4.1% in male donors (p = 0.16),
and an overall decrease in deferral rate from 8.4% (130 out of
TRANSFUSION 3
GOLDMAN ET AL

1,418 donation attempts) to 7.5% (113 out of 1,387donation

951
−204
Donations
3,674
6,640
3,486
−5,684
−16,930
−13,720
−22,535
1,532
2,352

−3,635
−5,487
−4,491
−27,026
attempts) (p = 0.09).
Change*

DISCUSSION
Basic eligibility criteria for frequency of donation and

317
−51
−727
−897
Donors
3,674
3,320
1,162
−1,421
−3,386
−2,253
1,096
1,532
1,176

1,350
2,446
minimum interdonation interval and Hb cutoff levels differ
between jurisdictions.3 Observational studies on risk factors
for iron deficiency performed in several countries, including
Canada, the US, Denmark, Australia, and the Netherlands
Donations (% donations)

demonstrate that high frequency of donation is a major risk

factor for iron deficiency.5,14–17 Hb deferral rates also increase
18 (<0.1%)
163,837 (100%)

293,394 (100%)
29,781 (18%)
48,420 (30%)
15,846 (29%)
30,840 (19%)

44,166 (15%)
55,257 (19%)
59,904 (20%)
57,800 (20%)
51,158 (17%) with frequent donation.3,6,7,10 The UK INTERVAL study,
7,240 (4%)

25,109 (9%)

457,231 where donors were randomized to donate at a specific dona-

Oct/2016 – Sept/2017

tion interval, clearly demonstrated the link between interdo-

nation intervals, ferritin levels, and Hb deferrals.8
The frequency of donation of female CBS donors was
TABLE 1. Donation frequency in last 12 months, repeat donors

higher than that seen in other countries.3 A large, national

ferritin study demonstrated that 75% of repeat female
Donors (% donors)

donors donating more than four times a year had ferritin

3 (<0.1%)
78,998 (100%)

100,510 (100%)

levels below 25 μg/L.5 Several other countries have a mini-

29,781 (37%)
24,210 (31%)
15,846 (20%)
7,710 (10%)

25,109 (25%)
22,083 (22%)
18,419 (18%)
14,976 (15%)
11,560 (12%)
1,448 (2%)

8,363 (8%)

mum interdonation interval of 84 to 120 days for female

179,508

donors, and/or permit female donors to donate a maxi-

* A negative (−) change indicates that there were fewer donors or donations in 2016–17 compared to 2015–16.

mum of three or four times a year. As a partial mitigating

strategy for iron deficiency in our female donors, we increased
the minimum interdonation interval to 84 days. We esti-
mated that approximately 9% of females were making
Donations (% donations)

more than four donations a year, and that there would be

a minimum annual shortfall of about 12,000 units due to
186,372 (100%)

297,885 (100%)
26,107 (14%)
41,780 (22%)
44,052 (23%)
36,524 (20%)
24,170 (13%)

41,814 (14%)
54,306 (18%)
60,108 (20%)
61,435 (21%)
56,645 (19%)
13,739 (8%)

23,577 (8%)

this policy change, based on donation loss from female

donors donating more than four times a year. Implementation
484,257
Oct/2015 – Sept/2016

was done using a phased approach, first in messaging to staff

and donors, then in the rebooking software, and finally in the
criteria manual. This enabled us to spread out the impact of
the change over time and largely avoid clinic deferrals of
female donors who were between 56 and 84 days from
Donors (% donors)

their last donation.

77,902 (100%)

99,160 (100%)
26,107 (33%)
20,890 (27%)
14,684 (19%)
9,131 (12%)

23,577 (24%)
20,907 (21%)
18,102 (18%)
15,027 (15%)
12,287 (13%)

After this policy change, donation frequency in female

4,834 (6%)
2,256 (3%)

9,260 (9%)

donors declined substantially, with approximately 22,500

177,062

fewer donations per year made by repeat female donors.

There was a substantial increase in new and reinstated
donors to make up for the donation shortfall, leading to an
expansion of the overall donor base despite a decline in
Donation Frequency

whole blood collections of approximately 2.3%. The Hb

distribution curve in presenting female donors shifted
slightly to the right. Because there are so many female donors
≥6

≥6
1
2
3
4
5

1
2
3
4
5

close to the cutoff of 125 g/L, this resulted in a substantial

decline in Hb deferrals. Perhaps most importantly, in terms
of donor health, there was a substantial decline in the
number of female donors with a Hb level below 120 g/L,
All females

who are most likely to experience negative effects on their

All males
Females

health and well-being.

Sex

Males

Total

In our observational study of ferritin levels, both frequency

of donation and a Hb level near the cutoff of 125 g/L were

4 TRANSFUSION

Fig. 2. Hemoglobin (Hb) distribution, July 1 to December 31, 2016 (− − -) and July 1 to December 31, 2017 (—), female (2A) and male
(2B) presenting whole blood donors.
shown to be associated with iron deficiency in male donors.5
Male donors with a Hb level between 125 g/L and 130 g/L on
average had donated more frequently than males with a higher
Hb level. Most countries have a Hb cutoff of 130 g/L or 135 g/L
for male donors.3,8 We therefore decided to implement a
change in Hb cutoff as a partial mitigating strategy in
male donors.18 As seen by US blood centers who recently
made this change, this resulted in an increase in Hb
deferrals in male donors. We estimated that the increase
in Hb cutoff to 130 g/L in male donors would result in
the loss of 2.5% of donations from male donors (11,700
donations annually). Donation loss was substantially
lower than predicted, with an increase in Hb deferrals of
0.9%, resulting in a donation loss of approximately 3,500
donations annually. Longer-term observation will be
needed to assess the impact of this change on overall Hb
levels in male donors. Preliminary results suggest a small
HEMOGLOBIN AND INTERDONATION INTERVALS
increase in overall Hb levels, which is likely multifactorial.
Males who fall below the cutoff have a minimum 56-day
pause in donation, rather than returning to donate with
an even lower Hb level. Increased focus on first time and
reinstated donor acquisition and closure of clinics reliant on a
small group of dedicated donors donating every 56 days
resulted in fewer males donating more than three times a year
and a slight decrease in donation frequency in males.
A particular concern with increasing the minimum Hb
level for male donors is an increased deferral rate of rare
phenotyped donors, such as Fy(a-b-) donors, who are pre-
dominantly of African origin and therefore tend to have
lower normal Hb levels.18,19 In Canada, Fy(a-b-) donors
are almost exclusively of African origin. Although deferral
rates were higher in both female and male Fy(a-b-) donors
compared to our overall donor base, the decrease in Hb
deferrals in females compensated for the increase in
TRANSFUSION 5
GOLDMAN ET AL
Fig. 3. Weekly hemoglobin deferral rates, from January 1, 2016 to June 30, 2018 as a percentage of female (3A) and male (3B) whole
blood donation attempts. Curves are shown for each year.
deferrals in males, resulting in a lower deferral rate after
the policy changes.
It is difficult to predict both positive and negative out-
comes of donor policy changes.13 Spencer et al. performed
a modeling study using data from six US blood centers
participating in the Retrovirus Epidemiology Donor Study-II
(REDS II) to estimate the impact of various changes in
donor Hb cutoffs and interdonation intervals on blood avail-
ability and donor iron status.20 A similar exercise was
performed by Gandhi et al. using a much smaller dataset
from the Mayo Clinic Rochester donor center.21 Not
6 TRANSFUSION
surprisingly, these studies demonstrate that the baseline
proportion of high-frequency donors in a given donor popu-
lation is a major factor in determining the impact of a
change in interdonation interval. CBS and Mayo Clinic
donors have a much higher frequency of donation com-
pared to the REDS II donors. At the beginning of our obser-
vation period, prior to criteria changes, the whole blood
donation frequency in CBS male and female donors in the
previous 12 months was 2.5 and 1.75, compared to 1.25 and
0.89 in REDS II donors and 2.7 and 1.5 in Mayo Clinic
donors, respectively. Although some of these differences

may reflect variable methodology, there is likely a substan-
tial difference in donation frequency in these donor popula-
tions. These studies emphasize that each blood center
needs to make decisions regarding optimal mitigation strat-
egies for iron deficiency depending on their own donor
population characteristics.22 The 2017 AABB Association
Bulletin on updated strategies to limit or prevent iron defi-
ciency in blood donors lists several possible interventions.
These include selective ferritin testing accompanied by donor
deferral and/or iron supplementation alone or combined
with increased interdonation intervals.2 Recent data from
blood centers that have implemented selective ferritin testing
in teenage donors demonstrated that temporary deferral of
donors with low ferritin resulted in a decrease in Hb deferrals
and an increase in mean Hb levels in donors.23 This mitiga-
tion strategy may also result in negative operational impacts,
such as donation loss and reduced donor return.24
In summary, changes in the minimum interdonation
interval for female donors and Hb cutoff in males had an
overall positive effect, resulting in fewer presenting donors
with a Hb level below 120 g/L, and for female donors, an
increase in overall Hb levels. Results were in part directly
due to the criteria changes and in part related to compensa-
tory actions resulting in an expanded donor base. Additional
effort was required on the part of our donor relations staff
to compensate for reduced donation frequency by our most
loyal donors, demonstrating the importance of coordinated
efforts to offset operational impacts of donor health initia-
tives. Clinic efficiency was improved due to a substantial
decrease in Hb deferrals. Further changes in interdonation
interval would result in large donation losses for our blood
center and would not allow loyal donors willing to take iron
supplements to donate as frequently as they wish. We are
currently evaluating additional measures to enhance donor
health, including improved education about iron needs and
the introduction of selective ferritin testing.
ACKNOWLEDGMENTS
We would like to acknowledge the project team and donor relations
staff at CBS that made these changes possible, Wenli Fan for pro-
ducing the Hb distribution graphs, and Jennifer Delorme for admin-
istrative assistance.
CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose.
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8 TRANSFUSION
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