Warning Letter: Midwestern Pet Food (MARCS-CMS 613845 — AUGUST 09, 2021) – Dead Puppies Aren’t Much Fun

Dogs teach us so many things. My first time dog sitting, I learned the difference between an asthmatic pug wheezing and preparing to vomit. Two days in and I could go from a dead sleep to holding him over the tile in three seconds. Sometimes, dogs vomit because they decided to eat the outcome of the last “why did the chicken cross the road joke”, and then they’re fine. Sometimes, dogs vomit because Midwestern Pet food sold you dog food with aflatoxin in it, and then they die. In that case, dogs teach us not to trust food with “holistic” in the name.

Figure 1. Vomiting is just (aflo)toxins leaving the body

The FDA got involved after more that 110 pets died of aflatoxin poisoning after eating certain pet food manufactured by Midwestern Pet Foods. Aflatoxins are mycotoxins, toxic compounds produced by mold1 . Aflatoxin poisoning causes the overactivation of the inflammatory response, damaging the liver. This causes side effects ranging from sluggishness and vomiting to convulsions and death. Aflatoxins can also be inhaled and absorbed through the skin, mainly a concern for the workers handling infected food grains2. Contaminated dog food isn’t likely to hurt a human scooping it out with their hands, but I’d recommend not snorting the powder at the bottom of the bag.

How does a well established3,  multimillion dollar company end up with aflatoxin, a very well known and extremely dangerous toxin, in its products? Midwestern pet food has a quality control department, and they tested for aflatoxins, presumably only releasing lots within allowable limits. Switching suppliers and disposing of tainted raw materials that failed aflatoxin testing is way cheaper than decontaminating every piece of equipment that it comes into contact with in the facility. Managers with site-wide production bonuses are VERY protective of their manufacturing lines, because a weeklong shutdown to disassemble and disinfect every piece of equipment that tainted materials came into contact with can wreck a plants profits for the year. So they wouldn’t allow contaminated materials to be used on their equipment. 

The company as a whole has no incentive to sell tainted batches, because even trashing a million dollar batch is cheaper than the negative press and government scrutiny that comes with a giant public health hazard. And yet, the FDA found almost 30 times the allowable limit of aflatoxin in their products, leading to a very public warning letter stating that there is a “reasonable possibility that a regular diet of such food will be fatal or injurious to the health of the pet.” Hard to PR your way out of that.

Aflatoxin was found in products across FOUR separate plants. This was not a single contamination event, but an inadequate company wide policy. A submitted food safety plan (the same for all affected plants) identified aflatoxin in incoming corn as a possible safety hazard. Destroying Aflatoxins requires temperatures of 300°C, so instead of mechanically destroying any possible aflatoxin, the decision was made to test all materials for aflatoxin contamination. The warning letter states Midwestern pet food “failed to follow proper sample preparation procedure … that your facilities reported as being followed. This led to potentially inaccurate analyses and test results for sampled products.

Aflatoxins are small (molecular weight < 1000), and have diverse chemical structures, with four major types. They also are tested for in a variety of different matrixes (the sample being tested, such as corn, wheat or dog food). This makes them hard to create robust testing methods for.

Figure 2. Every quality control scientist’s worst nightmare

Because aflatoxins are present in complex matrixes, sample preparation is one of the most important steps in their detection. A sample of dog food would be ground, mixed with the extraction solution (70:30 Methanol:Water), and then filtered and tested. Normally, you would compare the sample that you are testing to a sample that you know has aflatoxins in it, that underwent the same treatment as the sample. However, you can’t buy dog food with aflatoxin in it to compare your sample to. Instead, you buy pure aflatoxin and test that along with your sample. But if the sample preparation process doesn’t successfully extract aflatoxin from dog food, then there is no aflatoxin in the sample tested, but there could be aflatoxin in the dog food. That test would be negative for every product tested, even if there was aflatoxin in the dog food.

To prevent this, test methods should be validated (proven to work) on each individual product, proving that the sample preparation method actually removes any aflatoxins from the sample. But this is time consuming and expensive. To prove the sample prep could remove aflatoxin from dog food, a sample of each product would have to be incubated with a specific species of mold (so that it would have aflatoxins in it), and then tested repeatedly. Buying a kit off of the internet is fast and cheap. Proving it actually detects aflatoxins in your products is time consuming and expensive. 

Of course, then the FDA tells the entire world “your facilities failed to follow proper sample preparation procedures… that your facilities reported as being followed. This led to potentially inaccurate analyses and test results for sampled products.” It doesn’t take a consultant to tell you that validating your test methods is looking like a better and better deal.( but if you want to pay me six figures to tell you shit you already know, I could make some time)

Figure 3. What I do all day

It’s tempting to blame the dead dogs on lazy quality control testing leading to false negatives. But contaminated products are never simply a failure of quality control testing, but a failure of each step in the supply chain. Manufacturing didn’t mechanically destroy any possible aflatoxins in the raw materials, so they ended up in the products. By the time quality control finds (or doesn’t find) toxins in your finished product, you have bigger problems than just discarding one batch and papering over the holes in your process. Companies have to go back to their manufacturing process and figure out how to prevent issues from occurring in the first place.

I’m not trying to rag on Midwestern pet food specifically. Companies (even ones that don’t lowkey murder puppies) sometimes have contamination issues. God knows I’ve given myself food poisoning more times than I’ll admit to. But I’m poor, and Midwestern is worth 500 million dollars. I wouldn’t eat the same sketchy takeout more than once, but Midwestern kept producing batches after they knew they had a problem, without updating their manufacturing processes. Midwestern pet food eventually pulled multiple products over several months, each with aflatoxin contamination. Nobody wants to hear that the site is going to have to shut down for a week to clean every piece of equipment that came into contact with a contaminated batch, but nobody wants a dead dog either.

TL;DR: validate your methods or the puppy gets it

Figure 3. Look at him!

1Specifically, Aspergillus flavus, which grows on grains such as corn, wheat and peanuts which are used in dog food

2If Midwestern thought recalls and pet death lawsuits were expensive, wait until OSHA gets ahold of this

3Midwestern was founded in 1926

Allay Pharmaceuticals, LLCMARCS-CMS 609023 — JANUARY 27, 2021: FDA Mad Libs

When the FDA publishes warning letters, it redacts proprietary company information. This leaves me to guess at what it stands for. 

Allay pharmaceuticals recently earned a really nasty letter for their PPQ (process performance qualification) batches. When manufacturing drugs, sometimes ingredients are mixed together. During process performance qualification (PPQ)1,  manufacturers have to prove that the ingredients are mixed evenly. To do this, they mix the ingredients and take samples at several time points during mixing (say five, ten and fifteen minutes). After they mix the ingredients enough, they take samples from the top, middle, and bottom of the container they were mixed in. Then, they test them to make sure they all have the same concentration of the active drug. If they do, great! They have mixed it enough, and they can move on to actually making the product. If they don’t, they have to do it again. This is expensive. Manufacturers are required to make three passing PPQ batches before they can make drugs that will go into people. Each one has the real (expensive) drug product in it, and each has to be discarded afterwards. Failing PPQ batches are a big deal.

From this warning letter:

During your process performance qualification (PPQ), blend samples were (b)(4) before analysis. When samples are (b)(4), it potentially masks the variability of your blend. 

Test methods, including sample preparations, are proprietary information, so the FDA had to redact all of the details. I’m pretty sure (b)(4) is mixed. As in, during sample prep the blend samples were mixed before they were analyzed. Manufacturing pulls way more sample that you need for testing at each step2. Each sample would be tested in triplicate. So before testing, the scientists were mixing the bulk sample before pulling out three aliquots. That they were then testing for homogeneity. So the sample they tested would be more mixed than the bulk product they were supposed to be testing; which would “potentially mask the variability of your blend”. 

The FDA took samples from the PPQ lots. Three samples did not have enough of the active drug, and one sample failed content uniformity.  This is a big deal because it means that the manufacturing process can’t evenly distribute the active drug into the individual tablets. So some tablets have more of the drug than stated, and some have less. This is a huge risk to the patient. Allay Pharmaceuticals is going to have to recall a bunch of lots off the market, redo all three of their PPQ batches, and somehow assuage their shareholders. Couldn’t be me!

TL;DR: If the sample isn’t representative of the product, it doesn’t matter if it passes3

FOOTNOTE 

1making sure a manufacturing process works right

2as a backup and because it’s easier to measure larger amounts 

3See also, “why is everyone so upset that the freezer is down?”. If a sample melts and refreezes, it’s not the same as the bulk product. Then you have to request a new sample from manufacturing, and they’re judgey as hell. 

“Why do you need a new sample, again?”

“Because a hurricane knocked the power out and the freezer went down. I do not control the weather, Linda.”

A CHRISTMAS MIRACLE

I’ve been informed that the FDA has APRROVED using all of the vaccine in a vial, instead of only giving the number of doses in the instructions and trashing the rest. They did it, the crazy bastards.

One day there’s going to be a hallmark movie about a maverick FDA agent who tweeted this in time to save Christmas, vaccinate Grandma and get the girl. I look forward to sleeping through it.

Under Promise, Overfill

Merry Christmas, everyone! Especially to the twitter user who suggested we use more saline to reconstitute the vaccine. To get more doses from a vial, you see. Frothing at the mouth and gnawing on my lab notebook1 really gets the old heart pumping. Makes up for the exercise I haven’t been getting, between the zoom holiday parties and 50 hour workweeks. I’m getting old but midnights spent supporting manufacturing never change.

In happier news, there’s mysterious extra doses in coronavirus vaccines! It’s a Christmas miracle, yes?

Nope, just a quirk of manufacturing. Manufacturers routinely overfill vials to account for product lost to the dead space in needles and remnants on vial walls. From experience2, I’d expect 110-120% of the label claim3. The Pfizer vaccine comes as 0.45 mL of the concentrated vaccine, and is mixed with 1.8 mL saline to dilute it down to the proper concentration. With 2.25 mL of product for 1.5 mL worth of doses (5 doses of 0.3 mL) you could easily squeeze another dose out of a vial4. This could increase the number of available vaccine doses by 20%!

If, of course, the FDA doesn’t make this illegal while fretting that they only approved the vaccine for five doses a vial. On the bright side, if I die of covid before I get the vaccine, at least I won’t have to test extractable volume anymore.

TL;DR: God Bless Us, Every One

1My boss is going to have to deal with that paperwork. Deviation: analyst obscured raw data with saliva. Preventative Action: analyst deleted twitter

2Many hours spent verifying there are at least 0.5mL of drug product in a 0.5mL vial. Testing the extractable volume is only exciting during development work, by the time the product is ready to go into people manufacturing has the fill volumes on lock. Still, always entertaining to watch the brass try to justify keeping a batch that only has 0.4 mL of product in the vials, but is supposed to have 0.5. Can’t get blood out of a stone, and can’t get 0.5 mL out of those vials.

3How much medicine the manufacturer claims is in the vial / what the label says

4Trying to take two extra doses (7 doses/vial), isn’t possible because trying to get a 0.3 mL injection out of a vial with 0.45 mL of liquid in it is very difficult, almost certainly shorting the last patient

Front Door Pharmacy, ect. all: The List Goes on and on

Sometimes when I’m waiting for test results I daydream about the FDA talking real slow to explain to some Ivy league VP that if you put an opened drum of sterile wipes out on the loading deck, THEY’RE NO LONGER STERILE. Yes, Chad, even if they look fine. Yes, Chad, even if it’s, like, super convenient. I guess you gotta have someone to blame when the FDA comes around.

And now for this week’s sterile manufacturing hall of shame:

Dirty “sterile” equipment:

  • Front Door Pharmacy, LLC dba Pure Pharmacy, MARCS-CMS 608461 – clean room had “visibly dirty equipment”
  • Randol Mill Pharmacy MARCS-CMS 610545 – “visibly dirty surfaces” in sterile manufacturing areas

These are observations from routine FDA audits. Which happen once every 3-4 years, and are announced about six months in advance. If this is what’s going on when the FDA is there, I don’t even want to know what’s happening when they’re not1.

Using non-sterile cleaning products on sterile equipment:

  • Front Door Pharmacy, LLC dba Pure Pharmacy, MARCS-CMS 608461 (again) -“used unlabeled bottles of non-sterile (b)(4) and non-sterile (b)(4)2 to disinfect” sterile areas
  • Stemell Inc, MARCS-CMS 579013 – non-sterile disinfectants and non-sterile wipes used in sterile areas

Use sterile cleaners for sterile equipment! If you put sterile wipes somewhere that isn’t sterile, they’re not sterile anymore! It’s not rocket science!

Bonus: Straight up lying:

  • Akorn, Case# 55891 – “entries in sanitization records state that all required sanitization steps were completed in cleanrooms, many steps were actually skipped, and various pieces of equipment were not sanitized.”

Honestly I gave up after that, because it got too depressing. I believe in modern medicine, and as I’ve said before, I don’t want to put anyone off it because of what you read here. Of course, the cat hair in an Etsy seller’s essential oils gets rubbed on your skin, not injected into your spine. But hey, I still eat sausage. Best not to look too close, maybe.

1a lie, but you get the point

2proprietary information, but probably bottles of bleach and Clorox wipes

Franck’s Pharmacy, FLA-12-38: Was Blind, but Now I See

People see via numerous complex, delicate structures in the eye. Even small amounts of inflammation could damage a critical part, and once it’s broken it’s impossible to fix. To prevent this, eyes have immune privilege, which means that local inflammatory response is inhibited by blocking the activity of immune-competent cells. Instead, eyes are protected from infection by physical barriers like the blood retinal barrier. This prevents the flow of cells and bacteria in and out of the eye. Immune privilege preserves vision at the cost of a lowered defense against infections.

Anything that breaches the physical barriers of the eye can bring bacteria that would have free reign over the immunocompromised eye. Would you hope that eye injections were made in a nice clean area, perhaps away from cockroaches? Do I have news for you.

Before we go any farther, where is it OK to inject bacteria?

Figure 1. for the assholes at Franck’s pharmacy

Surgeons sometimes inject dye into the eye during surgery to visualize complex, transparent tissue. In this case it was Brilliant Blue G. At the time1 , Brilliant Blue G had not been approved by the FDA for this use,  so it was only available  in formulations not suited for eye surgery. Namely, sterile (see figure 1). Doctors could prescribe the formulation they needed off label, but were unable to source it from drug manufacturers. They turned to compounding pharmacies, who could make the formulation for individual patients. Things are going great and everybody’s making money, until patients start going blind. A total of 47 people would have partial or complete blindness from the Brilliant Blue G used in their surgeries.

The FDA investigated Franck’s pharmacy and found numerous breaches of sterile techniques, and “dead insects on the light panel “ above the sterile hood. They concluded that “This drug (brilliant blue G) consists of … filthy, putrid, or decomposed substance”, and “furthermore … all sterile drugs compounded by your firm … may have been contaminated by filth”.

The FDA managed to genetically match the species of bacteria (Fusarian incarnatum esquiti) found in patients’ eyes to bacteria found in samples of Brilliant Blue G injections. That’s incredibly specific, and almost guarantees the source of the infection was Brilliant Blue G. Agatha Christy never wrote a smoking gun this dramatic.

Animal Taxonomy Lesson for Kids: Levels & Diagram | Study.com

Figure 3. A quick biology refresher

Compounding pharmacies make custom formulations of medications for individual patients. For instance, a child might need a lower dose, or a patient might be allergic to a drug ingredient, like lactose or gluten. Compounded drugs are not FDA-approved, which means this pharmacy was not regularly audited by the FDA. Compounding pharmacies are exempt from current Good Manufacturing Practices (cGMP), the regulations that insure the safety, purity, and potency of drugs sold by drug manufacturers2. This is important because cGMP requirements require serious money, equipment and manpower to meet, and is well outside of the reach of the average pharmacist.

 Two things allow compounding pharmacies to weasel by without following these requirements. Fist, they only mix drugs and ingredients that have already been FDA approved and made under cGMP requirements. Second, drugs are were made for individual patients with prescriptions, so the risk to the public is lower3. These exceptions exist because no drug manufacturing company could afford to make a special formulation for an individual patient. If compounders couldn’t do it, it wouldn’t get done4

Mass drug manufacturing (as well GMP laws) are both relatively new. Before the 1900’s, almost all drugs were made in compounding pharmacies, for individual patients. If enough people got sick from a pharmacist, they just got together and ran him out of town. The rise of mass drug manufacturing, along with several tragic case studies5, led to the creation of the modern day FDA. Compounding manufacturers were grandfathered in, with 1938 rules exempting compounding pharmacies from most FDA scrutiny.

Frank’s pharmacy settled for millions and promptly went out of business to avoid paying. This incident, along with the fungus in the spine injection guys (more on that later, but fuck those guys) lead to the passage of the Drug Quality and Security Act, which gave the FDA more control over compounding pharmacies. On one hand, this act was a transparent power grab by the FDA. It would spark a chain of lawsuits claiming the FDA was overreaching by regulating the compounding of medications. On the other hand, cockroaches in eye injections.

I’m a card carrying, thanksgiving ruining libertarian, but the older I get, the more leeway I’m willing to give the FDA. The FDA wants to regulate fish oil? Well, they probably have a good reason. Free market principles don’t apply to drug production. Customers cannot make informed decisions about the purity of the drugs they buy. How could a patient possibly know that their sterile drugs are not, in fact, sterile?  It takes years of industry knowledge to be able to identify, much less anticipate, these types of problems. Not all of them are as obvious as cockroaches in the clean room.  

TL,DR: You can’t free market drug production

1this occurred in 2012, the drug would be approved for eye surgeries in 2019

2oh god the paperwork

3consider that the time Pfizer had carboard in their sterile injections. About a hundred thousand doses were impacted

4under cGMP requirements, each new formulation must be expensively extensively tested before it can be sold. A 500,000$ quote for the work to make a new formulation GMP compliant would be a hell of a deal

5The most famous incident was Elixir Sulfanilamide, which in 1937 was made with the poisonous solvent diethylene glycol, killing 107 people