UNITED STATES OF AMERICA
	DEPARTMENT OF HEALTH AND HUMAN SERVICES
	FOOD AND DRUG ADMINISTRATION

	
	
	TRANSMISSIBLE SPONGIFORM ENCEPHALOPATHIES
	ADVISORY COMMITTEE MEETING
	
	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.
	Gaithersburg, Maryland
	Thursday, June 27, 2002
	
	PARTICIPANTS:
	WILLIAM FREAS, Executive Secretary
	Scientific Advisors & Consultants Staff
	Center for Biologics Evaluation and Research
	Food and Drug Administration
	
	SHEILA D. LANGFORD, Management Specialist
	Scientific Advisors & Consultants Staff
	Center for Biologics Evaluation and Research
	Food and Drug Administration
	
	COMMITTEE MEMBERS:
	
	DAVID C. BOLTON, Chairman
	New York State Institue for Basic Research
	
	JOHN C. BAILAR III
	Department of Health Studies
	University of Chicago
	
	ERMIAS D. BELAY
	Centers for Disease Control and Prevention
	
	STEPHEN J. DeARMOND
	Department of Pathology
	University of California
	
	LISA A. FERGUSON
	Senior Staff Veterinarian
	United States Department of Agriculture
	APHIS, Veterinary Services
	
	PIERLUIGI GAMBETTI
	Division of Neuropathology
	Case Western Reserve University
	
	RICHARD T. JOHNSON
	Division of Neurology
	Johns Hopkins University School of Medicine

	
	
	COMMITTEE MEMBERS (CONT'D):
	
	J. JEFFREY McCULLOUGH
	Department of Laboratory Medicine & Pathology
	University of Minnnesota Hospital
	
	PEDRO PICCARDO
	Division of Neuropathology
	Indiana University
	
	SUZETTE A. PRIOLA
	Laboratory of Persistent and Viral Diseases
	NIH/NIAID
	
	ELIZABETH S. WILLIAMS
	Department of Veterinary Service
	University of Wyoming
	
	SIDNEY M. WOLFE, Director
	Public Citizen Health Research Group
	
	CONSUMER REPRESENTATIVE:
	
	SHIRLEY J. WALKER
	Vice President of Health & Human Services
	Dallas Urban League, Inc.
	
	NON-VOTING INDUSTRY REPRESENTATIVE:
	
	STEPHEN R. PETTEWAY JR.
	Pharmaceutical Division
	Bayer Corporation

	
	*  *  *  *  *

	

	
	C O N T E N T S
	TOPICS:                                    PAGE
	Update on Implementation of Revised
	Guidance On Blood Donor Deferrals
	For Risk of CJD and VCJD:
	
	Introduction                             568
	
	Effects on Blood Supply                  577
	
	Open Public Hearing                         707
	
	Studies of vCJD Infectivity in Blood        709
	of Experimental Mice
	
	Retention of TSE Infectivity by Planova     749
	Nanofilters as a Function of Spike
	Composition

	

	
	
	*  *  *  *  *
	P R O C E E D I N G S
	(8:32 a.m.)
	DR. BOLTON:  If you'd take your seats, I'd like to get started.
	DR. FREAS:  Good morning.  I have a few administrative announcements that I would like to make.  Yesterday morning we read into the public record the conflict of interest statement, and that conflict of interest statement that we read into the record pertains to today as well.  Basically it said that all standing committee members have general matters, waivers in order to participate in this meeting this morning. This morning we will have several people from several organizations coming to present their organization's views.  These people were not screened for conflict of interest, but all committee members were.
	So, Dr. Bolton, I turn the meeting over to you.
	DR. BOLTON:  Thank you, Bill. Welcome back to the committee members and to the public to our second day of this meeting.  Today's session really is informational.  We don't have any issues to vote on, so it makes it a little bit easier for us.
	We're going to hear an update on the implementation of the revised guidance on blood donor deferrals for risk of CJD and variant CJD that we have discussed many times and I guess was published in January. Is that right?
	DR. SCOTT:  That's correct.
	DR. BOLTON:  Yes.  Our first speaker will be Dr. Dorothy Scott from OBRR. Dorothy.
	UPDATE ON IMPLEMENTATION OF REVISED
	GUIDANCE ON BLOOD DONOR DEFERRALS FOR
	RISK OF CJD AND vCJD: INTRODUCTION
	DR. SCOTT:  Good morning.  As just mentioned, this part of the session is an update on implementation of our new geographic donor deferrals for risk of vCJD, and today we're going to hear from blood organizations, including the Department of Defense, as well as HHS, about the impact so far of the geographic donor deferrals.
	I'm going to briefly give you a little back of background about what went on before, although I think this committee probably remembers all of the work that you did which has come to this.  Briefly, this is a chronology of how we came to the point where we are at today.
	This committee recommended vCJD geographic donor deferrals in June of 2001, and we incorporated your recommendations into a draft guidance, which we published near the end of August.  We issued a final guidance after the comment period in January of 2002.
	The implementation of the FDA-recommended deferrals is in two phases called Phase 1 and Phase 2.  The first phase has been implemented at the end of May, so what you're going to hear today is about the blood supply based upon this implementation date, the different implementation dates for the American Red Cross and the Department of Defense, who implemented their own donor deferrals last year in October.  The Phase 2 of the FDA donor deferrals will be implemented by the end of this October.  I'm going to show you a comparison of these, so that it will make more sense in the context of the presentations that are coming up.
	I just want to remind you of some of the issues that the committee and the FDA had to take into account while deciding on what donor deferrals to recommend because obviously these geographic donor deferrals had a good chance of affecting the blood and plasma supply.  So, these are among the considerations.  One of them is precedent. The largest prior donor deferral we had deferred approximately 5 percent of donors.
	The estimated effects of the deferrals that were actually incorporated into the guidance were that about 90 percent of the risk of BSE exposure would be removed.  So, this is based on estimated donor-days exposure to BSE in European countries.
	But we also had to remember that some locations in the U.S. would be more affected by the new donor deferrals than others, so this 5 percent is an estimate from the REDS study that Dr. Williams talked about yesterday.  However, we anticipated and we were told that the New York Blood Center stood to lose up to 35 percent of their supply.  Around 25 percent of that was because of their Euro blood program. Dr. Jones will be talking about that in a few minutes.  It was also estimated that coastal cities would have higher donor losses because of the greater prevalence of travel.
	There were some efforts to attend with the supply impact of the new donor deferrals.  But, first, written into the guidance was phased-in deferrals for blood and blood components other than source plasma.  That's why we have two recommended dates of implementation for the different deferrals.
	We also accepted from the Pan-European geographic donor deferral source plasma, and I can talk about that if you want to, but we have been over that and we had presentations at the last meeting talking about the effect of fractionation and the removal of TSE agents in plasma derivatives.
	We also recommended pilot programs for deferrals that were more stringent than the ones that we recommended.  This committee additionally proposed a national recruitment campaign and also that there be a system to monitor the adequacy of the blood supply, and you'll be hearing about that from Steve Nightingale today.
	Just a very brief review.  These are the deferrals that we recommended in our final guidance.  This is Phase 1, just implemented.  The deferrals are for residence or travel to the U.K. for three months and more between 1980 and 1996; for France, five years more between 1980 and the present; for people who have lived on U.S. military bases for six months or more between 1980 and 1990 north of the Alps, 1980 and 1996 south of the Alps.  This was because of the British Beef to Europe Program, in other words, these bases had up to 35 percent British beef during these particular years.
	I do want to mention something that's come up since implementation of the guidance, and that is:  We've had a lot of questions about donors who were in the Navy and who may have been living on ships that were docked in these European countries here.  We have learned from the Department of Defense that they did not eat British beef to Europe and therefore those donors are not deferred.  It's only the donors that resided or were associated with the military bases that were on land, and the deferral for recipients of transfusion in the United Kingdom.
	This is the second phase of donor deferrals.  This is deferral of blood donors who've lived in Europe for five years or more between 1980 and the present.  Donors of source plasma for plasma derivatives remain eligible if they lived in Europe for this period of time.
	Finally, I just want to show you what the donor deferrals are now that we have in the U.S.  We have the FDA-recommended deferrals, the American Red Cross deferrals, and the Department of Defense deferrals.  I've already outlined ours just now, and you see our dates of implementation here.  The American Red Cross implemented a somewhat different set of deferrals in October of 2001, and I will just point out the two most salient differences, and I think that Dr. Page will also be showing you a similar table.
	Chiefly, we have the deferral, for five years or more, between 1980 and the present for people who resided in Europe. The American Red Cross donor deferral is for six months or more residence in Europe from 1980 on.  The Department of Defense has the same deferral as we do.
	In addition, the American Red Cross deferral for the U.K. is for 1980 to the present, whereas ours is from 1980 to 1996, as well as the DoD, and this is based on our assurance that in the U.K. contaminated beef has been kept out of the human food chain since 1996, and this committee heard a presentation -- several presentations, I think, about that -- recently in January. However, I understand from Dr. Page that the American Red Cross is likely to also change its deferral, based on these assurances as well, to be 1980 to 1996.
	Now, I'd like to introduce our speakers who are going to give us blood supply updates.  The first will be Dr. Nightingale from Health and Human Services, who will show us the results of his blood supply and demand monitoring.
	Dr. Robert Jones from the New York Blood Center will speak next, followed by Dr. Peter Page from the American Red Cross. Then we'll hear from Dr. Celso Bianco of America's Blood Centers, then from Major Alfred from the Department of Defense, and, finally, from Kay Gregory of the American Association of Blood Banks.
	So, thank you for your attention, and unless there are any questions, we'll move on to our first speaker.
	UPDATE ON IMPLEMENTATION OF REVISED
	GUIDANCE ON BLOOD DONOR DEFERRALS FOR
	RISK OF CJD AND vCJD: EFFECTS ON BLOOD
	SUPPLY
	DR. NIGHTINGALE:  I must explain my first slide.  The reason why you are seeing the slide that you see is because when I found that I was going to be speaking right before Dr. Jones from the New York Blood Center, I felt it was necessary to acknowledge that we really do appreciate the government, the difficulties that people who come to Washington from New York occasionally have, and if you're in the back row, the gentleman in the foreground is Mr. Posada of the New York Yankees, and the gentleman with his back to you is Mr. Matthews.  He scored the winning run last night.
	As I was watching Mr. Matthews score the winning run, I realized that perhaps the Department had not gotten as far as it could in implementing the national campaign that you recommended at your last meeting, and I realized they only had a few hours to come up with a suggestion for that campaign.  So, here it is, with the caveat that it's only a few hours old and that suggestion is that you call it, "Give me an O."  There are no Orioles fans in here?  Not one?  All right, there's one.
	Let's go to business.  Next slide. I have presented the outline of our program to you on several occasions, and so rather than present it in detail I'll present it very quickly.  We monitor the supply end of the blood industry by receiving daily reports from three community-wide blood services -- those in Seattle, Pittsburgh, and Tampa/St. Pete.  What we get from them is daily reports of their inventory by ABO and RH, their daily transfusion, their daily outdates and their daily exports.
	In this particular graph, the red is the daily inventories and the blue is the daily transfused and exports, and the black line in the middle is the ratio of the two. Actually to the perfectionist, the black line is the median inventory in days of inventory for these three blood sites.  So, what you see here -- what you would see perhaps even better if I get this light on -- is that this is -- this -- we started last August 15th.  These were the inventories right before September 11th.
	This is the September 11th bounce, and this is the September 11th work-off. This little dip here is right around Christmastime, and when Christmas utilization went down a little bit, the days of inventory went up a bit.  A little peak in January, and what you can see is they built up their inventories a little bit over the spring, in anticipation of putting the deferrals in, and, as you can see, starting around May the 15th, the inventories have indeed fallen a bit.
	You can see that the ratio of inventory to transfused here has also fallen a little bit in the last six weeks.  So, we are seeing -- what I think that you will see in other sites as well -- is that there is a drop in the inventories but at least in the sites that we're monitoring from the supply side were still in the same range.
	Down here is actually where the business end of this graph is.  You see the peaks on Saturdays and Sundays when you don't have so many surgeries and you have the same amount of blood in the bank.  We're still over a five-day supply but we are heading there on the producer side.
	Slide.  Can I have the next slide? Okay, we've got the next slide.
	This is the comparable data for the 26 hospitals that we are monitoring again.  You can see there's a somewhat smaller bump at September 11th because not all of our hospitals collected their own blood and most of the -- or, parts of it and most of this bump was from the portion of our hospitals that collected a significant portion of their own blood.  You can see that there was a slight rise up until the spring, and, really, right around the 15th of May you start to see the drop-off that you saw with the suppliers as well.
	Again, when you look at the ratio here, the business end is at the bottom here where the dots cluster.  We're still over 5 days.  We're about 6.97 days.  I didn't run it last night.  It was 7 the last time I ran it a couple days ago for our average for the last couple of weeks.  But, clearly, we see things tightening up.
	For the next slide, next pair of slides, I'm going to show you comparable data for O negative.  This is for the three community-wide centers:  Seattle, Pittsburgh, and Tampa.  You can see, again, there was the jump -- the September 11th jump.  You can see it bounced up and down a bit, and, again, you can see there is a trend going down.
	Where you look here, the key thing on the side here, this is a five-day supply of O-negative, and they're down below that. I think this is the point at which I wanted to introduce what I think is the utility of this, just so that we have a track record right now and whereas you see we are at the low end of where we've been over the last year, but we're still within range at this point.
	To go hospitals, you'll see the same thing once again.  Here you have -- things are getting tight.  Things are definitely getting tight here for O-negative, but, again, this is five days' supply, this is ten days' supply, and the hospital had been running very substantial, and it's coming down but we're still with what I think is the same range.
	There's only four more of these slides, and this is the -- except for Dr. Bailar, I think most of you will look and hope that I change this pretty soon. This is a box plot.  The reason I'm showing you a box plot is to try to show you that we really do look at the individual sites on a particular day to see what is the distribution of their inventory, and this is inventory in days of inventory.
	This is the median of the days of inventory of the sites, and the bars are the 2575, and the spike go the 2595, and probably most importantly -- it's a good thing Dr. Bailar is in the front row so at least he can see this -- the boxes below the 95th percentile are our lowest numbers. Those are the folks who are below the 95th percentile.
	What I have this up here to show you is that while -- you can see some of the excess up here in post-September.  The distribution of the inventories across our 26 sites has remained pretty constant. I think again what we're seeing is called a "leakage" for want of a better word.  I believe we definitely see a trend from the sites that we monitor -- at least we see a trend but we haven't seen a crash yet.
	The next slide, please?  I have this on here briefly to remind you, again, that we have a track record here, and this -- over a year this track record -- this is outdates from the hospitals to remind you that when we went from seven days to ten days to fly at the hospital level shortly after September 11th, we went from virtually zero, maybe one or two units outdated today, to a larger number -- still a small number.  But this is a rough estimate of what we see as the hospital baseline as closer to the top than to the bottom of their optimal utilization.
	The next slide?  This is the seventh of eight slides and is, to me, the most meaningful to explain to you what it is -- so that what we're trying to do with this monitoring program.  What you have here -- and I apologize for those of you in the back -- it says "Frequency of blood shortage reports by week."  Bottom line is they're going up.
	These are reports that we get from the sites that say either an order was delayed, an order was not completely filled, or we had to go to a non-customary site to get blood to fill our orders.  Before September 11th, we didn't see much.  That little blip was the September 11th, led by, I believe, 42 days after September 11th when there was a surfeit of blood in the system. There were no such reports.
	What we saw was a buildup around Christmastime.  A little bump in here which is not entirely explained but just might be a little internal part of the program.  We had a meeting in February where some people said, you know, we think you're not getting the whole story, so we had a transient rise of about three or four sites reporting shortage.
	It went away, but there is no mistaking this trend.  As in the last four weeks, the reports of these shortages, which we're calling "near misses," are definitely on the up.  We anticipate that these will be precursors of more serious events where elective surgery has to be canceled if in fact we get to that point.
	The last of my slides is that we do track this on a daily basis.  This is the median inventory in our hospitals, and there's only a single dot there, and that single dot there is not that elective surgery had to be delayed or canceled or nonelective surgery had to be delayed because of a blood shortage, but that was one case where it had to be delayed because AB negative plasma was unavailable.
	In a nutshell, then, what we have seen so far is:  No. 1, inventories are clearly slipping; probably No. 1A, inventories, as far as we see them, are still within the range but definitely at the lower end of the range that we've seen over the past year, the first year of this monitoring program; no. 2, the daily reports of what we call near misses -- incompletely filled orders and so on -- are definitely on the rise; but No. 3, we have not yet in our sample gotten a report of elective surgery being delayed or cancelled or nonelective surgery being delayed because blood was unavailable.
	That will be it.
	DR. BOLTON:  Thank you, Dr. Nightingale.  Are there questions from the committee?
	DR. BELAY:  Steve, what's the most recent inventory data that we have?  Is it through May or June?
	DR. NIGHTINGALE:  The most recent inventory data that you have is of 8 o'clock last night.  I put this together after I came back from the ball game last night. Literally.
	DR. BELAY:  Do you expect to see a drop in the summer, for example, because of, you know, summer vacations and everything else?
	DR. NIGHTINGALE:  I expect to see a drop in the summer, but I think it's important to remember that this is new methodology.  What we're picking up here is daily inventory reports and I've given you the raw data rather than moving averages. And it's not just because I have a statistician in front of me, but because I think we really need a full year's of worth of experience with this system and experience comparing this system to the other systems, other efforts by other individuals in place to get, first of all, the worth of this system and, secondly, to see how we can make this system better.
	There is a very specific problem here that we're trying to address, which is when you're watching a moving line on a daily basis, when do you know that you have a trend?  We are very fortunate that Jay Kadane of Carnegie-Mellon is working with us on that.  That's not a simple question.
	So, I think right now what I think the best that we can do for our colleagues is to say this is our raw data and to make it available as quickly as we can so that we can learn from this.  Hopefully we can help the people who manage the blood supply manage it better by this.
	DR. BOLTON:  Other questions?  I have one, Steve.  In your centers, what percentage of elective surgeries use autologous blood donations?
	DR. NIGHTINGALE:  We're not there yet.  The only things that we do this year are we collect inventory data and we collect shortage information.  This program might very well develop into that but it would take more money than we have for it right now.
	DR. BOLTON:  So you don't have an idea -- for example, when you say that elective surgeries are being delayed because there's not blood, you don't know how much that could be alleviated by autologous blood donation.
	DR. NIGHTINGALE:  We made a deliberate decision not to include autologous blood in these calculations, and also we don't include partial units -- the pediatric units -- in this calculation for consistency.  I think the issue of autologous blood utilization is something that my colleagues who are transfusionists rather than nephrologists or bureaucrats are better equipped with it than I am.
	DR. BOLTON:  Thank you.  Our next speaker will be Dr. Robert Jones from the New York Blood Center, and he will give us the update on the effects --
	DR. JONES:  We have a global communications problem.  It goes beyond my presentation.  If you could just give us a minute.
	DR. BOLTON:  Technological glitch. Anything anybody wants to say?
	I guess I'll take this opportunity to say something I meant to say before we began the presentation this morning.  That is that in our deliberations yesterday we were talking about trying to anticipate the effects that any decisions, recommendations that we made would have on tissue donations. And today we're getting an update on the effects that our deliberations over the last year, year and a half have had -- the guidance changes that we are having now on the blood supply.
	So, in some respects it might have been a good idea to have this update first, as a sort of precautionary informative session.  But in other ways, maybe that's a good thing that we didn't.
	DR. JONES:  We are getting close.
	Here we are.  Steve's presentation was interesting and important, and it brings to us the perspective of the hospital.  Now I'll try to bring you some perspective -- I think others that follow me will bring you the perspective of those that are closer to the source of this precious life-saving resource, the Donor Center perspective.
	I'll start off by giving you some good news, some feel good information, followed by some information that doesn't feel so good.  Not quite one month has passed since implementation of the first phase of FDA's vCJD blood donor guidance recommended by this committee.  Although it was very difficult to get much real quantitative information on the state of the supply, much anecdotal information is accumulating, suggesting that a hazardous state of the nation's blood supply is both likely and imminent.
	At present, red blood cell supply at New York Blood Center available for our hospitals is more than adequate.  Since the announcement of the guidance, we have been preparing for potential supply shortfalls by major reengineering of our blood donor recruitment and collection campaigns.
	Significant augmentations were made in our collections goals over and above our already aggressive and successful campaigns. Resources have been invested in news staff and recruitment and recruitment campaign strategies and materials.  Resources have been invested in new staff and recruitment campaign as necessary.
	We have also carefully and deliberately secured supply agreements with a diverse array of U.S.  Blood providers that range from 6,000 units per year up to 60,000 units per year from small independent blood centers to networks of independence, such as ABC and BCA, up to the largest single U.S. blood provider, the American Red Cross.  We salute the commitment of these blood-carrying organizations to help the New York area through this difficult implementation period.
	We deliberately structured our agreements to supply a substantial cushion because of the uncertainty that we faced and continue to face around how national donor willingness will play out.  Euro blood supply continued to be shipped until May 31st.  Actually, we do continue to receive the debt supply but that was a very small proportion of the overall supply.  So, essentially Euro blood is almost over.
	Finally, we have had significant gains in collections and processing efficiency so that our discards and rejects rates are reduced.  With all this our red blood cell inventory has sustained at more than a sufficient level for months. However, even with limited information since June 1st, a frightening trend is beginning to develop.  Since the end of May our overall red blood cell inventory, while still adequate, has dropped by 27 percent. So, we're riding up here and now we're starting to come down, more or less reflecting some of the things Steve was talking about.
	Availability of type O-negative blood will soon be at a rationing level. Actually, at the time I wrote this that was soon to be; now it is.
	Our whole blood collections have dropped precipitously to 13 percent below last month, May 2002; 19 percent below what would be expected for our whole blood collection campaign; and 12.5 percent below June of 2001 one year ago.  The number of donors presenting it during the first 17 days after implementing the guidance is 13 percent lower than last year at the same time.  This is most marked in our collections in New York City and in New Jersey.
	It is equally disturbing that many of our new U.S. suppliers are reporting substantial collections difficulties as well and are now not able to meet their commitments to New York.  This includes both independent ABC Centers and American Red Cross supplies.
	Individual centers are reporting unexpected impact of vCJD referrals, particularly those related to military service.  During this timeframe, ABC reports a significant increase in centers reporting less than one-day supply to where it is now in excess of 33 percent.  I'm sure Celso will give you an update on that.
	This indicates severe supply problems emerging in other parts of the U.S. and if this phenomenon is sustained, the supply in the New York/New Jersey area will eventually be as low as, if not lower than, those parts of the U.S.  We believe that the causes of this impending supply crisis are multifactorial and only partially resolvable in the short term.  First, the loss of Euro blood is clearly important to the New York area supply and, as such, impacts the national supply.
	Actually, I might switch to the second slide quickly.
	This is our collections curb, just to show you quickly.  This is the September 11th.  This is the trough that I refer to, and this is our June number.  So, you see, we're climbing back out of that trough, and this is what we project for June, only two or three days to be completed.
	Second, after Euro blood loss, the timing suggests the vCJD guidance is playing a major role in reduced donor willingness to donate, as well as actual exclusion from the donor pool.  Whereas ARC shortages are clearly not due to recent vCJD deferrals, non-American Red Cross centers are clearly being impacted, particularly those that are dependent on military and military retiree donors.  Many centers report that it is not only the number of donors that are being lost; as importantly, the types of donors as those who meet the criteria are often regular and frequent donors or apheresis donors of platelets.
	Third, there remains a donor apathy that continues to suppress blood donations nationwide since the surge of donations following 911.  This is exemplified in the trough of our monthly collections curve that is yet to return to our expected collections baseline.  I just referred to that.  After the peak, there was this trough.  We were climbing out of it, and now we see the June number.
	Whereas the magnitude of the suppression is difficult to quantitate and varies widely from center to center, our center has yet to fully recover from this reduction in donations, and most centers report similar pictures.
	We estimate that when the units lost because of collection and processing errors and expiration is factored in, so far the total loss of whole blood units for transfusion from the 9-11 experience was about 5 percent of our annual collections. Our experience more recently with focus groups on 9-11 donors also tells us that the U.S. donating public is still angered over the massive outdating of red cells that occurred and was reported after the 9-11 donations.
	These groups tell us that they don't understand that blood is perishable and that throwing away their donations is unacceptable.  Furthermore, they report that they are unlikely to respond to appeals for blood donations given the experience after 9-11.
	Finally, there's the historic drop-off in blood donations in the summer months.  Particularly disturbing is the sense that this drop-off began occurring in April and May, months that usually have high donation rates.  This deterioration has accelerated in June and just two days ago ABC, AABB, and ARC released a national appeal for blood donations.  An appeal this early in the summer is a dangerous sign that the conditions may get worse unless there is a massive outpouring of donors.
	These forces taken together portend a very serious problem with the blood supply that threatens to disrupt hospital care nationwide.  Again, I emphasize that the supply in the New York area is sufficient at the moment.  Based on assumptions of several weeks ago our supply is forecast to be adequate through the summer months.
	However, our assumptions did not include a massive shortfall in collections throughout the country that would impact our new suppliers and reduce their ability to supply New York.  Nor did they include the magnitude of reductions in donations we currently see in the New York/New Jersey area.  The overlay of vCJD deferrrals on the current donor apathy and summer donation contraction is a formula for disaster.
	Every day the nation's blood care systems must create the red blood cell supply that will last for only 42 days.  We are not banks.  We are pipelines.  The nation's blood supply is neither static nor stable.  It is dynamic and emminescent (phonetic).  As such, assumptions we made about supply even two months ago may not be valid.  There is no reserve supply to meet demand if collections continue to deteriorate.
	In light of the current national problems in blood donations, we urge this committee, again, to reconsider its precautionary position on vCJD referrals. While this policy was pursued in the good name of blood safety, we fear that patient safety is now in jeopardy.
	Thank you.
	DR. BOLTON:  Thank you, Dr. Jones. Questions from the committee?
	DR. WOLFE:  Back about 10, 12, 15 years ago, I think at the peak then there was a big campaign, particularly at the hospital level but elsewhere to do more autologous blood.  I'd just like to ask you -- Dr. Nightingale deferred the question about that, that came from Dr. Bolton -- what has your organization done recently, as in since the time that this program was going -- it was planned to be implemented to -- even though it's a little bit out of your purview.  But as part of a campaign to try and improve the balance of the blood supply, what has your organization done to promote more autologous blood donations?
	DR. JONES:  Well, it's not out of our purview at all.  We actually supply that service to virtually all the hospitals in the area.
	DR. WOLFE:  In terms of your public affairs, what have you done recently as part of your other efforts to try and keep the blood supply in balance?
	DR. JONES:  Well, our first efforts are to try to get more donations from the public.  We've always encouraged autologous donations.  When we get questions about it we talk to our hospitals.  The logistics around that are much more difficult than the standard way of operating with getting blood supply in through the public donors.
	DR. WOLFE:  So you haven't done anything new in the wake of this pending disaster that you're describing?
	DR. JONES:  We have done lots new to increase the --
	DR. WOLFE:  New things on autologous specifically.
	DR. JONES:  Oh, no.
	DR. WOLFE:  You've not done anything new.
	DR. JONES:  No, other than to be available and encourage blood bank directors.  We work very closely with them, and they're always ready to accelerate that if necessary.
	DR. WOLFE:  It seems to me that -- I mean, I think your point about people being turned off because of having to dump blood that was collected in the wake of September 11, and also there is still some residual concern about getting infections -- some rational, some not rational -- I mean, giving blood is not some way you get an infection.  But I think that it would seem like an ideal time to capitalize on those concerns and mount a much bigger and newer campaign on autologous blood.
	I mean, the -- when this was done back when, it resulted in a very important increase and then it sort of faded out. There hasn't been as much publicity.  I just would suggest that -- and I will to everyone who makes presentations today -- that they ought to figure out what they can do that they haven't done.
	You've said you've done anything new in the wake of this to try and encourage autologous blood.  Obviously it's not the only strategy, but it's one that cuts through a lot of the problems that you've described.
	DR. JONES:  Yes.  Now, we have, in fact, in the last few months, when we meet with our blood bank directors, which is once a month, put autologous donations on a higher plane of availability and their awareness.  So, we're talking about it where the blood bank directors.  We can't --
	DR. WOLFE:  But that's internally. That's, again, not public relations and trying to get the public to do this, right?
	DR. JONES:  It's really the doctors' decision.  That's really the people we have been working with.
	DR. BOLTON:  Dr. Linden?
	DR. LINDEN:  Well, just, along that line I'd just like to disagree that I don't think that would be a particularly beneficial approach.  At this point, over half of autologous blood is not used.  It's not needed.
	Most of the patients who are the best candidates for autologous are already donating.  If you had a broad-based appeal to the public, all you're going to get is patients who don't really need it and who aren't going to use it, and it's just going to use up resources that could be directed toward promoting community donations.  I mean, I'm not saying something couldn't be done, perhaps with the physicians, but I don't think that's something that would really particularly productive.
	DR. WOLFE:  I thought there had been a fairly measurable fall-off, you know, to autologous blood after the campaigns of 10 or 15 years ago.  I mean, maybe a lot of people are doing this.  But I think there are still a lot of unawareness on the part of the public.
	DR. BOLTON:  Let me jump in.  I mean, I brought this up because I had back surgery six or seven years ago and I was basically told, "You will donate autologous blood," and that's it.  It was just part of the procedure.  It seemed to me quite reasonable.  In fact, I was upset that I had to sign the waiver that said I realize that if they don't use my blood on me, they'll throw it away.  Since I'm a normal regular blood donor, it seemed kind of a shame to do that.  But I understand the paperwork behind getting my autologous donation mixed up with the general supply.  That sort of makes sense.
	But it seems to me that, for elective surgery, good communication with the surgeon to -- not from the public up but from the surgeon down -- to implement this kind of practice could save a tremendous amount of blood.  It certainly would reduce the number of elective surgeries that have to be delayed because there isn't blood available.  That was my only point.
	Steve, did you have a comment?
	DR. NIGHTINGALE:  Yes.  It might actually be easier for a nephrologist and bureaucrat to make this comment than, say, a blood bank director, given these particular circumstances.  But as someone who actually has been very actively involved in the blood business for the last five-year period, here is my response to Dr. Wolfe.
	Autologous blood donation, when it was first proposed and implemented, seemed like the ultimate no-brainer, something that couldn't lose.  In fact, the experience with it has been much less successful than was anticipated, and I believe the best summary of that is in the review of transfusion medicine.
	Was Mark the first author -- it's a two-parter in The New England Journal of Medicine -- Mike Collings over there can give you the reference -- that the expectations have not been realized because, first of all, the population that you're drawing from is not necessarily the population that has the same likelihood of using blood as the population as a whole. So you've got that imbalance there and that is why a little bit over half -- Dr. Linden may have the exact number of the blood that is not used.
	The second is that the amount of blood that you can get in the 42 days from a stable population may not match the dose that the individual needs.  You may have the blood in the bank and you say, "What the hay; let's give them a unit."  But that practice is not popular anymore.
	Blood is like a lot of medicine. Usually you don't need it, but when you need it, you need a lot of it.  I think in a nutshell that may explain why autologous donation has not been more enthusiastically proposed either in the blood world as a whole or in this meeting this morning.
	DR. WOLFE:  But in a time of crisis, at least as has been described, do you not think, particularly because there hasn't been a campaign recently, that that could not be one of the important components of trying to get the balance back?
	DR. NIGHTINGALE:  I think, real quick -- and here I am speaking back as the bureaucrat nephrologist -- what we need is long-term solutions to the summer slump.  As Bob said, there's a lot of things going on here, but one of the things that's going on here is the summer slump.
	The summer slump, yet early -- how much of this was a 531?  I don't know. Nobody else knows.  But this is a summer slump here.  It's ABC, ARC as far as I can tell, at least from my limited perspective, equally, and we've got to get out of the pattern of summer slumps and winter slumps, and that's going to take a lot of head scratching.  That's a solution to our problem.
	DR. BOLTON:  Dr. Linden?
	DR. LINDEN:  Just to follow up briefly on this, I agree completely with what Dr. Nightingale said and would just like to add that in fact studies have shown that most of the patients -- or many of them -- who do need blood following surgery who donated autologous blood is because basically they were anemic when they went into surgery because they don't -- if you compare them with patients who didn't do autologous donations, and other patients with the same blood loss don't need the transfusions; so basically they're just getting the blood back because they lost it in the first place.  So, promoting more of that in the same types of patients, you know, I don't think would be particularly productive, in my opinion.
	DR. BOLTON:  Ermias?
	DR. BELAY:  I was trying to understand the Euro blood loss.  Most of the ÄÄÄÄ policy would not kick in until probably October.
	DR. JONES:  That's true.  The big Euro blood loss -- and we knew this several months ago -- our biggest program was the Swiss program.  They elected, for many reasons, many political, not to ask the French question; so that took them out.  And the Germans followed along with the Swiss; they work fairly close together, those programs.  So that leaves the Dutch who were willing to incorporate the question about France into their donor forms.
	DR. BELAY:  You predicted an impending supply crisis, which you said is multi-factorial?
	DR. JONES:  I'm sorry?
	DR. BELAY:  You say the impending crisis is probably multi-factorial?
	DR. JONES:  Yes, I listed the factors.
	DR. BELAY:  Can you give us an idea what proportion of that would be attributable to the foreign policy that we recommended?
	DR. JONES:  Well, for us the timing suggests there's a strong impact on our own collections of the deferrals.  We anticipated that because of the cosmopolitan nature of our donor base.  I think the coastal areas were forecast to have much bigger impacts of vCJD deferral than for travel than any other parts of the country. So, we predicted that.
	We did surveys last year, which predicted something like 7 percent loss total when all the phases were in.  Now we're seeing we don't know what's relative to CJD but we've seen in the first three weeks 13 percent drop-off in donations or people showing up for the drives.
	MS. KNOWLES:  Can I ask a question? Can you give us that in numbers?  How many numbers does that translate to, in terms of donors?
	DR. JONES:  Over the period of the -- well, let me put it this way.  We anticipated 40,000 donations for the month of June.  We're going to come in at 33.
	DR. BOLTON:  Yes?  Please introduce yourself.
	MS. ELSAADANY:  I am Susie ElSaadany.  I am Chief of the Statistics ÄÄÄÄ Section at Blood ÄÄÄÄ Health, Canada -- Ottawa.  I'd just -- I'd like to elaborate on the autologous issue.  I just recently finished a study on autologous utilization at one of the biggest hospitals in Ottawa. I'd like to say that autologous blood donation is quite expensive.  And also we collect autologous blood for just-in-case scenarios.  Therefore, we end up losing between 60 to 64 percent of the autologous blood collected, because it turns out the patient doesn't need it.  So, I think it's quite expensive, unless you have a good utilization program, then it is quite a waste, in my opinion.
	DR. BOLTON:  Thank you.  Steve, and then John.
	DR. DeARMOND:  It seems like there's -- very simple-minded.  This is way out of my realm.  But two major factors seem to be involved here at least:  First, was the deferrals that the FDA recommended -- no question.  But clearly from the charts, New Yorkers will respond when needed.
	DR. JONES:  You may have to bring a couple of buildings down.  That's the problem.
	DR. DeARMOND:  But the results after that, of the rejection of giving blood, is also -- that seems unreasonable. So there seems to be a second problem, which is:  A poor education of the -- so, has there been increased attempts to educate the individual of the population in this area -- on TV, at baseball games, at other places --
	DR. JONES:  Yes, yes, there have been attempts.  In New York, the New York area, the message level is so intense that to drive any message through that chaos of messages is very difficult.  You know, crises get through fairly quickly, but routine -- certainly PSAs don't do the trick.  Paid advertising is prohibitively expensive in our area to do that.  So, what we've elected to do is educate donor chairpeople.  The best education and the best way to recruit blood donors is face to face.  We've learned that over a period of time.
	Massive appeals.  Our experience with advertising has not been real productive, and perhaps it's because of the nature of our market that it's very difficult to get messages through.  Other markets where there aren't quite so many messages may be easier.  But it's clear that the American public -- and I'm not just talking about New York -- the American public has no clue as to the way blood is perishable -- No. 1, that you have to get the supply in every day because it expires in 42 days.
	They were agas that this blood was thrown away.  It wasn't just the American Red Cross.  We had to discard lots because we didn't have transfusion recipients for all that blood.
	DR. DeARMOND:  So, don't they believe it when you say that?
	DR. JONES:  I just think it's something that doesn't register.  You know, blood donation is not something that's at the top of my mind.  I wake up every morning thinking about this, as does Peter and many people in this room, but we're a very small minority of the population.
	DR. DeARMOND:  But that message must be like taking drugs.  If you say "No," you should say, "Blood supply is perishable."
	DR. JONES:  I think if we had -- listen, I think if we had a national campaign sponsored by the federal government to drive this message home, it would work. We've been calling for that for well over a year, and it's not happened.
	DR. DeARMOND:  Well, that is the question.  How do you pay for it?  I think that you're right, that's really the way it's got to happen.
	DR. JONES:  The blood care system does not have the reserve dollars to do this.  We're struggling day to day just to get the blood supply.
	DR. DeARMOND:  How could that be done?  How could we get the government to do that?
	DR. JONES:  Well, you made a recommendation through the FDA to the Department of Health and Human Services, and I'm -- as a matter of fact, we sat with the Secretary himself and urged this, and it doesn't seem to be happening.  There are other priorities.  We all understand that. Unfortunately, it may take a crisis or a disaster to bring that about.
	DR. BOLTON:  Dr. Bailar?
	DR. BAILAR:  It's really just been covered.  I'm concerned that I haven't heard messages of any urgency.  I stay in very close touch with the news media, read three newspapers regularly every day, a fourth one on Sunday, I'm in and out of a lot of hospitals.  Somehow this message just isn't coming through and something has to be done about it.
	It may take a very long-term approach to this.  You have people out in schools telling kids these messages.  Give them something to take home to their parents.
	DR. JONES:  Yes, we do.  As a matter of fact, we have intensive programs related to the Department of Education, actually now through the New York Academy of Medicine, that takes on the task of health education in high schools in New York City, and this is part of their curriculum.  So, there are numerous ways that we're working to get the education out there.  But, again, it's a small message -- big to us but a small message in the fabric of numerous, and sometimes others think more important, messages.
	DR. BAILAR:  I would guess from what I hear here and other places that the problem is not that the public is reluctant to donate but that they don't understand the need.
	DR. JONES:  I think there's two things.  The 9-11 situation definitely put a new dynamic into the system as to the public's willingness or interest to donate blood.  Now, there was a significant amount of backlash that all the blood care organizations felt around that.  As much as you tried to educate them, this was something that was inevitable because of -- and that you can do what you can to freeze blood, that that strategy is expensive and not as effective.
	Still, the public operates on a very day-to-day kind of, you know, what-have-you-done-for-me-in-the-last- ten-minutes mode of thinking, and so I think we're dealing with that psychology.  It'll slowly, you know, ebb away as we have more appeals.
	I think one of the things we learned from 9-11 is the destructive impact of allowing that kind of surge of donations to happen.  We simply must not let that happen again because of the destructive impact.  We lost a lot of ground.
	DR. BOLTON:  Dr. Linden?
	DR. LINDEN:  Yes.  In terms of government actions, I can just let you know that Commissioner Novello has made funds available for a project that we're pursuing shortly through the Department of Motor Vehicles in New York, and everybody who renews a driver's license or car registration is going to be getting an insert that talks about the need for blood and gives the 800 numbers for both the Red Cross and the New York Blood Center.
	We're going to start with a million of those and then go from there and see how that works.  I'm not overly optimistic but it's an interesting sort of experiment, and if it were to work, that would be something that could be considered in other states as well.  Now, of course, I'm from New York. There's a lot of people in New York City that don't drive, but we'd at least reach some of the them.
	DR. BOLTON:  Those that drive don't drive well.
	DR. JONES:  I might add there's another dynamic sort of creeping into the system as we've talked to donors and focus groups, and that is the perception that's out there, especially with a lot of recent publicity about artificial blood and blood replacements, that this doesn't have to happen anymore, that they don't have to come to blood donation centers or go to blood drives because we've got the answer.  It's artificial blood.
	Now, we all know in this room that that will help.  That's No. 1.  No. 2, it's not here yet, and No. 3, we don't really know what the therapeutic utility of those -- or downside -- of those products is going to be as yet.  For the public to have that perception is most unfortunate.
	DR. BOLTON:  Other questions? Well, I actually just want to make one comment.  For those that didn't understand what Dr. Jones was saying when he said that the Swiss and the Germans didn't want to ask the French question, that's because the French -- the deferral for residence in France for greater than five years is part of the Phase 1 deferral, and that had to be implemented in the Euro blood portion, even though Euro blood is Phase 2.  So, if they weren't willing to ask the question, then you couldn't use that blood essentially. So, that's what the French question was.
	DR. JONES:  That's right.  Sorry if I didn't make that clear.
	DR. BOLTON:  Thank you, Dr. Jones.
	DR. JONES:  Thanks.
	DR. BOLTON:  Our next speaker is Dr. Peter Page from the American Red Cross. Dr. Page?
	DR. PAGE:  Thank you very much.  I appreciate the opportunity to provide some information that the Red Cross has collected in this matter of concern.
	Next slide, please.  Dr. Scott has reviewed already the chronology of deferral criteria that the FDA guidance has done and also deferred to the Red Crosses.  Just by way of background, there was an initial vCJD deferral back in March of 2000, which we implemented; and then early in 2001 Red Cross gave great thought to the appropriate thing to do and picked some geographic donor deferral criteria based upon the concern and the uncertainty of the epidemic and the risk, saying at the time that these criteria could be changed as new data might become available in the future.
	Next slide.  That decision in the spring of 2001 was implemented in October of 2001.  It takes some time to write our procedures, our training material and to train our 7,000 collections staff scattered to 36 regions throughout the country in order to do it.  Then subsequent to that in early January the FDA issued the guidance that would take place in two phases -- June and November of this year.  So, the Red Cross implemented it earlier and not at the time that other blood centers implemented their changes.
	Next slide.  This is a little bit more detailed than Dr. Scott's slide just to show that there have been changes in deferral and that the FDA, the Red Cross, and the Department of Defense have had differences already, and the last two lines just point out that Canadian Blood Services in H‚ma-Qu‚bec, have different criteria as well, including some that are even more strict in Quebec than ours.
	Next slide, please.  I'll focus on the two major differences as I think Dr. Scott did -- presence in the U.K. for three months.  The American Red Cross started off with 1980 to the present, and that remains today our stance.  The FDA cut it off in '96.  The other major difference is for the rest of Europe, which is -- for everybody it's still from '80 to the present that we require only six months' presence whereas the FDA and most of the rest of the U.S. is five years.
	There are some minor differences I want to focus on here as to military bases and small neighboring countries, which for simplicity of operations and minimization of errors we chose to do a little bit of lumping.
	Next slide, please.  So, first the U.K. deferral.  I've already mentioned our criteria and the FDA criteria.  Based upon input from several consultants with experience with vCJD and BOC in Europe and elsewhere, and also upon the reassurance of this committee a meeting or two ago about the effectiveness of measures in the U.K., in 1996, Red Cross has decided to not discriminate against perfective donors for time spent in the U.K. since '96.  We will be consistent with the FDA guidance in that regard, and our implementation time, for that is targeted for November of this year once again because we have to reprint our forms, develop training material, and train all our staff.
	Next slide.  However, for the rest of Europe deferral criteria, where we have only six months' presence required for deferral rather than five years, the consultants advised us that due to the lack of food chain controls in the number of many other European countries, the fact that there is not active surveillance in many of the countries and the concern about the potential for suppressing of some reports, they now have information about what we don't know and the level of concern remains.
	So, the question we asked ourselves was would there be any risk to the Red Cross in changing these criteria to be less strict and all other risk is theoretical and minuscule.  The feeling was if asked the question, there might be an increase.  So, for the time being, we are not changing our deferral criteria for six months in the rest of Europe.
	Next slide.  Now I want to review our experience in donor deferrals, blood actually collected versus our plan or our goal, and then also I have data on our blood distribution, levels to hospitals, and our inventory levels.  I will update it based upon some questions with some overheads at the end.
	Next slide.  We implemented our most strict deferral criteria on October 15th, 2001.  This is a chart of daily deferral percents for all American Red Cross blood centers, all 36 of them, and it is deferrals specific to variant CJD.  You can see that from the deferral implemented a while ago, it is less than a 10th of a percent.  That was due to more than six months in the U.K. or receipt of bovine insulin, and on October 15th, it went up to about 1 percent per day when we went to only three months in the U.K. and six months for the rest of Europe.  So, it averaged about 1 percent after we implemented it.
	The next slide is the same except by week, which goes from prior to October 15th up into the end of March of this year, and you can see that there is culling.  In other words, donors get the message that they will be deferred and don't come and show up in the first place, or when they arrive at the blood mobile there may be a sign that educates them about the deferral criteria and they don't even sign up or register so they aren't counted.
	So, the deferral data I'm showing you do not count the people who know not to come in the first place or the people who show up but don't sign in.  So, the deferrals are an underestimate of the loss of productive donors to us.  The amount of that we are not able to quantitate.
	Next slide.  There has been mention already about differences in various parts of the country, and coastal cities may have a higher deferral rate in our 36 regions.  I do have the data -- I can show you for all if you want, but we had a range implemented immediately after October 15th, one that went from .2 percent to a high in one region of 1.45 percent.  That has now come down to .25 to 1.15 percent in March of this year with partial culling.
	As to the actual number of donors registered but deferred and lost per month, they are in the right-hand column. Beforehand they were 360; immediately after October 15th, there were 5600 per month. Red Cross collects about a half million every month, as you'll see shortly, and that has dropped down to about 3700 per month.
	Next slide.  This is the first two of four similar graphs.
	This goes back to January of the year 2000, and the top one is the deferral rate, all presenting allogeneic donors; autologous not included.  It is by month.
	Dr. Scott referred to, previously, an almost 5 percent increase in deferral that occurred in August 2000 when Red Cross went from doing the hemoglobin sampling for adequacy of blood and the donor from the ear stick sample to the finger stick sample, and that change resulted in losing almost 5 percent of donors.
	If you look where October 15th in 2001 would be, you see an up for one month, but in the scheme of things you don't see a major change upward in deferral remembering.  Again, this doesn't count the people who didn't come and didn't register.
	The bottom slide here shows in blue our budgeted collection goal for every month.  Primarily, it differs from month to month, dependent upon the length of the month and the number of weekends and holidays, that ongoing patient needs every weekday remain about the same year round.
	In red is our actual collections. You can see that we did pretty well.  The big bump, or the peak in the red, is September and October of 2001 after September 11th, and the drop thereafter in December and January -- below goal.
	While January is often a difficult month as is December because of the holidays, we believe that there was a lot of negativism in the American public about the outdating of blood donations and blood donations not used after September 11th, and there was a fair amount of media publicity of that, and that's what we attributed to January.  Since then, up through April we've done pretty well, and I will show more data on that.
	The next slide shows distribution. This is the number of red cell units we distributed by month to all the hospitals served in our 36 regions, and you can see that that varies a bit.  If you look at September of 01, it's down, probably because the number of hospitals were collecting their own blood.  And with the excess blood collected after September 11th, blood was readily available from a number of sources, and less was requested of Red Cross during that period.
	Since then, however, I think you can see that our distributions, which reflect transfusions, had gone up every month for awhile -- may be leveling off again, but part of the reason for the shortage, we believe, is an increase in transfusion usage by patient.  So, we have other data that is consistent with that.
	Now, if you look at the average daily inventory of red cells in our Red Cross blood centers, which does not include the blood in the hospitals, you can see that in the year 2000 we had as low as 50,000 on an average for the month during the summer, which is low, at a time when we were on appeal and doing a number of other things.
	The subsequent summer of '01, prior to September 11th, we spent a lot of money on paid advertising, which did help a little, but it was very expensive, and that summer was not as bad as previous summers had been.  You see the increase in inventory.  That went up to 300,000 after September 11, and you see that as that outdated and donations didn't pick up again afterward that the inventory has gone down.
	Up through May it remains at a higher rate than May in previous years. However, I will show you an overhead that shows you that it's tanked since then.
	Next slide.  This is the last in the PowerPoint presentation.  I think this data suggests that when anticipated and planned for, new donor deferral criteria can be accommodated by intense, expensive, and vigorous donor recruitment efforts, which I think we have all engaged in.  After the increase in deferrals ÄÄÄÄ, there is culling and the deferral rate drops.  We also have noticed that with implementation of new tests.  The people who are ineligible are deferred and don't come back.  So, the rate of those who come is lower.
	But the point to emphasize is that we need more regular volunteer blood donations, and we still need them to prevent seasonal shortages which we're facing now. I will just try to show two overheads which give more recent data in that regard, if I can figure out how to do this.
	The first overhead will be our inventory levels by week, which is updated, and then the other one will be our projected inventory.  In Red Cross we have blood mobiles scheduled out up to six months, and we renew or refine those schedules and project units that all the schools, colleges, companies, and factories that we collect at so we can project how much we expect in the upcoming period.
	This, however, is our inventory that goes back about a year, and it shows that after 9-11, the inventory shot up and then it drifted downwards.  Not shown in my PowerPoint presentation is that the inventory has now more recently -- and this goes up to June 24 of this year -- it has dropped down.  It's down to levels of the summer of '01 before.
	So, as I think Dr. Jones said, you have enough blood today.  But the concern is in the upcoming periods, particularly with the July 4th weekend.
	So, utilizing our current inventory, our projected hospital usage, and our scheduled and projected blood collections, we show that the inventory next week with the holiday on a Thursday -- which is a difficult time for us -- will decrease and continue downward.  The black line is what our inventory was this time last year, which was more stable due to the increased efforts that we had made then.
	We, too, have made efforts already but I think the entire country and all the blood collectors together are right now trying to initiate a national media appeal for more blood donations to prevent that shortage, which could be quite severe.
	Thank you.  That concludes my remarks.
	DR. BOLTON:  Questions from the committee?  Steve?
	DR. DeARMOND:  When we were looking at this issue a year ago, the projection from the American Red Cross was -- I think it was under 10 percent loss of blood supply -- I can't remember -- it was 8 to 10 percent or something like that -- and that the FDA recommendations were the order of 5 percent, which seemed to be a reasonable compromise.  But now from your projections, are you going past that 10 percent loss of blood supply?  Has in reality the deferrals created an even greater loss?
	DR. PAGE:  I don't think that the projected loss now and next week is so much due to deferrals as to people not coming in the first place due to donor apathy, being on vacation, or not coming to the blood mobile.  Projection of a deferral loss or a testing loss in advance of implementation has always been difficult.
	There have been postcard surveys, there have been general surveys, and my personal sense is that they have generally overestimated what the actual accountable deferral or test loss was.  In part, I think that's because word gets out and people who think they're going to be deferred don't come at all.
	The problem is people who think they may be deferred and don't come might really be eligible.  So, I think the loss of who doesn't come is the greatest effect, and our problem now is people not coming to donate, that we need eligible people to appreciate the need.
	DR. BOLTON:  I'm sorry you took down the overhead because I have a question about that.  On your second overhead -- that's okay, we'll do it from memory -- on your second overhead you're projecting into the future a significant drop in collections.  Yet, if you look at your previous year's collection rate throughout the summer, it was pretty constant and even slightly increasing.  So, what's the basis for which you have the projection for decreased rate of collection?
	DR. PAGE:  This slide that you refer to is not collections; it's inventory. So while it includes the effect of decrease in collections, it also includes defective increase in transfusions, which are referred to or mentioned.
	DR. BOLTON:  But the question still pertains.  Your previous year's experience would indicate that the trend goes in the other way.
	DR. PAGE:  In the previous year we spent a great effort in donor recruitment with national mailings in tens of millions and with tens of millions of dollars in paid advertising, which had a minimal hub full effect.  We are continuing to do a number of measures but not spending that much money now.  I think as Dr. Jones alluded to, the word "world" may be a different place now and there may be some post-9-11 apathy and concern about every drop of blood or every drop of red cells not being used.
	DR. BOLTON:  So, your analysis of your advertising experience last year was that it was really not cost effective.
	DR. PAGE:  It was minimally effective but not cost effective in the scheme of things.  Having government company university leaders espousing importance of donating and providing the opportunity for their staff or their students is more important and something that is challenging but we continue to pursue.
	DR. BOLTON:  Other questions?
	THE WITNESS:  Allen Williams, CBER Office of Blood.  Peter, thanks for compiling and presenting this data.  I think they're very useful in trying to understand the dynamics of something like this.
	One question:  In your handout you had some of the regional data, and if you look at the range for approximately the last quarter of '01, the difference between the low and the high in the range is about seven-fold.  Now, we anticipated a higher rate of deferral in the coastal areas because of travel.
	We understood there would be a fair amount of military-related deferral, but we didn't know quite what the dislocations might be related to the military deferrals, and we're getting anecdotes suggesting that the Carolinas and Georgia in some areas are being hit hard.  Could you comment within the Red Cross system your observations?
	DR. PAGE:  Yeah, I have that data but I didn't project it.  I have it on an overhead, but Alan is correct, it is very different amongst regions.  The highest deferral rates for us were in the Norfolk, Virginia area and in Alabama, where we have high military collections.
	We don't have that great a percentage of collections in others.  Each deep set of three bars is one region, and on the left in purple is the northeast.  The north central is in yellow.  South central is next in white or light gray, and the orange is out in the west.  So, I think you'll see a difference amongst regions.
	The smaller bar in the beginning is March of '01 before our October implementation.  The next one is March of '02, a year later, comparing month to month a year apart, unaffected by recent deferral changes, and the back one is the highest immediately after October 15th.
	To my surprise, our greater Washington, D.C., metropolitan area region, which is headquartered in Baltimore but includes Washington, D.C. and some of Virginia, was not amongst the highest.  I've learned that that was one of several regions that did more than others in pre-educating donors at the site, that they would be deferred if they had traveled in Europe for these periods in time.  So, they weren't registered or weren't even counted.  So, a major factor in interregional differences is, I think, the operation or management practice differences in those donor recruiters about pre-educating people.
	DR. BOLTON:  Other questions?  I have one.  I'm curious.  This is perhaps a glass-half-full versus glass-half-empty question, but there seems to be a lot of focus on deferrals, and it can be quite obvious and dramatic the increase in deferrals when you look at the before and after the implementation of the guidelines. But, in fact, the collections don't seem to be affected that much, and as I discussed previously, the inventory experience at least has not been dramatically affected. Are you using -- do you use the deferral as an early warning, or is this -- I mean, obviously you're sensitized to that, but a one-percent increase in deferral rate due to vCJD criteria can be easily overcome by a few percent increase in traffic in, is that not right?
	DR. PAGE:  With advanced planning, and I would quibble with your use of the word "easily."  Donor equipment is not easy.
	DR. BOLTON:  Yeah, I withdraw the word "easily."
	DR. PAGE:  Yeah.  With notice.  I think part of -- the summer is traditionally a difficult period.  We collect up to 20 percent of our donations from high school and college students, and we collect when we drive our truck there and offload and collect in the auditorium a large number of people at once.  We can't go there in the summer because they're not there.
	So, that's 20 percent that we have to try harder to get from somewhere else amongst busy people who are on vacation as well.  Deferrals are what we can count but blood collections are what really matter, and those are not meeting goal now, and our projections are that they will be not meeting goal in the upcoming months either.
	DR. JONES:  I'd like the opportunity just to reiterate the point that the on-site deferrals are just the bare tip of the iceberg of what the impact of deferrals is, and with the people who aren't showing up in the perceived notion that one would be deferred I think keeps more people away than we can measure, No. 1, but a much larger number than just what we see on-site. That's our experience.  That's Peter's experience.  I'm sure Celso will be the same.  Collections have been dropping of dramatically since June 1st.
	DR. PAGE:  Yeah, collections from those who implemented deferrals are dropping June 1 perhaps due to new deferrals but also because of the traditional summer problem. Red Cross had no change in deferral criteria June 1, but our collections are lower now than in May.
	DR. BOLTON:  I think that it's going to take some time to discern which of the many factors are responsible for those drops, and I just want to be careful that the committee and the public don't take away the impression that these are solely due to variant CJD deferral criteria.
	DR. PAGE:  However, there could be concern that if there is more BSE or variant CJD in other countries in the future if similar practices are engaged that accumulative ads could only hurt.
	MS. KENNEDY:  I have a question. Good morning, Moia Kennedy with ÄÄÄÄ.
	DR. BOLTON:  Did you identify yourself?
	MS. KENNEDY:  Yes, I did, Moia Kennedy.  I have a question.  This may sound a little ignorant, maybe my brain is still asleep.  But when you're talking European deferrals, are you referring totally to Americans visiting Europe or have European countries traditionally donated -- the people, the European citizens, traditionally donated to the United States?
	DR. PAGE:  The deferral criteria don't relate to citizenship or place of birth -- accumulative number of months spent in the U.K. or in other countries of Europe.
	MS. KENNEDY:  Okay, but I guess my question was:  In the past, have Europeans donated and that has been imported into the United States?
	DR. PAGE:  My understanding is that in Europe the number of volunteer whole blood donations per hundred thousand population is much higher than it is in the United States and that within the United States it's higher in rural areas than it is in urban.
	MS. KENNEDY:  But has European blood companies --
	DR. BOLTON:  I think we're going to move on.  This is not a question that's directly relevant to the committee in deliberations at this time.
	MS. KENNEDY:  Thank you.
	DR. BOLTON:  Would you like to make a statement?  Introduce yourself, please.
	DR. WARWICK:  I'm Ruth Warwick, National Blood Service --
	DR. BOLTON:  Turn the microphone up, please.  Please stand closer to the microphone.
	DR. WARWICK:  Ruth Warwick, National Blood Service, U.K.  I wonder if I can just comment on the discussion that I've heard, which is that what the U.S. is experiencing now may be the beginning of what will be something that will be much more of a crisis in due course.  If I may give a little bit of the experience in the U.K., where we are anticipating that we may defer donors who have previously been transfused, and obviously the impact of that in the U.K. will be much greater than it would be in the U.S.  Secondly, we are anticipating the impact that a test for variant CJD may have on the donor population.
	With the first aspect, the donor deferral for transfusion in the U.K., we anticipate that may be between 10 and 15 percent.  We haven't got surveys to show that, but that's what we are anticipating, and with the introduction of a test we anticipate the donor deferral may be as high as about 50 percent because donors may not wish to be tested or to know the results of tests in the current climate.
	I give that as a background because there had to be, obviously, a much more stringent approach to having adequate supplies for blood transfusion for those recipients that really need it.  We haven't just looked at increasing the donor supply, but we've looked at the other end of the chain, which is improving usage, and that was what I wanted to comment on, but I had to give the breakdown to understand where I was coming from.
	One of the things that we are having to considerably do is to educate users to make sure that blood is used appropriately, because there is considerable variation in practice, and there's a huge literature in the United States showing that there is poor appropriateness of transition therapies of all sorts, particularly ÄÄÄÄ huge variations.  Changes in practice promoted by the FDA to the users might make a very dramatic effect on the converging between the donor availability and the usage of that ÄÄÄÄ aspect.
	We are also having to encourage the use of autologous but not in redeposit but in increasing the use of self-salvage in those operations where that's feasible. That's particularly in cardiac surgery, orthopedic procedures, and many others that you will be able to think of.
	All of these can be improved further by very stringent audit to ensure that best practice is implemented.  I think that even in the United States perhaps a very more long-term view and strategic view is what needs to be taken on board, not just donor acquisition.
	The other aspect, of course, is that if we know there are risks associated with therapy by transfusion of all sorts, then they become the liability issues to be considered because inappropriate transfusion having a transmitted infection of any sort of course cannot be defended.
	Thank you.
	DR. BOLTON:  Thank you very much. I think that's an important warning, if you will, to the blood collectors and the users of blood, that we don't in fact know what the future holds.  Our primary aim in recommending the deferrals is to prevent an epidemic of variant CJD in this country. It's not necessarily to prevent a single case but to prevent epidemic spread.  But we don't know what the experience will be in the U.K., and we are sort of preemptively trying to reduce our risk to the minimum acceptable while maintaining an acceptable level of blood.
	Obviously, if the situation worsens we will need to look very carefully at being more efficient in the use or blood as well as in the collection of blood.  So, I think those words were very important to hear.
	Yes, Dr. Linden.
	DR. LINDEN:  I just wouldn't want to leave the impression that that's not already being done.  I know in New York we just sent out some guidelines about blood conservation.  The utilization review committees are very active.  This is already being done to try to maximize blood usage to be appropriate and not be excessive, so that's already being done.
	DR. BOLTON:  Excellent.
	DR. LINDEN:  But I agree it's an important issue.
	DR. BOLTON:  Dr. Bailar and then we'll move on.
	DR. BAILAR:  What's the delay here? If this committee recommends a change in policy on day X, how long would it take for that to show up and increase donations?  Are we talking about three months, six months, a year?
	DR. BOLTON:  Steve, would you like to comment?
	DR. NIGHTINGALE:  Eighteen minimum, absolute minimum -- 36 if it's accepted.
	DR. BOLTON:  Thirty-six.  You mean in terms of getting something into regulation.  Or are you talking about an impact on the blood supply?
	DR. NIGHTINGALE:  Door to door.
	DR. PAGE:  Hopefully --
	DR. BOLTON:  Steve, was it up 18 to 36 months we're talking about?
	DR. NIGHTINGALE:  Yes.
	DR. BOLTON:  I'm not sure -- maybe that's not addressing Dr. Bailar's question.
	DR. NIGHTINGALE:  I'm sorry, since time is an issue I tried to give you my best guess without all the embellishments.  As I believe this committee knows, I can go on at some length but I don't think they want me to do so right now.
	DR. BOLTON:  Jay, maybe you have a different point of view.
	The microphone, please.
	MR. EPSTEIN:  It's a simple and direct question, but it's not a simple answer because everything depends on what exactly is done.  You know, on September 11th, the agency issued urgent guidance within 12 hours.  On the other hand, it can take upward of six years to do regulations.  So, the question is what's the situation?  What's the remedy?  If we're talking about new federal dollars then, you know, we have to get a budget proposed that contains the item.  We have to get an appropriation.  Perhaps that means a new program infrastructure.  If you're simply talking about public service announcements, well, then the question is who are you trying to commit?
	If you're looking for certain public officials, you have to get the issue up onto their radar screen, you know, then you need a process.  So, I think -- you know, we could answer the question if we were talking about a specific measure, but to say what would a decision here or a statement here do directly, that's unclear. I mean, will the media cover today's proceeding; will it be a big splash, a little splash; exactly what is the message that gets communicated?
	I mean, there are just too many variables to answer the question.  We could answer it we were talking about concrete steps.
	DR. BAILAR:  What I'm hearing in general is that there's absolutely nothing this committee can do about this year's summer slump, probably not next year's either.
	DR. BOLTON:  No, I couldn't -- maybe that's a little too pessimistic but we'll see.
	At this point, we're going to move on though.  Thank you, Dr. Page.  Our next speaker is Dr. Celso Bianco from America's Blood Centers.
	DR. BIANCO:  Thank you.  It's important that I explain that America's Blood Centers is a national network of locally controlled not-for-profit community blood centers that provide nearly half of the U.S. blood supply from volunteer donors. Collectively we operate in 45 states and serve more than half of the nation's 6,000 hospitals.
	America's Blood Centers' total blood collections exceeded 7 million donations in 2001.  FDA has asked us to comment on the impact of implementation of the extended donor deferrals for vCJD on May 31st, and we conducted a survey of our 74 U.S. member centers in the past two weeks.
	Obviously, the period since implementation is short for a precise assessment.  However, we obtained enough information to indicate that the impact will not be trivial.  We excluded H‚ma-Qu‚bec, our Canadian member, from the survey, because these members' implementation dates and criteria vary from those recommended by FDA.  All 74 ABC members in the U.S. implemented the extended vCJD deferrals of May 31st with no exceptions.
	Could I have the next slide. Thirty-one of or 42 percent of the centers, implemented only Phase 1 of the deferrals. However, 43 -- that is the two that you see -- that implemented in April -- plus the 41 here -- implemented both Phase 1 and Phase 2.  There is the Pan-European deferrals at the same time.
	The major reason for this approach was to avoid two rounds of modification of standard operating procedures, retraining staff, reprinting donor information sheets and registration forms.  In general, this approach was adopted by centers that believed that the additional impact of the Pan-European deferrals would be relatively small.
	The next slide, please.  This next figure shows the aggregate number of units collected by ABC member centers.  They are under Phase 1, and that's essentially a hundred percent or about 7.2 million units a year are under Phase 1 but, as you see, about 4.2 million of the 7.2 million are also using the criteria for Phase 2.
	The average percent of donors deferred for travel related to vCJD increased -- the next slide please -- oh, it's here -- from about .1 percent, that was the average in 2001, to 1.4 percent in June 2002.  The range of deferrals in 2002 vary from .3 to 4.6 percent.
	I should emphasize that these deferrals occurred at pre-donation medical history.  Unfortunately, we are unable to capture the data that would allow us to measure the number of potential donors who learned about the deferrals through the media or information provided by the blood centers and did not show up to donate.
	However, we have many anecdotal reports from our members, leading us to believe that this is not an insignificant number of donors and may be equal to or larger than the numbers of donors that are deferred at the donor sites.  Our largest member center, Blood Systems, performed an anonymous survey of donors in an attempt to estimate the donor loss related to the vCJD travel deferral.
	This work is being presented at the upcoming meeting of the American Association of Blood Banks, and the authors are Doctors Murphy, Connor, McEvoy, Hirschler, Busch, and others.  They have allowed me to present their major findings.  They distributed 10,000 anonymous questionnaires to donors earlier in 2002.
	Two thousand surveys were allotted to each of five geographic groupings of blood centers.  They received 84 percent responses, or 8,400 responses.  Overall, 3 percent of the donors responding to the survey met Phase 1 or Phase 2 vCJD criteria for deferral.  However, there were marked differences in predicted deferral rates between northern California, in which they reached 7.7 percent, and other geographic areas combined of 1.8 percent.
	Northern California deferrals were for U.K. travel and European residence or service at a military base, and the other geographical areas deferral was almost exclusively for service at a European military base.  This survey documented our major surprise with the travel deferrals.
	In the past we focused our concerns on the impact on donors in large U.S. cities on both coasts.  We now realize that military deferrals constitute a major component of the deferrals.  This should not have been a surprise because traditionally military personnel and their families have been dedicated contributors to the civilian blood supply.
	Some ABC centers are seeing substantial deferrals of high school and college students because they were military dependents and were born or lived in Europe for extended period of time.  Other blood centers have told us that they have seen significant attrition of donors at corporate blood drives with multi-national companies whose employees and families routinely are posted in Europe for extended periods of time.
	I'd like to go to the next slide and talk now a little bit about the status of blood supply among ABC member centers.
	The implementation of new deferrals came at a time when almost one-third of the ABC blood supply has been at critically low levels, as shown by the results of what we call our Stop Light Program.  In the Stop Light Program, ABC member centers report their red cell inventories daily via an internet program; an ABC posts its daily summary report on its web site.  It's not nice looking, but it's informative.  The web site is www.americasblood.org, and it's public.
	This figure summarizes the current data, and what we have seen agrees entirely with the picture that has been shown by both Dr. Page for American Red Cross and Dr. Jones for New York Blood Center.  That is, we classify -- or, the centers classify their inventories as green when they have three days or more of their average distribution in inventory and are comfortable with that; the yellow is two days of inventory; and red is one day or less of inventory.  So, as you see, in the weeks of June close to 30 percent of our centers had one day or less of inventory.
	So that there is no confusion with the nice but complex graphs that Dr. Nightingale showed to us, what most blood centers tend to do is to shift their inventories to the hospital to have the inventories available at the hospital level, so the complete picture is more difficult today.  But the way the inventories get supplied is by requests to blood centers.
	So blood centers with one day or less of inventory have fulfilled the hospitals.  The hospitals may be doing okay, but that's where the situation at the blood center is more complex.
	The next slide, please.  It's clear -- and this is the percent of the ABC blood supply at the code red, one day supply or less, as of June 19th.  It is clear that the current supply is less than optimal and that the trend is for a continuous decline.
	This past Tuesday, all donations, blood banking, and public health leaders have joined together to issue a call for eligible Americans to give blood this summer.  I'd like to extend this appeal to the members of the committee, and please donate blood.  The appeal comes in face of increasingly significant blood shortages. Last in a one-day supply in certain parts of the country.  The appeal was issued by the American Association of Blood Banks, America's Blood Centers, American Red Cross, the American Hospital Association, and the American Public Health Association.
	Now, I'd like to make a request to the committee.  We all share a common purpose -- the availability of a safe blood supply.  Concerns about the possible transmission of vCJD by transfusion have led us to implement strict donor deferral policies.  They are having an impact, a serious impact on the blood supply.
	They are not the only cause for these shortages, but I believe they are an important element of the shortages.  While we recognize that the data about the potential for transmission of TSEs in animal models continue to develop, we still lack evidence of such transmission among patients that receive transfusions in the U.K. -- and I would like to hear more from our U.K. colleague -- or even more elsewhere and patients that have received multiple transfusions and ÄÄÄÄ with concentrates for many, many years since the beginning of the BSE epidemic traced back to 1980.
	The number of cases of vCJD has increased slowly.  However we continue to add and maintain measures waiting for definite proof to determine whether TSEs are or are not transmitted by transfusion.  We respectfully request that FDA and this committee discuss mechanisms and criteria for review of those decisions.
	Our questions are how do we balance the theoretical risk of transmission with the real risk of blood shortages.  Or, more specifically, what would be the criteria or the requirements, or what would be needed for a decision to lift some or all of the vCJD- related travel deferrals.  We certainly are ready to participate of such effort and provide you with as much data and information we can gather.
	Thank you very much for the opportunity to comment.
	DR. BOLTON:  Thank you, Dr. Bianco. Questions?  Comments?
	I have one.  It's curious to me that the south was a -- 48 percent of the southern centers were at one day, yet that didn't seem to correlate with your vCJD deferral.
	DR. BIANCO:  Actually, Dr. Bolton, you hit the nail on the head.  That was a surprise.  Those are the centers where the military collections, where the military deferrals affected.  I realize only now that, for instance, one of our members is the large center in San Antonio, Texas. About 30 percent of their collections come from military bases, and that's true from several other regions.  I believe that you saw that in the Carolinas, Peter, and in other areas.
	DR. BOLTON:  Did that also show up in the 8,000 surveys that came back from that region for example?
	DR. BIANCO:  From that region?  The blood system is an interesting system that is more mid-west and West Coast.  They cover -- they have 23 centers, is our largest members.  But they do not have centers in the south.
	DR. BOLTON:  So, that survey was really a very remarkably good response, and even with what appeared to be very good data, you still could not tease out this effect in advance of the actual implementation.
	DR. BIANCO:  Well, it really emphasized the importance that the military have had as part of our donor base.  We never -- we always called them volunteer blood donors.  But now we are seeing the impact more clearly, and I hope Ron is going to help us more with that.
	DR. BOLTON:  Oh, Jay?  Microphone, please.  It's still not on.  Why don't you use one of these?  Use the table mike.
	MR. EPSTEIN:  Again, I don't have the data in front of me but my recollection is that we did predict approximately a 2 percent national loss due to the DoD-related deferral.  What was not predicted was the fine geographic distribution, because the survey wasn't capable of that.
	I think the surprise has been the extent to which the military-related donors contribute at certain centers.  But it's not that we were particularly off in our estimate of magnitude.
	DR. BOLTON:  Right.  I know that as the committee deliberated on this, we were well aware that the military personnel on active duty, as well as retirees, are regular and willing blood donors as part of the military culture.  And I certainly, for one, expected that they would have a significant impact in this way.
	The good side of that is that we can look to that as a model for the change in culture that we need to establish to begin to increase the percentage of all citizens that donate, because I think within the military there is a recognition that blood is important.  It's sort of a part of your duty to be a donor, and we just need to spread that throughout the rest of the population.
	DR. BIANCO:  I think that I tried to say that.  It was a surprise, but it shouldn't have been a surprise.
	DR. BOLTON:  You did say that. Dr. Piccardo?
	DR. PICCARDO:  Well, I think that we knew that the military contributes substantially.  But the point is that they did not respond or the percent of response to the survey was very low.  So, maybe the numbers aren't there, but we knew that they contributed substantially.
	DR. BOLTON:  Well, I think what Dr. Bianco said is that the survey didn't reflect that southern region, so even if they had responded in the mid-west and what have you, it didn't really reflect that some of the southern centers would be hit in that way, and I guess Jay was saying the same thing, that the regional distribution or the spottiness of the effect wasn't teased out.
	DR. PAGE:  Page, American Red Cross.  I just have to correct a statement that Dr. Bianco made about the American Red Cross.  The Carolinas region had a deferral percent related to CJD in March of '02 of .4 percent, which is less than our system average of 0.6 percent.  So, they were not amongst the highest.
	DR. BOLTON:  Yes, Dr. Gambetti.
	DR. GAMBETTI:  I assume that all of these data are based on the FDA recommendation for deferral rather than the Red Cross criteria.
	DR. BIANCO:  That is correct.  Our centers have adopted the exact recommendations of FDA for Phase 1 and Phase 2.  The only thing that I should note again is that about 60 percent of the centers decided to implement both Phase 1 and Phase 2 at the same time.  But they are the exact FDA criteria.
	DR. GAMBETTI:  So, there is no room for correction.
	DR. BIANCO:  No, there is room for collection, not correction.
	DR. BOLTON:  Dr. Williams.
	DR. WILLIAMS:  Thank you.  A very brief comment for the record on how the deferrals related to military went into the calculation.  We were not totally dependent on the survey for those numbers.
	We, in fact, got figures from DoD on the estimated proportion of military and ex-military residents in the states, did ÄÄÄÄ calculations on the likelihood of donations by that cohort.  In fact, ÄÄÄÄ has 2 percent.  In fact, in one site we did try to specifically survey the military population to see the proportion that it spent, the appropriate times in Europe and the U.K. that would result in deferral, and we got a less-than-10 percent response rate.
	So while they like to donate blood, they don't like to do surveys, so that was a difficult measure.  But I think the overall impact nationwide was probably on because of the way the data were obtained.
	DR. BOLTON:  Very good.  Okay, I think we'll move on now.  Our next speaker is in fact Maj. Ronnie Alford from the United States Air Force.  Maj. Alford.
	MAJ. ALFORD:  Good morning.  Can I have the next slide, please?
	We in the Department of Defense implemented the additional vCJD deferrals in October of last year.  We implemented the deferrals as recommended by the FDA with one notable exception, and that is we combined the north of the Alps and the south of the Alps recommendations and applied the more restrictive south of the Alps recommendations for all of Europe.
	One note of interest here is that from our assignment histories, we knew that we could expect 18 percent of those forces currently on active duty to be deferred based on the new deferrals.  That on top of the historical 25 percent deferral rate that we experienced prior to vCJD deferrals, our No. 1 deferral was for piercings and tattoos.  Of notable interest here, we do not include time aboard ship for naval forces that were on Mediterranean cruises. Only time ashore is accounted.
	Slide, please.  I put this slide in just to give the committee members an appreciation for where our donor centers are located.  We only operate 18 donor centers in the continental U.S., and you can see where they're concentrated with the huge void there.
	Slide, please.  In addition to our CONUS operations, we also operate six donor centers outside of the continental U.S., and you can see the locations.  So, total of 24 donor centers worldwide.
	Slide.  Our donor population.  Our donor centers within DoD.  We do not go outside of the gates of our installations, if you will, to collect blood.  So, we're totally dependent upon our active duty population and family members and civilian employees on base.  The lion's share of our collections comes out of that 1.38 million active duty personnel.  Ninety-two percent, in fact, of our donations come from those people.
	We only get 2 percent of our donations from family members.  Even though that family member number is fairly large, two-thirds of those are children.
	Our total donor operations within DoD are very small in comparison to the other speakers this morning.  We only recruit about 130,000 donors a year, and we only recruit off of about one-tenth of major DoD installations worldwide.  We only recruit from 32 DoD installations worldwide.
	So, we're getting about 9 percent penetration into our active duty forces. They're actually getting out to donate. Major interest here is that the distribution of that 18 percent is not even.  We have seen deferrals as high as 50 percent in some of our forces -- heavy armor units at Fort Hood, Texas, for instance, because of huge rotations to Bosnia over the past several years and also huge rotations to Germany.
	Slide, please.  It's very difficult to accurately determine the impact of the deferrals that we implemented.  This may be news -- it certainly is big news within DoD and certainly I think it goes along with the normal course of business for our civilian counterparts.  We have not traditionally had access to donor recruiters.
	We were successful in gaining funding and placing recruiters out into all of our donor centers this past year in October alone.  So, as we implemented the deferrals, we gave the donor centers recruiters and we have had a tremendous -- they've given us a tremendous boost in our collections.
	Again, we've seen self-deferrals at command briefings, and that's -- command briefings are when we actually get a battalion or a company, a large group of soldiers, sailors, airmen, marines, together and we would generally get a small five- or ten-minute time frame to brief those people. We've seen deferrals as high as 50 percent among those units.  Again -- and we've also some additional educational things from the DoD level going down.
	Although operation Enduring Freedom is not front-page news in The Washington Post every day, it's certainly front-page news at places like Fort Bragg because those are the places where those troops are coming from, the family members there, the soldiers remaining behind.
	That's very much on the forefront of their minds, so we've seen recruitment being eased because of forces being pushed forward into a theater of operations.  We have pushed about 15,000 units into southwest Asia and European evacuation routes as well.
	Another complicating issue is that because our donor centers are typically staffed with the laboratory technicians from the hospitals, a lot of those lab techs were forward deployed, so our donor centers lost staffing.  We did have reserves -- some reserve forces come in, but of course you lose productivity with bringing them up to speed and training and you lose one of your valuable trained staff to do the training. But we have seen a major bounce-back.
	Then probably the most important thing that we've done is expanded our collections at our basic training commands.
	Slide, please.  In a comparison of the year prior to implementation of the new vCJD deferrals to the six months afterward, we've actually increased our whole blood donations by 9 percent.  We are averaging 12 percent deferrals for vCJD, and that's, again, across DoD, again, with the greatest impact being with units with heavy European rotations.  We're seeing less than 1 percent in some of our basic training units.  That's actually basic training throughout all of the services.
	So, our total deferrals for fiscal year '01 was 25 percent.  Now we're down to 16 percent total.  That is for everything, including piercings and tattoos. So, we have actually -- we've made great strides here.
	Next slide, please.  Then just a graphical representation of our collections. Again, you can see the 9 percent increase.
	Slide, please.  So, in summary, although we did implement the additional deferrals in October, we took corrective steps to alleviate the increased deferrals by adding the recruiters and shifting collections to trainees.  Again, we went to war, which I think definitely made recruiting easier, although we really did not see a way of quantifying that.
	We've increased our eligible donations and the actual whole blood donations by 9 percent.  The range of deferrals, again, as low as 1 percent, as high as 50 percent.  Tremendous swings even though we do not see a clear geographical distribution, if you will, for those deferrals.  It's really more toward the mission of the units, and we pretty much have a good feel for the types of units that have heavy European rotations.
	Again, we have decreased our total deferrals by 40 percent.  That's clearly as a result of actually having donor recruiters and having effective donor education programs to let the people know -- the potential donors know -- if they are eligible to donate.  So, in regard to CJD deferrals, put a checkmark there.  We have certainly met that challenge and in fact increased our donations.
	Any questions?
	DR. BOLTON:  Thank you, Maj. Alford.  Questions.
	I guess I have one.  I'm the only one who has lots of questions today.  I've completely forgotten about the piercings and tattoos, so, I mean, this is a little off of our subject but can you inform me is that a lifelong ban or is it a year period of time from the time that the piercing or tattooing is done?
	MAJ. ALFORD:  It's a year.
	DR. BOLTON:  It's a year, okay.
	MAJ. ALFORD:  One of the things that we've noticed is that now that we're focusing on trainees, I guess it's the culture of the military I guess that many young men and women feel that you graduate from basic, "Let's go get a tattoo."  So, we're collecting them before we let them go get the tattoos.
	DR. BOLTON:  It's a very good strategy.  I was just going to ask -- not getting the tattoos so that they don't have to give blood, though, is that the --
	MAJ. ALFORD:  No.
	DR. BOLTON:  Other questions or comments for Maj. Alford?
	Very good.  Thank you very much. It's nice to see something that can be done in a positive way to deal with the situation.
	Our next speaker is Kay Gregory, Director of Regulatory Affairs, the American Association of Blood Banks.  Kay?
	MS. GREGORY:  I think the mike's on now.  I want to begin by explaining who the American Association of Blood Banks is. We're a professional society, so we don't actually collect blood or transfuse blood but our members all do, and we represent 8,000 individuals involved in blood banking and transfusion medicine both, and approximately 2,000 institutional members, and these include blood collection centers, hospital-based blood banks, and transfusion services as they collect, process, distribute, and transfuse blood and blood components and hemapoietic stem cells.
	Our members are responsible for virtually all of the blood collected and over 80 percent of the blood transfused in this country.  For over 50 years the AABB's highest priority has been to maintain and enhance the safety and the availability of the nation's blood supply.
	The AABB believes that lack of appropriate data is a major barrier to determining the state of the blood supply in the United States.  Although public health experts and the transfusion medicine community recognize the need for such data and committees such as this one routinely ask for this information, no agency is willing to fund a comprehensive ongoing collection and analysis of data about the blood supply.
	Because there is no systematic, scientifically valid routine collection of data concerning supply and usage, there's no established baseline and thus it's impossible to measure the effect of policy changes, such as the new vCJD deferral.  Any attempt to quantify the effect of the new vCJD deferral will be difficult if not impossible.
	At this point in time, it certainly is not possible to gauge the effect of a policy that was required to be implemented only on May 31st, 2002.  Any decrease in donations is compounded by the well-known summer slump in donations.  Moreover, the same difficulties in measuring the effect of new donor policies that were discussed at previous meetings of this committee with regard to the in initial round of vCJD deferrals are also applicable here, and you've heard some of these.
	It may be possible to measure how many donors appear at the blood center and are deferred because of vCJD criteria. However, we cannot measure how many donors self-defer because of advanced publicity, including significant efforts on the part of many blood centers to notify donors about this change.
	The committee should also keep in mind that the number of deferred donors does not equate to the number of blood components that are lost.  Apheresis donors can donate more often than whole blood donors, and deferral of such donors increases the number of blood components that cannot be collected.
	That said, AABB appreciates this committee's interest in the state of the blood supply.  The National Blood Data Resource Center, an independent subsidiary of the AABB, continues to collect data that may be of interest.  NBDRC captures data on a monthly basis from 25 blood centers in the United States.  This geographically and statistically representative sample accounts for 32 percent of allogeneic, whole blood, and red blood cells collected by U.S. blood centers annually.
	This slide illustrates the allogeneic collections for the most recent six-month period from December of 2001 through May of 2002.  Although not apparent from the graph, December monthly collections were the lowest reported for the entire year of 2001 -- only 319,000 units.  Thus far in 2002, monthly collections have averaged about 342,000, and that's not significantly different from the average for the same period in 2001, which was 338,000.  The 3.1 percent decline in collections experienced in May, however, is statistically significant when you compare April and May.
	We also collect inventory data twice monthly, and until recently we had not seen any significant fluctuations in 2002. However, between the third Wednesday in May and the first Wednesday in June, the sample experienced a 5.6 percent decline in whole blood, red blood cell inventories.  That is statistically significant.
	The NBDRC's monthly analysis of collection data provides an important first element of determining the true state of the nation's blood supply.  However, as we have stated to various government agencies and advisory committees, additional data on blood usage are also needed if we are to understand long-term trends and forces affecting the nation's blood supply.  The AABB strongly urges the Department of Health and Human Services to support this essential data collection and analysis.
	Thank you.
	DR. BOLTON:  Thank you, Kay. Questions?  Steve?
	DR. NIGHTINGALE:  Thank you.  I would like to make a follow-up comment on what Ms. Gregory said -- and if you'll show the -- it's slide No. 2 I want showed, if I could, please -- because I think we are on our way to getting to the point that Ms. Gregory and the AABB would like us to get to, and that is on a line that I neglected here.
	I want you to look at this line here, at the bottom.  This is the total usage of blood at the hospitals that are served by the three community-wide blood centers in Seattle, Pittsburgh, and Tampa-St. Pete.  It is not representative of the United States but it is representative of a lot of hospitals.  What I want to show you is that there is a lot of regularity in here where you see the two dips here. That's a Thanksgiving dip; that's a Christmas dip.
	I can't tell you how many of these blood units went for obstetric care, how many went for cancer chemotherapy, how many went for trauma.  But I can tell you over almost a year period this has been quite stable.  I personally think it's up in the air, and it's going to be discussed when we review our program in September just how much more detail we need to get into, but we may be a little closer to it with efforts like this than the people appreciate.
	That leads me to the second of the two points.  This stability -- this constancy of blood use -- this demand for blood has persisted over a time when the price of blood has gone up very, very substantially, and I think the committee should have an immediate appreciation for the fact that at least with the current supply and demand, the demand for blood at current prices is very, very inelastic.
	Blood is somewhere between $115-$200 a bag right now, substantially more than what it was before and probably not at its peak.  The question is how much more are hospitals willing to pay for blood and how much more are hospitals willing to pay for additional resources necessary to bring blood to the market.
	A question before you is -- before us is:  Whether or not the federal government should embark in a $10 million campaign to promote blood donation.  I will speak as an individual here just for this sentence, is that the 10 million that has been proposed seems to me to be a low ball estimate of the cost that it's really going to pay.  Ten million is less than one dollar per additional bag of blood, and I think it's going to take more than that, and when you make your recommendation, a little bit of economics should go into it.
	DR. BOLTON:  Steve, while you're up there, let me ask you this question.  What would it take -- not thinking in terms of dollars but in terms of organization -- to get all of the major blood collection organizations and centers and possibly the hospitals across the country to participate in a data collection system as you have established?
	DR. NIGHTINGALE:  I think that at this point if we wanted to -- I want to use this word carefully -- bang on the door real loudly as opposed to kick the door down, I'm sure that ABC and ARC would cooperate.  The information is available through back channels.
	We talk on the phone all the time. I think we have to respect the fact that the responsibility for blood collection in this country is in a private sector and not in the government, and we would be much more aggressive if that were not the case.
	We do not operate a Canadian system, and we try to get feedback from Red Cross and the ABC but how hard can we lean on you on this.  Sure, I'd love to have the daily numbers from the Red Cross and the ABC for my particular project.  The figures would look better.
	But the reason for this project is not to get a better paid ÄÄÄÄ transfusion. The reason for this project is to try to support the private sector -- do a very difficult job better.  That's why we tap on the door gently.
	DR. BOLTON:  Right, and my question comes from the assumption that the organizations that are actually doing this job in the private sector, and in the military as well, would benefit from having that global -- national picture to analyze and to really understand, for example, the effects of not only policy decisions that we might recommend, but other events that may occur.
	DR. NIGHTINGALE:  There are some realities in the business that we have here that are different, say, from Britain.  We have a competitive environment, and an ongoing philosophic, political, even economic question is how much of that is good and how do we keep it from, you know, competition for the same high school students, for example.  That's an area where I think a knee-jerk government response could very well be counterproductive.
	DR. BOLTON:  Right.  Well, I know there's a balance between how much that information would be useful and how much it would be scary in a sense to competitors sharing their information.  But I would certainly ask the various blood collection organizations to think about this and see if there isn't some way that -- I don't know if we can preserve the proprietary nature of some of the data and yet still make it useful not only for us but for them as well.
	Yes.
	MS. GREGORY:  If I could just add something.  The difficulty is not necessarily getting the data from the blood collection centers.  The difficulty is getting the data on the other end of it, and that is:  The transfusion data is much more difficult to get than the collection data.
	There currently -- as far as I know, Steve is the only one collecting any kind of data, and as he -- we don't know whether blood's being used for cancer patients -- exactly what it's being used for.  We would like to be able to have that information, but right now there is nowhere to get that from.
	DR. BOLTON:  Well, let Steve respond and then Dr. Bailar.
	DR. NIGHTINGALE:  Just last -- last -- I mean, one of the reasons, obviously, that we might like to have that information is to identify how much waste there is in the system.  I presented one piece of data:  In our system there is essentially not waste at all in the centers.
	We cover about 8 percent of the blood supply.  We see 10 units of blood outdated a day in 8 percent of the blood supply and, anecdotally, that's all AB positive that you can't get rid of.  That situation is different in Britain for several reasons.
	One possibility is the economic pressures are different.  Blood's expensive here, and we don't outdate it.
	The second question is how much education till we recommend to change physician practices.  I don't think it should be taken as received wisdom, but there is massive wastage of blood in the system right now.
	Harvey Klein, Director of the NIH Blood Center, and for that, my first resident when I was an intern -- said something that I feel is very wise and needs to be repeated here, which was HIV scared a lot of the slack out of the blood system right now, and the thing that I would follow up from Harvey is that the price of blood where it is right now -- if this hasn't scared the slack out of it, when blood hits 250, that's going to scare the slack out of it.
	DR. BOLTON:  Dr. Bailar?
	DR. BAILAR:  I'm pretty convinced. As a committee member, I'd like to make a strictly informal request to FDA to work with the private agencies in considering whether FDA should actively promote a substantially expanded and improved data collection effort, related to blood supply and usage and, if so, to return to this committee with any specific questions or proposals where we might help.
	DR. BOLTON:  Okay, Dr. Wolfe?
	DR. WOLFE:  When Dr. Scott made her presentation this morning, she pointed out -- and this is, for starters, just a question -- that back when this committee made the recommendations for deferral, there was also some recommendation for a national recruitment campaign.  Neither Dr. Bailar, who has raised this issue, nor I were there then.
	Was there specifically a proposal to try and do something about the so-called summer slump?  I mean, I'm all in favor of more data collection, too, but the data is unequivocal that year after year there's a summer slump, and it happens this year to coincide with the initiation of the deferral program so it makes it look worse.
	I would have liked to have seen seasonally adjusted data for some of the presentations that were made, but was there specifically a recommendation to try and do something about the summer slump? Dr. Linden has pointed out that New York creatively initiated this motor vehicle registration reminder at the beginning of the summer, and it seems like to focus more on campaigns at the time when there is a predictable slump would at least take some of the edge off.  Was there that recommendation, and what has been done by all the agencies that are involved?
	DR. BOLTON:  You're testing my memory, but my recollection is that there was not a request to specifically address the summer slump, but there was a request to move to improve recruitment by a national education campaign, and there was also a suggestion that this data collection system be instituted -- some means of trying to track the blood collections and usage.
	DR. WOLFE:  I would then add to Dr. Bailar's suggestion in addition to getting more data that we should use existing data and here and now request that all of these agencies that are involved come back with a very specific plan for dealing with the summer slump.  If, as suggested earlier, it will take yea number of months -- 12, 18 -- before that's implemented, we've lost already a year or whatever since the committee made a general recommendation but apparently did not focus on doing something about the summer slump. It seems like that would make it much more tolerable to implement this policy.
	DR. BOLTON:  Let's get Jay's input. Jay?
	MR. EPSTEIN:  Well, first, it's correct that there have not previously been proposals specifically directed to the summer slump.  However, the concept of the government getting more involved with efforts to both monitor and increase the blood supply do date back several years.
	When we first discussed the potentially large impact of precautionary policies directed toward variant CJD, it was recognized, particularly by Dr. David Satcher, then the Assistant Secretary and Surgeon General, that we would need to accompany any such policy by a program to monitor and increase the blood supply.  The department did adopt in November '99 an element of what we called our blood action plan, which is a plan that dated back to March '98, an element specifically to address monitoring and increasing the blood supply.  We did build on previous efforts.
	There was a period -- I think it was three years -- during which the NHLBI funded the NBDRC; you heard their report from Kay Gregory -- to produce monthly data. Up until that point in time, there were no periodic reports.  There were only surveys that were done basically as retrospectives covering approximately every other -- I'm sorry, once every two years there were these reports that were looking back several years.  And instead, effective roughly, the fall of '99 we had monthly data with a one-month lag.
	It was then recognized that those data were based on the collectors and didn't give us the other side of the equation which was used, and after much dialog and debate over responsibility in funding and so forth, the department took on the challenge of creating daily monitoring of hospital inventories coupled with shortage reporting. That's the system that Dr. Nightingale has been presenting.
	Now, you know, are we where we want to be in terms of data collection and analysis?  Well, I think the discussion today, and discussions that have gone on, you know, within the government and the blood industry, do suggest that much further progress could be made.  But we are where are because of the deliberate effort to do the very thing that you're talking about recommending.
	Now, there has also been a lot of talk about the relative role of the government versus the private sector in initiatives.  It's not a trivial issue. There have been efforts to engage government officials in public service announcements coordinated with urgent blood drives.  Some of that has been done.  I mean, there actually were videotapes of public officials and there have been efforts to coordinate the voice of the blood industry so that there are unified rather than competitive donor campaigns.
	We have also taken on the scientific challenge of trying to remove unnecessary barriers to donation by re-examining the deferral criteria, as well as the use of tests.  We've done that largely with the Blood Products Advisory Committee because many of those issues are not TSE related.  So, for example, we've reviewed the deferrals for body piercing, tattoos, and acupuncture.  We've reviewed the exclusions for males who have had sex with males.  We've reviewed whether we should continue testing for syphilis and so forth.  So we have been moving on all these fronts, but I certainly share the sentiment of the committee that more is needed in the current situation, that we're not yet on top of the problem, and I'm certainly appreciative of the remark that we need to focus in particular on this periodic summer slump.  Let me just say that December is no picnic either.
	DR. BOLTON:  Other questions or comments?  Very good.
	Well, that concludes our presentations on the blood supply of the revised guidance, and at this time I think we'll move to the open public hearing.
	Bill, do you want to --
	OPEN PUBLIC HEARING
	DR. FREAS:  Yes, Mr. Chairman.  We have not gotten any requests to speak at this morning's open public hearing.  Is there anyone in the audience who is not on the agenda who would like to address the committee on topics on the committee's agenda?  If not, this will be a very short open public hearing.
	I turn the microphone over to you.
	DR. BOLTON:  Okay, well, we're running about even with that short public hearing.  We are still running about 20 minutes behind time.  I would like to ask the committee members, sort of informally, would you like to take a 10-minute break and come back?  Okay, that will put us a half hour behind but I think we'll still be able to conclude, so let's meet back here at 11 o'clock.
	(Recess)
	DR. BOLTON:  Would the members of the committee please take their seats and we'll resume our meeting -- as well the members of the public?  I was obviously too lenient.  I gave you a 15-minute break instead of a 10-minute break.
	Okay, the final part of our meeting we'll have two presentations, also updates on some experiments with variant CJD and filtration.  So, the first presentation is by Dr. Larisa Cervenakova, and she will be speaking on studies of the variant CJD infectivity in blood of experimental mice.
	Dr. Cervenakova?
	STUDIES OF vCJD INFECTIVITY IN BLOOD OF
	EXPERIMENTAL MICE
	DR. CERVENAKOVA:  Good morning.  I would present studies in variant CJD infectivity in blood of experimental mice.
	Slide, please.  What I'm going to do -- I would like to compare our data, which are still in progress.  We didn't finish experiment yet, but we have a sufficient amount of data to give you the idea what's going on with use of blood infected mice with variant CJD, and I would do comparison to our previous experiments, which were done in also mouse model, using Fukuoka strain.
	At the end I will briefly show you one slide when I will compare these data with experimental data collected in hamsters infected with 263K strain, derived from scrapie in sheep.
	Next, please.  This is just to show you how the experiment was set up.  The brain tissue from the variant CJD 10 percent brain homogenate was inoculated in R3FADK (phonetic) mice by ICNAP route of inoculation, at the Institute for Animal Health in Edinboro.  We get brain tissue material from a mouse which developed the disease at 336 days after inoculation from ÄÄÄÄ and as well we got from the strain of mice susceptible to variant CJD, and we actually breed these mice in-house and inoculated them with 1 percent mouse brain homogenate, inoculated intracerebrally in group of mice.
	In one group of mice, we euthanized at 17 weeks after inoculation, in order to see if we can produce the disease clinically, and later on we saw, after 157 days, first thing was started to develop the disease.  At this point we euthanized the rest of the animals, and we collected from both groups of animals blood, pulled it together, separated it into components and inoculated the components.  We also collected brain tissue and spleens for later detection of the presence of abnormal prion protein in brain and spleen.
	Next, please.  These data compare actually the incubation period in mice infected with BSE and variant CJD and secondary transmission from the same strain of mice, and you can see the shortening of incubation period was shrunk for both strains -- for BSE and variant CJD.
	Next, please.  Because we wanted to compare our data to Fukuoka strain, it was important for us also to see if Fukuoka strain would take in R3 mice and what will be the incubation period for R3 mice and for Swiss mice, in which experiments with Fukuoka strain were done.  And you can see the incubation period for Fukuoka strain shown in yellow and for variant CJD is shown in blue and actually the incubation period for Fukuoka strain in both strains of mice is shorter than for variant CJD.
	Next, please.  This is by chemical ÄÄÄÄ, if you wish, or from PrP 27-30 in both strains of mice for Fukuoka strain and variant CJD, and you can see that there are differences in the profile, and the profile stays the same in both strains of mice.
	Next, please.  This is data on the presence of abnormal PrP in spleens of mice infected with the Fukuoka strain and variant CJD as a clinical stage of the disease.  And right now I would like to say that we did for clinical animals as well, we haven't done every animal, every single animal, but we actually can detect the presence of abnormal BRP in spleens of variant CJD infected mice at 17.
	We're accepting inoculation at 23 weeks after inoculation and very recently we inoculated another strain of mice with variant CJD strain just to propagate as the infection in animals and have animals ready for other blood infectivity studies.  And at 79 days after inoculation is 10 minus 4 infectivity in inoculate, we detected the presence of abnormal PrP in spleens of these mice, and this is the answer probably to the questions which you addressed yesterday.
	You can detect the presence of variant CJD agent 3 in no particular system clinically and, yes, we can but it is not very much different from what we know from other strains that in half the incubation period, approximately, we can detect the presence of PrP infectivity in spleens of the animals.
	Next, please.  This shows how the blood was separated into components, and we inoculated all of these components, but today I'll talk about buffy coat platelet rich plasma and buffy coat platelet poor plasma, because this is part of the experiment which is almost done, completed.
	Next, please.  Here are the pulled data from mice infected with Fukuoka strain and with 31OV mouse adopted BSE strain and the level of infectivity in blood components of these animals and you can see that this data correlates nicely together.
	Next one.  This slide is very busy, but it gives you the idea about the incubation periods in mice which were inoculated with Fukuoka 1 strain by intracerebral intravenous route of inoculation.  Buffy coat plasma, buffy coat in R3 mice inoculated with Fukuoka strain and various CJD inoculated R3 mice.  And as well, you can see different routes of inoculation.
	If you look at the slide, actually you cannot see significant differences between incubation period in mice infected with GSS or in mice infected with variant CJD.  This last blue across here shows that this animal was detected to be positive when all animals were euthanized at 560 days after inoculation by Western Blot resulted in clinical science of the disease.
	Next, please.  This table represents the groups which we inoculated with different dilutions, a clinical phase of the disease, and this is for buffy coat, and here in yellow you can see that actually we completed this group and conformed -- did the Western Blots on the -- these animals were actually euthanized.  All of them were euthanized at 560 days, and we were not able to perform Western Blot analysis on all of them, but this gives you a pretty good idea about what's going on.
	Here you can see that the incubation period when the first animal showed signs of the disease.  And here, as I told you before, the animal which actually was confirmed to have the disease only by Western Blot.
	Next, please.  This is data for inoculation of plasma, platelet rich plasma, platelet poor plasma for 23 weeks and ÄÄÄÄ phase 17 weeks.  These animals were already euthanized, these two groups, and this is still in progress.  They will be euthanized very shortly, and these animals are still incubating.  We saw a couple of those in both groups but as the animals were not confirmed yet to be positive for infection by Western Blot.
	Next, please.  This is data from the study which originated from Dr. Brown, and as you may remember that inactivity in buffy coat was found to be present during the incubation period and raised dramatically at the clinical stage of the disease.  Almost zero infectivity was found in plasma, but, again, that's a clinical stage of the disease.  You can see increase in the infectivity are present in plasma.
	Next, please.  This is data for variant CJD.  This is not completed yet, but I still put zero here right now.  But you can see, again, the infectivity titers in animals, you know, if this goes to the clinical stage of the disease.  But still you can see the difference, that the clinical stage shows infectivity is a little bit high, compared to the clinical stage of the disease.  And suddenly this is present in buffy coat, and we found this infectivity to be present in plasma at the clinical stage as well.
	Next, please.  These data compare the level of infectivity between Fukuoka strain in Swiss mice and R3 mice, because we did this comparison again, and you can see that there is pretty good agreement between the infectivity in buffy coat of Swiss mice and R3 mice infected with Fukuoka strain at the clinical stage.
	Next, please.  This is data comparing variant CJD and Fukuoka strain. Buffy coat and plasma inoculated by different routes of inoculation by IC and IV.  IC is shown in yellow and IV is shown in red, and you can see that intracerebral route of inoculation is most efficient for both buffy coat and plasma compared to intravenous route of inoculation, but we were able to show that it is possible to transmit the disease by both routes, and this is in comparison to Fukuoka strain.
	Next, please.  This is combined data for Fukuoka strain in mice, variant CJD strain in 263K scrapie strain in hamsters, and in all three rodent models you can see the highest level of infectivities present in buffy coat, and this is per ÄÄÄÄ buffy coat or per ÄÄÄÄ plasma, and as well in plasma rich infectivity present as well at the clinical stage of the disease.
	Next, please.  This is experimental data on transfusion studies.  You know about the experiments which were performed at NIH many years ago when chimpanzees were transfused and no transmission of the disease occurred.  This is data collected by Paul Brown in cooperation with us, and one transmission was achieved upon transfusion of 20 animals.
	This is data from Dr. Rowher's lab and, as well, he got three animals out of more than 100 transfused, and this is data from Fiona Houston from the United Kingdom when actually 24 sheep were transfused from 18 donors and 2 animals developed the disease, and this is our data with variant CJD.  We did also close to 100 transfusions, and we right now have three animals which developed the disease upon transfusion.
	Next, please.  Finally, I would like to acknowledge people who were my collaborators or my technical staff.  Thank you.
	DR. BOLTON:  Thank you, Dr. Cervenakova.  Questions?  Steve?
	DR. DeARMOND:  We see tons of data on mice and hamsters but absolutely nothing about human blood transmitted into any animal model.  What's going on with that? It's now 7 to 8 years, 120 people, lots of blood available for analysis.  What is the result of human blood into an appropriate animal model?
	DR. CERVENAKOVA:  Well, first of all I would like to say -- I haven't seen any published data, at least on blood transfusions from human to animal.  Suddenly it is very difficult to address this issue because we know that conventional mice are not very susceptible to TSCs -- human TSCs.
	In this case, what we have to hope for is that we have susceptible, maybe transgenic, mouse.  Even so, Dr. Brown is saying that maybe it is over-representing something.  But still probably it be valuable in order to test and inoculate if it proves to be a susceptible .
	The problem is, in my opinion, that when we were getting this sporadic CJD, in general we have very low level of infectivity in blood of animals.  If you have some infectivity present in blood of human, it probably also is at very low level.  If you look at the studies which were done -- and were done very recently -- by Moira Bruce in the United Kingdom, when she inoculated buffy coat lymphocytes from human infected variant CJD, the problem is that she inoculated a very small number of animals.
	Even if there is infectivity in the sample, she will be not able to detect it, because I forgot to mention that when we inoculated buffy coat only into five animals, we were not able, even with dilution 1 to 4, to 2, we were not able to see any infection.  In this case, it is really necessary to have a large group of animals to be inoculated, and I have to say that Bob Rowher is completely correct about it, that all his study points to the necessity to do these studies on the large scale.
	There is no way how to do it otherwise because if you have, let's say, 10 animals out of 100 to show the infection, it means that it will be one animal out of 10. And it's always a question:  Is it a true result, or it is just some kind of contamination?
	This is what you have to take into account, that once you work in the lab, you handle a lot of material, infectious material.  You have to really have worked out very well all the profiles which I showed you, because we are aware that if you Fukuoka, variant CJD, or some other strain, you may get cross-contamination.
	In this case, this is one of the way to prove that this is true result because the strain stays the same.  It doesn't change during the time.
	But I think that it is necessary to do transfusion transmission studies using small animals and probably try to use different transgenic mice and see how they will perform.
	DR. DeARMOND:  Well, everything you say is absolutely true and that's the way you would run the experiment, but the right experiment hasn't been done yet.  And we keep getting this stuff which implicates blood, but we don't know the real answer in humans.
	As far as I know, the 11 variant CJD patients who gave blood and was transfused to other people, those individuals haven't come down with the disease.  Intracerebral inoculation is certainly different than intravenous inoculation.
	So I don't understand, and Stan Prusiner I know is very upset because we haven't been able to get the blood for animal models that we know are susceptible to variant CJD from humans.  So, this is nice data, but does it have any relationship to the human condition, is what I'm saying?
	DR. CERVENAKOVA:  Well, there is probably -- what we can take from this, that we have to have our open minds, that if there's a possibility that low levels of infectivity are present in blood of people --
	DR. DeARMOND:  Well, our minds are open.  For the last two years, we voted to ban any import of blood because of this.
	DR. CERVENAKOVA:  Yes.
	DR. DeARMOND:  We believe that there might -- that there's a real risk --
	DR. CERVENAKOVA:  Yes.
	DR. DeARMOND:   -- but no one has shown it yet.  This kind of data doesn't help.
	DR. CERVENAKOVA:  I believe the group which actually had better good opportunity to do that is Dr. Prusiner's group, because he has susceptible transgenic mice to do the experiments, and --
	DR. DeARMOND:  Well, put some pressure on the British government and European government to send us the samples.
	DR. CERVENAKOVA:  Well, I don't know, actually, if this is British government, because right now there is a problem from our government to import even antibodies from Prionics.  You know, our antibody was kept on the border last time for three weeks without noticing, as if we have to have some kind of permit in order to get them.
	In this case, it is really difficult situation, but what I'm trying to say that experiments -- some experiments are in place, and probably is the best experiment right now which is going on it is the best experiment using squirrel monkeys, which originated from Dr. Brown.
	The experiment -- and I don't remember if it was presented here, but the experiment is set up in the ways that actually blood from patients with variant CJD patients infected with variant CJD was collected, separated into components, and buffy coat and plasma were inoculated in squirrel monkeys.
	But the number of animals is so low that I even question if we are going to see the infection, because you have three animals and if you don't have any of them developing the disease, what are you going to say?  There is no infectivity.  In my mind, no, you are not able to draw this conclusion.
	There is no money to expend this study to have significant number of animals, which will be sufficient in order to show that there is really nothing there.  This is very susceptible animal model to use for these kind of studies.
	DR. BOLTON:  Sue.
	DR. PRIOLA:  I have two really easy questions for you, I hope.  What's the infectious dose that you used?  Do you have an idea of the titer you inoculated, both IC and IV?  This was presumably a very high dose.
	DR. CERVENAKOVA:  Well, when we inoculated originally, we compared actually the dose which we inoculated and it is 7 LD50s for both, for Fukuoka and variant CJD, because this was important for us to show that it is.
	DR. PRIOLA:  Seven LD50s?
	DR. CERVENAKOVA:  Yes.
	DR. PRIOLA:  That's not much.
	The second thing is -- you alluded to this in part of your answer to Dr. DeArmond's question:  Controlling for lab contamination when you have -- even in the positive experiments you have, you know, just a couple of animals coming up, and it's obviously very low titer.  I assume you look in all the brains to see if you have the shift in size between the GSS, the Fukuoka, and the vCJD?
	DR. CERVENAKOVA:  Yes.
	DR. PRIOLA:  Did you do a parallel mock infection going -- doing exactly the same thing but using --
	DR. CERVENAKOVA:  Yes, we did.
	DR. PRIOLA:  Those were all conclusive.
	DR. CERVENAKOVA:  They're negative. They're negative.
	DR. PRIOLA:  All negative.  Same numbers of animals, etcetera.
	DR. CERVENAKOVA:  Well, we haven't done the same number of animals, certainly, but we do inoculate them, periodically, to have this control, because it is very difficult to produce a sufficient number of animals for this particular study, and this is why we switched to another animal, which was showed, actually, is susceptible to variant CJD and has the same incubation period.  And this is FVBn strain.
	DR. BOLTON:  Let me clarify.  The inoculated dose was 7 LD50s or 7 log 10 LD50s?
	DR. CERVENAKOVA:  Seven logs.
	DR. BOLTON:  Okay.  There's a little difference there.
	DR. CERVENAKOVA:  Yes.
	DR. BELAY:  The BSE agent transmission in the experimental sheep model that you showed.  There were two positives, right?
	DR. CERVENAKOVA:  Yes.
	DR. BELAY:  Now, the one positive that was published received blood obtained in the incubation period of the experimental sheep.
	DR. CERVENAKOVA:  Yes.
	DR. BELAY:  How about the second positive?  Did it receive also blood collected during the incubation period or at the clinical studies?
	DR. CERVENAKOVA:  I'm trying to remember it.  I believe it was also from pre-clinical but very close to the clinical phase.  Actually, I didn't include this data on transmission of scrapie from sheep which naturally develops the disease.  And it was recently shown that they achieved transmission in four cases of natural scrapie.  This data was submitted for publication and were present at the meeting in Bergen which I attended, but they are still not readily available.
	DR. BELAY:  How about the mouse transfusion study?
	DR. CERVENAKOVA:  Yes.
	DR. BELAY:  Was it also collected in the incubation to pre-clinical phase?
	DR. CERVENAKOVA:  No.  When we did our transfusion studies, these were animals which developed the disease.  At this point, we euthanized them, and they are actually coming even from different strains, but I don't think so it is important.
	What we did, we transfused into the same just to see because we tested a couple of strains and when the animals developed the disease we took the blood and transfused.  This data will be presented later in a more subtle way.
	DR. BOLTON:  Would you introduce yourself from the floor?
	DR. EGLIN:  Yes.  I'm Roger Eglin from the National Blood Service in England. If I could just make a few comments about the human cases of variant CJD we have: Although we've had 121 or 122 cases now, there are only 8 still alive, and it's proved very difficult to persuade the earlier cases to give reasonable amounts of blood.
	Their families have been very protective of the cases.  The cases tend go on to die, and they really don't really want to give blood donations or even sizable volumes at all.  So, that's proved a very difficult thing to do.  There is a natural experiment going on in the blood donor's in England, in that some blood donors have subsequently developed variant CJD, and there are 20 or so recipients of those under those transmissions as well.
	So, there's a natural experiment going on there with the longest incubation period of about 9 years so far.  No signs of any of those implicated recipients going down with illness.
	Thought I'd just make a comment on the sheep experiment as well.  Although it's 2 out of 24, in total it's actually 2 out of 2 of the ones that you would expect to be showing clinical signs at the moment, because the experiment was set up sequentially, they weren't all infected as a batch.  So, that makes it somewhat more impressive, and I believe there are some more suspects in that experiment.  They'll becoming ill, too.
	DR. DeARMOND:  But while you can't get blood from the patients during life for various reasons.  How about at autopsy?  I know that some of them denied having autopsies.
	DR. EGLIN:  A lot of them -- most of them do, yeah, and they die at home, and it's just proving very difficult.  They're not experimental animals.
	DR. DeARMOND:  There must have been at least a couple that will donate blood. Do you know the numbers who have allowed blood, or is it zero?
	DR. EGLIN:  I think it's very few, and I think some of the earlier cases, the blood was not stored in the most appropriate manner.
	DR. BOLTON:  Steve, Stan had a variant CJD patient at UCSF for treatment. What about that individual?
	DR. DeARMOND:  That's being looked at.  So, the patient was brought in and the blood was withdrawn from that patient and that's all under study right now.  But we're talking about seven years of disease and no data yet.
	DR. BOLTON:  Bob?  Would you introduce yourself, please?
	DR. ROWHER:  Yeah, Bob Rowher. Just to emphasize the last two points, that one of the biggest obstacles in making the demonstration which Steve is calling for is the lack of blood itself.  It's not just at the level of variant CJD, but that's also sporadic CJD.
	We have 300 and some cases of sporadic CJD in this country a year, and getting a unit of blood out of any of them has been extremely difficult.  I think it's something that if this committee was going to do something useful, in terms of advancing this idea and advancing the opportunities for these types of demonstrations, it would be to in some way facilitate, by virtue of a recommendation maybe, that some considerable effort go into making this possible.  The logical place for it to come through is Dr. Gambetti's efforts as the CDC repository -- I mean, the CDC-sponsored CJD repository.  So that's basically what I'm getting at.
	The other point I wanted to make is that we also mentioned the Baxter experiment.  This is an experiment that's going on at the cost of several million dollars a year, using squirrel monkeys, and it's main limitation was the monkeys were there and the blood wasn't.  They inoculated everything they could get their hands on, but when you sit down and add it up, I'm not sure we could get a positive demonstration on the hamsters, using the volumes of blood that were available for that experiment.
	The most promising aspect of that work, in my opinion, is that there is also going to be -- there have also been transmissions by the intracerebral route into squirrel monkeys and the blood from those monkeys will be used for subsequent transfusion experiments in monkeys, where there will be no species barrier.
	I think it's important to realize that even humans to monkeys there are undoubtedly a species barrier effect also involved there, and you're not necessarily going to see it when you're looking at very low titers, such as those that are involved in blood, even with direct transfusion from humans into monkeys.  So, the monkey-to-monkey experiment may be the most important one.
	The last point is that at the EMEA meeting in London last week, Fiona Houston presented an update on her sheep transmission experiments.  And she has now seen four naturally infected, scrapie-infected sheep transmit the disease by transfusion to 90 sheep.  This has been a missing link in this whole story.
	All of the experiments that have been done to date have been done on experimentally infected animals.  There's always been this question that was alluded to over here -- by -- I think it was Sue or somebody -- about whether we're just re-isolating the inoculum.  That's what we're finding in the blood.
	Those experiments that I showed you yesterday from our laboratory, we are now inoculating our animals and limiting dilution just to get around that effect.  We know that that has to be de novo infectivity that we're seeing in those particular cases. But in the case of the natural infection, this is not a question anymore, and there is really I think very solid evidence now that the blood of naturally infected animals -- in this case scrapie-infected sheep -- does contain infectivity.
	The BSE-infected animals are, by the way, experimentally infected, so they don't fall into that category.
	DR. DeARMOND:  Well, we seem to be successful at bringing a cohort of CJD patients to UCSF and getting blood from them, and for injection into mice you don't need a pint.  You can use what you get derived from that -- unless you want to concentrate the protein.  But we're taking multiple vials of blood from individuals and testing them for the CDI assay, which is the most sensitive -- at least that I know of -- immuno assay for the prion protein plus injection into our susceptible animals.
	So, I think the experiment can be done with humans, and one doesn't need to have high levels or huge quantities of blood.  But I still think the final -- we're judging policy right now on animal models without any evidence from human disease, and we really need to study the human disease. That's all I'm trying to say.
	I'm not sure that we haven't proven that there's an infectivity titer high enough to infect another human in blood. There may be some there but is it infectible?  Is the infectious agent, whatever you want to call it at this stage, in a state in the blood that can infect another human?  That's all the data that we need.  It's that simple.
	DR. ROWHER:  If I can just respond to that.  We do need that data, but I disagree with you entirely that we need small volumes.  The thing is we need large volumes, because if we're going to make this demonstration --
	DR. DeARMOND:  No question, we'd like to have large volumes, but in the meantime if we can get smaller volumes, two or three vials, 10 cc's, 20, 30, 50 cc's, even a hundred cc's, which we are able to get from volunteers, CJD patients -- that's at least a good start.  I wouldn't stop the experiment because we can't get a pint.
	DR. ROWHER:  Across the species barrier, you're going to have difficulties with that.
	DR. DeARMOND:  We don't have difficulties with some of the animal models. For instance, the bovinized PrP model is highly sensitive to both BSE prions and to variant CJD prions, and the MHU2M also with modifications of amino acids in the helical regions are highly sensitive to sporadic CJD.
	DR. ROWHER:  I will make an offer that I've made several times in the past to the Prusiner laboratory:  If they'll provide us with these mice, we'll do the experiments the way we do them in hamsters, and we will be able to answer that question one way or the other.
	DR. BOLTON:  Therein lies the problem.  Okay.
	DR. DeARMOND:  Well, we can do them also, and that's a political problem between Stan and --
	DR. BOLTON:  I agree, and we won't deliberate further on that here.
	Yes.
	MR. BARON:  Henry Baron of Aventis Behring.  I just wanted to bring some clarification to some of Steve's questions.
	We actually did the experiment with Stan, Steve, at least once.  We have already inoculated bloods from 13 CJD cases into the transgenic mice ÄÄÄÄ.
	DR. DeARMOND:  Sporadic --
	MR. BARON:  Twelve sporadics and one familial.  Now, this wasn't large volumes.  These were groups of 8 to 10 mice, each of which got 30 microliters of blood from a case.
	We also did plasma, red blood cells, and whole blood, and all these experiments were negative.  Now, one can use the caveat that we didn't do the whole blood volume on a given patient in that one or two infectious units for ML we missed because of the volume question, but nonetheless it's data, and it's negative data, and we want to do the same thing with the bovine transgenic mice with variant CJD cases.
	At Aventis Behring, we have the mice, as you know, and unfortunately, as he said, it's difficult to get the samples. What we are doing now is we're doing this in collaboration with a U.K. group, which has a grant, which gives them access to samples. So, we're trying very hard to address this question with the best possible models.
	DR. DeARMOND:  Hank, that's exactly right, and I think the current wisdom is that sporadic CJD is different than variant CJD and there's a large amount of data from transfusion studies that argues that sporadic CJD doesn't transmit through blood. The question is whether variant CJD, which is the whole basis of this, all these regulations, whether it does.
	MR. BARON:  Yes.  I mean, there's data on variant CJD, too, but it's very limited.  But for 10 years now, there have been 30 million transfusions in the U.K., and there's no evidence but it's early.  You don't know what the incubation period would be --
	DR. DeARMOND:  That's right.
	MR. BARON:  -- in human-to-human transmission of blood.  But, you know, data is continuing to be generated and I think that's all we can do, is work at it and generate data and hope that it continues to be negative.
	DR. DeARMOND:  So, what do you think of more mouse data, mouse transmission of Fukuoma and variant CJD?
	MR. BARON:  I think it helps, but I agree with you that the real proof of the pudding is in demonstrating that there's something in humans, and that's why we've really got to use these highly susceptible models to human prions, whether it's variant CJD or sporadic CJD.
	With respect to the sheep data, I'd just like to make one very brief comment, and I think we should all reserve judgement until the data is out and published.  I think if we all had a chance to look at the data, we'd see some very unusual and paradoxical discrepancies in the incubation times by transfusion as opposed to intracerebral inoculation of brain homogenate from BSE.  It's a study that merits some rigorous scrutiny I think.
	DR. BOLTON:  Point well taken. Dr. Piccardo will have our last comment or question on this subject.
	DR. PICCARDO:  Well, it's a question actually, Steve.  Forgetting the unfortunate human-to-human experiments, people have developed vCJD that donated blood, basically I don't have the update of what happened to the recipients.  Are those -- what are we -- are they alive or dead?  I mean, if they are dead, were they analyzed by an autopsy, etcetera, etcetera. So, it's an update; it's not a question.
	DR. BOLTON:  Microphone.
	DR. SCOTT:  I can give you what little information I have, and this is what I heard at the World Federation of Hemophilia from some people in the U.K. in January.  Apparently there are 12 living recipients of blood products from the people who came down with variant CJD, and the rest of the people died.  I think there were 20 or 22 recipients overall of non-CJD illnesses.
	The other so-called "natural experiment" that appears to be going on is that there were recipients of factor 8 in the U.K. in '96 and '97, which had a donor that had vCJD, and there are approximately 200 of those.
	So there is a substantial amount of recipients that died.  Did they specify what happened, how they were analyzed -- at autopsy or --
	DR. PICCARDO:  All we know is that their diagnosis was not CJD illness, and these were by death records I believe.
	DR. SCOTT:  So then the data is not precise.
	DR. PICCARDO:  Well, it's not precise, although we're assured from the U.K. that these people are believed not to have died of CJD, but they -- vCJD -- they could be incubating I suppose.  I would just make the point that if transfusion is difficult, transfusion transmission is difficult or rare, this tiny number of people for this amount of time probably wouldn't be sufficient if detected and has the same limitations in some of the animal studies that you're talking about.  So, I think to rely on this kind of a look-back, unless we get a positive, isn't going to tell us anything that really helps.
	So, the question is what happened with the people that remain alive?  Is there a mechanism in place to try to get more information when they eventually die, or there's nothing going on --
	DR. BOLTON:  My understanding is the patients that are alive are being followed prospectively.  Some of the recipients died, I think, before there was an awareness of a donation.
	DR. SCOTT:  Yes, the transfused people die a lot, and that was a limitation of the classical CJD look-back studies as well.
	DR. BOLTON:  I think we should move on.  Do you have a brief comment, Dr. Bianco?
	DR. BIANCO:  I just wanted to place a number on Dr. Scott's statement that people that received transfusions die. Because of the underlying disease, our experience with HIV and other HCD look-back, over 50 percent of the people that received transfusions died within the first year because of the underlying disease.
	DR. PICCARDO:  There is important information that can come from that people, which is analyze the spleen, for example.  I mean, if you're talking about people that died very shortly after they received transfusion, there is ÄÄÄÄ which is not the brain, but it's the spleen, so that is important information.
	DR. BOLTON:  I think we'll move on. We can discuss this a little bit later.
	Our final presentation for this morning and the meeting is retention of TSE infectivity by Planova nanofilters as a function of spike composition, and that will be presented by Dr. Louisa Gregori.
	RETENTION OF TSE INFECTIVITY BY PLANOVA
	NANOFILTERS AS A FUNCTION OF SPIKE
	COMPOSITION
	DR. GREGORI:  Thank you and good morning.  This presentation will switch, I think, the topic of conversation to something completely different.  I will be talking to you about our experimental data on the rotation of TSE infectivity by Planova nanofilters as a functional spike composition.
	In the management of viral contamination for manufactured product, we have three classical methods of defense against contamination that's deferred for blood and sourcing for biologicals, screening of donated blood and testing of the raw material, removal and inactivation. Although all of these methods have provided to be very effective against conventional analysis, in the case of TSE they all have presented challenge.
	TSE is characterized by a long incubation time, which limits the effect of deferral.  Also we don't have a rapid and sensitive assay to screen donated blood or test the raw material.  Finally, the inactivation -- TSE inactivation requires a harsh condition so they are usually not applicable to biologicals.  So, we're left, pretty much, with the removal methods.
	This is a slide just -- Bob Rohwer has already talked about this yesterday. I'm not going to repeat, and basically what I'm showing here, in terms of inactivation that you see ÄÄÄÄ we have either physical or methods that are rather harsh are also very harsh chemical conditions and usually we prefer to use a combination of both.
	So, clearly inactivation is not a valid option in this case.  As I said, removal -- methods of removal is where we are left for the TSE agent.
	I have listed here just a few methods like in this chromatography filtration.  Of course there are other methods, too.  I just want to tell you that I'm going to focus on this filtration method.  And whatever method we're going to use will have to be validated.
	In the validation studies, the most critical question to address is the type of spike to use.  If we are validating manufacturing product involved in blood or blood products, then we have two options: We can either start with infected ÄÄÄÄ and infected blood like from animal models -- we have done this in ÄÄÄÄ experiment -- or we can use brain spiked infectivity.
	In the infected blood, the advantage is the high relevance.  Of course we are removing the type of infectivity that might be present in the original material. The disadvantage is that we have low level of infectivity in blood, so we cannot demonstrate many logs of removal by the process, and also the ÄÄÄÄ is expensive because it requires animal assay.
	If we use brain ÄÄÄÄ infectivity, then the question, of course, is the relevance because brain infectivity might be present in a form and the characteristic that is different from the one present in blood.  However, the advantage is that the we can spike with a very high level of infectivity and therefore we can demonstrate several logs of removal by this study, and also we have in vitro alternatives, and this with I'm referring to the assay involving the biochemical measurement of the TSE ÄÄÄÄ PrPs.  Also, those are less expensive.
	In terms of brain-derived spike, what we can see is that it's rather arbitrary.  Each laboratory prepared their own spike in this large variation and often we cannot even compare the same study from two different laboratories, because the spike is different.  And also in a brain that are spike we can use whole brain.
	This is, of course, we have probably all form of infectivity present there, in terms of size distribution.  The question is:  Is the distribution appropriate for what we want to validate.
	Same thing is for clarify supernate (phonetic) and microsomes and ÄÄsomes.  They might be more homogenous, but it's still maybe not appropriate as a spike.
	Finally, we can use purified fibrils.  Fibrils are abnormal sectors that are present in the affected brain, and they can be purified and during the purification, basically, we prepare fibrils.  The majority component is the PrP, the prion protein. The problem with the fibrils is that they are insoluble and, again, they might be not even exist in the brain or in blood.
	As I said, we're going to be looking at filtration.  So, the advantage of filtration are the relatively independent from buffer composition, the flexible placement in the process.  The removal can be rationalized from particle size.  Of course, if you look at particle size that you want to remove, then you can design a filter that will remove only that size. Therefore, a list of principles could provide an absolute barrier.
	Of course, TSE presents a challenge also to filtration.  The problem is that we don't know unit size of the TSE agent. However, we know the operational size is probably this purse.  What I mean by that is that there is a wide distribution inside of the TSE infectivity and list in the brain homogenate.  So, the question is what is the appropriate pore size?
	This cartoon here represents, in scale, a ÄÄÄÄ fibril.  There's a sector, as I said, that's found in the brain, and they are associated with TSE infectivity by electromacroscopy (phonetic).  The size of these fibrils can go from 100 to more than a thousand nanometers.  The one depicted here -- it corresponds to 810 nanometers. Just to give you orientation, this bar here corresponds to 20 nanometers, which is the size of a small virus, like a pavel virus.
	In contrast -- I don't know if you can see this dot here -- but in contrast the prion protein, which is believe to be the TSE agent, is this dot here.  That's drawn in scale with the fibril.  This protein is at 27,000 dot molecular weight.
	So the question now is:  When we do a filtration study, what is it we're trying to filter?  Are we trying to filter prion protein or are we trying to remove fibrils, or are we try to move something in between.
	Even more important, what do we think is the -- what form do we think is present in your sample?  This is just a cartoon to introduce you to the Planova nanofilters that we used.  There was a 75 nanometer filter, the 35 nanometer filter, and a 50 nanometer filter.  This is how they would behave with conventional viruses.
	Large viruses are blocked by the 75 nanometer filter; the medium size virus by the 35 nanometer filter; and the very small viruses, like the pavel viruses, are blocked by the 15 nanometer filter.  Of course if we would have a molecular product, we would expect this to go through all filters and to be found in the 15 nanometer filtrate.
	This is a slide showing you the filter size versus the log removal for three conventional viruses -- the pavel virus, the BVD virus, and the HAE virus.  I also added the Viax 174.  This study was done by Elaine Elosikoff, and this is just to show you that these filters behave according to what you expect, according to their exclusion size.
	Now, this cartoon here.  I'd like to see some possible scenarios for the traditional TSE agents.  So if the TSE agent is the prion protein, or even an aggregated form of the prion protein, like for 5 or 10 molecules altogether, we would expect this protein to go through all the filters and to have infectivity recovered in the 15 nanometer filtrate.  On the other hand, if the TSE agent we are filtering is in the fibril form, then we know that during sonication and preparation fibrils, we are breaking down the fibrils, and I want you to know that the size, the unit size, of this broke down fibril is not more than 15 nanometers.
	So, what we would expect is that it's going to be some large fibrils that will be blocked by the 75 nanometer filter; some will be blocked by the 35; and obviously if it's more than 35, it would be blocked by the 15 nanometer filter and we find no infectivity on the 15 nanometer filtrate.
	On the other hand, as a hypothesis and as a model, we can also think of an additional component, a TSE agent that is not fibrils but is associated with fibrils, indicated here by the red dot.  Now, how would -- if this component exists, how would that be filtered?  Well, it depends on what kind of interaction it has with fibrils.
	If the interaction is strong, then it would behave just like fibrils in this filtration experiment.  On the other hand, if interaction is weak, or if we somehow can break this interaction, then this component, this TSE agent, then will be filtered according to its size.  So it could be potentially also be smaller than 50 nanometers and be found on the 15 nanometer filtrate.
	So, the question now that we ask in this experiment is:  What is the smallest unit size of infectivity?  If we cannot get to this question, then the next important question is what is, then, the operational ÄÄÄÄ size of filtration?  Do the filter-removed TSE infectivity stochastically and selectively?  That's the spike composition ÄÄÄÄ infilterability.
	There has been some early work on trying to determine the size of the TSE agent.  There was some work done using ÄÄÄÄ filters, and they determined the particle size is between 30 and 50 nanometers.  Also some other filtration studies in which they use 100,000 ÄÄÄÄ filters, and what they found is that only 1 percent of infectivity passed the filter and 99 percent was retained in retintate (phonetic).
	There were also two studies done by Tateishi's group in which they used the Planova filters for the removal of TSE agent.  This is the first study they used a CJD mouse brain homogenate and the infectivity titers measured by incubation time.
	This is their results.  I'm not going to show you everything because I don't have time.  The studies here basically demonstrate that the TSE agent has a size between 60 nanometers and 75 nanometers. This is not what we found in our studies but that's what is showed here.
	The panel that I'd like you to focus your attention on is this experiment here.  When they challenged the 40 nanometer filter with a 50 ÄÄÄÄ unit of TSE infectivity, they found only 23 that passed the filter.  However, the same filter changed with the same spike but in the presence of sarkosyl.
	They have complete -- the lost the removal and they have complete passages through filter of the TSE infectivity, clearly showing that sarkosyl has a solublizing effect.  Then it appears to reduce the apparent size of the TSE agent.
	The same group also investigated farther the effect of sarkosyl.  So, this is the second experiment that they did.  They used the ÄÄÄ filter 35 nanometer, 15 nanometer and 9 nanometer.  The vehicle was human with or without .5 percent sarkosyl. This is the spike, the TSE spike, and, again, to measure the titers by incubation time.
	The results are shown on this slide.  So, when they looked at a 35 nanometer filter, this is when they challenged it.  This is the reduction factor that they found, almost 5 logs of reduction without sarkosyl.
	The same identical experiment, in the presence of .5 percent sarkosyl reduced the reduction factor of 1.6.  So, basically, they had demonstrated again what I just showed you on the 40 nanometer filter, that sarkosyl has a solublizing effect.  It reduces the size of infectivity.
	They also looked at 15 nanometer system.  That was a very interesting experiment.  They challenged the same way without sarkosyl and with sarkosyl. Unfortunately, these data -- I'm not -- well, what they found basically, they reached the detection limit of their assay. So all they can say is that this is more than 5.86 and this is a reduction factor more than 4.2.  We cannot tell whether there is a difference in these two numbers or not.
	So, we really don't know where there is a difference in the presence and without sarkosyl for the 15 nanometer filtrate.  The same problem is for the 9 nanometer filtrate.
	When we designed our experiment, the objective that we had in mind was what is the operational filtration size of TSE infectivity, do 15 nanometer filters retain infectivity.  These are what seems to be the result of Tateishi's data, but we wanted to make a better measurement and address this question particularly.
	Then, are the filters removing infectivity at random or are they selecting a more attentive population.  Finally, we want to ask the question how dependent is filtration efficiency on the spike preparation?  So, this is what we prepared. Also we have two spikes.
	One is the brain homogenate spike from 263K hamster strain scrapie, then the PrP fibrils purified from the same models, the hamster model, and during the purification we used 1 percent sarkosyl. But I want to clarify that this sarkosyl was removed at the last step of the purification, so there was no sarkosyl in our experiment.
	Both spikes were treated with solvent detergent before adding to factor 8 ÄÄÄÄ in dilution from 1 to 100.  So, our vehicle was factor 8 eluate, and the spike were treated with solvent detergent. However, this solution was thinned, diluted 1 to 100.  So, there was no detergent, really, in our experiment.  But I want to emphasize that both preparations were exposed to detergents, and in that case we measured the titers by the end point titration.
	This is the experimental configuration on a study that we did.  This is the brain of homogenous spike, the purified fibril spike.  They are identical, in terms of configuration.  We spiked the material here, the first stage, and then filter on the -- the first filter was 75 nanometer.  Then the filtrate went through the first 35 nanometer.  The filter of this the second 35 nanometer and so on.  So, we spiked only once.  There was no spiking in the middle.
	We also put two filters.  There's millimeter in tandem, and this is because we wanted to address the question of what is the mechanism of these filters, and this point was mentioned yesterday by Bob Rowher. So in this particular case, what we wanted to learn -- if the first filter is selected, then what it goes through -- what passes through the first filter has a size that's less than 35 nanometers, so it would not be stopped.  It would not be removed by the second 35 nanometer filter.
	On the other hand, if this filter removes infectivity by stochastic or random event, then there's going to be some particles that pass through the filter that are larger than 35 and that will be stopped by the second 35 millimeter filter.
	This is the filter configuration. This is where the challenge material is placed to pump the liquid through the filter.  This is the Planova nanofilter, and then during filtration we closed this outlet.  We then look at pressure and make sure that we don't exceed the pressure for each filter.  During filtration we collect the filtrate on this tube here.
	This slide shows the results of this experiment, and this first line here corresponds to the infections dose per millimeter that used to challenge each filter.  This is the recovery, and this is the log of retention.
	So, for brain homogenate spike, we have a first filter remove four logs of infectivity.  The first 35 nanometer filter moved almost nothing.  Another thing, the second 35 nanometer removed more than the first one.
	As I already explained to you, this obviously was an unexpected result and it's not clear at this point why we see such a phenomenon.  It's possible that there is some other mechanism going on that we don't have control over.
	The second 35 nanometer filter was only 20 infections units per liter.  We challenged the first 15 nanometer filter and we saw no infectivity in the 15 nanometer filtrate.  So this corresponds to less than the 6 infectious units per milliliter, and this corresponds to more than .5 logs of retention for that filter.
	This is the result of purified fibrils.  The first 75 nanometer filter removed 3 logs or 3.1 logs of infectivity; nothing from the first 35 nanometer filter, and more on the second 35 nanometer filter. Again, this is the same thing I just talked about for brain homogenate.  Then the first 15 nanometer filter removed more than 2 logs of infectivity.
	So, if we compare now the data from the two spikes, where we used -- the first 75 nanometer filter removed more -- one or more of the brain spikes compared to the fibril spike, indicating that the infectivity distribution in the spike fibril is more toward the smaller size, compared to brain.
	In the 35 nanometer filter we show no difference basically, and also we -- in the 15 nanometer filter we saw there was a -- first of all -- a complete removal of infectivity for most of them.  For this fibril here, we saw more than 2 logs of infectivity removal, and of course the first thing we wanted to know is:  Is this the limit of the removal or this is the limit of our detection assay.  But if we could challenge the same filter with more infectivity, would we find more removal or not?
	So, the conclusion at this point is that the majority of removal was by the 75 nanometer filter, and this filter removed selectively.  That's because whatever passed the 75 nanometer filter was not blocked by the 35 nanometer filter, which means that it was smaller than 35 nanometer.
	This is a point I have already mentioned.  The second 35 nanometer filter removes more than the first.  The fibril preparation should ÄÄÄÄ less retention than brain homogenate, and this is for the first 75 nanometer filter.
	Also, the other conclusion is that the 15 nanometer filter retains more than 2 logs of infectious 35 nanometer filter. This is something, again, that Dr. Rowher was talking about yesterday that we think that the appropriate spike for a small filter like 15 nanometer filter.  It's really a pre-filter, some sort of pre-filter or what we call a condition filtrate, so that you remove all the large particles and you challenge that filter with particle size that are compatible with filter pore size.
	Also here the detergent may facilitate filtration infectivity.  That is because I said our samples, even though the experiment did not contain detergent, but the spikes were exposed to detergent.
	In summary, now, the spike modality can affect clearance potential, as I showed you for the two different spikes.  The effectiveness of nonfiltration can be strongly dependent upon process parameters. This is what I've been mentioning about the presence of the treatment of the spike with detergent we might have found a completely different results if we had not treated the spike with detergent.
	So, the idea here is that the result of nanofiltration depends exclusively -- in the context that nanofiltration is done with a specific of process parameters they apply to the spike, and to the vehicle, too.  So, this of course, is strongly cautious against over interpretation of removal studies and also extrapolation of data from one study to another.
	It's also suggested that ÄÄÄÄ of multiple removal step can always be assumed, and the serial tandem processing is an excellent means to reveal a selective removal.
	Okay, we're going back to our model here, our pictorial model.  What we found at this point in this study is that we have not found in any infectivity on the 15 nanometer filter, so we can exclude -- at least in that study will not support this model here, the single protein model.  It also doesn't support any of -- there is a particle, a TSE agent different from fibrils that can be filtered, that has a filtration size less than 15 nanometers.
	But it appears, at this point, to say ÄÄÄÄ fibrils and the ÄÄÄÄ has reduced the fibrils to a different -- to a distribution infectivity.  So, some are removed by the 75 nanometers; very few are removed by the 35; and all of them are removed by the 15 nanometers.
	As I said earlier, what we wanted to know is if we challenge the 15 nanometer filter with more infectivity, something that has already gone -- something like five or six logs of infectivity that have already been filtered to a 35 nanometer filter, so it's been conditioned, do we still find a complete removal of infectivity?
	We have done already the studies, but the studies are almost complete but we're still missing a piece of the puzzle, so I cannot talk to you about these studies at this moment.  But what we have done to address the unanswered question that came from the first study is what is the limited size of TSE agent?  So, we challenged the 15 nanometer filter with titers of around 6 or 7 logs of infectivity that have already been conditioned on the 35 nanometer filter.
	Also, the other question was:  What is the maximum pore size capable of removing infectivity?  Well, when we started the study, we thought it was something between 35 nanometers and 50 nanometers; so we tested some filters that had the pore size between these two values.
	Finally, we explored the effect of surfactant and like detergent on the filterability of TSE.  And we think we're going to get this completely studied in a short time, and we hope that we can present this at another time.
	Thank you.
	DR. BOLTON:  Thank you, Dr. Gregori.  Questions.
	DR. McCULLOUGH:  I would just say excellent design of your study and formulas and the hypothesis and very interesting results.  Just commending you.
	DR. GREGORI:  Thank you.
	DR. BOLTON:  I have a question actually.  When you say you have purified fibrils, was that material treated with proteinase-K?
	DR. GREGORI:  This one in particular were, yes.  They were --
	DR. BOLTON:  So, you did have fibrils there.  I just want to point out that there are alternate methods for purifying TRP which do not use proteinase-K digestion and those do not produce fibrils; they produce protein globules, and they will have different physical properties that may or may not filter in the same way.
	I think -- a major point that you made I think is very important to emphasize, and it's been done in your study and in previous studies by Dr. Rowher and in my laboratory and others, that it is indeed true that the exact biochemical milieu is very important in how the agent acts in filtration and centrifugation and many other kinds of biophysical conditions.  So, it's very difficult -- and we'll be going forward -- very difficult to extrapolate from any particular study designed in a certain way to other conditions that may apply.
	DR. GREGORI:  Yes, that's exactly my point.
	DR. BOLTON:  Steve.
	DR. DeARMOND:  Although the study was well designed and looks very nice, it's really difficult to interpret because in the one you start with a homogenate, which theoretically is the native state of whatever the agent is -- we presume it's prion protein.
	DR. GREGORI:  Yes.
	DR. DeARMOND:  The other is highly processed prion protein because the fibrils require proteinase-K digestion plus detergent to form them.  So, it's a different situation, and in both cases there's going to be a whole range of sizes of molecules from individual molecules that can pass through that in the native state would be about 30, 35 kilodaltons.  But they should pass the 35 filter.
	But the majority seem to be dimers or polymers, and we think even a hexamer is the basic unit, the basic natural unit of the infectious agent.  So, this is a very complicated thing to interpret.
	But the question I wanted to ask is:  The reduction that you're getting in infectivity titers by the time you get beyond the 15 nanometer is putting it in terms of the other chemicals ways -- sodium hydroxide denaturation and heating -- are you getting similar -- it looks like the decrease in titer is similar to treating sodium hydroxide and heat.  By the time you get to the 35, is it the 35 or at the 15 nanometer pore?
	DR. GREGORI:  I'm not sure I understand actually your question.
	DR. DeARMOND:  So you've got a marked reduction --
	DR. GREGORI:  I'm sorry, we were not doing activation.  Those are not inactivation studies.
	DR. DeARMOND:  But you end up arriving at inactivation.
	DR. BOLTON:  Steve, I think the answer to the question is yes.
	DR. DeARMOND:  Thank you.
	DR. BOLTON:  Because by the time they'd gotten past the 15 nanometer filter, they had no measurable infectivity, at least in the amounts that they tested.
	DR. GREGORI:  Yes.
	DR. BOLTON:  I don't know how many animals you inoculated with what volume, but it was below the level of detection within the assay parameters.
	DR. DeARMOND:  Then the 35 nanometer, was that comparable to standard denaturation?
	DR. BOLTON:  Well, we consider one normal sodium hydroxide for an hour or more to be essentially terminal activation, so I'm not sure --
	DR. GREGORI:  I still don't understand why we're considering removal same as an inactivation.
	DR. DeARMOND:  I was comparing reduction in infectivity titer using this technique -- thinking of industry.  So industry could use this technique to reduce infectivity titer to close to zero, without having to use sodium hydroxide and heat. So, I was going to the practical side.
	DR. GREGORI:  Oh, okay.
	DR. BOLTON:  Only if the method is applicable to their process.
	Sue?
	DR. CERVENAKOVA:  All right.
	DR. PRIOLA:  Two quick questions. One:  15 nanometers was the size you gave as the minimal unit size.  How many PrP molecules is that?
	DR. GREGORI:  How many what?
	DR. PRIOLA:  How many PrP single molecules --
	DR. GREGORI:  Fifteen nanometers?
	DR. PRIOLA:  Yes.
	DR. GREGORI:  I don't know.  I would say --
	DR. DeARMOND:  I think that's less than the size of a single one.  I think about 50, 60 nanometers go to a dimer, which is about 60, 70 kilodaltons.  I think that's what Tikvah Albert came up with, a cross- sectional diameter of the minimal diameter of the infectious agent.
	DR. BOLTON:  It's much more complicated.
	DR. GREGORI:  I really don't know this question.
	DR. PRIOLA:  That's fine.  I was just wondering if -- the second thing was more of a hypothetical thing.  Have you ever thought of spiking with something other than material from a clinical animal, taking into consideration what you said and what Dr. Rowher said yesterday that the nature of the spike is important, and it may be that the nature of the infectious aggregate, if it is in fact PrP SE, can differ in pre-clinical versus clinical animals.  It may be smaller in a pre-clinical animal, for example.
	DR. GREGORI:  Right, yeah, I understand the question.  No, we have not done that because usually these studies we go for the highest titer we can achieve to show removal.  And so we have never tried, as far as I know, we never tried the same studies with pre-clinical brains.
	DR. PRIOLA:  Yeah, it's more a hypothetical, scientific question than a practical application.
	DR. BOLTON:  I have a comment, actually.  In your study where you seem to get higher removal rates in the second 35 nanometer filter, were those samples along the line adjusted for constant protein concentration?  I forget if there was supplemental protein added to the material to begin with.
	DR. PRIOLA:  No.  These brains -- the homogenate -- the spike where in factorate monoclonal antibody eluate. That's constant as the vehicle.  So, that's the concentration of that protein supposed to be -- is not removed by these filters. So that would be the background of the studies.
	DR. BOLTON:  The question would be whether or not you're getting just adsorption to the filter and that could still, I suppose, happen in the presence of the antibody, but it sort of depends on what the protein concentration is.
	DR. DeARMOND:  Just one other comment on size.  If the prion protein, of course, in the native state, is triglycosylated -- or diglycosylated, mono, and no glycosylation, and the sugars account for about 35 percent of the volume of the molecule.  So, it's possible that the majority are going to be stuck at the 35, but the mono and then finally the non-glycosylated forms could get through multiple filters, and they could be a smaller proportion that would get through. So, it's a very complicated -- that's why the interpretation is extremely complicated here.
	DR. BOLTON:  I hope you're not confusing kilodaltons with nanometers, because the size --
	DR. DeARMOND:  I'm trying to remember the sizes of the molecule, and you're right, I can't do it.
	DR. BOLTON:  Dimers and trimers are going to be much, much smaller than 15 nanometers as a cross-sectional.  So, certainly -- now, I just wrote something on this, so I should remember it but I don't. But the size of a tetramer or hexamer is going to be much smaller than a 15 nanometer pore size, even smaller than 9 nanometer pore size.
	A shell of PrP of about 35 or 40 subunits might be in that range of 12 to 15 nanometers.  Other questions or comments? Ah, one more.
	DR. ESHKOL:  Maybe just to remind the audience.
	DR. BOLTON:  Would you introduce yourself?
	DR. ESHKOL:  Aliza Eshkol from Geneva ÄÄÄÄ.  I presented yesterday, data on the validation of the ÄÄÄÄ production, the possible validations, which included not only the filtrations, and we have never been able to remove by 20 nanometer filters more than 2 logs of infectivity.
	DR. BOLTON:  Again, I think that's important to point out, that the different milieu or the different pre-treatment makes these studies very complicated to interpret.
	At this point, just before we -- well, let me ask again, are there any other comments or questions from the committee?
	Dr. Belay has reminded me that there is in fact a single variant CJD case that resides in the United States, and he would like to bring the committee up to date on that case.  Dr. Belay?
	DR. BELAY:  Yes.  I think everybody's aware of this case because it's been in the media, widely reported.  This is a person who was born in England and moved to the United States as a teenager and has been residing or living in the United States since then.  The patient is still alive and receiving medical care in the United States.
	Initially, there was a question on whether or not this case should be assigned to the U.S. or to the U.K.  The working group had already made a decision that vCDJ cases should be assigned by the country in which they had illness onset or they resided at the time of illness onset.  Because this patient was a U.S. resident, it's now being called a U.S. case.
	DR. BOLTON:  Could you give us when she was a teenager, in terms of the epidemic, the BSE epidemic?
	DR. BELAY:  She was born and raised in the United Kingdom throughout the 1980s. As you recall, this is a time period where BSE was rising and no preventive measures were instituted to prevent export to humans.
	DR. BOLTON:  When did she move to the U.S?
	DR. BELAY:  Early 1990s.
	DR. BOLTON:  Any other questions or discussion?  Well, I would entertain a motion to adjourn then.
	One thing I would like to say, actually, before we do that.  It's clear that we have seen maybe the very early defects of the guidance implemented in January.  I think that we need to get an update on that at our meeting in October, so that we have a little bit better picture of what effects that may have had, so I would just ask David and FEA to arrange to have that done.
	DR. SCOTT:  We plan to do that and I want to thank all our speakers today for all of their efforts in updating us on the blood supply and also for the scientific updates, which were very informative and useful.  We will update you at the next meeting.
	DR. BOLTON:  Thank you, Dot, I was remiss in thanking everyone.  Thank you all, all the committee members, the members of the public for attending this meeting.
	(Whereupon, at 12:32 p.m., the PROCEEDINGS were adjourned.)
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