In India, SARS-CoV-2 virus-induced coronavirus disease 2019 (COVID-19) has already infected close to 31270 people, causing the death of 1010.
While these numbers are not comparable with values observed for the USA, Italy, or Spain, given the population of India, and the fact that the pandemic is now in an exponential stage of growth, the risks of a contagion that affects a large sector of the Indian population are real. There are no current effective strategies to prevent the spread, other than minimizing contact through social distancing, while no fully effective drugs to prevent or treat COVID-19 exist, although several candidate drugs and repurposed antiviral and immune-modulating pharmacotherapies are being tested or in compassionate use. One postexposure prophylaxis, convalescent (immune) plasma (CP), has shown some success in China and previously in the cure and therapy of other coronaviruses, SARS-1 and Middle East respiratory syndrome. Drawn from current patients who are infected with COVID-19, its CP (human anti-SARS-CoV-2 plasma) might be one way to modulate the infectivity of this virus or its effects postinfection.
In one of the study, 10 severe patients confirmed by real-time viral RNA test were enrolled prospectively. One dose of 200 mL of convalescent plasma (CP) derived from recently recovered donors with the neutralizing antibody titers above 1:640 was transfused to the patients as an addition to maximal supportive care and antiviral agents. The primary endpoint was the safety of CP transfusion. The second endpoints were the improvement of clinical symptoms and laboratory parameters within 3 d after CP transfusion. The median time from onset of illness to CP transfusion was 16.5 d. After CP transfusion, the level of neutralizing antibody increased rapidly up to 1:640 in five cases, while that of the other four cases maintained at a high level (1:640). The clinical symptoms were significantly improved along with increase of oxyhemoglobin saturation within 3 d. Several parameters tended to improve as compared to pretransfusion, including increased lymphocyte counts (0.65 × 109/L vs. 0.76 × 109/L) and decreased C-reactive protein (55.98 mg/L vs. 18.13 mg/L). Radiological examinations showed varying degrees of absorption of lung lesions within 7 d. The viral load was undetectable after transfusion in seven patients who had previous viremia. No severe adverse effects were observed. This study showed CP therapy was well tolerated and could potentially improve the clinical outcomes through neutralizing viremia in severe COVID-19 cases. The optimal dose and time point, as well as the clinical benefit of CP therapy, needs further investigation in larger well-controlled trials.
On April 13, 2020, FDA has issued guidance to provide recommendations to health care 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.
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 FDA, it is regulated as an investigational product. A health care provider must participate in one of the pathways described below. FDA does not collect COVID-19 convalescent plasma or provide COVID-19 convalescent plasma. Health care providers or acute care facilities would instead obtain COVID-19 convalescent plasma from an FDA-registered blood establishment.
Excerpts from the guidance document are provided below.
The Food and Drug Administration (FDA or Agency) plays a critical role in protecting the United States (U.S.) from threats including emerging infectious diseases, such as the Coronavirus Disease 2019 (COVID-19) pandemic. FDA is committed to providing timely guidance to support response efforts to this pandemic.
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.
Pathways for Use of Investigational COVID-19 Convalescent Plasma
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 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.
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). 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. For patients with serious or immediately life-threatening COVID-19 who are not eligible for or who are unable to participate in randomized clinical trials, 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.
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, while clinical trials are being conducted and an expanded access protocol is available, 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 Obtain a Single Patient Emergency IND
- For requests between 8am EST and 8pm EST (Mon-Sun), the requesting physician may contact FDA by completing Form FDA 3926 (https://www.fda.gov/media/98616/download) and submitting the form by email to CBER_eIND_Covid-19@FDA.HHS.gov. For eiND requests submitted via email during this time frame, FDA will respond within 4 hours.
- The completed form should include a brief clinical history of the patient, including: diagnosis, current therapy, and rationale for requesting the proposed investigational treatment in order to meet the expanded access use requirements in 21 CFR 312.305 and 312.310.
- The form should include information regarding where the COVID-19 convalescent plasma will be obtained.
- Providers should complete the form to the extent possible, and FDA will work with the provider if additional information is required. Providers are strongly encouraged to fill out the form electronically whenever possible.
- FDA will review the request and, upon authorization, send the requesting physician a confirmatory email that includes the emergency IND number.
- For requests between 8am EST and 8pm EST where the provider is unable to complete and submit Form FDA 3926 due to extenuating circumstances, the provider can contact FDA’s Office of Emergency Operations at 1-866-300-4374 to seek verbal authorization.
- For requests that are overnight between 8pm EST and 8am EST, the provider should contact FDA’s Office of Emergency Operations at 1-866-300-4374 to seek verbal authorization.
- If verbal authorization is given, the requestor must agree to submit an expanded access application (e.g., Form FDA 3926) within 15 working days of FDA’s authorization of the use. (21 CFR 312.310(d)(2)).
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 ProtocolExternal Link Disclaimer. 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 ≤ 93%,
- partial pressure of arterial oxygen to fraction of inspired oxygen ratio < 300,
- lung infiltrates > 50% 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
- Severe disease is defined as one or more of the following:
- Informed consent provided by the patient or healthcare proxy.
Collection of COVID-19 Convalescent Plasma
Health care 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.
- Donor Eligibility
- 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
- 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.
- A diagnostic test (e.g., nasopharyngeal swab) at the time of illness
- Either one of the following
1. Complete resolution of symptoms at least 28 days prior to donation
2. Complete resolution of symptoms at least 14 days prior to donation, AND Negative results for COVID-19 either from one or more nasopharyngeal swab specimens or by a molecular diagnostic test from blood.
- 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.
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.
- 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.
- 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.
A health care 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).