Quality Control And

Pathogen Inactivation of Platelets

Ohood Al.AyyadhiLaboratory ManagerBlood Transfusion servicesKuwait Central Blood Bank

Pathogen Inactivation

• Introduction.• Why Pathogen Inactivation.• Methods.• Kuwait Central Blood Bank Results.

Infectious Risks

Transfusion of biological fluids=

Viruses, Parasites, Bacteria, Prions, ???

Infectious Risks

Test

vs

Risk

Known Unknown

Pathogens of highest concern in the Middle East

• West Nile virus• SARS• Vaccinia• Chikungunya virus• Dengue• Avian flu virus (H5N1)• Borrelia burgdorferi• Trypanosoma cruzi

• Plasmodium falciparum• Leishmania • Babesia microti• HIV• HBV• HCV• HTLV• Bacterial Contamination

Kuwait Central Blood Bank

What’s our Scope?

• The ONLY Central Blood Bank• 21 Government Hospitals• 20 Private Hospitals• 2 Military Hospitals• Blood product supplier to Allied armies

• 69,000 Whole blood donations.• 100% Leukocyte Reduced RBC & Plasma.• 7,794 Apheresis Platelets (55,000 units).

What’s our Scope?

• AABB Accredited 1989.• CAP Survey 1994.• Accredited by the National Quality Program.• National Reference Laboratory.• Accredited as regional reference center for

Arabian countries.• AABB Immunohaematology Reference Lab IRL

self assessment 2008.

What’s our Scope?

• Training center for post-graduate hematologist.

• Training center for pre-graduate medical lab technologist.

• Training center for regional countries.• Therapeutic Apharesis Center.• National Antenatal screening program.

What’s our Scope?

Pathogens of highest concern in the Middle East (KCBB)

• Bacterial Contamination.• HBV.• HCV.• HIV.

Viral Infectious Risks At KCBB

2011 2010 2009 2008 HIV

68239 62720 60991 61771 Total Tests

4(0.006%)0

(0.00%)1

(0.01%)4

(0.06%) Anti-HIV

2 3 2 4 NAT-HIV

Infectious Risks at KCBB

2011 2010 2009 2008 HBV

68239 62720 60991 31771 Total Tests

122(0.19%) 163(0.26%)163(0.27

%)191(0.31

%) HBsAg

157 59 175 139 NAT-HBV

5715 (8.76%) 5657(9%)

6187(10%)

6059(9.8%) ANTI-HBC

3950 (6.06%)

3753(5.98%)

3754(60%)

3979(65%) ANTI-HBs

Infectious Risks at KCBB

2011 2010 2009 2008 HCV

68239 62720 60991 61771 Total Tests

110( 0.17%) 163( 0.26%) 208( 0.34%) 317( 0.19%) Anti-HCV

76 53 122 115 NAT-HCV

Infectious Risks at KCBB

2011 2010 2009 2008 HTLV

68239 65218 60991 31771 Total Tests

9 (0.012%)

12 (0.019%)

8 (0.01%)

14 (0.02%) Anti-HTLV

Infectious Risks at KCBB

2011 2010 2009 2008 MALARIA

8207 10830 11319 11218 Total Tests

728 (8.87%) 220 (2.03%) 239 (2.1%) 183 (3%) Anti-Malaria

Infectious Risks at KCBB

Bacterial Contamination Risksof Platelets At Kuwait Central Blood

Bank

HIV

HBVHCV

1996199419921990198819861984

1:100

1:1000

1:10 000

1:100 000

1:1 000 000

1998 2000

Transmission risk, per unit

Updated from: Goodnough LT e t al. NEJM 1999;341:126-7

Comparison of Residual Risks

2002

BacterialContamination

(platelets)

SepticFatalities(platelets)

Unit Transfused Risk per Million Units Confirmed Report of FatalityBacterial Contamination

Red Blood Cells 6.0 1.0Platelet pheresis units 32 7.1TOTAL, all units 7.4 1.1

Perez P et al. Transfusion 1999;39:2S.

Bacterial Contamination Risks

Perez P et al. Transfusion 1999;39:2S.

1/140,800

Unit Transfused Risk per Million Units Confirmed Report of FatalityBacterial Contamination

Red Blood Cells 6.0 1.0Platelet pheresis units 32 7.1TOTAL, all units 7.4 1.1

Bacterial Contamination Risks

1/140,800

Unit Transfused Risk per Million Units Confirmed Report of FatalityBacterial Contamination

Red Blood Cells 6.0 1.0Platelet pheresis units 32 7.1TOTAL, all units 7.4 1.1

1/31,000

Bacterial Contamination Risks

Perez P et al. Transfusion 1999;39:2S.

Frequency of Contamination

Ness PM et al. Transfusion 2001;41:857-61.Recalculation: LJ Dumont.

Plt Conc SDPPost-transfusion sepsis 402/million 75/millionFatalities 62/million 14/million

Based on Johns Hopkins’ Data

Compare:HIV 0.33/millionHCV 1/million

Ness PM et al. Transfusion 2001;41:857-61.Recalculation: LJ Dumont.

Frequency of Contamination

Plt Conc SDPPost-transfusion sepsis 402/million 75/millionFatalities 62/million 14/million

Based on Johns Hopkins’ Data

Bacterial ContaminationAABB STD 5.1.5.1

The blood bank or transfusion services shall have methods to limit and detect bacterial contamination in all platelet components.

History of testing in KCBBTest Date

Syphilis 1965HBVs-Ag 1970HIV-Ab 1985Malaria-Ab 1987HBVc-Ab 1992HBVs-Ab 1992HCV-Ab 1992HTLV-I&II Ab 1994HIV-I & II Ab 1997HIV-Ag 1997Bacterial Detection 2005NAT- HIV, HCV, HBV 2006

Bacterial Risk at KCBB

• 6,800 Apheresis Platelets (~ 40,000 units).• 0.5 – 1 confirmed cases of sepsis per year.

Bacterial Detection

• Scansystem

• March 05 – May 07

• 26,000 units

•eBDS Pall

• June 07 – May 08

• 14,000 units

•10% of collection tested by culture as QC

Summary results of QC of platelet aphaeresis component (10% collection)Detection System Tested

ComponentsInitial Positive

False Positive

False Negative

ScansystemMarch 05 – May 07

2475 5 (.20%) 5 (.20%) 1 (.04%)

eBDSJune 07 – May 08

1292 2 (.15%) 2 (.15%) 1 (.07%)

Total 3767(22,602)

7 (.19%) 7 (.19%) 2 (.05%)

Bacterial Detection

Mitigation

• Delay of component release (2 days)• Complexity of procedures• Results:

–False positives (0.2 %)–False negatives (0.05%)

• Safety?:–Did not prevent all septic transfusion reactions–Did change the risks of bacterial contamination.

Pathogen InactivationWHY ?

Why is Pathogen Inactivation Important?

• Reduced risk of bacterially contaminated platelet transfusion

• Further closing of window period for screened viruses

• Added protection against untested pathogens (e.g. Chagas)

• Pro-active protection against emerging pathogens (e.g. Chikungunya, West Nile)

• Possible reduction in adverse transfusion events

• Potential to revisit donor deferral strategies and enlarge donor pool

• Public expectation of ‘ZERO risk’

Pathogen InactivationSystems

Platelet Pathogen Inactivation Systems

• Intercept– Amotosalen + UV

• Intercept • Mirasol

– Riboflavin + UV

Platelet Pathogen Inactivation Systems

• Intercept• Mirasol• Theraflex UV

Platelet Pathogen Inactivation Systems

InterceptBlood System for

Platelets

DNA or RNAof pathogen

Mechanism of Action

Amotosalen

Intercalation Crosslinking

UVA Illumination

Double-strandedDNA or RNA

Single-strandedDNA or RNA

Helical Regions

Amatosalen Cross links Both Single and Double Stranded Nucleic Acids

INTERCEPT Blood System for Platelets

UVA Illumination Device

Integrated Processing Set

1Collection

2Amotosalen

3Illumination

4CAD

5Storage

Mirasol® Pathogen Reduction Technology System

Mirasol PRT System Overview

• The Mirasol PRT System uses riboflavin (vitamin B2) and UV light to inactivate pathogens, altering their nucleic acids so they cannot replicate.

Mechanism of Action

UV light + riboflavin: irreversible inactivation• Riboflavin molecules form complexes

with nucleic acids • UV light from the Mirasol Illuminator

activates the riboflavin molecule in the complex

• Photoactivated riboflavin induces a chemical alteration to the functional groups (such as guanine bases) of nucleic acids making pathogens unable to replicate

• Reduction of viruses, bacteria, parasites• Inactivation of residual white cell

+Riboflavin

(Vitamin B2)solution

UV LightPlatelet or

Plasma product

+

Mirasol PRT System Concept

Theraflex UVSystem

Theraflex

• Methylen Blue and UV illumination device used as a technique for Pathogen Reduction

Theraflex

KCBBClinical Experience with

Platelet PI

Pathogen Inactivation (INTERCEPT) Implementation

• Training, March 2008• Validation, May 2008• 100 % Pathogen Inactivation of Platelets

replaced 1st May 2008 • AABB inspection 15th May 2008

KCBB Results

Source

• Trima Accel version 5.2 / 6.0 • Hemonetics (MCS+) 998 CF-E

Collection dose

• Single dose (3-4 x 1011/unit)• Double dose (6-7 x 1011/unit)• Baby units (0.5 x 1010/unit)

KCBB Results

Source

KCBB Results

Collection dose

• Single dose (3-4 x 1011/unit)

• Double dose (6-7 x 1011/unit)

• Baby units (5 x 1010/unit)

DoubleSingle

KCBB Results

KCBB QC Results

Parameters:• Volume (Pre & Post)• Platelet Count (Pre & Post)• Count Loss• Culture

QC Samples:

• Total 990 (15.3%)• Valid 718 (11.1%)

KCBB QC Results

• Total:718• 66 % of tested units ≥ 3 x 1011/unit• 34 % < 3 x 1011/unit

– Pre-PI is < 3 x 1011/unit – Divided as baby units.

• Pathogen Inactivation process has no significant effect on the final product.

KCBB QC Results

KCBB QC Average Results

Parameter July-August2008

Pre Platelet Count 3.25

Post Platelet Count 3.05

Loss 0.21

August-September2008

3.8

3.2

0.6

All Culture NEGATIVE

KCBB QC Average Results

All Culture NEGATIVE

Collection Storage

Average time 2hr

Registration

Action

Duration

Process

Equip-ment

Random Donation

zero 02:00 02:15Time

Trim

a: R

estin

g tim

e 1h

rH

aem

oniti

c: n

o ne

ed fo

r res

ting

Prin

t lab

el

Aphaeresis PLT Collection toolsSealerComputer

IncubatorScalesClampsSealersComputer RAD-SURE (UVA illumination indicator)

Filtration StandsClampsSealersConnection deviceComputerScalesIntercept set (LV/SV)

End

Prod

uct:

leuc

ocyt

es re

duce

aph

aere

sis

plat

elet

pat

hoge

n in

activ

ation

Filtration

Filtration

Processing

Final Platelets

02:20

Illumination

02:30 08:30

Average time =6min Average time =6-16hrAverage time = 3-6min

CAD start

INTERCEPT Pathogen Inactivation Workflow

Present TestingTest Date

Syphilis 1965HBVs-Ag 1970HIV-Ab 1985Malaria-Ab 1987HBVc-Ab 1992HBVs-Ab 1992HCV-Ab 1992HTLV-I&II Ab 1994HIV-I & II Ab 1997HIV-Ag 1997NAT- HIV, HCV, HBV 2005Bacterial Detection 2006

Present TestingTest Date

Syphilis 1965HBVs-Ag 1970HIV-Ab 1985Malaria-Ab 1987HBVc-Ab 1992HBVs-Ab 1992HCV-Ab 1992HTLV-I&II Ab 1994HIV-I & II Ab 1997HIV-Ag 1997NAT- HIV, HCV, HBV 2006Bacterial Detection REMOVED 2008

Present Testing ProcessingTest Date

Syphilis 1965HBVs-Ag 1970HIV-Ab 1985Malaria-Ab 1987HBVc-Ab 1992HBVs-Ab 1992HCV-Ab 1992HTLV-I&II Ab 1994HIV-I & II Ab 1997HIV-Ag 1997NAT- HIV, HCV, HBV 2006Bacterial Detection REMOVED 2008

Pathogen Inactivation 2008

Clinical Effectiveness

• Platelet count loss.• Platelet activation.• Frequent platelet transfusion.• Compromised CCI.

Processing effects

Processing effects

• Same day release of Platelets.• Simple procedure.• No bacterial contamination.• Less allo-immunization.

Cost

• Expensive.

Cost

• Less expensive than:– Bacterial testing.

Cost Effectiveness at KCBB

• Better platelet products quality on TIME.• STOP Bacterial detection tests.• STOP Irradiation.• STOP Malaria testing.

Platelets Pathogen Inactivation

• Conclusion • PI highly prevalence agent.• PI vs. Testing; compromised budgeting.• PI in highly endemic areas.

Acknowledgment

• Dr. Reem Al.Radwan• Dr. Nabeel Sanad• Suhaila Al.Shatty• Samiya Al.Hamdan • Badriya Al.Radwan• Hanan Sheshtari• Ghadeer Ashkanani• Maryam Ameer

• Ghadeer Boland• Quality Control Lab• Quality Managment

Department• IT Department• Platelets Donation

Department

www.atmckw.com