1. Quality Control And Pathogen Inactivation of Platelets
Ohood Al.Ayyadhi
Laboratory Manager
Blood Transfusion services
Kuwait Central Blood Bank

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

4. Infectious Risks Transfusion of biological fluids =
Viruses, Parasites, Bacteria, Prions, ???

5. Infectious Risks
Test vs
Risk
Known
Unknown

6. 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

7. Kuwait Central Blood Bank

8. What’s our Scope? The ONLY Central Blood Bank 21 Government Hospitals
20 Private Hospitals
2 Military Hospitals
Blood product supplier to Allied armies

9. What’s our Scope? 69,000 Whole blood donations.
100% Leukocyte Reduced RBC & Plasma.
7,794 Apheresis Platelets (55,000 units).

10. 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.

11. 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.

12. Pathogens of highest concern in the Middle East (KCBB)
Bacterial Contamination.
HBV.
HCV.
HIV.

13. Viral Infectious Risks At KCBB

14. 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 4
NAT-HIV

15. 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

16. 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

17. 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

18. 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

19. Bacterial Contamination Risks of Platelets At Kuwait Central Blood Bank

20. Transmission risk, per unit
Comparison of Residual Risks
1:100
Transmission risk, per unit
HIV
Bacterial
Contamination
(platelets)
1:1000
1:10 000
HBV
HCV
Septic
Fatalities
(platelets) 1: 1:
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
Updated from: Goodnough LT e t al. NEJM 1999;341:126-7

21. Bacterial Contamination Risks
Unit Transfused Risk per Million Units
Confirmed Report of Fatality
Bacterial Contamination
Red Blood Cells
Platelet pheresis units
TOTAL, all units
Perez P et al. Transfusion 1999;39:2S.

22. Bacterial Contamination Risks
Unit Transfused Risk per Million Units
Confirmed Report of Fatality
Bacterial Contamination
Red Blood Cells
Platelet pheresis units
TOTAL, all units
1/140,800
Perez P et al. Transfusion 1999;39:2S.

23. Bacterial Contamination Risks
Unit Transfused Risk per Million Units
Confirmed Report of Fatality
Bacterial Contamination
Red Blood Cells
Platelet pheresis units
TOTAL, all units
1/140,800
1/31,000
Perez P et al. Transfusion 1999;39:2S.

24. Frequency of Contamination
Based on Johns Hopkins’ Data
Plt Conc SDP
Post-transfusion sepsis 402/million 75/million
Fatalities 62/million 14/million
Ness PM et al. Transfusion 2001;41:
Recalculation: LJ Dumont.

25. Frequency of Contamination
Based on Johns Hopkins’ Data
Plt Conc SDP
Post-transfusion sepsis 402/million 75/million
Fatalities 62/million 14/million
Compare:
HIV /million
HCV 1/million
Ness PM et al. Transfusion 2001;41:
Recalculation: LJ Dumont.

26. Bacterial Contamination AABB STD 5.1.5.1
The blood bank or transfusion services shall have methods to limit and detect bacterial contamination in all platelet components.

27. History of testing in KCBB
Date
Syphilis
1965
HBVs-Ag
1970
HIV-Ab
1985
Malaria-Ab
1987
HBVc-Ab
1992
HBVs-Ab
HCV-Ab
HTLV-I&II Ab
1994
HIV-I & II Ab
1997
HIV-Ag
Bacterial Detection
2005
NAT- HIV, HCV, HBV
2006 27

28. Bacterial Risk at KCBB 6,800 Apheresis Platelets (~ 40,000 units).
0.5 – 1 confirmed cases of sepsis per year.

29. Bacterial Detection March 05 – May 07 26,000 units eBDS Pall
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

30. Bacterial Detection
Summary results of QC of platelet aphaeresis component (10% collection)
Detection System
Tested Components
Initial Positive
False Positive
False Negative
Scansystem
March 05 – May 07
2475
5 (.20%)
1 (.04%)
eBDS
June 07 – May 08
1292
2 (.15%)
1 (.07%)
Total
3767
(22,602)
7 (.19%)
2 (.05%)

31. 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.

32. Pathogen Inactivation WHY ?

33. 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’

34. Pathogen Inactivation Systems

35. Platelet Pathogen Inactivation Systems
Intercept
Amotosalen + UV

36. Platelet Pathogen Inactivation Systems
Intercept
Mirasol
Riboflavin + UV

37. Platelet Pathogen Inactivation Systems
Intercept
Mirasol
Theraflex UV

38. Intercept Blood System for Platelets

39. Mechanism of Action UVA Illumination Amotosalen DNA or RNA of pathogen
Intercalation
Crosslinking 39

40. Amatosalen Cross links Both Single and Double Stranded Nucleic Acids
Helical Regions
Single-stranded DNA or RNA
Double-stranded DNA or RNA 40

41. INTERCEPT Blood System for Platelets
Integrated Processing Set 1
Collection 2
Amotosalen 3
Illumination 4
CAD 5
Storage
Amotosalen HCl is formulated in saline as a 3 mM solution.
The nominal volume used is 15 ml (apheresis) or 17.5 ml (Buffy Coats). When 15 ml of the solution is added to 285 ml of apheresis platelet concentrate, the final volume is 300 ml and the final amotosalen HCl concentration is 150 M.
The same concentration is achieved when 17.5 ml of the solution is added to 350 ml Buffy Coat platelets. In vitro studies have shown that the INTERCEPT Blood System platelet process retains its effectiveness with amotosalen HCl concentrations in the range of 120–180 M.
UVA Illumination Device 41

42. Mirasol® Pathogen Reduction Technology System

43. 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.

44. 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

45. + + Mirasol PRT System Concept
Platelet or Plasma product
Riboflavin (Vitamin B2)
solution
UV Light
Reduction of viruses, bacteria, parasites
Inactivation of residual white cell

46. Theraflex UV System

47. Theraflex

48. Theraflex
Methylen Blue and UV illumination device used as a technique for Pathogen Reduction

49. KCBB Clinical Experience with Platelet PI

50. Pathogen Inactivation (INTERCEPT) Implementation
Training, March 2008
Validation, May 2008
100 % Pathogen Inactivation of Platelets replaced 1st May 2008
AABB inspection 15th May 2008

51. KCBB Results Source Trima Accel version 5.2 / 6.0
Hemonetics (MCS+) 998 CF-E

52. KCBB Results Collection dose Single dose (3-4 x 1011/unit)
Double dose (6-7 x 1011/unit)
Baby units (0.5 x 1010/unit)

53. KCBB Results
Source

54. KCBB Results Collection dose Single dose (3-4 x 1011/unit)
Double dose (6-7 x 1011/unit)
Baby units (5 x 1010/unit)
Double
Single

55. KCBB QC Results Parameters: Volume (Pre & Post)
Platelet Count (Pre & Post)
Count Loss
Culture

56. KCBB QC Results
QC Samples:
Total 990 (15.3%)
Valid 718 (11.1%)

57. KCBB QC Results Total: 718 66 % of tested units ≥ 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.

58. KCBB QC Average Results
Parameter
July-August
2008
Pre Platelet Count
3.25
Post Platelet Count
3.05
Loss
0.21
August-September
2008
3.8
3.2
0.6
All Culture NEGATIVE

59. KCBB QC Average Results
All Culture NEGATIVE

60. leucocytes reduce aphaeresis platelet pathogen inactivation
INTERCEPT Pathogen Inactivation Workflow
Registration
Collection
Filtration
Process
Processing
Storage
Duration
Average time 2hr
Average time = 3-6min
Average time =6min
Average time =6-16hr
Time
zero
02:00
02:15
02:20
02:30
08:30
Random Donation
Filtration
Illumination
CAD start
Final Platelets
Haemonitic: no need for resting
Trima: Resting time 1hr
Print label
leucocytes reduce aphaeresis platelet pathogen inactivation
End Product:
Action
Aphaeresis PLT Collection tools
Sealer
Computer
Filtration Stands
Clamps
Sealers
Connection device
Computer
Scales
Intercept set (LV/SV)
Incubator
Scales
Clamps
Sealers
Computer
RAD-SURE (UVA illumination indicator)
Equip-
ment

61. Present Testing Test Date Syphilis 1965 HBVs-Ag 1970 HIV-Ab 1985
Malaria-Ab
1987
HBVc-Ab
1992
HBVs-Ab
HCV-Ab
HTLV-I&II Ab
1994
HIV-I & II Ab
1997
HIV-Ag
NAT- HIV, HCV, HBV
2005
Bacterial Detection
2006 61

62. Present Testing Test Date Syphilis 1965 HBVs-Ag 1970 HIV-Ab 1985
Malaria-Ab
1987
HBVc-Ab
1992
HBVs-Ab
HCV-Ab
HTLV-I&II Ab
1994
HIV-I & II Ab
1997
HIV-Ag
NAT- HIV, HCV, HBV
2006
Bacterial Detection
REMOVED 2008 62

63. Present Testing Processing
Date
Syphilis
1965
HBVs-Ag
1970
HIV-Ab
1985
Malaria-Ab
1987
HBVc-Ab
1992
HBVs-Ab
HCV-Ab
HTLV-I&II Ab
1994
HIV-I & II Ab
1997
HIV-Ag
NAT- HIV, HCV, HBV
2006
Bacterial Detection
REMOVED 2008
Pathogen Inactivation 2008 63

64. Clinical Effectiveness

65. Processing effects Platelet count loss. Platelet activation.
Frequent platelet transfusion.
Compromised CCI.

66. Processing effects Same day release of Platelets. Simple procedure.
No bacterial contamination.
Less allo-immunization.

67. Cost
Expensive.

68. Cost
Less expensive than:
Bacterial testing.

69. Cost Effectiveness at KCBB
Better platelet products quality on TIME.
STOP Bacterial detection tests.
STOP Irradiation.
STOP Malaria testing.

70. Platelets Pathogen Inactivation
Conclusion
PI highly prevalence agent.
PI vs. Testing; compromised budgeting.
PI in highly endemic areas.

71. Acknowledgment Dr. Reem Al.Radwan Ghadeer Boland 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