A global spectrum of emerging pathogens Today

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• ??
• ??????
• 2013?9?5???

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Bacteria The most frequenttransfusion-transmitte
d infection
Known pathogens Routine testing covers only a
limited number
New and emerging pathogens A risk that current
safety measures cannot eliminate
Screening limitations Gaps in current defenses
exist, due to the window period and limited
screening sensitivity
Leukocytes Residual cells and cytokines can cause
harmful post-transfusion reactions
Most transfusion recipients are battling serious
disease and have weakened immune systems
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Emerging Infections Disease continue to emerge
worldwide
Red newly emerging diseases Blue
re-emerging/resurging diseases
Adapted from Morens DM. Nature. 20044302429.
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Timeline of the WNV epidemic in the USA
PUBLIC HEALTH WNV was recognized as a threat in
1999
First identification in humans, horses and birds
in three states
66 human cases reported in 10 states
9,862 human cases, WNV Ab test approved
WNV activity in 47 continental states, 2,470
human cases
1999
2000
2001
2002
2003
2004
2005
199 WNV-() donors in 28 states
First documented transmission by organ transplant
and blood transfusion
WNV NAT implemented under IND transmission
confirmed or suspected in gt40 blood recipients
BLOOD SAFETY Experimental tests for WNV were
not implemented until June 2003
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West Nile virus in Europe

• Recent outbreaks of WNV in Europe reaffirmed that
  mosquito-borne viral diseases may occur on a mass
  scale, even in temperate climates1
• Frequent detection of equine, avian and human WNV
  in south France (2000 and 2003) suggests that
  some areas may be at increased risk of infection
  on a seasonal, rather than sporadic, basis2

1. Hubálek Z, et al. Emerg Infect Dis.
1999564350. 2. Dauphin G, et al. Comp Immunol
Microbiol Infect Dis. 20042734355.
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Healthy blood donors can carry a range of
asymptomatic herpesviridae infections
Virus Potential symptoms in recipient Prevalence Blood supply screening
CMV Pneumonitis, retinitis, birth defects 5085 by age 401 Tested as needed
EBV Mononucleosis, pneumonitis, hepatitis, oncogenic potential 95 by age 402 Not tested
HHV-6 Pneumonitis, fever, encephalopathy, rash gt90 in adults3 Not tested
HHV-7 Pneumonitis, fever, encephalopathy, rash gt90 in adults3 Not tested
HHV-8 Kaposis sarcoma Varies by geography Not tested
Severe symptoms most likely in immunocompromised
individuals. Moderate prevalence in
Mediterranean countries, low in rest of Europe.
1. http//www.cdc.gov/ncidod/diseases/cmv.htm 2.
http//www.cdc.gov/ncidod/diseases/ebv.htm 3.
Clark DA. Int J Hematol. 20027624652.
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Studies have shown CMV transmission by
CMV-negative and leukoreduced blood products
Study reference Number of patients CMV infection CMV disease Type of blood product used
Bowden, et al. (1995) 252250 2/43/6 0/03/6 CMV-negativeLeukoreduced
Ljungman, et al. (2002) 3349 36 00 Combination Leukoreduced
Nichols, et al. (2003) 360447 618 Not givenNot given CMV-negative or leukoreducedApheresis platelets
Ronghe, et al. (2002) 93 0 0 CMV-negative RBC and leukoreduced platelets
Foot, et al. (1998) 110 1 0 CMV-negative
Primary and secondary endpoints (infections day
21100 or 0100 after SCT)
Adapted from Ljungman P. Br J Haematol.
200412510716.
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Availability of safety measures against
transfusion-transmitted infections
Adapted from Barbara, J. Transfus Med Hemother.
200431(suppl 1)110.
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IV Therapeutics Process Availability
IV solutions Sterilization 1950s
Plasma fractions(FVIII, FIX, albumin) SD(one or more stages) 1980s
Plasma/FFP SD, methylene blue 1990s
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????????????
Trade Name Active Compound and Method Developer Approval/ Phase
Octaplas (SD) solvant Tri (n) butyl phosphate (TnBP) détergent Octoxynol-9 or Triton X 100 or Tween 80 or Chlolate de sodium B. HOROWITZ (NYBC,1985 1990)VI Technologies (Vitex) licensed in the US but is withdrawn and 20130117 approved for Blood-Clotting Disorders in US
Octaplas (SD) solvant Tri (n) butyl phosphate (TnBP) détergent Octoxynol-9 or Triton X 100 or Tween 80 or Chlolate de sodium ARC OctaPharma 1992 approved in France 2006 EU Mark
Mirasol ???285-365nmUVAUVB?? Navigant / Caridian-BCT CE mark in 2008
Theraflex MB-plasma 1 mM Methylene blue(MB) 180 J/cm2????( 590 nm) Springer,?? Grifols,??? Use in 20 countries MacoPharma 2008 approved in France. Oct. 2011 withdrawn in France
Intercept Amotosalen HCl(S-59)UVA light Baxter/Cerus 2010 EU Mark regulatory review in US
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Trade Name Active Compound And Method Developer Approval/Phase
INTERCEPT Blood System Amotosalen HCl (S-59)3 Joules /cm2 UV A light (320-400 nm) Baxter/Cerus 2002 CE Mark classe 3 2005 Afssaps France 2007 PEI German 2010 wissmedicSwis Phase III in US
Mirasol PRT Riboflavin??? 6.2 J/cm2 UV /visible light (265-370 nm) Navigant / CaridianBCT Phase I/II/III
Theraflex UV 0.3 J/cm2 monochromatic UV light(200-275 nm ) CaridianBCT/ MacoPharma RD
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?????????????
Trade Name Active Compound and Method Developer Approval/ Phase
FRALE S-303 (bifunctional alkylator) Baxter/Cerus Phase I/II/III in US stopped for neoantigen Phase I in EU Phase I in US
INACTINE PEN 110 (Ethyleneimine) VI Technologies Phase III
Riboflavin Riboflavin(Vitamin B2) 6.2 J/cm2 UV (265-370 nm) Navigant/ Caridian-BCT FDA approved clinical trials in the US
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?????????????
Radio
X, G
WAVE LENGTH (nm)
High energy

Low energy
200 250 300 350
400 590
750
UVC UVB UVA
VISIBLE
Amotosalen
INTERCEPT
3 J/cm2
Mirasol
6.2 J/mL
UVC
0.4 J/cm2
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The INTERCEPT Blood System

• Introduction Mechanism

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Nucleic acid targeting using amotosalen HCl

• Psoralen targets DNA and RNA (single- and
  double-stranded)
• Crosslinking reaction is initiated by UVA light
  (320-400nm)
• Replication of nucleic acid of pathogens and
  leukocytes is stopped
• Platelets, plasma and RBCs do not require nucleic
  acid function for therapeutic effect

Amotosalen
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Amotosalen crosslinks both single-
anddouble-stranded nucleic acids
Helical Regions
Double-strandedDNA or RNA
Single-strandedDNA or RNA
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Amotosalen mechanism of action
UVA Illumination
Amotosalen (S-59)
Targeting
Intercalation
Crosslinking
Helical region of single- or double-stranded DNA
or RNA
Multiple crosslinks block strand separation and
replication
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The INTERCEPT Blood System for plateletsA broad
spectrum of inactivation

• Bacteria
• Aerobic and anaerobic species
• Gram-positive and Gram-negative species
• Spirochetes (including Treponema pallidum and
  Borrelia burgdorferi)
• Viruses
• Enveloped and non-enveloped species
• Species with either single- or double-stranded
  DNA or RNA
• Protozoa
• Including Plasmodium spp. (malaria), Trypanosoma
  cruzi (Chagas disease), and Leishmania spp.
  (leishmaniasis)
• Residual donor leukocytes
• Prevents replication and inhibits cytokine
  synthesis

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Limitations of the INTERCEPT Blood System

• Not effective against HAV
• Highly infrequent labile component pathogen with
  few reported cases
• Not effective against bacterial spores
• Effective against vegetative state
• Not effective against prions
• Unique disease mechanism
• Very low frequency
• Preventable by other measures livestock
  management

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The INTERCEPT Blood System for Platelets

• Virus

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The INTERCEPT Blood System for plateletsViral
inactivation overview
Enveloped Enveloped
ss RNA HIV-1, HIV-2, HCV, HTLV-I, HTLV-II, BVDV, WNV
ss/ds DNA HBV, DHBV
ds DNA CMV
Non-enveloped  Non-enveloped 
ds RNA Bluetongue virus
ss RNA Calicivirus
ds DNA Simian virus 15
ss DNA Parvovirus B19

• Small non-enveloped picorna viruses (e.g.,
  poliovirus, HAV) are resistant to inactivation

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Measurement of pathogen inactivationLog
reduction

• ????????
• Log (Pre-treatment infectivity / Post-treatment
  infectivity)
• ?
• Log (Pre-treatment infectivity) Log
  (Post-treatment infectivity)
• ?????????,? lt1 infectious unit/volume assayed??
• gt ????????????
• Log reduction was reported based on the volume
  assayed

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Examples of log reduction calculations
Pre-treatment infectivity (IU/ml) Post-treatment results Post-treatment infectivity (IU/ml) Log reduction calculation Log reduction
106 5 organisms in 1 ml 5 log106 log5 5.3
106 5 organisms in 10 ml 0.5 log106 log0.5 6.3
106 No organisms in 1 ml lt1 gt (log106 log1) gt6
106 No organisms in 10 ml lt0.1 gt (log106 log0.1) gt7
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INTERCEPT Blood System for platelets
Inactivation of routinely tested pathogens
Pathogen Log reduction
Hepatitis B HBV (human, MS-2 strain) DHBV (model virus for HBV) gt5.5gt6.2
Hepatitis C HCV (human, Hutchison strain) BVDV (model virus for HCV) gt4.5gt6.0
HIV Cell-free HIV-1 Cell-associated HIV-1 gt6.2gt6.1
HTLV-I HTLV-I HTLV-II 4.75.1
Treponema pallidum (syphilis) gt6.8 to lt7.0
Approved product claims under CE Mark. gt
refers to below limit of detection for assay.
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INTERCEPT Blood System for platelets
Inactivation of additional enveloped viruses
Pathogen Log reduction
Cytomegalovirus gt5.9
SARS-CoV gt6.21
Vaccinia virus gt4.72
West Nile virus gt5.52
gt refers to below limit of detection for assay.
Approved product claims under CE mark.
1. Pinna D, et al. Transfus Med. 20051526976.
2. Lin L, et al. Transfusion. 20054558090.
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INTERCEPT Blood System for platelets
Inactivation of non-enveloped viruses
Pathogen Log reduction
Bluetongue virus, type 11 6.16.4
Parvovirus B191 standard protocol 30 min incubation 2.0 3.9
Feline conjunctivitis virus (calicivirus) 1.72.4
Simian adenovirus 15 0.72.3
Porcine parvovirus 00.2
Approved product claims under CE mark.This
incubation period was supplementary to the
standard operating protocol.
1. Sawyer L. Manuscript in preparation.
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Implementation Data Management
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INTERCEPT data management system (IDMS)
IDMS server
Registration
Add amotosalen
Illumination
CAD incubation
Storage
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Macopharma Platelets
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