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Blood Safety Transcripts
NATIONAL INSTITUTES OF HEALTH
PUBLIC HEALTH DEPARTMENT
ADVISORY COMMITTEE ON
BLOOD SAFETY AND AVAILABILITY
Monday, August 11, 1997
Lister Hill Auditorium
National Library of Health
National Institutes of Health
9000 Rockville Pike
Bethesda, Maryland
Transcribed From Provided Tapes By:
CASET Associates, Ltd.
10201 Lee Highway, Suite 160
Fairfax, VA 22030
(703) 352-0091
PARTICIPANTS:
Committee:
Arthur Caplan, Ph.D., Chair
Janice K. Albrecht, Ph.D.
Larry Allen
James P. AuBuchon, M.D.
Michael P. Busch, M.D., Ph.D.
Ronald Gilcher, M.D.
Edward D. Gomperts, M.D.
Fernando Guerra, M.D.
Paul F. Haas, Ph.D.
William Hoots, M.D.
Carolyn D. Jones, J.D., M.P.H.
Dana Kuhn, Ph.D.
Tricia O'Connor
John Penner, M.D.
Jane A. Piliavin, Ph.D.
Eugene R. Schiff, M.D.
Marian Gray Secundy, Ph.D.
John Walsh
Kristine MacDonald, M.D., M.P.H., Consultant
Ex Officio Representatives:
Eric Goosby, M.D., Office of the Secretary
Paul R. McCurdy, M.D., NIH
Mary Pendergast, J.D., FDA
Mary E. Chamberland, M.D., CDC
David Snyder, R.Ph., D.D.S., HRSA
CAPT Bruce Rutherford, MSC, USN, DOD
TABLE OF CONTENTS
Call to Order - Dr. Caplan 1
Opening Remarks - Dr. Goosby 2
Open Public Hearing 4
Agency Discussion, FDA - Dr. Mied 11
Agency Discussion, CDC - Dr. Margolis 23
Cost-Benefit Analysis of Lookback - Dr. AuBuchon 45
Legal Risks of Lookback - Ms. Ungerer 77
Effect of Lookback on Hospitals - Dr. Kaplan 100
Course and Outcome of Hepatitis C - Dr. Gordon 113
Course and Outcome of Hepatitis C - Dr. Seeff 125
Lookback Experience in U.K. - Dr. Robinson 148
Lookback Experience in Canada - Dr. Gill 173
Open Committee Discussion 185
P R O C E E D I N G S
Agenda Item: Call to Order - Dr. Arthur Caplan
DR. CAPLAN: I'd like to call to order the
Advisory Committee on Blood Safety and Availability. In so
doing, I'm going to give a little heads up to Eric. I'm
going to ask him to stand in for John Eisenberg, who is not
here yet.
This is the second meeting of the committee. We
are going to be looking over the next two days at the issue
of lookback for hepatitis C, which we will hear much about
throughout this morning's program. We are going to start
today with some public testimony in an open hearing, and
then move into some presentations which the committee asked
for at its last meeting when it was looking for more
information on cost/benefit, some of the legal issues
raised, some of the impact of lookbacks on hospitals and
blood banks, and some of experience of other nations that
have wrestled with the lookback question.
What I would like to do is just run through a
couple of brief housekeeping announcements, that are
important, particularly if you are out in the audience.
[Administrative remarks.]
Why don't I let Eric say a word at this point,
just about where we are at in terms of task and mission for
today.
Agenda Item: Opening Remarks - Dr. Eric Goosby
DR. GOOSBY: Thanks, Art.
I really am very happy to welcome you here. Dr.
Eisenberg has a conflict that he was given last evening by
the secretary, and sends his apologies for not being able to
be here. He will try to come in either late or with your
conclusions tomorrow.
This is the second meeting of the committee, and
you are focusing on a very difficult issue that has
concerned the Public Health Service really for a number of
years, and we really look forward to the focused discussion
that you are going to embark on today and tomorrow, focusing
on hepatitis C lookback, and analyzing and considering the
two proposals that were presented at the end of the last
meeting, worked on a little bit between meetings, and
looking at cost/benefit, legal issues, et cetera around the
hepatitis C lookback is going to be a very productive and
interesting discussion. We look forward to the conclusions
that this committee will offer the secretary.
I want to deal with a little business and announce
to the committee that we have identified an executive
secretariat who will also serve in some other functions
within the Office of HIV/AIDS Policy in the Office of the
Public Health and Science in the secretary's office. Dr.
Stephen Nightingale -- Stephen, if you could just stand up
for a second -- will be orchestrating, coordinating this
committee and the work of it, and will serve as a focus
point for committee members. We'll give out his phone
numbers and fax tomorrow, which are the same as mine.
Dr. Nightingale graduated from Harvard College and
the University of Pennsylvania School of Medicine. He
trained in internal medicine and nephrology at Johns
Hopkins, and is board certified in both areas. He has
taught at Hopkins, Case Western Reserve, the University of
Chicago, the University Center for Health Sciences in
Yaounde, Cameroon before becoming the chief of general
medicine at Cook County Hospital in 1982, and the medical
director of the Parklawn Memorial Hospital AIDS Clinic in
1988.
For the past year, Dr. Nightingale has been a
medical officer at the FDA Center for Devices and Radiologic
Health, and attending physician at D.C. General Hospital,
where he works in the AIDS clinic on a volunteer basis.
He is the author of 50 publications, has had
research interests that have included opportunistic
infections in HIV, and psychological influences on medical
decision-making. He is married to a Dr. Elizabeth Wiley,
who is associate chief of surgical pathology at Northwestern
in Chicago, and they have two boys, aged 14 and 20. He
lists his hobby as commuting.
So we are very happy to have someone of his
stature join our team, and hopefully can serve the needs of
this committee faithfully and effectively in the future.
So thanks, Art. I look forward to the
deliberation.
DR. CAPLAN: Thanks, Eric.
[Administrative remarks.]
We have two people who have requested time to
present to the committee, Jim MacPherson from America's
Blood Centers, and then Fay Lamb(?) from the Cooley's Anemia
Foundation. Is she here too?
Agenda Item: Open Public Hearing
MR. MAC PHERSON: Thank you, Dr. Caplan. Thank
you to the committee.
For those of you who have a copy of the statement,
I did not had a chance to see the draft until this morning
of the recommendations, so I have revised my remarks
accordingly to coincide with the draft of the statement.
America's Blood Centers, whose not-for-profit
members, community-based, provide nearly half the nation's
volunteer donor blood supply, thanks the committee for this
opportunity to once again address the issue of lookback
procedures for hepatitis C.
At the committee's April meeting our vice
president, Dr. Sela Bianco(?) provided a comprehensive
outline of the controversies and options surrounding this
issue, so today my comments will be short, and hopefully to
the point.
First, so-called donor lookback will not identify
the majority of patients who have infected by a blood
donor's potential silent infectious blood donation,
nevertheless, it is difficult to argue that blood centers in
possession of information about a recently acquired
infectious state of a donor should not perform lookback for
HCV as they already do for HIV and HTLV.
ABC only asks that a limit be placed on the time
of an infected donation, and lookbacks on previous
donations. Given that there are no public health issues
that would compel a longer period, we would support the one
year time limit recommended in the Drs. Hoots-Penner draft
as a reasonable balance between a patient's right to know
about the infectious status of his or her blood donation,
and the practicability of a hospital to search its
computerized patient records.
In addition -- and this comment may not be
effective any more if the draft is accepted by the
committee, but of course that is the point of today's and
tomorrow's discussion -- any such recommendation should only
be applied to this day forward; that is, the donor lookback.
To do so otherwise could stymie the current operations of
blood centers and hospital transfusion services for months
in exchange for very little public health gain, especially
given the high degree of false positive test results from
the first generation of HCV screening tests.
If the federal government feels compelled now to
require retrospective donor lookback for HCV after years of
rejecting that option, the government needs to provide
funding to support the hundreds of thousands of work hours
that would be required for blood centers and hospitals to
effectively perform this daunting activity.
Second, regarding past transfusion recipients --
and this is consistent with the Penner-Hoots draft -- as it
has for many years, ABC recommends two options to inform
patients about their risk and choices, about determining
whether they need to be evaluated for a transfusion
transmitted disease.
The first option is for the Public Health Service
to send a letter to all practicing physicians, one of its
"Dear Doctor" letters, recommending that a history of blood
transfusions be incorporated into routine medical health
histories. PHS should include guidelines as to when a
doctor and patient might need to consider testing for HCV,
HIV, et cetera.
For example, when a transfusion took place before
1990, for HCV for example, although I notice the draft is
not even recommending that. Ultimately, such health
decisions should remain between the patient and his or her
physician.
The second option is for the PHS to join with
organizations such as the American Liver Foundation to
develop and disseminate public service announcements making
patients aware of past transfusion risks, that can stimulate
a meaningful dialogue between the patient and the physician.
Finally, we remain proud that over the last seven
years we have been a leading voice in the blood community to
advocate for some reasonable approaches to informing blood
recipients about their past risk -- sometimes a lonely voice
-- even the face of public health uncertainty. We continue
to offer the committee any help or insights we can on this,
and other issues under consideration.
Thank you.
DR. CAPLAN: Questions? We should open the floor.
All right, let me ask Ms. Lynn to come down from
the Cooley's Anemia Foundation.
MS. LAMB: Mr. Chairman and members of the
advisory committee, my name is Fay Lamb and I am a
thalassemia patient. Today I represent the Cooley's Anemia
Foundation and its patient support network, Thalassemia
Action Group. For four years the Cooley's Anemia Foundation
has funded thalassemia research, patient care, public and
physician education, and has worked to assure a safe blood
supply.
Now some of you probably know to remain alive,
thalassemia patients receive an average of two units of red
blood cells every two weeks. Thalassemia patients are the
single largest group of chronically transfused patients. We
deserve a blood supply that is free from deadly viruses and
contaminants.
In the brief time that I have available this
morning, I intend to address the important issue related to
hepatitis C lookback, particularly as it relates to patient
notification that is on your agenda today. It is critically
important, however, that you understand how the world of
blood supply and blood safety looks to the people who have
to rely on the system to live.
Every time we go for a blood transfusion we know
we place our lives in the hands of large numbers of people
we will never meet: regulators from the FDA, researchers at
NIH, lab techs working for private for-profit companies.
The lives of thousands of persons receiving blood
transfusions every day rests on the faith that everyone is
doing his or her job. You have an awesome responsibility,
and to the extent that America has the safest blood supply
in the world, I am here to thank you.
I am also here to challenge you. In the midst of
criminal prosecutions of persons in the largest blood center
in our nation, think about the child, teenager or young
adult who has to receive blood regularly. They read a
newspaper or see a TV news report about unsafe blood, or
about lab techs receiving incentive payments to approve more
blood on a shift. They know people who have contracted AIDS
or hepatitis. They are frightened, and so are their
families.
This week, employees of the New York Blood Center
are on trial in federal court for breaching their duty and
obligation to properly test blood. At the same, this week
thousands of thalassemia patients in New York are being
tested for HIV. This action, as a result of the recall
stemming from the New York Blood Center.
It is within this context that Cooley's Anemia
Foundation views the hepatitis C lookback issue. Our
patients deal with so much, it would be tempting to say that
they are better off not knowing. It would in some ways,
seem easier not to make the effort to identify individual
blood recipients and notify them of HCV contamination.
One might even argue that on a cost/benefit basis,
it not worth going through all this effort, but would that
be right? I do not think so.
In spite of all the difficulties involved, it is
essential that this committee support the establishment of a
system that will result in the notification of patients, not
just suppliers, that there is a reasonable probability that
they have received tainted blood.
In addition, there should be a system comparable
to that which occurs in genetic counseling in which the
issues involved are fully explained to the patients. They
need to have the opportunity to know what their exposure is,
what the risks are, and what steps, if any, they can take to
address them.
This system, which would be a kind of ex post
facto informed consent, would be of tremendous benefit to
patients and their families. It would treat them fairly and
provide them with the opportunity to make individual
judgments about their medical status. I would suggest that
it should be paid for by an assessment against for-profit
blood centers.
I realize that much of what I have addressed is
beyond the scope of this advisory committee, but I do not
believe that you can adequately address the singular issue
that you are currently studying without taking into
consideration the larger universe within which patients
operate.
I thank you for the opportunity to present the
views of the Cooley's Anemia Foundation.
DR. CAPLAN: Questions? Thank you for those
statements.
I think what we will do is move, unless there are
others who might want to address the committee in the open
session? All right, then what I would like to do is move to
some input from the agencies.
Is Dr. Mied here? I didn't see him before. Oh,
he's hiding out there. Why don't you come forward, and
we'll maybe do these next two, and the move to a break after
that. I know there are some caffeine-dependent souls, but I
think we can do these two.
Dr. Mied, from the FDA.
Agenda Item: Agency Discussion, FDA - Dr. Paul
Mied
DR. MIED: Thank you, Dr. Caplan.
This morning I am going to summarize the FDA
policies related to lookback for transfusion transmitted
infectious agents. Then present some issues for
consideration in addressing the potential utility and
optimal design of a program of transfusion recipient
notification for HCV.
The issue at hand is whether and how to focus a
program aimed at the identification, notification, testing
and counseling of persons who may have been infected with
HCV through transfusion. Assuming that such an effort is
appropriate, what would be the most efficient way of
identifying the largest number of HCV infected transfusion
recipients?
Lookback refers to two procedures: product
retrieval, the tracing and retrieval of previous viral
marker negative collections from a donor who now tests
repeatedly reactive; and recipient notification, the
tracing, notification and counseling of recipients of these
prior negative units when the donor now tests positive.
There are two reasons for performing lookback.
When a donor now tests positive on a viral marker test,
product retrieval can be performed to interdict earlier
potentially infectious viral marker negative donations,
which may have been made when the donor was in the
infectious window period.
As you know, the window period is that time
interval between infection with the virus, and the
appearance in the blood of a viral marker such as an antigen
or antibody which is detectable in a serologic test for that
marker.
Secondly, to notify transfusion recipients so that
they may be tested and counseled regarding the risk of
disease, the availability of treatment and prevention of
secondary transmission. The current lookback policy for HIV
consists of both lookback procedures.
Recommendations for product retrieval. When a
donor now tests repeatedly reactive, and for recipient
notification related to prior collections from a donor
currently testing positive for antibody to HIV were put in
place in April 1992, in an FDA recommendation to blood
establishments. FDA also published a final rule in
September 1996, to require certain lookback procedures for
HIV.
The HIV lookback rule states that if a donor tests
repeatedly reactive on a screening test for antibody to HIV,
the blood establishment should promptly quarantine previous
collections intended for transfusion from that donor from
the past five years, or back to the time 12 months before
the last negative antibody screening test. If the data of
the last negative test is known, units collected more than
12 months prior to this date need not be quarantined. If
the data is not known, all units collected previously should
be quarantined.
Blood establishments should also quarantine
previous collections of plasma from the past six months if
intended for manufacture into injectable products. Now this
refers to unpooled units of source plasma or recovered
plasma, and this time period is limited to six months,
because that represents the practical limit of time that
plasma for further manufacturing generally remains in
inventory prior to pooling.
Now in addition to quarantining prior collections,
the blood establishment should also notify consignees such
as hospital transfusion services and manufacturers of plasma
derivatives of the repeatedly reactive HIV screening test
result so they can promptly quarantine prior collections
intended for transfusion, or unpooled units of plasma from
that donor until the donor status is clarified through
further testing.
The blood establish is also required to promptly
test the current donation using a licensed, additional, more
specific test for anti-HIV-1, and to notify consignees of
the result. Consignees should be notified of the results so
that they can release those quarantined units if the test is
negative, or destroy those units if the result is positive
or indeterminant. Notification of consignees regarding the
results will also enable those consignees to carry out
notification of transfusion recipients if the supplement
test is positive.
These transfusion recipients shall receive
notification for the purpose of testing for evidence of HIV
infection, early treatment if indicated, and counseling to
take appropriate precautions to prevent the further spread
of the virus such as to sexual partners. The transfusion
service shall notify the recipient's attending physician,
and ask him or her to inform the recipient of the need for
HIV testing and counseling. If the physician is unavailable
or declines to notify the recipient, the transfusion service
shall do so.
So that is a summary of FDA's policy for product
retrieval and recipient notification for HIV.
Now the usefulness of recommending similar actions
for hepatitis B surface antigen, anti-hepatitis B core,
anti-HCV and anti-HTLV-1 has been discussed at several
public meetings of the FDA Blood Products Advisory Committee
over the last five years. For each of these viral markers,
it has been necessary to examine the probability of units
from prior collections being infectious based on the
significance of the subsequent test information.
Now although FDA believes that currently there is
a very low risk of transfusion transmitted HBV, because of
the sensitivity of screening tests for HBV infections, and
although there is a continued absence of licensed
supplemental tests for anti-hepatitis B core and anti-HTLV-1,
FDA has determined that quarantine of in-date prior
collections from sero converting donors will provide an
added safeguard to the blood supply.
As a result, in July 1996, FDA issued a memorandum
to blood and plasma establishments which recommended product
retrieval for HBV, HCV and HTLV-1. The FDA recommendations
concerned the quarantine and disposition of prior
collections extending back five years from a donor who now
tests repeatedly reactive. If there is a record available
of the donor's last negative test result, then quarantine of
prior collections need only extend back to 12 months before
such a test.
Blood establishments should also notify consignees
of such products, and request the quarantine of those
products. This recommendation is directed at in-date,
unpooled units that are in the blood establishments' and
consignees' inventories, not products which have already
been pooled or further processed.
FDA also recommended additional testing of the
donor's current repeatedly reactive sample. For units
previously distributed, consignees should be notified of the
results of the additional testing so that they may either
release or destroy those quarantined products as
appropriate.
However, in regard to products already transfused,
FDA did not recommend consignee notification for the purpose
of recipient notification for HBV, HCV or HTLV-1 in this
memorandum.
In September 1991, the Blood Products Advisory
Committee recommended that additional information should be
obtained before recipient notification could be considered
for HBV.
Additionally, the committee decided that the data
available at that time did not justify recommending
recipient notification for HTLV-1, and advised FDA to
consider such recommendation for HTLV-1 when additional,
more specific licensed tests become available. As you know,
there are still no licensed supplemental tests for anti-HTLV-1.
I should point out that when screening for HTLV-1
antibody was implemented in 1989, blood establishments
voluntarily initiated notification and counseling of
recipients of blood or cellular components from donors who
have a confirmed, positive test for HTLV-1, -2 antibodies.
Since the number of infected donors identified were small, a
sequential, targeted lookback program was recommended by the
American Association of Blood Banks, and implemented without
much discussion or controversy.
In summary then, lookback policies currently in
place for these transfusion transmitted agents include both
product retrieval and recipient notification for HIV, but
only product retrieval at the present time for HBV, HCV and
HTLV. The question of whether recipient notification should
be recommended for these agents awaits further public
discussion of the legal, social and economic issues
involved.
Today, the Public Health Service brings before
this committee the issue of the usefulness of recipient
notification for HCV in the context of public health. The
screening of blood donors for antibody to HCV was
implemented in the United States in May 1990, when the FDA
licensed the first enzyme immunoassay for the detection of
anti-HCV.
Reflecting earlier discussions of the Blood
Products Advisory Committee, an NMWR issued in April 1991,
did not recommend at that time, product retrieval for HCV,
or targeted lookback, or general screening programs for
populations at increased risk of HCV infection for the
following reasons.
First of all, the lack of availability of a
licensed, additional, more specific test for anti-HCV could
lead to a high rate of following up of false positives on
the screening test. As you know, a specific supplemental
test for anti-HCV is now available.
Secondly, the anti-HCV screening tests were not
able to distinguish between ongoing infection and recovery,
thus the meaning of a repeated reactive result for any one
individual would not be clear. It is now clear that most
anti-HCV infected individuals have a chronic transmissible
disease.
Also at that time, 1991, many HCV infected donors
would have been deterred as a consequence of earlier
screening policies. For example, donor exclusion due to
risk factors of HIV, and implementation of testing for
surrogate markers for non-A, non-B hepatitis; that is,
anti-hepatitis B core, and ALT.
This deferral would make redonation and therefore
detection of HCV infection less likely, and this is still
true today. The available knowledge on routes of
transmission for HCV other than parenteral was limited at
that time, reducing the usefulness of medical counseling,
and this is still the case today.
Because of labeling limitations of approved
indications for alpha interferon therapy, only selected
persons were eligible for treatment for HCV infection, and
potential long-term benefits of such therapy were not known.
This is also still true today. Labeling limitations still
exist, and the long-term benefits of such therapy are still
not fully understood, although we know that some patients do
benefit from this therapy.
In March 1992, the FDA approved a multi-antigen
screening test which had increased sensitivity for
antibodies to additional HCV antigens. In June 1993, FDA
licensed an anti-HCV supplemental test, the REBA-2(?), and
the FDA Blood Products Advisory Committee unanimously
endorsed product retrieval from previous collections from
donors who test repeatedly reactive for anti-HCV, and who do
not have a negative result on a licensed supplemental test.
By a vote of five to four the committee marginally
endorsed consignee notification for purposes of recipient
notification, but reiterated many of the reservations
described earlier related to the lack of an established
public health benefit in performing this activity.
Now in deciding whether to recommend recipient
notification for a particular transfusion transmissible
infectious agent it may be helpful to address an antecedent
set of issues. These broadly applicable questions merit
consideration in addressing the potential utility and the
optimal design of recipient notification such as for HCV.
First of all, is the infection a significant
medical condition? We know that HCV infection is certainly
a very serious condition.
What is the incidence and prevalence of the
disease in the overall population? Is infection at an
epidemic level? If so, is it a new epidemic, or is it an
endemic condition?
What is the risk of transmission of the infection
by transfusion? What percent of the overall disease
frequency in the population is caused by transfusion? More
specifically, is transmission by blood transfusion a large
enough part of the total community transmission to merit
special public health measures? What is the risk of disease
following transmission of the infection?
What is the accuracy or specificity of the tests
for markers of the infection? Is there a supplemental or
additional test of greater specificity than the initial
screening test that is commercially available? Do the tests
distinguish between a chronic carrier state and being in a
state of recovery from the infection?
Are there opportunities for intervention
sufficient to warrant recipient notification? Are
interventions available? Is the disease treatable? If so,
is early treatment more effective than later treatment?
Can avoidance of co-factors such as alcohol be
recommended to the recipient?
Is there significant risk of secondary
transmission and disease? What are the roots, if any, of
secondary transmission of the infection? Is it transmitted
parenterally? Is it transmitted sexually? By household
contact such as sharing toothbrushes and eating utensils?
By other types of contact? What is the efficiency of
transmission by these different routes?
Is there opportunity for prevention of secondary
infection? Can intervention in lifestyle or activities
prevent secondary transmission?
What ethical considerations are involved in a
decision to notify or to not notify recipients? Should
recipient notification, if recommended, be prospective, that
is, subsequent to promulgation of a policy? Or should it
also be retrospective? For example, should the recipient
notification program be intended to capture all prior
collection before screening was implemented, or to capture
sero converters after screening was started?
The cost effectiveness of recipient notification
needs to be examined. Who should bear the cost, the
patient, the blood center, the government? A discussion of
these factors may suggest whether recipient notification for
HCV is justified.
Thank you.
DR. CAPLAN: Questions?
DR. PENNER: Do you have information on the
incidence and population? You referred to some figures
[inaudible].
DR. MIED: I have one figure. That is, that the
U.S. overall prevalence is about 2 percent. It is much
higher in certain areas for sure.
DR. PENNER: Would you agree that while all of the
information on positive tests from 1990-91, that information
would be available as a result of the Freedom of Information
Act if someone wanted to pursue that?
DR. MIED: I'm not sure I can answer that
question.
DR. CAPLAN: Other questions, comments?
I wonder if I could ask, on your slide that you
had up about the BPAC decision not to do consignee
notification, that was prior to some of the evidence about
alcohol use and so on wasn't it? In other words, the
situation has shifted somewhat about recommendations on
avoiding alcohol?
DR. MIED: That was back to 1991.
DR. CAPLAN: Yes.
DR. MIED: I don't think some more information has
come to light since then.
DR. CAPLAN: All right, if there are no more
questions, thank you.
Why don't I ask Dr. Margolis to come down from
CDC, who is also going to give us an agency perspective on
lookback. We'll do the break after we have had a chance to
hear from him.
Agenda Item: Agency Discussion, CDC - Dr. Hal
Margolis
DR. MARGOLIS: Thank you.
What I'm going to do this morning is to give you
kind of an update, since actually at the last meeting I
presented lots of data, and I think various segments of that
are going to be readdressed in the presentations today.
To kind of review a bit as I did at the last
meeting, it was this statement from the report the
Government Committee on Reform and Oversight that really has
prompted this agency look at what we are going to do in
terms of the issue of persons who are previously infected by
HCV that may have been transmitted by blood or blood
products.
This, as you recall, were what at least we were
framing as two questions that we felt needed to be addressed
in terms of real strategies that the department should take
to identify those persons who may have acquired their
infection from transfusion, to determine the infection
status, provide appropriate counseling in terms of medical
management, and then ultimately make recommendations in
terms of preventing future infections or transmission. Then
how should this effort be defined in a public health
perspective?
What I would like to do is really maybe frame a
few -- because we have pointed out the objectives were the
early identification of those persons with chronic
infection, and ultimately to reduce transmission. I think
if you put this in the context of a public health prevention
strategy, there are other pieces and I think it is important
for the committee to realize that at least we at CDC and in
other agencies within HHS are looking at the whole issue of
HCV prevention, which includes both acute disease
surveillance to prevent and assess what is going on with
prevention of new infections.
This is the issue which we are spending most of
our time discussing here, and which we feel is probably one
of the most important issues, is to educate the medical,
drug prevention and general community about HCV infection.
In terms of just some update information -- no hard data, no
slides -- but since we met the last time, we have had
several focus groups with physicians in terms of trying to --
and this is primary care physicians -- get to the issue of
what is it that they either know about HCV infection.
What would they like to see from an agency such as
us, and from those of us that are trying to educate? It
turns out that quite often a patient going to a primary care
physician, the physician isn't very knowledgeable about
diagnostic issues, about medical management issues, and as
you will see as I finish with this presentation, those are
some of the first things we feel are most important, is that
we have an informed medical community.
As I pointed out in the presentation last time, it
doesn't do us a lot of good to either generally educate the
public to go see their physician if in fact their physicians
don't know what to do.
Other parts of the prevention strategy include
implementing programs to prevent infection among drug users,
and to ultimately identify persons with chronic infection to
prevent transmission.
When one looks at the options for identifying
individuals at risk of infection, as was pointed out
earlier, one approach that has been suggested is that of
targeted lookback of transfusion recipients. I'm not going
to represent at least our model of what proportion of the
estimated 4 million infected individuals in the country we
feel are due to transfusion, but actually no matter how far
you push those figures, it is actually a very small portion
of the total HCV infected individuals.
The other approaches are that of educating the
public in general, and then as I said, educating health care
providers.
Probably to put this in a slide which I have now
updated from the last time was we are taking the approach
that if one looks at those individuals who may have been
infected by transfusion prior to the initiation of testing
in 1990, that it is really public and provider education
that is going to identify and appropriately handle those
individuals who may have been infected via that route of
transmission.
Again, it become physician and provider education
for having a high index of suspicious for that very small
number of individuals who have been infected during this
period between 1990 and the present. Then I think as you
heard, the sense is that for new sero conversions within the
donor population, the recipient notification is probably the
approach to take as we move forward, and has been proposed
in the draft by the committee.
The public issues are ones that quite frankly we
don't have necessarily the best approaches in terms of how
best to do this. There has been a lot of effort that has
been handled by voluntary agencies such as the American
Liver Foundation, who have been targeting a number of public
information activities.
I think also other voluntary health agencies that
deal with patient populations that may have been at risk for
specifically transfusion transmitted HCV infection have also
been carrying on very intensive and probably most adequate
educational campaigns.
Quite frankly, there are no data in terms of
surveys within the communities, though I think at least from
a conference held several years ago on the risk of chronic
liver disease among the hemophiliacs, and sponsored by the
American Hemophilia Foundation, at least there was some
survey data that suggested that essentially all hemophiliacs
under medical care had been in fact screened, and their
current HCV status adequately determined.
So again, in the very high risk populations, and
if one wants to look at that as kind of a combined medical
and public information issue, we feel that that has been
handled, but again, there are really no good survey data.
In terms of the remainder of the general
population, quite frankly at this point we feel there need
to be surveys, but really there hasn't been anything in
terms of determining what proportion of at risk individuals
have been identified.
Then again as I pointed out earlier, the need for
educating health care professionals.
[Tape change, text lost.]
. . . I'll put a slide up here in a minute.
I also have some handouts. There are also I
guess, extra copies out in the front. Let me also give you
these here.
What I'm passing out is the first document really
takes all the pieces of what I just put up in slides, and
tries to put some operational activities around it. This is
a working document that has been used at an Agency Heads'
Blood Safety Committee meeting just to review where the
various agencies are going in terms of these educational
activities.
I think at your leisure you can look through
these, but they basically just summarize some of the things
that I have mentioned, and include things such as the NIH
consensus conference, which was a major issue in terms of
providing a framework for physicians in terms of guidelines
as to where we are going, and how diagnosis, treatment and
management ought to be effective.
Another thing that we are doing, at least from the
CDC perspective is that -- I mentioned this again in the
presentation at the first meeting -- on November 22nd there
is going to be live, interactive satellite teleconference
entitled, "HCV Diagnosis, Clinical Management and
Prevention." In a two hour period, with case histories and
panel discussions and some of the experts being a part of
this, and again one of those handouts was an update on that,
we are trying to provide primary care physicians with take
home messages which include both what they are going to get
on the TV screen, as well as what they are going to get in
physical handouts.
Another thing that is going on besides what CDC --
this is being done by CDC and the Hepatitis Foundation
International, which is another liver disease voluntary
health agency -- is the American Digestive Health
Foundation's Hepatitis-Digestive Health Initiative, which is
again trying to provide take home message materials. In
other words, the easy to use guide to diagnosis, treatment,
medical management and prevention information that is also
going to be targeted to primary care providers.
So I guess what I want to do is just really let
the committee know that there are a lot of things going on
out there. In fact, I just came from a meeting yesterday
with the American Correctional Association, and talking with
all of the commissioners of corrections from all states in
the U.S.
Let me tell you that if one looks in prisons,
anywhere from probably 40-70 percent of prison populations
are infected with HCV; that is, at least, small surveys that
have been done. That really tracks with drug use, and this
is a major issue now within the correctional setting. Some
of those have acquired infections by transfusion, again
prior to 1990. What to do with that population is something
that is currently facing these people in terms of a public
health perspective.
We have also recently had a meeting with the
Council of State and Territorial Epidemiologists, a small
working meeting in terms of again, these public health
issues and how to get the message out, and how to deal with
such things as alternative test sites for HCV infection.
Nobody here in the blood banking community would
like to see people coming in to get HCV testing because
somebody comes in as a blood donor. We would much prefer
that there be in fact a place for testing to be done, for
those who can't afford testing because their current medical
coverage may not pay for that.
So these are some of the issues that are in fact
now beginning to come to the forefront, issues that are no
different when we saw with HIV, and which I think this
committee needs to be aware of as we move forward with some
of these prevention efforts.
At that point I'll stop I guess, and answer
questions.
The other thing I have, and which actually I will
do for everybody on this committee is that you will get a
little packet, so that you can publicize the teleconference
in your institution. As I pointed out, there are about 600
institutions that have signed up, and we definitely want to
make sure that physicians and providers at all levels take
advantage of this. It's free.
The production is free. The actual materials with
it, there is a charge, because there is going to be a
syllabus and materials that again, people can take home,
which will have many of the messages that we have been
discussing here.
DR. CAPLAN: Bill?
DR. HOOTS: Could you just refresh our memories
just in terms of the prevalence in non-high risk groups like
just a person off the street, male or female?
DR. MARGOLIS: Well, the data -- and I didn't go
back and put that up again -- but the data from the National
Health and Nutrition Examination Survey, which is a
statistical sample of the non-institutionalized population
in the U.S., the overall prevalence is 1.8 percent. That
translates to about 3.8 million individuals.
Unfortunately, in that data set, and when that was
done, and the midpoint of that is 1990, the question was not
asked as to whether you were an injection drug user. So
really those kind of risk factors that you would like to
have, are not available from that, but there are very
significant differences by race and ethnicity, with the
highest prevalences being in African Americans.
Again, these all tend to be younger individuals,
with kind of a mid age of around 40. So unfortunately they
are also predicting that there is potentially an epidemic of
chronic liver disease coming down the line.
I think I showed the last time also if one looks
in injection drug users, at least data from inner cities,
prevalences of 70 plus to almost 100 percent in almost any
population that has been looked at in the U.S., has been
found. So again, so the average person I think you can use
the approximately 2 percent prevalence.
PARTICIPANT: Dr. Margolis, I believe that there
are some CDC sentinel surveillance studies being conducted
by the CDC, along with I guess approximately 109 hemophilia
treatment centers, looking into the prevalence of hepatitis
in the population. Do you have any data on the morbidity
and mortality statistics there?
DR. MARGOLIS: Again -- and I didn't realize I
needed to go back and review -- I had shown that the
sentinel surveillance or the sentinel county of viral
hepatitis actually gives us our really only precise measure
of incidence, of new cases. In fact, the incidence of
hepatitis C has dropped by almost 90 percent since around
1990, most of that really attributable to apparent decreases
in incidence among injection drug users.
So that gives us new cases. New cases are down
dramatically. Again, some of the issues, as I put on that
slide, and one of the first things is actually the issue of
surveillance, our sentinel counties study, of which there
are four -- we now have another two counties we are just
adding -- actually because there are so few cases, we are
having a hard time accurately measuring new cases. So that
really means that every state in the United States needs to
start looking at hepatitis C. That is something that we are
actively working with state epidemiologists on.
The second question had to do with the hemophilia
treatment center surveillance, and actually I don't think
there is any summarized data at this point from that study.
That has really just, at least organizationally, gotten off
the ground here within the last year, and at least I'm not
aware of any data on incident cases of hepatitis C.
PARTICIPANT: The reason I asked that is I know I
was part and parcel of filling out the minimal data set. It
was requesting hepatitis C cases, you know, having done
studies for it. I think this is its second year. I was
just wondering if you had any kind of preliminary data on
that information, because again, it would ask us what are
the cases in which we have found that persons were deceased
due to liver problems.
DR. MARGOLIS: I'm not aware of, as I say, data on
incidence. I do know that there is a lot of data on
prevalent chronic infection in that population.
PARTICIPANT: I know that Dana is talking about
actually two different things. One is a data set which is
kind of retrospective and based on available data, and then
there is a prospective study, which I guess Dr. Margolis is
speaking of, in which the CDC will actually collect the data
on the hemophilia population prospectively. Pilots are
beginning this month for that.
In terms of the retrospective in hemophilia, the
problem, as you well know, comes from the complication of
multivariate risks, particular HIV plus HCV in terms of the
impact on death. I think the strongest data comes from Jim
Getter(?) and Elaine Isters(?) data that suggest that the
mortality rate in combination is very high in a relatively
shorter period of time than one would expect just with HCV
alone.
I don't think the natural history follow-up has
been long enough to get a good numerator over denominator.
DR. CAPLAN: Dr. Guerra?
DR. GUERRA: One of the very short-term
observations that we have made in San Antonio is I think we
an increasing use of the antibody testing to better define
the cause of liver disease, especially chronic liver disease
is that in 1996, and this was just something we looked at
very quickly without doing any specific analysis, there were
66 deaths we could directly attribute to hepatitis C that
was coded out on the death certificate, which was quite
interesting for us to have access to that information.
I wonder if there is some observation that is
taking place nationally from death certificate data, where
they are being signed out as hepatitis C?
DR. MARGOLIS: We have made estimates again, as I
had summarized at the first meeting, that there are about
8,000-12,000 HCV attributable liver disease deaths that
occur annually. That is based on applying prevalence data
from a single community study of all chronic liver disease,
to a national death certificate, multiple cause mortality
data.
We are, I hope, by the end of the next month here
in this fiscal year funding our first chronic liver disease
surveillance site, with the anticipation of at least having
four, maybe as many as six of these sites, to be able to get
national chronic liver disease surveillance, which will
include obviously HCV infection.
There is no such surveillance system at this
point. We have been struggling for several years to get
funding up, and we will fund the first one, and plan to fund
more. So I think we can then have national data, which will
also include information about potential source of
infection, realizing that you are going back pretty far
retrospectively. Again, I think it is going to be data
forthcoming. We don't have anything ongoing at this point.
DR. CAPLAN: Dr. Penner?
DR. PENNER: [Inaudible].
DR. MARGOLIS: We're hoping in the 10,000 range
minimum. I think with 600 sites, even if you have a few at
each site, we are already fairly well on our way. That is
our goal. Again, the materials that are being developed by
the Digestive Health Initiative are looking at probably a
similar number. Some is going to be overlap. We realize
you can't get all probably 40,000-60,000 primary care
physicians that are at least in some of the various
professional societies.
PARTICIPANT: [Inaudible].
DR. MARGOLIS: Well taken, and as pointed out,
when you have time, probably when you get back home and look
through that kind of implementation guide, the reality is
that I think everybody at CDC, NIH, FDA have been on the
talk circuit. That is from the agencies, and there are
plenty of other people in this audience who have been
attending and doing many of those meetings.
It is obviously a multi-pronged approach. We felt
that at least in this day and age, the input we are getting
is that the teleconference will capture -- and with CME
credit; this does have CME credit with it -- will capture
one segment of the primary care population so to speak. We
have been working with many other groups, and I think
everybody in this room who is at least dealing with chronic
liver disease or the blood bank community has been giving
those talks also. So it is not just single focused, just to
assure you that we are trying to look at those.
DR. CAPLAN: Mary Jane?
PARTICIPANT: Hal, I think you are probably aware
one of the proposals that was put forward by the committee
at the conclusion of its last meeting, and which I think
will be actively discussed in the next couple of days was to
include as part of the package of notification would be some
element of general education to physicians, providers and
the public.
I guess I wanted to ask you a sort of follow-up to
Dr. Penner's thoughts that if in fact the committee were
ultimately as part of its final recommendation to include
some sort of general education as part of the recipient
notification lookback strategy, do you feel that that would
fit with what you are doing now? Would any changes have to
be made, or further embellishment to the PHS education
program that is ongoing, that you are midst of right now to
accomplish that?
For example, your messages I'm sure include
transfusion before testing and et cetera. Could you just
kind of give that sense of --
DR. MARGOLIS: I think all of the messages that we
are discussing here in terms of risk factors are part of the
messages we are trying to get out. We have not gotten past
that bounds so to speak.
I think the intensity of it, and we have been very
honest in that in that update flow sheet I put down there,
there are some resource issues. All of this has been done
at this point, and again, let me just point out a few things
that are happening right now. There is a cooperative
agreement that is going to be awarded by the end of this
fiscal year, hopefully with at least two of the liver
disease voluntary agencies to assist in both trying to get
current information to the public and to health care
providers, as well as to develop new messages in areas where
there are gaps.
We know there are gaps out there. So getting back
to your comments, Mary, I think in terms of just the
magnitude of this, we need help, and we are trying to put
some money out there in that respect. CDC just initiated a
1-800 -- well, we're out of 1-800 numbers -- it's now a 1-88
numbers which are your toll free numbers for chronic liver
disease information. That just started, and again, that is
listed in that summary. That just started this month.
As I say, there is a lot of information that needs
to be out there for the public in various languages, in
various reading levels. I can assure you that has not been
encompassed with the same breadth that we have for let's say
hepatitis B vaccination, which we're a lot farther along
with. We and others, again, working with a lot of people
outside of the government, or trying to get these as quickly
as possible and as accurately as possible.
One of the other important areas is the broader
prevention issue, and we view that somewhere in 1998, we, at
least CDC, probably leading, but with all the PHS agencies,
need to really develop a conference on prevention issues for
HCV infection which bring in some of these other issues that
I brought up: getting this message into the substance
abuse, the drug use prevention community out there, the drug
treatment community, the public health community in general.
Frankly, nobody has been dealing with those at
this point. They are getting a barrage now, and they
realize we need some approach to this. I think
recommendations that come out of this committee will help to
at least set part of that in context.
I don't know if that answered your question. I
think the major risk factors are in there. Most of the
messages are there, and yes, we need to get different
iterations of the message out. I think that is the bottom
line.
DR. CAPLAN: Hal, do you have any success in
shifting knowledge about hepatitis C in preparing the
groundwork if people were to come with questions based on a
lookback, and dealing with the managed care industry at the
level above the individual doctor. This is on my mind,
because I was just out in Minnesota, and saw them trying
very hard to emphasize health maintenance in some of the
organizations that are out there.
So I'm just curious, what is the focus beyond
reaching to that individual practitioner, since so much of
our health care is now getting delivered at a higher
organizational level?
DR. MARGOLIS: We haven't opened those discussions
or those forums at this point. It is something on a long
list, and again, I can give you an example with hepatitis B,
where again we are already 10 years down the line with some
good prevention efforts. There has been in fact, a kind of
re-opening of that discussion; but, no, at least we haven't.
There may be others in other agencies that have, and it is
obviously something that has to happen.
PARTICIPANT: [Inaudible] on the lookback
situation and counseling that individual, because physicians
for one, won't. We know that there is the possibility of
cirrhosis. There is also the possibility of the infection
being trivial and of posing no impact on that individual's
lifestyle and how that individual is going to live and
ultimately die.
What is not clear is what are the risks. When a
physician presents this information to an individual
patient, he or she will want to know how do I counsel this
individual?
DR. MARGOLIS: I'm going to defer that question as
Dr. Seeff will present some of that data later. In fact,
Dr. Seeff is going to one of the participants in the
teleconference. I am going to let him deal with that in a
later presentation, because it is very important.
Our view is -- let me just put the overview on it
-- is that the primary care physician has to know the front
end risks. They also have to know what the hepatologist,
who they may be ultimately referring a patient to is going
to say in order to again, support those issues.
Yes, most people are not going to die from HCV
infection, and we have heard this again in some of these
small focus groups, is this is what the primary care
physician wants to hear in terms of how to counsel. I'll
let Leonard deal with that later.
DR. CAPLAN: One last question just on outreach to
different communities. This is from my sample since our
last meeting of asking some people with hepatitis C that
knew what to ask their doctors what they should do. None of
them could answer that question, so there is room. In the
three cases that I checked out in my ample survey design,
none of the doctors knew quite how to respond.
It did occur to me that these people said, well,
I'll ask my dentist, or I might see a nurse and I could ask
there too. What are we doing again, in terms of not just
for content, but where people are likely to get information
to reach out to those audiences? Any systematic efforts
that you are aware that go beyond the primary physician
audience?
DR. MARGOLIS: Again, in terms of targeting we are
putting a lot of our resources, personnel, time and efforts
at least into the front end of this teleconference, which
also helps us to get a message and materials that we can use
in a number of venues. We are sending information to try
and get nursing personnel as they would see appropriate.
We haven't targeted dentists, but we have gone
fairly wide in terms of providers outside the traditional
medical or physician community, so that's a start.
Obviously there are other groups that need to be targeted.
DR. CAPLAN: All right, if there are no more
questions? One out in the audience here.
PARTICIPANT: I just wanted to clarify a number on
prevalence. The 3.9 million estimate is based on the NHANES
data, correct? That is of the civilian, non-institutional
populations. It occurred to me when you spoke about going
to the corrections community this weekend, that you have to
add another 500,000 to that, since there are a million
institutionalized people. Then that doesn't include any
infection that there might in the military population. So
that's really a very conservative number, correct?
DR. MARGOLIS: Correct. That is how we state it,
that it is conservative. So it's really probably a minimum.
PARTICIPANT: Are you going to revise it so that
we would have an idea when we think about the numbers, that
really reflects the entire country?
DR. MARGOLIS: Well, we can add those on as data
become available. I think that right now the NHANES is
available. I think that gives us our best estimate to
grapple with, which points out that it is epidemic. It is a
very large number; so some of the criteria that were put up
here early on. Yes, we will try and add the others in as
best estimates become available.
DR. CAPLAN: All right, thank you.
Why don't we take our break at this point. So be
back here at say 11:15 a.m., and we will resume then.
[Brief recess.]
DR. CAPLAN: I would like to get underway. We've
got a number of other presentations. I wanted to thank Paul
McCurdy for helping me track down a number of people both
who you've heard from already, who we're going to hear from
for the rest of the day, really trying to respond to some of
the issues and requests for more information that came up at
the last meeting.
So we tried pretty hard to look for expertise,
both here and as you will see later on this afternoon, from
outside the United States, to get more information on some
of the themes and questions that you all had asked to hear
more about. One of the places we looked was down the aisle
and saw that Jim AuBuchon to actually talk about some of the
lookback issues. He has been studying some of these things,
and so I'm going to ask him to lead us off in this session.
Agenda Item: Cost-Benefit Analysis of Lookback -
Dr. James AuBuchon
DR. AU BUCHON: Thank you very much.
With the help of my colleagues as shown here, I
would like to present some data this morning on the cost
effectiveness of HCV lookback. In this presentation I am
focusing on the type of lookback that involves recipient
notifications. We are not talking about quarantining of
units. We're talking specifically about recipient
notification.
First to share with you my biases, I do speak
before you as a blood banker. There clearly are certain
roles which have come to be assumed by blood bankers over
the last several decades beyond just provision of a safe and
efficacious blood supply and management of donors and
provision of consultation, but also the concept of notifying
recipients of potential defects of those units that have
been provided to them.
The purpose of lookback, as you have hear
discussed very eloquently this morning, is to inform
recipients who have potentially been exposed, before they
discover for themselves that they have been exposed. The
concept would then allow for earlier therapeutic
intervention, possible interdiction of secondary
transmission to other individuals, and also information to
be provided back to the blood supply complex in order that
we could better address the issue of lookback in other
recipients who may have exposed from that same donor.
Now there are of course many problems with
lookback inherent in the system. It can be difficult to
determine who got a particular unit of blood. As time goes
on, more hospitals use a computerized recordkeeping system,
this is less of problem, but it remains a problem,
particularly as you go back in records beyond several years.
The location and contact of the recipients of a
particular unit of blood can be very difficult to ascertain,
particularly in a mobile society such as the American one.
It is important to have good clinical physician cooperation
in getting the information to the recipient, and that can
also be difficult as physicians tend to move around.
Follow-up care needs to be provided for the
recipients, so that the promise of therapeutic intervention
that may be beneficial can be fulfilled. If there is
potential secondary exposure the parties involved would also
need to be counseled, and that always raises an issue of
what these people should be told, and just how much is
legitimate to be shared with them.
It is very difficult to get information back to
the blood collecting agency after the lookback has been
completed, because the information has to flow usually
through several clinical care physicians back to a hospital
transfusion medicine specialist, and from there to a blood
center before any additional follow-up can be done. So it
is a tortuous pathway for data, to say the least.
With HCV lookback there are some specific issues
that cause more problems. Again as we have discussed some
of these already, a high proportion of HCV cases not related
to transfusion; not related to any known exposure route for
that matter. The number of transfusion associated cases is
declining even beyond that which can be explained by
testing. Secondary sexual transmission of HCV is
infrequent, so that is less of a reason to consider HCV
lookback and notification.
There clearly is a high rate of chronic infection
with HCV, but apparently a relatively low mortality
associated with that. We know that there is ineffective
treatment for late stages of HCV today, but we really don't
know if there is any better result of treating these
patients earlier on. We presume so. We would like to think
so, but we don't know that providing interferon therapy
early in the course of HCV infection really makes a
difference in who will go on ultimately to have cirrhosis or
other late stage problems.
We have problems indeed with the test itself that
we would be hanging our hat on in this notification system,
because of false positivity, and the fact that we are really
not determining infectivity, we are just determining prior
exposure of a donor to the agent.
Also, we have to acknowledge that today the
majority of the lookback cases are from transfusions that
occurred over five years ago, which makes tracing even more
difficult.
Because of all of these problems, and because of
the potential expense involved, about a year and a half ago
we began to look at the HCV lookback question with an idea
of applying decision analysis. Decision analysis is just a
mathematical model to project the effects of a particular
clinical decision or a public health decision. The model
then allows you to project the effect of a particular
choice, use of an intervention, and the amount of resources
consumed in the delivery of that intervention and the
downstream consequences.
Now decision analysis techniques can be used in
two basic modes. They certainly can be used on an
individual patient basis to try to quantify for a patient
who is choosing one of two different treatments, the
likelihood of them reaching the desired goal of better
health versus the chance that they may come into a side
effect.
The option here obviously is an attempt to
maximize the patient's health, and decision analysis can
provide some data for the physician and for the patient in
choosing the best approach.
Today we'll be looking at another application of
decision analysis, and that is more of a population-based
approach or macro economic approach where we are trying to
determine the relative benefit for resources expended to a
group of patients, or to the population as a whole. So the
concept here is if one spends a certain amount of money,
what is the benefit in terms of increased health for the
population?
Now all of us would like to have better health for
ourselves and for the population as a whole, and we know
that like most things, if we put more money into it, you
will get more benefit out of it. Unfortunately, the law of
diminishing returns certainly applies here. As you put more
resources into health care, you will still get better
population health, but the curve does flatten out.
Now what everyone would like us to do including
Congress, would like those in the health care system to
spend less money and get more improvement in population
health. That is a great idea. That is extremely difficult
to do.
What no one wants us to do is to spend more money
and not get any benefit out of it. That just doesn't make
any sense. Usually the question is, there is a new
intervention, a new way of doing something that provides an
improvement of health, but at an increased cost. What is
the angle on this yellow arrow here? Or in the vernacular,
what is the bang for the buck for this additional investment
in health care?
So this is a situation where decision analysis can
be helpful when there are multiple interventions that can be
applied, and their outcomes are not the same, or their side
effects are different, or when the resources they consume
are different, either direct resource consumption or some
indirect costs, and particularly when resources are limited.
When we can't spend all money on all projects for all
people, where can we get the most benefit out of directing
our resources?
There are many forms of economic evaluation that
can be applied in circumstances such as this. Cost-benefit
analysis is mentioned frequently, but actually done
relatively infrequently, because the end result of a
cost-benefit analysis really usually only ends up being a
restatement of the problem, but possibly with some
quantitation.
Instead, I would like to discuss today the use of
cost effectiveness analysis in this situation. Cost
effectiveness analysis is a methodology for evaluating
outcomes in costs that usually ends up in determining what
is called the cost effectiveness ratio.
It is a mathematical formula where you try to
gather all the information about the health effects of an
intervention, and put that in the denominator, and all the
changes in resource use, one intervention compared to
another, are captured in the numerator. So you end up with
a mathematical ratio.
Now just a comment on including not only the
length of life, but the quality of life, because in these
analyses that is important. We all want a long life, and we
would like this to be as long as possible. We would also
like a high quality life, that is, being able to do whatever
we would like to do.
If there were two interventions that both allowed
10 years of additional life, we would want the one that
provided the best quality of life, and that is usually
captured mathematically, or it could explained graphically
as well, you are trying to get the greatest area under this
longevity/quality curve. Trying to have the greatest
quality of life for the longest time period, just an
acknowledgement that not only is length of life important,
but quality as well, and that needs to be factored in.
In most cost effective analyses the terminology
which comes out is dollars spent per quality adjusted life
year. Well, what is a quality? It is not an unusual kind
of duck found only in New Hampshire. It is a mathematical
expression that takes into account the length of life and
the quality of life.
So for example, if two years of life were added to
a patient's life, and those two years were spent in
absolutely perfect health, the quality factor would be 100
percent, and that would then add 2.0 quality adjusted life
years to the model.
If, however, the patient had some other type of
morbidity, such as fatigue, the quality of life would be
reduced. Now the assignment of quality factors is a whole
other science in itself or an art form in itself, but I have
just picked 80 percent here to show you. You would take the
80 percent quality adjustment factor, multiple it by two
years of additional longevity, and the intervention would
then be said to provide 1.6 quality adjusted life years, and
so forth and so on.
Death is assumed to have a quality adjustment
factor of 0.
The end result then is the cost effectiveness
ratio, or marginal cost effectiveness, where the differences
in resources consumed between two different interventions is
compared to the difference in the outcome they provide. So
one needs to tally the cost of intervention A, and subtract
the cost of intervention B, and divide that by the
differences in outcome that they supply. That is usually
expressed as the life expectancy times the quality of life
between the two interventions.
Now this has been done numerous times. Many
people have made their academic career doing these kinds of
analyses, using fairly standardized approaches. What I'll
show here is just some numbers that have been generated.
There is no congressional mandate that any particular
threshold be met, but very commonly accepted medical-
surgical interventions have a cost effectiveness which
numerically comes out to less than $50,000 per quality
adjusted life year.
That is not to say that is what a year of life is
worth, but that is just how it usually works out. So for
example, giving Rh immune globulin prophylaxis to Rh
negative mothers to prevent future children from having
hemolytic disease of the newborn costs about $2,000 for
every year of life, called adjusted year of life, that is
saved.
You can see here is a range of examples. Even
some things that the public often thinks of as being
relatively exotic or expensive come in below this $50,000
per quality adjusted life year benchmark. Again, there is
no absolute requirement that this be met, but it is very
commonly found.
So decision analysis then provides a means of
comparing alternative treatments, particularly those that
have the same outcome, in an objective manner in order to
determine the resources expended, and the outcome benefit
that is achieved.
There are some limitations to this approach. For
example, it is very difficult to value intangibles. There
is no way to capture a non-economic variable very well
unless it affects the quality of life or the longevity of
the patient.
We have to take into account that not all
expenditures happen in current time, and not all benefits
occur in current time, and for both benefits and costs, a
discount rate needs to be applied to future expenditures and
future benefits.
It is very difficult to apply these models to a
particular patient. When N equal 1, the statistical
theories don't work real well obviously. That won't be a
concern of ours today.
I will point out that every one of the models that
you see in the literature has assumptions embedded in it.
It is not possible to entirely recreate reality in a
mathematical model such as this. So there are also
assumptions that go along with it. One has to read the fine
print, and the assumptions can in some cases, shade the
results one way or another.
To actually apply decision analysis, it's a
relatively straightforward thing to do. One first needs to
define all the possibilities that could occur after choosing
a particular course of action. That usually is seen as
drawing up the decision tree. Then one has to define the
probabilities of each one of these possibilities, and that
is usually done by reviewing the literature.
Finally, one needs to determine the cost and
determine the outcomes for a patient following each one of
the paths through this decision tree. This is usually done
either by reviewing the literature, or gathering information
from your own experience.
Now to apply this to HCV, I would first like to
share with you some data that we presented at last year's
meeting of the American Association of Blood Banks, looking
at HCV lookback in sort of a universal framework. That is,
looking back to all donations occurring after 1985, once the
donor was found to be anti-HCV repeat reactive.
Using number which were provided by the American
Red Cross and estimates of how frequently individuals
donate, we were able to predict that from 1990 to 1995,
there were approximately 91,000 repeat HCV positive donors,
that is, anti-HCV repeat reactive donors.
We then surmised that there would be five
transfusable components on average from each one of these
individuals, leading to about 450,000 components that were
eligible for HCV lookback, extending back as far as 1985.
This lookback system only works if the donor has donated a
second time, or has a prior donation.
The actual lookback tree, to give you an example
of what one might look like, is shown here. If there is a
component on which lookback could be processed, one has to
make the decision, is lookback done or is lookback not
performed? If lookback is performed, is the patient alive
or deceased? Obviously if they are deceased, there is no
benefit that can be achieved by tracing them; that is one of
the assumptions of the model.
If they are alive, they need to be traced to their
current location, and they need to respond in order for them
to get some benefit out of this system. If the patient is
alive but is not located, or does not respond, you have the
same situation as if no lookback has been performed at all.
In that case, there is the possibility that the patient
really had been exposed, that is the units that they had
received really had been infectious, and that they may had
gone on to develop chronic HCV. There is a possibility that
might not have developed chronic HCV.
If the lookback recipient is alive and does
respond, you have to consider also whether or not they were
truly exposed, or whether the situation was one of false
positivity. Have they developed chronic HCV? If they have,
are they suitable for some type of therapy, which we have
modeled here as interferon therapy. If they receive
interferon therapy, do they get any benefit from that?
Now here are some of the assumptions, and I don't
mean to bore you with all the details, but there are
important from a logistic and practical point of view. We
assumed that all blood centers had computerized records that
could be used for tracing units. If a blood center does
not, it has a big impact obviously on their cost.
We assumed that manual transfusion records were
available for donations prior to 1990 in hospitals, but that
computerized records were available after 1990. That's an
oversimplification obviously. We assumed that all
components distributed were transfused, and recipients only
got one exposure.
We assumed that the average age of transfusion and
notification was 60. This will become important in future
iterations of this model.
We assumed that all the HCV cases eventually are
diagnosed and followed, even if they aren't found through
this system. We assumed that treating when a patient had
asymptomatic HCV was effective, and that treatment later
would not be effective. That's a large assumption.
We assumed that there were no quality of life
adjustments for those patients receiving therapy. In other
words, we assumed that therapy has no side effects; that's
not exactly the case. We essentially considered all of the
recipients just as one group.
Here are some of the probabilities that were used,
assuming that 60 percent of the recipients were still alive,
about a 33 percent chance of tracing a recipient and getting
them to respond from the data based on the HIV experience; a
40 percent false probability rate.
About 70 percent of individuals with chronic HCV
would be suitable for interferon therapy, and 15 percent of
them would get some lasting benefit out of that therapy. In
addition, we assumed that if the treatment were
unsuccessful, or if there were no treatment, the HCV excess
mortality would be about 0.35 percent per year.
Now for some costs. The committee was very
interested in cost data at our previous meeting. Some of
these are estimates. Some of these are based on published
statements of cost. I show you here what it can amount to,
and it can be significant.
For example, identification of past units, about
$137 per donor, and an average of five donations being
involved for that $137. It's about $27 to trace and contact
a patient with a standard letter. If the individual needs
additional care, additional follow-up, you can see the costs
there.
We also had to come up with some estimates of
longevity based on published estimates of longevity after
transfusion, that is, if there were no HCV effect, about
12.4 years is the baseline longevity. With chronic HCV for
which there is no treatment or no effective treatment the
average decrement is a half a year, again, related to the
fact that there is relatively little excess mortality of
chronic HCV infection on average. The successful interferon
therapy would take the longevity of the patient back to the
baseline.
To show you overall cost then, if there were no
true exposure, the cost per recipient, that is cost for
completed lookback case would be $364. If interferon
therapy were applied and successful, $4,000. If you were
unsuccessful, you would have not only this expense, but the
expense of taking care of the patient's HCV anyway, and so
forth. So the expenses per case can be quite high.
Overall, the cost effectiveness calculated to
about $88,000 per year of life extended, or quality adjusted
life year. This then is slightly higher than the $50,000
that is seen for most commonly used medical therapies, but
they are not entirely out of the ball park.
I would note what happened; how is it we ended up
with something that wasn't quite as efficacious as we might
have wanted to? We started out with 460,000 recipients to
notify, of whom 60 percent were alive at the time of
lookback; 33 percent of those were traced and responded and
so forth and so on.
You can follow the numbers down to in the end the
yield, in terms of patients actually benefitting were less
than 1 percent of the recipients for whom the notification
was originally directed. So overall less than 1 percent of
recipients whose name came up as part of this lookback model
would achieve any benefit out of having received the
notification and gone through the therapy if that were
appropriate; a much smaller number than most of us would
like to see probably.
Showing the same thing here graphically; 91,700
anti-HCV positive donations, yielding 460,000 recipients to
notify. We lost some to intercurrent death; some couldn't
be traced; some wouldn't be able to be traced; some were not
actually exposed; not all had chronic HCV; not all of these
were suitable for interferon therapy, and we're left with
less than 1 percent that actually benefit from the whole
exercise.
Now in any cost effectiveness model certain values
have to be assigned to each variable, but those are somewhat
arbitrary. We don't know precisely the value of many of
these variables. So what's called a sensitivity analysis is
performed, where you vary the value assigned to particular
variables and see what happens to the results, to see which
variables have the greatest effect on the outcomes; to see
what the outcome is sensitive to.
So for example, look at the line here at
interferon benefit. Here is the number we used in our
baseline analysis, but it's a very steep curve, so any
change in this variable is going to have a large impact on
the outcomes for example.
We went through and looked at that for each one of
the variables, and you can see here that the number is not
important. The concept that if you change the proportion of
patients who benefit from interferon therapy, this would be
a large change in the cost effectiveness analysis outcome.
Also, the proportion of patients who are alive at the time
of notification can have a big effect on the outcome.
The patient age is very important here as well.
Notice that 60 years of age was our base case, but we could
also look at younger groups of patients. Not too
surprisingly, the cost effectiveness number gets better when
you go to younger and younger patients, because more of them
are likely to be alive, less likely to have died from
intercurrent illness. Also, more of them are likely to be
suitable for interferon therapy, so they can actually get
some benefit.
Therefore, from a preliminary observation on HCV
lookback we found that fewer than 1 percent of the
recipients to be notified get any benefit, and the
effectiveness was very dependent obviously on early
treatment being better than late; but younger recipients
would do better, and if we had more effective therapy, the
outcome result would be much better.
This is, as I said, what was presented last year.
Today I would like to propose some new data for your
evaluation, looking at some alternative approaches to target
the lookback -- so a difference use of the word "target"
than other speakers have used -- to target the lookback,
looking at those transfusions that have occurred in specific
time periods.
Concentrate on those situations, particularly
recent transfusion, where we have greater probability of
tracing. We can get a younger age of the patient
notification, and we can possibly base the notification on
confirmed positivity or supplemental test positive
positivity, as opposed to just the screening test positivity
as we have had in the past.
So previously we looked at all donations back to
1985. One option would be to look back to donations of 1990
and forward. Another would be to look at donations as far
as back as 1990, but use as the incident donation, only
those donations that were found positive in the second
version of HCV testing. A third option, only looking back
to donations in the last two years, similar to one of the
proposals before the committee.
So the option here in two and three, would then
allow us to look only at confirmed positivity, or again,
those donors who had had supplemental tests performed, and
were positive in the supplemental testing. What would that
do?
Well, it would allow us to focus on the people who
are most likely found to really be infectious based on Red
Cross data, using what is commonly known as "REBA 3.0."
About 60 percent of their repeat reactives come out to be
positive, and actually three-quarters of them are truly
infectious.
Using these data in each year, looking back for
two years, one would have about 23,000 repeat donors who are
HCV positive by this definition, and an estimate of 3
transfusable components from prior donations for each one of
these donors, yielding each year about 69,000 components per
lookback.
Shown here are the three different options and
some of the variables used. I would just like to point out
that by looking at shorter and shorter time periods closer
to the current time, we are able to reduce the mean age at
notification, and have an improved probability of the
recipient of that notification information being suitable
for interferon therapy.
Also, by restricting our interest to those donors
who are actually confirmed by supplement test positive for
anti-HCV, we have a greater likelihood of really targeting
those recipients who had been exposed to HCV through their
transfusions. Some additional assumptions need to be
included in the model. The most important is that all of
the version 2 and 3 EIA tests are confirmed or
supplementally tested.
Who would be involved in this? You can see the
numbers here of recipients actually benefitting. If we were
to look at more recent times, this number increases to the
point where we are looking at just the last two years.
About 1.7 percent of recipients who are notified would
actually achieve benefit. It's not huge. It's not 50
percent. It's not 90 percent, but it is better than less
than 1 percent.
The costs would decrease as the length of time
period of the lookback decreased such that for example if
you are looking at the last two years, the cost of the blood
service industry of providing this information would be
about $17 million per year, as opposed to about $173 million
with an open-ended lookback back to say 1985.
The cost effectiveness is also improved with
targeting more recent donations. You can see here if you
look at just the last two years, the cost effectiveness is
$42,000 per year of life extended, as opposed to what I
showed you earlier at $88,000.
So what are we trading off here? You can see that
as the treatment becomes more beneficial, the cost
effectiveness decreases; but the cost effectiveness is
already lower for any one of these options than the previous
analysis where we looked at all donations.
Additional benefit would be achieved in terms of
improved cost effectiveness if we had more beneficial
treatments, however, the downside is that fewer patients in
terms of absolute numbers would benefit, because we are not
going to be going after, not going to be attempting to
identify those donations that occurred prior to 1990.
So if you looked just here at the base case
analysis, you see if we looked at all donations back to
1985, we would probably end up notifying about twice as many
people as if we only looked at the last two years. The
benefit here is that the likelihood of the recipient
actually getting any benefit from the notification would be
improved.
So where does this leave HCV lookback in the cost
effectiveness scale of things? Shown here are some other
analyses that have been done on the cost effectiveness of
various blood safety initiatives and issues related to blood
safety. You can see that it actually looks like a good deal
whether you look at the prior analysis, the $88,000 per year
of life extended, or the current analysis shown in the dark
green. It looks like HCV lookback is a more cost effective
approach than many other things that blood bankers have done
over the last decade to improve the safety of the blood
supply.
However, on a different scale now, if you look at
HCV lookback compared to other more public health-type
issues, you can see that in general it still does not fare
particularly well unless you use the approach of limiting
the lookback to those individuals who are most likely to get
some benefit for limiting it to those donations that are
most likely to have transmitted the disease. In that case
then, that brings the cost effectiveness estimate of HCV
lookback down to within the same range of commonly accepted
public health measures.
So in conclusion, just note that the effectiveness
of HCV lookback is very critically linked to the age, the
date of transfusion and the effectiveness of therapy. The
cost effectiveness is similar to other preventive measures
if it is restricted to more recent transfusion. Obviously,
if we are ever success in medicine at developing more
effective therapies, this would affect the yield of the
program positively.
Just a cautionary note, that again the model did
assume that all version 3.0 reactive tests and the version
2.0 reactive tests that haven't been subjected to
confirmatory testing, were subjected to confirmatory testing
before the lookback process began, and that is not case as
to what has happened in most donations today.
Thank you very much.
DR. CAPLAN: Why don't we open the floor for some
questions and comments on this very interesting model.
Anybody on the panel?
I had a question for you, Jim. If I followed this
correctly, it seems to me that the real benefit is in the
interferon therapy for the correctly identified HCV infected
person. How would the calculations change -- not that you
are going to do them on the back of an envelope -- but if
you had people who stopped drinking or prevented
transmission by going to safe sex practices in some small
percentage way, or even factoring in just what we sometimes
hear about people wanting to know their status; those sort
of marginal harder to measure things. Any comments about
how those would alter the cost effectiveness that you gave
us just for the interferon therapy alone?
DR. AU BUCHON: Good questions. Patients may feel
better having a transfusion, knowing that they will be
notified if there is any potential problem of their unit in
the future. That type of psychological benefit would not be
captured in an analysis such as this, because on almost all
patients it would have no bearing on their future health.
No one is likely to require psychiatric hospitalization
because they weren't notified, or knew that they were not
going to be notified.
The benefit in this model was directed at looking
at interferon therapy. Everything was associated with
interferon therapy. If for example, interferon therapy and
cessation of alcohol consumption would improve the outlook
for the HCV notified recipient, then the benefit might not
be 15 percent, we might to go to 20 or 25 percent, or some
higher number. Obviously, that would improve the cost
effectiveness.
That is why I showed you some of the sensitivity
analysis curves to show that if therapy were more effective,
the cost effectiveness looks better. So it's all been
stated as an interferon benefit, but obviously what we are
talking about is just medical benefit, which interferon
apparently today is the largest interventional part.
PARTICIPANT: Ninety-one thousand is a problem.
About how many might be first time donors? Do you know?
DR. AU BUCHON: The 91,000 number takes that into
account already. I was using American Red Cross data where
88 percent I believe, shown on the slide, of their donations
are from repeat donors. That has already been taken into
account in the calculation.
PARTICIPANT: What were the products then that
they were going to elaborate?
DR. AU BUCHON: It was assumed that these where
whole blood donations that were going to plasma, platelets
and red cells. They would not all be transfused. They
would not all have been actually transfused and so forth.
So the number of components, the number of donations there
was estimated based on the Red Cross data from units
prepared from number of donations collected.
PARTICIPANT: Only some of those units are going
to have platelets, and only some of them are going to have
fresh units of plasma.
DR. AU BUCHON: That's correct.
PARTICIPANT: Other units of plasma will go to
fractionation, which will have some detergent treatment
after the fact, so probably the possibility of imparting
infection is going to be very limited, if at all in those
[inaudible]. So that might be subtracted out. So I guess I
question really the figures and the significance without
having the data at how they arrived at for the total number
of something like 400,000.
DR. AU BUCHON: This model only looked at the
transfusion of blood components. It did not look at blood
derivatives, because as you say, of the viral inactivation
techniques that are used for blood derivatives today. There
would be presumably no lookback that would yield any
benefit.
PARTICIPANT: To get the 400,000 figure you would
have to have four, at least five different products from
that each unit, and I don't understand it.
DR. AU BUCHON: It was assumed that with each
anti-HCV positive donation from a repeat donor, that there
would have been five transfused components at some time in
the past with that donor, over the previous 10 years.
PARTICIPANT: Then you also figured in the cost
for management of these cases, but that cost would be there
anyway, wouldn't it? The chronic hepatitis C problems of
hepatitis.
DR. AU BUCHON: It was assumed that the -- and
this may not be an accurate presumption as we gather more
information about hepatitis C -- it was presumed that the
vast majority of hepatitis C cases, although they may be
chronic in nature, are asymptomatic, and that they are not
always detected. Once detected, obviously a physician is
going to be following them closely.
PARTICIPANT: So you would not cost in the
treatment program of any sort, since the treatment is going
to go on anyway?
DR. AU BUCHON: For those individuals who were
notified of their potential exposure, and who were found to
be HCV positive, they would then be evaluated for potential
treatment, yes.
PARTICIPANT: But then treatment with interferon
for example, would go on and be handled anyway if the
patient came to the attention of a physician?
DR. AU BUCHON: Yes.
PARTICIPANT: So therefore that would not an
additional cost to the program?
DR. AU BUCHON: That's correct.
PARTICIPANT: So that's got to be excluded, right?
DR. AU BUCHON: And it is not included here.
PARTICIPANT: From the presentation, it looks to
me like the cost effectiveness was based upon the interferon
treatment, and the recipients benefitted; approximately like
1 percent of them did. Now it seems to me also that the
cost effectiveness bottom line could change, since you were
saying there was a response to notification of 33 percent;
at least that's what I understood it.
If these persons, 33 percent, did respond to the
notification, I think the bottom line could change. It
would allow for identification of these persons, resulting
in follow-up limited treatment, which would be the alpha
interferon. Also health maintenance, and also the
availability that when new, future therapies came on the
scene, they could be utilized. Then that would increase the
cost effectiveness. Is that correct?
DR. AU BUCHON: Absolutely. If the patient
doesn't respond to the notification, the system can't track
that patient, can't apply the future benefits. That is
entirely correct, which just reinforces the concept that the
more recent transfusions that are then included in the
lookback system are the ones that are most likely to be
beneficial, because we have a better chance of finding the
patient. They are probably still in the health care system,
probably still with the same physician or HMO.
DR. CAPLAN: We have time for one more. Eric,
over here?
DR. GOOSBY: I just wanted to get a little bit
better feel for the impact of your [inaudible]. In looking
at your sensitivity analysis, any minor change really in
response rate will have a fairly large impact on
[inaudible]. What exactly were you defining as a response
that determined that 15 percent? If you look at data for
people who were treated with alpha interferon, you get
responses way up into the 70 percent rate, but persistence
greater than two years, persistence greater than one year,
what exactly were you looking to determine the 15 percent
response?
DR. AU BUCHON: Fifteen percent was our reading of
the literature as the likelihood of a long term response.
Two years would be reasonable of PCR negativity; someone who
had truly cleared the virus, cleared the infection.
DR. GOOSBY: It is also reasonable to assume that
drops in viral load with hepatitis C improves one's clinical
course, although that has not been completely proven. I
don't know if the committee -- we passed out the
Hoofnagle(?) article at the last meeting. I just want to
highlight that for the committee, that that does look at
some of that data, specifically looking at the less than
optimal two year drop [inaudible]. In light of its kind of
disproportionate impact on the calculation, it is important
to keep that in mind.
DR. BUSCH: In your introductory comments you
pointed out that the cost effectiveness is preferred,
because you can really contrast various potential strategies
and just make choices, rather than having to put dollar
values in. You attempted at juxtaposing three options with
respect to lookback in that vein, and that's very useful,
because that is what the committee is struggling with.
I'm a little bit concerned that the last strategy,
which you concluded seemed to be most cost effective, didn't
incorporate an issue that we have chatted about.
Specifically, the units transfused prior to 1990, that are
from donors that are found positive now, unscreened product
from donors known positive. The transmission rate of those
-- probably those donors were chronically infected, and
because they weren't screened, those units were going out,
and it was very high. The transmission rate was probably
about 70 percent, which is the rate of viremia among
sero-positive units.
From 1990 to 1992, we know that first generation
test was missing probably at least 10 percent or so of
chronic carriers; probably even more. So again, a donor is
negative on the first generation test, but then picked up by
the second generation test, there is a very high probability
that that donor was viremic and transmitting during that
prior period, again, probably in the range of 50 or 60
percent.
Whereas, second generation screened blood on,
which is really the period that you seem to be concluded was
the most effective, in those units the risk is very small,
probably 1 in 10,000, perhaps less. In addition, if those
units were screened as negative by the second generation
test, and either picked up subsequent second or third
generation, what you are looking at is sero converters,
because the third generation test, the additional pick-ups
that have been obtained are either the rare sero converters,
or people with very old infections, who are not viremic.
So those second generation screen products
essentially have a zero risk of extraordinarily low
probability of transmission, even though the rare repeat
donor is found positive either from sero conversion or
because the third generation test is picking up these very
old infections.
So I'm just concerned that your model for the
recent period didn't factor down the probability that that
unit in fact infected the recipient. That you carried
forward your earlier 70 percent probability, because I don't
think those units from donors who sero convert now, have a
substantial probability of transmitting. So I'm surprised
that your numbers came out looking so good, because I think
the yield of truly finding infected recipients as a result
of second generation screening lookback is going to be very
small.
DR. AU BUCHON: I understand your question, Mike.
It is difficult to predict exactly what window period should
be applied here, and interdonation interval period to
predict the yield. Clearly, most recipients would be found
potentially exposed if we look back the greatest extent,
made the lookback program as broad as possible. In the
first model I showed, that was back to 1985. I figured that
was as far back as any hospital would have records that they
could utilize.
If we compare the number of recipients who would
benefit from the lookback program in that large umbrella
approach, say looking only at second generation and later
HCV positive individuals, the number of recipients benefit
varies by about two. That is, we would notify and get
benefit for about twice as many people if we looked back to
1985, as if we restricted it to just second generation and
forward.
That may be an overestimate of the effectiveness
of the lookback, restricting it to the more current period,
but it gives you some idea of what we are dealing with. It
is more cost effective approach to look at more recent
donations, but it's possible we may have overestimated
slightly, the yield from that.
DR. CAPLAN: Okay, we can come back to this. Jim
is going to be around, and we can ask more questions about
the model.
Thank you.
Is Lisa Ungerer out there? Ah, good. One of the
things that the committee was very interested in was some
discussion of some of the legal issues raised by lookback.
Lisa Ungerer is going to tell us a bit about that.
Agenda Item: Legal Risks of Lookback - Ms. Lisa
Ungerer, JD
DR. UNGERER: Thank you, doctor.
I think it was Dorothy Saylers who once that a man
approached a rabid dog with the caution of a lawyer
approaching an opinion. I hope that I'm not the evidence of
that today, but I guarantee you I do not have a gold plated
answer to all of the things that people have been talking
about today, which are fascinating.
Let me start with some basic principles of law
involving medicine. I'll start with my firm represents
doctors in the San Francisco area. We have represented
doctors in rural areas, and those doctors are going to be
judged by the same principle of law, which is that a
physician must act reasonably according to his specialty
under the same or similar circumstances. That is, a doctor
who is practicing at a huge medical institution and is doing
cardiac surgery is held to the same standard as a doctor
doing cardiac surgery in a 100 bed hospital.
The hospitals are going to be held to the same
standards. Blood banks, being medical providers, would be
held to the same standards.
When you come to the question of what is it that
patients are going to be told, the primary cases, at least
in my state, and I looked for others, but I didn't find
them, the primary cases involve what a patient is told
before treatment, not after treatment.
In my state it is Cobbs v. Grant, and what the
patient must be told is what the patient would need to
consider in order to make a reasonable decision about
whether or not they should have the treatment. They need to
know the risks, but they must know the benefits of the
treatment as well.
In my state, there are some recent cases which
talk about going back to the medicine itself to determine
how far out you go to talk about risk. Do you talk about a
risk that is known to exist in only a small minority of the
people, of which this particular patient is not a category?
For example, a risk only to diabetics, if this is not a
diabetic. In my state there is law on that that says, no,
you don't have to do that; other states, there is an open
question.
With lookback, the question of whether lookback
itself, whether it is targeted, whether it is all
transfusion recipients, or whether lookback is not done and
people come back by reasons of a community education
program, can invoke different types of lawsuits.
Whether or not there is a duty to do lookback is
completely unresolved, at least in my state. The one case I
could find was of a patient who was continued to be seen by
Doctor X. Doctor X received some information about a drug
product the patient had used some years before. He was held
to have a duty to talk to that patient when she came back to
see him, but that was a continuing relationship.
When we are looking about lookback, particularly
targeted lookback in the context of hepatitis C, we very
frequently find that we have patients who have not seen
these doctors for a number of years, and hospitals who have
not continued to treat these patients.
Leaving the law aside, whether or not look back
should be done has to go back to the first principle, which
is whether it is medically reasonable, whether it is
scientifically appropriate. In this context of this
committee, we may need to include whether it is appropriate
under the social sciences, because the question is not just
one of medicine, but how and if and even more directly, the
way to approach a patient to make it effective.
If you determine that the figures that Dr.
AuBuchon had up on the board just before are a reasonable
way to approach a patient, can contacting patients -- if you
look at 460,000 donations, and you come up with I have been
able to contact 54,000 people, is that good? Is that not
good? That's something that you need to factor into this.
In doing so, you will help avoid what I'm going to
call the avoidable lawsuit. The primary avoidable lawsuit
that this committee can help to avoid is one where somebody
says, I was incorrectly notified. The form of notification
was not one that I considered to be optimal.
Bearing in mind that a community blood center, a
freestanding blood center is not going to be contacting the
patients directly. They will contact the hospitals. The
hospitals will, if we use the current FDA model, contact
physicians, and physicians will contact patients.
What is it that you are going to be telling those
consignees to do, the hospitals to do, and ultimately
individual physicians to do? If you tell them to do
lookback, the way to avoid the avoidable lawsuit is to give
the hospitals and doctors the information they need to
communicate to the patient so that it is done in a way that
the patient will understand it.
When you download the information from the
Internet on the last meeting here, and you download the
information from the Internet on the NIH consensus
conference, you can't just hand that over to the patient;
they are never going to understand it, and many, many
physicians are not going to understand it.
So when you follow-up on what the CDC was doing,
yes, that is a good start, but I guarantee rural physicians
are not necessarily plugged into the Internet, and they are
not necessarily plugged in to watching teleconferences via
satellite. If that is done, would this committee recommend
materials that physicians can give to patients? Or
recommend at least that the three branches of the Public
Health Service sign off on those materials before they are
sent?
Another issue, and I think this may come up later
with other speakers, and it has come up a little bit before
is not only how far back in time do you go, and that also
you are going to have to go with the medicine on, but how do
you go about the process of contacting patients?
For example, I think it was assumed in the last
meeting that a hospital or a physician would send out a
letter to the patient. Well, if there is no response to
that one letter, then what does the doctor or hospital do?
Do you send out a second letter? A third? Do you do DMV
tracing, if that is legal in your state, which some of it
isn't? What do they do?
There is guidance needed there, because what is
reasonable in that context may well depend upon how far back
in time you are going, and whether or not you believe you
have actually been able to reach some portion of the patient
population who doesn't actually respond back to the same
physician who contacted them. I don't know that there is
any data on that.
The other thing that this committee may be willing
to address, and if not, then they might be willing to
describe a multidisciplinary approach so that someone in the
Public Health Service can address it is what is to be said
in these letters of outreach to get people to come back, to
get people to respond? Because the other avoidable lawsuit
is the fear of lawsuit.
You noticed a portion of people who were going to
test hepatitis C negative. In my state we have a case that
concerns AIDS, that someone who feared they were exposed to
AIDS -- in that particular case, it was by an accidental
needle stick -- but proved to be HIV negative on a number of
occasions, was not allowed to sue, because they had not
evidenced exposure to the virus. They were HIV negative.
In other cases, and in other states, there are
lawsuits progressing for fear of AIDS where the person says,
I know I was exposed, usually by sexual route, and I know
that this test says I'm HIV negative, but I'm afraid, and
I'm suing.
So the law itself on fear of cases is open. The
way to approach the patient, the prophylactic approach to
the patient is the bedside manner. The bedside manner
doesn't come across too well through a letter, but if there
are communications specialists who can reach out to the
patients to bring them back in to the doctor, then give the
doctor something they can do with these patients, so that
the patient who turns to be HCV negative doesn't go crazy
with worry for the next 20 years, that will help avoid one
of the avoidable lawsuits as well.
The last kind of lawsuit I want to address I'm not
going to call avoidable or unavoidable. I'm just going to
call it transfusion associated hepatitis C. I know of three
states where there have been hepatitis C lawsuits. There is
one in Florida in progress. There are several in Louisiana
in progress. I'm aware of one in Oregon where the
defendants got out on motion papers, a summary judgment,
because the plaintiff's didn't have a qualified expert to
talk about the medicine.
The cases in Louisiana are a little bit different.
They are very old cases from prior to 1982. It is a time
frame no one here has talked about. The suits are largely
based on a law that Louisiana had at the time where
hospitals were subject to strict liability in transfusing
blood, and the lawsuits there I understand have been largely
defended by settling them.
The lawsuit in Florida is progressing. I'm not
entirely sure how that will go. It involved transfusions of
a patient who believed they got hepatitis C. I have heard
varying reports of whether that was initiated by lookback or
not.
There are additional questions that may be
involved with respect to lawsuits that can come out of
lookback, and I don't think that anybody who is connected
with the voluntary associations, whether hospitals or
doctors, has considered the recordkeeping capabilities.
There is recordkeeping in terms of being able to trace
recipients.
There is also recordkeeping in terms of being able
to defend yourself if a lawsuit happened. If they have
tossed out their donor records prior to 1985, you can also
be sure that someone has tossed out what their protocols and
procedures were prior to 1985 as well, and those would be
very hard lawsuits to defend. If you can't say what you
were doing, it's hard to say that it was medically
appropriate.
Why do I say that this is going to be the forum to
come to patients and physicians if lookback is decided, why
this forum to try a patient-oriented, a communications
approach? It is my understanding that this forum as a
public forum incorporates a multidisciplinary approach to
these issues of medicine, and is a forum where contact can
be linked between the three agencies of the Public Health
Service.
In other words, rather than falling back on
certain voluntary associations to try to figure out the
practical aspects of what should be done, can this forum go
forward and pull the Public Health Service together? Work
together within the forum in terms of either the best or
most efficient method of communication, whether that is
community education or some form of lookback, and then go
forward from there?
There was discussion by Dr. Margolis that the CDC
has been relying a bit on voluntary associations. I tell
you that I don't represent the voluntary associations that
he was referring to, the liver association and what I
believe to be an association of doctors involved in
hepatology. There is one court who spoke in other contexts
about voluntary associations who involve themselves in
health care.
That court felt very strongly that any voluntary
association who sets forth health care recommendations, does
so at its peril. So that if it is found later not to have
been omniscient, it may still held liable. I would not bet
here that you could make a broad-based pronouncement and
have someone else, some non-governmental entity pick up the
ball.
Even though it's going to be a nasty amount of
work, if lookback is required, this forum, with the Public
Health Service may be the one that is going to have to say
what should be done and how.
DR. CAPLAN: Comments, questions?
PARTICIPANT: I had a question. Lisa, were you
suggesting that if we do lookback, that the shorter period
of time it is done, the less likely you're going to get a
lawsuit?
DR. UNGERER: No, I'm not suggesting that at all.
I would think though that if you go back -- I'm told that a
lot of hospitals retain records for eight years. In my
area, some of them retain them for much longer than that.
If you go back to a point beyond where hospitals are
retaining records, it would be very hard for them to do what
you have asked. The person who ultimately comes back and
says, I wasn't contacted, I'm going to have a form of
notification lawsuit; that is going to be a hard one.
That's going to be a hard one for the hospital,
because should they have anticipated that this would come up
some years from now may well be part of their defense, and
it may be hard for them to defend against that in the
absence of records.
PARTICIPANT: Is it important to establish a date
like we are discussing right now in that when you had a
first generation test and a second generation test? The
reason I ask that is would that be a vehicle which would
provide protection for the government? The reason I ask
that is because with lookback by notification of the
recipient provide for a legal recourse known as causation?
Can a person go back, in other words, and say if
you didn't establish that date, can they go back beyond that
date and say, if you didn't notify me, say we don't decide
to notify the 300,000 people prior to our first
generation/second generation test, would they be able to
come back with some kind of a legal recourse?
DR. UNGERER: They may, but you mentioned the
government, and it is my understanding that the government
would assert its immunity in that case. For others, I think
that if the person is ultimately diagnosed as having some
effect from hepatitis C, they may go back and say for
example, you did a cut off as of 1990.
Say I was infected with hepatitis C in 1987.
Would I say, gee, you should have notified me. I could have
done X. I could have done Y. I would think people might
file those lawsuits, but I can't give you any quantification
of how many people that would be; whether they would have
any success with those lawsuits; or whether indeed sending
out a mass notification of any kind, whether the community
education or attempted targeted lookback would avoid those
lawsuits, because with your targeted lookback, remember, you
are not going to pick up everybody.
Even with an effort to send out letters to all
transfusion recipients, we know from certain studies, at
least in the San Francisco area, it is thought that since
people didn't respond back to the hospital, that not a huge
portion of those people got the letters. So the
notification is not going to be a shield. I don't see it as
being used as a shield, although you could try. I don't see
it as an aggressive step for example, that a hospital could
take to insulate against future lawsuits.
PARTICIPANT: But it would be advised to establish
a date, just like HIV did?
DR. UNGERER: I think it would be advised to
establish dates when things happen medically, so that when
medicine changed, if it is reasonable to do lookback now,
why is reasonable now, versus 1990 versus 1991, versus 1995?
I think those things would be very important to establish,
because I was hearing that said today, and it was very close
to being articulated, but it really wasn't spelled out in a
way that I thought most people could understand it. If
medicine has changed, it would be useful to articulate how.
DR. CAPLAN: Dr. Hoots?
DR. HOOTS: Unlike HIV, the burden of proof it
seems is different. Here you have got a disease where
certainly we know it is transfusion transmitted, but as we
have already today, and as we heard before, a number of
individuals likely were infected, in fact assuredly were
infected by other means which would be virtually impossible
to pinpoint.
So in terms of the plaintiff's burden of proof,
how protected are entities -- blood banks, hospitals,
physicians -- just on that premise alone? Because if we
acknowledge in whatever recommendations we make, that HCV is
an endemic, if not epidemic disease, that it is in the
population from a number of sources, some of which are
virtually impossible to ascertain on an individual level,
therefore any ascertainment that does occur makes no
assumptions about the source of the infection, rather that
it is important for the person to be identified for their
own individual health needs, rather than [inaudible].
DR. UNGERER: I agree that would be an extremely
important and helpful thing to put into the deliberations of
the committee, and to include in any aspect of communication
to physicians. If you were to create something for
patients, I can't tell you how you could incorporate that
word-for-word. It would be nice if you could, but the point
would be to get them back in, and see if they could be
followed. I would agree, that would be helpful.
DR. ALTER(?): I'm Miriam Alter from CDC. I have
a question regarding how the court might view different
types of notification. We are talking about lookback, and
about notifying only certain people who received
transfusions before or after a certain date. In fact the
intent -- Dr. Margolis, correct me if I'm wrong -- the
intent is to notify the public in general about risks of
HCV, including that associated with transfusion, regardless
of what decision is made about lookbacks.
So would the court look differently a Public
Health Service effort to notify the public about their risks
of acquiring HCV from a transfusion in terms of in general,
making public service announcements, advertisements in the
public magazines and newspapers and those kinds of things,
versus a letter sent by the hospital or physician?
DR. UNGERER: I think some of that depends on the
level of effectiveness that you could ultimately show. It
may well be that the public approach could be more effective
in bringing people in for follow-up, but sitting here today
you can't prove which method is going to ultimately be more
effective.
DR. ALTER: You will never know.
DR. UNGERER: That's part of the problem with my
profession. I always get people five years after the fact
saying how good does it happen. To sit and prognosticate in
the future what lawsuits may occur is a little bit on the
academic side, and that is why I say you have to go with the
medicine. You have to go with what is medically and
scientifically appropriate, and what everyone forms a
consensus on they think is going to be effective and useful
dealing with patients who may have a serious disease, or who
may be asymptomatic, or may be HCV negative.
DR. ALTER: Could a patient say -- and I may have
asked this question, and you may have answered it -- could a
plaintiff say, my neighbor was transfused in 1993, and he
got a letter. I was transfused in 1989, and I didn't. I
found out because I heard it on television. Would that
person have more of a suit or a stronger case than the
person notified by letter just because they found out by
mass media instead of a specific letter?
DR. UNGERER: I'll commit myself. I'll say that
no, I don't think they would have a stronger case. The
problem is getting them to recall that after the lawsuit is
filed. The only way you would know that really is if that
prompted them to do something.
If I heard it on the television and didn't click
the television off and go back to making dinner, if I
actually did something, then that person wouldn't
necessarily have a notification suit, because the
notification had been effective. Failure suits come in when
the notification doesn't work.
DR. ALTER: I see; and they find out at some point
later on that they have this disease, not because they
heard, but because of another reason, they find out. Then
they realize that they were in this risk group.
DR. UNGERER: Yes, that is correct.
DR. ALTER: I see.
DR. CAPLAN: Let's do one more. Carolyn and
Peter, and then I've got to give Ron Gilcher five minutes to
come up here. Let's do Carolyn for the last question.
MS. JONES: I understand that lawyers have to give
the worst case scenario, and that is your job, but you
started off your presentation talking about informed
consent. Even back in 1985, when patients received
transfusions, it was part of the liturgy for them to know
that blood could transmit diseases. At that time we
couldn't specify all the disease that are transmissible by
blood, and we still cannot.
So part of this has to factor in that patients at
that time were made aware of the possibility of transmission
of unknown, yet undiscernible diseases. How does that play
in the scenarios that you have sort of worked out here?
DR. UNGERER: With respect, I would disagree that
many patients were made known of unknown and undiscernible
disease as of 1985. As of 1985, some patients may have been
informed of a risk of HIV, which was no longer a serious
risk, because of testing. They may have been informed of
risks of hepatitis in general, which might cover hepatitis C
here. I don't think anybody appreciated there might be
something such as CJAD, which we don't quite know today
whether or not it is in the blood supply.
A number of patients also who received
transfusions would have done so on an emergent basis, not
multiply transfused patients who come in on a chronic basis.
They may not have been informed of risk at all if it was
truly emergent -- your trauma victim, your accident victim.
So those patients in particular may say, I don't know this
was coming at all, and many of them may not even know they
were transfused.
DR. CAPLAN: Okay, thank you.
DR. GILCHER: Thank you, Art, for giving me the
chance to talk to the committee.
There are some points that I would like to bring
forth for consideration to this committee, because our
charge and our challenge is very great in terms of the HCV
issue on lookback. The points that I'm going to mention
this morning are on the slides that I am going to show, as
well as the handout that I have given to the committee. I
didn't have sufficient handouts for those of you out in the
audience.
Many of these points have already been made by
speakers this morning, especially Dr. Margolis and Dr.
AuBuchon. I'm going to use as the model, the Oklahoma Blood
Institute of which I am the president and CEO, and also a
blood banker by profession.
A quantum leap occurred when anti-HCV version 1.0
came into being in May of 1990, as you have heard this
morning, going from no test to a test, which unfortunately
had somewhere between a 35 and 45 percent false positivity
rate.
There was also another significant leap forward,
not as significant, and that was to version 2.0, which at
our blood center went into place on March 14, 1992. Many of
the false positives were eliminated. Version 3.0 was a
slight improvement, but not a lot compared to the other two.
Now the points that I have on this slide have
already been mentioned this morning, but I think they are
worth reiterating; mainly that there are probably at least 4
million Americans and perhaps more as we have heard, if you
include those who are imprisoned, affected with HCV.
Depending on who you read, there are somewhere between
10,000 to 24,000 deaths per year attributed to HCV.
Again, as we have heard, only a small percentage
of the infected people are from transfusions. In fact, the
numbers that you have heard this morning would place that at
between 7 and 8 percent. Meaning that at least 90 percent
of the HCV in this country is not from transfusions.
Another important point is that the infecting
transmitting donors who do not donate after May 1990, that
is not tested, will not be available to the lookback
process. We must consider that.
Then blood unit tracking. It is very clear that
we can track 100 percent of the units to the hospital, but
once you are at the hospital level, it is very difficult to
track back to the patient. Hospitals within our system,
many have already gotten rid of their records.
Now there are three time periods that I felt were
important, and this was really the gist of why I wanted to
present today, and in fact this has been in a sense
presented already by Dr. Margolis, and really by Dr.
AuBuchon.
The three time periods that I see of important is
before anti-HCV testing, and I am going to use May 1990,
although one could argue that that could be May 1992, since
the version 1.0 test had a high false positivity rate.
The second time period is the current HCV testing
and call that from May 1990 to present. I'll define present
as the point in time where we decide as a committee, what we
are going to do, when we don't really know when that will
be; whether that will be in 1997, or that may be in 1998.
Then a future HCV testing, which is beyond
present.
Let me remark then about my points that I feel
this committee should consider for each of these periods.
In period one, which is before testing, because hospital
records may not necessarily be available, I believe it is
going to be very difficult to reach the patients. It is
what I call educational publicity that may be most important
here, and we have heard that this morning; there are other
names to it.
That is, voluntary testing that would occur
because of educational publicity that would be put forth to
the general population. As we have heard, who does it? Who
pays? Who notifies? Who follows?
The legal concerns from these alleged transfusion
associated HCVs are important, and again, Lisa Ungerer has
addressed that to some degree as well. There are going to
be the true transfusion associated HCVs in this group, but
there are clearly going to be individuals who will come
forth, who got their HCV from another source, and the onus
will be unfortunately on the blood center to prove that it
did not come from that donor.
If we go to period two, which is after testing
began until "the present," and do we recipient lookback, we
have previously untested donors who know come forth as a
donor, and we detect them. So they are now a positive
donor. There really are two kinds of donors that I'm
talking about. Then we have the previously negative donor,
who comes forth now and is tested positive, and that is the
sero converting donor. Those are really the two kinds of
donors with which we deal at the present time.
Again, we have the same kind of legal concerns
when there is the possibility of an alleged transfusion
associated HCV infection. There is going to be the true
transfusion associated HCV, and of course there will also be
those who got that infection from another source.
But it is period three that I think is an
important one for us to consider. This is what I call
future considerations. There are so many changes that are
occurring at the present time. Let me address it first from
the standpoint of recipients, and second from the standpoint
of donors.
There are a number of ways that we could approach
it from the recipient standpoint. We could pre-test all
recipients, and if they are negative, we could then do a
post-test at some definable point in the future. We could
away repository presamples on the donors, and on the
patients, but in this case the patients are recipients, and
only do a pre-test if the post-test was positive, and that
is to determine if that recipient actually had the infection
before they were transfused. We could only do a post-test,
or in fact we could do no test, that is, a pre- or post-test.
These would be considerations with respect to cipients.
From the donor standpoint, we could collect
repository samples for HCV PCR, and I'm talking then about a
new generation of testing. If the recipient were to test
positive on their post-sample, we could go back, and
obviously this donor tested negative by conventional
testing, and then do a PCR test to see if they are positive.
Or the direction that we are moving now, and
within a year or two years we will see PCR testing
technology in place in this country for HIV and for HCV.
Could we use this as a pre-transfusion mode of testing, and
then not even be concerned about recipient testing, because
the number of recipients who would be infected once PCR was
put in place would be extremely small?
Then there could be variations of a theme on that,
and that is where PCR-type of testing could be used ahead of
time to test first time donors, and a variety of different
kinds of algorithms could be put in place. This is
currently being looked at by many blood centers. These are
the points that I wanted this committee to consider.
Now the last slide is really an anecdotal story
connected with it. My blood center has a repository, which
on September 1, 1997, will be 10 years old. There are
approximately 1.6-1.8 million samples in that repository;
every donor, on every donation. We have approximately a 2
milliliter segment that we have stored at less than minus 20
degree centigrade.
The story relates that I'm going to tell you now
very quickly to an attorney who regularly sues the Blood
Institute in cases of HIV and otherwise. That attorney
called me about a year and a half ago said -- she calls me
Ron now, because she knows me so well -- and said, Ron, I
would like to see you.
I saw her and she said when she came to my office,
"I have two transfusion recipients who allege that they got
post-transfusion hepatitis C from units of blood from the
Blood Institute." She said, "I know you have the repository
and I can subpoena that, but what I would like to do is to
have you test the units if I give them to you, and I will
trust you to do the testing. If the units test negative,
that is the samples in the repository test negative, I will
encourage my clients not to sue you, but if any of the
donors test positive, then we will in fact file suit."
Well, God looked over one shoulder, but not over
the other. There were two units on each case. These four
donors had not come forth as donors since testing had been
put in place. They were donors in 1988 in one case, and
1989 in another case.
In one case the two donors on the one recipient
tested negative, but unfortunately on the other, one of the
two donors tested positive. We cannot be sued for not doing
the testing, but the basis of the suit is that we improperly
selected that donor.
So this is another kind of issue that has to be
considered, and I believe this committee must consider those
kinds of issues as well.
Thank you for the chance to speak.
DR. CAPLAN: I feel we are moving down a path
where we are getting more and more cries of the heart here
from the law into the Blood Institute, but probably no one
is going to come with more zeal to this than our last
speaker before we take the lunch break, and that is Howard
Kaplan, about the impact of lookback on hospitals.
Agenda Item: Effect of Lookback on Hospitals -
Dr. Harold Kaplan
DR. KAPLAN: Thank you.
I'm going to take a look at the hospital impact or
implement issues. I thought we could look at it, since we
are considering a kind of Public Health medication, that we
might look at it in the context of this medication being
administered through hospitals -- compliance, efficacy,
potency, dating period, purity and safety -- to get back to
familiar ground.
For compliance, what is the capability of the
hospital to comply? What is the infrastructure? That has
been mentioned briefly, and there is some data to this, but
let's imagine for a moment you are in Paris, and you decide
to use your American Express Card. Getting credit involves
a 46,000 mile journal over phones and computers. The job
can be completed in five seconds.
This is from the "Micro Revolution Revisited," by
Large. The micro revolution hasn't really visited the
hospitals yet. Imagine if you were looking up for a
notification, a record. Two out of three hospital
transfusion services have no computerized information
systems. They rely on hard copy, not necessarily just
paper; some microfilm.
This is based on a study that was done around 1965
[1995?], reported in 1966 [1996?] at meetings. It hasn't
been published yet, but I believe it is going to be
published in Transfusion by Marfie(?) and her co-workers.
Thirty-six state, 910 responders with a heavy preponderance
of transfusion services -- and most of those being small
hospitals. That's the point about everyone being held to
the same standard.
Now let's take a look at what we know about
efficacy. This is unpublished study by Ron Strauss in
Cornell at the University of Iowa. I think it was completed
in 1966 [1986?]. The methods here were the donors who were
repeat reactive by HCV 2.0, and they retested prior donors
who tested positive by the 1.0, and then confirmed with REBA
2.0 or 3.0.
The notification was through the physician and it
was a mail notification of the physicians in which the
letter explained HCV epidemiology, the rationale for
lookback, and provided counseling advice. To make this
easy, the response form and envelope were included, and I
believe it was even a stamped envelope.
They identified 21 donors who fit those criteria;
11 of them had no pre-sero conversion donation. Of the 10
with the pre-sero conversion donation, there were 110
component produced; 68 of those 110 recipients had died.
The remaining 42, their physicians were notified by mail, as
we have just discussed. There are 11 no responses, and 31
responses to this notification of the physicians.
I have handouts for the committee; I'm sorry.
Twenty-one were actually tested. In five the
physician chose not to test. The patient had hepatitis, or
had prior existing disease; was unable to test. Those are
the 10 out of the 31. So the 21 that were tested, all 21
were negative. So out of 110 if you will, components that
required the lookback effort, no test positive, no case
found. It was a very small number.
I don't want to make more out of this, because
when I go into the realm of mathematics, I am clearly out of
my competence, but I do know there is the old idea of if
nothing is wrong, is everything all right? Here the
heuristic rule of three, if we put three over N, we get the
percent of missed events with a 95 percent confidence limit
interval, and therefore 3 out of 110 or 0.027 percent; 3 per
10,000 trials perhaps.
I know we are basing this on a very small piece of
information, but it is the only one I could find, and that
incidently, hadn't been published.
Now we have considered efficacy. Let's consider
potency in the context of how strong a hit will there be in
the hospital to this? This model, as all models, are models
for understanding, not as a belief system. The numbers I'm
using here are from New York, primarily from the New York
Blood Center, and the initial repeat reactive rate here is
0.88.
The Red Cross has figures somewhat lower than
this, 0.7 I believe. I have seen some figures that are up
to twice this value and more, but I think this probably does
represent looking at this, looking at New York state and
others, a reasonable model. Everybody seems to get to the
same place, somewhere a little bit above 0.2 percent repeat
reactivity.
These then, in this model of 100,000 donated per
year blood center, this idealized 100,000 unit per year.
The red would be the number of units, and the assumption is
that we are using a conversion of about 2.5 for each unit
made, 2.5 components produced.
We can follow that through and you see the drop
off. These first two years are not surprising. Here is
where we have the scrubbing effect of getting the reactive
donors out of the system, and also coupled with of course
the false positivity.
Now taking the 100,000 unit blood center, going to
1,000 at the hospital, my own experience, and based on what
we use from that 100,000 donor center, we probably use
somewhere around 20 percent of the components produced. So
we would probably get somewhere around 1,500 notifications
for this 7 year period of time.
Now I have not corrected for the number of first
time donors.
The workload impact, and this is an estimate, but
a conservative one, and it is in a blood transfusion
facility in which there is computerized support, looking
from receiving, logging in, looking up the disposition in
the computer, getting the chart, notifying the physician,
reviewing the chart, written notification, follow-up in
recordkeeping, a total of about 90 minutes total time is a
conservative estimate with computer support.
If the older records are off-line, we would have
to add time to that. Obviously if it is a paper system, and
particular paper systems as you go back this far, tend to be
filed off site. Off site ranges from warehouses to in some
of my prior experience, very wet basements.
Now if we take a look then at our 1,000 bed
hospital, one and a half hours per notification, 45
notifications, 2,318 hours. The average FTE of an employee
in a hospital is about 1,800 work hours per year. So we
come up with about 1.3 FTEs for the 7 year back log at our
hospital. I would like you to hold that thought, because it
is for per year.
The next thing we want to consider in this
medication model are the dating periods. There are two
dating periods, the one we talked about at some length,
which is how far back we go, and the other dating period is
how soon does the hospital react to this new information?
Can we take a year to notify once the decision is made, and
the information is available?
There is a great deal of pressure for rapid
notification. As Yogi Berra said, "It gets late awful early
out there."
Now there are a number of forces, the culture at
the hospital. We want to intervene. We have the
information. Take action. In the regulatory environment
what we are required to do, we are going to take that action
and document that we have done it as soon as we could.
Finally, the litigious environment that we live in propels
that forward.
Now if we take the time frame of 12 months, then
we have the 1.3 FTEs. If we do it in three months, we need
5.2 FTEs. Now there is not a cost increase, but it would be
density of effort; if you will, mission overload, or mission
load. We can talk about whether it is overload later, but
that would be in three months.
I didn't put one month down here, and I have to
admit that my mind boggled when I worked with quarters, and
the middle points are in error. Six months should be
doubling with this model, and four times what it would
require if we did it in a quarter. So it makes a big
difference as to how much time we are going to take to carry
out this task.
Finally, we were talking about the impact, the
infrastructure, how effective it is. Let's take a look now
at the purity of the data; the noise to signal ratio. Here
we know we have certainly in the early time, a 50 percent --
I think we have had some conservative quotes on false
positivity today -- but we will consider 50 percent a close
enough approximation.
Now that was at a time, the first two years, at a
time when there was no licensed supplementary test
available. So if this early time were to be corrected, the
1990, 1991 into 1992 testing were to be corrected, it would
require retrospective testing of repository samples, which
are far from standard, although I do believe, as Dr. Gilcher
points out, his institution and at others, including I
believe, the Red Cross, that has been carried out. It is
not carried out throughout the country.
In fact, it should be very clear to everybody that
today this supplementary testing is not carried out as a
routine in many centers.
Now fortunately, with current generations of the
HCV EIA, that is a lot closer to true positivity, but still
clearly there is a false positive noise.
Now if we look at again the 12 month-6 month-3
month model in which we work to carry out whatever the plan
is if there is targeted lookback, what I have done here is
just with the red part of the stacked column, indicate the
burden related to the 1990-91 time. It just shows again, it
is half the burden.
Now we have considered the usual and the very
important issue of safety. There is an underlying
assumption here that when we talk about cost, we talk about
dollars. I would like to just restate the obvious, that
there are risk trade offs that go beyond the dollars. Risk
trade offs are always a fundamental problem in decision-making.
The efforts to combat a target risk can
unintentionally foster increases in countervailing risks.
We have talked about false positive notification.
I think that is a very heavy burden for someone to go on
that odyssey once they get this notification. That is not
trivial.
Undesired notification -- some work done by Paul
Holland in looking back at known positive units that have
been transfused based on subsequent testing of repository
samples, some 19 percent of the people did not want to
participate; did not want to know this information. So we
talk about countervailing risks, and one of the absent
voice. There are many absent voices, but these are some.
Then finally an interest of mine, which I will
keep uncharacteristically brief is error induction. I will
use homeostasis of error, which we can all, I think,
appreciate. It is a state where we come back to the same
error level, the same risk. Anti-lock brakes have been a
technological improvement with the potential for increased
safety. Once we have anti-lock brakes, we like to consume
that margin of safety. We drive faster and closer to the
guy in front of us.
Here the workload in the hospital with hospital
staffing -- I have had the pleasure of right-sizing in my
laboratory -- we have across the country, supervisors doing
bench work. We have a very heavy workload. We probably
have some margin, but we start consuming this margin as we
add tasks.
These are very closely coupled systems, and very
linked. As we increase workload, the potential for error,
particularly we are not going to hire clerical people to do
this record review. It is not going to be additional staff
probably. Much of that will be absorbed by senior staff,
who carry that out now, because this review of records is
not considered a trivial activity, and it is carefully done
with some pretty senior people, because of the implications
of notification incorrectly, or not notifying.
So we should look at risk superior alternatives,
as phrased by Grayman Wiener(?), and this risk superior
alternative may be some combination of the education and
things other than targeted lookback by itself.
Now this is a simplified matrix by Grayman Wiener
of looking at risk trade off. Here, if we look, does this
countervailing risk versus the target risk affect the same
population or a different population? Is it the same type
of risk or a different type? I think here we move down to
risk transformation, where we are affecting different
populations potentially in terms of the safety of this
activity, and the risk will be of a different type.
Finally, the infrastructure to allow compliance is
less than optimum. The farther back we go, the harder it is
to assure any reasonable completeness in the hunt. Efficacy
with only the small information doesn't seem to be different
than what was predicted.
This will have a significant impact on hospital
workload, even with the conservative estimates. The dating
periods, the issue of how far back we go is not the only
issue. I think it is important to talk about in what time
period should the activity be carried out at the hospital.
The importance of the false positives, and
certainly how this plays out as risk trade off.
Thank you.
DR. CAPLAN: Thank you, Dr. Kaplan.
Maybe we have time for one question, if there is a
panel member or audience member who wants to put just one.
I'm just curious, when you projected those FTE
hours for record review and so on, that comes from other
similar sorts of studies where people --
DR. KAPLAN: That was our experience with for
example HIV lookback.
DR. CAPLAN: And you were completely computerized
on that one?
DR. KAPLAN: Yes. Well, those things that at
least we can look up, yes.
DR. CAPLAN: All right, thank you.
What I would like to do is give the committee a
little bit of a lunch homework assignment. When we come
back, we are going to hear a bit about some of the details
of course hepatitis C, a little bit more information there.
We are going to hear about lookback, the experience in some
other places on the globe. Then we are going to move to our
first discussion of where we are at with respect to our
recommendations.
My lunch assignment is this; I would like you to
lookback at the now writ in stone Penner-Hoots
recommendations. We also have them written on an overhead,
which we can show you later, but please review those,
because clearly we are going to go back there as a starting
point I would imagine, this afternoon.
You might make some notes about things that you
have heard today or thought about since the last meeting
that you think might lead us to want to modify, change or
add to what those statements say.
There were some agency responses that I think you
got in the mail too that had some comments, many of which
may interest you. I think it would be useful to review
those as well.
So if you could at some point during our lunch
break, take a look at those documents from the last meeting.
Fresh your memory on those. Take a look at the agency
comments. Then maybe make some notes, a few summary points
of things that you think we should return to in modifying,
editing, adjusting this document.
The work plan we will hear a bit more information.
I think we have gotten a lot of valuable information from
this morning's presentations, and I think it will be
illuminating for us hear in particular how some of these
other nations have dealt with it.
Then we are going to have it on our plate to sort
of wrestle with this for the rest of the day, and come back
to it again tomorrow morning, where I hope we can finally at
least finalize a pretty clear set of recommendations in
answer to the questions we got asked on this issue.
So that's the game plan, and if you do that during
the lunch break, I think we will get that much ahead.
[Whereupon the meeting was recessed for lunch at
12:45 p.m., to reconvene at 1:45 p.m.]
A F T E R N O O N S E S S I O N
DR. CAPLAN: Let's get underway. If I could have
Dr. Gordon come down.
We're going to have two presentations on the
course and outcome of hepatitis C, first by Dr. Stuart
Gordon, and then by Dr. Leonard Seeff. After that, we will
take a few questions. Then we'll be moving over to the
lookback experience in Canada and the U.K.
Dr. Gordon.
Agenda Item: Course and Outcome of Hepatitis C -
Dr. Stuart Gordon
DR. GORDON: Thank you, Dr. Caplan, Dr. McCurdy.
As Dr. Seeff will undoubtedly point out in the
next presentation, the outcome of hepatitis C is a function
of several variables, host related and virus-dependent. We
sought to determine whether mode of transmission affects
outcome. This presentation summarizes our abstract that was
reported at the American Gastroenterological Association in
May of this year.
This concept first arose in the late 1980s with
liver biopsy studies. It was observed at that time that the
then non-A, non-B chronic hepatitis was morphologically more
severe in patients with transfusion-related infection than
sporadically transmitted disease. The size of the initial
inoculum was implicated as the cause of this phenomenon.
After the discovery of the hepatitis C virus, Dr.
Miriam Alter described the natural history of community
acquired hepatitis C in the United States, and also observed
that severe disease histologically was more likely in blood
transfusion recipients than injection drug users.
We originally described the histopathology of
hepatitis C as it relates to mode of transmission in 1993.
In this report we observed that the total histologic
activity index score among blood transfusion recipients was
significantly higher, signifying more aggressive liver
disease histologically than among intravenous drug users.
Therefore, we attempted to determine in the
present study whether our previous histologic observations
translate into clinical outcomes, and answer the question,
does post-transfusion hepatitis C pursue a more aggressive
clinical course than disease that is parenterally acquired.
Our study took place at William Beaumont Hospital
in Royal Oak, Michigan. This is a 1,000 bed medical center
located at the Oakland County region just north of Detroit
Michigan. The demographic composition of the hospital
system market is summarized here. The region is 90 percent
Caucasian, and the socio-economic nature of the region is
considered upper middle-class, with an average annual
household income of approximately $58,000.
We studied the clinical course of 627
consecutively evaluated non-alcoholic patients who were
referred to our institution over a seven year period for
further evaluation of hepatitis C. Ours is not a transplant
center, and therefore no patient was referred specifically
for transplant evaluation.
Forty-five percent were transfusion recipients.
Forty-two percent or 262 patients acquired the disease via
parenteral exposure, primarily former injection drug use,
and 83 patients or 13 percent were without reported risks.
Incidently, in an anonymous questionnaire that was
subsequently mailed to the no risk individuals, a
significant portion of these patients subsequently reported
and admitted to prior injection drug use.
Liver histology was available in 463 patients, and
showed non-cirrhosis, varying degrees of chronic hepatitis
in 59 percent; cirrhosis in 37 percent or 173 patients; and
a hepatocellular carcinoma, all of whom had underlying
cirrhosis in 4 percent.
Follow-up was defined as the time from the initial
presentation with abnormal liver function studies, until
June 1, 1997. The duration of follow-up was from 1 to 24
years, with a mean of 45 months.
This slide shows the distribution of age of
hepatitis C acquisition, and age at presentation according
to gender. The overall mean age at presentation was 51.3
years for women, and 44.8 years for men. Not shown on this
slide is that prior blood transfusion was more common among
women than among men; 63 percent of the transfused group
were women. Parenteral transmission was more common in men;
71 percent of the injection drug users were men.
The age at acquisition as a function of mode of
transmission is outlined in this slide. The mean age of
hepatitis C acquisition among transfusion recipients was 36
years, whereas the mean age of hepatitis C acquisition among
the parenteral group was 19 years. Although the transfused
group acquired disease at a later age, the presumed duration
of disease was similar in both groups.
By univariate analysis, liver pathology appears to
be a function of age at presentation. The age at
presentation was 42.5 years for non-cirrhotics; 55 years for
cirrhotics; and 66 years for patients with hepatocellular
carcinoma. The presumed duration of disease was similar
between groups.
This slide points out histologic severity as a
function of mode of transmission. I point your attention to
the middle group of bars, where the blue bar shows that 118
patients, or 68 percent of the cirrhotic patients reported
prior blood transfusion. Only 40 of these cirrhotic
patients, or 23 percent acquired infection via parenteral
transmission.
Looking at it the other way around, 54 percent of
those in the transfused group were cirrhotic at
presentation. Among those who acquired the disease
parenterally, only 21 percent were cirrhotic at
presentation. By multivariate logistic regression analysis,
we found that the mode of transmission was more important
than age as a predictor of cirrhosis.
During the follow-up period, 59 patients
representing 31 percent of the cirrhotic group developed
hepatic decompensation. This table then shows the patients
with liver failure, and compares them to the 568 patients
who did not as yet decompensate.
By univariate analysis, both the age at
presentation and the presumed age at acquisition were
significantly older in the group of patients who
decompensated. The transfused group was significantly more
likely to develop liver failure than those who acquired the
disease parenterally.
Again here, multivariate analysis showed that the
risk of developing hepatic decompensation was more strongly
related to the mode of transmission than to the age at viral
acquisition.
Kaplan-Meyer(?) probability figures for lifetime
risk of development of cirrhosis based on mode of
transmission are shown here. In our population, 25 years
after acquisition of HCV, the cumulative risk of cirrhosis
in the transfused group was 52.5 percent, and was 35 percent
in the parenteral group.
Probability figures for cumulative risk of liver
decompensation among all patients based on mode of hepatitis
C transmission are shown here. Twenty-five years after
disease acquisition, the risk of liver failure was 17
percent in the transfused group, versus 6 percent in the
parenteral group. This risk was not related to gender,
prior anti-viral therapy, or disease duration.
In summary, in our population the probability for
development of cirrhosis after 25 years disease duration was
52.5 percent, and 35 percent in the blood transfusion and
injection use groups respectively. This probability of
liver-related morbidity after 25 years disease duration was
17 percent and 6 percent in the transfused group and drug
use groups respectively.
We conclude that post-transfusion hepatitis C is
more severe histologically and clinically than parenterally
acquired disease. Both the histological severity and the
risk of hepatic decompensation are more closely related to
mode of transmission than to age at viral acquisition or to
duration of hepatitis C infection.
DR. CAPLAN: Dr. Hoots?
DR. HOOTS: Is there anything that suggests that
there is a different genotype in the two populations?
DR. GORDON: We did not look at specific genotypes
in this population?
DR. HOOTS: How about previous studies with
comparing just transfusion and parenteral? Anything in the
literature to suggest that there is --
DR. GORDON: Genotype I is more common worldwide,
and anecdotally we have seen more genotype I among both
groups. There has been some to suggest that genotype III is
more common among injection drug users, but we didn't look
specifically at genotypes.
Dr. Alter?
DR. ALTER: This is what clinicians see, and I
think it is very helpful to have a really nice picture of
the disease that is most commonly seen in this setting.
I have to, however, argue one particular point,
and that is your estimate of the probability of cirrhosis
and decompensation . You are looking at the probability given that
someone has chronic liver disease, that they will go on to
decompensation, but you don't know that that is the
probability of someone who gets infected via transfusion or
any other route of actually going on to decompensation,
because we don't have the group of individuals in there who
didn't get sick, or weren't sick enough to be seen in this
setting, or weren't referred to this setting.
So that to look at the probability, you need the
entire group of infected individuals, not just those who
came to medical attention because of their symptomatic
disease, or because they were screened.
DR. GORDON: I don't know how you get at the issue
of the denominator, and that is true.
DR. ALTER: In this type of study I just think we
have to limit how much we can conclude from this study on
the natural history when you don't have the cohort of
infected people to follow.
DR. GORDON: Analogous though to other cohort
studies representing those patients referred for further
evaluation of hepatitis C. It does represent all patients
referred over a several year period, so presumably it
reflects a representative cross-section of what is seen in
the community in terms of initial diagnosis of hepatitis C.
DR. ALTER: So I absolutely agree with you,
because this is what clinicians are seeing, but I don't
think it is representative necessarily of all of the
individuals who get infected. So I just think we have to be
a little cautious.
PARTICIPANT: Any serologic data or viral load
data that you attempted to look at?
DR. GORDON: Not in this study. We previously
looked at viral load as it relates to mode of transmission,
and found no convincing correlation between mode of
transmission.
PARTICIPANT: How about to development of
cirrhosis?
DR. GORDON: Nor that; we found no close
correlation in a previous study, although we did find higher
levels of virus among those with more aggressive liver
disease. This is an issue that has been debated. We have
found that there was an association. Others have not found
as close an association.
PARTICIPANT: [Inaudible].
DR. GORDON: We did; 150 patients were treated in
this group, and we looked at the role of anti-viral therapy
and found that it really did not influence outcome.
PARTICIPANT: [Inaudible].
DR. GORDON: We had a larger group that I didn't
get into. We excluded alcoholic patients, surface antigen
positive patients, HIV positive patients as well. These
were all excluded from analysis. There were also 10
patients who died from non-liver related disease during the
course of the study.
PARTICIPANT: Two questions; one is a follow-up to
the question on anti-viral therapy. Did you have a small
percentage of responders in that group, and that's why you
didn't see any difference in outcome among the responders?
DR. GORDON: Correct. We did have a cohort of
responders both among the cirrhotic and the non-cirrhotic
group, and we entered that in and found that that was not a
significant variable in terms of influencing outcome.
PARTICIPANT: [Inaudible]. What type of follow-up
post-therapeutic intervention?
DR. GORDON: We just looked at those who were
treated versus those who were non-treated in terms of
overall outcome.
PARTICIPANT: So it wasn't on response?
DR. GORDON: It was based on response -- no, it
was based on those who were treated.
PARTICIPANT: Not based on response?
DR. GORDON: Correct.
PARTICIPANT: Okay. My second question had to do
with do you have a feel for whether persons with a history
of transfusion might be overrepresented in a referral group,
because the medical community in general is more aware that
transfusions is a risk factor for hepatitis C, and therefore
might be more likely to screen individuals who have received
a transfusion in the past?
DR. GORDON: That is always a possibility. It is
hard to say. These were all patients who were detected in
general with abnormal liver enzymes. They were detected by
a variety of means. Screening wasn't the predominant method
by which these patients came to referral, but it is possible
that they may have been detected by that method.
PARTICIPANT: Do you know why they were tested,
why their liver enzymes were tested?
DR. GORDON: All of these patients were referred
by primary care physicians in general, because they were
found to have abnormal liver biochemistries. A small cohort
were picked up by blood banks, et cetera, but as a rule most
patients were just picked up by primary internists because
of abnormal liver enzymes, not because of any screening.
PARTICIPANT: When I said screening, I was
referring to enzyme screening as well. I just was wondering
why they had been screened. Is it because they had a
history, or because they were going in for a routine
physical?
DR. GORDON: Mostly routine physicals. The
younger injection drug users are often picked up when they
go for insurance physicals, disability policies, et cetera.
They are picked up incidentally. So they are picked up for
a variety of different reasons. It's hard to say whether we
are selecting out the transfusion cohort.
PARTICIPANT: Just a couple of comments. I think
the point about your extrapolations to overall probability
of progression are well taken. If you look at early AIDS
calculations, the time from exposure to presentation, they
were much, much shorter due to the fact that people were
presenting, and we were basically catching the sickest
people in the early studies based on clinical diagnosis, and
tracking backwards. As we know, those numbers have
quadrupled in terms of estimated time from exposure to
disease.
Early on in HIV for the nineties there was also
data that indicated that transfusion was associated with
more rapid progression to disease, and that has completely
fallen apart once age has been factored in, as well as other
variables. Clearly, your data has major implications to the
discussion here about a broad public health campaign,
because if transfusion recipients are, as you seem to show,
four or five times as likely to progress clinically, then
they may warrant a more aggressive tracking, and more
aggressive notification method than would the general
population.
I'm concern that it just doesn't make sense to me
that they would be more prone to this liver disease absent
other confounders. They are not any different than anybody
else. It's either their underlying health status at the
time of transfusion, or their age and their immune control.
What is your hypothesis for the biological basis for this
accelerated progression?
DR. GORDON: For a nice discussion, the current
issue of Hepatology which just came out this month has a
paper from France which had similar results in terms of mode
of transmission, and there was a nice discussion in this
regard. The theory that has been proposed is size of viral
inoculant, and this is the most plausible explanation for
this phenomenon.
Age is obviously the major confounding variable.
We have two disparate populations, young men who are
injection drug users, and older women who are the recipients
of blood transfusion. By multivariate analysis we found
that mode was more important than age, but clearly this is
the most confounding variable here.
The plausible explanation other than possibly
genotype is the size of the initial inoculant.
DR. CAPLAN: All right, thank you very much.
DR. GORDON: Thanks.
DR. CAPLAN: We have Dr. Seeff next. Then I think
we will actually take one more break right after that; a
short one, allowing for some slide an AV manipulation.
Agenda Item: Course and Outcome of Hepatitis C -
Dr. Leonard Seeff
DR. SEEFF: Thank you, Dr. Caplan.
I was asked by Dr. McCurdy if I would review the
issue of the natural history of hepatitis C, which I would
plan to do with your indulgence, by spending a few minutes
talking about how you go about doing such a study, and the
difficulties intrinsic to doing such a study, and my view
that the perfect study has not been done, and will never be
done for a variety of reasons. I will present that here.
I would also like to discuss my review of what we
know about this disease, and then present some data from a
study with which I have been involved, a very long-term
follow-up study which in fact is a cohort study.
Let me start with what we do know about this
disease. I think there is no argument and everyone agrees
to this that about 70-85 percent of people who are acutely
infected with the hepatitis C virus will not lose the virus,
and will progress to chronic hepatitis. I think there is no
argument about this phase.
Where we are struggling and everyone seems to have
varying views on this is what happens after you get to this
point of chronic hepatitis, because there are potentially
four outcomes. One is that one could recover completely; or
one can go on to develop asymptomatic chronic hepatitis, and
live out one's life with asymptomatic chronic hepatitis; or
develop decompensated chronic hepatitis, usually with
cirrhosis; or end up with what is most feared, that is
hepatocellular carcinoma.
So I think that there are two general views that
have been expressed, and this the controversy. That is
there are those who believe that if one is infected with the
virus and lives long enough, that inevitably one will go on
to develop severe chronic liver disease, unless you die from
some other disease first.
The other possibility is that in fact not
everybody, regardless of how long you live with this
disease, will in fact progress to end stage liver stage. It
will be a subpopulation. The question we have if that is
the case, what are the factors that may promote progression,
or on the other hand, hinder progression? I guess that's
where the controversy lies at the moment.
So the trouble we have with this disease is that
the vast majority, and I believe more than 85 percent of
those who develop acute hepatitis have no clinical symptoms.
So we don't know when the disease begins. If you are going
to try to do a cohort study, you have to know where the
disease begins, and we don't know in the majority of people.
The other interesting thing is that most people
who get the disease and go on to chronic liver disease,
don't have any symptoms either. So it's a pretty silent
disease, both in its acute and chronic manifestations until
you reach towards the end.
The third issue of course is the fact that this is
a slowly progressive disease that takes two to three decades
at least before you reach end stage, and therefore it is
very tough to do a study in which you are going to follow a
disease for this period of time.
Here is an example when I talk about the lack of
symptoms. This happened to be in -- somebody, I guess,
asked this question a little earlier. We did a screen at my
hospital in January 1994, of what we hoped were going to be
1,000 admissions to the hospital, and we ended up with
almost 900, and to our utter amazement found that 21 percent
of people who walked into the VA hospital here in
Washington, D.C. were anti-HCV positive.
If we asked about a history of acute hepatitis,
only 8 percent knew that they had been infected. So the
majority had no idea that they were infected -- excuse me,
this was 10 percent, and a history of having had acute
hepatitis was present in only 8 percent. So the majority of
people simply didn't have any clinical evidence that they
were acutely infected.
With respect to duration, as I'm sure you are
aware, the studies that most people focus on are the one
from Japan, Dr. Kiosawa(?), and the one from this country,
Dr. Tong, and most recently a study from France, Dr.
Poinard(?). These were studies, at least the first two, in
which they studied people already in end stage liver
disease, and then tracked them back to when they thought
they might have begun with the disease. On the basis of
that, they came to the quite interestingly similar figures.
The first two studies suggested it takes about 10
to 13 years before you find chronic hepatitis; about 20
years before you see cirrhosis, and almost 30 years to the
development of hepatocellular carcinoma. Recently Dr.
Poinard, in an interesting study which has other
implications, suggested that the average duration from
infection to development of cirrhosis is about 30 years.
So it is a disease that goes on for a long time,
and therefore is very tough to do studies on. So in order
to do a study, the obstacles we face are: (1) that the
disease acutely is not identified in most instances; (2) the
duration of development of serious sequelae is markedly
protracted, and therefore takes your entire life to come up
with a conclusion on this outcome; (3) we are in a new phase
now where there is treatment, and that most people are being
treated one way or another, and therefore it's possible that
may modify outcome.
As a consequence, I believe we will never be able
to do a true natural history study. We will be able to do a
natural history study in people who are treated, and that
may modify in fact the natural history.
So how do we go about studying this disease? I
believe that there are three approaches. Either you do a
prospective study that begins with onset of the disease, but
as I mentioned, the onset is rarely identified, so you don't
know when it begins. It's tough to match people if you want
to have a case control study if you don't know when the
disease begins. The duration of follow-up is enormous, so
it's very tough to do such a study.
Or you can do a retrospective study, and that is
looking at people who come into a hospital with chronic
liver disease. Try to track back to the time where they
develop their disease, and then to assess the duration of
time. This is the issue I guess that Dr. Miramota(?) has
been referring to. This omits those people with
unidentified subclinical illness, which I will show you in a
moment, who never come to that hospital, because they have
no clinical evidence of liver disease and never identify.
The third possibility is to do a so-called
retrospective prospective or nonconcurrent prospective
study. That is to go back to early studies in which a
prospective study was done which permitted a case control
study to be done, pick it up in the middle, and then to go
forward and see what happens thereafter. I'll show you two
of those in a moment.
There is a problem with that also, because you
have historical evidence of the disease, and it takes a very
special setting to identify people who would fit into this
category. Obviously, if you have an intervening period of
time where you don't see the patient, you may miss some
valuable data.
So what has been done? I'm going to skip this by
just to show you that there have been a number of studies
that can be divided up into those prospective studies
beginning with acute disease. My next slide will show you
prospective studies beginning with already established
chronic liver disease. I'm simply showing you these to show
you what studies have been done. A summary of this is shown
here.
In five studies in which prospective follow-up has
taken place in the people with acute disease, and this is
follow-up studies with a mean of about 8-14 years, clinical
symptoms have been noted in this studies in about 10 percent
of incidences. Cirrhosis among those biopsied has raised
between 8 and 24 percent. Hepatocellular carcinoma in these
studies have been rare. Liver-related mortality has ranged
between 1.6 and 6 percent.
There is undoubtedly morbidity and mortality
associated with this disease even when you begin from the
beginning, but it is of modest frequency with respect to
morbidity or mortality. On the other hand, if you look at
people who come in with already established liver disease,
and there are four here, although I'm going to show you a
summary of three, of Tuckahashi(?) and Yano(?) from Japan,
and Dr. Myron Tong(?) from the United States, these were
instances in which people came into the hospital with
already established liver disease, and then they followed
them to see what the outcome was.
In summary, in three of those four studies -- the
other one was a very small one in Australia, and I have
dropped that out -- over a mean period of follow-up of 4-11
years, cirrhosis was found in 8-46 percent; liver cancer was
found in 11-19 percent.
In fact, in some of these studies patients already
came in with established liver cancer, and the mortality was
extremely high, so that there is in these studies where you
start with already established chronic liver disease and
follow them up, there is a high frequency of mortality and
morbidity over a relatively short time period. That is
quite different then if you start from the onset of the
disease.
Well, what about the retrospective prospective
studies? I'm aware of two. One is one I will be
discussing, which is the one that I have been involved with
at NHLBI, National Heart, Lung and Blood Institute
Transfusion Study; then there have been a number of studies
that I think many people know, the immunoglobulin studies
that were reported from Ireland and Germany, and a summary
in these studies, there is a modest frequency of mortality
and morbidity, and we are going to have to discuss what
modest means.
Just one reference slide to the immunoglobulin
study, and I'm sure you are all aware of this. This is a
study in which people received the Rh immunoglobulin that
happened to be contaminated with hepatitis C virus. A large
number of people were infected. This is a follow-up of 232
of these women over a 17 year period. Average age at
assessment when these were evaluated on recall was 45 years.
About a quarter of them did complain of mild
fatigue. If you look at the enzymes, almost 40 percent had
normal enzymes; 52 percent had enzyme values between 40 and
100 ALT values. Ten percent had ALT values greater than
100.
Liver biopsies showed mild chronic hepatitis in 55
percent, moderate chronic hepatitis in 38 percent, severe
chronic hepatitis in 7 percent. When they looked at
fibrosis, 1.8 percent of the patients with these liver
biopsies had fibrosis, and early cirrhosis was found in 2.4
percent.
So this was a rather staggering piece of
information, because this suggested that if you looked at
this particular cohort of individuals and followed them for
17 years, progression was very, very slow and minimal. Only
3 percent at most have ended up with cirrhosis. Well,
that's one study.
We have been doing a study, and I'm just going to
flash this up for a moment just to show you a lot of people
are involved in this. This is a study in which we went back
to post-transfusion hepatitis studies that were done in the
early seventies. There were five studies. They were two VA
cooperative studies. There is a long-term NIH study that
has been ongoing here, Harvey Alter(?). There is the
so-called TTV study, another NHLBI study, and a study done at
Walter Reed.
What we did was we accumulated the data from all
those five studies. The importance of those studies was
that all of these people were screened prospectively when
they came in for development of enzyme abnormalities. So we
were able to identify all hepatitis not on the basis of
symptoms, but on the basis of serum enzymes. It was pretty
much the same among the five studies.
So we combined these studies, and you can see a
lot of people, including Dr. Schiff, who I don't see here,
but I gather is on your committee, was one of the people
involved. We have been doing a study now which is about 21
years at this point.
The first part of it was a mortality study. We
wanted to find out what happened with respect to mortality,
and we began following these people about 18 years after
they had been transfused. We did a mortality study looking
at the NDI tapes, Social Security death tapes. We have
death certificates on every person. We also have medical
records by the way, on every single one of these people from
every admission between the time they were transfused and
the time we started the study.
I have spent hours going through 6,000-7,000
records, and I think people here will be well aware of the
fact that death certificates are fine, but they are not
terribly accurate. So we have some data that we can compare
death certificate data with what we see from the medical
record review, and also interview of proxies, of family
members. We have autopsy records on virtually everybody.
We have these hospital charts, and as I said here, family
proxy interviews were done.
Well, what did we find? As a single summary
slide, we published and it caused a lot of consternation in
people's minds, including ours, because we didn't expect
this, was that at the end of 18 years at our first cut --
excuse me, I forgot to mention we had a control. This was a
case control study. We selected two transfused individuals
who were carefully matched by about eight or nine different
criteria with the patients who were called non-A, non-B
hepatitis, and so therefore we had a case control study.
So 51 percent of the cases had died, versus 51
percent of the controls, which was clearly not significant.
Another cut of this, at 20 years of age showed
that again, there was no significance. When we restricted
this to hepatitis C, and it turns out that 70 percent of the
cases were hepatitis C, 30 percent were no. When we looked
specifically at the hepatitis C group, all cause mortality,
there was no difference.
There was, however, when we looked at non-A, non-B
hepatitis cases and liver related mortality, based on the
examination of the medical records at 18 years, there was a
slight increase in mortality, and it was significantly
higher among the cases than the controls. So we did see a
slight increase in liver-related mortality.
Now this complicated slide I'm afraid is the
survival curves. We have in red are the cases which you
probably cannot see. In yellow are the controls. Here we
have the data shown with respect to the age at the time of
transfusion. It turns out that in this particular study if
you were under the age of 55 when you were transfused, you
were more likely to die if you were a control than if you
were a case. On the other hand, if you were over te age
of 55, there was a higher mortality rate among the cases as
compared to the controls.
Now this is not the only study. There is another
recent study from France, Dr. Poinard's study, that would
suggest that age is an important determinant with respect to
outcome. We used to think that well, if we are going to
talk about treatment, should we be excluding people have
their CABG say when they are 65 develop the disease, because
after all it takes 30 years for problems to occur, therefore
why treat them?
Well, it turns out I think that there is a reason
to consider treatment if treatment works, and that is
because there seems to be a more rapid progression among
those who are infected over the age of 55, at least in this
study, and in some other studies, than among those under
that age.
Well, the next phase of the study, which is
turning out to be extremely interesting is our morbidity
evaluation. That is, we are trying to follow all the people
who are alive in the study, among those who have not died,
and we have tried to recall all the cases and their
controls. In every case we did initial historical,
clinical, biochemical and serologic evaluation.
We then followed each subject with biochemical
testing at least at three month intervals for at least three
values, over a period of six months in order to assess and
determine whether the patient had chronic hepatitis by our
definition, which was that there had to be at least two out
of three of those enzymes that were abnormal.
Later on we added a probable chronic hepatitis,
even if there was a single abnormality, if there was no
other basis that we could find for abnormal enzymes. In
many regards those two could look very similar.
We tried to get biopsies wherever we could, or if
they wouldn't permit us, we tried to get a surrogate test,
which mean upper endoscopy or a CAT scan or something to see
if we could find evidence of chronic liver disease.
Well, we ended up out of the 568 cases, which
again I'm sorry I forgot to tell you was the number of cases
that we are following, and the 984 controls, and we could
find 205 patients and 335 controls who were living and in
whom we could do follow-up, and most of the data come from
this particular group.
This is a single summary slide of where we are at
this point, and I will show it to you in a moment in graphic
form. Biochemical evidence of chronic hepatitis, that means
the persistence of serum enzymes, has been detected in
between 15 and 18 years later in 53 percent of cases.
Ninety percent of the people who are anti-HCV positive
originally are still positive. That means that 10 percent
by the way, appear to have lost antibody.
Seventy-two percent are HCV RNA positive, which
means that 28 percent appear to have lost virus. The
percent in whom we were able to detect chronic hepatitis was
somewhere between 24 and 36 percent. The percent with
cirrhosis was somewhere between 12 and 17 percent, so I
think that there is the figure then that has been used of
about 20 percent, which I didn't want to accept before,
because I thought that was 20 percent of those biopsied.
These are data that extrapolated back to the
entire group, and we think that something like 12 to 15
percent of people have got cirrhosis at this point, and you
can see there is about a 2 to 1 ratio. Twice as many people
have got hepatitis without cirrhosis, as compared to those
with cirrhosis.
Percent of people with overt liver disease,
clinical evidence of liver disease -- we are now talking
about 18 years later -- about 13 percent have got one or
other manifestation. By that I mean it could be
splenomegaly, it could by thrombocytopenia. It could be
viruses, which we call severe disease, or it could be a
psyches which we call severe disease, but there is one or
other clinical manifestation in 13 percent of people.
What I don't have over here is the cancer rate.
At this point we have 400 people who are hepatitis C
positive in a mean of 1974. We have 4 people who have
primary liver cancer, giving a cancer rate over this period
of time of 1 percent.
Now what was very important is when we biopsied
these patients, and we compared the histologic finding of
chronic hepatitis and cirrhosis with clinical manifestations
of liver disease, what was fascinating was that 94 percent
of these patients who had chronic hepatitis without
cirrhosis, had no clinical evidence of liver disease
whatsoever. Six percent had mild chronic hepatitis, and
none of them had severe chronic hepatitis.
On the other hand, once they had developed
cirrhosis, 14 percent had no clinical evidence of liver
disease, but 43 percent had mild, chronic hepatitis, and 43
percent had severe chronic hepatitis. So the development of
cirrhosis at this point in time, as far as I can determine,
dictates an outcome that is likely to be as we move into the
third and fourth decades, severe. This is where we are
going to run into problems.
Do we have any studies that might help us? Well,
here is a study from Italy recently published in
Gastroenterology; Dr. Alberti's group, Dr. Fatovich(?).
What they have is almost 400 people with compensated chronic
hepatitis that they were able to, by some retrospective
analysis, follow-up to see what's happened to them.
The probability of survival in this particular
group at three years was 96 percent. At five years it was
91 percent. At ten years it was 79 percent. On the other
hand, if they had an episode of decompensation, the
mortality increased to 50 percent. So clearly cirrhosis in
the patient who is decompensated has a poor outcome.
Here were their figures with respect to
hepatocellular carcinoma, decompensation and liver disease
mortality. They figured out that the annual incidence of
the development of hepatocellular carcinoma was 1.4 percent;
decompensation about 4 percent; and liver disease mortality
about 2 percent.
Now this is the outcome of our clinical study at
this moment, our follow-up study. If we took everybody who
developed transfusion associated hepatitis in 1974 who was
anti-HCV positive, where are they now in their follow-up?
This says 1994. It should be 1997, excuse me.
Fifty-one percent of the people who originally
seemed positive are still anti-HCV positive, are still
viremic and have biochemical evidence of chronic hepatitis.
Interestingly enough, 22 percent are sero positive and are
viremic, but have no clinical evidence of chronic hepatitis,
and this is a new group that people are now beginning to
worry about. We are seeing more and more of this in
individuals who have biochemical normality, but are anti-HCV
and PCR positive.
Seventeen percent were anti-HCV positive, but were
HCV RNA negative, and they have no chronic hepatitis.
Eleven percent had lost absolutely everything, and this has
been very surprising to us. They were neither anti-HCV
positive, nor RNA positive. They had no hepatitis.
So on the basis of this, it looks as though 27
percent of patients who were acutely infected in the early
seventies have now resolved their infection, and 49 percent
have got infection, but it is minimal liver disease that we
are seeing at this point in time.
So to summarize this study, this is a quick
summary that 51 percent of the patients who had acute
post-transfusion related, transfusion-related hepatitis C in the
early seventies remained viremic, but biochemical evidence
of chronic hepatitis. Twenty-two percent remained viremic
without biochemical evidence of chronic hepatitis.
Seventeen percent retained antibody without RNA or
biochemical chronic hepatitis. Eleven percent have neither
antibody, HCV RNA, nor biochemical evidence of chronic
hepatitis.
Liver biopsies revealed chronic hepatitis alone in
about two-thirds, and cirrhosis in one-third. When we
looked at clinical evidence of liver disease compared to the
liver biopsies, we found that clinically evident chronic
liver disease was detected in just 6 percent of those with
biopsies showing only chronic hepatitis, none of whom had
advanced liver disease, but in 86 percent of those with
cirrhosis, about of whom had advanced chronic liver disease.
So our conclusions is that the perception of the
severity of chronic HCV infection depends on the stage at
the time that you begin your initial evaluation. If you
begin studies, such as the prospective studies or the
retrospective prospective studies that I have shown you,
from the beginning of the disease, you see that is a slowly
progressive process of relatively modest severity, at least
in the first two decades.
I suspect that those who have cirrhosis are going
to run into trouble as we move into the third decade. The
question we have is how many people with chronic hepatitis
without cirrhosis will advance to cirrhosis and run into
trouble?
Studies beginning with already established overt
chronic liver disease define a more rapidly progressive
course, with evidence of severe sequelae, but this is a
biased group. You are looking at people who have come in
with already established liver disease, and all that group
of people who don't have disease that never get steered to
attention are missed out in an analysis of that nature.
Now if indeed there is a limited number of people
who progress, the question is, what is it that is
responsible? These are the things that I believe we need to
focus our attention. We have to look at host factors: age,
race, gender, immune status, genetic predeterminance. We
need to look at viral factors such as: viral strain;
quasi-species; viral quantity, as has been suggested several
times; mutant strains; extraneous factors such as
alcoholism; co-infection.
I might mention we have tested our group for
hepatitis G. We did find hepatitis G in the people who are
C positive, but do not find that it has any effect on
outcome. So G plus C, at least in this study, doesn't seem
to be any worse than C alone.
I see this disease, and I have shown this before,
and this is a slide that the AGA has, as an iceberg. I
think that more of the disease is undetected than is
detected. I think it is the detected disease that gives us
the greatest consternation and appropriately so. This is
the group that is defined already with I think potentially
severely progressive disease, and this is the group that we
need to look at.
Our problem is that when we see a patient in a
clinic who is anti-HCV positive, or has an abnormal ALT, we
cannot determine in an individual patient, as far as I can
tell at this point, who is going to do poorly, and who is
not. That is, of course, what we need to find out, because
I think that we have to do is to look for the risk factors,
and deal with those.
Also, we must be able to tell our patients what to
expect. Should they expect that they are going to die from
this disease, as so many people believe, which is not true
in most instances, or are they going to do fine? That's
what I think we have to struggle with.
Now this is a slide that Harvey Alter lent me.
This is his perception of the outcome, and I'm done. Sorry
if I'm taking too long. He feels that over a period of 20
years, this is the rate of progression of the disease,
perhaps reaching 10-15 percent who are going to end up with
clinically apparent liver disease.
Then there are three potential outcomes. Either
this line can go straight, or it can go up like that, or it
can go up like this. His data and our data would suggest
that it is going to follow this course, and that the
majority of people with this disease may yet outlive it. We
cannot tell, however, which it is going to be. So we
struggle with this issue, and we have to continue to look at
this disease in as much detail as we can.
I think I'm about done. I have one slide, and
this is from Miriam Alter. She gave me her slide, because I
don't have anything in our study that permits us to examine
the risk, comparing disease acquired by transfusion versus
risk acquired by other sources.
This was the study that was referred to early of
Dr. Alter's, in which she looked at the patients with
community acquired hepatitis C. This is the blood
transfusion group. This is the injection drug abuse group.
The interesting thing is that chronic hepatitis occurred at
about the same frequency.
If you looked at histology, there does appear to
be a worse outcome among those who were transfused, versus
those who were drug abusers as a basis for their
acquisition. The numbers, however, are very small. We have
got only one out of five here, so this 20 percent really is
somewhat inflated probably. Also as I think was pointed
out, the age at acquisition of the disease was not taken
into account, and so therefore, that may play an important
role as well.
I think I'm done. Well, thank you very much.
DR. CAPLAN: Questions?
PARTICIPANT: Question one, corollary question
two. Why do 11 percent clear their hepatitis C versus why
don't the rest do it? What are the factors that you know or
that we know enhance clearing versus the factors that do not
enhance clearing?
DR. SEEFF: Well, first of all, we have to confirm
this unequivocally. I'm giving you somewhat preliminary
data. We are in the process of double checking all of this,
because this is a figure that is twice as high as is
currently accepted. Data from Harvey Alter would suggest
that about 15 percent of people recovered from this disease.
In our case it was almost double that, 30 percent.
Once we have got all the data in, we will know
whether this is accurate or not. Why it is happening, I
don't know. It's a hugely important thing. I have an
enormous database. I'm busy looking at all of these various
subgroups now in great detail to see if we can account for
many of these things that you see here. That is a question
that deserves further examination, but I can't give you the
answer at this point.
DR. CAPLAN: We're going to take a brief break of
let's say 15 minutes. Try and be back in 15 minutes.
Is Dr. Robinson here?
DR. ROBINSON: Yes.
DR. CAPLAN: I think we're going to go with you
first, because I think you had a plane to catch after this
meeting? Is that true? So we'll have Dr. Robinson up next
when we come back from the break.
[Brief recess.]
DR. CAPLAN: I would like to get us underway
again. I think we are going to find the next two
presentations of special interest, because they involve
lookbacks in other settings. First, we have got Dr.
Robinson, who is going to tell us something about a lookback
in England. She is the National Medical Director of the
Blood Authority for England. She has left me a number of
materials which is brought about their lookback, which I
will have copied and made available to the committee by mail
after the meeting is over.
Agenda Item: Lookback Experience in the United
Kingdom - Dr. Angela Robinson
DR. ROBINSON: Well, thank you very much for
inviting me to your committee. It's been very interesting
to hear your debate, because as you will discover we were
where you are perhaps two years ago, and have gone on from
there to actually do an HCV lookback, and I'm sure you will
be interesting in where we have got to. A lot of the issued
you have discussed, I'll touch, or you can ask me questions
afterwards.
Just to give you a little bit of the background of
how we work, the first thing I'm sure you are all aware of
is the whole of our transfusion services is part of our
National Health Service. There is no Red Cross. It is
government run, and it is a non-paid, voluntary system.
The Department of Health has an advisory
committee, which is the Expert Ministerial Advisory
Committee on Microbiological Safety of Blood and Tissues of
Transplantation. It is a policy-making body, and it is the
only body that can come up with what will be mandatory
screening tests. I, as an individual, cannot start in any
blood center, a screening test unless it has had ministerial
approval.
It is chaired by one of our chief medical
officers, deputy chief medical officer. The members are
chosen by the minister and the chief medical officer. The
observers -- you will be entertained to see the territorials
are Wales, Northern Ireland and Scotland. In fact what it
means is it is a U.K.-wide advisory committee. What it
attempts to do is come up with advice that we all do at the
same time, same date, throughout the whole of the U.K.
We have our own professional advisory groups
within the service. Again, we try and make those U.K.-wide.
It is a little complicated, but these produce guidelines.
They are not regulations. It is the group that I would tap
into as a professional to say, well, what do we think about
this issue; what is the latest medical and scientific
thinking; should I take this into the ministerial advisory
committee as something that we should do?
So we have a red book executive committee that is
like to send us some guidelines for the service. Under
that, the most one in this context is the Signing Advisory
Committee on Transfusion and Transplanted Infections, which
I am a member of, as I am also a member of the MSBT.
The other thing it is important I think to be
aware of which enabled us to do this study in the way we
have is that we became a truly national organization in
1994, and have got ministerially approved reorganization
changes since November 1995. So it is have been a very busy
time for people like myself and my colleagues.
What it means is that all of our blood centers --
and again, our blood centers are large. We did have 14, and
we are now down to 10 that do processing and testing; but 14
centers still exist that give advice and follow-up, et
cetera, where consultants actively interface with the
hospitals.
It does mean that as the national medical
director, I can exert executive authority over all those
centers. If I say something should be done, it should be
done. Ha, ha. Well, you have to remember I was actually
one of what we call the barrens. I used to run one of the
transfusion centers in Yorkshire, so I'm very well aware of
the culture that exists out there.
Just to give you a little bit of background, I
have to correct that data, I'm sorry. We actually started
in September 1991. Now that is significant to this
audience, because it meant we started with the second
generation test. So we haven't got the problem of the first
generation test, the high rate of false positives. We
actually started with the second generation test, and with
the REBA, so we had a means of confirmatory testing.
That was again, a debated decision by that
advisory committee. Until the second generation tests came
in, we didn't start universal screening. The other
important thing is that every center started on the same
date throughout the U.K.
But the decision was made in 1991, no lookback. I
wasn't in the committee then, so I can't really tell you why
the decision was made not to do a lookback. My
understanding is that it was believed that the hepatitis was
relatively mild, and there was no treatment, so why inform
anybody, and it took such a long time, so let's not do it.
It was reviewed at various meetings, but it was
that standing advisory committee in 1994, where according I
think to your legal advisory that you had, we considered
that it was medically and scientifically appropriate at this
stage to undertake a lookback.
Part of that was because more of the natural
history and epidemiology of the disease was being known.
Interferon alpha was about to be licensed in our country,
and trials were suggesting there was a treatment available,
and we had the capability within the Service to actually
undertake it on a national basis.
This committee, the Ministerial Advisory
Committee, considered in September 1994, felt that there was
a duty of care, particularly to the younger recipients who
were likely to live that long time span, and set up a little
core group to report back, of which I was a member.
This discussion there went, well, yes, we
recognize the duty of care to the pediatric patients who
have been transfused, you can't give two levels of care,
therefore the recommendation was that if you were going to
do it, you do it for everybody.
Duty of care is actually a legalistic word, as you
know, and therefore we had to check all this out with the
legal people, who, although it is not written down, believed
that a case could be argued that if you had the information
that the intervention treatment was available, and you
failed to actually do your utmost to let that patient know,
then you were failing in a duty of care.
In January it was announced and a working party
was set up. On the January 11, 1995, there was a public
ministerial announcement with press release, question and
answer, brief. A help line was set up. There was a cascade
throughout the Service to let all the doctors, together with
the question and answer brief, we're back to what's the
message; consistency of the message; what are you going to
do; how are you going to do it; and when. So through that
cascade, every registered practitioner in the U.K. actually
got a copy of the press release of what was happening.
Just to compound and confuse, the media got
involved and did a wonderful group. "Panorama" is a BBC
documentary, and it did a wonderful -- that's sarcasm by the
way -- documentary on bad blood. Why hadn't we told all
these people that they had got hepatitis C? There were of
course 500,000 in the U.K. that have got it. The
implication was that they got it from blood transfusion.
It was an appalling program, and very, very
difficult for me. I was interviewed on that, but I was not
at that stage -- the interview of course was done in
December. I was well aware of what we were going to do, but
I was not going to let the "Panorama" documentary people
know that that was our decision.
We certainly didn't want them to imply -- you have
seen the process you went through. From 1991 to 1994, it
has been heavily, however, the result of that bad blood
program, as we anticipated, was that there were a lot of
worried multi-transfused individuals out there, or anybody
that had ever been transfused.
So we actually had to set up a help line, and also
made arrangements with our public health laboratory service
and with our GPs, that is our primary care physicians, that
if someone was really worried, and had been multi-transfused,
then they would be allowed to be tested and the
government would pay for it.
We had to give the preliminary actions for all our
blood centers. We then had to get our working party going
pretty hard to work out how were we going to do the rest.
How to get the counseling guidelines; how to get a uniform,
consistent message; how to make sure everybody was informed
as someone said earlier, in the right language and in the
right way.
I have given some of the documents to the
committee members, what was released at the time. I have
brought some highlights out. Tom Santville(?) was the
minister at the time, and this was part of his public
announcement that was released throughout the media in
January.
You will see that although recognizing that we
have one of the safest blood supplies in the world, we might
inadvertently suddenly have infected some people, and
therefore we are going to follow them up. Wording is so
important.
Another bit about wording. We shall do all we can
to care for patients who have become infected in this way
through counseling, and where appropriate, treatment.
In the chief medical officer's release, he said a
very significant group of words, which again I think might
be helpful for you. It said, we will follow-up all
recipients where records allow. The classic yes minister
cop out, if the records don't exist anymore.
I should add that in our country officially you
are supposed to keep medical records for 30 years. That is
the medical record document of patients. But of course as
we discovered, that is not always the case.
Now I realize this is small, but this is the
algorithm of how we actually set about it. In looking at
this algorithm, it was trying to make sure we covered
everything, to make sure we all did it in the same way. The
first thing was to make sure that only those who were
confirmed positive in that second generation test actually
were the components that we listed, and also make sure that
only the components that went to hospitals were listed.
In our country, every hospital blood bank has a
consultant hematologist in charge. So our link between the
blood center and the hospital was through that consultant
hematologist, and through that blood bank. So that was the
first step, was to get all those components listed.
The other decision we made was that any donor who
proved to the HCV positive when we started screening, we
worked on the assumption that all previous donations were
likely to be positive. That was based on some Scottish data
where in fact they had archived material back to ten years,
and although they were small numbers, it did suggest that
most of the donors who actually found to be HCV positive at
the time in September, nearly all their previous donations
were positive.
The algorithm goes on, and I won't go into great
detail, but what I am trying to illustrate is that we tried
to cover every option. For every option, we had a standard
letter to notify the hospitals through the consultant. A
standard letter that had gone through the legal people to
make sure that what we said and how we said it was
appropriate.
We had a form, and we tried to produce forms that
were simple, easy to fill out for every component such that
we could build up a database. There was the LBF-1. That
was for each component made from any of those donations that
were positive, there was a form which had the necessary
follow-up material that the technicians in the lab could try
and fill out for us, and also on which we would find out who
was the consultant in charge or the GP of that patient.
Then there was the suitability of the recipient
for counseling, and did they want us to do it, or did they
want to do it themselves. This is a very important point,
and I have heard that discussed today is how can you insure
that the counseling that the patient receives is of a high
standard, is consistent, and you are all saying the same
thing?
We actually produced a package. If the consultant
or the primary care GP wanted to do the testing and the
counseling themselves, then they were sent a package of this
is the information, together with a question-answer brief
for all the simple questions they might be asked.
Finally, whoever did the testing and counseling,
this is the form that comes back to me at the moment, so all
the living recipients, I've got the test results, and a
little bit more information back.
All the letters to the GPs, consultants, patients,
they were all standardized, legally approved in terms of
what we said, how we said it, and how we communicated and
contacted the recipients. I think in that case, yes,
everybody did use those letters.
The other difficult part was who was going to do
the testing, and who was going to pay for it? This is where
I did have fun and games. There were ten laboratories that
were recognized as being able and capable of doing a
reliable HCV PRC test, and this was the algorithm they were
supposed to be doing, which they had to contact the
recipient; screen them by an EIA; if that was positive, to
go ahead and do a REBA; if the REBA was positive, that came
back positive, and there was no need to do a PCR. They
would be onward referred to a hepatologist.
If they were negative, then a PCR was done. If
they were either indeterminant or negative by REBA, a PCR
was done. That is where I had fun and games, because when I
got the results back, everybody had done their own
serological algorithms, and it made interpretation very
difficult.
It was highlighted in this advice from our chief
medical officer. It was felt terribly important that the
patients hepatitis C status was done by an approved
diagnostic microbiology laboratory that really had the
capability of doing a reliable PCR test for hepatitis C.
Even with that proviso, some of our results had to be
repeated and sent to the reference laboratories.
I won't go into the, because there is limited, in
some of the counseling guidelines. They are in the
documents I have given you.
What I will do is what are attempting to do is get
a lookback central database. So we know the number of
donations, the number of components that were made, and the
number that were issued to hospitals. If they have gone to
another hospital, we had to go back and go around again.
The LBF-1 was that form that every hospital got where we
issued the components to.
There was no further action if it was found the
patient was dead, not traced, or not transfused.
The number that were followed up, of those that
were alive, and the LBF-3 is that final form that comes back
to me. At the moment, I have only got the data on all the
living recipients. I haven't got all the data on the
recipients that subsequently died, but I'm in the process of
getting that from each of my blood centers.
I suppose the bit you have all been waiting for is
how far have we got. Remembering this exercise began
properly in April 1995, it has proved a huge exercise.
Again, to put into context for you, our population is about
50 million compared to the states of say about 250 million.
So we are sort of that much smaller, but it gives you an
idea of how you can relate your figures or your potential
figures.
So you can see that the number of donors
identified pre-1991, was nearly 3,000. The number of
components identified and notified to hospitals was just
short of 12,000. I have to say this was quite close to our
estimates that we had made beforehand, like you have heard
from James AuBuchon. We were pretty close to what we
thought we would find. We thought we would find 3,000
living recipients from the number of transfusions that we
do.
Again, to put it into context, we collect about
2.5 million donations, and we think approximately 800,000
patients receive transfusions per annum. I think we worked
on the assumption that a donor would have given at least
three times before, and we would have made two components
from them.
You can see that the hospitals actually managed to
identify 6,000 recipients, and we have followed-up nearly
all of those that have been notified to us. You can see
that nearly 4,000 actually have subsequently died, and that
there are just over 2,000 living, of which we have actually
followed-up and counseled 1,500.
Thinking of the time span involved, this has taken
us a long time to get to that stage, and most of that has
been the hospital records. That has required a lot of stick
to actually try and get the information, because a lot of
the records, like they are here, are paper records. It is
time consuming, and does have to be done by someone who
knows what they are doing.
Now I have here, and I apologize, I have only got
this analyzed up to March, and we have more than this now,
but this is the data that I have got back on that LBF-3
form. So this data is where I have actually got the results
and entered them on my central database.
I looked at all the results, and tried to be --
regardless of which serological algorithm they used -- tried
to be very objective about what which were positive, which
were negative, which were indeterminant, and which I can't
really determine which are which. So in my central
database, and these are all the living recipients by the
way, none of the dead ones, I have got just over 1,000.
Just to put that in a slightly better form, or
more graphic form, you can see that of the living recipients
who we believe were put at risk by receiving an HCV positive
blood component, 581 were positive, 369 were negative, 75
indeterminant, and 27 I got no results at all.
The thing I should also say about when we started
testing is that although we did the second generation HCV
EIA and we did the REBA, we did not always confirm by PCR.
So in fact it could be that some of those that are negative
didn't actually receive a HCV positive component.
Again, a preliminary analysis of the data I feel
fairly secure about, just to give you an idea of male/female
split; how many actually are parents; who sort of ethnic
origin I have got so far. You see the vast majority are
Caucasian.
I think you will find this one interesting.
Again, I have to remind you that these are the living
recipients, not the recipients who have died. You can see
in the age group, this is the age of the recipient at the
time of transfusion. The blue are the recipients who have
been found to be HCV positive. The green are the recipients
who are HCV negative.
You will see interestingly in the younger age
groups, there appears to be a greater likelihood of possibly
the infection being cleared if they were transfused with
positive material. Whereas, as you get older you see there
is a much greater proportion of the recipients who are
actually HCV positive.
We are analyzing that in more detail, but it does
appear to be that there is some age factor involved in
whether the donation transmits or not, or whether in fact
that recipient is able to clear the infection once it has
been transmitted.
I also had a chance to look at the component types
to see if that had any influence on the ability of the
infected component to transmit. You will see that we have
got FFP, platelets, red cells, whole blood, other unknown.
You see really that each component would appear to be
equally able to transmit. There is no difference, although
I know some of the numbers are small.
Now you are wondering how far should you go back.
We actually tried to go back as far as records would allow,
I had been instructed. In fact, some hospitals and centers
have been able, as you see, to be able to go right back to
1978. If you take 1985 -- 1985 was when we started HIV
screening. In 1983, we started having the HIV information
leaflets. So our screening of donors from sort of 1983,
onwards should have actually taken out donors who were
previous IV drug users, et cetera.
What we found in our HCV positive donors who we
see, and we counsel all of them, many of them maybe have
been -- 70 percent of them actually were IV drug abusers in
the seventies; maybe did it once or twice, completely forgot
about it, and therefore didn't regard themselves as a group
that should be excluded from donating.
So I thought you might be interesting in actually
the span there of our ability to actually lookback. The
other rather interesting feature, earlier on it would seem
that our selection of donors maybe has got worse, rather
than better in terms.
Now I have only got the information on the forms,
and I'm following-up information now on all the recipients
to get more information and to get donor linkage
information. Of those recipients that have turned out to be
positive, 3.4 percent of them, 20 out of 581, have evidence
of symptomatic liver disease.
Just as a by-way, we did this at the same time,
because we do not test for anti-HCV core, and therefore we
just wanted to check in this multi-transfused group, whether
in fact they had also been transmitted with hepatitis B.
The information I get on the form is I get their
ALT results. You see that 20 percent have ALT results
higher than twice the high reference. There are some AST
results, and there is bilirubin. I haven't got the liver
biopsy information yet. All those that proved to be
positive would have been referred to hepatologists, and if
they had raised ALTs, almost certainly they are going to
have a liver biopsy.
It is an enormous amount of work to do a lookback
like that. It involves our own transfusion staff. It
involves the hospital blood bank staff. It involves a lot
of consultant time. Therefore, we felt if we are going to
do this, we want to try and get the maximum benefit out of
this major piece of work. So what we have actually got
funding to do now is we have got a national registry of
transfusion acquired, known date hepatitis C infection.
Obviously the core of this will be transfusion acquired.
I can already hear some arguments, it won't be 100
percent accurate, because some of those components that we
transmitted, we can't be absolutely sure were positive,
although the vast majority were.
Then any other HCV infections from other sources
with its known date will go in this central database. We
are now actually getting all the additional information from
the donor link up material, and getting a link post between
ourselves and our PHLS and CDSC. We are going to institute
an annual follow-up. It will provide a resource for
hepatitis for researchers if they want to do a particular
study of HCV, then maybe Dr. Seeff, we can provide them with
an appropriate cohort of a known date infected patients.
The aim of that registry is such that we can
monitor natural history and the long-term outcome of HCV.
That we can institute an annual follow-up. We can maybe
update the estimates of time from HCV infection to
biochemical, histological to actually being related illness
and death; monitor the numbers of new infections as they get
reported; and share this information both nationally and
internationally.
Again, thank you for inviting me to come, and good
luck.
DR. CAPLAN: Why don't we see if there are any
questions for Dr. Robinson about the lookback experience
there?
PARTICIPANT: Dr. Robinson, of the 581 living
identified positives, do you have any data that would talk
about the number that have identified an entered into care?
DR. ROBINSON: Yes. I can't give you that figure
now, but yes, it actually was relatively few. We do have
that information on the database; those that have already
been notified. That is on that LBF-3 green form. So I
would be able to go to the database and say, how many had
already been notified. It's actually quite a small
proportion of the total number.
PARTICIPANT: Two questions. One, you indicated
that you coordinated having PCR performed on the recipients
who were tracked in the lookback, and who were either
screened negative or REBA negative. Do you actually have
evidence on the yield that? What hiccups of infections were
found by PCR that had missed by standard serologic methods.
DR. ROBINSON: I was just trying to check that,
because I knew you would ask me that question. When I last
looked at it the night before, we had four cases so far that
were PCR positive, but EIA and REBA negative. It might be
slightly more than that. In each of those cases, they were
immunosuppressed individuals.
PARTICIPANT: It might be interesting to do
linkage studies on those cases with the donors.
The other question is, prospectively you have
focused on your program prior to implementation of HCV
screening. What is the British policy and experience with
continuing doing looking back associated with sero
converting donors subsequent to screening? Do you do that,
and do you have comparable yield data to parallel against
the retrospective?
DR. ROBINSON: Well, when we instituted the
lookback from September 1991, at the same time we then made
sure that any sero converters were also followed-up. It is
a separate database, and there are far fewer. The donor
base now is so clear, our instance of sero conversion is
very low. It's not going to yield any huge amount of
information.
PARTICIPANT: I wonder if you would comment on how
the differences in the medical care system of the United
States versus that in Britain might affect your ability or
one's ability to do the kind of lookback that you have
described?
DR. ROBINSON: I think probably the biggest
difference is the one that all the transfusion centers, all
the blood centers are actually within the National Blood
Authority's control. So you can actually say, this is what
you are going to do. This is when you are going to do it.
This is how you are going to do it. You still get
variations, but you stand a bigger chance of doing it.
Now the same applies to the hospital. We do have
some private hospitals, but most of them are within the
National Health Service. So again, you can use some stick
to say you must do it; that you are obliged to do it. They
will shout and they will squeal, and central monies were
provided. I think it cost us about just in testing alone, I
think they set aside something like 250,000 -- that's pounds
sterling.
The biggest difficulty at the moment is the
hepatologists are really struggling now, because these
patients are being referred to specialist liver centers.
They say they haven't been given sufficient monies to supply
the interferon. There are some combined
interferon/riboviron(?) trials in progress. If they get
referred to a specialist center, then they will get the
money centrally funded.
The other thing was at the same time, there is a
huge amount of governmental monies on HIV research, but very
little on hepatitis research. There has been a shift now
with actual tenders for studies to be undertaken in
hepatitis, and the hepatitis C field in particular, of which
the registry was fortunate in getting that funding, because
that is a resource that they will all need to have access
to.
DR. CAPLAN: Just one question about the content
of the counseling. It basically says what? We have some of
these materials here.
DR. ROBINSON: You have that. It was interesting
that I think your legal person was saying you've got to say
it in the right language. So the way we did that was first
of all, you had the ministerial press release, and then you
had the sort of department of health press type of language.
Then we had with the help line, it was very much a
lay person's question/answer, which again you have that very
basic, even to people who don't know what a transfusion is,
or if they have ever had one. The difference between a
product and a component is quite complicated.
The information that was cascaded to our primary
care physicians, which we call our general practitioners,
was a full -- basically, we assumed they knew nothing, but
gave them the scientific information that they would
require; then for those that were interested, more in depth
follow-up. The main message was if you have got one, and
you do the counseling yourself, you use this brief to
counsel them, and you refer that patient to a specialist at
a unit if they are positive.
We felt that was very important that a uniform
message was given. We did have one charity -- I think we
call it the Liver Trust -- that wanted to get involved, but
actually we maintained control of the information ourselves.
I think that being said, if you do it here, then that is
very good advice. Do it from your committee.
PARTICIPANT: One of the difficulties we have in
this country is people are so mobile, they move an average
of once every seven years. Also there are so many
fragmented media choices, it is hard to use them The London
Times and get as many people, but are people as mobile in
the U.K.?
DR. ROBINSON: They are as mobile, but the key
really was -- you probably don't have a similar system, but
with our general practitioner system and our national health
system, every patient is registered with a general
practitioner. They have a sort of national health number.
So if you can find the consultant on the medical record, in
the medical record at the hospital there will be the GP.
Even if the GP has not got that patient, that patient will
have registered with another GP, and therefore the records
get transferred.
So we are probably better able to trace patients
within our health service than you are, through that sort of
primary care registration system. Everybody does it,
because it costs you nothing, and you usually have to see
your GP at some stage during your life.
DR. CAPLAN: Let's do maybe two more.
PARTICIPANT: [Inaudible].
DR. ROBINSON: Yes, it's the process we have
actually got with the investigation. I think that there are
several stages along the way where you have got hiccups.
First of all, the list of components goes to the hospital.
At that point, you may lose some, because the hospital blood
bank records have been lost or burned or are untraceable.
So you lose some there.
The next one is can you find the medical record?
And we lose a few there.
We got to the point where in fact we have just
over 6,000 recipients that we were able to trace from 11,000
components; about 7,000. If you look at those, two-thirds
were dead, but it meant we had actually been able to trace
and find them and they were dead. One-third were living.
Of that third that were living, on the main date that I have
got, which is asking around -- I haven't got the full
information back, but on inquiry and updating -- we are
about 600 short in terms of have they actually counseled
them yet. I believe that probably we will be about 18 and
20 percent where we will never be able to trace.
The form was done in such a way that you will
counsel that recipient unless you can state valid reasons as
to why you're not going to. They had to be either the
patient was dying or it would upset them, or a certain age.
So there is only a small proportion of those were where the
consultant said, we do not think it is advisable to inform
that recipient. There are a few.
PARTICIPANT: [Inaudible].
DR. ROBINSON: Once informed, the vast majority
agree to be tested.
PARTICIPANT: A politically difficult question,
but in England you, one, didn't introduce anti-core. I
don't know if you did ALT. Two, there was a delay in HCV
testing relative to the rest of the world, first generation
to second generation. How much did that influence the
resolve behind the country's efforts into this lookback
program?
DR. ROBINSON: The main reason was it was becoming
quite clear that HCV was not a benign disease. It was also
very clear -- actually, I have to tell you at the time we as
transfusion centers, wanted to do it. If you are going to
start a test, and in fact I've got into the NSBT and said,
look, if we ever do this again, can we say that lookback and
mandatory, unless you say why not? I liked your legal
person who said, is it medically and scientifically
appropriate to do so?
The question there was, well, we don't know what
sort of disease it really causes. There is no treatment, so
why tell anybody?
PARTICIPANT: The value of your delaying
implementation, by the time you started, you had a good test
and a confirmatory --
DR. ROBINSON: The only thing I would say about
that is you can imagine the potential litigation now. We've
got four groups. We've got the pre-1985, the hemophiliacs.
You've got this very critical period between 1989 and 1991.
You've got the pre-1989, where our government would say,
we're not liable; no test. So I think the test cases will
be coming up soon. That period between 1989 and 1991, why
didn't you?
A lot of our argument was there were false
positives. Well, there were false negatives as well. There
are a lot of arguments. I give us a 50-50 chance. We
started testing with a test that was reliable, that we could
confirm, and we deliberately delayed until the second
generation test came in. I think that is going to be
interesting.
DR. CAPLAN: All right, I have to let Dr. Robinson
go, because she has got a plane to catch. I want to thank
you for your presentation.
I'm going to ask Dr. Gill to come down, and he is
going to tell us a bit about the Canadian experience with
lookback.
Agenda Item: Lookback Experience in Canada - Dr.
Peter Gill
DR. GILL: I was asked to talk briefly, for ten
minutes or so, about the Canadian experience, and to
concentrate a little bit on the cost of what it is costing
us to do this lookback.
I would bring you into the picture, and as very
good introduction to it all from Angela Robinson, about the
difference in the systems between the U.S. and Canada, and
the difference between Canada and the U.K.
In Canada we have been subject to a royal
commission of inquiry into the tainted blood scandal going
back to the mid-eighties, and the reason why we delayed HIV
testing between March and November. The launch of that
inquiry led into concerns about another potential blood
scandal, that is the hepatitis C virus infection of the
Canadian blood recipients, and why we didn't introduce ALT
and anti-core from 1986 on, when the United States
introduced it.
So the HCV side of the story arises mainly out of
that, and that royal commission of inquiry conducted
inquiries across the country from 1993 on, in which the main
stories coming out at that time were the stories of the
recipients. So on television every second night or so, you
would get a group of people who were victims of the Red
Cross tainted blood scandal. So that the general public was
alerted to hepatitis C through the commission of inquiry.
What we did in the Red Cross in 1994, was look at
what had been going on in terms of the pressures that we
were feeling about doing something about hepatitis C, the
pressures that we were feeling from litigation on HIV in
which we were advised that we should do all in power to
identify recipients of tainted blood.
So that in 1994, we formed an ad hoc committee of
a few of us within the Red Cross, and two or three
epidemiologists from the Public Health Service, and debated
the issue of hepatitis C lookback. We came to the
conclusion that we would do hepatitis C lookback based on
litigation. If we had the knowledge, we should go and track
the recipients.
If there was an opportunity to do something with
respect to lifestyle change, the consumption of alcohol,
that was significant. It being an emerging virus, we knew
discoveries were going to be made every X month. In terms
of the evolution of treatments, we expected to occur over
the next few years, therefore we decided to go ahead and do
a targeted lookback.
Now at the same time, there was a movement based
on the pressures from the Creaver(?) Commission's early
report in February 1995, that hospitals should do all in
their power to notify recipients of blood going back to
1978, as to whether or not they may have acquired HIV and
hepatitis C.
So the hospitals were put under a lot of pressure.
When we launched our hepatitis C lookback program, we did
get funding from the Canadian blood agency, and that is an
agency that represents the provinces. The provinces are the
funders of the blood supply, not the federal government.
The 10 provinces more or less went along with what they were
going to do. It required of them to be prepared to provide
the testing facilities, which again is an eventual
responsibility for the recipients of blood.
So we decided in mid-1994 to work with the liver
foundation on an education program, recognizing that both
the public and the physicians needed an education program.
The liver foundation convened a meeting of 25 hepatologists
in February 1995, came up with a program of education for
the general practitioner.
We put on a program jointly with the liver
foundation to advise general practitioners of the kinds of
patients that might come to them from either the donor base
or the recipient base in the Red Cross, as well as the
general education program for physicians. That was put on
in very city where there is a blood center, just to get the
whole program going for the public in general.
In addition, the liver foundation made a brochure
for physicians out of the program, and distributed it to
30,000 general practitioners. They put a brochure out for
the general public. They had a 1-800 hotline for
physicians, and a 1-800 hotline for the general public. So
this is how we introduced our educational program in March
1995, at the same time as we introduced our lookback
program. So our lookback program spans from March 1995
formally.
So to give you some idea of the background across
the country, this is the national data on hepatitis C, in
that we started testing in 1990, as soon as the test became
available. The same week you started in the United States,
we started testing for hepatitis C with the first
generation.
Because we were not doing ALT, we were not doing
anti-core, and as soon as the test became available, we
introduced it in our centers. This worked out around 1,550
positive cases on an annual basis out of about 1 million
donations a year.
We introduced EIA-2 in 1991, and at time we could
purchase it. Even though it was not licensed in the United
States, we purchased it, because we were allowed to with
agreement to buy a test ahead of licensure if our own
regulatory agency approved it. So we brought EIA-2 in 1991.
We introduced REBA at the same time, and test
thereafter. The basis of these figures are using EIA-2 and
REBA, and that became our standard test.
All the donors that were found repeat active on
EIA-1 and were submitted to a REBA-1 testing, we happened to
have a stored sample on them in the National Reference Lab,
and so we retested all those with REBA-2 to clear up the
false positivity of the EIA-1. That data was used to start
to lookback at the recipients of the previous donations.
Just to give you some idea of what we are looking
at in terms of the donors, the ratio of first time donors to
returning donors is about 1.5 to 1, but the prevalence in
first time donors is about 14 times higher than that in
returning donors.
In terms of what we were looking at for potential
incidence of sero converters, these are the numbers we
actually did find in terms of donors who previously tested
negative on an EIA-2, and then were subsequently found to be
REBA-2 positive on an annual basis. This is out of about 1
million donations a year, or about 750-800 donors a year.
So we picked up 10 in 1993; 6, et cetera. So that
the actual sero conversion rate to hepatitis C is very low
in the donor population. Most of our concerns in lookback
were donors who had not been screened previously, and had
returned after one, two, or three years after testing
started. Therefore, we had a need to identify the
recipients of those donations.
So we looked at it in two parts, the ones that we
identified which were positive before March 1995, when we
introduced the test, and after March 1995. In terms of the
completed lookback, I don't know the denominator here in
terms of the number of returning donors. That figure is
still being found.
You can see that components transfused, and in
terms of the recipient status, 32 percent were alive; 62
percent dead, and 6 percent not located.
In terms of the positivity, 64 percent of those
that we found alive were positive for HCV. After 1995, I am
not quite sure of the bias in these figures here, but
insofar as we are testing ongoing, it would look to be for
some reason or other, that the bias is towards not finding
positives at the same rate as prior to 1995.
In terms of looking at the year of transfusion,
again it rather very much follows the British story that
some of the hospital records may go back to as early as
1982, 1983, 1984, but the bulk of them are concerned with
more recent transfusions.
If I remember correctly, when I was a royal
[inaudible] in Montreal, we had to keep our records for
seven years. I don't know whether that is still so, but
probably it is on average about seven years. You keep them
for eight years to cover yourself for the seven years.
Somebody mentioned that I think here in the United States,
eight years is a common time to keep your records.
In terms of age, of those that are alive, with
implicated units you can see that given the gender of the
age when transfused, there is a cluster of female gender
outweighing the male gender in childbearing years.
Something like 66 percent of the recipients are under the
age of 60 at the time of transfusion.
That is the age when we started the lookback.
There is a shift this way, as you might expect.
Now in terms of the cost, I managed to get some
figures out of one major center about where they are at
currently with the lookback program. They have identified
5,361 blood components from hepatitis C positive returning
donors, and 3,207 of those components were assigned to the
local hospitals.
In terms of the cost of setting up the lookback
program and chasing at the hospitals, and in terms of
following-up at the hospitals, because of our being found at
fault for not doing all in our power to notify hospitals and
follow-up with the hospitals, whether they had themselves
instituted proceedings to find the recipients, we started
sending registered letters automatically to the CEO of the
hospital, as well as the blood bank director. We repeat
that twice, to make sure that we got some sort of response
back to get the status of the actual recipient tracing in
the hospital.
So in terms of those costs, the labor costs versus
other costs, this is what it has been costing this
particular center; something like $55 a component for the
total, but $93 for the ones where the hospital destination
has been assigned. So that is the current cost to a center,
and probably that is fairly similar to most of our centers.
We have 17 centers conducting these programs.
They are not uniformly computerized, and of course neither
are the hospitals in terms of record tracing. Some of those
records are sometimes found accidently. This particular
center moved house a few years ago, and suddenly came across
a box of records going back to 1986 or something like that.
Now in terms of the hospital side, I managed to
get some figures about ten days ago from one of our major
teaching hospitals as an example of what it costs them to
follow-up the notification by the Red Cross, and how they
went about it over the last four years.
This hospital received information from the Red
Cross on 182 lookback cases of hepatitis C. Of those, 159
were deemed to have been transfused, and of those, 121 of
the patients were deceased. Of the patients who were still
alive which they could follow, there were 29. The patients
who previously knew they were hepatitis C positive were 6.
There were 9 new cases located after these 159 transfused
patients; 4 with chronic infection; 5 with no chronic
infection.
The age range here is considerably higher than
what I alluded to in terms of the general national picture,
but this is a tertiary care hospital, and there is probably
some bias in this age package, with an overall mean here of
67 years, compared to something like 50 years with the
other. So that is what they found in the hospital.
What it costs them to find those patients is
listed here, and the breakdown of the costs in the hospital
for finding those 9 patients. The tech time, again, it was
alluded to before, we don't use causal people, causal
employees to do this work. They have got to be hospital
employees who are thoroughly knowledgeable, as the data
arising out of their investigation is of significance with
some potential litigation if they fail.
So these are the costs incurred at the hospital
level for following-up those 159 transfusions. If you look
at those costs in terms of per transfusion, of the 159 it is
costing something $780 per transfusion, however, when the
recipients are alive, there is further testing and
counseling, which raises it to $855 per transfusion for each
recipient who is alive.
If you divide the $124,000 by those 29, of course
it is running around $4,000 to identify each live
transfusion recipient, if you want to look at it that way.
For the ones which are newly diagnosed, to identify a newly
diagnosed hepatitis C patient, it is costing something like
$13,784 per patient.
Superimposed on what we have been doing as a
lookback, there have been new initiatives at the provincial
ministry of health level, because Creaver also recommended
hospital notification programs in quite a big way. Some
provinces have already got class action lawsuits for
hepatitis C taking place; the province of British Columbia,
and the province of Ontario in particular.
So that the current atmosphere in the hospital
sector is to do all they can do to notify transfused
recipients. So there are hospital notification programs
taking place. BC have almost completed their notification
program. In their notification program, because health care
is a provincial responsibility, the medical records'
addresses of recipients, et cetera, can be accessed through
the central provincial database on Medicare.
So that the process is ongoing now. The province
of British Columbia, the province of Nova Scotia, the
province of the New Brunswick are all into full fledged
hospital-based notification program.
We alluded to the potential, when we had our
committee meetings, of the pediatric hospitals in particular
should consider a notification program. Several hospitals
have done that across the country. There is a report of the
costing and the kinds of efforts that are involved in such a
program, which has just come out by Head L'Etale(?) in the
Canadian Medical Association journal of July 15th, with an
editorial commenting on the approach to hospital-based
notification programs.
So in Canada we targeted lookback programs
conducted by the Red Cross blood donor service. We have the
hospital-based notification program superimposed on that,
and somebody has got to sort out where these recipients are
going to be assigned to in terms of who found them. That is
what is ongoing right now. The material you got, I
presented to you, is an interim sort of assessment of things
as they stand at present.
Thank you.
DR. CAPLAN: Maybe just a couple of questions.
That was the first talk I have heard in some time where
someone couldn't say, but at least we have escaped the legal
concerns of the United States.
PARTICIPANT: [Inaudible].
DR. GILL: The numbers shared from both the U.K.
and Canada fit very closely with the model in terms of
likelihood of the patient still being alive, and also the
costs involved. They are not precisely the same, but appear
to be relatively close.
PARTICIPANT: In addition, the number of
positives, 67 percent is what I believe you are receiving.
Is that what is assumed?
DR. GILL: It depends on what time period the
donation falls in, the incident donation falls in, and
whether we are dealing with version 1, 2 or 3 positivity.
Generally close, however, the model that I used overall was
anticipating a higher infectivity rate than what has been
seen, but that was based on version 2 or 3.0 REBA
positivity.
I believe that is what you are using in Canada.
So possibly the model that I have been using has been
overestimating the yield slightly.
PARTICIPANT: But the cost factor is much lower in
Canada?
DR. GILL: No, the costs are relatively close;
within 20-30 percent.
PARTICIPANT: I thought I saw much higher figures.
DR. GILL: No, I don't believe so. I mean I will
have to look at this more closely, but I believe the cost
per each one of the individual operations and the overall
costs are fairly similar.
PARTICIPANT: [Inaudible].
Agenda Item: Open Committee Discussion
DR. CAPLAN: All right, thank you very much.
I picked up an article that Dr. Gill was kind
enough to leave me from the Canadian medical journal from
July, which I will also try and get copied and sent out to
you.
One of the things that occurred to me while I was
listening to the talks during the day is at the last meeting
of the committee there was a request made that we get more
information about a number of specific topics. My sentiment
from this day is that will be the last time you will ever
ask us for that again.
We have got a lot of information, and I know the
hour is late and we are trying to process it and mull it
over, but I would ask your forbearance that we do try to at
least open the discussion today, because that will get our
minds churning a little bit in the evening hours about
things that we have to get back to tomorrow.
My proposal would be this, that we at this point
take about an hour to talk some about some of the issues
that we have heard, maybe using let's call it the Hoots-Penner
statement as a template. I know that it was written
with great care, and extreme precision at the last meeting.
It is probably beyond revision, but in the off chance that
we might want to add or subtract something from those first
statements, maybe we could even put them up there, Paul, in
the spirit of editing.
If that is all right with the group, why don't we
maybe put those up there, but open the floor for some
comments about things that you think ought to be included in
the recommendations that this body wants to make. I would
say you could base that both on what we heard today, and
some of the reactions that we got from agencies that were
written and distributed out.
So let me do that, open the floor up; see if there
are any particular comments or themes that you would want to
see us try to reflect in answering the questions we have
been asked, and in making our recommendations.
One of the things that I don't think we said much
about in the two statements that I recall is how would we
like to see outreach coordinated with the medical community?
This has struck me as something throughout the day that is
crucial if we are going to go out and recommend some form of
lookback, some form of discussion with people who might have
been exposed, whether it was last week or ten years ago.
We have got to have a prepared medical profession,
health care profession to deal with questions and have
someone there to counsel. I would be curious to see what
others think about that. Certainly this committee is in a
position to ask the agencies and PHS to prepare some sort of
plan or move forward in that regard.
We may want to say more than that, but it does
strike me in listening to the experience in the U.K., in
listening to some of the things that have come up as matters
of legal concern, that we have got to have, if we do go in
the direction of recommending some sort of lookback, even if
at the level of just public service announcements, we are
going to be stuck with the obligation of making sure we have
got counseling, and an informed set of answers available.
People expect that, and deservedly so.
PARTICIPANT: A question on policy. How specific
and in how much detail would this committee be providing? I
would propose that we would be giving the broad focus, and
then from there it would be a matter of details being worked
out by the FDA and others as to specifically how it would be
carried out.
DR. CAPLAN: Well, it is fair to say -- and if
Eric or Paul want to jump in -- as I understand this, as I
looked at the committee's mandate, we have been asked to
answer questions in the level of detail and specificity is
really in our hands. We could get quite specific and say,
A, B, C, D, E, F and do this, this and this.
It is also fair to say that some of the agencies
are certain there, ready with expertise and knowledge about
communicating risks or launching a public education
campaign, and we could say look, the mandate falls to you to
follow these general, broad guidelines about what we are
trying to get to.
Personally, I think we are safer if we try to
paint with a little bit of a broad stroke, and not get into
too much of the detail about how to carry forward, but it is
not -- my understanding is it is within our charge to get
specific if that's what the committee wants to do.
PARTICIPANT: There is one very important issue,
which is does the committee in premise accept the first
statements of either one of these, which is that there is
the responsibility to identify, using whatever means
necessary, individuals who are HCV infected?
Because if we say yes to that, question, then
immediately step way beyond lookback, and start I guess
putting a moral onus on ourselves to make recommendations
about how that is to be done, because we all agree I think,
after seeing all this data, that lookback is only going to
accomplish a smidgeon, even at the very best, of the total
infected population in this country.
So therefore I think in terms of specificity
versus generality, I think we have to solve that question
first before we can go on. I think both drafts kind of take
that in the spirit of things, but I think it is important,
because we are going to get really -- the specific question
was with regard to lookback, and we may have to get very
specific about lookback.
There is then the question we have to decide it
seems to me is do we also want to get rather specific about
how else to identify individuals who are at risk for what we
have seen to be a pretty bad disease?
PARTICIPANT: While I generally think that more
information is better than less information, as you may have
gleaned from my presentation, I would be much more
comfortable endorsing a specific recommendation about a
patient's right to know about potential hepatitis
transmission in certain circumstances as we have been
discussing today, than a broad statement about a patient's
right to know about any infectious disease potential
transmission that could have occurred through a past
transfusion.
I would prefer that we focus on, even as a
statement or principle, the hepatitis C, because different
infectious disease risks carry with them different
scenarios.
DR. CAPLAN: One of the things that is on the
table as certainly part of the Hoots set of recommendations
that we started out looking at last time is the notion that
different periods of time in terms of when exposure occurred
possibly through blood transfusion, might lead to different
answers about obligations to inform, and obligations to try
and look back.
One of the things I would also like to have some
feedback about is whether people still believe that if you
will, what we have to say might be time sensitive in terms
of how we deal with individuals. Does it make sense to say,
well, people have a right to know, or that people have a
right to know relative to the time at which a particular
test was available? Is that morally relevant or not in
terms of what we have to tell someone if we couldn't detect
a particular virus prior to a certain date?
I guess adding on to your comments, I'm kind of
curious about what we think about the evolution of knowledge
in this area. Certainly for me, one of the things that does
become relevant is it is one thing to tell somebody, and
feel that people have a right to know when they have been
exposed to risks. If you know it, they should know it too.
Not all risks are equally nerve racking, and we
might dispute about how much harm or quality of life
impairment has to go along with that, but a second set of
fact has changed that definitely makes a difference to me
personally, and that is, what can be done?
There weren't interventions before; there are some
interventions now. Some of them are lifestyle, and some of
them might be interferon. Some of them might be information
about even being a donor again and this sort of thing. So
we have new knowledge that in some ways I think shapes my
attitude about obligation to disclose that is in part based
on patient benefit, recipient benefit if you will.
PARTICIPANT: I agree with you and others that the
patient has the right to know. My concern, as I said
earlier, is that what will happen is that we won't reach the
patients if we pick one particular method. I think the
Hoots proposal is time sensitive.
I think that reaching the patients prior to
testing is going to require one approach, whereas after
testing is going to require either one or two additional
approaches in order to effectively reach. It doesn't matter
whether we have intervention strategies or not, ultimately
we will.
I think that we must reach those people at this
point, but we really have to find a cost effective and
encompassing way of doing that. That is really what I was
talking about earlier.
PARTICIPANT: I just want to say I would really
endorse what Art and Ron just said in terms that this is
very -- and still is, but the period that we have been
really focusing on has been a very dynamic period, where
things change and are continuing to change. I like Ron's
approach in the slides he put up in terms of trying to
define some general time periods, or broad periods of time.
I guess I would say that perhaps we could really
even stratify even in more finer detail, that period of 1990
to 1992, 1993, when we had first generation and second
generation, with the availability of supplemental testing to
really try and nail down with much more accuracy, who might
truly be infected.
So I would really be supportive of at least the
committee working through important points in that time
period, and having a good understanding of what happened,
and hence what information could be made available to people
who might have been recipients in that period of time.
PARTICIPANT: If we put a date on something, does
that then imply you really have to try to speak to everybody
individually? Does it almost eliminate a general method?
Because a general method of communication, public service
announcements, et cetera, wouldn't really identify that
date. It would just say, if you have had this happen, then
you should go for testing, or if you had this sort of
lifestyle.
I understand what you are saying, Mary, and it
makes sense from the fact that the test is more definitive
later, but I am just concerned that it boxes us in if we put
a date on it.
PARTICIPANT: So we would be saying people who
received product, who became positive in 1988, would not be
notified, and if they found out inadvertently, and they
asked you why weren't we notified, you would say well, we
have a test, and tried to just draw the line there. I don't
think that is going to float very well if someone wants to
litigate.
Or even if you look at it rationally, it's drawing
a line that is very arbitrary to begin with, and making a
difference based on that arbitrary system of it would be
less costly, number one, which doesn't work very well these
days. Then secondly, that it was just because the testing
was done. The individual is still involved, and has
received the infectivity, and is proceeding to deal with it.
PARTICIPANT: I think maybe that's getting back to
what I was saying before. I agree with you; I don't think
you can do just that. I think if we can come up with a
strategy that says that we think we can protect a person who
was exposed in 1988, in a better fashion by another strategy
besides straight lookback, then I think we are on both
scientifically good ground, and perhaps even reasonable
moral ground as well.
I don't think we can afford to just say, well, you
were infected in 1988, and that was a difficult time, and
therefore we have to just kind of forget about you. I think
part of the reasons for the lines to be drawn was saying
okay, if we are going to apply precious resources to trying
to identify every foreseeable person, is this the strategy
to do it with?
I think the lines were drawn to say that for
people who were transfused in this period of time with these
tests, there is a reasonable expectation that you could
identify them if you used classic lookback methodology. If,
however, they were infected in 1982, or maybe even 1988,
perhaps the yield would be so low that the resources you
applied to find that person may be better used by another
methodology, be it PSA, be it direct physician education to
seek his or her population of patients in for testing that
could be at theoretical risk.
I think that was kind of the way the lines were
drawn, not to say that we're kind of shunting away from the
1988 people or the 1982 people or whatever.
PARTICIPANT: The minute you separate -- in other
words, you are discriminating. You have no really solid
basis for the discrimination. If you use cost, that is not
going to work, because the total cost situation from the HIV
status was so tremendous, that I think we are still reeling
from the fact that there were some things that we didn't do
when we should have done it.
So I think at this point we are in need of being
able to proceed to show the public that we are worried about
the infectivity is.
PARTICIPANT: [Inaudible]. If you take on the
idea that we have already discussed [inaudible], a lot of
those records for 1982, 1983, possibly even 1988, may not be
available. I think if you put together a strategy that says
from this committee if we are going to go in that direction,
that it does not seem prudent to include that time period in
a targeted lookback, but rather public service announcements
or whatever to reach that group, because it's not the cost.
I think if it was just an issue of cost, yes, it's
[inaudible].
PARTICIPANT: But what if the records are
available?
PARTICIPANT: If the records are available, I
think the language that the -- the idea of putting something
in place either from this committee or anything that comes
from [inaudible], such a litigious situation, that they want
to [inaudible]. I think they would be remiss or very stupid
considering the times that we live in [inaudible].
PARTICIPANT: Although we may not like to admit
it, I think costs are indeed an issue today. There are not
unlimited resources available for health care. As Dr. Hoots
said, it is not so much an issue of how much something
costs, but where we can get the best yield for the resources
that are available.
I would love it if Congress were to allocate $1
billion for this effort, and we could do everything for
every patient, but that is not the case. We are going to
have to be able to work probably within our current
resources, that is, no new funds available for this
endeavor, and we have to be sure that we reach as many
patients as possible to get the message across.
If there were one patient transfused ten years ago
who was going to come down with HCV, and we were out to find
that one patient, and it was going to cost us $200 million
to do it, we would say, we can't do it. That's too
expensive to save one patient's life.
If there were a million patients in the last
decade that we might help, and it would only cost us a
dollar a person, we would say sure, let's go do it. We are
somewhere in between those two extremes, and we don't have
unlimited funds to do it. So I think we do need to direct
our attention using different means for different time
periods to get the message across in the best way.
DR. CAPLAN: One thing the committee may want to
give some thought to before I turn the mike is the question
-- I was trying to link this before, making a recommendation
about lookback, trying to inform, how one gets information
to people who may have been exposed. Do we want to say
anything about the obligation, not only to counsel, but to
provide the means to treatment?
If you are really looking at your budget,
interferon for the uninsured, or interferon for the working
poor with not much in the way of insurance, there are some
real resource dilemmas there, and there will be some real
problems if you tell somebody, well, we think you have this
and this, but there is no money in the kitty to give you
anything in the way of treatment.
So we may want to make a recommendation that if we
are going to move in this area, we've got to move with a
commitment to provide treatment access or not, but at least
note it or say something about it.
PARTICIPANT: I agree that we need to focus on
time periods. It is critical. The data we saw from Canada
and Britain was all lookback predominantly to people who
received unscreened products. There, there was substantial
yield. In contrast, the data from Iowa was recipient
lookback of sero converters, screened blood, zero yield.
So the Catch-22 is that the people where we will
get yield, are the people who received unscreened blood
prior to 1990, and yet the truth if there will be
essentially zero yield to what's been proposed as ongoing
prospective lookback fortunately. The numbers may be great,
but the proportion of exposed, infected people from that
early period is very small, not only due to absence of
records, but due to the fact that we introduced surrogate
tests in the late eighties; that we waited until now to even
begin to move formally towards this process.
The other is that we did have a year or two of
screening with first generation tests where there no
confirmatory tests, and places do not have those samples to
go back to. So the first year or two of screening, which
culled the blood supply of all these donors who were
transmitting, we can't go back and sort it out and
effectively do it.
So when I look at it, we are left with a general
notification campaign for the period of time when recipients
were at substantial risk; 1 percent of all recipients per
unit were getting infected prior to 1980, and even higher in
earlier years, whereas now it is essentially trivial. The
real issue is what do we do with those interval years, and
where do we really draw the line on where to focus.
I think the message of the broad public health
message should be to the period of time when there was
substantial risk. If that message includes people getting
transfused today, it is diluting out the message, because
there is essentially zero risk today.
PARTICIPANT: I think everybody is talking about
numbers here, and maybe we ought to focus back on people.
If one of your family members had received blood in 1988,
would you like to know whether there is a 50 percent chance
that that individual might have come down with hepatitis C,
and you would like to be directly notified?
If you look at numbers, I think you can play that
game, but we already done the numbers with ALT many years
ago, and we lost. [Inaudible] at the blood situation now
and the blood business whole is very, very poor. I think
the minute you begin to back off and start playing numbers
games, then I think we are going to be still more liable
than we have been in the past, saying that we are not very
interested in the public. We're interested only in getting
something that is going to be cost effective, and not going
to create a lot of problems for us.
No, I think what we are really saying is how we
can be effective in reaching segments of the population at
different points in time. That is what I see as the real
issue. To use certainly a family member, I can understand
that, but if you don't reach them, they are never going to
know. So we have to define strategies.
One strategy that is used in a particular time
period doesn't preclude its use along with another strategy
in another time period. All I'm saying is I think we should
look at each time period. We should attempt to define it,
and talk about the most effective way, number one, Art, of
reaching the people.
I still say that treatment is secondary. You
can't treat until you have defined who is or is not
infected, whether they were infected by a transfusion or
not. So treatment is really secondary. It's reaching the
people, and in effect testing those individuals, or at least
allowing them the right to be tested, but they have to know.
PARTICIPANT: I think what we are talking about is
the cost risk here. Take your scenario. If you say to
everyone who has a family member who was transfused in 1988,
you need to be tested [inaudible]. It's a very expensive
proposition, but it will be very effective if we get the
message out to those individuals. Even though it may cost
more dollars to do it, it may be a far better use of those
dollars than it is to try to do lookback, and ignore the 90
percent that we'll never identify because the records are so
screwy.
So I guess that's what I'm erring on. In fact,
I'm not for a minute saying this is going to be a cheaper
way to go. I think this is going to be a more expensive way
to go, but I think it's going to be a more efficient way and
a better use of dollars, even though it is going to cost
more money to do it.
PARTICIPANT: One thing I think that I want to
talk about is the public's trust here. I think the main
thing we have to do is try and re-establish that trust,
especially in the blood supply; not so much in the
government as a whole, but in the blood supply.
I think if we can do this in a general way in
which we do not leave anyone out, whether it is in a general
statement or in a way of doing this through a lookback or
however, I think that's one of the things we all have to
remember, is that the public's trust in a sense has been
violated. A lot of the citizens do not have the trust that
they should have in committees such as this; in the blood
supply as a whole based on things that have happened in the
past.
Whatever we do, whether we are talking about the
human factor or the cost involved, that has to be a part of
it. We have to do this in such a way where people realize
we acknowledge the mistakes that were done in the past, and
we're trying our best now to include everyone, and not
exclude anyone. I just think that that has to be a part of
whatever we do.
PARTICIPANT: I think as I have been listening
today, and listening to all the different perspectives, and
the statistics and data that we have had, it is evident that
this is a serious either epidemic, endemic, whatever we want
to call it. I think we need to address it in a very
respectful way.
I think as we look at lookback, to me I'm just
seeing that we need to have probably a targeted lookback, as
we have discussed. It sounds to me as though we need to
fall down on some kind of a date, whether it was the second
generation specificity test in which we want to use as that
criteria of where we look. Do we go from that date forward?
Then what do we do from that date backwards?
Do we address it with a public health service
program to inform those prior to that date? What kind of
program should that be? I'm seeing that that is probably
the way that we need to go, but I don't think we can go in
either direction until we kind of set a date on what we are
going to use as our criteria for doing lookback. Then we
can do notification and so on and so forth.
DR. CAPLAN: One thing that I hear coming across
is if we divided our task in the right to know into
identifying people, and then having them counseled properly,
it kind of leads us to maybe different strategies about how
we lookback.
One way to identify the pool of people is to do
public service announcements, outreach, educational programs
for primary care providers, health care providers and so on.
Another question then comes up, well, we don't want to
necessarily panic everyone who had a blood transfusion
before 1988, and have them all in a tizzy, so can we do this
in a way that assures maybe notification, but appropriate
referral to someone who can then get a test done, and
counsel them, and have education that is meaningful to them
without causing undue concern?
Having said that, I guess we have a couple of
issues that would lead us maybe to draw some lines. One is
tests and when they became available, but I think what is
really fueling our concern about looking back into the
distant past is records, and the ability to find names and
samples, to follow what Mike was talking about too. They
are not there either after a certain time, or weren't
collected in that way.
So it seems to me we might want to be forthright
and say, look, it would be great if we could lookback and
identify exactly who this was, but we may not be able to,
given the state of our records. The next best strategies we
have got are kind of general announcements, physician and
health care provider education, and perhaps some form of
special populations. I keep thinking that it can't be quite
the same if we are dealing with hemophilia or sickle cell or
Cooley's anemia to find those people. They are going to be
easier to find than some other people in the general
population.
So we may be able to acknowledge that we are
talking about here is an inability to get the kind of
records and information that would lead us to it. It's
possible in other words to not just say, as records permit.
We could say, well, we're looking back in this way, because
it is our belief that we can't do anything else but to
lookback in this way for this particular population prior to
date.
The cut off date then become not when the test is
introduced, it becomes the seven years or the eight years
when people start hefting the records out to the basement.
PARTICIPANT: I agree very much. I think the only
disagreement I have with Keith on this is if one has general
statements that are floating around in the public domain
that if you have been exposed, you have a blood transfusion
in 1988 or 1987, you should go in and get this, how much
different is that sort of a message than if you get a letter
saying you have received blood in 1988. An individual who
has subsequently been tested was found to be positive for
hepatitis C. It may be that there is a chance that you will
have this infectivity, and therefore we would recommend.
Now that is sort of push -- drives people in,
whereas I think the general statements coming through the
television and in the newspapers and so on have a lot less
impact, because people never think it is them. That is just
my opinion.
PARTICIPANT: I guess I'm moving somewhere in that
same vein in that on any problem that is as complex as this,
I guess I want to avoid the tendency to say let's answer one
question. We have set that aside, and now let's answer a
second question. The first question, date of lookback;
second question, how do we then do this other type of
notifying?
If we were voting right now, I would be very
reluctant to raise my hand and say we only look back to date
X period, and now let's talk about these PSAs. I'm going to
say date X is fine with me. If I understand these types of
announcements, just a PSA is not going to do it, and I think
we all understand that.
So we're going to have to spend some time trying
to be creative. Use people that understand how to attract
people and the special audiences that we need to draw in,
like you mentioned, Art, before that is going to make some
sense to me. So these two questions in my mind, are very
closely interacted.
PARTICIPANT: At the same time, I think that we
have to certainly recognize the fact that this will take us
only so far, because I think as we heard in several
presentations today that suggests that there are other risk
factors; the group of IV drug users, the group of
individuals that find themselves in penal institutions.
We don't have enough information also about women
in their childbearing years, and the possible vertical
transmission to their infants. I think that as we begin to
take information out to the public, we have to recognize
that we can't just back and relax because we've done that,
without at the same time trying to gather the other data
that helps us to really understand the full impact of
hepatitis C in a population.
PARTICIPANT: To me, if we are going to need to
begin to talk dates, I think the introduction second
generation screening test is the critical date, because
subsequent to that time the risk of transfusions has
declined to essentially zero. Prior to that time, there was
a substantial risk, 1 in 1,000, and before that up to 1
percent or even higher as you go back in time.
So the message in any kind of general risk message
has to be the blood prior to that date carried a substantial
risk of HCV, whereas blood subsequent to that time did not.
That then is sort of the public general notification focus,
which I think does have to have an enhanced transfusion
risk. It can't just be that little piece that the CDC puts
this 5 percent of risks.
I think it's our obligation to bring the risk up
to attention, and some of the data we saw today about
increased progression potentially may even make it more
important. But then if we focus on the pre-1992, pre-second
generation screened blood for that, then what do we need to
do subsequently? I guess that's where the ongoing sero
conversion lookback becomes important, and part of the FDA
overall armamentarium with respect to recipient risk for
safe blood.
Today's blood is very safe, but one of the catches
we have to catch the rare transmission is lookback from sero
converting donors. So I guess I support doing that
lookback, albeit it will be extremely low yield, back to the
point of second generation screened blood, because we've got
sort of two overlapping or contiguous methods; one for the
pre-risky blood, and two, for the ongoing safe blood.
PARTICIPANT: Clearly, one of the things that has
to be a part of what we do is an auditing and monitoring
process to determine how effective that what we are doing
really is. We know the number of transfusions that occurred
in each time period. We can make an estimate or guesstimate
of the number of people who are still alive. Then we can
determine by whatever we decide to do, or what we feel
should be done, how many people are we reaching?
If we are not reaching them with the technique or
the method that we use, then that isn't effective. So we
really have to have as part of this -- theoretically it
would be nice to have some pilot projects out there, where
we could go and take certain areas and do a small test to
see how effective each of these concepts is, but we are
going to have to monitor and audit to see if we really are
effective. If we are not, we are going to have to come back
to the table.
PARTICIPANT: One avenue in terms of identifying
some people that might be at high risk other than IV drug
users and people in prison would be people who have the need
for transfusions on a regular basis or blood products on a
regular basis. There are obviously national genetic support
groups and things of that nature that we can use to help get
that message out, because they are more in tune with these
groups than we are as a whole.
They have daily contact or whatever with these
groups, and they can help get that message out. So if we
can tie this all together so that like I said, we don't
exclude anyone per se, I don't have a problem saying let's
start with the 1992 base in regards to the testing. I think
that because of the amount of people prior to that who have
had transfusions for whatever the reason, if we can include
them, if we can at least try our best to identify as many of
those groups as we can, and then enhance that by certain
public general statements or something.
By general, I don't mean anything very simple to
the point where people just gloss over it, but I mean there
is more than one way to do this. I think we can identify
certain groups in one way, and go after other groups in
another way. So we'll just have to figure out a way to tie
all that together.
PARTICIPANT: I agree. I think the other thing a
number of us were talking about over lunch, I think we can
kind of harken back to the early days of HIV before we were
trying to exclude donors. In terms of identifying
recipients there clearly, I think, need to be certain
subsets of individuals identified in the population who may
have received transfusions and not be aware of it, including
patients who underwent procedures for major trauma
[inaudible].
Their parents may be vaguely aware that they might
have gotten blood. As a pediatric hematologist, I can tell
you that comes up a lot in HIV. Did your child get
transfused? Well, I can't remember. I think he did, but
I'm not sure.
One of the other caveats that we can put into this
is to say that not only if you received a transfusion you
are at risk, but if you are in these groups, you may be at
risk, and therefore you may want to consult with your
physician, or with the physicians in the past to help you
ascertain whether you may be at risk. If there is any
question, be tested.
PARTICIPANT: Well, with family members I can just
sit here and tell you about family members that I know of
personally who have had transfusions that just aren't aware
of the circumstances. So if we make a general statement and
we get this out the right way, then there are going to be
people getting on the phone and calling their aunt or their
uncle or whoever, and say, I think I just heard something.
I think you need to call your doctor and be tested.
There are different ways to do this, and we just
have to explore all of them. I think that is one of them.
If you make the message important, people will listen to it.
They will call the people that they think might be a part of
this. That's another way of getting the word out.
So there are a lot of different ways of doing this
besides just a public announcement. We can do this. We are
not going to reach everyone, let's just face that. We're
not going to reach everyone, but I would like to say we are,
but we are probably not.
The more people we reach the sooner, the better,
because as we are sitting here talking, someone else is
being infected. I think that at some point we are just
going to have to get the best plan we can together, and at
some point if we find ways to improve upon that plan, let's
do so, but let's not stop the ball completely, because we
all want the perfect plan. That is probably not going to
happen.
I don't want to say let's waste the money either.
I just think that there are enough ideas here that if we get
this ball rolling, we will start getting in touch with
people, and making people aware, and word of mouth will do a
lot that we just can't do.
DR. CAPLAN: Tell me from the world of primary
care, is there a question, did you receive a transfusion
prior to 1990 or 1988 as a standard part of a good history?
Is that done? So that could be done.
PARTICIPANT: Just like you do vaccinations.
PARTICIPANT: [Inaudible].
PARTICIPANT: It seems to me that part of the
process for trying to get information like this out to these
groups that will inform the public in ways that we have not
always been so successful, that the academic training
programs early on in this process, even before a formal
statement is prepared, need to incorporate into the
curriculum, into the material that is taught to students
that all of these conditions have some very important
population impacts.
So that it is more than just talking about the
kind of [inaudible] in the context of a clinical syndrome,
but rather, it does affect a lot of people. Part of the
history gathering, and the interaction with an individual
patient or the family or with the community is to better
understand how some of these conditions really potentially
affect a lot of people. [Inaudible], that perhaps allows us
to do the kind of testing that informs the process.
PARTICIPANT: What I was going to say is that
again, attempting to reach people, there is one clever idea
that possibly could work. It would be two or three years
away, and that is using the Census. If they would include
in the Census in the year 2000, a question asking if people
had been transfused or a member of the family.
Then literature would be mailed back to those
individuals who indicated a yes, informing them of the
possibility of having been exposed, depending on the time.
I'm just trying to think of ways that this could be done,
not necessarily now obviously.
PARTICIPANT: [Inaudible].
PARTICIPANT: We're back to separating
notification versus specific versus general. I think you
summarized it pretty well. Specific, we have limitations in
trying to find them, as Carolyn was saying, because there
aren't records. But there are records in some places, and
up to maybe seven or eight years, but maybe more.
So one has I think, an obligation to pursue that
as far as one can, because you can't discriminate and say
there is a first class and a second class citizen. If the
line is drawn here, and we're not going to bother notifying
you, even though we have records.
Because you are liable to go back to that question
I asked earlier, Freedom of Information and find out, well,
these people knew something about me, and they decided that
they could make decisions about my health, and I can't,
because I don't have that information. The minute we begin
to superimpose ourselves upon that sort of decision-making,
I think we are in really big trouble.
The other is the general, which I think Keith is
pushing, and others. There are many ways of getting at this
problem of getting the information over to the public, so
the public can respond, and see that it is significant, and
see that they maybe should go in and get some testing done.
That has to go to the medical profession and the general
public.
We have lots of ways of doing that. I don't think
that is going to be an issue. I think it is getting people
to respond who have been getting commercials thrown at them
on television about five seconds, and expect them to jump up
and do something. People just don't do it. That's why I
like the idea of having notification for as far as we can on
a specific level, enough though it's costly.
Now I have run a Red Cross center for 15 years. I
know what it is like to do the HIV lookback. I have done it
with a lot of griping from the staff. I also sit on a blood
banking board at two of our local hospitals, so I know the
griping that will come when they have to start digging
through, but they can do it, and it has been done for the
HIV. It is a little expensive, and it will probably end up
costing us a little higher for the blood.
I remember about ten years ago someone saying,
boy, before you know it -- and I think Jim, you were at that
meeting -- blood is going to cost $100 a pint, and we all
laughed. Then it was about $42. Now it is about $90. So
it probably going to be like the cigarette situation,
they'll just pass it on.
We'll end up all paying for it, and it will $120
or $150 a unit, but to know that that unit is safe will be
worth the extra $50 in my mind, as opposed to trying to get
by with a lesser amount.
PARTICIPANT: I just wanted to seek a
clarification from Dr. Penner, and sort of going back to
Mike's comments and others have made about trying to draw a
line in the sand. Is the starting point for your doing
targeted lookback as long as records permit, the donor who
has generation two EIA with a supplemental, to somebody as
best we can tell is truly infected? Is that your starting
point?
DR. PENNER: No, I think we will be even be using
that 1990, where 50 percent are false positives. We would
be going back from 1990.
PARTICIPANT: So then the message is a little less
clear, because you are going back to people and saying, I
don't know whether you got blood. There is a 50-50 chance
your donor was infected, as opposed to people in 1992, where
you could have an increased level of certainty.
PARTICIPANT: Because it comes back to my mind of
saying, but I would rather hear that I have been exposed to
something with a 50 percent chance of giving me a problem,
or not hear about it at all. So I think that is the kind of
issue that we are making decisions on for our public.
PARTICIPANT: In addition to cost and yield, I
think we should remember Dr. Kaplan's comments today about
competing risks. The notification process is not without
some inherent risks for the recipient of that information.
The recipient who may not want to know that they have been
exposed, but beyond that, the burden of false positivity.
The fact that even with a negative result, the recipient
cannot be assured that he or she does not have hepatitis C.
So I think we should approach the targeted
lookback effort with the best information that we have. I
don't feel that we are being irresponsible in our medical
duties to say to the public, to say to individual patients,
we decided to take this process from point A onward, and not
further back, because that was the best information that we
had in order to base our system.
PARTICIPANT: But you are going to be saying the
same thing to the individual now, that perhaps you will not
have been infected by that product, even though it is the
latest testing, and we're sure it is positive. You don't
know, so you are still getting the same message that
individual receives the blood, you may be positive or you
may be negative, but we don't know until we test you. So I
don't see any distinction there, any difference.
PARTICIPANT: On a probability.
PARTICIPANT: Well, I think that is true. The
probability that you are infected with the new testing is
going to be much higher. I would like to reiterate again, I
spent the last ten years developing a product to treat this
disease. You create a patient when you tell them that they
are HCV RNA positive, when you tell them they are C
positive.
I think it is all fine to go back and identify
these people, but I think we need to think about what we are
going to do with them once they get that letter, because
there is a lot of misinformation in the medical community
about how you deal with this patient.
They may go to their local physician, and they
will be dealt with inappropriately. It will cost them a lot
of money. They will become very angry. They will become
very confused. They may not get diagnosed. So I think as
another part of this, I would like to see us think about
once we create these patients by telling them they are
positive, what we are going to do with them.
I'm having anxieties about creating patients based
on some of that false positivity that we were seeing with
those early assays. I have seen a lot of those patients
come in to clinical trials thinking they are positive, and
then when we really get a close at them, they are not.
So I think we need to think about those things,
because I really have a lot of concern, because once a
patient thinks he is positive, he begins to think like a
patient. If you look at some of the quality of life data
that I have looked at in baseline HCV patients, they change
their demeanor. They change their psychological make-up if
you will, once they find out they are chronically infected.
So I think we have to be a little careful about
who we identify; how sure we are when we tell them they are
positive. Then we at least give them some methodology on
who to get to and how, so they don't end up in the wrong
place, and end up with another misdiagnosis, and a lot of
money spent based on a letter we sent them.
I think it's important to be able to identify
them, but I think we have to be able to handle them, and be
pretty sure when we identify them that they are real
patients.
PARTICIPANT: [Inaudible].
PARTICIPANT: I'm trying to think back to a Jim-type
model in terms of cost. Before we started screening,
after we introduced ALT and core testing, we were talking
about 3 per 100 risk, is that right for HCV?
PARTICIPANT: That is probably a little high. I'd
say the general population prevalence of 1.8 percent is
probably on the high side, probably pre- anti-core.
Certainly post-HCV exclusions of 1985, I would say you're
probably around 1 percent. Once we added anti-core and ALT,
once we started prospective screening in 1990, we were
dealing with about 0.4 percent, 4 per 1,000 infected donors
found is the risk.
PARTICIPANT: When you are talking about trying to
educate the population to what is high risk, the concept in
the article on cancer risk in here is really a lot with how
you frame it. If you are talking about a disease like HCV,
where the potential outcome is severe a significant
percentage of the time. Even with a 1-2 percent risk, that
is a very high risk.
Then you get a question, well, if you cut your
losses in terms of not having to test people who were really
not at risk by not doing lookback or by not testing
everybody, do you have cost savings over the long haul?
That's what I'm having trouble dealing with.
It seems to me that with this high a risk, that if
you take the ones who are in that treatment range period,
that testing everyone will cost a little bit more, but the
yield will be extraordinary. The miss rate will be
extraordinarily low. That may counterbalance the increased
costs, which is what I was saying before.
So rather than going through the extra cost of
tracking those in that period from say from 1988 to 1992,
why not just advocate there being tested? I guess that's
what I'm saying. I obviously haven't worked out the
numbers. Do you have a comment about that? I don't know.
It just seems to me that when we see how much it
costs to do a lookback anyway, why not just test all those
individuals, or recommend that they all be tested, and try
to get them in to be tested?
PARTICIPANT: But you are still going to then be
separating groups out and saying some are going to be
notified this way, and others are not simply because we have
decided that we can use the money more effectively this way
than that way. When you begin to discriminate, then I think
you have set yourself up for some legal action.
PARTICIPANT: Except that if your yield is
extraordinarily high -- there is a remote chance that you
will miss that person because they didn't come in to be
tested, but it seems to me that for the population at large,
that is a risk that is well worth taking, because you are
going to identify so many more.
Are we going to make decisions based purely on
legal grounds, or are we going to do what is right for the
United States' population?
PARTICIPANT: I certainly don't want to miss your
point, John, because that is very critical, but I am also
thinking of something Larry said a little bit earlier.
There is a trust factor here. The type of points that Keith
is raising really to me says what is this message or
messages that are going to be sent out there, and how are
they going to be delivered?
I think that I'll just call it a PSA for now that
we are talking about in the abstraction is an incredibly
complex idea. It scares me on one hand to say, we're just
going to put out that general message, because I can see
that general message causing more problems than it is going
to create. Yet if it is done well, it could be as Keith
said earlier, much more expensive, but the yield could be
better. Under those type of conditions, if we could work
that out, then I am comfortable with it. If we can't work
that out, then I'm coming back to where you are at.
PARTICIPANT: Decisions whether or not to
implement a lookback program don't always depend on the
sensitivity and specificity of the test among others; the
probability of false positives. No one is considering, no
one has ever used ALT or anti-core results to identify a
lookback situation, because we know the yield would be
incredibly low, and we would be chasing our tail.
First generation anti-HCV testing, well, it was
better than the two surrogate tests. It wasn't all that
much better. Essentially what we are trying to do I think,
is decide how good a test has to be before we think that the
yield will be good enough to engage in the effort. Clearly,
the surrogate test did not have a good enough predictive
value to be used for lookback.
Anti-HCV testing probably does, but the question
of what version, when in that spectrum do you say enough is
enough? I think there are some differences of opinion.
PARTICIPANT: Fifty percent isn't bad. I would
take those kind of odds.
DR. CAPLAN: One of the things I can do for a
brief respite from turning this ground over is Paul reminded
me -- you will love this non sequitur -- that we have a
legal obligation or a duty or some clear cut requirement
upon us to approve the minutes of the last meeting. So why
don't I entertain a motion to approve them, and then we will
do that.
[The motion is duly made and seconded.]
All in favor? Opposed.
[The minutes were unanimously approved as
submitted.]
There you are.
It seems to me one of the things we could do is
perhaps try to summarize a bit some of the things that have
come up. We are actually making some progress not toward
necessarily consensus, but toward picking out some things
that I think we will have to hash at yet again tomorrow, one
of them being how do we insure coordination between looking
back or notifying, and making sure that there is someone
there with counseling and an appropriate set of answers when
people come with questions.
Another is whether we are going to be time
specific and why, which is to say is it due to the
specificity and accuracy of the test that drives time
sensitivity about looking backwards, or is it due to
recordkeeping, or is it due to the ability to perhaps pick
out subpopulations and get further, in terms of feasibility
in what is doable with them?
Does it make any sense in terms of yield to simply
go back and recommend testing? I can't help but think that
one of the things that we're aware of is that there is
supposed to be a bigger push for hepatitis C, however it is
caused anyway. That is going on, and to some extent some of
the PSAs or whatever they wind up looking like should be
tied into this general effort to alert the American people
about this 4 million plus problem, epidemic of hepatitis C.
So that is there, and that is in the background.
It is not just inventing the blood transfusion fueled
communication problem, but that is out there. How does that
piggy-back in I guess is what I'm trying to say in English?
How do the two link up?
We certainly heard some comments too just in this
discussion about the importance of monitoring and auditing,
and being ready to step back and say, well, even though we
recommended X, we may want to change direction here in terms
of where things are going, and that seems sage advice.
We heard people also mention that we've got to be
sensitive in the recommendation to making sure that people's
attention is commanded, but we don't scare folks out of
their wits. That is always a fun enterprise, although I
have to say that if Americans are good at anything, it is
probably the ability to do exactly that in an
advertising/communication mode. It just costs something.
The last general point that I picked up is that we
need to make sure too that we are sending out consistent,
uniform messages, whatever they are, so that people come to
have trust and faith that the blood supply not only is safe,
but the people who operate it are being square with them.
It makes me think that in our recommendations we
need to have a few words about why it is that when there was
no lookback, there suddenly is lookback. If I was being
wary of experts and pointy heads in Washington or Bethesda,
I guess I would want to know why are they all of the sudden
deciding to change something? I think we can answer that,
but we better, otherwise we are not going to have trust
cemented that way. We may stir up distrust inadvertently.
So we do need to say whether it's because we think
treatment modalities have shifted, or we understand more
about the danger of the disease than we did perhaps in 1988,
or whatever we want to say, but we better say something,
otherwise we are going to look like we are just back
filling, and that is not a good position to be in.
I'm going to try in the privacy of the wee hours
to capture some of those points. I was taking some notes,
and maybe I'll trot them forward tomorrow. I was trying to
summarize a little bit also to get you thinking along those
lines.
If I missed something, or there is some other
important issue that you think -- or recommendations -- I
ought to capture, then I wish you would take a little time
maybe to jot down some notes, or to write even a sentence or
two about what you think that ought to look like. My
summary was just meant as a jog. It wasn't supposed to be
comprehensive or definitive.
So if there are other things there that you think
ought to be there, please spend a little time between now
and eight o'clock in the morning tomorrow, all your waking
hours, trying to put some of those on paper so we can make
sure to capture that.
What we are going to do is we will reconvene at
eight. We have got brief presentations by Mike Busch and Ed
on communication of risk, which will undoubtedly undermine
everything we've done now. We'll be cast back into the sea
of despair.
Then we'll get right back to this, but our mission
tomorrow, instead of kicking around just general themes,
will be to really true and focus in on that language. I'm
going to have Paul or somebody up there with that pen
probably writing on the overheads pretty frequently to see
if we can get some consensus.
So I hope this gets us to a place where we are
ready to do some hard thinking and do some hard work, and
maybe push something out by after lunch tomorrow that we can
all sign off on.
PARTICIPANT: I have been considering for a while
today pointing out to the group that the Heart, Lung and
Blood Institute has had several national education programs,
some of which some of you may be familiar with. There is a
cholesterol education program, a high blood pressure
education program, and fairly recently an asthma education
program.
It is conceivable that some of the expertise that
has been used in the Institute to set up these programs,
could work with other parts of the Public Health Service in
setting up a somewhat similar program. There was also a
National Blood Resources Education Program. Each of these
has a professional and a lay educational component to them.
I suspect that Heart, Lung and Blood would not be the likely
lead agency in hepatitis, since our part of the operation is
relatively small.
It is conceivable either as a result of what is
mentioned and discussed here, and what is posed for the
future, that we could find out whether the Institute could
lend expertise to setting up a somewhat similar program. I
honestly don't know how effective they have been as far as
measurement of their ultimate goal, but I sure hear a lot
about some of them on the radio.
DR. CAPLAN: Before I break, I'm going to ask if
anyone either on the committee or in the audience wants to
offer any final comments or thoughts?
PARTICIPANT: [Inaudible]. We have to be very
careful as we identify individuals as HCV positive in terms
of their jobs, in terms of where they live, in terms of
family issues and all of that. I think we need to
[inaudible].
The other is just more for information. Has any
research been going on that perhaps Paul could show the
committee related to any prototype HCV vaccines that are
under study?
PARTICIPANT: There was a conference on the main
campus here. [Inaudible].
DR. CAPLAN: One reason sometimes to lookback with
as much precision as you can, and we have said this a few
times but I forgot it in my summary, is so that you are able
to move forward should the situation change. So one reason
for more precision in going back, even it if is hard to do
it, is that if you get a vaccine or some situation changes
on the therapy side, you are ready to move. That may be the
justification for the ongoing perspective lookbacks even now
at the small yield rates, or to pick up the PRC undetected
that Ed was talking about.
That is still a good point, stigma. We've got to
pay attention to that. It has certainly come up in many
other areas where pre-existing conditions might disqualify
somebody.
The ability to then say, well, we've got
information that could benefit you; because we did it now,
we can use it soon.
Any other comments? All right then, we will meet
here at eight o'clock.
[Whereupon the meeting was recessed at 5:30 p.m.,
to reconvene the following morning, Tuesday, August 12,
1997, at 8:00 a.m.]
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