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Paul-Ehrlich-Institut WHO Collaborative Centre for quality Assurance of blood products and in vitro Diagnostic Devices. Patients suffering from haemophilia had to face pain, impairments and death at an early age. Modern medicinal products help improve their quality of life and increase their life expectancy.
Paul-Ehrlich-Institut WHO Collaborative Centre for quality Assurance of blood products and in vitro Diagnostic Devices. Patients suffering from haemophilia had to face pain, impairments and death at an early age. Modern medicinal products help improve their quality of life and increase their life expectancy.
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Paul-Ehrlich-Institut WHO Collaborative Centre for quality Assurance of blood products and in vitro Diagnostic Devices. Patients suffering from haemophilia had to face pain, impairments and death at an early age. Modern medicinal products help improve their quality of life and increase their life expectancy.
Copyright:
Attribution Non-Commercial (BY-NC)
Formati disponibili
Scarica in formato PDF, TXT o leggi online su Scribd
WHO Collaborative Centre for Quality Assurance of Blood Products
and in vitro Diagnostic Devices Safety Assessment and Regulatory Issues in Blood Products Improving World Health Through Regulation of Biological Medicines Seoul, Republic of Korea, 1 April 2006 Paul-Ehrlich-Institut Federal Agency for Biological Medicinal Products www.pei.de Johannes Lwer Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 2 Plasma Products Industrially purified preparations (e.g. coagulations factors, antibodies) are manufactured from pooled plasma from a great number of donors In the past, patients suffering from haemophilia had to face pain, impairments and death at an early age; modern medicinal products help improve their quality of life and increase their life expectancy Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 3 Blood as a Medicinal Product Blood donations are processed to become blood components: Red blood cells, platelets (for haemostatis), plasma Blood transfusions are indispensible in modern medicine! Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 4 Regulatory Control of Medicinal Products in Europe: National and EC Activities Marketing authorization Official batch release Plasma derivatives, not recombinant products Regular surveillance inspections Ensuring e.g. Good Manufacturing Practice (GMP) Postmarketing surveillance CAP (Centrally Authorised Products) testing: spot checks with random sampling from the market Pharmacovigilance Reports of adverse events, regulatory measures Periodic Safety Update Reports (PSUR) Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 5 Challenges / past events overview Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 6 Safety Problems Pathogen transmission Virus infections: Human immune deficiency virus (HIV) Liver infection: Hepatitis B (HBV), Hepatitis C (HCV) Prions ? Creutzfeldt-Jakob-Disease Immunological incompatibility or allergic reactions Blood clotting (thromboses) Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 7 WHO Global Database 2001 - 2002 On the basis of 81 million donations per year in 178 countries worldwide only around 60% would be subject to stringent safety requirements. Deficient regulatory systems or lack of appropriate tests still account for about 40% of donations globally, i.e. 32 million donations are not or not completely tested http://www.who.int/bloodproducts/ivd/en/ Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 8 WHO Global Database 2001 - 2002 Virus / Bacterium Donations Not Tested Deficient Testing (about 35%) HIV 357.036 HBV 401.933 HCV 1.948.933 Treponema pallidum (Syphilis) 2.595.344 28.802.809
Data: http://www.who.int/bloodsafety/GDBS_Report_2001-2002.pdf and http://www.who.int/bloodproducts/ivd/en/ Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 9 Risk of Pathogen Transmission by Blood Products per Year Virus / Disease Prevalence in Donor Blood Minimum Risk of Infection (no test at all) Maximum Risk of Infection (no test plus deficient testing) HIV 1/1.000 1/10.000 35 357 2.915 30.000 HBV 1/ 10.000 40 3.000 HCV 1/50-1/100 19.489 38.978 307.517 615.034 Syphilis no data no data no data
Epidemiology varies in different countries/continents Other viruses may have to be considered in other countries/continents B19 infections are only serious for certain risk groups (e. g. sickle cell anaemia in Africa, pregnant women) Virulence may depend on epidemiological factors (e. g. HAV) HTLV (I + II) and HCMV are mainly cell associated. Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 10 Regulation of Blood Screening in Germany Viral marker Licence Date of First Assay Introduction of Testing Test Mandatory Since HBsAg 1 Mar 1976 End of seventies 1980 Anti-HIV 5 Jun 1985 immediately 1 Oct 1985 Anti- HCV 5 Jan 1990 1992 1 Jan 1993
Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 11 Virus Transmissions by Blood Products in Germany since 1985
Group of Product Method of Inactivation Transmitted Virus Number of Transmissions Year PPSB PL, UV HIV >10 1989/90 Factor VIII S/D-treatment HAV >80 1991 ff. iv-IgG Cohn fractionation HCV >250 1993/94 PPSB Pasteurisation HBV >30 1994 Factor VIII S/D-treatment HAV 6 1997
Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 12 Transmission of vCJD by Blood Transfusion Three cases of probable transmission of vCJD by blood transfusions have been observed in the UK. They were detected since blood donations, which vCJD patients had given before illness, are followed up Patient diagnosed with vCJD 6.5 years after red blood cells from a donor with vCJD 3.5 years after donation Patient having received red blood cells from donor with vCJD 18 months after donation, died 5 years later from unrelated cause; autopsy vCJD pathogen (prions) in his lymphatic tissue Patient diagnosed with vCJD 8 years after red blood cells from a donor with vCJD 20 months after donation Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 13 vCJD Risk of Blood Products? Red cell transfusions are large-volume, non- processed single donor blood components If a donor is incubating vCJD, his/her blood may contain prions There is no dilution, nor sufficiently effective removal of prions Plasma products are manufactured from large pools of donations, the haemophilia products are highly processed (fractionation, purification) If a donor is incubating vCJD, his/her plasma would be diluted in a large pool For several steps of manufacture, effective removal of prions has been demonstrated experimentally Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 14 Precautions Refrain from using UK plasma for fractionation Exclusion of donors possibly at risk CJD or vCJD of donor or in family Treatment with human pituitary hormone, TX of dura mater or cornea After cumulative stay for X (*) months in UK between 1980 and 1996 After operation/transfusion in the UK Recipients of blood transfusions (*) Recall of products, if vCJD donor identified (*) The measures taken may vary by member state Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 15 CPMP POSITION STATEMENT ON CREUTZFELDT-JAKOB DISEASE and PLASMA-DERIVED AND URINE-DERIVED MEDICINAL PRODUCTS London, 23 June 2004, EMEA/CPMP/BWP/2879/02 rev 1 Available data indicate that the manufacturing processes for plasma-derived medicinal products would reduce infectivity if it were present in human plasma. Manufacturers are now required to estimate the potential of their specific manufacturing processes A CHPM Note for guidance on the investigation of manufacturing steps came into force in October 2004 http://www.emea.eu.int/pdfs/human/bwp/513603en.pdf Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices Bakterial Transfusion Reactions 1995 - 2005 Total Suspected Cases 92 Causal relationship likely 45 Contamination of the sample 42 Unrecognised infection of the donor (Yersinia enterocolica, E. coli, Malaria) 3 Total - fatal outcome 15 Sepsis by pathogens detected in the bag containing residual sample (Yersinia (2x), Staph. aureus, Klebsiella pneumoni- ae, Proteus vulgaris, Enterobacter cloacae, Strept.pyogenes) 7
Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 17 Approaches to Control Potential Viral Contamination of Biologicals Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 18 Three principal complementary approaches can be adopted to control potential viral contamination of biologicals: selecting and testing source material for the absence of viruses, testing the capacity of the production processes to remove or inactivate viruses, and testing the product at appropriate stages of production for freedom from contaminating viruses. Approaches to Control Potential Viral Contamination of Biologicals Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 19 Donor Criteria Directive 2004/33/EC provides legally binding criteria in its ANNEX III: ELIGIBILITY CRITERIA FOR DONORS OF WHOLE BLOOD AND BLOOD COMPONENTS These state-of-the art requirements build on previous EC Recommendation 98/463/EC on the suitability of blood and plasma donors and the screening of donated blood, the Council of Europe guide, the monographs of the European Pharmacopoeia, particularly in respect of blood or blood components as a starting material, and recommendations of the World Health Organisation (WHO) They apply to the collection and testing of human blood and blood components, whatever their intended purpose, including plasma for fractionation Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 20 Diagnostic Window in HIV Detection NAT <500 copies/ml 0 1 2 3 4 5 6 7 S 9 10 11 12 13 14 15 16 17 1S 19 20 21 22 23 Day delay in recognition of HIV Current CE-marked by PEI/NB since 2003 HIV Ag/Ab combination HIV 1/2 antibody HIV single p24 antigen HIV 1/2 rapid After re-evaluation PEI 1994 CE-marked not by PEI in 2005 After re-evaluation PEI 1998 Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 21 Diagnostic Window in HCV Detection NAT HCV core Antigen HCV 2.0 0 10 20 30 40 50 60 Day delay in detection of HCV Current CE-marked Anti-HCV assays by PEI/NB since 2003 up to 2003 after re-evaluation PEI 1998 CE-marked in 2005 not by PEI Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 22 Summary I Quality Control of Screening Tests Crucial parameters: sensitivity and specificity Sensitivity: crucial for safety Sensitivity: close to 100% with clearly positive samples Biological sensitivity: seroconversion panels Analytical sensitivity: dilution series For antibody tests, analytical sensitivity does not correlate with biological sensitivity Analytical sensitivity should not be used for comparison of assays, but for control of consistency of batches Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 23 Summary II Quality Control of Screening Tests Specificity: largely economical, logistical and psychological issue, less for safety Specificity: >95% with large number of negative samples Specificity: >95% with tricky samples Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 24 1,0E+00 1,0E+01 1,0E+02 1,0E+03 1,0E+04 1,0E+05 1,0E+06 1,0E+07 1,0E+08 1,0E+09 1,0E+10 0 10 20 30 40 50 60 70 80 90 Days after infection H C V - R N A
( c o p i e s / m l ) 0,00 0,50 1,00 1,50 2,00 2,50 3,00 a n t i - H C V
( s / c o ) 59 days HCV NAT reduces the window period by ca. 60 days M. Nbling et al. The PEI mandated in Germany the NAT-testing for HCV (1 April 1999) and HIV (1 May 2004) of all donations for transfusion Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 25 Initial anti-HCV screening test Anti-HCV positive pools (anti-HCV 2nd) No. of plasma pools tested No. of HCV-PCR positive plasma pools none +++ 8 8 (100%) anti-HCV 1st +/- 85 65 (76%) anti-HCV 2nd - 123 49 (39%) HCV NAT in Plasma Pools M. Nbling et al. After introduction of HCV NAT, the HCV burden in all plasma pools used in the EC is below the detection limit, ensuring a high safety margin for the virus inactivation steps. Pools before HCV NAT: Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 26 Nucleic Acid Amplification Tests: Events in Europe 21 February 1994 Withdrawal of license for Gammagard 24 November 1994 NAT in plasma pools for certain IVIG 27 April 1995 NAT in plasma pools for certain IMIG 14 September 1995 NAT in plasma pools for certain IMIG 7 May 1996 Commitment for HCV NAT in plasma pools (EAPPI) 12 February 1997 Commitment for HCV NAT in plasma pools (EPFA) 21 October 1997 CPMP recommendation for HCV NAT in plasma pools from 1 January 1999 Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 27 1. Single donation 2. Testing pools 3. Minipools 4. Production pools 5. Intermediate products 6. Final products NAT: Appropriate Stage for Testing for Freedom from Contaminating Viruses Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 28 Appropriate Stage for Testing for Freedom from Contaminating Viruses It is due to statistics (Poisson distribution) that testing of final products for the presence of viruses (antigen tests, NAT) cannot ensure freedom from contaminating agents. Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 29 Viral Safety of Blood Transfusions after Introduction of NAT The selection of healthy donors and highly developed testing methods have reduced the risk drastically The residual risk of contracting a virus infection through a blood transfusion is extremely low and can only be assessed very roughly: For HIV and HCV it is markedly below 1 : 3,000,000 For HBV, NAT is difficult to perform and is not obligatory; in spite of this, only isolated transmissions HBV occur; testing for anti-HBc is currently introduced Experience will show whether new developments in the pathogen inactivation of blood components will bring about further progress Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 30 Spontaneous Reports of probable Transmissions of Hepatitis C Virus via Transfusions 1990-2005 (n = 60) 0 2 4 6 8 10 12 14 16 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year of Transfusion Introduction of NAT Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 31 Summary: Importance of in vitro Diagnostics First line detection of infectious agents (highest probability in blood donations) Crucial for the prevention of transmission of blood-borne pathogens Avoiding new starting points for transmission chains Impact appropriate control on safety of blood and blood products Independent control = unbiased control Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 32 Principles in the regulatory (independent) evaluation of IVD tests Licensing Verification of documents Laboratory control Official batch (lot) release Verification of documents Laboratory control Emergency cases methods Paul-Ehrlich-Institut WHO Collaborative Centre for Quality Assurance of Blood Products and in vitro Diagnostic Devices 33 Three principal complementary approaches can be adopted to control potential viral contamination of biologicals: selecting and testing source material for the absence of viruses, testing the capacity of the production processes to remove or inactivate viruses, and testing the product at appropriate stages of production for freedom from contaminating viruses. Approaches to Control Potential Viral Contamination of Biologicals Testing of blood donations with serological and NA tests Virus validation studies Plasma pool testing with NA tests