ORIGINAL RESEARCH
Safety of blood donation by individuals over age 70 and their
contribution to the blood supply in five developed countries:
a BEST Collaborative group study
Mindy Goldman,1 Marc Germain,2 Yves Grégoire,2 Ralph R. Vassallo,3 Hany Kamel,3 Marjorie Bravo,3
David O. Irving,4 Emanuele Di Angelantonio,5 Whitney R. Steele,6 Sheila F. O’Brien,1
for the Biomedical Excellence for Safer Transfusion Collaborative (BEST) Investigators
BACKGROUND: Some countries impose an upper age
limit on whole blood and double RBC donation while
others do not. We evaluated the safety of blood donation
in older individuals (≥71 years), and their contribution to
the blood supply of five countries.
STUDY DESIGN AND METHODS: Twelve blood
center members of the Biomedical Excellence for Safer
Transfusion (BEST) Collaborative from four countries
with no upper age limit for whole blood and double RBC
donation (Canada, New Zealand, England, and the
United States) or an upper age limit of 80 (Australia)
provided 2016 data on donors and donations, deferral
rates, and vasovagal reactions by donor age and sex.
Donors under age 24 were included in the number of
total donors and donations, but not in deferral and
reaction rate comparisons.
RESULTS: Older donors accounted for 1.0%
(New Zealand) to 4.3% (United States) of donors, and
1.5% (New Zealand) to 5.6% (United States) of
donations; most were between ages 71 and 76. The
deferral rate was higher in older compared to 24- to
70-year-old males, but very similar between older and
younger females. In contrast, vasovagal reaction rates
were either lower (male donors) or similar (female donor
for reactions with loss of consciousness) in older
compared to 24- to 70-year-old donors.
CONCLUSIONS: Exclusion solely based on older age
appears to be unwarranted based on safety concerns
such as donor reactions. Healthy older individuals can
continue to safely donate and make a significant
contribution to the blood supply past arbitrary age limits.
B
lood donor selection criteria are important to
protect the health of both donors and transfusion
recipients. However, criteria designed to protect
donor health are often based on past practice
and experience rather than on actual evidence and current
knowledge, and these criteria can vary between countries
with similar donor populations. Criteria regarding an upper
age limit may have an important impact on the potential
donor pool in countries with an aging donor population,
and vary considerably among developed countries.1,2
The Biomedical Excellence for Safer Transfusion
(BEST) Collaborative is in a unique position to bring
together data from multiple countries to assess the current
contribution of older donors to the blood supply interna-
tionally and the safety of donation for these donors. An ear-
lier study on donor and general population demographics
found that the upper age limit varied from 69 to 80, with
many blood centers having an upper age limit of 70; other
centers had no upper age limit.3 The aims of this analysis
ABBREVIATIONS: CIs = confidence intervals; Hb = hemoglobin;
LOC = loss of consciousness.
From the 1Canadian Blood Services, Ottawa, Ontario, Canada;
2
Héma-Québec, Québec City, Québec, Canada; 3Vitalant,
Scottsdale, Arizona; 4Australian Red Cross Blood Service, Sydney,
Australia; 5University of Cambridge, and National Institute for
Health Research (NIHR) Blood and Transplant Research Unit in
Donor Health and Genomics, Cambridge, United Kingdom; and the
6
American Red Cross, Rockville, Maryland.
Address reprint requests to: Mindy Goldman, Donor and
Clinical Services, Canadian Blood Services, 1800 Alta Vista Drive,
Ottawa, ON K1G 4J5, Canada; e-mail: mindy.goldman@blood.ca
Received for publication October 9, 2018; revision received
November 22, 2018, and accepted November 22, 2018.
doi:10.1111/trf.15132
© 2019 AABB
TRANSFUSION 2019;00;1–6
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GOLDMAN ET AL.
are to 1) assess the contribution that older donors make to
the blood supply in four countries that do not have an
upper limit for blood donation and in one with an upper
age limit of 80 years; 2) evaluate deferral rates for hemoglo-
bin (Hb), vital signs, and donor history in donors in the
24- to 70-year-old age group versus older donors; and 3)
compare reaction rates in 24- to 70-year-old donors to rates
in donors aged 71 or older. Donors under age 24 were
included in the overall number of donors and donations in
each country, but were not included in comparisons of
deferral and reaction rates. Younger donors have signifi-
cantly higher vasovagal reaction rates and different deferral
patterns and comprise a highly variable proportion of each
country’s donor base.3–5 Although the choice of a cutoff age
is somewhat arbitrary, the vasovagal reaction rate decreases
substantially in donors over 23.4,5 Additionally, some of the
contributing centers have more stringent minimum esti-
mated blood volume criteria for donors under age 24, while
others do not. Comparisons are most appropriate between
age groups within a country to control for variable deferral
policies and donor reaction definitions between countries.
This analysis may assist countries reevaluating their current
donor eligibility policies with respect to donor age.
MATERIALS AND METHODS
Blood center members of BEST with no upper age limit for
donation or an upper age limit of 80 were invited to partici-
pate in the study and were asked to provide the number of
male and female allogeneic whole blood and double RBC
donors and donations for calendar year 2016 for donors
under age 24, age 24 to 70, or over age 70 (≥71 years). Data
were received from 12 BEST collaborative blood centers in
five countries. Four countries could provide national data,
including Canada (Canadian Blood Services and Héma-
Québec), Australia (Australian Red Cross Blood Service),
England and North Wales (National Health Services Blood &
Transplant), and New Zealand (New Zealand Blood Services).
Seven blood centers in the United States representing
approximately 50% of national blood collections participated
(American Red Cross, Vitalant, Bloodworks Northwest,
New York Blood Center, Carter BloodCare, University of
California–Los Angeles, and Innovative Blood Resources).
The data from the seven US centers were combined to give
the US numbers.
Participating centers also provided data on the number
of individuals deferred for low Hb, vital signs (if performed),
and other donor history criteria for 24- to 70-year-old
and older individuals. Some centers do not perform
measurement of donor vital signs, while others perform a
combination of donor blood pressure and/or pulse and/or
temperature assessment. Donor history deferrals include all
deferrals based on the donor assessment questionnaire and
may be temporary or permanent. Finally, centers provided
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the number of all vasovagal reactions and vasovagal reac-
tions with loss of consciousness (LOC) in males and females
from their donor reaction databases for 24- to 70-year-old
and older donors.
Double RBC donations were counted as the equivalent
of two whole blood donations to fully quantify their contri-
bution to the blood supply, but as one donation in compari-
sons of deferral and reaction rates. Australia and
New Zealand do not collect double RBC donations.
Statistical analysis
To determine the percentage of the blood supply contrib-
uted by older donors, the total number of blood donors and
total number of donations for each country was calculated
by adding the number of male and female allogeneic whole
blood donors and donations for calendar year 2016 for
donors under age 24, age 24 to 70, or over age 70. Addition-
ally, for the US, double RBC donations were counted as two
donations in the total number of donations. The percentage
of donors or donations made by those aged 71 and older
was calculated overall and by sex. The percentage of older
donors by age category was calculated using the number of
donors in the specific category (e.g., 71–72) in the numera-
tor and the total number of donors aged 71 or older in the
denominator.
Donors under age 24 were not included in calculations
of deferral and reaction rates. Deferral rates were calculated
at the donor/individual level with the total number of indi-
viduals aged 24 to 70 years old deferred for Hb divided by
the total number of donors aged 24 to 70 years old, and the
same done for the 71 and older age groups and other defer-
rals. Deferral rates were separated into two categories: Hb
below cutoff, and all other deferrals (donor history ques-
tionnaire, vital signs if performed, and for some centers,
inadequate veins). The statistical significance of compari-
sons in deferral rates between age groups in each country
was determined by chi-square. Odds ratios for vasovagal
reactions (all vasovagal reactions and those with LOC only)
and 95% confidence intervals (CIs) were calculated for
younger (age 24 to 70) and older donor (age 71 and older)
groups by sex, using normal approximation. Some blood
centers record all vasovagal reactions, while others record
only reactions judged to be moderate and severe. Analyses
were done using Cochran–Mantel–Haenszel test and two-
sided p values, using a significance level of p less than 0.05.
RESULTS
Table 1 summarizes the number and percentage of donors
and donations and the mean number of donations per year
by donor age (≤70 vs. ≥71) and sex. The minimum age limit
and proportion of donors under age 24 varies in different
countries. In the US centers, double RBC donations make
up 19.1% of all donations. Older donors accounted for 1.0%
 SAFETY OF DONATION, OLDER DONORS

TABLE 1. Donors, donations, and donation frequency by donor age and sex, 2016
Donors Donations Donations/donor per annum
Country Total >71 % >71 Total >71 % >71 <70 >71
United States
All donors 3,835,233 159,218 4.15 6,787,043* 379,158 5.59 1.74 2.38
Males 1,874,100 92,111 4.91 3,747,000 238,696 6.37 1.97 2.59
Females 1,961,133 67,107 3.42 3,040,043 140,462 4.62 1.53 2.09
United Kingdom
All donors 881,270 32,225 3.66 1,605,568* 70,537 4.39 1.81 2.19
Males 399,380 17,727 4.44 760,731 40,737 5.35 1.89 2.30
Females 481,890 14,498 3.01 844,837 29,800 3.53 1.74 2.06
New Zealand
All donors 71,629 748 1.04 114,779 1,749 1.52 1.59 2.34
Males 32,168 423 1.31 52,935 1,031 1.95 1.64 2.44
Females 39,461 325 0.82 61,844 718 1.16 1.56 2.21
Australia†
All donors 376,337 8,192 2.18 668,362 20,853 3.12 1.76 2.55
Males 179,886 5,051 2.81 336,800 13,319 3.95 1.85 2.64
Females 196,451 3,141 1.60 331,562 7,534 2.27 1.68 2.40
Canada
All donors 538,488 6,039 1.12 1,038,296* 16,562 1.60 1.92 2.74
Males 271,130 3,915 1.44 578,993 11,449 1.98 2.12 2.92
Females 267,358 2,124 0.79 459,303 5,113 1.11 1.71 2.41
The total columns include donors and donations from all age groups.
* 8,912,388 whole blood donations and 650,830 double RBC donations. Double RBC donations were multiplied by two in calculating donations.
United States: 5,489,377 whole blood donations and 648,833 double RBC donations. United Kingdom: 1,605,448 whole blood donations and
60 double RBC donations. Canada: 1,034,442 whole blood donations and 1,937 double RBC donations.
† Upper age limit of 80.

to 4.2% of the donor population and contributed 1.5% to
5.6% of donations in each country. In all countries, there
were more older male donors than older female donors
(total of 119,227 older male vs. 87,195 older female donors;
p < 0.0001). Male donors accounted for 45% to 50% of
donors and 46% to 56% of donations from donors below age
71 and 55% to 65% of donors and 58% to 69% of donations
from donors over 70. In all countries, male and female older
donors donated more frequently than younger donors
(p < 0.0001; Table 1).
Figure 1 illustrates the distribution of donors over age
70. Most older donors are in the 71 to 76 age categories
(United States, 69%; United Kingdom, 87%; New Zealand,
100%; Australia, 92%; Canada, 88%). The United States has
the largest proportion of donors over age 80 (United States,
12%; Canada, 3%; United Kingdom, New Zealand, and
Australia, 0%).
Figure 2 shows the deferral rates in males and females
in the over 70 versus 24- to 70-year-old age group. For
males, the deferral rate for both Hb and all other deferrals
was higher in the older donor group in all countries. Overall
deferral rates ranged from 6.3% to 13.7% in 24- to 70-year-
old males, and 9.8% to 18.4% for males over 70 (p < 0.001
for all except New Zealand, p = 0.02). For females, the Hb
deferral rate was slightly higher in older donors in the
United States, United Kingdom, and Australia, and lower in
older donors in New Zealand and Canada. For other defer-
rals, the deferral rate was higher for the older age group in

Fig. 1. Percentage of older donors (age 71 or older) by age category.

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GOLDMAN ET AL.
Fig. 2. Deferral rates for Hb and all other deferrals, 24- to 70-year-olds and ≥71 year old male donors (A and B) and female donors (C and D).
the United Kingdom and Canada. Therefore, overall deferral
rates were very similar in each country for younger and
older female donors, ranging from 9.5% to 17% in 24- to
70-year-old females, and 9.2% to 21.0% for females over
70 (p < 0.05 for the United States, United Kingdom, and
Canada, and >0.8 for New Zealand and Australia).
The odds ratios (and 95% CIs) of all vasovagal reactions
recorded in the centers’ databases, as well as vasovagal reac-
tions with LOC are shown in Fig. 3A (males) and Fig. 3B
(females). For all countries except New Zealand, vasovagal
reactions and vasovagal reactions with LOC were less com-
mon in older compared to younger males. The number of
vasovagal reactions with LOC was very small in
New Zealand, making the CI extremely broad and analysis
difficult. Vasovagal reactions in females were lower in older
compared to 24- to 70- year old donors (Fig. 3B). However,
for vasovagal reactions with LOC, in most countries the 95%
CI crosses 1, demonstrating that these reactions were just as
frequent in female donors in the two age categories. Because
the number of vasovagal reactions with LOC is small, confi-
dence intervals are large, particularly for New Zealand, where
the total number of donations made by older female donors
is also small (two vasovagal reactions with LOC out of
718 donations from females over age 70).
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DISCUSSION
Establishing blood center criteria to ensure donor safety is
not an exact science. Often, criteria are based on “common
sense” or experience, rather than on evidence. As blood
centers became more regulated over time, these practices
have been codified in professional standards and regula-
tions, making it impossible to accumulate any further infor-
mation about safety in these ineligible donor groups. Using
data from 12 blood centers across five different countries,
our study shows that healthy older individuals can continue
to safely donate and make a significant contribution to the
blood supply. Hence, in the current context, exclusion solely
based on older age appears to be unnecessary. Although
health concerns more common in older people will render
some older donors ineligible for donation, our study sug-
gests that the combination of other donor selection criteria
and the donors’ own assessment of suitability largely
excludes donors at risk for an adverse reaction.
A previous study performed by the BEST Collaborative
donor group demonstrated variable lower and upper limits
for donation for first-time and repeat donors in different
countries.3 The US Food and Drug Administration does not
specify an upper age limit for blood donation. Historically,

Fig. 3. Odds ratio and 95% CI of the comparison between donors
≥71 years and 24 to 70 years for reported vasovagal reactions with
LOC and all vasovagal reactions in males (A) and females (B).
A ratio <1 indicates a higher reaction rate in younger donors,
while a ratio >1 indicates a higher reaction rate in older donors.
US blood centers have considerable experience with older
donors who often had multiple comorbidities due to large
autologous donation programs operating through the 1980s
and 1990s.6 Most US blood centers therefore removed their
individual upper age limits for volunteer allogeneic donors’
decades ago. The Council of Europe does not specify an
upper age limit, but the 19th edition of the European Direc-
torate Guide to the preparation, use, and quality assurance
of blood components specifies that donation by first-time
donors over age 60 and repeat donors over age 65 is at the
discretion of the responsible physician.7 Individual coun-
tries may also have their own regulatory requirements; this
was the case in Canada until 2004.8
Many countries are experiencing aging of both their gen-
eral population and their donor population, with a large
cohort of late-middle-aged Baby Boomers entering their
70s.3,9–12 Indiscriminately deferring these donors as they hit
an upper age limit, even if they meet all other donor criteria,
may result in the loss of many dedicated, safe donors. In an
era when information on donor criteria is available on most
blood centers’ Web sites, and donors may spend consider-
able periods of time in other countries with different criteria,
an upper age limit may also generate complaints of age dis-
crimination. This was the case in Canada before 2004, when
many “snowbirds” successfully donated blood during their
winter stay in the United States but were deferred due to an
upper age limit when they returned home.
SAFETY OF DONATION, OLDER DONORS
Older donors make up from 1% to 4% of the donor
base, donate more frequently than younger donors, and are
more likely to be male. Most are between 71 and 76 years
old. The larger proportion of American donors over age
80 is likely due to absence of an upper age limit to donation
for a longer time period in the United States, compared to
Canada and the United Kingdom, while Australia does not
accept donors over age 80.
Older males are more likely to be deferred than youn-
ger ones. Higher Hb deferrals may in part be related to the
decline in normal Hb levels with age.13 Because they donate
more frequently or develop chronic health conditions, older
males may also be more likely to become iron deficient.
The difference in overall deferral rates is minimal between
older and younger females. Hb deferral rates are similar or
slightly higher or lower in older compared to younger
females in different countries. This is likely due to higher
levels of iron deficiency anemia in premenopausal
women.14 Depending on the country, deferral rates based
on vital signs and the donor health questionnaire are stable
or increased to some extent in older donors; this may in
part reflect different eligibility criteria for health conditions,
such as cardiac disease or a history of cancer, that are more
common in the older donor population. Despite these small
differences, most donor presentations from older donors
result in a successful donation.
Finally, and most importantly, donation appears to be
safe in older donors. The odds ratios for both all recorded
vasovagal reactions, and vasovagal reactions with LOC are
lower (all vasovagal reactions in males and females, vasova-
gal reactions with LOC reactions in males) or similar (LOC
reactions in females) in older donors, compared to 24- to
70-year-old donors. These results are concordant with stud-
ies performed by blood centers in Germany, Canada, and
the United States on the safety of blood donation in older
donors.4,5,8,15–17 Although it is possible that there are other
physiologic effects of donation that have a greater impact in
older adults, individuals who continue to donate into their
70s likely tolerate donation particularly well.
Our study has several strengths. Results include over
488,000 donations from over 200,000 older donors and are
consistent across five different countries that all have
slightly different donor clinic procedures and eligibility cri-
teria. This provides increased assurance of the safety of
donation in older individuals. Our study also has some limi-
tations. As each blood center uses different definitions and
reporting practices, reported reaction rates may include all
or a subset of vasovagal reactions. We do not have sufficient
information about donor base composition, eligibility cri-
teria, or adverse donor reaction reporting in each country to
compare rates between countries. However, the same con-
ditions apply to both younger and older donor groups in
each country such that they are comparable within a given
country. For some countries, such as New Zealand, the
number of donations made by donors over age 70 was low,
TRANSFUSION 5
GOLDMAN ET AL.
so that for rare events, such as vasovagal reactions with
LOC, CIs for rates were large. We did not distinguish
between first-time and repeat donors, in part because in the
United States, first-time donors at a given blood center may
have simply relocated from another jurisdiction and not
truly be donating for the first time. In all countries, it is
likely that very few donors over age 70 are donating for the
first time; therefore, conclusions about safety apply primar-
ily to repeat donors. Older individuals who can continue
donating are obviously a small, healthy subset of the overall
population of older individuals. However, there is nothing
in these data to suggest that a first donation cannot be
made safely after the age of 70.
In conclusion, this large, multinational study suggests
that healthy older individuals can continue to safely donate
and make a significant contribution to the blood supply.
ACKNOWLEDGMENTS
The Biomedical Excellence for Safer Transfusion Collaborative
investigators, in addition to the study authors, are as follows: Peter
Flanagan, New Zealand Blood Services, Auckland, New Zealand;
Barbara Bell, Australian Red Cross Blood Service, Sydney, Australia;
James P. AuBuchon, BloodWorks Northwest, Seattle, Washington;
Jed Gorlin, Innovative Blood Resources, Minneapolis, Minnesota;
Merlyn Sayers, Carter BloodCare, Bedford, Texas; Beth Shaz,
New York Blood Center, New York, New York; Alyssa Ziman, Univer-
sity of California, Los Angeles, California;
We also acknowledge Samra Uzicanin and Jennifer Joly, from
Canadian Blood Services, for data analysis and secretarial assis-
tance, respectively.
CONFLICT OF INTEREST
The authors have disclosed no conflicts of interest.
REFERENCES
1. Goldman M, O’Brien SF. Our older population: donors as well
as recipients? ISBT Sci Ser 2017;12:404.
2. Fan W, Yi Q-L, Xi G, et al. The impact of increasing the upper
age limit of donation on the eligible blood donor population in
Canada. Transfus Med 2012;22:395-403.
6 TRANSFUSION
3. Goldman M, Steele WR, Di Angelantonio E, et al. Comparison
of donor and general population demographics over time: a
BEST Collaborative group study. Transfusion 2017;57:2469-76.
4. Eder AF, Dy BA, Kennedy JM, et al. The American Red Cross
donor hemovigilance program: complications of blood dona-
tion reported in 2006. Transfusion 2008;48:1809-19.
5. Wiltbank TB, Giordano GF, Kamel H, et al. Faint and pre-faint
reactions in whole-blood donors: an analysis of predonation
measurements and their predictive value. Transfusion 2008;48:
1799-808.
6. Mann M, Goldfinger D. Safety of autologous blood donation
prior to elective surgery for a variety of potentially “high risk”
patients. Transfusion 1983;23:229-32.
7. European Committee on Blood Transfusion. Guide to the
preparation, use and quality assurance of blood components.
19th ed. Strasbourg: Council of Europe; 2017.
8. Goldman M, Fournier E, Cameron-Choi K, et al. Effect of
changing the age criteria for blood donors. Vox Sang 2007;92:
368-72.
9. Greinacher A, Weitmann K, Lebsa A, et al. A population-based
longitudinal study on the implications of demographics on
future blood supply. Transfusion 2012;56:2986-94.
10. Sayer M, Centilli J. The aging of the donor base. Transfusion
2012;52:2717-22.
11. Lattimore S, Wickenden C, Brailsford SR. Blood donors in
England and North Wales: demography and patterns of dona-
tion. Transfusion 2015;55:91-9.
12. Zou S, Musavi F, Notari EP, et al. Changing age distribution of
the blood donor population in the United States. Transfusion
2008;45:251-7.
13. Beutler E, Waalen J. The definition of anemia: what is the lower
limit of normal of the blood hemoglobin concentration? Blood
2006;107:1747-50.
14. Rigas AS, Sorensen CJ, Pedersen OB, et al. Predictors of iron
levels in 14,737 Danish blood donors: results from the Danish
Blood Donor Study. Transfusion 2014;54:789-96.
15. Müller-Steinhardt M, Müller-Kuller T, Weib C, et al. Safety and
frequency of whole blood donations from elderly donors.
Vox Sang 2012;102:134-9.
16. Zeiler T, Lander-Kox J, Alt T. Blood donation by elderly repeat
blood donors. Transfus Med Hemother 2014;41:242-50.
17. Zeiler T, Lander-Kox J, Eichler T, et al. The safety of blood
donation by elderly blood donors. Vox Sang 2011;101:
313-31.