1. Progress in Developing New TB Vaccines Jerald C. Sadoff, MD Reversing the Tide: The End of Tuberculosis Columbia University March 7 th 2006

2. 2 Potential Impact of 50-90% Effective Vaccines Vaccines in combination with antibiotics could control the epidemic Pre-exposure or post-exposure vaccines could eliminate about 1/3 of disease and death A TB vaccine with pre- and post-exposure efficacy could achieve global control of TB Ziv et al, Emerging Infectious Diseases, Vol.10, No.9 September 2004 Lietman, T, Blower SM, Clin. Inf Dis.2000:30:S316-22 Lietman, T. Blower SM. Science. 1999:286:1300-01

3. 3 Aeras Global TB Vaccine Foundation Mission: To develop new TB vaccines and ensure their availability to all who need them Goals: - To obtain regulatory approval and ensure supply of a new TB vaccine regimen within 7-10 years - To introduce 2 nd generation vaccines with improved product profiles and efficacy against latent TB in 9- 15 years

4. 4 Foundations/Government Bill & Melinda Gates Foundation U.S. CDC, NIH, FDA DANIDA, Denmark EDCP, Europe STOP TB, WHO Academia Capetown Univ. S. Africa St. Johns, Bangalore Karolinska, Stockholm Max Plank, Berlin Leiden Univ. UCLA U.C. Davis Vanderbilt Univ. Colorado St. Univ. Harvard U. European TBVac Industry GSK, Rixenstart Belgium Crucell, Holland SSI, Denmark ImmunoBiology, UK Serum Institute, India Thymed, Germany Aeras

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9. 9 Field Site Developed in the Breede River Valley of the Boland-Overberg Region of Western Cape Province, South Africa Boland-Overberg Region Breede River Valley Ceres

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11. 11 India Site Palamaner Taluk St. John’s Medical College, Bangalore Palamaner Taluk Population of 350,000 Mostly rural ~ 3 hours from Bangalore TB incidence rate in adults of 150-200/100,000 St. Johns has long standing relationship with Emauss Leprosy Hospital in Palamner and has conducted large nutritional cohort studies in this community.

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13. 13 Incidence of tuberculosis in 11,667 BCG vaccinated infants with a smear and/or culture positive for M.tb Total TB incidence = 3.1% 2-year TB incidence = 2.7%

14. 14 Preliminary Conclusions and Approach Conclusion: Field trials of new TB vaccines feasible in this population Approach: Large cohort studies in 9000 infants and 12000 adolescents in S. Africa and India to confirm high incidence

15. 15 Basis for New TB Vaccine Development Humans are resistant to infection & disease –Only ~30% of exposed individuals are infected –Only ~10% of infected individuals get disease Human resistance related to the immune system –Humans with INFγ and TNF genetic and pharmacologic pathway defects highly susceptible to TB

16. 16 Potential Uses of Effective TB Vaccine

17. 17 Prime Boost Strategies 14 Weeks 24 Weeks

18. 18 Protection in Eight BCG Trials Trial and SubjectsDuration (years) Percent protection North American Indians (2792 subjects from 1935-1995 9-11 (60)80 (52) Chicago : infants12-2375 Georgia : school children20None Puerto Rico : population below 20 years5 ½ - 7 ½31 Georgia and Alabama : general pop.14 Great Britain : school children (54,239 subjects age 14-15 from 1950-72 1578 Mandanapalle, South India: general pop9-1431 Chingleput, South India : general population (265,172 subjects) 7 ½None Baily, G. V. J., et al, Indian Journal Medical Research 70, September 1979, pp. 349-363.

19. 19 BCG Replacements: Recombinant BCG & TB ready for Phase I rBCG30 over-expressing TB antigen 85B: Horwitz at UCLA which is not acceptable to regulatory authorities as a final product rBCGs escaping the endosome: Kaufmann at Max Planck Institute Aeras 403 rBCG – Aeras recombinant BCG combines Horwitz and Kaufmann discoveries Recombinant attenuated TB: Bill Jacobs at Albert Einstein University

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21. 21 Preliminary data from 17/30 subjects in trial

22. 22 Intracellular tropism of intracellular bacteria Courtesy of Dr. Stefan Kaufmann, Max Plank Inst. Infect. Dis., Germany

23. 23 pAF112 oriM P Ag85B Ag85AAg85BAg 10.4 rBCG Aeras 403 Strain Construction BCG Danish 1331 Pfo integration Plasmid for endosome escape AFV102 P hsp60 sacB OriE P kan Kan R ureC L-flank P Ag85B Ag85B leader peptide pfo ureC R-flank MCS ENEN pAF102 AFV112 Aeras 403 Over-expression Plasmid oriE P Rv3130

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26. 26 rBCG Vaccine - Aeras 403 New Fermentation and foam drying process developed which produces very high yield of room temperature stable vaccine Aeras factory can produce the worlds needs for bulk vaccine- 150-300 million doses/year Aeras bulk vaccine will be shipped to developing world manufacturers for foam drying, packaging and distribution Phase I clinical trials scheduled for August 06

27. 27 Prime Boost Strategies 14 Weeks 24 Weeks

28. 28 Candidates for boosting infants and adolescents in or about to start Phase I Recombinant fusion proteins in adjuvant –M72 fusionGSK/Aeras –Ag85B::ESAT6 SSI/TBVAC –Ag85B::10.4 fusionSSI/Aeras Vectored vaccines –rMVA-Ag85AOxford –rAd35-Ag85A-Ag85B-TB10.4 fusionAeras/Crucell –Oral Shigella dsRNA capsids Aeras

29. 29 rBCG prime with rAd35 Aeras 403 Booster Fold rise in CD8+T cells

30. 30 Prime Boost Strategies 14 Weeks 24 Weeks

31. 31 EM of procapsids in S. flexneri MPC51

32. 32 Completion of second strand triggers mRNA synthesis and secretion Nucleocapsid (NC) L M S P2 catalyzes synthesis of mRNA, which is passively secreted back through P4 hexamers on capsid surface for translation mRNA

33. Shigella-rdsRP vector Access cytoplasm Lysis due to  murI Release of rdsRP Invasion Nucleus Delivery of rdsRP by Shigella vectors to host antigen presenting cells Synthesis of recombinant segment-S and segment-M mRNA by RNA-dependent RNA polymerase activity of rdsRP EF2-independent translation of TB antigens Presentation of TB antigens in the context of HLA class I&II Induction of TB-specific CD4 + and CD8 + T cells

34. 34 rdsRP encoded antigen mRNA expression by HeLa cells HeLa cell 14 hr post-invasion by MPC51 carrying rdsRP LSMtb4 (85A-85B-10.4 encoded on rSeg-M) Probed with anti-85A IgY

35. 35 Mouse Dose Response/Immunogenicity Study Cellular immune responses of BALB/c mice vaccinated intranasally with varying doses of the Shigella-vectored nucleocapsid LSMtb4 (expresses Ag85A-85B-10.4 fusion) or Ad35 TBS administered IM

36. 36 Vaccine Development Timelines 2004 Preclinical Aeras Aeras 404 (oral) 2005 2006 20072008 Phase I and II Aeras 403/402 20092010 Field Site Preparation & Epidemiology Preclin. Aeras 402 & Aeras 403 Phase III Aeras 403 Prime Aeras 402 Boost Infants & Adolescents Aeras Crucell Aeras 2013 201220112014 Phase I and II Aeras 403/404 Phase III Aeras 403 Prime Aeras 404 Boost Infants & Adolescents Aeras 402 = Crucell Ad35 vectored TB vaccine Aeras 403 = rBCG with overexpression & endosome escape Aeras 404 = capsids In shigella for oral delivery

37. 37 Summary A moderately effective vaccine + drug control could virtually eliminate the TB epidemic Based on 20 years of research, a prime-boost vaccine strategy has great potential This new vaccine regimen could be licensed and available in 7-10 years The potential of rBCG prime given at birth followed by viral vector, capsid or protein boost to induce high levels of cellular immunity make this a very attractive vaccine regimen for TB, malaria and HIV

38. 38 Contact Information Jerald C. Sadoff, MD President & Chief Executive Officer Aeras Global TB Vaccine Foundation 7500 Old Georgetown Road, Suite 800 Bethesda, MD 20814 +1-301-547-2912 jsadoff@aeras.org

39. 39 Jerald Sadoff led or contributed to the development of these vaccines Licensed –Hepatitis A –Vaqta –H. Influenza conjugate –Liquid Pedvax –Varicella- 4 degree stable Varivax –Combination Hep B & H. Influenza – Comvax –Combination D, T, aP, Polio, H. Influ, Hep B –Hexavac –Measles, Mumps, Rubella, Varicella – MMRV –Rotavirus – Rotatech –Zoster – Zostovac –HPV – (license 06) –Cholera (Killed Whole cell +B -SBL) In phase IIB or III –Malaria (Army-GSK-RTSS) –HIV (Merck) –Cholera –Peru 14 –Shigella conjugate (NIH) In phase I –TB rBCG & M72