FDA Invites Patient Organizations to Take a Place at the Podium

By: Theresa M. Mullin, Ph.D.

Sometimes, the most valuable thing we can do as regulators at FDA is simply to listen. I’m reminded of that each time we hold a public meeting as part of the Patient-Focused Drug Development (PFDD) program.

Theresa MullinWe began PFDD to more systematically obtain the patient perspective on certain diseases and their treatments. The effort is part of an FDA commitment under the fifth authorization of the Prescription Drug User Fee Act (PDUFA V).

Each public meeting is focused on a specific disease area. Our commitment is to gain perspectives on at least 20 disease areas by the end of FY 2016. And having already held 17 meetings to hear from patients with diseases as varied as breast cancer, fibromyalgia and sickle cell disease, we are well on our way.

What have we learned so far? For one, thanks to PFDD we now have even more first-hand knowledge from those most affected by the diseases. We have heard directly from patients, their families, and care givers about the symptoms that matter most to them; the impact the disease has on patients’ daily lives; and their experiences with currently available treatments. For example, we’ve learned that for diseases that are progressive and severely disabling, patients and their families may consider an “ideal” treatment to be one that at minimum can halt disease progression.

These perspectives are critical to helping us understand the context in which we are making regulatory decisions for new drugs. And they’ll have ramifications for years to come. We believe that the long-term impact of PFDD will be better, more informed FDA decisions and oversight both during drug development and during our review of a marketing application.

Expanding the Benefits of the PFDD Meeting Model

This is a priority for FDA. To that end, we’ve committed to hold meetings for at least 20 disease areas, and are currently planning to hold 24 different disease-focused meetings by the end of FY2017, exceeding our commitment. We recognize, however, that there are many more disease areas than can be addressed in the planned FDA meetings where drug development and regulatory decision making would benefit from a meeting focused on obtaining the patient’s perspective.

To help expand the benefits of FDA’s PFDD initiative, FDA invites the independent efforts of patient organizations to identify and organize externally-led patient-focused collaborations to generate public input on other disease areas, using the process established through Patient-Focused Drug Development as a model. Given the tremendous number of diseases affecting the U.S. patient population and the effort required to conduct a successful PFDD meeting, externally led PFDD meetings should target disease areas where there is an identified need for patient input on topics related to drug development.

We recommend that patient organizations interested in conducting an externally-led PFDD meeting submit a letter of intent so that we are aware of their plans. Submission details and more information on considerations to take into account are outlined on FDA’s website.

Please note that an externally led PFDD meeting and any resulting products, such as surveys or reports, will not be considered FDA-sponsored or FDA-endorsed. And while we can’t guarantee FDA’s specific involvement at every meeting, FDA will be open to participating in a well-designed and well-conducted meeting.

And as the number of patient-focused forums continues to grow, we at FDA will continue to listen and look forward to gaining the additional insights that only patients, their families, and care givers can provide.

Theresa M. Mullin, Ph.D., is Director of FDA’s Office of Strategic Programs in the Center for Drug Evaluation and Research

What We Mean When We Talk About Data

By: Robert M. Califf, M.D. and Rachel Sherman, M.D., M.P.H.

Robert Califf

Robert M. Califf, M.D., FDA’s Deputy Commissioner for Medical Products and Tobacco

Medical care and biomedical research are in the midst of a data revolution. Networked systems, electronic health records, electronic insurance claims databases, social media, patient registries, and smartphones and other personal devices together comprise an immense new set of sources for data about health and healthcare. In addition, these “real-world” sources can provide data about patients in the setting of their environments—whether at home or at work—and in the social context of their lives. Many researchers are eager to tap into these streams in order to provide more accurate and nuanced answers to questions about patient health and the safety and effectiveness of medical products—and to do so quickly, efficiently, and at a lower cost than has previously been possible.

But before we can realize the dramatic potential of the healthcare data revolution, a number of practical, logistical, and scientific challenges must be overcome. And one of the first that must be tackled is the issue of terminology.

Defining Terms

Although “data,” “information,” and “evidence” are often used as if they were interchangeable terms, they are not. Data are best understood as raw measurements of some thing or process. By themselves they are meaningless; only when we add critical context about what is being measured and how do they become information. That information can then be analyzed and combined to yield evidence, which in turn, can be used to guide decision-making. In other words, it’s not enough merely to have data, even very large amounts of it. What we need, ultimately, is evidence that can be applied to answering scientific and clinical questions.

So far, so good. But what do we mean when we talk about “real-world data” or “real-world evidence”?

Rachel Sherman

Rachel Sherman, M.D., M.P.H., FDA’s Associate Deputy Commissioner for Medical Products and Tobacco.

Clinical research often takes place in highly controlled settings that may not reflect the day-to-day realities of typical patient care or the life of a patient outside of the medical care system. Further, those who enroll in clinical trials are carefully selected according to criteria that may exclude many patients, especially those who have other diseases, are taking other drugs, or cannot travel to the investigation site. In other words, the data gathered from such studies may not actually depict the “real world” that many patients and care providers will experience—and this could lead to important limitations in our understanding of the effectiveness and safety of medical treatments. Clinicians and patients must be able to relate the results of clinical trials—studies that are done in controlled environments with certain patient populations excluded and which may therefore be challenging to generalize—to their own professional and personal experiences. It seems straightforward, then, to think that studies including a much fuller and more diverse range of individuals and clinical circumstances could ultimately lead to better scientific evidence for application to decisions about use of medical products and healthcare decisions.

But “real-world evidence” has its own issues that must be understood and dealt with carefully. First of all, the vague term “real-world” may imply a closer relationship with the truth—that the real-world measurement is preferable to one taken in a controlled environment. For example, is “real-world” blood pressure data gathered from an individual’s personal device or health app better (e.g., more reliable and accurate) than a blood pressure measurement from a doctor’s office? It could be, because a patient’s blood pressure might be uncharacteristically elevated during a visit to the physician. But at the same time, do we know enough about the data gathered from the patient’s personal device—how accurate is it? Is the patient taking their own blood pressure correctly? What other factors might be affecting it?—to use it for generating evidence? Already we are being reminded of the complexities of potentially relying on data that were gathered for purposes other than the ones for which they were originally intended.

In most cases “real-world evidence” is thought of as reflecting data already collected, i.e., epidemiologic or cohort data that researchers review and analyze retrospectively. Also of interest is whether randomized trials can be conducted in these “real-world” environments. In considering comparisons of treatments, one must always consider the possibility that the treatments were not assigned randomly, but reflected some relevant patient characteristic. This is, of course, the reason for doing randomized clinical trials.

Better Terms for Complex Subjects

There is little doubt that the new sources of data now being opened to researchers, clinicians, and patients hold enormous potential for improving the quality, safety, and efficiency of medical care. But as we work to understand both the promise and pitfalls of far-reaching technological changes, we need a more functional vocabulary for talking about these complex subjects, one that allows us to think about data, information, and evidence in ways that capture multiple dimensions of quality and fitness for purpose (e.g., for appropriate use in regulatory decision making). The incorporation of “real-world evidence”—that is, evidence derived from data gathered from actual patient experiences, in all their diversity— in many ways represents an important step toward a fundamentally better understanding of states of disease and health. As we begin to adapt “real-world data” into our processes for creating scientific evidence, and as we begin to recognize and effectively address their challenges, we are likely to find that the quality of the answers we receive will depend in large part on whether we can frame the questions in a meaningful way.

Robert M. Califf, M.D., is FDA’s Deputy Commissioner for Medical Products and Tobacco.

Rachel Sherman, M.D., M.P.H., is FDA’s Associate Deputy Commissioner for Medical Products and Tobacco.

The Merging of Medical Products: Enhancing review of therapeutic and diagnostic combination products

By: Robert M. Califf, M.D. and Jill Hartzler Warner, J.D.

Combination products – medical products that do not fit into the traditional categories of drugs, devices, or biological products – are a growing and important category of therapeutic and diagnostic products under FDA’s regulatory authority.

Robert Califf

Robert M. Califf, M.D., FDA’s Deputy Commissioner for Medical Products and Tobacco.

These products, that combine drugs, devices, and/or biological product (“constituent parts”) with one another, come in three configurations. The constituent parts may be physically or chemically combined, co-packaged, or separately distributed with specific labeling for their combined use.

Products in this category range from familiar products such as prefilled syringes and surgical kits to novel and innovative products, which target and enhance therapies. Examples of groundbreaking combination products include antibodies combined with drugs for targeted cancer therapy and products that mimic or replace organs, such as an artificial pancreas.

Combination products pose unique challenges – both because they may involve new, complex technologies – and because their review at FDA often involves the expertise of more than one Center.

While review of such products falls to a cross-center team of experts, it is led by the medical product Center responsible for the constituent part that provides the product’s primary mode of action, which, in the case of a syringe prefilled with a drug, for example, would be FDA’s Center for Drug Evaluation and Research.

Effective coordination among FDA staff, and between FDA and the company, is essential – and depends on identifying the proper experts across Centers, supporting processes for communication, and implementing systems for efficient data access and sharing.

Jill Warner

Jill Hartzler Warner, J.D., FDA’s Associate Commissioner for Special Medical Programs.

FDA’s Office of Combination Products (OCP), within the Office of Special Medical Programs, oversees and coordinates FDA’s regulation of combination products. This includes helping to resolve differences of opinion between Centers or with sponsors, developing guidance and regulations, and working with the medical product Centers to develop processes and policies..

Congress has expressed interest in FDA’s regulation of combination products as part of the 21st Century Cures legislative initiative, with one major theme being the assurance that the premarket review process runs smoothly.

While we already have policies and processes in place to address such issues, we know we can do more. To that end, we’ve recently conducted a focus group study with reviewers from the different Centers based on input from industry to assess how we’re doing. The report confirmed that differences in communication, policies, practices, systems and application types can be challenging when the Centers work together on a review of a combination product. The report also recommended actions to take, confirming the value of efforts already underway. Consistent with these findings, we’re taking a number of steps to clarify regulatory requirements and improve our internal processes and IT systems. It may sound a bit mundane, but doing this work could help us work more efficiently and avoid unnecessary surprises for sponsors. These steps include:

  • Issuing more guidance for review of combination products (e.g., our pending draft guidance document on human factors);
  • Enhancing and simplifying data access and sharing for internal staff;
  • Making it easier for staff to request and monitor inter-center consults;
  • Updating and maintaining our internal contact directory for experts to review a combination product; and
  • Improving our internal standard operating procedures for premarket reviews and compliance activities.

Some improvements are already in place and others will be coming this year and next. We continue to want to hear your ideas for enhancing how we work with you on combination products. We are listening — and excited to do our part by evaluating innovative combination products and helping to improve the well-being of patients by approving new safe and effective therapies.

Robert M. Califf, M.D., is FDA’s Deputy Commissioner for Medical Products and Tobacco.

Jill Hartzler Warner, J.D., is FDA’s Associate Commissioner for Special Medical Programs.

FDA Invests in Innovative Ways to Communicate to Hispanics

By: Gloria Sánchez-Contreras, M.A.

En Español

National Hispanic Heritage Month–celebrated annually from September 15 to October 15—gives Americans a great opportunity to celebrate the histories, cultures, and contributions of Hispanic Americans whose roots are in Spain, Mexico, the Caribbean, and Central and South America.

Gloria Sanchez-ContrerasAt FDA, we join in this celebration as we continue to use innovative ways to reach Hispanics as part of our mission to protect the public health. To achieve this goal, FDA uses media strategies that are culturally and linguistically tailored to Hispanics, who, according to research, are avid users of online and social media.

There are 54 million people of Hispanic origin in the United States, making them the nation’s largest ethnic or racial minority group, with 17 percent of the nation’s total population, according to the U.S. Census Bureau. The United States has the second-largest population of Spanish-speaking residents in the world, ahead of Colombia and Spain, and second to Mexico, a recent study by the Instituto Cervantes shows.

These statistics cannot go unnoticed. FDA recognizes the importance of connecting with this growing and diverse segment of our population. Consequently, we have increased our online consumer information in Spanish and developed a variety of bilingual communications strategies to reach and engage all Hispanics.

One of the most important strategies we use is to make sure that messages created for Hispanics speak to them effectively. We consider Hispanics’ informational needs, lifestyles, and cultural health beliefs both when creating new messaging and when translating messaging from English to Spanish.

For example, we know Hispanics respond better when communications are in their primary language – which can be English or Spanish – and when communications use images that relate to them. We do this by employing a bilingual and bicultural team that reviews messaging for cultural competence and adapts translations to ensure they are culturally sensitive and in plain language.

In addition to our English-language communications, we have developed strategies to reach out to Spanish-speaking Hispanics online. Our Consumer Updates and drug safety communications are regularly translated into Spanish. We share Spanish-language information through our social media channels, including Twitter, Facebook, Pinterest, and YouTube.

In addition, we also have a complete Web section in Spanish for consumers (www.FDA.gov/ArticulosConsumidor), a press room (“Comunicados de Prensa”), and a central page (www.FDA.gov/Espanol) that links to a variety of Spanish-language content developed across the Agency’s product centers and offices.

These are exciting times, and it is a privilege to lead some of these efforts for our agency. The Office of External Affairs works diligently across FDA to share important and timely public health news with Latino consumers, stakeholders, media, and community organizations. And during Hispanic Heritage Month—and all the months of the year–we want Hispanics to know that FDA is a trusted source of consumer information.

Gloria Sanchez-Contreras, M.A., is a Bilingual Public Affairs Specialist and the Spanish-Language Communications Lead in FDA’s Office of Media Affairs.

A Quarter Century of Groundbreaking Science: The Forensic Chemistry Center

By: Stephen M. Ostroff, M.D.

This month marks the 25th anniversary of our Forensic Chemistry Center (FCC) in Cincinnati, Ohio. I recently joined former and current administrators and staff of this lab—one of FDA’s many incredible field laboratories—at an event celebrating this milestone.

Acting FDA Commissioner, Stephen Ostroff, M.D.One thing is clear: The last quarter-century has been a period of tremendous success at the FCC. FCC scientists use their scientific analysis and original research to investigate the physical and chemical characteristics and effects of adulterants on products regulated by the Agency, including chemical fingerprinting of poisons, glass, pharmaceuticals, food products and product packaging materials. By analyzing physical samples they can identify counterfeits, trace the origin of a pathogen or solve a crime.

In short, they are the CSI of FDA.

The commitment, expertise, and curiosity of FCC scientists have helped FDA overcome many scientific challenges, and made an extraordinary difference in the lives and safety of millions of Americans. Time and again the sophisticated analyses of puzzling substances by our scientists—often using innovative, esoteric methods, and groundbreaking research, along with the development of new processes and procedures—have made a critical difference in FDA’s ability to investigate and enforce–and protect the American public.

FCC Anniversary group photo

Former and current administrators and staff of the Forensic Chemistry Center (FCC) in Cincinnati, Ohio, at an event celebrating the 25th Anniversary. From left to right: Paul Norris, Director, Office of Regulatory Science; Steve Solomon, Deputy Associate Commissioner for Regulatory Affairs; Dr. Ostroff, Acting Commissioner of Food and Drugs; Phil Walsky, Deputy Director, Office of Criminal Investigations; Fred Fricke, former Director of FCC; and, Duane Satzger, Director of FCC.

FCC’s work has paved the way for passage of important laws, legal prosecutions, and consumer protection activities like recalls. And it has helped strengthen international relationships and advance international cooperation to ensure product quality and consumer safety.

Just a few highlights of FCC’s important efforts include:

  • In the 1990s, the lab supported some of FDA’s early work evaluating nicotine, which was recently cited in the proposed rule to deem additional tobacco products subject to the agency’s tobacco product authorities;
  • In 2001, after 22 people died in the Croatian Republic after receiving dialysis using certain devices, FCC’s analysis identified the presence of a toxic performance fluid in those devices that resulted in their recall by the manufacturers;
  • FCC investigated numerous illnesses and deaths of cats and dogs during 2007-8, which led to the determination that the pet food was adulterated with melamine and related compounds;
  • FCC’s investigation and analysis following the death of cattle in Washington State helped the FBI rule out the possibility that it was caused by terrorism;
  • Following the deaths of a number of infants in India who had been given the measles vaccine, FCC investigated the vaccine’s manufacturing process and discovered that the cause was not, as initially feared, a vaccine of poor quality. Instead the children had received pancuronium bromide, a muscle relaxant, which had been packaged in vials with similar size and shape to the vaccine, rather than the vaccine itself. This discovery was communicated to the Indian government, leading to a critical change in their immunization practices; and,
  • FCC developed a method for examining the sea animals impacted by the Deepwater Horizon oil spill, which helped determine when the seafood would be safe to consume.

It is an extraordinary record. And it’s meant so much to FDA—and the nation—over the past 25 years. But the anniversary and success of this one lab also underscores the remarkable work done by all of FDA’s laboratories across the country. These labs and the districts in which they are located are the critical front line eyes and ears of FDA. And they are the springboard for excellent science.

Good science is fundamental to the mission of FDA. We need it to make good regulatory decisions. It’s what the public expects and deserves. By being able to handle and apply the science of today and anticipate the science of tomorrow we can be more flexible and adaptive, and support innovation.

Having seen the impressive and important work our labs are doing, I’m more committed than ever of the need to invest in better facilities and the best support. We must maintain state-of-the-art laboratories and research facilities, and attract, hire, and retain the best scientists to work in them. First-rate regulatory science requires first-rate scientists working in first-rate facilities.

It’s why I’ve made this a priority for FDA. And why we will put it high on our list of subjects for discussion with Congress as they shape future budgets for the Agency.

The scientists in FDA’s field laboratories are among the unsung heroes of FDA’s work to protect the public health. So let me congratulate and thank those at the FCC and across FDA on the milestone occasion of the 25th anniversary of the Forensic Chemistry Center.

Stephen M. Ostroff, M.D., is Acting Commissioner of the U.S. Food and Drug Administration

Why Partnerships are Key to the Science of Patient Input

By: Nina L. Hunter and Robert M. Califf, M.D.

We recently announced the first FDA Patient Engagement Advisory Committee (PEAC), supported by the Center of Devices and Radiological Health (CDRH). The Committee will provide advice to the FDA Commissioner on complex issues relating to medical devices, the regulation of devices, and their use by patients. The PEAC will bring patients, patient advocacy groups, and experts together for a broader discussion of important patient-related issues, to increase integration of patient perspectives into the regulatory process, and to help drive more patient-centric medical device innovation, development, evaluation, and access.

Nina Hunter

Nina L. Hunter, Ph.D., a Regulatory Scientist in FDA’s Center for Devices and Radiological Health, currently on detail as a Special Assistant for Medical Policy to the Office of Medical Products and Tobacco.

With the PEAC offering an important avenue for patient views to be incorporated in the assessment of new medical devices, complementary programs in the Center for Drug Evaluation and Research (CDER) and the Center for Biologics Evaluation and Research (CBER) are continuing to explore multiple approaches to patient involvement in development programs for drugs and biologic products, respectively. The Patient-Focused Drug Development (PFDD) Program, led by Dr. Theresa Mullin, provides a way for scientists from across the Agency to obtain patients’ input on specific disease areas, including their perspectives on their condition, its impact on daily life, and available therapies. As part of this program, FDA is holding a series of public meetings, each focused on a specific disease area. Outcomes of these meetings include detailed descriptions of patient perspectives on the most significant symptoms and treatments.

While FDA continues our work on patient engagement through our newly formed advisory committee and the PFDD Program, public-private partnerships (PPPs) are key to empowering patients across the spectrum of medical product development and evaluation. Here we will describe three such important partnerships.

FDA is a founding member of the Medical Device Innovation Consortium (MDIC), a PPP created with the objective of advancing medical device regulatory science. MDIC recently issued a catalog of available methods that can be used for collecting data on patient preferences, along with a framework for considering how to incorporate patient preferences across the total lifecycle of a device. The ultimate goal is to use these data to guide the development, assessment, and delivery of medical devices that better meet patients’ needs. As the scientific evidence and methodological approaches in this area mature, FDA will continue to collaborate with others on efforts to collect and use patient preference data for regulatory purposes.

Robert Califf

Robert M. Califf, M.D., FDA’s Deputy Commissioner for Medical Products and Tobacco.

Like the MDIC, the Kidney Health Initiative (KHI) is a PPP that includes representatives from the FDA, healthcare professional societies, patient groups, and the medical products industry. Recently, KHI convened a workshop under the leadership of Dr. Frank Hurst and Ms. Carolyn Neuland, with patients, care partners, scientists, doctors, nurses, technicians, companies, and FDA, to hear discussions about the issues that patients with kidney diseases consider most important. More than 80 patients attended this workshop; many of these were not members of an organized patient advocacy group, but instead individuals truly driven to improve the plight of all patients with kidney disease. CDRH and CDER are working with the KHI to advance scientific understanding of the implications for patient health and safety posed by new and existing medical products, as well as fostering development of new therapies for kidney diseases. This PPP creates a transparent infrastructure and processes that facilitate collaboration and communication among the greater Nephrology community and FDA.

FDA has also held several meetings with the National Institutes of Health (NIH) throughout the PROMIS initiative, including the Patient Reported Outcome Consortium. PROMIS aims to provide clinicians and researchers access to efficient, precise, valid, and responsive patient-reported measures of health and well-being. PROMIS measures can be used as primary or secondary endpoints in clinical studies of the effectiveness of treatment, and PROMIS tools can be used across a wide variety of chronic diseases and conditions and in the general population. These tools pertain to all medical products, and they can be used to understand the burden of their disease and impacts of treatment on how patients feel and function in their daily lives, so that appropriate patient-centered outcome assessments can be developed and integrated into clinical trials to produce meaningful data to guide treatment decisions. Specifically at CDRH, the use of patient-reported outcome measures (PROMs) in regulatory submissions has increased significantly, with approximately 20 submissions per year citing PROMs prior to FDA’s guidance on the topic, to over 120 last year alone. This jump indicates significant interest by industry and clinical researchers in generating patient-centered evidence from studies done for regulatory purposes.

FDA is ready to advance the science of patient input and work with a wider community of patients, clinicians, and social science researchers in a collaborative way. We expect the number of partnerships with patients and their caregivers to grow, and the effort to become more effective as the underlying science and cultural understanding continues to develop.

Nina L. Hunter, Ph.D., is a Regulatory Scientist in the Center of Devices and Radiological Health, currently on detail as a Special Assistant for Medical Policy to the Office of Medical Products and Tobacco.

Robert M. Califf, M.D., is FDA’s Deputy Commissioner for Medical Products and Tobacco.

National Preparedness Month: FDA and Access to Medical Countermeasures During Public Health Emergencies

By: Brooke Courtney, J.D., M.P.H.

Just weeks after witnessing the fall of the World Trade Center on Sept. 11, 2001, I was a student volunteer in a New York City hospital emergency department when several people arrived saying they had been exposed to anthrax.

Brooke CourtneyOne had even brought a small plastic bag holding white powder. Around this time, the media was reporting on letters mailed that were laced with white powder confirmed to be Bacillus anthracis, which causes anthrax.

At the hospital, we wondered whether we might become exposed to anthrax and how it could be prevented or treated. We quickly escorted the patients who had been exposed to white powder safely away from others to be examined by physicians.

Fortunately, our patients hadn’t been exposed to anthrax. But the letters contaminated with the agent tragically led to five deaths, and 17 more people became ill. Many others were treated with antibiotics as a precaution.

That year, 2001, was a turning point in our nation’s readiness for public health emergencies, including those that result from deliberate attacks or from natural causes like a disease outbreak. In particular, the U.S. government has invested substantially in medical products required for diagnosis, prevention or treatment of a wide range of threats, including anthrax. FDA is part of that national preparedness.

At FDA, we work to help ensure the availability of safe and effective medical countermeasures (MCMs). These are the medical products, including drugs, vaccines, and in vitro diagnostics (IVDs), to counter chemical, biological, radiological and nuclear (CBRN) threats, including emerging infectious diseases like Ebola.

In 2010, FDA launched an agency-wide effort, the Medical Countermeasures Initiative (MCMi), to advance and coordinate the challenging, ongoing MCM development and emergency use work that was occurring in FDA’s product centers and other offices and with other federal partners. Our most recent program update details many of FDA’s MCM achievements since that time, including important, exciting product approvals and regulatory science advances.

At the foundation of FDA’s MCM efforts is a legal and regulatory framework strengthened by Congress after 2001 with the enactment of several MCM-related laws. For example, FDA now has the authority:

  • When the Secretary of HHS declares that the circumstances justify such an authorization, to authorize the use of unapproved MCMs and unapproved uses of approved MCMs under Emergency Use Authorizations (EUAs) during or in preparation for an emergency, and,
  • For approved MCMs, to authorize emergency dispensing by stakeholders, waive certain manufacturing requirements, and extend the useful life of product held in state and local stockpiles.

As an example of our legal authorities in action, we’ve issued multiple EUAs to facilitate access to uncleared IVDs to support disease detection and diagnosis during the H1N1 influenza pandemic and for H7N9 influenza, Middle East Respiratory Syndrome coronavirus (MERS-CoV), and Ebola virus that emerged in West Africa in 2014.

Today, our nation is far more prepared than at the time of the anthrax attacks with flexible emergency legal authorities, critical MCMs stockpiled or under development, and enhanced knowledge about how to prevent or treat threats. But, as the recent Ebola epidemic and MERS outbreak show, threats both known and unknown continue to evolve or emerge and require our constant attention and vigilance.

September is National Preparedness Month. And while FDA and other agencies work hard every day to help prepare the nation for potential threats, everyone can be involved in disaster readiness. As we approach the end of Preparedness Month, here are a few things you can do now:

  • Become familiar with disasters that might occur where you live; plans for your community, workplace or school; and what HHS is doing. You can also download a variety of free disaster apps.
  • Make and test a family plan (e.g., communicating during an emergency).
  • Make an emergency kit of supplies, including medical products, you’ll need for at least three days.

Brooke Courtney, J.D., M.P.H., is Senior Regulatory Counsel in FDA’s Office of Counterterrorism and Emerging Threats.

Destroying Certain Imported Drugs: A New Rule to Protect Patients

By: Howard Sklamberg and Melinda K. Plaisier

Recently, FDA published the final rule implementing section 708 of the Food and Drug Administration Safety and Innovation Act (FDASIA). This new rule, which will take effect on October 15, 2015, provides FDA with an administrative process for the destruction of certain drugs refused admission to the United States. Why is this important? These drugs can pose a serious public health risk to consumers in the United States.

Howard Sklamberg

Howard Sklamberg, FDA’s Deputy Commissioner for Global Regulatory Operations and Policy

On July 9, 2012, President Obama signed FDASIA into law. Title VII of FDASIA provides FDA with important new tools to help the agency better protect the integrity of the drug supply chain. One of those new tools is in section 708, which grants FDA the authority to use an administrative procedure to destroy a drug valued at $2,500 or less (or such higher amount as the Secretary of the Treasury may set by regulation) that was refused admission into the United States.

The majority of refused drug products subject to FDA’s new destruction authority come into the United States via international mail. Some of these mail parcels may include one or more drugs that are unapproved, adulterated, and/or misbranded, including counterfeit drugs and drugs that purport to be dietary supplements.

These drugs can pose a serious public health threat to consumers in the United States because they:

  • might not contain the active ingredient that patients need for treatment of their disease;
  • might have too much or too little of an active ingredient;
  • might contain the wrong active ingredient; and/or
  • might contain toxic ingredients.
Melinda Plaisier

Melinda K. Plaisier, FDA’s Associate Commissioner for Regulatory Affairs

In addition, drugs that are represented and sold as dietary supplements can contain hidden or deceptively labeled active pharmaceutical ingredients, some at levels much higher than those found in FDA-approved drugs. Such products can cause harm and have been associated with serious adverse events for consumers. Other purported dietary supplements, although they may not contain harmful ingredients, are promoted to prevent or treat serious diseases but have not been proven safe and effective for that purpose.

Prior to this rule, drugs imported via an International Mail Facility (IMF) that were refused admission because they appeared to violate the law were generally sent back to the U.S. Postal Service (USPS) for export. There has been little deterrence to prevent sellers from sending drugs that violate the law or resending previously refused drugs into the United States via the IMFs to circumvent import regulatory systems.

In fact, some of the parcels returned by USPS were resubmitted for entry into the United States by the sender, with the sticker indicating prior refusal by FDA still attached and visible. This new rule allows FDA to better deter such importation by having an administrative process in place to destroy a refused drug. Rather than returning the drugs to the sender, these drugs will be destroyed. Compared to the volume of entries at IMFs, the agency has limited on-site resources. By deterring violative imports and re-entry attempts, this new process will allow the agency to more effectively focus its limited resources.

Under the final rule, FDA will provide the owner or consignee of the refused drug with written notice and an opportunity to appear and introduce testimony to the agency prior to the destruction. If the drug is destroyed, section 708 provides that the owner or consignee is responsible for the costs of storage and disposal of the drug. However, FDA generally does not intend to pursue recovery of storage and disposal costs against individual consumers who seek to import a drug for their own personal use that is then refused and destroyed.

By enabling FDA to destroy certain drugs, this important action will allow FDA to continue to protect and promote public health.

You can look up the current status of any FDASIA deliverable and sign up to receive Title VII updates using FDASIA-TRACK.

Howard Sklamberg is FDA’s Deputy Commissioner for Global Regulatory Operations and Policy.

Melinda K. Plaisier is FDA’s Associate Commissioner for Regulatory Affairs.

Another tool helping developers navigate the difficult road to approval of drugs for rare diseases

By: Jonathan Goldsmith, M.D., F.A.C.P.

If you personally know 100 people living in the U.S., chances are that almost 10 will suffer from some form of a rare disease. If that makes it sound like rare diseases are not actually very rare in this country, that’s because there are 7,000 different rare diseases, 80% of which are caused by faulty genes. A rare disease is defined as a condition that affects fewer than 200,000 people living in the U.S., a country with almost 320 million people. When we do the math, it turns out there are roughly 30 million Americans who suffer from a rare disease. And sadly, about 50% are children.

Dr. Jonathan GoldsmithWith the vast majority of rare diseases still without FDA-approved treatments, we have recently released a new resource for drug developers — a draft guidance document — designed to help them navigate the difficult and unique challenges of developing and bringing to market new FDA-approved drugs to treat rare diseases.

When it comes to finding ways to test new treatments for rare diseases, we often cannot rely on the same methods that we use for testing treatments for more common, well-known diseases, such as diabetes or high blood pressure. Here’s why: In rare diseases, new drug development is especially challenging due to the small numbers of people affected by each disease, the lack of medical understanding of the disorder (because relatively few people suffer from it), and the lack of well-defined study results (endpoints) that can demonstrate that a potential treatment for a rare disease is safe and effective.

The new draft guidance is intended to help drug developers create more accurate and timely drug development programs by encouraging

  • a focus on understanding a disease’s “natural history,”
  • creation of study designs with clinically meaningful endpoints,
  • development of evidence needed to establish safety and effectiveness,
  • and the establishment of drug manufacturing specifications to ensure quality.

It is also important to note that FDA regulations provide flexibility in applying regulatory standards because of the many types and intended uses of drugs. Such flexibility is particularly important for treatments for life-threatening and severely-debilitating illnesses and rare diseases.

Our guidance document will help us build on the gains we’ve made in helping patients with rare diseases. Since the passage of the Orphan Drug Act in 1983, the number of new requests for orphan designation has continued to rise. In 2014 we saw 469 requests, the highest number of new requests in one year. Also in 2014, an unprecedented 41 percent of all novel new drugs (17 of 41) approved by FDA’s Center for Drug Evaluation and Research were for the treatment of rare diseases.

Our guidance document is intended to encourage drug developers to think early on in the process about all aspects of their program — and encourages careful planning which includes a foundation in strong science. Drug developers for rare diseases are often pioneers. Pioneers need maps and tools to guide them. We see this guidance as another important resource to help support their efforts.

FDA is committed to working with all drug developers and stakeholders to establish successful drug development programs that include regulatory flexibility, creative approaches and a scientifically sound basis.

Jonathan Goldsmith, M.D., F.A.C.P., is FDA’s Associate Director, Rare Diseases Program, Center for Drug Evaluation and Research

Welcoming FDA’s New Overseas Leaders: FDA’s Foreign Posts Provide a Vital Resource for Consumer Protection

By: Howard Sklamberg and Mary Lou Valdez

Howard Sklamberg

Howard Sklamberg, FDA’s Deputy Commissioner for Global Regulatory Operations and Policy

It’s simple but true: relentless global commerce and interaction demand a globalized FDA. That’s why we’ve made determined efforts – sometimes with great difficulty – to place our professionals around the world in the key countries and regions that produce FDA-regulated food and medical products.

The Vital Role of FDA’s Overseas Offices

Our foreign offices add an unsung, yet vital, element to the Agency’s global work. FDA posts in China, Europe, India, and Latin America, in close cooperation with FDA Centers and the Office of Regulatory Affairs, help to strengthen our ability to protect public health. Our foreign posts assist by:

  • Increasing our knowledge and appreciation of the global regulatory landscape;
  • Facilitating collaboration with foreign regulators to strengthen evidenced-based approaches to product safety and quality; and
  • Helping manufacturers in other countries to understand FDA standards and regulations.

Equally important, placing investigators in a top-exporting nation allows us to get to a site more quickly in a public health emergency or investigate indications of violations that could imperil public health.

Recent Accomplishments

The Latin America Office has deepened FDA’s ties with the regulatory partners in the 44 nations and territories comprising that vast region. For example, Mexican regulators have followed up on FDA inspection results and have taken immediate actions against firms and products that violate U.S. and Mexican law. Through a 2014 bilateral Statement of Intent, our Latin America Office is helping to implement a Produce Safety Partnership with Mexico, which is vital inasmuch as nearly one-third of FDA-regulated food products we eat are either grown in or transported through Mexico.

Lou Valdez

Mary Lou Valdez, FDA’s Associate Commissioner for International Programs

Thanks to the work of our China Office, FDA signed two Implementing Arrangements in late 2014 with our Chinese food and drug regulatory counterparts: the China Food and Drug Administration and the Administration of Quality Supervision, Inspection and Quarantine. The arrangements expand the number of in-country investigators and significantly increase FDA’s ability to perform inspections of firms that manufacture FDA-regulated products. We also work closely with Chinese officials to help strengthen the Central/Provincial inspectional roles to ensure product quality and safety and better secure supply chains.

The India Office regularly engages with Indian regulators and industry. India is a major source of generic drugs imported to the United Sates and, as such, we work closely with them on pharmaceutical quality. India also is the 7th largest supplier of food to the United States – principally shrimp, spices, and rice. Recently the India Office played a key role in coordinating a Memorandum of Understanding on Food Safety that FDA signed with the Export Inspection Council of India. The India Office also hosts a number of workshops to increase understanding of U.S. requirements such as records management with industries interested in exporting their products to the U.S.

The Europe Office has continued to enhance FDA’s partnership with the European Medicines Agency (EMA), with whom we actively share data, information, and technical expertise. Since 2009, FDA and EMA have strengthened collaboration through the exchange of dedicated liaison officers and by engaging in mutual scientific interests in such areas as advanced medical therapies, biosimilar medicines, blood products, orphan products, and veterinary medicines. In addition, Europe Office professionals have briefed nearly a dozen European Union (EU) nations on the landmark Food Safety Modernization Act, and have also analyzed more than 150 audit reports from the EU’s Food and Veterinary Office to bring FDA expertise to food facility site selection.

The European Office plays a key role in the Mutual Reliance Initiative (MRI), an important FDA-EU endeavor to evaluate our comparable regulatory frameworks for inspections of manufacturers of human pharmaceuticals to determine if we can rely on each other’s inspectional information. The MRI has led to FDA accompanying EU officials on audits of three EU nations. The Europe Office also managed an EU audit of FDA’s oversight of the Active Pharmaceutical Ingredient (API) manufacturers within the U.S. That exchange led to the EU relying on our oversight, and allowing U.S.-made APIs into the European market.

New Leaders at Our Overseas Posts

We can look confidently toward the future and the roles our foreign posts can play in support of the FDA mission globally. It is with an eye on that future that we are marking “a changing of the guard” as we welcome new Office Directors and Deputy Directors to FDA foreign offices.

We extend a warm welcome to:

China Office

Leigh Verbois, Ph.D., Director 

Europe Office

Donald Prater, D.V.M., Director

India Office

Mathew Thomas, M.B., B.S., Director

Latin America Office

Edmundo Garcia, Director, Director

Capt. Philip Budashewitz, Deputy Director

We also share our deepest gratitude as we say good-bye to an outstanding group of foreign post directors who are moving on to new opportunities: Christopher Hickey, Ph.D., (former Director, China Office), Carl Sciacchitano (former Acting Director, India Office), Michael Rogers (former Director, Latin America Office), and Bruce Ross (former Deputy Director, Latin America Office).

Howard Sklamberg is FDA’s Deputy Commissioner for Global Regulatory Operations and Policy

Mary Lou Valdez is FDA’s Associate Commissioner for International Programs