Acute hepatitis non-A, non-B following administration of factor VIII concentrates

Safety aspects in the manufacturing of plasma-derived coagulation factor concentrates

Plasma-derived coagulation factor concentrates, prepared using traditional manufacturing processes, have transmitted viral diseases, especially AIDS, hepatitis B and hepatitis C to patients. To date, more extensive selection of blood donors, improved screening procedures of each plasma donation for direct and indirect viral markers, and newly developed virucidal procedures, especially pasteurization and solvent-detergent, together with extraction technologies of plasma proteins based on high-resolution chromatographic separations, have diminished considerably the risks of transmitting these pathogenic agents. To ensure safety, each production process must be carefully validated, following a rigorous scientific approach to assess its ability to inactivate or eliminate viruses. In addition, Good Manufacturing Practices must avoid any variation from these validated viral inactivation processes and must eliminate risks of potential downstream contamination of purified plasma fractions following viral inactivation or elimination steps. Other side-effects associated with conventional low-purity preparations, such as acute haemolytic anemia due to contamination by isohaemagglutinins, or immunosuppression possibly due to an overload in fibrinogen and immunoglobulins, have not been reported following infusion of highly purified coagulation factor concentrates. Present state-of-the-art virus inactivation and protein-purification technologies have significantly improved the safety of plasma coagulation factor concentrates.

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.

Binding of hepatitis virus particles to immobilised procion blue-HB and cibacron blue 3GA

Two chemically similar triazine dyes, coupled to chromatographic gels, have been investigated for their ability to bind and retain hepatitis B surface antigen marker of the hepatitis B virus. Both dyes, Procion Blue-HB and Cibacron Blue 3GA, were effective in removing viral particles from plasma protein solutions. A number of combinations of dye and gel support have been tried, to obtain optimal binding. A Cibacron Blue-Trisacryl adsorbent achieved almost complete retention (greater than 99.5%) of HBsAg before breakthrough occurred. Binding was better at reduced flow rates and on large pore gel matrices, suggesting that steric restrictions limit the interaction. The interaction is directly between immobilised dye and the viral particle, rather than through plasma albumin, which also binds to these affinity adsorbents. These findings are important in the use of immobilised triazine dyes for plasma protein purification. Furthermore, the interaction may be utilised either for the removal of HB viral particles from plasma or as a rapid method of their purification.

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.

High risk of non-A non-B hepatitis after a first exposure to volunteer or commercial clotting factor concentrates: effects of prophylactic immune serum globulin

After a first exposure to factor VIII concentrates, 9/9 British patients treated with U.S.A.-derived commercial products, and 10/12 treated with British volunteer (NHS) products, developed acute non-A, non-B (NANB) hepatitis. Hepatitis following commercial products was more severe, and of shorter incubation. High previous exposure to NHS blood products seemed to prevent NHS but not commercial factor VIII-induced hepatitis; the latter was also not attenuated by administration of U.S.A.-derived commercial immune serum globulin (ISG). After a first exposure to NHS factor IX concentrates without ISG, 4/4 patients developed short incubation NANB hepatitis; one also contracted prolonged incubation hepatitis B. One patient treated with ISG and factor IX of proven infectivity did not develop hepatitis, suggesting protection by ISG. Observed differences between concentrates might be attributable to their content of different NANB agents, but dose-related effects could provide alternative explanations. This data provides a basis for comparative assessment of new products of possible reduced infectivity in only small numbers of patients.

The subcutaneous administration of the vasopressin analogue 1-desamino-8-D-arginine vasopressin in patients with von Willebrand's disease and hemophilia

Twenty-one patients suffering from mild von Willebrand's disease (vWd) and patients suffering from mild or moderate hemophilia A received 1-desamino-8-D-arginine vasopressin (DDAVP) (Minirin, Ferring AG) s.c. at a dose of 0.4 microgram/kg body weight. Additionally, two hemophiliacs and 22 patients with vWd received DDAVP i.v. Within the observation period of 3 h Factor (F) VIII:C levels increased 2.4 X baseline levels in hemophiliacs, and the maximal effect was observed 3 h post DDAVP s.c. In patients with vWd post DDAVP s.c. (i.v.) a 2.7 (3.4), 2.1 (1.9) and 2.2 (2.8) fold increase for F VIII: C, F VIIIR:Ag and F VIII:Rcof was observed. In eight patients suffering from vWd with additional F XII deficiency a small and transitory but significant increase of F XII levels was detected post DDAVP s.c. No local or systemic side effects were observed. In five patients with vWd tooth extractions were performed without bleeding complications under DDAVP s.c. treatment. Two patients practiced self-treatment by injecting the drug s.c. at home. We thus conclude that s.c. DDAVP is an effective, reliable, and cost-reducing form of treatment that does not bring with it the risk of transmitting infectious diseases in patients with vWd and hemophilia and that can be administered at home.

Incidence of infection with hepatitis B virus in 56 patients with haemophilia A 1971-1979

During each of the four-year periods 1971-1975 and 1975-1979, the annual incidence of hepatitis B infection has been assessed in 56 patients with haemophilia A by measuring plasma HBsAg, anti-HBs and anti-HBc levels. Infection rates of 7% and 9.5% per annum respectively were observed for each four-year period despite the screening of individual blood donations for HBsAg by techniques up to the sensitivity of reversed passive haemagglutination. The highest incidence of seroconversion was amongst severe haemophiliacs many of whom had received treatment predominantly with cryoprecipitate. Of the 16 patients in whom serological evidence of hepatitis B infection was obtained only one had an accompanying clinical episode of hepatitis. We conclude that haemophiliacs are still at high risk of infection by hepatitis B virus despite the screening of individual blood donors for HBsAg.

Hepatitis and haemophilia therapy in Australia

243 Australian haemophiliacs have been studied retrospectively over 4 1/2 years to assess the effect of treatment products on liver function and to determine the frequency of hepatitis-B markers in these patients. Commercial blood products are not used in Australia, and the patients were treated with products of blood from unpaid donors screened for hepatitis B surface antigen. Cryoprecipitate was the major treatment product, and only small amounts of factor VIII and IX concentrates were used. Despite the use of blood products obtained from entirely voluntary blood donors and the frequent use of single-donor packs of cryoprecipitate, markers of viral hepatitis were common in these haemophiliacs. Antibody to hepatitis B surface antigen was detected in 63% of the patients, and there were 66 cases of non-A, non-B hepatitis during the study. 29 of these episodes persisted for longer than 6 months. 13 patients (5.4%) had hepatitis B during the study; 2 patients remained HBsAg-positive for longer than 6 months. Abnormal serum aminotransferase levels were found in 34% of the patients; in 8% of patients these abnormalities persisted for more than 6 months.