Vaccines, Blood & Biologics
Transmissible Spongiform Encephalopathy Infectivity in Blood and Other Biologicals: Strategies for Detection, Decontamination and Removal
Principal Investigator: Luisa Gregori, PhD
Office / Division / Lab: OBRR / DETTD / LBTSEA
Creutzfeldt-Jakob disease (CJD) and its variant form (vCJD) are rare, fatal, brain diseases known as transmissible spongiform encephalopathies (TSEs), or prion diseases. The term "spongiform" refers to the appearance of holes in the affected brain tissue, resembling a sponge, when observed under the microscope. In cows, a similar disease is popularly called "mad cow disease." Consumption of beef from cattle infected with mad cow disease caused the appearance of vCJD in humans.
TSEs are particularly insidious infections because the agents that cause them can remain undetected for decades, causing no noticeable illness. These agents are not like viruses and bacteria and they resist standard decontamination procedures. In addition, there are no tests that identify individuals who have CJD or vCJD before disease becomes apparent. As a consequence, these agents have on rare occasions been transmitted through corneal or neural tissue transplantations, blood transfusions, contaminated neurosurgical instruments or by treatment with plasma-derived products or drugs made from infected tissues (such as human pituitary-derived growth hormones).
vCJD is of particular concern because affected individuals can have the TSE agent in their blood for years before there are any signs of infection. In the meantime, these individuals represent a potential source of vCJD infection risk if they donate blood for transfusion.
Four transfusion-transmitted vCJD infections have already been reported in the United Kingdom (UK). One additional infection attributed to treatment with a protein called coagulation Factor VIII that was obtained from vCJD-contaminated human plasma and used to treat a patient with hemophilia. The number of silently infected blood donors in the UK is unknown, but estimates range from a few hundred to several thousand.
To reduce the risk of transmitting vCJD by blood and other biological sources, FDA has recommended deferring people who are at high risk for CJD and vCJD from donating blood and tissues. The deferral policies are based on the theoretical risk posed by eating contaminated beef. Individuals are deferred from donating blood if they have resided or traveled for a total of three or more months in the UK (the country with highest number of mad cow disease cases) between 1980 and 1996; or if they resided or traveled longer than 5 years from 1980 to the present in Western European countries. The recommendation is slightly different for plasma donations. Individuals are also deferred if they received blood transfusion in the UK from 1980 to present. In addition, permanent deferral is recommended for individuals who have been diagnosed with vCJD or other forms of CJD, individuals who received a high risk tissue transplant (e.g., cornea or neural tissue), and donors with one or more blood relatives diagnosed with CJD. While protecting the public from the risk of accidental exposure to the TSE agents, those policies have deferred many donors who are unlikely to have been infected with TSE agents and may have contributed to blood shortage in some cases. This situation could be improved if a TSE screening test is available to test donated blood for the presence of vCJD agents. FDA has also encouraged the development of such a test.
Several commercial companies are developing test methods to detect TSE. However, a major difficulty is lack of reference standards to validate the candidate tests; that is, there is no standard sample containing a known amount of vCJD agent against which to compare a new test to verify that it works properly. Our laboratory is trying to resolve this difficulty by producing infected animal blood as reference standards. We also developed new animal models of vCJD infection in order to study how TSE agents cause disease.
In addition, our laboratory is studying ways to reduce the risk of transmitting TSE agents that might be present in blood using a variety of devices, such as filters. A similar approach will be applied to remove other pathogens from blood as well. This investigation is highly critical to the FDA mission of protecting public health from the threat of blood-borne pathogens while maintaining an ample supply of blood.
While the risk of dietary vCJD transmissions has decreased, secondary transmissions of vCJD by blood transfusion remain the major threat to the blood supply and to public health. The newly reported case of transmission by Factor VIII derived from human plasma in the UK has broadened the risk to include soluble plasma products. An ante-mortem plasma-based vCJD test would offer a valuable tool for reducing this risk.
Our research program focuses on separate but complementary approaches to developing a TSE screening assay with the goal of enhancing the safety of blood and other biologics, reducing the risk of iatrogenic transmissions, and improving CJD diagnosis. These goals are highly relevant to the FDA mission to protect and improve public health. The research will also generate valuable material for studies of TSE transmission in transgenic mice and how the genetics of the animal host affects the pathology of TSE and the replication of the infectious agent.
Detection of TSE infectivity is currently conducted using PrPTSE (Amplification of pathological prion protein of transmissible spongiform encephalopathies) as a surrogate marker. Although there are reported cases in which the relationship between infectivity and PrPTSE is questionable, in most cases the presence of PrPTSE correlates with infectivity. Thus, in our studies, we use PrPTSE as biochemical marker of TSE infectivity, and when possible, infectivity is confirmed with the animal bioassay.
In previous studies, a test was developed in which PrPTSE was first captured using an immuno-affinity resin followed by detection with either a Western blot or an Origen Analyzer (an ELISA-like assay). FDA developed another assay format called DELFIA to detect PrPTSE in infected tissues. Both assay platforms are very sensitive and are currently available in the laboratory. However, PrPTSE concentrations in blood may be below the detection limit of both assays. Therefore, our program also envisions a different strategy to increase PrPTSE concentrations in blood using a relatively new technology called Protein Misfolding Cyclic Amplification (PMCA) which amplifies PrPTSE in vitro. This approach must be thoroughly investigated and demonstrated to have the necessary sensitivity and specificity. If successful, PMCA has the potential for detecting PrPTSE in infected blood.
Our laboratory is also developing vCJD-infected reference standard materials suitable for validating candidate TSE screening tests. We will titrate vCJD-infected blood using a panel of transgenic (Tg) mice expressing the human PrP gene ("humanized"Tg mice) and wild-type mice. We will test humanized Tg mice that over-express PrP and mice that do not over-express PrP. These mouse models must be experimentally evaluated and compared because mice sensitivity to low infectivity levels cannot be anticipated a priori. Control studies will be conducted to ensure that under the conditions tested the mice do not develop spontaneous neurological disease that could affect the results of the titrations.
J Virol 2014 Dec;88(23):13732-6
Development of dose-response models of Creutzfeldt-Jakob disease infection in nonhuman primates for assessing the risk of transfusion-transmitted variant Creutzfeldt-Jakob disease.
Huang Y, Gregori L, Anderson SA, Asher DM, Yang H
Transfusion 2014 Sep;54(9):2194-201
Risk assessment for transmission of variant Creutzfeldt-Jakob disease by transfusion of red blood cells in the United States.
Yang H, Gregori L, Asher DM, Epstein JS, Anderson SA
PLoS One 2013 Oct 24;8(10):e78710
Red-backed vole brain promotes highly efficient in vitro amplification of abnormal prion protein from macaque and human brains infected with variant creutzfeldt-jakob disease agent.
Nemecek J, Nag N, Carlson CM, Schneider JR, Heisey DM, Johnson CJ, Asher DM, Gregori L
Vox Sang 2012 Oct;103(3):260-72
Prion reduction of red-blood-cells.
Coste J, Prowse C, Grabmer C, Schennach H, Santos Prado Scuracchio P, Wendel SN, Germain M, Delage G, Krusius T, Ekblom-Kullberg S, Tiberghien P, O'Riordan J, Murphy WG, Flesland O, Turner M, Williamson L, Gregori L, Epstein J, Asher D, Panzer S, Reesink HW
J Comp Pathol 2012 Jul;147(1):84-93
Squirrel monkeys (Saimiri sciureus) infected with the agent of bovine spongiform encephalopathy develop tau pathology.
Piccardo P, Cervenak J, Yakovleva O, Gregori L, Pomeroy K, Cook A, Muhammad FS, Seuberlich T, Cervenakova L, Asher DM
PLoS One 2012;7(5):e36620
Detection of prion protein particles in blood plasma of scrapie infected sheep.
Bannach O, Birkmann E, Reinartz E, Jaeger KE, Langeveld JP, Rohwer RG, Gregori L, Terry LA, Willbold D, Riesner D
Emerg Infect Dis 2011 Dec;17(12):2262-9
Candidate cell substrates, vaccine production, and transmissible spongiform encephalopathies.
Piccardo P, Cervenakova L, Vasilyeva I, Yakovleva O, Bacik I, Cervenak J, McKenzie C, Kurillova L, Gregori L, Pomeroy K, Asher DM
Transfusion 2011 Dec;51(12):2596-602
Estimation of variant Creutzfeldt-Jakob disease infectivity titers in human blood.
Gregori L, Yang H, Anderson S
Lancet 2011 Feb 5;377(9764):444-6
A prototype assay to detect vCJD-infected blood.
Vet Pathol 2009 Nov;46(6):1205-12
Characterization of a US sheep scrapie isolate with short incubation time.
Hamir AN, Richt JA, Kunkle RA, Greenlee JJ, Bulgin MS, Gregori L, Rohwer RG
Vox Sang 2009 Oct;97(3):226-33
Prion removal effect of a specific affinity ligand introduced into the manufacturing process of the pharmaceutical quality solvent/detergent (S/D)-treated plasma OctaplasLG.
Neisser-Svae A, Bailey A, Gregori L, Heger A, Jordan S, Behizad M, Reichl H, Römisch J, Svae TE
Emerg Infect Dis 2008 Sep;14(9):1406-12
Excretion of transmissible spongiform encephalopathy infectivity in urine.
Gregori L, Kovacs GG, Alexeeva I, Budka H, Rohwer RG
J Virol Methods 2008 May;149(2):251-9
A sensitive and quantitative assay for normal PrP in plasma.
Gregori L, Gray BN, Rose E, Spinner DS, Kascsak RJ, Rohwer RG
Can J Vet Res 2008 Jan;72(1):63-7
Experimental transmission of scrapie agent to susceptible sheep by intralingual or intracerebral inoculation.
Hamir AN, Kunkle RA, Bulgin MS, Rohwer RG, Gregori L, Richt JA
Dev Biol 2007;127:123-33
Characterization of scrapie-infected and normal hamster blood as an experimental model for TSE-infected human blood.
Gregori L, Rohwer RG
Lancet 2006 Dec 23;368(9554):2226-30
Reduction in infectivity of endogenous transmissible spongiform encephalopathies present in blood by adsorption to selective affinity resins.
Gregori L, Gurgel PV, Lathrop JT, Edwardson P, Lambert BC, Carbonell RG, Burton SJ, Hammond DJ, Rohwer RG
Transfusion 2006 Jul;46(7):1152-61
Reduction of transmissible spongiform encephalopathy infectivity from human red blood cells with prion protein affinity ligands.
Gregori L, Lambert BC, Gurgel PV, Gheorghiu L, Edwardson P, Lathrop JT, Macauley C, Carbonell RG, Burton SJ, Hammond D, Rohwer RG
Lancet 2004 Aug 7-13;364(9433):529-31
Effectiveness of leucoreduction for removal of infectivity of transmissible spongiform encephalopathies from blood.
Gregori L, McCombie N, Palmer D, Birch P, Sowemimo-Coker SO, Giulivi A, Rohwer RG
J Gen Virol 2004 Jun;85(Pt 6):1777-1784
Standards for the assay of Creutzfeldt-Jakob disease specimens.
Minor P, Newham J, Jones N, Bergeron C, Gregori L, Asher D, Van Engelenburg F, Stroebel T, Vey M, Barnard G, Head M, The WHO Working Group on International Reference Materials for the Diagnosis and Study of Transmissible Spongiform Encephalopathies
Biologicals 2004 Mar;32(1):1-10
Partitioning of TSE infectivity during ethanol fractionation of human plasma.
Gregori L, Maring JA, MacAuley C, Dunston B, Rentsch M, Kempf C, Rohwer RG