ret血他l画∩ 13月8p4) 0.2297 - wam net(ワム …...別紙様式第2 別紙(3)-3...
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deYelQPedgeneralisedskin rashand▲attendedthe Accident and Emergency Departmentof・Ⅵn Chaj HospiIal・IrtOctobeちhewassubsequentlYPi∈kedup
一一asone▼Pfthedenguecas甲basedoTISerOlogYreSu]t5
during.theadivecase牒ndingexerci甲わMaWan■
MoleculartestingperformedLOJlthedonat如 produdYaSPO坤ivefor・申喝u号了▲Yirus明把1-坤e
wo亘an recal一号dfo
foundtQbepositiveforcorrespqndingJgNIantibodies
よndトa如haern褐ghJtination-inhibitiontjtreofli2560・
Thisinddentwasthefirst.do⊂Um寧nted⊂iscs6fsuch
trans画S!ionln theliteIature,and sin⊂e October
仙唱ぬ咽M由JⅦ14トb3■血鋤・●w叩止血中和
macro町ti⊂anaemia一∴and panqtopenia∴She■・Wa5
diagnosedtohavevitanin812deficiencyanaemia, Whi⊂hwasrtreatedbYYitaminB12replacementand
rec占ivedabloodtFanSftJSionon24August2002.On day2post・tranSfusion,She developed、low瑠rade
feveちbLJtnOSkinrash,
OrretrO-Orbitalpain.ThepatiehtYVaStriatedwith antibioticsasbraurinarγtract・inねdionibasモdon thernicrobiologICalfindin名声・Thefever_Subsided3
daγ亨(aterandthepatientrecovereduneventful如The
bloodprodudshe,re⊂ejvedwasdona!edby.a17-year- Oldasymptomaticpatientliving恒Mり崎n,during
hisv行emicphぉeon17J叫200乙0ム寧4July2叩ちh寧
166
-
■Chu訂喝dal●
2002,(heHongKongRedCrossBloodltansfusion SerYice(BTS)hasintensifiedit5 donor deferra(
SySlemst{〉COunterthispossibility・SpecificaltYlitnow
asksaboutsymptomsotdenguefeverinthe8lood DonorRegistrationForm(Supp(ement)byremjnding aJIprospectivedonorstoinformtheBT5staffofaIl instancesforflu′feverlheada⊂he,eyePa]n′mtJSCJe/
ioint patn′VOmiting,and skin rash experienced2 weeksbeforeorafterblooddonation.
1n our stud)ldengue fe)er was far more COrnmOn than DHF・and dengue sho⊂k syndrome, Whichwererareevents,Ourpatient50nJymanifested mildbleedingwithgood⊂lini⊂a]out⊂OmeSand no
fataJities・ThecJinica)presentationsofdenguefeveT,
SUCh as feverlmYalgia,headache′and arthraJgia′ Were ⊂OmParable to findings reportedin other
Studies・10h120urpatients(35%)presentedwithfewer
gastroenteritissymptomscomparedtothoseofothers (50-98%).11・12 Lyrnphadenopathy was documented in▲OnIy16%ofour patients,Whichis rnuchJower
than the fjgure ofSO%reported elsewhere・13This difference maY be a⊂⊂OUnted for by]ess-than-
adequatephysiQlexamination・Gumbleedingand epjstaxiswerereportedin12%andlO%ofourpatients
respectivel≠Whichwas atso muchIowerthan that
reported previousIYn・12such diffeTenCeS COuld be duetothepopulationsstudied;Patientsre⊂ruitedin
endemkcountriesweremainlYen⊂OUnteredduring Outbreak5.inwhi⊂hbothdenguefeverandDHFwere COmmOn.Previousstudie5Showeddenguediseas
SeYeritycorre[atedwithhighviremiatitre5,SeCOndary
infection.and DEN-2seroけPeinfedion・-叩 Our findingsshowedthatthehaemorrhagktenden⊂ies anddurationofhospitaIisationtverenotrelatedto SPeCiEicserotypes・^Jthough some ofour patients
did receive pIate暮et transfusjons′the eff桓虻y Of
SuCh treatmentin speeding recoYerγ remains
COntrOVerSiaI・^ccordingtoThaiexperts′PlateJetsare
atmostimmediate)ydestroYedbYimmunelysisafter admini5tration.1‘
Our studY had severa(limitation5・Fi(5t/the
targetpatientswerelimitedtothosewithlaboratory- COn(irmed dengue admitted to public hospitals・ During1998 to 2005,DH received notification
Of 203 dengue case5.incIuding 77 who were admjtted topr.vatehospitalsorconsultedgeneraJ PraCtitionersonly・ThediseaseburdenmightaIsobe Underestjmated′be⊂aUSeSOmePatientsmighthave re⊂OVered.withoutseekingrnedicalattention,Whi(e Othersmightnothaveunde{gOneSerO[oglCaltesting・ Second,Statisti⊂aJana]YSIS⊂OUldnotbecarriedout
to compare cJinicaIandlaboratory parametersin PatientswithdenguefeveTandDH仁asthereweretoo
fewofthetatter・Third,]aboratoryresultsbefore2002
WerenOtaVaiJabIein thePubIicHealthしaboratorY )nforTnationSYStem・Fourth′nOta=clinicafsYmPtOmS
and5jgnslistedinTable2couJd be retrievedfrom the medicalrecords′a5SOme maYnOt havebeen SPedficatlYaSkedfororlookedfor.
fn conc暮usion.dengue fever should be COnSideredin the differentialdiagnosis of febrile Patientswithorwithout’atraVe=1istory.Healthcare PrOViders should therefore have an understanding Oftheinfe⊂tion,thespectrumofitsc]inicalfeatures, andmethodsofdiagnosi5andappropriatetreatment・ UntiltheAede5mOSquitocanbeeffectivelycontroJ[ed Or a COSトeffective va⊂Ci,neis deve(oped,dengue
feverwillremainapublichealthconcern,eSPeCiallY in South-East^sia.ControIat sourceis one of the
keYStO⊂Ombatingdenguefever、andrequJreSaCtive ParticipationfromaflsectorsofthecommunitY
Acknowledgemehts
The rnembers of D甲唱Ue ReviewWbrkingGroup gratefu]ly acknow]edge the CentralCommittee Onlnfe⊂tious Disease′Hospital^uthoritY for the
PrOVisionofpatientmedicaIrecordsandSurYeiflance and EpidemiologY Bran⊂h′ Centre for Protection for the epidemiolog.calandlaboratory lnPUt・Withouttheirsupport′OUrreViewwouldno( havebeenachieved.
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Pub】ications;1995.
6・Siluationofdenguefeve一九knguehaemorrhagicfeverinthe
おuth-Eas一心iaRegion.WHqRegiona卜0相ceforSouth
亡astA5iaweb5ite:htや仙父arO・Who・in昨N侶edionlO/
5ection332_1100.htm.Acce5Sed2ユAug2007・
7.W綬ktyInf∝liousDi5ea5e8utle血Isαialo坤neI2005;川1)・
Singapore,Minis吋O一日ei帆Singapore:h呼仙moh・
g仇・5g仙ohc叩漬b血i⊂5W㌍klγbu=e如5・aSPX・∧ccessd23
Aug2(氾7・
8.しimkittikuIKⅥng~akmongkonS.Jit帥血aph叩A.etal・ Clinioldi侮rencesamong PCR-PrOVen血nguese和t押e inkdions.ぬutheast A5ianJ甘甲州dれblk Hea仙
l・Oengリddenguehaemo汀ha由⊂毎柁-・Wkly【pi血mio=l∝
2000;75:193-も.
2・Gene-alconsideration~.h:Dengue haemo山一agic fevα:
diagnosis.打eatme叫1椚Ⅵndon and co柑Ot・2nd ed・
Geneva:肌伽IdHea叫Organizatbn;1997:ト11・
3・^uyeungTWQueTしLamK5.NIHL,SzetoML・The(irst Patientw仙l∝allya⊂qUireddenguek帽rinHongKong・ HongKongMdJ2003β:127-9・
4・Nimman=吋a S.CtiniQIsp血m and managem即tOf denguehaemo一打-a8ic組立田山e鮎tAsian=加甲州d PublicHea肋1987;柑:392-7.
5・NimmanityaS,Car(b91■DenguehaemorrhagicfeveLln: 他theraIl印.LedinghamJGG.ⅥねrreIIn~ed如鵬・Oxぬd
176 トb唱侮喝M由」\鳳†4No3■血2∝氾●v刷〟.hk画一αg
167
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-【ね咽膿ねⅥ訂inトb喝侮咽○
8h訂U′鮎Ianta~MaIaysia du血唱Ik y問rS1998-2003・
Southeast∧5ian)170PMedPubJicHealth2005;36:1179-
86.
13.Ryan FLWt50n M【′Kain KC.川舵SSa鮎rinternationat
tr訓el.NEngりルkd2002;347:50i-16.
14・VaughnDWGreenS,馳l甲nar叫iS′da】.Dengueviremia 【it叫anti叫re叩n軍門愉n′andviM梵碑⊂αdate Wi血dis飽父S餅訂吋JlnkdDi52000;18上2-9.
15・価nS.∧ungM♪れShwe‘TN.dal.Riskねcb帽indengue Sh∝ksyndrome.AmJlt甲山dHγg1997;56:56ト72.
托・∧l飲
Plateldね∩5血-Sbnsin Dengue Ha酬¶0汀hagic h佗r and
DengueSh∝k5yndrome・Dengue8u=din2003;27:138■3.
ZOO5;3も:t432-8.
9・血er喝e M卯仙y Ovi廿ap tndex- 2000-2006‥HKSAR bd andtEnvirdhh即ta1日ygi印e Depa沌ment wd汚ite: h牧P伽ww.khd・gOV・h兢afefoo仇kn糾Lkve爪ndex・hlml・
∧cces5d23∧喝2007・
10.払Iayanar∝,jS′Vaughn▼D叫Nimmann吋aSJdal・Early
⊂伽i00landlah洞tαγindicab帽Ofacutede爪印ei11ness・J
lnfectDis・1997;176:ユ1ユー21.
1l.SinghN8伽mbR,∧gan伯ISK,etal.≠e之0030u由一eakof De咽Ue如rjnDelhi.lnd軋知utheasl人sianJnopルId PublicHea仙2005;ユ6:11744.
1j・H=SSin N.Jaafarj.Naing NN.MatHA.Muhamad人目. MamalMN・Areviewofde叩uekⅦr涙idenceinKota
ミう
ト輌K叩M由JⅦ14No3■血相2∝冶■柵〟.叫.αg 177
168
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別紙様式第2 別紙(3)-3
医薬品 研究報告 調査報告書 報告日 一報入手日 新医薬品等の区分 摩生労働省処醐
識別番号・報告回数 2008年8月11白 該当なし
一般的名称 フィブリノゲン加第XIII因子 ClearanCeOfdenguevirusinthe
ベリブラストPコンビセット 販売名(企業名)
(CSLベーリング株式会社) 研究報告の公表状況 中国
2008Feb22.
問題点(血嬉分画製剤でのデングウイルスの不括化・除去) 使用上の注意記載状況・ デングウイルスは年間に世界で5千万から1億人が感染し、感染者の数十万人がより重篤で生命を脅かすデング出血熱やデングショック症 その他参考事項等 候群に進展する。
デングウイルスはフラピウイルス科に属し、直径50nmのエンベロープを有するRNAウイルスである。一般に血液などの高蛋白な体液で長
期間生存するので、輸血により感染する可能性がある。針刺し事故や骨髄移植、分娩での血液に関連するデングウイルス感染が報告されて
研 しlる。
究
報 出
⊂】 の 低温エタノール分画、陰イオン交換クロマトグラフィー、パスツリゼーション、S/Ⅷ処理とウイルスろ過を含むアルブミンやグロブリンの
概 各製造工程前に、高力価の培養デングウイルスセロタイプ2を正常人血紫にスパイクし、各製造工程でのデングウイルスのクリアランスを
要 TCID50アッセイ、RT-PCRで測定した。
デングウイルスの不括化・除去に対して、各製造工程前は全てで有効であった。
また、アルブミンの全製造工程(低温エタノール分画、パスツリゼーション)で少なくとも10.1210g減少すること、グロブリンの全製造
工程(低温エタノール分画、ウイルスろ過、S/D処理、クロマトグラフィー)では少なくとも14.24log減少することが証明された。
現在実施されている血躾分画製剤の製造方法は、デングウイルス伝播に関して安全である。
報告企業の意見 今後の対応
本剤の製造工程(低温エタノール分画、パスツリゼーション、イオン
交換樹脂等)でデングウイルスが不括化・除去できると考えられる。
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170
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AB了】仇㈲封沌
T札AⅣSFUS川Ⅳ COMPL川ATI(川S
Clearanceofdenguevirusintheplasma-derived
therapeutic proteins
n一仇加盈e,Pα〟J麒5.Cわα托,Cわ吉幻r5zeわ,5以fⅥ肋ノ0た,招αル乙rCわ〟,5揖〟町5,上.CJ勒
/りJ‥人■.川州/J.ゞ.・\′′川iJJ川わ〃パ.仙JJい/〃仙■′‖i‥・l/い=′‖汎用一丁州Il叫〔
enguevirusinfects50to100mi11ionpeople WOrldwide ayear;Ofthoseinfected,SeVeral
hundredthousanddevelopthemoresevere andlife-threateningdiseases,denguehemor- D BACKGROUND:Viratsafetyisofparamountimpor- tanceforhumanplasma-derivedtherapeuticproteins. Recentrepo丘SOfb100dTaSSOCiatedtransm桓Sionand
COntinuousreg10naJoutbreaksofdenguefeverhave PrOmPtedavaJjdatjonofclearanceofdenguevirusin themanufactureprocessesoflheplasma-derived PrOducts. STUDYDESJGNANDMETHODS:Ahightiterofcul-
tureddenguevirusserotype2wasspikedintoprocess SamPlesbeforeindividuaJstepsofalbuminandimmu- nogtobuIinmanufactureprocesses.includingcotd ethanoIprecJPitation,Cation-eXChangechromatography.
PaSteurjzation,S{)lvent/detergenttreatment,andvirus
firtratjon.Clearanceofdengueviruswasquantifiedwjth TCID5。aSSaySinthecultureofVeroE6ceIIsand,When
appropriate,reaトtimepolymerasechainreaction(RT-
PCR)assays・
RESULJS:TheindividualprocessstepswereaJleffec・
tiveintheinactivationand/orremovalofdenguevjrus,
andthedataobtainedclearlydemonst(atethattherisk OfdenguevirustransmissionwasreducedcumulativeLy byatleastlO.12andatleast14.24loginthealbumin
andimmunoglobuIinmanufactureprocesses. respectively. CONCLUS(ON:Thededicated viralinactivation andJor
removalapproachescurrentTyimplementedinthe manufactureofplasma-derivedproductsprovideagood SafetymarginwithTegardtothetransmissionofdengue Vims.
rhagicfeveranddengueshocksymdrome・DengueviruS belongs tothe family Flaviviridae,Whichin generalis known to survive overlong periodsinfluidswithhigh proteincontents,forexample,blood.Therefore,dengue viruSeS maybe transmittedviatransfusionofblood or bloodcomponents.Albeitrare,ithasindeedbeendocu- mented that blood-aSSOCiated transmission of dengue virus occursvia routesincludingneedle-Stickiniuries,1 marrowtransplantation,2intrapar[umandverticaltrans- mission,2andmucocutaneoustransmission,3Thiscanbe
aseriouspublichealthproblemwithoutpropercontrol meaSureS.
DengueviruSisalipid-enVelopedRNAviruS,Witha diameter ofapproximately50nm.4ReportedlY.dengue virus has been e圧ectivelyinactivated byphotosensitiz- ers5・6andissensitivetohightemperaturesandacidicpH.7 Thisstudyaimstodemonstrateforthe丘rsttimethatthe
ABBREVIATION:BVDV=bovineviraldiarrheavirus.
FromAdvantekSerumLaboratoriesLimitedandtheDepart-
mentofMicrobiologyPrinceofWhlesHospital,TheChinese UniversityofHongKong,Shatin.N.T,HongKong.
AddTeSSrePrlntTt!queStStO:Bing-LouWong,PhD,Advantek
Seruml月boratoriesLimited,3/RHKIB,2Biotechnology
Avenue,12Miles,niPoRoad,Shatin,N.T.HongKong;e-mail:
blwong@advantekbiologlCS.COm.
Theauthorsa∫etha∫1k魚11forpartialfundingsupportfrom
theInnovationandTbchnologyFund(S/P583/03).theGovern-
mentoftheHongKongSpecialAdministrativeRegion・Some
resultsofthepfeSentStudyareusedintheU・S・PatentaPplica-
tionnumberll/294,432andChinesepatentapplication
numberZOO610150052.2.
ReceivedforpubllCationMarch27,2007;revisionreceived
November12,2007,andacceptedNovember19,2007・
doi:10.1111/j.1537-2995.200乱m647・Ⅹ
MSFUSION2008;48:1342-1347.
1342 TRANSFUS10N Volume48,July2008
-
EuMtNAJ10NOFt)ENGUEVIRUS[NPLASMAFRACT10NAT10N
riskofdengueviruStranSmissioninplasmaderivativesis elimina【edbyspeci魚cvirusremovalandinactivationpro- Cedures.LogreductionofdengueviruSisinvestigatedat individualstepsofthemanuhctureprocessesofplasma- derivedalbumin andimmunoglobulins,Whichinclude COldethanolpreclpitation,Cation-eXChangechromatog- raphy.pasteurization,SOlvent/detergent(S/D)treatment. andvirusfi1tration.The evaluation ofthe manufacture
processesprovidesameasureofconfidenceforeliminat- ingdengueviruS・
Samplewithasequencedetectionsystem(ABI7900HTI AppliedBiosystems),andthecyclingconditionswere500C fbr2minutes・950CforlOminutesfollowedby40cyclesof 95bCfor15seconds,and600Cforlminute,aSWe11asa
dissociation stage of950C for15minutes,600C for 15minutes,and950Cfor15minutes.
FractionIVprecipitation
Thesupematantll+ⅠⅠIwaspreparedfromfrozenhuman
plasmathroughtwoconsecutivestepsofcoldethanolpre- Cipitationwith8percentethanolatpH7・1followedby
19percentethanolatpH5・85・8Duplicates of20mLof
SupematantII+ⅠⅠIwerespikedwith7・00logpermLeach
OfdengueviruSataratio(VOl/vol)ofl:10.EthanOl(95%)
WaSaddeddropbydropintothesupematantII+ⅠⅠItoa
丘nalethanoIconcentration of40percent,Which was
hrthermixedaト5to5・50Cforlhour,beforebeingcen」 trifugedat2300×gtOSeparatethefraction(F)Ⅳ&omthe
SuPernatantⅣThesupematantII十III,theFIV and,the
SupernatantⅣweretitratedforquantityofvirusesby
TCID50aSSayOrRTIPCRassay.
MATERJALSAND METHODS
Rawmaterial$
Normalhumanplasmawasobtainedfromtheplasma fractionator Shenzhen Weiwu Guangming Biological ProductsCo.(Shenzhen,China).All.chemicalsusedinthis
Studywereofeitherpharmaceuticalgradeoranalytical grade・ViruSfilters(Planova35N,10cm2)wereagiftfrom AsahiKasei(Tbkyo,Japan).
Vjruscultureandquantification
DengueviruSSerOtype2(SO47]00froInEnvironmental
HealthInstitute.Singapore)waspropagatedinC6/36cells (CDCGuangdong,China)inminimalessentialmedium
withlpercentfetalbovineserum(Gibco.GrandIsland.
NY)・DengueviruSWaSquantifiedwithTCID50aSSaySin
thecultureofVeroE6cells(ATCC,ManaSSaS,1乳).VeroE6
CenS(2・5×105cells/mL)wereseededin96-We11platesina
VOlumeoflOOpLperwe11.A托erldayofincubatiozt,50llL
Of medium was added to each we11.Each diLution of
Samplewasaddedat50pLperwe11,andfurtherincuba- tionwascarriedoutat36±20Cwith5percentCOz.Plates WereaSSeSSedforTCID5Oendpointascytopathice鮎cts
developedonthefifthdaylTheTCID50endpointwascal- CulatedaccordingtotheSpearman-Karbermethod,and the Poisson distribution was used when no virus was
detectedinsamples.Quantitativereal-timepolymeraSe Chainreaction(RT-PCR)wasusedtodetermineviruStiter
inthe chromatographyandcold ethanolprecipitation StepS・RNAofdengueviruSWaS eXtraCtedinduplicate fromsampleswithaviralRNAminikit(QLAamp,Qiagen, Hilden.Germany)accordingtotheproceduTeprOvidedby themanufacturer・DengueviruSCDNAwasreversetran- SCribedwithrandomhexamerswithreversetranscriptase (SupercriptIII,Invitrogen,C訂1sbad,CA).Quantitative
RTPCRutiuzingThqMantechnology仏ppliedBiosystems, FosterCity,CA)wasperformedonsamplesandproper COntrOIswithspecific primers(GTCん如コuAGAAGm- GjuCCTCCA and CTCⅧrGATGÅTGTAGCTGTCTCCG) andSYBRGreenfluorescentprobeswithconditionsopti- mi21edtodetect4・67copleSOfviralRNAfordengueviruS・ Duplicate PCR procedures were performedfor each
Pa$teurization
The puri丘ed albumin solution was diafiltrated with
8volumesofwaterandthenconcentratedtoaconcentra-
tionof22percentwitha30-kDacutoffcassette(Millipore,
Bedford,MA).Sodiumcaprylatewasaddedtotheconcen-
trated albumin solution to a final concentration of
32mmolperL,beforeadjustmentofpHto6.8tomake
20percentalbumin bulk_1加0-hundred miuiliters of
albumin bulk and duplicates ofthe steri1e一fi1tered
20percentalbuminina50一喝Lbottlewasheatedto590C
inawaterbath.fb1lowedbyspikingwithdengueviruS (6・67,7.50,Or7・67log/mL)ataratio(vol/vol)ofl:20and
l:25,reSpeCtivelytGentlemixingwithamechanicalstirrer
(Stainlesssteel)wasappliedtothebulkpasteurization・
SamplesweretakenoutforviruStitrationduringthetime COurSeOfalO-hourtreatmentat59to600C.
F‖precipitation
TheFII+IIIsepaLatedfromthesupernatantII+ⅠⅠIabove
WaS redissoIved.and NaAc-HAc bu鮎一(0.8mol/L-
4mol/L,pH3・9)wasaddeddropwisetoadjustpHto5・1・ Denguevirus(7・170r7.67log/mL)was畠pikedataratio (VOl/vol)ofl‥10into duplicates of 20mL of the pH-aqjustedFIl十III・Ethan01(95%)wasaddeddropby dropintotheFII+ⅠIItoa丘nalethanoIconcentrationof
15percent,Whichwasfurthermixed.at-5to5.5OCfor
l・5hour・beforebeingcentrifugedat2300×gtOSeparate
theFIII丘omthesupematantIII・TheFII+III,thesuper- natantIII,andtheFIIIweretitratedforquantityofviruSeS byTCID50aS$ay.
VoJurne48,July2008「隅ANSFUS10N1343
-
XIE ETAL.
Virus用tration
Aquantityof196mLofpartial1ypuri丘edimmunoglobulin WaSSPikedwith7.67logpermLdenguevirusataratio (VOl/vol)ofl:49.fouowedbyfiltrationwithaO.22-Pmfi1ter
(Steritop,Millipore)toremoveviralaggregates・Thefi1- teredimmunoglobulinwassubjecttovirusBltrationwith the35Nfuterinanormal-flowmanner,underconstant
pressureof80kPa.Samplesweretitratedforquantityof viruSeSbyTCIDsoassayorRT-PCRassay
RESULJS
FIV precipitation
Afterthe40percentedlanOlprecipitationofthesuperna- tantII+III.nodengueviruswasdetectedwiththeTCID50
assayinboththesupernatantⅣandtheFrVrrablel). DespiteitsdirectcytotoxicitytothevirusdetectorVeroE6 Cells,Whendiluted500-fold.40percentethanoldidnot
a仔ectthedeterminationofvirustiter・Resultsofquantita- tive RT-PCR clearly showed that genetic materials of denguevirusWere COnCentratedin the FⅣ(Tもblel), Whichis discarded during thealbumin manufacture. Becausechemicalinactivationbyhighconcentrationsof ethan01ismechanistical1ydifferentfromthephysicalparL titionlnge庁ectsbetweenfractions,thisFⅣpreclpitation StepprOvidesanextrasafetymarginintheeffectivecleaト anceofdengueviruses.
S/D treatment
Duplicates of27mL of theimmunoglobulin puri丘ed throughviruSfi1trationwereheated to280Cinawater bath,fouowedbyspikingwith7・160r7・83logpermL 〔kngueviruSataratio(VOl/vol)ofl二9・rItitonXLlOOand
tri-n-butylphosphatewereaddeddropbydropintothe immunoglobulin to a 再nalconcentration ofland O・3percent,reSpeCtivelyGentlemJjnngWaSaChievedwith amechanicalstirrer(Stainlesssteel)forthetimecourseof 16-hourtreatmentat28to300C,duringwhichsamples WCreremOVedforviruStitrationbyTCID50aSSay
Pasteurization
The kinetics ofinactivation of dengue viruSin the 20percentalbumirldufingthelO-hourpasteurizationat 59to600C afe ShowninFig・1・Thepasteurizationwas
CarriedoutatO.50Cbelowwhatisnormallyusedinthe manufacture,repreSentlngaWOrSt-CaSeSCenario.Dengue Cation-eXChangechromatography
A chromatography column oflO-mm diameter was packed to a bed height ofllcmwitheithernewCM SepharoseFastFlowresin(PharmaciaBiotech,Uppsala,
Sweden)orthe used resin that had previously been recycled476tjmeswiththeimmunoglobulinpuri丘cation process.Thecolumnwasequilibratedwith20mmolperL NaAcbu仔er,pH4.0.AdjustedtoapHof4・Owith1MHCl andanionicstrengthofl・4mSpercmwithpuri丘edwater. duplicatesof75mLoftheS/D-treatedimmunoglobulin SOlutionwerespikedwith7.670r7・83dengueviruSata ratio(vol/vol)ofll:20.Thevirus,Spikedimmunoglobulin SOlutionwasappliedtothecolumnatalinearflowrateof 40cm/hratambienttemperature.Afterwashingofthe CO】umnwithlOcolumnvolumesoflOmmolperLglyclne, pH7.0.immunoglobulinswereelutedwithlOOmmolper LglyclnetOgetherwith150mmolperLsodiumchloride, pH9.0.Thecolumnload.thenow-throughfraction.and the eluate fraction containing immunoglobulins were titratedforquantityofviruSeSbyTCID50aSSayOrRTTPCR aSSay・
(冨」)s⊃」S¢コぎ0凸
窟一裾
‾-・∵∴∵.
10
Pasteurization(hr)
Fig・1・InactivationofdenguevimsiJlalbtlminbypasteuri組一
也onovertime.(ロ)もu址pasteurimtiom;(◆)terminalpa5tel甘-
ization・Stockdenguevirus飴(6.670r7.50log/mL)were
SPikeda(aratio(vol/vol)ofl:20andl:25,reSpeCtively,inthe
t)ulkpastell血tionandterminalpasteurization・
● ; ● 、 】 壷.;.壷‥、こ壷≠-=-。一重モ..、…腰弓;…・‥..こ●...….:l.。….義男。ミ,.‥、.=.幸..。音... 1344 TRANSFUS10N VoIume48,Juty2008
-
EuM]NAT10N OFDENGUEVIRUS fN PLASMAFRACT10NAT10N
7hours.NoinfectiousviruSWaSdetectablebytheTCID50 assayintheimmunoglobulinfiltrate,thesampleobtained WhentheviruSfi1terwasreverselyflushedwithpurified Water,OrtheviruS-SPikedimmunoglobulincontroIstand- 1ngalongthewholeviruSfi1trationprocess・Tbditrerenti- atephysicalseparationfromthechemicalinactivationby thelow pH,the samples werefurther quantified for dengueviruSwiththe quantitative RトPCR assay.The RT,PCRdatashowthatdengueviruSWaSmuChmorecon- Centratedintheback-nuShfractionthanintheimmuno- globulin丘Itrate・Viralreductionbythevirusfi1trationwas Calculatedandshowninlもbles3and4.Theseresultsindi- CatethatdengueviruSiseffectivelyremovedbythe35N viruSaltration.
viruSWaSquicklyinactivatedbytheheattreatment,and infectiousvirus became undetectablewithin5minutes (Fig・l)・Tbtalviralreductionfbrboththebulkpasteuri- Zation andthe terminalpasteurizationis shownin 職ble2.
F=precipitation
Afterthe15percentethanolprecipitation,denguevirus WaSdetectablewiththeTCID50aSSayinboththesupema- tantIIIandtheFIII.withamajorityofinfectiousvirusin theFIII.ViralreductionfromtheFII+ⅠⅠItothesuperna- tantIIIwascalculatedandisshowninThble3.
Virus filtration
TheimmunoglobulinspikedwithdengueviruSWaSPrO- CeSSedat24to250Cthroughthe35Nvirusfilterwithin
S/Dtreatment
ThepresenceofS/Dwascytotoxictothevirusdetector Ⅵ汀OE6cells;Whendiluted1000-fold,S/Pdidnota仔ect
the determinationofviruS titer.Thekinetics ofinactiva-
tionofdengueviruSintheimmunoglobulinduringthe 16-hourS/Dtreatmentat28to300CisshowninFig.2.
DengueviruswasquicklyinactivatedbytheS/D treat-
ment,andinfectiousvirus became undetectablewithin lminute.TbtalviralreductionfortheS/Dtreatmentwas
Shownin恥ble3.
TÅBLE2.Clearanceofdengueviru$lnthe albuminpro¢eSS■
Process step Reductionofvirus(10g)
≧5.18†/≧5.35†
≧4.61
≧4.94/≧5.44
≧10.12‡/≧10.79‡
FIV precipitation Bulk pasteurization lbrmina(pasteurization Cumulative
★ Dataareshownfromduplicateexperiments,eXCePtbulkpas- teurization.whichwasconductedonce.
†ThedatafromtheTCID50aSSay.butnottheRT-PCRassay, areinchJded.
‡“8ulkpasteurization”isno=ncludedinthe”cumulative,” becauseitissimilarmechanistjca11ytolermina暮 PaSteUrization.”
(ロ0」)s≡S¢⊃P-0凸
3 2 1 0
16 1
SIDTreatment(hr)
0
-
XIE ETAL.
Cation-eXChangechrornatography
Afterthe chromatographystep oftheimmunoglobulin process,nOinfectiousviruSWaSdetectablebytheTCID50 assayinthecolumnload,theflow-throughfraction,the eluatefraction,Orthevirus-SpikedloadcontroIstanding along the whole chromatography process.Tbtalviral reductionfromthecolumnloadtotheeluatefractionwas
atleast7-04andatleast6・93logforthenewresinandthe 476-CyCledusedresin,reSpeCtively(Thble5).BecauseS/D WaSpreSentinthe startingmaterial,theeliminationof
denguevirus could be a result ofinactivation by the Chemicals▲Tbdifferentiatephysicalremovalfromchemi- Calinactivation.thesampLeswerefurtherquanti魚edfor denguevirus with the quantitative RT-PCR assay・The RT-PCRdatashowthatamajorityofdengueviruSWaS Observedintheflow-throughfraction・Tbtalviralremoval bythechromatographyprocesswascalculatedtobe3.66 and4・18logfbrthenewresinandthe476-CyCledused resin,reSpeCtively(rIhbles3and5).
D[SCUSSTON
Viralsafetyis of paramountimportance for human Plasma-derivcdtherapeutic proteins such asalbumin, αl-prOteinaseinhibitor,Clottingfactors.andimmunoglo- bulins.Recent documentation of blood-aSSOCiated
transmissionlJ3and continuous reg10naloutbreaks of denguefeverhavepromptedavalidationofclearanCeOf dengueviruSinthemanufactureprocessesoftheplasma, derived products.Itwas theintention ofthis study to investlgateCleaEanCeOfdenguevirusinindividualstepsof manufacture processes ofplasma-derivedalbuminand immunoglobulins.The results showninThbles2and3 Clearlydemonstrateforthe鮎sttimethatspecificvirus removalandinactivationprocedures reducethe riskof denguevirustranSmissionbymorethanlOlogcumulaL tivelyinplasma-derivedalbuminandimmunoglobulins・
Inthisstudy.coldethanolprecipitationisverye鮎c- tiveininactivatlngdengueviruSinthealbuminprocess. butmi1dly efFectivein removlng dengueviruSin the immunoglobulinprocess、Thisdi鮎renceine鮎ctiveness isprobablyduetothefac[thathigherconcentrationsof ethanoIwereusedinthealbuminprocess・Itisfairlyrea- SOnabletospeculatethatothertherapeuticproteinspre-
1346 TRANSFUSION Volume48,Juty2008
paredfrom plasmabysimilarlyhighconcentrations of ethanol,forinstance,α1-prOteinaseinhibitoraJldtrans- ferrinpuriRedfromtheCohnFrV;wouldhaveagood Safbtymarginwithregardtotransmissionofdenguevirus・
Pasteurizationinactivateddenguevirusveryquickly ande鮎ctivelyinthealbuminprocess.Thepresenceofa highconcentrationofalbuminorthealbuminstabilizing agentsodiumcaprylatedidnotseemtoprotectdengue virusfromthe heatinactivation.Caprylate has been Showntobeaneffectivevirus,inactivatingagentatmilli- molar concentrations under acidic conditions;9‾】Z
however,Caprylateappearsunlikelytocontributemuchto theviralinactivationcapacityofthepasteurizationstepas inthealbuminformulationitisusedunderneutralpH, Which do not favor the formation of the active
COmpOnent-thenonionizedformofcaprylate.Asshown
byalbumin’slonghistoryofviralsafetyinclinicalapplト Cations,thededicatedviralinactivationstepinalbumin manufactureprocesseshasbeenveryrobustintheinac- tivationofmanydifferentvirusesincludingWestNileviruS and bovineviraldiarrheaviruS伴ⅣDV),bothfrom the
SameFlaviviridaefamilyasdenguevirus・13r14 Virus filtration was very effective in separating
denguevirusfromthe、immunoglobulinRltrate(Table4).
ThedatasuggestthatchemicalinactivationbythelowpH COnditioncanprobablycontributetotheviralclearance CapaCityofthis process step.In aseparate studywith BVDVwhichisofsimilarsizebutnotsensitivetolowpH treatment,amqjorityofthespikedBVDVwastrappedin thePlanova35N丘Iter,Whichwasrecoveredintheback-
nushsample(unpublishedobservation). Likepasteurization,S/Dtreatmentveryquicklyand
e鮎ctivdyinactivateddenguevirusintheimmunoglobu- 1inprocess・Thisdedicatedviralinactivationstepinthe immunoglobulin manufacture processes has been very robustintheinactivationofmarrydifferentviruSeSinclud- ingWestNilevirusandBVDV13・14
Thecation-eXChangeChromatographywasorlginal1y intended to remove S/D from theimmunoglobulin process;however,itwasalsoobservedinthisstudyto e任ectivelyremovedengueviruSbya臨nityadsorption・In addition,thispuri丘cationstepwasmildlyeffectiveinthe
physicalremovalof BVDV(unpublished observation). Althoughthe chromatographic process may not be a
-
ELIMINÅT10NOFDENGUEVIFtUSJNPLASMAFRACT嘉ONAT10N
robustviralremovalsteplngeneral,itisindeede仔ectivein
theclearanceofden許IeViruS.
InsummarylthisstudyhasshoⅥlthate鮎ctiveclear-
anceofdenguevirusisachievedinthemanufacturepro- CeSSeS Ofalbumin andimmunoglobulins,prOviding additionalevidencesupportingtheviralsafetyofplasmaT derivedproducts.
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1998;351:498.
2・Rigau-PerezJG,VomdamAV.ClarkGG・Thedengueand
denguehemorrhagicfeverepidemicinPuertoRico,1994-
1995・AmJTfopMedHyg2001;64:67-74.
3・ChenLH.WilsonME・TraLnSmissionofdengueviruS
Withoutamosquitovector:nOSOCOmialmucocutaneOuS
transmissionandotherroutesoftranSmission.ChnInfect Dis2004;39:e56-60.
4・m血nRl,ZhangW.RossmarmMG,PlentnevSV,CorverJ,
LenchesE,lonesCT.StruCtureOfdengueviruS:implica-
tionsforflaviviruSOrganization,maturation,andfusion.
Ceu2002;108:717-25.
5・LinYL,LeiHY.WenYYILuhTY,ChouCK.LiuHS.Light-
independentinactivationofdengue-2viruSbycarboxy-
fullereneC3isomer.Ⅵrology2000;275:258-62.
6・HuangQ.FuWL,ChenB,HuangJF.ZhangX,ⅩueQ.hac-
tivationofdengueviruSbymethyleneblue/narrowband-
widthlightsystem.JPhotochemPhotobioIB2004;77:39-
43.
7・Man血gJS,CollinsIKE鮎ctsofcellcultureand
laboratoryconditionsontype2derLgueviruSinfectivity・
JClinMicrobiol1979;10:235-9.
8・CohnEJ,StrongLE,HuglesWLMulbrdDl,AshworthlN.
MelinM・TbylorHL・Preparationandpropertiesofserum
andplasmaproteins・ⅣAsystemfortheseparationinto
fractionsoftheproteinandlipoproteincomponentsof biologicaltissuesarLdnuids.1AmChemSoc1946;68:459-
75.
9・LundbladTL,SengRL・Inactivatironoflipid-enVeloped
viruSeSinproteinsbycaprylate・VoxSang1991;60:75-81・
10・KorneyevaM・Hottal.LebingW,RosendlalRS.Fran寧SL.
PettewaySRlr・Envelopedvirusinactivationbycaprylate:
arobustalternativetosoIvent-detergenttreatmentin Plasmaderivedintermediates・Biologicals2002;30:
153-62.
11・LebingW・RemingtonKM・SchreinerC′PaulHI・Properties
Ofanewintravenousimmunoglobulin(IGrV-C,10%)pro-
ducedbyvirusinactivationwithcaprylateandcolumn Chromatography・VbxSang2003;84:193-201.
12・JohnstonA.UrenE,lohnstOneD,WuJ.LowpH,Caprylate
incubationasasecondvifaiinactivationstepinthemanu- factureofalbumin.Parametricandvalidationstudies.Bio_
lo由Cals2003;31:213-21.
13・KreilTR,8ertingA,XistnerO,KindermamJ.WestNile
viruSandthesaLetyofplasmaderivatives:Veri丘cationof
highsafetymargins,andthevalidityofpredictionsbased OnmOdelvirusdata.TtanSfusion2003;43:1023-8.
14・RemingtonKM.TtejoSR,BuczynskiG,LiH,OsherofFWP,
BromllP,RenfrowH,ReymOldsR.PifatDY.Inactivationof
鴨stN辻evirus,VaCCiniaviruSandviralsurrogatesforreト
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Volume48,July20081TIANSFUSTON1347
-
別紙様式第2-1
番号10 医薬品
医薬部外品 研究報告 調査報告書 化粧品
識別・雛回数 離日 新医区分 厚生労働省処理欄
①乾燥抗HBs人免疫グロブリン 公表国
一般的名称 ②ポリエチレングリコール処理抗HBs人免疫グロブリン 研究報告の プエルトリコ
販売名 公表状況 1348-1354 (企業名)
<背景>
輸血を介したデングウイルス感染が1例報告されている。しかし、流行地域でのデング熱の発生率が高いこと、無症候感染の割合が高い 使用上の注意記載状況・
こと、およびウイルス血症の中央値が5日であることから、輸血に関連したデング感染は、報告されているよりもさらに広範匪=こ拡がっ その他参考事項等
ている可能性がある。 代表として静住用へブスプリンーIHの記載を示 <研究デザインおよび方法>
研 す。 ■2005年9月20日から12月4日までにプエルトリコにある米国赤十字へ提供された全ての血液ドネーションのデングウイルス(DENA)紺A 2.重要な基本的注意 究 の陽性率を、tranSCriptionmediatedamplification(TMA)法と呼ばれる特異タイプの核酸増幅検査を使って測定した。TMAの測定結 (1)本剤の原材料となる血液については、KBs抗
報 果が2回くり返して陽性であったものを、TMA法陽性のドネーションと定めた。TMA脇性のドネーションについて、IgM抗体のELISA、RT-PCR 原、抗HCV抗体、抗HIV-1抗体、抗HIV-2抗体陰性 およびウイルス培養による検査を行った。 で 、かつALT(GPT)値でスク1」-ニングを実施し 告 ている。更に、プールした試験血某については、
KIV-1、HBV及びHCVについて核酸増幅検査(NAT)を
の
、 るが、当該NATの検出限界以下のウイルスが混入
と、5つのドネーションだけがTMA陽性であった。
要 I している可能性が常に存在する。本剤は、以上の
検査に適合した高力価の抗HB5抗体を含有する血 紫を原料として、Cobnの低温エタノール分画で得
た画分からポリエチレングリコール4000処理、
DEAEセファデックス処理等により抗HBs人免疫グ
れるであろう。輸血後のデング感染の患者において、輸血感染を考慮すべきである。 ロブリンを濃縮・精製した製剤であり、ウイルス
‾報告企業の意見 今後の対応 不括化・除去を目的として、製造工程において
60℃、10時間の液状加熱処理及びろ過膜処理(ナ
ある。 影響を与えないと考える ノフィルトレーション)を施しているが、投与に
血典分画翠剤からのデングウイルス伝播の事例は報告されていない。万一、原料血紫にデングウイルスが混入し ので、特段の措置はとらな 際しては、次の点に十分注意すること。 ても、脚Dをモデルウイルスとしたウイルスバリデーション試験成績から、本剤の製造工程において十分に不括 い。
化・・除去されると考えている。
′\・・′7「rlI、.
-
178
-
TRAⅣSFUSI州1≠椚几川椚Ⅰ州S
Denguevirustinblooddonations,PuertoRico,2005
肋m助肋わαmme4蜘肱エgれ托e托,カ唱eエ.肋和之-力感血,疋卸乃m“わeた,Gre卯叩艮)∫励1
Arry且β和㍑枕身iePg短nerl,α托dSl措肌エS汀αmgr
engueviruS(DENⅥisamosquito-bome瓜a- viviruStranSmittedbythebiteofaninfected Aedksspp.mosquito.Inkctionbyeachofthe antigenical1ydistinctserotypesmENVll,-2, D
BACKGROUND:Asingfeinstanceoft(anSfusion-
transmitteddengueinfectjonhasbeenreported.The highincidenceofdengueinendemiccountries.thehjgh PrOPOrtionofasympIomaticinfection,andthemedian 5-dayviremia.however,SUggeStthattransfusion-
assocjateddenguetTanSmissionmaybemorewide- SPreadthandocumented. STUDYDESIGNANDME丁目ODS:Theprevalenceof
denguevirus(DENV)RNAwasdeternlinedina[IbIood
donationstotheAmerican Red Crossin Puerto Rico
fromSeptember20toDecember4,20O5,uSingaspe-
Cifictypeofnuc[eicacidamplificationtestca=ed
transcription-mediatedamp(ification
POSitivedonationsweredefinedasthosehavingtwo repeatedlyreactiveTMAresults・TMA-POSitivedona-
tionsweretestedbyenzyme-tinkedimmunosorbent assayforimmunogJobulinM(lgM)antibodies.by
reversetranscriptionl⊃Olymerasechainreaction(RT
PCR),andbyvira]culture・
RESULJS:’Twelve(0.O7%)of16;521btooddonations
testedwereTMA-POSitive.Fourwerepositiveby
RTPCR(DENVserotypes2and3)・Ⅵruswascultured
from30f4RT,PCR・やOSjtivedonations.Oneofthe12
TMA-POSjtivedonationswas暮gM-POSitive・Only5dona-
tionsremainedTMA・POSitivewhendiI血edl:16,aSis
doneforroutinemlnlPOOIscreenlngforother transfusion-tranSmissibleviralinfections(hepatitisC,
humaninlmunOdeficiency,WestNilevirus占spvNVsl).
CONCLUS]ON:Near(ylinlOOOblooddonationscon-
tainedDENVRNA,andviru$COu(dbecu(turedfrom
TMA-POSitivedonations,SuggeStingatran去fusiontrans-
missionrisksimilartothatwhichexistedintheUn托ed
StatesforWNVbeforeuniversaldonationscreenIng, Simi(artoWNV,JgMantjbodyscreenIng’islikelytobe
in畠fFective,andsomepotentia(Iyinfectiousdonations
Wi”bemiss寧dbyminipooIscreenlng・Transfusiontrans一
画SS!onsho山1dbeconsideredinpatientswithdengue
a代erbtoodtransfusion.
ー3,and-4)conferslifelongserotype-SpeCifici皿munity. Subsequentinfectionwithan0therserotypeispossible becauseimmunityto heterologous serotypesis short- uved・Most(53%-87%)dengueinfections are asymP-
tomatic ormi1dly symptOmatic.l‾3Dengueinhctionis Characterizedbyamedian5-dayvmmia.andincli血cauy apparentinfections,SymPtOmOnSetOCCurSldayaf[er
OnSetOfviremia・4・5TheclinicalspectrumOfdengueinftc- donrangesfrom denguefeverto deng叫ehemorrhagic
fever,dengue shock syndrome,and death.PrimarY
denguein飴ctionsof[enpresentwithfbaturescLfclassic
dengueftverincludingacuteorlSetOf輌r;arthralgia, myalgia,retrOOrbitalpain,headache,and rash.Subse-
quentinfectionwithaseconddenかesirbtypeincr8aSeS theriskofdevelopingdenguehemorrhagicfever,Whichis Characterizedbyfever,thrombocytoperda(plateletcount
≦100×109/L),hemorTha由Cmanifbstations,andevidence
ABBREVIAT10NS:ARC=AmericanRedCross;DENV=dengue
ViruS;IC=intemalcontrol;m=initial吋reactive;S/CO
ratio=Signal-tO-CutOffratio;TMA=tranSCription-mediated
ampl通cation;W=Ⅵ屯stNile血s.
FromtheDengueBranCh,DivisionofVector-Bomehdectious
Disease,CentersforDiseaseG⊃ntrOlandPrevendon,SanJuan,
PuertoRico;AmericanRedCross.Gaithersburg,Maryland;Gen-
Probe,hc・,SanDiego.Califomia;andtheDivisionofVector-
、BomeInfectiou云Disease,CentersforDiseaseControland
Prevendon,FortCouins,Colorado.
舶加即御伽旭叩醸敵地misbMobammed,phD,
DengueBranch,DivisionofⅥ∋CtOr-Bomeh鮎ctiousDiseases,
NationalCenterforZoonotic,Vtctor-Bome,andEntericDis-
eases,CentersforDiseaseControlandPrevention,1324CkⅢe
Cafiada,Sanluan,PROO920;e-maiLhmohammed@cdc・gOⅥ
ConAictofinterest:JMLandASBamemployeesofGen-
Probe,Inc・andareownersofequitystockopdonsin
Gen-Probe.
ReceivedforpublicationDecember13.2007;revision
receivedMarch31,2008,andaccepted.March31,2008・
doi:10.1111/j・1537-2995.2008.01771.x
WS叩SION2008;48:1348-1354.
料 デ
1348 TRANSFUS]ON Volume48,July2008
179
-
DENGUEIN BLOOD DONÅTlONS
dona也onsare CO11ectedannuallybytheAmerican Red Cross仏RC)collectioncentersandblooddonationdrive sitesinPuertoRico.Thesedonationsareusedinthecon-
tinentalUmitedStates,PuertoRico,andelsewhereinthe
Caribbean.Tb assess the potentialfor transfusion- associateddengueinLectioninPuertoRico.wetestedall blooddonadonstotheARCfordengueviralnucleicacid uslngareCendydevelopeddengue-SPeCi負cNATduringan u-Weekperiodofseasona止yh9ighteneddengueac
h2005.
MJn’ERIALSAND METHODS
Weanalyzed demographic data collectedfrom blood donorsandplasmaspe?imensfromanblooddonationsto ARCbloodcollectionc?nterSandblooddrivesinPuerto RicofromSeptember20toDecember4,2005.Thisstudy periodcommenced2weeksafterthepeakofseason叫 heighteneddengueactivityinPuertoRico(Fig・1).Plasma SpeCimenscontaimingethylenediaminetetraacetateasan anticoagulant(BDVacutainerPPTplasmチPreparatipn tubes,BD.FraJiklinu止es,N7)from血1blooddonations
duringthis$tudyperiodwereretainedinarepositoryat theARCfacilityinGaithersburg,Maryland.
Allspecimenswerefirstscreenedforthepresenceof DENVRNAusing a DENVIspecific N瓜■develop虐d by Gen-Probe,Inc.(SaLnDiego,WthatusestranSCription- mediatedampli丘cation(TMA).Specimensweretestedby TMAatGcn-ProbebytrainedARCsta鼠Allinitiglyreac- tive(m)specimens were retestedand TMA-pOSitive
ofincreasedvascularpermeabilityandplasmaleakage■6・7 Withtime吋SuppOrtivecare,denguehemorrha由Cfever case-fatalityratescanbereducedtolessthanLLperCent・8・9
TheprlnCipaldenguevectorisAedesaegypti・Itis fbundthroughoutthetropicsandsubtropicsandinlimited areas ofsome statesinthe southeasternUnited States. Aedesalbopictusisalsoacompetentvectorfordengueand hasbeenimplicatedpreviouslyindengueoutbreaks・10 AlthoughithasnotbeehdetectedinPuertoRico・Aalbop- ictLLSeXistsinsomepartsoftheAmericasincludingmore than20statesintheeasternhalfoftheUnitedStates.11 Antochthonous dengue transmission doe$SPOradical吋 occurinsouthemTbxasalongtheUmitedStates-Mexico border,withthemostrecentoutbreakoccumnginthe conti糾OuSbo王dertoⅥmSOfBrownsville/rbxas,andMata- moro占,恥Ⅰ血adipas(Mexico)・12・13Thissuggeststheende-
micityOf denguein SouthTbxas andthe risk of reemergenceofdengueinstatesthatborderMexicoaswell asinsoutheastemstateswithcompetentvector(S)and
Subtropicalclimates・Research.however・hasfoundthat diEerencesinhousing(e.g.,uSeOfaircondidoAmgand screens)andlifbstylemayp㌍Ventthisfromhappe血ngl12・13
Although飴wreportsdocu皿entDENVtransmission throughreceiptofinfectedblood,14tissues,150rOrganS,16 tranSfusion-aSSOCiatedden卯etranSmissionmaybemore
COmmOnthanPreviouslyrecognized・Thehighproportion ofasymPtOma也cinfections,themedian5-dayperiodof detectable viremia,andthe highincidence,eSpeCiany
ddringoutbreaks,SuggeStthatasubstantialnumberof donorscqddbeviremicatthetimeofdonation.haddi-
tion.nosocomialtranSmissionofDENV vianeedle-StickinjurY17●21hr血erindi- 450 CateSthe.tranSmissibilityofDENVby infected tblood.Viremicindividuals mayunkn0winglydonatebloodbefore SymPtOm OnSet Orif they remain asymptOmatic.WtstNileviruS(WNⅥ,a
relatedmosquito-borne且aviviruS,may
PrOvide a use餌・mOdelfor assesslng tranSfusion-aSSOCiatedDENVtranSmis-
sion.廿anSfusiontranSmissionofW
iswe11documented.andal1blooddona-
tionsintheUmitedStatesarescreened usingW7Wspeci8=CnuCleicacidampli一
丘cadontests(NÅ恥).22B
Dengue was first identified in ∴
i(year-rOundwithoccasionalishndwide Outbreaks.AmeanOf5446(range,2416-
10,048)suspectedcaseswerereported annu姐yduringthenonoutbreakyears 仕om1990to2004,Wheteas6039cases
Were rePOrtedin2005(incidences of 151versus159perlOO,000populadon/
year).Approximately 77,000 blood
〇 .〇
5 0
乍V ▲3
∽○∽■0-OJOq∈コN
0 0
■-J nV
▲フー 2
14 71013 代19 22 25 28 31封 3740 43 46 49 52
Weekofonsotof写ymPtOmS
Rg.l.Numberof$u叩eCted■岬)mdco鱒md†(¶denguec鮎朗吋Weekof synptomonset,PuertoRico,2005・■S11SPeCted=rePOrtedc鮎eOfden糾ewitha dinicalstLSPiciomofdenpe.†Co血ed=1aboratory-COnfimed巾y$erOlogyor
drologカC耶eOfden卵色
Volume48,Ju(y2008 TRANSFUS]ON1349
180
-
MOHAMMED ETAL.
SpeCimenswerethosethatwererepeatedlyreactive;al1 OtherswereconsideredtobeTMA-negative・Bothinitial
and repeatTMAscreeningwereperfbmedusingindi- vidualspecimens.AllIRspecimensweresenttotheCDC’s Dengue BranCh1月boratoryin SanJuan,Puerto Rico,
fbr supplemental testing by reverse tranSCription- polymeraSeChainreaction(虹PCR).24TbstingofdonaT tionswas unlinked to donorpersonalidentiBers;thus,
Subsequent contactwithdonors orrecipientswas not POSSible.Deidentifieddata丘■Omblooddonationrecords
WereuSedinthestatisticalanalYSis(describedbelow).The datawerestoredonaslnglepassword-PrOteCtedterminal attheCDC,andnoattemptwasmadetotracethedonors.
The study protocoIwas approved bytheInstitudonal ReviewBoardoftheARC.
WereteStedusingareal-timeRT-PCRassayforthedetec- tionofNS5genesequence(恥qMan,AppliedBiosystems, FosterCity,CA).24ThisRT-PCRtestis multiplexedand
detectsthefourdengueserotypesinonereaction.Itcan alsobeusedtoquandtativelymeasureviralRNAinblood SpeCimenswithasensidvityofapproximatelylxlO3to 5×103viralRNAcopleSPermLThesamplevolumeis
20pLderivedfromalOO-uLRNAextractobtained丘oma
O.24-mLserumSPeCi皿en.山1TMA-pOSitiveandIRspeci-
menswerealsotestedforthepresenceofimmunoglobu- 1inM(1gM)andimmunoglobulinG(IgG)antibodyusing IgMMAC-enZyme-linkedimmunOSOrbentassay(モLISA)
andIgG EuSA,reSpeCtively131Y32ⅥruS WaSisolated on C6/36cellsandbymosquitoisola・don・33・34
Stati$ticalanaIysis
AtrendanalysisuslngSimplelinearregressionwasper- formedtodeterm血eiftherewasachangeinthenumber Ofblooddonationscollectedduringthestudyperiod.The prevalenceofDENVRNAwasdeterminedbydividingthe number ofTMA-pOSitive donations bythe number of blQOddonadonscollectedduringthestudyperiod.InLbr- mation about donor characteristics(Seelもblel)was
ObtainedfromtheARC,$electronic donor database and
incl。deddate。fc。u。。ti。n,g。nd。r,date。frth,Zipc。de Ofresidence,ZlpCOdeofdonationsite,donationstatus (むst-timedonororrepeatdonor),phlebotomyprocedl,lre (WllOle blood,plateletpheresis,Orleukapheresis),and donationtype(allogeneic,directed,OrautOlogous).Both donorresidenceanddonationsitewererecodedintothe
threereglOnSOfPuertolruCOSetbytheUhitedStatesPostal Service(SanJuanMetropolitanArea,WeSt.andeast)and
thentreatedasbinarYVariablesintheanalyses(i.e..San JuanmetropolitanareaVerSuSOther).Agewasstratifiedby itsmedianandconsideredasabinarycategoricalvariable inanalyses,
DifferencesinTMApositivitybydonorcharacteristics WereaSSeSSedbytheFisher’sexacttestandexactlo由Stic regression.Potential、covariatesidentiBedforinclusionin the丘nalmultivariablehodelincludedcovariateswithap ValuelessthanO.200nbivariateanalysis.Agewasadded tothemodelapnonglVenitsassociationwithdengue infection.ZAl1comparisonsweremadewiththeuseofa two-tailedtest,andaTypeIerrorrateofO.05wasusedto assesssigni丘caLnCe.
RESULTS
Atotalof16,521blooddonadonswereco11ectedduringthe ll-Weekstudyperiod(mean,1502donationsperYeek [range・28ト1864】withoutasi卯i丘canttrend中donation
frequency)・TⅣelvedonadons(0.73perlOOOdonations)
Were TMA-pOSitive,dthtwo orlessidenti丘ed per Week.Eleven of these -12 donations were whole
TMA
Tbstingwasperfohnedusingaprototypedengue・TMA assayonafu11yautomatedsystemforNÅrbloodscreen 伊rocleixTigrjssystem.ChironCorp.,EmerYvi11e,CA)・The assayusesth(∋SameChemistryasotherhumanimmun0-
deficiencyviruS-1/hepatitisCviruSandWassays伊ro- cleixandUltrio,reSPeCtively,ChironCorp.)25-27andtargets SequenCeSthatareconservedacross allfourserotypes. Thustheassayusediscapableofdetectingal1fourdengue SerOtyPeS.TMAisanisothermalRNAtranscriptionampli一
丘cationsystemusingbacteriophageT7RNApolymeraSe andMoloneymtuineleukemiaviruSreVerSetranSCriptase (MMlVRT)toproduceRNAampliconsviaDNAinterme- diates.Viral1ysis andmagnedc-basedtargetcaptureof viralRNAarefouowedbyamPl迫cationanddetectionwith
theuseofchemi1uminescentprobes.26Thisteclmiqueis abletodetect3.4WestNileviralcopleSpermLata50 PerCentdetecdonrate・28Theanalyticalsensitivityofthe DENVTMAassayusedinthisstudyisverysimilaT,with50 PerCentdetectionat3・5vird「RNAcopleSPer如Landa SamPlevolumeofO.50mL.29Assayresultswerereported inrelativelightunits,Whichwereusedtoderivesignal-tO- CutOff(S/CO)ratios.Cutoffvaluesforthe DengueTMA assayinternalcontrol(IC)andanalytesignalswerecalcu- latedusingthesameformulaeusedfortheProcleix Assay.30Asamplewasconsideredreactiveifthea皿alyte
S/COratiowasatleastl.0,nOnreaCtiveiftheanalyteS/CO ratiowaslessthan1.0andtheICsignalwasabovetheIC CutOff,andinvalidiftheanaiyteS/COratiovaluewasless
than1.0andtheICsignalwasbelowtheICcuto氏
Supp]ementa]testing
AllTM-pOSitivespecimenswereretestedatal:16dilu- tioninplasmascreenednegativeforal1infecdousdisease markersincluding dengue RNA at Gen-Probe to de- terminethe e伍cacy of testing blood donations by
mlnlPOOledmethods.TheTMA-pOSidveandIRspecimens
13501月ANSFUS10N Vo山me48,」uly2008
181
-
DENGUEINBLOODDON〝nONS
blood・CO11ections,Whiletheotherwasaplateletpheresis fromanO-donor.Donoranddona仕onchamcteristicswere
Simi1aramOngtheTMA-POSitiveand-negative>donations (p>0.05forallvariables.Fisher’sexacttest).hamuldvari- ′ablemodeladjustedfbrage.donorswithresidenceinthe San如anmetrOpOlitan arear扉ere approximately three times morelikelythan donors residingoutside ofthe metropolitanareatObeTMA-pOSidve(a句ustedoddsratio, 3.0;95%con丘denceinterval,0.9-10.1).
The丘代blooddonationsthathadthehighestS/CO ratiosoninidalTMAtestingweretheo山yspecimenstobe Thn-reaCtiveatadilutionofl:16恥ble2).Fourofthese
fivespecimenswereposidvebyRT-PCRandhadquanti- fiablevirdloadsrangingfrom2×103to8×107viral
COpleSpermL・ThreewereidentifiedasDENV2andthe Otheras DENV二3.DENVwas culturedfromthreeofthe
fburspecimens.twobymosquitoinoculadonandonein CeuCulture・DENV・2andDEN¢3werethepredominant
SerOtypeSincirculationinPuertoRicoin2005. Serologictestingofthe12TMA-pOSitiveblooddona-
donsrevealedthatonlylwasIgM-pOSitiveand9were IgG-pOSi伽ebyELISACrhble2)・ThelackofIgGan仕body dtersinSpecimensl,4.and8indicates no previous
dengueinfectionsinthesepatients・ThepresenceofIgG andbodiesintheabsenceofIgMand- bodiescouldre瓜ectevidenceofprevi- OuSin飴CdonsinSpecimens2,3,5,7,9, 10,11,and12,andIgGdtersequalor greaterthanl:163,840inSpecimens3,7,
9.andlOindicate arecentor current
SeCOndaryinfectioninthosepatients.32 ThepresenceofIgGinthesoledonor withIgMantibodies(Speci皿en6)could
Sim血中 be re8.ective of recent or
Currentinftction.
0血er血an血e12TMA-pOSidve
SPeCimens.there wereanadditional threemspecimenswithS/COra孟son initialtestingofl.00,1.03.andll・58and
OnrePeatteStingofO・92,0・40,andO・07,
respectively:Al1werenega仕veonPCR,
IgM MAC-EuSA,and virus recovery.
neywere,however,一positive pnIgG
ELISA.htheWNVTMAassay,anS/CO rati00fgreaterthanOrequalto17has a positive predictive value fbr con一
点rmation of95 percent 仏RC data.
unpub止$hed);itislikelythatthisrela-
tionshipisthe same for DENVTMA.
TABLEl.Character‡$tjcsofal】andTMA-POSltjveblooddonors雷n Pue代OR‡co,$¢ tember20toDecember5,2005’
All donors TMA-POSitjv8 Characten$tic (n=…16,521) doncrs(n=12)
Ago(years) Ma18
Donation status Rlちt欄m8donor Repeat donor
Region of residence SanJuanMetropolitanArea East W9扇
PhlebotomyprDCedure Wh010blood Plat81占中ho帽5鹿 Pl坤叫咋卸叩吟鳳RBCpheresis Doubl8RBCpherosi$ Louk畠Pheresiさ
Donaゼm吋PO A1logoneiG Direded A山0logous
Regionofdonaぬn$it8 SanJuanMetropoIibnAr由 Ea$t Wost
37.0(1&85)
10.654(64.5)
5,056(30.6) 11.485(69.4)
6,631(40.1)
5,182(31.4) 4,706(28.5)
15,838(95.9) 627(3.8)
48(0.3)
7(0.0)
1(8.0)
16,400(99.3) 67(0.4)
54(0.3)
8,9糾(54.4)
3,870(23.4)
3,667(22.2)
囲刑㈹剛刑期
57 831 111000 200
●Dataarereporteda$rnedian(range)ornumber(%).
TABLE2.fl毎un$Of$uPPJementarytestingofTMAIRspecirTm(,)=12) TMAtestG即トProbe(SJCOrab)● Supph)mentaryt融ngCDCdenguebranch
Numberviml Mosquito Spedmen tnitialtest Secondtest l:16 PCR† RNAImL lgM‡ lgG Cell culture inoculation
D2 7.14×108 D3 8.12×107 D2 7.74×105 D2 2.OxlO3 Nega伽8 Und8t郎鹿d Nega厄ve Undetected Negative Und8teCted Negaゼv8 Undotected Nega伽e Undetected Negative Undetected Negative Undetected Ne9ath,e Undetected
1 31.96
‘2 30.31
3 29.22
4 29.17
5 23.89
6 21.22
7 17,78
8 17.41
9 17.24
10 5.97
11 4.08
12 1.53
9
.g.28.86朋.59.28.10〟.〇5調.15鹿
2
737812g2劇21153133151300
. 2728.27と8〇.〇.〇.〇.〇.〇.〇.
0.229. Nega厄Ve Nega伽e D2 0.幻7 1:10,248 Nega一行e [〉3 0.409 1:163β㈹ D2 Negative O.22g Nega削ら N09血e Nega也ve O.469 1:2,560 Negative Nega伽e 8.870 1:160 Nega伽e Nega伽e O.4O9 1:655,360 Negative Negative O.198 Negative Negative Nega伽e l.封0 1:163,840 Neg血e Neg血8 0.440 1:65年,360 Negative Negative O.368 1:10,240 Negat毎e Nega血相 0.270 1:2,560 Nega伽o Negative
嵐ざ
■ S/CO≧1con$id8redtoboread山嵐 †D2=DEN≠2.D3=DENV-3. ‡>2.00ロeonsid餅edpo$柑V8.
肋Iumeヰ8,July2008 TRÅNSFUStON1351
182
-
MOHAMMED ETAL.
Nineofthe12repeat-reaCdvesampleshadS/COvaluesin OneOrbothtestsof17-Orgreater・
DISCUSS(ON
Thisstudy;andasimi1aronerecendyconductedusing donationsinfIonduras,Brazil,andAnstralia,29arethefirst todocumentthepresenceofdengueviralnucleicacidin blooddonations・hPuertoRico,nearlylinlOOOdona- thnswaspositiveforthepresenceofdengueviraln11Cleic acidbyTMAFurthermore,1iveviruSWaSreCOVeredfrom threeofthe12TMA-pOSitivedonations.indicatingthatat leastthese3were capableoftranSmittinginfectionto recipients・Theprevalenceofdengueviralnucleicacidin
blooddonationsinthisstudywassimilartothatestimated forWNVintheareasexperienclngOutbreaksintheconti- nentalUnitedStatesin200235beforeuniversalscreerung using minipooINÅr wasimplementedinJuly2003.22 AssuminganarmualprevalencerateofO・73per1000(as bundinthisstudy)andthateachdonationismadeintoa meanOfl.45tranSfusablecomponents,36theremaybeas manyaS56potentialrYviremicdonadonsand81compo- nents generated h’Omthe approximately77,DOO blood donationsco11ectedaLnnuauybytheARCinPuertoRico・ Dengueincidenceishigh吋SeaSOnalandv虹iesconsider- ably丘■OmyeartOyear,37r38however.sotheprevalenceof potential1yviremicdonorscouldbecorlSiderablyhigher Orlowerthanthis丘gureatanyglVentime.FurthermOre, theth工ee m SPeCimenslackingreproducible results repe?tTMAtestingmayhavebeentrue-pOSitivespeci-
mensbutwithlowerviralloads.Ifthecase.thiswould
underestimatethetruepreValenceofTMApositivity. The unlinkedstudydesign didnotpermitcontact
Withthe recipients ofthe TMA-pOSitive donations to assesswhethertransmissionoccurred.Nevertheless,viruS
WaSCulturedh-Omthreedonationsandtheviralloadsof
thefburRTIPCRl)OSidve donationsindicatethattheir tranSfusionwouldhaveresultedininoculaordersofmag- nitudegreaterthantheamountofviruSSeCretedinthe SalivaofAedesmosquitoes.documentedtobeaslowas lO2viralparticlespersecredon.39TheRIしPCRassayusea inthisstudyhadlowersensitivitythantheTMAassay;and itwasnotpossibletoassesstheviral1oadoftheRT-PCR-
negativespecimens. OurresultsindicatethefeasibihtyOfNÅTasascreen-
1ngStrategyforDENV;ashasbeensuccessfuJyusedfor WNVOfconcem.wefbundthatsimulatedmimipooINAr (dilutionl:16)wouldnothavedetectedthemajority(70f 12,Or58%)oftheTMA-POSitivespeci皿enS;howevef.the
experiencewithWsuggeststhatnotallofthesedona- tionsmaybeinfectious.Approximatety30percentofWNV NÅトpositivedonationshaNeviral,loadsbelowthelimits
OfdetectionbyminipooINArandcanonlybedetectedby SCreerungOfindividualdonations.23・40AlthQughⅥWVha5
beentranSmitted打omtranSfusionsdetectableonlyby
1352 TRANSFUS10N VoIume48,July2008
183
indjvidualunitscreenmgandwithanestimatedlevelof ViremiaaslowasO・06plaque-fbrming皿its(PFUs)permL
(1PFUisapproximateけ400viralcopies),41mostdona- tionsonlydetectablebyindividualunitscreqninghadIgM andlgGantibodiesandwerehkelynotinfec也ousgiventhe fhctthatnear吋al1WNVtrans鮎siont=anSmissionshave OCCurred丘■Omantibody-negadvedonadons.22・25・42unLbト
tunately;thissamemarkerofinfectivityisnotappucable todenguet)eCauSeOfthehighprevalenceofpreexisting, CrOSS-reaCtivedengueantibodiesinthepopulationand thecomplexandvariableserologicresponseaftersecond- arydengueinftction.32・43
Theglobalincidenceofdenguehasrisenmorethan 30-foldinthepast50years・hareaswhereden計1eis endemic,however,tranSfusiontranSmissionoftheagent israrelyirⅣeStigatedformanyreasons,indudingthefact
thatthismodeoftransmissionisd臆culttoproveagainst abackgroundofendemicdengue.Insuchcases,thedis-
tinctionbetweenarecipientinLectionviamosquito-bome transmission as opposed to transfusion tranSmission maybetoocomplextodistinguish・Furthermore,many dengue-endemic countrieslackhemovignance systems withsu瓜cientresourcestoinvestigatecasesofrecipient infectionthat are potentiaⅡyrelated to trdnsfusion of blood components・Finany,SOphisticatedlaboratory testingmaynotbereadilywailableinm査nydengue- endemiccotntriesandsuchtestingisrequiredtodis血-
guish denguefrom other arboviralinLbctions as well as distinguishing cu汀ent dengueinfection&om pnor infections.
Incontrast,WhenWNVenteredtheUhitedStates,it
WaSagalnStabackgroundofana伽epopuladon.ThisperL
mittedthelaboratorylinkage of multiple transfusion recipientswithWNVin血ctiontoasingleinfecteddonor
withinseveralclusters ofW cases.hfectiousviruS
and/orviralRNAcouldalsoberecovered仕omretrieved COCOmPOnent plasma units;inthese cases,WNVwas
readilyidendjiedintheabsenceofcompetingarboviral infections・ThetranSmissibnityofWNVviabloodtranSfu- Sionhasbeenestal)lished,andourfindingsdocumenting thepresence ofDENVRNAinthePuerto Ricanblood SuPply,at alevelcomparible tothatwhich triggered 戸CreemingoftheUSbloodsupplyforWin2003,highー
Iighttheriskstotrqnsfusionsafetyposedbyemerging diseases such asthe vector-borne naviviruSeS.Further
evaluationisrequiredtoassesstheriskofdenguetranS- missionbyTMA-pOSitive donationsandthe cost and bene丘tofroutinedenguescre阜ninginendemicreglOnS・
ACKNOWLEDGMENTS
Theauthorsacknowledgethefollowhgindividualsfortheircon一
雨bu血nto也isrese8∫Ch:M∫5Di鮎Mag由yBorge$a皿dMf AntoniodeV岳ra(ARC-PuertoRico)fbrprovidingdataspecificto
thePRJre如nofARC;DrMark寧eattyO}ediatricDengueⅥlCCine
註ア
-
DENGU∈INBLOODDONÅT10NS
hitiadve)forassistingwithprotocoldevelopment;MrGilberto
SantiagoandMrMarkVerduinのengueBranch,CDC)fbrlabo一
円血Ⅳ飢甲p“七山MkhaeⅢ山肌SSOn(DengueBran叫FDqfbr
Stadsticalsupport;andDrEd■Notari(ARC),DrMathewmlelmert (0伍ce ofBlood.Orga皿,and otherTi$Sue Safety(proposed),
CDC),MrJoshuaSmith,Dr払teMcElroylDrD.FermhArgiie1lo,
andDrWel山IgtOnStm(DengueBranch,CDC)fortheirscientific
mputinprepaLingthemanuscript・
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ふ ′
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叫パ隼噂担ゆ㌣噂叫声‘u
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医薬品
医薬部外品 研究報告 調査報告書
化粧品
別紙3イ
報告日
年 月 日
第一報入手日
2008年6月13日 新医薬品等の区分
該当なし 識別番号・報告回数
総合機構処理欄
一般的名称 r 】 nid
】
研究報告の公表状況 Culture. オーストリア
販売名(企業名) Ehrlich,H.].etal,
N帥Engl.J.Med.,358-2573-2584
(2008)
本稿では,抗H5Nl型鳥インフルエンザワクチンの安全性及び有効性を検討する無作為化用量漸増第l・2相試験の試験成績につい 使用上の注意記載状況・
て記載した。BaxterBioscience社が同ワクチンを開発し,試験を実施した。当該ワクチンの主な特徴は,サルの腎臓細胞の培養株(ベ その他参考事項等 ロ細胞)で作成された自然発生するウイルス株〟Vietnam/1203/2004を利用していることである。ミョウバンアジュバントによる作 BYL-2008-0338
研 用も検討し,ウイルス全体をワクチンとして使用した。有効性エンドポイントとして,ワクチンの(i)へマグルチニン阻害を生じさ
究 せる能力,(ii)中和抗体を誘発する能力,(iii)注射21日後にセロコンバージョンを生じさせる能力を検討した。各被験者に対し,
報
告 の
概
要 有効性に関する限り,免疫応答はアジュバントなしの処方を投与した被験者において最も高い割合で認められたが,いずれの処方で
も第21日目から第42 日目で中和抗体の抗体価は同程度に増加した。さらに,ウイルス株A/lndonesia/05/2005及びA/Hong Kong/156/1997に対する交差中和が認められた。再鼠アジュバントなしの処方が最も高い免疫原性を示した。本試験では重要な用量
反応性の関連が示されなかったことから,今後の開発にあたってアジュバントなしの7.5ugの処方が選択された。
報告企業の意見 今後の対応
抗H5Nl型鳥インフルエンザワクチンが利用可能となれば、パンデミックの 現時点で新たな安全対策上の措置を講じる必要はないと考え
発生及び拡大を防ぐために有効であろう。血焚由来製剤工程におけるウイ
ルス除去は、インフルエンザウイルス除去に対しても有効と考えられる。
弊社製品の製造工程に使用されている血渠分画成分は,製造工程中のウイ ルスバリデーションにおいて,インフルエンザウイルスと同様の土ンベロ
ープRNAウイルスであるH川(レトロウイルス)の不括化・除去能が確認さ れでいる。各成分の製造工程における不活化・除去能は以下のとおり。
●アルブミン・カッター及びコージネイトFSの製造工程培地に使用され七いるヒト血清アル
プミン:17.8log以上
・プラスマネートカッター,コージネイトFS及びコージネイトFSバイオセットの製造工程
培地に使用されている加熱ヒト血梁タンパク:15log以上
●コージネイトFSの製造工程に使用されているトランスフェリン:9.1log以上
●べタフエロン皮下注,ゼヴァリンイットリウム(90Y)静注用セット及びゼヴァリンインジウ
ム(川‖静注用セットの製造工程に使用されているヒト血滑アルブミン:9.98log以上
-
I I l
ー ノ
■、■
188
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BYL-2008-0338
7’わ己 Nf二W ENGLANr=OURNAL∂_「入†E「=Cl三JE
ORIG王NAL AR.■11CLE
AClinicalTrialofaWhole-Virus H5Nl
Vaccine Derived丘om Ce11Cul[ure
.・い・・-∴∵ ∴∴、∴:∴ ∴・、、■」‥・∴- ‥‥・・、.ミー ー∴・.
, Paui良丁ヨr門口yah,M・B■,B-S‥Ci-r≡5t血1joukhadar,M.D・、EmanueieMontorno‡LPh.D.,
Da‡eFニisher,F叔.A▼⊂.P・.GregBerezしk,吼S.,SandorF再sれPh.D.,
Akx抑draLわW一己ase!雪盲,Ph・Dt,Nin3Vart盲an.Ph・DリRomanBobrovsky,Ph.D,,
Bor言s一品vaG.Pav室ova,Ph.D.,EvaMar毒aP6貼bauer,M.D.}○モ育iedKistner,Ph、D.,
andP.Noe‡Barreモモ,Ph.D.-わrthe8axterH5NIPandem盲clnポリenza
VaccineC圭in妄caiStudyTearn
ABSTRACT
B入⊂XGlモOUIヾD
Widespreadinfさctionsofavian specieswithavianinfluen2,aH5Nlvir11Sandits limitedspreadtohumanssuggestthattheviruShas【hepoten亡ial亡OCauSeahuman influenzapandemic.AnurgentneedexistsfbranH5NIvacciflethatise晩ctive agalnStdivergen亡StrainsofH5NIvirus・
ME丁目ODS
Inarandomized,dose・ざSCalation,Phaseland2studyirNOlvingsiXSubgro11pS,We inves[1gatedthesafityofanH5NIwhole-VirusvaccineproducedonVbrocelicul- turesanddetermineditsabili[ytOinducean[ibodiescapableoFneutralizingvarious H5NIs亡rains・lz][WOVisi亡S21daysapart,之75volunteersbetweentheagesof18and 45yearsreceivedtwodosesofvaccinetha[eaehcontained3・75FLg,7.5〃ノg,15jLg, Or30FLgOfhernagglutininantlgenwithalumadjuvantor7・5FLgOr15FLgOfhemag- glutininantlgenwithou亡a4jwant・SeroIoglCanalysiswasper丘)rmedatbaselineand Ondays21alld42.
RESULTS
Thevaccineinducedaneu[ralizinglmmunereSPOflSenO亡Onlyagainstthecladel (AIVietnamI1203!2004)viruSStraint)utaIsoagainsttheclade2and3strains.The useo(a4iuvantsdidnotimprovetheantibodyresponse・Maximumresponses【0【he VaCCirleStrainwereobtainedwithformulatiorlSCOntaining7・5FLgand15fLgOf hemagglutininantigenwithouta嘩uvant.Mildpaina亡theiftiectionsite(in9【027% OfLsubiects)andheadache(in6to31%ofsu旬ects)werethemostcommonadverse eventsider】tified氏〉ra11vaccinefbrmulations.
CONCLUS10NS
Atwo-dosevaccinereglmenOfeither7.5FLgOr15iLgOf-hernagglutininantigen Withou[a句uvantindueedneutralizingantibodiesagainstdiverseH5NIviruSStrains inabigbpercentageoFsu句ects,SuggeStlng亡batthisrnavbeause知IH5Nlvaccine. (ClinicalTrials,gOVnumber,NCTOO349141.)
FromtheDepartmentoFGloba‡Research and Development】Baxter BjoS⊂-帥Ce (H.j.【.,G.8.,S.FリんL.-臥.N.V..R.8..B.G.P‥
E.ト九R.0.K.,P・N.B-),andtheDepartment O†⊂tini亡alpharma⊂Ology,Medi⊂∂1Uni-
Ve(Sityofvienna,ViennaGeneralHospi- ta=M.M・,CJ・)・・】・▼bothinVienna;⊂hangl
Genera=」ospitat(H・M.L・0.)andtheNa- tionatUniversityofSingaporeandNation- a=JniversityHospital(P・A・T・.P・F・)→--al】 inSingapore;andtheUniversttyofsie=a, Siena,舶‡y(E・M-).Address reprint re-
queststoDr-Mt}llerattheDepartmento( ⊂linica】Pharmacology.Medi⊂at Univeト SityofVienna.ViennaGenerat Hosp■ta霊 (AfH),W紬ringerGt・rte118-20.1O90Vi-
enaa,Austria,Or at markus,mue=即@ meduniwien_a⊂.at,
Drs・Ehr=chandM白=即COntributedequaト tytothisarti⊂te・
N【ngtjMedZOO3;35g:2573一旦4・
⊂opy廟t◎2α鳩肌】S8√た〟iC拝5M‘d血f∫ock吋・
257∋ N ENGLJM亡Dう58;2ヰ WWW・Nり軋ORG jUNElコ.2008
Downloadedfrornwww.nqm.orgatBAYER-YAKUHINCO.,OnAugust17.2008. Copydght◎2008MassachusettsMedicalSociety.A]川ghtsreserved.
189
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T■たどNEWl三NGLÅがDJOUliNALげ川El)1Cl三ヾE
agesof18and45yearsinarandomized,partially blinded(betweengroups)clinicaltrialatthree Sites:OneinAustriaandtwoinSingapore.The Studywasdesignedbyitssponsor,Baxter.Data WereeOlleetedbytheinvestlgatOrSandwereheld and analyzed by Baxter.The manuserlptWaS Writtenbyasubgroupofindustryandacademic authors;allauthorscontribu【edtothecontent, had fh11access to the data,andvouch fbrthe COmpletenessandaccuracyofthedataandda【a analysis.
Theapproprlatelocalreviewboardsandethics COmmitteesapprovedtheprotocolfbrthestudy, WhichwasconductedineompliancewithGood ClinicalPracticeguidelinesandtheprovisionsoF theDeclarationofHelsinki.Thestudyinvestiga- torswereunawareofassignmentstostudygroups. (Fordetailsofthestudydesign,SeetheSupple- mentaryAppendix,aVailablewiththefu11textof thisarticleatwww.nqim.org.)
Theo切eetivewastoidentifytheimmunoge- nicityandsa丘q,Ofvariousdosesorinactivated H5NIwhole-virusvaccinein氏)rmulations with andwithouta4iuvant.TheprlmarylmmunOge- nieiryoutcomewasthenumberof’subjectswith hemagglutinationrinhibidonandneutralizinganti- bodiestothevaccinestrain(A/Vietnam11203I2004)
21daysafterthefirs[andseconddosesofvac- Cine.TheprlmarySafさtvou亡COmeWaSanySyS- temic reactionafterthefirstand second doses.
V▲C⊂lNE
Tbe monovalent avianinnuenza H5NIwho王e一
viruSVaCCine(BaxtezうWaS琶rOducedwiththewi1d-
typestrainAIVietnamI1203I2004,Whichwasob- tained丘omtheCentersfbrDiseaseControland
Prevemionand叩aSinactivatedwithformalinand ultravioletlight.Thevaccinewasmanufactured inVerocellcultureinanenhancedRSし3hcility 匝Srequiredfbrwild-typeH5NIvirus),aSde- SCribedpreviously.9
R▲NDOMほATtON▲NDFOLLOW・UP
Su句ectswereeligibletopartlCIPateiftheywere Clinica11yhealthy,understoodthestudyproce- dures,prOVidedwritteninfbrmedconsent,and agreedtokeepadai&recordofsymptoms・Wom- enwererequiredtohaveanegativepregzlanCy testatscreenlngandbeforeeachvaccination・
Subiectswererecruitedinthreestudycohorts inadose-eSCalatingmannerandwererandomly assignedtoreceivetwoO.5-mliQiectionsintothe deitoidmuscleatanintemlof21days(range,
HE EMERGENCE OF A NEW HU」ⅥANIN- fluenzapandemiccausedbyanavianviruS
.strainlSPOSSible.VaccinationagalnStpan- demicinfluenzaisconsideredtobethemosteF ftctiveoptlOntOlimitits spread・However,the conventionalapproaches亡Othemanuhctureofin- fluenzavaccineshaveanumberofdisadvantages andraiseconcernaboutwhethersufficientquan- titiesofane飽ctivevaecinecant)emadeavaiト
ableearlyenoughattheonsetoFapandemicto haveam毎o