> DEPARTMENT OF HEALTH AND HUMAN SERVICES
>
> FOOD AND DRUG ADMINISTRATION
>
> CENTER FOR BIOLOGICS EVALUATION AND RESEARCH
>
> This transcript has not been edited or corrected, but appears as
> received from the commercial transcribing service. Accordingly the
> Food and Drug Administration makes no representation as to its
> accuracy.
>
> **BLOOD PRODUCTS ADVISORY COMMITTEE**
>
> **76th Meeting**
>
> Friday, March 14, 2003
>
> 8:00 a.m.
>
> Hilton Gaithersburg
>
> 620 Perry Parkway
>
> Gaithersburg, Maryland
>
> PARTICIPANTS
>
> Kenrad E. Nelson, M.D., Chairman
>
> Linda A. Smallwood, Ph.D. Executive Secretary
>
> MEMBERS:
>
> James R. Allen, M.D.
>
> Kenneth David, Jr., M.D.
>
> G. Michael Fitzpatrick, Ph.D.
>
> Jonathan C. Goldsmith, M.D.
>
> Harvey G. Klein, M.D.
>
> Suman Laal, Ph.D.
>
> Judy F. Lew, M.D.
>
> Paul J. Schmidt, M.D.
>
> CONSUMER REPRESENTATIVE:
>
> Robert J. Fallat, M.D.
>
> NON-VOTING INDUSTRY REPRESENTATIVE
>
> D. Michael Strong, Ph.D., BCLD (ABB)
>
> GUEST SPEAKERS:
>
> Mark Brecher, M.D.
>
> Michael P. Busch, M.D., Ph.D.
>
> Lyle R. Petersen, M.D., M.P.H.
>
> Ruby N.I. Pietersz, M.D., Ph.D.
>
> Edward Snyder, M.D.
>
> [C]{.underline} [O]{.underline} [N]{.underline} [T]{.underline}
> [E]{.underline} [N]{.underline} [T]{.underline} [S]{.underline}
>
> Committee Update:
>
> Anticoagulants, Irradiation and Freezing
>
> of Blood Components,
>
> Judy Ciaraldi, M.T., OBRR 7
>
> Bar Code Label Requirement for Human
>
> Drug Products and Blood,
>
> Richard Lewis, Ph.D., OBRR 20
>
> Open Public Hearing:
>
> Dean Elfath, M.D., Baxter Healthcare
>
> Corporation 31
>
> Open Committee Discussion:
>
> Discussion on Extension of the Storage
>
> Period for Pooled Platelets,
>
> Jaro Vostal, M.D., Ph.D., OBRR 37
>
> Clinical Performance of Pre-Storage
>
> Pooled Platelet Products,
>
> Edward Snyder, M.D., Yale University 45
>
> European Experience with Extended
>
> Storage of Platelet Pools,
>
> Ruby Pietersz, M.D., Ph.D. 96
>
> Bacterial Detection in Platelet
>
> Products, Mark Brecher, M.D.,
>
> University of North Carolina 114
>
> Open Public Hearing:
>
> Louis Katz, M.D., America\'s Blood Centers 155
>
> Kay Gregory, MS, MT, AABB 158
>
> Questions for the Committee 166
>
> Update on Particulates in Blood Bags:
>
> Introduction, Richard Lewis, Ph.D., OBRR 206
>
> Discovery, ADR Investigation, Conditions
>
> of Collections Investigation, Peter Page,
>
> M.D., ARC 211
>
> Chronology and Field Overview,
>
> Jerome Davis, Ph.D. 239
>
> Testing, FDA Findings,
>
> Betsy Poindexter, FDA 250
>
> [C]{.underline} [O]{.underline} [N]{.underline} [T]{.underline}
> [E]{.underline} [N]{.underline} [T]{.underline} [S]{.underline}
> (Continued)
>
> Industry Investigations,
>
> Steve Binion, Ph.D., Baxter 261
>
> Follow-up ADR Monitoring:
>
> Clinical Studies, Sharyn Orton,
>
> Ph.D., OBRR 275
>
> Centers for Disease Control and Georgia
>
> State Division of Public Health,
>
> Matthew Kuehnert, M.D.,CDC 284
>
> Summary, Richard Lewis, Ph.D., OBRR 294
>
> [P]{.underline} [R]{.underline} [O]{.underline} [C]{.underline}
> [E]{.underline} [E]{.underline} [D]{.underline} [I]{.underline}
> [N]{.underline} [G]{.underline} [S]{.underline}
>
> DR. SMALLWOOD: Welcome to the second day of the Blood Products
> Advisory Committee meeting. I am Linda Smallwood, the Executive
> Secretary of the Blood Products Advisory Committee. Yesterday I read
> the conflict of interest statement that applies to this meeting. If
> there are any declarations regarding conflict of interest that need to
> be made for anyone participating in this meeting, please speak at this
> time. If not, then at this time I would like to ask Catherine McComus
> to come forward and just make a brief request regarding a survey that
> is being done regarding FDA advisory committees.
>
> MS. MCCOMUS: Thank you, Dr. Smallwood. Good morning. For those of you
> that were here yesterday, I apologize for repeating my plea. For those
> of you that are new today, I will be brief and ask you for your
> assistance to complete a survey. I have extra copies, in case you
> didn\'t get one yesterday, sitting on the registration desk. It is
> called conflict of interest and FDA advisory committees. I am asking
> your assistance to fill it out in regards to your opinions and what
> you know about how the FDA monitors the real or potential conflicts of
> interest of its advisory committee members.
>
> The survey should take about 15 minutes to complete. If you have a
> chance to do it before you leave the meeting there is a box where you
> can deposit it. If you don\'t have a chance, there is a postage-paid
> envelope. You can drop it in the mail and return it. If the advisory
> committee members have misplaced the copy of their survey, I have
> extras of those too.
>
> I will be here today. If you have any questions, I would be happy to
> talk to you more about the questionnaire and the survey. Again, I
> thank you very much for your assistance. Your opinions are very
> important and they will help to increase the validity of the study.
> Thank you very much.
>
> DR. SMALLWOOD: As you may note from the agenda, we have another full
> day and we will be timing speakers so that we can try to meet our
> schedule as planned.
>
> Today we will have ten advisory committee members that are eligible to
> vote. Dr. Liana Harvath is not with us today. Also, I would like to
> let you know that there is an electronic pointer here that is very
> small, like a pin, so when you finish making your presentation do not
> put it in your pocket. We will check.
>
> \[Laughter\]
>
> At this time I would like to turn the proceedings of the meeting over
> to the Chairman, Dr. Kenrad Nelson.
>
> DR. NELSON: Thank you, Dr. Smallwood. The first item on the agenda is
> a committee update on anticoagulants, irradiation and freezing of
> blood components, by Judy Ciaraldi.
>
> **Committee Update**
>
> MS. CIARALDI: Thank you very much. Good morning, everybody.
>
> \[Slide\]
>
> Today I am going to talk about anticoagulants, irradiation and
> freezing of blood components, a problem that we recently discovered
> and I think, at least for the moment, have resolved. I am going to
> describe how this issue came to light; give you some background
> information to explain the scope of the problem; let you in on what we
> discussed to develop our current thinking and then go over our current
> thinking.
>
> \[Slide\]
>
> We identified this problem during a routine review of a licensed blood
> center\'s labels. This licensed blood center is already approved to
> collect red blood cells by automated apheresis collection, and they
> are also already approved to irradiate blood components. They are
> currently using the codabar labels and wanted to switch to ISBT-128
> labels so they sent in a whole stack of labels.
>
> Among that stack was a label for irradiated apheresis red blood cells
> in ACDA/AS3. It is our custom during label reviews to check either in
> the codabar or ISBT catalogs to ensure that the firms are using the
> correct label code for the specific product. Initially we couldn\'t
> find an ISBT label code for this particular product. Upon further
> investigation and discussion, we determined that ACDA/AS3 units had
> not been evaluated for safety and efficacy after irradiation and after
> freezing. ACDA/AS3 is a novel anticoagulant solution that is used for
> automated red blood cell collection.
>
> The outcome of the review was that we told the blood center that we
> could not approve their ISBT label for this particular product and
> that they should discontinue making irradiated red blood cells out of
> AS3 products. We also shared our concerns with the ABB standards
> committee and word spread through the blood community and there were a
> lot of concerns raised, as you can imagine. The AABB wrote a letter to
> Dr. Jesse Goodman asking for a clarification of this issue.
>
> \[Slide\]
>
> To give you a little background on what these products are used for,
> they have specific uses. Irradiated products are used to prevent graft
> versus host disease in certain transfusion patients. Frozen red blood
> cells are used to store rare cells up to ten years and they can also
> be used to create a reserve red cell inventory. Red blood cells can be
> irradiated only, frozen only or both irradiated and frozen.
>
> We are concerned about the safety and efficacy of these products
> because we know that both processes damage the red cells, making them
> more prone to hemolysis and more rapidly cleared from the circulation
> during transfusion.
>
> \[Slide\]
>
> There are six anticoagulant preservative solutions that are approved
> for manual whole blood collections. They are listed on this slide. Of
> these, none are specifically approved to undergo irradiation and only
> two are specifically approved for freezing, the CPD and the CPDA-1.
>
> \[Slide\]
>
> There are four devices cleared for automated red cell collection and
> there are four anticoagulant preservative solutions that are approved
> to be used on these machines. The CPDA-1 and the CP2D/AS-3 are
> approved to be used on the Hemanatics MCS plus LN-8150 automated red
> cell collection device. The ACD-A/AS-1 is approved to be used on the
> Baxter Amicus and Baxter ALYX devices, and the ACD-A/AS-3 is approved
> to be used on the Gambro TRIMA device, and this is the one that was
> used at that licensed blood center. Of these, none is specifically
> approved to undergo irradiation and only one is approved to undergo
> freezing, the same one that was approved for the manual whole blood
> collection.
>
> The more we dug into our files, the more we realized that this was a
> bigger issue, bigger than just novel anticoagulants and bigger than
> just the red cells collected on the automated collection devices.
>
> \[Slide\]
>
> These procedures have been in blood centers for some time. They have
> been doing these procedures for a while. To give you some thought
> about that or some information, we started approving anticoagulants
> back in 1959 with the approval of the ACD-A anticoagulant. The CPD and
> CPDA-1 anticoagulants were approved in the \'70s. In the \'80s we
> started approving anticoagulants that had additive solution for
> extended shelf life. The first one, ACD-1, was approved in 1983. In
> 1987 CPD and CPDA-1 were approved for frozen red cell storage up to
> ten years.
>
> I think the blood banks will tell you that even though I have this
> listed as 1987 for ten-year storage, the blood banks were freezing red
> cells as early as the \'70s with the anticoagulants that were approved
> at that time for product collection. That storage time was three years
> and that is all that was approved. Unfortunately, I couldn\'t find the
> specific approval date in our files. It goes back further than our
> electronic records.
>
> The first irradiator was cleared by CDRH in 1991, and in 1997 CBER
> approved or cleared the first automated red cell collection device.
> There are currently 661 facilities that irradiate blood components and
> 233 facilities that freeze red blood cells. I tried to get a number of
> how many units have been frozen and irradiated, and there are a lot,
> and that data are not readily available at this time.
>
> \[Slide\]
>
> We spent the last few months discussing this issue. The discussions
> included officials from the Office of Blood Research and Review,
> specifically the Division of Blood Applications and the Division of
> Hematology. They also include officials from the Office of Compliance
> and Biologics Quality and lawyers from the Office of Chief Counsel.
>
> We performed a risk-benefit analysis and considered the following
> issues: First, historically DBA has always reviewed irradiation as a
> process without regard to specific anticoagulants. This is a little
> before my time when we started reviewing these, but I think part of
> this was because when CDRH approved or cleared these devices the
> approval letter and the operator\'s manual did not place any
> restrictions on what anticoagulants can and cannot be used with the
> procedure.
>
> In addition, there is a medical need for irradiated products to
> prevent graft versus host disease. Right now, for transfusion
> recipients that are at risk for this, it is the only procedure or
> process that will do this.
>
> In 1993 and 1987 we published memoranda dealing with irradiation and
> freezing respectively. Neither of the memoranda mentioned any
> restrictions on anticoagulants. In fact, anticoagulants are not
> mentioned at all in the memoranda. Both processes are in wide use by
> many, many blood centers. In spite of that, we haven\'t received any
> reports of any adverse events.
>
> But we are aware that the nation\'s blood supply is currently at a
> critically low level, and we know what the impact of asking for these
> products to be withdrawn or discontinued would be and that was
> certainly included in our considerations, and we are still concerned
> about the lack of safety and efficacy studies that have been submitted
> to CDER for these products.
>
> \[Slide\]
>
> While there are no specific submission approvals sent to FDA to review
> for irradiating and the variety of anticoagulants, we do have some
> information. Safety and efficacy data on irradiated products for some
> of the anticoagulant solutions were discussed at a \'92 and \'94 BPAC
> and we have those transcripts available. We reviewed the transcripts;
> we reviewed the literature. Based on that information and the
> considerations in the previous slide, it is our current thinking that
> blood centers may continue to irradiate products collected in approved
> anticoagulant solutions. What I mean by approved is approved for
> product collection, currently approved. FDA will seek data to support
> specific licensure of irradiated products in any new anticoagulants
> that are submitted to FDA to approval.
>
> \[Slide\]
>
> We consider it appropriate for blood centers to only freeze red cells
> in anticoagulants that are approved for this use. But because of the
> lack of adverse events reported during the long time that freezing has
> been performed in blood banks, and in the best interests of
> maintaining an adequate blood supply, blood centers may continue to
> freeze products in anticoagulants that are not specifically approved
> for this use.
>
> Because we are concerned about the safety and efficacy of these
> products, we will seek data to support specific licensure of the
> anticoagulants used to prepare red blood cells, definitely on any new
> anticoagulants that come around the bend or are submitted to the FDA,
> but we would like to see if we can get some data on the ones that are
> currently approved for product collection.
>
> \[Slide\]
>
> To summarize, red blood cells are currently being irradiated and/or
> frozen under conditions not approved by FDA. We are concerned about
> the safety and efficacy of irradiated and frozen products. We are also
> concerned about the potential impact on the blood supply if we require
> these products to be withdrawn or for the manufacture of these
> products to be discontinued. Therefore, the current practices may
> continue with the anticoagulants that are approved for product red
> blood cell collection and storage.
>
> We hope to resolve our safety and efficacy concerns quickly. Some of
> the automated red cell collection device manufacturers are currently
> sponsoring studies for the anticoagulants approved for their devices
> to their products to undergo irradiation and freezing. When data are
> available we will consider publishing a guidance.
>
> To close the story on this particular blood center that brought this
> problem to light, we called them back and told them that we would
> approve their ISBT label for their product and that they could
> continue to irradiate that particular product. Needless to say, they
> were very happy to get that news. We also prepared a response to the
> AABB letter to Dr. Goodman, was sent to them on February 27.
>
> \[Slide\]
>
> On March 5th we published the contents of that letter in an
> information sheet on our CBER web site. The title of that information
> sheet is FDA current thinking on irradiating and/or freezing blood
> components collected and stored in anticoagulant/preservative
> solutions not specifically approved for such use.
>
> As I was writing this talk as well as that information sheet, it
> struck me that the more complicated the issue gets, the longer the
> titles get of our documents. Thank you very much.
>
> DR. NELSON: Thank you, Judy. Yes?
>
> DR. FITZPATRICK: Judy, just for the record, I don\'t have a financial
> conflict of interest but I represent a group that has had a license
> application in for six years and probably has the largest repository
> of frozen red blood cells of any other organization.
>
> I just wanted to clarify two things. On the first slide, indications
> for use and concerns, you say both processes damage red blood cells
> and that they are more rapidly cleared from circulation after
> transfusion. In fact, frozen red cells have to have a normal
> circulation after transfusion to be approved. So, they are not more
> rapidly cleared, although we know irradiated red cells are more
> rapidly cleared. So, I wanted to clarify that.
>
> On the question of your two current thinking slides, I just want to
> make sure that we are clear. For irradiated products any anticoagulant
> that has been approved for collection of red cells can currently be
> used to be irradiated.
>
> MS. CIARALDI: That is correct.
>
> DR. FITZPATRICK: And continue to be a licensed product.
>
> MS. CIARALDI: That is correct.
>
> DR. FITZPATRICK: For frozen blood products, your statement, although
> worded the same, means something different. You are saying that only
> CPD and CPDA-1 are currently approved for freezing. Does that mean
> that those are the only products that can be licensed products as a
> frozen product?
>
> MS. CIARALDI: It is my understanding\--I wasn\'t present at the very
> last discussion and, in fact, I think I was inspecting your
> facilities, and I hope Alan Williams will come up and fill in the gaps
> here\--the discussion centered around the need to evaluate any new
> anticoagulants that come around, and I know that wasn\'t your
> question. But we were hoping that blood centers would submit data to
> us, retrospective data on the products that are currently on the
> market, currently being frozen, and they could provide some data to
> allow us to license these products officially. Alan, could you come up
> and clear that up?
>
> DR. WILLIAMS: It is a little bit of a quandary, but the answer to the
> question is, yes, they would continue to be licensed products but we
> do seek data to review the situation and will make an additional
> determination in the future but they would be considered licensed
> products, as they have been.
>
> DR. FITZPATRICK: A product collected in AS-3 could be labeled as a
> licensed product and frozen
>
> DR. WILLIAMS: That is correct.
>
> DR. SIEGEL: Yes, I think the nuance here is that because we have
> specifically approved anticoagulants for freezing we are encouraging
> the use of the specifically approved anticoagulants, but we are not
> taking a compliance attitude toward the use of approved anticoagulants
> that are not specifically approved for freezing. We are treating it as
> a policy matter and an ongoing scientific issue but it is not
> violative.
>
> DR. FITZPATRICK: If you received a request for a new label for a
> product using a different anticoagulant, would that be held in
> abeyance for data or would that be approved at this point?
>
> DR. SIEGEL: It would be approved as long as it wasn\'t a novel
> anticoagulant.
>
> DR. FITZPATRICK: Thank you.
>
> DR. NELSON: Thank you. Yes?
>
> DR. STRONG: I just wanted to point out that I also don\'t have any
> conflict of interest. I used to wear a blue suit similar to his. But
> the Navy has had data probably dating into the \'60s. Bob Valeri had
> data on 20-year stored red cells and has done the experimental work in
> at least a variety of anticoagulants. So, if it is data that we need,
> they probably have the most of anybody in the world.
>
> DR. FITZPATRICK: Just to clarify, that license submission that we have
> been working on for almost seven years now is for licensure for 20
> years for frozen blood, and the FDA has a lot of data on that. It is
> on units collected in CPDA-1 and CPDA does not include units collected
> in other anticoagulants at this point in time. But there is a huge
> amount of data available on those two anticoagulants.
>
> DR. NELSON: The second is discussion of a bar code label requirement
> for human drug products and blood. Dr. Lewis?
>
> **Bar Code Label Requirement for Human Drug**
>
> **Products and Blood**
>
> DR. LEWIS: Thank you, Dr. Nelson. Good morning.
>
> \[Slide\]
>
> Today the FDA is publishing a proposed regulation to require bar codes
> on all drug and biological products. This is part of the Secretary\'s
> initiative to address medical errors. As you may know, Secretary
> Thompson has a long-standing interest in addressing patient safety,
> particularly in medical errors. The concept of bar coding has been
> discussed in our agency for quite some time for a number of years to
> ensure that the right drug is administered to the right patient, and
> the right dose at the right time.
>
> In reviewing the available technology, the FDA has selected bar coding
> as a technology that is here and present and that should be
> implemented if it is possible to save and prevent any medical errors.
> In the internal discussions of technology, a number of different
> technologies were discussed and the question whether a particular
> regulation should be flexible enough to allow different types of
> technology, for example radiofrequency labeling or other types of
> available technology. The thought was that bar coding is a simple
> technology; it is here today; it is in use in many arenas and the
> implementation of bar coding would encourage its use more widespread.
>
> Also, part of the discussion was if a particular bar code should have
> a specific symbology that is used. In an open public meeting there was
> quite a bit of discussion and various viewpoints were expressed on
> that. The ultimate decision for drug and biological products was that
> the UCC/EAN symbology, which is relatively common and has some
> flexibility within it, could be and should be required for product
> labels.
>
> \[Slide\]
>
> Who would be required to label products with the UCC/EAN? It would be
> all drug manufacturers, repackers, re-labelers, private label
> distributors for all drug and biological products, with the exception
> of blood and blood components. The particular bar code would be the
> NDC number for the product. Again, it would be in the UCC/EAN
> symbology.
>
> For blood and blood components within the FDA we constantly hear the
> expression that blood is different but, of course, we like to say
> blood is special and we are special in that we will not require, or we
> do not propose to require an NDC number for blood and blood
> components. However, blood is addressed in the regulation and the
> recognition of the errors that occur in transfusion and the serious
> injuries that can result.
>
> \[Slide\]
>
> Studies have shown that the most common error outside of blood banks
> is that it is administered improperly to patients although labeled
> correctly. Less common medical errors include mislabeling of samples
> that are collected for patient typing and cross-matching, as well as
> the issuance of the wrong unit or testing errors.
>
> \[Slide\]
>
> A couple of my slides have been dropped or not updated. I apologize.
> The FDA has published guidance for industry that recognizes the use of
> uniform labeling for blood and blood components, that is, the ISBT-128
> system. In this particular guidance the FDA recognizes this as an
> acceptable bar coding and labeling practice except where it is
> inconsistent with the regulations. However, despite international
> convention and this particular guidance document, there is still not a
> uniform international bar coding system for blood that is in place in
> the United States.
>
> In determining the particular component of the proposed regulation for
> blood and blood components, there was discussion of what type of
> symbology should be used. As I just mentioned, the UCC/EAN symbology
> is to be required for drugs and biological products other than blood
> and blood components. There was consideration of the ISBT-128 and
> other technologies, and the ultimate decision was that the proposed
> regulation would require that blood and blood components be labeled
> with machine-readable information.
>
> \[Slide\]
>
> Some of the other components of the particular proposal include that
> all blood establishments would be subject to the requirement that
> blood and blood components would be labeled with machine-readable
> information. That would be blood and blood components intended for
> transfusion and other products from which products for transfusion
> could be removed.
>
> \[Slide\]
>
> The information that would be included in the machine-readable format
> would be a unique facility identifier, a lot number that relates to
> the donor, a product code and the donor\'s ABO blood group and Rh
> type.
>
> \[Slide\]
>
> The proposed regulation invites comments from industry. I should point
> out that this is a 90-day comment period so in comparison to many
> proposed regulations it is brief. We would like your comments on the
> use of ISBT-128, the use of a UCC/EAN symbology like drugs and
> biologics, and the ability of particular scanners to read either
> ISBT-128, UCC/EAN codes or others.
>
> \[Slide\]
>
> Additional comments are invited on how a particular proposal might
> affect a hospital\'s decision to purchase a machine reader. This was a
> component in selecting for drugs and biologics. It was the reason for
> selecting the UCC/EAN code. It was thought that by limiting the
> particular symbology a hospital might be more prone to implement a
> system that could read one particular symbology and not a vast
> different array of different types of symbologies. So, we ask that
> same question and solicit comments from the public and the industry on
> how that particular part of the regulation might affect the
> implementation and how the particular types of bar coding might be
> compatible with other blood labels or other bar codes that appear on
> drugs, biologics and OTC components.
>
> Thank you very much for the opportunity.
>
> DR. NELSON: Thank you. Any comments? Yes?
>
> DR. DAVIS: Do you envision this being used at the bedside as a point
> of care confirmation?
>
> DR. LEWIS: No, the intention is that the hospital would use it also to
> identify patients as well as the blood component. Although the FDA
> doesn\'t regulate hospitals and the practice of transfusion, the idea
> of requiring that these particular types of labels be on blood and
> other drugs would be that if they were there, a hospital would then
> implement a system to label the patient and then be able to see, by
> computer technology, that it is the right patient and the right
> product.
>
> DR. FITZPATRICK: If the intent is to try to label multi-product and
> the patient, given the need for look-back information and all the
> tracking required by GMPs for blood transfusion identification
> parameters, wouldn\'t it be possible, without regulating transfusion
> practice, to require a method of bar coding patient identification?
> Because most of the facilities are going to say there is no
> requirement to do this; how do I convince my administration that I
> need the funding to do it? Yet, if there were a requirement to do it,
> they might be able to convince the administration to get the funding
> to do it.
>
> DR. LEWIS: That is an interesting concept. We have been told that we
> can\'t go further than we are, but if there were some way to encourage
> that\--we have had discussions with JCAHO on how some of these
> particular practices might best be implemented.
>
> DR. ALLEN: I applaud your efforts to try to address this issue using
> systems type technology and I think if we are really going to address
> the issue of a lot of preventable errors in medicine, we have to do
> that. Unfortunately, medicine and hospital administration often
> doesn\'t think that way and it is, as has been stated a minute ago, a
> relatively unregulated environment. But I think until we develop a
> unified systems approach we are not really going to be able to address
> the issue successfully.
>
> A quick question, do you have any information on whether errors are
> more likely to occur with the infusion of a blood product to a
> hospitalized patient, to an inpatient in other words, versus a person
> receiving ambulatory therapy? That may be an issue that needs to be
> addressed also in terms of the identification from a systems approach.
>
> DR. LEWIS: I am not aware of studies, although that doesn\'t mean that
> they don\'t exist. The studies that I mentioned this morning are based
> primarily on some of Jeanne Linden\'s work where she has shown that of
> transfusion errors, ABO incompatibility transfusions, about 75 percent
> of those occur at the bedside and the other 25 percent occur in
> cross-typing.
>
> DR. STRONG: I applaud your efforts as well and I think this has been
> the single biggest safety problem in transfusion since the beginning.
> If you go all the way back to the beginning, clerical errors have
> always been our biggest problem. But we do have the situation, as Mike
> points out, that the hospitals are not really ready to spend capital
> to invest in upgrading information systems to implement this. We have
> been talking about code 128 now for five to ten years, and I can tell
> you, having just reviewed the hospitals in our area, that the majority
> of them still haven\'t upgraded their laboratory systems to accept
> that symbology. So, until we have some sort of regulatory pressure to
> do it, I don\'t know that it is going to move. There are just too many
> other financial pressures on hospitals to have them invest in it.
>
> MS. GREGORY: Kay Gregory, from AABB. Mike, in answer to your question
> about regulatory authority to require bar coding, while FDA probably
> can\'t do this, I think the way to do this would be if CMS were to do
> it and make it part of a hospital\'s conditions of participation there
> would be some regulatory key to doing this. Having just read some of
> the recent changes in CMS regulations, I think they may be moving in
> this direction because they specifically address upgrading hospital
> information systems and doing things like this.
>
> DR. FITZPATRICK: Along with your efforts, providing the wrong
> prescription to the right patient is also a huge problem. So, tying
> this together with CDER and drugs is a monumental effort and an
> excellent effort because that error rate is probably higher than the
> blood error rate and will get more attention, and may get more
> emphasis for funding if it were tied to that. You might be able to
> work on both issues at the same time, and it only makes sense to
> address both issues at the same time and in the same way.
>
> DR. LEWIS: That is one of the reasons that we invite comment on the
> particular type of symbology for blood and blood components and
> whether or not machine-readers could read both the symbology required
> for drugs and biologics as well as those that will be required for
> blood and blood components.
>
> DR. SCHMIDT: There was a prospective study in Belgium about four years
> ago. What they found after the blood had left the hospital blood bank
> were 165 procedural errors for 808 patients, and 15 of them were
> major. What you had was the hospital transfusion staff who are trained
> in this, looking for errors, to go out into the rest of the hospital
> and find out what was going on. It was a prospective study.
> Unfortunately, I don\'t think that interest or approach exists in the
> organ transplantation field where there are highly interested people
> in the hospital who go out and find out what is going on.
>
> DR. SIEGEL: I just want to comment. I think that people are correctly
> recognizing that a very broad system-wide approach has to be taken
> here. There is an umbrella organization, the Agency for Health
> Research and Quality, HRQ, that is part of the Department and has the
> mandate to address the whole issue of medical errors for the entire
> system. There are initiatives in CMS but what we are simply talking
> about here is the FDA piece. You know, we deal with product
> manufacturing and labeling and what we are talking about is the
> product label.
>
> The key message that we are trying to communicate to the public here
> in soliciting comments on the proposed rule-making is that a specific
> proposal is being put forward for how to label a blood unit. It is in
> your interest to think about whether that conforms or doesn\'t conform
> to your ideal expectations for where you think you are going with a
> machine-readable code. So, that is the heart of the message.
>
> **Open Public Hearing**
>
> DR. NELSON: I guess we are into the open public hearing now. Dr. Dean
> Elfath, from Baxter Healthcare, wanted to make a presentation.
>
> DR. ELFATH: Mr. Chairman, Madam Secretary, distinguished members of
> the BPAC, thank you for allowing me to speak this morning.
>
> I am actually here to talk about an issue related to licensing for
> irradiated red cells because in our effort to design a study that will
> meet the FDA requirements to license the red cell products collected
> on the ACDA/ADSOL combination, we found out actually that the original
> scientific data does not support the current FDA guideline.
>
> The current FDA guideline states that irradiated red cells have a
> shelf life of 28 days from the date of irradiation, not to exceed the
> original date of expiration. That means that units that are irradiated
> on day one or day zero of collection, the day of collection, expire on
> day 28 of storage. If the units are irradiated on day 14, they
> actually can be on the shelf for an additional 28 days and that means
> that they expire on day 42 of collection. If the units are irradiated
> any day after the 14th day of collection, they still expire on day 42.
>
> So, I summarized the data in the literature regarding the recovery
> studies, percent recovery of red cells on the date of expiration
> available in the literature. If you look at the first table, it
> summarizes the study that was done by Dr. Moroff, Dr. Holme and Dr.
> Heaton. Dr. Heaton as well as Dr. Moroff are in the audience here this
> morning. We can see that units were irradiated on day one and recovery
> studies were done on day 28, the percent recovery, 24-hours recovery
> after infusion, was 80.2 percent. That is an acceptable recovery
> because the FDA requires recovery above 75 percent of infused red
> cells.
>
> If we look at the units that were irradiated on day 14 and recoveries
> were done on the expiration date according to the current guideline,
> we will find that they were actually 70.7 percent. That is not
> acceptable. It does not meet the FDA requirement for 75 percent
> recovery at the end of shelf life.
>
> You can look at the following tables and basically they show the same
> type of data. But if you irradiate on day 14 and do recoveries on day
> 42, you do not meet the FDA standard for 24-hour percent recovery of
> infused red cells.
>
> So, I am proposing actually that the guideline be modified to limit
> the shelf life to 28 days of collection regardless of date of
> irradiation. This proposed standard is actually supported by current
> existing data, and it is in line with the European standard for
> irradiation of red cells for adults.
>
> If we would like to add a little more flexibility to accommodate rare
> types or special clinical situations, I am proposing that the
> guideline should actually be that irradiated red cells expire on day
> 28 from the date of collection or within three days of irradiation if
> irradiation takes place after day 28 of collection. There are no data
> to support this last proposed guideline but we have an experimental
> design that will generate the data that we believe will actually
> support the last guideline.
>
> I think this issue is very important because knowing what we need to
> meet will affect the design of the experiments that we, as
> manufacturers, will put in place to meet the FDA guideline. Thank you.
>
> DR. NELSON: Thanks, Dean. Comments? Yes, Harvey?
>
> DR. KLEIN: There are some data, Dean. One of the issues is that not
> all blood is irradiated in blood centers. Sometimes a hospital, as it
> is issuing a unit of blood, irradiates it. It goes to the patient\'s
> bedside and it comes back. You may want to keep it for another day or
> two days because of the requirement to use that unit of blood,
> possibly for that very same patient.
>
> Now, in the last citation you have by Moroff, Holme, AuBuchon and
> Heaton blood irradiated at day 26 and recovery study at day 28 has a
> perfectly acceptable recovery. That is only an N of five and I agree
> that you would like to have more numbers and perhaps more days, but it
> seems like your initial proposal would restrict the use of something
> that might do more harm than good.
>
> DR. ELFATH: Actually, that is why I like the second proposal which
> allows for irradiation after day 28 of collection on the condition
> that it then expires within three days. I think we can generate data
> to support that to add more flexibility to the guideline.
>
> DR. NELSON: Any other comments? Judy?
>
> MS. LEW: Could I just ask someone at FDA to clarify if it is true that
> the data here suggest that going out to 42 days\--that there is no
> data to support going out to 42 days? Where was the original approval?
> On what data was that gotten?
>
> DR. ELFATH: Actually, I have the original document that includes the
> guideline, and they acknowledge in that memo that actually there are
> no data to support recoveries on day 42 but, yet, the guideline ended
> up being that, yes, you can keep the units for 42 days. But it is not
> supported by the available data.
>
> DR. KLEIN: Paul Schmidt may remember this, there was a point in time
> where 70 percent survival was acceptable recovery and 75 percent is
> really a very arbitrary number. At least 25 percent of the cells are
> dead within 24 hours of transfusion anyway and 65 percent better or 80
> percent better is arbitrary. So, I suspect it may have been at the
> point of 70 percent that was approved. Paul, you may remember; I
> don\'t.
>
> DR. SCHMIDT: I don\'t either but it seems like Dr. Elfath made a very
> reasonable suggestion that this committee isn\'t being asked to do
> anything about by the FDA. I think he has called it to our attention
> and we could move on.
>
> DR. NELSON: Jay?
>
> DR. SIEGEL: I think we thank Dr. Elfath for bringing this to our
> attention and we will review our policy process when we came out with
> the guidance and consider these data, some of which were known at the
> time of the decision, I might point out, but, nonetheless, we will
> reexamine the policy and its basis.
>
> DR. NELSON: Thank you. The next topic is the discussion on the
> extension of the storage period for pooled platelets. Dr. Vostal with
> introduce the topic.
>
> **Discussion on Extension of the Storage Period**
>
> **of Pooled Platelets**
>
> DR. VOSTAL: Good morning, and thank you very much for this opportunity
> to present this discussion issue.
>
> \[Slide\]
>
> What we would like to talk about is extending of the storage period
> for pooled platelets.
>
> \[Slide\]
>
> Now, in the current whole blood-derived random donor platelets, this
> slide outlines the schematic and you start off with whole blood which
> is then subjected to a soft spin to separate the red cells and the
> platelet-rich plasma. These are then separated and the platelet-rich
> plasma is subjected to a hard spin. This brings down the platelets and
> the plasma is removed. However, a small amount of plasma is left
> behind to support the storage of these platelets. These are then
> stored as single units and they are now referred to as random platelet
> units. They can be stored up to five days. At the end of storage, they
> are then pooled and they are transfused within four hours of pooling.
>
> \[Slide\]
>
> The discussion we are going to have today is whether we should pool
> right before transfusion, as is currently done, or whether it would be
> better to pool immediately after collection and then store these
> platelets as a pool. There could be some economical advantages to
> pooling up front, and that is, if you employ bacterial testing under
> the current system you end up testing each one of these units. So, you
> could end up testing five or six times prior to making this pool.
> However, if we decide to pool up front, it would be possible to
> bacterial test this pool only once and then assure its safety to the
> point of transfusion.
>
> \[Slide\]
>
> So, this seems like a relatively straightforward idea and you may
> wonder why we haven\'t actually done this before. This slide shows
> some of the concerns that we have had that have sort of hindered our
> progress towards making this change.
>
> First of all, we have always wondered whether there could be a mixed
> lymphocyte reaction between cells from different donors that could
> lead to cytokine release and some potential platelet damage.
>
> Similarly, there could be a potential for the presence of
> anti-platelet antibodies that could lead to platelet damage. There is
> also a potential for bacterial proliferation in the platelet pool if
> one of these pooled units is contaminated at collection.
>
> The idea here is that if one of these units is contaminated the
> bacteria could grow up to its limit to a volume of approximately 50
> mL, what the volume of those random donor units is. However, if you
> combine the contaminated units with five other units, you now have the
> potential for the bacteria to multiply, proliferate during storage,
> and you would end up transfusing a lot higher total amount of bacteria
> to the patient. This concern has actually been demonstrated
> experimentally so it has always been one of the major reasons why we
> haven\'t moved towards the pre-storage pooling.
>
> Finally, we have also had concerns about multiple sterile connections
> that may lead to a failed connection and product contamination. As you
> make these pools, you have to use the sterile connector a number of
> times and if one of those wells failed you could then contaminate the
> pool which would grow bacteria during the time of storage.
>
> So, why do we think that we are ready to make this change at this
> time? Well, starting at the bottom, this subject was discussed at the
> last BPAC and it was decided that the multiple sterile connections are
> safe and that we can go ahead and proceed at least with this part.
>
> For bacterial testing and bacterial contamination we now have
> detection devices that are approved, that can be validated for
> screening these units, and may be able to get around the potential for
> bacterial contamination and bacterial proliferation in these pools.
>
> For the platelet quality here, we are looking at some of the data that
> has been collected in Europe. In Europe they have been pooling for a
> number of years and they don\'t seem to have any problems. So, one of
> the things we would like to discuss is whether the data obtained in
> Europe would be appropriate for the U.S. market.
>
> \[Slide\]
>
> Our current approach to moving towards extending the storage time for
> platelet pools would be to have the bag manufacturers validate storage
> bags for ability to store platelet pools for an extended storage
> period, and to have the device manufacturers validate bacterial
> detection devices for ability to detect bacterially contaminated
> pools.
>
> \[Slide\]
>
> The process of validating storage bags to store these pools would go
> through the same process that we usually use to evaluate platelet
> storage devices, and that would be [in vitro]{.underline} studies.
> This would be testing of pooled platelets at the end of the storage
> and these tests are outlined in the draft guidance for platelet
> testing and evaluation of platelet substitutes, released in 1999.
>
> Under normal circumstances we would then move to [in vivo]{.underline}
> studies under IND protocols. These are usually radiolabeled platelet
> survival and recovery at the end of storage. However, in this
> situation it may be difficult to do the classical study because there
> are ethical issues due to random donor platelets given to healthy
> volunteers and concerns about exposure of these volunteers to multiple
> donors.
>
> \[Slide\]
>
> So, we have considered other options and that would be actually
> transfusing thrombocytopenic patients and following the outcomes of
> those transfusions. These studies could be designed several ways. One
> would be using a stable thrombocytopenic population. This population
> of patients could be transfused with the pooled products and it would
> be the four-hour pool versus an extended storage pooled product. The
> outcomes could be a measure of corrected count increments after
> transfusion.
>
> In these stable thrombocytopenic patients it may be optional to do
> radiolabeling studies where you actually radiolabel the platelet pool,
> and since these patients require transfusions anyway you could follow
> the survival of those radiolabeled platelets.
>
> If there is limited access to these stable thrombocytopenic patients,
> we have considered going to all clinical thrombocytopenic patients,
> such as bone marrow transplants and chemotherapy patients. These could
> again be transfused with pooled products and the outcome would be a
> measure of the corrected count increments. Study size would probably
> depend on expected variability to platelet transfusions in this
> patient population.
>
> \[Slide\]
>
> As to what are the appropriate controls for these platelet studies, we
> would think that the right control would be using random donor
> platelets of similar age, either five days or seven days. The control
> would be these platelets stored in FDA-cleared storage devices
> individually and then pooled for four hours prior to transfusion, as
> opposed to the test group which would be stored as a pool in new
> devices intended for extended storage of platelet pools. This would
> mean pooling shortly after collection.
>
> \[Slide\]
>
> For validation of the bacterial detection devices, this validation
> would be very similar to what we talked about last time, in December,
> when we were talking about validating these devices for releasing of
> platelet products for transfusions.
>
> We would like to see [in vitro]{.underline} studies with spiked
> samples and laboratory studies would define appropriate sampling times
> for specific bacteria. Then we would like to see field studies with
> sampling of actual platelet pools. The sampling times are defined by
> the laboratory studies, and the study design would have a sampling a
> second time at the release of platelets for transfusion or at their
> outdate to confirm the results of the first sample used for culture.
>
> \[Slide\]
>
> The laboratory studies would be designed something like this. You
> would have a platelet pool that would be spiked with a relatively low
> amount of bacteria and at some point in storage, say, after day one, a
> sample would be taken and cultured to produce a result and, at the
> same time, there would be a determination of the colony forming
> units/mL to determine how sensitive this device is. The results from
> these type of laboratory studies could then be applied to the field
> trial.
>
> \[Slide\]
>
> The design of this trial would be something like this. It would be
> sampling of actual platelet pools. You would take a sample somewhere
> at a point that was identified by the laboratory studies. You would
> get a culture result and either at the time of transfusion or at the
> end of storage or even after day six or seven you would take a second
> sample, culture that result and get a confirmation of the original
> culture.
>
> \[Slide\]
>
> Just to briefly summarize what our approach is going to be, we would
> like to see validation of platelet efficacy, and this would be [in
> vitro]{.underline} and clinical studies. Dr. Ed Snyder is going to
> talk about these this morning. We would also consider looking at the
> European experience with platelet pooling, and this data is going to
> be presented by Dr. Ruby Pietersz this morning. Finally, the issues of
> validating the bacterial detection devices, the laboratory and the
> field trials approach will be discussed by Dr. Mark Brecher. Thank you
> very much.
>
> DR. NELSON: Thank you. Comments? No? Dr. Snyder, we will keep going.
>
> **Clinical Performance of Pre-Storage**
>
> **Pooled Platelet Products**
>
> DR. SNYDER: Good morning. Thank you very much for the privilege of
> allowing me to address the panel.
>
> \[Slide\]
>
> Our laboratory has done work on platelet storage for many, many years
> and I would like to present some of the data. Initially when Jaro
> asked me to talk he said there really wasn\'t much in the literature
> but, as always, when you go looking you find a lot. So, I am going to
> try to summarize a fair amount of material quickly, and some of the
> slides actually are small because they are scanned in from the
> original manuscripts but I will walk you through them. It should be
> visible to the committee but those in the bleachers may have a little
> trouble. So, it wasn\'t that I was oblivious; it was a planned move.
>
> \[Slide\]
>
> Our conflicts of interest\--because I am going to be talking about a
> fair number of commercial aspects, it is important to restate that I
> am conflicted intensively, which perhaps is the benefit of it\--the
> Pall Corporation, Cerus Corporation, Vitex, Baxter and Terumo.
> However, I have absolutely no equity; I have no stock in any of these
> companies whatsoever, although there are paid positions for most of
> them.
>
> \[Slide\]
>
> This is \"Happy Valley,\" a slide that I actually love. I have already
> picked out my house. Unfortunately, we do not live in \"Happy Valley\"
> so we need to address a lot of the issues of reality, such as costs of
> platelet products balanced against the benefit to medical care and so
> forth. I am going to be living over here, by the way, in case you are
> wondering.
>
> \[Slide\]
>
> These are the initial issues which I think the committee should
> consider for five- to seven-day storage of pooled random donor
> platelets.
>
> One, is there reason to consider a new standard of care? I think Jaro
> pointed this out with the bacterial detection devices and that it
> opens up the opportunity to look at this again.
>
> We need to be mindful of the quality of platelets in the pool bag at
> the end of storage. We need to be mindful of the effect of multi-donor
> plasmas on platelets. We need to be concerned about the effect on [in
> vivo]{.underline} recovery and survival because, as we will talk about
> in a few seconds, all of the [in vitro]{.underline} data are
> suggestive but really the only way to determine if platelets are going
> to survive is to do a survival study and patient transfusion studies.
>
> Effects on hemostasis also need to be considered, and that is
> something that has happened with the pathogen reduction trials. There
> has been a great emphasis on actually looking at hemostatic evidence
> by looking at patients, which we never really did before we used
> corrected count increments almost exclusively.
>
> Donor-donor lymphocyte effects to so called admixed lymphocyte culture
> effects needs to be evaluated. Bacterial contamination issues will be
> covered by Dr. Brecher. The role of pre-storage universal
> leukoreduction, should this be built into the concept or not? We will
> discuss that with some data.
>
> Effect on blood inventory\--hospitals are being stretched
> dramatically. When I gave a list of the upcoming cost increases for a
> unit of blood that are planned to our administrator last week, I left
> her in a state of shock, saying that there may be more coming; I do
> not know. Blood is considered something in the hospitals today that
> should be used less, and less, and less but you are treading water
> because the price for each unit and so forth keeps going up, and up,
> and up because of all of the changes. So, I think inventory effects
> and the increase in wastage is not a trivial issue and it does relate
> directly to the public health, the ability to have a product there
> when a patient is actively bleeding.
>
> \[Slide\]
>
> I come from Yale-New Haven Hospital. That is all I have been, in
> academic blood centers, and this is what we have done over the years.
> This is till 2002. We transfuse about 43,000 blood products a year.
>
> \[Slide\]
>
> To approximately 7,200 patients a year, 7,300.
>
> \[Slide\]
>
> We have only used random donor platelets. So, this is an important
> issue for us. We do not use very many single donors, we never have.
> When Joseph Bovy was the director we had 12-unit pools and then we
> went to eight, six, five. Due to a variety of budget reductions, and
> evidence-based medicine that really were needed, we are currently at a
> four-unit pool. Next year we are planning to go to a per platelet
> basis, not units of platelets but individual thrombocytes where we
> would actually charge\--
>
> \[Laughter\]
>
> In the future we are considering the virtual platelet transfusion. We
> would just show them a picture of platelets and charge for my time.
>
> \[Laughter\]
>
> \[Slide\]
>
> This is facilitated by a product that is under evaluation\--
>
> \[Laughter\]
>
> \--the \"platelet helper.\" Just add platelets for faster clotting.
> This is my favorite flavor but it does come in a variety of other
> flavors. That is the last humorous slide.
>
> \[Slide\]
>
> Random donor platelets\--we have done our best to decrease the number
> and we use about 12,000 units of random donor platelets. We use 40
> unit pools so there are about 4,000 to 5,000 pools a year. We waste
> about 10 percent, which is close to 1,000 units a year, because we
> have to have platelets on the shelf. We are the so-called 800 lb.
> gorilla. We are expected to have platelets to give to other hospitals
> when there is need or shortage. We also have to have platelets for the
> helicopters that land on the roof, etc. For us to lose about 10
> percent or more of our platelets because we pool for the operating
> room and then it comes back from the OR unused because when things
> happen in the operating room everyone starts screaming\--you try your
> best to make sure that they don\'t over-order but it happens and it
> comes back. If we sent it out as a closed system pool and it came back
> as that pool we could put it on the shelf and reuse it. This happens
> sometimes more, sometimes less. So, there would be a very practical
> reason why a closed system pool that was safe would be of benefit to
> our institution.
>
> \[Slide\]
>
> This is single donor. This is in hundreds. This spike actually was due
> to a study we did for a corporation but we are back to about 100. Most
> of these are atrially matched products for specialized patients.
>
> \[Slide\]
>
> What about the platelet storage lesion? Well, permit me to give a
> little bit of background for some of the members of the committee that
> may not be as up to speed on this so that when you see the slides it
> will be a little easier to understand.
>
> The storage lesion refers to any untoward effects on platelet
> structure and function during the collection process and storage as
> well. The mechanism of action of this is multifactorial. Every
> organization, group and committee has their \"Holy Grail.\" Our \"Holy
> Grail\" is to try to find an [in vitro]{.underline} assay that will
> tell you what is going to happen [in vivo]{.underline}. That
> apparently just doesn\'t exist because it is so multifactorial that we
> are really not quite sure what is causing it.
>
> The bad news is that [in vitro]{.underline} assays, per se, are not
> very predictive. The good news is that when used in conjunction with
> radiolabeling and [in vivo]{.underline} post-transfusion assessments
> you can get good data. If all the [in vitro]{.underline} data you look
> at by the criteria and the radiolabeled survivals are good and the
> transfusion studies are good, then you know you have a product that
> you can license with confidence.
>
> \[Slide\]
>
> The guidance for industry that Dr. Vostal talked about came out in
> May, \'99 and I understand an update is in process. But there were
> four categories of evaluation. One was [in vitro]{.underline} using
> three categories, morphology, biochemistry and function of platelets,
> and you will see some of these in the data.
>
> [In vivo]{.underline} platelet survival in the circulation includes
> radiolabeled survival with indium or chromium, as well as
> post-transfusion corrected count increments.
>
> Clinical hemostatic efficacy is an issue, which was very important for
> pathogen reduction, that was mentioned as being important in this
> document and it was raised for consideration as to whether it is
> needed for this study, and I will give you my ideas on that.
>
> Then, evaluating platelet substitutes really related more to other
> products and is not germane to this discussion.
>
> \[Slide\]
>
> The assays that are being used\--this is taken from Scott Murphy\'s
> Transfusion Medicine Reviews. There is the metabolic group, pH, which
> is probably the one that everyone looks at the most with the concept
> of swirl which is related to when the pH drops or the platelet
> undergoes a shape change from a disc to a sphere, and when it is in a
> disc you get refraction so it looks like it is opalescent; and when it
> undergoes a shape change it rounds up and you lose this opalescence
> and it loses this so-called swirl. So, that is one issue that is
> looked at.
>
> Then, you should see changes in pO~2~ which fluctuate widely. You can
> have a very wide range in pO~2~ and still have a reasonably viable
> platelet and pCO~2~ and bicarbonate are linked together for obvious
> biochemical reasons. The platelet count is important. As you
> metabolize through the anaerobic pathway as opposed to the creb cycle
> you build up lactate. You do not want a lot of lactate because that
> lowers the pH. If you go through the creb cycle you have CO~2~ which
> can be blown off because of the fact that the bag is porous and
> glucose will be consumed as well. So, you want to see these numbers to
> be fairly low. This number low, rather, and this number high as
> compared to day one.
>
> Morphology, generally you don\'t really need to do fancy electron
> microscopy work. Then there is LDH, which is in the platelet cytosol.
> If you see a lot of LDH release it means the platelet is breaking up.
> So, you want to see a low number here. Beta-thromboglobulin is in a
> granule in the platelet. You want to see low levels of B-TG if you
> measure irradiated.
>
> CD62P is actually a marker on the granule membrane surface. When the
> platelet undergoes release that gets to the exterior of the membrane
> and it can be detected and seen under flow cytometry. So, if this
> number goes up, this number should be up as well and we have general
> guidelines for where they should be, somewhere in the 20 to 30 to 40
> percent, hopefully.
>
> Hypertonic shock response is the ability of a platelet to pump out
> water when it is exposed to water. Extent of shape change has been
> studied extensively by Holme and Murphy, Moroff and others. The
> feeling is that the shape change that occurs in response to ABP may be
> more beneficial in predicting what happens [in vivo]{.underline}. Then
> there are some other values, platelet volume, some other factor assays
> which are really not very often used.
>
> \[Slide\]
>
> Then there are more esoteric ones which are not used, EM morphology
> and aggregation, which is beloved by the FDA. We refer to that as
> platelet aggregation studies. That was from Ted Spade actually, in New
> York, who coined it for me. There are a variety of other
> glycoproteins, microparticles, things which are not usually done.
>
> \[Slide\]
>
> Several of these slides come from Kathryn Webert, who was a Fellow at
> McMaster, who presented a talk on platelet pooling at the AABB and
> graciously gave me permission to borrow some of her slides for this
> talk, and I have indicated them with her name at the top of this.
>
> This just shows the difference between the platelet-rich plasma method
> which is used in the U.S., versus a buffy coat method, and Dr. Vostal
> discussed that previously so I will skip that in the interest of time.
>
> \[Slide\]
>
> First [in vitro]{.underline} evaluations comparing pooled platelet
> random donor concentrates with unpooled.
>
> \[Slide\]
>
> This is a summary that Kathryn had. There were several studies. I am
> not going to go into great detail in all of them; I picked several of
> them, Bertolini, Moroff, Wagner and Heddle. Bertolini\'s paper looked
> at unpooled units versus pooled. She stored platelets up to 15 days.
> This just shows you the different types of protocols that have been
> used. They stored them in PBC bags and did not leukoreduce.
>
> Moroff\'s paper in \'93, pooled versus unpooled, five-day storage in
> 732 bags; was leukoreduced. Steve Wagner\'s paper, pooled versus
> unpooled up to five days; did not leukoreduce. Heddle, with an
> abstract actually, using a different type of bag did leukoreduce. So,
> it is kind of all over the map. There is no large amount of literature
> using one standardized technique.
>
> \[Slide\]
>
> This is the top of Dr. Moroff\'s paper from 1993. I just wanted to
> bring this because I was practicing scanning things and doing very
> well actually. The bottom line is these studies demonstrate that pools
> of ABO identical PCs have satisfactory [in vitro]{.underline} platelet
> properties after storage.
>
> \[Slide\]
>
> Let\'s see why he said that. What Dr. Moroff\'s group did was to take
> pools of platelets and store them in six-unit pools for five days and
> compared them with individual units that were stored for five days.
> Then he looked at eight-unit pools as well and compared them with
> individual units that were stored for five days as well.
>
> Here are the various variables. Let me just walk you through this
> briefly. The platelet counts here are six times what these are; these
> are individual units. Six times 0.83 is roughly 4.7, and the same with
> the eight-unit pools.
>
> These were not leukoreduced, as you can see. This is 1 X 10^9^. This
> is a single unit over here so this is six times the amount. pH is
> important. pH at five days for the pool was 7.12; for the individual
> units was 7.14, 7.09, 7.2. This means that at least crudely pH is not
> falling when you store pools of platelets together even without
> leukoreducing.
>
> Morphology scores, out of 400, 290 versus 292 and 263 versus 263.
> Ideally it should be compared with day zero and some studies have done
> that but it wasn\'t done in this particular study.
>
> Hypertonic shock response, 50 percent recovery is very nice; 52, 49,
> 50, 44. The standard deviations here are fairly wide because of
> biologic variability so this is perfectly acceptable clinically.
>
> Beta-thromboglobulin release, 26 percent, 27, percent, 23 percent and
> 30 percent, no problems there. LDH, this is roughly a number that is
> compatible with a very intact platelet that is not undergoing lysis
> and so forth. So, this seemed to show that there were really no
> problems here.
>
> \[Slide\]
>
> He also pooled platelets that were prepared on day three instead of
> day one. This showed the platelet count as you see here. pH was 7.24.
> These were stored for an additional two days just to see if it had a
> problem if it was pooled later, and it did not with morphology. Shock
> was fine; volume was lovely. So, there was no problem here.
>
> \[Slide\]
>
> This is the second laboratory that did essentially the same thing.
> Just let me point out a few other things. There was really nothing
> different. The six-unit pools and eight-unit pools versus single units
> stored for five days showed no significant differences.
>
> For lactate here you can see 15, 14, 14. So, that implies that the
> pooled units versus the single units were not generating more lactate
> because there was a problem. Glucose, 14, 18, 16 with appropriate
> variability there. ATP was 7.22 versus 7.28, which was lovely. The
> CO~2~ showed really nothing out of the ordinary. So, his conclusion
> was that there was no problem and I have just shown you the data.
>
> \[Slide\]
>
> Nancy looked at P-selectin. A lot of people didn\'t look at P-selectin
> because when these studies were done we didn\'t have P-selectin. It
> was called Paguin actually, but I digress. This is in Nancy\'s
> abstract. She looked at pooled versus unpooled platelet concentrates
> for generation of P-selectin\--I am sorry, CD-62, the same thing, and
> it should correlate with beta-thromboglobulin because the CD-62 and
> the P-selectin are the same protein on the membrane of the alpha
> granule; BTG is what is inside the granule. A 40 percent level of
> P-selectin is really not a problem at day five. Again, you would like
> to see a nice standard of stored/unstored. It was in an abstract so I
> don\'t have any more data than this.
>
> \[Slide\]
>
> Bertolini looked at collagen. Presumably he looked at collagen 50 mcgm
> and 10 mcgm. When platelets are stored, at least with the PRP method,
> they really don\'t like to talk to agonists. They are really not very
> happy; they get less happy as they get stored so you have to go to
> dual agonists ofttimes. This was just showing that if you stimulate
> platelets with collagen 50 mcg/mL you get about 54 percent aggregation
> with the pooled, 55 percent unpooled on the first day of storage and
> if you used a smaller amount of collagen you got smaller levels.
>
> Most of what Dr. Bertolini did was comparing his work in a
> glucose-free media with buffy coat versus platelet-rich plasma. Again,
> there wasn\'t a lot of data but I thought this was useful because it
> had collagen in it.
>
> \[Slide\]
>
> For pH Bertolini again, pooled 6.7 and unpooled. The acceptable range
> down here, from what Kathryn wrote, is 6.2 to 7.6 for platelets. I
> kind of disagree with that. Although the 6.2 is the lower level, we
> like to see something that is probably not much below 6.7 and
> certainly not much above 7.2. I think 7.6 is way too high because you
> start getting the release reaction occurring if the pH gets too
> alkaline. But here Bertolini\'s was 6.7, 7.1; Moroff, 6.96 and 7.10;
> and Heddles\'s group was 6.8 and 7.0. So, there is really no evidence
> so far that there is any problem with pooling with a variety of
> different techniques.
>
> \[Slide\]
>
> In summary of this group, the morphologies were found to be higher in
> one study. If you do enough evaluations of enough assays you are going
> to find something that is significant. But they were all within
> acceptable ranges so you get into the not clinically significant but
> statistically\--osmotic reversal was not significantly different. The
> parameters reflecting platelet activation and lysis were not
> different. [in vitro]{.underline} metabolic parameters were not
> different, and the aggregations studies were no different.
>
> So, from the evidence from [in vitro]{.underline} assays here it would
> appear that pooling platelets is not a problem, which is good news.
>
> \[Slide\]
>
> What other studies are there? Well, evaluation of pooled platelet
> concentrates using pre-storage versus post-storage white cell
> leukoreduction: the impact of filtration timing. I chose these papers
> because these were papers that looked at pooled products in addition
> to doing other things with them, which included filtration.
>
> \[Slide\]
>
> This is one of those challenging slides for the folks in the back.
> This was a group that pooled large numbers of random donor platelets
> together. Then they either filtered them immediately or they let them
> store for five days and then filtered them later. So, there was an
> early filtration pool and a late filtration pool but it was all the
> same material. They pooled and split the product and filtered one
> group before and after filtration on day one, and then on day five
> they took the other half and they filtered it and stored it for up to
> nine days.
>
> What we see here, we are comparing pre- and post-filtration, which
> basically looks at the effect of the blood filter which is not what we
> are really interested in. Looking here at day five for the early
> filtration pools, if we look at important things, pH 7.1 so there was
> really no difference in pH after five days of storage before
> filtration or day five of this pool of platelets which is I think
> about six or seven units.
>
> pCO~2~ showed a little bit of a drop, which was statistically
> significant from day one but not clinically of importance. The
> bicarbonate shows it started to drop but that is a function of storage
> time; not a function of pooling in my opinion, so I don\'t think it
> shows any difficult problem. This was pooled with a PXL-8 pool filter.
> Glucose started to be consumed a little bit, as we see during storage;
> no big change there.
>
> There was an increase in LDH but, again, 130 plus/minus 131 compared
> to 299; no change there. If you look before and after with the late
> filtration\--and I don\'t recommend that these products be filtered
> very late; I think they should be filtered up front for reasons we
> will talk about in a little bit\--this is the early filtration pool
> and the late filtration pool and what they found was pH 6.9, 6.9. So,
> even out to nine days the pHs were maintained in large pools of random
> donor platelets.
>
> The CO~2~s were not excessively high. If the platelet had died the
> CO~2~ would actually go to zero because it would diffuse out of the
> product and the oxygen would go way up to like 190, 200 because the
> bag would become basically just a place for air to move back and
> forth; there would be no metabolism going on. So, the fact that the
> CO~2~ is in a similar range, even though it is a little lower, no big
> problem.
>
> There was consumption of bicarbonate, again a storage-related problem.
> Glucose was consumed compared to day one but no big problem there
> because day five certainly looked fine, as did the bicarbonate on day
> five. Then, LDH went up a little bit, as you might expect for a
> platelet that is having its little membranes beaten up 70 times a
> minute for nine days. You would be beaten up and have your LDH up too
> if it happened to you. So, this didn\'t show any problems.
>
> \[Slide\]
>
> They looked at other things and they looked at CD62 before and after
> filtration of the pool. This is again the percent of the alpha granule
> that is on the membrane and 19 percent is lovely. Looking at day nine,
> 39 percent does not show to me any excessive platelet activation.
>
> They looked at CD63 as well, granuloficin, and that went up as well a
> little bit but, again, nothing severe. Then they looked at GPIb and
> GPIIb3a with monoclonal antibodies and there was no change in that.
> So, the platelets are showing the same thing over and over again.
>
> \[Slide\]
>
> They also looked at thrombin generation with prothrombin fragment 1
> and 2, and thrombin/anti-thrombin complexes, and there were no changes
> really during storage showing that thrombin wasn\'t being generated
> with pools.
>
> So, you are looking at all these different kinds of things and it is
> all telling you the same kind of thing, you know, not to worry until
> we hear from Mark and then maybe we will have to worry.
>
> \[Slide\]
>
> We can skip this one and the next one. Those are about the individual
> filters.
>
> \[Slide\]
>
> There was a paper from Dr. Boomgaard, from the Netherlands, pooled
> platelet concentrates and filtered with three different filters and
> stored for eight days.
>
> \[Slide\]
>
> This relates to if we want to filter these, is there any one filter
> that might be better than another. They looked at a Pall, a Sepacell
> and a Bio P10 filter. There were appropriate amounts of
> leukoreduction. They had a massive amount of platelets pooled together
> and divided them into four. Three of them were filtered and one of
> them was not filtered. So, everything was pooled. There was no
> unpooled compared to the pools.
>
> \[Slide\]
>
> Here they stored them for eight days. Here we look at pH. If you go
> across, all of the filters started off about 7.1 and they all ended
> about 6.9. So, there was no problem with pH.
>
> CO~2~s were all lovely, 59 going down to 49. pO~2~s in the 100s, very
> nice. Swirling\--this was after Fratantoni\'s scale. I am not familiar
> with that. I would assume it went up to 4 being the best because it
> dropped down to 1.8. It happened consistently and I am sure it was a
> storage-related characteristic but there would presumably be some less
> swirl but still some visible. Morphology scores, out of 400 there were
> really the standard drops. This is really what we see.
>
> \[Slide\]
>
> Filtration with a whole bunch of filters, some of which have positive
> charges and some of which have negative charges on the membrane as the
> mechanism if white cell removal didn\'t appear to affect the
> platelets.
>
> Looking at glucose levels and lactate generation, they did it sort of
> in a 1:8 nanomole consumption per day and there was really no
> difference among them compared to the unfiltered group. Adding up all
> the AM, AD and ATPs there were no differences there except for some
> drops as you would see in storage. The beta-thromboglobulin levels
> seemed to be fine over eight days.
>
> \[Slide\]
>
> They also did aggregation studies. This was with ADP and collagen, and
> all these really show\--this is light transmission so it is the amount
> of aggregation\--over time this is what you see but there was no
> difference among the various filter groups. The dotted line is the
> unfiltered control. So again everything seemed similar; no problems.
>
> \[Slide\]
>
> We can skip this, and we can skip the next one as well.
>
> \[Slide\]
>
> I asked all the companies if they had any data that they wanted me to
> present. I got this from Cerus Corporation. I show it because they are
> pooled studies. This was published in [Infusion Therapy and
> Transfusion Medicine]{.underline}, which I understand is a German
> journal. They took two units of single donor platelets and divided
> them into two. So, they pooled single donor platelets, not random
> donors, and they were treating them or not treating them with their
> S-59 device. I mention this only because the field is now also looking
> at pathogen reduction. The question is, if we adopt this, is there any
> data that pathogen reduction technologies such as are available would
> have a negative impact on the pooling process? What data is out there
> that is discussable, and this is why I am showing this.
>
> The control units did not receive S-59 and were not illuminated, which
> is part of the S-59 process, and were not incubated with a compound
> absorptive device which removes any photo product that is remaining.
> They were stored at 22 degrees and samples were taken on days two,
> five and seven.
>
> \[Slide\]
>
> So, they are looking at pooled control or treated with the S-59. The
> summary of all of these various morphologies, etc. was that there was
> really no difference. This looks like the error bars are too high. So,
> it would appear that pooling at least two units of single donor
> product with or without S-59 treatment up to seven days did not show
> any differences [in vitro]{.underline} analysis.
>
> \[Slide\]
>
> They also did a study coded as DELL-240, which is pooled random donor
> platelets. Here they took individual random donor units and they
> pooled them. Seven units were pooled and filtered, and they took out
> the red cells.
>
> \[Slide\]
>
> The random donor platelets met the criteria. They had 2 X 10^11^. The
> S-59 is added to inactivate viruses, bacteria and things that have DNA
> or RNA. It will inactivated it once ultraviolet light is shone on it.
> So, the controls were made by pooling five conventional concentrations
> and giving them four hours after pooling. In addition, an important
> point is that the pools of the product that were in the test were
> stored PAS III. PAS-III does not have glucose. It is a material that
> is used to store the platelets that has bicarbonate, phosphate
> acetate.
>
> \[Slide\]
>
> After they added the S-59 treatment it was illuminated and then they
> were stored and samples were taken on day five and seven of storage.
>
> \[Slide\]
>
> What we have is day five control, which are units of platelets that
> were pooled within four hours; they were evaluated on day five. Then
> we had treated groups that were pooled at the beginning and stored for
> five days, and also sampled on day seven. So, these were stored for
> five days, individual units; these were pooled and stored as a pool
> for five days, and a pool for seven days but treated with the S-59
> technology.
>
> The pHs, over here, essentially are statistically significantly
> different. I did not get from the corporation any p values so I will
> just give you my impression that these are lower values, and certainly
> day seven is somewhat lower, but they are above the 6.2, 6.3, 6.4
> area. Although this is getting a little low for my taste, it is still
> acceptable.
>
> CO~2~s, 51 is fine; 33 is acceptable on day five; 26 is also
> acceptable. There is a wide range in pCO~2~ and 122 is fine; 61 is
> fine; 46 is a little on the low side but 61 a day or so later.
> Bicarbonates were low. Among the reasons the bicarbonates were low is
> there is no bicarbonate in PAS-III, which is the material the
> platelets were stored in, so they were low already.
>
> \[Slide\]
>
> Platelet counts are as you see here. Morphology scores were similar.
> Extent of shape change was statistically significantly lower, I am
> sure although I don\'t have a lot of data. This seemed similar to the
> control. Hypotonic shock response, there seemed to be no problems
> across the board. ATP seems a little lower than on day seven.
>
> \[Slide\]
>
> P-selectin values were higher, which could be due to the fact that
> there was extra manipulation going on during the generation of this
> treated product, but you would have to do sham studies to validate
> that. Lactate levels here are 13 and 17, showing similar levels to the
> 16 in the control. Glucose is much lower because there is no glucose
> in PAS-III. LDH seemed somewhat higher but not excessive amounts of
> hemolysis.
>
> The conclusions I got from this are that for this particular study I
> didn\'t see anything that I would interpret with the S-59 treatment of
> a pool as showing that this was going to be a major problem, but
> obviously a lot more data are needed and this wasn\'t analyzed
> statistically.
>
> \[Slide\]
>
> What about MLCs? Well, let\'s go back and look at some data. This is
> B. Margo and Sonny Dzik. This is mitogen response of lymphocytes and
> platelets. What Sonny and Margo did was look at\--I think the next
> slide will show this a little better.
>
> \[Slide\]
>
> They took platelets that were either fresh or stored right after
> preparation, random donor platelets, or stored for three days and
> treated them with three mitogens in products that were collected in
> CPD or CPDA-2. CPDA-2 is one of the four versions of CPDA that were
> originally evaluated but two, three and four were never licensed, to
> my knowledge, and just one made it through; two, three and four went
> bye-bye. But at the time apparently it was available to them.
>
> What they did was tritiated thymidine uptakes, which I think are
> familiar to most of the members of the panel. The concern is that the
> lymphocytes in the blood bag, and this was a non-leukoreduced product,
> would be stimulated by a mitogen and would undergo blast
> transformation. If it did, it would incorporate DNA materials or
> nucleotides from the environment. If they are radiolabeled and
> incorporated, you would then see how many counts there are. What he
> found was that there are 99,000 counts on day zero with CPD; a similar
> amount with CPDA, showing that adenine really didn\'t seem to have
> much of an adverse event, but by day three the count numbers were a
> lot lower. So, he was looking at the different mitogens. Here is
> 50,000 versus 41,000; 31,000 versus 37,000. There were no differences
> between the various storage preservatives or the various mitogens.
> Comparing day zero to day three, there were statistically significant
> drops, which they concluded was because of the storage. That is, as
> white cells store in a blood product they actually become less
> responsive, less immunologically reactive, which is a good thing. We
> don\'t want them going in and blast transforming and doing nasty
> things. This was greater than 0.05 just because the numbers were
> small. It was an N of 10 and it just didn\'t quite reach it, but it
> went from 50,000 to 21,000.
>
> So, this was sort of the first shot, as Sonny often does. He often
> gets there first and has very important data to come up with to get us
> thinking, and he succeeded again this time, showing that there really
> didn\'t seem to be a lot of blast transformation concern with this
> type of a product but we don\'t put this stuff in blood bags.
>
> \[Slide\]
>
> What other data are there? Drs. Vliet, Dock and Davey looked at
> factors in the liquid portion of stored blood that inhibit the
> proliferative response in mixed lymphocyte cultures. They took units
> of blood and stored them for up to 14 days, and took the supernatants
> from either CPD or CPDA\--CPDs are ADSOL, and took the supernatants up
> to 14 days, sampled them at different times, and added them to MLCs
> from normal donors, looking to see if there was something in the
> supernatant that would inhibit an MLC reaction. Was there something
> being generated to stimulate an MLC reaction?
>
> \[Slide\]
>
> I am going to skip this and come back to it. I want to put that
> towards the end.
>
> \[Slide\]
>
> The first thing they did was to take a look at 14 days of storage,
> with any changes in the mononuclear cells in any of the antigen
> typings for CD8, CD4, CD15, and they basically found that there was no
> difference during storage. They were not looking at changes in
> lymphocytes during storage. They were the same.
>
> \[Slide\]
>
> Then what they did, again, they took normal donors. They irradiated
> one of them so it was a one-way MLC. They had eight responders and
> they took samples up to 14 days and added them to the MLCs. What you
> see here is the percentage of relative response which they state is
> the net counts per minute in the test sample divided by the net counts
> per minute in the control. So, if there was no inhibition of the
> supernatant taken from these stored blood products, you should see 100
> percent here. In black is CPDA-1 and in the grey is ADSOL.
>
> As you can see, in all of these responders there appeared to be a
> greater inhibition due to the CPDA than there was to ADSOL, but in
> none of them was there 100, except one or two. Most of them were
> fairly low.
>
> \[Slide\]
>
> This slide shows when they grouped this together by day of storage.
> Now they took all eight responders and they added all their values
> together. They did it for day zero, day 7, day 14, and day 28 of
> storage. They showed that whatever this inhibition was, it occurred
> right away at day zero, which meant that you didn\'t really have a lot
> of time to generate cytokines and things like that. So, they are
> postulating that maybe it was plasticizer from the bag. Some people
> said, well, maybe it is less calcium because you need calcium. The
> material that was added from the stored blood supernatants was
> recalcified and heated. So, it wasn\'t complement. There was calcium
> there. They didn\'t have an answer. They don\'t know what it was that
> was inhibiting it.
>
> \[Slide\]
>
> They took MLCs again. They took five of the responders and they added
> either 10 percent normal human serum and they got counts of 18,000,
> 30,000, 38,000, 53,000, 44,000, showing some variability. They added
> adenine at 0.27 mg/mL which is the amount that would be seen in an
> ADSOL unit and they did find some inhibition when they added adenine.
> So, now they are taking normal human serum and adenine and adding it
> to a one-way MLC. They are not using the supernatant of the stored
> blood anymore; they are actually adding some products.
>
> They wanted to check whether these were responsible for the fact that
> there was inhibition. They found that adenine did inhibit it somewhat,
> 24,000 versus 44,000, 37,000, 53,000, but they didn\'t find it with a
> lower amount of adenine, 0.05, or with varying amounts of dextrose, 22
> mg or 6.3 mg. There were no differences here. All they found was that
> high dose adenine seems to have an inhibitory effect on platelet MLC
> but no one has really found much in the way of MLC.
>
> \[Slide\]
>
> Going back to Dr. Moroff\'s paper, he also did MLCs. I didn\'t mention
> it before because I was holding back the good news. He did tritiated
> thymidine uptake from five-day stored pooled an unpooled platelet
> concentrates. Here are the number of units. This is the thymidine
> uptake. There is really nothing there, 267 counts for the pool. For
> the individual units, basically 160, 250. Then a positive control was
> done which had the 10,000, 20,000, 50,000 that you see.
>
> So, clearly, lots of studies from different groups\--and there is more
> to come\--haven\'t shown that there really is an MLC occurring in the
> bag, for whatever reason. We don\'t really know why it is but it
> doesn\'t appear to be a lack of calcium. It may be something that is
> due to the plasticizer. Now I think we also know that it could be due
> to storage because when you store you lose some of the cofactors that
> are required, B7 and so forth, that are necessary for antigen
> stimulation.
>
> \[Slide\]
>
> Dr. Webert concluded that comparable low levels of thymidine uptake
> were detected in the mononuclear leukocyte fraction of pooled and
> unpooled stored for five days, indicating that mixing lymphocytes in
> the pool did not stimulate [in vitro]{.underline} immunologic
> reactions. Again, these are not leukoreduced products so leukoreducing
> would add another layer of comfort. That is why I gave you my conflict
> of interest statement, I do believe that is true but you need to know
> about the conflict aspects.
>
> We will skip this because this relates to the work we did, which I
> will get to next.
>
> \[Slide\]
>
> Now [in vivo]{.underline} evaluations comparing pooled random donor
> PCs with unpooled\--
>
> \[Slide\]
>
> Here I am. Apparently the only other paper that may be in the
> literature, and I am not sure, is an abstract that Gail Rock published
> in [Transfusion]{.underline} as an abstract where she may have pooled
> random donor platelets as well. I am not sure. I couldn\'t get hold of
> her before the meeting and I am not sure from reading the abstract
> exactly if she pooled and stored them as a pool. I don\'t know. They
> may have been stored and then pooled later on. That is in the
> bibliography that I sent you, her abstract in
> [Transfusion]{.underline} last year.
>
> We did a study, and this was in 1989. We took random donor platelets.
> We pooled them in four- and five-unit pools, both ABO compatible and
> ABO incompatible. We stored them for up to five days and looked for
> changes in [in vitro]{.underline} storage. We stored them in PL-732
> bags.
>
> \[Slide\]
>
> We can skip that.
>
> \[Slide\]
>
> This is zero hours, four hours, 24 and five days. C is compatible; I
> is incompatible. We pooled As and Bs together or just Os together.
> These were non-leukoreduced products. The white counts here are 1 X
> 10^6^/mL. LDH, going from zero hours, 7.4 percent. So, we took the LDH
> in the supernatant of the platelets, spun supernatant, and we took the
> total LDH by Triton lysing the platelet-rich plasma to get the
> denominator and we expressed that as a percent so we didn\'t have to
> worry about platelet count. So, 7.4 percent versus 8.0 with the
> compatible versus incompatible pools at zero hours; 7.4, 8.1 at four
> hours; 24 hours\--there was really no lysis going on.
>
> Then we looked at beta-thromboglobulin release, 18, 19, 18, 20, 20,
> 21, 27, 25, nothing except a little minor trend due to five days of
> storage.
>
> pH, 7.3, 7.3, 7.3, 7.2. pH started to fall and these units had about 3
> X 10^11^ in the bag so we were pushing what a PL-732 bag should be.
> When we did the [in vivo]{.underline} transfusion study we changed to
> a one liter bag to get better oxygen gas exchange.
>
> CO~2~s, 26, 26, 29 and 44, no problems; the platelets were viable.
> O~2~s were a little low here at four hours, and then they stayed
> somewhat on the low side but that was probably because we had them in
> a 732 bag and it was close to bulging.
>
> Lactates showed some elevation by five days, again showing it needed a
> little more oxygen. Glucose was consumed as well over five days, but
> no difference between compatible versus incompatible. Osmotic
> recoveries went down a little but were in a good range.
>
> We also looked at C3a and saw no generation of C3a during storage.
> Complement activation wasn\'t occurring. We don\'t really measure C5a.
> We are actually measuring SC5b9 which is the footprint because the
> body doesn\'t like C5a floating around; it does mean things so it
> tends to get bound quickly. It was under the low control of the test
> kit that was used at the time.
>
> \[Slide\]
>
> We then looked at MLCs. We did a paired study where we took three
> donors and made random donor platelets from them, and then took those
> and pooled them. We then took the same three donors and took their
> platelets separately that were not made into platelet concentrates but
> just taken out of the arm, and we used that in an MLC. The MLR refers
> to the three donors whose lymphocytes were taken, were stored at 37
> degrees with NHS and treated, looking for generation of T-cell
> activation markers, versus the same three donors in a pooled platelet
> concentrate MLC, trying to say you are not getting generation of MLC
> but could it have generated MLC at all? I mean, are those lymphocytes
> able to do anything? So, this was a control for that. This is zero, 72
> and 120 hours worth of storage. There is no error bar because it was
> an N of 1. That is the problem with the study; the numbers were too
> small but we wanted to get it out and it needs to be repeated.
>
> What we found was that the pooled concentrates, again, did not
> generate IL-2 receptor, transferring receptor or HLAA DR on LEU3
> positive cells. There was really no fluorescence. But the MLR from the
> same donors that were done under conditions that were not platelet
> storage, you were able to see a generation.
>
> \[Slide\]
>
> We also did tritiated thymidine uptake under the same conditions. Here
> are the pooled which showed no uptake, as others have shown multiple
> times. We found that by day 72 you had a very strong MLR, clearly
> showing that the lymphocytes were capable but something about
> preparing a blood product inhibited that.
>
> \[Slide\]
>
> We also looked at other types of platelet conditions, a four-unit pool
> that was stored up to seven to ten days, individual units of random
> donor outdated four-unit pools. We couldn\'t find any situation where
> there was a generation of a T-cell marker in those stored products,
> just looking at them at random.
>
> \[Slide\]
>
> Lastly, the [in vivo]{.underline} study where we took platelet pools,
> pooled them at day one; stored them for up to 96 hours. Prior to that
> we went to the IRB and got approval of the IRB for informed consent,
> written consent. Five patients were transfused in the study. They were
> actually given platelets. Gram stains were done, both gram stain and
> acridine orange plus a visual inspection. Corrected count increments
> were done one to two hours and the pooled were 11,000. This was a
> crossover study so these were the same people. This was the so-called
> standard sick thrombocytopenic patient. They were patients on
> chemotherapy who were not actively on chemo. They were not bleeding.
> They did not have big spleens, etc., sort of the standard condition.
> At 12-24 hours the CCI again was better for the pooled stored. There
> were no transfusion reactions associated with this, thank heavens, and
> everybody did well.
>
> \[Slide\]
>
> The overall summary was that storing as a pool is at least equivalent
> to individual units from all of the data, again summarized by Dr.
> Webert. There is no evidence of lymphocyte activity. There is some
> evidence that pooling may result in greater numbers. She was referring
> to Dr. Wagner\'s and other\'s work which will be presented later.
> There was no difference between pooled and unpooled.
>
> \[Slide\]
>
> Issues to consider are the issues that I mentioned before. Let me give
> you my thoughts on them very briefly so you can take a break.
>
> \[Slide\]
>
> The quality of platelets in the pool bag at the end of storage is
> adequate based on published data. I believe that is correct so I think
> that that is in our favor.
>
> More [in vivo]{.underline} studies are needed, as Dr. Vostal points
> out, but I think the data out there shows that it is not a fool\'s
> errand. There is good evidence to believe that the [in
> vivo]{.underline} data will show that this is doable if we can get the
> main concern, which is bacterial contamination, under control.
>
> The effects of multi-donor plasma on platelets is of little concern.
> Remember, I used compatible and incompatible pools. We did find that
> there was clumping of little bits of a few red cells that were in the
> pools. We actually did heat elutions on them and eluted off anti-A or
> anti-AB. There was less than 1, 2 drop in antibody titer. I don\'t
> think it is a big problem. I am not saying you should pool and store
> ABO incompatible. I don\'t think it should be done, and we didn\'t
> transfuse ABO incompatible pools but I don\'t think there are any big
> problems but I wouldn\'t recommend it anyway.
>
> The donor lymphocyte effects are not a problem. There apparently is no
> bag MLC. Buffy coat pooling in Europe I believe is supportive of the
> process and I don\'t feel we need to have extensive hemostatic
> evaluations which require hiring large numbers of research nurses to
> go to the floor and extend these studies out a year or two. That is my
> opinion.
>
> \[Slide\]
>
> Leukoreduction is beneficial. I realize there is not a lot of MLC but
> I would recommend if we are going to store pools leukoreduction should
> be used. That is my personal opinion, without any of the conflicts,
> because I think it just gives you an extra level of safety for storing
> a pool.
>
> \[Slide\]
>
> [In vitro]{.underline} patient transfusion data are needed.
> Radiolabeled normal volunteer donor studies are unethical. You can\'t
> transfuse a pool into an individual. I tried to think of a good way
> you could do it, maybe if they are identical twins but then it is the
> same platelets. I gave up. You just need to do patient transfusions.
>
> Bacterial issues will be addressed. Some pathogen reduction
> technologies appear compatible; others need to be evaluated. A partial
> extension is better than none. If you give us 72 hours of storage,
> that is okay, but don\'t give us eight hours because an eight-hour
> extension doesn\'t do anything because we can\'t get the bacterial
> testing back and eight hours is nothing. So, if the concern is that
> five or seven days is more than you want to do now, three days would
> be all right as well from my perspective, just from my perspective,
> and the public health needs would be served because we could reuse
> those pools and we wouldn\'t waste it and there would be more for the
> patient.
>
> \[Slide\]
>
> I will stop there and answer any questions if you have them.
>
> DR. NELSON: That was a rather large amount of data to digest, but
> interesting. Yes?
>
> DR. SCHMIDT: The question of room temperature storage I think has been
> taken care of\--you know, what is room temperature. It was a mess at
> the beginning. We found out that cold is bad and I think room
> temperature has finally been decided at 20 plus or minus 2.
>
> Just going through some of the material presented to us while you were
> talking, sometimes they don\'t say what the room temperature is. We
> had to buy little pieces of apparatus which made a room inside a room
> but, anyway, maybe our next speaker would tell us for certain that
> room temperature in Sweden, where a lot of these studies were done,
> relates to this because I presume it has been stabilized but it was a
> mess at one time.
>
> DR. SNYDER: The studies that were done at our institution, certainly
> because we were AABB accredited at the time they were done, we
> monitored the temperature of storage and they were 20-24 degrees. Most
> of the studies actually did state the temperatures and nothing popped
> out that they stored it in the cold or 17 degrees. I think everybody
> did the right temperature.
>
> DR. SCHMIDT: The document from the FDA that we got says U.S. holds at
> room temperature. It doesn\'t give the temperature.
>
> DR. SNYDER: Right.
>
> DR. GOLDING: Just a few immunological comments. I think your own data
> actually solves the mystery of why you don\'t get an MLC in the bag
> which was stored at room temperature, and the solution to that mystery
> is probably the temperature. When you do the same cultures at 37
> degrees you get very nice MLC reactions.
>
> The other point I would make related to that is that if you add
> calcium in the presence of the right temperature you would also get a
> good mixed lymphocyte reaction.
>
> But apart from that, I think there is a concern here and the concern
> is, sure, the leukoreduction removes intact white cells, not all of
> them and you still have some white cells. My question is how many
> white cell membranes remain in the prep. and what is getting into the
> patient, not what is happening in the bag, and in the case of pooled
> samples could that still be a problem in terms of getting an
> allogeneic response?
>
> DR. SNYDER: That is a valid point. It is one of the reasons why I
> personally prefer pre-storage because you have less microparticle
> formation by getting it out early rather than filtering it later. You
> still have some; I don\'t deny that. Your points are well taken. I
> don\'t have good answers, but I think studies need to be done to take
> a look at that.
>
> DR. KLEIN: I may have missed something here. Ordinarily you are
> pooling them in the recipient so really what we are worrying about is
> what is happening during the course of storage. I didn\'t see any data
> or hear any data to suggest that there is something nefarious
> happening in the period of storage regarding MLCs, unless I missed
> something here. So, I am not quite sure what the issue is in terms of
> what is going into the recipient. All those white cells go into the
> recipient anyway whether you pool them at the beginning of storage or
> whether you pool them at the end of storage.
>
> DR. SNYDER: You are right. It is a bit of a complex issue. I guess the
> concept would be that if there is an inhibition [in vitro]{.underline}
> maybe you are releasing it during transfusion and you are getting a
> donor-donor reaction inside the patient as a vessel.
>
> The other issue to bring to bear on this is one that many of the
> products given to patients with oncologic disorders are irradiated so
> that you are inhibiting it from there, whatever is left.
>
> The second thing is, and maybe Dr. Pietersz will speak to the issue
> because they have a lot of pooled buffy coats that have been used in
> Europe, tons, and I haven\'t seen tons of abstracts coming out about
> MLC reactions sweeping the European continent. So, hopefully, there is
> some information on buffy coats that will be brought to bear on this.
>
> DR. LEW: I noticed that in some of the studies there was a lot of
> variation of what was considered statistically significant. I don\'t
> know if it is just because the numbers are so large, but it varied
> from a p of 0.05, the standard, to 0.01. If you could just clarify
> that because I am wondering if it was always 0.05 and everything
> looked statistically significant so you just had to back off.
>
> DR. SNYDER: It depended on the investigator. There really was no
> standard approach. Nancy Heddle used 0.1, others used it as well. Your
> point is well taken. There is not a lot of standardization so I can\'t
> comment any further on that, but you are correct.
>
> DR. FITZPATRICK: Dr. Snyder, thanks. That is a great review of the
> parameters. I was hopeful that I would see more about the effects of
> hemostasis because what we saw was essentially survival and
> circulation and, to me, that is not really hemostasis. That is
> survival and circulation. That has been a problem with platelets
> forever, how do we show that they are effective when they circulate?
> We really don\'t have a good measure of that that is repeatable,
> doable. I would be happy to hear it if you can come up with something
> that would be more beneficial.
>
> DR. SNYDER: I don\'t. Your point is extremely well taken. Somebody may
> say the word \"bleeding time\" but it wouldn\'t be me. I think the
> feeling of the committee and the field is that we need to do
> hemostatic efficacy and then you need to really trot out the World
> Health Organization evaluation and do a full-scale evaluation of this.
> Hopefully, we could generate enough data with buffy coat from Europe
> that we may not need to do this, although it may be apples and apple
> sauce; it may not be exactly the same but similar. I would leave this
> to the group to discuss, but your point is well taken. There were no
> hemostatic data. All of this was done at a time when bleeding times
> and CCIs were fine, \"Happy Valley,\" but we are not there anymore.
> So, your point is correct.
>
> DR. GOLDSMITH: You talked about decreased wastage post-pooling, that
> these platelet packs could be returned from the OR. Could you comment
> on the storage of the platelet packs in the OR, what impact that might
> have on the viability of the platelets?
>
> DR. SNYDER: I could. It is a problem when platelets go out. We would
> not allow them to come back the next morning. We would have to think
> of a new paradigm. If we gave out a platelet pool we would have to
> track that. Most likely it would go out with some form of temperature
> monitor or in some type of a container so we could have a little
> comfort level. We would have to in-service the physicians and nurses
> that this was not something\--although some people probably hand out
> units of random donor platelets that are not pooled and they let them
> pool them at the point of care, we don\'t do that. Those come back as
> well. The same thing would apply to red cells. You would just have to
> make sure that the quality systems were in place in the operating
> room. But your point is extremely well taken. You would also have to
> be sure that it wasn\'t entered in some fashion and came back. But
> those are all concerns that I would love to address if we had a chance
> to have that type of a product.
>
> DR. SCHMIDT: I have some questions of Dr. Vostal. Are we going back to
> that?
>
> DR. NELSON: Is it a question? I mean, we are going to continue
> discussion. Final comment?
>
> DR. ALLEN: Just a question with regard to the filtration. At the
> present time we have an infusion period within four hours. Is it
> normally done at the time of pooling? You pool and then run it through
> the filter and then release it within a few hours?
>
> DR. SNYDER: Before I answer that let me say that it is not filtration
> per se; it is leukoreduction. So, process leukoreduction should be, in
> my perspective, as good as filtration leukoreduction. That having been
> said, it depends. Yale is 100 percent leukoreduced so if we pool it
> has already been leukoreduced. Others may want to leukoreduce in the
> lab, may leukoreduce as a pool because it is less expensive to use one
> filter than to have to use three or four if you are pooling three or
> four units. So, it depends on the facility and what their practices
> are.
>
> DR. ALLEN: If the storage period for pooled platelet packs were to be
> extended to, let\'s say, your proposed 72 hours, you would expect that
> the leukoreduction filtration might be done at the time of initial
> pooling or just pre release?
>
> DR. SNYDER: I personally would recommend leukoreduction at the time of
> preparation up front. I wasn\'t recommending 72; I said at least 72. I
> think five or seven would be okay as well. But I would not recommend
> post-storage leukoreduction. I think your best benefit, from the
> comments that were made by the gentleman before, is that pre-storage
> is best because it prevents cytokine generation; it prevents
> microparticles, etc.
>
> DR. ALLEN: Thank you.
>
> DR. NELSON: I think we have already discussed that in a previous BPAC
> meeting.
>
> DR. SIEGEL: Yes, we actually have published a draft guidance on
> leukocyte reduction. We encourage routine leukocyte reduction but
> cannot mandate it without rule-making. Be that as it may, for labeling
> products that are leukocyte reduced we strongly encourage pre-storage
> leukocyte reduction for the reasons that are being reviewed.
>
> DR. NELSON: Let\'s take a half hour break, until eleven o\'clock.
>
> \[Brief recess\]
>
> DR. NELSON: Back to platelets. Next discussion is by Dr. Pietersz to
> present the European experience with extended storage of platelet
> pools.
>
> **European Experience with Extended**
>
> **Storage of Platelet Pools**
>
> DR. PIETERSZ: Mr. Chairman, Madam Secretary, members of the Committee,
> I want to thank you for your invitation to be here and to share with
> you some data on buffy coat platelets. It is a special pleasure
> because the godfather of the buffy coat was Peter Prinz and later Hans
> Lowells from the Netherlands, and also Klaus Hoekmann from Sweden has
> been working a lot with the buffy coat development.
>
> I want to share with you the names of my collaborators in this huge
> investigation we did, Peter van der Meer is a post-doc. senior
> scientist. He did a lot of work on the [in vitro]{.underline} studies
> of the buffy coat platelets. Margrit Dijkstra is a Ph.D. student and
> Hank Reesink, as many of you know, is our driver or research in the
> Blood Bank of Amsterdam.
>
> \[Slide\]
>
> The Netherlands is a small spot on the map of Europe, and since \'98
> we have had a national foundation of the blood supply, named Sanquin.
> We have 60 million inhabitants and from February, 2002 we have had
> four blood bank regions and we have less than one million donations,
> 50,000 whole blood and 125,000 plasma apheresis. From these, 250,000
> are used for random platelets and only five to ten percent of the
> 250,000 are apheresis platelets.
>
> At this moment we have nine product sites but we will reduce that to
> four before 2004. We have four test labs including NAT testing and at
> this moment we still have 13 distribution sites because the traffic is
> very high.
>
> \[Slide\]
>
> Sanquin has national requirements and I have listed a few of them
> here. We have bacterial screening of all platelet concentrates or
> products from November, 2001. We have universal leukoreduction of
> cellular products from January, 2002. Sanquin also decided to have
> leukoreduced plasma and we have been collecting it since July 2002,
> and it should be issued as donor re-tested from April, 2003. There is
> a blood component guideline and I am the chairman of this committee.
> In January, 2003 we had the sixth edition.
>
> \[Slide\]
>
> We have component preparation. In the whole of the Netherlands we
> collect 500 mL of whole blood, plus/mins 50 mL. Our maximum collection
> time for platelet preparation is 12 minutes. We cool the whole blood
> within two hours with cooling elements to approximately 22 degrees C.
> and then we store it at ambient temperature. Ambient temperature is
> defined as 18-25 degrees. You can make the separation of whole blood
> within four hours of collection, but usually we store it overnight for
> 12-22 hours.
>
> Next, whole blood is given a hard spin centrifugation, about 30,000 g
> minutes. Then we have separation into plasma, buffy coat and red
> cells, and the red cells are suspended in SAGM solution, comparable
> with ADSOL, and we filter the red cells with an integrated filter.
>
> \[Slide\]
>
> For the separation we use automated equipment and we have programmed
> this equipment to have specific buffy coat specifications. The volume
> should be 50 mL, plus/minus 5 mL, a hematocrit of approximately 0.40.
> If we make platelets from them, we should have at least 75 X 10^9^
> platelets in the buffy coat.
>
> \[Slide\]
>
> For the buffy coat pooled preparation, we use five ABO identical buffy
> coats and one plasma, or you could use platelet additive solution. In
> many Scandinavian countries they use additive solution, and we have
> used plasma and later solution but now we are back on plasma.
>
> We use an integrated set bag system and then we register all the
> units, the original donation units, in a computer and link it to a
> pool number for traceability. It is very important that the whole set
> should be connected. Then we register in a computer.
>
> Then we transfer the content of the buffy coats into a pool bag. We
> add the plasma and give the whole pool bag a soft spin centrifugation
> and, again using automated equipment, we express the platelet-rich
> plasma through a leukoreduction filter into storage bags.
>
> \[Slide\]
>
> I will now show you this handling in pictures. Here you see an
> integrated set. This set is from Terumo. The set has six leads, pig
> tails, to which buffy coats can be connected with sterile connection
> and also the plasma. Then you have the pull-back here. The pull-back
> is connected to a leukoreduction filter and this is, again, connected
> to a platelet storage bag and we have a small sample bag and this has
> a special adaptor for later bacterial culturing.
>
> \[Slide\]
>
> We make the sterile connections so all the leads are checked. When the
> sterile connection is made we check all the connections.
>
> \[Slide\]
>
> Then the content of the buffy coat is just drained by gravity into the
> pool bag and also the plasma.
>
> \[Slide\]
>
> After soft spin centrifugation we have the centrifuge back on the
> automate. It is Compomat G4 from Cerus. We express the platelet plasma
> through the leukoreduction filter into the platelet storage bag, which
> is up here. Finally, we let the content of the filter drain into the
> platelet storage bag because most platelets are in the last
> milliliters of plasma so we want to harvest these as well.
>
> \[Slide\]
>
> You can see here that this automate helps us in timing of closing the
> tubing because if it sees the red cells, as you can see here, the
> sealing is closed and then the expression is terminated.
>
> \[Slide\]
>
> Here you see a platelet pool. It is labeled with ISBT code 128. We
> have had this bar coding already since \'98.
>
> \[Slide\]
>
> The platelet pools are stored on a horizontal agitator in a climate
> cabinet of 22-24 degrees for seven days.
>
> \[Slide\]
>
> Some advice for buffy coat pool are that the volume of the pool bag is
> of importance. The content is about 550 mL. So, you have a pretty
> filled bag. The hematocrit of the pool is about 0.2. Depending on the
> viscosity, you either have buffy coats in plasma or buffy coats in
> solution. So, that is a big difference. You centrifuge at about 1,000
> g. For us, we have a requirement that the yield of platelets following
> filtration, as you always lose some platelets at filtration, should be
> higher than 80 percent.
>
> \[Slide\]
>
> These are quality control data of 2001. We have made over 10,000
> pools, about 70 200 pools per working day, four working days per week.
> You see that the volume is approximately 312 mL and the requirements
> are 150-400 mL. For platelets we have a minimum requirement of 250,
> and you can see that the number of platelets, even without the 25 mL
> sample that we have taken off, is 364. Leukocyte counts should be
> below one million and you can see that it is far lower than that.
>
> The pH is measured at the day after expiry, on day eight. This is the
> quality control and you see here that the pH measured at 37 degrees is
> still very acceptable.
>
> \[Slide\]
>
> Here you see some differences between buffy coat pools made in plasma
> compared to buffy coat pools made in PAS-II. For about a year and a
> half we have used plasma and then we went back to PAS-II and we are
> now again on plasma. We like to switch sometimes. But you can see that
> the yield of platelets in the plasma pools is higher than in the
> PAS-II. You can also see that the number of pools having platelet
> number lower than 240 is very low. Over 99 percent contains more than
> 250 X 10^9^ platelets. For leukoreduction it doesn\'t matter whether
> you have plasma or PAS-II as the storage medium.
>
> \[Slide\]
>
> Anderson showed that the yield of platelets in buffy coats is slightly
> higher than from PLP and almost equivalent to an apheresis unit, just
> to show you differences.
>
> \[Slide\]
>
> Now I would like to discuss storage with you. Dr. Snyder already
> showed that the pH is very important for platelet storage. If you
> compare the pH and the platelet morphology, at pH 7.4 platelets will
> have disc-like morphology. They are happy platelets. At about 6.8 you
> will have spheres but this is still reversible to discs. In the
> Netherlands we have decided that for our requirements platelet
> concentrates should have at the end of storage a pH between 6.8 and
> 7.4 measured at 37 degrees. There is a difference between 22 and 37
> degrees but we have this requirement. Of course, you can go lower with
> the pH but then you will have balloon formation. The morphology will
> sort of resemble a balloon. This is not reversible anymore so these
> platelets are already not happy. If the pH is even lower they will
> die.
>
> \[Slide\]
>
> The drop in pH is caused by CO~2~ formation if enough oxygen is
> present, and without oxygen you will have lactic acid formation and
> the pH will drop even more quickly. For storage of pools it is very
> important what kind of storage medium you have because if the storage
> medium has a buffer capacity, then you will have a slower drop in pH.
> For instance, plasma has a high buffer capacity. Additive solution
> does not have a buffer capacity. The platelet concentration is very
> important, the number of leukocytes and, of course, the gas
> permeability of the container and the breathing surface is very
> important. I will now show you some examples.
>
> \[Slide\]
>
> Peter van der Meer did an experiment where he made a large pool of
> buffy coat platelets in additive solution. These are containers of
> various sizes and also of various materials. Here is 1.3 mL PL2410
> bag, Polyolefin bags 1.0 L and 1.5 L, 1.5 L CLX bag and a 1.0 L bag of
> DnDP-PVC. You see that during the storage for nine days almost all
> bags were appropriate in considering the pH. Only one bag had a quick
> drop in pH after day five. This is the swirling effect. We have a
> swirling score from 1-3 so 3 is the best swirling score and 1 is the
> score where we consider the platelets not healthy anymore.
>
> \[Slide\]
>
> You see the same picture and the pH. This one bag showed a big drop in
> pH and you see here that at 6.8 the line is crossed at about
> five-something days.
>
> From these experiments we concluded that it is very important to
> validate the size and the type of container you store the platelets in
> if they are stored as a pool. But there are many bags that are very
> acceptable to store the pooled platelets in.
>
> \[Slide\]
>
> Another thing that is of great importance is the concentration of the
> platelets. Peter van de Meer took all the data we had. The yellow ones
> are the platelet concentrates in plasma stored as a pool. The blue
> ones are platelet concentrates stored in PAS-II. You can see that
> where this line is crossing the 6.8 pH line the concentration is about
> 1.4, or somewhat higher.
>
> So, the conclusion is that you can easily store platelet concentrates
> at a concentration between 0.8 and 1.4 in all the bags I just showed,
> whereas for additive solution it is very important that the
> concentration of platelets is much lower, only 1.1. If you store as a
> pool it is very important that your storage medium equals these
> concentrations, otherwise, if you have higher concentrations you will
> more easily have a drop in pH.
>
> \[Slide\]
>
> I would like to switch now to some results of our bacterial screening.
> It was conducted as of November 1 but we started already in June,
> 2001. I show some of the results of one year follow-up of the
> components involved in the screening of leukoreduced platelet
> concentrates stored in plasma for up to seven days.
>
> \[Slide\]
>
> You saw the adaptor on the sample bag. We inoculate aerobic and
> anaerobic culture bottle from BacT/Alert from Biomerieux equipment. It
> is very easily done. With the special adaptor you can very elegantly
> fill the bottles in an air flow cabinet, and we collect in each bottle
> 10 mL. Here it is marked how many milliliters are collected in a
> bottle so it is very easy, and we have a sample of 10 mL. So, our
> total sample from the pool of platelets is 25 mL that we use for
> culturing and QC data.
>
> \[Slide\]
>
> We incubate the bottles in BacT/Alert for seven days or until a
> positive signal comes up. The positive signal is given by CO~2~
> development. The whole system is linked to a computer so if a positive
> signal comes up, then the monitor will flash and you will know exactly
> which bottle is positive. If that happens, we have confirmation of the
> bottles in a microbiology lab and I think it is very important for
> discussion that our definition of confirmation is that bacteria is
> growing in the culture bottle.
>
> \[Slide\]
>
> In the meantime, the issue of leukoreduced platelet concentrates is
> negative to date so we always check in the computer whether the
> concentrate has a negative signal. If the signal is positive, of
> course we block the pool and also the respective red cells in the
> center. Because our hospitals have their own inventories of platelet
> concentrates, we also notify the hospitals and they also block the
> pools in inventory and eventually the red cell concentrates. All the
> blocked components are recalled, and if there has already been a
> transfusion we have a request for information about the transfusion.
>
> \[Slide\]
>
> We cultured about 9000 platelet concentrates. In 81 cases we had a
> positive signal and there was no confirmation in the culture bottles
> in five cases, whereas we found bacteria in 76. So, we had a positive
> rate in the pools of 0.9 percent and when we looked at the positive
> ones during the months we saw a slight variation and especially, for
> the Netherlands, in warm months of July and August we saw a higher
> incidence of positive signals.
>
> \[Slide\]
>
> These are the detected bacteria. Most of them are skin bacteria,
> except for this one. What was of interest is that, for example, the
> Bacillus species grew within 24 hours. So, about 50 percent of the
> bacteria grew within 24 hours of inoculation, whereas the Propioni was
> growing late, after four to five days of inoculation.
>
> \[Slide\]
>
> From about 9000 platelet pools, 81 gave a positive signal and 76 were
> confirmed positive in the culture bottles. Predominantly skin flora
> was cultured and about 50 percent of the cultures became positive
> within 24 hours of inoculation, whereas the other 50 percent after
> four to five days of incubation. Most of these contained Propioni and
> we had no septic episodes mentioned by the hospitals.
>
> \[Slide\]
>
> I would like to share with you now some data of our clinical
> investigation of the five to seven day stored platelet pools. We
> included outpatients with hemato-oncological diseases. Exclusion
> criteria were serious bleeding, WHO grade 3 or 4. So, bleeding that
> required transfusion of red cells. The pre-transfusion counts should
> be lower than 20 X 10^9^/L. So an exclusion criterion were platelet
> counts higher than that, and refractoriness defined as two consecutive
> unsuccessful transfusions.
>
> \[Slide\]
>
> We calculated the count increments and corrected count increments.
>
> \[Slide\]
>
> We found that the data showed that 341 out of 349 transfusions of
> platelets of all storage data were successful. If a successful
> transfusion was defined as CI higher than 10 or a CCI higher than 7.5
> we found 95 percent successful transfusions. If we compared the
> five-day old and the seven-day old platelets, you can see here that
> there was no difference in unsuccessful transfusions.
>
> \[Slide\]
>
> If we compared the transfusions given to the same patient and then
> five-day old or seven-day old, you can see here that there is a
> difference in count increment. The seven-day old was slightly lower
> than the five-day old platelets but, as yet, we don\'t know what kind
> of difference is acceptable. If you say that a 20 percent difference
> is acceptable because, of course, older platelets will have lower
> increments, then this is still an acceptable difference.
>
> \[Slide\]
>
> When you calculated the corrected count increment and also took the
> transfusions given to the same patient of five- and seven-day old
> stored platelets, we had no difference but the power was only 31
> percent. So, we concluded that we need more data.
>
> \[Slide\]
>
> We concluded from this clinical study that is still going on that 95
> percent of the transfusions were successful for corrected increment
> and the CCI; that transfusion of leukoreduced platelets five- and
> seven-day old in the same patient had slightly lower CIs but that much
> more data are required in each arm for confident proof.
>
> \[Slide\]
>
> My final conclusions are that leukoreduced platelet pools can reliably
> be produced from buffy coats and integrated systems. I think that for
> sterility it is important that you have an integrated system. If you
> decide to pool PRP platelets, I think you can easily use the same
> system.
>
> [In vitro]{.underline} data are sufficient. Dr. Snyder also showed a
> lot of data and from Europe we also have other data but I could not
> show you all of it to allow seven-day storage in appropriate storage
> bags. So, validation of the storage bags is very important. Clinical
> evaluation of these buffy coat platelets show 95 percent sufficient
> increments of seven-day old platelets. Bacterial screening of all PC
> is feasible. It does not prolong the issuing of the platelets, and we
> found 0.9 percent of our pools positive but, again, this is the
> culture bottles that gave the confirmation and I do not know what the
> next speaker will say about that. Fifty percent was positive within 24
> hours so most of these pools could be tackled within the blood center.
> Thank you for your attention.
>
> DR. NELSON: Thanks, Dr. Pietersz for nice data. Questions? Were you
> able to interdict the platelet pools that had growth within 24 hours?
> It seemed like that would be feasible.
>
> DR. PIETERSZ: Yes, they were still in the blood center.
>
> DR. NELSON: So there were no adverse events from those positive
> cultures?
>
> DR. PIETERSZ: No, and we think, but maybe the next speaker will
> explain that in more detail, that those were the most dangerous
> bacteria.
>
> DR. NELSON: So, in those where there was delayed growth you showed no
> febrile reactions or adverse events in the recipients? Is that
> correct?
>
> DR. PIETERSZ: We did not have any records of septic episodes.
>
> DR. LEW: I think when I was looking at the literature they suggested
> that typically only one bag in, I think, a thousand or so is usually
> infected, and your data showed almost one percent or one in one
> hundred. Do you believe it is because you pooled first and then
> tested? Also, it sounded like the bug that most often grew is a slow
> grower. Is that responsible for the 50 percent rate on day four and
> five versus the idea that you did a dilution so it took more days to
> grow?
>
> DR. PIETERSZ: I think what is important is the definition of the
> confirmation. We had a meeting in Dublin last week, and if you say
> that you take a sample from the pool, you inoculate that in culture
> bottles, and if you would say that confirmation is repeat culture from
> the same sample, then we only had like 0.009 positives. But we defined
> confirmation as growth of bacteria in a culture bottle. So, that might
> be a difference in definitions because otherwise we would also have an
> incidence of 1/1,000, or even less.
>
> DR. NELSON: Thank you. Next is Dr. Mark Brecher, from University of
> North Carolina, bacterial detection in platelet products.
>
> **Bacterial Detection in Platelet Products**
>
> DR. BRECHER: Thank you. It is a pleasure to be here and I welcome the
> chance to talk about one of my favorite subjects, bacteria.
>
> \[Slide\]
>
> Similar to Dr. Snyder, in the interest of full disclosure I just want
> to say that I receive research support and am a consultant for certain
> advisory panels for a variety of companies, including Biomerieux,
> Pall, Baxter, and several others. If they don\'t support my research,
> please see me after this meeting.
>
> \[Laughter\]
>
> \[Slide\]
>
> What I wanted to do was to give a general overview of the whole
> question of bacterial detection, and I think we need to put this into
> some perspective. The rate of bacterial contamination is about 1/1,000
> to 1/2,000 bags that are bacterially contaminated. When we talk about
> the various viruses, we have done a wonderful job over the years of
> bringing down the risk of HIV from about one percent to about one in
> two million. HCV in the early to mid-\'80s was about half a percent,
> and it is down to about one in one and a half million and hepatitis B.
> But, clearly, the risk of bacterial contamination of platelets is
> orders of magnitude greater than the risk of viral transmission.
>
> \[Slide\]
>
> Looking over the literature, I tried to figure out exactly how big a
> problem we are really dealing with and I keyed in on the United
> States. In the United States there are roughly four million platelet
> bags transfused per year. That is, one million single donor apheresis
> packs and three million random donor platelets made from whole blood
> concentrates. So, approximately three-quarters of the doses that we
> are handing out are apheresis platelets and 25 percent are pools of
> random platelets.
>
> Now, if there are 1/1,000 to 1/2,000 bacterially contaminated bags,
> that means that every year we are handing out 2,000 to 4,000
> contaminated bags of platelets. The literature suggests that if you
> transfuse one of these bags, roughly one-quarter to one-sixth will
> have clinical symptoms. We are making about 333 to 1,000 patients sick
> per year. The literature worldwide suggests that of those who are
> symptomatic. So, roughly one-fifth to one-third will die so that means
> 67 to 333 deaths per year or a fatality rate per unit of approximately
> 1/12,000 to 1/60,000.
>
> Are these numbers real? I think the best data comes from Paul Ness and
> his group at Johns Hopkins were they found that the risk of dying from
> a pool of random platelets was 1/17,000 and the risk for an apheresis
> fatality was 1/61,000. Of course, they only know about the cases that
> were reported back to them so the real numbers may even be higher. So,
> I think that these numbers approximate the real risk in this country
> from bacterial contamination of platelets.
>
> \[Slide\]
>
> The bacteria that cause fatalities represent a broad spectrum of
> bacteria. [Staph. aureus]{.underline} and [Klebsiella]{.underline} are
> probably the two biggest ones but [Serratia]{.underline} is not very
> far behind. Roughly 59 percent are gram negatives, 59.7. So, roughly
> 60 percent of the deaths are due to gram negative organisms, of which
> the majority are [Enterobacteriaceae]{.underline},
> [Escherichia]{.underline}, [Salmonella]{.underline},
> [Proteus]{.underline}, [Klebsiella]{.underline} and [E.
> coli]{.underline}. This is quite distinct from what you actually find
> when you culture units. When you culture units roughly two-thirds are
> gram positive organisms but when you look at what actually kills you
> the majority are gram negative organisms.
>
> So, we have to come up with a system that will interdict all of these
> bacteria if we are really going to address the problem. Where do these
> bacteria come from? Most of the gram positives are thought to come
> from the skin. When we sterilize the skin we really don\'t sterilize
> it. All we really do is bacterial load reduction and there are still
> some bacteria left on the skin that will come up the needle. In
> addition, the needle goes through the subcutaneous tissues, cores our
> some of the subcutaneous tissues, sebaceous glands, hair follicles,
> etc. where the iodine solutions don\'t reach. So, some of the bacteria
> are coming up that way. Most of the gram negatives are thought to come
> from a donor who has a transient asymptomatic bacteremia. Those are
> the two major sources of bacterial contamination of platelets.
>
> \[Slide\]
>
> When we are talking about bacterial detection and the detection of
> reactions to platelets, it is all about timing. This is a series of
> cases that were found at the NIH Clinical Center, back in the early
> \'70s. During their epidemiologic surveillance they found that there
> was a series of [Salmonella cholerae-suis]{.underline} cases in the
> hospital. This led to a major epidemiologic search trying to identify
> the source of the [Salmonella]{.underline}. To make a long story
> short, they found that they all traced back to the fact that they had
> all had platelet transfusions and all of them had received platelet
> transfusions from the same donor.
>
> Further investigation showed that that donor had osteomyelitis so
> every time he came in to donate platelets he was shedding
> [Salmonella]{.underline}. The interesting thing about this case is how
> long did it take for the patient to become sick after they received
> the platelets? There was quite a range. It went from 5 days to 12
> days. The average incubation time before the patient became
> symptomatic was 8.6 days.
>
> So, it is no surprise that these cases were not linked to platelet
> transfusion. This is sort of a recurring theme we see in the
> literature. Many of the patients become sick sometime after the
> transfusion and they are not linked back to the original platelet
> transfusion unless someone comes looking, trying to figure out
> whatever happened to other components made from another bacterially
> contaminated product. In this case there were seven cases and one
> patient died and two patients had recurrent [Salmonella]{.underline}
> episodes.
>
> \[Slide\]
>
> When you do inoculation studies you put bacteria in a bag and you look
> and see how fast they grow, This is looking from a study that we did
> several years ago of 120 inoculated platelet units with [Staph.
> epi]{.underline}., [Staph. aureus]{.underline} and
> [Pseudomonas]{.underline}. We have done similar studies with a variety
> of other bacteria, the vast majority will become culture positive
> within one to two days. However, with [Staph]{.underline}.
> [epi]{.underline}. you often see that sometimes you don\'t detect
> bacteria in the bag until quite late. [Staph]{.underline}.
> [epi]{.underline}. can be bit of a slow grower.
>
> \[Slide\]
>
> This is data from the Holland Labs, the American Red Cross, Steve
> Wagner, where they put [E]{.underline}. [coli]{.underline} and
> [Staph]{.underline}. [epi]{.underline}. into bags. They inoculated
> with a low concentration of 0.1 organisms per mL and then they put a
> relatively small volume into a bacterial culture bottle, 0.5 mL.
> Normally when you put a volume in a culture bottle it is 4-10 mL. With
> [E]{.underline}. [coli]{.underline} by 24 hours they picked up 100
> percent but it required greater than 24 hours to pick up all the
> [Staph]{.underline}. [epi]{.underline}. because sometimes it takes
> time for these bugs to grow in the bag. Unlike viruses, where you can
> detect viruses in a sample right at the time of donation, you have to
> allow these bacteria to grow before a small sample taken from the bag
> will allow you to detect the bacteria.
>
> \[Slide\]
>
> This is similar data from the Canadian Red Cross, back when there was
> a Canadian Red Cross. On day one, which is the day on which the
> platelets were collected\--I would have called it day zero\--they
> found a contamination rate in 16,000 platelets of 0.02 percent.
> However, they came back two days later and they found a contamination
> rate of 0.07 percent. At that point there were only 10,000 platelets
> left to retest. Again, it illustrates that you have to let some time
> go by before you do your sampling if you are going to pick up all the
> bacteria.
>
> \[Slide\]
>
> One point I wanted to make is that in the United States we have two
> platelet products. We have single donor apheresis platelets, shown
> here, and then we have pools, which have already been discussed quite
> a bit so far this morning. What we really have is a two-tiered safety
> system. Since the chance of getting a bacterially contaminated
> platelet is a function of the number of donors and the number of
> needle sticks, apheresis platelets are intrinsically safe. Data from
> Johns Hopkins, where they have made a conscious effort to switch to
> 100 percent apheresis products, they found that the risk of getting a
> fatal transfusion or just becoming septic from platelet transfusion
> was five- to six-fold higher for pooled random platelets. So, we
> really have a two-tiered safety system in the United States and I hope
> we don\'t make this worse.
>
> \[Slide\]
>
> The shelf life of platelets is limited to five days because there is a
> fear that bacteria are going to grow over time. At one time platelets
> were licensed out to seven days, in the early \'80s. When you do
> inoculation studies at a variety of relatively low concentrations,
> what you find is that usually by day three, sometimes day four, the
> bacteria are already on the plateau of growth. Usually when bacteria
> grow it doesn\'t take five days to reach plateau. Usually they are
> there by day three. With some organisms, like [Bacillus]{.underline},
> usually within 24 hours they are on plateau growth. So, a day one or a
> day two platelet can be quite dangerous.
>
> In the data from the SHOT study from England, the Serious Hazard of
> Transfusion study, they had five deaths in the first couple of years
> of their surveillance study. Three of the five deaths occurred from
> platelets that were days one to three. So, early platelets can be
> quite dangerous as well.
>
> \[Slide\]
>
> This is data from our lab looking at [Staph]{.underline}.
> [epi]{.underline}. and shows that growth with [Staph]{.underline}.
> [epi]{.underline}. can be much more variable and can be quite slow. It
> seems to be somewhat of a function of the initial concentration that
> is put into the bag, unlike most of the other bacteria where it
> doesn\'t really seem to make much difference what the initial
> concentration is, but [Staph]{.underline}. [epi]{.underline}. is a
> problem.
>
> \[Slide\]
>
> This is jut to remind me to emphasize that you cannot test the whole
> bag for bacteria. So, you have to let some time go by, and we are
> running out of time here\--April, 2003.
>
> \[Slide\]
>
> There have been a variety of detection schemes that have been
> explored. Fortunately, many of these have played from my laboratory
> over the years. Many are low tech, such as looking at swirling, versus
> high tech, using antibiotics as probes. I am not going to talk about
> those because they never really made it to market. They are not
> available yet. So, I am just going to talk about what it is that we
> can do today.
>
> \[Slide\]
>
> We can do bacterial staining. This can be a Gram stain. It can be a
> Wright stain like they use in hematology labs. Most hospitals have
> these automated Wright stainers. You put a slide on a little conveyor
> belt and out it comes on the other side, a beautiful slide. And, we
> don\'t really care whether it is gram positive or gram negative; we
> just want to see it. However, with the Wright or Gram stain\--this is
> data from Lee Bland who used to be with the CDC\--you find that the
> pickup rate is only about 10^6^ CFUs per mL, so a million bacteria per
> mL. You could go to acridine orange and fluorescent microscoping and
> that gets to be a log better, but it is not that sensitive a system
> and looking at stains is very subjective and you can have a high
> false-positive rate.
>
> \[Slide\]
>
> An alternative relatively simple system that was initially described
> from my lab was to use multi-reagent strips, urine dip-sticks. We
> keyed in on two markers that could detect bacteria. One, we reasoned
> that as the bacteria grew they would consume glucose. So, we were
> actually looking for negative glucose. Basically, as they grow
> bacteria consume all the glucose. And, we looked for a drop in pH. We
> were looking basically for an orange pH, not green, a pH of 6.5 or
> lower. Actually, there is some bias in these strips when you use them
> on platelets as opposed to urine.
>
> \[Slide\]
>
> This is a paper where we published some of these pictures. This is
> looking at platelets that were inoculated on day zero. These strips
> were made on day three. You can see that with the [Klebs]{.underline}.
> [pneumoniae]{.underline} the glucose is blue; the pH is orange.
> [Staph]{.underline}. [aureus]{.underline}, blue and orange. On day
> three both of these bags were at 10^7^ CFUs per mL, basically on
> plateau. However, it doesn\'t pick them all up.
>
> \[Slide\]
>
> Here is [S]{.underline}. [marcescens]{.underline}. The glucose is
> green, as is the pH. This was at 10^3^ CFUs per mL. So, data from our
> laboratory and from other laboratories like Steve Wagner\'s lab,
> suggest that the dip-sticks are sensitive for about 10^7^ CFUs per mL
> and in some cases will pick things up down to 10^4^, 10^5^. But it is
> a very easy test to do. The strips are very inexpensive. But they have
> not really received wide use.
>
> There was one paper from M.D. Anderson Cancer Center that was
> published in [Transfusion]{.underline} last year. They looked at
> roughly 3,100 random platelets. They used the dip-sticks. They found
> two that were contaminated and were able to interdict those units so
> they were not transfused and very likely saved two patients\' lives.
> However, there was a relatively high false-positive rate in that 28
> units failed the dip-sticks. Either the pH was too low or the glucose
> was too low. Those were pooled. You might ask were those units any
> good anyway if the pH was low or the glucose was low. Maybe it is a
> good quality control measure, but a simple technique like this can
> interdict contaminated units.
>
> \[Slide\]
>
> We already heard a bit about the BacT/Alert system from Biomerieux.
> This is one of two systems that are currently approved by the FDA for
> in-run quality control of platelets. The BacT/Alert 3D, as you have
> already heard, has a color change. It goes from green, which is good,
> to yellow, which is caution. BacT/Alert 3D is a newer machine than the
> one that you saw from the Netherlands. Shauna Hayes is my research
> tech. Basically, what happens is that these bottles are checked
> roughly every ten minutes so it is almost real time. They look are
> reflectance of light off the color sensor. Not only does it look at
> what color is it absolutely, but it is hooked to a computer and keeps
> track of what is the rate of change in the color. So, the computer
> will pick up bottles that are positive before the human eye will
> notice the difference in color. So, it is a relatively quick system.
>
> \[Slide\]
>
> We have validated the system in our lab, looking at 15 different
> organisms that are known to contaminate platelets. What we found,
> using a variety of the bottles that were available, is that when we
> targeted inoculations at 10 CFUs per mL\--the actual mean was 10.9
> but, in fact, many of them were less than 1 CFU per mL\--is that for
> the vast majority of these organisms, we could pick them up generally
> roughly in 12 hours and, on the outside, about 25 or 26 hours, with
> the exception of [P]{.underline}. [acnes]{.underline},
> [Proprionabacterium]{.underline} [acnes]{.underline}, which is an
> anaerobic organism that is a slow grower and is generally thought to
> have questionable clinical significance, particularly in the context
> of platelets. But for the aerobes the system does extremely well.
>
> \[Slide\]
>
> Getting into the bags, sterility has been a problem. Sterile
> connection devices are the way you access these bags and there have
> been a variety of sampling devices that people have been exploring in
> this country. This is one we have been using. This is similar to the
> system you have already seen from the Netherlands. This is a system we
> are having custom-made for our lab where you sterile connect this on
> and there is a syringe. You just pull up the volume you want. There is
> a needle on this end and you put that into the bottles and you put in
> the exact volume that you want.
>
> What will it take to use a system like this to extend the shelf life
> of platelets? Assuming that the [in vitro]{.underline} function and
> [in vivo]{.underline} survival is fine, there is a question of whether
> an early culture is predictive of a late culture. That has already
> been alluded to this morning. At the last BPAC meeting, it was
> discussed what it would take to do a study.
>
> We have been doing a pilot study for the last year. In our first 12
> months we sampled roughly 2,400 apheresis platelets. What we found was
> that we had one collection, which was a triple collection, that had
> [Staph]{.underline}. [epi]{.underline}. The machine triggered at 14
> hours. We were able to interdict all three of those units so they did
> not go to a patient.
>
> We also had two collections that were doubles, so four bags, that came
> up with [Proprionabacterium]{.underline} [acnes]{.underline} on day
> six of culture. We were setting up our cultures on day two of storage.
> So, those units had already been transfused several days before. When
> we went back to talk to the clinicians, there were no ill effects
> attributable to the [P]{.underline}. [acnes]{.underline} in those
> patients, which gets to one of the questions that was asked before.
>
> In terms of a false-positive rate, we were sampling every bag with an
> aerobic bottle and an anaerobic bottle on two occasions. We basically
> inoculated 9600 bottles during this time period. We had one bottle
> that was contaminated by [P]{.underline}. [acnes]{.underline}
> presumably from my skin. I inoculated that bottle. I take full
> responsibility for that one. So, our false-positive rate was on the
> order of about 1/10,000 from inoculation. The way we proved that, we
> kept a sample bag on every bag and we only said it was a real
> contamination if we could either reculture the original bag or the
> sample and find the same organism in that bag.
>
> In theory, in terms of contamination I think you can get a rate as low
> as 1/10,000. That is a lot lower than the data we heard about from the
> Netherlands. Jim AuBuchon has been running a similar study at
> Dartmouth and his contamination rate has been running 0.5 to 0.6
> percent, which is much more similar to what they see in the
> Netherlands. That is perhaps what you see out in the real world where
> you have a lot of technologists doing it.
>
> So, what do we need to get this licensed? Well, the FDA says they
> don\'t want to see inoculation studies. They want to see real-world
> data. However, in my mind, where do the bacteria come from? They come
> from the skin. They come from trans-bacteremics.
>
> I don\'t know that inoculating bacteria into platelet bags is that
> much different so I am not sure that we really need real-world data.
> But if we were to do real-world data, the biostatisticians would tell
> you that they want to see 50 to 100 real events. Since we have a
> contamination rate of maybe 1/1,000 we would have to study 50,000 to
> 100,000 platelet bags to detect 50 to 100 real events. That sounds
> quite daunting but I think it can be done and we are having some
> discussions with some of the large blood collectors to see if we might
> be able to pull off a study like that in the next year or two,
> although I really question whether we really need to do that. That is
> my opinion.
>
> \[Slide\]
>
> The other system that is currently approved for detection of bacteria
> for in-run quality control is the Pall bacterial detection system BDS.
> This is a small pouch that is sterile connected to the platelet bag.
> You push over 6 mL as opposed to the BacT/Alert where we were using 8
> mL. It goes through a filter which filters out the white cells and the
> platelets but lets the bacteria pass. It is different depending on
> what organism you are looking at but, on average, 50 percent of the
> bacteria will pass the filter. It then goes into a little pouch that
> holds 2 mL, which has an SPS tablet which will enhance growth in this
> bag. Then you put that at 35 degrees centigrade in an incubator and
> let it sit for 24 hours. As the bacteria grow, they will consume
> oxygen. As opposed to the color changes that you saw with the
> BacT/Alert which was looking at CO~2~ and pH changes, this looks at
> consumption of oxygen. So, you measure the head space gas, and you
> look to see whether it is a pass or fail.
>
> Although there haven\'t been papers published on this, abstract form
> presentations at meetings suggest that this is sensitive down in the
> range of 10-100 CFUs per mL. This system is only good for aerobic
> organisms, not for anaerobic organisms. It has the advantage that it
> is a much more closed system. You don\'t have a needle waving in the
> air in the laminar flow hood so there is potential for less
> false-positive reactions.
>
> \[Slide\]
>
> What does the future hold? Teh future usually comes from the past. So,
> let\'s go to the next slide.
>
> \[Slide\]
>
> Where we are is here. This is a quote, one of the recommendations from
> the Institute of Medicine report on HIV in the blood supply where they
> said that the perfect should not be the enemy of the good. The
> implementation of partial solutions that have little risk of causing
> harm should be encouraged. That is where I think we currently are with
> bacterial contamination of blood products. We are at the point where
> we are starting to phase in partial solutions. They are not perfect
> but they are pretty good.
>
> \[Slide\]
>
> Here is a sage fellow, Ed Snyder. There have been three major FDA
> workshops that have dealt with bacterial contamination of blood
> products. Many of us in the field have felt that we need to do
> something about this. I thought Ed, in his summary comments from this
> meeting, said it better than anybody else: The imperative is to act so
> you don\'t have to explain yourself on Night Line. Regulation is
> necessary to achieve the goal. Nothing says I care like a page of
> 483s. Those are the deficiency forms you get from an FDA inspection.
> When all else fails, do something. Give us a mandate and we will do
> the rest.
>
> I think it is key, we have to have a mandate from somebody, be it the
> FDA, AABB or somebody, or we won\'t be able to convince the hospital
> administrators to let us do something.
>
> \[Slide\]
>
> Following the third meeting last summer, which was principally on
> pathogen reduction but it certainly found itself in bacterial
> contamination waters quite a bit, a group of the moderators and
> speakers got together and wrote an open letter to the blood banking
> community. What we said in this letter was that pathogen reduction has
> a lot of promise but it is not going to be here soon. Meanwhile
> bacterial contamination is a major problem in this country and we need
> to do something now. So, we urge the blood collection community to
> begin implementing bacterial detection strategies now. This was a
> letter from myself, Jim AuBuchon, Paul Ness, Roselyn Toby and Bill
> Blackman.
>
> This letter actually generated some very interesting responses.
> Actually, it was posted on a couple of web sites. Some people accused
> us of moral blackmail and asked us about what conflicts of interest we
> had with the various companies. Like Ed, I have no equity interest in
> any company.
>
> \[Slide\]
>
> So, things have been changing in recent months. The AABB has been
> considering a standard for the past six months. The original proposed
> standard was that the blood bank or transfusion service shall have a
> method to test for bacterial contamination of all platelet components.
> This wording has been changed a bit but the essence is still here. The
> standard has been approved as of last week, and will be effective in
> this country on March 1, 2004. So, essentially we have a year to gear
> up to do bacterial detection of platelets.
>
> \[Slide\]
>
> Similarly, the College of American Pathologists, CAP, and their
> laboratory accreditation program also now has phase I deficiency,
> which is in many cases a recommendation, does the laboratory have a
> system to detect the presence of bacteria in platelet components? They
> want you to look at all of the platelets. So, things are changing.
> There is a mandate and we are moving towards bacterial detection in
> this country.
>
> \[Slide\]
>
> What a lot of us want to see happen is that we want to see the shelf
> life go back out to seven days. This is just a timeline. In \'82
> platelets were extended to five days from three; in \'83, from five to
> seven. But because of several reports of bacterial contamination in
> older platelets, it was brought back down to five days. We think we
> can probably get it back out to seven days if we have a bacterial
> detection step somewhere in the system.
>
> \[Slide\]
>
> We have already heard that bacterial detection is being used in
> Europe. There are several countries now that routinely use a culture
> system for all their platelets. In addition, many of these countries
> are now extending platelets out to seven days, either countries or
> institutions\--Denmark, Netherlands, Yugoslavia and United Kingdom.
> There have been reports of extending platelets to seven days if you do
> a bacterial detection step, usually on day one or two of storage.
>
> \[Slide\]
>
> The other interesting thing is that it is very cost effective. We
> throw away about ten percent of the platelets in this country because
> of the outdate. If we could get an extra two days on the shelf life of
> platelets we would drop the outdate rate substantially and it would
> easily pay for itself. Jim AuBuchon, who I know has spoken to this
> committee before, is generally the guru of cost effective analysis as
> it applies to transfusion medicine. In virtually every cost effective
> analysis he has done\--leukoreduction, p24, NAT testing\--he always
> concludes it is not cost effective to do something and yet we wind up
> doing it anyway. In this case, he finally concludes that this is very
> cost effective. It is not even cost neutral; it would pay for itself.
> If we didn\'t outdate all those units, it would pay for all the
> culturing. Yet, we are very slowly walking toward that.
>
> \[Slide\]
>
> So, what are we going to do with random platelets? Well, we have a bit
> of a conundrum here. We have these sensitive culture systems that are
> usable for apheresis platelets but don\'t lend themselves to random
> platelets because of the volume that must be withdrawn and the cost of
> the systems. It is about \$25 a culture with either of the two systems
> that are licensed.
>
> What we are currently faced with is that if we are going to do a
> bacterial detection step for random platelets, unless we can pre-pool,
> we are going to use systems that are less optimal. We are going to use
> the dip-sticks. We are going to use Gram stains or Wright stains which
> are not the best systems.
>
> In addition, we have heard some data that said, yes, there is a risk
> that you have greater bacterial growth in a pooled random platelet if
> one of those platelets is contaminated but it is not a log difference
> in total dose. I don\'t think 10^6^ bugs per mL versus 10^7^ is going
> to make a difference in the patient outcome.
>
> In addition, what also hasn\'t been said is that in several of these
> pooling experiments, when you pool several platelets together often
> the bacteria didn\'t grow because one of the donors in that pool had
> antibodies that basically killed the bacteria. So, in some cases
> pooling may be better in preventing bacterial contamination of
> platelets.
>
> Nevertheless, unless we have pooling people are trying to figure out
> other ways of doing cultures so that we can try to culture the
> platelets. One system is this system which looks very complicated,
> whereby you would take approximately 2 mL from each random bag, bring
> that up into a syringe and then you would inoculate it into the
> bottles. You would leave all the original bags connected to the setup,
> ship it all out to the hospital and then, at the time that you are
> ready to pool, you pool into this common bag, here. So, it is
> pre-pooling that is not pre-pooling. You pre-pool just the sample but
> it is a lot of manipulation.
>
> Alternatively, Pall has a system where you put a little autostat
> filter\--both of these systems require leukocyte, or at least they
> were approved with leukocyte reduced platelets where you take your
> platelet-rich plasma, you can pass it through here, make it into
> platelets and then sample the system. You know, this is a lot of work
> for each little random platelet and it is going to be expensive. So,
> we are struggling with what we can do with platelets.
>
> When the AABB standard goes into effect we are going to take a
> two-tiered system of safety in regard to bacterial contamination and
> we are going to still have a two-tiered system because we are going to
> be doing sensitive testing on apheresis platelets and probably much
> less sensitive testing for random platelets. That makes a lot of us
> very uncomfortable.
>
> Questions?
>
> DR. NELSON: Thanks, Dr. Brecher. Yes?
>
> DR. LEW: Back to how often you actually get a positive, your
> definition was different from Dr. Pietersz. Dr. Pietersz said up
> front, you know, in the real world if you get a positive you can\'t
> wait around a couple of days for a second culture to come back. So,
> they usually hold it and then, you know, not transfuse. So, if you
> were using her same definition what would be your rate? Because that
> is the real world, if it goes out you can\'t wait for the false
> positive to come in necessarily.
>
> DR. BRECHER: Right. One thing you have to realize is when people toss
> out these numbers of 1/1,000 and 1/2,000 bacteria contaminated, those
> studies were all done with aerobic culture systems only. Now, all of a
> sudden, we are looking at anaerobic systems as well.
>
> In our experience with 2,400 platelets, we would have had seven that
> were truly contaminated that we detected and we would have had two
> that triggered on the machine that were not really contaminated, one
> which we contaminated ourselves with [P]{.underline}.
> [acnes]{.underline} and the other was a machine false positive. So, we
> are talking about roughly 10/2,400 so it is well under one percent. It
> is a low rate.
>
> For the real world I think Jim AuBuchon\'s data is probably better. He
> was seeing about 0.5 to 0.6 percent that you may have to throw away.
> But even when you figure that into the scheme of things, it would
> still be considered cost effective.
>
> DR. LEW: If I could just follow-up, do you think though that by
> pooling early\--I don\'t care what the number is, even it is just
> 1/1,000\--but if you pooled early then you would expect that to
> actually go a little bit higher.
>
> DR. BRECHER: Right, yes. That was clearly part of what was driving the
> numbers that Dr. Pietersz presented because she was pooling. But I
> really don\'t know what was true positive and what was false positive
> from her data because they didn\'t have a follow-up sample.
>
> DR. NELSON: Her data was expressed per pool, whereas the pool had more
> than one unit.
>
> DR. BRECHER: Right.
>
> DR. NELSON: Question?
>
> DR. SCHMIDT: You touched on some things which relate to old
> experience, and that is when the bacterial contamination of whole
> blood was a problem in bottles with rubber stoppers, and all, one of
> the things that would happen and that you were warned against\--I
> think Dr. Margaret Pitman, at NIH, demonstrated especially with
> [Pseudomonas]{.underline}, was that you if get enough bugs into the
> unit of whole blood it would use up all the glucose and it would be
> sterile but tremendously pyrogenic. We see some things here about
> glucose going down by itself and then going down with the bacteria so
> that culture would be useless. I guess it has to be at least
> considered, even though it is probably not happening.
>
> DR. BRECHER: Well, with platelets we don\'t see that probably because
> of the short shelf life of platelets. So, even though the glucose goes
> down you can still culture out the bacteria so they haven\'t died out,
> at least in the shorter setting.
>
> DR. NELSON: Yes, go ahead.
>
> DR. KUEHNERT: Matt Kuehnert, CDC. I just had a couple of questions.
> One was about the slide you showed on BacT/Alert as far as growth. I
> agree, our data and the SHOT data and other data showed that most
> virulent organisms grow fairly quickly, but you had one there that I
> don\'t think of as a skin commensal and that is [Strep]{.underline}.
> [viridans]{.underline} I think. I wonder if you have any comments on
> why that took so long to grow and whether it was some sort of
> exception.
>
> DR. BRECHER: It was still less than 24 hours on our inoculation
> studies. We had five different bottles we were looking at so some of
> the bottles spiked high but the standard aerobic bottles were less
> than 24 hours.
>
> DR. KUEHNERT: The other question I had quickly was about notification
> where a unit had already been transfused. What sort of workup do you
> do? I mean, in a clinical micro. laboratory you are going to Gram
> stain it; you are going to go to antimicrobial susceptibilities even.
> You may not want to do that for [P]{.underline}. [acnes]{.underline}
> but for other organisms you would. A clinician might well even request
> susceptibilities on [P]{.underline}. [acnes]{.underline} if you report
> it as a positive. I just wonder how you handle that or plan to handle
> a situation like that.
>
> DR. BRECHER: Well, we have been notifying our clinicians if a unit
> went out and we subsequently detected bacterial. We have had four
> examples of that with [P]{.underline}. [acnes]{.underline}. In each
> case there were no clinical sequelae from the [P]{.underline}.
> [acnes]{.underline}, which I don\'t think is much of a surprise. There
> are only three reports, usually fevers, that have been reported with
> [P]{.underline}. [acnes]{.underline} in the world\'s literature that I
> can find.
>
> Having said that, there are patients who develop endocarditis and
> joint infections, eye infections with [P]{.underline}.
> [acnes]{.underline} so it is not a completely innocuous bug but
> usually we don\'t see problems from it.
>
> DR. KUEHNERT: The follow-up to that, you used an aerobic and anaerobic
> bottle? Is that right?
>
> DR. BRECHER: That is right. We chose to use two bottles because we
> thought, and our data suggests, that two bottles are better than one
> at picking up low concentrations of bacteria. I think we don\'t have
> the complete answer to what is the story with anaerobic organisms. It
> turns out that almost all of the aerobes of interest grow quite well
> in the anaerobic bottle, with the notable exception of
> [Pseudomonas]{.underline} and [Bacillus]{.underline}. So, we have made
> the conscious decision to use two bottles and that one of them would
> be anaerobic, at least for the time being.
>
> DR. KUEHNERT: Thanks.
>
> DR. ALLEN: Thank you for you presentation; a lot of useful data. Three
> quick questions. I wanted to follow-up, first of all, on the potential
> for the reaction to endotoxin shock versus actual clinical infection
> that occurs. Does that happen in your experience with platelet
> transfusions, endotoxin shock?
>
> DR. BRECHER: Yes, it does. With the [Enterobacteriaceae]{.underline}
> often the bottom will fall out with these patients. It is usually the
> gram positives, that sometime later they become sick.
>
> DR. ALLEN: Any idea of the relative proportion of the two?
>
> DR. BRECHER: Well, roughly 60 percent of fatalities occur with gram
> negatives, the majority of which are [Enterobacteriaceae]{.underline}
> so most of the fatalities are with organisms that make endotoxin.
>
> DR. ALLEN: Second, are you aware of whether or not the Joint
> Commission has begun to address this issue in terms of their standards
> at all?
>
> DR. BRECHER: I don\'t know that they have specifically addressed it,
> however, if you are a CAP-accredited laboratory the Joint Commission
> usually doesn\'t look in this area very much. So, since the CAP has
> moved in this direction, essentially [de facto]{.underline} JCHO has.
>
> DR. ALLEN: Third, you know, I am not a blood banker and I had sort of
> made the assumption that most frequently the place of culture would be
> from the transfusion service rather than the blood collector, although
> certainly in a hospital you can have both functions together. Is that
> correct? You certainly implied at one point that in a very
> complicated, multi-draw system perhaps the place of culture actually
> might be in the blood collection center.
>
> DR. BRECHER: I think the most impact you are going to have is if you
> do your culture early, which means the blood center. If we do
> something late it will have to be a very rapid test. The trade-off is
> if you have a very rapid test it is not very sensitive, like the
> dip-sticks and the Gram stains. In the ideal world I think that it
> should be that whoever is collecting the product, which in some cases
> is the hospital or the blood center, do a test at 24, 48 hours. If
> that is negative after a prescribed time period, be it 24 hours or 48
> hours if it is a culture system, then I think we can make the case to
> consider going out to extending shelf life if that is really
> predictive that a later culture will also be negative, that a negative
> culture predicts a negative culture.
>
> DR. ALLEN: Given that kind of a system however, does that preclude the
> pool of platelets being transfused or used earlier if it is needed?
>
> DR. BRECHER: There are actually two paradigms for that. One is, as was
> described from the Netherlands, you go ahead and let those platelets
> go out into the inventory, into the world, and only if it is culture
> positive you call them back, which is the system we have been using at
> UNC as well as at Dartmouth. The other system people are talking about
> doing is sitting on those bags for 24 hours, 24-30 hours, waiting
> until they at least have some preliminary culture data and if that is
> negative, then they will go ahead and release the units. I think it is
> going to play out both ways in this country.
>
> DR. ALLEN: We really are talking about increasing the level of
> complexity of releasing the product however, aren\'t we?
>
> DR. BRECHER: Withdrawing the units is not going to be easy, there is
> no getting around that. Yes, it will be more complex.
>
> DR. LAAL: You mentioned briefly something about detection of ribosomal
> RNA.
>
> DR. BRECHER: Yes, we worked with GenProbe several years ago using a
> universal probe for ribosomal RNA, over ten years ago. However, that
> project was shelved. It may be coming back out. There are a variety of
> other high tech companies looking at various amplification techniques
> but they are not here yet. There are problems when you are looking at
> doing an amplification test because many of the enzymes that are used
> for nucleic acid amplification come from bacteria and, thereby, they
> are contaminated by some RNA and some DNA from the bacteria. In
> addition, normal blood running around in those often has some
> fragments of bacterial DNA. So, it is not an easy a solution as you
> might think; there are some problems.
>
> DR. LAAL: Still, are there any tests which are looking specifically at
> bacterial products like endotoxin detection, or something?
>
> DR. BRECHER: Actually, it is funny you should mention that. People
> have looked at endotoxin in the past. There hasn\'t been much
> attention paid to that recently. But I was talking to some of the guys
> from the FDA and the CDC that maybe we should dust that off and look
> at it again. It might particularly be more relevant for Third World
> countries if they can\'t use this high tech stuff, although dip-sticks
> are pretty low tech.
>
> DR. KLEIN: Mark, as I understand it you did your cultures in biologic
> cabinets and hoods.
>
> DR. BRECHER: We did them in laminar flow hoods, which is actually
> recommended by the company. Some people have done them out on the
> bench. Jim AuBuchon does his on the bench and his contamination rate
> is higher than ours.
>
> DR. KLEIN: I think that is the experience in many of the European
> countries as well which don\'t culture them in biologic cabinets.
>
> You mentioned cost effectiveness, and I know that cost effectiveness
> is really only relevant if you extend to seven days. I asked Jim about
> five days and, certainly, if you retain the platelets for 24 hours
> after culture there is no way that that is going to be cost effective.
> I am not sure that is a big point but I just wanted to make sure that
> is clear.
>
> Finally, in your review of the literature, Mark, and your own
> experience what percentage of the deaths related to bacterial
> contamination would be interdicted at 48 hours?
>
> DR. BRECHER: Well, most of the deaths are from the
> [Enterobacteriaceae]{.underline} and we know that the
> [Enterobacteriaceae]{.underline} grow very quickly in these units. So,
> I think we would probably interdict the majority of the deaths. That
> would be my guess.
>
> DR. KUEHNERT: Can I just add from our article, it basically would have
> prevented almost all of them except one. There was a day four, from my
> recollection, resulting in a fatality. Every other one was either day
> two or day three storage.
>
> DR. KLEIN: So, that is culturing on day one and releasing\--
>
> DR. KUEHNERT: I am sorry, I thought the question was about transfusion
> fatalities from bacterial contamination. So, day two or day three of
> storage was where almost all the fatalities were.
>
> DR. BRECHER: And that is similar to the SHOT data which implies, as I
> said, that when you look at growth curves these bacteria reach high
> levels within two or three days. Fortunately, they are also picked up
> very quickly with these culture systems and they were all gram
> negatives. That is another important point.
>
> DR. NELSON: Mike?
>
> DR. BUSCH: Just to update people, Blood Systems or UBS is planning to
> have bacterial screening in place by July 1st, including apheresis and
> randoms. Just to address the problems we are facing with the randoms,
> just as you indicate, right now you need to culture each random
> separately and you need to leukoreduce them before you can culture
> them. So, the cost to culture separately four, five or six randoms
> will actually drive the price of pooled randoms well above the price
> of apheresis. That is one of the issues.
>
> The other, in terms of your cost effectiveness, as Harvey was
> commenting, right now we run outdates of 5-12 percent in different
> regions. The problem is going to be that we are going to have a mix of
> BacT/Alert and Pall going on but with the BacT/Alert systems we are
> going to be inoculating those cultures in the component labs in the
> regions and then sending the culture bottles to the central lab that
> will do the culturing. So, the inoculation won\'t happen until 24-30
> hours after collection. Then you have the transport. That transport of
> the bottle doesn\'t count in the 24-hour culture and we plan to only
> label after these cultures have completed 24 hours. In essence,
> platelets are not going to become available for labeling and issue
> until approximately three days. So, I don\'t think we are going to see
> any savings. I think it is going to be the opposite until we get an
> extension of shelf life outdates and the potential crisis of platelet
> availability is going to be the challenge.
>
> DR. BRECHER: Right, and I think there has been no incentive to look at
> platelet solutions because the shelf life is limited to five days. If
> we open the door we may be able to figure out better storage solutions
> for platelets. Maybe we can eventually get to ten days.
>
> DR. NELSON: However, you said that the primary reason for going from
> seven back to five was the bacterial contamination issue. So, if that
> is solved\--
>
> DR. BRECHER: Very simplistically, that is correct.
>
> DR. KLEIN: That was in apheresis platelets. There aren\'t really any
> data on seven-day pooled whole blood-derived platelets.
>
> DR. NELSON: Comment? Please state your name.
>
> DR. LEE: John Lee, FDA. Given your comments about the growth kinetics
> and that the plateau phase might be reached in the first two days with
> most bacteria, how do you reconcile that observation with the fact
> that a flurry of additional bacterial contamination related fatalities
> occurred when the shelf life was extended from five to seven days?
>
> DR. BRECHER: Well, I think that that was very anecdotal. There are
> only a handful of cases that were reported, mostly from Johns Hopkins
> back then. I think that it may have been that people were looking a
> little more carefully because the platelets had just gone out to seven
> days and people were paying a little more attention, but I really
> don\'t have an answer for that.
>
> DR. NELSON: Thanks. Yes?
>
> DR. STRONG: Just another comment on the logistical difficulties of
> this. Mike points out that we will have a delay in release which will
> increase the outdate and perhaps reduce the availability of apheresis
> platelets. I have trouble with that term \"random\" because actually
> they are all random. As you point out, we don\'t have a good culture
> remedy yet because we can\'t pool up front and we can\'t store for
> seven days. Clearly, the standard that has now been set requiring
> testing of all platelets may result in a shift towards more apheresis
> platelets. You might argue that that is a good thing because they are
> safer. On the other hand, we won\'t have enough to begin with.
>
> We have heard from our hospitals that if they are going to be forced
> to test, such as dip-sticks or Gram stains, or whatever, they are not
> going to do that. They are going to order apheresis platelets, which
> we don\'t have enough of. So, there is a potential downside of all of
> this in that we will have a platelet shortage crisis. Mike has already
> brought that up. So, unless we can get seven-day platelets I think we
> have a potential real problem on our hands.
>
> DR. BRECHER: Right. I think we all need to step back and ask what is
> best for the patients, what is best for the country and what does the
> data support? I think there is a lot of data that we have heard today
> that suggests that we can probably pre-pool and we would have the
> safest platelets. So, we would have done everybody a favor I think if
> we can move in that direction.
>
> DR. NELSON: We are sort of fighting the lunch deadline but Dr. Katz
> wanted to make a statement and Kay Gregory, and then we will break for
> lunch and we will continue the discussion later.
>
> **Open Public Hearing**
>
> DR. KATZ: I want to point out a typo in our printed statement. The
> first line of the second paragraph says 1970s. It is supposed to say
> 1980s.
>
> I am representing America\'s Blood Centers, a national network of
> locally-controlled, not-for-profit community blood centers that
> provide nearly half of the U.S. blood supply from volunteer donors.
> Collectively, ABC total blood collections exceeded seven million
> donations in 2001. We operate in 45 states and in Quebec and serve
> more than half of the 6000 hospitals in the United States.
>
> In the 1980s the platelet outdate period was extended from five to
> seven days, and subsequently rolled back to five days when it became
> apparent that an increase in septic reactions to platelets was
> associated with the longer outdate. This was appropriate.
>
> Today ABC members are pleased to participate in the efforts of the
> blood community to control septic reactions to platelets using
> currently approved systems for bacterial detection. It is in this
> historical context that BPAC and FDA should address both extension of
> platelet outdates and the regulatory approach to allowing pre-pooling
> of platelets from whole blood, that is random donor platelets. The
> deployment of these detection methods should allow reconsideration of
> longer platelet outdating.
>
> ABC endorses the comments that you will hear from AABB primarily
> addressing pre-pooling. We further emphasize the importance of
> expeditious and non-burdensome attention to extension of platelet
> outdating to seven days and beyond potentially as a measure to enhance
> safety and availability of platelets to patients in need. The optimal
> use of bacterial detection systems requires a one- to two-day
> incubation using the licensed quality control systems available, and
> incubation cannot begin until 24 hours after component preparation.
> This will leave only one to two days of shelf life on a five-day
> platelet product, and may impair the availability of these products
> most critically for blood systems and transfusion services dependent
> on imports from remote collection facilities.
>
> The FDA should use the least burdensome approach to allowing extension
> of outdating for those products subjected to sensitive bacterial
> detection. We support the need for limited clinical studies of
> platelet recovery and survival to replicate the data that led to a
> seven-day expiration in the 1980s using current collection methods.
> For apheresis platelets, autologous studies will be acceptable. For
> pooled random donor platelets, studies in thrombocytopenic patients
> will be required. They should be statistically powered to demonstrate
> pre-agreed upon recovery and survival in comparison to one-day old
> platelets with pre-agreed statistical confidence, and not be
> unnecessarily large so as to inhibit the adoption of bacterial
> detection systems.
>
> Clinical trials using prevention of bleeding as an endpoint are not
> needed since recovery and survival are broadly predictive.
> [In]{.underline} [vitro]{.underline} studies of platelet function
> should not be required since their correlation with clinical endpoints
> is weak, and Dr. Snyder has already shown you that they are
> reasonable.
>
> The voluntary implementation of bacterial detection by the blood
> community represents a robust approach to the most serious current
> infectious risk of transfusion. FDA\'s participation as outlined above
> is in the best interest of the safety and adequacy of the blood
> supply. Thank you.
>
> DR. NELSON: Thank you. Kay Gregory, from AABB?
>
> MS. GREGORY: The American Association of Blood Banks is a professional
> society for over 8,000 individuals involved in blood banking and
> transfusion medicine, and represents approximately 2,000 institutional
> members, including blood collection centers, hospital-based blood
> banks and transfusion services as they collect, process, distribute
> and transfuse blood and blood components and hematopoietic stem cells.
> Our members are responsible for virtually all of the blood collected
> and more than 80 percent of the blood transfused in this country. For
> over 50 years, the AABB\'s highest priority has been to maintain and
> enhance the safety and availability of the nation\'s blood supply.
>
> The AABB strongly encourages the FDA to allow pre-storage pooling of
> platelets derived from whole blood, and further encourages the FDA to
> request only scientifically and medically reasonable data to support
> such a change in approved practice.
>
> The need for pre-storage pooling arises from the desire of blood
> collecting facilities to perform cultures of all platelet units to
> interdict those that are bacterially contaminated. Blood bankers
> recognize that bacterial contamination of platelets is the greatest
> residual infectious disease threat to transfusion recipients and
> causes both frequent deaths and substantial morbidity. Improvement in
> skin cleansing practices and diversion of the first few milliliters of
> collected blood are being implemented to reduce contamination of
> components by skin flora.
>
> Currently, however, the most effective way of dealing with this
> significant problem is to perform a bacterial culture on each unit.
> This is already feasible with apheresis platelet units, but culturing
> individual platelet units derived from whole blood imposes serious
> additional difficulties. The volume needed for the culture to capture
> contaminating bacteria will remove a significant portion of the small
> volume in a unit of platelets from whole blood, thereby reducing its
> clinical efficacy. Furthermore, the sheer number of cultures to be
> performed will overwhelm the technical capabilities and financial
> resources of the transfusion system. Blood bankers want to address
> this issue but we need a practical way of doing so.
>
> The AABB believes there are already adequate data to support the
> practice of storing pooled platelet concentrates for the remainder of
> the usual storage period of its individual units, providing that
> bacteria are reliably detected in the pool. First, ample data are
> available and have been summarized today by Dr. Snyder that this
> pooling does not lead to immunologic activation between donors such
> that a mixed lymphocyte reaction occurs.
>
> Second, the sterile connections through which the pooling will be
> conducted have already been discussed by this committee. BPAC
> determined that appropriate use of a sterile connecting device will
> not increase the likelihood of contamination. The resulting pool of
> platelets will need to be stored in a larger bag, of course, to
> facilitate the necessary gas exchange during storage. Manufacturers of
> bags used for storage of apheresis platelet units already have
> documented the capabilities of their bags to hold the requisite volume
> and platelet content of apheresis platelet units, and we believe one
> can reasonably extrapolate these data to whole blood-derived
> platelets.
>
> Finally, we must not ignore the experience of others. Blood centers
> across Western Europe have been pooling platelets derived from whole
> blood for many years very successfully. Although these are usually
> derived from buffy coats, they provide an adequate, safe system for
> platelet storage. There should be no need to conduct studies to
> document again the [in vivo]{.underline} recovery and survival nor the
> clinical utility of using pooled platelets.
>
> The agency is concerned that the increased volume of a pool of
> platelets, in contrast to a single unit\'s volume, would allow
> contaminating bacteria to generate a larger inoculum and, thus,
> represent a greater risk for patients. The scientific basis underlying
> this concern is not strong, particularly when the endpoint
> concentrations are considered. The increased volume of a pool would
> make a difference only when the bacterial growth had reached a
> limiting concentration, and this concentration is usually in the tens
> of millions of bacteria per milliliter and higher. The difference in
> the total inoculum of bacteria would be higher than that from a single
> unit, in direct proportion to the number of units in the pool,
> according to the FDA\'s concern. However, at such high concentrations
> the morbidity is likely to be dramatic regardless of whether the
> pooling was conducted before or after storage.
>
> The AABB recognizes that authorization of pre-storage pooling will
> require a reliable system to detect bacterial contamination. The
> systems already approved for in-process quality control testing offer
> this capability, and others are known to be under development.
>
> Although bacterial contamination is a very significant threat to
> platelet transfusion recipients, its relative rarity makes any study
> conducted on platelets from whole blood platelets collected and stored
> in the routine manner extremely difficult to study. The AABB suggests
> that the [in vitro]{.underline} or spiking studies that have already
> been conducted be referenced as the primary basis of acceptance of a
> bacterial detection system that could be used to allow pre-storage
> pooling. This would be analogous to using not blood donors but a
> population at high risk for HIV to document that a new HIV antibody
> test was sensitive for detecting that pathogen\'s presence.
>
> The FDA has not based its approval of HIV test kits on the
> documentation that when donors were tested a second time they remained
> negative. The effectiveness of these systems could be tested in the
> real world by retesting units at outdate after the initial culture to
> determine whether the initial culture was accurate. However, the
> enormous size of such a study, suggested to involve reculturing 50,000
> to 100,000 units, will effectively preclude the study\'s performance.
> The result will be that a significant proportion of platelets
> transfused in this country will never be cultured for bacteria, and an
> opportunity to enhance patient safety will be missed.
>
> Instead, we urge the agency to look at the entire problem, that of
> bacterial contamination as it currently exists and as it could be
> markedly reduced by culturing pooled units, and exercise the FDA\'s
> mandate to improve the safety of transfusion by taking reasonable
> measures.
>
> We would also add that the ability to leukoreduce multiple units of
> platelets through a single filter as part of the pooling process will
> provide an economical way of conducting pre-storage leukoreduction
> with all the advantages this committee has already recognized. Since
> the vast majority of platelet recipients benefit from leukoreduction,
> and since it is generally accepted that removal of leukocytes prior to
> storage minimizes the likelihood of febrile reactions, allowing
> filtration and pooling would be a boon to recipients even beyond the
> facilitation of culturing.
>
> Finally, the addition of bacterial detection systems will necessitate
> some delay in release of platelets, which may ultimately result in a
> higher frequency of outdates and wastage. Given that platelets are
> already in short supply in some areas of the country, a further
> decrement will worsen these shortages unless the storage period is
> increased to at least seven days, where it was in the \'80s before
> recognition of the importance of bacterial contamination was
> recognized and we went back to five-day storage. Extension of the
> dating period for bacterially tested pooled platelets should be
> encouraged. Thank you.
>
> DR. NELSON: Thank you, Kay. I think I would like to break for lunch
> now and come back at 1:30 and continue the discussion. Thanks.
>
> \[Whereupon, at 12:35 p.m., the proceedings were recessed, to resume
> at 1:35 p.m.\]
>
> A F T E R N O O N P R O C E E D I N G S
>
> DR. NELSON: Nobody else had asked to speak in the open public hearing
> but if anybody has any comments\--if not, I think we will proceed to
> the questions for the committee. Dr. Vostal?
>
> **Questions for the Committee**
>
> DR. VOSTAL: Thank you.
>
> \[Slide\]
>
> We heard a lot of data this morning concerning how to evaluate
> platelets and how to evaluate the bacterial detection devices. We are
> hoping to get some input from the committee on these two topics.
>
> One of the discussion points we have is that we would like to ask you
> if you could please comment on the FDA proposed plan for validating an
> extension of the storage time for pooled platelets. In general, we
> would like to have input on the assessment of platelet quality and
> validation of the bacterial detection system.
>
> DR. LEW: It was brought up earlier that at one point FDA had approved
> seven days. I guess I would just like to know has processing changed
> dramatically since then, that now it is really worthwhile having to
> repeat everything? Or, could there be just limited studies that you
> are recommending based on the fact that it has been approved before?
>
> DR. VOSTAL: Processing has changed a lot, especially for the bags that
> are used to store platelets and the gas exchange of those bags. So,
> since the differences are significant, we would actually like to see
> studies that demonstrate that the current storage conditions are
> adequate to support platelets out to seven days.
>
> DR. FALLAT: We heard a lot of data about the five- to seven-day
> storage done currently, but I guess not within the framework of the
> FDA. How much of that data\--is that enough support for the [in
> vitro]{.underline}? Not being in this field, I can\'t really answer
> that but I certainly saw a lot of good data, it seemed to me.
>
> DR. VOSTAL: Currently in the U.S. we only have five-date dating for
> platelets. In Europe there are countries that store their platelets
> out to seven days. However, as you saw from Dr. Pietersz, the
> collection of those platelets is different and the platelet product,
> called the buffy coat platelet, actually is different. So, one of the
> issues we are trying to figure out is whether that data for those
> platelets would apply to the U.S. situation. If it does apply, it
> would make it a lot easier for us because of their clinical
> experience.
>
> DR. NELSON: I wonder if you could summarize\--I am not clear on what
> the FDA proposed plan for validating these three issues is. Could you
> summarize that? In other words, what are we supposed to comment on?
>
> DR. VOSTAL: Yes, sorry. For evaluating platelets we have a standard
> procedure that we follow, and we have a platelet testing guidance.
> Usually it involves [in vitro]{.underline} testing on the platelets at
> the end of their storage period. Then, we go to radiolabeling studies.
> However, in this case it is difficult to do those studies because you
> have a pooled product and you would be giving that to a single
> volunteer donor and there are ethical issues involved in that.
>
> To get around that, we are proposing that studies to evaluate [in
> vivo]{.underline} efficacy of these platelets would take place in
> thrombocytopenic patients who would get transfused with a pool and you
> would follow the outcome of those transfusions by count increments and
> corrected count increments. So, for validating the storage bags
> themselves, that is our approach.
>
> DR. NELSON: And what is the N in that trial, or how many people do you
> think would have to be studied to validate the bags?
>
> DR. VOSTAL: Those studies will probably require somewhere around 50
> patients. There have been studies done, for example, there was a study
> done by Baxter in Europe that looked at the efficacy of
> psoralin-treated platelets. They did a study where they followed CCIs.
> That was a study that had a total number of 100 patients, 50 per arm.
>
> DR. NELSON: Clinical efficacy I guess would require a larger number,
> right?
>
> DR. VOSTAL: This is one of the difficult questions. I mean, the
> clinical efficacy of platelets is really their ability to stop
> bleeding or their ability to prevent bleeding. For changes that we
> consider relatively minor stress on the platelets, we take the ability
> of platelets to circulate as a surrogate to efficacy. But in
> situations where we feel that the damage could be extensive, for
> example, if you are introducing a pathogen reduction treatment that
> may be causing all sorts of damage to a platelet, then we think that
> is enough of a concern to go to a study that follows hemostasis and
> bleeding.
>
> But in this area, I think based on the European experience with pooled
> platelets and no problems with hemostasis in Europe, I think the
> concept is demonstrated, such that we probably will not ask for
> studies to look at hemostasis.
>
> DR. NELSON: Count increments would work?
>
> DR. VOSTAL: Right.
>
> DR. DAVIS: It sounds to me like you want to reinvent the wheel, but
> how long would it take to revalidate the information that you are
> asking for here?
>
> DR. VOSTAL: Well, I would guess that if you started today you would
> probably, you know, do [in vitro]{.underline} studies and then set up
> a clinical trial, I think probably within 12 months you could get an
> answer.
>
> DR. LEW: Have there been any studies already just comparing the
> European way of collection with the buffy coat and compared to how it
> is done here, to kind of help guide or give us a hint?
>
> DR. VOSTAL: I am actually not aware of any studies that compared
> platelets prepared by the PRP method and prepared by the buffy coat
> method. Dr. Snyder, are you aware or any?
>
> DR. SNYDER: There were a fair number of studies that compared them [in
> vitro]{.underline}. I think the point you asked about is [in
> vivo]{.underline} and transfusions, and I don\'t think there were a
> lot of those. I would have to go back and look, but maybe Dr. Pietersz
> would be able to comment on that. I think most of those were looking
> at [in vitro]{.underline} characteristics. Do you agree?
>
> DR. PIETERSZ: I know that Stan Holme did a lot of comparisons between
> PRP and buffy coat platelets, but they were [in vitro]{.underline}
> studies.
>
> DR. VOSTAL: I think the big difference between the PRP platelets and
> the buffy coat platelets comes when the PRP platelets are actually
> centrifuged hard in the bags so there is a platelet pellet which is
> then resuspended. The buffy coat platelets are always centrifuged on
> top of a red cell cushion. I mean, this is just my opinion but I think
> the buffy coat platelets are less stressed during the collection
> procedure.
>
> DR. KLEIN: I think that is right. There is a lot of [in
> vitro]{.underline} data that shows that there may be a slight
> advantage to the buffy coat system. There are no head-to-head
> prospective transfusion studies.
>
> I just want to comment that I think we have seen a load of [in
> vitro]{.underline} data on pooled platelets stored for five days or
> seven days. We know that [in vitro]{.underline} data in general is not
> predictive of performance [in vivo]{.underline}. Personally, I can\'t
> see any reason to do additional validation studies for pooled
> platelets [in vitro]{.underline}.
>
> On the other hand, there haven\'t been studies of pooled platelets,
> seven days, [in vivo]{.underline} and I quite agree with you, based on
> the European data I think we can feel confident that a relatively
> small study, looking at corrected count increments, could tell us
> exactly what we need to know to go ahead with these kinds of
> applications.
>
> DR. NELSON: I think the FDA would have to perhaps set some guidelines.
> In other words, I am not sure that if there was a statistically
> significant difference in the corrected counts that that would be
> clinically relevant because you could give a larger volume of
> platelets and make up for that. You know, maybe the FDA has this
> guideline but I am not aware of it, and they need to set some
> guidelines as to what is an acceptable comparison between the five-
> and seven-day storage.
>
> DR. KLEIN: I would be astonished if the seven-day platelets were
> exactly as good as the five-day platelets, and certainly they are
> never going to be as good as two-day platelets. I think everybody
> accepts that. But I guess the real issue is whether they are safe and
> effective. I am not going to design the study for anyone, even if a
> company supports it, but I think that you can very easily say five
> percent, ten percent, whatever you want, to say less than a five-day
> old platelet would be effective. If you can define effective, they
> will be effective; they will stop bleeding.
>
> DR. NELSON: We heard the numbers 75 percent and 80 percent and 70
> percent; you know, you pick a number I guess.
>
> DR. ALLEN: We have heard a lot of data and, yet, most of it is data
> that is several years old to five to six years old, looking at some of
> the containers, devices and the filters that are currently available.
> The studies are always running well behind available and approved
> capabilities. We heard Mike Busch comment from the floor about Blood
> Systems proposed introduction of bacterial culturing of pooled
> platelets and that that would be done through a centralized
> laboratory.
>
> The processes are changing very rapidly. So, I think somehow the FDA
> has to get in hand the information that it needs to make some of the
> decisions, and needs to encourage broad-based studies. Again, I am
> sorry that the full committee isn\'t here, but this may be an area
> where either the FDA should be funding some very targeted studies or
> NHLBI ought to be doing so, or other sources of funding but I think
> the FDA needs to work, as it has occasionally in the past, closely
> with academic institutions to design and implement the studies. When I
> say academic institutions I am certainly including the large blood
> collectors that have done this kind of research. I think we need to
> evaluate and collect data.
>
> I also think we need some way of realistically looking at the
> trade-offs such as Dr. Klein\'s statement that seven-day platelets,
> while they may be on a simple scale both safe and effective, probably
> aren\'t as good as five-day old, and those aren\'t as good as two-day
> old. I mean, from my perspective, although I haven\'t done clinical
> medicine in a long time, I would much rather get one- or two-day old
> platelets than five-day old platelets if I had to be a platelet
> recipient.
>
> We are talking about mechanisms that in fact are going to push that
> availability and use on out. So, I think we have to look at what are
> the trade-offs there. Yes, maybe it can be approved from a regulatory
> perspective but, as clinicians, we would always like to see them used
> or be made available at an earlier point. So, I think we have to be
> cautious about making final decisions about how long a culture has to
> be run before it can be released, and that sort of thing, and I think
> those are regulatory issues that the FDA has to wrestle with and I am
> not sure that we have nearly enough data today for us to give you good
> advice nor for you to make a really meaningful decision.
>
> DR. NELSON: On the third point, the validation of a bacterial
> detection system, was this referring to the BacT/Alert or culture
> based system, or some other system?
>
> DR. VOSTAL: Right now the only systems available are culture based,
> the two that are on the market. So, currently our studies are sort of
> geared towards validating those systems. If a system comes up on the
> market that has almost real-time recognition, real-time readout of the
> bacterial contamination I think studies could be designed a little bit
> differently.
>
> DR. NELSON: Was the FDA prepared to accept data, either partial data
> or a whole study, where the bag was intentionally contaminated with a
> certain number of level of organisms that are commonly found, or were
> you talking about essentially a natural history study? What sort of
> validation were you aiming for here?
>
> DR. VOSTAL: Well, what we have proposed so far is to do laboratory
> studies where you actually spike units with small amounts of bacteria.
> But we also feel that besides that we would like to see a field study
> that samples naturally contaminated units and you would get an idea of
> how sensitive that device is in the real-life situation.
>
> DR. NELSON: I guess one of the things that a natural field study would
> tell you that a spiked study wouldn\'t would be the frequency of false
> positives. You can learn that but the true positives might require a
> fairly large study I guess if you were looking at the range of
> organisms, etc. I think that is a constraint. But I would think that,
> in addition to a spiked study, at least a study that would allow some
> estimate of what the false-positive rate is, given a new method for
> the pooling and the extended shelf life, etc., and a new bacterial
> detection system might be worthwhile to learn what the false-positive
> rate is because that would influence decision-making, wastage of
> platelets, etc. and might uncover some problems.
>
> MR. VOSTAL: That would be a lot smaller study because you would only
> reculture the positives that you would get. So, the question is would
> that be sufficient, or should we wait to see results of a large field
> trial?
>
> DR. DAVIS: I would like to say again that as a blood user I have seen
> enough to convince me that I think it is safe enough to go ahead we
> pre-pooled platelets and keep them in storage for seven days. If it
> increases the supply of platelets, I am all for it. I have been in
> situations where I have been out of blood; I have been out of
> platelets and out of components. I don\'t want to be in that situation
> again.
>
> DR. KLEIN: I want to get back to the point that Jim Allen made a
> little earlier, that is, the issue is not whether the seven-day
> platelet is not as good as the two-day platelet but, really, I think
> what we are faced with is whether a seven-day pool of bacterial
> cultured platelets is better overall in terms of safety and efficacy
> than is a five-day pool at the time of issue that isn\'t going to be
> tested\--those are not going to be tested for bacteria. In fact, what
> will happen is a mandate for bacterial culture or testing, they will
> disappear and you will only have apheresis platelets. I think that is
> the practicality, which several people can comment on who are involved
> in large collection centers. That would be a major issue in terms of
> platelet supply in the United States because somewhere between 25-30
> percent of all platelets are today whole blood-derived, so-called
> random units.
>
> DR. STRONG: Just to amplify, the last two speakers have spoken on the
> issue of supply and I think that is critical. We shouldn\'t be
> striving for the perfect in this situation. We really are on a
> timeline here. We have a standard that has been set that needs to be
> implemented by March of 04 to do testing on all platelets. There
> isn\'t a system available right now for the whole blood platelet,
> which will result in forcing us to apheresis platelets. We really need
> to find a way to allow us to continue to use whole blood platelets in
> a way so we won\'t jeopardize the platelet supply.
>
> There are a couple of issues that I think need to be addressed. One is
> that the FDA hasn\'t set a good standard for what needs to be achieved
> in any kind of study that we do. Should it be 75 percent recover, 50
> percent survival, a CCI of X, whatever it may be? That is the place to
> start so that the studies can be begun. But if we can have a process
> that would allow us to implement a pooled platelet product that we can
> bacterially test while we collect the data, and actually I think there
> is a lot of data to suggest that it would be okay, but allow us to
> collect scientifically valid data in the interim period so that we
> don\'t have to wait for the three to five years that it would take to
> collect scientifically acceptable data to allow this to happen because
> that will be too late.
>
> DR. GOLDSMITH: Could you comment on the impact of the timing of the
> leukoreduction on the proposed trial designs as an additional
> variable?
>
> DR. VOSTAL: Well, I would agree with Dr. Snyder that pre-storage
> leukoreduction is optimal and the longer you wait, I think the less
> benefit you would get from leukoreduction.
>
> DR. NELSON: That is what has been recommended I think by BPAC. I
> don\'t think it is mandated but it is recommended at the present. Yes?
>
> DR. FITZPATRICK: A couple of things. I think we need to be clear that
> there are two purposes for platelets. One is prophylactic prevention
> of bleeding in a patient. The other is to stop bleeding in a patient.
> Counts and CCIs don\'t really address efficacy in both those
> situations.
>
> I think Dr. Snyder presented us with a bulk of data on different days
> of storage, even out to eight and nine days. So, [in
> vitro]{.underline} data shows that there really isn\'t an [in
> vitro]{.underline} difference in different bags, in different
> situations, in different collection systems. In systems that are
> currently used from an [in vitro]{.underline} perspective, the
> platelets look pretty much the same. There is a bulk of data on that
> that tells you that [in vitro]{.underline} there isn\'t much
> difference.
>
> Clinically and effectively, physicians I think will tell us that there
> is a difference in some patients as the platelets age. The older
> platelet may not be the best platelet for a frankly bleeding patient
> but we don\'t know that for sure and we don\'t have data to support
> that, or good studies to support that.
>
> The question on validation confuses me a little bit because there are
> two FDA approved devices for detection of bacteria in platelets that
> are approved. So, one type of validation is user validation, is the
> user using that detection system in the way the manufacturer intended
> for getting the appropriate results? I don\'t think that is what you
> are asking us. I think what you are asking is what should the FDA do
> for the user to validate that he can use that system and keep those
> platelets for seven days.
>
> In your presentation you suggested filtering at 24 hours or time of
> expiration at seven days, and doing a whole lot of units to do that.
> You heard from organizations saying that they thought that might be
> burdensome and increase the costs. I would agree with that. It would
> be burdensome to do that many units and increase that cost and you
> should maybe look at some spike assays for that with slow growing
> organisms, but if it is negative at 24 hours and you have evidence,
> with some statistic sampling, that it is negative at seven days we
> shouldn\'t ask every user to do that for 10,000 units.
>
> So, I think you are asking two types of things about user validation.
> If it is the user who is using it as the manufacturer intended, then
> the validation should be relatively simple.
>
> The other aspect of that, which I bring up somewhat tongue in cheek,
> is the fact that there is an application before FDA for a frozen
> platelet that can be kept for a year. It is my hope that we will be
> able to get that approved within the next few months but it requires a
> multi-center trial which would require funding. I would hope that we
> will be able to meet with the FDA soon to do that.
>
> But if there were available to the clinical population a platelet that
> could be frozen and easily thawed and used within minutes, not hours,
> for the frankly bleeding patient that would help with the supply
> problem. It has been shown to be effective in one clinical study, not
> in multiple clinical studies, and is an aspect where we should
> possibly start thinking about two different types of platelets for use
> in patients and alleviate some of the strain on the liquid platelet
> inventory by progressing as quickly as possible by getting this system
> licensed.
>
> It is my understanding right now that the only proposed regulatory
> body setting the standard\--we have CAP and AABB\--but the FDA has not
> proposed a guidance or a rule on bacterial detection in platelets. So,
> even within those standards we have the risk of a tiered system, as
> was talked about by the presenters. We have swirling; we have
> dip-sticks; we have multiple different methods of detecting bacterial
> contamination of platelets, some much more sensitive than others but
> some a lot less expensive than others.
>
> So, without rule-making or a guidance, and with the pressure on supply
> and inventory, and without the pre-pooling you will essentially
> mandate a two-tiered system in order to keep supply available. I
> don\'t think that apheresis platelets will just automatically replace
> random donor platelets because of cost pressures and because of supply
> pressures. So, because they have to have a system someone will use
> swirling, or someone will use dip-sticks. We know that those systems,
> while they may be better than nothing, are not the best available.
>
> You know, we have ample evidence of [in vitro]{.underline} stability
> of the product. We talked last time about the sterility of the sterile
> connection device. Perhaps we could move forward with pooling at least
> for five days and collect information on seven days. Maybe there is a
> way with postmarket information to be able to do that, or some focused
> studies at sites with seven days within NIH. But I think pre-pooling
> offers great advantages both to the patient and the center, and might
> help alleviate blood type shortages if the collection centers pool in
> pools of like type and then we don\'t have problems with the hospitals
> just picking whatever is on the shelf and pooling it. I think there
> are a lot of advantages to that.
>
> DR. VOSTAL: You made several points here\--
>
> \[Laughter\]
>
> In terms of the validation issue, what we would like to see is
> validation done by the manufacturer to support their intended use. So,
> we would like to see data. Currently, the two devices are validated
> for quality control of platelets.
>
> Our thinking is that if they would like to have a platelet screening
> or release of platelets as an intended use, then they would have to go
> through this field trial. But I am not talking about validation done
> by the actual user; this is for the manufacturers.
>
> Then you talked about different kinds of platelets, having platelets
> for prophylaxis and having platelets for treatment. I think there
> could be two different indications for platelet products. However, I
> think currently platelets that we transfuse basically are used for
> prophylaxis use, to be able to circulate so if there is a breach in
> the cardiovascular system they will be able to plug that up.
>
> You were talking about frozen platelets, I think we recognize the need
> for that for treating bleeding soldiers in the field and for acute
> treatment use. It might be something that may not be a platelet but
> could be a platelet-like product or something like that.
>
> In terms of being able to put together a guidance on bacterial
> detection in platelets, I think it is in the works. We are trying to
> put one together and, hopefully, we will get one together relatively
> quickly.
>
> DR. KLEIN: I would point out that we do have a standard really, a
> generally accepted standard for platelet transfusion. Whether it is by
> increment or corrected count increment, every clinician uses the
> generally accepted standard and I think that wouldn\'t be difficult to
> agree upon.
>
> I think the difference is whether this particular platelet stored at
> seven days is as effective in terms of increment as two-day platelets.
> I think as long as we don\'t have that mind set, as long as we look at
> the entire picture and say is it safe or is it bacterially tested and
> stored, and if it isn\'t and still meets a clinically accepted
> standard\--patients are quite different than normals who receive
> labeled platelets\--I think we can get a pooled product in an [in
> vivo]{.underline} trial with an acceptable endpoint and demonstrate
> that these are good, as I suspect they are from the European data
> which isn\'t exactly the same, or whether they are not. But we do have
> a standard to look at.
>
> DR. STRONG: I would also like to comment on your encouraging the
> manufacturers to do these studies because it has been our experience,
> at least thus far, that there is really no incentive for them to do
> that. They have [de]{.underline} [facto]{.underline} got the market to
> do what we are doing because the blood centers have decided to do
> that. So, there really is no incentive for them to spend the money to
> do all of the kinds of validations that you are talking about. So,
> somehow we have to get past that as well because the centers
> themselves cannot afford to do it.
>
> DR. SNYDER: Two comments, one relating to frozen platelets. Frozen
> platelets are something that I think is a good goal, however, it is
> logistically difficult for hospitals to deal with that. I assume it
> would be in DSMO they would be frozen, although I don\'t know for
> sure. If it is DSMO, that would be a problem. We would need IRB
> approval for sure because most noon-cancer patients would not
> necessarily want to get DSMO without knowing about it and the time to
> ask them about it is not when they are in extremis, etc. There would
> be some logistic issues, though it certainly would be useful. I
> wouldn\'t want to delay studies looking at what we can do better with
> liquid storage while we push a frozen protocol, not that you suggested
> that but I just wanted to say that.
>
> The other thing related to looking at five-day and then going to other
> studies to look at seven-day, if you can sit down with a large enough
> cup of coffee or chamomile tea, depending on your preference, you
> probably could figure out a protocol where you could pool\--and that
> is something else the agency needs to give some guidance on, how many
> units are you allowed to put into a pool\--if you could pool, let\'s
> say, eight units together and then you could divided it into two
> aliquots, one aliquot could be transfused into the so-called standard
> sick thrombocytopenic individual at day five and then you have all of
> day five, all of day six and all of day seven. You could then
> transfuse on day seven, and these patients normally require platelets
> perhaps three days later, the seven-day stored of the same pool. Then
> you could, therefore, get five- and seven-day data that could be
> comparable.
>
> Although that would be difficult and you might limit the number of
> patients, it might in the long-run be more efficient to consider doing
> it that way and at least you would get five- and seven-day data. At
> most academic centers you probably could put together a protocol like
> that.
>
> So, I think these are some things we should think about. I would hate
> to just do five-day and then have to come back and start all over
> again to do seven. We should be clever enough to figure out how to do,
> you know, baby and bath water at the same time.
>
> DR. NELSON: That is a good suggestion. Other comments? Have we
> commented sufficiently?
>
> DR. VOSTAL: We actually had three discussion points but I think we
> have run through most of them. Could I have the next slide?
>
> \[Slide\]
>
> The second one was to please comment on the applicability of the
> European experience with pre-storage platelet pooling of buffy coat
> platelets to the FDA proposed criteria for approval of pre-storage
> pooled PRP platelets.
>
> DR. STRONG: I would like to encourage us to be able to do both buffy
> coat and the current PRP approach. There is some data to suggest buffy
> coat platelets in fact might be better, particularly for extended
> storage, because of the things that you just talked about. But we
> should be allowed to explore both of those opportunities.
>
> Clearly, the European data is now coming to light, particularly the
> bacterial testing as well as clinical efficacy, that would suggest
> that it works. How we validate in this country is kind of the issue
> and we need to be able to move forward in doing that.
>
> DR. NELSON: I have one other question with regard to the bacterial
> contamination. Is it now FDA mandated, the initial diversion and the
> skin prep, or is that still whatever anybody wants to do? I know the
> AABB has made some recommendations but that might affect the frequency
> of bacterial contamination, particularly from skin flora. Is that
> mandate or recommended by FDA now?
>
> DR. VOSTAL: It is recommended by the FDA but not mandated. Actually,
> that was an issue we discussed at BPAC maybe a year ago, diversion
> pouch, and we put forth criteria for approval of diversion pouches and
> we have received several applications and several are already on the
> market.
>
> DR. NELSON: So, do you think most blood collection facilities are
> doing that now?
>
> DR. VOSTAL: Actually, I am not sure how many are involved.
>
> DR. STRONG: It partly relates to the availability of bags so there are
> still licensure issues.
>
> DR. KLEIN: Getting back to this discussion point, I think you have
> four issues that you began with, seems like days ago\--
>
> \[Laughter\]
>
> \--about pre-storage pooling. One of them had to do with the reaction
> between lymphocytes, the MLC. I think to answer this question, the
> European data, I feel very comfortable, has set that aside. The second
> had to do with the quality of the platelets because of possibly
> antiplatelet antibodies, etc., etc. Once again, I think I feel very
> confident that the European data is quite acceptable in that regard.
> The third had to do with bacterial contamination and, since we are
> going to be testing, we don\'t have to rely really upon the European
> data for that. The fourth one, I confess I have forgotten.
>
> \[Laughter\]
>
> DR. VOSTAL: It was the sterile connecting device.
>
> DR. KLEIN: So that is no longer an issue as well.
>
> DR. ALLEN: In the United States, does the FDA now require the PRP
> platelet preparation and does not approve the buffy coat? Is that
> correct? I mean, that is not an option to United States blood banks?
>
> DR. VOSTAL: Right, as far as I know, the buffy coat platelets are not
> licensed in the U.S.
>
> DR. ALLEN: I agree with Harvey Klein\'s comments. Based on the data we
> heard today, it certainly seems as though that is a very reasonable
> option to offer. I am not sure, from a process perspective, what it
> would take on the part of U.S. blood banks to switch over but I have
> no reason to think that it should not be available as an option.
>
> DR. SIEGEL: We don\'t mandate against buffy coat platelets, just that
> blood centers have not come forward requesting approval of buffy coat
> platelets.
>
> DR. KLEIN: That would really be a sea change in how blood centers
> function. That is not a minor change.
>
> DR. WAGNER: Steve Wagner, from the Red Cross. I just wanted to make a
> comment about buffy coat platelets. There are some differences in
> practices. To get a really good, high quality buffy coat from which
> you can make platelets you really need to hold whole blood for an
> extended period of time. Most of the European countries that are
> making buffy coat platelets hold the whole blood for more than eight
> hours, which is what we are currently allowed in the United States to
> hold whole blood. So, there is a variety of things that would have to
> change in order to be able to practice buffy coat platelets.
>
> In addition, when you make buffy coat platelets you are going to lose
> a certain number of red cells. So, that also has to be factored in.
> So, it is not an idle discussion to talk about conversion, but it
> would require quite a lot of work and a change in the way blood
> centers and blood providers operate, and the way in which the
> regulations now stand, as I understand it.
>
> DR. STRONG: I would agree with those comments. Clearly, it would be a
> huge process change for all of us. On the other hand, if it ultimately
> leads to improved platelets and perhaps even longer storage times, and
> there are data I think in several laboratories to suggest that the
> buffy coat platelets may be storable for longer periods of time,
> particularly with additive solutions which somebody commented on this
> morning, that we should encourage more experimentation with additives
> to extend the platelet storage time. Nevertheless, we have been
> through pretty major changes before in blood centers, NAT not being
> the least of those. So, I think it is entirely doable. It is just a
> matter of having the ability and the receptivity by the FDA to do it
> that would perhaps encourage some of that.
>
> DR. VOSTAL: Maybe we can move on to the last discussion point.
>
> \[Slide\]
>
> In case we didn\'t cover some of these things, if you could please
> comment on the following bacterial validation issues, how useful is
> the bacterial detection data on buffy coat platelets collected in
> Europe to validation of bacterial detection devices for PRP platelet
> pools?
>
> If bacterial detection devices are validated for PRP prepared random
> donor platelet units, do they need to be revalidated for PRP platelet
> pools?
>
> If bacterial detection devices are validated for leukoreduced platelet
> products, do they need to be revalidated for non-leukoreduced platelet
> products?
>
> DR. NELSON: I think with regard to the second question there, you
> might get more false positives and true positives actually in a pool.
> But I would be concerned about whether the pooling actually did
> something to the false-positive rate. Maybe I am wrong but that could
> certainly influence how platelets were handled.
>
> DR. ALLEN: Again, I go back to the point I made about every time you
> change the process, even in a small way, it may have an impact. For
> example, if we find that from a year from now a large proportion of
> all blood being collected has that initial diversion system in place,
> perhaps the potential for contamination from skin bacteria and skin
> plug bacteria may increase significantly.
>
> Given the systems that I have seen demonstrated on slides, they look
> fairly complex. Nonetheless, they have the sterile connector systems
> in place. I think they are trying to make them people-proof, which is
> probably good. Nonetheless, they look reasonably complex to use and my
> hospital infections experience from many decades ago suggests that the
> more complex they are, the greater the chance for somebody to screw up
> somewhere.
>
> So, I am not sure that they need to be totally revalidated.
> Nonetheless, I think the FDA should encourage studies of each new
> process change and that ought to be a continual event. Even once you
> get useful products and systems on the market and in use, we need to
> continue to look at these.
>
> To my mind, I think there are a number of questions in terms of the
> bacterial contamination, one being can we reliably detect bacterial
> contamination very early without waiting for that 24-hour sampling
> period?
>
> Second, if you are pooling, are you then reducing the amount of the
> volume that might come from any single contaminated unit and what
> would that do to the sensitivity of being able to detect, or the
> rapidity with which a system, such as the radiometric assay, would
> become positive?
>
> So, I think for each of these stages questions need to be raised and
> be looked at. I am not sure I would necessarily suggest that they have
> to go through a whole revalidation process but I think part of the
> academic inquisitiveness that is the essence of the scientific method
> on which our practice of medicine should be based suggests that we
> ought to be continuing to do studies of this type.
>
> DR. NELSON: One question is are the same bacterial detection devices
> used in Europe? You mentioned there are two licensed, are these the
> same in the U.S. and Europe?
>
> DR. VOSTAL: Actually, I am not sure which ones are licensed in Europe.
> The BacT/Alert is being used in Europe.
>
> DR. NELSON: Right.
>
> DR. VOSTAL: I am not sure if the other ones are.
>
> DR. KLEIN: Again, in focusing on the questions that you are asking
> here, if you remember the slide that Ed Snyder showed comparing the
> way you prepare platelet-rich plasma and platelets compared to buffy
> coat, they are not that different. One is a hard spin first and one is
> a soft spin first. The quality of the platelet may be a little
> different but basically the component is extremely similar. So, in
> terms of how useful is the data from Europe for platelet-rich
> plasma-derived platelet concentrates, I think they are very relevant.
>
> On the other hand, if you are talking about leukoreduced versus
> non-leukoreduced platelets, there may be quite a difference there. We
> are not just thinking about BacT/Alert but we are looking at any
> system and certainly the Pall system is an indirect measurement,
> looking at oxygen consumption, and we don\'t know that there isn\'t a
> difference. So, I would think that we would have to validate
> leukoreduced versus non-leukoreduced, although if you are looking at
> buffy coat platelets that are leukoreduced, I think those data are
> very applicable to our leukoreduced platelets. If you have data on
> buffy coat platelets that are not leukoreduced, those are very
> relevant to non-leukoreduced platelets.
>
> DR. NELSON: Actually, theoretically non-leukoreduced blood might
> actually clear some bacteria that were present.
>
> DR. KLEIN: I have heard that stated, and certainly the Europeans feel
> that their hold on blood for 18-24 hours prior to filtration is really
> beneficial but, again, I think we need some data on that and we really
> don\'t have any. We have numbers but we don\'t have data.
>
> DR. DICKSTEIN: Rob Dickstein, Pall Corporation Yarrow. For the record,
> the Pall BDS bacterial detection system has been licensed in Europe
> for approximately a year and a half now.
>
> DR. NELSON: So, yes, yes and no I guess.
>
> DR. STRONG: Well, I think there is validation and then there is
> validation. There is no process that we change, as Jim points out,
> that we don\'t validate. I think the question here is do we have to
> revalidate the bacterial detection system itself rather than the
> process. So, we will definitely validate the process. Whether we have
> to go through the entire gamut of testing every organism at different
> doses, and what-have-you, I think is really the issue and then the
> differences I think are quite apparent.
>
> DR. FITZPATRICK: The ultimate goal appears to be is, is there an
> impact on sensitivity of the detection system. So, I think each
> process or change in process needs to be evaluated on the number of
> bacteria that would be present at the end of the chance of the
> process. So, a non-leukoreduced product should have more bacteria
> present than a leukoreduced product. If there is an impact, then the
> manufacturer has to revalidate that system, but if it is validated on
> a leukoreduced product I wouldn\'t think you would have to go
> backwards.
>
> I just want to support Dr. Klein. I think there is ample evidence
> there is not enough difference in the procedure in producing the
> platelet between Europe and hard spin to invalidate the bacterial
> detection systems or even scientifically think of a way that it could
> possibly invalidate those systems. So, that data should be very
> applicable.
>
> DR. EPSTEIN: Just to play devil\'s advocate, if the white cells
> incubated overnight eat up more bacterial which are then cleared when
> you filter, then it matters how long you dwell and when you filter. In
> theory, you might have lower bacterial concentrations then that,
> depending when you culture, might or might not detect the
> contamination. So, the two things can interact.
>
> DR. FITZPATRICK: If you are culturing at the end of that incubation
> period, theoretically you can do that, yes.
>
> DR. EPSTEIN: Yes. What I am trying to say is you have to look at it as
> an integrated process. One of FDA\'s concerns about claims that
> bacterial detection systems are release tests, namely, that they
> assure at some level of confidence a negative culture at the time of
> issue or control testing outdate, has to do with when do you test and
> under what conditions do you test in relation to that assertion. It is
> the definition of those conditions in relation to the process as a
> whole that is the question.
>
> DR. FITZPATRICK: I agree, Jay. That is why I think the analysis should
> be comparing the processes so that they are applicable, and if there
> is evidence to show that there might be a reduced load at the end of
> that period because of the white cell interaction, then the
> recommendation, if you are not going to revalidate, would be that you
> culture prior to that I guess to avoid that complication until you can
> figure it out.
>
> DR. KLEIN: But remember that there is a lot of European data, and some
> of them are doing their pooling and filtering after eight hours, just
> as we do. Some are doing it, as the Dutch do, usually between 18 and
> 24 hours. Some are doing it at 24 hours. There are a lot of data out
> there and I would still argue that for any given process that is
> similar, whether you do a hard spin first or do a soft spin first, is
> not going to make a difference. You just want to make sure that the
> systems are comparable and then you can use the data that are
> generated in Europe.
>
> DR. SCHMIDT: Does hard spin versus soft spin have anything to do with
> throwing down the bacteria into the final product? Are you spinning
> down bacteria?
>
> DR. VOSTAL: Well, I don\'t have any data on that. I would think that
> platelets would be comparable size, maybe even bigger, so I would
> think that if platelets are staying up the bacteria are as well.
>
> DR. LAAL: You would need to spin much harder to get the bacteria to
> come down.
>
> DR. STRONG: Just to comment on the release issue, I don\'t think most
> of us are considering this to be a release test because you have to
> incubate it to get a final result, and if you incubate five days, you
> won\'t have any platelets left. So, the challenge here is at what
> point do you culture? When can you accept a certain level of
> detection? And, is that good enough?
>
> DR. NELSON: After the culture is taken, how long does it have to
> incubate and be negative before the platelets are released?
> Twenty-four hours? I mean, sometimes you use platelets that are two or
> three days old.
>
> DR. STRONG: I think the majority of people at this point are planning
> to store the platelets for 24 hours, take a culture, release the
> platelets, then allow the culture to go on as long as the platelet is
> still in storage. The data suggest that you should expect the majority
> of cultures to become positive at 24 hours of the initial culture.
>
> DR. NELSON: At least with clinically relevant organisms.
>
> DR. KLEIN: The Dutch are releasing right away, as soon as they take
> their sample, and then calling back any positives. Others are holding
> for anywhere from 12-24 hours where are virtually all the organisms
> that are going to show up will show up. But that is something where,
> again, I think there is going to be some controversy about when to do
> it, and there may be several ways.
>
> DR. SIEGEL: I just want to mention that the two approved systems for
> quality control culture are different in that the BacT/Alert has a
> continuous readout, the culture continues to incubate and can be read
> out at any time during the storage period of the platelet. Whereas,
> for the BDS system you have a fixed time at which you read it, either
> 24 or 30 hours, but you read it one time and you do not continue to
> incubate. So, it is not exactly as Dr. Strong described if you use
> BDS.
>
> DR. NELSON: Do you think most blood collection facilities are going to
> go to culture?
>
> DR. STRONG: Well, we don\'t have a scientific survey at this point in
> time. I think it looks like the majority are but it kind of depends on
> your size as to which system works better for you, and also the
> logistics of how far you are transporting platelets to a test center.
>
> DR. KUEHNERT: Matt Kuehnert, CDC. I was going to make a comment on the
> question about when to release platelets. I wasn\'t sure whether the
> question was when should people or when are people going to. It is
> sort of a difficult thing because of the spectrum of how organisms
> behave. Certainly, there is a bimodal distribution roughly between
> gram negatives and gram positives, with the gram negatives growing
> more quickly.
>
> But one thing that was brought up earlier was endotoxin assay. That
> would certainly be a quicker potential way to capture units that might
> be right at the edge of becoming positive, had just been releases,
> say, on day two and then two hours later it gets recalled and it is
> sort of too late, already sent out. I guess that is not on the agenda
> but I just wanted to sort of add that as a potential ancillary test
> that could be used in conjunction with culture. But I don\'t think
> there is an easy answer to when to release because we are talking
> about organisms that all have different characteristics.
>
> DR. NELSON: Are all potential blood donors who are on any sort of
> antibiotic, prophylactic or otherwise, excluded as donors, and is that
> system pretty good? Because this could influence how quickly an
> organism might grow out.
>
> DR. KLEIN: Yes, they are unless they are on acne antibiotic but
> essentially they are eliminated because of their underlying illness
> and antibiotic is a marker for an underlying illness.
>
> DR. STRONG: In terms of endotoxin, actually we are doing endotoxin
> assays now on certain cellular products, such as islets, prior to
> release. I think that would be a logistical challenge for blood
> centers who are processing 10,000 or 20,000 units a day to do that
> many endotoxin assays, but we have been forced to do other things.
>
> DR. VOSTAL: All right, thank you very much.
>
> DR. NELSON: Thank you. The next issue is an update on particulates in
> blood bags. Dr. Lewis?
>
> **Update on Particulates in Blood Bags**
>
> **Introduction**
>
> DR. LEWIS: Thank you, Dr. Nelson.
>
> \[Slide\]
>
> We appreciate the opportunity. This was a last minute addition to the
> agenda. Thank you, Dr. Smallwood for allowing us to put this on late
> in the planning process but it has been an ongoing concern at the FDA
> as well as at blood organizations, exactly what are white particulates
> that have been identified in some blood units. In order to update you
> on a number of ongoing studies, as well as the entire issue, we asked
> for some time here.
>
> \[Slide\]
>
> The FDA received information on this particulate matter from the
> American Red Cross on January 31st. Their report told us that they saw
> it in Baxter blood bags. They saw it only in the southern region and
> then, a few days later, noted that there were adverse events
> associated with some of the lots of blood bags in which they had
> identified particulates and that there was some investigation of a
> fatality of an individual who had received a couple of units of blood,
> and that blood was also collected in blood bags that were of the same
> lot as some of the others in which they had observed particulates.
>
> \[Slide\]
>
> This is one of the first photos that the FDA received. This is from
> Dr. Chris Hillyer at Emory. He had taken a unit of blood that had
> these particulates in it and passed them through a normal kitchen
> sieve and there is some material that didn\'t pass through the sieve.
> This was of some concern.
>
> \[Slide\]
>
> He has isolated one of these particulates and shows it here. It is
> about 8 mL.
>
> \[Slide\]
>
> During the course of the investigation, the American Association of
> Blood Banks was kind enough to put some photos of various types of
> particulates that had been observed on their web site. Throughout the
> course a number of different types of particulates were identified.
> Type C or type 1 is very small, later referred to as \"starry night.\"
> Type 2 are larger particulates. Type 3, atypical bubbles were seen.
> Type 4, kind of a yellow oil slick on the top of the blood unit.
>
> \[Slide\]
>
> These are further pictures. In the upper right, a normal bag compared
> to a type 4, and then other normal appearing units.
>
> \[Slide\]
>
> This was type 5. Some of the particulates that are seen in the closeup
> on the right were later identified as materials on the outside of the
> bag.
>
> \[Laughter\]
>
> It is funny now!
>
> \[Slide\]
>
> This is a close up of type 1. Some of the particulates there.
>
> \[Slide\]
>
> Type 2, with larger aggregates.
>
> \[Slide\]
>
> These were the oil bubbles. Initially the observations suggested that
> there was a particulate at the bottom of the bubbles, however, it was
> later noted that the nature of the bubbles was such that the light
> that was used to illuminate the blood bag was reflective in the back.
>
> \[Slide\]
>
> The same thing when the same bubbles were taken with polarized light.
> It was shown that there were in fact bubbles there that did not
> coalesce, however, there weren\'t particulates in them.
>
> \[Slide\]
>
> Again, type 4. This is the oil slick. I am not sure what the
> perspective is of this photo but you can see that in the middle there
> is a long, stringy fibrinous material.
>
> \[Slide\]
>
> From the Red Cross we heard that some of the conditions where they
> observed these particulates were that the bags had previously been in
> the cold, removed from the cold, the bags placed flat and particulates
> could be observed after about ten minutes. The observations were with
> the label down.
>
> \[Slide\]
>
> We noted that our regulations require a visual inspection and on
> February 7, one week later, the FDA issued a statement that we put on
> our web site encouraging visual inspection over and above the required
> visual inspection. We thought that the procedures that were used by
> the Red Cross were appropriate and we noted that this was an interim,
> precautionary measure.
>
> \[Slide\]
>
> At that time we asked that any observations be reported by email or by
> phone. One of the next speakers, Jerry Davis, from the FDA, will
> comment on some of the reports that we have received at those sites.
>
> \[Slide\]
>
> During all this time the CDC was involved and they did a number of
> studies. Matt Kuehnert is going to present some of those studies, both
> clinical as well as laboratory investigations into some of these
> particulates.
>
> I am going to stop there right now. I have a number of other slides
> and I would like to finish at the end of our session with those
> particular slides, but we have a number of speakers who will tell us
> about some of the investigations that they have completed and that are
> ongoing. Dr. Peter Page, from the American Red Cross, will talk about
> the discovery of these particulates, some of the ADR investigations
> and the various conditions of collections that led to their
> conclusions.
>
> DR. NELSON: This reminds me of an experience that I had as a hospital
> epidemiologist at the University of Illinois. There was a surgical
> patient that needed a unit of fresh-frozen plasma immediately. So, the
> junior resident went to the blood bank, got the fresh-frozen plasma
> and on the way to the OR stopped at a food microwave, turned it on,
> and the bag partially exploded. I was called because of the blood on
> the inside of the microwave. But it was transfused into the patient
> and it was highly particulate at that point.
>
> **Discovery, ADR Investigation, Conditions of**
>
> **Collections Investigation**
>
> DR. PAGE: This will be a little different from that.
>
> \[Slide\]
>
> I have a number of slides presenting our initial observations, actions
> and thought processes as we went along, and I am going to try not to
> duplicate what I expect will be covered by others.
>
> \[Slide\]
>
> The first couple of slides are background information which will help
> put in perspective some of our earlier findings and rationale. The
> grey parts of the map represent the 36 Red Cross regions in which Red
> Cross traditionally recruits, collects and distributes blood
> components. The 36 regions are divided into four areas, as indicated
> on this slide, for management purposes.
>
> \[Slide\]
>
> This slide is the same map but reflects an initiative that was ongoing
> in January and February of this year. The American Red Cross uses all
> three vendors\' blood collection sets for whole blood, the primary one
> of which is Baxter. We were in the process of converting from an older
> Baxter blood collection set, known as SampLink, to a newer Baxter
> whole blood collection set, known as Y-Diversion. The three areas,
> western, north central and north Atlantic, had completed their
> conversion to the new collection set. All the leftover bags, in a
> variety of lot numbers, from the older collection set had then been
> sent to the south central area to be used up. So, all the older Baxter
> blood collection sets were in the southeast of the U.S. and
> represented a larger number of different lots than ordinarily
> individual regions would use.
>
> \[Slide\]
>
> The first region in which white particulate material was noticed is
> the southern region, which is based in Atlanta, and the next region in
> which it was noticed was the Tennessee Valley region, which is
> headquartered in Nashville.
>
> Red Cross collects over six million units of blood using Baxter whole
> blood collection sets for two-thirds, Pall/MedSep for a quarter and
> Terumo for eight percent. The southern region collects essentially
> only in Baxter blood collection sets and was using all of the older
> version. The southern region is not able to provide for all its
> hospital needs from its local collection but imports 44,000 units of
> red cells from other regions which could use different lots and a
> variety of blood collection set manufacturers.
>
> The Tennessee Valley region is a smaller region and uses Baxter, the
> old collection set, but 38 percent of their blood is collected with
> Pall/MedSep. They collect more than their hospitals need so they
> export units. These differences had an effect on how the impact of
> what we did affected those two regions.
>
> \[Slide\]
>
> This is one of two slides giving day by day chronology of the early
> events, a couple of which Richard Lewis already referred to. It was on
> Monday, January 27 when a new employee noticed something that he
> thought might be peculiar in a unit of red cells and brought it to his
> supervisor\'s attention. A number of other experienced blood center
> staff looked at it as well and agreed that this white glob or
> particulate material was unusual. So, more red cells were inspected
> and more units with white particulate material were seen, and all
> those units in which it was seen and the plasma corresponding to it
> were quarantined. That day they began an inspection of the entire red
> cell inventory in the Atlanta region for this.
>
> \[Slide\]
>
> On Tuesday, the next day, more units were seen with white particular
> material in the inventory and those and their co-components were
> quarantined. If what particulate material was seen in a unit of whole
> blood or if it was seen in a red cell prior to leukoreduction
> processing stopped. In other words, we did not continue our ordinary
> practice of separating whole blood into red cells and plasma, and if
> we saw it in a non-leukoreduced red cell we didn\'t leukoreduce it. We
> weren\'t going to be using the unit or any of the components in any
> event. That was the day that we notified the bag manufacturer, which
> in this case was Baxter.
>
> \[Slide\]
>
> By the next day we had noticed 50 units of red cells with white
> particular material from a multiple number of different bag lots, all
> the old Baxter collection sets. Chris Hillyer, at Emory University, in
> particular began looking at these after straining in the kitchen sieve
> and also under the microscope in a variety of ways, which we will talk
> about later.
>
> \[Slide\]
>
> Next day we saw 80 involving even more bag lots. So, Red Cross
> quarantined all the southern region collected units in lots that had
> been affected to date and provided only red cells imported from other
> regions to its hospitals. The Red Cross asked hospitals in Georgia to
> not transfuse souther region locally collected units except in
> emergency, if they were needed, and in that event to inspect the units
> prior to transfusing the red cells. If the unit was collected in a
> region other than southern region, it was okay to use those units.
> Accordingly, a large number of elective surgeries were cancelled in a
> large number of hospitals in Atlanta that day.
>
> Next Friday the number continued to grow as we continued to collect
> and were noticing it in more bag lots as all collections were being
> inspected. That day we alerted the FDA and that same day, in Atlanta,
> the FPPI came to pick up a couple of units of red cells with white
> particulate material to deliver to the CDC for testing, which you will
> hear about later. Due to the lack of surgeries, being postponed, and
> the blood shortage there was a press conference.
>
> \[Slide\]
>
> On Saturday Chris Hillyer called me to say that there was a young
> patient on ECMO, extracorporeal membrane oxygenation. It replaces the
> lung for patients with severe lung disease. An experienced ECMO tech,
> whose seat is right in front of the filters in the machine, noticed
> white particulate material accumulating in the filters. The process
> went on for several days so we weren\'t able to remove the filter to
> look at it yet but this tech said these filters were in front of his
> face every time he did an ECMO, which he had done for years, and this
> was new; he had never seen it before.
>
> \[Slide\]
>
> On Sunday, at 1:45 in the morning, we got a call that the Tennessee
> Valley region had seen white particulate material in ten units in
> using four bag lots. Shortly thereafter, it was 23 lots and some
> 30-some units. At nine o\'clock that Sunday we spoke with the FDA and
> there was a lot of discussion as to whether and what to do since this
> was felt to be a new finding of unknown significance and we didn\'t
> know for sure what it was that was in these bags. We were somewhat
> reassured by the fact that there had not been any adverse reaction
> reports associated with this to date. But we discontinued use of the
> older bags in all regions, all the regions in the southeastern U.S. We
> precipitated our conversion to new bags and got new bags into all
> those regions and discontinued use of the older bags. There was one
> day on which we didn\'t collect blood in two regions because we
> didn\'t have staff trained for the new bags in tie but we got that
> solved by the next day.
>
> We quarantined all the components, red cells and plasma, from all
> units collected in all lots of older bags in the souther region and
> Tennessee Valley region. There was a lot of discussion about this. We
> didn\'t think it was lot specific because of the large number of lots
> involved, and we weren\'t prepared to, or FDA agreed there wasn\'t a
> rationale to require doing this for the whole system, but we would
> focus the initiative to the two geographic sites at which this had
> been observed since it had not been observed elsewhere yet, thinking
> that there might have been something different in those geographic
> sites.
>
> We then began an inspection of our entire inventory in all regions and
> we initiated inspection of all upcoming whole blood collections. The
> unit that the CDC had received\--there was a report on biothreat
> agents that they have a standard screen for using PCR and it was
> negative, permitting the CDC to then have their environmental and
> chemical lab begin its analysis.
>
> Next day is Monday. Baxter and Red Cross scientists from the Holland
> Lab and from Chicago were in Atlanta that morning, examining the white
> particulate material in some detail.
>
> \[Slide\]
>
> On Wednesday\--well, let me say that Red Cross had earlier reviewed
> the adverse reaction reports from Tennessee Valley and southern
> regions and had not found any reports since January 1st that seemed to
> be temporally or causally related to the timing of our observing these
> white particulate materials. However, after we had asked the hospitals
> not to transfuse any southern region collected units and to quarantine
> them, a physician in the hospital gave second thought to a patient who
> had died about ten days earlier who, in retrospect, died while
> receiving a second unit of red cells. At the time that unit was not
> felt to be a transfusion reaction related to the death but, based on
> thinking about it further, they gave it second thought and raised the
> question. We were notified. We notified the FDA that day. We made the
> decision later that day to withdraw all components collected in those
> two particular lot numbers of bags system-wide.
>
> As Dr. Lewis mentioned, there were two bag sets involved in those
> units of red cells transfused to that patient, and one of the lot
> numbers had already had 18 other units with white particulate material
> identified in its collections. The other lot number for the other red
> cell had one other one. So, we thought it would be prudent to take
> that initiative at that time.
>
> On Friday, February 7th, we noticed white particulate material in
> another vendor\'s collection set and we also noticed it in units
> collected from Baxter\'s new whole blood collection set. We got
> reports that non-Red Cross blood centers had noticed white particulate
> material, some of them, involving the third collection set vendor as
> well.
>
> \[Slide\]
>
> This is sort of a summary of the initiatives we took going back to
> January 27th, when we right away quarantined the red cells and plasma
> from each whole blood collection in which white particulate material
> was seen in the red cell. Then, on February 3rd, we quarantined and
> withdrew all components collected in the southern region in all Baxter
> collection sets. A couple of days later we did the same thing in the
> Tennessee Valley region and Nashville as well.
>
> After the fatality, which was at least temporally related to
> transfusion but not necessarily causally related, we withdrew all
> components collected in the two collection set lot numbers used for
> transfusion to that patient from all of our regions. Those were
> primarily in the southeast.
>
> Then subsequently, a bit later, on the 10th after some discussions
> with the FDA and based upon some safety studies which were not
> alarming, which I will get to in a minute and you will hear more about
> later, we released from quarantine all the leukoreduced red cells,
> quarantined up here. Remember, that was almost 10,000 red cells at a
> time when the blood supply was not flush. I may be getting to that in
> a minute.
>
> The plasma units we kept in quarantine and we destroyed any red cells
> that had not been leukoreduced. You will hear later about the number
> of investigations that we have started and are ongoing.
>
> \[Slide\]
>
> The next several slides are a variety of pieces of information. In
> Atlanta we quarantined 7,869 red cells. I don\'t have on here
> Tennessee Valley. It was a substantial number but not as large. There
> were more than 10,000 plasmas involved, plasma having a longer shelf
> life, units collected in those lot numbers more than 42 days ago were
> still in inventory and that is why the number is bigger. These numbers
> represent, on a day by day basis, the number of red cells that we
> shipped in from other blood centers to supplement the blood supply in
> Atlanta since the quarantine had had a massive effect on them. So,
> there were 7,800 quarantined. We shipped in almost 9,000 units. We
> want to express thanks to several other non-Red Cross centers who
> helped out in sending several hundred units as well. They were more
> than gracious and offered to help. These are the number of plasma
> units that were sent in, including plasma from a non-Red Cross center
> as well.
>
> \[Slide\]
>
> This is that same map again. The red slashes indicate regions in which
> Baxter blood collection sets, the old and the new, had had white
> particulate material found. Regions of Pall only are blue, and the
> combination of Baxter and Pall. So, there was no geographic focus or
> logic that we could make out of this although we did look.
>
> \[Slide\]
>
> These are product code numbers, and these are anticoagulants, and
> these are the component packs, whole blood, red cells, red cells
> leukoreduced from Baxter and Pall, and the number of units with white
> particulate material seen in them. The total here is 356. I would like
> to point out that it was seen in 16 units of whole blood, that is,
> units that had not been spun at all and units that had not been
> filtered. It was seen in 286 non-leukoreduced red cells, but it was
> also seen in 70 leukoreduced red cells. Remember that if we saw it in
> whole blood we stopped processing and didn\'t separate it. If we saw
> it in a non-leukoreduced red cells we stopped processing and didn\'t
> leukoreduce them. The point here is that it was seen in leukoreduced
> and also prior to leukoreduction or prior to separation.
>
> \[Slide\]
>
> Dr. Lewis gave you nice pictures of the four types. Red Cross has not
> seen any type 4s and we have seen basically half and half type 1s and
> type 2s in our first several hundred units.
>
> \[Slide\]
>
> This tries to describe the frequency of the observation. This goes
> back a while now. In the southern region, in the first 11,800 units we
> inspected we saw 198 units with it, for a 1.6 percent observation
> rate. Tennessee Valley inspected about as many but saw fewer, for an
> 0.28 percent rate. Nineteen other regions had 0.01 to 2.15 percent
> observation rate so Atlanta was not the highest. In 15 regions we saw
> none in over 40,000. So, in about a quarter of a million units we had
> seen 662 and 0.28. An updated figure from Atlanta alone is that as of
> ten days ago we had seen 973 units, representing 53 lots, 49 Baxter
> and 4 Pall MedSep.
>
> \[Slide\]
>
> Putting together the recipient complication reviews that we had, Dr.
> Linda Chambers, of our donor and recipient complications program,
> reviewed from January 1st from all 36 regions and there were 45 cases
> excluding infectious complications and of all levels of probability of
> association with transfusion, in other words highly suspect and not so
> highly suspect, and including regional investigations that are not yet
> complete. Sixty-five percent of the involved components were collected
> in Baxter sets. It is actually 66 percent of whole blood collections
> for Red Cross use of Baxter sets so there was no over-representation
> of white particulate material in Baxter sets.
>
> Nineteen cases were submitted as possible TRALI, transfusion related
> acute lung injury. Historically, we have good data on this and get 2.4
> cases per week. So, in 7.5 weeks we would have expected 18.3 cases and
> we had 19. Nine were in patients who received blood only collected in
> Baxter. Another nine involved only non-Baxter collections and one
> involved both. So, there was no over-representation of the observation
> in Baxter collections. This took us a little while to compile.
>
> \[Slide\]
>
> I put in this slide because it is an interesting observation that I
> don\'t yet understand. There was a high school blood drive in Georgia
> using a single Baxter old blood collection lot number. These are the
> whole blood numbers, unique number assigned to each collection. They
> are all serial in a row. There is one missing here but that was QNS.
> That was a unit that was incompletely collected so there wasn\'t
> enough blood in it for making a component.
>
> We saw on several blood mobiles runs of serial whole blood numbers. We
> did also see one by itself or two or three, but it was striking that
> some others would have none or one mobile would have a long run, a
> gap, another run, another gap. There were type 3, type 2 and type 1 in
> this run. This was especially where we were monitoring a large number
> of other parameters regarding that blood collection mobile unit\--you
> know, how many minutes did it take for the unit to collect? What were
> the lot numbers of the arm preps? Was there a particular phlebotomist
> involved? Was there a particularly newly trained set of phlebotomists
> involved? The answer is we found no variable that we could tie to it.
>
> \[Slide\]
>
> There was a large number of studies, and I am sure this is not
> complete because I know Baxter, FDA, Emory and others have also done
> this, but I have divided them by the studies on the anticoagulant
> preservative in empty collection sets, and then examination of white
> particulate material itself, and then red cell units that have
> material in it. So, empty whole blood collection sets from implicated
> and control lots were frozen and thawed and no particular material was
> seen in these solutions. Units were then collected at the Holland Lab
> in these sets and no white particulate matter was seen.
>
> You might wonder why we did this. There was a particularly cold snap
> of weather in Atlanta right prior to the initiation of this
> observation, as well as there was in Nashville, and this was an early
> postulate and concern. The anticoagulant preservative solutions were
> filtered and no white particulate material was seen on filters by
> microscope, the question being were they in the bag before blood was
> collected. The CDC\'s environmental and chemical lab found no
> difference in the number of volatile organic compounds in empty blood
> collection sets from implicated lots versus control. Emory, Baxter,
> Red Cross and others have done staining of peripheral smears from
> units with white particulate material. There have been traditional
> paraffin block sections. There have been a number of studies which I
> suspect will be described later. None of these showed any foreign or
> unexpected material in them. The material is largely platelets.
>
> If you look at red cells with the material, the biothreat assay was
> negative, as I mentioned, by CDC. Their culturing is negative for
> bacteria and I think microbacteria may still be pending but everything
> has been negative. The CDC assay for endotoxin was negative. They
> looked at red cell units with and without white particulate material
> for volatile organic compounds, but we later figured out that the
> control units were collected in non-Baxter bags so that the results
> were no invalid; there were other reasons for the bag to show the
> differences, but nothing of concern was identified there.
>
> FDA and we are working on looking at pre-storage leukoreduction and
> standard blood administration set filtering to see what particulate
> material is reduced or eliminated by pre-leukoreduction filtration,
> and then the blood administration set that is used at the bedside as
> all units of red cells are transfused.
>
> \[Slide\]
>
> I won\'t go through these but I alluded to it on an earlier table. The
> manufacturing variables with no correlation are all these things which
> have been looked at informally, some; others more formally and those
> informal to date are going to be looked at rigorously by CDC
> statisticians, whose help we appreciate.
>
> \[Slide\]
>
> Those variables with correlation, platelet rich components. In Atlanta
> we don\'t make platelets from whole blood collections, and it was seen
> primarily in units from which platelets were not to be made, which
> meant that the whole blood was shipped to the lab in the cold and the
> only spin was a hard spin, packing the platelets down in there. It was
> seen pre-leukoreduction. If you then leukoreduced it larger materials
> didn\'t go through and there weren\'t as many of them seen. Initially
> it was correlated with Baxter collection sets but remember that
> Atlanta only used Baxter collection sets so that did not pan out.
>
> I mention this in part because we are reviewing temperature and time
> of transport from the collection site to the component lab. This is
> not final, but nothing striking has appeared to us yet. The
> co-component plasma, in view of the fact that these were felt to be
> adherent groups of platelets, some but not all of which appeared
> activated, it has been suggested and we are arranging to have
> performed the plasma in those units to be evaluated for products of
> platelet activation and also products of the clotting cascade. There
> has been no evidence of clots in the red cells or no evidence of clots
> in the plasma upon traditional visual examination.
>
> The fatality is felt to probably now be unrelated. The review of
> recipient complications from all regions has been negative and not
> shown an increase recently or association with any bag type. I believe
> Dr. Kuehnert will tell you about the Georgia Department of Health
> survey of all hospitals which did not find anything striking or
> surprising. Two large Boston hospitals which both collect blood
> themselves and receive blood from the Red Cross had noticed white
> particulate material in both types of components. They reviewed their
> transfusion reactions for the last three months and compared it with
> the previous year and did not find any uptake or increase.
>
> \[Slide\]
>
> This is my next to last one, I believe. The overall assessment\--I
> think it is important to point out that there is no evidence of
> foreign material in the components but we did not know that in the
> beginning and we did not know it with assurance for a while. As I
> think you will hear, they are primarily platelets, some but not all
> activated. The size and numbers seem to be decreased by leukoreduction
> filtration. No correlation with adverse reactions, thankfully.
>
> It is not clear still why it is newly noticed now. A number of
> long-time people who work in labs say if it had been in there before,
> particularly the type 2s, they would have noticed before and a number
> of people feel it is new. The investigation is ongoing. There are a
> number of studies still in progress.
>
> \[Slide\]
>
> My last slide just sort of summarizes Red Cross recent actions. FDA
> did come out with a statement near the end of February, and it was
> around that time that we released from quarantine. But prior to
> release from quarantine we re-inspected every unit and we did not
> release any unit in which white particulate material had previously
> been seen. We kept in quarantine or destroyed all components from any
> donation with white particulate material. We left standing the
> voluntary withdrawal of all the components from the two collection
> sets related to the fatality. We did not release any non-leukoreduced
> red cells, of which there are very few because we use essentially
> universal leukoreduction. The plasma, as I mentioned, remains in
> quarantine pending the coag. studies. If they are negative, we have an
> internal process of material review board which would permit us to
> review and consider whether they could be released.
>
> We plan to reassess as new information accrues and when all studies
> are completed. We appreciate the help and cooperation of a large
> number of other agencies, the FDA, the CDC, Baxter and Emory, and look
> forward to continuing sharing of information and collaboration in this
> regard. That is it. Thank you very much for your attention.
>
> DR. NELSON: An interesting investigation. How old are the old Baxter
> bags? Have they been around for quite a while?
>
> DR. PAGE: The dating period on collection sets I think might be on the
> order of 18 months. The date of manufacture of these bags went from
> February, 02 up through November of 02. So, the oldest would have been
> almost a year.
>
> DR. ALLEN: But well within the time.
>
> DR. PAGE: Oh, we do not use outdated blood collection sets.
>
> \[Laughter\]
>
> DR. STRONG: Did you notice any difference between collections on
> mobiles versus centers, or what is the mix there?
>
> DR. PAGE: No, we didn\'t. We have a number of fixed site centers in
> Georgia. One uses automated mixers and that is the only one. They saw
> some but no more than others. We saw it in most of the other fixed
> sites. There was no correlation with the temperature of the weather,
> the day of collection, the distance from the center. We looked at
> everything for which we could get data.
>
> DR. STRONG: I just noticed that in that sequential numbers that you
> had, that looked like a high school drive and depending upon how many
> staff and how many donors are showing up, they can get pretty hectic
> so sometimes they under-mix or don\'t store the units in the right way
> and it is very difficult to correlate any of that.
>
> DR. PAGE: I agree. Our traditional staffing for high school drives is
> we send one extra nurse, just because it is a high school. We had
> collection staff and component staff from other regions come visit
> Atlanta and look over their shoulders, review their procedures to see
> if anything had been changed, seeing if they weren\'t following the
> procedures, and mixing was looked at carefully and did not seem to be
> different.
>
> DR. STRONG: I might add though that when you have somebody looking
> over your shoulder you tend to do a much better job. We have seen
> those kind of variables on mobiles.
>
> DR. PAGE: I agree; I agree. I would say that this was also observed in
> non-high school drives. There were a couple of high school drives in
> the first week but it was observed at fixed sites which probably are
> the most controlled environment, and it was observed at a number of
> drives that weren\'t high schools. I just picked one as an example.
>
> DR. NELSON: The makeup of these bags I guess is proprietary
> information but I wonder what the differences are between the old and
> the new or between Baxter and Pall. It is probably a complex plastic
> with many different components.
>
> DR. PAGE: The Baxter old and new, there is no difference in the bag.
> The only difference is the plastic on the tubing from which you
> collect the samples for testing. There are differences between Baxter
> and Pall, and those were provided to CDC as they were doing their
> analysis of organic volatile compounds. I think Baxter is speaking
> later and could talk to that better than I.
>
> DR. GOLDING: I appreciate that this is an ongoing investigation and we
> are not sure which types of particles are more worrisome than others,
> but just looking at the pictures that Dr. Lewis showed, some of then
> are probably not significant. In other words, if you see bubbles, and
> you have different lighting and you stop seeing the bubbles that
> particular particle is not important.
>
> My point is that once we have defined which of the particles are the
> more important particles or more likely to be pathogenic, in other
> words, if you see platelets or you see fibrin or you see something
> that looks more suspicious, it may be worthwhile considering going
> back and looking at the data and doing some kind of subset analysis in
> terms of if you now look at the ones that look like they could be
> pathogenic, what was the adverse event rate in terms of those
> particular bags, and other subset analyses that may be relevant in
> this situation.
>
> DR. PAGE: I am not sure I understood your train of thought but I
> don\'t believe we have seen any adverse reactions that could be tied
> to this yet. I mean, there are those who worry more about the type 2s
> in as much as they are larger.
>
> DR. GOLDING: Well, for example, you showed the incidence of TRALI and
> you said, well, the incidence wasn\'t different with those
> particulates or without the particulates. But if you now just looked
> at the incidence of TRALI with particulates that were composed of
> platelets, the type 1 or the type 2, and you now look back at acute
> lung injury, will something drop out of that that is very different?
> At the moment it is confounded by a lot of particles that probably
> have no relevance to the safety of the product.
>
> DR. PAGE: I should point out that we are not aware of a unit with
> white particulate material observed and having been transfused. Now,
> that could have happened prior to our noticing the problem, but when
> we did we started inspecting all units and told hospitals to inspect
> any that they used. But there was no difference in units transfused
> collected in the old Baxter bags of similar lot numbers. So, I don\'t
> think we know of a unit with white particulate material having been
> transfused.
>
> The other point I might just make is there are those who say they have
> been there all along. The literature and older textbooks do describe
> small white particulates being seen in blood after a week or a couple
> of weeks of storage. These were seen in whole blood, fresh from the
> blood mobile or the blood center, and were seen before and after
> leukoreduction, which is done in the first day or so after collection.
>
> DR. ALLEN: I had dinner last year with a blood banking colleague who
> related to me that they had had a donor at their center who was on the
> apheresis machine after having eaten two Crispy Cream donuts. The
> level of chylomicrons was so high that it totally plugged up the
> machine. We may need to start taking food histories from our donors.
> Just in terms of full disclosure, I own no Crispy Cream stock. I do
> eat Crispy Cream donuts.
>
> DR. NELSON: Which is why the high school is so suspect I guess.
>
> DR. PAGE: In platelet or plasma apheresis you can notice lipemia
> during the collection. I whole blood you might not. But in the sample
> tubes that are sent to the laboratory for testing after spinning
> visual inspection is required and testing is not performed if it is
> lipemic. That is found, but with a low enough frequency that it
> hasn\'t been justified to ask donors that question.
>
> DR. LEW: I am just curious since it looks like it might be platelets
> or you all are thinking it might be, have you all looked at the
> platelet counts in the particular particulate positive blood versus no
> particulate positive blood?
>
> DR. PAGE: We haven\'t. This is all in whole blood collections and we
> don\'t do platelet counts on whole blood donations. When whole blood
> came from the mobile and it was seen there, one could arguably do a
> platelet count on those but we didn\'t, and we weren\'t thinking about
> it at the time. I don\'t believe we know well what the platelet count
> should be on a red cell unit pre- and post-filtration for
> leukoreduction, but that is something that is being looked at
> prospectively now.
>
> DR. ORTON: I am Sharyn Orton, from the FDA. I am going to be giving a
> presentation in a few minutes that is actually going to address some
> of that because I do have some data from other blood centers.
>
> DR. NELSON: Good. Thank you. Next is Jerome Davis.
>
> **Chronology and Field Overview**
>
> DR. DAVIS: I have some slides.
>
> \[Slide\]
>
> I am in the Office of Compliance in the Center for Biologics.
>
> \[Slide\]
>
> I am going to talk briefly about FDA\'s investigation of the reports
> on particulates. Dr. Page gave a very good chronology already and so I
> am going to try not to repeat too much of what he said, but I am also
> going to give an overview or kind of a summary of the particulate
> reports that we received.
>
> \[Slide\]
>
> As has been stated already, CBER was notified on January 31st by the
> American Red Cross that the southern region, Atlanta, Georgia had been
> finding multiple units of blood products that contained white
> particulates. The bags used to collect these units were made by Baxter
> and multiple lots of the PL-146 bags were involved.
>
> We learned that as the Atlanta Red Cross suspended the use of certain
> lots of Baxter bags and put new lots in use, they began finding
> particulates in those additional lots. The number of bags with
> particulates and the number of implicated lots of Baxter bags
> continued to increase over time.
>
> On February 2nd, 2003 ARC\'s national location, the Tennessee Valley
> region, also reported finding particulates in units from four lots of
> the same type of Baxter bags that were being used in the Atlanta
> region.
>
> A number of hypotheses were posed as to how those particulates were
> forming. It was suggested, as somebody mentioned earlier, that the
> unusually cold conditions in Atlanta this winter may have caused
> inadvertent freezing of the bags. Our follow-up investigation at the
> American Red Cross facilities focused on the receipt, storage and
> handling of the blood pack units both in-house and during mobile
> collections. We also focused on the follow-up investigations that were
> done by the American Red Cross.
>
> In addition, official samples were collected of units that the Red
> Cross had observed particulates in, as well as unfilled Baxter
> collection bags. Other Red Cross locations, including Birmingham and
> Mobile, Alabama, eventually also detected particulates in units and
> FDA initiated inspections of those sites also.
>
> On February 3rd FDA began receiving reports of particulates in blood
> collected by non-ARC facilities. In addition, FDA began to receive
> sporadic reports about particulate matter in bags manufactured by
> Terumo and later on in bags manufactured by Pall. FDA also conducted
> inspections of the blood bag manufacturers, first Baxter and then
> eventually Terumo and Pall. Those inspections focused on complaints,
> adverse reaction reports, bag components and materials, manufacturing
> records and their follow-up investigations regarding the particulate
> reports.
>
> As FDA\'s investigation continued, additional samples of blood units
> containing particles, as well as unfilled blood pack units, were
> collected from the American Red Cross and from non-ARC collection
> centers and investigations were conducted at some of those non-ARC
> collection centers.
>
> We also sampled bag materials and components for analysis. At last
> count, 13 of FDA\'s 19 district offices were involved to some extent
> in the investigation, and this continues to be an open and ongoing
> investigation.
>
> \[Slide\]
>
> On February 7th FDA issued a \"talk paper\" and an information alert
> on particulate matter in blood bags. In both documents the agency
> recommended that blood establishments implement the ARC\'s enhanced
> visual inspection procedures and, if abnormalities were detected, to
> quarantine the products and report their findings and any adverse
> reactions potentially related to the presence of particulate matter to
> the FDA.
>
> \[Slide\]
>
> On February 27th FDA issued another press statement and I think that
> has already been mentioned. We also issued this frequently asked
> questions document which answered questions that were being posed by
> the blood industry regarding the management of units containing
> particles, as well as their co-components.
>
> \[Slide\]
>
> I wanted to go back and talk about the February 7th \"talk paper.\"
> That requested reporting of abnormal units and any adverse reactions
> that were potentially related to the presence of white particulate
> matter. We requested that the reports be reported to the BPP
> Deviations email account and also to this 800 number.
>
> CBER set up an access database to capture all the particulate reports
> and the adverse reaction reports or, you know, any that happened to be
> reported.
>
> \[Slide\]
>
> As of March 10th, we had only received one adverse reaction report,
> and this was a rather vague report where a woman indicated that her
> mother-in-law had had difficulty breathing post-transfusion. We had
> attempted to contact this person to get some additional information. I
> think this was actually reported on February 10th and up to this point
> in time we still have not received any additional information. There
> still really isn\'t any real link to white particulate matter. Like I
> said, it is kind of a general complaint. We didn\'t have any AERs
> reported to the 800 number.
>
> \[Slide\]
>
> As of March 10th, we had received a total of 97 reports. Actually, not
> all of them came into the email address or to the 800 number. If we
> received reports while our investigators were out inspecting the bag
> manufacturers, if they had received any complaints or any reports of
> white particulate matter, that information came back to CBER and we
> also contacted those establishments to collect information about them.
> There were also some other reports that came in to other parts of FDA.
>
> \[Slide\]
>
> Like I said, as of March 10th we had received a total of 97 reports
> and 94 of them were collection facilities and three of them were
> transfusion services.
>
> \[Slide\]
>
> We attempted to get kind of standard information from all the
> reporters. Some of the key information we got was the number of units
> with white particulate matter, as well as the number of units that
> they inspected. We tried to get an indication of what types of white
> particulate matter they were finding and in what products. We wanted
> to collect details about the blood pack units; who was the
> manufacturer; the lot numbers of the bags; how the bags were stored
> and information like that. We wanted to collect information about the
> processing of the units, were they refrigerated or not; were the units
> hard spun or were they soft spun; were platelets made, that sort of
> information. We also asked what was the method of agitation.
>
> \[Slide\]
>
> This slide gives just a general idea of the geographic breakout. The
> 97 reports were received from facilities in a total of 40 states and
> the District of Columbia. As you can see just from the states that are
> listed there, it is a pretty widespread distribution from coast to
> coast, and north, south and the center of the country.
>
> \[Slide\]
>
> In the 97 reports there was a grand total of 1,508 bags that contained
> white particulate matter. There was a grand total of 315,000-plus bags
> inspected. That gave us a percentage of bags with white particulate
> matter of about half a percent. I notice that differed somewhat from
> what Dr. Page reported. I think he said the Red Cross had 0.28
> percent.
>
> \[Slide\]
>
> This gives a general breakdown of the bag manufacturers. The majority
> of the reports were in Baxter bags but, as you can see, there was also
> particulate matter found in the bags made by other manufacturers. In
> about 20 percent of the cases we didn\'t get the information reported.
>
> \[Slide\]
>
> This slides is a breakdown of the types of products that we found
> particulates in. The majority of them were red cells. The second line
> there, you can see these are leukoreduced. In 103 cases the
> particulates were found in red cells that had already been
> leukoreduced. These are autologous red cells and in some cases
> autologous whole blood. There was only one case where there was a
> leukoreduced whole blood unit. Quite a few of the reporters did not
> report this information.
>
> \[Slide\]
>
> This gives a breakdown of the types of particles that were found. The
> great majority of them were types 1 and 2. Again, this refers to the
> types that are on the AABB web site, the types that Dr. Lewis went
> over. I think Dr. Page said they didn\'t see any type 4. We didn\'t
> see much. It was interesting that in some cases reporters found
> particles but they didn\'t feel like they fit into any of these four
> categories. Again, in about 20 percent of the cases the reporters did
> not indicate what type of particulate matter they were.
>
> \[Slide\]
>
> This gives and indication of how the units were processed. Again, out
> of the 97 reports, in 26 cases the unit was refrigerated and then hard
> spun. Down here, in 32 cases the unit was hard spun but there was no
> indication given by the reporter whether or not the unit was
> refrigerated or not. But you can see that in the majority of these
> reports the unit was hard spun. Here we only had five cases where the
> reporter did a soft spin and made platelets. Again, in about 20
> percent of the cases the reporter did not indicate how the units were
> manufactured.
>
> \[Slide\]
>
> This is the last slide I have. There were 94 collection centers. Kind
> of late in the process of gathering this information we started asking
> about the method of agitation and in quite a few cases we were not
> able to get this information, but when we did, in 28 cases the method
> was manual. In 20 cases it was automated. In four cases it was a
> combination of both.
>
> That is all I have unless there are any questions.
>
> DR. NELSON: Thank you. Were any of these reports made during or after
> transfusion into a patient or were these all units that were noticed
> prior to transfusion?
>
> DR. DAVIS: I believe that they were all reported prior to transfusion.
>
> DR. NELSON: From what we saw, presumably there must have been a fair
> number that were not noticed and were actually transfused if the
> prevalence is half a percent, I would suspect. Yes?
>
> DR. PAGE: With respect to the prevalence, the difference between the
> 0.4 percent as reported by the FDA and the 0.28 percent reported by me
> and Red Cross, I think there are two factors there. I believe, from
> listening to you, your prevalence is based only upon blood centers
> that saw any. Of Red Cross 36 regions, there were 15 regions that did
> not see any but their inspections were included in our denominator
> which would accordingly be a basis for being larger.
>
> DR. DAVIS: That is a good point.
>
> DR. PAGE: Also, in the beginning we did not report these as real until
> they were \"confirmed\" by observers in Atlanta experienced in these
> observations. Particularly prior to the AABB web site showing
> pictures, we wanted to make sure there was consistency in what we were
> reporting, measuring and acting to. So, there were a fair number of
> suspect units observed in other regions, sent to Atlanta, that in
> Atlanta were declared to be not real or not it. So, I think we may
> have prevented some over-reporting of false positives.
>
> DR. FITZPATRICK: What is the current level of reporting in the past?
> Is there a bell-shaped curve in reporting? Are we seeing less
> reporting now than we had?
>
> DR. DAVIS: Yes, the number of reports has definitely fallen off over
> time. I think since last Thursday, eight days ago, we have received
> one report.
>
> DR. FITZPATRICK: And the distribution of reports of bag manufacturers,
> is that about proportionate to market share?
>
> DR. DAVIS: I can\'t answer that. Maybe Steve Binion can address that.
>
> DR. NELSON: Who is the next speaker? Steve Binion, from Baxter?
>
> DR. PAGE: From the Red Cross experience, remembering that we use all
> three vendors\' bags, Baxter is right on the money as to percent of
> white particulate material observations compared to percent of bag
> collections. The other two are pretty similar to the percent of bags.
> So, I wouldn\'t say that there is a real difference in frequency.
>
> DR. BINION: Steve Binion, from Baxter. I am just glad that Dr. Page
> was able to handle that because I don\'t have the market breakdown
> with me.
>
> DR. NELSON: You should! Steve, are you going to make a presentation?
> You are listed.
>
> DR. BINION: Yes.
>
> DR. NELSON: We are ready for you.
>
> DR. BINION: Steve Binion, from Baxter. I apologize, I was looking at
> the wrong agenda I guess; I thought there was another FDA speaker.
>
> DR. NELSON: Oh, right. The nameless person from FDA, Betsy Poindexter.
> Sorry, you weren\'t listed. Go ahead.
>
> **Testing, FDA Findings**
>
> MS. POINDEXTER: Good afternoon.
>
> \[Slide\]
>
> I am here today to present not so much the FDA findings but those
> studies that are under way by groups that have agreed, either
> coercively or voluntarily, to perform studies for us.
>
> \[Slide\]
>
> I am with the Division of Hematology, Laboratory of Cellular
> Hematology. The labs that have volunteered to do some studies for us,
> in addition to our own lab\--I am with Dr. Vostal in the Division of
> Hematology\--are Dr. Joe Hutter, at CDRH in the Office of Science and
> Technology. They are looking at both the bag surfaces and the bag
> composition, as well as the anticoagulant solution. They don\'t have
> the facilities for handling biologics so they won\'t be handling any
> of the blood products per se.
>
> The Forensic Chemistry Center in Cincinnati, Dr. Karen Wolnik and her
> group are looking both at the blood bags, the anticoagulant solutions
> and particles that have been in those bags. They do have blood
> products.
>
> Dr. David Stroncek, at the NIH, Department of Transfusion Medicine,
> has voluntarily submitted a protocol to us and we have commented on
> it. He believes that in the next couple of weeks he will be able to
> initiate his studies with one of his SBB students to try to replicate
> this phenomenon in their hands, using bags that were collected from
> the field as well as the bags that they generally use in DTM.
>
> Dr. McDonald Horne, at the NIH Clinical Center Hematology Service, has
> worked with Dr. Stroncek and is working with us to identify some of
> the fibrinous like or particulate like material.
>
> Dr. Gary Moroff, at the Red Cross, has also submitted a protocol for
> trying to replicate these procedures at the Red Cross at the Holland
> Labs.
>
> \[Slide\]
>
> In our laboratory at CBER we are looking at visually examining the
> blood products. We have taken digital photographs of each of the
> products that have come in at various time points so, if there were no
> particles to start with and particles developed over a period of time
> that we have had them in refrigerated storage, we would capture those
> events. We are also distributing the blood products that have been
> gathered from the field to the test facilities that have been doing
> some testing for us. We are collating the test results. Right now that
> spreadsheet is blank because the tests are in very preliminary stages,
> and we do have a database for all the samples that we have collected,
> all the blood unit numbers, the lot numbers of the products, the bag
> manufacturers, physical descriptions of bags, the collection sites,
> etc.
>
> \[Slide\]
>
> These are some photos that we have taken of the blood units that we
> have received. As you can see on the left side, these were definitely
> type 1 and perhaps type 2 particles. These were the \"starry night\"
> or dandruff-like particles that were described in Dr. Hillyer\'s
> photos. They were not there when you first got the bag out of the
> refrigerator but if it sat there for a few minutes they rose to the
> surface. If you were to mix the bag these would go back into
> suspension but then if you were to let it settle again, they would
> again rise to the surface. The bag on the right-hand side, again, has
> flake-like, type 1 material.
>
> \[Slide\]
>
> If you notice this blood, here, if you look at this unit, let it sit
> long enough you see the fatty plasma settle out and you will have this
> white sheen across the top of the unit. So, there is the blood here
> and then there is a little bit of a surface there. The bag on the
> right-hand side was a unit that was collected through a military
> facility. You can see that it has the bubbles and it has the
> reflective pattern in there, as well as some little particulate matter
> in various areas of the bag.
>
> \[Slide\]
>
> It is a challenge to try to photograph these things because if you use
> a flash on your camera you create so much more reflection than what is
> already being created by the overhead lights, as you can see from the
> adhesive tape on this bag, but you can definitely see particulates in
> various areas of this bag, and platelets probably would not have been
> made from this unit. I should probably put type 1 and type 2 for this
> bag, as well as reflective bubbles.
>
> What I might point out on this one, as well as this one, is that the
> material was adherent to both the top surface and the bottom surface
> of the bag. So, irrespective of whether you turned it label side up or
> label side down, the material was adherent to the bag and even with
> gentle agitation it was unlikely that that material was going to move
> around.
>
> \[Slide\]
>
> At the CDRH, they are going to employ a number of different tests for
> the bag materials, as well as the anticoagulant. They are using
> differential scanning and calorimetry, gel permeation, chromatography,
> FTIR to evaluate anomalous peaks in the PVC used in the storage
> container. HPLC may be used to evaluate adhesives on labels. Soxhlet
> extraction matters for plasticizer analysis and thermal gravimetric
> analysis to analyze material stability after extreme temperature
> storage.
>
> We have provided CDRH not only with some of the test bags and the
> control bags, meaning a lot that was manufactured this year rather
> than last year at the Baxter facility, but we took bags that we had in
> our lab and subjected them, similarly to what the Red Cross did, we
> froze some and thawed them. We also heated some to 56 degrees for a
> number of hours and then brought them back to room temperature and
> froze them. Early in this investigation we were very concerned that
> there may have been some transient thermal effects or cold effects on
> the anticoagulant or bag systems that might have caused these problems
> to occur in the Atlanta region. So, we were sort of investigating all
> possible realms.
>
> \[Slide\]
>
> The FCC or the Forensic Chemistry Center in Cincinnati, is looking at
> the anticoagulant solutions, the blood storage container. The are also
> using FTIR and GS mass spec, SEM and microRaman spectroscopy, as well
> as light microscopy. They do have blood products with particulate
> matter and they are doing photography, chemistry and histopath.
> analysis on those samples.
>
> \[Slide\]
>
> This is a photo that they sent us through email last week. This is a
> particle that they pulled out of one of the blood bags that they had.
> As the red arrows generously point out, you can see the cross-hatching
> on this particle that is identical to the cross-hatching on the
> internal surface of the red cell bag. When I saw this photo I said
> great shot but, number two, I wanted to know whether this was a
> fee-floating particle or whether this was a particle that was adherent
> to the inner surface of the bag. The scientist said that it was
> something that he was able to pull out of the blood; it was
> free-floating in the blood. So, it was obvious that at some point it
> had laid on the surface of the bag and was probably adherent. Maybe
> through additional jostling of the bag, through the manipulations it
> was feed up but still maintained that scar of contact.
>
> \[Slide\]
>
> At the NIH Department of Transfusion Medicine they have developed a
> protocol to compare the test bags recently evaluated to the control
> bags of another manufacturer. They are evaluating donor
> characteristics such as diet, over-the-counter medications or
> prescription drugs, blood chemistries and complete blood counts and
> coagulation profiles to identify perhaps if a donor whose blood goes
> on to form particulates may have a higher fibrinogen, a higher
> platelet count, a higher white blood cell count to start with that may
> just aggravate what may be a rather normal occurring phenomenon.
>
> They are also going to look at the pre-storage leukocyte reduction on
> the formation of these products and see whether, if you filter fresh
> after collection within the first couple of hours at room temperature,
> whether you can perhaps reduce the numbers of particulates that are
> formed versus leukocyte reduction within the 72-hour period that is
> generally allowed for pre-storage leukocyte reduction.
>
> \[Slide\]
>
> The NIH Clinical Center Department of Hematology has been performing
> some visual, morphologic and physical evaluation of the particles.
> They had received two products, one with what I considered type 1 but
> was adherent to the bag surface, and type 2 which was actually on a
> leukocyte-reduced bag from the national region that had a great number
> of floating type particles in it. The fibrinous material that was
> adherent to the bag was very similar to what other people have found
> that contained platelets, white blood cells, occasional red blood
> cells in a fibrin-like base. The second product that was
> post-leukocyte reduction, when those particles were separated and
> warmed in a saline suspension, the saline became milky, and they sent
> them off to the clinical chemistry service who determined that they
> were triglycerides without any cholesterol. So, they are going to be
> looking at some additional samples on that.
>
> They have also done some paraffin blocks and those results are
> pending. Because of the chylomicrons that they experienced in the
> second sample that we gave them, they are going to do additional
> analysis on other products for us.
>
> \[Slide\]
>
> Dr. Moroff, at Holland Labs, is also going to be looking at donor
> characteristics. I didn\'t want to be very specific on any of their
> protocols because they are their own property and they are yet to be
> under way. They are going to evaluate products for either hard spins
> or soft spins. They are going to do the visual, morphologic, physical
> examination of the particulates in the blood. They are also going to
> look into the effects of pre-storage leukocyte reduction on white
> particulate material.
>
> \[Slide\]
>
> In summary, laboratory studies are under way on a number of fronts.
> Preliminary studies support previous reports of normal biological
> material, and results from additional studies are pending. Thank you.
>
> DR. NELSON: Thank you. Questions? Yes?
>
> DR. FITZPATRICK: Betsy, what is the timeline for these studies to be
> finished?
>
> MS. POINDEXTER: Dr. Moroff, last week, had to go to IRB yet. For Dr.
> Stroncek it was going to be a couple of weeks before they could get
> under way due to time constraints within the blood centers. Everybody
> was under constraints. Because of the bad weather, and January being a
> low donation month anyway, they were fighting for every good blood
> sample they could get but it will be a couple of weeks at least. I
> think that the start to finish, probably two to four weeks, six weeks
> max. I think when we spoke earlier on the phone we had thought that it
> would be within the next three weeks. That was before we knew what
> their actual timelines were.
>
> DR. NELSON: Previously we have talked about whether leukocyte
> reduction and filtration should be done at the time of collection or
> later. It looks like with this problem maybe it should be done both
> places, one to reduce leukocytes; the other to reduce the white
> particulate matter.
>
> MS. POINDEXTER: We got a number of units from one region that had been
> leukocyte reduced, pre-storage leukocyte reduced and they had the
> dandruff or\--
>
> DR. NELSON: That is why I said that maybe we need a second filtration.
>
> MS. POINDEXTER: Right. If I can go back to the gentleman who talked
> about Crispy Cream, if you note that these particles were first seen
> just after the Super Bowl\--
>
> \[Laughter\]
>
> \--and being in the region, and Florida was playing in that game, you
> can just picture a lot of households with barbecues and fried chicken
> and fatback greens and everything else.
>
> DR. NELSON: You know, we have identified the culprit and he is us. Dr.
> Binion?
>
> **Industry Investigations**
>
> DR. BINION: I am Steve Binion, from Baxter. Thanks again for the
> opportunity to come to the podium.
>
> \[Slide\]
>
> I want to start by just sort of cutting to the bottom line and let you
> know that at this point we have no evidence of any association, of any
> problems with Baxter BBPUs or those of other manufacturers associated
> with the observations of white particulate matter.
>
> \[Slide\]
>
> I will try and not duplicate any of the other presentations but just
> quickly, from Baxter\'s perspective, we were contacted on January 28th
> by ARC to inform us of reports of white substance, as it was termed
> then, that had been observed during component processing in Atlanta.
>
> On January 30th there was again an additional update from ARC
> indicating that it had been noted in whole blood leukoreduced red
> cells and plasma. Our information at that point was that 67 collected
> products had been quarantined.
>
> \[Slide\]
>
> January 31st, we reported in a teleconference with FDA, the American
> Red Cross and CDC preliminary results from analysis of samples that
> had been obtained from Atlanta Red Cross, indicating that the material
> appeared to be composed of blood-related substances and, at the same
> time, we initiated a review of aspects of the BPU manufacturing while
> analysis of the samples continued.
>
> \[Slide\]
>
> February 3rd, as Dr. Page had reported, our scientists met in Atlanta
> with ARC staff to examine product samples and review the observed
> phenomena. At that time 21 samples were provided to Baxter by American
> Red Cross. These were made up of 20 samples of collected blood
> products and one unused blood pack unit.
>
> \[Slide\]
>
> From the company\'s perspective, we focused on five areas of
> investigation: review of the BPU manufacturing process; analysis of
> the phenomena that had been observed in ARC samples, and I want to
> stress that at the outset of this situation we invited both American
> Red Cross and FDA scientists to join us in northern Illinois on site
> at Baxter, and I think it was a very positive aspect of the
> collaboration and interaction with Red Cross that we did have two Red
> Cross scientists join us for the week of February 3rd and, from the
> FDA perspective, we also enjoyed meeting the investigators.
>
> In addition to analyzing the particulate phenomena that had been
> reported, we also undertook chemical analysis of the anticoagulant and
> additive solutions, as well as chemical analysis of the BPU
> containers. The final area that we initiated studies involving the
> white particulate matter issue was focused on examination of blood
> component processing. Now, I am speaking in the past tense but I want
> to stress that our efforts to understand this situation are ongoing.
>
> \[Slide\]
>
> Looking quickly at the review of our BPU manufacturing process, we
> focused on product surveillance records, the manufacturing process
> itself and a review of batch records. From the product surveillance
> standpoint, we looked at reports to us over the past two years. This
> represented product history in excess of 500,000 BPUs and we had
> received only two reports of observations that could be termed similar
> to those that were reported out of Atlanta Red Cross. The
> manufacturing process and batch records review is still ongoing, still
> looking for anything out of the ordinary but at this point review of
> more than 50 lots of BPUs produced has not indicated any problem that
> could be associated or potentially correlated with these phenomena.
>
> \[Slide\]
>
> With regard to the analysis of the phenomena as they were observed in
> the ARC samples, and I think initially reported in photographs that
> were published, we undertook this activity the week of February 3rd
> with Baxter particle science laboratory scientists as well as
> histologists, etc., etc., working with the ARC scientists. These five
> categories that you see here represent the Baxter documentation of the
> ARC reported phenomena which were posted to the AABB web site.
>
> I just wanted to point out that the descriptions and categorizations
> were developed in collaboration between Baxter and ARC scientists who
> were in our facility that week. Very quickly, five categories of
> phenomena were identified in the samples that were returned to Baxter
> from American Red Cross, microaggregates which were described visually
> as blood debris, clumpy blood debris. Category two was
> microaggregates. Tracking bubbles is the description in the Baxter
> report. That was explained to me as microaggregates which actually
> were in contact with bubbles in the units. Number three was bubble
> phenomena. These were unusual looking reflective bubbles that, upon
> further analysis, turned out to be bubbles. \"Starry night,\"
> described to be white particles at the blood sheeting interface, and
> there was also oiling phenomena which was described as semi-liquid
> droplets in the seam area of the bag.
>
> The microaggregates, at least the microaggregates that were examined
> in the samples that we had, were shown to contain leukocytes,
> hemoglobin and fibrin. That is category one. Category two was similar
> to category one but less formed.
>
> Item number five, the oiling phenomena, were determined, at least in
> samples that we looked at, to be composed of a diffuse meshwork of
> proteinaceous material. The bubble phenomena, upon further analysis,
> were consistent with a saturated ester containing material that might
> occur in blood. There was no evidence of hydrocarbon or a silicone oil
> moiety present. Category four, the \"starry night,\" was consistent
> with proteinaceous material and/or triglyceride or lipid material.
>
> I think upon further analysis, our conclusion, based on the samples
> that we analyzed, was that the white particulate matter and other
> phenomena, at least in the samples that we analyzed, were consistent
> with blood-derived material.
>
> \[Slide\]
>
> As I mentioned earlier, one of the samples that was provided by ARC
> was an unused Baxter BPU which clearly, visible to the naked eye, had
> something that looked like white particulate matter associated with
> one of the bags in the container. Upon further examination, that
> material was determined to be on the external surface of the bag and
> it was shown chemically to be identical in composition to the white
> donor tubing segment pigment.
>
> \[Slide\]
>
> We tested file samples of several lots of the BPUs that had been
> implicated in the observations. What we found uniformly was that, as
> expected, there was an extremely low particulate burden in the
> solutions. There was no evidence of precipitation or any sort of
> suspension, resuspension anomalies with the solutions. We repeated on
> those file samples the chemical release testing that had been
> performed when the lot was originally manufactured and released to the
> field, and the product was still within specification.
>
> \[Slide\]
>
> Our next step in terms of chemical analysis was to examine the
> possibility that there was some difference in the blood pack unit
> plastic material\'s composition, or some change in that that could be
> correlated to the phenomena. What we found there was that all the
> products, both test and control\--we tested what we call test
> products, BPUs from lots that had been associated at that time with
> the phenomena, and control products at that point were pulled from
> similar products that were not implicated in these observations. The
> bottom line there is that all products demonstrated chemical
> constituents related to the bag manufacture at expected levels, and
> testing to date indicates no evidence of any unexpected constituents
> in the bags themselves.
>
> \[Slide\]
>
> Finally, the last area that we looked into was examination of blood
> component processing conditions. I am not going to go through this
> slide in detail. I simply want to point out that using BPUs from
> Baxter as well as two other manufacturers, and you know who you are,
> we were able to replicate the majority of the phenomena that had been
> reported and observed in the ARC samples. Under the same conditions
> under which the phenomena were reproduced\--again, I am not talking
> about all of the, you know, type 1, 2, 3, 4 but some combination of
> those.
>
> In the instance in which the product was buffy coat reduced component,
> we were not able to replicate the white particulate matter finding.
> This is certainly not all-inclusive or all-encompassing, but it did
> confirm the possibility of reproducibly recreating these phenomena in
> bags from three different manufacturers.
>
> \[Slide\]
>
> Where we are at this point is that the company has decided to provide
> a grant to a group of blood banking and transfusion medicine experts.
> The hope here obviously is that this group will be able to study the
> situation and advance in awareness of factors that may have
> contributed to these recent observations of the aggregation phenomena
> in collected blood.
>
> \[Slide\]
>
> The panel will include Drs. Jeffrey McCullough, Roger Dodd, Ronald
> Gilcher, Scott Murphy and Merlin Sayers. At this point, as I said, we
> have not closed out our interest, nor our investigation into these
> phenomena. We look forward to the expert panel as it begins its
> activity. I want to just close by thanking you for the opportunity to
> give you an update on what Baxter has done in relation to the white
> particulate matter issue. Thanks.
>
> DR. NELSON: Thank you, Dr. Binion. Any comments or any questions? Yes?
>
> DR. FITZPATRICK: It is first I have heard that anybody has been able
> to reproduce the phenomenon.
>
> DR. BINION: Okay.
>
> \[Laughter\]
>
> DR. FITZPATRICK: Are you at liberty to share with us how you did that?
>
> DR. BINION: Let me back up a little bit. First of all, I want to say
> that the processing conditions were developed based on discussions
> between our physiologists and ARC staff. Again, I want to stress that
> I think from day one in this situation we have been working in a very
> collaborative, very open manner with ARC, FDA and CDC as well.
>
> Having said that, with the level of detail I have in front of me, I am
> happy to share. None of the units were leukoreduced. They were
> processed on the day of collection. They were cooled one and a half
> hours before processing. They were centrifuged at 4,200 rpm for 7.5
> minutes at 4 degrees C and they were then stored refrigerated.
>
> The ability to reproduce the phenomenon in the processed units in this
> instance appeared to be related to the handling of the components
> during processing and I believe the centrifugation aspects. Needless
> to say, we are continuing to look into this.
>
> DR. NELSON: This reproduction suggests it may be the bag and not the
> donor. But I wonder if anybody has looked at donors who provided the
> potential transfusion recipients with white particulate matter, and
> whether or not the donor, on repeat donation, also did it again.
>
> DR. BINION: The data that I presented here were obviously a laboratory
> study. We have those same questions. I think it is much more along the
> lines of what was described as Dr. Moroff\'s planned studies to look
> at the possibility of donor biological variability or contributing
> factors associated with the donation. Our efforts at this point were
> focused on understanding it and looking at whether there were
> conditions using bags from Baxter, as well as other manufacturers,
> that could shed some light on this situation.
>
> DR. PAGE: I should point out that this has only been observed from
> whole blood donations and there is a required 56-day interval
> between\--
>
> DR. NELSON: Right, I understand that.
>
> DR. PAGE: There was one autologous donor\--white particulate matter
> was seen in several autologous units by us and I think, as mentioned,
> by someone else. One of those autologous donors who had white
> particulate material on one autologous donation donated again and it
> was not seen on the subsequent donation a week or two weeks later.
> That is an N of one.
>
> DR. NELSON: Right.
>
> DR. GOLDING: The data that Steve presented led us to believe, at least
> some of us at the FDA, that the interpretation is that the hard
> spin\--the type of processing with the hard spin is a definite factor,
> and what could be happening here is first you take the whole blood and
> you put it in the cold and you activate the platelets. Then you do a
> hard spin and you remove the plasma so you are leaving the platelets,
> those activated platelets with the red cells in the bag, and that was
> generating particles, and those particles would be associated with
> platelets.
>
> Now, my plea is, and I tried to say this and I probably didn\'t say it
> right after Dr. Page spoke, that I think we need to take all the data
> and look at it in terms of the type 1 particles which I think the
> evidence shows are the platelet particles. Taking all the data and
> looking at it in terms of all the types of particles is confounding
> and is probably imprecise.
>
> I would like to ask, Dr. Binion, I mean, you did this, you reproduced
> it. On one of your slides you said all types of particles were
> reproduced. But the critical particles are the type 1 particles or the
> ones that are associated with platelets. To what extent was that
> represented?
>
> DR. BINION: I don\'t have that level of detail available to me here.
> The point to even taking that path in the first place was to just
> understand if there was something reproducible or potentially
> reproducible in the processing that might shed some light on this. But
> I will get that answer for you.
>
> DR. GOLDING: I think the same thing applies to Dr. Page, whether it is
> a particular bag or a particular process, I think it is worthwhile
> going back and saying, well, with the type 1 particles, which bags,
> which process.
>
> DR. BINION: I think the only conclusion from that table that I
> presented is that looking at the processing of the components has to
> be factored into any effort to understand this phenomena. I think that
> is the only conclusion that I would draw from the information that I
> presented.
>
> DR. KUEHNERT: Matt Kuehnert, CDC. Just a real quick question about the
> handling. You said you were able to reproduce it based on the
> handling. Could you elaborate? I mean, did you throw it out a window
> or tap on it?
>
> DR. BINION: Actually, I didn\'t perform the studies. I believe the
> difference would have been gentle versus less than gentle handling. I
> think as this information is shared with the expert panel, and I think
> as reports from ARC and, hopefully, other studies are also made
> available to the panel that information would be forthcoming.
>
> DR. ORTON: Steve, I will be able to give some more information about
> that in my presentation.
>
> DR. PAGE: Now that I may understand Dr. Golding\'s question a little
> bit better, we have a spreadsheet that describes the number of units
> of each type from each region and correlates that with bag type and
> product code. That was emailed to the FDA about three weeks ago. So,
> the data is available that we can look at in that regard with you,
> which we would be glad to do.
>
> DR. NELSON: Next is Sharyn Orton, FDA.
>
> **Follow-up ADR Monitoring**
>
> **Clinical Studies**
>
> DR. ORTON: As you can tell, I have been dying to get up here.
>
> \[Slide\]
>
> What I am going to describe is some clinical studies that we are
> proposing and actually have ongoing right now at a couple of blood
> centers.
>
> \[Slide\]
>
> One of the things that the task force talked about was the safety
> issue. Even if we determine whether we can or cannot make these, or
> whether they are normal or not normal, we are concerned about the
> transfusion of these blood products. So, although adverse events have
> not been linked to transfusion of blood containing the recently
> described particulate matter, controlled studies are needed to further
> clarify the safety of such units.
>
> In fact, there are reports in the literature that some particulate
> matter results from routine preparation of red blood cells, primarily
> by the hard spin method. The reports in the literature actually give
> 17-93 microns at the beginning of storage. After 21 days they go up to
> 9 g. There is quite a bit of literature from the \'70s and the \'80s
> that does describe this. So, it may be reasonable to assume that at
> least a certain proportion of these particles are, in fact, normal and
> a lot of reports I have gotten from my blood center colleagues who I
> have talked about these clinical studies do, in fact, support that
> type 1 particles are fairly normally seen and, when it comes to
> reproduction, can be reproduced fairly easily.
>
> \[Slide\]
>
> We know the particulate matter appears to be comprised of normal blood
> cell substances, seen less frequently in leukofiltered red cells, and
> in fact the leukofiltration appears to remove most of the observable
> particulate matter. We do have some preliminary data from ABC that
> would support that.
>
> \[Slide\]
>
> So, the scientific question is whether red cells with observable
> particulate matter can be transfused safely. Do these transfused red
> cells result in a higher than expected adverse event rate?
>
> The other question we wanted to consider was does the presence of
> these pre-leukofiltration particulates affect the post-leukofiltration
> counts?
>
> \[Slide\]
>
> So, with the clinical studies we want to evaluate differences in
> adverse event rates between patients that receive units that were
> originally determined to have particulates and patients who received
> units that were not determined to initially have particulates. We also
> want to evaluate post-leukofiltration counts of these particulated red
> cells, both pre and post counts of white cells and platelets.
> Currently, we do have two blood centers that are participating in
> these studies.
>
> \[Slide\]
>
> What we know currently from these two blood centers is that, in fact,
> 60 red cells that very early on were observed with type 1 particulates
> were released for transfusion. The medical director at that center
> determined that they saw this all the time. Ninety percent of those
> units have been transfused. There have been no adverse events reported
> with any of those units.
>
> As far as leukofiltration, one of the participating blood centers has
> looked at 32 red cells that had particulates. They leukofiltered them.
> The total comes to 76 between the two blood centers and, in fact, all
> of the post-leukofiltration white counts were below 5 X 10^6^. In
> fact, over 70 percent were less than 1 X 10^6^. One of the blood
> centers did do the pre and post platelet counts. They did 4, had the
> pre and post platelet counts done and the mean removal was 85 percent
> and the median removal of platelets was 92 percent. In fact, there is
> a reference in the literature from the early \'80s that the
> leukofiltration filters do, in fact, remove about 80 percent of
> platelets.
>
> \[Slide\]
>
> What we have asked as far as adverse event rates, we have asked our
> two blood centers to perform a cohort study. When we consider the
> exposure is either the presence or absence of particulates in a
> prepared red cell, the outcome would be whether there is an adverse
> event. This can be done retrospectively or prospectively and our
> measure of effect is going to be relative risk.
>
> \[Slide\]
>
> What we are having the blood centers do is select particulated red
> cells, leukofilter them and from the same day and preferably hard spin
> also select two red cells that aren\'t observed to have particulates,
> that were also leukofiltered and that were shipped to the transfusion
> service so the transfusion service would get a unit that had
> particulates leukofiltered and also had two units that weren\'t
> particulated and were leukofiltered from the same day. The transfusion
> service will be provided with the whole blood numbers of these units
> for follow-up and the status of the type of red cell it was will be
> blinded so that they won\'t know whether we started with particulates
> or not.
>
> \[Slide\]
>
> We are asking the transfusion service to document either a report or
> lack or report of any adverse events for all of the whole blood
> numbers that are provided and, if necessary, provide some historic
> transfusion reaction rates just for red cells. We do have some
> information that suggests that for leukofiltered red cells the
> transfusion reaction rate in general runs around 0.1 percent, and for
> the non-leukofiltered red cells approximately 0.5 percent. The data is
> to be de-identified and sent to me for analysis. I am looking at both
> by center and preferably pooled data because of the sample sizes that
> are needed to actually get statistical significance with this kind of
> study. If necessary, further review or reported reactions might be
> warranted.
>
> \[Slide\]
>
> This breakdown is not correct. Currently we have 144 non-leukofiltered
> red cells that were observed to have particulate matter, determined to
> be type 1 and what is normally seen, and have been transfused or were
> released for transfusion; 136 leukofiltered red cells that had
> particulate matter have been released for transfusion. The
> corresponding essentially controls have already been identified and
> are currently in follow-up for adverse events. From 100 of the
> leukofiltered red cells that had the particulate matter, 50 have
> actually been transfused, with 94 of their control counterparts, and
> there have been no adverse events reported at all. Keep in mind that
> the sample size is not large enough to make a statement statistically,
> but this is where we are going.
>
> \[Slide\]
>
> As far as pre/post leukofiltration counts, we are interested in both
> the white cells and the platelets, as I mentioned. Again, data would
> be de-identified and sent to us for analysis.
>
> \[Slide\]
>
> FDA is asking blood centers to participate in these studies. It is
> very important that we get blood centers who can get the information
> from the transfusion services. We are not just interested in the blood
> centers that do 100 percent leukofiltration. We want any blood center
> regardless of what their percentage is. Depending on how we identify
> the different criteria, we are interested in all types of red cells,
> and the only way we are really going to get a large enough sample
> size, I believe, is to have larger participation.
>
> What we have found from the blood centers that are participating right
> now is that by asking for reported adverse event data we are not
> asking for too much extra work to be done. Our original plan was to do
> chart review which we knew was not going to be practical when you
> start looking at hundreds, perhaps thousands of units. Anybody in any
> blood center that is interested in participating can contact me. My
> contact information is here. Thank you.
>
> DR. NELSON: Thank you. Did you have any problems getting this through
> the IRB?
>
> DR. ORTON: This data is all retrospective. You know, these were early
> on in the reporting when blood centers were starting to look at their
> units. Many medical directors determined that what they were seeing as
> far as the type 1s was that this was normal, and were leukofiltering
> because they did or were releasing them prior to us ever actually
> making a statement\--
>
> DR. NELSON: I understand that but you are proposing a prospective
> study and I just wondered if there were IRB issues with that because
> you wouldn\'t propose that the particulate matter would be beneficial.
> If anything, it could have no effect; it could be\--
>
> DR. ORTON: Correct, but our recommendation was also to take
> particulated units and leukofilter them and transfuse them. I mean,
> that is what our recommend is. Richard, do you want to make any
> comment about that?
>
> DR. NELSON: I thought you were also transfusing leukofiltered units
> with particulates.
>
> DR. ORTON: Well, as I mentioned, the study could also be
> retrospective. Some of the blood centers have tracked these kinds of
> things and there is some retrospective data.
>
> DR. LEWIS: The two blood centers that Dr. Orton mentioned were
> identified after the units had been released for transfusion. They
> notified us that they had identified particulated matter in a certain
> number of units and had made their decision that they were still safe
> and released them. The FDA hasn\'t taken a regulatory stance. In all
> of our statements we are suggesting an enhanced inspection and
> quarantine but there is no guidance, there is no regulation that would
> prevent them from using these products.
>
> DR. ORTON: In fact, as I said, there is no question that there were
> some particles that were determined not to be normal, but for others
> one of the medical directors determined that they see them on a
> regular basis and did not feel that these were abnormal; they see them
> all the time. Thank you.
>
> DR. NELSON: Having tried to get a lot of projects through the IRB, I
> know that I would have had problems here and one would have to
> certainly get the informed consent, and that might be a problem if you
> did it prospectively. But I think the answer is important as to
> whether or not this has any adverse events, but it is a conundrum
> between getting an answer to an important question and dealing with
> the potential ethical issues as well. Dr. Kuehnert, from CDC, our
> final speaker today?
>
> **Centers for Disease Control**
>
> **and Georgia State Division of Public Health**
>
> DR. KUEHNERT: Thanks for the invitation to do the final presentation
> at this BPAC.
>
> \[Slide\]
>
> I am speaking on behalf of the Georgia Department of Public Health who
> took the lead on this part of the investigation and we gave technical
> input. I think this is one of the rare studies I have been involved
> with where we were hoping to prove the null hypothesis.
>
> \[Slide\]
>
> First some background. These photos are courtesy of Chris Hillyer,
> type 1 matter.
>
> \[Slide\]
>
> I not even going to really read this. It has been presented just
> previously. Basically, after it was discovered that white particulate
> matter was found in blood products, the question was had any of it
> been transfused and, if so, whether there was an increase in reactions
> that were associated with transfusion.
>
> \[Slide\]
>
> So, our objective was to further investigate temporal association of
> adverse patient events with particulate matter. We queried transfusion
> services in Georgia to provide data on transfusion reaction rates over
> time; trends over time by component or supplier; and proportions of
> reaction types for one month, the month in which this was discovered.
>
> \[Slide\]
>
> Methods.
>
> \[Slide\]
>
> We developed a one-page questionnaire to collect monthly data from
> January, 2002 through January, 2003, which I will refer to as the
> entire survey period. We asked transfusion services to report
> reactions as defined by their institution; the number of monthly
> transfusions by component type; the predominant supplier for the
> survey period; and, in addition, detailed information for reactions
> that occurred in January, 2003.
>
> \[Slide\]
>
> The detailed information for reactions in January included date of
> reaction; component type; component supplier, American Red Cross,
> community blood bank or Department of Defense; type of reaction,
> either hemolytic reaction, bacterial contamination, other febrile
> non-hemolytic allergic reactions or transfusion-related acute lung
> injury or otherwise or not specified.
>
> \[Slide\]
>
> A list of Georgia transfusion services was compiled using contact
> information from the American Red Cross, the FDA and the American
> Association of Blood Banks. The questionnaire was distributed on
> February 7th. A reminder was made to non-responders by the 11th, and
> date of collection was completed by the 21st.
>
> \[Slide\]
>
> Reaction rates were defined as number of reactions per 1,000
> transfusions. Reactions were compared by component type supplier and
> time periods of interest. This was a little tricky in what to compare
> to because we didn\'t know when the problem actually started; we just
> knew when it was detected. So, we chose to use the month in which it
> was detected as the referent period and we chose just sort of
> arbitrarily the same month in the prior year and also compared it
> against January to December, 2002, or the remainder of the survey
> period. We compared proportions of reaction types within January, 2003
> by week and half month, and used chi square and Fisher\'s exact test
> for statistics.
>
> \[Slide\]
>
> The results.
>
> \[Slide\]
>
> One hundred and thirty-one transfusion services were identified in
> Georgia, 7 couldn\'t be contacted or said they didn\'t transfuse
> anything over the survey period. So, there were 124 surveyed and 108,
> or 87 percent, of transfusion services responded, which I thought was
> really remarkable. In fact, we sent out the survey on a Friday at 4:00
> and by Tuesday over half of the transfusion services had responded. I
> would say that by the end of that week about three-quarters had
> responded. So, I thought this was really amazing compared with what I
> have experienced before with surveys.
>
> \[Slide\]
>
> Over the survey period there were 1,213 transfusion reactions over
> half a million transfusions. That works out to about 2.3 reactions per
> 1,000 transfusions. The rates by products were RBCs, 2.42, you can see
> the range, 1.79 to 3.11; plasma, 1.48, a pretty wide range, 0.62 to
> 3.53. These are the rates for each month. These are the ranges for
> those. For platelets, 3.36, with a range from 2.12 to 5.42. Reaction
> rates did not differ when we compared January, 2003 versus January,
> 2002 overall, in other words, all components and all suppliers, or
> when we compared January, 2003 versus the rest of the survey period.
>
> \[Slide\]
>
> This just graphically displays that. You see the variability which was
> most remarkable I think in platelets and plasma compared to RBCs which
> was relatively flatter.
>
> \[Slide\]
>
> Next we looked by supplier, comparing January, 2003 versus the
> previous year and there was no significant difference. However, within
> supplier comparisons, when we compared from January to January, there
> were a couple of differences in just components when stratified and
> looking at community blood banks only. There was a significant
> increase in reaction rate associated with plasma, and a decrease in
> reaction rate, approaching significance, for platelets. You can see
> the numerator is very small, 0/6 and 6/1 but, nevertheless, that is
> what the statistics say. There were no differences in trends over the
> survey period for components collected by the Red Cross.
>
> \[Slide\]
>
> For community blood banks you can see there is a lot of variability in
> plasma, in this black line. The blue line is platelets, and a
> relatively flatter line for RBCs.
>
> \[Slide\]
>
> The numbers are much greater for Red Cross. I think it was over 80
> percent of components that were transfused by Red Cross compared with
> community blood banks. So, the lines are flatter; the numbers are
> larger.
>
> \[Slide\]
>
> Looking at the detailed information in January, two were due to
> bacterial contamination. The majority were other febrile,
> noon-hemolytic reactions. There were some allergic reactions. Some
> were categorized as \"other\" and there were no TRALI cases reported.
> When we looked at the proportion of reactions categorized as an event
> type, there was no difference in the proportions when comparing by
> either half month or by week, sliced a couple of different ways.
>
> \[Slide\]
>
> Here it is just graphically displayed by component type. You can see
> by day the distribution over the month.
>
> \[Slide\]
>
> Lots of limitations to this. The goal here was to do it very quickly.
> We really wanted to make sure that it was just a one-page
> questionnaire, although when we got into the detailed data people had
> to sort of cut and paste it, but we really tried to keep it to one
> page. Of course, it was collected retrospectively so there is
> responder bias. We used the definitions of reactions by each
> institution so that introduces bias. If there was a sufficiently small
> adverse event rate due to units with particulate matter, we might not
> be able to detect it even with our large numbers, depending on what
> the rates were. Finally, there were changes in manufacturing\--there
> could have been changes in manufacturing or modification of components
> over the time period that might confound potential trends due to
> particulate matter.
>
> \[Slide\]
>
> In conclusion\--
>
> \[Slide\]
>
> \--we found in Georgia adverse monthly transfusion reaction rates of
> 2.42 for RBCs, 1.48 for plasma, and 3.36 for platelets per 1,000
> transfusions over the survey period. For reactions reported in
> January, 2003 rates by blood component or supplier did not differ from
> the remainder of the survey period overall, and there were no
> significant changes in proportions of reaction types. There were some
> differences on stratified comparisons between individual months but
> those numbers are very small and there was a lot of variability during
> the survey period so our statisticians cautioned us about drawing
> conclusions. If we had used different time periods, such as quarters
> where there is sort of smoother data, we would not have seen those
> differences, but that is not what we chose at the outset so we were
> stuck with what we started with and that is what we found.
>
> \[Slide\]
>
> I would like to acknowledge Martha Iwamoto is the officer who did all
> the work, but couldn\'t be here today to present it. We had a lot of
> help from the FDA, especially in getting the transfusion service list.
> That was very helpful. We had Mary Chamberland who helped out a lot,
> as well as statistical help and some input from folks at Emory.
> Thanks.
>
> DR. NELSON: Thank you. Well, it is reassuring data even though it is
> retrospective. Does this compare pretty much with what is in the
> literature, or what one would expect from the overall rates of
> transfusion by product? Is that pretty comparable with what other
> places have published?
>
> DR. KUEHNERT: I would be curious just to hear what literature there is
> out there on it on a multi-center basis. I did a little bit of a
> literature search and I know that Dr. Linden has done a lot of work
> with transfusion errors and New York State has pretty comprehensive
> reporting, but I wasn\'t able to find published reports on transfusion
> reaction rates in a state or in a large number of centers.
>
> DR. NELSON: Yes?
>
> DR. ALLEN: Thank you. That was very different from the other
> presentations and I think rounded out the presentations nicely. Just a
> comment and a quick question, I am delighted to see actually that you
> did do it all retrospectively because I think had you tried to get
> retrospective comparison information with prospectively collected
> data, the difference in methods would have totally biased the period
> of prospective interest.
>
> Question, information obviously went out to the transfusion service
> directors, and I suspect the Red Cross was in touch with them because
> of the various issues. Was there any information in the general media?
> Was this something that got picked up? Just how much was out there and
> what impact do you think that had on what happened?
>
> DR. KUEHNERT: It is hard to say. You know, we set the cut-off point at
> January 31st. I think it hit the media over the weekend. There may
> have been some rumors before that where some transfusion services
> heard about it. You know, I think in looking at the reaction types
> there may have been some bias because we did notice that there were an
> awful lot of \"others\" and when we looked we actually had to weed out
> some because it said, you know, suspected something but then when we
> looked again it wasn\'t related to transfusion. We thought it was kind
> of odd to report that it is not associated with transfusion. Why would
> you report it? But overall we didn\'t see a jump in rate in January.
> So, maybe in the categorization it might have made a difference but
> otherwise, since they have a standardized way to report transfusion
> reactions, I don\'t think it had much of effect. We told them to just
> use the records they had.
>
> DR. NELSON: Dr. Lewis is going to summarize this issue for us.
>
> **Summary**
>
> DR. LEWIS: I have some more slides in that previous side set. While
> you are loading that, I think that it is obvious from what we heard
> this afternoon that this was an incredibly intensive effort and
> required a lot of resources from a lot of different people, with
> incredible cooperation between regulatory bodies, other scientific
> organizations, as well as industry.
>
> DR. NELSON: Did you tap into the bioterrorism research fund for this?
>
> DR. LEWIS: Actually, the FDA Emergency Operations Center, which was
> organized in response to September 11, was activated and was used.
>
> DR. NELSON: You have to find some way to spend this money I guess.
>
> DR. LEWIS: I wanted to use the Commissioner\'s statement that was
> published on February 27th as a summary and conclusion, and it is
> really where FDA\'s thinking is right now.
>
> \[Slide\]
>
> Dr. McClellan issued an update on our investigation of the particulate
> matter and, as part of the title to emphasize it, there was not, and
> still is not, evidence for any increase in adverse events associated
> with the particulate matter.
>
> \[Slide\]
>
> The exact cause is still unexplained. There is no evidence of a threat
> to blood safety, although there has been all along some concern about
> blood supply.
>
> \[Slide\]
>
> The investigations at a number of different places showed that the
> particles themselves are composed of normal blood substances,
> primarily platelets, and the rate of adverse reactions has not
> increased. This is supported by the studies that you heard about from
> Dr. Kuehnert and Dr. Orton.
>
> \[Slide\]
>
> All analyses have been negative for infectious agents, chemical
> contaminants and any defects in the blood bags.
>
> \[Slide\]
>
> In spite of initial reports, the particulates were not limited to the
> Red Cross collections or to Baxter blood bags.
>
> \[Slide\]
>
> Again emphasizing, no evidence of adverse reactions that are
> associated with it.
>
> \[Slide\]
>
> Baxter\'s testing showed no changes or obvious differences in process
> in particle composition or any of the materials that they use.
>
> \[Slide\]
>
> This is the short list of participating individuals and organization.
>
> \[Slide\]
>
> This goes to the predominant current theory of the cause.
>
> \[Slide\]
>
> This has to do with how blood is processed today. When whole blood is
> hard spun in order to collect plasma, and if there is not to be a
> platelet collection from the particular units, this hard spin spins
> the platelets and white cells into the red cells. The platelet-poor
> plasma is collected and the particulates have been predominantly
> observed in these types of red cell units. When platelets are to be
> collected, the whole blood units are soft spun and platelet-rich
> plasma is expressed. Currently the use of apheresis platelets is much
> more predominant today than it has been in the past. Thus, there are
> more units in the last decade that would use the hard spin to collect
> red cell units. As a result of that, the observation of particulated
> units in red cells may be more frequent.
>
> \[Slide\]
>
> We currently think that there is still some uncertainty with what is
> causing this. We encourage people to continue with their enhanced
> visual inspection, distinct from the required visual inspection. It
> may not be necessary\--if the units are leukoreduced, to go ahead and
> use units that have been leukoreduced even if particulate were
> observed before leukoreduction. Again, the enhanced visual inspection
> seems to be beneficial only before units are leukoreduced.
>
> \[Slide\]
>
> In centers where it is not normally leukoreduced and particles are not
> observed, it is probably safe to assume that the units do not pose an
> increased risk.
>
> Let me just say that the work ahead will at least require accumulation
> of a lot of data and, hopefully, we will be able to draw some
> conclusions from all of those data, if nothing else, to define what
> has caused these particulates and possibly use that information to
> improve the quality of blood.
>
> I would like to also take the opportunity to thank all the presenters
> who took the time and effort to put together presentations for us
> today, all of whom did this on short notice and presented a lot of
> information. Thank you, Dr. Nelson.
>
> DR. NELSON: Thank you. Yes?
>
> DR. FITZPATRICK: Richard, I want to say one thing. I think the FDA\'s
> initial response was very admirable to what occurred and the way they
> approached it, but I think now we seem to be mired in the need to
> explain the phenomenon and devote a lot of resources to it when, at
> the same time, we were briefed on a non-plan on how to deal with West
> Nile Virus.
>
> So, I am concerned about the priorities here. This is a very
> interesting scientific phenomenon for a lot of people; they want to
> devote a lot of time and resources to it. Yet, in a practical sense
> there appear to be no adverse events. It is 12 million donations a
> year from 12 million different biological individuals and the
> proportion of observation is about the same as the manufacturers\'
> market share. Now, that we have had our peak of intense scrutiny we
> seem to not be seeing it anymore, maybe because people don\'t want to
> deal with it anymore. It is hard to tell.
>
> So, I question the rationale behind the need to explain something that
> may never get explained, in a manner that does that which may be
> taking resources away from everything else. There needs to be an
> \"extraction\" policy as well as a \"dealing with\" it policy.
>
> DR. LEWIS: Thank you very much. I think no one appreciates your
> comments more than those of us at the FDA who have been dealing with
> this. We recognize the need to draw some important conclusions from
> all of these efforts and we would like to do it as quickly as we can.
>
> DR. NELSON: Dr. Smallwood is going to announce the next meeting where
> we will get a further update on white particulate matter.
>
> DR. SMALLWOOD: Just to let you know, the tentative dates that are set
> for the next Blood Products Advisory Committee meeting are June 19th
> and 20th. It will be in this hotel. So, please use your usual
> resources for confirming this and tell your friends that left. Thank
> you.
>
> \[Whereupon, at 4:45 p.m. the proceedings were adjourned\]