Workshop on Plasma Standards Building 45 National Institutes of Health, Bethesda, MD August 31, 2004 PARTICIPANTS Moderator DR. Les Holness Jay Epstein, Introductory Remarks Elizabeth Callaghan, Summary of June 20, 2003, BPAC Donna DiMichele, Need for High Quality Product Albert Farrugia, Product Quality Sharyn Orton, Current U.S. requirements for SP, FFP, Cryo, and recovered plasma Johannes Dodt, Paul-Ehrlich-Institut, Current Council of Europe and European Pharmacopoeia Standards for SP, FFP, Cryo, and recovered plasma Tom Walker, Canadian Blood Services, Current Canadian Standards for SP, FFP, Cryo, and recovered plasma Albert Farrugia, Therapeutic Goods Administration, Australia, Current Australian Standards for SP, FFP, Cryo, and recovered plasma Mary Gustafson, PPTA, Overview ZLB Behring, Daniel Albrecht, Plasma for Fractionation Octapharma, Barbara Glantschnig, Current Practices ZLB Behring, Jon Knowles, Current Practices Grifols, Jim Sesic, Current Practices Baxter, Roger Brinser, Current Practices Bayer, MaryAnn Lamb, Current Practices ZLB Behring, Jim Viane, Issues Related to Frozen Storage Biolife, Roger Brinser, Impact of change ARC, Peter Page, Current Practices AABB, Susan Wilkinson, Current Practices ABC, Mike Fitzpatrick, Current Practices P R O C E E D I N G S DR. HOLNESS: Let's get started. I'm Les Holness. I'm with Division of Blood Applications at CBER. There are a few announcements before we start our session today. There is no smoking anywhere in the building. The bathrooms are on the left side and both sides of the main conference room outside and upstairs. The cafeteria is on the floor above. Telephones are on the right outside. There is a message board right outside this conference room, area code 301-496-9966. Transcripts of the workshop will be available on the CBER website 15 working days after the meeting. There are also evaluation sheets at the back of your handouts. If you'll fill those out at the end of the session and leave them with us, it will be very helpful. Our first speaker today will be DR. Jay Epstein. He's the Director of Blood Research and Review at CBER, Food and Drug Administration. DR.EPSTEIN: Well, I don't know that I'm a speaker so much as a greeter. It's my pleasure and privilege to welcome everyone to this FDA Workshop on Plasma Standards, and I'd like to start by thanking the principal organizers, who are DR. Holness, DR. Weinstein, and Elizabeth Callaghan, and also special thank to Joe Wilczek for providing logistical support for this meeting, including rescuing it when we lost our venue at Lister Hill. And I hope there wasn't too much confusion with people going to the originally planned location. I also want to thank in advance both our speakers and attendees for their efforts to ensure a successful meeting, and especially those who have come from Australia and Europe and other long distances. So I guess the lead question is: Why are we here? And to start, I'd like to show some of our meeting objectives which are related to information gathering that will help FDA develop an ultimate policymaking initiative. So what are the objectives? Well, we seek to obtain information that would aid in the development of regulatory standards for the entities that we now call recovered plasma, and subjects of concern include potential labeling and the freezing, storage, and shipping conditions. We additionally have the objective to review scientific data, regulatory requirements, and current industry practices regarding the freezing, storage, and shipping of plasma to ensure the safety, purity and potency both of the labile and the non-labile plasma components, and we have also the opportunity, if you will, to explore the potential to harmonize the requirements with other regulatory bodies, recognizing also that in this field many of the standards are standards rather than regulatory requirements as one looks place to place. Of course, we hope to ensure that any regulatory decisions that our agency might make will be based on a good understanding of the current science, but also a perspective on the need or lack of need for change and the practicality of any proposals that might be made. So what are the policymaking goals? They're summarized on this slide. We seek to identify the quality of plasma based on labeling to indicate the conditions of freezing. In other words, as products are distributed in the U.S. and worldwide, it should be patent through their label exactly what condition of plasma is being offered. We seek to remove barriers to conversion of plasma collected with the intention for use in transfusion or conversion to use in fractionation. This is a request that we have received from parts of the blood industry that are uncomfortable with the current limitations which reduce flexibility. We do, however, feel that where we may relax some barriers, we need to retain some distinctions, and the issue is to retain only those distinctions which are important. And some of the distinctions that will need to be considered are: labeling that would distinguish plasma coming from a whole blood collection versus an apheresis collection; product characterization based on intended use at the time of collection, which is now fundamental in the FDA regulations; as well as the aforementioned conditions of freezing. And we want to ensure that our regulatory standards, as I stated, conform to the scientific state of the art. Now, just a word about process. It's important to note that policymaking in this area will be a deliberative process. No one should expect a rapid change, and we will certainly proceed in a public manner with ample opportunity for notice and comment. Now, in particular, regarding this workshop, let me just note that this is only one venue for collecting information. Additionally, there's been some concern how public are we pressing companies to be. Proprietary or confidential information will be considered through one-on-one discussions with the regulated industry. There is no intention here to impose or compel disclosure of proprietary or trade secret information. So whatever information is being shared is being done voluntarily. Additionally, in the spirit of information sharing, it is our intention to establish a docket--I believe we have to do that by publishing an FR notice. That has not yet happened, but we will establish a docket for this workshop that will provide a mechanism for further sharing of public information. In other words, people can write to the docket and provide information that is then made public for the ongoing dialogue. And as I said, any policy proposals will be developed through a public process of notice and comment. Now, for the remainder of my remarks, I'd like to provide a brief overview of the program and pose some questions that I hope will be discussed at the meeting, predominantly in the panel discussions. So starting with now, Day 1, and looking at the morning, we'll first have a summary of the June 20, 2003, Blood Products Advisory Committee, where we made some proposals and heard recommendations on standards for recovered plasma, and in particular, focus on the need to develop specifications for the allowable storage conditions and dating periods of a product which is potentially a licensable product. We will hear a consumer perspective on the need for high-quality plasma products, and then we will review manufacturing standards for plasma for fractionation, which come basically in two parts: first, a special guest invitation to review the literature on the effects of time to freezing, rate of freezing, and the freezing and storage temperature on the integrity of plasma proteins; we will then have a segment where we review our regulatory standards around the world, starting with the FDA framework, which, as you know, does not have requirements for recovered plasma; and then the overview and rationale of the international standards for plasma freezing, storage, and shipping respectively from the Council of Europe and the European Pharmacopoeia, Canadian standards, and Australian standards. In the afternoon today, we will then have--I guess I fell behind a little bit. The next one. In the afternoon, we will then hear about the current practices in the plasma fractionation and the blood collection industries, and this will be followed by the first of two panel discussions. Now, the first panel will focus on the science, the current practices, and the regulatory oversight of plasma preparation, and we've famed two questions in particular: What conditions of plasma collection, processing, shipping, and storage are necessary to ensure safety and efficacy of plasma derivatives? And a subsidiary question, whether the same standards should apply to all plasma independent of the end products that may be made from different collections? And then the second question: Should any restrictions between placed on further use of plasma based on the conditions of plasma collection, processing, shipping, and storage? Is there such a thing as a recovered plasma which was frozen sufficiently after the time of collection that it shouldn't be used to make an injectable? And, of course, we will be informed hopefully by current practices. So that panel will conclude today's session, and then tomorrow, which is a half-day meeting, is mostly about straw men. I guess that's sexist, but I've never heard anyone speak of "straw women." It's probably unflattering. But the idea is that we will listen to proposals on candidate regulatory frameworks for recovered plasma, and you'll hear proposals from the FDA, from sectors of the blood industry and the plasma industry, and then once again, that will be followed by a panel discussion. Now, the questions for this panel include the following--again, the subject being the framework issues for possible licensing of recovered plasma. So, first off, what should we call the various plasma products that are distributed for further manufacturing use? How should they be labeled? In particular, should they carry labels according to the time and/or rate of freezing? And if so, what would be a suitable stratification for such labeling? Should they continue to be labeled according to intended use? And then what distinctions should be made from source plasma? Should the regulations be neutral, for example, if a fractionator seeks to switch wholly from source plasma to recovered plasma should we have no concerns at all about validation of end products, or should we be concerned about revalidation at some level? Now, I am aware that a certain amount of confusion and apprehension has surrounded the run-up to this workshop, and I'm hopeful that my remarks have served to clarify the focus of the meeting. And I do look forward to a productive day and a half of information sharing and thoughtful discussion. So at this point, I'm going to turn the podium back to DR. Holness so that we can begin the meeting in earnest, and thank you very much. DR.HOLNESS: Thanks Jay. Now for a summary of the June 2003 Blood Products Advisory Committee, Liz Callaghan will give us the summary. She's Deputy Director, Division of Blood Applications at CBER. MS. CALLAGHAN: Good morning, everybody. I hope you didn't have too much of a time getting over here from the other building. Sorry about the confusion. I would like to give you a brief summary of the June 20, 2003, Blood Products Advisory Committee meeting. Actually, the issue with recovered plasma started at the Blood Products Advisory Committee on June 13, 2002. FDA made a presentation to the committee and asked if we should, in fact, develop standards for recovered plasma. The committee unanimously voted yes, and they gave us some additional recommendations: come up with an alternative name; develop a strategy to allow apheresis plasma from whole blood donors to be used for further manufacture; and to distinguish this component from source plasma. FDA then went and developed some strategies, and they were presented at the June 20, 2003, BPAC. To address the alternative name issue, FDA asked, Could we name the product "component plasma"? And to address the apheresis from whole blood issue, FDA proposed defining recovered plasma or component plasma as "plasma that is collected manually or by apheresis, either separately or concurrently with other blood components, from donors who meet all whole blood donor suitability requirements." To address the distinction between source plasma, FDA proposals moving the requirement to freeze immediately after collection into the definition of source plasma. FDA also proposed two additional issues: One, should the time to freezing standard be defined for plasma for manufacture into labile derivatives? And should there be a 10-year expiration date for this product? There were several industry presentations, and this is a very short list of what was presented, and I took highlights from it, and these were some of the suggestions that industry had: They all agreed that we should license recovered plasma. There was a suggestion that we harmonize with EU standards. Some felt that we should have freezing temperatures consistent with FFP. Another suggested name was "plasma for manufacture." There was a suggestion of a 2- to 3-year expiration date. And they did not want any specific time to freezing. The committee had discussions, and these were the recommendations we got from the committee: "Component plasma" was a possible name. There should be a different name for plasma for manufacture into non-injectable products. The committee felt that there was not enough data available to comment on the changing of the definition of source plasma to include freezing immediately after collection. There was not enough data available to decide on the appropriate temperatures or the dating periods for the product. There was not enough data available to comment on the time to freezing as a criteria for manufacture into labile products. And they suggested that we have a workshop to collect this needed data, which is why we're all here today. So hopefully we will be able to satisfy the Blood Products Advisory Committee. Thank you. DR.HOLNESS: Our next speaker is DR. Donna DiMichele. She's Associate Professor for Clinical Pediatrics, School of Medical Sciences at Cornell University in New York. Welcome. DR.DiMICHELE: Good morning, everyone. I'm Donna DiMichele, and I'm here actually to present what I was asked to do, and that is the consumer-physician perspective on this issue. And I just wanted to say that I will do this on behalf of several organizations. I do not speak basically with my own views. I am speaking on behalf of the consumers as represented national by the National Hemophilia Foundation, as well as those represented internationally by the World Federation of Hemophilia. So in that way, I'm actually internationally representing the bleeding disorders community. By the way, I apologize that this talk was actually sent at the last minute so you don't have a handout. As typical for physicians, they sometimes get a little busy. Now, with respect to the National Hemophilia Foundation, we have several bodies that include the Medical and Scientific Advisory Council to the National Hemophilia Foundation, and there is a working group called the Blood Safety Working Group, which is a subgroup of the Medical and Scientific Advisory Committee, that also has views that are represented in this discussion. Now, I'm going to start by actually delivering the message straight out in terms of what we have to say, and basically what the message from the bleeding disorders community is is that it is incredibly important, in our view, that whatever standards are developed have the goal of both preserving the intent to produce as well as optimizing recovery of clotting factor proteins as an essential responsibility of the plasma collectors and fractionators, given national and global needs of this community. And I'm going to talk a little bit more in detail about the global needs of this community. We'll also suggest that national and international harmonization of plasma collection, storage, and processing may indeed provide the most cost-effective way for all stakeholders to fulfill this collective responsibility to produce safe and effective as well as affordable product in adequate supply. However, we will stress that in calling for harmonization, in our minds the goal of harmonization is that of equivalence rather than uniformity of process and outcome. Now, there are other stakeholders, there are other consumers who are not going to get a chance to speak today, and on their behalf, particularly on behalf of those patients receiving immunoglobulin and Jonathan Goldsmith of the Immune Deficiency Foundation, I also want to add that these consumer groups also have concerns and would like some input into the issue of plasma standards, especially as it relates to what we're now calling source versus recovered plasma. And their issues are multiple, including efficacy, in other words, the amount of antibody that's actually in the product, as well as safety. And safety issues including recordkeeping, adverse events rates, and donor and donation issues as well as supply are all going to be factors with respect to their goals in these discussions. Now, back to the issue of the bleeding disorders community, I just want to say that the intent of this presentation will not be specifically to enter the debate on specific regulatory standards for plasma intended for fractionation with respect to collection, storage, and manufacturing, particularly issues that are going to be very critical in terms of time to freezing and freezing temperature. Nor are we intending to discuss the scientific basis for maximizing yield of labile and non-labile clotting factors, which we think to be important, but there are people more qualified than me to represent those issues. And, in fact, DR. Farrugia will continue with that discussion after me. Now, we predicate a lot of what we say on the fact that there is a need, and the reason that we feel like we have to actually convey this message is because there is a sense in the United States that clotting factor therapy is now recombinant, and particularly for Factor VIII and for Factor IX, that there is no requirement or very minimal requirement for plasma-derived Factor VIII and Factor IX. And so, therefore, why should standards continue to be important with respect to particularly Factor VIII, which is a labile clotting factor? And, indeed, if you actually look at the U.S. figures--I don't know if I can use a pointer here. If you actually look at the U.S. figures, indeed, 70 percent is recombinant; therefore, only 30 percent of the clotting factor that's used for hemophilia A is now plasma-derived. But the fact of the matter is that the requirements at somewhere between 1.1 billion units total or 1.4 billion units in the unit are such that even 30 percent represents a sizable amount of clotting factor, as you can see here by the approximate number of units being about 420 million for Factor VIII. And that's plasma-derived Factor VIII. Now, similarly for Factor IX in the U.S., as well as for bypassing agents, the split is about the same. It's about 75-percent recombinant and 25-percent plasma-derived. Factor IX is a rare disease, so the requirements are only about 65 million in terms of a total number of units, but that's still sizable. The bypass agent requirement, the numbers are a little bit proprietary and, therefore, were not included in this. What's totally unknown is the amount of plasma-derived product that's needed to treat all the other disorders, including von Willebrand disease and the rare bleeding disorders, which I'm going to come back to, for which there are no recombinant products licensed in the United States. Now, that's the U.S., but, however, what we're going to present here today is more of a global view because the hemophilia community and the bleeding disorders community is a global community. And if you look at the same situation across the world, excluding the United States, more like 58 percent of the clotting factor that's used--and you can see to the tune of a billion units of Factor VIII and 135 million units of Factor IX--is plasma-derived. And I want to thank the World Federation of Hemophilia for these numbers, which came from a WFH global survey. And I just want to state that those numbers, as large as they are, represent only 25 percent of the world's hemophilia patients because 75 percent get almost no treatment whatsoever. So you can imagine that the capacity, the world capacity for this clotting factor is tremendous, and as large as it is, is minimally represented. The numbers for bypass agents as well as the plasma-derived requirement for rare bleeding disorders and von Willebrand disease is also unknown globally, but you can imagine is quite huge as the rare bleeding disorders are oftentimes very well represented in countries where consanguinity of marriage is frequent. And, by the way, I also want to thank publicly Patrick Robert from MRB for help in putting together these numbers, which I'm sure are an approximation. But hopefully they do indicate that the need is still tremendous. Now, I said I represented the National Hemophilia Foundation, and certainly the National Hemophilia Foundation has indeed gone on record, in November of 2000, to advocate for a movement to recombinant replacement therapy in the United States, and that's MASAC Recommendation No. 106 involving both Factor VIII and Factor IX products. And to paraphrase this recommendation, recombinant Factor VIII products, including recombinant Factor IX product, are and is the safest with respect to viral transmission and should be considered the treatment of choice for individuals with hemophilia A and B. And I think that's what sort of set off the premise that the issue of plasma-derived Factor VIII and Factor IX is no longer important. I do want to say, however, from a physician's perspective that ever since this recommendation came out, there has been a lively debate, a very lively debate which continues to this day, as to the merits of plasma-derived versus recombinant factor with respect to everything from the development of antibodies in individuals, what we call inhibitors, to inhibitor therapy, and then including the treatment of bleeding and immune tolerance, and even because of times of shortage as to whether the viral transmission issues are more theoretical versus real especially when we've had to resort to plasma-derived products, which we consider to be virally quite safe these days. So the issue of recombinant, I guess it's to say the issue of recombinant is not a said-and-done issue, and you're going to actually hear, for those of you who are going to the World Federation of Hemophilia meeting in Bangkok, there's going to be a lot of symposia dedicated to that very topic. Now, despite their going on record to recommend recombinant product, the NHF, however, has already come out in support of the maintenance of a plasma-derived supply in their report language to Congress in 2003, and essentially it's a lot of what I'm presenting to you today. With respect to blood safety, the NHF wrote that the committee is aware that several standards currently are followed regarding the collection of recovered and source plasma from blood and encourages the FDA to work with all stakeholders and collectors of blood and plasma to ensure equivalence of these standards in safeguarding the nation's supply. So this is something that the NHF has indeed gone on record to state. Furthermore, Mark Skinner in his presentation in April of this year to the North American PPTA had this to say: that indeed there was a future and continuing role for plasma-derived products in the United States for rare bleeding disorders, for times when recombinant is not an option, patient preference in some cases, as a supply backstop, as we know very well, and oftentimes because of reimbursement and cost issues that don't allow recombinant therapy as an option. Now, the Medical and Scientific Advisory Council, of course, is the one that put out Recommendation No. 106, and so it, too, has gone on record to encourage the U.S. transition to recombinant especially Factor VIII and IX. But in a letter by the Chair of MASAC, Keith Hoots, to Jessie Goodman that was just sent this August, MASAC had this to say about its position with respect to plasma-derived products: "Despite the fact that they are on record for encouraging U.S. transition to recombinant, there are cogent arguments on behalf of the bleeding disorders community for preserving and internationally harmonizing standards for plasma colleague, processing, and storage for these reasons"--they're going to come up again and again: only option for rare bleeding disorders, such as Factor V, which is also another labile clotting factor, Factor XI, and currently the only treatments for these disorders is FFP, fresh frozen plasma. There's certainly no recombinant bundle of factor preparation. Von Willebrand disease is probably one of the most common bleeding disorders that we care for, and there is no recombinant product. In his letter, DR. Hoots states, "The potential for exploiting underutilized plasma and plasma fractions to increase supply, potentially lower the price for the developing world"--and this issue is going to come up, as I present the World Federation view. There's certainly a role for plasma-derived products in immune tolerance, an issue that's very near and dear to my heart. And another issue that he states is that there are implications of national standards for blood collection and processing with respect to international needs. And, therefore, the issue of harmonization we feel is quite important. And, of course, last but not least, we have had catastrophic shortages of recombinant Factor VIII just recently, and it was only because of the availability of high-quality plasma-derived Factor VIII that no individual in the U.S. experienced emergency bleeding for which there was no replacement therapy, and the situation was the same in Europe. The Blood Safety Working Group of the Medical and Scientific Advisory Council is doing some long-range planning with respect to their goals, and a key goal of the Blood Safety Plan is also the availability of plasma-derived products for a lot of the same reasons that I've already stated, including something I'm going to get to later, and that is maintaining also economic feasibility for other plasma-derived products, such as IVIg. Now, recently, in the Journal of Thrombosis and Hemostasis, the Medical Director of the World Federation, Paul Giangrande, and many others involved in the World Federation of Hemophilia, wrote a letter refuting what was written by DR. Shanbrom indicating that the official recommendation of World Federation is to utilize recombinant products in the treatment of hemophilia. And it's often that the NHF view gets confused with the World Federation view, and so I'd like to present the World Federation view on plasma-derived products because indeed it is not the same. And in that letter, DR. Giangrande wrote, "It is certainly not the policy of the WFH to recommend only recombinant products for the treatment of hemophilia. There is and will continue to be a global requirement for both plasma-derived and recombinant coagulation factor concentrates, and the aim of the WFH is to ensure the availability of an adequate quantity of safe and effective products for the treatment of hemophilia across the world." And, in fact, most recently, in 2003 and 2004, there has been some danger that clotting factors would come off the WHO, World Health Organization, essential drug list, and the WFH put through an application that was basically trying to make the case for the continuing need for clotting factor concentrates on the essential drug list. Now, basically, as you're going to see, the application was for plasma-derived products and not recombinant products because the issue with respect to the world and the World Federation is the issue of do you have plasma-derived concentrates or do you have blood products, local blood products, where viral safety issues are very considerable problems. And, in fact, the case they make is that across the world major surgery would be difficult with blood bank products alone; that early therapy to minimize morbidity and mortality is not possible with just blood bank products along; and that in the developing world, as I've already said, bloodborne virus screening is inadequate. To make this point, there is the issue in Venezuela where if you look at the column on the left, where you look at years of treatment 5, 30, 60, and depending on what you consider to be the risk--low, mid, or high--in terms of the frequency, that's the estimated risk for HIV infection in individuals receiving cryoprecipitate in Venezuela. Now, if Americans were receiving cryoprecipitate and not recombinant or plasma-derived product, they would have a risk. But as you can see in the column on the far right, that risk is considerably lower. So this is a huge issue globally. And, in fact, their recommendation was that not only was there a requirement for factor concentrates, the nature of which would depend on the economic capacity of the country, but they estimated the minimum requirement to be one unit per head of population. What this translates into is for Factor VIII, 20,000 units per year per patient; for Factor IX, the same; and notice these are plasma-derived concentrate. So this comes back to what I said before, that the need for plasma-derived Factor VIII and Factor IX, not only when you look at U.S. needs but certainly world needs, is tremendous. Now, we understand, however, that there's an economic side to this, and Jan Bult in his presentation to BPAC this past July and to the Blood Safety Advisory Committee in August presented some of these issues, the reality of plasma economics to the community. And there are two sets of recent developments. One is what's going on in the industry with respect to consolidations and divestitures and the closure of plasma collection and fractionation facilities, such that there is a reduced volume of fractionated plasma for use for these products, although there is no near-term threat to plasma therapy availability. On the other hand, there's a potential for new companies, enhanced technologies, and the potential for higher yields. And that issue is an important and exciting one from our standpoint. Indeed, although the goal of this presentation is not to discuss the technology for maximizing clotting factor yield, there is some scientific data that is available to suggest that we may be able to get more out of our products than we do already. And some of that will be touched on by DR. Farrugia in his presentation to follow mine. And there's certainly ample data that was generated in the '70s and '80s by Gail Rock, who I believe is also here today. And I thank her for that information. Now, again, this is another slide that was borrowed from Jan Bult, and in this, again, this plasma economics issue, he taught us--and we need to be taught and we're happy that we're taught. But he taught us that there are drivers for plasma economics, but then there's the revenue side. And, indeed, as the lower bar shows, the current driver for plasma and plasma-derived products is immunoglobulins, and there's no doubt about that, with albumin being second. But as you can see by the magenta line, there's also a cost to manufacture products, and if there's going to be profit, it comes from the sale of multiple products, including, for instance, Factor VIII. Now, regardless, however, he's also taught us that there's no economic gain if you make more product or if one product drives the manufacture of more product that sits on the shelf. So this product has to be used. And so with respect to clotting factors and certainly what the community is asking for with respect to achieving maximum factor yield, we think that it does make economic sense. In, again, the continuing letter of DR. Hoots to Jessie Goodman, he writes, "It's recognized by members of MASAC that insistence on the highest standards for plasma collection, processing, storage, and shipping come with a price tag. And it may well be, however, that the capacity to use every plasma fraction will prove to be cost-effective and that higher up-front costs may be offset by mutually beneficial contracts for factor concentrates to developing countries." And in its application, the World Federation does have some cost figures that don't look that bad when you're talking about plasma-derived products. And in their statement, in their application, they state that plasma-derived Factor VIII and IX have been purchased at prices as low as 10 cents a unit, with the cost usually in U.S. dollars of 20 cents to 30 cents more commonly seen. However, these costs do compare, these prices do compare with the cost of producing cryoprecipitate in some countries which can be approximately 20 cents a unit. So that there is some economic potential for the developing world to actually have plasma-derived products that are safer at potentially no additional cost. Also with respect to the issue of making additional products, I'm very happy to say that the same bleeding disorders community has recently championed the cause of treatment for rare bleeding disorders, which actually does not exist in a satisfactory way, in our opinion, and the Blood Safety Advisory Committee recently last week did come up with a recommendation to the Department of Health that recommends the development of products to treat individuals with blood disorders, including obtaining additional licensed indications for already licensed products, approval of licensed indication in the U.S. for European licensed products, and the development of new products. And we believe, if we can work together, that that will only help in this issue of plasma economics. An important caveat, as I finish, and I go back to our other community of plasma fractionation users, we believe very strongly that in maximizing clotting factor production, as you talk about regulatory issues, we hope and we feel very strongly that the increased costs, if there are any, cannot and should not be borne by others who currently benefit from plasma fractionation, including patients with immunodeficiency and autoimmune disease who currently benefit from immunoglobulins and individuals with alpha 1-antitrypsin just to mention a few. In bringing to you our views, our hope is that--our promise is, actually, that we will continue to work with the regulatory community and industry and plasma collectors to continue to make this a viable effort, like I said, not only nationally but globally, by working on issues that are currently problematic. Again, PPTA has taught us that reimbursement in the United States is a particularly big problem, and we will continue to advocate for reimbursement of these products, again, to make this an economically viable venture. We will work with you in terms of harmonization of regulatory requirements, and we will work with you with respect to global access to care, which is a critical issue in the hemophilia global community. Finally, in closing, I would like to thank the organizers of this workshop and wish all the participants good luck. We applaud this meeting, and we applaud all of you coming together, and we wish you every success in consensus building. Thank you very much for your time. [Applause.] DR.HOLNESS: Any questions for DR. DiMichele? DR.FITZPATRICK: Donna, hi. Thanks. I'm Mike Fitzpatrick from America's Blood Centers. A great talk, and you presented the case for plasma products and the need for them, and we would agree with that, and that you can increase the yield for fractionation with different storage and freezing. But what I didn't hear was anything about efficacy of the current product. Do you see a problem with efficacy with the products that are manufactured under the current standards? DR.DiMICHELE: You know, that's a good question and thanks for that question, Mike. I think, you know, when we talk about efficacy, we can't dissociate safety from efficacy. And I think if you want to just talk about efficacy, I guess in terms of certain licensing tests that look at the licensing of this product and certainly in our post-licensure use of this product, I don't believe that we have identified glaring--any glaring lack of efficacy, no. And are there differences in products? Probably. Do we see them in patients? Yes. There are groups of patients who actually respond better to one than another for reasons that are still not clear. And it's not always one product versus another. Sometimes it's recombinant versus plasma-derived. Sometimes they'll respond better to one plasma-derived product versus another, von Willebrand factor-containing or not. And we also know, you know, there's been a big flap in terms of assaying Factor VIII these days and what assays are best. And we know that a lot of these products assay very differently by clotting and chromogenic methods. So there are probably small differences in efficacy. Why we don't pick it up, however--and this has been a huge discussion as we do something else through ISTH, and that is, we're looking at global blood clotting assays to assess clotting factor efficacy. What that may show us is that at the levels at which we dose currently--we dose at very high levels--we're not going to see differences in efficacy. If we can get to the point--and, again, this is to maximize availability. If we can get to the point of understanding how to do individual patient dosing based on the characteristics of an individual patient's clotting system and we're able to use lower doses, might we see differences in efficacy? At minimally effective, you know, clotting factor levels we might. So I guess what I would say to you, to answer your question, is no, I think our dosing practices--not generally, may be based on assays, may be based on certain patients that we see, and most likely not at this time based on our dosing practices. Are there other questions? [No response.] DR.DiMICHELE: Okay. Thank you very much. DR.HOLNESS: Our next presentation will be on product quality, and here to present will be DR. Albert Farrugia. He's a senior principal research scientist and head of the Blood and Tissues Unit, Office of Devices, Blood and Tissues, Therapeutic Goods Administration, Woden, Australia. DR.FARRUGIA: Well, while the slides are coming up I'd just like to say good morning, and I want to thank the FDA and commend them for this initiative, for this workshop. I think it's very timely. Unlike Donna, I'm not representing anybody here. I'm acutely conscious that anything I say is going to be transcribed and may be taken down in evidence later on, so I'm speaking here basically to my own views, and I'm delighted to have had the chance to review a field which is very close to my heart and on which I cut my blood banking and scientific teeth 25 years ago. And now I need the slides. Well, you know, when I submitted the first draft of this talk about three weeks ago, my generous hosts had the temerity to suggest that 85 slides in 45 minutes was pushing it a bit. So I said okay. So I sent them the handout which you actually have, which I believe is about 70 slides, and yesterday some further doubts were expressed by my good friend DR. Weinstein. He was very gentle about it, so I trimmed to the absolutely ruthless minimum of 60 slides. [Laughter.] DR.FARRUGIA: Therefore, you'll see that some of the stuff which you've got in the handout is not actually here. There are things which I think are less relevant to the immediacy of the issues as I understand them now. So what I will do is I'll go over very briefly some current standards, and I won't go into these in details. They're on the slides. I think this will be dealt with later on in the day. I'll review the scientific data. This is mostly based upon empirical observation. There is, I think, relatively little basic science. I'll attempt, mainly unsuccessfully, to wrestle with that. I think this will generate immediately the tensions which, as I say, underpin the situation, particularly in this country. And then I'll have the temerity to suggest some possible approaches. As I've said, this is a very personal presentation. I have lapsed into personal indulgence over the course of it, and the views are entirely my own, and basically they're my own as they were about three weeks ago. I have a suspicion I'm going to change some of them before the end of these two days. So there are a number of available standards, and in Europe, we've got, in terms of plasma for fractionation, an unusual monograph in the European Pharmacopoeia, and this is a monograph for human plasma for fractionation itself. And there is also now--and I will say something more about this in the second talk because we give this a lot of importance in Australia--a guideline for generation of a document of a so-called Plasma Master File, which does give some reference to the storage and freezing conditions as they are presented in the European Pharmacopoeia monograph. In the European environment as well, there is a standards-based distinction between plasma for fractionation and plasma for transfusion. And the Council of Europe Guide for Blood Components, which also happens to be the Australian standard for these products, includes chapters on fresh frozen plasma and similar components, and it specifies that these are not applicable for plasma for fractionation and refers the user to the European Pharmacopoeia monograph. And, of course, in the United States you have Title 21, subpart G, Source Plasma, of the CFR, and that's about it. And I guess this is one of the reasons why we're having this workshop today, to try and bring, as DR. Epstein said, recovered plasma into the regulatory fold. Now, I'll continue by making what I think is a contentious statement. I was told by Mark Weinstein to be contentious to, you know, generate discussion. I think that basically--and we can debate this; I hope we will--most of these regulatory requirements which do cause some level of tension within the industry and between industry and regulators underpinning blood and plasma storage, freezing, and so on are essentially predicated on the needs of Factor VIII. And, therefore, most of this presentation in terms of the science is going to focus on the properties of Factor VIII in relation to blood bank manufacture in relation to plasma freezing and all the issues with interest us. I think Donna has made some statements about this, but plasma-derived Factor VIII production is becoming reasonably marginal in the developed blood economies. I think this is great news. I think plasma-derived Factor VIII concentrates have served us well and have now earned--in countries which provide the level of health care which we associate with the First World, they have earned an honorable retirement, and it is one of my personal views that this is a good thing, and we should not be too upset about it. However, it is the case--and it has been shown by Donna--that this is still a very important product and is still basically the only product of immediate conceivable access in the developing world, and fractionators, therefore, still ship plasma for Factor VIII manufacture not just for what is becoming an increasingly limited domestic market, but also in the hope of supplying the emerging markets. As to how much this is actually impacting in the global market for Factor VIII is still a matter, I think, of some doubt. Despite the fact that it is true that you can get Factor VIII now, depending on how well you can bargain, I guess, for a relatively modest cost, it's still uncertain in my mind as to how much these products are actually penetrating in the developing world, because what may be a modest cost for us is still, I suspect, prohibitive for most environments attempting to crank up a health care system. Now, Factor VIII is the most labile plasma therapeutic protein. I don't know how contentious it is. I think it's still the case. I would say that conditions affecting Factor VIII, however, may affect other proteins in ways which are still unknown. And, therefore, I would say that tailoring the conditions to optimize Factor VIII preservation is still a valid goal. This can be debated, I think, very strongly, and I hope we will do so. Now, the immediacy and the relevance of Factor VIII, I think, in terms of the standards is shown by this particular manifestation in the European environment in which in both the standard for plasma for transfusion and the standard for plasma for fractionation delineated is a somewhat curious requirement for Factor VIII levels in the resulting plasma product. I'll just use this as an illustration to link to the Factor VIII story. I personally view this as being one of the requirements in the European environment which is more eccentric than scientific, and I'll say something about this when I talk about Australia. Now, I have chosen to essentially address the issues in relation to the stages in the part of manufacture from the basic blood collection or the plasma collection to the end product of concentrate as far as the impact on what is of interest in this talk. And so you will notice that I'm not going to actually cover the slides which affect the issues of anticoagulant because I don't think that they are of immediate interest today, although they do have some linkage and they are very interesting issues. Therefore, you can see that in these stages we look at the anticoagulant and its effect on preserving or otherwise Factor VIII, the collection method, whether it is true apheresis or whole blood collection; and then the things which are of interest to us today, the time and the temperature to separation and freezing, the freezing rate, storage conditions of the frozen plasma. Now, here is a slide which is, again, old and honored, and it shows the basic properties of Factor VIII in blood bank normal anticoagulated donations. And I think there are some interesting features here which perhaps are not widely appreciated. This slide shows the situation at three storage conditions of temperature for the blood. First of all, observe what happens in normal blood bank storage; that is, the well-characterized, very well known so-called biphasic decay of Factor VIII. If you store the blood, however, at room temperature, here defined at 22 degrees, you will see that the drop is significantly less. This other line here, which is entirely superimposed on the 22-degree Centigrade line, shows what happens when you store at blood bank 4 degrees Centigrade storage, and then just before you harvest the plasma through separation and freezing, you warm the blood up--I think these experiments I did were about 15-minute warming--and you get the Factor VIII basically back in the plasma. This is essentially a manifestation of the well-known phenomenon of cryoprecipitation, and it shows that really Factor VIII is not well preserved under conditions of standard blood bank storage for whole blood. And I think this is something which needs to be kept very strongly in mind. I think this next set of data from Jan Over from the Dutch environment shows the situation again over there, which you can see that the amount of Factor VIII when the blood is stored between 0 and 4 degrees is actually significantly less than when the blood is stored at room temperature. And there's also a bit less protein, and, again, this is entirely understandable in relation to the phenomenon of cryoprecipitation. So immediately we start seeing doubts thrown on many of these statements which are made that we have to cool the blood quickly and go to that level. Now, collection method. Well, there's a lot of data. This is just a summary of various studies from the U.K. and also from Australia, and essentially you see that when you are collecting generally through the recovered plasma mode, you're going to get less product, less Factor VIII in the intermediate stages of manufacture than if you collect in the apheresis low citrate or normal citrate mode. This is easily understandable in my view from two components involving the apheresis environment, one of which is that you're certainly going to freeze faster when you are collecting through apheresis, and you are probably, because of the lower anticoagulant concentrations in most machine systems, you are going to have a lower citrate concentration. And as was shown many years ago by Gail Rock, who's been mentioned today, low citrate is good news in terms of Factor VIII. However, I want to start immediately making the emphasis which I'll make several times throughout the slides. And I think this is unfortunate that this field actually has tended to taper off in terms of new investigations. These are somewhat old studies, and they focus on products which are not exactly representative of the generation of Factor VIII concentrates which we are accustomed to now in the First World, the high-purity, highly viral-inactivated concentrates. These are mostly low- and intermediate-purity products, and these products--and I'll emphasize this point in later data. The question is still open as to whether you have an enhancement in yield. In lower-purity products, it is certainly the case, especially upscale in the manufacturing process, but as you approach more closely the final product, the differences in yield accruable from the initial difference of amount of Factor VIII in the plasma starts to diminish as you can see. Let's now talk about the important area of time and temperature, separation and freezing. This is data from our Blood Service from about 10 years ago, and it shows the various types of plasma which were being handled then. And you can see it being related to the Australian mandatory standard of the amount of donations which actually have less than 0.7 IUs per mL, international units of Factor VIII per mL. You can see that when we have freeze donations which are frozen in less than 12 hours, it's just 1 percent. When whole blood donations are frozen in less than 12 hours, this goes to 13 percent, a demonstration of the phenomenon I described earlier. When the whole blood is kept for less than 18 hours, it goes up to 27 percent. And when it's less than 24 hours, it goes up to 40 percent. This, as I emphasize, is simply a demonstration of the amount of Factor VIII in the plasma, and this is very well known. This is data from Jim Smith for intermediate-purity concentrates in the United Kingdom quite some time ago, and it essentially shows that when you look at plasma from different ages, you do get some levels of enhanced Factor VIII yield in the plasma. And then when you look at the effect of the pack type on the freezing on the Factor VIII, you get not such a high level of difference at all. Now, does this matter? Does the fact that some delayed blood processing leads to frozen plasma have decreased Factor VIII levels? In other words, does this affect the yield and quality of fractionated products? I think it is quite a legitimate point to be made, primarily by the industry, that this is what needs to be the primary focus. I agree myself that this is the most important matter. Let's see what the data tell us. This is data from Jan Hellings, a study which was done in Holland, again, more than 20 years ago, which shows that when you store the blood overnight at 22 degrees Centigrade, you get a decrease in the amount of Factor VIII, and this decrease is reflected in the distribution of the Factor VIII in the fractions upon cryoprecipitation. This is small-scale data. In this study as well, which formed part of a major doctoral thesis, Hellings showed that this was actually linked strongly to the fact that proteolytic degradation was occurring and having an effect on the Factor VIII molecule and, in fact, on the association between Factor VIII and von Willebrand factor as the blood was exposed to longer periods of time at room temperature. And I think this needs to be kept in mind. There is evidence that if you keep blood stored for a prolonged period of time at room temperature, it does have an effect on molecular integrity. This is data from my lab in the Red Cross in the late '90s in Australia, in Melbourne, and you can see that there is a significant difference in the amount of plasma Factor VIII between 6-hour and 18-hour blood. This difference is retained not to the same level, at the level of the cryoprecipitate. The difference, however, although still there, loses significance when you get to the stage of a low-purity Factor VIII concentrate, as this then was. So I think here we're seeing the picture starting to emerge that differences in the plasma, which can be moderated by moderating the storage and freezing conditions of the plasma, are not necessarily retained in the final product. And I remind you that these were products of a low purity. This was a low-purity product, about 2 IUs per milligram, and also it only had a single viral inactivation step. And I reiterate my regret that there is not much data on this kind of situation in relation to the current generation of Factor VIII concentrates. I think it's a general case, and in some ways a pity, that fractionators certainly don't publish this data anymore. I think the focus has been entirely on safety and on generating viral inactivation capacity in the processes, and this is entirely appropriate. But this kind of study has not been shown, in my view, in relation to the very high purity concentrates which are available today. I am aware of some data which is available to me on a regulatory basis which I cannot share fully but which indicate that for high-purity Factor VIII concentrates, these differences do not exist. Here is, again, some data from the United Kingdom, from, again, quite some time ago, showing the differences which are accruable, and at the level of these types of products, you do get some levels of differences in the recovery of the Factor VIII international units per final kilogram of plasma in the final product. Again, these are historic. These are not products which are manufactured anymore. These are low-purity products. And does this matter? Okay. It depends. There is no doubt that the cryoprecipitate yield is affected. Low-purity and intermediate-purity products may well reflect this difference in the yield of cryoprecipitate. But as I said, there is no data for the current generation of Factor VIII concentrates. Now, I'll sort of philosophize later on on what no data means to the regulator. But let's discuss a bit the question of freezing rate, and I think that this is really very important because it is actually a significant gap in the regulatory and scientific debate much of the time that we do not actually talk about freezing rate. Statements are made that plasma should be frozen at some temperature or other, and here you see the ranges which are noted in the various standards and requirements. And I find the language to be remarkably ambiguous, things like, for example, European Pharmacopoeia says you should cool rapidly at minus 30 so that it is frozen at minus 20, and the CFR for source plasma, should be stored at a temperature not warmer than minus 20. There is little recognition in my view in these documents of what I think is the most important and obvious parameter, which is the freezing rate. And here is just an illustration of how freezing rates can vary on fairly similar conditions. This is data generated by Ron McIntosh in the Protein Fractionation Center in Edinburgh, in which he is looking at plasma frozen under two different conditions, a very standard regimen, and also using the phenomenon of super-cooling. The conditions are described on the slide, but you can see that a freezing environment of minus 50 can lead to significantly different freezing profiles depending on the manipulation which the plasma has been subjected to. So I think freezing rates need to be defined much more rigorously than they are now. Here is data from some personal studies done some years ago, again, in Melbourne, in which we compared the freezing of plasma in a minus 30 cold room compared to the freezing of plasma in a minus 30 mixture of halogenated hydrocarbons. And these are basically the kind of freezers which are used to freeze most of the plasma in Australia today. And you can see that the freezing rates vary dramatically between these, not just in terms of what you see in the plasma through appropriate temperature probes, but also what happens to the medium, and depending on the capacity of the medium itself. And these do have some effect on the eventual products which you can generate. In these studies, again, we're only looking at the amount of Factor VIII harvested in the cryoprecipitate in the blood bank. And essentially the message is that the faster you freeze relative to these kinds of freezing conditions, the more Factor VIII, significantly enhanced Factor VIII you can generate inside the cryoprecipitate. I think it's extremely important to define the conditions because people say, okay, we will freeze at minus 30. Minus 30 in what? There's a hell of a difference between putting something in a minus 30 cold room and putting it in a minus 30 cabinet freezer. And there's also a significant difference, obviously, between putting about a ton of plasma in a minus 30 cold room compared to putting a couple of units. And, therefore, I emphasize the importance of the rate in the things which we're interested in. Here's a nice study from G. Carlebjork, who I believe now the corporate affiliation is to Octapharma, done in the mid-1980s when he was still working for that time-honored company Kabi. And you can see that you can get very different freezing times between different freezing conditions. And you can then relate these to the levels of Factor VIII generated, which I'll show in a subsequent slide. And the amount of Factor VIII as harvested in the cryoprecipitate and the total amount harvestable between the fractions varies between the freezing rates. Here is some data now from, again, work which Chris Prowse and I did in Edinburgh quite some years ago, and this is comparing, again, the yield in cryoprecipitate between fast freezing--and at that time we defined this because we had the equipment to do it--as minus 70 ethanol bath cooled with liquid nitrogen--and slow freezing, which was, again, simply sticking it in a minus 40 cabinet freezer. And again, you see--and this was done using the thaw-siphon cryoprecipitate technique, something which is basically of only historical interest these days, alas, and it basically showed us that with fast freezing we could get significantly higher levels of Factor VIII in the cryoprecipitate. But, interestingly, what this data also showed was that the Factor VIII was actually not too different in the total amount recovered between cryo and cryosupernatant plasma. In other words, there was a redistribution of the Factor VIII between the two fractions, and this redistribution could possibly have been occurring, although we lacked the means to investigate this thoroughly, to molecular differences generated as a result of the freezing rates. And, therefore, the question arises: Does this matter eventually when it hits the patient? Again, I don't want to go over too much in detail on these slides. You have the handout. But, again, this is data from Jan Over showing pretty much the same effect which I have shown on previous slides. So what is important? We need to define the conditions. Rapid freezing. I would call rapid freezing, as I have gained the perspective over the years, to be the ability to attain minus 30 in about 30 minutes, and this is entirely empirical. As I'll show you, I hope, later on, there is very little basic science behind this. But achieving this level of plasma core temperature results in better Factor VIII yields up to the stage of the cryoprecipitate relative to a slower freezing regimen. And we know that the ice crystal structure and the physical nature of cryoprecipitate are affected by the plasma freezing rate. We have various data on this from the literature to which we have also contribute. There is also data--and this was actually shown on the previous slide from Jan Over's work, amongst others, that slow freezing also increases the amount of fibrinogen in the cryoprecipitate. Now, this is obviously something which is of great interest and has its pros and con. If you are making cryoprecipitate as a fibrinogen source, which is what most people do these days, this is a good thing. If you are making it to make Factor VIII, well, you might well be indifferent today at the level of purification which is attainable as a result of things like monoclonal affinity chromatography. It doesn't matter much. But in the old days, I can remember when a lot of fibrinogen in the cryoprecipitate resulted in headaches. It meant that you had to work much harder removing it in order to generate viral-inactivatable product. I would reiterate that the effect of freezing rates on Factor VIII yields in the current concentrates is not well recorded. There may well be people who have data, and they may well be going to show them here today, and I stand ready to be correct. Storage conditions, very contentious. Well, here is data again from Prowse and myself in Edinburgh in the mid-1980s, and essentially we looked at material which had been subjected to slow and fast freezing, as defined on the previous slides, and then stored at two temperatures: minus 20 and minus 40. Reiterating, the important thing was the initial freezing rate. Once the plasma has been frozen under those different conditions, it did not matter in the time frames which we studied here, which was only up to six months, what temperature you stored it between these two temperatures. Now, I note with interest the prospect of storing plasma for fractionation for 10 years. Forget it. Why do you want that problem? Apart from anything related to the issues we're discussing today, in 10 years' time all the safety factors related to the things which really move us today are going to have shifted to the level that it just will not be usable. I'll just say as a caveat to this that at the moment we're struggling with this precise issue in Australia in relation to long-term cryopreserved products such as cord blood. It just ain't worth the headache, folks. Of interest as well is the situation of what happens when you vary the storage temperature, and I think this is actually quite of higher significance. This is data from Ron McIntosh again which shows that when you do vary the storage temperature during storage, you get a difference in the actual weight of the cryoprecipitate, and this is easily understood in terms of the amount of fibrinogen deposited. And here is a dramatic study which Chris and I did, again, in which we deliberately subjected to the plasma during frozen storage some level of temperature challenge, some level of temperature insult. I am relating this here to the relevant statement in the CFR to show you that there is actually quite good reasons for some of the things which are in some of the standards. But essentially what happens when you do subject plasma to deliberate fluctuations in storage temperature, as you see it on this slide, is that there is actually very little effect on the amount of cryoprecipitatable Factor VIII, but there is a dramatic increase in the amount of cryoprecipitatable fibrinogen. And when you do subject it to these temperatures fluctuations, you get much higher levels of fibrinogen. Now this, again, may be good news or it may be bad news. Here is an interesting piece of data, though, from Jim Smith again, and this again is at the level of dried low-purity concentrate in which he went the whole hog and he thawed, absolutely thawed, and refroze again the frozen plasma and looked at the effect on intermediate-purity Factor VIII. And while the amount of plasma Factor VIII dropped significantly when this happened, when the plasma was totally thawed and refrozen, the amount recovered in the final product did not budge. Interesting. Now, let's just review some other aspects of this which are very interesting, and if you look at, for example, what happens in terms of fractionation and how the plasma is manipulated by the fractionator. Well, what we have is plasma which is held in frozen storage for some time, and that has to be brought to the appropriate state for it to enter the fractionation process. And one of the first things which is done is that this plasma is so-called conditioned. It is slowly warmed in order to be able to handle it for fractionation. I remind you that one of the first things which has to happen to plasma is that the plastic bags in which the plasma is stored have to be removed, and this has to be done under conditions which retain the integrity of the plasma in terms of its eventual fractionation fate. So this is what is called conditioning, and the plasma is gradually conditioned by softening it to a warmer temperature. This makes it easier to remove the pack and makes it more amenable to crushing and melting. And this is shown nicely on this somewhat diagrammatic representation by Peter Foster, again, from the Scottish Fractionation Center. This was an issue which interested us greatly when we worked in fractionation in Australia, and we looked at how conditioning could result in having an effect on the final products. And we looked at different conditioning regimens. Essentially we looked at what happened if you are able to fractionate the plasma without any conditioning at all, i.e., if you're able to strip off the plastic packs while having that minus 40 deep frozen state. You can't do this on a large scale, but you can do it if you're doing it on a small model scale. And we did this by splintering the packs in chucking them in liquid nitrogen. Then you could condition to a cold temperature, and I believe this was something like minus 10, or you can condition to a warmer temperature, something like minus 5 to 0 degrees. This is published in Transfusion. Essentially what we found was resonant with the findings which we had made years earlier in relation to temperature variations during storage, which is that when you condition to warmer temperatures and then start the fractionation process, the amount of Factor VIII, again, in both the cryoprecipitate and in subsequent stages of the fractionation process does not change. It doesn't matter. But the amount of fibrinogen is dramatically affected, and when you condition at warmer temperatures before you start the actual thawing of the plasma, you get significantly higher levels of fibrinogen. These studies, again, were done at a time when we cared about this. We did not want a high level of fibrinogen because, amongst other things, we were attempting to dry heat treat this product at 80 degrees for three days, and we found that high fibrinogen at these levels in these conditions was very bad news. You just couldn't do it. Nowadays, of course, with things like high-purity concentrates, (?) exchange, and monoclonal chromatography, the proteins are stripped of the Factor VIII anyway. And I suspect that these effects would not be seen at all. This is a hopelessly complicated slide which essentially says exactly what I've just said, so I'll leave you to mull over it at a later time. Of course, you can actually exploit this effect when you are actually trying to increase the amount of fibrinogen in cryoprecipitate as a route to fibrinogen-enriched cryoprecipitate at blood bank levels. So we introduce this technique in the Melbourne blood bank in the early '90s--I hope it's still there--in which we deliberately conditioned the frozen plasma to a warmer temperature before the final thaw to generate cryoprecipitate in order to have fibrinogen enrichment in the cryoprecipitate. And this was published as well, but it basically resulted in a product which was significantly higher in fibrinogen. The Factor VIII was really not affected much. The von Willebrand factor stayed the same as well, another important consideration, and the enhanced fibrinogen allowed us to generate an in-house fibrin glue which had a significantly enhanced adhesive strength. So what is important? I would say that as long as freezing is optimized, storage requirements appear to be very flexible in the range of minus 20 to minus 40 in the practical periods of storage possible which I think are imposed on us today. If you go for 10 years, I don't know what will happen, but I would advise you very strongly not to go for 10 years. And maintaining a steady storage temperature is more important than the absolute storage temperature within this range. And while temperature changes can affect the quality of the cryoprecipitate, this can be not necessarily a bad thing and can be exploited to improve both blood bank and industrial cryoprecipitate. Now, let's talk a bit about basic science. Don't worry about this hopelessly complicated slide here, but I captured this from the Internet from a Canadian site because I found it a good demonstration of the so-called theory behind much of what is reflected in the standards in relation to freezing and storage. And this relates, of course, to the concept of the eutectic point of plasma. And I don't want to give you the impression that I have any level of physical chemistry knowledge which can attempt to explain what the eutectic point is, but I will simply say that there is no such thing. And here is one of, I think, a few studies now in the literature, but, again, I salute the elegance of the Scots in this. And this is a study in which they basically attempted to detect eutectic points in plasma through resistivity measurements in plasma which had been frozen to low temperatures and then slowly warmed. And you have a situation here--I can't see it now either. You have a situation here where you are comparing plasma to 0.9 percent sodium chloride. And in the 0.9 percent sodium chloride, of course, you can detect a distinct eutectic, but in the plasma you can't. It is as simple as that. It does not happen. I'm informed by physical chemists that this should not be something which should astonish anybody because eutectics and eutectic points are essentially phenomena associated with crystalloid solutions, and plasma is a solution of 5-percent colloid in crystalloid. And so we should not expect these conventional parameters to apply. And here is data from McKenzie, a very interesting series of studies, not very well reflected in the literature, available through meeting proceedings and similar types, but which show that actually plasma in the frozen state, as it is frozen and subsequently warmed, undergoes a large number of transitions apart from the transitions associated with traditional eutectics. And these may well have different levels of importance in the things which we are interested in, but has not been studied sufficiently in my view, as reflected in the literature, to allow us to delineate absolute points which are crucial. There is no such thing as a eutectic point in plasma. So what can we do to study this? Well, here, again, is elegant data from G. Carlebjork, and you are looking here at a temperature freezing curve in which he managed to measure calorimetrically the phase change, energy changes associated with the freezing cycle. And he then related this to the time achievable in times of the phase change and to subsequently the Factor VIII levels, and he found that the faster you go in that phase change, the time for the--the shorter the phase change, the higher the Factor VIII levels. Again, an empirical set of data which tends to underpin the thesis that fast freezing is good news. So in terms of plasma freezing and storage, conventional eutectics offer no guidance. One should freeze so that the phase change is as rapid as possible on the basis of Carlebjork's data. And in my view, storage so that this is maintained at minus 20 degrees Centigrade appears to be adequate. But now let me be more contentious. The argument is flung at us: Why should this be an issue for regulators anyway? Because what we've been talking about mostly has related not to safety and quality--I will not have the temerity to say anything about efficacy--but to yield, and this is our business. Is there any evidence that blood/plasma processing affects safety and quality as opposed to yield? Well, I don't know. Here is an interesting study relatively recently in Transfusion which absolutely floored me, which indicated that the activation level in the Factor VIII molecule as assessed to the differential measurement using the clotting and the chromogenic assay is actually higher when you so-called fast freeze under the conditions of this study. And this is also reflected in the amount of prothrombin activation product in the plasma, indicating that in fast freezing there is activation of coagulation and the resultant effect possibly on the proteins, including the Factor VIII. There is no indication from this study whether this has any effect further down in possible fractionation. This is the only study that I'm aware of which might indicate that fast freezing might have an effect on the product quality. But there was another interesting study in relation to this whole issue which came about when we had the famous incident involving inhibitor development in a product marketed--and I think this is public information. In fact, this is extracted from the literature--by Octapharma. And in this study, which was a follow-up on the basic clinical observation and clinical problem, the investigators looked at the effect on the Factor VIII molecular integrity of what they called collection conditions as assessed through parameters meant to detect activation, such as fibrinopeptide A and thrombin-anti-thrombin complexes. They then related this to molecular changes which they found in the final product and related those changes to the level of inhibitor development in patients. And basically, to cut a long story short--and I again refer you to the literature--they made the correlation that plasma which showed evidence of coagulation because of what they called poor storage generation conditions resulted in molecular changes which eventually could be linked to the development of inhibitors. Now, this is obviously a very interesting and quite potentially important observation. I would, however, make one point on this study, which is that in the study, in relation to the amount of activation markers in the plasma, at least as assessed through fibrinopeptide A, the level of fibrinopeptide A in both the normal and elevated plasma was much in excess of what is traditionally found in blood bank condition plasma. And this is data from Chris Prowse which shows that essentially the level of fibrinopeptide A in plasma is very low compared to even the normal levels which were found in the previous study. So I would contend that in relation to this one study which I have been able to source, the amount of fibrinopeptide A there was not really something which was normally encountered, and I don't think that it is representative. And so the question which was, I think, addressed in some ways by Donna in her answer to the question from the floor earlier on to my mind is still an open one. I hear with interest what she says about, you know, products are different and patients react differently and so on, but I could only wish to see some data in the literature which can lend itself to some level of objective assessment. And I would be delighted to be made aware of some data today. And, of course, now I started out by saying--and I'm approaching, you'll be glad to know, the end of my talk. But I started out by saying that there are other things one can get out of plasma. It's not just Factor VIII. Here is data which was made aware to me by John Finlayson which shows that when plasma is generated from outdated blood compared to source plasma, the fragmentation of intramuscular immunoglobulin was significantly enhanced during storage of the final product in the plasma generated from outdated blood. And here is some other data, again, from John Finlayson that albumin made from plasma from outdated blood shows higher levels of prekallikrein activator, and you know what that does to you. I would say that these are data of enormous interest, but I suspect that the interest is more historic. But I don't think we know. Are these issues mainly of historical interest? Are there other plasma proteins which can be affected by poor storage conditions and which are more relevant to the industry today than perhaps Factor VIII is? And we've heard--and I think quite convincingly--from Donna that Factor VIII is still relevant. Is this part of the great unknown? And what does the great unknown mean for regulators? The great unknown, when we have the great unknown, we tend to go back to our mainstay, the precautionary principle. However, I think there is another issue, and this is: What is actually a quality product? Now, this is a definition from the Internet, from one particular area. I think it's a good definition, and I think that reliability, consistency, and the ability to continue performance in stress or volume situations, I think it's quite important to look at this. And I would say that you cannot get reliability, consistency, and the ability to constantly perform in possibly stressful and varied conditions if you don't define them very rigorously and you do not align them to some parameter which, for lack of anything else, you can say is indicative of good or bad things happening, if you like, in the plasma. And I think we need to have a defined manufacturing process, specified freezing and storage conditions, and robustness to volume and temperature changes. In other words, I would contend what we need is that extremely important concept of good manufacturing practice. And I do not think you can get good manufacturing practice if you allow people to shelf plasma at any temperature they like for the amount of time they like purely on the presumption that it's not going to have any effect on the final product. I think the process has to be defined at the outset. So this is my final serious slide, and I think that overall there is a need for clear and unambiguous wording in the standards which are currently used. I think that all of us in the regulatory community have failed miserably in this, and I think the wording is very ambiguous and results in confusion. I think we need a process which results in a consistent product in terms of plasma for fractionation, and this would form the basis of any standard. And this should be a manifestation of GMP more than anything else. However, it is the case that empirical observation appears to support greater flexibility than some current requirements. There is little evidence that any of these requirements have a bearing on product safety. Obviously, basic conditions for minimizing microbial contamination and preserving product integrity should be defined. However, I do agree that requirements such as Factor VIII levels in the plasma should basically be left to be negotiated between the manufacturer and the supplier, and I reiterate that I think requirements such as are found in the European plasma for fractionation and plasma for transfusion requirements on Factor VIII levels are in my view difficult to justify and certainly have no sense in relation to process control type concepts. I'd like to thank very much the FDA for the opportunity. I'd like to thank you all for your attention, and I would like to thank you all for reminding me of when I was very young. Thanks. [Applause.] DR.FARRUGIA: And I believe I'm on time. DR.HOLNESS: Are there questions for DR. Farrugia? DR.EPSTEIN: Well, Albert, thank you for this masterful overview. I have a regulator-to-regulator question. You know, there's a lot of interest and effort at harmonization, but when you consider that some of the more stringent standards that are rigidly adhered to by various highly respected bodies may be unduly stringent, how do you attempt to harmonize? Because there's rarely incentive to harmonize with lesser standards. DR. FARRUGIA: Well, I think that's very true, and I think we need to generate a framework, first of all, whereby we can do this because we don't have this in the blood area, and I think it's a great problem that in terms of plasma products they seem to be at the moment outside frameworks like the ICH. However, I'll say something about the rigor and difficulties of standards, and this is that it's actually not too difficult with good will to attain most of the requirements which there are currently available. It's less easy to justify them, but sometimes it's quite possible to minimize loss of energy by simply adhering to them. And I shall show this in relation to the Australian environment because we do adhere, we do mandate the European standards, and we find that they are actually quite achievable by our industry in what I think is logistically a challenging environment. But I agree, and I don't have any suggestion other than that we need to generate the ability to have a framework to discuss. Once we do that, we can then agree on some basic conditions along the lines which I have tried to indicate in terms of, again, agreeing on what empirical observations support certain types of conditions. MR. COEHLO: Yes, I had a question in regards to your fast freezing, which I thought was pretty fascinating. Since most of the heat in plasma to be removed is at the point of fusion, heat of fusion, then the fast freezing which you accomplished really did two things. It did most of the work for the storage freezer so that you're not putting heat in the storage freezer, because you independently froze those down below fusion. DR.FARRUGIA: That's right. MR. COEHLO: So you stabilize your long-term storage temperature, and you do most of the work ahead of time and get higher Factor VIII yields. So would you--I'm trying to go from what you said there. Would that be your recommendation that you accomplish that fast freezing-- DR.FARRUGIA: Yes, I--entirely, entirely, because, I mean--and you see this if you're a blood banker. I mean, if you just take a bunch of plasma bags and shove them in a minus 30 freezer, if you look into that freezer after six or eight hours, you'll see that the plasma is still liquid because the capacity just isn't there. Of course, if you pop it in a minus 30 cold room, you know, with substantial capacity and there is nothing else there at the same time, you will find that you freeze much quicker. But I agree. What we found, which was perhaps surprising, was that at least at the level of minus 20, if you then put it at minus 20, then the amount of Factor VIII is basically staying the same. But, yes, I agree. I think the fast freezing is the crucial parameter. MR. COEHLO: Yes, I had once noted that 12 hours after--the way the language often is is put it in a freezer. DR.FARRUGIA: Yes, I agree. MR. COEHLO: Presuming that something happens repeatedly in there, and often it's very-- DR.FARRUGIA: Yes, the statements are regrettably ambiguous. This is reflected in the CFR. Place in a temperature no warmer than minus 20. Well, you know, what do you mean? MR. COEHLO: Thank you very much. DR.HOLNESS: Would you give your name and affiliation, please? MR. COEHLO: I am an interested party. My name is Phil Coehlo. I'm the CEO of ThermoGenesis Corporation. DR.FARRUGIA: DR. Rock, how nice to see you, Gail. DR.ROCK: Gail Rock from Ottawa, Canada. I have one question and then perhaps a comment. I was intrigued with your statement that we don't really know what other plasma proteins are going to be affected by sort of leaving things at room temperature for 12 hours or longer. Has anybody looked at the metalloprotease that's so important in the treatment of TTP? Because we only can use FFP for TTP because of this enzyme. And being an enzyme, it doesn't seem to me that it would do well standing around. DR.FARRUGIA: I don't know. DR.ROCK: I guess we'll soon find out. DR.FARRUGIA: Yes. DR.ROCK: All right. My comment really is don't completely denigrate the double freezing or recycling of cryoprecipitate because in our hands, as you know, when we used heparin at 8 units per mL in a blood bag and did a double cryoprecipitation, we were able to produce in a blood bank a Factor VIII concentrate with 666 units of Factor VIII per liter in an intermediate-purity product. So when applied specifically and goal-oriented, the double refreezing can be very effective. MS. GLANTSCHNIG: Octapharma, Barbara Glantschnig. I want to comment on the effect of the freezing speed for different plasma qualities, and, again, I'm speaking only from our experience there as we fractionate both qualities. For the recovered plasma, I absolutely agree that the speed of the freezing is very relevant and very important. For the source plasma, we see from experience and from comparison between source plasma manufactured in, let's say, Germany and Austria that the flash freezing is really not such a critical parameter. We don't see any big difference in yields or behavior of the different plasma from both countries, one shock frozen and the other not shock frozen. So minus 30 big walk-in freezer requirements seems to do the job from experimental data for the source plasma. DR.FARRUGIA: Well, you know, I hear what you're saying and I'm interested. But we had a tussle with our local industry on this issue of apheresis freezing, and we basically made the point to them that it doesn't seem to us to be sensible to have put in the enormously expensive infrastructure to generate apheresis plasma and then not freeze it at least within the time frames of the standards. And I would reiterate that point. But we've never seen any instances of apheresis plasma, although it's difficult, we only fractionate about 35 percent of the plasma apheresis in Australia where flash freezing has proven to be detrimental. DR.HOLNESS: Now it's time for a coffee break. You can bring food and refreshments into this room, if you like. We'll restart the session at 10:30. Thank you. [Recess.] DR.HOLNESS: Our next speaker will cover current U.S. requirements for source plasma, fresh frozen plasma, cryo, and recovered plasma, and Sharyn Orton is the branch chief of the Blood and Plasma Branch of Division of Blood Applications at CBER. Sharyn? DR.ORTON: Good morning. Everybody had better get in here quickly because I only have four slides, so you'll miss it. I actually have the easiest presentation. Elizabeth asked me just to review what we regulate, hence, the four slides. For source plasma for injectables, I've put all the CFR citations on the slides for anybody who needs them. The CFR states to freeze immediately, store at temperature no warmer than minus 20 degrees Centigrade. The expiration is 10 years, and they are shipped at minus 5 degrees Centigrade or colder. For non-injectables, the CFR states to freeze and store according to intended use of the final product. For source liquid plasma, which has come up as a question quite frequently, for non-injectables store at 10 degrees Centigrade or colder and ship at 10 degrees Centigrade or colder. Fresh frozen plasma and cryo. Fresh frozen plasma is to place in the freezer within 8 hours or within the time frame specified in the directions for use for the blood collecting, processing, and storage system; to store at minus 18 degrees Centigrade or colder; and the cryo is made, of course, from the FFP. Expiration is 1 year, or 12 months, from date of collection, and ship at minus 18 degrees Centigrade or colder. For recovered plasma, freeze, store, and ship, as you know. For those of you who don't know what this is, this is a black hole, and hopefully we'll get more information today that will help us move forward with recovered plasma. Thank you. DR.BIANCO: Sharyn, Celso Bianco, America's Blood Centers. There is one area that probably we'll come back to in the discussion, that is, the intent of collection. Do you want to talk a little bit about it? DR.ORTON: Actually, Jay's a better person. He's talked about that before. He's not in the room at the moment. I'd rather not take that on. DR.HOLNESS: I'd just like to announce there are additional handouts at the front table. Our next talk will be about the current Council of Europe and European Pharmacopoeia standards for source plasma, fresh frozen plasma, cryo, and recovered plasma. And to talk about that we have Johannes Dodt. He's the head of the Blood Coagulation Factor Section at the Paul-Ehrlich-Institut in Langen, Germany. DR.DODT: Good morning, ladies and gentlemen. It's a pleasure for me to be here and to speak about European regulatory requirements for plasma for fractionation. I thank Mark for inviting me and giving me the opportunity to speak about this. As you heard, I'm from the Paul-Ehrlich-Institut. This is the German Federal Agency for Sera and Vaccines, and I am here to give you my personal view on this. I'm working in Group 6B, so I'm a little bit--I have a little bit of experience with the development of the monographs, and I will talk about this later. But the first development of the monographs took place in the '90s, beginning of the '90s, and at that time I wasn't really there, and I reviewed the minutes of the meetings to give you an overview how the monograph developed and what are the requirements of the monograph. First of all, I will start my talk to remind you about the importance of plasma for fractionation for the manufacture of blood products, and after that I will give you a brief legal background for human plasma for fractionation, and then go in detail into some issues of the monograph plasma for fractionation, which are under discussion during these two days, and finally I will summarize my talk. The quality design of blood products is an all-embracing concept. The quality cannot just be tested at the finished product level, but the quality, safety, and efficacy of the blood products, as for all biologicals, depends on several parameters which are, for example, the starting material, the manufacturing process itself, the control tests, and the in-process controls, specifications, the equipment, and operational standards. For the blood products, the starting material is an important factor which could contribute to the quality, and here are some of the criteria which define the quality of the blood. As in starting material, these are the donor selection exclusion criteria, the screening tests used, the epidemiology of the donation centers, and the storage and transport, equipment, and the quality system under which the donation centers are operated. And today's issues are storage and transport, and I will go into detail later. But, first of all, I'd like to show you the legal background in the EU, and, first of all, I have to mention the Directive 2001/83 that is the general Community code relating to all medicinal products for human use. And then there is the famous Recommendation No. R(95) of the Council of Europe on the preparation, use, and quality assurance of blood components. I'd like to mention and to point out that this is not a legally binding document. The Council of Europe is a group of more than 40 countries representing Europe, not only the EU, and this is an agreement between all these countries to have a common standard for plasma for transfusion. But that is not a legally binding document, although it represents a common-sense and a state-of-the-art document. So in some kind it is binding, but it has no legal status. And you should know it is not intended for plasma for fractionation. Plasma for fractionation is in the European Pharmacopoeia Monograph, Human Plasma for Fractionation, and the quality aspects are laid down there. And you can refer in general when you like to produce blood products to the CPMP note for guidance on plasma-derived medicinal products, which gives you some explanation how to manufacture blood products. The EU has decided to give the--or to set standards for the quality and safety of collection, testing, processing, and storage and distribution of human blood and blood products, to give that a legal background, so there is a directive beginning--that came into force the beginning of this year, and that is Directive 2002/98. And this sets the standards for plasma for transfusion, or for any plasma, whether it is intended for transfusion or for the manufacture of blood products. And there are annexes to this directive. These are technical annexes, and one is Directive 2004/33 that came out also early this year, and another will follow soon. And, again, the European Pharmacopoeia Monograph applies to human plasma for fractionation. And both with the two new directives, the recommendation of the Council of Europe will not have the same level of applicability in the European Union. The scope of the new directive and its technical annexes cover only plasma for fractionation, the collection and testing of this plasma, but the standards for plasma for fractionation are covered by the monograph, Plasma for Fractionation. This should be kept in mind. The directives were developed in order to ensure that there is an equivalent level of safety and quality of blood components throughout the EU, and whatever their intended purpose is, and it includes the starting materials also for medical products and that should be established by this directive. For this, you should know that directives are not directly binding documents, but they have to be transformed into national law of the EU member states, and the directives give a legal frame which has to comply by the national laws, but you can go beyond this frame. You can have stricter requirements in your national laws if you like or if there is a need. And the implementation and application of the directive or the transform into national law, transformed directives, is the duty of the member states, and the elaboration of the technical requirements, technical annexes of the directive, involves scientific committees in the European Community. There is a transposition phase for the member states, and the new directive should come into force at the latest the 8th of February next year. Again, I have summarized the requirements of the Council of Europe recommendation, but remember this is for plasma for transfusion. And it relates to whole blood and apheresis plasma and there is defined the time from collection to freezing, which is 6 hours but not more than 18 hours, 6 hours for apheresis plasma, and the freezing temperature is to minus 30 degrees within 1 hour. That means a rapid freezing process to a core plasma temperature of minus 30 degrees. And the storage and expiration is also mentioned there, and it is when it is stored at minus 25 or below, 24 months. As I said before, the legally binding document for plasma for fractionation or setting the standard for plasma for fractionation is the European Pharmacopoeia Monograph. The European Pharmacopoeia has the task of laying down common standards for the composition and preparation of substances, for example, excipients, starting materials, or finished products. The medicinal products marketed in the EU have to comply with the relevant Pharmacopoeia monographs, and that is also mentioned in Directive 2001, which is the general code for human medicinal products. They have the force of law in the EU, and the monographs are elaborated by expert groups and expert groups dealing with the blood products is the expert Group 6B at the European Pharmacopoeia. I'm a member of that group since 2001, so I cannot tell you everything about that. But Group 6B worked since September 1991. There have been 25 meetings, and you see it is a never-ending--plasma for fractionation is a never-ending story. And it was 18 times on the agenda, and I promise next week we have the next meeting, it is again on the agenda. So you are not the only people discussing plasma for fractionation. So, in principle, the issue is clear. We have blood or plasma recovered from blood and plasma by apheresis, and how should we bring that into the frozen state? There are two main players: time and temperature. And time can mean time to freezing, time for the freezing process, storage, and temperature can mean to which temperature should the plasma be cooled down and how should it be stored, at which temperature, or at which temperature should it be transported. This is the scope of the workshop. This was outlined in the announcement of this workshop, and I'd like to go now into some detail on how does the European Pharmacopoeia deal with these issues. First of all, I will show you this slide. As I told you, the monographs should develop standards, and in this case a standard for plasma for fractionation. And the intention of Group 6B is always to provide assurance about the high quality, and that means protein integrity, of the source material for the manufacture of blood products. And we are always considering more or less scientific data and discuss scientific data, and when the monograph goes out for consultation, industry can comment on that. And in our final discussion, we also consider the need of industry for our decisions. What I'd like to make clear is that we have only one standard for plasma for fractionation, and that is already given in the definition which is the first part of the monograph. And plasma for fractionation is the liquid part of human blood after separation of the cellular elements from blood collected in a receptacle containing an anticoagulation, or separated by continuous filtration or centrifugation of anticoagulated blood in an apheresis procedure. It is intended for the manufacture of plasma-derived medicinal products. This means we have one standard, but the plasma for fractionation can be obtained either by apheresis or by whole blood, recovered blood by the separation of plasma from whole blood. Now I'll try to show you how the monograph developed, and I took the third edition of the Pharmacopoeia monograph to discuss some issues which are important and are discussed during this meeting. First of all, should it depend on the final--should the definition of the storage and the freezing temperature depend on the final product. In our first--or that is not the first, but it is the same as the first. In the third edition, we made it dependent on the final product how the plasma should be frozen. And you see for labile products, as soon as possible, but the latest within 24 hours. That is true for plasma obtained by plasmapheresis and from whole blood. And for non-labile products, it stated separation within five days of the expiry date of the whole blood. And that is plasma obtained from whole blood. But then in the third supplement in 2001, we changed this definition. It was recognized that we should not give a definition on the--or make it dependent on the final product, but it depends whether the factor is labile in plasma or not. And so we changed the wording to make it clear that for coagulation factors which are labile in plasma, they have to be frozen as soon as possible, but at the latest within 24 hours. And for non-labile, we introduced this definition as soon as possible, but at the latest within 72 hours. And this is for plasma obtained from whole blood. We had a lot of scientific data. Albert presented these very nicely. And most papers, as I know, and Albert already mentioned, focus on labile components in plasma, and also in finished blood, finished policy, and they are the coagulation Factors VIII and V. And it has been shown in literature that time to freezing is a very crucial factor for the recovery of these labile components, and the best preservation of labile components in plasma is obtained when you freeze it within 6 hours after donation, and you lose some Factor VIII activity during storage between 16 and 24 hours, and additional loss is observed for longer storage. I think the Factor VIII was at that time an important factor for the collection of blood and, therefore, it was chosen as the lead factor for this. But it should always depend on your need or what you like to manufacture from the plasma, whether you need storage--time to freezing, which is according--it depends always whether this is a labile--whether the product of your intention is labile in plasma or the factor is labile in plasma or not. So the freezing temperature itself, in the third edition I'm referring to here, we had the wording, "Any plasma intended for the manufacture of coagulation factors or other labile components is processed shortly after separation or collection of it is frozen by cooling rapidly to a temperature of minus 30 degrees or below." That is important to note because we changed that already in the next year, and from the minutes of the meetings, I read that it was never the intention of Group 6B to fix it as it was the first time, to a temperature of minus 30 degrees. On the other hand, because--I will show you later or in the next slide--there were no data from industry who supported storage at minus 20. I think the Group 6B decided to do it similar to the conditions for plasma for transfusion in order to preserve the integrity of the proteins in plasma. Nevertheless, we have then changed that again and divided that in the sections for factors that are labile in plasma and when obtained by plasmapheresis from whole blood, plasma intended for recovery of proteins that are labile in plasma is frozen by cooling rapidly at minus 30 degree. And for the non-labile, it is frozen at minus 20. We have heard that rapid freezing is essential for the preservation of proteins or Factor VIII in plasma, and so the plasma for transfusion requires that, to reach a core temperature of minus 30 within 60 minutes. But for the plasma for fractionation, this time is not specified, and it means rapidly at minus 30. Rapidly at minus 30 can mean that you have storage which is capable of holding the temperature at minus 30 when you put in your blood banks or the plasma banks, but it does not go below minus 30, and you have evaluated your process that it is rapidly--that it is a rapid process and it means that you don't spend too much time from donation to the freezing process. At that time industry asked for freezing at minus 20, but Group 6B decided not to set the minus 20 because industry couldn't provide any data which were in favor of the minus 20 freezing. And we don't--even today we don't have the data, but meanwhile industry is satisfied with the current regulation in the EU. Then let's come to the storage temperature. In the second version of the monograph, it was mentioned storage should be done at minus 25 degrees. We heard about the eutectic point. Probably there is no--I learned today, but at that time it was discussed that the storage should be below the eutectic point, and it was a very controversial discussion whether repeated passage across eutectic point might lead to a degradation of proteins, and it was well recognized that this was in contrast to the U.S. and WHO documents. But later, when Group 6B again changed the storage conditions to minus 20, and it was recognized and we heard today that you can store plasma at or below minus 20. The scientific evidence for the storage temperature was shown, and, therefore, the monograph was changed. Now we come to the famous storage and transport conditions, and that really has been discussed a long time. And in the beginning, in the third edition, you remember the plasma should be stored frozen at or colder than minus 25. Therefore, there was a time restriction to the shipping condition at or below minus 20, and the time restriction was 4 weeks, and there was also the ability that there was an excursion of the time for not more than 72 hours and if the plasma at all times maintained below minus 5 degrees. When there was a change in the storage condition for the plasma, the time restriction for the shipment was removed, and the transport condition was still there. When the storage temperature is exceeded on at most one occasion for not more than 72 hours and if the plasma is at all times maintained at a temperature of minus 5 degrees. Again, with the current edition there is a change to this. It was recognized that maybe this restriction is not adequate and that industry may lose a lot of plasma when that excursion occurs not only once but two times or several times. And, therefore, we mention now that the temperature is between minus 20 and minus 15 for not more than a total of 72 hours without exceeding minus 15 on more than one occasion, as long as the temperature is at all times minus 5 or lower. We have given some information of industry and examples of industry that when the temperature in the storage goes down to minus 15, it takes about 12 hours--it takes about 12 hours that it goes down to minus 15, and that it takes again about 12 hours to come up to minus--come down to minus 20. So for us it was convincing that this could be at more than one occasion, and we changed it according to the need of industry. So excursions are allowed which guarantee that the plasma is still in its frozen state and suitable for fractionation, and it complies with the requirements of industry. Then expiration. The monograph does not mention an expiration for plasma for fractionation. And is this really a matter of concern? I think in practice not. According to the marketing authorization, we have that fixed to two or three years, depending on the application, and our data from batch release show that plasma is almost manufactured 6 to 12 months after collection. And all concerns which have been discussed were safety concerns, for example, state-of-the-art screening of the donations, and that the marketing authorization holders, I think also the safety concerns and economical reasons, though there is no need for them to store plasma longer than two or three years. This is the complete text which deals with the issue of storage transport of plasma for fractionation, and it reads, "When obtained by plasmapheresis, plasma intended for the recovery of proteins that are labile in plasma is frozen by cooling rapidly at minus 30 or below as soon as possible and at the latest within 24 hours. When obtained from whole blood, plasma intended for the recovery of proteins that are labile in plasma is separated from cellular elements and is frozen by cooling rapidly at minus 30 or below as soon as possible and at the latest within 24 hours of collection. When obtained from whole blood, plasma intended solely for the recovery of proteins that are not labile in plasma is separated from cellular elements and frozen at minus 20 or below as soon as possible and at the latest within 72 hours of collection." I have put the wording together to this table to make that clear. The excursions are given at the bottom, and you see there is a question mark, plasma obtained from plasmapheresis. It's not mentioned there. There's a current discussion on this, what should the time to freezing be for plasma obtained by plasmapheresis when it is intended for proteins which are labile--not labile in plasma. But that is under current discussion whether there should be a time limit or whether it is common practice that it is frozen in a short period of time, let me say, 6 hours after donation at the latest. So there are still open issues which are not discussed. For example, the conditions depend on the factors which are labile or non-labile, but there is no definition given in the monograph. That is for me a little bit strange, and I would prefer to have at least some examples what the monograph means with labile and non-labile and so on, and that could be reason for further discussion of the monograph. When we heard about the current intended revision of the plasma storage and transport conditions, or when that was published by FDA, Professor Seitz, who is head of Group 6B, wrote a letter or a comment on this revision, and he very much pointed out that we are interested in harmonization of these conditions, and at least this would allow an exchange of plasma for fractionation or an exchange of intermediates according to the need of manufacturers and according to the need of people in different parts of the world. So I think it would be very good to have the same quality standards for plasma for fractionation in the countries where plasma is fractionated. To harmonize the standards in the U.S. and Europe would be a first starting point for this. And I think industry would also appreciate harmonization of these standards because they are globally operating. For them, the logistics would be easier, and they would have maximum flexibility and availability of plasma and intermediates. And what I'd like to say is that industry is satisfied with the EU regulations at this time because they are evidence based and, we feel, well balanced. I think not everything is scientifically--for each of the parameters we are discussing, there is a clear scientific decision, but I think it is the practice and everybody is well satisfied with these practices at this time. The last point is: How do we maintain harmonized regulations? That is another issue for the next meeting perhaps, but at this time we should start perhaps with the harmonization of regulations regarding plasma for fractionation. So let me summarize what I wanted to--the information I wanted to give you. There is one standard for plasma for fractionation in the EU. The collection and testing of plasma is regulated by Directive 2002/98, and the production and the manufacture of plasma for fractionation is regulated by the European Pharmacopoeia monograph. And the EU would highly appreciate harmonization of standard for plasma for fractionation, and it would be an advantage for regulators and industry. Thank you very much for your attention. [Applause.] DR.HOLNESS: Questions for DR. Dodt? MS. CARR-GREER: Allene Carr-Greer with AABB. You spoke briefly to current discussions about whether there should be a different set of freezing standards for product collected for non-labile final product by apheresis. Can you say more about why you would consider that an apheresis collected product needs a standard separate from the whole blood? It was your Slide 27. You had the question mark there. DR.DODT: That was non-labile. MS. CARR-GREER: Non-labile. DR.DODT: And for the non-labile from recovered plasma there is a restriction to the time for freezing, that is 72 hours, and at this time there is no time fixed for the time to freezing for the plasmapheresis-obtained plasma because Group 6B--I can say here briefly what we discussed. We wanted to fix that at 24 hours for the non-labile because we thought it was common practice in a plasmapheresis center to do the freezing immediately. But there have been--some member states are opposed to this because they have national laws which require a 72-hour time to freezing for the plasmapheresis plasma when intended for the production of non-labiles. So we have probably to take into account the national law of some of the member states. MS. CARR-GREER: So you are looking at some pre-existing-- DR.DODT: Pardon me? MS. CARR-GREER: You are looking at pre-existing conditions in some of the member states, not necessarily a science or evidence based-- DR.DODT: In this case, we have to because the Pharmacopoeia Commission didn't agree to this draft where we said that plasmapheresis plasma has to be frozen in a time below 24 hours. But this will be discussed at the next meeting. My personal point of view is that a time of 24 hours to freezing does not--is not opposite to the national laws. They can still have their national law requiring a 72-hour time to freezing, whereas the monograph says when it is used for fractionation, it is 24 hours. But that's my personal point of view. MS. CARR-GREER: And if I could just ask one more question, would this be plasma collected by apheresis at the same time a red cell is collected? Or is this purely plasmapheresis? DR.DODT: This I don't know. And this is out of the scope of the monograph. But maybe some of the plasmapheresis centers can give you an answer, and I believe there are some people around here. MS. CARR-GREER: Thank you. DR. EPSTEIN: Thank you, DR. Dodt. Could you comment for me how the product labeling works? You've suggested that the conditions of freezing are linked to whether you're making labile or non-labile plasma proteins. But how is that determined when the product is actually placed in commerce? Does the label say that it's intended only to make labile products or non-labile products? Or does the label simply state the conditions of time to freezing and freezing temperature? In other words, how is the message communicated? DR.DODT: This I don't know. This is, I think, the part of our GMP inspectors to take care about the labeling of the products. This is not described in the monograph, and this is not described in the marketing authorization. So I think in general, plasma is frozen at minus 30 because then you have the better flexibility whether you--either you make non-labile or labile products from it. So I don't know whether there are any donation centers which do the freezing at minus 20. As far as I know, at the time of the development of the first plasma for fractionation monograph, there was only one manufacturer who did the fractionation of one product only, which was a non-labile one, and for that reason maybe this was included in the monograph. But I don't know that correctly, probably. But there could be somebody who knows it better. DR.EPSTEIN: I'm hearing you state that, in fact, the common practice is minus 30 freezing in less than 24 hours. DR.DODT: Yes. DR.EPSTEIN: For fractionation. DR.DODT: Yes. DR.FARRUGIA: I've got some comments, and they might pre-empt what I was going to say later, but it doesn't matter. The first one is, particularly in Europe, a large amount of plasma for fractionation is recovered plasma. DR.DODT: Right. DR.FARRUGIA: Particularly in the (?) type environment. Now, you have shown us that there are differences between the standards for plasma for transfusion versus those for fractionation. I mean, this creates a substantial problem for people who generate plasma and after the requirements for transfusion are met, the rest is shipped for fractionation. So I just wanted to know if you wanted to comment on that. The second one, and I'm a bit hesitant because there's a large man behind me here-- [Laughter.] DR.FARRUGIA: But you made the interesting comment that the industry is satisfied. My understanding is that the industry in this country is not satisfied. And my understanding also is that it's the same industry. So I just wondering whether you wanted to comment on that. DR.DODT: You're right that most of the plasma for fractionation is obtained from plasma from whole blood, and here are the conditions. And I think time from collection to freezing you have more stringent conditions, and the freezing temperature is more stringent. So most of the donation centers are doing the freezing to minus 30, and they do the freezing--time from collection to freezing is 6 hours, but not more than 18 hours. So that perfectly fits with the monograph, and there is no reason why plasma which was originally collected under these conditions cannot be used for plasma for fractionation. DR.BULT: DR. Dodt, Jan Bult, PPTA. You mentioned the desire from the European perspective for harmonization. The good thing of the workshop today is we'll gather a lot of information that will give us a picture whether that's achievable or not. But one of the things that you mentioned is that the difference between the minus 20 and the minus 30 is based on science, and you explained that the reason why the 30 degrees was chosen for plasma for fractionation is because you did it for transfusion. I'm not so sure that that is science. The question that I have for you is: If you talk about the need and the desire for harmonization, do you believe that the Expert Group 6B will be willing to reconsider the minus 30 degrees and, for example, take the U.S. example? DR.DODT: Yes, I can think about a revision of the monograph, but it will be based on scientific data. And at this time we do not have scientific data for the freezing at minus 20. At the time the monograph was developed, industry was asked to provide data, and they didn't. And, therefore, as I explained, initially the temperature was fixed to that for the plasma for transfusion in order to avoid--or in order to guarantee the quality of the plasma. So it is up to industry to provide data that plasma frozen at minus 20 has the same quality and is good enough to assure the quality of the finished product. And then Group 6B will be convinced and can change the monograph. I can't see any reason why we shouldn't do that. DR.FITZPATRICK: Mike Fitzpatrick from ABC. I was curious about the difference in the expiration dates between plasma for transfusion and plasma for fractionation and the rationale behind three months at minus 18 to minus 25 and a year at less than minus 25, but no expiration period at all for plasma for fractionation. DR.DODT: I haven't been involved in the discussion about plasma for transfusion, but there was heavy discussion about this expiration date for plasma for fractionation. That was also before my time. But, nevertheless, in one of the last minutes, I read that this should be again discussed. But as I told you, I think there's at present no need to set an expiration date. It's not in the interest of industry to have plasma collected and stored for years, and it is not in the interest of industry, for example, to retest all the donations or maybe single donations or plasma--yes, single donations when there are some emerging diseases which are coming up during the time of storage and which could make it necessary to have special tests which we are knowing now on these plasma units. So I think it is in the interest of industry to use the plasma as soon as possible. And, on the other hand, I said that it is mostly fixed in the marketing authorization. And there is it two to three years. PARTICIPANT: I just would like to make a comment on Jay's statement, current practice is minus 30. I think this really depends, especially in the recovered plasma sector, so if the blood banks know that the product will not be used for factors, it's clearly minus 20. We cannot say the current practice is minus 30. It really depends on the use. I think if we have, let's say, smaller blood banks, then they tend to assign the plasma for fresh frozen, and then they redesign it to plasma for fractionation. But especially bigger blood banks, they have a constant overflow of plasma they do not use for fresh frozen, and clearly this plasma is only frozen at minus 20. DR.DODT: Thank you. DR.HOLNESS: Now we'll have a discussion of the current Canadian standards for fresh frozen plasma, cryo, and recovered plasma. And for that we'll have DR. Thomas Walker, and he's the Director of Regulatory Affairs of Canadian Blood Services in Ottawa, Canada. DR.WALKER: Good morning, ladies and gentlemen. First of all, I'd like to thank the FDA for inviting CBS to come and, we hope, contribute to what promises to be a very important meeting. Secondly, I'd like to declare that although I'm speaking about government regulatory requirements, I'm doing so not as the regulator. I'm doing so as a regulatee. There might be a slight difference of perspective or maybe even a conflict of interest there. That said, what I want to do is, first of all, list the plasma products that we make in Canada, the indications for their use, the freezing methods we use, the storage conditions, quality control requirements, shipping methods, and then I'd like to summarize some challenges that we encounter because of the current requirements. I would also like to point out that if you go hunting for any of these standards in documents published by Health Canada or by other standards organizations in Canada, you won't find them. They are interpretations of language like "freeze immediately" that we, CBS, have written into our standard operating procedures which have been approved by Health Canada. So what I'm going to present is not necessarily something issued by Health Canada. It is approved by Health Canada. So what do we make? This should be very familiar to those of you from