oversight

Blood Supply: Availability of Blood

Published by the Government Accountability Office on 1999-09-23.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                               United States General Accounting Office

GAO                            Testimony
                               Before the Subcommittee on Oversight and Investigations,
                               Committee on Commerce, House of Representatives




For Release on Delivery
Expected at 9:30 a.m.
Thursday, September 23, 1999
                               BLOOD SUPPLY

                               Availability of Blood
                               Statement of Janet Heinrich, Associate Director
                               Health Financing and Public Health Issues
                               Health, Education, and Human Services Division




GAO/T-HEHS-99-195
Summary


          While there is cause for concern about shortages of certain blood types or
          in certain regions, the blood supply as a whole is not in crisis. Although a
          recent report by the National Blood Data Resource Center (NBDRC)
          projected that the demand for blood will outstrip the available supply by
          next year, we believe that this study overstates the decline in the blood
          supply. Moreover, most of the decline found by NBDRC was in donations
          targeted for specific individuals—not in the community supply of blood
          available to anyone in need—and the projection relies on data from only 2
          years.

          At the same time, the Department of Health and Human Services (HHS),
          which oversees the nation’s blood supply, has initiated a major policy
          change—and is considering another—that could further affect the blood
          supply. Specifically, the Department’s Food and Drug Administration has
          recommended prohibiting blood donations from individuals who spent a
          total of 6 months or more in the United Kingdom between 1980 and the
          end of 1996 because of concerns over the possible transmissibility of the
          human form of “mad cow” disease. The U.K. donor exclusion policy has
          been estimated to reduce the blood supply by approximately 2.2 percent.
          Blood banks fear that the actual loss due to this exclusion will be greater,
          but it is not possible to assess the accuracy of these estimates.

          HHS has also proposed removing barriers to donation by individuals with
          hemochromatosis—and iron-overload disease that may be treated by
          drawing blood—to make up some of the loss from the decreasing
          donations and possible losses from the U.K. donor exclusion. While the
          estimates of the potential increase in the blood supply from donations by
          individuals with hemochromatosis vary widely, most of these increases
          could not occur until current regulations are changed. Therefore, such
          donations would not affect the available blood supply for some time.




          Page 1                                                      GAO/T-HEHS-99-195
Blood Supply: Availability of Blood


               Mr. Chairman and Members of the Subcommittee:

               I am pleased to be here as you discuss the availability of blood to meet the
               nation’s requirements as well as recent and proposed policy changes
               regarding blood donation that may affect the future supply.

               A recent report by the National Blood Data Resource Center (NBDRC), a
               group representing blood banks, projected that the demand for blood will
               outstrip the available supply by next year. At the same time, the
               Department of Health and Human Services (HHS), which oversees the
               nation’s blood supply, has initiated a major policy change—and is
               considering another—that could further affect the blood supply.
               Specifically, the Department’s Food and Drug Administration (FDA) has
               recommended prohibiting blood donations from individuals who spent a
               total of 6 months or more in the United Kingdom between 1980 and the
               end of 1996 because of concerns over the possible transmissibility of new
               variant Creutzfeldt-Jakob disease (nvCJD), the human form of “mad cow”
               disease. HHS has also proposed removing barriers to donation by
               individuals with hemochromatosis—an iron-overload disease that may be
               treated by drawing blood—to make up some of the loss in blood donations
               from the decreases in donations and losses that may result from the U.K.
               donor exclusion.

               In light of these developments, you asked us to discuss the results of our
               recent correspondence on the blood supply.1 In that report, done at the
               Committee’s request, we provide information on (1) recent trends in blood
               donation and the demand for blood transfusions, (2) the expected effect of
               a ban on donors who have traveled to the United Kingdom, and (3) the
               potential effect of policy changes to allow units of blood collected from
               individuals with hemochromatosis to be distributed. The points I will
               present today are discussed in more detail in the correspondence.

               In summary, we found that, while there is cause for concern about
               shortages of certain blood types or in certain regions, the blood supply as
               a whole is not in crisis. We believe that the NBDRC study overstates the
               decline in the blood supply. Most of the decline found by NBDRC was in
               donations targeted for specific individuals, rather than in the community
               supply of blood available to anyone in need. Further, the projection of a
               shortage relies on data from only 2 years. The U.K. donor exclusion policy
               has been estimated to reduce the blood supply by approximately 2.2

               1
                Blood Supply: Availability of Blood to Meet the Nation’s Requirements (GAO/HEHS-99-187R, Sept. 20,
               1999).



               Page 2                                                                       GAO/T-HEHS-99-195
             Blood Supply: Availability of Blood




             percent. Blood banks fear that the actual loss due to this exclusion will be
             greater, but it is not possible to assess the validity of their concerns.
             Estimates of the potential increase in the blood supply from donations by
             individuals with hemochromatosis vary widely, from 300,000 to 3 million
             units. Regardless, use of such donations will require changes to current
             regulations, which may delay their availability for some time.


             About 8 million volunteers donate approximately 12 million units of whole
Background   blood each year. Sixty percent of the population is eligible to donate, and
             about 5 percent of the eligible population actually donate each year.2
             There are four sources of whole blood from volunteer donors for
             transfusion. The first, allogeneic donations, is the most important
             category, accounting for roughly 90 percent of the blood supply. Blood
             from allogeneic donations is available to any patient in need, and efforts to
             increase the blood supply usually focus on increasing participation in
             blood drives or otherwise raising the number of allogeneic collections.
             Second, autologous collections involve blood taken from patients before a
             medical procedure for their own use. Third, directed collections involve
             blood donated for use by a particular patient. A small portion of the
             autologous and directed collections ultimately are “crossed over” to the
             general supply. Finally, less than 2 percent of the total blood supply is
             imported.

             Blood banks maintain a supply cushion to meet the uncertain demand for
             blood. Local demand for particular blood types varies over the course of
             the year, and blood banks want to ensure that trauma patients and others
             who may require many units of blood can be treated promptly whenever
             the need arises. The supply cushion means that some blood is
             discarded—in 1997, for example, about 4 percent of the allogeneic blood
             supply expired without being transfused.

             New variant CJD is a chronic, progressive neurodegenerative disease that
             is inevitably fatal. It has a long, but unknown, incubation period. As of
             August 1999, there had been 43 confirmed cases—41 in the United
             Kingdom, 1 in France, and 1 in Ireland. It is suspected that all of these
             individuals contracted nvCJD from eating contaminated tissues from cattle
             infected with bovine spongiform encephalopathy (“mad cow” disease) in
             the United Kingdom, probably prior to 1990. Estimates of the number of
             U.K. residents who will ultimately manifest nvCJD range from the

             2
              To be eligible to donate, a person should be at least 17 years of age, weigh at least 110 pounds, be in
             good physical health, and pass a physical and medical history examination.



             Page 3                                                                            GAO/T-HEHS-99-195
                    Blood Supply: Availability of Blood




                    hundreds to more than 500,000. In the United States, there have been no
                    documented cases of nvCJD.

                    Hemochromatosis is the most common genetic disease in Americans of
                    European descent—about 1 in 10 may carry the gene for this disease, and
                    as many as 1 million Americans have evidence of hemochromatosis.3 The
                    proportion of individuals, however, who have the mutations associated
                    with hemochromatosis and later develop the disease is unknown because
                    not all of these individuals become ill. Treatment of hemochromatosis has
                    two phases: (1) iron depletion therapy, in which the patient receives a
                    therapeutic phlebotomy, or drawing of blood, about 1 to 2 times a week
                    for several months up to 3 years to remove excessive iron stores, and
                    (2) maintenance therapy, in which the patient continues to undergo
                    therapeutic phlebotomies but less frequently (2 to 6 times a year) to keep
                    body iron stores low and iron levels normal for the remainder of the
                    patient’s life.


                    The blood supply has decreased over the last decade, and there is some
Recent Trends in    evidence that in recent years the demand for blood has increased.
Supply and Demand   However, any conclusions about the trends in the blood supply are
                    hampered because information about the blood supply has not been
                    gathered routinely. The last systematic survey of the blood supply was
                    conducted by NBDRC in 1998, which measured units collected and
                    transfused in 1997. NBDRC will release the results of a new survey of blood
                    collections this November, and the National Heart, Lung, and Blood
                    Institute of the National Institutes of Health (NIH) has recently arranged for
                    NBDRC to collect data on blood donations on a monthly basis from a sample
                    of blood centers.

                    Earlier this year, NBDRC projected that the demand for blood will outstrip
                    supply by next year.4 We found that current evidence indicates the blood
                    supply has declined more slowly than assumed for that projection. NBDRC’s
                    projection rests on the overall 5.5 percent decrease in the blood supply
                    from 1994 to 1997 and on the observed 3.7 percent increase in the number
                    of units transfused during those years. (See table 1.)



                    3
                     There are two genetic mutations, C282Y and H63D, associated with hemochromatosis. C282Y is
                    considered the major mutation; fewer data are available on the prevalence of hemochromatosis in
                    other populations.
                    4
                     This projection did not consider the consequences of excluding travelers to the United Kingdom from
                    donating blood or of any other policy changes that may affect the blood supply.



                    Page 4                                                                        GAO/T-HEHS-99-195
                               Blood Supply: Availability of Blood




Table 1: Blood Supply Trends
                                                                                                                       Percent
                                                                                                                       change
                                                                 1989           1992           1994           1997 (1994-1997)
                               Total units collected      14,229,000 13,794,000 13,340,000 12,602,000                         –5.5
                               Total community
                               supply                     13,296,000 12,303,000 12,075,000 11,837,000                         –2.0
                               Total units transfused     12,059,000 11,307,000 11,107,000 11,517,000                         +3.7

                               Our analysis of the blood supply data found that the 5.5 percent figure
                               suggests a more serious decline than actually occurred in the community
                               supply of blood (available to anyone in need). Most of the 5.5 percent
                               decrease came from a drop in blood not included in the community
                               supply, which decreased only about 2 percent from 1994 to 1997. The
                               number of units designated for particular transfusion patients, both
                               autologous and directed donations, decreased by 37 percent from 1994 to
                               1997, accounting for two-thirds of the overall 5.5 percent decline. Indeed,
                               there was an even larger decline in the number of such units that had been
                               collected but not used.5

                               While other evidence seems to indicate that the blood supply cushion has
                               narrowed, it is difficult to determine if shortages are worse now than in
                               earlier years because blood banks have no incentive to collect more blood
                               than can be used. The American Red Cross informed us that the number of
                               days’ supply decreased below the comfort level in many of its centers and
                               gave us data showing less than 1 day’s supply on hand for some blood
                               types in some regions at one point this summer. America’s Blood Centers
                               reported anecdotal evidence of shortages in many of its affiliated blood
                               banks this year. Shortages occur more frequently in some regions, as do
                               shortages of blood types O and B. Furthermore, the 1998 NBDRC survey
                               found that at least some surgeries and medical procedures have been
                               postponed due to blood shortages. Specifically, 8.6 percent of the hospitals
                               surveyed indicated that elective surgeries were cancelled on 1 or more
                               days in 1997 due to blood shortages; 24.7 percent of hospitals said that
                               they were unable to meet nonsurgical blood requests on 1 or more days in
                               1997.6

                               Blood banks can mitigate the effects of local blood shortages by
                               transferring blood from regions with an excess supply to those with

                               5
                                The number of autologous and directed units collected but not transfused dropped 63 percent
                               between 1994 and 1997.
                               6
                                Among all hospitals responding to the survey, the mean number of days with surgeries cancelled was
                               0.44 and the mean number of days with unmet nonsurgical blood requests was 2.1.



                               Page 5                                                                       GAO/T-HEHS-99-195
                         Blood Supply: Availability of Blood




                         shortages. The American Association of Blood Banks’ National Blood
                         Exchange and the American Red Cross together moved about 1.1 million
                         units of blood between blood centers last year. This blood is purchased by
                         centers in shortage areas from centers with surpluses of particular types
                         of blood.

                         Estimates of the future demand for blood are also uncertain. On the one
                         hand, persons aged 65 and older receive twice as much blood per capita as
                         younger individuals, so the aging of the population may increase the
                         demand for blood products. Further, some procedures requiring blood are
                         being performed with increasing frequency, and the range of treatments
                         requiring blood or blood products is increasing. On the other hand, some
                         evidence indicates that the use of blood can be substantially reduced. The
                         amount of blood used for the same procedures varies widely among
                         hospitals, and at least one pilot program has shown that clinical outcomes
                         would not be affected if the use of blood were substantially reduced.
                         Similarly, improved surgical techniques and better understanding of the
                         clinical thresholds that trigger blood transfusions has reduced the demand
                         for blood in some instances.


                         Last month, FDA issued guidance recommending that collections be
Expected Effect of       prohibited from donors who had traveled or resided in the United
Excluding Donors         Kingdom for a total of 6 months or more between 1980 and 1996—because
Who Have Resided or      of the theoretical risk of transmitting nvCJD through blood
                         transfusions—which has raised concern among some about the effect such
Traveled in the United   a policy would have on the blood supply. FDA will review this policy at
Kingdom                  6-month intervals, to consider any new scientific information and the
                         policy’s effect on the blood supply.

                         While it has not been shown that nvCJD is transmissible by blood
                         transfusion, animal research suggests that infection by blood is
                         theoretically possible—in some cases, direct injection of blood from a
                         contaminated animal into the brain of another has caused infection.
                         However, no cases of transmission by blood in humans have been
                         documented. In the United Kingdom, 4 donors subsequently diagnosed
                         with nvCJD gave blood that was transfused into 10 recipients. None of
                         these recipients have developed nvCJD to date, although they may later
                         because of the long incubation period.




                         Page 6                                                    GAO/T-HEHS-99-195
                             Blood Supply: Availability of Blood




Effect on the Blood Supply   The 6-month U.K. residence interval was selected to balance the twin goals
                             of minimizing losses to the blood supply and eliminating as much risk as
                             possible. A survey of blood donors by the American Red Cross found that
                             23 percent of donors had traveled to the United Kingdom between 1980
                             and 1996. Only one-fifth of the blood-donor travelers had been in the
                             United Kingdom for more than 30 days, and just 1 in 10 of them had a
                             cumulative stay of 5 months or more. The Red Cross analysis estimated
                             that the 6-month exclusion criterion would result in a 2.2 percent
                             reduction in the blood supply and eliminate 87 percent of the risk of
                             collecting blood from a person infected with nvCJD.

                             Blood banks have expressed concern that this exclusion will result in
                             more than a 2.2 percent loss. First, there is the possibility that some
                             potential donors will fail to attend to the details of the policy and not
                             donate blood even though they are eligible to do so. For example, donors
                             who traveled to the United Kingdom only in 1997 may stop donating even
                             though they remain eligible to do so. Second, there is concern that
                             potential donors may become discouraged because their friends or
                             neighbors are excluded, heightening the sense that it is difficult to pass all
                             the screening criteria for giving blood. Third, there is worry that excluded
                             U.K. travelers will not return to donate blood if, and when, the restriction
                             is lifted.

                             Blood banks are also concerned about other burdens imposed by this
                             exclusion. For example, according to research conducted by the American
                             Red Cross, donors who resided or traveled in the United Kingdom are
                             disproportionately repeat donors. Without these donors, the blood banks
                             will need to recruit a large number of first-time donors to replace them
                             because first-time donors are roughly twice as likely to have disqualifying
                             medical conditions as regular donors. Second, the effect will vary by blood
                             center, as those with a larger proportion of U.K. travelers will lose more of
                             their donors than other blood collection centers. The Red Cross survey
                             found that the proportion of donors affected in some blood centers were
                             35 percent greater, and others 50 percent less, than the overall average.


Risk Reduction               Estimates of the degree of risk reduction achieved by this exclusion are
                             problematic. First, the degree of potential risk to be mitigated is unknown.
                             Second, because the prohibition applies only to future donations, some
                             blood from donors who would now be excluded has entered the blood
                             supply in the recent past. Third, because so little is certain about how
                             nvCJD is acquired, estimates of the beneficial effect of any prohibition



                             Page 7                                                       GAO/T-HEHS-99-195
                      Blood Supply: Availability of Blood




                      threshold—other than a complete ban on potential donors who have
                      traveled to the United Kingdom at all—are uncertain. For example, the Red
                      Cross estimate assumed that the risk of acquiring nvCJD increased directly
                      with each day spent in the United Kingdom. Any change in this assumed
                      relationship would lead to a significantly different risk reduction estimate.
                      Indeed, HHS told us that the Department did not totally agree with the Red
                      Cross risk formulation and that its choice of the 6-month threshold was
                      based on other information. In particular, HHS told us that all of the
                      individuals in the British cases (41 of the 43 known cases) were born in
                      the United Kingdom and resided there for at least 10 years between 1980
                      and 1996; thus, the Department reasoned that any exclusion threshold of 1
                      year or less would reduce the presumed risk tenfold or more.


                      In April 1999, the Public Health Service’s Advisory Committee on Blood
Potential for Blood   Safety and Availability recommended that policy changes be made to
Donations From        allow blood collected from individuals with hemochromatosis to be
Individuals With      distributed for transfusion.7 Making hemochromatosis patients eligible to
                      donate would essentially guarantee an increased number of donors
Hemochromatosis       because they have to periodically have blood drawn to treat their
                      condition. Members of the advisory committee concluded that blood
                      products from individuals with hemochromatosis carry no known
                      increased risk to recipients. Therefore, they recommended that HHS change
                      its policies and remove any barriers to the use of this blood. At the same
                      time, the advisory committee recommended that HHS take steps to
                      eliminate any financial incentive for these individuals to donate blood.
                      Since individuals with hemochromatosis may have to pay to have their
                      blood drawn through therapeutic phlebotomy,8 there would be a financial
                      incentive to avoid this cost by donating blood. Unless this incentive is
                      removed, FDA is concerned that these potential donors will not truthfully
                      answer screening questions about risk factors that would disqualify them
                      from donating, thereby compromising the safety of the blood supply.

                      According to one survey, most individuals with hemochromatosis are
                      insured or partially insured for therapeutic phlebotomies. However, even


                      7
                       Hemochromatosis is a disease of iron regulation that results in excessive iron absorption and
                      accumulation, leading to organ damage. The human body cannot excrete excess iron, so it remains in
                      the body unless it is lost through menstruation, childbirth, hemorrhage, or blood donation. Iron is
                      highly toxic when an excessive amount is absorbed. Some clinical chronic conditions associated with
                      hemochromatosis include severe fatigue, diabetes mellitus, heart disease, cirrhosis of the liver, and
                      cancer.
                      8
                       Therapeutic phlebotomy is the removal of a full unit of blood from an individual, about 500 mls, for
                      the purpose of treating a disease.



                      Page 8                                                                           GAO/T-HEHS-99-195
Blood Supply: Availability of Blood




though therapeutic phlebotomies are a necessary medical treatment for
some individuals, insurance does not always cover the costs. The average
cost of the procedure per unit of blood ranges from $52 at blood centers to
$69 at physician offices and $90 at hospitals, with an average out-of-pocket
cost of $45 for all respondents to the survey.9 These out-of-pocket costs
are a financial incentive for persons with hemochromatosis to not disclose
any disqualifying conditions and volunteer for blood donations. In one
study, 37 percent of the hemochromatosis patients surveyed reported
being voluntary donors before their diagnosis and 54 percent of the
individuals attempted to donate blood after diagnosis.10 The results from
the National Donor Research and Education Study sponsored by NIH show
that about half of the individuals who responded that they had
hemochromatosis (only 0.4 percent of those surveyed) were volunteer
donors. At present, there is no routine screening for this disease.

In the United States, blood obtained by therapeutic phlebotomy from
individuals with hemochromatosis is currently discarded. Although
hemochromatosis is inherited, not transmitted, and there is no evidence
that the use of hemochromatosis blood for transfusion carries any risks to
recipients,11 hospitals and physicians hesitate to use this blood. FDA
permits the use of blood from individuals with hemochromatosis, as long
as they meet the same donor suitability criteria as any other donor, but it
requires that this blood be labeled as coming from a hemochromatosis
donor, which effectively impedes the use of this blood. Some in the U.S.
blood industry consider hemochromatosis donors to be the same as paid
donors, implying a decreased level of safety.12 In 1996, the American
Association of Blood Banks issued standards discouraging transfusion of
blood from donors who had therapeutic phlebotomies. Because many
blood centers conform to these standards, this policy effectively excludes
most individuals with hemochromatosis from donating blood.

FDA has agreed to make the necessary regulatory changes to remove
barriers to donation once financial incentives for hemochromatosis




9
 S. M. McDonnell and others, “A Survey of Phlebotomy Among Persons With Hemochromatosis,”
Transfusion, Vol. 39 (1999), pp. 651-6.
10
    S. M. McDonnell and others, “A Survey of Phlebotomy Among Persons With Hemochromatosis.”
11
    The processing of whole blood units into packed red cells removes most of the iron-enriched serum.
12
  Data show that blood from paid donors is more likely to transmit disease than that from volunteer
donors; R. A. Sacher, “Hemochromatosis and Blood Donors: A Perspective,” Transfusion, Vol. 39
(1999), pp. 551-4.


Page 9                                                                          GAO/T-HEHS-99-195
              Blood Supply: Availability of Blood




              patients are removed.13 There are several different requirements that
              would need to be changed. FDA currently requires an 8-week interval
              between donations to prevent iron depletion of donors, but individuals
              with hemochromatosis at the initial stage of treatment undergo
              therapeutic phlebotomies 1 to 2 times a week. FDA also requires blood
              from therapeutic bleeding, including for hemochromatosis, to be labeled
              with the disease for which the bleeding was performed, which discourages
              health care providers from using this blood.

              As an initial step, FDA recently agreed to consider case-by-case exemptions
              to existing regulations on blood labeling and frequency of blood collection
              for blood establishments that can verify that therapeutic phlebotomy for
              hemochromatosis is performed at no expense to the patient. However, FDA
              officials have publicly stated that in making these exemptions, they will
              require a commitment from blood collection facilities to concurrently
              provide safety data, including viral marker rates, incidence of
              transmissible infections based on seroconversion rates, frequency of
              postdonation reports of undisclosed risks, and reports of adverse events.

              Individuals with hemochromatosis have the potential to make up some of
              the loss in blood donations due to the U.K. donor exclusion policy.
              Estimates of increases in the blood supply through donations by these
              individuals vary widely, from 300,000 to 3 million units—although the
              former is generally considered a better estimation. Regardless, changes to
              current regulations affecting blood from hemochromatosis patients will
              occur considerably later than FDA guidance to exclude donors, which has
              already gone into effect. It seems unlikely that the issue of coverage of
              therapeutic phlebotomies by insurers will be quickly addressed and that
              anything less than full reimbursement may be considered undue donor
              incentive. Therefore, unless blood centers absorb the costs of providing
              therapeutic phlebotomies to persons with hemochromatosis, it is also
              unlikely that FDA will revise current regulations.


              On the basis of the information we reviewed, we conclude that the blood
Conclusions   supply is not in crisis. However, there is cause for concern about the
              possibility of some regional shortages and shortages of some types of
              blood. These may be exacerbated somewhat by the U.K. donor exclusion
              policy, which will affect blood banks differently. Potential additions to the
              blood supply from hemochromatosis patients cannot occur for some time,

              13
               The American Association of Blood Banks has also indicated that, if FDA changes the regulations, it
              would make changes to its standards related to the use of blood from patients with hemochromatosis,
              so that centers could remain in compliance with the association’s requirements.



              Page 10                                                                       GAO/T-HEHS-99-195
                  Blood Supply: Availability of Blood




                  since blood from these individuals will not be entered into the community
                  supply until issues related to who pays the costs of therapeutic
                  phlebotomies are resolved and regulatory changes are implemented.


                  This concludes my prepared statement, Mr. Chairman. I will be happy to
                  respond to any questions that you or Members of the Subcommittee may
                  have.


                  For future contacts regarding this testimony, please call Janet Heinrich at
Contacts and      (202) 512-7119. Key contributors to this testimony include Marcia Crosse,
Acknowledgments   Martin T. Gahart, and Angela Choy.




(101897)          Page 11                                                    GAO/T-HEHS-99-195
Ordering Information

The first copy of each GAO report and testimony is free.
Additional copies are $2 each. Orders should be sent to the
following address, accompanied by a check or money order
made out to the Superintendent of Documents, when
necessary. VISA and MasterCard credit cards are accepted, also.
Orders for 100 or more copies to be mailed to a single address
are discounted 25 percent.

Orders by mail:

U.S. General Accounting Office
P.O. Box 37050
Washington, DC 20013

or visit:

Room 1100
700 4th St. NW (corner of 4th and G Sts. NW)
U.S. General Accounting Office
Washington, DC

Orders may also be placed by calling (202) 512-6000
or by using fax number (202) 512-6061, or TDD (202) 512-2537.

Each day, GAO issues a list of newly available reports and
testimony. To receive facsimile copies of the daily list or any
list from the past 30 days, please call (202) 512-6000 using a
touchtone phone. A recorded menu will provide information on
how to obtain these lists.

For information on how to access GAO reports on the INTERNET,
send an e-mail message with "info" in the body to:

info@www.gao.gov

or visit GAO’s World Wide Web Home Page at:

http://www.gao.gov




PRINTED ON    RECYCLED PAPER
United States                       Bulk Rate
General Accounting Office      Postage & Fees Paid
Washington, D.C. 20548-0001           GAO
                                 Permit No. G100
Official Business
Penalty for Private Use $300

Address Correction Requested