回科会表
分査
１事
調
平薬 血座
薬事 。食 品衛 生 審議会
平成 2 5 年 度第 1 回 血 液事業部会安全技術調査会
14100∼ 16:00
吉澤委員長
議 事 次 第
日時 :平 成 25年
14:00∼
7月 10日
平成2 5 年 7 月 1 0 日 ( 水)
厚生労働省 1 9 階
専用第 2 3 会 議室
(水)
16:00
場 所 :厚 生 労働 省 19階
(専用 第 23会 議 室)
議題 :
1.日 本赤十字社 にお け る平成 24年 度 ヘ モ ビジ ラ ンス につい て
2 シ ャー ガ ス病 に対す る安全対 策 の進捗状況 につい て
内 田委 員
野
大 戸委 員
口 委
員
岡 田委 員
田 委
員
委
3.血 小板製剤 の病原 体不活化 技術 導入 に関す る検討 につ いて
4 血 漿分画製斉」
の ウイ ル ス安全対 策 について (非公 開)
5 そ の他
杉 浦 委 員
配 付資料
座 席表
委 員名 簿
新 津 委 員
本赤十字社
設置要 綱
料
1
日本赤 十字社 にお け る平成 24年 度 ヘ モ ビジ ラ ンスについ て
資
料
2
(日本赤十字社提 出資料)
シ ャー ガス病 に対す る安全対策 の進捗状況 につ いて
(日本 赤 十字社提 出資料)
資
料
3
血小板製剤 の病原体不活化技術 導入 に関す る検討 につい て
資
料
4
血 漿分 画製剤 の ウイ ル ス安全 対策 につ いて (E型 肝炎 ウイル ス及
び ヒ トパ ル ボ ウイ ル ス B19)(非 公 開、委員 限 り資料)
(日本赤十字社提 出資料)
濱 口委 員
血 液 対 策 企 画官
資
血
血
課
液
対
策
課
長
液
長対
補策
佐課
(事務局席 )
傍 聴
席
安 全技術 調 査 会 委 員名 簿
氏
名
ら
、
りがな
内 田 恵 理 子 う ちだ えりこ
大 戸
斉
お おと ひとし
現
薬 事 。食 品 衛 生 審 議 会 薬 事 分 科 会
職
国
立医薬品食品衛生研究所 遺伝子細胞医薬部 第一室長
福
島県立医科大学医学部長
白 阪 琢 磨
しらさか たくま
国 立感染症研究所血液・
安全性研究部第一室長
政法人国 病院機構大阪医療 ターエイズ先端医療研
:ン
勢 蔀賃
千
新 津
望
に いつ のぞみ
埼 玉医科大学国際医療センター造血器腫瘍科教授
漬 口
功
は まぐち いさお
国 立感染症研究所血液 安全性研究部長
岡 田 義 昭 お かだ よしあき
ー臨
ン
セ
ン
タ
名
古
屋
医セ
床
研
究
た
う
らわ
る 算聾
杉 浦 亙 すぎ
勇P奏
贋詳
鎮蒸灌葬 療
牧 野 茂 義 ま きの しげよし
国 家公務員共済組合連合会虎の門病院輸血部長
山 口 照 英 や まぐち てるひで 国 立医薬品食品衛生研究所生物薬品部研究員
吉 澤 浩
司 よ じざわ ひろし 広 島大学名誉教授
血液 事業部会安 全 技術 調 査会 設 置 要綱
(目的 )
第 1条 安 全 な血液製剤 の安 定供給 の確保 等 に関す る法律 (昭和 31年法律 第 160
号 )に お いて 、国 は、血液製剤 の安全性 の 向上 に関す る基本 的かつ 総合 的 な
施 策 を策定 。実施 が求 め られてい る こ とを踏 ま え、血液 製剤 に関す る安全性
の確保 対策 に関す る諸事項 を調査 ・審議 す ることを 目的 として、薬事分科会
規 程第 4条 に基づ き、血液事業部会 の 下 に 「
安全技術調 査会」 (以下 「
調査
会 」 とい う。)を 設置す る。
(調査 会 の審議事 項)
第 2条 調 査会 は、以下 に掲 げる事項 を検 討 す る。
一 血 液
製斉1に混入す る可能性 の あ るウイル ス等 の感染性 因子 の検討
ニ ウ イル ス 等 の感 染性 因子 の不活化技術 等 に関す る検討
脇 田 隆 字 わ きた た かじ 国 立感染症研究所ウイルス第2部部長
三 血 液 製剤 の安全性 に関す るガイ ドライ ン 等 の検討
(計 11名 ,氏 名五十音順 )
四 そ の他 、血液製剤 の安全性 の確保 に関す る重要事項 の検討
(調査 会 の組織)
第 3条 調 査会 に所属す べ き委員 は、部会 に所属す る委員 、臨時委員及 び専門
委員 (以下 「
委員等」 とい う。)の 中 か ら、部会長 が指 名す る。
2 調 査 審議 にあた っては、議題 の 内容 等 に応 じて、部会 長 の判断 によ り他 の
委 員 または参考人 に出席 を求 め る こ とが で きる。
3 部 会 長 は、第 一 項 の規定 によ り調 査会 に属す べ き委員 等 を指名 した場合 は 、
部 会 においてその 旨を報告 しな けれ ばな らな い。
(座長 の選任)
第 4条 調 査会 に座 長 を置 き、調査 会 に属 す る委員等の互選 に よ り選任す る。
2 座 長 は、調査会 の事 務 を掌理す る。
3 座 長 に事 故 が あ る ときは 、調査会 に属 す る委員等 の うちか ら座長 が あ らか
じめ指 名す る者 が 、そ の職務 を代理 す る。
(調査 会 の 開催)
第 5条 調 査会 は、年 1回 の 開催 とす る。
2 前 項 に規 定す る場合 のほか 、委員等 が必 要 と認 め る ときは調査会 を開催 す
日会 料
０議 資
¨
一
驀
成事 全
平薬 安
日
るこ とがで きる。
(/Jヽ
委員会 の設 置)
6条
座 長 は、必要 に応 じて 、調査 会 の 下 に小委 員会 を設置す ることがで き
第
る。
2 月 ヽ
委員会 は 、 当該調 査会 の審議事 項 の うち、特 に重点的 な検討 を要す る事
感染症報告
輸血 後副作用 ・
2012年 まとめ
項 の 審議 にあた る。
3 月 ヽ
委員 会 の委 員 は 、調査会 の委員 の うちか ら座長 が指猛 す る。
(議決)
7条
部 会 へ の 報告 の要否等、議決 を行 う必要 が ある調査会 の議事 は 、調査
第
会 に属す る委員等 で会議 に出席 した もの の過 半数 で決 し、可否同数 の ときは、
座長 の決す る ところに よる。
(議事 の公 開)
8条
調 査会 は原 則 として公 開す る。 た だ し、公 開す るこ とに よ り、委 員 の
第
自由 な発言 が制 限 され公正 かつ 中立 な審議 に著 しい支障 をお よぼすおそれ が
ある場合 、又 は 、個人 の秘密 、企業 の知 的財 産等 が開示 され特定の者 に不 当
な禾」
益又 は不利 益 をもた らすおそれ が あ る場合 については 、座長 は、 これ を
非公 開 とす るこ とがで きる。
日本構十字社の安全対策
(染
筐貝1)
第 9 条 こ の規程 に定 めるもののほか 、調 査会 の運営 に関 し必要 な事項 は 、部
会長 が部会 に諮 り決定す るもの とす る。
融
+殺 電
・
・
・
・
…・
・
… ●検診 (問診票の保管期間 41年 間)
・
ト
●検体保管 … …… … … … ・
1996年9月∼ (保管期間11年間) … … … 枷 清軸 検
… … … … … …ト
・
・
・
・
・
● 自己申告 ・
…・
4・・
8月より20本プー ル)
●核酸増幅検査 (2004年
・
・
く,・
1・
● 白血球除去
(2007年1月より全面導入)
プール血漿
・
(… ・
●献血後情報
く……●新鮮凍結血漿の貯留保管
(`か月間保管)
オブザ ーバL〆
非溶 血 性 副作用
1靡
医療機関からの臨床データ、患者血液および献血者保管検体の検査結果などから評価
」RCS/BSH/SyD舷
感染症報告の推移(件数)
副作用 ・
+鸞 爛
非溶血性副作用報告症例 の概要(2012年)
1,194
1,287
患者性別 男 性
1,476
1,603
883名
女性
1,939
712名
1,720
1,670
1,709
1,716
1,743
0
200
400
600
800
1000
1200
1400
1600
1000
2000
□非溶血性副作用 圃溶血性副作用 □ GVHD疑 い
100.
非溶血性副作用の分類別内駅
1,809
2008
2009
201
2011
2012
150´
( 中 央値) ( 0 ∼1 0 2 歳)
患 者 年 齢 o6歳
501
572件
(359%)
190件
(119%)
アナフィ
ラキシー(様)反応
156 件
(98%)
アナフィ
ラキシー(様)ショ
ック
242 件
(152%)
呼吸困難
26 件
輸血関連急性肺障害
血圧低下
その他
(121%、 心原性肺水腫疑い44件 を含む)
193 件
輸 血 関 連 循 環 過 負 荷
0'
一ヽ
“
1,881
1,823
2501
2∞ ￨
10 件
(16%) ・
2 “ 2 年4 月 報 告 分 よりT A C O 評 価 開 始
(06%):TRA日
90件
(56%)
116 件
(73%)
6、p_TRAL1 4
+雲 蜘
5
Transfusion-Related
AcuteLungInjury
+霊 t爛
RALI)
輸血 関連急性肺障害 (丁
概念
輸 血後 6時 間以内(多くは2時 間以内)に急性のり
Hb原 性肺水腫を伴う
呼吸困難を呈する重篤な非溶血性輸血 副作用
適切な処置をしないと死亡する場合もある
静
発熱反応
0.69
￨■
ⅢⅢい■応
1,￨
■
アナフィラキシ…(1蒙
ヨ
ツク
)シ
危険因子
1.18
0.72
。
診断基準
誤味、肺炎、有書物吸入、肺挫傷、溺水
・
重症敗血症、ショック、多発外傷、熱傷、
>ALЦ 急性 の肺障害)
急性膵炎、心肺バイパス、薬物過剰投与
・
0
急激 に発症 口
低酸素血症
possible TRALI
口
胸部X線 上両側肺野 の漫潤影
口
左 房圧上昇(循環過負荷)の証拠がない
>輸 血以前にAL:が ない
>輸 血 中もしくは輸 血後 6時 間以内に発症
>時 間的に関係のあるAL:の 他 の危険因子がない
011
￨￨=11Ⅲ
蒙
￨￨=￨￨￨1撫
TACO(輸 ●関連循環過負荷)
0.02
Ⅲ
ⅢⅢ
Ⅲ轟 Ⅲ
中 111,中
:
血圧低下
■Ⅲ
︲
︱ ︱ ︱ヨー ー ー
呼吸困難 :心原性肺水腫疑い含む
+ 目壼t 苺
非溶血性副作用報告内訳 (症状別)… 2004∼2012-
TRALlと
possible TRALl(2004-2012)
%
0
2004
―
奪麻 疹
-勲
2005
―
2006
アナフィ
ラン
( 様) 反応
2007
2008
2009
→ ← アナフィ
ラキシー ーl 「呼吸困難
(様 )シ
ンク
-TRAu ‐
2010
2011
2012
2004
―血圧低下 ― ― その他
￨
L_
2005
2006
* 1 人の患者で2 回発症 ( 2 0 o 5 年
)
'2007
2008
2009
( ) 内 の数字は死亡例
2010
2011
2012
―
―
￨
+殺 蜘
丁RALlに係る血 液製剤 の抗 自血球抗 体陽性等 の内訳
￨
￨
+醜
日赤 における輸 血 関連循環過負荷 (TACO)評価基準
2.胸 部X線 上で肺浸潤影を認める。
3.輸 液 ・
輸血過 負荷を認める。
4.輸 血 中・
輸血後 6時間以内に発症
殴 献
飛
5.血 圧上昇
露
︱１ １ １ １ １ １ １１ １ １ １ョーー ＋
件数
。
∞ 。
５ ０ ∞ Ю Ю
詢 1.急 性呼吸不全 :Pa02/日
02 300mmHg以 下又は、Sp02 90%以下(room alr)
■0 代
20代
30代
40代
6.頻 脈
7.BNP、 NT‐
proBNP値 を参考とする。
1∼4は必須とする。
50代
年齢
除外項 目
・
透析中の患者
口
人工心肺使用中・
後の患者
・
補助体外循環装置を使用中の患者
・
現在治療をしている心不全又は慢性呼吸不全がある場合
輸血 関連循環過負荷TACO
(Transfusion
associated
circulatory
overload)
輸 血に伴う循環負荷 による心不全であり、呼吸困難 、頻脈 、血圧上 昇などを認
める。胸部X線 で肺浸潤影など心原性肺水腫の所見を認 めることが ある。
輸 血 後6時 間 以内の発 症が 多い 。
患者 内訳
T A C O I T r a n s f u s b n a s s o d a t e d d r c u l a t o roya dO)vの
e暫定的診断基準
‖
(!SBT working party)
a
b
c
d
e
急 性呼吸不全
頻脈
血 圧上昇
胸 部X線上急性肺水腫もしくは肺水腫の悪化
輸 液・
輸血の負荷の証拠
のうち4つを満たす。
原因製剤
複合製剤内訳 :7
BNPの 上昇はTACOの 診断の補助となる。
‘
一
一
Ｌ
，
１ ，︱︱︱ ︲
︱︱︱︱︱︱︱︱ ︱︱ ︲
11■
輸血終了後6時間以内の発症。
￨
病原体別因果関係評価結果(2012)
感染症
病原体
報告件数
HBV
50
HCV
40
細菌
30
1
HEV
4
4
CMV
3
l
HTLV-1
1
VZV
1
真菌
1
︲︲
︲︲
︲
︲
︲
︲
一
］
HBV&HCV
特定
JRCS/BSH/SV
Dli,
輸血後感染(HBV/HCV/HIV)症 例 の推移蠅告年)
病原体別感染症報告数の推移
20(1)
５
６
２
( 件)
300
13て
1)
■H B V t t H C V 園 細 菌 □そ の 他
Ｍ
13
Ｍ
250
隕
舅
四
■
一
６
銅 ︲
２
︲
０
２
０
２
■ ■ ■ Ｅ ２
一
2005
。
。
２
１ 日 ３
０。
﹃
８
０
０
２
例
2004
目︱
爾
■
2011
2
1
2010
。
こυ ２
鱚
回
７
０
０
２
５
０
０
２
2010
４
勒
胃
一
2009
０
７′ ２
画
．
６ ■ｌ ｌ Ｅ
︲
３
︲
緻
■
2004
尿
型
0
翻
■
50
繭
囮 扁 囃 颯 颯 下 一 一 四 一 Ｈ
■
100
11(1)
９
４
︲
３
５
︲
隋
Ｅ
隋
150
￨
11(1)
鱚
200
一
―
20p_NA丁 時期別の 1年 当たりHBV受 血 者 感染症例 数
輸血による細菌感染疑い症例
(献血者感染状況別分 類 )
９
4 年 5 ヵ月
(20088-201212)
輸血との因果関係が高いと評価された症例 (自血球除去製剤)
検出菌
８
再貪募
=
７
６
５
夏 (鰍臨D二
製剤名
報告年(保存 日数)
9taphylococcus
aureus
2006年 (3)、2008`手 (4)
,tr"わθ
οωぉ ″ε
gaをοttθ`撃 屁ク,効〃,(0群 レンサ球菌)
2008年 (4)、20114手 (4)
４
itreptococcus agalactiae
PC
2009年 (3)
３
２
=trepわ
οοοο
“ No騨
１
浴雛)=
=(8断
θ
S(A群 溶血性レンサ球菌)
`0124「(4)
9erratiamarcescens
`009年 (4)
０
>保 存前 白血球除去
・
血小板製剤 :2004年 10月
・
全血採血 由来輸血用血液製剤
4,ltzop-uer
l日20p NAT
Eウ インドウ期(個別NAT陽 性)撻 ウインドウ期 (個別NAT陰性)
薔感染既住(個別N奸陽性) 醸
> 初 流血除去の導入
: 2007年 3月
感染既往(
+雪 雹
認
細菌症例 と解析結果
日赤 ヘモビジランスの まとめ
60
t製 剤 「
陰性」
50
40
> 輸 血関連急性 肺障害 (TRALI)の症例 は 、添付文書 へ の記載 以降 (2006年)、
減 少傾 向にあり、2011年以降で死亡症例 はない。
●製剤 「
陽性」(患者菌と異なる)
> 輸 血 関連循環過負荷 (TACO)に ついて は 、今後添付文書 へ の記載等含めて、
医療関係者 に周知 していく必要 がある。
30
> 輸 血 後 B型 肝 炎症例 は、HBc抗 体基 準 の 厳格化 により、更 に減 少していくと考
えられるが、安全対 策の評価を今後も実 施 していく。
20
> 血 小板輸血 による細菌感染症例 は、年 に1例程 度発症 しているが、死亡例 は
な い。ま た、保存前 自血球除去 導入 後 、赤血球製剤 による細 菌感染症例 は
確 認されていない。
10
0
︱
・
*医 療 機 関より報 告 取 り下 げ
囲一
参考
●血液製剤の安全性確保対策の変遷
7月
10日
平成 25年
薬 事 ・食 品 衛 生 審 議 会
日 本 赤
安 全 技 術 調 査 会 資 料
シ ャ ー ガ ス 病 に 対 す る安 全 対 策 の 進 捗 状 況 に つ い て
1 安 全対策
○平成 24年 10月 15日 採血分 より開始
● 中南米滞在歴等確認票 (別紙 1)の 1∼3の いずれ かに該当する方 に、献血 の受
付 時に申告 をお願 いす る。
● 該 当献血者 の血液 は、血漿分画製剤用の原 料血漿 として利用する。 (製造制限)
○実施状況
平成 25年 6月 4日 現在 (全採血者数 :3,310,073人)
分類
1中 南米諸国で生 まれ た、又は育 っ
0.04%
2 . 母親 が 、中南米諸国で生まれた、
又 は育 った。
lgg ^. 2)
0.006%
3(1.に 該 当 しない方)で 中南米諸
国 に通 算 4週 間以上 滞在 した。
3,909ノ｀
012%
計
5,425ノ｀
0.16%
分類 1+2に 該 当す る人 を含む。
分類 2+3に 該 当す る人 を含む。
〒105‐8521東 京都港区芝大門―丁目1番3号
*お問い合わせは、
最寄りの赤十字血液センター医薬情報担当者へお願いいたします。
対採 血者数比
1,328ノ(1)
た。
《
発行元》日本赤十宇社 血液事業本部 医薬情報課
調査対象者数
別紙 1
2 疫 学調査
中南米滞在歴等確認票
① 実施期間 :平成 25年 1月 8日 ∼平成 25年 6月 4日 (全採血者数 :761,365人)
愛知 ・岐阜 ・二重 ・静岡県血液 セ ンター先行実施 :平 成 25年 1月 8日 開始
全セ ンター実施 :平 成 25年 4月 23日 開始
② 検査法 :ELISA法
(Ortho社)
1 . 中南米諸 国で生 まれ た、又 は
育 った。
2 母 親 が、中南米諸国で生まれ
た、又は育った。
調 査 対象者
献血者数
(延べ数)
448メ 、1)
588メ 、1)
25ノ｀2)
71メ 、2)
該当する質問番号に丸印 (O)を つけてください。
調査応諾率
762%
35.2%
3(1.に 該 当 しない方 )で 中南米
諸 国 に通 算 4週 間以 上 滞在 し
779ノ 、
l
人
701%
た。
計
1 , 2 5 2 ノ｀
(対採血者数比)
(016%)
1,770ノ｀
質問に該当される方からいただいた血液は、血漿分画製剤用の原料血漿として利用させていただきます。
(※200mL、 400mL献 血にご協力いただいた場合、赤血球成分は輸血用として利用されません。)
１ ２ ３
分類
以下の質問はシャーガス病の安全対策として、輸血を受けられる方の安全を官るためにうかがうものです。
中南米諸国で生まれた、又は育つた。
)
(国名
母親が、中南米諸国で生まれた、又は育 つた 。 ( 国 名 :
)
( 1 . に 該当 しない方) で 中南米諸国に通算 4 週 間以上滞在 した。
( 国名 :
期間 :
:
( 国名
期間 :
:
( 国名
期間 :
)
)
)
707%
陰性 :1,252人
検査実施状況
陽性 :0人
1)分 類 1+2に 該 当す る人 を含む。
2)分 類 2+3に 該 当す る人 を含む。
3 今 後 の予定
<中 南米地域対象国>
アルゼンチン
スリナム
ブラジル
ウルグアイ
チリ
ベネズエラ
エクア ドル
ニカラグア
ベリーズ
エルサルバ ドル
パナマ
ペル ー
ガイアナ
パラグアイ
ボリピア
グアテマラ
フォークラン ド諸島 (英領)
ホンジユラス
コスタ リカ
フラ ンス領 ギ アナ
メキシヨ
コロンピフ
① 検査試薬 の評価
疫学調査で 日本では承認 され ていない検査試薬 を使用 していることか ら、試 薬 の評
価 を実施す る。
③ 疫 学調査 のま とめ
お よそ 5,000人 分 のデー タが集積 された時点でデー タを取 りま とめ、今後 の対応
について検討す る。
代筆者名
血液センタニ記入欄】
【
受付 日 :
献血者 コ ー ド :
センタ ー名 :
施設名 :
採血番号 :
検査 : 有
・ 無
日会料
０議 資
．
審
会
月生
査
衛
一品¨
食
・
成事全
平薬安
ミラソルの低減化能の評価について
感染性因子の リスク評価 と低減化技術の効果について検討を行 つた (別紙 2)。
日本 赤 十 宇 社
【
検討結果の概要】
> 血 小板製剤の細菌汚染に対 しては、従前か らの初流血除去及び白血球除去等の
感染性 因子低 減 化技 術 ミラ ソル の 導 入検 討に係 る考 え方
対策に加え、現在の有効期間を維持 しなが らミラソルを導入す ることで、より
―層 の感染防止効果が期待できると考 える。
平成 24年 度第 3回 運営委員会 (平成 24年 12月 19日開催)に おいて、日本赤十字社
が実施 した ミラソルの評価デー タと開発メー カーが報告 したデータ等の間に、感染性因
> 地 球温暖化による国内感染も懸念 されるデ ングウイルスに対 しては、ミラソル
子に対する低減化能に差異があるとの指摘 (別紙 1)が あつた ことか ら、 ミラソルを選
血漿製剤についても対応が求められる。したが って、国内のサー ベイランス状
NATに よる地域限定的なスク
況を注視 しつつ、「
居住地域毎の献血制限」や 「
リー ニ ングの実施 」等の安全対策が必要 とされ る。チクングニヤウイルス等の
の低減化効果がほとんどないと思われるが、そのような状況では、赤血球製剤、
択 した経緯 と併せ、引き続 き臨床試験開始に向けた準 備 を進めていくことについて考え
方をまとめた。
場合 も同様 と考えられる。
1 ミ ラソル選択の経緯
● 平 成 20年 7月 23日 に開催された、薬事 ・食品衛生審議会血液事業部会運営委
員会 ・安全技術調査会 合同委員会において、次の理由によ リリボフラビンを用
いる感染性因子低減化技術 ミラソルの導入に向けた検討について報告 した。
【
選 定の理由】
1)導 入 目的及び対象製剤
輸血感染症が重篤にな り易い細菌感染症対策 とする。対象製剤は血小板製剤 と
する。スク リー ニ ング NATを実施 している HBV、HCV、HiVの輸血感染症につい
ても一層の予防が可能と考えられ る。
また、新興 ・再興感染症について も低減化処理効果がある程度期待できる。
3
結論
> 血 小板製剤に対 し感染性因子低減化技術を導入する主 目的は細菌対策であ り、
細菌に対する一定の低減化効果が期待できる。
> 現 時点で ミラソルの検討を中断 し、インター セ プ トに変更することになった場
合、必要な機材 ・資材を準備 し、ミラソル と同様 にインターセプ トも評価する
必要が あり、低減化技術の導入に一層の時間がかかることになる。
> ミ ラ ソルによる低減化能が期待できない感染症があるものの、それ らについて
は、赤血球製剤や血漿製剤への対応を含めた対策 を講 じる必要があ り、NAT等
の導入が有効 と考 えている。
2)添 加する薬剤の安全性が高い
現時点で使用可能な低減化技術は、いずれ も血液に薬剤を添加する。
以上 よ り、他の技術 も含め世界的な低減化技術の開発及び導入状況 について、
ビタ ミンであるリポフラ ビンを低減化剤 として用いるミラソルの安全性は、他
今後 も情報収集 を継続 し、ミラソル導入に向 け準備を進めてい くことに したい。
の技術 と比べて高 いと考 えられ る。
3)血 液事業に導入 しやすいシステム
ミラソルは、日赤の血小板製剤の採取 ・製造工程等を殆ど変更する ことな く血
液事業に導入できる。また、低減化処理工程による製品供給の遅れも小 さいこ
とか ら、血小板製剤の安定供給に与える影響 も軽微 と考えられる。
● 上 記の報告等に対 し、血液事業部会 (平成 21年 12月 24日開催)に おいて次の
事項が了承 された。
血 液事業部会における確認事項】
【
・リボ フラビン (ビタミン 32)を用いた技術を重点的に評価すること。
・当該技術について残 された課題の評価を実施す ること。
- 1
別
Pathogen and Leucocyte lnactivation for IBS/TheranexO/Mirasol°
紙
Platelets
(日赤調 面データ追加)
C V ProwselcompOnent pathogen inactivationia critical review.Vox Sanguinis 2013, 104: 183-199
Viruses
THF
>6 . 1
HIV-1 (cellfree)
>6.2
ClinicalisolateHIV-1
>3.4
ClinicalisolateHIV-2
>2.5
Latent proviral HIV-1
“ 一
一
HIV-1(cellassociated
)
MIR
郁 ” ・
Enveloped Viruses
日本赤十字社
HepatitisB
>5.5
(2.3)
HepatitisC
>4.5
(3.2)
IBS
Escherichia coli
>6.4
>4.0
44
Serratia marcescens
>6.7
>4.0
4.0
Klebsiellapneumonia
>5.6
4.8
2.8
4.5
>4,9
>4.6
Pseudomonasaerugi nosa
>4.6
Salmonella choleraesuis
>6.2
Yersinia enterocolitica
>5.9
Enterobacter cloacae
5.9
Orienti a tsutsuga mushi
(scrub typhus)
4.5
All detectable*.1
Bacteria
Gram-negative
4.7
Staphy lococcus epi derm idis
HTLV-II
5.1
Staphylococcusaureus
Cytomegalovirus
(cell-free)
>5.9
All detectable*1
(3.5)
>4.3
>5.0
(2.1)
>6.6
4.8
6.6
>4.8
>6.8
Listeria monocytogenes
>6.3
Corynebacteri
um min utissi
mum
>6.3
Bacillus cereus (incl spores)
Duck HBV(HBVmodel)
>6.2
BaciIIus cereu s (veg etative )
>6.0
West NileVirus
>6.0
Bifidobacteri um ado lescentis
>6.2
SARS-CoV
>5.8
Proprionobacterium acnes
>6.2
Chikungunya
>6.4
Lactobacillus species
>6.4
Clostridi um pe rfri ng ens
(vegetative)
>6.5
>4.7
Spirochaete bacteria
IBS
丁HF
InfluenzaA virus H5N1
>5.9
Dengue
)5,0r2
PRV
Non-envelopedViruses
>5.1
2.1
1?
1.7
(>5)
MIR
日本赤十字社
42
3∼5
4.0
☆
36
>6.0
5.4
>2.0
2.2
BVDV(HCVmodel)
5.8
4.0(平均値 )
>5.0
THF
Streptococcus py ogen es
日本赤十字社
3.3
Gram-positive
HTLV-I
Cytomegalovirus
(cell-associated
)
MIR
4.3
1.9
4.5
>2.0
0,4r2
2.5'2
2.8'2
日本赤十字社
Treponema pallidum
(syphilis)
Borrelia burgdorferi
(Lyme disease)
>6.8
>6.8
-
―
- : no dataavailable
☆:day3(有効期間最終日)の状
・
8本中7本が 106 cFU/mL以 上
対照群('F低減化群 )・
8本中4本が培養陰性 他の4本 は105 cFU/m味 満
低 減 化 群 ・………・
日本赤十宇社
﹁ ” ﹃●∽一
一〇 〇
〓 Ｈ刀
ＶＷ Ｎ
口丼勢 十 囀洋
総合判定
A:現 状の安全対策及び導入を予定している検査法で、殆どの感染を防止することができる。
B:Minsdの 導入により、感染防止効果が期待できる。
C:Mirasdでは感染防止効果が期待できない。NATの 改良もしくは他の低減化法などの安全対策の導入を考慮する必要がある。
Ｖい
それらのリスクとMirasd(リ
ボフラビン法)による低減化効果を評価した上で、下記の評価基準により総合的に判定した。
ヽむ∽ミＯＳｔヨ むおさ聖Ｃヨ
2)、3)の 中には多くの感染性因子が含まれるが、その中で特に社会的影響が大きくなる可能性があり、
輸血医療界で討議 ・
検討がなされているものを中心に選択した。
Ｏ・
〇
口丼 卦 ＋ 判詳
1)現在スクリーニング検査をしているが、なお輸血感染のリスクが残つていると考えられるもの
2)日 本ではスクリーニングをしていないが、輸血による感染が証明されているもの
3)輸血による感染がおこることが考えられるもの
Ｖ い ・ω
Ｖ９ ｏ
Ｖい ｏ
Ｖ ヽ ・ω
〇
Ｖヽ・
〓 Ｈカ
〇
ＶＯ・
▼
既知の感染性因子のうち次のものを評価した。
︵
コ
⊃口一
ｏュ”︶
ゴ゛︵
ヽミＮ、
ヽ“、ＯＮＱ３●ｏ
↓工 ﹁
Ｖ ｕ ・］
Ｈ口 ０
Ｖｕ ヽ
い Ｏｏ﹁ ∞ ω
マ
▼
︻つす 一
σ澪 ＯＱ
▼
感 染 性 因 子 の リス ク 評 価 と低 減 化 技 術 の 効 果
０，９Ｑ口∽、Ｑ一
︵
∽００い０︶
むヨ０おヽ
い０﹂
∽
Шヽ
ヨＯｘヽ
い
ヽコヽ
︵
０３●粋一
０﹁
ｏＯお︶
卜０おヽヨＳ む ヨミｏヽ﹂おむ
σ口σの∽一
︵
ｏ∽一
∽︶
Ｔヨｏ件一
〇２３
ｍヽ００いご ヨヽ
Ｑｉ
ｏヽ
ｒＯ 〓 ｏＯ ｏく静①
﹁ ︲ｏＱ 一くご σヨ ”く
一
″
一
５一
Ｔヨ一
わＯＱ一
〇己
∪ Ｚ ＞ ∃ ５ ２ ﹁ｏｏけご う
︵ｏうｏ ●αＯＣ舞 つｏ﹁ × σ●∽０ ﹁ｏ一
３︶
つ０ 一
つ ﹁０●０﹂ ０つ
く ヨ ｏ﹁●∽０ ０す０一
︵
０く一０ え一
つの ∽くう″す０∽一
∽¨
Ｚ Ｏ 日Ｔ ∞ Ｏ ﹁ 自Ｆ︲﹂σ ∽く コ″す０∽一
∽
０﹁０くのコ″∽ ０一
∽００∽①
ζｃュコ０ ■５０Ｑ ↓＞１
０＜エワ¨
︱ ¨う０ ０●″
〇
● ●く”〓口σ一
て 一﹁ ぉ バ ３ ｏ一＾● ｏす０ｌ Ｅ す０﹁０ 汁すＯ α一
﹁０お う言 昇 Ｃαく ， Ｓ ●ｏ ，ｏくｏ σＯ●３ ＣコＱＯ■ ｏだｏコ ∂ ﹁ ｏ●ｏゴ ● ６ ０ ０﹁ｏｏヨ ｏう０３´
つ
別紙 2
感染性
因子
[細菌汚染の頻度]
本邦における PCの 細菌汚業の潜在 リスクは、4万 あま りの期限切れ PCの培養
調査か ら、臨床的に意味のある細菌に汚染され る頻度は、PC 5,400本に 1本
とされた。これは欧米の頻度 とほぼ同等または半分の レベルである。
[敗血症の リスク]
汚染された製剤がすべて敗血症 を起 こすわけではな く、細菌数が少な くとも
105 0FU/mL以
上に増殖 した極一部の製剤が臨床的に問題 となる。
(メこ南
R:Relationship between bacteria: load, species viruience, and
transfusion reaction with transfusion of bacteria:ly contaminated
R, Good CE, Lazarus H‖
, Yomtovian RA. Clin lnfect
p:ate!ets. 」acobs ‖
Dis. 2008 Apr 15:46(3):1214-20.)
上になると症状は重篤 となる。
細菌の種類にもよるが、一般に 107 0FU/mL以
細菌
対策及び低減化技術の効果
リスク評価
[臨床の現場で同定 された汚染 PCの 頻度]
本邦で、 この 6年 間に敗血症の原因 となった汚染 PCは 7製 剤である。
day3(有
day2の製剤が 2例 、
原因製剤の保存期間は、
採血 日をdayOと した場合、
効期間最終 日)の製剤が 5例 であった。
2007年 以降、輸血感染による死亡911の
報告はない。初流血除去、自血球除去
を していることに加え、出庫時に外観、スワー リングの有無を確認 し、諸外
国よ りも有効期間を 1∼2日 短 く規定 していることによると推定 される。
総合
判定
ー
[スパイク実験による評価] (日 赤デ タ)
1400
実際に混入すると推定される量の S aureus(55∼
0FU/パッグ)を、2本ずつ同条件 とした 8組 (合計 16本)
の PCにス′《
イクした実験の結果。
day3(有効期間最終 日)の状態
対照群 (非低減化群)
上、 琳可ま104 0FU/mL
8本 中 7本 が 106 0FU/mL以
低減化群
8本 中 4本 が培養陰性
満
他の 4本 は 105 0FU/mL未
・&rr2オル 滋臓"“ ″sお よび `″ ′
“″ ノ
dlisに対 して
は、約 4 Logの低減化が得 られている。
[開発企業デー タ]
ッグの濃度で PCに
13種 20株 の細薗を 20∼100 0FU/パ
接種 し7日 間培養 した結果。
多 くの文献や報告か ら、敗血症 を起 こした菌の頻度を考
慮に入れ ると、91%の 細菌感染症例に有効であると結論
付けた。
R:A laboratory comparison of pathogen reduction
(,こ
南
techno:ogy treatment and culture of p!ateiet
products for addressing bacterial contamination
concerns. Ooodrich RP, GiimOur D, Hovenga ‖
, Keil
SD.Transfusion 2009 Jun: 49(6): 1205-16.)
Minsdの 導入 によ り完全な不活化ができる訳ではな い
が、現在の有効期間内には臨床的に問題 となる菌量に達
しないことが予想 されるので、感染防止効果が期待でき
る。
2
感染性
因子
リスク評価
HBV
[理論的推計]
● HBc抗 体判定基準の見直 しにより、オカル トHBV感染による感染はほぼなくな
ると思われる。
● 近 い将来、現行の 20プ ール NATから新たな個別 ‖
AT(lD―MT)へ 移行する予
定であり、ウィン ドウ期の献血による感染も減少することが期待される。過
去 10年間のウィン ドウ期の PCによる輸血感染症 (TTl)の原因製剤の 6096が
ID―
NAT陽 性であつた ことか ら、ヘモビジランスで日赤が把握する PCに よる
HBV感染確定例はこれまでの 40%以 下に減少する。
● HBVの ウィン ドウ期の長さ、PC供給数などから、lD―
NAT陰性のウィン ドウ期
に存在 しうる PCの 数は 1年 間に 11.5バッグと推定される。IDHATを す りぬ
BVは、最大で約 4,000
けるHBV陽性の 1′｀ッグ (血漿量約 200mL)に存在する ‖
コピー と推定される (Roche社の 95%平 均検出感度 (LOD)(18.6コピ‐ or
3.21U/mL)による)。
[日赤ヘモビジランスコ
● 日 赤が把握 している HBV感染確定例のうち、lD―
MT陰 性の血小板を原因とす
るものは 0.9症例/年 である。
[理論的推計]
● ID―NATが 施行 された状態で残るリスクは、pre―
ramp up phase(感
染後末梢血
NAT
中のウイルス量が急激に増加するまでの期間)にある血液 と、そ こから ID―
陽性までの期間にある血液であるが、前者は感染性がほとん どないことが動
HCV
物実験で示された。
('そ
責:Infectivity in chimpanzees (Pan trog:odytes)of p:aSma coilected
浦
before HCV RNA detectability by FDA―licensed assaysi implications for
transfusion safety and HCV infection outcomes. Busch ‖P, ‖urthy KK,
Kieinllan SH, Hirschkorn DF, Herring BL, Delwart EL. Racanelli V, Yoon
JO, Rohermann B, Aiter HJ. Blood. 2012 」un 28;119(26):6326-34.)
また、後者の期間は極めて短 く (約2日 )、その間にあ りうる献血は 0.2例未
満/年 と推定 される。PCだ けを考えれば 0.03例未満/年 となる。
[日赤ヘモ ビジランス]
● 現 行 20プ‐ル NAT導入以降、4年 間、輸血感業例はない。
対策及び低減化技術の効果
[リスクを有する ドナーに対する効果]
● 4,000コ ピー/パツグの PCに Miいd(低 減化能 (LRV)
2 3 Log)を適用すると、20コ ピー/パッグとなり、ウ
イルスがわずかに残存する。
● 一 方、PCに 含まれるウイルス数がこのウィン ドウ期 25
日間に vira:!oadの 低 いものから高いものまで均等に
分布すると仮定すると、約 60%(年 間約 6.5′ヽッグ)
中の HBVは 完全に不活化される。
● 残 りの約 40%の PC(年 間およそ 5パ ッグ)に おいて、
不活化されない HBVが 1コ ピー/パッグ以上残ることに
なる。ただし、これ ら少数のウイルスが残存 した PCの
感染性は不明である。
[ヘモビジランスヘの効果]
● ID―NAT導入後のリスクは 0.9症例/年 となるが、
Mirasd
によりその半数以上が防止できる。
理論的には、lDHAT下 では 30年 に 1例 の HCV汚 染 PC
が出ると推定される。
Mirasdによる BVDVの低減化能 (LRV)は 1.9(日赤デー
NATでも検出不可の極微量のウイルス
タ)であるが、lD―
に対しては低減化効果が期待される。
総合
判定
感染性
因子
対策及び低減化技術の効果
リスク評価
総合
判定
[理論的推計]
● 感 染から20プール NAT陽性までのウィン ドウ期は約 11日で、抗体検査陰性 ・ ● ID―NAT下 で、33年 に 1例 の HIV汚 染 PCが 出ると理論
20プール NAT陽性の献血数から計算すると、この期間内に献血が 2.0例/年
的には推定 されるが、感染例は報告されていない。
の割合で存在すると推定される。
● ID―NATで も検出不可の HIVの PC中 の vira!loadは 最
● ID―NATになるとウィン ドウ期は若干短縮するが、 リスクのある献血の数は大
NATの 95%LOD
大 4,000コ ピー/パ ッグである(現行 ID―
きく変化 しない。このうち PCの陽性例は供給数から計算 して 03例 /年 ほど
を 421U/mLと して計算)。
NAT陰性の血液を原因とする感染は世界的にも報告されて
である。しかし :D―
● ID―NAT下 で、Mirasd(LRV≧ 4.6:日 赤デー タ)に よ り、
いない。
十分に不活化 され る。
[日赤ヘモビジランス]
0 20プ ール NAT導入(2004年)以降、輸血によるHIV感染例はない。
● 世 界のどの地域 においても、成人の半数以上は感染の既往がある。急性感染 ● Mirasdに よる LRVは>5 Logと されている。107コピ_
にある献血者もほとんどが無症状である。
/mLの PCを 低減化すると、102コピ_/rLと な り、最低
感染濃度 10°コピー/mL以下となる。
● 輸 血感染を起こすと、リスクを有する患者 (赤血球造血の盛んな患者、免疲
起こす ● Mirasdに よリヒトパルボ B19に 対する安全性は高まる
抑制患者など)で 一時的な骨髄無形成クリーゼ (aplastic crisis)を
が、後に回復する。上記の状態にない患者での輸血初感染では、軽度の貧血 ・
と推定される。
発熱 ・発疹などの比較的穏やかな症状を認めることがある。
ヒ ト′く
ルボウ ● 著 明なウイルス血症は通常 2∼3週 間で終息するが、低 レベルのウイルス血症
は 3年 にも及ぶ場合がある。ウイルス血症は極期で 1012コピ_/mLに 達する。
イルス
B19
7コ ピ
● 日 赤では、CLEIAによる抗原スクリーニングを行つている。感度は 106∼
ー/mLであり、それ以上の血液は排除されている。
綸血感染を起 こした血液製剤で、ウイルス レベルが判明 しているものの うち
最低のものは 103コピ_′直 レベルであつた。 (文献 :Symptomatio parvovirus
B19 infection caused by b!ood oomponent transfusion.Satake‖
, Hoshi Y,
omose SY,
Hino S,
Tadokoro K.Transfusion.
2011
Taira R.
‖
Sep;51(9:1887-95)
リスク評価
0 0W感
C‖V
染が懸念される患者への抗体陰性血の輸血により、感染はほとんど予防
されると推定される。一方、日赤では全ての製剤に保存前白血球除去を導入
しており、それ単独でも抗体陰性血輸血と同程度に感染が防御されている。
両者を組み合わせた場合には更に安全性が高まるといわれている。
対策及び低減化技術の効果
Mirasdの cell associated Cmlrの
低減化デー タはない
が、oo::freeの CWの 低減化能は 2.l Logとされてい
る。左記の理由によ り残存 リスクは非常に低い。
A
● ウ ィン ドウ期の血液が感業を起こす可能性が論 じられている。ただ し日本で
はそのような報告はない。
● ウ イルス血症 ドナーの頻度 :北海道では約 8,500人に一人の割合であり、
genctype 3が 93%、 genotype 4が 7%程 度検出される。北海道以外では
少ないとされるが正確な数字はない。
genotype 4は
HEV
● Passive surveil:ancoに
よれば、HEV陽性血液が輸血された場合に感染が成
立する確率は 1.1%前後と推定される (ウイルス血症 ドナーは推定 675人 /
年、確定された感染例は 1.2例/年 。ヘモビジランスは 6分 の 1のみ捕捉す
ると仮定すると 1年に 7.2例感染)。
最大 107コ
潜伏期は 3∼8週 、ウイルス血症は 4∼6週 持続 し、genotype 4で
ピー/mLに達する。
フオローできた献血者 31名 中、ALTレベルが 45を越えた者 52%、100を超え
た者 35%。
● 輸 血感染を起 こした血液製剤で、ウイルス レベルが判明 しているもののうち
最低のものは 103コピ_/mLレ ベルであつた。
● 本 邦での輸血感染による死亡例は報告されていない。輸血感染例の ALT最 高
値は genotype3で1,336:U、
genotype4で1,6651U。
● 文 献上は、移植患者などでの慢性化、肝硬変への進行などが報告されている。
合定
総判
感染性
因子
Mirasdの低減化能は、genotype 3に
ついて ≧3Log(日赤
デー タ)が可能 (LRVの上限値はまだ不明)。
● 過 去 4年 間の HEV―
NAT陽性献血の うち、96.4を 占める
106コ ピ_/mL未 満の製剤については、感染例 をほぼ無
くす ことがで きる。
感染性
因子
リスク評価
High viremiaを呈す るのは鳥類である。 日本でアウ トブレイクが起 こるに
は、感染 した渡 り鳥が 日本に飛来 し、それ を吸血 した蚊が生 き延びることが
条件 となる。 日本にいる蚊の多 くが媒介蚊 (イエカ、ヤ ブカなど)で あるた
め、アウ トブレイクが起 こる可能性がある。哺乳類はウイルス血症の レベル
が低いため通常、終末宿主 となる。すなわち、蚊 ― ヒ トー蚊の感染環は存在
しない。
● 感 染 して発症するのは 15∼20%、 脳炎など重症に至るのは 1%未 満 とされる。
対策及び低減化技術の効果
総合
判定
WNVは株 の違いによ り低減化効果に違 いが ある。
ヒ ト由来株 ;
3.0-4 0 Log (‖
CDC)
Y-99-F!amingo、USA―
3 onfils!ab.民間検査機関)
≧5.lLog(Uganda1987、
トリ由来株 :
1.3Log(New York、 日赤)
1.5Log (‖
Y-99-4122、Oolorado State Univ.)
● 感 染後 5∼6日 で最大 105コピ_/mLレ ベルのウイルス血症 とな り、通常 10日
● 対 策 として、渡 り鳥を除 く感染媒体 (人、蚊、野鳥)ご
で 101コピー レベルに下がる。
米国で NAT導 入前、28例 の輸血感染が報告 された。米国赤十字社では、NAT
とに居住地域等による献血制限 とNArを 準備 している。
によ り 2003年 か ら 2010年 までに少な くとも 1,200人のウイルス血症の献血
#:NATの 感度―Novartis PR00LEIX Systeln 95%CL、
8.2oopies/mL
者 が 同 定 され た 。 米 国 の NATは 最 初 プー ル で 開 始 され た が 、 そ の 後
breakthroughが
NAT
見 つかつたため、感染の高浸淫地域 ・時期の時点では lD―
WNV
● 海 外において現行 ID―
NAT体 制下で輸血感染例は 2010年
の 1例 のみの報告である。Miraso:に
より、ヒ ト由来株に
● ヒ トでの viremiaのレベルは低 く、時に lD―
NATを必要 とするレベルである。
対 しては低減化効果が認められ るので、感染防止効果が
期待できる。
を施行するようになった。
感染性
因子
リスク評価
Dengue
Chikun
gunya
自然宿主となる動物は不明。日本での媒介蚊は、通常見られるヤブカ メ“"
′fbのた加 (ヒトスジシマカ)で あり、日本においてもアウ トブレイクの可
能性がある。
ヒトで高い viremiaを呈するので、蚊 ―ヒトー蚊の感染サイクルができる。
オース トラリア ・クイー ンズラン ドやシンガポール国内などでアウ トブレイ
クが起 こるが地域は限定されており、現地住民による季節的な献血の中止が
施行されている。
輸血感染例は 3事 例 5症 例のみである (シンガポール、ホンコン、プエル ト・
リコ)。
輸血感染が少ないと考えられている理由 :
1)蚊 の唾液を介することが感染性を高める可能性がある。したがって直接
的な輸血による感染性は低い。(仮説)
2)浸 淫地域では受血者の多くがすでに免疲抗体を持つている。
3)同 時に輸血される血液が中和抗体を持 つている。
4)免 疲が抑制されている患者では症状が軽い可能性がある。
ただし、浸浬地域ではデング以上に大きな問題があり、よく調査されて
いない。
初回の感染では 5∼8割 が無症状である。serotypeに
特異的な免度が長期間持
続 し、異なった serotypeのウイルスに感染 し交差反応的に免疫応答が起きた
ときに重症化する。
109コピー/mLとされている。NAT試薬は商業ベースで開
ウイルス血症は 105∼
発中。米国赤十字により、プエル ト・リコで試験的に NATが施行されている。
対策及び低減化技術の効果
Mirasdによる低減化は 0.4 LRV(日赤データ)と 低い。
(オース トラリア赤十字から 1.2∼2.O Logの低減化能
が報告されている。2012年)
総合
判定
総 じて、低減化には非常に抵抗性が高 く、また力価の高
いウイルス血症であるため、低減化/不活化の対象とな
りにくい。むしろ当骸地域居住者の献血制限や、NAT:こ
よるスクリーニングが適 していると考えられる。
● 家 畜、鳥類、爬虫類に感染するとの情報がある。ウイルスの突然変異により、 ● Mirasdの 低減化能 :日 赤デー タで 1 7LRVの低減化が可
日本にもいるヒトスジシマカにも感染するようになったと言われる。
能。感染 doseが不明であるが 、Mirasdによる低減化だ
● ウ イルス血症について :無症候性患者では 8X101∼3X105コ ピ_/mL(中央値
けでは安全性は保証できない。
3.4X103コピ_/mLl、症状のある患者では 2X10∼ 2X100コ ピー/nL(中央値
5.6X105コピ_/mD。
● 日 本でも感染が広がる可能性があるが、蚊が媒介するた
● 2012年 11月の時点において輸血感染例の報告はない。
め感染地域が一気に拡大する可能性は低 く、当該地域居
住者の献血制限が有効 と考えられ る。
C
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場 ０ ８ う０８
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滝 ３υｔ ａ 占﹄
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ピ ω〓 ０〇一
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pathogeninactivation I 87
Component
dose tested) were obseryed for amotosalen-treated blood
products, with margins ten times higher for amotosalen, as
it can be gjven at higher concentrations. ln the najority of
inhibiting leucoc).te cytokine production. As PI is usually
Table3 PathoqenandLeu(ocyt€lnactivationforlBs/TheraflerD/MrrasoloPatelers)[11,16,]8,36-381
doses tested.
adopted for all units, errors inherent in selectiv€ processing
(e.g. gamma-irradiation, CMV testing) are avoided and the
security and safety measures for gamma-irradiation would
Similar safety was obserued for carcinogenicity and genotoxicity [29], with lower margins (>40) in the less clini-
no longer be needed [44].
Most plasma PI methods cause 20-300/bloss of coagula-
cally relevant phototoxicity tests [29-3 t]. No evidence for
the formation of novel antigens by PI was found for amo-
tion factor VIII, although fibrinogen and coagulation inhib-
(Ce1 8SOC ated)
itor content are more clinically relevant for single donor
plasma. Oth€r coagulation facton are better retained [45],
HⅣ l(cu l free)
tests, no toxicity
was observed at the highst
tosalen-treated plasma or platelets in preciinical studies or
using samples from patient trials [33]. Available data,
although less rigorous (Table 2), suggests a similar absence
of toxic effects and neoantigens for Mirasol@ technology
I r l , ] 4 ,3 s l .
THF
although there are concerns over flbrinogen levels in MB
plasma [46]. The US SD plasma process gave high lossesof
protein S, antiplasmin and antitrypsin associated with
sites and bacteria, but less so for nonlipid-enveloped
viruses and bacterial sDores.The observed differences in PI
largely relate to:
(1) which nonlipid-enveloped viruses are susceptible to
inactivation, for example SD is ineffective against these,
(2] the ability of any sensitize$ or radiation used to penetrate component or cells, for example MB is ineffective
on cellular pathogens due to its reduction to inactive
forms within cells.
When viral testing is in place, transfusion-mediated
infection only occurs duilng the window period where
viraemia is present but testing cannot detect the infection.
With low- to medium-titre pathogens (e.g. West Nile
Virus) PI is well able to deal with residual risks [39,40].
Where pathog€n titres are high early after infection (e,g.
parvovirus B19) PI capacity may be exceeded unless testing is also in place and enables high titre units to be discarded. No NA-targeting Pl technology is effective against
prion diseases. There are two areas where inactivating ,rl
tittes of bacteia is impoftant. Fi6tly, to cover higher loads
that may arise for rapidly growing species between collection and processing (<tg h for buffy coat platelets). Second to provide better assurance that no bacteria remain
after PI.
of
selec(edunits to completely inactivate leucocytes. There is
a relatively narrow gap between the dose of radiation to
inactivate leucocltes and doses that damage RBC. PI prevents CVHD by killing leucoc)'teswith higher ma€ins of
safety that are technology-specifrc [41,42]. PI can eliminate CMV transnission [43] and reduce febrile reactions by
Escherichio coli
44
Setrotio morsescens
>6 7
>4o
40
fryponozonocruzi
Klebsiello pneunon@
>5.6
4.8
28
L?ishnonio nexicono
Pseudomonos
4 5
>49
>46
45
Solmonello
>6 2
>53
Leishnonio nojor
>5 0
>4 3
Bobesio microti
>5 3
{babesiosisl
\231
Ye5inio
>5I
-
33
59
>43
>20
>50
-
>50
>6 6
48
42
enterocolitico
{3.2)Fnterobocterc/oo@e
jrientio
tsutsugomushl
( s c r u bt y p h u s J
associated)
(ce‖
Cvtome9Jo■rus
-
ulail-posltlve
-
Stophylococcus
Leucocyte
A‖detectable・(35)
12.1) Stophyloco.cus
T - c e l lv i a b i l i t y
>5 4
(limitingdilutioil
epidernidis
6-6
>48
40
(cel fre)
I per83
DNAmodification
(on€ adduct
Clinical studies and pharmacovigilance
per x base pai6)
BVDV(HCV modeo
58
Streptococcus pyogehes
>6 8
-
Listerio
>6 3
-
22
Polym€ras€
Inhibited
chain reaction
Plasma components
@2012TheAuthorlsl
Vox Sanguinis
@2012 international
Society
ofBloodTransfusion
VorSanguinis
7O4,| 83-199
12013)
>6
Jish lama*igote)
For Mirasol@ and IBS plat€lets stored 5 days,
results are close to the proposed FDA limit of 67qo of fresh
platelet recovery and 580/0of fresh survival [a7, a8]. The
Mostplasmatrialsassess
coagulation
factoFincrcments
in
patientsratherthanusingclinicalend-points,
Theylargely
reflect factor content,although changesin factor survival,
comparedwith literaturevalues,were reported.
Comparative kineticsafter control and test transfusionin the same
individuals
havenot beenundertaken.
Table5 liststheclinical studies[50-6a]for plasma.IBS plasmahas the most
extensivepreclinicaland clinical assessment
programme.
The fiP studyhad a clinicalend-point{remission
within
30 days)andfoundno difference
vs standardplasmain the
life-sving plasmaexchange
therapy,althoughunder-powered
to demonstratenoninferiority [54]. Therearevery few randomizedclinicalstudiesof SD or MB plasma.
Table5 summarizesthese,along with some obseruational
studies.
A recentreviewcoverstheseand further observational
studies [45]but in generalno difference
wasseenfromstandard
(oftenunder-powered)
FFPin suchstudies
otherthan:
(11 manyEuropean
preferuseof octaPlas
seruices
for TTP
treatmentgiven its safety record (virus transmission,
TRAU)I551,valjdationfor prion removalandcompQtitive pricing.
studieshavesuggested
{2) Threesmailnonrandomized
MB
plasmais lesseffectivein 'nP [62-64], despiteretention ofADAMTS-l3 1661.
Pldsnodiunfolciporum
-
viability.
remains unclear [49].
>4.0
5.9
-
recovery and survival. Table 4 summarizes data for platelets, denonstrating PI nethods result in some loss of cell
relationship between ,r dto vrability and increased glycolytic flux obserued in both Mirasol@ and IBS platetets
>6 4
(promastigote)
by autologous radiolabel studies in volunteers, to determine
122, 3al. The extent of Pl is technology-specifrc [38]. cenerally, PI is effective against lipid-enveloped viruses, para-
Grsm-negative
45
(Chagas'disease)
Cellular product potency is initially assessedpoststorage,
Table 3 summarizes PI for the IBS. Theraflexo and Mirasol@
p l a t e l e t p r o c e s s e sI i i , 1 6 , 1 8 , 3 6 , 3 7 ] .
Similar data are
reported for amotosalen-plasma and S-303 processes
MIR
Imalarir]
thrombosis in liver transplant patjents, Such losses are le$
for the OctaPlas@process {451:
l m p a c t o f p r o c e s s i n og n p a t h o g e n sa n d
product potency
GvHD is currently prevented by gamma-inadiation
€nvelopedViruse5
(HBV modeD
nonocytogenes
>5.1
Corynebocteiun
Bocillus cereus
r'
No l1 I or lL-l [t synthesis
>6 3
minutissinun
-
Cytokine synthesisr
l M u r i n em o d € l T A G V H D :
/
Prevents disease
3 6
(incl spor6)
2.1
Eocillus cereus
l>51
Bifidobacterium
>6 0
(wgetdtiveJ
>6.2
odolescentr5
-
Proptionobocterium
>6 2
Loctobocillus
>6 4
Clostridiun
>6 5
pet f ri nge n s (veg e t o t ive)
-
3 5to>5
(546)
Spirochaete bactelia
l>5)
Trepenono pollidun (syphi isl
>6.8
11 8l
Bor.elio butgdorferi
>6 I
([yme diseasrJ
N ! m b e r s s h o w l o g r e d u c t i o n o f v a r i o u sp a t h o g e n so r l e u c o c y t € sf o r l B S ,T h e f a f l c x q( T H F ja n d M i r a s o l c { M l R ) t e c h n o l o g i € sW
. here log feduction is shown as
> X , n o d e t e c t a b l e p a t h o g e n r e m a i n e da f t e r t f € a t m e n t . ' i n a c t i v a t e d t o l i m i t o f d € t e c t i o n . S i m i l a r d a t a w e r e o b t a i n e d f o r p l a s m a [ 2 2 ] . O n l y i l l u s t i a t i v ed a t a
for selected pathogens are shown; th€ cited references @ntain additional data. Date in p3renthrsesshow data for model pathogens analogous to those lisied, for exampl€ animal parvovirus rather than human paruovirus Bl9; murine rather than human CI\rV.Some of the Miraslo
wer€ provided by R Goodrich, TerumoSgf (pe6onel communication) but is also cited in reference 38. -: no deta available
O 2ol 2 The Author{s)
Vox Sanguinis
@ 201 2 International
Vor Sanguinislzjl1'l
t04, 183-199
Society ofBlood
Transtusion
bacterial inactivation data
Componentpathogeninactivation189
Table4
RecoveryandSuruivalDatalnHealthyVolunteeEforMira5oloandlBs{reatedplateletsefter5dstoragr
MrasOI(n=241147〕
lBS(n‐
16)〔
48]
Design
ClinicalSetting
Crossovervolunteer
Factor Vll ft PT kinetis
Main Result
Amotos,Cn tS-59〕
(%)
Recovery
Survival
ldj
et
}
a5 l0 〔
ct
o1
Cfossover volunteer
1511
Itit i5 assumed that fresh platelets have 65% recovery and a life span of 8 daF then both technologie5 are close to th€ proposed FDA standard that stored
platelets sho!ld have a recovery of 67q0 of fresh and a suruival of 580b of fresh in paired healthy volunteer studi€s
(31 A study of MB, SD and quarantine plasmas in ljver
transplantation recipients found higher hepatic anery
thrombosis rates for SD plasma recipients, and higher
ct ol{52]
score did not. Increments for reference platelets in T-sol
additive or plasma did not differ [82].
rection in
to MB plasma, have replaced this product with IBS plasma
Janetzko et aL[74] found no difference by longitudinal
regression analyses or lh-CCI (ll 600 vs 15 100) for IBS
in France[46]. Higher rates of allergic reactions over
4 years, as well as two severe reactions to MB plasma,
to MB, have been reported [69, 70].
personalcommunication, 20t l).
other studies in Table 6 used a noninferiority
and over 6 5 million units of OctaPlas@transfused without
with
najor side-effectsl3l, despite the ljver study cited earlier.
Data for IBS (>500 000 units) and Mirasol@ (>1000 units)
end-point.
plasma were less extensive, but still encouraging. A formal
of
7483
IBS plasmas
reported
similar
adveree
rcactions rates to conventional plasma [7 l].
Most clinical trials of PI platelets assume products will be
randomized design
with primary end-points of corrected count increment {CCI)
or haemostatic^leeding
score {Table 6) [3, 11,72-80).
Absolute platelet count is a poor surrogate for bleeding tendency and count increment is dependent on patient size,
product dose and type, number of prior transfusions fmost
betlveen 7 5ch and 30qo for the primary
the PI arm had petechia€ or faecal occult blood. Kerkhoffs
noted signiffcant differences in grade 2 or greatilbleeding
(no non-inferiority
trials limit analysis to the frret I tmnsfusiors, or assesssin-
assumption) [85].
A pilot study [76] for 7 days stored platelets, found no
difernce (15noninferiority
assumption) in lh-CCI
gle transfusions), storage medium, storage time, etc. To
between IBS and reference platelets (6587 vs 8935) or in
allow for this, longitudinal regrcssion analysis, rather than
haemostatic scorc or adveNe events. The larger TESSI study
ratio data [increments or CCIS),has beer recommended
[81], Outcomes are affected by the type of r€ference prod-
I77l comparcd single transfusions of reference platelets in
T-Sol or SSP additive with IBS platelets, after 6 or 7 days
uct, older platelets and those storcd in earlier platelet addi-
storage. The pfinary end-point of th-CO noninferiority
(30q0margin) was met (8163 vs 9383, ratio 0 87) in the 201
patient study. Ih-CI, RBC use, time to next transfusion and
tive solutions performing less well. The negative impact of
combining gamma-irradiation with PI also merits attention,
0f the trials listed in Table 6, four did not use a noninferiority design:
The EURoSPRITE study [72] found no difference in
) h-CCI in 103 patients for IBS vs reference bufly coat
platelets. While the 24h-CCI differed, linear regressjon
analysis of CI at 1 or 24 h, and post-transfusion bleeding
Recovery, tolerance and eff,cacy 0K
in 3l (22J:
S h o ( e r h a l f - l i f e f o r f r b r i n o g e n ,p r o t f r o m b i n
w i t h c o n g e n i t a lc o a g u l a t i o n
fibrinog€n:
deficiencies
Prothrombin:3 {3J
2 (ll
tactor Vr
7 (4)
FactorVtl:
3 (2)
F a c t o rX l :
bleeding score did not differ, whereas 24h-CCI (4589 vs
6549) and 24-CJ(t t.r vs t5.2 x 10s,/l)did.
tl (6)
F a c t o fX l l l :
3 (3)
Protrin C:
3 (3)
Factof V+Vllli 0 (01
Mintzet ol [53]
Randomi2edContolledTrial
n = 121.605-59 and 6t std fFP
Acq!iredcoagulopathy
detect differences
in
but not PTT(>4 8 secj. No differerces
had cirhosisl
in factorVll increment orcomponent
usewere seen erther
Mintzer or [5a]
RandomizedContolledTrial
SDplasma"
Horowitz,Pehta[55]
Ir fthra review[56i
tlewelyn,
Williamson,
Fi5heret ot [57]
Wieding,Rathgeber.
zenkei et ol [58]
Beck.Mort€lsmans.
Kretschme[et ol [591
LerneiNel50n,
Sorcia,et ol [60]
l4ccadhy[61]
MB plasma'
RathgebeI
Wieding.
Zenkeiet ol I58l
Afiiaga,
de la Rubia,
Linar€s,
et ol [621
Alvare2-[atren,
D€l
Rio,Ramirez.
el o/. [63]
del Rio-Garma,
Alvarez-lr16n,Madinez
et ol. t64l
obseruational
396T4164
patientsRCfin TTP.
Plus
44 liverdisease
[57Tr).
l0 warfarinreversal
€t 6
chronicTTPpatients
ThromboticThfombocytopenic
Prevents or arresE bleeding (87%l
( 日l
F V
F V
I F X , F XDl . F X ‖
O 2012 TheAu(horls)
Vox Sangujnis
@ 2012 lnt€rnationalSocietyof BloodTranstusion
Vor Sanguihis(20131
104, I 83- 199
TTP; no diffefent from FFP
3 2 ' P ( 2 7 S O v s l , s t a n d a r d FEffective
FP)
in liver disease, werfarin r€veEal and
chronicTIP
Randomi2ed
Contolled
Trial
5Ds FFP(, = 491
Randomized
ConUolled
Trial
(, = 71)
SDvsMB plasma
No clinica difference.(20% noninferiority
would require38 patients per am)
Purpura {TIP)
No differ€nce clinical efficacy or haemostatic
coilection; ! case B19 on standsrd FFP
Card opu mOnarv bypass surge呼
No clinical difference, Poor protein S and
antiplasmin rise after SDP
Randomized
Trial
Controlled
SDs FFP{n = 40)
Randomized
ControlledTrial
22 5Dvs 23 FFP
No difference clinical efficaq
obfwational 355D,62 FFB
48 cryotupernatant
900b r€sponse with SD vs 70%-75% for othere
No difference clinjcal effiracy or PT
coiiection 132% vs 26%)
RandomizedControlledTrial Cardiop!lmonerybypasssurgeryNo clinical
(n = 7ll
5Dw MB plasma
obseryational
13 FFPvs7 [48
or
haemo5tatic coifection
difference, Poor protein S
and antiplasminriseafter SDP
Plasma
exchangeforTTP
TIP
Retiospective
27 MB w 29 FFP
i,lulticentric.observational,
TTPremission
by day
prospective
I of plasmaexchange
cohortstldl
Compare
MB (63)andquarantine
FrP(391
[rg 57% femission vs 69% FFP
Greatrr recurrence and morta ity with Mg
MB plasma was associated with a lower
likelihsd
of remission on day I lodds
f e t i o 0 . 17 1 .
l v l Bp a t i e n t s r e q u i r € d m o r e € x c h a n g e sl l l v s 5 ) ,
a
l a r g e r v o l u m e o f p l a s m a{ 4 8 5 v s 2 1 6
mllkg) and presented more recrudescences
bleeding. The study
included buffo coat piatelets stored for up to 7 days in
plasma (reference), PASIII additive or PASIII with IBS
Noninferiority for changes in PT l< 4.6 sec)
( l \ 4 a i n l yl i v € r d i s e a s e ,7 5 %
The H0V0N study [78] used a 2ool0noninferiority design
with a lh-CCI primary end-point. It was not blinded, nor
powered to
and factor Xlll w literatuf€values
I (1)
factor X:
firmed noninferiority. Differences were found for lh-Ccl
(l | 100 vs 16 000), transfusion interval (1 9 vs 2.4 days)
adverse reactions [83] or transfusion interval adjusted for
dose [84]. Snyder ct4l. [83] found no difference in WHo
grade l, 2, 3 or 4 bleeding rates, although more patients in
No diff€r€nce C or S kinetics
voluntrers
lncrement (€thalf life)
17 5-59 Et 18 std FFP
In the 645 patient, SPRINT trial {731 primary end-points
of grade 2 bleeding (assuming 12 50/ononinferiority margin) or gnde 3 and 4 bleeding (7 5% noninferiorigr) con-
in this study, by direct comparison
Kin€tics in warferinized
design,
and number of platelet tmnsfusions (8.4 vs 6.2), but not
Platelel components
less effective and use a noninferiority
margins
No differenc€ PT or fvll kinetics
1 0 7T € n s f u 5 i o n si n 3 4 p a t i e n t s
patients for reference and IBS platelets.
lh-CCI differences( l0 400 vs I 3 600) were not signifrcant.
requiring hospitalization due to specific immune response
in
warfarinized volunteers
0p€n label Pharmecokinetic
l0
and reference platelets. The coresponding study for bufry
coat plateletsyielded similar data (A. Stassinopoulos,Cerus,
Companies have reponed over l 9 million units of MB
l7 pfotein C and 16 prot€in 5
Slichter et a/.1751showed comparable bleeding time cor-
plasma use with MB [67, 68].
Recently, AFSSAPS,due to concerns over allergic reactions
study
lV = 27 S-59 s std FFP
w h i l e o n P Et h r r a p y ( 4 6 % 6 2 1 % )
'see aЬ
o further sma‖
oOservalonal stud esmalzed
sun・ n Tab eS 6 a 7 n recentreview 145]
0 2012 The Authorls)
Vox Sanguinis o 2012 internalomal sOctc,ofBIoOd TransFusion
V げ勁″
lllis1201 9 104,183-199
gン
190 C V Prowsc
pathogeninactivation I 9l
Component
N (Test/Re0
Mean storag€
Technology
(reference
prepafation)
Tablc 6 (COnt nucd)
Primary
daysOest,/Refl end-point
Secondary
end-points
A$ocaated
N [Tert,/Re0
MeanstorBge Primary
daysOest/R€fl end-point
Technology
studies
(r€fercnce
E U R O S P R I Tv E
an
R h e n e ne t o t [ 7 2 ]
A m o t o s a l e np o o l e d
BC platelets
{pooled BC plotelets
56dor 8 Tx
52/51
134 doys/
3sdoys)
observation
with2Sd
preparation)
CCI €t Cl at 24 h
Haemostasis and
M RACLE〔
フ
91
b l € e d i n gs c o r e .
Intention
e ′σ′[ フ
31
a p h e r e s i sp l e t e l e t s
{opheres6 p/ofe/ets
gg8%gonno
Riboflavinkeated
apheresisplatekb
in T-sol or plosmo)
RCT,20%
noninferiority
stofed l-5
Tx interval
or8Tx.
Noninferiority
RCT[l2 5% or
7 5% assumptjon)
314/321
(3 4 doys/
36doys)
lx interval
R e dc e l l a n d
Grade3R4
plotelets in plosno)
I83,841
Refractoriness
Infection rate
bJeeding.
WHO bleeding
CCI and Cl at 1
and 24h.
Adve6€ Events
PREPARES
[3. 11,80]
lx interual
Amotosalen BC
Iogistic regression
Integrated se!s
G r a d e2 o r g r e a t e r
B l e e d i n gs t u d y o f
bleeding ICTCAt
NOn nferiolitv(く1 50bl
Netherlandsstored
ccl
complications.)
1-7 dayslopheresis
ofdose vs
J a n e t z k o7 4c], l l l 〔
Logistic regresiion
(3 7 dσ
ぃ/
θ2dσys)
apheresis inteqrated
sets (9ommo
R e d c e l l sa n d
p l a t e l e tu s a g €
Rate of HLA
ccl
alloimmunization
Multicentet
incremert
nonrandomized,
opheresis
G r a d e2 o r g r e a t e r
bleeding
prospectivr
3.11.80〕
〔
Blreding time
ccl
p l a t e l e ta n d
R B Ct a n s f u 5 i o n s
alloimmuni2ation
i n v o l v i n g2 f t r t r e s
a p h e r e s i si n t e g r a t e d
int€rval
u s l n g M i r a s o la n d
al o-antibody
2 using l85
plorclets in plosno)
r2θ“ys/
3 2 doγ
リ
Pathogen
A m o t o s a l e nB C
inNenents lpooled
I and 24 h.
Tx int€toal;
of dose 6
plotelets in plosnol
S chte7 et
σ
′[75〕
Cl and CCI at
g r a d e2 b l e e d i n g
plotelets in plosmo)
7 d a y ss t o r a g e
studies?
p l a t e l e t su s a g e
to treat RCT
28 d treatment
period
stor€d in plasma in
S i m o n s e ne t o i [ 7 6 ]
Astociated
€nd-points
ccr-24h
5/
(2θdσ
′
26 dOゅ〕
riboflavin 8C ptatelets
irodioted
Secondary
non nfenolty Of
(7 do"/
15%0も 'On
7 dgyl
C o m p a r i s o no f 2 - 3
Thromboelastogram
Adve6eevents
Reductiof, - Exiended
days and then
measurementsand
bleeding
Storage Study (PRt55),
7 days stofed
co(rlation w th CCI
CCI
D e n m a r k [ 3 , 1 1 ,8 0 ]
r r f e r e n c ea n d
Mjrasol Piatelet3
BC plotelets
in l-so4 6591
BC.buffv cOat
gomno itrodioted
Amotosalen 6 ft7
LozanO cl ol 1771
daysplateleb
nottnfe■
o ltv
(aθ
″ oθJ
(IBSJ[86% pooled
BC, 140h
opheresis plo(elets
in f Sol or
SSP+ odditive,
74%gonno
14% for test)
Amotosalfn l-7
κ
crkhofFs er ol[78〕
days pmled
8C
I B Sa r m
RC1 20%
(`力
´/
c u i t a i l e de a r l y
(plasma vs PAS
vs lBSl {pooled
4 dσソ
s)
BC ploklets in
0 2012 Thc Authorlsl
Vox Sanguinis o 2012 1ntcrna●
onal sOcie,oFBlood Transfuslon
7oI Sa"夕
“i"`(2013)104.183199
treatnent Thc lBS arm was curtaned early due tO excess
significantly different for the two arms. Further studies of
blecding,including、
vHo gradc l blccds,often regardcd as
Mirasol platelets are planned in the Netherlands, Italy and
clinically insigniflcant Low ratcs of gradc 2 blccding(6Denmark [3, I 1, 80].
7%vs∼ 60Qbl〔
841 comparcd wth mOstthals173,77,85-87〕 About 600 000 IBS platelets have been transfused vs
were observed Difrerenccs wcrc noted(inten●
on to treat lO OOOMirasol@ units [3, I l]. Safety suNeillance rcports
analysis〕
fOr lh―
CCI(17 100 vs 15 300,vs l1 400),thC IBS
for IBS product include use in Belgium, France, Spain, Nordata bcing 31070 10WCr HowNer,conidencc hm■
s wcrc
way and ltaly IBB 90]. Comparison of component usage,
w i t h i n t h c p r c s p e c i n e d 2m 0a 0r 4g 0i n n O n i n f including
crionサ
RBC transfusions, during introduction of IBS
Thc only Mirasol・
tnal(Miraclc)[791 comparcd CCI
lh― platelets into routin€ use has revealed no significant change
in l10 pattents en
g市reFerencc or trcated platelets stored
in eitherBelgium or France [9t, s2]. Reports from Germany
up to 5 days(209o noninFcHoH″
Imio Tlle study Failed the
and Switzerland are also encouraging [93, 94]. French
noninfcnonty end―
polnt(mean lh CCI rcduccd by 240/o annual haemovigilance reports include advene events
frOm 16 939 to l1 725)and,athough it was a sman study,
(mainly allergic) for plasma and platelets. These are lower
blecding scorcs{any WHO bleed gradc from l(04)wcrc for IBS plateletsstored in additive solution than for platelets
different 5907o of Mirasol product recipients bled in
vs plasma
4307o (10-15 per 100 000), while MB plasma {-7 per
For reFerence Nether this,nor RBC or platelet usage,were
100 000) rateswere higherthan IBS orSD plasmas [95].
0 2012TheAutholls)
Vox Sanguinis o 2012:ntcrnalona!Socie,oFBlood Transfusion
Vο
χ S a″
r″
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is(2013)104,183199
192
Conponentpathogen
inactjvation 193
C.V. Prowse
The obseruations of reduced Cl for PI platelets with little
continuing discussion about the design of pivotal platelet
impact on haemostasis [73] are consistent with the PLADo
trial which reported no difference in haemostasis between
Pl trials with the FDA. A number ofPI technologies are CE
marked (marketing authorization) in Europe, where octa-
gen Reductioil
high, medium and low dose groups of platelet recipients
[87], In contrast, a meta-analysis of PI platelet trials {961
Plas@is licensed as a pharmaceutical. Pl companies tended
to gain CE marking using the medical devices directive
uithin
repofied reduced increments drd haemostatic efftcacy. The
increment data is consistent with most individual trials
classIIb route but there is now a strong trend towards class
III registration, which requires regulatory review of pre-
[97], current study designs suggesting a 200/0reduction in
increment is acceptable.The increased bleeding tendency
reported [96] has not been observed in IBS trials with this
clinical and clinical data {Table I J.
primary end-point (the major one, SPRINT,having a nonin-
Individual European countries require marketing authorization at national (France, Switzerland) or regional (Germany) level. Approval by insurance (Belgium) or
feriority design) or in a subsequentmeta-analysis I9Bl. That
point is partially conceded in a later report by the same
author, no excess bleeding being found for IBS products
government funders (UK) may also be required.
[99]. Inclusion of grade t bleeds, possibly predictive of
more severe bleeding, and period of obseruation are potential confounders [98, lOo]. The absenceof change in plate-
labels {1061 and PCR inhibition assays [107], have been
establishedto conhrm completion ofprocessing on individ-
Methods, inciuding chromatogmphic assay of amotosalen photodegradation products [105], use of IJV sensitive
ual units.
let, RBC or plasma use in seNices adopting PI, suggests no
gross changes in haemostatic effrcacy [9 l, 92].
Cost-effectiveness
Table7 summarizespublisheddata otr the cost-effectivenessof SD plasma.Thesedo not take accountof reducing
bactedalor emerginginfections.They do illustratethe significant impact of reducedTRALI dsk (due to dilution of
The 2007 Canadian PI consensusconference concluded PI
causativeantibodiesin the largeplasmapoolsused[45])on
was worth purcuing, particularly to saf€guard against
for this product[1ll], althoughmalecost-effectiveness
emerging infections Il0l]. The IBS systen allowed mainteonly plasna provides an altemative. The TRALI benefit
nance of plateiet supply in R€union during a Chikungunya
would not apply to sjngledonor productsand it not yet
virus outbreak [102]. A 2010 meeting in Strasbourg of PI
as usedin
clearif it doesfor minipools(6-10 donations),
companies, blood seruices and regulatory agencies [3]
the IBS-treated, plasma minipool product PLASMIX
emphasized the increasing adoption of PI in Europe.
or completely
Sixte€n countries have either paftially
[il2, il3].
Cerus developedcosting models, including bacterial
adopted plasma PI; l3 platelet PI. MB and 5D plasmas are
and emerginginfection risks, and applied thesein Japan,
the only PI components licensed in Canada, with evaluaand USA [l14-117]. Independent
Belgium,Netherlands
tions ongoing in Japan. The UK SABT0 committee recomhave also beenpublished.Custer€/a/. [118]
assessments
mended that Pl ptatelets not be introduced in 2010 [103].
whole blood, as well as plasmaand platelet,
considered
The AABB published a 2010 monograph on available techPI approachesand assessedinfections, TA-GVH, febrile
nologies and implementation experience [104].
reactionsand transfusioninducedimmune modulation,
concludingthe cost per Quality Adjusted Life Year
Regulatoryaspects
remainedabove$l million for most patientgroups,well
sales
exceeding
I 000000IBSkits,no component above usually acceptedlimits. However,at the 20ll
Despite
There
is a
AABB conference,he included emerging infections
the FDA.
are ljcensed
by
PI techDologies
Outcomesfrom recent meetingson pathogen
i n a c t i v a t i o na n d i t s i m p l e m e n t a t i o n
modefled on HIV or West Nile virus, concludin1:
Tcchnology would be "a boryain".
acute agent the cost-efectiueness
an
wouU be aeryJauoutable
the blood safety context. Meailuhile,
agent of similar preralence
saaings
'PothoFo/
based
on
fol a chr,nic
cost
be substartial
(and litigation)
health-care
therc aould
arcided
RBC at that time. The Cerus revised, second-generation
5-303 process demonstrated equivalent 24-h recovery to
F u t u r ed i r e c t i o n s
conventionaf RBC after 35 days ofstorage, in uitro characteristics meeting EU and US RBC standards and will be used
Development
ofRBCPI
in Phase 3 patient effrcacy studies Il27l.
Photoinactivationmethodsfor opticallydenseRBCrequirts
high dosesof tJV light, dilution or use of thin layers of
product.Cerushavedevelopedan alternativepurely chemical approach.
TheirS-303compound(Fig.2) is a FRangible
compound [120] designed
Anchor-Linker-Effector(FRALE)
to reactquickly at neutral pH after binding NA but also to
deccimpose,
through hydrolysisof a strategicLinker bond.
This separatesthe NA-rcactive part from the NA-binding
grcup and genentesa compoundwith rcducedafflnity for
NA. Initial clinical experiencedemonstratedeffrcacy in
patientsundergoingcardiovascularsurgery,but antibodies
to treated RBC formed in two multitmnsfused patients,
The prccesshas now been
without clinical consequ€nce.
revised,using the samecompoundsbut increasedlevels of
protectantglutathione (going from 2 to 20 mM) to minimize side rcactions and is restafting efficacy Phase III
patienttrials Il2l]. Preclinicaltoxicology(Table2) [32] is
acceptableand inactivation of pathogensis reponed as
similartothoseshownin Table3 [122].
OALY (US$) [Ranqe)
$9743000(A‖ >$2800000)
$2 ,56398($'10000-$7600000)
$90000(approx C50 0000(C'2335-C99005)
(l n3500 w"h100o mortJ ttv)
0 2012 The AuthoISl
oFBlood Transh●on
Vox Sangumヽ o2012 hterna●onal Soclc●
1/o■
Sa"g“i"is(2013)104,183199
yet to be fualized or licensed,shelf life may be reduced to
35 days (5-103) or possibly even <28 days (extrapolated
l'rom Mirasol@data: Table B) [l 26- I 28].
Studies on plasma atrd platelets from trcated WB have
yet to be rcported.
Use of such an approach in fomard
this frcld (R Goodrich,TerumoBCT.BCI
0 2012 The Authorls)
onJ Sodctv oFBlood TransFll●on
Vox Sanguinls o 2012 1ntcrna■
Vat Sθ"′″′lS(2013)104,183-199
interest in
pereonal communi-
cation). The US Department of D€fence has also funded WB
PI studies with S-303 sirce2OO2 [122].
0ther
The
directions
2009 National
Heart, Lung
and
Blood
Institute
workshop on research opportunities in blood component
〔〕
Amotosalen(S-59)
military settings
may be less restricted, with continued military
中
ｃ ｎ
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l
R e i d l C r` 1 el ti l σ
Cost Fr
Recovery and survival studies of RBC ,fioz ahole blood
f4zB/ processed using Mirasoi@ technology found significant loss of viability associatedwith UV doses required to
achieve PI [128]. For existjng RBC PI processes,which have
がくI Ч
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55300)
1 1 0 8 1$ 2 8 9 3 0 0 (>A$‖
8 0 J . / m L R Bfco r w h o l e b l o o d [ 1 2 3 - 1 2 5 ] .
Table I summarizes PI RBC studies in man i126-1301.
The 2003 frnding of antibodies to treated RBC in
multitransfused patjents curtailed all cljnicai studies on PI
corb'[1 l9].
Table 7 Solvent Deterqent Plasma CosF[ffectivenes5 sludres
AubuChOn a 3 rkmever
り
ackson et ol[109〕
Pcrdra l1101
TerumoBcT's Mirasolo technology is being developed
for the treatment of uhole blood lhrough adjustment of the
for platelets and plasma to
dose from 6 J/mlpusya
2
S-303・ 2HCI
((c3っ〕
(》
c
S-300 0 HCI
Component pathogen inactivation
Study type
Study d€sign
24-h Recovery (ve6ior
Two period, cross over study
References
126〕
e:ὰ〔
I S-303)
24-h Recovery {ve6iof
I 5-303)
Phate I srfety and
l o e r a b r l i l y( v e r g o n
Singl€ arm, with some subjects having
prior exposure to 5-303 t(ated
RBCS
Singlearm safety evaluatioh of full
unit t ansfusion:
r 5-303)
RecoveryandLifespan
Twoperiodcrossoverstudydesign
at es da/s(hal「
re 33 days
fOr test and 40 davs reFerencc)
(version 1 5-303)
P h a s e3 A c u t r a n a e m i a
(ve6ion 1 5-303)
E f f c a c y a n d s a f e t yo f a l l o g e n e i c
2 0 0 b u t s t o p p e da t 1 4 8
t r a n s f u s i o n sN
. o n i n f e r i o r i t yd e s i g n -
Beniamin
\14 + 14)Ptimary
er dl.[1291
I Horowitz B, Bonomo R, Prirce AM, el
a,/.: Solvent/detergent-treatedplasma:
a virus-inactivated substitute for fresh
frozen plasma. Blood 1992; 79i826831
2 Prowse CV; Pathogen inactivation of
blood components. TnflsJus Altemat
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0: I 39- 146
3 Council of Europe,European Committee {Panial Agreenert) on Blood
Transtusion (CD-P-TS),Symposium on
end-point met
P h a s e3 C h r o n i c
ana€mi,
( v e r s i o nr 5 - 3 0 3 )
Efficary and s.fety ofallogeneic
5 0 b u t s t o p p e da t 2 5
tfansf!sions. Two period crossover
rt ot J1301
i l u d y N o n i n f c r i o r i t yd e s i g f .
Two period cfossover study
88%s 90%24 h recov€ryat
35 days(half-life
37 days
for teil rnd refercnce)
50-73%24 h recovery
at 42
days(half-lifel0-35 days)
L i f e S p a nl v e r s i o n
2, s-303J
Recovery and Life
Conlan
R r c o v e r ya n d L i f e s p a n . D o s e r a n g i n g
Cancelat
et ol.1121)
Canceles
4
et ol [128]
blood treated
with Riboflavin
5
ft u\e
" R e s u l c f e p o i l € d f o r 4 v o l u r t € € r s € a c h a t 2 2 a n d 3 3 l / m l R s c ,a n d 3 a t 4 4 J , h l R s c
L a t e s t r e p o n s f o r w h o l e b l o o d c i t e u s i n g e d o s e o f 8 0 J , / m l R s c [ 12 3 - ] 2 5 1
6
PI identifred two fundamental questions, among others
[ 1 3l ] :
First, could PI b€ applied to whole blood, making jt more
affordable and easier to implement? Based on preliminary
data Il 26- I 28], this remains challenging and may be limited to whole blood use in military applications with minimal storage (seesection Development ofRBC Pl).
'virtually
Second, can PI render components
leucodepleted', with savings and improvements from filters facilitating
PI introduction?
Data from the TRAP trial, which
found equivalent rcductions in alloimmunization for leucodepleted and LlvB-treated platelets, are promising [132].
to 0 and 225 casesper
133/1466478J,corresponding
million[95].
WhereIBSplasmaandplateletPI hasbeenadopted,
there
hasbeenlittie changein component
usage,andthePI processhas s€curedmicrobiologicalsafety from viruses and
bacteria.
Concemsaboutadve6etoxicologicaland immunological effects seem unfounded. Elsewherecost of PI
remainsa concern,but PI inactivationof leucocytes
can
substitutefor gamma-irradiationand leucodepletion.
Togetherwith the security against emerging pathogens,
these considerationsincreasingly make Pl technologies
goodvalue.
Eneouraging data from Belgium show alloimmunization
with IBS plateletswas reduced,despite use of non-PI leucofrltered RBC [133].
Since 1990, significant progress has been made in Pl
technology. In routine use, the anticipated benefits of PI
become tangible, offering hope for an even safer blood supply. For example, French haemovigilance reports found no
cases of sepsis associated with use of IBS platelets
(0,/104 I l8 between 2006 and 201 I, whereas 33, including
5 deaths,were observed in conventional platelets recipients
Acknowledgements
Chris Prowse is the only author of thjs review and is
responsible
for its entirecontent.
7
Declaration of Interest
O 2012TheAuthor(s)
VoxSanguinis
O 20I 2 Internarjonal
Society
ofBloodTransfusion
Vol Songuillis
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８寮当逼＞
只場 己ョ至 Ｈ 網軍 ｃ侶 Ｒ 出 ︹目２沼 潮目 百 づ饉 一＾
∽
身 ■ Ｓ ■瑶 穏 ｍ ３ ｏ
二邸 脅 瑠 侶 塑
選ｏ
︵
○任メ 撫 総 Ｉ Ｎ導 戻︶
Blood Institute on April 9, 2013
al Cental
Downloaded from http://cid.oxfordjoumals.org/
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，
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０ち υｃ 一ε
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卜 ０ ● ｏ、 コ ● ６ 一 協 〓
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９
く
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ぜ ， ３ ａ ８ ●”﹁ Ｐ‘ ３
ｏ﹁ ｏ一ｏ一●ｏ ■ 一２ ｏ〓一一●ｏ ．
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８一
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３ 一 ●¨
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■ っ ︼ ∞ｏも ぅ一
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３３ｏｘｏヽ■ Ｎｏ‘ 日ｏこ ●■ ， ｏ〓一つ０●
︵
００●ｏ﹁お＞︼
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ぉ〓 ｔ〓´∽
Ｃ５ ＮｎＯ‘ ¨Ｃ¨
´
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０コじ目←
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‘一
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一
， ３一
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﹄
０一
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当 ｚ
→ ∞
一
旨 ２ ∽己 一員 ● 一 月 ２ 〓 日
口 ｏコ ﹁ 日
︼
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∽
●ｏ●
己霧﹁一
寅一
こ ｏ工“ｒ●６〓ｏ国 ︵
卜゛０ ＝ ヽ●●●一
己∽
じ 、 ３ ８ ｏ い ｏｎｌトト Ｏ ＾
一●２ 一こ ∽員● 一 員ｐ ﹁ 日
︼０ ざ い０ ´
∽０∽にυ 卜 ∽＞ ０守︶ ｏυ員“υＣ一ＲＰ ∽ ︻
ｃｕ﹁僣 一●´∽ ´
ヽこ ｏ︼ 一〇Ｃ 一¨
● ００●ｏ︼ｐ︾¨
一
´ ｆ 〓 つ Ｊ ｔ 〓 一¨ε も ｏ ３ ‘ ， 日 υ︼ｏ一ｏお
じ、 ﹁ ｏｆ
︼ｏ。 ３ 埓 ｏ い︻
∽＞ ｎ６こ
ごＯ Ｓ い０ 一
´ｏｅ ∽己 ∽ｏ２ 一 ｏｏ﹁﹁日
占ョ
卜つ つｏ■ ８ ８ 一ｏ０
∽に も ‘炒 ‘ 〓 ２ ，ｏ Ｏ︼ ∽Ｓ‘ ∽員綸 ∽Ｃ ∽ｃＳ 一 守゛ ３ ｏ●一 日 ０こ
員ｏ﹁ やヽ 口に● ｏ● 、ｏ∽﹂ｏ Ｏ一に︼ ｏ“い
Ｓ 崎０ ざ 卜Ｎ ″ ０
，Ｅ００ ∞〇゛︶ ８ ●ｏ﹁ ｏこ つ∽ ｏ＞一
も ｏ 卜一 一ｇ ｕＶ ｏＯ ∽〓 ●● べ゛ 〓一〓 ′ 一曽 ｃ、
at Ccntral Blood lnstilui€ on April 9, 2013
frcm http://cid.oxfordjournals.org/
DoMl@ded
メｎｄむ 工も 日 ｏ‘ ”編 ｏ曽 υ一ロコ ８ ｏ〓 ０モ´
， 日 ● ３ｏ﹁遍 日 昌 Ｂ
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〓 ０● ｔ 、 ﹁〓 ●ｏ■ 一
３一
，日 ９首 聖 ０一
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金¨
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Ｏ︻
゛
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、 ｇ ＞﹁ 営 ｏ〓 ０日 Ｊ〓 ｏｆ 娼 碍 一
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一 聖 ０ ︶ ０ ■ ｏ０
、お Ｅ ︰
∩ 毬 ８ ﹄‘
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●
ぜ Ｖ ● ｏマ ｔ ｏｏお ｏち “， ”ｃ， お ８ ﹄ ∽一●ｏ一
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ｔ ” 罵 ¨粂 ●● 対■ 日 ３一●ｏｏ ﹁ 員“ ¨
︼ｏ ｏ‘ ﹂ｏ 一●● 員ｏυ ●狡 ０一●一員ｏ ｏ●一一員ｏ
ＱＯの０＞ 一
﹂
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、
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﹂“目●ｏ■●ｏ日
plttelet lR0Pl units,by surveillancamethod,July 1991Table2. Contaminatiorof single-donorplatelet{SDP)and random-donor
Decembor2d16.
゛
゛
DiffB.enF
Ior all on[s
passive
. Slaphylococcus
lt8durersis
o s/€4,hfloeocf,uswanei
x Viridansgroupslrepboeus
. Slr€ptomccus
bovis
げ
゛
゛
ご
︵
コＥ ヽ も 〓 ｃ３ｏｏ ■■ ま 〓 ●
. Staph@occusepidemidis
. S'lqphylococcus
aureus
::8
. Billllus ereus
! P$udomonasaerugiros
r Seraliamaffiffns
::`
●=
ReaCtion grade
There
reacti0ns
andseverity
in 45 cases,1991-2006.
loadt0 otcutrence
of transfusion
andbacterial
0f bacterial
species
figure 1. Belationship
quantitati0n
epidermidisconlaninatton
wasnotperlormed
for 1 caseol Staphylonccus
1 unithad2 contaminants;
because
are46 datapointsshown,
reaction.
with no transfusion
182,700 EU, 11,373 EV, and 34,646 EU, respectively. In the
fourth case of contamination with gram-negative bacilli, which
was due to S. marcescensdetected at a level of5 x l0' cfu/ml
no clinically detectable reaction other than transient leukocylosis occurred in a 2-week-old, prematur€ neonate with congenital neutropenia and thrombocytopenia;
endotoxin content
of the organism was 4.3 EU per million organisms, md the
total endotoxin content transfused was 173,100 EU,
Reaction severiV was associated with bacterial load and virulence, with all severe reactions (grade 3 and higher) associated
ith loads of >105 cfu/ml and/or more-virulent bacterial spe-
cies (P, aeruginosa,S, marescens,S. aureus,B. cqeus, and Sboris)(frgorel). The meanbacteriallbadwashigherin patients
with transfusionreactionsthan it wasin thosewithout transfusion reactions(3 x 106 cfu/ml vs. 2.4x l0' cfu/ml; P<
,002) and was higher in patientswith severereactionsthan it
was in thosewith mild or moderatereactions(9.2x 101cful
mL vs. 3 x 105cfu/ml; P<,008). Reactionratesfor morc virulent versuslessvirulent bacterialspeciesw€re 3.5-foldhigher
(95o/oCI, 1.9-6.2-foldhigher) in thosewith any reactionthan
in thosewith no reaction(91.7%vs.26.5%;P = .001)and 8.5fold higher(957oCt, 2.0-36.6-foldhigher) for severereactions
6
than for mild
or moderate reactions (50yo vs. 5.9Vo:, P =
(4.5o/o) of 44 bacterially contaminated units transfused and 2
(l2.5Vo) of 16 septic leactions were detected by passive sur-
.002) (table 3). These reaction rates were also significantly
than when it was
higher when bacterial load was >10'cfu/ml
veillance, and we conclude that the real prevalence of these
(4-fold and >34-fold higher, respectively) but did
occurrences is greatly underreported in studies relying on pas-
on the basis of the Presence of neutropenia or the absence of antibiotics effective against contami-
sive suneillance. The fatality rate, howev€r, did not differ be-
nants (table 3). Age ofplatelet uniti also showed no difference,
propriately
but this analysis was limited by the age of the platelet units
relatively small sample size). [n addition,
being either 4 or 5 days in most cases.
showed that septic reactions, as defined in our study, occurred
<10' cfu/ml
not differ siFnificantly
Detection
sensitivity.
The rensitivity
to detect bacterial contamination
of methods required
of platelet products on the
basis of counts of the 46 bacterial species present in 45 transfused, contaminated units or Pools is shown in figure 2 (quantitation was not pelformed
a semitive
detection
method
for the remaining case). Whereo
(with
a cutoff
value of l0' cfu/
mL) would be needed to detect >95olo ofaU contaminants and
>900/o of contaminants
resulting in transfusion reactions, less
sensitive methods (with a cutoff value of l0' cfu/ml)
would
have detected all severe, life-threatening, and fatal reactions.
∞
our
by a
suruei]lance
in l8 (4lo/o) of 44 patients uith contaminated transfusions and
that 2 (ll.l%)
of l8 septic reactions were fatal.
Based on 2004 data, nearly 3 million
platelet units were
transfused in the United States in the form of 1.4 million SDP
units and 1.5 million RDP units, the latter administered in an
estimated 0.2H.38
million pools of {-6 units [8]. Contami-
nation rates are similar for SDP and RDP urits, but the contamination
rate per transfusion, as expected, is 4-6-fold higher
for RDP pool transfusions {9]. The fatality rate associated with
bacterial contamination of platelets is estimated, based on recent data obtained by passive suneillance, to be -2 deaths per
million
units transfused (-6
deaths per year in the United
States), and the rate ofseptic transfusion reactions is estimated
ｍ
contaminated platelet units, a 27.7-fold higher rate ofbacterially
to be 10-13 casesper million units transfused (30-40 cases per
∞
contaminated platelet units transfused, and a 10.6-fold higher
year in the United States) [], 10, ll].
”
rate of septic transfusion
０
ｍ
Our study documented that a 32-fold higher rate ofbacterially
recognized (albeit, our study was limited
veillance, ompared
reactiom
were detected by active sur-
with passive surveillmce (table 2). Only 2
passive surveillance
Our data generated by
reflect similar frndings, with detection
rates
of 15 cases of septic transfusion reaction and 7 fatalities from
コ
”
Table3. Diffelencesin the prevalenceand severilyof translusionreactionsb8sedon virulenceol the bactorialspecies,leukocyte
counb ott|ansfusiontecipients,tBatnenf wilh anlimicrobialagentsactiveagainstth8 brcterisl cotrtaninantat tie tins oltransfusion,
plateletuoit age,and baclerialload.
”
10°
10'
10`
10=
102
1。
0etection 80n31uVlty(cf」
mL〕
1
;rtirr+rode.G-to- rzl
+None (n= 26)
・
― SeverO.ll●
nいO or●
:●
tal("=8) * Any @dlon (t = 20)
lh"●
4
6
1
―
o
s
l
n
電
￨=三 型
t0 detecl
methods
required
limils0f detection
0f platelets
based0n detection
of bacterial
c0ntamination
0f detection
FigureZ. Plotof accuracy
reaclions.
andseverity
of transfusion
in 45 casesfor all casesandbased0n the presence
46 bacterial
contaminants
BacterialContaminationof Platelets. CID 200at46 (r5 April) ' 1217
B e c e r o ro l a n t b r o n c s
More'virulenr
species
11/12(91.7)
Any ranslusionreaction
Severetransfusionreaction 6/12 (50.0)
Less-virulenl
species
OR
(95% CD
9734(265) 31{1962) (001
10/23{435),0/23(435)10(0●
19) 23 6/8(750, 14/38(368)
NOTE. Dataar6orooonion{%,olfansrusionrecipients,unlessolherwiseindicated.P<,0l,byPearson'slteslwithBonferronicotreclon,wasconsidered
to be sGistic6lty significanl. SGtisrical signitic6ne is indicated by boldlaca type. cfu, colony-{orming unils; NA, not applicable.
1218・ CID 200■ 46(15 Aprll)・ lacObs et al
０ ０９ ω
・
”
お〓〓ｏｃｏ●ｃｏ︺
０■ ●賃〓
ｔ，●●営０囀 ﹄
Ｆ■〓口０‘‘，゛３ ８︶
ち 島ｒｒｓおし
DrscusstoN
tween the surueillance methods, suggesting that these were aP-
● ｏく ユ ｏ●αｏＯ や ｏ日 テ¨
● 、 いさ ｏｘ♂ 宍一 ｏ〓 ””， ９ ヽ ”¨● ｏ日 轟 一” ， ｏＯ す い， 日 ｏ ｏコ ＞ ０■
Mld Mode●
O S¨に h瀾編ing
by actve
suN6illance
NOTE. Atotatdt56.Es3SDPunitsandls2,l00RDPunilsio36.4lSpoolsweretianslusedduringlhesurveillanceperiod.P<.0l,byPearson'sr'rest
with Bonferroni correction. was consid6red lo be slaiislically signilicanl.
、０● ９ ∂ 二 ﹂
３ 一口 ０８ ︼
〓 Ｆ “● ｏコ ２ ュ 一や ０２ 一
υｏ姜Ｌ ｏａ ＆ ”●ヨ 〓 一
８ ヨ ●一
∽８ ヽ Ｒ ｏ８ ¨
０一
None
beeeen.ares
bacterially contaminated plat€let transfusions per million trans-
pected to produce severe reactions. No reaction occurred in
platelets, such as the use of SDP units rather than RDP pools
fused units. However, our data generated by active suryeillance
the case ofcontamination
and the use ofyounger
with S. marcascenJin a neonate with
rather than older units [20], should be
continued, with universal use ofdiversion pouches in collection
suggest that as many as 900-1200 contaminated units could be
congenital neutropenia who received the largest amount ofen-
traDsfused annually in the United States, resulting in 300-400
dotoxin
(173,130 EU), and deficiency in or desensitiation of
systems. Several solutions have been proposed to further reduce
septic reactions and 6-20 deaths per year. These projections
phagocytic effector cells or defects in the IFN--y-IL-12 uis may
these risks. The first is to increile the sensitivity of bacterial
based on our data could also be underestinates, because the
explain the lack of response and suwival of this patient [15].
Our data also provide unique information on the relation-
detection performed at 24 h by increasing the volume cultured
active suryeillance culture method used had some limitations,
including an analpical sensitivity of l0 cfu/ml,
ships between bacterial levels and transfusiol
which would
not have detected lower levels of contamination;
using only
reactions. The
severity of reactions was l0' cfu/ml,
obes; and not culturing platelets that were <4 dap old for 84
tion threshold of a clinically useful detection method at time
months.
of use should be at least 105 cfu/ml
Furthermore, our study demonstrated the relationships between bacterial species and levels, unit age, neutropenia, antibiotic
indicating that the detec(table 3 and figure 2). In
of methods for at-issue testing.
mL. These parameters can be used to guide the development
Two recent changes in transfusion medicine practices<ul-
rence and severity of reactions. The presence or absence of
ture of SDP units 24 h after collection, with release for use if
neutropenia showed no significant association with reaction
occurrence or severiry Receipt of appropriate antibiotic therapy
culture results were negative after an additional 12-24 h [16)
and use of a diversion pouch on the inlet line of the plarelet-
at the time oftransfusion
pheresis collection kit to trap and eliminate skitr contaminants
showed some association with a lower
occurrence of any transfusion reaction, with the 950,6Ct ofthe
OR just reaching statistical signifrance. However, no associa-
relative roles of these changes at this time. In a recent study
tion could be shown with severe reactions, because there were
of I million
[17]-have
been beneficial, although it is dimcult to assessthe
apheresis platelet donations, these measur€s ap,
no patients with severe reactions who had not been receiving
pleciably decreased the rate of septic reactions ftom l8 to 5.4
antibiotics. Unit age at time of use showed no association with
occurrence or severity ofreactions, but this analysis was limited
reactions per million transfused units, but theydid not declease
the fatality rate (2.1 vs. 1.8 deaths per million transfused units),
by most units being either 4- or S-days old at rhe time of use.
because fatalities were associated with bacteria that were not
In the previous 3 decades, small doses ofendotoxin
(2-4 ng/
kg, equivalent to 1,1-28 EU in a 70-kg adult), administered
intravenously to thousands of volunteers to study acute in-
qpical
of skin flora [ll]. Because tlvo-thirds of the 60 deaths
reported to the US Food and Drug Administration from 1995
responses, have generally been found to be safe,
through 2004 were associated with Enterobacteriaceae [l], the
risk of septic and fatal reactions, particularly with these more
although 4 cases of severe bradycardia or protracted asystole
virulent, non-skin-associated contaminants, is therefore likely
have been reported [12]. A study of patients with septic shock
showed median plasma endotoxin loads of I 3,000 EU I l3], and
to remain. There is also a need for a national hemovigilance
a self-administered
intravenous etrdotoxin dose of I mg
( 100,000 EU) resulted in shock and multiple-organ dysfiuction
States I I 8], an approach that has been successfully used in other
in a patietrt [14]. The amounts of endotoxin present in the 3
units that were contaminated with gram-negative bacilli and
transfusion-associated adverse events and, thereby, to improve
flammatory
system for adverse events from blood product use in the United
countries to coordinate the recognition and documentation of
failure were
the overall safety of transfusions [19]
Although these trends are encouraging, the well-recognized
11,373 EU, 34,646 EU, and 182,700 EU, with such levels ex-
modalities currently in use to limit bacterial contamination of
were associated with septic shock and multiorgan
fable
3.
that holds considerable promise, with several manufacturers
working on a variety of methods [23]. Detection of endotoxin
by the limulus lysate method, although limited to detecting
glam-negative contaminants, would have detected all fatal cases
in our series. Based on our findings, successful implementation
ofthese solutions in the United States could prevent the tlansfusion of up to 900-1200 contaminated units annually, thus
avoiding 300-400 septic reactions and 6-20 deaths per year
Acknowledgments
W€ thank our clinicaland laboratoryservices,for their conkibutions(o
th€ @re of the patienb studied,and the Charl€sRiver Laboratories,for
providint the materialsused for endotoxind€termination.
Pokntial confidt of interat. M,RI. has receivedresearchsupport
fiom Gambro, H€mosystem,Immunetics,PaI, and Veril. R.A.Y has re@ivedresearchsupport ftom Pall,Gambro,Hemosyilems,and V€rd and
is an advisorto Verd, Imhunetics, GenPrim€,andPall.C.E.G.andH.M.L.i
no conflicts.
unil age
CIin Microbiol
8. Whilaker
utilization
Human
ofblood.omponens.
Rev 2005i l8:195-204.
Bl, SullMn
M. The 2005 nationwide
btood collection and
survey report. RockviUe, MD:
Serices,
osnbcsrpt.pdfl
Department of Health and
2005. Available at: h$p://w.aabb.org/apps/do6/
Accessed I May 2007.
9. Morrow
lF, Brain€ HG, Kickler TS, Ness PM, Dick lD, Fuller AK.
Septic reactions to platelet transfusionsr a persistent problem. JAMA
l99r;266:55H.
10. Ku€hnert Ml,
terial infeciion
Roth VR, Haley NR, et al. Transfusion{ransmittedbac,
in the United States, 1998 through 2000. Transtusion
2001i 4l:1493-9.
ll.
Eder AF, Kennedy rM, Dy BA, et al. Bacterial scre€ning ofapheresis
platelets and thc r€sidual risk ofseptic rransfuion reactions: theAmerien Red Cross experience (2004-2006). Transtusioaz0l7; 47 tt t3UL
I 2. van Eijk LT, Picklcrs B Smits P, Bouw MB van der Hofl€n lC. Sev€re
vagal rcsponse aher endotoxin adminisration
in humans. Inrensiv€
Care Med 200,1130r2279-81.
13. Casey LC, Balk RA, Bon€ RC. Plasma cytokine and €ndotoxin levels
corr€late with survival in patients with the sepsis slndrome. Ann lntern
Med 1993; I l9177l-8,
14. Taveira da Silva AM, Kaulbach HC, Chuidian FS, kmb€rr DR, Sufftedini AF, Danner RL. Brief report: shock and multiple-organ dy*
tunction
after self-adminhration
of Salmonella endotoxin.
N Engl I
Med 1993;328rI457J0.
15. kkstrom-Himes
JA, Gallin JL lmmunodeficiency
diseases cased by
defects in phagocytes. N Engl I Med 2000;343:1703-14.
16. American Assciation
of Blood Banks (AABB). Guidance on impl€mentation
of new bacteria and redu€tion
B€thesda, MD:
standard. Bulletin 04-07.
AABB, 2004.
17. McDonald
CB Roy A, Maha,an B Smilh R, Charlett A, Barbara,A.
Relative values of the interventions ofdiversion and imDrov€d donorarm dhinfection
to reduce th€ bacterial risk iiom blood transfusion.
Vox Sang 2Og;86:178-82.
Reterences
I. Niu MT, KnippenM, SimmonsL, HolnessLG.Transfhsion-transmitted
Klebsiellapneunoniae fatalities, 1995 to 2004. TransfusMed Rd
20n6i20t149-57.
2. BenjaminRl, WagnerSl. The residul riskof sepsisrmodelingtheeffect
of concentrationon bacterialdetectionin so-bottle culture systems
and an esimation of false-negative
culturerates.Transfusion2007;47:
l38t-9,
3. YomtovianP-{, PalavecinoEI- DysktraAH, et al. Evolution of sur
veillancemethodsfor ddection of bacterialcontaminationof platel€ts
in a university hospital, l99l through 2004. Transfsion 2006;46:
7 t9-30.
4. Zza S,Tokarsll, YomtovianR, et al. Bacterialcontaminationofplate-
Bacterial count
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BacterialContaminationof Plat€leb . CID 2008:46(15 April) . l2l9
2OO7i47:621-4.
I8. Kaplan H. Safer design. Transfuior
(Continue.l.)
5 days
criteria for adv€rse
1220・CID 2008:46(lS Ap日 )。,acobs et al
2OO7;471758-9.
19. Lundy
D, Laspina S, Kaplan H, Rabin Fastman B, Lawlor E. Seven
hundred and 6ry-nin€ (759) chances to learn: a 3-year pilot project
to analyse transfusion-related
near-miss events in the Republic oflre-
land. Vox Sang 2007;92:233J1.
20. Prowe
C. Z€ro rolerance. Transfusion 2007;47:1106-9.
21. Yomtovian R, Tomasulo B lacobs MR. Plateletbacterialcontaminarion:
assessing progress and identiryi ng quand.ries in a rapidly wolving 6eld.
Transfusion 2007i47:1340{.
22. N6sbaumer
W A)lesdorfer D, GrabDs C, et al. Pr€v€ntion of rransfusion ofplatelet components contaminated with low levels ofbacteria:
a comparison
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23. Palavecino EL, Yomtovian RA, lacobs MR. Deteding bacrerial contamination in platelet producis. Clin Lab 2006i52:443-56.
υｏモＬ ｏ”αｏα い０ヨ ，¨
Ｃ 、ぉ こ ｏ×♂ 員とｏｃヨ Ｌ ∽９ 嗅 ２ ｏｏ■ ８ 一”ざ Ｒ 〓 詠 ●ａ ● ｏ● ＞費 〓 Ｐ ０９ い
terial species,particularly gram-negativebacilli,andhigherbacassociated with both the occur-
in the United States in the next few years [22]. The rhird solution is an at-issue bacterial-detection method, an approach
would have deteded >950lo of all cses and >90% of all reactions, whereas all cases would have been d.etectedat )02 cful
although regulatory ap-
terminology
7. Brecher ME, Hay SN. Bacterial contamination
proval has been received in Europe, this is not likely to occur
addition, a method with a detection threshold of 101 cfu/ml
and the occurrence and swerity of
transfusion reactions (figure I and table 3). More-virulent bacterial loads were sigrificantly
the need for bactedal detection, od
一絆 Ｎｏ８
υ Ｏそユ 勲 ¨
α００ い０日 〓 ‘ ヽ ｏ〓 ｏｘ♂ 興とｏｃヨ ２ いｏ﹁ヽ ２ ０ｏ●●Ｌ ”δｏユ 〓 ∽〓ビ お ０” ＞ ０﹃一
administration,
the culture at a later time [21]. However, increasing the volume cultured results in only a modest increase
in detection rates of -259o [2]. The second proposed solution
is to use pathogen inactivation technology, which also obviates
Cancer Institute. Common
events v3.0. Belhesda, MD: National lDstitutes of Health, 2006.
6. Sanders RB Geigcr TL, H€ddle N, Pui CH, Howard SC. A revised
classification scheme for acute trahsfusion reactions, Transfusion
or performing
bacterial load that differentiated between the occurretrce and
aerobic incubation, which would have missed obligate anaer-
leb at a university hospital: increased identificarion due to intensined
surveillance. Infect Crntrol Hosp Epid€miol t99{; l5:82-7.
5. National
(別紙2-参 考文献②)
BL0011 0011PONENTS
A laboratory comparison of pathogen reduction technology
treatment and culture of platelet products for addressing
bacterial contamination concerns
Raymond P Goodrich, Denise Gilmour, Nick Houenga, and Shawn D. Keil
BACKGROUND:Concernsover the risk ot baclerial
contamjnationof plateletproductshave led to implemenlalionof bacleria cultureand other screening
methods.New approachesfor dealingwith this issue
have also been oroDosed.
STUDYDESIGNAND METHODS;A directcomparison
of treatmentwith ribotlavinand ultraviolet(UV) light
pathogenreductiontechnologyIPRT] system)
(N,lirasol
versusbacterialculture tesling (two-bottlesyslem,
48-hourquarantine)was undertakenlo comparetheir
etfectiveness.Thirteen clinicallyrelevantbacterial
organisms(20 strains) were used in this evaluation.
Flesultswere comparedwith spiking levelsat 20 to 100
colony-fomingunits (CFUs)per productand al less
than 20 CFUs Der Droducl.
RESULTS:At spikinglevelsof 20 to 100CFUSper
product,the riboflavinand UV light processdemonstrated91% effectivenessagainsta broad spectrumof
bacteria-In comDarison.lhe culturemethod demonsiEted an ability to detect up to 917oof the same
conlaminanls,when used in the two-bottle,48-hour-toreleaseconfiguration.At lower initialtiters of contaminatingagents (<20 CFUs per product),lhe etfectiveness
of PRT increasedto 98% whereasthe culture melhod
eflectivenessdecreasedto 66%. Eftectivenessot lhe
culturemethodturther decreasedto 607. when a onebottlesystem was used.
CONCLUSION:The resullsfrom this work suggestthat
the riboflavinand UV light processmay provideup to
98% prolectionagainst lransfusionol bacteriallycontaminatedunits at the most clinicallyrelevantcontamination levels (<20 CFUs per product).This compares
lavorablyto the 60% lo 66% ettectivenessof bacterial
culturetesting using a 48-hourquarantineperiodbefore
productrelease.
acterial contamination of platelet (PLt) products has been identifiedas one of the most significant risks associated with the transfusion
of blood components,reportedlyoccurring at
levelsas high as l:2000to l:3000donatedproducts.r3The
stomge ofPLI products at room temperaturefor extended
periods of time provides a medium and a condition of
storage that can sustain bacterial growth, Product contamination at the time of collection is typically from rhe
donoq although contamination from external sources has
been reported. Even though the contamination levels of
bacteria are believed to be extremely low bacteria can
proliferate to high titers beforc trilsfusion.as The inability
to detect these low levels of bacteria at collection can
result in severe consequences to PLI transfusion recipients md include morbidity and fatal reactions. Given the
frequency of bacterial contamination, the AABB promulgated a new Standard effective March 1, 2004,mandating
the implementation ofmethods to detect and r€duce bacteria in PLI units.6
The implementation of PLI product screening has
been successfulin identilying contaminated products and
reducing their trmsfusion into patients.T'r3The level of
success that has been observed varies in accordance with
the rechnique thar is utilized and has severallogistic consequences. Because the level of bacteria present at the
time ofPLT donation is low detection is limited by several
factors, including the initial titer of bacteia, the size and
ABBREVIATION: PRT = pathogen reduction technology.
Froin CaridianBCT B,otcchnolojes,LLC,Lakewood,Colorado
ス″ “
θ
ss′̀′″″′″クレ0お ":Raンmond P Goodrich,PhD,
ChieF Science OmceL caridianBCT B,otechnologies,LLC,1215
Quau street,Lakewood,C080215e― maiL raygoodrich@
carldianbct com
RecciVed
f o r p u b l i c a t i o n F e b sr iu oa nr y
received December 17,2008,and accepted December 20,2008
d o i : 1 0 1 1,1115′3 27 9‐9 5 2 0 0 9 0 2 1 2 6 x
コ&知NSFuS10N 2009:49:1205‐
1216
Volume 49,」une 2009 TRANSFuSiON 1205
13,2008:re●
GOODRICH ET AL
timing of the test sample, and the growth kinetics of the
specific bacterial species.Low levelsofbacteria at thetime
of donation, particularly for slow-growing organisms.
pose a challengefor most culture methods.r0r2
To compensate for these factors, a postdonation
product incubation before sampling and increased
sample volumes for testing were evaluated.'aWhile these
methods do increasethe sensitivityof the detection of
contaminated units, they requirc an additional prerclease
storage interyai jn which products are held before testing
and then subsequentlyheld for an additional period after
sample is withdrawn to allow detectionof contaminated
units. This rnay result in as much as a 48-hour reduction
in the initial storageperiod, a period in which product
quality may be at a maimum, althoughthe intent was to
increasethe storageinterval for an additional 2 days to
compensate for the testing period before release.r{r5
Becausemost PLI products in rcutine use historicallyare
used within a 48- to 72-hour period of collection, this
change in pmctice could representa major shift in possible clinical experiencenecessitatedby the additional
r6rT
culture time requirements.r3
An a.lternativeapproach that has been proposed for
assuringa decreasein the transfusionof PLI units contaminated with bacteria has been the use of pathogen
reduction technology (PRT). Severalof these methods are
currently in development or in actual clinical use in
Europe.rs2rThe technologiesare basedon the use ofphotochemical agents, which can be activated by ultraviolet
(UV) light in specific spectral regions md then carry out
chemical modifications to DNA and RNA that prevent
their subsequent replication." These modifications in
essencerenderbacterialagentspresentin these products
incapable of growth during storage and thus also incapable of causing complications after transfusion,
The challenge for PRT methods, unlike that of bacterial detection, are not low titer levels that are present at
donatlon, but rather higher titer challenges that may
develop during storage.For PRTto be efective at preventing transfusion of units that may cause complications in
this regard, it must be able to effectively prevent growth of
lowlevels ofcontaminatingbacteria, which may be present
soon after donation. The inability of these techniques to
perform adequately in this fashion might lead to subsequent growthofbacteriaduringstorage.
BecausegroMh of
bacteria may lead to the formation ofpyrogenic agentsand
endotoxin,inactivationof productsat time intervalsconsiderably after collection would likely be ineffective in
preventing pyrogen- or endotoxin-mediated clinical reactions. As a result, these methods arc usua.llycarried out at
shortinterualsaftercollection(e.9.,<22hrin the caseofthe
riboflavin and UV light system specifications).
This study was undertaken to assessin a laboratory
setting the ability ofthe dboflavin and ItV light processto
inactivate bacteda in products sumciently soon after col1206 TRANSFUSIONVolume49. June 2009
RIBOFLAVIN AND UV LIGHT VS BACTER:AL CULTURE TEST:NG IN PLT PRODuCTS
lection to prevent growth of the bacteria during subsequent storage. Results from this work were compared
directly to a culture method using a sumcient postcollection, presampling incubation period (24 hr) and postsampling detection window (24 hr) to assure the detection of
low levels of contamination in spiked prcducts. Comparisons were then made between the ability of the PRT
method to inactivate bacteria spiked into these smples
with the ability to detect lowlevels ofthese agentsafterthe
appropriate presample and postsample culturc times.
MATEBIALS
AND METHODS
A panel of organisms identified in prior hemovigilance
programs was selectedfor evaluation in this study.r3These
included the following speci.es'.Staphylococcusepidermiclis, Staphylococcus auteus, Propinnibacterium rcnes,
Streptococcusmitt, Streptococcusagalactrre, Streptococcw pyogenes,Serrutia marcescerc,Acinetobacterbaumannii, Yersiniaenterocolitica, Bacillw cereas(spore-forming
agent), Escherichia coli, Enterobacter cloame, and Klebsiellapneumoniae. Multiple strains of both S.epidermidis
and S.aure6 were tested: five strains ofS. aurem and four
strains of S. epidermidis. Severalgroups identified these
organisms to be of interest,2a26A minimum of three repli,
cates for each bacterial strain were tested in independent
spiking studies. Although identified as an organism of
interest, Prouid,enciarettgeriwas nottested in this study.
The range of contaminating bacteria used for this
studywas between 1 md 100colony-forming units (CFUs)
per product. Bacteria were grom in a nutrient broth for
up to 36 hours, after which time they were centrifuged,
concentrated, and then resuspendedin a minimal nutrient medium. Bacteria stock culture concentntions were
determined through the use of an endpoint plating
scheme for all organisms excepl P acnes and B. cercus.
Bacteria cultures were stored at 4'C until they were ready
to be used. An endpoint plating scheme was not used to
determine the stock culture titer of P acnes and B. cereus
due to the relative instability of these organisms when
stored at 4'C; instead, historical data were used to estimate the titer of the culture md the organism was used on
the day it was harvested. Inoculating doses were determined mathematically using the initial culture titer value.
Results from actual clinical experience with detection
times and growth curues for these organisms in culturc
suggestthat this level of contamination is consistent with
actual clinical experience.132T-30
Notable exceptions with
regard to the spike titer limirs were B. c€reusat 103 CFUS
per product and P acnesat 596 CFUSper product. The B.
cereus titet was an unintended resu.lt; howevei it was
determined the 103CFUs per product value was within
the mnge of experimental error used to measure the titer
of the stock culture. It also represented a worst-case
scenario for riboflavin and UV light-trcated units given
the I to 100 CFUSper product range this study was investigating. The initial titer for P acnes was increased to
ensure that an adequate amount of organism would be
present at Day 7 so that it could be detected in the positive
control.
General study design
Figurc I provides a diagram of the overall study design
utilized in this work. A direct comparison of the riboflavin
and ItVlight processto bacterial screeningwas performed
using double PLI units. Each incoming double PLT
product was split into 2 units and each unit was inoculated with a clinically relevant bacterial dose. This was
done to allow ample volumes to be available for each test
condition. One unit was treated with the riboflavin and
UV light process according to methods described previously while the other unit underuent bacterial screening
using a culture method.3rThe volume of the unit used for
culture was maintained at 280 mL on averageto simulate
mean product volumes experienced in the clinical setting.
For the riboflavin and UV light treatment, the units had
on averagea final volume of225 mL. Additionally, a small
volume of the original double PLI product (before inoculation with bacteria) was set aside md allowed to incubate
at 22C for 7 days. The smple serued as the negative
control. This was the study design that was followed when
Gram-positive bacteria were tested. However, due to the
susceptibility of Gram-negative bacteria to complement
activity found in plasma-derived products, heat treatment
was used to deplete the native complement activity. For
Gram-negative bacteria, each incoming double PLI
product was centrifuged and the non-complementdepleted plasma was expressed ofl. Pooled, recovered
human AB+ plasma was heat treated at 56"C for 45
minutes in a water bath and clarified via centrifugation to
remove any precipitate. The PLIs werc then resuspended
in a comparable amount of complement-depleted recovered human AB+ plasma and allowed to rest overnight.
Becausemany organismscan be inactivatedby complement, this process assured that we were evaluating a
worst-case situadon, which promoted optimal growth
conditions.AJIwork, not including collectionof the apheresisPLTS,took place at CaridianBCTBiotechnologies
(Lakewood,CO).
Bacteria culture testing
The bacterial screening procedure utilized here involved
incubating all collected PLTSfor 24 hours at 22"C on a
Fig. l. Study diagram overview. The figure deptcts the general smpling
md treatment schemes usd for both the bacteria culture
testing md rlboflavln md UV llght trcatment dms of the study.
Volume 49」 une 2009 TRANSFuS10N 1207
G00DRICH ET AL
PLT shaker before sampling to allow growth of contaminantsto high enough titers to incr€asethe probability of detection in small-volume samples.The specific
sampling protocol followed was consistent with the recprotocol, which was
ommendations of the PASSPORT
under evaluation in the United States as a method for
reducing transfusion of bacterially contaminated products stored for up to 7 days.'nThis protocol was ctrried
out according to the following procedure: After 24 hours
of incubation, l0 individual B mL samples were withdram from each unit and two 4 mL aliquots from each
sample were inoculated into two bottles (aerobic and
anaerobic media, BaCT/ALERT, bioMdrieu, Durham,
NC) respectively.These individual samples were used to
represent multiple sampling events. In the PASSPORT
protocol, if the product remained negative after 24 hours
of monitoring (after 24 hr of storagepresampling; total of
48 hr), it was released for transfusion; however, monitoring for bacterial contamination continued lor 7 days to
allow an increased sensitivity to detect organisms later in
storage that may have been at too low a titer level to
detect earlier. This same approach was utilized in this
study plan. The l0 sample pairs withdraM from each
unit were considered as 10 individual sampling events.
Paired bottles that did not test positive during monitoring were considercd as a failure to detect- The data
were also reanalyzed to simulate the effectiveness of the
procedure when only a single 4-mL aerobic bottle was
used.
After sampling, the remaining PLI units were placed
back into the PLT incubator at 22'C for an additional 6
days.An aliquot from each product was then sampled at
Day 7 as a positive growth control for the paired PLI pruducts. Inoculated bottles were then monitored for a period
of 7 days after sampling. Any negatives that would have
been obseryed during this period would have eliminated
paired bacterial screening and riboflavin and IIV lightlreated units from the frnal data analysisdue to a failure of
the organism to proliferate in the positive control. There
were no positivecontrol units in any of the studieswhere
the inoculated organism failed to survive. The positive
controlwas alsotestedfor the 7-daybacterialload using a
conventionalendpoint dilution-platingmethod with agar
plates.
PRT-treated units
Each unit of rhe split double collection was spiked with I
to 100 oryanisms, incubated for a minimum of 2 hours
after spiking, and then treated according to the riboflavin
and UV light method for PLTS(Mirasol PRT process, Car.
entire unit was
idianBCT)as describedpreviously.3rThis
then placed into incubation at 22"C tnder standil'd PLI
storage conditions for 7 days. At the end of the 7-day
period, an 8-mL sample was removed and placed into
1208 TRANSFUSIONVolume49, June2009
R:80FLAV:N AND UV L:GHT VS BACTERIAL CuLTURE TESTING lN PLT PRODuCTS
culture using the method described above. lnoculated
bottles were then monitored for a period of 7 days after
sampling. Any positives observed during this period were
counted as a positive event.
Test inclusion requirements
The following requirementshad to be met or paired PLi
units were removed from the study and a replacement pair
used:
The collected double PLI product must have had a
PLI concentration range of 1180 x 103to 2100 x 103cells
per pL and a volume greater than 480 mL. Apheresis
double PLI units were collected using the CaridianBcT
Trima Accel platform. PLIs were allowed to rest 2 hours
before manipulation.
.
.
.
The negative control must have remained negative
for bacterial growth.
The positive control must have been positive for bacterial growth.
The bacterial load dosed to each unit must have been
between I and 100 CFUSper product as determined
by an independent culture ild titer determination,
which involved titering of the actual dilution used to
spike the product. Exceptionswith regild to the spike
titer limits were 8. cereuJat 103CFUs per product and
P acnes at 596 CFUSper product.
Determination of overall etticacy
For the determination of overall performance, the contamination frequency reported in hemovigilance studies
wasused to ca.lculatethe expected clinical performance of
theproduct.23For this calculation, the overa.lleffectiveness
ofthe method for detecting (culture method) or inactivating (PRT method) the species present was multiplied by
the occurrence frequency reported in the literaturc. For
multiple strains of the same organism, overall mean
values for all strains were used to estimate effectiveness
for that particular species.This multiple thus provides a
rough estimate of the potential ability of each method to
interdict a proportion of the expected contamination
eventsin the clinical setting: Occurrences= Reports from
hemovigilance studies of the number of casesobserved,
Frequency = Occurrences of this individual species nolmalized for total number of reported events,and % Effectiveness= Ability to detect or to inactivate the particular
agent.Each sample was evaluated in a minimum ofthree
separatereplicate spiking experiments for each strain ofa
given species ofbacteria; Overall effectiveness= The multiple of the % Effectivenesswith the Frequency of Occurrence for this agent reported in the cited hemovigilance
studies.
RESULTS
Ar overall summary of bacteria testing results is provided
in Table l. A total of 29 separate studies were conducted
with at leastthree replicates for each sftain tesred.Emphasis was placed on organisms according to the prevalence
reported in published hemovigilance studies to simulate
actual clinical experience as much as possible.a Table 2
shows a comparison of overa[ efncacy of the culture and
PRTmethods evaluated in this study at spiking levels of20
to 100 CFUSper product.
Both the culture method md the riboflavin and UV
light treatment demonstrated 9l% effectivenessat detection or inactivation respectively,when culturc testing was
pedormed using the two-botde, 48-hour-to-release
method, These results appear to be within the ranges of
clinical observations for culture detection methods
sampling and incubation techemploying similil
niques.ra2e'30
At lower levels of contamination (<20 CFUS
per product), the effectiveness of the riboflavin md UV
light heatment increased to 98% (Table3), whereas the
culture method decreasedto 66% (Table4), which is more
consistent with clinical obseruations, possibly suggesting
that actual clinica.l contamination levels are more frequently in this range. Using a one-bottle method, the
effecdveness of the culture method under these conditions decreased further to 607. (Table5). As one might
expect, the culture method showed a reduced abiljry
to capture a contaminant when the sample titer is lower,
making detection less likely, while the ability of a PRT
method to achieve complete inactivation increased at
lower bacteria levels(seeFig. 2).
Several agents were not uniformly detected by the
culture method employed in this study. Not unexpectedly, these ile primarily organisms exhibiting a slow
growth rate at 22"C. Such behavior makes detection by a
culture method difficult due to the inability to obtain an
adequate bacterial inoculum for culture detection. In this
study, any detection that occuned in the bacteria culture
arm of the study was counted as a positive detection
event, even if this occurred outside ofthe 24-hour release
window with the exception oI P acne\ which took
TABLE 1. A summarytable ot orqanismsthat were evaluatedin thls studv'
cunure lmO unt‖
inocu um lter
7‐
day poslive growth
Organ sm type
Gram(″
deteclon(mean hrl
(CFus/prOducl)
oOntr0 1ler(CFUymし
)
ATCC numbo「
)
ス bawη
ann″
17961
76=11
61
36xlび
179611
A. baumannii
B. cercus
65× 1び
E. cloacae
29005+
E. cloa@e
E. coli
27× 1び
K. pneumoniae
P acnes
S. hat@s@ns
S. aureus
292131
S. aureus
S. aurcus
S. aureus
25923+
S, aurcus
16× 1び
S. aureus
700787+
S, aufeus
S. aureus
272171
S- aurcui
S. epidermidis
12228+
S. epidemidis
S. opidetmidis
29xlび
S. epidetmidis
700578す
S. epidetmidis
S. epidemidis
S. agalactiae
700D46+
S. agalactiae
S. milis
S. pyogenes
Y. enlerocolitica
' These
agenls were selected from the reports of several hemovigilancestudies (BACON, BacTHEl\4,SHOT), which providedestimales ol
lhe lypes and frequency of contaminafionof PLT producls wilh bacleria. Several slrains of predominantorganisms wsre used to represenl
po$ible variaiion in the nature ot lhe @ntaminants and test the ellectiveness tor both lhe culture and the inaclivationhethod as a tunction ot the strain wilhin a given bacterialspecies. Incubation lim€s after inoculaiionof culturs bollles to deteiion using the BaCT/ALERT
method are lislgd as well as the tinal tile6 measured at Day 7 of incubalion ol the posilive contrcl producls.
t Samples tested at less than 20 CFUS per product.
r = positive; - = negative; NA = nol applicabl€;NT = not tested.
Voume 49,」 une 2009 TRANSFuSION 1209
GOODRICH ET AL
R:BOFLAVIN AND UV LIGHT VS BACTER!AL CuLTURE TEST:NG IN PLT PRODUCTS
T A B L E 2 A s u m m a r y t a b l e f o r c o m p a r i s o n a n d c a l c u l ae tf ti oc na c oy l o of vt eh re a ‖
twO methods used in this
study(PRT and culture)'
% Elfectiveness
Cullure
Mirasol
ATCC number
Occuffences
Overall eflecliveness
Mirasol
Cullure
E. coli
B. cereus
S. aurcus
・ /.Frequency
33
'ep
organism
demldls
ATCC number
12228・
27
700046
6249
BAA 1064
29005
9
1oo
1oo
1oo
1oo
8
1OO
100
２
６
６
100
100
Eflecilvoness:
２
43A62
8045
３
S agalacrlae
S"′ lls
S ρノogelles
ε α
οa c a θ
P acnes
S. mar@scens
K. Dneumoniae
A. baumannii
Y. entelocolitia
cunure method
ec‖
veness
Overal ereclveness
%E“
５
A. baumannii
Y. entetucolitica
20
０
S. agalactiae
S. mitls
S. pyogenes
E. cloacae
P acnes
S. marcescens
Occurrences
７
80
B3
g7
87
100
100
90
90
100
97
100
100
100
100
100
0
100
100
. 100
100
Ettectiveness:
S. epidemidis
TABLE 4. Summary lable lor culture method eftecliveness usino two-botile culture method
Results demonskale the reduced ability lO detecl these organisms, likely due to the lower initial lite6 presenl al the 24-hour sampling lime
tDint. Occur€ncos = Repods from hemovigilance sludies of the number of cases obsetoedt Frequency = Occu(ences of this individual
species normalizedfor total number of reporled evenls; o/oEffeclivenoss= Abilily to dotect or to inactrvatethe padicular agent. Each sampte
was evaluated in a mjnimum of three separate replicale spiking expeimenls lor each slrain of a given species ol bacteria.Overall
effectiveness= the multiple of lhe 7" Etfeciivenesswilh the Frequencyof Occuiience lor this agent repoded in the citsd hemovigitance
studies.
' Samples
lested al less than 20 CFUS per product.
'Allsampleswerespikedat20to'l00CFUSperprodlctiniliallywilheachoflhespecissindicated.Occuren@s=Reporlsfromhemovigilance sludies of lhe number ol cases obseNed; Frequency= Occ!trences ol lhis individualspecies normalizedfor tolal number of repod€d
evenls; 7" Ellecliveness= Ability to detecl or to inactivale Ihe pariicularagenl. Each sample was ovaluatedin a minimum of ihree separate
replicate spiking experimenls for each slrain of a given species ol bacteda. Overall ettectiveness= lhe multiple of the o/oEff@tivenesswith
the Frequencyof Occ!trence for lhis agent r6poded in lhe cited hemovigilancesludios.
TABLE 5, Summary table lor culture method eltectiveness usinq one-bottle (aerobic) culture method
Culture method
０
２
Occurrences
８
７
６
TABLE 3 Summarv table for ribof!avin and uV:Ioht effecJveness
70 Frequenry
ATCC number
12228'
Organism
S"ldemfdls
a cereυs
N!‐
0001
13
loo
５
ATCC number
っldls
%EfFeclveness
12228
Overan ereclveness
100
33
４
Ottan sm
S eplde′
%Frequency
33
Occurrences
20
３
S agalaclraθ
Sm″ ls
Sp/09enes
こcloacaο
700046
6249
BAA 1064
29005
1oo
93
1oo
1oo
３
２
１
１
S, mrces@ns
K. pneumoniae
Y. enterocolitica
０ ∞ ∞ ∞ ∞ ∞ ∞ ∞ ∞
∞ ５
S. agalaciae
S. mil6
S. pyogenes
E. cloacae
100
66
100
Eflectivene6
' Samples tested at less than 20 CFUS per producl
significantly longer to detect (Table1). As the data in
Table 1 suggest, thjs window may be inadequate for
several of the slow growing organisms given that mean
detection times for several strains of S. epidermidis were
on the order of l9 to 23 hours and well beyond this value
for P rcnes (107 hr). The late positives detected in the
1210 TRANSFUSION
Volume49,June2009
case of P acnes were not included in the effectiveness
sums that are reported here.
Agents not uniformly inactivated by the PRT method
employed in this evaluation included S. aureus and A.
baumannii. Interestingly, separatehigh spike titer studies
with A. baumannii and S. aureus (data not shown) have
4 ba″ "an″″
17961
100
' Samples lesled al less than 20 CFUS per product
demonstrated the ability to inactivate up to 2.6 and
3.6 logs/ml of these agents. For the culture method, A.
baumannii was more readily detected due to its rapid
growth chnacteristics. This obseruation raises the point
that the effectiyenessof eliminating bacteria contamination also needs to consider the tJ,?e oforgmism involved,
as some Gram-negative species tend to be of greater
concern in terms of potential adverse outcomes in
patients. For this particulil Gram-negative species (A.
baumannil, however, no fatalities were observed in the
hemovigilance programs referenced above.z3Thisanalysis
is not capable of taling clinical outcomes into full
account.
Surprisingly, a spore-forming agent tested in this
stldy, B. cereus,did show complete inactivation in the
PRT-treatedsamples, suggestingthat the ability to inactivate this class of agents in general may be dependent on
the levels of spores that are present in the product at the
time of treatment and not on whether the agent can be
classified as spore-forming. The culture method consistently failed to detect P acnes even at the higher spiking
levels studied. ln all other caseswhere failures occuffed,
partial efficacy was demonstrated wjth either the bacterial
detection or PRT method.
DiSCuSsloN
The results from this study allow comparisOn Of the
ribofla宙
n and uV light PRT method for pathogen reduc‐
tion Of PLT prOducts and the bacterial culture method for
Volume 49」 une 2009 TRANSFuS10N 1211
GOODRICH ET AL
RIBOFLAVIN AND uV L:GHT VS BACTER!AL CuLTURE TESTING:N PLT PRODuCTS
０ ０ ０ Ｃ Ｏ ＞ 〓 ０ ０ いｈ り 。
か
ヽ
5.15
cFU
20-103
CFU
Flg. 2, lllustration ofthe effectiveness
ofPRT (a) versusbacteria culture testing(D at two bacterlalcontamlnatlonlevels.
Shadedareareflectsreportedeffectiveness
ofbacteria culture
methodsin routine clinical use.Iar'3o
detection of bacteria contaminatjon in PLI products.
Not surprisingly, the bacterial culture method requires
extended incubation times ofthe product before and after
sampling to increase,thelikelihood of detection events.
Such a requirement may quariltine PLISwhen they ile at
the height of their clinical performance. Although studies
have shom that PLls stored for an extended period to
compensate for this time loss during quarantine exhibit
similar in vivo recovery and survival properties, there is a
paucity of information concerning the clinical performmce of these products when they ae used in the routine
treatment of patients with thrombocytopenia.3'z Little
information is available on the performance ofthese older
products relative to count increments, transfusion frequency, transfusion requirements, and efficacy in preventing bleeding.3'?Thedata that are available in this
regard demonstrate reduced levels of corrected count
increment values for products stored for extended time,
dependenton the storagemedium utilized.33-3?
The PRT methods that have been proposed also have
the potential to affect PLI quality and performance. Their
propensity to alter cell metabolic and activation properties as measured in vitro has been well documented in the
literature.3r'38
Recoveryand survival studies of these products also demonstrate differences rclative to untreated
contrcls at the same time point jn storage,although these
1212 TRANSFUSION
Volume49.June2009
valuesfall within the limits establishedforhistorical products currently in routine clinical use.3sThese products
have also been evaluatedin randomized prospectiveclinical studiesfor sevemlofthe parameterslistedabove.r?.re20
For riboflavin md UVlight-treated products, clinical data
obtained in a randomized, prospective, blinded clinical
study demonstrated that there was no change in PLI or
red cell transfusion rcquirements and no increase in
bleeding or adverse events in thrombocltopenic patients
receiving PRT-treated PLT products as compared to
patients receiving untreated products.oo
Proof of the efficacy of a PRT method in the clinical
setting would require tens of thousands of samples in
order to establish the ability of the procedure to prevent
transfusion of bacterially contaminated units. Some
authors have suggestedthat the lack ofsuch data justifies
not implementing PRT methods in clinical settings.arThis
seems,however, to be a circular argument in that such
data will not be available until these methods are more
rcutinely applied in the clinical setting and appropriate
analysescan be caried out. Since such a condition does
not presently exist, we undertook this study to evaluate
the effectivenessof the process for inactivating the most
commonly identified bacterial species from several
hemovigilance reports on contamination of PLI products
with bacteria. A direct comparison with bacterial culture
methods was employed to compare effectivenesslevels
and provide a referencewith current practices designedto
decrease transfusion of bacterially contaminated PLI
Products.
The effectivenessof both methods was compared for
two diferent levels of bacterial contamination: less than
20 CFUs per product and 20 to 100 CFUS per product. At
the higher contamination levels, equivalent performance
(91% effectiveness) was observed for the two methods
studied here when bacteria detection was performed
using a two-bottle method with 24-hour incubation and
a 24-hour minimum culture period. I{owever, at lower
initial bacteria tite6 (<20 CFUSper product), the dboflavin and UV light procedure (performed on the day of collection) demonstrated signifi ciltly greater effectiveness
as compared to bacteria cu.lture using the methods
describedhere, that is, 9B%versus 66%. Interestingly,outcomes reported from larger-scale clinical evaluations of
bacteria culture performance in detecting md abrogating
tmnsfusion of bacterially contaminated units suggest
that these methods are only about 50% to 70% effective
(seeFig.2). This has been reported by Dumont and colleagues,taBeniamin and colleagues,'?s
and Foley and colleagues3o
based on extensive routine use experiencewith
bacteria culture methods. The approach usedby Foley and
colleagues involved holding apheresis products only 12
hours before culture and thus may explain the lower
detection rates reported in that study. A similar performance is also predicted based on modeling of available
data from several sources.42lvhen combined with these
reported findings and as suggested by Eder and costudy,tathe
workers13and with results from the PASSPORT
resultsfrom our study indirectly confirm that contminating events ae likely to occur at levels ofless than 20 CFUs
per product and hence that the outcomes for this range of
bacteria titers may be the most clinically relevmt.
lt is important to point out that the bacterial detection method used in our study involved a two-bottle
culture method with a 24-hour postcollection sampling
period and a z4-hotr postsampling culture period (total
of 48-hr quarantine). Not a.ll culture methods currently
in use in the routine clinical pnctice employ this
44Reduction in the amount ofsample tested
approach.r3'{3
(one bottle vs. two bottles) or reduction in the presampling hold time or the postsampling culture time to
release are likely to significantly decrease the ability of
culture methods to detect .contaminated units. The
outcome for bacteria detection efacacy in our study (66%
effectiveness) is comparable to actual observations
made in the clinical setting (approx. 5070-7070effectiveness).ro'?q$
Our results indeed demonstrated that the bacteda detection effectiveness dropped from 66% to 60%
when using only a one-bottle test.
The data contained in this reDort also provide evidence that neither method may b" e*pecrei (o provide
100% protection against all septic transfusion events.
Given that all contaminated units do not lead to sepsis,45
the frequency of significant clinical events that are
obsened should decrease dramatically with a PRT
method in place.
The reason for failures in the case of the bacterial
detection system seemsclearlybased on the groMh kinetics ofthe organisms employed and the titer ofthe bacteria
that are present in these preparations. Lower titers of
slow-growing orgmisms at donation are not only harder
to detect initially, but also less likely to reach detection
limits during quarantine.
In the case of PRT-treated products, the reasons for
failures ile less clear. It would be reasonable to assume
that low tite$ ofa given species present during treatment
(20-100CFUSper product) should easily be inactivated by
these techniques given results from high-titer studies,
which report efficacy levels exceeding 4 to 6 log/ml
(equivalent of 300 million CFUs per product for a 300-mL
product). The results in this work suggestthat this is not
the case. Some suggestion for a possible mechanism of
action here comes from the work of Clawson andWhite,a6
who described as long as 30 years ago the propensity for
certain species of bacteria to interact with PLI surfaces,
primarily through protein A receptors, We speculate that
the possible adherence or engulfment of cenain bacterial
strains by PI-:ISvia these t)?es of mechanisms may act as a
shield to sensitizer uptale and light exposure, affording
prolection of these agents against the PRT method being
applied. If such is the case, a conelation should exist
between the ability of these organisms to interact with
PLIS via these mechanisms and their ability to be inactivated to completion even at low spike titers, where a larger
proportion of the population may actually be bound.
lnternal studies conducted separately using these species
spiked into plasma products (no PLIs present)demonstrate complete inactivation, consistent with this possible
mechanism (data not shoM).
It is also possible that interactions with other bacteria
at higher concentmtions create shielding effects against
treatment. One may also not rule out the potential ofbacteria defense mechanisms against PRTtreatment. Regardless of the precise mechanism involved, the results do
suggest that inactivation of the larger proportion of free
organisms may provide an inadequate or incomplete
picture ofthe ability to maintain culture negativeproducts
during storage.
Similar concerns ile also present when addressing
spore-forming bacteria in their spore form. These agents
would be expected to be naturally highly impermeable to
photosensitizers and thus resistant to these treatments.
If such is the case, this work has profound implications
regarding appropriate methods for evaluating rhe etrectiveness of both PRT trcatment methods and bacteria
detection methods. Because these properties may vary
from strain to strain within a given species of bacteria,
it would be important for such work to employ several
strains oftest organisms and not extmpolate resultsfrom a
single strain to cover all strains within a given species.
Such was the case for several organisms studied in this
work where results vilied as a function of strain within a
given species of the same organism. As demonstnted by
the results ofthis work, selection ofa particular strain with
low inrer4ction potential could provide a false estimate
of inactivation efficacy extrapolated to all other strains.
Detection methods mpy also be biased in a similar fashion
depending on the presence or absence of cellular agents
in the testing matrix dudng culture or detection. Clearly
the particular strains seen clinically wonld appear to be
those most relevant for this type ofanalysis. Likewise, the
use of high-titer spike studies alone for demonstrating
efacacy against bacteria in general can be only a partial
and potentially misleading estimation of clinical efficacy,
given that this is far removed from the actual clinica.lexperience with regard to contamination levels in donated
products at the point at which PRT methods may be practically and appropriately applied. Inactivation of high
tite6 would also seem clinically irrelevant ifaccompanied
by high endotoxin levels that ile not reduced by these
processes, which, upon infusion, can generate severe
reactions even in the absence of viable bacteria.
The work of Nussbaumer and coworkersaTwith an
alternative, approved PRT system describes 100%emcacy
ofthe Drocessfor all ofthe clinical strains that were tested.
Volume 49」 une 2009 TRANSFuS:ON 1213
G00DRiCH ET AL
The use of clinical strains isolated ftom contaminated
blood samplesmay afford samplesthat are more relevant
to the actual clinicalsetting,but the ability to demonstrate
reproducibleresultswith such strains,due to their limited
characterization and availability, is often constrained. As
suggestedfrom our work as well, the use of single stnins
of a given organism may provide a false sense of overall
effectiveness for a given species of bacteria. The use of
multiple strains, as demonstrated here, may yield variable
results. Prowsea3described several concerns with the
approach utilized in prior malyses of the effectivenessof
inactivation with other PRT methods. This included the
lack of a positive control. In this study, samples which
failed to grow in the positive control caused the elimination of both samples from the test and control groups
from the study population as it would be impossible to
determine if inactivation had occurred due to the treatment process or if the bacteria were simply inactivated by
complement or other blood product componentsalqne,
not directly associated with the treatment method. In
addition, in this study, for Gram'negative bacteria, which
are known to be sensitiveto complement,we eliminated
the possibility of bacteria elimination by complement
action alone through heat inactivation of test sample
plasma before spiking with bacteria.
ln summary the purpose of this work was to address
the ability of the riboflavin and UV light method to inactivate bacteria in contminated PLI products and to
compare outcomes with those obtained using a culture
method that is being employed routinely today. The
results from this work suggest that the riboflavin and UV
light process may provide up to 9B7oprotection against
transfusion of bacterially contaminated units at clinically
relevant contamination levels (<20 CFUs per product) as
compared to the 6070 to 6670 effectiveness of bacterial
culture testing obsened in this study.Thus, use of a PRT
method may afford greater levels of protection than bacterial detection by any particle-based detection method,
even with larger sampling volumes and extended incubation times. A true determination of the validity of this
analysis and this approach for approimating clinical
outcome can only be provided once more routine application of PRTmethods occurs.
This analysisdoes not take into accountother properties that the PRT methods may provide relative to
prcvention ofviral, parasitic,or white cell-mediatedcom{s's3These
plications of transfusionof blood products.3r
may be additional targets for hemovigilance analysis of
products treatedwith theseprocessesonce they are used
in a more routine fashion.The PRT approach may thus
afford a means to address multiple transfusion-related
concerns related to blood safety in a single platform.
Clearly, bacterial detection methods are not intended
to provide prevention of viral, parasitic, or white cellmediated complicationsor other utiliry This too may be a
1214 TRANSFUSIONVolume49,June2009
R:BOFLAViN AND UV LIGHT VS BACTER:AL CULTURE TESTING IN PLT PRODuCTS
consideration in decision-making processes by transfusion medicineprofessionals.
Schrezenmeier Il, Walther-Wenke G, Mtiller TH, Weinauer
amotosalen HCI and ultraviolet A light for pathogen
F, Younis A, Hollaid-Letz T, Geis G, Asmus l, Bauerfeind
inactivation: the SPRINT trial. Transfusio[ 2005;45:1864-
U, Burkhart J, Deitenbeck R, Fijrstemann E, Gebauer W,
Hitchsmann B, Karakassopoulos A, Liebscher UM, Senger
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Sang2003;84:96-I04.
spective multicenter study comparing pooled whole
Kumar V, Lockerbie O, Keil S, Ruane P, Platz M, Martin C,
blood-derived platelets and apheresis platelets. Transfusiol 2007i47 1644-52.
Ravanat l, Cadet J, Gooddch R. Ribollavin and Uv-light
based pathogen reduction: extent and consequence of
Yomtovian R, L@arus HM, Goodnough LI, Hirschler NV,
EderAF, Kennedy lM, Dy BA, Notari EP, Weiss IW, Fang
DNA damage at the molecular level. Photochem Photobiol
Morissey AM, lacobs MR. A prospective microbiologic surveillance program to detect and prevent the transfusion of
CT, Wagner S, Dodd RY, Beniamin RJ; American Red Cross
2004i80.15-21.
Regional Blood Centers. Bacterial screening of apheresis
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SN, larvis V{R. Transfusion-transmitted bacterial infection
components: risks, strategies, and regulationr joint ASH
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and platelet concentlates using riboflavin and ultraviolet
Rentas Fl, Harman R, Gomez C, Salata t, Childs i, Silva T,
Lippert L, Montgomery L Richards A, Chan C, Iiang L .
Reddy H, Li l, Goodrich R. Inactivation ofOrientia tsut-
Yomtovian R, AuBuchon lP. Detection ofbacterial con-
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Benjamin RL Wagner St. The resjdual fisk of sepsis: modeling the effect ofconcentration
on bacterial detection in
Asano H, Lee CY, Fox-Talbot K, Koh CM, Erdinc MM, Mdschner S, Keil S, Goodrich RP, Baldwin WM.Treatment
Mo-bottle culture systems aDd an estimation of false-
with riboflavin od
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zation to platelet trmsfusions ild
ultraviolet light prevents alloimmuni-
Kleinman SH, Kamel HT, Harpool DR, Vanderpool SK,
Transplantation 2007:B4:I174,82. U
cardiac transpluts.
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all rightsreserved.
1216 TRANSFuS10N Volume 49,」
une 2009
From bloodjournal.hematologylibrary.org-qt
Cenlral Blood Institutedo Japanese Red Cross Society on April 8,
2013. For personaluse only.
TRANSFUSION
MED,C'NE
Infectiviryin chimpanzee
s (Pantroglodytes)of
plasma
collecred
beforeHCv
n\4_{"_tggqUitity
byFDA-licensed
assays:
implications
for transtusion
safery
and
HCV
infeCtiOn
From bloodjournal.hematologylibrary.orgat Central Blood Institute c/o Japanese Red Cross Society on April 8,
2013' FOTPETSONAIUSEONIY'
BLOOD,28JUNE2012.VOLUI\iIE119,NUMBER26
NCVINTECTIVITYDUFINGACUTEINFECTION
6327
The animalswere nroritored by testingblood samplesfor HCV RNA by
(EIA). liver eDzyme
anti-HCV by enzymelinked immunoassay
i!ffiiltr;":ifiJffi;i*:1"T:TffiJ".l'':,"::1*..|:PCR,
levels. se6 1-..i; assays.lf infecled, weekly or biweekly nronitoring
contirrued;however.if thefe was no detectableinfection after 6 weeks.the
;lj;:JT""#ffiTffiffill'f;:Tjlj:::$il:t$:.}ffJ:X
anin)!l was fe$tedfor an interval of up to 3 weeksand thenbecameeligible
mnsmission,
providedau relevanrto broader
theseexperiments
issues
jnfusion with anotherdonor plasmasample.This sequencewas repeated
of HCV transmissibility,
theabilityto d@umentpreviousHCV infec- for
jnfection
OUtCOmeS
Vito Racanelli,sJoo ChunYoon,5BarbaraRehermann,s
and HarueyJ. Altero
in HcV inf@tion.
rEloodSyslefrs ResearchInslilule,San Francisco,CAI ?DepadmentoiLaboratoryMedicine,
UniversityofCalifornia,San Francisco,San Francisco,CA;3Teras
BiomedicalResearchInstiluteand SouthwestNaiionalPimale ResearchCenlei SanAntonio,TX; lDepadmentol Pathotogy,
UniversityoI BritishCotumbia,
vancouvei BC; 5lmmunoloqy
Section,LiverDiseasesBranch,NationalInstituleol Diabelesand Digestiveand KidneyOiseases,NationatInslitutesoi Heatth,
Depadmentol Healh andHumanSeruices,Bethesda,MD;and 6lnlectiousDiseaseSectioo,DepadmentolTranstusionMedicine,NalionatInstitutesof Heatth.
BelhesdaMD
PreparationotHcv-RNA-positiveplasmadonorpanels
MethOdS
with several difTereDtdonor plasma santplesutrtil evidenceof
could be ascenaiDed.After conlirmation of infection. animals were
moni(oredtor a perjod of I year b dererminethe outcomeof inleclion. No
additional infusionswith donor plasmawere perfornreduntjl complerionof
lhis l-year period.
Laboralory assays
HCV RNA quanlifcation in plasma dotor patrelr. Two different assays
wer€ performedas previouslydescribed.rTheCOBAS Anplicor HCV
Plasmafor chimp inoculation sludies was selected from a €ollection of
Monitor (Versiol 2.0 assay;Roche Molecular Systems)HCV PCR assay
was able (o quanlify HCV RNA down to a lower limit of 600 lU/mL
|'om1ocommercia|dono'swhocon.tocontain1.2HcvRNAcopies/mL
Samplesthat were negaliveon this assayweretestedusjng the dHCV TMA
assayusingmultiple0.5-mLreplicatesof plasma.The limit of detection
(LOD) of each replicate assay is l2-l copies/ml (5OE LO\
955.
donor Thesedonations@cured at approximatelytwice-weeklyintervalsin
2 chimpanzees to assess infectivity durconRdence
interaal[Cll | ].l-l 3.2).16
was dererHCV RNA corcentration
mined basedoD the percentageofreplicates $at gavepositiveresultsusing
plubit analyses.
ECV RNA deuction and quantifcation in the recipient chinqs. HCv
|icensedassays'transmittedHcvinfec-chimpx355deve|opedacUteviremiawithsiduat
RNA deteclion was performed using the COBAS Amplicor Hepatilis C
Virus Test (VeNion 2.0i Rshe Molecular Systems)and quaDtifica{ionof
HCV RNA was performed using the COBAS Amplicor HCV Moritor
(Version2.0 a$suy).
HCV Ab dekction. lnitial screeningof plasmadonor panelswas done
(Orlho Diagnostics).Repeatreactive
rory Hcv ldHcv] assay;cen_probe)on 4 replicareso, 0.5 mL of ptasma using a third-generationHCV Ab EIA
Intfod u CtiO n
samples
were funher evalualed by the Recombinantlmmunoblot Assay
for eachdonation.rMultiple additionalreplicates(n - 20 or 23) ofselected
(RIBA; Version 3i Novadis Diagnostics).Initial screeningof chimp sera
was done using aDanli-HCV 2.0 EIA (Abbo( Laboratories)with confirmation by RIBA.
HCV RNA extructiotr, anp$catio,t, cloning, seqilen.irg, and phlloHcvRNAconcenrationsriseexponential1yinwhathasbeensubjects'Withrespecttob|oodsafery,iftbe..blipS',aIefoundtou"f'i"."i"Lj:
genctic anallsis. HCV RNA was extractedfrom 140 pL of plasDa from
one viremic time pojn( from eachoflhe 5 plasmadonorsimplicatediD HCV
b?nsmission10 chimp X33l and from 2 viremic time points from lhe
definitjon, is characterized by lack of detectable plasma vjremia by
mating HCV transfusion-transmission risk because such modeling
TMA) donations.
,nfected chimp using the QIAamp Viral RNA Mini Kit following the
commetcially available HCV RNA assays, which are primarily
assumes that donations given before the extrapolated beginning of
nranufacturcr'sinstructions (QIAGEN). Extraction and amplilication of
based on PCR technologies. However, by performing quadruplithe ramp-up period arc noninfectious.ro-r2
donor and chimp sampleswere performedon differentdrys ro eliminatetbe
pos$ibility of cross-contanination.Details of the amplification, cloning.
sequencing,and phylogenetic analysis procedure$are in supplemental
Methods.
ALT andAST measurerterta.Serumsamplescollectedfromthe
study
unimals were analyzedfor alanine aminoransferase(AST) and asparate
(ALI)
aminohansferase
levelswith a UnicelDXC600 serumchemis[y
analyzer(BeckmanCoulter).Enzyme levels wereconsidercdnornul ifthey
were within the normalraDge(AST I l -25 U/L; ALT 2 I -55 U/L) eslablished
al the pnmatecenter.
CD4 prowtutive re$poilsesto HCV Ags. PBMCs were isolatedfrom
AcD-anticoagutated chimpanz€e blood via gradient centrifugation as
Triplicale cuhures of 20O000 PBMCs werc stimulated with
described.2?
and SIv infections as "blip" viremia)3e that precedes ramp-up by
infectivily from donations inirially 6wssed as acuning immediately
I p8lmL HCVcore, NS3. helicase.N54, NS5A, N55B proteins(Mikrogen)
varying intervals up to 2 months.
before the onse( of mp-up-phre
viremja. Next, we evaluated
or buffer control a$ previously described.2sCulturcs were labeled wilh
Genenl ,ormat gt chimp inoculafion experlments
BecauseHCVRNAlevelsareverylowinthisveryearlyphase
I pci irHjthymidine (Amersham)on day 5 and haryested16 hours la(er
infrctivity of nonviremic and low-level HCV RNA-positive (blip)
Separate culturcs stimulated with or witbout PHA (l pglnrl.; Murex
ofinfection,i(hasnotbeenposSibletodeteIminewhethertheRNAdonationsfrmdonomwhodemonstmtedintennittentHcvRNA}'ifiH;xl]l.iTl;;llt;;ii''::Lij
Biotech Limited) were labeledwith IsHlthymidineon day 2. The srin]ulaand Southwest Nalional Primate Resarch Center, tn Ass@iation for
tion index (Sl) was calculatedas a ratio of theaveragenumberofcounts 6r
Assessmentand Accreditation of Laboratory Animal Care-accredited minute of4 replicateculturcsin the presenceofAg comparedwith cortrol
buffer or medium.
usins
a sensitive
transcriprion-mediated
copies/ml
rrom
rhe$medonor,
x3ss
was
nili:Trjl[:JTlii;ruT#:"""Tfi11J1fi16J"::J:",1,1Hi:1
rh.onrineversionorhisaiicreconrainsadarasupprement.
:n','f"::ilf;:.*i',1?$j",l|tJifi"iil1:"#:#i"::',;ll
Besults
infusedone after another,ora premixedp@l of5 U (250-mLtotal;olume).
Funherdetailsofthe timing ofthe infusionsin the various experimentsare
Orcvjdedin Figure I and supplementalFigure |, and in "Resuhs."
Three chimp inoculation experiments were performed in multiple
phases as described below and in Figure l.
6326
BLOOD,28 JUNE2012 . VOLUMEI I 9, NU[.4BER
,U
at CentralBlood Institutec/o JapaneseRed CrossSocietyon April 8,
From bloodjournal.hematologylibrary.org
2013. Forpersonaluseonly.
BLooD.28JUNE2o12.voLUME119.NUMBER26
Experiment | (lnfectivity of v6ry early tamp-up plasmal
by"CV Mon瞳 o=Assay
B:,ppソHCV Panei10083
B
０
bソHCV MOnltor Assaゾ
■■ R e a c t i v e
3l against NS3. Responws wee mainuired at wek 6 and 8 aftq
infusion, md declined to slighdy above baselineat wek 10. By
ニ ー
¨
ー
crlNonoReaclive
l.iwreksafterinfusion,HcvRNAandHCVAbwereundet@tableand
ALllevelswrenomai,thusleavingnoresidualevidenceofprior
」
ーー
50 mLot ptasma containing an eslimaled 300 m0 Hcv RNAcopies (6000 copietmL) iom a subsequ€nt €ady ramp-uhphaso donalion lrcm lhe same donor.
０
０
０，
。
１
from weeks 5 through I with a peak value of 68 U/L. Proliferation
of PBMC ro HCV Ags was not derectable preinfusion or at week 2,
bu( a cles peak was detecuble at v*k
4. Responses werc exclusively
taryetedagainsl nonslructuml HCV Ags as evidened by SIs of33 and
27 against NS5B and NS5A, respectively,29
against NS4 and
∞
０
・
”
０
and c22 nondettrtable). ALT was elevaled
∞
０，
ｍ
5l I and NS5 at +/-,
0
Ｘｏ●Ｃ一Ｃ●¨
︵
夕Ｇ一ョ‘虐“の 一
RNA copy present in 20 mL of plasma).
After infusion. chimp X355 was evaluated w@kly for the first
| | weeks, then biweekly until week 29 after infusion, with a final
assessnlenl at I year after infusion. Tests performed were HCV
collected from weeks 9 tirrough 13 were RIBA positive bul never
showed Ab reactivity to the core (c22) Ag. Samples at weeks
15 and 17 showed very low Ab reactivity by RIBA (c33 at | +,
20
０●●●０●●﹄ 〓ｏ● 卜 ＋守０ ０
dHCV TlvlA and viral load assays, were estimated by backextrapolation frcrr measurcd viral loads during the subsequenl
ramp-up phase of each donor to have been collecled liprn 4 10
| 6 days before the onset of the rarnp-up phase (defined as one HCv
mild hepatitis (peak ALI 68 IU/L) and transienl HCV infection
with viremia developing al week 2 and persisting until week 9.
Peak viral load was 5.2 x ICF copies/ml at veek 4. HCV Ab was
first detected at week 8 and persisted until week | 7, after which it
became undetectable throughout follow-up (sctorevcrsion). Samples
０”¨
”●ＬＯ﹄〓０しＬ 一
■Ｌ●〓‘〓 。Ｌ
detected during the eclipse phase and were selected so as to be the
donations that immediately preceded the first ramp-up viremia
donation (Figure 2A, and supplernental FiSure IA-E). These
donations, which testednegative for HCV RNA by quadruplicate
prcteins were pedormed before infusion and biweekly until week
l0 after infusion. As shown in Figure 3, chimp X355 developed
∞
０
。，
６
Experiment I, phase I involved infusjons of 50 mL of plasma
(during a single infusion episode) from each of 5 different source
plasma donors into an HCV naive chimp (X355). The infused
donations were from donors in whom there was no HCV RNA
1認
s50
1盤
RNA (quaiitative and, when indicated, quantitative), HCV Ab,
ALT. and AST. Assays for PBMC prolifemtive responses to HCV
∞
０
。′
８
Experiment l: testing the intectivity of plasma immedlately
betore the ramp-up phase
Ll
― Ⅵr a l L o a d l Um′
●●●︶く 〓 “ ＞０エ
︰０ ︲コ Ｅ■ ● ¨
Flgure t. Experimenlat design and s6quen6 ot plasma intusions and lollow.up ol chlmpanzess. Expedment I asse$ed the intectivily ol plasma hat lesld HCV BNA
negative by ticensed diagnosric assays and was obtained in the daysjust before €mp-up vtemia. (A) Fifty millililers of prF€mp-up phase plasma from each of 5 mmmerdal
apheresis donorswasinlused s6qu€nlially duringasingle experimenlalpro@dureinlochimpX35S. (B) Whentansmission waslinkedlo 1 donofbyphylogeneticsqusncing,
idetoals. hh a#als
ws€ lollwed
to a sM
simal (X331) at Swe*
dorcr we€ tansfud
50-m L oldma sffiples ftom each ol 4 €adier domtioG kom tMt iwlhted
tor vtotogic, serotogac,and @tfmediared immune responses to assess evid€nce of HCV inleclion. Experiment ll axamined lhe int€dvily olsamples from 5 donorc who had
iniermilenr towiev€l HCV HNA ('blips") detectod dudng lhe eclipsephase otHCV inlsction by inllsions inlochjmp X331. {C) Phase 1: lnlusion ol a pool of2$ hL(50 mLol
to ilips) o{ HCV BNA-nsgatile plasha fEm the eclips6 phase. (D) fras€ 2: 50-nL plasma sampl6s lrcm blip viemic unib
ptasmddonor troft doctions @ttected sub*quenl
hon th€ octips€ phas6 trom lhe same 5 donors were sequentially intused at 6-we€k inleruds. Phas€ 1 and phasg 2 infusions did nol lransmit HCV inteclion lo the recipient
animat (chimp X33l). (E) Phas€ 3: To confirm this chimp's sus@ptibitity to HCV Inl*tlon, 50-mL pl6ma sampl€s from sach ot 3 progfesively high€rtiler HCV RNA.positive
donations collected during the eaily ramp-up phase of inleclion trom one ol these 5 donors were intused at A-week interuals. In experimenl lll, chimp X355 who had
spontanoousty recovered |rom HCV jnlsclion and losl antlHCV as well as virus, was rechallenged 3 years lalel to detemino whether pdor infoclion conl€tred prolection
againstreinfetion.(Fl)lnllsionof50mLolplasmacontaininganesthated80HCVANA@pies{1.6copies/mL)trcmthepreviousinloctingdonalion (F2)Rechallengewlh
”
Chimp X355
3 years after recovery
3 yea6 after HCV cleatance
”
― □
∞
Ｘ〓ｏＯ卜 ●●〓”０〓ＬＯ“
く 〓Ｆ ゝ０ ¨
Experiment lll (Rechallenge of transiently infected chimpl
一
レЮ
M…
。
donor 10083.
つ
Experirnent ll(lnfectivity of eclipse phase plasma)
”
HCV Naive Chimp x331
simple HCV Pane1 10081
A
∞
圃―□
Flglro 2, Represenlallve viremla results lrom 2 ot lhe
10 plasma donors uged In chlmpanzee Inlection
experlments (dala frod all 10 panels ls pres€nl€d lr
Eupplemenlal Flgure !), (A) TMA and vial load rcsull9
over tme fiom olasma donor panel 10081, who did nol
demonstrale inlerminenl blips ot HCV RNAbetore dele.
vilemia. Nlmbors abov€ bars
tion ol ramp-ufphase
represenl the order in which aliquols wer€ infused into
chimpg. Infusion 1 was pad ol a [ansmiIing pool lhal
was inlused into chimp x355. Inllsions 2-5 were each
inlused into chimp x$l al inleruals ol I weeks belween
vkal load in th (amp-up ad
intusions. l idbates
posl-ramp-up phase ol HCV inlection in donor 10081,
(B) TMA and vial load resulls ov6r tim€ trom plasma
donor panet 10083 who manitestod intsrmittent bllps oi
HCv RNA reaclifry during h€ slipse phase ol acule
'!alley'and
HCV infection. &lh HCV RNA-negalive
HCV 8NA-posilive "blip" samples were infused anlo
chimp X331 (s@ Figurc 1, eperimenl ll). NumFrs
above bars identify aliquols and lhe oder inlused anlo
chimps, Nol6 bal lhe unils were infusd an a differenl
oder than they were collecled and lhal inlusion 1 was
pool, l indi@l6s vid load ln
pan ol a nodfansmilng
Ｘ■∽●卜 ゛ｏ一“０〓Ｑ●ヱ
く 〓Ｆ ヽｏ ﹃
□一口
HCV Naive Chimp x355
∝
g轟 鰍]Ⅷ譜 J割
];l;腑
(l現
:堆
R蝋￨よ6"9
:::」
‖
」
[iWttL:γ :習馳
軋
∞Q[￡
思
鰐Ⅷ:‖
and nioclvly monl
X350(See F Oure l eXpeimentり
HCV
。d ine and box)anl‐
(SOid lne)HCV RNA(dasい
■
med●ted mmune respOnselb。
Om pand)
(bOゆand co「
0 2
8
10
12 14
WoekS
16
∞
ma hemad∞
可
山aw∝
gttξ
“
留譜鑑」
習譜 ぬ
∞認肥
“
臨]11で
:。
71:L:[符
‖
:ふ
Bm“
reglon sequences irOm 5 plasma dOnOrs(lo031,
10051,100o2,10017,and 10022)and a Chimpanzee
(X355)intuSed with a pool oi 50 mL o,plasma from
°
り
♀
‖
∬
』
測:絆Ji:;1:::」
IⅧ鱈署罵
飩
。
。
罷」
腹 明き習騨
IN:鰐
Q:￡
];lF:l聞
還
哩illl:::1騰
6鰤
Tabie l Es●mated HCV RNA concentra“
ons Ofec“ pse‐phase dona“ ons wnh b‖ p viremia infused into chimp x331(expenment‖ ,phase 2)
Days precedlng
ramp-up'
No. oITMA-posltlve
replical€s (7.)
o「
E,た2(404nt,lor dOnors and the chimp and△
dOned
ences Fron genotypes la(HCVH H77,and Hc,1)
O●
10(L2.」
Kl)and“ (K3a)were nc uded The maximum
had not been infected in phase 2 ofexperiment I, was used for these
studies, which were begun 22.5 months after the completion of
expedment I. In phase I of experiment II, a 250-mL plasma pml
from nonviremic donations obtained during the eclipse phase of
infection from 5 different source plasma donors was infused into
chimp X33l (see supplementalFigure lF-J for time points used in
these infusions); these HCV RNA-negative donations were collected during the RNA-negative "valleys" between inteilni(ent
HCV RNA-positive eclipse-phasedonations (blips). This chimp
concentmtion of 1.2copieslmL( gc CI 0.5-1.9copieyml). Inrebospect, this initially HCV RNA-negarive donation was probably in rhe
very wly mp-up phaseof infwtion such that muhiple replicatetesting
was required to dercr the very low level of HCV RNA that ws prest.
before the first quantifiable HCV RNA-positive donarion (viral
load of 6 X l0r HCV RNA copies/ml) from rhis donor (donor
1008 I ). To increase the sensitivity for derecrion of HCV RNA in
the transmitting and nontransmitting source plasma donations,
23 addilional 0.5-mL plasma replicates from rhe infused donatioDs
To confirm that the donation thar initially infected chimp X355
was the earliest infectious donation in the panel of serial
donation samples from the implicated donor, we conducted
phase 2 of this experiment. A second HCV naive chjmp (chimp
X33 | ) was infused on separateoccasions with 50 mL of plasma
from HCV RNA-negative units donated by the transmitting
were rested under code for HCV RNA by the TMA assay. In rotal,
2 of the 2'l replicate TMA assays were positive with plasma from
the donation implicated as infectious by phylogenetic analysis,
Bcause 50 mL of plasma fiom this donation was infusd, we estimate
that chimp X355 acquired HCV inf@don after being b'ansfusd with a
total of - 60 HCV RNA copies (9570 CI: 25-95 @pies).
whereassimiltr multiple replicateTMAtesting perfomed on identielly
pressd
lioren{hawed plasna from the orher 4 donations in the
donor that had been collected 14, t0,7, and 3 days before the
transmitting donation (Figure 2A). Chimp X33l was monitored
weekly for6 weeks aftereach 50-mLinfusion (total of24 weeks)
to document evidence of HCV infection by HCV RNA, HCV
transmitting p@l gave negative rcsulb. A probir analysis indicated rhat
the dHCV TMA-posilive donation lrad an estirnated HCV RNA
Ab, and ALTIAST testing. There was no evidence for HCV
infection in this second recipient chimp.
113(053191)
337(215447)
329(208● 38)
TMA indicates lranscdotion-medlaled amolltication,
'PlasmaJrom
HCV RNA-n€galiv6 donallons fron each ofhese five donorc wefe previously intused into chlmp X33l end fesutted in no evidence of HCV intection, These
donalions wer€ collected prbr lo ramp-up vtemia at days -31, -23, -19, -21, and -18, respediv€ly.
l€vels
wsre eslimated from probit analysis ol replicale l€sting ofthe HCV WHO lnternational Srandard (NtBSC Codes: 97/690); copies p6r milititer were bas€d
IRNAcopy
on a conversion ladorof 3.4 RNA@pieglU.
In experimen( II, eclipse-phase RNA-positjve and RNA-negative
donations were selected from 5 ofthe 37 source plasma donors who
had intermittent HCV RNA detected in the eclipse phase of
infection (Figure l, supplementalFigure lF-J). Chimp X331, who
HCV infection except for the @il-mediated immune res[mnsewhich
remaineddetechble as late as week 2l after infusion.
Sequencing of HCV RNA and phylogeneric analysis revealed
that lhe chimp HCV isolate was very closely related to an HCV
isolate obtained from a subsequent highly viremic donation from
one of the 5 source plasma donors used in the infecting inocula
(Figure 4). The transmitting donation had been collected 4days
222(120017)
1122(935‐ 1367)
2/27(7)
10727(38)
10/27(37)
Experlment ll: testlng the Inlectivity ot plasma during the
eclipse phase
1∞22
mにslt
(95%“duc al“
6/27(22)
2y27(85)
correspOnding to the nrst hypeivarlable re9 0n(HvR l)
was monitored weekly for 6 weeks for HCV RNA, HCV Ab, ALT,
and AST. There was no evidence for viremja, Ab seroconversion. or
ttansaminase elevation, indicating that these HCV RNA-negative
eclipse-phasedonationswere not infeclious.
One month later, phase 2 of tbis second experiment involved
infusions of 50 mL of low-level HCV RNA-positive eclipse-phase
plasma from each ofthe same 5 source plasma donors into the same
chimp {Table l, supplemenlal Fjgure lF-J). The infusions of the
5 units were separated by 6-week intervals during which the
recipient chimp was monitored for evidence of HCV infection.
There was no virologic evidence for transmission of HCV infectjon, and no evidence for humoral or cellular immune rcsponses.
Finally, after an additional 6-month interval, phase 3 of this
experiment was conducled. In light of the muhiple exposures to
HCV RNA from eclipse-pbase infusions. the aim of this phase was
to establish that chimp X33l was susceptible to HCV infrction
when infused with a sufficietrt HCV RNA dose. Three 50-mL
plasma infusions from HCV RNA-positive units obtained eilher
immediately
before ramp-up or during the ramp-up phase of
infection from one of the 5 donors (plasma donor 10083) used in
phases I and 2 were infused at 8-week interyals (Figure 28, Table
2). These 3 units had increasingHCV viral loads ( 1.5 copies/ml,
3.0 copies/ml, and 6.8 X 105 copies/ml). The chimp was
monitored weekly for 8 weeks for HCV RNA, HCV Ab, and
ALT/AST afier the Rrst 2 infusions and rhen weekly for
f2 weeks and biweekly until week 24 after rhe rhird infusion.
Liver biopsies were performed immediately before the infusion
containing 6.8 X 105copies/ml and at weeks 2, 3, 5, and 7 after
that infusion. No HCV infection was detected over an 8-week
follow-up period after each of the firsr 2 infusions (infusion of
74 HCV RNA copies [.5 copies/ml X 50 mL] and 149 HCV
RNA copies [3.0 copies/ml x 50 mL]). In conhasr, after infusion of the donation with 6.8 x 105 HCV copies/ml (toral
infusion of 3.4 X l0? copies [6.8 x I05 copies/rnl x 50 mL]),
the recipient chimp developed viremia at l-week postiniusion
(peak titer 1.3 x 105 copies/ml) which persisred until week
l6 (Figure 5). All liver biopsies were normal. Unexpecredly,
HCV Ab !rever developed over the 24 weeks of follow-up.
Experiment lll: testinq whether transient HCV Intection
protected against rechallenge
Experiment Ill (Figure | ) was conducted to deterftine whether the
acquisition of HCV infection from a low-dose inoculum, followed
by viral clearance, would protect against rechallenge by the same
HCV strain. In this experiment, performed 34 months after recovery flom the initial experimental transmission of HCV to chimp
X355, this same chimp was challenged with a 50-mL plasma
infusion from the same low-vircmic (l .6 copies/ml), early windowphase donation that had lransmitted rhe initial HCV infection. The
chimp was morrjtored weekly for l2 weeks during which time there
was no evidence of a second HCV infection, implying some level
of immunity even though anri-HCV and Hcv-specific
cellmediated immunity were not detectable before or after the HCV
challenge.
Table2. Estlmated HCV BNA concentratlons ot donations intused into chimp X331 to prove susceptibitity to HCV infection (experiment lt,
phase 3)
HCV RNA copleゴ
mL omputed
Pha36 ol
lntectlon
DaF precedlng
ramp.up
rep‖cates(%)
3/27(11)
9/27(33)
measured by VL assav)
lnfused
copleS
143(071‐ 223)
2991183●
05)
TMA indical€s tan$iplion-medialed
ampllflcaion; VL, Urd load; and NA, not applj€bte.
'RNAcopylevels were€slimated tiom probit
analysisol replicate testing olthe HCV WHO Intemational Standard (N|BSC Codesi 971690)i copiespsrmilititerwerebased
on a conversioo laclor ot 3.4 RNA@piedlU.
tThi6 donation was posiiive by quanlilalive HCV nNA lesling at a concentation of 6.8 x 105copi€s/mL and was not subiected to reoticato TMA testino
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12
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Week3
20
22
To further assessprotective immunity,4 weeks later, the chimp
was rechallenged with a 50-mL plasma infusion from the subsequent rarnp-up phase donation (donated 4 days later) given by this
same donor, which contained 6000 HCV RNA copies/ml (for a
total infusion of 300000 HCV RNA copies). The chimp was
monitored weekly for l0 weeks, then biweekly until week 24, and
then monthly until week 52. Chimp X355 was reinfected with HCV
as evidenced by developmentof low-level HCV viremia that was
only present at weeks 1,2, and 3 and only quanlifiable at week
| (1620 copies/ml). HCV Ab deveioped at week 5 and persjsted
through week 20, was intermittently detected at weeks 28 and
32 and then reverted to negative on 3 subsequentmeasurcments.
ALT remained noilnal thrcughout the l-year follow-up period and
this chimp did not mount any PBMC proliferative responsesto the
challenge inoculum. A1 week 52, the chimp expired from an
unrelated pyelonepht itis and Eschericltia coli sepsis precluding any
further follow-up.
Discussion
We studied the infectivity of human plasma collected in various
stagesof acute HCV infection to defite the relationship between
HCV RNA as detected by the mosl sensitive RNA assays and
infectivi4, in the well-established chimp infection model. we
demonstmted that infusions of 50mL of piasma from each of
5 hurnaD source plasma donors thought to be in the late eclipse
phase of infection (iust before or at the beginning of the ramp-up
phase) at the time of donation into an HCV-naive chimpatrzee
resulted in a mild and transient HCV infection characterized by
low-level viremia, HCV Ab production, and HCV-specific T-cell
immure rcsponses. This was fol)owed by viral clearance, mpld loss
of HCV Ab, and marked diminution of the cellular immune
response. Sequencing of isolates established that the infection was
a single plasma donor in the group of 5 used in the
experimental infusion. Based on performing HCV TMA on
27 replicatesamplesfrom the tmnsmilting donation, we established
that this plasma had an estimated HCV RNA concenttation of
fiom
Flgure 5. Results ot lransmisslon erperlmenls In
chlmp 331 (see Flgure 1, €xpeilmenl ll). Affer demon.
skalang thal valley phas6, blip phase, and pr+ramp'up
phase in{usions {50 mL) from €ach ot 5 plasma donors
wero not infectious in chimp X331, lhis animal was
challenged wih a ramp-up ph6e inmulum conhidq
340 000 total RNA copies in a volume ol 50 mL. Chimp
X331 was intected as indicated by th€ detedion ol Hcv
ffNA lrom weeks I lo 16, bul lhen HCV RNA cl€aredl
HCV Abs and celFmedialgd immune responses lo HCV
were not detect€d and lhe ALT level was nol elevaled. By
week 18, there was no residlal evidence fral this
inf6lionhad occurred.
24
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not close the infectious window period comple(ely and may nol be
waranred given its projected very low incremen(al yield and poor
cost-effecti veness.ro25,30
A further set of experiments was performed to evaluate the
infectivity cif 2 types of donations from the surprisingly prolonged
@fipse phase of infection observed in 74qo of tlte plasma donor
panels we studied. These included donations that were HCV RNA
positive
and estimated to contain from I to 20 HCV RNA
copies/ml- (60 to 561 HCV RNA copies per infusion) and other
intervening donations from [he same donors that we.e HCV RNA
negative by sensitive m!ltireplicate testing. Infusjons of 50 mL of
plasma from either ofttiese 2 donation types frcm each of 5 donorc
with such intermitent HCv RNA "blips" did not cause infection
when transfused into a single chimp, who was later proven to be
susceptible to HCV infection when infused with a ramp-up phase
viremic sample from one of these same donors.
Thus, although HCV RNA was intermittently detected during
the eclipse phase of infection for up to 8 weeks before ramp-up
viremia, our results show that transfusion of such units was not
infectious in chimpanzees. In contmst, we demonstrated infectivity
witb an early ramp-up phase sample at a total infusion dose of
60 HCV RNA copies. Japaneseinvestigators have shown that even
lower doses of HCV RNA (total inoclla of 20 HCV RNA copies)
I .2 copies/ml and hen@ the donor was probably in the early phase
ofHCV ramp-up viremia (rather than the eclipse phase) al the time
ofthis donation. The definition ofthe transition between the eclipse
and ramp-up phases is not precise and the mechanisms leading to
this transition are not known, as discussed in Clynn et al.r Based on
the 50-mL plasma infusion from this donation, we estimated that
RNA copies were infused into the reipient chimp.
Samples collected from 3 to 14days previously from the same
donor were infused in 50-mL aliquots into another HCV naive
chimp and did not cause infection, indicating that the transmiltinS
donation was obtained at or near the time when the donor first
60 HCV
became infectious. This also indicated that the duration of infectious viremia before detectable RNA by donor screening nucleic
acid assay technology (NAT) assays was very brief.
This experimentaltransmissionhas some parallelswith the first
reported human case of transfusion-transmitted HCV infection
fiom a unit retrospectively shown to be HCV RNA negative by a
sensitiveindividualdonation NAT (ID NAT) assay.2'Inthis human
transmission,HCV RNA could be demonstratedinconsistentlyin
the transmittingdonation when evaluated in multiple replicatesby
dHCV TMA testing,Ieading to tbe conclusion that HCV RNA was
present,but at a very low level (estimaledat < l0 copies/ml-).The
donor of this unit may have been in the very early ramp-up phase
with HCV RNA levels below the level of consistentdeteclion by
even the most sensitive ID NAT screening method, as occuned in
our chimp lansmjssjon experiment. Data from this study in
chimpanzees, other chimp expefimental studies using serially
diluted ramp-up phase plasma infusions,ral6and the clinical case
report of a breakthroughtransrnissionlqdemonstralethat ID NAT
cannot completely eliminate the risk oftransfusion transmission of
HCV given the high level infectivity of ramp-up phase virus. Of
relevance to transfusion safety, it appears that blood transfusions
from donors in the early stage of acute HCV jnfection can be
infectious before the time ofRNA detection by routinely performed
NAI screening, including the most sensitive ID NAT test cunently
availabfe which has a 509o limit of detection of 12.1 copies/ml057o Cl 1l.l-13.2\.26 Hence. conversion to individuai donation
NAT from cunently used mini-p@l NAT (MP NAT) screening will
from an acurely infected chimp transmitted HCV infection to
recipient chimps.ra Hence, during the ramp-up phase of early HCV
infection, infusions with very low copy numbers are highly
infectious whereas infusions having equal or higher copy numbers
of HCV RNA obtained during the eclipse phase are not infectious.
This suggests critical differences in the presentation or packaging
of HCV RNA during the eclipse and ramp-up phases of HCV
infection as discussed below.
There are multiple possible explanations for the Fnding of
intermittenl HCV RNA detection in some donors during the eclipse
phase. This rray replesent persistent low-level viremia that occurc
at a concentration that is at or near the limit of assay detection and
thus, based on assaylimitations,is detectablein some samplesand
nondelectablein other serially collectedspecimens.Another explanation is that periods of HCV viremia alternate with nonviremic
periods as a result of inlermittent releaseof viral particles into the
plasma from focal replication sites such as the liver and possibly
NAT, MP NAI fourth generation Ag/Ab assays), as reviewed in
detail elsewhere.2
We have shown thal a chimp infected with HCV from infusion
of a low-dose early ramp-up inoculation developed a lransient
HCV infection as evidencedby lowlevel and shorFlived viremia,
and both humoral and cellular immune responses;by week 17,
virologic, serologic, and biochemical evidence of HCV infection
had disappeared and very lowlevel T-cell responses werc the only
fesidua ofpast HCV infection. A second chimp also inoculated with
plasma from the early ramp-up phase of HCV infection developed
transient viremia but failed to seroconven. SjDjJd examples of
transient infections without seroconversion or with seroconversion
followed by seroreversion have been reported in experimental
chimp infectivity studies,r5and rarely in human HCv infections
after transfusion and injection drug-use exposures.6,73r'16Our
expedmental findings conoborate these previously reported human
observations in establishing that more HCv infections occur jn
persons than are clinically, virologically, or serologically identified
by cross-sectional serologic or NAT screening.
Lastly, these experiments in a single chjmp indicate that HCV
infection from a low-dose inoculum did not confer protective
immunity to rechallenge, as we demonstrated only Iimited protection when the chimp who developed but then lost detectable
adaptive humoral and cellular immunity was rechallengedwith a
higher dose of the identica) HCV strain.
A noteworthy limitation of our study is that we had access to
only 2 HCV naive chimps to evaluate the infectivity of a large
number of donations from l0 donors with different patterns of
eclipse and ramp-up phase viremia. Consequently, we had to
judiciously design experiments with reuse of the same chimps for
multiple infusion experinents. This could have rcsulted in either
immunization or tolerance to HCV, perturbing our ability to
ascenain infectivity of donor plasma. However, we do not believe
this seriously compromised interpretation of our experiments
because all the chimps wer€ carefully evaluated using sensitive
assays for detection of HCV RNA and both humoBl and cellmediated immunity and each animal was negative by all these
parameters before viral challenge. Funhermor€, in the chimp
(X331) that was uninfected after challenge with blip and valley
ec)ipse-phaseinf!sions, we confirmed HCV susceptibility by
transfusing a high liter inoculum from the ramp-up phase of
even peripheral blood cells. Third. these episodes could represenl
infection.
repeated HCV exposurcs or reinfections which abort, until a
In summary, these studies demonstrate that: ( | ) Larye volume
particularly nt variant is nnally lransnlitred and disseminates. plasma transfusions can hansrnit HCV infection before RNA
Perhapsthe most likely explanationis that early in HCV infbclion, detection by curent donor screening assays.but the inlerval of
HCV RNA can be releasedinto plasma as nonvirion-associated infectivity before RNA detection appears to be very brief (4 days in
nucleic acid or as defective, nonreplication competent viilons. The
data appear to be most consistent with the hypothesis that complete
infectious particleslikely do not circulate until immediately before
this experiment). (2) The noninfectivity of eclipse-phase"blips"
indicates that these may represent incomplete virions and can be
ignored when calculating HCV residual transfusion fisk. (3) Markerc
the mmp-up phase of HCV infection, leaving a very nanow
window of infectivity before detectability by sensitive blood donor
of HCV infection can be rapidly lost after exposure to low-dose
inocula, suggestirlg that mote HCV infections occur than are
curently documented. (4) HCV infection from a low-dose inocu-
screening and diagnostic assays.
Whatever the explanation, this series of experiments, and those
of others,ra,r6 establish that HCV RNA intermittently detected
during the eclipse phasc of HCV infect;on can be ignored when
performing mathematical modeling of residual transfusiontransmitted HCV risk. This lack ofinfectivity (or perhaps very rare
infectivity, which we were not able to demonstrate in our small
study) is consistent with repofrs of only a very few transfusiontransmissions from HCV NAf-screened units. Thus, risk modeling
can use the time period from the extraPolated beginning oframp-up
phase viremia to detectable virus by the screening method used (ID
lum does not necessarily confer protective immunity to rechairenge
frorr a higher dose of the hon)ologoussu ain.
Acknowledgments
The authors thank Stuart Armsttong and Abigail Schrock for expert
assislancewirh figure development cnd preparation.
This work was supported in part by National Hean, Lung, and
Blood Institutegrant R0l HL-076902 and contractN0l -HB-2?09 l.
From bloodjournal.hematologylibrary.org
a1CentralBlood Institutec/o JapaneseRed CrossSocietyon April I,
2013' Forpesonaluseonly
6ss4 BUscHelaf
BlooD,2sJUNE2or2.voLuverrs,nuveEnzo
Authorship
Con! ibution: M.PB., S.H.K., B.R., and H.J.A. designed the study!
K.K.M. and H.J.A. conducted and monitored tlre animal research:
D.F.H., B.L.H., E.L.D., VR., J.C.Y, and B.R. conducted research
on samples, and compiled and analyzed datai M.PB.. K.K.M.,
S.H.K., E.L.D.,8.R., and H.J,A. analyzedda(a,and contributed to
the linal design and the developmentof the manuscript;and M.PB.,
S.H.K.. and H.J.A. wrote ihe manuscript.
Conffict-of-interest disclosure: The authors declare no competing fi nancial interests.
The cunent affiliation for B.L.H. is University of Sydney,
Sydney, NSW Australia. The cunent affiliation for VR. is Depament
of Intemal Medicine and Clinical Onology, Univenity of Bai Medical
Sch@|, Bili, ltaly. The curent affiliation for J.C.Y is Ewha Womans
Univemity Schol ofMedicine, Seoul, Republjc ofKorea.
Corespondence: Michael P Busclt, MD, PhD, Blood Systems
Research Institute, 270 Masonic Ave, San Francisco, CA 94118;
g.
e-mail: mbusch@bloodsystems.ot
TRANSFUS10N 00MPL10AT10NS(別
紙 2-参 考文献④)
Symptomatic parvovirus Bl9 infection causedby blood
component transfusion
Masahiro Satake, Yuji Hoshi, Rikizo Taira, Shun-ya Momose, Satoru Hino, and Kenji Tadokoro
References
T r a rわ
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s 7 ● 2 0 0 ●4 5 ( 6 ) 0 9 4 1 0 0 2
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ls C virus(HCV)infecJon and to prOieCt HCV
ncidence rates」Crln M′
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e9 c tu oS n‐ d 子
200(8)12161226
J7/a′″eρar 2003 15(2)120128
2007151(12)42904296
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led 2000i6(5)578‐
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a c u t e h e pIas“ C P e p a f o 1 0 9 / 2 o 0 4 ; 4 0 ( 1 ) 3 7 9 7
2003143(3)1173‐
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ciency vレ
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stud′″中 torOay 200■
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436(7053)961‐
966
η2004 44(3)
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quences ltrtransfusion υ
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200545(2)254264
w ndow pelod mOde1 7rans"s′Oη 2002 42(3)
υVlrOf 2004173(1)187196
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Sa"19997αゅ
BACKGROUND:
Althougha riskof transfusiontransmiltedhumanparuovirusB19V (TT-819V) infection
has been a concern,there have been very few reports
ot clinicallyrelevantTT-819Vcaused by the transfusion
ol a B1gv-conlaining
lt has therelore
bloodcomponent.
beena matterof debatewhethera universalB19V
screeningwithan appropriate
is required.
sensitivity
STUDYDESIGNAND METHODS:Throughthe Japanese Red Crosshemovigilancesystem,clinical reports
on possibleTT-819Vwere collectedlrom 1999 to 2008,
duringwhichB19Vdonorscreening(sensitivity,
10'0
lU/mL) was conductedand repositoryblood samples
from donorswere available.
RESULTS:Eight patientswith TT-819V caused by
componenltranslusionhave been identified.Four
patientsdevelopedsustainedanemia and pure red
blood cell (RBC)aplasiaand one patientdeveloped
pancytopenia.The underlyingdiseasesin these five
patientswere eitherhematologicmalignancyor
hemolyticdiseases.The viral loads of the responsible
componenlsfor lhese cases rangedtrom 103to 103
lU/mL. Two patientswho underuentsurqicaltrealment
without any hematologicdisorderexhibitedonly moder.
ate symptoms.The 819V DNA sequenceidentity
betweena patlentand the linkedblood donor was confimed in five ol the eight patienls.All ol the components responsiblelor the eight cases were positivefor
(lg)lV.
anti-B1
9V immunoglobulin
CONCLUSION:Vulnerabilitylo seriousB1gv-related
hematologicdisordersdependedon the palient's underlying diseasestate of an enhancedeMhropoiesis,nol
on the viral load of the comDonenttransfused.To
preventclinicallyrelevantTT-819V a stralegy is suggested in which patientsat risk of acquiringRBC
aplasiaor pancytopenia
are largeled.
nfection by human parvovirusBl9 (Bl9Vl is
common in any geographic area and causes
I
erythema infectiosumor fifth diseasein childhood.
I
-I- The infection in adults is usuallyasymptomaticbut
may cause a transient red blood cell (RBC) aplasia in
patients in the state of an enhanced erl,thropoiesis or
may cause persistent anemia in immunocompromised
patients.'-3
The prevalenceof anti-Bl9V immunoglobulin
(lg)G increases steadily even after childhood, suggesting
that B19Vinfection occursfrequentlyduring adulthood.3-6
In acute infection, the viml load in peripheral blood
reaches as high as l0''z IU/mL.7 The frequent primary
infection among adults and the high viral load without
symptoms imply the presence of a considerable number
of blood donors with a high viml Ioad, which mises the
possibility of a considerable risk of transfusiontmnsmitted Bl9V infection (TT-Bl9V).
Although TT-819V cases have often been reported
after the trmsfusion of plasma derivatives,s'r0there have
been very few reports of clinically relevant Bl9V infection
that is considered as a result of the transfusion of a BlgVcontaining blood component (i.e., RBCS, fresh-frozen
plasma IFFPI, or platelet [PLI] concentrates).rr'r5
lt has
J
ABBREVIATIONS:AML= acute myeloid leukemia; Bl9V=
human parvovirus Bl9; JRC= Iapanese Red Cross; nt =
nucleotide(s); RHA = receptor-mediated hemagglutinatioll;
TT-Bl9V = transfusion-transmitted human parvovirus Bl9V;
TTI(s) = transfusion'transmitted infection(s).
From the Iapanese Red Cross Central Blood lnstitute aDd
the Japanese Red Cross Blood Seryice Headquarters, Tokyo,
lapan.
Addrcss correspondetxceto: Masahiro Satake, Iapanese Red
Cross Tokyo Metropolitan West Blood Centel Midori-cho 3256,
Tachikawa, Tokyo 190-0014, lapan; e'mail ma'satake@
tokyo.bc.jrc.orjp.
There was no support for this article in tbe form of grants,
equipment, or drugs.
Received for publjcation November 2, 20I0; revision
receivedDecernber ll,2010, and acceptedDecember 13,2001.
doi: l0.l I I I /i.1537-2995.2010.03047.x
T R A N S F U S I O N2 0 1l ; 5 1 : l B B 71 8 9 5 .
VOlυ
me 5'`September 201l TRANSFuS10N 1887
B19V INFECT10N 8Y COMPONENT TRANSFuSiON
SATAKE ET AL
JRCblood centers are the sole facilities in Japan that deal
with blood procurement and processing, testing, and
delivery of blood components.The IRC hemovigilance
system has been functioning since 1993and covers the
entire country with I million patients being transfused
every year.Although the reporting of suspected TTI cases
to JRCis not mandatory, it is obligatory for every physician
to report TTI casesto the lapaneseMinistry of Health,
Labour and Welfare,which in turn refers this information
to IRC. Eventually,JRCis able to obtain all information
on suspected TTls and other serious adverse reactions
causedby blood tnnsfusion. The system also includes a
complete sample archivefrom all blood donations since
1999,which enablesus to investigatethe cause ol a TTI
using the repository blood samples obtained from the
donation associatedwith the TTI. For TT-BI9V cases,a
lookback study for the possibiliry of previous donation
with viremia has not been performed.
Beceptor-mediated hemagglutination assay
In 1998,JRC implemented a receptor-mediatedhemagglutination (RHA) assayas a screening test for B19V and
used it for all donated blood until 2007. The theoretical
basis of the RHA assay system was described elsewherere'?o;
briefly, it is a Bl9V antigen detection method in
which the jndicator RBCSagglutinate via B19V particle
binding to globosideson the RBCmembrane at a critical
pH (pH 5.6 a 0. l). The sensitivity of RHA is approximately
10'0IU/mL, and by this method,300 to 400 Blgv-positive
donors with very high titer viremia have been identified
every year'?tAlthough the sensitivity of RFIA is not satis1888 TRANSFuS:ON Volume 51
Polymerase chain reaction analysis of 819V and
antibody detection
On receiving a report ofa suspected case ofTT-Bl9V polymerase chain reaction (PCR) analysis was caffied out to
detect the B19V DNA in patient sera obtained before md
after the index blood trmsfusion as well as in repository
tube(s) obtained from the donation(s) from which the
blood component(s) suspected of causing TT-Bl9V had
been processed. BtgV DNA was extracted using a total
nucleic acid isolation kit (MagNA Pure LC, Roche Diagnostics,Tokyo, Japan)and mplified and quantified using
a Bl9V quantification kit (Lightcycler, RocheDiagnostics,
Tokyo, Japan). The fomard and reverse primers were
located at Nucleotides (nt) 2046 to 2064 and nt 2110 to
2092,rcspectively.The probe used was mapped at 24 bp of
nt 2067to 2090.The 95% detection limit ofthe PCRsystem
is 289 IU/mL, as determined by probit analysis. Dircct
Bl9V DNA sequencingwas performed targeting1069bp
(nt 1884-2952)
intheNSi/\/Pl region forCasesI to4.23As
for Case5, BtgV DNA was sequencedfor a total of l9 13 bp
coveringthe NS (4B9bp lnt 1396-1884]and 225bp [nt
1962-2lB7l),NS-VPl (597bp [nt 2370-2966]),and \ryl
regions. Sequenceidentity was
{602bp int 2984-35851)
assessed
fortheseregionsbetweenthe patientsampleand
the blood donor sample.IgM ild IgG specificfor Blgv
werc detected by enzyme-linked immunosorbent assay
(Pano-lgM and Parvo-lgG, Denka Seiken,Tokyo,Japan).
RESULTS
The annual number of blood donations in Japan is
approximately 5 million and the annual number of components released to m€dica] facilities for RBCS,FFP and
PLT concentrate are 3.3 million, 960,000, and 730,000,
rcspectively.Data presented in this article were coliected
during the period from 1999 through 2008 when repository blood smples from donors were available. Duting
that peiod, JRC received only 15 reports of suspected
TT-Blgv from physicians, among which we were able to
identify eight casesofTT-BI9V. This indicates that the case
frequency of documented TT-BIgV is eight per 50 million
or approximately one in 6 million donations. Details ofthe
nve T}B19V cases that were confirmed by BI9V-DNA
sequenceanalysisare described below (Table 1).
Case 1
A 4l-year-old man with hairy cell leukemia underwent
a treatment rcgimen including a course of cladribine
TABLE l Cases estab‖
Bgtore
kanslusion
57, male
AML (M4)
Atter chemolherapy
35, lemale
Placenla previa
59, male
Rectal cancer
61. male
AML
Atler chemotherapy
shed as having￢
Atter
lransfusion
ONA(十 )
lgM(+)
lgG(十)
41, male
Hairy cell leukemia
After chemotherapy
DNA← )
lgM(―)
19G(―
)
＞
．
‘
Ｇ
９
︲
PATIENTS AND METHODS
Hemovigilance system
factory, it has greatly contributed to the lowering of the
viral load in a plasma pool that is manufactured into
plasma derivatives.'z2
ln 2008,IRC implemented a chemiluminescence enzyme immunoassay-based screening
assaythat is also an antigen detection assaywith a sensitivity of approximately 107IU/mL.
，
，
．
¨，
＜ ↑
て
Ａ
¨ Ａ ¨
Ｎ Ｍ
Ｎ
ｇ
Ｄ ︲
Ｄ
thereforc been a matter ol debate whether a universal
Bl9V screening with an appropriate sensitivity is indeed
required for securing blood component safety. In rhis
regard, several studies have been conducted to establish
the frequency of blood products harboring TT-Bl9V risk
and the frequency of clinically relevant TT-Bl9V cases.In
most such studies,a reasonto implement a Bl9V screening method that coverc all blood donations has not been
verified becauseno caseof clinically relevantTT-819V was
identified during the study period.'u''"
JapaneseRedCross(lRC)blood centersestablisheda
hemovigilance system in 1993 and have been collecting
voluntary rcpofts on transfusion-transmitted infections
tTTIS) and other adverseeffects as a result oftransfusion.
Thrcugh the system, JRChas so far obtained five established and three probable casesofTT-819V In this article,
we describe the details of T'I-Bl9V cases,each of which
representeda typical clinical couBe ofBl9V infection.
DNA(― )
DNA(十 )
19M← )
190(+)
DNA(+)
lgM(十)
lgG(+)
卜B19V infecuon
Symptoms and laboratoryfindings
RBC aplasia (3 months)
Reticulocytopenia(1 month)
Viremia level ol 1 x 10r'zcopies/mL
Pure RBC aplasia (approx. 2 months)
Systemic eruption (3 weeks)
DNA(十 )
lgM(+)
19G(十)
Sustained high fever (5 days)
DNA(+)
High fever
Disseminatederythema
Pure RBC aplasia (7 weeks)
Reliculocylopenia
Translused
components
RBCs lrradiated)
DNA(+)
18× 1051U′mL・
2× 106!u/bag十
19M(+)
19G(十)
PC lrradiated)
DNA(+)
19M(+)
lgG(―)
RBCs lrrad ated)
DNA(十)
mL
30× 1051U′
3× 106Uわ ag
oM(+)
gC(+)
RBCs(lrradiated)
DNA(+)
51X1031u′mL
5× 1041u′Oag
19M(+)
19G(十)
PC lrradiated)
DNA(+)
igM(十)
10G(+)
' Viral concentralionin lhe donaled blood
1 Estimaledviral load in the componenl.
PC = PLT concentrate.
(2-chlorodeoxyadenosine)for 7 days in May 2005. On Day
0, 9 days after the completion of cladribine treatment, he
was transfusedwith I unit ofRBCs becauseofanemia. The
reticuloc)'te proportion in his peripheral blood decreased
from 3.6% on Day 6 to 2.4 and 0.370on Days B ild 10,
respectively.Bl9V PCRanalysiswas performed on his Day
ll serum, which revealed a viremia level of lxl0r'?
copies/mL. The IRC cenftal Iaboratory also detected B19V
DNA and anti-Blgv of both IgM and IgG classes in sera
obtained on Day 22. On the basis of these findings, the
diagnosis of RBC aplasia due to TT-BI9V was made.
Reticuloc]'te counts rmged from 0.1% to 0.270since then,
and the patient remained RBC transfusion dependent
requiring occasional grilulocyte*colony-stimulating
factor (G-CSF) administration. His reticuloc!'te count
started to increase in late June and the complete resolution of anemia was confirmed in late August. The repository sample from the index donation for the RBCS was
found to contain 1.8x 10sIU/nL BlgV DNA as well as
anti-Blgv ofboth IgM and lgG classes.The patient was
administered G-CSF because of existing leukopenia
caused by the preceding chemotherapy with cladribine,
not by BlgV infection (Y Tsukada, manuscript in
preparation).
Case 2
A 57-year-old man received chemotherapy for acute
myeloid leukemia(AML,M4). After the completionof chemotherapyin May 2005,he receivedmultiple blood transfusions because of sustained marrow suppressiot:. The
index blood transfusion of the PLI concentrate responsible for TT-BI9V was carried out on June 14 (Day 0). A
delayed recovery of RBC generation was noted despite a
complete recoveryofwhite blood cell and PLI generation.
Marrow examination was carried out on Day 2l revealing
pure RBC aplasia as well as a complete remission of AML.
His peripheralblood samplecollectedon Day24 waspositive for BlgV DNA and anti-819v of both IgM and IgG
classes.He becme negative for anti-819V IgM on Day 35
and RBC genention rccovery was recognized I month
later A pretransTusionsample obtained on Day -21 was
negative for both B19V DNA and anti-Blgv of both
classes.The repository sample from the index donatjon
for the PLI concentratecontained 9.7 x 103IU/nL Bl9V
DNA and the anti-Bl9V ofthe lgM classbut not that ofthe
IgG class. Seventeenblood components had been transfused to this patient before the maffow examjnation, but
only the repository sample from the index PLI concentrate was positive for Bl9V DNA.
Volume 51, September2011
TRANSFUSION 1889
SATAKE ET AL
Case 3
A 35-year-old woman with placenta previa received a
transfusion of 5 units of RBCSin tune 2005 becauseof
massive bleeding on delivery.On Day 7 after the index
transfusion,she developeda fevet of3B"C.Four dayslater
she developed systemicsmall eruprions,which led her
physician to suspect a viral infection. Laboratory testing
revealed the presenceof anti-Blgv IgM in the blood
sample collected on Day 12. A.ll the symptoms disappeared 1 month after transfusion without specific medication. The pretransfusion sample collected on Day 0 was
found to be negativeboth for Bl9V DNA and anti-Blgv
of both IgM and IgG classes. Posttransfusion samples
obtained on both Day 47 and Day 60 contained BlgV
DNA and anti-B19V of both classes.A rcuospective study
revealed that a repository sample from t of the 5 units of
the RBCScontained3.0 x 105IU/mL BlgV DNA as well as
anti-Bl9V of both classes.
Case 4
A S9-year-old man with rectal cancer received a transfusion of2 units ofRBCs during a surgical operation in April
2006. Although his postoperative cou6e was uneventful
for 5 days, he developed a high fever of3B to 40'C on Day
6 postoperation and the fever remained for 5 days despite
medication with antibiotics and antipyretics. The fever
thereafter rcsolved spontaneously. [t was reported that a
surgical complication was unlikely from the viewpoints of
the operative procedure and postoperative cou6e. A posttransfusion sample collected on Day 22 was found to be
positivefor Bl9VDNAand anti-Bl9Vofboth IgM and Igc
classes: these three markers were all negative in a pretransfusion sample obtained I day before operation. A
repositorysamplefiom the donation for I ofthe 2 units of
the RBCstransfusedcontained5.I x 103IU/mL B19VDNA
as well as anti-BlgV of both IgM and lgc classes.
Case 5
A 6l-year-old man undergoing chemotherapyfor AML
received24 blood transfusionsfor 4 months in 2002.He
developeda high feverand disseminatederythema22 and
26 days after the index transfusion (Day 0), rcspectively.
Reticulocltopeniadevelopedand pure RBC aplasiawas
corrfirmed by marrow examination. BlgV DNA was not
detected in his pretransfusionsample collectedon Day
-49 but was detected in his posttransfusion sample collected on Day 25. I-le recovered from pure RBC aplasia 7
weeks after the transfusion.The responsibleblood component was a PLI concentrate transfused in mid-May,
whjch was found to be positive for anti-Blgv of both tgM
and IgG classesand BlgV DNA. Data on the B19V DNA
concentration in the repository sample from the index
cOmponentare nOt available.
1890 TRANSFUSIONVolume51, September
2011
819V iNFECT10N 8Y COMPONENT TRANSFuS:ON
In the first four cases presented above, complete
genome sequence identity was established for nr 1884
to 2952 of BlgV between the patient posttransfusion
samplesand the associateddonor repository samples.For
Case5, yiral sequenceidentity was established for a total
of 1913bp (seePatientsand Methods).Figure I presentsa
phylogenetic tree of the B19V DNA sequencesfor the five
establishedcases.
In addition to these five caseswith established B19V
DNA sequence identity between donors and recipients,
JRC blood centeN have three reports of probable cases
of TT-BlgV (Table2). In all three cases,B19V DNA was
detected in postuansfusion samples and linked donor
repository samples, but data on BlgV DNA sequence
analysis were not available. The first case was reponed
elsewhere in detailrs; briefly, a 52-year-old womm with
paroxysmal nocturnal hematuria was regularly receiving
RBC transfusions with prednisolone administration. She
developed pancltopenia with high fever and general
malaise 13 days after the index transfusion (Day 0). She
thereafter received a continuous coulse of tanslusions
with RBCSmd PLI concenuates together with G-CSE
Sherecoveredfrom pancfopenia approximately I month
after the index transfusion, although the reticuloc],re pro.
portion remained low for a longer period. Anti-BfgV IgM
was detected in her posttransfusion smples with increas.
ing titer in the following months. Before the onset of
panc)'topenia, the patient had received transfusion of I
unit ofRBCSon Days -56, -32, 0, and +1. Repository blood
samplesfrom the four components were sublected to PCR
analysisand only one sample from the index blood component was verified to be positive for B l9V DNA. Strikingly,
the BlgV DNA-positive blood component attributed to
this infection was a washed RBC unit processed from a
donation containing6.8 x 103IU/mL BlgV and anti-Bl9V
ofboth IgM and lgc classes.The blood obtained 4 months
later from the samedonor still had a viral load of 1.6x 103
IU/mL but no specific IgM. The second patient was a
28-year-oldwoman with hemolytic anemia. Shesustained
a prolonged severe anemia after transfusion of I unit of
RBCs.Marrow exarnination verified hlpoplasia of a RBC
lineage.The proponion of peripheral blood reticulocltes
remainedas low as 0.17ofor I month. Blgv DNA was not
detectedin her pretransfusionsample.The blood component responsiblefor this casewas an RBCunit positivefor
anti-Bl9V of both IgM and IgG classes.The third patient
was a 7g-year-old man who received transfusion of I unit
of RBCduring pelvic tumor resection.He did not develop
any clinical symptoms after the transfusion but routine
postoperative blood analysis revealed a decreasedreticulocyte counr thar lasted for I week. Further investigation
verified the anti-Blgv IgM conversion. The responsible
RBCunit containedanti-Bl9V ofboth IgM and IgGclasses.
In one of the three probable casespresented above,
BlgV DNA was negative in the pretransfusion sample,
AJ249431‐2
AY0644762
AXa13421‐ 3
A」2494303
AY083234 3
PD卜3‐
05143 Case 2
PDl‐3‐
05'17
Case l
PD:-3‐06074 Case 4
PD卜 305186 case 3
Z70599‐1
M24682-1
Z7052年 1
PD卜3‐
02069 Case 5
Fig l.Phブ ogenetic tree Of B19v DNA for nve established cases.PDl‐
3‐05117,05143,‐ 05186,‐06074,and‐ 02069 correspOnd to
Cases l,2,3,4,and 5,respecthuy.For these cases,the B19V DNA sequence wasidentic」 be■veen tllose obtained from b100d
donors and those from mllsFused patients forthe region indicated under Patients and Medlods As reFerences,Other seque
published in CenBank frOm GenowpeS i t0 3 are also shown.
TABLE 2.Probable cases of T r B19v infection
Case
Patient profile
1
52, lemale
Paroxysmal nocturnal hemaluda
2
28, temale
Hemolylic anemia
3
79, male
Pelvictumor
Before
kanstugion
After
Fansfusion
DNA (+)
lgM (+)
Symptoms and laboratory
findings
High fever
General malaise
Pancytopenia(1 monlh)
DNA (-)
ONA (+)
Prolongedsevere anemia
RBC hypoplasia
Reticulocytopenia(1 month)
DNA (+)
lgM (+)
No symptoms
(1 week)
Reiiculocytopenia
Transfusedcomponents
Washed RBCS (iradiated)
ONA {+)
6.8 x 103ILJ/mL'
lgM (+)
tgc (+)
RBCS (iradiated)
DNA (+)
lgM (+)
lgc (+)
RBCS (irradiated)
DNA(+)
. rgM (+)
whereasin the other two cases,anti-Bl9V IgM was positive in the posttransfusion samples, which supports the
notion that thesethree are TT-BIgV casesas well.
clinicalillness.The associationof the Bl9V infection with
transfmion was proved by serologic data available and
viral sequence homology analysis. From a phylogenetic
tree of B I 9V DNA for the fi ve establishedcases(Fig. l), it is
apparcntthat lhe Rvepairs of BlgV DNA all belongingto
D:SCUSS:ON
GenotypeI are very closebut distinct genomes.
VVe described in this repOrt flve established and three
There have been only flve previously reported cases
ved overt
of TT-819V caused by the transfusion of blood
probable T■B19V cases,seven of which shoル
Vo:ume 51
TRANSFuSiON 1891
SATAKE ET AL
components,rr'r5one of which was cited in this afticle as
a probable case.rsAlthough the TRIP Dutch National
Hemovigilance reported one possible case of TT-BI9V
in 2007,'z4there has been no report of TT-819V in the
litemture published by hemovigilancesystemsin other
countries including SHOT in the United Kingdom and
hemovigilance in France. One asymptomatic case of
TT-BI9V has recently been reported during a donorlinked prospective study.rBThe possible reasons for the
paucity of the reports are as follows: l) a considerable
proportion oftransfusion recipientsarc immune to Bl9V
2) B19V infection usually does not causea seriousillness
even in nonimmune adults but rcsults in a deleterious
outcome only in a small proportion of patientswho are in
the specificconditionsdescribedabove.3)Passiveimmunization by the transfer of neutralizinganti-Bl9V often
occurs with concurrent transfusion.G4) The risk factorc
that increasesusceptibilityof recipientsto severeBl9V
disease,and the signs and symptoms of.TT-819Vinfection, are not well recognizedamong physicians.
h view of almost the sarne BlgV seroprevalence in
it is inconceivablethat
Japan and westerncountries,2r32s
we encountered these casesbecauseB19V infection is
more common in Japan.It is also unlikely that the Bl9V
genot!?e commonly found in Japan is more virulent and
causes morc serious illnessesin transfusion recipients
because the Bl9V genome variance is small in a defined
genotlpe and the BlgV genotypes found in the established casesae all Genot)?e l, the t)?e commonly found
in westem countries. Moreover, B19V-related serious illnesses as a result of infusion of Blgv-contminated
plasma derivatives have often been reported in western
countries.2 We speculate that we were able to collect
TT-BI9V cases owing to the efncienr hemovigilance
system of JRC.It should also be noted that physicians are
very cooperative in reporting suspected TTIS to blood
centers, which is possibly facilitated because JRClaboratories are capable of investigating the causality of TTIS
using complete sample archives from all blood donations.
Ifthe implementarionofa universalB19Vscreeningis
under consideration or required by a national authority
regulating blood progrm, it is necessary to establish a
cutoff level for screening. ln this rcgard, the infectious
dose of Bl9V DNA in blood componentsthat might cause
TTIs has been a subjectofdebate.r72G23
In general,a viral
load of approximately los IU/mL is becoming to be
accepted as an infectious dose for TT-B19V ln our clinical
observation, the viral concentrations of the components
that caused RBC aplasia in susceptible patients were
1.8x 105IU/mL in CaseI and 9.7 x 103IU/mL in Case2.
The viral concentrations ol the components that caused
lessseveresymptoms such as febrile reaction or skin eruption were 3.0 x 105IU/mL in Case3 and 5.1 x 103IU/mL in
Case4. Another patient with probable TT-819V in our case
series developed a sustained pmc''topenia after the trans1892 TRANSFUSION
Volume51,September
2011
B19V iNFECT10N BY COMPONENT TRANSFuS10N
fusion of a washed RBC unit processed from a donation
containing 6.8x 103 IU/mL BtgV Alrhough these data
may indicate that the components with very low viral
loads are infectious, it is yet to be determined whether the
lower limit of infectivity is 103or l0s IU/mL, becausemost
previous studies have not dealt with the blood components with vircl loads in this range and few data are avai.lable to determine the lower limit.
!\4rile data necessary to determine the infectious
dose of B19V in the blood components arc still lacking,
clinical symptoms due to B19V infection acquired by
blood component tmnsfusion appear to be related to the
clinical state of the transfusion recipient. Each clinical
courseofthe five establishedcasesdescribedin this report
representstlpical characteristicsof acute Bl9V infection
after a respiratory tract infection that have been described
in the literature.r 3\^Ihena patient with an enhanced erlthropoiesisreceivesa transfusionwith a B19V-containing
component,the cell production ofalineage susceptibleto
BlgV mainly the RBC lineage,"3ois totally impaired by
BlgV which directly leads to RBC aplasiain the manow
and anemia in the peripheral blood because the RBC
count or hemoglobin level in their peripheral blood was
maintained by the enhanced eq'thropoiesis as presented
in Cases1, 2, and 5. If a patient has been in the state of
immunosuppression, it will delay the elimination of BI9V
and the recovery ofthe affected cell lineage in the marrow
The underlying diseasesfor the two of the three probable
cases (i.e., paroxysmal nocturnal hematuria and
hemolytic anemia) also represent the tlpical conditions
that could lead to serious hematologic disorders after
BlgV infection. On the other hand, in recipients who are
immunologically competent md not in the state of an
enhanced erfhropoiesis, BlgV transmission may not
occur or if TT-819V occurs it may result in outcomes
limited ro laboratory findings (e.9., seroconversionor
DNA conversion) or moderate symptoms not morc severe
than a sustained fever, generalized skin lesions, or arthropathy, as shom in Cases3 and 4. These slmptoms subsequently resolved without medication possibly owing to
a rapid viral neutralization by their intact immune
responsebefore memia developed. It is possible that the
patient in Case 4 presented only mild symptoms not
because the viral load of the component was low but
becausehe was not in the state of an enhmced erythropoiesis when tmnsfused. lt is, thus, more explainable to
consider that the clinical state of the patient rather than
the viral load of the component determines the clinical
courseofTT-Blgv In Cases2 and 5, there is a slightpossibility that the clinical course ofacute BlgVinfection was
modified by the passivetransfer olneutralizing antibodies
from other PLI concentrates transfused. None of the
patients presented above received FFP transfusion.
It could, however, be argued that we have identified
TT-819V casesassociated with a relatively low viral load
and specific IgM because these cases were identified
under the screening by RHA, which detects and excludes
very high titer viremic donations. It is therefore possible
that TT-Bl9V associated with low-viral-load component
transfusion is only a portion of all TT-819V cases that
could be represented by casestransfused with high-viralload componentsIt is of note that all the components for the three
probable TT-BI9V cases as well as the five established
caseswere positivefor anti-819VIgM, ln the four casesof
TT-Bl9V reported in the litemture exceptfor one probable
casedescribedin this article,2 ofthe 3 units oftransfused
components tested were also specificIgM positive.rI12ra
These findings strongly suggestthat the presence of specific IgM in the component with or without specific IgG is
a risk factor for TT-819V The positivity for specific [gM
implies that the donors were in the early recovery phase
from an acute primary infection. It is therefore conceivable that the seven blood donors in this study who were
also positive for specific IgG had anti-Bl9V IgG of insufficient titer or an immature specificity that is incapable of
full neutalization of BlgV although it has been considered that infectivity is absent or at least modulated once
specific IgG is present.
Deep insight is needed to determine whether universal preventive measures should be implemented to
eradicate TT-BI9V First, the degee of seriousness of
Bl9V-related illnesseshas to be taken into consideration.
Sustained fever is uncomfortable and skin lesions are
painful to patients but they are essentia.llybenign and
self-limited with bearable duration. Although the condition of TT-Blgv-related pure RBC aplasia sometimes
requires RBC transfusion, patients eventually recoverfrom
anemia. Pancltopenia presents a real prbblem necessitating a course of intensive therapy.3l [t must be carefully
deliberated which ofthese illnessesshould be the target of
a new preventive measure that might be implemented.
Second, cost-effectivenessmust be considered relative to
the frequency ofTT-Blgv In ]apan, more thm 5 million
people donate blood and approximately t million patients
receive blood transfusion mnua.lly, In such a circumstance,TT-Bl9Vwas found to occurat such a lowfrequency
that onlyseven caseswith symptomswere reported dudng
the past 10 years, four of which had an impaired RBC
production and one had pmc,'topenia. These caseswere
among only 15 reports of suspected TT-BI9V suggesting
either that TT-BI9V occurrence is very rile or that most
clinicians are not aware ofTT-Bl9V Moreover,most symptoms eventually spontmeously resolve,which night lead
to the overlooking or misdiagnosis of the infection. These
clinical outcomes ofTT-Bl9V may not support the idea of
implementation ofa universal donor screeningstrategy to
cope with TT-Bl9V However,ifmore evidence is accumulated showingTT-Blgv-related serious illnesses,its implementation mav be reouiredin the future.
The universalscreeningofdonated blood for Bl9Vby
nucleic acid testing (NAT)-based algorithm is currently
carried out in Germany.'?T
With the detecrion limit of los
IU/mL, it is surelycontributingto the decreasein not only
the viral load in pooled source plasma but also the frequency of seroconversion or sl,mptomatic infection after
component transfusion. Our finding of the infectivity of
blood componentswith 103IU/mLviral load suggeststhat
this measuremay not completelyeliminateTT-BtgV cases
with serioushematologicdisorders.The implementation
of NAT screeningwith a much higher sensitivityfor Bl9V
is, however, unlikely because it would impair the current
blood progmm becauseit would result in rhe discarding of
a considerablenumber of components.
Another strategy may be feasible in which an indication for the transfusion of Bl9V-safer blood components is
defined and components with negligible Bl9V infectivity
are identified, the strategy cun€ntly being recommended
in the Netherlands.3'?Ourexperience with TT-Bl9V
enabled us to define patients at risk of Blgv-rclated
serious jllnesses; that is, patients with the indication of
TT-Blgv-safer components, namely, Bl9V-seronegative
patientswith an enhancederlthropoiesisor with hercditary RBC disorders having an increased RBC turnover.3
Seronegativepregnant women are another population at
risk because of the high risk of hydrops fetalis.r Blood
components with no or negligible viral loads will be identified by screeninga proportion ofthe current component
inventory using NATwith high sensitivity.To avoid adonation duilng the NAT window period and early recovery
phase after acute infection, components should be
selectedamong donations that show positivity for specific
lgG aswell as negativity for specinc IgM continuously over
a long period (e.g.,>6 months or 1 year).32
Pathogen reduction ild/or inactivation is a novel
strategyfor the prevention ofTTls.33lt is, however, considered to be difficult in general to mitigate the Bl9V infectivity of blood components because of the rigid viral
capsid of Bl9V that hindersthe entry of the photosensitizer and the extremely high viral load found in blood
donors in acute-phaseBl9V infection.
In conclusion, eight cases of TT-B19V caused by
transfusionwith Bl9V-contaminatedblood components
have been identified through the hemovigilance system.
lvhether a patient developed a serious Blgv-related
hematologic disorder as a result of component transfusion depended on the patient's underlying diseasestate
such as an enhancederythropoiesis,
not on the viral concentration of the component transfused.
ACKNOWLEDGMENTS
WethankDrY Tsukada,
DepartmentofHematoloBy,
KeioUniver'
sity,Tokyo;Dr E.Omoto,Departmentoflnternal Medicine,YamagataPrefecturalCentralHospital,Yamagata;
Dr P Takano,Blood
Volume51,
Seolember2011TFANSFUSION1893
SATAKE ET AL
B19V iNFECT10N BV COMPONENT TRANSFuS!ON
Transfusion Service, St Maria Hospital, Fukuoka; Dr Y Igarashi,
lordan l, Tiangco B, Kiss l, Koch W. Human parvovirus
Bl9: prevalence ofviral DNA in volunteer blood donors
Department of Surgery Yamagata Cify Hospital, Yamagata; and
Drs A. Ozaki and M. Yamaza-ki, Department
Kaneawa
of Hematology,
and clinical outcomes oftransfusion recipients. Vox Sang
l99B;75:97-102.
University, Kanazawa for providing TT-BI9V case
pollmerase chain reaction screening assay. Transfusion
BroM
2007:47tl? 56-64.
cellular receptor for Bl9 paNovirus. Science 1993;2621
KE, Anderson SM, Young NS. ErFhrocyte P antigen:
Davenport R, Geohas G, Cohen S, Beach K, Leo A, Luc-
tt4-7.
chesi K, Pehta J. Phase IV study ofPlas+@SD: hepatitis A
(HAV) and paNovirus Bl9 (BI9) safety results. Blood 2000;
von dem Borne AX, Bos Ml, Joustm'Maas N, Tromp ,F,
van'tVeer MB, van Wijngaarden,du Bois R, Tetteroo PA. A
96:451a. Abstract 1942.
reports to tRC blood centers. We also rhank Dr H. Mizoguchi, a
tRC senior advisor, for the critical reading ofthe manuscript and
Abe R, Shichishima T, Ogawa K, Saitoh Y, Maruyama Y.
Neutropenia due to paNovirus Blg infections in patients
discussions.
with parorysmal nocturnal hemoglobinuria. Blood tnnsfusion and natural infecrion cases.Acla Haematol 2006;lI6:
Schmidt M, Themann A, Drexler C, Bayer M, Lanzer G,
mudne monoclonal lgM antibody specific for blood group
P antigen (globoside). Br I Haematol l986;63:35,46.
Menichetti E, Lechner S, wessin D, Prokoph B, A.llain IP,
Osaki M, Matsubara K, Iwasaki T, Kurata T, Nigami H,
CONFLICT OF INTEREST
245-8.
Seifried E, Hourfar MK. Blood donor screening for paNovi
Harigaya H, Baba K. Severe aplastic anemia associated
Plentz A, Hahn L Kniill A, Holler E, lilg W Modrow S. Exposure of hematologic patients to paruovirus BI9 as a con-
rus B19 in Germany ed
with humil
taninant of blood cell preparations ild
The authorc have no conflict of interest for this article.
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Volume 51. Seolember 2011 TBANSFUSION 1895

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