Convenience, the bane of our existence, and other barriers to donating

BACKGROUND: To prevent donor loss and improve retention, it is important to understand the major deterrents to blood donation and to identify factors that can be effectively addressed by blood centers. STUDY DESIGN AND METHODS: A 30-item self-administered questionnaire was completed in 2003 by 1705 first-time and 2437 repeat US donors who had not donated in 2 to 3 years. Asian, Hispanic, black, and white first-time and repeat donors rated the importance of deterrents to donation in their decision to not return with a 1 to 5 scale. Categorical analysis of variance methods were used to compare the importance of deterrents between first-time and repeat donors of different race or ethnicity. RESULTS: Not having a convenient place to donate was most commonly cited as an important or very important reason for not returning by 32 to 42 percent of first-time and 26 to 43 percent of repeat respondents. Although bad treatment and poor staff skills were less of a barrier than convenience, they were more important for minority donors. Other factors such as physical side effects, foreign travel, or length of the process appeared less important. CONCLUSION: Inconvenience is a major barrier to donating, suggesting that mobile collections and increased hours of operation might help recapture lapsed donors. The finding that lapsed minority donors were more likely to give bad treatment and poor staff skills as important reasons to not donate is disconcerting in light of the changing donor demographics and increased efforts to recruit these donors.     

Quantifying losses to the donated blood supply due to donor deferral and miscollection

BACKGROUND: Donors are deferred for multiple reasons. Losses related to disease marker rates are well established. Donor and donation losses for other reasons, however, have not been extensively quantified. STUDY DESIGN AND METHODS: To quantify these losses, three data sets from the Blood Centers of the Pacific were combined, permitting detailed analysis of year 2000 allogeneic whole-blood donations. RESULTS: During 2000, 13.6 percent of 116,165 persons who presented for donation were deferred at presentation. Short-term deferral accounted for 68.5 percent (hematocrit was most common at 60%); long-term deferral accounted for 21 percent (travel to a malarial area and tattoo or other nonintravenous drug use needle exposure were most common at 59 and 29%, respectively); and multiple-year or permanent deferral accounted for 10.5 percent (UK travel [variant Creutzfeldt-Jakob disease] risk and emigration from a malarial area were most common at 38 and 11%, respectively). Disease-marker-reactive donations represented 0.9 percent of donor outcomes. The prevalence of deferral and also miscollection (under- and overweight units) varied by age, sex, and first-time versus repeat donor status. Overall, miscollection led to a loss of 3.8 percent of 100,141 collections, ranging from 1.9 percent in repeat male donors 40 to 54 years of age to 10.7 percent in first-time female donors 16 to 24 years of age. CONCLUSION: Loss of units from both first-time and repeat donors due to temporary deferral and loss of units from miscollection are more common events than losses due to disease marker testing. Some of these losses may be avoidable and could increase the blood supply without having to recruit new donors.     

Lapsed donors: an untapped resource

BACKGROUND: There is a clear need for methods to recruit and retain donors without compromising blood safety. Although prior studies report lower viral prevalence rates in repeat donors than those in first-time donors, it is unknown if this relationship holds after a lapse of several years between donations. STUDY DESIGN AND METHODS: A total of 6.4 million allogeneic donations collected at five US blood centers from 1991 through 1998 were classified by donation history (first-time vs. repeat) and by length of time between donations (lapsed interval length). The prevalence of HCV, HIV, and HBsAg was compared by donation history and lapsed interval length. The relationship between lapsed interval length and donor demographics was explored. RESULTS: Repeat donors who delayed their return for over 5 years were significantly less likely to test positive for a viral infection than were first-time donors. The likelihood of a positive test result appeared to increase steadily with lapsed interval length for HCV and HBsAg, but not for HIV. Younger, less educated, and nonwhite donors were less likely to return than others. CONCLUSIONS: Recruitment of donors who have not returned for several years could be an effective way to increase the blood supply while preserving blood safety. Understanding the relationship of donor demographics to return behavior is important for recruitment efforts.     

Blood donor satisfaction and intention of future donation

BACKGROUND: New regulatory requirements for donor eligibility challenge blood centers to recruit and retain enough donors. This study evaluated correlations between overall satisfaction with the donation process and donor demographics and the effect of both on a donor's intent to return. STUDY DESIGN AND METHODS: An anonymous, self-administered questionnaire was given to donors at multiple sites of one blood center over a 3-week period. First-time and repeat donors were asked questions on demographic characteristics, satisfaction with the current donation process, motivation for current and future donations, and intent to return. RESULTS: More than 75 percent of donors rated the overall donation process at 9 or 10 on a scale of 10 (mean, 9.19; standard deviation, 1.09), with female, high school-educated, and first-time donors giving higher satisfaction ratings than male, college-educated, and repeat donors, respectively (all p < 0.001). Donor satisfaction was correlated with intent to return for another donation (p = 0.002). For the current donation, donors rated altruistic motivations most highly. Medical testing was the most highly rated incentive for future donations, followed by frequent donor programs and convenient donation times and locations; preferences varied by demographic subgroup. CONCLUSIONS: Blood donor satisfaction varies among demographic and donation history subgroups and is positively correlated with the intent to return for future donation. Although the primary motivation among all donors was altruism, incentives to future donation may need to be tailored according to demographic subgroups.     

Promotion of high school blood donations: testing the efficacy of a videotaped intervention

"Life to Life," an 11-minute videotape based on social learning principles, was used by 10 blood centers in presentations to 4970 high school students one week before school blood drives. At each school, some students saw the videotape and others attended a blood center's customary presentation. Students also completed a brief questionnaire assessing donation attitudes, donation history, and intent to donate. The videotape accounted for a relative increase of 18.7 percent in donations even when other factors were not controlled for. Results were analyzed with logistic models and showed a consistently positive effect over all models used. For students who had never donated, the estimated odds ratio for actual donation (videotape:control) was 1.528. When the model included both type of presentation and ethnicity, the relative increase in donation over that after the blood centers' usual presentation was 69.8 percent for first-time donors. Among previous donors considered alone, the effect on donation was not significant. Whatever their donor history, students who viewed the videotape showed significantly more positive attitudes toward donation and had greater intention to donate than students who saw the blood centers' standard presentations. These results suggest that this videotape is a useful tool for recruitment of high school blood donors.     

Increasing blood availability by changing donation patterns

BACKGROUND: There is a declining margin between US blood collections and transfusions. Donation patterns were examined to characterize returning first-time donors and predict the impact on blood availability of decreasing the number of nonreturning donors. STUDY DESIGN AND METHODS: First-time donors giving between 1991 and 1994 were followed for 3 to 6 years. The impact of decreasing the number of nonreturning donors in a 12-month period was projected using the Poisson distribution to model the donation patterns of 539,063 donors who gave in 1995. Repeat donors were classified as "returning first-time" (gave a first-time donation within 12 months of their index donation), "established" (gave a repeat donation), and "inactive" (didn't donate in the 12 months before their index donation). RESULTS: A total of 49 percent of first-time donors did not return within 6 years. Returning first-time donors tended to be US born, white, and had more than a high school education. In 1995, 30 percent of donors were first time, 31 percent were established, 7 percent were returning first time, and 32 percent were inactive, giving 1.5, 2.4, 1.9, and 1.7 donations in 12 months, respectively. Reducing nonreturning donors by 5 percent could increase blood collections by 2.7 percent. Similarly, 15 or 25 percent reductions in nonreturns could increase collections by 8.6 or 16.0 percent, respectively. CONCLUSIONS: Most donors are not giving near the donation limit. A substantial increase in donations could be achieved by a relatively small decrease in donor nonreturn. Research is needed to understand why approximately half of first-time donors donate only once.     

影响公民自愿无偿献血的因素调查分析

目的了解影响公民无偿献血的各种因素以及公民决定献血的重点因素,以制定有针对性的招募策略。方法依照知、信、行(KAP)理论设计调查表,对成都市2385名献血与未献血的公民做现场问卷调查,通过对其无偿献血的知识、态度、行为的研究来做相关分析。结果①对无偿献血的认知:成都地区公民对我国实行无偿献血制度的知晓率较高(87.5%),但对无偿献血常识和危险行为方式总的知晓率较低(分别为29.4%、32.5%),其中献血者(1349名)对无偿献血常识和危险行为方式总的知晓率(分别为33.4%、38.1%)均高于未献血者(1036名)(分别为24.2%、25.1%)(P<0.05);文化程度越低,对献血常识和危险行为的知晓率越低,职业分布以医生的知晓率最高,农民的最低。②了解渠道:献血者通过人际传播的渠道了解的比例高于未献血者(P<0.05)。③献血动机:未献血者、初次献血者和重复献血者愿意献血的主要原因是“献爱心”,但献血动机比较多样,街头献血的行为受各种环境因素的影响;“人道主义”、“同伴招募”和“健康检查”是促使公民初次献血的因素,而影响初次献血的重点因素是“便利和勇气”;再次献血的公民主要是“献爱心、没什么特别原因和享受用血优惠”。④关注信息:未献血者如果打算献血,最希望了解的依次为“献血后是否影响身体”、“是否会感染疾病”、“血液相关知识”、“相关疾病知识”、“献血后优惠”、“献血时间地点”和“其他“。⑤对待献血的态度和行为:认为献血不影响身体的公民占73.5%,献血者(76.3%)的比例高于未献血者(70%)(P<0.05);献血者愿意继续献血的占93.3%,重复献血者(97.1%)高于初次献血者(91.1%)(P<0.05);77.3%的献血者表示“如有危险行为时选择放弃献血”。结论动机、认知、态度、个性及职业与文化程度等自身因素,献血法律法规、献血宣传方式、献血服务过程等环境因素亦都会影响公民献血。献血者招募的策略,首先应研究不同人群对献血不同的需求,采取针对性的措施,促使公民献血;其次,应为献血者提供安全、舒适和方便的服务。     

Prevalence of transfusion-transmissible viral infections in first-time US blood donors by donation site

BACKGROUND: Understanding the donor base, infectious disease prevalence, and donation loss at various blood donation sites will help maximize blood collection efforts and blood availability. STUDY DESIGN AND METHODS: Using donation data collected at five US blood centers, the prevalence of HIV, HTLV, HBsAg, and HCV in first-time whole-blood donations at 10 donation sites was evaluated: military, education, religious, professional, industry, services, community, health care, government, and fixed sites. Donation loss from screening test reactivity at each donation site was also evaluated. RESULTS: During the study, 1.2 million first-time whole-blood donations were collected. Military and education sites had a low prevalence of all viral markers, except for HBsAg, which was highest at education sites. Variations in viral marker prevalence among donation sites were partially explained by donor demographic differences. Donation loss varied by donation site, ranging from 3.3 percent at education sites to 6.4 percent at industry sites, indicating differential efficiency of blood collection efforts. CONCLUSION: Different rates of positive viral test results and donation loss in first-time whole-blood donors were observed at various types of donation sites. This information may be useful in estimating the yield of usable units from specific blood drives and in allocating resources to meet blood center collection goals.     

Mailing of a sickle cell disease educational packet increases blood donors within an African American community

BACKGROUND: Low blood donor rates among African American persons are recognized; however, few strategies exist to increase these numbers. STUDY DESIGN AND METHODS: A 1-year, prospective, ecologic study performed before and after an educational intervention designed to test the hypothesis that increased education about the importance of blood donation for children with sickle cell disease (SCD) would result in an increase in total blood donors among African American persons. RESULTS: Approximately 5000 videos were mailed to 50 percent of the households in a zip code where 98 percent of the residents are African American. In the first 6-month interval after mailing the video packet, there was a 75 percent (217 vs. 124; p = 0.05) increase in the total number of presenting donors and a 64 percent (126 vs. 77; p = 0.02) increase in the total number of first-time donors from the same 6-month period in the previous year. During the second 6-month interval, the total number of first-time donors declined. No significant increase in donor activity was noted during the two 6-month periods after the intervention in the surrounding zip codes. CONCLUSION: A mass mailing directed toward educating African American persons about the importance of blood donation for children with SCD may increase the number of total African American donors.     

Donation reactions among autologous donors

Studies of risk factors associated with reactions among autologous blood donors have been limited. Therefore, 2091 autologous and 4737 homologous donations were examined. Donors at greatest risk for reaction were autologous donors who had reactions at first donation; among 45 who made repeat donations for the same surgery, 17 (38%) had repeat reactions. The group least likely to experience reactions were the autologous donors greater than or equal to 66 years old; they experienced a 1.9 greater than or equal to percent (6/310) incidence of reactions. More reactions were seen in both autologous and homologous donors in the categories of first-time donor, female gender, decreasing age, and lower weight. Multiple logistic regression analysis showed that all of these variables were independent predictors of donor reaction, with first-time donation (odds ratio, 2.4) and female gender (odds ratio, 1.9) being the strongest predictors of reaction. Donor room personnel should be alerted that autologous donors who react at first donation are very likely to react at subsequent donations. Contrary to common concern, elderly autologous donors are least likely to have reactions.     

Vasovagal reaction rates and body weight: findings in high- and low-risk populations

BACKGROUND: The effect of weight on vasovagal reaction rates has not been evaluated in high- and low-risk populations or in first-time versus repeat blood donors. In addition, vasovagal reaction rates and weight have not been evaluated based on solicited information. STUDY DESIGN AND METHODS: A total of 1073 Caucasian high school students from randomly selected whole-blood drives in 2001 and 949 randomly selected Caucasian donors from the general donor population in 2001 and 2002 were subdivided into weight groups and evaluated for vasovagal reaction rates. RESULTS: The high school population had a much higher vasovagal reaction rate than the general donor population (8.0 vs. 2.6%). The vasovagal reaction rate was inversely proportional to body weight in first-time blood donors in both populations, but the trend was not as well defined in repeat blood donors. Solicitation of information from the general donor population increased the vasovagal reaction detection rate by 2.5 times (from 2.6% to 6.5%), and it is suggested that the vasovagal reaction rate might be as high as 27 percent in first-time general donors who weighed between 110 and 139 pounds. CONCLUSION: Body weight is a very important determinant of vasovagal reaction rates in first-time donors, but previous successful blood donation appears to mitigate the effect of body weight on vasovagal reaction rates. Solicitation of information from blood donors increases the number of vasovagal reactions detected and enhances the data.     

Donor retention as a function of donor reactions to whole-blood and automated double red cell collections

BACKGROUND: Although reactions to whole-blood (WB) donation are known to decrease donor retention, potential effects of reactions to automated double red cell (2RBC) donation upon retention have not been investigated. STUDY DESIGN AND METHODS: The authors investigated effects of donor status (first-time, experienced) and reactions (absent, present) upon retention of all male allogeneic WB and 2RBC donors (n = 45,296) donating within the American Red Cross Central Ohio Region during a 12-month period. Donor age, race, and status (first-time, experienced); phlebotomist's reaction rating; and phlebotomy procedure (WB, 2RBC) were collected for the initial donation by each donor. Dates of any donation attempts in the 12 months starting from the donor's first eligible date after the initial donation were also collected. RESULTS: On average, WB donors were less likely to react and more likely to donate again and returned more quickly to donate than 2RBC donors, even after accounting for differential delays in eligibility. Reactions decreased the likelihood of repeat donation among all first-time donors regardless of initial phlebotomy procedure. Among experienced donors, however, reactions depressed retention of WB donors by 27.6 percent, whereas reactions lowered retention of 2RBC donors by just 3.6 percent. CONCLUSION: Although 2RBC donors were more likely to react, first-time 2RBC donors were no more affected by reactions than first-time WB donors. Experienced WB donors suffered a larger drop in retention as a function of reactions, in fact, than did experienced donors who gave 2RBC donations. Potential reasons for this data pattern require further investigation.     

Retention of "safe" blood donors. The Retrovirus Epidemiology Donor Study

BACKGROUND: There are obvious advantages to increasing donor retention. However, for reasons of blood safety, certain donors may, in fact, be more desirable to retain than others. “Safe” donors are defined as those who provided a blood donation that was negative on all laboratory screening tests and who subsequently reported no behavioral risks in response to an anonymous survey. This study identifies the most important factors affecting the intention of “safe” donors to provide another donation. STUDY DESIGN AND METHODS: An anonymous survey asking about donation history, sexual history, injecting drug use, and recent donation experience was mailed to 50,162 randomly selected allogeneic donors (including directed donors) who gave blood from April through July or from October through December 1993 at one of the five United States blood centers participating in the Retrovirus Epidemiology Donor Study. Before mailing, questionnaires were coded to designate donors with nonreactive laboratory screening tests at their most recent donation. RESULTS: A total of 34,726 donors (69%) responded, with substantially higher response among repeat donors. According to reported intentions only, the vast majority of “safe” donors indicated a high likelihood of donating again within the next 12 months. Only 3.4 percent reported a low likelihood of donating again. A comparison of those likely to return and those unlikely to return reveals significant differences in demographics and in ratings of the donation experience. A higher proportion of those unlikely to return were first-time donors, minority-group donors, and donors with less education. The highest projected loss among “safe” donors was seen for those who gave a fair to poor assessment of their treatment by blood center staff or of their physical well-being during or after donating. CONCLUSION: These data suggest that efforts to improve donors' perceptions of their donation experience, as well as attention to the physical effects of blood donation, may aid in the retention of both repeat and first-time donors.     

Multicenter comparison of serologic assays and estimation of human herpesvirus 8 seroprevalence among US blood donors

BACKGROUND: As part of assessing the possibility of transfusion transmission of human herpesvirus 8 (HHV-8 or Kaposi's sarcoma-associated herpesvirus), HHV-8 seroprevalence was estimated among US blood donors, the performance of HHV-8 serologic tests was compared, and the presence of HHV-8 DNA was tested for in donated blood. STUDY DESIGN AND METHODS: Replicate panels of 1040 plasma specimens prepared from 1000 US blood donors (collected in 1994 and 1995) and 21 Kaposi's sarcoma patients were tested for antibodies to HHV-8 in six laboratories. HHV-8 PCR was performed on blood samples from 138 donors, including all 33 who tested seropositive in at least two laboratories and 22 who tested positive in at least one. RESULTS: The estimated HHV-8 seroprevalence among US blood donors was 3.5 percent (95% CI, 1.2%-9.8%) by a conditional dependence latent-class model, 3.0 percent (95% CI, 2.0%-4.6%) by a conditional independence latent-class model, and 3.3 percent (95% CI, 2.3%-4.6%) by use of a consensus-derived gold standard (specimens positive in two or more laboratories); the conditional dependence model best fit the data. In this model, laboratory specificities ranged from 96.6 to 100 percent. Sensitivities ranged widely, but with overlapping 95 percent CIs. HHV-8 DNA was detected in blood from none of 138 donors evaluated. CONCLUSIONS: Medical and behavioral screening does not eliminate HHV-8-seropositive persons from the US blood donor pool, but no viral DNA was found in donor blood. Further studies of much larger numbers of seropositive individuals will be required to more completely assess the rate of viremia and possibility of HHV-8 transfusion transmission. Current data do not indicate a need to screen US blood donors for HHV-8.     

Changing age distribution of the blood donor population in the United States

BACKGROUND: The American Red Cross has been maintaining a research database of all blood donors. Such a database provides a unique opportunity for monitoring changes over time in donor and donation patterns. STUDY DESIGN AND METHODS: Changes in age distribution among blood donors were analyzed through comparison of the volunteer donor population in 1996, 1999, 2002, and 2005, before and after adjustment for demographic changes of the general population in the United States. RESULTS: Donations by repeat donors 50 years or older as a proportion of total donations increased from 22.1 percent in 1996 to 34.5 percent in 2005, or 1.4 percent per year, whereas donations from repeat donors of 25 to 49 years decreased from 49.1 percent in 1996 to 37.1 percent in 2005, or 1.3 percent per year. After adjusting for general population trends, the effective number of donors decreased by more than 10 percent in female and male repeat donors of age 20 to 49 years and male first-time donors of age 25 to 49 years from 1996 to 2005; female and male repeat donors of age 25 to 39 years decreased by greater than 40 percent. Prevalence rates of major infectious disease markers decreased by 3.3 percent or more per year for first-time donations and by 6.4 percent or more per year for repeat donations. CONCLUSION: The aging patterns of blood donors suggest the need for improved recruitment and retention in the young adult and middle-aged groups. A severe shortage of blood and blood components may be forecast in the foreseeable future unless offset by significant increased supply or reduced usage of blood and blood components.     

A case-controlled multicenter study of vasovagal reactions in blood donors: influence of sex, age, donation status, weight, blood pressure, and pulse

BACKGROUND: Vasovagal reactions occur in a small, but significant number of blood donors. These reactions may decrease return donation and disrupt blood collection activities. The purpose of this study was to define the contributory role of sex, age, weight, blood pressure, and pulse in vasovagal reactions with syncope in blood donors. STUDY DESIGN AND METHODS: A retrospective case-control study involved 1890 blood donors with syncope from three large United States blood centers during 1994 and 1995. Case controls and random population controls were used in a logistic regression analysis to determine the significance of individual variables to syncopal reactions. RESULTS: Female donors, young donors, first-time donors, low-weight donors, and donors with low predonation blood pressure had higher absolute donation reaction rates than other donors. When each variable was adjusted for other variables by regression analysis, age, weight, and donation status (first-time or repeat donor) were significant (p<0.0001), and sex, predonation blood pressure, and predonation pulse were not. The most important variables, in descending order, were age, weight, and donation status (first-time or repeat donor). CONCLUSIONS: Donation-related vasovagal syncopal reactions are a multifactorial process determined largely by age, weight, and first-time donor status.     

Safety of blood donations following a natural disaster

To evaluate the relative safety of blood donations given in response to a major disaster, donor demographics and infectious disease test results were compared for donations made during the 10 days following the October 17, 1989, San Francisco Bay Area earthquake and those made during the preceding 6 months. These comparisons were made for donations given to the regional blood center in the area that was immediately affected by the disaster (Irwin Memorial Blood Centers) and for those given in an unaffected region (Los Angeles/Orange Counties Region, American Red Cross Blood Services). The rate of donation increased more than 200 percent during the 5 days following the earthquake in both the disaster-affected and unaffected regions. Both the disaster-affected and unaffected regions observed significant increases in the proportions of donations by first-time donors, by persons aged 20 to 39 years, and by women. The rates of confirmed positivity for infectious disease markers for post-earthquake donations did not differ significantly from rates for homologous donations given during the preceding 6 months, particularly when the rates were adjusted for the increased representation of first-time donors. Approximately 39 percent of post-earthquake first-time donors gave blood again within the following 6-month period. It is concluded that donations given after major disasters are essentially as safe as routine donations and that active efforts to recruit these donors again can be undertaken without reservation.     

Decreasing seroprevalence of human immunodeficiency virus type 1 in a regional blood donor population

Blood banks have intensified their efforts to discourage donations from individuals at risk for the human immunodeficiency virus (HIV-1). Since the onset of HIV-1 donor screening in April 1985, a marked reduction in seroprevalence has been seen at the authors' institutions: from 51 cases per 100,000 donors in 1985 to 13 per 100,000 in the first 6 months of 1988. Data from 3.5 years have been analyzed for temporal trends in the association of HIV-1 seroprevalence with donation site (urban vs. non-urban) and donor gender. The association of HIV-1 seropositivity with an urban donation site decreased through 1987 as the urban-to-nonurban donation odds ratio declined from 6.48 in 1985 to 2.54 in 1987. Despite this decrease, both men and women who donated in urban areas had a significantly higher seroprevalence than those in nonurban areas. Male donors had a higher overall HIV-1 seroprevalence than female donors. However, the male-to-female odds ratio declined from 2.94 in 1985 to 1.96 in 1988, and male gender was no longer significantly associated with HIV-1 seropositivity. This change in the donor profile appears to reflect declining numbers of seropositive men who acknowledge risk factors and greater numbers of women with no identified risks for HIV-1. This study documents a dramatic decrease in HIV-1-seropositive donors and suggests that the deferral of high-risk individuals has become increasingly successful.     

Who donates blood at five ethnically and geographically diverse blood centers in China in 2008

BACKGROUND: In China recruitment and retention of sufficient numbers of safe blood donors continues to be a challenge. Understanding who donates blood, particularly those who donate larger (>200 mL) whole blood (WB) units, will help blood centers to target more effective recruitment and retention strategies. STUDY DESIGN AND METHODS: Demographic characteristics of 226,489 allogeneic WB donors from January to December 2008 at five geographically and ethnically diverse, urban blood centers were analyzed. RESULTS: The typical Chinese WB donor can be characterized as first‐time volunteer (67.9%), male (56.9%), less than 45 years old (93.8%), and Han ethnicity (86.1%). Most donors had some college or below educational level (77.5%), donated at a mobile collection site (97.6%), and donated 300‐ or 400‐mL units (76.0%). Differences in WB volume donations and donor demographics exist among the five centers. CONCLUSION: In China compared to the United States, donations are made by younger donors and donors give infrequently and make smaller WB donations. To help ensure supply adequacy, continued efforts are needed to have donors give larger volumes of WB in China.