Request for Information (RFI) on Design of a Pilot Operational Study To Assess Alternative Blood Donor Deferral Criteria for Men Who Have Had Sex With Other Men (MSM), 14801-14804 [2012-6091]
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DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Request for Information (RFI) on
Design of a Pilot Operational Study To
Assess Alternative Blood Donor
Deferral Criteria for Men Who Have
Had Sex With Other Men (MSM)
Office of the Secretary, Office
of the Assistant Secretary for Health,
Department of Health and Human
Services.
ACTION: Notice.
AGENCY:
The Department of Health and
Human Services (HHS) is seeking to
identify interest and obtain information
relevant to the design of a pilot
operational study (or studies) on
alternative donor deferral criteria that
would permit blood and plasma
donations (subsequently termed ‘‘blood
donations’’) by men who have had sex
with other men (MSM).
Based upon documented higher levels
of certain transfusion-transmissible
infections (e.g. Human
Immunodeficiency Virus (HIV) and
Hepatitis B Virus (HBV)) in some groups
of men who have had sex with men, all
men with a history of this behavior
since 1977 are currently deferred from
donating blood. However, the increased
effectiveness of donor testing for HIV,
HBV, syphilis and other infectious
agents has greatly enhanced blood
safety. As a result, questions have been
raised about the need to continue an
indefinite deferral of all MSM and
whether there could be blood donation
by MSM who may not be at increased
SUMMARY:
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Wyoming.
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risk. In June 2010, HHS sought advice
from its Advisory Committee for Blood
Safety and Availability (ACBSA) on the
issue of the current MSM deferral
policy. The Advisory Committee noted
that the existing policy is suboptimal,
but recommended that the policy
should be retained pending the
completion of targeted research studies
that might support a safe alternative
policy.
HHS and the agencies responsible for
blood safety are committed to efforts to
maintain and enhance the safety of the
nation’s blood supply, taking into
account all new and emerging scientific
information. Consistent with the June
2010 recommendations of the ACBSA,
HHS seeks to determine through
appropriate studies whether blood
safety can be maintained or enhanced
under revised blood donor screening
criteria that would permit donation by
some MSM. This request for information
(RFI) is being issued in recognition of
the challenges of designing such
studies.
This RFI seeks information from
interested parties regarding the design,
logistics and feasibility of a pilot
operational study (or studies) to assess
alternative blood donor eligibility
criteria for MSM. Responses to this RFI
will inform HHS on the design, logistics
and feasibility of such a study, which,
if feasible, could result in identifying
potential pathways toward future
alternate policies that will maintain or
enhance the current very high levels of
blood safety. The concept is to conduct
a pilot operational study, in which
MSM who meet specified criteria would
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Federal Register / Vol. 77, No. 49 / Tuesday, March 13, 2012 / Notices
be permitted to donate blood, with
additional safeguards in place to protect
blood recipients during the course of the
study. Data would be gathered to assess
the effectiveness of the specified criteria
to select low risk donors among MSM.
Upon completing all data collection
activities, there will be a transparent
and evidence-based evaluation of
current and possible future MSM blood
donation policies.
This RFI is for information and
planning purposes only and should not
be construed as a solicitation or as an
obligation on the part of HHS. HHS does
not intend to award a grant or contract
to pay for the preparation of any
information submitted or for the use of
such information by HHS. Whereas all
responses to this notice will be carefully
considered, acknowledgment of receipt
of responses will not be made, nor will
respondents be notified of the
evaluation by HHS of the information
received. No basis for claims against
HHS shall arise as a result of a response
to this request for information or to the
use of such information by HHS as
either part of our evaluation process or
in developing specifications for any
subsequent announcement.
All responses must be received
no later than 4 p.m. EDT on June 11,
2012 at the address listed below.
DATES:
You may submit comments
identified by docket ID number HHS–
OPHS–2012–0003, by one of the
following methods:
• Federal eRulemaking Portal: https://
www.regulations.gov. Enter the above
docket ID number in the ‘‘Enter
Keyword or ID field and click on
‘‘Search.’’ On the next page, click the
‘‘Submit a Comment’’ action and follow
the instructions.
• Mail/Hand delivery/Courier [For
paper, disk, or CD–ROM submissions]:
Richard Henry, M.L., M.P.H., Office of
the Assistant Secretary for Health, U.S.
Department of Health and Human
Services, 1101 Wootton Parkway, Tower
Building, Suite 250, Rockville, MD
20852.
Comments received, including any
personal information, will be posted
without change to https://
www.regulations.gov.
ADDRESSES:
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FOR FURTHER INFORMATION CONTACT:
James Berger, Acting Director for Blood
Safety and Availability, Office of the
Assistant Secretary for Health, Office of
the Secretary, U.S. Department of Health
and Human Services, 1101 Wootton
Parkway, Tower Building, Suite 250,
Rockville, MD 20852.
SUPPLEMENTARY INFORMATION:
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General Blood Safety Strategy
Current high levels of safety of the
U.S. blood supply are provided by five
overlapping layers of protection. These
include:
• First, potential donors are provided
educational materials and also asked
specific questions about their health,
and about risk factors for certain
transfusion-transmissible diseases (i.e.,
medical, behavioral and travel-related
risks), as a basis for acceptance or
deferral.
• Second, the donated blood is tested
for evidence of transfusion transmissible
infections by highly sensitive laboratory
assays. These include tests for infections
which can be acquired through high risk
sexual behaviors including HIV, HBV,
and/or syphilis.
• Third, blood establishments must
keep a current list of individuals who
have been deferred as donors in order to
prevent future collection or use of their
blood.
• Fourth, blood products are
quarantined until the testing is
completed and the donation records
have been verified for suitability of the
collections.
• Fifth, blood establishments must
investigate any breaches of these
safeguards, correct system deficiencies,
and maintain records for FDA review.
Rationale for Current Deferral Policy
for MSM
Deferral of potential donors prior to
donation combined with highly
sophisticated and sensitive laboratory
testing of donated blood are among the
multiple overlapping safeguards
currently in place to protect the blood
supply. Of particular concern for blood
safety are infections known to be
transmissible by blood transfusion,
including HIV and HBV. Deferral of
MSM from donation of blood is based
on well-documented observations of a
markedly higher prevalence 1 (current
infection) and incidence 2 (newly
acquired infection) of these
transmissible agents among some MSM
than in the non-MSM general
population. Additionally, there is a
theoretical concern that persons at
increased risk for known sexually
transmitted diseases might also be at
increased risk to acquire sexually and
blood transmitted infections that may
1 https://www.cdc.gov/hiv/surveillance/resources/
reports/2009report/index.htm.
2 Prejean J, Song R, Hernandez A, Ziebell R, Green
T, Walker F, Lin LS, An Q, Mermin J, Lansky A,
Hall HI; HIV Incidence Surveillance Group.
Estimated HIV Incidence in the United States,
2006–2009. PLoS One. 2011;6(8):e17502. Epub 2011
Aug 3.
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emerge in the future and for which no
donor screening tests exist.
The risk of infection from a blood
transfusion is now extremely low (less
than one in one million units transfused
for HIV and less than one in 280,000
units transfused for HBV). These risks
have diminished dramatically in the
past three decades as a result of the
overlapping safeguards. From recently
published modeling studies,
transfusion-transmitted infections,
while rare, are now generally attributed
to the interplay of three factors: (1)
Failure of donor selection measures to
accurately defer an at-risk donor, either
by deficiencies in the donor screening
process or failure of a donor to provide
accurate answers; (2) donation by an
infected individual during the ‘‘window
period’’ when early infection cannot yet
be detected by current testing; and (3)
inadvertent release of a donated unit of
blood (a) before all testing is known to
be negative; (b) before other criteria
affecting blood safety and quality are
determined to have been met; or (c)
despite a positive screening test or other
finding of unsuitability (Quarantine
Release Errors or QRE).
Reconsideration of MSM Deferral
Policy
There have been advisory committee
meetings 3 and a public workshop 4 over
the past decade, which have reexamined
the deferral policy, taking into account
existing scientific evidence related to
deferral of MSM from blood donation.
In addition, there has been increased
interest in changing this policy from
some members of the U.S. Congress, the
public and interested advocacy groups.
Most recently, in June 2010, the HHS
ACBSA 5 heard presentations of
currently available scientific data and
recommended to the HHS Secretary that
the current MSM deferral policy, while
suboptimal, should be retained pending
the completion of targeted research
studies that might support a safe
alternative policy. Based on these
recommendations, the Assistant
3 Blood Products Advisory Committee held
September 14, 2000 https://www.fda.gov/ohrms/
dockets/ac/cber00.htm#Blood%20Prducts.
Advisory Committee on Blood Safety and
Availability held June 10–11, 2010 https://
www.hhs.gov/ash/bloodsafety/advisorycommittee/
recommendations/msm-deferral_qa_20110722final.pdf.
4 FDA Workshop on Behavior-Based Donor
Deferrals in the NAT Era held March 8, 2006 https://
www.fda.gov/downloads/BiologicsBloodVaccines/
NewsEvents/WorkshopsMeetingsConferences/
TranscriptsMinutes/UCM054430.pdf.
5 Advisory Committee on Blood Safety and
Availability held June 10–11, 2010 https://
www.hhs.gov/ash/bloodsafety/advisorycommittee/
recommendations/msm-deferral_qa_20110722final.pdf.
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Federal Register / Vol. 77, No. 49 / Tuesday, March 13, 2012 / Notices
Secretary for Health charged relevant
agencies to develop and carry out such
studies, including a pilot operational
study of revised deferral criteria for
MSM.
A public workshop was conducted
and three funded studies are in progress
to help re-evaluate the MSM deferral
policy:
(1) Workshop on Quarantine Release
Errors (QREs):
FDA convened a workshop in
September 2011 to better understand
and find ways to prevent errors in
quarantine management that could lead
to inappropriate release of blood (QREs).
While only a very low proportion of
QREs present serious health threats,
QREs continue to occur, both in
community based and hospital based
blood collection establishments. It was
determined that human error during
non-computerized operations frequently
contributes to the QREs that occur. As
a result of the workshop, AABB is
establishing an industry-led task force to
study the QRE issue, to identify best
practices, and to propose additional
interventions. In particular, application
of human factor engineering will be
brought to bear in a review of blood
banking practices to better optimize the
interface between human and
automated steps as a way to improve
process controls. The output of the task
force will be used by government
agencies to establish guidance on best
practices in quarantine control of blood
components.
(2) Study on the Epidemiology of
Transfusion-Transmissible Infections in
U.S. Blood Donors:
An analysis of data on the prevalence
and incidence of certain major
transfusion-transmissible infections (e.g.
HIV, HBV, and Hepatitis C Virus (HCV))
obtained from routine donation testing
of blood donors was initiated in 2011.
This study will provide baseline
estimates of the current risks of
transfusion-transmitted viral infections
in the U.S. blood supply. Additionally,
the current risk factors (including
heterosexual) reported by infected
donors and their relative prevalence
compared to other donors as controls
will be determined, thus providing
information as to which risk factor(s)
should be targeted by optimized donor
screening strategies. This study is
supported by the National Heart, Lung,
and Blood Institute (NHLBI) of the
National Institutes of Health (NIH) and
is being conducted as part of the second
Retrovirus Epidemiology Donor Study
(REDS–II). This study includes the
American Red Cross, Blood Systems,
Inc., and the New York Blood Center
which together are responsible for
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collecting approximately 60 percent of
the U.S. blood supply.
(3) Study on Evaluation of the current
Blood Donation History Questionnaire
(DHQ):
Several factors, including culture,
social conditions, and language fluency,
contribute to different interpretations of
the questions that comprise the current
blood donation screening questionnaire.
A study to assess donor understanding
and interpretation of the DHQ screening
questions (cognitive evaluation) was
conducted approximately ten years ago
by the National Center for Health
Statistics of the Centers for Disease
Control and Prevention (NCHS, CDC).
Because techniques for questionnaire
evaluation have advanced considerably
over the past decade, the HHS Office of
the Assistant Secretary for Health
funded NCHS, CDC to re-evaluate the
DHQ, with particular emphasis on
donor understanding of the behavioral
risk questions intended to prevent
transmissible infections. This study will
help determine whether the existing
MSM deferral questions are understood
and properly interpreted by donors. It
may also determine more effective ways
to communicate with at-risk
populations through donor questions.
(4) Study on the Attitudes and
Behaviors of MSM Toward the Blood
Donation Screening Process:
Blood donors must accurately assess
their individual risk(s), and then selfdefer from donation or disclose their
risk(s) for the current screening process
to effectively maintain blood safety.
Failure to self-defer or disclose risk after
a potential exposure to a transfusiontransmissible infection may result in the
collection and release of an infectious
blood donation, which may be
associated with a false negative
laboratory test during early infection
(the ‘‘window period’’). For this reason,
it is important to evaluate whether MSM
with increased risk would reliably selfdefer or disclose risks if permitted to
donate under revised selection criteria.
A study funded by the Food and Drug
Administration (FDA) and being carried
out by the NHLBI REDS–III program
will assess attitudes and behaviors of
MSM toward current and possible
future blood donation policies. This
study is specifically designed to
examine whether MSM comply with the
current deferral criteria and whether
MSM would be likely to comply with
potential different deferral criteria.
Information Requested
HHS is interested in obtaining
information about the design, logistics
and feasibility of a pilot operational
study to assess alternative blood donor
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14803
acceptance criteria for MSM.
Specifically, HHS requests information
from private and public sector
stakeholders regarding potential pilot
operational study designs, including
innovative and cost effective approaches
to evaluate alternative blood donor
acceptance criteria for MSM.
Input is requested for the following:
(1) Candidate acceptance criteria for a
pilot operational study that would
permit blood donation by MSM. For
example, MSM with one year or five
years of abstinence from sex with other
men, or other criteria, subject to study
designs with additional safeguards.
(2) Possible study designs that would
generate useful information regarding
the safety of candidate acceptance
criteria while maintaining current levels
of blood safety during the pilot study.
Possibilities might include but are not
limited to the following:
(a) Pre-donation Donor Testing
In a pre-donation testing strategy,
MSM who are presently deferred, but
who would be eligible to donate during
the pilot operational study under
modified acceptance criteria would be
screened for donation with the
candidate modified criteria and have a
blood sample drawn for standard donor
screening,6 and potentially, additional
tests at their first session in a blood
collection center. They would not be
permitted to donate a unit of blood at
that time. MSM donors who meet all
other donor eligibility criteria, and have
negative pre-donation test results,
would be invited to return within a
defined period, at which time standard
donor screening and testing would be
performed and blood for use in
transfusion would then be collected.
A pre-donation testing strategy would
focus on the prevalence of HIV and
other transfusion-transmissible
infections in the MSM population.
Infected donors would be identified and
deferred based on prescreening results.
Quarantine release errors (QREs) would
be avoided, because infectious units
would not be drawn and entered into
inventory.
Unanswered questions regarding a
pre-donation testing option include: (1)
the added costs of donor testing if
provided by the collection center; (2)
the added cost and complexity of
6 Current tests include Antibody to HIV–1 and –2
(Anti-HIV–1, –2), HIV–1 RNA (HIV–1 NAT),
Antibody to HCV (anti-HCV), HCV RNA (HCV
NAT), Antibody to HTLV–I and –II (Anti-HTLV–I/
II), Hepatitis B Surface Antigen (HBsAg), Antibody
to Hepatitis B Core Antigen (Anti-HBc), West Nile
Virus RNA (WNV NAT), Antibody to Trypanosoma
cruzi (Chagas’ disease), and a serologic test for
syphilis.
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tracking the results of pre-donation
testing; (3) the period within which a
potential MSM donor would need to
return to complete an actual blood
donation; (4) concern that pre-donation
testing of only MSM could be seen as
discriminatory; and (5) the residual
impact on safety due to window period
donations that would not be reduced by
pre-testing.
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(b) Post-Donation Testing
In a post-donation testing strategy,
MSM who are presently deferred, but
who would be eligible to donate during
the pilot under modified deferral
criteria would have a unit of blood
drawn. This unit would be segregated
from other units and placed in a
separate quarantine. The donor would
be asked to return for ‘‘post-donation
testing’’ within a specified period
following the donation that would
exceed the ‘‘window period’’ for
transfusion-transmissible infections but
be within the expiration dating period
of the unit of blood (i.e., within 14 to
42 days post-donation for red blood
cells or from 14 days to within one year
for plasma for transfusion). For donors
who continue to meet acceptance
criteria and have negative ‘‘postdonation test’’ results, the unit would be
released for transfusion. Such
collections would be most applicable to
repeat plasma donations given the
longer shelf life of frozen plasma,
providing greater flexibility for the time
of ‘‘post-donation testing’’ of the donor.
Also, plasma for transfusion could be
collected at the time of ‘‘post-donation
testing’’ initiating a new quarantine for
a new collection.
Placing units drawn from MSM
donors in quarantine until qualifying
‘‘post-donation testing’’ results are
obtained would address the issue of
recent (i.e. ‘‘incident’’) infections.
Infectious units would be entered into a
quarantine portion of the blood bank
inventory prior to the availability of
screening test results. However, if more
infectious units are drawn and placed in
inventory, these units would be subject
to quarantine release errors.
There could be the same or similar
unanswered questions for the postdonation testing strategy as are outlined
above under the pre-donation testing
strategy. In addition, blood
establishments would need to maintain
stratified and potentially larger
quarantine inventories and would incur
the costs of discarding all units in
quarantine for which a donor failed to
return for ‘‘post-donation testing.’’
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(c) Combined Pre-Donation and PostDonation Testing
Under this scenario, an MSM donor
seeking to donate under modified
deferral criteria would be screened with
a questionnaire and asked to give a predonation testing sample. Assuming the
blood sample is negative for infectious
markers, and the donor meets all other
eligibility criteria, the donor would be
invited to return within a defined
period to donate a unit of blood. This
unit would be placed in quarantine and
the donor again would be asked to
return, this time for post-donation
testing also within a specified time
period.
This strategy would provide the
strictest control over any increase in risk
to the blood supply. Both incident and
prevalent infection concerns would be
addressed. However, this scenario
would require a potential donor meeting
the candidate MSM acceptability
criteria to make three appearances at a
blood collection facility within
specified time periods in order to have
a donation released for transfusion.
Blood establishments would face
challenging logistic issues in conducting
such a study concurrently with normal,
highly standardized blood collection
operations.
(3) Input is requested on the data that
should be gathered and the criteria used
to evaluate the results of the pilot
operational study. For example, should
MSM donors and non-MSM donors be
asked to participate in surveys on their
understanding of the donor screening
questions, their specific sexual
behaviors and their motivations to
donate blood? Should the study
outcome be based on observed markers
of transfusion-transmitted infections in
MSM donors compared with other
donors? Should MSM donors with
positive screening tests be interviewed
to better understand their risk factors,
their understanding of the donor
questionnaire and their motivations to
donate if they did not appropriately selfdefer or disclose their risk?
Requested RFI Responses:
Please comment on each of the above
scenarios, or propose additional pilot
operational study designs for
consideration. In your response, please
address each of the following:
• Revised criteria that should be
considered to permit blood donation
by MSM
• Blood safety considerations and safety
mitigations that should be considered
• Impact on blood establishment
operations
• Staff training and staff perceptions
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• Tracking of pre-donation and/or postdonation test results
• Inventory management
• Donor perceptions regarding the
possible changes in deferral policy
within the operational study scenarios
(including both MSM and non-MSM
donors)
• Public reaction, if any, and impact on
blood drives
• Potential venues where the study
could be conducted
• Study costs
• Willingness of blood organizations to
participate in a pilot study
• Data elements that should be gathered
during the study, including those that
may be associated with future
emerging infections
• Criteria for evaluation of the study
results and conclusions
• Expected timeframe for each proposed
study.
Dated: March 8, 2012.
Richard Henry,
Deputy Director, Blood Safety & Availability.
[FR Doc. 2012–6091 Filed 3–12–12; 8:45 am]
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DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Advisory Council on Alzheimer’s
Research, Care, and Services; Request
for Nominations
Office of the Assistant
Secretary for Planning and Evaluation;
Department of Health and Human
Services.
ACTION: Request for Nominations.
AGENCY:
HHS is soliciting nominations
for a new, non-Federal member of the
Advisory Council on Alzheimer’s
Research, Care, and Services to fill the
position of ‘‘representative of a state
public health department.’’
Nominations should include the
nominee’s contact information (current
mailing address, email address, and
telephone number) and current
curriculum vitae or resume.
DATES: Submit nominations by email or
USPS mail before COB on April 4, 2012.
ADDRESSES: Nominations should be sent
to Helen Lamont at
helen.lamont@hhs.gov; Helen Lamont,
Ph.D., Office of the Assistant Secretary
for Planning and Evaluation, Room 424E
Humphrey Building, Department of
Health and Human Services, 200
Independence Avenue SW.,
Washington, DC 20201.
FOR FURTHER INFORMATION CONTACT:
Helen Lamont (202) 690–7996,
helen.lamont@hhs.gov.
SUMMARY:
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[Federal Register Volume 77, Number 49 (Tuesday, March 13, 2012)]
[Notices]
[Pages 14801-14804]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2012-6091]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Request for Information (RFI) on Design of a Pilot Operational
Study To Assess Alternative Blood Donor Deferral Criteria for Men Who
Have Had Sex With Other Men (MSM)
AGENCY: Office of the Secretary, Office of the Assistant Secretary for
Health, Department of Health and Human Services.
ACTION: Notice.
-----------------------------------------------------------------------
SUMMARY: The Department of Health and Human Services (HHS) is seeking
to identify interest and obtain information relevant to the design of a
pilot operational study (or studies) on alternative donor deferral
criteria that would permit blood and plasma donations (subsequently
termed ``blood donations'') by men who have had sex with other men
(MSM).
Based upon documented higher levels of certain transfusion-
transmissible infections (e.g. Human Immunodeficiency Virus (HIV) and
Hepatitis B Virus (HBV)) in some groups of men who have had sex with
men, all men with a history of this behavior since 1977 are currently
deferred from donating blood. However, the increased effectiveness of
donor testing for HIV, HBV, syphilis and other infectious agents has
greatly enhanced blood safety. As a result, questions have been raised
about the need to continue an indefinite deferral of all MSM and
whether there could be blood donation by MSM who may not be at
increased risk. In June 2010, HHS sought advice from its Advisory
Committee for Blood Safety and Availability (ACBSA) on the issue of the
current MSM deferral policy. The Advisory Committee noted that the
existing policy is suboptimal, but recommended that the policy should
be retained pending the completion of targeted research studies that
might support a safe alternative policy.
HHS and the agencies responsible for blood safety are committed to
efforts to maintain and enhance the safety of the nation's blood
supply, taking into account all new and emerging scientific
information. Consistent with the June 2010 recommendations of the
ACBSA, HHS seeks to determine through appropriate studies whether blood
safety can be maintained or enhanced under revised blood donor
screening criteria that would permit donation by some MSM. This request
for information (RFI) is being issued in recognition of the challenges
of designing such studies.
This RFI seeks information from interested parties regarding the
design, logistics and feasibility of a pilot operational study (or
studies) to assess alternative blood donor eligibility criteria for
MSM. Responses to this RFI will inform HHS on the design, logistics and
feasibility of such a study, which, if feasible, could result in
identifying potential pathways toward future alternate policies that
will maintain or enhance the current very high levels of blood safety.
The concept is to conduct a pilot operational study, in which MSM who
meet specified criteria would
[[Page 14802]]
be permitted to donate blood, with additional safeguards in place to
protect blood recipients during the course of the study. Data would be
gathered to assess the effectiveness of the specified criteria to
select low risk donors among MSM. Upon completing all data collection
activities, there will be a transparent and evidence-based evaluation
of current and possible future MSM blood donation policies.
This RFI is for information and planning purposes only and should
not be construed as a solicitation or as an obligation on the part of
HHS. HHS does not intend to award a grant or contract to pay for the
preparation of any information submitted or for the use of such
information by HHS. Whereas all responses to this notice will be
carefully considered, acknowledgment of receipt of responses will not
be made, nor will respondents be notified of the evaluation by HHS of
the information received. No basis for claims against HHS shall arise
as a result of a response to this request for information or to the use
of such information by HHS as either part of our evaluation process or
in developing specifications for any subsequent announcement.
DATES: All responses must be received no later than 4 p.m. EDT on June
11, 2012 at the address listed below.
ADDRESSES: You may submit comments identified by docket ID number HHS-
OPHS-2012-0003, by one of the following methods:
Federal eRulemaking Portal: https://www.regulations.gov.
Enter the above docket ID number in the ``Enter Keyword or ID field and
click on ``Search.'' On the next page, click the ``Submit a Comment''
action and follow the instructions.
Mail/Hand delivery/Courier [For paper, disk, or CD-ROM
submissions]: Richard Henry, M.L., M.P.H., Office of the Assistant
Secretary for Health, U.S. Department of Health and Human Services,
1101 Wootton Parkway, Tower Building, Suite 250, Rockville, MD 20852.
Comments received, including any personal information, will be
posted without change to https://www.regulations.gov.
FOR FURTHER INFORMATION CONTACT: James Berger, Acting Director for
Blood Safety and Availability, Office of the Assistant Secretary for
Health, Office of the Secretary, U.S. Department of Health and Human
Services, 1101 Wootton Parkway, Tower Building, Suite 250, Rockville,
MD 20852.
SUPPLEMENTARY INFORMATION:
General Blood Safety Strategy
Current high levels of safety of the U.S. blood supply are provided
by five overlapping layers of protection. These include:
First, potential donors are provided educational materials
and also asked specific questions about their health, and about risk
factors for certain transfusion-transmissible diseases (i.e., medical,
behavioral and travel-related risks), as a basis for acceptance or
deferral.
Second, the donated blood is tested for evidence of
transfusion transmissible infections by highly sensitive laboratory
assays. These include tests for infections which can be acquired
through high risk sexual behaviors including HIV, HBV, and/or syphilis.
Third, blood establishments must keep a current list of
individuals who have been deferred as donors in order to prevent future
collection or use of their blood.
Fourth, blood products are quarantined until the testing
is completed and the donation records have been verified for
suitability of the collections.
Fifth, blood establishments must investigate any breaches
of these safeguards, correct system deficiencies, and maintain records
for FDA review.
Rationale for Current Deferral Policy for MSM
Deferral of potential donors prior to donation combined with highly
sophisticated and sensitive laboratory testing of donated blood are
among the multiple overlapping safeguards currently in place to protect
the blood supply. Of particular concern for blood safety are infections
known to be transmissible by blood transfusion, including HIV and HBV.
Deferral of MSM from donation of blood is based on well-documented
observations of a markedly higher prevalence \1\ (current infection)
and incidence \2\ (newly acquired infection) of these transmissible
agents among some MSM than in the non-MSM general population.
Additionally, there is a theoretical concern that persons at increased
risk for known sexually transmitted diseases might also be at increased
risk to acquire sexually and blood transmitted infections that may
emerge in the future and for which no donor screening tests exist.
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\1\ https://www.cdc.gov/hiv/surveillance/resources/reports/2009report/index.htm.
\2\ Prejean J, Song R, Hernandez A, Ziebell R, Green T, Walker
F, Lin LS, An Q, Mermin J, Lansky A, Hall HI; HIV Incidence
Surveillance Group. Estimated HIV Incidence in the United States,
2006-2009. PLoS One. 2011;6(8):e17502. Epub 2011 Aug 3.
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The risk of infection from a blood transfusion is now extremely low
(less than one in one million units transfused for HIV and less than
one in 280,000 units transfused for HBV). These risks have diminished
dramatically in the past three decades as a result of the overlapping
safeguards. From recently published modeling studies, transfusion-
transmitted infections, while rare, are now generally attributed to the
interplay of three factors: (1) Failure of donor selection measures to
accurately defer an at-risk donor, either by deficiencies in the donor
screening process or failure of a donor to provide accurate answers;
(2) donation by an infected individual during the ``window period''
when early infection cannot yet be detected by current testing; and (3)
inadvertent release of a donated unit of blood (a) before all testing
is known to be negative; (b) before other criteria affecting blood
safety and quality are determined to have been met; or (c) despite a
positive screening test or other finding of unsuitability (Quarantine
Release Errors or QRE).
Reconsideration of MSM Deferral Policy
There have been advisory committee meetings \3\ and a public
workshop \4\ over the past decade, which have reexamined the deferral
policy, taking into account existing scientific evidence related to
deferral of MSM from blood donation. In addition, there has been
increased interest in changing this policy from some members of the
U.S. Congress, the public and interested advocacy groups.
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\3\ Blood Products Advisory Committee held September 14, 2000
https://www.fda.gov/ohrms/dockets/ac/cber00.htm#Blood%20Prducts.
Advisory Committee on Blood Safety and Availability held June
10-11, 2010 https://www.hhs.gov/ash/bloodsafety/advisorycommittee/recommendations/msm-deferral_qa_20110722-final.pdf.
\4\ FDA Workshop on Behavior-Based Donor Deferrals in the NAT
Era held March 8, 2006 https://www.fda.gov/downloads/BiologicsBloodVaccines/NewsEvents/WorkshopsMeetingsConferences/TranscriptsMinutes/UCM054430.pdf.
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Most recently, in June 2010, the HHS ACBSA \5\ heard presentations
of currently available scientific data and recommended to the HHS
Secretary that the current MSM deferral policy, while suboptimal,
should be retained pending the completion of targeted research studies
that might support a safe alternative policy. Based on these
recommendations, the Assistant
[[Page 14803]]
Secretary for Health charged relevant agencies to develop and carry out
such studies, including a pilot operational study of revised deferral
criteria for MSM.
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\5\ Advisory Committee on Blood Safety and Availability held
June 10-11, 2010 https://www.hhs.gov/ash/bloodsafety/advisorycommittee/recommendations/msm-deferral_qa_20110722-final.pdf.
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A public workshop was conducted and three funded studies are in
progress to help re-evaluate the MSM deferral policy:
(1) Workshop on Quarantine Release Errors (QREs):
FDA convened a workshop in September 2011 to better understand and
find ways to prevent errors in quarantine management that could lead to
inappropriate release of blood (QREs). While only a very low proportion
of QREs present serious health threats, QREs continue to occur, both in
community based and hospital based blood collection establishments. It
was determined that human error during non-computerized operations
frequently contributes to the QREs that occur. As a result of the
workshop, AABB is establishing an industry-led task force to study the
QRE issue, to identify best practices, and to propose additional
interventions. In particular, application of human factor engineering
will be brought to bear in a review of blood banking practices to
better optimize the interface between human and automated steps as a
way to improve process controls. The output of the task force will be
used by government agencies to establish guidance on best practices in
quarantine control of blood components.
(2) Study on the Epidemiology of Transfusion-Transmissible
Infections in U.S. Blood Donors:
An analysis of data on the prevalence and incidence of certain
major transfusion-transmissible infections (e.g. HIV, HBV, and
Hepatitis C Virus (HCV)) obtained from routine donation testing of
blood donors was initiated in 2011. This study will provide baseline
estimates of the current risks of transfusion-transmitted viral
infections in the U.S. blood supply. Additionally, the current risk
factors (including heterosexual) reported by infected donors and their
relative prevalence compared to other donors as controls will be
determined, thus providing information as to which risk factor(s)
should be targeted by optimized donor screening strategies. This study
is supported by the National Heart, Lung, and Blood Institute (NHLBI)
of the National Institutes of Health (NIH) and is being conducted as
part of the second Retrovirus Epidemiology Donor Study (REDS-II). This
study includes the American Red Cross, Blood Systems, Inc., and the New
York Blood Center which together are responsible for collecting
approximately 60 percent of the U.S. blood supply.
(3) Study on Evaluation of the current Blood Donation History
Questionnaire (DHQ):
Several factors, including culture, social conditions, and language
fluency, contribute to different interpretations of the questions that
comprise the current blood donation screening questionnaire. A study to
assess donor understanding and interpretation of the DHQ screening
questions (cognitive evaluation) was conducted approximately ten years
ago by the National Center for Health Statistics of the Centers for
Disease Control and Prevention (NCHS, CDC). Because techniques for
questionnaire evaluation have advanced considerably over the past
decade, the HHS Office of the Assistant Secretary for Health funded
NCHS, CDC to re-evaluate the DHQ, with particular emphasis on donor
understanding of the behavioral risk questions intended to prevent
transmissible infections. This study will help determine whether the
existing MSM deferral questions are understood and properly interpreted
by donors. It may also determine more effective ways to communicate
with at-risk populations through donor questions.
(4) Study on the Attitudes and Behaviors of MSM Toward the Blood
Donation Screening Process:
Blood donors must accurately assess their individual risk(s), and
then self-defer from donation or disclose their risk(s) for the current
screening process to effectively maintain blood safety. Failure to
self-defer or disclose risk after a potential exposure to a
transfusion-transmissible infection may result in the collection and
release of an infectious blood donation, which may be associated with a
false negative laboratory test during early infection (the ``window
period''). For this reason, it is important to evaluate whether MSM
with increased risk would reliably self-defer or disclose risks if
permitted to donate under revised selection criteria. A study funded by
the Food and Drug Administration (FDA) and being carried out by the
NHLBI REDS-III program will assess attitudes and behaviors of MSM
toward current and possible future blood donation policies. This study
is specifically designed to examine whether MSM comply with the current
deferral criteria and whether MSM would be likely to comply with
potential different deferral criteria.
Information Requested
HHS is interested in obtaining information about the design,
logistics and feasibility of a pilot operational study to assess
alternative blood donor acceptance criteria for MSM. Specifically, HHS
requests information from private and public sector stakeholders
regarding potential pilot operational study designs, including
innovative and cost effective approaches to evaluate alternative blood
donor acceptance criteria for MSM.
Input is requested for the following:
(1) Candidate acceptance criteria for a pilot operational study
that would permit blood donation by MSM. For example, MSM with one year
or five years of abstinence from sex with other men, or other criteria,
subject to study designs with additional safeguards.
(2) Possible study designs that would generate useful information
regarding the safety of candidate acceptance criteria while maintaining
current levels of blood safety during the pilot study. Possibilities
might include but are not limited to the following:
(a) Pre-donation Donor Testing
In a pre-donation testing strategy, MSM who are presently deferred,
but who would be eligible to donate during the pilot operational study
under modified acceptance criteria would be screened for donation with
the candidate modified criteria and have a blood sample drawn for
standard donor screening,\6\ and potentially, additional tests at their
first session in a blood collection center. They would not be permitted
to donate a unit of blood at that time. MSM donors who meet all other
donor eligibility criteria, and have negative pre-donation test
results, would be invited to return within a defined period, at which
time standard donor screening and testing would be performed and blood
for use in transfusion would then be collected.
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\6\ Current tests include Antibody to HIV-1 and -2 (Anti-HIV-1,
-2), HIV-1 RNA (HIV-1 NAT), Antibody to HCV (anti-HCV), HCV RNA (HCV
NAT), Antibody to HTLV-I and -II (Anti-HTLV-I/II), Hepatitis B
Surface Antigen (HBsAg), Antibody to Hepatitis B Core Antigen (Anti-
HBc), West Nile Virus RNA (WNV NAT), Antibody to Trypanosoma cruzi
(Chagas' disease), and a serologic test for syphilis.
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A pre-donation testing strategy would focus on the prevalence of
HIV and other transfusion-transmissible infections in the MSM
population. Infected donors would be identified and deferred based on
prescreening results. Quarantine release errors (QREs) would be
avoided, because infectious units would not be drawn and entered into
inventory.
Unanswered questions regarding a pre-donation testing option
include: (1) the added costs of donor testing if provided by the
collection center; (2) the added cost and complexity of
[[Page 14804]]
tracking the results of pre-donation testing; (3) the period within
which a potential MSM donor would need to return to complete an actual
blood donation; (4) concern that pre-donation testing of only MSM could
be seen as discriminatory; and (5) the residual impact on safety due to
window period donations that would not be reduced by pre-testing.
(b) Post-Donation Testing
In a post-donation testing strategy, MSM who are presently
deferred, but who would be eligible to donate during the pilot under
modified deferral criteria would have a unit of blood drawn. This unit
would be segregated from other units and placed in a separate
quarantine. The donor would be asked to return for ``post-donation
testing'' within a specified period following the donation that would
exceed the ``window period'' for transfusion-transmissible infections
but be within the expiration dating period of the unit of blood (i.e.,
within 14 to 42 days post-donation for red blood cells or from 14 days
to within one year for plasma for transfusion). For donors who continue
to meet acceptance criteria and have negative ``post-donation test''
results, the unit would be released for transfusion. Such collections
would be most applicable to repeat plasma donations given the longer
shelf life of frozen plasma, providing greater flexibility for the time
of ``post-donation testing'' of the donor. Also, plasma for transfusion
could be collected at the time of ``post-donation testing'' initiating
a new quarantine for a new collection.
Placing units drawn from MSM donors in quarantine until qualifying
``post-donation testing'' results are obtained would address the issue
of recent (i.e. ``incident'') infections. Infectious units would be
entered into a quarantine portion of the blood bank inventory prior to
the availability of screening test results. However, if more infectious
units are drawn and placed in inventory, these units would be subject
to quarantine release errors.
There could be the same or similar unanswered questions for the
post-donation testing strategy as are outlined above under the pre-
donation testing strategy. In addition, blood establishments would need
to maintain stratified and potentially larger quarantine inventories
and would incur the costs of discarding all units in quarantine for
which a donor failed to return for ``post-donation testing.''
(c) Combined Pre-Donation and Post-Donation Testing
Under this scenario, an MSM donor seeking to donate under modified
deferral criteria would be screened with a questionnaire and asked to
give a pre-donation testing sample. Assuming the blood sample is
negative for infectious markers, and the donor meets all other
eligibility criteria, the donor would be invited to return within a
defined period to donate a unit of blood. This unit would be placed in
quarantine and the donor again would be asked to return, this time for
post-donation testing also within a specified time period.
This strategy would provide the strictest control over any increase
in risk to the blood supply. Both incident and prevalent infection
concerns would be addressed. However, this scenario would require a
potential donor meeting the candidate MSM acceptability criteria to
make three appearances at a blood collection facility within specified
time periods in order to have a donation released for transfusion.
Blood establishments would face challenging logistic issues in
conducting such a study concurrently with normal, highly standardized
blood collection operations.
(3) Input is requested on the data that should be gathered and the
criteria used to evaluate the results of the pilot operational study.
For example, should MSM donors and non-MSM donors be asked to
participate in surveys on their understanding of the donor screening
questions, their specific sexual behaviors and their motivations to
donate blood? Should the study outcome be based on observed markers of
transfusion-transmitted infections in MSM donors compared with other
donors? Should MSM donors with positive screening tests be interviewed
to better understand their risk factors, their understanding of the
donor questionnaire and their motivations to donate if they did not
appropriately self-defer or disclose their risk?
Requested RFI Responses:
Please comment on each of the above scenarios, or propose
additional pilot operational study designs for consideration. In your
response, please address each of the following:
Revised criteria that should be considered to permit blood
donation by MSM
Blood safety considerations and safety mitigations that should
be considered
Impact on blood establishment operations
Staff training and staff perceptions
Tracking of pre-donation and/or post- donation test results
Inventory management
Donor perceptions regarding the possible changes in deferral
policy within the operational study scenarios (including both MSM and
non-MSM donors)
Public reaction, if any, and impact on blood drives
Potential venues where the study could be conducted
Study costs
Willingness of blood organizations to participate in a pilot
study
Data elements that should be gathered during the study,
including those that may be associated with future emerging infections
Criteria for evaluation of the study results and conclusions
Expected timeframe for each proposed study.
Dated: March 8, 2012.
Richard Henry,
Deputy Director, Blood Safety & Availability.
[FR Doc. 2012-6091 Filed 3-12-12; 8:45 am]
BILLING CODE 4150-41-P
