1. Global TB Vaccine Foundation

2. Progress in Developing TB Vaccines Second Stop TB Partners Forum New Delhi, India March 25, 2004 Jerald C. Sadoff MD 3. Aeras Mission

To develop and insure availability of new effective TB vaccines for all people who need them

4. Aeras Goals

To obtain regulatory approval and insure supply of a new TB vaccine regimen to prevent TB in the next 7-10 years

To introduce 2 ndgeneration vaccines with improved product profiles and efficacy against latent TB in 9-15 years

5. Infants vaccinate vaccinate Adolescents Latent Infection Acute Infection Reactivation in Adolescents and AdultsHighly infectious 6. Infants vaccinate vaccinate Adolescents Latent Infection Acute Infection Reactivation in Adolescents & AdultsHighly infectious 7. Aeras Strategy

To bring the best current vaccine candidates forward as fast as possible

To insure manufacturing and supply at an affordable price

To eliminate delay between licensure and availability through early factory construction

Every year lost costs 2 million lives

8. Rationale for TB vaccine potential

Human immunology Humans with IL-12 and INFpathway defects highly susceptible to TB

Animal models that mimic human TB can be protected with vaccines

20 yrs of iterative testing of antigens that healthy infected humans respond to have narrowed the choices

9. Prime Boost Strategy For Protection against Acute Infection and Disease in Infants 10. Candidates for the Priming of Newborns:

BCG

Recombinant BCG

Live attenuated recombinant TB variant

11. Candidates for Boosting Infants and adolescents

Recombinant fusion protein in adjuvant

Vectored vaccines

• MVA recombinant

• Adenovirus recombinant

• oral shigella auxotroph dsRNA expression system

Heat shock associated proteins

12. Recombinant Live Prime

rBCG30recombinant BCG over -expressing Ag85b (Marcus Horowitz) in phase I clinical trials

rBCG Lysteriolysin O (Steffan Kaufman)

Auxotrophic live TB

• TB Vac candidate

• Bill Jacobs, Barry Bloom

• Aeras/Kaufmann

13. Booster Vaccines for infants and Adolescents Recombinant Fusion Proteins

GSK/IDRI Mtb72f fusion protein in AS01/AS02 (Steve Reed) in Phase I clinical trials

SSI ESAT-6/Ag85b fusion protein in SSI adjuvant (Peter Anderson)

SSI Ag X/Ag85a fusion protein in SSI adjuvant (Peter Anderson)

14. Booster Vaccines for infants and Adolescents Vectored Vaccines

Oxford MVA Expressing Ag85a (Adrian Hill) in Phase I clinical trials

Aeras/Crucell Adenovirus vector expressing TB antigens

Aeras Shigella dsRNA vector expressing TB antigens

15. Vaccines to prevent the latent state or reactivation from the latent state

DosR regulon controls expression of many proteins expressed during the latent state

BCG can be locked in latent state and present DosR regulated proteins

Latent state proteins vaccines as:

• Recombinant proteins

• Vectors Adeno, MVA and Shigella

• Heat shock associated proteins

16. rBCG30

Recombinant Tice BCG which over-expresses Ag85b

Protects Guinea pigs better than BCG

Has been produced to cGMP standard at the Korean Institute of Tuberculosis

A modern bio-fermentation process for its final manufacture being developed at Aeras facility at Biovac in S. Africa

17. 18. rBCG30

Thirty subjects enrolled at two sites in phase I trial

• Dr. Dan Hoff- St. Louis University

• Dr. Thomas Littlejohn Winston Salem N.C.

Vaccine shown safe and well tolerated to date in these volunteers

19. Intracellular tropism of intracellular bacteria Courtesy of Dr. Stefan Kaufmann, Max Plank Inst. Infect. Dis., Germany 20. rBCG:: ureC - llo +

Max Planck Inst. Stefan Kaufmann

Escapes endosome through expression of Lysteriolysin O and Urease C which punch holes

21. Protective capacity of rBCG:: ureC - llo +in the murine aerosol model of tuberculosis BALB/c mice were immunized with 10 6CFU BCG or rBCG:: ureC - llo +and challenged 120 days after vaccination.Bacterial load in lungs was determinedpost aerosol-challenge withM. tuberculosisH37Rv. 0 10 20 30 40 50 60 70 80 90 100 2.5 3.5 4.5 5.5 Naive BCG p BCG p ureC BCG p ureC - llo + Days post-challenge Log 10cfu in lungs Courtesy of Dr. Stefan Kaufmann, Max Plank Inst. Infect. Dis., Germany ------2.12-fold (log 10 ) ------1.13-fold (log 10 ) 22. 0 25 50 75 100 125 150 0 10 20 30 40 50 60 70 80 90 100 110 BCG Pasteur rBCG p :: llo + rBCG p :: ureC - llo + Intravenous dose/mouse: BCG p-- 8x10 7 rBCG p ::llo +-- 1x10 7 rBCG p :: ureC-llo +-- 3x10 7 Virulence of BCG p :: ureC - llo +in SCID mice Day post infection Percent survival Courtesy of Dr. Stefan Kaufmann, Max Plank Inst. Infect. Dis., Germany 23. Mtb72f is the lead booster candidate

Produced in partnership with GSK-BIO and IDRI (Steve Reed)

Given with adjuvant AS01

Phase I in 30 adult volunteers nearing completion

Acceptable safety and tolerability

24. Construction of Mtb72f Mtb32 C-term = Ra12 Mtb32 N-term = Ra35 Mtb39 = tbH9 Mtb32 C-term Mtb39 Mtb32 N-term 192 1 391 195 1 323 ~14KD ~39KD ~20KD 25. Corim VI Study (monkeys):20 weeks post-challenge 26. Corim VI Study (monkeys):48 weeks post-challenge 27. CORIM VI study (monkeys):99 weeks Post-Challenge BCG/Mtb72f BCG/AS02 AS02 28. PR 4558A, Group II, 10/30/2001 29. PR 2799F, Group III, 10/30/2001 30. PR 2799F, Group III, 12/30/2001 31. Shigella -rdsRP vector

Access cytoplasm

Lysis due to asd

Release of rdsRP

Invasion Nucleus A live oral vaccine against TB is possible: Delivery of rdsRP byShigellavectors Synthesis of recombinantsegment-S mRNAby RNA-dependent RNApolymerase activity of rdsRP Amplification of mRNA encoding TB antigens by alphavirus ampliconEF2-independenttranslation of TB antigens Presentation of TB antigens in the context of HLA class I&II Induction of TB-specific CD4 +and CD8 +T cells 32. Epidemic Dynamics

R = R 0(1-EC)

Where:

R 0= the number of infectious TB casescaused by 1 TB case

C= % of population covered by the vaccine

E= vaccine efficacy= 1-Incidence vacinees

Incidence controls

IfR< 1Epidemic is eliminated

33. Slide courtesy of Chris Dye, WHO, Geneva 34. Fig 2rBCG30 Live TB Vaccine Yr 1 Yr 2 Yr 3 Yr 4 Yr 5 Yr 6 Yr 7 Yr 8 Process Devel Phase III Manufacture Release Phase III Material Release Assay Validation Clinical Operational Characterization Infection Detection & Disease Stdy rBCG30-4Phase I S. AfricaPPD- , 11-12 yr StdyrBCG30-5Phase I S. Africa + 2Other Sites PPD- , 5 yr Stdy rBCG30-6Phase I S. Africa + 2Other SitesInfants 3 Months Stdy rBCG30-1 Phase I US PPD- Adults 30 Subjects 110 GP 30 Subjects 30 Subjects 90 Subjects (30/Site) 90 Subjects (30/Site) Stdy rBCG30-3Phase I USPPD+ Adults Koch Phen Guinea Pig Study 30 Subjects Stdy rBCG30-2Phase I Africa PPD- Adults Stdy rBCG30/72f-1Phase II S. Africa + 2 Other Sites Prime Boost4-Arm Trial Neonates648 Subjects (216/Site)

BCG

rBCG30

BCG Prime + Mtb72fBoost

rBCG30 Prime + Mtb72f Boost

Site Development/Epidemiology/Infrastructure/Training Operaqtional Chaqracterization Immune Response, Disease, Infection Assays Go/NoGo 35. Fig 3rBCG30 Prime + 72f Boost Subject to a Later Supplemental Request Yr 1 Yr 2 Yr 3 Yr 4 Yr 5 Yr 6 Yr 7 Yr 8 Interim Analysis (POC)

BCG

rBCG30

BCG Prime + Mtb72fBoost

rBCG30 Prime + Mtb72f Boost

Final Scale Up Development & Manufacture 72f Final Scale Up for Manufacturing rBCG30 Pivotal Phase III 3 Arm Study Adolescents & Adults Interim Analysis (POC)

Placebo

Mtb72fBoost

rBCG30 Prime + Mtb72f Boost

25,000 Subjects Pivotal Phase III 4 Arm Study - Neonates 26,000 Subjects Initial Safety Initial Safety Go/NoGo 36. Summary

A moderately effective vaccine + drug control could eliminate the 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

A new vaccine to prevent reactivation possible in 10-12 years