Event ID: 440661
Event Started: 12/13/2005 8:57:01 AM ET
Good morning. This is a test.

I have few announcements. Dr. Amy patterson is out and Dr. Owe rilely serving with Dr. Patterson instead. We will begin this morning with a couple of announcements. First I want to remind all of the RAC members to sign in at the desk outside this room. Second, we've reserved a table for lunch today. I will remind you of this again in alleys in the back room. Third, for any of you who are driving today, please get your complimenttary parking passes outside of the rhyme. Dr. Riley will read us conflict of interest statement.

being a member of this economy makes--committee makes you--standards of ethical conduct of employees of executive branch. You received a copy of this document when you were appointed. In every meeting in addition to reminding you--we like to review the steps that we take and ask you to take in ensuring any conflicts of interest we address. Personal profession financial interests. We use this information for the base of--that could compromise your ability to be objective in giving advice. While we waive conflicts of interest for general matters we have relied on a great degree for you to attentive during the meetings for a possibility to arise that could affect your interest. If you reuse yourself in the discussion and leave the room. You are also required to reuse yourself from the preliminary protocol or review process. If you have any questions about the rule of conflict of interest or committee managers or officers will be happy to address them.

Thank you very much Dr. O rilely. We will procedure from the constitution of September 21st meeting. Dr. NaomiRosenberg.

I reviewed the minutes along with nick and I found no errors in the minutes that were presented.

Thank you both very much. The gene transfer safety assessment board rr report is next and Dr. He willbellda will leadoff.

I am begin with a brief review.

I forgot to take a vote on approving the minutes. I'm moving too fast. All those--no I have to take a roll call for approving the minutes.

Is that really a motion?

Yeah, just a second I'm getting myself organized. We're taking a brief pause. I need a motion to approve the minutes.

so moved.

I second.

Dr. Magisca moved and Naomi Rosenberg second. Take on motion.

Aye.

Wara aye,.

Aye,.

Wara--i'm sorry weber and grave and grave Weber. Thank you. Now that we have done that he will now move ton to the gene transfer safety assessment board report.

In the last quarter this were 18 submissions to the RAC. 12 of those were not selected for in-depth review and mustic discussion. These included nine for cancer, one for peripheral artery December, one for museum diseases and enfection December. Three plasma vectors, one a retro viral vector, one a her peas viral vector. Protocol is a plasma expressing mach mow globin A and aqua pore ra one. Procall 732 replicated adeno-virus with individuals with advanced tumors. 734 with individuals of Cleo blas Tacoma. 739AAV ser row type 6 for the first time expressing human placenta with individuals for the cystic fryrose sis.

Thank you very much doctor. Dr..

RAC 700147 amendments in the last quarter 37 were PI changes and two protocol design modification. There were 14 procall stage changes, 46 annual reports and seven responses to N1C1 and 41 other amendments. The RAC received notification from Dr. Enknit--ken knit wine berg in Children's Hospital in Las Angeles with infants of children with a patient previously not have a bone marrow transplant. Procall allows for enrollment of patients and high risk of more bility or mortality. As for the potential subject add seminated the investigators fell into this category and planned to offer his parents the option of enrolling him on other parol protocol 494 as well as transplant. A second notification to the RAC was that single subject exemption will not be included with the 609 which a study of children with disease.

Thank you, doctor. We are very privileged this morning to ra brief discussion before our first protocol presentation in risk-benefit assessment in early stage.

I think there was another one that Dr. Peter offs going to read.

I'm sorry Helen. Are you doing the next?

No doctor federoff of going to do it.

I poll gize.

This is protocol 699 a study of for the treatment of high Greg low ma using blunt cells genetically modified placing themselves on hold due to very preliminary animal studies that show add normal hue mat pleas sis amild proliffertive disease transgene in the animals and full pathology report and testing for replication confident retro virus will be provided.

And that is full amendment discussion. Dr. Owebellda will included this.

The gene tran fierce safety assessment board reviewed 11 seven were classified as A1 and possibly associated and unexpected and four classified as possibility associated and expected. After reviewing we thousand there was one adverse event in protocol 619 that's protocol by Dr. Crystal to teach patients with ser roid lipo know sis with an AP vector. There was a 4 and a half-year-old boy with a moderate disease who had surgery on September 20th. Eight days later two seizures which were controlled by reduce the anti-seize sure medication the patient had seizures nine months ago and not sense that time.

thank you. And now we'll go onto our presentation this morning which involves the risk-benefit assessment in early phase pediatric research. This is dear to my heart because I'm a pediatrician. Dr. GilmanGrave will discuss this and a brief comment for his specific expertise for being here this morning from since 1985 Dr. Gilman Grave served as of NIBT ofen fans and children. He works with the NIHnd programs on adult disease and especially interested it ceases disease prevent and ascertain takening the early and os pea yo porosis. He currently chairs the NICHD institutional review board. He also serves on the subcommittee on research involving children for the secretary's advisory committee on research. In this capacity federal regulation toss protect children involved in research projects and the children's health act of with 2000. He also searched as task leader entitled ethical conduct of clinical research involving children which was mandated in 2002. For these accomplishments he was been awarded outstanding and mare torous service medals. He is particularly well-versused and-suited to discuss the issues of protection of children in the conduct of clinical research. Dr. Grave.

Where did you ever get all that material?

I was handed it this morning and I summarize it.

I don't remember being in involving in all of that. First of all I'm not a pediatrician Dr. Wara imi'mn internist I've been provide here since 1972 and emmerged in pediatric issues and six month he had a the Burnham general hospital. I'm about to subject you to abuse by PowerPoint. I was telling Dr. Nelson this morning that PowerPoint is totally eliminated public discourse in this coun and people end up looking at the slide instead of the person presenting. But we'll have to put up with that because unfortunately when you're dealing with very fine nuances of distension between--discontinuingtion between the levels of risk of the words that were wren and they are very important and written by professors of law and lawyers. And they have stood the test of time. I think the three remarkable productions of the national commission between 1974 and 1979 first research on fetus that came out in 1975 followed by research involving children that we'll pay attention to this morning and finally Belmont report in 1979 these three documents are absolutely stunning. They're sort of like the constitution. We should be so proud of these document. The national commission did an incredible job if an atmosphere that was fear struck by tuskeyee revelations and in order to save federal research in biomedicine and pave the way for the establishment of biomedicines is as stonishing--I don't have copies of these three documents but they are available on the web but I do have seven or eight books to give out ethical conduct in clinical research involving children. Sarah car was sinned enough to give you one chapter which is 4. One of panelists Dr. Nelson in the back room I was a the humble project officers. That was any involvement with that introduction let me get on with the meat of the presentation. This is to remend you of the fact that we're dealing with very 71able children in this kind of research and obviously demand special protection. They are the future of our republican and we--republic and we need to take good care of them and remember any intervention we put on them at this tender age stays with them lifetime. One of characteristics of the children is they are growing all the time. Any intervention you may come up with in a child may have a long, lasting linger effect that is the heart and essence of the pediatrics which is the field of development biology. This is the third slide I would show you about the development and care and concern about drugs in that country back in the 1906 when they passed the pure food and drug act in sponges to the children when he were getting heroin and morphine and color ra form in their medicines to stop them from couching. Thisas followed the food and drug act in 1978 to the children who were given those drugs that lead to the food and drug cosmetic act in 1938. Finally a great tragedy of pha lid mid which some of you may remember in early 19 60s in yes, ma'amThere is a pattern here followed by a legislative Fiat. One of the important things about this particular piece of legislation which was remarkably important at the time is the third point the law of unintended consequences. They mandated it be tested in adult and instead of children. It led to therapeutic or fins which are children given drugs. Why some the current legislation is so child-oriented and child-focus for very good reason. Now about 80% of drugs given to children have never actually been tested specifically in children for that point. This slide is about the national commission. It was mandated in the national research act of 1974 which was introduced by senators Ted Kennedy, Jacob Jeffadvice and Walter Mondale and this was a absolutely a very important piece of legislation. It imposed a moratorium on fetal research lifted a year later after the commission's wonderful report. Research involving children is of interest. This quote actually comes from a letter that the Chairman of the the commission Dr. Kenneth Ryan a gynecologist from harvard wrote to president Carter he said it raise ethical concerns because of in come pentancy to give informed consent. It's hard to remember when you look at the two infants sitting there the such bliss. The send part is these concerns should not be answered by restricting participation and research to people that have come tent to consent. Namely adults. This is of the hard of in your rencode it was only people who could give consent. That's adults. One of key break through of the commission and job they set themselves to do was to find a way that children could participate in research and this was a letter to the president as I said. And the letter went on and Ken Ryan pointed out there are two key questions that have to be addressed. The first was under what conditions is participation in children and research ethically acceptable? The answer as it turns out depends on the thoughtful analysis of risk and benefit including non-beneficial or non-therapeutic research which might be the nub of the argument. Under second question what participation bet subject of the parents. How can we get around the fact that children cannot consent for themselves if they are to get permission or actively accept children's assent. There were other key vic riess that they had. Each one is pretty much autumn mouse and loosely overseen by the office of human research and protection how can they review the results of all 3,000RIBs. There's a lot of local authtomy here and some may agree and others disagree. The other is component analysis some may have heard some may not. It's deacon instructing a protocol to look at the parts to see if each has a certain level of refreshing or possibly the risks differ in which case you could find for one part of the protocol but not the other. Finally is secretarial review peen the department of health and human services review by the secretary and important research for some major serious problem that the RIB felt at sea with that they couldn't approve it. Maybe we'll kick it upstairs to the secretary and more about that later. The task the commission set before then as I indicated is it ethical to do research involving children. The nurenburg code would say no. 3 low again that--that thought only medical research for the interest of the child therapeutic research and dealt with this at great length and thought the term itself therapeutic research as an inherent contradiction. If it's research, how can you possibly know the outcome and therefor it couldn't completely be therapeutic because the so-called therapy that you're trying you think will be beneficial might have detrimental effects like they did. The minute you introduce the term research you are no longer talking about pure therapy. I think this was brilliant punctureture ofl Ramsey's balloon. He was big on good works and thought that fashioning of the concept of parental permission in children's asset was key here. And in a way some consider a benefit more about that later. The Belmont report. This is their final magnumowepus and it is short like the constitution. They had three key principles ba benefitsis carries the word benefit with it. They address children in it. They said we need to find better ways to treat children and it it's a benefit to justice in serving children from they are constantly figuring outweigh we could inject those tiny helpless creatures into research for their own good especially having experienced nur iturg and Tuscany and all thetion they said protection to harm first do no harm, second minimize harm and quoted Bernard who said injury no one regardless of benefits to others. And this is where Paul went to terribly awry in the willowburg experiments and he started injecting them with the Hepatitis vi withecause they may get it anyway. He should have paid attention to Claude injury known andd an important key principle we must keep many mind. It has entailed a discussion with the research of children without the immediate prospect of direct benefit and greater than minimal refreshing is inadmissible. That's the word they used. In admissible. They said you can't use such a strong word you mittt rule out a great benefit this is the attention of the concept and attention RIBs wrestle with everyday. Respect for persons is a little more straightforward and can be handled quickly. They simply indicated that individuals with capacity to consent 18 years old and above are treated auto mousely and any by definition has legally auto me. It implies and ethical and imperative to obtain consent of children and inform them of risks. That's my own deduction from that that could with argued but I think it's acceptable. The third principle is justice and we can quote historically the burden serving as research subjects fell largely on the full ward patients and fell to the private patients. They mention the tus key gee studied this ethical principle is children should be proposed the benefits of research as well as adults instead of being treated as or fins as you've heard and extrap lated down to. Federal policy as we know it is incorporated in so-called title 45 of the code of federal regulations part 46. Title 45 deals with public hmm health and part 46 deals with protection of human subjects. Subpart B is basically derived almost word for word from the national commission's research on the fetus that I showed you in the subpart D is derived almost word for word for the national commissions record research dating on children back to 1977. Spitee many lookees in the last years not a single word has been changed in the last 22 years and it definitely stood the test of time despite repeated challenges. This is the category of per miserable research in children. There are four of them. We'll go through these quickly now and focus a little bit more in detail later. But there's minimal risk. Greater than men mal risk but with the prospect of direct benefit which means you could go to extremely high levels of risks if you have a extremely high levels of benefits. As a minor increase over minutenal risk ind no prospect of direct benefit this is by far the most controversial four part of subpart. Two commissioners out of the 11 decrended from this and thought there should be no kind of research and subpart B for fetal research there is no such comparable phraseology. This is very important and very controversial aspect of subpart D that bears a lot of discussion. And then finally not within the scope of the above categories but presents a reasonableable opportunity to prevent or treat a serious problem that is the secretarial review that you heard me mention. There's a footnote here that the FDA has comeable and regulatory proinvestigatings 21CRF that is the code of federal regulations 21 deals with food and drugs. And they're subpart is 50 which deals with human row searchrotection. The definition in minimal risk generally is product for two vectors. But the discussion actually in 45C of our 46102 mens the men mal risk or probability or magnitude of harm or discomfort about paited in--anticipate in research are not greater than those daily life orfulysical or psychological testing. What I want to focus on is the vector business because you can have an enormous amount of harm airplane crash or car crash leading to death with an extremely low probability. For instance the risk of dieing for any one of news airplane crash is about 1 in 2 pone 3ion so we would get on the plane in a minute. I think there's few of us that wouldn't. Oddly enough death in the car crash is 1 in 6400 which is several three orders of magnitude greater yet we consider going to car completely minimal risk because we figure the probability is so low even know the magnitude may be enormous. I bring this up because many of the dire consequences in children as giving them an experimental vaccine as a risk of dieing 3 orders of magnitude less than driving in a car but it's hard to convince people of RIB of that. This is actual code fication and it doesn't make difference if it's their put particular or not. That's an--their pewic or not. Greater than men mal risk. This is key focus that you probably ought to be looking at today in view of some of the protocols that you are all involved with. And the risk is justified by the anticipated benefit. I think this actually implies heroic procedures that might be entailed in life-threatening illnesses for instance total body irradiation for total transplant for Leukemia. The second bullet is about available alternatives and third is about permission of the children and their parents and guardian. Only one parent has to sign for they aretic research. Now remember the IOM the institute book it was made for the benefit of children. In considering how to ascertain the prospect of direct benefit the institute of medical empaneled a group of experts pediatrics cling Dr. Nelson. They helped to guide our thoughts about benefit and risks had this book. I brought seven copies of it. You can scalp you one want of these I can get you one. It's easy for me to obtain more copies. This panel dealt with the prospect of the direct benefit and thought there should be a tanable positive outcome cure disease, relief of pain and increase mowility and we have to think about whether it leads to transient or permanent benefit. We talked about compensating levels of risk and benefit and one break through point they had was the business about collateral or indirect benefit he's in a study he must be learning a lot about biomedicine he's experiencing hospital care from the inside. He's getting great medical care and monitored. Nop of these things should be considered direct benefits they are definitely indirect benefits. You would be surprised how often committees wrangle with how there's a benefit from being in the hospital and being monitored and from getting a little bit of remuner ration. Interestingly enough the commission 30 years before this had gone to the heart and soul of the direct benefit by saying the expert of success should be scientific sound to justice whatever risk is involved. You would be surprised how many protocols we had to Wade through that have a fatal flaw. That simply aren't scientifically sound enough in their fast draft to go forward and even offer benefit. The institute of medical report recommended providing guidelines for RIBs. That's one of key point of this. They really thought that the subpart D as rine is really fine and shouldn't be tampered with. In fact it's written very interesting ways that encourage dialogue. You could say that given the same protocol two or three RIBs might come up with two or three different anes and you can't say any one of those answers is right. The process is right. The process is right just like our constitution in ways bedevilling arrest cane and ob truce. Some of the beauty is not defined but encourages dialogue. That's very important and key heart--from my point of view the key heart of protection is the dialogue that we all enter into when we deal with these kinds of protocols. They came up with an example of a study that is not approvalable under direct benefit. And let me just read this phase 1 pediatric cancer protocol will give a doesage with no probability of amillating the subjects' disease or management. The subcommittee of research involving children in human research protection that's we just love though acronyms. And Dr. Nelson sits on this panel too and he might have come up with this example. You give this dose just it so what the connectics maybe there's to possibility this small micro dose is going to alter the cancer of this child. You can't claim a direct benefit. But it might be approvalable under the next category which a mean for increase above minimal risk with no prospect of direct benefit that would be an argue that RIB would have to make with itself. Council for international organizations and medical sciences weightd in a few years ago about thought of face 1 trails. Because children are unique and affected by childhood illnesses it maybe impossible to extrapolate from children as adults we have heard. They thought we have to deal with this dilemma and sometimes go directly to phase 1 research in children not waiting for studies in adults. And this would be especially appropriate for diseases that don't occur in adults or pediatric respiratory deficiency or some of the congenital heart disease that children have. I think we'll see more and more of when you can start research in children without sort of short-circuiting prior researches in adults. We have resent FDA draft guidance on this too. Just this year the FDA reminded people that--investigatingors--that they already had in the way the guidelines were already written under the INDs they really could use early phase 1 clinical trails without a therapeutic intent that would involve screening or micro dose studies this is generally of limited duration and conducted before tradition and safety studies. This was a remarkable guidance out of the FDA and has an important foot not that Sarah car pointed out to me. This is a quote these types of studies would not be carried out in pediatric patients but I would say in some cases they could be. Generally, the word generally permits that I think. The second guidance the FDA come out this year is how to comply with the pediatric research equity act. This act of passed unanimously by both houses of congress a few years ago in order to give the FDA authority to require pediatric studies of drug companies if they had been used in children but not tested in children from 1999 to the present. This is remarkable action of couldess to a number of things that happened recently in in the pediatric community. In 1998 the FDA put out a pediatric rule ta said the same thing we have the right to demand a drug company to study drug in children if we think they should and support is necessary. This was taken to court by a number of groups would were very conservative and felt that this way overstepped the authority of the FDA and in fact justice Kennedy in 2002 struck this down and said the FDA did not have such authority but could ask congress for such authority. Well congress was so anxious to give this authority to the FDA because it felt it was so important that drugs be studied in pediatric age groups that he passed the pediatric research accunom mousely in both houses in congress even war against the Japanese was not unanimous. This shows how important in a town in Washington how important it is. If happened in 1990 when the institute of medical sen add another conference on pediatric oncology. An unsung hero is Dr. Summer gasee who some of you may know who thumbped the tub about this leading to the network in 1994 which is just had a wonderful partnership with the FDA. The FDA has paid much more attention to pediatric pharmacology over the past ten years. A number of offices and feed--pediatricians have make--we had a pediatric research equity act. The other thing that fed into this even though they weren't children one was April-year-old one was 22-year-old they had promise and potential and also the Erica gripes suit at onhoskins--john hop kins. It led to congressional angst for life threatening disease for which adequate treatment is not available may been earlier that happen my occur in less disease. The urgecy for the needs for product may justice the trails despite the relative lack of safety and ineffectiveness of the information. I think for life threatening illness that the pediatric research equity act paves the way for important studies early on. This is 46406 the minor increase overminimal risk and no prospect. There was to con 10 shes that two out of--contentious that two auth of 11--out of 11 descending. The in stute addressed this and said this is a slight increase in minimal risk. Duration of possibility and magnitude of the risk and also I'd say yes, risk, duration and possibility of magnitude. We come back to the two vectors we saw before they added duration. There is a idea of comensable ability you dothe treatment and not related to their experience if the past life. You have to argue otherwise it cannot qualify for 406. The bedevilling word and the panel thought it referred to a set of physical, psychological or effect health or well being. Some examples might be a genetic predisposition to obesity, living if poverty, live if a high level of lead in the environment like the kids in the Baltimore or being Annie yo Nate or adolescent. He was on the panel as staff. Arely in data? In fact recently about unpublish data. They didn't know she signed up for this but it's important. Finally the situation of the proposed subject. I don't know what that actually means. 44 or 6 a--446 and ofl important and overlooked by the way. Some kicked back and found not be be 407 by secretarytary panels. You wonder why there are four possibilities in subpart D why is one hardly used in the top one.

There's a group here in NIH who are very concerned about the fac that the rules and regulations are undefined and mean so many things to so many people. Interesting enough. When they went back to look at data and risk and children how RIBs look at this a paper was written by nars canand hop Kens in 1971 they asked several directors of and chairs of pediatric programs what they thought about a risk one I recall is where you particular a needle in the eardrum and let the fluid drain out. These are pediatric professors now one-third said a minutenal risk, one-third thought it was a minor increase above minimal risk and other third found unacceptable to be approved by the RIB. Here you have premeditation trick leaders unable to determine among themselves or come close to an agreement about a procedure. Here sexual activity survey. These are RIB chairs 22% said minimal. This is stunning to me that you can have so many leaps in immediate tricks and--feedatrics. 15% thought it was perfectly minimal. This was so studied so many R I B chairs felt so strongly about protocol changeby for change of captionners] The risk of playing football is 1 in 250 games. Risk of playing football or dieing in a car crash. This brings me to an absolutely stunning quotation from Alex that I never forgotten since I learned it in college. In America sooner or later everything ends up in court this includes REB members and there is a great fear in the land now and strong demand for in demmething should go horribly awry in the a studied end up in court. It has happened and end up again. I like to say no deed goes unpunished. Ethical principle and as a result of that. Differs from adults. Quite a number of drugs Ike gappapentin and total max--one was found to have twice the mortality of other comeable drugs in use in feedatrics. Ribbowvirine increased suicidal ideation. There are other things that come out in children not seen in adult. This brings us to the fact that our ethical issues continue to need an assessment from time to time. [please tannedy for change of captioners] -- or what bob would call the fallacy of the package deal is -- is part of what goes to avoiding the term therapeutic research but it's not meant, I think, to address that there can't be research that offers the prospect of direct benefit. But this prospect has to be put into context. It's not a threshold that you have to reach for anything to be prospect. So that would be I guess the key issue there.

Can I ask just one followup question? The hypothetical, on this whole prospect of benefit for you and your IRB. Let's say same kinds of animal studies and only animal studies have been done and you're talking about doing something on kids. One -- hopefully to emiruate deafness and the other blindness. One could think that those would differ in terms of harm. Would you look for the same quantum of evidence about prospect of benefit with both?

Well, neither is life-threatening.

Right.

And I think the assessment of the impact of blindness and deafness will vary depending upon the community you speak with. My own bias, I wouldn't limit theing withness *pness to apply any data, any adult data, any kind of preclinical data or on the nature of the condition. You know, the devil's in the details and the aply kablt of the models and the question of what can you get when you do it in adults. Is it applicable, is it not? It really has to be looked at in detail. It's a difficult question to answer hypothetically. I might add, I don't know what the IRB would do and I'm no longer the chair, so --

Okay.

I have a question. I'm also be willederred by the need as an IRB member myself to define prospect of direct benefit when our IRB, as well as nationally we've been instructed to try to separate science from our job of assessing risk benefit. I find it almost -- no, impossible, not almost, it's impossible to do.

Yeah.

Without assessing science and I'm wondering what your comment on that would be.

Well, you remember what the commission said. They said that you shouldn't even enter into this unless there's a possibilities that -- that this is going to work scientific cli. I mean, remember that -- here it is. The expectation of success should be scientific cli sound to justify whatever risk is involved. I think that is such a key quotation and implies so much about just what you're saying and our IRB wrestles with this all the time and I think that it seems to me some of the early part of subpart D actually mentions things that have to be scientific cli as well as ethically sound. So we regard this as an inherent part of our charge and I don't think it -- I don't think you can separate them. I completely agree with you. I don't think the national commission ever thought so either.

So let me then urge everyone to refocus IRBs on the science of the studies they're reviewing both locally at UCSF and nationally through a presentation by OHRP about six months ago to those of us involved in Pete yat Rick aids, I have specifically heard that -- and through the RAC actually, through comments by those being reviewed that, you know, science is reviewed over and over again and your task is to look at risk benefit. And my personal sense, my gut sense is, I can't do one without the other.

You're absolutely right.

Ms. Kwan?

I have two kind of unrelated questions. For the first one, I apologize if it's incorporated in your slides and I may have missed it. But the idea of minimal risk or slightly above minimal risk in allowing the research to go forward, was there any comment or interaction with the possibility that the risk could be eliminated by using another method or, you know, conduct -- obtaining the same piece of information without even minimal risk. Is that a factor? So, for instance, if -- if the trial were to be delayed six months to get additional data from an adult study, for example, but that the risk is considered minimal or slightly above minimal, is there any interaction in saying well, then you should wait?

I think that would be very wise counsel. And in fact, one of the key principals of the Belmont report was the -- all efforts to minimize risk at whatever level of risk you're at. So I would say absolutely.

Okay. The -- the second one, and I may be -- I'm going to take it out of context, but I think before this committee in previous sessions we have been faced with some investigators telling us that in a dose escalation study, let's say the dose was begun at a higher level than would otherwise be recommended because that's the only way that a pediatric research subject might possibly derive therapeutic benefit, how does that fit in with the reports and the directives and the advice?

Well, I guess my first question is how do they know what the dose is and why do they have to escalate it? Do you remember why? They thought that -- in other words, this is working adults at a lower dose but wouldn't work in a pediatric patient? Is that the idea?

I -- I don't -- can't cite a specific study, but I think the comment was, well, your animal studies would suggest that you start at a lower dose. Why did you pick such a high dose to begin this? And that was in response to that kind of question.

Well, it sounds like they're begging the question, if you ask me. That doesn't sound like a good answer, frankly. How do they know? But of course you could point out some of the drugs that I just mentioned that do need higher doses in pediatrics. I mean, this is not unheard of. I don't know if we're talking about actual drugs or vectors, but this is a very important problem and that's why I brought up the new guidance from the FDA that actually permits the studies of phase 1 in so called microdoses just to actually get PK without hoping for a therapeutic benefit. I think this is an important break through. But the FDA says that you always had this capability of -- of presenting a study like that but it's not used very often. That's why they came out with the recent guidance in April.

Consent is a critical component of ethical studies in adults. Can you just briefly discuss the role of assent particularly related to age and children?

Well, that's an accident children and the commissioners felt that it was up to local IRBs to determine and sometimes in cases each individual subject whether they were capable of assent or not. At the NIH we generally use and it's been promulgated a few places age 7, but that is very arbitrary and certainly there are 7-year-olds that are terribly precocious and others that aren't and couldn't understand what you're talking about. So you have to tailor it to the individual. And in some cases there have been guidances that the IRBs should actually look at individual children or have a -- a proxy or a liaison to follow the -- the consent or assent process in individual children depending on the severity or possible harms that could come in such a study.

How severe does the disease have to be before you would say the child -- that the parents consent would override the child's assent?

That's very interesting. That's a wonderful question. And people have wrestled with that and it's written down in -- in a number of documents and guidances and it is that the -- the parents -- if there's absolutely no other way this child could get similar therapy, this is the only avenue to improving the child's health, the child squirms and squawks and says no, the parents can override that, absolutely, if that's the only hope for therapy in that child in the research venue and it's clear and it's written down in a number of places.

Could you comment on the role of the states in imposing more restrictive limitations on pediatric research than those that are offered in the federal guidelines? For example, I'm told by our legal department at the Hopkins IRB that the attorney general of this state takes a pretty dim view of most of those categories of pediatric research. Could you comment on that? Not Maryland in particular, but the principle.

The Erika grimes suit brought up this very ancillary decision by the court, which was that parents or guardians could not consent to enter a child into nontherapeutic research that carried any quote -- any, underlying risk and Dr. Nelson and I were talking about this earlier in the corridor and that was changed because they realized that they -- the court realized it was out of consonance with federal guidelines that did permit research, minimal but not any risk. And the federal guidelines are written such that at least as far as determining the age of assent or consent in children and emancipated minors and minors living apart from their parents or minors who are parents themselves, state regulations hold -- are the most important or paramount. The state regulations could, at least in some cases abrogate any overriding federal regulations.

I was curious about that nice example you showed about the IRBs indecision or lack of consensus on what constituted risk. Has a similar study been done for adult? Is there a similar lack of consensus for adults?

That's a wonderful question. I don't know. This has been a very poorly studied area. Partly because it's -- it hasn't been an appealing area of study for journals to publish. I mean -- or even for people to go into. It's pretty remarkable. I mean even if people of pediatric pharmacology. When I was in medical school I heard I know he's a pediatrician but he's a pharmacologist too? I mean, there were certain areas people didn't go into in certain periods but now we have a lot of people interested in pediatric pharmacology. But now we're desperately needing quantify kags as the biomedical establishment becomes much more finely nuanced and many more risky procedures are on the horizon. We need these data but we need them desperately in children.

It would be interesting to go back and redo the perception of risk question to physicians -- kinds of risks that you had up there. Frequent blood draws, skin testing for allergies and ask those who are responding whether they've ever been involved or have been involved within the last five years. For instance, in obtaining blood from children. I suspect that the -- the differential in per spepgs is at least in part based on direct experience.

Absolutely. I thought that -- well, you're right on target it's almost like you're reading my mind because I've been thinking some of these pediatricians or chairs of departments probably haven't seen anybody except on rounds or done a procedure for years where as the interns and residents, we do these things all the time. Are there other questions? Yes.

Initially you talked about the two vectors attributing to the assessment and in the IOM introduced ration. Can you further expound on the duration and are the there any pragmatic points you'd like to convey to us?

I think the duration refers to -- I think this came up from a peripheral point of view in the guise of insulin clamps and how long would the insulin in the fusion be running. And if a child should become dangerously high bow glycemic, was there an instant remedy? And so in that case we're talking about a duration of a couple of hours, so using that as a -- as an example in your mind, you could extrapolate other kinds of procedures. Who knows how long is a child exposed to risk and sit reversible during that period of time and should something untoward happen would it be reversible there after.

Other questions? Thank you very much. This was a wonderfully informative and provocative presentation and will help us as we move forward to look at gene transfer in children and youth. We're going to take a break. We -- we had originally been scheduled to break until 10:15. It is now 10:15 so we'll break until 10:30. Thank you all.

The first protocol for discussion during this RAC meeting is protocol 740 entitled the phase I safety study using adenoassociated viral vector to deliver the gene for human RPE65 into the retinal pigment epithelium. The principal investigator is Albert Maguire from the University of Pennsylvania and the sponsor for this protocol is Katherine High from the same institution. And Dr. Maguire is going to present.

Good morning. I'm not Dr. Maguire. Dr. Jeanne Bennett and we're going to give a tag team presentation this morning.

So Dr. Bennett who will be presenting and in what order so we'll be prepared.

It will be first me, then fratzer Wright, then Albert Maguire and then Chris rocky. But first, on behalf of the team, I'd like to express our -- our sincere appreciation for the opportunity to discuss our propoetzed study here at the RAC today. I'd like to extend special thanks to the RAC committee and the reviewers for their comments and questions and I'd also like to thank Dr. Graves for providing such a helpful frame of reference this morning for studies in pediatric populations. So this is our phase I study. As you can read. The phase I study with LCA using adenoassociated viral vector to deliver the human gene remember 65 into the retinal pigment epithelium. it is involving investigators for the appointments at chop and at the University of Pennsylvania. As you just heard the PI of the study is Dr. Albert Maguire who will be presenting this morning. He's also my husband, and I -- I am the scientific director. I I'll lead in -- I'm obviously leading in now and Fraser Wright who will also be speaking this morning is the director of the CCMT vector core. So the oraleder of presentation is thus. First I will give you a little bit of background about the human disease and then I'll describe the preclinical and proof of concept studies, and the preclinical safety studies. Then Fraser Wright will briefly describe vector manufacture for the proposed human clinical trial and then Dr. Albert Maguire will discuss the proposed human clinical trial involving pediatric subjects including topics such as subject selection, trial design and future plans, and finally, Mr. Chris rocky who is a patient advocate will say a few words. So the original proof of concept studies took place over five and a half years ago starting in about July of 2000 and involved the investigators shown in this slide here. There are three centers involved. Wonderful scientists from Colonel, from University of Pennsylvania, and University of Florida and there were three different dogs involved in this -- this -- beginning study, one of whom is named Lancelot who you'll see in a second. We've also benefitted tremendously from funding for this study and the succeeding studies from the national eye institute and foundation citing blindness and other institutions including research to prevent blindness. This study has evolved because of the exciting result to include an expanding set of collaborators that you can see here. Clearly there are multiple institutions involved now in addition to the additional ones at the University of Pennsylvania and University of Florida. There are also investigators from other institutions and they're all listed here and I apologize if I inadvertently left any one person out. So what is labor congenital amaurosis or LCA? This is an early on set retinal degeneration with severe vision loss present from birth. It's also associated with abnormal eye movements where the eyes have abnormal movements. The symptoms are apparent in infancy and early childhood and mutations in any one of at least nine different genes can give rise to the disease. Importantly, there's no treatment for this disease and there's no cure for this disease. Mutations in the following genes have been found to cause LCA. And they're all listed here. And this listing is from a wonderful web site called RETNET which keeps progress of retinal genetics in retinal disease and I'd like to introduce you to the cells that are involved in -- in the primary cause of this disease. This is a cartoon of a cross section of a human eye going from front to back. And here if we focus on the back on the retina, which is shown here, this is a cartoon structure of the cells and the connections of these cells in the back of the retina. We're going to rotate this tissue 90 degrees and you see it here, and the cells that -- that are initially involved in this form of LCA caused by mutations in RPE65 are called the retinal pigment epipeel yum cells. These cells are the nurse cells to the photo cells which are the sensory cells in the retina and they provide important ingredients including vitamin A precursors to these cells which is critical for vision. Now, normally these cells contain a protein called RPE65, stands for rep specific 65 protein. As you can see here in a normal dog retina when it's subjected to immu know histic chemical for RPE65 protein, the protein is spent specifically in these cells where as it's absent in an affected dog. RPE65, the gene encodes an enzyme which is a retinoid isomerase and this is what is the critical blockade -- the critical block aid in the disease is caused by a lack of production of the important vitamin A derivative which is necessary for vision. Now, the proof of concept studies that I'm going to describe to you take advantage of two naturally -- one naturally occurring animal model and one genetically engineered animal model and these are shown here. The nch rally occurring animal model is a dog. The Swedish dog shown here is Lancelot who is one of the first three dogs who benefitted from treatment with a vector containing the normal version of RPE65. This is at his third trip to Congress where he's been an important advocate for the importance of biomedical research. And he is the dog who is now five and a half years post treatment and still seeing. We've also taken advantage of a mouse, which is knocked out of RPE65. This mouse was generated by Michael redman at the NEI and generously provided for these studies and we performed studies in adult mice and in fetal mice that I'm going to describe. Importantly, both of these models have similarity in phenotype to humans with LCA caused by RPE65 mutations. Now, the vector. You've heard the word vector early this morning by dra Graves and here it has a different sense. The vector here is what we use to deliver the corrective gene to the diseased cells. And in this case it's an adenoassociated virus. A recombinant virus which is not capable of replication and even in wild type virus has never been associated with any disease in humans or in animals. This virus that we're going to use contains serotype II ITRs. Those are inverted repeats and capsules which you see in this diagram and within it the DNA that is delivered to the cells includes a con stitchtive promotor. The Dr. Maguire will tell you a little bit more about this and production of this in a few minutes. But here are the scientific results and this shows the results that we first noted in Lancelot, the dog who you just saw who has been to Congress. So what you're seeing here are results from electroretinograms. This is a noninvasive global testing of retinal function, the electrical -- power of the retina after it's exposed to light. And here on the study was performed by Sam Jacobson and colleagues and what you're seeing here is a normal sighted dog, the wave form increasing accordingly to be very reproducible and quantitative and gives a good quantitative figure of the amount of vision that the animal has. As you can see, the wave form is very reproducible in terms of timing and amplitudes. Before treatment Lancelot had a severely abnormal ERG and you can see even at the highest intensity of light exposure there is barely a blip. These months after treatment you can see that he has an essentially normal appearing retinogram especially when you compare this what you see in a normal sighted dog and this effect has persisted. This shows 13 months after treatment and again it's now five and a half years after treatment and the results have recently been published in fact this month in molecular therapy. As I mentioned, this therapeutic effect has persisted and shown here it is evidence again published in the same article just going over three years and again it's now five and a half years where you can see year one, year two, year three. There's per distance of the effect. Now, what I'm going to show you here is a movie demonstrating the visual behavior which results from this treatment. You just saw the electroretinograms and -- and I think this is really going to show why this is so important. So what you're going to see here, there are three dogs. This dog here is just a friend. He's a large dog who is normally sighted and he's -- basically they're playing with two dogs, twins, who are both affected with the disease but one was treated and the other was not. And so what you see here, the treated dog is playing with the other dog. He's walking around picking up objects that he sees on the floor, moving without a problem. The untreated dog doesn't see the object that's thrown to him. He walks over here, bumps into this dog. Turns around, trips over the other dog. The treated dog is ready to catch objects that are thrown to him, walks around with them, eager to play. The untreated dog knows there's something going on but he doesn't see what's happening. In fact, he didn't see the handkerchief which was thrown to him. He wants to play but he just bumped into this other dog. He walks around very tentatively. He doesn't see this object thrown here and he just bumped into the other dog again. Again the other one is walking without a problem and the untreated dog walks around very cautiously lifting up his paws very gingerly because he's so used to bumping into objects and doesn't want to bump into them. Now, we have continued over the past five and a half -- five years to look at the results in additional series of dogs and this shows a series of 26 dogs which received subretinal injection of AARV 65. What this graph shows is again, electrofizz logical responses, ERGs, in these dogs and it's monitored in terms of rod photo ceptor function. The similar results are found for cone function. So what you see here is on the vertical axis, these are amplitudes of the ERGs and the normal sighted dogs who are untreated have amplitudes that fall in this range. Tun treated dogs or untreated eyes have amplitudes in this range, and this dashed horizontal line you see shows the maximal amplitude in an untreated dog. Each of these triangles, by the way, underKates one eye that was -- was subject to study. Now, when we injected this particular intervit rally, there is no improvement in rod -- however, when the material is injected subretinally so that it can -- 23 out of 26 of these eyes showed success in terms of recovery of this electrophysiological response. When we went along and further analyzed these mice in terms of histology, what we found was with these particular eyes which fell below this threshold, the injection actually went subRPE. So if we look at this data from another viewpoint, that's 23 out of 23 successes when the material went into the subretinal space. I mentioned that Lancelot is presenty five and a half years post treatment. He's certainly healthy from a clinical perspective and enjoying his trips to Congress and dinner dances and continues to enjoy vision in his treated eye. To date there have been rescue in these affected animals and I'll show you in terms of dogs and mice. So out of 35 injected eyes from affected dogs 97% of those have sho*e shown success in terms of rescue vision after injection subretinal injection of the greater than a.1X doles of AARP 65 and I'll show you that shortly. These are in ages approximately 3 months to 14 months of age when they're treated. In contrast, soo*e oh out of 16 dog eyes showed a therapeutic effect when they're injected intervit rally or subpigment epipeel yum. For mice we found that when we injected mice in utero, nine oud of 13 eyes showed success. That's 69% and I'd like to remind you what a technical feat that is. This is really submicroscopic surgery. Then with adult mice, mice at post natal ages of 2 to 47 months we found 24 out of 30 or 80% of the mice showed response to the treatment. And -- and importantly, this 80% is our success rate in accurate subretinal injection in adult mice. This is -- so this is -- if you scale it to that success rate, this is 100%. Then when weed at affected mice at post natal ages greater than 157 months, IE, very old mice, we found that only 16% of those eyes showed a therapeutic effect. preclinical toxicity studies of all the animals showed that they all remained clinically healthy for the duration of the study. No adverse effects in terms of food consumption, hematology, clinical values, there was a mild and reversible ocular inflammatory response after surgery except for one eye and by the way, ocular inflammatory responses occur naturally after surgery in any species. And in response to one of the RAC reviews I'd like to describe what we think the cause of that extra inflammation was. And that -- the -- that is as follows. In the fall of 2001, lab grade vector preparations were combined and these are four different preparations to inject a set of 11 dogs or 20 eyes. And we found that a number of these eyes had inflammation after surgery which is, what I just said, we typically see this after surgery, and all except one responded to medical treatment and that medical treatment involved eye drops and in some cases some con gynotitle injection of steroids. We were very concerned about this inflammation particularly in this one dog and we did a study to evaluate the possibility that our vector stock was contaminated with bacteria or there was bacteria present within the eyes. We tapped the eyes, grew out the sample, found no evidence of bacteria. We thought perhaps the vector was replicating evening though that's very unlikely and we looked at that by looking for presence of rep and cap by PCR and by immoo no histochemistry and so no evidence of that. And importantly, we've not seen any sorts of inflammatory reactions of any of the dogs initial Liz treated or those that have subsequently been treated with 65. And we think we've identified the cause of this inflammation which is shown as follows and this is published in this month's journal molecular therapy. When we ran out each of the vectors which were combined, I said the -- remember I said there were four different vectors which were combined into one solution. When we ran them on a protein gel and did silver stemming of the gel we found that one of the vector preps gave rise to a series of multiple bands on this gel where as a -- another vector, which was coinjected with it had what we expected to see, which are the these predominant bands associated with AAV. And so just to conclude, we feel that the most likely explanation for the inflammatory response in this set of dogs was due to the coinjection of this dirty vector prep in these eyes. Now, importantly, all of the dogs that we followed long-term after coinjection of these batches of vector showed rescue of visual function. Now, what about vector spread beyond the retina? The RAC has traditionally had an interest in what happens in terms of transfer to the testes and the ovaries and what is possibly the transmission of parent to child. We've seen no evidence of transmission of the DNA from treated dogs or mice, and in -- in our series of dogs, Lancelot, who was one of the three dogs, was -- is the proud father and grandfather of more than 50 puppies, children and grandchildren. He was mated with an affected dog and none of those dogs have first of all shown rescue of the phenotype. They were all born blind. And second of all, in biodistribution size which we'll get to we found no evidence by PCR or presence of the vector in the gonads. Mice we breed from the initial stock provided by Dr. Redman and we don't on purpose cross treated mice with other mice, but in certain situations these mice do breed actively when we're maintaining them long-term so they have reproduced and we've seen no evidence of transmission of the DNA to any of those offspring. Now, I think it's important to bring up results from a hemothelia B clinical trial with which Dr. High has been involved. In one trial, 140 trillion, that's a lot of zeros, vectors, that's more than three log units higher than what we intend to inject in the eye. This many were injected into skeletal muscle in humans and there was absolutely no evidence of PCR of vector in the semen samples of these affected males. In the second study the same amount of virus was injected systemically into the hepatic artery and in those individuals there was transient detection of vector sequence in some -- in semen of some of the individuals, but this all cleared by 16 weeks after treatment. So we think that this risk is minimal. And now I'm going to tell you about the possibility of vector spread to the brain and elsewhere. We're particularly interested in the brain, obviously because the eye is connected to the brain via the optic nerve. Let me just stop this for one second. And so one question is where is the vector localized, where's the protein localized. And so what you see here is a fundus view of one dog immediately after injection. The eye extends in this extent of the screen. What you're seeing here is actually the refleckive to pedoum of the half of the eye and the optic disk is right here. This is where it receives the injection just a few minutes before we took this picture so the virus is contacting the epipeel yum cells in this portion of the retina only. We let this dog go, measured its vision, it was rescued and then we looked at the tissue by immu know fluorescence to locate the 65 protein. And what you're going to see is a cross section going all the way across the retina and this movie was very nicely done by Kelling and it's again in this paper which was just published. So here is the entire section of retina made by overlapping these sections. And what you're seeing is immunofluorescence. We're going to get to shortly, the region where the material was injected which is right here and here you can see this apple green color which reflects positive RPE cells localized only to the injected portion of the retina. Notice also that there were no gangliocells. This is important because those cells send their ax son out through the optic nerve. They make up the optic nerve into the brain. So the question is do we see this protein in the optic chi yachl of the brain, which if we don't, that's a good indication that it's not making it to the brain. This is representative of an immunofluorescence of the optic chi yachl of the affected dog. And you see this on kick chiasm section. Now, it's also important to note that we have been able to successfully repeat the administration in contralateral eyes treated with AV 2 despite small increases in AB 2 specific antibodies after the injection of the first eye and this particular experiment involves the transfer -- we injected one eye of a mouse with AVE GSP and waited three weeks until there were antibodies present in the serum and injected the contralateral eye and this is what we see at the six week time point. Similarly in monkeys we injected one eye subretinally with GFP and waited for -- in this case, seven months for each of these animals. There was evidence that there were antibodies, mild antibodies, levels of antibody in the serum of these animals and we injected the second contralateral eye and these are the differences you see in those two eyes. There's exquisite -- Now, one other question is how do we determine the dose levels of -- for the therapeutic effect? And this has been done using the cumulative experience with 29 eyes of affected dogs after subretinal treatment with AA VRP 65 in this particular dose range, plus a dosing study in 15 affected dogs over a four and a half log unit range of doses of this virus going from this level to this level. And the data is shown here and was presented at the RAC last June. This is performed by Dr. Jacobson and colleagues, and what it shows is, again, the ERG amplitude threshold at -- before -- in untreated animals, control animals and then after treatment. And this is, again, in dogs. Each one of these circles represents an individual dog, because one eye of these dogs was treated. And the vector dose is increasing as shown in this grated series down at the bottom, a portion of the graph. What you can see is as the dose increases, there is an increasing number of eyes that respond -- show response in terms of visual function. And I'd like you to note that even at the lowest dose, which we plan to use in our study in -- in a human population, there was evidence of a treatment effect, and Dr. Maguire will go more into these details. So one more question about dose and inflammation. We have looked clinically at affected dogs and unaffected monkeys after subretinal delivery of AVRP 65. This is clinical grade vector and these animals were scored by a team of veterinary ophthalmologists or human ophthalmologists for the degree of inflammation going from the front to the back of the door. Cornea, interior chamber, lens and vitreous. And the inflammatory changes were apparent in both monkeys and the dogs after injection of the vector and after injection of the vehicle. There was a minor trend of increasing ocular inflammation with dose familiarly at the 3X dose, however, most of these -- or essentially all of these inflammatory changes resolved after one month. There were slightly higher inflammatory changes noted in the canine study than in the nonhuman primate study and this is not unexpected. In fact, the canine eye is known to be -- to respond with much more inflammation to surgical procedures than the eye of any other species including humans. So finally, we've looked at preclinical toxicity data in terms of the injections and the tissue effects. This slide shows the photograph of a retina that -- three months after its subretinal injection of a 1X dose. This is the to pedodal half and this is the nonto pedodal half. The cannula entered the space at this location and this leaves predictably a scar in that location and what I've drawn here is the borders of the retina as identified from the original injection photos. This bleb extended out in a dumbbell shape. If we look at the needle entry site, predictably you see trauma at the injection site and the retina is folded up and there's sometimes rosettes formed in this location. In some eyes, in some regions of the retina we did see iminflammatory cells and these are shown here. Please note that there are no inflammatory cells identified in the subretinal space which is where the vector was delivered and in addition, there is evidence in some of the animalss of thinning of the outer nuclear levels shown here, the photo ceptors and this is likely a result of the injection procedure itself, but please note that there are definitely distinct photo ceptors remaining here. So finally, we feel that's very important to conduct a GLP preclinical toxicity study to evaluate the potential toxicity and biodistribution of the clinical grade vector that will be made at the CCMT, and we'll -- we have designed these studies and have been discussing the design of these studies with the FDA and these -- this study will involve both early and late time points for analyses. So now I'd like to hand over the podium to Dr. Fratzer who will tell you a little bit about the vector corps in the clinical grade vector.

Yeah, so, okay. So I'm Fraser Wright. I'm the director of the clinical vector corps at the center for molecular therapeutics at children's hospital Pennsylvania. I have five slides and I'd like to briefly go over our new facility at the children's hospital of Philadelphia, describe the process for which we will make AV 2 gene transfer vectors and give some description of some o of the characterization that we will be forming on the vectors. In this first slide, we have a -- this is a picture of the Abe ram's research center. This is part of the children's hospital of Philadelphia. In the building is located our new clinical vector core. It's up on the 12th floor right here. This is a 10-year old building and the area we've designed this in is actually only two years old. On the right side in panel B is our clinical vector core. It's a 5 room facility. We designed this in collaboration with the FDA at a type C meeting back in April and we have implemented recommendations from that meeting. The area involves a staging room, gowning room, subculture room and a degowning room. Unidirectional flow and other standard come poets of GMP manufacture. We also have a QC lab closely associated and an R&D lab in support of these activities. In total we have approximately 2,000 square feet of space supporting these activities. Can you hear? Okay. Now I have two slides that will describe our process for making the AAV vectors. In the first slide I will talk about our biosynthesis. we start with HEK 29 human embryo cells from a well character rietzed master cell bank. We see these cells in roller bottles and once we've reached the appropriate level of approximately 70% we perform a triple transient transvection of the cells. Foe lowing this transection process we perform a media exchange into serum free media to reduce serum components. The purification method that we have developed and optimized is outlined in this slide. Essentially we harvest the material and remove some of the culture components. Media components by filtration and -- the concentrated material is liced, the cells are liced by microfluidization ho mojization and the vector, which can pass through a point to a micron filter is recovered from this and separated from the cell debris which is contained in a filtration step. Subsequently we apply this material to an exchange column. This is a 50 H S column which we have previously published details of for purification of AV 2 vectors. Concurrently we perform a digestion step on the vector. The material that is recovered from the columns and essentially purified AAV particles however it is composed of everybody advertise capsids and genome particles. Following the gradient -- we appoint two micron filtration and we have made arrangements for final labeling and Vile fill and finish at a qualified contract manufacturing organization. I won't go through in detail the -- the list of assays that we perform for our quality control characterization of the vector however I will inindicate this list includes qualified assets for the -- these assays are performed on each and every lot of the vector. I've outlined the methods that are used here and these are generally standardized and in most cases published methods. As the last slide I just want to give an indication of the quality and purity of the vector that is produced using this manufacturing or G and P manufacturing process. I've indicated two sodium -- electrophoresis gels here. In the left panel is a gel in which we've loaded two -- and stained with silver staining. It's a highly sensitive method to pick up proteins. We'll pick up the product as well as the impurities. Essentially all we see at these loadings which give substantial levels of the VP 12 proteins, these are the expected proteins, these are observed and e season usually no significant levels of impurity proteins are observed. Similarly when we perform blue staining on much higher loadings of gels so this is another way of assessing the purity using a different type of a stain. We see essentially no significant bands other than the VP 1, 2,nd 3 corresponding to the expected AA V 2 vector proteins. So I'll finish off with that and pass the podium to Dr. Ma Dr. -- Maguire for further presentation.

Thank you. I'm Albert Maguire, the PI for this proposal. I am a retina specialist and surgeon at the University of Pennsylvania. In order to eliminate any potential conflict of interest related to my participation in this and other trials, I forfeited any financial benefit related to a pending patent based on this therapy. And likewise, my spouse and collaborator, Dr. Bennett has wa*ifzed any financial interest as well. To begin my presentation, I'd like to go over some of the clinical features of this condition which are important to consider in context of this proposal Leber Congenital Amaurosis is an incurable disease which begins with near blindness and ends with complete blindness. Affected individuals are born with poor vision and this poor vision is slowly extinguished over time, ultimately resulting in total blindness in adulthood. In the year 2005, there is no treatment for this disease. Care is entirely supportive and is based solely on adapting to a life without vision. This is, therefore, a disease of morbidity, not moralty. LCA results in loss of function, namely vision. It is organ specific, actually tissue specific in that it only affects the retina. Leber Congenital Amaurosis is a rare disease. In the form of LCA formed by mutations in the RPE65 gene is rarer still. There are very few individuals that have been identifyed with this gene defect and it is estimated that in the entire United States the number of people with this disease may be on the order of 2,000. This is truly an orphan disease. Leber's amaurosis is a pediatric condition. Patients with LCA do not succumb to the disease but their eyes do. Their retinas do eventually die. It is not relevant to speak about an adult form of this disease. There is no such thing. Most investigators accept the notion that the possibility of deriving a benefit from treatment diminishes with age. And this is what underlies our rational for proposing a pediatric trial. These are photographs from two LCA patients. One age 13 years, the other 27 years old. This is the optic nerve. The macula, which is the center of the retina where we get our central vision. The retina -- note the extensive pigmentary changes in this older eye, which occurs in areas of the generated retina. The retina is fused in these areas and is surgically inaccessible. We are most interested in treating the macula, which is here, a 3 X 3 millimeter area of nerve tissue which is responsible for our ability to read, recognize faces, drive, and so on. You can see just looking at these pictures the potential challenge of doing surgery in this older patient with this surgically inaccessible area of retina. Arguably, our animal -- our animal studies are most properly considered as pediatric models for LCA. The vast majority of our gene transfer experiments in animal models were done in animals under one year of age. The dog studies were done exclusively in animals under two years of age. While delivering the vector, it's possible in older animals, the surgery is technically challenging due to difficulty of injecting the older degenerated fused retina. What is clear is that our greatest success in terms of recovery of visual function occurs in younger animals. As previously stated, success in the dog model was documented in animals less than a year and a half years of age, and investigators at other institution -- other institutions report similar results in young RPE65 mutant dogs. Studies we performed in aged mice with RPE65 disease, demonstrated a substantial reduction in treatment affect in the older animals. This was true both in terms of the percentage of animals that showed a treatment response and also in terms of the absolute degree of physiologic rescue of the retinogram. This is data taken from the studies on aged mice. First, note the decrease in the treatment effect in terms of the recovery of the electric response of the retina. In the -- notice the difference in scale. This is 25 microvolts in the older mice. 50 microvolts in the younger mice, indicating a much larger electrical response in the younger mice. Further more, the raw percentage of treated animals, which demonstrate any evidence of rescue is substantially decreased in the older population. You saw this slide before. We have over 80% success rate in terms of any recovery in ERG in the younger group and much less, less than 20% in the older group. Parenthetically, again, this difference between 100% and 80% is attributable to the fact that our success rate in achieving subretinal injections in mice is on the order of 80%. I'm pretty good at doing these injections, but I'm not that good to get every single mouse injection. So the main rationalE, so this is the main rationALE for a pediatric trial. We feel this is a pediatric disease and therefore appropriate to do a clinical trial in children. Like many other inherited pediatric diseases the opportunity for benefit is lost over time and from the point of view of a clinical trial, the amount of useful information is diminished as well. If we are evaluating respiratory distress in a premature infant, how much do we learn by evaluating pulmonary surfactant in a normal adult and should we put healthy adults in a study for which they can derive no benefit? Another factor which we should recognize relates to the difficulty of doing surgical delivery in older degenerated retinas. Not only is there less viable tissue, there's less tissue. As I stated before, the degenerated retina is fused together and cannot be successfully injected. The older the subject, the less retina available for surgery and the greater the difficulty of doing that surgery. We recognize the important ethical considerations inhernts in a phase I clinical trial in a pediatric population. We have sought guidance from our -- from representatives from the children's hospital IRB to both better understand and to respond to the issues involved. The level of protection for child participants in clinical trials should be set at the highest possible level. We have implemented several layers of protection in our protocol with special emphasis regarding informed consent and willing participation. By far and away, the most serious risks in this study is the use of general anesthesia. The risk of morbidity would be limited to the potential complications involving the one treated eye. Based on the preclinical data, we believe the above risks are justified by the anticipated direct benefit to child subjects and the relation of the anticipated benefit to the risk is at least as favorable as available with alternate approaches of which there are none. Although the primary purpose of this phase I study is the collection of safety data, based on results from our animal experiments there's also the prospect of direct benefit to partis -- participants in the study. This is not a pharmacogenetics in healthy individuals. We will be evaluating primary and secondary outcomes of visual function for evidence of a therapeutic beneficial effect. Second, while order of preference places adults before children, we feel that a study of adults may yield diminishing returns both in terms of potential benefit and in terms of knowledge to be gained from the study. As stated before, this is a pediatric condition. All agree that the ultimate target population will be infants and young children. Performing a study in older adults with devastated retinas may not provide adequate information to proceed with further -- further studies in a pediatric population. Now, on to the study. This will be a phase I study evaluating the AAV vector in individuals with Leber Congenital Amaurosis. Again, know that this is a safety study. We anticipate a potential for benefit and vision will be one of our outcome measures. This will be a dose escalation study with three groups of three subjects, each, and a total of nine subjects, so that's 3 X 3 groups, total of 9 subjects. It should be noted that the lowest dose of vector to be used did show evidence of efficacy in our animal model studies. We have chosen the sample size based on the principle that only the minimum number of subjects should be exposed to the potential risk in order to obtain valid information needed to proceed with further investigation. Three subjects per dose cohort has been typical for early gene transfer protocols. It is critical to keep sample size to a minimum, particularly for rare disorders such as Leber Congenital Amaurosis. The proposed sample size, should, however, provide sufficient safety and dose response data to establish a likely best to initiate a plan in younger children than this. The time interval between subjects and between dose escalation is based on acute safety data and the biologic considerations of transgene expression. Based on the known delay of up to 6 weeks between the delivery of AAV 2 and the onset of transunit expression, this interval will be between the first and second subject -- the interval between the first and second subject will be six weeks. There will then be a minimum two-week delay between the treatment of testimony second and third subjects, and between the third subject and the first subject in the next dose cohort. To be eligible for inclusion in this study, subjects must be legally blind due to RPE 65 form of Leber Congenital Amaurosis. Both eyes must be sighted and we will treat only one eye. The other eye will serve as a nontreated control. Subjects will include individuals between the ages of 8 to 18 years of age, and I will elaborate further on the rational between this specific age selection later in the presentation. Standard precautions will be implemented for females of childbearing age. Subjects and families must be willing to adhere to the study protocol as discussed in the informed consent document. Individuals participating in the study must likewise be available for long-term follow up. We have given careful consideration to the consent assent procedure for this study. We have met with representatives of the children's hospital of Philadelphia IRB to discuss the issues and to -- and to develop what we feel is a reasonable and appropriate approach. Our goal is to provide the highest standard of protection possible in terms of informed willing participation. With this in mind, for subjects under the age of 18 years, we are requiring both parental consent and patient assent in order to participate in the study. At any time if the subject decents or if a parent with draws consent the subject will be excluded from further participation but will be provided study related care. In our written response to this committee we have elaborated on other aspects of this process including which individuals will participate in the process, the availability of additional reference materials such as audio tapes, the use of talking points and so forth. One aspect which I'd like to mention here is the presence of an anesthesiology representative in the consent assent process. The major risk in this study will be the use of general anesthesia and therefore we would feel that it is most appropriate to have an anesthesiologist as part of this informed consent process. We have responded to the comments of the committee and have expanded our informed consent to comprehensibly detail the possible risks related to the surgical procedure itself and to the administration of either too little or too much transgene. We will implement exclusion criteria relating to ocular systemic and the psychological condition of the subject and family. These are detailed in our study protocol, but there are some aspects I'd like to specifically mention here. We will be screening all subjects for the presence of neutralizing antibodies to AAV 2 and exclude these with those of 1 to 1,000 although we found that the retina is a favorable environment in terms of immune response, we will nonetheless take these precautions. Finally, a subject may be excluded from the study if in the investigator's opinion, they are some -- they are somehow unsuitable for participation. In my experience, I have excluded subjects from other studies because I have felt their participation would be unduly stressful for themselves or their caretakers and I feel especially strongly about this in the context of this present proposal. Both -- both health related -- for our assessments, we will be looking at on -- and the physiologic in terms of effect of toxicity with regard to structures of the eye. As we have developed a extensive table, which is in your handout in the protocol for systemic evaluation based on the world -- world health organization toxicity scale and we will use this in addition to -- we have stocking rules based on the dose limiting toxicity and we will be incorporating a data safety monitoring committee which will have access to all this data and they will help decide about the need for additional s*up subjects at a dose -- dose limiting toxicity is identified and they will also determine -- determination of further participation in the trial. Both health related and vision specific quality of life assessment will be incorporated into this study. A trained technician will deliver the quality assessment instrument either in telephone conversation or in face to face interview. An assessment instrument for health related quality of life has been validated for children -- yeah?

Move your slides in the other direction.

Thanks. An assessment instrument for quality of life has been validated for children adolescents to age 2 years of age. The vision quality of life assessment is problematic. The national eye institute has developed a visual function questionnaire which has been validated to measure vision targeted quality of life in adults, but this has not been done for children with low vision. We would clearly need to modify the existing instruments to be both age appropriate and vision appropriate and I've been in contact with experts in low vision and in pediatric ophthalmology for input on this issue. before closing, I'd like to revisit the issue of age selection in this proposal. I've already discussed the rational for doing a pediatric trial in general. I'd like to now share our reasoning behind the specific age selection in this study, that is 8 to 18 years of age. There are two additional risks that come into play when we consider children below the age of 8 years. First, children under 8 are susceptible to loss of vision due to amblyopia. If there is something that transiently impairs vision, the visual system can be impaired on a central basis. The older the child, the easier this problem amblyopia is -- the easier it is to treat and by the age of eight, children are no longer at risk for this problem. Second, there is the issue of eye growth. After birth, the eye grows rapidly so that by the age of 3 years, it approaches adult dimensions and by the age of 8, the structures around the eye, the eyelids, the orbit are of adult proportions. After the age of 8, size is not a factor in terms of surgical risk. Looking forward, we foresee using the information from the 8 to 18-year-old group to develop a clinical trial for the younger age groups. Based on risk benefit considerations, we would like -- we would move to the 3 to 7-year-old population where the risk of amblyopia may be increased, but the potential benefit of rescue would likewise improve. We would proceed lastly to the youngest subjects which pose the greatest risks in terms of both amblyopia and surgical challenges, but likewise, may derive the greatest benefit. We have tried to weigh these multiple considerations bearing on risks and benefit in coming up with our age criteria. In closing, we hope the RAC members will take into consideration the balance of risk benefits we have presented in their deliberation and recommendations. Dr. Bennett and I have described the scientific and medical considerations which have gone into the design of this proposed stud diz and for a perspective from a parent of a child with LCA, I would like to introduce Mr. Chris rocky.

A year ago I never would have imagined -- a year ago I never would have imagined that I'd be standing here. Our beautiful son Ty Christopher was born on December 18th, 2004. Excuse me. He's our first baby. It was the happiest day of our lives. When doctors pronounced him healthy, you were ecstatic. He was the best Christmas gift we could have ever gotten. Two months later when Ty wasn't making eye contact -- I'm sorry. We knew there was a problem. After many doctor visits and testing, we had our diagnosis. Ty has Leber Congenital Amaurosis we were told to take our baby home and adjust our expectations. Sorry. Ty is blind.

If you want to continue, that's fine. You don't have to. We understand.

Yeah, I want to continue.

Okay.

Ty is blind. Our hearts broke when we were told that there's no treatment. I can't describe how we felt at this time. It was very dark time in our lives. The beautifully illustrated children's books we bought for him were replaced with plain white braille books. The nursery we so lovingly decorated for him he sadly can't see. The bicycle I couldn't wait to buy him will be instead a white Cain to help him get around. My dreams of teaching him to play baseball in the backyard were gone. My heart sank the day I realized my wife would never see his face light up when he walked into the room. All our dreams for his future were taken the day we found he has LCA. I'm sorry. What makes this even harder for us is that this is a genetic condition. We planned on filling our house with children, unfortunately any future children we want to have will have a 25% chance of also being born with LCA. When the time comes, we will have to make that difficult decision whether or not to have more children. LCA has not only affected us, but also our families. Ty is is a long awaited first grandchildren on both sides of our families. Seizing the pain in our parents' eyes when they come to see their grandchild is devastating. I can't tell you the amount of pain this has caused not only us but our families as well. This is why I urge you to let those wonderful doctors to perform their trial for gene therapy of LCA in children not only for Ty but for many other families affected by this. It is so important for us to do all we can to help these children see. They deserve their sight. We understand the doctors are trying to develop a treatment and that there are some risks but no guarantees, but unless they're allowed to try, nothing will get done. This Christmas, Ty can't see the festive decorations in our house. He can't see the Christmas tree. Or the pile of presents that will be under it for him. But with your help, maybe in a few years, he will. You see, our son Ty,, thank you.

Thank you very much. And thank you Ty, as well, for joining us this morning and I want to thank the entire group who presented for clearly answering at least, I believe clearly answering the majority of the RAC's questions and for directing your presentations towards what we consider to be the major issue for discussion this morning. That is the conduct of this particular gene transfer trial in children and youth. And because the thrust of our discussion this morning is going to center around the risk benefit analysis of this particular study in children and youth, we've chosen to reverse our usual discussion sequence. Generally we begin with questions, comments regarding the science of a study and conclude with questions and comments regarding the ethics, the risk benefit analysis, the consent document. Today we're going to reverse that and we're going to begin with Dr. Powers questions and comments. Dr. Po*uzers?

Thank you. Just as a preparatory remark, I'll say that just reiterate what was said this morning by Dr. Grave. There are very few kinds of protocols that would come before the RAC, probably of greater public interest than one that would involve pediatric research subjects. I think Dr. Grave pointed out quite nicely that it's -- it's a very controversial area. It's been controversial from the beginning, even though the language has remained as Dr. Grave pointed out the same, so too have the debates. And so trying to understand these very difficult slippery concepts of minimal risk and ordinary life and things of that sort, it's really tough and it would vary among members of the RAC, if I had to predict if we were to be looking at this or any other protocol, our own gut feeling, I think at this one moment might vary in part because, you know, we talk about these decisions as being decisions under risk, but they're probably decisions under uncertainty and that is to say that we really truly can't quantify some of these risks or some of the benefits either. We -- we rather impressionist cli gesture at those benefits soy want to thank the investigators for spending a lot of time in the written remarks they gave us which were only briefly summarized here in a public arena. They tried to do an awful lot to address a task. I think it's really a tall order. Let me start with I guess my most relatively minor points first in inverse order as I've put them in my questions for the investigators. My first question for the record was an open ended question asking the investigators to discuss the quality of a life assessment, how it would be administered, by whom, what kind of information would be gathered, what its overall focus was. They provide add considerable amount of information in the public discussion today about that. It was very helpful to see, not only in terms of just what it would be like from the experience of the family and the subject, but from what kind of information scientifically would be gathered. So that was very helpful and my question has been rather fully annalsed, I think, in that regard. Other scientific comments -- colleagues, I'm sure will have comments in that area, nonetheless. Secondly, I asked to describe the -- the process of assent. And they did provide a great deal of information about that, some of which we've heard in a public presentation today. I want to commend the investigators for their detailed and thoughtful discussion they provided us of how that process would work and I want to commend them also, I think, for taking probably the most risk aversive posture that might be done here. We're requiring the -- the con sent of both parents and the consent -- the assent of the child, and to make an individualized judgment about whether a participation would be too stressful or inappropriate otherwise for particular subject and subject families. And the process that was laid out in some detail struck me as a -- as a very thoughtful and nuanced and cautious one so, again, I appreciate the level of reflection and responsiveness to that question. Thirdly, I asked about the selection process, and within the -- the discussion today and then the document, much information was given -- was very helpful to see why they thought about not going below 8 why they thought about staying as low as 8 as compared to maybe reaching up to the slightly higher years where the process of comprehension and understanding might be considerably advanced in the subject themselves. They seem to provide a great deal of information in that area and again, I -- I would dez fer further comment on that to my scientific colleagues as to where they have more fine grained accounts. But I appreciate the efforts to provide some considerable information about subject selection and the age choices. Finally, in essentially the biggest central question, is the overall process of risk benefit. Dr. Grave offered this morning a -- a cat gorization and typically we would think of -- of a phase I study in this arena or any other arena as one in which it's nonbeneficial research. Where the prospect of benefit is -- is one in which we need to be sure and informed consent process is not overstated and that we're really doing safety studies, and so you start at least with a baseline assumption at least for the purposes of further discussion of whether this is a nonbeneficial study such that you need to have a more cautious view about how much more than minimal risk is likely to be there and how much generalizable knowledge. I gather from the presentation, this is my first really question at this juncture for the investigators is that their ultimate discussions with their IRB and their own internal discussions would lead them to characterize this as the study in which there is some prospect of benefits, and that -- and it's in that category among those shown by Dr. Gave this morning that they would characterize this study and so my first question is a compound one, if you will. Is that, in fact, your assessment of which category for analysis this falls within, and a second part of that is what would you say to one of your own IRB members if they were to say, I see this as nonbeneficial research, greater than moral levels of risk, considerably more and perhaps maybe a good candidate for the 17th of these studies to go to the secretary.

Well, to answer your first question, I -- I would reiterate, we do consider this a phase I study with the prospect of efficacy, prospect of benefit and that's how we have -- we will be presenting it to our IRB. And in terms of the science -- in terms of going to the IRB, in fact, we've had informal discussions and very helpful with our IRB. We would address that question by -- once again presenting the science aspect. I think what you've seen with the animal experiments rarely do, I think, have two animal models for a condition like this, rarely do you see such compelling evidence, both in terms of the functionality of the animals, their behavior, and in terms of the objective physiologic response. And those are the -- those are the arguments I would present to the IRB in that -- in that context.

The -- I guess another component is -- is to think out loud about the kinds of things that might change the risk benefit equation even if only marginally. Could you comment I guess that your conclusion is that some proceeding ahead with some adult studies would -- would not even marginally change the risk benefit calculus in this instance? Is that a fair judgment

Well, I'd like to point out that this is a continuum, this disease. And actually, we will have -- in looking at it by definitions from different groups, we have adult, addless sent and children in that 8 to 18-year-old age group. The concern I have is when you look at, again, from a scientific standpoint, a retina, a tissue which is completely atrophic and nonviable, there is much less possibility of deriving useful information that can be used to project studies in the younger population. In addition, I think somebody had mentioned the aspect of doing a -- the pharmacology of a smaller eye. And, yes, these eyes aren't completely -- these aren't totally adult size, so we will be deriving information that I don't think you can get in normal full-sized adult eyes by shifting into this smaller group. The dosing may turn out to be different.

Yes. Thank you. I appreciate the one part of the equation, which is the uniqueness of information to be gained from this population. My -- my question actually went to the other side of the coin slightly, and that is whether proceeding first in a kind of staged way with some further adult studies would provide you with information that would change the risks that you profile as you move to this population. Would there be no gain or some gain and what kind of gain if there is some gain would be attainable?

I guess my answer to that is we have a lot of excellent animal safety data already, which we feel more than adequately addresses the safety issue. And in fact, we've had discussions with the FDA about the safety issue, and they're in agreement, they -- they feel that we would only need a small additional animal study to satisfy their cry tier iteria which I think are pretty stringent and they had not recommended a adult trial.

Okay. I think at this juncture I would like to hear more from the scientific colleagues but I think that certainly sets the predicate for discussing whether this in fact fits that particular category or one of the other kinds of categories. These are not easy calls. I will simply say that. And I -- I do commend you in particular for having this extended discussions at the IRB at the front end and I appreciate the time you spent trying to help us get a handle on that. What you're likely to hear in here and beyond is -- will be messy because reasonable people will deeply disagree about how to characterize that, even among those who very much appreciate the terribleness of this condition and the importance of moving forward with a lot of clinical -- preclinical animal model material. So I will stop for the moment with that.

Ms. Shapiro?

I too want to thank the investigators and the other speakers both for their presentations today and for the very complete response to -- to our questions. Many of my comments and concerns and questions overlap with Dr. Powers so I'll try to be brief. But just a bit more on the risk benefit ratio which of course is key here. I, myself, found compelling the discussion of the prospect of benefit for children in this protocol, which leads me to ask the investigators if they care to answer this as an aside whether given that IRBs always are charged with a risk benefit evaluation, whether they were wrong to have approved the adult study. You can answer that or not, I guess. U I'm still concerned and --

I'd actually like to hear that answer.

Good. Me too.

And perhaps not as -- as -- as directed as wrong, but perhaps -- well, let's see what you answer. Wrong is a strong word.

Yes. Sorry.

I'm going to take the advice of my colleagues and just say that that is a study that's -- has another sponsor and although I am actually the surgeon for both studies and I think there is a rational for both, I don't think I should comment in detail on somebody else's --

Pleading the 5th. That's wise.

Perhaps inserting different study. They're two different studies with different goals.

Yes.

However, I, too, like Dr. Powers am going to be anxious to hear about the cat gorization of risk for these children and I myself was not focusing when I head this as a nonscientist and the risks of the anesthesia as nearly as much as the risks of the unknown, I suppose. I appreciate the investigators' responses about cleaning up the informed consent document a bit so that the references to the child and the child's parent is not going to be confusing. There -- there was an issue that -- that I asked the investigators and they kind of threw back to us about whether this particular informed consent form should talk about the Gail singer case and to me it's just really out of place -- and you think it is too. They responded that in the past, RAC reviewers had asked for that to be included so I don't know if we're going to talk about it or what. And finally, the assent process which I do appreciate the expansion in terms of description about that, a statement is made that if a prospective child participant decents the child won't participate in the trial which sounds good although I don't know what would count as decent from an 8-year-old so I hope some additional thought will be given to those tough questions about the process.

Thank you. I'm going to go next and I've already commented that the reason for asking that this study be further discussed publicly discussed with the RAC is the nonfatal nature of LCA, the likelihood that these children will live for decades, we hope they will, and the issue of risk benefit in children and youth when a similar study in adults has been proposed and apparently is moving forward but is not yet enrolled. Terms of the preclinical studies, I asked whether any of the data from the nonhuman primate studies that -- were performed in conjunction with the earlier adult study, which we've reviewed would be relevant to this study. And the answer simply is and it's perfectly acceptable, different sponsor, different study, truly we should be relying on the preclinical data that's directly relevant to this study and I certainly accept that. I asked that the group discuss the evidence for the absence of vector spread beyond the retina. -- in particular, any evidence of spread toward the central nervous system, because, again, in the earlier adult study, we heard evidence that there was spread toward the central nervous system. I really appreciate the careful attention to this sort of data that was presented to us today, and am very comfortable with it. That is, there's no evidence of spread towards or to the CNS from either the dog or the mouse model. I asked for some evidence or some description of whether vector transmission occurred from mother or father to infant, that is vertical transmission, and the information which was presented to us was compelling, especially -- I don't remember the exact number of dogs that Lancelot has fathered, but many, many, many, and although, unfortunately they were subject to the recessive nature of this disease, none -- no vector -- no demonstration of vector was seen. I asked for the range of antibody both to AAV and to RPE65 following gene transfer in the animal models. It does occur. The protocol has been modified to take into consideration preexisting antibody to AAV and to add that as an exclusionary criteria. I -- I'm not sure. I'll just -- this is my personal thought, not to go into the RAC statement. I'm not sure I would exclude because in dogs, who have been -- who've received A AV to one eye and who have had the presence of antibody, successful surgery has occurred. Successful gene transfer has occurred to the contralateral eye. I'm not certain that in the presence of that data I would have modified the exclusion criteria, but I'll leave that up to others. That's truly not for the RAC's discussion. That's your decision. In terms of clinical trial design, I asked whether there was any other experience with subretinal injections and the proposed age group and asked whether that specific risk could be discussed with us and I -- and the answer I received was perfectly satisfactory and really is directed towards my own ignorance, which is, we don't inject subretinally in -- in children, so there is not, for many indications, so there is not a large body of evidence oris k specific data to present to you, but we believe, we the investigators believe that this is virtually risk free in this patient population and at this particular age. And of course the -- the group has invoked the risk of anesthesia which is perfectly appropriate in this age group so I think that's fully satisfactory as well. I asked how the dosing was determined and we heard a perfectly satisfactory discussion of dosing based primarily on Lancelot and the other -- other dogs. I asked that the investigators include both in the protocol and in -- and in appendix M some discussion of how dose escalation would occur taking into consideration the acute safety data. This was not in the original protocol that we received and it now is, including a TOX table for DSM V and it's fully explained in the material that we received from the investigators is absolutely more than adequate and I thank femme there are that -- for including all that for us. And I asked about the time interval before dose escalation in order to fully assess DLT and I suppose potential efficacy as well in -- in the children and youth. We heard that there will be six weeks between the first and second subject in each dose cohort and then two weeks between the next two and that that is justified on the time that it takes for expression of the vector in the preclinical data. That's a very -- it's a satisfactory explanation. Terms of the consent, I thought the consent was quite well written and easily comprehended. I, of course, appreciated the provision of an audio tape for the youth who by the time they will assent will be blind and unable to read. I appreciated a copy of the consent in braille for exactly the same reasons. I asked that the investigators consider surgical risks which we the RAC have been made aware of during our earlier public review of the adult protocol in which I recalled as including such issues as corneal decompensation potential cataracts and the consent has been modified although I also understand that these are remote risks for children and young youth in comparison to older adults so the consent has been modified. And I asked whether there was a risk of receiving either too much or too little of the transgene for obvious reasons and the consent again has been modified. So all of my concerns have been more than adequately addressed and I thank the investigators for their careful attention to details which are perhaps more difficult to address in children and youth than they are in adults and Dr. Vial, you are next.

Okay. Thank you. So yes, I would also again like to reiterate my thanks to the investigators. They have provided extensive responses to my questions in great detail and I will just for the record sort of read my questions into the -- into the record. So my opinion is scientifically I think there's a very strong rational for this trial that's well grounded in the literature and in the prez clinical studies, certainly Lancelot and the other dog studies I think are very compelling in terms of the effects of this gene therapy. My predominant issue was related to the toxicity, and although toxicity is relatively low, it is not absent, so I was particularly interested in the severe toxicity in a dog if with the rapid ocular inflammation was not controllable and I just asked if there were f*urltder details of that and the investigators presented a lot of clear data regarding their interpretation that this -- this adverse event was due to impure vector preparation and I think the -- the evidence for that is compelling. Just had one question, just -- just to sort of push it to the limits as to whether there was any expression data obtained from that dog just in case this toxicity could have been caused by massive overexpression of the transgene indicating some toxicity that if -- if in vivo gene transfer would be very efficient there would be some sort of toxicity but in general terms the data provided regarding that toxic event was very compelling, I think, and thank you for providing that. I asked whether the investigators had any evidence of integration for the vector and they replied, again, with a lot of detail that there's -- there's preliminary evidence. There is none -- there is evidence for persistence and with -- with Lancelot 5 and a half years post treatment there don't appear to be any toxicities with integration which were addressed by the investigators. One of the one of the areas that I was interested in is long-term, if -- if there is expression of the transgene and this transgene is being expressed in children who have never seen it immunologically due to the mutation. One of the chronic chances of developing immunity, the cells which are expressoing this gene and this protein and again, there was extensive discussion from the investigators which I am grateful for. I'm not sure if my questions can be answered readily in terms of chronic levels of T-cell reactivity against protein over long periods of time but certainly there's good evidence for the more acute levels of auto immunity being very low in terms of antibodies and so on. I asked also that in protocol 677 the studies were undertaken with monkeys and are these data relevant and available to the PI in this protocol, that's an issue which has come up earlier, and the -- the response to that is essentially it's a different study and I might come back to that just right at the end. I asked whether there would be any selection as to the RPE65 mutations that will be included or excluded related again to the chances of raising auto immune responses to the transgene if the mutation is one that prevents the immune system ever having seen this product, and the canine mutation in indeed as I understand it is a known mutation so again Lancelot is ongoing evidence of that and may be not an issue. So I also asked about the systemic distribution and the sensitivity of the studies and they were very well addressed. So essentially all of my questions have been very well addressed. Any outstanding issues would be the chances of auto immune reactivity against the transgene in a chronic situation down the line, and I guess I would just -- my final point is -- which has been ratzed earlier, one of the links between this current group of investigators and those investigators in the previous adult study, I understand that these are different -- different studies, different sponsors, but I would perhaps like to raise it just one more time in the sense that there's a -- there's a compelling argument here that this is a pediatric disease. We've heard that today so it does raise the question of whether there's any value in gene transfer to adults as proposed in an earlier trial and if that was a completely separate study, then I think it would be sufficient to say this is a separate study, separate sponsor, but there are data from -- from the previous group and there is clearly a connection with the current study in terms of shared surgeon and so on which just leaves me with a feeling that maybe there is some sort of conflict -- I don't mean a conflict of interest in any way, but it would be northeast nice to see a greater level of open communication between the two studies if there were data from the previous -- from the adult study that was relevant, will that be readily accessible by this group? If there were shared members of the group. So that's -- that's really all I have to say, but I do thank the investigators and think they have some excellent preclinical studies here. And thank them for their responses.

So we are left, really, with three issues that I -- that I see. Yes? Ms. Kwan?

No, we're not -- we're going to have a discussion. I wanted to summarize first what I think is left and then we're going to have a discussion. I hope with some participation from the public who's here as well. Issue number 1 is Dr. Powers, what is the risk benefit as we see it for children in youth? Is this slightly greater than minimal risk with prospect of direct benefit to all those who participate? We need to discuss that. Second, is Dr. Vile's remaining concern that there may be chronic autoimmune activity in these children as they grow older with express transgene?

Yes.

That's a remaining concern, I believe.

That is something that is in my mind. You know, I don't want to be hyper critical and I'm not sure how I would test that but that is a concern.

That is a concern and third, I believe the group, three of us mentioned it, remain concerned that the ongoing studies in adults, study in adults with shared members of the current group, that those results should be accessible and freely exchanged between groups in order to enhance both studies. I think that's as well as I can state that. So I'd like to open this up for discussion. In particular, I think discussion of the first of the risk benefitish shuz where -- where are we? Dr. Powers, where do you see us? I -- I'm inclined to see things in the same way that the investigators in the discussions are seeing the same things. I think this is the kind of case where the quality of the animal model data give us at least a reasonable basis for thinking this potential benefit. I mean, it's something incongruent with the way we categorize phase I studies but this is something the RAC has learned to realize that this is not like cancer studies and other things, that classification scheme would seem to recommends one cat gorization, but I don't think that's a poz it here. So I think that scheme ma, I think that's a reasonable cat gorization. As to the second half of that given that kind of cat gorization, I think it would fit quite reasonably within the category of slightly more than minimal risk. And I was initially, like Dr. Wara, particularly curious about the interretinal, it has the kind of layperson's yuck factor, like my God, that's got to be scary. But I suppose we submit ourselves to all sorts of things in routine medical environments and this doesn't sound that much more disturbing. Given the -- the information about the vector, which seemed to be another big problem, it doesn't seem to be looming as large in my mind given the information about the -- the anesthesia. I think that's important and I think the investigators, I mean counter intuitively to me, I think they have the right to further elevate this up in their discussions. Given the prospects of the -- of bondness more fully, slight loss of function in one eye given what they can expect otherwise, that particular adverse outcome doesn't look beyond the pale to me either. So increasingly, absent any further kind of conversations and my scientific colleagues the main things I see in the tradeoff list look within the reasonable range of judgment that an IRB might make and it wouldn't occur to me that the RAC would be necessarily in a position at this juncture to advise differently from what I think an IRB might reasonably reach as our own conclusion in this matter. That's my preliminary assumption of that absent hearing anything else more compelling that I've missed on that list.

Thank you. Many Shapiro?

I have a question for the group. The risk benefit ratio necessity quantifying somehow kind of both risk and benefit, I myself as I said before am convinced that there is a prospect of benefit. So my scientific colleagues and those with experience on this RAC which I don't have much of, do we feel comfortable getting our arms around to a sufficient extent, the nature of risk with animal data only? And the quantum of animal data that we have on this? Short term, long-term, acute, chronic, the whole ball of wax, or do we need something else?

Well, I'll take a crack at this. For me, the problem is that as the investigators presented to us today in the protocol, this is a pediatric disease, so the risks that we see in adults may not inform at all what's going to occur in children. For instance, postop rative cataracts. Those kind of risks that may occur in adults may never be seen in children or vice versa. There may be risks in children not seen in adults and that, for me, is at the crux of -- partly at the crux of why we need to do research in children. Diseases are different, risks are different, benefits are different. So it's really, in my view, the balance of risk benefit in children and youth that needs to be looked at. And sometimes one can learn from adults, but you know, as we do more and more research in children, it's becoming clearer and clearer that we overexpect, we overanticipate being informed by ongoing work in adults unless -- unless there's something very clear that happens. And that's just not the way research usually is. Both risks and benefits are usually more subtle although I have to say in this disorder, disease, it may be that the benefit hopefully is not subtle in this particular age group. So I think, you know, when you have really good preclinical large animal data to go further to ask more may not even be respecting physiology or growth and development, but I'm a pediatrician. That's my bias. So Dr. Weber? And we're going to open this up to everyone.

I think from my standpoint when they put in risks there the local risks cataracts, bleeding and infection and then the more systemic risks but they're choosing the worse eye in a disease that degenerates even if they have one of the bad outcomes they still have the vision and the quote unquote better eye and the worse eye will become the better eye later. So the function is still remaining for the individuals even in the worst of side effects in many ways and that changes for me at least the benefit analysis.

Dr. Federoff?

I was just going to try to address the -- the extrapolation of data that might accrue from understanding the outcome in adults and whether it's relevant to understanding the particular application here in these younger individuals given the progressive nature and the degenerative nature of the disease, it's very likely that what might be learned may not allow you to assess the extent to which there might be benefit and I would say perhaps even the risks associated. So if one relied or one thought one could rely on that as a way to guide this study, it may effect *ifzly preclude the effectiveness of this calculus that Dr. Powers was referring to and this is true for many degenerative diseases where the end stage may not inform you about the earlier stages where there might be an opportunity for remediation. So my sense having listened and read and I also commend the investigators in thoughtfully responding that there seems to be an overwhelming amount of preclinical data that support the application and I think the question is -- really is the age range, the correct one to assess this calculus and my estimation is from the discussion that this is something that seems quite reasonable.

I was going to encourage you to add a fourth point of discussion which has to do with scientific validity of the study which seems to me is particularly highlighted in the circumstance that we've all discussed so thoroughly this morning, the additional burden on pediatric research, and I'm not sure if this is the time to bring it up, but if you'll come back later, I'd be happy to express some concerns. I've been able to resolve my personal debate about risk benefit in favor of this being an appropriate intervention in an appropriate age group with regard to risk benefit. I'm persuaded by my own attempts to make extrapolations from older individuals and from other species which of course we do all the time, age and other species are just surrogates for what we think we know about biology and if we think that the biology extrapolates, then we're comfortable making those leaps. If we're uncomfortable with the biology being different, then we wouldn't extrapolate even from other pediatric experiences in -- into this circumstance. So I -- I find those reasonably persuasive. What I'm not totally satisfied with, though, is the scientific validity of the research design that's actually proposed. And let me just make a couple of points and then maybe those can be picked up by my colleagues if they seem to rez Nate. The stated purpose of the trial is to determine safety and toll rablt and the second is to look at clinical efficacy. If you look at the protocol, there is no discussion or definition of either the safety or tollerability in the outcome of this study. Instead what we have is a dose escalation. That's the basic design and then if you also look at the dose escalation as being somehow integral to the study, there's no discussion of how the dose escalation information will be used. So I think that the disconnect between the basic design of the study and the stated purposes raises a concern about whether this is really the -- the proper design. The denominator that's chosen for these cohort sizes of three individuals, I think, is although familiar to us and by now almost rote may not be appropriate given the goal of safety and tollerability. For example, we had a considerable appropriate debate about a rather extensive series of animal studies with regard to safety. Yet we're prepared to accept a much lower standard of evidence in terms of cohort size of 3 human subjects to believe that we have illustration of safety. And I -- I think that the fact that we are debating a large series of preclinical evidence, but would be persuaded by a minuscule experience of human evidence is -- is a disconnect. It's frob my not -- not correct. So I think at the very least, there needs to be a definition of what safety and toller ability means in the outcome section of the protocol and how the acquired data will be used to assess it with some properties that are reasonably reliable. For example, just to make a point about safety, if in a cohort of three individuals, no serious side effect or no serious adverse event were observed, there's still a reasonable probability that such an event could occur with a frequency as high as 70%. So in other words, a small denominator doesn't rule out some pretty clinically significant frequencies of events. Similarly, on the efficacy side, if you observe some dramatic evidence of efficacy in three out of three subjects on a given cohort, you could still have a lower bound on efficacy that was only 30%. So in other words, a pretty modest or even poor frequency as efficacy that might not justify pediatric patients could still give you an apparent success rate of 3 out of 3. So I think those are the kinds of issues that might be reflected in the protocol that investigators have thought about them and chosen a research design that would -- that would explain why they're doing what they're doing. Thank you.

Can I ask you to discuss how you would approach a very rare disease such as the one proposed in the context of what I agree with you on is clearer, more robust clinical trials design. In other words, if you have a disease where, you know, if there are 2,000 subjects in the country, which is I believe what I heard with this disorder and the investigators propose for scientific reasons and risk benefit reasons to limit this study to those between age 8 and 18, let's just -- let's just suppose that there are only 60 such subjects in the country of that age group and they're scattered all over the country and those that are on the east coast may be willing to engage in a clinical study. Let's say a third of them agree. We're down right almost at the number of subjects that the group is proposing to enroll. So how do we deal with this tension? The desire to have more scientifically robust phase 1 studies but in disorders that are fortunately limited to very few subjects? I don't know how to do it.

Well I'm not going to be able to give you a satisfactory answer to that here today. I mean, I'm very sensitive to the fact that there are some conditions that are extremely orphaned and where the logistics of doing the trial is quite difficult. But I'm not willing to make the leap from the fact that it's difficult to do a trial to say that we should be doing studies that may not provide us with reliable answers to the study questions. I and this commit tease and no one told the investigators what they had to investigate. They said it. They said they want safety and tollerability. And all I'm asking is that they produce a plan in the protocol that would convince friendly skeptics, friendly reviewers that in fact, that goal is achievable.

Got it. Thank you for helping me. Ms. Kwan?

I have some concerns considering the participant selection that I think could affect risks and benefits there. I -- I was -- I noticed that there was considerable weight put to the hazards of associated with general anesthesia to the extent that the investigators intend to include an anesthesiologist in with the interview. There was also mentioned by the investigator that he also was concerned about the psychological evaluation of potential participants. Yet I think that that dissolved to his personal insp*inth chul response to the potential participation as opposed to having, let's say, psychologists who would specialize in the family dynamics and my particular concern is of within the 8 to 18 age group, the group that is preadolescent and early teens, say from the ages of about 12 to 16, I've had quite a bit of experience working with that particular population, and if anything can be said about that, it's a highly diverse population psychologically. A lot of things are happening. It is also a time where family dynamics get to be blown out of proportion because of hormonal issues, issues of separation from parental support and guidance, depressions, just those early adolescent years would make, I think, some participants much more vulnerable to a catastrophic psychological result from a failure in outcome. And I would just suggest that some greater thought needs to be butt in play in terms of actually evaluating potential participant in the preteen and early teen years as well as that -- that participant's family support system and the dynamics within the family in the selection of a participant.

Any response from the group?

First, I'd like to speak about the safety issue. I guess as I stated in some respects we're looking at safety as a lack of toxicity and we've defined our dose limiting toxicities based on the world health organization toxicity scale for the systemic aspects of where we define abnormalities and we've adapted a ocular toxicity scale from a gene transfer study that is currently in phase II and actually have expanded on that to specifically look at dose limiting toxicities with regard to the eye, and the absence of those toxicities being, I guess, our unstated definition of safety and we have stopping rules when we have decided that we have exceeded that as well. But this is not just cosmetic.

And clearly, we would agree with that, though I would add that in a -- this phase I study which typically the number of individuals would be limited than expanded in further efficacy studies,. The second -- the -- from the invest sga torrs' standpoint, the estimate of 2,000 people in this country with Leber Congenital Amaurosis is again, from the investigators' standpoint optimistic. As of now, there are only 200 or so identified patients with this condition and this is just a projection of what may be derived by extensive screening. So we are really working with a very, very limited population to respond to the general anesthesia issue, I did have a slide up that specifies that we do consider indeed the major risk based on -- that is a risk of moralty for a ASA I or II individual in this population between 8 and 18 years old to presumably would not have cardiovascular disease, the risk is -- published is 1 in 50,000 but in our institution I believe there have been no reported deaths that have occurred.

My name is Dr. Katherine High and I'm the director of the center for molecular therapeutic which is acting as a sponsor for this study so I wanted to respond to one of Dr. Vile's questions. About immune response to the transgene product. And our -- my particular research interest has been for hemophilia B and as is the case with liver congenital amaurosis, there are both dog mode models for hemophilia B. We have done studies for dogs mice and humans and we can say that we have a complete data set and that we have found is that the mice and the dogs actually are a good guide for looking at immune response to the transgene product and that is a data set where I think that we can -- or that's a data point on which we can say with some confidence that the animal data does allow one to extrapolate to the humans. So in their case they have carefully sought antibodies to RPE65 and have not found them in mice or dogs and so I would -- I would feel some level of confidence that that is an issue that will not impact on safety in a human study and so to echoDr. Wara's comment, for me it's always difficult to judge risk benefit without talking about what we know in terms of the science, so I think your issue is one that we can probably place considerable weight on the animal data in terms of the response to the tran