Solvent-detergent Treatment Research Articles

Pharmaco-economics of blood transfusion safety: review of the available evidence.

Pharmaco-economics provides a standardized methodology for valid comparisons of interventions in different fields of health care. The role of pharmaco-economics in the safety of blood and blood products has, however, been very limited to date. This review discusses the pharmaco-economic evaluations of strategies to enhance blood product safety that have been published in the scientific literature. We reviewed pharmaco-economic methodology with special reference to cost-effectiveness analysis. We searched the literature for cost-effectiveness in blood product safety. Net costs per quality adjusted life-year (QALY) gained varied from cost-saving for human immunodeficiency virus (HIV)- and hepatitis C virus (HCV) antibody screening and leucoreduction to several million US dollars per QALY gained for solvent-detergent treatment of plasma, nucleic acid amplification testing and HIV p24 antigen testing. To date the safety of blood transfusion has been largely determined by available technology, irrespective of pharmaco-economics. Net costs up to several million US dollars per QALY gained were found for interventions implemented.

Enveloped Virus Inactivation by Caprylate: A Robust Alternative to Solvent-Detergent Treatment in Plasma Derived Intermediates

Solvent-detergent treatment, although used routinely in plasma product processing to inactivate enveloped viruses, substantially reduces product yield from the human plasma resource. To improve yields in plasma product manufacturing, a new viral reduction process has been developed using the fatty acid caprylate. As licensure of plasma products warrants thorough evaluation of pathogen reduction capabilities, the present study examined susceptibility of enveloped viruses to inactivation by caprylate in protein solutions with varied pH and temperature. In the immunoglobin-rich solutions from Cohn Fraction II+III, human immunodeficiency virus, Type-1, bovine viral diarrhea virus (BVDV), and pseudorabies virus were inactivated by caprylate concentrations of ≥9mM, ≥12mM, and ≥9mM, respectively. Compared to solvent-detergent treatment, BVDV inactivation in Fraction II+III solution was significantly faster (20–60 fold) using 16mM caprylate. Caprylate-mediated inactivation of BVDV was not noticeably affected by temperature within the range chosen manufacturing the immunoglobulin product. In Fraction II+III solutions, IgG solubility was unaffected by ≤19mM caprylate. In albumin solution from Cohn supernatant IV-1, 40mM caprylate rapidly inactivated BVDV, demonstrating versatility in inactivating enveloped viruses potentially present in other protein solutions. Our data show that caprylate is a robust enveloped virus inactivating agent for immunoglobulins and albumin which may potentially be utilized for other proteins; viral inactivation was not adversely affected by protein content and the buffer composition conditions evaluated. Within the parameters examined, caprylate inactivation of enveloped viruses provided comparable activity or advantages relative to the current, standard solvent-detergent treatment. Copyright 2002 The International Association for Biologicals. Published by Elsevier Science Ltd. All rights reserved.

Parvoviruses and blood products

Erythrovirus B19 (B19), a small isocahedral, non-enveloped virus (18–26 nm), is a ubiquitous infection agent in industrialised countries. Depending on the infected host, B19 has a wide range of disease manifestations from asymptomatic (the majority) to severe, including persistent infection. The risk of B19 transmission by blood products is enhanced by a high virus titre in the infected donor, by pooling of a large number of donations, and by the virus's resistance to effective inactivation methods such as heat and solvent-detergent treatments. B19-DNA has been detected in single donations, in manufacture plasma pools and in plasma derivatives (clotting factors, albumin, antithrombin III and immunoglobulins) produced by different processes. B19 transmission is mostly found in patients treated with clotting factors, as shown by a higher seroprevalence in treated haemophiliacs, by the presence of B19 DNA, and by active seroconversion. Chronic B19 infection can successfully be treated with polyvalent intravenous immunoglobulins. The key role of neutralising anti-B19 antibodies and of the virus titre has been demonstrated by B19 transmission after infusion of several B19-positive plasma batches treated with solvent-detergent. Two strategies can be followed to reduce the B19 risk: (1) reducing the viral load in the manufacture plasma pool by discarding B19-DNA-positive donations; (2) developing new strong virus inactivation methods. The physico-resistant properties of B19 make it a good model for new emergent viruses capable of infecting blood products.

Pathogen Inactivation in Blood Products

A combination of the economic importance of blood as a resource and the advent of the AIDS epidemic has led to a requirement for improved pathogen screening techniques for donated blood. However, due to window periods where infective agents cannot be detected, the ability to disinfect of blood and its derivatives plasma, platelets and red blood cell concentrates has assumed great importance. Whereas conventional disinfection techniques such as solvent-detergent treatment or ultra-violet irradiation may be employed in plasma or protein concentrates, the collateral damage associated with such treatments disallows their use with cellular fractions. In many ways the pathogen selectivity required here is akin to standard antimicrobial chemotherapy but is complicated by the requirement for activity against the full range of microbes--viruses, bacteria, yeasts and protozoa--rather than simply antibacterial or antiviral etc. The recent problems due to prion agents in the blood supply mean that such agents should also be included in any proposed disinfecting regimen. Several new approaches to microbial disinfection have been proposed by academia and the "blood industrials" : targeted chemotherapy, photochemotherapy and photodynamic antimicrobial chemotherapy.

Development of a highly purified multicomponent leukocyte IFN-alpha product.

A purification process was developed to obtain a human interferon- alpha (IFN-alpha) product that contains all major IFN-alpha subtypes produced by human leukocytes. The purification was accomplished by immunoaffinity chromatography using two monoclonal antibodies (mAb) and gel filtration. The process comprised two effective virus inactivation steps, solvent detergent treatment, and incubation at low pH, and the purified product was filtered with a 15-nm pore size virus removal filter. The overall yield of IFN-alpha in the process was about 60% when starting from the culture supernatant of Sendai virus-induced human leukocytes. The specific activity was about 1.0 x 10(8) IU/mg. The level of DNA and protein impurities including mouse IgG was very low. The product contained seven main subtypes: IFN-alpha 1, IFN-alpha 2, IFN-alpha 8, IFN-alpha 10, IFN-alpha 14, IFN-alpha 17, and IFN-alpha 21. The subtypes IFN-alpha 4 and IFN-alpha 7 were minor components. Reverse-phase HPLC indicated a constant subtype composition for the product from batch to batch. Stabilization of the pure IFN-alpha solution with albumin and Tween 80 was compared. In virus filtration, a better yield and higher filtration capacity were obtained with Tween. The addition of albumin resulted in the formation of IFN-albumin aggregates. During long-term storage, IFN-alpha was stable in both solutions for 2 years at 2-8 degrees C. The new method makes it possible to extensively purify all major IFN-alpha subtypes and obtain a virus-safe and stable product with a constant subtype composition.

Development of a Pharmaceutical Apotransferrin Product for Iron Binding Therapy

High-dose chemotherapy of patients with haematological malignancies results in extracellular iron accumulation and appearance of non-transferrin-bound iron, which is thought to predispose the patients to septic infections and contribute to organ toxicity. We describe the development of a human plasma-derived apotransferrin product for iron binding therapy. The product is purified from Cohn fraction IV of human plasma by two ion exchange chromatography steps and ultrafiltration. The process comprises solvent detergent treatment as the main virus inactivation step and 15nm virus filtration and polyethylene glycol precipitation as removal steps for physico-chemically resistant infectious agents. Product characterization by electrospray and MALDI-TOF mass spectrometry indicated no other chemical modifications than N-linked glycan chains and disulphide bonds, except minor oxidation. The purity of the product was more than 98%, main impurities being IgG, IgA and hemopexin. The product had intact iron binding capacity and native conformation. A stable liquid formulation for the finished product was developed. The product has proved safe and well tolerated in early clinical trials in iron binding therapy.

Viral inactivation of fresh frozen plasma.

Viral inactivation of fresh frozen plasma.

Viral Inactivation of Intramuscular Immune Serum Globulins

A new process for the production of intramuscular immunoglobulin products is described which includes viral inactivation through solvent-detergent treatment. Removal of solvent-detergent was accomplished by precipitation, filtration and diafiltration. Process-scale preparations had appropriate antibody potency levels, and improved IgG integrity relative to traditional IGIM products. Moreover, acceptable results were obtained in all in vitro and in vivo pre-clinical toxicology testing, as well as clinical evaluation. Scaled-down experiments demonstrated that the new process provides effective viral inactivation. Taken together, these results indicate that the new products should have the same efficacy of the previous IGIM products albeit with safety and processing improvements.

Human Intravenous Immunoglobulin Preparation and Virus Inactivation by Pasteurization and Solvent Detergent Treatment

ABSTRACT Human intravenous immunoglobulin (IVIG) solutions were prepared by two different methods and compared to each other. The crude immunoglobulin fraction obtained from Cohn-Oncley fractionation of plasma was further purified and subjected to virus inactivation, either by polyethylene glycol precipitation and pasteurization at 60°C for 10 hours, or by ion exchange chromatography and solvent/detergent treatment.

Ion-exchange chromatography separation of the detergent and the solvent from immunoglobulins after solvent–detergent treatment

For inactivation of lipid-enveloped viruses during the immunoglobulin production, the solvent–detergent (S/D) method was applied. Tri-n-butyl phosphate (solvent) and Triton X-100 (detergent) were removed from S/D treated immunoglobulins by ion-exchange chromatography on Q-Sepharose Fast Flow (FF). During the chromatographic procedure immunoglobulins remained bound on a Q-Sepharose FF, whereas solvent and detergent were eluted by washing with starting buffer. Elution of immunoglobulins was achieved by increasing the ionic strength of the starting buffer. The final immunoglobulin preparation contained less than 10 μg/ml of Triton X-100 and less than 2 μg/ml tri-n-butyl phosphate. It was confirmed that the S/D procedure did not cause a significant change in polymers and specific antibodies content. Immunoglobulin classes were also not affected by the same procedure.

Hepatitis C virus and blood transfusion: past and present risks

The risk of HCV transmission by blood and blood products has been greatly reduced since the early 1980's. Selection of non-remunerated donors, donor selection to prevent HIV transmission, initial surrogate testing in some regions, and introduction of anti-HCV testing have all contributed to this. ALT surrogate testing has become obsolete since the introduction of anti-HCV testing. The residual risk of HCV transmission due to donations in the anti-HCV window period at present is about 1 in 100 000 transfusions of cellular products, and transmission of HCV by plasma products treated with modern inactivation methods such as solvent-detergent treatment, has not been reported. Hemovigilance programmes, which are presently being installed, will provide more data on the safety of blood transfusion. Introduction of HCV nucleic amplification technology (NAT) as a quality control of manufacturing pools for plasma products or as a form of blood donor screening by minipools is anticipated in many European countries for the coming year. Given industrial developments, NAT testing of individual blood donations may become available within the next 2 years. HCV NAT testing will further annihilate the residual risk, and the cost-effectiveness will become relatively low in comparison with other public health measures.

Removal of Viruses from Human Intravenous Immune Globulin by 35 nm Nanofiltration

Viral safety is an important prerequisite for clinical immunoglobulin preparations. A common manufacturing practice is to utilize several virus removal/inactivation process steps to ensure the safety of human intravenous immunoglobulin (IVIG). In this regard, we examined the use of Planova 35 nm filters to reduce potential loads of both non-enveloped and enveloped viruses prior to end-stage solvent detergent treatment. The nanofiltration process was validated for removal of a variety of enveloped and non-enveloped viruses ranging in size from 70 nm to 18 nm including: Sindbis virus, Simian Virus 40 (SV40), Bovine Viral Diarrhoea virus (BVDV), Feline Calicvirus, Encephalomyocarditis virus (EMC), Hepatitis A virus (HAV), Bovine Parvovirus (BPV) and Porcine Parvovirus (PPV). The filtration procedure was carried out by first spiking a 7% solution of IVIG with <108virus. The spiked IVIG solution was then filtered through a 75 nm Planova filter followed by two Planova 35 nm filters in series (75/35/35). The 75 nm prefilter is incorporated into this process to increase the capacity of the 35 nm viral removal filters. As a result of the inclusion of the 75 nm pre-filtration step it was possible to assess the removal of virus by the 35 nm filters independent of possible aggregation of the initial viral spiking material. Samples were collected at each step and immediately titred by viral plaque assay. A process control sample of the spiked load solution was held at the same conditions for the duration of the filtration process and then titred to determine the extent to which antibody neutralization may have contributed to overall viral reduction. Control assays of spiked IVIG were performed to establish the degree of toxicity of the IVIG solution to the indicator cell lines and the extent to which the IVIG interfered with plaque formation in the assay system. This combined data was used to establish assay sensitivity for the calculation of log removal by the filtration process. It was noted that toxicity/interference effects could have a significant effect upon apparent log reductions, and these effects could vary greatly, even within viruses of the same family. The results of these studies indicate that 35 nm filtration is very effective for removing substantial quantities of both non-enveloped and enveloped viruses from IVIG. Complete clearance (to the limits of detection of the assay) was obtained for all viruses larger than 35 nm. Interestingly, viruses reported to have mean diameters of less than 35 nm (EMC and HAV) were at least partially removed by the filtration (4·3 and >4·7 logs removal, respectively). Even small viruses such as PPV were to some extent removed from the IVIG solution by the filters (2·6 logs removal). Reduction of BPV would not be assessed due to extensive neutralization and interference with plaque formation by the IVIG. Sindbis and SV40 also were subject to neutralization and assay interference due to the IVIG, though to a lesser extent. We conclude from these studies that the 35 nm mean pore size is functionally efficient in removal of smaller size viruses from spiked IVIG concentrates.

Virus inactivation by solvent/detergent treatment and the manufacture of SD-plasma.

Solvent/Detergent (SD) is an extraordinarily effective means for eliminating enveloped viruses from plasma and plasma products. The safety margin suggested by the rapid and complete kill of enveloped viruses observed in the laboratory has been confirmed repeatedly by groups worldwide and by thirteen years of routine clinical use encompassing an estimated 35 million doses of a wide variety of products. Throughout this time, there has not been a single documented case of enveloped virus transmission by an SD-treated product. This record of safety spawned the development of SD-treated plasma as a substitute for fresh frozen plasma (FFP) and has encouraged the adoption of SD for the treatment of non-blood products such as monoclonal antibodies and those derived from recombinant DNA procedures. This review summarizes the use of SD treatment, including its use in combination with other viral elimination procedures, and also summarizes Vitex's initial experience in the manufacture of SD-Plasma, recently licensed by the U.S. FDA.

Analysis of human plasma products: polymerase chain reaction does not discriminate between live and inactivated viruses.

The viral safety of human plasma products is based on the careful selection of donors and donations and the removal and inactivation of human pathogenic viruses that could potentially contaminate human plasma. For the analysis of the final products for potential virus contamination, the use of polymerase chain reaction (PCR) has been proposed. To test whether this method can discriminate between infectious and inactivated viruses, the following studies were performed. Infectious and virus-inactivated preparations were titrated with specific PCR, using viruses such as hepatitis B virus (HBV), hepatitis C virus, bovine viral diarrhea virus, and poliovirus. The inactivation method employed was pasteurization (10 hours, 60 degrees C) or solvent/detergent (SD) treatment; in the case of HBV, there was consecutive treatment by both methods. Pasteurization of HBV and hepatitis C virus as well as SD treatment of HBV or pasteurization of HBV followed by SD treatment did not affect the detectability of these viruses by PCR, whereas an infectivity study in chimpanzees demonstrated that infectious hepatitis C virus was inactivated by pasteurization. Pasteurization also had no effect on the PCR titers of stabilized bovine viral diarrhea virus or poliovirus preparations, but it destroyed the infectivity of these viruses completely after only 4 hours' heat treatment. Pasteurization or SD treatment destroys the infectivity of the viruses tested, but neither significantly affects their detectability by specific PCR. Therefore PCR is not a suitable measure for testing the viral safety of finished plasma products that have been subjected to virus inactivation.

Intravenous Anti-D Treatment of Immune Thrombocytopenic Purpura: Experience in 272 Patients

AbstractWe report the results of intravenous anti-D (WinRho, WinRho SD) therapy in 261 non-splenectomized patients treated at the New York Hospital-Cornell Medical Center over the period from 1987 to 1994. Children (n = 124) and adult patients (n = 137) with classic immune thrombocytopenic purpura (ITP; n = 156) or human immunodeficiency virus (HIV) related thrombocytopenia (n = 105) and acute (n = 75) or chronic (n = 186) disease at the time of the initial anti-D treatment were studied. In addition, 11 previously splenectomized patients were treated as a separate group. Our objectives were to evaluate the following. (1) Efficacy of anti-D: The response after the initial infusion was analyzed according to clinical parameters, such as patient's age, HIV status, gender, disease duration, pretreatment platelet count, and hemoglobin value, as well as treatment-related factors, including the dose of anti-D, the solvent detergent treatment of the preparation, and the type of administration. (2) Use of anti-D as maintenance therapy: The duration of response after the initial infusion and the results of subsequent treatments were evaluated. (3) Safety/toxicity of anti-D: Postinfusion reactions and hemoglobin decrease after treatment were studied. Anti-D is a safe treatment providing a hemostatic platelet increase in greater than 70% of the Rh+ non-splenectomized patients. The group with the best results is HIV− children, but all patient groups respond and the effect lasts more than 21 days in 50% of the responders. Duration of response is not influenced by HIV status; furthermore, HIV+ patients show no adverse effects on hemoglobin decrease or HIV disease progression. Patients with chronic ITP after splenectomy have minimal or no response to intravenous anti-D.

Cryoprecipitate prepared from plasma virally inactivated by the solvent detergent method.

There remains a small risk of viral transmission from single-donor blood components such as fresh frozen plasma (FFP) and cryoprecipitate which have not been subjected to a viral inactivation procedure. It is now possible to subject pooled FFP to viral inactivation by the solvent detergent (SD) treatment method, but with some loss of coagulation factors. To establish whether cryoprecipitate prepared from SD plasma would be suitable for the treatment of hypofibrinogenaemia and von Willebrand's disease (VWD), control and SD cryoprecipitate were assayed for factor VIII. von Willebrand factor (VWF) and fibrinogen content. In SD cryoprecipitate, levels of VWF activity and antigen were only 36% and 37% of control values respectively, whereas fibrinogen was 72%. The highest molecular weight multimer of VWF:Ag were absent from both SD plasma and SD cryoprecipitate. SD cryoprecipitate would thus be unsuitable for treating VWD, but would provide an alternative to untreated individual donor units of cryoprecipitate for the treatment of hypofibrinogenaemic states.

Successful Clinical Use of a Plasma-derived, Dual Virus Inactivated Factor VIII Concentrate Incorporating Solvent-detergent and Dry Heat Treatment

Successful Clinical Use of a Plasma-derived, Dual Virus Inactivated Factor VIII Concentrate Incorporating Solvent-detergent and Dry Heat Treatment

Factor VIII Inhibitors in Previously Treated Haemophilia A Patients with a Double Virus-inactivated Plasma Derived Factor VIII Concentrate

Antibodies to factor VIII (inhibitors) are usually produced at the beginning of treatment with factor VIII and are rare in multitransfused patients. Such antibodies are deemed to be patient-related, as supported by the description of a number of associated risk factors. However, a second category of inhibitors has recently been identified, namely antibodies occurring in multitransfused patients as a result of exposure to a particular factor VIII concentrate. A first outbreak of product-related inhibitors was recently described. The present paper describes the second well-documented occurrence of such inhibitors. Eight out of 140 multitransfused patients with severe haemophilia A developed an inhibitor to factor VIII shortly after changing treatment to a double-virus inactivated plasma-derived factor VIII concentrate. In addition to solvent-detergent treatment, this concentrate was pasteurised at 63 degrees C for 10 hours. Exposure to the pasteurised product before inhibitor detection ranged from 9 to 45 days. Inhibitor titers varied between 2.2 and 60 Bethesda Units and recovery of transfused factor VIII ranged from 0.21 to 0.68 (expressed as i.u./dl factor VIII rise per i.u./kg administered). In contrast to usual inhibitors in haemophilia A patients, these product-related inhibitors showed complex inhibition kinetics. They were found specific for the factor VIII light chain. The inhibitors gradually declined when exposure to the pasteurised product was stopped, despite further treatment with other factor VIII concentrates. The present data stress the importance of carefully monitored clinical studies, both in previously treated and previously untreated patients, before introduction of a new or modified clotting factor concentrate.

Determination of the inactivation kinetics of hepatitis A virus in human plasma products using a simple TCID50 assay

The transmission of hepatitis A virus (HAV) associated with use of FVIII concentrates has been reported in a number of European countries. All of these cases were associated with products inactivated by use of solvent detergent treatment. These reports have emphasized the necessity of evaluating virus inactivation methodologies for their ability to inactivate HAV. Such studies had previously been hampered by the difficulties associated with titration of HAV, because of the minimal cytopathic effect of most strains of virus on tissue culture cells. We have developed a simple, rapid, TCID50 virus titration system using a cytopathic strain of HAV which allows extensive kinetic studies of HAV inactivation. This has been compared with the standard radioimmunofocus forming (RFF) assay which is presently used for HAV titration. The reproducibility of the TCID50 assay was demonstrated to be equal to that of the RFF assay and the 95% confidence intervals for titres determined by both assays were also equal. The thermal stability of the cytopathic strain was studied and shown to be equivalent to that of a noncytopathic strain. The kinetics of HAV inactivation by heating in aqueous solution were compared to those of HIV-1 and a number of model viruses. It was demonstrated that HAV was highly stable, with 5 hours heat treatment at 60 degrees C in aqueous solution being required to inactivate 5.8 log10 virus. In contrast to heating in aqueous solution, lyophilization followed by 1 hour vapor heating at 60 degrees C was sufficient to inactivate 5.9 log10 HAV.

Intravenous immunoglobulin and hepatitis C virus: an overview of transmission episodes with emphasis on manufacturing data

A number of episodes of non-A, non-B hepatitis (NANB) have been associated in the recent past with the administration of intravenous immunoglobulin (IGIV). It now appears that hepatitis C virus (HCV) is the cause of NANB, although not all the factors leading to HCV transmission by IGIV are completely understood. Nevertheless, based on a retrospective analysis of two episodes of HCV transmitted by anti-Rh D immunoglobulin (anti-D), cold ethanol fractionation clearly is important in ensuring viral safety; both of these intravenous anti-D preparations were manufactured without benefit of this purification step. Other episodes of HCV transmission have been associated with IGIV produced using chromatography (particularly DEAE-Sephadex ® chromatography), with has been used after cold ethanol fractionation to further purify immunoglobulin G. DEAE-Sephadex chromatography may have only a marginal partitioning capacity, such that infective HCV virions are not further fractionated into waste fractions. All IGIV preparations associated with HCV transmission were formulated as lyophilized preparations, which may be important in stabilizing HCV before administration to patients. The role of anti-HCV screening in improving the viral safety of IGIV preparations remains unclear, but additional viral inactivation steps, such as solvent-detergent treatment or incubation at pH 4.0, probably are required for IGIV manufactured using chromatographic procedures.