VIRAL INACTIVATION OF BLOOD PRODUCTS
Wednesday 26 April 2017
VIRAL INACTIVATION OF BLOOD PRODUCTS
Overview of the relevant period – 1972– 1982: early steps in virus inactivation – impact of limited plasma supplies on production and research – development of Cryosupernatant Factor VIII – improved HBsAg testing – growing evidence of hepatitis antigen in Scottish patients – processing developments related to improved yield – increasing interest in virus transmission – use of Cryoprecipitate in Glasgow and West of Scotland as product of choice – developments in commercial markets – change of direction in SNBTS research and development in early 1982 – position at end of 1982– 1982–1991: trends in SNBTS research and development in 1983 and the impact of AIDS – progress with pasteurisation – growing awareness of AIDS risk to people with severe haemophilia – position reached in June 1983 prior to renewed collaboration with Dr Johnson – clinical trials of SNBTS pasteurised product begin in September 1983 – adverse reaction reported in Edinburgh – trial of Supernine proved satisfactory – inaugural meeting of British Blood Transfusion Society in December 1983 – SNBTS present on steps to maintain yield while addressing reduction in aggregates and removal of infectivity risk – English research and development in 1983 – ethical issues relating to trials – position reached with dry heat treatment at mid-1983–1984: exchange of technical information between Scotland and England – full report of adverse reaction to SNBTS product in Edinburgh – growing understanding of prevalence of NANB Hepatitis transmission in haemophilia patients – further trials of amended SNBTS pasteurised product proposed for September 1984 – production forecast for January 1985 – growing resistance to trials of SNBTS product – continued persuasion of clinicians to trial the new products – May 1984, Genentech announce cloning of gene for producing Factor VIII – policy case for development of domestic heat-treated product developed – summary of work of Factor VIII Study Group circulated in June 1984 – Protein Fractionation Centre (PFC) in Edinburgh processes presented at 18th Congress of the International Society of Blood Transfusion
July 1984 – In October 1984 English dry-heated Factor VIII was available for clinical trial –
Dr Mannucci summarised the position in the commercial market – Groningen and CDC’s advice on inactivating HTLVIII (HIV) – claims for commercial products’ effectiveness in increasingly competitive market – HTLVIII (HIV) antibodies found in Scottish haemophilia patients in November 1984 - PFC’s temporary heat treated product (68˚ C for 2 hours) released for solubility tests in December 1984–1985: all existing stocks heat-treated on temporary basis, with regional stocks recalled – Blood Product Laboratory (BPL) in Elstree intimate in January their intention to trial their heat-treated product (68 - 70˚C for 24 hours) in the spring – January 1985, sucrose incorporated in SNBTS product – Scottish scientists collaborate with Institut Pasteur – SNBTS pursue research of high-purity product – work on pasteurisation suspended temporarily – clinical evaluation studies of pasteurised and dry-heated product discussed – March 1975 HT Factor VIII dry heated at 68˚C for 24 hours available for clinical trials – In England, the Winkelman process for purifying plasma for dry-heat treatment at high temperature patented on 5 March 1985 - PFC’s temporary heat treated product
(68˚C for 2 hours) to continue in issue after development of product dry heated at 68˚C for 24 hours – 11 April 1985, SNBTS receive copy of patent specification for English 8Y – Risk of neo-antigens raised as an issue – November 1985, Dr Prince suggests that heat treatment at 60˚C would not inactivate HLTVIII – Dr Foster questions English freeze drying conditions initiating collaboration on refinement of English procedure - product dry heated at 68˚C for 24 hours in production November 1985 and temporary product recalled – December: Professor Montagnier casts doubt on effectiveness of 68˚C dry heat treatment for 24 hours – 1986: controversy over reports of seroconversion following use of Factor VIII – February:
Dr Smith sent SNBTS the final details of 8Y production – SNBTS decided to manufacture
from April 1986 and issue from January 1987 – a considerable overlap in products resulted – May 1986: SNBTS proposals for replicating English 8Y using Scottish systems and equipment – at the 21st Congress of the International Society of Haematology SNBTS present on virus inactivation, emphasising the importance of the freeze drying cycle – May 1986 Dr Prince publishes his concerns about the effectiveness of heat treatment - SNBTS development work continued – DHSS require all plasma for production to be ‘validated’ – plasma quality revived as an issue – summary to mid-1986 – commercial products in mid-1986 – closer collaboration with England proposed – Results of testing of English 8Y reported to UKHCDO in September and subsequently published – December 1986, Dr Smith informs Dr Foster of results of plasma conditioning tests – programming of production and supply of SNBTS products in second half of 1986 – availability and supply of 8Y – PFC succeed in producing Factor VIII dry heat treated to 80˚C for 72 hours in August – trials were postponed following a late problem – SNBTS production of modified product, dry-heated at 75˚C for 72 hours agreed October 1986 – Z8 available for clinical trials in December 1986 – International developments in 1987 including reports of HIV seroconversions after treatment with heat-treated Factor VIII- In the UK a liaison group set up by NIBSC, NBTS and SNBTS – there was growing concern at the lack of compensation for patients taking part in trials – SNBTS production from January 1987 at 80˚C for 72 hours – NANB Hepatitis begins to re-emerge as a major consideration –June: Z8 performs well in trials subject to solubility – Z8 issued for clinical use – controversy within SNBTS over the use of Z8 – report on freedom from NANB Hepatitis transmission by BPL 8Y and 9A reported in September 1987 – Further trials were approved to ISTH standards – 1988: January CDC emergency meeting in Atlanta – April: PFC facility approved for HIV tests – evidence accumulating that product dry heat treated to 80˚C for 72 hours non-infective for HIV, NANB Hepatitis and Hepatitis B – commercial companies applying solvent-detergent technology – October 1988 genetically engineered blood clotting agents announced – these were expected to be safer and less costly than current products – 1989: in the USA new generation solvent detergent products began to be licensed – gamma-irradiation technology was described – Advisory Committee on the Virological Safety of Blood set up – SNBTS research and development of S8, a high purity product continued – Z8 solubility becomes a focus for increasing complaint – NANB Hepatitis safety was questioned – Medical and Scientific Committee set up – Chiron’s test for HCV discussed – Z8’s viral inactivation effectiveness accepted by the end of the year – For S8 the working assumption was that the Johnson method would be preferred – 1990: collaboration with CRTS Lille initiated with a view to increased purity – development proposals included solvent detergent methodology – discussions with a view to entering into formal collaboration with CRTS – summary of position at end of 1990–1991: licensing arrangements agreed with New York Blood Centre for solvent detergent technology.
11.1 The general approach in Scotland to the manufacture of blood products has been discussed in the Introduction. By the time PFC Liberton was commissioned, Hepatitis A and Hepatitis B (HAV and HBV) infection was dealt with primarily by screening of donated blood. Apart from cytomegalovirus and Epstein-Barr virus, hepatitis viruses that were neither A nor B were known or believed to exist, but had not been characterised. PFC’s manufacturing processes were designed to remove impurities, including viruses, to an intermediate level of purity, but it was known that residual viral infectivity remained in the final products, and in particular that there remained a risk of transmission of viral infection.
11.2 By the beginning of the reference period, clinicians, scientists and technicians interacted, responding to developments in their parallel fields in addressing the risk of viral infection, as understood at the time. What could be achieved technically, however, was often limited by the current state of generally accepted, and available, scientific knowledge.
11.3 As previously discussed, heat treatment in the production of human albumin products (pasteurisation of the solution at 60ºC with stabilisers) had been developed in the 1940s in the USA. Albumin was stable when subjected to heat. It was thought that plasma proteins other than albumin, such as Factor VIII, were not heat-stable, and therefore that heat could not be used to achieve virus inactivation.
11.4 By about 1981 or 1982 it became clear that during the 1970s there had been some experimental programmes aimed at applying heat-treatment procedures in the manufacture of products other than albumin. In particular, commercial manufacturers, including Behring, Cutter and Hyland, first used heat treatment to try to make factor concentrates virus-safe. Of their very nature such experiments were not disclosed. Commercial considerations, including the need to avoid jeopardising intellectual property rights by premature disclosure, required secrecy. It is important to avoid investing researchers and other workers generally with knowledge of the developments achieved before publication of the discoveries made by leaders in the field.
11.5 Virus inactivation procedures, other than those inherent in the manufacturing process, did not become a major preoccupation of SNBTS research and development until about 1982. The emphasis was on process. Thus, the annual report of SNBTS for the year to 31 March 1976 noted that, despite rigid quality control by both regional centres and the PFC, an occasional batch of coagulation factors produced Hepatitis B (HBV) in recipients, although routine radioimmune assays for this agent had been negative. The response, a proposal for improving safety, involved adoption of a special centrifuge method of removing virus particles from fluids. It was anticipated that the method would remove the hazard of HBV as well as other potential causes of transfusion-induced hepatitis such as Hepatitis A (HAV) or cytomegalovirus.
11.6 Two points of note are that more effective centrifugation was seen as an effective response to the risk; and that there was no reference to experiments with heat-treatment, or the possible beneficial effects of heat-treatment, in Scotland at this time. Rather, the emphasis was on developing understanding of the emerging risks of viral infection; on discussion of the particular risks associated with the use of therapeutic products; and discussion of the possible means of removing hepatitis viruses from those products by manufacturing processes, balancing purity of the product against the need to achieve an acceptable yield of factor activity.
11.7 By the end of the 1980s, through a combination of effective screening of source plasma and the selection of effective manufacturing processes, Factor VIII and Factor IX products were ‘safe’ in respect that they achieved inactivation of the main known viruses which threatened the recipient of blood products. A conference was held in Rome on
18 and 19 January 1990 with the title ‘Factor VIII Concentrates and Treatment of Haemophilia: State of the Art in 1990’. It was attended by reputable experts from the United States of America, mainland Europe and the United Kingdom. The American Haemophilia specialist, Dr Aledort, reviewed the history of replacement therapy.
Dr Morgenthaler gave an account of virus inactivation methods, in particular supporting what became the preferred United Kingdom approach of heat-treatment to 80˚C. But, in relation to choice of product, it is perhaps Dr Aledort’s contribution that should be noted. According to a report of the proceedings by Dr J Smith (originally of PFC, then of BPL/PFL), Dr Aledort said that, in the case of previously untreated patients, he would use a monoclonal product. But, apart from patients involved in a study programme, for all other patients he would use the cheapest concentrate he could get, given that they were all HIV-safe. Re-infection of ‘old lags’ (as Dr Smith recorded it) with Non-A Non-B Hepatitis (NANB Hepatitis) was not a hazard.
11.8 The comments identified two significant facts by this stage in developments: long term patients were likely to have been infected with NANB Hepatitis in the course of their treatment, and were therefore not exposed to additional risk. There were alternatives to concentrates derived from human plasma for previously untreated patients. And the threat of HIV infection had been dealt with. In the event, HCV screening became available in 1991, and that provides a rational terminal point for the part of the investigation covered by this chapter.
11.9 As matters stood at that stage, there was confidence in the United Kingdom that the standard factor concentrates produced by the fractionation services in England and Wales and in Scotland did not transmit NANB Hepatitis or HIV. In the wider market, emphasis moved from viral safety to ‘purity’, ie the removal of contaminants such as fibrinogen, from the final concentrates. This was reflected in a major change in the direction of research and development in Scotland, with the opening up of a collaborative project with CRTS, Lille, in the production of high purity products.
11.10 The discussion will be divided into four broadly defined periods of interest: the period up to 1981; 1982 to late 1984; 1985-1987 and 1988 onwards.
The 1970s to 1981
11.11 At the beginning of the period, knowledge of the risks of hepatitis transmission was developing. Writing in the British Journal of Haematology in 1973, Dr Biggs reported a decision in 1967, at a meeting of most of the directors of haemophilia centres of Great Britain, to study the incidence among haemophilia and Christmas disease patients of transfusion hepatitis and of antibodies to blood clotting Factors VIII and IX. These were recognised to be the most alarming complications associated with the treatment of these patients. Her comment was rather tentative:
Transfusion hepatitis is a disease caused by several viruses which may occur in donor plasma. There is every reason to suppose that these viruses may be present in the various protein fractions used to treat haemophilia and Christmas disease…
11.12 Dr Biggs chaired a committee of the Medical Research Council (MRC) which reported on Factor VIII therapy for haemophilia A patients based on a survey during the period 1969–1972. The report commented on alternative forms of preparation available at the time. It was found that cryoprecipitate and freeze dried concentrate scored roughly equally in relation to transmission of hepatitis B, except in the case of mildly affected patients to whom very little treatment had been given. In their case there was a higher incidence of hepatitis when treated with concentrate. The seeds of some of the issues that were to affect research and development over the reference period were already sown.
11.13 In Scotland, the directors of haemophilia centres and of the SNBTS began to meet in November 1973 to discuss common interests, with particular emphasis on factor VIII concentrates and the treatment of haemophilia patients. Factor VIII concentrates had become available for clinical use in Great Britain in the course of the previous year.
Dr Biggs’ MRC report was to hand. The primary interest of the joint meeting at that stage appeared to be in the quantity of supplies available.
11.14 Early versions of concentrates were being produced in Edinburgh at the Royal Infirmary in 1972–73. By November 1975 adverse reactions had been reported in two cases of patients receiving the Edinburgh product, and use was suspended temporarily. Reports were inconclusive, and thought to point to an allergic reaction. Supplies resumed, and the emphasis in discussion returned to availability. A major meeting of the blood transfusion and haemophilia reference centre directors was held in Sheffield on 22 October 1976. Representatives of the fractionation facilities, including the Protein Fractionation Centre at Liberton, Edinburgh (PFC), attended. Production and availability of supplies were the topics for the meeting.
11.15 In Scotland, concern about the supply of fresh frozen plasma required to service the production capacity at PFC Liberton arose in 1975–76, prompting research into the use of cryosupernatant fractionation for the production of Factor VIII. A formal proposal for development of this procedure was made in January 1976. It was thought that the material would be of low potency and low specific activity. In the event, assay of the material was very close to the values predicted. In a circular dated 19 January 1977
Mr Watt (Director of PFC) acknowledged that the product was inferior, but said that it did have haemostatic capability. Large reserves of the material, 70,000 IUs, were available. The material was distributed for trial, within Scotland (as at Aberdeen) and by Dr Jones at Newcastle.
11.16 At about this time, scientists at PFC were engaged in a collaborative study with a team led by Dr Johnson of New York University. A report of a proposed project for the isolation of Factor VIII was produced. The report concentrated on yield and purity: the interaction of these objectives was central to achieving adequate supplies. The report dealt with protective additives (heparin, polyethylene glycol (PEG) and combined heparin/PEG) prior to freezing; thawing by continuous feed, with the addition of ethanol; extraction of cryoprecipitate; albumin adsorption; intermediate purification; PEG precipitation and filtration. There was no reference to steps that might have been taken specifically to reduce infectivity by heat-treatment or other additional procedure.
11.17 Similarly, a paper prepared in March 1976, in England, outlined the production procedures applied in Elstree and Oxford. It narrated that donations were screened for HBsAg, as was the case in Scotland. It was noted:
Nevertheless the most sensitive tests cannot eliminate the possibility that the fraction may be icterogenic. Therefore the risk of transmitting hepatitis cannot be disregarded.
11.18 The conclusion was that patients should be monitored. The risk of transmission of Hepatitis B had been reduced by screening. But the impression left is that risk was inherent in the therapy. NANB Hepatitis was yet to be seen as posing a serious threat.
11.19 Other therapeutic materials were in development at this time, and in particular DDAVP, a vasopressin analogue that had been shown to increase biologically active Factor VIII. It was thought that scientists engaged in synthesising such analogues would develop one that stimulated a release of Factor VIII and had no other side effects. DDAVP was thought to be close to that stage. Against that background Dr Cash and others proposed to inject themselves with DDAVP, and then plasmapherese themselves to collect an appropriate volume of plasma for testing. Mr Watt was asked to fractionate the pool, produce Factor VIII and provide it to the Edinburgh centre for study. Mr Watt advised on the quantities required.
11.20 As discussed more fully in chapter 10, PFC continued to encounter problems related to the availability of materials. In 1977 all research and development work on Factor VIII was suspended for more than five months because PFC had no spare haemophilic plasma substrate from routine production to support research activities. This prevented PFC from making process changes aimed at increasing Factor VIII yield. The same issue arose again in March 1978, when PFC returned to the question of Factor VIII deficient plasma required for in-process quality control. In addition PFC staff were engaged in a development programme designed to improve Factor VIII yields, and required additional supplies. It was a continuing problem. In July, Mr Watt complained that supply was still limited and spasmodic, with the result that PFC’s production of Factor VIII was beginning to be a spasmodic affair. PFC had to resort to commercial purchases of substrate plasma for confirmatory assay purposes. Future supplies of Factor VIII were under threat, and
Mr Watt had postponed or cancelled programmes aimed at increasing yield.
11.21 Other Scottish centres engaged in research at this time. The principal scientific officer at the South East of Scotland Regional BTS submitted a grant application for funding of research into the improvement of stability and yield in Factor VIII. The paper described the work carried out in the recent past, at the centre, into the causes of Factor VIII decay. Dr Cash supported the application. PFC thought that the application should have been submitted in collaboration with PFC scientists. The Scottish Home and Health Department (SHHD) remained neutral.
11.22 Meantime, infectivity had become a more prominent issue in 1976. On 22 July 1976, there was a report of jaundice in a five-year-old boy. He was found to be a carrier of HBsAg. A major review was carried out. It was discovered that a batch of Factor VIII had been contaminated: three patients contracted hepatitis ‘which fortunately was not serious in any patient’. Associated products were also infected. The contaminated donation had passed a screening test. The response to this incident was to increase the sensitivity of the tests applied, using a method developed by Dr Dane of the Middlesex Hospital Medical School. Dr Dane had a well-recognised radio-immuno assay for identification of HBsAg that had been used as a reference level test. On 11 January 1977 Dr Hopkins wrote to Dr Dane. Dr Hopkins reported that in a comparative study, the up-rated Edinburgh assay and Dr Dane’s assay had produced more or less identical results when used on ‘weak’ HBsAg positive samples. It was decided to continue subjecting material to Edinburgh and Dane tests for a period. The topic was raised again on 24 January 1977. In February 1977, PFC sent eight Factor VIII samples and one DEFIX sample to Dr Dane for testing: they were all negative for HBsAg. The improved tests seemed to have succeeded. They were found to produce no material difference and the duplicate test was discontinued. At this stage testing of donations for hepatitis B antigen appears to have been the most useful assay available. But there was no single test that was universally accepted.
11.23 Soon after, there is evidence of a widening interest in the hepatitis threat. On
9 March 1977, Dr Craske, consultant virologist at the Public Health Laboratory, Manchester, wrote to Dr Cash. He had been conducting a survey of the incidence of post-transfusion hepatitis associated with the use of two commercial products, Hemofil and Kryobulin, and NHS (Elstree) factor VIII in England and Wales. He asked whether it could be widened further to include patients treated with Edinburgh Factor VIII. Dr Cash supported the idea strongly, and invited him to come to a meeting of the SNBTS and haemophilia centre directors on 30 May 1977. In anticipation, in May 1977 Dr Craske sent to Mr Watt a revised protocol for surveillance of the prevalence of jaundice after transfusion with Edinburgh Factor VIII concentrate. It set out in some detail the object of the exercise, and the methods to be applied, with a projection of the outcome anticipated. Dr Craske duly attended the meeting. A decision on widening the exercise to include Scotland was postponed because, it was said, some Directors were absent. In January 1978 domestic arrangements were made for centralising reports of Scottish cases and it was hoped that that would satisfy Dr Craske. Post-transfusion hepatitis was now clearly identified as a topic requiring study and report in the United Kingdom.
11.24 On 21 June 1977, three Edinburgh workers sent Mr Watt of PFC a copy of a draft paper dealing with the incidence of HBsAg in haemophilia patients on long term therapy with ‘Scottish Factor VIII’. An earlier study, from 1972, and the current study spanning 1971–72 to 1975–76, each showed a significant prevalence of antibody response to HBsAg. One patient had clinical hepatitis B. In his reply Mr Watt commented on the problems associated with tracing the source plasma. The Factor VIII would have been made in Edinburgh using plasma drawn from all over Scotland. There was no way PFC could separate plasma from the different regional centres under normal processing conditions.
11.25 Edinburgh research at this time included half-life trials of various products, taking account of plasma age, yield and other topics related to PFC’s production capacity. In September 1977 Mr Watt commented on current investigations into unsatisfactory performance at PFC. The focus was on process issues. Factor VIII yield and the method of recovery of factor VIII content were highlighted, though the method used was said to be the best available. Plasma crushing, at that stage, was described by Mr Watt as a ‘disaster area’ because of the non-homogeneous nature of the plasma mixture. Between then and the end of the year, an MRC working party on Factor IX development, including Scottish DEFIX, was a focus for discussion. The minutes of the meeting of the MRC’s Working Party on Factor IX Concentrates on 20 January 1978 reflect that body’s then current area of interest. Two trials were in hand. Neither touched on hepatitis infectivity, though it is clear that thrombogenicity was a recognised problem with
Factor IX products.
11.26 Within the Edinburgh facility, PFC had considerable knowledge of and had developed techniques to deal with the manufacture of Factor VIII cryoprecipitate by 1978.  For the fractionator, yield of Factor VIII activity was important, and the balance between purity and yield was vital. When the Edinburgh scientist Dr Pepper applied for a research grant on 15 June 1978, the specified areas of interest were Factor VIII stability and yield. Edinburgh research had dealt with methods of maximising the rate of thaw of frozen plasma within the constraint imposed by Factor VIII solubility, and the use of sophisticated mixing and temperature control systems using a thaw-siphon technique. Blocks of frozen plasma were crushed to increase the surface area over which heat was applied. By continuously removing the thawed plasma, below the solubility temperature of the Factor VIII component, over a wide area of plasma ‘snow’ produced by crushing, dissolution of the Factor VIII was avoided and the degree of Factor VIII degradation was reduced. It was said that the surface area factor had been ignored by others. The design of processes for crushing and continuous thawing, using fluid removal for temperature control, became one of the defining features of research and development work at PFC for a considerable time.
11.27 Sporadic incidents of infection continued to be recorded at the end of the decade. On 28 February 1978 Factor VIII infectivity was reported in three patients by Aberdeen and North-East of Scotland BTS. Two of the patients were known to be actively immune and one to be a carrier: the Factor VIII did not do harm to these patients. Mr Watt’s response was that they would find that all patients exposed to the particular batch (batch 227) would already have received other questionable material. Risk of exposure to Hepatitis B was treated as a norm. In the case of DEFIX, thrombogenicity remained the focus for concern.
11.28 On 28 April, 1978, Mr Watt notified Dr Cash that a batch of PFC NY Factor VIII (batch 280) had been found to contain one donation that was HBsAg positive. The same donation had been used in a DEFIX batch (batch 363). Mr Watt cautiously suggested that the batches should not be issued, but doubted whether there was enough information for decision. Dr Cash replied on 1 May 1978 stating that the current practice was that blood products, whatever their final HBsAg status, should not be issued if an original donation was known to be HBsAg positive. The importance of initial screening was emphasised, whatever the benefits of the manufacturing process might be in reducing infectivity.
11.29 Achieving purity of concentrates by appropriate processing continued to be a major issue at this time. In 1978, Dr Johnson and co-workers published a highly technical paper on the preparation of plasma fractions by solid-phase polyelectrolytes. This set out a useful analysis of the sequences of isolation and purification of factors together with a general narrative of known technology.
11.30 At the end of 1978, Edinburgh and South East Scotland Regional BTS had completed and were writing up the results of a study of in vivo Factor VIII survival rates in haemophilia patients, comparing cryoprecipitate and PFC intermediate Factor VIII. In 1979, the MRC working party continued its work on Factor IX. On a UK level, work was undertaken to develop a new British Working Standard Factor VIII concentrate. The papers on the Edinburgh research were available in June. A paper by Toolis and others found that similar half-life results were obtained from cryoprecipitate prepared by continuous thaw-siphoning; cryoprecipitate prepared by overnight thawing; and intermediate Factor VIII concentrate, but that the immediate recovery of Factor VIII activity was higher with concentrate. Prowse & McGill examined the efficiency of recovery by continuous thaw-siphoning as against overnight thawing and fast-thawing. The continuous thaw-siphon (‘Mason’) method gave the best results.
11.31 Close collaboration continued between Dr Johnson and Scottish scientists in 1979. Infectivity was an issue in the context of this work. At the 7th International Congress of Thrombosis and Haematology, London, in July 1979, scientists from the two groups collaborated in publishing a presentation on polyethylene glycol (PEG) precipitation for the removal of Hepatitis B surface antigen from a concentrate of factors II, IX and X of intermediate purity (PFC’s three factor DEFIX was of this type). Various fractions were assessed for potentially thrombogenic materials, and the results were reported. The product was intended for use in treatment of Haemophilia B, and reflected an emphasis at the time on the risk presented by Hepatitis B in that context. The focus on infectivity was relatively narrow.
11.32 Workers from the Scottish team made a presentation on large scale plasma thawing for Factor VIII recovery at the Congress in July 1979. By then, on their assessment, intermediate purity freeze dried Factor VIII was ‘widely accepted as the product of choice in the treatment of Haemophilia A’, but supplies from Scottish resources were inadequate. Yield was therefore at the forefront of research. Their poster presentation commented on the substantial loss of Factor VIII that could occur during the production process.
A point of major loss existed when plasma was thawed for removal of cryoprecipitate. To overcome this, in a production scale operation, the rate of thaw had to be maximised within the constraint provided by Factor VIII solubility, which was temperature dependent. The process they had developed had that objective.
11.33 The process referred to, using pilot-scale equipment to study continuous thawing, and utilising fluid removal for temperature control, was that discussed in Dr Pepper’s application for funding. Design of prototype equipment for use with fresh frozen plasma would follow.
11.34 Taking up some of the points made at the 7th International Congress, Dr Foster and colleagues contributed an article to the British Journal of Haematology relating to SNBTS research into the reasons for loss of yield. They reported on experiments that showed that both antigen and coagulant activity were lost in the initial cryoprecipitate step. During subsequent steps antigen levels were remarkably constant, whereas coagulant activity gradually declined. Their results suggested that improvements in the cryoprecipitate stage would be the most beneficial approach to improving the yield of Factor VIII in intermediate concentrate.
11.35 These sources emphasise the importance attached at the time to obtaining high yield from source plasma. In the wider context, interest in viral transmission was picking up. On 26 May 1979, The Lancet contained a letter by Dr Mannucci on the subject of post transfusion hepatitis. There had been a report of fatal and non-fatal post transfusion NANB hepatitis following the administration of prothrombin complex concentrates. Italian experience had not been so extreme, but he pressed for investigation. Mr Watt commented that he remained convinced that the risks were not anything like as serious as recent publications had suggested. An overall review article subsequently published in The Lancet on 23 July 1988 commented that before the introduction of process steps designed to inactivate contaminating viruses, virtually all lots of coagulation factor concentrate prepared from plasma pools transmitted NANB Hepatitis.
11.36 In the Scottish context, again taking up points made at the 7th International Congress of Thrombosis and Haemostasis, Dr Foster and Doctor Johnson and their teams from SNBTS, PFC, Glasgow Royal Infirmary and New York University Medical Centre collaborated on research into methods of removing viruses from Factor IX and prepared a paper. The article was received in June 1979, revised on 15 October 1979, and published in 1980. It compared PFC’s DEFIX product with Supernine, the PFC product that had been subject of continuing research and development since at least 1974. The description emphasised the importance of the use of PEG (polyethylene glycol) in the processing of Supernine. The introduction noted that the major problems concerning the clinical use of Factor IX concentrates were their potential for transmitting hepatitis and the possibility of thrombogenic complications in recipients. The Inquiry team has not identified a similar publication dealing with Factor VIII infectivity at this stage.
11.37 Internationally, there was some movement. On 3 September 1979, the Council of Europe Public Health Committee prepared a document on freeze dried human antihaemophilic factor concentrates. So far as hepatitis was concerned, the test prescribed was that the product should, when tested by radio-immunoassay, be shown to be free from Hepatitis B surface antigen. The PFC product licence already specified a requirement that the product should be HBsAg free, and there was anxiety that the test should be ‘radio-immunoassay or by another method of equal sensitivity’, so as to preserve flexibility in selecting among the various tests available. The terms of the monograph suggested to Scots doctors ample scope for controversy in other respects. But it was a further indication that the focus for regulation at the time was on screening source plasma.
11.38 In January 1980 an issue arose between Glasgow and Edinburgh that gave further emphasis to the preoccupation with Factor VIII concentrate yield. Dr Gabra of Law Hospital produced a paper promoting the advantages of cryoprecipitate in the treatment of haemophilia. He argued that dried cryoprecipitate was popular outside the UK, and should have most of the advantages of the dried NHS Factor VIII concentrates, namely long shelf life, easy storage and pre-determined dosage. He added economy of production cost and reduced hepatitis risk on account of the small pool-size involved as features of the product. The Glasgow team had therefore explored the possibility of producing lyophilised small pool Factor VIII cryoprecipitate from five donations and freeze drying these small pools. The experiment and production methods were described. The approach was said to have had support (dating from March 1979) from NIBSC. The proposal won the support of Dr Mitchell, Dr Prowse and Dr Cash but not of Mr Watt. Mr Watt dismissed the product as:
a step back in history…a suitable product for Turkey (perhaps) but not Scotland where we discarded a better product in 1972 as being unsuitable to the state of clinical practice.
11.39 The project was taken up and only abandoned in Glasgow in 1983 following the closure of the facility at Law Hospital. Further development was transferred to Edinburgh. It was a further illustration of the emphasis on yield and process in SNBTS research and development. In relation to avoiding or limiting virus transmission, the method emphasised small pool size rather than processing or heating.
11.40 The level of interest in post-transfusion hepatitis generally appears to have changed early in 1980. A working party on post-transfusion hepatitis, formed by the Blood Transfusion Research Committee of the MRC, met for the first time on 14 February 1980. The function of the working party was agreed to be to promote research to assess the nature and size of the problem of post-transfusion hepatitis in the UK with particular reference to changes in transfusion practice, for example the use of products prepared from pooled plasma from large numbers of donors and the introduction of commercial products from abroad.
11.41 The minutes of the first meeting of the working party contain a report of discussion of the inactivation of hepatitis viruses in blood derivatives. There was discussion of research currently being carried out by Bayer (Cutter Laboratories) into inactivation using β-propiolactone, but it was recognised that the working party had inadequate information, and a review of the literature was instructed.
11.42 It was noted that there was some epidemiological evidence from studies in Factor VIII associated NANB Hepatitis that commercial Factor VIII concentrate from the USA was associated with one type of hepatitis, and that NHS Factor VIII and a type of Factor IX made by Immuno Ltd in Austria might be associated with one or more different types, distinct from those in American commercial material. The most likely explanation was said to be that the PEG/glycine fractionation method concentrated one serotype of virus and inactivated others. It was also noted that research was being carried out in the USA into procedures which would eliminate or decrease the concentration of virus in the product as part of the fractionation process. Searle Laboratories Ltd were said to be carrying out a project with the Blood Products Laboratory, Elstree, using the polyelectrolyte method for the fractionation of plasma.
11.43 The polyelectrolyte method had been described by Doctor Johnson (above at para 11.29), but the Inquiry has not discovered any reference to it in the work of Scottish scientists prior to the date of this meeting.
11.44 A literature search at the time would have disclosed a number of sources of information. An article reflecting work by Behring made major claims that a new manufacturing process had made available a ‘safe Factor VIII concentrate’. The paper described a wet heat-treatment (pasteurisation) process developed from the procedures used to produce albumin. Tests on chimpanzees had shown no clinical signs of Hepatitis B infection. It was said that the chimpanzees also remained free from NANB Hepatitis. It was claimed that, as the concentrate used for the experiments had been manufactured from pooled plasma, it seemed reasonable to assume that any NANB Hepatitis viruses had likewise been eliminated and inactivated.
11.45 The Behring process was said to depend on two principles: high purification of Factor VIII with the simultaneous separation of the hepatitis virus and subsequent inactivation of such hepatitis virus as was not separated in the first step by heating for 10 hours at 60˚C in solution. During the fractionation steps, the Factor VIII remained preferentially in solution whereas the insoluble contaminating proteins such as fibrinogen became precipitated. The heating step was similar to the procedure used routinely for albumin: stabilising chemicals were used. Glycine and sucrose were described for the first time as stabilisers to protect Factor VIII and prevent its denaturation by heat. The heat treatment resulted in additional purification. Proteins which were not protected by glycine and sucrose became denatured in this step and fell out of solution. From the supernatant of the heated step the Factor VIII activity was separated by salt precipitation and came out of the solution as a native product. A translator, W Zolg, Edinburgh, noted that there was no mention of the yield of Factor VIII either overall or at intermediate stages in the preparation the concentrate. The yield of Factor VIII was later given as about eight per cent of the initial plasma.
11.46 Based on data from Germany the publication suggested, by way of background, that the incidence of hepatitis among patients with haemophilia was similar to that seen among patients who had received transfusions of six or more units of blood. Haemophilia patients receiving Factor VIII concentrate had been shown to have hepatitis rates of 60%. Other tests had suggested rates even higher. No systematic investigation of the prevalence of NANB Hepatitis had taken place, but case reports suggested that for patients with haemophilia there had been a shift in the spectrum from Hepatitis B to NANB Hepatitis, as had been reported with post transfusion hepatitis. NANB Hepatitis was described as frequently running a chronic course. The risks of hepatitis among people with haemophilia had become very serious and urgent measures were required to combat it: hence the development of the new product by Behring.
11.47 The chimpanzee test results were said to be clear and significant. The animals in the control panel injected with un-heat-treated Factor VIII were infected with hepatitis. The monkey which received the heated Factor VIII concentrate showed no symptoms of hepatitis B or of NANB hepatitis.
11.48 On 5 March 1980, a patent application concerning the pasteurisation of Factor VIII was filed by Bayer (Cutter Laboratories), based on discoveries made in their research laboratory during 1978–1979. The final version of the specification was published on 3 April 1984 and the product (Koate HS) was approved for clinical use by the Federal Drugs Agency in due course. The Bayer process appeared to be very similar to the original pasteurisation process used by Behring.
11.49 When information from Europe became available it stimulated interest in Scotland. On 27 October 1980, Dr Cash wrote to Mr Watt:
During the meeting in Bonn I learnt, for the first time, that Beringwerke are getting rather excited – following chimpanzee studies – that their preparations of factor VIII, made from HBsAg positive plasma (starting at 90 ng/ml), appear to be safe. The reason given is that they are heat treating the product for
10 hrs at 60˚C in the presence of glycine and sucrose. Apparently the glycine and sucrose protect the VIII from denaturation. Sounds unbelievable; thought you might be interested.
11.50 It appears that, until October 1980, Dr Cash at least had not been aware of the developments in the rest of Europe. The position of other Scottish scientists has not been noted, though a representative of the Edinburgh and South East Scotland BTS was present at the MRC blood transfusion research committee meeting on 14 February 1980. When the SNBTS and Haemophilia Directors met on 30 January 1981 (for the first time since 1977) the topic was not mentioned, though Dr Cash and Mr Watt were both present.
Dr Cash had prepared a paper to facilitate discussion of SNBTS future planning of factor VIII and IX concentrates: the time was thought opportune for reconsideration of the service’s capacity to meet genuine clinical needs. In the light of the recent announcement by the UK government of the intention to achieve self sufficiency, he noted that it was important that all interested parties examine the quality of Factor VIII in some detail. However, yield and potency were the issues remitted to PFC. Thrombogenicity was an issue in relation to Factor IX. But otherwise infectivity was not discussed.
11.51 There are SNBTS statements indicating that pasteurisation studies, requiring a high purity concentrate, began in 1981. But, at this stage, it may be reasonable to infer that, while viral inactivation was on the agenda, heat treatment by pasteurisation had not been identified as an immediate priority project within SNBTS. The emphasis within PFC on techniques for large-scale plasma thawing for the recovery of cryoprecipitate Factor VIII continued from the Seventh International Congress on Thrombosis and Haemostasis, 1979, into 1982. Foster, Dickson and others published in Vox Sanguinis an article, ‘Control of Large Scale Plasma Thawing for recovery of Cryoprecipitate Factor VIII’. The article had been submitted in June 1981, and was accepted for publication in October. Yield was emphasised, and in particular the loss of procoagulant activity at the cryoprecipitation stage of processing:
Factor VIII is at risk during the process of cryoprecipitation from both its solubility behaviour and labile nature. Rapid processing is desirable to minimise inactivation, but the solution temperature must also be held below the factor VIII solubility limit, otherwise resolution of precipitated factor VIII is inevitable. These two essential requirements are in conflict with one another and the extent of this is related to the scale of manufacture. Hence, though good recovery may be possible at an analytical scale, loss is already significant in the routine preparation of single-donation cryoprecipitate and increases further at the industrial scale, where plasma pools of up to 1000 litres may be processed as a single batch.
The essential process design problem is to maximise the rate of thaw within the temperature constraint provided by the solubility of Factor VIII.
11.52 The solution proposed, reflecting earlier publications, was to maximise the surface area available for heat transfer and to adopt continuous steady-state operations in unvarying temperature conditions. Scottish scientists were not alone in pursuing this line of research. On 23 November 1981, there was a conference at Groningen on systems for efficient separation of Factor VIII from human fresh frozen plasma. There were contributions from a range of specialists covering process and equipment, assay problems, the use of heparin and other topics. The report of the conference indicates wide discussion, in general, with open exchange of technical information.
11.53 On 24 September 1981, the Haemophilia Centre Directors Hepatitis Working Party issued its report for 1980–1981, the third and final year of a retrospective study financed by the DHSS. The final section of the report on ‘Recent Hepatitis Research’ commented:
2) Recently published evidence concerning the use of ultra violet light and β proprio-lactone to inactivate hepatitis viruses in factor IX preparations claimed that 90% or more of infectivity due to non-A, non-B viruses had been removed. It is likely that commercial factor IX preparations treated by this method will become available with claims that they are associated with a low risk of transmitting hepatitis. The only way that infectivity for non-A, non-B hepatitis can be shown other than human inoculation is by inoculation into chimpanzees. Since very few of these animals are available, it is difficult to see how every batch treated by this method will have quality control assurance with respect to non-A, non-B viruses. This information should be borne in mind when considering purchase of these preparations.
11.54 On 10 November 1981, Dr Cuthbertson (SNBTS) produced a paper on microbial contamination during Factor VIII manufacture. He found that there was no correlation between microbial ingress and batch acceptability, but undertook study to assess the risk because it was recognised that microbial contamination was undesirable. On 14 December 1981, Dr Mitchell wrote to Dr Cash intimating that the Law Hospital Drying Plant would have to close, despite efforts to upgrade it. It appears that research and development of freeze-dried cryoprecipitate continued at Edinburgh for a time thereafter.
11.55 Interest was stimulated in the production of heat treated products by the public facilities. On 17 December 1981, Dr Cash wrote to Mr J G Watt, Dr R J Perry, Dr P Foster, Dr C V Prowse, Dr F E Boulton, Dr D S Pepper, and Dr G S Gabra intimating that he was forming an SNBTS Factor VIII concentration study group with himself as chairman and the addressees as members. The remit of the group was to explore new developments in the widest possible sense with regard to the production of Factor VIII concentrates and thereby create the opportunity for cross fertilisation and for co-ordinated research within the SNBTS.
1982–1984: Early steps in heat treatment
11.56 The first meeting of the SNBTS Factor VIII concentration study group was held on
28 January 1982. The meeting provided an opportunity for the participants to describe the work currently carried out or planned at their several centres. Methods of production of safer products identified for research included viral inactivation by pasteurisation, irradiation, ultra violet light and β propriolactone treatment, and high purity. Dr Foster described the current work of PFC. Areas to be investigated were identified by him as improved purity (in terms of specific activity and low fibrinogen content) and improved solubility, with considerable attention to cryoprecipitate recovery. Removal of microbiological/viral/pyrogenic contaminants also came under this heading. Viral inactivation was not highlighted in his list of current research priorities. The SNBTS headquarters laboratory reported on experiments on irradiation of dried Factor VIII as a method of inactivating viral contaminants. In summing up, Dr Cash identified viral inactivation by irradiation as a project requiring study. Among the study groups set up, Group D: Safety was aimed at improving product safety, eg by irradiation to remove viral infectivity.
11.57 The Safety Action Group met on 9 and 10 February 1982. There were two broad conclusions on virus inactivation: for effectiveness there required to be a satisfactory infectivity assay; and any attempt to heat or irradiate Factor VIII concentrate presupposed a more purified, more stable concentrate than those available. The efficacy of viral inactivation appeared to favour heat treatment over irradiation over adsorption. The first conclusion therefore was that without a means of measuring effectiveness, no assurance could be given that a product was safe. The second reflects earlier thinking, and recurs thereafter: a purer product was required for viral inactivation. The search for increased purity continued to be important. The paper set out a summary of current knowledge, at some length. But it is an important statement of what was understood within the group at the start of its activities, and of what was expected to emerge from research:
1. SUMMARY OF WHAT IS KNOWN:
We have restricted ourselves to viral risks, which include in addition to hepatitis B, a probable two (or more) hepatitis non-A, non-B, CMV, herpes, human polyomas and Kreutzfeld-Jakob agent. Considerable progress has been made in the last two years in evaluating the protein and DNA structures in hepatitis B...Relatively less hard scientific data is available on non-A, non-B hepatitis. However, incidence by manufacturer, incubation times and liver biopsy all indicate that two or more agents are responsible…It seems likely that developments in non-A, non-B will follow the same route as hepatitis B, but over a considerably shorter time span, (e.g. 5 years vs 10 years) due to technological gains, notably in genetic manipulation…
Presumably, further improvements in the efficiency of hepatitis-B by e.g. RIA will only happen slowly and at greater cost than previous improvements. On the other hand, we can anticipate rapid progress in screening for non-A,
No discussion of possible inactivation strategies can take place without concurrent evaluation of the impact (cost and effectiveness) of immunisation, screening, etc. Obviously, to be attractive, inactivation must be cheap, reliable and capable of killing more than one virus…it should be developed within two years. Any longer than this is too unpredictable as regards other developments which may make inactivation obsolete.
Turning first to γ-irradiation as a method of inactivation, it is possible to calculate the dose required for a given degree of inactivation and is largely a function of the degree of double strandedness of the nucleic acid, to a lesser extent, MW also has an influence. In practice, other physical and chemical factors such as temperature and reducing agents also have modifying effect. Unfortunately we do not have any data on the DNA/RNA of non-A, non-B viruses, and the situation is complex with hepatitis-B due to variable double strandedness, repair kinase and incomplete genome. All these factors lead us to conclude that some sort of trial inactivation is desirable with a model virus (eg SV-40 or polyoma) which is readily available and can be easily bioassayed for infectivity following irradiation. Hopefully, more model viruses can be included to generalise the findings in respect of MW type of nucleic acid and degree of double strandedness. As with all inactivation tests, we have to ask ourselves how much inactivation is worthwhile? Calculations suggest that γ-irradiation will achieve 10²–10³-fold inactivation of hepatitis B. However, bearing in mind that screening has now reduced infectivity to such titres, it could be attractive.
An alternative to γ-irradiation is heating (pasteurisation). This has been attempted by Behringewerke who now market “Faktor VIII HS” in which HS implies,`safe from hepatitis’. Unfortunately only one paper has been published (in German) and no details are given of solution compositions or yields. However, estimates by PFC indicate 8% yield which is rather low. Examination of the process shows that by RIA of HBsAg and chimpanzee infectivity a total reduction of 107–108 occurred, but much of this must be due to removal of antigen by physical means (RIA for HBsAg< 1 ng/ ml in final product). In fact the process clearly only works because large amounts of protein (fibrinogen) are removed prior to the heating step and these preliminary steps may well be responsible both for the removal of hepatitis and the low yields. Thus we conclude that heating of itself may not be an inherently low-yield step, nevertheless it is clear that low fibrinogen (= high purity) is a desirable product for both heat inactivation or γ-irradiation processes.
A third approach which has been used for FIX concentrates (but not for FVIII concentrates) is a combination of β-propiolactone and UV irradiation. This has been used by Biotest Serum Institute (Frankfurt) but very little practical information is to hand. Published information is contradictory: one paper states that a total 104-fold reduction is achieved (10³-fold inactivation and 10¹-fold purification) whereas a more recent abstract claims 107-fold reduction or 108-fold if a third treatment step (aerosol adsorption) was used. This latter step was only applied to normal serum pools but it implies that (a) adsorption is feasible to reduce infectivity at low concentrations and (b) that Biotest are not totally satisfied with β-PL-UV on their own. Furthermore, since about 40% of FII is inactivated, we may predict that FVIII:C will be greatly inactivated, though no published data is to hand.
Finally, although little data is available, some attention has been given to non-specific filtration/adsorption of hepatitis virus. Kabi have published a method in which dextran sulphate was used to purify HBsAg and more recently caprylhydrazide agarose was used to adsorb out HBsAG from FIX concentrates. Obviously, further work and information are needed in this area, but it has one great attraction, namely that removal of infectivity can reasonably be equated with removal of HBsAg assayed by RIA and thus obviating the need for infectivity assays during development work. However, such assays are not yet available for non-A, non-B virus and the adsorbents may well have to be redeveloped and tested for each virus type.
Assay of infectivity is the major problem to be faced in this work. At present only one assay is established, that in chimpanzees. This service is available commercially and without a serious waiting list (at present). We are informed by Dr Kellner of the NY Blood Bank that acquisition of suitable chimpanzees cost $8,000 per animal and a further $1400 per month for laboratory testing and care. Thus each chimpanzee will cost about £10,000 per 6 month trial, and a straightforward experiment (3 samples, 3 controls) would cost £60,000 minimum.
More recently, reports from Panama indicate that Owl monkeys can simulate closely the human hepatitis-A virus infection. If they can also be infected with other human hepatitis viruses, then the cost of acquisition and availability of animals would improve. However, we should not anticipate that such a colony would be any cheaper to run and it would still be (geographically) very inconvenient. It also has to be developed to the same state as the chimpanzees which may take some time.
Finally, the most attractive possibility would be a tissue culture assay for hepatitis virus. No such assay exists, but we should actively pursue those working in the area to see if such an assay is likely to appear in the near future. Also, we might consider undertaking such work ourselves. A cell line (‘Alexander’) of human hepatoma has been established which appears to have incorporated the genome corresponding to the HBsAg but not to the core antigen, ie it does not produce infective material but this does not constitute a tissue culture assay of infectivity.
11.58 The report proposed work on filtration, heat inactivation and irradiation, and literature search. A schedule of the resources required was set out. This paper appears to be important in defining the position of Scottish workers (in Edinburgh and Glasgow at least) at the time, and disclosing the level of understanding of the complex issues that were beginning to be addressed. A considerable intelligence gathering exercise was thought necessary to equip the group to carry out its remit. It was noted that Dr Macleod was conducting research on the behaviour of Factor VIII:C (Factor VIII activity) in higher purity concentrates, and in the presence of stabilising salts. Otherwise, the paper appears to raise questions whether the members of the group had more than second hand information about the topics addressed and whether they had been actively engaged in relevant research prior to the start of Dr Cash’s scheme.
11.59 When the SNBTS Directors met on 16 March 1982 and on 15 June 1982, viral inactivation was not discussed. Meantime, the SNBTS Factor VIII Study Group met on
30 March 1982. Dr Pepper spoke to the Factor VIII Safety Action Group’s first report, above, summarising the options identified in the report; providing some context; and passing on the group’s recommendations. He is reported to have said that relevant factors to be taken into consideration were that Hepatitis B was still a risk although reducing now that screening was available; available data indicated that the properties of NANB Hepatitis were similar to those of Hepatitis B although this was by no means certain; there was a view that there were separate classes of NANB Hepatitis virus, and that the pathology of NANB Hepatitis virus was still not well defined. Because of this it would not be worth pursuing inactivation unless there was a commitment to prove that treatment was effective. He said that the methods of inactivation available were heat treatment, irradiation or adsorption.
11.60 The report provoked considerable discussion. Laboratory facilities would be a challenge, partly because of the need to separate facilities using infected and uninfected material. The PFC microbiology facilities would not be ready in time. The laboratory at Law Hospital could not accommodate the equipment. Mr Watt raised issues over the use of chimpanzees, but it was stressed that access to animal models was required immediately. The decisions recorded were:
• Dr Pepper should contact Dr Craske at Manchester for details of reactions to Factor VIII in the hope of getting some contaminated product.
• Dr Prowse ‘pointed out that PFC would have samples of infected material, although this would not, obviously, include commercially produced VIII.’
• Dr Cash offered to contact Dr Mannucci, and Dr Prowse offered to contact Dr Ludlam to ask for help.
11.61 Meantime work would go on within the resources available.
11.62 The Factor VIII Safety Action Group held its second meeting on 30 March 1982. The group identified the study of inactivation by heat, irradiation and hydrophobic adsorption on the various Factor VIII complex activities as courses of research action to be undertaken. Central to that was continued work on the heat process as developed by Behringwerke, consisting of heating to 60˚C for 10 hours. A second report was prepared for the Factor VIII Study Group’s meeting on 3 June 1982. This report showed movements in thought over the relatively short period from February into March 1982.
Possible courses of action are becoming clearer, also limitations are very evident. It is proposed that action continue to investigate the effects of heat, radiation and hydrophobic adsorption on FVIII activities. It is also proposed that action be taken to investigate other infectivity assays than chimpanzees, notably owl monkeys, using established colonies. It is also proposed that a model of hepatitis B inactivation be set up using Woodchuck hepatitis virus as the closest analogue. This will require either assay of samples in the U.S. or establishment of a Woodchuck colony here. Finally, it may also be desirable to offer a research grant to apply for sufficient funds to use the existing commercial chimpanzee infectivity model. Efforts are continuing to make personal contact with leading groups in the field (e.g. NIH) to stay abreast of current and future developments…
Roughly speaking, three courses of action are being undertaken simultaneously. These are:
1. Study of the condition of inactivation by heat, irradiation and hydrophobic adsorption on the various FVIII complex activities.
2. Investigation of possible infectivity assays.
3. Procurement of known positive, titred infective material, namely hepatitis B, non-A, non-B and Woodchuck H.V.
Detailed actions under these headings are as follows:
1 Inactivation Processes
(a) PFC (Alex Macleod, Peter Foster and ? (sic)) should continue their work on the heat process as developed by Behringwerke. This consists of heating to 60˚ for 10 hours in the presence of 50% sucrose and 2 M glycine and has a yield of biological activity of 8%. Attempts must be made to confirm this with existing intermediate purity material, see how the newer higher purity material behaves, and try to improve the yield figure considerably. This latter work could fit in well with existing work of Peter Foster concerning metal ion and poly acid salt additives. We are entitled to assume the results of BoB that 60˚/10 h inactivates non-A, non-B by chimpanzee assay (Tabor et al).
(b) DSP will arrange for more samples to be irradiated at different temperatures and from different degrees of fibrinogen removal, to see the effect of these variables. Supplies of porcine high potency FVIII:C may have to be purchased if suitable material is not procured gratis from Speywood. At present, it seems that low fibrinogen is a pre-requisite for a soluble product following r.5 mRad, though reduced water content and/or low temperature during irradiation could obviate this problem. Unfortunately, the existing commercial irradiators do not offer low temperature processing.
(c) DSP will synthesise capryl hydrazide agarose (as per Einarsson’s paper from Kabi) to see if it removes the different activities from a FVIII complex. If it does remove them (desired result) we are entitled to assume that HBV will be removed. However, this is not a major benefit since HBV is a minor risk now compared with non-A, non-B hepatitis. There is a good chance (which will require proving) that non-A, non-B will be removed also by this approach. If the FVIII:C is recovered in high yield, alternative chemistry for synthesis will be investigated (eg epoxide – mercaptan coupling) to give the same uncharged C8 alkyl hydrophobe, but to avoid the problem of patent piracy. Furthermore, (since it is implied in Einarsson’s paper) a better alternative to non-cross linked agarose will be tried. The best candidate on the grounds of chemistry, rigidity and porosity is Sephacryl S-100.
2. Infectivity Assays:
Because of the time taken to solve this problem, it is appropriate that efforts be made now before any positive results are available from the inactivation study. One general point should be made and that is that since heating (60˚10 hrs) is now widely held to be effective in destroying infectivity, we might be able to dispense with an infectivity model completely and go straight to human trials
(this is what Behringwerke are doing), if we could improve the yield of FVIII:C after heating.
(a) RS (Somerville) is contacting various persons in North America with a view to arranging infectivity trials of hepatitis B and non-A, non-B in owl monkeys. Colonies exist in Panama (Gorgas Institute) and in Maryland
(Ft. Detrick). Other colonies exist in the UK and JW is pursuing these for more details. Both Edinburgh University (Bush Estate) and Inveresk Research are able to offer commercial rates of colony care at least an order of magnitude less than chimpanzees and with a much shorter time scale. Unfortunately, on paper at least, the owl monkey is unlikely to be susceptible to human hepatitis virus B (and non-A, non-B). The latter are DNA viruses, belonging to a separate class (‘slow viruses’) from the hepatitis A virus, which is an RNA virus, similar in many respects to the enteroviruses like polio.
(b) Information is still being gathered about existing chimpanzee colonies, and how they are used, what results are being obtained and at what costs. It is clear that chimpanzees can be used at a much younger age than was previously mentioned (2 yrs vs 3 yrs). It is also rumoured that NIH costs (contracted to a colony in US) are lower than those in Liberia. As we are not a commercial concern (?) it might be possible to use this colony instead. No details have come to hand yet about Zuckerman’s chimpanzees in London.
(c) Since our last meeting, some details have surfaced concerning the woodchuck hepatitis virus (Werner et al, J Virol., 1979, p. 314–422) which is a close homologue of human hepatitis B. It has about 5% of DNA homology and is physically identical to the human material. It is not known (to me) whether this poses an infectivity threat to humans, but I am assuming it is of low risk. In addition to Werher’s group in Philadelphia, a second group headed by Dr Gerin is also using this model in Washington DC It is a prime candidate for modelling the physical inactivation processes and we now propose that it replace the earlier proposal of different unrelated viruses. Most importantly, an infectivity assay is available and it can be handled in an ordinary laboratory. This makes it a very good candidate for a research grant submission. I am presently unaware of any woodchuck colonies in the U.K., but this could be pursued by DSP or JW.
3. Procurement of Infective Material
(a) This has proved a frustrating search. Various people were contacted in the UK but none had much to offer. C Rizza in conjunction with J Craske are running a prospective trial of ‘first time’ haemophiliacs receiving NHS and commercial concentrates. Samples (10 ml) are taken at regular intervals and Craske uses these for putative screening tests. CR has the liver enzymes done and all data relevant to batch numbers are entered on a computer data base, together with other regular haemophiliacs who report incidents. Depending on who you ask, the infectivity of NHS/Commercial concentrates in first time haemophiliacs (receiving 3000 units from batches of 5000 donations) is either 100% (J Craske) or 50% (C Rizza). Clearly this is non-A, non-B at low dilution. Hepatitis B is much less common, it is said that it takes 4 exposure-years before this is acquired. Thus, we must assume that all batches of NHS VIII concentrate and commercial concentrates (of 5000 donations or more) are positive for non-A, non-B. I doubt that the levels would be detectable, however, (even assuming that we had an RIA/IRMA for non-A, non-B) and thus we cannot even guess at what their chimpanzee infectivity titre might be. In an effort to get hold of titred concentrates, I have written/telephoned Drs Gerety, Tabor and Alter at NIH/BoB, but so far nothing has materialised. They are of the opinion that ‘factor concentrates’ are one type of virus, ‘F’, and plasma is another type of virus ‘H’. I suspect that the situation is more complicated than that, but the conclusion is the same, namely high titre non-A non-B (≥ 10³ ciu/ml) does not exist in concentrates, so will have to be obtained by plasmapheresis of infected haemophiliacs. Dr Alter at NIH Blood Bank is alleged to have this material.
(b) Whilst pursuing the possible ‘black list’ of batch numbers, I was led to Duncan Thomas at NIBSAC, who did have two library samples of Armour AHF batch J70902, which was reported in November 1980 to have given rise to three separate ‘hepatitis’ incidents in 3 separate individuals. Unfortunately, the 3 episodes were ‘B’, ‘non-A, non-B’ and ‘uncharacterised’, so either the concentrate is multiply infected or the clinical data are very unreliable. So far this is the only material I have actually got my hands on, but it illustrates the problem of small sample size and the impracticability of doing e.g. chimpanzee infectivity studies on such material, leaving only one vial for experimental work! It was pointed out that most FVIII batches are consumed long before any hepatitis is seen/reported, but in a few favourable cases of larger batches or smaller Centres, some recall does result in a number of vials being returned. I understand that Jim Smith/Elstree gets this material, though whether it is available to us is another matter! JS alleges it could be salvaged on about one occasion per year.
(c) This latter information raises the interesting question as to what happens to Scottish material? It is inconceivable that we do not have frequent non-A, non-B contamination. Do any vials survive long enough to be withdrawn? Are the clinical reports available? Do ‘first time’ haemophiliacs get special attention as regards LFT’s, reporting of symptoms and segregation of batch numbers? It seems entirely likely that PFC’s library of FVIII:C concentrates must contain significant quantities of non-A, non-B material, albeit diluted. If we could identify a particular batch with certainty, this would be of some value for future work in this area.
11.63 There is a question for the Inquiry whether this discussion underlines a degree of uncertainty in Scotland about the project generally, despite contact with a wide range of experts. At the same time it may suggest a determination to pursue a solution in Scotland.
11.64 The Factor VIII Study Group met on 3 June 1982. Dr Foster summarised the work on identifying suitable reagent(s) which could be substituted for citrate during production of Factor VIII, as it was known this was a major cause of inactivation of Factor VIII:C. Clotting problems could be counteracted by the addition of heparin, but solubility was more difficult to resolve. The results obtained so far, using sodium phosphate and glycine were not promising. Studies were currently being carried out using maltose, which had shown improved solubility, but it was not yet known if the improvement was sufficient to compensate for the absence of citrate. In terms of fibrinogen removal the working party were able to specify Factor VIII losses which would be necessary to achieve a stated arbitrary figure of fibrinogen content. Zinc concentrations in the final product were a cause for concern. There had been much work but, to date, little progress. Dr Pepper presented the Safety Action Group’s report. Discussion centred on the proposed animal studies and the options available. This again provoked discussion, and no definite decisions were taken.
11.65 On 10 June 1982, Dr Pepper prepared a paper on inactivation by detergents. The proposal derived from work on Factor IX concentrates, and was not directly applicable to Factor VIII, but he proposed that the method might be adapted, with suitable detergents, to Factor VIII with a view to targeting the hepatitis virus specifically.
11.66 The Factor VIII Safety Action Group met on 23 June 1982. A Protocol for an infectivity model in the tamerin sanguinis labiatus using putative human NANB Hepatitis virus was available. This document summarised the procedures for the trial of NANB Hepatitis human virus by the inoculation of up to nine tamerin monkeys. The stages proposed were the validation of infective source material; infectivity titration; and inactivation titration. The minutes of the meeting indicate that study was still proceeding across a broad front. Investigation of the Behring approach was continued by Dr Macleod. Water content was to be studied. Samples had been obtained for radiation. Adsorption and filtration were current issues. Dr Foster’s work on purification required further experimentation with specific forms of HBsAg. Detergent studies were promoted. Animal studies were still being considered. And progress was being made with sourcing of materials.
11.67 On 9 and 10 June 1982, Dr Farrugia (Edinburgh BTS) visited Dr Smith at PFL, Oxford, for discussions on PFL’s current production.
11.68 In July 1982, the MRC decided to disband its blood transfusion research committee. NBTS proposed that they and the Scottish directors should set up a joint research committee.
11.69 In August 1982 Dr Foster attended the ISH/ISBT Congress in Budapest. He produced a lengthy report dated 14 October 1982. It covered the preparation of non-infective blood derivatives (Factors VIII and IX) at paragraph 2. In relation to Factor VIII, he reported that two new products by Biotest and Hyland were described. Behring did not present, but documents were available.
11.70 The Biotest pasteurisation technique used ‘β-PL/UV’, (β-propiolactone and Ultra Violet). Details of animal experiments were provided. The manufacturing method was set out. The Hyland project was not listed, but described on invitation. Dr Foster reported:
The method was said to involve pasteurisation and details of chimpanzee experiments were presented.
Concentrate was spiked with hepatitis B and heat treated. Control chimps developed hepatitis (ALT peak) after 6 weeks, ALT levels then returned to normal but were raised again at week 11. This was thought to be evidence of infection by both B and non-A, non-B. The experimental chimps have shown no evidence of infection to date (ie after 8 months) but they are still being observed. It was also stated that the viral challenge that had been inactivated in this study was 300 CID (Chimpanzee Infective Doses) but that a higher challenge (30,000 CID) had not been ‘completely’ inactivated by pasteurisation. No details of the experiment were given.
The method of stabilisation of FVIII was not reported but privately it was admitted that this had been discovered accidentally and that the yield was about 200 iu/l. The method is therefore probably different to the sugar/glucose stabilisation of Behringwerke.
11.71 He provided details of other studies including a study by Rubenstein of heat treatment applied to coagulation factor concentrates in freeze dried form. Products from different manufacturers behaved differently. One product would not withstand heat treatment while another gave 50% retention of Factor VIII:C after 10 hours at 80˚C or 71% retention of Factor VIII:C after half an hour at 100˚C.
11.72 Dr Foster made personal comments:
In the process presented for FVIII the mechanism(s) of viral inactivation/removal are difficult to discern. There would appear to be 6 possible components with only their combined effectiveness tested in the animal study. These components are:
(i) HB Antibody in the Plasma Pool –The titre of this was not stated but it seems to have been insufficient alone to protect the control chimp (i.e. tested with spiked cryoppt extract).
It is of interest to note that in his lecture on fractionation Brummelhuis gave a figure of 0.4 iu/ml IgG(H) to be added to a product such as factor VIII for HB protection.
Presumably non-A, non-B protection may be provided by IgG(N) added to the product, or perhaps administered separately (intravenously?)
(ii) Tween 80 – This acts by stripping off the viral coat, a mechanism currently being investigated by the Scottish group. No details of detergent fractionation were given.
(iii) UV Irradiation – Conditions not specified but probably the same as the fibrinogen method.
(iv) PEG Fractionation – details not given but could conceivably involve a 3.5% cut which could precipitate some virus.
(v) β-PL – Conditions not given, but certainly more gentle than previous examples.
(vi) Aerosil Adsorption – said to be essential to obtain non-infective product. Exact conditions not given.
Aerosil is an effective adsorbent of fibrinogen and at one time formed the basis of a high-purity method being researched at NYBC. The method was said to be finally abandoned due to problems of activation etc (Horowitz, personal communication). The use of Trasylol in the fibrinogen method…may be relevant here, though no mention of this was made for the FVIII process.
Although FVIII was said to be very sensitive to β-PL no information was given on yield, degree of inactivation etc. Hence a considerable number of important questions remain to be answered.
The work of Rubenstein using labile factors in their freeze dried state is very interesting but freeze drying is also likely to protect the virus and infectivity data is essential.
The Hyland product is perhaps the most interesting. If the yield indicated…is confirmed this is probably higher than the present method for Hemofil and therefore represents a definite break-through in FVIII stabilisation. Will this ever be published?
11.73 Scottish workers had not resolved any of the issues identified, but attention had already turned to the use of what would be a rare resource when developed. Dr Cash addressed the Budapest Congress on SNBTS’s programme to meet clinical demands into the next century. Dr Foster reported that it was generally agreed among those attending the Congress that ‘hepatitis free’ concentrates should be restricted to use in haemophiliacs with no previous signs of infection. Dr Foster’s report appears to have been available among the papers for the meeting of the Factor VIII Study Group on 14 October 1982 (below para 11.81), but the minutes do not refer to discussion of its contents.
11.74 Dr Foster seems to have procured a copy of a Behringwerke paper, published on
16 July 1982, which emphasised the variation in purity and in the content of active components in a range of commercial products, against the standard of the Behringwerke product, and emphasised the highly purified nature of that product. In contrast to the published paper, which emphasised the need for high-quality preparations for effective treatment of haemophilia patients, and the requirement for ‘standardized, highly purified Factor VIII concentrates, free from infectious material, particularly hepatitis viruses’, but made no explicit claim for the Behringwerke product, a typescript paper on the Behringwerke product produced at the Budapest Congress 1982 stated:
Until recently it has been impossible to eliminate the danger of hepatitis from certain plasma products, in particular clotting factor concentrates. When using factor VIII concentrate for haemophilia it was therefore necessary to weigh the benefits against the hazards. Now, however, thanks to a new manufacturing process, a safe Factor VIII concentrate is available. Experimental and clinical trials have confirmed its freedom from hepatitis risk.
11.75 The paper discussed the risks to which patients with haemophilia were exposed by the need for lifelong replacement therapy with coagulation factor concentrates. Chronic liver disease had replaced haemorrhage as the major hazard. There had been a shift in the ‘virus spectrum’, similar to that which had occurred in post-transfusion hepatitis, Type B having been partly replaced by NANB Hepatitis which had proved especially dangerous among patients with haemophilia. The paper proceeded:
The risk of hepatitis among haemophiliacs had become very serious and urgent measures were required to combat it. In principle there were two possibilities:
1. Active or passive immunization of haemophiliacs.
2. Introduction of products free from hepatitis risk.
11.76 Vaccines and immunoglobulins against hepatitis were not available for NANB Hepatitis. Single donor cryoprecipitate derived from medically supervised regular donors would have solved the problem only for a very small number of patients. Sterilisation by a combination of β-propiolactone treatment and ultra-violet irradiation was not applicable to Factor VIII. The paper proceeded:
In view of these facts we endeavoured to work out a method of producing hepatitis-free concentrate. We chose heat sterilisation, because it had been used for albumin for many years and was of established value. The removal of hepatitis risk by the albumin production process is based essentially on three stages: 1. Screening of all donor plasma by a third generation test and rejection of HBsAg-positive donations. 2. Elimination of hepatitis virus (BV) during the fractionation process. 3. Inactivation of any residual virus particles by heating the final product to 60˚ for 10 hours. The Factor VIII molecule is highly susceptible to elevated temperatures and the heating process was made feasible only by addition of stabilizers which protect the molecule from thermal inactivation.
11.77 At that stage, proof of the elimination of NANB Hepatitis had not been established: the final outcome was a product free from Hepatitis B virus. However, it was said:
In the light of the experimental and clinical results it may be said that the possibility of transmission of hepatitis B by Factor VIII HS can be ruled out. Furthermore non-A/non-B has so far not been observed and the characteristic signs have not been seen. However, long-term observation is being continued so that a definitive statement can be made.
11.78 Much of the information collected was very repetitive of the terms of the Heimburger article from 1980. But the paper reflected the strongly advertised claim that, notwithstanding the qualification in the final paragraph, Behringwerke had developed a hepatitis-free product. The Mannucci trial of Hemofil T (Travenol) product (treated at 60°C for 72 hours), begun in 1982, was destined to show NANB Hepatitis transmission in previously untreated patients treated with this product. Dr Mannucci imparted this information at a meeting in Barcelona in September 1983. However the report reflected the general interest in the subject in 1982, and in the virus infectivity model applied in Germany, and may explain the approach to research adopted in Scotland in 1982 and 1983 in particular.
11.80 On 16 September 1982, Dr Foster prepared a progress report on the development of high-purity Factor VIII. He discussed the prevention of Factor VIII inactivation during processing; the development of a high purity method; dealt particularly with the use of zinc; and noted that hepatitis experiments were being carried out in the USA by Dr Bier at CDC, Phoenix.
11.81 The Factor VIII Study Group met on 14 October 1982. Since the last meeting Dr Foster had become aware that patent applications had been filed by some commercial companies on the use of dextrose. He therefore thought it worthwhile to study the effects of this sugar on solubility. The report of the work of the Safety Action Group appeared to show a change of direction. It had been concluded, at least meantime, that irradiation was not a practical proposition. Further study of adsorption was now thought not worthwhile. Some aspects of the work were thought to qualify as research projects, but not to be immediately applicable to clinical products. Various detergents had proved quite successful, but should not be pursued at the expense of heat treatment, which was considered a better option. For purposes of virus inactivation, heat treatment was now the first option of the group ‘in view of developments which had occurred since the last meeting’. Dr Macleod (PFC) would continue studies of heat process using high purity product. Edinburgh BTS would assist if necessary. Dr Milan Bier had started work on zinc fractionation and it was thought that it would be worthwhile to await his results. There was no substantial progress in relation to animal trials, but they remained a material part of the work envisaged. The recommendation at this stage was to abandon attempts to apply the Behringwerke method to intermediate purity Factor VIII and to concentrate on the use of high-purity material.
11.82 Background information on the patent position was provided later, in 1984, in a memorandum from Dr Foster to Dr Perry and others. Sorbitol was first used as a stabilising agent at PFC in October 1982 by Dr Macleod after reading papers by Gekko et al which Dr Pepper had distributed. PFC had not at that time seen Behring’s patent (USA patent 4297344, 1981) but had an understanding of the process from the Zolg translation of Heimburger’s paper (above at paras 11.44-11.50). All of the Behringwerke data related to saccharose, but the patent claims were wider. The PFC process might lie outwith the patent because of the specific use of sorbitol, the concentration used, the use of calcium as a stabiliser, and the fact that the patent did not cover Factor IX. But NRDC had not wished to pursue a patent application on behalf of SNBTS.
11.83 Events over the summer of 1982 appear to have led the Safety Action Group to narrow the scope of its activities. There was no minute of any challenge at the Factor VIII Study Group meeting of the views expressed by Dr Pepper. On 19 October 1982, Dr Foster wrote to Dr Smith, BPL:
On the FVIII front we are still grinding away at the yield problem and have started to look again at the high purity situation. We are currently pursuing precipitation by metal-ions, which is something we stumbled on with Milan Bier a few months ago. The early results are interesting but its going to be stuck on the lab bench for a long time yet. Everyone is getting very hot about pasteurisation, especially since Budapest. The little work that we have done suggests that higher purity material is needed and so far FVIII (using Duncan’s CAG assay) has always gone into the solids phase!
Supernine has at last entered into some serious clinical study with early results very promising…
11.84 Dr Smith replied on 3 (November?) 1982. He offered the conjecture that for a year or two clinicians would have to make hard choices and that ‘the patients may have to be the test animal’, given lack of knowledge of what NANB Hepatitis was and what chemicals might do to it. He said that BPL were doing a little on heating Factor VIII, but only on gentle conditions for the removal of fibrinogen. This may be an important representation of BPL’s research and development work at this time.
11.85 Between 19 and 22 October 1982 the second International Max v Pettenkofer Symposium on Viral Hepatitis was held in Munich. There were reports of American chimpanzee trials of heat-treated human antihaemophilic factor concentrates which claimed success and of German (Behringwerke) processes which were also said to be successful. Dr Foster reported to Mr Watt on 26 October 1982 that there had been considerable progress.
11.86 Subject to concern about patent rights, greater optimism was again reflected in a memorandum from Dr P Foster and Dr A Macleod to Mr J. Watt on the subject of pasteurisation:
In recent weeks our studies on the heat treatment of labile fractions have shown dramatic results using sorbitol as a protective agent.
In initial experiments good results have been obtained using either sorbitol alone (fibronectin,1gG) and sorbitol/glycine mixtures (FIX, FVIII, plasminogen). While it is important to stress that these are very early results and that much more work remains to be done, the potential impact of this work suggests that we need to clarify the patent situations as soon as possible.
11.87 They noted that patents could have been filed that covered the area. Mr Watt wrote to Dr Cash on 18 November 1982 asking him to take steps to protect the Scottish work.
11.88 Advice on patent protection was sought, and in the Journal of the International Society of Thrombosis and Haemostasis there was a brief statement of the pasteurisation claim made in name of Dr MacLeod, Dr Dickson and Dr Foster. The critical claims were:
A factor VIII preparation has been pasteurised after the addition of 1850g of sorbitol and 50g of glycine per litre of factor VIII concentrate. The pH of the solution was carefully controlled during pasteurisation and no precipitate formed during the heating process. The recovery of FVIII activity over pasteurisation was greater than 70%. The sorbitol was removed by diafiltration.
Factor IX concentrate has been found to be stabilised by the addition of 1300g of sorbitol and 50g of glycine per litre of concentrate at pH 7.2. The FIX recovery over the pasteurisation process was 65% and there was no increase of in vitro thrombogenic activity as measured by the NAPTT and Tgt50 tests.
11.89 The distinctive characteristic claimed for the method was the use of sorbitol and glycine before pasteurisation.
11.90 There appears to have been keen awareness of competition from commercial manufacturers at this stage. A meeting took place on 15 December 1982 at BPL to discuss the ‘implications for the Haemophilia and Blood Transfusion Services of Commercial Introduction of “Hepatitis-Safe” Factor VIII and IX’. The paper set out a number of ‘commercial considerations’, including an analysis of the market for various products, price competition and the impact on product availability, and price inflation through claims of safety. It proceeded:
The above statement defines the need for centralised, fully controlled prospective trials of ‘HS’ materials, best operated through a properly executed National Clinical Trial lodged with the Regulatory Authority.
End results will carry a level of significance of value to user and producer. Information beneficial to the UK will be optimised.
Manufacturers entering the trial should undertake to make positive contributions of data and financial support in return for a properly conducted trial in a well-documented community of haemophiliacs.
[It is realised that overseas producers do not have access to trial facilities of equivalent quality and variety elsewhere.]
11.91 The authors offered the following proposals (to whom it is not possible to say):
(a) That random exploitation of the haemophilia service by commercial organisations for the study of ‘hepatitis-safe’ products should be discouraged.
(b) That the Haemophilia Services should create a formal basis for controlled clinical trial of alleged ‘hepatitis-safe’ products in line with the requirements of Medicines Act.
(c) That the Haemophilia Services, PHLS and NBTS should combine resources in a manner likely to advance economic treatment of NHS haemophiliacs with safe products.
11.92 This approach appears necessarily to have implied delay in use of the new products on an authorised basis.
11.93 On 6 January 1983, Dr Cash wrote to Dr Forbes, Consultant Physician at Glasgow:
I thought I ought to let you know, in advance, that we (PFC) hope to have a new factor VIII concentrate available by the late Spring of 1983 for preliminary studies … The production method will have to remain a secret at the moment until patenting formalities have been finalised … I write to enquire, in advance, whether you would be prepared to collaborate with us and undertake the necessary studies [with Dr Ludlam at Edinburgh].
11.94 Subject to the changes of direction during the year, pasteurisation of a high-purity product, using sorbitol and glycine as stabilisers, seems to have emerged as the main characteristic of PFC’s proposed solution to virus inactivation in Factor VIII and Factor IX.
11.95 A material issue relative to chimpanzee studies emerged from a letter sent by Dr Cash to Dr DL Aronson, Director, Coagulation Branch, Division of Blood Products, Bureau of Biologics in Bethesda, Maryland, USA dated 20 December 1982. Dr Cash was interested in the chimpanzee tests required for licensing in the USA. Information was available relating to proposals for animal testing in the USA. In particular SNBTS had a copy of a note, prepared by Dr Aronson, of a meeting held at the Office of Biologics on
9 September 1982. At that meeting it was decided to recommend to NHLBI that it should attempt to coordinate animal studies, establishing a common inoculum, identifying a group of colony-bred chimpanzees and establishing common procedures. It was recognised that chimpanzee studies were ‘slow and fraught with inherent problems’.
Summary of position by the end of 1982
• The prevalent understanding of the natural history of Hepatitis B infection was that it was an unpleasant illness, but seldom dangerous, and usually followed by complete recovery.
• Advances in viral biology had led to improved screening techniques which reduced the prevalence of transfusion- transmitted Hepatitis B, though by the end of this period many haemophiliacs had blood markers showing that they had been infected with HBV.
• NANB Hepatitis, recognised as due to one or more blood-borne viruses in 1974 and first described in haemophiliacs in 1975, was generally thought to have an acute self limiting course, or to lead to mild chronic hepatitis with a ‘probably benign’ prognosis (Sherlock 1981).
• SNBTS research and development work on optimising Factor VIII yield and on purification, which had been the predominant feature of the 1970’s, continued.
• It was beginning to be understood that technological advances in increased yield and potency of Factor VIII and Factor IX had not made the products safer in terms of virus transmission.
• A wide-ranging investigation of methods of virus inactivation had been initiated and was in progress in Scotland as elsewhere.
• Inactivation methods, whether based on chemicals or heat, reduced dramatically the yield and efficiency of Factor VIII and Factor IX obtained from blood, and there was a lack of blood markers for NANB Hepatitis.
• While a variety of experimental programmes had been started in Edinburgh and Glasgow, pasteurisation of a high purity product, using stabilisers at the heat-treatment stage, was emerging as the favoured option.
• The risk of infringing the intellectual property rights of others was under investigation, but it was believed in Edinburgh that SNBTS had a sufficiently distinctive process to warrant patent protection for it.
• There was a perceived need for animal testing prior to release of any new product for trials or clinical use.
1983: The HIV/AIDS Epidemic
11.96 At the beginning of 1983, it was anticipated that a number of commercial suppliers would market heat-treated products in the near future. In Scotland, it was thought that NHS suppliers had to demonstrate their capacity to manufacture similar products. Similar views were expressed in England. In a letter dated 10 January 1983, the PHLS wrote to the DHSS enclosing a copy of a letter intended to be sent for publication in The Lancet on the risk of NANB Hepatitis. The covering letter explained that ‘drug companies are planning to introduce ‘hepatitis reduced’ products, and it seems likely that attempts may be made to use the method of doing trial transfusions on a named patient basis and not submitting them to formal clinical trial.’ The proposed letter referred to the viral inactivation methods that had been published, and the lack of methods of assaying the infectivity of preparations containing NANB Hepatitis viruses other than by chimpanzee inoculation or parenteral injections in man. And it stated:
It is important that any new ‘hepatitis reduced’ factor VIII or IX concentrate should be assessed by suitable prospective trials in patients with no known previous exposure to factor VIII or IX concentrates. These products are likely to be expensive, and in our opinion it would be valueless to use these preparations in patients who have received more than 5 batches of factor VIII, as it is likely that they have already been exposed to all non-A, non-B viruses commonly associated with transfusion hepatitis.
11.97 Whether to rely on chimpanzee studies, and the restrictive definition of human groups likely to be useful for trial purposes became controversial issues in the course of the year: many patients with little or no previous exposure to factor concentrates would be children.
11.98 The relative position of Scottish research was set out in a memorandum sent by Dr Foster to Mr Watt on 11 January 1983. PFC research and development work on the pasteurised product was well advanced, and clinical tests were due within three months. The procedural proposals were set out. By now, it had been agreed that the product would be prepared by the zinc fractionation method also under development in PFC’s research and development section, so that the clinical test would involve a test of the zinc product both heated and unheated (HTZFVIII and ZFVIII respectively). The pasteurisation conditions had not been determined precisely, but the requirements for materials were predicted on an approximate basis. The intention was to produce sufficient material for tests on six patients with non-heated ZFVIII, and six with HTZFVIII heated at 60˚C for ten hours. The narrative disclosed that Dr Foster was able to make a rough approximation of the yields achieved by the English NY process, but implicitly he did not have reliable data from England. A preliminary budget was prepared by 14 January 1983, but there were serious qualifications: there had to be a clearer idea of the methods to be used before ‘any kind of sensible process design’ could be devised. When Mr Watt returned from the USA, he wrote to Dr Cash, on 1 February 1983, dismissing the budget as premature and inaccurate.
11.99 On 12 January 1983, Dr Pepper prepared a report for a meeting of the Factor VIII
Safety Group on 2 February 1983. The document noted progress on radiation, adsorption and detergent processes, in addition to heat treatment and purification. The report stated:
Heat treatment continues to be the ‘best choice’ and additional evidence is provided (mainly by word of mouth) that manufacturers in Germany, USA and UK are actively working on heat treatment. Patents have been issued to Behringwerke in Germany (No 2,916,711) and the USA (No 4,297,344) for the heat-stabilization of factors II, VIII, XIII, ATIII and plasminogen using glycine-sucrose. An additional advantage claimed for this process is low fibrinogen. Not mentioned however is the yield of FVIII:C which is likely to be low. Cutter and Hyland are also pursuing heat treatment, and it is reported that Cutter are patenting other sugars and Hyland have empirically found around 60% yields with one raw material, the reason for this is not known.
A copy of a report from the Bureau of Biologics meeting on 9 September 1982 summarises the views of Dr Kosow (ANRC) which confirms earlier reports that protein denaturation is the likely route of inactivation by heat.
Heating of NANB has proved effective with 100CID using 60˚/10 hrs….
11.100 Dr Pepper was, in the event, somewhat premature in concluding that heat-treatment had ‘proved’ to be effective at 60˚C for ten hours. But his comments show an understanding of what was happening in the market and highlight the nature of the developments: these were viewed as innovative products, incorporating patentable inventions. If the UK public service manufacturers were to compete in this market, they would either have to purchase licences or develop products sufficiently differentiated from the patented products to avoid infringement. There was evidence of considerable effort being made to identify the essential elements in the manufacturing procedures adopted by commercial manufacturers, and to develop distinctive processes to support domestic products.
11.101 Dr Pepper also discussed animal infectivity trials that emphasised the need to use chimpanzees as the only animals suitable for the purposes of study. Discussions with the US Department of Health and Human Services, FDA, Bethesda, led to a letter dated
13 January 1983 setting out a summary protocol for tests. The letter did not address the issue of the tests required for licensing that was raised by Dr Cash in his letter dated 20 December 1982 (see para 11.95).
11.102 Dr Foster was in touch with Dr Smith at the PFL at this period, and kept him informed of progress on current research and development in Scotland. He sent a comprehensive letter to Dr Smith on 20 January 1983. The letter provided a great deal of technical information on the research and development work that had been carried out in Scotland. The substance of the information was repeated, in less technical terms, in a report for the SNBTS Factor VIII Study Group dated 24 January 1983. Dr Foster set out data on the Factor VIII project. As in his letter to Dr Smith, he reported that the laboratory study was virtually complete. He discussed the loss of Factor VIII activity in processing, the effect of adding citrates, the possible consequences of introducing calcium into the process, and the implications for stability. He reported on progress with the high purity project. And there were two sections on hepatitis specifically. These provide a picture of the current state of development on inactivation and related processes:
Dr Bier (Tucson) has completed his study of the effect of zinc precipitation on spiked cryoprecipitate extract. The extract (TE1) was redissolved in 30 ml H2O and 0.1 ml of a positive serum (HB titre 10 (to the six)) was added. Following zinc precipitation analysis by RIA showed no precipitation of HBsAg, either with or without heparin (2 u/ml).
Following the decision at the last meeting of the working party (14/10/82), to make heat treatment the priority method for study, further effort has been directed towards this topic.
A formulation of protective additives has been established which consistently shows a 70 – 80% FVIII recovery (1-stage assay) over the heating process (10 hours at 60˚ C). However substantial losses have been experienced during both the reagent addition and the reagent removal operations. Study of these problems is now in progress and early results suggest that careful attention to control of pH and temperature is particularly important. The solutions are also relatively viscous and success will depend on the establishment of an appropriate process engineering design for large-scale operations.
11.103 The SNBTS and Haemophilia Directors met next on 21 January 1983. Dr Cash’s notes for the meeting commented that heat treated products ‘which should have a reduced risk of transmitting hepatitis’ would be commercially available in 1983. PFC was working on the project and it was hoped that in 1983–84, in association with the facility’s work on a low fibrinogen product, limited supplies would be available for clinical trial. Work was proceeding on Factor VIII and Factor IX. The same paper noted the problem of AIDS in the USA, but did not relate the emerging problem to work on heat treated products. The minutes of the meeting noted the developments reported, including development of a new method of providing a high purity Factor VIII concentrate low in fibrinogen that was currently subject to a patent application. It was anticipated that small amounts of this product would be released for limited clinical trials later in the year. In relation to heat-treatment of Factor VIII, he reported that, associated with the high purity project, PFC was also going ahead with the development of a heat-treated product with a reduced risk of transmitting hepatitis. Concern was expressed about the commercial firms who might capture the market for their own heat-treated product, and, by offering supplies of their material for clinical trials, might pre-empt the available suitable patients before the PFC product was ready for similar trials. Mr Watt explained the problems which had to be overcome in preserving acceptable yields and providing a product which was not too expensive, considerations that were of less importance with the commercial product. Directors were made aware of the fierce competition facing the PFC from commercial concerns and were asked to bear in mind the stated policy for the Scottish Health Service to be self-sufficient in blood products. PFC would have limited amounts of heat-treated Factor VIII available for trials in the near future, and Haemophilia Directors agreed to support PFC as much as possible in the development of clinical trials of the NHS product. It was agreed that the SNBTS Factor VIII Study Group should keep these developments under review and help to promote whatever collaboration was required to bring the PFC heat-treated Factor VIII most effectively into therapeutic practice.
11.104 On 24 January 1983, Immuno of Vienna held a meeting at London Airport. Immuno’s product had been tested on chimpanzees. At this meeting Dr Craske disclosed the results of work at Oxford that showed that previously completely unexposed patients with von Willebrand’s disease and mild haemophilia who were treated with BPL Factor VIII had 100% incidence of hepatitis, and that patients who had previously received four to five batches of material had a 50% chance of developing NANB Hepatitis. After discussion it was agreed by the experts present that product tests should in the first place involve adults with large Factor VIII requirements (and therefore a history of therapy). In view of the ethical considerations, one would progress to treating children only after satisfactory experience with adult patients. Immuno produced a summary of the discussion that was circulated on 24 March 1983. The impression conveyed was more optimistic than that set out in the participators’ reports. But comments attributed to Professor Bloom included four that would have been significant:
Haemostatic activity in terms of in vivo recovery and half life and absence of toxicity should be ascertained in adult haemophiliacs.
The material should then be assessed in the treatment of adult haemophiliacs susceptible to non A, non B hepatitis by a properly conducted trial in susceptible patients in appropriate need of treatment….
The material could then be used on newly diagnosed children.
Trials could be arranged by the Committee of the Haemophilia Directors, and it would be best to use five separate batches with two patients receiving each batch.
11.105 In January 1983, AG Welch visited the Cutter Laboratories in Berkeley California. He reported back to PFC that Cutter used sucrose in the pasteurisation of Factor VIII.
11.106 On 1 February 1983, Mr Watt appeared to be more pessimistic about the rate of progress than some of his colleagues. He thought that the ‘real problem’ of achieving the heating stage and executing all subsequent stages to the point of final dispensing would take time. He doubted whether it would be practicable in 1983–84. The best that could be done in the current year would be to prepare some small lots for clinical evaluation.
Dr Cash was anxious not to lose momentum.
11.107 The Factor VIII Study Group met on 2 February 1983. Dr Pepper’s report of the Safety Action Group repeated the proposition that heat treatment remained the method of choice, but commented on Immuno’s chemical methods, on irradiation, and on detergent methods. In relation to animal studies, variable results, high costs and shortage of animals and of infected materials suggested that ‘the optimal infectivity model will probably be high risk human beings’ This may have been intended to reflect the outcome of the discussions hosted by Immuno.
11.108 So far as Factor IX products were concerned at this time, Dr Foster proposed the setting up of a dog colony for thrombogenicity testing. He also wrote to Mr Watt suggesting that the opportunity should be taken to improve the existing NY process used by PFC by using techniques derived from the inactivation programme. There were mixed responses to the proposal, some supportive, but others reflecting an anxiety to avoid additional work rather than re-establishing NY production after the refurbishment of PFC which was due to take place in 1983.
11.109 On 3 February 1983, Dr Cash wrote to Dr McDonald at Glasgow Royal Infirmary proposing a meeting of the Scottish Haemophilia/Transfusion Directors Working Party on the heat-treatment of Factor VIII concentrate. He was anxious to maintain the momentum of work in hand at the PFC. He noted that Dr Forbes and Dr Ludlam were prepared to test the new PFC products in patients with severe haemophilia, in respect of in vivo yield and half life, and wished to discuss serial liver function tests in mild to moderate cases following a single infusion of the new preparations.
11.110 On 22 February 1983, Mr Watt wrote to Dr Rizza at Oxford referring to PFC’s new purification procedure for Factor VIII concentrate which had ‘performed well in study of heating to 60˚ for ten hours’. It was expected that clinical studies to estimate half-life efficiency etc would commence shortly. The next stage would be to try to discover whether or not the manufacturing process had been successful in inactivation of virus material. He continued:
Some anxiety exists for rapid movement in the development of the new product and it is clear that the most sensitive need will be to establish its relative safety. This would be in the interest of both UK fractionators if we are able to succeed in competing successfully with imported product with claimed safety. Do you agree that it would be possible to establish safety by seeking evidence of NANB in mild haemophiliacs following administration of the new product? I should think this to be possible ethically since this preparation would be, at the very worst, safer than existing products and is treated by a method which can be expected to make it completely safe.
11.111 On 1 March 1983, Dr Rizza replied:
I was glad to hear of the progress you are making…especially since 3 drug companies have been in touch with me in the past 3 weeks pushing strongly to formalise studies of their different preparations in mildly affected haemophiliacs. I think it will be necessary to use infrequently or previously untransfused haemophiliacs, von Willebrand’s patients and carriers of haemophilia to ascertain to what extent hepatitis risk has been reduced. I see no ethical problem with this. The difficulty with this kind of study has been and always will be I think the small number of previously untransfused patients who come for treatment. At this Centre we have managed to collect about 30 suitable patients over a 2 year period but the patients were not recruited all at once but came in for treatment in the usual random manner and I think that this should be remembered. In other words, although we may have a group of 500 mildly affected patients on our books, only a few of those per year require factor replacement for surgical procedures. I do not think it would be ethically justified to give the material without a good clinical indication.
11.112 Dr Rizza offered to participate in trials. Mr Watt replied, thanking him and expressing complete agreement with his ethical points on 9 March 1983. Amongst other matters, he said that he had been concerned that it might be necessary to carry out experiments in chimpanzees to satisfy the licensing authority, but understood that animal experiments using chimpanzees would not be required to satisfy licensing authorities ‘providing we do not make claims of freedom from infection’.
11.113 Dr Foster gave a presentation on ‘Methods for Preparing non-infective blood product’ at the Department of Haematology, RIE, on 8 March 1983. In addition to a wide-ranging account of blood product production, he discussed: methods of removing and inactivating virus (including chemical– BPL/UV, detergent and an unknown method by Immuno); heat treatment; pasteurisation problems (including NANB Hepatitis); the Behringwerke process; the Hyland method; work in progress towards better Factor VIII yield and the need for better fractionation processes and stabilisation during pasteurisation; and high purity methods of production. Dr Foster gave a further presentation on: ‘Factor VIII. Progress in Fractionation’ at the Scotblood Conference in Dundee in March 1983. He discussed: problems in the manufacture of Factor VIII concentrates; yields; metal ion precipitation; the effect of citrate; stability; and PFC research and development projects.
11.114 Heat treatment was discussed at a meeting of the Haemophilia and Blood Transfusion Working Group on 22 March 1983. Heat-treatment research was now the focus for work, and it was reported that Factor VII research and development had been postponed meantime. Mr Watt reported on heat treatment development work. He explained that PFC was not trying to heat treat the existing Factor VIII product. Dr Foster and colleagues in USA were working on a completely new Factor VIII product of higher quality with a lower fibrinogen content. A trial batch of plasma had been used to produce small amounts of this product in two forms: not heated and heated at 60˚C for 10 hours. These were now available in small quantities for clinical trials in comparison with the routine intermediate concentrate. The new processes could be accommodated at PFC and ‘the new processes had been patented’.
11.115 Mr Watt said that the new product was not the same as current commercial heat-treated products, and that there were encouraging results in terms of reduced infectivity. Dr Forbes and Dr Ludlam agreed to take part in the tests.
11.117 On 7 April 1983, Mr Watt responded to proposals for testing for inhibition, and to questions posed by Dr Ludlam. He set out PFC’s position as follows:
Our aim at PFC in heat treatment of F VIII is to achieve a ‘kill’ of virus equivalent to that achieved with the accepted process used for albumin when excessive virus is present. Using markers we need to cover a good range to allow a claim that the method can be expected to reduce markedly the risk associated with the product as compared to the standard product now available. No one can claim that their product is ‘virus-free’, the only admissible claim is that the risk is reduced and this disposes of the ethical problem since such products can be claimed to be less likely to transmit infection. Some may well be relatively less likely than others but this will become clear only after several thousand clinical experiences with the product.
11.118 On the previous day, 6 April 1983, Dr Foster had sent Mr Watt a memorandum that set the aim rather higher in relation to Factor IX: ‘Clearly our aim is to achieve non-infective, non-thrombogenitic products in reasonable yield.’ He discussed a range of possibilities.
In terms of testing, he saw little interest in animal testing, so far as PFC was concerned.
11.119 Mr Watt’s response to Dr Ludlam’s proposals for testing was set out in a letter to Dr Cash on 18 April 1983: he thought them unnecessary or premature. Dr Cash responded with unqualified support for Dr Ludlam. The tests were neither unnecessary nor premature.
11.120 In a letter to Dr Smith, PFL, dated 27 April 1983, Dr Foster updated Dr Smith on progress in Edinburgh with fibrinogen precipitation, and continued:
I can confirm that our second pilot-scale production run of the zinc-sorbitol process will be on 17/18 May….The material from our first test has completed all of its QC and is ready for some preliminary clinical assessment (ie FVIII recovery and ½ life in severe haemophiliacs). However some questions are being raised about FVIII neo-antigens; my personal view at the moment is that this is probably a bit esoteric, considering the amount of ‘junk’ already present in cryoprecipitate and concentrates. Nevertheless there may be some hoops that we will have to jump through.
11.121 At this time a copy of the Behringwerke paper produced at the Budapest Congress in 1982 was circulating in Edinburgh. Dr Cash received a copy from Dr Foster. Dr Ludlam received a copy from Dr Cash.
11.122 On 2 May 1983, Dr Foster reported to Mr Watt that a production test of calcium addition to Factor VIII had been carried out and appeared to give an increase in process yield. In a separate memorandum of the same date he noted that material from the pilot scale test of NY760 and NY761 was available for clinical evaluation. NY760 failed a pyrogenicity test.
11.123 On 3 May 1983, Dr Foster circulated a memorandum on a strategy for heat treatment of Factor VIII. The objective of existing strategy had been to cope with the hepatitis problem in haemophilia patients. Severe haemophilia patients who were established users of therapeutic products had already been heavily subjected to untreated products, and were highly likely to have been infected with hepatitis. Only mild and moderate patients could benefit from a treated product in the foreseeable future. Therefore, there had been a target of heat treatment for 30% of total production in 1984–85, following the pilot scale exercise in 1983. With the advent of AIDS, review was necessary. In the context of AIDS, the haemophilia patients most at risk were severe patients. Heat treatment looked ‘the most likely possibility that we have to face up to’. All Factor VIII would have to be pasteurised. There was a risk of a general move back to treatment with cryoprecipitate which would threaten plasma supplies. Dr Foster proposed acceleration of the heat treatment programme, and set out the requirements to do that.
11.124 Mr Watt wrote to Dr Cash on 5 May 1983. His letter set out the case for acceleration. In the course of that, he provided information. It had been found that heating for a shorter time ‘now known to be less than one hour’ at a higher temperature was much more effective. In a comparative test, heating at 70˚C for less than an hour reduced the same viral burden by four times the reduction achieved at 60˚C for ten hours (subject to the limitations of sensitivity of the assay).
11.125 The rate of progress with research and development was now swamping SNBTS headquarters laboratory with samples.
11.126 On 9 May 1983, Dr McClelland asked Mr Watt for samples of a number of identified batches of Factor VIII to test for putative markers of NANB Hepatitis after one of Dr Ludlam’s patients developed raised liver enzymes and raised bilirubin. The patient did not have markers for Hepatitis B. Mr Watt passed the request on to Dr Perry on 13 May 1983. In a letter to Dr McClelland of that date, he warned that there could be some problems if samples were released from the PFC product library, since the products were still current and further ‘adversity’ might arise.
11.127 Meantime, Dr Foster had submitted samples of NY760 and NY761 to the MRC’s immunoassay team. On 13 May 1983, the first results were reported to be satisfactory. Immunoreactivity was preserved. In a second report dated 25 May 1983, the MRC team intimated that Factor VIII was not altered immunologically by any of the processes used in preparation of NY760 or NY761.
11.128 On 1 June 1983, Dr Cash responded to Mr Watt’s letter of 5 May 1983. He was making contacts ‘with a view to getting NY761 put into patients’. He encouraged Mr Watt to make progress with the costing of the acceleration programme: there was no money in 1983–84 for the work, on current instructions, but that might change on a full case being made.
11.129 On 13 June 1983, Dr Cash wrote to Dr Ludlam inviting him to trial NY761 alone (NY760 having failed a pyrogenicity test), and proposing a trial protocol.
11.130 A meeting of the Factor VIII safety sub-committee was held on 15 June 1983. The discussion indicated the position as it was understood at the time:
Considerable progress has been made at PFC in producing heat treated FVIII and clinical trials should start towards the end of the summer in Glasgow and Edinburgh. No infectious model for non-A, non-B has been produced yet. The putative ‘AIDS’ virus must be considered as a potential hazard in FVIII concentrates.
1. Heat Inactivation
A comprehensive series of time/temperature studies have been carried out at PFC using sorbitol/glycine additive in FVIII and albumin, with albumin and caprylate as control. Different target viruses are used but vaccinia (as suggested by BoB) is most useful as it is (a) DNA virus; (b) double stranded; (c) lipoprotein enveloped; (d) contains a DNA polymerase and (e) can be easily grown and assayed in tissue culture. Individual heat cycles produce differing rates of inactivation at differing time/temperature points when FVIII:C is bioassayed.
11.131 The minutes proceeded to set out a preliminary protocol for the study which would involve heat treatment at 60˚C for ten hours and 70˚C for half an hour. The paper expressed the hope that there could be clinical trials in Glasgow and Edinburgh. Other work reported included the investigation of non-heat treatment processes, with the second choice of inactivation process emerging as either irradiation or the use of organic solvents. In reporting the work of others, it was noted that the Behringwerke process had been licensed to Kabi, and that Armour were negotiating an exclusive licence of a Purcell patent using chloroform treatment. Immuno were developing a chemical process. The impression is of widespread activity involving a range of experimental procedures. The focus for this activity had now widened to include AIDS as well as NANB Hepatitis. The minutes note:
1. Acquired Immuno-deficiency Syndrome (AIDS)
Although not proven to be a virus, this apparently infectious agent has been found in haemophiliacs in the UK. It would seem wise to try somehow to encompass AIDS inactivation along with HBV and NANB inactivation schemes. In this regard, it reinforces the choice of heat or irradiation as opposed to antibodies, adsorbents or detergents which are likely to be more specific to a particular class of virus. Taking a pessimistic view, some viruses are known with heat resistance up to 80˚C, so 70˚C may not be sufficient.…
11.132 Hepatitis B vaccines and diagnostic reagents were discussed. In relation to NANB Hepatitis, it was stated:
5. Non-A, non-B:
As predicted in our earlier reports, a serological (DS-antigen ELISA) test for NANB has been reported by the Organon Group (Duermeyer et al…) The results were very interesting, however the prognostic potential of the assay remains to be confirmed. A trial to do this is being undertaken by Dr McClelland in conjunction with Dr Howard Thomas (Royal Free Hospital, London), who has a similar NANB antigenic marker. The trial is necessarily rather long-term, consisting of placing donor samples in a deep freeze and waiting until a recipient develops NANB. The samples are then analysed for the DS-like antigen retrospectively.
11.133 In relation to animal testing, the discussion noted:
In this case, we are likely to have a low priority for scarce animal resources and inevitably the work will be considerably delayed. On the credit side, it seems certain that commercial and/or government organisations in the US will already have planned similar experiments to those proposed by us (eg NANB or B viruses in FVIII concentrate and sucrose/glycine and pasteurisation) and that the results of these are likely to be publicly available before we can make significant progress. Whilst this is not a very satisfactory substitute for testing sorbitol/glycine protection, it could give us additional justification for proceeding directly to human subject testing…
11.134 The paper ended with proposals for further action, including more work on heat treatment.
11.135 On 27 June 1983, at the World Federation of Haemophilia meeting in Stockholm, the SNBTS learned that Professor Johnson of New York was working on a new method of Factor VIII purification. In a private discussion following an SNBTS presentation, Professor Johnson enquired if SNBTS might be interested in working on this project with him as he believed that SNBTS were thinking along the same lines as he was. The potential value of Professor Johnson’s method in resolving the technical difficulties SNBTS were experiencing in the development of pasteurisation was immediately appreciated.
11.136 Dr Foster reported the discussions with Professor Johnson to Mr Watt and he wrote to Professor Johnson on 1 August 1983 proposing collaboration, initially on a confidential basis. By this stage Mr Watt had resolved to leave PFC at the end of March 1984, and a degree of urgency was reflected in his letter. He set out a number of procedural issues that would arise, if the parties were to collaborate formally. Dr Foster would later report that work on this project began in August 1984.
11.137 Meantime, in July 1983, Dr Foster, and colleagues from PFC and University of Arizona, Tucson, gave a poster presentation at the 18th International Congress on Thrombosis and Haemostasis, Stockholm, on ‘Zinc Fractionation of Cryoprecipitate’. It mentioned that ‘heat treatment of coagulation factor concentrates is being developed to reduce the risk of viral contamination’. A number of conclusions were set out, including a statement that: ‘The factor VIII solution produced by zinc fractionation can be pasteurised (60º, 10 hrs) in the presence of appropriate stabilisers’.
11.138 On 13 July 1983 the biological sub-committee of the Committee for the Safety of Medicines considered the different operational possibilities for reducing the risks from concentrates. It considered withdrawing all Factor VIII and Factor IX concentrates but decided that it was ‘probably impossible’ to satisfy the UK demand for concentrates by only using cryoprecipitate. The sub-committee also rejected Dr Galbraith’s recommendation that all USA preparations should be withdrawn from the market on the basis that this was impracticable on the grounds of supply. The possibility of licensing USA blood products in such a way as to ensure that they were used as sparingly as possible was also considered. For example a product licence could be modified to state that it was ‘not for use in children with mild haemophilia’. It was decided that the risk/benefit considerations in different categories of patient were too finely balanced to justify action by means of the licensing system. It was preferable to leave the matter to clinical judgment.
11.139 On 23 August 1983 Dr Foster wrote to Dr Smith at PFL informing him of recent progress. Further experiments were proposed for 29–30 August. It was intended to heat at 60˚C for ten hours, but Dr Foster thought that this would probably complete their work under those conditions. The study was virtually complete, and they had found that Factor VIII:C survived fairly well for one hour at 70˚C, and that eight logs of vaccinia could be killed in half an hour at that temperature. The chosen regime therefore was 9.25 hours heat treatment at 60˚C followed by three quarters of an hour at 70˚C.
11.140 In a letter dated 29 August 1983 to Mr Wastle of SHHD relating to proposed publication of production data, Dr Cash said: ‘You may wish to include in the statement that an SNBTS heat treated factor VIII concentrate will undergo initial clinical trials within the next 2-3 weeks. This may be of importance because if AIDS is a virus then we would anticipate the heat-treated product will be safer.’ Dr Cash provided figures for blood products used in Scotland. Over 90% of the commercial material was from the USA.
11.141 On 6 September 1983, Dr Ludlam wrote to Dr Cash saying that he was about to infuse the first PFC heat-treated Factor VIII on the following day. On 13 October 1983, Dr Cash advised Dr Mitchell that heat-treated Factor VIII was on its way for testing in Glasgow. Other material was dispatched to Glasgow and Edinburgh BTS on 31 October 1983.
11.142 On 13 October 1983, Dr Cash wrote to Dr Ludlam asking him to liaise with
Dr Forbes and consider how to check for NANB Hepatitis transmission in ‘virgin’ haemophiliac patients, especially in Scotland where there were so few patients.
11.143 The Haemophilia and Blood Transfusion Working Group met on 14 November 1983. Dr Ludlam reported on his trial: one patient had been treated on three occasions. The results compared favourably with other products in terms of half life and recovery. But the patient had experienced minor adverse reactions and had become anxious. It was not clear whether the product was the only cause of his upset. Dr Forbes had not put his batch on trial. Dr Foster reported the move to more severe heat treatment up to 70˚C.
Dr Forbes reported that there were not enough ‘virgin haemophiliacs’ in Scotland for trials. Dr Ludlam had trialled Supernine and found it satisfactory. He recommended production. But there was a licensing problem: the licensing authority did not want a second Factor IX licence, and there was a desire to retain DEFIX. The issue does not appear to have been resolved. Dr Ludlam’s trials appear to have resolved or at least reduced his concerns about neo-antigens.
11.144 At a meeting of SNBTS Directors on 8 December 1983 it was acknowledged that Glasgow Western Infirmary/Royal Hospital for Sick Children appeared to be the last remaining hospital to use substantial quantities of commercial Factor VIII in the West of Scotland.
11.145 Dr Prowse and colleagues prepared a report, revised during the year, and brought up to date in December 1983, of a literature survey of the ways Factor VIII was lost ‘from donor to fractionator’. There were recommendations on time limits for collection, mixing, use of anticoagulants, freezing and storage at the point of donation.
11.146 On 16 and 17 December 1983 the inaugural meeting of the British Blood Transfusion Society took place. Board No. 1 of the Poster Abstracts by Peter Foster, Alexander MacLeod, Bruce Cuthbertson, Ida Dickson and Joan Dawes (all but the last being PFC; Joan Dawes was MRC/SNBTS) entitled ‘Towards a High-Yield, High Quality Factor VIII concentrate’ described the Scottish Factor VIII product at that time:
Scottish Factor VIII concentrate is prepared as an intermediate-purity product because of the higher yield obtained in comparison to high-purity methods. Although improvements in quality are desirable, particularly a reduction in fibrinogen content and removal of infectivity risk, these must be achieved without major loss of yield if self-sufficiency is to be maintained.
A process aimed at achieving this has been developed, combining a number of original features:
(1) Continuous plasma thawing to maximise FVIII recovery in cryoprecipitate (Foster et al Vox Sang 42, 180-189, 1982)
(2) Precipitation of fibrinogen using zinc (Foster et al Thromb Haem 50, 117, 1983)
(3) In-process stabilisation of FVIII with calcium (Foster et al Thromb Haem 50, 117, 1983)
(4) Heat treatment in the presence of sorbitol and glycine (MacLeod et al, Thromb Haem 50, 432, 1983)
Heating conditions for viral inactivation have been carefully defined, using a range of model viruses, to gain a kill comparable to that achieved in the pasteurisation of albumin solutions.
Factor VIII, fibrinogen and other components of the final product have been analysed by radioimmunoassay. No immunological differences have been observed between heated and non-heated products, suggesting that the conformational integrity of the proteins has been retained.
11.147 These appear to have been major claims relating to SNBTS research into preparation of Factor VIII products at the end of the year.
1983: England and Wales
11.148 In the course of 1983, English research appears to have taken a different route from Scots research. However, it is not clear to what extent this was known in Scotland. On
11 July 1983 Dr Craske prepared a report, subsequently incorporated into the annual report of the UK Haemophilia Centre Directors Hepatitis Working Party for 1982–1983, in which he identified the factors to be considered in the selection of commercial hepatitis reduced products for clinical trial in the evaluation of residual infectivity for hepatitis viruses.  He listed three approaches to viral inactivation processes: 1. Freeze drying followed by dry heat treatment usually at 60˚C; 2. Treatment with chemicals (e.g. ß-propiolactone, ultraviolet light). 3. Pasteurisation by heating at 60˚C in the presence of stabilisers.
11.149 The report noted that several manufacturers would shortly be offering trial batches of the products described. By now it was known that three chimpanzees treated with Hyland’s heat treated Factor VIII (as developed to that date) had developed hepatitis. Dr Craske commented that it was possible that Factor VIII concentrate prepared from plasma donations obtained in the USA might be contaminated with a putative infectious agent associated with the cause of AIDS. There was, as yet, no product which was made from sources which were not likely to carry a risk that a putative virus associated with AIDS would be present in the plasma pool from which the Factor VIII was fractionated, and which was heat treated. There was, therefore, in his view, a considerable ethical problem when considering the evaluation of the new heat treated products for their residual infectivity in clinical trials in patients infrequently treated with Factor VIII who had no prior exposure to freeze dried concentrate.
11.150 In relation to NHS products, he noted that: ‘It is to be hoped that a hepatitis reduced product will be available from NHS sources before long’. However, the report does not identify the processes envisaged, either in England or in Scotland. It is not known whether Dr Smith or Dr Rizza shared with haemophilia directors the information they had received from Scotland about research and development there, nor is it known whether Dr Smith at BPL shared with English colleagues the information he received from Scotland.
11.151 Dr Craske’s report can be compared with an unpublished document dated
26 July 1983, under the heading of the Central Blood Laboratories Authority, which discloses what was happening at the time in England. After some introductory comments, the document went on to discuss the means available for inactivation:
Heat treatment represents only one pathway by which viruses may be inactivated. Nonetheless, it is the most favoured route at present. Heat treatment may take place during the process of blood product purification, ie during a wet process step or heating a finished freeze dried product can be attempted. Heat transfer in the wet state is more homogeneous and efficient and to satisfy reliability in manufacture is to be preferred; however, wet treatment is associated with more molecular damage of heat unstable proteins than occurs with the dry-heat route.
Wet-heat pasteurisation of blood products at BPL is now available with albumin fractions, anti-thrombin III, factor XIII, and is likely to be successful during this calendar year with factor IX. The loss of yield of factor IX incurred may be tolerated within the considerable excess of source material available to the fractionation facility.
Wet-heat of factor VIII intermediate concentrate is likely to require a longer programme of work if a satisfactory reliable method is to be developed which does not carry unacceptable penalties related to loss of yield of factor VIII activity. Progress with this procedure will be reported to the Authority.
Dry-heat: the majority of commercial manufacturers are currently depending upon dry-heat of the finished factor VIII concentrate to reduce the infectivity of the product relative to transmission of hepatitis. The associated claims (which are entirely unfounded in scientific and quality control terms) are that the heat process will inactivate the putative virus transmission causing AIDS.
Appreciating pressure under which users are currently operating in the management of haemophilia, BPL has undertaken preliminary studies to assess yield of factor VIII intermediate concentrate after dry-heat. It has been shown possible to maintain greater than 95% of factor VIII activity in the finished product after heating at 75˚C for ten hours or heating at 60˚C for 24 hours. Both these presentations of heat exceed the requirements established for virus inactivation by wet-heat with albumin products (60˚ C for ten hours).
Since this form of product treatment will allow BPL to present to clinical managers of haemophilia a product carrying equivalent weight of claims for safety as those of rival commercial organisations, this product is being advanced with high priority to enable manufacture to become routine by the late summer 1983.
To introduce the product, the full co-operation of the haemophilia directors will be required since a non-human primate testing facility is not available to BPL accepting that this system of testing may not be appropriate with regard to hepatitis or AIDS transmitting viruses.
Introduction of an extra stage in the process of purification of factor VIII may impose costly intermediate reorganisation of manufacturing and equipment for which there is no budgeted sum. It is assumed that this contingency will be met recognising the political sensitivity of AIDS transmission in the UK caused by treatment with blood products.
11.152 It appears that by this stage in the summer, the emphasis had moved towards improving the competitive position of BPL, with concomitant emphasis on the need for investment in the public sector facilities. For present purposes, the document provides a clear assessment of the position adopted by researchers in England. Dry heat treatment had been selected as the preferred route for research and development, with an ambitious target date for production.
11.153 The circulation of this document is not known, and in particular it is not known whether it was available to Scots scientists at or about the time of its production.
11.154 There are issues about the functioning of the public blood products bodies that remain unresolved. However, it appears to be clear that in the course of 1983, at the latest, the approaches to product research and development had been set for the time being, and that they were very different one from another. Scotland at this date pursued pasteurisation as the preferred form of treatment: England pursued dry heat treatment as the preferred method of reducing viral infectivity.
11.155 It appears that in regard to NANB Hepatitis studies on chimpanzees, the dry heat treatment of Factor VIII and IX had not been encouraging. It was noted that further work was necessary, and that products should be subjected to evaluation before being accepted.
11.156 Early in 1984, there was a development in information exchange between England and Scotland. On 5 January 1984, Dr Smith of BPL (‘Jim’) sent a memorandum to Dr Foster enclosing a copy of dry-heating results to date, and offering any other information that might be of practical value to Dr Foster. The data were circulated within PFC. BPL’s strategy had been to heat conventional 8CRV concentrate for the maximum time and at the maximum temperature compatible with achieving less than 10% apparent loss of Factor VIII concentrate activity and without other undesirable characteristics developing. The experimental method was explained. The technique described was said to be too difficult to use as a control for routine pasteurisation. The paper disclosed that promising results had been achieved and reported by Dr Smith to his colleagues in July 1983. It went on to narrate subsequent experiments, including the use of PFL material as a control. It appears from the narrative that the two English research facilities were working together on the experiments. The results achieved showed a high level of Factor VIII concentrate recovery at 24 hours’ and 72 hours’ heat treatment at 60˚C, and good pyrogen test levels. There were no adverse results sufficient to threaten the product.
11.157 By this date at the latest, therefore, Scottish researchers had information about English experience. In relation to success, the information was different from that given to the Central Blood Laboratories Authority working group on AIDS on 14 October 1983.
11.158 On 11 January 1984, Dr Ludlam wrote to Dr Cash, reporting the outcome of his clinical trial of heat- treated Factor VIII Batch NY761.
I write to let you know the outcome of infusing the heat treated factor VIII. The above batch of material was given to a single severe haemophiliac on three separate occasions ….
Infusions were accompanied by reactions on all three occasions. On the first the recipient had a short episode of diarrhoea beginning an hour after the infusion. On the second and third occasion he felt ill towards the end of each infusion. He developed transient central chest pain, pallor and retching. There was no change in his pulse, BP or temperature. To ascertain whether this was likely to be an organic reaction to the concentrate we gave him a ‘placebo’ infusion of ordinary SNBTS factor VIII. He was told that it was the heated material and the infusion protocol was identical. He had no adverse reaction to this standard product. I therefore have to conclude that this batch of material genuinely gave rise to significant and unacceptably adverse reactions in the recipient.
11.159 So, the initial trial of the PFC pasteurised Factor VIII appeared to have failed in Edinburgh. Dr Cash replied on 16 January 1984 sharing the conclusions, and expressing the hope that a further batch, with improvements in heat treatment and lower sorbitol content, would be available in April. However, on 25 January 1984, Dr Gillon wrote to Dr Boulton expressing the view that sorbitol was unlikely to be the cause of the transfusion reaction.
11.160 The Factor VIII Study Group met on 12 January 1984. Dr Smith’s work on dry heat treatment at 60˚C for three days was reported by Dr Cuthbertson. This would be investigated, but it was noted that the Hyland product made by this method was still infective. In other respects, the research and development work reported by
Dr Cuthbertson related to PFC’s pasteurisation project. Various slides of the results of the work were shown demonstrating the reduction in virus titre achieved with a variety of stabilisers, and with various temperatures, for various vaccinia. There was no reference to the failure of the clinical trial in Edinburgh. The development of assays was reported, and there was a report on yield. Dr Foster and Dr Dickson provided a progress report on their studies to improve yield and quality on Factor VIII concentrate. This noted that the laboratory study of zinc fractionation was virtually complete, and that heat-treatment experiments were continuing.
11.161 By late January it appeared that PFC’s problems with pyrogenicity in Factor VIII had resolved (though without explanation).
11.162 A joint meeting of directors of SNBTS and haemophilia directors was held on 2 February 1984. Dr Cash prepared notes for the meeting. The published paper on NANB Hepatitis transmission in Oxford patients was before the committee. It was thought that contamination in Scotland was likely to be of the same order. It was reported that PFC work designed to introduce a heat treated Factor VIII concentrate had progressed satisfactorily so that small batches heated at 60˚C for 10 hours had been infused in volunteer patients in Edinburgh and Glasgow. Work was in hand to explore the feasibility of more rigorous heat treatment.
11.163 Dr Cash was asked for his views about the phasing in of heat treated Factor VIII for routine clinical use. Dr Foster said that two batches had been released for study.
Dr Ludlam expressed some concern about higher sorbitol levels in the product and referred to the adverse reaction noted in one of his patients. Mr McDonald reported that in Dr Forbes’ trial, using a second batch with reduced sorbitol, three patients had been monitored and following treatment had been haemostatically secure. Dr Ludlam agreed to take part in further trials with a different batch of material. The working group would monitor progress. Dr Ludlam also agreed to trial the product in the management of patients with von Willebrand’s disease. Dr Cash informed the meeting that it was hoped to introduce Supernine for routine use, subject to licensing requirements. Meantime, work on heat-treating Factor IX was continuing at PFC.
11.164 Dr Ludlam wrote to Dr Foster on 6 February 1984 referring to PFC’s ‘new, more purified preparation of Factor VIII’ and asking for details of the final specification PFC hoped for. The letter reflected some underlying hesitation to experiment with the haemophiliac patient who had previously had an adverse reaction. It is apparent that by now the first stage in the research and development exercise in 1983 was well advanced.
11.165 On 9 February 1984 the National Institute for Biological Standards and Control, who gave scientific advice to the licensing authority, and the CSM met to examine the infectious hazards of blood and blood products with particular reference to hepatitis and AIDS.
11.166 On 9 February 1984, the cost of producing heat treated Factor VIII at PFC was reported by Dr Perry to Dr Cash. This related to the more severely heated product under development at that time. The report analysed the process in detail from the stage of pasteurisation of the Factor VIII solution, (with sorbitol as stabiliser), dilution, filtration, precipitation, centrifugation, drawing-off supernatant, washing the precipitate, further centrifugation, and product formulation. It was envisaged that all Factor VIII would be produced by this method in April 1985 and be available for clinical use at that time. The report reflected a high degree of confidence in the pasteurisation process by this stage. Small to medium-scale production would take place between April and December 1984. Full-scale production would follow in January 1985 following commissioning of equipment and facilities, and in April 1985 the product would be available for clinical use.
11.167 Dr Foster wrote to Dr Ludlam on 10 February 1984, with preliminary information on the intention to produce a high-purity product, in an attempt to persuade him to trial a second batch of heat-treated Factor VIII. Dr Ludlam replied that he would need to think further. Dr Forbes’ patients in Glasgow had no adverse reactions. Dr Ludlam thought that the sorbitol used in the process might have been the cause of the adverse reaction. This led to much correspondence in March, without incriminating sorbitol.
11.168 The programme set out by Dr Perry in February became more firm. On 17 February 1984, Dr Cash wrote to Professor Bloom. SNBTS hoped to have sufficient wet heat-treated Factor VIII for limited clinical studies by September 1984. He said that they were keen to put the product into ‘virgin’ haemophilia patients and would welcome help.
11.169 On 22 February 1984, Dr Foster wrote to Dr J Garrott Allen at Stanford, outlining SNBTS work on heat treatment.
11.170 In February 1984, Dr Cash prepared a report on the work of the Factor VIII Study Group, with analyses of the work of its various working sections. The group was thereafter to meet once a year. Its main work had been to establish scientific and operational groups which actively collaborated with the SNBTS, and that had been achieved. Its continuing role would be to provide advice on plasma specifications.
11.171 Research in March included work on calcium/heparin additions to plasma to stabilise Factor VIII. There was discussion of the ‘anticoagulant cocktail’ used in the processing of Factor VIII. Work in Dr Prowse’s department had suggested that heparin could be dispensed with. Dr Ludlam did not accept the suggestion.
11.172 Dr Forbes’ trial of the PFC product was successful: none of the patients had any reactions.
11.173 Dr Smith moved to the PFL before 22 March 1984. Cooperation with him continued.
11.174 On 28 March 1984, Dr Cash wrote to Dr Forbes saying that he was beginning to plan ahead for clinical use of the SNBTS product. On 5 April, Dr Perry wrote to
Dr Pepper proposing a structured clinical trial and evaluation covering all aspects of safety, efficacy, half-life etc. On 27 April he made the same proposal to Dr Cash. A batch of heat-treated Factor VIII was available for clinical trials in April 1984. Dr Perry put matters in motion on 3 May 1984 in a letter to Dr Pepper. Also on 28 March, Dr Cash wrote to Dr Rizza encouraging cooperation on trials. Dr Rizza agreed to talk.
11.175 On 29 March 1984 the UK Haemophilia Centre Directors and the Haemophilia Centre Directors Hepatitis Working Party wrote to all UK Haemophilia Centre directors giving an update on trials of ‘hepatitis reduced’ Factor VIII. There were at present eight different products in preparation or available for trial. Clinical trials had only been completed on one product, Hemofil HT, which was dry heat-treated. Results indicated that there was still a 63% attack rate of NANB Hepatitis on first exposure in patients who had not received Factor VIII concentrate previously. The letter called for cooperation between the Haemophilia Centre directors in co-ordinating trials of the new heated products. Directors were asked to ensure that a clinical trial certificate was obtained by the manufacturing companies because if studies were conducted on a named-patient basis, the doctor would be liable for compensation arising out of any ‘unexpected hazards’.
11.176 On 25 April 1984 Dr Cash wrote to Dr Crawford at Carluke that he was most anxious to look at the incidence of hepatitis and transaminitis in ‘virgin’ haemophiliacs who received SNBTS heat treated Factor VIII concentrate. He enclosed a copy of the protocol Dr Rizza was using in England, with modifications for Scottish use and a copy of the paper by Fletcher and others. He invited Dr Crawford to co-ordinate a Scottish study that he intended to promote at the meeting of all Scottish Haemophilia Directors in June or July of that year. The paper discloses Dr Cash’s approach at this time to the way ahead:
The recent development of ‘hepatitis reduced’ factor VIII, where attempts have been made to reduce the infectivity of concentrates due to hepatitis viruses by pasteurisation, [β] propriolactone, UV light and chemical treatment, has made it important to obtain objective evidence as to the safety of these products with regard to (1) the risk of transfusion [sic] of hepatitis, (2) the survival of factor VIII in vivo and (3) tests to exclude the presence of immune complexes and other factors which might cause allergic reactions. This is to exclude the possibility that the methods used to inactivate hepatitis viruses in factor VIII concentrate might alter or denature other plasma proteins present.
Trials for (2) and (3) can be carried out by evaluating the use of ‘hepatitis free’ concentrate in severe haemophiliacs on regular factor VIII therapy. The assessment of residual infectivity of concentrate for non-A, non-B hepatitis and hepatitis B can only be carried out on patients known to be susceptible to non-A, non-B hepatitis. A prospective study, south of the border, of 30 patients each given one or two batches of factor VIII to cover an operative procedure or other treatment requiring concentrate showed that all 9 patients who had not received blood concentrates before, contracted non-B hepatitis after receiving their first transfusion of either US commercial factor VIII or NHS factor VIII.
It is proposed to assess the residual infectivity of SNBTS ‘hepatitis reduced’ factor VIII by means of a clinical trial in patients who have not previously been treated with large pool factor VIII concentrates.
11.177 The procedures proposed identified the prospective group as patients ‘attending any of the participating Haemophilia Centres’ during the study period. It was stated that the object of the study would be explained to them, and their consent or, if under 16 years of age, the consent of their parents obtained. Full medical examination, and details of the patients’ histories were required, subject to the exigencies of the situation: emergency admissions would require modification of the procedures. The tests and follow-up procedures were prescribed.
11.178 Dr Cash did not say whether SNBTS had received approval for this study from a research ethics committee.
11.179 On 30 April 1984, Dr Pepper wrote to Dr Perry commenting on the lack of private sector funding for research. The Haemophilia Society had been approached, but were prepared to assist only if there were an AIDS angle, and then only to a limited extent. There were no industry sponsors.
11.180 On 3 May 1984 Genentech announced that it had cloned the gene for producing Factor VIII: genetically engineered Factor VIII would be the result. Genentech entered into an exclusive contract with Speywood Laboratories Ltd, Wrexham, for the European distribution of the product.
11.181 A Minute from A E Bell in SAH to ‘Mr Murray’, dated 23 May 1984, discussed CSA’s case for funding to produce heat-treated Factor VIII . Dr Bell said that he had no wish to comment on the technical case, but thought the SNBTS paper failed to make the policy case, which he outlined.
I have no comment on the paper itself which is essentially technical. What it fails to bring out is the policy case for proceeding with this development. The objective of this more complicated means of producing factor VIII from plasma is to reduce the risks of transmission of viral disease, particularly hepatitis. At present nearly all ‘virgin’ (newly-treated) haemophiliacs become infected with NANBH, although not usually of dramatic severity. About 40% show evidence of infection by hepatitis B. The longer term effects of such infection in haemophiliacs is not known with certainty because until relatively recent years haemophiliacs had little prospect of living into middle or old age. However a significant proportion of ‘normal’ patients infected with hepatitis B go on to suffer severe liver impairment which, apart from the personal aspect, makes significant demands on health care resources … This is not a matter of product differentiation for marketing purposes but represents a genuine and important advance in therapy. The heat treated factor VIII may also prevent the transmission of AIDS, though it is too early to make such a claim with any confidence. It is not for me to say how this development... should be financed but I can say that it is a genuine technological advance and a failure to bring it about would be very difficult to defend publicly.
Dr Cash prepared a report in June 1984 on the work of the Factor VIII study group and its working parties from the inception of the project, on Dr Cash’s initiative, on
17 December 1981. The main Group had met on a total of six occasions, and there were 19 meetings of working sections between January 1982 and June 1984. The summary of the work on reducing viral contamination over the period stated:
There were three broad options: physical and chemical treatment of the final product and in-process affinity techniques. All were examined in detail and as a consequence the following decisions were made:
(a) Wet heat treatment was considered to be the most appropriate immediate target area. This decision has been implemented….It should be emphasised that Dr Bruce Cuthbertson’s team have been able to respond to a request by the Study Group that appropriate in vitro virus models should be established to monitor this work. This decision may prove to be a critical factor in subsequent studies.
(b) Radiation has been investigated in Dr Pepper’s laboratory….This work will be further pursued when more highly purified products are available.
(c) Chemical and affinity treatments (currently favoured by several commercial companies) have been rated a low priority option, pending examination of the results of (a) and (b) above in view of potential long-term toxicity. However,
Dr Pepper has been invited to retain an active interest….
11.183 At this date, therefore, SNBTS research into virus inactivation remained firmly focused on pasteurisation, but other options were not closed. To protect SNBTS intellectual property rights, on 9 July, 1984, Dr Foster sent a paper on stabilisation of proteins to heat to Research Disclosure, New York, for publication.
11.184 On 26 June, Dr Cash wrote to Dr Perry with arrangements for the issue of heat-treated Factor VIII for clinical evaluation, to be used on a named-patient basis.
11.185 Between 22 and 27 July 1984 at the 18th Congress of the International Society of Blood Transfusion in Munich there was further publication of PFC’s methods: an abstract by Alexander MacLeod and others dealt with the Scottish position:
PASTEURISATION OF FACTOR VIII AND FACTOR IX CONCENTRATES
We have used sorbitol and glycine as stabilisers and have found good recoveries of both FVIII and FIX activity after heating in solution at 60˚C for 10 hours.
In a subsequent study of viral inactivation using a range of model viruses we found that sugar stabilisation reduced the degree of viral heat inactivation compared to a standard albumin solution stabilised with caprylate. For example, heating at 60˚ inactivated a challenge of 8.5 logs or vaccinia/ml in 30 minutes using caprylate stabilised albumin, but only 4 logs after 10 hours using sorbitol (or sucrose) stabilisation.
More severe heating conditions have therefore been developed to increase the degree of viral inactivation without major loss of coagulation factor activity. In the presence of 65% sorbitol and 1.7% glycine a FVIII solution, prepared by zinc fractionation, was heated at 60˚ for 9.5 hours followed by 0.5 hours at 70˚ giving a 77% recovery of clotting activity over the heating step with inactivation of at least 7 logs of vaccinia virus/ml. In this process, careful control of pH, ionised calcium concentration and temperature are all important to avoid major loss of FVIII activity. Further viral inactivation may be achieved by adding ethanol to the stabilised FVIII solution.
A FIX concentrate has been pasteurised in a similar manner giving about 60% recovery of clotting activity over the heating step with no increase in thrombogenicity as measured by standard in vitro tests (NAPTT, TgtSQO).
11.186 On 6 August 1984, Dr Foster sent details of the procedure to Dr Horowitz of the New York Blood Centre for evaluation. Dr Horowitz thought the method sufficiently different from Behring’s to carry out the work, but warned that he would publish the results, including the method of stabilisation. Dr Foster invited him to publish whatever he considered appropriate, and referred to prior publications as already mentioned. In September, preliminary arrangements were made to cooperate with Institut Pasteur. There was also correspondence with Professor J Garrott Allen at Stanford University.
Dr Foster would later report that work on the collaborative project with Professor Johnson, begun in August 1984, had so impressed PFC that the zinc heat treatment process was shelved so that maximum effort could be given to the newer method.
11.187 Dr Cash’s paper of June 1984 discussed preliminary clinical evaluation studies of SNBTS heat-treated Factor VIII, reporting success in studies to date and proposing a series of new studies using product pasteurised at 60˚C for 10 hours, plus an additional period at 70˚C. On 31 October 1984, Dr Cuthbertson wrote to Dr Tedder at the Middlesex Hospital proposing that Factor VIII be sent for assaying to test the inactivation of HLTV III.
11.188 On 20 August 1984 Dr DBL McClelland produced a paper, ‘Clinical trials– compensation for medicine induced injury’. The paper recommended that the SNBTS consider providing compensation to patients injured by a trial product without the need to prove negligence.
11.189 On 31 August 1984 Behringwerke filed a patent application concerning the use of calcium stabilisation of Factor VIII during pasteurisation and the use of a purification method for the recovery of Factor VIII following pasteurisation that was similar to that developed by Professor Johnson’s group.
11.190 There was a ‘haemophilia meeting’ in Cardiff in or around October 1984. Notes of talks were received at PFC on 6 November 1984. Dr Lane spoke of the methods of heat inactivation that might be tried. He intimated that BPL had a dry product which was available for trial in the Midlands and North England. He observed that Factor VIII ‘may
need to be much purer before it can be safely heat-treated’. There is no note of the comparator he had in mind. At the same meeting Dr Mannucci spoke about European trials of Hemofil T. The trials were described. Seventeen patients with a first exposure were followed up. After six months, 12 had post transfusion hepatitis. In 11 cases it was due to NANB Hepatitis. One only was jaundiced. There was an attack rate of 70%. So far as AIDS antibody was concerned, Dr Mannucci reported that there was apparently no seroconversion of any patient after one year. Dr Mannucci gave a summary of the wider picture:
Of the other concentrates, Cutter like Hyland are producing a dry factor VIII whereas Behring and Alpha Laboratories produce a wet concentrate. Armour’s ‘superheated concentrate’ is a dry preparation. Immuno are trying a low pressure steam and the NYBC a lipid solvent but this is not released. For factor IX concentrates Biotest are proceeding with their UVBPL, Kabi are proceeding with hydrophobic interaction chromatography and Behring are proceeding with a wet heat preparation.
The Alpha concentrate is apparently being tested. For the Behring concentrate of FVIII prospective results appear to show a 20% NANB attack rate but the follow-up is apparently very erratic. The Armour product may be tested but the NYBC is only experimental.
Preliminary results on the double-inactivation process (heat then chloroform) still indicates some short incubation NANB.
All factor IX concentrates have been followed up acceptably and there has been no post transfusion hepatitis.
11.191 On 1 and 2 November 1984, there was a Plasma Fractionation Conference held at Groningen, the Netherlands. Peter Foster attended. In a covering letter to his notes sent to Dr Cash on 6 November 1984, he described the information gathered as ‘encouraging’. He reported data provided by CDC on the incidence of AIDS in haemophilia patients to date. There were two notes. The first under the general heading of HLTVIII, was in these terms:
Heat inactivation studies (probably by Cutter)
Starting level of virus 10 to 5 particles/ml (LAV)
68˚ wet heating (German method) Complete inactivation in 4 minutes
68˚ dry heating <10¹ particle/ml after 1 hour, complete inactivation at 24– 78 hr.
11.192 In relation to removal of NANB Hepatitis virus infectivity, he noted:
Clinical trial of heat treated FVIII in virgin haemophiliacs (Mannucci) has shown NANB, but no sign of HTLVIII after 1 year (suggests that Hyland method, 60˚, 72 hrs, dry heat, will inactivate HTLVIII….
11.193 The information recorded on the effectiveness of dry heating at 68˚C for an hour in inactivating HIV was to have a significant impact on PFC’s approach to the treatment of products already manufactured, including products in issue.
11.194 By the end of the year, there was a considerable volume of publicity material and research results in circulation relating to the products being developed by pharmaceutical companies.
11.195 Travenol, a pharmaceutical company, published material on Hemofil T. It acknowledged that its original product, Hemofil AHF (human) could not be guaranteed free from ‘viral bioburden’, and that one of the most significant risks was hepatitis infection. Heat treatment resulted in the production of Hemofil T AHF (Human). It was not claimed that the product eliminated all danger of hepatitis, but studies on chimpanzees suggested that the risk was reduced. In an article in the Journal of Infectious Diseases Vol 150, No 2 (August 1984) ‘Reduction in Risk of Hepatitis Transmission by Heat Treatment of a Human Factor VIII Concentrate’ (Hollinger and others–academic research from Houston but with the involvement of Travenol) the chimpanzee experiments were described. The product was infected with NANB Hepatitis then heated at 60°C for more than 10 hours; none of the four chimpanzees injected with the heated concentrate developed biochemical or ultra-structural evidence of NANB Hepatitis.
11.196 Another company, Alpha, published material on Profilate. Its claim was more robust:
Today the logical step has been taken in providing a safe antihemophilic Factor VIII. Alpha Therapeutic Corporation has added to its manufacturing process a unique treatment step which has effectively inactivated both hepatitis B and at least one type of non A, non B hepatitis in chimpanzee studies, as well as three viral markers in vitro, while demonstrating bioequivalence to the non-treated product.
11.197 The new product, Profilate Heat-Treated AHF (Human), on test, produced ‘viral inactivation study data’ that compared favourably with other manufacturers’ products tested. Hyland and Armour products were the controls to which this comment referred. The results were said to be encouraging in that they showed that the product offered a reduced hepatitis risk for haemophilia patients. The Alpha product was licensed in the USA in 1984.
11.198 Armour published data tracing the history of development from H.T. Factorate to HT Factorate Generation II, an AHF (Human) USP (Dried) preparation. Their claim was that the product reduced the risk of transmission of hepatitis virus, and in particular, significantly reduced the risk of NANB Hepatitis transmission.
11.199 Other information relating to products included Behring’s work. On 31 August 1984 Behringwerke filed a patent application concerning the use of calcium stabilisation of Factor VIII during pasteurisation and the use of a purification method for the recovery of Factor VIII following pasteurisation. The risk of this application being made was the incentive that led PFC to publicise the results of collaboration with Professor Johnson’s team in Research Disclosure (see paras 11.183 above).
11.200 Meantime, another Bayer product was licensed: Koate HT Factor VIII (heated at 68ºC), was licensed by the Federal Drugs Agency in February 1984. At the time, it was the only company which subjected its Factor VIII concentrate to dry heating at 68ºC.
11.201 Immuno were licensed to supply heat treated Kryobulin (heated at 60˚C for 10 hours) and had material available for supply in March 1985. Immuno were developing their Factor IX product FEIBA. According to second hand information, they were having difficulty in satisfying the licensing authorities in the United Kingdom.
11.202 Most of the underlying technical information relating to these products was commercially sensitive and was not published. At a more public level, experiments on the effect of heat treatment on HIV that had been added to Factor VIII concentrate were begun at the US CDC in spring 1984 and were completed in the late summer of 1984, in collaboration with Bayer (Miles/Cutter). A summary of the findings was published by CDC in MMWR on 26 October 1984. Results from the studies were published in a peer-reviewed journal in August 1985.
11.203 The Lindsay Report found that the results of the research, showing the HIV virus to be sensitive to heat inactivation, were considered highly significant by the CDC and were widely publicised, both formally and informally. There was not yet any clinical proof of the effectiveness of heat treatment against the HIV virus but there was an immediate recommendation by MASAC that ‘Treaters using coagulation factor concentrate should strongly consider changing to heat treating products with the understanding that protection against AIDS is yet to be proved’. This increased the pressure on the manufacturers, including the British public sector fractionators, to develop methods of viral inactivation. The Lindsay Tribunal found that there was no general move to the use of heat-treated commercial concentrates until after October 1984.
11.204 However, it appears that both in the commercial sector and in the public facilities, research and development in relation to heat treatment had been well established fields of activity at earlier dates, and commercial products in particular were available before October 1984.
11.205 On 22 November 1984, PFC sent to Dr Boulton four vials of heat-treated Factor VIII, (68˚C for two hours) planned for limited release the following week, for solubility tests. The first infusions were successful in Edinburgh (though full results were not available). In anticipation that the complete data would be acceptable (which they were), arrangements were put in hand to distribute material from specified batches:
Batch 024070461: Belfast
Batch 024070471: Glasgow
Batch 024080491: Edinburgh and Inverness
Batch 024090561 Aberdeen and Dundee.
11.206 This was estimated to be one month’s supply. The covering letter to haemophilia directors asked that they note clinical efficiency and that they test for HLTV-3 antibody and neo-antigens. Glasgow acknowledged receipt of their first batch on 11 December 1984.
11.207 In a look-back study discussed by Cuthbert and others, ‘Efficacy of heat treatment of factor VIII concentrate’ it was reported that it had been discovered that two of the first batches of PFC NY heated in Nov 1984 (ie at 68ºC for two hours) and two of the first batches of modified NY heated in January and February 1985 (ie at 68ºC for 24 hours), had each been prepared using a donation infected with HIV. Contaminated batches had not subsequently been found to have transmitted HIV, confirming the effectiveness of the heat treatment processes used.
11.208 Meantime, on 29 November 1984, a meeting of Haemophilia Directors and representatives of SNBTS was convened to discuss the implications of recent findings of HTLV III antibodies in Scottish haemophilia patients, measures being taken by the SNBTS to prevent transmission of AIDS by blood products, and media related matters. Dr Perry explained that PFC had for some time been developing methods of heat treating Factor VIII, aimed particularly at preventing transmission of NANB Hepatitis, but that it would be some months before these developments would result in routine wet heat treatment of all PFC product. PFC had commenced, as a short term measure, heat treating lyophilised Factor VIII at 68˚C for two hours. This was not expected to cause significant deterioration in the product and clinical trials were already in progress. Assuming these trials revealed no unexpected problems, all PFC Factor VIII being issued from about the beginning of January 1985 would be heat treated in this way. The possibility of batch dedication of Factor VIII was being considered but difficulty was foreseen. Dr Perry confirmed that the licensing authorities were aware of, and did not take exception to, this procedure.
11.209 The Inquiry team has not discovered any other records of discussions of virus inactivation in any of the minutes and board papers of the SNBTS directors for the year 1984.
11.210 The NBTS wrote on 14 December 1984 that Haemophilia Directors would be willing to assist with clinical trials of Scottish products.
11.211 The Haemophilia Centre Directors Organisation’s ‘AIDS Advisory Document’ dated 14 December 1984, noted current understanding. In concentrates HTLV III was thought to be inactivated by dry heat treatment at 68ºC for 24 hours. It was unlikely that this process completely inactivated NANB Hepatitis.
11.212 At that stage the regime intended in Scotland, in the short term, was dry-heating for two hours at 68ºC. Full-scale production on this basis was commenced in January 1985. The next development, dry heat treatment at 68ºC for 24 hours, had yet to be implemented: intermediate Factor VIII dry-heated at 68˚C for 24 hours became available for clinical evaluation in March 1985.
11.213 In December 1984 Dr Perry sent a letter to all Transfusion Directors. The first infusions of dry-heated Factor VIII had been successful in Edinburgh. The first batches of Factor VIII were to be dispatched to certain regional treatment centres. Continuous supply of heated product should be available after 10 December.
1985-1987: PFC High Temperature Heat Treatment
11.214 At the beginning of 1985, SNBTS had in issue or in stock substantial quantities of Factor VIII manufactured before mid-December 1984 that had not been heat-treated. It was decided to recall these products from the regions and dry heat treat all stocks at 68˚C for two hours. The heat treating of these existing products caused some incidental technical problems unrelated to virus inactivation. On a more general level, Dr Pepper wrote to Dr Cash on 7 January 1985 with detailed proposals for detection of damage to Factor VIII induced by heat treatment. He discussed physico-chemical techniques; immunological techniques and biological techniques. None of them was clearly suitable, but he recommended the first category. The paper was discussed at the meeting of the Factor VIII Study Group on 7 February 1985.
11.215 On 7 January 1985, Dr Cash wrote to Dr Perry to put on record points which had arisen at a meeting with BPL. There had been apparently satisfactory exchanges about Factor IX dog studies. In relation to Factor VIII it was noted that:
(b) BPL planned to trial (in the next 3–4 months) their heat treated product. Their initial product had been dry heated at 60˚ for 3 days but they now planned to use 70˚ (dry) for 1 day. Dr Cash had the impression that some batches could not stand these temperatures.
(c) BPL did not plan to consider wet heat unless dry was shown to be inadequate.
(d) They appeared to be well advanced in the production of a very high purity product. They were not involved with the Alan Johnson techniques. Their method would be patented in due course and SNBTS would have free (Crown) access at that time.
11.216 He also reported on BTS proposals for studies on chimpanzees, and on his apprehension that because SNBTS were not represented on DHSS committees, the service was at risk of being disadvantaged. Dr Perry responded to this letter on 15 January. He too had heard of BPL’s preference for 68–70˚C for 24 hours, and that the current difficulties related to solubility which, he noted, could suffer from being rather a subjective matter. He also knew of the high-purity product, an extension of the zinc process. But he thought that Johnson’s ideas had been used in developing BPL’s work. He shared Dr Cash’s apprehensions about BPL’s access to chimpanzee studies.
11.217 At least general knowledge of BPL’s current research and development work appears to have circulated within SNBTS by this stage. Further, it was known that English researchers intended to restrict their interest to a specific regime, dry heat-treatment, expressly relegating wet heat-treatment for consideration if and when the dry-heating approach proved inadequate.
11.218 On 8 January 1985, Dr Perry wrote to Dr Thomas, NIBSC, giving formal notification of the prevailing policy at PFC Liberton, and therefore throughout Scotland, for the manufacture of heat-treated Factor VIII. The information was as follows:
(a) All FVIII issued from PFC had been heat-treated since mid-December 1984;
(b) PFC would recall all existing regional stocks of non-heat treated FVIII for heating and reissue;
(c) The heating conditions applicable were 68˚C for two hours in the dry state. Those conditions were the best that could be achieved with the existing product without compromising solubility, and in the knowledge that a joint CDC/Cutter study suggested that they might provide 4–5 logs inactivation of HTLV III virus.
(d) Analytical specification and in vivo characteristics were identical to the unheated precursor;
(e) There was no significant deterioration;
(f) Plans were well advanced for the manufacture of a new product which would be subjected to more extreme conditions of temperature and time.
11.219 On 8 January, Dr Cuthbertson sent Dr Tedder vials of Factor VIII lot 023110090, ‘the one implicated in transmission of HTLV III’, for testing. On 9 January, he sent five vials to Professor Murray at the Department of Genetics, Edinburgh University, for assessment, including one batch said to be strongly associated with seroconversion to HTLV III. On 9 January, Dr Perry reported to Dr Cash that progress had been made with the Institut Pasteur, and that agreement had been reached on a collaborative study of the heating protocols of PFC Liberton Factor VIII with respect to LAV inactivation.
11.220 Meantime, SNBTS were in correspondence with Immuno about their source plasma and testing of final product. Donors were not tested for HTLV III markers, nor were final products.
11.221 Following intelligence about the sucrose content of Sandoglobulin IV, PFC Liberton decided on or about 18 January 1985 that all new batches of FVIII would be manufactured using a modified formulation which incorporated sucrose at two per cent. The modified product was expected to be available for clinical trials within six weeks.
11.222 A review of manufacturers’ data in January 1985 revealed that each used filtration after reconstruction of Factor VIII. A question was raised whether PFC Liberton should introduce such a step in view of the solubility problems experienced with the SNBTS product.
11.223 On 24 January 1985, Dr Cuthbertson visited the Pasteur Institute in Paris. He had extensive discussions on possible collaboration on heat inactivation with Dr Montagnier’s team, extending to pricing of tests to be performed in Paris on Scottish material. In discussions with Dr Barré, the outline of an experimental protocol was developed.
Dr Perry confirmed that PFC Liberton wished to proceed with the collaboration on 8 February 1985. The Pasteur Institute sent a detailed protocol for the study on 14 March 1985. PFC Liberton proposed modifications.
11.224 The Factor VIII study group met on 7 February 1985. Dr Pepper’s report to Dr Cash of
7 January 1985 detailing proposals for detection of damage to Factor VIII induced by heat treatment was on the agenda, along with an update on virucidal action during the past year. The update paper contained a summary of developments. Wet heat research and development had been in abeyance, firstly because the scale-up of the zinc high-purity project had been shelved due to other developments in Factor VIII manufacture, and secondly because of pressure on PFC Liberton to complete dry-heat treatment of all existing batches of Factor VIII. The paper contained an account of recently published work, and comments on the several techniques that might be developed for viral inactivation.
11.225 In a progress report for the group dated February 1985, Dr Foster reported a fall in Factor VIII content in a range of plasma lots. He reported on the joint PFC Liberton/Law Hospital plasmapheresis study, and concluded that consistent quality could not be assured by current methods of manual collection, but might be achieved by machine plasmapheresis or the use of anticoagulants at the point of collection. He reported that results from zinc precipitation were disappointing compared to the earlier laboratory data, and offered an explanation, including comments on problems associated with sorbitol. The heating conditions reported as applicable to the experiments were 60˚C for 10 hours followed by 20 minutes at 70˚C, and 16.5 hours at 60˚C followed by 20 minutes at 70˚C. The use of calcium was introduced. However, work on ZHT had been suspended in October 1984 to give priority to a new process which promised a higher purity product in high yield.
11.226 He reported on the high-purity product in these terms:
The details of this are strictly confidential and are covered by confidentiality agreements signed by PFC in October 1983 and August 1984. However the overall process is likely to include some steps developed from the ZHT process. The form of the process is:
(ii) Precipitation of cryo extract to reduce fibrinogen load. This will be by zinc precipitation and/or a modified PEG precipitation (McIntosh unpublished results).
(iii) New procedure (confidential).
(iv) Pasteurisation. Heating in solution with sorbitol as a stabiliser is the preferred option at the moment but severe heating of the freeze dried powder may be possible (Smith unpublished results) and may be of interest.
At the time of the last meeting of the Study Group our preferred option for viral inactivation was heating in solution, as opposed to heating the freeze dried powder, for the following reasons:
(v) It is likely to achieve a greater degree of viral kill. This is particularly important if relatively heat resistant viruses are to be destroyed (eg HBV)
(vi) Preliminary animal and clinical data from heated dried products suggested little effect on HBV and incomplete inactivation of NANB.
(vii) In theory the procedure is difficult to control both within a batch (eg due to variation in the glass vials) and from batch-to-batch (eg due to variations in moisture content after drying).
Although heating in solution would seem to be still the preferred option recent information concerning HTLV III has led to the introduction of a dried-heating procedure for the existing product. The decision to pursue this option was based on the following points:
(viii) The AIDS virus (LAV, HTLV III) is relatively heat sensitive. (Desmyte ISBT July 1985) and can be destroyed by the dried-heat method (MMWR 33 589-90, 1985; Jason, Groningen Symp. Nov 1985; Mannucci, unpublished results).
(ix) A number of haemophiliacs treated with SNBTS FVIII were found to have a positive test for anti-HTLVIII.
Much of this information became available at least in a tentative form, at about the same time, resulting in the initiation of a dried-heating study to enable the rapid introduction of a heat treated product….
11.227 Though cryptic in its terms, the report appears to support a number of tentative conclusions. Work on the ZHT pasteurisation regime had been suspended in October 1984. Dry-heat treatment had come into focus with the publication of data indicating its effectiveness in destroying HTLV-III, and the apparent discovery of infectivity of the existing product, leading to dry-heat treatment of the existing product. However, for the ‘new’ product, heating in solution, utilising some of the technology developed in relation to ZHT, was still the preferred option.
11.228 It appears that at this stage PFC Liberton had not resolved to follow the English route but had opted for dry-heat treatment as a temporary expedient to deal with existing products. All non-heated product had now been withdrawn and was being heated.
11.229 In a report dated February 1985 on preliminary clinical evaluation studies of SNBTS heat-treated Factor VIII, Dr Cash commented on the worldwide interest in the development of techniques designed to reduce the infectivity of pooled blood products, and the selection of heat treatment as the most appropriate for the SNBTS. He commented on the use of sugars to protect Factor VIII from the effects of heat. He said:
In vitro virological studies have demonstrated that in the sugar medium selected (sorbitol) the traditional wet pasteurisation process (60˚C for 10 hours) is less than optimal and an additional period at 70˚C has now been included.
Preliminary in vivo and in vitro studies (carried out in Edinburgh and Glasgow), using a 60˚ for 10 hours wet heating procedure demonstrated that the sugar appeared to prevent heat denaturalisation of factor VIII. The proposed new studies will be performed using products exposed to dry heat (68˚ for
24 hours) and wet heat (as described above) and are designed to assess biological acceptability, clinical efficacy and residual infectivity. The need to assess both dry and wet heat arises because the former is less costly and subject to lower yield penalties. However the wet heat is likely to be more virocidally effective.
11.230 The proposals for the study were specific:
Bioacceptability studies (In vivo recovery and ½ life)
It is proposed that detailed studies are performed on a maximum of 12 stable (not bleeding) severe multi-transfused haemophilia patients and 6 Von Willebrand Disease patients….Particular emphasis is required for the VWD studies because we need to know whether, in the event of withdrawal of intermediate VIII, we have concentrates which are of value to VWD patients.
Clinical Efficacy Studies
It is important, for licensing purposes, that we obtain as much information as possible on the clinical efficacy of the products.
[It] is unclear, at the present time, as to the number of patients required to complete this study. Certainly it will be important to include patients undergoing both minor and major surgery in which clinical evidence of haemostasis is more easily ascertained.
Residual Infectivity Studies
These difficult but vital studies require access to patients who, ideally, have not been previously exposed to blood and blood products. The model protocol…is based upon the work at the Oxford Haemophilia Centre and it should be noted that a prolonged period of study is required. It is suggested that a total of 15 patients should be used and that the previous Oxford study using BPL intermediate VIII will be used as controls.
It is proposed that the first priority for the product currently available should be the bioacceptability study and that the other two studies are not commenced until this is completed and the data examined by the SHS BTS/Haemophilia Director WP.
PRODUCT RELEASE/STUDY CO-ORDINATES
Clinical colleagues who wish to contribute to these studies, will obtain their supplies of this material through their local Regional Transfusion Centre. Release of product for clinical evaluation will be made on a named patient basis only.
11.231 Annex IV, which set out the trial protocol, repeated, with minor alterations, comments on residual infectivity studies on SNBTS heat-treated Factor VIII concentrate set out in the paper Dr Cash sent to Dr Crawford at Carluke on 25 April 1984. The object of the studies was to obtain objective evidence as to product safety with regard to (1) residual infectivity, (2) in vivo recovery and survival of Factor VIII, and (3) tests to exclude the presence of immune complexes and other factors which might cause allergic reactions:
Studies which cover (2) and (3) can be carried out by evaluating the use of concentrates in severe haemophiliacs on regular factor VIII therapy. The assessment of residual infectivity of concentrates can only be carried out satisfactorily in prospective studies. In a preliminary study, South of the border, on 30 patients each given one or two batches of factor VIII to cover an operative procedure or other treatment requiring concentrate, showed that all 9 patients who had not received blood concentrates before contracted non-B hepatitis after receiving their first transfusion of either US commercial factor VIII or NHS factor VIII (Fletcher et al 1983), as assessed by liver function tests.
It is proposed to assess the residual infectivity of heat treated SNBTS factor VIII by means of a clinical trial in patients who have only minimally been exposed to large pool factor VIII concentrates, based on the protocol developed in Oxford.
11.232 The comments indicated a firming-up of decisions on the direction of March 1985 research: wet heat processing was up-graded in terms of temperature, and dry-heat treatment was to be investigated. On 8 February 1985, Dr Cash wrote to Dr Rizza and Professor Bloom outlining the studies SNBTS wished the UK haemophilia directors to carry out on the 68˚C two-hour dry heated product; an intermediate dry-heated product at 68˚C for 24 hours; and a high purity wet-heat treated product, still not fully specified. But the situation in England and Wales had changed, and the response was not an unqualified offer of help. All of Professor Bloom’s ‘regulars’ were HTLV-III antibody positive and most of the others were being used to test BPL products. He would re-assess the request when details were known.
11.233 At the meeting of the Factor VIII Study Group on 7 February 1985 continuation of various studies was agreed. Each of the reports prepared for the meeting was presented and discussed, with agreement on the proposals for continued study, but few positive decisions. The current collaboration with Professor Johnson was noted, but shrouded in secrecy because of the confidentiality agreements in place. In relation to clinical trials, it was agreed inter alia that haemophilia directors would be asked to keep serum samples from all patients receiving heat-treated Factor VIII. The principal agenda items identified for future discussion were antigenic changes in heat-treated Factor VIII; the results from clinical trials; and the effects of ionised calcium additives in different types of plasma.
11.234 On 4 March 1985, Dr Perry wrote to Dr Boulton intimating that two batches of heat-treated Factor VIII treated at 68˚C for 24 hours (the dry heat regime) would be available for clinical trials within two weeks. One hundred vials of each of two batches were sent on 13 March. On 7 March, samples of unheated Factor VIII were sent to
Dr Froebel at Glasgow for her to arrange HLTV III screening.
11.235 On 5 March 1985, a patent data sheet on the Winkelman process for purifying plasma by precipitating out fibrinogen and fibronectin with heparin was filed with specification. It set out a procedure for producing a high-purity Factor VIII concentrate that could be pasteurised (ie wet heated at 60˚C for hours) or freeze dried and then dry heated to a temperature of at least 70˚C for at least 24 hours with little or no loss of Factor VIII activity or solubility.
11.236 The SNBTS and Haemophilia Directors met on 7 March 1985. Dr Cash and Dr Perry produced papers for the meeting. It appeared that the period from November 1984 to March 1985 had been difficult. Dr Cash reported: ’It has been a period in which disaster struck in Australia and in which both UK transfusion services were implicated in the transmission of HTLV-III viruses.’
11.237 The Australian incident appears to have related to the deaths of three babies in Brisbane from AIDS, not associated with British product. In Queensland emergency legislation was enacted imposing criminal sanctions for donors giving false information about the suitability of their blood. Dr Tedder responded by calling for a ban on active homosexuals being used as blood donors. Dr Cash said that there had been justified criticism of the way SNBTS had made available unlimited supplies of heat-treated products in late December. He proceeded to discuss the products in issue for development. The standard routine SNBTS issue was dry (intermediate) heat-treated (68˚C for two hours). The heat treatment programme had been based on preliminary information received from the USA (in November 1984) specifically with regard to HTLV-III. It involved dry heat treatment of the existing intermediate product without the addition of stabilisers. It was anticipated that this heat-treated product would remain in issue until the autumn of 1985. Prospective products were dry (Intermediate) HY (68˚C for 24 hours) and high purity (HT) product.
11.238 Apart from contributing to heightened awareness of the risks of HLTV-III transmission, the relevance of the Australian incident is obscure. The look-back study by Cuthbert and others in Vox Sanguinis, 1988, referred to above, would in due course appear to support the effectiveness of the initial heat-treatment regime. If SNBTS’s action was precipitate, it appears that it may have been justified by events. Dr Perry commented that current heat-treated material (68˚C/2 hrs) should be available for the treatment of all haemophiliacs in Scotland and Northern Ireland. An on-going programme was underway to subject all existing stocks (including those recalled from RTCs) to those heating conditions. His projection agreed with Dr Cash: stocks of this material would last until autumn 1985. In relation to prospective products, he reported:
PFC has now developed a new formulation of the existing product which permits more rigorous heating conditions to be achieved without compromising product solubility. All FVIII manufactured since January 1 1985 has been formulated so that the reconstituted product will contain approximately 4% sucrose. In all other respects the product is identical to the standard intermediate purity FIX (sic). It has now been established that this product can be heated in the dry state to 68˚ for 24 hrs without reducing solubility….Two batches of this material are now available for clinical evaluation. Subsequent batches have been formulated with sucrose but will not be heated until a satisfactory clinical evaluation of the heated product has taken place.
In order to avoid substantial accumulations of unheated and untested batches of FVIII at PFC and also to ensure continuity of product supply later in the year, it is strongly recommended that a suitable clinical trial be planned and implemented with a view to obtaining sufficient clinical experience of this new product to permit heat treatment and release of accumulated product stocks. For this purpose, preliminary product evaluation should be completed by mid-May. This will ensure that adequate stocks of product can be distributed in July/August to RTCs.
11.239 Dr Perry reported briefly on Factor IX: work was proceeding and it was hoped that a heated Factor IX product would be available by the end of 1985 for preliminary clinical studies. The minutes record that Dr Cash emphasised the urgent need for evaluation of the new 68˚C/24 hour Factor VIII product. After discussion it was remitted to the working group to consider the matter in detail, and to facilitate clinical evaluations in Scottish centres. It was also proposed that the working group should look into the question of involving hospital ethical committees in evaluation proposals.
11.240 On 7 March 1985, PFC Liberton sent 50 samples of unheated Factor VIII, dating from 1980 onwards, to Dr Froebel for HTVL VIII screening.
11.241 These records confirmed the position current as at the beginning of March 1985. They also raise issues about policy in relation to the rolling out of new products reflecting technological developments. All existing stocks, heat-treated at 68˚C for two hours were to be used until exhausted in the autumn. The new formulation, prepared for heating at 68˚C for 24 hours, would be held un-heated pending trials of the preliminary batches, and issued in July or August when sufficient clinical experience of the product had accumulated. The policy of exhausting existing supplies before new (and ex hypothesi superior) products were released appears to have been settled.
11.242 Dr Cash wrote to Dr Boulton following the meeting narrating the agreement to proceed to clinical trials, and intimating that PFC Liberton had material heated at 68˚ for 24 hours ready for bioacceptability trials. In March, Dr Ludlam threatened to withdraw cooperation in clinical studies because of the lack of compensation arrangements for participants. There was also reluctance from Glasgow Royal Infirmary. Dr Ludlam explained his position in a letter to Dr Cash dated 4 April 1985: it was a conditional offer of support. Dr Boulton reacted to these developments in a letter to Dr Cash dated 19 April 1985.
11.243 Before the working group met, there were significant developments in England. Dr Cash had intimation of these by 1 March 1985. But full publicity was given at the Edinburgh meeting of the British Society for Haemostasis and Thrombosis on 26 March 1985. The poster disclosed a new BPL product, 8Y, prepared by heating freeze-dried concentrate at 60˚C for 72 hours. Prospective studies on three surgical patients showed no evidence of transmission of NANBH.
11.244 On 2 April 1985, Dr Foster wrote to Dr Perry and Dr Cash saying that the PFC Liberton intermediate concentrate with and without calcium had been heat treated at 68˚C for two hours, with increased potency, and was ready for issue. On the same day, Dr Cash wrote to Professor Bloom with arrangements for trials of the latest product heat treated at 68˚C for 24 hours. Professor Bloom responded with arrangements on
10 April 1985.
11.245 On 11 April 1985, Dr Smith of BPL sent Dr Foster a copy of the patent specification for BPL’s 8Y product, and offered full details of its performance. A visit took place soon after. In April, SNBTS were approaching completion of Dr Pepper’s work on purification of Factor VIII which promised to be patentable. SNBTS were also considering research on making artificial Factor VIII-deficient substrate using their large range of monoclonal antibodies.
11.246 On 24 April, Dr Cuthbertson wrote to Professor Weiss. The HSE had agreed that PFC Liberton could perform freeze-drying experiments. The way was open for the collaboration to proceed. PFC Liberton would heat Factor VIII in vials at 68˚C for 2, 12, 24 and 48 hours. Professor Weiss’s team would assay residual infectivity. However, it soon emerged that HSE had unresolved technical problems with the proposals.
11.247 The risk of developing neo-antigens as a result of administration of heat-treated products, which had been mentioned from time to time, became a major issue at a meeting of a specially convened group on 9 May 1985. Dr Bird, a principal proponent of the theory that heat-treated products gave rise to such risks, attended. It was agreed that long-term clinical studies (two to three years) were required and arrangements were put in hand to commence the project.
11.248 The working group met on 15 May 1985. It was reported that the heat treatment of Factor IX was a high priority, and that tests on dogs were under way at Cambridge. Clinical evaluation was expected in two to three months’ time. First results from Cambridge were good. In relation to Factor VIII, the information was equivocal, but it appears that preliminary clinical evaluation had been encouraging, and thatproduction had been commenced, and was continuing, at 68˚C (dry heat) for 24 hours plus two
per cent sorbitol. (However, it was also minuted that it was agreed that PFC Liberton should commence production in August. The programme remains unclear.) Dr Cash repeated the need for ‘virgin’ patients for the residual infectivity study.
11.249 An assessment was made of Factor VIII stocks on 24 June 1985. The number of months of stock held varied across the regions from two to 12. The lists are not available, but the information suggests that this stock had been treated at 68˚C for 2 hours, that new material was being prepared to the new specification, but was held from delivery pending labelling and packaging, and that decisions on ‘eventual’ issue would be required when that was done. The new material (68˚C for 24 hours) was not expected to achieve freedom from NANB Hepatitis.
11.250 On 4 July, results from Professor Bloom, added to results from Edinburgh, indicated excellent validation of the biological efficacy of PFC Liberton’s ‘latest batch’ of heat-treated FVIII. (The product would have been dry heated for 24 hours at 68˚C (the ‘second generation’ Factor VIII) in May 1985, if the same as the Edinburgh test material.)
11.251 On 9 July 1985 the CBLA’s central committee for research and development in Blood Transfusion held their sixth meeting. Clinical trials of BPL’s factor 8Y (dry heated at 80˚C for 72 hours) were being conducted. Several patients had already safely passed the point at which the first evidence of transmission of NANB Hepatitis would have been expected.
11.252 On 26 August 1985, Dr Perry wrote to the Scottish transfusion directors and NIBTS director intimating that PFC Liberton had almost exhausted their stocks of the original heat treated product (68˚C for two hours) and that the ‘new’ product would be issued within the next two months.
11.253 In November 1985, SNBTS received pre-publication prints of Dr Prince’s papers that would undermine the confidence that heat treatment at 60˚C would inactivate HLTV-III.
11.254 On 13 November 1985, Dr Foster wrote to Dr Smith (PFL) enclosing papers, slides, and other information relating to PFC Liberton’s work. He included the report published in Research Disclosure: ’before we learned that Cutter had already patented virtually everything‘.
He also said:
One question I’ve been meaning to ask you; what are the freeze drying conditions for your new FVIII concentrate (especially during primary drying). We have some preliminary data that suggests that drying conditions may be particularly critical for the subsequent sensitivity of both protein and virus components to heating (not unexpected).
11.255 Dr Smith replied on 11 December 1985 with an account of the freeze-drying conditions used at Oxford. This was the beginning of collaboration on research into whether the conditioning of plasma was a significant factor in ensuring the effectiveness of the final product.
11.256 Meantime, controversy developed over the use of dry heat-treated products in haemophilia therapy when Dr Prince published the paper referred to above. The paper challenged the efficacy of lyophilized heat-treated products in the treatment of haemophilia and caused a flurry of activity in November 1985, when Dr Perry wrote to Dr McClelland proposing that Professor Weiss should be encouraged to treat evaluation of infectivity in IgG and Factor VIII urgently.
11.257 The Factor VIII study group met on 21 November 1985. In relation to fractionation, Dr Perry reported that currently PFC Liberton was producing intermediate Factor VIII with the addition of two per cent sucrose, heated at 68˚C for 24 hours. He noted that BPL was currently applying dry heat at 80˚C for 72 hours, with losses of yield of 5–10%. He hoped that when the new (Johnson) process for high-purity product was available the PFC Liberton yield would be improved. It was not intended that PFC Liberton should alter its process at that time. In an update on virucidal procedures, it was agreed that Dr Pepper would conduct studies on material supplied by Dr Smith, PFL. The comparative effectiveness of heat treatment and irradiation was mentioned, but unexplained. There was again anxiety to re-establish collaboration with Professor Weiss on HTLV III inactivation studies. Dr Perry wrote to Professor Weiss on 25 November 1985, and again on 12 December 1985. By the date of the second letter contact had been re-established and Dr Perry set out the agreement reached for onward progress.
11.258 On 27 November, Dr Cuthbertson sent a circular to regional directors intimating the withdrawal of old formulation Factor VIII (no sucrose: 68˚C for two hours), and requiring the return of all vials with the code 02 to PFC Liberton. The material had remained on the shelves for months longer than originally anticipated, despite production of Factor VIII heated at 68˚C for 24 hours, with two per cent sucrose.
11.259 On 29 November, again in response to the Prince article, Dr Cuthbertson wrote to Dr Onions at the Glasgow Veterinary School proposing the repeat of an earlier experiment on retroviral inactivation (reported at Oxford in September) to which Dr Onions had contributed. Dr Prince was about to publish data showing that only one log of HTLV III inactivation was achieved on dry heat treatment at 60˚C for 24 hours, compared with the 37 logs claimed by CDC. This was thought likely to provoke all manufacturers to test their own products. Dr Onions was asked to carry out experiments on PFC Liberton immunoglobulin products. Dr Cash set out his understanding of commercial procedures in a letter to Dr Perry on 2 December 1985: Cutter’s regime was 68˚C for 72 hours (dry); Armour’s was 68˚C for 20 hours (dry); Alpha’s was 60˚C for 20 hours plus an ‘organic solvent’; and Immuno used steam heating. In relation to IgG, PFC proposed comprehensive testing of all current batches at issue.
11.260 At the meeting of the SNBTS directors on 10 December 1985, Dr Cash reported that it was anticipated that Professor Montagnier and co-workers at the Pasteur Institute would shortly publish a paper expressing the opinion that 68˚C dry heat treatment for
24 hours might not eliminate HTLV III virus in Factor VIII. Dr Perry said that PFC Liberton were doing experiments to ascertain the facts both in Factor VIII and immunoglobulins. PFC Liberton’s long-term plan was to heat blood products at 80˚C for 72 hours. PFC Liberton had a nine months’ supply of Factor VIII in stock, some of which had been processed in January 1985. It might be possible to re-heat Factor VIII that had previously been heated for 24 hours. The first Factor VIII from plasma tested for HTLV III antibody would be issued in February 1986. The DHSS were about to issue a letter to manufacturers to say that IV IgG must all be manufactured from HTLV III tested plasma.
11.261 Just as PFC Liberton were producing intermediate Factor VIII with the addition of two per cent sucrose, heated at 68˚C for 24 hours, the work of Dr Prince and Professor Montagnier was casting doubt on the effectiveness of the regime. However, in January 1986, results from trials of PFC Liberton heat-treated Factor VIII were reported by Edinburgh. There were qualifications about the size of the group studied, but otherwise the product was thought to be satisfactory. Results from Professor Bloom’s trials of calcium stabilised Factor VIII were also received, and thought to be valuable in supporting SNBTS’s findings on this project. Dr Foster thought that it was time to publish the results. Professor Bloom was prepared to be acknowledged in the proposed paper, along with Dr Greedharry, his researcher.
11.262 There was considerable uncertainty on a number of issues in 1986. A meeting was held at NISBC on 7 February 1986 on the virological aspects of the safety of blood products. The report, relatively optimistic in its terms, stated inter alia:
Retroviruses consist of single-stranded RNA with a lipid envelope, and would be expected to be sensitive to heat, detergents and organic solvents….Dr Minor described the inactivation of HTLV III, which is relatively easily achieved by heat or chemical means. Infectivity is destroyed by wet heat at 30 min, or dry heat for 48 hours at 68˚. However, the virus is surprisingly resistant to inactivation when dried and can survive freeze-drying….
11.263 However, in discussion, Professor Weiss emphasised that at that time no measurement of inactivity was sufficiently sensitive to detect reliably virus in blood products. And Dr Thomas, commenting on Italian experiments, pointed out that there were limitations on the value of using chimpanzees for studies on NANB Hepatitis.
11.264 On 11 February 1986, Dr Prowse reported to Dr Cash and others on a meeting held at BPL Elstree to discuss English studies of the collection and fractionation aspects of the use of apheresis plasma. Studies had been carried out in Sheffield, Leeds and Oxford. Results to date encouraged further studies at the three centres. Dr Prowse had agreed to participate in studies of the effects of the mode of anticoagulant addition and plasma filtration as a discrete part of the overall exercise.
11.265 From 11 to 13 February 1986, there was a conference at Newcastle on AIDS, sponsored by the Haemophilia Society. Dr Foster prepared notes. There was controversy over suggestions of HTLV III seroconversion following use of Factor VIII. Further reports were to emerge. On 15 March 1986, a letter by White and others to The Lancet gave an account of probable HIV seroconversion following treatment with heat-treated Factor VIII concentrate. On 5 April 1986, Van Den Berg and others, in a letter to The Lancet, published further data of probable HIV seroconversion following treatment with heat-treated Factor VIII concentrate. In response to a letter from Ralph Rousell of Cutter Laboratories, protesting at the absence in the March and April 1986 papers by White and Van Den Berg of the heat treatment protocol followed, it was stated that the heat treatment, in both cases, was 60˚C for 30 hours in a lyophilised state. That identified the product as Armour–they were the only manufacturer using that heat treatment protocol at the time. The Travenol dry heat treatment protocol was 60˚C for 72 hours. The Cutter protocol was 68˚C for 72 hours.
11.266 On 18 February 1986 Dr Pepper wrote to Dr Smith. On 26 February 1986,
Dr Smith replied with details of the last significant stage in the production of 8Y.
Dr Pepper had raised with him the question of fast freezing. Dr Smith thought that any change in the composition of the freeze-drying mixture would take a long time and much work, but encouraged a start on the study. He noted that he was ‘not so sure that very fast freezing’ was feasible on a manufacturing scale, but wanted to keep in touch with thinking in Edinburgh.
11.267 The Factor VIII Study Group was re-named the Coagulation Factor Study Group.It met under that name on 27 February 1986. In anticipation, Dr Prowse prepared a paper on the feasibility of centralising feedstock plasma Factor VIII assays, and made recommendations. Dr Gabra prepared a paper on the value of quality assurance of the assays. The minutes of the meeting recorded that both topics were continued for further discussion. On a separate issue, it was recorded that PFC Liberton and the Edinburgh BTS laboratory were producing inconsistent results in assays of thawed plasma feedstock. It appears that the lack of an agreed plasma specification and inconsistent practices were still affecting the overall quality of plasma available for fractionation. The discussion of fractionation topics was led by Dr Perry. The final phase envisaged improved freezing, ‘Zn treatment’ and improved freeze-drying. The heat regime would be 80˚C for 72 hours. Manufacture would start in April 1986 and issue from January 1987. Other virucidal options were reported, including the resumed collaboration with Professor Weiss. He commented that freeze-drying conditions differed as between PFL and Elstree for Factor VIII products. Further model virus studies were proposed and agreed. Parallel studies in improved freeze drying conditions for Factor IX were reported. Studies on dogs had been completed and would be published.
11.268 The collaboration with Professor Bloom’s team proved less than satisfactory: Professor Bloom’s colleague, Dr Greedharry, could not complete the studies requested.
11.269 In February 1986, Dr Cash prepared notes for the SNBTS and haemophilia centre directors meeting to be held in March. The report was paraphrased in the report of the meeting.
11.270 Dr Perry’s notes contained added detail:
In January 1985, PFC distributed heat treated FVIII (68˚/2hr) to all centres in Scotland and Northern Ireland and this material was used until September/ October 1985 when a new formulation product, heated at 68˚ for 24 hrs was issued. At the time of writing there have been no reports of HTLV III seroconversion following the use of either of these products although equally it is recognised that the current heat treatment regime is unlikely to produce a non-infective product with respect to NANB or Hepatitis B….
Most recently unconfirmed reports have emerged which suggest that HTLV III may be less susceptible to heat inactivation than was originally thought. In response to these reports, PFC has recently recalled all residual stocks of 68˚/2hr material.
Directors will be aware that the Blood Products Laboratory are currently issuing a FVIII product which has been heated at 80˚/72 hrs and preliminary clinical data indicates that this material is non-infective with respect to HTLV III, NANB and Hepatitis B. While it is unlikely that the current PFC product could be successfully treated under these conditions, a major development programme has been underway for 12 months with a view to the production of a high purity FVIII product which can be formulated and heat treated, under conditions which give comparable levels of viral inactivation. Such treatment may not require such vigorous heating conditions.
11.271 Some Factor IX was by this stage in routine issue after heat treatment at 80˚C for 72 hours. Future products under development included a high yielding high-purity and non-infective Factor VIII. So far as the minutes of the meeting disclose, the information in the reports was received without serious discussion.
11.272 An unattached document, which appears to have been intended as an addendum to paragraph 5 of Dr Perry’s notes, reflected a change of scientific opinion (after discussion with Dr Smith):
It is generally believed that heat treatment of this severity can only be achieved with high-purity products (eg BPL, FVIII is 5 iu/mg). However, recent research at PFC has shown that this is not the case and that severe heating can be tolerated even at low purity if key process steps are carefully controlled prior to heat treatment.
This information will enable a non-infective product to be achieved using intermediate-purity material without compromising the development of the very high purity product noted in para 5.1.
The advantages of this course of action are:–
(i) Provides non-infective FVIII product more quickly than will be possible with the very high purity product.
(ii) Will allow the new very high purity product to be properly assessed and phased-in without undue haste.
(iii) May be effective in the treatment of von Willebrands disease…
(iv) Is expected to be available at a higher yield…and purity…than the current product.
It is likely that a product of this type will be available for evaluation in April 1986.
11.273 It appears reasonable at this stage to infer from these papers that major problems had affected SNBTS’s long-term proposals for a high-purity product. That had been hoped to provide a medium for dry heat treatment to the levels achieved in England. PFC Liberton had not expected to be able to apply very high temperature treatment to its intermediate Factor VIII product. But it had lately been discovered that careful control of certain ‘key process steps’ (from other sources, the conditioning of plasma, in particular) enabled the product to tolerate high temperatures. Dry heat treatment to 80˚C for 72 hours had become feasible.
11.274 At the meeting of SNBTS and haemophilia directors and SHHD held on 5 March 1986, Dr Cash noted that there was emerging evidence from Montagnier’s laboratories that HLTV-III was more sensitive to heat. The minute states:
Dr Cash informed members that even material dry heated at 68˚C for
24 hours may not be non-infective with regard to HTLV III and NANBH. Dr Perry explained that the PFC had recalled all residual stock of material heated at 68˚C for 2 hours for testing….He said that difficulties have arisen in relation to the heat treatment of the new high purity product and it has been decided to introduce an intermediate stage: a product which is only 2–3 times purer than the existing intermediate FVIII but can be dry heated at 80˚C for 72 hours. It is hoped that this intermediate product will be available for clinical evaluation in April and for routine clinical issue within 3 months….
Dr Cash pointed out that current information indicates that the HTLV III virus is killed when dry heated at 80˚C for 72 hours….
11.275 Dr Cash emphasised that there would be a substantial overlap when the high-purity product was issued in the summer. It was agreed that the new products could be slotted into the batch dedication system.
11.276 Research and development planning now covered two new heat-treated products. Dr Perry’s report was before the group. In relation to production, as Dr Perry acknowledged, there would be a substantial overlap when the high-purity product came on stream.
11.277 On 5 March 1986, Dr Foster wrote to Dr Perry and others noting the confusion in the minds of colleagues outwith PFC Liberton caused by the multiplicity of PFC Liberton products discussed. He suggested that products should be named. He said:
Within the next few months we could have four FVIII products in clinical use simultaneously:
1) FVIII, 68˚ 24 hours
2) FVIII, 68˚ 72 hours
3) FVIII, 80˚ 72 hours
4) PFC/NYU FVIII.
11.278 For the first three he suggested Factor VIII HT1, 2 and 3. But products 3 and 4 were likely to have a long-term future. Product 3 had been called ZHT, but since virtually all products were heated, he suggested ‘Z8’. For product 4 he suggested ‘REAL 8’. Dr Perry agreed generally. But he proposed putting products 1 and 2 into a single category: ‘FVIII HT’ ‘since we will not be announcing the 68˚ variant’. If that had been done, no distinction would have been drawn between the 24 and 72 hour preparations in published material, or on labels or packaging.
11.279 On 17 March 1986 there was a meeting at PFC between BPL and SNBTS scientists to discuss commonality of interest in plasmapheresis and virus inactivation studies.
Dr Smith reported on the plasmapheresis studies in England. In relation to the latter topic, Dr Cuthbertson outlined studies performed in Aberdeen to date. The note reports:
Evidence is emerging which suggests that product freezing and freeze drying has an impact on the efficacy of subsequent virucidal processes such as heating.
It was agreed that Dr Smith would liaise with Dr Cuthbertson with a view to establishing the level of virus activation achieved with BPL 8Y material. This would involve the transfer of samples between BPL and PFC and the development of a protocol which accurately simulated routine BPL formulation and treatment conditions.
11.280 Both centres would be involved in this work. This appears to have been the first formal indication by PFC Liberton that conditioning was important. BPL was engaged in studies on chimpanzees. PFC Liberton hoped to use the results. PFC Liberton outlined their collaboration with Professor Weiss. It was agreed that HTLV III studies would be confined to Edinburgh meantime. Dr Smith outlined the results of 8Y tests to date: no cases of viral infection had occurred. It was agreed to attempt to reconcile protocols for product release and recall.
11.281 On 26 March, a brief report was produced on the results of a freezing trial that was said at that time to show that there was not a significant change in the degree of protection for heat treatment depending on the freezing procedures adopted in the processing of NY5. 
11.282 Data from a trial of varying freezing conditions noted on 26 March 1986 suggested that a small change in freezing caused a difference in appearance and solubility and led to further research.
11.283 On 4 April 1986, SHHD wrote to Dr Cash and others to propose a meeting to evaluate the effectiveness of PFC Liberton fractionation process in inactivating HTLV III in blood products.
11.284 In April 1986, the US FDA approved for clinical use Bayer’s pasteurised Factor VIII product, Koate HS (patent application 5 March 1980, published on 3 April 1984).
11.285 Dr Perry sent Dr McClelland the results of irradiation tests of PFC Liberton
Factor VIII on 17 April 1986. Dr Cuthbertson prepared a protocol for evaluating the virus kill in the English 8Y product.
11.286 In April 1986, Dr Pepper became interested in researching thrombogenicity in surfaces that materials came into contact with in the course of processing. He sought Dr Cash’s advice on the way forward.
11.287 On 9 May 1986, Dr Cuthbertson wrote to Dr Lane, BPL, sending a brief outline of the experiments PFC Liberton planned to use in evaluating the virus kill in the 8Y product. It was proposed to use PFC Liberton’s systems and equipment, in particular the Usifroid SMJR freeze-dryer, to duplicate BPL’s 8Y process with PFC Liberton product. Model viruses would be introduced to 8Y material, which would be freeze-dried, and thereafter heat treated according to progressively more demanding temperature and time regimes. The third phase would take the exercise forward to trialling HTLV III in 8Y. This appears to be a major step forward in collaboration between the two research teams directed towards obtaining empirical proof of HTLV III inactivation.
11.288 Results from various studies were reported from Scottish workers and from Cardiff relating to the assay of FVIII with and without calcium. Osmolality of Factor VIII concentrates emerged as an issue (initiated by Dr Ludlam). On 20 May a meeting of haemophilia directors was called for 11 July 1986 to discuss Dr Cash’s proposal for investigation of the issue whether heat treatment degraded constituents of Factor VIII. A question arose whether PFC Liberton should join Celltech in their study of purification of Factor VIII. Dr Boulton tried to encourage Dr Perry to engage in studies relating to transmission of HTLV III. It appears there was much activity at this time.
11.289 At the 21st Congress of the International Society of Haematology and 19th Congress of the International Society of Blood Transfusion (Sydney, 11–16 May 1986) Drs Cuthbertson, McIntosh and Foster presented a paper on virus inactivation in plasma derivatives. From its summary, it concerned effects on the heat stability of viruses of additives used to stabilise proteins when heating in solution, as well as the effect on stability of freeze-drying conditions and product formulation. They reported on SNBTS experiments that showed it was the nature of the freeze-drying process rather than the purity of the product per se which was critical to achieving dry heat treatment at more severe conditions. This was the intelligence shared with English colleagues at the joint meeting on 17 March 1986. It is difficult to deduce from publications concerning virus inactivation what the parameters of these processes may have been, but this appears to relate back to the Scottish modifications of the BPL process referred to above following discussions with Dr Smith.
11.290 In The Lancet of 31 May 1986, a letter from Dr Prince contained the anticipated warning against over-confidence in dry heat treating:
Recognition of the transmission of human immunodeficiency virus (HIV) by blood derivatives such as factors VIII and IX has led regulatory authorities to demand sterilisation procedures for these products. In the United States the National Hemophilia Foundation’s Medical and Scientific Advisory Council has recommended that lyophilised, heat-treated products should be used for the treatment of haemophilia, and the data on which this recommendation was based have been published. However, two recent reports of HIV (HTLV-III) seroconversion in recipients who received only heat-treated factor VIII and the following laboratory experiment findings suggest caution in reliance on dry heat inactivation….
11.291 Following discussion of the experiment, (a) at 27˚C for 48 hours, and (b) at 60˚C for different periods, for which results were published, the letter proceeded:
The virus inactivation resulting from heating alone was surprisingly modest,…Lyophilisation alone resulted in an additional…(measure) of inactivation. These results are consistent with those reported by Levy et al….
The finding of only modest sterilisation process efficacy for HIV adds to concern about the efficacy of this procedure. It should, however, be stressed that this finding does not mean that dry-heat treated products are unsafe with respect to transmission of AIDS. Indeed three studies have reported absence of anti-HIV seroconversion in recipients of dry-heat treated FVIII preparations. Purification and processing steps before lyophilisation can remove or inactivate virus, and lyophilisation alone under commercial conditions probably inactivates more virus than is observed with shelf freezing. Furthermore some products are heated above 60˚ C. Nevertheless, these findings indicate the need for caution in relying on the efficacy of dry-heat sterilisation. Long-term surveillance of recipients of such products for seroconversion to anti-HIV is still required.
11.292 In a letter to The Lancet dated 21 June 1986, Dr Barrowcliffe and others of NIBSC set out findings on Factor VIII degradation in heated concentrates. PFC Liberton’s product was included, but was not commented on specifically. The general conclusions of the letter were rather negative: there was no evidence that heated Factor VIII was any less effective haemostatically than its unheated predecessors, but in some cases heat treatment might be accentuating proteolytic degradation.
11.293 The coagulation factor study group met on 23 June 1986. The minutes contained reference to Dr Cuthbertson’s overview of inactivation studies, small scale production
of phase 3 Factor VIII, and progress on phase 4. Dr Pepper intended to continue with heat plus irradiation for virucidal effect. There was some evidence that heat-treated Factor IX might not be effective in inhibitor patients. It was recorded that: ’there were two batches of DEFIX held in PFC which had not been issued as they were associated with HIV+ve donations’ . Dr Cuthbertson outlined developments in virus inactivation. HIV experiments were expected ‘soon’ at Edinburgh. Dr Foster reported that the phase IV high purity product would not allow heating at 80˚C. (It had been intended to heat at 80˚C for 72 hours.) The product would tolerate heat treatment at 55–60˚C in the dry state, which appeared to achieve virus kill. Application of the plasma specifications was being monitored. Discrepancies in Factor VIII:C results as between PFC Liberton and SNBTS were thought to be due to losses in transportation. The centralisation of assay had not been supported, but an experiment in swapping material between Edinburgh and Glasgow was agreed. Citrate and plasmapheresis studies continued, as did dog studies and work on Factor IX concentrates.
11.294 Another factor was recognised in 1986: the need to ensure that all plasma used for blood product production was ‘validated (HTLV III) plasma’. SNBTS were already engaged in work with Professor Weiss, and a collaborative study was under way in March 1986, when the SNBTS directors were advised that DHSS medicines division had announced that all products issued after 1 July 1986 must be validated. When the topic came up again at the SNBTS directors meeting on 24 June 1986, it appeared that PFC Liberton used screened and unscreened plasma. Factor VIII concentrate in issue was derived from unscreened plasma, but that was expected to change. Most Factor IX was from screened plasma. But it was noted that no details of testing methods for HIV and Hepatitis B had as yet been submitted to the medicines division.
11.295 On 25 June 1986, Dr Foster took up the issue of the difference between six-hour and 18-hour fresh frozen plasma. He provided comparative data and reiterated his view that use of ionised calcium was necessary to ensure preservation of Factor VIII activity in the processing of cryoprecipitate: the subject of the Cardiff study. He stressed the importance of concentrating on future production in which calcium would be added. Dr Cash responded by asking for statistical analysis of the data. Dr Cash’s intervention appears to have caused an adverse reaction. (Dr Foster sent the data on 11 August 1986: 18 hour cryoprecipitate was consistently lower yielding, but the difference in the final NY product was not statistically significant. The result was expected to be different with Z8.)
11.296 On 1 July 1986, Dr Cash wrote to Dr Boulton about trials of Factor VIII. He defined the scope of further Factor VIII trials narrowly: half-life and recovery studies were all that were required to get nearer to a definitive product. His reason:
I can best emphasise the point by stating that we have already agreed that until such times as we have a product which is to be the definitive product for at least 5 years we won’t consider further the awesome task of a NANB study on virgin haemophiliacs.
11.297 Summary of Developments to Mid-1986:
• There had been a period of sustained research and development into viral inactivation across a broad range of methodologies.
• Early confidence that many of the difficulties confronted in the 1970s and early 1980s would be overcome, and that non-thrombogenetic, non-allergenic, effective and less potentially infective products would become available were undermined by:
– Emerging knowledge of the natural history of NANBH
– Continuing lack of a marker for the condition
– The arrival of AIDS and HIV, and the dominance these acquired in research activity, almost to the exclusion of other infections.
• There had been at least two years of intensive research, increasingly in response to the threat of AIDS, in the commercial and public service sectors.
• In Scotland, initial confidence that the domestic product was safe because of reliance on local volunteer blood donation was dashed in 1984–85 by the finding of HIV positivity in a cohort of patients in Edinburgh.
• Inactivation of the AIDS agent was severely hampered until late 1985 by lack of reliable, widely available tests for the virus.
• Screening of plasma donations for HIV/AIDS relieved pressure in the system.
• Overall progress was slowed by issues relating to commercial confidentiality and the protection of intellectual property rights.
• A general consensus was emerging, from clinical studies, clinical observations and laboratory studies, that whereas lyophilised Factor VIII heated for
30 hours at 60˚C would not protect against NANBV transmission, dry treatment at 68˚C for 72 hours, or pasteurisation (as used in Bayer’s Koate HS Factor VIII) were very probably sufficient to kill HIV and prevent transmission.
• Emerging evidence of the prognosis for haemophiliac patients infected with chronic NANBH was beginning to shift the focus back to preventing the transmission of that virus.
• However, research had not progressed sufficiently to justify study of NANBH transmission by the Scottish product in the case of ‘virgin’ haemophiliacs.
11.298 In June 1986, the World Haemophilia Federation Conference was held in Milan.Dr Smith attended and produced notes. A copy appears to have been available in Scotland. Trials of various products were reported. There were adverse comments on Kryobulin:
Eibl was given a tedious ten minutes to explain why he thought that the patients had acquired their HB adventitiously, through living in filthy Southern Italy. This did not go down too well with his hosts, and does not explain why all three contracted HB after the same lot….
11.299 Dr Smith recounted information given about various forms of heat treatment. Evidence available to the Lindsay inquiry, indicated that word was spreading in the medical community about a possible association between an AIDS seroconversion and Armour dry-heated Factor VIII (ie 60˚C for 30 hours in a lyophilised state). Dr Smith’s notes do not reflect this intelligence. However, Armour’s product, Factorate, issued before January 1986, when all donations in Britain began to be screened, was withdrawn in July 1986. Other heat-treated products such as Travenol (60˚C for 72 hours) and Cutter (68˚C for 72 hours) were not withdrawn, but were gradually replaced in the period after
1 January 1987. It seems this development was prompted primarily by the search for a form of viral inactivation effective against the risk of transmission of NANBH, although general misgivings about the effectiveness of dry heat treatments at temperatures of in the region of 60˚C against the risk of transmission of HIV may have contributed to the development.
11.300 There may be a question for the Inquiry whether the precise dry heat-treatment protocol was critical to the effectiveness of the product to inactivate HTLV III, and therefore as to the appropriate approach to research.
11.301 Meantime, pasteurised products began to appear. Alpha Profilate was a heat-treated, wet method product, heated at 60˚C for 20 hours. Armour were licensed to market in the USA Haemate P, the pasteurised heat-treated Factor VIII developed by Behringwerke. Cutter were licensed to manufacture Koate HS, a heat-treated pasteurised product. The wider market appears to have been moving towards pasteurised products at this time, though further change was imminent.
11.302 On 21 July 1986, Immuno distributed a circular intimating that dry-heated products had been discontinued: all products would be subject to steam treatment for the future, and that included FEIBA.
1986: England and Wales
11.303 As mentioned above, a meeting was held at the NIBSC on 7 February 1986 on the virological aspects of the safety of blood products. Amongst the points raised in discussion, it was noted that there was a general agreement that a closer scientific liaison should be established between the Blood Products Laboratory at Elstree, the Protein Fractionation Centre in Edinburgh and NIBSC. The recommendations included:
A working group should be established between the BPL, Elstree, the PFC, Edinburgh and NIBSC, which would meet periodically and provide a forum for the exchange of technical and scientific information pertaining to the safety of blood and blood products, especially in relation to virus contamination and the evaluation of manufacturing procedures to inactivate or eliminate viruses.
11.304 That did not happen immediately, but the informal contacts between Dr Smith and Dr Foster continued.
11.305 In June 1986, Dr Fletcher and others presented a paper to the Haemophilia Congress in Milan which gave the results of the clinical use of BPL Ffactor VIII and IX heat treated to 80˚C.
11.306 On 8 July, Dr Smith reported progress in England with the Scottish-inspired study of plasma conditioning. In a memorandum dated 7 August 1986, Dr Evans, BPL, set out a proposed standard freeze-drying programme for 8Y.
11.307 In September 1986, Dr JK Smith (BPL/PFL) prepared an interim report for UKHCDO on the study of previously untreated patients who had received BPL Factor VIII and IX concentrates 8Y and 9A, heat-treated in the freeze-dried state at 80˚C for 72 hours as the final stage in processing. The report dealt with patients who had had no large-pool concentrate exposure before treatment with BPL 8Y or 9A. The patients had been followed up for at least 16 weeks and had had at least four infusions during that period. The interim results essentially showed no clinical or laboratory events attributable to transmission of the three main blood-borne viruses: HIV, NANBH and HB. The results were not totally conclusive: the English studies had shown that none of the patients followed had developed adverse signs or symptoms, but that could not exclude the possibility that others might react adversely. A formal prospective clinical trial was to follow. It was also noted that there was no HIV seroconversion attributed to the interim product HLH/8CRVH (heated at 70˚C for 24 hours) which had been issued in early 1985.
11.308 The full results of the trial were published in The Lancet in October 1988 (Study Group of the UK Haemophilia Centre Directors, ’Effect of dry heating of coagulation factor VIII concentrates at 80˚C for 72 hours on the transmission of NANBH’.
11.309 The product description of 8Y, together with the clinical trial protocol, were sent to PFC Liberton on 1 August 1986 when Scotland agreed to participate in the trials.
11.310 On 7 August 1986, there was a report of freeze-drying work in relation to 8Y sent by Dr Evans to the freeze drying working party: BPL was trying to standardise its procedures.
11.311 On 8 December 1986, Dr Smith sent Dr Foster, on a confidential basis, a paper on the effects of plasma conditioning on subsequent cryoprecipitation and cryo-extraction. He explained that the 8Y process reflected know-how not yet sewn up by patent. The studies provoked by Scottish empirically-derived information had now received a measure of analytical support and theoretical under-pinning.
11.312 On 17 December, PFL circulated a paper on 3–4 kg scaling of the 8Y and 9P processes to give a method for producing Factor VIII and Factor IX in acceptable yield and quality.
11.313 By the end of the year, and notwithstanding the international developments noted above, English research and development continued to focus on dry heat-treatment, and to claim effectiveness for the products BPL had started general issue of 8Y in September 1985.
Second half of 1986: Scotland
11.314 On 2 July 1986, Dr Perry wrote to Dr Boulton intimating that PFC Liberton were poised to launch yet another Factor VIII product, heated at 80˚C for 72 hours, which ‘should therefore be comparable to 8Y’ and better than anything available commercially. He suggested that virgin haemophiliacs might have access to this product before the stocks of existing products were exhausted.
11.315 On 4 July 1986, Dr Boulton wrote to Dr Perry with manuscript data, thought to reflect a telephone conversation between them, on future production:
Production stops Sept.
Phase II product being used up: no more available end March
Phase III product being produced, having been verified as being virucidally equivalent to BPL 8Y. Hence ½ life and recovery studies on ‘non virgin’ haemophiliacs are required between Sept and Dec.
From about Sept 1987 PFC version of 8Y will be produced. Hence ½ life and recovery studies + NANB etc on ‘virgin’ haemophiliacs are required.
In the meantime, any Edinburgh ‘virgin’ haemophiliacs requiring therapy could be given BPL 8Y
11.316 Dr Perry replied that this was about right. He said:
The PFC phase IV product (very high purity, non-infective as assessed by model virus studies etc) is planned for production in January ’87 therefore it is hoped that supply will be in September ’87–after we’ve used up stocks of Phase III product. This product is more than equivalent to 8Y, it’s much better!
While there will be no PFC product virucidally comparable to 8Y until September ’86, after that time it would be my intention to supply the Phase III product to ’virgins‘ since we hope to demonstrate by that time that it is virucidally equivalent thus removing the need to go South. However, in the immediate future (July–September ’86), we could probably get supplies of 8Y for special cases. It would of course be preferable if these were obtained and supplied through PFC.
11.317 A policy of using up stocks of product manufactured using superseded technology appears to be implicit in the programming. But there was recognition of the need for a more flexible approach in the following exchanges.
11.318 Dr Boulton also wrote on 7 July 1986, asking, on Dr Ludlam’s behalf, for access to BPL products, against the possibility of the need to treat a previously untreated patient. Dr Perry wrote to NBTS on 10 July 1986 asking if a small quantity of BPL 8Y could be made available pending production of the Scottish product heated at 80˚C for 72 hours.
BPL replied positively on 24 July: some 8Y had been set aside for Scottish use. Further, Scotland was invited to consider a ‘novel proposal’ that Scots might take part in the trialling of Factor VIII Y. The letter referred to the adverse publicity relating to Armour, and the use of donations that had not been certified anti-HIV screened. BPL would not use unscreened material in future, but current batches were not made from screened material. Dr Perry would have to bear that in mind: there had been parliamentary questions. Dr Perry told Dr Boulton that BPL would supply the material, and that he would pass it on ‘on the understanding that, in the event that the material is used in suitable virgin patients, appropriate serial samples would be taken to contribute to their overall infectivity study’.
11.319 In July 1986, Dr Winkelman and others produced an extensive report on the BPL 8Y model, with reference in particular (at the end of the report) to the work of the Scots scientists, Drs Farrugia, Prowse, Foster and others on aspects of the freezing and thawing processes involved. Note was taken of the Scots research in relation to Factor VIII. In the context of Factor IX, the conclusion was that:
There is no information yet on how different softening conditions are affecting factor IX, but it will be interesting to look for differences if only to convince ourselves that there are none.
11.320 Dr Smith sent a copy of the report to Dr Perry, noting that work since the report was written:
seems to confirm that plasma pre-softening has been a major variable, previously unrecognised by us at least, influencing the weight and fibrinogen content of cryo and the following stages….
11.321 He also hoped that PFC Liberton’s model virus work was going faster than PFL’s. He anticipated that, as with freeze drying, BPL would be ‘wonderfully’ equipped in the long run, but that there was currently frustration.
11.322 On 15 July 1986 Dr Foster sent vials of PFC Liberton’s new, phase III Factor VIII from the first pre-production batch to SNBTS headquarters’ laboratory for study. The heated product had been treated at 80˚C for 72 hours.
11.323 On 21 July 1986 material from conventional PFC Liberton Factor VIII batches and from the new intermediate Z8 concentrate heated at 80˚C for 72 hours were sent to NIBSC for trial. Some of the material found its way to the blood components assay group who replied on 14 August 1986 commenting adversely on the high level of aggregates found: heating induced more aggregation of solids than previously, which was a disadvantage for clinical purposes. The issue of the ‘purity’ of Z8, which was to become significant, had arisen.
11.324 On 7 August 1986, Dr Perry wrote to Dr Boulton intimating that PFC Liberton had successfully manufactured two batches of Factor VIII treated at 80˚C for 72 hours and, subject to quality assurance, was well on target to proceed to clinical trials in August or the beginning of September.
11.325 Meantime, problems were being experienced with the Factor VIII in issue: patients were reporting difficulties in reconstituting the product.
11.326 Dr Boulton wrote to Dr Perry on 22 August 1986 asking about supplies of the phase III and IV products. On 29 August 1986, Dr Perry replied intimating that there had been ‘an eleventh hour problem’ at PFC Liberton with freeze drying Z8. PFC’s target dates for clinical trials in early September had been postponed.
11.327 The coagulation factor study group met on 14 October 1986. The agenda referred to dog studies, and a note on a related meeting on 10 July 1986 was appended. Also made available was a note (dated 13 October) on the current status of model virus studies in ‘Old’ Factor VIII (NY); DEFIX; Z8 and BPL 8Y. The tests on BPL material were those prepared by Dr Cuthbertson on 30 April 1986.
11.328 The minutes of the meeting show that Dr Cuthbertson presented his data. There was extensive discussion of progress on Z8. Dr Foster reviewed the studies undertaken; the approach that had been adopted to routine production proposals; and steps taken to deal with emerging problems. Of interest are notes on freeze-drying the second tranche of lots, 4–8. There were losses of Factor VIII:C ranging between 30 and 70%. Solubility times ranged between 35 and 40 minutes. These results were regarded as failure, and were attributed to the performance of the freeze-drier. There was a suggestion that heating to 80˚C was unnecessary, and that 72˚C for 72 hours produced an appropriate yield. It was agreed that the haemophilia directors would be asked to take part in a small study of a product prepared in that way. Dr Dawes reported on the high level of aggregates in her study of 8Y:
It was noted…that studies on 8Y and NY product had produced results never seen before: peaks on heated and non-heated product similar; fibronectin was removed; constituents could not be identified and more sensitive assays were required.
11.329 Phase IV had not progressed due to the emphasis on Z8. Dr Cash wrote to
Dr Perry on 15 October 1986 expressing the view that it was timely to commence production on a regime of 75˚C for 72 hours, but expressing the hope that 80˚C for 72 hours would continue to receive attention. On 13 November 1986, Dr Cash wrote to Dr Boulton advising him of the intention to produce Factor VIII at 75˚C for 72 hours and asking for cooperation in preliminary clinical trials for half-life and percentage recovery.
On 26 November 1986, that was followed up by a draft specification of the product and some analytical data. Dr Boulton replied on 1 December 1986. It appears that he would have to lodge the material in the cold room before he told Dr Ludlam about the request.
11.330 On 13 November 1986, Dr Dawes of MRC/SNBTS blood components assay group wrote to Dr Foster proposing to write up and publish material on tests of Factor VIII. The manuscript notes on the face of the letter suggest an adverse response to the threat of premature exposure of the experimental work carried out. The written response on 20 November 1986, while more moderate, was equally pointed, and indicated that PFC Liberton would not be pleased with publication.
11.331 On 18 November 1986, the British Technology Group intimated that they were withdrawing from involvement in the attempt to patent PFC Liberton’s plasma Factor VIII recovery inventions. The reason given was that the patent would be unlikely to generate sufficient licensing income. At this stage the early advent of recombinant Factor VIII was anticipated.
11.332 On 1 December 1986, a new group met under Dr Perry’s chairmanship to review the status, results and future of clinical trials sponsored by SNBTS, including the regulatory aspects of trials. So far as Factor VIII Z8 was concerned, Dr Perry reported that the product was available for half-life and recovery studies in Edinburgh, Glasgow and Northern Ireland prior to its introduction into routine use. Dr Boulton was coordinating the study, and its results would be used to support the application for licence variation.
11.333 On 1 December 1986, Dr Boulton wrote to Dr Perry about Z8 studies, as mentioned above. On 5 December 1986, Dr Ludlam did express reservations. However, on
11 December 1986, Dr Ludlam wrote to Dr Cash:
I was pleased to learn recently … that 8Z is shortly to be available for clinical assessment. I have obtained ethical approval to undertake recovery and survival studies in haemophiliacs. I am now awaiting an appropriate commitment from either OFC, SHHD or DHSS concerning the question of indemnity should any of the patients materially suffer as a result of assessing the new factor VIII product....
11.334 On 16 December 1986 Dr Foster replied to Dr Smith’s letter of 8 December 1986 indicating that Scottish research had also confirmed the earlier observations that conditioning was material to the success of the process. He also reported the problems that had been experienced with dry heating at 80˚C. He explained the problems that had arisen in their work on freezing and freeze-drying. The large-scale freezer that had been purchased performed differently from the smaller production drier that had been used earlier, and from the pilot drier, and variations in total protein of the final product gave batch-to-batch variations in solubility. But he stated:
We now believe that we have overcome all of these problems (only time will tell) by means of a special freezing technique and by designing our freeze drying cycle more carefully.
Freezing turned out to be the most critical area. Poor results (solubility) were linked to the presence of ‘crystalline’ structure after freezing and the degree of crystal formation increased with increasing protein concentration….
We found that an ‘amorphous’ structure was needed and that some form of product supercooling was required to achieve this….
11.335 The result of the work was a two-stage freezing process, which he outlined.
Dr Foster and his team planned to write up the work, and he promised to send Dr Smith a copy of the manuscript when it was available.
11.336 On 17 December 1986, the SNBTS directors met. There was no discussion of PFC Liberton production.
11.337 Internationally, 1987 witnessed some significant developments. European organisations, including the Swiss Red Cross, the German Red Cross, an Italian company, Aima, CNTS in Lille and Kabi in Sweden, began to produce Factor VIII and IX treated with solvent detergent to inactivate viruses (under licence from the New York Blood Centre). The first commercial fractionator to produce concentrate using the solvent method in America was Hyland in 1988. There were numerous publications dealing with viral inactivation in the course of the year. Some advertised the results of tests of specific products. Processes discussed included pasteurisation; the solvent detergent method; and various approaches to dry heat treatment.
11.338 In June 1987, a paper by Dr Prince and others, ‘The development of virus free labile blood derivatives–a review’ concluded that the present status of virus sterilisation in labile blood derivatives revealed it to be at an early stage of development. Several processes had been found to be inadequate; others still looked very promising, although that too might prove to be an illusion as further data accumulated. Continued process development was required unless natural coagulation factors were replaced by those based on recombinant DNA technology.
11.339 By the end of the year, the switch of manufacturing processes mentioned in 1986 had developed. On 21 December 1987, following a telephone conversation with Dr Dale Lawrence of US CDC, Professor Bloom circulated information about HIV seroconversions in ‘naïve haemophiliacs’ who had received commercial heat treated Factor VIII. Much of the information reported, about Armour and Travenol, was already known. He commented that switching to wet treatment (as in Hemate P (Hoechst) or Koate HT (Cutter)) would be expensive and lead to shortages. He also reported that CDC intended to convene an emergency meeting in Atlanta on 11 January 1988 He thought it was likely that the FDA would withdraw certain dry heat-treatment licences in the USA. He commented that BPL’s product (dry heated at 80˚C for 72 hours) was ‘in the air’, and that the whole subject should be discussed in the New Year.
11.340 It appears that there was a lack of settled scientific consensus in the international community. The absence of general consensus forms part of the background to domestic research and development during the year.
1987: the United Kingdom
11.341 On 19 January 1987, NIBSC, NBTS and SNBTS agreed (with the support of DHSS) to set up a Liaison Group which would draw up guidelines for the manufacture of biologicals used in transfusion medicine. It was further agreed that there should be three working parties:
(1) On therapeutic products manufactured at RTCs.
(2) On therapeutic products manufactured at fractionation centres and
(3) On diagnostic reagents for immunohaematology.
11.342 The loss of confidence in virucidal technology that developed internationally during the year came to be reflected in attitudes in the United Kingdom. Dr Ludlam had a particular concern about provision for those taking part in trials of PFC Factor VIII. On
9 January 1987, he wrote to Dr Cash:
Given written SHHD assurance that appropriate compensation will be available to patients/relatives in the context of clinical assessment of Z8, then I would respond to your questions as follows. (a) I would be happy to organise immediately the appropriate infusion studies … I am prepared to act very quickly particularly as my decision has embarrassed PFC plans … I would ask that the Department extends its indemnity until a product licence is obtained… I would be very reluctant to purchase commercial factor VIII and would prefer old intermediate (NY) factor VIII. I do not underestimate the difficulty of PFC undertaking this particularly as to have stocks ready for February it will be necessary to start production presumably now … I am most grateful to you for your general support of my concern but I do apologise for the extra worry and time it is causing both to you and PFC.
11.343 On 13 January 1987, Drs Bennett and Dawson of Aberdeen Royal Infirmary wrote to Dr Cash expressing the same view as Dr Ludlam, namely that the SHHD must give written assurance concerning compensation, as outlined in Dr Ludlam’s letter, as a condition of proceeding.
11.344 On 13 January 1987, Dr Cash wrote to Dr Ludlam:
Right now, assuming SHHD deliver the necessary assurances, we’ll keep your team in reserve to test the 80ºC/72 hours material which will very soon be with us. In the meantime Charles Forbes has agreed to look at the 75ºC/72 hours product. All being well we should just slip past the rocks I felt some days ago we were destined to founder on.
11.345 The reservations were to be taken seriously. SNBTS records contain a note of a telephone conversation on 15 January 1987 with Dr Heppleston, Dundee, repeating the point: he would require SHHD assurance about compensation as a condition of proceeding. However, he made it clear that in any case the hospital’s medical staffing situation was ‘so diabolical’ that there was no way that he could give a commitment to do the work at that time. On 19 January 1987, Dr Hann, Consultant Haematologist, Royal Hospital for Sick Children, Glasgow wrote to Dr Cash:
I agree with Chris that as usual the administrative process here has dragged on for too long, and it leaves us all ’between the devil and the deep blue sea‘. I believe very strongly that children should not be used in this situation and would like to leave my comment at that, especially as I do not know what Z8 is.
11.346 The SNBTS and haemophilia directors met on 9 February 1987. It was reported that SHHD had obtained Treasury consent for a limited compensation scheme for participants in clinical trials. Mr Macniven agreed to investigate the position in relation to ‘named patient’ administration which followed trials. Dr Cash’s report for the meeting noted that work was in hand to assess the new generation of donation screening kits available for specificity and sensitivity. It was recorded that PFC Liberton had succeeded in producing Factor VIII and Factor IX dry heat-treated at 80˚C for 72 hours and that batches manufactured since January 1987 had been dry heat-treated at 80°C for
72 hours, and were safer than ever before. Validation tests in the context of HIV had begun in the summer of 1986 and were making satisfactory progress. Z8 was approaching routine clinical use, and would be phased in using the existing batch dedication system, subject to priority for special cases. Thereafter PFC Liberton would return to the high-purity project. So far as Factor IX was concerned, demand had not been met, partly due to a refusal to issue product before completion of thrombogenicity tests, and partly due to increased use in Haemophilia A patients with inhibitors. PFC Liberton proposed to produce an activated product.
11.347 Dr Perry’s report contained further detail. The new Factor VIII Z8, produced initially at 75˚C for 72 hours and thereafter at 80˚C, would give a higher yield, greater solubility, lower fibrinogen and higher specific activity. All production since January 1987 had been at the higher temperature. Virus inactivation studies were under way. Full regulatory approval was anticipated in late April 1987. At January 1987, there were significant stocks of NY, heated at 68˚C for 24 hours, and of the lower temperature Z8 and a relatively small quantity of the 80˚C product. He noted that it would be necessary to agree a plan for phasing out the NY product and phasing in Z8. NY had not been manufactured since July 1986, providing an opportunity to build up stocks of Z8. He noted that it was hoped that full regulatory approval for the new product would be obtained by late April 1987.
11.348 In discussion on these reports, Dr McClelland commented on HIV positivity in donations. There was a report on NANB screening. Dr Forrester suggested that in the United States between 5% and 25% of transfusions transmitted NANBH. In the United Kingdom as a whole the figure was 2.5%. In Scotland during the past decade there had been between one and five cases per annum. The condition appeared to be relatively benign, despite some long-term risks. However, a Scottish study was to be set up.
11.349 Dr Ludlam and Dr Forbes agreed to accept the new product for trial. However, it was also reported that there had been a fall in the use of Factor VIII in Scotland during 1986, and that on a population basis overall use was less in Scotland than in England and Wales. The reservations about factor concentrates appear to have extended beyond the testing of Z8. But matters did not proceed smoothly.
11.350 On 23 February 1987, Dr Ludlam wrote to Mr Murray, SHHD:
I have received a copy of your letter of 6 February to Dr JD Cash about arrangements to compensate individuals who receive heat treated factor VIII. I note that the Department is prepared to apply the ABPI guidelines in the event of a serious reaction occurring during the clinical trial of heat treated factor VIII concentrate. There is some ambiguity in your letter as to what constitutes a clinical trial. Presumably the Department is prepared to follow the ABPI guidelines between the first test injection of heat treated factor VIII concentrate being given and a full product licence being obtained from the CSM. As the PFC and SNBTS are very anxious that appropriate trials begin immediately I should be grateful for an early reply.
11.351 The SNBTS directors met on 3 March 1987. Dr Perry tabled a summary of the preliminary results of virus inactivation tests in Factors VIII and IX, albumin and immunoglobulin. Heating for 72 hours at 80˚C had given satisfactory results using model vaccinia and SLF viruses. In the same test system vaccinia were inactivated to a satisfactory degree by heating in solution for 10 hours at 60˚C (Behringwerke method). It was noted that a company in the USA had patented the concept of dry heating coagulating factor in 1982 and had reinforced this in 1984 by a continuing patent. It was understood that companies manufacturing Factor VIII had not challenged the patent and were presumably paying royalties. It was believed that BPL was being pursued for royalties.
11.352 The coagulation factor study group met on 2 June 1987. The fresh frozen plasma specification had not yet been adopted. There was discussion of the topic. The experiment involving exchange between Glasgow and Edinburgh had thrown up comparable results, but there were issues over transportation. Improvements in the processing of Factor VIII Z8 were reported: there had been modifications of freezing temperatures and operating procedures in conditioning plasma; solubility problems had been addressed; and recovery and survival at 80˚C were good. Dr Cuthbertson reported progress on virucidal options: NY 68˚C data were produced showing no seroconversions. Irradiation and detergent options were discussed and research work agreed.
11.353 On 3 June, Dr Boulton reported the results of the Edinburgh trial of Z8. With one exception, a patient who (typically in the patient’s own view) reacted to Factor VIII with mild tightness of the chest and mild neutrophilia, there were no adverse reactions, and half life and percentage recovery were not noticeably different from other forms of Factor VIII. However, Dr Boulton made some observations that caused concern about the licensing of the product. His data showed variations from other results that caused concern and would require exploration before being submitted to DHSS. Further, several vials took a long time to complete solution. Home therapy required a product that went to solution relatively quickly. Discrepancies, internal and in comparison with other results, suggested that more work was required to enable a product licence to be sought.
11.354 The SNBTS directors met on 10 June 1987. The patent issue raised on 3 March 1987 was dealt with. Dr Perry understood that the CBLA had been approached by the Sinai Medical Centre (the patent holder) to apply for a royalty-free agreement for the NHS. CBLA appeared unwilling to do so and, apart from the fact that they appeared to be taking legal advice, it was very difficult to discover exactly what they were doing. In relation to clinical trials, it was reported that work was in hand for the revision of the current compensation schemes. It was proposed by Dr Forrester that the CSA should get the ABPI guidelines extended to cover all SNBTS products involving volunteers of any product given for non-therapeutic reasons.
11.355 On 10 June 1987, Mr Murray, SHHD, wrote to Mr Donald, General Manager, Common Services Agency, on the subject of clinical trials of Factor VIII: arrangements for compensation, clarifying certain matters relating to the compensation scheme provided by the department. On 11 June 1987, Dr Ludlam wrote to Dr Forrester, complaining that Dr Forrester’s draft minutes of their meeting was not a correct record: ‘If the Department is now reneging on its undertaking then that is an issue which will have to be considered separately.’
11.356 It appears that Z8 was in use by 11 June 1987: Dr Ludlam protested that it should not have been:
I am led to believe that the issue of Z8 to patients has begun. I was aware that the standard product was running short and that we had agreed to discuss the further evaluation of the new material but I was under the impression that there were several weeks’ supply left. I do not recall that I agreed that patients should be treated with this material. So far as I am aware it does not have a product licence from the CSM nor a clinical trials exemption certificate. I am unclear on what legal basis it is being issued and who is responsible for any adverse side effects ….I am now faced with a fait accompli over Z8. This has comprised my position and reduced the clinical options open to me; ie either to accept the situation and hope for the best or to go over to the purchase of commercial factor VIII.
11.357 This led to further correspondence. Dr Ludlam issued a letter to his patients which provoked an adverse reaction among colleagues. Dr Cash wrote to Dr Ludlam on 25 June taking issue with the terms of the document, in particular in relation to the comparison between SNBTS and commercial products, and pointing to the history of developments: 
I was surprised to learn that you were not aware of the extreme shortage of the NY product by February–after having received my ’Russian roulette‘ letter in December. The reason for the shortage, as you will recall, was the long delay in establishing the t/2 studies. Once again I referred to this problem at the meeting on the 9 February and Haemophilia Directors agreed to my proposal that we could start, forthwith, phasing Z8 into the RTC lanes when they needed topping up.
11.358 On 30 June 1987, Dr Ludlam wrote to Dr Cash: they had different recollections about what was agreed on 9 February; he had objected to Z8 being introduced without local arrangements being made while he was abroad; he had amended the patient consent document by deleting the reference to commercial products; and he hoped that Dr Cash was satisfied that he had recommended the PFC Liberton product strongly to the patients. He agreed to meet and work out a constructive way forward. On 13 July 1987, Dr Cash and Dr Ludlam arranged to meet on 25 August at Dr Cash’s home.
11.359 Dr Ludlam was not alone in expressing concern about the SNBTS product.
Dr Lowe published an article in which he cast doubt on the effectiveness of heat treatment at this time, and advocated the use of cryoprecipitate as a lower risk therapeutic material. There was a reaction to this step.
11.360 On 29 June 1987, Drs Cuthbertson and Foster wrote to Dr Perry regarding
Dr Boulton’s findings. There were unacceptable variations among the results from different tests. They proposed an SNBTS meeting to discuss the issues raised before submitting the data to DHSS in support of a licence application.
11.361 The Scottish Health Service Central Legal Office wrote to Dr Cash at length on
15 July 1987 on compensation for clinical trials and product liability. 
11.362 The paper anticipated in January 1986, on trials of calcium-stabilised Factor VIII was prepared and circulated in July 1987. A second draft was circulated in August 1987. Vox Sanguinis sent the paper to referees. Both referees approved the paper for publication subject to certain comments.
11.363 On 11 August 1987, Dr Foster wrote to Dr Cash commenting on the yield differences between six-hour and 18-hour cryoprecipitate: he anticipated that the differences at the cryoprecipitate stage would be reflected in the final product now that the manufacture of Z8 was in hand.
11.364 On 24 August 1987, Dr McClelland reviewed a paper by Dr Cuthbert on haemophiliacs who received batches of Factor VIII containing HIV positive donations and made comments. He sent it on to Dr Perry (who was ‘responsible for all the regulatory aspects of these products’) for review. Dr Perry also commented. The paper was intended for submission to The Lancet as a letter. The draft was optimistic in tone. Discussion tempered the possible conclusion that heat treatment had worked completely. The published letter set out the following discussion:
No new seroconversions have occurred amongst haemophiliacs treated at this centre since heat treatment of FVIII concentrate was initiated by SNBTS in December 1984. By retrospective studies we have identified two batches of FVIII concentrate which each contained an HIV-seropositive donation from individuals later found to be anti-HIV-seropositive. In both cases stored reference serum collected at the time of the donation was anti-HIV-positive, leaving no doubt that both batches had been contaminated with HIV. This study indicates that the relatively mild heat treatment applied to these batches prevented transmission of HIV infection in this cohort of haemophiliacs. However, there is evidence from other centres of seroconversions following transfusion of FVIII concentrated by a variety of methods. Factors other than the heating conditions such as the viral load within the plasma pool may also contribute to the infectivity….Because of these reports, and to further increase the margin of safety, a more rigorous heating process for SNBTS FVIII concentrate preparations is now used (80˚C for 72 h) in the hope of completely eliminating HIV (and possibly also hepatitis) transmission.
11.365 On 16 September 1987, Dr Smith, Oxford, prepared a report on surveillance of NANBH transmission by BPL concentrates 8Y and 9A dry heated at 80˚C for 72 hours. It was not conclusive, because of ‘imperfect evidence’, but ’…the apparent near-zero incidence’ justified further study. Consent forms for further study were prepared. The consent form emphasised the voluntary nature of participation, and drew attention to certain risks associated with it. A related protocol dated 12 September 1987 indicated that the purpose was to re-assess Factor VIII 8Y under stringent clinical trial conditions. Significant background comments included:
Some 15-25% of multi-transfused haemophiliacs have liver biopsy evidence of chronic active hepatitis or cirrhosis, and recent studies suggest that liver disease is an increasingly common cause of death. A major cause of liver disease is thought to be the transmission of the agent(s) responsible for non-A, non-B hepatitis (NANBH) by therapeutic clotting factor concentrates. In patients receiving conventional unheated concentrates for the first time, acute post-infusion NANBH is a virtual certainty, implying invariable contamination of these products. Because there are no reliable serological tests for NANBH, attempts to eliminate this contamination have largely focussed on the possibility of sterilizing concentrates by chemical or physical means.
Although heating in the freeze-dried state at 60˚ is probably effective against human immunodeficiency virus (HIV), clinical studies in ‘first exposure’ recipients have shown that the incidence of NANBH still remains close to 100%. Heating in solution appears to be more effective in neutralizing NANBH, but there is a penalty in decreasing yield of factor VIII.
The Blood Products Laboratory (BPL) has recently developed fractionation methods which allow factor VIII to be heated to 80˚ for 72 hours with minimal loss of factor VIII activity. This material is issued under the code name 8Y.
11.366 It was explained that unremunerated donations would be used and serologically screened for anti-HIV and HBsAg, and that donations would not have been screened by ALT or anti-HBc.
11.367 The 19th meeting of the UK Haemophilia Centre Directors was held at the Royal Free Hospital Medical School, London on 25 September 1987. The proposed trial of 8Y and 9A was commented on. Dr Kernoff was reported to have said that experience with 8Y and 9A clearly indicated that they were safer than previously available NHS and commercial concentrates as regards HIV and hepatitis transmission. However, it was undeniable that the evidence on safety was somewhat ‘soft’ in scientific terms. ‘Hard’ evidence, comparable with that available for certain new commercial products, could only be obtained from a rigorously performed ‘virgin patient’ study, carried out in accordance with the protocol suggested by the ISTH. As Dr Smith had previously acknowledged, the BPL tests had not met this standard. For this reason, a new study was to be mounted of the 8Y product in patients who had never previously been exposed to any blood or blood products. Dr Kernoff and Dr Rizza would be the coordinators, with data collection at Oxford. The Treasury had agreed to indemnify participants on the same basis as was normally done by the pharmaceutical industry, and a clinical trial exemption certificate had been applied for. Dr Kernoff said it was important for participants to seek approval for the study from their local ethical committees.
11.368 The SNBTS directors met on 6 October 1987. The status of the patent claimed by the Sinai Medical Centre was still unclear but PFC Liberton had reported their method at the 1987 conference of the International Society of Thrombosis and Haemostasis and there had been no approach by the Sinai Medical Centre. Dr Perry would continue his investigations.
11.369 On 9 November 1987, Mr MacNiven, SHHD, wrote to Dr Cash indicating that the compensation arrangements for Factor VIII might be extended to the therapeutic stage as well as clinical trial stage of trials.
11.370 The SNBTS directors met on 8 December 1987. Dr Perry reported that the Sinai Medical Centre appeared to have withdrawn their patent claims. Stanford University had filed an application which appeared to be out of time. CBLA believed that there was no longer a patent problem.
11.371 The CDC emergency meeting at Atlanta of manufacturers and USA haemophilia doctors to discuss seroconversions to HIV in ‘naïve’ haemophiliacs who had been treated with heat-treated Factor VIII in North America took place on 11 January 1988.
11.372 Internationally, the BPL product was gaining support. On 29 February 1988, the New England Medical Centre Hospitals, Boston, USA wrote to BPL Elstree, asking BPL to apply for US Food and Drug Administration approval of the BPL process for heat treatment of Factor VIII (Factor 8Y ie heated at 80˚C for 72 hours). The medical centre expressed the view that BPL factor 8Y was the safest concentrate available, and encouraged the application so that it would be available in the United States.
11.373 The SNBTS directors met on 12 April 1988. Professor Collee of Edinburgh University had inspected the facility at PFC Liberton, and had approved it, orally, for transfer there of HIV validation studies. SHHD said that a submission was with the minister, and that a decision could be expected soon.
11.374 In April 1988, Dr Cash prepared ‘Notes for Scottish Health Service Haemophilia Centre/Transfusion Service Directors’ Meeting: May 1988’. On 19 April 1988, Dr Perry prepared ‘Notes for Haemophilia Directors Meeting May 1988 (Scotland only)’. Dr Perry wrote that clinical evidence was accumulating to indicate that dry heat treatment of coagulation factor concentrates (80˚C/72h) was capable of providing non-infective products (HIV, NANB and HB). Whilst these data were derived from studies of 8Y (BPL product), model virus studies at PFC Liberton indicated that the SNBTS product (Z8) had a comparable level of virus inactivation. Model virus studies had also established that dry heat treatment (80˚C/72h) was comparable in virucidal efficacy to ‘new generation’ solution heated commercial products. HIV inactivation data was not available. Transfer of HIV testing to PFC Liberton (subject to SHHD approval) was imminent. It was anticipated that 80˚C/72h dry heat treatment would be shown to be highly effective in HIV inactivation.
11.375 By this stage, it was clear that a submission for product licensing would require to be supported by HIV inactivation data to meet DHSS requirements. Formal submission for the grant of product licence variations (Factor VIII and Factor IX) had been delayed pending the availability of HIV data.
11.376 It was noted that PFC Liberton had established a two-stage development strategy for Factor VIII products. The underlying policy was to concentrate on product virus safety, more appropriate dose size and national self-sufficiency. An emphasis on product purity per se was considered inappropriate at that time.
11.377 In a letter dated 21 April 1988 from Dr Ludlam to Dr Forrester (SHHD) it was noted:
Liability for FVIII concentrates:
[T]here have been discussions about the legal basis under which products are being issued for the treatment of patients with congenital disorders. I should be grateful if you could clarify the position for products issued since 1983 (particularly as these now form the basis of a legal action).
I am concerned about future arrangements for the testing of coagulation factor concentrates produced by PFC. The potential difficulties are exemplified by Z8 and testing it for viral safety ….Our difficulty in Scotland will be to find sufficient previously untreated patients in which to assess this product.
11.378 The SNBTS Directors, Haemophilia Centre Directors and SHHD met on 5 May 1988. Dr Cash and Dr Perry produced a report for the meeting. It was reported that PFC had succeeded in producing Factor VIII and Factor IX dry heat treated at 80˚C for
72 hours. HIV validation was in hand.
11.379 Dr Foster wrote to Dr Smith on 9 May 1988 with comparative yield data. He thought that the results had been affected by a breakdown of the plasma conditioning unit which had had to be rebuilt.
11.380 On 14 June, 1988, the SNBTS Directors met. Use of PFC Liberton for HIV validation studies had been approved. On 23 June 1988, there was the first meeting of the Scotland and Northern Ireland Factor VIII working party.
11.381 On 2 July 1988, The Lancet carried a letter by Dr Foster and others supporting the effectiveness of dry heat-treated products. The International Medical Technologies Corporation, Los Angeles, wrote a supportive response.
11.382 Alpha Therapeutic Corporation hosted a conference from 18–19 July 1988. Dr Cuthbertson reported. There had been discussion of developments in commercial products. Alpha was applying solvent-detergent technology with final dry-heat treatment. Data were provided on the incidence of HBV, and Delta virus. Dr Mannucci spoke on trial protocols. He found BPL’s trial data unacceptable. He continued to maintain that dry-heat treatment was ineffective in inactivating NANB, and that the NYBC data were wholly inadequate to support their claims that it did. Anecdotal material claimed that the Behring product was associated with HBV transmission.
11.383 On 23 July 1988 a Lancet article by Dr Horowitz and colleagues was published on virus safety of solvent-detergent-treated Factor VIII concentrates. This contained a good introduction on the pre-heat treatment phase of manufacture (already mentioned), and the initial attempts at heat treatment as an introduction to discussing the solvent-detergent method:
Human albumin, heated with specific stabilisers when liquid, has never been reported to transmit virus, and so many manufacturers first used heat treatment to try to make other blood products virus-safe. Several studies on viral infectivity of heat-treated coagulation factor concentrates in newly diagnosed patients have been reported. Blood products heated in the lyophilised state at 60˚C, or 68˚C, continued to transmit NANB hepatitis at high frequency, whereas lyophilised product heated at 80˚C, or heated in the presence of raised moisture, , and product heated in solution at 60˚C do not. Each of the process methods seems to decrease, and may eliminate HIV transmission.
The movement towards processes other than dry heat treatment in the commercial sector was well established by this stage.
11.384 On 11 October 1988, the Scotsman announced the use of genetically engineered blood clotting agents (at the Royal Free Hospital, London, by Dr Peter Kernoff,). Synthetic Factor VIII had arrived.
11.385 In a report dated 15 October 1988 entitled ‘Coagulation Concentrates: A 1988 Status Report’, the American Blood Resources Association set out an apology for the current state of the industry (interestingly there is a manuscript note to that effect on the covering letter from John Cash to J T Donald of the CSA). It set out to justify the high cost of products. And it explained some of the problems confronted, including lack of product liability insurance.
11.386 On 18 November 1988, Dr Cash wrote to Dr Ludlam about the proposed clinical trials of Z8 in a Factor VIII PUP Study. Its major purpose was to ascertain the safety of the current SNBTS product with a view to using the data so derived for future product licence applications. The primary aim of the study was to assess HIV and NANB virus transmission by Factor VIII/IX concentrate. Participating centres were to be Aberdeen, Belfast, Dundee, Edinburgh, Glasgow (GRI and Yorkhill), and Inverness.
11.387 By now, the use of genetically produced materials was anticipated. On 25 November 1988, in an internal SHHD memorandum from Graham Calder to Mr D Macniven (cc
Dr McIntyre, Mr Hamil), Dr Schild, Director of the National Biological Standards Board (NBSB) and National Institute of Biological Standards and Control (NIBSC) was quoted as saying that by 1990 at the latest a Factor VIII genetically produced from rDNA would be freely available from the commercial market at a cost much less than the products currently extracted from human plasma and that the product would ‘of course’ be much safer.
11.388 On 14 December 1988, Dr Cuthbertson sent Dr Ludlam data on HIV infection following the use of Behring’s heated products and conventional unheated products. Seven of twelve patients in the second group were infected. All of the patients who received only Behring products were HIV negative.
11.389 Dr Perry sent a memorandum to Dr Foster and others (not including Dr Cash) on
22 December 1988. There had been a modification to the Z8 freeze-drying cycle that had led to a major improvement in product quality and perhaps yield. But he was concerned that the modification could have been introduced many months previously. There were other modifications in the same position. He called for a review of the management of change, for a scientific audit, and for clarification of the role of research and development staff in relation to such processes.
11.390 Internationally, the USA Food and Drug Administration and NHLB co-sponsored a ‘Factor VIII Conference’ at Bethesda, Maryland on 9–10 March 1989. There is a brief conference report. Drs Lane and Smith attended from England. The Committee of Experts in Blood Transfusion and Immuno-Haematology met at Liege 23–26 May 1989. Dr Gunson analysed the responses to a questionnaire on NANBH. It provided good information on what was happening in other countries.
11.391 In the United States, regulatory approval of new generation products continued. In March 1989, the US FDA licensed for clinical use Bayer’s chemically (solvent/detergent) treated Factor VIII product, Koate HP (which replaced Bayer’s pasteurised Factor VIII product, Koate HS).
11.392 Published material provided information on progress. ‘The Use of Purified Clotting Factor Concentrates in Hemophilia: Influence of Viral Safety, Cost and Supply on Therapy’ by Pierce, Lusher, Brownstein, Goldsmith and Kessler, provided a snapshot of where US scientists had got to with heat treatment and viral inactivation. It was noted that the leading cause of death in persons with haemophilia had become AIDS.
11.393 Information about new production methods continued to emerge. In June 1989, an article on the ‘Effect of Gamma Irradiation on the Human Immunodeficiency Virus and Human Coagulation Proteins’ was published by Kitchen and others. The abstract stated:
The effect of gamma irradiation on HIV and plasma coagulation factors F VIII:C, F VIII: vWF and F IX was studied ….The use of gamma irradiation to inactivate infectious agents present in human plasma may eliminate the need for any post-production viral inactivation methods and provide a means of assuring the safety of as yet untreated products such as cryoprecipitate and fresh frozen plasma.
11.394 In 1989 a paper was published by Winkelman and others on the method of manufacture of BPL’s 8Y Factor VIII (dry heated at 80˚C for 72 hours). The key step in the new manufacturing process was said to be the use of heparin at temperatures above ambient to precipitate fibrinogen and fibronectin. The 8Y concentrate had been in use since 1984 and results of NANBH surveillance in 33 susceptible patients showed no transmission of NANBH.
11.395 In 1989 a paper by Pasi and others was published reporting that the BPL Factor VIII product 8Y (dry heated at 80˚C for 72 hours), introduced in 1985, appeared to have prevented transmission of HCV and HIV. 
11.396 In the United Kingdom, the regulatory framework was about to change. The first meeting of the Advisory Committee on the Virological Safety of Blood was held on 4 April 1989. The members were Dr Lane, Professor Zuckerman, Dr Summerfield (Middlesbrough), Dr Tuddenham, Drs Perry and Mitchell from Scotland, Dr Minor (NIBSC) and Dr Mortimer of the PHLS. Related groups noted were CSM and the Biologicals Subcommittee; the National Transfusion Directorate; the UK Advisory Committee on Transfusion Transmitted Diseases; the NBTS/NIBSC Liaison Group; the NBTS/CBLA Liaison Group; the EAGA; the Advisory Group on Hepatitis; the MAC (Microbiology Advisory Committee). The landscape was well populated by committees. The remit of the advisory committee on the virological safety of blood was discussed. It was envisaged that it would have a role in relation to regulation: the EC Directives on blood products could have a major impact on the UK. Products that had until this time been made under Crown privilege would have to be licensed. Blood would have to be harvested from donors selected according to the Directives and certain tests for virological conditions might be mandatory. It would also have regard to NANBH, in respect of which it was recorded that the issue of surrogate or direct testing for NANB was of some urgency.
11.397 On 22 May 1989 the Advisory Committee on the Virological Safety of Blood held its second meeting. Papers produced included material abstracted from the UKBTS/NIBSC Guidelines (Draft March 1989). Part 5 dealt with viral inactivation, and set out a specification for the validation of virus inactivation procedures used during the manufacture of clotting factor concentrates.
11.398 The specification outlined minimum requirements. Because of the complex interaction of a number of factors influencing inactivation, the specification required that each manufacturer must validate each product individually. It then provided:
In order to minimise the virus challenge to the manufacturing process, each individual plasma donation used for the manufacture of coagulation factor concentrates must be tested for the presence of hepatitis B surface antigen and for antibody to the human immunodeficiency virus, type 1 (HIV-1). In future it may become necessary to test for other viral contaminants. The assay methods must comply with the minimum requirements defined in the appropriate specification for each product….
Validation of formal virus inactivation step
1) Data should be generated which demonstrate that at least one single stage in the manufacturing process is capable of inactivating at least 105 infectious particles of HIV per ml of solution (ie a 5 log reduction in the concentration of viable virus.)
2) It is widely recognised that the transmission of non-A, non-B (NANB) hepatitis is a major potential problem. The agent(s) of NANB hepatitis have not yet been cultured and it is, therefore, recommended that data are generated on the ability of the process to inactivate a range of other ‘model’ viruses to include RNA and DNA viruses, both enveloped and non-enveloped. It is suggested that these might include Vaccinia and Semliki Forest viruses as these have both proved fairly resistant to heat inactivation.
These were clear indications of the development of a regulatory framework for ensuring viral safety.
11.399 At PFC Dr Rooney produced a laboratory protocol for the pharmacokinetic study of Z8 and S8 in haemophilic patients on 14 February 1989. Dr Prowse had a number of reservations which he set out in a letter to Dr Rooney dated 17 February 1989.
11.400 SNBTS research and development work proceeded on a high-purity product, now designated S8. The ‘S8 Group’ met on 28 February 1989. The date of the first full clinical trial production run was confirmed as 3 April 1989. However, a number of research and development issues remained to be resolved: the diafiltration buffer required modification; the formulation process required fine tuning; the freezing and super cooling aspects of lyophilisation were under investigation; and modifications to the zinc precipitation agent were continuing, among other things. A draft specification for the new product was prepared and circulated with the notes of the S8 group meeting held on 10 May 1989. A forward programme was agreed.
11.401 The report of the first meeting of the Scotland and Northern Ireland Factor VIII working party, dated April 1989, dealt with statistics relating to blood collection, Factor VIII manufacture at PFC Liberton, purchases from commercial sources, the development of the new Factor VIII product and viral safety among other issues. Without the supporting papers the report is not helpful. But these points emerge:
• The existing Factor VIII manufactured by PFC Liberton (Z8) was not an optimal product and a new higher purity concentrate was under development. This had progressed more slowly than originally anticipated. It was anticipated that the first infusions would occur in June and a formal phase I study (of percentage recovery and half life) would take place at the premises of Drug Development (Scotland) Ltd in September. Thereafter a phase II study would follow to demonstrate clinical efficiency.
• There was no evidence to suggest that Z8, heated at 80˚C for 72 hours, would transmit HIV or NANBH. Although there was substantial evidence to demonstrate HIV safety (no seroconversions were known since 1985 when heat treatment was introduced) there were very few data positively to demonstrate NANBH safety. To date the second 8Y study in England and Wales had not recorded any episodes of NANBH. One meeting of the working party had been given over solely to consider methods for viral inactivation. The opinion of the group was that at that stage only heat treatment was preferable to a solvent detergent technique.
11.402 The SNBTS and haemophilia directors met on 21 July 1989. Dr Stewart prepared notes on 23 June 1989 for the meeting setting out production statistics and forecast data. Dr Ludlam presented the first report of the Scottish and Northern Ireland Factor VIII working party. The new product S8 was discussed: the haemophilia directors expressed the hope that this product, which had the same purity as the commercial products, would be available soon. Z8 had a low purity. He said that there was an international movement towards high and very high purity products ‘even though evidence of their value was lacking’, and that directors were coming under pressure to use them. It was pointed out that purity did not equate with safety, and was associated with lower yield.
11.403 The SNBTS directors met on 29 September 1989. There were reports on the advisory committee on virus safety of blood and tissue, and on the UK advisory group on transfusion-transmitted diseases: HTLV1, and Hepatitis C, as NANBH had been designated. Testing for NANBH (including the Chiron test) was now a focus for work. There were reservations about the Chiron test, but it was thought that HCV testing was now inevitable under the Single European Act, if other European countries were already testing. Directors were required to develop a protocol for testing and donor counselling. Ortho (Chiron) would be kept advised.
11.404 So far as concerns viral inactivation at this stage, Z8 was effective by the end of the decade to inactivate HIV and NANBV. That was the view of Dr Ludlam as expressed in his expert opinion prepared to support SNBTS’s application for a product licence variation for Z8:
Factor VIII Z8 has been the concentrate treatment of first choice for my patients since its introduction into routine use in 1987. This is consistent with the view of the UK Haemophilia Reference Centre Directors report…which recognises FVIII products which have been dry heat-treated at 80˚ for 72 hours as being amongst the safest available products with regards to the risk of virus transmission.
11.405 On 8 November 1989, Dr Pepper prepared an agenda entitled ‘FVIII Improved Stability and Yield’ for a meeting of the product development group to be held on
10 November 1989. Priority areas for discussion included terminal heating and other virucidal steps. The items listed included: improved stability in process, terminal heating and during transportation; improved stability of von Willebrand Factor activity; assay methods; empirical and theoretical approaches to process development; and viral inactivation (a manuscript addition indicated that it was assumed that the Johnson method would be the initial aim). Internal memoranda indicated that self-sufficiency remained the goal of CSA and the SNBTS. But, with two three-month shut-down periods anticipated in the following year, it was thought that PFC Liberton could not supply demand in 1990–91.
11.406 The product development group met on 10 November 1989. Priority areas for action identified (other than viral inactivation) included additional plant; assay development; stabilisers and other specific matters. Various options for development of the high-purity product were discussed, and in particular terminal heating (including both dry and wet heat and possibly solvent-detergent) as virucidal steps. It was agreed that there would be empirical and theoretical studies of variables. Existing and novel stabilizers were to be studied. Assays for detergents and solvents were to be set up. Viral inactivation of Hepatitis B, especially by wet heat, was to proceed to clinical trials in three years. Work was to be done on viral inactivation of Hepatitis B (especially wet heat). Three years to clinical trials was thought to be a reasonable estimate of the time required. In relation to Hepatitis B, it was noted that a major area requiring discussion was how toxicology and safety should be tackled.
11.407 On 29 November 1989, Dr Perry recorded that Dr Foster had agreed to take the lead in defining key control parameters for Factor VIII manufacturing processes.
11.408 On 30 November 1989, there was a ‘Z8 trouble shooting’ meeting, apparently one of a series. Analysis had demonstrated increasing fibrinogen content in process cryoprecipitate resulting from coolant problems. The increase made the overall Z8 process less efficient, and led to a decline in solubility. The complaint of the haemophilia directors about the usefulness of the product appeared to have been substantiated. Improvements were scheduled for research and development.
11.409 An undated paper of unknown circulation set out ‘Current Issues on High- and Ultra-pure Factor VIII Concentrates’ possibly in November 1989. It contained data showing: the specific activity and concentration factors of a range of commercial products; protein content of various commercial products; tables comparing the purity of a range of products in terms of specific activity and fibrinogen content; and potency data. The data appear to show that a number of commercial products were not of high specific activity and high purity.
11.410 The position achieved by SNBTS research and development at the end of 1989 appears to have been difficult. Z8 seems to have been an increasingly unpopular product among haemophilia doctors. It was acknowledged to be very safe but, in comparison with commercial products and BPL 8Y, it was lacking in purity with consequential disadvantages in its administration. S8 was not making the progress hoped for. Dr Mayne suggested that Scottish plasma should be sent to England for processing as 8Y.
11.411 In the early 1990s the approach to manufacture changed, with development involving collaboration with CRTS, Lille, in the production of purer products. As at
2 February 1990, Lille concentrates were dry heat-treated at 80˚C for 72 hours. It appeared that terminal heat treatment could be a valid option for ‘high purity’ products.
11.412 The SNBTS Directors met on 13 February 1990. Discussion centred on viral safety; HCV testing; AIDS; and other issues. In relation to production, Dr Perry tabled a standard operating procedure for product recall. This reflected practice in England and Wales and was a step towards harmonisation of practice in the UK. It represented a relaxation of the original criteria because it provided for action on the results of serology of the donation at the point of donation. Dr Gunson was present and reported on BPL plasma specification. Dr Perry undertook to maintain contact to ensure that the two UK fractionation centres remained in harmony. It was also agreed that there was a need for a forum to debate the professional elements of SNBTS work and to consider methods of interface with SHHD and NBNTS. If this was only happening at the beginning of 1990, there may be questions for the Inquiry about timing, and whether previous opportunities for cooperation had been lost. Apheresis guidelines were revised on a UK-wide basis.
11.413 Research into other topics continued. On 20 March 1990, Dr Pepper reported on work on a cross-linked pyridoxal stroma free haemoglobin. A patent application was prepared, and a paper prepared for publication.
11.414 Dr Ludlam wrote to Dr Perry on 30 April 1990:
As you know we have several research projects examining both HIV and the effect of factor VIII concentrates on the immune system. It is becoming increasingly clear to us that library samples that may be held at PFC from batches of factor VIII issued previously will be extremely useful. I wonder if it would be possible for you to retain all library samples for batches of factor VIII issued after 1980. If this poses you with a storage problem perhaps you could let me know.
I wonder if you could give me an idea as to what library batches you might have in stock?
I wonder if you could let me know the number of bottles of the batch of factor VIII we believe was implicated in the transmission of HIV in 1984? We have developed a PCR for HIV RNA and in the near future we would like to examine the batch and other associated batches.
11.415 Dr Prowse wrote a development proposal paper in April. In respect of viral inactivation in a new product, he wrote:
Given the yield losses incurred by use of dry or wet heat treatment, our current problems in routine application of severe heat treatment (due to the critical limits in terms of freeze drying for success using this technique) and Jim Smith’s statement that severe heat treatment of products under 10 mg/ml is very difficult to achieve, I believe that we will need to adopt established solvent detergent methodology. However, recent in-house data on heat treatment of the Lille product…suggests it may be possible to retain in excess of 70% VIII activity at a specific activity of 100u/mg. Thus we should not abandon terminal treatment, but should continue to work on this as a ‘belt and braces’ approach.
11.416 Because of time constraints, he advocated sub-licensing an established technology such as that of CRTS Lille. He also proposed a collaborative effort with England and Wales. For the longer term he proposed chromatography processes.
11.417 On 9 May 1990, representatives of the Glasgow and West of Scotland BTS attended a meeting at St Thomas’ Hospital at which Cutter reviewed new technology for the production of recombinant Factor VIII. Prototype products had had two years clinical use by this stage, and were ‘ok’.
11.418 The need for a high-purity product had been discussed by Dr Cash in a memorandum dated 22 May 1990. In relation to viral inactivation, he thought that terminal dry heating should not lightly be abandoned. Because there was an open invitation to acquire CRTS Lille technology, solvent detergent had to be considered seriously. The vast majority of the world’s fractionators had taken that route. He proposed that PFC Liberton ‘bite the bullet’ and opt for the total Lille package. As a matter of background, as matters progressed, it appears to have been recognised by this stage that SNBTS had had success in producing a Z8 Factor VIII that was virucidally effective.
11.419 The National Science Laboratory was formed in the first half of 1990 by the amalgamation of the SNBTS Headquarters Laboratory and staff drawn from the Edinburgh and South East Regional Centre, under the direction of Dr Prowse. The purpose of NSL was to provide a basic science facility for the SNBTS, mainly directed towards the development of blood products with the PFC.
11.420 On 12 June 1990 the SNBTS directors met. This was to be the last directors’ meeting in its current form. The directors’ meetings would be replaced by a medical and scientific committee. Such a committee was required to consider medical and scientific matters presented by its proposed sub-groups and to reach decisions as to how to advise the management board. Future methods of liaison with the SHHD had to be decided and contact with the NBTS directorate would be maintained.
11.421 Dr Foster and Mr McIntosh visited Lille on 9–11 July 1990 and prepared a report. They had mixed impressions of the Lille operation. Some aspects of the plant impressed: the freeze-drying facility, and the autoclaves, for example. PFC personnel should visit those. But manufacturing practice and organisation were thought generally to be poor; safety of the product was questionable; there were deficiencies in the Factor VIII process; and the product was relatively untried in terms of clinical assessment. In detailed analysis, the report commented on the large and impressive investment in plant and equipment, and the space available. But the comments on practice were severe. The general conclusion was that practice was not up to American or UK standards. Apart from visiting the facilities, the reporters thought that collaboration was required on a range of technical matters, and recommended a review of SNBTS’s strategy for development of a high-purity Factor VIII.
11.422 On 13 July 1990, it was reported that Dr Prowse was making progress in establishing a joint venture with NIBSC on the immunosuppressive properties of Factor VIII concentrates.
11.423 A protocol for the pharmacokinetics study required in connection with S8 was prepared by the beginning of August 1990, but was thought to be at risk, in relation to regulatory requirements, by draft ICTH guidelines that had just been announced. Dr Stewart wrote to haemophilia directors to canvass their views. On 9 August 1990, he wrote to Dr Ludlam. On the basis of the limited response he had, he had made minor changes to the protocol. With one exception, relating to blood sampling, Dr Ludlam approved the protocol. Dr Stewart reported to Dr Cash. Dr Stewart wrote to Drug Development (Scotland) Ltd, Ninewells Hospital, Dundee, and regional directors of BTS, to enlist support in the study.
11.424 Discussions with Lille continued, and regulatory requirements in France were progressed in October 1990. On 30 October 1990, SNBTS sent details of SNBTS methods for preparation of Factor VIII (S8) to Lille. Arrangements were made for the supply of CRTS documentation for licence purposes if it were agreed to proceed. This was the beginning of a new chapter in factor concentrates research and development.
11.425 On 16 October 1990, a meeting was convened to discuss the relative ineffectiveness of S8 in virus inactivation compared with Z8: S8 fell below the UK minimum standard for vaccinia kill. Further studies were agreed.
11.426 As these matters were progressing, Dr Foster wrote to Dr Prowse, on 21 November 1990, a long letter in which he challenged much of the thought on process options, and the efficacy of the arrangements proposed. Manuscript annotations on the letter take up the challenge on most of the points made. The letter ended with an extensive discussion of the roles of suitably qualified engineers in process planning, and a plea for closer cooperation with the ‘emerging NSL’.
As at the end of 1990:
• There had been a succession of newly designed and re-designed Factor VIII concentrates employing a wide range of technologies, in the United Kingdom, including Scotland, and internationally.
• In retrospect it appears probable that no transfusion, Factor VIII, or Factor IX-related cases of HIV infection occurred in Scotland after the introduction of heat-treatment (at 68˚C for two hours) in 1985.
• Increasingly, procedures to reduce the risk of transmission of NANBH, latterly re-designated Hepatitis C, gained prominence, focused on heat treatment, stabilisation of proteins, and the use of detergents.
• It appears that difficulties over legal indemnities and questions about the licensing of new, but promising, products may have affected the introduction of the best new products into routine widespread clinical practice.
• But, PFC Liberton’s standard production concentrates were by this time safe in terms of virus infectivity, if less pure than some commercial products.
• Z8, heated at 80˚C and introduced around June 1987, did not transmit NANB Hepatitis/HCV.
• In pursuit of purity, SNBTS engaged with CRTS Lille in product development, but by the end of the year, safety with the emerging product had not been validated.
11.427 Virus inactivation continued to be a matter of importance in relation to the development of new high-purity products.
11.428 In January 1991, studies were proposed in supercooling plasma in the process of producing cryoprecipitate. In the same month toxicology studies were proposed relating to the use of Tween 80 and TNBP in blood concentrates. On 8 February 1991, Professor Cash distributed available data to haemophilia directors and others: the definitive toxicology report was not available.
11.429 Contact with the New York Blood Centre relating to licensing of solvent/detergent technology continued. This was a necessary treatment step in the manufacture of the Lille product. On 21 January 1990, the centre wrote setting out the licensing arrangements and fees required for access to the technology. It appears that the licence was agreed by 15 February 1991.
11.430 On 22 February 1991, the Medical Research Council Human Genetics Unit at the Western General Hospital, Edinburgh, proposed publication of data on research into the effects of Z8 and S8 Factor VIII on in vitro lymphocyte cultures. Their conclusion was that intermediate-purity Factor VIII concentrates could potentially accelerate the progression of disease in haemophiliacs infected with HIV.
11.431 On 3 May 1991 a technology exchange agreement was signed between the French and Scottish blood transfusion services to enable the SNBTS to produce a high-purity Factor VIII.
11.432 Following an article in The Lancet, Dr Foster wrote to Dr Prowse on 12 June 1991, proposing to refer to NSL for study a question whether the solvent detergent method threatened the binding of phospholipids to Factor VIII, affecting virus inactivation, VIII yield, and product antigenicity. A manuscript note on the letter indicates that Dr Stewart thought this a good idea.
11.433 The development and use of SNBTS fibrin sealant attracted surgical interest in January 1992. The product was thought to have potential for use in a number of surgical procedures.
11.434 In November 1992, Dr Cash wrote to Dr Ludlam. There had been reports of Hepatitis A transmission in Factor VIII concentrates. SNBTS had discussed the issue, and proposed to expedite developments that would enable PFC Liberton to introduce a terminal dry heat procedure in coagulation factor concentrates.
11.435 The New York Blood Centre wrote to Mr McIntosh on 16 November 1992. The reports had related the outbreaks to the use of solvent detergent-treated products. Dr Horowitz had written commenting that a great deal of study would be required before the treatment could be implicated. But as holders of the patent licensed to SNBTS they were clearly concerned. A paper produced in Northern Ireland implicated Octapharma (using the same technology) in Hepatitis A outbreaks.
11.436 At the meeting of the SNBTS medical and scientific committee on 9–10 November 1993, it was agreed that the introduction of steps necessary to deal with transmission of the Hepatitis A virus had been effective. Increasing yield and purity of Factor VIII were again priority issues. Matters had come full circle with the effective elimination of the risk of HIV/AIDS transmission.
 Introduction – Blood Products
 A product developed using monoclonal antibodies, that is highly purified specific antibodies against particular antigens reproduced from lymphocytes primed with antibody to the target antigen
 ’Jaundice and Antibodies directed against Factors VIII and IX in patients treated for haemophilia or Christmas Disease in the United Kingdom’, British Journal of Haematology, 1974, 26, 313.[SNB.001.4837]
 Oxford Haemophilia Centre
 [SNB.001.4822] For a graphical presentation of the volumes of factor VIII products used in the United Kingdom from 1969 until 1985 see Appendix 3 to the United Kingdom Regional Haemophilia Directors report of
4 February 1991. [SNB.001.5870]
 Productive of symptomatic disease
 In particular the causative role of the primary plasminogen activator from endothelial cells.
 Regional Centre, Edinburgh
 Hemofil was a Travenol product. Immuno produced Kryobulin under licence
 Whitman and others published a paper: ‘The Recovery of Factor VIII from Fresh-frozen, Indated and Outdated Human Plasma’ Thrombos.Haemostat (Stuttg.) 1976; 36: 71-77 [SNB.007.1303] This was a topic of apparent general interest at the time.
 Foster, Paterson, Johnson & Middleton: Later published as ‘Thrombogenicity of Factor IX concentrates and polyethylene glycol processing’, Thrombosis Research, 1980, 17; 273-279 [LIT.001.0208]
 ‘Intermediate Purity Factor VIII Concentrate; Changes in Antigen and Coagulant Activity during Production’, B.J. Haem, 1980, 46; 334
 Dr P. M.Mannucci Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Milan
 Hruby et al, ‘Transfusion-related short incubation hepatitis in hemophilic patients’, JAMA, 1978; 240: 1555-1557; Fletcher, Trowell, Craske, Pavier, Rizza, ‘Non-A, non-B hepatitis after transfusion of factor VIII in infrequently treated patients’, British Medical Journal, 1983; 287: 1754 - 1757 [LIT.001.0239]; Kernoff & Ors, ‘High Risk of non-A, non-B hepatitis after a first exposure to volunteer or commercial clotting factor concentrates: effects of pooled human immunoglobulin’, Br J Haematology 1984; 58; 174. [LIT.001.0800]
 The materials studied were Factor II IX and X concentrates (Supernine) pooled from the eluates of factors adsorbed from citrated factor VIII depleted plasma. Polyethylene glycol processing was employed. PEG processing was found to increase the thrombogenic material in the discarded precipitate, implying increased purity in the Supernine as compared with DEFIX.
 But this was not a new stance for Dr Cash: the Cash and Spencely paper in BMJ 18 September 1976 [LIT.001.0255] had suggested a possible re-think of freeze-dried cryoprecipitate. See also [SNB.007.1622] for progress with the project.
 This explanation was not sustained by later research, but it indicates the state of belief at a time when full scientific explanations were not available.
 Heimburger et al, ‘Factor VIII concentrate – now free from hepatitis risk: progress in the treatment of haemophilia’, Die gelben hefte, 1980; 4: 165 - 174 [SNB.004.5880]; see also Heimburger et al, ‘Factor VIII concentrate highly purified and heated in solution’, Drug Research, 1981; 31: 619 - 622 [SNF.001.0881]. This version of the text was translated into English by W Zolg. See [SNB.008.6794] for German version.
 Compare the later development of solvent-detergent technology
 A Kroniger, A Kumpe, W Wormsbacher, B. Herchenhahn, (Schriftleitung: Prof Dr Dr hc H. G. Lasch; Prof Dr Dr h.c. P Matis.
Dr F Knuchel) Factor VIII Concentrates Die Medizinische Welt 16 July 1982.
 The two abstracts may refer to the same product.
 The DOH document has had all identification of participants redacted out
 The cut off at five batches appears to refer to data reported by Oxford suggesting that patients who had previously received four to five batches of material had a 50% chance of developing NANB Hepatitis.
 It was noted at this meeting that freeze dried cryoprecipitate production would be abandoned meantime by PFC
 German patent reference 291671
 Quality controls
 The Haemophilia Society, in their submissions to Archer, asserted that in May 1983 it was discovered that the HIV virus could be destroyed by exposing it to dry heat at 68°C for one hour. This assertion was apparently made on the basis of a USA Public Health Service press conference held in July 1983 concerning the Hyland Heat Process. It has not been verified. However, see ‘Notes from the meeting on plasma fractionation’ at Groningen 1 - 2 November 1984 [SNF.001.3373]
 the MRC researchers published their work
 These markers turned out to be spurious.
 Dr Smith’s letter of 3 (November?) 1982 had indicated that BPL were doing a little on heating factor VIII, but only on gentle conditions for the removal of fibrinogen, a position that appears different from what developed in 1983. [SNB.007.3267]
 The concentration of virus in the material.
 Appendix 8
 A possible explanation of the adverse reaction was offered in January 1983 when an article was published suggesting that sorbitol intolerance was an unappreciated cause of functional gastrointestinal complaints. Dr Ludlam was not convinced. [SNB.007.4329]
 However, Dr Ludlam questioned the appropriateness of infusing the patient who had reacted adversely to the earlier product.[SNF.001.3218]Dr Foster explained the reasons for the request: [SNB.007.4147] But Dr Ludlam remained unconvinced [SNB.007.4277]
 McDougal et al, “Thermal inactivation of the acquired immunodeficiency syndrome virus, human T lymphotropic virus-III/lymphadopathy virus, with special reference to antihemophilic factor, J Clin Invest 1985; 76(2):875-7 [LIT.001.0826]
 Lindsay Report, page 154
 The accuracy of the dating of the second set of samples is questionable. [SNF.001.3176] speaks of heating on this regime as a proposed new study. On 4 March 1985, Dr Perry wrote to Dr Boulton intimating that two batches of HT Factor VIII treated at 68˚ for 24 hours would be available for clinical trials within two weeks. [SNB.007.5001]
 A year previously
 The Oxford group
 [SNF.001.1091] The process was written up in Winkelman et al, “Severely heated therapeutic factor VIII concentrate of high specific activity”, Vox Sang, 1989; 57: 97-103, a report of the 8Y process developed at PFL Oxford
 [SNB.004.7780] at 7782 Lindsay, page 90 says that this was the first published account, but that does not appear to be the case in view of Dr Jones’ data. www.dohc.ie/publications/pdf./Lindsay.pdf?direct:1
 Lindsay, page 90 www.dohc.ie/publications/pdf./Lindsay.pdf?directdirect:1
 However, product leaflets did state the period of treatment.
 Dr Foster’s letter to Dr Smith dated 13 November 1985 may be an earlier suggestion to the same effect: see para 11.254
 [SNB.010.6169] McDougal, Martin, Cort, Mozen& Others: ‘Thermal inactivation of the acquired immunodeficiency syndrome virus, humanT lymphotropic virus – III/lymphadenopathy associated virus, with special reference to antihemophilic factor’: J Clin Invest 1985; 76:825-77. [SGF.001.1835] McDougal, Evatt: ‘Case for concluding that heat trated licensed anti-hemophilic factor is free from HTLV-III: Lancet 1985: ii: 890-1
 [SNB.004.7780] White, Matthews Weinhold, etc: ‘HTLV-III seroconversion associated with heat-treated factor VIII concentrate’: Lancet 1986: i: 611-2; Van den Berg;etc: ‘Seroconversion to HTLV-III in haemophiliac given heat-treated factor VIII concentrate’: Lancet 1986: i: 803-4
 See paragraph 11.262
 A joint research group of MRC/SNBTS
 Schimpf et al, ‘Absence of hepatitis after treatment with a pasteurized factor VIII concentrate in patients with hemophilia and no previous transfusions’ New England Journal of Medicine, April 9 1987; 316(15):918–922 [LIT.001.0643] on Hemate P; Kernoff et al, ‘Reduced risk of NANBH after a first exposure to wet heated factor VIII concentrate’ British Journal of Haematology, 1987;67: 207-211 on Hemofil T.
 Sinai Medical Centre
 Lowe, ‘Haemophilia, blood products and HIV infection’ Scottish Medical Journal, 1987; 32:109–111
 [SNB.001.5522] [SNB.001.5526]. The latter document described Dr Lowe’s article as ‘dangerous nonsense’ and the question was posed as to the use of commercial products in the infected patients. However, there was also adverse reaction to a letter Professor Cash sent to the Lancet in April 1987 [SNB.007.6592]
 Van der Berg et al, ‘Seroconversion to HTLV-III in haemophiliacs given heat-treated factor VIII concentrate’ Lancet, 1986; i:803–804 [LIT.000.0000]; White et al, ‘HTLV-III seroconversion associated with heat-treated factor VIII concentrate’ Lancet, 1986:i:611–612 [SNB.004.7780]; Lawrence et al, ‘International surveillance for HIV seroconversion in haemophilia patients receiving heat-treated factor concentrate therapy (Anbstract)’ 3rd Int. Conf on AIDS 1987 p 9
 Dr Perry’s report paragraph 3.0
 Gerety and Aronson, ‘Plasma derivatives and viral hepatitis’ Transfusion, 1982; 22:347-351
 Columbo et al, ‘Transmission of non-A, non-B hepatitis by heat-treated factor VIII concentrate’ Lancet, 1985;ii:1-4 [SNF.001.3237]; Simoni et al, ‘Three-year follow-up of hemophilic children exclusively infused with heat-treated factor VIII’ Ric Clin Lab ,1986;16:216; Preston et al, ‘Non-A, non-B hepatitis and heat-treated factor VIII concentrates’ Lancet, 1985;ii:213
 Allain et al,‘Clinical evaluation of a heat-treated high-purity factor VIII concentrate’ Ric Clin Lab, 1986;16:245
 Smith et al, ‘Interim results of surveillance for NANB in patients receiving heated concentrates produced in England’ Dev Biol Std, 1987; 67:323-325
 Morfini et al, ‘A prospective multicentre safety study of a steam heated factor VIII concentrate’ Ric clin Lab, 1986;16:244
 Auerswald et al, ‘Long-term surveillance study on a new pasteurised factor IX concentrate’ Ric Clin Lab. 16; 216; Schimpf et al, ‘Absence of hepatitis after treatment with a pasteurised factor VIII concentrate’ New England Journal of Medicine, 1987;316:918-922
 CDC, ‘Survey of non-US haemophilia treatment centres for HIV seroconversions following therapy with heat-treated factor concentrates’ MMWR, 1987; 36:121-124
 As more fully reported in 1988 by the Study Group of the UK Haemophilia Centre Directors on surveillance of virus transmission by concentrates, ‘Effect of dry-heating of coagulation factor concentrates at 80ºC for 72 hours on transmission of [NANBH]’, Lancet, 8 October 1988:814–816 [LIT.001.0330]
 On 5 January 1990, Dr Prowse wrote to Dr Horowitz, New York Blood Centre to ask about a sub-licence for solvent detergent technology under a patent in names of A.R. Neurath and B Horowitz [SNB.007.6984].
 The notes of the meeting require construction: for example, the sentence: ‘The Jehovah was not a real PUP’