In Japan, blood collection services have been provided exclusively by the Japanese Red Cross Society for many years, so this is the first time that a survey has been conducted in conjunction with globalization. And this is a first study that use real world evidence to investigate Japanese public opinion of blood donation and blood selling. Against the backdrop of an international shortage of immunoglobulins, the demand for plasma, the raw material for immunoglobulin’s, is increasing [1]. In Japan, the use of immunoglobulins has rapidly increased owing to the approval of preventive treatments for ChronicInflammatory Demyelinating Poly-neuropathy or hypogammaglobulinemia and the launch of concentrated solutions [2].Currently, this shortage is covered by imports; however, such increase in import not only makes domestic companies vulnerable, but also increases the risk that stable imports of immunoglobulin will not be possible in the event of an ultimate shortage of plasma [3][4]. The Japanese government has stipulated that companies entering the blood collection business in Japan must be non-profit, foreign companies are reluctant to enter the market. [5] However, the demand for plasma will continue to increase in the future in Japan. How to respond to this situation is a serious problem for Japan. This study analyzed public opinion regarding the blood services and plasma fractionation business in Japan in the wake of the globalization and is expected to significantly contribute to future policy decisions by the Japanese government and foreign companies.

The research was conducted through an anonymous web, survey carried out by N. M.– Japan’s largest research company with 27 million registered monitors. A total of 16,494 inexperienced and experienced blood donors aged between 18 and 69 years residing in each of Japan’s 47 prefectures were randomly selected to avoid regional bias. A total of 1,040 people were randomly selected from 16,494 for the survey to avoid bias based on age or blood donation experience.[Table ]

Table 1: Survey to avoid bias based on age or blood donation experience.

Questions asked are listed under    1?   2?

For 1?, the answers were ?Yes, ?Rather Yes, ? Rather No, ?No and divided into two groups with ?? as “Yes” and ?? as “No.” We investigated the significant differences between each age groups, and correlation between age and answers to each question and between answers to each question. (Table 2) In addition, for 2?, responses were obtained in units of 1,000 yen, with the lower limit being 1,000 yen and upper limit being 10,000 yen. All analyses were divided into six age groups, from teenagers to those in their 60s. And the overall percentage was adjusted by the population in October 2020 when the survey was conducted. The population in October 2020 was 1,172,000 in 18 years old, 1,208,000 in 19 years old, 12,703,000 in their 20s, 14,213,000 in their 30s, 18,345,000 in their 40s, 16,677,000 in their 50s, and 15,678,000 in their 60s. The percentage for each age group was multiplied by the population, and the total number was divided by the total population of 79,996,000. The population was calculated (Table 3) to the nearest 1000 people. Statistical analyses were performed using IBM SPSS Statistics Ver. 26 for Windows. Correlations were calculated using Pearson’s correlation. The coefficients of correlations and differences between age groups were determined using the chi-square test. The significance level was set at p<0.01 (two-tailed).

1? Questions on the Japanese blood services and plasma fractionation business.

1. If a commercialization of Japanese blood services is

Considered, would you support it?

2. Do you agree with the globalization of Japan’s blood services?
3. Do you think there is a need to pursue greater safety in blood products in Japan?
4. If Japan were to consider introducing a blood selling system in the future, would you support it?
5. If you were to receive blood transfusion in the future, would you prefer blood products derived from Japanese blood?
6. If you were to receive blood transfusion in the future, would you prefer blood products derived from donated blood?
7. When importing immunoglobulin preparations from overseas, are you particular about ensuring that Japanese safety standards are complied with?
8. Do you think Japan should strive for domestic self sufficiency in immunoglobulin preparations?
9. Do you think we should promote a proper use of immunoglobulin preparations and strive to reduce the amount used?
10. If a foreign company opens a blood collection center in Japan in the future, will you use it?

2?   if a blood selling system were introduced in Japan in the future, how much is the minimum suggested price?

Table 2: Percentage of respondents who answered yes or Rather Yes.

Table 3: The overall results (%) were adjusted to the population ratio.

1.       75.2% of the respondents were against the commercialization of Japanese blood services. A negative correlation was observed with age, and there were significant differences between the age groups. Among those in their 60s, 88.9% were against the idea.
2.       47.0% of the respondents agreed with the globalization of the plasma fractionation business; however, there Were significant differences between age groups. Among those in their 30s, 54.8% were in favor of the idea, with more people in favor than against it. There was a negative correlation between those who said they were in favor of globalization and those who said they were particular about blood products derived from Japanese blood (-0.27), A negative correlation was also found between the former and people who preferred to donate blood. (-0.29).
3.       60.7% of the respondents did not find it necessary to pursue a greater safety in blood products.
4.       67.3% of the respondents showed support to the introduction of a blood selling system, and a weak negative correlation was observed with age (-0.16). The approval rate among people in their 60s was low at 51.1%, but the approval rate among teenagers was high at 77.0%. There was a positive correlation between responses supporting the introduction of a blood selling system and responses supporting commercialization (0.32). (Fig.1) On the other hand, there was a negative correlation between responses supporting the introduction of a blood selling system and those who answered that they were particular about products derived from donated blood (-0.26). There was a weak positive correlation between those who supported the introduction of a blood selling system and those who supported globalization (0.12).

Figure 1: Correlation between those who support the introduction of blood selling and those who support commercialization.

5.       The preference of the Japanese for products derived from Japanese blood was as high as 69.8%, and there was a strong positive correlation (0.43) with the preference for products derived from donated blood.
6.       52.4% of the respondents preferred preparations derived from donated blood; this was weaker than the preference for preparations derived from Japanese blood.
7.        89.3% of the respondents were very concerned about the safety of imported immunoglobulin preparations.
8.        40.0% percent of the respondents favored the promotion of domestic self-sufficiency in immunoglobulin preparations. Significant differences were observed between the age groups. There was a weak positivecorrelation between those who supported domestic self-sufficiency in immunoglobulin and age. (0.11) 23.0% of the teenagers supported the promotion, compared with 47.3% of those in their 60s. Additionally, 51.0% of those in their 60s who have donated blood supported the promotion. Responses to promoting domestic self-sufficiency had a negative correlation with responses in favor of globalization (-0.29) and a positive correlation with responses to concerns about safety standards when importing globulin products. (0.28)
9.       35.0% of the respondents favored promoting a proper use of immunoglobulin preparations. 65.0% of the respondents opposed the idea of reducing the amount of immunoglobulin used and promoting its proper use. There was a positive correlation between responses in favor of proper use of immunoglobulin and responses in favor of domestic self-sufficiency of immunoglobulin. (0.29)
10.     Only 4.2% of the respondents said yes to using foreign companies’ blood collection facilities.
2. If Selling blood is allowed in Japan, how much is the minimum suggested price? The average amount suggested by those with a blood donation experience was 3,680 yen, whereas that suggested by those with no experience was 4,832 yen. A significant difference was observed between those who had never donated blood and those who had. The average was 4,160 yen. The most common answer was 1,000 yen (22.1%), followed by 5,000 yen (20.3%), and 10,000 yen (15.2%). 80.7% of responses were priced below 5,000 yen.

          Table 4: Average minimum suggested price for selling blood for each age group.

Japan has been unable to cope with the rapid increase in the Demand for immunoglobulins and has continued to rely on imports since 2019 when it began emergency imports. However, as imported globulin preparations take less time to finish the treatment and are easier to treat than domestic preparations are, reliance on these products makes domestic companies vulnerable, and if there is a global shortage of immunoglobulin due to emergencies such as natural disasters, wars, infectious disease outbreaks, there is a risk that stable imports will no longer be possible. Taking into consideration the fact that only 35.0% of people in this survey agreed with the proper use of immunoglobulin and the materials from the Ministry of Health, Labor and Welfare, the demand for immunoglobulins will continue to increase, the government needs to discuss drastic measures [6]. 67% of the respondents supported the introduction of a blood selling system, with the percentage of teenagers being very high, at 77.0%. Responses supporting domestic self-sufficiency were positively correlated with age, with the older the age, the higher the support rate, and it was also found to be negatively correlated with responses supporting the introduction of blood selling. (-0.17) Considering the current situation where the youth are declining to donate blood [7][8][9][10], these results can be interpreted to be due not simply to the age-related differences in thinking but to the fact that the Japanese society is moving toward a gradual globalization and commercialization of blood services. This indicates a shift from free blood donation out of goodwill to a for-profit blood collection. The study results revealed that a suggested minimum price for the Japanese was far lower than the market price in the United States. At first, this may seem advantageous to foreign companies, but the results also showed that only 4% of the respondents were willing to use a foreign company’s blood collection center in the future. And responses supporting the introduction of blood selling has a positive correlation with the responses supporting commercialization. (0.32) But it has a weaker positive correlation with those who were in favor of globalization (0.12) This shows that those who support blood selling may want commercialization, but not necessarily globalization. To summarize the results of the survey, young people will donate blood for a fee at facilities other than foreign companies, and blood will be collected by not from poor people for money but well-intentioned blood donors as before. And if they need a blood transfusion, they want to use safe blood products made from Japanese blood collected at those facilities. This is what young people want. However, will reality go as planned? The number of people in their 60s who opposed the introduction of a blood selling system and its commercialization was large, and there was a significant difference between each age group (p<0.01). There are two possible reasons why there is a significant difference in the favorable opinions of people in their 60s. One is that they have experienced the AIDS crisis that rocked Japan in the 1980s. [11] Just when they were old enough to donate blood, an incident occurred in Japan in which many people contracted AIDS from blood products made from blood sold in the United States. The other thing is that they are of an age when they barely know about Japan's past blood-selling era. Blood selling was legal in Japan until 1964, but as a result, hepatitis became widespread, with more than one in two people receiving blood transfusions developing hepatitis. In addition, many poor people suffered from poor health due to blood selling, and society was in dire straits. Therefore, in an effort to eliminate the blood selling system from Japanese society, there is a history of many young people and volunteers making great efforts to win over the blood donation system. Most of today's young people are unaware of its history and misery. In Japan, there is no education about these things. In order to ensure that the image of blood selling portrayed by the younger generation does not deviate from the reality, people who know about the old days of blood selling need to seriously convey the reality of the situation. Just as the number of people who can talk about the war is decreasing, the generation that can talk about Japan's blood selling era is also gradually aging. Through initiatives such as blood donation education, it is necessary to actively pass on one's own experiences to the next generation and make them aware of the significance of donating blood honestly.

This survey revealed that a large number of people were in favor of introducing a blood selling system. For a long time, Japan has closed its blood services domestically. Therefore, little information was available about the world situation; A few people have a knowledge of the fact that the WHO recommends domestic self-sufficiency through well-intentioned blood donations [12].and that the blood donation system is being compromised by blood selling in some countries. And very few people know the actual situation of the poor people who support America's blood selling industry. Furthermore, Japan also had an era of blood selling and they have not communicated how they have overcome that tragic situation [13]. In order to run ideal blood services in the future, it is necessary to actively provide information about the world situation, Japanese history, and the reality of the blood services, and to make people aware of the importance of donating blood in good faith. We believe that the results of this study are a sounding alarm for Japanese society. It is a very serious problem that young people are losing the spirit of helping each other. Youth need to be taught the meaning of the spirit of mutual aid. We must make people realize that this spirit is the foundation that supports human society in all areas, including medical care, welfare, and nursing care. To achieve this, society as a whole need to seriously face this problem and strengthen home education and school education to foster a spirit of mutual aid

Acknowledgements

We would like to express our sincere gratitude to Dr. Hirokazu Tsuno for his cooperation in the research, and to Ms. Maiko Murakami, who helped with the English translation, and to Mr. Yuichiro Sugawa, who helped conduct the survey. This research received research funding from the Ministry of Health, Labor and Welfare.

Conflict of Interest

There are no conflicts of interest to disclose regarding this research.

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