Seven-Day : Quality Implications, Safety Benefits, and Implementation Challenges

10/13/2018 Faculty Disclosures

The following faculty have no relevant financial relationships to disclose: – Peter Schubert – Dirk de Korte

www..org 2 Faculty Disclosures The following faculty have a relevant financial relationship:

– Sandra Ramirez-Arcos MSc, PhD : – Michael Jacobs bioMerieux: Invited guest speaker by bioMerieux Verax: Consultant ASPAC Industrial Microbiology to the Japanese Pall: Grant/Research Support Red Cross Symposium Gambro: Grant/Research Support Cerus: Invited Speaker to a Cerus-sponsored Meeting Hemosystem: Grant/Research Support Immunetics: Consultant – Ralph Vassallo MD GenPrime: Grant/Research Support Grant/Research Support bioMerieux: Consultant Fenwal: Grant/Research Support Fresenius Kabi: Consultant Charles Rivers Labs: Grant/Research Support HemaNext: Consultant bioMerieux: Consultant Cerus Corp: Consultant BioSense Technologies: Consultant Terumo BCT: Speaker's Bureau Lynntech: Blood Systems: Consultant

www.aabb.org 3 Learning Objectives

• Compare in vitro quality of 5-day and 7-day platelets • Review clinical outcomes of transfusing 5-day and 7-day platelets • Discuss the impact of extending shelf-life to 7 days on patient safety • Analyze the challenges posed to blood suppliers and blood centers with the extension of platelet shelf-life to 7 days

www.aabb.org 4 In vitro quality data to support 7-day platelets

AABB Educational Session, Boston, October 13, 2018

Dr. Peter Schubert • Research Associate, Centre for Innovation, Canadian Blood Services • Clinical Associate Professor, Pathology, University of British Columbia Our laboratory received research funding from TerumoBCT, MacoPharma and HemaNext.

6 Topics to be covered

• Aspects of the platelet shelf-life

• Learn about platelet function/assays to determine in vitro and in vivo platelet quality

• Compare in vitro and in vivo quality of platelets stored for 5 vs. 7 days

7 Shelf-life of platelet concentrates

1986: FDA reduces storage time from 7 days -> 5 days

• Risk of bacterial contamination Platelet Platelet In vitro/in vivo quality deterioration • Introduction of pathogens by Safety Quality (platelet storage lesion) donor

→ This short shelf life presents a significant challenge in meeting the platelet needs of hospital patients, especially around long weekends. → It also led to discards due to outdates. 8 Tools to assess in vitro quality

Quality monitoring program (QMP)

MPV Quality Control Research in vitro pH parameters pH Glucose Platelet yield Lactate Platelet response (to agonist) (determined by platelet count pO2 Platelet microvesicles and PC volume) pCO2 Annexin-V (apoptosis) rWBC Platelet activation (P-selectin) Platelet aggregation Morphology (score) Omics technologies … Levin et al, Transfusion, 2012

9 In vivo quality: recovery and survival

Slichter et al, Blood, 2013 r2 ranging from 0.08 to 0.31

recovery survival Platelet count

0 3 6 12 24 Annexin-V (%) ESC (%) HSR (%) Post-transfusion (hrs) In) Cr) PLT recovery (%) PLT 51 111

pCO2 (mmHg) pO2 (mmHg) Glucose (mM) pH Stored PC ( Fresh PLTs ( PLTs Fresh • Poor correction between in vitro parameters and PLT recovery • Same results seen for PLT survival (r2 ranging from 0.03 to 0.41) Studies assessing 7-day platelet quality

 Only a few studies investigating the quality comparing 5-day with 7-day platelets

 Some studies assessed quality after extended storage

 Studies variables Storage solution Storage Production method

(PRP, pooled, apheresis …) 11 Studies example I Sandgren & Saeed, , 2011 Pooled PCs in 70% SSP+ Storage time *P<0.05 Day 5 Day 7 Parameter **P<0.01 PLT # [109/L] 886 ± 96 833 ± 106 n.s. pH (37°C) 7.12 ± 0.02 7.14 ± 0.03 n.s.

Glucose [mM] 4.9 ± 0.4 3.9 ± 0.5 n.s.

Lactate [mM] 8.8 ± 0.4 10.6 ± 0.7 n.s.

CD62P [%] 22.5 ± 3.8 25.4 ± 3.0 *

Pac-1 [%] 23.0 ± 7.1 15.3 ± 3.6 n.s.

ESC [%] 14.4 ± 4.2 10.5 ± 2.5 **

12 Studies example II Dumont & VandenBroeke, Transfusion, 2003 Aphesesis PC in plasma PLT # *P<0.05 Day 5 Day 7 group **P<0.01 1 7.58 ± 0.09 7.39 ± 0.12 *

2 7.46 ± 0.04 7.24 ± 0.06 * pH (37°C) 3 6.98 ± 0.62 6.76 ± 0.74 n.s.

4 7.29 ± 0.17 7.21 ± 0.18 n.s.

1 26.9 ± 5.7 44.1 ± 5.9 *

2 25.4 ± 8.0 39.8 ± 4.5 n.s. CD62P [%] 3 25.9 ± 26.9 49.4 ± 39.6 n.s.

4 15.3 ± 8.5 21.5 ± 8.4 n.s.

PLT # [109/L]: 1: 1.1 – 1.8; 2: 2.4 – 2.8 ; 3: 3.5 – 4.5 ; 4: 5.1 – 5.9 13 n=24 Day 5 Day 7 Study example III Recovery (%) 63.0 ± 11.2 53.9 ± 13.8 p > 0.05 Dumont et al., Transfusion, 2002 Survival (hours) 160.8 ± 37.5 133.6 ± 45.1

Studies example IV Slichter et al., Blood, 2013

There were some significant differences in vivo recovery and no differnces in survival between stored platelets at 5- and 7-days of storage. 14 CBS data to support the move from 5- to 7-day platelets

Pooled buffy coat PCs n=26 Brief data interpretation: Day 5 Day 7 p-value  Most parameters exhibit a 9 821 ± 79 825 ± 109 0.743 PLT count (x 10 /L) statistically significant difference pH 7.24 ± 0.07 7.19 ± 0.08 0.011 between day 5 and day 7 (trend Glucose (mM) 14.6 ± 1.4 13.4 ± 1.3 4 x 10-11 into the same direction). -4 Lactate (mM) 12.2 ± 0.8 15.7 ± 1.3 9 x 10  Within the standard deviations, CD62P (%) 33.4 ± 3.6 38.0 ± 4.2 2 x 10-9 the results for these parameters are quite similar. Apheresis PCs n=21 Day 5 Day 7 p-value  Data show a continuation of the development of platelet storage PLT count (x 109/L) 1164 ± 80 1208 ± 111 0.123 lesion. pH 7.20 ± 0.1 7.10 ± 0.1 5 x 10-6  pH values are still in spec (>>6.4) Glucose (mM) 13.3 ± 1.6 10.7 ± 1.8 3 x 10-9 Lactate (mM) 10.5 ± 2.8 14.5 ± 3.9 1 x 10-7  Platelet activation increases as a result of degranulation. CD62P (%) 31.1 ± 8.0 40.3 ± 11.3 6 x 10-5

15 Introduction of 7-day platelets: a quick turn-around in Canada

16 Introduction of 7-day platelets: a quick turn-around in Canada

 Delaying sampling for bacterial detection from 24 hours to 36 hours or longer, along with increased sampling volume that allows for testing growth in both aerobic and anaerobic conditions, improves the safety of platelet concentrates (Sandra Ramirez- Arcos)

 For most variables, the difference between 5- and 7- days of storage was smaller than the observed standard deviation (Dana Devine)

 Platelet products continue to fulfill all quality control requirements

 Modeling the potential impact of a seven-day shelf life on inventory revealed improved product availability and an about a 30 per cent reduction in product wastage (John Blake) 17 Pathogen inactivation technologies: an extra layer of safety

Safety Shelf life Quality

UV light ± photosensitizer

• Risk of bacterial contamination • Introduction of pathogens by Pathogen • Numerous in vitro studies report reduced that PITs have some negative donor PC effects on the quality of platelet concentrates

• Clinical studies show evidence of  PIT to cover low level of pathogens (not minor decreases of platelet in detected by BacT systems) PIT vivo survival, but these have not  Pathogens not screened for (no test been associated with increased available) 5-day 7-day storage bleeding in patients receiving  Unknown emerging pathogens (Zika et al.) pathogen-reduced platelets

18 Conclusion

 In vitro data show higher PSL development on day 7 vs. day 5, but pH still in spec

 In vivo (radio-labeled) data support the 5-day to 7-day shelf-life change

→ Improved inventory management

→ Reduction of wastage

→ Cost reduction

19 Visit blood.ca Seven-Day Platelets A Patient Safety Perspective

Ralph R. Vassallo, MD, FACP Vitalant EVP / Chief Medical & Scientific Officer Adjunct Associate Professor of Medicine, University of Pennsylvania School of Medicine October 14, 2018 The 7-Day RT-Stored Platelet

• 1983-1986 & 2005-2008 under PASSPORT in the US • Currently available in Europe • Convenient collection days, reduces outdates • 2006 UNC data: 6 mo. pre/post study with 60% in-house 7d unit collections → 54% ↓ in outdates with modal shift from D3 to D4 • 2017 Héma-Québec data: 63% ↓ with modal shift from D4 to D6 • The price for those 2 additional days: • Lower CCIs, perhaps increased unit use (particularly with additional ‘quality hits’ such as PAS and PRT) • Equivalent 7d bleeding outcomes in prophylaxis… other patients?

Hay SN. J Clin Apher 2007;22:283; Delage G. Transfusion 2016;56(S4):28A - 22 data from oral abstract and personal communication. July 18th BPAC

Please comment on the advantages and disadvantages of each of the various strategies to control the risk of bacterial contamination in platelets, including the scientific evidence and the operational considerations involved 5-day dating options: • 8-10 mL 1° culture with Days 4 & 5 Point-of-Care testing

• 8-10 mL 1° culture with 5 mL Day 3 BacT (Hopkins)

• Minimal Proportional Sample Volume [MPSV] ≥ 3.8% 1° culture (BSI) • Pathogen Reduction Technology (7d in Europe) 7-day dating options: • 1° culture with Days 4, 5, 6 & 7 Point-of-Care testing

• 16 mL 1° culture with 16 mL Day 4 BacT (IBTS; BacT is US FDA-approved) • 16 mL per split 1° culture (NHSBT; Delayed Lg. Vol. Culture [DLVC])

23 Cerus INTERCEPT Blood System

Step 1 Step 2 Step 3 Process Complete Amotosalen Illumination CAD Storage

Mirasol PRT System

24 French, Swiss & Belgian HV Experience: 7d PRT Plts

Benjamin RJ. Transfusion 2017;57:2946. 2006-2015 France • 49/2,575,224 non-PRT Plts → 19/M certain/probable STRs • 0/214,293 PRT units → < 4.7/M (OR 4.1; 95% CI 0.7-164.3) Switzerland • 2005-2011: 15/156,773 non-PRT Plts → 95.7/M certain/probable STRs • 2011-2015: 0/167,200 PRT units → < 6.0/M (OR 13.9**; 95% CI 2.1-589.2) 2009-2015 Belgium • 9/252,809 non-PRT Plts → 35.6/M high-probability STRs • 0/227,797 PRT units → < 4.4/M (OR 8.1**; 95% CI 1.1-353.3)

25 Total: 0 of 609,290 PRT Units Cerus INTERCEPT Blood System

Wagner SJ. Vox Sang 2016;111:226. 1 of 15 Amicus PAS-C units treated at 30 hours positive for 1 of 5 transfusion relevant spiked organisms (3 bags each) versus 0 of 15 treated at 24 hours • True positive with spore-former or high-count organism

Very few reports of STRs in PRT-treated units Klebsiella pneumoniae (2015 Switzerland; possible) Staphylococcus haemolyticus (2016 Belgium; possible) Acinetobacter calcoaceticus-baumannii complex (2018 US [5d unit]; definite) • False positive retrograde contamination from the administration set • True positive post-PRT bag contamination

26 Delayed Large Volume Culture [DLVC]

0 │ 1 │ 2 │ 3 │ 4 │ 5 │ 6 │ 7 │ Collection 16 mL aerobic/anaerobic Inoculum from each split

Sample ≥ 6 hr Useful shelf life 36 hrs hold Delayed Large Volume Culture (UK) CBS variant: 16 mL for each split from the mother bag; 8 hr hold

H-Q variant: 20 mL from the mother bag at 48 hrs; 12 hr hold

27 NHSBT’s DLVC Feb 2011 - Mar 2018 86 months (1,957,462 units) Platform Trima Apheresis Pooled BCs Collections tested 1,355,720 Rate 601,742 Rate True Positive 0.03% 0.07% False Positive 0.2-0.3% 0.1-0.2% STR rate/M Units 0 / 1,355,720 1* / 601,742 * S. aureus

5 near-miss components from 4 collections with sometimes evanescent clots 4 - S. aureus 1 - Serratia marcescens

July 2018 BPAC transcript; McDonald C. Transfusion 2017;57:1122. 28 DLVC – Statistics

• Raw TP rates have been compared with US rates – confounded by different initial fraction of contaminated units and bacterial loads (different donors, separators ± PAS, single vs. triple mix, staff skills, arm prep, sample diversion, AP vs. PRP-WBD vs. BC-WBD ± LR) • Known 2.3x higher OR for TPs, but 3.8x higher OR for STRs with Amicus collections using older software versus Trima • Incremental interdiction rate (add’l TPs) not available for DLVC

Nov 2017 BPAC transcript; Eder A. Transfusion 2017;57:2969.

29 DLVC – Statistics

• Outdate cultures not helpful due to small numerators and denominators 331-662/M D8 PASSPORT (8 mL) 498-746/M D7 5d MPSV (10-28 mL) 620/M D5 Verax Plts 161/M D7 DLVC (16-48 mL: 1 of 6,217 → S. pneumoniae) • FNs measure of interest, but complicated by passive STR reports 1 order of magnitude lower than active reports; rough equivalency can however, be calculated DLVC passive: 1 per 326,000 to 1,957,462 → Active: 1 in 33K – 196K • Compared (for 5d platelets) with: 1 per 10K active surveillance in Univ. Hosp. Case MC & ARC’s 1 per 100K passive / 1 per 10K active 1 per 10K in the Verax pivotal trial 1 per 409K passive / 1 per 41K active with MPSV

Nov 2017 & July 2018 BPAC transcripts; Hong H. Blood 2016;127:496; Jacobs MR. Transfusion 2011;51:2573; Dumont LJ. Transfusion 2010;50:589. 30 DLVC & the Anaerobic Bottle

Role of the anaerobic bottle • 49.8% anaerobic-only (48.5% both, 1.7% aerobic-only) • 20.7% anaerobic-only without P. acnes (still higher sensitivity) • Lower specificity: 77.9% false positives vs. 21.7% in aerobic bottles Strong argument for sampling each component • 47.7% of doubles with only 1 infected component • 50% in 1 and 20.6% in 2 of 3 triples

July 2018 BPAC transcript.

31 Cost for All Approaches

Availability Issues • Donor replacement cost estimated at $55 to $135 per donor • DLVC: split rate reduced by 16-48 mL volume loss and lost products with high anaerobic bottle FP rates • PRT: split loss from restrictive guardbands, increased discard rate due to high concentration settings • 2° POC testing: lost products with false-positive discards Savings • Estimated ~$14-78K saved per non-fatal sepsis avoided • Reduced wastage (⅓ to ½ outdate rate)

32 Cost (cont’d)

Direct & indirect operational costs • PRT Savings: ↓ BacT/Zika/CMV and irradiation costs; ≥ 6d shelf life outside US • PRT Costs: Likely more transfusions with 7d Plts and high acquisition cost (Blood center pass-thru for kit and disposables, hardware & maintenance, BECS/procedure changes, collections/recruitment changes incl. Amicus PAS, personnel time/training/competency, QC, recovery of lost BacT/CMV/irradiation revenue)

• DLVC Savings: ≥ 5d shelf life • DLVC Costs: Blood center pass-throughs (↑ BacT incubators, controllers & bottles; sampling supplies; BECS/procedure changes; personnel time/training; collections/recruitment changes to increase yield)

33 Cost (cont’d)

Direct & indirect operational costs • 2° POC Testing Savings: Incremental 24 hr shelf life extension • 2° POC Testing Costs: Test cost (incl. retest x 2 every 110-200 units, estimated 15-20% will undergo re-testing, but ~1/3rd will not require any testing), personnel time/training/competency, BECS/procedure changes, FDA registration/inspection, floor staff education, validation, proficiencies

• 2° POC Culture Savings: 2.5-3.5 day shelf life extension • 2° POC Culture Costs: Add’l BacT incubators/controllers, bottles, sampling supplies, personnel time/training/competency, BECS/ procedure changes, FDA registration/inspection, floor staff education

34 Cost (cont’d)

Published cost models

PRT POC Test POC Cx Total $819.98 $664.95 $650.38

Acquisition $742.48 $556.70 $556.70 Testing $0.00 $25.55 $16.43 Transfusion $77.50 $82.70 $77.25 Hopkins estimate; Sept. 5, 2018 AABB eCast

PRT POC Test DLVC $708.34 Total $891.42 $738.02 w/o upcharge Acquisition $616.96 $521.43 $521.43 Processing $3.53 $38.68 $12.03 Transfusion $166.06 $166.06 $166.06 Outdate/Extra Tfxn $104.87 $11.85 $8.82 Li JW. Transfusion 2017;57:2321; adjusted to 7d savings

35 Summary

• July 2018 BPAC discussion • PRT not ready for universal implementation; dramatically lowers risk at very high cost • Need for wide variety of alternatives, particularly in rural settings and during seasonal shortages • Theoretically less interdiction for DLVC than exquisitely sensitive 2° testing • Anaerobic bottle alarms faster and detects rare obligate anaerobes • DLVC successfully lowers risk of bacterial contamination with little disruption of transfusion service activity, wide availability and low cost • Impressively low adjusted rate on key indicator – STRs – in the UK • Some impact on platelet availability, decreased by 7d outdate • Likely three 7d alternatives will appear in Draft Guidance • POC Testing, POC Culture, DLVC 36 Thank you Clinical Efficacy of 7 Day Stored Platelets

Dirk de Korte Product and Process Development, Sanquin Blood Bank Blood Cell Research, Sanquin Research Amsterdam, The Netherlands

AABB Educational Session, Saturday October 13, 2018

21 March, 2019 | 38 DISCLOSURE

NOTHING TO DISCLOSE

21/3/19 | 39 Learning Objectives

• Will 7 days storage have a negative impact on clinical efficacy of platelet transfusions?

• To understand the balance between maximal shelf life and optimal use of donor gifts

• To allow you to make a choice in strategy to optimize platelet supply in combination with high quality products

21/3/19 | 40 Clinical Efficacy

Pre-Clinical •In vitro quality Presentation Peter Schubert Healthy volunteers •Radiolabeling recovery/survival data

Clinical data •Recovery/survival data in patients •Clinical outcome • Bleeding Presentations • Time to next transfusion Michael Jacobs •Adverse effects; microbiological safety and Ralph Vassallo

21/3/19 | 41 Recovery/survival

• Various measures • Count Increment (CI), Corrected Count Increment (CCI), Recovery (%), Survival (days)

• Recent meta-analysis by Caram-Deelder et al. Vox Sang. 2016 • Different methods used to quantify recovery: CI, CCI and recovery/survival • Different platelet products: Apheresis, PRP-derived, BC-derived (plasma and Platelet Additive Solution (PAS)) • All products combined: more generic conclusion • Not restricted to clinical studies

• General problem with clinical efficacy How to discriminate between product quality and patient effects

21/3/19 | 42 Recovery/survival

• 46 papers included (25 with up to 7 days) • All in favor of fresh, with fresh as 0-2 days and old as 3-5 or 3-7 days (as reported) • Similar pattern if 0-2 days compared to 5-7 days

old fresh

From: Caram-Deelder et al. Vox Sang. 2016;111:374-382 21/3/19 | 43 Recovery/survival

• General conclusion Older platelets lower mean CCI (mean difference -2 (±80% of fresh)) Older platelets lower recovery (about 80% of fresh) Older platelets lower survival (about 70% of fresh)

• Pro: no limitations for inclusion, likely to cover all literature in this field • Contra: lack of data comparing day 5 directly to day 6/7, small absolute difference without clinical significance mainly radiolabeled platelet studies, autologous in volunteers, not restricted to clinical use

From: Caram-Deelder et al. Vox Sang. 2016;111:374-382 21/3/19 | 44 Recovery/survival

• Focus on 5 – 7 days

• CCI reported by Dijkstra-Tiekstra et al. Transfusion 2004 • 1 h after transfusion • Buffy coat derived platelet concentrates (PC) in plasma

• CCI reported by Kerkhoffs et al. Br.J.Hematol 2010 • 1 and 24 h after transfusion • Buffy coat derived platelet concentrates (PC) in plasma or PAS-C (Intersol)

21/3/19 | 45 CCI1h

From: Dijkstra-Tiekstra et al. Transfusion 2000;44:330-336 21/3/19 | 46 Recovery/survival

• Focus on Day 5 to Day 7

Dijkstra: • Significant difference between day 2 and later, but no significant differences between day 3, 4, 5, 6 or 7 Kerkhoffs: • CCI1h: about 10-15% lower on day 7 vs day 5 • CCI24h: about 10 % lower for plasma and about 30 % lower for PAS-C (in line with in vitro difference in quality parameters)

• Type of additive solution is important! • Recent data with PAS-E: similar CCI as for plasma units

From: Dijkstra-Tiekstra et al. Transfusion 2000;44:330-336 and Kerkhoffs et al. Br.J.Hematol 2010;150:209-217 21/3/19 | 47 Clinical Outcome

Recent meta analysis Aubron et al. Critical Care 2018 •Allogeneic platelet transfusions •18 studies included • Critical ill patients (5 studies) • Hematology patients (13 studies)

•Critical ill: No association between storage time (5 days) and clinical outcome: mortality, infections

•Hematology: No associaton between storage time (7 days) and clinical outcome bleeding However: lower CCI if >2/3 days stored

From: Aubron et al. Critical Care 2018;22:185-198 21/3/19 | 48 Clinical Outcome

Limitations mentioned by Aubron et al. •For critically ill patients: • Limited by number of studies, retrospective, day 5 • Needs to be confirmed by prospective research

•For hematology patients: • More prospective, but still limited (variation) • Stable patients: how in actively bleeding patients

•Last sentence “Evidence is lacking to show that stored platelets are as safe and effective as the freshest PLT’s in massively transfused patients. Prospective research addressing these issues is warranted”

From: Aubron et al. Critical Care 2018;22:185-198 21/3/19 | 49 Clinical Outcome

Meta analysis by Kreuger et al. Vox Sang. 2017

•Safety outcomes • Increased risk for transfusion reactions with older non-leukoreduced platelet concentrates • No difference between fresh and older platelets for leukoreduced platelet concentrates

•Efficacy outcomes • Tendency to increased risk of bleeding (RR 1.13 (CI:0.97-1.32) for older platelets (but mix of platelet products) • Shorter transfusion interval for older platelets

From: Kreuger et al. Vox Sang 2017;112:291-300 21/3/19 | 50 Pathogen Reduced Platelets

Pathogen Reduced (PR) platelets •Based on in vitro data: • extra negative effect on platelet quality •Question: effect on clinical efficacy?

•Cochrane analysis (12 trials) hemato-oncological patients Estcourt et al. 2017 • Two recent trials not yet included

21/3/19 | 51 Cochrane 2017 PR Platelets

• No evidence for increased incidence of clinically significant bleeding complications (WHO Grade 2 or higher) • 5 trials, 1392 participants; RR 1.10, 95% CI 0.97 to 1.25; I2 = 0%; moderate-quality evidence

• Probably no difference in the risk of developing severe bleeding (WHO Grade 3 or higher) • 6 trials, 1495 participants; RR 1.24, 95% CI 0.76 to 2.02; I2 = 32%; moderate-quality evidence. Minimal number of Grade 3 or higher bleedings

• Participants who received PR platelet transfusions had an increased risk of developing platelet refractoriness • 7 trials, 1525 participants; RR 2.94, 95% CI 2.08 to 4.16; I2 = 0%; high-quality evidence, though the definition of platelet refractoriness differed between trials

From: Estcourt et al. Cochrane Database Syst Rev. 2017;7 21/3/19 | 52 Cochrane 2017 PR Platelets

• PR platelet transfusions required more platelet transfusions • 6 trials, 1509 participants; mean difference (MD) 1.23, 95% CI 0.86 to 1.61; I2 = 27%; high-quality evidence

• Probably shorter time interval between transfusions • 6 trials, 1489 participants; MD -0.42, 95% CI -0.53 to -0.32; I2 = 29%; moderate- quality evidence.

• Participants who received PR platelet transfusions had a lower 24-hour corrected-count increment • 7 trials, 1681 participants; MD -3.02, 95% CI -3.57 to -2.48; I2 = 15%; high-quality evidence

From: Estcourt et al. Cochrane Database Syst Rev. 2017;7 21/3/19 | 53 Two Recent PRT Studies

I. EFFIPAP study with Intercept® in PAS-C, Garban et al. Jama Oncol. 2018

•3-arm study with 790 patients; bleeding WHO Grade 2 or higher as primary endpoint

•Noninferiority was not achieved when PR platelets in additive solution were compared with platelets in plasma (4.4%; 95%CI, -4.1%to 12.9%)

•Noninferiority was achieved when the PR platelets were compared with platelets in additive solution (2.6%; 95%CI, -5.9%to 11.1%).

•The proportion of patients with grade 3 or 4 bleeding was not different among treatment arms.

From: Garban et al. Jama Oncol. 2018;4:468-475 21/3/19 | 54 Two Recent PRT Studies

II. PREPAReS study with Mirasol® in plasma (van der Meer et al., Blood,2018)

• 2-arm study with 470 patients; bleeding WHO Grade 2 or higher as primary endpoint (using same scoring system as EFFIPAP)

• PR platelets were noninferior in preventing bleeding only in intention to-treat analysis

• In contrast to animal models, alloimmunization could not be prevented when using PR platelets

From: van der Meer et al. Blood 2018;132:223-231 21/3/19 | 55 Cochrane 2017 PLUS

• EFFIPAP and PREPAReS included using Cochrane software

Patients with bleeding WHO ¡Ã 2

• Risk of bleeding WHO Grade 2 or higher is 12 % higher for PR platelets

• Mean Difference for CCI24 slightly higher (-4%) than in Cochrane 2017 (-3%)

Kindly provided by J-L.H.Kerkhoffs 21/3/19 | 56 Discussion/Conclusion

• Older platelets have lower recovery/survival compared to fresh, but absolute differences between 5 or 7 days storage are limited

• For standard platelets in plasma no or minimal effect of longer storage on clinical efficacy. For newer products, i.e. platelets in additive solution (different formulations) and/or PR not enough evidence

• Risk of “slippery slope” (late Scott Murphy) • Products must be compared to ‘golden standard (Fresh)’ and not against other platelet products which are noninferior to ‘golden standard’ (FDA requirement for recovery/survival data)

21/3/19 | 57 Discussion/Conclusion

• Longer shelf life reduces outdating of valuable donor gift

• Studies must focus on how to inhibit development of storage lesion • For example: use of PAS-E instead of PAS-C

• More clinical data needed, but very complex studies; questionable what is meaning of grade 2 bleeding

• Existing data with mix of storage times in which the proportion of older (5-7 days) platelet concentrates is limited; difficult to conclude on 5 or 7 days efficacy

21/3/19 | 58 Secondary testing strategies to detect bacterial contamination of 7-day platelets

Michael R. Jacobs, MD, PhD, FRCPath, D(ABMM), F(AAM)

Professor of Pathology and Medicine Case Western Reserve University Director, Clinical Microbiology University Hospitals Cleveland Medical Center

Cleveland, OH Disclosures

Grants bioMerieux Charles River Labs Fenwal Gambro Genprime Hemosystem Immunetics Pall Verax Speaker fees bioMerieux Verax Immunetics Scientific Advisor BioSense Technologies (uncompensated) Lynntech, Inc. Blood Systems Inc. Other Member of the Bacterial Contamination Task Force of AABB Member of the Bacterial Contamination Task Force of International Society for Blood Transfusion Interventions to reduce transfusion of bacterially contaminated platelets

• Primary culture of apheresis units – introduced in 2004 • Use of diversion pouch • Change in skin prep methods • Prepooling and primary culture of whole-blood derived units – introduced in 2007 • Secondary test at or close to time of issue – Commercial assays – Secondary culture • Pathogen reduction FDA draft guideline options

Strategies for 5-day platelets: 1. Primary culture followed by secondary rapid testing within 24 hours prior to transfusion 2. Primary culture followed by secondary culture on Day 3 3. Minimal proportional sampling volume (MPSV) 4. Pathogen reduction technology Strategies for 7-day platelets: 1. Primary culture followed by secondary rapid testing within 24 hours prior to transfusion 2. Primary culture followed by secondary culture on Day 4 3. Large volume delayed sampling (LVDS) culture-based testing

FDA: Bacterial Detection Testing by Blood Collection Establishments and Transfusion Services to Enhance the Safety and Availability of Platelets for Transfusion; . 2014 http://www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/Blood/UCM425952.pdf Bacterial contamination and septic reaction rates pre- and post- primary culture at University Hospitals Cleveland Medical Center

Post-primary culture • 34 contaminated products despite primary culture • Use of these products resulted in 8 septic reactions, 1 fatal • Reactions delayed 6-24 h post-Tx • NONE of these 8 reactions were reported to the transfusion service AABB 2018 poster BBC65 Current status of US apheresis platelet supply

• 400 contaminated apheresis units per million = 800 per year with approx. 2 million transfusions/year • Septic reactions are rarely reported by passive surveillance - likely <10% reported • Estimated ∼100-200 septic reactions/year (∼50-100 per million) with several fatalities • Despite recent interventions, platelets were responsible for 10 of 19 contamination or infection associated fatalities reported to FDA 2012-2016 • Six recent septic reactions with 3 fatalities from apheresis units associated with Klebsiella pneumoniae, Acinetobaceter species and Clostridium perfringens • FDA draft guidance recommends secondary testing based on 2012 BPAC meeting • Extension of outdate to 7 days makes secondary testing even more important due to continued bacterial growth during storage Jacobs MR, Smith D, Heaton WA, et al.: Detection of bacterial contamination in prestorage culture-negative apheresis platelets on day of issue with the Pan Genera Detection test. Transfusion 2011; 51: 2573-82. Fatalities Reported to FDA Following Blood Collection and Transfusion for Fiscal Year 2016. https://wwwfdagov/downloads/BiologicsBloodVaccines/SafetyAvailability/ReportaProblem/TransfusionDonationFatalities/UCM598243pdf Horth RZ, et al. 2018. Fatal Sepsis Associated with Bacterial Contamination of Platelets - Utah and California, August 2017. MMWR Morb Mortal Wkly Rep 67:718-722. Jones J. 2018. Call for Cases: Acinetobacter Calcoaceticus-Baumannii Complex Sepsis Associated with — Multi-state, 2018. https://epix2cdcgov/v2/Reports/StandardReport/Displayaspx?id=66484&print=True&PSR=False FDA: Bacterial Detection Testing by Blood Collection Establishments and Transfusion Services to Enhance the Safety and Availability of Platelets for Transfusion; in FDA, (ed). 2014 http://www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/Blood/UCM425952.pdf Challenges in detection of bacterial contamination

Growth of bacteria in platelets based on one viable organism in a 400 ml unit (0.0025 organisms/ml) 1.E+09 1.E+08 1.E+07 1.E+06 1.E+05 1.E+04 1.E+03 1.E+02

1.E+01 no lag, 8-h gen time 1.E+00 no lag, 4-h gen time no lag, 1-h gen time Bacterial load (cfu/ml) . 1.E-01 auto-sterilization 1.E-02 1-day lag 1.E-03 3-day lag 0 1 2 3 4 5 6 7 Days after collection

Palavecino, E. L., R. A. Yomtovian, and M. R. Jacobs. 2010. Bacterial Detection limit using 8 ml culture volume contamination of platelets. Transfus Apher Sci 42:71-82. Nine secondary culture or testing studies showing apheresis contaminants missed by primary culture: Independent of volume, time of testing and test method

3-20 mL per collection used for primary culture

All show overlapping 95% confidence intervals

66 Studies in red boxes are interdiction studies PASSPORT study: 7-day apheresis platelets • PRIMARY bacterial culture release test (RT): Aerobic and anaerobic culture bottles were inoculated with 4 to 5 mL 24 to 36 hours post- collection. • 388,903 COLLECTIONS were accrued 9/2005 through 1/2008 from 52 regional blood centers • 14 reported septic transfusion reactions: 36/million; 95% CI 22- 60/million) transfused on Days 3-7; three were from Day 6 or Day 7 APs. • Outdate cultures had four TPs of 6039 tested (662/million; 95% CI, 180-1695/million).

Adapted from Dumont et al Transfusion 2010, 50:589 FDA-cleared secondary testing methods*

• Rapid assays – Verax PGD Test: cleared for up to day 7 for APH and pooled, with SAFETY MEASURE claim – Immunetics BacTx Test: cleared as a quality control test for up to day 5 for APH and pooled • Secondary culture – BacT/ALERT BPA and BPN culture bottles: cleared for use on days 4-6 to extend dating to 7 days APH and pooled, with SAFETY MEASURE claim *Cleared indicates approval for use by US FDA through 510(k) submission; currently, secondary testing is recommended by FDA but is not required Verax PGD Assay BacTx Assay

WBDP pools Analytic sensitivity LRAP • Single-use, qualitative test Analytic sensitivity in LRAP The BacTx Bacterial Staphylococcus Staphylococc for the detection of aureus Detection Kit is a rapid, us aureus Pseudomonas Pseudomona aeruginosa aerobic and anaerobic qualitative assay for s aeruginosa Staphylococcus Gram positive and Gram epidermidis the detection of aerobic Staphylococc us… negative bacteria Enterobacter and anaerobic Gram aerogenes positive and Gram Propionebact • Detects the presence of Bacillus cereus erium acnes negative bacteria in conserved bacterial Klebsiella Bacillus surface cell wall antigens, pneumoniae apheresis and cereus Escherichia coli Klebsiella lipoteichoic acid and prepooled, whole-blood oxytoca Streptococcus lipopolysaccharide, using agalactiae derived platelets Escherichia Clostridium coli specific antibodies perfringens Streptococcu Serratia marcescens s agalactiae

101 102 103 104 105 106 107 Clostridium 1.E+01 1.E+02 Detection1.E+03 limit1.E+04 (CFU/mL)1.E+05 1.E+06 1.E+07 perfringens Serratia marcescens Detection101 102 limit103 104 105 (CFU/mL)1.E+01 1.E+02 1.E+03 1.E+04 1.E+05

69 Verax Insert P00583 Rev. H Apr 2017 BacTx Bacterial Detection Kit for Platelets August 16, 2013 CF-B502-706 Effectiveness of the Verax PGD Test was Demonstrated in a Major Multi-center Study

• 2 years, 18 US hospitals • 27,620 primary culture negative doses tested with PGD • Units with reactive results cutured • Results – 1:3,069 PGD detection rate (326 per million) • 0.5% false positive rate

Day 3 Day 4 Day 5 Total

Contaminated Doses Detected 4 2 3 9

Bacillus Bacillus Species CoNS (2) CoNS (2) CoNS E faecalis (2)

Jacobs MR, et al. Transfusion 2011;51:2573-82 70 Bacterial species Age of unit Confirmation Bacterial load Transfusion isolated by culture at (days) method* (CFU/ml)** status 12 Primary Culture issue false negative doses PGD positive found among 27,620 Bacillus sp; P. acnes 3 BC NT Not Tx CoNS 3 PC, GS NT Not Tx apheresis platelets split unit PGD tested on day CoNS 3 PC, GS NT Not Tx of transfusion Enterococcus faecalis 3 PC, GS NT Not Tx (434/million) CoNS; Peptostreptococcus 4 PC, BC, GS NT Not Tx CoNS 4 PC NT Not Tx PGD Test did not include CoNS 5 PC, GS 1.3 x 10e6 Tx – no rxn reagents to detect S. oralis Bacillus sp. 5 PC, GS 1 x 10e7 Not Tx Tx – septic – this has been added to CoNS 5 PC, GS 1.2 x 10e7 the test shock* PGD negative – concurrent culture group Bacterial load below LoD Streptococcus oralis 5 PC, GS 2 x 10e7 Septic Reaction of PGD Test CoNS 5 PC 4 x 10e2 No Reaction PGD negative – passive surveillance group Allergic Equivocal Gram stain; not Streptococcus sanguinis 5 GS -/+, BC NT Reaction possible to determine if

allergic or mild septic Jacobs et al. 2011. Transfusion 51:2573-82. BC = broth culture; PC = plate reaction as clinical features culture GS = Gram stain NT = Not Tested for quantity *documented bacteremia with 71 overlap same organism THE NUMBER OF DOSES STUDIED IS SIMILAR TO THE NUMBER OF APHERESIS TRANSFUSIONS EVERY WEEK!

Jacobs, M. R., et al. 2011. Transfusion 51:2573- 14 82 PGDprime: Second Generation PGD Test*

• Simplified sample processing – no centrifugation required • Two additional capture lines for increased breadth of reactivity • Improved specificity: Fragmented antibodies (Fc fragment removed) to eliminate most false positive reactions No false positives in 2,459 platelet doses tested in in-house studies to date • Development complete, currently in validation studies

*under development – not cleared by FDA

73 Secondary testing of platelets by day 4-6 BacT/ALERT culture

Safety measure testing can be used to extend dating of platelets provided the following conditions are met. • Sampling should be done no sooner than Day 4 post collection with both aerobic and anaerobic bottles and with 8-10 mL sample per bottle. • Negative results from Days 4-6 of safety measure testing can be used to extend the dating of platelets to 7 days. NOTE: Timing of negative is not defined (min of 12 h in draft guidelines) – interpreted as negative at time of issue • For use in U.S. platelets must be stored in FDA cleared or approved 7-day storage bags labeled with a requirement to test every product with a bacterial detection device cleared by FDA and labeled as a safety measure.

https://www.fda.gov/downloads/BiologicsBloodVaccines/BloodBloodProducts/ApprovedProdu cts/SubstantiallyEquivalent510kDeviceInformation/UCM596342.pdf Johns Hopkins Day 3 secondary bacterial culture

• Performed on primary culture (using 8-10 mL in BacT/ALERT BPA) negative apheresis platelets received from supplier on Day 3 post collection • 5 mL inoculated into BacT/ALERT BPA aerobic bottle upon receipt (Day 3) using a sterile connection device and sampling kit. • Bottles incubated at 35 degrees C for 3 days; products used if negative at 24 h. • 23,044 platelet products tested 10/2016-11/2017 and transfused days 4 and 5 • Eight positive cultures were detected - 1:2881, 347(CI 179-684)/million, 7 of which were positive within 24 h. Five of the eight cases were probable true positive (repeat reactive); 217(CI 96-506)/million and interdicted; the remaining three cases were indeterminate. • No septic transfusion reactions were reported (previously ∼40/million). • Cost $27 per unit; $77,935 per averted case

Bloch EM, Marshall CE, Boyd JS, Shifflett L, Tobian AAR, Gehrie EA, Ness PM. 2018. Implementation of secondary bacterial culture testing of platelets to mitigate residual risk of septic transfusion reactions. Transfusion 58:1647-1653. Active surveillance Passive surveillance

1000 Mix of buffy coat pools and apheresis units Eder Kamel Ramirez McDonald McDonald 276 2010-2014 2008-2012 2017 No primary testing With primary testing* 144 146 Amicus 20014-2016 Septic Septic 100 Trima Septic + near Septic + near 78 misses misses 56 50 40 38 25 23 21 19 19 18 15 14 15 12 12 11 10 10 10 9 7 7 6 5.3 6 5 4 3 2.2 2 2 2 (95% CI) (95% APH Pooled Fuller Erony 1 1 Jacobs 2004- 2009- 0.8 2004-2017 2006 2016 *Investigation of 514 reported cases of suspected platelet Septic reactions are rarely reported by transfusion associate sepsis from 2012 through 2016 by passive surveillance - likely <10% are the UK Serious Hazards of Transfusion (SHOT) group 0.2 reported 0.1resulted in only one case determined to be a septic 0.1 reaction Septic transfusion reactions per million million per reactions transfusion Septic Conclusions • Extension of shelf life to 7 days makes the need for secondary testing or pathogen reduction even more compelling • Studies to date, including current and higher volume/delayed testing, did not detect all contaminated units – more data are needed as numerators are low in many of these studies • Two studies of secondary testing within 24 h of use have been shown to provide additional safety for 5-day platelets – PGD rapid test on days 3-5 – secondary BacT/ALERT aerobic bottle culture on day 3 • Use of secondary testing allows shelf-life to be extended to 7 days – PGD Test and BacT/ALERT day 4-6 aerobic + anerobic bottle culture are FDA- cleared for 7-day platelets Thank you Backup slides Gold standard for bacterial contamination

• The gold standard for determination of bacterial contamination rates is CULTURE at time of use or at outdate • The utility of interventions can be absolutely documented by such cultures • Other parameters, such as reported septic transfusion and mortality rates, can result in rates being greatly under-reported

Dumont LJ, Kleinman S, Murphy JR, Lippincott R, Schuyler R, Houghton J, Metzel P. 2010. Screening of single-donor apheresis platelets for bacterial contamination: the PASSPORT study results. Transfusion 50:589-99 Bacterial contamination of US apheresis platelet supply

• Continues to occur despite recent interventions, responsible for 10 of 19 contamination or infection associated fatalities reported to FDA 2012-2016 • Bacterial species causing fatalities included Serratia marcescens (n=2), Staphylococcus aureus (n=4), coagulase-negative staphylococci (n=2), Acinetobacter species (n=1) and Enterobacter aerogenes (n=1) • Serratia marcescens cases were associated with pooled platelets and the others with SDP

Fatalities Reported to FDA Following Blood Collection and Transfusion for Fiscal Year 2016. https://wwwfdagov/downloads/BiologicsBloodVaccines/SafetyAvailability/ReportaProblem/TransfusionDonationFatalities/UCM598243pdf Six recent septic reactions with 3 fatalities from apheresis units

• 2 fatal reactions associated with SDP from the same collection contaminated with Clostridium perfringens reported from Utah in 2017 • 2 septic reactions, 1 fatal, associated with SDP from the same collection contaminated with Klebsiella pneumoniae in California in 2017 (a third co-component was also contaminated but was not transfused) • 2 septic reactions in Utah and California in 2018 associated with Acinetobacter calcoaceticus- Acinetobacter baumannii complex

Horth RZ, et al. 2018. Fatal Sepsis Associated with Bacterial Contamination of Platelets - Utah and California, August 2017. MMWR Morb Mortal Wkly Rep 67:718-722. Jones J. 2018. Call for Cases: Acinetobacter Calcoaceticus-Baumannii Complex Sepsis Associated with Platelet Transfusion — Multi-state, 2018. https://epix2cdcgov/v2/Reports/StandardReport/Displayaspx?id=66484&print=True&PSR=False Secondary testing demonstrates much higher detection of contamination than primary testing Days 3-5 vs at-issue

100 or outdate 90 Day 1 vs at-issue or 85.7 80 75 70 outdate 60 53.6 Primary 50 40.6 40 culture has 27.7

Percent detection 30 22.2 19.5 21.9 poor 20 8.3 sensitivity 10 0 Pearce APH Murphy cultured PGD non- PGD Blajchman Yomtovian anaerobes Pearce excl. Pearce Dumont APH Dumont with Murphy day 4 culture day PGD cultured PGD

PGD study: Cultured subset: N=10,424, 5 culture positive (any titer); 4 culture positive at ≥104 CFU/mL LoD; 3 detected by PGD Test PGD study: Non-cultured subset: N=17,196, 6 detected by PGD Test; 1 detected by passive surveillance

Murphy WG, et al. Vox Sang 2008;95(1):13-9. Pearce S, et al. Transfus Med 2011;21(1):25-32. Blajchman MA, et al. Transfus Med Rev 2005;19(4):259-72. Dumont, L. J., et al. 2010. Transfusion 50:589- 99 83 Yomtovian R, et al. AABB 2011 abstract SP410 Jacobs MR, et al. Transfusion. 2011, 51:2573- 82 Passive surveillance for septic reactions

• The limitations of passive surveillance are illustrated by the strict criteria used to diagnose a septic transfusion reaction in the UK. • This requires that the same bacterial species be isolated from the platelet unit and the patient’s blood culture • Investigation of 514 reported cases of suspected platelet transfusion associate sepsis from 2012 through 2016 by the UK Serious Hazards of Transfusion (SHOT) group resulted in only one case determined to be a septic reaction • The SHOT report noted “Haemovigilance systems for bacterial TTI (transfusion transmitted infection) are passive and as such rely on clinical colleagues to report suspected TTI.”

Bolton-Maggs PHe, Poles D, et al on behalf of Serious Hazards of Transfusion (SHOT) Steering Group: The 2016 Annual SHOT Report. 2017.