Plasma derivatives and viral hepatitis

Explanation of inconsistencies in the determination of human serum albumin thermal stability

Thermal denaturation of human serum albumin has been the subject of many studies in recent decades, but the results of these studies are often conflicting and inconclusive. To clarify this, we combined different spectroscopic and calorimetric techniques and performed an in-depth analysis of the structural changes that occur during the thermal unfolding of different conformational forms of human serum albumin. Our results showed that the inconsistency of the results in the literature is related to the different quality of samples in different batches, methodological approaches and experimental conditions used in the studies. We confirmed that the presence of fatty acids (FAs) causes a more complex process of the thermal denaturation of human serum albumin. While the unfolding pathway of human serum albumin without FAs can be described by a two-step model, consisting of subsequent reversible and irreversible transitions, the thermal denaturation of human serum albumin with FAs appears to be a three-step process, consisting of a reversible step followed by two consecutive irreversible transitions.

Overview of Albumin and Its Purification Methods

As the most frequent plasma protein, albumin constitutes more than 50% of the serum proteins in healthy individuals. It has a key role in oncotic pressure maintenance and it is known as a versatile protein carrier for transportation of various endogenous and exogenous ligands. Reduced amounts of albumin in the body will lead to different kinds of diseases such as hypovolemia and hypoproteinemia. It also has various indications in shocks, burns, cardiopulmonary bypass, acute liver failure and etc. Further applications in research consist of cell culture supplement, drug delivery carrier and protein/drug stabilizer. So, the demand for albumin increased annually worldwide. Due to different applications of albumin, many efforts have been accomplished to achieve albumin during a long period of time. In this review, an overview of serum albumin and different purification methods are summarized.

Evaluation of albumin structural modifications through cobalt-albumin binding (CAB) assay

Human serum albumin (HSA) is the most abundant protein in the human body. HSA injections prepared by fractionating human blood have mainly covered the demand for albumin to treat hypoalbuminemia, the state of low concentration of albumin in blood. HSA in solution may exist in various forms such as monomers, oligomers, polymers, or as mixtures, and its conformational change and/or aggregation may occur easily. Considering these characteristics, there is a great chance of modification and polymer formation during the preparation processes of albumin products, especially injections. The albumin cobalt binding (ACB) test reported by Bar-Or et al. was originally designed to detect ischemia modified albumin (IMA), which contains the modified HSA N-terminal sequence by cleavage of the last two amino acids. In this study, we developed a cobalt albumin binding (CAB) assay to correct the flaws of the ACB test with improving the sensitivity and precision. The newly developed CAB assay easily detects albumin configuration alterations and may be able to be used in developing a quality control method for albumin and its pharmaceutical formulations including albumin injections.

Intravenous immunoglobulins: evolution of commercial IVIG preparations

Since its first use in 1952, human immunoglobulin has been used to treat people who have inherited antibody deficiencies. This article summarizes IVIG clinical development in primary immunodeficient patients and manufacturing improvements introduced over time. Manufacturing improvements include purification procedures that have reduced the incidence of adverse events and improved clinical efficacy, as well as virus inactivation and removal steps that have increased safety from blood-borne infections. Current manufacturing procedures, IVIG production trends, and recent clinical trial results are also reviewed.

The role of ascorbate and histidine in fibrinogen protection against changes following exposure to a sterilizing dose of γ-irradiation

Sodium ascorbate and histidine were employed to protect fibrinogen against modifications followed by a gamma-irradiation process that could potentially inactivate the blood-borne viruses in plasma-derived products. Fibrinogen was irradiated (50 kGy total dose, on dry ice) using a 60Co source. Samples were analyzed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and western blot. Carbonyl groups were measured by the 2,4-dinitrophenylhydrazine-coupled method, and the fibrinogen clotting activity was assessed by different functional assays. In irradiated fibrinogen, the carbonyl group concentration was elevated three-fold versus control; and moderate fragmentation of largely Aalpha and Bbeta chains was revealed. The rate of thrombin-catalyzed fibrinogen polymerization was inhibited (average 50%) with normal fibrinopeptide release and with a minor decrease of total clottable fibrinogen and alpha-polymer formation. Ascorbate reduced the incorporation of carbonyls to the fibrinogen molecule (by > 50% at 50 mmol/l; P < 0.001). Contrary to ascorbate, which alone delayed the fibrinogen polymerization rate, histidine abolished irradiation-induced inhibition of fibrinogen polymerization (by 80% at 50 mmol/l; P < 0.001). In conclusion, even though ascorbate effectively protects fibrinogen from oxidation due to its adverse effects on fibrinogen function, it may not serve as a suitable radioprotective. On the contrary, the first definite evidence is provided that radiation-sterilized fibrinogen in the presence of histidine greatly retains its clotting capability.

Pathogen inactivation and removal procedures used in the production of intravenous immunoglobulins

Patients with immunodeficiencies or some types of autoimmune diseases rely on a safe therapy with intravenous immunoglobulins (IVIGs) manufactured from human plasma, the only available source for this therapeutic. Since plasma is predisposed to contamination by a variety of blood-borne pathogens, ascertaining and ensuring the pathogen safety of plasma-derived therapeutics is a priority among manufacturers. State-of-the-art manufacturing processes provide a high safety standard by incorporating virus elimination procedures into the manufacturing process. Based on their mechanism these procedures are grouped into three classes: partitioning, inactivation, and virusfiltration.

Virus safety of intravenous immunoglobulin: future challenges

Patients with immunodeficiencies or some types of autoimmune diseases are dependent on safe therapy with intravenous immunoglobulins. State-of-the-art manufacturing processes provide a high safety standard by incorporating virus elimination procedures into the manufacturing process. Based on their mechanism, these procedures are grouped into three classes: partitioning, inactivation, and removal based on size. Because of current socioeconomic and ecological changes, emerging pathogens continue to be expected. Such pathogens may spread very quickly because of increased intercontinental traffic. Severe acute respiratory syndrome-coronavirus and the West Nile virus are recent examples. Currently, it is not possible to predict the impact such a pathogen will have on blood safety because the capacity for a globally coordinated reaction to such a threat is also evolving. The worst-case scenario would be the emergence of a transmissible, small, nonenveloped virus in the blood donor population. Examples of small nonenveloped viruses, which change host and tissue tropism, are discussed, with focus on parvoviridae. Although today's immunoglobulins are safer than ever, in preparation for future challenges it is a high priority for the plasma industry to proactively investigate such viruses on a molecular and cellular level to identify their vulnerabilities.

High frequency of hepatitis B virus infection in patients with beta-thalassemia receiving multiple transfusions

BACKGROUND AND OBJECTIVES

Hepatitis B virus (HBV) may occasionally be transmitted through transfusion of blood units that are hepatitis B surface antigen (HBsAg) negative but HBV DNA positive. Children with beta-thalassemia are particularly susceptible to HBV because they receive multiple blood transfusions. These children have high infection rates despite vaccination against HBV. Post-vaccination infections may be a result of viruses harbouring surface (S)-gene mutations (e.g. G587A) in a region critical for reactivity to antibody to hepatitis B surface antigen (anti-HBs). The true prevalence of HBV in individuals with beta-thalassemia has not been studied previously.

PATIENTS AND METHODS

Seventy patients with beta-thalassemia (median age 6 years; range 8 months to 22 years; 49 male), who had received seven to 623 (median 61) units of blood each and three doses (10/20 micro g) of HBV vaccine (Engerix B) before presentation to us, were included in the study; 50 of the 70 patients had received transfusions prior to vaccination. Enzyme-linked immunoassay for serological markers [HBsAg, antibody to hepatitis B core antigen (anti-HBc) and quantitative anti-HBs] and polymerase chain reaction (PCR) followed by Southern hybridization for molecular detection of hepatitis B, was performed on all samples. The PCR-amplified product was cloned, sequenced and the nucleotide and deduced amino acid sequences for the HBV S and polymerase (P) genes were analysed for mutations.

RESULTS

Four of 70 (5.7%) individuals with beta-thalassemia were HBsAg positive and 14 (20%) were anti-HBc positive. The prevalence of serological markers increased with number of transfusions (P < 0.01). Of 70 patients, 53 (75.7%) had an anti-HBs titre of > 10 IU/l following vaccination and 17 (24.3%) were non-responders (< 10 IU/l); 22 (31.4%) of the 70 were DNA positive. The frequency of HBV infection in beta-thalassemia was similar in vaccine responders and non-responders. The virus was of subtype ayw (genotype D) in the five DNA-positive samples in which a 388-nucleotide region of the S gene was sequenced. Mutations occurred at 13 positions in the S gene and at 10 positions in the P gene. Hydrophobicity plots revealed differences in amino acid regions 117-165 and 195-211. Some of these amino acid substitutions coincided with the putative cytotoxic T-lymphocyte epitopes of both S and P proteins.

CONCLUSIONS

A high frequency of HBV infection was seen using molecular methods in thalassemic patients. The frequency of infection was similar in vaccine responders and non-responders. A number of mutations were observed in the S gene, which could have implications for viral replication as well as virus-host cell interaction.

Production and characterization of a reconstituted high density lipoprotein for therapeutic applications

A method is described for the large scale preparation of reconstituted high density lipoproteins (rHDL) suitable for therapeutic use. Apolipoprotein A-I (apoA-I was isolated from precipitates obtained by cold ethanol fractionation of human plasma. This process includes several steps for virus removal and virus inactivation, among them pasteurization. Reconstitution of lipoprotein particles was performed by cholate dialysis using soybean phosphatidylcholine as the lipid source. An apoA-I:lipid ratio of 1:150 (mol:mol) was obtained. Redissolved rHDLs were disc-shaped particles resembling nascent HDL, as assessed by electron microscopy. The method was optimized for low content of free apoA-I protein as well as the low concentration of free lipid. The product was stabilized by lyophilization in the presence of sucrose. In vitro studies show potential effects it the prevention of gram-negative septic shock and in the inhibition of atherosclerosis.

Hepatitis A transmission by factor IX concentrates

Factor IX concentrates unlike factor VIII concentrates have not to date been associated with the transmission of hepatitis A virus (HAV). A retrospective study by reverse transcriptase polymerase chain reaction on a batch of factor IX concentrate used to treat two haemophilia B patients who developed jaundice and IgM anti-HAV antibodies within 50 days of factor IX administration in 1985 revealed the presence of HAV RNA. These findings indicate that factor IX concentrates can transmit HAV and that appropriate viral inactivation steps to inactivate nonenveloped viruses as well as enveloped viruses are necessary to ensure the safety of factor IX concentrates.

The effects of pasteurisation on albumin: an EPR binding assay for polymeric albumin

The ability of a nitroxyl fatty acid (NFA) to bind specifically to albumin is abolished when, in the absence of stabilizers, a 4% solution of this protein is heated above a critical temperature of 60 degrees C. This treatment leads to the formation of "albumin polymers" as classically evidenced by GPC. Since the bound fraction is evidenced in EPR spectroscopy by a large anisotropic component, the presence of this anisotropy can be used in the assessment of the quality of the pharmaceutical preparations of albumin, which are usually pasteurized in order to inactivate viruses. Moreover, in sharp contrast with the behavior of albumin dispersions, lyophilised albumin subjected to heat treatment at 70 degrees C for 24 h left the protein untouched regarding its NFA binding and GPC profile.

Reduction in transmission of hepatitis C after the introduction of a heat-treatment step in the production of C1-inhibitor concentrate

BACKGROUND

The transmission of viral infections via protein concentrates made from a large pool of plasma depends on the selection of donors, fractionation process, and virucidal methods. To date, no data are available on the infectivity risk of plasma concentrates of the inhibitor of the first component of complement (C1-INH).

STUDY DESIGN AND METHODS

The prevalence of blood-borne viral infections and levels of transaminases were evaluated in patients treated with a large-pool plasma concentrate of the inhibitor of C1-INH before and after the introduction of virucidal methods. The study included 85 patients with hereditary angioedema and 4 with acquired angioedema. The patients were divided into three groups: 1) 48 untreated patients; 2) 22 patients treated with non-virus-inactivated C1-INH concentrates; and 3) 19 patients treated with virus-inactivated concentrates. Serum samples obtained at various times after the infusion of concentrate were assayed for alanine amino-transferase and tested for hepatitis B surface antigen and antibodies to hepatitis C virus (anti-HCV) and human immunodeficiency virus (anti-HIV); anti-HCV-negative subjects exposed to the concentrate were also tested for HCV RNA.

RESULTS

Prevalences of HCV infection and elevated alanine aminotransferase are significantly lower in patients treated with virus-inactivated concentrates than in those exposed to non-virus-inactivated concentrates. No patients were anti-HIV positive.

CONCLUSION

This study suggests that C1-INH concentrates transmitted HCV, but that the virucidal methods adopted are effective in reducing the infectivity.

Virus safety of human immunoglobulins: efficient inactivation of hepatitis C and other human pathogenic viruses by the manufacturing procedure

Human immunoglobulins are plasma derivatives with a low risk of transmitting viral infections. To the present, no proven case of human immunoglobulins transmitting human immunodeficiency viruses has been reported. However, there have been a few reports on the transmission of hepatitis C virus by these plasma proteins. To improve further the safety of both 5s iv human immunoglobulins and 7s im immunoglobulins, we introduced a 10-hour heat treatment of the aqueous solutions at 60 degrees C (i.e., pasteurization) into the manufacturing procedure. This treatment was not added to the manufacturing procedure of 7s iv immunoglobulin that already contained the S-sulfonation as a virus inactivating method. We now report on experimental data that show that the whole manufacturing procedures of the above immunoglobulins inactivate efficiently hepatitis C virus and that the specific virus inactivation methods alone, namely, pasteurization or S-sulfonation, also inactivate completely viruses of the flavivirus family, to which the hepatitis C virus belongs. The inactivation of the Flaviviridae bovine viral diarrhea virus, tick-borne encephalitis virus, and yellow fever virus by pasteurization or S-sulfonation was at least 10(5). The clearance of HCV achieved by the entire manufacturing process of each of these immunoglobulins was also at least 10(5). The experiments therefore show that pasteurization or S-sulfonation provides a high margin of safety to human immunoglobulins regarding the transmission of hepatitis C virus.

High-temperature short-time heat inactivation of HIV and other viruses in human blood plasma

An ultra-short-time heating system was used to process blood plasma spiked with various viruses (HIV, vesicular stomatitis virus, encephalomyocarditis virus). Virus reduction and recovery of plasma proteins were measured at various temperatures from 65 to 85 degrees C. Processing at 77 degrees C and 0.006 s resulted in a high level of virus kill, including greater than or equal to 4.4 log10 HIV, while maintaining protein structure and activity essentially intact.

Inactivation of viruses found with plasma proteins

Plasma protein solutions such as albumin and intramuscular immune globulin have long histories of viral safety. Coagulation factor concentrates as traditionally manufactured frequently transmitted HBV, HCV, and HIV. Indeed, it is probable that every vial of concentrate contained infectious HCV. Modern coagulation factor concentrates have a greatly improved safety record arising, principally, from the implementation of virucidal procedures. It is interesting to note that the same methods that failed to substantially reduce NANBHV transmission in clinical studies are those that were found to inactivate less than 10(4) ID50 of HIV, HBV, and/or HCV in preclinical studies (Table 17-5). Implementation even of these methods nearly eliminated the transmission of HIV by coagulation factor concentrates. A summary of the results of the most successful procedures is given in Table 17-10. The results show 0/564 patients had evidence of HIV transmission, 6/151 patients had evidence of HBV transmission, and 2/301 patients had evidence of HCV transmission. As compared with those procedures described in Table 17-5, the greater kill of HIV, HBV, and NANBHV demonstrated preclinically, and the improved clinical results, are most notable. The data, examined in terms of units transfused, are presented in Figure 17-1. Since the average adult hemophiliac in the United States receives 80,000 units of clotting factor per year, the best of the concentrates show safety over the equivalent of at least 10-human-years of treatment. Are the best of today's coagulation factor concentrates safe from the transmission of HBV, NANBHV (including HCV), and HIV. Given the limited number of patients eligible for clinical studies, and the length, difficulty, and expense of such studies, the best answer comes from a knowledge of the initial virus load coupled with information regarding virus removal, serendipitous inactivation, and intentional sterilization. A recently completed analysis of these factors (Horowitz 1990) indicates that the best of the modern coagulation factor concentrates are likely to be as safe as albumin (Figure 17-2).

Common variable immunodeficiency: the disorder and treatment

A case of common variable immunodeficiency, a relatively rare disorder, is presented. This case was complicated by the presence of an anti-IgA antibody in the patient's serum and a history of a possible anaphylactic reaction to a prior intravenous infusion of gamma-globulin. Common variable immunodeficiency is actually a heterogeneous group of demonstrable immunoglobulin deficiencies that have in common low levels of most immunoglobulin isotypes, the inability to form antibodies to antigen, an absence of gross defects in cell-mediated immunity, and the presence of recurrent bacterial infections. The history of immunoglobulin deficiency and its treatment is reviewed. Although the primary therapy for common variable immunodeficiency is gamma-globulin replacement, ancillary measures such as early treatment of infections with antibiotics are also important. Intravenous gamma-globulin replacement therapy is preferred to intramuscular replacement therapy in these patients because intramuscular doses must be limited in volume to minimize local pain and take 2 to 14 days to achieve maximal blood levels, during which time in situ degradation of up to 50% of the administered dose can occur. Five intravenous gamma-globulin preparations are currently available in the United States. The potential adverse effects of intravenous gamma-globulin infusion and the precautions currently taken to ensure safety during administration of this product are discussed.

Transmission of human immunodeficiency virus type 1 by dry-heated clotting factor concentrates. Transfusion Safety Study Group

The Transfusion Safety Study monitored susceptible persons for human immunodeficiency virus type 1 (HIV-1) infections transmitted by plasma products and blood components. Through December, 1988, 6 subjects without antibody to HIV-1 (anti-HIV-1) became seropositive after receiving dry-heated factor VIII concentrate. The preparations implicated in 3 cases were derived entirely from anti-HIV-1-screened donors. In all instances, HIV-1 infection could be explained by concentrates heated at 60 degrees C for 24-30 h. Limiting consideration to concentrates and components administered after study entry showed that 4 of the seroconversions occurred among 122 subjects given 10 million units of factor VIII concentrates. No seroconversions occurred among 84 subjects given 5 million units of factor IX concentrates, or 83 who received components from over 26,000 unpaid donations. Serologic surveillance of anti-HIV-1-negative subjects provides important information, and should be routine in the management of persons receiving clotting factor concentrates.

Vaccination of infants and children against hepatitis B

Hepatitis B infection and its sequelae constitute a significant public health problem in the United States. It is estimated that 300,000 acute hepatitis B infections occur each year, with about 25% accompanied by both clinical illness and jaundice. Some infections become chronic and ultimately may cause development of liver cirrhosis or primary hepatocellular carcinoma. The risk of chronicity is especially great with infections that occur in infancy. Highly effective vaccines comprised of purified hepatitis B surface antigen (HBsAg) particles are now available for the prevention of hepatitis B infection. A first-generation vaccine utilized HBsAg derived from the plasma of infected persons; this has now been replaced by two similar vaccines that incorporate HBsAg produced by genetically engineered strains of the common bakers' yeast, Saccharomyces cerevisiae. Improved use of vaccine is needed to reduce and ultimately eliminate hepatitis B infection. Vaccination already is recommended for persons recognized to be at increased risk of exposure to virus-containing blood or other body fluids (e.g., infants born to carrier mothers, household or sexual contacts of carriers); however, mass vaccination of adolescents and infants is needed to interdict effectively a majority of all exposures to the hepatitis B virus.

Transfusion-associated hepatitis B: past and present

Thus, it can be concluded that: (1) Hepatitis B, even before the introduction of donor screening for HBsAg, probably never accounted for more than one-quarter of all cases of transfusion-associated hepatitis. (2) As of 1988, the frequency of this viral infection in blood recipients, now that sensitive donor screening for HBsAg is routine, is less than 10%. The exception are multiply transfused populations, such as hemophiliacs, the majority of whom have evidence of current or past exposure to hepatitis B. However, new inactivation procedures are likely to reduce the attack rate in virgin populations of hemophiliacs. (3) Interdiction of paid blood has proved far more effective than donor screening for HBsAg in reducing the overall frequency of transfusion-associated hepatitis. (4) The current requirement that all donors be screened for anti-HBc and ALT as surrogate markers of non-A, non-B hepatitis infection, and for anti-HIV, is likely to reduce the hepatitis B attack rate even more, perhaps to near zero. (5) The long-term outcome of transfusion-associated hepatitis B has not been determined, a task that will remain difficult to accomplish because of the paucity of current cases. Information in this regard will need to be derived from the recall and reevaluation of pedigreed patients who participated in prospective studies that were conducted in the distant past.

Inactivation of lipid-enveloped viruses in labile blood derivatives by unsaturated fatty acids

Virus sterilization of blood plasma derivatives by addition of several naturally occurring fatty acids was evaluated using vesicular stomatitis virus and Sindbis virus as markers for lipid-enveloped virus inactivation and human immunodeficiency virus (HIV). Inactivation of greater than or equal to 10(4) tissue culture infectious doses (TCID50) of marker viruses added to antihemophilic factor (AHF) concentrates, with 60-100% retention of AHF activity, was achieved with oleic, 11-eicosenoic, linoleic, linolenic, palmitoleic and arachidonic acids. Elaidic, gamma-linolenic, palmitic, and arachidic acids and another fat-soluble compound previously reported to inactivate virus, butylated hydroxytoluene, were less effective. A long chain mono- but not a di- or triglyceride also displayed virucidal properties. Evaluation of the inactivation of HIV added to an immune globulin solution on exposure to 0.033% sodium oleate for 20 min indicated inactivation of greater than or equal to 10(3.4) TCID50. The degree of virus inactivation depended on the sample composition. A favorable balance was achieved between degree of virus inactivation and retention of protein function for AHF concentrate, prothrombin complex concentrate, antithrombin III concentrate, and immune globulin solution on incubation with 0.033% (w/v) sodium oleate at 24 degrees C for 4-6 h. Virus inactivation in whole plasma and plasma cryoprecipitate was not complete despite use of higher concentrations of sodium oleate and/or incubation at 37 degrees C. Reduced virus kill in these less purified derivatives probably is a consequence of their endogenous lipid and/or albumin.

Effect of citric acid and lyophilized autologous plasma on healing following periodontal flap surgery in monkeys

The purpose of this histologic, histometric, and autoradiographic study was to examine the effect of citric acid conditioning and lyophilized autologous plasma (LAP) application on healing following periodontal flap surgery. Mucoperiosteal flaps were elevated in six rhesus monkeys using the modified Widman flap procedure. A total of 24 quadrants were treated, each included the first and second premolar and first and second molar teeth. Cementum was removed from the exposed root surfaces, and reference notches were inscribed into the roots at the alveolar bone margin. Two treatment modalities were employed: (1) surgery plus citric acid conditioning, to serve as control and (2) surgery plus citric acid followed by LAP application (400 mg/ml saline). Flaps were returned to their preoperative positions and sutured. Animal sacrifices were scheduled to provide observations 3, 7, 14, 21, 28, and 45 days after surgery. Each monkey received an intravenous injection of tritiated thymidine, 1 microCi/gm of body weight, 1 hour before it was killed. Tissue specimens were processed for evaluation following standard procedures. Histologically, tissue sections were examined for: (1) proliferation and attachment of epithelium, (2) organization and maturation of periodontal fibers, (3) inflammatory cell types, (4) presence or absence of new cementum deposition, and (5) degree of vascularity of the tissues. For histometric evaluation, the radicular notches were used as reference points. The distances examined histometrically were: (1) from the root surface notch to the alveolar bone crest, (2) from the root surface notch to the apical extent of the junctional epithelium, and (3) from the free gingival margin to the apical extent of the junctional epithelium. For autoradiographic evaluation labeled cells were counted in five spatial compartments at 400 X magnification: (1) oral epithelium, (2) crevicular area, (3) supracrestal connective tissue, (4) coronal periodontal membrane, and (5) coronal bone marrow. For each the histometric and autoradiographic evaluation involved a total of 36 tissue sections per quadrant (9 sections per tooth). Tooth and quadrant means were obtained for each monkey. The plasma-treated and control quadrants were compared at each time point by the paired t test. N = 2 monkeys were used for each comparison. Histologic results showed that in teeth that were acid-conditioned after root planing, the epithelium often migrated apically reaching the radicular notch. Those teeth that were conditioned and subsequently treated with LAP demonstrated fiber attachment to the planed root surface and little or no epithelial downgrowth.(ABSTRACT TRUNCATED AT 400 WORDS)

Heat stability of lyophilized C1 inactivator concentrates

Heat stability of lyophilized C1 inactivator (C1-INA) concentrates of intermediate and high purity has been investigated under several heat treatment protocols that include heating for 96 and 192 h at 68 degrees C and for 10 h at 80, 90 and 100 degrees C. Both types of concentrate showed high stability in functional activity, with not more than 5% loss in any of the time-temperature combinations evaluated. However, the C1-INA antigen from both concentrates showed small but progressive changes in crossed immunoelectrophoretic pattern, in proportion to the intensity of heat treatment. High-pressure size-exclusion chromatography revealed only minimal signs of aggregation in the high-purity concentrate, but a significant and progressive aggregation of nonspecific protein contaminants present in the intermediate-purity concentrate, making the high-purity concentrate preferable for heat treatment.

Studies on the effect of heat treatment on the thrombogenicity of factor IX concentrates in dogs

This study examines the effects of heat treatment for 72 h at 80 degrees C on the potential thrombogenicity of lyophilized human coagulation factor IX concentrates. Since heating generated minor amounts of thrombin, concentrate was prepared with antithrombin III addition prior to heat treatment. Changes in coagulation parameters were followed prior to and after infusion of 100 iu/kg of heated and unheated concentrates to dogs. All batches produced a transient fall in platelet count during infusion and a delayed rise in plasma fibrinopeptide A, accompanied by a minor prolongation of the activated partial thromboplastin time. Such changes were less marked for heated batches. Control infusion of a 'failed' factor IX concentrate showed an additional fall in fibrinogen, rise in fibrin degradation products and a more rapid rise in fibrinopeptide A, while thrombin infusion caused an even more dramatic intravascular coagulation. These studies indicated no increase in the potential thrombogenicity of freeze dried factor IX concentrates as a result of heat treatment.

Tri(n-butyl) phosphate/detergent treatment of licensed therapeutic and experimental blood derivatives

Incubation of an AHF concentrate with 0.3% tri(n-butyl)phosphate (TNBP) and 0.2% sodium cholate was shown to inactivate at least 10,000 infectious doses of lipid-enveloped viruses, including hepatitis B and non-A, non-B viruses and HTLV-III [Prince et al., Lancet i, pp. 706-710, 1986]. The use of TNBP/detergent combinations for virus sterilization was evaluated further to determine its effect on the structure and function of a wide variety of blood proteins. Vesicular stomatitis and Sindbis viruses were used as markers of virus inactivation. TNBP/detergent treatment did not significantly alter the function of AHF, factor VII, factor IX, factor X, fibrinogen, factor XIII, fibronectin, anti-HBsAg and anti-HA in normal serum globulin, haptoglobin, tumor necrosis factor, alpha-interferon, and both native and chemically polymerized stroma-free hemoglobin. As compared with partially purified derivatives, the extent of virus sterilization of plasma and component cryoprecipitate with 0.3% TNBP and 0.2% sodium cholate at ambient temperature could be improved by raising the TNBP concentration and temperature. Virus sterilization by TNBP/detergent mixtures appears to be generally applicable to blood protein derivatives.

Hepatitis B vaccination of 113 hemophiliacs: lower antibody response in anti-LAV/HTLV-III-positive patients

One-hundred thirteen adults and children with hemophilia or other congenital bleeding disorders were vaccinated against the hepatitis B virus. Each patient was given three subcutaneous injections of the vaccine at monthly intervals and then a fourth booster dose 14 months after the first. The vaccine was highly immunogenic, since 111 of 113 patients (98%) produced anti-HBs (10 mIU/ml or more). After the first three vaccine doses and after the booster dose, ten anti-LAV/HTLV-III-positive hemophiliacs produced anti-HBs but had a lower average titer than anti-LAV/HTLV-III-negative hemophiliacs. Of the 23 patients treated with concentrates in the 15 month postvaccination period only, none acquired HBV infection. Of the 50 patients treated with concentrates also in the 6 month prevaccination period, one developed hepatitis B. In summary, the vaccine was highly immunogenic in both children and adults with hemophilia; anti-LAV/HTLV-III-positive patients responded to the vaccine, but the average anti-HBs response was lower; no case of hepatitis B occurred in patients treated with concentrates only in the postvaccination period.

Hepatitis B virus, hepatitis non-A, non-B virus and hepatitis delta virus in lyophilized antihemophilic factor: relative sensitivity to heat

Lyophilized plasma derivatives are more stable to heat than when they are in the liquid state. Commercial Factor VIII (antihemophilic factor) was seeded with a measured quantity of hepatitis B virus. The contaminated material was then lyophilized and subjected to heat of 60 degrees C for 30 hr. Chimpanzees were inoculated with the heat-treated antihemophilic factor or sham-treated antihemophilic factor that had been held at 4 degrees C. Surprisingly, hepatitis B virus survived the heating procedure with no apparent loss in titer: the incubation period to appearance of HBsAg was that expected for the challenge dose of virus. Even more surprising, one chimpanzee (the recipient of the unheated antihemophilic factor) also developed non-A, non-B hepatitis and two chimpanzees (recipients of the heated antihemophilic factor) also developed delta hepatitis. Neither of these agents was a contaminant of the hepatitis B virus challenge pool, since the purity of this hepatitis B virus pool was established previously in chimpanzees. Thus, both a non-A, non-B agent and the delta agent apparently contaminated the commercial antihemophilic factor. This is the first direct evidence for contamination of antihemophilic factor with the delta agent and confirms previous seroepidemiologic evidence for its presence in pooled plasma derivatives. Subsequent inactivation studies were performed with antihemophilic factor experimentally contaminated with the Hutchinson strain of non-A, non-B hepatitis virus. In these studies, heating at 60 degrees C for 30 hr in the dry state rendered antihemophilic factor free of detectable non-A, non-B hepatitis virus.

Transmission of non-A, non-B hepatitis by heat-treated factor VIII concentrate

In-vitro and animal studies have shown that viral agents can be removed from or inactivated in clotting factor concentrates by physical or chemical treatment. However, clinical data have as yet not substantiated the results of these studies. 13 haemophilia A patients who had not been treated previously with blood or blood products were given a dry-heated factor VIII concentrate and were tested serologically over the next 12 months. Hepatitis developed in 11 patients (84%) and was invariably of type non-A, non-B. Morbidity was not related to the lot of the therapeutic material or to the number of infusions. The incubation period was either 5 or 8-11 weeks, and only 1 patient had symptoms. Aminotransferase elevation showed both monophasic and biphasic patterns. During the follow-up period signs of the disease disappeared in 10 patients (90%). These findings contrast with the absence of non-A, non-B hepatitis in chimpanzees given the same heated concentrate. Thus, clinical studies in first-exposure haemophiliacs are essential for the true evaluation of the safety of new "treated" concentrates.

Epidemic non-A, non-B viral hepatitis in Algeria: strong evidence for its spreading by water

A waterborne epidemic of non-A, non-B hepatitis occurred in Medea, an Algerian town of 68,000 inhabitants during the autumn and winter of 1980-1981. About 6 weeks before the epidemic, there had been a chlorination failure and an accidental sewage contamination of the river water that supplied large parts of the town. From October, 1980, to January, 1981, 788 cases were notified. This epidemic affected mostly young adults, who usually recovered; however, a high rate of mortality was noted among pregnant women (nine patients, nine deaths). Serological examinations performed on 57 hospitalized patients excluded both hepatitis A and B. The waterborne nature of the epidemic was suggested by a study of the case distribution according to water supplies. The epidemic was severe in the areas supplied by the untreated river water. Few cases were reported in the areas receiving spring water, where chlorination never failed. A mild incidence of infection was noted in the areas supplied by a mixture of untreated river water and chlorinated spring water.

Hepatitis safety of a new prothrombin complex preparation, sterilized according to the method of LoGrippo. Results of a prospective clinical trial

In a controlled, prospective clinical trial with almost 300 patients undergoing cardiovascular surgery, the hepatitis risk was examined of a new prothrombin complex (PPSB) preparation produced from pooled plasma, which was cold sterilized according to the method of LoGrippo with beta-propiolactone and UV-light. Of 268 evaluable patients, 102 belonged to a group receiving PPSB and 166 belonged to a control group without PPSB. 25 batches of PPSB in dosages of up to 4,500 units per patient, in total, were used. The mean requirement for transfusion of blood or plasma was 10 units per patient in the group receiving PPSB and slightly more than 2 units per patient in the control group. In both of the groups, 3 hepatitis infections occurred (5 cases of non-A, non-B, 1 case of type B), corresponding to hepatitis incidences of 2.9 and 1.8%, respectively. The difference in hepatitis incidence between both groups was statistically not significant. This demonstrates, on the one hand, the hepatitis safety of the sterilized PPSB and, on the other, that multiple transfusion is no longer associated with a high risk of hepatitis when the guidelines of modern donor screening are followed.

Pasteurization of C1 inactivator in the presence of citrate salts

Conditions have been determined under which the C1 inactivator (C1-INA) can be pasteurized to reduce the risk of transfusion hepatitis associated with its use for replacement therapy in patients with genetic or acquired deficiencies. Recovery of 90% of the biological and immunological activity of a C1-INA concentrate was achieved following heat treatment for 10 h at 60 degrees C in the presence of 3 M potassium citrate. Crossed immunoelectrophoresis in heparinized agarose was used to demonstrate the ability of the pasteurized C1-INA to bind heparin and to form a precipitation pattern with antibody which was almost indistinguishable from that of an unheated control. High pressure liquid chromatography and enhancement of the fluorescence of 1,8-anilinonaphthalene sulfonate were used to show that other proteins present in the concentrate were also stabilized.