1
	DEPARTMENT OF HEALTH AND HUMAN SERVICES
			FOOD AND DRUG ADMINISTRATION
CENTER FOR BIOLOGICS EVALUATION AND RESEARCH
		BLOOD PRODUCTS ADVISORY COMMITTEE

								67th MEETING
Friday, September 15, 2000 8:00 a.m.
						Hilton Gaithersburg
		620 Perry Parkway Gaithersburg, Maryland

			2
PARTICIPANTS
Blaine F. Hollinger, M.D., Chairperson
Linda A. Smallwood, Ph.D., Executive Secretary
MEMBERS
	John M. Boyle, Ph.D.
	Mary E. Chamberland, M.D.

Richard J. Kagan, M.D. Jeanne V. Linden, M.D. Gail B. Macik, M.D. Daniel L. McGee, Ph.D. Mark A. Mitchell, M.D. Terry V. Rice
Paul J. Schmidt, M.D. David F. Stroncek, M.D. Sherri O. Stuver, Sc.D.
NON-VOTING CONSUMER REPRESENTATIVE Katherine E. Knowles
NON-VOTING INDUSTRY REPRESENTATIVE Toby L. Simon, M.D.
TEMPORARY VOTING MEMBERS
Paul R. McCurdy, M.D. Kenrad E. Nelson, M.D. Carmelita U. Tuazon, M.D.

		3 C O N T E N T S
Welcome and Opening Remarks		5
COMMITTEE UPDATES
Summary of Workshop on Recruiting Blood Donors,
Successful Practices:
		Gilliam Conley		6
Summary of Workshop on Hemopoietic Cells from Cord Blood: Ellen Lazarus, M.D.	20
Summary of Public Meeting on Regulation of Bone Products: Ruth Solomon, M.D.	28
Summary of Joint Transmissible Spongiform Encephalopathies and Vaccines and Related Biological Products Advisory Committees Meeting:
		David Asher, M.D.	37
Update on Rapid HIV Test Approval Requirements and Standards:
		Kimber L. Poffenberger, Ph.D.	47
	III. Current Utility of Screening Blood Donors
for Antibody to Syphilis
FDA Framework:
		Chiang Syin, Ph.D.	56
Background on Clinical Syphilis:
		Lauri Markowitz, M.D.	66
Background on Diagnostic Testing for Syphilis:
		Roger Y. Dodd, Ph.D.	79
Syphilis Surveillance and Blood-Borne Transmission:
		Lauri Markowitz, M.D.	91
American Red Cross NAT Donor Study:
		Sharyn Orton, Ph.D.                            116
REDS Study of Syphilis Screening as a Surrogate Test:
		Alan Williams, Ph.D.                           132
Maricopa County STD Study:
		Lauri Markowitz, M.D.                          152
CDC Proposed Studies:
		Dr. Hsi Liu                                    164

							4
C O N T E N T S (Continued)
Open Public Hearing
		Presentations
			AABB, Louis Katz, M.D.	178
			ABC, Celso Bianco, M.D.	182
Questions for the Committee:
		Martin Ruta, J.D.,Ph.D.	185
Committee Discussion and Recommendations	186
IV. Classification of HLA Devices
FDA Presentation of the Issue:
		Sheryl Kochman	209
Third-Party Review Program:
		Eric Rechen	220
Open Public Hearing	235
Charge to the Committee	235
Questions for the Committee:
		Sheryl Kochman	236
Committee Discussion and Recommendations	238
			V. Report of Intramural Site Visit:
Laboratory of Molecular Virology,
Division of Emerging and Transfusion Transmitted Diseases
Introduction and Overview:
		Hira Nakhasi, Ph.D.	252
		Indira Hewlett, Ph.D.	257
		Subhash Dhawan, Ph.D.	267
(Committee Discussion and Recommendations in Closed Session)

			5 1		         P R O C E E D I N G S
	2		      Welcome and Opening Remarks
	3		DR. SMALLWOOD:  Welcome to the 67th Meeting of the
	4	Blood Products Advisory Committee.  This is the second day
	5	of our meeting here.  I am Linda Smallwood, the Executive
	6	Secretary.  Yesterday, I read the conflict of interest
	7	statement that applies to both days of this meeting.
	8		At this time, if there is anyone who needs to make
	9	any declarations regarding any affiliation that may be
10	perceived as a conflict of interest regarding this meeting,
11	please do so at this time.  If not, then we will proceed.  I
12	would just like to remind anyone that is speaking, when you
13	go to the mike, please give your name and your affiliation
14	so that it can be recorded appropriately in the transcript.
15		At this time, I will turn the proceedings of this
16	meeting over to the Chairman of the Blood Products Advisory
17	Committee, Dr. Blaine Hollinger.
18		Dr. Hollinger?
19		DR. HOLLINGER:  Thank you, Dr. Smallwood.  We have
20	two items, basically, this morning.  We first start out with
21	some committee updates on several workshops that have been
22	held and several other issues from advisory committees and
23	updates.  Then we go into a session on utility of screening
24	blood donors for antibodies to syphilis.  That will take
25	this morning.

			6 1		This afternoon, we then have something on
	2	classification of HLA devices and finally a report of an
	3	intramural site visit on the Laboratory of Molecular
	4	Virology.
	5		So, having said that, we will start off, then,
	6	with a summary of the Workshop on Recruiting Blood Donors,
	7	Successful Practices, that was held July 6 to 7, 2000.
	8		Gilliam Conley?
	9		           COMMITTEE UPDATES
10	       Summary of Workshop on Recruiting Blood Donors
11		          Successful Practices
12		MR. CONLEY:  Good morning.  It is nice to be part
13	of the opening act for the main events to follow later
14	today.
15		[Slide.]
16		In talking about the workshop that we held in

17	Rockville, it was difficult to fit all of the issues into
18	two days, but we pressed a lot of information in a very

19	tight time frame.  So it is even more difficult to do a ten-
20	minute or so recap of that.
21		I was alarmed, as I was making bullet points, that
22	flying past some of these issues in a bullet point almost

23	makes them seem insignificant.  Just keep in mind, please,
24	that each of the bullet points would all warrant a lot more
25	lengthy discussion so, if everybody will regard my

			7 1	presentation this morning as the Readers Digest Condensed
	2	Book that was made from the cliff notes of the meeting, then
	3	we will all be in the right perspective for what we are
	4	working with.
	5		The committee has got a handout of the summary.  I
	6	will have a correction to that as I go through--a
	7	clarification, really--as I go through the presentation. 

	8	So, even trying to condense it to a three-page summary, I
	9	also made mistakes.
10		[Slide.]
11		There were a lot of people, when FDA announced
12	that they were going to have this workshop, wanted to know

13	why the FDA was having a workshop about donor recruitment. 
14	I have to say that FDA has always been in support,
15	certainly, of donor-recruitment issues but the Public Health
16	Service at large became much more interested when, in 1999,
17	the National Blood Data Resource Center published a report
18	where they predicted significant blood shortages sometime
19	this year.
20		In defining why we would be involved, certainly,
21	as a member of the Public Health Service Group, the mission
22	to enhance the wealth and well-being of the public is part
23	of our mission and this workshop fits easily into that.  The
24	FDA mission of guarding the safety and efficacy of the blood
25	supply in the U.S., likewise, low supplies certainly will

			8 1	mean that there are safety issues to be concerned about.

	2		But the most important part of the workshop was
	3	really to share proven donor-recruitment strategies.
	4		[Slide.]
	5		These are just the basic facts about the meeting,
	6	when it was held, where it was held.  It was important to a
	7	lot of our participants that, being a government-sponsored

	8	workshop, they didn't have to worry about registration fees. 
	9	So some people on tight budgets could afford to come.
10		We advertised, as best we could, in the short time
11	frame that we had.  It was published in the Federal Register
12	and our colleagues at ABC, AABB and the ADRP--and if you are
13	not familiar with that group, donor-recruitment
14	professionals group, all did the best they could to get the
15	information out.
16		We especially were appealing for donor recruiters
17	or even donor groups to participate in the workshop. 
18	Indeed, about half of our participants at the workshop were
19	donor recruiters and we did have a few representatives from
20	donor groups.
21		We deliberately limited the time for the speakers
22	in the first day.  We really put the pressure on them to

23	bring the most important facts out very quickly and in a
24	short time frame.  In our second day, we had discussion

25	groups and we used facilitators for our discussion groups,

			9 1	again to keep them on track.  Each group has a focus task to
	2	bring back to the main meeting.
	3		I think this time pressure and this focus and this
	4	facilitation kept things on track very well for the meeting. 
	5	Our speakers, for the most part, all rose to the challenge
	6	and put a lot of information in a short period of time.
	7		We also asked all of our speakers to be as fact-

	8	based as they could.  We wanted people who had observations
	9	that showed that what they were reporting on was successful
10	over time.  In the donor-recruitment literature, it is easy
11	to find anecdotal stories and we did not want to hear that
12	if we have a donor drive that has a luau theme that we get
13	more donors, unless you had done it repeatedly over a number
14	of years and could show that it made a significant
15	difference in how you were recruiting donors.
16		So that is what we were looking for.  In a way,
17	the two-day session gave us both a set of fact-based
18	presentation and then a conventional wisdom because the
19	people who were there, many of whom were donor recruiters,
20	were in our discussion groups.  So we compare, in some ways,
21	the things that have been proven versus the things that
22	people at a gut level think work.
23		You will see, when I present later, places where
24	there was not clear agreement.  Mostly, it was because we
25	could see a difference in some of the presentations and what

			10 1	people wanted to continue doing.
	2		Ultimately, when we started planning this
	3	workshop, our goal was to have a guidance document on donor-
	4	recruitment.  Again, this seemed to set a lot of people's
	5	teeth on edge, the thought that the FDA might start setting
	6	regulatory guidance about donor recruitment.
	7		In fact, Dr. Epstein clarified at the opening of
	8	the meeting that that was not the ultimate goal, that we
	9	don't want to get into this in a regulatory way but in a way
10	to encourage blood donation.  So we will get into areas

11	where there was clear agreement between the two days and
12	between virtually all the presenters that are key aspects
13	about blood donation and then we will cover where there is
14	not clear agreement.

15		[Slide.]
16		This is the area where I am very nervous because a
17	lot of these bullet points look very simple and succinct,
18	but there is a lot of detail and a lot of information that
19	goes behind them.  Successful donor-recruitment programs are
20	multifaceted with demonstrated expertise in customer
21	relations, advertising and marketing, public relations and
22	in management issues.  It is a wide spectrum of business and
23	marketing practices that have to be applied well to be
24	successful.
25		Successful programs exhibit a culture of hard

			11 1	work, innovation and cooperation, at least the speakers who
	2	came forward for us and talked about their program.  These

	3	seemed to be aspects of their programs.
	4		[Slide.]
	5		Successful programs have all the employees in
	6	their organization focussed on blood donation and they are
	7	all thanking and encouraging donors.  This is especially

	8	true among the collection staff, the people who have the
	9	most face-to-face contact with the donors.  Successful
10	programs emphasize panel recognition and there is a
11	difference between recognition and giving incentives and
12	gifts.
13		We heard, over and over again, that the long-term
14	donor who is the altruistic donor who is donating for
15	internalized reasons really can be turned off by incentives. 
16	But what they are not turned off by are those constant
17	"thank you"s, the encouragement, the celebration dinner for
18	your multi-gallon donors once a year, public recognition of
19	the importance of their altruism and those kinds of issues.
20	That is what we mean by donor recognition.
21		So it is important that their altruistic behavior
22	be reinforced at each donation and at notable milestones in
23	their donation history.
24		[Slide.]
25		When it comes to advertising, successful programs

			12 1	are keyed to an emotional appeal.  They put a human face on
	2	both donors and transfusion recipients.  Pictures of empty
	3	blood shelves don't really cut it.  They don't do anything. 
	4	Those that tell the story of a transfusion recipient or tell
	5	the story of a long-term donor, those advertising appeals
	6	and campaigns do have an impact.
	7		Advertising campaigns can definitely benefit from
	8	partnerships.  And we heard about partnerships with sports

	9	teams, t.v. and radio stations that have been very
10	successful.  Paid advertising, especially, also seems to
11	bring other benefits in that the donor centers establish a
12	relationship with the local t.v. and radio stations.  We
13	were told that then, when they have to go on appeal and

14	there are public-service announcements made, they seem to
15	appear in better time slots when you are already also a paid
16	customer.  So there is a spinoff benefit.
17		It was also noted, though, that advertising,
18	although it increases awareness, it does not put a donor in
19	the chair.  People don't come flooding to your donor center
20	because they have seen your latest well-conceived, high-
21	impact ad, no matter how much of a human face you put on it.
22	To put a donor in the chair, you still need to ask them to
23	donate and preferably one-on-one face-to-face.
24		Successful corporate campaigns are those campaigns
25	that are run usually by a large corporation and they work

			13 1	when you have buy-in and support from the top management of
	2	the organization that you are working with.  They also seem
	3	to have a natural growth pattern in that once a corporate
	4	campaign has been successful, the executive officers of that
	5	company like to challenge similar companies to do the same
	6	thing.  And so there is a natural growth pattern to
	7	corporate campaigns.
	8		[Slide.]
	9		Successful telemarketing, and telemarketing

10	includes those annoying people that always call you at
11	dinner time to try to sell you something.  But blood-donor
12	centers have also used it successfully to call their donors
13	to schedule them for new appointments or to remind them of
14	existing appointments.
15		These seem to work well when they are linked to a
16	real-time donor database.  By real-time donor database, I
17	mean that when I am sitting down as a telemarketer to make

18	my calls, I am not calling you when you just donated at 1:00
19	p.m. this afternoon and annoying you with an evening phone
20	call.
21		Instead, I have got real-time data that tells me
22	what your donor history is.  Similarly in my database, when
23	I call you, I know, based on your donor history, when you
24	like to donate, where you like to donate.  I know your blood
25	group so I know if it is one of the things my inventory

			14 1	needs.
	2		Not just picking up the phone and calling donors. 
	3	That is not telemarketing, but a system that is linked to a
	4	database where things are tied together with real and
	5	important information.
	6		Successful donor education definitely belongs in

	7	the schools as early as possible as part of the science and
	8	health curriculum.  We heard reports on Puget Sound's
	9	successful educational program, My Blood Your Blood, that
10	was originally put together with an NHLBI grant and is now
11	being revamped and continuing under the auspices of AABC,
12	but, again, a program that has shown to be very successful
13	and, in the long run, if we want to have donors in the

14	future, we have got to get out there and educate our donors.
15		Pretty much the feeling of the group was that
16	community education is not as successful.  It is nice to get
17	that information out, but where you get the real bang for

18	the bucks is educating the younger potential donor, the
19	child of potential donors, using that education and that
20	recruitment technique where you can.
21		[Slide.]
22		We heard heart-felt concern from virtually
23	everybody at the meeting that it is difficult in pressing

24	financial times and competitive times when the reimbursement
25	issues in the hospitals and healthcare have a trickle-down

			15 1	effect to the blood centers that it is very difficult to put
	2	together good programs and maintain good donor-recruitment
	3	programs in that situation.
	4		It was very clear that successful programs
	5	recognize that donor recruitment is essential.  They put it
	6	up front and you see the difference in that belief in the
	7	funding, staffing and involvement of donor-recruitment
	8	people in organizational planning.  You know, maybe this
	9	should have been my first bullet point because that is the
10	overarching, recognize how important it is, put it up front,
11	support it, integrate it into your entire blood center and
12	you will see a difference.
13		So the successful programs are the ones that keep
14	the donor and the recipient as the focal point of their
15	purpose and what they are trying to accomplish.
16		Now into the area where there were discussions and
17	not clear agreement.  So if I can see the next slide,
18	please.
19		[Slide.]
20		Incentives were clearly an area of concern,
21	confusion and disagreement.  First of all, there was data

22	and evidence presented that incentives, and probably the
23	larger the incentive the more the impact, have an adverse
24	impact especially on long-term donation.  You may get more
25	first-time donors but for building a cadre of long-term

			16 1	repeat donors, incentives really don't work.
	2		Yet, despite some of the evidence that was
	3	presented at the meeting in the discussions, it was clear
	4	that people are reluctant to give up their incentives.  Here
	5	I come to, in my summary, where you need to make a
	6	correction because I mentioned that some states have
	7	apparently outlawed incentives.  Based on the remarks, as I
	8	initially heard them, I said that New York was one of those
	9	states, Dr. Linden has clarified for me that, indeed, all
10	that New York State really does is enforce FDA's incentive
11	issues as they understand them.
12		What the gentleman, Mark Thornhill, who reported
13	said was that they do not use incentives at their Red Cross
14	Center and it was supported by a very conservative approach
15	in New York.  I think it is a matter of interpretation but
16	it also illustrates the confusion about incentive issues. 
17	There was a strong request that FDA clarify where they stand
18	on incentives and, indeed, work is in progress.  It will

19	probably be a guidance for field inspectors that will be
20	publicly available on exactly how to interpret the FDA's
21	stance on incentives coming out later this year.
22		Incentives are further clouded by the fact that
23	some of the things that we call incentives are also
24	advertising; t-shirts.  The gentleman from Florida Blood
25	Services said, "If you are in the Tampa Bay area at any

			17 1	sporting event, if you look around, you will see our t-
	2	shirts."
	3		Indeed, he described the efforts that they do to

	4	come up with new and attractive designs, and t-shirts are
	5	very important.  Again, they bring in the first-time donors. 
	6	For them, they are also free advertising.  So I guess you

	7	have to balance those kinds of issues, too, in incentives.
	8		Another area where there is not clear agreement
	9	was all about advertising.  While some centers reported
10	great success in using paid advertising and recruiting and
11	maintaining donors, there were still many that felt that
12	advertising was either inappropriate or unaffordable for
13	their centers.  And so an ongoing debate there.
14		I recognize that some people are having great
15	success.  I recognize that others still have problems with
16	the issue.
17		[Slide.]
18		As a spinoff of our discussion about the success
19	of corporate donor-recruitment programs, there was some

20	discussion about whether corporations should be able to
21	realize tax breaks for the expenses associated with those
22	programs.  Again, there was a lot of skepticism about that
23	as an issue and, certainly, it is not within FDA purview to

24	say anything about the tax schedule, especially the business
25	tax schedule, but it is not a cheap affair to sponsor a

			18 1	corporate donor program because usually a lot of the donor-
	2	recruitment personnel are coming from your own center.
	3		There may be dinners.  There may be awards.  There
	4	may be incentives that are given out usually which the
	5	corporation pays for.  Of course, once you open that door,
	6	then you get into issues about should they be able to
	7	somehow expense the time off for donors to donate and so it
	8	was seen as quite a quagmire.  I think that is why a lot of
	9	the skepticism on that issue.
10		[Slide.]
11		Those are kind of the issue-related things.  I
12	wanted to present to this group, on the next slide, at least
13	one more issue just because we heard it spontaneously from
14	many different people that, in their blood centers, one of
15	their problems is a conflict between their donor recruiters
16	and their donor operations staff.
17		What it come down to is if I am bringing in more
18	and more people and then I want you to handle them
19	competently, but you have limited resources to do that, and
20	now, because you have limited resources, you have offended
21	one of the people I recruit so they won't come back again,
22	there is a natural tug here between the two.
23		What it comes down to is the most successful
24	organizations have integrated the recruiting and encouraging
25	of donors so that permeates the entire organization and it

			19 1	is part of everyone's job.  So, together, they find
	2	solutions to resolve the problems while remaining focused on
	3	their primary goals.
	4		Some organizations have made this shift to a new

	5	approach to an integrated system of recruiting donors.  It
	6	sounds like many blood centers are still struggling with
	7	that change and many of them said that they needed to
	8	institute some kind of a culture shift in their own
	9	organization.
10		A lot of information in two days and where do we
11	go next.
12		[Slide.]
13		Again, recognizing that donor recruitment is not
14	the area of FDA's expertise, the people at the America's
15	Blood Center have agreed to spearhead the writing of a

16	document about best practices or successful practices in
17	donor recruitment and contact person is on this slide, Susan
18	Parkinson, at ABC.
19		The reviews that we got from the participants at
20	our workshop were some of the best we have seen at any FDA
21	workshop.
22		[Slide.]
23		So I have to, on the next slide, at least
24	acknowledge the speakers.  My time is brief so I am not
25	going to read all the names, but these were the people who

			20 1	came and spoke for us.
	2		[Slide.]
	3		In this slide, you will see the people who
	4	facilitated the discussions on Day 2.
	5		[Slide.]
	6		On the last slide, I just have to thank the people
	7	that were on the planning committee for the workshop and a
	8	special thank you to Susan Parkinson at ABC who was very
	9	helpful in identifying people who had successful practices
10	so that we could contact them and invite them to speak at
11	our workshop.
12		I will be happy to answer any questions.
13		DR. HOLLINGER:  The next item is a summary on
14	Hemopoietic Cells from Cord Blood, Dr. Lazarus.
15	  Summary of Workshop on Hemopoietic Cells from Cord Blood
16		DR. LAZARUS:  Good morning.
17		[Slide.]
18		The Cord Blood Meeting was sponsored by the
19	National Heart, Lung and Blood Institute and CBER.  It was
20	held at the Mazur Auditorium of the Clinical Center of NIH
21	on August 14 and 15.  This was predominantly a scientific

22	meeting as opposed to a regulatory meeting.
23		It consisted of cord blood bank, clinical
24	transplantation and basic scientific presentations followed
25	by panel discussions which summarized the main points of

			21 1	each session and gave the audience to ask questions and
	2	express opinions.
	3		Several of these presentations included clinical
	4	and nonclinical data that were submitted to the docket in
	5	response to the FDA requirement for data for proposed
	6	Hemopoietic Stem Progenitor Cell Standard that was published
	7	in the Federal Register and an unedited transcript of this
	8	meeting will soon be up on the web.
	9		[Slide.]
10		The objectives of the two-day meeting were first
11	to discuss the current status of unrelated allogenic,
12	placental in local blood banking and transplantation and

13	secondly to discuss the scientific issues regarding the
14	characterization of placental and local cord blood grafts
15	and the data supporting development of cord blood-product
16	standards and then, finally, to identify future research
17	directions
18		[Slide.]
19		The first session consisted of presentations by
20	representatives of public cord blood banks in the U.S.,
21	Canada and an international organization, NETCORD.  There
22	was data presented addressing the major issues in cord

23	blood-bank collection, procedures, processing and frozen
24	storage and infectious disease testing, HLA testing, product
25	characterization, shipping and thawing.

			22 1		[Slide.]
	2		And then the panel discussion at the end of this
	3	first session focused on the similarities and differences in
	4	cord blood-bank practice among the centers.  One of the
	5	major differences that was apparent is in the way the
	6	various centers perform and report cord blood-product cell
	7	counts and by ability and other assays used to characterize
	8	the product.
	9		Some of the donorists suggested the development of
10	uniform criteria for product cell counting possibly
11	supported by voluntary laboratory certification programs. 
12	Another major area of nonuniformity is in criteria for donor
13	exclusion.  All of the panelists were able to agree that, as
14	a minimum requirement, all cord blood units should be
15	characterized with respect to total nucleated cell counts,
16	ABO/Rh type.  They should all undergo hemoglobinopathy
17	screening and, of course, HLA typing.
18		However, a recurrent issue, the optimum level of
19	resolution for the HLA typing remains unresolved.
20		[Slide.]
21		The second session addressed essential issues for
22	communication between cord blood banks and transplant

23	centers.  The presenters provided information regarding
24	search algorithms used to select the optimal cord blood

25	product for each patient.  Among the most important criteria

			23 1	that fell out were HLA match, cell dose and confirmation
	2	that the transplant will be performed under an IRB-approved
	3	protocol.
	4		Most of the current systems that were described
	5	were automated on-line systems.  Web-based systems are being
	6	developed and then, interestingly, several multibank
	7	cooperation levels were presented.
	8		[Slide.]
	9		In the next session, transplant outcome data were
10	presented describing the effects of HLA disparity, cell
11	dose, recipient age and underlying disease on engraftment
12	and survival outcomes.  There was a comparison of pediatric
13	bone-marrow transplants and umbilical-cord transplants from
14	HLA-identical sibling donors.  And then data were presented
15	from the New York Blood Center, St. Louis, consolidated data
16	from Duke and University of Minnesota.
17		Transplant outcomes in 68 high-risk adult

18	recipients were presented and some Japanese data. 
19	Basically, the data showed that umbilical-cord blood has
20	been successfully transplanted in hundreds of pediatric

21	patients and a much smaller of adult patients, and that cell
22	dose is the major determinant of transplant outcome while
23	extensive HLA disparity is also very important.
24		[Slide.]
25		The next session consisted of other scientific

			24 1	presentations.  Among the topics presented were ex vivo

	2	expansion of cord blood and several talks on different
	3	approaches to identify and characterize hemopoietic stem
	4	cells and their possible correlation with engraftment
	5	potential.
	6		[Slide.]
	7		Then, at the end of the meeting, a list of
	8	possible standards, standards for cord-blood products, was
	9	derived based on the presentations and discussions that had
10	occurred during the two-day forum.  The general attitude
11	expressed at the meeting was not resistant to the
12	development of cord-blood products and transplantation and
13	the suggestions that were derived are as follows.
14		The products should be processed and stored in an
15	accredited lab setting or cord-blood bank and should be
16	collected in accordance with some standards.  The donors
17	should undergo infectious-disease screening and testing. 
18	Maternal and family history should be obtained and maternal
19	informed consent should be obtained.
20		The minimum product volume was recommended to be
21	30 milliliters and the product should be sterile or free of
22	bacterial contamination.  The product should be
23	characterized with respect to ABO/Rh, HLA typed at the A, B

24	and DR beta 1 loci.  It should be characterized with respect
25	to the post-procession, cell counts and possible viability.

						25
		1		The transplant unit should be selected to be a
		2	minimum of three out of six locus HLA match and the
		3	suggested cell dose for small recipients, under
		4	50 kilograms, was 2 times 10		           
					7 per kilogram and, for larger
		5	recipients, over 50 kilograms one times 10		           
							7 per kilogram
		6	recipient body weight.
		7		[Slide.]
		8		Finally, the future research directions were
		9	presented.  This lists for you some of the suggestions that
	10	were made.  One is development of voluntary certification
	11	programs for cord blood banks.  There is interest, of
	12	course, in techniques to increase cell dosing and these can

	13	include ex vivo expansion combining units and perhaps other
	14	strategies that are yet to be developed.
	15		There is interest, of course, in development of
	16	DNA-based technologies for infectious-disease and sterility
	17	testing and for development of laboratory markers to detect
	18	the true hemopoietic stem progenitor cells.
	19		There is interest in pursuing prospective
	20	comparative studies of cord blood versus bone-marrow
	21	transplantation in pediatric patients and well as consuming
	22	and expanding ongoing studies of the efficacy of cord blood
	23	for transplantation in adults.
	24		And then, finally, it would be important to
	25	investigate the possible multipotentialities of cord blood

			26 1	cells.
	2		Thank you.
	3		DR. HOLLINGER:  Thank you, Dr. Lazarus.  Dr.
	4	Linden?
	5		DR. LINDEN:  On your second-to-the-last slide, you
	6	mentioned recommending or saying that products should be
	7	stored and collected by an accredited bank.  My question is
	8	accredited by whom and, if you are referring to private
	9	organizations such as FACT and AABB, is FDA considering
10	recognizing private organization and accreditation?  Could
11	you please elaborate that issue?
12		DR. LAZARUS:  As I said, the meeting was basically
13	a scientific meeting so, at the end of the meeting, when
14	discussion occurred, there really wasn't a discussion of who
15	should be making the standards and enforcing the standards
16	but rather there was an acceptance of the concept of
17	standards and accrediting organizations.
18		So who would do it wasn't really discussed.
19		DR. HOLLINGER:  Dr. Stroncek?
20		DR. STRONCEK:  There has been national activity
21	around stem-cell donations and collections for about fifteen
22	years as far as unrelated donors.  Cord blood activity
23	really goes back almost ten years.  It is probably about
24	five years it has been really popular.  I commend the FDA in
25	the battle you fought to get this under some kind of

			27 1	organization around it.  I know it has been a difficult
	2	battle, so I would encourage you to go ahead and set up your
	3	standards.
	4		We have heard a lot about FACT.  I am Chairman of
	5	the NMDP Membership Committee and all these organizations

	6	are trying, but there is kind of a consensus.  They have a
	7	consensus on the areas you pointed out, but as far as the

	8	tightness of the regulation, it is not there unless the FDA
	9	moves forward and comes up with their own standards and
10	starts to handle it like a blood product.
11		For example, you mentioned cell counts.  Cell
12	counts is one area where, as you pointed out, there is huge
13	disagreement on even how to do a cell count, what a cell
14	count means, where that is in stark contrast to the
15	regulation and the care we must use for the reagents we use
16	for ABO typing or for viral testing.  These results are very
17	comparable from one center to another across the country.
18		I can tell you these cell counts are not
19	comparable across the country.  As the data suggest, cell
20	count is a critical measure in these outcomes.  So I applaud
21	the FDA's efforts and encourage them to move forward and to
22	bring up the basic aspects such as cell counting in cord

23	blood banking up to the same standards we have in blood
24	banking.
25		DR. HOLLINGER:  Thank you.  Thank you, Dr.

			28 1	Lazarus.
	2		The next presentation is on a summary of the
	3	Public Meeting on the Regulation of Bone Products.  Dr.
	4	Solomon.
	5	  Summary of Public Meeting on Regulation of Bond Products
	6		DR. SOLOMON:  Good morning.
	7		[Slide.]
	8		I am going to be summarizing an open public
	9	meeting held on August 2 of this year.
10		[Slide.]
11		The meeting was announced in the Federal Register
12	on July 18 and the title of the meeting was Human Bone
13	Allograft Manipulation and Homologous Use in Spine and Other
14	Orthopedic Reconstruction and Repair.  The meeting was held
15	in Bethesda and a docket was set up.
16		The purpose of the meeting was to provide
17	information to help FDA in clarifying the regulation of

18	human bone allografts under the proposed approach to the
19	regulation of cellular and tissue-based products.
20		To give you some background, in February of '97,
21	FDA announced a risk-based approach to the regulation of a
22	broad spectrum of cells and tissues where the degree of

23	regulation would be proportional to the risk.  Since '97,
24	FDA has published two proposed rules to implement the
25	proposed approach.

			29 1		They are the registration proposed rule and the
	2	donor suitability proposed rule.  A third rule on good
	3	tissue practice will be published shortly.
	4		[Slide.]
	5		Criteria for determining risk is set forth in the
	6	proposed rules.  For some products with low risk, there
	7	would be no premarket submission, to review and approval of
	8	an application and the concerns would be focused on
	9	preventing communicable disease transmission, the legal
10	authority being Section 361 of the Public Health Service
11	Act.
12		In order for a human cellular and tissue-based
13	product to fit into this category, all four of the following
14	criteria would need to be met.  The product would need to be
15	minimally manipulated, and I will define some of these terms
16	a little later, not promoted or labeled for any use other
17	than a homologous use, not combined with or modified by the
18	addition of any component that is a drug or device, and does
19	not have a systemic effect, with certain exceptions.
20		Other products which do not meet all four of these
21	criteria would be more rigorously regulated as a biologic,
22	drug or device requiring a premarket submission to FDA.
23		[Slide.]
24		The meeting focused on the first two criteria,

25	manipulation and homologous use.  Many comments to the

			30 1	dockets of the proposed rules had expressed concern that
	2	bone allografts would be regulated as medical devices rather
	3	than as 361 tissues.  FDA asked five questions to focus the
	4	discussion.  The first asked which processing procedures

	5	apply to human bone allograft fall within or outside of
	6	FDA's proposed definition for minimal manipulation.
	7		[Slide.]
	8		The definition, as proposed, for minimal
	9	manipulation for structural tissue such as bone meant
10	processing that does not alter the original relevant

11	characteristics of the tissue relating to the tissue's
12	utility for reconstruction, repair or replacement.
13		Examples of such minimal manipulation procedures
14	were given in the preamble to the proposed rules.
15		[Slide.]
16		Public discussion and comments on manipulation
17	included the following.  Some people felt the criterion

18	should be eliminated.  Some felt, because the definition was
19	vague, we should repropose it with more specificity and
20	examples.  Others felt that the definition should be
21	pertinent for each product type.
22		Other comments said that preshaping or threading
23	bone, whether in the tissue bank or in the operating room,
24	does not alter its original relevant characteristics.  And
25	this was really the main focus of the meeting in that there

			31 1	is a product called a bone dowel which is a cylindrical
	2	segment of bone machined to have threads, like a screw, and
	3	used in spinal fusion.
	4		They perform a similar function to metal
	5	prostheses and the metal prosthesis are regulated as medical
	6	devices, so the concern was that the bone dowels might also
	7	be regulated as medical devices.  But this comment mentioned
	8	that threading, which is done to a bone dowel, should be
	9	considered minimal manipulation.
10		[Slide.]
11		Others suggested that any process which does not
12	alter the essential microstructural elements of the
13	allograft is a minimal process.  Still others felt that the
14	result of manipulation should be more important than the
15	fact of manipulation, that validation to insure that
16	processing does not affect the product was the way to go
17	and, as an example of more than minimal bone products
18	modified by genes, genetic therapy, was felt to be more than
19	minimal but anything less severe than that would be
20	considered minimal.
21		The second question focused on homologous use,
22	which use of human bone allograft fall within or outside of
23	FDA's proposed definition of homologous use which appears on
24	the next slide.
25		[Slide.]

			32 1		By homologous use, we meant the use of a cellular
	2	or tissue-based product for replacement or supplementation. 
	3	And for structural products, such as bone, it occurs when
	4	the tissue is used for the same basic function that it

	5	fulfills in its native state in a location where such
	6	structural function normally occurs.
	7		In other words, the function of the bone in the
	8	donor and the function in the recipient were the same,
	9	essentially the same.  The proposed rule focused on whether
10	the product was promoted or labeled for any use other than
11	homologous use.  Examples were given in the preambles.
12		[Slide.]
13		Again, the public discussion on this point varied. 
14	Some people, again, said, "This is not a good criterion. 
15	Eliminate it."  Others said it was vague, we should
16	repropose the definition with more specificity and examples,
17	and the definition should be pertinent to each product.
18		Others pointed out that when an allograft is used
19	in the same manner as an autograft, it should be considered
20	homologous use.
21		[Slide.]
22		Others wanted us to tweak the definition a little
23	and say "same basic characteristics" instead of "same basic
24	functions."  But the main points that were made were that

25	fusing bone to bone should be considered homologous use.  We

			33 1	are not trying to replace the disc but rather to fuse bone.
	2		These bone dowels, for instance, had a long
	3	history of safe and effective use in spinal fusion and there
	4	was a lot of literature on them.  Finally, the use of bone
	5	anywhere in the skeleton or in any orthopedic procedure
	6	should be considered homologous use.
	7		[Slide.]
	8		Then we asked what risks to health have been

	9	identified and characterized for human bone allograft
10	products.  The comments ranged from, "There are no risks,"
11	to other comments that said, "We should evaluate risk by
12	looking at what alternatives the surgeon had."  The

13	alternatives were either to use an autograft which had much
14	more morbidity than an allograft or to use a metal
15	prosthesis which weakened over time.
16		However, some people did point out that there were
17	certain risks to using bone in spine, and those included

18	infectious-disease transmission, possible collapse of the
19	bone dowel, non-fusion in the spine, a graft versus host
20	response.  One comment suggested that we would do a risk
21	assessment for each product and if significant new risk
22	exists, then we should promulgate additional regulations.
23		[Slide.]

24		The fourth and fifth questions were similar.  We
25	asked what controls have been identified to adequately

			34 1	address the risk to health in bone allograft products.
	2		[Slide.]
	3		The discussion pointed out that there are industry
	4	standards, the AATP, American Association of Tissue Banks,
	5	has industry standards and, also, the ASTM, the American
	6	Society for Testing Materials, has standards for the metal
	7	protheses.
	8		Also, some tissue banks have elected to become ISO
	9	9001 certified.  Other controls in place are peer review of
10	the literature articles and the large body of experience
11	that we have with the products and no reports of collapse.
12		[Slide.]
13		Finally, the last question said, "What industry
14	standards are available and what standards will be needed in
15	the future?"  Again, the existing standards that were

16	pointed out were those of the ATB.  Those are really
17	processing standards and standards aimed at infectious-
18	disease control.  Not all tissue banks are members of ATB

19	and those that are not, some follow the standards but others
20	don't.
21		The ASTM standards, again as I mentioned, are for
22	metal implants.  It is not certain whether tissue banks that
23	make allografts hold to these same standards as the metal

24	implants.  However, the several orthopedic surgeons and
25	neurosurgeons did point out that they felt that standards

			35 1	were needed in this area, standards aimed at performance,

	2	standards for biologic activity and potency, standards for
	3	mechanical performance, standards for processing and
	4	determination of bone density.
	5		[Slide.]
	6		Lastly, the perceived advantages of regulation as
	7	a medical device were pointed out and the concerns were
	8	decreased patient access to treatment, decreased
	9	availability and supply, increased cost, increased reliance
10	on autografts or metal prostheses, slowing of ongoing
11	industry standards, development and interference with the
12	practice of medicine.
13		[Slide.]
14		Finally, the FDA will take all comments under

15	serious consideration.  We are moving forward with the
16	finalization of the first proposed rule, the Registration
17	and Listing Rule, and it is possible that the definitions

18	and criteria would be modified in that final rule based upon
19	the comments that we have heard, both at the meeting and to
20	the previous dockets, and that additional examples would be
21	given in the preamble.
22		[Slide.]
23		Next I would like to read a statement into the

24	public report on another matter pertaining to tissues.
25		DR. HOLLINGER:  We really are getting a little

			36 1	far--I am trying to limit everyone to about eight minutes. 
	2	We have been going over every time.  So could you maybe
	3	summarize, then, what you have to say and then we will move
	4	on.
	5		DR. SOLOMON:  Okay.  It is just a one-page
	6	statement.
	7		[Slide.]
	8		It has to do with U.K. deferral as it relates to

	9	cell and tissue products.  Basically, this might be hard to
10	read, but, "The regulations currently in effect for human
11	tissue and transplantation require donor screening and
12	testing for HIV-1 and 2, HBV and HCV.  The proposed
13	regulations for suitability of donors of these products

14	would include the above and, in addition, donor screening
15	for the transmissible spongiform encephalopathies including
16	CJD.
17		"As you know, in November of '99, as a
18	precautionary measure for variant CJD risk, FDA recommended
19	that blood donors who have resided or traveled to the United
20	Kingdom for a cumulative period of six months or more from
21	1980 through 1986 be deferred.  This recommendation was made
22	after a pilot study of the effect on the blood supply and
23	with ongoing monitoring of the blood supply.
24		"To date, no parallel recommendation has been made
25	for cell and tissue donors.  FDA is looking at the issue of

			37 1	donor deferral based on U.K. travel and residency for cell
	2	and tissue donors.  FDA will address the issue in future
	3	guidance developed through the process of notice and
	4	comment.
	5		"FDA is soliciting data or information from the
	6	cell and tissue industry and the public in order to help us
	7	make a better informed decision on this matter.  Such
	8	information could include the likelihood of transmission of
	9	variant CDJ by cells and tissues, the differences in risk
10	among different cells and tissues.
11		"We know that classical CJD has been transmitted
12	by cornea and dura mater.  These tissues, as well as cells
13	and tissues rich in leukocytes and vascularized organs may
14	have a higher theoretical risk of variant CJD.  Finally, and
15	probably quite important, is we are soliciting data or

16	information on the impact, on the supply, of cell and
17	tissues that such a deferral might have."
18		Thank you.
19		DR. HOLLINGER:  Thank you, Dr. Solomon.
20		I think we are going to move on then.  Our next
21	one is on the summary of Joint Transmissible Spongiform
22	Encephalopathies and Vaccines and Related Biological
23	Products Advisory Committee.  Dr. Asher?  You have eight
24	minutes.

25	 Summary of Joint Spongiform Encephalopathies and Vaccines

			38 1	     and Related Biological Products Advisory Committee
	2		DR. ASHER:  Good morning.
	3		[Slide.]
	4		I apologize for not having a slide set available
	5	to Dr. Smallwood until this morning.
	6		[Slide.]
	7		On July 27, the FDA Advisory Committees on
	8	Transmissible Spongiform Encephalopathies and Vaccines and
	9	Related Biological Products met jointly to consider the
10	recent discovery by the agency that, in spite of FDA
11	recommendations dating back to 1991 not to do so,
12	manufacturers had used materials from cattle in BSE
13	countries to prepare several important childhood vaccines.
14		The term BSE country refers to a country that has
15	diagnosed bovine spongiform encephalopathy in a native-born
16	cow or a country that UDSA concludes may have BSE and
17	prohibits importation into the United States of its animals'
18	meat, et cetera.

19		[Slide.]
20		The committee has reviewed regulatory history
21	relevant to vaccines and then the risk associated with the
22	various bovine-derived materials used, risks that depend on
23	the tissues used, when and where they were obtained as well
24	as the manufacturing process.  Model risk assessments were
25	presented by the FDA and the manufacturer.

			39 1		Although the committee did not vote, they offered
	2	suggestions to CBER.  The bovine-derived materials of chief
	3	concern were fetal-calf serum obtained from animals in the
	4	U.K. during years in which BSE was prevalent and used to
	5	prepare a viral vaccine and a gelatin-derivative pancreatic
	6	extract and meat broth used to prepare a bacterial vaccine. 
	7	Those materials were all from moderate-risk BSE countries. 
	8	The identities of the vaccines, none of which has been
	9	withdrawn from the market, have been kept confidential so
10	far.
11		[Slide.]
12		FDA regulations require biological products to be
13	free of extraneous microbial agents.  Conscious of that in
14	1991, CBER first expressed concern about spongiform
15	encephalopathies and asked manufacturers to send information
16	on sources of bovine and ovine materials used to
17	manufacturer biologics.
18		[Slide.]
19		In 1993, CBER revised a points-to-consider
20	document asking that serum used in the cell culture be free
21	of the BSE agent and sent letters to manufacturers asking

22	them to review the document.  In December of that year, FDA
23	requested, in letters published the following year, that

24	most bovine materials used to manufacture FDA-regulated
25	products intended for humans not be sourced from BSE

			40 1	countries and noted that the USDA maintains the list of such
	2	countries.
	3		Following recognition of new-variant CJD in young
	4	people in the United Kingdom and France and its probable

	5	connection with exposure to the BSE agent, FDA reminded
	6	manufacturers of its previous requests and, again, noted
	7	that the BSE list is kept by the USDA.
	8		[Slide.]
	9		A temporary exemption from recommended BSE-free
10	sourcing that had been extended to bovine gelatin in 1994
11	was rescinded for injectable and implantable products in
12	September, 1997.

13		[Slide.]
14		Nevertheless, earlier this year, CBER learned that
15	the four bovine-derived materials had been used in the
16	manufacture of vaccines.
17		[Slide.]
18		The previous guidance was then repeated in a
19	letter from the CBER Director and points that had apparently
20	been misunderstood were clarified, particularly emphasizing
21	that CBER had recommended BSE-free sources of bovine-derived
22	materials at all stages of manufacture and that the USDA was
23	to determine the BSE countries.
24		FDA had not previously addressed the situation in
25	which a country, once considered BSE free, was later place

			41 1	on the USDA's BSE list while products produced with the
	2	bovine materials were still in inventory.
	3		[Slide.]
	4		That became an issue early in 1998 after USDA
	5	included all of Europe on the BSE list.  Ruminant products
	6	prohibited by the USDA include gelatin for human consumption
	7	but the prohibitions include bovine serum.  In practice,
	8	however, if ruminant serum is not identified on an export
	9	manifest as a component of a product, the USDA would
10	probably not stop its importation.
11		[Slide.]
12		Ruminant serum, itself, can be imported into the
13	United States under USDA permit for uses unlikely to bring
14	it into contact with animals of any kind, not just
15	ruminants.
16		[Slide.]
17		Knowing that bovine-derived materials from BSE
18	countries were used to manufacture vaccines, can we estimate
19	the risk.  At the moment, there are ten BSE countries listed
20	here, ten countries known to have BSE, in chronological
21	order.  The vast majority of cases still occur in the United
22	Kingdom where more than 750 have been registered so far this
23	year.
24		Let me say, first, that there is no
25	epidemiological evidence, and that study in the U.K.

			42 1	addressed that hypothesis and it was recently published, no
	2	evidence to suggest that any vaccine has been a risk factor
	3	for new-variant CJD.
	4		[Slide.]
	5		Temporal and geographic risk.  Although BSE has
	6	been found in U.K. cows born in the late 1970s, it is

	7	thought that 1980 marks the probable beginning of the
	8	epidemic followed soon afterwards by Ireland, France,

	9	Portugal, Switzerland and, more recently, in the Benelux
10	countries and Denmark.
11		[Slide.]
12		BSE countries peaked in the United Kingdom at the
13	end of 1992.  It has probably peaked in Switzerland but the
14	situation in other countries is not clear.
15		[Slide.]
16		The USDA simply considers various countries either
17	to be BSE-free or to be unacceptable.  The European
18	Commission's Scientific Steering Committee has attempted to
19	estimate the probable occurrence and prevalence of BSE in

20	twenty-five countries that voluntarily submitted
21	information.
22		The two countries with the highest risk are the
23	United Kingdom and Portugal followed by the eight other
24	countries that have found cases in native cattle.  The EC
25	also suspects that at least three other European Union

			43 1	countries, Germany, Italy, France and Spain probably have
	2	cases and the USDA agrees with that.
	3		[Slide.]
	4		The EC classification of the United States and a
	5	number of other countries is category II--that is,
	6	provisionally free of BSE--because we imported cattle from
	7	the U.K. during early years of the outbreak, rendered some
	8	of them into meat and bone meal and instituted a ban
	9	prohibiting its feeding to ruminants only in 1997.
10		[Slide.]
11		Only a small number of countries are considered to
12	be definitely BSE-free by the EC.
13		[Slide.]
14		As for tissue risk, thus far only neural tissues
15	and intestinal tracts of cattle with BSE have been
16	demonstrated to contain the infectious agent although
17	studies are limited in number and sensitivity.  Both the EC
18	World Health Organization and the OIE, the counterpart of

19	WHO for animal diseases, have accepted four risk categories
20	for bovine tissues based largely on studies of other animal
21	TSE's, especially scrapie in ruminants.
22		Higher-risk tissues are listed here.
23		[Slide.]
24		The materials used to prepare the vaccines, shown
25	here bolded, are all from tissues in the two lower-risk

			44 1	categories.  However, as have our FDA advisory committee,
	2	the EC Steering Committee concluded that ruminant blood and,
	3	presumably, other lower-risk tissues, have a theoretical
	4	potential to transmit disease.
	5		[Slide.]
	6		Not only is there a risk that the tissue, itself,
	7	may sometimes carry small amounts of infectivity, there is
	8	also a risk that it may become contaminated with high-risk
	9	material during slaughter.
10		[Slide.]
11		Vaccine-manufacturing processes have a substantial
12	potential to reduce the amount of BSE agent by should any
13	agent be present in the final product, administration by the
14	intramuscular route would be much more likely to result in
15	infection than the oral route, which is thought to be the
16	most likely route by which humans have acquired new-variant
17	Creutzfeld-Jacov disease.
18		[Slide.]
19		FDA used a risk-assessment model proposed by
20	PhARMA, the Pharmaceutical Trade Association, to estimate,
21	in a general way, what the risks might be that the BSE agent
22	could enter some stage of the vaccine production and
23	expressed that as infectious doses of agent per number of
24	doses of vaccines produced.
25		Some estimates are listed on this slide.  Although

			45 1	such assessments must be considered unreliable because of
	2	the uncertainties and the assumptions on which they are
	3	based, nobody disagreed that the risk seems to be very small
	4	and, in some scenarios, negligible.
	5		[Slide.]
	6		Considering the small theoretical risk of
	7	transmitting CDJ by BSE-implicated vaccines and the
	8	importance of the products which cannot be replaced in the
	9	short run, but not ignoring our special obligation to afford
10	every possible protection to children, the committees offer
11	advice that I summarize in the final eight points.
12		Theoretical risk of transmitting vCJD by fetal-

13	calf serum and presumably other low-risk materials from BSE
14	countries in vaccine seems very small but should not be
15	ignored.  Fetal-calf serum and other bovine materials from
16	animals in BSE countries currently used to prepare working
17	viral and bacterial seeds in cell banks should be replaced
18	as soon as possible with serum and other bovine materials
19	from BSE-free sources.
20		The risk of BSE from fetal-calf serum used to
21	prepare master seeds is negligible and probably exceeded by
22	the risk of deriving new master seeds, the biological

23	properties of which cannot be accurately predicted.
24		[Slide.]
25		Bovine products obtained from any country before

				46 1	1980, the probable start of the BSE outbreak in the U.K.
	2	should be of no concern.  The benefit of immunizing children
	3	with the implicated vaccines outweighs the remote
	4	theoretical risk of CJD.  Vaccine should not be withdrawn
	5	from the market.  There should be additional public
	6	disclosure that bovine components from BSE countries were
	7	used to manufacture vaccines and that disclosure should

	8	include changes in the package insert, announcement in a
	9	journal article or a joint statement by the Department of
10	Heath and Human Services and possibly by letters to
11	healthcare providers.
12		[Slide.]
13		Because they do not have the same proven benefit
14	as licensed vaccines, investigational vaccines should be
15	considered separately and participants in clinical trials
16	should receive all relevant information concerning

17	theoretical risk of new-variant CJD associated with bovine-
18	derived materials from BSE countries used to prepare
19	investigational vaccines and that information should be
20	included in the informed-consent document.
21		Thank you.
22		DR. HOLLINGER:  Thank you, David.
23		Any questions?  Dr. Nelson?  One question.
24		DR. NELSON:  What to tell the public is really a
25	knotty issue.  I am not sure that you can adequately inform-

			47 1	-what are you going to do about it?  You say that there
	2	should be public disclosure, but what are you going to say?
	3		DR. ASHER:  In the first place, the advisory
	4	committee joint meeting, itself, constituted, to my mind, a
	5	form of public disclosure.  It was an open public meeting
	6	and representatives of the press were there.
	7		I think that if the remote nature of the risk is

	8	presented along with a reminder of the high benefit of the
	9	vaccine, I would hope that the public would be prepared to
10	accept it without panic.  There are precedents for that. 
11	Recall when retroviral activity was discovered in certain
12	cell cultures, the fact was disclosed.  It was presented as
13	a remote risk, which it is.

14		As in this case, there was no disease attributable
15	to the exposure and the public accepted it without reaction. 
16	The alternative of keeping the information secret, I
17	believe, in today's world is unacceptable.

18		DR. HOLLINGER:  Thank you, David.
19		The final presentation is an update on rapid HIV
20	test approval requirements and standards.  Dr. Poffenberger?
21		 Update on Rapid Test HIV Test Approval
22		       Requirements and Standards
23		DR. POFFENBERGER:  Given that I have eight minutes
24	and there were copies of the slides available to everyone on
25	the table outside, I am going to try and trot through these

			48 1	slides instead of walk through them.
	2		[Slide.]
	3		Switching topics for your last time before the
	4	main session starts, I am going to tell you something about
	5	FDA's requirements and standards for approval for rapid HIV
	6	test.
	7		[Slide.]
	8		First, I want to emphasize that these extended
	9	standards and revised requirements apply exclusively to
10	rapid HIV tests intended for diagnosis and they do not apply
11	to tests for blood screening.
12		[Slide.]
13		At the previous Blood Products Advisory Committee
14	Meeting held June 15, the public-health needs for rapid

15	tests were discussed and data for some of the tests was
16	presented.  The FDA actions to facilitate approval of rapid
17	tests were reviewed.
18		Among these actions were reduction in the sample
19	size for specificity determination and, in March of 1999,
20	the postponement of the requirement to include Group O
21	antigen in rapid HIV tests.  FDA also made a commitment in
22	the June meeting to revisit the sample sizes needed to

23	demonstrate clinical sensitivity and specificity of the
24	test.
25		At the end of that session, this committee

			49 1	concurred with standards for approval of rapid tests that
	2	are separate and different from the standard for approval of
	3	blood-screening tests.
	4		[Slide.]
	5		The standard for sensitivity concurred with on
	6	June 15 is 100 percent sensitivity on the FDA HIV-1 panel;
	7	that is 11 out of 11 positives.  The lower bound for the
	8	95 percent confidence interval must be at least 98 percent
	9	for studies that include all confirmed positive serum or

10	plasma samples from a study of positive individuals with a
11	sample size of 1,000 and for positive samples from a high-
12	risk population study whose sample size is at least 500.
13		[Slide.]
14		The standard for specificity concurred with on
15	June 15 is the lower bound for the 95 percent confidence
16	interval must be at least 98 percent for serum or plasma

17	samples from individuals in low-risk populations in a study
18	of 6,000 individuals.
19		[Slide.]
20		Today, we are extending those standards to apply
21	to all sample types; that is, the 98 percent minimum

22	acceptable performance standard for sensitivity and
23	specificity is being extended to all sample types;

24	venipuncture whole blood, finger-stick whole blood, oral
25	fluid as well as for serum and plasma samples.

			50 1		[Slide.]
	2		In addition to extending the standards, we are
	3	revising the clinical-trial requirements.  Since June, FDA
	4	has followed through on its commitment to revisit the trial-
	5	size requirements for rapid tests.  As part of this process,
	6	we sought additional input from statisticians and met with
	7	our public-health partners at the CDC and the NIH.
	8		The result is that the requirements which have
	9	historically been based on blood-screening intended uses are
10	being revised to reflect the distinctly different intended
11	uses for the rapid test; that is, for a test that will
12	primarily be used on fresh specimens in populations with
13	unknown HIV prevalence.
14		[Slide.]
15		The next few slides are going to show you first
16	what the previous standard was and what the revised
17	requirement is.  HIV-1 sensitivity was previously defined in
18	a study of 1,000 samples from individuals known to be HIV-
19	positive.  These samples could be repository and/or fresh
20	with at least 200 samples coming from individuals with AIDS.
21		In the revised sensitivity-study requirement, the
22	manufacturer may propose a trial size of sufficient power to
23	demonstrate that the test meets the 98 percent standard. 

24	However, the FDA is requiring that a minimum of 500 fresh
25	samples be tested for each specimen type that the

			51 1	manufacturer wishes to claim.
	2		Although 500 is the minimum acceptable number, FDA
	3	strongly recommends that 1,000 samples be tested in order to
	4	increase the chance that performance in the study will meet
	5	the 98 percent standard.  AIDS samples are no longer
	6	required since the predominant use of these tests is
	7	expected to be with populations of unknown serostatus.
	8		Samples with recent seroconverters are desirable
	9	in this study.
10		[Slide.]
11		The previous requirement for a prospective study
12	in a high-risk population has not been changed.  A study of
13	at least 500 samples should be conducted in sites of
14	intended use in an HIV-1 endemic population.  The change is
15	in the way that the results from this study will be used. 
16	The rapid test results with confirmed positive samples from
17	this study will be combined with the results with the known
18	positive samples from the sensitivity study described on the
19	previous slide to make the determination of sensitivity.
20		The results with negative samples from this study
21	will be used to report specificity of the test in high-risk
22	populations.
23		[Slide.]
24		The requirements for specificity are being

25	changed.  Previously, 6,000 samples from a low-risk

			52 1	population were required.  Under the revised requirements,
	2	the manufacturers are free to propose a trial size of
	3	sufficient power to demonstrate that the test meets the
	4	98 percent standard.
	5		The FDA is requiring a minimum of 500 fresh
	6	samples from a low-risk population for each specimen type. 
	7	The FDA is also requiring a minimum of 500 fresh samples
	8	from a high-risk population for each specimen type.  Again,
	9	the FDA strongly recommends 1,000 samples be run in each
10	population.
11		Please note that only a single prospective study
12	in a high-risk population is required.  As noted in the
13	previous slide, the results from this trial will contribute
14	to both sensitivity and to specificity determinations.
15		[Slide.]
16		In making the choice of study size, the
17	manufacturer should consider these points, that the absolute
18	minimum size for each study is 500 fresh samples for each

19	sample type.  The risk that the study will not meet the 98-
20	percent standard for the lower bound of the 95 percent
21	confidence interval increases as the sample size decreases.
22		This is why the FDA is recommending that 1,000

23	samples be tested.  If the manufacturer chooses a small
24	sample size and the study fails to meet the standard, the
25	manufacturer should have a plan in place for conducting a

			53 1	second trial or for extending the trial to an increased
	2	sample size using an appropriate p-value correction.
	3		A valid plan for handling this failure should be
	4	in place before the initial study begins.
	5		[Slide.]
	6		In addition to revising the trial-size
	7	requirements, FDA is taking other action to facilitate
	8	approval of the rapid HIV tests.  As was mentioned earlier,
	9	FDA announced in March of 1999, that rapid-test
10	manufacturers would not be required to add group O antigen
11	to their test immediately but could postpone that addition
12	for two years.
13		Today, FDA is taking the further step to drop the
14	requirement for addition of group O antigen to rapid HIV
15	tests.  Although this is not a revision, FDA is advising
16	rapid-test manufacturers that a claim for HIV-2 detection is
17	optional.
18		If manufacturers that wish to pursue an HIV-2
19	claim are having difficulty completing their HIV-2
20	prospective study, they should apply for approval for an

21	HIV-1 claim and may amend their product to include HIV-2
22	when the studies are complete.
23		Labeling for diagnostic tests for HIV does not
24	typically distinguish fresh and stored sample studies. 
25	Because the primary use of these tests is expected to be

			54 1	with fresh samples and because data has shown there may be
	2	differences in sensitivity and specificity performance with
	3	stored versus fresh samples, the data will be listed
	4	separately in the labeling.  Any study to be reported should
	5	include a minimum of 500 samples.
	6		[Slide.]
	7		This and the next two slides describe data
	8	requirements for rapid HIV tests that have not changed. 
	9	Given the time constraint, I may just pass through those.
10		[Slide.]
11		And the next slide.
12		[Slide.]
13		One more please.
14		[Slide.]
15		The actions described today are aimed at
16	facilitating approval of rapid tests while assuring the
17	safety and effectiveness of those tests in the settings and
18	with the sample types of intended use.  The 98 percent
19	standards for sensitivity and specificity apply to all rapid
20	tests.  The revised trial requirements apply to all

21	manufacturers that have not completed their studies.
22		Those manufacturers with completed studies that
23	meet previous trial requirements may be labeled differently. 
24	They would also have the option of conducting new trials
25	that meet the revised requirements.

				55 1		[Slide.]
	2		FDA has contacted all rapid-test manufacturers
	3	with whom we had previously discussed clinical-trial plans. 
	4	These revised requirements are designed to assure the safety
	5	and effectiveness of these rapid tests as they will actually
	6	be used.  The requirements are meant to facilitate approval
	7	and not to delay it.
	8		Manufacturers or sponsors with questions or
	9	concerns should contact FDA to request a teleconference or
10	meeting.  The point of contact is the Division of Blood
11	Applications at 301 827-3524.
12		Thanks.
13		DR. HOLLINGER:  Thank you, Dr. Poffenberger.
14		Any questions?  That concludes the updates for
15	this morning.  We appreciate those updates.  I wish we had,
16	really, more time to discuss them and go through them. 
17	These are very important issues here.
18	       III. Current Utility of Screening Blood Donors
19		       for Antibodies to Syphilis
20		DR. HOLLINGER:  We are going to move then to the
21	first discussion today on the screening on blood donors for
22	antibodies to syphilis.  We have eight speakers in the first
23	part before the break.  We are going to try to make sure
24	everybody has about fifteen minutes.  We are going to try to
25	keep everybody to that.  There may be some leeway if someone

			56 1	has a little less and the other a little bit more, but I
	2	would like you to sort of all try to do this so we can get
	3	through this in a reasonable time.  Then we will take a
	4	break and go on with our open public hearing.
	5		I am going to turn this over to Dr. Chiang Syin.
	6		             FDA Framework
	7		DR. SYIN:  Good morning.
	8		[Slide.]
	9		It is my pleasure to be here presenting the FDA
10	framework on donor screening for syphilis.  Serological test
11	for syphilis is the first test instituted for donor
12	screening against communicable disease markers.  It
13	fulfilled an obvious need, as shown in the next slide, to
14	protect the public health over half a century ago.
15		Today, we face a completely different picture in
16	which no case of transfusion-transmitted syphilis has been
17	reported in the U.S. in recent years.  The utility of
18	screening donors for antibody to syphilis is being raised
19	again.
20		[Slide.]
21		This is right after World War II as the effort by
22	the PHS to combat the syphilis problem.  You could show that
23	at that time we had close to a million cases a year of
24	syphilis identified in the U.S.  But before we get into more
25	of the specifics of the syphilis testing, let me briefly

			57 1	outline the various aspect of FDA's approach to testing.
	2		Since you are quite aware of the FDA authority and
	3	our role in regulating blood and blood products, I will not
	4	get into the first two parts.
	5		For the third item, for the decision-making

	6	process, as a part of the regulatory process, the FDA
	7	established standards and provided guidance, as you know. 
	8	Considering approval and the recommendation of donor-
	9	screening tests depends on the sponsor's demonstration of
10	safety, efficacy and manufacturing consistency.
11		Policies are developed in cooperation with other
12	PHS agencies with public input, including BPAC.  This is
13	exactly the reason that we are here today.  For the next
14	point, our current policy on testing.  Like HIV and

15	hepatitis testing, serological test for syphilis is required
16	by regulation since 1958.
17		For other tests now amended by the regulation, FDA
18	may put forth recommendations for their use.  We can also
19	look at the perspective on the surrogate tests.  Medical
20	history is important to address conditions for which testing
21	is not available or impractical and to address risk in the
22	window period.
23		Medical, including behavior, history is used as a
24	surrogate marker for transmissible diseases, including HIV,
25	hepatitis, and CJD.  Many consider that the continuation of

			58 1	requiring syphilis testing for blood-donor screening was
	2	based solely on its unsubstantiated potential for a
	3	surrogate marker for HIV.
	4		[Slide.]
	5		Currently, in the U.S., serological tests for
	6	syphilis are considered as a class II device and cleared by
	7	FDA under the 510(k) mechanism.  This test could be
	8	generally divided into two groups.  The first one is the
	9	non-treponemal test and the second one is the treponemal
10	test.
11		The two groups have distinctive characteristics
12	that make them useful for different purposes.  Non-
13	treponemal tests detect nonspecific cardiolipin antibodies. 
14	Non-treponemal tests are useful for monitoring the
15	progression of disease and the response for therapy.  The

16	most commonly used test today that has been used is the
17	Venereal Disease Research Laboratory test, so-called VDRL
18	test, and the rapid-plasma reagent, RPR test.
19		The problem with those tests is obviously the

20	biological false-positives which may occur in persons with a
21	variety of bacterial and viral diseases and those with
22	noninfectious conditions such as autoimmune diseases.  The
23	low sensitivity of non-treponemal tests in early and late
24	syphilis and the potential for biological false-positives
25	may require confirmation of non-treponemal test results with

			59 1	a treponemal test to establish a diagnosis of syphilis.
	2		On the other hand, the treponemal test
	3	incorporates specifically the treponemal antigen into the

	4	system.  The traditional gold standard was the Treponema
	5	pallidum immobilization test, to so-called TPI.  It was
	6	replaced by the fluorescence treponemal antibody with
	7	absorption test and it was called FTA ABS, as you know.
	8		Later on, Treponema pallidum hemoagglutination

	9	test, the TPHA, was developed.  The Olympus TKPT system for
10	automating syphilis testing cleared by FDA in 1990 is a

11	modified microhemagglutination test.  The treponemal test
12	has a higher sensitivity, I believe, in the primary and in
13	the late syphilis.

14		[Slide.]
15		As you can see on this slide, the treponemal test,
16	in general, has a sensitivity of 70 percent to 99 percent. 
17	If you see only the first two items in the last column, it
18	shows only 1 and 0 percent.  That actually was not shown in
19	the package that I sent to you.  I overlooked putting this
20	as a result of after treatment.  You can see those non-
21	treponemal tests would have difficulty to pick up previously
22	infected syphilis patients.
23		Anyway, early in primary syphilis, the antibody

24	level may be to low to detect and the test result may be
25	nonreactive.  The test cannot be used to diagnose late

			60 1	syphilis, especially if treated as shown on the slide,
	2	because the titer or antibody will eventually decline to
	3	undetectable levels.
	4		The treponemal tests have a higher sensitivity in
	5	the primary and late syphilis as I indicated earlier. 
	6	Unlike non-treponemal tests, once the reactive treponemal-
	7	based antibody test will remain reactive regardless of
	8	whether the individual has been successfully treated or not. 
	9	Biological false-positives are also common for this type of
10	test, even though some studies indicated may be slightly
11	lower than the non-treponemal-based tests.
12		In general, the specificity of both types of tests
13	are comparable and neither test could detect the so-called

14	window period infection.  This is a point which you have to
15	be careful at later discussion.
16		[Slide.]
17		This lists some of the advantages and the
18	disadvantages of the value of the syphilis testing for donor
19	screening.  This is a table I adopted from the 1996 review
20	written by Dr. Richard Cable on the evaluations of syphilis
21	testing of blood donors which has been included in your
22	package.
23		The disadvantage, as listed, is, as you can see,
24	obviously there will be an extra financial cost for whoever
25	is footing and bill and the false-positives and associated

			61 1	consequences, like, obviously people understand the stigma

	2	associated with a positive result for syphilis.  Also, the
	3	consequences of discarding a useful unit due to a false-
	4	positive result.
	5		On the other hand, the testing may have value in
	6	contributing to the elimination of transfusion-transmitted
	7	syphilis, or at least preventing an introduction of this
	8	pathogen in transfusion patients.
	9		[Slide.]
10		To put the FDA framework in perspective, let me
11	briefly review our policy on syphilis testing in the
12	historical context.  Statutory requirements of syphilis

13	testing of blood and blood products are clearly stated in
14	Title 21 of the Code of Federal Regulations under 640.5(a)
15	and 640.65.
16		Syphilis testing, at a national level, was
17	instituted in 1938 and required by regulation in 1958.  The
18	most current memo from FDA was issued on December 21,	1991. 
19	It was the recommendation for donor deferral and product
20	distribution.
21		[Slide.]
22		Since 1950, transfusion-transmitted syphilis was
23	almost nonexistent in the U.S.  There was only a single case
24	reported in 1968 by NIH and, along with the fact that the

25	low prevalence of syphilis in the general population since

			62 1	the mid-50's, and other contributing factors I will touch
	2	upon in the next slide, the FDA Advisory Panel of Blood and
	3	Blood Derivatives, in 1978, recommended elimination of
	4	syphilis testing due to a lack the public-health values.

	5		The recommendation was published in 1985 and it
	6	was accepted by PHS.  But, as you recall, 1985,
	7	unfortunately, was the year that we are embroiled in the
	8	heat of the AIDS epidemic.  FDA decides to withhold the

	9	proposed rule to revoke the testing requirement because of
10	the potential surrogate value as a marker for AIDS risk.
11		Since then, the validity, or the surrogate value,
12	of syphilis testing in blood donors for HIV has often been
13	challenged.
14		[Slide.]
15		As I previously mentioned in the pros and cons of
16	syphilis testing for donor screening, the lack of documented
17	case of transfusion-transmitted diseases was often--
18	transfusion-transmitted syphilis was often cited as one of
19	the major reasons for the elimination of syphilis testing.
20		These are several major factors that we could
21	identify.  The first one, obviously, is a low or lower
22	prevalence in the U.S. population since the '50's and the
23	practice of refrigerated blood storage.  I believe this is a
24	practice generally adopted in the '50's as well.  And
25	improved donor-selection process; this is accompanied by the

			63 1	emerging of modern blood bank practices.
	2		The other one we cannot overlook today is that 
	3	maybe a uniform application of screening tests may also
	4	contributed to it.  Last, but not least, transfusion
	5	recipients were often under antibiotic therapy.  I believe

	6	the discovery of penicillin to cure syphilis and has been
	7	adopted since the '40's may also contribute to the lower
	8	prevalence of syphilis in the U.S. population.

	9		Although we believe those have contributed to the
10	disappearance of transfusion-transmitted syphilis, we have
11	problems to pinpoint the precise nature of each factor.  I
12	hope today's presentation by other groups may shed some
13	light on those factors.
14		[Slide.]
15		In 1995, a Consensus Development Conference on
16	Infectious Disease Testing for Blood Transfusions was held
17	in NIH.  Elimination of syphilis testing was one of the
18	issues under extensive discussion.  However, at the end of 
19	meeting, it was concluded that the testing of donors for

20	syphilis should continue despite little surrogate value. 
21	The major reasons cited were that many blood components,
22	especially platelets, are stored at room temperature,
23	conditions that will not inactivate Treponema pallidum and
24	also because of lack of definitive laboratory data to
25	invalidate the value of the syphilis test.

			64 1		[Slide.]
	2		The slide I downloaded from the CDC web-site, just
	3	trying to show you the low prevalence of the syphilis cases. 
	4	But you have to keep in mind, this is 1990 to the current

	5	data.  If you look at the 30's, and the 40's and the 50's
	6	data, you can see this is a drastic upswing at the
	7	beginning, in the 30's and the 40's.
	8		I mentioned earlier, this is just to show you we
	9	are anticipating to see a continual decline of syphilis in
10	the general population in the U.S.
11		[Slide.]

12		With the poor predictive value and the high false-
13	positives from either treponemal or the non-treponemal-based
14	tests, and the lack of a surrogate value for other
15	infectious diseases, FDA decided to solicit public comment
16	on whether we should eliminate the testing as part of the

17	proposed rule, updating the requirement for testing human
18	blood donors for evidence of infection due to communicable
19	disease agents.
20		The proposed rule was published in the Federal
21	Register in 1999.

22		[Slide.]
23		Our primary concern is to insure blood safety and
24	an adequate blood supply.  As I remember in the last BPAC
25	meeting in June, I believe Dr. McCurdy made an interesting

			65 1	comment.  He said--this is probably difficult to see how we
	2	keep adding a new test, how could we ever consider dropping
	3	any tests.  At this point, I think we will only expect to

	4	see more scientific data to support either the elimination
	5	or retention of donor screening for syphilis.  I hope that
	6	will be the only criteria and that no other factor will be
	7	involved.
	8		[Slide.]

	9		As Dr. Hollinger has pointed out, we have a lot of
10	presentations today.  Following my presentation will be Dr.
11	Markowitz of CDC.  She will touch upon the background of
12	clinical syphilis.  Also, from the American Red Cross, Dr.
13	Roger Dodd will go over the background on diagnostic testing
14	for syphilis.  He will be followed by Dr. Markowitz, again,
15	on syphilis surveillance and blood-borne transfusion.

16		After her presentation, Sharyn Orton from the
17	American Red Cross would present the American Red Cross's
18	new data using the PCR method to evaluate the serologically
19	confirmed positive serum to show whether any Treponema
20	pallidum could be detected.
21		[Slide.]
22		Her presentation will be followed by Dr. Alan
23	Williams going over the REDS study of syphilis screening as
24	a surrogate test.  We hope that his presentation will

25	clearly show the lack of surrogates tests for other

			66 1	infectious disease markers.
	2		Dr. Markowitz will present their investigating
	3	report in the Maricopa County SDT study.  CDC today will
	4	also present a proposed study to try to evaluate the
	5	syphilis testing, its value.  This will be presented by Drs.
	6	Hsi Liu and Stephen Morse.
	7		Finally, I believe Dr. Ruta is going to present a
	8	set of questions for you to evaluate.  Thank you.
	9		DR. HOLLINGER:  Thank you.
10		We will start, then--the next presenter will be
11	the background on clinical syphilis.  Dr. Markowitz?
12		    Background on Clinical Syphilis
13		DR. MARKOWITZ:  Good morning.
14		[Slide.]
15		I think I can be fairly brief with this first
16	presentation because what I would really like to do is just
17	provide some background that will be relevant for the
18	subsequent presentations this morning.  So I am just going
19	to highlight some of the main features but not be
20	comprehensive.  I have also snuck in a few slides on the

21	epidemiology of syphilis in the U.S. which I think will be
22	relevant for our discussion today.
23		[Slide.]
24		Syphilis is a sexually transmitted disease caused
25	by T. pallidum which is a spirochete, as I am sure everyone

			67 1	knows.  Syphilis has a highly variable clinical course and
	2	is characterized by episodes of active clinical disease
	3	interrupted by periods of latent infection.
	4		It is quite well known that symptoms and signs of
	5	early syphilis are often missed or confused with
	6	manifestations of other diseases.
	7		[Slide.]
	8		Syphilis is classified into sequential clinical
	9	stages to guide patient management and management of sexual
10	partners and, in the case of pregnant women, to guide
11	newborn care.  However, despite their clinical and public-
12	health utility, these stages are not precise and, in
13	individual patients, they often overlap.
14		This slide shows the general time course of the

15	different stages, and they are quite variable, that about
16	ten to 90 days after infection, signs and symptoms of
17	primary syphilis are manifest.  These include the classic
18	ulcer and regional lymphadenopathy.
19		Signs and symptoms of secondary syphilis occur
20	between one and six months after primary syphilis.  But one
21	to three months later, the symptoms of secondary syphilis
22	resolve and the patient enters what is considered a latent
23	phase.  About 70 percent of persons with untreated syphilis
24	will remain latent while 30 percent will develop tertiary
25	disease which can include cardiac and neurologic

			68 1	manifestations or benign late syphilis.
	2		[Slide.]
	3		Just some basic features of primary syphilis.  The
	4	classic manifestation, of course, is the ulcer.  The classic
	5	ulcer is single, painless and appears at the site of
	6	inoculation.  The location can be quite variable and the
	7	specific location and the degree of discomfort are important
	8	determinants of whether and when the ulcer is detected by
	9	the patient or the clinician.  In women, the ulcers are
10	often cervical and, as a result, often go unnoticed.
11		Not all the chancres have a classic appearance and
12	they are traditionally single and painless.  But they can be
13	multiple and, as a result, can be misdiagnosed as other
14	ulcerative SDTs.  As I mentioned before, they can be

15	painless and may be completely missed.  The untreated
16	lesions will heal spontaneously in a few weeks.
17		[Slide.]
18		Secondary syphilis is manifested by variable skin
19	and mucous-membrane lesions and constitutional signs and

20	symptoms.  Patients will often have persistent healing
21	chancres and the rash, which is commonly macular, can evolve
22	to a papular, even pustular, rash and patients can have a
23	combination of these different rashes.
24		It is classically present on the trunk and the
25	rash is the most common manifestation of secondary syphilis. 

			69 1	Other manifestations are generalized lymphadenopathy,
	2	headache, fever, condyloma.  Of note, and of importance for
	3	this discussion, is that some patients with secondary
	4	syphilis will not report any systemic illness at all at the
	5	time when they are diagnosed.
	6		[Slide.]
	7		After primary and secondary stages, most patients,
	8	for a variable period of time, will become completely
	9	asymptomatic.  In this stage, the only evidence of infection
10	is serologic.  This is considered the latent syphilis.
11		About 25 percent of patients with latent syphilis
12	will develop relapses to the secondary stage, demonstrating
13	the very characteristic waxing and waning part of syphilis. 
14	Latent syphilis is somewhat arbitrarily divided into two
15	stages; early, latent and late-latent.  In light of the data
16	indicating that about 25 percent of patients will develop

17	relapses into secondary syphilis, and that most of these
18	relapses occur within the first year of latency, latent

19	syphilis of less than one year duration is considered by CDC
20	as early-latent.  These patients are considered potentially
21	infectious.
22		Patients who have latent syphilis of more than one
23	year duration are considered late-latent and are deemed

24	relatively noninfectious.  However, as I will mention a
25	little bit later, congenital syphilis does occur with late-

			70 1	latent disease and transfusion-transmitted cases have also
	2	been reported.
	3		[Slide.]
	4		Just briefly, to review these stages from the
	5	pathogenesis point of view, after sexual exposure, T.
	6	pallidum invades the body through the mucous membranes and
	7	it attaches to the host cell and it begins to multiply. 

	8	Within hours, the organisms appear in the regional nymph
	9	nodes and disseminate to multiple organs and tissues.
10		The chancre develops at the site of inoculation
11	and is considered to be teaming, and is teaming, with
12	treponemes.  Secondary syphilis is considered the
13	disseminated stage with treponemes throughout the body and
14	the condyloma is also teaming with treponemes.
15		In the latent stage, treponemes are in the spleen
16	and lymph nodes and intermittently seed the blood stream. 
17	As shown in the slide, the latent stage can revert to the
18	secondary stage.
19		[Slide.]
20		This just reviews the stages, primary, secondary,
21	latent divided into early and late, and then the tertiary
22	which I am not going to really touch on for this
23	presentation this morning.
24		[Slide.]
25		Just a few words about congenital syphilis.  I

			71 1	think it is relevant for our discussion.  It is one of the
	2	major causes of morbidity and mortality from syphilis.  It
	3	does demonstrate blood-borne transmission.  Congenital
	4	syphilis can result in several outcomes which I have listed
	5	on the slide and the risk of maternal-fetal transmission
	6	changes with stage of disease.
	7		However, a vertical transmission can occur at any
	8	stage.  The risk is highest in primary and secondary disease
	9	where vertical transmission has been reported about 70 to

10	100 percent of pregnancies.  In about 40 percent of early-
11	latent, there is transmission and in about 20 percent of
12	late-latent.
13		[Slide.]

14		Just very briefly, I think most people know this,
15	but penicillin is the treatment of choice for syphilis. 
16	There are different regimens for the different stages but it
17	is very effective.  There is no resistance to penicillin
18	that has been reported for syphilis. There are alternatives,
19	also, available for people with penicillin allergy.
20		[Slide.]
21		I am not going to go into this because I see that
22	both the presenter before me and after me will go over the
23	diagnostic tests.  So I think I will just skip over this.

24		[Slide.]
25		I am also not going to go over this to save time,

			72 1	but I wanted to point out that we do have a variety of case
	2	definitions for surveillance at CDC and they have used both
	3	clinical criteria and the laboratory criteria that are going
	4	to be discussed this morning.  Both probable confirmed cases
	5	for each of the stages have been developed.
	6		[Slide.]
	7		I am not going to go over this, either.  This is
	8	for the early-latent clarification.
	9		[Slide.]
10		I do want to touch on some epidemiology very
11	briefly again.  This slide shows the number of cases from

12	1941 to 1998 reported to CDC.  We normally follow primary
13	and secondary cases because these represent incident cases
14	in the time period which is being studied.
15		This slide shows primary and secondary in the
16	yellow, early latent in the red and then total cases in the
17	blue line.  As you can see, we have decreased to very low

18	rates in the U.S.  In 1998, which is the last year for which
19	we have really completed our data, we have 6,993.  It is
20	slightly less in 1999.
21		You can see that syphilis in the U.S. declined
22	dramatically in the '50's with the widespread use of
23	penicillin in U.S. programs that were implemented.  There
24	was an epidemic in the 1990's.  That was a nationwide
25	epidemic and since that time, rates have decreased really

			73 1	throughout the country.  Last year, because of these really
	2	remarkably low rates, the Public Health Service announced a
	3	national syphilis elimination goal.  The goal is decrease
	4	syphilis to a rate below 0.4 per 100,000 by the Year 2005
	5	and also to have 90 percent of the counties in the U.S. free
	6	of syphilis.
	7		So that initiative is one-year old now and the
	8	goal is, again, 2005.
	9		[Slide.]
10		This shows the rates by gender in the U.S.  The 
11	rates have been greater in men than in women, but the
12	difference between the genders is narrowing.  Both of the

13	rates are below the Year 2000 objective which is the dotted
14	line.  The overall rate in the U.S. is 2.6 per 100,000.
15		[Slide.]
16		This slide just shows the age-specific rates for
17	men and women showing that the rate for women in highest in
18	20 to 24-year-old women with a rate of 6.1 per 100,000 and,
19	for men, it is slightly older; it is the 30 to 39-year-old
20	age group has the highest rate for men of 6 per 100,000.

21		[Slide.]
22		Despite the overall decline in syphilis, it
23	remains an important problem in the South and it affects
24	predominantly African-Americans with the rates of about 20
25	to 30 times higher in African-Americans than non-African-

			74 1	Americans.
	2		This slide shows the rates around the country.  We
	3	had 40 states that were below the 2000 objective which is in
	4	yellow.  You can see that all of the high-rate states are in
	5	the South.  There were five states that had rates greater 8
	6	per 100,000 and seven states with rates 4 to 6 per 100,000
	7	in all these except Arizona and Maryland, I think, are in
	8	the South.
	9		[Slide.]
10		The geographic focus is even more striking if you
11	look at the county map.  78 percent of the over 3,000
12	counties in the U.S. reported no cases of syphilis in	1998. 
13	There were only 310 counties that reported rates above the
14	2000 objective.  Another way to look at this is the counties
15	in red, here.  There are 28 counties that reported half of
16	all cases in 1998 so it really is quite a focal disease now
17	in the U.S.
18		[Slide.]
19		I think I am going to skip this.  It might be
20	touched later but this is just to mention that there is--I
21	think most people know an association between syphilis and
22	HIV.  Just briefly, I will mention this.  There was a review
23	of 30 studies that look at the prevalence of HIV in syphilis
24	patients.  These were 30 outbreaks that were investigated.
25		In male syphilis patients, the mean HIV prevalence

			75 1	was 27.5 percent.  In women, the median HIV prevalence was

	2	12 percent.  So these diseases often travel together and,
	3	even this year, we have several outbreaks of syphilis among
	4	HIV-infected persons.
	5		[Slide.]
	6		This is my last slide, just to say that even
	7	though syphilis is a very focal disease, we do have
	8	outbreaks and now the outbreaks will become more sporadic

	9	and, perhaps, more unpredictable in different cities.  In
10	2000, these are four of our largest outbreaks and, by no
11	means, the only outbreaks.  There is an outbreak in Miami

12	with 81 primary and secondary cases.  Los Angeles, which is
13	having a large outbreak of syphilis among HIV-infected men,
14	112 cases.  Indianapolis, this is mainly heterosexually
15	transmitted in Indianapolis, 228 cases.  In Detroit,
16	163 cases.
17		So it still is a disease which we are seeing
18	outbreaks in the U.S.
19		That's all I have.
20		DR. HOLLINGER:  Thank you.  The outbreak in
21	Indianapolis didn't occur after the Bobby Knight firing, did
22	it?
23		Any questions of Dr. Markowitz in general?  Just
24	one question; does everyone that is infected with syphilis
25	develop clinical symptoms?  That is one question.  The other

			76 1	question is at what stage or stages is the blood considered
	2	to be infectious for transmission?  If it is going to be
	3	covered by somebody, I can deal with it later.  But, if not,
	4	could you answer that?
	5		DR. MARKOWITZ:  I would say that probably not
	6	everyone does develop--well, the issue is do they develop
	7	symptoms or do they recognize symptoms.  I think some people
	8	don't recognize symptoms so they are picked up and they
	9	report never having symptoms.
10		So, in that situation, the primary stage can be
11	totally missed.  People may not report any symptoms and they
12	can be picked up only on the basis of the serologic tests. 
13	So that does happen.
14		When the blood is infectious, I tried to
15	illustrate that.  Maybe I wasn't so clear on my pathogenesis
16	slide.  The feeling is that in primary and secondary,

17	certainly, the patients are bacteremic and, in latent
18	syphilis, early-latent syphilis, there is intermittent
19	seeding of the blood stream so there would be bacteremia
20	during early-latent.

21		My understanding of the old literature is that it
22	is in late-latent as well, because there are cases of
23	congenital syphilis that occur in late-latent and because
24	there are some transfusion-transmitted cases that have
25	occurred in those stages.  So I think the risk decreases. 

			77 1	And I think the data from congenital syphilis would
	2	illustrate this best.
	3		DR. HOLLINGER:  Questions?  If not, we will move
	4	on.  Thank you, Dr. Markowitz.  The next presenter, Roger
	5	Dodd, is going to talk on--oh; I'm sorry.  I did promise Dr.
	6	Schmidt that he could show two slides.  But you don't get
	7	fifteen minutes, Paul.
	8		DR. SCHMIDT:  Part of this is a going-away gift to
	9	Blaine.  He can say, "I was at a committee in Washington and
10	they showed slides of patients," or at least parts of
11	patients.
12		[Slide.]
13		This patient is the case that you keep hearing
14	referred to which is the last case of transfusion-associated
15	transmitted syphilis in the United States.  This was a
16	patient we had in 1966 at the Clinical Center of NIH who had
17	a lymphoma.  Among other treatments, he had 25 units of very
18	fresh platelets, all negative by the VDRL and, several
19	months later, he came back to the clinic like this.
20		He was well treated, but we were able to retest

21	all but three of those donors.  All the ones retested were
22	still VDRL-negative.  We were not able to retest three of
23	the donors.
24		[Slide.]
25		This next slide, there was classic secondary

				78 1	syphilis.  The old literature describes it as this way and

	2	commonly seen on the extremities.  I had never seen a case
	3	before or, obviously, since.  We mentioned in our report we
	4	ought to be seeing more of these with the introduction of

	5	fresh platelet transfusion, but we haven't seen them.  Of
	6	course, in my thinking, it was always that post-transfusion
	7	syphilis was a disease of direct transfusion, direct donor-
	8	to-patient transfusion.
	9		Also combined with the fact that in that era which
10	was pre-World-War II, we did not have penicillin.  So this
11	died out pretty rapidly after World War II.
12		But, anyway, thank you for the opportunity to show
13	a patient.
14		DR. HOLLINGER:  Paul, just one question.  You said
15	the VDRL was negative in this case.
16		DR. SCHMIDT:  I'm sorry; in all the donors, and

17	negative in the patient when admitted to the hospital but
18	strongly positive in the other tests as well when he was
19	retested at this stage.
20		DR. HOLLINGER:  But it was never proven that any
21	of the other donors were positive; is that right?

22		DR. SCHMIDT:  That's correct, but there were three
23	who avoided us and--
24		DR. HOLLINGER:  David?
25		DR. STRONCEK:  I have kind of an obscure question. 

			79 1	Do you know anything--if we are given more apheresis
	2	platelets now and if a donor was infected, would the
	3	bacteria be more or less concentrated in apheresis platelets
	4	than in peripheral blood?
	5		DR. SCHMIDT:  I hope we are going to talk about
	6	the studies to find out why platelets don't transmit.  The
	7	number of platelets given is enormous.  I do have a copy
	8	here of the first NIH minimum requirements for whole blood
	9	which are 1945.  In there, it says, "The random selection of
10	donors should yield only one bleeding containing viable S.
11	pallidum in approximately 9,000 bleedings."
12		So you can make the calculations at the much
13	greater frequency of it in donors at that time, but still,
14	with all the platelets we are giving, we should be seeing
15	it.
16		DR. HOLLINGER:  Thank you, Paul.
17		Roger?  Dr. Dodd on diagnostic testing for
18	syphilis.
19	       Background on Diagnostic Testing for Syphilis
20		DR. DODD:  Thank you very much, Blaine.
21		[Slide.]
22		I would like to follow Mike Busch's lead and offer
23	my tribute and thanks for your service as chairman of this
24	committee.  I would like to point out that I have known
25	Blaine for many, many years and his hair turned white long

			80 1	before he joined the committee.
	2		[Slide.]
	3		My job, really, is to try and guide you through
	4	the morass of the diagnostic tests for syphilis and to
	5	indicate how they are used in the transfusion environment or
	6	the blood-screening environment.  I think my primary message
	7	is that you really have to kind of dissociate the two
	8	components; that is, you have to not think exclusively about
	9	the diagnostic data that you have heard to date because this
10	is all founded on some clinical expectation that there is
11	going to be a disease and checking out that expectation vis
12	a vis screening where you really have no other information
13	at all about the individuals who are tested.
14		[Slide.]
15		I wanted to make three key points before
16	proceeding.  The first one I have already made and this is a
17	commonality for all aspects of blood-donor screening, that
18	screening asymptomatic populations is very different in
19	context from performing diagnostic tests.
20		Secondly, and this is a message you have already
21	heard, in this particular case, syphilis, the sensitivity,
22	the clinical sensitivity of any test varies with the phase
23	of disease and the nature of the test, itself.  Finally, I
24	shouldn't need to remind this audience, but the positive

25	predictive value of any test--that is, the proportion of

			81 1	reactive results that turn out to be true positive--is
	2	inversely proportional to the prevalence of infection in the
	3	population.
	4		So, if you have a very low prevalence of
	5	infection, you may have a--did I get this right way around? 
	6	If you have a low prevalence, in any case, you will have a
	7	very low predictive value, positive predictive value.
	8		[Slide.]
	9		You have just heard about the key phases of
10	syphilis, clinical syphilis, primary, secondary, latent and
11	late and/or tertiary disease.  We would also point out that
12	we need to have in our minds what happens after successful
13	treatment.  That may not be the right place to put it in
14	this particular sequence.  And I would also comment that
15	clearly there is a pre-seroconversion phase that we do not
16	know a great deal about but we might want to recognize that
17	there is some potential for infectivity before what is
18	classically termed the primary syphilis.
19		[Slide.]
20		As you have already heard, and I am going to
21	choose to look at these in three different categories, there
22	are really different categories of tests, diagnostic tests,
23	for syphilis.  The non-treponemal tests are, in fact, tests
24	for antibodies that react with a relatively non-specific
25	antigen.

			82 1		In the early days of syphilis work, there were
	2	attempts to develop a syphilis antigen from which to develop
	3	tests and these were developed by various treatments of
	4	organs from infected individuals.  These tests worked and it
	5	wasn't until much later that it was determined that the
	6	antigens which were putatively syphilis antigens actually
	7	came from the organs, themselves.
	8		Quite a lot of effort was put towards developing a
	9	standardized cardiolipin antigen which is not a treponemal
10	antigen although some believe that the agent, itself, really
11	may be some of these sorts of antigens.  Typically, and I am
12	not trying to be exhaustive here, the tests that fall now
13	into this category are VDRL and RPR, which you already heard
14	about.
15		Treponemal tests, really there are two sets of

16	these.  The first is some way of directly observing the
17	organism, itself, the spirochete, and this is done on
18	exudates from lesions and does not really relate to our
19	discussion right now.
20		But conventionally there are really three
21	techniques that are in use right now.  The first is the

22	fluorescent treponemal antibody test so you are really doing
23	a standard fluorescence assay.  The ABS refers to an
24	absorption step which removes a number of the antibodies to
25	nonpathogenic treponemes before the test is undertaken.

			83 1		And there are a number of agglutination tests,
	2	red-cell and now even particle agglutination tests in which
	3	particles are coated with treponemal antigens and are used
	4	to detect antibodies.  There is at least one EIA test which
	5	is also designed to detect antibodies to treponemal
	6	antigens.
	7		You will hear a little bit later what is really an
	8	investigational test at this time, nucleic-acid testing,
	9	either for treponemal DNA and/or for RNA.  I will only
10	mention that briefly as I go through the rest of this
11	presentation.
12		[Slide.]
13		This is a chart that I stole from a very nice
14	review by Sandra Larsen dealing with diagnostic testing for
15	syphilis.  I think quite a lot of points can be made from

16	this graph.  Here you see the various phases of disease,
17	primary, secondary and the late stages of disease.  Late in
18	this case actually starting on this graph at ten years and
19	going out to 40 years.
20		The first thing is that both treponemal and non-
21	treponemal tests come up relatively rapidly at the early

22	phases of primary disease.  As I pointed out, we really
23	don't know what is happening here but I suspect that there
24	might be some potential for dissemination of the organism
25	although that is not really relevant to the rest of the

			84 1	discussion, I think, other than what you will hear from
	2	blood banking organizations.
	3		I think the key thing to recognize here is that,
	4	on this chart, are two treponemal tests, a
	5	microhemagglutination and the fluorescent treponemal
	6	antibody test.  Both of these come up, although at slightly
	7	different periods, and are maintained throughout the
	8	disease, itself, or throughout the course of syphilis.
	9		On the other hand, here RPR or non-treponemal test
10	drops off over the years.  But I would point out again, on
11	this diagnostic chart, that it never really--the sensitivity
12	of this test never really drops to zero in terms of
13	untreated disease.

14		[Slide.]
15		So just commenting, again, briefly on the non-
16	treponemal tests, I have already discussed the fact that
17	they detect antibodies to a nonspecific antigen.  The

18	specificity of the non-treponemal tests is considered to be
19	100 percent in secondary disease; that is, 100 percent of
20	cases will be detected by non-treponemal tests.  But

21	subsequently there is a decline in both the levels of
22	antibody and the proportion of individuals who react and
23	this decline is very marked with treatment.
24		If you look at the specificity of these non-
25	treponemal tests, they are quoted as 97 to 99 percent.  That

			85 1	means that in a nonsyphilitic population, you might expect 1
	2	to 3 percent of all tests to be false positive.  Not very
	3	impressive.
	4		[Slide.]
	5		This, again, from Larsen's paper, represents the
	6	changes in titers of results from non-treponemal tests
	7	attendant on treatment with penicillin.  You can see the
	8	titers drop very rapidly into essentially undetectable
	9	levels within three months of initiation of treatment.  So
10	this is a key component of the non-treponemal test site.
11		[Slide.]
12		Treponemal tests, as I discussed, detect
13	antibodies directly.  The sensitivity of the treponemal
14	tests is quoted as 100 percent in secondary and latent, so
15	the point here is that the treponemal tests remain high

16	throughout the course of disease.  So the decline with
17	disease is not so apparent and reactivity is maintained
18	after treatment.
19		Although the treponemal tests generally have

20	higher levels of specificity, it is not 100 percent so you
21	will still get false-positives and these will represent a
22	fairly high proportion of all reactives in, for example, a
23	donor population.
24		[Slide.]
25		I don't think that we need to spend much time on

			86 1	what is sensitivity, what is specificity and what is
	2	predictive value other than to point out that predictive
	3	value will vary with prevalence.  These are inherent
	4	characteristics of the test, itself.
	5		[Slide.]
	6		Having said all that, here are some data taken

	7	primarily from the Larsen paper and also from one of the
	8	manufacturer's product inserts.  The points to be made on
	9	this particular chart which represents diagnostic
10	performance is that in primary syphilis, none of the tests
11	is 100 percent sensitive.  In fact, all of them are in the
12	83, 84, 85 percent range.
13		So even in primary syphilis, the sorts of tests
14	that are used for screening or diagnosis may not always be

15	reactive.  Secondary syphilis, however, when, in many cases,
16	the individual is symptomatic, these tests are all
17	100 percent sensitive so it should pick all of those up. 

18	The other point is that the non-treponemal test listed here
19	drops but only to about 73 percent in late or post-latent
20	syphilis whereas the two treponemal tests maintain their

21	levels throughout this disease.
22		[Slide.]
23		Let's see how this pans out in the blood-center
24	environment.  This represents primarily the American Red
25	Cross algorithm for syphilis screening of donors.  Other

			87 1	major blood organizations have rather similar algorithms. 

	2	We screen each donation by an agglutination test, the PK-TP
	3	test which runs on an automated blood typing machine and
	4	reactive samples are repeated in duplicate.
	5		The repeatedly reactive samples are then further
	6	tested for confirmation by FT-ABS fluorescent treponemal
	7	antibody ABS or, in some cases, by treponemal enzyme
	8	immunoassay test.  Certainly, in our case, from this group,
	9	the positive and minimally reactive samples are further
10	evaluated by a non-treponemal test, RPR.  This is used for
11	counseling only and the concept is that the an RPR reactive
12	is more likely to represent active disease.
13		[Slide.]
14		This represents 22 months worth of data from the
15	American Red Cross system.  So this is the number of
16	repeatedly reactive donors that turned up in our testing on
17	a monthly basis round about 800 with a peak when we moved
18	from a PK 7100 to a PK 7200 system generating, if you like,
19	a new population of what must be false-positive results

20	because the FTA ABS confirmed and the RPR rates did not vary
21	very significantly here although I think you can see a
22	little peak here.
23		[Slide.]
24		If we look at that in terms of numbers, those data
25	averaged out on a monthly basis so our system collects about

			88 1	500,000 units each month.  Amongst those, almost 900, or
	2	0.18 percent are repeatedly reactive by the screening test,
	3	the treponemal screening test.
	4		Of those, 424, or only 43 percent, are actually
	5	confirmed by FTA ABS representing 0.08 percent of our donor
	6	population or our donations, to be more accurate.  As you
	7	will hear later, if you take these kinds of samples that are
	8	PK-positive, FDA-positive, or PK-reactive, FDA-positive, and
	9	you do PCR on them, whether for DNA or RNA, Sharyn Orton
10	found that none of them had detectable levels of treponemal
11	nucleic acids and the 95 percent confidence interval of that
12	observation would not exclude the possibility that some

13	3 percent of this group could potentially be at least
14	circulating detectable RNA or DNA.
15		Within this whole group, only 23 percent are
16	actually RPR-reactive.  You will remember from the
17	diagnostic category, you would not expect to find this at
18	any stage.  You would expect all of these to be true-
19	positives and probably 60 or 70 percent of them should be
20	RPR-positive if you didn't have treated individuals in this
21	group.
22		[Slide.]
23		This is not really critical, but these are bulk
24	data.  What I really wanted to point out is that we

25	categorize the fluorescent antibody testing into two groups,

			89 1	minimally reactive which represents 9 percent of the total

	2	here tested and, of those, only 6 percent are RPR-reactive,
	3	leaving one to wonder if there isn't some form of false-
	4	positivity for both markers.
	5		Of the 9,300 or so that were confirmed as greater
	6	than plus, 29.4 percent were RPR-reactive, again a very low
	7	number and, again, overall, a similar figure, 24.5 percent
	8	of FTA ABS reactives were RPR-reactive.
	9		[Slide.]
10		So I don't want to draw any strong conclusions

11	from this.  My comments about these kinds of observations
12	would be first of all that in a pre-screened donor
13	population--that is, many of them have been tested time and
14	time again, the positive predictive value of the PK test is
15	less than 50 percent for antibody.  We don't know what it is
16	for disease but, clearly in terms of its relationship to
17	detectable nucleic acid, it is much lower than 50 percent.
18		The frequency of reactive test results among PK-TP
19	reactives, so you take these screening-reactive individuals
20	and you confirm them is actually inconsistent with the
21	diagnostic model, so this is the real message; don't equate
22	diagnostic models with screening models.
23		I think that a small to zero proportion of STS
24	confirmed positives have evidence of active TP infection in
25	studies to date.

					90 1		Thank you very much.
	2		DR. HOLLINGER:  Thank you.
	3		Questions?  Carmelita?
	4		DR. TUAZON:  Later on, the PCR, are the 97 RPR
	5	reactive?
	6		DR. DODD:  Dr. Sharyn Orton will be discussing
	7	that along the way.
	8		DR. HOLLINGER:  Thank you.
	9		Ken?
10		DR. NELSON:  Of these that are repeatedly
11	reactive, you then counsel or have histories on the donors. 
12	How many of those have had a history of syphilis in the past
13	that was treated?
14		DR. DODD:  I don't know if Sharyn is going to show
15	this data, but when we get down to this confirmed group, on
16	the basis of case-control evaluations, and correct me if I
17	am wrong, Sharyn, about 50 percent of them report having a
18	past history of syphilis, in many cases treated syphilis.
19		So, certainly, we are picking up some individuals
20	with a history of prior syphilis.  I heard your question and
21	I don't know the answer to how that distributes by RPR but,
22	perhaps, Dr. Orton can comment on that.
23		DR. NELSON:  And those that don't have a history,
24	then they are referred for medical evaluation, I guess?
25		DR. DODD:  They are notified and the results are

				91 1	interpreted to the best of our ability and they are advised
	2	to seek medical support.  But this is generally a hands-off
	3	process rather than a personal interaction.
	4		DR. HOLLINGER:  Roger, you seem to suggest that
	5	the difference between the RPR-reactives and the FDA-
	6	positives, that 22 percent versus 43 percent, is either
	7	because of post-treatment of latent syphilis?  Is that the
	8	assumption?
	9		DR. DODD:  I think the simplest explanation in my
10	mind is that if you accept that the FDA's really, truly
11	confirm, then the majority of them must represent treated or
12	are long past infection.
13		DR. HOLLINGER:  Thank you, Roger.
14		Dr. Markowitz now is going to return and talk

15	about syphilis surveillance and bloodborne transmission.
16	     Syphilis Surveillance and Bloodborne Transmission
17		DR. MARKOWITZ:  Thank you.
18		[Slide.]

19		I don't know what the real correct title of this
20	talk should be.  It has had different titles.  But actually
21	the main thing I am going to talk about is something that we
22	tried to address at CDC and that is whether or not persons
23	with infectious syphilis, primary or secondary primarily,

24	will actually go to donate blood, will they not be sick
25	enough, will they not be picked up at the time of intended

			92 1	donation.
	2		So that was the main purpose of our analysis of
	3	surveillance data.  Then we did find that those cases of
	4	primary and secondary syphilis do go to donate blood.  So,
	5	after that, we tried to obtain some estimates of the
	6	potential of transfusion-transmitted syphilis.  So I will
	7	walk you through both of these exercises.
	8		[Slide.]
	9		The main question that we attempted to answer was
10	do persons with infectious syphilis donate blood and, if so,
11	how many, approximately, each year donate blood.  That was
12	the main initiating objective of this exercise.
13		In order to review this, what I am going to do is
14	first briefly provide an overview of syphilis surveillance
15	in the U.S. so people can understand how we obtain these
16	data.  Then I will give some information on reported cases
17	that we did identify from donor screening that were reported
18	to CDD and, finally, I will present some estimates that we
19	made on the potential of transfusion-associated cases that
20	might occur in the absence of screening.
21		[Slide.]
22		Syphilis, I think as most people know, is a

23	reportable disease in the U.S. and reporting to health
24	departments occurs through various routes.  I have tried to
25	represent this schematically on the slide.

			93 1		First of all, a symptomatic person can present to
	2	a clinician and be diagnosed with syphilis and then be

	3	directly reported to the health department.  Also, both
	4	symptomatic and asymptomatic persons could have serologic
	5	screening either as a diagnostic test or because they are
	6	ill or just for routine screening.
	7		Those serologies are directly reported to the

	8	health department, so the health department can obtain both
	9	a case report and a serologic report.  Once a serology or a
10	case is reported to the health department, further
11	evaluation occurs.  The first thing that happens is that
12	serology and there is checked in a registry that is actually
13	kept in all health departments.  This allows the health

14	department to determine which serologies may be follow-up
15	titers on previously diagnosed and treated cases.
16		These cases are not investigated further.  Health
17	departments with a very high case load actually have other
18	criteria for which they use for making decisions on

19	investigation or noninvestigation of cases.  If it is
20	indicated, after checking in the central registry, the

21	follow up is initiated by the health department and a team
22	of investigators would go out and investigate the cases, or
23	I should say the person.
24		The persons are interviewed, examined or their

25	medical records are reviewed and the case definitions that

			94 1	CDC uses for surveillance are applied.  At that point, the
	2	disease-investigation person either makes a decision that it
	3	is not a case, in which case, it is not reported, or it is a
	4	case that is reported to CDC.
	5		Since this is often a population that is very hard
	6	to follow up, in many states, there is a sizable proportion
	7	of persons with positive serologic tests for syphilis that

	8	cannot be located and are lost to follow up and, therefore,
	9	cannot be reported or evaluated.  So only cases that

10	actually have a full evaluation get reported to CDC.
11		[Slide.]
12		The syphilis reporting system has changed in the
13	past decade as state and local health departments have moved
14	towards electronic reporting for all communicable diseases. 
15	NETS, which is the National Electronic Communication System
16	for surveillance, was first implemented by CDC and state
17	health departments in 1992.
18		This has allowed collection of data that was not
19	previously available on cases.  Relevant for our discussion
20	is that source of report is one of the fields that is
21	collected electronically now.  So if a patient comes in and
22	was reported by a private physician, it is private
23	physician.  If it is the STD clinic, STD clinic.  And if it
24	is a blood bank, it will say blood bank on there.
25		Now, the previous system, which has been in place

			95 1	for a long time, is the STD morbidity report system.  This
	2	will be eventually replaced by the electronic system, NETS. 
	3	It collects hard-copy data as aggregate data from all 50
	4	states.
	5		Detailed information is not available on all of

	6	these cases.  Since 1992, each year more states have sent
	7	data electronically and, in the Year 2000, all but a very
	8	few states are now reporting electronically.
	9		[Slide.]

10		To estimate the donation-identified cases of early
11	syphilis, and for this exercise, we just looked at primary,
12	secondary and early-latent from 1995 to 1998, we used the

13	source of report field in the NETS data that was coded as
14	blood bank.
15		In order to estimate the number of cases that
16	occurred in the whole country, we had to make an adjustment
17	because not all states were using NETS in 1995 to 1998.  So
18	we adjusted the NETS data using all the data that reported
19	from the STDMR system by multiplying by an estimation
20	factor.  This was simply dividing the STDMR cases by the
21	NETS cases.
22		Then we multiplied the number of NETS cases that
23	had been identified as having blood bank as their source by
24	this estimation factor to come up with a projected total
25	cases for the U.S.

			96 1		[Slide.]
	2		This slide shows the data that we came up with
	3	using this.  First of all, you will note that the estimation
	4	factor decreases between '95 and '98 because more states
	5	were reporting electronically.  So we didn't have to make as
	6	large of an adjustment in the later years.
	7		We also made separate adjustments for primary,

	8	secondary and early-latent.  In this column is the total
	9	cases reported in the U.S. and these are the numbers that
10	were reported to NETS and then our estimation factor.

11		This is the number of cases that had blood bank as
12	their source of report.  So, overall, in these four years,
13	we had 67 primary and secondary cases that had blood bank as
14	their source of report.  And then, using our estimates, that
15	turned out to be 142 cases during that four-year period that
16	had blood bank as their source of report.
17		For early-latent, there were an actual 261 cases
18	through our electronic reporting system who had blood bank
19	as their source and that projected up to 785 estimated cases
20	that would have had blood bank as their source.  Now, there
21	are problems with all this but I am just walking you through
22	to show you how we try to get these estimates.
23		So then a total of primary, secondary and early
24	latent, we had 927 estimated cases during the four-year
25	period that were reported through the blood-banking system. 

			97 1	These are people, then, that were detected, had a positive
	2	serology by the blood bank and they were referred--they were
	3	investigated by the health department and the health
	4	department made a determination that, in fact, yes, they
	5	were primary, secondary and early latent based on a review
	6	of clinical records and interviewing the patient.
	7		[Slide.]
	8		One major limitation of the NETS data that came up
	9	actually when we were doing this analysis is the fact that
10	the NETS data doesn't really distinguish between a blood
11	bank and a plasma center so that they would both be coded as
12	blood banks.
13		When we actually first saw these data, we were
14	surprised, ourselves.  So what we did is we went back and we
15	called the STD program directors of four states that
16	accounted for the majority of donation-identified cases in
17	1998.  This is a year-and-a-half later when we did this
18	because this is all occurring in the last year in response
19	to our discussions with FDA.
20		So this was not a real-time interview of these STD
21	program directors.  But just to let you know, one director
22	said almost all the identified cases were from plasma
23	centers.  One STD program director said they were all from
24	blood banks.  In two other states, they said they were from
25	both and the proportion from blood banks was only slightly

			98 1	less than the proportion from plasma centers.
	2		I didn't bring this data but most of these, the
	3	four states that reported the majority of the cases
	4	identified through blood banks or plasma centers were all in
	5	the South in areas that we know are high-incidence states.
	6		[Slide.]
	7		Just to put this in perspective, and if anyone got
	8	an earlier slide, there was an error that I have corrected
	9	but I just wanted to show you the proportion of blood-

10	donation-identified cases in relationship to all of our
11	reported cases and they actually account for a very small
12	percent.
13		So, during these four years, there were over
14	43,000 primary and secondary cases.  Only 0.3 percent were
15	identified through the blood-donation system  There were

16	over 76,000 early-latent cases and 1 percent were identified
17	through this--they had source of report of the blood-bank
18	system.
19		[Slide.]
20		The next thing we tried to do was to estimate the
21	number of donors who would be potentially infectious.  To do
22	this, we made a variety of assumptions.  In this slide, I

23	have shown the assumptions we used to find out how many
24	infectious donors would result from these primary and
25	secondary cases.

			99 1		So the first assumption was that all primary and
	2	secondary cases were bacteremic at the time of donation. 
	3	The second assumption was that early-latent cases, 5 percent
	4	of them, would be bacteremic.  We could pick different
	5	numbers and I am mainly walking you through so you could see
	6	our thought process that we used.
	7		So, therefore, we had 102 primary and secondary
	8	cases divided by 4 to get the yearly number times 100
	9	percent is 36 of those, 36 primary and secondary per year,
10	would be bacteremic at the time of donation.  For early-
11	latent, 785 divided by 4 times 0.0510, so we came up with
12	possibly 46 donors per year would be bacteremic at the time
13	of donation.
14		[Slide.]
15		The next part of this I even had more difficulty I
16	think getting some real data.  I have had some discussions
17	with a variety of people at the American Red Cross and the
18	FDA after we made our initial assumptions, and I will
19	present two different ways we looked at this.
20		The more we thought about this, we realized we
21	didn't have a lot of good data to estimate the risk posed by
22	these 46 bacteremic donors.  The reasons for that are the
23	following, and I am sure other people here will come up with
24	other reasons.
25		First of all, we didn't really know what we should

			100 1	use for the treponemal survival time in stored blood.  There
	2	are data in the literature but all of it is not very
	3	consistent.  We also didn't know the proportion of
	4	transfused blood components with storage times that would
	5	all survival of treponemes.  Most people feel that the
	6	current storage procedures will not allow prolonged storage
	7	of treponemes but that, in some parts of the country,
	8	fresher blood is transfused, blood that has not been stored
	9	as long.  This may vary and we really didn't know the
10	proportion of storage time of the different blood components
11	or of the different units that are used across the country
12	today.
13		We also did not have data on the component-
14	specific treponemal densities.  I think that there are some
15	people who feel that treponemes can survive in platelets,

16	some people who feel that they can't, because of different
17	reasons.  And so we felt that we really couldn't come up
18	with good specific estimates for this.
19		So this is by way of saying that the estimates
20	that we came up with have a lot of uncertainty in them.

21		[Slide.]
22		This is the first estimate we came up with which I
23	think I was questioned about so I have done a subsequent
24	one.  But since this wasn't a memo that we sent to the FDA,
25	I am going to walk through this.

			101 1		The first assumptions that we made were that, for
	2	each donation, there would be two components.  So the 46
	3	bacteremic donors would result in 92 components.  The risk
	4	from transfusion of these components would range from 0.001
	5	from stored, if it was a stored component, to 0.05 if it was
	6	a fresh component.  These estimates are not really based on
	7	hard data so I can't really provide specific background
	8	information to substantiate these.
	9		But if we were going to use these estimates, then
10	we would have a low of less than one transfusion-associated
11	case occurring per year to a high of 4.6 transfusion-
12	associated cases per year.
13		[Slide.]
14		After talking with a variety of people in the
15	blood-banking industry, we decided to come up with the
16	worst-case scenario to estimate transfusion-associated cases
17	in the absence of screening.  I think this is because the

18	blood-bank industry would assume, and this is what I was
19	told, that if a unit had treponemes in it, that we should
20	assume 100 percent risk.
21		So we came up with these assumptions.  We were

22	assuming inadequate refrigeration or storage, if there was a
23	blood shortage and there was a very short storage time, so
24	inadequate to kill the treponemes.
25		And then we assumed that there were between 1 and

			102 1	1.5 risk components per donations.  Here we are assuming
	2	that, perhaps, some of the components would not contain
	3	spirochetes and would not be, therefore, at risk and that if
	4	you got one of these units, your risk of getting a
	5	transfusion-associated syphilis would be 100 percent.
	6		So, using this estimate, the 46 donors per year,

	7	100 percent risk, and 1 to 1.5 components per donation, one
	8	would come up with between 46 and 69 cases a year.  So,
	9	again, I think we could plug different numbers in here and,
10	again, our assumptions are not very precise, but, just to
11	walk you through some of the process that we used.
12		[Slide.]
13		So, in summary, recent changes in surveillance

14	have allowed identification of syphilis cases detected
15	through blood banks or plasma centers.  Again, we can't
16	distinguish those.  We estimated that, from 1995 to 1998,
17	syphilis screening by blood banks and plasma centers
18	resulted in 927 cases of early syphilis being detected.

19		Some parameters that we need to estimate the risk
20	of transfusion-associated syphilis from these donors are not
21	really available.  Survival of treponemes in the different
22	blood components under current storage conditions will

23	determine whether these cases pose any real risk for
24	transfusion-transmitted syphilis in the absence of
25	screening.

				103 1		DR. HOLLINGER:  Thank you.
	2		Questions?  Dr. Linden?
	3		DR. LINDEN:  I have one question.  Could you
	4	please clarify what you considered to be "fresh" because
	5	fresh blood, per se, isn't really transfused anymore.  What
	6	time line did you consider to be fresh and what was stored?
	7		DR. MARKOWITZ:  In our first assumption, where we
	8	used the fresh, stored by 0.001 and fresh being 0.05, I
	9	think that that was probably not a good use of those words. 
10	We meant like less storage and more storage.  But, in
11	talking with the American Red Cross, it was our impression
12	that there are some units that are transfused relatively

13	soon after they are obtained.
14		But I can't really speak to that issue.  It was
15	suppose to be a range.
16		DR. HOLLINGER:  Do you have a comment about that,
17	Jeanne?
18		DR. LINDEN:  I am still not sure what relatively
19	soon means because I am thinking platelets versus red cells. 
20	You are talking three days, two days, one day, five days?
21		DR. MARKOWITZ:  That is why I presented this

22	second analysis where we use a new terminology called
23	inadequate storage because I think that we don't really know
24	how long is long enough to kill the treponemes.  So I
25	presented that first slide where we used the fresh and the

			104 1	stored terminology because we had communicated that
	2	previously to FDA and I wanted to walk through how we came
	3	up with those calculations.
	4		But I think it is better to use this term
	5	inadequate storage because it is my understanding that the
	6	data are not absolutely clear what adequate storage is.
	7		DR. HOLLINGER:  I thought Dr. Cable, in his
	8	article, said something to the effect of five days, or three
	9	to five days or something like that, seemed to be sufficient
10	to eliminate the infectivity of syphilis in blood.
11		Paul?
12		DR. SCHMIDT:  I think those are all very old
13	experimental data when they first started putting citrated
14	blood on the shelf.  That was all refrigerated.  Into this,
15	you have to build the fact that platelets are stored at room
16	temperature so it is not only a question of time.  But that
17	variable I don't think anybody has ever looked into.
18		I had a question.  As you mentioned early on, not
19	all positive serologic tests in donors that are reported to
20	health departments are followed up.  We find, for example,
21	that there are certain parts of town they like to follow up
22	and other parts of town they don't based on what they
23	usually think syphilis is due to.
24		Wouldn't, then, your estimates based on what

25	health departments report to the CDC be lower than the

				105 1	actual?  In other words, there are blood-donor cases that
	2	don't get into that system.
	3		DR. MARKOWITZ:  I think there are several things
	4	that could bias it to be lower than I reported.  In addition
	5	to what you pointed out, some patients who were referred
	6	into the SDT clinic for evaluation if they have a positive

	7	serologic test for syphilis, they might be coded, because
	8	this is not totally standardized, as source of report being
	9	the STD clinic rather than the blood bank.
10		So I think that is actually a larger issue than
11	the one you brought up.  Most of the cases that don't get
12	followed up, there is actually a set algorithm they are
13	supposed to follow.  In cities, where they have a lot of
14	syphilis serology to follow up, they focus on high-risk age
15	group, women of reproductive age, and things like that so
16	that they would actually follow up people--much older
17	people, for example, they would decide not to follow up.

18		DR. HOLLINGER:  If I recall Roger's data, it would
19	appear that about 5,000 cases were positive by the FTA ABS
20	in the American Red Cross.  If you then double that to
21	10,000, that is pretty close to the 10,000 or 12,000 that

22	you are reporting per year.  I think you have reported 927
23	per month.  Is that right--or 927 per year?
24		DR. MARKOWITZ:  The 927 was over the four-year
25	period.

					106 1		DR. HOLLINGER:  Over a four-year period?
	2		DR. MARKOWITZ:  It was a four-year period.  That
	3	was a four-year period; yes.
	4		DR. HOLLINGER:  Sorry.  Okay.
	5		Dr. Mitchell?
	6		DR. MITCHELL:  So you are saying that your
	7	estimates are from 0.09 cases per year to 69 cases per year?
	8		DR. MARKOWITZ:  I see you are looking at the
	9	earlier estimate.  I would say it is from 0, yes, from 0 to
10	69 cases per year.
11		DR. MITCHELL:  But, in fact, we have seen 0 cases.
12		DR. MARKOWITZ:  This is in the absence of
13	screening.  What we are saying here is this is what we would
14	see in the absence of screening.

15		DR. MITCHELL:  Okay.
16		DR. CHAMBERLAND:  Lauri, just another area of
17	potential misclassification in the surveillance database,

18	classification of stage of disease, would it most likely be
19	done stage at presentation and evaluation to the Department
20	of Health as opposed to the stage of disease, let's say, for
21	purposes of discussion, when someone was presenting to blood
22	bank because, depending on the interval of time, and I don't
23	know if you collect data on interval of time between source
24	of report, meaning the time the patient was initially

25	tested, and their definitive evaluation at the health

				107 1	department.
	2		So is that another potential source?
	3		DR. MARKOWITZ:  Yes; that has come up again as to
	4	how good are these classifications.  I think that, if
	5	anything, there will be people misclassified as early-latent
	6	cases where they may have been primary, secondary, at the

	7	time of donation because of the time lag between donation
	8	and full evaluation by the health department.
	9		DR. CHAMBERLAND:  Just one other question about
10	the surveillance system.  I wanted to ask you if the
11	implementation of the electronic surveillance system was
12	uniform in the country or, for example--because, certainly,
13	distribution of cases is not uniform with the focus in the
14	Southern states.
15		So is the electronic surveillance system--how is
16	that implementation faring in those parts of the country

17	where you see the most cases because then that factors into
18	this estimation factor.
19		DR. MARKOWITZ:  I don't know the answer to that,
20	how it was roled out.  I don't know that actually.  But I do
21	know that, in 2000, all except four states are reporting
22	electronically.  But, in 1995, during the '95-'98 period,
23	many fewer states were reporting electronically
24		DR. TUAZON:  If you look at your estimate of
25	potentially infectious donors, you have the premise that the

					108 1	primary and secondary are 100 percent bacteremic.  In fact,
	2	they are probably not so that is actually an overestimate
	3	because I think the secondary or disseminated disease, those
	4	are probably 100 percent spirochetemic but the primary
	5	actually may not be.
	6		So, in essence, your estimate of 0.09 is probably
	7	an overestimate.
	8		DR. MARKOWITZ:  Yes; that could be.  We based that
	9	on maybe congenital syphilis.
10		DR. TUAZON:  Because we really don't know the--
11		DR. MARKOWITZ:  We don't know.  We can't say for
12	sure.  I could have put a range in there as well in terms of
13	the percent that were bacteremic.
14		DR. TUAZON:  But even those who are bacteremic, we
15	really don't know the infectious dose, how many spirochetes
16	would be capable of causing disease.
17		DR. MARKOWITZ:  Right.  And that is why the
18	estimate of 0.001 and	0.05, that was supposed to represent
19	all of these different factors, the density of the treponeme
20	in the component.  We didn't really know what to put in
21	there and it was really more of a guesstimate.  We sort of
22	got together and said, what can we really use here?  But
23	there are a lot of different factors that go into whether or
24	not a unit is actually really going to be a risk unit.
25		DR. ORTON:  I am Sharyn Orton from the Red Cross. 

			109 1	I had a lot of conversation with Lauri and I think maybe I
	2	can shed a little bit of light on the worst-case scenario
	3	risk factor assessment that she did.
	4		When we discussed the old papers which I went back
	5	to, even some of the whole-blood studies that were done as
	6	far back as 1927, the only thing that those papers really do
	7	is discuss an inoculated concentration of treponeme and the
	8	length of time it takes before that inoculation in a unit of
	9	whole blood is no longer viable or no longer causes rabid
10	infectivity.
11		All of those authors state two things.  One is

12	that we do not know what the concentration is in a person
13	who is truly infected so you cannot necessarily extrapolate
14	a certain concentration of inoculated material no longer

15	being viable at five days to necessarily what happens in a
16	human.
17		The second thing is that they do not state that
18	the refrigeration kills the organism.  What they state is
19	this is the length of time that it is viable.  There has

20	been some extrapolation to room-temperature platelets, but I
21	could find nothing in the literature that actually has a

22	comparison of the organism live, inoculated live, into a
23	component at room temperature and then rabid infectivity
24	studies being done.

25		The next part that I just want to mention is when

			110 1	it comes to platelet concentrates, and this actually will

	2	impact slightly the study I will be presenting to you, we
	3	have, in the transfusion medicine field, always been

	4	concerned about platelets because of room-temperature
	5	storage for the reason I stated before.
	6		However, the oxygen tension of the platelet bags
	7	is dramatically higher than anything a spirochete can
	8	withstand for even periods of hours.  The literature clearly
	9	states that anything above 3 percent oxygen tension, the
10	organization will be dead in a matter of hours.
11		In the current bags we use, the oxygen tension is
12	almost 16 percent.  So when I talked to Lauri, I didn't feel
13	that a platelet is a large risk, if any risk at all, and

14	that I agree that, with primary syphilis, we don't really
15	know the concentration but we have to assume the if a human
16	is spirochetemic, a red cell has 100 percent transmission
17	risk.

18		So that is basically where we got those.  They are
19	worst-case-scenario figures but I think they more clearly
20	represent if a donor walks in and they are spirochetemic, it
21	is closer to 100 percent than 0.1 percent for the
22	transmission.  That is where those figures came from.
23		DR. HOLLINGER:  Yes; please?
24		DR. WILLIAMS:  Alan Williams, Red Cross, Holland
25	Lab.  Many times, hospital blood banks are structurally

			111 1	affiliated with clinical laboratories and, because of donor
	2	testing, may have the best access to syphilis serology.  Can
	3	you, in fact, rule out that some of the reports made by
	4	blood banks might represent non-donors?
	5		In addition, have you considered the fact that

	6	autologous donors may also be tested by both hospital and
	7	community blood centers and are known to have higher levels
	8	of infectious-disease marker rates, but would not represent
	9	a threat to the community blood supply.
10		DR. MARKOWITZ:  We don't have data on any of that
11	because the only thing we get is really this one piece of
12	information that says source of report.  So, unless we went
13	back and interviewed, talked to the surveillance people in
14	the state, I think in the time frame that would allow them
15	to remember these cases to be able to follow up on them, I
16	don't think we would be able to distinguish those.
17		DR. KLEINMAN:  Steve Kleinman.  I know probably
18	each state does this differently but it might be a useful
19	thing if, if the case is reported to the health department
20	from a blood center or a plasma center, if they could
21	include, as part of their evaluation actually asking these
22	people whether they have been recent blood donors.  That

23	might be something that you could prospectively collect over
24	the next year in evaluations done at state health
25	departments.

			112 1		Because I agree with what Alan said, and from the
	2	limitations you gave, we really don't know whether these

	3	people--from a coding form, we really don't know for sure
	4	whether they were active blood donors or whether they were
	5	just an anomaly of the system and the type of reporting.
	6		DR. DODD:  Roger Dodd.  One other thought here is
	7	that we now are required to defer, for at least one year

	8	after clinical syphilis, anybody who presents with a history
	9	of syphilis, or we have to ask them about a history of
10	syphilis.  Potentially, some of these may be reported back
11	without even entering the blood system.
12		DR. MARKOWITZ:  I don't know if there is a
13	mechanism.  You are saying that they wouldn't even donate,
14	blood then.  But there is a legal requirement for reporting
15	positive serologic tests for syphilis.  So that would be

16	much more likely to be reported than if somebody just said
17	they were a case.  I don't think there is a mechanism for
18	those patients to be reported.

19		DR. HOLLINGER:  As there is for hepatitis which is
20	very much underreported.

21		Yes; go ahead.
22		DR. BIANCO:  Celso Bianco, America's Blood
23	Centers.  The other part of the equation that would be

24	interesting.  You said, in the absence of testing, this
25	would be the risk.  But just following what Dr. Dodd just

				113 1	said, we ask our donors for any history of venereal disease
	2	and will defer them for a year if they reveal any history.

	3		So that also would reduce the number of
	4	individuals that ultimately, without testing, would be part
	5	of your estimate.
	6		DR. MARKOWITZ:  I would assume that these cases

	7	that made it through and got reported to CDC, I would have
	8	assumed that they would have been asked that question and

	9	would be deferred so they wouldn't even get into the system;
10	isn't that right?
11		DR. BIANCO:  Possibly.  Yes.
12		DR. HOLLINGER:  Dr. Simon?
13		DR. SIMON:  I thought I understood that there were
14	two issues here and from the discussion, I just wanted to

15	clarify.  We are dealing with, really, two issues, one is
16	the safety of the blood supply and, if we stop testing for
17	syphilis, will that be impacted, and then whatever public-
18	health benefits we may be supplying by screening the people
19	who come into our centers.
20		So, even if we decide the blood supply is safe,
21	there is another issue, do we have a public-health benefit;
22	is that correct?

23		DR. HOLLINGER:  Certainly, the blood supply is the
24	issue right now before the committee about the testing.
25		DR. SIMON:  So we are not dealing with the issue

			114 1	of whether we are performing a public-health benefit by
	2	doing this testing?
	3		DR. HOLLINGER:  We are dealing with it, but I
	4	don't think it is part of the agenda, as I understand it.
	5		Paul?
	6		DR. SCHMIDT:  I would hope that we are dealing
	7	with the public-health aspects unless the public-health
	8	authorities are willing to put up some money for the blood
	9	centers to do some of their screening.
10		DR. SIMON:  Maybe Dr. Markowitz can respond to
11	that.  Does the CDC and the public-health establishment see
12	a benefit from the reporting they are getting from blood and
13	plasma centers because, actually, in plasma centers, the
14	testing is done for the safety of the recipient because all
15	those products are frozen and it was retained in order to

16	get that information on the recipient and send them for
17	treatment if they were positive.
18		DR. MARKOWITZ:  That is a separate issue, is the
19	benefit for the patient versus a global public-health issue. 
20	One of the reasons I showed the slide that had the

21	information on the percent of all of our cases that
22	identified through this kind of screening was to illustrate
23	that it is actually a small percentage.
24		But it is still something.  1 percent of our
25	early-latent cases were identified through this mechanism. 

					115 1	We have not developed a formal stand on this on whether or
	2	not CDC feels that this is a vital part of syphilis
	3	surveillance.  We don't consider it--we have many other ways
	4	that we are trying to enhance syphilis surveillance because
	5	of the syphilis elimination initiative that was started last
	6	year.  There have been a lot of additional efforts being
	7	made to try to locate and treat all syphilis in the U.S.
	8		So we don't feel that this should be a major
	9	component of the syphilis elimination effort.  But it is not
10	that it is not helpful.  It is.  But it is not a major
11	component.
12		DR. HOLLINGER:  Dr. Boyle?
13		DR. BOYLE:  Just a point of clarification.  Early
14	in your presentation, did you say that 50 percent of all new
15	cases are coming from 26 counties?
16		DR. MARKOWITZ:  Yes.
17		DR. BOYLE:  So, with 3,000 counties in the United
18	States, basically 1 percent of counties were responsible for
19	50 percent of all new cases.
20		DR. MARKOWITZ:  And they are not the same counties
21	every year.  That is one of the tricky things.
22		DR. BOYLE:  Okay.  Thank you.
23		DR. MARKOWITZ:  I think there are several endemic
24	areas, which is mainly the South, that occur for the bulk of
25	all cases, but then, every year, there are different

				116 1	counties that are having outbreaks.

	2		DR. HOLLINGER:  Dr. Katz?
	3		DR. KATZ:  I am a clinical infectious-disease doc
	4	so I have to have several jobs to make a living.  One of
	5	them is I run an STD clinic at the health department so we
	6	get the referrals, and my blood center sends in
	7	approximately two reports of RPRs for every ten we get from
	8	the plasma centers, locally.
	9		I don't know if that holds up nationally, but I
10	think that that is important data that we probably need to
11	have for this type of decision.
12		DR. HOLLINGER:  Thank you.
13		We are going to take a ten-minute break and then
14	we are going to come right back and start again.
15		[Break.]
16		DR. HOLLINGER:  We are going to continue on.  The

17	next speaker is with the American Red Cross NAT Donor Study. 
18	Sharyn Orton?
19		   American Red Cross NAT Donor Study
20		DR. ORTON:  I would like to thank you for inviting
21	me here today to present this data.
22		[Slide.]
23		I would also like to thank everybody who was
24	involved with the American Red Cross through the American
25	Red Cross ARCNET Program.  This is an epidemiologic group of

			117 1	four blood centers that do quite a bit of our surveillance
	2	work.
	3		I would also like to mention Dr. Hsi Liu who is

	4	also here today and who will be speaking shortly from the
	5	Centers for Disease Control and Prevention who collaborated
	6	with me on this study.
	7		[Slide.]
	8		The scientific question that we started with was
	9	do blood donors with confirmed positive syphilis tests have
10	evidence of circulating T. pallidum and, if so, what is the
11	prevalence.  Theoretically, these confirmed positive

12	syphilis tests should represent antibody detection to either
13	current or past infection.
14		[Slide.]
15		Our hypothesis was the confirmed positive syphilis
16	tests in blood donors do not represent current infection. 
17	How did we arrive at this hypothesis?
18		[Slide.]
19		There is quite a bit of anecdotal evidence from

20	blood donors who have been notified of confirmed positive
21	syphilis tests.  One of the medical directors at the Red
22	Cross pointed out that the largest number of phone calls
23	they get from donors who receive counseling letters
24	complaining have to do with syphilis tests.

25		In addition, a later study that I did, a survey of

			118 1	donors, both cases and controls, I got numerous, dozens, of
	2	phone calls from these individuals.
	3		Secondly, there is evidence in the literature that
	4	in low-risk populations, most, if not all, positive results
	5	represent antibody from previous disease or biological
	6	false-positive reactivity.  This goes quite to the
	7	predictive value of the test in this population.
	8		[Slide.]
	9		Next, we know that conditions associated with
10	biological false-positive test results can affect all of the
11	tests currently in use for screening of donated blood and
12	these tests, as Dr. Dodd pointed out earlier, for the Red
13	Cross, are the PK-TP, the FTA ABS and the RPR.
14		[Slide.]
15		In order to do our study, we made a few
16	assumptions.  Our first assumption was that an individual
17	with spirochetemia is not likely to present as a blood
18	donor, or, associated with that, a blood donor is not likely
19	to present with spirochetemia.
20		The reason that we made this assumption was that
21	syphilis is a rare disease in the United States.  In 1998,

22	the CDC reported an incidence of 2.6 per 100,000 population. 
23	This incidence in whites is actually 0.5 per 100,000.
24		Peak spirochetemia, from the literature, occurs

25	primarily during the secondary phase which almost always

			119 1	presents as acute symptomatic disease with fever, lymph
	2	adenopathy and macropapular rash.
	3		[Slide.]
	4		In addition, there has not been a documented case
	5	of transfusion-transmitted syphilis in this country in over
	6	30 years despite the fact that spirochetemia may occur
	7	during the primary phase and this phase may be asymptomatic
	8	and may be seronegative early in the course of the phase,
	9	and transfusion-transmitted syphilis would likely result in
10	a secondary-phase syphilis that should be recognized.
11		[Slide.]
12		So our goal was to determine if there was any
13	evidence of circulating T. pallidum in the blood of donors
14	who are PK-TP reactive, FDA-ABS-positive by specific
15	detection of DNA or RNA as a surrogate measure of potential
16	infectivity.
17		[Slide.]
18		Our sample size that we used was a target sample
19	of 100 PK-TP-reactive FTA-ABS-positive blood donations.  50
20	of these would be from donors who were subsequently RPR-
21	positive and 50 from RPR-negative donors.  We went ahead and
22	were using existing platelet concentrates from these
23	donations.
24		Now, this study was started several years ago and,
25	at that time, it was the first of the studies that I did in

			120 1	syphilis, based on the literature and the concern by
	2	transfusion-medicine experts about platelet transfusion
	3	temperature storage, we decided to use the platelet
	4	concentrate.
	5		As I mentioned to you earlier, we now know that,

	6	based on oxygen tension, this product is not likely to be a
	7	product that is going to have viable treponeme.  So there
	8	our concern was were we using a component that was really a
	9	legitimate component to use for this test.
10		There is evidence in the literature that T.

11	pallidum spirochetes are likely to segregate with white
12	blood cells.  This goes back to some work that has been done
13	as far back as 1978.
14		On this slide, you can see the, in the preparation
15	of the platelet concentrate, the yields of white cells are
16	relatively high in the platelet concentrate, only one log
17	lower than in whole blood when you talk per ml.  So we felt
18	that, while whole blood would have been a preferable
19	component, we don't have whole blood available to us because
20	of the component preparation and we did have the platelets
21	available.
22		[Slide.]
23		The PCR testing that we did for T. pallidum, we
24	did two different tests.  Actually, the CDC did two
25	different tests.  The first was a specific DNA test using

				121 1	the polA gene target.  This is work that Dr. Hsi Liu did for
	2	us.  They used capillary electrophoresis and a fluorescent-
	3	detection system.  It is read on an ABI 310 genetic analyzer
	4	and the sensitivity of the test was 10 to 25 organisms per
	5	100 microliters of platelet concentrate extracted.
	6			[Slide.]
	7			The second test that was used was a multiplex PCR
	8	test which included testing for T. pallidum.  It uses a
	9	47 kD basic membrane protein-gene target for T. pallidum. 
10	It is sensitive to ten organisms per 100 microliters of
11	platelet concentrate extracted.  In the event that this test
12	would come up positive, another confirmatory test would have
13	been done with individual PCR which is sensitive to one
14	organism.
15			[Slide.]
16			The RT-PCR procedure that we used is a 16S rRNA

17	template for reverse transcription of production of cDNA. 
18	We used detection by Southern Blot or, more recently, an
19	Agilent Biolanalyzer.  This particular test can be quite

20	sensitive, down to 10	                
			-3 organism equivalents.  We
21	consistently considered a one-organism per 140 microliter
22	platelet concentrate extracted for the control as an
23	acceptable run.
24			[Slide.]
25			For the DNA, both assays included internal and

			122 1	external control samples.  The positive external controlled
		2	samples were provided by my laboratory and were diluted to

		3	50 organisms per 100 microliter from stock T. pallidum,
		4	Nichols strain, cultures from Sheila Lukehart's lab at
		5	University of Washington.

		6		RNA-positive controls diluted to 10		   
						-1 genome
		7	equivalents per 140 microliters were prepared from the same

		8	stock samples.  All assays also included negative controls.
		9		[Slide.]
	10		Ultimately, we tested, as I counted yesterday, 101
	11	of each.  101 samples tested negative for T. pallidum DNA by
	12	both assays and 101 samples tested negative for T. pallidum
	13	RNA.  I do want to point out that, in all, more than 101
	14	samples were run.  There was an overlap of about 30 samples
	15	that had both tests done.
	16		[Slide.]
	17		There were some study limitations, the first being
	18	that the optimal sample for detection of T. pallidum is
	19	fresh blood for two reasons.  The test procedures work
	20	better with fresh blood and the concentration of organism is
	21	higher in fresh blood.
	22		Also, because we can never prove a negative test
	23	result, in a pilot study of this size, with a sample size of
	24	100, and all-negative test results, there is up to a 3
	25	percent chance that there is an incorrect interpretation of

			123 1	no evidence of infectivity.
	2		[Slide.]
	3		There are differences in findings between this
	4	study and a study that is going to be presented today by the
	5	CDC and also from some of Dr. Markowitz' information.  The
	6	study that is going to be presented later has to do with
	7	syphilis-infected individuals.  I want to point out that the
	8	differences in the population here is that these are blood
	9	donors.  The prevalence in disease in the two populations is
10	very, very different and, therefore, the predictive value
11	expected for the tests is very different.
12		As Dr. Dodd mentioned results of a case-control

13	study that I did, approximately 50 percent of blood donors
14	with confirmed positive test results report a previous

15	history of syphilis greater than one year prior to the
16	donation that we were addressing.
17		It turns out about 30 percent of them are repeat
18	donors who have had a previously seronegative.  So it
19	appears that we also see some intermittent seroreactivity in
20	those panels.
21		[Slide.]
22		In conclusion, we did not demonstrate circulating
23	T. pallidum DNA or RNA in platelet concentrates of PK-TP-
24	reactive FTA-ABS-positive blood donors in this pilot study. 
25	This data is not consistent with a diagnostic model.

			124 1		[Slide.]
	2		Further, it is unlikely that the blood of donors

	3	with confirmed positive syphilis test results is infectious
	4	for syphilis.
	5		[Slide.]
	6		Last, I would like to thank all of the ARCNET
	7	staff, also Dr. Chen from CDC and Sheila Lukehart from the
	8	University of Washington.  Thank you.
	9		DR. HOLLINGER:  Thank you, Dr. Orton.
10		Dr. Mitchell?
11		DR. MITCHELL:  On one of the later slides, you
12	reported that 50 percent of the blood donors reported a
13	previous history of syphilis.  Does that mean that
14	50 percent did not report a previous history?
15		DR. ORTON:  Yes; that is correct.  What we did in
16	this case control is we identified all confirmed positive
17	donors in a time period from four regions that surveys were

18	sent to.  We did not have 100 percent response rate.  So, of
19	the ones that responded, it was 50 percent.  And, yes,
20	50 percent of the confirmed positives reported no previous
21	history of syphilis; that's correct.

22		DR. HOLLINGER:  Ms. Knowles?
23		MS. KNOWLES:  You said this was an ongoing study,
24	but it sounds like it is now completed?
25		DR. ORTON:  It was completed as of Tuesday.

			125 1		DR. HOLLINGER:  Dr. Schmidt?
	2		DR. SCHMIDT:  Confirming from the old literature,
	3	DeGowin and Hardin published a book immediately after World
	4	War II.  Dr. Hardin was the blood officer for the European
	5	theater where they collected a lot of blood by civilians,
	6	but civilians and soldiers.  The quote from that is,
	7	"Wasserman-negative blood is more dangerous than that which
	8	reacts in the test."
	9		I don't know about the Wasserman test, but the
10	other thing, for the Red Cross, he says, "Physical
11	examination should be performed on perspective donors to
12	detect primary and secondary manifestations of the disease. 
13	The male genitalia should be examined particularly for
14	chancres but, in most clinics, the female genitalia are not
15	inspected because of the difficulty of finding the lesions."
16		DR. ORTON:  I think you would have to pay your
17	donor staff a lot more money if you want to do that.
18		DR. HOLLINGER:  Dr. Epstein?
19		DR. EPSTEIN:  How many of the samples tested were
20	from donors with a positive RPR.  You said the target was

21	50.
22		DR. ORTON:  Yes; the first group that were tested
23	with both DNA tests, there were 50 RPR-positives.  Even

24	though there was some difference in the actual samples of
25	the RNA, we did 50 as well.

					126 1		DR. EPSTEIN:  Is it fair to deduce that about 25
	2	of them lacked a history of prior treatment?

	3		DR. ORTON:  In these individuals?
	4		DR. EPSTEIN:  Of the actual 50 that were RPR-
	5	positive, how many lacked a treatment history?
	6		DR. ORTON:  We have no information on the
	7	individuals from the samples for the DNA and RNA testing. 
	8	The case-control study was done on an entirely different
	9	group of individuals so I have no information on the RPR-
10	positives.  Are you talking about the case-control study,
11	how many were RPR-positive?
12		DR. EPSTEIN:  No.  What I am trying to get at is
13	that if we think that the bacteremia may be in the fairly
14	acute untreated patients, with respect to donors, then the

15	piece that matters here is what percent of RPR-positives who
16	lack a treatment history were in the tested cohort.
17		DR. ORTON:  I have no information on the actual
18	donors themselves from the tested cohort.
19		DR. HOLLINGER:  That would have been very

20	important, wouldn't it?  It seems like that is a very
21	important piece of information.  You have done this study to
22	look at this.  I would think you would want to know that.
23		DR. ORTON:  At the time, we knew absolutely
24	nothing.  So we didn't know if we would even find positives. 
25	So this was, indeed, a pilot study just to find out whether

			127 1	we would detect any DNR or RNA at all.
	2		DR. HOLLINGER:  But we still don't know anything
	3	because we don't have the information that is critical.
	4		Dr. Nelson?
	5		DR. NELSON:  Isn't the perinatal data persuasive? 
	6	These perinatal cases are extensively investigated with
	7	regard to treatment, with regard to stage, and there is some
	8	transmission in the latent stage so that, irrespective of

	9	what the DNA results are, it suggests that transmission is
10	possible during the latent stage in the absence of
11	treatment.  Isn't that true?
12		DR. HOLLINGER:  Dr. Kleinman?
13		DR. KLEINMAN:  I have two questions, Sharon.  The
14	PCR assays; you didn't tell us anything about their
15	validation.  I don't know much about T. pallidum strain
16	differences but if they have been substantiated across
17	different strains, if, in fact, they have been applied to
18	cases of secondary syphilis and do, in fact, yield positive
19	results, as you might expect them to, is that going to be
20	presented by the CDC speaker?  Or, if not, can you tell us
21	something about it?
22		DR. ORTON:  The RNA procedure that we do at the
23	Holland Lab was a procedure that was very extensively

24	validated by Sheilah Lukehart.  It is used on spinal fluid. 
25	She also used it on whole blood, a variety of stages, of

			128 1	phases, as well.
	2		Hsi, if you want to comment.
	3		DR. LIU:  This is Hsi Liu from the Center for
	4	Disease Control.  In terms of the PCR, I would say that we
	5	have performed extensive sensitivity and specificity studies
	6	on the DNA polymerase I target that we used for detecting T.
	7	pallidum.
	8		The reason we selected DNA polymerase I is that
	9	this is a relatively conserved within T. pallidum.  The
10	target we selected, later on, Dr. Markowitz will talk about
11	the two unique features.  But I would just stress that not
12	only the sensitivity and specificity and, also, would stress
13	that we can detect approximately one organism per PCR
14	reaction, which is correlated very well to what Dr. Orton's
15	present, approximately 10 organisms per 100 microliter of

16	the sample.
17		Did I answer your question?
18		DR. HOLLINGER:  Do we have any knowledge at all
19	about how many organisms are present in an ml of blood in
20	various phases of infection?
21		DR. LIU:  This is a question probably in the mind

22	of all the committee members, how many organisms are there. 
23	The answer is we do not know.  However, because the
24	sensitivity of our test is close to about 103 to 104
25	organisms per milliliter of blood, and later on you will see

						129 1	that we were able to detect some of the organisms,
	2	therefore, therefore, there must be that many organisms in
	3	the blood circulated in the patients.
	4		Does that answer your question?
	5		DR. HOLLINGER:  In a way.  In the plasma industry,
	6	because of the development of infections, periodically
	7	panels have been made, seroconversion panels, and things
	8	like this.  Are similar kinds of things available for
	9	syphilis seroconversion?  Do we know, for example, in the
10	plasma industry, what is the number of patients who have

11	some sort of seroconversion from RPR-negative to positive,
12	during follow up?
13		DR. SIMON:  I don't know.  We haven't collected
14	that data.
15		DR. HOLLINGER:  But the tests are done on all the
16	individuals who have plasma donations; is that correct?

17		DR. SIMON:  It is done on all donors when they
18	initially present the first time.  And then it is done on

19	all donors every four months in conjunction with their serum
20	protein electrophoresis.
21		DR. HOLLINGER:  What number seroconvert?
22		DR. SIMON:  I don't know.  We have not collected
23	that data.  I guess it would be interesting.  But we do a

24	screening test and then a confirmatory test and the donors
25	are reentered.  We are allowed to reenter them if the

			130 1	confirmatory test is negative.  And the ones who are
	2	confirmed positive are reported and referred for treatment.
	3		DR. HOLLINGER:  Steve?
	4		DR. KLEINMAN:  My other question, Sharon, was you
	5	have made some statements about platelet concentrates and
	6	oxygen tension, and I wonder--it is such an emphatic
	7	statement that you made that we don't have to worry about
	8	platelet concentrates because of the oxygen tension.  Then I
	9	have two questions.  Is the oxygen tension in platelet
10	concentrates today substantially higher than when they were
11	first made years ago?
12		DR. ORTON:  Yes.
13		DR. KLEINMAN:  Secondly, is this medium the same
14	as applying oxygen tension to other preparations?  If we

15	haven't done the experiment, how do we know for sure with
16	this?
17		DR. ORTON:  It was actually 1985--I have a
18	reference, Steve, I can get you--there have only been two
19	references since the early '70's that I could find, both

20	addressing the oxygen tension in the platelet bag regarding
21	spirochetes.  They are both in 1985.  I don't have them
22	right at my fingertips.
23		So is there no risk?  We don't know if there is no
24	risk.  But I guess what I wanted to point out was we have
25	been really focussing on platelets because of room

			131 1	temperature.  I suspect that they are extremely low risk
	2	versus a red cell that is refrigerated.
	3		Actually, Dr. Liu made a very interesting
	4	statement to me yesterday.  He said, "Through all of this
	5	handling of components, what is the first thing we do right
	6	away when we are collecting these components so we can do
	7	the testing is we stick them on ice so that we will organism
	8	to do our DNR and RNA.  We certainly don't leave them at
	9	room temperature."
10		So, intuitively, along with, like I said, the
11	oxygen tension--yes; it has gone from less than 10 percent
12	in the early '80's to over 60.
13		DR. KLEINMAN:  You also mentioned, I think partly
14	in passing, that there is some evidence that the spirochetes
15	segregate with white cells.
16		DR. ORTON:  That's correct.
17		DR. KLEINMAN:  I wondered how good that evidence
18	really is.
19		DR. ORTON:  Dr. Liu, can you answer that as well?
20		DR. LIU:  At the end of the presentation, we will
21	have some proposed experiments, but I will just let you know
22	the data we have collected so far--at CDC, we have separated
23	blood components into plasma and buffy-coat fraction after
24	we spike the whole blood with organisms.  We were able to
25	detect an organism in all the fractions even though, for the

			132 1	buffy coat, for example, you do a ficoll-hypaque and, and,

	2	after that, you wash, like, three times and you can still
	3	detect organism in that fraction.
	4		The worst fraction that we used was the serum

	5	which is put in the refrigerator for--actually, at room
	6	temperature--for overnight and then refrigerated.  That has
	7	very, very little organism in the serum fraction.
	8		DR. HOLLINGER:  Thank you.  Thank you, Dr. Orton.
	9		The next speaker is Alan Williams on the REDS
10	Study of syphilis screening as a surrogate test.

11		    REDS Study of Syphilis Screening
12		       as a Surrogate Marker Test

13		DR. WILLIAMS:  Thank you, Blaine.
14		[Slide.]
15		I was asked to provide some information about the
16	value of serological tests for syphilis in the context of
17	their surrogacy for behavioral-risk values.  What I will do
18	is provide a couple of slides just to review data from the
19	literature primarily from correlation of marker rates
20	between syphilis and other markers but then spend some time

21	on a study from the REDS Survey Program in which we actually
22	looked at risks at blood donors and were able to correlate
23	them with both anti-hepatitis-B-core and serologic tests for
24	syphilis, both of which have been arguably associated with
25	behavioral risk in donors.

			133 1		[Slide.]
	2		Both anticore and STS, as I will refer to it,
	3	result in a substantial loss of donors for anticore.  The

	4	current prevalence is 0.45 percent in the donor population
	5	and we loose approximately 40,000 donations per year.  For
	6	the PK-TP, it is 0.18 percent.  We loose about 16,000
	7	donations per year.
	8		That is the current situation.  In fact,
	9	historically, we have lost many more donors due to the
10	anticore test who, at some point, might be able to be
11	reentered as active donors.
12		Both reactivities exhibit marginal predictive

13	value for the specific infection in populations such as
14	blood donors who have low infection prevalence.  And the

15	surrogate value for behavioral risk detection for these two
16	markers is speculated, but largely unknown.
17		[Slide.]
18		Specific to syphilis, the correlation of serologic
19	tests for syphilis with HIV and other infection markers in
20	risk populations has been known for many, many years and, in
21	fact, in the early days of HIV, syphilis positivity was felt
22	to be a fairly strong predictor or likelihood of developing
23	AIDS or having an HIV-positive test result.
24		In the blood-donor situation, there have been two
25	major studies, also describing test reactivity over labs,

			134 1	the study by Herrera et al. from the CDC published in
	2	Transfusion in 1997 and by John Aberle-Grasse in our group
	3	at Holland Laboratory, both showed strong evidence of
	4	correlation between STS and HIV as well as hepatitis and
	5	other markers.
	6		However, in both papers, these correlations were
	7	then extrapolated to the likelihood of STS predicting a
	8	window-period HIV infection and, due to the rarity both of

	9	incident HIV and the shortness of the window period, which,
10	in fact, at that time was described by anti-HIV testing, it
11	was determined in both studies that the predictive value of
12	STS would be less than one window-period case per year.

13		As I mentioned, that was based on anti-HIV as a
14	screening test.  One would expect that, with the advent of
15	p24 testing and now NAT testing, the that the predictive
16	ability would be cut in half or even lower than that.

17		But this summary was reflected in the NIH
18	consensus statement on infectious-disease testing for blood
19	transfusion and was generally accepted by that group as
20	representing an absence of surrogate value for this test.
21		[Slide.]
22		You have seen some of these dates before.  I will
23	only mention it to the effect of saying that, in 1938, the
24	STS was indicated for syphilis purposes and then the test
25	was retained for its surrogate value in the early '80's. 

			135 1	This was then dismissed at the NIH Consensus Conference and
	2	there was some question about residual value for syphilis
	3	and we are debating both issues today.
	4		So just in case this pendulum swings back, we took
	5	the opportunity of the survey research program in REDS to
	6	collect some further data which, I think, shed light on the
	7	surrogacy value.
	8		[Slide.]
	9		So the objective of this program was to use
10	established measures of blood-donor risk behaviors to assess
11	the value of anticore and syphilis as surrogate indicators

12	of parenteral and sexual risk in the blood-donor population. 
13	I think anticore is going to prove to be useful as a
14	comparative measure in this study.
15		[Slide.]
16		REDS has conducted several large-scale anonymous
17	blood-donor surveys.  The first one was done in 1993
18	followed in 1995 and this most recent data that I will show
19	is from the 1998 donor survey.  In addition to the five REDS
20	sites located in Baltimore-Washington, Detroit, Southern
21	California, San Francisco and Oklahoma City, for this survey
22	we added the New York Blood Center, the Blood Bank of San

23	Bernardino and Life Blood Blood Center in Memphis, and the
24	whole study is coordinated by the Medical Coordinating
25	Center in Westat.

			136 1		Obviously, many people are involved with these
	2	studies.  I can't name them all but we are certainly
	3	grateful for the cooperation.
	4		[Slide.]
	5		In terms of methodology, this was first
	6	established with the 1993 survey.  We used an anonymous mail
	7	survey sent to donors approximately four to six weeks after
	8	inactive donation.  The donors are all allogeneic donors and
	9	are selected to be over 18 years of age.
10		We have a very highly quantified database for all
11	of the REDS sites in our coordinating center and we can use
12	this as a sampling frame to do a very well-structured sample
13	for this survey.  The data I will show you is from a monthly
14	probability of sample of donors, April through October of
15	1998.
16		This comprised a total of 92,500 sample donors at
17	the AIDS sites.  In this survey, we had a 57 percent survey-
18	response rate.  This is slightly lower than we have had in
19	the past and we attribute it to the fact that this
20	questionnaire was getting rather long because we were trying
21	to build a lot of additional things into it.
22		So we have had response rates up as high as
23	76 percent in the past.
24		[Slide.]
25		In addition to getting data from the survey form,

			137 1	itself, we have the ability to tap into other data available
	2	from the sampling frame and pre-code the surveys.  Even
	3	though they happen to be anonymous, you can take something
	4	like an existing laboratory test result and pre-code the
	5	survey.  In the time frame in which we need to get these
	6	out, we can only deal with the initial screening-test
	7	result.  The confirmatory tests are not yet available.  But,
	8	for anticore, the screening test is the only test that is
	9	available and for STS, the PK-TP has at least a fairly high
10	level of confirmability with the FTA ABS, so we are
11	certainly in a better position than we would be with some of
12	the other viral screening tests.
13		So we pre-coded our outgoing surveys into those
14	that were anticore-positive and no other markers, STS-
15	positive and no other markers, any other marker and totally
16	seronegative.
17		We over-sampled this group to get a better
18	representation.  We actually did not sample.  We used the

19	whole population of anticore and STS-positive donors that
20	were available.
21		[Slide.]
22		The questionnaire, itself, captures demographics
23	about the donors, information about the donors and history
24	and experiences.  There is an extensive behavioral-risk

25	assessment which goes beyond the actual screening done at

			138 1	the blood center, but the questions are formulated so that

	2	we can actually reproduce responses to the questions that
	3	would be asked at the blood center.
	4		This survey has been applied to multiple
	5	investigations.  The one I am describing today, surrogate
	6	value of syphilis and anticore screening, or using it for
	7	studies of incentives to blood donors, hemochromatosis and
	8	studies of HIV test seeking.
	9		[Slide.]
10		One concept that I think most of you have heard
11	before that is critical here is what we are calling
12	deferable risk.  Deferable risk, in the context of a study
13	like this, is risk factors that have been self-reported by

14	an individual responding to a survey that, if identified at
15	the time of blood donation, should have resulted in that
16	donor's deferral.
17		[Slide.]
18		There is a long list of screening questions.  The
19	latest count is some thirteen questions associated with

20	potential infectious-disease risk and the range from male
21	sex with males since 1977 to ear and other body piercing,
22	obviously different levels of specificity.
23		[Slide.]

24		Our results stratified by the testing we obtained,
25	the overall deferral estimate for the negative donors is

			139 1	2.9 percent.  Now, this is a little higher than the estimate
	2	published for the '93 study, and this is largely due to the
	3	addition of additional questions at the blood center
	4	including things like incarceration, birth in Africa, and
	5	ear piercing.
	6		But our background rate here is 2.9 percent.  The
	7	rate for deferrable risk in anticore-positives is 8 percent,
	8	STS-positives, 13.7 percent and other, 11.5 percent.  We did
	9	the appropriate odds ratios and then subjected these to a

10	logistic-regression model adjusting for gender, age, race,
11	ethnicity, education, center and first-time donor status.
12	You can see that the adjusted odds ratios really did not
13	vary too much after doing that.
14		[Slide.]

15		This, in fact, is a little bit of a teaser because
16	if you look at the next slide, one thing that is built into
17	our overall deferrable-risk measure are two questions

18	related to history of syphilis.  So, clearly, we had to
19	correct for those.  One; "In the past twelve months, have
20	you had a positive test for syphilis?"  This is a group of
21	blood donors that has been found positive at the blood

22	center and, presumably, have been notified of that test
23	results so that creates a very muddy situation.
24		The other question; "In the past twelve months,
25	have you been treated for syphilis or gonorrhea?"

			140 1		[Slide.]
	2		If you exclude those two questions and take
	3	another look at the deferrable risk, the negative value
	4	becomes 2.7 percent, the anticore value, 7.3, STS, 4.7 and
	5	for any other markers, 11.5 percent with the appropriate
	6	odds ratios.
	7		Interestingly, once you do the adjustment for the
	8	same variables, anticore stays relatively close at 2.5.  The
	9	STS variable becomes non-significant at 1.3, and the other
10	variables stay significant at an adjusted odds ratio of	3.6.
11		[Slide.]
12		Now, as I mentioned, there is a wide range of risk
13	behaviors that the blood center asks about.  So we wanted to
14	pick some of those that we felt were, perhaps, the most
15	important and look at the specific values here.
16		So we looked at the proportion of MSM and
17	injecting-drug-use what I am calling "burden" associated
18	with anticore and syphilis test-positivity.  What you can
19	see is the columns add up to a total burden of MSM risk in
20	the active panel population that we are surveying.
21		For MSM, 94 percent comes from the seronegative
22	group, 3 percent from the anticore, 0.3 from the STS and 2.6
23	from other test markers.  You can see consistently the

24	anticore group is a little bit higher. For all the risk
25	levels, the STS remains rather low in proportional

			141 1	contribution.
	2		I think one observation that sort of validates our
	3	method of looking at this is you see a fairly high value for
	4	the other tests related to IDU and even sexual contact with
	5	an IDU.  We think this probably reflects hepatitis C
	6	emerging as a test result.  And that would make sense.
	7		[Slide.]
	8		So, in summary, when controlled for first-time
	9	donor status and demographic factors, anticore-positive
10	donors have a 2.6-fold higher level of reported deferrable
11	risk than seronegative donors and the value of anticore, as
12	a surrogate, needs to be considered in the context of other
13	variables that have elevated levels of deferrable risk.
14		Now, we see differences between males and females
15	and first-time and repeat donors at a magnitude of about 2. 
16	CUE panels have a deferrable-risk odds ratio of about 13. 
17	And HIV-test-seeking donors an odds ratio of about 8.  So I
18	think you need to keep the magnitude of some of these odds
19	ratios in mind when assessing the relationships to things

20	like anticore positivity and incentives and some of the
21	other variables that we determine.
22		[Slide.]
23		To summarize the STS data, when controlled for
24	first-time donor status, demographic factors and history of
25	syphilis, STS-positive donors do not report a higher level

				142 1	of deferrable risk than seronegative donors when those STD
	2	questions are removed from the formula.
	3		[Slide.]
	4		The results of the study indicate that when
	5	measured directly, STS does not appear to have value as a
	6	surrogate predictor of behavior risk in U.S. donors.
	7		Thank you.
	8		DR. HOLLINGER:  Thank you, Alan.
	9		Dr. Boyle?
10		DR. BOYLE:  Alan, how did the response rate vary
11	by the four strata?
12		DR. WILLIAMS:  I don't have the figures with me,
13	but they were lower in the seropositive group.  They
14	traditionally are.
15		DR. BOYLE:  A lot, lot lower or just somewhat
16	lower?
17		DR. WILLIAMS:  Probably a half to a little bit
18	less than a half.
19		DR. STUVER:  So are those categories, then,
20	mutually exclusive?  In other words, the STS positive, they
21	were only positive for that screening marker?
22		DR. WILLIAMS:  That's correct.
23		DR. STUVER:  What was included in the other lab
24	reactivity category?
25		DR. WILLIAMS:  Any screening test used by the

			143 1	blood center would be initial reactives for HIV, for HTLV,
	2	hepatitis B surface antigen, anti-HCV, any other screening
	3	test that was available immediately found on collection.
	4		DR. HOLLINGER:  Dr. Mitchell?
	5		DR. MITCHELL:  When we are looking at HIV, we talk
	6	about the test-seeking behavior.  Is there any evidence of
	7	that with regard to the syphilis or RPR?  Have you looked at
	8	that at all?
	9		DR. WILLIAMS:  We have not looked at that.  The
10	test-seeking behavior analysis that we did was based on the
11	'93 data and we found a prevalence of 3 percent of
12	respondents who had sought testing in the past year in a
13	blood-bank setting.
14		We have correlated that with deferral risk but not
15	with the test positivity.  We didn't have that as a variable
16	at that time and we have not done the '98 analysis on that
17	yet.  That is good point.
18		DR. HOLLINGER:  Alan, you make a comment about--
19	you didn't show a slide on this, but you said if parallel
20	molecular studies continue to show an absence of T. pallidum
21	in STS-positive donor, the requirement for STS testing of
22	donated donor should be removed.
23		Can you tell me sort of how much parallel
24	molecular studies would you need to feel comfortable with
25	that?

				144 1		DR. WILLIAMS:  I suspect the way to really hone on
	2	the issue is to define the donors with seropositivity that
	3	would be expected to have--if any group has active
	4	infection, try your best to define those clinically and by
	5	questionnaire and do the nucleic-acid technology on that
	6	group.
	7		We were limited to, essentially, a convenient
	8	sample of platelet samples in first looking at this because
	9	it was a first shot.  Our presumption is that probably most
10	of the infection that is real is remote and that about half
11	of it is not real.  But probably the ideal would be some

12	sort of a collaborative study between the CDC field sites
13	and a laboratory capable of doing infectivity studies to
14	look at those subjects specifically.
15		DR. HOLLINGER:  Thank you, Alan.
16		I think, Dr. Kleinman, you have a few comments,
17	also, on the REDS study, too?

18		DR. NELSON:  I don't know if it is in the database
19	that Alan presented, but you asked about the plasma centers. 
20	I am interested in repeat donors, what is the frequency of
21	incident RPRs.  Are those data available?
22		DR. KLEINMAN:  I am going to present that for
23	REDS.  I don't know about the plasma centers.
24		DR. NELSON:  Oh; okay.
25		DR. KLEINMAN:  As an independent analysis in REDS,

			145 1	we decided to look at the frequency of PK seroconversion in
	2	REDS donors.  This is going to be presented at this year's

	3	AABB and I am sorry I don't have any slides now.  The
	4	analysis is preliminary.
	5		But we looked at four of the REDS centers from
	6	1995 through 1997.  They all followed the same testing

	7	protocols, screening by PK-TP, on the Olympus, 7,100,
	8	confirmation by FTA and then the RPR for the confirmed
	9	positives.

10		We found 103 donors who went from PK-TP-negative
11	to PK-TP-positive, FTA-positive, on a subsequent donation. 
12	When we calculated that as an incidence rate, we got 15.5
13	per 100,000 person years.
14		The mean time from negative donation to positive
15	donation was six and a half months in that two-year

16	database.  When we took at look at the demographics of those
17	donors and compared them to PK-negative donors, the
18	positive, if you will, potential seroconverters, although I
19	am not sure that is the right interpretation--they were more
20	likely to be greater than 36 years of age, more likely to be
21	black or Hispanic, have lower educational levels and be born
22	outside the U.S.
23		Of these factors, race and age remain significant
24	in multivariable analysis.  Interestingly, about three-
25	quarters of the seroconverting donors, when tested by RPR,

			146 1	were negative.  And one-quarter were positive, similar to
	2	what Roger presented for the overall donor set.  This is
	3	quite confusing to us because we would expect, if they were
	4	truly recent infection and they had not yet been treated, or
	5	if they had only recently been treated since their coming in
	6	within six months, that we might expect that they would
	7	still be RPR-positive.
	8		So it brings up a couple of alternative
	9	explanations for these people, that some portion of the
10	dataset might be persons who are now false positive on both
11	assays since they both are T. pallidum assays, and from a

12	comment that Dr. Orton made earlier about her experience in
13	her case-control study, it also brings up the possibility
14	that, at first screening, some of these people were false
15	negatives, that, in fact, their old infection that
16	intermittently becomes positive.
17		So that is really as far as we can go now.  Just
18	to recap, now, of 103 of these individuals in these four

19	centers, REDS collects about 9 percent of the blood in the
20	U.S., 8 to 9 percent.  So you might say if this were done

21	nationwide, we would find about, in a two-year period, 1,000
22	serological conversions and only some portion of these
23	represent new infection.  Others probably represent false-
24	negative or false-positive tests.
25		So that is as far as I can explain the data.  But

				147 1	the demographic data do indicate that these people fall into
	2	categories that you might expect from clinical syphilis case
	3	reporting which is at least being non-white and having lower
	4	education level.  So we have some confusion of explanations.
	5		DR. HOLLINGER:  Thank you, Steve.
	6		Questions of Steve?  Sherri?
	7		DR. STUVER:  So the overall mean between the
	8	negative and the positive is 6.5.  That is what you said?
	9		DR. KLEINMAN:  Yes; 6.7.
10		DR. STUVER:  Did you look at whether there was a
11	difference in the mean time for the RPR-positives versus the
12	RPR-negatives?
13		DR. KLEINMAN:  Yes; in fact I have that data.  The
14	RPR-positives were 8.2 months and the RPR-negatives were
15	6.1.  I don't have the confidence intervals.  I don't know
16	if those were different numbers.  Probably not.
17		DR. HOLLINGER:  You don't know if they have been
18	treated or not, you said?
19		DR. KLEINMAN:  No; these are just a review of
20	database information so all we have is the demographics.  We
21	don't have the samples, so we can't do any further testing
22	to elucidate this.  These are just historical data reported
23	by the blood centers which we retrospectively, as they
24	became interested in syphilis in the last couple of years,
25	decided we should go back and look at.

				148 1		DR. HOLLINGER:  Thank you.
	2		Yes?
	3		DR. NELSON:  What about the geographic
	4	distribution?  Does it follow Lauri's map?
	5		DR. KLEINMAN:  Yes--well, none of the REDS centers
	6	are located in the South.  One of the centers is Baltimore-
	7	Washington, D.C.
	8		DR. NELSON:  Baltimore has the distinction of, in
	9	1998, being the city with the highest incidence and

10	prevalence of syphilis which has now been shifted to
11	Chicago.
12		DR. KLEINMAN:  Ken, I am glad to hear about your
13	claim to fame, but actually we did look at that, and the
14	Chesapeake Region was not higher than the other three
15	regions, so, to that extent, we did have some geographic
16	information and it didn't follow the clinical-case
17	distribution.
18		DR. HOLLINGER:  Mary?

19		DR. CHAMBERLAND:  So my sort of variation on that
20	question is were they, then, uniformly distributed among the
21	five REDS centers?
22		DR. KLEINMAN:  Unfortunately, I don't have that

23	data with me and I don't remember.  I don't know if it was
24	uniform, but I don't think we saw--we suspected that we
25	might find a peak in Chesapeake, so I specifically remember

				149 1	that we looked at that and didn't find that.
	2		DR. MITCHELL:  Were these repeatedly reactive? 
	3	Did they come back for further donations?
	4		DR. KLEINMAN:  The donors that we included were--
	5	the ones that I gave you did not come back for further
	6	donations, I think, in general, although a few might have. 
	7	We did have a few other donors who went from negative to
	8	positive but then returned again and were negative, so we
	9	excluded those.  We figured those had enough evidence to be
10	false-positives since they were not consistent.  But I don't
11	know, within this dataset, whether some of these people, I
12	think, did have multiple donations.
13		But most of them were one-time negatives to one-
14	time positives, lost-to-follow-up, no further information.
15		DR. MITCHELL:  Also, you said that the prevalence
16	of foreign-born was higher?
17		DR. KLEINMAN:  Yes; in the basic analysis, it was
18	higher, but in the multivariable analysis, that dropped out
19	as a risk.
20		DR. MITCHELL:  Okay; because I was wondering
21	whether you would be able to distinguish something like yaws
22	from syphilis with the test.
23		DR. KLEINMAN:  We could probably do more
24	demographics by country or origin, U.S. versus non-U.S.  I
25	don't have that data, though.

			150 1		DR. CHAMBERLAND:  Just another question to help
	2	sort through this, whether or not some of these represented
	3	at least, on a previous donation, false-negatives, and I am
	4	assuming that most of these are from repeat donors.  Because
	5	of the repository capacity of REDS, do you have the ability
	6	to go back and pull samples from even earlier donations to

	7	see if there is any--
	8		DR. KLEINMAN:  We haven't looked at that. 
	9	Unfortunately, the years in which these data were
10	calculated, we wanted to wait until people were well into
11	the PK which started in 1993 but really the protocols were
12	more established in 1995.  Our repositories are general
13	repository collections go from 1991 through 1995 and scaled

14	off.  So we might have some previous donations from a few of
15	the--and we only put about 15 percent of our donor samples
16	in the repository.
17		So I think we, unfortunately, while we might get a
18	few samples and it is worth looking for, it probably
19	wouldn't help that much.
20		DR. HOLLINGER:  Dr. Nelson?
21		DR. NELSON:  In some studies we have done in drug-
22	using populations in Baltimore, we have found some
23	fluctuations of the so-called treponemal tests and even
24	differences between different laboratories.  So I think that
25	both false-negatives and false-positives are a reality with

				151 1	these.
	2		DR. KLEINMAN:  Yes; my sense is these data are not
	3	as useful as we thought they would be at first because I
	4	think the explanation for them are across the gamut, new
	5	infections, false-negatives, false-positives.  I don't think
	6	we will have any way to sort out what proportion were due to
	7	each.
	8		DR. NELSON:  We found, since this cohort that has
	9	been actually followed every six months since 1988, people
10	who the tests--with or without treatment, there is a
11	tremendous fluctuation.  When we got the SCD records, who
12	also had another set of data done in the different
13	laboratory, we found that there was surprising--I mean, some
14	of it was pretty concordant, but there were much higher

15	rates of discordance, both in the treponemal and the non-
16	treponemal--particularly in the treponemal test.
17		DR. KLEINMAN:  I was certainly surprised, and I
18	don't know if this would hold for people on the panel, but
19	you learn about syphilis diagnostic testing and read the
20	textbooks, and it seems fairly straightforward.  And then,

21	when you actually go and talk to people who have experience
22	and see that the tests perform with a lot more fluctuation
23	than you would be led to believe.
24		So I think I am less optimistic about the ability
25	to interpret these data than I was when we began.

				152 1		DR. HOLLINGER:  Does the Red Cross have any data
	2	on seroconversion in repeat donors?
	3		DR. DODD:  Dr. Katz advised me, just say no.  It

	4	is buried in a huge database.  We haven't analyzed it, to
	5	the best of my knowledge.  But we can do that.
	6		DR. HOLLINGER:  Before we finish today?
	7		The next; again, Dr. Markowitz is going to talk
	8	about the Maricopa County STD study.
	9		       Maricopa County STD Study
10		DR. MARKOWITZ:  Thank you.
11		[Slide.]
12		One of the things I want to say before I present
13	these data is I am going to present data on the
14	amplification of DNA polymerase gene T. pallidum from the
15	whole blood of persons with syphilis.  This study was

16	conducted during the molecular subtyping of T. pallidum
17	during an outbreak investigation of syphilis in Maricopa
18	County, Arizona.

19		We were looking at a new subtyping scheme that had
20	been developed in our lab using amplification techniques of
21	the arp and tpr genes.  It was not really designed to look
22	at this issue of the safety of our blood supply, and so
23	there is really, as Sharon pointed out earlier, some very
24	basic differences between our study population and the study
25	population that was presented earlier.

			153 1		We actually decided to look at this only after we
	2	had discussions with the FDA related to syphilis screening

	3	in blood bank.
	4		[Slide.]
	5		As background, I wanted to show you the epicurve
	6	of syphilis in Maricopa County since 1988.  There was a

	7	major increase in cases in 1990 that coincide with the
	8	national epidemic of syphilis, then cases decreased and then
	9	began increasing again in 1996.  They have continued to have
10	this increase through 2000 despite declines in the rest of
11	the country.
12		Maricopa County, in case people don't know, is
13	basically Phoenix, the Phoenix, Arizona area.
14		[Slide.]
15		So our study population was persons attending the
16	Maricopa County SDT clinic who either had signs and symptoms
17	of syphilis or who had a sex partner with infectious
18	syphilis.  These people are required to be investigated by
19	the health department.
20		[Slide.]
21		We used the following case definitions for this;
22	an incubating syphilis is a person with significant sexual
23	exposure to infectious syphilis but who, themselves, have no
24	signs or symptoms of syphilis and are non-reactive on RPR

25	and MHA-TP.  For primary syphilis, it was someone with a

			154 1	genital ulcer who had a positive dark field.  This is a
	2	definite case.  The STD clinic had the ability to do dark-
	3	field examinations.
	4		Secondary was rash and/or lymphadenopathy with
	5	reactive serologic test for syphilis and latent was someone
	6	with no signs or symptoms but with reactive serology.
	7		[Slide.]
	8		Data was collected on exposure to syphilis and
	9	clinical data from the medical records, serologic testing. 
10	5 to 10 mls of whole blood were collected in tubes
11	containing EDTA, were stored at 4 degrees and then were
12	shipped to CDC for analysis.
13		[Slide.]
14		Prior to amplification for the arp and tpr genes
15	for subtyping, the samples were screened using a polymerase
16	chain reaction to amplify the DNA polymerase gene, polA. 
17	Primers were designed based on the unique region of polA and
18	were used to amplify 378 base-pair product.
19		Appropriate positive and negative controls were
20	used for each set of replications.  The samples were kept at
21	4 degrees until analyzed by agaros-gel electrophoresis.  To
22	validate the polA PCR, we confirmed testing using two
23	additional targets, the arp and the tpr genes.
24		The choice of polA was made because it is a highly
25	conserved housekeeping gene for T. pallidum.  The gene

			155 1	target has unique properties and it contains four additional
	2	inserts in sequence and it is high in cysteine content.
	3		[Slide.]
	4		The additional targets that were used for
	5	molecular typing that were also used in this study include

	6	the acidic-repeat protein, which has multiple repeats and
	7	can be used to distinguish among clinical strains, and the
	8	tpr gene, which is a multiple-gene family and is also used
	9	to distinguish among clinical strains for our subtyping
10	scheme.
11		[Slide.]
12		These are our basic results.  Of 32 blood

13	specimens that were obtained, polA was amplified from
14	thirteen, or 41 percent, and seven, or 22 percent, were

15	positive by at least one additional target, either the arp,
16	tpr or both.
17		[Slide.]
18		This slide outlines the clinical stage of persons
19	from whom PCR was done and for whom we had either polA
20	amplified and those who had at least two targets.  As you
21	can see, polA was amplified from persons in every stage of
22	disease.  We had eight people who were incubating--that is,
23	people who had contact but no evidence of syphilis
24	clinically or serologically, and polA was amplified in four
25	of these individuals.

			156 1		There were seven cases of primary and polA was
	2	amplified in one, one case of secondary and that person had
	3	polA, and twelve latent cases and polA was amplified in
	4	seven.  There were four persons that were included that were
	5	suspected syphilis but actually turned out to have other
	6	ulcerative STDs diagnosed, and polA was not amplified from
	7	any of those individuals.
	8		We were able to get additional targets on fewer. 
	9	Part of the reason for this is that we went back later to
10	look at these samples, so the conditions may not have been
11	as good.  We had two incubating, one primary.  So both the
12	primary and the secondary were able to be--we had greater or
13	equal to targets for both of those.  Latent, three.  And,
14	again, none of the persons with nonsyphilis ulcers.
15		[Slide.]
16		This slide outlines the range of polA
17	amplification by the serologic tests.  For those that were
18	nonreactive, RPR nonreactive, polA was amplified in three of
19	these.  Rpr titer, one to one to one to four, four out of

20	seven, and those with greater or equal to one to eight, six
21	out of 14.  For the MHATP, the treponemal test--well, these
22	were at ones that were not done.  Fourteen were not done. 
23	Of those that were reactive, nine out of fourteen and, of
24	those nonreactive, one out of four.
25		[Slide.]

			157 1		Our conclusions; in this study, T. pallidum DNA

	2	was amplified from whole blood; samples from persons known
	3	to have untreated syphilis or exposure to syphilis; and the
	4	viability of T. pallidum that yield the DNA from these
	5	samples is really not known.
	6		But the data do suggest that potentially

	7	infectious spirochetes are present in blood during
	8	incubating primary, secondary and latent stages.
	9		[Slide.]
10		I mentioned this earlier, but there are two
11	fundamental differences between our study and the ARC study. 
12	First, there is a major difference in the study population. 
13	Persons in the study were patients with untreated syphilis,
14	seen at STD clinics or those who were recently infected. 

15	And then, the ARC study, this was a donor population and
16	there was not actually good history on the treatment or the
17	disease status of any of those persons.
18		However, they were likely to have late-latent or
19	treated syphilis.  There are also differences in the blood
20	component, as was mentioned earlier.  We looked at whole

21	blood and the ARC study looked at platelets.
22		[Slide.]
23		The last slide here, I just wanted to mention
24	there is one other study that looked at this issue.  This

25	study was recently published in 1999.  It was conducted in

			158 1	Italy and it has results somewhat similar to ours.  In that
	2	study, sera was used instead of whole blood.  They looked at
	3	patients in different stages of disease as well as treated
	4	patients and they tested patients by a commercially
	5	available nested PCR kit which they purchased from BioLine
	6	which is produced in Turin, Italy.
	7		The DNA extraction and amplification were
	8	performed according to the manufacturer's specifications.  I
	9	have collapsed some of the categories from the paper for

10	this slide, but, basically, they had twenty seronegative
11	subjects.  None of these were PCR-positive.  They also had
12	twenty subjects who were previously treated, had syphilis
13	and were documented to have it previously treated, and none
14	of those were PCR-positive.

15		They also looked at six patients with PNS syphilis
16	and six of those were PCR-positive and nine patients with
17	latent syphilis, and six of those were PCR-positive.  So, at
18	least there is one other study that has found results fairly
19	similar to what we found.
20		DR. SCHMIDT:  In your methods and case
21	definitions, you told us the incubating people had a
22	nonreactive RPR, the secondaries had a reactive.  What about
23	the primaries, the seven primaries?  Was their RPR positive?
24		DR. MARKOWITZ:  That wasn't part of the case

25	definition.  Serology was done--I actually should have

				159 1	brought those data, but, actually, the definition required

	2	they have a positive dark field, dark-field examination of
	3	their ulcer.
	4		DR. SCHMIDT:  But do you know the answer for the
	5	seven?
	6		DR. MARKOWITZ:  Not all of them were positive.
	7		DR. SCHMIDT:  Okay.
	8		DR. MARKOWITZ:  Because, actually, if you look at
	9	the serologies, there are more negative serologies than can
10	be accounted for.  So some of them were RPR-negative, as we
11	know occurs in primary syphilis.
12		DR. HOLLINGER:  The one that was positive, PCR-
13	positive, was what?  Do you know that?  Do you know the

14	reactivity?
15		DR. MARKOWITZ:  No; I did not bring a line list of
16	the data so I don't have those broken down.
17		DR. MITCHELL:  In the Italian study, you grouped
18	together the primary and secondary whereas we were expecting
19	in the secondary phase, they should always be viremic.  Do
20	you know the differences?  Do you know whether all of the

21	secondary stages were--
22		DR. MARKOWITZ:  No; I have the paper.  They also
23	lumped primary and secondary.  The way that they broke it
24	out, which I think addresses your question, was they looked
25	at it by serologic status.  They looked at the latent by

				160 1	serologic status and the primary and secondary by serologic;
	2	that is, they did not break it out by primary and secondary.
	3		DR. HOLLINGER:  Dr. Nelson?
	4		DR. NELSON:  You raised the issue that the PCR-
	5	positive might not always equate with infectivity but has
	6	anybody done rabbit inoculation of PCR-positive samples?  I
	7	mean, that is the model.
	8		DR. MARKOWITZ:  I was asking Dr. Liu or Sharyn
	9	Orton to address this.
10		DR. LIU:  Actually, if you just wait for a few
11	minutes, I will present some of the proposed studies.
12		DR. HOLLINGER:  Dr. Tuazon?
13		DR. TUAZON:  In your PCR results, those with the
14	two targets positive, are those the same ones with the polA-
15	positive, or these are different?
16		DR. MARKOWITZ:  No; they are a subset of polA.  So
17	everyone who is polA--we wanted to see, just to make sure
18	there were not issues, other issues, that could have
19	accounted for the polA positivity.  So all those that are
20	greater than two are a subset of the polA-positives.
21		DR. HOLLINGER:  Just for my understanding of the
22	polA and the other targets, is there a reason why some of

23	the polA are positive, for example four are positive, two
24	are just--the other targets are seven and three.  Why--

25		DR. MARKOWITZ:  Again, Dr. Liu may address these,

					161 1	but I think they are harder targets to amplify because they
	2	are larger targets.  Hsi, do you want to--
	3		DR. LIU:  I believe you just answered the
	4	question.
	5		DR. MARKOWITZ:  Okay.
	6		DR. HOLLINGER:  Thank you.
	7		DR. LIU:  Actually, I will just make it very clear
	8	that the polA target is only about 400 base pairs.  However,
	9	the other two targets are over 1,000 base pairs, and are
10	relatively difficult to amplify.
11		DR. HOLLINGER:  Thank you.
12		Did you have a comment?  Please?
13		DR. NAKHASI:  Hira Nakhasi from FDA.  I am looking
14	at the data from CDC and from the Red Cross.  The data which
15	is presented here which is the number of positives
16	incubating, primary, basically they are seropositive; it
17	that right?  The number comes from where, the seropositive? 
18	The eight, seven, one, twelve--
19		DR. MARKOWITZ:  Let me go back--
20		DR. NAKHASI:  PCR in whole blood by syphilis
21	disease stage.
22		DR. MARKOWITZ:  Did you ask if those are
23	serologically--
24		DR. NAKHASI:  Yes. They were selected on the basis
25	of serologically positive.

					162 1		DR. MARKOWITZ:  No.  I put up our case definitions
	2	and the incubating were not seropositive by definition.  By
	3	definition, incubating syphilis is someone who has been
	4	exposed to infectious syphilis but doesn't have any evidence
	5	of infection yet.  And, for primary syphilis, in this
	6	situation, we did not require a positive serologic test if
	7	they were dark-field positive.
	8		DR. NAKHASI:  My question is where is the number
	9	coming from, and then, when you have PCR-positive, only 50
10	percent in some cases, or one in seven, or seven in twelve,
11	does that mean that what the Red Cross found out that, even
12	though they were antibody-positive, but they could not
13	detect any treponemal DNA.
14		DR. MARKOWITZ:  We did not detect--if I understand
15	your question, we did not detect treponemal DNA in everyone
16	who was--
17		DR. NAKHASI:  Antibody-positive.
18		DR. MARKOWITZ:  Was antibody-positive.  I don't
19	know if you can get the slide back up there but, for
20	example, we did detect it 100 percent of the secondary
21	cases.  There was one secondary case, that person.  But, in
22	the latent cases--
23		DR. NAKHASI:  It was seven out of twelve.
24		DR. MARKOWITZ:  Yes; so the remaining ones, we did
25	not detect.

					163 1		DR. NAKHASI:  And they were antibody-positive.
	2		DR. MARKOWITZ:  Yes; they were antibody-positive.
	3		DR. NAKHASI:  So, therefore, it doesn't differ

	4	that--we had projected there were differences but I don't
	5	see that many differences because of the fact of--the more
	6	cases are antibody-positive and then only a few are DNA-
	7	positive.  So what they found was they also found--in their
	8	case, they found none, whereas you find some cases.
	9		DR. MARKOWITZ:  If we could go back to the slide.
10		[Slide.]
11		You are talking about this slide here?
12		DR. NAKHASI:  Yes; I think so.  Yes; that is one.
13		DR. MARKOWITZ:  So you are saying seven of twelve
14	latent, for example, all of those were positive, had

15	positive serologic tests for syphilis, so five of the latent
16	cases who had a positive serologic test for syphilis, we

17	were not able to amplify polA in five out of the twelve.
18		DR. NAKHASI:  Okay.
19		DR. LIU:  I think I can clarify this a little bit
20	if you are looking for whether there is a direct relevance
21	between the serological test and the DNA amplification, I
22	think my answer would be you will not be able to see
23	100 percent correlation.
24		DR. NAKHASI:  Thank you.

25		DR. SEN:  I have one question.  The ARC tested the

					164 1	16S ribosomal RNA--
	2		DR. HOLLINGER:  Could you state your name, please?
	3		DR. SEN:  Yes.  Keya Sen from FDA.  They tested
	4	the 16S ribosomal RNA ARC which is very high copy number RNA
	5	and at the DNA level, too, there are several copies.  So do
	6	you have plans of testing the 16S ribosomal RNA, a third
	7	target, with those samples.  Maybe you will see better
	8	correlation.
	9		DR. LIU:  Actually, Sharyn would be the person
10	better to answer that question, but in terms of our studies,
11	we did not use the 16S RNA for the test.  Number one, is
12	that we are not using the test in the laboratory.  Number 2,
13	there were some specificity problems with test.  And we have
14	not been able to evaluate the specific test.
15		Thank you.
16		DR. HOLLINGER:  Thank you.  Dr. Liu, I think we

17	are going to go on, then, with the CDC-proposed studies. 
18	Dr. Liu is going to start off.
19			CDC Proposed Studies

20		DR. LIU:  Thank you very much.
21		[Slide.]
22		I would like to clarify that.  I will not be able
23	to propose a study to answer all the questions that we have
24	talked about today, but the following proposed studies are
25	what we think is pertinent.

			165 1		[Slide.]
	2		CDC proposed to study four major questions. 
	3	Question No. 1, is which blood components contain 
	4	treponemes.  We are already starting this study at this
	5	point.  Which fractions of the blood are infectious?  What

	6	is the prevalence of donated blood with treponemes and what
	7	is the concentration of treponemes in the blood?
	8		[Slide.]
	9		In terms of which blood components may contain

10	treponemes, all these studies were done in collaboration
11	with ARC.  What we propose to do is to spike whole blood and
12	then separate it into fractions in the American Red Cross
13	using their methods and perform either PCR or
14	semiquantitative PCR which is developed at CDC at this time
15	to determine whether we can detect organisms in the blood.
16		[Slide.]
17		In terms of what is infectious, this is a very
18	tough question and we propose to spike whole blood as

19	before, separate it into fractions and then perform the
20	rabbit infectivity test which will answer the question we
21	brought early on.  But I would like to be cautious that the
22	rabbit infectivity test is very time consuming and
23	expensive, and we will not be able to do a very large
24	portion of this test.
25		[Slide.]

			166 1		Furthermore, a very important question is what is
	2	the prevalence of circulating T. pallidum in donated blood. 
	3	We propose to expand the ARC study that Sharyn has mentioned
	4	early on to regions of higher syphilis incidence. 
	5	Unfortunately, or fortunately, in the United States, the
	6	cases of syphilis are declining so we really think that now
	7	would be the best, and maybe the only time, to perform the

	8	study in this country.
	9		Additionally, this will be collaborating with all
10	those sites including another location that is in South
11	Africa which has a very high prevalence rate of syphilis. 
12	The method is very simple.  You obtain blood and then

13	perform PCR which will be able to detect the DNA of the
14	organism.
15		[Slide.]
16		Then we also propose additional studies including
17	to test the different stages of syphilis and then these will
18	be validated with STS, the serological tests.  And we will
19	extract DNA of CDC and then do either PCR or
20	semiquantitative PCR to answer those questions.
21		It is a long meeting.  I am the last presenter, so
22	I think this will be all.  Are there any questions?  Yes,
23	please?
24		DR. McCURDY:  You were talking about using
25	discarded blood for your spiking studies.  Is that outdated

			167 1	blood or fresh?
	2		DR. LIU:  In the original slide, I believe, the
	3	committee members received a piece of paper outlining the
	4	studies.  No; we are not using discarded blood at all. 
	5	Actually, Dr. Orton and I have already started the study and
	6	yesterday we separated some of the blood fraction, and then
	7	I believe we used fresh blood.
	8		DR. McCURDY:  Because, if you are going to
	9	separate it into components, you will get different results
10	if it is stored rather than separated fresh.
11		DR. LIU:  We are using fresh blood, number one. 
12	And, number two, in terms of the storage problem,
13	unfortunately, it is going to be really complicated because
14	the different components will be stored a different length
15	of time.  We will not be able to answer all the questions,
16	but we will design a study to answer part of the questions,
17	like, for example, platelets we may just leave at room
18	temperature for one hour, two hours, or maybe a day and then
19	test for the DNA.
20		However, remember that whether we can detect the
21	DNA or not has nothing to do with infectivity.  So it has

22	nothing to do with the transmission of disease.
23		DR. McCURDY:  I might point out, also, that
24	whereas random donor platelet concentrate from whole-blood
25	donations are often, if not usually, stored for a couple of

					168 1	days and may be subject to oxygen tensions that would
	2	destroy the treponema.  Pheresis platelets are much more
	3	likely to be given fairly promptly and a certain number of
	4	them, at least, are drawn for a particular patient.
	5		So those may carry a different risk than the
	6	random donor platelets.
	7		DR. LIU:  Yes; I agree with you.
	8		DR. HOLLINGER:  Dr. Schmidt?
	9		DR. SCHMIDT:  I don't understand number three,
10	expand the Red Cross study to areas of higher syphilis
11	incidence.  In the United States?
12		DR. LIU:  We are thinking of the United States
13	because right now there are really not too many places have
14	a high incidence.
15		DR. SCHMIDT:  In the hopes of collecting a
16	donation from a person with infectious syphilis.  Why not go
17	to Maricopa County, Arizona, where you have all of this
18	stuff and give them $25 and you would have a unit at all of
19	these different stages.  To go to South Africa to do this is
20	just--I don't understand.
21		DR. LIU:  The reason being because the question
22	really is related to whether the person who donated the
23	blood in the blood bank has a high risk.  If you are talking
24	about the people in Maricopa County, these are patients with
25	syphilis, active syphilis or latent syphilis.  We have

					169 1	already shown that we can detect organisms there.
	2		DR. SCHMIDT:  But then why do we want to do that
	3	again?
	4		DR. LIU:  Pardon me?
	5		DR. SCHMIDT:  What about this person being a blood
	6	donor for the Red Cross is different as far as their bugs
	7	from somebody in Arizona?
	8		DR. LIU:  The question is quite straightforward. 
	9	Whether we are interested in detecting organisms in the
10	blood or whether we are interested to study whether people
11	donate blood in the blood banks are the high risk.  To
12	answer the first question, we pretty much show that if you
13	are in the high-risk group, like the Maricopa County
14	studies, there are organisms floating in the blood.  Whether
15	these are infectious or not, we do not have the data right
16	not to support that.
17		In terms of the Red Cross study, it is 100 percent
18	for the purpose of the safety of our nation's blood banks. 
19	That, if you want to do it, for example, for the committee
20	to determine whether serological tests should be used or

21	not, this is the only time in my presentation--that will be
22	the only few places we can do that study.

23		Does that answer your question?
24		DR. SCHMIDT:  No.  But you have your mind made up.
25		DR. LIU:  Oh, no, no.  Not at all.  I do not have

			170 1	any mind set at all.  But if you can explain, or maybe
	2	someone can help me to explain.  Sharyn?
	3		DR. ORTON:  Dr. Schmidt, I think what Dr. Liu
	4	meant by doing studies in areas of higher incidence, what we
	5	did was I mapped what counties had the highest incidence of
	6	syphilis in the country and where we happened to coincide
	7	having blood donors come from.
	8		The idea was, rather than just taking a random
	9	sample of blood donors who test positive for syphilis is go
10	into areas where we do know that the incidence is higher and
11	look at the components from those donors who test positive
12	for syphilis.  I think that is what he was talking about.
13		If we are going to find a donor who has evidence
14	of syphilis by DNA or RNA PCR, we are more likely to find it
15	going into counties where the incidence of syphilis is
16	higher and, therefore, look at those corresponding Red Cross
17	sites in those areas.
18		I think that is what he meant.
19		DR. LIU:  Thank you very much, Sharyn.
20		DR. STRONCEK:  But I think the question is, are
21	blood donors in the U.S. that test positive by the FTA
22	assay, are they infectious or not, then I agree going to
23	counties in the U.S. where there is a higher incidence might
24	be worthwhile, but if South Africa is not using exactly the
25	same blood donation screening and testing information, it is

			171 1	totally irrelevant because there are different factors.
	2		If you really think that this study is impossible,
	3	you are not going to find blood donors positive, then I
	4	guess you are saying that we should just get rid of the
	5	syphilis testing.
	6		DR. LIU:  Unfortunately, I cannot make that
	7	decision as to whether we should abandon the syphilis test. 
	8	That is up to the committee to decide.  We are here to
	9	present the current data we have and also present the
10	potential studies.
11		The study in Africa will answer some biological
12	questions.  It may not be directly relevant to the safety in
13	the blood banks.  However, they do answer some questions.
14		DR. HOLLINGER:  Dr. Simon?
15		DR. SIMON:  I had one question.  I don't know if
16	Dr. Liu is the right person, but I don't believe it has come
17	up, unless I have missed it, it seems to me, in my memory,
18	that when the FDA in the '80's was looking at abandoning the
19	test, that one of the concerns was that the positive STS, or
20	the RPR, would be passed; in other words, that the recipient
21	wouldn't get syphilis but would have a positive test and
22	that would have certain recriminations.
23		What is the situation regarding that?
24		DR. LIU:  I think you are right.  I am not the
25	right person to answer that question.  Anyone?

				172 1		DR. SIMON:  In other words, do you transmit a
	2	positive test result as a passive factor of blood
	3	transfusion and then you have a problem that someone has a
	4	positive test.
	5		DR. LIU:  Dr. Orton will answer your question.

	6		DR. ORTON:  I do know that there have been some
	7	papers.  I don't know the exact figures off the top of my
	8	head or how long ago they were that did talk about when

	9	seropositive units were transfused into somebody, the length
10	of time that they remained seropositive and the titers that
11	are seen.
12		It is not seen for long.  The titers are not high. 
13	But I don't remember that being a particular concern.  Maybe
14	back then when it was done more routinely as a routine test
15	in the hospital or something, but I don't, in recent years,
16	remember that being an issue with transfusing those units.

17		DR. SCHMIDT:  That was done experimentally in Dick
18	Walker's study which Cable refers to where he intentionally
19	gave STS-positive blood and he followed that and observed

20	that and did discuss it.
21		DR. SIMON:  In those days, people, of course, had
22	to have it for marriage and so on.
23		DR. HOLLINGER:  Dr. Tuazon?
24		DR. TUAZON:  Do we have information on the false-
25	positivity of PCR such as in Lyme disease or other

			173 1	treponemal infections?
	2		DR. LIU:  You are talking about the PCR we are
	3	using at CDC?
	4		DR. TUAZON:  Right.
	5		DR. LIU:  I have not clarified in great deal,

	6	early on when someone asked me about the specificity and
	7	also the sensitivity of the test.  To test for specificity,
	8	we have performed the PCR test on relatively high
	9	concentrations of DNA in organisms including almost all the
10	spirochetes, including Borrelia bergdorfii causing Lyme

11	disease, and leptospirosis, many different serotypes and
12	other nonpathogenic treponemes.
13		The test that we are using at this time is only
14	positive on pathogenic treponemes including the three
15	subspecies.
16		DR. HOLLINGER:  Dr. Nelson?
17		DR. NELSON:  I think international studies are not
18	irrelevant to this issue because I think the real issue is
19	if you have some--the problem is we have got so many, like,
20	false-positives previously treated, et cetera, in the U.S.
21	blood donors that there are places where there are a lot of
22	true-positives.
23		The issue is when a blood bank processes the
24	specimen, is it still infectious.  There may even be places
25	where blood is not screened and that would also be an

			174 1	interesting population because there are ethical issues,
	2	certainly, but if one could identify what the rate of
	3	transfusion-transmitted is, there may be international blood
	4	banks in Africa, Asia, somewhere, where screening is either
	5	not done or not routinely done or something where you could
	6	actually get some real data on transmission.
	7		I would think that an international population
	8	might be able to contribute some very important information
	9	on this although this kind of study would be difficult.  I
10	assume that, in South Africa, donors are screened and, if

11	they have a positive result, they are not transfused.  Is
12	that correct?
13		DR. LIU:  I believe that South African blood

14	donations should be screened.  I do not know that as a
15	matter of fact, but I believe they do.  And you were right
16	that, in my view, it is very important to study this
17	organism not just including in this country but also expand
18	it to other territories.
19		We have to realize that this organism is very
20	difficult to study.  It grows very, very slowly and we know
21	very little about the biology of these particular organisms.
22		DR. HOLLINGER:  Are they screened in Thailand?
23		DR. NELSON:  Yes.
24		DR. NAKHASI:  Dr. Liu, when you mentioned that the
25	experiments to test the biological infectivity in the

				175 1	rabbits will be expensive or it was a difficult situation to
	2	do that, I was thinking is it possible, instead of doing a
	3	DNA PCR, one can RNA PCR which will tell you whether, in
	4	this case, the bacteria is replicating, which will give an

	5	indication that it is infectious, as compared to DNA which
	6	could be just a piece of DNA lying around.
	7		DR. LIU:  I believe that both RT PCR--we are
	8	talking about RNA PCR, RT PCR.
	9		DR. NAKHASI:  Yes.
10		DR. LIU:  RT PCR and the regular DNA PCR pretty
11	much answer the same questions.  In theory, the RT PCR
12	should be more sensitive than the DNA PCR.  Right now, like
13	I said, we have not been able to evaluate that.
14		DR. NAKHASI:  I don't agree with your earlier
15	assertion that DNA and RNA will give you the same answer. 
16	The RNA will give you whether it is replicating because if
17	the parasite, or in this case the bacteria, is lying there
18	and not doing anything, which will be just the DNA.  If it
19	is replicating, you know, because it has to make the

20	proteins and all those things, the RNA will be there.
21		So if you see an increase of RNA, that is an

22	indication which is the case with HIV and other things, you
23	do HIV RNA PCR which you gives you an indication whether it
24	is infective.
25		DR. LIU:  Let me sort of readdress your question a

			176 1	different way.  I believe you are concerned that DNA, if we
	2	detect DNA, it could represent dead organisms because DNA is
	3	either dead and they can stay there.  However, RNA poses the
	4	same question because the RNA we are using right now is 16S
	5	ribosome RNA and they are also very stable.  Even after the
	6	organism is dead, it can stay in the blood stream.
	7		DR. NAKHASI:  Yes; I agree with that.  Thank you.
	8		DR. HOLLINGER:  Steve?
	9		DR. KLEINMAN:  Just to comment on the need for
10	international studies.  It seems to me that if you want to
11	answer the blood safety question in the U.S., then, really,
12	the issue is whether you have zero tolerance or low-risk
13	tolerance.  We already know that even if units are
14	infectious, even if that is proven by international studies,
15	it seems sort of obvious from the estimates that the number
16	of cases transmitted per year would be very low in the
17	States.
18		So if you start with the assumption that if we can
19	document that the cases are likely to be above zero, we

20	won't change the policy.  Then I don't think you need to
21	document the extent of the problem.  I am not sure what the
22	implications of that are, but I think you could define the
23	need for studies by the policy parameters you are going to
24	set.
25		You can say if there is even one case of syphilis

			177 1	that would be transmitted per year, based on eliminating the
	2	test, that would be unacceptable an we would want to keep
	3	the test.  I think you go down a potentially different track
	4	than if you say, "Gee, well, we would consider dropping if
	5	it is only five cases per year."
	6		Then you might have to actually document the
	7	number of cases per year in the States.  I guess my comment
	8	is more relevant to doing the studies at the high-incidence
	9	centers within the U.S.  So I am not sure we need to
10	document--do we need to document how frequently it might
11	occur in the U.S. or just that it is biologically plausible
12	that transmission could occur if we dropped testing.
13		DR. NELSON:  I think it is useful to understand

14	the biology.  For instance, for infectious viruses, there
15	are multiple steps to try to decrease the risk.  I don't
16	think anybody would suggest that we should tolerate a few
17	cases of syphilis just to get rid of the test.  But the
18	questions are really different; how can you process the

19	blood to decrease the risk or what is the highest--I mean,
20	there have been issues related to are platelets safe or are
21	they hazardous.
22		We really don't know and I think there are
23	possible ways to get some answers to the question.  This is
24	very difficult because there isn't a good animal model and
25	the culture of the organism isn't feasible.  So I think that

			178 1	well-designed international studies might yield some
	2	important and useful data.
	3		DR. HOLLINGER:  Thank you.
	4		I am going to go on, Paul, to the open public
	5	session and get that finished.  We will come back.  We will
	6	have time to talk.  There are two people that have asked to
	7	talk.  The first one is Dr. Katz from the AABB.
	8		          Open Public Hearing
	9		              Presentation
10		DR. KATZ:  Thank you, Blaine and committee
11	members.  We have distributed a written statement that has
12	been amended.  So if you were going to fall asleep because
13	you have already read it, stay awake at least, perhaps,
14	towards the end.
15		The serologic test for syphilis has been retained
16	in the United States for two ends, as we have heard;
17	prevention of transfusion-transmitted syphilis and as a
18	surrogate for risk behaviors associated with HIV infection. 
19	Transfusion-transmitted syphilis has not been recognized in
20	the United States for more than 30 years and, in fact, in
21	'85, as you have heard, and FDA committee recommended
22	elimination of the STS for blood donors.  This
23	recommendation was not implemented due to the concerns about
24	surrogacy.
25		The reasons for the disappearance of transfusion

			179 1	syphilis are multiple including the declining incidence of
	2	infectious syphilis in this country to historically low
	3	levels and donor-deferral policies in the blood centers that
	4	reduce the presentation to donate of those at risk for
	5	infectious syphilis.
	6		Storage of red blood cells at refrigerator
	7	temperatures is probably an important contributing factor as
	8	well as the improved oxygenation of platelets over the last
	9	fifteen years.  Still, there are transfusion of fresh red
10	blood-cell components and platelets stored at room
11	temperature may be a risk as well.
12		Receipt of antimicrobial therapy by those ill

13	enough to require transfusion support may be important in
14	preventing either infection or recognition of transfusion
15	syphilis.  From a biological standpoint, it must be

16	emphasized that the spirochetemia associated with the
17	majority of transfusion transmissibility of T. pallidum
18	often occurs before the serologic test for syphilis is

19	positive and I think that we can extrapolate from that that
20	spirochetemic donations are being transfused with some
21	frequency in this out as we speak.
22		At the NIH Consensus Conference in January 1995,
23	it was concluded that, and I quote, "The current blood-
24	storage conditions would not appear to provide an adequate
25	margin of safety against transfusion-transmitted syphilis

			180 1	should the donor-screening test be eliminated.  Further
	2	information concerning T. pallidum survival under blood and
	3	platelet storage conditions and the application of molecular
	4	techniques to assess the presence of T. pallidum DNA in
	5	serologically positive units would allow better assessment
	6	of this question."
	7		Data presented at the AABB national meeting and

	8	again today, by Orton et al., based on PK-TP-positive FTA-
	9	ABS-confirmed donors using two PCR methods found none with
10	detectable DNA.  On the other hand, we have heard the data
11	from CDC that suggest that, particularly in early syphilis,
12	spirochetemia can be demonstrated by sensitive nucleic-
13	amplification testing.
14		Regarding the value of STS as a surrogate for
15	other transfusion-transmitted diseases even prior to the
16	implementation of sensitive NAT assays for HIV and HCV, the
17	Consensus Development Conference concluded that surrogacy
18	was no longer an issue.

19		We are aware of the CDC data suggesting that there
20	are early syphilis cases being reported among blood and
21	plasma donors and, unfortunately, as the CDC investigators
22	have stated, they are unable to segregate paid plasma donors
23	from volunteer whole-blood donors in their data.  We view
24	this as a serious flaw in the context of discussing the STS.
25		Taken against a background of historically low

			181 1	infectious syphilis rates in this country and the failure of
	2	clinicians to recognize even isolated cases of transfusion-
	3	associated syphilis, we are not sure of the applicability of
	4	the CDC data to the volunteer whole-blood-donor sector.
	5		Ramsey and Sherman reviewed FDA-reported blood-

	6	component recalls in the United States from 1990 through
	7	1997.  Of an estimated 241,800 components recalled,
	8	57 percent or almost 140,000, were for incorrect syphilis
	9	testing.  These were primarily a single large recall of
10	units where weakly reactive serologic tests for syphilis
11	results may have been called negative.  This recall was

12	classified by FDA as a class III recall, not likely to cause
13	adverse consequences.
14		With these points in mind, AABB believes the
15	serologic test for syphilis could safely be eliminated based
16	on the absence of recognized transfusion-transmitted
17	syphilis in over 30 years despite the undoubted transfusion
18	of some components from seronegative spirochetemic donors.
19		We have listened to the presentations this morning
20	and understand the concerns that have been raised and would
21	support further studies to document the absence of
22	transmissible T. pallidum in whole-blood components and
23	apheresis platelets if the committee is not, at this time,
24	willing to endorse discontinuation of the serologic test for
25	syphilis.

			182 1		Thank you.
	2		DR. HOLLINGER:  Thank you, Dr. Katz.
	3		Dr. Bianco, from America's Blood Centers?
	4		              Presentation
	5		DR. BIANCO:  I am amending the printed statement

	6	that was distributed to the committee and the audience in
	7	the sense that we favor the elimination of the requirement. 
	8	However, we recognize that a lot of information was provided 
	9	today and that some studies are likely to add information,
10	particularly in terms of studies of survival of the
11	treponemes in blood and the infectivity studies.  They are

12	the most critical piece of information missing here for a
13	final decision.
14		However, the basis for favoring the elimination,
15	the primary reason for this position is the lack of
16	documented cases of syphilis transmission by transfusion in
17	decades.  As we heard from Dr. Schmidt, he saw the last case
18	in 1966; the declining incidence of syphilis in the U.S.
19	population; effective deferral of individuals in risk
20	behavior through medical history and direct questioning
21	including deferral of individuals with a history of venereal
22	disease in the past year; and the poor survival of
23	spirochetes in stored components which will be further
24	studied.
25		I should also add that indirectly NAT testing for

			183 1	HIV and HCV is contributing to prolonged storage because we
	2	cannot easily release products before 36 or 48 hours after

	3	the collection of the product.  But no platelet is
	4	transfused today with less than 36 hours of life on the
	5	shelf.
	6		Even if syphilis was effectively transmitted by
	7	transfusion, which I think it is not, the assay currently
	8	used for screening of blood donors is, unfortunately,

	9	worthless.  PK-TP and the similar assay, HMA-TP, are
10	specific assays that detect antibodies to treponemal
11	antigens.

12		Individuals who had syphilis remain positive for
13	their lifetimes, even after effective antibiotic treatment
14	and cure.  Thus, nearly all those reactive for the AIDS

15	assay are immune and do not transmit the disease.  For
16	example, it is not uncommon for blood donors to reveal that
17	they were infected and were treated during World War II or
18	Viet Nam and continue to have a positive PK-TP antibody
19	test.
20		Actually, CDC recommends the use of reagent-type
21	tests for screening in healthcare settings including STD

22	clinics.  These tests do detect active infection and turn
23	negative upon appropriate treatment.  Unfortunately, these
24	assays generate a large number of false-positive results and
25	are not automated for use in blood-donor screening.

			184 1		MHATP and, similarly, the PK-TP are appropriate
	2	for confirmation of positive reagin test results to
	3	eliminate the false-positives.  So I think that even if it
	4	were transmissible, the screening in the manner that we do
	5	today is inappropriate.  It creates a population of
	6	stigmatized individuals that had a infection 30, 40, 50
	7	years ago and that represents no danger to the blood supply.
	8		In summary, we recommend that the studies that

	9	were proposed today be conducted and we believe that if
10	those studies provide some assurance that the treponemas
11	don't survive, that the test should be dropped.
12		Thank you.
13		DR. HOLLINGER:  Thank you, Celso.
14		I know the American Red Cross did not have a

15	statement, but is there any feeling from the--is anyone here
16	from the American Red Cross that would like to make a
17	comment
18		DR. DODD:  I think it is very simple.  The
19	American Red Cross position has been ably presented by the
20	last two speakers.  Our feelings are entirely consistent

21	with the AABB and ABC position.  Thank you.
22		DR. HOLLINGER:  Thank you, Roger.

23		Are there any other comments from the public that
24	anyone wishes to make a statement at this point?  If not, I
25	am going to close, then, the public portion of this.  Why

			185 1	don't we go ahead and put the question forward, and then we
	2	will have any additional discussion that is needed.
	3		      Questions for the Committee
	4		DR. RUTA:  Dr. Hollinger, members of the
	5	committee, thank you very much.  We turn to you again to ask
	6	you for advice about the information that you heard this
	7	morning.  Just briefly, to put things in context, we raised
	8	the issue of syphilis testing at this time because last year
	9	the FDA issued a proposed rule to update the requirements
10	for donor testing and also a second rule of notification
11		We received comments on those two rules and we had
12	a public meeting to allow people to give oral comments.  As
13	part of the rulemaking, we solicited comments specifically
14	on the utility of testing for syphilis.  We received five
15	comments supporting the elimination of syphilis testing and
16	two opposing the elimination of syphilis testing.
17		We asked for data and, this morning, you have
18	heard some data presented by Dr. Williams and Dr. Orton of
19	the American Red Cross.  I wanted to thank them for
20	submitting data.
21		We also became aware of data that our colleagues
22	at CDC had which we thought were of value considering and so
23	we invited them to come and present it.  I wanted to thank
24	our colleagues from CDC, Dr. Liu, Dr. Morse and particularly
25	Dr. Markowitz who gave three talks this morning.

				186 1		Now we turn to committee and ask for the
	2	committee's advice.  The first question we have for the
	3	committee is do committee members agree that current
	4	scientific data are insufficient to warrant discontinuation
	5	of donor testing for antibodies of syphilis.
	6		Shall I continue with all the questions or would
	7	you want to take them one--
	8		DR. HOLLINGER:  If you would, please.
	9		DR. RUTA:  If the answer is in the affirmative, if
10	so, committee members are asked to comment on the adequacy
11	of the additional studies as proposed to resolve the value
12	of testing for antibodies to syphilis in preventing the
13	transmission of syphilis through blood transfusion.
14		Finally, the last question is do committee members
15	believe that donor testing for antibodies to syphilis should
16	be retained as a surrogate marker of deferrable high-risk
17	behavior even if it is proven that such testing is no longer
18	useful for prevention of transfusion-transmission of
19	syphilis.
20		DR. HOLLINGER:  Thank you very much.
21		Committee Discussion and Recommendations
22		DR. HOLLINGER:  So we are going to deal with the
23	first question first.  Is there anyone who has some comments
24	to make at this point.  With a couple of double negatives

25	here, basically the first question says, if you vote yes,

			187 1	you are voting for continuation of testing, the current
	2	testing that is being done.
	3		Paul?
	4		DR. McCURDY:  I was wondering, as the morning went
	5	on, if the pathogenesis of some of the manifestations,
	6	particularly secondary syphilis and the skin manifestations
	7	had to do with antigen-antibody reactions as it does for

	8	many of the infectious diseases because, if that is the
	9	case, then a fair number of patients who are getting
10	transfused with fresh components, platelets and others, are
11	immunosuppressed and may not have any of the manifestations
12	of secondary syphilis that were illustrated by Paul Schmidt
13	in his case of some time ago.
14		I am not quite sure how one would approach that
15	but the neonate is immunosuppressed and they get fresh red-
16	cell components.  And marrow-transplant patients and
17	oncology patients are immunosuppressed and they get lots of
18	transfusions including lots of platelets, both pheresis and
19	random-donor platelets.
20		DR. HOLLINGER:  Dr. Tuazon, since this is your
21	specialty here, would you comment?
22		DR. TUAZON:  For the secondary stage, it has been
23	documented, when you have the skin lesions such as shown by
24	Dr. Schmidt, you could biopsy those lesions, show the
25	spirochetes.  So there is active spirochetemia during the

				188 1	second stage of the illness.  It is just like bacteremia.
	2		DR. McCURDY:  But the manifestations do not relate
	3	to the development of antibodies that attack those
	4	spirochetes when they are in the skin.
	5		DR. TUAZON:  I am not sure that is any data on
	6	that, antigen-antibody reaction, but the classic
	7	presentation of secondary syphilis is actual invasion of the
	8	spirochetes through the systemic organs to the blood stream.
	9		DR. HOLLINGER:  Maybe a question here; patients
10	with HIV, with AIDS, who are immunosuppressed and they
11	acquire syphilis, they would have the same manifestations as
12	anyone--
13		DR. TUAZON:  They do, and they are much more
14	difficult to treat because of their underling cell-mediated
15	immune depressions.  It is harder for them to eliminate the
16	syphilis.  I was just telling Dr. Schmidt of my one
17	experience where I had an HIV guy who had disseminated

18	syphilis that did not respond to two weeks of high-dose,
19	20 million units of penicillin, and had to be treated for
20	six weeks to get rid of the skin lesions that were steaming
21	with spirochetes.
22		DR. HOLLINGER:  So those with maybe CD4 counts of
23	less than 200, let's say--
24		DR. TUAZON:  No, no; this guy had actually a good
25	CD--

			189 1		DR. HOLLINGER:  I understand that.  In answer to
	2	the question about immunosuppressed people, if they have a
	3	low level, less than 200, less than 100, and they get
	4	syphilis, they have chancres, they have the usual
	5	manifestations?
	6		DR. TUAZON:  No; I think that stage that you are
	7	talking about is the secondary stage because that is the one
	8	that would mimic the transfusion-transmitted disease.
	9		DR. HOLLINGER:  Dr. Nelson?
10		DR. NELSON:  There are a couple of case reports,
11	or several, in the literature about atypical clinical
12	appearance of syphilis in patients with HIV and
13	immunosuppression including people with secondary
14	manifestations without--who are RPR-negative who do not have
15	antibodies where the organism has been found by biopsy and
16	finding spirochetes.

17		In most of these cases, antibodies appeared later. 
18	They eventually appeared.  But maybe agammaglobulinemic

19	would be--I don't know if there are such cases, but AIDS
20	patients are immunosuppressed but it is complex.  It is more
21	cellular, et cetera.  But I think the question you are

22	raising is whether or not some blood component, or blood
23	recipients, might have, in fact, been infected and it was
24	just not clinically recognized because of their clinical
25	state.

					190 1		I think that is a relevant question.  I think the
	2	other issue is many are on antibiotics and they may have
	3	been infected but not recognized for other reasons.
	4		DR. HOLLINGER:  Dr. Schmidt.
	5		DR. SCHMIDT:  In the question as presented, is the
	6	question really do committee members agree that current
	7	scientific data on the transmission of syphilis are
	8	insufficient because otherwise you are asking both questions
	9	in the first question.  I want to make sure everybody, since
10	it is presented negatively already, we are going to double
11	twist this here.
12		DR. NELSON:  We could just vote yes.
13		DR. HOLLINGER:  Paul?
14		DR. McCURDY:  There is one other issue that
15	occurred to me in light of these questions.  Yesterday, we
16	were asked very definitely to separate the plasma side from
17	the whole-blood side.  It would seem to me that the multiple
18	steps that go through infractionation and inactivation and
19	such would make it extremely unlikely, even if a very
20	infectious unit got in, that it would carry through to the
21	final derivatives.
22		I guess my question is should we, here, separate
23	the plasma from the whole-blood side as well.
24		DR. HOLLINGER:  We don't have data, even, from the
25	plasma section about whether there is seroconversion.

			191 1		Dr. Simon?
	2		DR. SIMON:  I just wanted to reiterate, and I hope
	3	my FDA colleagues will correct me if I misspeak, but my
	4	understanding is that the syphilis requirement for testing
	5	plasma donors is strictly for the donor's benefit.  We can
	6	actually shift product from donors who have tested positive
	7	for fractionation into final product so that, with the
	8	frozen product, there has been no concern about transmission
	9	of syphilis.
10		So I agree with you that we can separate the two
11	issues and, if there is not felt to be a public-health
12	reason to continue to test the plasma donors, it would
13	appear that we could drop that testing at this time because
14	that is not a test done on the unit.  That is a test done on
15	the donor initially every four months.
16		DR. RUTA:  I think that is not actually quite
17	right.  If someone in the source-plasma setting were to test
18	positive on the screening test and then confirmed positive,
19	then those units could only be used as controls for the

20	syphilis test.  I think what you are referring to, if
21	someone tested reactive on the screening test and then were
22	shown to--that that were a false-positive or that they had
23	been treated, then they could be reinstated.
24		DR. SIMON:  Yes; they can definitely be
25	reinstated.

					192 1		DR. RUTA:  But the confirmed-positive units are
	2	not allowed to be used for fractionation.
	3		DR. EPSTEIN:  I think that point is that since the
	4	donor is only tested once every four months that positive

	5	units might have been collected, shipped and used pending
	6	the next test.
	7		DR. SIMON:  Oh; right.  Okay.
	8		DR. EPSTEIN:  But a known positive unit is
	9	restricted to in vitro use.
10		DR. SIMON:  Yes.  I should clarify; once you have
11	identified the donor, then those units cannot be shipped. 
12	But there is no look-back required.
13		DR. HOLLINGER:  So just answer Dr. Schmidt's
14	question, and this is regarding transfusion.  The question
15	really is do the committee members agree that current
16	scientific data--
17		DR. SCHMIDT:  I am asking do you want to insert
18	data on the transmission of syphilis.  In 1a), are just
19	talking about the validity of the test in preventing or not
20	preventing the transmission of syphilis.  Are we excluding
21	HIV from this first question?

22		DR. HOLLINGER:  Yes.
23		DR. RUTA:  Yes.
24		DR. HOLLINGER:  That is the second question.  I
25	think that was fairly understood.

			193 1		John?
	2		DR. BOYLE:  I have been doing some math.  My math
	3	may be wrong because I have pulling things together.  If it
	4	is at any point, please point it out to me, but what I heard
	5	from the Red Cross is positive tests lead to the exclusion
	6	of about 16,000 donors per year.  They represent half of the
	7	blood industry and its 32,000 donors who are testing
	8	positive to the STS after having denied any experience on
	9	the screening questionnaire.
10		According to another set of information, 50
11	percent of those who had tested positive upon reinterview

12	admitted that they did have a history of syphilis.  Now, if
13	those two pieces actually agree with each other, then, by
14	dropping the screening test, we are reintroducing 16,000

15	people per year donating who do have a history of syphilis
16	at some unknown state in that process and we have other

17	information put up here saying that, at various points in
18	the history of the disease, that they, indeed, even in the
19	late latency stage, can transmit by blood.
20		If all those pieces are correct, then I would be
21	concerned that part of our success in the last 30 years in
22	not having any of these things was having this test in
23	place.
24		DR. HOLLINGER:  I think everything you said seems
25	to me, as I hear it, is probably correct except that the

			194 1	issue of "can transmit in blood."  I don't think we know. 
	2	That is the issue that is before us.
	3		DR. SIMON:  Also, these are people presumably--

	4	because the question says "in the last twelve months."  So
	5	they can come back as donors.  So these are people who
	6	presumably were successfully treated.
	7		DR. KATZ:  The donor question is regarding
	8	venereal diseases during the past twelve months.
	9		DR. WILLIAMS:  The 16,000 estimate also is a U.S.
10	estimate, not a Red Cross estimate.

11		DR. HOLLINGER:  Thank you.
12		DR. McCURDY:  There is also one other question
13	about the public-health significance of screening.  At one
14	time, in the past, many places abandoned screening for

15	serological tests for syphilis, like hospital admissions and
16	that sort of thing.  And I guess my question is what
17	proportion of the cases that ultimately are reported to the
18	CDC, cases of syphilis, are detected by screening versus the
19	proportion that are detected by either clinical
20	symptomatology or contact tracing or something along that
21	line.
22		DR. HOLLINGER:  Do you know, Dr. Markowitz?  She
23	will be back in a few minutes?
24		DR. LINDEN:  Didn't we have that data in her
25	presentation?

					195 1		DR. HOLLINGER:  I don't know how to interpret that
	2	but there were, again, the 927 that they got from the blood
	3	donors.  That represented four years--Dr. Markowitz?
	4		Why don't you rephrase the question, Paul, again?
	5		DR. McCURDY:  I am asking the question about the 
	6	relative value of screening a population for syphilis versus
	7	detecting cases by either clinical manifestations and

	8	clinical suspicion or contact tracing or that sort of thing. 
	9	My impression is that screening is pretty inefficient.

10		DR. MARKOWITZ:  Are you saying from a public-
11	health point of view?
12		DR. McCURDY:  Yes.
13		DR. MARKOWITZ:  I think all of these 927 cases
14	would not have been picked up clinically because they were
15	not picked up by the questions that were asked when they
16	went to donate blood.  I think, in many other settings,

17	there are a fair number of syphilis patients that are only
18	picked up through screening.
19		DR. McCURDY:  In the 50's, and 60's, at the City
20	Hospital in Washington where it was commonly--every patient
21	that was admitted commonly got a serological test for
22	syphilis, very few--not zero, but very few--of the patients
23	that were detected that way were not already known to the
24	rapid treatment center at that hospital.

25		So screening didn't pick up very many new cases in

			196 1	that relatively high-risk population.
	2		DR. MARKOWITZ:  Well, maybe I misunderstood your
	3	question.  I think there are better ways to try to detect
	4	syphilis cases.  But I think that these cases would not have
	5	been picked up, these 927 cases.  They may have presented
	6	months later with a different manifestation and been picked
	7	up, but, unfortunately, we don't have all of the data on

	8	these 927 cases.  We were not able to go back and really
	9	find out a lot of detailed information about them.
10		But, from what we do know, it appears that they
11	would not have been picked up clinically.
12		DR. MITCHELL:  I think that the question is

13	whether other screening--do they still do premarital
14	screenings in most states and do those pick up a large
15	percentage of new cases of syphilis?
16		DR. MARKOWITZ:  Some states have eliminated
17	premarital screening, but, actually, I don't have those

18	data.  So it is not done universally.  One place where we do
19	screen is in jails and detention centers.  That has been a
20	major component of the syphilis elimination effort, to pick
21	up cases who have not been previously treated in those
22	facilities.
23		DR. MITCHELL:  So are you saying that when you
24	screen in a high-risk population, you are likely to get--let
25	me see; are you saying that screening in low-risk

			197 1	populations does not provide a significant portion of the
	2	number of new cases that you see?
	3		DR. MARKOWITZ:  Yes; that is true.  Screening in
	4	low-risk populations does not provide a large percentage of
	5	total cases that are reported.  The vast majority of the
	6	cases that are reported are through SDT clinics, people that
	7	come in for care, the vast majority.
	8		DR. HOLLINGER:  Yes?  Go ahead.
	9		DR. EPSTEIN:  While we have Dr. Markowitz, I have
10	two questions.  Your estimate for the cases identified
11	through blood-center screening were 36 primary-secondary and
12	785 early-latent.  But the Red Cross data, which were on

13	whole-blood-donor screening, which should have been only
14	even a subset if some of your data also came from source-
15	plasma screening, which were based on only 500,000 per
16	month, average monthly figures, if multiplied by 20 to give
17	us a yearly estimate, would have estimated 8,500 FTA-
18	positives of which 2,000 would be RPR-positive.
19		So there is, at the very least, a ten-fold
20	discrepancy between the estimate through the surveillance
21	system and the directly applicable actual report data from
22	the Red Cross. I wonder whether you had noted that and
23	whether you have thought about that in terms of your
24	estimate of the potential risk of stopping donor screening.
25		And then a second question; you showed a slide

				198 1	which went by rather quickly on the percent of antibody-

	2	positives that had positive PCR.  I wondered if you could
	3	simply repeat what those findings were, perhaps show the
	4	slide again, if that is possible.

	5		DR. MARKOWITZ:  The first question is that the Red
	6	Cross found--extrapolated by many more positives that we
	7	found.  That doesn't really surprise me because we were not
	8	reporting positives.  We were reporting how many, actually,
	9	of the positives turned out to be cases that got reported.
10		DR. HOLLINGER:  Actually, with disease.
11		DR. MARKOWITZ:  With disease.  We did a small
12	study in Chicago last year to just evaluate their

13	surveillance system, and it was something like only
14	5 percent of the positive serologic tests for syphilis that
15	come in to the health department ultimately get reported. 
16	The rest of them, they determine, are old follow-up titers
17	that people are getting serial titers done to follow

18	treatment and they are determined not to be cases.
19		There is a huge amount of work that gets done just
20	to wade through all of these serological tests that come in
21	to the health department and to find out which ones of those
22	are actually cases.  So that does not surprise me at all. 
23	Health departments, the labs in Chicago, for example,
24	43 labs are required to report every month to the health
25	department.

					199 1		There is just a huge amount of data coming in so
	2	that is consistent with, I think, what goes on.
	3		DR. EPSTEIN:  The second question?
	4		DR. MARKOWITZ:  The second question?  Can I see
	5	that slide?  Do you just want me to go over the data?

	6		DR. EPSTEIN:  Yes; I would just like you to
	7	restate what percent of seropositive had positive PCR.

	8		DR. MARKOWITZ:  It varied by the different tests
	9	and, if I can get a hard copy--can you get that slide back
10	up?  Is that possible?  Oh; I have it here.  Of those who
11	were RPR-positive, one to one to one to four, four out of

12	seven, or 57 percent, were polA-positive.  Of those who that
13	had a titer greater than or equal to one to eight, six out
14	of fourteen were polA-positive.
15		And then, of those that were MHA-TP-reactive, nine
16	out of fourteen were polA-positive.  Of those that were MHA-
17	TP-nonreactive, one out of four was positive.

18		DR. HOLLINGER:  Thank you.  David?
19		DR. STRONCEK:  My understanding of this is we have
20	a disease that is not transmitted with blood.  There is
21	pretty good data to suggest that, at least not at this time. 
22	We don't know why.  We don't know if the donors just don't

23	have it.  We heard data on one test, the PCR comparison that
24	was done on inadequate samples.  And then there is some

25	thought that the processing of blood may inactivate the

			200 1	bacteria, but we don't know what part of it is.
	2		The data seems to be fairly straightforward to
	3	get, especially in terms of what else we are doing for blood
	4	and the other things we see at scientific meetings.  Blood

	5	is safe now, but things change.  The incidence of disease
	6	changes.  The way we process blood changes, and so on.
	7		There are a number activation steps coming down
	8	the line that might take care of the bacteria, if we don't
	9	need it.  So I think it is kind of imprudent right now
10	without more data to not vote yes for this.

11		DR. HOLLINGER:  David, you made some statements. 
12	I don't know how you can say that something is not
13	transmitted by blood when you are testing for it.  Let's
14	just take NAT testing of HCV right now.  If it were the one
15	test that would being used, you might say that patients with
16	HCV don't transmit HCV to people because you have eliminated
17	that.
18		I am not saying it is transmitted, but it doesn't
19	seem like we have the data to make that statement.  So the
20	fact that we may not have seen any transfusion-transmitted
21	cases may be because it is not transmitted.  It may be

22	because the test is eliminating those but you would ask,
23	well, what about the ones in the window period.  Why don't
24	we even see some of those coming through.
25		But we have missed a lot of positives.  Even all

			201 1	those HCV cases which we are now detecting, those sort of
	2	don't come to the forefront in the clinical arena anyway
	3	about why haven't we seen all these cases anyway.  They are
	4	probably there.  We are just not detecting them.  So I am
	5	not sure that that is--
	6		DR. STRONCEK:  I agree with you.  I meant to say
	7	we are not seeing transmission.
	8		DR. HOLLINGER:  Sorry about that.
	9		DR. SIMON:  I thought the data that were presented
10	indicated that a fair number of people have the spirochete
11	in their circulation who test negative, that our test is not
12	specific.  So we know, in fact, that we are not picking them
13	up and they are being transfused, and yet we are not having
14	cases.  Isn't that correct, based on the data?
15		DR. STRONCEK:  Yes; but there is other data that
16	suggests that none of the donors are--it is all old
17	infections.  So I think that the data is still unclear on
18	what is going on.
19		DR. HOLLINGER:  I am going to call for the
20	question, then, that we have up there so we can vote on it. 
21	We will be voting on the first question of, do committee
22	members agree that current scientific data are insufficient
23	to warrant discontinuation of donor testing for antibodies
24	to syphilis.  Again, a yes vote here would mean that you

25	believe that currently the testing should continue because

				202 1	of lack of the scientific data at the present time.
	2		So all those that are voting yes, in favor of this
	3	question, raise your hand.
	4		[Show of hands.]
	5		DR. HOLLINGER:  All those opposed?
	6		[Show of hands.]
	7		DR. HOLLINGER:  Abstain?
	8		[No response.]
	9		DR. HOLLINGER:  Toby?  Industry?
10		DR. SIMON:  Opposed.
11		DR. HOLLINGER:  Kathy I think left you something. 
12	Ms. Knowles.
13		DR. SMALLWOOD:  Ms. Knowles would agree with those
14	that voted "yes."
15		DR. HOLLINGER:  Please read the results.
16		DR. SMALLWOOD:  The results of voting on Question
17	1a), there were 13 "yes" votes, 2 "no" votes, no
18	abstentions.  The industry representative agreed with the
19	"no" vote and the consumer rep left a note that she would
20	agree with the "yes" vote.
21		DR. HOLLINGER:  Carmelita, do you want to comment
22	about anything?  The reason I am asking you is that you have
23	a great deal of experience with this but, also, it goes into
24	the second part of the question in 1b).  So if you wouldn't
25	mind, could you share with us--

			203 1		DR. TUAZON:  I think we have data for thirty years
	2	that there are no cases of transfusion-transmitted disease. 
	3	And we know historically that, in terms of the clinical

	4	presentation, if a transfusion-transmitted disease is to
	5	occur, it will present systemically, that you can diagnose
	6	and it is easily treatable.
	7		In contrast to the implications in terms of

	8	transfusion-transmitted HCV and HIV, syphilis is very
	9	treatable and curable compared to those other diseases.  So
10	those are, really, the major reasons that I think that the
11	testing could be eliminated, plus the fact that, as
12	mentioned earlier, there may be cases that are not
13	serologically positive with blood that has been donated and
14	has been transfused, and yet we have not documented

15	transfusion-transmitted syphilis or over 30 years.
16		DR. HOLLINGER:  Thank you.
17		Paul, do you have any comments?
18		DR. SCHMIDT:  I agree and I think I said my
19	feelings before.
20		DR. HOLLINGER:  Okay.  I think what we will do,
21	because we will come back to this 1b) if we have some time
22	here.  There has been a lot of discussion anyway on part
23	1b), so I want to go to 2 for a minute so we can get the
24	questions out of the way.  The second question, basically,

25	is saying--it really is a moot point, I suppose, basically,

				204 1	now that I look at it again.  It is kind of a moot point.

	2		DR. SIMON:  It is moot, or does the FDA want to
	3	know this when those data come in?
	4		DR. HOLLINGER:  Do you want to know the answer to
	5	this anyway--I mean the vote anyway?
	6		DR. RUTA:  Sure.
	7		DR. HOLLINGER:  The question is, do committee
	8	members believe that donor testing for antibodies to

	9	syphilis should be retained as a surrogate marker of
10	deferrable risk behavior even if it is proven that such

11	testing no longer is useful for prevention of transfusion-
12	transmission of syphilis.
13		As I say, it is kind of a difficult question to
14	deal with because we have already said the answer above.
15		DR. EPSTEIN:  I think we would like the question
16	voted because, after all, this is advisory and we are not

17	sure where the agency will come out and, perhaps, in a year
18	we may all feel comfortable dropping it for prevention of
19	syphilis transmission and question 2 will still be hanging
20	in the air.
21		DR. HOLLINGER:  Are you saying you may not pay
22	attention to what we do here anyway?
23		DR. EPSTEIN:  Oh; we listen very closely, Blaine,
24	particularly to you.

25		DR. HOLLINGER:  Let's act is if we, then, answered

			205 1	that question the other way and then answer the question
	2	about whether you think it should be retained as a surrogate
	3	marker for deferrable high-risk behavior.  That is basically
	4	the question.
	5		Ken?  Please.
	6		DR. NELSON:  The way the question is stated, I am
	7	not sure, and given the reality of the situation, I am not
	8	sure how I would vote.  But if, in fact, the specificity of
	9	the test were--if we could eliminate the false-positives
10	that are the major problem for the blood banks right now--if
11	that issue could be dealt with in some way, then I would
12	vote yes.
13		The reality is that we are going to retain the
14	test anyway.  But I think it does have value as a surrogate
15	marker.  The problem is that there are so many--with the
16	current blood-donor population, there are so many false-
17	positives that significantly impact the blood bank.  But I
18	think it is of value as a surrogate if, in fact, the
19	specificity were higher.
20		It has been shown in all of the HIV studies.  That
21	was in the original CDC case-control cohort of KS, that was
22	the KS patients before AIDS was actually defined, that was
23	the strongest association.  There have been odds ratios of
24	10.  So, even though it turns out in the blood-donor
25	population that it isn't such an important surrogate--and

				206 1	the reason is that is it is nonspecific, mostly.
	2		DR. HOLLINGER:  So we will go ahead and vote on
	3	this.  The question, then, really is just a "yes" vote here
	4	would be that you believe that the testing for antibodies to
	5	syphilis should be retained as a surrogate marker of
	6	deferrable high-risk behavior.  That is what a "yes" vote
	7	would be .
	8		All those who would vote "yes" on this question,

	9	raise your hand. In other words, should it be retained as a
10	surrogate marker of deferrable high-risk behavior assuming
11	that we had voted not to--all those that believe that.
12		[Show of hands.]
13		DR. HOLLINGER:  All those "no?"
14		[Show of hands.]
15		DR. HOLLINGER:  Abstaining?
16		[One hand raised.]
17		DR. HOLLINGER:  Dr. Simon?
18		DR. SIMON:  I agree with the "no"s.
19		DR. HOLLINGER:  Could you read those please?
20		DR. SMALLWOOD:  The results of voting on question
21	no. 2, there were 5 "yes" votes, 9 "no" votes, one
22	abstention.  The industry representative agreed with the

23	"no" votes.  The consumer representative would have agreed
24	with the "yes" votes.
25		DR. HOLLINGER:  Dr. Chamberland?

			207 1		DR. CHAMBERLAND:  I guess I just wanted to say
	2	that the reason I voted to abstain is that I think probably
	3	I would have been able to vote "no," but I feel like this is
	4	kind of an add-on to a discussion that was largely focussed
	5	to address the first question.
	6		Alan Williams did a very nice job with his
	7	presentation, but I think there are other data that may not
	8	even contradict his final findings, but there are other
	9	data.  I think Ken Nelson alluded to that.  So I think my
10	sense is that it just didn't get adequate time for
11	presentation and full discussion, the lateness of the hour,
12	et cetera.
13		So that was why I sort of came down on the
14	"abstain" side of things.  It may very well merit another
15	go-around.
16		DR. HOLLINGER:  Thank you.  We have got just a few
17	minutes because the more important thing is the cafeteria is
18	going to close before too long.  But have we responded, with
19	all this done today and the discussions in regards to the
20	adequacy of additional studies as proposed, to resolve the
21	value of testing?
22		I think the feeling was that some of these studies
23	should be done and they could be done internationally.  I

24	think there was some discussion of that and there should be
25	some review of individuals--I mean, some of the laboratory

			208 1	studies for blood products, if it is done properly.
	2		DR. RUTA:  I think we heard some valuable advice.
	3		DR. EPSTEIN:  I would encourage members of the

	4	committee that have further comment on potential studies
	5	simply to communicate with the agency over the next couple
	6	of weeks.
	7		DR. NELSON:  One additional study that I could
	8	think of to answer the question about PCR measure of
	9	infectivity is you could take patients with active syphilis
10	who are being treated and repeatedly study the decay, if you
11	will, of the PCR positivity in their blood as treatment
12	progresses, or after treatment.
13		My prediction is that PCR would disappear rapidly. 
14	But I don't know that there are data on that.
15		DR. HOLLINGER:  Very good.
16		It is now around 1:30.  We are going to break
17	until 2:15.  I would like you to meet back in here so we can
18	then deal with the medical-devices issue for HLA and then
19	into the site visit.  Thank you.
20		[Whereupon, at 1:30 p.m., the proceedings were
21	recessed to be resumed at 2:15 p.m.]

			209 1	         A F T E R N O O N   P R O C E E D I N G S
	2		                                       [2:20 p.m.]
	3		DR. HOLLINGER:  This committee often sits as a
	4	medical devices committee for medical devices.  This is a
	5	session today on the classification of HLA devices.
	6		If you have read the stuff that they sent you,
	7	this should be, I think, a relatively straightforward issue
	8	here.  But I think we need to have someone talk to us a
	9	little bit about these class I, class II, class III devices.
10		Sheryl Kochman?
11		   IV. Classification of HLA Devices
12		     FDA Presentation of the Issue
13		MS. KOCHMAN:  My charge today is go over some of
14	the issues pertaining of the classification of HLA devices.
15		[Slide.]
16		First, I would like to provide you with an
17	introduction and background to issues.  My objectives are to
18	provide an overview of the current regulatory status of HLA
19	devices, to provide a background regarding medical-device
20	classification.  We will ultimately also provide an overview
21	of the third-party review program.
22		[Slide.]
23		For the purposes of today's discussion, we are
24	defining HLA devices as in vitro diagnostic reagents and
25	kits for use in determining the HLA phenotype of genotype of

			210 1	an individual or for detecting and identifying antibodies to
	2	HLA antigens.
	3		[Slide.]
	4		These HLA devices include characterized polyclonal
	5	or monoclonal antibodies for determination of phenotype and,
	6	for those of you who are blood bankers, you can view these
	7	as being analogous to blood-grouping reagents.  They also
	8	consist of DNA-based assays for determination of HLA
	9	genotype.  They also include characterized leukocytes for
10	detection and identification of antibodies.
11		Again, for those who are blood bankers, this would
12	be analogous to reagent red-blood cells.  Those products are
13	currently CBER-licensed IVDs, just to give you a sort of a
14	sense of where there might be some parallels.
15		We are not, during this discussion, including
16	those in vitro diagnostic reagents or kits that are used to
17	predict disease; for example, anti-HLA-B27 can be used to

18	detect the HLA B27 antigen as a marker for ankylosing
19	spondylitis.  Those specific products are regulated by the
20	Center for Devices and Radiological Health, so we are not
21	covering them today.

22		[Slide.]
23		I will provide you with some regulatory history. 
24	A lot of this was in the packet that was distributed ahead
25	of time.  The first product license for leukocyte-typing

			211 1	serum, which is what they were called at the time, was
	2	issued in December of 1974.  In December of 1977, FDA
	3	guidelines for the production, testing and lot release of
	4	leukocyte-typing sera were issued.
	5		In August of 1980, FDA issued a proposed rule
	6	recommending that the additional standards for leukocyte-
	7	typing serum be revoked.  Finally, the final rule was issued
	8	on August 10 of 1982 revoking the additional standards for

	9	leukocyte-typing serum and revoking the licenses that went
10	along with those.

11		[Slide.]
12		The effect of those proposed and final rules was
13	that they utilized the expanded-control authority under the
14	Medical Device Amendments to the FD&C Act.  This means that,
15	in addition or instead of the standards that were being
16	applied at the time, there were provisions against
17	adulteration, misbranding, registration.
18		There was a need for classification requirements
19	regarding banned devices, notification and other remedies,
20	records and reports, in some cases, restrictions on sale,

21	distribution or use and good manufacturer practice.
22		[Slide.]
23		Furthermore, all manufacturers that had been
24	previously licensed and also new unlicensed manufacturers
25	were notified that they were to register and list under

			212 1	21 CFR	807.  New manufacturers additionally were required to
	2	submit premarket notification submissions, commonly known as
	3	a 510(k) submission, Part 21, CFR 807.  It added the
	4	requirement that labeling conform to 21 CFR 809.10 which is
	5	labeling for in vitro diagnostic substances, also the
	6	requirement that manufacturing be conducted so it conforms
	7	with 21 CFR 820.
	8		At that time, they were known as the current GMPs
	9	and this is currently known as the Quality System
10	Regulation.  The proposed and finals rules also indicated
11	that device classification would follow.
12		[Slide.]
13		In the meantime, CBER received, reviewed and
14	cleared a number of 510(k) submissions.  According to my
15	records, there were approximately 65 submissions that were
16	processed.  Letters variably refer to the devices as class I
17	and class II despite the fact that there was never a formal
18	classification rule issued.
19		So, when that was discovered, it was determined

20	that the current letter should list the devices as being
21	unclassified, which is what current letters go out as.
22		[Slide.]

23		The basis for this confusion appears to be that
24	the proposed rule clearly states that a request for
25	classification has been made and will be published upon

			213 1	receipt.  But that proposed rule also stated that if the

	2	proposal were to be published in final form, the device
	3	would be subject to the General Controls Provisions.  This
	4	will come a little clearer later on when I talk about the
	5	difference in classification.
	6		There was also a statement that agency believes

	7	that these and other general controls applicable to medical
	8	devices are sufficient and also that the appropriate
	9	regulatory status of the product will be considered in the
10	course of classification.
11		[Slide.]
12		Because of the lack of classification, we have had
13	a number of problems the first of which is confusion in
14	industry about which standards should be applied to the
15	manufacture and distribution of those devices.  In addition,
16	there has been confusion within CBER about what review

17	criteria should be applied to the review of the 510(k)
18	submissions.
19		There also appears to have been an erroneous
20	belief within the industry that registration, listing and
21	510(k) submissions are not needed.  We have a number of
22	anecdotal reports that there are manufacturers out there

23	manufacturing and distributing these kits without having had
24	them registered or 510(k)-cleared.
25		There is also confusion in ORA about whether or

			214 1	not to inspect these devices and what standards to apply
	2	during an inspection.  This is based on the fact that,
	3	because of limited resources, the field has had to make some
	4	cuts as to what will and will not be inspected.  They have
	5	gone to a risk-based approach in their inspection process
	6	and, as a result, class I devices, which are generally
	7	considered to be low-risk, are usually not inspected.  Class
	8	II devices are inspected basically on an as-needed basis and
	9	class III devices tend to be inspected more regularly.
10		The other problem that is associated with the lack
11	of classification here is that we have been unable to
12	proceed with some of the initiatives pertaining to FDAMA,
13	the Food and Drug Administration Modernization Act. 
14	Specifically, we would like to proceed with making these
15	devices eligible for third-party review.
16		[Slide.]
17		I want to briefly go over device classification. 
18	First, we will talk about preamendments devices. 
19	Preamendments devices are those which were on the market

20	prior to the enactment of the Medical Device Amendments of
21	1976.  There are three classes into which those devices are
22	placed; class I, class II and class III.
23		[Slide.]
24		Class I devices are those in which general

25	controls alone are sufficient to provide reasonable

			215 1	assurance of safety and effectiveness or it is unclear if
	2	general controls alone are sufficient to provide reasonable
	3	assurance of safety and effectiveness but the device is not
	4	life-supporting, life-sustaining or of substantial
	5	importance in preventing impairment of human health.
	6		[Slide.]
	7		General controls, which is the thrust of putting a
	8	device in class I, include establishment registration,
	9	product listing, conformance to the QSR and, as I mentioned
10	before, this was previously the GMP, conformance to device
11	labeling requirements, submission of a 510(k), if
12	applicable.  Some class I devices do not require submission
13	of a 510(k) any longer.  Others do.
14		And there are also other controls within the Act
15	that are applied to devices in class I.
16		[Slide.]
17		Most class I devices are now exempt from the
18	requirement to submit a 510(k).  Those that are not exempt
19	are designated as reserve devices.  Most class I devices are
20	not subject to the design-control provisions of the QSR. 
21	For those of you not familiar with the medical device
22	portion of the CFR, design controls are relatively new and
23	have been put in place to assure that a device is designed
24	to meet its intended specifications.
25		But, in the case of most class I devices, they

			216 1	don't have to adhere to those.  Furthermore, some class I
	2	devices are even exempt from the requirements of the CSR. 
	3	It is important to note that class I is the least stringent
	4	regulatory category.
	5		An example would be a blood grouping view box, the
	6	old-fashioned slide agglutination viewer.
	7		[Slide.]
	8		For a class II device, general controls alone are
	9	insufficient to provide reasonable assurance of safety and
10	effectiveness and there is sufficient information to
11	establish special controls.
12		[Slide.]
13		Special controls include performance standards,

14	special labeling requirements in addition to those required
15	for class I devices, use of guidance documents, use of
16	recommendations during the review process, possibility of
17	including patient registries, postmarket surveillance and
18	"other actions deemed appropriate by the Commissioner."

19		It is important to note that, for a class II
20	device, special controls are used in addition to the general
21	controls, so it is a higher level of control.
22		[Slide.]
23		Class II devices are generally considered to be
24	moderate-risk devices.  They may be life-supporting or life-
25	sustaining.  Some have been exempted from the requirement to

			217 1	submit a 510(k).  And the most common example in the blood-
	2	bank area of a class II device would be an automated blood-
	3	grouping and antibody-test system.
	4		[Slide.]
	5		For a class III device, there is insufficient

	6	information that general or specific controls, as I just
	7	previously described, will provide reasonable assurance of
	8	safety and effectiveness and the device is life-supporting,
	9	life-sustaining or of substantial importance in preventing
10	impairment of human health or it presents a potential
11	unreasonable risk of illness or injury.
12		[Slide.]
13		Premarket approval is required for class III

14	devices.  The manufacturer must submit these during the
15	process of a premarket review.  Scientific and regulatory

16	review is done to insure the safety and effectiveness of the
17	device.
18		[Slide.]
19		Again, class III devices are high-risk devices. 
20	This is the most stringent regulatory category.  General

21	controls also apply here.  A current example of class III
22	device used on blood banks would be the electromagnetic
23	blood and plasma warming device.
24		[Slide.]
25		There is also a device classification of post-

			218 1	Amendments devices.  Post-Amendments devices are those which
	2	are introduced to the market after enactment of the Medical
	3	Device Amendments of 1976.  Now, if you will remember, I
	4	stated that the first license for HLA devices was issued in
	5	1974.  So, clearly, HLA devices were on the market prior to
	6	the enactment of the Medical Device Amendments.
	7		The classification process that I just described
	8	would apply but, just to provide full background
	9	information, when the device comes to market after 1976,
10	there are two routes of classification.  They can either be
11	the same regulatory class as the device to which it is
12	deemed substantially equivalent or it can be a class III if
13	not substantially equivalent to a device already legally on
14	the market.
15		The big question there is what is substantial
16	equivalence.  Substantial equivalence means the device has
17	the same intended use as the predicate device and it has the
18	same technological characteristics as its predicate device
19	or it has different technological characteristics but does
20	not raise new concerns of safety and effectiveness.
21		Are there any questions on the classification
22	process?
23		DR. HOLLINGER:  Just a question about substantial
24	equivalence.  It always seems a little unfair to me--I am

25	sure there is a reason for it, obviously, but you have

			219 1	somebody comes in, the initial group, and they do all this
	2	work to get their device on the market, and then someone
	3	else comes along afterwards that has a comparable device and
	4	they don't have to do all this work.
	5		Is that I understand substantial equivalence to
	6	mean?
	7		MS. KOCHMAN:  It doesn't really mean that they
	8	don't have to do as much.  The first device sort of sets the
	9	standard.  So the subsequent submitters would have to make
10	sure that their device has been through the same level of
11	rigor and testing, the same level of GMP and manufacturing. 
12	So the following people have to do everything as well as or
13	better than the initial submitter.
14		But some of the mystery is taken out of the
15	process of how to get it through the FDA, especially if they
16	choose--once a device has been cleared, the packet is

17	available under freedom of information for other device
18	manufacturers to find out, well, how did these people get
19	their device to market.
20		So the first people do sometimes have the
21	difficulty of treading a new path.  But, as far as the
22	amount of work that is done, the followers on actually do
23	the same level of work.  They just have a little bit better
24	map of how to get there.
25		DR. HOLLINGER:  The financial costs are about the

			220 1	same?
	2		MS. KOCHMAN:  Yes; I would think so.
	3		DR. HOLLINGER:  Any other questions?
	4		Thank you.
	5		Eric Rechen will talk about the third-party review
	6	program.
	7		       Third Party Review Program

	8		MR. RECHEN:  Thank you very much.
	9		[Slide.]
10		I am Eric Rechen.  I am with FDA's Center for
11	Devices and Radiological Health and I helped to coordinate
12	the third-party review program in that center.  It is a
13	pleasure to address the panel today, hopefully very briefly
14	for your sake, about this program.  The reason I am talking
15	about this program is because, depending on how HLA devices
16	are classified, this program could be used to facilitate

17	rapid marketing clearance of those products, of new models
18	of those products.  And that is the essence of the 510(k)

19	program which is what the third-party review program applies
20	to.
21		[Slide.]
22		The basic purpose of the third-party review

23	program is twofold.  It is to provide an alternative to
24	FDA's process that can yield more rapid marketing clearance
25	decisions than FDA's traditional review.  It also, then, by

			221 1	doing so, by offloading reviews to third-party reviewers, it
	2	frees up FDA resources to focus on higher-risk products.
	3		[Slide.]
	4		The origin of the program was about four years
	5	ago.  At that time, our center had experienced some
	6	significant 510(k) review backlog and so, as a reinventing
	7	government initiative, we started what we then thought would
	8	be a two-year pilot program to see whether third-party
	9	reviews improved the efficiency of our 510(k) process.
10		Before that two-year pilot ran its course, in 1997
11	Congress enacted the FDA Modernization Act and they
12	basically codified this pilot program into the Food, Drug
13	and Cosmetic Act.  So it is now a statutory program.
14		The law gave us a year to convert our pilot into
15	the accredited persons program, and we did that.  And so we
16	formally implemented the accredited persons program late in
17	1998.  On this slide, I have noted a website.  We have a
18	third-party web page on our center's web site, and this has
19	all the relevant documents for this program, some of which I
20	will refer to in a few minutes.
21		[Slide.]
22		In a nutshell, here are the main features of the
23	program.  First, FDA acts as the accreditor for outside
24	review organizations under this program.  The law required
25	that we issue a Federal Register notice that laid out what

			222 1	our accreditation criteria would be.  Essentially, we
	2	consider whether an organization is technically competent,
	3	whether it has adequate personnel to do reviews of the
	4	devices they seek to review, and we also look to see that
	5	the organization and its personnel are not conflicted to do
	6	these reviews.
	7		We have, at this point in time, accredited twelve
	8	organizations to do various types of device 510(k) reviews. 
	9	It is a voluntary program from the manufacturer's
10	standpoint.  What I mean by that is a manufacturer can elect
11	to use this program or they can elect to still submit to
12	FDA.  It is the manufacturer's choice.
13		If the manufacturer chooses to submit to an
14	accredited person, the process is essentially this.  The

15	manufacturer contacts one or more organizations that are
16	accredited to review the types of device that the
17	manufacturer makes or is intending to make.
18		The manufacturer negotiates for a review and pays
19	a fee for service, which is determined through that
20	negotiation between the third party and the manufacturer. 
21	They then send the 510(k) to the organization they have
22	contracted with.  The accredited person reviews the 510(k)
23	using the same criteria as FDA and documents its review and
24	submits it recommendation and documented review and the
25	original 510(k) to FDA.

			223 1		FDA still has authority to issue the final

	2	decision.  Under the law, FDA is required to issue a
	3	decision within 30 days of receiving a third-party
	4	recommendation.
	5		[Slide.]
	6		This next slide just shows you the twelve
	7	organizations that are currently accredited to do reviews
	8	for various devices.  The only thing I would point is there
	9	is a diversity of organizations here.  Most of them are
10	U.S.-based test or certification houses that are also
11	European notified bodies and test houses.
12		There is an organization from Taiwan.  There is
13	even one state government.  The California Department of

14	Health is an accredited person.  At this point in time, of
15	course, none of these organizations are accredited
16	specifically to review HLA devices, but it is an open
17	accreditation process and so, at any time, these
18	organizations or other organizations could apply to become
19	accredited of HLA products are included in the program.
20		[Slide.]
21		A key point is what products are eligible for
22	accredited-person review.  The statute actually doesn't say
23	what is eligible.  It says what is not eligible.  This
24	slides summarizes what accredited persons may not review. 
25	They may not review the highest-risk products, essentially. 

			224 1	That is, they can't review class III products that are
	2	subject to premarket approval or that will be made subject
	3	to premarket approval but are currently being reviewed under
	4	the 510(k) process.
	5		And they also may not review certain types of
	6	class I devices, and that is--the first category would not
	7	apply to HLA products, but the permanently implantable
	8	devices.  They also may not review life-supporting or life-
	9	sustaining devices and they may not review 510(k)s that
10	require clinical data for determination of substantial
11	equivalence.
12		That is a little, perhaps, more difficult

13	criterion to understand but, basically, to equate HLA
14	products to the in vitro devices that we review in our

15	center, we have many IVDs that are included in the program
16	even though they typically require comparative testing of
17	human samples of using an established test and the product
18	that is the subject of a 510(k).

19		That normal comparative test, just involving human
20	samples, has not been defined for purposes of this program
21	as being excluded.  So many IVDs are included in the
22	program.  However, if an IVD requires a full-blown clinical
23	study where patients are tracked and the results of those,
24	and the patient outcomes and the test results are being

25	matched, then that is something that typically would be

			225 1	excluded under this program.
	2		[Slide.]
	3		Based on the statutory criteria, the agency has
	4	put out a list of device types that are eligible for
	5	accredited-person review.  At this time, the list includes

	6	211 types of medical devices, all class I devices that are
	7	not exempt from 510(k) plus 57 selected class II device
	8	types.
	9		In Fiscal Year 1999, we received more than 1600
10	510(k)s for eligible device types.  We very recently, I

11	think in June, proposed a very broad expansion of the
12	program that would essentially include all remaining

13	products that meet the statutory criteria for accredited-
14	person review.  That is about 460 additional class II device
15	types.
16		When I say "all," I mean all that are regulated by
17	our center.
18		[Slide.]
19		At this time, devices that are reviewed by CBER or
20	CDER are not included in the program but, of course, they

21	could be.  Very rapidly, what our program experience has
22	been was industry participation up to this point is still
23	low.  We only have about 3 percent utilization of the
24	program for eligible products.

25		But the utilization is growing.  This year, we are

			226 1	receiving about 40 to 50 510(k)s that were reviewed by an
	2	accredited person.  The reviews that we are getting have
	3	essentially been very good quality reviews.  In Fiscal Year
	4	1999, we accepted 100 percent of accredited-person
	5	recommendations without changing the recommendation and, in
	6	90 percent of the cases, we were able to accept that
	7	recommendation without requesting any substantive additional
	8	information.
	9		Essentially, we accepted it on our first FDA

10	review cycle.  The reviews so far, the accredited-person
11	reviews, have yielded, on average, more rapid marketing
12	clearance.

13		In Fiscal Year 1999, there were 29 510(k)s cleared
14	through that process with a third-party review and, in those
15	cases, the average total elapsed time from the day that an
16	accredited person initially received a 510(k) to the day we
17	issued a final clearance was 57 days.  That was about
18	46 percent faster than traditional in-house reviews
19	conducted by FDA.
20		So that is all I have prepared to say.  I hope
21	this gives you some information that might be useful to you
22	in determining how to provide an efficient clearance process
23	for HLA products if they are classified such that they are
24	eligible for this program.
25		DR. HOLLINGER:  Questions?  Paul?

				227 1		DR. SCHMIDT:  It was my understanding that the
	2	reason that we are special government employees while we are
	3	on this committee and cannot accept any foreign emoluments

	4	or anything else is that the FDA could only accept advice
	5	from federal employees, and not from outside bodies.
	6		I am sure that is a different mechanism, but how
	7	do you see that in relation to the program you are

	8	discussing in which the work is being farmed out?
	9		MR. RECHEN:  This is a program provided under
10	different statutory authority and so, essentially, Congress
11	has made the cut that here is another mechanism by which the
12	agency can obtain recommendations about marketing clearance. 
13	So these bodies, again, are subject to a lot of the same
14	conflict-of-interest controls that you are accredited
15	through a specific process provided by law.

16		Does that answer your question?
17		DR. SCHMIDT:  Could that be applied to the
18	clearance of blood products in the same way in the future?
19		MR. RECHEN:  Certainly, products that meet the
20	statutory criteria, meaning class I or class II, that meet

21	the other criteria could be made eligible should the agency
22	elect to make them eligible.
23		DR. SCHMIDT:  Thank you.
24		DR. HOLLINGER:  Does that also mean that an
25	accredited person could not be an SGE?

					228 1		MR. RECHEN:  An accredited person cannot be a
	2	federal government employee.  I assume that would also apply
	3	to special government employees.
	4		DR. HOLLINGER:  Yes?  Gail?
	5		DR. MACIK:  Of the various ones that have gone

	6	through this process of the various 510(k)s, how many of
	7	those were class I and how many were class II?
	8		MR. RECHEN:  I don't have an exact cut for you
	9	right here.  I certainly could provide one.  But in Fiscal
10	Year 1999, the vast majority of those 29 that we cleared
11	were class II products.  So most of them are on the higher-
12	risk spectrum of the low to moderate-risk ones that are
13	eligible for review.
14		DR. MACIK:  But they had no clinical data?  So
15	these were really just looking at GMP-type aspects,

16	sensitivity, specificity of the device, or whatever?
17		MR. RECHEN:  We are looking at--and I tend to
18	speak in more broad device terms; under the 510(k)
19	substantial equivalence process, we are essentially looking
20	at the technology of the product--that is, its design,
21	materials, and such, and also its intended use, does it have
22	the same patient population and indications for use as its
23	accredited product.
24		DR. MACIK:  But that also includes whether or not
25	it performs as it is said to perform; right?

				229 1		MR. RECHEN:  Correct.  Particularly the way the
	2	substantial-equivalence criteria are spelled out in the
	3	Food, Drug and Cosmetic Act, if there are differences
	4	between a newly proposed product in its technology from a
	5	previous one, then the 510(k) needs to show that this
	6	product is as safe and effective as the previous product.
	7		That often involves performance data, bench-type
	8	testing or animal testing, in the case of other types of
	9	devices.
10		DR. MACIK:  Those still could be done by this
11	outside group as long as there was no tracking of clinical
12	data?
13		MR. RECHEN:  The manufacturer is responsible for
14	providing all the data.  So they are not the ones
15	responsible for testing--I mean the accredited person is not
16	the one responsible for testing the product.
17		DR. MACIK:  But you need someone how can review

18	what the manufacturer gives them and see that, yes, all
19	those tests were done, all the comparisons were done and

20	understand what they are looking for with that.  So that is
21	all done by this outside group.
22		MR. RECHEN:  That's right.  They essentially act
23	as FDA's primary reviewer and then we act as a quasi-
24	supervisor of that review.
25		DR. HOLLINGER:  It looked like everything you

				230 1	showed up there was an organization, not a person, as you
	2	looked at it.  Do you accredit an organization or do you
	3	accredit persons within the organization, or persons, also?
	4		MR. RECHEN:  The term "person" is used in the law
	5	in its legal sense.  Essentially, what we are looking at is
	6	organizations.  I guess, theoretically, it could be a person
	7	that we accredit, but, typically, what we are looking at is
	8	an organization.
	9		DR. HOLLINGER:  Mary?
10		DR. CHAMBERLAND:  In your slide in which you
11	detailed the list of eligible devices, your last bullet said
12	that devices that are reviewed by CBER and CDER were not

13	included.  Is that because both of these centers chose not
14	to utilize, or at least initially utilize, this option. 

15	And, with this HLA device that we are going to be looking at
16	today, which comes under CBER's purview, would this, then,
17	be the first CBER device to be utilizing the accredited-
18	person review?
19		MR. RECHEN:  I answer to your second question
20	first, yes; this would be the first one that would be made
21	eligible under this program.  Of course, other ones could be
22	made eligible.  The reason they are not included; there is a
23	little history there.  This program, as I said, was
24	initiated as a center initiative by the Devices Center.  So
25	it kind of just started out as a center pilot.

			231 1		It was then codified into the law which would have
	2	allowed, certainly, other center's devices to be enrolled. 
	3	Correct me if I am wrong, I believe that CBER has elected,

	4	to this point, not to include its products because the
	5	number of such reviews that they typically do at this point
	6	are so low that it wasn't cost-effective for them to train
	7	their staff and get involved in the program.
	8		But I think, at this point, they are looking to
	9	rethink that.
10		DR. HOLLINGER:  How do you get away from a
11	conflict of interest here?  It seems to me you have got an
12	organization out there who has something and they want to
13	get it reviewed.  They can choose the accredited person and
14	then they can work out a contract of how much to pay that
15	person.  The person could charge them $10,000 an hour if he
16	wanted to, or the organization could.

17		That looks just like a conflict of interest to me. 
18	It is almost as if I were on an advisory board, or
19	scientific advisory board for a company, that was coming
20	before this committee for a review of something and I would
21	have to recuse myself because of that.
22		So I am not sure I understand how you get away
23	with from that kind of conflict.
24		MR. RECHEN:  It is a good question and one that I
25	think a lot of people have grappled with, although I guess I

			232 1	would point out that this program is certainly not unique. 
	2	There are car-inspection programs and other things where
	3	that same kind of model applies.  But, basically, yes; there
	4	is a fee for service and, on its surface, that has the

	5	appearance of a conflict.  Someone is getting money to
	6	provide a service.
	7		What we do, though, is when we accredit the third
	8	party, we look at their policies and procedures to insure
	9	that they don't have a financial or other conflict, meaning
10	that they don't have personnel who are involved in medical-
11	device work, that design devices, that manufacture or sell
12	devices.
13		There are a whole set of criteria that we look

14	for.  There are, also, under our law, criminal authorities
15	where we can take criminal action if a third party takes a
16	bribe or anything to that effect.  These organizations, to
17	point to some of the ones that were on that list, are like
18	underwriters' laboratories or others who have a long history
19	of being involved in accepting money from outside parties to
20	test or to certify their products and have fairly well-
21	established procedures to insure that they have a reputation
22	that is not tarnished by the fact that they are taking
23	money.
24		That is a fairly vague answer, but I think if you
25	looked at our accreditation criteria, we certainly could

			233 1	make the a little bit more specific.
	2		DR. SIMON:  Just briefly, I would speak to that
	3	because we have had recent experience becoming ISO
	4	certified.  It is the same situation.  In fact, British
	5	Standards Institute, which was the first organization on
	6	that list, is a common ISO-certifying organization.  It is
	7	the one we use.
	8		I guess you are speaking more for the conventional
	9	FDA paradigm which, obviously, does not have this
10	involvement.  But, also, this has now gotten into clinical
11	research.  I would guess the majority of clinical research
12	is done by IRBs that are paid, also, for the review of
13	protocols.
14		So it is obviously something that has gotten into
15	our society, for better or for worse.

16		DR. HOLLINGER:  Mr. Rice?
17		MR. RICE:  I just have a question.  You say that
18	there is low utilization of the program currently.  Is that
19	simply because of its infancy, or is this additional cost,
20	perhaps, to getting their products on the market where they
21	are not paying the FDA if they choose to use FDA's approval
22	process?
23		Just as a question of interest, are these costs
24	maybe prohibitive to hire out the third-party analysis as

25	opposed to waiting for the FDA?  Maybe that explains the low

			234 1	utilization, or is there still a lack of trust of industries
	2	to be able to take comfort in this new paradigm?
	3		MR. RECHEN:  Again, a very good question.  I think
	4	you hit on a lot of the reasons.  It is a new paradigm and
	5	it takes some getting used to.  People in the device
	6	industry have been using the 510(k) process and submitting
	7	to FDA for over twenty years now.
	8		So it takes some reeducation to learn to do
	9	something different.  There is some uncertainty involved,
10	but I think our experience, to this point is trying to
11	dispel some of that uncertainty.
12		The fee is an issue.  For device reviews, we do

13	not have user fees.  So, for an FDA review, there is no fee
14	other than the time it takes to submit to FDA.  For third
15	parties, there is a fee.  A major factor, though, is since
16	this program was initiated, our own internal review times
17	have improved significantly and we are not running backlogs
18	right now in our center.
19		So that negates some of the incentive to look
20	elsewhere.

21		MR. RICE:  The only thing I can see, perhaps, just
22	a question in my mind, is if the industry has the choice of
23	either going the accredited-persons route or the FDA route,
24	would there, or might there be, a tendency maybe for an
25	industry to choose the accredited-person route because maybe

			235 1	they don't feel the FDA's review would be as sympathetic, or
	2	kind, since you are leaving it up to the industry's choice
	3	to go either route?  It is just a question.
	4		MR. RECHEN:  I will address it, and I will try to
	5	be brief.  Accredited persons know that FDA has to buy off
	6	on their review and so they are going to be out of business
	7	real quickly if they do something that they know we are not
	8	going to approve of.  So they are in the business of trying
	9	to make us happy as well as the manufacturer.
10		          Open Public Hearing
11		DR. HOLLINGER:  There is one industry presentation

12	here by Pel-Freez.  I don't have the name of the individual. 
13	I'm sorry.  Is there someone here from Pel-Freez that wishes
14	to comment?
15		Then I think we move into the charge to the
16	committee.
17		        Charge to the Committee
18		DR. SMALLWOOD:  I will be very brief.  The charter
19	of the Blood Products Advisory Committee permits this

20	committee to sit as a medical-device panel when it is
21	necessary to review or discuss issues related to the seeking
22	of advice, recommendations for approval or, in this case,
23	classification of medical devices which are regulated by the
24	Center for Biologics Evaluation and Research.
25		For this particular session, we have Dr. Khanal

			236 1	Matal of NIH who formerly was the Chief of the HLA lab here
	2	at FDA.  And we also have Dr. Carmelita Tuazon who is a
	3	member of the CDRH Microbiology Panel.
	4		When this committee is sitting as a medical-device
	5	panel, there are specific voting procedures when approval is
	6	sought or, again, in this case, a specific recommendation is
	7	desired.  Accordingly, this panel, then, will be
	8	specifically requested to do one of three options, the first
	9	being to vote in agreement with the recommendation.  The
10	second is to vote in agreement with the recommendation with
11	conditions which must be specifically defined.  Thirdly, to
12	not agree with the recommendation.
13		You will hear, after my presentation, the specific
14	question or questions that have been prepared by the CBER
15	FDA Review Committee regarding this classification.  After
16	you have had your discussion, then you will vote as I have
17	indicated.  What happens next after your recommendation is
18	that the FDA will make a decision on the appropriate class. 
19	There will then be published a notice of the panel
20	recommendation to classify these devices.
21		Following that, there will be a review of comments
22	from the public and then there will be a final published
23	Federal Register notice classifying these devices.
24		Are there any questions?  Thank you.
25		      Questions for the Committee

			237 1		MS. KOCHMAN:
	2		[Slide.]
	3		Before I get to the questions, I thought it might
	4	be helpful if I reviewed some of the provisions that we just
	5	went over.
	6		[Slide.]
	7		This is to kind of give you a status, remind you
	8	of where we are, where do HLA devices fit in the scheme of
	9	things that were presented today.
10		[Slide.]
11		Current CBER review incorporates special controls;
12	that is, we have performance standards.  As an example,
13	there must be at least 80 percent concordance between a new
14	device and a device currently legally on the market.  We
15	currently employ special labeling requirements and we
16	currently have recommendations that are issues during the
17	510(k) review.
18		So we are clearly, at this point in time, applying
19	special controls.  As you will recall, special controls are
20	what is used when a device is class II.
21		Also, CBER does not view the device as being high-
22	risk.  We view it as being moderate-risk since it is not
23	life-supporting, life-sustaining or of substantial
24	importance in preventing impairment of human health and does
25	not present a potential of unreasonable risk of illness or

			238 1	injury.
	2		[Slide.]
	3		How would CBER propose to regulate the HLA devices
	4	in the future.  We would propose that we continue to require
	5	submission of a 510(k), that we would continue to require

	6	special labeling, we would continue to review against our
	7	performance standards, we would continue to apply
	8	recommendations, that we would prepare and implement a

	9	guidance document to assist both the industry and FDA
10	reviewers in knowing what criteria to apply to these
11	devices, and, once that guidance document was available, we
12	would make HLA devices eligible for third-party review.

13		That would also require that we identify and
14	accredit third-party reviewers.  So, right now, CBER's

15	recommendation is that HLA devices, as defined earlier in
16	the presentation, should be placed in class II.
17		The question, therefore, to the panel is, does the
18	committee agree that HLA devices for use in detecting
19	antibodies to HLA antigens or determining HLA phenotype or
20	genotype should be classified as class II devices.  Further,
21	from that, since class II devices can either be exempt or

22	nonexempt reserved, should these devices be exempt from the
23	requirement to submit a 510(k)?
24		DR. HOLLINGER:  Thank you.
25		Committee Discussion and Recommendations

			239 1		Are there questions on the issue about HLA
	2	devices, anyone that has any thoughts?  Just to refresh my
	3	memory, all the HLA testing, a lot of HLA testing, is used
	4	for things such as organ transplants?
	5		MS. KOCHMAN:  Yes.
	6		DR. HOLLINGER:  Then, I guess if I were looking at
	7	that, then I would come back over where it says devices of
	8	moderate risk; it says, it is not life-supporting, not life-
	9	sustaining.  But then it says, "or of substantial importance
10	in preventing impairment of human health and does not
11	present a potential unreasonable risk of injury or illness. 
12	I would then say, well, if the results that were obtained
13	from a device that it would alter what would happen with the
14	transplant, that would create a problem for me.
15		MS. KOCHMAN:  That is one of the reasons we have
16	Dr. Matal here.  I feel he is uniquely qualified to answer
17	those kinds of questions.
18		DR. MATAL:  Mr. Chairman, before we get into that,
19	really what would be very interesting to hear is what
20	Devices is doing in handling the B27 device that they have
21	already been marketing for some time and has gone through

22	Devices.  Would you comment on that?  That is not being
23	reviewed by third-party review.
24		MR. RECHEN:  Unfortunately, I can't answer that
25	question specifically, but I certainly could get an answer

				240 1	to that.
	2		DR. MATAL:  It seems to me that the two devices
	3	would be very similar.  HLA B27 reagents are very similar to
	4	what we are talking about.
	5		DR. HOLLINGER:  Gail?
	6		DR. MACIK:  I totally disagree with that.  You are
	7	using the one device to diagnose a disease or a disorder. 
	8	You are using the other device to determine compatibility
	9	for a transplant in which, if you are incompatible, you have
10	a major reaction and/or, in the case of bone-marrow

11	transplant or liver transplant, could lose the organ.
12		So I think these are very different devices.

13		DR. MATAL:  Let me separate the two issues here. 
14	One is these reagents are really diagnostic reagents who
15	type for our genetic profile, the genes and antigens that we
16	have.  That is a genetic marker, like blood typing.  Now,
17	what happens in transplantation is the second step where how
18	you match a donor and recipient, whether it is a bone-marrow
19	or a kidney transplant.
20		If matching is done properly, then the transplant
21	succeeds.  If it is done poorly, it will not succeed.  The
22	fact that these reagents are all devices to type our genetic
23	markers, that is pretty much the same for B27 or for any
24	other reagent.  Applicability is a second-step issue, is the
25	way I see it.

			241 1		I mean, in terms of quality control of these
	2	reagents, we could have pretty much the same quality control
	3	because, basically, you are typing basic genetic markers.

	4		DR. MACIK:  But, in classifying these, you have
	5	already tied it to a level of risk associated with a device
	6	to decide what classification.  The level of risk is

	7	significantly different between something used as a
	8	diagnostic for a disorder and something used as a
	9	compatibility--
10		DR. MATAL:  I totally agree.  The only part that I
11	am mentioning is that accuracy of typing is the issue in

12	trying to classify this product.  False-positives, false
13	negatives.  I think premarket notification would be very
14	useful which lists the incidence of false-negative and
15	false-positive typings.

16		But in terms of applicability of this profile, is
17	the next step.  I think the two could be separated.  For me
18	to think that the HLA typing, done correctly, could make a
19	difference between the success or failure of a transplant,
20	would not happen.  It is not actually typing that determines
21	the success or failure of a transplant.  It is the matching
22	of the donor recipient that makes the success or failure of
23	a transplant.
24		MS. KOCHMAN:  I would like to point out also that-
25	-I understand your point about the risks associated with

			242 1	transplant, but keep in mind that there also risks
	2	associated in transfusion.  The automated blood-grouping

	3	instruments that determine a donor's type and presence or
	4	absence of antibodies are currently class II.
	5		Certainly, if you give an incompatible blood
	6	transfusion, you can have a fatality.  So if you put it in
	7	that perspective, there is very much a parallel between the
	8	automatic blood-grouping systems and the HLA typing
	9	reagents.
10		DR. MACIK:  I would agree with that.  But I would
11	also agree that transfusing a blood component would also be

12	associated with a serious life-threatening consequence if it
13	were not done appropriately.  I think both of them, for that
14	one statement as Dr. Hollinger pointed out, if you are
15	inaccurate in your typing, whether it is HLA or AB/O typing,
16	you can cause a serious and, perhaps, fatal event with that
17	mismatch.
18		MS. KOCHMAN:  Right.  But we know enough about
19	both blood grouping and about HLA phenotyping to know what
20	is important to have the kit be able to do.  We can
21	prescribe the standards that a device must meet in order to
22	assure safety and effectiveness.
23		In order for it to go to the level of class III,
24	there has to be an assessment that we don't really know what
25	is necessary to insure safety and effectiveness.  I would

			243 1	say that, for blood-grouping instruments and for HLA test
	2	kits, we know what is necessary.
	3		We can develop performance standards that say the
	4	device must detect this, this, this and this.  The device
	5	must be specific.  The device must not have cross-
	6	reactivities, et cetera, et cetera.  So it is a subtle
	7	difference between--and I am not discounting that injury is
	8	possible.  But my definition of class I devices also
	9	included that injury could be possible.
10		But is there a substantial risk of injury?  I
11	would say if the device conforms to the performance
12	standards we use, then there is not a substantial risk. 
13	There is an implied risk, but not a substantial risk.  It is
14	a risk we can mitigate by having performance standards.
15		DR. HOLLINGER:  Dr. McCurdy?
16		DR. McCURDY:  I think, when one is talking about
17	organ transplants, solid-organ transplants, what I
18	understand about the situation is exactly as you say.  When,
19	on the other hand, you are talking about stem-cell
20	transplants, marrow, peripheral blood, cord blood, I think
21	it is a moving target.  I think that now DNA-based

22	technology is here for both class I and class II HLA
23	categories, but the degree of resolution varies and I don't
24	think we know exactly what standards should be applied to
25	the matching of stem-cell transplants where you have got a

				244 1	two-way street; that is, you can reject the transplant or
	2	the transplant can reject the host with GVH.
	3		I don't think I am really suggesting that this
	4	should be class III, but I think the standards necessary for
	5	stem-cell matching versus solid-organ matching versus B27
	6	classification--I think the risks are considerably
	7	different.
	8		DR. MATAL:  I very much agree with this and I
	9	would say that this is why you really don't want to have it
10	in class III.  But in class II, you have very good, solid
11	special controls, is what you need, in addition to general
12	controls.
13		DR. HOLLINGER:  Dr. Simon?
14		DR. SIMON:  I would agree with the class II.  I do
15	agree with the discussion that this is not trivial and
16	should not be class I.  I think of class III as something
17	like if a respirator stops, boom; the individual is gone. 
18	So I would speak for the class II.
19		Where I am having more trouble is the second
20	question on the requirement to submit a 510(k).  I wonder if
21	one of our two experts could speak to that.
22		DR. HOLLINGER:  To what additionally this asks
23	for?  The additional things?
24		DR. SIMON:  Yes; whether they should or should not
25	be exempt for a requirement to submit a 510(k).  I wouldn't

					245 1	know how to vote on that.
	2		DR. MATAL:  I am very much in favor of their
	3	submitting the 510(k).
	4		MS. KOCHMAN:  Yes; as I mentioned, we would
	5	propose, in the future, to still require a 510(k)
	6		DR. SIMON:  So you would propose that we answer no
	7	to that second question.
	8		MS. KOCHMAN:  Correct.
	9		DR. SIMON:  Yes to the first question and no to
10	the second.
11		MS. KOCHMAN:  Correct.
12		DR. HOLLINGER:  And the 510(k) is just what?

13		MS. KOCHMAN:  It is a submission of all of the
14	data that the manufacturer has collected to show that his
15	device is substantially similar.  I will use substantially
16	similar.  I think that is a little bit easier for people to
17	understand--substantially similar to a device that has
18	already been cleared to go on the market.
19		So, right now, we have FDA scientists reviewing
20	that data package.  Once we get a classification, we can,
21	then, target our program to having third-party reviewers

22	also be eligible to review that data package.
23		DR. HOLLINGER:  Yes, David?
24		DR. STRONCEK:  My impression is the best labs that
25	do the highest, the best, typing for stem-cell transplants

			246 1	are using in-house-generated tests.  After we vote to
	2	clarify the regulation of HLA, will that have implications
	3	for these in-house tests?  Will the universities and
	4	cutting-edge labs that use those tests not be able to get
	5	reimbursed if they are not licensed?
	6		DR. MATAL:  I think any time you are using a cell
	7	that came out of a human being, you always can get an HLA
	8	profile of that donor by using the regular sample.  And that
	9	is what they do.  They have the HLA profile of that donor
10	from whom they extracted the cell that led to your
11	collection of the stem cell.
12		So whatever other special tests they do, they are
13	probably for identification of whatever.  I am not quite
14	clear as to what your point is, about inside tests of
15	institutions.
16		DR. STRONCEK:  I think most transplant centers
17	probably don't buy a commercial kit.  These are probably
18	low-resolution kits used by labs that don't regularly test. 
19	If we pass this regulation, is that going to have
20	implications for these cutting-edge laboratories that do the
21	best testing, that they won't be able to charge insurance
22	companies?
23		Right now, bone-marrow-transplant patients, when
24	they finally go to transplant, the testing is extremely
25	thorough but very expensive.  Those are not done with Pel-

				247 1	Freez kits.  I can tell you that.  Will this mean that if
	2	the transplant center wants to charge $2,000 for this typing
	3	that they are going to have to go through and get their in-
	4	house kits licensed?
	5		DR. MATAL:  No, no.  I didn't quite understand
	6	your question before.  Any HLA laboratory in the country has
	7	the freedom to use any reagents, all the reagents they can

	8	find, from anywhere.  And then they try to come up with the
	9	best phenotype of a given person.
10		No two laboratories in this country, in this
11	world, use the same reagents for typing.  Actually, even in
12	the same lab, over time reagents change.  So, no.  What

13	every laboratory is trying to do is to come up with the
14	best, most accurate, phenotype with the reagents available
15	to them.
16		Different laboratories buy different kits from
17	different companies and they use what they consider works
18	best in their hands or what they can afford, and so forth.

19		DR. HOLLINGER:  Dr. Kagan, did you have something?
20		DR. KAGAN:  Given the fact that we are going to be
21	looking at a bit of a moving target, as Dr. McCurdy had
22	suggested, does the agency possess the authority to modify
23	the special controls over a period of time once this has

24	been classified, perhaps, as a class II device?
25		MS. KOCHMAN:  Yes.

			248 1		DR. MATAL:  As a matter of fact, the very first
	2	controls that you approve to be applied ought to be
	3	scrutinized pretty well because that is where--this is a

	4	complex technology, as we all know.  So the first set of
	5	standard special rules that are chosen to be applied for

	6	accreditation or whatever, they ought to be thought through
	7	well.
	8		MR. RICE:  I think, for me, the key point is the
	9	substantially equivalent classification.  The FDA is going
10	to decide whether or not the submission, the new device
11	submission, is substantially equivalent to some established
12	or existing predecessor before the company gets to decide
13	whether or not they are going to pursue a class II outside
14	of the agency, go through the accredited person?
15		MS. KOCHMAN:  I'm sorry; I didn't understand the
16	question.

17		DR. MATAL:  If I may address this one.  If, let us
18	say, there is one of those companies--although I did not see
19	any of them which had known expertise in the field of HLA,
20	but let us say there is an institution that has been
21	accredited to evaluate a kit submitted to FDA.
22		One of the most practical ways to do that is that
23	this institution that is doing the accrediting has a way to
24	phenotype human beings.  They may have a type panel--
25	actually, they should have a type panel of donors.  This new

			249 1	kit comes in and they test it against known donors and
	2	against known reagents that they have already on board.
	3		So it is a question of comparison.  And they have
	4	to satisfy themselves that here is an unknown donor and you
	5	are doing HLA typing of this unknown donor.  Is the
	6	phenotype reasonably accurate and complete or not?  It does
	7	not matter what reagents they use.  The key thing is did
	8	they come up with the correct phenotype?
	9		The phenotype of a human being is verifiable.  Our
10	HLA phenotype is our biological identity card.  You can get
11	a person's type anywhere.  So known typing panels is one way
12	to establish accuracy of comparisons.
13		DR. HOLLINGER:  I think we will go ahead and call
14	for the--Gail, do you have something?
15		DR. MACIK:  Just a couple of quick things.  One is
16	that I agree that many places do their own typing because
17	they are not that comfortable with kits and what is
18	available or sending it out to special labs because this is
19	not a testing system that is well controlled.

20		You already brought up the fact that many of these 
21	systems out there are not even classified yet and what are

22	we going to do.  It has just been hanging out there.  So I
23	think it is a good idea.  But the one question that actually
24	comes back a little bit more to the special persons for
25	accrediting, when we were talking about conflict of interest

			250 1	with these outside agencies, one of the things that you had
	2	mentioned was that no agency that had any particular
	3	interest in the field would be reviewing it and then, on the
	4	other hand, it says, well, there has to be a company that
	5	has special HLA expertise that you would send it to.
	6		Those seem to be a little contradictory.
	7		DR. MATAL:  See, the way you deal with conflict of
	8	interest, first of all, let's say, honorable people are
	9	doing the review.  That is one thing.  The second this is,
10	as long as they do not have a direct financial involvement
11	with the manufacturer or any of their relatives or family. 
12	You check for that and then you leave it to honorability of
13	the parties doing it because, after all, as you said before,
14	if they are passing everything going through just for the
15	money, they will not be in business very long.
16		DR. HOLLINGER:  I think we will call for the
17	question.  I will read it and then we will vote on it.  The
18	first question is, does the committee agree that HLA devices
19	for use in detecting antibodies to HLA antigens or
20	determining HLA phenotype or genotype should be classified
21	as class II devices.
22		All those that agree with that recommendation,
23	raise your hand.
24		[Show of hands.]
25		DR. HOLLINGER:  All those that disagree?

				251 1		[No response.]
	2		DR. HOLLINGER:  Abstain?
	3		[No response.]
	4		DR. HOLLINGER:  Dr. Simon?
	5		DR. SIMON:  Agree.
	6		DR. SMALLWOOD:  The results of voting on the first
	7	question, there were 13 "yes" votes, there were no "no"
	8	votes, no abstentions.  The industry representative agreed
	9	with the "yes" vote and the consumer representative left a
10	note that she agreed with the "yes" vote.
11		DR. HOLLINGER:  There is a second part to this and
12	I presume this would be under the second part that you
13	mentioned, Linda, about whether there is agreement with the
14	recommendations with conditions.  One of the conditions that
15	is put up there is should they be exempt from the
16	requirement to submit a 510(k)?  Should they be exempt from
17	the requirement to submit a 510(k)?
18		All those that agree that they should be exempt

19	from the requirement to submit a 510(k), raise your hand.
20		[No response.]
21		DR. HOLLINGER:  All those opposed?
22		[Show of hands.]
23		DR. HOLLINGER:  Abstaining?
24		[No response.]
25		DR. SIMON:  Opposed.

				252 1		DR. SMALLWOOD:  The result of voting on the second
	2	question, there were zero "yes" votes, 13 "no" votes, no

	3	abstentions.  The industry representative agreed with the
	4	"no" votes.  I do not have a report from the consumer
	5	representative in her absence.
	6		DR. HOLLINGER:  Thank you.
	7		   V. Report of Intramural Site Visit

	8		    Laboratory or Molecular Virology
	9	 Division of Emerging and Transfusions Transmitted Diseases
10		DR. HOLLINGER:  The final session is on the report
11	of the intramural site visit, Laboratory of Molecular
12	Virology, Division of Emerging and Transfusion Transmitted
13	Diseases.  Two of our committee members were part of that

14	site-visit committee, Dr. Nelson and Dr. Stuver.  So they
15	will be here to help us also as we look through this.
16		You all have received this, anyway.  We have some
17	introductions and overviews of the programs here.  We will
18	start with Dr. Nakhasi who is the Director, Division of
19	Emerging and Transfusion Transmitted Diseases.
20		Dr. Nakhasi?
21		       Introduction and Overview
22		DR. NAKHASI:  Thank you, Mr. Chairman and thank
23	you, committee members.  This is my first committee meeting

24	here because I was appointed as the Division Director only a
25	few months back, so I think it is a new experience with this

			253 1	committee.  Even though I have been in the FDA for the last
	2	sixteen years in the Office of Vaccine and other advisory
	3	committee meetings.
	4		[Slide.]
	5		I know it is getting late and I think the
	6	important thing is the people whose labs were site-visited,
	7	they need to spend some time.  So I will just go quickly
	8	through the organization and what the performance is and the
	9	activities are in the Division of Emerging and Transfusion
10	Transmitted Diseases.
11		The Division of Emerging and Transfusion
12	Transmitted Diseases is abbreviated DETTD.  This is the

13	Office of the Director where myself and other people are
14	helping me out.  The organization is in the form of three
15	laboratories, research laboratories, and one testing lab.
16		The three laboratories are the Laboratory of
17	Bacterial Parasitic and Unconventional Agents--Dr. Asher is
18	the chief of that--the Laboratory of Molecular Virology--

19	Indira Hewlett, whose lab was site visited and you will hear
20	from her the representation--and also, then, we have a
21	Laboratory of Hepatitis and Related Emerging Agents.  Dr.

22	Robin Biswas is Acting for the time being.  And we have the
23	Lot Release Testing for all these, HIV-1, HIV-2 and the

24	hepatitis test kits which is under the leadership of Dr.
25	Roberts.

			254 1		[Slide.]
	2		The Laboratory of Molecular Virology, whose site
	3	visit was held in June, is organized in five sections. There
	4	is a Regulatory Section, and then there are four research
	5	sections.  The Molecular Virology Section, which is Dr.
	6	Indira Hewlett's lab, she will be presenting today and Dr.
	7	Subhash Dhawan whose section also was reviewed, he will be
	8	presenting their scientific review.
	9		[Slide.]
10		The mission of the division is to plan and conduct
11	research on pathogenesis, evaluate and standardization of

12	retrovirus hepatitis, parasitic bacterial and transmissible
13	spongiform encephalopathy related to blood screening and
14	diagnostic tests.
15		With the laboratory personnel reviewed, evaluate
16	and recommend appropriate actions on investigational new-
17	drug applications, biological applications, PMAs, 510(k)s--
18	you just heard what the 510(k) is--I am trying to learn,
19	myself, that--related to viral, parasitic and bacterial
20	tests for blood screening and diagnostics, and also help to
21	disseminate policies, procedures and guidelines and we seek
22	your help whenever we have to change the policies, as you
23	know very well.
24		[Slide.]
25		It performs the inspection of the manufacturing

			255 1	facilities where these products are being made and performs
	2	laboratory tests and reviews manufacturing of lot-release

	3	protocols by the licensed test kits.  In addition to that,
	4	it provides scientific expertise and technical advise to
	5	other components of FDA, PH agencies, advisory committees. 
	6	And we, the people in the laboratory, also are involved on
	7	national collaborations with other academic institutions

	8	related to the safety and efficacy of blood screening and
	9	diagnostic kits for these infectious diseases.
10		[Slide.]
11		Last year, we had some 247 INDs, PLAs, IDEs, PMAs,
12	all these things reviewed in one year.
13		[Slide.]
14		The research activities which are going on in the
15	laboratory are HIV pathogenesis, diagnostic testing of blood
16	safety.  Those are the things which you will hear from
17	Indira's laboratory and also Dr. Subhash Dhawan's
18	laboratory.  We also have some activity of HTLV-I and II, a
19	detection assay for blood donors.  But it is a minor

20	activity.  The majority of tests are related to HIV.
21		Then we have the activities going on, research
22	activities going on, and the detection for the PSE, tissue
23	spongiform encephalopathy in individual culture, in vitro
24	and in vivo models.

25		[Slide.]

			256 1		In my laboratory, we are working on these
	2	parasitic diseases.  We have chosen Leishmania because that
	3	is what I have been working on for the last ten years.  In
	4	addition to that, we are now working also on the malaria and
	5	chagas diseases because these are all bloodborne pathogens.
	6		[Slide.]
	7		In addition to that, there is a laboratory working
	8	on bacterial contamination of blood and blood products and
	9	which you heard in the morning, syphilis.  Even though we
10	don't work with syphilis, we are developing tests for other
11	bacterial contaminations.
12		There is a laboratory which is involved in studies
13	the pathogenesis of hepatitis B and C and the development of
14	DNA-based diagnostic kits.
15		[Slide.]
16		The total number of people in the division are

17	around 38 and out of which there are six tenured senior
18	investigators and a regulatory staff of 13.  The rest of
19	them, except the administrative staff, are mostly research
20	fellows which are helping these tenured investigators with
21	an annual measly amount of $600,000.
22		[Slide.]
23		We published last year 22 articles in peer-

24	reviewed journals and the members of the division have been
25	invited to national and international meetings and also have

			257 1	established quite a bit of collaboration with international
	2	and national institutions.
	3		[Slide.]
	4		The purpose of the site visit was to review Dr.
	5	Hewlett's research program.  That was one thing.  The second
	6	was to review Dr. Dhawan's program and make recommendations
	7	for the future recommendation to GS15.  The other activity

	8	which was just for information's sake was Dr. Cowan's
	9	regulatory activity on HTLV.  But that is not part of
10	today's discussion.  These are the two things which are
11	related to the research activity.

12		At this point, I will turn the mike over to Dr.
13	Indira Hewlett.  She will talk about her research program
14	and give a little detail about her laboratory.  Then Dr.
15	Dhawan will talk about his program.
16		Thank you.
17		DR. HEWLETT:  Good afternoon.
18		[Slide.]

19		I will try to be as brief as possible.  I know it
20	is getting very late in the day and I am sure you are trying
21	to run out of here and catch your flight out of wherever you
22	are flying out of.  My name is Indira Hewlett.  I am Chief
23	of the Laboratory of Molecular Virology.  What I am going to
24	try to do is give you a very brief overview of the this

25	programs and then talk a little bit about some of the

			258 1	projects that were presented at the site visit that was held
	2	in June of this year.
	3		[Slide.]
	4		LMV was first created during the reorganization--
	5	this is the CBER reorganization of 1993.  It was reorganized
	6	further in 1999 to include the HTLV section.
	7		[Slide.]
	8		The regulatory mission of the laboratory is to
	9	review and license product applications for in vitro tests
10	to detect HIV and HTLV in blood, plasma and other body
11	fluids.  We develop guidelines, review criteria and
12	standards for validation of tests and policies related to
13	their use, and some of this activity involves making
14	presentations to the Blood Products Advisory Committee, as
15	you probably know.
16		In 1991, FDA--that is, the Centers for Devices and
17	our center, CBER, agreed in the Intercenter Agreement, to

18	move all of the HIV or the human retroviral test kits under
19	the purview of CBER.  They were actually always under the
20	purview of CBER, but there was some question as to whether

21	to split up the jurisdiction of diagnostic versus the blood-
22	screening kits between the two centers.
23		However, as a result of this agreement, all of the
24	kits are now reviewed by our center and, specifically, in
25	our laboratory.  These tests include those for donor

			259 1	screening, conventional and rapid test for diagnosis, tests
	2	for patient monitoring, drug-resistance tests as well as
	3	home-use tests.
	4		[Slide.]
	5		To support the regulatory mission of the
	6	laboratory, we have some research programs that are focused
	7	primarily on basic and applied aspects.  So there is basic
	8	and applied research on HIV-1, HIV-2, and HTLV disease.  We
	9	conduct laboratory investigations on disease transmission
10	and pathogenesis and we develop and evaluate methods to
11	insure blood safety from HIV and HTLV transmission including
12	testing for viral markers.
13		Finally, we have been engaged, over the past
14	couple of years, in developing laboratory standards and
15	panels for HIV and HTLV tests, and we have participated in a
16	number of international collaborative efforts to evaluate
17	and standardize nucleic-acid-based tests for HIV.
18		[Slide.]
19		This just shows the organization of the
20	laboratory.  You have already seen from Dr. Nakhasi's slide
21	how the division is organized but the laboratory consists

22	of, as he said, five groups.  This group, which is actually
23	manned by regulatory scientists, we, at the present time,
24	have about three regulatory scientists that spend
25	100 percent of their time on new activities.

			260 1		We have four research sections, the Molecular
	2	Virology Section which I head and I am going to very briefly
	3	discuss some of the work going on in this group.  The
	4	Immunopathogenesis Section is run by Dr. Dhawan and he is
	5	going to talk about his work after my presentation.
	6		The Gene Regulation Section is headed by Dr.
	7	Andrew Dayton.  This group is looking at the molecular
	8	biology of HIV infection focussing on tat and rev.  Finally,
	9	we have the HTLV Section that is looking at HTLV
10	pathogenesis and is looking at developing diagnostic tests
11	for HTLV as well.
12		[Slide.]
13		So now, switching to the Molecular Virology
14	Section specifically, my group has been engaged in projects
15	on pathogenesis and diagnosis.  These are just a couple of
16	the projects that have been ongoing in the past four years. 
17	We have been looking at the virologic and genetic
18	characteristics of two groups of two specific types of
19	infections; that is, isolates from rapid and long-term
20	nonprogessors.  These are clade-B-virus infected
21	individuals.
22		And then we have another area of research looking
23	at isolates from patients with unusual variants,
24	specifically the HIV group-O viruses.  We are also looking
25	at genetic diversity of HIV-2.  We are looking at inhibitors

			261 1	such as the T20 which is an inhibitor of virus entry, using
	2	this to look at mechanisms of virus entry, specifically the
	3	clade-B virus and its interaction with t-cells.
	4		We also have some projects in diagnostics, and I

	5	will discuss this later.  Finally, we have developed some
	6	reference reagents and are continuing to engage in
	7	developing reference reagents for the subtypes of HIV.
	8		[Slide.]
	9		So, in the next couple of slides, I am going to
10	just briefly discuss some work in HIV group O.
11		[Slide.]
12		The reason we got interested and involved in

13	looking at variants and, actually, for the past three or
14	four years, we have been moving towards looking at genetic
15	diversity, specifically with an eye toward looking at

16	evolution of viruses and, obviously, their impact on
17	diagnostic tests because those are the products we regulate
18	at CBER within my branch.
19		But it was this report and a couple of other
20	reports which I think some of you on this committee may be
21	familiar with and aware of that were discussed, actually, at
22	the BPAC in 1994, 1995, where it was observed that some
23	specimens from patients with HIV group O were not detected
24	by FDA-licensed assays, specifically assays that contained
25	synthetic peptides or recombinant antigens.

			262 1		Obviously, this observation caused much concern in
	2	the area of blood safety and the issue of whether currently
	3	licensed tests were safe and were we protecting our blood
	4	supply from new variants of HIV.
	5		[Slide.]
	6		We obtained some isolates from collaborators in
	7	Germany and Spain.  We did some virologic studies.  This is
	8	infection of the PBMCs with three different isolates.  What
	9	we observed was these viruses were able to replicate in
10	PBMCs.
11		[Slide.]
12		They were able to infect monocyte-derived
13	macrophages.  This is p24 antigen production.  This is
14	actually--I guess it is reversed--it is reverse-
15	transcriptase activity on the Y axis.
16		[Slide.]
17		We looked at coreceptor usage and, as observed by
18	other investigators, the subtype was not the determinant of
19	coreceptor usage.  Rather, it was the phenotype of the
20	virus.  So NSI viruses--that is, isolates that were typed as
21	NSI viruses--used CCR5.  The ones that were of SI phenotype
22	used the CXCR4 coreceptor.
23		[Slide.]
24		We did sequence analysis to make sure that these
25	were group O viruses.  This is just a phylogenetic tree

			263 1	analysis placing the isolates--they are in red here--in the
	2	group O cluster of viruses.
	3		[Slide.]
	4		So our conclusion, and that was just a snapshot--
	5	we obviously did a number of other experiments as well, but
	6	those were just the key observations.  Our conclusion was
	7	that both the target cells that are used by HIV viruses,
	8	namely the PBMCs and the MBMs, monocytes, are susceptible to
	9	infection by group O, similar to clade-B HIV-1.
10		We found that the coreceptor use was related to
11	phenotype, not genotype.  We also looked at the chemokine
12	and cytokine production and found no differences in
13	chemokine production between the group-O viruses and the
14	clade-B viruses.
15		Sequence analysis of these isolates indicated that
16	there was variability in the V3 region to the extent that is
17	seen in clade-B strains and there was also a high degree of
18	conservation in the core region.  We looked at the protease
19	genes, again, similar to what was seen with clade-B viruses.
20		So our overall conclusion was that virologic
21	characteristics were similar to group-M viruses.  In fact, I
22	didn't show you any of the clade-B data in the interest of
23	time.
24		[Slide.]
25		In the second part, I will discuss some of the

			264 1	work we are doing on diagnostics.
	2		[Slide.]
	3		As I mentioned earlier, there was concern about
	4	peptide-based assays and their ability to detect variants,
	5	not just group O but variants in general.  But we focused on
	6	the HIV group-O issue.  What we did here was to make a

	7	number of peptides from the envelope region.  This just
	8	shows the sequences of the peptides.
	9		[Slide.]
10		We screened them using a couple of group-O sera
11	that were made available to us and we found that there was
12	differential reactivity depending on the combination of
13	peptides.
14		What we did was to make combinations and screen

15	them this way.  This particular sample turned out to be also
16	negative on Western Blot, so it is possible there wasn't
17	enough antibody here and we may need to--it either lost its
18	antibody on storage or it may not be an adequate sample for
19	testing.
20		[Slide.]
21		We tested a couple of additional specimens that we
22	obtained from Genetic Systems using one of these
23	combinations.  And we find you get very good reactivity even
24	at a very high dilution.  This is a 1 to 1000 dilution.
25		[Slide.]

			265 1		We have developed some primers for detection of
	2	group M and group O.  These are just the regions from which
	3	the primers were derived.  There is pol and envelope-based

	4	primer sequences.
	5		[Slide.]
	6		We have analyzed a limited number of isolates. 
	7	But, since the time this slide was made, we have actually

	8	checked a couple of additional isolates and what we think we
	9	have is a couple of--one set of primers that is cross-
10	reactive for the different subtypes.  We have got a couple
11	that are specific for each of the groups--that is, group O
12	and group M.  We are looking, specifically, at clades A
13	through F in this particular slide but there are, obviously,
14	other additional clades that have been identified.
15		At the time that we developed these reagents,
16	group N had just been discovered.  It is very difficult to
17	get samples of group N subtype to test.  However, we have

18	also developed group-N-based assay.
19		[Slide.]
20		So, using these tools, we have just initiated a
21	study with the Cameroon Ministry of Health looking at blood
22	banks.  In the future, we will be looking at STD clinics. 
23	These studies involve using rapid tests to screen samples
24	and to look at interesting samples--that is, those that are
25	weakly reactive or have unusual patterns.  We will be doing

			266 1	virus isolation, further testing using in-house assays.

	2		We will also do nucleotide-sequence analysis
	3	looking for recombination and mutation, the goal being to
	4	look at new variants and to identify or to study their
	5	virologic and diagnostic characteristics.
	6		[Slide.]
	7		Finally, another aspect of our research is
	8	development of reference reagents.  We have developed two
	9	panels for HIV, one which is based on a plasma specimen. 

10	The second is a cultured virus spiked into negative plasma. 
11	These panels have been evaluated in multicenter
12	collaborative studies that are of an international nature
13	under the auspices of the WHO.
14		The first panel, panel A, has actually been
15	adopted as the WHO international standard at this point, so
16	it is a lypohylized preparation that is available for
17	standardization of HIV RNA tests.
18		[Slide.]
19		We are continuing this work by pursuing clade
20	panel development in collaboration with a number of
21	organizations including the CDC, Walter Reed, the Navy and
22	NIH and NIBSC.
23		[Slide.]
24		So to summarize the research activities in LMV, we
25	are looking at viral and host factors in disease

			267 1	progression.  We have got projects in diagnostics looking

	2	at--where we are developing in-house PCR and immunoassays
	3	for the different HIV groups.  We have applied this assays
	4	on occasion to investigation of products, and if we have

	5	time to talk about that today, and to clinical disease.
	6		We are also engaged in laboratory studies to
	7	define optimal strategies for detection of different
	8	variants.  You saw some of that research.  We are also

	9	continuing to be engaged in the development of reference
10	agents for quantitation and lot release of HIV RNA assays.
11		[Slide.]
12		This is the final slide, just to acknowledge the
13	people who were involved in the research that I just
14	discussed.  These are the people in my group.  We obtained
15	group O samples from Enzo Soriano, from Lutz Gertler in
16	Germany and some from Leopold Zekeng.  The standardization
17	work was done with the NIBSC.
18		Thank you.
19		DR. HOLLINGER:  Thank you, Indira.
20		Any questions of Indira?  The next person who is
21	going to talk is Dr. Dhawan in the Laboratory of Molecular
22	Virology, also.
23		DR. DHAWAN:  Good afternoon, Mr. Chairman and

24	committee members.  My name is Subhash Dhawan and I will be
25	talking about part of the work that I presented in the site

			268 1	visit.  But, in the interest of time, I will discuss only
	2	the work that I either published or is in press only in the
	3	past one year.
	4		[Slide.]
	5		I will begin my talk with this slide showing the
	6	structural organization, very briefly.  I head the
	7	Immunopathogenesis Section in Dr. Hewlett's lab and, without
	8	going into all the details, I have currently one ORISE post-
	9	doctoral fellow and one staffer that needs to be filled.
10		My responsibility at LMV is 50/50, research and
11	the regulatory process.  As a regulatory, I review products
12	related to HIV diagnostics.  I occasionally respond to
13	correspondence from blood-bank organizations and also have
14	performed inspections in the past.
15		My research interests would constitute 50 percent
16	of my time, more or less.  My interests are in the viral
17	immunology of HIV infection.
18		[Slide.]
19		This is the HIV pathogenesis and study the role of
20	virus and host factors that promote HIV pathogenesis.  I
21	will limit my talk to ten or fifteen minutes.  I realize
22	that this has been a very busy meeting, but, being the last
23	speaker, I do have certain advantages.  I can go for another
24	five minutes.  Right, Mr. Chairman?
25		[Slide.]

			269 1		Very briefly, I would just to highlight my
	2	accomplishments in the past four years since the last site
	3	visit.  I submitted twenty research articles and was asked
	4	to write three book chapters, most of them published.  I
	5	filed three patents with the U.S. and abroad, international,
	6	and I am happy to say that these patents are now being
	7	considered for licensing by a leading manufacturer.
	8		In 1996, I received CBER's Director's Targeted
	9	Scientific Achievement Award for Research.  In 1999, last
10	year, I received at Director's Targeted Award for $120,000 a
11	year for two years to support my research.
12		[Slide.]
13		In addition to research, I also am involved in the
14	regulatory process, as you can see.  Since the last site

15	visit, I chaired sixteen PLAs, which are major and minor
16	supplements.  They could be from two volumes to thirty

17	volumes.  And two PMAs, original.  And one PMA supplement
18	where it was not approved.
19		As a reviewer, I participated in two PLA
20	committees, three INDs originally, one IDE which now--this
21	is an old slide--which I have received and I am currently
22	reviewing it.  I responded with correspondence with blood-
23	bank organizations.  But, of course, as a regulatory
24	responsibility, I attend several pre-IND and IND meetings. 
25	In the past, I have inspected two facilities.

			270 1		[Slide.]
	2		In the next ten minutes or so, fifteen minutes,
	3	maybe, I will be talking about the studies on the tat
	4	protein, which is the progress report from 1996 to the
	5	present and which I am updating right now.  It will
	6	approximately from July 1999 until last month.  I will be
	7	discussing only very briefly.
	8		My interest has been studies on HIV tat protein. 
	9	Here I am talking about tat protein in Dr. Gallo's meetings
10	on human virology, the entire session they are discussing on
11	tat right now.  So my interest in tat protein is because of
12	its important role in the disease progression.
13		[Slide.]
14		My interest was first in its role in the
15	pathogenesis and as a diagnostic tool for HIV and the
16	factors that contribute to promote viral pathogenesis and,
17	also, because it is important in the disease progression, my
18	interest was to use this protein or the antibody of this
19	protein as a little bit as a diagnostic tool for HIV
20	infection and also, third, because of this involvement in
21	AIDS pathogenesis, to use this as a potential AIDS vaccine
22	which Dr. Gallo had proposed.
23		The very recent summary from his institute, which
24	came out last month, he is proposing a clinical trial in the
25	United States and Europe in 2002 and it is expected to be on

			271 1	the market in 2003.

	2		[Slide.]
	3		HIV tat is produced by HIV-infected cells in the
	4	acute phase of infection.  It is known to produce HIV
	5	pathogenesis and causes apoptosis and immunosuppression of
	6	normal cells even in the absence of HIV infection.
	7		[Slide.]
	8		This is an old slide taken from a book chapter by
	9	Bill Hazeltine which he published in 1984 demonstrating the
10	role of tat, how tat can be pathogenic, how it works,
11	basically.  Very briefly, again, tat is released by HIV-

12	infected cells and it can be taken up by the cell that it
13	has produced.  It can also be taken up by the adjacent
14	cells.
15		When the tat is taken up by the cell that it has
16	produced, it promotes HIV replication, activates IV LTR and
17	promotes viral pathogenesis and HIV replication.  The way it
18	acts on adjacent cells, it activates those cells and makes
19	them more susceptible to HIV infection which is the role of
20	extracellular tat.
21		[Slide.]
22		I wish I had more time to talk about this, but
23	with the time limitation--this is the model that I proposed
24	nearly five years ago.  I am happy to say whatever is in the
25	slide, it is all published.  This constituted, basically,

			272 1	the two-thirds of my work that I presented at the site visit
	2	I will not have time to go into details.
	3		But, very briefly, HIV-infected cells release tat
	4	protein and it binds to leukocytes, promotes the binding to
	5	endothelial cells, and then the cell that is activated, it
	6	migrates and responds to the tat which is left by infected
	7	cells in tissue and released as protease as oxygen radicals
	8	and resulting in tissue damage.
	9		This work that I described in two sentences took
10	me five years to do.  And it is all published.
11		[Slide.]
12		Just to show you how tat works and what does tat
13	do; as you can see over here, the tat enhances the HIV
14	replication of monocytes.  This is the control, HIV-infected

15	cells, and the cells that were treated with HIV tat protein. 
16	You can see that the virus replication, as a measure of p24,
17	was twofold to threefold and, in some cases, even more.
18		The panels on the bottom show the HIV-associated
19	cytopathic effect which we determine as a measure of
20	multinucleated giant cells.  You can also see this tat-

21	enhanced cytopathic effect dramatically in monocytes.
22		[Slide.]
23		This is the very recent work we have published in
24	the Cutting Edge Section of the Journal of Immunology last
25	year.  We wanted to find out--we all know, between this

			273 1	slide and the previous slide, there are a number of steps,
	2	which I don't have time to go through, but we know that tat,
	3	and everybody knows, that the tat mediates cell
	4	pathogenesis.
	5		But the question was the tat is about 86 amino-
	6	acids long and what portion, what domains of these tat
	7	proteins that consist of core domain basic and RGD domains,
	8	what domains are responsible for the pathogenesis.
	9		So what we did was we mapped the entire sequence
10	and made several synthetic peptides, not only from Group M
11	but also consists of B, and also with other subtypes, and

12	examined their ability to promote viral pathogenesis which
13	is shown in the next slide.
14		[Slide.]
15		This shows the cells that were treated with
16	recombinant tat as well as different synthetic peptides. 
17	And we measured p24 as an index of virus replication.  As
18	you can see here, controlled cells not treated with
19	anything, just only infected with the monocyte strain of
20	HIV, the p24 level was 471.  When these cells were treated
21	with recombinant tat, the p24 level was dramatically,
22	fourfold, higher as compared to the control ones.
23		I would like to draw your attention to this
24	peptide, tat 21 to 40, which had activated similar to what
25	we saw in recombinant tat.  And we found this peptide

			274 1	represents one of the active domains of the tat protein.
	2		Very briefly, again, as you can see, this peptide
	3	is a very difficult peptide and, yet, very important.  It
	4	has seven cysteines, six cysteines, seven cysteines, in it. 
	5	These two cysteines at 22 and 27 are very extremely
	6	important for the activity because when we treated these
	7	cysteine residues from this peptide, we lost almost half the
	8	activity of the peptide.
	9		Another peptide is 53 to 68 derived from the basic
10	domain also enhanced the virus replication by greater than
11	twofold.  To figure out these two domains are very important
12	to promote viral pathogenesis.  The other peptides taken as
13	a control had apparently no effect on them.
14		[Slide.]
15		This slide shows the HIV-associated cytopathic

16	effect.  As we can see, previous to what we saw in the
17	previous table, the recombinant tat enhanced the
18	pathogenesis measured, or scored as the formation of
19	multinuclear giant cells, was much higher compared to
20	infected cells not treated with tat.

21		When we treated the cells with these two peptides,
22	especially with 21 to 40, the cytopathic effects were at
23	least fourfold to fivefold higher.  This is just the control
24	peptide, had no effect and the morphology of these cells was
25	similar to what we saw in the control cells.  This panel

			275 1	represents the morphology of uninfected monocytes.
	2		Just to summarize, these two peptides were
	3	extremely important.
	4		[Slide.]
	5		This is--very briefly, again, we tested the
	6	ability of these peptides to promote angiogenesis formation. 
	7	As we know, tat is involved in the Kaposi's sarcoma, with
	8	the angiogenic-related diseases, at least in the HIV-

	9	infected individuals.  So we wanted to know if tat can
10	promote the formation of new blood vessels.
11		This experiment was done by using fertilized eggs,
12	the cam assay, basically.  We tested this peptide, placed it
13	on a cover slip, and put it on cam of the fertilized eggs,
14	and examined the blood-vessel formation.  As you can see,

15	this represents the control with no peptide.  That is the
16	vehicle.  That is the recombinant tat.  This is the peptide
17	21 to 40, 51 to 68.  And this is the control peptide.

18		As you can see, it is very clear that these
19	peptides, just like the recombinant tat protein, promoted
20	the formation of new blood vessels as seen over here by the 
21	spoke-wheel pattern.  This is just to summarize the data,

22	but the bottom line is that these peptides turn out to be
23	having more activity that is promoting HIV replication.
24		[Slide.]
25		Again, this data was published last year in the

			276 1	Cutting Edge Section of the Journal of Immunology.  This
	2	work--a major contributor in this study was Bob Boykins and
	3	myself and the rest, the others, helped a lot, too.
	4		[Slide.]
	5		Actually, I switched the slide here.  Now it is
	6	IV-tat and anti-tat antibody potential progressive
	7	prognostic marker for HIV disease progression.  I had
	8	mentioned earlier, the tat is related to disease progression
	9	and in the seropositive, non-progressive, they are reported
10	to have a high level of anti-tat antibody.
11		Currently, the prognostic markers for inhibition
12	of clinical symptoms are CD4, interferon count, interferon
13	alpha and viral load, and so forth.  But, to identify
14	accurately the disease state of an individual, it may take
15	several months or even years.  So there is a need for a
16	rapid diagnostic test.
17		So I took advantage of the information that the
18	seropositive, non-progressive, they have high-level of

19	antibody compared to rapid progressors, and designed,
20	attempting--actually, we are attempting to design a test
21	using the synthetic peptide we talked about previously.
22		[Slide.]

23		The next slide is very preliminary data, but this
24	study, again, was done in a blinded fashion on the sample
25	that was provided by Cindy Clayberger at Johns Hopkins.  We

			277 1	tested the reactivity of the cocktail on the peptide we
	2	talked about in the previous slides and showed that the--our
	3	interpretation was, and let me point it out here--it is
	4	based on the level of anti-tat antibodies.
	5		These are clinical diagnoses.  These were the
	6	identity of individuals that were provided to me by Cindy

	7	Clayberger, undecoded samples.  As you can see over here,
	8	within reasonable agreement, we were able to accurately

	9	interpret the clinical stage of the disease although we
10	realize there are some cross-reactivities with the normal
11	specimens and also some false positives.
12		But this study was done only on thirteen samples

13	so we need to do more study on that, and so we are currently
14	working on it.
15		[Slide.]
16		Now, the HIV-tat multiple peptide, the peptide

17	missing here, peptide conjugate--now, we have designed a
18	novel synthetic immunogen to develop a potential AIDS
19	vaccine.
20		[Slide.]
21		In the earlier few slides we saw 21 to 40 and 53
22	to 68, these two peptides, they were involved in
23	pathogenesis.  We later on identified tat 9 to 20 sequences
24	from group O.  We also enhanced virus replication in
25	monocytes by threefold to fourfold.

			278 1		[Slide.]
	2		We used these synthetic peptides and designed a

	3	synthetic construct and successfully attached these three
	4	peptides on a single core, and produced a very homogeneous

	5	molecule that was 12 kiloDalton molecular weight as shown in
	6	the SDS electrophoresis to the right panel.  It was very
	7	pure and the first time we were able to prepare this
	8	molecule in the past.
	9		[Slide.]
10		This, again, just to show the physical
11	characteristics of the peptide, this MPC, we did a mass spec
12	analysis and found that the theoretical mass and observed
13	molecular mass, they were in very close agreement.  No one
14	has been able to show this correlation so far because of the
15	complexity of this molecule.
16		[Slide.]
17		This again is to show this MPC.  This is a Western
18	Blot analysis of the MPC molecule over here, and you can see
19	it ranges from 0.5 to 5.0 micrograms.  I would like to draw
20	your attention here, I used recombinant tat protein as a
21	control.
22		Now recombinant tat protein is being considered as
23	a potential candidate for the AIDS vaccine.  Can we approve
24	this molecule for a vaccine?  We can see there are multiple
25	bands here and we don't know which of the bands are

			279 1	responsible for the activity.
	2		On the other hand, our construct is a homogeneous
	3	species, close to about 12 to 13 kiloDalton, and, in spite
	4	of heavy loading, up to 5 microgram per ml as opposed to 1
	5	or 2.5 micrograms of recombinant tat protein, we didn't see
	6	anything over here.  It showed a good reactivity with
	7	polyclonal anti-tat antibody.
	8		[Slide.]
	9		We tested the ability of this peptide conjugant to
10	examine immune response.  What we did was we immunized
11	BALB/c mice at different concentrations of doses of this MPC
12	molecule.  As you can see, this induced a very high immune
13	response at all three different doses that the mice were
14	immunized with.  The antibody level was high enough to be
15	detectable up to 243,000 dilutions.
16		The bottom panel shows the effect of these
17	antibodies--by the way, this was done only in mice, so far. 
18	We are working on the other animals, especially, right now--
19	but we tested the ability of this anti-tat MPC antibody to
20	see if it can inhibit HIV replication.
21		As you can see over here, the anti-MPC antibodies,
22	when added in vitro, to in vitro culture, substantially
23	inhibited HIV replication in monocytes.
24		[Slide.]
25		This is again a pictorial demonstration of the

			280 1	cytopathic effect of the ability of anti-tat antibody on HIV
	2	pathogenesis.  This is an HIV-infected cell culture in the
	3	absence of tat; tat, as you can see, enhanced the cytopathic
	4	effect.  Inclusion of this anti-tat antibody to either of
	5	these cultures significantly reduced the cytopathic effect.
	6		[Slide.]
	7		I wish I had more time to talk about this.  That

	8	was using the laboratory strain, the BALB strain, of HIV. 
	9	The next question was how effective this could be when we
10	take the clinical isolates.
11		So what we did was we isolated viruses from cells
12	isolated from rapid progressive, late progressive and long-
13	term non-progressors and did the same experiments that we

14	did with the laboratory strain and found, very briefly, that
15	it was able to inhibit HIV replication in monocytes by these
16	clinical isolates up to 58--67 percent, actually.
17		Of course, there is some variation, but that
18	depends on the viral isolate and also the susceptibility of
19	cells to these viral isolates.  But the results were very
20	impressive.
21		[Slide.]
22		This is to show the diagrammatic representation of
23	the mechanism that I propose, how this MPC could inhibit HIV
24	pathogenesis.  HIV-infected monocytes, HIV-infected cells,
25	are shown over here.  HIV-infected cells that produce tat,

			281 1	as I mentioned earlier, it can be taken up by the cell,
	2	itself, or it can act on the adjacent cells and can produce
	3	and result in cell fusion and cause multinucleated giant-
	4	cell formation and, hence, increase viral production.
	5		We believe that the addition of anti-tat MPC
	6	antibody blocked this step.  It inhibited the cell fusion
	7	and, hence, reduced the viral production by infected cells. 
	8	This work I actually presented in July at the meeting and I
	9	got good response on that from one of the audience from my
10	talk.  He called me when I came back and he showed his
11	interest in collaborating with me.  And he is from one of
12	the primary centers in San Antonio, Texas  He has proposed a
13	collaboration to test in the primate model.
14		[Slide.]
15		In summary, basically, our study defined a role
16	for HIV tat in the regulation of immune function which I did
17	not talk about today, and in the pathogenesis of HIV
18	infection.  We have identified a functional domain of the
19	HIV tat protein that is sufficient to transactivate, induce
20	HIV replication and trigger angiogenesis.
21		Our findings provide a new approach to developing
22	potentially effective and safe subunits of HIV tat vaccine. 
23	This is important to know because this is a totally
24	synthetic construct and does not have any viral components
25	and it poses to threat to the recipient, and it can be

			282 1	produced in bulk, in a large quantity, and also in a bigger
	2	lot size for the consistency.
	3		Our preliminary results of the serum specimen
	4	performed in a blinded fashion, as I indicated, the
	5	correlation of anti-tat antibody with the actual disease

	6	stage of the patient and we are currently screening more
	7	patient samples to substantiate our findings.
	8		[Slide.]
	9		I believe this is the last one.  I would like to
10	thank you all.
11		DR. HOLLINGER:  Thank you, Dr. Dhawan.  Any
12	questions for Dr. Dhawan?  If not, I think, this ends the
13	open public meeting.  We will need to clear the room except
14	for people from the FDA and committee.
15		DR. SMALLWOOD:  This does close out our open
16	session.  We are going into closed session.
17		Thank you.
18		[Whereupon, at 4:21 p.m., the meeting was
19	adjourned.]