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Willer, David

External Threat as Coercion

Wendel, Silvano

Fontão-Wendel, Rita

Altobeli de Brito, Mayra

Cardoso, Regina

IMMUNOHEMATOLOGY, Volume 32, Number 1, 2016 13
Rare donor program at the Hospital Sírio 
Libanês, São Paulo, Brazil
S. Wendel, R. Fontão-Wendel, M.A. Brito, and R. Cardoso
Review
The rare donor program at the Hospital Sírio Libanês 
began in 1990, with the encouragement of Delores Mallory, 
John Moulds, and Marcela Contreras, because at that time no 
such strategy was available in Brazil. In addition, an important 
contribution of rare sera was supplied by the international 
Serum, Cells and Rare Fluids (SCARF) program. Although 
managed by local funds and having a modest capacity for 
screening rare donors, all inventory units are available for any 
transfusion service either from Brazil or overseas.
Since the inception of our rare donor program, 84,426 
donors have been screened by serologic methods for several 
antigens, rendering a total of 161 rare donors, according to 
different blood group systems (Table 1). Furthermore, since 
2012, we have found 36 new rare donors who currently actively 
contribute with regular donations whenever needed.
Table 1 depicts our results through December 2014. In 
addition to testing all 84,426 donor samples for the main Rh 
antigens (D, C, c, E, e), we also tested for the presence of Goa 
(RH30) in 20,344 donors to potentially find DIVa donors. 
A total of 186 rare units (26 from 2012–2014) were made 
available to 75 Brazilian patients, not only in our hospital, but 
in 13 additional hospitals or blood services facilities across the 
country. In addition, because storage of rare units in the frozen 
state is not widely available in Brazil, Hospital Sírio Libanês 
served as a facilitator for storage, thawing, and shipping of 34 
rare units that included k– (N = 1), K0 (N = 2), Kp(b–) (N = 
7), Yt(a–) (N = 10), Vel– (N = 12), and Di(b–) (N = 2), which 
were supplied either by national or international agencies 
(American Red Cross, New York Blood Center, Canadian Red 
Cross, and Osaka Red Cross) to seven blood services in the 
country during this period. There were two requests not filled 
during this period (one for a U– patient and one for an Rhnull 
patient).
We have not yet identified any Rhnull donors; this phenotype 
is recognized as the rarest in the world. Nevertheless, we 
understand that identifying such a donor, where high rates of 
failure are expected, can only be accomplished by an ongoing 
Rh antigen screening of all new donors, which we carry out in 
our service.
We were aware of one incompatible transfusion case: the 
serum from a previously transfused patient was sent to our 
laboratory for investigation and anti-Dib was identified. This 
patient was subsequently transfused with two Di(b–) units 
through  our rare donor program with no further hemolysis.
We have very strong support from voluntary non-
remunerated donors in our service. We provide no special 
incentives for either rare donors already in the program or 
for those who are enrolling through screening procedures. 
In other words, although rare donors are quite unique, they 
receive the same care provided to any regular voluntary donor. 
So far, we have not perceived any untoward effect by applying 
this policy.
In summary, a rare donor program requires perseverance, 
patience, and long-term commitment, given that one cannot 
predict when rare blood will be needed. Being part of a global 
program under the aegis of several agencies (International 
Society of Blood Transfusion, AABB, American Red Cross, 
EFS [Etablissement Français du Sang], Canadian Red Cross, 
Japanese Red Cross, Sanquin, etc.) with active cooperation 
Table 1. Phenotypes of rare blood donors identified at the Hospital 
Sírio Libanês as of 2014
Phenotype Tested donors* Total 2012–2014†
k– 84,656 118 24
Di(b–) 40,551 13 4
r'r' 84,426 6 3
r''r'' 84,426 5 1
Kp(b–) 50,232 5 1
RzRz 84,426 3 1
ryry 84,426 2 0
Vel– 9,477 2 0
Kx– (McLeod) 50,232 2 0
Oh (Bombay) 84,426 2 1
K0 50,232 1 1
U– 17,163 1 0
PP1Pk– 23,050 1 0
Jk(a–b–) 32,915 0 0
Total 161 36
*Since 1990.
† New donors added to our rolls between January 2012 and December 2014.
14 IMMUNOHEMATOLOGY, Volume 32, Number 1, 2016
S. Wendel et al.
and mutual support increases the chances of finding a rare 
unit for a rare patient.
Silvano Wendel, MD, PhD (corresponding author), Medical Director, 
Blood Bank, Hospital Sírio Libanês, Rua Dona Adma Jafet, 91, 
São Paulo, Brazil 01308-050, snwendel@terra.com.br; Rita 
Fontão-Wendel, BSc, PhD, Laboratory Head, Blood Bank, Hospital 
Sírio Libanês, São Paulo, Brazil; Mayra Altobeli de Brito, BSc, 
Laboratory of Immunohematology and Molecular Biology, Blood 
Bank, Hospital Sírio Libanês, São Paulo, Brazil; Regina Cardoso, 
BSc, Immunohematology Laboratory, Blood Bank, Hospital Sírio 
Libanês, São Paulo, Brazil.


Rare donor program at the Hospital Sirio Libanes, Sao Paulo, Brazil

Alcantara, Ramir

Chay, Jason

Ang, Ai Leen

IMMUNOHEMATOLOGY, Volume 32, Number 2, 2016 55
Singapore rare donor program
R. Alcantara, J. Chay, and A.L. Ang
Review
In Singapore, rare blood donors are those whose red 
blood cells (RBCs) lack a high-prevalence antigen or lack a 
combination of common antigens that can only be found in 1 
in 1000 or fewer blood donors (Table 1).
The Health Sciences Authority’s Blood Services Group 
(BSG) is the national blood service in Singapore. The BSG has 
been maintaining a registry of donors with rare blood types 
since 2004. RBC units from these donors are cryopreserved 
using the high-concentration (40%) glycerol method and a 
slow freezing rate. Frozen rare donor RBC units are stored at 
–65°C or lower in mechanical freezers and are kept for up to 
10 years.
With more patients receiving blood transfusions for 
complex surgeries and undergoing aggressive treatments 
for hematological diseases (chemotherapy, bone marrow 
transplant, etc.) in Singapore, our national Red Cell Serology 
Reference Laboratory started to notice an increase in the num-
ber of multiple RBC alloantibodies in transfusion recipients 
and the appearance of RBC antibodies not previously seen in 
Singapore (e.g., anti-k).
Since 2011, BSG has been maintaining a regular inventory 
of non-cryopreserved phenotyped blood to ensure that 
antigen-negative RBC units are readily available for patients 
because the thawing and deglycerolization process of frozen 
blood units takes several hours. This inventory includes Fy(a−), 
Fy(b−), Jk(a−), Jk(b−), S−, and s− RBC units, as well as units 
with multiple common antigen–negative combinations such 
as R1R1 Fy(a−) or Fy(b−); R2R2 s−; or R1R1 Jk(a−) or Jk(b−), 
and s−.
The Singapore Rare Donor Program aims to meet the 
rare blood requirements of patients in Singapore through 
appropriate targeted screening among the regular voluntary 
blood donors. An example of this initiative was the mass 
screening of blood donors in 2013 using the urea lysis test 
on the Olympus PK7300 as a rapid screening for Jk(a–b–) 
donors after having to supply blood for a surgical patient with 
alloantibody to Jk3. We were able to identify an additional 10 
donors, all confirmed to be Jk(a−b−) by serology. Our study 
also showed that the prevalence of Jk(a–b–) phenotype was 1 
in 3600 in the Singapore donor population.
If rare blood cannot be found among our donor population, 
we first discuss with the clinician if autologous transfusion 
is possible. If not, we screen the patient’s immediate family 
members (siblings and parents) to look for the rare blood 
phenotype. We apply similar stringent selection criteria as 
for any other blood donor before accepting blood donations 
from these family members. In 2014, we had to supply blood 
for a neonate with hemolytic disease of the fetus and newborn 
caused by anti-Hr0. Because of the urgency of the transfusion 
requirement and ABO incompatibility with the mother, we 
screened the mother’s siblings and found one of them to be 
negative for Hr0; this individual became a regular voluntary 
blood donor.
Because knowledge of the distribution of blood groups 
present in our donor population can help in the identification 
of rare phenotypes, we are presently revising our screening 
strategies using our local antigen prevalence data to make the 
screening process for rare blood types more efficient. We are 
also in discussion with the Singapore Red Cross to design a 
program for maintaining our existing rare blood donors and 
recruiting new blood donors. Under a unique partnership with 
BSG, the Singapore Red Cross is responsible for the national 
blood donor recruitment and retention program.
BSG follows a policy of voluntary non-remunerated blood 
donation, and rare blood donors are managed in the same way 
as the rest of the blood donors, with no material rewards or 
incentives. However, they are informed that they will be given 
priority access to the rare blood inventory in the event that 
they need blood themselves.
Currently, we have 37 active donors that meet our 
definition of a rare blood donor, and we have included them 
in our rare blood donor registry (Table 1). From these donors, 
we were able to collect 43 RBC units, which are currently in 
our frozen inventory. Between 2012 and 2014, there were three 
cases (liver transplant, lung resection, and placenta previa) of 
patients in Singapore requiring rare blood, and these patients 
were fully supported. Besides screening for donors of rare 
blood required locally, we also hope to find some donors of 
other rare blood types encountered in other Asian countries 
[Rhnull, Di(b−), etc.]. We have not transfused incompatible 
blood to recipients requiring antigen-negative RBC units.
Rare donor units collected and kept in frozen inventory 
starting from 2006 follow the International Society of Blood 
Transfusion (ISBT) 128 standard for labeling, which is the 
56 IMMUNOHEMATOLOGY, Volume 32, Number 2, 2016
R. Alcantara et al.
global standard for the identification, labeling, and information 
transfer of human blood, cell, tissue, and organ products across 
international borders and disparate health care systems. This 
system will facilitate international shipping of blood products 
available in Singapore to other countries if there is a request for 
rare blood units, although BSG has not imported or received a 
request from other countries or blood centers to provide rare 
donor units in recent years.
Acknowledgments
The authors would like to express their special thanks to 
Mr. Marvin Millana, Ms. Rosalind Loo, and Ms. Clara Lim for 
their valuable help in the Singapore Rare Donor Program.
Ramir Alcantara, MD (corresponding author), Registrar, Blood 
Services Group, Health Sciences Authority, 11 Outram Road, 
Singapore, 169078, ramirmd@yahoo.com; Jason Chay, MD, Blood 
Services Group, Health Sciences Authority, Singapore; Ai Leen Ang, 
MD, FRCPath, Consultant, Blood Services Group, Health Sciences 
Authority and Department of Hematology, Singapore General 
Hospital, Singapore.
Table 1. Donor and cryopreserved unit information for blood types 
considered rare in Singapore (in ≤1:1000 donors) as of 2015.
High-prevalence antigen-negative
Phenotype
Number of 
donors
Number of 
cryopreserved 
RBC units
Jk(a−b−) 32 36
H– (Oh) 4 5
Hr0– (D−−) 1 2
Multiple antigen-negative combinations
R1R1, Jk(a−) or Jk(b−), Fy(a−) or Fy(b−), and s− 0 0
R2R2, Jk(a−) or Jk(b−), Fy(a−) or Fy(b−), and s− 0 0
R2R2, Fy(a−), s− 0 0
rr, Jk(a−) or Jk(b−), Fy(a−) or Fy(b−), and s− 0 0
r˝r˝, Fy(a−), or s− 0 0


Singapore rare donor program

Hustinx, Hein

Lejon Crottet, Sofia

Scharberg, Erwin A.

Weinstock, Christof

IMMUNOHEMATOLOGY, Volume 32, Number 2, 2016 63
Rare donor programs in Switzerland, Germany, 
and Austria
H. Hustinx, S. Lejon Crottet, E.A. Scharberg, and C. Weinstock
Review
In 2009, the Working Party on Rare Donors of the German 
Society of Transfusion Medicine and Immunohematology 
(DGTI), which represents the German-speaking countries 
of Switzerland, Germany, and Austria (Fig. 1), started to 
develop a joint database for rare donors. The database was 
implemented in 2011 in Berne, Switzerland, and is maintained 
by the Swiss Red Cross Blood Service (public access: http://
www.iblutspende.ch/en/rare-donors/rare-donors.html).
Germany and Switzerland, which have mostly Caucasian 
populations, started rare donor programs in the 1990s 
(Table 1), focusing on donors negative for Kpb, Vel, Lub, and 
Yta. In 2003, Seltsam et al.1 conducted a survey for patients 
with antibodies against high-prevalence antigens in the 
major reference laboratories and blood services in Germany, 
Switzerland, and Austria. During the 20-month observation 
period, 56 cases were reported. In 71 percent of these cases, 
antibodies against Kpb, Vel, Lub, Yta, or Coa were detected, 
confirming the direction of the early programs. In recent 
years, high-throughput molecular methods were developed 
and implemented. These methods have made it possible to 
test donors for high-frequency alleles independent of the 
availability of specific antisera, which often were not available 
in appropriate quantity and quality. At present, about 1100 
donors with rare blood types are listed in the DGTI database 
(Table 2). Most of these donors are registered by the Swiss 
Blood Services. The listing of German and Austrian donors 
has not yet been completed.
In order to keep blood donation on a volunteer basis, no 
incentives are offered for rare donors.
In 2012, Switzerland imported four red blood cell (RBC) 
units with the Lu(b–) phenotype and exported two RBC units 
with the Jk(a–b–) phenotype. Seventeen rare blood units [1 
Lu(b–), 3 K+k–, 5 Yt(a–), 8 Vel–] were shipped within the 
country. According to the German authorities no RBC units 
were imported in 2012. Germany exported 302 units to 
European countries, although the number of rare phenotypes 
included was not specified. From 2012 to 2014, 136 (37 
cryopreserved) units were shipped domestically [44 Lu(b–), 
71 Yt(a–), 3 Vel–, 9 AnWj–, 4 Co(a–), 1 Kp(b–), 2 PP1Pk–, 
1 RzRz (CCD.EE), 1 GE:–2]. Requests for rare phenotypes are 
not systematically documented by most blood services, thus 
no exact data are provided for unfilled requests.
Neither in Germany nor in Switzerland were intentionally 
incompatible transfusions reported in the case where a request 
for rare units could not be filled. It is likely that other measures, 
such as administration of erythropoietin or inclusion in an 
autologous blood program, were taken. This information, 
however, is scarce and laboratories normally cannot track 
these cases.
There is one known donor with the Rhnull phenotype in 
Switzerland. This donor carries the allele RHAG*01N.02. 
In Germany, one donor with Rhnull and one with the Rhmod 
Fig. 1. Blood service centers in Austria, Germany, and Switzerland 
that reported rare donor screening programs. Centers (noted with 
squares) also store frozen red blood cell units.
Munich
Ulm
Hagen
Baden-Baden
Springe
Berne Zurich
Vienna
Germany
Austria
Switzerland
64 IMMUNOHEMATOLOGY, Volume 32, Number 2, 2016
H. Hustinx et al.
Table 1. Historic and current testing methods and consequent donors identified in rare donor programs in Austria, Switzerland,  
and Germany
Program location/organizer Years
Number of 
donors tested Method of testing
Rare donor screening/number of donors identified
Lu(b–) Kp(b–) Yt(a–) Co(a–) LU:–14 Vel– MAR– Fy(a–b–) S–s– U– Lan– K0
Austrian Red Cross Blood Center, Vienna, Austria — C. Jungbauer et al. 2007–2015* 25,000 Molecular X X X X X – – – – – – 30 additional alleles are tested
20 2 68 31 8 – – – – – –
Interregional Blood Transfusion SRC Ltd., Berne, Switzerland — H. Hustinx et al. 2010–2011 52,000 Serologic – X – – – – – – – – – Additional antigens were tested
2011–2012 40,000 Serologic – – – – – X – – – – –
2013 35,000 Serologic – – – – – – X – – – –
2011–2015† 21,000 Molecular X X X X – X – – – – – 22 additional alleles are tested
35 10 60 46 – 13 – – – – –
Red Cross Blood Service, Institute, Zurich, Switzerland — B. Frey et al. 2012–2015‡ 40,000 Molecular X X X X X X – – – – – Additional alleles are tested
44 6 86 28 7 3 – – – – –
Red Cross Blood Service West Institute, Hagen, Germany — B. Just et al. 1996–1998 22,000 Serologic – – – – – X – – – – –
2004–2005 2000 Serologic – – X – – – – – – –
2008–2009 5600 Serologic X X X X X – – – – –
2009–today§ >250 Serologic – – – – – – – X X – –
8 3 19 11 – 17 – 62 3 – –
2012–today¶ >4000 Molecular X X X X – X – – – – – Additional alleles are tested
5 0 9 12 – 0 – – – – –
Bavarian Red Cross Blood Service Institute, Munich, Germany — J. Burkhart et al. 1999–2000 5500 Serologic X X – – – – – – – –
1999–2000 5000 Serologic – X – – – – – – – X –
1999–2000 5000 Serologic – – – – – X – – – – X
5 0 14 – – 0 – – – 1 0
Red Cross Blood Service NSTOB Institute, Springe, Germany — F.F. Wagner et al. 2005–2007# 3400 Molecular X X X X – – – – – – –
2007–2013** 64,000 Molecular X X X X – – – – – – –
2013–today** >22,000 Molecular X X X – – X – – – – –
209 11 190 146 – 12 – – – – –
Red Cross Blood Service Baden-Württemberg, Hessen Institute, Baden-Baden, Germany — 
E.A. Scharberg et al.
1998–2012 15,000 Serologic X X – – – – – – – – –
2013–2014 35,000 Serologic X X – – – X – X – – –
2013–2014 150,000 Serologic – – – – X – – – –
12 1 – – – 5 8 3 – – –
Red Cross Blood Service Baden-Württemberg, Hessen Institute Ulm, Ulm, Germany —  
I. von Zabern et al.
2009–2010# 2500 Molecular X X X X – – – – – – –
2 0 13 3 – – – – – – –
*Six multiplex polymerase chain reactions (5–7 primer pairs) for a single blood donor2; agarose gel electrophoresis.
†In-house method.
‡Matrix-assisted laser desorption/ionization, time-of-flight (MALDI-TOF).3
§Only donors of African or Asian origin are included.
¶MALDI-TOF; testing for VEL*01N/01N was added in 2014.
#Manual testing using agarose gels.4
** Semi-automated testing using pooled capillary electrophoresis; CO switched to VEL in August 2013.
IMMUNOHEMATOLOGY, Volume 32, Number 2, 2016 65
Rare donor programs: Switzerland, Germany, and Austria
Table 1. Historic and current testing methods and consequent donors identified in rare donor programs in Austria, Switzerland,  
and Germany
Program location/organizer Years
Number of 
donors tested Method of testing
Rare donor screening/number of donors identified
Lu(b–) Kp(b–) Yt(a–) Co(a–) LU:–14 Vel– MAR– Fy(a–b–) S–s– U– Lan– K0
Austrian Red Cross Blood Center, Vienna, Austria — C. Jungbauer et al. 2007–2015* 25,000 Molecular X X X X X – – – – – – 30 additional alleles are tested
20 2 68 31 8 – – – – – –
Interregional Blood Transfusion SRC Ltd., Berne, Switzerland — H. Hustinx et al. 2010–2011 52,000 Serologic – X – – – – – – – – – Additional antigens were tested
2011–2012 40,000 Serologic – – – – – X – – – – –
2013 35,000 Serologic – – – – – – X – – – –
2011–2015† 21,000 Molecular X X X X – X – – – – – 22 additional alleles are tested
35 10 60 46 – 13 – – – – –
Red Cross Blood Service, Institute, Zurich, Switzerland — B. Frey et al. 2012–2015‡ 40,000 Molecular X X X X X X – – – – – Additional alleles are tested
44 6 86 28 7 3 – – – – –
Red Cross Blood Service West Institute, Hagen, Germany — B. Just et al. 1996–1998 22,000 Serologic – – – – – X – – – – –
2004–2005 2000 Serologic – – X – – – – – – –
2008–2009 5600 Serologic X X X X X – – – – –
2009–today§ >250 Serologic – – – – – – – X X – –
8 3 19 11 – 17 – 62 3 – –
2012–today¶ >4000 Molecular X X X X – X – – – – – Additional alleles are tested
5 0 9 12 – 0 – – – – –
Bavarian Red Cross Blood Service Institute, Munich, Germany — J. Burkhart et al. 1999–2000 5500 Serologic X X – – – – – – – –
1999–2000 5000 Serologic – X – – – – – – – X –
1999–2000 5000 Serologic – – – – – X – – – – X
5 0 14 – – 0 – – – 1 0
Red Cross Blood Service NSTOB Institute, Springe, Germany — F.F. Wagner et al. 2005–2007# 3400 Molecular X X X X – – – – – – –
2007–2013** 64,000 Molecular X X X X – – – – – – –
2013–today** >22,000 Molecular X X X – – X – – – – –
209 11 190 146 – 12 – – – – –
Red Cross Blood Service Baden-Württemberg, Hessen Institute, Baden-Baden, Germany — 
E.A. Scharberg et al.
1998–2012 15,000 Serologic X X – – – – – – – – –
2013–2014 35,000 Serologic X X – – – X – X – – –
2013–2014 150,000 Serologic – – – – X – – – –
12 1 – – – 5 8 3 – – –
Red Cross Blood Service Baden-Württemberg, Hessen Institute Ulm, Ulm, Germany —  
I. von Zabern et al.
2009–2010# 2500 Molecular X X X X – – – – – – –
2 0 13 3 – – – – – – –
*Six multiplex polymerase chain reactions (5–7 primer pairs) for a single blood donor2; agarose gel electrophoresis.
†In-house method.
‡Matrix-assisted laser desorption/ionization, time-of-flight (MALDI-TOF).3
§Only donors of African or Asian origin are included.
¶MALDI-TOF; testing for VEL*01N/01N was added in 2014.
#Manual testing using agarose gels.4
** Semi-automated testing using pooled capillary electrophoresis; CO switched to VEL in August 2013.
66 IMMUNOHEMATOLOGY, Volume 32, Number 2, 2016
phenotype are known. The molecular background of the Rhnull 
donor is under investigation. The Rhmod phenotype is caused 
by heterozygosity for the RHAG*01N.03 allele and a new allele 
with a single nucleotide polymorphism causing an amino 
acid substitution located at the transmembrane/intracellular 
border. This donor carries Rh antigens at a very low level that 
can be detected by absorption and elution methods only.
References
 1. Seltsam A, Wagner FF, Salama A, Flegel WA. Antibodies 
to high-frequency antigens may decrease the quality of 
transfusion support: an observational study. Transfusion 
2003;43:1563–6.
 2. Jungbauer C, Hobel CM, Schwartz DW, Mayr WR. High-
throughput multiplex PCR genotyping for 35 red blood cell 
antigens in blood donors. Vox Sang 2012;102:234–42.
 3. Meyer S, Vollmert C, Trost N, et al. High-throughput Kell, Kidd, 
and Duffy matrix-assisted laser desorption/ionization, time-
of-flight mass spectrometry-based blood group genotyping of 
4000 donors shows close to full concordance with serotyping 
and detects new alleles. Transfusion 2014;54:3198–207.
 4. Wagner FF, Bittner R, Petershofen EK, Doescher A, Muller TH. 
Cost-efficient sequence-specific priming-polymerase chain 
reaction screening for blood donors with rare phenotypes. 
Transfusion 2008;48:1169–73.
Hein Hustinx, Interregional Blood Service Swiss Red Cross, 
Bern, Switzerland; Sofia Lejon Crottet, PhD, Interregional Blood 
Service Swiss Red Cross, Bern, Switzerland; Erwin A. Scharberg, 
MD, German Red Cross Blood Service Baden-Wüerttemberg, 
Baden-Baden, Germany; Christof Weinstock, MD (corresponding 
author), German Red Cross Blood Service Baden-Wüerttemberg–
Hessen, Institute Ulm, Helmholtzstrasse 10, 89081 Ulm, Germany, 
c.weinstock@blutspende.de.
Table 2. Rare donors listed in the German Society for Transfusion 
Medicine and Immunohematology (DGTI) database as of 2015
Phenotype Number of donors
K+k– 316
Yt(a–) 214
Lu(b–) 145
Fy(a–b–) 105
Co(a–) 101
Vel– 39
r´r´ 39
Kp(b–) 28
r″r″ 26
Lu(a–b–) 10
MAR– (Rh:–51) 7
PP1Pk– 3
RzRz 3
D–– 3
S–s–U– 2
S–s–U+var 2
Jk(a–b–) 2
Kx– (McLeod) 2
Jr(a–) 2
Lan– 2
Di(b–) 1
Lw(a–b+) 1
Oh (Bombay) 1
Pk (P–; GLOB:–1) 1
Rhnull 1
H. Hustinx et al.


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