key: cord-1000149-sfgrliqs authors: Izak, Marina; Gendelman, Veronica; Bransburg‐Zabary, Sharron; Stoyanov, Evgeniy; Gat, Roni; Cohen, Daniel; Chen, Jacob; Maor, Yasmin; Benov, Avi; Lev, Boaz; Zimhony, Oren; Shinar, Eilat title: Qualifying coronavirus disease 2019 convalescent plasma donors in Israel date: 2021-06-14 journal: Vox Sang DOI: 10.1111/vox.13162 sha: 06504fd6cd5dca2358b295d3bb2d48bd5f718064 doc_id: 1000149 cord_uid: sfgrliqs BACKGROUND AND OBJECTIVES: Passive immunization using investigational COVID‐19 convalescent plasma (CCP) is a promising therapeutic strategy and could improve outcome if transfused early and contain high levels of anti‐SARS‐CoV‐2 antibodies. We report the management of a national CCP collection and distribution program in Israel. MATERIALS AND METHODS: From 1 April 2020 to 15 January 2021, 4020 volunteer donors donated 5221 CCP units and 837 (20.8%) donors donated more than once. Anti‐nucleocapsid IgG antibodies were determined using chemiluminescent immunoassay method (Abbott). A statistical model based on repeated IgG tests in sequential donations was created to predict the time of antibody decline below sample/cut‐off (S/CO) level of 4.0. RESULTS: Ninety‐six percent of CCP donors suffered a mild disease or were asymptomatic. Older donors had higher antibody levels. Higher antibody levels (S/CO ≥4) were detected in 35.2% of the donors. Low positive (S/CO ≥1.4–3.99) were found in 37%, and 27.8% had undetectable antibodies (S/CO ≤1.4). The model predicted decrease antibody thresholds of 0.55%/day since the first CCP donation, providing guidance for the effective timing of future collections from donors with high antibody levels. CONCLUSIONS: An efficient CCP collection and distribution program was achieved, based on performing initial and repeated plasma collections, preferably from donors with higher antibody levels, and only antibody‐rich units were supplied for therapeutic use. The inventory met the quantity and quality standards of the authorities, enabled to respond to the growing demand of the medical system and provide a product that may contribute to improve prognosis in patients with COVID‐19. Coronavirus disease 2019 , caused by severe respiratory syndrome coronavirus 2 (SARS-CoV-2), is one of the biggest global health threats of the last century. At the time of this writing, a year into the pandemic, specific treatment remains elusive [1] . Although the available vaccines may become a principal game changer in the prevention of new infection, passive immunization by transfusion of COVID-19 convalescent plasma (CCP) is still used widely. This strategy is based on century-old reports that describe the efficacy of treating patients during the 1918 influenza A pandemic by transfusions of CCP [2] [3] [4] and from small reports, showing encouraging clinical benefit of CCP in patients with severe COVID-19 [5] [6] [7] . Based on these reports, the Israeli Ministry of Health (MOH) requested Magen David Adom National Blood Services in Israel (MDANBS) to establish an investigational CCP program as a part of a national COVID-19 treatment protocol. As of today, data accumulated worldwide suggest that transfusion of CCP is safe and effective [8, 9] . Recent data from matched controlled studies [10, 11] , from randomized clinical trial [12] and from retrospective analysis [13] showed benefit of CCP in patients treated early with CCP containing high-titre antibodies (Ab), while others did not show decrease in mortality [14, 15] . Based on these data, U.S. Food and Drug Administration (FDA) issued on 4 February 2021 a revision of the Emergency Use Authorization (EUA) for CCP and limited the authorization to the use of high-titre CCP only [16] . Several trials are ongoing, investigating clinical benefit of CCP [17] and standardization of serological and neutralization assays [18] . In Israel, transfusing CCP is currently an integral component of the early treatment of COVID-19, as a part of a national investigational program. All aspects of CCP collection, processing, testing and distribution to hospitals nationwide are centrally performed by Magen David Adom National Blood Services (MDANBS), to assure standardization, quality and impartiality. The treatment protocol was based on transfusion of two CCP units (200 ml each) 24 h apart, to patients approved by the MOH research committee. The results of treating the first group of COVID-19 patients have been previously reported [19] , and the correlation of clinical benefit with higher anti-SARS-CoV-2 Ab in transfused CCP was shown. A key question for every CCP collection and distribution centre is how to select the right plasma donors. In this article, we report our experience accumulated since 1 April 2020, in recruiting CCP donors and in inventory management, as our aim is to qualify and supply for transfusion CCP units with highest anti-SARS-CoV-2 antibody levels. The Ethics Committee of the MOH approved an Institutional Review Board (IRB) protocol to recruit individuals who recovered from COVID-19 as potential CCP donors and conduct laboratory tests to qualify and supply CCP units for treatment. CCP collections were initiated on 1 April 2020, according to the first FDA protocol [20] , with local modification to comply with the MOH regulations and the IRB protocol [21], similar to programs established simultaneously around the world [22] . Potential CCP donors required evidence of COVID-19 by molecular tests and two consecutive negative test results after symptomatic recovery, thereafter 14-day deferral needed before plasma collection. Recovered COVID-19 patients were referred to the MDANBS by various sources, including MOH's database, the Israeli Defense Forces, cohorts in closed ethnic communities and social media. Donors gave their consent for transfer of personal data to MDANBS. All CCP donors were non-remunerated volunteers whose health histories complied with MOH and MDANBS criteria for blood donations. Only males or nulliparous females were recruited to mitigate the risk of transfusion-associated acute lung injury (TRALI). A Donor Recruitment Call Center was established and operated by trained MDANBS personnel, who conducted telephone interviews with potential donors to assure compliance with requirements. Pre-donation screening included evaluation of potential donors' records in the MDANBS computer database (Progesa, MAK-system) to identify prior disqualifying deferral. CCP collections were initially performed at the main MDANBS plasmapheresis donation centre that routinely performs apheresis plasma collections and had been involved in similar projects previously [23] . To respond to the rapidly growing demands for CCP, four additional donation sites were opened, additional mobile apheresis equipment Commercially available assays for anti-SARS-CoV-2 Ab differ by the Ab subclass (IgM, IgA, IgG or total antibody), the targeted antigen (subunit 1[S1] of the spike protein, nucleocapsid protein [N] or the receptorbinding domain [RBD]) and by assay method, that is, lateral flow assay (LFA) [24, 25] , neutralizing Ab assay (nAb) [26, 27] , enzyme-linked immunosorbent assay (ELISA) [28] and chemiluminescent immunoassay (CLIA) [29, 30] . For this project, we used multiple laboratory methods to test the presence of different anti-SARS-CoV-2 Ab. Serum samples were tested for anti-S IgG and IgA, using ELISA (EUROIMMUN AG, Germany), performed in the Research Laboratories of the School of Public Health, Tel Aviv University during the first month of the project (April, 2020). A positive result was defined as a sample to calibrator absorbance (S/CO) ratio ≥ 1.1 [28] . Starting 1 May 2020, all CCP collections were tested for anti-N by CLIA, performed on the Architect i2000 SR (Abbott, Green Oaks, IL) automated immunoassay analyser [29] . Testing also included samples retained from the first month's apheresis collections. Positive result was defined as S/CO≥1.4 [29, 30] . Having accumulated a sufficient CCP inventory (since 1 October 2020), we quali- First 230 CCP collections were tested by EUROIMMUN. Anti-S1 IgG Ab were undetectable in 17% (39/230). As the results of the test were not available at the time of CCP release, 19 of these CCP units were transfused. Two-weeks' follow-up was available for 15 patients that received at least one unit of CCP with undetectable anti-S1 IgGAb levels, and as discussed previously [19] , the lower mean antibody level in transfused plasma was a predictor of worse outcome in the group of 49 patients analysed in the study [19] . (Table S2 ). In stratification to age strata, there was no difference in antibody levels between genders. NAb activity was determined in 53 CCP units from 29 donors, as described previously [19] . The median nAb titre was 1:160 (inter- (Table S1 ). As we aimed to deliver only antibody-rich CCP to COVID-19 patients, only donors with initial anti-N IgG level of S/CO ≥ 4.0 were invited for subsequent donations, and two CCP units were delivered to patients: one unit with IgG S/CO ≥ 7.0 and one with S/CO ≥ 4.0, providing an average S/CO ≥ 4.5. The timeframe of Ab decrease was predicted by statistical model as 0.55%/day (Table S3 , Figure4) and could be calculated relatively to the level at the first collection, for example, if initial S/CO was 10.0, the decrease to S/CO of 4.0 will take 92.65 days (Table S4 ). The prevalence of ABO/Rh blood groups in CCP donors was similar to that of blood donors in the general Israeli population, according to the MDANBS database from 2019. Higher prevalence of blood group A and a lower prevalence of group O among COVID-19 patients reported previously [32, 33] was not seen in CCP donors in Israel; however, higher percentage of AB group in convalescents (9%) comparing to blood donors (8%) was statistically significant (p = 0.002). This report describes the steps taken to rapidly establish a program for the recruitment of volunteer CCP donors, qualifying their plasma by a multi-assay laboratory protocol and supplying it to COVID-19 patients in Israel. Over 2300 COVID-19 patients treated until 15 January 2021, as a part of an investigational, multi-institutional national program. Patients recovered from COVID-19 were referred by the MOH or responded to calls in the social media to become CCP donors. To facilitate recruitment of eligible individuals, personnel of CCP Call Center conducted health-screening interviews. Although only 11.6% of the calls yielded appointments, of which 72% of the donors showed up, remarkable low percentage of donors (4.5%) were deferred on site, compared to a deferral rate of 11% in our regular blood drives. The low percentage of deferrals on site was probably a result of predonation telephone interviews with potential donors to assure compliance with requirements, the tactics that were not accepted for regular blood donations. The relatively high percentage of CCP units dis- Our study has few limitations. One is the fact that 88.4% of individuals who were referred to the MDANBS were found to be noneligible due to health issues, parity in women or refused to donate. Consistently low compliance rate of COVID-19 convalescents to donate plasma was recently described by our colleagues [34] . We need to further study this phenomenon. Secondly, we used anti-N Ab as a surrogate marker of anti-viral neutralizing activity; however, follow-up of repeated nAb or anti-S IgG was not available during the study period. Thirdly, no anti-N IgGAb were found in high proportion of our CCP donors, in agreement with published data on lower Ab levels anticipated in cohort of asymptomatic individuals [35] and in patients with mild symptoms [36, 37] , with rapid decline of anti-N and nAb [38] . Anti-S antibodies were undetectable in 17% of our donors by EUROIMMUN test and in 14% by the rapid POC lateral flow test. We are awaiting for follow-up results of nAb tests in a larger group of CCP donors that will be performed by the Israeli Institute for Biological Research; they will be helpful to understand better the relationship between anti-N and nAb. Another limitation was unknown period between recovery and donation in many donors. It is clear that early CCP donation soon after recovery is associated with higher antibody levels, but unfortunately, the donors' information provided from the sites to MDABS was uneven and sometimes incomplete. Currently, all expectations are concentrated on the results of vaccination programs. Although over 3 million individuals were already vaccinated in Israel by the Pfizer-BioNTech vaccine [39] , urgent requests for CCP units for new COVID-19 patients are being added daily. Gaps in knowledge still exist for the timeframe for SARS-CoV-2 antibody formation and decline, the relationship between antibody levels and the severity of COVID-19 disease and the protective effect of antibodies against re-infection with the SARS-CoV-2 wild type or variants [40, 41] . In this ongoing project, we focussed on rapid creation of sufficient CCP inventory, by collection of CCP with higher antibody levels, as we believe that a better outcome for COVID-19 patients can be achieved by providing CCP transfusion early during the course of the disease. This challenging task was achievable and maybe less complicated in Israel, where the country's blood collection processing and supply is concentrated in a centralized Blood Services Establishment. Building a CCP inventory was achieved by being part of an integral, multi-disciplinary program involving community stakeholders (hospitals), governmental regulators (MOH) and research laboratories, all supporting the national program for donor recruitment and laboratory qualification of CCP. We encourage additional programs to share their experiences to support a timely determination of best practices for CCP programs during the current pandemic. Infectious Disease Society of America Guidelines on the Treatment and Management of Patients with COVID19 Treatment of pneumonic disturbance complicating influenza Value of convalescent blood and serum in treatment of influenza pneumonia Meta-analysis: convalescent blood products for Spanish influenza pneumonia: a future H5N1 treatment? 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How to cite this article We thank all the volunteer donors and MDANBS employees for contributionto the CCP collection and distribution. We thank S. Gerald No conflict of interest to disclose. https://orcid.org/0000-0002-4297-6373