Blood transfusions are lifesaving therapies and one of the most commonly performed medical procedures in the United States.^1,2 Despite the ubiquity of transfusions in health care in the United States, during 2008–2017, blood transfusions and collections declined substantially. This trend was attributed to several factors, including the implementation of patient blood management programs, improved clinical treatment of anemia, and the increasing frequency of minimally invasive surgery. More recent data collected between 2019 and 2021 suggested a stabilization in the national blood supply and further pointed to the need for ongoing monitoring to ensure that blood availability meets demand.³

Since 1971, efforts to measure the adequacy of the US blood supply and understand trends in blood collection and utilization have been conducted. Since 2013, the U.S. Centers for Disease Control and Prevention (CDC) and the Office of the Assistant Secretary for Health (OASH) have conducted the biennial National Blood Collection and Utilization Survey (NBCUS).^3–7 The NBCUS provides nationally representative estimates of blood collection and utilization, which help inform national blood policy, blood-related regulatory efforts, and emergency preparedness.

To understand the current dynamics of blood collection and use in the United States, 2023 data on blood and blood component collection, distribution, and transfusion were analyzed. Additional data on transfusion-transmitted infection screening marker reactivity are included.

The methods used to develop, manage, and analyze the 2023 NBCUS have been previously described.^3–7 The sampling frame consists of two portions: (1) acute care hospitals and (2) blood collection sites (community-based and within hospitals). The 2021 American Hospital Association (AHA) database was used to determine the acute care hospital survey sampling frame. The sampling frame was enhanced in July 2023 by comparing it with AHA’s monthly updates of facilities that had opened or closed since 2021. Acute care hospitals were excluded if they: (a) performed <100 inpatient surgeries annually; (b) were in a US territory or freely associated state; (c) were operated by the military or Department of Justice; or (d) were classified as a rehabilitation, long-term acute care, or a psychiatric hospital. After exclusion, 3543 hospitals were included in the sampling frame, and 2478 were chosen as part of the sample (Figure 1). Acute care hospitals were categorized based on the number of inpatient surgeries performed in 2021: 100–999, 1000–1399, 1400–2399, 2400–4999, 5000–7999, and >8000. Forty percent of hospitals performing 100–999 inpatient surgeries annually were randomly selected (n = 708/1773); 100% of hospitals performing ≥1000 inpatient surgeries annually were included.

The U.S. Food and Drug Administration’s (FDA) Blood Establishment Registration (BER) database was used to develop the sampling frame for community-based and acute care hospital blood collectors. All blood collecting centers were sent a survey. Community-based blood centers were stratified into the following categories based on the number of whole blood or red blood cell (RBC) units collected in 2021: <50,000, 50,000 to 199,999, 200,000 to 399,000, and >400,000 units.

Participating facilities were sent a REDCap (Research Electronic Data Capture, Nashville, Tennessee) survey link to confirm their contact information, which took place from October 2023 until January 2024. In March 2024, the 2023 NBCUS was launched. The survey consisted of two sections: one pertaining to blood collection and the other pertaining to transfusions.

Response rates were calculated using the American Association of Public Opinion Research (AAPOR) guidelines.⁸ All sampled facilities were asked whether they collected blood in 2023; only those that responded yes were considered eligible for the blood collection section. Similarly, facilities were asked if they transfused blood in 2023 as eligibility to respond to the blood transfusion section. Response rates were calculated for each section following AAPOR Response Rate 4 (RR4), which includes completed and partial responses in the numerator and the denominator.⁸ All eligible facilities were included, as well as an estimated number of facilities with unknown eligibility (unanswered question regarding whether they collected blood or transfused blood in 2023).

To account for survey non-responses, weighting was used and calculated as the ratio of the total number of eligible participants to the total number of respondents. Community-based blood collection centers (BCC) in the strata with 400,000 or more RBC collections were designated a non-response weight of 1.0. The Taylor Series method was used to calculate confidence intervals (CI).⁹

Multiple imputation with chained equations was used to account for missing data entries among survey respondents. A two-step imputation process was used to accommodate distributions skewed toward zero using established imputation factors from previous surveys. Imputed variables were all continuous and non-normally distributed. Multiple imputation was applied to whole blood and apheresis RBCs collected, distributed, rejected, outdated, and transfused, and to whole blood-derived and apheresis platelets, plasma, and cryoprecipitated antihemophilic factor (AHF) units distributed and transfused. Data on reactive units rejected for specific disease markers were collected for the first time for the following pathogens: human immunodeficiency virus (HIV), Human T-cell lymphotropic virus type 1 and 2 (HTLV-1/2), Treponema pallidum, Trypanosoma cruzi, West Nile virus, Babesia spp., and hepatitis B and C viruses. Those data are reported unweighted and without imputation. Whole blood-derived platelets were expressed as apheresis equivalents based on the reported pool size. In a sub-analysis, differences in the unweighted number of RBC units transfused were calculated by comparing matched data among acute care hospitals that completed both the 2021 and 2023 surveys to better understand trends.

National rates of whole blood and RBC units collected per 1000 population were calculated by dividing the total estimated number of units collected, before the removal of rejected units, by the 2023 US population aged 16–64 years. National rates of whole blood and RBC units transfused per 1000 population were calculated by dividing the total estimated number of units transfused by the entire 2023 US age-stratified population estimated from the U.S. Census Bureau.¹⁰ All analyses were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA).

This activity was reviewed by the CDC and was conducted consistent with applicable federal law and CDC policy.ⁱ

Following several years of declining national blood collection and utilization during 2008–2017, the findings from this analysis of the 2023 NBCUS suggest a continued stabilization in the blood supply, consistent with the plateau observed during the 2019 and 2021 reports.^3,7 Although RBCs and whole blood transfusions declined slightly compared with 2021, transfusions only varied from 1% to 5% during recent NBCUS cycles (2019–2023).^3,7 Coupled with the stabilization in blood collections nationally, these findings suggest a new baseline for blood availability has been established in the United States. The response rate for the 2023 NBCUS was the highest ever recorded, most notably among blood collectors in community-based and hospital-based collection centers, adding to the precision of the findings described here.

Consistent with the findings in this study, the European Blood Alliance has documented declining blood collections followed by a flattening trend.¹¹ The stabilization of the US blood supply observed here may be due to a variety of reasons. Blood collection establishments have likely reached greater sustainability, as is evidenced by less consolidation in recent years, primarily among community-based blood collectors. In 2017, there were 65 community blood collectors, followed by a decline to 53 in 2019. This number has remained constant through 2023, coinciding with the plateau in collections during that period. The impact of consolidation of blood establishments is further reflected in the proportion of blood collected by the five largest entities, which comprised 56.9% of all units collected in 2015 and increased to 66.3% in 2023.⁵ Although stable, blood collections (total available supply) have returned to pre-COVID-19 pandemic levels, and the gap between blood collection and transfusions widened, suggesting more robust elasticity in the blood supply nationally.¹²

Previous studies have suggested that future demand for RBCs may increase due to an aging population and increasing prevalence of medical conditions requiring transfusions.³ However, in keeping with findings of a 2023 European Commission report on blood safety noting declining utilization (0.6%–8.9%) among 15 countries, the present analyses observed a decline (4%) in US RBC transfusions, supporting the hypothesis of widening adoption of patient blood management and other clinical practices which lead to the conservation of blood components.¹³ Additionally, advancements in less-invasive surgical procedures and the use of pharmacologic alternatives to transfusion have likely contributed to reductions in RBC utilization. In contrast, transfusions in emergency and critical care settings increased in every NBCUS from 2017 to 2021. However, in 2023 the trend in emergency department blood use slowed. While this may reflect changes in the epidemiology of injury,^14,15 additional study is required to further understand this observation.

Efforts to improve blood safety during the last 20 years have substantially reduced the infectious disease risk to the US blood supply. Currently, platelet blood components pose the greatest risk of infection from bacteria due to their storage at room temperature. Furthermore, whole-blood-derived pooled platelets were associated with a higher risk of infectious disease transmission due to more donor exposure in a single unit.¹⁶ The findings from this analysis showed a continued shift away from whole-blood derived platelets in favor of apheresis platelets, which have historically been associated with a lower risk of viral blood-borne pathogen transmission risk.¹⁶ Additionally, blood establishments continued to implement platelet safety measures by adopting pathogen-reduction technology (PRT). In 2023, the proportion of apheresis platelets subjected to PRT increased substantially (49.2%). Though PRT does provide enhanced safety, some infectious risks persist, including spore-forming bacteria, rapidly proliferating pathogens, non-lipid enveloped viruses, and manufacturing-level contamination of blood collection kits.^17–19 While PRT has enhanced platelet safety, similar pathogen inactivation technologies are currently unavailable for RBCs and other control methods are necessary.²⁰

Variables regarding discarded units of blood due to reactive infectious disease testing by eight disease markers were newly added to the 2023 NBC US. The findings indicate that most (67%) of the reactive units were associated with hepatitis B virus or T. pallidum, which may reflect recent increases in the incidence of syphilis and previously described studies that have demonstrated that two-thirds of people living with hepatitis B virus may be unaware of their infection.^21,22 While data on specific disease markers cannot be directly compared with previous NBCUS, the number of units rejected on testing has more than doubled since 2015. This may reflect an expansion of blood donation screening to include pathogens such as Babesia spp. and highlights the effectiveness of these blood safety measures to mitigate disease transmission risk.

These findings are subject to the following limitations. Data presented here provide the only national estimates of the blood supply based on blood collected and transfused in the United States. While the NBCUS includes annual aggregate totals reported by blood establishments and healthcare facilities, these data are cross-sectional and do not provide insight into seasonal or monthly changes. Localized or contained periodic blood shortages cannot be quantified using these data. While response rates were robust, not all blood collection establishments or transfusing facilities responded to the survey. To account for this, weighting and imputation were used. The impact on overall estimates presented here is likely minimal. Transfusion-transmitted infection testing described here included positive screening test results resulting in product discard. Results of confirmatory testing were not included in this survey, and all discarded products may not represent true infection.

The NBCUS continues to serve as the most accurate source of estimating RBC collections and transfusions in the United States. Findings from the 2023 NBCUS indicate a continued stabilization in blood transfusions and collections, suggesting a new baseline for blood availability has been established in the United States. Additionally, the 2023 NBCUS estimates suggest the US blood supply was able to exceed demand on an aggregate, annualized, national level. CDC and CASH will continue to monitor blood collection and transfusion trends to inform national policy and strategic planning; these efforts are critical to maintaining a safe and secure blood supply.