New rays on blood safety

Jed Gorlin, MD, vice president of medical and quality, Innovative Blood Resources, St. Paul, Minn., jokingly refers to “the whole sordid history” of the U.S. government’s interest in removing cesium irradiators, before laying out the issues involved.

“I certainly sympathize with the Department of Homeland Security, whose job it is to minimize risks and opportunities for malfeasance,” he says. While the risks from radioactive sources is not direct harm, “One simply needs to look at the circle drawn around Chernobyl or Fukushima to recognize there are large radii in which people will no longer be able to live for a hundred years, and understand the economic and personal impact. It does need to be addressed.”

On the other hand, cesium irradiators can’t be wished away. Decommissioning a cesium irradiator costs $100,000 or more, Dr. Gorlin says, with a significant portion now paid by the federal government.

“That’s why government support is such an important factor,” says Stephen Wagner, PhD. And even if the government continues to fund disposal of cesium irradiators through its Off-Site Source Recovery Program, the process can be slow, he says. As senior director of the American Red Cross, Holland Laboratory, Transfusion Innovation Department, Rockville, Md., Dr. Wagner is familiar with how that process has played out at multiple Red Cross sites as they switched to x-ray irradiators. “You may have to wait a year or two before you’re able to arrange a pickup for an old gamma irradiator,” he says. “It requires a lot of planning.”

Whether that will continue with the new administration is anyone’s guess. While some in Washington see an event like the Paris attacks as ample reason to view cesium irradiators as a target, others may view the devices through a different lens, arguing that over-regulation is the bigger problem. That could create a “let-people-deal-with-it-themselves” approach, as Dr. Jhang puts it.

In recent years, compliance related to the security of existing cesium irradiators has only grown more onerous, Dr. Gorlin says. Given that difficulty, if a blood bank is ready to purchase a new irradiator—for whatever reason—“I can’t see anybody buying a new cesium irradiator.” This is a point of bafflement for Dr. Gorlin, actually. “If the government really is intent on assisting us in that direction [to remove cesium irradiators], wouldn’t the logical first policy be not allowing new instruments to be sold in the U.S.? Which is not the case.”

Nevertheless, Dr. Gorlin is quick to praise the work of those who regulate radioactivity in the United States through the National Research Council. “When certain overenthusiastic government officials wanted to ban cesium irradiators overnight [post-9/11], with no plans for whether there were available replacements, they did an amazing job of gathering subject matter experts” and laying out a more thoughtful response. The government’s part in assisting with decommissioning and “hardening” cesium devices “was a tribute to government at its best,” he says.

X-ray devices have their own monitoring requirements, but Dr. Gorlin says they’re far less onerous—comparable, he quips, to the requirements used to oversee dental x-rays.

Drs. Jhang and Kamen also predict that the regulation of cesium devices will only become tighter in the years ahead. For staff, that will likely mean added requirements in terms of training, qualifications, and background checks. For institutions, that could spell higher security and insurance costs. “So the cost-benefit analysis must include future regulation,” Dr. Jhang says.

The regulatory requirements were already daunting in 2007, when Children’s Health in Dallas took over the transfusion service from its blood provider, says Daniel K. Noland, MD, an assistant professor of pathology at the University of Texas Southwestern Medical Center, Dallas, and medical director of the transfusion and tissue service for Children’s. Looking at the background checks, locked doors, and radiation badge monitoring required for a gamma irradiation source, “We chose to go with an x-ray irradiator. Looking at all the costs, we thought it was much more effective for us,” Dr. Noland says. “You have to look at it the same way as you look at purchasing any other instrument. You look at footprint. We don’t have to have this behind a locked door—we can have it right there in the blood bank.”

After that initial purchase, Children’s bought a new x-ray irradiator in 2014. The older-generation device had its problems, particularly with the power supply, Dr. Noland reports, though he adds that the center could always meet its throughput demand. The newer instrument has had no such issues, although “We did have an issue getting it through customs [from Canada] initially,” he says, which led to a delay of a week or two. The problem was dealt with over the phone, and Children’s used alternative sources of irradiated blood products in the interim. “I got the impression that customs was a relatively unusual but not unheard-of problem.”

Lengthen the time frame by a few more years, and blood centers might be able to add another variable to the mix: It’s possible the need for irradiators of any type may disappear if pathogen inactivation technologies continue to take root. “I’m not holding my breath,” says Dr. Gorlin, but he adds that some might say it’s reasonable to hold off on purchasing an x-ray irradiator in the hope that red cell pathogen inactivation will be viable at some point, alongside platelets. The field has advanced, he concedes, and he suggests this has even led to stagnation in the x-ray irradiator market.

The x-ray devices have already been through two rounds of development, which further clouds the cesium versus x-ray debate. The unreliability of earlier x-ray models helped cast a gauzy light around the cesium devices.

Cesium irradiators “never break down, and they last forever,” says Dr. Gorlin. He knows of one cesium irradiator, a Nordion serial No. 1 machine, that “probably has the longest irradiation cycle on the planet, but it still works.” And with few moving parts—“other than changing a motorcycle battery every now and then”—the ongoing maintenance cost, he’s heard, is “bupkis.”

Based on his own experiences of making the switch, x-ray irradiators are far less reliable, burning out with regular frequency. Backup plans are essential. “Companies are reasonably good at making repairs,” he says, but it can take 24 hours or more to get a device back online.

His blood system was an early adopter of an x-ray irradiator. “The good part about being early is you get a discount,” he says. “The bad part is you don’t generally want to buy a new car the first year of the model, because the manufacturer is still working out the kinks.”

Echoing Dr. Jhang, Dr. Gorlin does see progress in the x-ray irradiators, however. “My understanding is that the reliability has improved significantly,” though he still sounds a bit battered from his early-adopter experiences. He also credits the vendor for promptly servicing the machine when it required repairs, which was often. Reflecting further, Dr. Gorlin says that making the switch “was a very different experience, moving from a machine that never needed repairs or replacement” to one that did. Another x-ray machine at a different site—this one without external cooling requirements—had what Dr. Gorlin calls a tenuous first year, but since then has been “pretty well behaved.”

It’s worth noting that earlier model x-ray irradiators required external water cooling, which added space and infrastructure complexities; the newer machines do not. When one of Innovative Blood Resources’ blood centers replaced its x-ray irradiator several years ago, after more than 10 years, it purchased one that still required external cooling, Dr. Gorlin says, since the infrastructure was already in place. “It was the path of least resistance.”

Unfortunately, he says, there are not enough data to provide Consumer Reports-type (or CAP TODAY product guide, for that matter) comparisons and guidance on different models.

Dr. Wagner agrees. The Red Cross has a number of x-ray irradiators that are more than 10 years old. “But there is not enough good data to know exactly what the lifetime of an x-ray device is in a blood bank. And we know even less about the new devices, although I would suspect that with their newer designs, they might last a little longer.”

Dr. Kamen suggests that the x-ray irradiators have not only improved but also that users are becoming savvier about their operation. Not all his colleagues share his affability. Speaking of one institution that became unhappy with an x-ray device purchased nearly a decade ago, Dr. Kamen notes that it was one of the older devices, which were deemed difficult for, among other things, their lack of self-cooling. “They probably used the machine too much during a short period, which caused the x-ray tube to overheat and break,” Dr. Kamen says. He compares it, appropriately enough, to a car. “Let’s say I give you a brand-new car with a five-year warranty, in perfect condition. If you drive it for five months without stop, what do you think is going to happen?”

But other colleagues tell more successful stories, he says. As for his own system’s newer machines, he says, he’s been told by the manufacturer that they will handle about 2,000 hours of use, or roughly eight years. “And it’s not that you throw the machine away after eight years; you just change the tube.”

Looking back, Dr. Kamen suggests that blood centers still grappling with the issue learn from Mount Sinai’s experience and switch directly to x-ray irradiators. Enhanced security, working with the police department, and FBI background checks were expensive and time-consuming, he says.
And for those who have decided, Dr. Kamen offers another bit of hard-won experience: Don’t underestimate the amount of planning and time it takes to dispose of and replace and validate a new device. “You can’t just leave it to one department and assume you can switch it out in a month or so.” Six to nine months, depending on available personnel, is more reasonable.

Training on the new irradiator was fairly seamless, Dr. Jhang says. Mount Sinai sent a couple of members from its radiation safety office as well as from the blood bank to undergo intensive operations training at the company’s headquarters. In addition, the company did onsite training for the rest of the blood bank staff. “It took about five days to train the 30 staff,” he says.

Anticipating downtime, Dr. Jhang says the blood bank has created a log to document throughput and better understand uptime operations. “If it breaks down, we want to know what will be triggering it—how many units in a given amount of time would cause it to overheat?” Mount Sinai would have to purchase units if an extended repair time depleted its inventory. “It’s doable, but obviously it’s something we have to think about in our calculus—what would be the cost impact if there’s a prolonged downtime?” he asks.
(That’s less of an issue at the Red Cross. With its nationwide blood bank network, Dr. Wagner says, “We’re able to ship blood where it’s needed in emergencies. So we can react to an instrument going down.” And, he notes, cesium irradiators also experience downtimes, despite many glowing reminiscences to the contrary.)

Dr. Jhang also recommends that anyone installing an x-ray irradiator consider the work environment. Is ventilation adequate? What is the temperature range in the area? “If the machine overheats, you can’t run it,” Dr. Jhang says. He and his colleagues neglected to make robust calculations regarding the heat output of the x-ray irradiator. “We found the area warmed up much more than we thought it would, so we had to go back and install additional air conditioning.”

At Children’s Health, Dr. Noland was told that since Dallas has “hard” water, the x-ray tube shelf life might be shorter. To eliminate that possibility, the center changes the water filter more frequently than is typically recommended. “We haven’t experienced any decrease in the longevity of the tube,” he reports.

Among these reassuring, almost tame observations, it’s easy to forget the concerns that first launched the debate over removing cesium irradiators. But as several observers suggest, there’s much to ponder beyond immediate economic or safety returns.

Says Dr. Jhang: “I think you have to be forward-looking and say, ‘OK, maybe this is not 100 percent benefit to my institution, but there is benefit to the community and protecting citizens in the surrounding areas.’ ”

Adds Dr. Gorlin: “I think it’s the right thing to do.”
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Karen Titus is CAP TODAY contributing editor and co-managing editor.