: FROM PARASITES TO PREVENTION

Global Health: Voices from the Vanguard 11 Lecture Series University of Georgia Athens, GA January 20, 2009

Stephen L. Hoffman, M.D. [email protected]

01.20.09 SANARIA 1 MALARIA

P. falciparum responsible for more deaths in children in the world than any other single infectious agent

Thousands of children will die today of malaria, an estimated million in the next year.

01.20.09 SANARIA 2 SANARIA’S PRIMARY MISSION

To develop, license, and deploy a based33 on attenuated sporozoites that reduces morbidity and mortality in infants and children in sub-Saharan Africa.

01.20.09 SANARIA 3 BEN KEAN Course in Tropical Medicine

44 Second Year of Medical School

01.20.09 SANARIA 4 SUMMER FELLOWSHIP

COLOMBIA55

Year Off in Colombia, Ecuador, Peru

01.20.09 SANARIA 5 01.20.09 SANARIA 6 Experience Tropical Medicine First Hand

77

Typhoid Fever – 10 days in the hospital Amebic dysentery x 3 Giardiasis

01.20.09 SANARIA 7 Family Medicine Residency 88

Diploma in Tropical Medicine and Hygiene LSHTM

01.20.09 SANARIA 8 JOIN THE NAVY! 99

01.20.09 SANARIA 9 THE JOY OF MAKING AN IMPACT

01.20.09 SANARIA 10 01.20.09 SANARIA 11 01.20.09 SANARIA 12 13 01.20.09 SANARIA 14 01.20.09 SANARIA SEARCHING FOR A SHORTCUT TO A 1515 CURE

15 01.20.09 SANARIA 16 01.20.09 SANARIA 01.20.09 SANARIA 18 01.20.09 SANARIA 19 01.20.09 SANARIA 20 01.20.09 SANARIA “Dad, check them for malaria.”

01.20.09 SANARIA 21 A VACCINE IS THE ANSWER 2222

Need to Retool

01.20.09 SANARIA RISKY BUSINESS-CRASH LANDING KENYA

23 01.20.09 SANARIA COMBINING BUSINESS WITH PLEASURE

24 01.20.09 SANARIA 25 01.20.09 SANARIA THE ROAD TO SANARIA • Develop subunit vaccine for malaria – Many clinical trials of PfCSP vaccine • Conclusion – Single protein vaccine not adequate for military personnel – Immunize with irradiated sporozoites • Identify targets and immune mechanisms – Better subunit vaccine – Sequence the genome of P. falciparum • Join Celera Genomics • Analyze irradiated sporozoite data

01.20.09 SANARIA 26 01.20.09 SANARIA 27 Pf IRR SPZ-Pf CHALLENGES (5-14 INFECTED MOSQUITOES)

# IMMUNIZING BITES # PROTECTED/ # PROTECTED/ # CHALLENGED # CHALLENGES

> 1000 Immunizing Bites 33/35

1st challenge 13/14 (93%) 13/14 (93%)

Re-challenge <10 wk 6/6 (100%) 15/15 (100%)

Re-challenge 23-42 wk 5/6 (83%) 5/6 (83%)

<1000 Immunizing Bites 5/15

01.20.09 SANARIA 28 INTERPRETATION

• Limited studies – 35 challenges in 14 people • Protective immunity as good as protective immunity of any vaccine for any indication.

Hoffman et al. JID, 2002 Luke and Hoffman, J Exp Bio, 2003

01.20.09 SANARIA 29 WHY NOT PURSUED PREVIOUSLY?

• Technical limitations-not practical • Discovery and cloning of perhaps “major” targets of attenuated sporozoite and naturally acquired immunity – Circumsporozoite protein (CSP) (1979) – Merozoite surface protein 1 (MSP1) and other asexual erythrocytic stage antigens (1981-1983) • By 1984 a subunit P. falciparum CSP or asexual erythrocytic stage vaccine was “imminent.” • No need to pursue attenuated sporozoite vaccine

01.20.09 SANARIA 30 RATIONALE FOR STARTING SANARIA

• Immunogen reproducibly protects non-immunes for at least 10 months. • Success based on bio-engineering, and applied entomology, parasitology, and biology. – Producing a vaccine in mosquitoes and controlling all elements of the production process • Counsel of experienced, prominent individuals. – CBER – Merck Vaccine Institute • Plan for paying for development and deployment in Africa. – Same vaccine for entire world

01.20.09 SANARIA 31 SANARIA’S APPROACH DIFFERENT

• Live attenuated whole organism – Other approaches subunit, recombinant • Prevent infection in > 90% of recipients – Other current approaches are intended to reduce parasite burden by reducing rate of infection and/or replication of parasites, and thereby the pathological effects of the parasites.

01.20.09 SANARIA 32 WHY IS SANARIA WORKING ON AN ATTENUATED LIVE PARASITE VACCINE?

Why isn’t Sanaria working on a modern recombinant or synthetic vaccine?

01.20.09 SANARIA 33 INTENDED CHARACTERISTICS OF THE VACCINE

• Prevents infection by P. falciparum in greater than 90% of recipients, – For at least 6 months without additional exposure to sporozoites – Indefinitely with exposure to sporozoites • Re-immunization • Natural exposure to infected mosquitoes

01.20.09 SANARIA 34 THIS LEVEL OF PROTECTION HAS BEEN ACHIEVED WITH ATTENUATED SPOROZOITES IN HUMANS.

This level of protection has not been achieved by recombinant or synthetic vaccines in humans.

01.20.09 SANARIA 35 WHO WILL BE IMMUNIZED TO FULFILL OUR MISSION?

• Infants in sub-Saharan Africa – Approximately 25 million born annually • Directly reduce morbidity and mortality • Pre-adolescent and early adolescent girls – New cohort of 7.5-10 million annually • Reduce fetal loss and morbidity and mortality in offspring • Travelers from non-endemic countries to endemic countries – 100 million such travelers annually • Protect travelers • Provide funds to drive optimal deployment of vaccine to the other two populations • Others – Many other populations in Africa, Asia, Oceania, and the Americas • Mass Administration?

01.20.09 SANARIA 36 LIFE CYCLE OF PLASMODIUM

01.20.09 SANARIA 37 SANARIA PfSPZ VACCINE: PROGRESS

Research & Development

Process Development

Manufacture - cGMP

Clinical Trials

01.20.09 SANARIA 38 RESEARCH AND

DEVELOPMENT3939

01.20.09 SANARIA 39 CRITICAL R&D QUESTIONS

• Can one administer the attenuated sporozoites by a route that is practical for a vaccine? – Yes • Can one produce adequate quantities of sporozoites? – Yes • Can one at a reasonable cost produce attenuated PfSPZ that meet regulatory requirements to be a vaccine? – Yes

01.20.09 SANARIA 40 MAJOR CHARACTERISTICS OF SPOROZOITES REQUIRED TO MEET REGULATORY REQUIREMENTS

• Free of pathogens – Standard FDA-mandated assays • Free of significant amounts of mosquito salivary gland material – Salivary gland material assay • Adequately attenuated – Physical and biological assays • Potent (cryopreserved) – Potency assay

01.20.09 SANARIA 41 PROCESS

DEVELOPMENT4242

01.20.09 SANARIA 42 PROCESS DEVELOPMENT

ƒ Integrated campaigns ƒ7 performed in 2006 ƒ Production campaigns (engineering/shakedown) ƒ5 performed in 2006

01.20.09 SANARIA 43 MANUFACTURING UNDER CURRENT GOOD

MANUFACTURING4444 PRACTICES (CGMPs)

01.20.09 SANARIA 44 GMP PRODUCTION CAMPAIGNS FOR TOXICOLOGY LOTS

ƒ Release assays ƒ Stability studies ƒ Toxicology studies ƒ Retention

REQUIRES A TOTAL OF 228 VIALS

01.20.09 SANARIA 45 PRODUCTION CAMPAIGNS 7-10 Toxicology Lots

Production Campaign Number

7 8 9 10 Mean

Mosquitoes 2201 1509 2146 2217 2018 dissected

Number of 301 281 360 351 323 vials produced

02.13.0801.20.09 SANARIA 46 PRODUCTION CAMPAIGNS 7-10

ƒIn Process Assays ƒRelease Assays ¾Vaccine Bulk Product ¾Vaccine Final Product (in vial) ƒStability Assays on Vaccine Final Product

01.20.09 SANARIA 47 RABBIT REPEAT DOSE TOXICOLOGY

STUDIES4848

safe and non-toxic

01.20.09 SANARIA 48 INDIVIDUAL SERA PfCSP ELISA/PfSPZ IFA 2 weeks after 4th dose

PfCSP ELISA PfSPZ IFA PfSPZ Vaccine Geometric Mean Geometric Mean Immunization OD 1.0 Titer group 49 N=24 N=24 SC 5,131 3,200

ID 55,805 51,200

01.20.09 SANARIA 49 BIODISTRIBUTION STUDIES 5050

no unexpected results

01.20.09 SANARIA 50 Team working at ‘dismal strip mall…’ National Geographic, July 2007

01.20.09 SANARIA 51 SANARIA’S NEW FACILITIES

01.20.09 SANARIA 52 NEW FACILITIES PHYSICAL PLANT GRAND OPENING 10/26/2007

We celebrated the perfect end to an early chapter in the story of the fulfillment of our mission!

01.20.09 SANARIA 53 NEW FACILITIES PHYSICAL PLANT

11/28/2007 Shakedown production campaign.

01.20.09 SANARIA 54 01.20.09 SANARIA 55 PRODUCTION CAMPAIGNS 20-25 “PfSPZ Vaccine Clinical Lots”

5656

01.20.09 SANARIA 56 EACH PC DESIGNED TO PRODUCE AT LEAST ENOUGH VIALS FOR

• Release Assays • Retention Samples • Stability Assays • The first clinical trial –100 volunteeers

01.20.09 SANARIA 57 PRODUCTION CAMPAIGNS 20-25

Production Campaign Number

20 21 22 23 24 25 Mean

Mosquitoes 2997 2997 2244 3173 2655 2727 2799 dissected

Pf 62,774 84,492 64,390 74,107 79,065 61,508 71,056 Sporozoites/ Mosquito

Number of 474 576 476 718 632 543 570 vials produced

01.20.09 SANARIA 58 CONTROL ASSAYS

• In-process • Vaccine Bulk Product • Vaccine Final Product

01.20.09 SANARIA 59 SUMMARY OF PRODUCTION CAMPAIGNS 20-25: IN-PROCESS ASSAYS

Production Campaign Number 20 21 22 23 24 25 Disinfected Eggs Pass Pass Pass Pass Pass Pass Bioburden USP<61> Pupae used Pass Pass Pass Pass Pass Pass Bioburden USP<61> Pf gametocyte infected blood meal Pass Pass Pass Pass Pass Pass Bioburden USP<61> Pf infected mosquitoes used ( > Pass Pass Pass Pass Pass Pass Bioburden USP<61> Alanine dosimetry beads Pass Pass Pass Pass Pass Pass

01.20.09 SANARIA 60 SUMMARY OF PRODUCTION CAMPAIGNS 20-25: RELEASE ASSAYS FOR VACCINE FINAL PRODUCT

Production Campaign Number 20 21 22 23 24 25 Pass Pass Pass Pass Pass Pass Quality – visual appearance,

Pass pH Pass Pass Pass Pass Pass

Identity – reactivity in IFAT with MAb against Pass Pass Pass Pass Pass Pass PfCSP

Quantity of sporozoites/vial Pass Pass Pass Pass Pass Pass

Safety - Sterility USP <71> Pass Pass Pass Pass Pass Pass Safety - Bacterial endotoxin Pass Pass Pass Pass Pass Pass

Safety - General Safety Test – 21 CFR 610.11 Pass Pass Pass Pass Pass Pass

Safety - 6-Day Hepatocyte Attenuation Assay Pass Pass Pass Pass Pass Pass

Potency – 3-Day Hepatocyte Potency Assay Pass Pass Pass Pass Pass Pass

062807 01.20.09 SANARIA 61 STABILITY STUDIES

6262

062807 01.20.09 SANARIA 62 STABILITY OF PRODUCTION CAMPAIGN 2 (Vialed, 7/5/06)

DATE OF TESTING (Months after Vialing)

July 2006 January 2007 May-June 2007 Dec-Jan 2008 June 2008 (0 m) (6 m) (10.5-11.5 m) (18 m) (24 m) Pass Pass Pass Pass Pass Quality – visual

pH Pass Pass Pass Pass Pass

Quantity of Pass Pass Pass Pass 100% sporozoites/vial Potency – 3-Day Pass Pass Pass Pass 91% Hepatocyte Assay

Sporozoite Viability FIO 100% Assay

01.20.09 SANARIA 63 STABILITY OF PC 9 AND PC 10 “Toxicology Lots” 6464 At 18 Months Stable and Sterile (> 11%)

01.20.09 SANARIA 64 IND 6565

01.20.09 SANARIA 65 PHASE I TRIAL WITH CHALLENGE – U.S. 6666

01.20.09 SANARIA 66 CLINICAL TEAM

U.S. Military University of Maryland Program Center for Vaccine Development

01.20.09 SANARIA 67 A Phase 1 Trial with Challenge of The PfSPZ Vaccine Administered Subcutaneously or Intradermally to 6868 Malaria-Naïve Adult Volunteers

01.20.09 SANARIA 68 GROUPS 1 – 4 (SC and ID)

4 7 SC Dose 1 2 3 7 ID

7,500 SPZ/dose

6969 11 SC 11 ID 30,000 SPZ/dose

11 SC 11 ID 135,000 SPZ/dose 5 6

3 months 11 SC 135,000 11 ID SPZ/dose

7/21/08 01.20.09 SANARIA 69 Group # Volunteers Route # SPZ per # Doses # Infectivity Challenge Immunized injection Controls

7 SC 7.5 K 3 Wks post 1 4 6 7 ID 7.5 K 4th dose

11 SC 30 K 3 Wks post 2 4 6 11 ID 30 K 4th dose 7070

11 SC 135 K 3 Wks post 3 4 6 11 ID 135K 4th dose

11 SC 135 K 3 Wks post 4 4 or 6 6 11 ID 135K 6th dose

01.20.09 SANARIA 70 TIMELINE

2008 2009

December January Feb April/ May Aug/Sept

7171

l ee co n n o ll t s tio ig ot a n n c s pr y e t tio e e l b ill m rs a ot D a d w it i iz r V in ve D ) u F n p A - F o # cr u st ta N l pr UM D e m ir a C va p ( N r F d E o a s r I D rt im S r B o IN a pp IR t f it t A ai m S w ub -S

01.20.09 SANARIA 71 IMMUNOLOGY STUDIES

• Antibodies – ELISA (Protein Potential/WRAIR) • PfCSP, PfLSA-1, PfMSP-1, PfEBA-175 – IFA (Protein Potential) • Sporozoites, Liver stages, Asexual and sexual erythrocytic stages • T cell studies (whole sporozoites) – ELIspot (NMRC) – Intracellular cytokine staining (VRC, NIAID)

01.20.09 SANARIA 72 SOME CLINICAL VACCINOLOGY QUESTIONS

• Dose • Number of doses • Interval between doses • Volume of each dose • Number of sites for each dose • Route of administration • Longevity of protection without any exposure • Boosting of protection by exposure to sporozoites • Protection against heterologous challenge • PROTECTION AGAINST P. vivax!!

01.20.09 SANARIA 73 CLINICAL DEVELOPMENT PLAN

7474 How do we achieve a successful BLA and commercialization ASAP?

01.20.09 SANARIA 74 CLINICAL DEVELOPMENT PLAN – EXPERIMENTAL CHALLENGE

7575

U.S. (USMMVP, U of MD CVD, others?) Europe (RUNMC, others?) Colombia (Instit of Immunol)

01.20.09 SANARIA 75 CLINICAL DEVELOPMENT PLAN

– FIELD 7676STUDIES

1st Step-Africa U of MD CVD, NIAID, Noguchi-Ghana

01.20.09 SANARIA 76 SITE VISIT TEAM

• MVI (Laurence Lemiale) • CVD (Matt Laurens, Chris Plowe) • MCTA (Bernhards Ogutu) • NAMRU-3 Ghana (Karl Kronmann)

• Sponsored by MVI, Navy, MCTA, HHMI

01.20.09 SANARIA 77 01.20.09 SANARIA 78 HOW DO WE GET THE

PfSPZ VACCINE7979 THERE?

01.20.09 SANARIA 79 NIAID PHASE II SBIR (Navrongo, Manhica) COLD CHAIN TRIAL, GHANA August 2008

GOALS: 1. Demonstrate PfSPZ vaccine transport through a below -140oC cold chain from Sanaria to the clinical trials site at Navrongo. 2. Determine infrastructure and LN2 availability at Noguchi Memorial Institute and Navrongo; determine needs for receiving, storing and handling vaccine for a clinical trial. OUTCOMES: 1. PfSPZ vaccine samples travelled 14,500 miles. Viability assay indicated no change in spz viability. 2. 3 sources of LN2 are available. Hub (Noguchi) and spoke (Navrongo) distribution feasible. Needed upgrades identified.

01.20.09 SANARIA 80 NIAID PHASE II SBIR COLD CHAIN TRIAL GHANA August 2008

0oC

-140oC

01.20.09 SANARIA 81 WHERE ARE WE GOING WITH THE MANUFACTURING PROCESS AND CONTROL ASSAYS? Optimize Efficiency

Scale-Up8282 Validate

Required for Design of Facility for Manufacturing PfSPZ Vaccine for Pivotal Phase III Studies and Commercial Launch

01.20.09 SANARIA 82 RESEARCH

• Parasites • Mosquitoes • Extraction • Formulation • Thermostabilization • Logistics • Administration

01.20.09 SANARIA 83 LIFE CYCLE OF PLASMODIUM

01.20.09 SANARIA 84 MALARIAMALARIA VACCINESVACCINES ININ THETHE TRANSITIONTRANSITION FROMFROM SCALESCALE--UPUP TOTO ERADICATIONERADICATION

Vaccines that reduce morbidity and mortality without preventing transmission

ScaleScale upup DiseaseDisease andand EradicationEradication CoverageCoverage TransmissionTransmission EliminationElimination

Vaccines that prevent transmission by preventing blood stage infection and/or productive gametocyte infection of mosquitoes

01.20.09 SANARIA 85 LIFE CYCLE OF PLASMODIUM

01.20.09 SANARIA 86 HOW GOOD IS

GOOD ENOUGH?8787

01.20.09 SANARIA 87 COLLABORATIONS and PARTNERSHIPS

01.20.09 SANARIA 88 FUNDING • NIAID (SBIR Program) • USAMRMC • Institute for OneWorld Health • PATH-Malaria Vaccine Initiative • Top Institute Pharma (TI Pharma) • BMGF

01.20.09 SANARIA 89 ACKNOWLEDGEMENTS

• ADVISORY COMMITTEE • EAC – SAFETY • CLINICAL VACCINOLOGY ADVISORY GROUP

01.20.09 SANARIA 90 01.20.09 SANARIA 91 01.20.09 SANARIA