IMMUNOGENETICS OF INHIBITOR FORMATION IN HEMOPHILIA

NIH GUIDE, Volume 26, Number 37, November 7, 1997

RFA:  HL-98-002

National Heart, Lung, and Blood Institute

P.T.

Letter of Intent Receipt Date:  February 10, 1998
Application Receipt Date:  March 24, 1998

THIS RFA USES "MODULAR GRANT" AND "JUST-IN-TIME" CONCEPTS.  THIS
RFA INCLUDES DETAILED MODIFICATIONS TO STANDARD APPLICATION
INSTRUCTIONS THAT MUST BE USED WHEN PREPARING RESPONSES TO THIS
RFA.

PURPOSE

To improve understanding of inhibitor formation and immune
tolerance induction in hemophilia patients.  The goals of this
initiative are to be able to predict those patients most likely to
develop inhibitors, to specifically and safely block inhibitor
formation, and to induce tolerance or neutralize existing
inhibitors, so that the risks and suffering caused by antibody
inhibitors is reduced or eliminated.

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 RFA, Immunogenetics of Inhibitor Formation in
Hemophilia, is related to the priority areas of maternal and infant
health and heart disease and stroke.  Potential applicants may
obtain a copy of "Healthy People 2000" (Full Report: Stock No.
017-001-00474-0 or Summary Report:  Stock No. 017-001-00473-1)
through the Superintendent of Documents, Government Printing
Office, Washington, DC 20402-9325 (telephone 202-512-1800).

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.  Minority
individuals and women are encouraged to apply.

MECHANISM OF SUPPORT

This RFA will use the NIH individual research project grant (R01)
mechanism of support.  Newly independent investigators who may wish
to consult with a program representative (see INQUIRIES section)
are encouraged to apply.  Specific application instructions have
been modified to reflect "MODULAR GRANT" and "JUST-IN-TIME"
streamlining efforts being examined by the NIH.  The MODULAR GRANT
concept establishes specific modules in which direct costs may be
requested as well as a maximum level for requested budgets.  Only
limited budgetary information is required under this approach.  The
JUST-IN-TIME concept allows applicants to submit certain
information only when there is a possibility for an award.  It is
anticipated that these changes will reduce the administrative
burden for the applicants, reviewers, and Institute staff.

For this RFA, funds must be requested in $25,000 direct cost
modules and a maximum of seven modules ($175,000 direct costs) per
year may be requested.  Any necessary escalation must be included
within the number of modules being requested.  Only limited budget
information will be required and any budget adjustments made by the
Initial Review Group will be in modules of $25,000.  Instructions
for completing the Biographical Sketch have also been modified. In
addition, Other Support information and the application Checklist
page are not required as part of the initial application.  If there
is a possibility for an award, necessary budget, Other Support and
Checklist information will be requested by NHLBI staff following
the initial review.  The APPLICATION PROCEDURES section of this RFA
provides specific details of modifications to standard PHS 398
application kit instructions.

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
4 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 1998.  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 RFA, 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 1998, $1,500,000 total costs
will be available for the first year of support for this
initiative.  The award of grants pursuant to this RFA is contingent
upon receipt of such funds for this purpose.  It is anticipated
that approximately six new grants will be awarded under this
program.  Applicants may request up to four years of support.  The
specific number to be funded will, however, depend on the merit and
scope of the applications received and on the availability of
funds.  Direct costs will be awarded in modules of $25,000, less
any overlap or other necessary administrative adjustments.
Facilities and administrative costs will be awarded based on the
negotiated rates.  If collaborative arrangements involve
subcontracts with other institutions, Ms. Jane R. Davis of the
NHLBI Grants Operations Branch (telephone: (301-435-0166) should be
consulted regarding procedures to be followed.

RESEARCH OBJECTIVES

Background

Hemophilia A and B are hereditary bleeding disorders characterized
by complete or partial deficiency of factor VIII and factor IX,
respectively.  Alloantibodies, factor VIII or factor IX inhibitors,
can occur from exposure to plasma derived factor concentrates or
recombinant factors used to treat bleeding episodes.  Approximately
15-20% of severe hemophilia A patients and 1-3% of severe
hemophilia B patients develop these antibody inhibitors, which
specifically neutralize the activity of the replacement factor and
complicate treatment.  The patient's immune characteristics along
with the clinical situation and the available therapeutic options
must all be considered in the management of bleeding episodes in
hemophilia patients with inhibitors.

Autoantibody factor VIII inhibitors have also been identified.
These occur in nonhemophilic individuals and are often identified
during the postpartum period or in association with autoimmune
diseases, lymphoid malignancies, and drug actions.  These
individuals with no previous history of a bleeding disorder are
considered to have "acquired hemophilia".  Although the incidence
of autoantibodies is rare, they are a source of morbidity and
mortality.

At this time it is not possible to predict which hemophilia
patients will develop antibody inhibitors.  Only a few prospective
studies have yet been performed in which inhibitor assays were
frequently assessed following exposure to replacement factor in
order to identify all patients in whom an inhibitor develops. 
Transient inhibitory antibodies have been identified in these
studies, but these have disappeared during continued therapy with
factor VIII.  The incidence of  inhibitor formation initially
increases with the number of factor VIII treatments, but appears to
plateau after 50-100 exposure days.  Inhibitor formation is much
more common in severe hemophilia than in moderate or mild disease
and some molecular defects, most clearly large deletions and
nonsense mutations in the factor VIII light chain, appear to
predispose to inhibitor formation. Parameters such as the
concentration, type (purified or recombinant) of replacement
factor, and treatment history may also affect the likelihood of
antibody production, but there is no overall understanding of why
some hemophilia patients develop inhibitors while many appear to
avoid this complication.

A major achievement has been the induction of immune tolerance in
some hemophilia patients with inhibitors.  While immune tolerance
regimens vary considerably, similar 60-80% rates of tolerance
induction have been reported.  An understanding of the mechanism of
immune tolerance induction may explain why tolerance can be
successful in many, but not all, hemophilia A patients with
inhibitors.  Creative approaches have been developed to temporarily
reduce the antibody titer or to bypass the need for factor VIII in
treating inhibitory patients.  While these approaches have often
effectively dealt with the individual situations, they have not
solved or improved the understanding of antibody inhibitors.  Also,
there are some concerns in utilizing these products because of the
lack of consistent, reliable hemostasis and reports of adverse
experiences. Therefore, it is important to understand the mechanism
of the immune response, to identify the individuals at risk, and to
develop procedures to avoid inhibitor formation or induce immune
tolerance.

Increased understanding of the structure and function of factors
VIII and IX and of human immune response provides an atmosphere for
major advances in antibody inhibitors. Studies have localized
inhibitor epitopes in the A2 and C2 domains of factor VIII and have
demonstrated that antibodies from inhibitor plasmas were either
fully of partially neutralized by A2 and C2 domain polypeptides. 
A hybrid human/porcine factor VIII molecule was not inhibited by
inhibitor antibodies specific for human factor VIII A2 domain,
suggesting that modified recombinant factors may provide a means to
bypass the effects of some inhibitory antibodies.

Better understanding of the human immune response to factors VIII
and IX will provide additional opportunities for effective
treatment of patients with antibody inhibitors or for prevention of
their development.  Recently, factor VIII-specific T cells have
been identified in patients with factor VIII inhibitors.  T cells
responding to an exogenous protein may either promote the
development of an antibody or establish a state of tolerance. 
Interactions and signaling pathways are being identified between
antigen, T cells, and B cells.  Many important accessory molecular
interactions are now known, which provide opportunities to
selectively modulate the immune response.  An example is the CD40
ligand (CD40L), which is transiently expressed on T cells and which
binds to CD40 bearing B cells.  Blockade of the CD40L-CD40
interaction during protein antigen immunization was seen in animal
studies to specifically block the antibody response to that
antigen.  If the knowledge of these molecular interactions were
applied to the regulation of inhibitory antibodies it would open
new avenues for immunoregulation and treatment of inhibitors.

There have been improvements in the therapy for hemophilia patients
with the introduction of high purity and recombinant factors.  In
the future gene therapy may provide the next major advance in
hemophilia treatment.  However, the complications of inhibitor
antibodies will still be an issue unless there are advances in our
ability to modulate the immune response.  When a normal gene is
inserted into a hemophilia patient, the immune response will not
only affect the survival of the newly synthesized factor, but the
cytotoxic T cell response may specifically destroy the cells that
have become the sites of new factor VIII synthesis.  Therefore, it
is important to study the immune response to factor VIII and factor
IX in parallel with the development of gene therapy of these
hereditary disorders.

The following are examples of broad areas of research interests
related to inhibitor antibody formation and immune tolerance
induction.  Applicants are encouraged to be innovative and creative
in designing their research studies within the context of this
special program.

o  identify factors that predispose to inhibitor formation in
hemophilia patients

o  define the mechanism of the immune response to factor VIII

o  explore the mechanism of immune tolerance induction and identify
reasons for success or failure in individual patients

o  explore the mechanisms for inhibitor-induced acquired bleeding
disorders

o  investigate specific interactions between antigen, T cells,
and/or B cells with the goal of  blocking the immune response to
factor VIII or factor IX

o  utilize hemophilia animal models to study inhibitor formation
and mechanism of immune response to replacement therapy

Because expertise in both hematology and immunology would be
beneficial, collaboration of investigators engaged in these and
other appropriate disciplines is encouraged. Particular
encouragement is offered to experienced immunologists to apply
their research knowledge to the problem of antibody inhibitors in
hemophilia.

SPECIAL REQUIREMENTS

Upon initiation of the program, the NHLBI may sponsor annual
meetings to encourage the exchange of information among
investigators who participate in this program.  Travel funds for a
one day meeting each year, most likely to be held in Bethesda,
Maryland, should be included in the modules. Applicants should also
include a statement in the applications indicating their
willingness to participate in such meetings.

INCLUSION OF WOMEN AND MINORITIES IN RESEARCH INVOLVING HUMAN
SUBJECTS

It is the policy of the NIH that women and members of minority
groups and their subpopulations must be included in all NIH
supported biomedical and behavioral research projects involving
human subjects, unless a clear and compelling rationale and
justification is provided that inclusion is inappropriate with
respect to the health of the subjects or the purpose of research. 
This policy results from the NIH Revitalization Act of 1993
(Section 492B of Public Law 103-43).

All investigators proposing research involving human subjects
should read the "NIH Guidelines for Inclusion of Women and
Minorities as Subjects in Clinical Research", which have been
published in the Federal Register of March 28, 1994 (FR 59
14508-14513), and in the NIH GUIDE FOR GRANTS AND CONTRACTS of
March 18, 1994, Volume 23, Number 11.

Investigators may obtain copies from these sources or from the
program staff or contact person listed below.  Program staff may
also provide additional relevant information concerning the policy.

LETTER OF INTENT

Prospective applicants are asked to submit, by February 10, 1998,
a letter of intent that includes a descriptive title of the
proposed research, the name, address, and telephone number of the
Principal Investigator, identification of any other key personnel
and participating institutions, and the number and title of the RFA
in response to which the application may be submitted.  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.  A faxed letter of intent may be
used in place of a posted one.

This letter of intent is to be sent to:

Dr. C. James Scheirer
Division of Extramural Affairs
National Heart, Lung, and Blood Institute
6701 Rockledge Drive, MSC 7924
Bethesda, MD  20892-7924
Telephone:  (301) 435-0266
FAX:  (301) 480-3541
Email:  [email protected]

APPLICATION PROCEDURES

Applications are to be submitted on the research grant application
form, PHS 398 (rev. 5/95).  Applications kits are available at most
institutional offices of sponsored research and may be obtained
from the Division of Extramural Outreach and Information Resources,
National Institutes of Health, 6701 Rockledge Drive, MSC 7910,
Bethesda, MD 20892-7910, telephone 301/710-0267, email: 
[email protected].  Use the conventional format for research grant
applications and ensure that the points identified in the section
on REVIEW CONSIDERATIONS are fulfilled.

BUDGET INSTRUCTIONS

The total direct costs must be requested in accordance with the
program guidelines and the modifications made to the standard PHS
398 application instructions described below:

o  FACE PAGE - As a reminder, Item 7 should be completed to
indicate Modular Direct Costs requested and Item 8 should reflect
Total Costs (Modular Direct plus F&A costs).

o  DETAILED BUDGET FOR THE INITIAL BUDGET PERIOD  Do not complete
Form Page 4 of the PHS 398 (rev 5/95).  It is not required nor will
it be accepted at the time of application.

o  BUDGET FOR THE ENTIRE PROPOSED PERIOD OF SUPPORT - Do not
complete the categorical budget tables on Form page 5 of the PHS
398 (rev. 5/95). Only the requested total direct costs line for
each year must be completed based on the number of $25,000 modules
being requested.  Applicants may not request a change in the amount
of each module.  A maximum of seven modules ($175,000) direct costs
per year may be requested and each applicant may request up to four
years of support for this RFA.  Direct cost budgets will remain
constant throughout the life of the project (i.e. the same number
of modules requested for all budget periods).  Any necessary
escalation should be considered when determining the number of
modules to be requested.  However, in the event that the number of
modules requested must change in any future year due to the nature
of the research proposed, appropriate justification must be
provided.  Total Direct Costs for the entire Proposed Project
Period should be shown in the box provided.

o  BUDGET JUSTIFICATION
- Budget justifications should be provided under "Justifications"
on Form Page 5 of the PHS 398.
- List the names, role on the project and proposed percent effort
for all project personnel (salaried or unsalaried) and provide a
narrative justification for each person based on his/her role on
the project.
- Identify all consultants by name and organizational affiliation
and describe the services  to be performed.
- Provide a general narrative justification for individual
categories (equipment, supplies,  etc.) required to complete the
work proposed.  More detailed justifications should be provided for
high cost items.  Any large one-time purchases, such as large
equipment requests, must be accommodated within these limits.  No
specific costs for items or categories should be shown.

o  CONSORTIUM/CONTRACTUAL COSTS - If collaborations or subcontracts
are involved that require transfer of funds from the grantee to
other institutions, it is necessary to establish formal subcontract
agreements with each collaborating institution.  A letter of intent
from each collaborating institution should be submitted with the
application.  Only the percentage of the consortium/contractual
TOTAL COSTS (direct plus facilities and administrative costs)
relative to the total DIRECT COSTS of the overall project needs to
be stated at this time. The following example should be used to
indicate the percentage cost of the consortium, "The consortium
agreement represents 27% of overall $175,000 direct costs requested
in the first year."  A budget justification for the consortium
should be provided as described in the "Budget Justification"
section above (no Form Page 5 required for the consortium).  Please
indicate whether the consortium will be in place for the entire
project period and identify any future year changes in the
percentage relative to the parent grant.

If there is a possibility for an award, the applicant will be
requested to identify actual direct and facilities and
administrative costs for all years of the consortium.  Please note
that total subcontract costs need not be calculated in $25,000
modules.  However, when subcontract funds are added to the parent
grant budget, the total direct cost amount must be included in the
number of $25,000 modules requested.

o  BIOGRAPHICAL SKETCH - A biographical sketch is required for all
key personnel, following the modified instructions below.  Do not
exceed the two-page limit for each person.
- Complete the educational block at the top of the form page; -
List current position(s) and those previous positions directly
relevant to the application;
- List selected peer-reviewed publications directly relevant to the
proposed project, with full citation;
- The applicant has the option to provide information on research
projects completed and/or research grants participated in during
the last five years that are relevant to the proposed project.

o  OTHER SUPPORT - Do not complete the "Other Support" pages Form
Page 7).  Selected other support information relevant  to the
proposed research may be included in the Biographical Sketch as
indicated above. Complete Other Support information will be
requested by NHLBI staff if there is a possibility for an award.

o  CHECKLIST - No "Checklist" page is required as part of the
initial application.  A completed Checklist will be requested by
NHLBI staff if there is a possibility for an award.

o  The applicant should provide the name and phone number of the
individual to contact concerning fiscal and administrative issues
if additional information is necessary following the initial
review.

Sample budgets and justification page will be provided upon request
or following the submission of a letter of intent.

Applications not conforming to these guidelines will be considered
unresponsive to this RFA and will be returned without further
review.

Applicants from institutions that have a General Clinical Research
Center (GCRC) funded by the NIH National Center for Research
Resources may wish to identify the GCRC as a resource for
conducting the proposed research. If so, a letter of agreement from
either the GCRC program director or principal investigator could be
included with the application.

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.  In addition, the RFA title and
number must be typed on line 2a of the face page of the application
form and the YES box must be marked.

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:

CENTER FOR SCIENTIFIC REVIEW (formerly Division of Research Grants)
NATIONAL INSTITUTES OF HEALTH
6701 ROCKLEDGE DRIVE, ROOM 1040 - MSC 7710
BETHESDA, MD 20892-7710
BETHESDA, MD 20817 (for courier/overnight service)

Send an additional two copies of the application to the Chief,
Review Branch 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 Center for Scientific Review. 
Otherwise the NHLBI cannot guarantee that the application will be
reviewed in competition for this RFA.

Applications must be received by March 24, 1998.  If an application
is received after that date, it will be returned to the applicant
without review.  The Center for Scientific Review (CSR) will not
accept any application in response to this RFA that is essentially
the same as one currently pending initial review, unless the
applicant withdraws the pending application.  The CSR 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
CSR and responsiveness by the NHLBI.  Incomplete applications will
be returned to the applicant without further consideration.  If
NHLBI staff determines that the application is not responsive to
the RFA, it will be returned to the applicant without further
consideration.

Applications that are complete and responsive to the RFA will be
evaluated for scientific and technical merit by an appropriate peer
review group convened by the NHLBI in accordance with the review
criteria stated below.  As part of the initial merit review, a
process may be used by the initial review group in which
applications will be determined to be competitive or non-
competitive based on their scientific merit relative to other
applications received in response to the RFA.  Applications judged
to be competitive will be discussed and be assigned a priority
score. Applications determined to be non-competitive will be
withdrawn from further consideration and the principal
investigator/program director and the official signing for the
applicant organization will be notified.

Review Criteria

The goals of NIH-supported research are to advance our
understanding of biological systems, improve the control of
disease, and enhance health.  In the written review, comments on
the following aspects of the application will be made in order to
judge the likelihood that the proposed research will have a
substantial impact on the pursuit of these goals.  Each of these
criteria will be addressed and considered in the assignment of the
overall score.

(1) Significance

Does this study address an important problem?  If the aims of the
application are achieved, how will scientific knowledge be
advanced? What will be the effect of these studies on the concepts
or methods that drive this field?

(2) Approach

Are the conceptual framework, design, methods, and analyses
adequately developed, well-integrated, and appropriate to the aims
of the project?  Does the applicant acknowledge potential problem
areas and consider alternative tactics?

(3) Innovation

Does the project employ novel concepts, approaches or method?  Are
the aims original and innovative?  Does the project challenge
existing paradigms or develop new methodologies or technologies?

(4) Investigator

Is the investigator appropriately trained and well suited to carry
out this work?  Is the work proposed appropriate to the experience
level of the principal investigator and other researchers (if any)?

(5) Environment

Does the scientific environment in which the work will be done
contribute to the probability of success?  Do the proposed
experiments take advantage of unique features of the scientific
environment or employ useful collaborative arrangements?  Is there
evidence of institutional support?

In addition, the adequacy of plans to include both genders and
minorities and their subgroups as appropriate for the scientific
goals of the research will be reviewed.  Plans for the recruitment
and retention of subjects will also be evaluated.

The initial review group will also examine the provisions for the
protection of human and animal subjects, the safety of the research
environment, and conformance with the NIH Guidelines for the
Inclusion of Women and Minorities as Subjects in Clinical Research.

The personnel category will be reviewed for appropriate staffing
based on the requested percent effort.  The direct costs budget
request will be reviewed for consistency with the proposed methods
and specific aims.  Any budgetary adjustments recommended by the
reviewers will be in $25,000 modules.  The duration of support will
be reviewed to determine if it is appropriate to ensure successful
completion of the requested scope of the project.

AWARD CRITERIA

The anticipated date of award is September 1998.  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.  Designated
funding levels are subject to change at any time prior to award,
due to unforeseen budgetary, administrative and/or scientific
developments.

INQUIRIES

Inquiries concerning this RFA are encouraged.  Potential applicants
should request sample budget pages.  The opportunity to clarify any
issues or questions from potential applicants is welcome.

Inquiries regarding this programmatic issues and requests for
sample budget pages may be directed to:

Dr. Rebecca Link
Division of Blood Diseases and Resources
National Heart, Lung, and Blood Institute
6701 Rockledge Drive, Room 10178
Bethesda, MD  20892-7950
Telephone:  (301) 435-0070
FAX:  (301) 480-1046
Email:  [email protected]

Direct inquiries regarding fiscal matters to:

Ms. Jane R. Davis
Grants Management Office
National Heart, Lung, and Blood Institute
6701 Rockledge Drive, MSC 7926
Bethesda, MD  20892-7926
Telephone:  (301) 435-0166
FAX:  (301) 480-3310
Email:  [email protected]

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.

The PHS strongly encourages all grant and contract recipients to
provide a smoke-free workplace and promote the non-use of all
tobacco products.  In addition, Public Law 103-227, the Pro-
Children Act of 1994, prohibits smoking in certain facilities (or
in some cases, any portion of a facility) in which regular or
routine education, library, day care, health care or early
childhood development services are provided to children.  This is
consistent with the PHS mission to protect and advance the physical
and mental health of the American people.

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