New Technology application for blood components preparation: Pathogen Inactivation for Platelets By M. Slaedts, Sr. Manager – Deployment, Cerus Shenzhen, China April 24th, 2015

Key areas for consideration Current Challenges in Blood Safety Pathogen inactivation is a Proactive Approach Global Status & Regulatory Approvals Pathogen Inactivation for Red Cells Introducing INTERCEPT for Platelets in routine Impact on the production of Blood Components

Current Challenges in Blood Safety

Patients and doctors fear infectious transfusion risks 1. Risks of transmission of infectious agents to patients are linked to contamination of blood donors and blood products. 2. Reactive measures do not account of the next viral risk, window period not closed. 3. While Preventive measures (Pathogen Inactivation) have reduced the risk of infectious diseases. 4. Time interval between risk recognition and screening test. 5. Emerging & re-emerging pathogens feared : WNV, Chikungunya, Dengue, Ebola, … 6. Epidemiological modifications of populations of donors and recipients: linked to migrations of populations and climate changes.

Community Keeping Up with Emerging Pathogens

Re-emerging Pathogens – e.g. Dengue World-Wide Burden > 4-fold increase in cases reported over past 30 years, ~50M dengue illnesses/year. 1 Recognized increased transfusion-transmitted risk, reported per 10,000 donors:1, 2 ~0.5 - Australia 2004 ~18 - Singapore 2007 ~7 - Puerto Rico 1995-2010 ~19 - Key West, Florida, US Peterson LR et al. Transfusion 2012;52:1647-1651. CDC: http://www.healthmap.org/dengue/en/

Average RBC Unit Charge (US) * The Current Reactive Safety Approach Requires Continual Addition of Costly New Tests Average RBC Unit Charge (US) * HIV-1 Ab HBc, ALT HTLV-I HCV 1.0 HIV-1/2, HCV 2.0 HIV-1 p24 Widespread Leukoreduction HIV-1/HCV NAT Chagas’ Test WNV NAT 25 years of testing, partial protection against just 7 agents: HIV, Hepatitis B, Hepatitis C, HTLV, leukocytes, West Nile virus, Chagas’ disease Others? $250 Dengue? Chikungunya? Babesia? $200 Introduction of PI could stop and even reverse the cycle of additions $150 $100 1985 1990 1995 2000 2005 2010 2015 * RBC price data adapted from B Custer & JS Hoch, Transfusion Medicine Reviews, Vol 23, No 1 (January), 2009: pp 1-12

Current Limitations of Testing: Infectious Window Periods with Nucleic Acid Testing (NAT) Window Period in Days Busch, MP; et al. Advances in Transfusion Safety – Volume IV, Developments in Biologicals, 2007, vol 127, pp 87-112. Kleinman, et al. J Clin Virol 36 Suppl. 1 (2006) S23-S29. Comanor L, et al. Vox Sanguinis (2006) 91: 1-12.

Need for a Robust Approach to Prevent Bacterial Contamination of Platelets AABB Standard 5.1.5.1 (first added in March 2004) The blood bank or transfusion service shall have methods to limit and detect bacteria or inactivate bacterial contamination in all platelet components. 2010 Variance in favor of Pathogen Inactivation.

Why inactivate pathogens in labile blood components? Increase transfusion safety by a proactive rather than passive approach Prevent sepsis due bacterial contamination Closing the window period Save lives

Pathogen Inactivation: A Proactive Approach to Safety

INTERCEPT Mechanism of Action Small molecules (amotosalen and S-303) penetrate cellular and nuclear membranes and intercalate into helical regions of DNA or RNA present in pathogens Amotosalen forms covalent crosslinks to nucleic acid base pairs upon exposure to UVA light DNA and RNA replication are blocked, inactivating pathogens and leukocytes Nucleic acid intercalation Docking Crosslinking Unable to replicate UVA illumination or pH reaction Amotosalen or S-303

INTERCEPT Blood System – for Platelets and Plasma Step 1 Amotosalen Step 2 Illumination Step 3 CAD Process Complete Storage Plasma 13

The importance of a Broad Spectrum of Inactivation Routinely tested agents ENVELOPED VIRUSES GRAM-NEGATIVE BACTERIA SPIROCHETES Treponema pallidum Borrelia burgdorferi PROTOZOA Trypanosoma cruzi Plasmodium falciparum Leishmania sp. Babesia microti LEUKOCYTES T-cells HIV-1 HIV-2 HBV HCV HTVL-I HTLV-II DHBV BVDV CMV WNV SARS Vaccinia1 Chikungunya Dengue2 Influenza A Klebsiella pneumoniae Yersinia enterocolitica Escherichia coli Pseudomonas aeruginosa Salmonella choleraesuis Enterobacter cloacae Serratia marcescens Anaplasma phogocytophilum Orientia tsutsugamushi3 ENVELOPED VIRUSES HIV-1 HIV-2 HBV HCV HTLV-I HTLV-II NON-ENVELOPED VIRUSES GRAM-POSITIVE BACTERIA SPIROCHETES Bluetongue virus, type 11 Simian Adenovirus-15 Feline calicivirus Parvovirus B19 Human adenovirus 5 Staphylococcus epidermidis Staphylococcus aureus Streptococcus pyogenes Corynebacterium minutissimum Listeria monocytogenes Propionibacterium acnes Bacillus cereus (vegetative) Lactobacillus sp. Bifidobacterium adolescentis Clostridium perfringens Treponema pallidum (1) Sampson-Johannes A, et al. 2003. Transfusion. 43:83A; (2) Lam S, et al. Transfusion 2007;47:131A; (3) Rentas F. Transfusion 2004;44:104A.

Synergistic Approach to Blood Safety: Closing The Window Period Risk with INTERCEPT PI HBsAg Anti-HCV Days Titer Anti-HIV MP-NAT Peak Viremia in Asymptomatic Donor: HIV: <10^7 geq/mL HBV: ~10^9 geq/mL HCV: ~10^8 geq/mL Estimated concentration viable virions: HIV: <10^4 viable virions/mL HBV: ~10^6 viable virions/mL HCV: ~10^5 viable virions/mL PI log reduction in platelets: HIV: ~6 HBV: ~6 HCV: ~4.5 Adapted from Kleinman SH et al. Transfusion 2009;49:2454-2489.

High Efficacy necessary for a Proactive Approach to Emerging Threats Infectivity Log Reduction Pathogen INTERCEPT West Nile virus > 6.0 Chikungunya virus > 6.4 H1N1 virus > 4.1 H5N1 virus > 5.9 Dengue virus > 5.0 O. Tsutsugamushi > 5.5 XMRV > 4.0 T. Cruzi > 5.3 B. Microti L. Mexicana

No Sepsis Fatalities with INTERCEPT Platelets: French & Swiss National Hemovigilance Data Conventional Platelets INTERCEPT Platelets Year Units Transfused (n) Transfusion Transmitted Infections (Fatalities) Units Transfused (n) Transfusion Transmitted Infections 2006 231,853 4 (0) 6,420 2007 232,708 9 (2) 15,393 2008 239,349 6 (1) 15,544 2009 241,634 9 (0) 21,767 2010 253,149 2 (1) 22,632 2011 267,785 3 (1) 22,392 2012 275,834 7 (2) 24,849 2013 278,234 4 (1) 25,089 29,900 1 (0) 6,600 26,500 34,265 34,750 Total 2,057,046 45 (8) 249,601 France: p = 0.039 / Combined p = 0.006 French HV data: 2006-2011: Sweeney J, Lozano M. Platelet Transfusion Therapy. Bethesda: AABB Press, 2013. 2012-2013: French National Agency for Medicine and Health Product Safety/ANSM, Hemovigilance Activity Reports. Swiss HV data: SwissMedic Haemovigilance Annual Reports, 2010-2013.

Status of Regulatory Approvals 2002 2003 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 EU CE Mark Class III France Afssaps Germany PEI * Switzerland Swissmedic Singapore HSA Mexico, COFEPRIS US FDA Platelets EU CE Mark Class III France Afssaps Switzerland Swissmedic Germany PEI * Mexico COFEPRIS US FDA Plasma Phase I / II Phase III Reg. Review Marketing EU & ROW EU & ROW Platelets Plasma Red Cells USA Platelets Plasma Red Cells

INTERCEPT Blood SystemTM Global Status ● More than 10 years of routine use ● Kits sold to produce over 3,000,000 INTERCEPT platelet and plasma units ● Used in >100 Blood Centers in 20 countries Centers in Routine Use Commercially Available Regulatory Activity Initiated / Application Pending Review

INTERCEPT Red Blood Cell Program

INTERCEPT RBC – Mechanism of Action S-303 is a nucleic acid-targeted alkylator that quickly diffuses into viruses, bacteria, parasites and blood cells Glutathione (GSH) is used to quench side reactions of the effector with other biological materials Targeting Docking & Permanent Crosslinking (Helical regions of DNA & RNA) Anchor Linker Effector Reaction Degradation

INTERCEPT RBC Process – Gen 2 Reconstitution Set Integrated Processing Set STEP 1 Add RBC and mix with reagents STEPS 2 & 3 Inactivate & remove STEP 4 Transfer RBC for storage

INTERCEPT RBC Activities are Global NHSBT United Kingdom Evaluation Completed EFS Alsace Alsace, France Evaluation Completed Uppsala University Sweden Evaluation Completed DRK Frankfurt, Germany Clinical Study In Progress Hoxworth, Ohio/ Blood Center Wisconsin USA Clinical Study In Progress Innsbruck Austria Evaluation In Progress Cagliari / Torino Italy Clinical Study In Progress ARCBS Australia Evaluation Completed Clinical Studies In vitro Evaluations

Design & timing for Phase III US study under evaluation INTERCEPT RBC System – Development Status Three clinical studies globally, 2 are completed: Europe: Phase III acute anemia results reported. Primary endpoint met; no statistical differences in adverse events between INTERCEPT-treated and control RBCs. Europe: Phase III chronic anemia trial ongoing. US: Phase II recovery & survival study results reported. Primary endpoint met; FDA criteria for RBC recovery fulfilled. Plan to submit for European approval H2-2016, possible approval 2017 2013 2014 2015 2016 2017 EU Report Results Approval Decision Ph III acute – 50 pts CE Mark Review Ph III chronic – 70 pts (estimate ≥3 years for completion1) US Report Results Ph II R&S – 28 pts Design & timing for Phase III US study under evaluation 1. Currently evaluating methods to accelerate enrollment & possibility of additional clinical sites.

Introducing INTERCEPT Blood System for Platelets An operational review

The INTERCEPT Blood System for Platelets Production Storage & distribution Platelet connection Amotosalen Illumination CAD Final Storage Transfer the platelets by gravity in the CAD bag. Incubate the platelet product by continuous agitation Connect the Platelet Concentrate to the INTERCEPT Set Transfer the platelets together with Amotosalen by gravity into the illumination container and ensure appropriate mixing prior to illumination Transfer of the platelets by gravity into the final storage container UVA Illumination ~5 mins

Intercept UVA Illuminator 2 Illumination chambers 2 illuminators can be stacked over each other Average Throughput: 11 illumination cycles treatments per hour

Processing requirements - rational RBC impede UVA light transmission More plasma impedes UVA light transmission and decreases inactivation efficacy Less plasma results in more UVA light transmission and may impact platelet viability Amotosalen volume is fixed, so changes in component volume change the Amotosalen concentration in the illumination container Low dose was set to meet Council of Europe Guidelines High dose is the highest platelet dose that has been validated Platelet Dose Volume RBC Content Plasma Content

INTERCEPT Platelets: Broad Processing requirements designed for flexibility Parameter Suspension Media Suspension Medium Platelet Additive Solution Plasma Platelets (x1011) 2.5 -8.0 2.5 - 8.0 Volume (mL) 255 - 420 Plasma (%) 32 - 47 100 RBC/mL <4×106 Adsorption Time (hr) 4 - 16 16 - 24 Apheresis collections Pooled Random Platelets - From Manual to Automated methods

Lessons learned from Implementation Feedback from Blood Banks Lessons learned from Implementation

INTERCEPT Blood SystemTM deployed at over 100 blood banks Successful deployments are multiples, worldwide spread in various types of environments Centers in Routine Use Commercially Available Regulatory Activity Initiated / Application Pending Review

Implementation context

Pathogen Inactivation: last production step prior to release components Apheresis Whole Blood donations Collection of Blood Pool Random Platelets Variety of production methods Component Preparation PI Platelets PI Plasma PI Red Blood Cells (*) Pathogen Inactivation

“… Pathogen inactivation or reduction systems that are applicable to platelets will further reduce the risk of transfusion reactions due to bacterial contamination…” “…Thus, from the point of clinical relevance current evidence none of the products proofed superior.” “… Therefore, to be on the safe side from the donor’s perspective we are in favor of using the abundance of platelets available from whole-blood donation.”

Quality Management drives the implementation steps Personnel & Organization Quality Assurance & Processing Managers different & independent Changes to be documented Master Validation plan Planning for validation Qualification Documentation Approvals Implementations succeed because: They are well planned Staff is well trained Management of risks is in place Right Implementation Partners are involved Blood Bank Suppliers

8 steps leading to INTERCEPT implementation Site Assessment Implementation planning Adjustment of production, if any Installation of Illuminator Train the Blood Bank Trainers Process Qualification Operator training Conversion to routine operations

Customer feedback: Switzerland – Introduction of INTERCEPT platelets for Apheresis and Pooled Random Donor platelet components during the 2010-2011. 13 Blood Centers 2010 Red Blood Cells 308.670 Platelets Concentrates 29.900 Fresh Frozen Plasma 61.500 From nearly 100 % Apheresis collection, now converting platelet production to reach 60% Pooled Random Donor Platelets.

Case study : Blood Transfusion Service Zurich, Switzerland – Workflow & Throughput Dr. David Goslings – Head of Production

Towards Pathogen Inactivation Implementation at the NBTS Sri Lanka 2013 - NBTS evaluate successfully the INTERCEPT system for Platelets Abstract published at ISBT Seoul - 2014 Conversion from single donor platelets to pooled random donor platelets. 2015 – Pilot phase includes 1500 Platelets transfusions

Hong Kong Red Cross Blood Transfusion Service - 2014 Preparation of Pooled Buffy-Coat Pathogen Reduction-treated Platelet Concentrates in Platelet Additive Solution Using Top and Bottom Method. Cindy Chan, Thomas Lau, Barry Chui, CK Lee, Elizabeth Chua, WC Tsoi, CK Lin Hong Kong Red Cross Blood Transfusion Service, Hong Kong, China In preparation for clinical evaluation of pathogen reduction-treated platelet Pool of 5 Buffy Coat in SSP+ Preparation of INTERCEPT platelet concentrates in SSP+ PAS was successfully developed

Conclusions – Operational Technology fit with platelets from both Apheresis and Pooled Random Donor Collections for optimal production efficacy System has been designed for throughput capacity allowing the system to fit into small to large production sites Demonstrates ability, in a quality manner, to support succeffull implementation of the technology in multiples environments conditions worldwide

Conclusions

Conclusions Recognized challenges exist in ensuring blood safety today, including the bacterial contamination risk in platelets, or the increasing prevalence of emerging pathogens. INTERCEPT is a proactive approach to address such risks, and has demonstrated high levels of inactivation for a broad range of clinically relevant pathogens. INTERCEPT for platelets and plasma has been in use for over 10 years, and counts over 3’000’000 transfusions experience. The RBC system in advanced clinical development. INTERCEPT received approval by multiple Regulatory Authorities around the world after thorough review (incl. CE mark III, US FDA). The submission process for Registration of INTERCEPT started in China. 43

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