UNITED STATES OF AMERICA

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	FOOD AND DRUG ADMINISTRATION
	CENTER FOR BIOLOGICS EVALUATION AND RESEARCH

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	BLOOD PRODUCTS ADVISORY COMMITTEE

	72ND MEETING

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	FRIDAY
	MARCH 15, 2002

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This transcript has not been edited or corrected, but appears as received from the commercial transcribing service.  Accordingly, the Food and Drug Administration makes no representation as to its accuracy.

		The Committee met at 8:00 a.m. in the Grand Ballroom, the Gaithersburg Holiday Inn, Two Montgomery Village Avenue, Gaithersburg, Maryland, Dr. Kenrad E. Nelson, Chairman, presiding.

PRESENT:

KENRAD E. NELSON, M.D.               Chairman
JAMES R. ALLEN, M.D.                 Member
MARY E. CHAMBERLAND, M.D.            Member
KENNETH DAVIS, JR., M.D.             Member
DONNA D. DiMICHELE, M.D.             Member
SAMUEL H. DOPPELT, M.D.              Member
ROBERT J. FALLAT, M.D.	Consumer Representative
LIANA HARVATH, PhD	Temporary Voting Member
F. BLAINE HOLLINGER, M.D.    Temporary Voting Member
JEANNE V. LINDEN, M.D.       Temporary Voting Member
RAYMOND S. KOFF, M.D.                Member
JUDY F. LEW, M.R.                    Member
TERRY V. RICE                        Member
PAUL J. SCHMIDT, M.D.                Member
DAVID F. STRONCEK, M.D.      Temporary Voting Member
SHERRI O. STUVER, ScD                Member
LORI A. STYLES, M.D.                 Member
LINDA A. SMALLWOOD, PhD      	Executive Secretary

	I-N-D-E-X
	Page

III. Review of Data Supporting Extension of	
     Dating Period for Platelets

	A.  Introduction and Background	12
		Jaro Vostal, M.D., Ph.D.

	B.  Extension of Platelet Storage	16
		Sherrill Slichter, M.D.

	C.  Safer, Cheaper and Just as Good	56
		James AuBuchon, M.D.

OPEN PUBLIC HEARING

	D.  Committee Discussion	112

IV.   Bacterial and Fungal Contamination of
	Human Tissue Intended for Transplantation

	A.  Introduction and Background	140
		Ruth Solomon, M.D.

	B.  Microbial Contamination and Cross	147
	    Contamination Concerns During Processing
		Mary Malarkey

	C.  Preliminary Findings From 	168
	    Investigation of Allograft-Associated 	                Infections
		Marion A. Kainer

	D.  Reducing the Risk of Tissue 	203
	    Transplant-Transmitted Infections
		D. Ted Eastlund, M.D.
	
	E.  Adverse Reactions After Corneal	241
	    Transplantation
		Michael A. Lemp, M.D.

OPEN PUBLIC HEARING	265

	F.  Committee Discussion

ADJOURNMENT	273

	P-R-O-C-E-E-D-I-N-G-S
	(8:07 a.m.)
		DR. SMALLWOOD:  May I ask the Committee members to please be seated.  
		Good morning.  Welcome to the second day's session of the 72nd meeting of the Blood Products Advisory Committee.  I am Linda Smallwood, the Executive Secretary.
		On yesterday I read the conflict of interest statement that pertained to the proceedings of this meeting.  If there are any questions concerning that, you may see me at the break, and I will be happy to share that statement with you.
		For today's meeting, we will have Dr. Jeanne Linden, who is a consultant and who will be participating with us today.  Also, two of our members will be -- that were present yesterday are absent, Dr. Fitzpatrick and Dr. Klein.
		I would just like to ask the Committee members, if you need to have arrangements made for taxis, to please see the young ladies at the desk outside during the break.  
		There will be one deviation from our agenda this morning.  We will start out with a presentation from Dr. Richard Lewis who will provide you with a summary of a workshop on medical errors.  Other than that, we will proceed with our agenda as printed, and hope to keep on time.  Thank you.
		DR. LEWIS:  Thank you, Dr. Smallwood.
		I have a 15 minute summary of the workshop, and Dr. Smallwood told me that I had to do it in seven minutes.  That was one of the conditions of being on.  So she is serious about keeping on time today, and I'll try to do my best to do that.
		In the month of February we helped sponsor a workshop on best practices to reduce transfusion errors, and I think this is a very important subject, and it was a worthwhile workshop, which was sponsored both by FDA and the Agency for Health Care Research and Quality, both HHS agencies.
		If I could have the next slide, please.
		We looked at various areas of errors that could occur in transfusion services and blood banks.  We summarized some of the current safety initiatives within Health and Human Services, looked at what some of the sources are for errors, looked at some systematic errors and how to address them, how reporting could figure in on errors in transfusion, and looked at some of the technology that could address some of those problems, both current technology and future technologies.  Next slide.
		Within HHS, to summarize some of the Patient Safety Task Force initiatives:  The Patient Safety Task Force is an HHS-wide task force which includes members from FDA, CMS, CDC, and AHRQ.
		The ARHQ also has some independent work on patient safety.  They are funding grants and contracts to address medical errors, and also lead the Patient Safety Network, which is an effort to device a large computer analysis method, not a single database but a method to look at all of the different types of information relating to errors that might be contained within HHS.  
		We also heard from CMS and discussed their Quality Improvement Organization, which also is an error reporting emphasis.  Next slide.
		Some of the sources of transfusion error:  We heard that there are roughly -- this is data from Kathleen Sazama as well as Jeanne Linden.  Roughly,  over the last ten years 37 deaths per year occur as a result of transfusion errors.  Estimates are that about five percent of -- this represents about five percent reporting.
		The majority of those errors are ABO incompatibility, roughly 56-59 percent of fatalities, and these errors generally occur either at sample collection or at the actual transfusion.  Twenty-five to 29 percent of those errors occur at the blood bank.  Next slide.
		So it was confirmed by presentation from Hal Kaplan that the human/system interface is where most of these particular errors occur, and some of the contributing factors are wrist band removal, incorrect labels, and confusion over the name of the patient.  Next slide.
		We heard form Dr. Michael Busch about infectious disease testing, and he had looked at a large database of discordant results between NAT testing and serology in both HIV and HCV studies.  He commented that investigating these particular discrepancies offered an opportunity to see where errors might occur in testing.
		He put forth a rather large number.  If you consider the errors in testing as well as prevalence, the chances of getting an infectious disease from a unit of blood were about one in one billion.  Next slide.
		We discussed systematic errors, and errors in a particular system and how one operates come from both the organizational level, physical contact with the patient, the environment that the individual -- in which they work, as well as the social attitudes in the particular establishment.  It was pointed out that it is important to identify points in a process where errors are most likely to occur.  Next.
		One presentation addressed some of the inexpensive devices that are used in other areas.  That was referred to as Poka-Yoke.  It's a Japanese system, and some of the examples that they gave were, as you enter a parking garage, for instance, there is a wooden bar that hangs down that stops vehicles that are too large from going in.  We saw how doors would have a handle on it to pull and a plate to push, and we were encouraged to look at some simple, inexpensive devices that prompt us technically to do the right thing and void errors.  Next slide.
		In evaluating the donor history questionnaire, Susan Wilkinson presented some work that she and some of her collaborators have done using an objective structured clinical examination.  They had trained donors and tested the interviewers for their competency, and used this as a system of evaluating the actual donor history, the individuals taking the history as well as their interpretation of the responses.  Next.
		We looked at a number of reporting systems which changes the focus from identification -- In a hospital setting, it encourages changing the focus from identification of a liability situation to one in which you are constantly self-examining your system to determine where there might be particular errors.  Next.
		We heard form Sharon O'Callaghan, who discussed the FDA Biological Product Deviation Reporting in manufacturing.  Most of those reports come in the areas of quality control, labeling or routine testing.  
		This particular system also includes a root cause analysis, and some of the major identification of causes for errors were that the individuals were too busy, that there were clerical errors or handwritten, as well as additional needs in the particular environment.  Next slide.
		MERS-TM is a system that I would hope that everyone has at least heard of, a reporting system that focuses on systems and training rather than individual liabilities, again.  We heard an example of its implementation at a large facility and their event recognition and system correction methods.  Next slide.
		Barcoding today has a focus of HHS, and the Secretary Thompson has encouraged the development of a regulation that would require all drugs and biologics to have barcoding.  The overall scope of that rule is yet to be decided, but look for this spring a large workshop to discuss both the scope as well as the type of barcoding.
		We should all be familiar with ISBT 128, and we heard about the regulations and implementation of new rules to remove barriers to implementation of ISBT 128.  Next slide.
		We heard other technology trends.  The automated donor interview was presented, and some information on how that facilitates the donor history.  Dr. AuBuchon presented patient identification system, the blood lock, and his estimates were that it saved, in his facility roughly $200,000 quality adjusted life years, and he pointed out that, although this is very high for other implementation of medical procedures, however, in the context of some of the things that we do to reduce the incidence of infectious diseases in blood, this was rather small.
		We also looked at laboratory instrumentation and some of the testing equipment, and how that particular equipment incorporates systems so to reduce interactions with humans and automate the process as much as possible to reduce errors in testing, as well as some patient identification systems, barcoding on wrist bands as well as on blood banks, and how that could reduce numbers of errors.  Next slide.
		In terms of future technologies, we heard some interesting presentations from the International Biometrics Association.  They talked about identifying the actual biological unit through things such as voice scans, facial scans, and fingerprint analysis.  		I thought it was very interesting, in terms of fingerprint analysis, that there were devices as small as an inch in diameter that one could place their thumbprint on and read the individual immediately.  It seemed to me that that could be very applicable to the patient setting where you could find an individual's fingerprint, whether they are conscious or unconscious, and identify the appropriate unit.
		Software to identify an individual is available, and rapid -- Actually, it's faster to verify that an individual is who you think that it is than it is faster to identify an individual.  I think this verification would be something that would be applicable in the hospital setting.
		Thank you very much.  I don't know how I did for time.  I hope that I stayed within my boundaries.  I appreciate the opportunity to present this.  I thought it was an important topic and, hopefully, we will address it again at the AABB convention this fall.  Thank you
		CHAIRMAN NELSON:  Any questions or comments?  Yes, James?
		DR. ALLEN:  In one of your early slides where you showed 37 deaths per year and estimated that was about five percent reporting, given that the event is a death, I'm surprised at the degree of underreporting.  Is there any explanation for that or ways to correct that?
		DR. LEWIS:  These were data from Dr. Sazama from M.D. Anderson, and she didn't cite, and I didn't follow up, what her actual sources were.  She said that it had been reported.  I was surprised, too, and it isn't in our regulations that it is mandatory reporting for all deaths that are associated with transfusion.  
		CHAIRMAN NELSON:  Thank you.  
		DR. LEWIS:  Thank you.
		CHAIRMAN NELSON:  The first topic today on the agenda is review of data supporting extension of dating period for platelets, and this will be introduced by Dr. Vostal from the FDA.
		DR. VOSTAL:  Good morning, and thank you for the opportunity to introduce this session.  Today we are going to talk about the extension of platelet shelf life from five days to seven days and about the quality of platelets that have been stored out to seven days.  
		Just as an introduction, I would like to direct your attention to the slide over here that covers the platelet storage milestones that we have had over the history of.  Starting in 1981, back then platelets were stored out to three days, but improved plastics and bags allowed random donor platelet storage to increase from the three days to five days.
		Things were going pretty well.  So in 1984 this was further increased to seven days.  However, about a year and a half later, in 1986, there was a BPAC Committee meeting very similar to this one.  That discussed the incidence -- an increased incidence of bacterial contamination associated -- or bacterial contamination and substance -- transfusion substance reactions associated with platelet transfusions.
		Based on this data, the dating period for platelet storage was moved back to five days.  Now we fast forward to 2002, and we are coming to a point where we think we may have methods of controlling bacterial contamination of the platelet.  This could be either by detection or decontamination.
		So the question comes up again:  When we have the bacterial contamination problem under control, whether we can extend the shelf life of platelets back out to seven days.
		Could I have the next slide, please?  
		We have some reservations about directly extending the shelf life, and that is because there are major differences between platelets that were stored out to seven days in 1984 and the platelets that we are using today.  
		For example, if you look at the differences in the products that were used, in 1984 it was only random donor platelets that were stored out to seven days, but today we like to do random donor platelets as well as single donor apheresis platelets.  		Leukoreduction wasn't carried out back then.  So there are plenty of leukocytes in these products.  However, today leukoreduction is almost universal.  So there is a big difference in terms of number of white cells present in these platelet products.
		The storage conditions themselves have changed.  The plastic bags that were used in 1984 have been improved with different plastics, and some of the apheresis instruments also have different plasma to platelet ratios.  So all these things put together make for a different condition for storing platelets out to seven days.
		If I could have the next slide.  Now this slide -- This is a cartoon modified from Scott Murphy's review in Transfusion Medicine Reviews in 1999.  It kind of focuses on the different factors that play a role in storing platelets.
		Of course, there is the plastic bag that's gas permeable to oxygen and carbon dioxide.  The  platelets are themselves stored at room temperature in plasma, and they have the presence of leukocytes.  The biochemical events that take place in these cells is that free fatty acids are metabolized by oxidative metabolism to ATP, and glucose is metabolized by glycolysis to lactate and lactic acid.
		Now the ratio of these -- or the predominance of these pathways is determined by the availability of oxygen that is diffusing through the outside -- through the bag.  
		In the lack of oxygen, the predominant pathway is glycolysis and produces lactic acid, leads to generation of acid in plasma.  This is usually buffered by bicarbonate that can convert -- that can combine with the acid and generate CO2 which can then diffuse out of the bag.
		If there is -- So in cases where there is low oxygen present, you can have a lot of acid generation.  And if it overcomes the bicarbonate present in plasma, you can have a drop in acid or drop in pH.  You can also have a rise in pH if the number of platelets present is decreased or if the number of leukocytes that also contribute to the cycle is decreased.
		So the pH at the end of storage of the platelet product sort of indicates the conditions that the platelet went through when it was stored out.
		Just to show you that we think these conditions are changes, I would like to show you the next slide.  This is data that is collected by the FDA from platelet products that are submitted to FDA for licensure, and we measure pH at outdate of these platelet products.
		You can see that in 1995 pH was close to 7.  By '96-97 and up to '99, there is a rise in pH.  This may not seem that much, but if you look at the next slide, here we show the percent of the products tested that have a pH greater than 7.4.
		As you are going from '95 to '99, you can see that by 1999 more than 40 percent of the products have a pH greater than 7.4.  
		Now it's not clear whether this has any detrimental effects on platelets when they are transfused, but I think it demonstrates that the conditions for platelet storage are changing over time.  That is why we are actually interested to see whether the platelets that are stored out to seven days under the current conditions will still work when transfused today.
		So with that brief introduction, I would like to welcome Dr. Slichter, who is the Executive Vice President of Research at Puget Sound Blood Center.  She is going to continue with the clinical aspects of seven-day platelet storage.
		DR. SLICHTER:  Thank you.  Could I have the first slide, please.  As Dr. Vostal has mentioned, in 1986 over 15 years ago now, the dating time of platelets was shortened from seven days to five days, because of bacterial concerns, you know, as this -- let's see, have we got a pointer?  There.
		Because of this difference in growth rate of bacterial in platelets, which as everyone knows, are stored at room temperature, versus growth rate in red cells which are stored at four degrees Centigrade.  So that's why the dating period of platelets was, in fact, reduced.
		If you look at the data -- and this is a literature review done by Mo Blajchman, reported in 2000 -- bacterial contamination of a platelet component is not insignificant, .3 to 1.6 percent.  Transfusion associated sepsis is one in 50,000 transfusions with a 20 percent fatality rate, and would suggest that there are 50 to 100 deaths per year associated with bacterial contamination.
		Now the causes of bacterial contamination are pretty well understood.  Probably the biggest reason for bacterial contamination is inadequate skin preparation prior to the venipuncture.  One way to potentially avoid this complication is to remove the first aliquot of blood, which is considered to reduce the risk by taking either the skin plug out of the system and diverting it prior to drawing the rest of the blood into a bag.
		The real advance, I think, in terms of whether there is a possibility for extending platelet storage is in the last two areas.  There are -- and Dr. AuBuchon who follows me will discuss this.  There are a variety of systems now that may be able to be used to detect the presence of bacteria prior to release of the product from the blood center that will allow us to prevent bacterial transfusion, and extend platelet storage.
		The other process that is moving along is a decontamination process.  So that there are techniques now available for pathogen inactivation of platelets prior to their storage.
		Now what I am going to talk to you about today, because I have a limited amount of time, is I am going to concentrate on the in vivo transfusion aspects of platelets.  As many of you in this room know, there are a variety of methods of in vitro  testing of platelets to determine the quality of the platelets.  
		It is at least my opinion that those in vitro assays can tell you whether it's a go or no go, meaning that if the in vitro assays look very abnormal, you probably don't have a product that will survive in vivo.
		If the in vitro assays, however, look reasonable, you really, in my opinion, don't know whether that is going to give a very high recovery and a good survival or something much more modest.  So what I am going to concentrate with you on today is in vivo evaluation of platelets during storage.
		There are really two major techniques that we use.  One is to store autologous platelets in normal volunteers.  We radiolabel the autologous platelets and reinfuse them.  
		Because we have two different isotopes that we can use, either chromium or indium, we actually have the opportunity to store two different products under differing conditions and simultaneously or sequentially transfuse those products into the same normal volunteer.
		Now the reason why that is a distinct advantage is because, for reasons that we really don't understand, there are substantial differences in how well each individual platelet stores.  So that the ability to compare in the same individual labeled platelets and simultaneous reinfusion is a big advantage.
		Now once the data suggests that radiolabeled viability measurements in normal volunteers are reasonable, then we go to transfusion experiments in thrombocytopenic patients where viability is measured by platelet increments, corrected count increments which I'll describe, days to next transfusion, and also, importantly, to measure hemostasis; because, after all, platelets are supposed to prevent or control bleeding.
		Now I am going to talk about two different aspects of how to determine the quality of the platelets.  Both of them have to do with looking at the platelet increment, which is the post-transfusion minus the pre-transfusion count, and then making a correction for the volume of distribution.  
		So the platelet recovery does it by blood volume divided by number of platelets transfused.  The corrected count increment makes a similar adjustment based on body surface area, again divided by number of platelets transfused.
		Now this is a very important slide that I am going to spend a little bit of time on, because one of the issues is that we know that, on average, about 60 percent of the platelets that we transfuse circulate.  The other third are pooled in the spleen, and the normal platelet survival is somewhere around eight to ten days.
		So the issue becomes, if we only have a cell which has an intrinsic life span of eight to ten days, how long can we really expect to extend storage in vitro and get a product that is worth transfusing?
		Well, the very interesting study that Stein Holme did with Andy Heaton in 1995 looked at five-day stored platelets, which is the green line here, compared to fresh, and you can clearly see that both the recovery and the survival is reduced.  But interestingly, they, simultaneously with the five-day stored platelets, harvested platelets from the same normal individual and radiolabeled them fresh at the time that this was infused.
		What this data shows is that the viability of the platelets after two days in vivo is the same as after five days in vitro, suggesting in fact that the platelet does not have an intrinsic lifespan, but rather the lifespan is influenced by the conditions under which it is maintained, and that you are worse off to be in vivo than in vitro.
		What he then did is do a calculation which he called mean residual platelet lifespan, which looks at the area below the survival curve divided by the initial platelet recovery, and basically showed that, if you make that calculation, this is in vitro mean residual lifespans and in vivo.  So that the platelet aging in vitro was only .44 percent of the -- was only 44 percent of that in vivo.
		So that what this suggests is that, in fact, if we do store in vitro, we may be able to get a useful product that's been stored for eight, ten or even somewhat longer because of the difference.  He attributed the difference between how platelets survive in vivo and in vitro to the differences in storage temperature.
		So in vitro, we store at 22.  In vivo, as you know, that's 37.  So the metabolic activity of platelets in vivo is substantially higher than it is in vitro.
		Now the next set of data that I am going to show you looks at the issue which Dr. Vostal alluded to, that there are a variety of platelet products now available for storage.
		So since it's been 15 years since we have been able to store platelets for seven days, a lot of the data that I am going to show you is at five days of storage.  But the first thing I wanted to address with the audience is:  Is there a difference in five-day storage of platelets based on the method of preparation of the platelets, because we know that platelets can suffer a collection injury.
		In other words, if you centrifuge the platelets too hard during their preparation, that produces an injury, and in addition, there is a storage injury.
		So we, as everybody, I think, in this  room knows, make platelet concentrates by what's called the PRP system where we take whole blood.  WE do a soft spin.  We remove the supernatant PRP, which has a high leukocyte count.  We do a hard spin, and then we re-suspend the platelets in a small volume of residual plasma.
		In contrast, in Europe they make so called buffy coat platelets.  Here what happens is you take the whole blood and, instead of doing a soft spin, you do a very hard spin, which then concentrates the platelets as well as the white cells on top of the red cells.  You then remove the buffy coat layer.  You pool the buffy coats and do a soft spin.
		So that the issue here became the hard spin to make a platelet concentrate in the U.S. is done at the end, and the platelets are hard spun against the walls of the bag.  
		In this system the hard spin is done against the red cell layer, which theoretically means that the buffy coat platelets, in fact, may be a better quality platelet, because at no point are the platelets hard spun against the walls of the bag.
		Now this is starting to show the data on storage time in plasma on post-transfusion platelet viability.  These are paired, radiolabeled, autologous platelet storage studies in normal volunteers.
		In this study there were nine volunteers who participated.  Their platelets were stored in PRP platelet concentrates, and this is recovery and survival data at zero recovery and survival at five days.
		Now in some of these studies they didn't provide in the manuscript the p-values.  So anything that had a statistically significant p-value I will have listed on the slide.  So there is some decrease both in recovery and survival here.
		These are buffy coat platelets, again some decrease in recovery and survival, but you will note that the recoveries and survivals at both time zero and five days are basically the same.
		This is now apheresis platelets stored for one day or five days, and absolutely no difference in this data.  
		This is now five-day versus seven-day, nine individuals in two separate studies.  What you can see here is basically there is no difference between five-day and seven-day stored platelets, autologous platelets in plasma in normal volunteers in this one study.
		Now this is five-day storage of different types of radiolabeled autologous platelets in plasma.  This is PRP-PC, buffy coat PC, nine individuals.  This is platelet recovery, no difference.  This is buffy coat versus apheresis C, which is Cobe.  This is PRP apheresis F, which is Fenwal.  This is PRP apheresis H which is Haemonetics.  No difference in any of this data between the different types of products when stored for five days.
		Now this is survival data from the same studies.  Again no difference in the survival or recovery of different types of products when direct comparisons are made in the same normal individuals.
		Now the other thing that is of interest, I think, when we consider extending platelet storage is whether or not the use of additive solutions would provide a benefit.
		As you know, we now store platelets in plasma.  Many of the buffy coat preparations done in Europe are pooled and re-suspended in a platelet additive solution.  Use of a platelet additive solution may provide benefit, because it may improve the quality of the platelets during storage, and also allow us to salvage more plasma for other uses.
		So this just lists the kind of platelet additive solutions that have been used and are available.  They have a variety of different kinds of things in them.  What they all contain is either acetate, gluconate or citrate as sources of metabolic energy, because one of the problems you will notice is that none of these solutions contain glucose, because glucose tends to caramelize under sterilization conditions, and so there needs to be provided alternate sources of nutrients to support oxidative metabolism.
		Most of the studies have used a residual plasma concentration of somewhere around 35 to 30 percent to provide some glucose.  So that none of these studies are stored in 100 percent of the additive solution.
		Now this is a study again done by Stein Home, published in 1994.  The reason to show you this data, I think, is because it quite nicely shows the storage lesion.  So that over time -- This is plasma stored platelets.  You can see that over time, and he stored platelets up to 15 days where the platelet recovery is less than ten percent.
		You can see that there is loss of viability over time.  He then looked at PAS-2 stored platelets, starting at five days, showed that they were the same at five days as plasma, but some improvement actually in the quality of the platelets when stored in PAS versus plasma over time, starting at seven days of storage.
		This is the same study, but now instead of looking at platelet recovery, looking at platelet survival, again showing the loss of survival of platelets in circulation.  Same data at five days, but an improvement at seven days in PAS compared to plasma.
		This is studies that we have recently been doing in Seattle looking at Plasmalyte.  The only storage solution that is commercially available for us to use is Plasmalyte.  We have used Plasmalyte concentrations of 50 to 82 percent and, in fact, think that the recovery is better with the higher Plasmalyte concentrations than the lower.
		So our current standard is to use about 80 percent Plasmalyte.  Here is our -- We did six normal volunteers, paired observations.  This is five-day storage in Plasmalyte versus plasma.  As you can see, the data is exactly the same.  
		This is now ten normal volunteers stored for seven days, Plasmalyte versus plasma, and as suggested in the prior slide from Dr. Holme, at seven days we are getting better recovery, statistically significant difference in Plasmalyte compared to plasma, and a bit better survival compared to plasma, but does not reach statistical significance.
		Now the other thing I would like to share with you, kind of again in regard to Dr. Vostal's statement that we are now storing platelets under conditions that are truly different than they were 15 years ago.  What I would like to point out to you is that these recoveries of 80 and 64 percent in Plasmalyte are extremely high, and much higher than we would have predicted.  
		The old data would have been somewhere around 40 to 50 percent recoveries at five and seven days, and I don't have a good explanation for this except to say that I've got the same technician who is using the same radiolabeling techniques, and we can't identify that it is a difference in how we are processing the platelets that have led to this difference.  
		Now what we next did is do paired studies in normal volunteers, did five normal volunteers, where each bag of their apheresis collected platelets -- one was stored for five days, one for seven days, but both were stored in Plasmalyte.  
		What you can see here is that the recoveries are exactly the same, some decrease in survival, but not a statistically significant difference.  So that going from five-day Plasmalyte to seven-day did not produce a change.
		The only clue we have about why the recovery may be better in our current studies is because, in order to do the Plasmalyte storage studies, we needed to have donors with high platelet counts.  
		So what you can see here is this is our five versus seven-day Plasmalyte data that I just showed you.  This is then the platelet count of the donor, and you will notice that the donor whose platelet count is around 200,000 has, in fact, a recovery in the fifties, which is what we would anticipate, but there seems to be a higher recovery in people who have higher platelet counts.
		This may be very interesting, because this may be a physiologic thing, that one of the reasons potentially why people have high platelet counts is because they have less storage of their platelets in the spleen, and again you notice how close the recoveries are for an individual donor, always higher for the five-day than for the seven-day, but very close data when the same normal individual is used for paired observations.
		Now the last part of the talk I am going to talk about what we are really interested in, which is ow well the platelets do when they are transfused into thrombocytopenic patients.
		This is very old data which we collected that basically shows that the normal platelet recovery is around 60 to 65 percent.  Normal platelet survival is somewhere between eight and ten days.  But if you get a thrombocytopenic patient who actually needs transfused platelets, although their recovery is similar to what's found in normal, their survival, in fact, is reduced, and it is around five days under optimum conditions.
		Now platelets are lost by two mechanisms.  One is senescence with a maximum platelet lifespan of ten days.  But interestingly, there is a random platelet loss in hemostasis.  So about 7,000 platelets per microliter per day are lost in what we consider to be an endothelial supportive function, and this loss is irregardless of the age of the platelets and is to prevent us from leaking through our vascular system.
		Now there's a direct relationship -- Once you get to less than about 100,000 platelets, there is a direct relationship between platelet count and platelet survival.  So that the lower your platelet count is at the time you are transfused, the more reduced is your platelet survival.
		So that when you are talking about transfusing platelets into people whose baseline platelet count is somewhere around 10-20,000, you are talking about a survival of about two to three days.
		So the point of this discussion is that, in terms of storing platelets, we would like to have platelets which have basically a normal recovery, and then as long as the survival of platelets is at least two or three days, if not more like five or six days, because you don't want the survival of the product to be shorter than the intrinsic survival of the cell in the patient.  
		So I think, since the average platelet lifespan under optimum conditions -- I think most clinicians would think, if they get a five-day survival out of transfused platelets, they are doing very well.  So I think that's the target that we conceivably ought to use.
		Now I picked again out of the literature the best studies that I could find which made good comparisons.  This is now fresh versus five-day plasma stored PRP platelet concentrates into the same -- from the same donor into 12 thrombocytopenic patients.  So the donor came back on different occasions and  transfused the same thrombocytopenic patient.
		You can see here that five-day storage, recoveries are about 47 percent less than fresh, survival 8 1/2 days versus 6 1/5.  So less, but obviously very good data.
		This is now transfusion of one, three and seven-day plasma stored PRP into the same 16 patients.  So they were given three transfusions of either one, three or seven-day stored platelets.  This is looking at corrected count increments at an hour and 24 hours.  No difference between three-day and seven-day stored for either one hour or 24 hour CCI, but a statistically significant difference between one hour in either three or seven at both time periods.
		This is now looking at 18, 17, 13 patients, all of whose platelets were either PRP, buffy coat or apheresis.  This is the number of each type of transfusion that these 18 patients got.  So they got all PRP-PC, 162 transfusions.  
		Storage time averaged about three days with all of the preparations, and none of these are statistically significant differences in terms of one hour or 24 hour CCIs.
		This is the patients transfused with platelets stored for three to five days in plasma, PAS or Plasmalyte, and the type of product.  So this is buffy coat.  This is apheresis, buffy coat, apheresis.  		The only statistically significant difference, interestingly, was for buffy coat platelets stored in plasma versus PAS-2.  CCIs at both one hour and 24 hours were better for plasma than for PAS-2, but none of these other differences are statistically significantly different, again suggesting that all of the products that we have available do basically the same thing under the same storage conditions.
		Now I am going to end up the talk with a discussion about the pathogen inactivation system that is currently farthest along in its development.  It is a system that has been proposed by a Cerus-Baxter consortium.
		It involves using basically a PAS-3 solution.  They call it InterSol.  So 65 percent PAS, 35 percent plasma.  They add a psoralen called amatosolin as 59 to the collected platelets.  They then expose this platelets to UV-A light, and then they transfer the UV-A exposed light platelets to another container that has an absorption device that removes any residual breakdown products of the amatosolin or any remaining whole product.  Then it is finally transferred to a storage container.
		Now it is important that this product, in fact, be in a storage solution, because UV-A light has very poor penetrance.  So reducing the amount of residual plasma allows better penetrance and, therefore, an inactivation process to proceed.
		Now using this inactivation process, this is the data that was obtained in 16 normal volunteers who had apheresis collection done.  Half of the product was treated.  Half was not treated, and this is the platelet recovery and survival data after five days of storage.
		Although there is a statistically significant decrease in platelet both recovery and survival, the quality of the product is still within clearly an acceptable range.
		Now there have been two transfusion trials, one done in the U.S., the so called SPRINT trial, one done in Europe, the so called euroSPRITE trial, that have actually looked at pathogen inactivated platelets transfused into thrombocytopenic patients.
		In the U.S. trial the platelets were collected by Amicus apheresis machine.  In the SPRINT trial buffy coat platelets were used.  This now looks at the platelet increment at one, 24 hours, platelet transfusion interval, and platelet transfusion events.
		What you can see, again as would have been predicted by the normal volunteer radiolabeled studies, the recoveries and survivals of the treated platelets are statistically significantly less for both the Amicus as well as the buffy coat treated platelets.
		Here the differences are not statistically significant, but there is clearly a trend for the treated platelets to provide less quality platelets than the control.  Here you see again that the transfusion interval is the two to three days that I discussed with you is what we usually see in thrombocytopenic patients.
		Now these products were stored for up to five days.  So I think the issue is this is a pathogen inactivation process which introduces some loss of viability of the platelets following treatment, and then the issue becomes, if we take these five-day stored platelets and extend them to seven days, what is the data going to look like, since we have a somewhat compromised product even at five days that is  statistically significantly less quality product than similarly transfused control platelets.
		So I think that's an issue that needs to be addressed.  Finally, the last slide just looks at the primary endpoint, interestingly, for the U.S. SPRINT trial was not does the platelet count go up, do the platelets survive, but rather are the platelets hemostatically effective.
		So I think the FDA rightly wanted to make sure that the treated platelets, in fact, were still able to provide hemostasis.  So this is the treated platelets.  This is the control platelets.
		Patients who have WHO Grade 2 bleeding, percent in each arm, was exactly the same.  WHO Grade 2 bleeding is more than petechiae and ecchymosis, but a bleeding that does not require a red cell transfusion.  Grade 3 bleeding requires a red cell transfusion.  Grade 4 bleeding means that it's a life threatening type of bleed, and again bleeding events were the same.  Days of bleeding -- we are looking at mean a bit more in the treated than the control, but the median was the same.  Duration of platelet support was the same.  
		So with that, I will conclude.  Thank you.
		CHAIRMAN NELSON:  Thank you, Dr. Slichter.  Any questions or comments?
		DR. LEW:  Yes.  On a slide before, you showed events, and I didn't know what those events meant, but it looked like there was more in the treated group than the nontreated.
		DR. SLICHTER:  Yes.  This is -- Events means the number of times that you were transfused with platelets.  So in both the SPRINT trial and the euroSPRITE trial, in order to support you through your thrombocytopenic period, you needed about 25 percent more platelets.  Yes, Toby?
		DR. SIMON:  One fact that I kind of wanted to probe that isn't directly in your presentation but harkens back to the discussions of 15 years ago when we shifted back from seven to five days:  As I recall, the bacterial growth in the platelets was generally between three and five days.
		So a seven-day platelet was not necessarily more likely to be bacterially contaminated than a five-day platelet, but the thrust was that, as platelets -- that the longer the interval you allowed, the more longer storage you would have.  So that pushing it back might potentially reduce.  Is that the right recollection?
		DR. SLICHTER:  I think that's the right -- You know, what they are doing in Europe now, interestingly, is they are storing their buffy coat platelets for five days, and in some blood centers they are then using a pathogen inactivation system to then determine if the product at five days is bacterially contaminated.  If it's not, then they are now storing them for seven days.
		In specific answer to your question, Toby, I think that's right.  I mean, I think -- and I think Dr. AuBuchon will talk about that most people feel that a pathogen inactivation system -- you can't use it on day zero, because there is not enough time for the bacteria to have grown to allow their detection.  But if you start the detections process at three or four days, then probably you are going to have enough bacteria to see them, if they are there.
		I think, Toby, that the reason why -- You know, you probably know this better than I, because I think you were at the FDA or in the blood products -- in the government anyway at the time that this decision was made.  But I think the reporting did show that there was more evidence of bacterial contamination.
		Probably, as the first slide I showed, there has to be a certain log growth of platelets in order for it to be clinically relevant to a transfused patient.  
		DR. SIMON:  The major reason I'm bringing this up is just so people understand what I think is correct, that it's not so much that more growth occurs between five and seven days, but rather that the longer the storage, the more likely.  So the feeling is, if you go to seven days, you would get more contamination than if you had five days.
		DR. SLICHTER:  Oh, yes.  
		DR. SIMON:  The other issue:  I think that there was a feeling pragmatically that, if you had five days, it took care of most of the clinical problems, because you got -- It used to be three days, and then your Friday platelets expired on Monday, and it was terrible if you were a patient who needed platelets early in the week, and that five days allowed that you get through that, and holiday weekends.  But when you dealt with a lot of smaller hospitals and rural, seven versus five really did make a difference in helping with supply, whereas in the most urban metropolitan areas, it wasn't such a key issue.
		CHAIRMAN NELSON:  You know, but given the variety of organisms, I wonder if between five and seven you might get a higher burden and more clinical events.  Is that --
		DR. SIMON:  It would certainly be possible, but I think most of the problem occurred, as I recall -- I guess Jim will talk about it in a little more detail between the three and five days.
		DR. SLICHTER:  The other issue, I think, is that I have been told that there's some data that the storage solutions are bacteriostatic.  So that we may get some additional benefit, not only on the quality of the platelets by putting them in a storage solution, but potentially also on the rate of growth of bacteria.
		DR. HOLLINGER:  Is the issue with wanting to store from five to seven days one that a lot of platelets are outdated in that time, and what percentage are they, or is there some other issue of being able to more effectively use the platelets for patients and so on?  What's the major issue of wanting to extend it?
		DR. SLICHTER:  Yes.  The major issue, I think, is shelf life and outdating.  The outdating rate depends a lot on how good your blood center is about managing your inventory.  I think our outdate rate for platelets is maybe around 10-15 percent.  Is that right, Mike?  Okay.  Mike Strong is here from our blood center, and he knows the numbers.  
		So that's part of the issue, but for, as Toby said, a lot of small centers, they don't have an inventory that allows them to be as flexible as a large major metropolitan transfusion service such as we are happens to be.
		So I think, as long as we can document that we have a good quality product -- You know, it's kind of like when we went from 35 day stored red cells to 42.  You know, people said, well, you know, what do you need that extra seven days for?  Can't you manage your inventory?  And it made a very big difference in terms of outdating, once we eventually got the extended red cell storage.
		So I think that anything we can do to extend platelet storage will be a welcome addition for blood centers.
		DR. DOPPELT:  Do you have any idea by how much this will increase your inventory on shelves?  I mean, how many more platelets.  If you keep platelets for seven days, by how much will this increase the number of platelets you have available?
		DR. SLICHTER:  I don't know.  Mike, do you have any answer to that?
		DR. STRONG:  Strong, Seattle.  As Sherrill mentioned, for red cells we made a conversion to the additive solutions a few years ago, and it clearly dropped our outdate on red cells from about -- We were running about four to five percent, and we are now less than one percent.
		For platelets, the extra couple of days -- The big difference there is considering the time frame of the week and when you are drying the platelets, and as Sherrill mentioned, the weekend -- and as Toby has also mentioned, the weekend is where you suffer, because you can't get as much collections over the weekend either for apheresis or for whole blood platelets.
		So the extra two days really makes a big difference in how that inventory is managed over the course of the week.  So my guess is it could drop it as much as 50 percent by having that extra couple of days.
		DR. DOPPELT:  Can I ask a second question?
		DR. SLICHTER:  Please.
		DR. DOPPELT:  How effective are these platelets from a hemostatic standpoint, if they are extended for seven days?  I couldn't get a clear understanding of that.
		DR. SLICHTER:  There's really very, very little in the literature about even fresh platelets, five-day platelets, in terms of their hemostatic efficacy.  What I would say to you is that I am not aware of a situation in which the platelets are viable and not functional.
		So that in our experience, if the viability, meaning the recovery and survival of the platelets, is good,I'm not aware of a discrepant situation between function.  So for example, when we stored platelets at four degrees Centigrade, they had a good recovery and extremely short survival and did not correct bleeding time.
		So I think it is important that, when we get to seven-day stored platelets similar to what the FDA required for the pathogen inactivated platelets, that we in fact look at hemostasis and make sure that with extended platelet storage, hemostasis is still there.  But I don't know of any real data, even when seven-day stored platelets were approved and licensed, that really looked at -- specifically at hemostasis.  But most clinicians would tell you that, you know, once you put platelets in, you ordinarily expect to see bleeding controlled and didn't.
		I mean, there was not a hue and cry from the clinician saying, my god, everybody is bleeding to death now that you have seven-day platelets, but I think it's important not to forget that we are transfusing platelets to provide hemostasis.  So we need to make sure that that is, in fact, evaluated.
		DR. STRONCEK:  I guess a couple of things.  Managing platelet inventories is much more difficult than red cells.  I agree with what Sherrill and Mike have said, that red cells most places, I think, have a one percent outdating, but platelets it's ten to 15 percent.
		On transfusion services even in big hospitals, there  tends to be a handful of users that can use a lot of platelets.  So there are times when it's slow.  You know, the business is slow, and having an extra seven days helps.  Then long weekends, it makes a big difference.
		Then as far as -- You know, the effectiveness of platelets -- Maybe, Sherrill, you can comment on this, but my impression of platelets is when they get old, they tend to get cleared, but they still are probably somewhat effective with hemostasis.  		There were those platelet -- what were they? -- freeze dried platelets that people were trying to market about five years ago where it ended up they were platelet membranes which had very -- just minutes as far as half-life, but at least in animal models they showed that they were able to go to lesions and cause some hemostatic effect.
		So I would guess that, even if these platelets don't have as long a half-life, when they are there they probably help in some way.
		DR. SLICHTER:  Yes.  The other thing, I think, just information for the committee, we did a study looking at the platelet transfusion trigger and looked at 5,000, 10,000 and 20,000 as a trigger, and looked at radiochromium labeled stool blood loss as a quantitative measure of how much bleeding you do, depending on the level you are transfused at.
		I would tell you -- and there's data in the literature from transfusion trials -- that if you look at 20 versus ten, it's the same.  When we looked at 20, ten and five for a quantitative blood loss in the stool, it was the same.
		So I think the number of platelets that you need -- I mean, I mentioned that there are 7,000 platelets per microliter per day that are involved in an endothelial supportive function.  
		So I think, as long as you have at least 7,000 platelets circulating and they are of some quality, probably hemostasis is effective.  So I think the number of platelets you need to provide hemostasis is relatively small.
		DR. SCHMIDT:  We used to transfuse platelets that had been collected in the EDTA, because as we looked at the platelets under EDTA, they looked nice and round and, therefore, they must be good.
		I think we stopped doing that because of data out of Seattle which was post-cardiac surgery in which the message was kind of, if the platelet count went up significantly after transfusion, that was bad, because the platelets weren't doing their job.  They're not hemostatically effective.
		Was that Laurie Harker's data or --
		DR. SLICHTER:  I don't think Laurie ever--
		DR. SCHMIDT:  It was very old.
		DR. SLICHTER:  Well, it was very old data, and I think it was really Frank Gardner who -- and Dick Aster who really documented that EDTA spheres the platelets so that they are irreversibly sphered and compared to citrate collected platelets, they had very poor recovery and very poor survival.
		So I'm not sure that there was ever functional data on EDTA compared to citrate collected platelets.  I think that the viability of the platelets was substantially compromised in EDTA compared to citrate, but those were studies that were done by Aster and Gardner.
		DR. SCHMIDT:  But the studies of post-cardiac surgery -- I can remember that message, that if the platelet count goes up, that's bad, because they are not going to the walls of the vessels.
		DR. SLICHTER:  I don't think that's --
		DR. STYLES:  I think you make a very good point, which is that we could probably increase the platelet supply just by educating the clinician about the proper level at which to transfuse patients.  We could probably make a much greater impact than anything we would do with dating.
		I think, to me, the issue -- What seems to me you have said is that these platelets are probably effective or what is going to constitute effective enough and that they are probably going to result in an increased exposure of thrombocytopenic patients at the current level of clinical practice.
		I don't think that people are going to radically change, though I wish they would, the level at which they transfuse patients, but given the level of current practice, I would say that your data show pretty consistently that they are going to get more transfusions.
		Now the issue of whether you can give them a better product -- But I'm a bit concerned about that, given the problems of infection currently.  Now pathogen inactivation may eliminate that concern, but the other problems, especially in the multiple transfused patients with resistance to platelets, which I see all of the time and is a real problem.
		DR. SLICHTER:  Yes.  I think that is a problem, and I think the other issue that I've tried to address a little bit is the issue that, once you take one hit like if you have a collection injury and then you -- so that you hard spin the platelets against the walls of the bag initially to make a platelet concentrate by the PRP method, and then you store them, then that collection injury is magnified.
		So one of the concerns that at least I have is whether the pathogen inactivated platelets which have a processing injury from the pathogen inactivation, whether when we extend the storage of those, is that going to be a problem?  I don't know the answer.  
		I don't think any studies have been done.  I mean, they have done in vitro studies with the pathogen inactivated platelets for seven days and have shown that they have good quality, but as I've mentioned, I think in vitro and in vivo may not necessarily be the same.
		I also agree that we could substantially reduce the number of platelets transfused if we did, in my opinion, two things, which is reduce the trigger and also reduce the dose, because we don't need a 60,000 post-transfusion platelet count.  I mean, that makes the doctor feel good, but the patient doesn't need it.
		DR. STYLES:  I have one last question.  Were both these trials blinded?
		DR. SLICHTER:  Yes, they were both blinded trials.  Absolutely.  That was very important, particularly for the U.S. trial which looked hemostasis.  So the bags were covered.  The people who were doing the bleeding assessment had no idea which arm of the study the patients were in.
		DR. KOFF:  Can I ask you about the temperature issues that you've raised?
		DR. SLICHTER:  Yes.
		DR. KOFF:  David mentioned cryopreserved.  You've talked about the differences between 22 and 37, and now I see the reference to the Aster work that, I guess, looked at -- I'm not that familiar with it -- looked at -- must have looked at a curve at different temperatures in storage.
		DR. SLICHTER:  Yes.  Right.
		DR. KOFF:  Are there sufficient data -- Have those studies been repeated?  Have they looked not just at survival but hemostasis?  It just seems, without completely being ignorant of this, that if 22 is better than 37 and maybe there is a role for cryopreservation, is there some wiggle room for lower temperatures which would still maintain platelet function, survival, reduce bacterial contamination, growth at least?
		DR. SLICHTER:  Yes.  That's a very good question, because the issue is, if 37 is worse than 22, why don't you just keep going down?  We did look very early on at 4, which was the same temperature that we store red cells.  That was no good.  And Aster did do a very careful set of experiments going down from 22 to 20 to 18 to 15 to the dah-dah-dah.
		As soon as you got to something less than 20, you started to show substantial decreases in viability.  There were no function measurements made.  So I can't talk about function, but I can talk about viability.
		So I think we are not going to be able to push that particular envelope, which is a great idea, but I think is not going to get us where we want to be.
		DR. SAYERS:  Thanks.  Sayers, Dallas.
		Just a cautionary note.  Some would view that physician education is an oxymoron, but with that aside, just a question, Sherrill, of clarification.  
		You made mention about what some centers in Europe were doing looking at five-day platelets.  Now were they then subjecting some of those platelets to bacterial detection or bacterial inactivation?  If it was detection, were they just throwing out ones where they had --
		DR. SLICHTER:  The latter, Merlyn.  
		DR. SAYERS:  It was inactivation?
		DR. SLICHTER:  So they looked at detection, not inactivation.  The inactivation procedures are going to be done up front.  So you prepare the platelets.  You pathogen inactivate, and then you store.  
		So in Europe what they are doing is they are taking five-day platelets which are going to outdate.  They are then subjecting them to a pathogen detection process.
		DR. SAYERS:  I see.
		DR. SLICHTER:  And then the ones that are positive -- they are not transfusing the ones that are negative.  They are transfusing and allowing them to then better manage their inventory.
		DR. SAYERS:  Thanks.
		DR. LEW:  Just to follow up on Dr. Styles' comments, has anyone looked in the patients who need them continuously, assuming that they are going to get some that are earlier platelets and some that are later platelets, how much extra transfusion they will get, and then balance that to the other risks for platelet transfusion, as well as for people who may need it acutely for trauma, what it may entail in terms of extra platelets?
		Twenty percent or 25 percent that you mentioned seems awfully high in terms of the extra needs for someone who needs it chronically.  Has someone done those type of analyses at FDA or someplace else?
		DR. SLICHTER:  Not that I know of.  But, you know, one of the advantages of pathogen inactivation is that you inactivate the pathogens.  So that, even though you may have to give more platelets, they are in fact pathogen inactivated.  So the issue for the clinician becomes, as often with advances in science, there are tradeoffs. 
		So the tradeoff that you as the clinician have to recognize is you get a produce which is going to be pathogen inactivated for both bacterial, viruses and protozoa -- okay? -- and a broad range of viruses, bacteria and protozoa, and is that worth the fact that you may have to then increase the number of platelets that the patient requires.
		You know, one of the issues then becomes whether they are alloimmunized, but in this trial they did look -- At the U.S. trial they did look for the development of lymphocytotoxic antibodies in both arms.  There were over 300 patients per arm, a wide variety of patients, and the incidence of lymphocytotoxic antibodies in both arms was about five to six percent, and these are leukoreduced apheresis platelets that were transfused in both arms.
		DR. HOLLINGER:  I guess maybe we should in many cases promote single donor apheresis, just in terms of bacterial contamination, and just using a single donor sometime when you would have to use multiple units or bags which would compound the issue, I guess, of contamination.
		What percentage right now -- I have a couple of questions, but what percentage of the platelets that are currently used are from single donor versus random donor?  Do you know?  For patients?
		DR. SLICHTER:  Speak up, Jim.  Two-thirds apheresis, Jim says.
		DR. HOLLINGER:  Two-thirds are apheresis?  		The other question is just a technical one.  I was just curious.  Most of these studies are done with chromium labeled cells or indium.  Most cells -- I don't know about the platelets.  Red cells are usually negatively charged, and you put chromium on and they become positively charged.
		We used to use that actually to add antigens to the cells for doing serologic tests.  But what happens to cells?  Do we know, when you do a chromium labeling, does it alter the cells in some way -- the platelets in some ways that it -- where they might be more uptaken, the spleen or other places, endothelium and so on?  Do we have an idea about that, because that's what a lot of these studies are based on in recovery and survival?
		DR. SLICHTER:  Yes.  Well, we were concerned about that very issue.  So in the early days Scott Murphy was doing radiolabeling studies and doing them after storage.  So one of the issues was, was he getting that great data, because the dead cells wouldn't take up the label?
		So we actually did labeling studies pre-storage and, in addition, did some studies comparing fresh versus -- well, stored versus labeled in the same thrombocytopenic patient to try and look at the issue.
		As best I know, our data, nor am I aware of any data in the literature that suggests that the labeling process per se is somehow damaging to the cells or giving a different answer, but that's a very good question.
		Everybody now does post-labeling.  We do it, because we had a secretary who was ordering our chromium and found something cheaper in the book than what we were ordering.  So she ordered that for us, and lo and behold, it was cheaper because it wasn't sterile.  
		So I had some septic normal volunteers, because I stored their platelets for three days with nonsterile chromium, and I was one very nervous Nellie.
		CHAIRMAN NELSON:  Okay.  Thank you.  
		DR. SMALLWOOD:  Excuse me.  May I ask that everyone that has a statement to make or responding to a question please come to a mike and announce your name.  I know we know one another, but for the record we need to have it recorded, and our transcriber does not know everyone.  Thank you.
		CHAIRMAN NELSON:  Dr. AuBuchon.
		DR. AuBUCHON:  Fresh from my Olympic performance.  Thank you very much for the invitation to appear before the Blood Products Advisory Committee today.  I would like to extend some of the remarks that Sherrill has begun about using seven-day-old platelets and the clinical conditions which surround the situations in which they may be useful.
		I will warn you at the outset that I will be proselytizing you, because I think there is an opportunity in using seven-day-old platelets with a bacterial detection system in order to improve the safety of transfusion recipients.  Next slide, please.
		Today essentially I will be talking about two things:  First, briefly, why we are interested in this subject; and then whether it is really feasible in a hospital setting, practically, to use seven-day-old platelets.  Next slide, please.
		We are all aware of the increased safety over the last several decades that has been achieved through more stringent donor screening and augmented test procedures.  This is a success story of which we all should be proud.  Next slide, please.
		However, imposed on top of this are the residual problems that really have not changed over the last two decades in terms of bacterial contamination, particularly of platelets.  The risk of a unit of platelets having detectable bacteria is approximately one in 3,000.
		The probability of a septic death, as you will see, displayed from a number of different studies exceeds the risk of HCV or HIV transmission.  Next slide, please.
		Indeed, looking at FDA data gleaned from reports from hospitals of transfusion fatalities -- next slide, please -- the two top reasons for deaths are hemolysis, as was discussed earlier by Dr. Lewis from the Error conference, and bacterial contamination.  Next slide, please.
		So when we transfuse a unit of red cells or a unit of platelets, we think we know what we are putting into the patient.  Next slide.
		However, we may be putting something in that we do not anticipate and we do not wish to transfuse, namely, bacterial in the case of red cells or occasionally, as some platelets will have some gram negative contamination, also endotoxin.  Next slide, please.
		Bacterial contamination is very frequent.  It is initially at very low concentration, as Dr. Slichter referred to.  We are talking about the initial inoculum in a unit of whole blood as being somewhere on the order of one organism per milliliter or possibly even less.  
		Therefore, if we were going to apply some type of detection system that depends on a sensitivity on the order of 10, 100, 1000 or more organisms per mil, we will have to let some time elapse before there is a sufficient concentration to detect these organisms.  
		These bugs in blood are very difficult to detect.  They are difficult to detect in the unit.  They are also very difficult to detect in the patient, because particularly for platelet recipients, these individuals, at the same time that they are thrombocytopenic, are often neutropenic.  They are susceptible to fevers and to sepsis.
		So when a patient becomes septic after a transfusion, the clinician or even the blood banker may not suspect that the origin of the organisms was the bag of blood as opposed to the patient's GI tract or some other intrinsic source.  Next slide, please.
		There are numerous reports in the literature documenting just how frequent contamination is.  A number of reports from around the world place this risk in the order of hundreds, if not thousands, of cases per million units of platelets transfused.
		I've chosen to represent the rate as per million, because now we are often talking about the risk of HCV or HIV in terms of number of cases per million units, often less than one unit per million units.  Here we are talking about hundreds or thousands of units per million units transfused.  Next slide, please.
		Data from the United States from the CDC's bacterial contamination study recently published in Transfusion and previously presented at AABB meetings indicate that there are several hundred clinical cases of post-transfusion sepsis annually in this country, and on the order of one to two dozen deaths.
		Now this is a case report study and, undoubtedly, is an underrepresentation of the risk in the United States.  Next slide, please.
		Looking at longitudinal data gathered in very careful study from Johns Hopkins shows that the risk of post-transfusion sepsis to be on the order of 100 to several hundred per million, whether you are talking about platelet concentrates or apheresis platelets, single donor platelets, and the fatality rate, 14 to 62 per million.  Again, contrast that to the HIV rate of now less than one per million.  Next slide, please.
		Probably the largest study that has been conducted and reported to date comes from France, their ongoing hemovigilance surveillance system.  Here they noted that the fatality rate, not just the rate of sepsis now but the fatality rate, due to bacterially contaminated platelet products was approximately seven per million.  Next slide.
		Dividing that out, that's one per 140,000, again orders of magnitude greater than the risk of HIV transmission.  Next slide, please.
		There are some changes that can be associated with bacterial contamination of platelets, such as formation of clots in the bag, discoloration, presence of gas bubbles.  These are not always reliable, not always present, not always detectable.  Next slide, please.
		Some individuals, some institutions have attempted to use gram staining or acridine orange staining to detect bacterial by visual examination of the slide of the unit before releasing it for transfusion.  These techniques will pick up some units that are contaminated.  However, their sensitivity is in the range of 105 to 106 organisms per milliliter, obviously beyond what we would like to transfuse instead of a, hopefully, sterile product.  Next slide, please.
		There is also a concern about false positive rate.  When you are looking for small bacteria amongst a sea of small platelets, you can frequently end up with a false positive result from that kind of screening.  Next slide, please.
		As Sherrill indicated, there are, obviously -- and Jaro indicated -- there are obviously biochemical processes going on in platelets, production of acid in CO2, and it is theoretically possible to detect the formation of these components in platelets, also the same thing that is going on in bacteria. 
		So as bacteria are growing, they are producing acid and producing CO2, and you could theoretically detect bacteria presence by looking for these output.  Next slide, please.
		There are a number of proposals that have been brought forth and a number of detection devices that are attempting to use this.  We don't have anything that is reliable at this point to detect these metabolic end products as an indicator of bacterial contamination.  Next slide, please.
		One problem is illustrated here from a paper from Dr. Mark Brecher's lab at the University of North Carolina, noting that it is possible to find a drop in glucose in bacterially contaminated units and differentiate that from a sterile control unit.  The glucose is, obviously, consumed by the bacterial.  Next slide, please.
		The problem in terms of setting this up as an ongoing detection device is that there is a broad range of glucose consumption that can be found in platelet units, and one would theoretically have run the risk of releasing a product that was severely contaminated with bacteria and yet still falling within the "normal range" for glucose in a platelet unit.  Next slide, please.
		Swirling has also been advocated as a means of detecting the presence of bacteria.  Swirling can be thought of -- or maintenance swirling can be thought of as a poor man's pH meter.  
		Platelets in their normal discoid form will align with the flow of plasma.  So if one takes a unit of plasma, rocks it back and forth, you can get a shimmering seen through the unit because of the diffraction grading that is caused by the alignment of the platelets.
		If the pH drops for whatever reason, including bacterial contamination and production of acid, the platelets will sphere and blow a pH of about 6.2 and will no longer swirl.  So this might be one way of trying to detect contamination.  Next slide, please.
		We have attempted to look at this, and the sensitivity varies by the organism, depending on the pH drop that is seen.  There is not 100 percent sensitivity.  It will work sometimes.  It won't work all the time.  Next slide, please.
		Indeed, one could measure pH or measure glucose on a laboratory instrument, and whenever we take one of our contaminated units into our chemistry laboratory to run it through the pH meter, the chemistry techs form a phalanx guard around the blood gas instrument.  They don't like to see us coming and have us contaminate their instrument, but you can detect changes in pH that way.  However, there is false positivity to deal with again there.  Next slide, please.
		There are a number of companies that are currently developing simple, quick, fast, cheap techniques to detect byproducts of bacterial growth or to affect bacteria themselves, in order to document that a unit does not have platelet -- bacterial contamination or does not have at least a number of platelets above a certain threshold.  These are not yet available on the market, but we look forward to seeing some of them in the future.  Next slide, please.
		Now what about culturing?  We haven't talked about that yet, and that is usually regarded as the gold standard for detecting bacteria.  One takes a culture and, if nothing grows, you call the source sterile.
		The traditional concept for testing that a blood center would do would require that the result of the test be negative before the unit is labeled and released.  That's obviously what we do for viral testing.  However, with bacterial testing that will not work very well, because first of all, you have to allow the unit to sit for at least one or two days before a small aliquot from that unit can reliably be used to detect bacteria.
		You could do destructive culturing and culture the entire unit on day zero and see if there are any bacteria present, but that, obviously, does not yield a transfusable product.  
		So the techniques that are being used in European centers, particularly Belgium and the Netherlands, involve culturing on Day One, allowing the bugs to grow up for at least a day, taking a small culture, and seeing whether that turns positive.  However, it's not really possible -- next slide, please -- to hold the unit until the culture is verifiably negative, which may take several days before a microbiology lab will stamp negative on the report.
		One will have to have a system whereby the unit can be released for transfusion prior to the final result being known as negative.  Now there is a possibility that the unit will be in the hands of the hospital before the culture turns positive.  In that case, there has to be a system for recalling that unit.  
		It is also possible the unit could even be transfused before the culture turns positive.  However, in that case it's likely that the storage time has been very short, and the bacteria will not have grown up to a level that is dangerous or that the inoculum is clinically dangerous to the patient in that time period.  
		Essentially,  you have a race between growth at 22 degrees in the bag versus growth at 37 degrees in the culture bottle -- in an instrument, for example, automated culture instrument, and the bacteria are going to grow faster at 37, and you are more likely to find the growth in the instrument before it becomes a problem for a recipient of that unit.  Next slide, please.
		I would like to share with you today our experience in using a slightly different concept from the traditional one, and that is applying a hospital based system to verify the sterility of platelet units.  Next slide, please.
		The technique we have been using now for almost three years in our institution is applied to apheresis platelets.  All of our platelet units are apheresis platelets, and they are cultured on Day Two -- that is, the second day after collection -- by taking a 5 milliliter aliquot obtained by sterile connecting device and placing it in an automated culture system, the BacT/Alert system.
		The unit is then put on the usual rotator for release for transfusion and is used as needed.  Next slide, please.
		What organisms might we have to detect?  Well, based on the CDC's BaCon report, you see here a listing of the organisms that were found in blood contamination, and this shows both red cells and platelets.  The isolates which are found in red cells are shown with the asterisks.
		It's a wide group of organisms.  However, these are the same organisms that the BacT/Alert system detects day in and day out, and has for well over a decade, in hospital microbiology laboratories, starting with very low inoculums from patients who have substance or some other bacterial infection.
		So we are using this system in this matter.  Although it is not approved for detection of bacteria in platelets for the purpose of releasing for transfusion, BacT/Alert has recently been approved by the FDA for quality control testing of platelets, which in my mind essentially amounts to the same function in terms of what we are expecting it to do in the laboratory.  Next slide, please.
		When should the culture be drawn?  As I said, in Europe the culture is usually drawn on Day One.  We opted for a Day Two culture in order just to make absolutely sure that any bacteria that were in that bag would be detected with a small aliquot for culture.
		For example, in a preliminary study where we inoculated sterile units with 1 CFU per ml., we found actually all of our units growing on Day One, and Day Two even had a higher inoculum in the bag.  So we feel that Day Two was safe, but the European experience indicates that Day One may be just as safe.  Next slide, please.
		How long will it take before the cultures turn positive, if there are bugs in the bag?  These data, again from our Brecher's lab at UNC, indicate that on average we are looking at between ten and 20 hours.  There are some slow growing organisms, anabacterium, for example, which could be found.  It's not a major contaminate in platelets, but far and away most of the organisms that we would be concerned about would be detectable beginning at a relatively low inoculum within a day.  Next slide, please.
		So after we take our culture on Day Two, we go ahead and release those units whenever they are needed.  We will interdict their release if the microbiology laboratory informs  us that a culture is positive.  Next slide, please.
		We would hope that this would not only provide assurance of sterility, but as I'll talk later, I think this will allow us to extend storage to seven days, allow us to store after pooling platelet concentrates, which is not currently allowed in this country, although it is done in Europe, and also allow for reduced cost of leucocyte reduction; because one could pool five or six units of platelet concentrates and then use only one filter rather than multiple filters.  Next slide, please.
		In our first two years of using this approach, we have cultured about 2600 units of single donor apheresis platelets.  We had 16 initial positives, 0.6 percent.  Eleven of these could be recultured and were not confirmed.  We had been saving additional aliquots where we could retest the unit, and in all those 11 that we could retest, we did not get growth of any organism.  Five, we were not able to reculture.  
		One of those latter five cases, it occurred that the unit was transfused before we got the report of growth from the microbiology laboratory.  The patient had done well on the transfusion.  We cultured the patient and did not grow anything.  So again, we believe that all of these 16 were indeed false positives.  It's a relatively low false positive rate, which is encouraging.  Next slide, please.
		That was our first two years of experience that we reported recently at the AABB meeting.  Shortly after we closed the data for those first two years, we had an interesting report.
		We received a unit from an outside supplier.  About five percent of our units do come from an outside blood center.  The remainder we collect ourselves.  We cultured it on Day Two, the day that it arrived.
		It was actually a split unit.  So we had two different bags, but we knew it had come from the same donor by the numbering system.  The next morning we got a report from the microbiology laboratory that one of the two splits was growing bugs.
		We were surprised that the other one had not also alarmed, and we thought maybe this is a false positive, that we contaminated the culture somehow.  However, the afternoon the other one also grew.
		So we had then interdicted two units that were bacterially contaminated from the same collection process.  It was the same staph epi. organism in each half of the bag.  
		We were pleased that the system had indeed worked the way it was supposed to work and prevented two patients ultimately from receiving contaminated platelets.  Next slide, please.
		Now I know this committee is charged not to be concerned about cost, but I can assure you that hospital transfusionists are concerned about cost.  I would like to talk a little bit about cost in order to document how this technique can be made not only cost effective but even cost saving, so that hospitals will implement it.
		We have been able to identify the costs involved in this technique, and I have tried to capture all of the costs except the amortization of the BacT/Alert incubation cabinet.  It amounts to $16.50 per unit cultured.  Next slide, please.
		If you scale that up for 100 units, you're looking then at $1600.  Our outdate rate and the national outdate rate for platelets is 15 percent.  So 15 percent -- If we could avoid that 15 percent at $500 per unit, as the approximate cost of single donor platelets, you can see that that is several times greater than the cost of doing the culture.
		Would we entirely eliminate all outdating if we were able to extend storage because we are doing bacterial detection?  No, but back in the mid-eighties when we did have seven-day platelets, the outdate rate dropped from around 15 percent to three to four percent nationally for platelets.
		So I think we would be able to recover the cost of culture, if we were able to extend the storage time.  Next slide, please.
		Indeed, in our experience, we always have more units being required for transfusion than what we outdate the previous day.  I would hope so.  Otherwise, we wouldn't be very good inventory managers of our platelets.  
		So I think that, if we were able to extend storage because of a bacterial detection technique, it would be able to be brought in without an increase in cost.  Next slide, please.
		But do seven-day-old platelets survive and function as well?  As Dr. Slichter very nicely showed, there are changes during storage, and fresh platelets are not the same as five-day-old platelets, are not the same as seven-day-old platelets.
		Some institutions have shown that giving older platelets does not provide as much support for patients and results in them needing additional platelet transfusions.  In our hands we have not been able to document that in that the corrected count increments are not different using five-day-old platelets versus younger platelets.
		There is some difference of opinion on that, but clinically five-day-old platelets seem to work just fine, although one can look very closely and possibly define some differences with increased storage age.  Next slide, please.
		We were involved in a study, again recently reported at the AABB, funded by Gambro and in collaboration with our colleagues at Red Cross in Norfolk, looking at the effect of storing apheresis platelets that were collected on the Gambro Spectra instrument for five or seven days -- or collected on the team instrument also, and collected and then stored for five or seven days.
		This was both an in vitro study and in vivo study with chromium, indium radiolabeled recovery and survivals.  Next slide, please.
		The platelet units were standard leukoreduced plasma suspended single donor platelet units.  Next slide, please.  Again, these were leukoreduced at the time of collection.
		If one looks at the changes in pO2 and pCO2 or pH between Day One and Day Five and then on to Day Seven, one can certainly see some differences with increased storage time.  
		Day Seven is not exactly the same as Day Five.  However, I would note that the pH remained above 6.2 and did not indicate any likelihood of going upward.  These pH were falling, although remained above the 6.2 threshold throughout seven days.  Next slide, please.
		Glucose continued to be consumed, and lactate continued to be produced throughout that period, and the rate of glucose consumption and lactate production was no different in that additional two-day period.  Next slide, please.
		The platelets, of course, showed some evidence of loss of function and increased activation during storage.  That is what is normally seen as part of the storage lesion.  The changes were not great.  They were small, as has been noted by others.
		There was a difference between five and seven days, but they are in the approximate same area. As you will see when we get to actual human data, the increase in activation of these platelets did not prevent them from being hemostatically -- apparently hemostatically effective by virtue of them continuing to circulate.  Next slide, please.
		Looking at the recovery and survival at five days versus seven days, there were statistically significant differences.  There were declines in both recovery and survival.  Next slide, please.
		Shown here in tabular form, these numbers are very similar to those that Dr. Slichter showed from a number of other laboratories in which one can see a decrement in both recovery and survival with the additional two days.  However, these numbers still look quite acceptable in comparison to other reported studies.  
		In particular -- next slide, please -- I'd like to contrast these numbers to data that were submitted to the FDA in support of licensure of seven-day platelets, now almost 20 years ago.  Next slide, please.
		If you look at this study in comparison to the data of Archer et al., we have better results at seven days than were accepted previously for both recovery and survival.  Next slide, please.
		If you look at the difference between five days and seven days, there is less of a reduction in both recovery and survival than was seen in data from 20 years ago.  
		Therefore, based on clinical trial data in normal subjects, it would appear that the seven-day platelets that we have available to us today, stored in different kinds of plastic, stored with different amounts of possibly different anticoagulants than were used 20 years ago and stored in leukoreduced fashion, are at least as good, if not better, than the platelets that were judged acceptable 20 years ago for seven-day storage.  Next slide, please.
		Now we've been taking some of this work to a practical point in the transfusion service laboratory.  Our platelet units, of course, outdate on Day Five, but we keep them on the rotator until the morning of Day Eight -- so in other words, the morning right after the outdate at midnight on Day Seven -- for pH and swirling checks.  Next slide, please.
		Looking at 91 Cobe Spectra units, 96 percent of them showed swirling on Day Eight, and the pH, average pH, was 6.86.  97 percent were about 6.2 for pH, and the maximum pH was 7.3.  So we did not appear to have high pH problems, and very few of the units did not maintain their pH out to Day Eight.  Next slide, please.
		Now we are an academic medical center, but we are not in a city setting.  We are three hours away from our blood supplier who could supply us back-up platelets in case of unusual need.  There are certainly times when we have unusual need, and we cannot get platelets fast enough.
		In that case, we have to do something.  We exhaust our supply, and we need more platelets.  Because we have cultured units that have not grown bacteria on our platelet incubator, we have by medical necessity, medical emergency, occasionally had to use units beyond five days of storage in order to support patients who needed platelet transfusion.
		So I would now like to share with you some of our experience of transfusing platelets that are in Day Six or Day Seven of storage for patients who needed transfusion, and we have assessed the clinical outcome here by corrected count increments taken one hour after transfusion.  Next slide, please.
		We have conducted 40 such transfusions over the last three years on Day Six or Day Seven.  All of them appeared to yield the expected clinical results.  That is, we never have to transfuse another unit because the patient did not stop bleeding.
		In those patients who were stable and in whom we were able to measure corrected count increment within an hour, we had 21 instances where we could evaluate what the outcome was.  Next slide, please.
		Shown here are these 21 corrected count increments.  7500 is usually used as the CCI indicating a successful transfusion.  The mean CCI of these older platelets was 14,000, and only one was at 5,000 or below.  Next slide, please.
		Shown here on a probability curve, you can see that 90 percent were above 7500.  In any clinical trial of platelet transfusions, these would be regarded as excellent clinical outcomes.  Next slide, please.
		Therefore, we feel that these data support the concept that, although there is a storage lesion and that one can indeed detect differences between platelets that have been stored for five days versus seven days, that clinically seven-day platelets worked quite well.
		Now the question was raised by the Committee a few minutes ago, well, what if we have to transfuse more platelets?  Is that going to be more of a risk for the recipient?  If we are transfusing leukoreduced platelets, transfusing additional platelets should not induce any additional alloimmunization.    
		What about the other risks involved?  What if, if we went to seven-day platelets, we had to transfuse ten percent more platelets?  So let's compare not culturing our units and storing them only for five days versus culturing the units, extending the storage time to seven days but maybe have to transfuse ten percent more platelets or one additional platelet for every ten that would otherwise be transfused?
		I'm not saying that this will necessary.  I'm looking at this sort of a worst case scenario.  Next slide, please.
		One calculates out the HIV risk.  There would, of course, be an increase in the HIV risk, because one would be exposed to more units.  Next slide, please.
		However, the septic mortality would be greatly reduced, and in this case I am showing that essentially to be zero, because I believe this culturing technique is, if not 100 percent sensitive, very close to that.
		So if one looks at the total risk -- I've just used HIV here, but HIV and bacterial contamination risk -- you can see that the total risk is actually lower for the patient, even with the extension of the storage time, providing you are detecting the bacteria.
		Well, to return to cost, this is an extra unit that is going to cost the hospital something more.  How is the hospital going to deal with that?  Next slide, please.
		There would, obviously, be an increased cost for this additional unit.  There would also be the culturing cost involved.  So the total cost would be $720 greater with this worst case scenario adding culturing.  Next slide, please.
		That is an average of $65 a unit.  Next slide, please.  However, if we are able to reduce or eliminate the outdating by extending the storage period, this $65 per unit will entirely disappear, and  the hospital would not have any increased cost.  It might actually see even decreased cost by using this approach.  
		I have not attempted to figure into the scenario of taking care of those occasional cases where there is septic transfusion.  Next slide, please.  
		Now if we were able to apply a bacterial detection system such as culturing and go to seven-day dating, I think this would potentially allow us to pool units of platelets shortly after their production in a blood center, in other words, give prestorage pooling.
		This would be very advantageous for a transfusion service who wouldn't have to worry about trying to pool platelets at the last minute as a surgeon is wanting to transfuse platelets during an operative procedure.  It would allow for prestorage leukocyte reduction with a single filter for an entire pool, obviously reducing filtration cost.  
		It would, of course, allow us to assess sterility in this highest risk component that we are now transfusing, and reduce outdating.  Next slide, please.
		So, therefore, I would conclude that by applying these techniques, platelet storage for seven days is indeed feasible.  It's practical.  There is adequate maintenance of function.  One sees the expected recovery and survival that is associated with adequate clinical efficacy, and indeed this efficacy is indistinguishable from that achieved with shorter periods of storage.  
		We would be able to use bacterial culturing, for example, as we've been shown to reduce septic shown risk and reduce overall risk for patients, making transfusions safer, and to do this without any increase in cost, and this is extremely important for hospitals.  
		I think, therefore, this indicates this is a practical method that can be applied.  Next slide, please.
		I would like to just close with a few commentaries on the next steps that we should, I hope, proceed along.  The first relates to recognition of the clinical significance of bacterial contamination in platelets, and then I think the importance of us, quote, "thinking outside the box," applying some nontraditional approaches to get to the bottom of this problem, which has been around a long time.  Next slide, please.
		I would pose the rhetorical question:  What I weren't up here talking about bacterial contamination, but we were talking about HIV?  if the risk of HIV today were recognized at one in 140,000, bells would be ringing an alarm.  We would be throwing our hands up and saying we have to do something about this, and we have to do something now.  This would be the lead story on the nightly news.  It would be the headline in the Washington Post tomorrow, and the public would be demanding that we take some reasonable action to reduce this risk.
		I frankly don't see the difference between dying of HIV and dying of bacterial contamination.  In fact, today one could make the argument that you are worse off if you die of bacterially contaminated platelet unit, because you are dead within an hour or two as opposed to HIV infection where there is now often effective antiretroviral therapy, and you may live for decades or longer.
		Therefore, I think it's appropriate that this Committee look at this situation, and also that we take a step forward and do something different to address this problem.
		I applaud Dr. Vostal and the agency for bringing this to the Committee's attention, and I hope that we can use the innovation that is available from our common thought process to provide some leadership for the field to move in a production direction.  Next slide.
		Part of that leadership, I think, is working outside the box and doing something a little bit different.  Now I'm not standing up here presenting a device for a 510(k) approval or licensure.  I'm not representing a commercial concern.
		There are techniques available today.  There will be some commercially sponsored ones in the future, but there are some today that can be applied.  		Almost every hospital that transfuses platelets today has an automated culture system in its microbiology laboratory.  This culturing approach can be used practically to improve the safety of platelet transfusions.
		It is also important that we gather data from multiple sources.  We are not likely to have a single clinical trial that is going to document that, by doing culturing or some other technique, we are absolutely certain that we will eliminate bacterial contamination.  That's just not going to happen.  
		We are going to have to look at all of the data available in the transfusion literature and the microbiology literature to say does it make sense that we apply this approach to make platelet transfusion safer.  
		Finally, I think it's important that we not relax our standards but take a different endpoint as our decision point for determining whether or not this is the appropriate thing to do.  Usually, the agency is looking for proof of safety and efficacy before approving a new approach.
		To prove that a bacterial detection system such as culturing will detect all contaminated units or even will absolutely reduce the frequency of sepsis would require the culturing on two different occasions of over 13,000 units before one had a statistically significant sample to document the safety of the technique.
		That's just not a practical trial that can be performed.  In other words, we might culture on Day Two and then culture at a later time period, say at outdate, to document that the Day Two culture was indeed accurate in showing no bacterial growth.
		13,000 cultures times two is a very large study, which I am not aware any company is willing to undertake and, clearly, we as a hospital that transfuses 1500 units of platelets a year is not about to undertake that study.  However, based on data from a number of sources, I think we can reasonably conclude that these culturing techniques will detect bacteria reliably and at least reduce the risk of bacterial contamination, even if we can't, with statistical competence, say that it will absolutely eliminate the chance of bacterial contamination.
		Final slide, please.  So I think we can apply all of the data that are out there and are continuing to be gathered to make platelet transfusions safer, and that is really the onus that is on the blood bankers in this country as well as the agency that guides and regulates us.
		Thank you very much.
		CHAIRMAN NELSON:  Thank you.  Yes, Dr. Lew?
		DR. LEW:  Actually, I had a question.  You mentioned that when you looked at 2500 units cultured over two years, that you got 16 positives, but you thought they were false positives.  Yet that would imply, if you really think that's true, that then your rate of contamination is obviously substantially lower than anybody else's.
		I think there were another slide earlier suggesting that the range of contamination was around your lower .6 to 1.6 or something.  
		It would also be interesting to know what bugs grew from those 16.
		DR. AuBUCHON:  The usual rate of bacterial contamination of platelets is quoted in the literature.  It's about one in 3,000, and if yo look at our experience in terms of documented repeatedly positive cultures, we are right in the same ballpark.
		It's interesting to look at those 16 initial positivity cases and note when they occurred.  We have a relatively small transfusion service laboratory, 15 technologists who are very highly motivated, very skilled and relatively senior.  They did not all begin culturing at the same point.
		We started with the supervisor working out the technique with my research techs, and then one by one introducing the bench techs to the technique.  All of the cultures that were initially positive and could not be confirmed occurred within two weeks of a new technologist learning the culturing system.
		On finding one of these cultures, we would go back to the technologist, retrain the technologist to make sure that they really understood what they were doing, and then we would not see additional positives.
		So it appears that these initial cases of growth were due to contamination at the time of culturing.  It did not truly represent the units being positive.  As I said, in the 11 cases we were able to reculture, they were indeed negative. 
		So this is something that is very much technique related.  Why do we have a lower rate than has been reported elsewhere?  I would say that many of the studies that have been reported in the literature did not have the capability of going back and reculturing the unit to document that the bugs that were growing in the microbiology laboratory had really come from the unit as opposed to coming from the culturing process.
		CHAIRMAN NELSON:  You actually really raise two issues, I guess.  One is the issue of routine culture monitoring of platelets, and the other is of extending the life or the usefulness of the platelets to seven days.  They are both related.
		I wonder how many blood banks now do platelet culturing.  I know some other than yours do, but how common is it?
		DR. AuBUCHON:  The quality control culturing of platelets, of course, is done routinely by all collecting agencies, but at this low rate of contamination QC cultures are really useless.  As I said, we've been doing this routine culturing technique for now almost three years.
		Two months ago the University of North Carolina, Dr. Brecher's laboratory, began using it routinely.  They are the second hospital to be doing it in the country.  
		With discussions with colleagues last night, I am aware of a couple of other blood centers in the country that are now considering doing it, all arising from situations where they had contamination cases.  They had fatalities, and now they realize that it really is a problem and they need to address it.  
		So it is very limited in scope at the present time.  In Europe I believe all of the Flemish Red Cross centers are using this technique and all of the blood centers in the Netherlands are using this technique.
		CHAIRMAN NELSON:  Well, perhaps sometime we are not asked to vote or render an opinion, but it seems like a useful technique that maybe should be standard practice, and the Committee is not asked to give an opinion on this today in a vote or anything like that, but maybe the FDA maybe sometime in the future might consider more formal consideration of all the pluses and minuses.
		The other thing that I was quite concerned about is the false positive rate.  That seems to be quite high, you know, given the -- That could present some problems, but nonetheless, it does look useful.
		DR. AuBUCHON:  Well, I understand .6 percent looks high.  Of course, that is lower than what is usually quoted in the literature for the positivity rate in taking bug cultures from a normal person, but I can tell you, for example, right now the last time that we had a positive culture on a platelet, initial positive -- it's been over six months, because we haven't had any turnover in our technologist staff.  They are all now well trained.  They are all used to doing it.
		So we had clusters of these positivities when we brought in new technologists into the process.
		DR. KATZ:  I'm very interested in hearing thoughts from the FDA about how they would approach, for example, the multiplicity of automated culture systems and the whole approach to regulation of extending to seven days, under what circumstances, what instruments.
		CHAIRMAN NELSON:  Dr. Vostal, you want to represent the VDA?  You can be Jay Epstein.
		DR. VOSTAL:  Well, we are really thinking about this quite hard, and it is a difficult question.  We have seen devices that have come to us and presented data that's been collected by spiking experiments in vitro.
		We have -- It's a major step to accept that data and go and say it's okay for use in clinical situations.  However, as Dr. AuBuchon pointed out, doing a clinical trial as we are used to doing would require an enormous amount of resources, because it would be a very big trial.
		We are considering alternate ways of looking at this, but so far we haven't really come up with a good solution yet.  But we would welcome any input and comments from manufacturers or academicians that could help us in dealing with this problem.
		I mean, I think, as Jim pointed out, it's something that should be done.  It looks like it's the right thing to do, and we certainly want to do that.
		DR. STYLES:  Just to clarify some of the data you presented, what was the n on your controlled trial of five versus seven days of platelet storage?
		DR. AuBUCHON:  The total n between the two centers was 24.
		DR. STYLES:  Twenty-four?  Okay.  It seems like sort of -- Something I'm always struck -- I know the difficulty of these studies is that the n's are quite small to say there is no statistical difference in that your power is extremely low.  So your chance of making type 2 error is very high.
		The second thing is:  Do you have any information on the age of the platelets that were associated with the septic events?  You seem to have a pretty good handle on the data of the patients -- of not only the reported sepsis patients but the reported fatalities.
		DR. AuBUCHON:  The best illustration of the effect of storage age and sepsis, I think, comes from the paper published from Johns Hopkins, Morrow the first author, JAMA from almost ten years ago now.
		They noted that, although most of their platelets were transfused on Day Two or Day Three, most of their -- almost all of their septic cases came from platelets that had been stored for four or five days.
		There clearly is a time period through which the bacteria have to grow up so that they can become a clinically important inoculum.  
		DR. STYLES:  I agree with that.  I mean, it makes sense that that is obviously going to be associated with it, but my understanding of the issue is that in '84 we went back to five days, because we saw an increase in infections.  So in essence, we made a mistake.  We went form five to seven, and then we went back to five very quickly, because we saw that that didn't make a difference.
		Then now the opinions that are being put forth is, well, the platelets today are not what they were in 1984.  There's been some good data demonstrating, I think, that probably the function, the viability, whether measured in vitro or in vivo, is probably better.
		Outside of your culturing techniques, though, I haven't seen a lot of data which indicates that they are less likely to be infected, whether they are functional or not.  I'm not sure if you are aware of any data.  I don't know if the FDA has any data on maybe just surveillance of outdated units.
		I'm really concerned, however, that we are just going -- while the platelets may function just as well or nearly as well, probably not as well, that they are still at the same risk of causing bacterial or are bacterially contaminated.  So the very reason that we made the change hasn't really changed.
		DR. AuBUCHON:  I think that relates to what Dr. Simon was talking about earlier, and that is by Day Three or Day Four for the most of the organisms that are in platelets, one would expect to find somewhere between 10,000 and a million organisms per milliliter.
		Now if you let the units sit for another two days, you can probably get it up to a billion organisms per milliliter.  But, frankly, I wouldn't want to be transfused with a million per milliliter.
		So if one extends the shelf life of platelets from five to seven days, the effect with respect to bacterial growth doesn't really come from the additional two days from day five to day seven.  It comes from the mean time for which platelet units are held.
		In my experience -- I was working in a blood center when we went from five days to seven days -- the average age at transfusion increased by one day.  So there is that additional day, and that day really comes in the middle of the current five-day storage period where bacteria could grow to an important inoculum.
		DR. STYLES:  I understand his point, but at the same time, we did this experiment.  We went from five to seven days, and I wasn't around, but it was a mistake, at least by the FDA's opinion, and that we went back to a five-day period.
		What data is there to support that the situation -- I understand all about the inoculation issue and the bacterial burden, but I'm just asking for some data which would indicate that the situation has changed from what it was in '84.
		DR. AuBUCHON:  Well, I would --
		CHAIRMAN NELSON:  If it is linked to a culture, a negative culture, that's a change.
		DR. STYLES:  Oh, I absolutely agree.  There's a culturing -- I agree with your system.  I think this is the way we should be going.  I think this is a very important problem.  Hence, my reluctance to want to go back and subject people to potentially contaminated units.
		I think the culturing or some other detection system is definitely the way to go.  But if FDA asks us, can we now have the platelets go from five to seven, there isn't any system in place that gives us additional monitoring.
		So then you -- Well, so why do we do that?  The argument that seems to be being proposed is that, well, platelets are actually better today than before.  I'm just asking -- Maybe I've missed it, but where is that data?
		DR. SLICHTER:  Can I make a comment, because I think you have a very -- I'm glad that the Committee or at least you are of the opinion that the quality of the platelets are seven days now is probably better than it was before.
		So I think we have a good quality product.  But I don't think either Dr. AuBuchon or myself or probably anybody else in the room is suggesting that we just license now to go from five days to seven days, because we still have the bacterial contamination problem.
		So I think what we are saying to the Committee and to you is that there are two methods that we may now be able to solve the bacterial problem.  That will then allow us to extend storage to seven days, because the quality of the product will allow us to do that.
		So I think we are saying that you have to combine the seven-day viability function of the platelets with either a pathogen inactivation system or a pathogen detection system, and that what I think we are trying to say is that at least -- I mean, I think Dr. Vostal asked me to present on seven-day stored platelets at the AABB, because I had been saying for years that the FDA, in my opinion, reduced the storage time of platelets form seven days back to five days not only because of the bacterial contamination problem, but because of the quality of the platelets.
		As Dr. AuBuchon presented, the data that was used for seven-day licensing in terms of quality -- those are very poor quality platelets.  So I think he challenged me to say, well, you know, put your money where your mouth is and get up and review the data.  
		Having reviewed the data and having done some studies of our own which I presented to you today, I personally am very comfortable that a seven-day stored platelet, particularly if it's stored in an additive solution, is a good quality platelet, is worthy of being licensed, but that has to be combined, in my opinion and I think in yours, with a system to ensure by either detection or inactivation that we don't have bacterial contamination, because that issue has not gone away.  
		DR. STYLES:  I agree with you.
		CHAIRMAN NELSON:  And also another two days storage might improve, at least by culture, the likelihood that we would detect bacterial contamination before the platelet unit was given.
		DR. SIMON:  Yes.  I think -- I was hoping that maybe we could make some recommendations to Dr. Vostal of how it might be proceeded.  But I guess we have to say first that there are really -- in some respects, these are two separate problems, because as Dr. AuBuchon showed, the amount of bacterial contamination did not really go down, although I don't know that things were monitored that well back then.
		At the same time as there was a concern about going to seven days, it's not clear that that problem has been adequately dealt with.  So one could propose that we need to proceed with some kind of either bacterial detection or bacterial inactivation, regardless of whether we go to five or seven days.
		If we focus on the seven-day issue, isn't it possible in a regulatory framework for the FDA to accept company submissions for seven-day platelets based on quality and function and viability, and to allow their licensure, but only allow their use if there is a bacterial detection system put in similar to Dr. AuBuchon's or if -- Of course, if it's going to be inactivation, it would all be submitted as a package.
		So if company X submitted their seven-day platelets and they looked very good, FDA, I would think, could approve conditional that anyone who wanted to use it would have to submit a protocol first showing that they had adequate bacterial detection.
		That would allow places that are proceeding, as Dr. AuBuchon, Dr. Brecher and others are, to begin to go to seven days.  But it would require submission of data.  That seems to me to be one paradigm that might allow us to move ahead.
		DR. DOPPELT:  I just have one question on the culturing.  I'm not familiar with exactly what physically -- how physically you do this culture, but you had some false positives.  
		What is the possibility that in the process of taking the cultures, you actually take a negative unit and introduce an infection?
		DR. AuBUCHON:  Well, any manipulation of a unit could always introduce bacteria.  The manner in which we obtain the aliquot involves sterility -- a docking sterile connection device of a small transfer pack and running an aliquot out the entire unit in a unidirectional manner into that other bag, and then sealing it off.
		So the only way in which the collection process could potentially contaminate the unit would be through the sterile connection deice.  Now the FDA has approved the use of the SCD for splitting samples and going into platelet units.
		We performed a validation study of the SCD that at that time was marked by Turumo, the SCD-312, about a decade ago, because we were surprised there was nothing in the literature on that.  We cultured over 400 weld.  
		These welds were not conducted in standard conditions.  They were conducted after painting the outside of the tube with a high concentration of bacterial suspensions and performing the welds in some cases on a wet piece of tubing, as the external portion was wet, and that's not the way one would normally conduct a weld.
		Of those 447-some welds, the only ones that resulted in any contamination of the product on the inside were in those cases where the weld was obviously faulty, and there was reason to have a faulty weld because of the tubing being wet.
		So when we had a good weld, which, of course, we always have to check for when we use the sterile connection device, it appears that we have a high confidence that the interior of the tubing will remain sterile.
		I believe, in the cases where it looks like we contaminated the aliquot, that probably occurred at the time that the needle was being placed to recept them into that small sample bag.  That's probably where we picked up the organisms.
		DR. CHAMBERLAND:  Jim, that was a nice presentation.
		My question has to do with your comments about practicality.  I wondered about the generalizability of your approach for institutions that essentially would be the opposite of what yours are.  You are almost entirely self-sustaining in terms of platelet collection and get a small amount from an outside supplier.
		How would such a system or could such a system work well where hospitals acquire their platelets largely from an outside supplier and very little internally.  
		Would the onus then fall on the blood collection center to initiate the culturing, because my sense is that hospitals would be receiving these platelets from an outside supplier at various days into the five-day duration.  So there might not be adequate time.
		You know, you did your culturing on Day Two.  What if you get a Day Two platelet?  What are your thoughts about that?
		DR. AuBUCHON:  You raise a very good point, Mary, that in different logistic situations one may need to use a different protocol. 
		In an urban setting a university hospital probably does not maintain, relatively speaking, as large an inventory of platelets and might depend on multiple deliveries daily from their blood center, and might only keep the platelet in inventory for a few hours, not for the full storage period of the platelet.
		In such a situation, I think the appropriate approach would be to work out a collaboration between the supplier and the hospital where the supplier is in the situation where they can collect the culture early on, and they would need to set up a system to rapidly identify the recipient hospital and to provide the information to that hospital to pull the unit off the shelf if it was in the hospital's hands rather than the blood center's hands at the time the culture was positive.
		That is essentially what is being done in Europe, in not only the Belgian and Dutch blood centers but also in several German and Spanish blood centers that are doing this.  It's the blood center that is doing the culturing.
		That hasn't been the approach that was going on in this country.  Our blood centers seem to continue their focus on detecting viruses.  So I felt that, if we were going to do anything with detecting bacteria, it was going to have to be done in a different manner.
		DR. ALLEN:  This whole issue -- It's a fascinating problem, and I think the discussion this morning has been very helpful.  My personal feeling is that we are not quite ready to move forward yet.
		I think, certainly, the data on the quality of the platelets, although that's not an area that I'm expert in -- Reading through the background paper and hearing the presentation and discussion this morning, I'm of the opinion that we certainly are moving forward to where seven-day platelets in terms of their quality is certainly satisfactory.
		I think the issue of how one detects and deals with potential bacterial contamination is still a much more thorny issue.  As I look at the list of -- and I have not read the paper by Kuehnert, the so called BaCon report, but it's a recent report.  
		You look at the list of gram positive bacteria.  Those very likely are skin contaminants, and that 60 percent of them -- it just basically says this is an issue that ought to be aggressively looked at, because we are going to do ourselves a big favor if we can reduce those skin contaminants at the time of collection.
		Nonetheless, the skin contaminants aren't necessarily the ones that are going to create the biggest problem to the patients.  In actual fact, some of the cultures that were done in Dr. AuBuchon's laboratory may not have been false positives.  They may well have been true contaminants at a very low level.  
		They went back to confirm and, in fact, they had died off in the original.  I think that certainly is not out of the question.  
		The gram negatives -- Forty percent of the contaminants were gram negatives, including some bacteria that I scratch my head in terms of how they got there, some of the Serratia species, in particular.  Those are clearly bacteria that can grow to very high levels, even though they are in a refrigerated setting.  They certainly can create very significant endotoxic sepsis in patients.
		There is one, the Yersinia enterocolitica, I would guess, may have been an intrinsic contaminant in from the blood of the patient, and that's an infrequent issue, but certainly historically one that occasionally has occurred.  I think those who remember the platelet collection at the NIH, I think, back in the 1970s where there was a donor with chronic osteomyelitis.
		So those are other donor issue.  But those gram negative bacteria bother me, and I think that is an issue that has to be dealt with.
		Then one comes to the opening discussion that we had this morning on reducing risks or errors in our system and the need to begin looking at problems on a systemwide basis.
		When we do that, I run right up against a problem with having individual hospitals around the country being responsible for culturing each and every unit of platelets that's going to sit around for more than three or four days.  
		The question that Dr. Chamberland asked, you know -- well, maybe there needs to be some sort of a system between the collecting agency and the hospitals and so on -- I think there's a lot that has to be very carefully thought through and worked out here.
		I'm concerned with this system that requires us to go into every single unit of platelets, take off 5 ml aliquot, send it for culturing and so on.  They are not insolvable problems.  What we need is to make sure that we've got some good -- the best minds thinking about this and good research in this area.
		That's maybe an area where NHLBI and the CDC and the FDA need to collaborate together to put the money out there, get the right protocols in place to help address this so that we can move forward in the years ahead.
		I think this is an exciting development and, clearly, I'm very pleased with the information on the quality of the platelets themselves, and let's see if we can address the contamination issue.
		CHAIRMAN NELSON:  Yes.  
		DR. HARVATH:  I wanted to follow up on that a bit, and also to ask Dr. AuBuchon if you and Dr. Brecher and others who have taken this type of approach with the BacT/Alert system have considered combining your efforts in a multi-center approach, and perhaps approach the FDA, since you are already implementing this in your blood programs.
		You mentioned that you needed an n, I think, of 13,000 for the BacT/Alert system, and I'm not sure how many times they may have asked you to sample the same unit.  But would you be able to approach that n of 13,000, let's say, with the groups who are taking this approach currently in the country to combine your effort and data to justify using that particular culture system?
		DR. AuBUCHON:  The problems in conducting that trial -- and we did have some discussions, preliminary discussions, about it -- really related to logistics and cost.  In discussions with the agency about how this would be put together, we really faced a dilemma.
		One approach would be to culture on Day One or Day Two, whatever the -- let's call it the test point of culture was -- and then culturing on a later date and using this second culture as the gold standard, anticipating that if the unit were truly contaminated, we might miss it on the Day One or Day Two culture, but we would certainly pick it up on the later culture.
		The agency was of the mindset that we would need to perform that second culture on Day Five, since that's the day of outdate.  Well, if we were to hold all of our units until Day Five in order to culture them, we would not be able to transfuse them essentially.  We would outdate most of them.
		That would then force the sponsor of that trial to not only pay for the culturing but to pay for the units, which would have been enormously expensive, well over several million dollars.
		The other approach would be to allow for the transfusion of the unit on Day Six or Day Seven after culturing it on Day Five.  That, however, would require an IND, IRB approval, and informed consent to the patient, which although I would have no ethical concerns going to a patient and asking for their consent to receive a cultured unit on Day Six or Day Seven, practically that was a huge problem when you multiply it by 13,000.
		So we have not proceeded along that way.  I would like to propose a simplified approach whereby a second culture conducted at least 24 hours after the first one or at the time of release could be the gold standard culture against which the earlier one could be compared.  But I lack a sponsor for such a trial.
		DR. FALLAT:  You had a very nice presentation, Dr. AuBuchon, and you make a very cogent argument that this is a big problem.  I kind of share the questions about the ability to expand your hospital across the country, but we haven't heard anything more about the UVA decontamination system, and where does that stand, and where is the data on that, and is there more of that data from your -- You know, can we hear a little more discussion about what some of the other solutions to this contamination problem are, beyond just culturing?
		DR. AuBUCHON:  Well, those -- I think you probably will be hearing more about the psoralen inactivation systems in the future.  I shared the concern that Dr. Slichter mentioned as to whether or not platelets treated in this method will be able to be stored for seven days and yield a successful clinical result.
		In vitro, it looks like they may.  However, in vivo we already have data at five days that they are not the same as untreated platelets, and they would -- although if we have to transfuse more, that would not confer any additional risk relating to bacterial viruses, because they would be inactivated.
		One always has to raise then the issue of will we have enough platelets if, all of a sudden, we are having to transfuse twice as many.  Will we be able to produce twice as many platelets?  I doubt it.  And the other issue of the toxicity of the technique itself, particularly when you start transfusing more of this material -- does that become the overriding concern then?
		DR. SLICHTER:  Well, maybe I can address that  a little bit about the pathogen inactivation.  I mean, I think the companies that are proposing this technology have a lot of in vitro data and in vivo animal model systems that the pathogen inactivation process works, but you know, when they went before the FDA, the FDA did not ask them to do an infectious disease trial with the pathogen inactivated product, because the numbers would have been gargantuan.
		So the FDA, I think, accepted their animal model systems, their in vitro contamination data suggesting that the process does inactivate a wide variety of bacteria, viruses and protozoa, and then the FDA, I think rightly, wanted to concentrate on the fact of what is the quality of these products and, specifically, do they provide hemostasis.
		So I think, in support of the pathogen inactivated platelets, hemostatically they are every bit as good.  I think part of the reason for that is, even though the count doesn't go up as high and they don't survive as long, as I've mentioned, I think you need very few platelets in order to provide hemostasis.  
		So I'm not surprised that the hemostatic efficacy was similar, because after all, the counts did go up.  The platelets did survive.  They just were not as good as the noninactivated product.
		So I think that we do have available to us two separate methods to extend storage, either detect or inactivate, and I think that, you know, although I didn't discuss it, they collected an enormous amount of adverse event data.
		I mean, every time the patient reached for a Kleenex, it was recorded.  Between the control and the treated arms of the trial, there was no evidence of any adverse consequences, and these people were transfused for up to 28 days, and in some of them they got a second cycle of either pathogen inactivated or control platelets for an additional 28 days, if that particular patient needed a second course of platelet transfusion therapy.
		So I think there is a lot of data on the fact that there are to adverse events in the patient related to the transfusion of this product.
		CHAIRMAN NELSON:  Okay.  If there are no other burning comments at the moment, I would like to take a break now.  People can check out and what have you.  If we could do it like in 20 minutes or so, so we could -- because people are going to have to catch planes at the afternoon.
		(Whereupon, the foregoing matter went off the record at 10:34 a.m. and went back on the record at 10:58 a.m.)
		DR. SMALLWOOD:  Are the individuals present that will be making presentations during the open public hearing?  Dr. Bianco and Dr. Valeri?  They are out in the hall?  Thank you.
		CHAIRMAN NELSON:  Well, someone please tell Dr. Bianco, if he doesn't come, I'm going to give his talk.  Is Dr. Valeri here?   We are supposed to have a committee discussion, which we have already had, sort of.
		DR. SIMON:  Dr. Nelson, we might in this interlude just ask, have we given the FDA -- I mean, is this what they want from us?
		CHAIRMAN NELSON:  Yes.  You know, I could probably give an erroneous summary, but to say that the Committee is very interested in the concepts presented and the idea that it might be feasible to put in some detection systems that could be routine, if not more widespread, and if that was possible, we then could move to seven days.
		Whether or not these two decisions are linked, in my mind, they sort of are.  But in a way, they are a little bit separate, too, in that the issue of the function of the platelets after seven days and whether or not that increases the contamination risk is still a little bit of an open issue.  
		You know, I think the data that were presented were quite interesting.  My understanding was that there were more -- not in transfusion medicine, but I know Dr. Yamatovian from the Cleveland Clinic has reported on this, and Dr. Gilcher I heard yesterday from Oklahoma Blood Centers says they routinely culture platelets.
		Now whether or not, you know, they follow a FDA approved protocol, I guess, is another thing, but the fact is that I think there are more centers that are actually doing cultures and basing some transfusion medicine decisions on these data.  But the fact is it's not a -- you know, it's not a routine procedure at the moment.
		I guess one of the issues is what are the steps that we would need to move to make it routine.  One might be a clinical trial.  I think one of the issues is the fairly high rate of false -- apparently false positive cultures, and if all of those units were discarded, it would certainly nullify the advantage of the ones that would be salvaged by the five to seven-day cultures.
		DR. SIMON;  I think he had that in his financial analysis, the workup of the false positives.
		CHAIRMAN NELSON:  Well, right.  According to his, but if in fact only one culture were taken and there weren't a five-day or a culture taken later to confirm whether or not it was a false positive, if the unit was just destroyed based on a single positive culture, then we could actually go backwards in terms of the number of units that would be -- you know, that we would lose units.  Yes, Dave?
		DR. STRONCEK:  You know, I've sat in on some other discussions on the problem with bacterial contamination of blood, and there really isn't a lot of great data.  There's a few studies, and the data we saw this morning, while it's interesting and it's hopeful, there's only -- what? -- 2000 units we saw.
		So that's not -- With the low incidence, it's not a lot of data.  One thing, though, I'm confused about.  What if -- Maybe Jim can answer the question, or Vostal.  What is involved in doing one of these protocols?
		You know, superficially I would think a person would have to go through their IRB and get consent to culture blood and then extend platelets to seven days, but some -- and you may even have to go through the FDA to get an IND or something.  
		Are there a lot of barriers or is all this -- I didn't get that part from the discussion, and is that creating a barrier for people to do this?
		DR. VOSTAL:  Well, I think the studies would have to be done under IND.  Jim has been talking about these studies for a couple of years now.  One of the problems we had with him going ahead and using seven-day old platelets is we weren't really sure or we didn't have any data demonstrating that the current storage condition would produce a good platelet.
		You know, now he's got data that we could extend the shelf life up to seven days.  You know, that opens up the door for using that extension, as he was saying, to sort of pay for the cost of the study, you know.
		If you could have a detection system or you could do a trial under IND where you are going to be looking at the effectiveness of the detection system, platelets you culture at Day Two and then a confirmatory culture maybe at Day Five or two days later, and then pay for the cost of that study by reducing your outdating of the platelets.
		So I think we have -- You know, we are moving toward being able to use seven-day old platelets, but I think one thing that maybe wasn't clear up front is that there are two issue.
		One issue is whether the platelets will work.  So it's platelet efficacy.  The other issue is the detection system, you know, or decontamination system.  We have to take care of the bacterial contamination problem first.
		We may be doing it out of sequence that we are looking at data on the efficacy of the platelets, but we certainly would not approve any of these -- or bags for extending shelf life -- without having some kind of a system in place to take care of the bacterial contamination problem.
		DR. STYLES:  Could this Committee come up with some sort of statement that we endorse the continuation of research in that direction, which is that we feel that there is adequate -- this is only my suggestion -- adequate data to suggest that the platelets are effective enough at seven days that then you -- because you made a very good point.  Clearly, we wouldn't go forward with any sort of decontamination if the platelets weren't any good at the end.
		Maybe this Committee's role is to state that we feel fairly comfortable, if everyone agrees to that, obviously, that the data that exists supports the idea that these platelets are functional enough so that efforts to go into contamination are warranted or suggested.
		DR. VOSTAL:  Well, I think that would be good.  It would encourage people getting into that research.  You have to keep in mind that the data we saw today was only on a single platelet storage system, and that data could be different for different bags, different manufacturers.
		So we would need to see data from each manufacturer to approve them for extension to seven days.
		CHAIRMAN NELSON:  I also wonder if some thought could be given to the study design that might be acceptable to the FDA, given the costs that were mentioned.  I know Dr. Yamatovian from Cleveland did a study in which there was a -- Platelets, I think, as I recall the study, were randomly either cultured or not, and then the patient was given standard platelets or cultured platelets, and they looked at febrile episodes.  They looked at etcetera.
		A study like that -- It seemingly maybe could be done with perhaps less cost if you didn't have to pay $7 million for the platelets that cultured at Day Five.  
		It seems to me that maybe there are study designs that could generate larger numbers at less cost that might provide data that would be useful for us to see the effectiveness of culturing platelets.
		DR. HOLLINGER:  I think along those same lines, I think Dr. Allen brought that up nicely, that much of the bacteria -- some of the bacteria that are seen probably are coming from the skin.  
		There were, I think, some studies that at least suggested you could reduce that substantially, not entirely but substantially, by the simple method of just removing 15 to 30 -- I don't know what the exact number -- 15 to 30 ml of blood initially at the start, and that one would consider the FDA suggesting to manufacturers that they incorporate something in their technology that would do that.
		It's not going to eliminate it all, and you are still going to have to have, I think, these other methodologies, whether it's pathogen inactivation or detection.  But it would still give you that little bit buffer for completeness there.  So I think that would be another thing.
		DR. VOSTAL:  That's a great idea.  I think actually, it was a year ago that we had a discussion here at the Committee where we discussed the version of the 30 ml blood collected.  There was a clinical trial done in Europe that demonstrated it could be effective.
		There was an  in vitro study done by Steve Wagner at the Red Cross, showed that we could model the removal of 90 percent of the bacteria in the first 30 cc's.  So I think the outcome of that discussion was that the Committee recommended this is a good idea, and we encourage the manufacturers to put this in place.
		The only problem with that is, you know, you have to take it on faith.  We don't really have any data what the current infection rate is, and you wouldn't know if you are actually improving things or not.
		MR. DUMONT:  Larry Dumont from Gambro BCT.  A couple of comments on Dr. Hollinger's point, and then a question for FDA on it.
		First of all, on the removal of the first aliquot of blood, I think a lot of people are familiar with those studies.  Actually, in France they have an interesting report where they have looked at this problem, and they said the number one danger is the skin contaminants, and the two things that need to be done to address that -- number one is proper antisepsis of the skin, and they have a national system.  
		So they implemented a universal retraining of all their phlebotomists, and they went out and taught people how to do it correctly and not to re-palpate after they decontaminated and things like that.  
		Then they also instituted this mandatory removal of the first aliquot that comes through the needle.  They were able to measure reduction in the septic transfusion reactions.  Didn't eliminate it, but it was a substantial reduction.  So that certainly is an effective approach.
		I think the data from Johns Hopkins demonstrates that every needle puncture carries an incidence risk of about 70 per million of having a septic transfusion reaction.  That's not even bacteria in the bag, but in fact a clinical septic transfusion reaction.  So you can do the numbers from that, and  that's in a pretty controlled situation.
		My question to FDA, which they probably can't answer right here, but some of the logistics of such a clinical trial -- One of the points that Dr. AuBuchon brought up was actually consenting patients, if you were under an IRB and IND type mode.
		I know there are some options where you do not have to always consent a patient with a clinical trial.  So if there was an IND approved through FDA, and these could be -- trials could be set up, does the FDA think that it would be possible to have a trial where you would not have to consent every patient to receive a seven-day-old platelet?
		DR, VOSTAL:  Well, that's a really tough question.  I think we would have to take that to our clinical branch for discussion and consideration.  I think, from my point of view, I would think there would be -- you know, you should require a consent up front.
		DR. BIANCO:  I think that Larry's -- Celso Bianco, America's Blood Centers -- should be taken into account, because it's not going to get worse than what it is now.  If anything, it will be better or it won't work.  So I think here is a situation where, if everything is done according to the current system, present rules and things like that, and if you have a way of sampling those bags that is more effective than we have today, that probably it would be worth discussing it with IRBs and all that.  Thank you.
		DR. LEW:  The other thing I was going to add, though:  Could the study design be different where, instead of demanding that they do it on Day Five and then thus using older platelets, then do it before the time of release, just before release, just doing the study design a little bit differently.
		You could actually collect data on dose response to give you a hint if it's going to be a problem at Day Five.  That might be more acceptable, I think, to the public as well.
		Sitting on the board -- Sitting on the IRB at my institute, I can tell you for sure we would not allow older blood without informed consent.
		CHAIRMAN NELSON:  Dr. Smallwood just reminded me that we are now in the open public hearing.  So if anybody wants to make a comment, and is Dr. Valeri here now?  Okay, because he asked -- and, Celso, you are listed, but was that your speech, what you just said?
		DR. BIANCO:  I have said enough.  This has been a very healthy, very informative discussion.  Thank you.
		CHAIRMAN NELSON:  Okay.  Well, are there any other comments, and what does the FDA -- What would the FDA like for us to do rather than just discuss the issue?  
		DR. VOSTAL:  The point we were actually looking for in this discussion was:  The design of these trials to look at the way the bags can store platelets is such that you would do them -- As Jim was showing, you do a survival at Day Five, and you do one at Day Seven, and compare the two.
		Pretty much, we all agree that there is going to be decrease in the survival and recovery at Day Seven.  Our question is:  When we see these systems come to us, you know, what should be the acceptable difference?  Should a ten percent difference or a 20 percent difference be adequate or should we set some kind of an absolute limit for platelet efficacy?
		CHAIRMAN NELSON:  I wonder on the issue of the informed consent.  I agree that, you know, given where we are, the informed consent for seven-day, you would have to consent a patient.  But patients might consent if it were coupled with a cultured bag.
		In other words, if the patients -- If we are saying -- you explain, you know, here's the way things have been done.  There is some risk.  We are trying to reduce the risk by culturing the bag and reducing the -- and actually improve the detection by, you know, if there's contamination, to allow enough time actually to be sure we detect it and divert those units, so that we may give you something that's a little -- may be a little less effective in terms of the platelets, and the estimate is ten percent or something.  But it may also be a little more -- a slightly likelihood that it might be a little more safe.
		Therefore, it isn't that, you know, we want you to take an inferior product that may not stop your bleeding, but we want you to -- we are offering you something that we think, you know, might decrease some risk associated with the procedure.
		DR. STYLES:  I don't think it's a problem with the study in itself.  I just think that they have to have informed consent.  So what I'm hearing, though, the problem is going to everyone of these patients every time you have to do a blood transfusion.  That is going to be very, very hard to do.
		DR. HOLLINGER:  Is Dr. AuBuchon still here or has he gone?
		CHAIRMAN NELSON:  He's gone.
		DR. HOLLINGER:  I guess he's gone.  I thought i heard him to say -- and maybe one of the other Committee members or somebody here could correct  me.  But I thought he said that some of the blood -- I mean, they culture it on Day Two, but that presumably some of the platelets are given before they get an answer back.
		If that's the case, I was wondering what he does then, let's say, on Day -- say, platelets are given on Day Three, but on Day Four, Day Five, the culture is positive.  Do they then go back and tell the physician I have a positive culture with a staph. aureus or something like this to the physician or the patient or -- I wasn't sure if anything was done with that information.
		It turns out possibly, although Dr. Allen mentioned it may have just been a negative culture because the bacteria were gone at that point.  But if it were really a truly positive culture, would that make a difference?  Does anybody --
		DR. SIMON:  Yes.  He would have to, I believe.  From the data he gave, that hasn't happened, and the system almost always catches the positives within the day.  So he has that day, and it's very -- Those that are transfused on Day Two are highly unlikely to have an adequate amount of growth to cause  a problem.
		DR. HOLLINGER:  But, Toby, just a question.  If you have some bacteria -- Again, I'm not sure how this works.  If you have some bacteria in a platelet culture -- I mean in platelets, and it's given to an individual, even though it's a low concentration, I presume that once it goes into an individual, that there would be growth of that -- potentially growth of that bacteria in the individual at 37 degrees.
		DR. SIMON:  But potentially.  But many of these people have no problem.
		DR. HOLLINGER:  I understand that, but I just wonder.  I mean, is it because there are other immune mechanisms going on that are preventing that, and there are probably many of them getting antibiotics and other things?
		CHAIRMAN NELSON:  You know, there are all kinds of procedures associated with bacteremia.  You go to the dentist.  You get a proctoscopy.  You get  TUR, almost 100 percent of people will have -- and you know, they are cleared.  These patients may not clear them quite as well, but I think a negative culture on a patient doesn't mean a thing.
		DR. STYLES:  You know, you were talking about all of this, but I think what Dr. Vostal said about, before any of that can even go forward, is the problem of establishing a standard of minimum platelet efficacy.
		To my mind, the problem is there are so many ways of measuring platelet efficacy, and one will have to decide on whether one is going to use an  in vivo versus an  in vitro measure with the attendant difficulties of each one of those and the interpretation of them.
		So maybe the Committee could discuss -- Well, what is actually the question before us, I think, from reading the statement was:  Is there a minimum level?  My response to that would be it depends on what you want to use as your measure.
		Then can we decide on a measure that we would recommend to be used, because that's really, again, I think, the first question.
		DR. VOSTAL:  I think we sort of accept radiolabeled studies as a surrogate for platelet efficacy, and platelet efficacy would be the way platelets circulate and stop bleeding.    But those are -- If you want to do a bleeding study, it's a very large study.
		So historically, we have accepted radiolabeled studies on products or on platelets that have been stored under differing conditions.  So for us to evaluate these new conditions out to Day Seven, we would still look at the radiolabeled studies.
		The numbers we were looking for is, you know, what's the minimal recovery, and what's the minimal survival that would be still useful as a platelet product.  
		I had some discussion with Sherrill during the intermission, and she was giving me some of her ideas about that.  She thinks that it's a five-day survival 50 percent, somewhere around 50 percent recovery.  Did I get that right, Sherrill?
		DR. SLICHTER:  Yes.  The point is that I think that patients don't do the same thing with platelets as normals.  Okay?  So what I've tried to show you is that, as soon as you are thrombocytopenic, your survival is reduced proportionate to how thrombocytopenic you are, but your recovery is, in fact, the same as in normals.
		So Jaro and I were discussing at the break -- He asked me this question, and you know, I think we have five-day stored platelets.  That's the accepted end of the storage interval.  So I think we have to get -- If we are going to extend storage, I think it has to be the same as or better than, conceivably.
		What I have, I think, already documented is that in Plasmalyte seven days is better than five days in plasma.  So I think there are ways that we can get a good quality product.
		So you are toying with the fact that you need very few platelets, 5-10,000.  So even -- But I think that we have to give a platelet product that is as good as the patient can use.  
		So in other words, if the survival of the donor platelets in the patient is only two days, then I think we have to have a product that will survive at least two days in normal volunteers and expect it to be two days in patients.  But, you know, some people -- their platelets survive four, five, six days between transfusions, and those are not common, because patients have a zillion things happening to them.
		So I don't know that you want to have a standard that is 20 percent less for recovery and survival, say, than five-day.  So I would prefer to have us think about a recovery that's relatively close to normal, because most patients can get a recovery that's pretty close to normal, and then a survival somewhere of four, five, six days.
		I would be very comfortable as a clinician saying this is a good quality product.  This is as much -- The patient doesn't need an eight, ten-day survival, because they never have an eight, ten-day survival.  So why should we aim for that as a gold standard, and we don't have that now.
		DR. VOSTAL:   Just a -- I wonder if I could get you to put a number on that recovery, because some of your studies are showing recovery of 80 percent.
		DR. SLICHTER:  Well, yes, and as I mentioned, I'm just dumbfounded at how good the recoveries are, and I think it may be that somehow the manufacturers, unbeknownst to us, gave us a bag or a storage material or gosh knows that's better than what we've had, and also, you know, the data that I showed that the higher your platelet count, the higher is your recovery, which is an unknown, at least to me anyway, potentially biologic phenomenon.
		So I would not hold this to a 70-80 percent recovery for the product, but I think somewhere around 40 to 50 percent would be fine with me.
		DR. STYLES:  Can you review again how you define platelet recovery?  I'm sorry.
		DR. SLICHTER:  Yes.  It's the increment which is the pre -- the post minus the pre, and then adjusted for blood volume.  So 75 times the increment, because 75 ml is the usual blood volume determination.  Then divide it by the number of platelets transfused. 
		So what you are trying to look at is, of the platelets that I transfused, how many of them circulate following transfusion?  The normal recovery is somewhere around 60 to 65 percent, because normally a third of the platelets are pooled in the spleen.
		So if you asplenic, it's like 90 percent.  So, you know, whether -- but these donors, we have had a 90 percent recovery donor come back and be retransfused in another set of experiments, and they are still 90 percent.
		I think I showed you the 5,7 day data with the Plasmalyte that, my gosh, the recovery was exactly the same in the same donor, within a few percentage points.  So that's how the recovery is calculated.
		So you can think of it as how many do I put in, and how many circulate.
		MR. DUMONT:  Larry Dumont.  I wanted to comment on the number.  First of all, I think one has to be really careful about the number, because there are differences between laboratories and centers when these studies are done.
		Dr. AuBuchon didn't show all the details of that data, but since I designed the experiment and did the analysis, I can tell you that the two centers -- There was a significant difference between Dartmouth and Norfolk.
		You know, you can adjust for that in the analysis, of course.  So you have to be very careful about a specific number.  I think the studies that are done to make the argument, it's imperative that those are well paired studies because of this random problem that we have.
		Then just to reemphasize, too, what Sherrill said about the differences between subjects in these normal donors.  I mean, we have some donors or subjects that they may have a recovery of like 40 percent, and they always have a recovery of 40 percent, and you have others that have a recovery of 80 percent, and they always have a recovery of 80 percent.  
		So it's also very critical to pair things so that you can adjust for those in the analysis.  So I would be very worried about an absolute recovery number, an absolute survival number without this comparative and being able to adjust for all these other confounding factors.
		DR. STRONCEK:  So it's too bad Jim's gone -- or Dr. AuBuchon is gone.  I hope the FDA didn't pay for his ticket.  It would have been nice to have him here for the rest of the discussion.
		Anyway back to the study design question, I think it's going to be very -- You know, I agree.  You have to get informed consent, but I think, thinking through how a person would do that -- this would be an extremely difficult study to design and implement.
		If I were going to ask my IRB to give seven-day platelets, I would not want to give them unless I had no more five-day platelets on the shelf, because we have heard there might -- We're not quite sure that they are sterile, and we don't know -- and it looks like they are not going to function as well.
		So you would want to give five-day platelets first.  So I would not want to have my fellow go up a route of platelets and say okay, to a patient, you can either get nothing or you can have this old platelet, you know, when you're bleeding, please sign.
		So, you know, you would probably want to prospectively get everybody to consent to the protocol.  The problem becomes, if you get half the people that don't -- You know, you say, well, here, there's a possibility we might give you old platelets versus another product -- you know, our standard product, which is five days.
		So you know, on a Monday morning when you are short of platelets, you have eight people that need platelets.  You have five products that are in date.  Well, the people that don't consent to the study, they are going to get the fresh ones, and the few people that do consent would always get the old ones, and it gets very, very tricky to figure this out.
		DR. ALLEN:  I think we have to be very careful.  I mean, fortunately, committees don't often design studies.  I think we have to be very careful in terms of how we couch this in the concept.
		The frequency of contamination is not going to go up between five and seven days.  What might go up or change is the level of bacterial concentration in that period of time, although, as Dr. AuBuchon and other speakers earlier said, by five days, if you've got a bacteria such as Serratia marcescens or one of those others listed in the study that is very happy to grow in a cold environment in a plasma enriched environment, it's not going to make any difference whether you've got levels at five days or at seven days.
		Most of those bacteria can reach concentrations of 106 to 109 bacteria per ml within 24 to 48 hours.  So I think we have to be very cautious about how we couch the terminology, and I think it would be very good to go back and look at what happened in the -- was it in the Eighties when they went back -- or Seventies when they went back and made for that brief period of time -- enabled seven days? -- and see if we can tease out from the literature of those days exactly what happened and what data were available.
		It's not the level of -- or it's not the frequency of contamination that's going to create the problem.  I would almost wonder if in that additional period of time whether what is happening is that you are getting bacterial die-off and the endotoxin rate is going way up.
		I mean, it's not a simple answer, and I'm not concerned that we are going to create a less safe environment because the frequency of bacterial contamination is going to go up between five and seven days.  
		I think, if the issue is one of platelet efficacy at first, I think the data are beginning to be accumulated that we in fact do have effective products out to seven days.  You know, I think you can couch your patient consent very well in terms of the making available platelets to them that might -- you know, to the patient population that might not otherwise be available when they are badly needed.  That perhaps is the benefits that's there.
		I think the study design is very critical, and exactly how one provides effective -- or good information to the patients as one gets informed consent is a very critical issue.  But, you know, in terms of the potential risk of bacterial contamination, I think we have to look at how we couch that message very carefully also.
		CHAIRMAN NELSON:  Yes?
		MR. NELSON:  I'm Ed Nelson from Pall Medical.  Just a couple of points.  Point of clarification on what Jim presented:  The Gordon Archer studies that he presented looking at five-day and seven-day were not data that were submitted to the FDA in their deciding on seven-days.
		They reviewed data that, in fact, Toby Simon and Scott Murphy -- studies of theirs, and on average I think the five-day studies or a series of them averaged between 46 and 51 percent at five days and 40 percent to 45 percent at seven days.  That's really the sort of data that I would expect to see now unless the methods have changed somewhat, which they may have.
		Secondly, I sort of would like to support what Larry said about an actual, exact cutoff for approval.  Depending on what patient -- or what normal subjects you pick, you can get a mean ranging from 40 up to 60.  Obviously, you don't try to pick subjects, but that can happen.
		So we would be more in favor of doing an actual double labeled comparison study within the same subject to look for differences.
		CHAIRMAN NELSON:  Thanks.  A couple of maybe brief comments.  If we want to get out by 3:30, unless it's anything critical, we need to break in five minutes or so.
		DR. DOPPELT:  One quick question.  We've been focusing mostly on platelet numbers and survival, and what really counts is the function of the platelets.  So my question is how difficult is it to do in vivo tests for the function of the platelets?
		I mean, for example, is the correction of bleeding time of value?
		DR. SIMON:  I tried doing those studies for many years, and I think others would agree, they are very difficult to do.  But they can be done.  I think they have -- Sherrill has shown more through evaluation of hemostatic effectiveness, because the bleeding time studies were just nonreproducible and difficult to do.
		DR. STYLES:  And the bottom line really is need for further transfusions or platelets.  That's why those endpoints, I think Sherrill showed -- Dr. Slichter showed were -- Those are the ones they looked at where the clinicians' bottom line was going to be do I need to give them more platelets because of this or are they having red cells or more bleeding complications; because those -- You mentioned the bleeding time is pretty inaccurate, risk for -- risk of bleeding.  That's been done over and over in a lot of surgery studies.
		DR. FALLAT:  Well, I couldn't agree more that this is not the forum to be developing a protocol.  But I think we have clearly demonstrated that we have a major problem here with infection and that we have a real need to try to extend the time.
		So we have three different problems, extending the time and correcting the contamination by either culturing or by perhaps using a decontamination method.  The fourth problem is we don't have enough money to do it.
		I would suggest that the FDA sponsor a workshop which would combine industry, academia, and the various blood banks and so forth to really hassle out these issues and really in that forum decide how best to proceed.  I don't think this is the forum to do that.
		CHAIRMAN NELSON:  Thank you.  I agree.
		Okay.  Let's break now and come back at 12:30, and we will try to end by 3:30 this afternoon.
		(Whereupon, the foregoing matter went off the record at 11:39 a.m.)

	A-F-T-E-R-N-O-O-N  S-E-S-S-I-O-N
	(12:37 p.m.)
		DR. SMALLWOOD:  I would just like to remind all of the speakers, if you have presentations to make, I hope you have seen the gentleman over here to my left to have your presentations loaded onto the computer.
		We have a full session this afternoon.  I would also like to advise speakers to please speak as long as necessary, but to move quickly through the program, because our Committee members will be leaving, and we do want to give full consideration to this topic.  Dr. Nelson.
		CHAIRMAN NELSON:  Thank you.  The first topic is bacterial and fungal contamination of human tissue intended for transplantation.  To introduce the topic, Dr. Ruth Solomon from FDA.
		DR. SOLOMON:  Good afternoon.  This is the final topic of this BPAC meeting.  This topic is being presented today to inform the BPAC members about recent reported cases of bacterial contamination associated with musculoskeletal tissue allografts.
		FDA is concerned about transmission of communicable disease by human tissue intended for transplantation, since we regulate this tissue.  Next slide.
		As you may know, there has been a recent report of sepsis and death in a young recipient of fresh osteochondral tissue allograft from a cadaveric donor following knee surgery that he had.  The organism that was cultured from his blood was Clostridium sordellii.
		For those who are a little rusty on their microbiology like I was, Clostridium is an anaerobic, spore forming bacillus that is normally found in the human GI tract.  
		Investigations of this case were performed by the Minnesota Department of Health, the CDC, and FDA.  There have been additional reports of bacterial and fungal contamination of tissue allografts.  Next, please.
		To give you a preview of this session, I will be summarizing the current and future FDA regulations that address this issue.  Then mary Malarkey from our Office of Compliance at FDA will talk about microbial contamination and cross-contamination during processing of tissue, including the guidance that recently published.
		Dr. Marion Kainer from CDC will update us on CDC's ongoing investigation of allograft associated infections.  We will also hear presentations from Dr. Ted Eastlund who will present the tissue bank perspective, and Dr. Michael Lemp who will present the eye bank perspective.  Next.
		FDA has been regulating human tissue intended for transplantation since 1993 when it issued an Interim Rule.  The interim rule was then finalized in 1997 and became effective in January 1998.  It is codified in 21 CFR Part 1270.
		The legal authority for our promulgating these regulations is Section 361 of the PHS Act, which states that the Federal government can propose regulations that control communicable disease introduction and spread.
		The main focus of the interim and final rules was on donor screening and testing for HIV, Hepatitis B and Hepatitis C, because of concerns about imported tissue for which donor screening and testing were not being done.
		With that as its main focus, there are very few requirements in the current regulations that address processing.  Next slide, please.
		1270.31(d) in the current regulations says that there shall be written procedures prepared, validated, and followed for prevention of infectious disease contamination or cross-contamination by tissue during processing.  Infectious disease agents can include, but are not limited to, bacteria and fungi.  Next slide.
		Compliance with 1270.31(d) and all requirements in Part 1270 is determined during inspection of the tissue establishment.  Recently, we promulgated some additional final rules under 21 CFR Part 1271 which published January 2001 and became effective in April.
		These regulations require that tissue establishments register with the FDA and list their products and update the registration and product listing annually.  Next slide.
		As you probably know, FDA has proposed two regulations which we have received comments on and are in the process of finalizing, but they have not been finalized yet.  These are the suitability determination for donors of human cellular and tissue based products, a proposed rule that issued in 1999, and current good tissue practice for manufacturers of human cellular and tissue based products, inspection and enforcement, a proposed rule which was published in January 2001.  
		I would now like to briefly review some of the requirements in the GTP proposed rule.  Remember that these requirements are not currently in place, but they would become effective after the GTP proposed rule is finalized.
		These are the sections of the proposed rule that I think focus on the issue today:  First of all, the GTP requirements are intended to prevent the introduction, transmission and spread of communicable disease through the use of cell and tissue products, by helping to ensure that the products do not contain communicable disease agents and that the products do not become contaminated during manufacturing.  By manufacturing, we mean recovery, processing, storage, labeling, packaging, and distribution.  Next, please.
		Then another proposed requirement is that establishments should establish and maintain a quality program whose functions would include:  Investigating product deviations and complaints; ensuring that appropriate corrective actions are taken, both short term and long term; performing audits at least annually; and reporting the findings to management.  Next, please.
		In addition, there would be requirements to have process controls.  The establishment would have to control and monitor manufacturing processes to ensure that each product is not contaminated and is manufactured so as to prevent transmission of communicable disease by the product.
		There would be in-process monitoring and control:  Representative sampling; control of the product until required inspection and tests were completed and specific requirements were met.  Next, please.
		There would also requirements for process validation when the results of a process cannot be fully verified.  Validated processes would have to be monitored to ensure that the specified requirements continued to be met.
		When any changes to or deviation from a validated process occurred, revalidation would be required, and any process related claim in labeling or promotional materials would be based on a validated process.  Next, please.
		There would also be requirements for receipt and distribution of tissue products.  There would be procedures established for receiving and accepting or rejecting products for processing, distribution or any other step in manufacturing.  Each incoming product would be inspected for contamination.  Next.
		In addition, there would be requirements for tracking; that is, maintaining a method of tracking a tissue product from the donor to the recipient and vice versa, from the recipient to the donor.   Next, please.
		Lastly, there would be requirements for reporting to FDA of adverse reactions involving the transmission of a communicable disease, if the adverse reaction was fatal, life threatening, could result in permanent impairment of a body function or permanent damage to a body structure, or necessitated medical or surgical intervention to prevent permanent impairment.
		Also product deviations that could lead to an adverse reaction would also be required to be reported to FDA.   Just to remind you that at the present time adverse events following tissue transplantation are not required to be reported.  They can be voluntarily reported through FDA's MedWatch system.  Next.
		Although we are not asking the Committee to vote on any particular questions, we would like to have a general discussion of possible mechanisms to prevent bacterial and fungal contamination and communicable disease transmission by human tissue, and these possible mechanisms will be presented by Dr. Kainer.
		FDA and CDC investigations are ongoing.  Dr. Kainer will mention that currently investigations are being performed to identify risk factors associated with Clostridium infection post-allograft transplantation.  CDC is working with states on that.
		In addition, CDC is working together with AATB to do a survey of tissue banks to determine current processing methods and quality control procedures.
		Lastly, the goal is to develop sterilizing methods which would eliminate bacteria, fungi and bacterial spores without adversely affecting the tissue allograft quality.
		We are going to be holding questions until the Committee discussion, but the next speaker, who is Mary Malarkey, cannot stay until the end, and she will address questions immediately after her talk.  
		CHAIRMAN NELSON:  Thank you, Dr. Solomon.  Are there any questions or comments directly related?  Okay.  Dr. Malarkey.
		MS. MALARKEY:  Good afternoon.  I am pleased to be here today to participate in this session about a very important topic for FDA, and that is our concerns regarding microbial contamination and cross-contamination of tissue during processing.  Next slide, please.
		To that end, I would like to speak about what we've been doing over about the last ten months.  That is the evolution of our concerns; what the current thinking is at FDA, and this includes what current industry thinking is as well; some information sharing and gathering activities that have been underway and the results of those activities; and finally where we are going in the future.  Next slide, please.
		In late 2000 there was an E. coli transmission by cancellous bone chips.  A sample was taken in the operating room and cultured, and following surgery the next day the patient developed signs and symptoms of sepsis.
		The blood cultures on the patient were positive for E. coli, as were the culture results from the preop culture.  Wound re-exploration was necessary, and the patient did recovery but, of course, required antibiotic treatment and a longer hospital stay, and one can expect not a very pleasant outcome altogether.  Next slide, please.
		FDA was not notified of this incident, and it came to light during an inspection in May of 2001.  Many of the items associated with this incident were documented on the FDA 483, which is our list of inspectional observations.
		At that time, we realized that the manufacturer had withdrawn some, but not all, of associated tissue from the same donor.  I should say that during the course of the inspection, that was done.  So a total recall was performed.  Next slide, please.
		The result of this was a Class 1 voluntary recall because of the harm that had been caused and the potential harm that additional units of tissue could have caused to potential recipients.  Class 1 is our most severe designation in terms of health hazard evaluation.
		We published this in our FDA Weekly Enforcement Report, as is required under our regulations under Part 7, on August 1, 2001, and I should say that this is an ongoing investigation with respect to the tissue bank.  So I can't comment much further on what is going on in that regard.  Next slide, please.
		Around the same time we became aware of a voluntary recall due to potential mold contamination.  This affected about 1300 units of tissue.  Again, this is an ongoing investigation.  So the same applies.  And of course, the very tragic fatality in Minnesota more recently, and we have become aware of other transmissions, if you will, as identified by our colleagues at CDC.  Next slide.
		Our current thinking:  Well, the industry standards -- and I'll go through some of those in a moment -- speak to control and prevention of contamination and cross-contamination of tissue during processing with respect to microbial agents.
		As Dr. Solomon said, our current regulations require validation of -- well, preparation, validation and following of procedures in this regard.  Next slide, please.
		Now I have excerpted some of the industry standards.  These are certainly not all inclusive, but some that I feel that speak to the subject at hand today.
		From the American Association of Tissue Bank standards for tissue banking, we have -- The expectation is the standard operating procedures manual will establish a list of organisms which necessitate discard, sterilization and/or disinfection of tissue.
		Further, basically, the regulation under 1270.31(d) is reiterated within their standards.  That is, there must be written procedures that are prepared, validated and followed with regard to this issue.  Next slide, please.
		Microbiological culture samples should be taken prior to any treatment of the tissue with disinfecting agents or antibiotics, and this is, of course, to guard against false negative results from the incoming tissue.  
		Also cells and/or tissues with bacterial contamination may be released, but only if adequate measures are taken to identify and eliminate those microorganisms.  
		The one thing that is somewhat lacking, we believe, in the current standards for tissue banking is, if microbial testing is performed in-house at the tissue bank, there is very little guidance on how that should be performed, what the methodology should be, the sampling techniques, etcetera.
		On the other hand -- next slide, please -- there is an AATB Technical Manual that was published in 1992 on musculoskeletal tissues, and this goes into great detail on requirements for microbial testing and sampling methodologies.
		One of the important discussion points in this document is the importance of bacteriostasis and fungistasis testing.  Again, for those of you who aren't up on your microbiology, what this is is -- It's an evaluation of any inhibitory effect that the test article may have on recovery of microorganisms during the course of a sterility test, put in simple terms.  
		In this case, it is very important, since antibiotic soaks and soaks in other bacteriostatic rather than bacteriocidal agents is often performed.  Also, there is discussion of the various sampling methods such as destructive versus swab testing.  Next slide.
		Now in regard to the EBAA standards, we are talking here, of course, about other than in situ recovery -- that is, if a whole globe is taken and then further processed in a biological safety cabinet.  		The standards are not very specific, but they do give information on equipment cleaning and maintenance, but they don't really go into environmental controls or validation with regard to this processing.
		We do understand that microbial cultures of eyes are generally not taken at tissue banks -- excuse me, at eye banks, and that's not the issue I'm trying to get through here.  It's just the processing itself and controlling any further introduction of contamination to the tissue.  Next slide, please.
		Well, what do our regulations say?  Well, Dr. Solomon already addressed 1270.31(d), which is very important here.  
		There is also -- next slide, please -- a very important definition of processing under 1270.3(p).  Basically, processing is any activity performed on tissue outside of recovery, and this would include any steps to inactivate and/or remove adventitious agents.  Next slide, please.
		There is also 1270.31(e), and this speaks to verification rather than validation.  That is, if you are using current processes that are part of technical manuals, for example, that you would want to verify the effectiveness of those procedures.  But it wouldn't necessarily necessitate, if you will, full validation.  Next slide.
		So just to reiterate, processing includes all activities performed on tissue outside of the realm of recovery.  So this then would include testing, microbial testing, both pre- and post-processing, and any other activities that are undertaken on the tissue even at the procurement site, such as storage or labeling.  Next slide, please.
		So in summary, we believe that the current regulations do require validation or verification of these procedures to prevent contamination or cross-contamination of tissue during processing with respect to microbial agents, and we believe that the current industry standards support that thinking.  Next slide.
		What have we been doing since these concerns arose?  Well, we have taken on several information sharing and gathering activities.  In  regard to tissue banks that we have found some problems with in this regard, we have sent Untitled Letters.
		These are regulatory letters which describe our current thinking and our expectations.  They don't quite rise to the level of a warning letter or a more serious action, but they do warn firms that these are our expectations.  
		We recognize that guidance would be necessary to the industry in regard to our current thinking, and we began some outreach programs in this regard, both internal and external.  Next slide, please.
		In terms of gathering of information, we sent a request to all the FDA district offices and asked that, during the course of their inspections of tissue banks, they would review and document certain issues.  This began about mid-August of 2001.
		The next few slides go over the request that we gave to the field and asked them to address during the course of the inspections and documented in the reports.  I won't read through each and every one of them, but basically we wanted to know if the firm has procedures in place in this regard; whether the procedures are validated or verified based on the scientific literature; -- next slide -- are the procedures being followed; some questions regarding microbial testing, how it's performed, what standards are used, what types of sampling methods are used.  Next slide.
		Finally, is there any evidence of release of contaminated tissue, and finally, how are the finished products labeled?  Next slide.
		IN terms of outreach, we participated on a panel at an AATB one-day validation symposium back at the end of November.  I want to say, this was a very intense program, quite intense, very well put on program, and provided a lot of information to the tissue industry.
		We are also going to be involved in the presentations at the AATB annual meeting about a week from now, and Dr. Kainer from CDC will also be there.  So the Department will be well represented.  Next slide, please.
		I should also say that we also are doing internal training with regard to the field investigators with all of these new developments to keep them abreast of our current thinking.  
		Probably very, very new is our Guidance for Industry which was actually just published or just issue March 8.  This is the Guidance for Industry on validation of procedures for processing of human tissues intended for transplantation.  A notice of availability was published in the Federal Register Wednesday, March 13th.
		What I have done for the Committee is there's some manila envelopes that should be in front of you that contain copies of my slides, because I think there were updates, as well as the guidance and the Notice of Availability for your information.  Next slide, please.
		Now just briefly what the guidance says.  It gives our current expectations with regard to viruses, bacteria, fungi and TSE associated prions.  We say that currently we expect that procedures will be prepared, validated and followed to prevent contamination or cross-contamination of tissue during processing by viruses, bacteria and fungi.
		We talk about validation versus verification, what that means, and we give some broad examples about how these studies may be undertaken.  Next slide, please.
		With regard to TSE associated prions, we acknowledge that technology is not quite there to do full validation studies.  However, we expect, as technology progresses, that this requirement will be readdressed.
		For those tissue banks that are currently engaged in high risk processes with respect to TSE, we strongly encourage heightened screening and recovery procedures be put into place to minimize the risk, and we speak very briefly as to the current regulations and the proposed GTPs with regard to commingling and pooling.  Next slide, please.
		Finally, we let industry know that these procedures and data wills be reviewed during inspection, and any deficiencies will be noted on the FDA Form 483.  Next slide.
		The Notice of Availability that just published the day before yesterday:  We are soliciting comments on this guidance, but this guidance was issued for direct implementation due to the public health concerns involved here.
		We are asking industry, if they would, to submit information on what current methods are in place, and we wish to have further public discussion on this issue and hope for -- We recognize that we will need more additional, specific guidance in the area of bacterial and fungal contamination of tissue.  Next slide.
		With regard to our information gathering, the results there -- and I want to stress that current resources as they are do not permit us to do an exhaustive review of all establishment inspection reports that are prepared as a result of inspections of tissue banks.  This was a project that we undertook because of the current situation.
		We reviewed 60 establishment inspection reports with regard to the information that we requested from the field.  This is a small percent -- It's not everyone out there, obviously, the whole universe.  So I also want to stress that.
		I've done the breakdown here also to show that a lot of these sites aren't really doing any processing.  There's distributors and testing labs for donor screening activities that would not be considered processors.  Next slide, please.
		With regard to the problems identified, again I want to qualify this, and I'm not saying that these problems are everywhere or they are completely lacking.  There are different degrees, as is always the case, but we did see in our review that these is lack in many cases of full validation or verification of procedures in this regard.
		There also seems to be a lack of clarity as to what processing is.  This was especially at eye banks, for example, that do the whole globe and then do further processing, and also at procurement sites where, for example, bacterial testing is performed on the tissue after recovery.  
		Unfortunately, also we saw in some cases procedures are in place, but they are not always being followed.  Next slide.
		We did see problems with microbial testing:  Lack of verification or validation of sampling and testing procedures.  For those of you who are familiar with destructive versus swab testing, both have their pluses and minuses.
		With destructive testing, you are really evaluating the entire test article, but you can only really use a representative sample of the entire lot.  So what is a representative sample is one of the big issues here.  To be representative, one has to assume that the process is consistent and uniform.  That is consistent form time to time, and uniform with respect to each piece of tissue being treated in the same manner.
		IN regard to swab testing, you can actually look at 100 percent of tissue with this method.  However, it has its own drawbacks, mainly the recovery of whatever is of interest from the test article, and then the ability to recovery from the swab into the microbiological media.  So in the biopharmaceutical industry we have seen data anywhere form 30 to 80 percent recovery in this regard.  
		Lack of bacteriostasis and fungistasis testing:  As I mentioned earlier, this could lead to false negative results, and this is a big concern.  Even for contract testing, we weren't always sure whether this was addressed, this inhibitory effect of the test article.  Next slide.
		We saw some inconsistencies at times in handling of incoming positive microbial results.  There are often various procedures in place, depending on what the microorganism is it that is identified as, but in some cases we saw that there is some retesting, reprocessing, and reworking going on until the desired results are obtained.  
		So, in fact, there is very little rejection of tissue.  We understand that it's very precious, but in some cases it may be in the best interest not to perhaps proceed with processing of certain tissue.  Next slide, please.
		So finally, where are we going?  Well, clearly, we believe we need to develop more specific guidance in respect to this area, and we do want to work with industry and other scientists in the agency as well as in the Department at CDC to develop this guidance.
		We will continue to monitor the validation and verification procedures and activities in industry through inspection and surveillance, and we are prepared to take enforcement actions as necessary.  This is never our preference.  We would much prefer that industry take heed and do what is right here, and I think it's really up to all of us, industry, regulators and scientists, to ensure the safety of the tissue supply.  
		On my final slide -- last slide, please -- I have got some -- where you can get the guidance document on the CBER website.  The Notice of Availability is also under the DOCKETS Website, and I believe for the Committee I have put that website on the last slide.
		Thank you.
		CHAIRMAN NELSON:  Thank you.  Any questions?  Dr. Schmidt?
		DR. SCHMIDT:  It used to be common practice for the orthopedic surgeons to have a freezer outside the operating room, and they know what they put it, and they took it out.  
		Now I expect with the current financial climate at the hospitals, the administrators would rather buy them a freezer than sign up with a licensed organization to get their material for them.  I'm curious as to are they part of the industry?  How many of them are there?
		We have an orthopedic surgeon, and I wonder if he would speak to the status of that.  Does this fall through the cracks?
		DR. DOPPELT:  I'm the orthopedic surgeon.  It used to be in years past common practice for small hospitals and so forth to keep, for example, femoral heads, say,  for grafts in other patients.  
		As the whole field has progressed in terms of the need for various serologic testing and sterility testing and so forth, basically, those places have essentially dried up.  They don't exist, because number one, they can't afford to do all the testing.  Number two, neither they nor the hospitals want the liability, if they are not going to follow all the rules that are basically promulgated.  So, basically, they don't exist anymore.
		DR. CHAMBERLAND:  I may have missed it, but can you give us some sense of what the denominator is in terms of number of tissue banks, and I believe also isn't there a differentiation between those that are licensed and -- or just so what is the universe of tissue banks that we're dealing with?  Then also some sense of, up until these recent events, what FDA's ability has been to perform routine inspections and whatever?  
		I would imagine you can only inspect per year some fraction of what's out there.
		MS. MALARKEY:  Unfortunately, I am unsure as to exactly how many registered banks we have currently.  Dr. Solomon may have that information.  I do know that with the 1271 registration rule, actual tissue processors were supposed to all have registered by a given time, and then there is a three-year implementation for other cellular therapy based sites to register.
		It is also important to note that, as my slide indicated, not all of them are full service tissue banks or necessarily performing processing.  So I would defer to Dr. Solomon.
		DR. SOLOMON:  Okay.  We have currently 460 registered establishments in our database.  Eighty of those voluntarily registered.  They were not required to register now, but would be required to register when all of our rules are in place -- for instance, reproductive banks and hematopoietic stem cell banks.
		Of the -- So that leaves us with about 380 that had to -- were required to register.  Out of those, we recently tallied that more than half of them either distribute only or test only.
		On the form that they have to fill out to register, we ask what functions they perform.  So we wanted to know how many distribute only and test only for some inspection priority purposes, and also we have also heard that the Congress and the public are saying, you know, why do you have 460 banks when we only expected you to have about 150 tissue and eye banks.
		I think, based on the people that have joined the -- voluntarily joined the professional organizations in the industry, but I think that distributors and test labs would not be likely to join AATB or EBBAA.  So that might account for some of the discrepancy in the numbers.
		DR. CHAMBERLAND:  And then, Dr. Solomon, up until recent events what has been your capacity to do inspections of the banks that you are aware of?
		DR. SOLOMON:  Do you want to take that?
		MS. MALARKEY:  I was going to say, I think as of now we have inspected all of the tissue banks that are full tissue banks.  Is that -- about 160-some, based on that math when you take out the distributors and testing labs.
		I think it is fair to say that we cannot get out to every one every year, and there is some priority given based on the activities and based on their prior history.  If we saw problems, we would obviously want to go back in a more timely fashion.
		DR. SOLOMON:  But I believe currently the aim is to inspect every two years.
		MS. MALARKEY;  Yes.
		CHAIRMAN NELSON:  You reported a couple of instances, one of which was only detected during an inspection.  Do you think that there -- What do you think the level of unreporting of recognized events might have been, and what is the plan to correct or get all of events reported, investigated?
		MS. MALARKEY:  Well, I believe the -- In answer to your first question, I don't really know what the universe is out there; that is, how many times this has occurred without our knowledge.  I believe that Dr. Kainer has some information perhaps on that.
		I certainly don't want this to sound like we believe it's a rampant problem, but it is out there.  
		In respect -- I'm sorry, sir, your final question?
		CHAIRMAN NELSON:  Well, I guess the guidance or after these rules are promulgated, theoretically, that would more effectively required reporting, I guess.
		MS. MALARKEY:  Yes. Certainly, the adverse events, as Dr. Solomon stated, would be reported.  So that would give us an idea when this occurred, and we would be able to act on it.
		DR. DOPPELT:  I'd just like to say that I think the issue of data gathering and reporting is a serious issue and a potential -- and a clear gap in the entire system.  
		The AATB does inspect banks and requires that they have an adverse file -- you know, any problems with the tissue that they have distributed.  The problem is that they send out a form with the tissue that the hospital is supposed to report back to, and they may or may not get it, and they can get it, and they may or may not get a response.
		So the system is there, but it doesn't respond very well in terms of getting that information back, and I think, clearly, one of the things is that somehow you have to develop a system where, if there is a problem, at least the AATB is notified, the CDC, FDA, etcetera; because if you are going to try and establish trends, you would like to do it early on, not two years after the fact.
		MS. MALARKEY:  Absolutely.
		DR. DiMICHELE:  When you cited the evolution of concerns, you started in the year 2000.  Yet I'm assuming that tissue banks have been in existence for a while.  I don't know how long, and maybe you can educate me on that.
		I'm just trying to understand what the previous history has been, you know, in the absence of regulation in terms of infections.  I guess maybe what people are thinking is that there have been infections.  There just hasn't been systematic reporting, and we just don't know what's happened before this time.  Is that --
		MS. MALARKEY:  Well, as Dr. Solomon says, we have been regulating the tissue industry since the early Nineties, 1993, and the focus initially was more on the transmission of viral infectious disease agents such as Hepatitis C, B and HIV.
		I can't speak to what happened pre-regulation, but that has been the focus, and our attention has certainly gone elsewhere as a result of recent -- more recent events.
		CHAIRMAN NELSON:  Okay, thank you.  The next presentation is Dr. Marion Kainer from CDC.
		DR. KAINER:  Could I have the first slide, please?  Good afternoon.  Thank you for allowing me the opportunity to update the Committee on these infections.
		Musculoskeletal allografts includes tissues such as bone, tendon and menisci.  In 1999 650,000 allografts were distributed in the United States.  This compared to 350,000 in 1990.  Next slide.
		Once consent is obtained from a donor, tissue is procured by sometimes several tissue procurement or organ procurement organizations.  They can involve skin banks, eye banks, solid organs, as well as musculoskeletal tissue.
		One tissue procurement organization may send tissue to several tissue processors.  Thus, a single tissue processor may then distribute it to several tissue distributors, and then it gets implanted into multiple patients.  One donor can give rise to about 130 tissues.
		The tissues you see down at the bottom are bone, tendon, meniscus, and bone screws.  Next slide, please.
		In November of 2001 a 23-year-old man in Minnesota had reconstructive knee surgery using a femoral condyle -- that is a bone-cartilage -- allograft.  Three days later he developed pain in his knee.  There was rapid progression to shock, and he died the following day.  Blood cultures obtained premortem grew Clostridium sordellii.  Next slide.
		The tissue came from a donor who I will refer to as Donor A.  That donor had no signs of sepsis.  He had no risk factors for Clostridial infection.  The body was refrigerated 19 hours after death, and the tissue was procured 23.5 hours after death.  A single tissue procurement organization was involved, and all tissue was sent to a single tissue processor who I will refer to as Tissue Processor A.  Next slide.
		A total of ten tissues were implanted into nine patients located in eight states.  That includes the patient in Minnesota.  We contacted the health care providers of all recipients of the tissue, and identified one additional symptomatic patient, a 17-year-old who had a femoral condyle and meniscus implanted.
		He developed septic arthritis and fever with absolutely no response to first generation cephalosporins which have no anaerobic cover.  He was admitted to hospital eight days after surgery with a dramatic response to ampicillin-sulbactam, an antibiotic which has got excellent anaerobic cover.  No anaerobic cultures were taken.
		There were 19 non-implanted tissues still at Tissue Processor A, and these were cultured at CDC.  Clostridium sordellii was isolated from two tissues, one fresh femoral condyle and one frozen meniscus.  Of note, all processing cultures at Tissue Processor A were negative.
		Let me just take you through some tissue processing.  The tissue bank receives unprocessed donor tissue.  It is debrided and this is a knee showing after initial debridement.  Then different parts are taken out of the knee to get the parts which you want, and this was trying to get the patellar tendon.
		This is the femoral condyle.  This is what was implanted into the Minnesota patient who died, and meniscus tissue.  Okay.
		Now let me take you through what happens at Tissue Processor A.  At Tissue Processor A you get the allograft, and at the same time there is a bit of companion tissue which may be a sliver of cartilage, for example, from a femoral condyle.  Those are processed identically.
		After the debridement, you have the allograft, the femoral condyle or the meniscus and the companion tissue, and they are placed into a working container.
		This antibiotic solution is added.  In the container you still may have residual vegetative forms of Clostridium species, and you also may have Clostridium spores.  After some time -- next slide -- the antibiotics will kill the vegetative forms of the Clostridia.  They will have no effect on the Clostridium spores.  Next slide.
		After having been soaked in this antimicrobial solution, the allograft tissue is packaged.  The companion tissue is cultured.  The companion tissue is placed into a culture medium, and you may also have a transfer of some of the Clostridium spores, and over time -- next slide -- you will have growth of those Clostridium spores into vegetative forms, and that is how you detect a positive culture.  Next slide.
		Now let's go through this again.  Same process.  Next slide.  But instead of just transferring the actual companion tissue, you are now transferring antibiotics as well.  So what happens now?
		You get some of the Clostridial spores germinating, becoming vegetative, but they get killed by the antibiotics, and therefore, the cultures are negative, something which we call bacteriostasis, and so one would not know that you had Clostridial spores present.  Next slide.
		So we hypothesized that the discrepancy in culture results between Tissue Processor A and CDC were due to bacteriostasis.  That is, that there was residual antibiotic transferred along with the companion tissue.  
		Another fact is that the companion tissue may not be representative of the whole allograft, partly because it is statistically only a small sample, but also the surface area-volume relationship is such that you may have much better penetration of the antibiotic-antifungal solution into smaller companion tissue than you do into the actual allograft.
		This would result or explain in the false negative results, which Tissue Processor A experienced.  
		CDC published in the December 7th MMWR the case in Minnesota and also alluded to four other cases of septic arthritis due to contaminated anterior cruciate ligament allografts, and we solicited additional case reports.  I will now discuss these additional cases.  
		First of all, the definition:  For purposes of this report, an allograft associated bacterial infection was defined as:  A surgical site infection at the site of an allograft implantation occurring within 12 months of allograft implantation in an otherwise completely healthy patient who has no predisposing risk factors for infection, such as diabetes.
		Cases could be culture negative if they were diagnosed by infectious diseases physicians or surgeons and you had diagnostic such as a knee aspirate or operative findings which supported the diagnosis of a surgical site infection.
		We excluded any cases where the only organisms isolated were Staphylococcus aureus or Staphylococci spp., since these are common causes of surgical site infection, and we did not want to contaminate our sample, unless in these cases -- sorry, back on slide -- unless there was additional epidemiologic or microbiologic evidence suggesting allograft contamination.
		By epidemiologic evidence, I mean that you had two recipients who had Staphylococcus aureus and they both had tissue from the same donor.  That would be the additional evidence.  Next slide, please.
		We ascertained cases by notices on electronic list service, through the MMWR, Food and Drug Administration, and through some state regulatory authorities.  As of March 11 we had a total of 26 cases of allograft-associated infections which met the preceding case definition.  
		Thirteen or 50 percent of these allograft-associated infections were due to Clostridium species.  Twelve of those were due to Clostridium septicum, one due to Clostridium sordellii.  The Clostridium sordellii was the patient who died in Minnesota.  
		Of note, 11 of the 13 or 85 percent of the implicated allografts came from one tissue processor, Tissue Processor A.  
		Now to what tissues were involved:    Tendons required for ACL reconstruction, eight; two femoral condyles; two bones; and one meniscus.  Most of these were frozen.  The femoral condyles were fresh.  
		Now in 11 or 85 percent of these 13 cases, additional evidence implicated the allograft as a source of infection.  That is, there was a common donor or cultures of nonimplanted tissues were positive.  All 13 allografts were processed aseptically, and there was no terminal sterilization for any of these.
		Now to some of the clinical features of these patients.  These are young patients.  The median age was 35, ranging from 15 to 52.  Symptom onset occurred at a medium of 8.5 days, but ranged from two to 85 days.  
		Many of these patients required multiple reoperations, often requiring removal of the allograft.  They required prolonged intravenous antibiotic therapy, and some had serious complications from the pick lines or central lines, including secondary bloodstream infection, embolization of the pick lines, and several required total knee replacements because of ongoing pain and stiffness and, as we mentioned before, there was one tragic death.
		Now to the non-Clostridium species infections.  There were 13.  Eleven of these were due to gram negative rods.  Two were culture negative, and five of these are polymicrobial.  In eight or 62 percent of these infections, additional evidence implicated the allograft, i.e., a common donor or microbiology.  We are still investigating the others, because we have not contacted all the other recipients of those tissues.
		Now what about the allograft implicated here?  Ten were tendons used for ACL reconstruction, which were frozen, one fresh femoral condyle, one bone which was freeze dried, and one frozen meniscus.  Three allografts were reported to have undergone irradiation.
		Now nine patients had allografts which originated from six tissue processors which are currently AATB accredited.  Fifteen patients had allografts which came from two tissue processors which are currently non-AATB accredited, and in two patients we still have not traced back which tissue bank actually did their processing, because just because something is labeled as one tissue bank doesn't mean they did the processing.  Next slide.
		So of tissues processed at Tissue Processor A, 85 percent -- accounted for 85 percent of cases of the Clostridium species infection, and 54 percent of the total cases of allograft-associated infections.
		So what are factors which may have led to the release of contaminated tissue at Tissue Processor A?  First of all, they used an antibiotic/antifungal cocktail or solution, and that is nonsporicidal.  Their pre-packaging cultures had a false negative result.  They did not perform any pre-processing cultures, and they went outside industry standards with respect to tissue retrieval time limits.
		So let me just go through what happens to tissue.  You have a death of a donor.  Tissue is procured.  Tissue is processed, and tissue is released.  
		Tissue Processor A used an antibiotic/antifungal solution which is nonsporicidal.  The cultures, which are taken post-processing, were false negative because of bacteriostasis.  They did not take pre-processing cultures.  They did not take procurement cultures, and there was a significant time lag in terms of before the tissue was procured.
		So this combination of events probably led to the contamination -- contaminated tissue being released by Tissue Processor A.  How could you avoid this?  Have a sporicidal method, by far the simplest method, but it's not as easy as that.  
		Ethylene oxide is associated with poor penetration of tissue and has also been associated with immune-mediated synovitis.  Gamma irradiation, particularly at high doses, can impair the biomechanical properties of tissues.
		So in the past it's very much been trying to get a balance between the need for sterility and the need to keep biomechanical function.  There are, however, some new technologies which are focus of research and development.
		There are some promising low temperature chemical sterilization methods which appear to be sporicidal and which don't affect the biomechanical properties of tissue, once implanted.  
		I will now describe the steps which were provided to Tissue Processor A by CDC to reduce the risk of allograft-associated bacterial infections:
		Whenever possible, to use a method that can kill spores to sterilize tissue.  If a nonsporicidal method is used, it is important to remember that aseptically processed tissue is not sterile, and health care providers should be informed regarding the risk of bacterial infection.
		So if you are using a nonsporicidal method, how can one decrease the risk of releasing contaminated tissue?  One:  Culture tissue before suspension in the antimicrobial solution.  You, therefore, don't have a problem of bacteriostasis.
		If Clostridium species or other bowel flora are isolated, all tissue from that donor that cannot be sterilized should be discarded.
		Second, culture methods should be validated to ensure that residual antimicrobials do not result in false negative results, and performing both destructive and swab cultures should be considered to increase sensitivity.  The recommended time limits for tissue retrieval should be followed.
		After receiving a report of a potential allograft-associated infection, remaining tissue from the donor should not be released until it is determined that the allograft is not the source of infection.  
		Health care providers of recipients of tissue from implicated donors should be contacted to determine where there are additional cases, and a sample of nonimplanted tissue which underwent the same processing method as the implicated allograft should be cultured by an independent laboratory using a validated method, so we don't run into a problem of bacteriostasis again.
		Other steps were included:  To perform a one-time audit of unreleased tissue inventory to estimate the proportion of unreleased tissue inventory that may be contaminated with microorganisms or spores.
		So in conclusion, to reduce the risk of allograft-associated infections, if nonsporicidal methods are used, then process and quality control measures should be in place to reduce the risk of releasing contaminated tissue, but the best way to move forward is to have methods to sterilize tissue that do not adversely affect the functioning of tissue when transplanted into patients.  Thank you.
		CHAIRMAN NELSON:  Thank you very much, Dr. Kainer.  Questions?  Yes?
		DR. DiMICHELE:  Thank you for all that wonderful information.  I have two questions.
		The first is with respect to Tissue Bank A and potential predisposing problems to what happened.  I noticed in the last report that the tissue -- that basically, when you had to go back for tissue verification, you went to the medical examiner, suggesting that this body was in the care of the medical examiner.  
		The question in another document of patients who die a traumatic death with respect to predisposition to Clostridia has been raised.  I'm just wondering whether the victim or the person who died, the cadaver from whom these tissues came -- was he a trauma victim?  Do you know?  And is there any question as to whether harvesting from trauma victims actually increases this problem?
		My second question relates to the fact that -- again, the question I asked before, in that there hasn't been a lot of bacterial contamination problems at least presented to anyone in CDC or FDA before.  Even in the case finding data that you presented, there doesn't seem to be quite consistent clustering.  
		In other words, given all the tissue banks that are involved, there haven't been many that have been implicated and, certainly, this one that's been overimplicated and everything that we are seeing.  Is this, in your estimation, an isolated problem or is this a more global problem that we are dealing with?
		DR. KAINER:  With respect to the harvest of tissue, the donor for -- Donor A -- he did not die of trauma.  So that does not represent a risk factor.
		There have been some studies performed by other investigators, some from overseas, which show that the chance of finding positive blood cultures or bone marrow cultures at the time of procurement increases in patients who have died -- in donors who have died from trauma, specifically for Clostridium species, in particular.
		That does not happen so much for the other bacteria, and the time interval from donor death to tissue recovery also -- The increase in Clostridial species -- It's predominantly Clostridial species which increase with that time interval.
		With respect to your second question, there is currently no centralized required reporting system.  It is -- I don't believe that we have an epidemic, but we are certainly seeing much larger numbers when we had initially thought, partly because clinicians never used to even consider the allograft as being a source of infection.
		Most orthopedic surgeons involved in the care of these patients believed that the allograft they implanted into their patients was sterile.  So they would never have even reported it in the past.  So I don't necessarily think it's a new problem, but something which probably has not been recognized.
		You now have an industry which is greatly increasing the number of allografts from 350,000 in 1990 now to 650,000.  I don't -- Even though there is a cluster around one tissue processor, and I think there was a combination of events at that particular tissue processor which led to the release of contaminated tissue, but the problems are still, I believe, something which the whole industry needs to take note of.  There are at least eight tissue processors involved at the present time.  
		Does that answer?
		CHAIRMAN NELSON:  Are there any guidelines, either by the Association or FDA or anybody, about which donor, if you will -- that's what you call the person who died -- the characteristics.  In other words, how soon after death the tissue must be taken or any characteristics.
		I assume, if he died of sepsis, he wouldn't be acceptable.  But if he had a gunshot wound to the abdomen or, you know, something like that, are there any guidelines that pertain to which donor is an acceptable donor?
		DR. KAINER:  My understanding is that there are industry guidelines from the AATB which specify the time limits for tissue retrieval, and my understanding is that you can retrieve up to 24 hours after death if the body had been refrigerated at 12 hours after death.
		With respect to whether you can reject a donor or not, I'm not entirely sure whether the industry guidelines specify those details, but the next speaker will probably be able to assist with that question.
		DR. ALLEN:  Two or three quick questions.  		Let me just confirm what you said early on about this one tissue donor.  He was not refrigerated until 19 hours after death?  
		DR. KAINER:  That is correct.
		DR. ALLEN:  And what is the potential within a tissue processing plant for contamination and subsequent transmission of the contamination to other specimens rather than intrinsic contamination?  Was there any evidence of that based on your examination of the processing unit?
		DR. KAINER:  We had the opportunity to observe some of the processing at Tissue Processor A, and there really did not appear to be a lot of opportunity for cross-contamination of tissue at Tissue Processor A.  I believe the tissue came in most likely contaminated, and then the process there failed to eradicate or reduce the number of Clostridium spores efficiently.
		DR. ALLEN:  And given that Processor A had a large bulk of the Clostridial infection subsequently, that was -- it was a problem inherent in their processing methodology, as you described, that enabled that?
		One other final question.  How frequently or as a standard of practice are antibiotics with a broad range of coverage used for the recipient at the time of surgery, and does that in fact mitigate some potential low level contamination of tissues that are being implanted?
		DR. KAINER:  So far, most -- There is no orthopedic guideline as to what antibiotic to use, but probably 95 percent of the orthopedic surgeons involved in these cases have used a first generation cephalosporin, Cephalozolin, one dose.
		If patients have received a femoral condyle, that operation is more painful.  They stay in hospital a little longer, and they may have additional doses of cephalozolin, maybe up to 48-72 hours, but that is a standard preoperative antibiotic cover given.
		DR. ALLEN:  Yes, and that really is much more to do with the prevention of a nosocomial surgical wound infection rather than contaminate -- you know, dealing with contamination.
		DR. KAINER:  That is correct.
		DR. ALLEN:  Thank you.
		DR. DOPPELT:  Yes.  I might just add:  After most orthopedic surgical procedures, including allografts, usually you give Anceph, either one dose or for 24 hours, depending upon the case.  If they are penicillin allergic, it's Vancomycin.
		So usually, but it's not given assuming that there is going to be some transmission of disease.  It is given just in the usual course of management.
		In regard to -- If I can just add one thing in regard to the donor screening, I believe Dr. Eastlund has some words on that, but there is a uniform donor screening form that we use as well as do OPOs.  So there are strict criteria that you are supposed to follow in terms of no evidence of infection and no sepsis and so forth.
		In this particular instance, Bank A, they did not adhere to the standards in the industry, which is -- or they were sort of splitting hairs, let's say.  As you pointed out, the body is -- the donor body is supposed to be refrigerated as soon as possible, preferably within 12 hours, and the procurement is supposed to be done and completed within 24 hours.
		So in this particular instance, the information that Dr. Kainer has is that the body wasn't refrigerated until 19 hours.  Procurement, I believe what you were saying was that it started at 23 1/2 hours.  
		So that's kind of splitting hairs and, depending upon how large the procurement is, it could go for several hours.  So they would have been outside the window for refrigeration, also outside the window for actual time of retrieval.
		DR. CHAMBERLAND:  Do either you or do FDA have any estimate of what proportion of the universe of tissue processors Tissue Processor A accounts for? In this particular investigation, to date it's accounted for a little more than 50 percent of the identified infections, but I am curious as to, number one, what proportion of the processing market does it encompass.
		Then just also for my own information, is Tissue Processor A a discrete entity located in one physical location or is Tissue Processor A some sort of a corporate entity that might have multiple -- offices is not the right word, but facilities located around the country?
		DR. KAINER:  I'll answer the second question first.  Tissue Processor A predominantly processes tissue all at one site, but I believe they have arrangements with some other tissue processors who also process some of the tissue.  All this tissue was processed at one facility -- all the implicated tissue was processed at one facility.
		With regard to market share or denominator data, I have attempted to get that information, and I'm not privy to it.  I'm sorry.  But my understanding is that they have a reasonably large market share for the femoral condyles and the menisci, and a relatively -- a smaller market share for the anterior cruciate ligament tendons.
		DR. DOPPELT:  I believe that's right.  I think that Bank A does a fair amount of banking of, let's say, fresh frozen in situations where you want viable chondrocytes or you want the viable chondrocytes and a menisci or something.
		I don't know -- I'm not privy to their absolute numbers, but I believe it's a fair statement -- maybe Dr. Eastlund when he speaks can add to it, but I think that there are about 73 or 75 accredited -- AATB accredited tissue banks which probably accounts for about 98 percent of the tissue that's distributed and used in the United States.
		So if you sort of work backwards, overall they probably represent a fairly small part of the market share.
		In regards to that, I would just add one other thing.  I mean, I think this is an exceptionally important issue, and you know, we need help from wherever we can get it.  But I would point out that in terms of the incidence of infection, if you look at -- Dr. Kainer has identified 26 or so.  Now there may be some more, but let's say 26 over three years, and there is roughly now about 850,000 grafts done a year.  		If you do the math, that turns out to be about .001 percent. infection rate.  If you look at surgical procedures in general, you've got 500,000 post-op infections in about 25 million procedures done a year, which represents about two percent.
		So in this particular instance, the infection rate related -- or associated -- I shouldn't say related -- associated with allografts is .001 percent compared with the general surgical infection -- post-op surgical infection rate of two percent.  And the orthopedic community, depending upon what cases you are doing, it could be anywhere from, you know, one or two percent, maybe even lower if you are just doing arthroscopic procedures.  So --
		CHAIRMAN NELSON:  I noticed in your database you excluded people who had an underlying condition, and, you know, many people who have a knee replacement, I guess, don't have an underlying condition, but there are circumstances where  somebody had some immune deficiency.  So they might even be more susceptible.
		I wondered, do you think that that may have affected the total numbers that you -- I understand why you did it, and it's right to do it that way, because you wanted data that were clean and that were -- and to estimate, you didn't want to contaminate it with what could have been an endogenous infection.  
		Nonetheless, when you start to estimate the rates and .01 percent, it may be higher than that if we take into account a more susceptible patient population.
		DR. KAINER:  Sure.  There were multiple patients who were excluded because they had underlying conditions, and we just did not want to include them in this database.  So these are 26 patients where they were healthy patients undergoing elective procedures, not life saving procedures, elective procedures to improve the quality of life.
		Unfortunately, for most of these they ended up having a far worse quality of life than they had prior to surgery.
		DR. LEW:  One thing that might help if you are going to do this prospectively to try to gather data, particularly if you are saying it's such a rare event, that if you could include in it collection of the organism, only because it could address the issue if there is something in the manufacturing processing and then patient-to-patient contamination, you could do the genetic testing and see.
		Antibiotic profile is sometimes useful, but for Clostridium I don't think so.  So, you know, that might be worthwhile, particularly if it is rare enough.  You could really get a lot of data from clusters.
		DR. KAINER:  We have collected this data retrospectively.  Unfortunately, most of the isolates were not available for genetic fingerprinting, although two of the cases which were reported in the December 7th MMWR of Pseudomonas aeruginosa -- they were genetically identical in pulsed-field gel electrophoresis.
		DR. STYLES:  Just a quick comment about what you were saying about surgical infections.  My impression is that overall those are underreported, and I suspect from the data that you have said that some of these infections are underreported.
		I think it behooves the orthopedic community or any of the communities that use tissue bank tissue, if you will, to really ramp up their reporting of incidents, because I think what may be happening  is surgical infections that are being attributed to the surgeon could in essence be not their fault.
		I mean, I feel sorry for the orthopedic surgeon that had cared for this unfortunate patient in Minnesota, and I think that it would actually be to their own benefit to -- and would be helpful in determining not only the true incidence of problems but how the FDA's interventions actually impact that, to go back to the actual communities using the tissues and say let's try and gather more data here because, you know, just my experience with these sort of things is these infections in a number of cases could be related to a variety of things and are not generally reported or further explored.
		DR. DOPPELT:  Well, yes, I agree.  I think there may be more cases, and I'm sure if Dr. Kainer investigates, we will find that there are some more.  But let me just say that, in terms of post-op infections, it's not that it isn't being reported.  It is being reported.  It's just not being reported to the right people.
		Every hospital has their own infection control program.  So they know about every infection.  Each department has their monthly QA reports in which they go over their infections.  
		The problem is that the tissue banks that are providing the tissue aren't getting the information back.  The CDC isn't getting the information back.  The FDA isn't getting the information back.
		So you know, that goes back to what I had said before, that we have to somehow develop a system where this information is reported to the interested party so they can take action appropriately.
		DR. HOLLINGER:  Are there -- You mention at the bottom there -- you said there are methods to sterilize -- Are there methods to sterilize tissues that would not adversely affect the things, and what was -- For example, what --
		DR. KAINER:  There are some.  I know that there is at least one company which has got a low temperature chemical sterilization method, and I believe that they have validated that and have implanted bone with that, and I believe there is some soft tissue about to -- Some soft tissue is also about to undergo that.
		Certainly, Tissue Processor A is actually working very hard at trying to get to that as well, but they haven't implemented it as yet.
		DR. CHAMBERLAND:  Just in follow-up to some of the comments that were made about reporting, can you share with us, are there any discussions underway within CDC, CDC-FDA collaboratively, in perhaps trying to consider what possible approaches to perhaps more active or systematic surveillance might be undertaken to try and get a better estimate of what the true level of allograft-related infection might be?
		DR. KAINER:  Ideally, what we would really like is to have a very simple system for clinicians to report to, so that they have sort of like a one-stop shop.  They would report the condition once, and it goes to all the relevant right people instead of asking the Commission to report to six different people, the consequences being that they don't report any at all.
		Any such system requires a motivation of people.  It is voluntary, and also requires resources.  But it is something we are certainly very interested in exploring wider, also in conjunction with the American Academy of Orthopedic Surgeons.
		 Tissue processors would like to have from tissue processors denominator data so that one can actually work out the rates of infection, and not just denominator data of total tissue but also by type of tissue and type of processing, so that one can identify what processing method is a problem and then can remedy that.
		So that is what the idea system would be, but then there are proprietary issues, and it is confidential market share information which tissue processors may not want to share.  
		So there are some challenges ahead, but that would be the ideal system, to also have the denominator data, so that patients and health care providers can have informed consent about what is the actual risk.
		DR. SOLOMON:  Could I comment?  As I mentioned before, reporting of adverse events is not currently a requirement, but we have proposed it.  We  have received several MedWatch reports on tissues, but again that's voluntary.
		I also would just like to comment that, if we discover a case of contamination on inspection, if the inspection is ongoing, we are not at liberty to make that public and to share that information.  
		DR. CHAMBERLAND:  You can't share that with state and local health departments or CDC, if you are investigating?
		DR. SOLOMON:  I don't believe we --
		DR. CHAMBERLAND:  So those entities would have to independently -- through an independent source learn that information, if there were adverse events associated with allograft transplantation.  They would have to come to other entities through another channel?
		DR. SOLOMON:  As I said, right at the beginning of an ongoing investigation we could not make that information public.  If we issued a warning letter, for instance, that is public information, and there is some data that we have shared with Dr. Kainer, but I just wanted to make the point that we are somewhat restricted in what we can make public.
		DR. LINDEN:  On the issue about reporting, in New York we do have mandatory reporting for adverse events, and we license the transplant sites as the hospitals as well as the tissue banks.  
		Unlike the blood banks which are really excellent in the reporting, the tissue banks -- it's erratic.  There are some that report a ton of trivial things, but in this particular case there were a couple of these events that did occur in New York that were not reported to us.  Tissue Bank A is licensed by New York and didn't report these to us.
		So even if you have a mandatory reporting requirement, that doesn't mean people are necessarily going to report.  I agree absolutely that sharing of information, however we can get people to report it and share that between public health agencies, would be a really, really positive thing to happen.
		DR. HOLLINGER:  I think you're right, and I think that,  you know, one of the problems is that the tissue banks as well as other organizations don't get the reports from the clinicians or the people who see the problem in the first place.  That's really one of the big issues.
		Part of that is because of the questions that are often asked clinicians and others to do.  You know, sometimes these require a fair amount of information which I -- It depends on what you want your adverse reports to say.
		If you are looking for an early surveillance of problems that are occurring, then you don't have to ask a lot of questions.  I know you like to have it.  People like to have it for reports and look at this and so on.  But if it's for an early surveillance, then it doesn't require a lot of information.  Got an infection, and here's what it is, and then it's a requirement then, I think, of the tissue bank and so on when they start seeing things or even other organizations to then go back and try to ferret out a lot more of that information.  
		I find sometimes that there is just -- You know, you sit down and you say I don't have the time to go through this, and you end up not doing it rather than at least sending some information off to the organizations that could use it.  
		CHAIRMAN NELSON:  I was rather struck with the importance of Clostridium sordellii in this, and I wondered.  You know, one method to alert to a problem, if somebody got a Yersinia blood culture in somebody who was transfused, that would immediately send a bell that, you know, maybe it was the transfusion.
		I wondered to what extent Clostridium in a post-operative patient should alert the fact that it may be the allograft rather than, you know, a bacteremia or operative infection or something.  Do you have any sense on that?
		DR. KAINER:  We have actually collaborated with the Emerging Infections Network, and the questionnaire has gone out to 500 infectious disease physicians to actually report all Clostridium infections and what proportion of those were actually allograft associated.
		So we will, hopefully, get some data on that.
		DR. STRONG:  Strong, Seattle.  I might also mention that, although a lot of tissue banks do get reports -- for example, in Seattle I think about 95 percent of our transplant records are returned, but it's generally cosmetic things:  Did they like the way it looked?  Was it packaged properly?
		We rarely get the longer term follow-up clinical information which is really the important information.
		DR. DiMICHELE:  Two questions.  Are there standards for non-banked tissue that's transplanted, you know, taken out of someone and put right back into someone else, hearts, kidneys, you know, those kinds of organs?
		Secondly, are there other international standards that might be helpful in helping us reestablish our own in this country?
		DR. KAINER:  With respect to standards for organ transplantation, I'm really not the best person to answer that at all, and I'm not aware of many additional standards internationally.
		I know that in Australia they don't -- there is some work going on at the present time in revising some of their standards, but I haven't done a call-out to the international community yet.  But representatives from AATB probably will be able to answer that question.
		DR. STRONG:  I think I can help answer that. Again it's Strong in Seattle.
		I have visited many of these countries, and most of the standards that have been developed have come from AATB, because the original standards were developed in AATB.  So they have followed along.
		So I think, if anything, the other countries, including the European Association of Tissue Banks, the Asian Pacific Association, have followed AATB standards, but they are probably even slightly behind our own, although I must say that in Asia, for example, because they have such difficulty with donors for cultural and other reasons, that the majority of their tissue is irradiation sterilized.
		So one could question which is the safer way to go, but they do use the high dose sterilization in those countries.
		DR. SIMON:  I believe -- I'm not an expert on this, but I believe the organ procurement is separately regulated through other Federal statutes and, I guess, not by FDA but UNOS is under some other part.
		DR. SOLOMON:  Yes.  That's correct.  HRSA, Health Services and Resources Administration, regulates organ transplantation.  FDA does cells and tissues.
		In terms of whether autologous tissue is removed and then put back into the same individual, we have that as an exemption from registration.  So that is not regulated by FDA.  The hospital JCAHO probably has standards, but that was an exemption in our registration rule.
		DR. SIMON:  I was going to say, you know, there's a little bit of sort of de javu or interest as a blood banker sitting in on this discussion, because when the public became concerned that blood was transmitting infection, there certainly was a regulatory response from FDA who had some very strict regulation.
		I guess the FDA clearly knows how to do it.  If there's a sense that the voluntary regulation through the tissue banks is not adequate and that the current state of regulation is not adequate, then I think the same rulemaking process, regulatory process, that was used, that has been used in blood banks, could be used here.  
		If there's a sense that this is a very rare breakdown in the system and this is not an ongoing problem, then perhaps one needn't go in that direction, but it seems to me that that's where we are here.
		CHAIRMAN NELSON:  Okay.  In order to try to meet our deadline, I would like to move to Dr. Eastlund who is from the University of Minnesota for the next.
		DR. EASTLUND:  Good afternoon.  My name is Ted Eastlund.  I am the Blood Bank Medical Director at the University of Minnesota, and I'm happy to come here to give you some words representing the American Association of Tissue Banks of which I've been a President in the past.
		Some of my early remarks can't always be attributed to AATB, though, because at the end we will make sure we'll discuss that for five minutes or so, but I will try to take an equal amount of time to give you some background on cadaver tissue donation, use, complications of it, and what is done to prevent that, and then go to the issue of the recent reports since November of infections from allografts.  I -- Well, that's enough about me.
		The American Association of Tissue Banks has been in existence since 1976, and it is a voluntary, as you know, professional organization similar to the American Association of Blood Banks.  It has approximately 1200 members, and there's about 74 tissue banks involved.
		It is there to establish standards.  It also is there to inspect and accredit, and it also certifies tissue banks.  So hundreds of tissue bank specialists that are certified are operating in tissue banks in the United States.
		To start -- next slide.  And you should have a handout also that has all of these slides.  So we will go quickly this first five minutes or so.
		I've listed in here from a while back a multiple of tissues that are used routinely in the United States, and many of them are structural, the ones on your right on your handout and up here -- or your left up here, I should say.  The others are more metabolic and for replication and, of course, blood fits into that area.  Next slide.
		But in tissue banking, most commonly it's thought of as these types of tissues, not exclusively but bone with hundreds of thousands of bone components, products being used every single year; corneas with who knows exactly, 40-50,000 corneas transplanted a year, or so; skin; tendons; cartilage; and heart valves.  Next slide.
		Because this recent exposure of risks for bacterial infection came up with tendons and bone, I thought I would just say a few things about that.  Bone banking, bone transplantation was done by pioneers for close to 50 years, and it really usually meant large pieces of bone, unprocessed, which are shown right here with a person with a not so malignant giant cells tumor of the distal femur, and a chunk of donated bone was implanted over there to the right.  Next slide.
		Equally so, up on the top of the humerus up here, an equal mount of bone was put there to replace to replace the cancer.  And indeed it works, and it was successful, and this type of tissue with bone banking went on.  You might say it was not large scale bone banking, but it went on for quite a while.
		When cyclosporin came around to suddenly make organ transplantation very useful and common, it led to the required request legislation in 1987, and suddenly there was an explosion of available donations, and cadaver tissue donation became a very large availability.  Next slide.
		With it, and even before, came another very common use of bone, and that is to revise those hip implants who became loose, a fair percentage, after 20 years.  For instance, it might protrude into the pelvic cavity or it might migrate upwards.  Next slide.
		You could use a piece of bone, commonly even in one way as a femoral head, and shape it, screw it in, and use it.  Next slide.  Or if it was erosion of the proximal femur for loosening, then you could take a section of cadaveric proximal femur and place it into that site.  Next slide.
		In the November and in the December MMWR articles, it was prominent about sort of living, fresh osteochondral allograft, the Minnesota case, and also in December came four patients from two tissue banks where patellar tendon for anterior cruciate ligament repair were associated with infections in recipients, and it's those cases that led to notification to AATB to start becoming active and involved in evaluating these and look for preventive measures and look at existing standards and practices.  
		So this is the anterior cruciate ligament that can be repaired.  Next slide.  With it, you can see on the top a bone tendon block.  The bone is a little butty on each end, but that's part of the patellar bone, the patellar tendon of a cadaver, and also the proximal tibia piece of bone.  Next slide.
		It shows you that you can screw into place the bone on the proximal and the distal part of the knee and have an equivalent of a new ACL.  Next slide.
		This is the bone screws that can hold in the bone, and in these cases bone screws are involved also.  Next slide.
		Now go to the different kinds of infections that can be and have been, I should say, clearly transmitted -- clearly transmitted from bone graft.  Not a question of association with, but were documented cases in the literature.  
		We can't go over all the viruses and other proteins that can infect, but you can see bacteria.  All the way across the top is the number one or most common thing that -- not in numbers -- but it's there for all those tissues.  Next slide.
		In bone we have known for years that Hepatitis, HIV, tuberculosis and bacteria has been transmitted in the past.  Next slide.
		Matter of fact, the oldest case, in the Fifties, was actually tuberculosis where, you know, you used to collapse the lung, plombage, put in things, take the ribs, and you can use them in other patients and transmit tuberculosis into spine, surgical recipients.  Next slide.
		But when you look at sort of prevalence of how common is it, some of the pioneers, Mankin and Tomford and many others, these surgeons here even are involved with that organization, the early bone banks.  They looked and they found around out of 300 recipients had a bacterial infection that they thought possibly was related, but when you looked at clinically, you didn't see there was any clearcut evidence that these were really causing the infection, except on the bottom one where three recipients had Serratia, and indeed it was from the same donor.  
		So there was some indirect evidence that it could have been the bone after all, but it kind of represents what I have sort of learned over the years, that if it is caused by an allograft, it's very, very rare and even probably rarer than this.  Next slide.
		Then a few years ago it showed that processing can actually introduce things to cause allografts to cause infections, and in this case it was actually a pericardium used as an equivalent to dura to replace a dural defect in the craniotomy surgery. 
		In this case you see they had balanced salt solution, which is an in vitro reagent used to wash the pericardium.  That had anthropi -- Ochrobactrum anthropi, and also three recipients developed the same in their meningitis infections.
		So processing in this case an equivalent.  Three years before that it was shown in processing a pancreatic islet cells infected plenty of patients with Enterobacter cloacae.  So processing itself can also contribute.  Next slide.
		What do we do to prevent this?  Just like blood donations, just like organ donation, any of the transplantation, it's donor health screening, physical exam, blood tests, autopsy if it's a cadaveric donor, and tissue processing steps.  Next slide.
		Medical history is similar.  First of all, for blood donors you asked the same questions, but you ask a lot more, because not only are you trying to reduce transmissible infection and malignancy, but you can have conditions that can make the tissues unfit for use.  So all those things are looked for, and then the universal same questions for HIV and Hepatitis behaviorals.  Next slide.
		The testing that is required by AATB is HIV antibodies, Hepatitis B surface antigen, HTLV, syphilis and HCV.  Of these, HIV and Hepatitis B surface antigen, I think, have FDA approved kit with caveric blood.  Next slide.
		Physical exam:  It's a little bit more than a blood donor, but we indeed look for injectable drug sites, but also behaviors of HIV infection and also trauma over donated sites or sites of infection in the patient physically also.  Next slide.
		So in general, it's the same.  But the most important things to reduce the risk are the fact that it is voluntary, the fact that medical history screening takes place first before you do testing to avoid an unnecessary high rate of false negatives, and then there's donor procurement and testing.  Next slide.
		The processing is alluded to already.   First of all, the collection:  It's done in a morgue or in a surgical suite, very commonly with  prescribed methods for cleaning and preparing the room, cleaning and preparing the body, sterile drapes, sterile equipment, aseptic surgical procedures, preserving blood vessels for the embalmer, and also bacteriologic testing is frequent.  Next slide.
		At processing, which is already alluded to, the clean rooms that are used are similar to medical device type clean rooms, controlled environment, debriding and cutting into the desired shapes, disinfection steps, sterility testing, final packaging and, for many tissues, final sterilization steps.  Next slide.
		Now what came up again since December were these cases; first of all, the Minnesota case of a death.  We won't go over that.  Next slide.
		Then two other cases, two other tissue banks, a Florida tissue bank and a Texas tissue bank in the December MMWR by the CDC.  In one, which I will call one case, but it was two patients, they had infected ACLs.  These were not Clostridiums but Klebsiella and Citrobacter, and also they found the same organisms on the bone at the processing tissue banks.
		What happened here was the final release procedures were inadequate.  They thought everything was done, but it really wasn't irradiated, even though they said it was and distributed it.  So it was a mistake, an error of release.  That's what caused this whole thing.  Next slide.
		Whereas, on the other one it was the case of two patients who had Pseudomonas aeruginosa during ACL repair, arthroscopically putting in a patellar tendon implant.  Both patients three weeks later developed a serious Pseudomonas aeruginosa infection.  It was in the same surgical center, different arthroscopes, different surgeons, different days of surgery, but it was from the same donor.  Not only that, but it was from the same left knee.  
		Now -- next slide -- but since this was an AATB accredited tissue bank and it was the only one we knew at that time that was AATB accredited, we inspected them.  Two inspectors thoroughly inspected it and could not find any evidence that it really was the donors that were involved.  
		These other findings which looked like enough to say it was from the tissue actually might be circumstantial, because when we looked at it -- I won't take time to go over all the details, but there were no signs on the physical exam type or blood testing during processing.  
		This was in a clean room, Class 100 with Class 100 area for the critical processing, and in a larger Class 1000 procedure.  The testing that was done:  First of all, monitoring of clean room during that time period was totally normal.  No Pseudomonas. 
		Then when it was irradiated, it was done in the normal fashion.  When it comes back, you look at certain things to see  was it truly irradiated, and I've listed those things.
		The spore strips that were put in there that are infectious -- they were no longer -- there was no growth.  The cold process, companion pieces from the same tissue that was processed and came back with no growth.
		The digital indicator, sort of like an irradiation visual indicator only these change color at 1.5 million rads, not 2500 in blood -- they changed color.  Dosimetry -- that is, testing to see what dose was actually applied at the irradiation facility -- that demonstrated it was 1.6 to 2.0 megarads, and other tissues from other donors in the same box all came back no growth.
		So we looked at it as saying, okay, this was irradiated.  There's not any question about that.  And yet everything points to this donor.  Next slide.
		So we came to the conclusion that we cannot tell you what happened at this accredited tissue bank or what happened in the recipient to cause the Pseudomonas infections in two patients at the same place. 
		It could have been the tissues, but we found no evidence.  We found evidence that it probably wasn't, but you can never say for sure.  Matter of fact, what puts a question in your mind:  If you look at the D10 value for Pseudomonas aeruginosa, the D10 value is the dose of irradiation that will eliminate 90 percent of the bugs.
		Well, this has a very tiny one, and these numbers will show you that it reduces 300 logs of bacteria, even with 1 megarad, and make a 1.6 to 2.0.  Next slide.
		Just as another illustration that other things can have an impact at the surgical site, and I'm sure this was looked at, but even last week they showed that some bronchoscopes can transmit Pseudomonas aeruginosa because of some loose ports, and that was at Johns Hopkins.  Next slide.
		Last, I'll just go over old information that shows, even taking clean sterile packs of supplies and a sterile clamp and putting it into media, you can have up to 2.7 percent on average in multiple sites of contamination and bacteria.  So you all know that OR sites can also contribute to this.  Next slide.
		So in summary, we have reacted to the two cases -- that is, two tissue banks, the MNWRs and working with the CDC in December where one of the patellar tendon cases in two patients was clearly from tissue bank error, but the other one -- oh, and then the other one that we looked at, we could not figure it out.  So basically, we were left with the Tissue Bank A one where there was a failure of inadequate control of bacterial contamination.
		They have been the cause of focus of attention on these things by our organization:  Microbial control during allograft processing; final release procedures; the existing state of reporting and investigation of infections; and also the lack of a need for studies on the prevalence of infections in these patients.  Next slide.
		What we've done since then is form a special task force of which I've been the Chair, and we inspected the tissue bank involved, and it looks like we have some more to look at, and we have reviewed our own standards and actually made some changes in that already regarding procurement cultures.
		We are going to be working developing guidance documents and taking some of the ones that were mentioned in our technical manuals regarding bacteriostasis, regarding culture requirements and sampling requirements at the  -- and look at those to see which ones require more standard setting versus voluntary guidance.
		At our workshops next week at the mid-year meeting and our annual meeting, we will be covering in detail with CDC and others infectious complications, types and prevalence standards, regulations, sterilization steps, disinfection steps, and the bacteriologic testing.  Next slide.
		So a final comment is that we really are thankful that we have been working with the CDC and actually look forward to further working with them and collaborating in both investigations, also in prevalence studies and in preventive steps, and in general we have been in agreement with them about the steps they recommended to Tissue Bank A.
		Most of these recommendations have already been in our standards or manuals already.
		Thank you.  Any questions?
		CHAIRMAN NELSON:  Thank you.  You know, in contrast to the Clostridium, the Pseudomonas is a ubiquitous aquatic organism.  Was there any storage or exposure to aqueous solutions or anything like that in these cases, you know, after they left the tissue bank?
		DR. EASTLUND:  Well, during processing, of course, it's used with on-site manufactured sterile deionized water.  That had -- We looked at the records.  All  the quality control testing and the routines were all normal, and nothing there; whereas, implantation -- that's a different question.
		I'm sure there was plenty of flushing and irrigation, but that's at the time of surgery inside the joint, and not necessarily storage.
		DR. DOPPELT:  Well, I just wanted to make a few comments.  In one of the -- You mentioned the bronchoscopy and the Pseudomonas there.  For those of you who don't know how arthroscopic procedures work, usually the equipment is sterilized the day before and, if you are doing multiple procedures, the first cases that you do, because you have like two or three scopes in the hospital -- the first set, the first couple of cases are done with what was already sterilized the night before, ethylene oxide.
		Now there's newer methods with ionization.  When you are getting to your third or fourth case, the equipment may be just placed in some bacteriocidal solutions.  So it isn't really as sterile and clean as if it had been sterilized the night before.
		For those of us, for example, who do arthroscopy on patients who have already had allografts or who have total joints, like a total knee, we insist that those cases be done as a first case so that we know that the equipment has been properly sterilized.
		So in this particular instance, we have tissue coming from one bank, two pieces of tissue, that the recipients ultimately got Pseudomonas.  If I understand what Dr. Eastlund is saying, and I believe I agree, that I don't see how that tissue could have left the bank with Pseudomonas being on it.
		I mean, you have to eliminate what's impossible, and anything else, no matter how unlikely, is possible.  You know, the log order for sterilization was -- I mean, just there could not be Pseudomonas on that tissue.  So it has to have occurred someplace later.  
		Then I just wanted to add one comment that Dr. Simon -- in response to Dr. Simon.  The AATB does have standards, and the FDA has regulations in terms of procedures for processing.  In 1996 we had required in our standards that you shall, must, get pre-processing cultures.
		There was perhaps some overconfidence that the final cultures and the processing of decontamination and washing and so forth would eliminate virtually everything and that it would be appropriate to change that to "you should" obtain pre-processing cultures, but you still have to get final cultures.
		Now Dr. Kainer has pointed out that there are, obviously, some faults with that, because of issues of bacteriostasis.  We have since gone back and had the Task Force on Sentinel Events and the Standards Committee review all of this, and it was their recommendation, and the Board approved it, to go back and insist that all banks, all accredited banks, have pre-processing cultures.
		Nevertheless, the AATB had done a review of the banks that were accredited, and they had reviewed 50.  45 or 46 out of the 50 still continued all these years -- I mean since '96 -- still continued to do pre-processing cultures.  So the majority of tissue that was processed and distributed had always had pre-processing cultures.
		So we have tightened things up, but that has been the case, that the pre-processing cultures for the most part have been done and will be done.
		DR. SIMON:  The question I would like to address, which is a continuation of my prior comment, of course, to Dr. Eastlund, our speaker and perhaps also to Dr. Doppelt:  Given the outstanding job that it appears that the AATB is doing with its member banks, but assuming that it's not a legal requirement to be a part of that, do you feel that the FDA needs to create a regulatory process, environment, paradigm that is more similar to what it does for blood?
		DR. EASTLUND:  Well, first of all, the FDA has good tissue bank practices in the -- ongoing, not yet finally implemented, and has a number of things there, and they have the inspection capacity already.
So I'm not the one to ask, but I'm not sure -- I think it's sitting there.
		DR. SIMON:  Well, you know, yeah, I would agree, it's sitting there.  The question is does more need to be done with it, because, for example, we heard a lot about, well, you know, we can't get people to report this.  Well, among the blood banks, you know that the FDA has ways of making sure that we do what they expect us to do, and it's been a very firm regulatory process.  
		I guess the question is:  Is that needed here or is that not the case or is it adequate?  You seem to be saying you think it's adequate.
		DR. EASTLUND:  Well, in many areas -- I mean, for instance -- I can't answer the resources of the FDA, but reporting requirements -- that's still an open issue, because tissue banking sit right in the middle of a couple of monolithic establishments.  
		One of them is blood banks who are responsible for the traceability in a hospital for the blood.  You call ten years later from a blood center, and you can find out the recipient.  If you are a recipient, you can call ten years later and find out who the donor was.
		So tissue banking is not quite like that.  On the other hand is the medical device manufacturers who are responsible for tracking, and they have the patients -- or the orthopedic surgeons filling out a form that goes to the manufacturer who is responsible.
		So tissue banks are in between.  Is it the tissue bank, manufacturer, responsible or is it the hospital that's really responsible to keep this flow going?
		We are in between, but in the early Nineties the American Association of Tissue Banks went to JCHO to try to get their agreement on setting up standards so that hospitals were responsible for logging in, for proper monitoring and storage, and for keeping track of the recipients.
		We also went to AABB who also has a standard in the area of what's called tissue dispensing facilities that requires, again on a voluntary basis, that the facility that uses the tissue, that has gotten it from an outside supplier, is responsible for this traceability.
		So it's there, but how it sits with requirements for the FDA to hear about it is another story.  I don't think at this point, although the new emergency regulation, I guess, implies some of that maybe about mandatory reporting of deaths.
		Currently, you may get very good actions by a tissue bank if they get a report of a positive culture and they investigate it and find out it was  nothing that was related to the tissue, they will send back -- they will do a root cause analysis and stuff, and send back a letter to the surgeon in the hospital.  But it ends there.
		If they find a true infection from their tissue, then they still report it to the hospital, but they don't necessarily report it to AATB or FDA.  So I'm not sure where that sits as far as the requirement to report to FDA a transmitted disease by the tissue.
		DR. SOLOMON:  Could I just clarify?  The way FDA regulates blood and the way FDA regulates tissues is quite different.  Blood components are licensed products.  They have been regulated since the Seventies or maybe even earlier.  
		I don't know if Linda could talk to that -- Dr. Smallwood.  But anyway, they are regulated both under the PHS Act, which gives us the authority to require that they be licensed, and also under the FD&C Act, which gives tremendous authority in terms of GMPs and other things that you find us doing to blood banks.  
		Also for blood components, in order for a blood bank to get a license it has to submit an application to FDA, and the application is reviewed in terms of the SOPs, and various QC data have to be submitted, and then FDA grants that blood bank a license.  So we have quite a bit more regulatory tools when it comes to blood banks.
		Now tissue has only been regulated since '93, and a conscious effort was made then not to be over-heavy handed.  So that the authority under which we regulate tissues comes just from the PHS Act, and it's Section 361 which speaks to communicable disease.
		In other words, tissue banks are not licensed.  Tissue banks do not have to submit an application with any data and get approved.  Tissue banks do not have to follow GMPs.
		As I mentioned before, we are trying to get GTPs in place, but they are not effective yet.  So there's quite a difference in the degree of regulation and the legal authority behind the regulation.
		DR. HARVATH:  I was wondering, for the AATB's experience the thoroughness to which the history of your donors, your cadaveric donors -- what kind of compliance do you get with your tissue banks?  I mean, if there's a piece of missing information, for example, someone who may not have an extensive medical history file -- If there is a piece of missing information, does that disqualify the tissue from being harvested?
		DR. EASTLUND:  Well, there is a whole list of required information that must be -- just like a blood donor's history.  There's always more information out there that you could always get also.  		For those required -- Another difference is that required information comes from the next of kin.  So you can always say, well, this is not a direct interview of the donor.  So there is that issue.
		There is also the same issue as there is in blood donors of more information out there you could go after if you wanted to.  Now if it's an autopsy that is done, we need to look at that, and it does not require that there is an autopsy.
		On the blood side, if a person had Hepatitis five years ago and was reported to the State Department of Health, the blood bank won't know that necessarily.  I mean, so there is always more information you could have.
		The basic required information must be obtained or you do not use that donation.  You do not make the collection, period.  So there is a prescribed amount that must be there, period.  You can just say that the sources maybe are different than a living donor.
		DR. HARVATH:  In your experience as an AATB inspector site visitor, do you find that there is absolute compliance with those requirements?
		DR. EASTLUND:  For many years, there's been very compliance.  Otherwise, they wouldn't be accredited.  Not all banks are accredited tissue banks, but that's an absolute.  You don't get accredited unless you do it, period.  
		DR. FINLAYSON:  I hesitate to try and add anything to Dr. Solomon's magnificent description of tissue, but inasmuch as this is the Blood Products Advisory Committee, I wanted to add one small historical fact on blood regulation.
		I believe the Public Health Service Act, as it was amended in 1944, mentioned blood, and I believe that the first blood bank was licensed in the mid-1940s.  Actually, there were blood products which were licensed even earlier than that.  Albumin, for example, was first licensed in 1941, immune globulin in 1943, and blood grouping and typing agents at the same time.
		So it's not since the Seventies.  It's more like the Forties.
		DR. STYLES:  I don't know if anyone else was -- or maybe I'm just naive, but I was rather struck by the lack of oversight by the FDA in this area.  I would have thought that anytime you -- I mean, look at all the oversight in xenotransplantation from animals, and yet, gosh, when I read through this, I was like you mean they are not already requiring this?
		I mean, I don't know that I speak to the issue here, but I don't know if anyone else was a bit stunned by that.
		DR. HARVATH:  I can only speak to it as my experience when I worked at FDA, but just in the area of hematopoietic stem cell transplantation, you know, FDA has not regulated that, you know.  So I mean this whole proposed approach to cell and tissue based therapies was really an attempt to become more inclusive of these areas, and there's been enormous amounts of work throughout the 1990s, especially from 1995 on, in trying to capture this information and try to work with the different communities involved in these areas of cells and tissues. 
		Some of the areas have been very cooperative in working with the agency, and others have been quite skeptical of FDA becoming involved in regulating that area.
		DR. STYLES:  I will say that I was struck that it seems like the organization has been very forthcoming and seems to be, at least from appearances, very cooperative with the overall process, which I think will probably, you know, mean that people won't come down on you when you cooperate.  But I just wanted to point out I was just amazed by that.  I didn't even know that about it.  I thought they were all -- I thought it was a blood product.
		DR. LINDEN:  On that issue I have a little bit of perspective about regulation of tissue banks.  We in New York have been regulating them since about 1989, and there has been great improvement.
		I mean, my major comment would be this is a slow process.  You can't adopt a regulation and expect everybody is going to just comply overnight.  When you set standards, it may take a couple of visits before people really fully understand what is expected of them.  
		It's not like the blood bankers who are very compliant, really understand the expectations.  Additionally, with tissue banks there are a lot of other challenges.  As was mentioned, you are not getting the history directly from the donor.  Things are technically more difficult.
		Most of the -- Many of the facilities are for profit, and not that there is anything wrong with that, but that there are proprietary and competitive issues that we don't see as much in blood banking.  But there have been great improvements, and I think that FDA really has the right idea of adding to their existing regulatory structure with the Good Tissue Practices.
		That will be a big improvement, but we all have to understand that's going to be a slow process that will take some time.  But I think we are really making steps in the right direction.
		DR. LEW:  This may have been mentioned earlier, but how many are really involved with the AATB group, and how many tissue banks are totally separate, and does FDA's rule, I'm assuming, is for everybody, not just those involved with this organization?
		DR. SOLOMON:  That is correct.  You have to follow FDA regulations whether you are accredited by AATB or EBAA or not.  It has no relationship.
		DR. LEW:  So what percentage are a part of this AATB group, and what percentage aren't, and is it public information to know when you do your inspections?  Is there a difference in terms of which one violates these rules more often?
		DR. SOLOMON:  I wish we had someone from Compliance to answer that.  I can tell you that, in terms of prioritizing the inspections, if a bank is AATB or EBAA accredited, that would be a lower priority in terms of FDA visiting them than a bank that was not accredited.
		I don't really know the numbers.  I think it's about 60 percent of the tissue banks are accredited.  I don't really know.
		DR. EASTLUND:  Well, I'm not sure either.  I think Sam could help, but I have heard someone say that over 90 percent of the tissues used is from accredited tissue banks.  That is, bone tissues.
		The other question is what percent of the infections were from accredited tissue banks.  There's two different questions.  It looks like, from your data, there are -- Of course, the bulk of the Clostridium ones were from a nonaccredited bank, and the other bacteria are still ongoing investigations, including a couple of AATB accredited banks.
		So I'm not sure of the answer.  Sam, do you have an idea about the percentage of nationwide use of bone type tissue?
		DR. DOPPELT:  Yes.  I think -- Well, I don't have an exact figure, but for bone, as I said before, there's about -- Overall, considering bone, skin banks, etcetera, there's about 73 or 75 accredited banks.
		For those that are doing musculoskeletal tissue, the accredited banks account for, I think, somewhere about 95 to 98 percent of the tissue that is distributed in the United States.  Now the other two to five percent -- there could still be a fair number of smaller banks.  I mean, you only know what you know, and you don't know what you don't know.  
		So I'm not sure how many other banks there are.  Membership in the AATB is a voluntary sort of thing.  So we don't have any way of forcing people to join or follow the standards, and I think the proposed GTPs will go a long way to sort of getting everybody on the same page.
		DR. EASTLUND:  One point about that, if I could just say that the -- to remind you that the bulk of the tissue transplantation is bone, and the bulk of these infections have been osteochondral and tendons with just a little bit of bone.
		So I think it would point to a general good track record of most of the bone transplantation that's going on.  
		DR. HOLLINGER:  Obviously, I think that tissue banks should be accredited.  They all should be accredited by some organization, whether it's the FDA and/or -- sounds like the AATB.  Sounds like they are doing a very good job of regulation or at least looking at their banks.
		A question I had was, if you can tell me, among the AATB banks what percentage of the tissue banks -- or what percentage of the tissues that are obtained are from the medical examiner's office, and is there any difference between the cultures which are pre-processed cultures and after the processing?  Is there a difference in the amount and number of the tissues, the percentage of tissues that are destroyed because they are contaminated?
		DR. EASTLUND:  I'll sort of rephrase the question, too.  I think you are asking what percent of all the bone type tissue collected is from a morgue, whether it's a medical examiner or not, versus an operating room.
		That percentage has changed over the years where it used to be bulk of it non-OR ten, 12 years ago, to the bulk of it being OR or a thing that's even more controlled, a collection facility produced and -- put in by the tissue bank, and that sometimes is in a medical examiner's office, a dedicated room.
		So now it's changed over to most of the tissue is in a very controlled atmosphere, not the morgue.  And the morgue ones are done with a prescribed amount of cleaning ahead of time.  But for numbers, I'm not sure if Jean or Bob or if Sam has a number.
		DR. SCHMIDT:  If you are saying, Ted, OR, this means living donors?
		DR. EASTLUND:  No.  This is a -- The routine is that, once someone dies, they may have a temporary storage in the morgue, and they are brought up into the OR.  That's absolute routine.
		DR. SCHMIDT:  We've just really talked about cadavers today, but aren't there bones from living people and other parts?
		DR. EASTLUND:  That's right.  The most common is the femoral head, which I alluded to.  Well, I think I did -- the femoral heads from total hip replacement.  That has died off quite a bit, because there's such a large need for bone, and that can provide a small amount.
		So the amount of living donor bone has declined, but it's still there, to a degree. And that is under the same standards.  It's a little different, though, because since you are a living donor, you can be retested, and that's a requirement six months later to be retested.  And they also get hepatitis B core testing, at least in our standards in accredited ones, and retesting for HIV and HCV at the end of six months.  
		That was a long history, but that was set in place because semen transmissions back in '85 in Australia, and that's a routine for all of our semen banks also, the same retesting plans.
		DR. DOPPELT:  I was just going to just sort of reemphasize one point, so there isn't any confusion.  I think very few procurements now are done in morgues.  I don't know -- I don't have a figure, but clearly, as Dr. Eastlund said, the numbers have shifted.
		So when an individual is pronounced dead in a hospital and they are a suitable donor, the procurement occurs in that hospital, usually in that hospital operating room.  
		DR. HOLLINGER:  We're going to talk about this in a minute, but I'm not sure that's true for corneas.
		DR. DOPPELT:  You're right.  That's a different --
		DR. DiMICHELE:  I just wanted to ask Dr. Eastlund a couple of questions.  
		With respect to -- You said donors are voluntary.  That means that the people who are determined to be suitable donors are people who have already signed a little card that I'm willing to be a tissue donor.  Is that what you mean?
		DR. EASTLUND:  No.  I was alluding to paid versus nonpaid donors, whereas in blood it's definitely a high risk to pay the donors.  It increases risk of infections.  Whereas, in cadaver tissue donor they are not paid.  
		It's not that they have agreed ahead of time, and even though they have signed a donor card --
		CHAIRMAN NELSON:  What would they do with the money?
		DR. EASTLUND:  Well, as you may know, this is a hot issue in transplantation, because of the shortage of organs.  Right now, it's very much on the cusp of giving money to the next of kin to help with funeral expenses as a motivation or as a way to increase the number of organ donors.
		In tissue donors there is no payment.
		DR. DiMICHELE:  Well, then I have more questions, because the question is, okay, so who is determining the suitability of the donor then, and -- Okay, let me ask that question first, because I have a follow-up.
		DR. EASTLUND:  The tissue bank staff directly interviews the next of kin.
		DR. DiMICHELE:  Of everyone who dies?
		DR. EASTLUND:  That's right.  When it's a donor, a potential donor who dies, there is immediate screening.  A small percentage of those who are approached actually meet the suitability requirements.
		DR. DiMICHELE:  And with respect to that, one of the things that you said is in terms of the history.  You said that conditions -- you know, that you check for conditions rendering tissues unfit.  
		Now I don't expect you to go through the whole list of those, but are there a lot of conditions or just a few conditions?
		DR. EASTLUND:  There's a lot, and it's specific.  If you have rheumatoid arthritis and everything else is okay, you don't donate bone.
		DR. DiMICHELE:  So it's pretty stringent?
		DR. EASTLUND:  It is stringent.
		DR. DiMICHELE:  And lastly, you know, the kind of regulation, again coming from the blood industry, whatever, that we're kind of used to requiring the FDA is very labor intensive, is very financially intensive in terms of the resources that are required to police the operations.
		How does your organization fund itself in terms of policing the -- or inspecting and ensuring a certain quality of your member organizations?
		DR. EASTLUND:  American Association of Tissue Banks, you mean?
		DR. DiMICHELE:  Yes.
		DR. EASTLUND:  Well, it has, of course, dues, and that can be fairly expensive, but a large portion is also annual meeting income.  To give you an example of American Society of Hematology, they recently reported in their annual report, 40 percent of their revenue was from their annual meeting, and that's -- I'm sure for AABB it's another big bulk of the whole revenue.
		There is also fees, if you are accredited for inspection.  So it's more fees for a tissue bank than it is for an individual person.  So it's a  member organization of professionals plus, you might say, an establishment organization of tissue banks, and there's different fee schedules for them.
		DR. DiMICHELE:  And how many people work through the AATB?
		DR. EASTLUND:  Only about 1,200 members and about 74 tissue banks or tissue establishments?
		DR. DiMICHELE;  No.  How many people are doing inspections?
		DR. EASTLUND:  Oh.  Well, we have --
		DR. DiMICHELE:  Full time staff, I mean.
		DR. EASTLUND:  Two or three full time or near full time tissue bank inspectors.  But there is also voluntary inspectors that accompany them.  So you have the professionals in tissue banks with inspectors also.  Not so much voluntary anymore?  Okay.  So they are all paid inspectors, and it's the staff that do that.
		In our inspection of these problems that develop, we've had one voluntary professional plus a paid professional.
		CHAIRMAN NELSON:  Could we get your name for the record?  
		DR. EASTLUND:  Jean Moew, Executive Director of the American Association of Tissue Banks.
		MS. MOEW:  Were you referring to the size of the staff or the inspectors?
		DR. DiMICHELE:  I was referring actually -- Yes, to the size of the staff and, you know, inspectors.  Who carries out this function, I guess?
		MS. MOEW:  Okay.  We have seven people on staff, and we have three consultant inspectors, and  that's the size of the staff.  We develop standards, inspect and accredit the bank, and certify personnel who work in the bank.  It is a lot of work.  
		DR. DOPPELT:  I might just add one point.  As De. Eastlund mentioned, there is a fee associated with being inspected.  So, you know, the AATB doesn't send these people out just for nothing, but that may be one -- I'm not sure, but that may be one reason why some banks that aren't accredited choose not to be, because they don't want to pay an inspection fee.  They may or may not be able to pass muster when they get inspected, but there is a cost associated with being inspected.
		MS. MOEW:  Oh, and I meant to say that the people who do our inspections are all, except for one, former FDA inspectors, and one of them is a former head of CBER Compliance.  So we have, we feel, a very professional group doing our inspections.
		DR. ALLEN:  Two questions.  Health care economics being what they are today, I assume that hospitals charge for the use of the operating room for harvesting of tissues, and I just wondered who actually pays that?  Is that the collection organization that would pay that?
		DR. EASTLUND:  Yes.  Number one, there are no expenses that the donor family is responsible for.  Number two is there are some places that do not charge for that.  But number three is that the procurement facility -- the procurement agency then has to pay that.
		DR. ALLEN:  Okay.  And second, what is the background and training of the people who harvest the tissue?
		DR. EASTLUND:  The qualifications of the people who do the actual procurements vary quite a bit.  We happen to have over the years a mechanism of certifying procurement specialists and tissue bankers.
		So within the AATB accredited banks, they have a course that is taking place and a certifying exam, and it's quite comprehensive.  Then, of course, there is on-the-job training.  
		As far as qualifications for education ahead of time, it's widely variable, depending on the tissue bank; whereas, some might be medically trained in the beginning, there are some that are funeral directors.  We have physicians that do it, nurses, medical technicians.  It's a wide variety.  Dental assistants have been procurement specialists also, but you have to go through the training first.
		CHAIRMAN NELSON:  I'd like to move --Yes?
		DR. LEW:  Yes, just one other thing.  It sounds like you all are very good about going to different places and inspecting.  But I'm just trying to think in terms of what FDA has suggested, to gather more information, and particularly to look at the issue of infection.
		Is it available to you, particularly from your member people who belong to your organization, to get data like on the percentage who have positive cultures, what grew, and then after they are put in a special antimicrobial solution, you know, how often do they have to do that to sterilize it, and what do you allow?  Are there standards where, you know, after you have tried once or twice to sterilize and it doesn't work, then you have to get rid of it?
		Is all that information easy for you to gather to offer to FDA for review?
		DR. EASTLUND:  It's obtainable, and currently the CDC is working with the AATB for a very detailed look at that.
		CHAIRMAN NELSON:  Okay.  In order to try to finish up, I would like to invite Dr. Michael Lemp to talk about adverse reactions after corneal transplants, the eye banks perspective.
		DR. LEMP: Thank you very much, Dr. Nelson.  It's a pleasure to be here this afternoon.
		What I'd like to do in the time that we have here is to go through quickly some of the slide material which you have all been provided, and share with you some of our experience in eye banking.
		I am Clinical Professor of Ophthalmology at Georgetown and George Washington University.  I'm a corneal surgeon.  I'm a former member of the EBAA board, and I've performed about 3,000 corneal transplants over the last 30 years, both here and abroad.
		What I'd like to do is share with you a little bit of our experience in eye banking, which I think might be germane to some of the interests that you have here, because we have a fairly extensive experience going back approximately 50 years in this subject.  Next slide, please.
		The first eye bank opened in 1944 in New York City.  Corneal transplantation actually has a history that goes back about 100 years, but it's really only been done in any large numbers for about 50 years.  So it was really in the 1930s and Forties a rare operation.
		We had no system of getting tissue.  It was catch as catch can when donor material became available.  It was only in the 1950s that corneal transplantation developed to the point where it became more widely used, and particularly in the 1960s.
		This is why that you find that the EBAA was founded in the early 1960s.  It's the oldest association of transplant organizations.  It went through a series of developments.  So that by 1980 medical standards were promulgated.
		There are 93 member U.S. eye banks.  There is only one eye bank which is not a member of the EBAA in the U.S.  So it's a pretty inclusive organization.  In the year 2000, 46,000 corneal tissues were collected by members of the EBAA.  About 35-37,000 of those were transplanted here in the United States, and the rest of that tissue was sent abroad.  Next slide.
		What is the potential for transmission of infection through corneal transplantation?  The charge here today is bacterial infection and perhaps fungal infection.  
		There are two conditions in ophthalmology, for those of you who don't deal with this every day, that we worry about post-operatively in terms of infections.  One is infectious keratitis, and the second is endophthalmitis.
		I'd like to just show you a few pictures and show you what this is.  Keratitis is an infection of the cornea -- next slide -- which means this is what a corneal transplant looks like, a modern corneal transplant.  The central area that you see has been transplanted.  
		That very fine suture that you see holds it in place.  It's a 10-0 nylon suture.  Those sutures stay in place for a long period of time, because this tissue is somewhat unique in its avascularity.  It takes a long time for healing to occur.
		Now that has some implications for the possibility of post-operative infection that are not necessarily donor related, and so trying to sort these things out as to what might be donor related and what is not donor related is an issue that requires some explication.  Next slide.
		This is a picture that shows a case of infectious keratitis post-operatively in a corneal transplant.  Keratitis is basically a bacterial infection.  It causes a breakdown of the corneal epithelium and stromal involvement that you see here without evidence of deeper involvement in the eye.  Next slide.
		In contrast, you have a picture here of a post-op patient.  This was taken about 24 hours post-op of the corneal transplant, and this patient has endophthalmitis, which carries with it a much worse prognosis, and that is an infectious condition in which there are involvement not only of the outer layer of the eye like the cornea but the interior layer of the eye.
		It carriers with it a very guarded prognosis.  Even though many of these eyes are saved, the visual potential is not high in many of them that have this.  That relates to many factors, including the speed with which it is recognized and treated, but also to the virulence of the organism.
		The organism that we most fear in ophthalmology in these cases is Pseudomonas, and within 24 hours, because of the liberation of the proteolytic enzymes that Pseudomonas has, you can irreversibly destroy eye tissue.  So that's a real concern of ours.  Next slide.
		Now let's consider what is the incidence of post-operative infection after anterior segment surgery.  In ophthalmology that means surgery of the front of the eye, and the major categories that we fall into are cataract surgery, glaucoma surgery, and corneal transplantation.
		Now the overall incidence is actually quite low.  If you look at that, you can see that cataract surgery is 0.08 percent incidence of post-operative bacterial infections.
		Glaucoma surgery to reduce the pressure in the eye, making a valve-like opening in the eye for aqueous to drain out, has a slightly higher incidence but still quite low.  When you combine cataract and glaucoma surgery, which is what trabeculectomy is, it's about the same incidence.
		Penetrating keratoplasty or corneal transplant has a slightly higher incidence of post-operative bacterial infection, but it's still quite low.  Next slide, please.
		This is another example of a severe case of Pseudomonas endophthalmitis post-operatively.  Next slide.
		Now what are the factors that are unique to corneal transplantation that might predispose it to the slightly higher incidence of post-op infection?  These are non -- perhaps most of these are non-donor issues.
		There is a prolonged healing time.  When you put a corneal transplant in place, the average healing time is a year, and sometimes a year and a half, because you have to keep sutures in.  
		You have to keep sutures in for a long time.  They can loosen up.  They can become a nidus for infection, and that is frequently a site for post-operative infections, and they can occur months, up to a year or more after the surgery.
		The epithelial surface is disrupted itself, which makes a good spot for bacteria to adhere, and many of the disease processes which necessitate corneal transplantation alter the surface defense mechanisms that make patients more likely to get an infection.
		Finally, we typically use corticosteroids on an extended basis post-operatively, which makes patients a little bit more susceptible to infection.  Next slide.
		A couple of general statements.  I'd just like to share with you briefly what some of our experience is with this.  There has been some interest in this recently, and just to share with you three relatively recent studies that have been done.
		Now the question is:  Is there a clinical utility in performing routine cultures of tissue that's taken to be transplanted?
		Over the years, a number of places have routinely cultured the donor rims, as we say.  Just to orient you once again, there are two ways of taking corneal tissue, one of which is to enucleate the whole globe, which has been done for many, many years, and that's the way it was done routinely prior to the last ten or 15 years.
		The last ten or 15 years it's been much more common to simply excise a bit of cornea and the surrounding sclera and put that into a culture medium and to transport it in that way.  We have a good culture media now which can keep the important cells, the endothelial cells of the cornea, in pretty good shape for at least a week post-operatively, and in some cases longer than that.
		It relates to a question that just came up about 15 or 20 minutes ago.  Where does this normally happen?  Well, nowadays it normally happens in the hospital, maybe a hospital morgue.  
		It may be in a funeral director's place, wherever the tissue can be gotten, because it should be gotten within 12 hours of the time of death.  So it's usually in those circumstances that the tissue is taken.
		Now despite the fact that I have said that it is common practice, it has been over the years, to take routine cultures, this has become a controversial issue because of a number of studies that have been done.  Next slide.
		The donor corneas undergo a sequence of preventive strategies designed to minimize contamination and transmission of infection, and these are the standard things that go on with other tissues such as chart review, social and medical interviews, aseptic technique and antiseptic rinse of the cadaver eye, etcetera.
		These things are not particularly unique to ophthalmology from the other tissue processing.  Next slide.
		So you want to provide it with altering its integrity, form or function, and that means, as far as corneas is concerned, it's transparency.  Next slide.
		It can't be sterilized and still be viable for transplantation.  The cells die, and the tissue won't live.  So it is preserved in a corneal storage medium, and the medium also contains broad spectrum antibiotics to discourage bacterial growth.  Next slide.
		The EBAA promulgated the standards in 1980 for the practice of procurement and distribution of corneal tissue.  Next slide.
		These are some of the things the eye banks are required by EBAA's medical standards to have, and they are fairly standard, and I think that they are also typical of other tissue procurement procedures.  Next slide.
		Once again, the EBAA has a very complete procedures manual.  A medical director and the eye bank director are responsible for each bank for assuring that the eye bank personnel comply with all the applicable procedures, etcetera.  Next slide.
		The procedures manual also talks about pre-ocular tissue recovery and donor preparatory procedures, and they are fairly explicit, and this is pretty stringently enforced.  
		The EBAA, in the process of certifying the member eye banks, perform site visits.  There is a two to three-year inspection cycle.  At any given time, 90 percent of the members of the EBAA are judged to be in compliance with all of these.
		At any given time, slightly less than ten percent, a problem has been identified, and it's usually in the process of being reconciled.  So there is a continual process going on.  Next slide.
		These are some of the things that we do.  Next slide.
		And the contraindications.  As was alluded to in a question just a little while ago, are there many exclusionary criteria?  There are lots.  These are just a few of the ones that are sort of hot issues now, exclusionary criteria, particularly the ones that relate to prion disease and to active septicemia and active bacterial or fungal endocarditis.  
		Social medical history is particularly important in terms of transmission of conditions like HIV.  Next slide.  Let's continue.  Just go next slide.
		These are, once more, just a little bit more about the various things that go through.  You can see that in your material that you have.  Next slide.	
		Now the issue of corneoscleral rim cultures:  The EBAA says it's optional for eye banks.  What has basically happened over the last ten years is that many of the eye banks and the corneal surgeons have gotten away from getting corneal rim cultures.
		There's a cost factor involved, but the main reason was that over the past 15 years there have been a number of studies looking at corneal rim cultures and seeing what relationship they had to proven cases of bacterial endophthalmitis.
		The bottom line is there's not much.  The culture rate -- next slide; just keep going, and we'll skip through that, too.  
		There is a recent study by Everts, et al., that looked at this.  The culture rates that have been reported range from about five percent to 32 percent positive cultures in tissue that's collected.  That's a pretty high percentage in many of them.
		I was one of the authors in one of the studies.  We found a 28 percent positive bacterial culture in corneal rims in about 230 cases.  In none of those cases was there any post-operative infection, and in most of the other studies, all of which have been retrospective, that looked back, there's been very poor correlation between what you find in the corneal rim cultures that were taken and the cultures that you get from the offending organisms in real post-operative infections.
		That speaks to the fact that one of the major sources of post-operative infections, when they do occur, is the resident bacterial population in the recipient rather than the donor.  Next slide.
		In this study five percent of the corneoscleral rim cultures yielded microorganisms, mostly coagulase-negative Staph.  Two patients in this series developed endophthalmitis, one with Staph and one with Pseudomonas, within three months after transplant, and each had a negative culture, and neither patient's infection was temporally related to the transplant procedure.  In other words, it was a long time afterwards.  Next slide.
		The authors of this study concluded that preop donor corneoscleral rim cultures are unreliable predictors of endophthalmitis, and the discrepancy between the results of these cultures and subsequent endophthalmitis, they believe, rendered them invalid as a quality assurance procedure.  Next slide.
		There are several other studies.  There is one by Wiffen, et al., that looked at the value of routine cultures again.  This study is of interest, because it's one of the largest studies.  It's over 1,000 patients that were looked at consecutively in a university setting.  Next slide.  This was from Mayo.
		The rim cultures are available as you see here.  There were three cases of endophthalmitis.  The rim cultures were negative in all three cases.  The rim cultures were positive in just under 20 percent of the cultures that they took in the study.  Next slide.
		They concluded that routine corneal donor rim cultures have no predictive value for the infective complications of penetrating keratoplasty.  Next slide.
		Finally, there is another study from New York by Speaker, et al., that looked at some of the causative organisms of endophthalmitis following not just corneal transplant but other kinds of surgery.  Next slide.
		They found that the organism isolated from the vitreous, which is where you can get a positive culture in the interior of the eye, was genetically identical to organisms isolated from the patient's skin, conjunctiva or nose in 82 percent of the cases, and in two of two cases following corneal transplantation.
		It speaks to the fact that the primary culprit is the resident bacterial population on the recipient.  Next slide.  Next slide.
		These just show you that there's been lots of studies that have been done about corneal rims at this point.  Next slide.
		Once again, gram positive organisms are the most frequently present on both the donor and recipient external tissues, and they are the most common causes of post-operative endophthalmitis.  Next slide.  Next slide.  Let's just skip over that.
		So the Eye Bank Association of America has an adverse reaction registry.  It's been in place for a considerable period of time.  It seems to be working pretty well.
		We are certainly not satisfied with the fact that we have any cases of post-op endophthalmitis, but the incidence is quite low in this regard.  There is more detailed information about the EBAA procedures which are very similar to those for other tissue bank operations here.
		One final thing that I would leave you with is there is a study ongoing now to try to identify the predictive factors that may give a clue to a patient that's at higher risk for developing post-operative endophthalmitis, and the results are not in of that study, but it is in process right now, and the EBAA will be monitoring that closely.
		I think those are the points that I really wanted to cover here.  I thank you for your attention.
		CHAIRMAN NELSON:  Thank you very much.  Questions?  Patients who get a corneal transplant -- do they have perioperative or preoperative antibiotics or is that not used?
		DR. LEMP:  There is some variation in that.  Preoperative, no.  Almost nobody does that anymore.  Perioperative, yes, but they are almost never systemic.  They are topical antibiotics, and they are used varying times, anywhere from a few weeks to a few months post-operatively.
		CHAIRMAN NELSON:  In some surgeries like C-section, you know, that's dramatically reduced the perioperative infection rate, the use of just a day or the dose or two of antibiotics, when the problem is with the endogenous flora of the patient.
		DR. LEMP:  We have the same experience in ophthalmology, and the use has gone way down.
		DR. ALLEN:  That answered one of the questions.  The other one was just is it common or uncommon to culture the anterior nares preoperatively and, if there is Staph. aureus isolated, treat that with topical antibiotics before surgery?
		DR. LEMP:  It's extremely uncommon.  It's not done.  Actually, just as a point I will tell you that as a surgeon one of the things that bothered me a few years ago was the fact that you could get contamination of the field by nasal secretions and what-not.
		One of the things that I was very stringent about when we used to use a lot of general anesthesia was that they used atropine to dry up the nasal secretions, so you wouldn't have that kind of a thing as a potential contaminant.  But, no, they are not routinely cultured.  Maybe they should be, but they are not.
		DR. HOLLINGER:  Despite the recommendations and all the good information that suggests the rim cultures are not predictive, what percentage of ophthalmologists still culture the rim?
		DR. LEMP:  I'm not sure we have good data.  Pat, do we have good data?  I don't think we do have good data on that.
		DR. HOLLINGER:  I can tell you from Houston, I serve on a medical board of the Lion's eye bank which is one of the larger ones, I think, in the country, and about 50 percent still culture.  I think we are in the process of trying to recommend -- make another recommendation to them that they probably don't need to do so.
		Some of it, I think, is because of concerns about litigation and so on, probably more than anything else.  Usually, it's the older ophthalmologists and sometimes the younger ones.
		DR. LEMP:  Habits are hard to change.
		DR. DiMICHELE:  Is there any correlation data with infectious keratitis?  I mean, most of the data is association with rim cultures with endophthalmitis, but what about infectious keratitis, and is there any reason to care about that, if there isn't?  I mean, in other words, all this data that you have shown us for endophthalmitis, but what about infectious keratitis?
		DR. LEMP:  Well, number one, infectious keratitis can lead to endophthalmitis, number one.  Number two, even in the absence of endophthalmitis, infectious keratitis can destroy the integrity of the corneal tissue, therefore destroy its transparency,  and the purpose for which you did the corneal transplant is not served well.
		We have less information about that, but we do have some information, and actually there are some slides in there that I didn't take the time to go over that break out the incidence of keratitis versus endophthalmitis and also the relation to the corneal cultures.  They are not predictive for that either.
		DR. STYLES:  In your experience, is keratitis more common than endophthalmitis?
		DR. LEMP:  Thank goodness, yes.
		DR. STYLES:  Then why does your registry seem to indicate that the reported cases that infectious keratitis is less common?
		DR. LEMP:  Because I don't think they are reported as much, because they are not considered as important, because --
		DR. STYLES:  So you are saying that you have incomplete reporting then of your adverse reaction registry with states.  It specifically tells them to report infectious keratitis, but you are saying you suspect that it's not being reported?
		DR. LEMP:  That's a suspicion.  I can't prove it, but i know from a clinician and from a clinical practice that what happens is that many of these cases, if you recognize and treat it with antibiotics within two days, it's gone, and you don't have tissue destruction, and you have no consequence from it afterwards and --
		DR. STYLES:  So you think you're just getting -- You're getting the more severe cases, and the relatively benign cases are just being passed off then?
		DR. LEMP:  I think that's probably true of all reporting.
		CHAIRMAN NELSON:  How long -- You said the nylon sutures stay in for a year.  You then take them out?
		DR. LEMP:  Usually, yes.  They degrade over about a two-year period, about between year tow and year three.  They actually break down, and then they can separate.  Then a loose end sticks up and becomes quite irritating.
		The real reason that you take them out at a certain point afterwards when you feel you've got good wound integrity and you've got a good scar around the edge is the fact that they exert a certain tension on the shape of the cornea, and that affects the refraction and whether you've got a lot of astigmatism or what-not, and you try to get them out so it can assume a shape you know what you're dealing with, and you see how you can correct the refractive error you've got at that point.
		DR. FALLAT:  How do you explain the large number of rim cultures that are positive, five to 30 percent, in view of the fact that it's stored in antibiotic solution?  Is there an explanation for why you have such a high percentage of positive cultures?
		DR. LEMP:  Well, that -- As Dr. Nelson was saying, those cultures are taken prior to storage in the antibiotic solution.
		DR. FALLAT:  What about prior to use?
		DR. LEMP:  Well -- Excuse me?
		DR. FALLAT:  What about prior to actually putting it --
		DR. LEMP:  Sometimes they are taken, yes, in both settings.  You're right about that.  Well, number one, the antibiotics we use don't cover the entire spectrum that we have, and so I think that a lot of it has to do with -- The disparity in the reporting that you get between five and over 30 percent also has to do with the efficacy of the culture mechanisms that you use.
		You are certainly going to get a higher positive rate if you don't use transport medium and things like that, and there's a big variation in that from where these cultures are taken.  But it's very common.  I think they are just contaminated, and I think that the antibiotics that are used in the solution are not completely effective in eradicating them, really.
		DR. LEW:  I'm just wondering if we can learn something from the different groups, because EBAA is obviously an older, more established group than the AATB.  I notice that you have already this adverse reaction reporting.
		It's got holes in it, you know, as was pointed out, but can FDA learn from this and have it as a requirement for -- or request all the groups to have something set up to do this?
		Also I notice the differences that your group mentions that you do go back and expect people to train everyone appropriately, and it's in your guidelines.  I suspect when you go to do your reviews on site, you want to have documentation of that.  Is that also required for AATB?  Is that something that they want to implement as well?
		Instead of reinventing the wheel, take what's good, and then elaborate that for FDA.
		DR. LEMP:  Good point.
		DR. DOPPELT:  Can I could just make a comment?  In the AATB standards, they do require that each bank keep an adverse reaction file.  So that information is there.  They don't -- currently, they don't have to -- You know, every time an incident occurs they don't have to report to the AATB.  However, if they are an accredited bank, we would review that file when they come up for reaccreditation, which is every three years.
		I think one of the issues for the AATB and for the FDA and CDC is, you know, what kind of reporting structure do you want to have?  When you have an incident, when do you know about it?  		Obviously, one of the messages here is that we'd like to hear about it sooner rather than later.  So that's something that needs to be changed.  I mean, so the data is there.  It's just that it's not getting to the office in a timely fashion.  So we have some homework to do.
		DR. LEW:  What about the training issue?  Is that also a requirement, and you will check on that whenever you go for site visits?
		MS. MOEW:  Yes.  Training is required, and training files are inspected at the time of inspection, and they are maintained and documented.
		CHAIRMAN NELSON:  Your data never really specified, of the keratitis and endophthalmitis, how much was -- how many incidences were believed to be because the cornea was contaminated or infected when it was put in place, as opposed to the endogenous infections of the graft from the patient.  Your data aren't too clear on that.
		DR. LEMP:  We don't have data that are clearer, because it wasn't looked at from that point of view.  
		CHAIRMAN NELSON:  Are there episodes, you know, during your 40-60 year history or whatever, that it clearly was, you know, either two eyes from the same patient?
		DR. LEMP:  Oh, yes.  But those are mostly anecdotal things that we have.  Clinically, the thing that -- There are two things that we hang our hat on in that type of thing.
		Number one is the proximity between the time of the surgery and the initiation of the infection.  Practically all of these will occur within 48 to 72 hours of the time you do the corneal transplant.
		Number two, what happened to the other eye tissue that was -- Now that's not -- The second one is not a really good predictor, because I've had my own experience with that in which back 25 years ago I had a case of endophthalmitis, a terrible case of endophthalmitis, Pseudomonas, that occurred, and I transplanted both corneas into two different patients the same day.  One got an infection.  The other one didn't.
		Now that was prior to our taking donor rim cultures.  It wasn't commonly done at that time, but I meant the two donors together didn't correlate into -- didn't result in infection in both of the recipients.
		DR. ALLEN:  What proportion of -- Well, let me ask it a different way.  How long after surgery is the patient discharged home?  I assume that many of these are done in an out-patient surgical setting today?
		DR. LEMP:  Usually about 45 minutes.
		DR. ALLEN:  My question, obviously, was in terms of follow-up and where a post-op infection, even one occurring within 24 to 48 hours, it's --
		DR. LEMP:  Usually, typically, the patient is seen the next morning.
		DR. ALLEN:  But it's in an office setting, not in a hospital setting where --
		DR. LEMP:  That's correct.
		DR. ALLEN:  So it's outside of the routine infection control?
		DR. LEMP:  Usually, yes.
		CHAIRMAN NELSON:  We still have one person that wanted to make a statement, Wilson Burgess.  Is he here?
		MR. BURGESS:  Thanks for adding me on.  My name is Billy Burgess.  I'm the Senior Vice President of Research for Clearant, and we are a company that is using new methods, we think, of gamma irradiation for pathogen inactivation, and we've heard about gamma irradiation some today, and I'm in absolute agreement that conventional gamma radiation affects the structural integrity of bone.
		I think by the use of antioxidants and some methods we've developed, we can maintain good structural integrity.  I just wanted to show you a few slides, because we've really turned our attention to the tissue program right now because of some thoughts we had about emerging pathogens, concerns about not being able to really process aseptically material that is not sterile coming in.
		You know, I'm not going to spend a lot of time on the advantages.  I'm not going to spend any time on the advantages of gamma radiation.  You know, the main strength is that it's not discriminatory in terms of pathogens.  
		If it's nucleic acid based gamma radiation or inactivate, it's penetrating which we think it's important for the tissue industry.  It has a potential to serve as a terminal sterilization.  
		There is no addition in our process of the addition of toxic chemicals like the psoralens that have to be removed later.  It's scalable, which again fits, I think, some of the needs of tissue, and validation is relatively straightforward.  Next slide.
		The advantages of 50 versus 25 kilograys --  25 kilograys is really the tops that any tissue bank, I think, would use -- comes in being able to get resistance for us, to get complete inactivation of the lipid enveloped viruses, and we've been able to get up to 6 logs of reduction in the non-lipid enveloped viruses, and to date the non-lipid envelopes aren't the real disease problems, but in terms of the potential for emerging pathogens we think the non-lipid envelopes are a concern.  Next slide.
		I'm not going to give a big advertisement for Clearant today, but the literature teaches against the use of gamma irradiation for biologics as well as for tissue.  Our focus since we started about two years ago has been on plasma derivatives and individual therapeutic proteins.
		We've been successful in a number of these endeavors, and I think we've made significant progress on devitalized tissue.  I'm not going to show you a lot of the tissue data today.  We can talk about it.  		I was presenting to a bunch of investors this morning, and finally relaxed for a bite of lunch, and our President, Bill Drohan, came and said why don't you see if you can get on the end of the BPAC meeting, and so there's not a lot here, and I know it's late.  Next slide.
		This is just a model that we use where we take a bone chamber, a piece of cortical bone, drill out holes, and then put various infections or pathogens in it.  In this case, this is a vial of Clostridium sordellii that came from the ATTC, put that bone into the gamma irradiator, and I'll just show you some of the results that we've gotten to date.  Next slide.
		This is inactivation porcine parvovirus in that bone, almost 6 logs of inactivation of the toughest virus we have in our hands to inactivate.  Next slide.
		This is the Clostridium experiment.  We took the spores, put them in the bone, and then after irradiation, there's zero, 25 kilograys.  That's two and a half megarads or 50 kilograys, 5 megarads, then cultured those under anaerobic conditions.
		What you can see is that gamma irradiation is very effective in killing.  We get about 8 logs of reduction in terms of the dilution series where we see Clostridium growth.  You know, that's the Clostridium growth there.  We get about 8 logs of reduction, but at 25 kilograys or two and a half megarads, we can still pick it up in the stock in the first one to ten dilution.
		Contrast 50 kilograys.  We are unable to detect any residual Clostridium growth.  The next slide just shows an attempt to quantitate a little better.  These are the undiluted plates after 24 hours, a lawn of Clostridium growth.  We can still see the beginning of a lawn after 25 kilograys, no growth after 50.  Next slide.
		This is the 104 dilution, unirradiated, 25 kilograys, were gone by 104, and 50 kilograys, obviously, no growth.  Next slide.
		106 dilution, still pick up colonies in the unirradiated samples, none in the 25 or 50, and then maybe one more slide.
		Then, obviously, you know, Staph. epidermis, E. coli -- those are all easy to kill with gamma irradiation.  We can kill everything.  We can spike into the assay at 25 kilograys, but we do have this residual Clostridium spore content after 25 kilograys that we can't pick up with 50 kilograys of gamma.
		This was done at room temperature.  These were irradiated on dry ice where you can see the log reduction in the 25 kilograys, a little more problematic.  
		So that's really all I had to share, and thanks a lot for giving me a chance to share some data. But I think there are some effective means to deal with the Clostridium and other resistant spores.
		I know there's not a lot of data that we put out there yet on the utility of gamma for doing tissue.  That's forthcoming.  We've got a number of tissue banks we are working with on this problem now.
		DR. HOLLINGER:  Did you say you could use 50 kilogray?
		MR. BURGESS:  We can.  Everything that we've done has been -- We didn't want to be another step in the pathogen inactivation.  So the 25 kilograys is great for most bacteria.  It's pretty effective for the envelope viruses.  Envelope viruses, we've got effective means in the plasma industry at least to deal with those, but the recoveries that we are seeing with 50 kilograys on things like IVIG are greater than 95 percent.
		In terms of the tissue of the bone right now -- You know, we can take conventional gamma, irradiate bone, 25 kilograys, there's a 25-30 percent reduction in the structural integrity.  We can reproduce the data that's in the literature pretty well.
		By the use of these antioxidants during irradiation, at 25 kilograys the integrity in structural testing is indistinguishable from unirradiated statistically, and we are at about 90 percent retention of structural integrity after 50 kilograys which is well within the variance that we see just from different tissue samples.
		CHAIRMAN NELSON:  May I ask, were all tissues -- It was pointed out that more tendons and -- was a bigger problem, actually, than bone.  That's true for all the tissues?  You can do the same thing?
		MR. BURGESS:  I can't tell you we're there on tendons yet.  I mean, we've been mostly active in the bone program, because that's the biggest part of the industry.  But soft tissues are certainly on our list.
		We've got -- We haven't done a spike in the soft tissues.  We've got some recovery data.  
		CHAIRMAN NELSON:  How far away are you from marketing or offering or FDA licensure or whatever it takes to have this available, do you think?
		MR. BURGESS:  We've got one tissue bank that we are -- I think we've agreed to everything but the financials in terms of -- and in terms of plasma, fractionated are the same deal.  We're not negotiating the science anymore.  Other people are doing negotiating the financials.
		So with tissue we think it has potential to be soon.
		DR. DOPPELT:  I do have a question.  I may have missed this.  What are you adding as an antioxidant?
		MR. BURGESS:  Well, it's not a cookie cutter sort of procedure.  Depending on the therapeutic -- You know, there are two goals.  There is primary damage from gamma irradiation which we can't control but doesn't really damage proteins.  It hits nucleic acid.
		The secondary damage from gammas is the problem, and that's the free radicals, reactive oxygen species that are generated from the interaction of gamma photons with water and oxygen.
		So there are two approaches Clearant has taken.  One is to control things like moisture, water to reduce the potential to generate those free radicals, and then by the use of protectants or antioxidants to protect the protein from any free radicals that might be generated.
		The most effective one that we've used is ascorbate, which -- that's its normal function in our bodies, to protect us from cigarette smoke and other oxidants, and it proves to be an effective protectant for gamma irradiation as well.
		DR. DOPPELT:  So what you are saying is that, for example, bone morphogenic proteins and other proteins would not necessarily be affected by the radiation?
		MR. BURGESS:  Yes. We've done some work on -- With tissue it's hard to say which BMP or which factor you are going to work with.  We've done some -- certainly, some work with the purified individual factors and can maintain the mitogenic activity, the differentiating activity of those proteins in a test tube.
		For tissue, I've shown you the structural data.  We've got some cell culture assays that you can look for the BMP type activities in vitro.  The real test is to do ectopic implants and show that you can stimulate ectopic bone formation in animal models, and we don't have that data.
		CHAIRMAN NELSON:  Do your procedures have to undergo like FDA licensure or be acceptable to AATB or what are the criteria to get this to be an available standard routine, ordinary procedure?
		MR. BURGESS:  Tom Lynch, who used to be at CBER, is head of our regulatory, and I'd really rather have him speak to those.  But, clearly, there will be FDA review for the therapeutics, the biologics.  The tissue depends probably on the timing.
		CHAIRMAN NELSON:  Dr. Solomon, our instructions were to have a discussion this afternoon.  I think we've had a discussion.  But is our discussion adequate for your needs or do we need to do or say or consider anything else?  Okay.
		So for once, we have met our target.  So we'll see you in June, I guess.
		(Whereupon, the foregoing matter went off the record at 3:35 p.m.)