Page
1
1 U.S. FOOD AND
DRUG ADMINISTRATION
2 + + + +
+
3 CENTER FOR
BIOLOGICS EVALUATION AND RESEARCH
4 BLOOD PRODUCTS
ADVISORY COMMITTEE
5 + + + +
+
6 92ND
MEETING
7 + + + +
+
8
WEDNESDAY, SEPTEMBER 10, 2008
9
The
meeting convened at 8:00 a.m. in the
10 Plaza Ballroom of
the Hilton Washington
DC/Rockville Executive Meeting Center, 1750
11 Rockville Pike, Rockville, Maryland, Frederick
12 P. Siegal, M.D., Chairman, presiding.
13 COMMITTEE MEMBERS PRESENT:
FREDERICK
P. SIEGAL, M.D., Chairman
14 JUDITH R. BAKER,
M.H.S.A., Consumer
Representative
15 MARK BALLOW, M.D.,
Member
ARTHUR W.
BRACEY, M.D., Temporary Voting
16
Member
17 HENRY M. CRYER,
III, M.D., Ph.D., Member
ADRIAN M.
DI BISCEGLIE, M.D., Member
18 MAUREEN A.
FINNEGAN, M.D., Member
THOMAS R.
FLEMING, Ph.D., Temporary Voting
19
Member
SIMONE A.
GLYNN, M.D., M.Sc., M.P.H., Member
20
LOUIS M.
KATZ, M.D., Non-Voting Industry
21
Representative
MATTHEW
J. KUEHNERT, M.D., Member
22 ROSHNI KULKARNI,
M.D., Member
23 This transcript has
not been edited or
corrected, but appears as received from the
24
commercial transcribing service. Accordingly,
25 the Food and Drug Administration makes no
representation as to its accuracy.
Page 2
1 COMMITTEE
MEMBERS PRESENT: (cont.)
FERNANDA
LESSA, M.D., M.P.H., Temporary Non-
2 Voting Member
(Topic I)
KATHERINE
A. McCOMAS, Ph.D., Member
3 FRANCISCO J.
RENTAS, Ph.D., Member
4 BARRY S.
SKIKNE, M.D., Temporary Voting Member
(Topic
II)
5 ANN B. ZIMRIN,
M.D., Member
6 FDA
PARTICIPANTS:
DONALD W.
JEHN, M.S., Designated Federal
7
Official
8 JAY EPSTEIN,
M.D., Director, Office of Blood
Research
and Review, CBER
9 JESSE GOODMAN,
M.D., M.P.H., Director, CBER
SALIM A.
HADDAD, M.D., Division of Hematology,
10 Office of Blood
Research and Review,
CBER
11 LESLIE HOLNESS,
M.D., Chief, Blood and Plasma
12 Branch, Division
of
Blood
Applications, CBER
13 JARO VOSTAL, M.D.,
Ph.D., Office of Blood
Research
and Review, CBER
14
GUEST
SPEAKERS:
15 MARK E. BRECHER,
M.D., University of North
Carolina
School of Medicine
16
GARY M.
BRITTENHAM, M.D., College of
17 Physicians and
Surgeons, Columbia
University
18 BARBARA BRYANT,
M.D., University of Texas,
Medical
Branch, Galveston
19 RITCHARD G. CABLE,
M.D., American Red Cross
Blood
Services
20
SARAH E.
CUSICK, Ph.D., U.S. Centers for
21 Disease Control
and Prevention
JERRY A.
HOLMBERG, Ph.D., Executive Secretary,
22 Advisory Committee
on Blood Safety and
Availability
23 KARIN MAGNUSSEN,
M.D., Copenhagen University
Hospital
24
THOMAS
MONTAG-LESSING, M.D., Ph.D., Paul-
25 Ehrlich
Institute
DAN A.
WAXMAN, M.D., Indiana Blood Center
Page 3
1 T-A-B-L-E O-F
C-O-N-T-E-N-T-S
2 Statement of
Conflicts of Interest,
Acknowledgment of Members . . . . . . . . . . .4
3
4 Opening
Remarks . . . . . . . . . . . . . . . 14
5 Committee Update. . . . . . . . . . . . . . . 14
6 Topic I. Strategies to Enhance Bacterial
Safety of Seven-Day Platelets for Transfusion
7
8 Jaro Vostal,
M.D. . . . . . . . . . . . 35
Mark
Brecher, M.D.. . . . . . . . . . . 47
9 Thomas
Montag-Lessing, M.D. . . . . . . 78
Louis
Katz, M.D.. . . . . . . . . . . .103
10 Salim Haddad,
M.D.. . . . . . . . . . .130
11 Open Public Hearing
. . . . . . . . . . . . .151
12
Open
Committee Discussion and Questions . . .152
13
Topic II:
Iron Status in Blood Donors
14
Leslie
Holness, M.D.. . . . . . . . . .287
15 Gary Brittenham,
M.D. . . . . . . . . .296
Sarah
Cusick, Ph.D. . . . . . . . . . .331
16
Karin
Magnussen, M.D. . . . . . . . . .347
17 Barbara Bryant,
M.D.. . . . . . . . . .362
Dan
Waxman, M.D.. . . . . . . . . . . .400
18 Ritchard Cable,
M.D.. . . . . . . . . .416
19 Open Public Hearing
. . . . . . . . . . . . .458
20
Questions
for the Committee
21 and Discussion. .
. . . . . . . . . . .467
22 Adjourn
Page 4
1
P-R-O-C-E-E-D-I-N-G-S
2 8:07
a.m.
3 CHAIRMAN
SIEGAL: We're already a
4 little late,
so let's try and get started. If
5 everybody
could settle down.
6 MR. JEHN:
Okay. Mr. Chairperson,
7 members of the
Committee, invited guests,
8 temporary
members and participants, I'd like
9 to welcome you
to this 92nd meeting of the
10 Blood Products
Advisory Committee.
11 I'm Donald Jehn,
the Designated
12 Federal Official
for this meeting.
13 This meeting will
be completely
14 open to the
public.
15 At this time I'd
like to introduce
16 the individual
seated at the head table for
17 today. Would the
members and temporary
18 members please
raise their hand as their name
19 is
called.
20 To the left of me
is our BPAC
21 Chairperson Dr.
Frederick Siegal, Medical
22 Director of
Comprehensive HIV Center, St.
Page 5
1 Vincent's
Catholic Medical Centers, New York.
2 To the right
of me and going
3 around the
table counterclockwise, Dr.
4 Fernanda
Lessa, she's going to be a nonvoting
5 temporary
member for Topic I only. She's from
6 the CDC in the
Epidemic Intelligence Service
7 Officer,
Division of Health Care Control and
8 Prevention.
9 Next, Ms.
Judith Baker, our
10 Consumer Rep. She's
Regional Administrative
11 Director of Federal
Hemophilia Treatment
12 Centers, Regions
9.
13 Dr. Mark Ballow,
Chief, Division
14 of Allergy &
Immunology, Department of
15 Pediatrics, SUNY,
Buffalo.
16 Dr. Henry Cryer,
Chief of Trauma
17 and Critical Care,
Division of General
18 Surgery,
UCLA.
19 Dr. Adrian Di
Bisceglie, Professor
20 of Internal
Medicine, Chief of Hematology,
21 Saint Louis
University.
22 Dr. Arthur Bracey,
Associate Chief
Page 6
1 Department of
Pathology, at St. Luke's
2 Episcopal
Hospital, Houston.
3 Dr. Edwards
will join us in the
4 afternoon.
5 Dr. Maureen
Finnegan, Associate
6 Professor
Department of Orthopedic Surgery,
7 University of
Texas, Southwestern Medical
8 Center.
9 Dr. Thomas
Fleming, Professor of
10 Department of
Biostatistics, University of
11 Washington.
12 Going around to
the other side,
13 Dr. Harvey Klein,
Chief, Division of
14 Transfusion
Medicine, NIH.
15 Dr. Matthew
Kuehnert, Director,
16 Office of Blood,
Organ, and other Tissue
17 Safety, Division of
Health Care Quality
18 Promotion,
CDC.
19 Dr. Roshni
Kulkarni, Professor,
20 Department of
Pediatrics and Human
21 Development,
Michigan State University.
22 Dr. Katherine
McComas, Assistant
Page 7
1 Professor,
Department of Communications,
2 Cornell.
3 Dr. Francisco
Rentas, Chief, Blood
4 Services and
RMC Blood Manager.
5 Dr. Ann
Zimrin, Associate
6 Professor
Division of Hematology Oncology,
7 University of
Maryland School of Medicine.
8 Dr. Lewis
Katz, our industry rep.
9 He's the
Executive Vice President of Medical
10 Affairs,
Mississippi Valley Regional Blood
11 Center.
12 The Committee
members not in
13 attendance are Drs.
Manno, Toxel and Trunkey
14 for this
meeting.
15 I'd like to thank
you all for
16 attending this
meeting.
17 I now have the COI
statement to
18 read. Please bear
with me.
19 The Food and Drug
Administration,
20 FDA, is convening
the September 10th to 11th,
21 2008 meeting of the
Blood Products Advisory
22 Committee under the
authority of the Federal
Page 8
1 Advisory
Committee Act, FACA, of 1972. With
2 the exception
of the industry representative
3 all
participants of the Committee are special
4 Government employees or regular Federal
5 employees from other agencies and are subject
6 to the Federal Conflict of Interest laws and
7 regulations.
8 The following
information on the
9 status of this
Advisory Committee's compliance
10 with federal ethics
and conflict of interest
11 of laws including
but not limited to 18 U.S.
12 Code 208 and 712 of
the Federal Food, Drug and
13 Cosmetic Act are
being provided to
14 participants of
this meeting and to the
15 public.
16 FDA has determined
that all
17 members of this
Advisory Committee are in
18 compliance with the
Federal ethics and
19 conflict of
interest laws under 18 U.S. Code
20 208. Congress has
authorized FDA to grant
21 waivers to special
Government employees and
22 regular Government
employees who have
Page 9
1 financial
conflicts when it is determined that
2 the agency's
need for a particular
3 individual's
service outweighs his or her
4 potential
financial conflicts of interest.
5 Under 712 of
the Food and Drug and
6 Cosmetic Act
Congress has authorized FDA to
7 grant waivers
to special Government employees
8 and regular
Government employees with
9 potential
financial conflicts when necessary
10 to afford the
Committee their essential
11 expertise.
12 Related to the
discussions of this
13 meeting members and
consultants of this
14 Committee have been
screened for potential
15 financial conflicts
of interest of their own
16 as well as those
imputed to them, including
17 those of their
spouses or minor children. And
18 for the purposes of
18 U.S. Code 208 their
19 employers. These
interests may include
20 investments,
consulting, expert witness
21 testimony, contract
and grants, CRADAs,
22 teaching, speaking,
writing, patents and
Page 10
1 royalties and
primary employment.
2 The Committee
will discuss
3 strategies to
enhance bacterial safety of
4 seven-day
platelets for transfusion. This is
5 a particular
matter involving specific parties
6 Topic
I.
7 For Topic II
the Committee will
8 discuss iron
status in blood donors. This is
9 a particular
matter of general applicability.
10 For Topic III the
Committee will
11 discuss options for
blood donor screening and
12 reentry for
malaria. This is a particular
13 matter involving
specific parties.
14 In addition, the
Committee will
15 hear updates and
informational presentations
16 on several topics.
These updates and
17 presentations are
not for discussion by the
18 Committee, and
therefore the Committee members
19 were not screened
for financial interests
20 relating to these
presentations and
21 informational
updates.
22 Based on the
agenda and all
Page 11
1 financial
interests reported by members and
2 consultants no
conflict of interest waivers
3 were issued
under 18 U.S. Code 208(b)(3) or
4 712 of the
Food, Drug and Cosmetic Act.
5 With regard
to FDA's guest
6 speakers the
agency has determined that the
7 information
being provided is essential. The
8 following
information is being made public to
9 allow the
audience to objectively evaluate any
10 presentation and/or
comments.
11 For Topic I, Dr.
Mark Brecher is a
12 science advisor and
speaker for several firms
13 and receive
research support from several
14 firms that could be
effected by the Committee
15 discussions.
16 For Topic II, Dr.
Barbara Bryant
17 is a principal
investigator on an NIH protocol
18 that could be
affected by the Committee
19 discussions. She
recently was employed by the
20 Department of
Transfusion Medicine, NIH,
21 though she's now
actually at the University of
22 Texas,
Galveston.
Page 12
1 Dr. Richard
Cable is the PI on a
2 grant that
could be affected by the Committee
3 discussions.
4 Dr. Karen
Magnussen is an advisor
5 for the Danish
Blood Donor Organization.
6 Dr. Louis
Katz is serving as the
7 industry
representative acting on behalf of
8 all related
industry and is employed by the
9 Mississippi
Valley Regional Blood Centers. In
10 addition, Dr. Katz
is employed part-time with
11 the Scott County
Health Department, Iowa and
12 the Genesis Health
System in Davenport.
13 Dr. Katz is a
member and chair of
14 various committees
with the America's Blood
15 Center and the
American Association of Blood
16 Banks.
17 Industry
representatives are not
18 special Government
employees and do not vote.
19 In addition, there
may be
20 regulated industry
or other outside
21 organization
speakers making presentations.
22 These speakers may
have financial interests
Page 13
1 associated
with their employer and with other
2 regulated
firms. The FDA asks in the interest
3 of fairness
that they address any current or
4 previous
financial involvement with any firm
5 whose product
they may wish to comment upon.
6 These
individuals were not
7 screened by
the FDA for conflicts of interest.
8 This conflict
of interest
9 statement will
be available for review at the
10 registration
table.
11 We would like to
remind members,
12 consultants and
participants that if the
13 discussions involve
any other products or
14 firms not already
on the agenda for which an
15 FDA participant has
a personal or an imputed
16 financial interest,
the participants need to
17 exclude themselves
from such involvement and
18 their exclusion
will be noted for the record.
19 FDA encourages all
other
20 participants to
advise the Committee of any
21 financial
relationships that you may have with
22 the sponsor, its
product and, if known, its
Page 14
1 direct
competitors.
2 Thank
you.
3 Now it over
to the Chair, Dr.
4 Siegal.
5 CHAIRMAN
SIEGAL: I'd like to
6 welcome
everyone back from a somewhat
7 tempestuous
and somewhat actually continuingly
8 tempestuous
summer. Hopefully this summer
9 won't be as
agitated as the summer was.
10 As you've heard
from Don, we'll be
11 talking first about
strategies to enhance the
12 bacterial safety of
seven-day platelets and
13 this afternoon
we'll be considering iron
14 status and blood
donors. And I think perhaps
15 we should start
right away with a Committee
16 update. This will
be a summary by Jerry
17 Holmberg of the May
29th to 30th Meeting of
18 the DHHS Advisory
Committee on Blood Safety
19 and
Availability.
20 Dr.
Holmberg?
21 DR. HOLMBERG:
Thank you, Mr.
22 Chair.
Page 15
1 Since our
last time meeting at the
2 Blood Products
Advisory Committee we did have
3 a meeting of
the Advisory Committee for Blood
4 Safety and
Availability on May 29th and 30th.
5 And, sir, with
you permission, I am going to
6 spend a little
bit more time talking about
7 some of the
topics that were discussed and
8 specifically
dwell on the recommendations.
9 Because I do
believe that there's
10 a lot of synergy
that has taken place between
11 the Advisory
Committee which is the
12 Secretary's
Committee for Blood Safety and
13 Availability and
also the FDA's Blood Products
14 Advisory Committee
and some of the topics that
15 you will be
discussing today.
16 First of all, I do
want to go
17 through and just
explain a little bit about
18 the recommendation
that came out of the
19 January meeting of
the Advisory Committee on
20 Blood Safety and
Availability.
21 And I apologize
for the print
22 being pretty small
there for those people in
Page 16
1 the audience
but, hopefully, the Committee has
2 handouts and
also can read this along. I will
3 read this for
you.
4 But at the
January meeting of the
5 Advisory
Committee there was a recommendation
6 on pathogen
reduction and the Department
7 looked at
various aspects of this and the
8 Secretary, or
the Assistant Secretary for
9 Health, Dr.
Garcia, responded to Dr. Bracey
10 with a letter just
recently, and I will read
11 that to
you.
12 "The decisions and
the
13 recommendations
made by the Committee at the
14 January 2008
meeting are substantial to
15 supplying an
additional layer of security to
16 the safety of blood
products. This area of
17 new technology is
exciting and has generated
18 much discussion
within the Department.
19 The Department
fully supports a
20 cooperative effort
within its public health
21 agencies together
with stakeholders to advance
22 development and
validation of pathogen
Page 17
1 reduction
technologies for all transfusable
2 product
components. We are committed to
3 providing
regulatory, scientific, and
4 surveillance
advice to facilitate the
5 development of
such products.
6 This summer
the National Heart,
7 Lung, Blood
Institute will review the current
8 status of
pathogen reduction, identify primary
9 critical
non-infectious related research
10 needs, and identify
action that could advance
11 this important
area.
12 Funding to support
any new
13 initiative is
always a challenge. However,
14 with the support of
the Department, its
15 operating divisions
and other stakeholders,
16 this additional
layer of security could become
17 a
reality.
18 In the long-run
cost
19 neutralization and
even cost reduction
20 avoidance could be
possible with the
21 elimination of
procedures, e.g., irradiation
22 and leukoreduction
and/or reduction of
Page 18
1 emerging
transfusion transmitted infectious
2 diseases."
3 We were all
very pleased with this
4 response from
the Assistant Secretary for
5 Health and we
are moving forward to see how
6 the government
can move forward in this area.
7 The next
topic that was really
8 discussed was
some of these areas that were
9 discussed at
your last Blood Products Advisory
10 Committee; but for
completeness, I'm going to
11 reiterate some of
the information that was
12 presented. I'm
going to be looking at the
13 blood safety team
that was presented by Dr.
14 Holness. Dr.
Solomon presented the Tissue
15 Safety Committee
and then the area that was
16 not discussed here
at the Blood Products
17 Advisory Committee
was Dr. Rios' discussion on
18 organ transplant
related serious adverse
19 events.
20 First of all, just
to reiterate
21 some of the things
that Dr. Holness mentioned
22 in his
presentation. This was based on 2007
Page 19
1 data. You can
see that even in 2007 TRALI
2 still remains
to be a number one reported
3 fatality.
4 I would also
like to draw your
5 attention to
the six microbial deaths and
6 three of them
are Babesia related. I would
7 also draw your
attention that on Friday there
8 will be a
workshop on Babesia that the FDA is
9 sponsoring.
10 If we look at this
information
11 based over 2005,
2006, and 2007 you can see
12 the percentages and
also the number of
13 reported cases for
TRALI and also for
14 microbial
infections. This is a composite
15 number so just to
draw your attention to that.
16 Also, Dr. Holness
brought the
17 attention of the
Advisory Committee the
18 information that
there is a pending rule out
19 there that was
posted on March 14, 2003,
20 Safety Reporting
Requirements for Human Drug
21 & Biological
Products.
22 I think all of
this information
Page 20
1 and some of
the information that I'm
2 presenting on
the safety teams and also the
3 organs and
tissue all relate to what we are
4 trying to do
in conjunction with the AABB and
5 UNOS on
biovigilance. Just to draw your
6 attention to
the comments from this, even
7 though it was
published in 2003, are still
8 under review
for safety reporting.
9 Also moving
on to the tissue
10 aspect of the
presentation, some of the things
11 that tissues get
reports in from tissue
12 establishments and
Dr. Solomon brought a lot
13 of this to our
attention. Again, some of
14 these same
reporting mechanisms are mechanisms
15 that we eventually
will integrate into the
16 biosurveillance
process.
17 Again, the tissue,
just highlight
18 some of the areas
between 2006 and 2007 with
19 the adverse
reactions. You can see with the
20 bone and the eye
and muscular tissue and also
21 skin being really
high in the reported adverse
22 reactions.
Page 21
1 If we look at
the data and compare
2 it to
infectious versus noninfectious, you can
3 see that even in 2006 and 2007 56 percent of
4 the cases and 74 percent were related to
5 infectious agents.
6 Now switching
to organs. What
7 I've done is
I've taken Dr. Ortiz-Rios'
8 presentation
and I've summarized it into just
9 several
slides. Primarily looking at
10 infections if we
take the organs and the cause
11 of death being
infections in 2001 through
12 2006, about 21.5
percent of the causes of
13 death in kidneys
were due to infections. You
14 can see 19 and 18
and hearts.
15 If we look at the
period of time
16 in 2001 to 2004 in
a period of greater than
17 one year or less
than three years you can see,
18 of course, that the
infectious cause of death
19 has dropped off in
these various organ
20 transplants.
21 This is a slide
that combines both
22 the unknown cause
of death and the missing
Page 22
1 data in the
organ transplants. You can see
2 that in kidney
and liver and heart that the
3 percentage is
16.8 to 16 percent but over the
4 period of
greater than one year to three years
5 the amount of
missing data or unknown cause of
6 death
increases the number of cases that are
7 reported. You
see a total of 14 percent going
8 to 28
percent.
9 There was a
similar slide showing
10 that definitely
with the expanded number of
11 years there was
also an increased number of
12 cause of death for
malignancy. Now, the organ
13 procurement network
database has some problems
14 with it. This is
operated by UNOS. There is
15 no data collected
for serious viral, bacteria,
16 fungal, or
parasitic infections.
17 Donor related
malignancy data, I
18 should say, are
collected but not nearly
19 inclusive. Also
that the OPTN has a Disease
20 Transmission
Advisory Group but it's voluntary
21 reporting, no
enforcement and limited follow-
22 up.
Page 23
1 Some of the
things that HRSA, one
2 of the
operating divisions within HHS, is
3 dealing with
is to define the reporting
4 expectations
of the Organ Procurement
5 Organizations
and CDC and also the state
6 health
authorities. To strengthen their
7 Advisory
Committee interaction for
8 determination
of donor transmission.
9 To strengthen
Donor Transmission
10 Advisory
Committee's communication on
11 potential tissues
and organ destinations.
12 Also to clarify and
expedite CDC involvement
13 in the
investigation as an event unfolds.
14 HRSA has asked
OPTN when NAT
15 testing for HIV
could become nationally
16 instituted. Also
they are continuing to work
17 with CDC to study
events for guidance on how
18 to screen more
effectively without loss of
19 organs due to false
positives, and to
20 investigate the
possibility of an explicit
21 approach to -- to
investigate the possibility
22 of an explicit
approach to relating the risk
Page 24
1 without versus
the risk of transmission with
2 the transplant
for an individual case.
3 I bring that
up because there is a
4 recommendation
that comes out of some of those
5 observations
and I will present that later on.
6 One of the
things we did have,
7 moving on to
the main focus of the meeting,
8 Dr. Wright,
who is the Principal Deputy
9 Assistant
Secretary for Health, did charge the
10 Committee on, first
of all, bacterial
11 contamination of
platelet concentrates, both
12 apheresis and whole
blood derived, and also
13 the red cell age as
a variable in transfusion
14 outcome.
15 As far as the
platelets, he asked
16 the Committee to
think about is the risk
17 associated with
bacterial contamination of
18 platelet
concentrates and subsequent detection
19 for both apheresis
and whole blood derived
20 platelets
acceptable? If the risk associated
21 with the available
detection systems is
22 unacceptable, what
does the Committee
Page 25
1 recommend for
next steps?
2 As far as red
cell age, do current
3 data support a
change in medical practice from
4 transfusion of
red cells stored for as long as
5 42 days to a
shorter period? If so, what
6 would be the
impact? Is there a need for
7 additional
research? What impact would change
8 have on blood
availability? Should the blood
9 banking
industry strive to produce improved
10 red blood cell
products?
11 As we moved into
the discussions
12 on the platelets,
our first discussion was Dr.
13 Murphy's discussion
in which he did a study on
14 bacterial
contamination of platelet
15 concentrates where
he cultured at four days.
16 The conclusion of
that was that there is low
17 sensitivity of
cultures due to the low number
18 of bacteria and
delay or slow growth of the
19 bacteria.
20 Basically the
comment was that
21 sampling will never
reach an acceptable level
22 of detection no
matter how large the sample or
Page 26
1 sensitivity of
the test. This will lead to
2 increased
morbidity, more recalls, and loss of
3 product.
4 I can't
remember whether it was
5 Dr. Murphy or
someone on the Committee and we
6 do have
various Committee members at the table
7 that probably
can clarify this if I say it
8 wrong but I
think the statement that really
9 caught my
attention was that we will never be
10 able to culture to
sensitivity -- to
11 sterility, I should
say. Culture to
12 sterility.
13 Dr. Dumont
presented the passport
14 and the risk
assessment. Dr. Benjamin
15 presented the ARC
experience, especially with
16 the diversion
pouch. Also, Dr. Jacobs
17 presented
information on the detection and
18 some of the
challenges of bacterial
19 contamination of
platelets.
20 I do want to
highlight some of the
21 comments that Dr.
Jacobs presented, primarily
22 because I think it
will help you in some of
Page 27
1 your
discussions today. First of all, his
2 comment was
that whole blood derived platelets
3 should be
cultured early to bring their level
4 of testing up
to that of apheresis platelets.
5 The optimum
volume and condition
6 to provide the
most cost effective method for
7 detection of
bacterial contamination by early
8 culture needs
to be further studied. Also,
9 the value of
the anaerobic culture needs to be
10 clarified. The real
incidence of bacterial
11 contamination needs
to be studied by
12 quantitative
cultures at time of issue to
13 assess the value of
preventative and detection
14 methods.
15 Also, the
quantitative cultures of
16 platelet units need
to be performed on units
17 with positive early
culture broth cultures.
18 And the clinical
efficacy and cost
19 effectiveness of
point of issue assays by
20 hospital
transfusion services either as a
21 stand-alone test or
in addition to early
22 culturing needs to
be determined. The safety,
Page 28
1 efficacy, and
cost effectiveness of pathogen
2 inactivation
in the eradication of bacterial
3 contamination
needs to be determined.
4 We then moved
on to the discussion
5 on the age of
the red cell which I think that
6 may have been
what the Chair was referring to
7 as some of the
storms experienced over the
8 summer. There
has been quite a bit of
9 literature
recently on the age of the red cell
10 and who gets fresh
red cells and who does not.
11 We started looking
at the
12 discussion of the
red cell storage lesion.
13 Dr. Bunn presented
quite a comprehensive
14 review of that.
Also the new insights into
15 the healthy red
cells with the nitric oxide.
16 Also Dr. Koch from
Cleveland
17 Clinic presented
her data on the 6,000 reviews
18 that she did in
cardiac surgery on the age of
19 red cell. Then also
Dr. McMahon from Duke
20 presented some of
the changes again with the
21 nitric oxide effect
in aged red cells.
22 Dr. Glynn
presented some of the
Page 29
1 things that
the NHLBI was working on. In
2 fact, the
Transfusion Medicine and Hemostasis
3 Network has
put together a protocol called
4 RECESS.
5 By the way, I
just wanted to let
6 you know that
the Transfusion Medicine and
7 Hemostasis
Network has been in existence for
8 about six
years and is really a very powerful
9 arm to get
some of these studies done. Dr.
10 Steiner presented
what they are proposing for
11 that and also that
the NHLBI has put forward
12 a funding
opportunity announcement for basic
13 research on
transfusable red cells.
14 So let me just try
to finish up
15 with less than a
minute to go. I think I'll
16 probably go over my
time. Anyway, the
17 recommendation on
bacterial contamination is
18 that the Committee
appreciates that
19 intervention
including culture and diversion
20 have reduced the
risk of bacterial
21 transmission.
22 However, more
effective methods
Page 30
1 are needed to
further limit or eliminate the
2 risk of
bacterial contamination of platelets.
3 Additionally,
the current status of disparate
4 levels of
safety for platelet products is
5 highly
problematic.
6 The Committee
recommends that
7 additional
measures, e.g., prevention,
8 detection,
pathogen inactivation, be adopted
9 to reduce the
difference in safety profile
10 between whole blood
and apheresis platelets
11 and reduce the
overall risk of bacterial
12 contamination of
platelets.
13 The Department
should monitor the
14 current status of
platelet availability and
15 potential for
meeting future needs. Support
16 should be
established for initiatives to
17 extend platelet
storage life as a strategy to
18 improve platelet
availability.
19 I'm sure you'll
have a lively
20 discussion on the
platelets today and I am
21 very appreciative
that several of our
22 Committee members
are also on your Committee
Page 31
1 with Dr.
Bracey being the chair of our
2 Advisory
Committee for Blood Safety and
3 Availability
being a temporary voting member
4 for this
meeting.
5 Going on for
the red cell age in
6 transfusion,
the Committee recommended that
7 based on the
available scientific data of red
8 cell storage
the Committee is concerned about
9 the potential
toxicity associated with
10 progressive storage
of red blood cells,
11 particularly in
certain clinical settings,
12 e.g., cardiac
surgery, ICU, and trauma.
13 However, absent
the availability
14 of definitive
safety data from adequately
15 controlled clinical
trials, and in the absence
16 of any analysis of
the impact of shortened red
17 cell dating on
blood availability, the
18 Committee believes
that a change in practice
19 is
premature.
20 The Committee
recommends efforts
21 to optimize blood
transfusion practices in
22 these areas through
research and promulgation
Page 32
1 of clinical
practice guidelines based on
2 scientific
evidence of safety and efficacy.
3 As needed, the
Committee recommends the
4 Department be
supportive of operations
5 research on
management of blood inventory.
6 The Committee
finds that the
7 available
scientific data from observational
8 and limited
prospective clinical studies are
9 insufficient
to resolve concerns regarding
10 safety of
progressive stored red cells.
11 Therefore,
adequately controlled
12 clinical research
is needed to correlate basic
13 science findings on
the adverse effects of
14 progressive red
cell storage with clinical
15 outcomes. In
parallel, studies are needed to
16 establish the
efficacy of transfusion
17 therapies in
various clinical settings.
18 The Committee
recommends new and sustained
19 investment in basic
and clinical research in
20 this
area.
21 Then the meat of
the
22 recommendation was
that whereas the HHS
Page 33
1 Advisory
Committee on Blood Safety and
2 Availability
is charged with advising the
3 Assistant
Secretary on public health issues
4 related to the
safety of tissue and organ
5 transplantation and after review of the
6 current status of safety and utilization
7 reporting for organs and tissue the Committee
8 recommends enhanced acquisition of data on
9 tissue distribution and utilization to allow
10 current surveillance activity to better
11 determine the frequency of adverse events.
12
Capture of appropriate data
13 regarding
etiological agents of infection
14 reported following
organ transplant to allow
15 for better
assessment of infectious risk
16 related to
transplantation.
17 And to support the
acceleration of
18 the development of
a rapid infectious disease
19 assays for use in
the organ transplant setting
20 as a strategy to
improve both safety and
21 availability of
organs.
22 And to also
enhance utilization of
Page 34
1 the Center for
Medicare and Medicaid Services
2 and other
available databases to improve
3 monitoring of
organ transplant practices and
4 related
outcomes through cooperative
5 arrangements
with other agencies. So the last
6 recommendation
was actually dealing with the
7 first
discussion points on the safety teams
8 and also the
adverse events related to tissue
9 and
organs.
10 Just to follow up
here, the
11 nomination for
ACBSA closed on June 30th and
12 are currently being
vetted. The ACBSA Charter
13 is in the process
of being renewed. We are
14 under the Sunset
Law and do have to be renewed
15 every two
years.
16 We are continuing
to work on the
17 biovigilance
coordination throughout the
18 Department. We will
be reporting soon,
19 hopefully within
the next month, the National
20 Blood Collection
and Utilization Survey. Our
21 meeting is upcoming
in December on the 16th
22 and 17th of
December right here in this hotel
Page 35
1 and this is
our website. Thank you.
2 DR. SIEGAL:
Thank you, Dr.
3 Holmberg.
Let's move directly into the Topic
4 I on seven-day
platelets. We are going to
5 hear first an
introduction from Jaro Vostal
6 from
FDA.
7 Dr.
Vostal.DR. VOSTAL: Good
8 morning. It's
my pleasure today to be able to
9 introduce this
topic that we are going to
10 discuss today and
the topic on the agenda is
11 Strategies to
Enhance Bacterial Safety of
12 Seven-Day Platelets
for Transfusion.
13 As a way of
introduction, as
14 pretty much
everyone is currently aware,
15 bacterial
contamination of platelet products
16 remains a serious
problem. It occurs
17 frequently to the
best of our knowledge.
18 Approximately one
per 2,000 to one per 5,000
19 collected units are
contaminated.
20 Bacteria can grow
in platelet
21 products to very
high levels during storage at
22 room temperatures.
This brings on the serious
Page 36
1 consequences
that can lead to morbidity,
2 mortality of
patients who are transfused with
3 these
contaminated products. This is
4 underscored by
the reports to the FDA that 60
5 deaths were
caused by bacterially contaminated
6 platelets
between the years 1995 and 2004.
7 So part of
the problem that we
8 have with
bacterial contamination of platelets
9 is that
platelet storage supports bacterial
10 growth. Platelets
are collected -- collected
11 platelets are
stored at room temperature in
12 gas permeable bags
and so far we have not been
13 able to move away
from room temperatures.
14 Storage of 4
degrees is associated with rapid
15 clearance of
platelets from circulation.
16 Storage is also in
plasma, a
17 medium that can
support bacterial
18 proliferation.
Based on these issues the
19 current shelf life
of platelets is five days.
20 There were two
historic attempts to extend
21 shelf life of
platelets to seven days and this
22 was in 1985, the
mid '80s, and more recently
Page 37
1 in 2005.
Unfortunately, both times the shelf
2 life was
reduced back to five days over
3 concerns of
increased bacterial contamination.
4 Now, there
are methods currently
5 available to
decrease bacterial contamination
6 of platelet
products and these include skin
7 disinfection,
the diversion of initial small
8 volume of
blood that is collected away from
9 the final
collection bag because it's thought
10 that some of the
initial blood actually
11 carries the
bacteria to the final product.
12 Then there are
detection methods
13 using cultured
based bacterial detection
14 devices and more
recently cleared antibody
15 based bacterial
detection devices with a rapid
16 turn
around.
17 The clearance of
these bacterial
18 detection devices
by the FDA is based on the
19 intended use for
these devices. The FDA
20 recognizes two
intended uses right now. One
21 is for quality
control and the intent here is
22 to monitor blood
collection process for
Page 38
1 increased
rates of contamination.
2 This type of
intended use can be
3 cleared based
solely on the in vitro data
4 performed by
the device. The other intended
5 use is a
release of products for transfusion.
6 The intent
here is to monitor each product to
7 determine
suitability for transfusion. This
8 is a more
rigorous process and FDA clearance
9 is based on
evidence of clinical performance
10 in addition to in
vitro data.
11 These are the
bacterial detection
12 devices that are
currently on the market. The
13 culture based
devices are the BacT/ALERT
14 device manufactured
by bioMerieux. It has a
15 Q/C indication.
There is an eBDS devices
16 manufactured by
Pall Corporation. It also has
17 a Q/C
indication.
18 And there is the
antibody based
19 rapid detection
device by Verax that has
20 received an
indication or a clearance as an
21 adjunct to a Q/C
device indication. That is
22 because on its own
it didn't have sufficient
Page 39
1 sensitivity to
be placed in the Q/C indication
2 category.
3 The
application of these bacterial
4 detection
devices to extend shelf life was
5 used around
the mid 2000's, around 2005. It
6 was focused on
the BacT/ALERT device. The
7 device, as I
mentioned, was cleared for a Q/C
8 indication but
the manufacturer did not pursue
9 a release
indication.
10 It fell onto the
manufacturers of
11 blood storage bags,
Gambro and Fenwal, to take
12 up this indication
or take up this objective.
13 They started out by
validating their own bags
14 to show that they
can store platelets up to
15 seven
days.
16 Then Gambro went
on to collect
17 available
performance data on the Q/C
18 application of the
BacT/ALERT system and
19 submitted this data
to the FDA with the intent
20 to clear the
system, meaning clear the bags as
21 well as the
bacterial detection device for
22 storage of
platelets up to seven days.
Page 40
1 Part of this
clearance was that
2 the company,
Gambro, committed to a post-
3 market study
of BacT/ALERT performance for
4 detection of
contaminated platelet products
5 stored to
seven days in the Gambro collection
6 container.
This became known as the PASSPORT
7 study.
Subsequently, Gambro was joined by
8 Fenwal in the
study thus permitting
9 cooperating
users of the Fenwal collection
10 container to
release seven-day platelets.
11 Now, the PASSPORT
study was
12 designed to
validate the performance of the
13 BacT/ALERT
bacterial detection device by
14 retesting platelet
products at outdate.
15 During the study
products were tested at day
16 one and the ones
that were negative were
17 placed into
clinical use and the outdated
18 products were
retested at outdate to make sure
19 they were still
negative based on the initial
20 determination by
the device.
21 Unfortunately,
approximately one-
22 and-a-half years
after initiation of the
Page 41
1 PASSPORT study
it was terminated over concerns
2 of increased
bacterial contamination of seven-
3 day platelets
and platelet storage reverted
4 back to five
days.
5 What the
PASSPORT study pointed
6 out along with
several other studies is that
7 the bacterial
detection as currently applied
8 is missing
contaminated products. Several of
9 these studies
indicate that testing with the
10 BacT/ALERT device
during the first day post
11 collection
identifies only a fraction of the
12 contaminated
products.
13 There was an
American Red Cross
14 study that looked
at five-day-old platelets.
15 They were tested
with a BacT/ALERT device and
16 documented an
increased septic reaction rate.
17 There was a
PASSPORT study, as I mentioned,
18 and this documented
higher than expected
19 contamination rate
of the retested products at
20 outdate.
21 Finally, there was
an Irish Blood
22 Bank study on
seven-day platelets. They were
Page 42
1 also retested
on day four and documented a
2 high
contamination rate at the outdate of day
3 seven. These three studies suggested the way
4 we are applying these bacterial detection
5 devices is not sufficient to capture all
6 contaminated platelet products.
7 The objective for today's
8 discussion is
to discuss ways to apply
9 existing
bacterial detection technology to
10 reduce the
bacterial risk of six and seven-day
11 platelets and bring
seven-day platelets back
12 to the
market.
13 As you are
contemplating some of
14 these issues that
we are going to hear today,
15 I wanted to make
sure that you thought about
16 some of these
things that are needed to
17 consider for
successful detection of
18 bacterially
contaminated platelet units.
19 First of all, the
initial level of
20 contamination at
the time of collection is
21 very low and it is
not exactly clear how low
22 it is but it could
be one to ten bacteria per
Page 43
1 bag and one
bacteria is called 1 CFU, or
2 colony forming
unit.
3 The bag
volume ranges from 250 to
4 400 ml. The
initial bacterial concentration
5 in the bag at
the time of contamination could
6 be very low in
the order of 0.01 CFU/ml. Even
7 though it's
such a low initial contamination,
8 during storage
the bacteria can grow to levels
9 of greater
than 10 to the 12 CFU/ml.
10 The sensitivity of
the culture-
11 based devices is on
the order of one to five
12 CFU/ml. The
strategy for successful detection
13 need to take into
account the device
14 sensitivity for
both aerobes and anaerobes
15 bacteria, the
amount of volume sampled from
16 the product, and
also the time for bacteria to
17 proliferate into
detectable range. This could
18 vary for the
slow-growing bacteria versus the
19 fast growing
bacteria.
20 Just to
graphically demonstrate
21 the issue that is
facing these devices, the
22 way to detect
contaminated platelet products
Page 44
1 is to be able
to avoid sample error at the
2 beginning.
This is a hypothetical situation
3 where you have
a bag that is contaminated with
4 a very low
level of bacteria on day one. You
5 can see that
the bacteria will proliferate
6 into a very
high bacterial load at day seven.
7 Now, if you
are trying to detect
8 bacteria on
day one you have to be fortunate
9 enough to
actually capture a bacteria in your
10 sample. If you
don't manage to do that, then
11 the device has no
chance of detecting a
12 contaminated unit.
Your chances of detecting
13 a contaminated
sample improve over the time of
14 storage and by day
two and day three your
15 chances of
detecting a contaminated unit
16 improves
substantially.
17 This is also
demonstrated in this
18 graph which
compares the strategies for fast
19 and slow growing
bacteria. Again, this is the
20 hypothetical growth
curve. Here is the
21 storage days for
platelets. Here is the
22 bacterial load
inside the bag. Bacteria start
Page 45
1 off with very
low contamination here and they
2 proliferate
for fast growing bacteria within
3 a day or
two.
4 So if this is
the sensitivity of
5 your bacterial
detection device, if you are
6 sampling at
day one, you're likely to pick up
7 one of these
fast growing bacteria. But this
8 other one
being that it's slower growing based
9 on bacterial
species, or based on the
10 conditions in the
platelet bag such as some
11 plasma products or
some platelet products
12 support bacteria
better than others, based on
13 that the growth may
be just a little bit
14 slower and would
cause the device to miss this
15 contaminated
bag.
16 The situation gets
even worse with
17 slow growing
bacteria that don't start to
18 proliferate until
days three and four. If you
19 are sampling, let's
say, at day three or day
20 four, you are
stretching the ability of the
21 device to detect a
contaminated unit. You
22 might have to wait
until day five to seven to
Page 46
1 actually have
a better chance of detecting
2 that.
3 A few other
additional points to
4 consider for
today is what is the optimal way
5 to monitor the
performance for sensitivity of
6 the day one
culture and this would be a
7 discussion on
whether it is appropriate to
8 have a
confirmatory culture at outdate versus
9 a septic
transfusion reaction of the patient
10 population that is
transfused with these
11 products.
12 Finally, what is
the appropriate
13 intervention that
will assure the safety of
14 day six and seven
platelets if you decide to
15 put these products
back on the market.
16 Thank you very
much. These are
17 some of the
questions that you will be -- that
18 we will be asking
you later. One of them is
19 does the Committee
agree with the FDA that the
20 reporting of sepsis
should be active and not
21 passive?
22 Another question
is in addition to
Page 47
1 the reporting
of sepsis does the Committee
2 agree with the
FDA that: (a) additional
3 aerobic and
anaerobic cultures should be
4 performed on
day five both to increase the
5 safety of
platelets on days six and seven and
6 as a baseline
measure? Finally, (b)
7 surveillance
cultures should be performed at
8 outdate after
day seven to provide a
9 bacteriological endpoint for this study.
10
With that introduction we have a
11 panel of
distinguished speakers that will
12 actually provide
further data on these very
13 issues. Thank you
very much.
14 DR. SIEGAL: Thank
you, Dr.
15 Vostal.
16 We will now hear
from Mark Brecher
17 from the University
of North Carolina School
18 of Medicine, Issues
and Detection of
19 Bacterially
Contaminated Platelet Products.
20 Dr.
Brecher.
21 DR. BRECHER: Thank
you. I was
22 asked to provide
some background and go over
Page 48
1 some of the
current issues about bacteria
2 contamination
of platelets. A couple of
3 potential
conflicts. I actually don't own any
4 shares in any
company like my family only has
5 two shares of
stock. Each of my daughters has
6 one share of
Disney stock.
7 We have done
a great job in
8 reducing risk
from various transfusion
9 transmitted
diseases. HIV, which used to be
10 1 percent of units
in the early '80s, is now
11 down to one in 2
million. But for the longest
12 time we really
didn't do much about bacterial
13 contamination of
platelets which through
14 multiple studies
generally using aerobic at
15 outdate found rates
of about one in 2,000
16 units were
bacterially contaminated.
17 Through the years
bacterial death
18 from contaminated
units has been one of the
19 leading causes of
death from transfusion.
20 Sixty cases over 10
years from bacteria
21 contaminated
platelets so roughly six cases
22 per year the
majority being gram negative
Page 49
1 organisms.
This is a repeated finding from
2 multiple
countries that the bugs that kill
3 people roughly
two-thirds of them are gram
4 negative
organisms.
5 I was
heartened by the data that
6 Dr. Holmberg
presented this morning that in
7 2007 the FDA
only had three cases of bacterial
8 deaths if you
exclude the Babesia. It looks
9 like we
certainly are heading in the right
10 direction but it's
thought that many cases go
11 unrecognized and
that this is simply the tip
12 of the
iceberg.
13 Just to remind
people about the
14 different types of
platelets, this is somewhat
15 of an old slide but
blood can be donated and
16 it goes into a
receptacle. In the old days it
17 used to be a glass
bottle. We generally don't
18 do direct donor to
recipient transfusions but
19 comic books have
historically used this as a
20 plot device in many
cases for the passive
21 transfer of super
powers.
22 If you are keenly
paying
Page 50
1 attention, you
are going to ask yourself how
2 did they get
the needle through Superman's
3 skin? They do
explain this. They have a
4 doctor here
saying, "Thank you for puncturing
5 your skin with
your fingernail," which raises
6 all kinds of
questions about super infections.
7 The other way
to -- this is how we
8 would make
random platelets from a whole blood
9 donation. The
other way is to hook up a donor
10 to an apheresis
machine, some of the older
11 Fenwal CS-3000s,
and just selectively take off
12 a therapeutic dose
of platelets from a donor.
13 See this happy
donor here. I like this donor
14 so much I married
her.
15 Where were we just
a few years
16 ago? Roughly 4
million platelet bags were
17 transfused per year
in the U.S. Roughly a
18 million apheresis
and 3 million random
19 platelets with a
contamination rate of 1 in
20 1,000 to 1 in
2,000. There were 2,000 to
21 4,000 bacterially
contaminated bags that we
22 were handing out
and transfusing every year.
Page 51
1 People often
say, "Well, most of
2 those wouldn't
have caused sepsis." There is
3 some estimates
that as low as 1 in 10 may have
4 caused
clinical sepsis. If you look to the
5 literature the
number is probably higher. It
6 depends on
whether you're talking about gram
7 positive or
gram negative organisms.
8 There is some
data from the
9 University
Hospital of Cleveland from Roslyn
10 Yomtovian and Mike
Jacobs that they for years
11 cultured platelets
and they screened them with
12 a gram stain. When
they pulled out the most
13 heavily
contaminated units with the gram
14 stain, they still
had a 40 percent incidence
15 of clinical
sequelae in recipients.
16 Probably the real
answer is
17 somewhere in here
but maybe a little but
18 higher but we're
talking about 200 to 1,600
19 cases of clinical
sepsis. Not all of them
20 will die again
depending on the gram positive
21 or gram
negative.
22 Maybe one-fifth to
one-third will
Page 52
1 result in a
fatality. We are talking about
2 perhaps 40 to
500 deaths per year from
3 bacterial
contaminated platelets or 1 in 7,500
4 to 1 in
100,000 fatalities per unit. These
5 are a lot of
cascading assumptions. Is there
6 any validity
to this? You can again go to the
7 literature.
8 Data from
Johns Hopkins found that
9 with a pool of
six random platelets there was
10 a rate of 1 in
17,000. For apheresis platelet
11 it was roughly 1 in
68,000. Very similar to
12 data from the
University Hospital of Cleveland
13 of 1 in 58,000 for
apheresis and from France
14 1 in
150,000.
15 So are there a lot
of assumptions
16 going down this
cascade. They do seem to be
17 real so there was
probably about 100 to 200
18 deaths per year
from bacterially contaminated
19 platelets.
20 Some of the data
from the
21 University Hospital
of Cleveland they had 32
22 recipients of which
13 had reactions of 41
Page 53
1 percent, nine
had severe reactions, 28
2 percent. In
three cases the patients died so
3 that was 10
percent. Again, they screened out
4 the most
heavily contaminated units so you
5 would have
expected that the fatality rate
6 would have
been higher.
7 The FDA has
convened several
8 meetings
through the years to discuss
9 bacterial
contamination. This was a summary
10 from Ed Synder from
Yale at the end of a
11 workshop in 1999
where he felt that the sense
12 of the meeting was
the imperative was to act.
13 You don't have to
explain yourself on
14 Nightline. I have
often said we just have to
15 wait until a
celebrity dies and then it's
16 going to hit the
fan.
17 Regulation is
necessary to achieve
18 the goals. Nothing
says I care like a page of
19 483s. Those are the
deficiencies that the FDA
20 hands out on their
inspections. When all else
21 fails do something.
Give us a mandate and we
22 will do the
rest.
Page 54
1 There was a
feeling in the blood
2 banking
industry that we wanted to do
3 something but
our hospital administrators
4 wouldn't let
us do something unless there was
5 a mandate to
do it because it would cost
6 money.
7 In 2002
things began to change.
8 There were two
companies that brought to
9 market quality
control testing. One was the
10 bioMerieux
BacT/ALERT which is an automated
11 liquid culture
system that has color metric
12 sensors at the
bottom of the bottles that as
13 C02 is generated in
the bottles the color
14 changes from, I
guess, green for go to yellow
15 for
caution.
16 This method looks
at both the
17 absolute color
change and the rate of change
18 so there is a
little bit of applied calculus.
19 Much of the data
was generated in my lab for
20 this submission.
That was in February of
21 2002. I think it
was in September or October
22 of 2002 the Pall
Bacterial Detection System,
Page 55
1 BDS, was
brought to market.
2 This looks at
the P02 in the head
3 space of a bag
so as the bacteria grow they
4 consume the
oxygen. I used to say it couldn't
5 be a Pall
product if it didn't have a filter
6 so there was
the filter. The problem with
7 this first
model was that the filter took out
8 50 percent of
the bacteria.
9 That wasn't a
good thing. They
10 modified it. They
took the filter out and
11 made a few other
changes and they had the
12 enhanced bacterial
detection system on the
13 market.
14 Another meeting
with the FDA
15 addressed bacteria
and a variety of other
16 issues but mostly
pathogen reduction occurred
17 in the summer of
2002. After the meeting
18 several of the
speakers and moderators got
19 together and they
issued a public letter to
20 the blood banking
industry.
21 In this letter
they said that
22 pathogen reduction
isn't going to be here
Page 56
1 anytime soon.
This is Jim Aubuchon from
2 Dartmouth; Ros
Yomtovian, University Hospital
3 of Cleveland;
Mo Blajchman, McMaster; Paul
4 Ness, Johns
Hopkins, and myself.
5 We said that
bacteria
6 contamination
is a problem. We can do
7 something
about that and the blood banking
8 industry needs
to go ahead and do that. A lot
9 of times
people write these sort of open
10 letters and nothing
much ever happens but this
11 letter really
seemed to be a tipping point in
12 bacteria
contamination and it garnered a lot
13 of
attention.
14 Shortly thereafter
the two
15 voluntary
accrediting agencies in the U.S.,
16 the American
Association of Blood Banks and
17 the College of
American Pathology issued
18 standards. The ABB,
the blood bank or
19 transfusion
service, shall have methods to
20 detect bacterial
contamination.
21 From CAP the
laboratory shall have
22 a system to detect
the presence of bacteria in
Page 57
1 platelet
components. That is really what got
2 things moving.
We finally had a mandate from
3 someone that
we had to do something.
4 What some of
you may not know is
5 that right
before the ABB standard went into
6 effect in
March 2004 the Acting Assistant
7 Secretary of
Health, Christina Beato, wrote a
8 letter asking
that it be delays because they
9 were worried
about its affects on the
10 availability of
platelets. This is really at
11 the 11th hour. This
is, I think, February
12 24th was the date
on this.
13 The ABB responded
that further
14 delaying
implementation will compromise
15 patient safety and
public health. The country
16 did go on to
implement bacterial detection.
17 ABB task force
looked at the impact shortly
18 after the
implementation of the testing and
19 they found that for
the majority of blood
20 centers, hospital
blood banks and transfusion
21 services that their
ability to provide
22 platelets was not
really effective after the
Page 58
1 implementation.
2 Similarly,
the majority said they
3 were not
experiencing increased platelet
4 outdating so
for the majority of centers it
5 went down
pretty well. One interesting fact
6 that came out
of the survey was that for
7 apheresis
platelets the vast majority of
8 people were
doing one of the culture methods.
9 However, for
random platelets most
10 people were doing
non-culture surrogate
11 methods such as
monitoring the pH of the
12 random unit or the
glucose often using urine
13 dip sticks which is
a very insensitive method.
14 I say this and I'm
one of the ones who put it
15 in the literature
but it only picks up about
16 10 to the 7th
colony forming units per ml.
17 The other
interesting thing, the
18 true positive
pickup rate was about 1 in
19 4,000. You will see
that using early culture
20 of 1 in 4,000, 1 in
5,000 seems to be the
21 recurring number
that we are picking up. With
22 the non-culture
method it was only one in
Page 59
1 roughly 18,500
or a 4.6 fold difference in
2 sensitivity.
3 We know from
many culture studies
4 that the
contamination rate per bag should be
5 the same so
clearly this method of using pH
6 and glucose
was not really addressing a
7 majority of
the problem.
8 I just wanted
to mention that the
9 College of
American Pathology has a proposal
10 on the table to
change their standards in 2009
11 where they will no
longer allow for
12 insensitive methods
such as swirling pH or
13 glucose.
14 The sensitivity of
the method must
15 be at least 10
CFU/mL 24 hours after the
16 collection or at
least 10 to the 5th CFU/mL 72
17 hours after
collection. Hopefully this will
18 get to the
dichotomy of safety that we
19 currently
have.
20 Now, there are
several ways that
21 you can reduce the
risk of bacterial
22 contamination, one
of which is going to all
Page 60
1 apheresis
platelet supply. At Johns Hopkins
2 in the mid
80's 52 percent of their platelets
3 were apheresis
platelets, 48 percent were
4 pooled random
platelets.
5 They made an
active effort to go
6 to 100 percent
apheresis platelets. By 1998
7 99 percent of
their platelets were apheresis
8 platelets. The
reaction rate during this time
9 period went
from 1 in 5,000 to 1 in 15,000.
10 When you teased
out the
11 differences between
random platelets and
12 apheresis platelets
there is about a 5.6 fold
13 difference in
reaction rate. Don't forget
14 they were
transfusing six packs, pools of six.
15 It, again, gets
back to that the risk is per
16 bag of platelet
product.
17 One of the other
things that came
18 out of the survey
is we went back through the
19 literature and we
plotted out what percentage
20 of apheresis
platelets were being transfused
21 in this country.
Interestingly it made almost
22 a perfect straight
line so that by 2004 we
Page 61
1 were at
roughly 79 percent of all doses handed
2 out in this
country were apheresis platelets.
3 Jim Aubuchon
extended my line saying that by
4 2010 we'll be
almost all apheresis platelets.
5 I think that
is a bit optimistic.
6 The most
current data, preliminary
7 data from a
survey of transfusion practice inn
8 2006 estimates
that we are currently sitting
9 around 88 or
maybe 89 percent of all platelets
10 handed out in this
country are apheresis
11 platelets. I'm not
sure when we are going to
12 cross the line of
standard of care. I'm not
13 sure what is the
standard of care. Is it 95
14 percent? I'm not
sure.
15 Other
interventions that we've
16 tried is diverting
the first volume of the
17 donation. We say we
sterilize the skin. We
18 don't really
sterilize the skin with iodine
19 solutions. What we
do is we do a bacterial
20 load reduction. You
cannot get all the
21 bacteria off the
skin. There are bacteria in
22 the hair follicles,
spacious glands, sweat
Page 62
1 glands that
the iodine never reaches. A
2 needle is
going through there and is making a
3 core and
pulling that up the needle.
4 However, data
from a variety of
5 studies and I
just picked two. This one is
6 from France
where the first 15 mL 76 were
7 contaminated
but if they diverted the second
8 15 mL only 21
of the 76 were contaminated.
9 Study from
the Netherlands.
10 Actually, the
author is out in the audience.
11 18,000 collections,
.35 percent were
12 contaminated. If
they diverted the first 10
13 percent it dropped
to .21 percent.
14 You can decrease
the bacterial
15 contamination in
the bag. However, as Ros
16 Yomtovian likes to
say, we should not be
17 diverted by
diversion. Two-thirds of the
18 fatalities are gram
negative organisms. What
19 we are dealing with
here are mostly gram
20 positive
organisms.
21 Yes, we can
decrease gram
22 positives but we
are not really attacking
Page 63
1 those bugs
that cause death which are mainly
2 gram negatives
and are thought to principally
3 come from
donors who has a asymptomatic
4 transient
bacteremia.
5 The other
thing with putting a
6 diversion
pouch on a bag is that you would
7 think it would
be a very simple thing to do
8 but it has had
its own set of problems. Those
9 first 15 mL or
so of blood are often then used
10 to do your viral
tests. Even that had
11 problems.
12 Recent data from
the American Red
13 Cross published
last year where they looked at
14 the true positive
contamination rate using an
15 early culture found
that with two-arm
16 apheresis
procedures the rate of bacterial
17 contamination was
twice as high as a single-
18 arm procedure. The
COBE Trima here only does
19 a single-arm
procedure. It came to light that
20 the diversion pouch
of both of these
21 manufacturers was
put on the wrong line.
22 It was put on the
return line, not
Page 64
1 the draw line,
so the bacteria coming up into
2 the collection
set was contaminating your
3 collection set
and then it was being diverted.
4 Little things.
Here is a picture Richard
5 Benjamin
provided of that diversion pouch that
6 you see here
which is actually on the return
7 line. These
sets have been modified.
8 So the
question is have we really
9 done anything.
Have we accomplished anything
10 with the bacterial
culturing of early units.
11 The first large
paper in this country was from
12 the American Red
Cross and they looked at the
13 first 10 months of
having bacterial culture
14 versus the 10
months prior where they were not
15 doing bacterial
culture.
16 What they found
was with the
17 septic reactions --
that's not good. From
18 March through
December 2003 they had 15 septic
19 reactions, 12 were
high probability, two were
20 fatal. In the same
period there were only
21 eight involving
apheresis but only three were
22 such a high
probability so it was a 75 percent
Page 65
1 drop in high
probability septic events.
2 Well, that
was pretty good.
3 Subsequent
data from the Red Cross looking at
4 a longer time
period suggested maybe only 50
5 percent.
Clearly it seems like we impacted on
6 the number of
septic transfusion reactions.
7 However,
those reactions that do
8 occur tend to
occur on older units. What we
9 don't know,
however, is how the breakdown of
10 the yes is in this
country. For example, here
11 we have 13 cases
that occurred on day five but
12 we don't know, for
example, are 60 percent of
13 the platelets
transfused on day five and only
14 10 percent on day
two?
15 We don't really
know the
16 denominator for
these cases. Again, it's
17 worrisome that the
older the unit the more
18 risk of a septic
transfusion reaction. What
19 we also don't know
is are the bacteria that
20 are slow growing
are they plateauing around
21 day five. We don't
know if day six or day
22 seven platelets
would actually have a higher
Page 66
1 septic rate
per unit.
2 This is data
from Hema-Quebec
3 putting in a
variety of interventions. They
4 were measuring
the septic transfusion reaction
5 rate in
thousands. The line stopped here
6 because in
this presentation of ABB they
7 didn't have
anymore reactions. As far as they
8 could tell 100
percent had been presented by
9 all these
interventions.
10 This is data
looking at 123,000
11 apheresis platelets
from blood systems, the
12 second largest
collector of blood in this
13 country. What they
found in the 24-month
14 interval that there
had been three known
15 septic reactions in
the time period before but
16 none after. We are
clearly preventing many of
17 these
cases.
18 Data from the Red
Cross. Their
19 septic transfusion
reaction rate was 1 in
20 40,000. When they
began culturing it dropped
21 to 1 in 75,000.
After they added diversion in
22 their current
estimates are now 1 in 175,000
Page 67
1 so we are
impacting.
2 Data using
the Pall eBDS is a
3 little harder
to find but here is a report
4 from 118,000
apheresis and random platelets
5 from 23 U.S.
blood centers. Their true
6 positive
contamination rate was 1 in 5,000,
7 very similar
to using the BacT/ALERT. There
8 was one
reported case of a missed staph epi so
9 this also
seems to be effective.
10 This is combined
data from the Red
11 Cross and blood
systems looking at 1.23
12 million apheresis
products, roughly a year's
13 worth of apheresis
platelets in this country,
14 207 isolates many
of which are gram negatives,
15 chierchia, E. coli
that invariably would have
16 killed people. Are
we saving lives? There is
17 no question in my
mind we have saved a lot of
18 lives by doing
these interventions.
19 However, there is
some data that
20 continues to be
worrisome. This has already
21 been alluded to.
This is a paper from Murphy
22 from Ireland. What
they found was that when
Page 68
1 they did their
early culture they detected 35
2 cases out of
42,000 or .08 percent.
3 Another 3,000
were recultured on
4 day four and
they picked up another .12
5 percent. Of
8,000 that outdated they found 18
6 that were
positive or .22 percent. They said
7 that the early
culture only had a sensitivity
8 of less than
40 percent which was not optimal
9 at
all.
10 However, when you
look at papers
11 like this you need
to understand the full
12 picture. What they
do in Ireland is not what
13 we do here. They,
for example, culture their
14 apheresis platelets
after 12 hours from
15 collection. We wait
at least 24 hours,
16 sometimes 36 hours
before we take our sample
17 to minimize the
sampling error.
18 I'm not sure you
can carry this
19 data forward. The
other thing is they are not
20 looking at the
transfusion septic reaction
21 rate whereas we
are. They are just looking at
22 the culture
positive rate. Some of these bugs
Page 69
1 probably
wouldn't hurt anybody if they had
2 gotten
them.
3 Another
vexing problem that
4 remains is
that of anaerobic bacteria. There
5 have been a
few cases of sepsis and death from
6 anaerobic
organisms from platelets and from
7 red cells.
This is from the literature. Two
8 cases of
clostridium. The FDA is aware of
9 another couple
cases of clostridium from red
10 cells, clostridium
from platelets and U
11 bacterium from
platelets. Use of anaerobic
12 model could
potentially interdict these few
13 cases, these rare
cases.
14 The other
interesting thing about
15 anaerobic model
it's a different media than
16 was in the aerobic
model. Some organisms like
17 that media better.
For example, if you look
18 at various strep
organisms from the data from
19 my lab, strep
pyogenes the aerobic model takes
20 19 hours, the
anaerobic model 13.8 on average.
21 Strep viridans 43
hours in the
22 aerobic model, 21
in the anaerobic model. I
Page 70
1 have argued
for a long time that difference in
2 time may make
the difference between whether
3 you are able
to interdict a unit or not.
4 There is also
some data at low
5 concentrations
of some bacteria. This is a
6 staph
lugdunensis that actually killed a
7 recipient. At
low concentrations the
8 anaerobic
model seems to be much faster than
9 the -- the
anaerobic model seems to be much
10 faster than the
aerobic model.
11 This is looking at
a preparation
12 of 1.5 CFU/ml. We
put 1 mL into a bottle, 2
13 mL, 3 mL, 4, 5, 6,
8, and 10. Then we made up
14 the volume
difference with saline so there was
15 no dilutional
effect.
16 There is a
suggestion that at very
17 low concentrations
the anaerobic model may be
18 even more
sensitive. Here we had three out of
19 three that came up
positive in the anaerobic
20 model but in the
aerobic model only one of
21 three came up
positive.
22 Okay. Other
initiatives that move
Page 71
1 toward rapid
detection. This was discussed at
2 BPAC in March
2006. Several companies then
3 were pursuing
this. Immunetics has a
4 peptoglycan
based assay. GloBac looking at
5 bacterial ATP
there are two systems that use
6 lateral flow
devices.
7 Verax is one
that is currently
8 approved and
you've already heard about that
9 today. There
was one other company that
10 actually had an
interesting method that used
11 bacillus spores
that would fluoresce if there
12 was another
bacteria nearby but they have sort
13 of dropped out of
the race.
14 At this meeting
Ros Yomtovian and
15 Mike Jacobs
presented their data on their long
16 surveillance at
University Hospital of
17 Cleveland. They
have subsequently gone on and
18 published this
experience in two different
19 papers, same figure
in both papers.
20 What they
presented was that at 10
21 to the 5th CFU/mL
it would have prevented all
22 fatal reactions, 91
percent of serious
Page 72
1 reactions, 79
percent of all reactions. 10 to
2 the 3rd would
have prevented all serious
3 reactions, 79
percent of all cases and 95
4 percent of all
reactions.
5 It's from
data like this that the
6 feeling is
that we need to have a sensitivity
7 of around 10
to the 4th CFU/mL for a rapid
8 test. They
were really only evaluating for
9 acute
reactions.
10 Random platelets
you could pool
11 them. They used to
only be good for four
12 hours. Acrodose
System came online in 2005
13 with FDA approval.
You can now pre-pool and
14 keep the entire
shelf life at the banks.
15 Preliminary data
from the Red
16 Cross shows a 5.8
fold higher true positive
17 rate of cultures
compared to apheresis
18 platelets so this
is worrisome. We don't
19 really have
separate transfusion reaction
20 data. I think this
is a worrisome
21 development.
22 Cases continue to
slide through.
Page 73
1 MMWR reporting
some cases in 2004. The CDC
2 sort of dinged
the Red Cross for not following
3 the
manufacturer's recommendations regarding
4 volume for testing in one case. This is a
5 case from Kansas City. It's an E. coli death.
6 In this case they have their
7 BacT/ALERT
cabinets in a back room. They
8 loaded the
bottles on Friday, closed the door,
9 and walked
away for the weekend. They had a
10 computer interface
but the computer interface
11 went
down.
12 There is a
flashing red screen on
13 the BacT/ALERT if
there is a positive
14 detection but, of
course, no one could see it.
15 There is an audible
alarm. They turned off
16 that audible alarm.
They walked in Monday
17 morning, saw that
the machine was flashing,
18 tried to call back
that unit but it had been
19 transfused within
the previous hour at a
20 hospital so
mistakes can still happen. No
21 system is going to
be perfect.
22 This is a case of
streptococcal
Page 74
1 death from
Florida that is about to be
2 published
where they were actually culturing
3 the random
platelets by taking a bit of the
4 tubing and
pulling it with several other units
5 together but
they were doing their sampling
6 two hours
after the production of platelets.
7 They weren't
waiting for the 24
8 hours. There
is no surprise that there is a
9 sampling error
that they missed. Again, they
10 were not following
the package insert
11 recommendations for
culturing which is to wait
12 at least 24
hours.
13 Another thing that
worries me is
14 that there are
cases that we are just not
15 aware of that are
slipping through our
16 fingers. This is a
paper from the NIH
17 Clinical Center
from 1973 where one year they
18 noticed they had
all these salmonella cases
19 being
reported.
20 They brought the
CDC in and did
21 this being
epidemiologic search. Long story
22 short they found
out that every patient --
Page 75
1 when they
checked further everyone had a
2 platelet
transfusion from the same donor.
3 Working up
the donor extensively
4 they found he
had osteomyelitis. The
5 interesting
thing is how many days from the
6 transfusion
until they became sick. It was on
7 average 8.6
days. By then people had
8 forgotten they
had even given a platelet. It
9 worries me
there may be other cases out there.
10 There were several
deaths, multiple
11 recurrences of the
salmonella.
12 Similarly, just a
few years ago
13 there was a recall
of a couple lots of Heparin
14 that was in a
catheter set that was
15 contaminated with
Pseudomonas. CDC followed
16 up on many of the
people who had received this
17 contaminated
Heparin and it turned out that
18 there were 15
patients in Michigan and 13 in
19 South Dakota who
had a delayed onset of
20 Pseudomonas
fluorescence.
21 This ranged from
84 days to 421
22 days. If the CDC
hadn't been following up, do
Page 76
1 you think
anyone would have realized that it
2 came from the
Heparin that they used a year
3 ago? There is
a concern that any bacteria
4 could be bad
bacteria.
5 Pathogen
reduction we already had
6 mentioned this
morning. There was a Canadian
7 conference
last year where the FDA finds it
8 problematic
which is why we don't have
9 pathogen
reduction yet in this country and the
10 Canadian regulators
had basically a similar
11 opinion.
12 I'm running out of
time. Across
13 the world most
people are using the
14 BacT/ALERT. Many
countries have gone to seven
15 days. A few notable
exceptions. Japan is not
16 doing any bacterial
detection. They were only
17 keeping their
platelets for three days. I
18 understand now it's
four. France is gradually
19 implementing
pathogen reduction.
20 Okay. Several
years ago I was
21 invited to speak at
a workshop on bacterial
22 contamination and
it was entitled, "Bacterial
Page 77
1 Contamination.
So Have we Missed the Boat?"
2 I thought that
was the wrong -- where is my
3 sound? Let's
try this again. No sound.
4 Okay. Let's
turn the volume up. Thank you.
5 Okay. Sorry
for this technological delay.
6 Okay. I
thought that was the
7 wrong
question. This is the first
8 undocumented
use of this well-known phrase,
9 "Have we
missed the boat." I thought that was
10 the wrong question.
The better question is do
11 we know where we're
going?
12 (Whereupon, a
video was played.)
13 DR. BRECHER: So
it's important
14 that you have to
know where you're going. By
15 the way, if you're
curious the subtitles were
16 in Swedish. This is
a company that makes GPS
17 navigation
gear.
18 Do we know where
we're going?
19 We're going toward
better patient safety.
20 Have we done that?
No question. We have
21 saved many lives
from what we've already done.
22 Now I'm done. Sorry
for running a little
Page 78
1 over.
2 DR. SIEGAL:
Thank you, Dr.
3 Brecher.
4 Do we want to
take questions at
5 this point or
go on? Let's go on for now.
6 Next is Thomas
Montag-Lessing, M.D. from Paul-
7 Ehrlich
Institute on bacterial detection in
8 blood
components.
9 DR.
MONTAG-LESSING: Mr. Chairman,
10 ladies and
gentlemen, I am pleased to have
11 this opportunity to
speak here in front of the
12 Blood Products
Advisory Board. My topic is
13 bacterial detection
in blood components.
14 Since Jay Epstein
asked me to report something
15 about our work in
the past 10 years regarding
16 blood standards, of
course we do it with
17 pleasure.
18 Considering the
introduction of
19 Dr. Vostal and the
excellent review of Mark
20 Brecher, there is
no need for me to discuss
21 residual risk and
whatever. I would like to
22 start immediately
with the question what is
Page 79
1 PEI. PEI means
Paul-Ehrlich Institute.
2 Ten years ago
we understood that
3 the usual
reference strains coming or used in
4 microbiology,
for instance, coming from the
5 so-called from
the ATCC, American Type Culture
6 Collection,
cannot automatically be used in
7 blood
components since a lot of them are not
8 able to
multiply to grow up or they remain
9 without any
reaction and so on so we started
10 to collect strains
which are able to grow up
11 in platelet
concentrates.
12 The next question
we asked as
13 microbiologist is
are you able to grow up in
14 platelets from as
much as possible different
15 donors in order to
exclude impairments or any
16 interferences from
the immune systems of the
17 different donors.
So our strain standards are
18 characterized in
platelets from at least a
19 hundred different
donors.
20 The next step is
following a
21 specially developed
procedure our standards
22 are deep frozen and
ready to use, stable, and
Page 80
1 shapeable and
so they are defined and consist
2 mainly of
living cells. That is the
3 prerequisite
that we are able to perform real
4 life spiking
of blood components.
5 That means
contamination of one
6 platelet bank
with 10 corresponding to .03 per
7 mL. That point
had been mentioned already by
8 Jaro Vostal.
Under real life conditions that
9 means
imagining the actual level is acceptable
10 in the given blood bank. This is a real life
11 contamination. That's what microbiologists
12 don't think at all but our approach in low
13 saturation mimicking or the simulation of real
14 life contamination.
15 In consequence,
PEI standards are
16 two to four and
that is very important.
17 Objective
validation and assessment of methods
18 for screening and
especially for pathogen
19 reduction methods
because it is very important
20 to have objective
data after validation in
21 order to assess
these approaches.
22 Two years ago we
proposed a WHO
Page 81
1 whether they
are interested in installation of
2 these bacteria
standards, WHO bacteria
3 standards,
since there is no reference
4 material
available at all following a proposal
5 of my
colleague who is in the audience. We
6 just started a
discussion with the American
7 Type Culture
Collection to involve them in the
8 current
process.
9 Inside the
working party for
10 transfusion
transmitted infectious diseases
11 from the
International Society of Blood
12 Transfusion. The
bacteria group is a subgroup
13 of the working
party. We agreed last year
14 that we should
perform in collaboration
15 between WHO and
ISBT an international
16 validation study in
order to characterize the
17 strains as a
crucial prerequisite for
18 installation of the
strains as WHO standards.
19 Just for
illustration I'm going to
20 show you that we
worked so-called PASSPORT of
21 our blood standards
in order to prevent any
22 confusion with the
PASSPORT study headed by
Page 82
1 Larry Dumont,
of course, we will change the
2 name to
certificate but this is the former
3 version as
discussed in the last ISBT meeting
4 in China in
Macau.
5 My post-doc
included a photograph
6 as a PASSPORT
procedure. Okay. The
7 certificates
contain information regarding the
8 gross
conditions of the given strain in
9 platelet
concentrates under real life
10 conditions. It's
very important.
11 We learned only 10
years ago that
12 there is no chance
to reduce the volume of the
13 platelet
concentrate or to work with smaller
14 batches. I like to
call it two poly-
15 dimensional systems
which are interacting and
16 there is no chance
using my small brain I have
17 to understand what
is happening in such a
18 complex
situation.
19 Okay. Furthermore,
we included
20 the information how
the bacteria are growing
21 on typical culture
plates and what about the
22 picture of the gram
staining. Furthermore,
Page 83
1 our bacteria
strains are genome sequenced.
2 That means
basing on the 16S small subunit
3 ribosomal RNA
bacteria can be identified to
4 know exactly
regarding their species.
5 One further
information. In order
6 to prevent any
mixing up or any change during
7 different
cultures we characterize our strains
8 using the
so-called randomly primed rapid PCR
9 fingerprinting
working with random primers
10 which is giving a
clear picture regarding
11 stability of a
given strain.
12 That is the method
actually used
13 by the colleagues
from forensic medicine who
14 trained or whatever
for identification of
15 gangsters or
whatever you would imagine.
16 This is an
illustration of a
17 prevalidation study
we did together with the
18 National Guard
Service in London with the help
19 of Dr. Carl
McDonald. I like to say these are
20 the numbers on the
left-hand side estimated
21 regarding the count
of bacteria in my lab and
22 here are the
results produced in the London
Page 84
1 lab and some
of them are looking like
2 certifications
and we are very proud of the
3 result.
4 The plan
which The National
5 Validation
Study should go on -- this is a
6 list of
partners involved up to now. We are
7 happy that we
could involve colleagues from
8 Asia, from
Hong Kong, up to colleagues from
9 South
Africa.
10 The study will
start with the
11 shipping and
sending out of -- and that's in
12 September 2008,
this year. The next ISBT
13 meeting is in March
of next year in Cairo,
14 Egypt. We will have
a workshop which will
15 discuss the results
of this study.
16 This PI blood
standards hopefully
17 in the future WHO
blood standards can be used.
18 I would like to
start with one example
19 regarding
validation of pathogen reduction
20 methods we did two
years ago or two-and-a-half
21 years ago with
Cerus or, this time, the Baxter
22 Company.
Page 85
1 Here we can
see one experiment
2 dealing with
isolated spores from bacillus
3 cereus. You
know bacillus cereus belongs to
4 the so-called
spore forming bacteria and
5 bacteria
spores that are very, very stable
6 because they
are dry. They are heat stable
7 and stable
against irradiation and so on.
8 The
microbiologist wait when we
9 spike platelet
concentrates with altogether
10 three times 10 to
the 6th isolated spores for
11 bacillus cereus
corresponding to 10 to the
12 four per mL. Then
no spore will be killed
13 after the treatment
because, as I mentioned
14 already, the spores
are dry. Where there is
15 no water there is
no effusion and there is no
16 biochemistry and
that will be dead away.
17 Surprising was the
next experiment
18 in which we tried
to follow real-life
19 conditions as
mentioned already. That means
20 we contaminated
platelet bags with 10 spores
21 per bag, stored the
bags overnight as a usual
22 procedure in a
blood facility, and thereafter
Page 86
1 we performed
treatment. As we can see here
2 the spores
survived. The products were not
3 sterile.
4 The question,
of course, was what
5 about the
lifestyle of the spore-forming
6 bacteria in
PC. There were no spores when we
7 contaminated
10 spores per bag and store in
8 the platelet
bank overnight. Then the spores
9 should
germinate into vegetative forms.
10 Vegetative forms
of bacteria, of
11 course, can be
killed without any problem.
12 Why did bacillus
cereus survive? The
13 explanation you can
see here in this
14 experiment we did
in my department.
15 We contaminated
platelet
16 concentrates and
parallel typical usual
17 microbiological
culture medium and followed --
18 monitored all
together 40 hours, following
19 sample drawing
every hour. This could be done
20 only because it was
summertime and the
21 trainees were
students so I could ask them for
22 something so often
all of the day up to 24
Page 87
1 hours.
2 Okay. As you
can see there was a
3 very
interesting result. All of the time we
4 found in the
PCs concentrate residual spores.
5 The red points
demonstrate what happened in
6 the classical
microbiological culture medium.,
7 and me as a
microbiologist I since studied one
8 year
microbiology and that is described in the
9 textbooks.
10 Spores will
germinate in
11 microbiological
culture medium and over a
12 given time, in this
case around 30 hours, I
13 have vegetative
cells only. In platelets
14 there is heavier
spores and the consequence is
15 very clearly there
is no chance to evacuate
16 spore-forming
bacteria by the intercept
17 procedure or any
other methods.
18 We are just going
to perform in
19 October this year
the same experiments with
20 the riboflavin
procedure by Navigant. The
21 company has a new
name but I'm always
22 forgetting the new
name.
Page 88
1 Okay. I would
like to add the
2 question are
spore-forming bacteria relevant.
3 A short look
into the PubMed educates you that
4 there are a
lot of severe events up to fatal
5 cases induced
by spore-formers. Mark Brecher
6 already
mentioned the cause of klebsiella
7 pneumonia, a
lot of people are doing the same.
8 Here I listed
the frequency of
9 spore-forming
bacteria in several publications
10 up to the number
here mentioned in a paper,
11 with one in 500.
Then I remembered the cake
12 shown by Mark
Brecher here. There were around
13 five percent
spore-forming bacteria in the
14 isolates.
15 The reason is very
easy to
16 understand. The
alcoholic disinfectants we
17 are using because
they are working very, very
18 fast are not
sporicidal at all so spore-
19 forming bacteria,
typical environmental
20 bacteria can come
into blood components.
21 Coming to the
validation of
22 screening methods I
would like to focus to
Page 89
1 rapid methods
as already announced in the
2 title. Allow
me to repeat shortly what is the
3 crux in
bacteria screening of blood
4 components.
Usually contamination happens
5 with very,
very low counts of bacteria.
6 That means 10 to 100 CFU/mL
7 corresponding
to .03 to .3 CFU/mL. There are
8 also mentioned
.01 CFU/mL that can happen, of
9 course, too.
Thereafter the bacteria are able
10 to grow up. I would
like to repeat that we
11 developed our
bacteria standards in such a
12 manner that we are
able to imitate real life
13 conditions in
contamination.
14 That is the
extractum of what is
15 happening after a
bacteria entered a blood
16 component during
the blood donation. Starting
17 with the count
around .03 CFU/mL there is a
18 given phase, an
adaptation phase of the
19 bacteria to the new
environment as usually
20 happens. Then
there's the growth stage
21 usually the
geometric growth stage, and then
22 the stationary
phase is reached.
Page 90
1 I like to
call this approach shown
2 in detail by
Mark Brecher Dutch approach
3 because the
Dutch colleagues were actually the
4 first
worldwide who installed platelet
5 bacteria
screening as mandatory nationwide in
6 2001. We
called it early sampling combined
7 with culture
methods and the idea was to say
8 considering
that the contaminating or the
9 count of
contaminated material is so low we
10 should wait at
least one day.
11 Let's give the
contaminating
12 bacterial strains a
chance to start its
13 multiplication or
having the chance to have at
14 least one bacterium
in my bottle before
15 analyzed. The two
approaches available on the
16 market are the
BacT/ALERT machine and the Pall
17 eBDS as
demonstrated by Mark Brecher.
18
I would like to show you one of
19 the cases we had to
deal with the last time
20 inside a National
Red Cross study in Germany.
21 One apheresis
platelet concentrate consisting
22 of two therapeutic
units had been -- oh, thank
Page 91
1 you. Sorry. I
didn't know. I hope you could
2 hear me up to
now.
3 A sample had
been formed from the
4 apheresis
units 20 hours after donation. Both
5 samples were
incubated into a BacT/ALERT
6 machine as
well as Pall eBDS the cartridges
7 remained
sterile and transfusion of the
8 products
happened. They produced two fatal
9 cases in the
patients.
10 Because we have a
very good
11 contact list the
colleagues from the
12 University Hospital
in Germany we could get
13 the platelets back
and we could analyze them
14 in my department
and we found in one 10 to the
15 8th CFU/mL of
klebsiella pneumonia and the
16 second bag 10 to
the 9th CFU/mL klebsiella
17 pneumonia including
tons of endotoxin of
18 course you know,
klebsiella negative bacteria.
19 This event fitted
very well with
20 the clinical
outcomes. I had to write the
21 assessment for the
prosecutor so I could study
22 the clinical data,
too. That means all these
Page 92
1 things were
very, very understandable. What
2 we did is we
characterized the strain
3 following our
approach. That means spiking
4 different
platelet bags or platelet bags from
5 different
donors with .03 CFU/mL and saw a
6 very
interesting outcome.
7 In several
cases the klebsiella
8 pneumonia
strain grew as other strains we
9 observed
before already. That means very
10 fast. But there
were platelet bags in which
11 a very much
prolonged adaptation phase or --
12 I just forgot the
other term. The strain
13 needed up to three
days to enter the cutoff
14 for the
determination of this experiment.
15 That means 10
CFU/mL.
16 So the diagnostic
that I described
17 to you before, that
means we contaminated
18 platelet bags with
.03 CFU/mL, draw a sample
19 after 31 hours with
a negative result. When
20 we repeated a
sample drawing two days after
21 contamination we
could produce a positive
22 result.
Page 93
1 The
consequence is that in biology
2 there is a
diagnostic window in platelet
3 bacteria
screening and this window can be
4 dependent on
the given strain and donor
5 properties can
be changed or can be prolonged.
6 The
consequence, the conclusion is that we
7 should draw
the sample as late as possible
8 imagining that
the contaminating bacterium,
9 Vostal
mentioned the one bacterium per bag,
10 Jaro Vostal
mentioned, give the bacteriums a
11 chance to grow as
long as possible, to
12 multiply as long as
possible.
13 Let's hold the
entity of platelet
14 back together and
let's draw the sample as
15 late as possible in
order to increase the
16 chance to get the
bacteria in our method or in
17 order to overcome
the sampling error. This
18 approach had been
proposed by the already
19 mentioned ISBT
working party on Transfusion
20 Transmitted
Infectious Diseases subgroup in
21 Transfusion Today
in March 2006.
22 What rapid
methods, feasible
Page 94
1 methods for
rapid bacteria detection do we
2 have? First, I
would like to show you flow
3 cytometry
developed by Becton Dickinson
4 Biosciences
Europe. The Verax system had been
5 mentioned
already. Then universal bacteria
6 PCT NAT where
no -- where still no commercial
7 variant is
available.
8 Then I would
like to show you some
9 data with a
newly developed system which is
10 able to measure
without pH inside blood
11 effects without
opening the bag, the rapid
12 detection of
microbes in PCs using flow
13 cytometry. As you
can see here, it's a very
14 simple and very
easy procedure.
15 A sample of 50
microliters drawn
16 from the platelet
bag is mixed with 450
17 microliters of a
lysis buffer containing the
18 fluorescent dye
Thiazole orange. Then
19 incubation for five
minutes measuring for 30
20 seconds. That means
result within 10 minutes.
21 These are some
results obtained with different
22 bacteria. You can
read it yourself, staph
Page 95
1 aureus, staph
epidermidis, bacillus cereus,
2 klebsiella
pneumoniae are the bacteria left
3 inside the
gray events or the platelet debris.
4 Very
important ingredient here
5 marked by the
red events absolute count beads
6 implemented
into the lysis buffer which
7 guarantee that
during measuring there is not
8 any impairment
of the machine when the sample
9 is drawn and
so on and so on and so on.
10 These are data we
performed in my
11 department in order
to characterize how flow
12 cytometry can be
used and how the signals are
13 produced after
artificial contamination with
14 .03 CFU/mL. You see
the time after
15 contamination and
the bacteria is clearly
16 growing
up.
17 As you can see
here in these two
18 pictures there is a
problem regarding the
19 differentiation
between the platelet debris
20 and the bacteria.
In consequence a two-step
21 method has been
developed which prolongs a
22 little bit the time
up to diagnosis from 10 to
Page 96
1 20 minutes but
is producing much better
2 discrimination
between the platelet debris and
3 the bacteria
signal.
4 Okay. Next
information and then I
5 would like to
finish with the flow cytometry
6 data. There is
a way to increase sensitivity
7 of rapid
bacteria detection by flow cytometry
8 simply by
drawing a sample, take the sample
9 into tube,
incubate the tube at 37 degrees.
10 This is shown here.
That means sample drawn
11 16 hours after
contamination almost no signal.
12 Then
pre-incubation at 37 degrees
13 for one hour, for
two hours, and that is the
14 sample drawn from
the platelet after 18 hours.
15 You can see you
have to compare it with the
16 pre-incubated
sample. It's an impressive
17 increase in
sensitivity of the method. All
18 together the
increase per one hour incubation
19 at 37 degrees is
around one lock step.
20 Summarizing rapid
bacteria
21 detection using
flow cytometry detects
22 bacteria and fungi
because of resin-sized
Page 97
1 nuclear-phillic cowering or laboring genome
2 and ribosomes of microbes. It's feasible
3 sensitivity is 103 to 104 CFU/mL can be
4 improved by pre-incubation. Result is
5 available after 20 minutes.
6 Rapid
bacteria detection using Pan
7 Genera
detection system developed by Verax and
8 now offered in
collaboration with Abbott.
9 Mark Brecher
mentioned it already. We do not
10 have up to now our
own experiences on the
11 basis of the
available data. I would like to
12 assess it as a
feasible approach too. It
13 detects a broad
spectrum of bacteria. It's
14 not able to detect
fungi. Sensitivity between
15 103 to 105 CFU/mL
result after around one
16 hour.
17 Rapid detection of
microbes using
18 real time universal
bacteria and, of course,
19 fungi, PCR NAT. The
basis is that on the
20 ribosomal RNA of
microbes bacteria as well as
21 fungi they are
highly conserved sequences so
22 there is a chance
to perform in one PCR
Page 98
1 identification
and analyzing detection of any
2 bacteria
species or any fungal species
3 imaginable.
4 These are
data from my post-doc
5 Dr. Melanie
Stomer in my department working
6 with bacterial
suspensions alone there is a
7 sensitivity in
RTPCR of 16 CFU/mL. Not bad
8 but when we
are going into platelet
9 concentrates
one of the scientific backgrounds
10 for this
sensitivity is that the mitochondrial
11 DNA from human
beings has cross-reacting
12 regions with the
ribosomal RNA from bacteria.
13 That means
sensitivity in PCs for several
14 reasons is 102 to
103 CFU/mL.
15 In my knowledge,
there is no
16 commercial variant
available up to now from
17 universal bacteria
PCR. Me, personally, I
18 know a lot of
different groups at least in
19 Europe which are
dealing with and which
20 approved the
approach. From my perspective,
21 sensitivity is
acceptable. There is one
22 problem considering
real time PCR, especially
Page 99
1 reverse
transcriptase, real time PCR. Of
2 course, I need
a few hours for production of
3 the result and
so PCR is not a real rapid
4 method when
compared with the other methods I
5 showed
you.
6 A few data
regarding an
7 interesting
approach which is available or
8 have been made
available by a company from
9 Seattle, BCSI,
Blood Cell Storage, Inc.
10 Actually they
performed or they developed a
11 procedure for
in-line pH measuring in platelet
12 bags without any
opening of the system by a
13 scanning procedure
of resin-sized - labeled
14 here to a membrane
inside this blue cylinder.
15 What we did we
contaminated the
16 platelet bags
following the approach .03
17 CFU/mL starting
dose. Here you can see the
18 data regarding
bacterial growth. This is the
19 pH. The pH will
drop down after the bacteria
20 had reached a high
number. In this case
21 klebsiella
pneumoniae strain 108 per mL. That
22 could be
abated.
Page 100
1 That had been
published by Steve
2 Wagner in the
middle of the '90s evaluating
3 the pH
measuring as a screening method.
4 Surprisingly
after this decrease there was a
5 re-increase of
the pH inside the platelets.
6 I have not
time enough to discuss it up to the
7 last detail.
In my eyes, it is at least a
8 very
interesting result.
9 The same
holds true, for instance,
10 for yeast in this
case -- this one was from
11 Canada. This is a
summary of the results
12 obtained with
different strains, different
13 blood bacteria
standards in comparison to the
14 negative control.
At least this approach
15 could be used or
would produce better results
16 than the approach
mentioned by Mark Brecher.
17 That means the pH
measuring with
18 dip sticks or
strips or whatever. Of course,
19 generally pH
measuring in PCs is not accepted
20 to be a solitary
approach for platelet
21 bacteria screening
because of its low
22 sensitivity. On the
other hand there are time
++