Blood Safety: Transcripts - January 1998
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADVISORY COMMITTEE ON BLOOD SAFETY AND AVAILABILITY
Third Meeting
"The Influence of Transmissible Spongiform Encephalopathies
on Blood Safety and Availability"
Volume II
Friday, January 30, 1998
Hubert H. Humphrey Building
Room 800
200 Independence Avenue, S.W.
Washington, D.C. 20201
P A R T I C I P A N T S
Arthur Caplan, Ph.D.
Larry Allen
James P. AuBuchon, M.D.
Michael P. Busch, M.D., Ph.D.
Ronald Gilcher, M.D., F.A.A.P.
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.
Kristine Moore, M.D., M.P.H.
Tricia O'Connor
John Penner, M.D.
Jane A. Piliavin, Ph.D.
Eugene R. Schiff, M.D.
John Walsh
Paul R. McCurdy, M.D.
Stephen D. Nightingale, M.D.
Mary E. Chamberland, M.D.
David Snyder, Rph, D.D.S.
C O N T E N T S
AGENDA ITEM
Committee Discussion
Lunch
Discussion of Supply Issues
Old Business
New Business
Adjournment
P R O C E E D I N G S
DR. CAPLAN: Accordingly, I asked Ed if he would tell us a bit about
albumin and the problems that come up in the manufacture of that product, which he has
kindly agreed to do. I was shocked to see that no matter where he went, he travels with a
couple of slides and is instantly prepared to talk at a moment's notice.
I'm going to ask him to get us back on track. Then what I'm going to do is
open the floor for reconsideration of those themes that I talked about yesterday for you
to consider that we might move through. Just to remind you--I'm sure you slept on them and
have many other ideas about other topics or themes that we might use to organize our
morning deliberations.
One was prevention and upstream issues with respect to safety of the blood
supply. What can we do to make sure that CJD and TSE are minimally problematic for the
blood supply now and in the future? What do we want to say about that given what we've
heard?
The second theme I had was surveillance, testing, and monitoring to see
what is in the blood supply, making sure that we know what's out there, and who do we tell
about it and how and when.
Third was managing known or probable risks in the supply of blood and
blood products. That takes us to how do we distribute lots that are believed to be in
jeopardy. How do we reach the point where our policies that are in place through the
federal agencies are contributing to shortage in ways that don't make sense relative to
public health and the overall need for blood and blood products.
And the last theme I had was protecting vulnerable groups. We heard some
yesterday from certain groups who couldn't get products. That may in part be due to
withdrawal of tainted units or units that people are worried about in terms of product.
That's why I wanted Ed to tell us a little bit more about this area as well today. But
also other groups, hemophiliacs, who are constantly exposed to the blood supply and are
very much worried about the risks that they bear if efforts aren't made to minimize the
risk of TSE and CJD in the life-saving substances that they have to be exposed to on
almost a continuing basis. Children are involved. High users of blood are involved, people
with particular medical problems. What are we doing to weigh their interests relative to
the overall interests of society, who also obviously use a great deal of blood and blood
products, but not necessarily on a systematic basis.
So prevention, surveillance, managing known risk, protecting vulnerable
groups--those are the themes I thought we could use to organize a lot of this morning, but
we can add to them or change them. We might even decide that we're going to look at three
of them but not four, or two of them but not four, and that we have things to say about
two of them but maybe not about the other two.
I think even if we have points to consider rather than consensus, that
would be very helpful to the Secretary, to Dr. Eisenberg, to the agency heads. I think
they want to hear not only from us about what we agree about, but they may want to hear
points that we may not agree about but that are important to weigh, so that if we could
even begin to list considerations as a public body that they need to bear in mind as they
make decisions, say at the TSE committee level or in other places where agencies have to
wrestle with problems, that would be of help to them, I am sure.
Before we move to Ed, let me ask Mac if he--oh, there you are. He had a
couple of housekeeping announcements. Mac, are you back there? He's ducking this duty. Are
you ready to give us the housekeeping?
Some of you left your room messy this morning--no, no, it's not that.
[Laughter.]
DR. CAPLAN: Not quite that bad a housekeeping job. Some of you want to get
reimbursed, some of you believe you should be paid more, and this is the man who can solve
all your problems.
DR. McMURTRY: I want to talk about essentially the reimbursement issues
and travel in particular. If any of you took a taxi in--you want a microphone?
DR. CAPLAN: Yes, we want this on the record.
DR. McMURTRY: On the record. Okay. Anyway, I need you to know about
receipts and things like that. Essentially, I don't need receipts. If you spent more than
$75 on a taxi or limo, I do need that receipt. But anything under $75 I don't need. I
don't need receipts for your meals. I don't need receipts for your hotels. What I do need,
however, is I need to know the time that you left your home--I mean, when you walked out
the front door Wednesday, and I need to know what time you walk in the front door tonight.
So when you send your stuff in for reimbursement, please write that down on just a piece
of yellow paper and send it to me, a sticky, I don't care. Just make sure I know those
times.
The other critical thing is I sent everybody a conflict-of-interest form.
I have gotten some of these back, and some of them I haven't gotten back. I have to have
conflict-of-interest forms, or we're going to be illegal. So if you would, get these in to
me just as quickly as you can. If you need to see last year's, let me know. I can fix you
up with a copy of last year's. But I have to have these conflict-of-interest forms.
Also, regarding reimbursement, I sent you a green form for direct deposit.
If you haven't, fill that out and send it back to me. We'll be happy to reimburse you, but
it has got to be direct deposit. The Federal Government doesn't cut checks anymore. So if
you will be sure that I have your conflict-of-interest and your direct deposit.
Yes, ma'am?
DR. PILIAVIN: I didn't get that.
DR. McMURTRY: Okay. I'll get you one.
DR. PILIAVIN: Or I lost it. Probably the latter.
DR. McMURTRY: If you know that you sent me one before and you have been
reimbursed before, that one will still count. But if you're not sure, then send me another
one.
DR. PILIAVIN: Can you get me another one?
DR. McMURTRY: You bet. Actually, I've got a stack downstairs. I'll bring
them up.
DR. CAPLAN: They're all filled out to my account.
[Laughter.]
DR. McMURTRY: Okay. That's it. If you all have any questions, don't
hesitate to call me, and I'll, you know, fix it.
DR. CAPLAN: All right. At this point, I'm going to turn the floor over to
Ed.
DR. GOMPERTS: Okay. Steve and Art asked me to give the group a perspective
of the manufacturing processes that are currently being used within the biopharmaceutical
industry, and specifically, because of the debate at the recent TSE Advisory Committee, in
relationship to the utilization of albumin. And albumin is a fairly well characterized
protein solution that is used pretty broadly to stabilize various proteins and peptides
from vaccines to complicated proteins. And my own particular narrow expertise is related
to the recombinant factor VIII process, although I'm certainly not part of the
manufacturing group that are involved in this.
But I thought I would give some--I was asked to give some perspective as
to this process, and I'm trying to deal with it as generically as possible, and also to
keep it as simple as possible.
Let's have that first overhead, please.
I thought we'd have a process check that advisory committees and focus
groups sometimes can get the wrong end of the circle or the square, and moving on to the
topic--you can tear them off or whatever. That's it. Okay.
Now, in the recombinant protein biotechnology manufacturing, the key to
this whole process is the recombinant cell bank, which is an engineered cell line--and
I'll get back to this--where you have the host cell together with a gene construct. And
this cell bank is made up of a long-term storage system where the master cell bank is
stored, and from there a working cell bank, multiple vials of these cells are taken and
used over a period of time. And these cells are then put into a manufacturing culture
system, which is called the bioreactor, and the target protein is then harvested and has
to be purified because these cells are doing all sorts of things--and I'll come back to
that--and the harvest then results in a process because this harvest is usually a
complicated process. And this process has to have specific specifications so that we can
make sure that the end result, the end therapeutic protein, does and is what it's supposed
to be.
Next one.
Now, the actual factory is the cell line, and the cell line can be
mammalian cells, for example, Chinese hamster ovary, baby hamster kidney, vero (?) cells
which are derived from monkey kidney cells. So there are a number of different potential
cell lines, but the bottom line is these cells are--they grow ad infinitum. They continue
to grow provided you take care of them, and it's this particular target cell line that is
then modified.
But, also, biotechnology has also focused on the potential for yeast to be
engineered to produce peptides or proteins or even bacteria. And, of course, these cell
lines are then--a target gene is included, and, of course, this target gene provides the
blueprint for the protein. And it can be a protein, but it may also be a polypeptide, a
short polypeptide, a long polypeptide, but it is the gene that we'll code for the ultimate
desired targeted protein.
If you could move that up just a little bit.
So the recombinant process is taking this target gene and getting it into
the cell. But to get it into the cell, you need something to carry it, which is called a
vector, which is a bit of a bacterial DNA. And this carries this target gene, usually with
enhancers, so that a little bit of DNA to make sure that the cell focuses on making the
target protein rather than making just lots and lots of, for example, CHO cell proteins.
And this is put into the host cell, and this is actually the genetic engineering process
the gene jockeys perfected�some years ago.
Now, when you put the cells into--and start getting them growing, whether
it's in a large bioreactor--and I'll show you a couple of photographs, slides, shortly--or
into small vials, as we start to expand the cells from the working cell bank, these cells
require an environment that is conducive to growth, because we have to keep these cells
happy and comfortable, because it's only happy and comfortable cells that are going to do
the job that we want them to do efficiently.
So we have to focus on the correct neutral pH. They have to get oxygen.
They've got to breathe. And when they breathe, there is metabolism going on and carbon
dioxide is produced, which has to be removed. They have to be kept warm and comfortable.
There have to be salts and water, and there have to be nutrients, calories so that they
can make their proteins, amino acids, the basis bricks and structure of the proteins, and,
of course, trace substances, whether they are trace vitamins or even metals.
And there is the potential in this culture system to damage the cells, and
we can damage them obviously by not enough oxygen or incorrect pH, but also there can be
physical damage, such as these cells need to be moved around a little bit so the stirrer
can't move too fast, or the oxygen bubbling through can cause damage to the cells. And,
also, osmotic pressure, because if there is too much water or altered salts, there is an
osmotic pressure gradient set up, and, in fact, albumin is a very important protein that
maintains the osmotic pressure in our blood stream as you and I sit here, but also it is
used within the bioreactor to help support the cells and also carry trace substances
around, as they do in the blood.
In addition, these cells are living cells, and they make other proteins,
including enzymes that break down the target proteins. So proteolysis has to be thought
about and has to be focused on, especially with complicated proteins such as recombinant
factor VIII. And then there are substances to encourage growth, such as insulin,
transferrin, and including a soup that is obtained called fetal calf serum, which is
really a number of different growth factors. So these are, in fact, proteins that are
added to the whole solution to assist these cells in growing. So you've got the albumin,
the insulin, transferrin, and these are just some of them. And they're not all added to
the recombinant factor VIII system, but they are added depending upon the manufacturing
process, depending upon the cell line that is established. So there is a lot of variation
around this, and I'm just giving you a very brief overview.
Next one.
Now, the key technical events clearly is the establishment of the master
cell bank, but it's also important to recognize that in a complicated protein such as
recombinant factor VIII, the purification process has to be a very powerful one. And the
process requires the monoclonal antibody system, which is bound to a fixed particle, a
sepherous(?) bead, and this is used to bind the factor VIII and purify it.
So in actual fact, in the recombinant factor VIII process, we're really
looking at two master cell banks: one for the CHO cell line, with the factor VIII, but
also a cell line that makes the monoclonal antibody, which then is utilized in the
purification process. So all those, the pH and the oxygen and the stirrer problems and pH,
et cetera, all this will also focus in on the monoclonal antibody cell line, and the
transferrin issue that was mentioned yesterday was really focused on the monoclonal
antibody cell line in that situation.
Other key technical events are obviously the cell culture and protein
production, purification, and using the monoclonal antibody here, final product stability
and formulation, and, finally, quality assurance. Now, this is not a minor issue because
each one of these steps--and these are a very brief summary of a very complicated process.
Quality assurance goes all the way through because we have to be quite sure that the
master cell bank is going to function right across those many, many vials exactly as the
first one, that the thousandth vial is going to be the same as the first vial in all its
characteristics, including the gene for the recombinant factor VII. And monoclonal
antibody cell line, all the way through, quality assurance is a major target.
As I've mentioned, the master cell bank media components, the
characteristics of the sugar, the water, the albumin, et cetera, all these have to be
focused on from a quality point of view, cell line, manufacturing processes, purification,
all the way through. And in actual fact, in the process for the recombinant factor VIII,
there is well over 500 separate assays from start to finish that is used in routine
regular manufacturing.
Now, the other view of this quality assurance testing program is focused
on the drug substance, which is the crude product prior to moving it into the final vial.
And, again, there is focus on the working cell bank, the inoculum, condition medium, the
bioreactor condition medium. Inoculum is when you take the cell line out of the deep
freeze and start to expand that cell line, which is somewhat different from that of the
bioreactor. The post-production cell line testing, the chromatography systems, and
finally, the bulk drug release testing and the environmental and utility testing programs,
because the facility, the environment, the bioreactors, et cetera, have to be tested and
assured that there is sterility and appropriateness in that environment.
Finally, the actual drug product which goes into the vial, we have
to--when we get the bulk substance, it has to be tested. Does it meet all quality
specifications that have been set up, sterility, endotoxin testing, and, finally, the
release testing, and, finally, the lot release?
The working cell bank, which is used to expand into the bioreactor, is
evaluated from the point of tumorigenicity, karyology. There is the potential, for
example, of the CHO cell to have different chromosomes, abnormalities in the DNA that are
manifested much larger than just a single gene. So karyology, iso-enzyme analysis, in
other words, the cell line is examined in a number of ways to ensure that it is what it's
supposed to be.
The cell line is evaluated from the point of view of growth rate and the
doubling times, the amount of protein that we're targeting, how much is being produced,
and this is a very important target, an important indicator of how well the cell line is
doing, because if the cell lines are not growing properly, then clearly there is something
wrong with the environment to that cell line. And if the amount of protein that is being
produced is insufficient, that cell line is not doing what it's supposed to do, and there
is something wrong, and that needs to be understood and corrected.
Also, the actual target gene insert, this has to be mapped on each event
because we have to be assured that the target gene is going to make the protein that we
want, not an altered protein, a different insert. This can change, and this has to be
assured that it doesn't. And, similarly, the DNA sequence of the factor VIII.
Finally, purity of cell line from potential microbial and viral
contaminants, and this is not a trivial issue.
Now, the purity testing of the cells prior to and after cultivation, we
focus on the potential for microbial contaminants, such as mycoplasma, sterility for
bacteria and fungi, and also the potential for adventitious viral contaminants. Is it
possible for viruses from the external environment, is it possible for those viruses to
have affected and infected that particular cell line as it's growing and making that
particular protein that we have in the bottles, in the vials? And this is focused on
regularly using multiple different cell lines to see if these cell lines have the
potential for becoming infected by and, therefore, an indicator that there has been
something that went wrong.
Also, the potential for retroviral contaminants is examined and evaluated
in a number of different ways.
The separation process of the targeted protein from the crude media that
is harvested from these cells goes through a number of different processes in this
particular process for recombinant factor VIII. There's a filtration which is physical to
remove the cells then from the actual solution. It's then passed across the monoclonal
antibody chromatograph, and this binds the particular part of that recombinant factor VIII
protein that the antibody is targeted at, binds the epitope. But, also, two separate
steps, ion exchange chromatography, binding positively charges molecules and negatively
charged molecules, these are designed to remove extraneous proteins that could come from
the cell line, the CHO cells, that could contaminate the ultimate therapeutic product.
Next slide.
And just put in a somewhat different way, you have the conditioned media
filtration and then the multiple steps ultimately resulting in the bulk, that bulk
substance, the recombinant factor VIII, which is then characterized, tested, and tested
again after it's put into the final vials.
Now, the potential for contamination with viruses, this could occur from
the CHO cell line; it could occur from the monoclonal antibody cell line; it could be from
adventitious viruses. And the process for the production and purification of the targeted
protein is then validated with a number of targeted viruses, a number of RNA viruses
enveloped and unenveloped, and the DNA virus as well, from the point of view of exclusion
of these viruses from the actual process to give a fair amount of assurance that the
ultimate product is not contaminated, in addition to evaluating the cell lines on each
occasion.
Next slide.
Okay. Moving on to the slides, I thought just a few pictures to reinforce
my words here. I have a cartoon of the CHO cell, and this is the vector that carries the
factor VIII into the Chinese hamster ovary cell.
Next one.
A slide of the storage facility for the vials going into the lyophilizer
here, the issue of sterility being important.
Next one.
We have the cells from the working cell bank that are being expanded.
There is some stirring going on here, and, of course, these cells are suspended in
various--water, solution, glucose, salts, and, of course, albumin there as well.
And the cell line needs various substances to allow a balanced growth
situation such as amino acids, growth factors, minerals, oxygen, carbon dioxide, and there
are waste products that have to be dealt with as well.
Next slide.
A bioreactor itself, and there are three of them in each particular suite,
and, again, the sterility situation.
Okay.
And the characterization of the protein, this is three separate lots of
the protein undergoing peptide mapping, and it has to be identical on each occasion. If
there is a little bump that doesn't fit in, there's something going wrong here.
Next one.
And, also, the genome mapping that goes on here.
Good. Any questions?
DR. MOORE: What proportion of factor VIII that's used in the United States
is recombinant?
DR. GOMPERTS: I cannot give you a definite answer on that, but it's
probably 60, 70 percent.
Dr. McCurdy?
DR. McCURDY: The attempts or what was done to take care of potential viral
contamination in the recombinant was fairly impressive. Could you contrast or compare
what's done with the plasma-derived material to ensure that that's as unlikely to be
contaminated as possible? I mean, you're using fetal calf serum. I presume that might have
a very, very, very remote risk, but nevertheless a potential risk of BSE or something like
that. And you've obviously looked at a lot of potential sources of contamination. Could
you, as I said, compare or contrast what's done to plasma?
DR. GOMPERTS: I think, first of all, it's important to recognize that the
biopharmaceutical processes that are used are not static, and that the systems are focused
on from the point of view of improvement. And the processes--and I indicated here that
albumin and insulin and fetal calf serum are used, but modern technology is focused on
processes that will not--where it will not be needed, where albumin will not be needed,
where insulin, for example, could be replaced with recombinant insulin and so on. So the
whole process of the biopharmaceutical industry, like everything else, is evolving. I
think that was not mentioned in my presentation.
Now, when one extrapolates to the human plasma-derived protein, first of
all, the source of the protein in the biopharmaceutical recombinant process, of course,
there's a lot of focus on the CHO cell. And in the plasma protein, the human plasma
protein situation, of course, there is a lot of focus on the donor. And that has the donor
focus and how the donor is characterized has also evolved to the point where today we're
in a very much better situation characterizing those donors and understanding what is
going on there, including asking them about whether they've had a hole in the head, in the
dura mater.
Then, of course, the actual handling of the plasma and its fractionation.
The actual processes in the fractionation purification are subject to viral validation
steps. There are viral inactivation steps. Some of them are pretty efficient, but
primarily targeted against the enveloped viruses. And the focus obviously on endotoxin and
sterility and bacterial contamination are pretty extensive.
So the concepts, the issues, the problems that the plasma protein
fractionation process has been focusing on, manufacturers have been focusing for some
while, obviously impacted a fair amount of thought from the point of view of the
recombinant process as well. So there is some analogy and homology as well.
DR. CAPLAN: I had two questions for you. One is--this is slightly off
base, but I'm just curious. There was a discussion not far from here last week about
xenografting and the use of animal organs and transplant, a lot of concern about
piggybacking viruses using whole organs and obviously not subjecting them to these kinds
of processes. But is there a concern that while we test for what we know, we might be
carrying along some other viruses or retroviruses that we don't understand? Is that
something that is in the background of all this? Or are people pretty convinced that the
level of handling is such that it's going to be able to handle anything that hasn't got a
test to detect it?
DR. GOMPERTS: Art, you know, as usual, you're on the ball. The process has
to be robust, and we have to be assured that it can take care of, theoretically, anything
that comes along. But the potential for contamination must always be considered. And,
hence, the TSE issue, of course.
DR. CAPLAN: And the second question I had for you is: Can you comment at
all about cost? How does cost drive recombinant production versus donor generated? I mean,
are we talking significant savings when we can get volunteers and start that way as the
culture medium? Or how does that work?
DR. GOMPERTS: Well, the major cost in a biopharmaceutical process is the
plant and the expansion of the plant. Clearly, there is a cost in maintaining a production
process, the quality assurance that is ongoing.
The major cost as far as plasma is concerned is if the plasma has to be
purchased. If it's volunteered, then you don't pay for it. But, also, there is a cost in
plant. So, again, there are some similarities within that underlies the basic investment
and potential return on that investment.
Other questions? Yes, Dr. Guerra?
DR. GUERRA: That seems to be a very complex and involved process. I
wonder, how long does it take from start to finish to have a product that you can then
take to a hospital or clinic?
DR. GOMPERTS: We described a process from cracking that master cell--that
working cell bank vial to finishing up and closing down the process when all the product
has been made the cell line has the potential to become less stable. We call that a
campaign, and a campaign lasts six months.
DR. CAPLAN: Okay. Thank you.
Well, at this point, what I'd like to do is open the floor for comments
from the committee about whether the identification of the themes that I put on the table,
matters of prevention and looking upstream to try and protect the blood supply from risks,
surveillance, and testing, and monitoring, how we manage risk when it's in the supply or
suspected to be in the available supply, what policies are doing to the way in which the
supply is handled, and then looking out for the interests of groups especially vulnerable
due to their reliance on blood and blood products, and due to perhaps in the case of
children their inability to look out for their own interests.
Are there other issues that we should put on the table? Yesterday I said
that I thought we could handle liability matters under the probable risk, what are we
doing with the supply of blood. That's certainly an important sub-theme. But does anyone
want to put any other major questions on the table?
If not, then what we can do, I think, is maybe turn to the first issue for
a little discussion. That was the prevention and upstream issues, and here I can say a few
words about a couple of things that I heard yesterday that I'd just be interested in
having us discuss.
One was the whole question of how TSE and CJD might enter into the blood
supply coming up through the food chain. And when I was talking about--or listening to
this yesterday, a few people came up to me, at least one person, a congressional staffer,
and said: Well, you know, we've been very attentive to that; we have tried to put a
complete ban on the use of animal feeds for human food, that that is something that the
FDA is alert to and they understand that in the food chain rendering and feeding animal
foods to other--I guess it's actually a mammal ban, not just an ungulate ban, that these
aren't supposed to be in the food chain any longer.
One of the things that occurs to me is that saying it's so doesn't
necessarily make it so. Another thing that occurred to me is that it might still be
important for us to comment on the importance of this practice, having watched what
happened with this--what is it?--alternative CJD or new variant CJD, watching the BSE
experience across the pond there, that this is very important for us to be stressing. It
may be that FDA and the food industry understands it, but as an upstream threat to the
blood supply, that makes it part of our concern.
We did hear a bit, also, as you recall, about the ways in which certain
TSE organisms might be in the natural population. That was the discussion of the elk and
the deer. I think we heard a 6 percent figure for some deer populations carrying possible
TSE agents and whether we were doing what we should to monitor that and seeing how that
might be entering into the human food chain through hunting practices or eating deer and
that sort of thing. So that may be an area we want to say something about.
I heard yesterday, too, to put this in a different light, that we should
do more in terms of having a stable supply of blood and blood products to try and
encourage donors. If you remember, some of the testimony circled around the idea that if
we have a lot of donors who are very healthy and not in risk groups, then that would help
supply more plasma and other important blood substances to the overall pool. So when I'm
thinking of prevention and upstream issues, do we want to say anything or do we want to
flag something as important about how to expand the available pool of high-quality blood
and blood products?
And the other area that I can think of where prevention, upstream
questions come is: Are we doing what we need to do to identify, monitor, test for CJD? And
this was the discussion we had yesterday about: Are we tracking epidemiologically this
disease and TSE diseases in terms of death certificates? Can we get better epidemiology to
see what's going on out there? Are doctors trained adequately to diagnose and discuss the
possibility of this disease being present? Are we sure that the records are as good as
they could be so that we know what's going on as a matter of preventative epidemiology?
I don't mean for that to be an exhaustive list, but I think those kinds of
things fall under what I'm trying to capture when I say we need to prevent or think about
improving the quality of the blood supply. So why don't we start the discussion off with
that issue and maybe think about some of those problems?
DR. GILCHER: I think there are some basic ways that we can look at this,
because in a sense we need a grid or a plan. For example, agents which are currently in
the population--let's take the Creutzfeldt-Jakob agent, whatever that really is. Does it
really pose a threat? And what we can look at is: Is that agent increasing in the food
chain or the blood supply or the general population? And has there been any risk
associated with it in terms of the transfusion of blood or blood products before we took
out those particular individuals who we consider to be at risk versus an emerging agent?
For example, the new variant Creutzfeldt-Jakob agent may be truly be a
different agent, and that would be a greater concern to me because that's an agent we want
to keep out.
So what I'm saying is that we really need to be looking at what is already
there and what may be either a mutation or a new variant or an emerging infectious agent
that could get into the blood supply.
DR. MOORE: After the end of the day yesterday, I was thinking last night
about this first issue, some of the prevention implications of looking at TSE agents. And
I actually tried to outline the major modes of transmission, which are food-borne--we know
through Kuru--and then there's this theoretical concern of animal to human food-borne
transmission. And then a second area is iatrogenic, for which we have, you know, quite a
bit of data as to the occurrence of that in the United States. And then the third area is
transfusion-associated, which, again, is theoretical and not yet documented, but there's
certainly reason to be concerned about that.
Then if you'd look at sort of those three areas of transmission, and then
started thinking about, well, you know, how do we approach this from a public health
perspective, I mean, what are the surveillance needs in each of those three areas, and
then what are the policy needs in those areas? For example, some of those policy issues I
think we can look at today around transfusion, and some of them are actually outlined in a
handout that Mark produced yesterday on policy change. And I would really like to see this
group talk specifically to some of those issues because I think we can have some good
input there.
Then I think there's also some policy needs in the area, for example, of
infection control that have not been addressed and in issues around regulation of organ
donors, for example. Some of those pieces are in place, but I still think that we have
some gaps in terms of policy or regulatory issues in that area.
Then we can get into sort of policy issues with the transfusion area.
Again, I think we can talk some about those. But I think that when we look at this whole
issue, I think it--it started getting very complicated in terms of what I think some of
the needs are. I think that, you know, we can look at surveillance issues; we can look at
what are some of the critical research needs. And in doing this last night, I kind of
started developing this grid of, you know, how do we approach these different problems.
And it occurred to me that I think most of these issues start to get beyond the scope of
this group, and I think that we could spend the whole time sort of trying to flush out,
you know, what are the sort of public health prevention issues here.
And it occurred to me that one of the ways to approach this is for this
group to make a recommendation that is a little bit more generic and that basically calls
for the Public Health Service to bring together a group--this is sort of a method that's
used very commonly in the Public Health Service, particularly by CDC--to develop some
prevention and control recommendations. And the process way that this often works is to
bring together a group of people with various expertise, and in this area you might need
some USDA-type people. You'd certainly need FDA-type people. You'd need state health
people. You need people involved in infection control, people involved in transfusion
medicine, sort of an ad hoc group of a variety of different players to start looking at
developing some guidelines for prevention and control of CJD, and this has been done, you
know, with a variety of other communicable disease agents in the U.S.
That kind of a document can then be used to identify what are the policy
needs, what are our infection control recommendations, what is needed in the area of
regulation, what are the surveillance needs, and then what are the research needs, the
gaps that we don't have filled in, and sort of start using that as a framework to develop
a Public Health Service plan to address some of these issues.
So I guess what I would like to see this group do is really ask for that
kind of a process to be conducted as opposed to us trying to flush out what are all of
those issues, because I think it is a very critical and important area that needs careful
consideration and really a process that could take up to a couple of years, I mean, to do
that kind of thing and really draft guidelines and start looking at that, at least a
minimum of a year-long process, if not more.
I guess that's my comment. I'd like to see us maybe--that our
recommendation be that that process be started.
DR. CAPLAN: Ed?
DR. GOMPERTS: When I look at the issue of TSE and blood transmission, I'm
sort of torn in a number of directions. First of all, I tend to be a little perhaps
emotional about it because I personally and professionally have gone through the HIV
epidemic, and I don't want to go through another one. And I sort of smell, sense that
something could happen. So, you know, my response tends to be perhaps a little knee-jerk
or emotional. I don't know. But then I try to separate myself from that and look at the
science and what do we actually know and what don't we know.
Looking at what's happening and what has happened, we do know that this
infectious agent, whatever it is--and that's one of the unknowns--this infectious agent
can be transmitted and has reliably been transmitted through the food chain. And this we
have seen among the New Guinean natives, the people. We've seen it with BSE. There was in
our own country some years ago an outbreak in the mink encephalopathy episode which
definitely was food-transmitted. So we know that major outbreaks have occurred that way,
and that is going on right now, of course, in Britain.
They have been iatrogenic, and the blood transmission has the potential to
be a iatrogenic situation, which we're looking at pretty carefully.
So if we look at where we stand from the point of view of CJD and blood
transmission and CJD epidemic within our country, we're looking at it, as I see it, as an
emerging disease, whereas in the United Kingdom and in Europe, it actually has emerged. So
what worries me is this, I think, very really concept of silent subclinical amplification.
And if we were to prevent this episode within our country, I think we have to focus on
what's going on in Europe and what have the British people and government, how have they
dealt with it. And it's obviously been devastating to the country, to their beef industry,
dairy industry, et cetera, as well as the unfortunate people who have been impacted by
this disease.
So when I look at what we're doing here, I'm not happy that the--we could
do more. We have introduced a ruminant feed ban, and I don't know to what extent that is
enforceable, but it has been introduced. But what I don't see is the second major step
that the British introduced, and that is the prevention of utilization of animal brain
material in the human food situation.
So while we're not feeding (?) cows, rendering them and feeding them to
cats and dogs and zoo animals and cattle, healthy animals going into the abattoirs, filet
steaks are being eaten, but so is the potential for bovine as well as porcine as well as
sheep brain.
DR. CAPLAN: Hold on one minute, Ed. I just had an announcement. Are there
some doctors here from Portugal? They need to call their office right away.
DR. GOMPERTS: So, you know, the Brits, I think in '89, introduced the
ruminant feed ban and in '92 introduced the prevention of utilization of animal brain into
foodstuffs. And that second part we need to do here, and the sooner, the better.
DR. CAPLAN: John?
DR. PENNER: I agree with Ed, and I think the protection and prevention
level, we need to focus a little bit more attention.
One suggestion, we still have the problem with screening donors, and I'd
like--I'm not aware that we have any kind of donor brochure--maybe I can be corrected on
that--which while the donor is waiting to give blood could at least amplify his
information a bit as to what they're getting at with respect to CJD and TSE. And then the
questions, I suspect, are pretty varied around the country depending on the blood banking
community that is asking the questions of the individual donors. And perhaps that needs to
be a bit more specific and consistent so that we can exclude the individuals who come in
who have had their brain surgery or have had the human growth hormone and perhaps we could
reduce that incidence, at least, and that would be one way.
The next aspect I think is on the surveillance end, and I think what we
could do very specifically is get the groups that have the heavy blood users to commit
themselves to autopsies. In other words, to get their people--recognizing the difficulties
in obtaining autopsies, that they'd commit themselves to having an autopsy when one of
their members dies, so that we are at least able to look at this a bit more consistently
over time and with enough of a population so we can say yes or no, there has been some
evidence of this disease infecting them.
So those are kind of minutiae things, but they might shore up some of the
problems that we're facing.
DR. CAPLAN: Dr. Hoots?
DR. HOOTS: To kind of add a little bit to what both Ed and Kristine said,
I think one of the things that--and you led into it when you were talking about the elk
and deer population. If we look at the likely agents to cause problems for our blood
supply and for the population, certainly because the surveillance is adapted to things
that we could easily first examine, like bacteria and fungus and all the way down to
viruses, it's becoming--it seems that this is a paradigm for the potential for either a
partial or complete zoonosis sort of infection, and I think one of the things that has
traditionally happened up to now because of resources and everything else is that some
association has been backtracked to an animal source for an infection, be it HIV or be it
CJD or whatever. And if a more concerted, directed sort of effort on behalf of the Public
Health Service, kind of like Kristine was talking about, could be directed towards--and,
again, I'm a little naive in terms of what actually does exist, but just in terms of my
own knowledge of how things have been tracked, it's always been retroactive and
retrospective.
If we could use CJD as a paradigm, almost, for a strategy to look for
zoonotic disease, disease where agents spread across species, I think in a way we could
get a lot of bang for the buck, and using this as a starting point, because this is where
we are now and this is where the big fear is now. But it might not only be beneficial for
the purposes of CJD, but down the road it may be very purposeful and very important for
other new agents, as you alluded to at the beginning--and you asked Ed about new agents
coming into the blood supply or into the human food chain, either one.
So I think some sort of, at least, examination of what is there from the
CDC and others worldwide, world health surveillance, and then how could we augment this
using CJD as the reason and the rationale for putting resources into that sort of early
look, and perhaps using, again, the short-term paradigm of the wild animal population in
the United States that is a source of at least a TSE, maybe not a TSE that we get as
humans, but we don't know that yet. And I think that's something that we might at least
ask to be explored, because we don't obviously know how to do it, but we could at least
learn more about how--if it's feasible, and if that's something, a direction, a
bidirectional look instead of a unidirectional, retroactive, retrospective look.
DR. McCURDY: During the discussion yesterday, there were a couple of
things that occurred to me that might be helpful in this area that are already going on in
the Heart, Lung, and Blood Institute. We have several studies that have been looking at
hepatitis, non-A, non-B, hepatitis C, hepatitis B and so forth. Some of the cases of
hepatitis that are being reviewed through the years through death certificates and others
were people who had their episode during World War II. So this is a very long follow-up.
We now have just started a follow-up, natural history type of follow-up on
hepatitis C and other similar disorders in a pediatric, neonatal intensive care unit
population. And it is our plan now--Dr. Niemo(?) and I discussed this briefly yesterday.
It is our plan now at least to look into unusual neurologic syndromes that might have
occurred in these people, and perhaps some of them died at a time when autopsies were more
common, and if there is brain tissue, we may be able to get it, get blocks, and have it
reviewed.
The neonatal intensive care units, of course, have very heavy, fairly
heavy donor exposure, perhaps a transfusion from a different donor every day or two. At
least until recently, current practice, I think, is to dedicate a donor to a neonate. But
before, every day it was a new donor. So there's fairly heavy exposure there, and we
should be able to get some information, probably negative, but we'll have to see.
DR. CAPLAN: One thing that I noticed yesterday, just following up the NIH
story, was that there were a couple of comments from some of the people who presented to
us that they found more could be done to sponsor basic research. I remember a little bit
of complaint about having to shape the tighter experiments due to the shortage of rats,
which I took wasn't a matter of volunteering but cost. And then I did see, too, that
people said there is a need to maybe even centralize a facility that takes on TSE, and we
may not have to resolve that particular issue, and what's the best way to organize and
structure research in this area both on detecting new agents and studying existing known
ones. But we could say, if we want to, something about the importance of making this more
of a priority.
It's a little bit apple pie, but I don't think it would hurt since we did
hear requests about that saying that some of the efforts are scattered and maybe not
centralized or organized in quite the way they ought to be to study TSE.
But one thing that occurs to me, as I can sort of recap a little bit on
this theme, because I will bet--I'm going to make a bet here--that we may have some areas
of consensus. I like Ron's suggestion about thinking about this a little bit as emerging
agents versus existing agents issue with prevention, and I heard Kristine's suggestion
also that we could make a recommendation, which she actually quickly wrote down on a piece
of paper, and I think it's a pretty good statement about what we could ask CDC to do and
agencies to launch in terms of taking on some of these questions. But just to recap, it
seems to me one set of things that people have now mentioned is whether we need some sort
of standardization of what people are told about what they eat.
Should we be simply saying to people and urging a campaign that says you
shouldn't be eating the central nervous system? Whenever you eat anything, don't eat that.
Do we need standardization on what we tell donors in terms of what they need to be
thinking about as things that may have happened to them to put them at risk? Do we need
standardization of screening more than we've got, looking for potential donors to be able
to be identified that might have encountered things that put them at risk of transmission
here? Can we encourage in some serious way the commitment to autopsy? We're not going to
order anybody, but we certainly can flag it and say that it would be very important to
mount a campaign here, because if we're going to understand this and really get an
understanding of what the theoretical risk is, this is a key route, and we could certainly
do that without waiting for the CDC committee or some other agency to do something.
It seems to me that we may even want to say something about the importance
in the national debate of talking about--with the FDA and the state agencies that are
responsible for hunting, to let them know that this food chain issue is a real one and
it's going to be stressed again and that this committee wants that watched carefully.
One might say, well, of course, we're going to watch it carefully. The
nation's agricultural industry will collapse if we don't take this problem seriously. But
I am worried about, personally, others ways in which things enter the food chain. And I
think that's just got to be taken into account.
Again, while we could wait for specifics of how to carry that through from
the committee, I don't personally mind us trying to say something like that now today and
charging any committee or all of the agencies to keep a handle on it.
So those are some of the things I heard, and in this area, it may be that
it wouldn't be too difficult for us to kind of get consensus on a lot of those points and
maybe say something along the lines that I just tried to articulate.
Yes, Ron?
DR. GILCHER: Part of the reason I was dividing it into emerging and
existing agents is--and I didn't say it at the time--it relates to outcome. And one of the
concerns that we heard yesterday that's so important is that we could actually make our
health care less safe if we remove products that need to be available for selected
patients. And I think there's a greater risk--I don't know that I'm correct, but I believe
that there is a greater risk in an emerging agent as opposed to an existing agent, so that
if we're taking out with a withdrawal or even a recall a group of plasma derivatives, I
would want to have us focus on the emerging agents versus the existing agents in terms of
that, because right now we're having withdrawals that are related to the existing agents
that, in fact, may be hindering health care.
DR. CAPLAN: Jane?
DR. PILIAVIN: I just want to very strongly second what you just said. I've
been sitting here listening to this discussion as if--and the way we're talking about
expending resources on this issue, it sounds as though we are actually faced with a
threat, a known new threat. And what we're actually faced with is a set of epidemiological
data in the United States that suggest to me very strongly that old-style CJD is not a
threat to the blood supply. And I think it's absolutely critical that we sit and think
about the expenditure of resources as well as the issue of withdrawal of product which
with only an infinitesimal probability is dangerous, whereas not having the product has
already probably killed people and, if the thing continues, will kill more people. And
nobody, as far as we know, has ever been killed by CJD in the blood supply.
I think it's really, really important. I was glad to have Lola Lopes,
who's an old friend of mine, here talking about risk, although she didn't, I think, focus
as much as I would have liked her to focus on deciding between different kinds of risk.
And I think, at least in my four years on the BPAC, we weren't allowed to talk about those
risks. We were only allowed to talk about safety. This committee is supposed to focus on
safety and availability and to try to do this very, very difficult decisionmaking about
different kinds of risk. And so far today I've mainly heard people talking about the risk
of what could be in the blood supply.
Now, I quite agree that if I were in Great Britain, I would be thinking
very hard about the new agent. But I think there is as yet no evidence that that new agent
is here. This discussion of monitoring the food chain I think is absolutely really
important, but in terms of a whole lot of other issues, I just think we have to think
about where best to put our money and our time and our effort.
DR. CAPLAN: Jim?
DR. AuBUCHON: You mentioned having information available to the general
public and donors regarding what they should eat and what they should not eat. It's had
limited success in other areas of consumption. But I think Ed was suggesting something
really one step further, and that is a ban of central nervous system materials getting
into the human food chain.
I don't always know what is meant when I read the labels on different
foodstuffs in terms of what's in there, and possibly there's something there that we might
not want there. I think that is worthy of further pursuit. We don't have any nutritionists
or agricultural people around the table here. Possibly that's something that could be
handled through the suggestion of a CDC-led group.
The other item I'd like to comment on was Dr. Penner's comment about
standardization of questions. I think that is an important question. I think that for the
most part, most blood-collecting agencies are asking the same question. Obviously about
half the blood supply does go through the exact same sort of questions with the American
Red Cross. The American Association of Blood Banks does have a standard questionnaire,
which many institutions, although possibly not all, do use.
One consideration might be for an FDA-generated questionnaire. Many of the
recently added questions having to do with newer types of HIV risk and now CJD risk have
essentially been given to us by the FDA, and we ask them in the way that they are
requested that we ask them.
So something to consider, although it's not necessarily the focus of just
CJD at present.
DR. CAPLAN: Larry?
MR. ALLEN: Regarding the food chain, in this area, this region of the
country, already we've been talking about some of the results of animal waste getting into
the bays and things like this. One of the things that we're hearing now that the farmers
are using now, are pooling some of this animal waste in the reservoirs, and then using it
as fertilizer for certain food products. And I'm just curious as to is the FDA or anyone
else monitoring the use of these types of new ideas. And, you know, there's a concern with
pooling in--you know, keeping this waste in these reservoirs for a certain amount of time
and the bacteria and fungi and whatever might develop during that time then being used
agriculturally. So is anyone, to our knowledge, here monitoring this or studying what's
happening with this?
DR. CAPLAN: I personally don't know, but if we flag this issue, we'll get
a sort of--that may be the place for this. Kristine's group would, in fact, go
specifically to--
DR. MOORE: I just want to also make just a quick comment that addresses a
couple of the issues that people have raised, and one is that, you know, when you look at
efforts of CDC and FDA and other agencies, USDA, there's a very large food safety
initiative right now that's been put forward. So, again, I don't think that we really
necessarily need to get into that a lot. The CDC is putting a lot of effort, and FDA and
USDA, on it.
Then another big area at CDC right now is emerging infections, and there's
a lot of surveillance projects and a lot of research projects. So just to keep it in
perspective, there are a lot of other efforts going on that I think touch on many of the
concerns, and very legitimate concerns, that people have raised in this brief discussion.
Just so that you know that.
Again, I would like to see us really focus on what are the methods,
particularly specific to blood safety, that we can comment on here today, looking at donor
deferral issues, looking at product withdrawal issues, looking at the possibility of
exempting certain products, the issue of labeling products, then this whole issue of
leukocyte filtration and leukocyte-depleted blood.
I think that those are some specific issues that we can talk about as well
as the need for research that's specifically would improve the safety of the blood supply.
And I think one of the most important issues there is the development of a screening test.
I strongly urge this group to make that a very high recommendation because we can't really
learn a lot more about the epidemiology of this disease until we can identify the
denominator and start looking at who the carriers are. I think we're hampered severely in
our efforts to develop appropriate recommendations until we have some of those pieces in
place.
DR. KUHN: I think to kind of go along with that is some of our focus of
attention I think needs to--according to, I think, your four points that you have made
here today or for us to discuss today, is to kind of take a proactive course of safety by
recommending, perhaps recommending pool sizes according to what various users of product
would perceive as reasonably safe. I know that was a discussion yesterday. I know for
alpha-1 and the hemophilia population, they may feel comfortable with a different size
pool, and as for people who were using IVIG, I think the primary immune-deficient people
and I know sickle cell sometimes uses that. They might need a higher pool because they
need high-titered plasma and it's derived. And I don't know how big their pool has to be
in order to derive that high-titered plasma.
But I also think that this would--by limiting the pool size, it would also
help to limit the economic impact on withdrawals. So I think we should kind of seriously
look at that and hopefully make some recommendations towards that end.
DR. CAPLAN: Paul?
DR. HAAS: A quick comment back on the risk issue. Our discussion yesterday
or the discussion we were given obviously used an economic type of example, a payout-loss
type of thing. And I don't think that that was done just because it's an easy way to run
an experiment. If you look at economic behavior, typically we're driven by cost. And one
thing I guess I want us as a committee to be concerned about--I like what Jane was saying.
That might make a whole lot of sense for us around this table, but I guess I'm a little
concerned that once we get away from this table that, if the costs associated with blood
products somehow comes down because the concern for the current CJD is less evident, that
then the societal concern about this lessens, the government concern lessens, and then the
focus on the new CJD doesn't happen.
I don't want my words to be misconstrued. I don't want us to create a
false shortage out there, by any means. But if there is--if we get less of a shortage,
there will be less of a concern. Economic behavior is very strong in that direction.
DR. CAPLAN: Paul?
DR. McCURDY: Another brief comment about something that is in progress.
The National Institutes of Allergy and Infectious Diseases, in collaboration with Heart,
Lung, and Blood, is looking into the question of pool size with regard to the various
different needs of the immune-deficiency people, et cetera, et cetera. This is in its
early stages, but probably should move forward more rapidly in the next several months to
see how this goes.
The original pool size, I understand, was governed by the size of the
centrifuge in Dr. Cohn's laboratory. Later it was arbitrarily chosen and then increased
because the primary goal of immunoglobulin was to prevent measles. And it was tested for a
number of times after that in measles epidemics.
That's not so much the problem anymore, and I think it does merit looking
into and trying to develop some science behind it.
DR. CAPLAN: Let's do a comment from Mary, then Dr. Guerra, and John, too.
Then what I'd like to do is take those three comments. Then I'm going to put some
proposals in shaky language on the floor just on this area, and I'll tell you why. It
relates to what Paul was just talking about. I think we should start off with both
prevention and surveillance. I'm a little loath to just say leave it to the agencies to go
figure it out. I want to tell them more than that, but at the same time, it seems to me if
we listened to that risk discussion yesterday, one way to secure the trust and support of
people who are in the vulnerable groups is to say we will commit to prevention, we are
going to survey and monitor, we will research what's going on here. We're not going to
turn you into the canaries. There's a lot of canary metaphors that came in yesterday
saying, well, you'll know there's a risk when we start to die. And I think if the risk
discussion I heard was correct, what we should say is, no, we will monitor, we will
survey, we will prevent.
And so that is why we are willing to then look at some other questions
about supply and pool size and so forth. But if we don't, then I think there is a fear,
partly grounded in the history of the '80s with HIV, that the testing then becomes the
human recipients, and that's not an adequate way to protect their interests since they're
vulnerable.
I did have a mild plot here in starting with prevention and surveillance,
but it is built on this risk idea that you've got to front-load in order to secure trust
at the distribution of the system, roughly on equity grounds.
Anyway, so let's do those three, and then we'll maybe concretely look at
and decide whether we want to endorse a couple of ideas.
Mary?
DR. CHAMBERLAND: Just a few comments on a whole range of topics that have
been brought to the table. Maybe just to pick up where you just left off, maybe suggest a
slight modification of the structure that you've outlined in terms of how the
recommendations from this group might be put forward, and they sort of actually follow
along the rubric that CDC has developed in organizing its emerging infections plan, and
that would be to couple surveillance, what we call surveillance and response, research,
both--and I've heard here today and yesterday both basic and what we at CDC more often do
is applied research, prevention and control, okay, because I think you need to go through
the first two that lead you to the prevention and control, and something that's sort of
related is either the infrastructure that's in place currently within our public health
service agencies, state and local health departments, et cetera, to carry out those
activities. So that's just a slight modification of what you've been putting forward,
which I think is a good approach to kind of construct some recommendations around.
Regarding surveillance, I just wanted to amplify that there are currently
within the Public Health Service, and specifically within CDC, surveillance systems that
generally organize themselves around pathogen-specific surveillance systems, surveillance
systems that deal with donors, and then recipients. In the latter, clearly CDC's most
evolved and extensive surveillance efforts relate around the hemophilia population and,
you know, I think there are some gaps that could be further addressed. So we look forward
to hearing recommendations from the committee.
I think the second major point I wanted to make, and to re-echo what I've
heard also, is that which Jane and Kris have been saying, that we may be of better service
to the department that has charged the group if we try and really focus most of what we
want to recommend specifically on the transfusion-related issues. I've heard a lot of
issues about food safety and animal disease and surveillance. And while those are clearly
issues that impact on this, I think for our group to delve into them in a very detailed
way would probably get us sidetracked to what we've been principally charged. I think we
can--there are other groups in place, the TSE committee and others. And so I think if we
put forward our concerns but try not ourselves to cope with it in a lot of detail, we'd be
more helpful.
Then the last sort of comment was about--it's come up several times about
recommendations about pool size, and I know that this is a topic that this summer
generated a congressional hearing, et cetera. And I think I've heard John mention an
interest in having that topic brought before the committee. And I think that is an
important issue, but I don't think that we have had nearly the amount of information or
structured discussion about that. So I guess I would just put forward a recommendation
that before the committee would want to articulate anything very specific about reduction,
you know, even recommending actual numbers, if that be the case, that we would probably
want to evaluate that with more detailed information that could be brought to the
committee.
MR. WALSH: I would reaffirm that, that we ask--I think Dr. McCurdy already
said, the NHLBI is already looking at the pooling size issue. But I think it's also
totally appropriate and important for this committee to request the FDA and industry to
explain the reasons for shortages, what's impacted the shortages in certain blood
products, and why. And I think to the extent that CJD withdrawals have impacted factor
VIII and IVIG and alpha-1 protease inhibitor products, to some extent we didn't make Dr.
Weinstein's hit list with the alpha-1, but we got over 16 lots withdrawn.
So I think it's very important that this committee ask for a specific
report regarding what is affecting the supply and then address those issues more
specifically.
DR. CAPLAN: Just so I don't forget, even though that's a matter that's
going to come up, I suspect, under what I was calling managing known or probable risks, in
the spirit of consensus, things that I suspect we can do, is anybody going to dissent from
the idea that we request a report on why shortage exists and that we encourage industry to
also supply this committee with a statement or report promptly about their views about why
shortage exists?
Okay. So that's one we can hold for later, maybe.
Dr. Guerra?
DR. GUERRA: I certainly support the notion of trying to better define the
scope of the shortage, but along with that it would be very helpful to see, you know, the
trends in supply and demand. The demand side has certainly been increasing very
significantly.
But I think a part of the discussion of some considerations for the
future, there's no question that the public health side of it is very compelling, and we
need to better define the scope of it. I think that we would fall short if, in fact, we
focused all of our attention just on the domestic side of it and how that impacts the
populations here, given the fact that we're so much of a global community today and that
there are parts of the world where I think the food chain issue is a very significant one
and where people that left their home countries years ago, probably having been perhaps
exposed to those parts of the food chain, that because of culture and tradition or need
and whatever, availability of their food sources, have for many years, I'm sure, ingested
any number of products that were closely tied to the central nervous system.
I think we would have a wonderful opportunity to make some very long term
observations of individuals that have come from those parts of the world. But I think part
of it--this reminds one somewhat of the early days of the AIDS epidemic. I think that the
clinicians and certainly in the instance of postmortem exams that were being done, the
pathologists were not so experienced and knowledgeable about really making the kind of
assessments or interpretations of the material that they were studying and being able to
attribute that to a common pathway of the HIV-AIDS virus. And I think we were seeing--as I
looked at some of the death certificates of individuals that were dying within certain age
groups, very unusual conditions that were being signed out and coded on the death
certificates but, in retrospect, really were manifestations of AIDS, the full sequence of
events, et cetera.
I think that it is incumbent on this committee's work and the
recommendations that we initiate an educational process so that the pathologists that are
doing the neuropathological evaluation of tissues that are submitted, and at the same time
perhaps encourage the greater use of postmortem examinations in those instances where
individuals perhaps could fit the spectrum of disease that maybe could be attributed to
new variant CJD or some within that spectrum so that they really come up to speed with
really what that consists of.
I suspect that there would be a wide scatter as they look at tissue
specimens in trying to reach that diagnosis. But I think if we could give them some of the
information and the tools to better reach at least that diagnosis on a list of others, it
could be very helpful in at least help us to come closer to understanding what some of the
numbers might be.
Then I think that we need to also carry the public health message around
the country, from local health officers, the state level, where a lot of information is
assembled, to see if we can begin to determine--and also this relates, I think, to the
whole issue of zoonotic transmission of disease or emerging diseases in nature, et cetera,
where we are observing some very interesting trends, you know, whether it's clusters of
animals that are dying in certain parts of a region, a state, or whether it is other
clustering of conditions that require hospitalization, very unusual conditions that I
think collectively could really inform this discussion from a public health standpoint.
DR. CAPLAN: All right. We'll let agony dominate there.
Larry?
MR. ALLEN: Two things. Regarding product shortages, along with whatever
recommendation we make in that regard, we need to find out about projections, what these
manufacturers feel is needed based on whether or not there's going to be recalls or not. I
know they're not just arbitrarily making certain lots of product without having some
projections. We need to know what they feel these projections are, first of all.
Secondly, regarding the donor pool size, irregardless of if there are
studies being made now on what's the proper size for different products, there's a matter
of trust here that I don't think has been dealt with. Some of the speakers yesterday spoke
of being told that they--they were told that the lot sizes were 30,000 to 60,000, only to
find out that they were much higher numbers. I would like to know--maybe someone like Dana
or someone else here could say--I would like to know who--where did they get these initial
numbers from, you know, and why did these things happen? This is very important to the
public trust in general. And we need to know why these things happen in the first place so
we can make sure they're not repeated again.
DR. CAPLAN: I have a sense that the issue we're going to talk about after
we examine a couple of statements about prevention, public health upstream issues, is
going right to what was number 3 for me, which was managing known probable risk and the
supply issue. People are chomping to get there. That's fine. We can go right to that after
we do this.
There's a reward if you will all simply asset to what I'm about to say.
You can have a break.
It seems to me we want to flag a concern, and I'm going to say that I'll
ask Dr. Nightingale to write very fast here, but we'll try and hone the language, so to
speak. This is just for the spirit of it. But it does seem that we could agree that we are
concerned about both the problem of identifying and assessing the level of risk that known
agents currently pose to the blood supply, and we're very worried and concerned about this
issue of emerging agents, and that we need to make sure that we have a prevention and
public health approach that responds to both. So that would be the first thing I'd sort of
put out there as a preface, that we're trying to wrestle with both. We know we've got
theoretical issues, but as Jane said, I guess we still don't know that anybody ever died
of CJD. So--
DR. PILIAVIN: From blood.
DR. CAPLAN: I mean from blood, but we have this problem also of the
emerging agents that threaten the blood supply, and that both need to be attended to in
all agency and federal approaches to protection of the blood supply.
Are we comfortable with that kind of spirit approach there?
It seems to me then the next thing we might want to say is that, while
much is being done to protect the food supply, it is of concern to this committee that
these efforts be carefully monitored, that they be pursued zealously, that consideration
be given to making sure that CNS substances do not enter into the human food chain in any
way, either through current agriculture or hunting or just what's going on at restaurants,
and that this has global implications in terms of trying to understand, too, what happens
with some Americans or residents here, what they may have been exposed to.
But what I'm getting at is it seems to me that part of the need to protect
the food supply is that we stress its importance, that we want to make sure that we are
not just talking about animal feeds, but what we're talking about ultimately is what goes
into human beings, and we would like to see policies and steps taken to ensure that more
or less we have a zero tolerance here. Is that something we could move towards?
Actually, when you were talking before about changing food habits, one of
the things I was going to say on that score is this might be a restaurant approach as
opposed to a food approach. I know what I can order in restaurants and I could get brains
at a number of places if I wanted them just for lunch. So it may not just be a matter of
telling people what's good for them to eat, but we may be talking here about something
that the committee is trying to set out and say, look, there's a real risk here for new
agents as well as existing agents, and we're trying to discourage this.
So I'm looking to see do you want to push in that direction. It has
ramifications for how people outside this room are going to hear this. That's not a small
statement you just made.
T2A DR. MOORE: I actually don't think we ought to get into specifics
there. I think our message should be that we are concerned about multiple modes of
transmission and that they need to be addressed--including food-borne transmission, and
that these issues need to be addressed.
I think for us to really get into specific issues like, well, should
people be allowed to eat brains or should there be regulations around central nervous
system issues, I guess I'm a little uncomfortable with that as a public health person. I
really think those may be very important issues, but I think that it needs the right
people at the table to look at those issues. And I think that I would rather call for a
process that allows for that, that we--our focus is blood, but we are concerned about
prevention and control, broader prevention and control issues, and would like to see
processes that address those issues.
DR. CAPLAN: Let me read one other thing here, since I'm doing a little
tactical maneuvering. Kristine actually wrote up a statement, and I'm just going to read
it to you. It says: Disease prevention and control concerning TSE infection--that's the
topic--and the recommendation she suggested we think about is that we recommend that the
Centers for Disease Control and Prevention--and I added "and other federal agencies
as appropriate"--rapidly develop a document that addresses issues around disease
prevention and control of TSE infection in the United States. Specifically, the document
should address issues around possible food-borne transmission, iatrogenic transmission,
and transmission from blood and blood products. Surveillance, education, research, and
prevention strategies should be addressed as part of this report.
So that's a recommendation that's on the table, which I can read back, if
you need to hear it. But the reason I'm doing something a little tactical is: If we don't
say this committee announces to the United States that no one should eat anything from the
central nervous system as one of our conclusions, thereby having pickets with white big
chef hats standing outside the doors, we can certainly say we want a group to answer this,
and fast. And that is one of our concerns.
So what I'm trying to do is make sure that we don't just say, well, the
committee will look at this and seven years later we'll find out. I think it is of
interest to us to get an answer fast, rapidly. We'd like to have a recommendation on this
matter of should there be any CNS allowed into the human food chain, period, by any means,
and what's going to be done to stop that.
I am willing to make that as a recommendation to a group such as this to
answer it on scientific expertise grounds. Are we comfortable that way? Okay. I see a lot
of head nods that way.
DR. SCHIFF: Do you need a motion here?
DR. CAPLAN: I'm moving toward that.
DR. SCHIFF: So moved.
DR. CAPLAN: Okay. Second?
DR. MOORE: What's the motion on the table?
DR. CAPLAN: That your proposal go with the recommendation that one of the
first injunctions we have is an answer to the question of should CNS be banned from the
human food chain, the ingestion of CNS? We want an answer to that question from this
group.
DR. MOORE: That's a recommendation--
DR. CAPLAN: No. We are charging the group as something to look at. The
question on the floor is: Should we create this group the way I read it? All right. We'll
do it in bits and pieces.
Let's put this proposal forward, motioned, and then we'll discuss it, and
I'll repeat it again. We recommend the Centers for Disease Control and Prevention and
other federal agencies rapidly develop a document--there's no time there, but
rapidly--that addresses issues around disease prevention and control of TSE infection in
the United States. Specifically, this document should address issues around possible
food-borne transmission, iatrogenic transmission, and transmission from blood and blood
products; surveillance, education, research, and prevention strategies should be addressed
as part of this report.
So that is--the motion is that we endorse that. We can have some
discussion of that.
DR. JONES: I am comfortable with that, but with the exception of the need
to have to be a little bit more specific and not say "other federal agencies,"
but say who we mean. I'm not comfortable with CDC having the charge alone. So we are
talking about HHS and FDA specifically, I imagine, and I don't know what other regulatory
agencies might be--
DR. CAPLAN: Probably USDA.
DR. JONES: Yes. So somebody--you know, I think we need to specify that.
DR. CAPLAN: We can add those. That's fine. We can add specifically USDA,
HHS--
DR. JONES: And then state a time specific for a return response.
DR. HOOTS: I think we need to sort out those two issues about the CNS
versus everything else, because I think that the proposal for the report is very global.
It is going to take a lot of time if it is going to be done well.
The other issue, at least as it is being discussed, is much more exigent,
and I think they should be separated out.
DR. CAPLAN: Dr. Guerra?
DR. GUERRA: If not separated out, perhaps rearranged in a sequence,
because to go directly to the food chain really calls a lot of attention to it, and we may
not quite be ready in terms of the information.
The other question I have is how we're using iatrogenic in this
recommendation. Kristine, do you want to respond to that? I'm not sure that it's so
different than we use it in regard to blood products--
DR. MOORE: Yes, I was thinking of the issues like--there was list, I think
Larry actually showed a slide yesterday. I can't remember what the title of your slide
was, but had known iatrogenic--
DR. SCHONBERGER: Pituitary-derived growth hormone, gonadotropin--
DR. MOORE: Dura mater transplant.
DR. SCHONBERGER: Dura mater, neurosurgical procedures.
DR. MOORE: Right, there was sort of a list of procedures that had been
associated with--it was really basically that list, was what I was thinking about.
DR. GUERRA: I think it's a very specific list so that one could
probably--rather than just using iatrogenic--
DR. SCHONBERGER: Corneal transplant.
DR. MOORE: Yes, corneal transplant. Maybe we could give some examples in
there.
DR. GUERRA: Otherwise it's a bit open.
DR. MOORE: Maybe in the food one, we can give examples of brain tissue.
DR. SCHONBERGER: The organizations that have been involved have been NIH,
Department of Agriculture, the Food and Drug Administration, the CDC particularly, and
then, of course, the entire academic and private institutions and so on. But those are the
main governmental institutions.
DR. GUERRA: Has the World Health Organization been involved at all?
DR. SCHONBERGER: Yes, of course.
DR. GUERRA: Because I guess that should be on the list as well.
DR. CAPLAN: What we're going to do here a little bit is, even though we've
got some expertise that is sitting over that way, I want to keep the dialogue going over
this way.
Ron?
DR. GILCHER: Much of what I wanted to say has been said, but in summary,
the concern that I have is the introduction of central nervous system material into the
food chain. There are those people who want to eat it knowingly, but there are those of us
who do not want to. And it gets introduced into processed foods, for example, and we
unknowingly are eating this.
I think it is very important to have both the educational component from
the standpoint of educating the public, but there needs to be the public health
perspective of making sure that it's not introduced into foods unknowingly, and,
therefore, the public is ingesting this without ever knowing they have done so.
DR. CHAMBERLAND: Just a suggestion from a procedural point of view. I know
that you and probably most of the people sitting around the table are chomping at the bit
to go to a break; however, thinking back to the last time the committee had to deal with
voting on specific recommendations, I would propose, so that we are all very clear about
the recommendation that is currently on the table, that it either be put on a transparency
or written out so that we could actually see it individually. As you recall, we had to go
through a post-meeting exercise of, you know, passing around various drafts of the
recommendation.
So I think to make sure that there is real clarity about the
recommendation and how people might want to modify it, I would suggest that maybe that
happen during the break.
DR. CAPLAN: We are prepared. We have an overhead ready to go. So we will
do that once we get toned down here a little bit. We'll put it up on the overhead and look
at it when we come back.
I fear that we may not be able to avoid the post-prandial, further
ruminant recycling of the recommendation to you in the mail, but, Paul?
DR. HAAS: Very along the same way of Mary's comment, and it has already
been made, is that given the broad nature of the recommendation as it now stands, I am
afraid it gets out of these hands and then disappears.
I would like the recommendation to be very--maybe targeted, use bullets,
and along the lines of what someone else said, after the bullets, maybe specific times or
whatever--be very direct about this.
DR. CAPLAN: My inclination also is to say that this group, its first order
of business should be to answer specifically by date Y what they want to tell us about
this food chain issue. This is just me speaking personally now, not as Chair, but I am
very worried. People keep telling me that we're on top of the food thing and we've got the
food ban in, and I'm not convinced that that is the whole answer to this question, partly
because of what comes in here from other places, partly because of who comes in here from
other places, partly because of what is processed, and partly because of other ways that
we just allow things to be put on restaurant tables and so on.
So I would like--that to me is an area we should be pushing, and even
though others are saying, ah, we're on top of that, I'd like to see this group charged, if
we agree to create it--which is the motion--with that kind of task. There are a couple of
other tasks that we might assign them, but it seems to me that is one that we would like
to get an answer to right away, and we may not have the expertise to do it in this room,
but we certainly can express a concern that that be a first order of business.
The reason I go through that is, as we move on voting on this, we can say
that we want this group and that we can tell it some things that we think it ought to be
doing by a certain time as you think about this.
DR. GOMPERTS: As I understand it, the proposal is to have government write
a report, an educational report, different departments within our government to write that
report. That report would be focused on TSEs, food, et cetera. It's a rational proposal.
However, the proposal should be that we ask government not only to give the current
status, but an evaluation of what is taking place within our country in relationship to
what is going on in other countries, in other major--parts of the world where there are
major epidemiological issues, United Kingdom, Europe specifically, in addition where
issues and problems are perceived and what is to be done about those issues and problems.
So it's more than just a status end.
I think the time line issue is absolutely critical. We don't want to wait
18 months for this. I think a six-month time line is--I shouldn't go longer than that.
DR. CAPLAN: Is that a suggestion to modify the proposal to six months?
DR. GOMPERTS: Yes. Six months, and ensure that, A, there is an analysis of
epidemiological issues in other parts of the world as will impact our country, and, in
addition, a statement of where the issues, where the problems, where the holes are, and
how they're going to be met.
DR. SNYDER: I just want to bring one thing up. I may be a little naive on
this, but it seems to me from what we heard yesterday that we know that units are being
withdrawn. It's not totally clear to me all the reasons, but it seems pretty apparent that
in some cases, because units are drawn, they enter the manufacturing at some stage, and
then subsequently they find out that one of the things that we know or known iatrogenics
are, you know, discovered, in my opinion, way too late.
If we know, for example, when the first dura mater transplant was
performed, if we know that human growth hormones are definite risk factors, then those
units should be banned--banned or placed on hold until somebody with the proper
credentials can either say that, no, this person never had growth hormone or, you know,
the dura maters won't even be being transplanted at that point in time.
To me, that is something that we can do right now that will affect the
withdrawals. And, Dr. Penner, I agree completely with you. That is something that can have
a pretty immediate effect. If it's even any question, don't let it enter the blood supply.
Hold it until you can resolve that issue, and just make that a standard.
DR. CAPLAN: Again, leaking toward the supply question. Let me put the
suggestion back on the table to rephrase it, and then I want to do a couple of other
things that people suggested we recommend. But keep in mind that if we say that
appropriate federal agencies, which we will spell out--I won't pick on the CDCP anymore,
but appropriate federal agencies be convened to develop a report, within six months has
now been suggested, which will thrill everybody at the agencies, that addresses issues
around disease prevention and control of TSE infections in the United States, existing and
emerging. Specifically, the report should address issues around possible food-borne
transmission, iatrogenic transmission, and transmission from blood and blood products.
Surveillance, education, research, and prevention strategies should be addressed as part
of the report.
I think Keith had an emendation that he wanted, that the report also
reflect what is going on in other countries faced with TSE agents, and--I'm not phrasing
that right, but something about capturing our response relative to what other countries
are attempting to do. And then it seems to me if we vote on that and say yes, we'd like to
get that, we can then tell them some things we want to do next, like please address the
issue of food supply first in your report or feature that or get to that first.
So does anyone want to move a vote, or would you like more discussion on
that little paragraph?
DR. PILIAVIN: I think we want the transparency.
DR. CHAMBERLAND: We want to see it.
DR. CAPLAN: Oh, excuse me. You want to see it on the transparency. I won't
even hold you to what you vote on, but are we ready to say that that goes to a
transparency? Let me put it that way.
DR. PILIAVIN: I don't think we need to vote on that.
DR. CAPLAN: Okay. We'll try and write that up.
Here is what I'd also like to see, maybe if Steve can really write fast,
just some other simple things, maybe on transparency. When we come back, we can look at
them. One was that we encourage appropriate patient groups and professional societies to
stress the importance of autopsy, and training of persons to interpret findings and
educational efforts to understand how to interpret the results of autopsies with respect
to TSE, some phrasing like that. If we got that, I think we'll be able to get some place
with it, that we request that the NIH tell us about the needs they have to take on the
challenge of TSE now in emerging agents, and whether they have suggestions about the
organization infrastructure that they think would meet the challenge.
I keep thinking, by the way, that we've listened to $100 million
withdrawals on the supply end, and if I was not mistaken, it was $7 million on the budget
end. Am I right about that? So what I'm asking here is for the NIH to do something they'll
hate to do, which is tell us why they need more money and what ideal structure they would
use to take on this emergent area, as well as the existing one. That could include
veterinary, animal monitoring as well as people. So we need a specific set of
recommendations that we can consider and then endorse about budget infrastructure and how
their research is set up.
We saw those slides, and Paul has told us a number of things that are
going on at the different institutes. But maybe if we got a sort of overall picture, at
our next meeting we could then say, well, we think this is a plan and this is a challenge
and we recommend that Congress move on this and that this happen. So some phrasing about
the infrastructure budget requirements to take on both existing an emerging challenges. I
think we could get that up and request that that come back to us maybe for endorsement.
The other one that I thought was--and I'm opening the floor for
others--that we ask for standardization and screening of donor brochures and materials
with respect to TSE. It's a pretty simple thing. I'm not sure whether it ought to be
FDA-generated or whether it should come from AABB or who ought to do it, but that
standardization is important and that knowledge about TSE be reflected in donor screening
and recruitment and that that just ought to be happening. That just seems to be important.
So those are some other ones I think we can probably get up and onto a
slide and maybe it won't generate too much discussion. Any others that anyone on the
committee thinks we need to--would like to see done as well on the public health
prevention side of this? I know we'll talk supply as soon as we get done. I could see that
gleam in your eye.
I know we'll have a convivial, fun time enjoining the agencies to get
reports to us within five minutes. Why don't we take a 15-minute break? And we'll see you
back here.
[Recess.]
DR. CAPLAN: All right. You may take a minute to read that. While you're
looking at it, we can open the floor up for some comment and discussion. Kristine?
DR. MOORE: This is just a small issue, but I am wondering, we may want to
say expert working group or groups, because Mary and I were talking that the people that
may deal with iatrogenic issues in hospital infection control issues, you know, may sort
of have their own little group, and the people who do food safety and food-borne
transmission, USDA, that's a different set of players. And I'm not quite sure how this
might best be structured within the Public Health Service, and I'd like to give them a
little bit of flexibility. So I suggest it say group or groups.
DR. CAPLAN: Okay.
DR. MOORE: And I also think that six months, as I mentioned to you during
the break, I think six months--you know, I'm really--having served on some of these kinds
of groups, my experience is that it's been a one-year to two-year process to bring people
together, draft--
DR. CAPLAN: Actually, hold up on that.
DR. MOORE: Okay.
DR. CAPLAN: I'm about to say something nasty, so I'm catching myself here.
But it was something on the spirit of let's see if we can agree what we want them to do,
and then we can fight about how fast they can do it.
DR. MOORE: Okay.
DR. CAPLAN: Yes?
DR. JONES: Who changed CDC and the other agencies to the Public Health
Service? I thought we said we were going to be specific.
DR. CAPLAN: Yes. What we can do there--I don't know how that got changed.
That was probably Jim's fault.
DR. AuBUCHON: It's not my fault, but I was watching over your shoulder.
[Laughter.]
DR. AuBUCHON: Steve suggested that the Public Health Service was the
appropriate agency to put up there in order that the recommendation or the final output
came back to this committee. And he pointed out that there are a number of Public Health
Service interagency guidelines that are produced, and that was just his thought, that that
was the most appropriate way through government circles to get this taken care of.
DR. CAPLAN: Let me say to the group--
DR. AuBUCHON: That's his information. I know nothing about it.
DR. CAPLAN: Let me say to the group on this one, we will get it as
specific as need be, but we probably don't have to worry about that particular substantive
issue right now. We can give an "e.g." or an "i.e." or an example and
just list them there so that it's clear. We want them to get the right groups. They'll
want to get the right groups. We may not be able to figure out exactly who should be
there, but we can give some for instances or examples and flesh that out. So what we might
say up there at the Public Health Service thing is say, "e.g., USDA, FDA," et
cetera, something like that.
DR. CHAMBERLAND: The other thing is I would say the wording
"establish an expert working group" is very--let me put it this way: There are
already established groups, advisory committees that exist that actually would be
available to address some of these issues. And so I think we're--I don't want us to make a
recommendation that is so--that locks us into such tight language in the sense that we're
not--I think we need to have the department come back and tell us what currently exists in
terms of formed working groups, advisory committees, et cetera.
For example, I know within CDC there is an advisory committee on hospital
infection control issues. CDC's advisory committees actually operate differently than some
of the other committees in that they produce products. The infection control guidelines
that are issues now are the recommendations of an advisory committee, and it's one of
CDC's thick MMWR reports.
So if we wanted, for example, iatrogenic transmission to be addressed,
that's a logical group. It already exists. They could write a report.
DR. CAPLAN: You know what? That reminds me, we might want to amend that.
DR. CHAMBERLAND: Then there's this whole--the FDA and Department of
Agriculture may have groups or mechanisms.
DR. CAPLAN: Yes, we can say establish--
DR. CHAMBERLAND: We may not want to reinvent the wheel.
DR. CAPLAN: We can say establish as necessary an expert working group or
groups. Again, the point of the--what the committee is asking for is answers to make the
agencies generate them up from the information they have. I personally will go on record
and say if there is a 400-page report on iatrogenic illness, I don't want it sent to me. I
want to see something that is usable, that responds to the concerns that the committee
has. So it may require some kind of abstracting or summary. But I do understand that we
don't want to call for reinvention. This is not an attempt to say please set up more and
more bureaucracy. But the way to phrase that, Mac, again, might be--
DR. PENNER: Establish or utilize.
DR. CAPLAN: Establish or utilize an expert working group or groups. Then I
think in the spirit of what's--Trish?
MS. O'CONNOR: Since we are the Blood Safety and Availability Committee,
would it be a good idea to start out explaining why--since we start out talking about
food-borne transmission--and, of course, that does affect the blood. But do we need to
sort of say--there is so much that's unknown about this disease and it's possible that
it's transmitted through the blood, and this group, that this is why--
DR. CAPLAN: Yes. And, in fact--
MS. O'CONNOR: --you're recommending this?
DR. CAPLAN: I think that's a good idea. Somewhere back in Steve
Nightingale's notes--remember I had that little preface that said because we are concerned
about the safety of the blood supply and the issue both of existing possible risks and
emerging risks.
MS. O'CONNOR: Right.
DR. CAPLAN: So that should be the preamble to this recommendation, or
something like that.
MS. O'CONNOR: Right.
DR. CAPLAN: And I know that Steve had something come up. There's an
emergency down where he is. But he's got these notes. When he comes back, we'll tell him
to transform them. That's what I hope to get to you in the mail, and I was joking in
saying there's no way we're going to be able to escape a little bit of post-meeting, check
this through the mail, and it's that preface. But I think you're right. We do need to
explain why are we worrying about food. People are going to want to know that. And the
answer is because we're concerned, from what we've heard in the past couple of days, about
not only existing but emerging, and this is one way to sort of push our concerns.
As I said to you before, just to hog the mike slightly on this matter, I
know that people are doing things. I heard that clearly, and I know there are agencies out
there outside the ambit of health agencies that deal with human beings over at the USDA
level. But I don't think that should stop us, my personal view, from saying what you want
to say about coping with existing and emerging risks. So it seems to me that's very
important.
I'm not persuaded that our piling on on this matter is going to be a
deficit or a problem, that we're sort of saying we're concerned about this, too, and we
want this to happen.
DR. HAAS: Could you say something about how you see the role of this
expert group, whoever it is, in making recommendations about blood components, plasma
derivatives, and policy, how that differs from this group? Do you see this group making a
recommendation back to the department on blood not involving you? Are you asking for a
group to make recommendations to you?
DR. CAPLAN: To us.
DR. HAAS: To us.
DR. CAPLAN: To this group.
DR. HAAS: So you'd like another expert panel to be called on to make
policy recommendations on blood and transfusion before you consider them?
DR. CAPLAN: I think the sentiment is that some of the issues up there
require scientific expertise not currently present in this room. But before we say do X,
Y, or Z, we better get in usable form that information back in front of the committee. Do
I have that sentiment correct? So it's really back to us, and, again, that's why I'm
stressing, I don't know that it requires setting up five new groups. There may be five
groups already doing it, but it's getting that information out of each agency,
coordinated, usable, back to us on those questions, is the way I would see that.
DR. JONES: Then why not, rather than say establish an expert working
group, why aren't we recommending to the Public Health Service that they coordinate the
development of a report to this group that does what you listed there?
DR. CAPLAN: That's better language.
DR. CHAMBERLAND: A clarification for me, because I'm a bit confused. Is
this report supposed to just summarize existing information about what is known about
food-borne, iatrogenic, or blood-borne transmission? Or is this report supposed to make
specific recommendations? Because what I heard Kris initially articulate was a report that
addressed surveillance, research, prevention, and control.
And I agree with the point that was just being made that--I understood the
charge to this committee was to make specific recommendations about
transfusion-transmitted infections or related issues, and I--
DR. CAPLAN: Not what is known. I think--
DR. CHAMBERLAND: Are we comfortable with sort of passing on to another
group the responsibility for making recommendations? Because, quite honestly, within the
PHS right now, FDA has laid out for us their existing--their current policy, their current
guidance, their current regs that relate to the CJD issue. And Mark Weinstein's talk
yesterday outlined some additional areas that are under discussion. And I got the sense
that the FDA is seeking some input from this committee or comment from this committee on
what they currently have in place and where they might be going. Is that correct?
DR. CAPLAN: Yes. Actually, you've led all the way back around to the need
to then charge this group with answering a couple specific questions. If we are meeting in
six months and they say we told you what we already know, I'm not going to be happy. But I
would very much like to see us, if we then approve the creation of this coordination of a
report, which I think is a good idea, to say we would like a specific answer to the
question: Should there be a ban on CNS in the food supply? That is something I would like
to have a recommendation back on, since I think it is of concern to this committee that we
have the expertise necessary--if you push me today, I'll say yes. I think the agencies
don't want to hear that quite today. They probably want to say something about the pros
and cons of that, but I think the group is ready to say something about that, if we can
get something back specifically on that matter in six months. What do the agencies think
about putting a ban on CNS in the food chain? Where are we with this?
That is clearly part of the way to respond to the emergent issue, and if
we approve this creation of this coordinated group, I'm going to offer to the group a
couple of other opportunities to say other questions they might like specifically
addressed in that report. One would be, to me, should we try to ban CNS animal substances
in the food chain across the board, and what could we do to do that? Is that reasonable?
I think the American people are going to want to know: Should we be
serving it at dinner? What about the elk? Where are the hunters? What are you doing to
coordinate the state health department interventions, et cetera, et cetera? It should be a
fun report.
Yes?
DR. MOORE: Just one point of clarification from my perspective. I was also
think of this as sort of a broader audience than this group, you know, really more of an
MMWR that is used more widely by state health departments, not just a report for this
group. I see several documents that could come out of this, and maybe one of them is a
report to this group. But I also see it as a broader--you know, trying to address some of
the issues that you've raised by sort of a different group of people that have the
appropriate expertise in those things.
DR. SNYDER: Just one quickie. Technically, it should be the Department of
Health and Human Services.
DR. CAPLAN: That gets the charge?
DR. SNYDER: Yes, because organizationally, although it still exists in
law, the Public Health Service, as far as the current organization, with operating
divisions, it doesn't really exist within the hierarchy that's currently in--but as I
said, in law, it still does exist. But I would do it that way, since we are the
Secretary's advisory committee.
DR. CAPLAN: You can make that note, too.
DR. HAAS: I'd just like to comment. I guess that--and this is sort of a
daunting task, in part because you're asking the Department of Health and Human Services
to make recommendations on a product that it does not have any jurisdiction or any
authority over. So, at best, what the department could do would be to advise the--make a
recommendation to the Department of Agriculture. So that is a little bit tough.
The other problem with the six-month time frame is that there is a good
deal of potential to use existing committees, but because of the law that generates public
advisory committees, they have to be chartered, they have to be listed in the--well, if
you want to--unless you want the report to be written by government officials only and not
have public hearings, not have comments. You're essentially asking for a group to make a
recommendation without the input of industry, without the input of people that would be
affected, without--essentially, when you take the short time frames, you essentially have
real limitations in terms of how you put together outside input because of the Federal
Advisory Committee Act.
There are some real challenges in doing something as broad as recommending
taking an entire group of products off the market that aren't even in the jurisdiction of
this department.
DR. CAPLAN: Well, you know, my response to that--and I'll let others get
into this if they want to--is to say I don't know that we want a recommendation. I think
what we want to know is a report that gives us information about a concrete question like
should we take all CNS out of the food chain. What facts can be coordinated by the
department from whatever resources they have to do to get it that bear on this question?
I think we're ready to offer some advice about that. My hunch is if we
advised on it today it might lead to an interesting set of headlines tomorrow. But I do
think that it would be appropriate to ask the agencies to move on this and pull together
the relevant information.
It's not that we need a recommendation, but I think in this area, for
prevention, trying to anticipate whether we've got the--here's a second issue. Do we have
an infrastructure comparable to what other nations are doing to anticipate challenges from
new risky TSE agents? That will be my second proposal that I would like to get some facts
about.
Then we can recommend, I think at the next meeting, whether we think we're
up to it or not up to it. But while I hear the problems, personally, about what it's going
to take to make the agencies move, I also heard a lot of concern here today that emerging
agents may not be getting the response they want. So I think the committee--my personal
inclination is to just put our foot down collectively and say, yes, but we need facts that
bear on these issues.
If you want us to vote in lieu of being able to pull together that
information, I think we'd vote on the side of caution. That might be something to ponder,
for those who want to be motivated to collect information.
DR. JONES: I think that I'm concurring, Arthur, but I think perhaps in
response to some of the governmental officials that we need to be very explicit relative
to the fact that we're talking about a progress report and that we're talking about
utilization of existing information, existing organizational mechanisms, and not the
creation of a new set of advisory groups or entities, to bring forth information that
perhaps then do address more specifically the questions that you were raising earlier. We
might need to delineate under each category specific questions: if they have the
information, this is what it is; if they don't have it, they should say so; if they can't
get it because of lack of jurisdiction, they should say so.
And I suppose, going back to my concern about who put the Public Health
Service up there, was the notion that we had talked about the Department of Agriculture as
inclusive in this, and it was not just HHS. So, again, we need to make that clear that
we're talking about a coordinated response from governmental agencies that are affected,
but not one that is going to use the traditional bureaucratic delaying tactics for making
decisions. We wan information.
DR. GOMPERTS: Clearly, it's a complex issue, and what I see this
particular committee with this type of statement doing is, first of all, focusing
government on this issue. I think there are so many officials who should know about this
issue who do not, whether it's federal or state or whatever. I think this is a very
important means of focusing our government as well as outside government on this issue
that there are unknowns and we need to know where we stand today. That's the first thing.
I think from a time line point of view it's probably doable. There needs
to be--one way to do it would be to have a formal workshop where government officials and
perhaps knowledgeable scientists are asked to talk around this issue and actually work to
develop a document, a report, as to where things are today. I think it's doable. And that
time line is doable. The question is, of course, resources to do that, and I don't think
the resources are all that considerable to bring... That's one way to shut me up.
[Laughter.]
DR. CAPLAN: While Ed restores his microphone, let me say that what I'm
hearing, just so you'll understand what you're going to be asked to vote on in a second,
if I can move us to close discussion on this, is we recommend that the Department of
Health and Human Services coordinate a working group or groups--maybe that sound still
like we want to invent something--coordinate an effort to develop a report may be enough,
without getting into the creation of groups, to address these issues. The task is to
report to us an audience, not to anybody else, on these themes, and with that change, are
people ready to countenance a vote on the creation of that? Or do you want to discuss
further?
Can I get a motion then?
DR. CHAMBERLAND: Jay wants to comment.
DR. EPSTEIN: I sense some lack of clarity here. What I'm hearing is the
sense of the committee that there are some topics that you want to talk about on which you
feel you were not brought the relevant data. I don't actually hear you asking for an
action plan or asking--I'm sorry.
I would just like to comment that my sense of what's being said here is
that the committee is putting forth a sense of the committee that there are topics you
think you should address on which you have not been given information. Now, partly that's
because they weren't seen as within the scope of the agenda for the meeting, but, you
know, we've evolved to this point. And I'm not sure it's really at the level of a
recommendation at all. You're simply saying here are some topics we think are important
for this committee to address, and we want the data brought to us.
I'm just having trouble trying to distinguish that framework of looking at
what's being said from what exactly is the recommendation. Because all the discussion
around this recommendation has focused on what information ought to be brought to this
committee, and that's what we do as a matter of course. You establish topics, you change
the agenda, we bring you information you may need. And that's all I'm really hearing here.
Maybe I'm missing something.
DR. CAPLAN: John?
DR. PENNER: Jay, I don't see anything wrong with the way this is being
asked. I think we are asking for that information, but we can't sit through maybe about 12
or 15 hours of five different groups getting together to try to consolidate this
information. We could have them do it themselves without us being present so at least we
can get an idea where we're at at this point. Who is overseeing what's going on in USDA?
Are we having products that are being scrutinized? Do we know whether the elk are being
taken care of or whatever? For all we know, we may be talking about things that have no
meaning; they've already been done.
So we need that consolidated, and I think rather than spend two or three
days here, it would be better to have the agencies put it together. That's what I think
Art's after.
DR. MOORE: I guess my original thought was a bit different. I think that
Art started out the morning by saying, you know, what are some of the upstream issues that
need to be addressed, and I was trying to look at a mechanism that would allow some of
those issues to be addressed separate from this group. Because I did not envision
information coming back to us so we could make decisions about whether or not it's
appropriate to have certain materials in the food supply. I was just trying to figure out
what's the mechanism within the Public Health Service or within the Department of Health
and Human Services to facilitate some of the concerns and questions that Art raised
initially which were, you know, what do we know about this or what do we know about that.
Jay, my sense was to get this into a different form, not for this group,
but just to make a recommendation that there is a need for developing guidelines. And I
don't see that at all as part of this group. But when you get outside of our areas, I
don't think this group has an infection control expertise. I don't think this group has
food technology expertise. We don't have the surveillance expertise.
You know, I think that there's just a whole lot of issues that are very
pertinent to the question about how prevalent TSE agents are in the population that may
ultimately lead to issues around blood safety. But I don't think that those are issues
that belong to this group.
DR. CAPLAN: Now, what the Chair is going to do is something extraordinary?
I'm going to actually restrict discussion at this point to people who vote on this group.
Agency people and other people who are ex officio I think I don't want to hear from for a
minute because I want to find out what the group wants.
I'm interested in what you all, the voting members of the Blood Safety and
Advisory Committee, want. On the table is a proposal that you get a report back from HHS
that is coordinated about information on those questions, that this be brought back to you
as the audience, not other federal agencies, not the world, not the MMWR--you--and that
what you are then going to do is probably ask two specific questions beyond that, which
is: One, what, in fact, should be done about the food chain? Two, do we have an
infrastructure to anticipate emerging diseases that is comparable to or at least as good
as what other nations have done? The two things I've got concretely on the table.
If you're a voting member, not an agency person, does that capture what
you would like to see?
DR. JONES: Can I put that in the form of a motion, Arthur?
DR. CAPLAN: Okay.
DR. JONES: I so move.
VOICE: Second.
DR. CAPLAN: Discussion?
DR. PILIAVIN: I think I would like to find out a little bit more about the
TSE committee in FDA, because it's conceivable that that committee has already done most
of what we want here. I begin to feel like I'm the Scrooge here, but I am concerned about
spending time and effort and money on things if it isn't necessary to spend time and
effort and money on things. And maybe Jay, whom you didn't want to hear from, could tell
us whether the TSE committee--
DR. CAPLAN: Remarkably enough, I still don't.
Again, what do you as a committee want to hear from these agencies? I
think that's the issue on the floor for discussion.
MR. WALSH: I think in following on with what Jane said, I think we're
asking for information. If the information's available, I would expect that the agencies
would present it in a form that we could digest it and come back with a recommendation,
which is what our charter is. So if the TSE committee, task force, has already got this
information, I would expect it be made available to us and it would be a time saver and a
money saver. I don't think it's inappropriate for us to ask for information to be able to
make a recommendation.
DR. CAPLAN: Right. And I think again, just to be clear, the way this is
phrased, it may not require anything more than providing and coordinating as opposed to
creating a special group. We can sort of drop that kind of phraseology as far as that
goes.
DR. SCHIFF: Yes, I agree. I think what we're concerned about, as has been
stated many times, is not the well-established CJD. We've heard many times that really
isn't changing; they're taking measures. We can argue about if those measures are too
stringent. What we're worried about is this variant. And if the screening of donors is
going to be did you have dura mater, did you get pituitary, it may have no bearing
whatsoever on this. And you are getting at where the mode of transmission may be. It may
be in what they're eating, as occurred in England. And if that's the case and we're
concerned about the blood supply, then we have to be looking at something completely
different in screening donors.
So I think this information, even though it may be getting away from
safety of blood, that it does relate to it, and it would be helpful to this committee, if
we're really trying to make the blood safe for what may be an emerging variant.
DR. AuBUCHON: I support the recommendation. However, my attempt to be
Scrooge would just be to offer my comment that I think we have heard, between this meeting
and our prior meeting on CJD, presentations by the world's experts who are performing
experimental studies on this subject. And we will not see any additional research
information come to us. We may learn something more about what other agencies are doing,
and that may be important to us.
DR. BUSCH: Yes, I agree. I think we've seen most of the data that exist.
We've heard the limited resources, the focus on this is very recent; and I think what we
are asking for here, at least what I would like to see us asking for, is really a
strategy, a consensus statement of what we know but more of an alert to the public and a
strategy for building a research agenda toward these issues.
DR. CAPLAN: I think that's something we could--the spirit of allowing us
to be able to--the information should come to us in a way--and I'm looking for something
that we'll probably be doing in the mail here--that we would be able to communicate and
alert the public about these matters and the challenge of emerging threats to the blood
supply. That's part of the way we want the information crafted, is what we're calling for
on what has now become modified enough that even though we'll vote on it in a second,
we'll probably have to send it out to you and let you read it again carefully. But we can
at least approve as a first go. I think I'm going to ask for a vote on this.
What you're voting on is--Steve, can you read that? We'll recommend--I do
want to change that first line--that the Department of Health and Human Services
coordinate an effort to develop a report within six months--we're changing that, so we're
not talking about groups and new outfits.
DR. NIGHTINGALE: The formality is it will be within the aegis of the
Public Health Service--my understanding in my short time in this job is that if it is
under the aegis of the Public Health Service, it will in some way simplify the task of
accomplishing what you wish accomplished.
DR. CAPLAN: Give us the metaphysics of whether it exists or not.
DR. SNYDER: No, no, no. Not the metaphysics. Just the idea that, you know,
when you're looking at some of the food issues and the food chain issues, the Department
of Agriculture is going to have to be in there. But that means that the Secretary needs to
talk to that Secretary. So in coordination with--
DR. CAPLAN: Yes, yes.
DR. SNYDER: --the U.S. Department of Agriculture.
DR. NIGHTINGALE: Would the phrase "coordinate an effort to
develop" convey the sense that you wish?
DR. CAPLAN: Yes.
DR. NIGHTINGALE: So the first sentence now reads: We recommend that the
Public Health Service coordinate an effort to develop a report.
DR. CAPLAN: And remember, too, this will come with a preamble that says
because of the threat of emerging agents, as well as the existence of current risks, we
want this. That's what the backdrop is, so that it's not up there as part of the
recommendation, but that will be the preface to it. That's why we're moving on this.
All in favor of that modification, with the provision--
DR. NIGHTINGALE: A point of order.
DR. CAPLAN: Yes?
DR. NIGHTINGALE: On behalf of the Public Health Service--a point of order.
Does the motion that we're voting on including a preamble to be written, or is it the text
as modified on the screen?
DR. CAPLAN: With the preamble, which is buried, actually, in your notes,
believe it or not, somewhere. Preambled that way, can we move this forward and make it
subject to fine-tuning and revision by mail? All in favor?
[A show of hands.]
DR. CAPLAN: Opposed? That was easy. Okay.
Now, Steve, was it possible for you, given the problems that came on
downstairs, to capture any of those other quick recommendations we had about training and
so on?
DR. NIGHTINGALE: The first of the ancillary issues was a question about
the NIH budget, and it was a recommendation regarding priorities of the NIH budget. I
believe implicit in that from the discussion yesterday by Dr. Gibbs and others was a
discussion about the priority of developing a screening test.
DR. CAPLAN: Let me ask--we didn't get that on slides, though, overheads.
Not yet? Okay.
Then I want to ask the group just an administrative issue. You will recall
before the break, many hours ago, that I listed a set of possible recommendations about
autopsy, training, the NIH budget in terms of making sure that the agency let us know what
they think it would take to anticipate new risks and to test for current risks in the
blood supply, the development of the screening test. We can, I think, if it's easier
rather than trying to do this in our heads, send these out. Would that be--do you want to
try and work through those quickly, or would that be all right if we just tried to
construct them and mail them out to you for approval? Mail them?
DR. PILIAVIN: Talk about them.
DR. CAPLAN: You want to talk about them some more.
DR. McCURDY: Just a point of clarity. I think one of the crying issues or
the very definite need is a test that facilitates research in the study of the TSEs. A
test that would facilitate research is probably--not necessarily but probably different
from a screening test. And it may be that one evolves from the other, but I think it might
be worthwhile to talk about a test rather than use the adjective screening.
DR. CAPLAN: Okay. I understand.
DR. PILIAVIN: Perhaps it's my training as a social psychologist, but I
really do believe in the efficacy of group discussion in terms of the clarification of
issues.
DR. CHAMBERLAND: I was just going to say--
DR. CAPLAN: Oh, by the way, we can open the floor back up to the entire
huge swatch of humanity now.
DR. CHAMBERLAND: I think I'm following up on what you just said, Jane. I
would have difficulty if I was a voting member of this committee to kind of know what I
was voting on in some instances. I'm sorry, Art, but I didn't really quite grasp
everything that you just said that you suggested be put in the mail to the committee
members.
Are you outlining a series of recommendations that would be made about
this committee is in favor of resources?
DR. CAPLAN: Yes.
DR. CHAMBERLAND: I really think it would be helpful to have a draft of
those done over lunchtime to see where we're going.
DR. CAPLAN: We can try that, okay.
DR. CHAMBERLAND: And some discussion.
DR. CAPLAN: We can try that.
DR. CHAMBERLAND: Because we had a lot of--it made it hard doing it by the
mail.
DR. CAPLAN: Just to remind you again, Steve, what we're talking about here
before we try to get these down, then maybe on the slide side and also then shuffled
toward the non-controversial matter of supply issues, one was a recommendation that we try
to have patient groups and professional societies encourage--highlight and encourage the
importance of autopsy, in training of persons to interpret the findings, educational
programs to help professionals understand the diagnosis of TSE.
We had a recommendation about the need to standardize screening of donors,
that brochures and other information be sensitive to the challenge posed by TSE. During
the break I had some discussion with people from the Red Cross who said we're doing a lot
of that, and we want to make sure that that, of course, goes on across the board, but that
would be a second recommendation that came up from the discussion this morning.
The third is that we ask the NIH to specify what their research needs and
infrastructure would be to deal with the challenge of TSE now and in the future, including
the development of a--I should use Paul's language here--test. Not a screen, test for
these agents, that this be a priority. I think those are the ones I had.
So we can look at those probably pretty fast right after lunch and kind of
review those, unless there are others that I forgot here.
DR. MOORE: This may be a little bit tangential, but yesterday there was
some discussion about better diagnosis not just in human populations but in animal
populations as well.
DR. CAPLAN: Part of that NIH--yes.
DR. MOORE: So the veterinary community may also be included in that
training effort.
DR. CAPLAN: I forgot that, but that was part of that NIH issue of what are
we doing to monitor animals as well as people.
DR. HOOTS: Yes, and just to extend that one more step, not only testing as
a determinant for TSE but discrimination of TSE agents or between agents.
DR. CAPLAN: Those aren't so bad. There's only three or four of them there,
so we can do those right after lunch.
John?
DR. PENNER: Could we then perhaps provide some thought for the lunch break
about the supply area?
DR. CAPLAN: I think we're ready to head that way unless anyone wants to
comment further on other things that came up about--remember, we're still talking
prevention and upstream issues. That's what these recommendations are meant to capture. If
we've got that on the table, then let's shift at this point to a discussion of a place
where--never wish for something, you might get it, which is, well, is the committee ever
going to say anything about various things that it has been asked concerning issues of
risk, management of supply, withdrawal of product and so on. That hour has come. We'll
talk about this now until approximately noon, I suspect.
What I was going to do is basically open the floor to see what specific
sub-issues people might want to talk about under the general rubric of supply. Unlike the
prevention and upstream issues, I don't have a proposal to make, but John does.
DR. PENNER: Jane brought this up, and all of us have talked about it, and
yesterday we heard from a number of the blood user groups as to their feelings about
whether products should be released or not released. And there's a good deal of divergence
of opinion here, depending on the group, and what their resources are for getting
alternative products. Some, as you already heard, such as the alpha-1 antitrypsin, don't
have other resources, other availability. So that one has to then weigh risks, and I don't
think that a governmental agency is in a position to be able to weigh those risks without
the population being involved that are receiving the products.
So with that in mind, I would propose that we would at least develop a
committee, which would be public users, an advisory committee, that would be able then to
review the product use for individual groups or users. That would include individuals from
each of the user groups. It also would include individuals say from the manufacturers.
It would be the purpose of this group to recommend product retention or
exclusion based on the risk for individual users. They would be able to review any of the
recall cases that have questionable decisions and identify, therefore, restriction of use
of those products.
I think that is the general tenor that I'd like to get across, and I think
Jane could add more, and others. But--
DR. CAPLAN: Are you thinking about this--not to put more load on here, is
this with the TSE group that exists?
DR. PENNER: With the TSE group, whatever--because I think we need some
group that is able at least to look at it on the basis of need and decide that perhaps
it's more important that this product be available than restrict it, because the
individuals who are using this product will suffer significantly without it, recognizing
that there is a potential or theoretical problem that develops if you use the product, as
opposed to a real honest to goodness life-threatening situation without it.
The public can be involved in that, and I think we've got a number of
things that we can add to a preamble to that, such things as given the fact that there's
no evidence of blood transmission for the infection, given the fact that there is only a
theoretical or possible infection in certain individuals, given the fact there is no assay
for the agent, and given the fact that the product preparation may even reduce or
eliminate any infectivity, depending on which product we're talking about and what
procedures it goes through, and then given the fact that different populations have
different risk factors or needs for product, some of which are life-threatening.
DR. NIGHTINGALE: Dr. Penner is undoubtedly aware of the regulatory
complexities his proposal raises. Would Dr. Penner wish to specify any potential
resolutions to those complexities at this time?
DR. PENNER: It would be a matter of establishing a group or committee that
would be advisory to FDA on this subject.
DR. NIGHTINGALE: That advisory committee would be distinct from the Blood
Products Advisory Committee; is that correct or incorrect?
DR. PENNER: That's correct.
DR. CAPLAN: Well, why not? Okay. Let's go this way, and--
DR. HAAS: I'd just like to point out some of the challenges of doing that.
In fact, you know, we do consult with patient and consumer groups when we do this. But
we're available 24 hours a day for emergencies and for supply problems. We have complete
access to confidential trade information and other types of information which companies
are not willing to make public or discuss publicly. The law--and it's something we didn't
invent; this is Congress--requires that all public meetings be announced in the Federal
Register six weeks before the meeting.
There are some products where, in fact, you do have a couple of months
before you have to make a decision, and it could come to such a committee meeting. But I
think there are other areas where this would largely be an after-the-fact review of
decisions that we would already have to make, because I don't think you want to put us in
the position of not being able to release product that we currently have the authority to
release until it has been publicly discussed and vetted by a larger group, and discussed
by a group that may not have the full--the access to the same kind of information that we
have.
So I think that we are all very sympathetic to the notion that everybody
has to participate in this decision and that the people who use the product perhaps have
the most important opinions about some of these decisions. But this would be the fourth
advisory committee on blood products that would require meeting, staffing, Federal
Register notices, and how its jurisdiction would differ from our other advisory committees
and what you would like them to do that you at your committee on availability would not
consider, I guess my question would be: Is this a function that this committee would be
willing to serve, knowing that you would probably need to meet at least probably monthly?
DR. CAPLAN: There's a threat.
[Laughter.]
DR. AuBUCHON: I like Dr. Penner's idea; however, I've lived in the
Washington area twice, and I don't really care to do it again.
I wonder if we might be able to accomplish the sense of Dr. Penner's
approach in a slightly different way, and that is, to recommend or encourage the FDA to
continue to consider or increase its consideration of the supply issues and the burden
that the lack of particular derivative availability may have on certain groups of
patients. There are certainly mechanisms available, I believe, for the FDA to contact
various patient groups and get their input in an informal manner to consider as part of
the decisionmaking process.
I am not aware of this as fact, but it is my feeling and understanding,
however, that that won't entirely solve the problem. Because even if the FDA tells a
manufacturer, okay, we will let you release this particular lot, that authorization comes
with the requirement that it be labeled in a particular way, and that potential users be
advised that there is possibly an increased risk of transmission of CJD through that
component. As a result, even with that special authorization, many manufacturers are
probably not willing to release the derivative because of the fear of future lawsuits.
They're unlikely to be sued because something isn't available: It's just not available,
sorry, that's the way it is. However, if they release it, even in a compassionate mode,
they may get sued because it's thought to transmit something in the future.
Without the type of liability backstop protection that vaccine
manufacturers have, they can--in this situation, my guess is that many manufacturers just
aren't going to push it.
DR. CAPLAN: So to just have two issues up on the table, maybe we can focus
in for the time being on Dr. Penner's proposal and ways in which the committee might want
to see consumer involvement either added to existing structures or something new put on
the table that the FDA would have to do to incorporate more consumer perspectives. And
then there is a second question, which I would like to hold discussion on for a minute,
about what might we say about liability and compensation issues for harm in terms of
trying to encourage increases in the supply of blood that's out there. But let's put that
one on hold for a second and just look at the Penner suggestion about consumer input.
The proposal is to create a new body that would advise on issues when they
come up about withdrawal and withholding, and I suspect is not yet clear, I guess, to the
TSE group. Is that what you were thinking? Let's talk that way for the time being.
DR. MOORE: This is a point of clarification. Yesterday, Mark, when you
presented the transferrin case and talked a little bit about that, it sounds like what I'm
hearing, it relates to what you're saying because that was kind of there were some
decisions made on a case-by-case basis and consumers were involved in that decision.
What's the process? Who was invited to be involved in that process? And could that model,
which is a much less formal--I am also very concerned about creating another formal group
that doesn't have the flexibility that I think you may be actually hoping for. Is there a
less formal way, and can we use that kind of a process to achieve what you're suggesting?
DR. WEINSTEIN: There has been an initiative, in fact, in that transferrin
situation there, a decisionmaking process, an analysis, risk analysis was performed by the
FDA with the involvement of the CDC and the NIH, a decisionmaking process, how this
occurred, how--you know, each step of the way, the analysis was given to the hemophilia
community. We asked for their input about the--what they thought of this decision. There
was communication at all levels here as this progressed.
DR. MOORE: Yes, I think there are a couple of issues here. One, some of
the issues that I think you're suggesting could actually be addressed by this advisory
group, but I'm wondering if we could maybe modify your proposal to say something like that
a protocol or a process be developed for case-by-case issues of product release, with a
risk/benefit analysis and involvement of consumer groups, maybe modifying your language.
DR. PENNER: Formal protocol.
DR. MOORE: Formal protocol. Would that be able to be achieved in a way
that might be useful, particularly when you're dealing with sort of these case-by-case
situations? I think basically it would be this group basically condoning that process.
DR. WEINSTEIN: I think you proposed that. There are confidentiality issues
here that come into play here, you know, whether the individuals we are consulting with
have the access to confidential information, that can occur if they are to help in the
decisionmaking process here, if they are learning of our decision, somewhat there can be a
difference in--
DR. MOORE: Maybe seeking input, like come up--using the model that you
basically used. I think confidentiality is certainly a very important issue, and I don't
know if--I think you can't really breach confidentiality there, but somehow involving
consumers in the decisions, which is what you did before.
DR. WEINSTEIN: Well, as I say, this is what--our usual procedure is to
involve the members of the affected communities in telling them about situations that are
developing and their thoughts come into play about our final decisions.
DR. CAPLAN: Let me just ask a question to the committee, some of whom have
members from these communities that are affected. If we were to say as a preface to John's
proposal, just as a preamble or preface, that the committee had a sense that consumer
involvement and groups at risk is not adequately reflected in the current processes used
in making decisions about supply and withdrawal, if we were to make that as a preamble, is
that something that members of this committee, particularly those who are in some of these
groups, feel is true? Or is it the case that as the agency tries to reach out to the
public and affected groups that people do feel engaged and involved as appropriate?
What I'm trying to get at here is, for the committee members, are we
trying to fix something where we have a sense that more consumer involvement is important,
more accountability is important? Or is it the case that some of what is going on isn't
well understood and that has to be systematized? And I'm just asking if you have
experience with one of the affected groups, if you could comment on that.
MR. WALSH: We haven't had any experience with being consulted about having
product released, you know, with the acknowledgment of potential issues on a withdrawal
basis. But I think based upon the model that Mark presented yesterday, if we as a
committee made it known that we--you know, not necessarily applaud the FDA, but that this
seems like a good process, but we would encourage the FDA to have members of this
committee or have this committee help facilitate interaction with a consumer group on a
particular supply issue or withdrawal issue, then that would be appropriate. And I think
that needs to be formalized. I think that's part of our charter, obviously, the reason why
we have consumers sitting on the committee, is to express a consumer's input. And I think
we ought to probably formalize that in some way, short of what Dr. Penner had proposed.
DR. CAPLAN: Dana?
DR. KUHN: I think we have gotten consumer input with the testimonies
yesterday and hearing what their concerns were and even giving direction in the ways that
we should be going. I think as far as the shortage of supplies that are going, you
definitely need to continue to have consumer input. Because how do we know--you know, I've
heard stories about IDF patients dying because they did not get their product. And I think
that we need to continue to have that consumer input.
But, you know, is the issue here--are we talking about developing another
committee to look into--that has consumer representation?
DR. CAPLAN: That's the Penner proposal.
DR. KUHN: I think we already have it here, and I think we need to just
utilize it and continue to get that information coming to us to make these decisions.
DR. CAPLAN: Let me note, by the way, it was said--and I think it's
true--there is a set--that must be on my mind now, but there is a set of questions about
needing to act fast and make a decision within the constraints of proprietary requirements
and so forth that regulatory agencies face. There is also an opportunity for this group,
if we want to in certain instances, to review what was done. That is possible, and we
could say the way the process worked didn't reach out far enough, we want that formalized,
we'd like to have some discussion of how that goes, and then critique it or comment upon
it and so forth.
So in one sense, what is put on the table is whatever we propose to get
standardized or formalized, consumer involvement in decisionmaking, has to be responsive
to the fact that decisions have to go quickly sometimes, and then at the same time, can
this group here offer more input, or should it, to the procedures and policies that are
followed to make sure that the voice of consumers is heard.
So there really are kind of two. One is, Is the consumer input into the
withdrawal decisions as they arise adequate? Another is, What could we do to be more
involved in commenting on how that goes?
DR. FIGAL: Well, I would just respectfully ask that before you pass a
resolution that starts by declaring that it has been inadequate, that you give us an
opportunity to systematically present how we do have outreach to the communities, how we
do involve them with different decisions, where it's easy, where it's hard. And we haven't
really done that. I think you've heard some of that as a byproduct. If you'd like to do
that in a future meeting, we'd be happy to do that because it can always be improved. But
it's a very important issue to us, and we work very hard at it.
DR. HOOTS: In another way I think we may be in a good position to help on
the prospective side of this. One of the things that we really haven't had direct
information about, except vicariously from the testimony yesterday, is the things that are
specifically impacting supply at any point in time. There are clearly issues that haven't
been discussed that we probably need to not necessarily be aware of on a confidential
basis in terms of Company X being off-line for X period of time, or those sorts of thing.
But, clearly, those issues probably are having a substantial, and maybe even substantial
even beyond some of the things we've already talked about, impact on supply.
I think that we are in a position by our charter to have a reporting
mechanism give us information each time we meet, or even between times we meet, if it's
not frequent enough, about what things are impacting the nation's blood supply in terms of
availability. You know, has one company run into a problem? Not specifying what, just say
that there is a problem, and that we anticipate the impact of this problem to be eight
months down the road the number of units of grams of IVIG or units of factor VIII or
factor IX may be cut by this percentage, and, therefore, that we would anticipate there is
going to be an issue.
I think by having--I know the FDA does this on a routine basis. I think
we, in terms of trying to look at it globally as well, and also to maximize the amount
of--to help the FDA get the maximum consumer input, could utilize this information,
because I think those--a lot of times we hear or we have heard, at least in this meeting,
issues that clearly will impact the supply, like recalls from CJD. But we don't know how
to frame that into the total context of the supply, and until we have that information, we
may overreact in our recommendations or underreact in our recommendations.
So I'd like to see us get more of those supply issue-related data into
this committee.
DR. GOMPERTS: Listening to the discussion on the supply issue, I think
first of all, I don't think this committee has heard enough about it yet. The supply issue
is complex. There are many factors, starting off from donors and different types of
donors, all the way through to specific products. And I believe this committee needs to
spend some time on this, and my recommendation is our next committee meeting should spend
a fair amount of time on this issue.
We have heard from Dr. Weinstein, as far as the immunoglobulin issue, that
it's a multifactorial issue and that, indeed, the FDA is looking at a number of ways to
alleviate that particular problem.
What this committee should be looking at is some ways, as well, where
possible avenues could be sought from alleviation, whether it's the CJD issue or others,
but at least we should start thinking along those lines.
From the point of view of consumer representation, we heard really clearly
yesterday--and we've heard in the past as well--that the hemophilia community are very
concerned about transmission of infectious agents, and that is the top priority, and that
will and should continue to be the top priority.
However, at this point in time, supply of factor VIII and factor IX to
that community is not massively constrained. But once it is, then it will--certainly the
issue of supply to that community will very much become a top--because the management of a
bleeding disorder, a bleeding situation, has to be a priority.
However, a different group of consumers, or consumer groups we are not
hearing from and won't hear from, are those with, for example, immunoglobulin is used in
the management of Kawasaki disease or Guillain-Barre, or for that matter users of albumin
in a shock situation.
So we have to look as broadly as possible from that point of view, but as
far as Dr. Penner's point is concerned, I think the Blood Products Advisory Committee of
the FDA should be asked to look at this, the supply issue, that there is broad consumer
representation on that committee. And that certainly is one way to do it as well.
DR. PILIAVIN: I'm not exactly sure how to say this. Obviously safety is
the most critical issue. However, I want to return to the data we saw yesterday which
suggests that there is no safety issue with regard to CJD, the normal old-fashioned kind
which has been around for over a hundred years, and there's no evidence that anyone has
ever gotten it through the blood supply.
Certainly there has been concern among consumer groups, particularly the
most strongly organized of them, about safety, and they have indeed been very badly burned
in the past, and this is all very understandable. At this point, I think we really need to
focus on the safety issue around availability, and I'm putting it that way on purpose
because I really see this as, at this point, a more critical safety issue. And, again, it
seems to be affecting groups that don't have a voice, and here my sociologist hat goes on,
and I am really very concerned about the way a system works that listens only to those who
have, for one reason or another, political power and doesn't listen to the concerns of
those who, for whatever reason, historical, economic, have no such power.
I would like to at least talk about the possibility of changing the
current set of regulations regarding recalls based on what we think we really know about
the data. I don't think that at the present time traditional CJD is a danger to the blood
supply. And what is a danger to the blood supply is all of these recalls that, number one,
prevent there being product for people who need it, and, two, drive up the cost of this
product so much that even if it is available, many people are not able to afford it.
DR. MOORE: I actually agree with Jane, and I would like to--I think one of
the issues that this group was asked to look at is: Should we even have these product
withdrawals? And I really would like to see some discussion of that.
Along with what Jane has said, I would just like to add the point that
many people who are either at risk for CJD or who subsequently develop CJD and have
previously donated blood products are never identified. And I think that--that's one
issue. So there probably is a greater level of contamination--I mean, we're kind of--I
don't know if you guys heard the story of the person who looks for his keys under the
lights because that's where the light is. You know, and I think that that's an important
consideration here, that it may be that contamination is fairly ubiquitous and that we're
being able to address this, a small piece of the issue, and it's unrealistic to try to
capture every possible infectious unit that may end up in a blood product.
The other thing--and I think it was mentioned yesterday--that I think is
an important point to consider is that when you actually look at the product withdrawals,
my understanding--and, Mark, correct me on this--is that most of the product--by the time
there is a withdrawal, most of the product has already been distributed and used, anyway.
Is that correct? And what was your figure again yesterday of the percentage of product
that is still available?
DR. WEINSTEIN: Actually, I have a little mini-presentation here about the
relationship to withdrawals and product supply and all that sort of thing. I don't know if
we want to give it now or--
DR. CAPLAN: Can you do it in two minutes?
DR. WEINSTEIN: It will take ten minutes.
DR. CAPLAN: Maybe we'll do that after lunch.
We have basically three issues on the table. One is: Does the committee
wish to say something about consumer perspectives and involvement? There's a Penner
proposal that appears to me to be at least comatose right now but could be revivified.
There is, nonetheless, an issue about what to do about consumers, and John may want to
rethink based on the discussion he heard how he might want to revise or revamp that
proposal to present to us.
Secondly, we have the compensation question, which I disconnected from
this but which is not irrelevant to issues of withdrawal policy. If we think about ways in
which we might try to approach compensation for harm or proven harm or move toward the
kind of thing that has been done with the vaccines, we could say something about that and
say we urge the exploration of ways to enhance compensation and reduce liability for this
situation so that we don't find legal liability getting in the way of supply. That is
something for Jim to think about over lunch.
Then this third issue has now come up. Does the committee--are we prepared
to say anything about withdrawal policy given what we have heard about risk posed by
standard existing CJD in the blood supply relative to what that is doing to the
availability? And we don't have to necessarily have Jane make a proposal; she sort of made
one for us that we recommend that CJD be treated differently than it currently is under
policy with respect to withdrawals. And we can discuss that certainly when we come back,
too.
If we do those three questions, plus a review of the other recommendations
on prevention, plus a little bit of old business, that is going to pretty much make up the
rest of today's meeting, because there is an opportunity there to go back. You saw the
letter from the Secretary. Anybody remember hepatitis? It was a thing we talked about a
long time ago. But we have a response, and we can comment on that response if you so are
inclined as old business.
So those are the things that I think are going to make up the agenda after
lunch. If we are going to do this and get out of here by 3:30-ish or 3:15-ish, then we've
got to be back here at 1:00 on the button. Okay? Okay. And somewhere there is a 10-minute
presentation on what we are doing already on the supply. We will see how that evolves.
But, in any event, Jim, if you want to think a little bit about
compensation, John, if you want to think about how to reshape that proposal about consumer
involvement, then we can go to those things. We will start with the recommendations, the
other ones on prevention and upstream kinds of things.
Okay. See you in one hour.
[Luncheon recess.]
AFTERNOON SESSION
[1:07 p.m.]
DR. CAPLAN: I'm going to ask Dr. Nightingale to put the three
recommendations about prevention and public health up on the overhead.
While you are pondering these three bits of advice that we are delivering,
let me remind you again about order of business here. This morning we were trying very
hard to say that we needed information supplied to us by existing agencies or whatever it
takes to make sure that we are confident that the infrastructure exists for handling
emergent threats to the blood supply. That is what that request or recommendation,
depending on how you would like to phrase it, is all about.
These three other recommendations are in the spirit also of trying to
anticipate future threats to the safety of the blood supply and its availability, asking
for these things to be done.
Then I think we have in front of us the amicable and interesting review of
Dr. Penner's idea about the participation of the laity in the deliberations of FDA with
respect to withdrawal. We have the issue of compensation and whether we would like to ask
or advise that agencies or PHS take a look at what they have in the vaccine area and
whether that might be extended this way. And most particularly then, we are going to go
into a discussion of what we know now about CJD, what do we want to say about its impact
on the blood supply.
I think in particular the agencies are looking to us to see whether we
want to say something about that, advise about whether there should be a change in that,
and so that's pretty much what I want to do. I know I promised 10 minutes on the subject
of what FDA already knows about CJD-related post-donation. In fact, in the interest of
time, I'm going to ask that those get distributed, and we will, in fact, ask questions as
needed instead of having a presentation on this, because I want to make sure I let--during
the break, people were chewing my ear off about the CJD thing. So they may have inhaled
about as much information as they want, and they may want to exhale a bit of what their
views are about that.
So I am hoping we can actually go quickly through these. Remember, the
recommendations that are up there--can you read them? A little focus on that. Now, don't
be picky and ask to read these.
The first one is meant to emphasize the importance of postmortem
examination for the protection of public health, training physicians. I think we are
missing one thing here that I recognize we didn't get up there. But we have a training
recommendation. We have a recommendation about standardization of procedures for screening
donors ta risk.
By the way, if that is already being done by many groups, that is fine. We
are just urging that it be done. It doesn't matter whether people say we are already doing
it. It's just that we want to make sure that it's done.
We are recommending that the NIH tell us what it needs in the way of
infrastructure and research to promote research on TSE, both animal and human, trying to
look forward to the challenges that we heard about yesterday. And what is missing up
there, the other recommendation, Steve, was that we try to encourage autopsies with
respect to--oh, it's on the tail end here, recognize--essentially, dealing with autopsy
tissues. Well, let's see.
What I'm looking for here, too, is that we encourage people--and the
affected groups, right. The importance of postmortem examination. Does that capture that
all right? Okay. It's just my verbiage there.
Discussion? And use the microphone, please.
DR. AuBUCHON: With respect to the second recommendation up there, I think
indeed you are correct that the standardization is pretty much already in place because
the FDA has been very clear about the questions that we are to ask perspective donors
about their CJD risk.
However, I would like to offer for the committee's consideration the
expansion of that and recommend standardization of donor information and donor questions,
donor medical history questions, for all subjects. In other words, have the FDA prescribe
precisely what we are to ask all donors, as a minimum.
DR. CAPLAN: Comment?
DR. PILIAVIN: I would like to go back to the issue that was raised, just
as a suggestion for what we ought to ask, as to--we were talking about this at the break.
Wouldn't it make sense to have people ask if they have ever had brain surgery, have them
temporarily deferred until they can come back with you and tell you yes or no whether they
had a dura mater transplant. That way we would certainly avoid almost all of these
potential recall problems.
Similarly, with the hormones, have you ever had a shot that a doctor told
you was a hormone? And then if they say yes, go and find out what it was.
DR. CAPLAN: One of the things that I've heard about that particular issue
is that sometimes it takes a little while for the wheels to turn, that they donate and
then they go home, they think about it, they ask, so they may not have an answer right on
the spot.
DR. PILIAVIN: I can't imagine not knowing you'd had brain surgery. I mean,
the specifics of the brain surgery.
DR. CAPLAN: That may be, although I guess some of this was when you were a
child or when you were small or you have to ask your mom, did I ever fall down? But I get
the point. We can certainly encourage that as part of Jim's comment.
DR. AuBUCHON: Yes, well, this could be potentially problematic, because
although brain surgery is pretty dramatic and one knows that one's head was opened up,
there are other types of surgeries where dura mater grafts may have been used that are not
brain surgery, including spinal surgery. And if we say brain or spinal surgery, then we'll
have a number of people reporting to us that they had lumbar disk surgery, and they will
call that spine surgery, when that probably did not involve dura grafts. So it gets
complicated.
DR. CAPLAN: Let me make a suggestion here and try and incorporate these
two into that second recommendation. We could modify this and say that we want--we urge
standardization of donor information, and that the committee feels that it is very
important that this information try to reflect risk factors so that these donors can be
more effectively isolated. And then let the specific questions be handled. Would that
be--I mean, they know where we're going, and they can work on the phrasing. Is that all
right? Did you get that, Steve? I know you weren't paying attention. It's on the tape,
though.
I don't even know if I can repeat what I just said, but what we're trying
for is that we want standardization of donor information and donor deferral, with special
attempts, a special effort being made to try and discourage--to identify and discourage
people who might be at risk so that they are not put into the supply. They can work out
the details in the questions that might do that, whether it's brain surgery or did you
ever have a dural transplant or have you ever had growth hormone and so forth. But the
question should be, as part of standardization of donor information, aimed at trying to
isolate people who might pose risks. And so that's what the committee would like to see
done, standardized pushed.
Are we all right with that modification on No. 2?
I heard him. What modifications are you proposing? he said. That we would
modify the standardization, recommendation No. 2., to include standardization of donor
information and more questions aimed at identifying and isolating people who might be at
risk of TSE in the blood supply. That's where we got into this--and Jane is actually
scratching away here. But I'm willing to say for discussion purposes we could
probably--we've got the spirit of it in terms of what's being sought there,
standardization of donor information, questions that would identify persons who pose risk
being standardized, so that they could be used to isolate.
DR. SNYDER: I'm just wondering, since for growth hormone small
children--that's usually when they receive it, there's a possibility they could not know.
But what would be the value of having a registry of some type where any time there is a
dura mater transplant, that that person's name is entered into that registry, or if there
is growth hormone administered, that's kept on record.
DR. CAPLAN: A donor deferral registry?
DR. SNYDER: Basically, yes.
DR. CAPLAN: There are donor deferral registries now, and when we talk
about standardization, that is part of what would happen. You'd enter this information
into the donor deferral registry.
DR. PILIAVIN: He's talking about something when the procedure was done,
not depending on the donor itself. None of that sort of thing goes on with donor deferral
registries.
DR. CAPLAN: But if we ask for standardization, it could, easily. So if you
write this correctly and we take it on faith that we get the language here, what we're
looking for is an attempt to get those questions standardized, get that information, and
then kept in the donor deferral registry, so that anybody who did once have a pediatric
growth hormone injection would pop up on the registry as deferred.
DR. SNYDER: I'm front-end on that. I'm back to what Jane said, back to
when the original--
DR. CAPLAN: Oh, okay. Zing down here. Kristine?
DR. MOORE: I would like to offer a comment on mentioning registries.
That's a very--that's a major issue that gets into confidentiality. We've been dealing
with this immunization registries issues, and it requires legislative action. It is a very
big, big thing, and I'm not sure we really want to wade into that.
DR. CHAMBERLAND: Yes, I think along those same lines, the development of a
registry that would presumably be hospital- or provider-based that would record
identifying information about people that received dura mater- or pituitary-derived
hormone therapy, and then how that would then be cross-referenced against a donor
registry, and there is no national donor registry, you know, et cetera, I think are very
complex issues and the confidentiality issue. So I'm not sure that that is something that
can be really addressed.
DR. HOOTS: The other thing, I wasn't clear if he was talking retrospective
or prospective, but obviously prospective is going to be low yield because it's
recombinant growth hormone now and because they're doing brain autopsies before they--I
mean, you're looking for CJD before they clear the dura mater, anyway. So it would only
work retroactively and retrospectively, and then you get into all the problems of finding
data that we talked about with hep C.
DR. CAPLAN: Ron?
DR. GILCHER: I agree with Mary. I think trying to create these donor
deferral registries is a real can of worms. I think there is actually an easier way to do
this, and I wasn't going to say this, but since we've gotten into it, if we handled it at
the blood center level, for example, it would be very easy in our system to specifically,
when the donor comes through who has the history of back or cranial surgery, not allow
that plasma to go into the pool. The red cell can be used as an individual donor, but we
could simply limit that plasma from getting into the pool so that we wouldn't--the cost of
taking it out up front is a few dollars, as opposed to a couple million dollars or more if
it gets into the pool and taking the pool out.
So, again, I think we could make those kinds of recommendations and
working with FDA could do it at the blood center level and totally avoid the whole issue
of registries.
DR. CAPLAN: Okay. I know Jane is busily writing here to see--a minute.
If I could, could we get a motion to move on the first recommendation?
VOICE: So moved.
DR. CAPLAN: And discussion--I guess I need a second, technically. Second?
VOICE: Second?
DR. CAPLAN: Discussion?
[No response.]
DR. CAPLAN: Vote. All in favor?
[A show of hands.]
DR. CAPLAN: Ah, we like that one.
How about No. 3?
DR. CHAMBERLAND: I just have a comment about No. 3. Perhaps, Art, you're
planning to address this in a subsequent part of the discussion this afternoon, but I
think that I heard comments raised in the last couple of days about the identification of
gaps, particularly with respect to the development--you know, basic research, development
of screening tests, et cetera. But I also think that there are other gaps within the PHS,
the issues related to surveillance of these diseases, and I'm sure there are gaps, you
now, in terms of with the FDA.
So I'm wondering if No. 3--while I don't deny that there's a real need, I
don't know whether it should perhaps be made more comprehensive to broaden maybe the
different agencies within the PHS that have varying roles and responsibilities that relate
to the issue of TSE.
DR. CAPLAN: Further discussion? We can add one, but I think if we've got
that one sitting up there and folks seem comfortable with it--
DR. BUSCH: One word perhaps in terms of tests, it should be which can
diagnosis and discriminate among these conditions.
DR. CAPLAN: I have a feeling if we get that, some of the things about
surveillance will fall out--into place, I mean.
DR. CHAMBERLAND: As I read the recommendation as it stands now, it's to
promote research--it recommends to one agency within the PHS, NIH, promote research on the
TSEs. And so that's rather restrictive, and I guess I'm just--yes, I think that there are
other agencies within the department that clearly--
DR. CAPLAN: I mean, should we just add FDA to that one?
DR. CHAMBERLAND: Well, maybe within the PHS.
DR. NIGHTINGALE: Would the committee feel that changing National
Institutes of Health to Public Health Service would meet Dr. Chamberland's suggestion?
DR. SCHIFF: I think you're talking basic research here. You need a test.
They don't have a test, and I'd focus it, and I'd leave it at the NIH. I don't think
anybody will do it better. You need some basic scientists on this, and rather than
spreading the money all over the place, give them--you know, money doesn't necessarily
solve this problem. They tried that with cancer for years. But at least give it a crack,
focus it, and say put this money toward developing a test.
DR. CAPLAN: Ed?
DR. GOMPERTS: I'd take that one step further. I think we need to know what
the etiologic agent is. It's basic research. And I don't think there's been enough.
DR. CAPLAN: Kristine?
DR. MOORE: I totally agree with the need for basic research, particularly
the etiologic agent and testing. But you also have infrastructure support there, and I
think that there is a big public health component to this that also affects what we're
trying to do here. So I would go back to not limiting this to just NIH. I mean, I think
CDC certainly has a role here. I think FDA has a role. And so back to what Steve had said
about the Public Health Service, I just really hate to exclude these other agencies from
being part of that.
DR. CAPLAN: Let's move this on a mini-vote. Do I hear a lot of sentiment
to replace NIH with PHS on this proposed alteration, or do you want to leave it as it is?
How many want to leave it as it is?
[A show of hands.]
DR. CAPLAN: How many want to modify it to include PHS?
[A show of hands.]
DR. CAPLAN: Okay. Can I get a vote or a motion to move on the third one?
VOICE: So moved.
VOICE: Second.
DR. CAPLAN: All in favor?
[A show of hands.]
DR. CAPLAN: Okay. Opposed? Abstaining? I've got to do this more
democratically.
All right. Now, how about No. 2? Got any language that you're ready to try
out?
DR. PILIAVIN: I'm ready to try. It's a little long.
We recommend that FDA develop new screening or processing procedures
designed to better exclude individuals who might have iatrogenic risk factors for CJD as
follows: one, temporarily deferring donors who report a history of brain or spinal surgery
or injection of any hormone product until details can be obtained, or, two, develop an
algorithm at the blood center level that use only red blood cell products from such
individuals and discard the plasma until details of the treatment are known.
DR. CAPLAN: That's definitely overhead material.
DR. SCHIFF: I'm bothered by "any hormone product." You might
have women taking estrogen.
DR. PILIAVIN: Injectable hormone.
DR. SCHIFF: Insulin is a good one. You know, I think it gets too broad.
DR. CAPLAN: Okay. Well, let me ask this: On the second proposal that we
have up there, if we were to add something along the lines that Jim proposed, not quite
get ourselves to the registry and deferral thing, we may be able to move this and come
back to this one via mail and subsequent discussion.
Jim?
DR. AuBUCHON: What I would suggest is rather than Jane's proposal--nicely
worded, but I'm afraid it will get us into more trouble than it's going to help us--I
suggest that we take the proposal as on the screen, but put a period after the word
"donors." We recommend nationwide standardization of procedures for screening
donors, period. And then the FDA, with its usual means of getting expert advice on these
types of subjects, can come up with a standard set of what they feel is the best way to
screen out those donors who may be at risk for CJD, HIV, and all other concerns that we
may have.
DR. CAPLAN: Too broad? I'm seeing--
DR. SCHIFF: Yes. I think we're trying to get at TSE. I'd stick with--I
think we've got to stay focused here or it won't get done.
DR. CAPLAN: Comments?
DR. PILIAVIN: I'd rather go back to that.
DR. CAPLAN: Anybody want to move that second one, then, in that spirit?
VOICE: So moved.
VOICE: Second.
DR. CAPLAN: I should allow for a little more discussion, but let's try all
in favor, see where that gets us. We've got sentiment out there on that one.
[A show of hands.]
DR. CAPLAN: Opposed? Abstaining?
[A show of hands.]
DR. CAPLAN: All right. One abstention I see--two. Two. I'll let that one
fly up there. We'll try and wordsmith it a little bit.
DR. HOOTS: Are we voting on Jim's--
DR. CAPLAN: No, no. 2. We dropped Jim's. It's just like it is right up on
the board.
DR. HOOTS: Oh, okay. Sorry. I didn't know what we were voting on.
DR. CAPLAN: Jim's amendment was gracefully rejected. Jane's proposal was
thrown out the window. It's what's up there.
The focused proposal, your 4. Okay. Hoots changed his vote.
DR. NIGHTINGALE: I heard reference to wordsmithing with respect to the
second of the three. Could you define what, if any, wordsmithing is anticipated by the
committee?
DR. CAPLAN: You can think of this as what the NFL would have done. As we
review the tapes, we'll see to make sure that we got the language that people were calling
for. That's what I meant. Nothing that isn't on the record, of course. We wouldn't
wordsmith them that way--at least if they catch us. Okay. So, we could actually pull those
three things off the wall.
What I would like to do next is move us back, if we could, to a discussion
of the supply issues, and I'd like to open up the discussion, even though this will, I
suspect, be one we may not resolve, but we shall see. Everything we've done up until now
has been with an eye toward handling issues as they may come up as threats to the blood
supply of new TSE agents, with a little bit of attention to trying on the standardization
side of dealing with CJD. But we have this question before us now, which we can talk about
for a little while here.
Given what we know about CJD, as we talked about before lunch, is the
committee ready to offer any advice to the agencies, PHS and the agencies, and its member
agencies, about what this committee believes should be done with respect to withdrawals as
a way to cope with the threat that CJD poses or theoretically poses to the blood supply?
I'm just going to put that question out there, and I'd like to have
comment. Dana?
DR. KUHN: I guess after the testimony yesterday, it became overwhelmingly
evident to me that the reason that we are here today is because of a past history of HIV.
It was described and studied by the IOM, and that is history and that is reality. And we
are also here because of the concerted and organized efforts of community groups
rationally advocating for blood safety. And as far as CJD goes and changing the charge of
this commission, I believe that there is not enough scientific evidence at this time to be
able to change that policy--I'm not saying amend the policy--to help the shortage of
supply. But when you have persons like Dr. Rohwer saying as far as we know we do not have
a problem, and we have Dr. Schonberger saying CJD by blood transmission is small and
theoretical, and then when these are not published yet but they are in the works of being
published, I don't consider that good scientific evidence.
I believe that we need to really think about this before--and what is
more, we are talking about relaxing the CJD policy at the same time the BPAC is
recommending readmitting high-risk donors back into the plasma pool. There's something
wrong with this picture at this time.
I think, thinking about the big picture and dealing with supply also, you
know, we have blood collection sources, fractionaters, and we have the FDA. And it seems
that they all have pertinent information, and it is all treated as propriety. And I
understand that each one has propriety rights, when in actuality this information is
germane to the public health issue and policies, and often this information is only
obtained by congressional committees or consent decrees.
It would be an ideal to have this information regarding collection,
pooling sizes, process, practices, and to be honestly shared for the ultimate achievement
of making good policy for public health safety and ensuring trust issues, which we heard
about and were given information about. Until this happens, I don't think we're going to
have good enough information to make good policy.
I think also in regard to the policy that we have before us right now,
this present FDA CJD policy brings equity to the shared risk, those of the manufacturers
and those of the consumers. Consumers have had to shoulder all the risk, and I think it
has to be shared risk. I think we have to look at this as a policy which levels the amount
of acceptable risk each has to assume, one the loss of revenue--and I don't want to
continue to see the loss of revenue. I think each one deserves, each industry person
deserves to have revenue. But I don't think we need to have the loss of potential life and
health, either. There is a balance that needs to come out here.
Then I think I would rather sit here four years from now and say we could
have changed the policy than to sit here four years from now only to say we did the best
we could based upon the scientific data, which is incomplete at this time, while thousands
of people are dying.
I think that's where we need to start to focus attention here. Unless
someone can prove to me that they have good scientific data that has been published and
that we can confirm, saying that we can release this product in, and we're willing to
accept the responsibility, I think--and especially, as I know, that industry has so many
protections now, blood shield laws and product liability laws, there is no shared
responsibility here. It's all being taken on one shoulder, and that is the consumer.
DR. BUSCH: I guess I'll be the con here. I feel the policy should be
reversed, and I think it's worth quickly reviewing the history of the policy's
implementation and then addressing the scientific rationale for the policy and the
consequences of it.
In terms of history, the original review of this issue back in, I believe,
late 1994 by the BPAC resulted in a virtually unanimous vote not to recall derivatives.
The other vote was to actually withdraw cellular components when a donor did acknowledge a
risk of CJD, and the rationale was it's not a big loss to the system. That was
subsequently reversed by a special advisory committee convened specifically to address
this issue, and with broad community representation. And we've lived with the policy for
three or four years now.
During that time, I think the science is that the epidemiology does not
support a transfusion-associated risk of this phenomenon. There is the laboratory data
which does suggest it's potentially possible.
The other I think very important scientific analysis that Dr. Rohwer
alluded to and I believe is impressed now is the analysis of the relative risk of a
derivative that was made from a pool that had a recall versus one that did not. And the
truth is, at least the evidence supports that there's a very long preclinical infectious
phase. Given the incidence of CJD and the likely infectious prodromal phase, it's very
likely that all derivatives are manufactured from product that could be contaminated if
this is an infectious product and that the likelihood that the case that happened to be in
the light and come to light and been pulling those products selectively as reducing risk
is extremely small, and I think it's a false sense of security to the community that's
being put out there that the products they're getting today are safe when, in fact, we
know that many of these will likely be recalled with the subsequent disclosures, if the
disclosures really work.
That really gets to the third issue, which is the consequences of this
policy in terms of the blood collection arena. Not only is there hundreds of millions of
dollars of lost revenue, which from the gateway.html sector I know is the marginal revenue
that can go into research toward increased safety, as Dr. Davis said yesterday, but the
consequences have in essence been because the whole blood sector gets this information
back, it is my understanding that 80 percent of the recalls have been from the whole blood
collection arena, whereas the whole blood collection arena is only responsible for about
20 percent of the derivative distribution. And, in fact, the source plasma arena has in
truth managed to circumvent this policy by its exclusion of older donors, by their limited
follow-up of donors over time, and most impressively, they used to buy recovered plasma,
and now that recovered plasma is sold to Europe where it's fractionated and used, and the
notifications that might evolve related to a U.S. donor are simply ignored in Europe,
where they have addressed this decision and decided it's inappropriate to recall these
derivatives.
So I think the consequences of this have been actually a gutting of the
volunteer donor recovered plasma programs that essentially are going to be phased out
unless this policy is changed, because the whole source plasma industry--the whole
derivative manufacturing industry has gone to source plasm, commercial paid donors. And I
don't think that's in the interest of the nation's blood supply.
DR. MOORE: I think another issue to consider that we haven't really talked
about or seen data on from this group is in the processing of these products, what is the
likelihood--or how effective are the current procedures in possibly eliminating the CJD
agent? And are there data that we could see that might help with knowing whether or not
the--you know, what's done with blood products may be actually eliminating these agents,
too. That's another issue that we haven't really considered. And are there data from the
blood banking folks or people here that could speak to that issue?
DR. PENNER: I think at this stage it's impossible for us to take a rigid
stand because we just don't have enough data to be able to do so in saying to eliminate
all the product or to allow all the product to go in, because in either event there are
risks that we have to take, and we don't have the information to be able to determine.
It seems to me, then, the only option we have is some sort of a flexible
program that would allow the products to be evaluated as to their need to be withdrawn or
not to be withdrawn, depending on the needs of the groups that require the products.
Therefore--and this was what I intended to come up with on the original
proposal was some way of having some more formalized consumer evaluation or involvement in
the process for the withdrawal of the products.
Now, we had heard that there is a procedure or process, but we don't
really know anything about it, and whether the involvement of the consumer is very formal
or is it very informal, as it's carried out now. And perhaps that's the one thing that we
could do as a group, is at least to require a formalized type of consumer involvement in
the withdrawal decisions, and that might easily be--it may even be present, for all I
know, but at least it could be identified and then we could say that as far as we're
concerned as a committee, it could come to us to have to review and we could decide
whether the consumer is being well represented in the decisions that might be a little bit
more arbitrary than we think would be worthwhile.
DR. HOOTS: Well, at the risk of adding more--probably fog than anything
else, I think there are times when we're lumpers and times where we're splitters, and I
really am hearing so many arcane angles to this one issue of do we relax this for the sake
of supply. I think we need to step back for a moment and very, very carefully decide what
we're discussing.
Mike raised some very important issues related to private paid donors
versus public sector voluntary donors. That's a very important issue in its own right.
We have heard issues related to historical safety concerns, and clearly
that's our number one mandate, supply being our number two mandate. I think we have to be
very, very careful and very sure that we don't feel extorted in any way about issue number
one until we have explored all the opportunities to make sure we've maximized issue number
two; that is, that we know enough about the supply issue to guarantee that we have
interceded in every way that we can to maximize the supply, to forestall the shortages,
before we make categorical decisions that might in some way or even theoretically reduce
the safety.
My concern is that we haven't done that. I don't think--I mean, I've spent
a lot of time over the last almost two decades trying to understand how the supply works,
at least for one component, factor VIII, and I've learned a lot. But I also know that
there are arcane nuances that are into the equation at every turn that I don't have a clue
to.
I think we need to know at least some of those arcane influences before we
decide that categorical decisions about making safety decisions are going to influence it
positively enough to justify the risk.
I still think on the safety side as well, even though all the
epidemiologic data so far weighs in heavily on the side that classical CJD does not confer
a substantial risk to our population, there are enough issues related to ambiguities about
that, about the relationship, even though we think we know that BSE caused new variant.
But in terms of the TSE categories in terms of what allows things to jump species, et
cetera, things that we don't know, that I think we have to be very cautious on the safety
side first. But I think in the meantime we do have a responsibility to ascertain
everything within our power about how to maximize, first and foremost, safety being
considered a priori, how to get the supply maximized for each of the constituent groups
that we now represent collectively, and, secondly, that we make sure in the process that
we don't throw out babies with the bath water in terms of sacrificing the volunteer blood
donor group for the commercial side or vice versa. Because we are in this together all the
way, it seems to me, and I don't think we have the luxury of saying we're going to do it
to the benefit of this side and to the detriment of this side. We have to balance all the
issues, and I don't personally think I have anywhere near enough information to balance
those issues at this time. I want to know more before I vote about making dramatic changes
in the screening process.
DR. GILCHER: I'd like to support the prior three committee members, but
especially what Dr. Busch said. At lunch there is always an educational forum at each
table, and specifically what Dr. Busch discussed was the subject of our lunch educational
forum. I'd like to be sure that all of our committee members understand that 80 percent of
the world's supply of plasma is derived here in the U.S., either as raw product or as
finished product, and it goes to Europe.
Theoretically, there should be no shortage of any of these products here
in the U.S. There may be a shortage somewhere else in the world as a result of the fact
that we would have it. But we generate the plasma in this country, but we don't see the
benefits of it. And I think that we should really understand that as a committee better.
The total committee should understand the sources of plasma in the world and that 80
percent of that is derived here in the U.S., but we don't have 80 percent of the product
available, and then the excess goes somewhere else in the world. And, clearly, we have
shortages as a result of the economics of that.
The second point that I'd like to make is that--and I agree with Dr.
Busch, and maybe I have a slight modification in that I think the line in the sand needs
to be redrawn. For example, I think the issues with withdrawal of finished product because
of family history should probably be relooked at. On the other hand, where the donor has
CJD and is in the pool, perhaps their erring on the side of safety and withdrawing the
pool is a different issue. But I think we should relook at the specific issues and redraw
the lines in the sand.
DR. HAAS: It does follow right from--because I was at this educational
forum that Ron was talking about. The type of thing that's coming from Keith's comment and
others, I think another aspect of that is that if we were all talking about private sector
issues, we just let the market drive it, price and quantity be out there, if it was all
public sector, we would be making the political decision. But it's a combination of the
two. And one aspect of that combination that I don't think I've heard here in these two
days is that, given that I'm hearing that an awful lot of our volunteer plasma is shipped
out overseas, another way to deal with that is whether there's a regulatory way to lessen
that move that could provide us some of the plasma that's not here.
Again, I'm certain there's a lot of complications associated with that,
but that's another way of dealing with the type of issue that Keith was talking about as
opposed to how we look at the safety issues.
DR. PILIAVIN: I would like to reiterate something I said this morning. I
think it's misleading to talk about safety versus availability. There are a variety of
aspects of safety. Only one of those aspects of safety has to do with transmissible
diseases in the blood. Availability is a safety factor if what you mean by a safety factor
is something that affects whether people get a product that makes them healthier or saves
their lives. And my judgment at the moment, from what I've heard--and I certainly hope
that we hear more about availability and what causes shortages and so on. But what I'm
hearing right now is that our major safety problem with the blood supply and the blood
product supply at the moment is availability for certain groups of people.
In the conversation I had yesterday--I was not in on that particular forum
at lunch--I was talking to someone who says that it's a mystery to him why nobody is
concerned about the fact that more people die from A/B/O mismatches and they're dead the
next day than die from any of the other things that are currently a problem in the blood
supply. And then if we're thinking about safety, one of the things we ought to be thinking
about is how to reduce the human error that leads to these A/B/O mismatches, not be
thinking about theoretical factors that nobody has yet died of.
DR. SCHIFF: I want a point of information here. The message I got from the
presentation of the British experience was that they don't do these things in England.
Now, if anybody is more concerned about this problem then they are, I would like to know
who they are. So here you have scientists who are acutely aware of this emerging variant,
the BSE, and yet in their blood system they are not putting in these measures.
I think they are looking very carefully for any way they can curtail what
was like a small epidemic there. So I would take advantage of their experience and endorse
what Jane is saying. I don't feel that we are relaxing safety at all here. I think, if
anything, we're going to help people, and I'd pull out all these restrictions.
Now, from a psychologic standpoint--and that's what it really is; it's
emotional. If you had somebody that had CJD, you hate to take their blood. But I think
that's strictly emotion and it's a psychologic effect, not a scientific basis for doing
it.
MR. ALLEN: I'm not going to sit here and pretend to be anybody's expert on
the material that I'm hearing today or any of the past meetings. I'm curious as to the
percentage of these products that are being withdrawn because of CJD versus other reasons,
other contaminants, or whatever. I can't believe that we're--what Dr. Busch said to me,
one thing he said kind of summed it all up. He said there's a scientific possibility.
Science is all we have to go by here.
None of us here can claim to have enough information to know what is going
on with this particular agent. Until we do, whether you consider some of our opinions
emotion or not, that's the facts. We do not have enough scientific information.
It was also mentioned about a false sense of security. We've heard that
before. There was also a mention of what's done with blood products may be eliminating
this agent. "May be" are the key two words in that statement. We just do not
know.
One of the things that made me want to be on this committee was to help
re-establish the American public's trust in this government, and that's why I'm still here
instead of walking out of this door. So what we need to realize here is that this goes
beyond the group of people sitting at this table and our own personal opinions about this.
There's a matter of trust here. I would rather look at someone and discuss why they lost a
certain amount of money versus looking at someone and why they lost their brother, sister,
mother, or whoever.
We need to learn from the mistakes that were made in the past and make
sure, irregardless of the consequences financially, commercially, we don't repeat them.
There's got to be some options where we can increase the production of these products, be
it through smaller pooling sizes, which has been discussed by the FDA. One of the mentions
by some of the members of the FDA has been their approach has been to take the most
conservative route. I don't believe they need our approval in order to withdraw these
products or release these products. I don't believe they really do.
So there's more reasoning here than we realize. So I think we just need to
all step back for a minute before we start talking about releasing these products until
we, one, know more about these agents scientifically, and, two, know more about what we
can do to increase the production of these products while we're working on finding out
about this agent.
T3B DR. CAPLAN: One of the issues that has come up a couple of times now
is steps to increase the supply. There's also a question on the table, which I'd be
interested if someone wants to address it, about the impact of CJD on overall blood
product supply. I took it as--I have a number in my head that 10 percent of albumin was
going back because of withdrawals over the past year. Did I make that up or did I hear
that yesterday? If I can get corrected on this. Yes, CJD-related.
DR. PILIAVIN: Ten percent.
DR. CAPLAN: Yes, that's what I think I heard in the testimony there
somewhere yesterday. And pushing on the supply side--I guess for this committee, this may
be the one place in the world where this could happen--of course doesn't address the issue
of cost, what it costs to pull it, what it costs to get it out of there, and what that
does in terms of budget; or to put it another way, even if we expanded the supply side and
pushed for that to happen by some means, there is this question out there still that some
will want to know about, about what it costs to track and recall--I heard a number, too,
of about $100 million being spent by blood collection agencies to do the withdrawal
process, so it's not a trivial expense even if the supply side goes up.
Jim, did you have something to say on the point? No? Mike?
DR. BUSCH: I think on the supply side, you know, one should ask why is 80
percent of the plasma derivative in the world derived from U.S. source material, and the
truth is because the U.S. is essentially the only country that still has a substantial
commercial paid plasma donor program. The rest of the world, the European Union, have
moved exclusively to non-remunerated donors. In the U.S., there is a large and I think
safe plasma derivative industry now because of the knowledge we've gained, the
inactivation procedures that have been implemented. And I don't doubt for a moment that
that could be expanded dramatically. As indicated today, all derivatives that are
manufactured and being distributed in the United States are now exclusively going to be
derived from commercial paid donors. And that's the side that can be expanded. And if
that's a decision that this committee would endorse and we should push in that direction,
I think that should be explicitly recognized.
One other point I wanted to make is that this history of CJD, family
history, it was mentioned yesterday that only 10 percent of CJD is familial. So 90 percent
of the problem in terms of family member history of CJD is totally irrelevant. Ninety
percent of CJD is spontaneous and is not even being detected by this history of CJD
question.
DR. CAPLAN: Jim?
DR. AuBUCHON: I have difficulties with both sides of this question, and
I'm getting a little bit sore sitting on the fence. But could I suggest to the committee
another way to look at the current donor screening techniques and the current decisions
about what we do with plasma when we find a risk factor in a donor--and I don't have the
answer even how I would answer this question, but if today, with what we know today,
imperfect as it is, if we had no donor screening, if we had no quarantine and withdrawal
process, would we recommend that those be implemented? In other words, we are starting
from scratch. Would we put in what we have today? Or would we put in something else?
DR. CAPLAN: Ron?
DR. GILCHER: I can't answer your question, Jim, but in responding to what
Mike said about the plasma supply, I have a great concern--and I have to say this, Dr.
Busch--that is, I do not want to see the paid source of plasma in this country increased
because, very clearly, I'm sure in your system as in our system, and in others, they are
trying to acquire that plasma by going to the volunteer sector and making donations to the
church or to the fraternity. And I would see that impacting the other aspects of our blood
supply.
I really believe that in this country the volunteer sector could
significantly increase the source plasma from volunteer donors. So I think this is a very
important issue. I want to get that on the table.
DR. HOOTS: Just to kind of add to what Jim said in terms of how to think
about these issues, one of the ways, I guess harkening back to the days of pre-HIV when we
knew there was something there but we didn't know what, you kind of learned to ask
yourself, well, when we can screen for this disease, what decisions would we make? And
then how can we anticipate any--or can we anticipate anything in the meantime that gets us
there?
I think in this case as well we need to say when we are able to screen,
first of all, for a TSE, and then secondarily for a TSE that we know is implicated in
causing human disease, you know, how will that relate to what we're doing now? And will we
look back and say, all right, we had the proper strategy to go from what we didn't know to
know what we do know.
I mean, obviously, that is kind of what we've been all the way around the
table here. We don't know exactly how to do that.
I think if we frame our thoughts in those terms, it sometimes--at least it
helps me in saying, okay, how much caution do we err towards? And kind of a corollary to
that is that any decision you make at this time, is it influenced by whether that
definitive diagnosis could be done 12 months from now versus 12 years from now?
I think those are the kinds of things that make this a very complex issue,
and while we're having so many people around the table who are maybe either sitting on the
fence, switching from one side of the fence to the other, or else saying I just prefer to
deal with this particular issue but not that particular issue.
DR. CAPLAN: Let me ask for clarification on a couple of things just in
this discussion. One is, Does it make a difference, as we think about this, the kind of
disease we're talking about, the fact that it is usually a late onset disease unlike AIDS?
It could strike people down younger. I understand that. But overwhelmingly it's a problem
that most people outlive. Does that make a difference to the decision about using
withdrawal as the way to deal with the risk?
The second question I have is, What if we do get a test? What if this NIH
mandate that we give them and throwing money at it gives us a diagnostic discriminating
test and it turns out that this particular CJD virus is really out there incubating and we
couldn't ever get pool sizes down to the level that we would eliminate it? What would we
do, to get into the hypothetical mode? Would we--do what?
I mean, we would screen, but what if we couldn't sort of get it down to
small enough sizes that anybody would find it economical to make life-saving blood
products? I have a feeling that it may be out there, and that our hope to find the test
may--again, don't wish for what you don't really want, because when you get it, you may
find out that there's more of it out there and you're not quite sure how to deal with it.
The third question I have is, to go back to something that John put on the
table and that's been kicking around a little bit: If in the short run the issue is right
now, today, there's no IVIG, there isn't enough supply for people with alpha-1
antitrypsin, and we know there are harms befalling us, are we ready to say that we
have--is it possible really to use a more flexible response in terms of withdrawal policy?
Does that get us anywhere in the short run, while we talk about building the supply? I
mean, we're sitting here and the FDA and some of our friends on the government side have
said you can't ask us to write a report in six months. Well, I'll make the statement, you
won't get an increase in the plasma supply for a year, no matter what we do today. I'll
just tell you that.
So for the coming year, if people still can't get IVIG, then what? And it
seems to me when I listen to the testimony, I'm trying to weigh the demands of people in
the here and now to say we can't treat, we have problems getting things we need. I would
like to hear some discussion about a policy option. Is there some way to be more flexible
in the shorter run, while we can certainly revising expanding the paid donor pool, trying
to hound the companies into telling us what the heck they're doing, putting America First
labels on all plasma products, little flags?
I mean, I can imagine a bunch of things we could do. I will tell you, if
I'm sure of anything, we're not going to do them so that they will budge the plasma supply
for some period of time. I mean, we can call for them, but it will take a while to have
them. Whereas, we might be able to have a response that is flexible--or are we just
blowing smoke on this? Are we about as flexible as we can be now and that's not going to
really do anything?
So on those issues, I'd like to have some more comment or discussion. Ed?
DR. GOMPERTS: You've raised a number of points, and the previous comments
have also raised a number of issues, so if you can bear with me.
I think first of all, from the point of view of the subclinical incubation
issue, I don't think that is an issue here. We could probably, from our point of view,
dispense with that.
The second thing, from the point of view of the test, you know, we can
find a screening test and screen as much as we want. That won't be the answer. The answer
is, once we've identified the etiologic agent, to exclude it from the products, whether
it's whole blood or whatever. And that is the target with HIV, which has been very
successful. Testing, sure, but also inactivation. And that I think is a two-step
objective, really--or three steps: identify the agent, screen it, and get rid of it.
Now, the other thing is, from the point of view of a step-wise approach to
these different products, I think the albumin one is a fairly straightforward one, because
we've seen through Dr. Rohwer's presentations, although it's--I agree with the previous
speaker that it's not yet in the public domain from the point of view of peer review.
However, we can see that on spiking experiments, the agent, whatever it is, is being
excluded from the albumin crude fraction. And in that situation, if we are able to confirm
that observation by a separate set of experiments, I think most of us, if not all of us,
will be pretty comfortable from the point of view of albumin and not withdrawing albumin
under the current concerns with CJD donors, et cetera.
Similarly--
DR. CAPLAN: By the way, let me just jump on that one and note to the
committee, we could say, at least in this regard, that the committee urges the rapid
completion of those experiments and that we do so with the hope that policy about albumin
might be modified. That's a flexible policy.
DR. GOMPERTS: I'd take it one step further. There are several validation
experiments that are being carried out by a number of different manufacturers looking at
their processes from the point of view of spiking experiments, looking at not only the
crude fractionation procedures that were done in the spiking experiment, but taking it
further through monoclonal affinity, ion exchange chromatography, et cetera, with
different products, to determine the exclusion capability of these various steps. And once
these are done, and right now there isn't enough laboratory space and there's not enough
hamsters to do all the validation experiments, they will be done.
So that may well--
DR. CAPLAN: If we need hamsters, they're at my house.
[Laughter.]
DR. GOMPERTS: But they will be done, and I'm sure when the data is in
we'll certainly hear about it.
I'd also want to provide some information. We've heard about plasma donors
and volunteer donors and paid donors. First of all, there are volunteer donors who
volunteer because they're getting something out of it, whether they're getting a glass of
orange juice or having their cholesterol test taken or a T-shirt or because of peer
pressure, the Bloodmobile is at work.
Similarly, in other countries, individuals are labeled as volunteer
donors, but they actually are getting a day off from work, whatever. So the discrimination
of volunteer versus paid is a gray area.
However, for every one liter of plasma, there is approximately one paid
donor, anywhere between 700 and 900 milliliters of plasma. Whereas, in a volunteer donor,
you're going to have three to four donors contributing to that. So when one talks about
pool size, are you talking about pool size from the point of view of volume, or are we
talking about pool size from the point of view of donors? And that is not a trivial issue.
Another major difference between volunteer donors and paid donors is that
paid donors can donate their plasma twice a week, three times a week, and do so. Whereas,
the blood donor, the volunteer donor is a lot less frequent. And one of the issues
certainly from the point of view of plasma safety that has been introduced by industry is
that a first-time paid donor unit of plasma is not used until the donor comes back. And if
that individual doesn't come back, it's thrown out. Because the data indicates that there
is a higher prevalence of blood-borne viruses within those first-time donors, which does
impact, if we extrapolate that appropriately, to the volunteer sector. That is an issue,
especially with a CJD questionnaire. Because if an individual comes in to donate and he's
asked these questions, and many of these things happened 10, 20, 30, 40 years before, and
he goes off and he comes back nine months later, then tweaks and says this is what
happened to me, then we have to chase that unit of plasma that was done eight or nine
months before; we have a withdrawal. So the issue of donor, volunteer or paid donor, et
cetera, is complicated.
Finally, if one were to suddenly increase the numbers of paid donors so
there's lots and lots of plasma, it still has to be fractionated, and the fractionation
facilities that we have today have a finite capacity, which is constrained. And by cutting
back the actual pool size, you're going to worsen the situation, not alleviate it, because
the filter presses and the centrifuges and the processes will turn out to be major
bottlenecks, as they are.
DR. CAPLAN: Just on that, do you think the industry operates close to
capacity now?
DR. GOMPERTS: Absolutely.
MR. WALSH: Just to get Jim off the fence before he gets injured, maybe it
would be worthwhile to consider the fact that we need the presentation of what is the
present procedure process for managing blood and blood product withdrawals. Information
like that is available. Mark could provide it, and we need to have it. That sort of
information up front, and then to take a look at that and see if the procedure is formal
enough, does provide the consumer involvement and can respond effectively to some of the
needs of this community. And at that point, we might wish to address some of the exclusion
items. But at this point, I think we're kind of talking around the circle.
DR. HAAS: I think somewhat along that same line, I'm a little disturbed,
if I'm hearing this correctly, that we're hearing about withdrawals, I think $120 million,
the number that has been thrown out, and we're taking that, I believe, as a trend line,
that that somehow is continuing on infinitum into the future. I'm not so sure that's a
very good basis for a trend line. Will the withdrawals continue at the same rate given
that we have a certain particular practice that's been in place for a couple of years? Or
will those withdrawals drop off significantly?
I honestly don't know that answer, but if they drop off, some of the
supply question gets addressed. But I guess I want us to be thinking about being careful
about projecting $120 million continuing on for a long period of time.
DR. MOORE: One issue--I think there are a couple of issues that we've
talked about today that may impact positively on supply, and one of them is trying to do
an improved donor screening, which may alleviate some of the withdrawals.
Another issue that was brought up in Mark's presentation yesterday was the
issue of exempting dura mater recipient donors if the dura was not pooled and if the dura
donor brain was autopsied and found to be CJD-free.
Mark, do you have any sense of what that might do--say we approve of that
and the policy gets changed. In terms of supply, in the handout that you gave us, it looks
like there were 123 plasma units--wait, maybe--the second graph doesn't really show it,
but just to get--do you have any sense of how many lots might be spared from withdrawal if
the--
DR. WEINSTEIN: Fall into that category?
DR. MOORE: Fall into that category.
DR. WEINSTEIN: Part of the problem here, as I understand it from the TSE
committee and the representatives of the dura mater industry, they're describing how
frequently autopsies are done. I believe the number was very low, so that at least as they
have been done before this issue was raised, something on the order of maybe 5 percent was
the number that I seem to recall of autopsies that were done on these patients.
This policy or this procedure may have changed within the dura mater
production industry here, but I believe that that would be a relatively small effect.
DR. MOORE: What about the pooling, dura that has not been pooled? What
would that impact on if you relaxed restrictions?
DR. WEINSTEIN: If that was the only criteria, plus say the notification
aspect of it, that would be--for the U.S., we have had only non-pooled dura since, I
believe, '87, I believe.
DR. MOORE: And the way the policy is right now is that if it--pooled or
non-pooled, those products are withdrawn if you find that history subsequently. Is that
correct?
DR. WEINSTEIN: Well, as I mentioned in the presentation, we had a
situation in which we used this criteria, that is, use non-pooled criteria. We used the
situation of autopsy and donor notification to allow the release of some material. So that
was an action that we took. It is not a formalized policy at the moment.
DR. MOORE: Because one thing as a group we might do is try to see if that
policy could be changed to exempt dura that was not pooled, given the fact that there's
never been a case of CJD in a donor--in recipients of non-pooled dura; correct?
DR. WEINSTEIN: Well, again, I think we should reflect on the TSE committee
recommendations and how--this was criteria that was brought to our attention by the TSE
committee.
DR. SCHONBERGER: Just as a matter of information, there's something like
66--that ballpark--of dura mater-associated CJD cases, and of that group, I think there
are two or so that are not part of the pooled dura association. There may be another one
that's under investigation now that may simply be a chance association that we're actually
in the middle of an investigation. The bulk of the problem with dura mater has been one
particular brand called Lyadura, and that product was made by a company in Germany, and
they distributed the product internationally. But it was never really approved to be
distributed in the United States. So our problem with that particular brand should be
minimal. Therefore, in the United States, this problem of the dura mater-associated CJD
should be minimal.
DR. CAPLAN: Jay?
DR. EPSTEIN: Thank you, Art. If I could just add a few clarifications. No
U.S.-approved product has ever had a pool processing for dura. The TSE Advisory Committee
in July 1996 recommended that we could relax the exclusionary policy in the case of donors
who received a dura product that was not pooled in processing. However, the FDA, faced
with a situation of 19 reported donors with a history of dura mater which would have
affected at a certain point 100 percent of the inventory of one of the major suppliers,
made the decision to exempt the policy, provided that it was, A, non-pool processed, but
concurrently evidence of negative autopsy. Not either-or. Both-and. And we were able to
exempt on that basis about one-quarter of the affected lots. What Mark says is correct,
that for the industry practice as a whole, there hasn't been more than 5 or 10 percent use
of autopsy routinely. However, in the incident that we investigated, about a quarter were
able to be exonerated.
The other point that was made a little bit earlier--I think it was by Dr.
Haas--is that these reports should decrease over time, because you have donors with this
past history who are gradually being purged out of the donor pool, and as we learn later
and later, the likelihood that there is an in-date product from that donor does decrease.
So some of the problem will decrease. The part of it that will not decrease is the
sporadic CJD, because one doesn't know when it's going to happen. But certainly for
histories of prior receipt of dura mater or prior receipt of human growth hormone, at
least in theory, all persons could figure it out today and tell us if they ever donated,
and we'd be done with all the retrospective cases. There could still be some prospective
for people who don't realize it until they're actually asked as a donor. And that
phenomenon is quite real.
DR. AuBUCHON: Could I suggest that the FDA possibly consider requiring
autopsies on all dura donors? After all, the prosector has to be right there, anyway, in
order to get the dura, and requiring histologic examination of the brain would seemingly
not be a difficulty for the families.
DR. EPSTEIN: If I may, the FDA is developing additional regulations for
communicable disease controls related to transplantable human tissues, as well as
cell-derived products, and we do have under consideration to promulgate a requirement for
negative brain autopsy to qualify dura donation. And that's consistent with the more
recent recommendation of the TSE Advisory Committee from its October '97 meeting. So
that's exactly what it's in the works.
DR. CAPLAN: Nonetheless, it still might be useful if we endorsed that
idea.
DR. EPSTEIN: Sure. But it is prospective. In other words, it's not going
to change--
DR. CAPLAN: Right. I understand.
DR. EPSTEIN: --the fact that there may have been past donors.
DR. CAPLAN: I understand. But this is a parade that has a little rain.
Keith?
DR. HOOTS: Well, as Dr. Gomperts just told me, the other advantage to this
is that it creates an economic incentive for autopsies. So it gets to our other issue as
well.
DR. CAPLAN: That's true. That's true.
Let me suggest a split to some extent in how we might think about this
issue of CJD. One set of questions, it seems to me, that agencies might be benefited by is
if we said something about in the short run we would like to see such and such happen.
Another set of issues is in the long run we would like to see such and such happen.
It seems to me we have heard some discussion about the need to make sure
that the supply is where it should be. A lot of factors impinge upon that. The committee
keeps asking for more information about why we have shortage. I guess we can certainly
request that every step be taken, including whatever it takes to let people see
proprietary information or be sworn in or have their memories erased, or whatever it is,
that we have some understanding of shortage, that we certainly want to come back and
address issues of ways to increase the supply, maybe looking at the paid-unpaid and so
forth.
But in the short run, I keep thinking about the people who came and talked
to us yesterday. Do we want to try and say something about CJD and withdrawal for the
next, let's say, year? Do we want to say something about urging the FDA to take a flexible
or tolerant attitude as a sort of general orientation, that they should lean in the
direction of supply more than they have? That's one way to do it and let them figure it
out at the TSE level.
We could say withdrawal should cease for the year, and then we'll come
back. That's another opportunity.
We could say put some more consumer groups on and formalize that, and then
let them work it out case by case as it breaks.
There are three proposals I'm putting before you. One--well, one is a
split. Let's look at supply and come back and do what we can to encourage and increase the
supply. But in the short run, with CJD there in the hear and now and shortage in the here
and now for some groups that came and asked us and sat there in front of you, a response
to them is to say, no, we're satisfied with how these things go; no, we think we should be
more willing to err on the side of supply than safety, and that's the general message we
want for the next year, or limit it time-wise however you want. We want to see a process
formalized with consumers more formally involved--not informally consulted but formalized
at the TSE level to make the call. That's another way to do it.
Another is to just say in the next year stop the withdrawals, let the
supply move, and we'll come back and look at it, but it's time limited.
Any sentiment, any enthusiasm or comment on taking any of those
strategies? Keeping in mind this background problem of trust and what people have to say
generally about making sure that what will happen after that year happens. I understand
that issue, too. But we could split the thing and kind of do it that way if there's
enthusiasm for that.
MR. ALLEN: I personally would really like to know at some point soon what
percentage of these withdrawals is because of CJD, period. That's important.
DR. CAPLAN: Does anybody want to try and take a whack at that right now?
Jay?
DR. EPSTEIN: Since '95, it's about 50 percent of all the derivative
withdrawals.
DR. CAPLAN: Fifty percent.
DR. EPSTEIN: Right.
DR. CAPLAN: By the way, what would be other major reasons?
DR. EPSTEIN: Well probably the second leading reason has been concerns
over actual or potential bacterial contamination.
DR. CAPLAN: Okay.
MR. WALSH: How many of that 50 percent CJD withdrawal were the result of a
person actually identified as having been deceased, diagnosed with CJD, as opposed to
family history?
DR. EPSTEIN: Yes, Mark brought those data, and they're in the handout that
you received. I don't know the figure off the top of my head, but you have it in front of
you?
DR. CAPLAN: Do you remember, Mark?
DR. WEINSTEIN: I think it was something on the order of 30 percent. That
was the handout yesterday.
DR. CAPLAN: Thirty percent were identified as having--
DR. WEINSTEIN: Yes.
MR. WALSH: It's 30 percent of 50 percent or a total of 30 percent?
DR. WEINSTEIN: Of the total CJD for '97, I believe, something on the order
of 30 percent. We can look at that slide, if we want. We may have more handouts here.
DR. CAPLAN: Yes, Keith?
DR. HOOTS: From what you just said, if you add that to the ones that were
withdrawn for dura and the ones that were withdrawn for growth hormone, which I don't
think anyone on the committee has spoken in favor of letting those through, then we're
essentially up to 100 percent. So what are we--I mean, other than that small percentage of
family donors, we're not going to impact supply significantly regardless of what we say,
unless we go way to the part that nobody has even talked about in terms of freeing up the
supply from CJD risk.
DR. SCHIFF: One of your options was--I would like to take the bull by the
horns here and beg the issue; that is, to relax the restrictions on CJD as they are right
now, relax them for one year, reassess. Obviously it's controversial, but I'd like to beg
the issue. I would support that.
DR. KUHN: And so I'm going to do a little more compromising, and I would
say I'd be more willing to do a flexible program which would follow along the lines of Dr.
Penner, saying let's have a little more consumer involvement with the withdrawal of the
product, working closely with FDA. I think there was a time in which the hemophilia
population was asked one time, was asked by FDA about some product that was very badly
needed, and we were faced with a decision to make whether or not we would like to have
this released into the population and it was badly needed. And I think that came down to
be some of our own decisions on whether or not we should have it in the community.
You know, we then assumed responsibility in many ways, and I think if it
does go in, maybe perhaps it needs to be labeled specifically so, again, people have an
option if they get this bottle or this bag of whatever they can choose whether or not they
want to take it by the label that's on it.
DR. AuBUCHON: With all due respect to the concern that chronic users of
derivatives have for the safety of the blood supply, my primary concern is the future
safety of the blood supply because at the moment I really don't see that it's being
threatened by classical CJD as it clearly is already present in the population and
probably in our derivative supply.
My concern is for, if any theory, the theory of amplification through
future passages of the agent through more human hosts. Therefore, the idea of temporarily
relaxing the requirements on donors or manufacturers regarding CJD for a defined brief
period of time makes sense to me, because it addresses the critical problem--potentially
addresses some of the critical problem that we are facing right now in terms of supply,
but yet it gives us plenty of time to interdict the multiple passages through more people
that would ultimately result in the real disaster, if one could occur through this
disease.
DR. CAPLAN: Motions? Comments?
MR. ALLEN: Is there a potential that the manufacturers will say they won't
release these products for fear of liability? I heard that yesterday.
DR. CAPLAN: I can't imagine in these United States that would not be a
consideration. Yes, I think that probably is an issue. It may not be one that we can fix,
but that certainly could restrict what they're willing to do even if we advise and
advocate for more liberal policy.
MR. ALLEN: Then once again, our recommendations per se don't mean anything
to the FDA in terms of what they actually do or do not--
DR. CAPLAN: They're advisory.
MR. ALLEN: Is that correct?
DR. CAPLAN: They're advisory.
MR. ALLEN: So they do not need our recommendation in order to release
these products?
DR. CAPLAN: Yes. I think that's a fair statement, too.
MR. ALLEN: So then the next statement to me would be: Why haven't they
done this, knowing about this shortage, on their own?
DR. CAPLAN: I think they've tried to form a policy that is oriented
towards safety. I think that wheN BPAC advises them, safety dominates the discussions. So
that when we get formed and get asked the question about availability and safety and put
cost and supply into the mix, they may be looking toward us for a broader perspective.
That's probably the way that sorts ut.
DR. JONES: Could someone clarify again just how much time--what we're
really going to buy with a year in terms of what you would be able to determine? I mean,
it would seem to me that we're talking longitudinal issues. So what will a year tell us?
And then who is going to be keeping the data and the information during that year?
DR. AuBUCHON: I don't think Dr. Schiff's proposal or my support of it had
to do with any data gathering during that year period other than the ongoing research that
is already going on right now. Certainly we would not expect to see any additional
information from recipients of transfusion products or derivatives within the next year
that's going to help us, and none of us would, I think, propose that year moratorium with
the idea that we could maybe infect some people and then find them and then resolve the
question. That's obviously not the intent.
The year moratorium might provide us some leeway in terms of increasing
the supply and getting us over a difficult period right now and at the same time allow us
some additional--accumulation of some additional information from researchers to help us
understand more about this disease and how it might or might not be transmitted or
amplified in the future.
As I said, I'm not concerned about the safety today as much as I am the
potential for more transmission in the future. That future might be 50 years from now.
DR. CAPLAN: Why don't we do, in the interest of time, the bold,
extraordinary idea of entertaining a motion, if someone wants to make it, on the one-year
meeting, then we can discuss it around the motion?
VOICE: So moved.
VOICE: Second.
DR. CAPLAN: The motion is that there be a one-year moratorium on
withdrawals in order to increase the supply, not for research purposes, the shortage, to
address the shortage.
MR. ALLEN: This moratorium, would these products be released labeled,
first of all?
VOICE: Not at this time.
MR. ALLEN: So the consumer would have no idea of the potential of these
products.
DR. CAPLAN: That's the way the motion is now. Just out there.
MR. ALLEN: Couldn't we correct this?
DR. CAPLAN: Yes. You can amend the motion. I'm just giving you the motion
the way it was made. It was to put a moratorium on withdrawals one year to meet the
shortage, and when you do that, you aren't saying label or disclose or consent, you're
just saying to go that way. Did I get that straight? Yes.
Discussion?
MR. WALSH: I disagree. I think to throw out or disregard everything that's
gone on up until this time in trying to provide at least some option of protection, even
though we're unsure of what we're protecting, is going to get us into a good deal of
difficulty. We already have the problem, as Allen has discussed before, of having lost
faith--or lost face with the public with respect to what we're doing to protect them from
the blood program here. We're going to just arbitrarily eliminate any controls at all and
just say, well, let's go at it for a year and see what happens, which doesn't sound to me
like it's a very honest approach to it.
DR. CAPLAN: Okay. We'll go to Eugene, then Larry.
DR. SCHIFF: Well, I'd disagree with that. We're not, you know, flippantly
saying let's retreat here. I think we've really looked at this as best we can. We've
benefited from the experience in England. And I think we're doing an injustice to people
by continuing it. I don't think--I think--to save face, I think that's why we're here.
You're trying to get a spectrum of disciplines here to carefully examine the situation
right now, and in many cases you have to say, listen, we made a mistake, let's get rid of
that. You know, what is it they always say? Fifty percent of what we say today is going to
be wrong in ten years. If we only knew which 50 percent.
So I think that to retract this doesn't mean we don't care. I think it
means we do care, and we think that what we have in place now is destructive. At least,
that's what I feel.
MR. ALLEN: If we're going to do this, being the Blood Safety Committee, we
should retract this based on labeling these products so that the consumer is aware of the
risk. That's the only way we should be discussing this.
DR. SNYDER: From a liability point of view--I'm not an attorney, but
there's a thing called informed consent, and there's a thing also called informed refusal,
which is more prevalent now. So if you don't have that, they're not even going to want to
play in this ballpark, in my opinion.
DR. MOORE: I was just going to say that going with the product, I suggest
that we label all products. Because really this agent is probably in all of the products.
If they are at very low levels, it has likely inactivated by procedures in processing the
material and I really think that we are not--again, a point that's been made a couple of
times. I seriously doubt if this policy is having an impact to improve blood safety.
DR. CAPLAN: Paul?
DR. HAAS: Almost a question but a comment. I understand that there is one
company out there right now that has some withdrawn product and has said that we will make
it available to the public knowing that we have withdrawn it. I guess there are all types
of signing going on.
I would be curious as to whether anyone has used that product. If they
haven't used the product, why haven't they used it? Does that mean that there really isn't
this shortage out there?
I mean there are some interesting questions that that company's experiment
could provide us and that might help in some of these questions that are going on.
MR. ALLEN: And also, can't we consider releasing products that are
actually, that we are actually short on instead of just releasing everything?
DR. CAPLAN: There's actually two friendly amendments I guess they are. One
is to think about labeling, although that may not be our purview relative to what the law
requires about all this, but we could certainly say that we think that people should know.
And we could also say--and this was the weaker version of the release
thing--that we favor this but we want it done on the basis of what has got demonstrable
need as opposed to just for any reason, we're just going on a moratorium. So, that we
could weaken the Schiff resolution that way.
DR. EPSTEIN: I think it's important that the Committee know the current
policy of the FDA which dates all the way back to the withdrawal policy put in place in
August of 1995, which is that we have been willing to permit distribution or continuation
on the market, as the case might be, of products involved with CJD risks provided that the
lots contained associated information or a notice or a label.
And it has mainly been resistance on the part of the industry to operate
in that mode that has prevented the continued use of these products with appropriate
notice. We have also brought several times, at least three times that I can recall, the
question of a generic label on all plasma derivatives that would say that there is
theoretical risk of CJD.
And that, too, has been resisted by the industry on the basis that it's
not a proven risk and that if they were to put it on their label they would create
liability in relation to cases of spontaneous or atherogenic in CJD in product recipients
and that that's a long-term risk. I mean people may incubate or have had the exposure
history 30 years ago and the company would be liable.
So, what we're talking about are, in fact, the issues that have been the
stick point. FDA doesn't need, in fact, to be advised to permit distribution with
appropriate warning labels because that's, in fact, their policy.
And in the specific case that Dr. Weinstein explained about the Factor
VIII products that have been exposed to "implicated transferon" we did allow it.
The notification there was not lot-specific. However, there was extensive dialogue with
the hemophilia community. They were fully aware of the decision based on risk analysis.
In the case of the immune-globin intravenous, again, the use community was
fully aware--
DR. CAPLAN: Jay, I do want to ask you a question. In the short-run when we
heard yesterday there were a shortage of IVIG and other products, even if the FDA policy
has been to release with notification in certain instances, is it your view or the FDA
view that the shortage that seems to be present now would be alleviated by our saying that
we would like to see more tolerance or more attention to this need?
In other words, we all understand that releases have been done but people
were in here yesterday saying they were facing shortage and there are health harms taking
place now. Is the policy not liberal enough, is the question?
DR. EPSTEIN: There would be some mitigation of the shortage. I think that
absent other changes the shortage will not go away. But certainly the CJD related
withdrawals have an impact. It's not so much the withdrawals as the quarantine. It's the
products that are in process when the discovery is made and the large lots that are not
released.
The lots that have already been released I think you've heard, we estimate
that no more than, perhaps at most, 5 percent of the product ever gets retrieved because
these products are in short supply and they are very rapidly consumed once distributed.
So, it's' actually not as much the withdrawals, it's the fact that the
withdrawal policy results in the quarantine of products that is never distributed. And,
so, that impact would be felt ultimately in supply. But I can't tell you today to what
extent that would relieve the shortage. I wish I knew. I think it would be beneficial but
I don't know that it would solve the shortage problem.
DR. AuBUCHON: Question, Jay.
I understand you can only speculate on this, but if the FDA were to allow
the release of implicated lots without a warning label, do you feel that the manufacturers
would be more likely to then take your authorization for release and go ahead and actually
release those lots?
DR. EPSTEIN: Yes, I do. I think that the issue of labeling or user warning
has been fundamental in the debate. I do believe that there would be distribution of
implicated products because we have many times been asked whether they could distribute.
I think there is another sort of legal technicality when we say, would FDA
authorize release? Because in many cases there's no release approval action required of
the FDA, for example, if the product has already been released.
And since, as Dr. Weinstein explained, we currently view these as
withdrawals, not recalls, because we can't prove a health hazard. There's a legal question
about whether we would actually be able to interdict it.
But, nonetheless, the current situation has been that the manufacturers
seek the FDA concurrence before re-releasing withdrawn material or releasing quarantined
material and there is reluctance to take that step if FDA says we can only accept that
with a specific label.
DR. CAPLAN: Let me break Robert's Rules of Order because there is a motion
and a proposal up. But if Dr. Schiff would allow it, I was going to see if we could hold
off on moving ahead with a vote about that proposal about withdrawals being suspended and
put forward a slightly different one to see if that might get us somewhere before we have
to go out of here. That is that the committee recommends or advises that quarantine and
withdrawals for the next year as they affect supply should be relaxed in order to permit
an increase in supply and let the FDA work with industry to take such steps as necessary
to make that supply possible.
It may be a judgment, it could be company by company for all I know about
what's on that label and what's not on that label. We can certainly add something about
the importance of consumer information to it. But what I'm starting to think maybe we
could get a consensus on is that in the short-run, right now, to the extent to which
quarantined and withdrawal are impeding supply to people in the here and now who need it,
the FDA might be instructed by us to try and solve that problem by relaxing their stance
on those issues.
Is that something we could get a consensus on? Maybe I will make a motion
in my own little proposal there.
MR. ALLEN: With consumer notification?
DR. SNYDER: Unless I'm misinterpreting my FDA colleague, the issue is the
companies and liability. So, unless there was some type of congressional action which
formed something similar to the vaccine injury compensation program they may not be
willing to assume that liability? Is that what you're saying?
DR. CAPLAN: If we wait for congressional action to form that compensation
program, we will be solving the shortage into the next millennium.
So, as a short-run option, the question is, we can still say with consumer
notification and let the companies and the FDA bang it out. I'm not sure that it is a
completely useless recommendation to say we want to see quarantine and withdrawal edge
toward supply in the short-run, even with notification in some form that this is going on.
The FDA has told us that they try to notify in a lot of areas anyway so that is their
current policy.
I think what may be involved here is lot restrictions and so forth in the
short run. Any sentiment for--in other words, that we try to do whatever the policy is
that they are handling for disclosure that maintains and that we try to relax to increase
supply to meet immediate demand with respect to quarantine and withdrawals.
That's my motion. Any second?
MR. WALSH: This is in concert with the users?
DR. CAPLAN: The standardization of users involved?
MR. WALSH: Yes. I know initially you had mentioned that.
DR. CAPLAN: Let me keep it separate for now though we can come right back
to that if we can get some agreement on this.
DR. JONES: Would you repeat what you said?
DR. CAPLAN: That for one year, starting from whenever, soon, one year for
now, for the next year that FDA be advised by us to relax quarantine and withdrawal policy
in order to meet short-term gaps in supply; that they follow standard policy that they
have now about consumer notification but that they understand the committee's concern that
this supply issue be addressed.
MR. ALLEN: I still don't understand why the FDA has not done this on their
own? Why do we need to be a part of this if they don't meet our recommendations in the
first place?
DR. CAPLAN: They can but I think they want it. Maybe they're eager to have
your support in a public way. I mean in the sense they've come and asked us. It's not that
they won't but they have asked you.
MR. WALSH: I thought I heard Jay say earlier that that's their current
policy and that their current policy isn't working now because the manufacturers don't
accept it because of the liability issue.
DR. CAPLAN: They have and we may not be able to solve all the rules. All
we can say is, liberalize where you are.
MR. WALSH: So, we're just regurgitating?
DR. CAPLAN: No. I suspect the quarantine of the lots may actually be able
to flow a little easier if this goes.
DR. GOMPERTS: I think the label issue is probably--
DR. CAPLAN: They're not going to bend their notification issue. I hear
what your concerns are. I will tell you that the proposal is to try to urge them to be
more liberal on the supply consistent with what they already do in consumer notification.
If you wait for label withdrawal now or notification, modification in policy you wont get
any.
DR. GOMPERTS: I understand that. But let me go one step back to something
a little bit more basic. We have heard not only at this meeting but at other meetings that
the likely scenario is each lot of whatever product has an individual in there who is in
the clinical, who has donated plasma in the pre-clinical phase of this disease. And,
therefore, what we're looking at here is an artificial distortion of the issue. Okay?
So, therefore, if we're looking at safety, if there is an agent in there,
then none of this stuff should be released. That is the one extreme.
DR. CAPLAN: Understood.
DR. GOMPERTS: The other extreme is that there should be information in
each of these products, in each of these lots that indicates that A, there has been no
transmission, there is no epidemiology to associate cause. However, it is possible that
this might occur, every lot, and then this whole issue goes away.
Now, from the liability point of view, yes, there is an issue. However,
from a public safety point of view the availability of product right now and in the
short-medium term is very real. So, I think the key to it is the information issue.
And to get a moratorium and say, yes, these lots will be released and we
can do that anyhow with a label.
DR. CAPLAN: I know they can do it, they haven't done it, let me point out.
DR. GOMPERTS: Because--
DR. CAPLAN: But if you tell them to do it, they may do it.
DR. GOMPERTS: You are saying one product is potentially unsafe and this
product potentially isn't. And there's that distortion. It's a legal distortion, it's a
real distortion. And, so, let's deal with it the way it really is. Treat all products the
same and have the information in there.
DR. EPSTEIN: The FDA did bring to its blood products advisory committee
the proposal that all plasma derivatives be labeled with the theoretical risk of CJD. That
proposal was not endorsed and it has been consistently resisted by the industry. FDA would
accept that proposal but I think that we also have to take into account that there have
been consumer complaints about that resolution.
Consumer organizations have said, you know, we understand your arguments
that one lot is not different than another lot but, you know, boy, if you know about a CJD
or CJD-at-risk donor, we want to know about that lot. And this is what the issue has
really been all about.
DR. MOORE: Getting back to the industry point about labeling. We talked a
little bit earlier and several people have brought up the issue of something comparable to
the vaccine compensation issue which is a piece of legislation that I don't fully
understand. And Jay, maybe you could speak to that. Like if there is some kind of label
and a big part of the concern is industry concern would something like a compensation
package impact on that?
That doesn't address the consumer issue that you just raised but--
DR. EPSTEIN: Well, I'm beyond my expertise speaking to that issue and
there may be other people here who can. My sense, however, is that that kind of strategy
would be helpful but, you know, it's a congressional issue to enact such a thing.
DR. MOORE: We could make that recommendation.
MR. ALLEN: I would feel a little bit more at ease if the FDA could go
back, talk to the manufacturer, get a consensus of what's going on and then ask us to make
a recommendation. Not until they have a consensus because once we make a recommendation we
may not like what they end of agreeing to. And, you know, there's just too much open
ground there for something to happen.
DR. CAPLAN: Let's see if this phrasing might be something. We will call it
the Caplan motion, since I'm the only one who is for it.
[Laughter.]
DR. CAPLAN: And we will look at it and while we are looking at that, let
me ask, can we get agreement--I don't want to let this slide away. We heard something, I
think, that if we could conduct experiments aggressively with respect to albumin, that
this might help free up the supply there. Is that something that we're all in consensus on
in terms of recommendation that we urge that these experiments proceed expeditiously? Can
I get a motion there?
This was the follow-up on the studies that we heard about from Dr. Rauer
and it's all about spiking and titers, that if we could finish those things up quickly,
given the ways in which we are handling albumin, it might be possible to say that CJD is
not--if I'm getting this correct--such a risk with respect to albumin.
But these experiments have to appear and we have got to urge that they get
done expeditiously? Yes?
DR. PILIAVIN: Yes.
DR. CAPLAN: So moved, second? Good. Vote?
All right that one is on the table and we will drag that one back out.
Who can be against rapid research. All right.
DR. NIGHTINGALE: Dr. Caplan's proposal reads, we recommend that during the
next year the FDA work with industry to relax current CJD guidelines on quarantine and
withdrawal of blood products to the extent necessary to relieve product shortages. We
recommend FDA follow standard policies regarding notification while considering committee
concern over shortages.
DR. CAPLAN: The last sentence?
DR. PILIAVIN: I propose if we omitted that last sentence.
DR. CAPLAN: On standard policies on notification?
DR. PILIAVIN: Yes.
DR. CAPLAN: Well, basically what you'll do then is you will be trusting
that is they work with industry and we could add in here as part of this consumer groups
to formalize the standardization, consumer involvement that we will let those parties bang
it out but what we're trying to do is indicate that the shortage in the short-run is real.
We don't want CJD to stand in the way of it in the short-run. That's really what that's
trying to do.
So, maybe--
MR. WALSH: Appropriate consumer groups.
DR. CAPLAN: And appropriate consumer groups up in the work with industry,
just put and. Put parentheses around it, let's see how that goes for a while. Vulnerable
but not excised yet.
MR. WALSH: Why are we striking the last sentence?
DR. PILIAVIN: Because they're already doing it.
MR. WALSH: Then it should stay in there.
DR. PILIAVIN: But Jay has already said that this is essentially what they
are doing and this is what industry wont buy. So, we are not going to get anything if we
don't get rid of that last sentence.
MR. ALLEN: There's an issue here. How can you talk to the consumers about
products being released without notification?
DR. CAPLAN: Well, my comment is, we could get rid of the last sentence,
not because it means the end of notification. It means that whatever FDA does, it has to
do standardly across-the-board.
I'm not sure that we've told them to change their notification policy. I'm
trying to pump the issue of how they negotiate it out with industry. They may decide to
create a compensation thing.
They may say the sentiment was that your liability is less because this
committee told us that we want shortage alleviated. So, when you go to court, remind them
of that. I don't know what they'll do. But in the short-run, it seems to me--
What I'm saying is if we eliminate the sentence, you don't say that we're
giving up on notification, what we say is negotiate it with those groups, formalized, get
at the shortage issue in the short-run to the extent CJD is affecting it and we will work
out an effective notification policy to make it happen or compensation, or whatever it
takes.
I actually am kind of--I don't want to see notifications just go flying
out the window but I don't want to hamstring them into saying, well, here you don't, there
you do.
I'd rather, if they can get industry to calm down and say, the message
was, go with shortage. Bring that to court, that is what your advisory committee said,
maybe that will calm them down. I'm not optimistic but it might.
So, that's my hope that if we tell them to get at the shortage thing in
the short run that may give impetus to getting at product. There are other ways to mount
liability reduction besides saying you did notify, you didn't, to tell you the truth.
If this committee says, shortage in the short-run is important for the
sense of the nation, the public, that's what you use. You go to court and say that's what
they told us to do, that's what we tried to do, industry saying.
I will be available to testify any time.
[Laughter.]
DR. CAPLAN: But I mean we may not be giving up on anything on
notification.
MR. WALSH: I agree. I think this is about the best that we could come up
with that would move through the system and provide some immediate response.
DR. SCHIFF: Why don't we vote with and without that last statement. I'm
trying to get this thing going. In other words, take it out, vote on it, and if that
doesn't pass, vote on it with it in.
DR. CAPLAN: Is there a second for that idea?
DR. PILIAVIN: Second.
DR. CAPLAN: Oh, gosh, all right. We're voting on, just to be clear,
everything up until the brackets.
DR. PILIAVIN: With consumer groups in there?
DR. CAPLAN: With consumer groups in there.
DR. NIGHTINGALE: You got it in there.
DR. CAPLAN: All right. All in favor, please, raise your hand?
[A show of hands.]
DR. CAPLAN: All opposed.
[A show of hands.]
DR. NIGHTINGALE: I've got eight in favor, I have five opposed. That motion
passed?
DR. NIGHTINGALE: I have eight for those in favor and I have five votes
against. And Dr. Bush was not in the room, that's 14. Are there any members who did not
vote?
No.
DR. CAPLAN: Dr. Guerra had to leave early, he's not here. We voted on that
recommendation without the paragraph at the end of it. My vote is in favor of that.
What I think is important to do at this point, having done that, is to
reflect the fact that there is a lot of concern on the part of the committee that
notification and consumer understanding be attended to. We do have the consumer
representative in there.
It has to be taken very seriously but the general goal is to try and
address shortage in the short run without doing anything that inhibits what people can
expect and cement trust between those providing them their blood and those who receive it,
for the record, says the chair.
The other thing I think we need to do, having gotten this far, is probably
shut that thing off and then move back to a discussion of something else.
It's a shift of gears and I'm going to ride us right to it because I want
you to have a chance to comment on it. We have a letter that responds to our Hepatitis C
policy in front of us. It's in your folders, materials at the back.
It says, we heard your recommendations about look back, we're going to do
certain things to implement those recommendations. That's what I would consider to be old
business.
Is there anyone on the committee who wants to respond or comment upon this
response that we've received?
We did get a fax from the American Liver Foundation but that's a group
providing you with input of what they would like to see happen.
Dr. Schiff?
DR. SCHIFF: Yes. I like the letter with one exception. There is an absence
of specifics here. In other words, there is a strong endorsement, we're going to do more
than you ask. But there's no time-line here. What are you going to do more? I would like
to see more substance to it. That's what bothers me, but I like the fact that it's a
favorable response.
DR. HAAS: I'm not quite as kind as Dr. Schiff in the sense that I saw it
as milquetoast. I don't think the letter said much at all unless we get those specifics
that are out there. I think we ought to ask for time lines. We ought to ask what the
promotional campaign is going to be like.
Right now, I don't think we know anything other than they said, gee, that
was nice work.
DR. MOORE: Just to speak to that a little bit. I was at a meeting right
before coming here in Atlanta where we did, where time line actually was presented. And I
think that the folks at CDC, at least, are working really hard at trying to come up with
some very specific goals over the next six months. And I don't know if there is some way
that that could be brought to this group.
I think that the issue is that those are still in formulation. But that
was very encouraging to me in the sense that I think that they have some very concrete
plans about bringing together people to talk about alternative test sites and trying to
implement some of those issues.
So, I know a lot of thinking has gone into that and, you know, maybe we
could get somebody from the Hepatitis Branch to address that. But anyway the information I
have is it was very positive.
DR. PENNER: I think that's good but can't we just ask and get that
information as soon as possible?
Can we put a time line in? I, for one, would like to see a time line come
in and six months would be reasonable because things are moving along, the individuals
have to be notified.
DR. NIGHTINGALE: This is Steve Nightingale, I should speak on behalf of
the Office of the Secretary that it is the intent of the Secretary and everyone in the
Secretary's Office to proceed as quickly as possible with the Secretary's recommendations.
As far as while there is not a specific time line for publishing, for
example, a guidance, this is certainly under consideration and I believe that it would be
reasonable for the committee to expect further notification from the Office of the
Secretary prior to its next meeting, whenever that is.
I think it would be fair to me to suggest, to the extent that I can, on
behalf of the Secretary's Office that that would be considered a reasonable time line on
the Secretary's behalf if something further is not available to you by that time.
DR. CAPLAN: Does anybody want to suggest that they would like to have a
written report prior to the next meeting as part of their--
DR. PENNER: Yes, I'll propose that.
DR. PILIAVIN: I will second that.
DR. NIGHTINGALE: We try to consult with our members as much as we can but
I think you could anticipate the last week in April and the last week in July as target
dates for the next two meetings of the committee. If we need to have an extra meeting in
the year, that would be before the end of the Fiscal Year which is September 30th.
DR. CAPLAN: One of the things I hope we can do then is move on this vote
to say that by the time we meet next, be it April or whenever, that we would have a report
to us before the meeting so that we would be able to discuss it when we got here about the
implementation of this recommendation, that is sort of the motion, I think.
In favor?
[A show of hands.]
DR. CAPLAN: Opposed?
[A show of hands.]
DR. CAPLAN: So, we will look for that to come.
DR. HOOTS: Can you just add to that that we get the information before it
is released to the press?
DR. CAPLAN: Yes. In other words, we read it, know what's going on, then
we're ready to talk about it when we get here. What I'm a little nervous about,
personally, is that we get here and we kind of have to deal with whatever it is and we
can't come grumpy if they didn't do, get going. We will be ornier if we have read it
before it got here.
If it comes to us, I can't tell you it won't go the press at the same
time, but I mean someone may give it out or leak it, we would, of course, want to try to
keep all our communications confidential and act in a professional manner about all this,
but I think what the sense of the group is that we would like to get a report as part of
our next agenda book, have a statement, see what's happened to implement.
DR. PENNER: In the same context, can we get a report on the recall
situation as to what has transpired after our recommendations?
DR. CAPLAN: You mean this?
DR. PENNER: Yes, just what we had voted on.
DR. CAPLAN: I assume that would be a communication to us, we would
recommended that to FDA, so, I assume that is coming backwards, coming from there.
DR. PENNER: Okay.
DR. CAPLAN: Any other old business?
[No response.]
DR. CAPLAN: All right, new business?
One thing I would like to hear about is if we have an April meeting and we
have a June meeting, we go that route for schedule roughly. What, are there topics and
themes that we need to examine?
I mean clearly one of the things we have got to come back to, it seems to
me, just without any dispute is we have got to get to the general question of what are we
doing about supply?
Overall, where is the question of supply? Why shortage? What are we going
to do about this with respect to blood and blood products? Having talked some about
short-run issues and CJD, what's going on with respect to supply overall?
It is obviously an obligation we have to take seriously and go back and
see what we can do on that score. So that would be one I would put on the table.
DR. JONES: We've heard a lot today about the other committees and other
groups who are working in related areas.
DR. CAPLAN: The TSE and the B-Pack?
DR. JONES: And I would like to hear either from them or to have a brief
report summarizing their mandates, their activities, their charges, so that we, perhaps a
flow chart that we could talk about in terms of who is supposed to be doing what and how
we interface or don't interface. It would be very helpful.
DR. CAPLAN: One thing we could do is at one of those meetings upcoming we
could have a session where we just talked informally with no particular--I mean we could
ask them sort of what are you working on, what concerns you have, how could we be helpful
and so on, almost as a little bit of informal dialogue.
I've talked about this with Steve and I don't know if the committee cares.
Is there a sense that you would like to have an opportunity to talk about issues, just
open-ended, without having to have an agenda pressed forward so that you could just say,
you know, CJD is great and I'm fascinated by Hepatitis, but what really bothers me about
blood safety availability is X, whatever it is, why does it cost so much or why don't they
collect more blood? Or, I don't know what it is.
But would you like to have time set aside for open forum? I mean any
issues that people want to put on get discussed? I think the people that chartered us will
give us things to do and it's always a fascinating activity but I don't think it is unfair
that we let some issues bubble up if there are issues that people want discussed.
Hemochromatosis, and there are a bunch of things out there that we could talk about and
I'm just curious, does that seem like a reasonable thing to schedule a part of the meeting
on, to have an open discussion?
I see a lot of heads nodding around that. So, maybe we should do that as
part of one of the upcoming meetings, too, a little bit of exploration to see what issues
we might want to get to.
Jim and then Paul.
MR. AuBUCHON: I would like to suggest a subject for future consideration
to see whether the committee members would be interested in delving into this. It relates
to the supply side and specifically how we take care of our donors?
When donors are found to be reactive in an infectious disease screening
test, usually the results are attempted to be confirmed in some type of more specific
confirmatory tests.
And then that information is in some way shared back with them to assist
in their own health care in the future, in addition to helping the blood collector decide
what to do in terms of future deferral of that donor.
There are some situations, most notably testing for HTLV-I, where there is
no licensed confirmatory test and also an anti-Hepatitis B core. And this causes great
difficulties in counseling of these donors.
And in some cases an unlicensed confirmatory test is available but the
blood center may not use the results of that information to counsel the donor.
And, therefore, the blood center is often in a quandary and the donor is
left in the dark. I think that this committee might be interested in learning about these
kinds of situations and provide some impetus to rectifying problems where they may be
found.
DR. HAAS: Mine is an elaboration on the supply issue, too, and it's an
issue that Mike and Ron and Ed, I think, all talked about and that is this looking at the
commercial fractionators, the voluntary sector.
Let's look and see how those things are fitting together, what's going on?
Is there a real problem in terms of maybe hurting the voluntary sector or vice versa? What
difference does it make? We ought to look at that really pretty closely.
DR. HOOTS: One thing I would like to hear a little bit more discussion
about it was raised is recipient notification and the system, implementation of that
system.
DR. CAPLAN: Gene?
DR. SCHIFF: This is almost naive, but I heard raised that there were more
deaths from mis-matches than any of these things. Well, is that within our purview? If it
is, let's deal with it. How can we correct that problem?
DR. CAPLAN: It absolutely is.
We did talk, too, and we could put this as a possible topic for
consideration, compensation, liability. And a lot of what we were trying to grapple with
now is through the process of notification. I will tell you that notification and warnings
usually fall apart. You sign informed consent forms, you say you've been told.
When people use those as a way to protect themselves, they don't go far.
There may a need to think about insurance or schemes that give people compensation if they
can be established to have been injured through blood transfused diseases and so forth.
But that general issue is there and so compensation/liability questions
are things we might want to be talking about. The other one I think that I have to put on
the table that always interests me is why does a unit of blood cost what it does?
I've always been concerned that we spend a lot of money on it and we have
all kinds of issues that come up about price but just as we ask the question about the
donor, voluntary versus paid, how does that work?
I still remain interested in cost. And what can we do to drive down the
cost, if anything, because that will free up more resources to do other things.
So, one of my pet interests is trying to look at that but that may be too
ungainly, unwieldy for us but it is something I put on the table.
DR. KUHN: I would also like to look into probably what you would call a
blood component injury act. Explore that.
DR. CAPLAN: Yes, yes.
MR. WALSH: I would also like in the context of the supply issue to get the
answer addressed that I brought up yesterday or get an answer or some information with
respect to what actually causes the supply and why?
DR. CAPLAN: The shortage problem.
MR. WALSH: And that might encroach on whether problems the FDA sees and
the way that manufacturers are responding to the inspections and some of the observations
made.
DR. CAPLAN: Steve, I have to say I was asked a couple of times in the
breaks, what could we do, is it possible to go into executive session if there are issues
of proprietariness and so forth?
Can the committee ask questions or see information that would otherwise
not have to be made public or that people wouldn't want to make public in that area?
DR. NIGHTINGALE: Yes. This committee is governed by the very same
regulation that all other Federal advisory committees are and you can go into executive
session. I think a committee of this stature, a Secretarial committee does have an
interest in maintaining openness of its meetings to the greatest extent possible.
I might add, since I have the microphone right now, discussion about how
the future agendas, in fact, are made. While the Advisory Committee Act actually has the
agenda under the authority of the designated official for the meeting, which is me, in
fact, the way that we're going to make the agendas for the committee are to elicit
comments from you, certainly during the meeting, but I would encourage you to make
suggestions after the meeting, as well, preferably through Dr. Caplan, if you could.
What we will be doing is taking your suggestions to the blood safety
committee which you will recall is the committee of the agency, the PHS agency heads, and
those recommendations will be submitted to the Assistant Secretary for Health.
Because the charter of the committee states that this is a committee that
advises the Assistant Secretary for Health and in the long run it has its greatest impact
if it addresses issues that are of concern to the Assistant Secretary.
So, I think your time will be best spent if we go through that process but
I wanted you to understand that that process is intended to incorporate your ideas and
suggestions to the greatest extent possible.
DR. CAPLAN: Someone else asked me during the break just as a procedural
issue, if requests come to talk to reporters, to comment on things that the committee
does, and people aren't sure what to do about that, what should they do?
DR. NIGHTINGALE: As one says in other contexts, I'm glad you asked that
question. We do have a press officer available at all meetings.
The decision of the Department is that the Assistant Secretary of Health,
currently Dr. Eisenberg, is the Acting Assistant Secretary for Health, will be the person
who responds to the press on behalf of the Department.
You are free to say whatever you wish but the official response will be
delivered by the Secretary's Press Office.
DR. CAPLAN: If there's no more new business, I'm actually going to drive
us toward a conclusion here. I think that we will be sending out some calendars, trying to
pinpoint dates. I doubt we will be back here. Probably somewhere in D.C. in a hotel.
I think I'm going to push us because I hear a lot of concern about this
and I think we owe it, based upon what we were trying to do, to address short-run shortage
today to get supply up there, to find out what we can about why there is shortage, to push
that issue forward.
We can't sort of yell about shortage and how we want to make advice about
trying to meet that problem unless we really go at the general question of what we can do
to increase supply.
And I think that has just got to be something we have to move to next. It
seems to me we just have to go there.
Paul?
DR. McCURDY: I think it's worthwhile being sure that you understand there
are really two major components to the supply of blood and blood products.
One of them is the derivative supply which we've addressed primarily today
and we have had presentations today and the other one is the whole blood supply. And they
are relatively separate.
The only cross-over is in the recovery of plasma area. And we've heard a
little bit about that. But the whole blood, Pack Cell, platelet issue.
DR. CAPLAN: When I'm talking about supply now, I mean for blood products,
I don't mean for--we can get to the bigger--
DR. McCURDY: I think it is appropriate to be specific because they are
quite different.
DR. CAPLAN: Yes, yes.
But for what I'm saying is having, trying to wrestle with this issue of
shortage and the immediate demand and how the committee wants to think through that.
We do need to come back and address the question of why is there shortage
of blood product and what could be done to enhance the availability of blood product.
But I think we should, too, look at the blood supply overall issue. But I
would like to see us get back to that blood product thing as soon as we can.
Thank you.
[Whereupon, at 3:18 p.m., the above-entitled meeting was adjourned.]
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