From research to clinical trials Brigitte Gicquel Institut Pasteur Coordination of TB ETHICS and TB VACCINE Cluster of the European Commission

Today, we observe an acceleration in the accumulation of knowledge: An increase of the quantity of knowledge Improvement of existing technologies (recent technologies) There is not an increase of discoveries

During the last five years, we observe an accumulation of complete sequences of major living organisms: *The complete sequence of the Human genome *The complete sequences of most pathogenic Organisms *The technologies of mass parallel analysis (transcriptome, proteome) This doesn ’t mean we can easily derive vaccines from this knowledge

During the last five years, we observe also major scientific breakthroughs: *The role of innate immunity *The biology of dendritic cells *The existence of T cell populations responding to non protein antigens (CD1 restriction) *More recently the diversity in microbial (« Beijing ») and human populations (high or low gIFN producers, IL4 differential splicing etc…) *The role of T regulatory cells

« Modern » research tends to make use of big equipements and big technical teams. This kind of research is essentially supported by big Pharma with the aim to discover new molecules and interventions for existing markets.

« Modern » research tends to make use of big equipements and big technical teams. This kind of research is essentially supported by big Pharma with the aim to discover new molecules and interventions for existing markets. There is no willingness for finding molecules to solve public health problems disconnected from any market. The aims of researchers and organisations working on Poverty Related Diseases is to benefit of existing knowledge to derive molecules useful to solve public health problems of populations disconnected from The Market

In the context of TB, several laboratories including big Pharma have produced Vaccine candidates. TB is not only a problem of DC countries. The disease is still present in any country of the world. However « The Market » is not existing yet. Now we have to test these vaccine candidates in clinical trials

90%: no disease (90%) PPD + Culture - (10%) 5%: disease within 0-2 years (  30-40% in HIV + subjects) 5%: disease during the life time (Aging, malnutrition, HIV…  Reactivation) (  2-10%/year in HIV + subjects) Alveolar Macrophage Mycobacterium tuberculosis Alveoli Immunity T lymphocyte

Macrophages Apoptotic particles Immature dendritic cells Mature dendritic cells Induction of adaptive responses Danger signals Protection Mycobacterial live vaccines Mycobacterial ligands Sub-unit vaccines and viral vaccines  T cells Clinical trials NKTcells The new consortium: TB-VAC Under negotiation with the EC CD4 T cells CD8 T cells Adjuvants The TB Vaccine Cluster

Aims of the TB vaccine cluster *To investigate different components of the immune sytem that are important in protection or disease development *To study vaccine candidates able to induce these different components 1 Vacccine candidates that have been previously isolated 2 New vaccine candidates that will be discovered during this project *To organise task forces to test vaccine candidates with standardised protocols 1 Guinea pig model (aerosol) 2 Macaque models (intratracheal) *To understand correlates of protection -> to provide parameters to follow clinical trials

Rationale for a joint initiative Industry/Academy for a research project: *The necessity to design a product that could be produced at an industrial level. Otherwise large scale vaccination is hopeless *Several biological companies have been involved in research at an early stage: ex1: Merck for DNA vaccination in collaboration with Institut Pasteur of Brussels ex2: Corixa isolated vaccine candidates in collaboration with GSK In the TB vaccine cluster: *Aventis participates in the TB vaccine cluster (production and purification of antigens) *GSK participates in the TB vaccine cluster to test adjuvants and vaccine candidates previously isolated and tested in in house animal models

4 projects *Coordinated by P. Andersen (DK): pre-clinical studies *Coordinated by C. Martin (ES): attenuated strains *Coordinated by J.-J. Fournié (F): non-protein antigens *Coordinated by T. Ottenhoff & J. Thole (NL): correlates of protection, Necrosis /fibrosis, Physiopathology analysis, Immune parameters Task forces for animal testing Advantages : *standardization of the protocols *testing by teams not involved in the discovery of the vaccine candidates Two industrial partners *Adjuvant *Production/purification of antigens

Models of Primary TB Vaccine candidates Previously isolated (tested in mice) Promising antigens In different vectors New vaccine candidates Isolated during this project Task force: Guinea pigs Task force: Macaques The macaque models: Cyno/Rhesus Mice 2 rounds completed 1 round is ongoing 1 round completed 1 round Ongoing 1 round waiting  and CD1 ligants

Survival - BCG - Mtb PhoP mutant - BCG MVA/85A - FP/85A - Saline Survival of guinea pigs up to 26 weeks post high-dose (500CFU) aerosol challenge

THE TB VACCINE CLUSTER ( ) *Sub-unit vaccine candidates that provide protection have been identified *Protection conferred by sub-unit vaccine candidates are superior to BCG in a murine model *However, in other animal models no protection superior to BCG or even equal to BCG was observed *Prime boost protocols including BCG, DNA and/or viral vectors showed protection *New attenuated mycobacterial live vaccines have been identified: *One provide protection superior to BCG in a murine model. *Another one provide protection in the murine and in the guinea pig model at least equal to BCG without additional safety concern

From the recent discoveries in immunology: Important variations between mamal species: relevence of animal models? Important variations between individuals: Different environments (ex: BCG efficacies) Different genetic backgrounds? From studies of bacterial populations: Important variations between strains: majors types i.e.W-Beijing, Haarlem, Manilla, etc…. Induce different immune responses

ELISPOT IFN-  assay PPD (p=0,1) TBHD SFC/10 6 PBMC

Importance of human systems: In vitro systems Ex vivo/in vitro systems Clinical experimentation: Study of the different populations in need of a vaccine For DC countries: *Opportunity for different countries with limited infrastructures to participate to the development of vaccines *To study the immune responses of the populations *To improve infrastructures *To establish ethical committees

Two other EC FP5 projects derived from the TB vaccine cluster have been since launched : *AFTBVAC-Development of a tuberculosis vaccine in Africa *TBETHICS-Enhancing ethical evaluation, review and monitoring in international collaborative research in tuberculosis *Other ongoing FP5 projects are providing important results for the design of pre-clinical and clinical trials Mol.Epidemiolgy TB: New generation of genetic markers and techniques for the epidemiology and control of tuberculosis *Other projects will be necessary to investigate the diversity of human responses to infection and to vaccination

Importance to study human immune responses as soon as possible To search for antigens that are recognised by human populations: Ex: SSI, GSK Production of antigens Pre-clinic studies Clinical studies

Existing knowledge Products Industries Clinical research New drugs and vaccines Pre-clinical studies NGO and Public funds The tendency: To fill the gap

Knowledge Applied research Products Industries Clinical research New drugs and vaccines Pre-clinical studies NGO and Public funds Questions Problems To solve Research

The classical flow: Research to human drugs or vaccines Questions Personal curiosity Industrial problem to solve Health problem To solve Research Preclinical Research (efficacy) Industry (Production) Preclinical research (efficacy, safety) Clinical trials Safety, responses, efficacy New drugs and New vaccines

European Research Centers and Universities DC Research Centers Health CareCenters in endemic area: DC DC Universities

Prerequisit for human testing: The existence of epidemiological data The existence of an effective National Tuberculosis Programme The tested populations must have an immediate, mid-term and long term benefit. Immediate benefit: Improvement of diagnostic laboratories Increased access of the population to diagnosis and treatment Mid term benefit: Improvement of training capacities Technology transfer Long term benefit: Access to the vaccine that will be developed

Macrophages Apoptotic particles Immature dendritic cells Mature dendritic cells Induction of adaptive responses Danger signals Protection Mycobacterial live vaccines Mycobacterial ligands Sub-unit vaccines and viral vaccines  T cells Clinical trials Different steps to investigate

Requirement of many different expertises Possibility to benefit from recent knowledge: *The complete sequences of several mycobacterial genomes *Existence of genetic tools to develop functional approaches *Biochemical characterisation of important mycobacterial compounds *Characterisation of cellular populations reacting to Mycobacterial compounds

Next step: Integration of European and African countries The problematic: *To develop vaccines to protect the population in need of such a vaccine The means: *To integrate the European and African capacities *To conduct clinical studies in Africa: *To determine the reactivities of the African human populations to vaccinial antigens *To undertake phase I trials in Africa to identify immune responses and make sure of the absence of adverse effects in populations in need of vaccination

VACSIS University College of London London School of Hygiene and Tropical Medecine Statens Serum Institute (Denmark) Institut Pasteur (France) M.R.C. (The Gambia) A.R.H.I. (Ethiopia) University of Zambia Institut Pasteur of Madagascar

The Tuberculosis Vaccine Cluster QLK2-CT

From Langermans et al. (2001) Proc. Natl. Acad. Sci. 98:

generating new vaccines protein antigens live attenuated vaccines non-protein antigens results contribute to rational selection of new candidates results contribute to rational selection of new candidates new vaccine candidates new reagents for testing immune response understanding new vaccines immune response in man and experimental models model systems for assessing immune correlates screening new vaccines experimental animal models of infection Candidate vaccines for Phase I clinical trials

Social value Economic value Vaccines Pharmaceuticals From Rappuoli R. et al. Science 9 August 2003