Full Text HL-94-007

GENE THERAPY FOR HEMOPHILIAS A AND B

NIH GUIDE, Volume 22, Number 44, December 10, 1993

RFA:  HL-94-007

P.T. 34

Keywords: 
  Blood Diseases 
  Gene Therapy+ 


National Heart, Lung, and Blood Institute

Letter of Intent Receipt Date:  February 10, 1994
Application Receipt Date:  March 10, 1994

PURPOSE

The Thrombosis and Hemostasis Branch, Division of Blood Diseases and
Resources, National Heart, Lung, and Blood Institute (NHLBI), invites
grant applications for studies that may lead to the successful
application of gene therapy for hemophilias A and B.

HEALTHY PEOPLE 2000

The Public Health Service (PHS) is committed to achieving the health
promotion and disease prevention objectives of "Healthy People 2000,"
a PHS-led national activity for setting priority areas.  This Request
for Applications (RFA), Gene Therapy for Hemophilias A and B, is
related to the priority areas of hemophilia, and thrombosis and
hemostasis.  Potential applicants may obtain a copy of "Healthy
People 2000" (Full Report:  Stock No. 017-001-00474-0) or "Healthy
People 2000" (Summary Report:  Stock No. 017-001-00473-1) through the
Superintendent of Documents, Government Printing Office, Washington,
DC 20402-9325 (telephone 202-782-3238).

ELIGIBILITY REQUIREMENTS

Applications may be submitted by domestic and foreign for-profit and
non-profit organizations, public and private, such as universities,
colleges, hospitals, laboratories, units of state or local
governments, and eligible agencies of the Federal government.  Awards
in response to this RFA will be made to foreign institutions only for
research of very unusual merit, need, and promise, and in accordance
with PHS policy governing such awards.  Applications from minority
individuals and women are encouraged.

MECHANISM OF SUPPORT

This RFA will use the National Institutes of Health (NIH) individual
research grant award (R01) and is a one-time solicitation.
Applicants, who will plan and execute their own research programs,
are requested to furnish their own estimates of the time required to
achieve the objectives of the proposed research project.  Up to five
years of support may be requested.  At the end of the official award
period, renewal applications may be submitted for peer review and
competition for support through the regular grant program of the
NHLBI.  It is anticipated that support for the present program will
begin September, 1994.  Administrative adjustments in project
period/or amount of support may be required at the time of the award.
Since a variety of approaches would represent valid responses to this
announcement, it is anticipated that there will be a range of costs
among individual grants awarded.  All current policies and
requirements that govern the research grant programs of the NIH will
apply to grants awarded in connection with this RFA.

FUNDS AVAILABLE

It is anticipated that for fiscal year 1994, $2,000,000 (total costs)
will be available for this initiative. It should be noted that award
of grants pursuant to this RFA is contingent upon receipt of such
funds for this purpose.  It is anticipated that about seven new
grants will be awarded under this program.  The specific amount to be
funded will, however, depend on the merit and scope of the
applications received and on the availability of funds.  If
collaborative arrangements involve sub-contracts with other
institutions, the NHLBI Grants Operations Branch (telephone:
301-594-7436) should be consulted regarding procedures to be
followed.

RESEARCH OBJECTIVES

Hemophilia is a hereditary bleeding disorder that results from a
deficiency in either blood coagulation protein factor VIII or factor
IX.  Although treatment advances over the last three decades have
permitted a near-normal lifestyle and life-span for many individuals
with hemophilia, complications of treatment and inability to actually
prevent acute bleeding episodes result in significant morbidity and
mortality.  In addition, most of the severe hemophilia population has
been infected with human immunodeficiency virus or hepatitis virus
from treatment with blood products before 1985.  The availability of
virus-free clotting factor concentrates and recombinant factor VIII
have provided improved treatment.  However, treatment is generally
initiated once a bleeding episode begins, not in a prophylactic
regimen to prevent bleeding episodes.  This reactive treatment
approach continues to result in significant morbidity (i.e., joint
damage) and occasional mortality.  The annual cost of treatment for
bleeding episodes in the severe hemophiliac ranges from $50,000 to
$100,000.  Costs of treatment for the patient with inhibitors to
factors VIII or IX can exceed this amount by many fold.

Gene therapy would be a useful alternative to current treatment
because it provides continuous production of the deficient clotting
factor.  Studies of the structure and function of factors VIII and IX
provide information and tools for the gene therapy approach.  The
genes for factors VIII and IX are cloned and functional proteins can
be expressed.  Studies show that factor VIII and IX genes do not
require strict regulation and 5 to 10 percent of the normal plasma
concentrations of these proteins can reduce severe hemophilia to
mild.  Since factor VIII is a large, complex protein and factor IX is
a highly post-tranlationally modified zymogen, different problems
need to be addressed for each protein.

Currently, very low in vitro expression levels of factor VIII impede
further progress in gene therapy of hemophilia A.  The large factor
VIII gene has limited the use of currently available vectors.  The
transduction and expression of truncated forms of factor VIII is
lower than that of factor IX with the same vectors.  An inhibitory
sequence that reduces expression was identified within the factor
VIII coding region.  Basic research is needed to define the minimal
requirements for a stable, functional protein and the mechanisms
necessary for improved expression of the gene.

The factor IX studies, which are more advanced, have had difficulty
maintaining adequate in vivo expression levels.  Using
retroviral-mediated gene transfer for ex vivo transduction of
myoblasts, human factor IX was expressed in mice.  A clinically
significant plasma factor IX level was achieved but was maintained
for only a few weeks.  Viral-mediated transduction of hepatocytes in
vivo resulted in persistent low level expression of canine factor IX
in hemophilia B dogs.  Other promising gene transfer systems have
been identified, such as the adenovirus, adenoassociated virus and
direct transfer of plasmid DNA.  Approaches employing stem cells or
fetal liver cells may also prove promising.  To advance further,
these and other new and creative approaches in gene therapy
technology need to be applied to factor IX studies.

Inhibitors, antibodies capable of neutralizing the procoagulant
activity of infused replacement proteins, are a serious problem for
some hemophilia patients.  The mechanisms of inhibitor formation are
not thoroughly understood and are likely to be complex.  The
potential for inhibitors to the gene therapy products must be
considered. There is a need to develop strategies to avoid this
complication or to eliminate inhibitors once present.  The
identification and production of active coagulation factors with
reduced antigenicity could be important to both gene therapy and
replacement therapy.

Currently, canine models for hemophilias A and B exist in colonies
maintained in the United States.  The existence of these established
animal models provide an excellent means to test new gene therapy
procedures.  The development of a small animal model for hemophilias
A and B may also prove useful for safety and efficacy testing prior
to larger animal or human studies.

The purpose of this RFA is to encourage research that may lead to the
successful application of gene therapy for hemophilias A and B.
Studies are needed that address the specific problems that currently
impede progress in this area.  This program encourages creative and
innovative approaches to these problems.  The focus is on basic,
fundamental research to address issues of gene transfer, protein
expression, functional proteins and inhibitors as they apply to
factors VIII and IX.  It is hoped that the gene therapy systems would
be developed to the point of testing in animal models and that they
would have the potential for human application.

Examples of promising research topics include, but are not limited
to:

o  improving the expression of stable, functional factor VIII or
factor IX,

o  improving delivery technology so that it targets a specific organ
or cell type,

o  developing an ex vivo or in vivo gene transfer system for
sustained expression of the coagulation factor,

o  producing a cell culture or small animal testing model for
preliminary studies,

o  producing modified or truncated factor VIII or factor IX with
reduced antigenicity,

o  applying stem cell or fetal tissue technology to introduce the
corrected gene,

o  developing gene transfer systems that could be applied to in utero
correction of the genetic defect.

Applications may address other objectives that would advance the
hemophilia gene therapy research.  Studies may include one or several
research topics but should retain a common theme and focus.  Because
issues may involve factor VIII or IX protein structure, hemophilia
therapy and gene transfer technology a collaboration of investigators
having expertise in these and other appropriate disciplines is
encouraged.  Particular encouragement is offered to experienced gene
transfer investigators, who are currently pursuing other research
interests, to apply their expertise to hemophilia gene therapy.

SPECIAL REQUIREMENTS

Upon initiation of the program, the NHLBI will sponsor annual
meetings to encourage the exchange of information among investigators
who participate in this program.  In the preparation of the budget
for the grant application, applicants may request additional travel
funds for one meeting each year to be held in Bethesda, Maryland.
Applicants are encouraged to include a statement in the applications
indicating their willingness to participate in such meetings.

STUDY POPULATIONS

SPECIAL INSTRUCTIONS TO APPLICANTS REGARDING IMPLEMENTATION OF NIH
POLICIES CONCERNING INCLUSION OF WOMEN AND MINORITIES IN CLINICAL
RESEARCH STUDY POPULATIONS

NIH policy is that applicants for NIH clinical research grants and
cooperative agreements will be required to include minorities and
women in study populations so that research findings can be of
benefit to all persons at risk of the disease, disorder or condition
under study; special emphasis should be placed on the need for
inclusion of minorities and women in studies of diseases, disorders
and conditions which disproportionately affect them.  This policy is
intended to apply to males and females of all ages.  If women or
minorities are excluded or inadequately represented in clinical
research, particularly in proposed population-based studies, a clear
compelling rationale should be provided.

The composition of the proposed study population must be described in
terms of gender and racial/ethnic group.  In addition, gender and
racial/ethnic issues should be addressed in developing a research
design and sample size appropriate for the scientific objectives of
the study. This information must be included in the form PHS 398
(rev. 9/91) in Sections 1-4 of the Research Plan AND summarized in
Section 5, Human Subjects.  Applicants are urged to assess carefully
the feasibility of including the broadest possible representation of
minority groups.  However, NIH recognizes that it may not be feasible
or appropriate in all research projects to include representation of
the full array of United States racial/ethnic minority populations
(i.e., Native Americans, Blacks, and Hispanics).  The rationale for
studies on single minority population groups should be provided.

For the purpose of this policy, clinical research includes human
biomedical and behavioral studies of etiology, epidemiology, (and
preventive strategies), diagnosis, or treatment of diseases,
disorders or conditions, including but not limited to clinical
trials.

The usual NIH policies concerning research on human subjects also
apply.  Basic research or clinical studies in which human tissues
cannot be identified or linked to individuals are excluded.  However,
every effort should be made to include human tissues from women and
racial/ethnic minorities when it is important to apply the results of
the study broadly, and this should be addressed by applicants.

For foreign awards, the policy on inclusion of women applies fully;
since the definition of minority differs in other countries, the
applicant must discuss the relevance of research involving foreign
population groups to the United States' populations, including
minorities.

If the required information is not contained within the application,
the application will be deferred until the information is provided.

Peer reviewers will address specifically whether the research plan in
the application conforms to these policies. If the representation of
women or minorities in a study design is inadequate to answer the
scientific question(s) addressed AND the justification for the
selected study population is inadequate, it will be considered a
scientific weakness or deficiency in the study design and will be
reflected in assigning the priority score to the application.

All applications for clinical research submitted to NIH are required
to address these policies.  NIH funding components will not award
grants or cooperative agreements that do not comply with these
policies.

LETTER OF INTENT

Prospective applicants are encouraged to submit, by February 10,
1994, a letter of intent that includes a descriptive title of the
proposed research, the name, address, and telephone of the Principal
Investigator, the identities of other key personnel and participating
institutions, and the number and title of this RFA.  Such letters are
requested only for the purpose of providing an indication of the
number and scope of applications to be received; therefore their
receipt is usually not acknowledged.  A letter of intent is not
binding, and it will not enter into the review of any application
subsequently submitted, nor is it a necessary requirement for the
application.  The letter of intent is to be sent to:

Acting Chief, Centers and Special Projects Review Section
Division of Extramural Affairs
National Heart, Lung, and Blood Institute
Westwood Building, Room 553
Bethesda, MD  20892
Telephone:  (301) 594-7448
FAX:  (301) 594-7407

APPLICATION PROCEDURES

Applications are to be submitted on the research grant application
form PHS 398 (rev. 9/91).  This form is available in an applicant
institution's office of sponsored research and from the Office of
Grants Information, Division of Research Grants, National Institutes
of Health, 5333 Westbard Avenue, Room 449, Bethesda, MD 20892,
telephone (301) 710-0267.  Use the conventional format for research
grant applications and ensure that the points identified in the
section on REVIEW CONSIDERATIONS are fulfilled.

To identify the application as a response to this RFA, check "YES" on
Item 2a of page 1 of the application and enter the title and RFA
number:  GENE THERAPY FOR HEMOPHILIAS A AND B:  NHLBI RFA HL-94-007-B

The RFA label available in the PHS 398 application kit must be
affixed to the bottom of the face page of the original copy of the
application.  Failure to use this label could result in delayed
processing of the application such that it may not reach the review
committee in time for review.

Send or deliver the completed application and three signed, exact
photocopies of it to the following, making sure that the original
application with the RFA label attached is on top:

Division of Research Grants
National Institutes of Health
Westwood Building, Room 240
Bethesda, MD  20892**

Send an additional two copies of the application to the Chief,
Centers and Special Projects Review Section at the address listed
under LETTER OF INTENT.  It is important to send these two copies at
the same time as the original and three copies are sent to the
Division of Research Grants.  Otherwise the NHLBI cannot guarantee
that the application will be reviewed in competition for this RFA.

Applications must be received by March 10, 1994.  If an application
is received after that date, it will be returned to the applicant
without review.  The Division of Research Grants (DRG) will not
accept any application in response to this announcement that is
essentially the same as one currently pending initial review, unless
the applicant withdraws the pending application.  The DRG will not
accept any application that is essentially the same as one already
reviewed.  This does not preclude the submission of substantial
revisions of applications already reviewed, but such applications
must include an introduction addressing the previous critique.

REVIEW CONSIDERATIONS

Upon receipt, applications will be reviewed for completeness by the
DRG and responsiveness by the NHLBI.  Incomplete applications will be
returned to the applicant without further consideration.  If the
application is not responsive to the RFA, NHLBI staff will contact
the applicant to determine whether to return the application to the
applicant or submit it for review in competition with unsolicited
applications at the next review cycle.

Applications may be triaged by an NHLBI peer review group on the
basis of relative competitiveness.  The NIH will withdraw from
further competition those applications judged to be non-competitive
for award and notify the applicant Principal Investigator and
institutional official.  Those applications judged to be competitive
will undergo further scientific merit review.  Those applications
that are complete and responsive will be evaluated in accordance with
the criteria stated below for scientific/technical merit by an
appropriate peer review group convened by the Division of Extramural
Affairs, NHLBI.  The second level of review will be provided by the
National Heart, Lung, and Blood Advisory Council.

Review Criteria

The factors to be considered in the evaluation of scientific merit of
each application will be similar to those used in the review of
traditional research grant applications, including the novelty,
originality, and feasibility of the approach; the training,
experience and research competence of the investigator(s); the
adequacy of the experimental design; the suitability of the
facilities; and the appropriateness of the requested budget to the
work proposed.

AWARD CRITERIA

Funding decisions will be made on the basis of scientific and
technical merit as determined by peer review, program needs and
balance, and the availability of funds.

Awards in response to this RFA will be made to foreign institutions
only for research of very unusual merit, need, and promise, and in
accordance with PHS policy governing such awards.

INQUIRIES

Written and telephone inquiries concerning this RFA are encouraged.
The opportunity to clarify any issues or questions from potential
applicants is welcome.

Inquiries regarding programmatic issues may be directed to:

Dr. Rebecca Link
Division of Blood Diseases and Resources
National Heart, Lung, and Blood Institute
Federal Building, Room 5C14
Bethesda, MD  20892
Telephone:  (301) 402-2237
FAX:  (301) 496-9940

For fiscal and administrative matters, contact:

Ms. Jane R. Davis
Grants Operation Branch
National Heart, Lung, and Blood Institute
Westwood Building, Room 4A15
Bethesda, MD  20892
Telephone:  (301) 594-7436
FAX:  (301) 594-7492

AUTHORITY AND REGULATIONS

The programs of the Division of Blood Diseases and Resources, NHLBI,
are described in the Catalog of Federal Domestic Assistance number
93.839.  Awards will be made under the authority of the Public Health
Service Act, Section 301 (42 USC 241) and administered under PHS
grant policies and Federal regulations, most specifically 42 CFR Part
52 and 45 CFR Part 74.  This program is not subject to the
intergovernmental review requirements of Executive Order 12372, or to
Health Systems Agency Review.

.

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