ASSURING THE SAFETY OF THE BLOOD SUPPLY. Michael P Busch, MD, PhD Blood Systems Research Institute University of California, San Francisco

Transcription

1 ASSURING THE SAFETY OF THE BLOOD SUPPLY Michael P Busch, MD, PhD Blood Systems Research Institute University of California, San Francisco

2 ZIKV Risks of major TTVs linked to interventions, and accelerating rate of EIDs of concern to blood safety Recent arbovirus threats Perkins HA, Busch MP. Transfusion-Associated Infections: 50 Years of Relentless Challenges and Remarkable Progress. Transfusion, 2010; 50(10):

3 Arboviruses Arthropod Borne viruses Descriptive, not taxonomic Mosquitoes, gnats, sandflies, etc Ticks Four major families Togaviridae, Flaviviridae, Alphaviruses, Bunyaviridae These are all ss-rna enveloped viruses Human and sylvatic cycles 3

4 Simplified Patterns of Vector-Borne Disease Scenario one: People are incidental hosts Transmission Scenario two: People are primary hosts National Center for Emerging and Zoonotic Infectious Diseases Division of Vector-Borne Diseases Bacterial Diseases Branch Courtesy of Lyle Petersen, US CDC

5 Daily Airplane Flights

6 Evaluating an EID threat to blood safety 3 basic questions need to be answered: Is it in the blood supply? Necessitates a way to measure the agent in donors during epidemics Estimation of donor risks: prevalence, incidence, durations of detection Estimation of blood component risks Temperature, preparation, storage duration effects on infectivity? Is antibody in the infected donor or co-transfused components protective? Is it transfusion-transmitted and what is the risk? Is transmission risk dependent on stage of infection or VL in the donor/component Do recipient antibodies from prior infection protect from TT If transmissible by transfusion, does it have a clinical impact in transfused recipients? Is TT disease more or less severe than usual routes of infection

7 World distribution and spread of WNV Lignage 1 Clade 1a Clade 1b Clade 1c Lignage 2

8 U.S. WNV blood donor screening timeline WNV found in Queens, NY 1 23 TTIs reported 2 6 TTIs reported 3 MP NAT adopted 3 1 TTI reported 3 ID NAT triggering adopted 3 ID NAT triggering enhanced 4 1 TTI reported 4 ID NAT triggering enhanced 4 1 TTI 1 TTI reported 5 reported 6 All transfusion-transmitted infections (TTIs) traced to WNV RNA(+) / Antibody(-) transfusions, except for 2013 case in which donation had very low VL with IgM and IgG 1 Lanciotti, RT, Roehrig JT, Deubel V, Smith J, Parker M, Steele K, et al. Science, Pealer LN, Marfin AA, Petersen LR, Lanciotti RS, Page PL, Stramer SL, Stobierski MG et al. N Engl J Med Busch MP, Caglioti S, Robertson EF, McAuley, JD, Tobler LH, Kamel H et al. New England J Med, 2005 Stramer SL, Fang CT, Foster GA, Wagner AG, Brodsky JP, Dodd RY. N Engl J Med Kleinman SH, Williams JD, Robertson G, Caglioti S, Williams RC, Spizman R et al. Transfusion Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. 2013

9 Window Periods for acute WNV infection parameters, and need for tragetted ID-NAT WNV RNA (geq per ml) MP-TMA detection RNA IgM SC IgG SC 5.8 1x ID-TMA 6.1 6x ID-TMA IgM IgG days MP-NAT 10 1 ID-NAT Busch et al, JID, Days following infectious mosquito bite

10 June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept Dec March June Sept December March June September December March June September December WNV Positive Donations , CTS No WNV positive cases during winter months

11 Dengue virus blood screening timeline TTI in Hong-Kong IND NS1Ag screening implemented by ARC in PR & S Florida TTI in Singapore NS1 Ag + rapid retrospective TMA testing TTI in PR IND prospective TMA screening implemented Seroprevalence in PR blood donors 1 DENV RNA in blood donors and TTI in PR 3 DENV RNA in Brazilian blood donors 4 Estimated DENV prevalence in PR blood donors from 1995 to REDS-III Study of donor viremia and TT in Brazil 1 Mohammed H., Tomashek K.M., Stramer S.L., Hunsperger E., Transfusion August Petersen L.R, Tomashek K.M., Biggerstaff B.J., Transfusion August Stramer S.L., Linnen J.M., Carrick J.M., et, Transfusion August Dias L.L., Amarilla A.A., Poloni T.R., Covas D.T., Aquino V.H., Figueiredo L.T.M., Transfusion August 2012

12 Estimated and observed RNA donor viremia in Puerto Rico TMA: = 0.18% % % % %

13 Number of cases per week Number of cases REDS-III Dengue Study Sites and Epidemic Activity Recife and Rio de Janeiro Dengue Epidemics in Recife ( ) Dengue Epidemic in Recife Weeks Dengue Epidemics in Rio de Janeiro ( ) Sabino et al, JID 2016 Busch et al, JID 2016 Weeks

14 Sabino et al, JID 2016 Subject accrual & results of DENV RNA testing

15 9.1 days (95%CI: days) period of detectable RNA by ID-NAT 9% 6.2% IgM Rate NAT 2% Busch et al, JID case of clinical dengue diagnosed for every 3 infections 853 cases of reported clinical disease per NAT yield donation

16 DENV symptoms for case and control patients during the 45-day chart review period Sabino et al, JID 2016

17 Chikungunya Virus Makonde language: to dry up or be contorted Alphavirus 3 genotypes West African East/Central/Southern/East African (ESCA) Asian Like dengue Man-mosquito-man transmission cycle Aedes aegypti is the traditional urban vector Also spread by Aedes albopictus

18 Chikungunya Virus Disease Acute onset of fever and severe pain in multiple joints Mortality low but extremely debilitating; symptoms often last months to years Most infected persons become symptomatic No antiviral therapy; treatment is symptomatic Lifelong immunity following infection No licensed vaccines; prevention relies on avoidance of mosquito bites & mosquito control

19 Reported Chikungunya cases and Number of Countries/Territories with Local Transmission in the Americas, Dec 2013 Mar 2015 Cases reported to PAHO to April 24 (week ) 50 countries/territories in the Americas Susp d Lab conf d Imprt d Deaths US PR 31, All 1,367,343 30,

20 Real-time TMA Assays on the Panther Target amplification by biphasic real-time TMA Amplification reaction is divided into 2 steps (linear/exponential) Allows higher level of multiplexing Detection occurs during the amplification step using molecular torches or beacons (paired fluorophore/quencher) Quantitative or qualitative assays Up to 6 real time fluorometer modules could be mounted under the incubator The real-time TMA technology is currently under development and is not available for commercial sale; the performance characteristics of this product in development have not been established.

21 % Seroreactive High Incidence of Chikungunya Virus and Frequency of Viremic Blood Donations during Epidemic, Puerto Rico, 2014 Calculated ID rate IgG % NAT reactive Simmons et al, EID 2016 Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

22 Detection of CHIKV RNA+ donations by Hologic CHIKV/DENV assay applied to 3008 individual donations % NAT reactive NAT Serology # ID-NAT+ only Serology no antibody 2# 1/16 ID.only. diln (1/2 tests positive) Seronegative no antibody 12 1/16 ID.only. diln (2/2 tests positive) IgM.and/or.IgG no antibody /16 diln IgM+ 6 MP.detectable Seronegative 11 1/16 diln IgM+ & IgG+ 7 MP.detectable IgM.and/or.IgG 13 ID-NAT+ only IgM+ & IgG+ 30 ID NAT only MP detectable 0 Sept Oct Nov Simmons et al, EID 2016

23 Dynamics of CHIKV viremia in blood donations Eclipse period ID-NAT only MP-NAT ID-NAT & seropositive Indeterminate 0.5 days± days± days±5.3 CHIKV viral load (c/ml) ID only Seronegative (n=2) MP+ve Seronegative (n=11) MP+ve IgM positive (n=6) MP+ve IgM and IgG positive (n=4) ID only IgM and/or IgG positive (n=33) Simmons et al, EID 2016

24 Zika virus (ZIKV) Arbovirus surveillance (Dick et al. 1952): Isolated from the blood of a sentinel rhesus monkey (placed in the forest in 1947) Isolated from a pool of Aedes africanus mosquitoes in Ziika forest, Uganda (1952) Humans: Serosurveillance: detection of neutralizing antibodies in human sera collected from East Africa (Smithburn et al. 1952) Isolated from a human in Nigeria in 1954 First isolation of the virus itself from ZIKV-infected human (Simpson et al. 1964) 24

25 ZIKV is a Flavivirus related to DENV Classification: Flaviviridae family Flavivirus genus West Nile virus Dengue Japanese encephalitis Yellow fever Spondweni virus clade Asian strains East Africa West Africa Structure: 50 nm in diameter Enveloped: cell membrane derived Capsid: icosahedral symmetry + single stranded RNA ~11kb 25

26 Aedes aegypti Nervous mosquito Feeds on Humans meal Year round Transmission Cycle of ZIKV Transmission cycle of ZIKV Vector: Aedes mosquitoes Sylvatic Urban Different Aedes mosquitoes can transmit ZIKV including: aegypti, albopictus, stegomyia, polynesiensis, africanus, apicoargenteus, furcifer, hensilli, luteocephalus, and vitattus, etc. Aedes albopictus Calm Feeds on multiple animals Diapause in winter 26 Figure 2. Distribution of ZIKV mosquito vector

27 WHO cumulative detection of mosquito-borne ZIKV infections, Jan 2013 to April countries since first outbreak since countries reporting sexual transmission - 29 countries reporting congenital abnormalities - 22 countries reporting increases in Guillain-Barré syndrome

28 Why ZIKV Transfusion Transmission Concerns? Up to 80% of ZIKV infections asymptomatic/illness is generally mild public health surveillance based on clinical case reporting is insensitive ZIKV can result in severe congenital syndromes & Guillain-Barré syndrome ZIKV RNA detected in asymptomatic blood donors ZIKV transfusion transmission reported 4 cases (Brazil); 3 donors ZIKV may persist in whole blood longer than plasma 1-3 months vs weeks (diagnostic assays) Unknown impact of travel/sexual contact ZIKV interventions are available 2 investigational screening assays on newly available platforms Licensed pathogen inactivation for plasma/platelets; investigational methods in development (red cells/whole blood) FDA classification as a Relevant Transfusion-Transmitted Infection

29 ZIKV disease cases reported to CDC by US state or territory (Jan March ) US Local Travel Continental 221 (215 FL) 4,779 (6 TX) Territories 38,

30 ECDC recommenda on FDA guidelines FDA revised guidelines WHO recommenda ons FDA approved INTERCEPT TM (Cerus) CDC EUA Diagnos c assay ZIKV outbreaks: Yap Island 2007 French Polynesia 10/ /2014 Brazil/La n America 03/2015 present Caribbean Islands including Puerto Rico 01/2016 present Con guous U.S. including FL and TX 08/2016 present South East Asia 08/2016 present ZIKV TTIs in Brazil 1 st NAT for blood screening (Roche IND) High seroprevalence in Yap popula on Poten al for ZIKV TTI nd NAT for blood screening (Hologic IND) WHO Interna onal Standard Access to ZIKV isolates 10/2015 Access to Brazil ZIKV TTI RNA+ plasma 02/2016 Compila on of results and analyses of test performance. 07/ /2016 Produc on/characteriza on of ZIKV viral stocks 12/ /2016 Discussion of donor screening op on with CDC, FDA, and blood screening companies 12/ /2016 Distribu on of ZIKV assay analy c performance panels to addi onal diagnos c and research labs. Return of results. 03/ /2016 Distribu on of ZIKV assay analy c performance panels to blood screening companies, CDC, and FDA labs. 02/2016

31 Nucleic acid detection assays for blood screening (IND) Roche cobas 6800/8800 System cobas ZIKV test Hologic/Grifols Procleix Panther system Procleix Zika virus assay 31

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33 Weekly Detection Rate of ZIKV RNA in Blood Donated in Puerto Rico 365 (0.53%) tested This project has been funded in whole or in part with Federal funds from the Biomedical Advanced Research and Development Authority, Office of the Assistant Secretary for Preparedness and Response, Office of the Secretary, Department of Health and Human Services, under Contract #HHSO C.

34 ZIKV Confirmed Positive Blood Donations in US States N=47 (Aug Mar ) 6.25 million donations screened 47 confirmed positive/210 reactive Conf d based on repeat 1 NAT, alt NAT, Ab (IgM) 1:133,000 conf pos; 22.4% PPV; % spec Of 47, state of residence: 25 (53%) FL, 6 CA, 4 NY, 5 TX, 1 NV, 1 AZ, 1 MA, 1 WV, 1 TN, 1 PA, 1 IA Majority have remote travel to an active area

35 Staging of ZIKV NAT yield cases with valid IgM results RNA copies/ml ID-NAT only IgM neg (n=14) MP-NAT reactive IgM negative (n=192) MP-NAT reactive IgM positive (n=26) ID-NAT only IgM positive (n=93) Black symbols = Peurto Rico (n=306) Red symbols = Continental US (n=19)

36 NHLBI-funded REDS-III Studies of ZIKV Participate in development of INDs to enable testing of the US blood supply Study viral and immune parameters and clinical outcomes in ZIKV+ donors Characterize viral, serological and cellular immune markers of early stages of asymptomatic vs symptomatic ZIKV infection (with and w/o prior DENV Abs) Investigate compartmentalization of Zika virus in blood components Identify and store index blood components and follow-up samples that can be further studied to characterize the performance of existing and future assays, Characterization of transfusion-transmission of ZIKV in macaques (collaboration between REDS-III with the UC Davis Primate Center) ZIKV/CHIKV/DENV NAT testing surveillance of minipools from the 4 REDS-III Brazil Hemocenters ZIKV/CHIKV/DENV transfusion-transmission study being launched at the largest hospital in Latin America (Hospital das Clinicas, Sao Paulo) ZIKV/CHIKV transfusion-transmission study in chronically transfused SCD patients

37 Zika RNA positive donor enrollment and follow-up activities Extended Follow-up Characterization of humoral and cellular immunity Discriminate recent vs remote infections Detect ZIKV reinfections 6 Month 9 Month 12 37

38 WNV RNA compartmentalization in blood Rios et al. Clinical Infectious Diseases log higher WNV viral load in whole blood than in plasma Lai et al. Transfusion Longitudinal cohort of 10 WNV+ blood donors Higher WNV viral load in whole blood than in plasma after seroconversion WNV RNA cleared in plasma within 15 days post-index in 9/10 donors Persisted in whole blood up to 90 days post-index in 5/10 donors Confirmed in cohort of 56 WNV+ blood donors, Lanteri et al. Transfusion, Re-testing plasma PBMC and whole blood WNV persists in the RBC fraction WNV RNA is more persistent in symptomatic WNV+ blood donors pathogenesis How does WNV stick to the RBCs?

39 5 Asymptomatic donors Plasma - 10 days (range 7 37) WB -22 days (range ) VL higher in whole blood 6 symptomatic travelers Serum + for 3 days; WB + for 2 months

40 Higher levels of ZIKV RNA in red cells vs plasma in index donation samples after IgM seroconversion 8 Pre-IgM (n=65) 8 Post-IgM (n=45) Log 10 ZIKV RNA IU/mL Log 10 ZIKV RNA IU/mL Plasma RBC unit 0 Plasma RBC unit

41 Longer persistence of ZIKV RNA in whole blood and RBC blood compartments than in plasma and body fluids ZIKV IU/mL Plasma Visit ZIKV IU/mL Red blood cells Visit ZIKV IU/mL Whole Blood Visit 10 7 PBMC 10 7 Urine 10 7 Saliva ZIKV IU/mL ZIKV IU/mL ZIKV IU/mL Visit Visit Visit 1. Testing whole blood extends detection period for diagnosis of clinical cases and monitoring pregnant women and travelers. 2. Impact on donation policy: to extend deferral period or consider NAT testing whole blood. 3. Considerations for testing for solid organ, tissue and semen donations 4. IS RBC-ASSOCIATED VIRUS INFECTIOUS?

42 IgM/IgG results on samples from ZIKV NAT+ donors enrolled in REDS-III Study with up to 6 months follow-up ZIKV IgM non-reactive (P/N <2.0) at index ZIKV IgM Equivocal (P/N 2.0 to <3.0) at index ZIKV IgM Reactive (P/N >3.0) at index 20 ZIKV IgM 20 ZIKV IgM 20 ZIKV IgM P/N 10 P/N 10 P/N Days from Index Day(s) from Index Day(s) from Index 20 ZIKV IgG 20 ZIKV IgG 20 ZIKV IgG P/N 10 P/N 10 P/N Day(s) from Index Day(s) from Index Day(s) from Index DENV IgG negative donor

43 Characterization of blood transfusion-transmission of Zika virus in macaques Characterization of transfusion-transmission of ZIKV in macaques (collaboration between REDS-III Central Lab (BSRI) and the UC Davis Primate Center) Aims: Dynamics of acute ZIKV TT infection in a macaque model Characterization of minimal infectious dose for ZIKV in pre and post-ab SC stages of infection Characterization of the effect of pathogen-reduction on transmission specifically at high viral loads FDA and HRSA leveraging this study by extending monitoring of ZIKV infected macaques to investigate distributions/persistence in tissues and organs of interest

44 Acute ZIKV Infection Dynamics in Blood in Macaques Coffey et al., PlosOne, 2017

45 ZIKV RNA in organs/tissues 14 days post-infection in Macaques Coffey et al., PlosOne 2017

46 Characterization of blood transfusion-transmission of Zika virus in macaques Aim 2A. Minimal infectious dose in ramp-up phase Serial dilutions in macaque plasma Serial follow-up For ZIKV infection Plasma from ZIKV RNA+ IgM- blood donor Intravenous infection of macaques Aim 2B Minimal infectious dose in the presence of ZIKV antibodies Serial dilutions Serial follow-up For ZIKV infection Plasma from ZIKV RNA+/IgM+/IgG blood donor Aim 3. Analysis of efficacy pathogen reduction technologies Serial follow-up For ZIKV infection Plasma from ZIKV RNA+ blood donors PRT of plasma Re-challenge of uninfected animals with non-prt plasma

47 Dilution in macaque plasma Infectivity of Brazilian plasma implicated in TT Viral load (IU/ml) In vitro infectivity (PFU/ml) Mouse infectivity adjusted to be equivalent of 1ml Macaque infectivity using 1 ml Not Tested Not Tested Not Tested Not Tested Not Tested Not Tested /1 infected /2 infected /6 infected 0/2 infected Below LOD 6/6 infected 0/2 infected Below LOD 4/6 infected 0/1 infected Below LOD (~0.2) 6/6 infected 0/1 infected 0.03 ND (~13) Below LOD (~0.04) 1/6 infected ND ND (~5) Below LOD 0/6 infected ND Macaque infection occurred between 3,000 9,000 RNA copies and pfu.

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50 Acknowledgements REDS-III Central Laboratory, Blood Systems Research Institute Brian Custer Marion Lanteri Thema Gonzalez Sonia Bakkoor Tzong-Hae Lee Graham Simmons Mars Stone REDS-III Brazil Program Ester Cerdeira Sabino, the Fundaçao Faculdade de Medicina and Hospital das Clinicas of the Medical School of the University of São Paulo with participation of 4 blood centers located in: Bello Horizonte - Minas Gerais (Fundaçao Hemominas), Recife - Pernambuco (Fundaçao Hemope), Rio de Janeiro (Fundaçao Hemorio), and São Paolo (Fundaçao Pro-Sangue). REDS-III Data Coordinating center, RTI International Don Brambilla Marian Sullivan UC Davis Koen Van Rompay Lark Coffee REDS-III Chair Steve Kleinman REDS-III ZIKV Oversight Committee Jay Epstein, FDA Hira Nakhasi, FDA Matt Kuehnert, CDC Lyle Peterson, CDC Brad Biggerstaff, CDC NHLBI Simone Glynn Allison Cristman Kelli Malkin Shimian Zou