New vaccines for Tuberculosis

Current and future perspectives

Jelle Thole

Tuberculosis Transmission

Tuberculosis in the worldAccording to latest WHO data, in 2006:

14.4 million prevalent cases of TB 9.2 million new cases, 0.7 million in HIV-positive

people 1.7 million TB-related deaths, 0.2 million in HIV-

positive people 0.5 million case of multidrug-resistant cases (MDR-

TB)

Drug resistance and TB/HIV co-infection are keybarriers to progress

Estimated numbers of new cases, 2006

No estimate0–999

10 000–99 999100 000–999 999

1 000 000 or more

1000–9999

Estimated number of new TBcases (all forms)

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the WorldHealth Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or

boundaries.Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

© WHO 2006. All rights reserved

Worldwide Distribution of New TB Cases, 2006

New TB cases per 100,000 population in 2006

No estimate0-24

50-99

100-299

300 or more

25-49

TB/HIV Coinfection

TB is the most common presenting illness among peopleliving with HIV on ARV treatment worldwide

TB is the leading cause of death among HIV positiveindividuals in Africa

85% of 217,000 people that died of HIV associated TB in2006 people lived in Sub-Saharan Africa

At least 1/3 of the 33.2 million people living with HIV arealso infected with TB and have a greater risk ofdeveloping TB disease (5-10 % annually)

Estimated HIV prevalence in new TB

cases, 2006

No estimate

0–4

20–49

50 or more

5–19

HIV prevalence in

TB cases, (%)

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on th e part of the World Health

Organization concerning the legal status of any country, territo ry, city or area or of its authorities, or concerning the delimi tation of its frontiers or boundaries.

Dotted lines on maps represent approximate border lines for whic h there may not yet be full agreement.

! WHO 2006. All rights reserved

Drug Resistance: Multidrug-resistant TB (MDR-TB) Drug-resistant TB is widespread and found in all 81

countries recently surveyed by WHO. Multidrug-resistant TB (MDR-TB) does not respond to the

standard six month treatment using first line-drugs (i.e.resistant to isoniazid and rifampicin).

MDR-TB can take up to two years to treat with drugs thatare more toxic, and 100 times more expensive.

WHO estimates 500,000 new cases and 110,000 deathseach year

Highest rates in countries of the former Soviet Union andChina

Extensively Drug-Resistant TB (XDR-TB)

Extensively drug-resistant TB (XDR-TB) is defined as MDR-TB plusresistance to any fluoroquinolone and any of the second-line anti-TBinjectable drugs: amikacin, kanamycin or capreomycin).

40,000 new cases of XDR-TB each year 45 countries with at least one confirmed case of XDR The true scale of the problem remains unknown in some pockets of

the world. Only six countries in Africa—the region with the highest incidence

of TB in the world--were able to provide drug resistance data forthe latest WHO surveillance report.

Other countries in the region could not conduct surveys becausethey lack the equipment and trained personnel needed to identifydrug-resistant TB.

MDR-TB and XDR-TB are highly lethal in people living with HIV --studies show case fatality rates of over 90%.

Calmette & Guérin(1906-1921) Attenuated M. bovis First used in 1921 1928 recommended

for wide spread useby League of nations

Widespread use after1945

Most widely usedvaccine

BCG Vaccine

AERAS GLOBAL TB VACCINE FOUNDATION

British School ChildrenBritish School ChildrenBritish School Children

S. India (Madanapalle)USA (Georgia & Alabama)S. India (Chingleput)USA (Georgia Children)

USA (Chicago Infants)Puerto Rico (Gen. Pop.)

N. American Indians

Brazil (Sao Paolo)Argentina (Buenos Aires)Brazil (Belo Horizonte)Cameroon (Yaounde) Canada (Manitoba Indians)

Surinam (Rangoon)Sri Lanka (Colombo)Colombia (Cali)Argentina (Santa Fe)

Togo (Lome)Thailand

Indonesia (Jakarta)

Vaccine Efficacy (%)-900 -500 -300 -100 0 20 40 60 70 80 90 Population

Variable Efficacy of BCG vs. Pulmonary TB

Genealogy of BCG vaccines

Brosch et alPNAS, 2007,104: 5596

Variable efficacy of BCG

Genetic variation in BCG strains Genetic variation in populations Differences in virulence between TB strains (eg.

Beijing) Protection against endogenous infection but not

exogenous re-infection Interference by non-tuberculous mycobacteria (eg.

M.avium) Interference by concurrent parasitic infection (Th2

–induction)

Current vaccines against TB

One vaccine, BCG,reduces risk of severepediatric TB disease

Variable protectionagainst adult pulmonaryTB, which accounts formost TB worldwide

Risk of disseminatedBCG in HIV positiveinfants

Exposure to infectious particles

No Infection (70%) Infection (30%)

Early Progression

1-2 years (5%)

Resistance

(

95%)

Late Progression

Lifetime (5%)

Resistance (95%)

Preventionof Latency

Differential Vaccines

Prevention ofReactivation

(Improved)prevention ofinfection and

disease

Therapeutic Vaccines

New TB Vaccines

Identify “protective” immune response duringinfection and disease

Identify antigens involved Design a vaccine capable of inducing a

protective response

Immune response

No correlate of protection known

Innate:

Stimulate TLR throughadjuvants

Acquired:

(CD4) Th1 T cells (IFN-γ, TNF-α)activate macrophage to kill Mtb

CD8 T cells lyse and kill infectedcell and Mtb

Classes of Antigens

Secreted:Antigen85

ESAT6

CPF10

Latency:DosR:

Rv2029

HSP16Resuscitation:Rv3407

Stress :HSP65

HSP70

HSP16

RD antigens notpresent in BCG:

ESAT6

TB10.4

Glycolipids:

SGL

Recent adjuvants in TB

MPLA from S. Minnesotaplus QS21 from soap barktree in oil or liposomes

TLR4 signalling,

Depot

GSKBioAS01B/AS02

Antimicrobial peptide,KLK, withimmunostimulatory

oligonucleotide, ODN1a,

TLR9 signalling,

APC,

Depot

IntercellIC31

SSI

Origin

dimethyldioctadecylammonium bromide (DDA),and trehalose 6,6’-dibehenate (TDB)

TLR ?

Depot

What

DDA/TDB

VaccineNonclin Phase IIIPhase I Phase II

Design of new vaccines Improve BCG

Adding antigens from RD regions (eg. ESAT6) Overexpression of antigens (Ag85) Engineering phagosome escape (Hly, Pfo)

Attenuate M.tuberculosis Deleting essential genes (eg. Phop, auxotrophic mutants)

(Viral) vector based MVA, Adenovirus, rBCG

Subunit antigens combined with adjuvants Secreted antigens (Ag85, ESAT6, TB10.4) Strong immunogens (Rv1196, Rv0125) Latency antigens (hsp16, DosR etc) Adjuvants (IC31, AS02/1B, DDA/TDB)

NLUKFRITESGEBEDKCH

SenegalGambiaEthiopiaSouth Africa

TB-VACDesign and testing of vaccine candidates against

tuberculosis: identification, development, andclinical studies

Consortium of 29 European + 4 African Partners 1-1-2004 - 31-12-2008 17 mE EC FP6, and 1.8 mSF OFES

Project overview

Discovery and Preclinical Development

5 new vaccine candidates (live and subunit) 15 candidate surrogate markers 3 candidate adjuvant molecules Preclinical animal models

Vaccine efficacy immunogenicity Safety Post-exposure

> 50 publications; >10 IP

BCG::RD1

BCG::RD1 gives betterprotection

Overcomes inhibition ofprotection to BCG afterpre-exposure to M.avium

BCG::RD1 more virulentthan BCG in SCID

Protective Capacity rBCG ΔureC-HlyChallenge “Beijing“ (200 CFU 120 d post vaccination)

0 50 100 150 200 2502

3

4

5

6

naiveBCG PasteurBCG P ΔureC-Hly

time post challenge [day]

log

CFU

Bei

jing

/ lun

g

* Δ log = 2.3

* Δ log = 2.1

Δ log =2.3Δ log = 2.1

Grode et al., J Clin Invest. 2005 Sep;115(9):2472-9.

M. tuberculosis::PhoP

Signal Transduction Systems enable bacteria to detectenvironmental stimuli and respond to them

P

ATP

ADP

11 TCSs in M. tuberculosis

limited number of TCS when comparedwith other bacteria

Sensor Protein

Transcription Factor

Attenuation by deletion of PhoP gene

Nonparametric Survival PlotKaplan-Meier Method

Time post-challenge (days)

0 20 40 60 80 100 120 140 160 180 200

% s

urv

iva

l

0

20

40

60

80

100

M. Tb/PhoP

M. microti/RD1

BCG-MVA/85-FP/85

DNA-BCG

rHly/ureC BCG

TT-LAM/L3

BCG

Saline

SurvivalSurvival

- BCG

- Mtb PhoP

- BCG MVA/85A - FP/85A

- Saline

Survival of guinea pigs up to 26 weeks post high-dose (500CFU) aerosolchallenge

Geneva meeting: WHO, Aeras, EMEA, FDA

CryoTEM picture of LipoVac liposomesCryoTEM picture of LipoVac liposomes

Cationic liposomes+

Immunomodulator

Stable formulation based on

DDA/TDB – a novel adjuvant for theefficient induction of both cell-mediated

and humoral immune responses

Long-term immune responses and protection

with Ag85B-ESAT6 in DDA/TDB

Frequency of IFN- ! producing cells*

Months post immunisation

0 2 4 6 8 10 12 14

Sp

ots

/10

6 c

ells

0

250

500

750

1000

Spleen

Naive

BCG LipoV

ac

Lo

g1

0 C

FU 3.0

3.5

4.0

4.5

5.0

Log10 CFU in lungs

Naive BCG LipoVac

Log10 C

FU

4.0

4.5

5.0

5.5

6.0

*measured by ELISPOT after restimulation with vaccine (Ag85B -ESAT-6) antigen

Naive BCG DDA/TDB

Product development teams for 6 vaccines GMP production of 2 vaccines 3 vaccines in phase I/IIa trials 3 new vaccines entering down stream

development One adjuvant entering clinical trials

(DDA/TDB) Capacity in 2 new African clinical trial sites

(AHRI, Ethiopia; Ledantec, Senegal)

Downstream development

Diablerets Feb 08

Discovery

Pre-clinicalefficacy

GMP-Production

Non-clinicalsafety

IND

file

Effective protection(mice , g-pigs, N-hu Prim)

Lot consistency-

- FormulationIncl. neonatal.

TOXstudies

As RQ

by RA

Ph1 Trials Safety / immunogenicityadults (in area of production)

PPDneg

BCGprimed

LTBI ortreated

TB

HIVinfected

Ph2a- Safety / immunogenicity ados. + infants

Adults/Ados Infants[Formulation.

Bridg.]Interference

studies

HIV posados/infants

2009-10

Ph1-Safety / immunogenicityadults (high endemicity area)

PPD neg &BCG primed

LTBI

Phase IIb Phase III

Adults/ados infant Adults/ados infants

ProductDevelopmentTeam (PDTs)

Diablerets Feb 08

Pre-clinicalefficacy

GMP-Production

TOXstudies

IND

file

Effective protection(mice , g-p, N-hu P)

DoneOK

OK

(UK)

Safety / immunogenicity(EU- adults)

PPD negBCG

primed

JAN 2004

Immunogenicity:excellent primary + secondaryresponses

Safety: low reactogenicity

0 4 12 24

MVA85A

0

250

500

750

SFC

/1x1

06 PB

MC

Response to: Ag85Aweeks

MVA-Ag85AU-OXF + IDTUK + DE

MVA live vector expressing Ag85A

BCG + MVA85A

Diablerets Feb 08

Ph2a-Safety / immunogenicity ados. + infants (AFR)

Ados/ InfantsAge de-

escalationDose

escalationInterference

studiesHIV infectedados/infants

Ph1- Safety / immunogenicity(AFR- adults)

PPD neg &BCG primed

LTBI HIV infected

Phase 2b AFR Phase 3 AFR

AdosInfants2008-12

Ados 2009- Adults 2009-12

Safety / immunogenicity(EU- adults)

PPD negBCG

primedLTBI or

treated TBHIV

infected

MVA-Ag85AU-OXF + IDTUK + DE

MVA live vector expressing Ag85A

JAN 2008

Pre-clinicalefficacy

GMP-Production

TOXstudies

IND

file

Effective protection(mice , g-p, N-hu P)

DoneOK

OK

(UK)

Diablerets Feb 08

Ph1-Safety / immunogenicity(AFR- adults)

PPD neg &BCG primed

LTBI

Pre-clinicalefficacy

(mice , g-p, N-hu P)

GMP-Production

Pre-clinicalsafety

IND

file

Effective protection

++Done- DK

(several lots)

neonatal mice

OKTOX

studies

OK

OK(NL, UK)

Safety / immunogenicity(EU- adults)

PPD negBCG

primedLTBI

Ag85B-ESAT6+ IC31 (H1)SSI + Intercell

ESAT-6Ag85B

Ethiopia

JAN 2008

Immunogenicity: good primary responseSafety: low reactogenicity

-2 0 6 12 320

250

500

750

Ag85B ESAT6 H1

IFNγ

SFU

/ 106

PB

MC

-2 0 6 12 32-2 0 6 12 32weeks

IFNγ ELISPOT

Resp. to:

Diablerets Feb 08

Trials Status Funding source

Phase 1 –trial(s) in PPD neg Done 04-05 - USA/BE GSK

Phase 1- trial(s) in PPD pos(BCG or latent TB)

Done 05-06 - CH TB-VAC & GSK

Phase 1 – trial(s) in HIV pos Planned 08 - CH GSK & TB-VAC

Completed & on-going trials – USA + Europe

Mtb72F + AS-02M72+AS02 or M72+AS01GSKBE

Ra35TbH9 39 kDaRa12

M72- AS01

Pre-clinicalefficacy

M, GP, NHP

GMP-Production

TOXstudies

IND

++ Doneseveral lots

OK OK

JAN 2008

Diablerets Feb 08

Trials Status Funding source

Phase 1 –trial(s) in PPD neg Done 04-05 - USA/BE GSK

Phase 1- trial(s) in PPD pos(BCG or latent TB)

Done 05-06 - CH TB-VAC & GSK

Phase 1 – trial(s) in HIV pos Planned 08 - CH GSK & TB-VAC

Completed & on-going trials – USA + Europe

Mtb72F + AS-02M72+AS02 or M72+AS01GSKBE

Ra35TbH9 39 kDaRa12

M72- AS01

Pre-clinicalefficacy

M, GP, NHP

GMP-Production

TOXstudies

IND

++ Doneseveral lots

OK OK

• Highly immunogenic in BCG-primedand Mtb-exposed individuals(boosting)

• Vaccine shown to be safe withacceptable local reactogenicity inBCG-primed individuals

JAN 2008

Diablerets Feb 08

Candidate -vaccines

DeveloperInitial cGMPProduction

RegulatoryAssessm.

Phase IPPD-

Phase I/IIIn PPD+

Clinical Trialsin PPD+ andHIV exposed

MVA-Ag85A,

(VV, Pr-b)UOXF Done (lot1) Done (lot1)

On-going2003-4

UOXF

Mtb72fhybrid

recAg +AS02

GSKbio Done (lot1) Done (lot1)InitiatedFeb 2004

USA

Ag85B-ESAT6

recAg + IC31

SSIplanned

TB-VAC CANDIDATE VACCINES WP6 M- 0

Planned 2007Done 2007Done 2007MP-

VPM/BPRrBCG-UreC-

Hly

2007

Ethiopia

2007

Leiden09/ 2005Leiden

Done(lot1)Done 2004SSI

Ag85B-ESAT6

recAg +IC31

2007Lausanne

2005

UOXF

Clinical Trials in

PPD+ & HIV+

09-2005Lausanne

2004-5

UOXF

Clinical Trialsin PPD+

InitiatedFeb 2004

USA

On-going2003-4

UOXF

Phase I

Clinical Trials

Pre-PDTexploratorymeetings

UNIZAR

INSERM/ULB

Mtb- PhoP

HBHA

2007EthiopiaDone (lot1)Done (lot1)GSKbio

Mtb72fhybrid

recAg +AS02

2006

Senegal

The Gambia

South Africa

Done (lot1)Done (lot1)UOXFMVA-

Ag85A,

(VV, Pr-b)

RegulatoryAssessm.

Initial cGMP

ProductionDeveloper

Candidate -vaccines

TBVAC CANDIDATE VACCINESWP6 M-42

website: www.tb-vac.org

TuBerculosis VaccineInitiative (TBVI)

Foundation to facilitate European effortstowards the development of new TB vaccines

5 March 2008

TBVI Activities

Facilitate Discovery, Preclinical and Early clinical TBvaccine development

Responsibility and Ownership of candidate vaccine withindividual project partners

Guide and Advice on development by tailor made productdevelopment teams (PDT)

Stimulate late clinical development through productdevelopment partnerships

TBVI Industry/EDCTP/AERAS/PDP

Discovery Preclinical ClinicalPhase I/IIa Phase IIb/III License/

Phase IV

Product development teams

TBVAC Vaccine Pipeline

+CNRSGL

TBDIPASBCG-RD1

+IPLHBHA

+UNIZARMtb-PhoP

+MPIIB/VPM

BCG-ΔureA-Hly

+SSI85B-ESAT6-

IC31

+GSKBIOM72-

AS01B

+UOXFMVA85A

PDTWhoVaccine Discovery Nonclin Phase IIIPhase I Phase II

Global pre and non clinical developmentpipeline

As of March 2008:• 10 Priming, Pre-exposure candidates• 17 Boosting, Pre-exposure candidates• 12 Post-exposure – immunotherapy candidates

Nine additional candidates scheduled forclinical trials in 2008 according to sponsors

TB vaccines in clinical trials

Subunit fusion protein of Ag85Band TB10.4 in IC31 adjuvant, toboost BCG

SSI85B-TB10.4in IC31(HyVAC4)

Recombinant BCG overexpressingAg85B, to replace BCG

UCLArBCG-Ag30

Detoxified Fragmented MTB, totreat latently infected individuals

ArchivelPharma

RUTI

Crucell

SSI

GSKBio

UOXF

Origin

Recombinant adenovirus35expressing Ag 85A, 85B, 10.4 toboost (recombinant)BCG

Subunit fusion protein of Ag85Band ESAT6 in IC31 adjuvant, toboost BCG

Subunit fusion protein of Rv1196and Rv0125 in ASO1B adjuvant , toboost BCG

Recombinant vaccinia expressingAg85A, to boost BCG

What

rAd35-Ag85A,85B,TB10.4

85B-ESAT6

in IC31(Hyb1)

M72 in

AS01B

MVA85A

Vaccine Nonclin Phase IIIPhase I Phase II

ImprovedBCG

rBCG-HlyrBCG-PFOMtb-PhoP

Future TB vaccinesLe

vel o

f Pro

tect

ion

BoostMVA85A

72MH1

HyVac4Ad35/Ag85A

B,TB10.4

1950 2000 2020 2025 2030 2050

LatencyDosR

Rv3409

STOP-TB/MDG:less than1 case/million in2050

Summary and Future challenges

More TB vaccine candidates than ever before,and prospect of new vaccine between 2015-2020

Keep pipeline filled with second and thirdgeneration vaccines Vaccines (latent bacteria, improved protection) Delivery (systems/adjuvants, applications (needless)

and routes eg. ID, mucosal) Preclinical models to select for clinical development

Biomarkers and correlates of protection (Global) clinical site development