Peter Hotez MD PhD Walter G. Ross Professor and Chair, Department of Microbiology, Immunology, and Tropical Medicine, The George Washington University President, Sabin Vaccine Institute Director Human Hookworm Vaccine Initaitive Innovation in the Control of Neglected Tropical Diseases University of Washington Global Health HHVI Human Hookworm Vaccine Initiative

1. Eradicate extreme poverty and hunger. 2. Achieve universal primary education. 3. Promote gender equality and empower women. 4. Reduce child mortality. 5. Improve maternal health. 6. Combat HIV/AIDS, malaria and other diseases. 7. Ensure environmental sustainability. 8. Develop a global partnership for development. Millennium Development Goals

The New Global Health Celebrities Global Fund $4.6 billion over 2 years PMI Expected to reach $135 million for 2007 PEPFAR $15 billion over 5 years (2003-2008)

AIDS TB Malaria Apparently there are only three diseases on that planet !

1. Eradicate extreme poverty and hunger. 2. Achieve universal primary education. 3. Promote gender equality and empower women. 4. Reduce child mortality. 5. Improve maternal health. 6. Combat HIV/AIDS, malaria and other diseases . 7. Ensure environmental sustainability. 8. Develop a global partnership for development. Millennium Development Goals

The Neglected Tropical Diseases Core Group Protozoan Infections Human African Trypanosomiasis Chagas Disease Leishmaniasis Bacterial & Viral Infections Buruli Ulcer Dengue Leprosy Trachoma Helminth Infections Ascariasis Hookworm infection Trichuriasis Schistsosomiasis Lymphatic Filariasis Onchocerciasis Dracunculiasis

Protozoan Infections

Human African Trypanosomiasis

Chagas Disease

Leishmaniasis

Bacterial & Viral Infections

Buruli Ulcer

Dengue

Leprosy

Trachoma

Helminth Infections

Ascariasis

Hookworm infection

Trichuriasis

Schistsosomiasis

Lymphatic Filariasis

Onchocerciasis

Dracunculiasis

Neglected Tropical Diseases (NTDs) Most prevalent infections of poor people Over ONE BILLION people infected worldwide Ascariasis 807 million Trichuriasis 604 million Hookworm 576 million Schistosomiasis 207 million Lymphatic Filariasis 120 million Trachoma 84 million Onchocerciasis 37 million Hotez PJ et al. N. Engl. J. Med. 2007; 357: 1018-27

Most prevalent infections of poor people

Over ONE BILLION people infected worldwide

Ascariasis 807 million

Trichuriasis 604 million

Hookworm 576 million

Schistosomiasis 207 million

Lymphatic Filariasis 120 million

Trachoma 84 million

Onchocerciasis 37 million

NTDs are Chronic and Disfiguring Buruli Ulcer Leishmaniasis Leprosy (Hansen’s Disease) Property of the Global Network

Disabling “ It’s quite a problem for me when I have to stand at work for long periods.”

Impairment of child growth and development Hookworm leads to 40% reduction in future wage earnings Age (months) 0 3 6 9 12 15 18 21 24 27 17 16 15 14 13 9 12 11 10 8 7 6 5 4 3 2 PERCENTILES Treatment for 2 days Weight (kg) Property of the Global Network Children have the highest worm burdens

… and Stigmatizing “ People make fun of me. “

Global Burden of NTDs DALYs 91.4 million 84.5 million 67.3 million 62.0 million 58.6 million 56.6 million 49.2 million 46.5 million 34.7 million 38.7 million Per DALY Funding DISEASE Lower Respiratory Infections HIV/AIDS Unipolar Depression Diarrheal Disease Ischemic Heart Disease Neglected Tropical Diseases Cerebrovascular Diseases Malaria Road Traffic Accidents Tuberculosis $0.62

NTDs and Poverty Impairment of intellectual and physical development in children Adverse pregnancy outcome Reduced productive capacity/worker productivity NTD’s PROMOTE POVERTY Property of the Global Network

Impairment of intellectual and physical development in children

Adverse pregnancy outcome

Reduced productive capacity/worker productivity

Malaria and the NTDs The “Perfect Storm” of Anemia Increased Susceptibility Geographic Overlap “ The Perfect Storm” of Anemia Brooker et al. Malaria Journal 2006; Hotez et al. PLoS Medicine 2006

VERSION 1.0 1970s VERSION 2.0 2005 VERSION 3.0 VISION FOR THE FUTURE Opportunities for NTD Control

VERSION 1.0 1970s

VERSION 2.0 2005

VERSION 3.0 VISION FOR THE FUTURE

Version 1.0 The Beginning of NTD Control

NTD Elimination Lymphatic filariasis – South Pacific Lymphatic filariasis - Zanzibar Trachoma - Morocco Schistosomiasis - Egypt

Version 1.0 World Health Assembly Resolution 54.19 Goal of attaining a minimum target of regular administration of chemotherapy to at least 75% and up to to 100% of all school-age children at risk of morbidity by 2010 Benzimidazoles Mebendazole Albendazole Praziquantel

Goal of attaining a minimum target of regular administration of chemotherapy to at least 75% and up to to 100% of all school-age children at risk of morbidity by 2010

Current Pharmaceutical Commitments Pfizer – Azithromycin Donation 120 million doses provided since 1999 Pfizer – Azithromycin Donation 120 million doses provided since 1999 Over 600 million treatments provided since 1998 GlaxoSmithKline – Albendazole Donation Over 600 million treatments provided since 1998 GlaxoSmithKline – Albendazole Donation 50 million tablets in 2007 Johnson & Johnson – Mebendazole Donation 50 million tablets in 2007 Johnson & Johnson – Mebendazole Donation Over 539 million treatments provided since 1988 Merck & Co., Inc – Mectizan Donation Program Over 539 million treatments provided since 1988 Merck & Co., Inc – Mectizan Donation Program 200 million tablets 2008-2017. Merck KGaA – Praziquantel Donation

MDA Coverage 2005-07

Ascariasis Trichuriasis Hookworm Schistosomiasis Lymphatic Filariasis Onchocerciasis Trachoma

Version 2.0 Global Distribution of NTDs

Version 2: the Rapid Impact Package The Rapid Impact Package Albendazole (GSK) or Mebendazole (J&J) Diethylcarbamazine or Ivermectin (Merck) Praziquantel Azithromycin (Pfizer) BIG SEVEN NTDs Ascariasis Trichuriasis Hookworm Lymphatic Filariasis Onchocerciasis Schistosomiasis Trachoma Bonuses: Strongyloidiasis Trematodiases Taeniasis Scabies US $0.50 all inclusive DRUGS + delivery +equipment +health education materials +Training of personnel +Monitoring and Evaluation US $0.50 per person per year

The Rapid

Impact

Package

Albendazole (GSK) or Mebendazole (J&J)

Diethylcarbamazine or Ivermectin (Merck)

Praziquantel

Azithromycin (Pfizer)

Bonuses:

Strongyloidiasis

Trematodiases

Taeniasis

Scabies

Rapid Impact Package = Cost Effective Only $0.50 per person per year!

The Global Network Alliance of the major NTD partners Treated 34 million people in 2007 NTD Advocacy Fills the funding gap

Alliance of the major NTD partners

Treated 34 million people in 2007

NTD Advocacy

Fills the funding gap

The U.S. – U.K. Partners of The Global Network for Neglected Tropical Diseases (GNNTDC)

The Buzz on NTDs “ The world is now paying attention to these [neglected] diseases and making progress in unprecedented ways, with ambitious goals, excellent interventions, and growing evidence of multiple benefits for health. The attention to long-neglected diseases is a positive sign that health is a responsibility shared by the international community.” Dr. Margaret Chan, Director-General of the WHO “ Comprehensive, Africa-wide control of malaria and NTDs together would probably cost no more than $3 billion a year , or just two days of Pentagon spending . If each of the billion people in the rich world devoted the equivalent of one $3 coffee a year to the cause, several million children every year would be spared of death and debility, and world would be spared the grave risks when disease and despair run unchecked. A new Global Network for Neglected Tropical Disease Control is helping make this opportunity a reality .” - Jeffrey Sachs, Director of the Earth Institute, Scientific American January 2007 “ It quickly became clear that this story is not just about the staggering numbers of the world’s citizens overwhelmed by HIV, AIDS, TB, and malaria. And it’s not just the story about one billion people who are afflicted with disabling, oftentimes stigmatizing, neglected tropical diseases , such as human hookworm infection and elephantiasis… it’s all about the faces of dying children and sick mothers who haunt those who have seen them...What struck me, and what I think struck us all…that these challenges are all interconnected .” - Clinton Global Initiative, Closing Remarks The Brownback-Brown amendment provides a significant financial incentive for pharmaceutical companies to produce neglected tropical disease treatments by awarding them with a FDA priority review voucher for bringing to market such products. “ It is unacceptable that neglected diseases like leprosy, hookworm, and river blindness cause over 500,000 deaths annually. A total of 13 such diseases afflict the poor in Africa, Asia, and the Americas, and I am hopeful that this amendment will work toward reducing deaths and suffering from these diseases ." -Senator Sam Brownback, May 2007

“ The world is now paying attention to these [neglected] diseases and making progress in unprecedented ways, with ambitious goals, excellent interventions, and growing evidence of multiple benefits for health. The attention to long-neglected diseases is a positive sign that health is a responsibility shared by the international community.”

Dr. Margaret Chan, Director-General of the WHO

New Lead Ambassador: Alyssa Milano Made a personal donation of $250,000 to the NTD drug fund Will stand as a spokesperson for NTD advocacy “ Stop NTD” online campaign “ Words cannot fully express the devastation and horror caused by NTDs. Until now these diseases have been hidden in the shadows, but working with the GLOBAL NETWORK, I am focused on bringing this tragedy into the public eye” - Alyssa Milano, May 2007

Made a personal donation of $250,000 to the NTD drug fund

Will stand as a spokesperson for NTD advocacy

“ Stop NTD” online campaign

White House announced $350 million Leveraging into $1 billion fund at the G8 agenda Structure of the fund WHO Global Network Carter Center The Global Fund to Fight ATM Gates Foundation World Bank Harmonizing donation and distribution programs for maximum efficiency Does Pharma have capacity What about the other $1.5 billion A Global Fund for NTDs

White House announced $350 million

Leveraging into $1 billion fund at the G8 agenda

Structure of the fund

WHO

Global Network

Carter Center

The Global Fund to Fight ATM

Gates Foundation

World Bank

Harmonizing donation and distribution programs for maximum efficiency

Does Pharma have capacity

What about the other $1.5 billion

Estimated gaps by medicine 2008-2012 Total funding gap for medicines = US$ 222 million 1,842 million tablets in US$ 147 million 95% 51% 3,805 million tablets in US$ 64 million 2,686 million tablets in US$ 11 million 37% 49% 63% 100% 5%

Version 2.1: Linking NTD Control with Malaria and HIV Control “Roll back anemia” “Tropical disease no more” Geographic overlap and increased susceptibility IPTi/IPTc and Rapid Impact Package IPTp and Rapid Impact Package LLITN and Onchocerciasis/LF ART and Rapid Impact Package Malaria and HIV Vaccines and Rapid Impact Package Vaccines do not work with hookworms and schistosomes

Geographic overlap and increased susceptibility

IPTi/IPTc and Rapid Impact Package

IPTp and Rapid Impact Package

LLITN and Onchocerciasis/LF

ART and Rapid Impact Package

Malaria and HIV Vaccines and Rapid Impact Package

Vaccines do not work with hookworms and schistosomes

Drug Failure: Mebendazole for Hookworm

NEW TOOLS FOR DISEASE CONTROL THE ANTIPOVERTY VACCINES Low efficacy of Mebendazole Re-infection within 4-12 mos Diminishing efficacy Hookworm Re-Infection Product Development Partnership Sabin Vaccine Institute George Washington University FIOCRUZ Instituto Butantan London School Hyg. Trop. Med. Queensland Inst. Med. Res HHVI Human Hookworm Vaccine Initiative

Low efficacy of Mebendazole

Re-infection within 4-12 mos

Diminishing efficacy

The Global Distribution of Human Hookworm Infection Necator americanus is the predominant species 576 million cases (25% of the poor); 50 million in LAC 22 million DALYs Wherever Rural Poverty and Adequate Climate Overlap

Adult worms injure their host by causing intestinal blood loss: Anticoagulants: Factor Xa and Tissue Factor-VIIa Inhibitors Hemolysins, and Hemoglobinases Intestinal blood loss: 25 Necator worms = 1 ml blood loss = 0.55 mg Fe = Child’s daily iron intake Iron Deficiency Anemia and Protein Malnutrition Hookworm-Blood Loss

Anticoagulants: Factor Xa and Tissue Factor-VIIa Inhibitors

Hemolysins, and Hemoglobinases

Intestinal blood loss: 25 Necator worms = 1 ml blood loss

= 0.55 mg Fe = Child’s daily iron intake

Iron Deficiency Anemia and Protein Malnutrition

Pediatric Hookworm Disease Pallor and Anasarca Iron deficiency anemia Protein malnutrition Growth stunting Intellectual retardation Impairment in memory/cognition Reduction in school attendance Reduction in school performance 43% Reduction in future wage earning Impact on health, education and economic development

Anti-L3 Vaccines X-irradiated Larvae Anti-adult Blood-feeding Vaccines L3 Adult

Xir-L3 VACCINES OPERATE BY INHIBITING L3 TISSUE INVASION Reduction in Worm Burden + Egg Counts Inhibition of L3 penetration in vitro

ANTI-L3 ANTIBODIES INHIBITION OF L3 TISSUE PENETRATION (Somatic Migration ) REDUCED NUMBER OF ADULT HOOKWORMS REDUCTION IN HOST INTESTINAL BLOOD LOSS REDUCTION IN FECAL EGG COUNTS REDUCTION IN MALNUTRITION AND ANEMIA L3 Hookworm Vaccine: Proposed Mechanism

Ac -16 L3 Surface Protein: SAA-2 (“ Ac -16”) 65% Inhibition of L3 Invasion

L3 secreted protein (21-22 kDa) PRP (Pathogenesis related protein superfamily) Immunodominant protein of X-ir L3 vaccines Anti-ASP-2 antibodies inhibit larval invasion Protective antigen in dogs ( A. caninum ) and in hamsters ( A. ceylanicum and N. americanus ) 6) Developed as a Pichia pastoris recombinant vaccine on Alhydrogel ASP-2 ASP - 2 ASP - 1 PR 1 PR1 PR1 MT MT MT SP SP c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c 45 kDa ASPs = Single and double PR - 1 domain Proteins 21-22 kDa Hotez et al. Immunol. Rev . 1999; Int J Parasitol 2003; PLoS Medicine 2005

L3 secreted protein (21-22 kDa)

PRP (Pathogenesis related protein superfamily)

Immunodominant protein of X-ir L3 vaccines

Anti-ASP-2 antibodies inhibit larval invasion

Protective antigen in dogs ( A. caninum ) and in hamsters

( A. ceylanicum and N. americanus )

6) Developed as a Pichia pastoris recombinant vaccine on Alhydrogel

0 10 20 30 40 50 60 70 80 90 a-irL3 a-ASP-2 Control GROUP % reduction in L3 penetration ANTI ASP-2 ALSO INHIBITS L3 THROUGH TISSUE N = 5 9 12 Bethony et al. FASEB J 2005; 19: 1743-5 Goud et al. Vaccine 2005; 23: 4754-64

APR-1 (Blood-feeding Aspartic Protease) Anti-APR-1 Antibodies in Hookworm Gut Anti-APR-1 antibodies reduce host blood loss Reduce fecal egg counts Loukas et al. PLoS Medicine 2005; 2: e295

Fraunhofer USA CMB Rapid Expression of Green Fluorescent Protein and LicKM in Nicotiana benthamiana 24 hrs after infiltration 48 hrs after infiltration Green fluorescence is indicative of GFP expression LicKM 800mg/kg 1 2 3

Na -GST-1 Na -APR-1 fragment 5a Fuse Na- APR-1 fragment 5a to C-terminus of Na -GST-1 A multi-antigen adult fusion protein vaccine Na -APR-1 is an efficacious antigen but is difficult to express at high yield Protection is thought to be mediated by antibodies that neutralize enzymatic function neutralizing mAbs map to fragment 5a fragment 5a is expressed in soluble form in E. coli as a GST-fusion protein we are now fusing APR-1 fragment 5a to the C-terminus of N. americanus Na- GST-1 to produce a chimeric antigen

Na -APR-1 is an efficacious antigen but is difficult to express at high yield

Protection is thought to be mediated by antibodies that neutralize enzymatic function

neutralizing mAbs map to fragment 5a

fragment 5a is expressed in soluble form in E. coli as a GST-fusion protein

we are now fusing APR-1 fragment 5a to the C-terminus of N. americanus

Na- GST-1 to produce a chimeric antigen

Bivalent Strategy Adult Antigen + Larval Antigen Adult antigen L3 antigen ADCC Neutralizing antibodies Inhibit migration Attenuate L3 Reduced host blood loss (Hookworm Disease) Neutralizing antibodies Inhibit Blood Feeding 1. Reduced worm burden 2. Reduced fecundity Larval Antigens Under development Na -ASP-2 Na -SAA-2 Adult antigens under development Na -APR-1 Na -GST-1

Inhibit migration

Attenuate L3

Antigen Discovery Research & Development Process Development / Quality Control cGMP Manufacture Product Development Strategy Developing Recombinant Vaccines: The Process Phase 1 Clinical Trials Technology Transfer to cGMP Facility

Sabin-Brazil Technology Transfer D C V M N

HHVI Field Site Development Americaninhas 68% Hookworm Prevalence Phase 1/Phase 2 trials to take place in Minas Gerais, Brazil Americaninhas Minas Gerais

Americaninhas

68% Hookworm Prevalence

Phase 1/Phase 2 trials to take place in Minas Gerais, Brazil

A Multivalent Vaccine for Hookworm and Schistosomiasis?

TSP-2 discovered through genomic/proteomics approaches: Antibodies to TSP-2 bound outer tegument of adult S. mansoni X63 X252 Recent proteomics studies identified TSP-2 as an abundant tegument protein Braschi et al 2006 (biotinylation of worm surface) Van Balkon et al 2005  -thioredoxin  -thioredoxin teg nuc  -TSP-1  -TSP-2  -TSP-2 teg tub teg nuc tub teg teg nuc nuc a b c d e f membrane 1 2 3 4 C G C C C C G/A G/A E/Q E/Q G/A K G/A F/Y G C E/Q P W/F/Y EC-1 EC-2

Putative Resistant Low (1-99 epg) Medium (100-399 epg) Heavy (400+ epg) Patient Group anti-TSP-2 IgG1 IgG from putatively resistant individuals selectively recognises TSP-2 0.000 0.500 1.000 1.500 2.000 2.500 OD (492 nm) Patient Group 0.00 0.25 0.50 0.75 1.00 1.25 1.50 OD (492 nm) Putative Resistant Low (1-99 epg) Medium (100-399 epg) Heavy (400+ epg) anti-TSP-2 IgG3

Future Trends in NTD Control The “Antipoverty Vaccines” Fold them into existing structures, i.e., rapid impact package Drugs + Vaccines in Integrated Framework Human Vaccine-Linked Chemotherapy Alternative Health Delivery Mechanisms School-based Health Systems and Child Health Days

The “Antipoverty Vaccines”

Fold them into existing structures, i.e., rapid impact package

Drugs + Vaccines in Integrated Framework

Human Vaccine-Linked Chemotherapy

Alternative Health Delivery Mechanisms

School-based Health Systems and Child Health Days

Neglected Infections of Poverty in the U.S. Chagas Disease 3,000-1,000,000 (Hispanics) Congenital CMV 27,000 (50 X risk AfrAmer) Cong Toxoplasmosis 4,000 (Hispanics/Afr Amer) Trichomoniasis 884,000 (10 X risk AfrAmer) Cysticercosis 41,000-169,000 (Hispanics) Toxocariasis 1.3-2.8 million (>20% AfrAmer) Hotez PLoS NTDs 2008

World’s first peer-reviewed, open-access journal devoted to the NTDs Launch supported by Bill and Melinda Gates Foundation Papers on pathology, epidemiology, treatment, control, prevention Magazine section devoted to policy and advocacy International editorial board—half of the Associate Editors are from endemic countries Accepting submissions in early 2007 “ It is expected that the journal will be both catalytic and transformative in promoting science, policy, and advocacy for these diseases of the poor.” — Peter Hotez, Editor-in-Chief

World’s first peer-reviewed, open-access journal devoted to the NTDs

Launch supported by Bill and Melinda Gates Foundation

Papers on pathology, epidemiology, treatment, control, prevention

Magazine section devoted to policy and advocacy

International editorial board—half of the Associate Editors are from endemic countries

Accepting submissions in early 2007