Quebec says "small is beautiful" when it comes to blood
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* Susan Pinker

If anyone can inspire confidence in Quebec's blood supply, it's Dr. Francine Decary, the affable hematologist at the helm of Héma-Québec, the province's blood agency.

All other provinces and territories contract for blood products from Canadian Blood Services (CBS), so why is Quebec going its own way? From her spacious new offices in Montreal, Decary summed up the province's main advantage in controlling its own blood system: small is beautiful. After the federal government's Krever report was issued in 1997, says Decary, the public needed complete confidence in a safe and secure blood system. Part of gaining that confidence depends on accountability, and Decary says this is easier to ensure when the scale is smaller. FIGURE

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/162/5/691/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/162/5/691/F1)

Figure. Dr. Francine Decary: "We are closer to the community."

In many respects, the 2 agencies are similar. "The most fundamental difference is size," Decary says. "We are much closer to the community."

Although safety issues are determined at the national level by the Bureau of Biologics and Radiopharmaceuticals at Health Canada, the 2 Canadian blood agencies can interpret national policy in ways that reflect their constituencies. A case in point is Health Canada's decision about protecting blood products from contamination with the prion that is believed to cause new variant Creutzfeldt-Jakob disease (nvCJD).

A recent study indicates there is no species barrier preventing humans from contracting nvCJD from cows infected with bovine spongiform encephalopathy (BSE). This means there is a theoretical risk of transmission of nvCJD via the blood of donors who have spent a significant amount of time in countries where BSE has been detected.

Although no one has ever contracted nvCJD from blood products, experts advised that precautions be taken to protect the blood supply from any possible risk. As a result, Health Canada issued a policy last summer prohibiting blood donations from people who have spent a total of 6 months or more in the United Kingdom since 1980.

Both blood agencies had to balance the real risk of not having enough blood against the unproven risk of the transmissibility of nvCJD from donated blood. And even though both were bound to observe the donor restrictions specified by Health Canada, their respective policies differed.

CBS opted to apply Health Canada's exclusion rule to the letter and has excluded donors who have spent a cumulative total of 6 months or more in the UK. It expected that this would reduce blood donations by 3%, an amount that would not endanger its fragile supply. But a few weeks after this announcement, CBS accelerated its media campaign to address a critical shortage of blood and offset any future losses of donors resulting from the nvCJD exclusion.

Héma-Québec applied a slightly more stringent standard to Health Canada's rule, and decided to exclude donors who had spent a total of 1 month or more in the UK since 1980. Decary says the primary reason for taking a different route than CBS is that fewer Quebecers go to the UK than Canadians from other provinces. Limiting donors to less than a month's stay in Britain eliminated much of the theoretical risk of transmission of nvCJD from blood products, yet diminished blood donations by the same manageable 3%.

"It is a risk-management decision, not an epidemiologic one," says Decary, who refused to take credit for acting cautiously. "If nvCJD appeared in France, we'd have the other side of the coin."

But another reason Héma-Québec can afford to be choosier about donors could be that the Quebec agency has not yet experienced a shortage of blood. With a smaller, tighter-knit community to canvas and with blood drives organized by grass-roots organizations, the blood supply has remained at a stable level since the inception of the agency in the fall of 1998, says Jean-François Lamarche, a Héma-Québec spokesperson.

The agency also delivers its blood products differently than CBS. It has designated certain hospitals as hubs that are accountable for the quality and quantity of blood products needed, as well as for the standards for transfusion within specified boundaries. "We wanted someone to be accountable, and used a model form Philadelphia," says Decary.

Other distinctions between the 2 agencies are more subtle, but both Dr. Graham Sher, vice-president of medical, scientific and clinical development at CBS, and Decary prefer to focus on similarities instead of differences. "For both, safety is paramount," says Sher, who added that the larger geographic area covered by CBS fosters "complexities and a greater number of relationships."

However, the fact that information and blood products go back and forth between the 2 agencies ensures ongoing collaboration.