Plasma fractionation in countries with limited infrastructure and low-/medium income: How to move forward?

Toward a Sociology of Plasma Products

Over the past 20 years, plasma has become a medical treatment characterized as "liquid gold" to signal its lifesaving potential. Through a manufacturing process termed fractionation, plasma, collected through blood donation, is turned into Plasma Derived Medical Products (PDMPs). The World Health Organization (WHO) has underlined the importance of PDMPs for global health care, including a number of PDMPs on the WHO Model List of Essential Medicines. The process of collecting plasma from a donor, manufacturing plasma derived treatments, and distributing those treatments globally requires the coordination of multiple social actors operating in different social, political and economic contexts, but has received little attention in scholarly literature on public policy or the social sciences. This paper will introduce a set of analytic questions and concepts that can direct a sociology of plasma products. We build on the behavioral turn in the policy sciences to identify relevant policy questions emerging from this field and offer the analytic tools necessary to investigate how different social actors in this space make meaning of plasma. To do this, we will draw on key concepts in the sociology of health and illness.

Towards personalized and rational use of immunoglobulins amid expanding indications and shortages

The development of intravenous IgG (IVIG) formulations in the 1970s enabled expanded use for treating primary antibody deficiency syndromes and autoimmune conditions. Recent advancements include the use of IVIG in secondary immune deficiencies related to hematologic malignancies and stem cell transplantation, along with the newly emerging prophylactic applications following chimeric antigen receptor T-cell (CAR-T) therapies. Novel therapeutic areas such as bispecific antibodies (BsAbs) for lymphoma and myeloma have increased the use of IgG, given the associated risks of infections. Today, the concept of a rational personalized clinical use of IgG in the context of evolving clinical indications in high-income countries (HIC) is emerging, as unmet challenges in line with managing shortages due to increasing demands globally. The current work aims to review and link the indications for IgG to their characteristics and formulations, their dose, route and frequency of administrations and duration of therapy to meet the needs of individual patients. It will also explore the means to rationalize and monitor IgG use in HIC in the time of shortage, while explaining pragmatic strategies to improve supply and use in low- and middle-income countries (LMIC).

Stepwise options for preparing therapeutic plasma proteins from domestic plasma in low- and middle-income countries

Industrial plasma fractionation, a complex and highly regulated technology, remains largely inaccessible to many low- and middle-income countries (LMICs). This, combined with the limited availability and high cost of plasma-derived medicinal products (PDMPs), creates deficiency of access to adequate treatment for patients in resource-limited countries, and leads to their suffering. Meanwhile, an increasing number of LMICs produce surplus plasma, as a by-product of red blood cell preparation from whole blood, that is discarded because of the lack of suitability for fractionation. This article reviews pragmatic technological options for processing plasma collected from LMICs into therapies and supports a realistic stepwise approach aligned with recent World Health Organization guidance and initiatives launched by the Working Party for Global Blood Safety of the International Society of Blood Transfusion. When industrial options based on contract or toll plasma fractionation programme and, even more, domestic fractionation facilities require larger volumes of quality plasma than is produced, alternative methods should be considered. In-bag minipool or small-scale production procedures implementable in blood establishments or national service centres are the only realistic options available to gradually reduce plasma wastage, provide safer treatments for patients currently treated with non-pathogen-reduced blood products and concurrently improve Good Manufacturing Practice (GMP) levels with minimum capital investment. As a next step, when the available volume of quality-assured plasma reaches the necessary thresholds, LMICs could consider engaging with an established fractionator in a fractionation agreement or a contract in support of a domestic fractionation facility to improve the domestic PDMP supply and patients' treatment.

Hyperimmunplasma: Gewinnung, Verarbeitung und therapeutische Anwendungen

Das Prinzip der passiven Immunisierung ist seit dem 19. Jahrhundert bekannt und wird auch bei aktuellen Pandemien als Ansatz zur Prophylaxe und Therapie eingesetzt. Der Schutz wird hierbei übertragen durch Blut, Serum oder Plasma, welche Immunglobuline gegen spezifische Krankheitserreger, Bakterientoxine oder sonstige Antigene enthalten, sowie durch aus Humanplasma industriell aufgereinigte Immunglobuline. Die aktuell verwendeten Reinigungsverfahren für Immunglobuline aus Humanplasma beruhen auf der von Edwin J. Cohn entwickelten Fraktionierung von Plasma. Zur Gewinnung von Immunglobulinen mit hohen Antikörpertitern gegen spezifische Antigene, sogenannte Hyperimmunglobuline, muss zunächst Hyperimmunplasma gezielt von ausgewählten Spendern gewonnen werden. Diese Spender haben erhöhte Antikörpertiter gegen spezifische Krankheitserreger, Bakterientoxine oder sonstige Antigene, wenn sie im Rahmen einer vorangegangenen Infektion natürlich immunisiert wurden, einen zugelassenen Impfstoff zur Immunisierung erhalten haben oder gezielt zum Zweck der Plasmaspende immunisiert wurden. Aktuell sind in Deutschland, Österreich und der Schweiz Hyperimmunglobulinprodukte für verschiedene Anwendungen im Patienten zugelassen, von denen die meisten aus humanem Blutplasma gewonnen werden. Um die Herstellung der Produkte und damit letztlich die Behandlung der Patienten gewährleisten zu können, werden resiliente Lieferketten benötigt. Hierzu bedarf es unter anderem Änderungen in den Rahmenbedingungen für die Spenderimmunisierung in Deutschland.

Low-Cost Optical Assays for Point-of-Care Diagnosis in Resource-Limited Settings

Readily deployable, low-cost point-of-care medical devices such as lateral flow assays (LFAs), microfluidic paper-based analytical devices (μPADs), and microfluidic thread-based analytical devices (μTADs) are urgently needed in resource-poor settings. Governed by the ASSURED criteria (affordable, sensitive, specific, user-friendly, rapid and robust, equipment-free, and deliverability) set by the World Health Organization, these reliable platforms can screen a myriad of chemical and biological analytes including viruses, bacteria, proteins, electrolytes, and narcotics. The Ebola epidemic in 2014 and the ongoing pandemic of SARS-CoV-2 have exemplified the ever-increasing importance of timely diagnostics to limit the spread of diseases. This review provides a comprehensive survey of LFAs, μPADs, and μTADs that can be deployed in resource-limited settings. The subsequent commercialization of these technologies will benefit the public health, especially in areas where access to healthcare is limited.

Animal derived antibodies should be considered alongside convalescent human plasma to deliver treatments for COVID-19

Published data on the first 5,000 coronavirus patients to receive plasma shows promise in the United States. However, delivering convalescent plasma therapies in low- and even middle-income countries is both difficult and costly. Here we discuss the advantages and disadvantages of antisera raised in animals that may allow poorer countries to control the devastating effects of COVID-19.