The U.S. Food and Drug Administration (FDA) has issued guidance to provide recommendations to healthcare providers and investigators on the administration and study of investigational convalescent plasma collected from individuals who have recovered from COVID-19 (COVID-19 convalescent plasma) during the public health emergency, states a FDA press release.
The guidance provides recommendations on the following:
· pathways for use of investigational COVID-19 convalescent plasma
· patient eligibility
· collection of COVID-19 convalescent plasma, including donor eligibility and donor qualifications
· labeling, and
· record keeping
Because COVID-19 convalescent plasma has not yet been approved for use by the FDA, it is regulated as an investigational product. A healthcare provider must participate in one of the pathways described below. The FDA does not collect COVID-19 convalescent plasma or provide COVID-19 convalescent plasma. Healthcare providers or acute care facilities should instead obtain COVID-19 convalescent plasma from an FDA-registered blood establishment.
One investigational treatment being explored for COVID-19 is the use of convalescent plasma collected from individuals who have recovered from COVID-19. Convalescent plasma that contains antibodies to severe acute respiratory syndrome coronavirus 2 or SARS-CoV-2 (the virus that causes COVID-19) is being studied for administration to patients with COVID-19. Use of convalescent plasma has been studied in outbreaks of other respiratory infections, including the 2003 SARS-CoV-1 epidemic, the 2009-2010 H1N1 influenza virus pandemic, and the 2012 MERS-CoV epidemic.
Although promising, convalescent plasma has not yet been shown to be safe and effective as a treatment for COVID-19. Therefore, it is important to study the safety and efficacy of COVID-19 convalescent plasma in clinical trials.
The following pathways are available for administering or studying the use of COVID-19 convalescent plasma:
1. Clinical Trials
Investigators wishing to study the use of convalescent plasma in a clinical trial should submit requests to the FDA for investigational use under the traditional IND regulatory pathway (21 CFR Part 312). CBER’s Office of Blood Research and Review is committed to engaging with sponsors and reviewing such requests expeditiously. During the COVID-19 pandemic, INDs may be submitted via email to [email protected].
2. Expanded Access
An IND application for expanded access is an alternative for use of COVID-19 convalescent plasma for patients with serious or immediately life-threatening COVID-19 disease who are not eligible or who are unable to participate in randomized clinical trials (21 CFR 312.305). The FDA has worked with multiple federal partners and academia to open an expanded access protocol to facilitate access to COVID-19 convalescent plasma across the nation. Access to this investigational product may be available through participation of acute care facilities in an investigational expanded access protocol under an IND that is already in place.
Currently, the following protocol is in place: National Expanded Access Treatment Protocol
3. Single Patient Emergency IND
Although participation in clinical trials or an expanded access program are ways for patients to obtain access to convalescent plasma, for various reasons these may not be readily available to all patients in potential need. Therefore, given the public health emergency that the COVID-19 pandemic presents, and while clinical trials are being conducted and a national expanded access protocol is available, the FDA also is facilitating access to COVID-19 convalescent plasma for use in patients with serious or immediately life-threatening COVID-19 infections through the process of the patient’s physician requesting a single patient emergency IND (eIND) for the individual patient under 21 CFR 312.310. This process allows the use of an investigational drug for the treatment of an individual patient by a licensed physician upon FDA authorization, if the applicable regulatory criteria are met. Note, in such case, a licensed physician seeking to administer COVID-19 convalescent plasma to an individual patient must request the eIND (see 21 CFR 312.310(b)).
To facilitate requests for eINDs for use of COVID-19 convalescent plasma to treat patients, health care providers seeking an emergency IND may want to consider the eligibility criteria used for the National Expanded Access Treatment Protocol. These criteria include:
· Laboratory confirmed COVID-19
· Severe or immediately life-threatening COVID-19, for example,
· Severe disease is defined as one or more of the following:
· shortness of breath (dyspnea),
· respiratory frequency ≥ 30/min,
· blood oxygen saturation ≤ 93percent,
· partial pressure of arterial oxygen to fraction of inspired oxygen ratio < 300,
· lung infiltrates > 50percent within 24 to 48 hours
· Life-threatening disease is defined as one or more of the following:
· respiratory failure,
· septic shock,
· multiple organ dysfunction or failure
· Informed consent provided by the patient or healthcare proxy.
· Collection of COVID-19 Convalescent Plasma
Healthcare providers or acute care facilities seeking to use COVID-19 convalescent plasma should include information in the IND submission that the COVID-19 convalescent plasma will be obtained from an FDA-registered blood establishment that follows the donor eligibility criteria and donor qualifications described below in collecting plasma from donors.
COVID-19 convalescent plasma must only be collected from individuals who meet all donor eligibility requirements (21 CFR 630.10, 21 CFR 630.15). Note the additional donor eligibility requirements for the collection of plasma by plasmapheresis in 21 CFR 630.15 (b). Donation testing for relevant transfusion-transmitted infections must be performed (21 CFR 610.40) and the donation must be found suitable (21 CFR 630.30).
COVID-19 convalescent plasma is collected from individuals who meet the following qualifications:
Evidence of COVID-19 documented by a laboratory test either by:
· A diagnostic test (e.g., nasopharyngeal swab) at the time of illness
OR
· a positive serological test for SARS-CoV-2 antibodies after recovery, if prior diagnostic testing was not performed at the time COVID-19 was suspected.
· Complete resolution of symptoms at least 14 days before the donation. A negative result for COVID-19 by a diagnostic test is not necessary to qualify the donor.
· Male donors, or female donors who have not been pregnant, or female donors who have been tested since their most recent pregnancy and results interpreted as negative for HLA antibodies.
· SARS-CoV-2 neutralizing antibody titers, if available
When measurement of neutralizing antibody titers is available, we recommend neutralizing antibody titers of at least 1:160. A titer of 1:80 may be considered acceptable if an alternative matched unit is not available.
When measurement of neutralizing antibody titers is not available, consider storing a retention sample from the convalescent plasma donation for determining antibody titers at a later date. Although optional for all IND pathways, storing samples for single patient eINDs is not recommended.
Registered and licensed blood establishments that collect plasma intended for transfusion do not need to request a supplement to their license or obtain their own IND to collect and manufacture COVID-19 convalescent plasma for investigational use provided they 1) follow their standard operating procedures for plasma collection and all applicable regulations, and 2) collect plasma from individuals that meet the donor qualifications specified above, which would be included in the applicable IND(s) held by a health care provider or other sponsor.
Once manufactured, the COVID-19 convalescent plasma may be distributed for investigational use.
Blood establishments do not need to request an alternative procedure or exception under 21 CFR 640.120(a) to collect COVID-19 convalescent plasma.
Labeling
The container label of COVID-19 convalescent plasma units must include the following statement, “Caution: New Drug--Limited by Federal (or United States) law to investigational use." (21 CFR 312.6(a)).
In addition, the requirements in 21 CFR 606.121 for the container label apply, including the requirement to include a reference to the circular of information.
The FDA recognizes that the current circular of information does not contain specific information about COVID-19 convalescent plasma regarding indications for use, dosage information, contraindications or cautions, but it provides information on the use of plasma.
We recommend the use of a uniform container label for COVID-19 convalescent plasma. In particular, we recommend the use of the International Society of Blood Transfusion (ISBT) format specified in the United States Industry Consensus Standard for the Uniform Labeling of Blood and Blood Components Using ISBT 128.
The manufacturing process used and the expiration date on the label for COVID-19 convalescent plasma should be the same as for other plasma products that are of the same type. For example, COVID-19 Convalescent Plasma, Fresh Frozen, should be frozen within 8 hours after collection, stored at -18C or colder and have an expiration date one year from the date of collection.
Recordkeeping
A healthcare provider who is participating in an IND, including an expanded access IND or eIND, must maintain records for the COVID-19 convalescent plasma unit(s) administered to the COVID-19 patient (21 CFR 312.62). Such records should include the unique identification number(s) (e.g., the ISBT donation identification number(s)) of the unit(s).
