Requests for “unvaccinated” blood lead to delays and patient harm

Directed donation emerged from fear-driven safety concerns

Blood transfusion has been a fundamental part of modern medical practice. Its safe and effective use relies on a system of anonymous, voluntary blood donation, driven by altruism and community spirit. This model is supported by rigorous donor screening, infectious disease testing, and strict quality control measures.

Another approach is directed donation, in which a specific donor provides blood for a designated recipient. This is typically reserved for rare situations, such as when a patient has an uncommon blood type and no compatible donors are available within the community. However, directed donation has also been used under other circumstances, for example, during the early days of the human immunodeficiency virus (HIV) epidemic, when fears of infection from unknown donors led to a surge in such requests.

In response, screening protocols were strengthened, and nucleic acid testing was introduced to improve the detection of viral infections. Today, the risk of transfusion-associated infection for major viruses is estimated to be less than 1 in 1 million units.

Recent trend targets “vaccinated” blood

The coronavirus disease 2019 (COVID-19) pandemic has led to a resurgence of this practice, driven by the misconception that blood from vaccinated donors may be unsafe.

Regulators and professional organizations have strongly opposed such requests, noting that blood centers do not record COVID-19 vaccination status. Moreover, available evidence supports the safety of blood from vaccinated donors.

Despite this, some patients remain convinced and continue to request directed donations from unvaccinated donors.

Real-world case series

The current study examines the real-world consequences of acting on such requests outside standardized consultation pathways, building on prior literature that has largely addressed the issue from theoretical or ethical perspectives, with limited data on clinical outcomes.

The authors report on a two-year period at the Vanderbilt University Medical Center (VUMC) blood bank during which standard transfusions were refused because the blood was perceived to come from vaccinated donors. They assessed clinical outcomes, blood utilization, and the downstream impact on healthcare operations.

Over this period, the blood bank processed 144,856 units, of which directed donations accounted for just 0.03 % (48 units). All of these were requested due to concerns about vaccinated donors and involved 15 patients, 9 of whom were pediatric.

These cases spanned a range of clinical scenarios, including elective major surgery, critical illness, transplantation, and cancer care. Documented involvement of ethics and transfusion medicine specialists was rare, highlighting a significant gap in oversight.

Fate of directed donations

Of these patients, 13 received one or more directed donor units. Two patients, despite five RBC units being donated for them, did not undergo transfusion after the units arrived, with no documented adverse outcomes.

Overall, 31 of the 48 units were transfused to their intended recipients. Of the remaining units, most were released into the standard inventory, while three were retained in frozen storage for the intended recipient, and two expired before use and were discarded.

Adverse clinical impacts

In four cases, refusal of standard blood products by surrogates, typically parents or guardians making medical decisions on behalf of patients who are too young or unable to consent, was linked to adverse outcomes. Two children requiring cardiovascular surgery experienced delays or cancellations, while one patient developed hemodynamic shock after hemoglobin levels fell to 3.6 g/dL.

In another case, hemoglobin dropped to 5.9 g/dL due to delayed transfusion, followed by a later transfusion at 9.2 g/dL, outside institutional guidelines, to avoid wasting the directed unit.

Immediate safety concerns

Transfusion medicine specialists play a critical role in guiding safe transfusion practices, assessing infectious disease risks, and recommending evidence-based alternatives to directed donation. In this series, however, many requests bypassed these standard safety pathways. By contrast, other institutions require formal involvement of transfusion medicine experts before such requests proceed.

Most cases involved surrogate decision-making, with parents acting on behalf of children who could not provide consent.

“The safety of the blood supply is predicated on layered risk reduction in which no single layer, including testing, is assumed to be infallible.” Directed donations may carry a less favorable donor profile than community donations, as they bypass the foundational safeguard of anonymous, voluntary donation.

All transfused patients in this series received at least one unit of blood from a family member. First-time donors, who are more common in directed donation, carry a slightly higher residual risk of transfusion-transmitted infection, although the absolute risk remains very low.

In some cases, parents may unintentionally underreport behaviors that increase infection risk, based on the mistaken belief that their blood would be inherently safe for their child.

Directed donations from family members also carry a risk of transfusion-associated graft-versus-host disease (TA-GVHD), a rare but potentially fatal complication that requires irradiation of the blood product before transfusion. This adds complexity, cost, and additional processing steps that may be overlooked when requests proceed without specialist input.

Long-term issues

Directed donations can also have longer-term consequences. Recipients may develop immune sensitization to the family donor, potentially excluding that individual as a future organ or stem cell donor.

Another concern is transfusion-related acute lung injury (TRALI), a serious and potentially fatal reaction linked to maternal blood transfusion in children. This occurs when maternal antibodies, formed during pregnancy against paternal antigens, trigger an immune response in the recipient. Modern transfusion practices are designed to minimize this risk.

Third-party consequences

Unused directed units are often released into the general blood supply. However, neither the clinician nor the eventual recipient is typically aware that these units originate from donor groups with less favorable risk profiles than standard repeat volunteer donors. This effectively shifts potential risk from a consenting family to an unrelated patient, raising ethical concerns around the principle of doing no harm.

Future directions

The case series suggests that these requests were driven by concerns about the use of vaccinated blood and were associated with care delays, clinical deterioration in some cases, and inefficient resource use. In some cases, the patient deteriorated while waiting for the units to arrive.

To avoid such situations, the authors recommend establishing structured consultation workflows for all directed donation requests and replacing optional online submission pathways with a mandatory transfusion medicine consultation before blood collection proceeds. These should include bloodless medicine specialists and transfusion medicine specialists.

Institutional policies should be amended to prevent directed donations for non-safety reasons, protecting clinicians and patients alike. Moreover, they recommend developing differential pathways depending on the nature of the need.

Finally, public education is essential to correct misconceptions about transfusion safety based on COVID-19 vaccination history.

The authors note that the study is limited by its small size, the inclusion of only cases in which directed units reached the blood bank, and its observational design, which means causation cannot be definitively established.

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Journal reference:

• Jacobs, J. W., Hall, E., Tahiri, T., et al. (2026). Directed donations for unvaccinated blood: A departure from evidence-based medicine associated with clinical harm, resource waste, and oversight gaps in a two-year single-center series. Transfusion. DOI: https://doi.org/10.1111/trf.70195. https://onlinelibrary.wiley.com/doi/10.1111/trf.70195