Requirements for blood and blood components intended for transfusion or for further manufacturing use. Final rule

The Food and Drug Administration (FDA) is amending the regulations applicable to blood and blood components, including Source Plasma, to make the donor eligibility and testing requirements more consistent with current practices in the blood industry, to more closely align the regulations with current FDA recommendations, and to provide flexibility to accommodate advancing technology. In order to better assure the safety of the nation's blood supply and to help protect donor health, FDA is revising the requirements for blood establishments to test donors for infectious disease, and to determine that donors are eligible to donate and that donations are suitable for transfusion or further manufacture. FDA is also requiring establishments to evaluate donors for factors that may adversely affect the safety, purity, and potency of blood and blood components or the health of a donor during the donation process. Accordingly, these regulations establish requirements for donor education, donor history, and donor testing. These regulations also implement a flexible framework to help both FDA and industry to more effectively respond to new or emerging infectious agents that may affect blood product safety.

Platelet-rich plasma and blood components for non-transfusion use: technical and medicolegal aspects

There are a large number of publications describing the use of platelet-rich plasma (PRP) in multiple fields of application. These illustrate a large number of therapeutic elements with different and specific actions within 'platelet gel' (this term is used in the current regulations to define this product). This term, however, lacks specificity and, depending on the method used in its production is variable both in its blood composition and in platelet concentration, and several publications consider better and easier methods of platelet gel production, which may or may not lead to greater standardization in the product. The authors illustrate the general aspects of PRP and other blood components for non-transfusion use, briefly touching on the history and different fields of application and the rational of for its use. Given the increased use of such preparations, the authors describe critically the regulations in force in Europe and propose a new regulatory framework aimed to simplify and facilitate the use of such material as a therapeutic agent within medicine.

[Introduction of regulations of administration of blood components into clinical practice]

The authors describe "The regulations of administration of blood components" taking into account the purposeful parameters of homeostasis, which must be obtained during transfusion of blood components. The volume of erythrocytes and plasma transfused in the Center during the first and second quarters of 2006 and 2007 years were compared with the main indicators of the medical activities. The introduction of the limiting strategy of hemotransfusions based on the advantages of the world conclusive medicine was not followed by worse results of treatment, but promoted economy of facilities and blood components for the country.

[Jehovah's Witnesses refusal of blood: religious, legal and ethical aspects and considerations for anesthetic management]

The refusal of Jehovah's Witnesses to agree to blood or blood product transfusion based on religious beliefs is one of the most challenging conflictive issues health care givers have to face today. Such conflict is a by product of the ideological and religious diversity in society today. The perioperative care of such patients constitutes a genuine challenge for anesthesiologists and surgeons from technical, scientific, ethical, and legal perspectives. We review the reasons why Jehovah's Witnesses refuse transfusion and discuss the ethical, legal, and anesthetic aspects of their care. The literature up to August 2005 was reviewed by MEDLINE search. The following search terms were used: Jehovah's Witnesses, anesthesia (and anaesthesia), legislation and jurisprudence, ethics, blood transfusion, alternatives, anemia (and anaemia), erythropoietin, trigger, and critical care. To further cover ethical and legal aspects, we reviewed current laws in Spain and similar practice settings.

Programme en transfusion des étudiants en médecine

In France, transfusion medicine training program has been updated. A national committee of professors in transfusion medicine propose a series of 13 items which represent the minimum knowledge that general practitioners should possess. This overview of transfusion medicine is far below the level that specialists should reach and they will need an additional specialized training. Several French universities have set up their own training program which is quite similar to the work of the committee of professors. The following recommendations are not strict guidelines but is a common basis which will be improved in 2005 according to new evidence based transfusion medicine.

Bericht zur Meldung nach � 21 TFG f�r die Jahre 2001 und 2002

The report pursuant to Section 21 German Transfusion Act is based on data referring to 4.53 and 4.66 million allogeneous whole blood donations and 1.35 and 1.89 million apheresis donations respectively for the years 2001 and 2002. Since 2000, the quantity of plasma for fractionation from apheresis has doubled to approx. 1 million litres in 2002. At the same time, the number of private apheresis facilities has also increased. The data on plasma for fractionation (both from whole blood and from apheresis) have shown a sharp increase for both report periods, mainly due to the rise in the quantity of plasma from apheresis. In spite of this, the quantity for plasma for fractionation available to the German market declined by 43% during the report period, due to increasing export figures. The data on the manufacture of blood components are reliable, since the notifications are almost complete. In 2001, 4.32 million transfusion units of erythrocyte concentrates, the most important product derived from whole blood donations, were manufactured, compared with 4.45 million in 2002, out of these, slightly less than 77 percent were manufactured in the blood donations services of the Red Cross. The consumption values reported were clearly below the figures for the manufacture, with 3.2 million transfusion units in 2001 and 3.5 million in 2002. However, some facilities of the health service did not meet the requirement to notify their figures. As far as the data on manufacture, imports and exports of plasma derivatives are concerned, further improvements are required because of the complexity of the matter and the various implications to be taken into account. However, a statement on the supply situation cannot be yet made anyway, due to the missing notifications on the consumption figures.

American fresh frozen plasma for neonates and children

From the spring of 2004 the United Kingdom Blood Services have been importing fresh frozen plasma from United States donors for all neonates and children born after 1 January 1996. The decision to mandate the use of American plasma in this age group was taken by the Department of Health in 2002 as part of its precautionary approach to the risk of transfusion transmitted variant Creutzfeldt-Jakob disease. In this article we explain the background to this decision and explore some of the implications it raises for clinical practice.

Transfusion transmission of HCV infection before anti-HCV testing of blood donations in England: results of the national HCV lookback program

BACKGROUND

An HCV lookback program started in England in 1995.

STUDY DESIGN AND METHODS

Data from all English blood centers were collated to describe the outcomes of the HCV lookback program in England and to create a retrospective cohort for study. Numbers of recipients identified, numbers that were tested, and numbers that were found to be HCV infected were summarized. The data set created was used to describe the outcomes of the lookback and the HCV infections detected.

RESULTS

A total of 4424 recipients of 9222 blood components made before donation testing for anti-HCV from the donations of 1286 donors found, on subsequent testing, to be anti-HCV positive or indeterminate were identified. Of these, 1351 blood recipients were reported as having been traced for testing. Fifty percent of tested recipients were found to be HCV infected. Factors positively associated with HCV infection in tested recipients were more recent year of transfusion and PCR positivity of the donor at the time of their testing.

CONCLUSIONS

The majority of components entering lookback did not result in a tested recipient. However, this lookback has identified a large group of HCV-infected individuals. Follow-up of this group for disease progression will inform the natural history of HCV infection.

Probability of receiving testing in a national lookback program: the English HCV experience

BACKGROUND

The HCV lookback program was designed to trace and offer testing to recipients who received transfusion of blood components from donors subsequently found to be anti-HCV positive. Only approximately 20 percent of transfusable components entering lookback did result in a recipient obtaining testing through this program.

STUDY DESIGN AND METHODS

Data from English blood centers were collated to describe the outcomes of the HCV lookback program. The data were used to assess factors affecting the likelihood that recipients of lookback components received testing by the program.

RESULTS

In total, 4424 recipients of 6687 blood components that had been issued for transfusion were identified. The lookback resulted in a tested recipient for 1067 components. Factors positively associated with receiving testing in identified recipients were younger age at transfusion, more recent year of transfusion, certain component types, and transfusion under the care of certain medical specialties; these effects were largely explained by the association of these factors with survival after transfusion.

CONCLUSIONS

Not accepting testing through this program was largely due to death before the lookback and partly due to inability to access information from records and to decisions that testing was not in recipients' best interests. The probability of obtaining testing through this lookback was associated with several factors that could be used to focus the efforts of similar lookbacks in the future.

[Transfusion of fresh frozen plasma (FFP): audit of prescriptions]

OBJECTIVE

To review fresh frozen plasma (FFP) prescriptions and compare their validity to the legal french guidelines (law of the 12/03/91).

STUDY DESIGN

Assessment of all prescriptions has been carried out by a multidisciplinary committee.

PATIENTS

All the adults transfused with FFP over one year in a teaching hospital.

METHODS

Following each head of department's agreement and following a written notice to all prescribers within the hospital to inform them of the undergoing study and its methodological validation by the board of quality experts, each delivery of FFP was followed by a questionnaire addressed to the prescriber. A board of experts then assessed the significance of the prescription in accordance with the legal requirements after reviewing each medical file.

RESULTS

144 prescriptions to 89 patients were assessed: 23% were judged inappropriate by the experts and 6% did not respect the law. The inappropriate transfusions distribute as follows: intensive care patients (73% of which 80% in multiple organ failure (MOF) and 20% in haemorrhagic shock), cirrhotic patients (12%), patients treated with vitamin K antagonists (12%), obstetric patients (3%). Nine percent of the appropriate transfusions were judged in insufficient volume. The hospital mortality rate was 48%. Among prescribers, 59% were not aware of the law.

CONCLUSION

A significant proportion of FFP transfusions is inappropriate. This study, which is the first step of a quality assurance program, will be followed by local recommendations for clinical practice. The current standards of prescribing FFP are more restrictive than those defined in the legal french guidelines.

['Variant of Creutzfeldt-Jacob disease and blood transfusion'; report of the Dutch Health Council]

The new variant form of Creutzfeldt-Jakob Disease (vCJD), which has been diagnosed in about 100 patients--mostly in the United Kingdom (UK)--is considered to be associated with the consumption of beef contaminated with the agent bovine spongi-form encephalopathy (BSE). Although no cases of vCJD have been reported until now in the Netherlands, large quantities of beef have been imported from the UK in previous years; furthermore about 17 cattle with BSE have been detected in the Netherlands. Concern about the possible transmission of vCJD via blood and blood-products has led to a number of countries taking precautionary measures. Following questions raised by the Minister of Health, Welfare and Sport, the Health Council of the Netherlands issued a report to address the need for certain precautionary measures such as the leukodepletion of blood and the exclusion of donors at risk for vCJD. The Health Council recommends the routine leukodepletion of cellular blood components. The exclusion of donors who have resided in the UK for six or more months during the period 1980-1996, was considered to be insufficient to contribute to risk reduction. The Minister has recently decided to follow these two recommendations. However, she is of the opinion that the Health Council's recommendation to exclude all donors who have previously been transfused with cellular blood components is unnecessary. A common European position regarding such precautionary measures is deemed to be necessary. This would allow the exchange of blood components between countries and would also prevent donors, patients and the public at large from being confused or uncertain about the safety of blood components.

[Indications for labile blood products]

The aim of blood transfusion therapy is to supply specific labile products to patients in quality and in quantity. Different basic blood products are available: red blood cell concentrates, platelets concentrates and fresh frozen plasma, and according to their biological parameters, some of them can be selected and secondly adapted. Therefore, because some blood products are very rare and expensive, it is not possible to systematically use blood products having all the specifications. Also, it is necessary for clinicians to know blood product indications in order to avoid inadapted and abusive prescriptions inducing blood product unavailability damaging for other patients. The benefice risk ratio must be continuously measured, because these human products have some adverse effects: specially immunologic reactions and transfusion transmitted diseases. The systematic cell blood product leukoreduction since April 1st 1998 in France, allowed us to decrease these risks and to obtain a good tolerance. The hypothetical prion blood product transmission must be taken into consideration by plasma leukoreduction and limiting the blood product transfused number, in the respect of each specific clinical situation.

[Establishing a quality assurance system in transfusion medicine exemplified by the Heidelberg University Blood Bank]

BACKGROUND

The 'Zweite Verordnung zur Anderung der Betriebsverordnung für pharmazeutische Unternehmer vom 13. Juli 1994' requires a quality assurance system for the manufacturing of blood products.

METHODS

On the basis of national law and guidelines we worked out a concept for establishing a quality assurance system at a university blood bank and applied it to the university blood bank at Heidelberg.

RESULTS

The quality assurance system of the university blood bank at Heidelberg is based on the components 'quality of structure', 'quality of process' and 'quality of result'. The internal standard is specified in written form for every aspect of structure, process and result by standard operating procedures (SOP). The SOP serve as a basis for the quality system manual and the laboratory reference books. The quality assurance system described here integrates a programme for carrying out internal quality audits as well as a concept for updating SOP at regular intervals.

CONCLUSIONS

The concept underlying the quality assurance system of the university blood bank at Heidelberg allows continuous quality improvement in transfusion medicine; moreover, it offers the chance to integrate quality assurance in transfusion medicine in an interdisciplinary, patient-orientated, not only regional concept of quality assurance.

[The legally required guidelines for reporting risks or side-effects caused by blood components]

OBJECTIVE

To prevent dangers to health resulting from the application of drugs, the legislator requires the central registration and evaluation of all drug risks, especially of side effects and reciprocal effects. Since 1988 pharmaceutical enterprises have had to denominate a qualified person ('Stufenplanbeauftragter') who is responsible for the fulfilment of obligatory reporting. In case of complaints or side effects he has to take suitable measures according to a special plan ('Stufenplan').

DATA SOURCES

The basis of this survey are the legal requirements for drugs ('Arzneimittelgesetz') and supplementary regulations which define the duties of the 'Stufenplanbeauftragter'.

RESULTS

Blood components are subject to the legal requirements ('Arzneimittelgesetz') without reservations. Therefore the corresponding regulations have to be applied without modification in institutes for transfusion medicine. In this article the tasks of the 'Stufenplanbeauftragter' are summarized and practical experience of a university institute for transfusion medicine is presented.

CONCLUSIONS

In connection with the transmission of viral infectious diseases it became evident that the 'Stufenplanbeauftragter' is very important for the initiation of effective measures in case of serious side effects. The security of blood components could be improved by the realization of the corresponding legal requirements in the institutes for transfusion medicine.

[Transfusion medicine in unified Europe. Brief report on the status of transfusion medicine in central and east European countries]

Requests of the Council of Europe are harmonization of policies, encouragement of voluntary, unremunerated donation, self-sufficiency and introduction of EC quality standards. Present conditions were evaluated by a study in 11 countries of Eastern and Central Europe. Quality control is usually done according to USSR guidelines. Alarming are decreasing numbers of blood donations of 15% within 2 years. For satisfaction of FVIII needs plasma production has to be increased 3 times. In the countries of Western Europe too self-sufficiency is not yet reached. Strong efforts should be taken in Eastern, Central and also in Western Europe to reach self-sufficiency in the evolving unified Europe.

[Transfusion medicine in unified Europe]

The European institutions have been dealing with blood and blood products since 1956. A need for action currently exists with regard to the European Community's Directive 89/381/EEC. The aims of the Directive are: the elaboration of strict quality and safety criteria for medicinal products made from human blood and blood products, with special reference to preventing the transmission of viral diseases, and the demand for self-sufficiency within the European Community in human blood and blood products on the basis of voluntary and unremunerated blood donations. In May 1993, the Commission submitted a report on the implementation of this Directive. In principle, the Member States are in agreement that self-sufficiency on the basis of unremunerated donations should be achieved. Differences of opinion exist, however, with respect to the national self-sufficiency of each Member State and the definition of 'unremunerated'. Germany's standpoints enjoy greater acceptance today than they did only a few years ago; consequently, there is reason to assume that, even in the wake of developments within the European Community, the basic structures of the blood and blood products supply system in the Federal Republic of Germany will be maintained.