Comprehensive Results of Cord Blood Transplantation Study: From Donor Screening to Banking Process

1. Results of the Cord Blood Transplantation Study (COBLT) Unrelated Donor Banking Program from Donor Screening to Characterization of Banked Units Joanne Kurtzberg, MD 1, Elizabeth L Wagner, MPH 2, John K Fraser, PhD 3, Mitch S Cairo, MD 4, LeeAnn Jensen PhD 5, Geoff Cohen MS 2, Shelly L Carter, ScD 2, Nancy A Kernan, MD 6 and *** 7. 1 Duke University Medical Center, Durham, North Carolina, 27705 ; 2 The EMMES Corporation, Rockville, Maryland, 20850 ; 3 University of California, Los Angeles, California, 90095 ; 4 Georgetown University Medical Center, Washington DC, 20007 ; 5 National Heart, Lung and Blood Institute, Bethesda, Maryland, 20817 ; 6 Memorial Sloan-Kettering Cancer Center, New York, New York, 10021 and 7 ***sponsored by the National Heart, Lung and Blood Institute, Bethesda, Maryland, 20817

2. Background • COBLT: The Cord Blood Transplantation Study – sponsored by the NHLBI • Banking study • Transplant Study • Initiated in 1996 and funded: • 1 Coordinating Center (EMMES) • 3 Cord Blood Banks • Choc/GT Mitch Cairo • Duke Joanne Kurtzberg • UCLA John Fraser • 7 Transplant Centers • 21 additional centers added over tenure of the study

3. Banking Study: Plan of Attack • Steering Committee: • Chair, Nancy Kernan, MD • Bank Directors • Coordinating & StatisticalCenter - EMMES • Representatives from NHLBI • Transplanters, OB, Ethicist, Lab Techs • Created and validated SOPs for program • Monthly meeting x 18 months

4. Standard Operating Procedures • SOPs • Donor screening and recruitment • Donor education and consent • Maternal donor medical history and testing • Collection and transportation • Processing and cryopreservation • Maternal Sample and Cord Blood Testing • Quarantine and release • Long term storage • Search Registry

5. SOPs - Continued • Standardization and validation of laboratory procedures • HLA by molecular techniques • Cell counts, viability, CFUs, CD34 and subsets, CD3,4,8, CD19, CD16/56 • Creation of internet based banking data system and search registry • Interlaboratory/bank QA/QC program with sample exchanges for testing, HLA typing, banking and thawing

6. Study Eligibility • Collections ex utero • UCBs >40 ml or 6x10e8 TNC • Initiation of processing within 48h of collection • Recovery of >60% of TNC post processing • +CFU growth • Negative maternal ID testing and maternal and family risk history • Negative homozygous hemoglobinopathy • All banked units passed a study algorithm defined by the steering committee

7. Timeline • Recruitment initiated in October, 1997 • Collections initiated in December, 1997 • SOPs published 1998 • Fraser et al, J Hematotherapy 7:521-561. • <www.emmes.com> • Collections completed June, 2001.

8. Total Total consenting collections Total Total Total and not recorded on 70% 85% 98% 83% Screened approached consented excluded monthly 34799 24240 20710 before recruitment delivery forms 20278 16764 15% 17% 30% 2% Total refusals 3530 Total not approached: 10559 Total collection failures at delivery: 3514 Reasons for not approaching Total excluded prior to delivery: 432 potential donors Reasons for excluding consenting Reasons for failure to collect Pregnancy related 63% donors prior to delivery Collection staff not at center or Personal medical history 12% unavailable 44% Pregnancy related 20% Personal risk behavior 8% Placenta/cord exclusion Personal medical history 41% Language barrier 7% 41% (including placental abruption) Personal risk behavior 20% Family history 3% Other delivery exclusion Family history 9% 7% Unable to consent 3% Other 10% Miscellaneous/undocumented 8% Private cord blood bank 2% Other / not documented 2% Figure 1 - Numbers of Women Screened, Approached, Consenting and with Collections Made Data from Monthly Recruitment Forms April 1998 to March 2001

9. Moved to long-term storage 9112 Total 64% 82% Cryopreserved collections Already shipped 303 11096 17207 Available in bank 8133 Still in quarantine 676 Reasons for discard 36% 18% Number Percent Insufficient volume/cell count 5171 64 Discarded Discarded Positive maternal ID test 646 8 6111 1984 Maternal history exclusion 613 8 Processing issues 297 4 Collection issues 294 4 No maternal sample 243 3 Subsequent medical information 224 3 Failed post-processing sterility test 194 2 Insufficient cell recovery 170 2 Withdrew consent 90 1 Administrative issues 57 1 Shipping/storage issues 91 1 Missing 5 0 Total 8095 100 Figure 2 - Numbers of Collections Made, Cryopreserved and Banked (December 1997 to August 2001)

10. Table 1 - Influence of Type of Delivery on Cell Counts and Volume Note : All differences highly significant (P< 0.0001).

11. Table 2 - Weight, Volume and Cell Counts of Stored CBUs by Ethnic Group

12. Table 3 - Percent of Collections Stored by Mother's Ethnicity

13. Table 4 - Correlations of Cell Counts, CBU Volume, Infant Birth Weight and Gestational Age *** P<0.001

14. 12 11 10 9 TNC (x 108) 8 7 <2.5 2.5 - 3.0 3.0 - 3.5 3.5 - 4.0 > 4.0 Birth weight (kg) Figure 2a - Total Nucleated Cells by Birth Weight

15. 5.0 4.5 4.0 CD34 (x 106) 3.5 3.0 2.5 2.0 <2.5 2.5 - 3.0 3.0 - 3.5 3.5 - 4.0 > 4.0 Birth weight (kg) Figure 2b - Total CD34 Cells by Birth Weight Bars show mean and 95% confidence limits (mean +/- 1.96 standard errors).

16. 12 11 10 TNC (x 108) 9 8 7 <37 38 39 40 > 40 Gestational Age (weeks) Figure 2c - Total Nucleated Cells by Gestational Age

17. 5.0 4.5 4.0 CD34 (x 106) 3.5 3.0 2.5 2.0 <37 38 39 40 > 40 Gestational Age (weeks) Figure 2d - Total CD34 Cells by Gestational Age

18. 3.0 2.5 Adjusted mean CD34+ (x 106) Total post processing count 2.0 1.5 Caucasian Hispanic Other African American Asian Figure 3 - Adjusted Mean Total Post-Processing CD34 Counts by Race

19. Conclusions • The COBLT Banking Study has demonstrated the resources required to establish and maintain a network of cord blood banks with common SOPs and Quality Systems. • A MCC (EMMES) created and maintains a web based data management system for data collection and analysis.

20. Conclusions • >35,000 women were recruited and screened over 3 years. • 15% refused to participate in the study. • Approximately 53% of CBUs collected from these donors were successfully banked creating an ethnically diverse inventory of >8,000 total units. • The main reasons for exclusion were insufficient cell volume/counts or positive ID testing on the maternal sample.

21. Conclusions • Strong correlations were observed between UCB collection volume and nucleated cell and CD34 content. • Units collected from African American donors had lower cell counts and CD34 counts per ml of UCB collected. • Factors correlating with higher UCB TNC content included higher birth weight, delivery by c-section and increasing gestational age at delivery (not beyond 40 weeks).

22. Conclusions • These observations can be used to create an algorithm for identification of desirable units at a collection site to maximize resources committed to units that are processed, tested and banked.

23. Acknowledgements • NHLBI: LeeAnn Jensen, Paul McCurdy • Study Chair: Nancy Kernan • The MCC – The EMMES Corporation • Shelly Carter, Liz Wagner, Geoff Cohen • Bank Directors • Mitch Cairo, John Fraser, Joanne Kurtzberg • HLA • UCSF, UCLA, NMRI