Combined Multi-marker Screening and Randomised Patient Treatment with Aspirin for Evidence-based Pre-eclampsia Prevention

Informacje na temat projektu

ASPRE

Identyfikator umowy o grant: 601852

Projekt został zamknięty

Data rozpoczęcia 1 Maja 2013

Data zakończenia 31 Października 2016

Finansowanie w ramach

• Specific Programme "Cooperation": Health

Koszt całkowity € 7 556 140,90

Wkład UE € 5 839 800,00

Koordynowany przez

FETAL MEDICINE FOUNDATION
United Kingdom

Final Report Summary - ASPRE (Combined Multi-marker Screening and Randomised Patient Treatment with Aspirin for Evidence-based Pre-eclampsia Prevention)

Executive Summary:
Combined multi-marker screening and randomised patient treatment with aspirin for evidence-based pre-eclampsia prevention (ASPRE Project #601852) is funded through FP7-HEALTH-2013-INNOVATION-2, HEALTH.2013.0-1: Boosting the translation of FP projects' results into innovative applications for health. ASPRE aimed to translate the results of FP6 funded PREGENESYS project (#37244)] into effective prenatal care and drive the market for screening tests and software. Pre-eclampsia (PE) is a major cause of short- and long-term death and damage for the mother and her baby. ASPRE aimed to effectively identify pregnancies at high risk for developing PE and prevention with aspirin. Pregenesys project has identified the markers for screening the risk to develop PE, and in vitro models suggested that aspirin is the most promising PE prevention agent. Small-size clinical studies indicate that prophylactic use of low-dose aspirin starting before 16 weeks’ gestation can decrease the prevalence of PE by 50%.
According to the WHO guidelines PE screening is to be determined based on demography and medical history, and women at increased risk are advised to take low-dose aspirin daily from early pregnancy until delivery. In the UK, the National Institute for Health and Clinical Excellence (NICE) has issued guidelines recommending that who have any one major high-risk factor or any two moderate-risk factors to develop PE should be treated by aspirin. NICE guidelines yielded 40% detection rate (DR) of preterm PE and 35% for all-PE for a false positive rate (FPR) of 10%. ASPRE offers an alternative prediction model combining the prior risk with the values of multiple biomarkers including: (i) mean arterial pressure (MAP), (ii) uterine artery pulsatility index (PI) by ultrasound colour Doppler (protocols for both developed by the Fetal Medicine Foundation (FMF; Beneficiary 1), and (iii) biochemical biomarkers (developed by Wallac (Beneficiary 5) and hylabs [Beneficiary 2]). The newly developed FMF algorithm for PEscreening in the first trimester suggests that high risk women (top 10%) will be offered prophylactic aspirin at 150 mg per night from the first-trimester. The algorithm predicts 75% DR for preterm PE (<37 weeks’ gestation) and prevent 50% of these cases.
ASPRE has implemented three components clinical study: a screening quality study (SQS) and a main study of a screening phase, followed by a double blinded randomised controlled trial (RCT) of aspirin vs. placebo in high risk women to assess the efficacy of aspirin in preventing preterm-PE. The data capture tools and the PE risk calculator have been incorporated within a software package that has been developed by astraia [Beneficiary 4], allowing high throughput data acquisition and risk prediction.
During the SQS (February-July, 2015), 10,445 women who attended for the 11-13 weeks visit were assessed for eligibility. In total, 8,775 women were evaluated, and 239 subsequently developed PE (2.7%), including 17 (0.2%), 59 (0.7%) and 180 (2.0%) who developed PE<32 weeks (early), <37 weeks (preterm) and >37 weeks (term), respectively. In combined screening by maternal factors, MAP, uterine artery PI , serum PlGF and PAPP-A, the DR was 100% (95% CI 80-100) for early PE, 80% (95% CI 67-89) for preterm PE and 43% (95% CI 35-50) for term PE, at 10% FPR. The SQS has confirmed the effectiveness of the ASPRE screening approach and established a process of quality assurance for biomarker data acquisition.
On 20th July 2015, the ASPRE main RCT of aspirin vs. placebo commenced and recruitment concluded on 20th April 2016. A total of 26,941 women with singleton pregnancies were screened for preterm-PE, with 2,971 (11.2%) women identified as high-risk. 1,776 of the 2,641 eligible pregnant women agreed to take part in the RCT, of which 800 women were randomly assigned to aspirin and 824 to placebo groups, respectively. Excluding lost to follow up (n=4), 822 in the placebo group and 798 in the aspirin group were analysed. The RCT has demonstrated that aspirin is associated with a significant reduction in the rates of preterm-PE.
We anticipate that within the next 5 years about 3 million women will be screened by the ASPRE model, and 10% will be treated by aspirin to prevent at least 8,000 preterm-PE cases, translated to into avoidance of many maternal and perinatal deaths. The estimated cost saving is at least €MN803 for immediate health care cost and much higher for long-term treatments. These achievements create a major health and social benefits for pregnant women and their babies.
Wallac launched the CE-marked DELFIA® Xpress PlGF 1-2-3™kits, and registered extended use of PAPP-A kit for PE screening. astraia developed PE risk prediction software, incorporated into its first-trimester screening programme for adverse pregnancy outcomes. hylabs launched the CE-Mark automated PP13 kits, developed a new algorithm (with the addition of PP13) for PE prediction in twins, and issued a PCR test of PP13 promoter polymorphism as another PE risk biomarker in singletons. Hananja [Beneficiary 3] got GMP approval for aspirin prophylaxis in pregnant women, evaluated aspirin in uterine arteries' vasodilation, and developed aspirin compliance tests. ASPRE partners published already 80 peer reviewed articles and anticipate more, including the ASPRE RCT publication in 7/2017. The FMF has conducted ASPRE presentations in 4 “World Congress of Fetal Medicine” and 4 “Advances in Fetal Medicine Courses” describing ASPRE protocol, prediction algorithm and preliminary SQS results. All commercial partners made numerous ASPRE presentations in tradeshows and congresses. The 3 ASPRE-related patents (and many derivatives) were registered and 3 trademarks recorded.

Project Context and Objectives:
Combined multi-marker screening and randomised patient treatment with aspirin for evidence-based pre-eclampsia prevention (ASPRE Project #601852) is funded under FP7-HEALTH-2013-INNOVATION-2 under topic HEALTH.2013.0-1: Boosting the translation of FP projects' results into innovative applications for health. ASPRE aimed to translate the findings of the FP6 funded PREGENESYS project (#37244) into clinical practice and generate markets for screening tests and software. Preeclampsia (PE) is a serious complication that develops in at least 2% of pregnancies, representing approximately 172,000 women in the European Union (EU) each year and can cause maternal and perinatal death or disability. PE is a leading cause of iatrogenic preterm delivery and approximately 40,000 babies are born before 37 weeks in Europe each year. There is also extensive evidence that the risk of adverse outcome in relation to PE is much higher when the disease is severe and of early onset requiring delivery before 37 weeks’ gestation (preterm-PE) than at term. PE also poses long-term effects on the life and health of women and their babies. Women who develop PE in pregnancy have an increased risk of developing chronic diseases such as hypertension, cardiovascular disease and stroke later in life with a reduction in life expectancy by approximately 10 years. The children born to mothers with PE are also at increased risk of chronic diseases such as cardiovascular disease and diabetes mellitus, thus transmitting the health complications to the next generations. The estimated cost of treating women with PE and their babies during pregnancy and the immediate postnatal period is €18-22 billion per year in the EU alone. However, this is a gross underestimate if the long-term implications of PE on healthcare are also considered.
• The traditional approach to screening for PE is to identify risk factors from maternal demographic characteristics and medical history. Several professional bodies have issued guidelines on routine antenatal care recommending that at the booking visit, a woman’s level of risk for PE, based on factors in her history, should be determined and women at increased risk are advised to take low-dose aspirin daily from early pregnancy until the birth of the baby. In the UK, the National Institute for Health and Clinical Excellence (NICE) has issued guidelines recommending that women should be considered to be at high-risk of developing PE if they have any one high-risk factor or any two moderate-risk factors. The high-risk factors are history of hypertensive disease in previous pregnancy, chronic kidney disease, autoimmune disease, diabetes mellitus or chronic hypertension and the moderate-risk factors are first pregnancy, age >40 years, inter-pregnancy interval >10 years, body mass index at first visit of >35 kg/m2 or family history of PE. However, the performance of such approach is poor. The estimated detection rate (DR), for a false positive rate (FPR) of 10%, of the NICE method is about 40% for preterm-PE and 35% for all-PE.
• The Fetal Medicine Foundation (FMF, Beneficiary 1) has proposed an alternative approach to screening for PE, which allows estimation of individual patient-specific risks of PE requiring delivery before a specified gestation. The approach uses the Bayes theorem to combine the background risk from maternal characteristics and medical history with the results of various combinations of biophysical and biochemical markers of placentation. A fundamental component of this approach is a
• survival-time model for the gestational age at delivery with PE. This approach assumes that if the pregnancy was to continue indefinitely all women would develop PE and whether they do so or not before a specified gestational age depends on competition between delivery before or after development of PE. The effects of variables from maternal characteristics and obstetric history and biomarkers is to modify the mean of the distribution of gestational age at delivery with PE so that in pregnancies at low risk for PE the gestational age distribution is shifted to the right with the implication that in most pregnancies delivery will actually occur before development of PE. In high-risk pregnancies the distribution is shifted to the left and the smaller the mean gestational age the higher is the risk for PE. We have examined 120,492 singleton pregnancies at 11-13 weeks’ gestation, including 2,704 (2.2%) that developed PE. In the model the mean gestational age for delivery with PE for a reference population (Caucasian racial origin, weight 69 kg, height 164 cm, nulliparous, spontaneous conception, no family history of PE and no history of diabetes mellitus, systemic lupus erythematosus or antiphospolipid syndrome) is 55 weeks. The estimated standard deviation was seven weeks. Variables that shift the distribution of the gestational age at delivery with PE to the left, include advancing maternal age, increasing weight, decreasing height, increasing inter-pregnancy interval in parous women, Afro-Caribbean and South Asian racial origin, previous pregnancy with PE, conception by in vitro fertilisation and medical history of chronic hypertension, diabetes mellitus and systemic lupus erythematosus or antiphospholipid syndrome.
• Extensive research in the last 20 years has identified a series of early biophysical and biochemical markers of impaired placentation - uterine artery Doppler, mean arterial pressure and several serum biomarkers including maternal serum pregnancy associated plasma protein-A (PAPP-A) and placental growth factor (PlGF) at 11-13 weeks’ gestation can identify a high proportion of pregnancies at high-risk for PE delivering before 37 weeks (preterm-PE). The two biochemical markers have been developed by Wallac (Beneficiary 5), which have been prospectively evaluated by the FMF for the effective prediction of PE. These biomarkers are adjusted for certain maternal factors, obstetric history and gestation and the values are expressed in multiples of the expected median (MoM) of the normal. Bayes theorem is used to combine the background risk from maternal factors and obstetrics history with MoM values of biomarkers, taking into consideration of the significant correlations between biomarkers. At false positive rate 10%, the combined model predicted about 75% of cases of preterm PE.
• There were three components to the clinical study of project ASPRE – a screening quality study and a screening study followed by a double blind randomised controlled trial (RCT) of aspirin vs. placebo in the prevention of preterm-PE. The data acquisition requirements and the PE prediction model developed by the FMF have been incorporated into an electronic clinical report form (CRF) and a software package that have been developed by astraia (Beneficiary 4), allowing high throughput data acquisition and risk prediction.
• Between April and June 2014 an internal pilot study was conducted at King’s College Hospital, London, the major clinical site of the FMF research network in the UK. During the 2 months period, 1,089 women (98.4%) were screened 56 high-risk women were randomised. A review by the Trial Management Group of the internal pilot study at King’s College Hospital demonstrated that the study had been successful with respect to recruitment to both the screening study and the randomised drug trial; however it has also highlighted the complexity of the main ASPRE trial and confirmed the need for enhanced quality systems to be in place in advance of starting the trial in order to ensure the quality of pivotal data. Therefore, a screening quality study was introduced to precede the main ASPRE trial. The aim of this study was to establish systems that would monitor quality in a more detailed, formalised manner at sites and use these systems to assess quality, identify areas for improvement and, where required, implement strategies to improve quality e.g. re-training. This was based on the DQASS system that has been successful for improving the quality of the ultrasound and biochemical measurements in the NHS fetal anomaly screening programme in the UK.
• In July 2014 ASPRE was chosen for an in-depth inspection during a routine Medicines and Healthcare products Regulatory Agency Good Clinical Practice inspection. Due to a series of significant issues experienced with the incumbent IMP supplier, the Quality Management Group of the Study Sponsor – UCL-CCTU, recommended to the ASPRE consortium that an alternative supplier be appointed. The consortium accepted this recommendation and after extensive investigations and negotiations has selected Actavis (an EU pharmaceutical company) to supply the bulk IMP and Mawdsley Brooks & Co Ltd (Mawdsley) to undertake packaging, labeling and distribution of the pills to clinical sites by May 2015.
• During the screening quality study (between February and July 2015), a total of 10,445 women who attended for the 11-13 weeks scan were assessed for eligibility, of which 309 (3.0%) were excluded as they did not fulfill the inclusion criteria and 714 (6.8%) declined participation. 9,422 eligible women agreed to first-trimester combined screening for preterm-PE, whilst an additional 381 women (4.0%) were not screened for various reasons (CRL <45 mm or >84mm, detection of major fetal defect on scan, miscarriage or multiple pregnancy). 9,041 underwent screening, of which 266 were further excluded for reasons identified during the evaluation (2.9%). In the remaining 8,775 women, 239 developed PE (2.7%), including 17 (0.2%), 59 (0.7%) and 180 (2.0%) at <32, <37 and >37 weeks, respectively. In combined screening by maternal factors, MAP, uterine artery PI and serum PlGF and PAPP-A the DR was 100% (95% CI 80-100) for PE at <32 weeks, 80% (95% CI 67-89) for PE at <37 weeks and 43% (95% CI 35-50) for PE at >37 weeks, at 10% FPR. These DRs were similar to the estimated rates in the dataset used for development of the model: 89% (95% CI 79-96) for PE at <32 weeks, 75% (95% CI 70-80) for PE at <37 weeks and 47% (95% CI 44-51) for PE at >37 weeks. The screening quality study has concluded that a combination of maternal factors and biomarkers provides effective first-trimester screening for preterm-PE. The screening quality study has also established a process of quality assurance of the acquisition of the measurements of uterine artery PI, MAP and serum PlGF and PAPP-A.
• The sample size for the main RCT was revised, aiming to complete recruitment within 10 months, instead of 18 months. The sample size calculation was based on a 76% DR of the first-trimester combined screening for preterm-PE at a screen positive rate of 10%. With the aim to achieve a significant 50% reduction in the prevalence of preterm-PE from 7.6% in the placebo group to 3.8% in the aspirin group, with a power of 90%, and 5% significance level, it was necessary to randomise 1,600 high-risk pregnancies. Allowing for 10% loss to follow up or withdrawal, it would be necessary to randomise a total of 1,760 high-risk pregnancies, 880 women in each of the aspirin and placebo arms. On the assumption that 60% of high-risk pregnancies would agree to randomisation we needed to identify 2,933 high-risk pregnancies (that would constitute 10% of the screened population). We would therefore have to recruit a total of 29,330 pregnancies to the screening study.
• On 20th July 2015, the ASPRE main RCT of aspirin vs. placebo commenced and recruitment concluded on 20th April 2016. A total of 26,941 women with singleton pregnancies were screened for preterm-PE, with 2,971 (11.2%) women identified as high-risk. 1,776 of the 2,641 eligible pregnant women agreed to take part in the RCT, of which 800 women were randomly assigned to aspirin and 824 to placebo groups, respectively. Excluding lost to follow up (n=4), 822 in the placebo group and 798 in the aspirin group were analysed. The RCT has demonstrated that aspirin is associated with a significant reduction in the rates of preterm-PE.
• Wallac [Beneficiary 5] successfully launched the CE-marked PlGF 1-2-3 ™ kit (DELFIA® Xpress random access platform), together with registration of extended use for the PAPP-A kit for PE screening. astraia [Beneficiary 4] completed the development of PE screening software for risk prediction, which was incorporated into their comprehensive first-trimester screening programme for adverse pregnancy outcomes. hylabs (Beneficiary 2) completed the automated PP13 test and registered the kits for CE-marking, together with the development of a new algorithm (with the addition of PP13) for the prediction of PE in twin pregnancy. hylabs issued a PCR test to identify PP13 promoter polymorphism as another risk predictor for PE in singleton pregnancy. Hananja [Beneficiary 3] received GMP approval for aspirin prophylaxis in pregnant women, evaluated the effect of aspirin in vasodilation of uterine arteries, and developed the method to determine aspirin compliance. ASPRE partners published already 80 peer reviewed scientific papers. We anticipate more papers to be published, including the ASPRE RCT publication in the summer of 2017. The FMF (Beneficiary 1) has conducted PE-specific symposia in four “World Congress of Fetal Medicine” and four “Advances in Fetal Medicine Course” that included presentations of ASPRE protocol, prediction algorithm and preliminary results of the screening quality study. Wallac, astraia and hylabs presented the ASPRE project in numerous tradeshows, exhibitions, scientific congresses and other international meetings. Three ASPRE-related patents, and many derivatives have were registered and three trademarks recorded.

Project Results:
Project objectives

Project ASPRE aimed to evaluate the accuracy of first-trimester multi-marker screening for the development of preterm preeclampsia (preterm-PE), and conduct a randomised control trial (RCT) of aspirin vs. placebo in the prevention of preterm-PE in high-risk women.

The main objectives for the second 24 months and of the project overall were:
• To develop and implement the trial protocol and its amendments (including the selection and training of recruiting sites of the FMF research network to participate in the study).
• To obtain regulatory approvals for the trial protocol and its amendments by all relevant regulatory bodies.
• To develop all tools and means to conduct the study (kits, software, aspirin and placebo) and supply them to sites.
• To manufacture and label the investigational medicinal products (aspirin and placebo) with the respective quality and stability records and deliver the kits to sites.
• To develop a software package with screens for data acquisition (electronic case report form), calculation of multiple of median for the biomarkers, risk calculation and pregnancy follow up.
• To introduce a screening quality study to ensure that all recruiting sites conduct first-trimester screening according to the pre-specified quality and standards.
• To prospectively validate the first-trimester combined screening for PE based on maternal history, biochemical and biophysical markers.
• To conduct the RCT of aspirin vs. placebo in high-risk women for preterm-PE and examine whether aspirin could prevent the development of preterm-PE.
• To establish the regulatory infrastructure and process for the conduct of the clinical study.
• To identify and develop additional biomarkers for predicting PE and establish the required information for adding more biomarkers for improved prediction of PE.
• To disseminate the results of the ASPRE project to a wide audience internationally.
• To manage the project’s technological and financial aspects and build the foundation for collaboration and communication including contingency plans to accommodate project changes.
Overall progress and achievements
General
The ASPRE project was the largest multi-centre clinical study carried out to assess the efficacy of first-trimester combined screening for preterm preeclampsia (preterm-PE), with delivery before 37 weeks’ gestation and evaluate, through a randomised control trial (RCT), whether aspirin is effective in preventing preterm-PE in high risk women.
The major goal of project ASPRE was successfully achieved demonstrating benefits of first-trimester combined screening followed by effective prevention with aspirin. The study has demonstrated that aspirin at 150 mg/day given at night to high-risk women at 11-13 weeks till 36 weeks reduces the risks of PE at <32 and <37 weeks’ gestation by 80% and 60%, respectively. There was no reduction in the risk of PE at >37 weeks’ gestation.
The project results will provide major contributions for Europe to remain as a leader in prenatal care and will attract strong visibility to EC funded projects.
During ASPRE, the participating SMEs developed their respective products required to implement the study and these ASPRE-related products will be used for screening and prevention of PE in medical practice. It is estimated that the results and the visibility of the project, and the major educational and marketing campaigns will make a substantial difference in the prenatal care of pregnant women. It is believed that there will be significant market growth of the participating SMEs and industry partners.
Highlighted significant results per work package
WP1: Design of clinical study, analytical methods, algorithms and software
• Establish the clinical study protocol, and its amendments, ethics committee approval and publication of the protocol to provide clear guidance as to how women should be screened, who should be treated with aspirin, and what data should be collected, and how the data will be monitored. This achievement involves the design of a prediction algorithm for risk calculation and the development of software for data acquisition, calculation of multiple of median of the biomarkers and calculation of risk.
• Set up investigational medicinal products (aspirin and placebo) manufacturing for the study.
• Evaluate potential biomarkers for improved risk prediction.
WP2: Production of reagents, aspirin, placebo, and software
• Complete development and manufacturing of a new type of robust, mono-clonal antibodies (Mabs) for accurate and reproducible PIGF kits for the use as one of the two biochemical markers to predict preterm-PE according to the prediction algorithm.
• Supply of PAPP-A and PlGF kits to all ASPRE recruiting sites.
• Supply of the semi-automated PP13 kits as a potential biomarker for improved risk prediction.
• Completion of software development for the clinical study.
• Provision of investigational medicinal products (aspirin and placebo) for the ASPRE main RCT.
WP3: Patient enrolment for risk assessment and stratification
• Conduct of a screening quality study with 10,445 women that enabled the prospective validation of the prediction algorithm, the establishment of a process of quality assurance for the acquisition of biomarkers, and the training of all research team members in implementing the screening phase of the study.
• Set up all the required regulatory monitoring procedures, logs, study documentations and reporting tools.
• Development of specific screens in the software for the screening quality study.
WP4: Aspirin vs. placebo randomised trial
• Conduct of the main ASPRE RCT, aiming to screen 29,330 eligible women to randomise 1,760 high-risk women to either aspirin or placebo groups. Trial drug compliance and side effects will be monitored, A process of reporting of serious adverse events will be established.
• Set up all the required regulatory monitoring procedures, logs, study documentations and reporting tools.
WP5: Analytical and quantitative outcome analysis
• Set up the process of data acquisition, analysis framework and quality assurance.
• Develop the prediction algorithm and statistical analysis plan to assess the efficacy of aspirin in preventing preterm-PE in high-risk women.
• Develop the contingent model for patient management according to risk assessment in the first, second and third trimesters, according to the inverted pyramid model of prenatal care.
• Building the foundation for improved risk prediction with additional biomarkers.
WP6: Automation, and scale up for marker diagnostics and production of software packages
• Complete development and production regulated GMP pr*ocesses for new and improved kits for biochemical assessment in predicting the risk of PE.
• Develop prototype for nucleic acid based PE biomarkers for identifying targeted groups for additional PE prevention programme among those that are not helped by aspirin.
• Issue certified software packages to manage prenatal care in women at risk of developing PE.
WP7: Ethics and regulatory affairs (no deviations)
• Regulatory registration and CE Mark for new products for the assessment of the risk for developing PE by biochemical markers.
• Complete all procedures for enabling ASPRE study compliance according to GCP.
• Periodic reviewing by the UK MHRA and set up additional requirements for a new batch of aspirin and placebo supply to the recruiting sites.
• Managing the ASPRE Trial Steering Committee, Quality Management Group, and the Independent Data Monitoring Group to assure the compliance of ASPRE monitor ASPRE with the GCP Guidelines, and the rules of the International Conference on Harmonisation (ICH) n order to allow future inclusion of ASPRE procedures and results in national and international guidelines for preeclampsia monitoring and prevention.
WP8: Dissemination, training and exploitation
• Major dissemination and education campaign during the World Congress of Fetal Medicine and the December Course by the Coordinator.
• Multiple dissemination and education campaign by the industry partner during several professional symposia, congresses and tradeshow.
• Multiple training activities to all site-PIs, research fellows and lab technicians in all aspects of the clinical study: data acquisition in the software, PAPP-A and PlGF testing with kits, use of ultrasound for the measurement of uterine artery PI, blood pressure measurement with automatic monitors, risk calculation, follow up of participants and collection of pregnancy outcomes.
• Publication of about 40 peer reviewed articles reporting the ASPRE project and tens of poster and oral presentations in scientific congresses worldwide.
• Establishing IP policy and patent registration related to the ASPRE project.
• Create the foundation for public cooperation with patient organisations and other stakeholders.
WP9 Project management and coordination
• Complete the Consortium Agreement.
• Coordinate technological development and submission of three project amendments.
• Conduct 8 consortium meetings and General Assembly.

• The consortium achieved its major initial objectives.
• The consortium faced delay in starting the clinical study. As a result the project was extended for six months without additional budget to enable the completion of patient recruitment to the randomised controlled study, and completion of collection of outcome data of all randomised participants.
• Once collection of outcome data was completed, it was possible to evaluate the efficacy of aspirin in preventing the primary outcome. Evaluation of secondary outcomes, aspirin/placebo compliance and additional biomarkers will continue beyond the study official end date.
• During the project, the consortium implemented several contingency plan, involving budget and responsibility transfer to enable reaching its major and immensely successful ending and meeting project objectives.

Accordingly the section below is written according to the topics and the impact on specific WPs and tasks.
• The potential impact (including the socio-economic impact and the wider societal implications of the project so far) and the main dissemination activities and exploitation of results (not exceeding 10 pages).
• The address of the project public website, if applicable as well as relevant contact details.
• Furthermore, project logo, diagrams or photographs illustrating and promoting the work of the project (including videos, etc...) as well as the list of all beneficiaries with the corresponding contact names can be submitted without any restriction.

The Main achievements by Beneficiaries
• Developing the clinical study protocol combining first-trimester screening and prevention with aspirin and applying for ethical approval.
• Developing and validating a risk assessment algorithm for the calculation of patient-specific risk of developing preterm-PE, based on maternal history and multiple biomarkers testing..
• To provide scientific evidence to support the value of early screening and prevention of PE by low dose aspirin.
• Strengthen the concept of the inverted pyramid model for prenatal care by confirming the effectiveness of first-trimester screening of PE and its prevention by a therapeutic intervention.
• Dissemination of the project results to healthcare professionals in international scientific meetings and publication of a number of significant peer reviewed journals, thus providing the evidence for changing the clinical care of pregnant women at the international level.
• The FMF was also in charge of conducting the consortium periodic meetings; organising the amendments and the contingency plans and providing all reports as required by the European Commission.

While the final project analysis is underway and the dissemination plan is still on-going extensively, the FMF has accomplished all other objectives.

1. The protocol was developed, ethically approved and published.
2. The risk assessment algorithm was found to accurately predict PE at 100% for PE <32 weeks, 75% for PE <34 weeks and 40% for PE at term at a FPR of 10%, as anticipated.
3. Aspirin was found to be associated with a 80% and 60% reduction in the rate of PE <32 weeks and <37 weeks, respectively.
4. Compliance with the use of aspirin/placebo was 86%, which is considered high.
5. The FMF conducted many workshops, lectures and symposia and will continue to do so in the coming months.
6. ASPRE results strengthen the inverted pyramid model for prenatal care – effective first-trimester screening followed by effective prevention with aspirin, thus moving the emphasis of prenatal care from the late second and third-trimester to early pregnancy. The approach will improve health and care for pregnant women.
7. ASPRE study has also provided the FMF an opportunity to run an additional study entitled SPREE Screening program for preeclampsia, which is an UK-based multi-centre, non-interventional study to enrol 16,850 singleton pregnancies. The study aims to compare screening for PE by NICE guidelines (history only) versus screening with history and MAP and PAPP-A, and screening with history, MAP, uterine artery PI, PAPP-A and PlGF (ASPRE algorithm). Started in May 2016, the study completed enrolment in December 2016 and completion of outcome data is expected in August 2017. If successful, the study has the potential to make a step change in the promotion of first-trimester PE screening (by ASPRE method) and prevention with aspirin to become the standard of pregnancy care in the UK.
WALLAC (Beneficiary 5)
The objectives of Wallac include:
• Developing a new highly sensitive and robust PIGF kit for first, second and third-trimester prediction of PE.
• Standardise the use of this marker according to gestational week to improve risk prediction and incorporating the testing for this marker into the prediction algorithm to develop PE.
• Filing the product for CE Mark and obtaining CE Mark approval.
In order to reach these goals the company was committed to:
• Manufacture and provide the new kit for all facets of the ASPRE study and train the local lab team in testing.
• Training and supply of DELFIA analysers to ASPRE clinical sites.
• It also conducted a major dissemination campaign to educate users and expose them to ASPRE programme and its advantages.

ASPRE is awaiting the major peer reviewed article, but so far the company achieved its goals:

1. Kit development completed, high throughput manufacturing – validated and the kits were supplied to the sites along with DELFIA-Xpress analyser to sites that did not have it before.
2. The FMF created a methods to verify the kits are used according to protocol and perform within performance specifications
3. Wallac was able to register the DELFIA-Xpress PlGF 1-2-3 kits for use in predicting the risk to develop PE in the first, second and third-trimesters of pregnancy. Wallac further evaluated these kits as an aiding tool for first-trimester prediction of Down’s syndrome. Finally, Wallac also verified the use of PAPP-A kits of DELFIA Xpress for PE prediction and launched a new intended use for these kits and the specification of their use for this purpose.

Assuming it will take time for ASPRE results to be published in high impact peer reviewed journal during the summer of 2017, and the longer time required to be incorporated into new guidelines, a sale progression is anticipated to be slow initially and reach rump up only within 3 years after the end of ASPRE.
ASTRAIA (Beneficiary 4)
The objectives of astraia included:
• Develop and implement the improved PE risk algorithm within the existing package of first-trimester pregnancy evaluation, thus expanding the user benefit and reach to a larger customer base.
• A second aspect of the work was to develop a data transmission service to send data from the clinical sites to the central database in UCL-CCTU.

In order to reach these goals the company was committed to:
• Developing screens’ structure and appearance for data acquisition, for risk screening and for the randomised aspirin and placebo phase.
• Incorporating the new FMF model for software required for risk prediction.
• Validate the risk prediction model in the software with test cases.
• Train all the clinical site-PIs and research fellows in the use of the software, data acquisition and aspirin treatment.
• Develop a data transfer interface for merging data of individual medical centre with the central database in UCL-CCTU.

Some of ASPRE activities are still awaiting to the major peer reviewed article, the company achieved many of its goals:

1. ASPRE software package was fully developed and astraia developed a simple method to incorporate the risk prediction algorithm with its former package for predicting first-trimester chromosomal abnormalities. They also added a simple way of updating for future development. This way the user of astraia will have a broader usefulness of astraia software to build customer loyalty and trust. The multiple function software also enable astraia to reach to new customer
2. In addition, astraia development of the interface to transmit data from medical centre to a central computer open for it the way to offer new products to customers involved in multi-site clinical studies, and need this newly development.

Assuming it will take time for ASPRE results to be published in a high impact peer reviewed journal during the summer of 2017, and the longer time required be incorporated into new guidelines, astraia anticipates a sale progression in the market. Uptake of ASPRE risk prediction algorithm is anticipated to be slow initially. Algorithm availability over the FMF website may also contribute to a slow increase in sale. However, the astraia package is fully validated and comply with regulatory requirements for a medical product, and in the medico-legal atmosphere today the product is anticipated to increase its sales once there is a widespread uptake of the ASPRE method of prediction and prevention of PE.

Hannaja (Beneficiary 3)
The objectives of Hananja included:
• Developing the procedure, protocol, QC and logistics for making aspirin and placebo for the clinical trial.
• Assess aspirin metabolite and its model of affecting pregnancies in the process of preeclampsia prevention
• Developing the compliance testing of aspirin and placebo using various procedures to determine aspirin metabolised in participants’ blood samples.
• Evaluating potential model for aspirin mechanisms in preventing PE.
Coordinating the software features screens with the UCL-CTU.

To reach these goals astraia had:
• Manufactured the aspirin and placebo for the internal pilot study.
• Coordinated all procedures and supply the aspirin and placebo for the internal pilot study.
• Assisted UCL-CCTU and all parties in the process required to enable aspirin and placebo provision for the main RCT through a subcontractor, based on Hananja’s specifications used for the internal pilot study.
• Developed methods and procedures for blood draw, provided them to the FMF, and designed the process for testing aspirin compliance.

While ASPRE dissemination is still undergoing, and awaiting submission to a high impact peer reviewed article, the company achieved many of its goals:
1. Aspirin and placebo were provided to the internal pilot study that was included in the main analysis of ASPRE study.
2. The procedures and methods for making aspirin and placebo including source of raw material and features were successfully validated in the study.
3. Infrastructure for compliance testing was established and testing will be conducted during the coming months.
4. Studies in animal models revealed that during pregnancy aspirin caused vasodilation of the uterine arteries to improve the supply of oxygen and nutrients to the foetus. The arteries of non-pregnant or third-trimester pregnany are not sensitive to aspirin.
5. These elements will help Hananja to register aspirin for use in pregnant women.
6. A spin-off of ASPRE for Hananja is the development of a model for using PP13 replenishment for targeted personal therapy in a population with impaired molecular function/structure. This may help in the future to offer cure from PE to patients who are not helped by aspirin.

Hylabs (Beneficiary 2)
The objectives of Hy-Laboratory included:
• Generating a new and robust PP13 kit based on tissue culture derived monoclonal antibodies and novel recombinant PP13 with performance specification.
• Convert the PP13 kits into an automated robotic kit version with performance specification.
• Filing the new kits to obtain the CE Mark.
• Generate nucleic acid based new test for predicting PE according to existing PE marker sequence or identify new nucleic acid base new PE markers.
• Assist the FMF in the management and financial aspect of the ASPRE project, including supervision to all major project requirements such as aspirin and placebo supply to the project, sponsoring the medical centres, managing the administrative parts of UCL-CCTU as a third party acting as the study sponsor and regulatory body, help in building contingency plans and in meeting the EC requirements.
.
To reach these goals Hy-Laboratories had:
• Created and verified the new semi-automated and automated PP13 kits.
• Developed methods for blood draw and processing for PP13 tests and trained the respective medical centres.
• Implemented the robotic PP13 testing analyser, and assisted the FMF major clinical site at KCH, London, to conduct the testing.
• Developed methods for DNA extraction and purification to enable qRT-PCR base sequencing of cell free DNA in pregnant women blood and converted this into a new product.
• Develop NGS based screening of new preeclampsia marking
• Created the legal and financial infrastructure for all involved sub-contractors.
• Conducting disseminating activities.
• Established the required infrastructure for supporting the FMF administratively and financially.

The company has accomplished many goals, and will leverage on the positive outcomes of ASPRE but will still need to go beyond the ASPRE official period to accomplish all its goals.

1. The company has completed the development of the PP13 semi-automated and automated kits.
2. The procedures and protocols were verified and the products were registered and approved by the CE-Mark.
3. The added value of PP13 in predicting the risk to develop PE was evaluated, verified and published along with the respective algorithm for predicting the risk to develop preeclampsia among twin pregnancy.
4. The use of PP13 in predicting the risk to develop PE either as a part of a wider risk predicting algorithm or in replacing any of the existing serum biomarkers is awaiting further analysis. Ll samples were tested and once ASPRE main analysis completes it will be possible to complete this task.
5. Hylabs has developed a prototype for qRT-PCR test of PP13 promoter polymorphism and evaluated its use in PE prediction. When combined with the qRT-PCR test of the truncated variant of PP13, that has been published, the two tests could be used to identify patient that are targeted for PE prevention through the potential use of PP13 replenishments. This approach is the subject for a new development of an orphan drug submitted for funding to Horizon 2020.
6. The company developed new methods and bioinformatics combining NGS and qRT-PCR for identifying new markers of PE based on nucleic acid testing. In the era of non-invasive DNA analysis this test has the potential for being used for novel applications in prenatal diagnosis.
7. The company gained extensive experience in conducting and participating in EU funded projects, which will help it in promoting its future business development. Activities in this project helped the company gain access to additional funding for NGS by the Israeli government and other bi-national funding.
o Develop methods for DNA extraction and purification to enable qRT-PCR base sequencing of cell free DNA in pregnant women blood and turn this into a new product
o Develop NGS based screening of new preeclampsia marking
o Create the legal and financial infrastructure for all involved sub-contractors
o Conducting disseminating activities.
o Build the required infrastructure for supporting FMF administratively and financially.

The company has accomplished many goals, and will leverage of the positive outcome of ASPRE, but will still need to go beyond the ASPRE official period to accomplish all its goals.

• The company has completed the development of the PP13 semi-automated and automated kits.
• The procedures and protocols were verified and the products were registered and approved by the CE-Mark
• The added value of PP13 in predicting the risk to develop preeclampsia was evaluated, verified and published along with the respective algorithm for predicting the risk to develop preeclampsia among twin pregnancy.
• The use of Pp13 in predicting the risk to develop preeclampsia either as a part of a wider risk predicting algorithm or in replacing any of the existing serum biomarkers is awaiting further analysis. Ll samples were tested and once ASPRE man analysis will come it will be possible to complete this task
• Hylabs develop a prototype for qRT-PCR test of PP13 promoter polymorphism and evaluated its use in preeclampsia prediction. When combined with the qRT-PCR test of the truncated variant of Pp13, that has been published, the two test could be used to identify patient that are targeted for preeclampsia prevention through the potential use of Pp13 replenishments. This approach is the subject for another development of an orphan drug submitted for funding to horizon 2020.
• The company developed a new methods and bioinformatics combining NGS and qRT-PCR for identifying new markers of preeclampsia based on nucleic acid testing. I our era of non-invasive DNA analysis this test has the potential for being used for novel applications in prenatal diagnosis
• The company gained extensive experience in conducting and participating in EU funded projects which will help it in promoting its future business development. Activities in this project helped the company gaining access to additional funding for NGS by the Israeli government and other bi-national funding.

Potential Impact:
ASPRE partners expect the project to pave the way from the development of scientific knowledge and technological breakthrough to the market by stimulating the development of new products, tools, technologies, patents, dedicated business paths and innovative marketable applications. ASPRE addresses with the topic of HEALTH.2013.0-1: Boosting the translation of health research projects’ results into innovative applications for health by improving both diagnostic and management of major clinical events relating to PE. ASPRE builds on the success of a previous EU funded project (PREGENESYS) in order to improve outcomes for women with PE and their children. Translation of the results of the previous project will be achieved by automation and scaling up the technologies and software required for the cost effective and large scale screening of populations of pregnant women, and conducting a clinical trial to define the effectiveness of aspirin in reducing the prevalence of PE. ASPRE addresses a multidisciplinary strategy of chemistry, bio-engineering, safety, regulatory and ethics bridging research centres, academia and companies, involving professionals, patient advocacy groups and policy makers under the same umbrella, to facilitate fast innovation and technology transfer from “bench to bedside” thereby becoming the field leaders.
ASPRE project forms the basis for a frame shift in deploying prenatal care to reduce the short-term and long-term maternal and perinatal morbidity and mortality of one of the most devastating pregnancy disorders. The improved screening and prevention proven by the ASPRE project will actively contribute to bringing the expected significant to increase the application of biomedical engineering, ICT and biotechnology in medicine. The expertise gained by the partners through many years of RTD in this area will be distributed across the European Union, Israel and Iceland and subsequently worldwide. ASPRE main achievements in combining technology and clinical research will drive forward the goals of the Innovation Union as outlined in the 7th Framework of RTD and now in the Horizon 2020 initiative, and will deliver innovative research in the EU and boosting SME competitiveness within a global marketplace.
Size of the population with PE
Number of pregnant women cited in relevant literature. Rates of PE within populations of pregnant women vary substantially. Routinely collected data suggest rates of between 2% and 8% in Europe and other high income countries.34 Rates may be 3-folds higher in developing nations.34 Estimated numbers of cases of PE each year in different regions are summarised in Table 3.1. Clearly, these are conservative estimates based on the lowest percentage
Table 3.1: Estimated number of cases of PE and preterm PE in major markets each year
Region Pregnancies Estimated number of:
Cases of PE (2% of total) Cases of preterm PE (1.0% of total)
EU 8,600,000 172,000 86,000
US 4,130,600 82,612 41,306
Japan 1,060,700 21,214 10,607
Latin America 4,500,000 90,000 45,000
Asia - Australia, New Zealand, Korea, Singapore 850,000 17,000 8,500
Canada 450,000 9,000 4,500
Sources: CIA World Factbook
ASPRE has indicated that the administration of 150 mg aspirin daily weeks 12-36 in women identified t be at high risk to develop preeclampsia will reduce the rate of preterm PE by at least 50% translated into at least 10,784 annually within 5 years of completion of this research project (Table 3.2). Figures in Table 3.2 are based on the following assumptions, which also form the basis for the calculation used to estimate the sample size for our clinical trial: (1) The screening tests developed in this project will enable healthcare providers to identify the 10% of pregnant women at greatest risk of developing PE, (2) Of these, 7.6% would develop preterm PE if left untreated, (3) Treatment with aspirin would prevent 50% of these cases of preterm PE. In addition, the estimate is based on our market share predictions (shown in Table 3.8). The ways in which we aim to achieve our market share predictions are discussed in more detail below.

Table 3.2: Number of cases of PE avoided through screening and effective treatment with aspirin

EU 2017 2018 2019 2020 2021
Number of women screened 946,000 1,419,000 1,892,000 2,365,000 2,838,000
Share of total pregnancy market 11.0% 16.5% 22.0% 27.5% 33.0%
Number of high risk women identified through PE screening and treated with aspirin 94,600 141,900 189,200 236,500 283,800
Number likely to get preterm PE (7.6% of those identified as high risk) 7,190 10,784 14,379 17,974 21,569
Number of cases of PE avoided (50%) 3,595 5,392 7,190 8,987 10,784

Socio-Economic Impact
Members of the ASPRE consortium have conducted a cost effectiveness analysis of a predictive prenatal PE screening in Israel and have concluded that, with a prevalence rate of 3%, the cost per PE case prevented would be below the actual cost of a PE case. With a higher prevalence, the cost per PE case prevented is cheaper than the cost of screening, when one evaluates only the costs associated with prenatal care and delivery up until hospital discharge of the baby and the mother. If the entire cost including the longer-term healthcare costs associated with preterm birth are taken into account, we estimate that healthcare providers in Europe could save as much as €803 million each year (Table 3.3).This estimate is based on the cost of immediate and long-term care costs for PE (Table 3.4) and the costs of screening and equipment established in the business plan (see Section 3.2 below).

Table 3.3: Savings to the healthcare system

EU 2017 2018 2019 2020 2021
Cost of screening pregnant women (€mn) 92 138 184 229 275
Cost of treatment with aspirin (€mn) 1.4 2.1 2.8 3.5 4.3
Number of analysers/software licenses required each year 4,730 2,365 2,365 2,365 2,365
Investment in diagnostic equipment (€mn) 118 59 59 59 59
Investment in software (€mn) 9 5 5 5 5
Total yearly investment (€mn) 221 204 250 297 343
Number of cases of PE avoided (50%) 3,595 5,392 7,190 8,987 10,784
Costs saved due to PE cases avoided (€mn) 382 573 764 955 1146
Overall healthcare cost saving (€mn) 161 369 514 658 803

Assumptions:
Combined cost of screening tests €97; One analyser/software license required for 200 tests.

Table 3.4: Immediate and long-term costs associated with each clinical event of PE

Costs € Reference
PE (average) 11,132 Simon et al, 2009
Eclampsia 27,857 Simon et al, 2009
Complications
Preterm birth (longer term cost not included in PE cost) 15,283 Lloyd et al, 2009
FGR (longer term cost related to PE) 3,707
Stroke (late complication in the child) 32,383 Sandercock et al, 2004
Cardiovascular disease 15,898 Ara et al, 2008
Average cost per case of PE avoided 106,259
Costs to individuals are also high for each case of PE, particularly through loss of earnings due to time away from work due to sickness and, in the postnatal period, for attending the Neonatal Intensive Care Unit (NICU). Few studies have assessed the extent of these costs, however, estimates from a US study suggest they may exceed costs of care for the affected individuals themselves. Based on these analyses, we estimate conservatively that costs to individuals will amount to €8,200 per case of PE and that costs saved through screening and prevention of PE will be €88 million each year from the fifth year post project.

Table 3.5: Savings to individuals

2017 2018 2019 2020 2021
Costs saved by individuals (€mn) 29.5 44.2 59.0 73.7 88.4

Quality of Life Impact
Avoidance of PE is an important outcome for at risk women and their babies, as the condition is a major cause of maternal and perinatal morbidity and mortality. 18% of direct obstetric deaths in the UK are associated with hypertensive disease, whilst in developing nations in Africa and Asia this accounts for 10% to 15% of all maternal deaths, rising to 25% of maternal deaths in Latin America, altogether leading to the deaths of more than 76,000 women each year. Obstetricians managing cases of preterm PE are faced with the challenge of balancing the need for achieving fetal maturation in utero with the risks to mother and fetus from continuing pregnancy. These risks include FGR, in addition to progression to eclampsia, placental abruption and HELLP syndrome (a group of symptoms in pregnant women including haemolysis, elevated liver enzymes and low platelet count). Preterm delivery is, in itself, associated with higher infant mortality rates and increased morbidity resulting from FGR, thrombocytopenia, bronchopulmonary dysplasia, cerebral palsy and an increased risk of various chronic diseases in adulthood, particularly diabetes, cardiovascular disease and obesity.
Additional health problems in later life may also face women who have experienced PE, as the condition is associated with an increased risk of death from future cardiovascular disease, hypertension, stroke and diabetes.4,9 Life expectancy of women who developed preterm PE is reduced on average by 10 years. Furthermore, mothers with PE are more likely to suffer from postnatal mental health issues and have an overall impaired quality of life. Mothers experiencing PE in their first pregnancy are often put under pressure not to get pregnant again, thereby further reducing birth rates, which already at an all-time low in some EU nations, and causing stress and anxiety within families.
Implementation of an effective screening and treatment programme would provide clear health benefits for pregnant women. In addition, helping women to understand their risk status may have the additional benefit of prompting women to comply more closely their program of antenatal and postpartum care.

DISSEMINATION AND EXPLOITATION OF PROJECT RESULTS AND MANAGEMENT OF INTELLECTUAL PROPERTY
Management of Intellectual Property
Our IP management and exploitation of IP involves the protection of new development of ASPRE foreground and progressing the background IP.
• The list of progress in registered patents and trademarks is provided below in Template B1 of all exploitable IP to be derived from the project results, type of IP and owners/partners involved
• It also provides the type of protection (trademarks and patents) for each.
• Subsequently, a sale forecast is provided with assumption

Accordingly, our aim to ensure commercial exploitation becomes evident. In the case of the ASPRE project, the majority of the IP to develop screening and treatment exists within the background IP covering know-how and licenses required for development of screening and treatment protocol. ASPRE focused on the value of aspirin in prevention of preeclampsia to sustain the market penetration of respective products. Nevertheless the partners ensured the protection of foreground IP generated through the program.
Table 3.7: Background IP ownership by partners

IPR type Owner Comment
Patent Wallac Many patents to several newborn and perinatal tests and analysers
Secret knowhow AST License required for use of source code required for risk algorithm implementation
Facilities, knowhow, experience HAN GMP facilities for manufacturing of test drug/placebo including storage and shipment. Also knowhow and experience in preparing, conducting and evaluating clinical trials. Extensive background and experience within the field of drugs in pregnancy and lactation
Patents hylabs PP13, antibodies and immunoassays for predicting PE with PP13. US # 6,548,306, US# 7,211,405, EU # EP1,051,487, US #6,790,625, EP1171470
Dissemination and Exploitation of Project Results
Dissemination is a key aspect of any publicly funded research work; we will ensure that IP developed during this project is protected prior to dissemination. Any public disclosure will require signed authorisation from the project Exploitation Board prior to wider disclosure. During the planning of our dissemination activities for this project four target communities have been identified

• Project team – A project website was established before the kickoff meeting to provide tools for information management in addition to regular project meetings to advance the project work. The project partners and clinical Co-PIs met every six months to share progress, achievement, discuss and overcome difficulties and outline the plan and goal for the next six months.

• Clinical community – The World Congress of Fetal Medicine and the advanced winter course of FMF were extensively utilized and will be utilized in the future to disseminate ASPRE protocol and results through lectures and posters and booths of the commercial partners. ASPR partners have already published 80 pear review articles including the screening protocol. There is about the same number of publications anticipated with the main clinical study results. More presentation are anticipate din main professional meeting word wide and tradeshows.

• General public – Demonstration of project objectives, activities, ethical framework and results to the public was and will be performed through the preparation of material suitable for the general public. This involves discussion with patient organizations (preeclampsia foundation and FECEN ). After the publication of the main ASPRE publication in a leading pear review article, a major publication campaign will start to enable wide exposure of the ASPRE project results and benefit to pregnant women and their families. With access to, and involvement with, the following groups we have outstanding vehicles to disseminate the results of this project to a wider audience of potentially interested parties.

Website – The website was established before the kick off meeting at month 2. It is dedicated to the project and has confidential and public domains. In the confidential domain all project reports, PPTs of technology, financial and clinical progress were outlines and password protected. The public domain includes the project goals and main activities. The site will be maintained for at least 2 years following the end of the project. Through the website and other methods of knowledge dissemination, the consortium has and will encourage the use of screening and therapy proposed in ASPRE.
National and International scientific conferences - Our members have and will use their international network to facilitate ASPRE results spread through organisations such as The World Congress of Fetal Medicine, ISUOG, ISSHP and national Maternal Fetal medicine Organizations. Clinical data presentation in these organisations symposia will raise ASPRE project profile, enhancing results dissemination. Stands at local national and international meetings in the EU and global congresses and tradeshow relevant to obstetricians and fetal medicine specialists and laboratory leaders have been and will be arranged to publicise the study amongst clinicians who sees pregnant women eligible to participate in the clinical trial.

Patient organisations – throughout ASPRE the respective clinical sites issued posters and brochures to make the study known to pregnant women and encourage them to join the study enrolment. The Coordinator and partners plan major campaign to get ASPRE results to the popular media after the publication of the main ASPRE results in par review publication. This campaign aimed to major newspaper and media, letters to editors, etc. If on time, then there will be a major publication in the June 2017 World Congress of Fetal Medicine. Relevant publications include Nature, Molecular Therapy, Obstetrics and Gynaecology, Human Reproduction.

Public dissemination- Public dissemination of ASPRE are planned to compliment scientific dissemination. Taking into account public interest, we will interact with patient advocacy groups such as Preeclampsia Foundation and European Foundation for the Care of Newborn Infants, and with national, European and international newspapers and audio-visual press media to disseminate project results. We will organise a public engagement day alongside an established scientific conference during the last year of the project, past examples of these types of public outreach days show a great deal of success in reaching out to local schools and national media. We envision that the day will be interactive, and intended for members of the public to find out about screening and treatment of PE. There will be talks from experts, affected women and their families as well as specialists from the scientific media to produce information in a manner accessible to the general population.

Short business plan – how do you intend to exploit the results and potentially the route to market?
ASPRE will lead to the availability of Doppler ultrasonography, automated blood pressure monitors and diagnostic kits to enable conduct of these tests, software for PE risk prediction, and a 150 mg ‘pregnancy’ aspirin dosage form as shown in Figure 3.1 and discussed in section 3.2.1 above. The following six steps are needed to increase the acceptance of the new clinical practice:
1. Increase the publication of our clinical studies with the ASPRE screening methods and tools in peer-reviewed journals (see the large amount already published in template A1 below)
2. Promote inclusion of the ASPRE screening and prevention model in national guidelines
3. Promote the registration of aspirin for pregnant women through regulatory bodies.
4. Support national studies when required.
5. Conduct studies of cost effectiveness of screening and prevention
6. Push for reimbursement for ASPRE methods performance.
The ASPRE project will build on the six steps indicated above and will work to publish cost effectiveness analysis.. In the April 2015 DIP congress in Berlin, a debate started with Dr. Liona Poon, ASPRE Co-PI of the Clinical trial, was followed by a vote of obstetricians indicated that 78% would consider starting ASPRE model of screening and prevention after the formal publication of ASPRE.
The most common reasons for not wanting to start treatment are shown in Figure 3.2 and reflect the different steps in the acceptance process. ASPRE partners will each on its own and altogether aims to improve education, training and QA for healthcare professionals involved in pregnancy care. We will direct training of about 500 healthcare professionals in the process of screening for PE, in order to introduce the new pyramid of prenatal care. In addition, we will undertake the wide ranging dissemination program to bring ASPRE methods of PE screening to the attention of many tens of thousands of patients and healthcare professionals throughout the world. In combination with Wallac and its affiliation with the worldwide PerkinElmer international sales force we believe that, as a consortium, we are well placed to build market acceptance for PE screening.
Exploitation of FOREGROUND

DELFIA® Xpress PlGF 1-2-3 IVD-kit
• Its purpose – to identify the risk to develop preeclampsia in the first, second and third trimester
• How the foreground might be exploited, when and by whom – beneficiary 5 will exploit it to sale kits of PlGF for screening the risk to develop preeclampsia in the first, second and third trimester
• IPR exploitable measures taken or intended – patent protected
• Further research necessary, if any – Further research to extend proof of usability in improving Down syndrome screening, fetal growth restriction, still birth among others in singleton and in twin pregnancy
• Potential/expected impact (quantify where possible) – Several million euros in sales in the next five years.

DELFIA®Xpress PAPP-A kits
• Its purpose – to identify the risk to develop preeclampsia in the first trimester in addition to use in prediction Down syndrome
• How the foreground might be exploited, when and by whom – beneficiary 5 will exploit it to sale kits of PAPP-A for screening the risk to develop preeclampsia in the first trimester
• IPR exploitable measures taken or intended – Patent expired for Down, negotiated for preeclampsia.
• Further research necessary, if any – Further research to prove usability to other pregnancy complications in singleton and in twin pregnancy. Potential cooperation with beneficiary 3 in using targeted drug approach for Pp13 use in preventing preeclampsia in patients with impaired DNA sequence or RNA expression of PP13.
• Potential/expected impact (quantify where possible) – Several million euros in sales in the next five years.

PP13 ELISA KITS
• Its purpose – to identify the risk to develop preeclampsia
• How the foreground might be exploited, when and by whom – Beneficiary 2 will exploit it to sale kits of PP13 for screening the risk to develop preeclampsia in singleton and twin pregnancy
• IPR exploitable measures taken or intended – Patent of the kits will expire in 2019.
• Further research necessary, if any – Further research to proof usability in twins, and mainly for the nucleic acid based screening by PCR and other methods and in twin pregnancy
• Potential/expected impact (quantify where possible) – Several thousand euros in sales in the next five years.

PREECLAMPSIA RISK PREDICTION ALGORITHM
• Its purpose – to identify the risk to develop preeclampsia in the first, second and third trimester
• How the foreground might be exploited, when and by whom – Mainly beneficiary 4 and potentially beneficiary 5 will exploit it to sale software packages and services for screening the risk to develop preeclampsia in the first, second and third trimester. Beneficiary 1 will use it for major education and dissemination campaigns
• IPR exploitable measures taken or intended – Trademark protection
• Further research necessary, if any – Further research for other pregnancy complication. Software o support data transfer and multiple site clinical studies
• Potential/expected impact (quantify where possible) – Several thousand Euros in sales in the next five years
ASPIRIN FOR PREECLAMPSIA
• Its purpose – To prevent the development of early and preterm preeclampsia
• How the foreground might be exploited, when and by whom – Mainly beneficiary 3 will exploit it to license the production of extended use of aspirin to treat pregnant women.
• IPR exploitable measures taken or intended – Patent protection
• Further research necessary, if any – Further organization of ASPRE research and data for registration with regulatory authorities and additional research in isolated uterine arteries.
• Potential/expected impact (quantify where possible) – Several thousand Euros in sales in the next five years
Commercial and Public Exploitation

The exploitation of sales from the ASPRE study in the first five years is anticipated to show a slow start as summarized in the table below.
Projected revenue (€k) 2017 2018 2019 2020 2021 Total
Diagnostic kits and analyzers((€k): Wallac 630.00 1,590.00 3,230.00 5,550 8260 19,260.00
Diagnostic kit sales (€k): hylabs 3.48 10.44 24.74 35.75 54.11 128.51
Software license sales (€k): AST 80.00 104.00 109.00 115.00 120.00 528.00
Pregnancy' aspirin sales (€k): HAN 0.27 0.68 1.24 2.18
Total 713.48 1,704.44 3,364.01 5,701.43 8,435.35 19,918.70

This is mainly attributed to the anticipated issues

• Per review publication - First and foremost, all partners need to see the major pear review publication of ASPRE incorporated in PubMed even before print. This is anticipated in the summer of 2017. There were 1100 physicians from all other the world attended FMF advanced winter course in December 2016 in London who have learn about APRE results with the primary indication of preeclampsia prevention. However, the publication above is inevitable to drive ASPRE incorporation into guidance, standard of care and major sale rump.

• Guidelines - Next events to take place for sale growth is the process of guideline changes. In the UK we hope a relatively faster process because of the significant participation in ASPRE, and the conduct of the SPREE study, funded by the UK and aims to compare the current NICE guidelines of aspirin use in preeclampsia prevention based on maternal history and prior risk to ASPRE model that quantify risk combining maternal history and risk factors and multi-marker testing. With recruitment completed in 12/2016 and results anticipated in 7/2017, this may drive the change in NICE guidelines, which at best can be expected by 12/2017 and most likely later. Canada and Australia that have done fractions of ASPRE may come next. Yet guideline changes in other countries may take longer.

• Reimbursement – This is crucial to drive the market. In Europe particularly, where prenatal care is mainly a public health issue, it takes additional time to move from professional societies' guidelines to placing healthcare instruction to inclusion in the standard of care and obtain approvals for ASPRE procedures incorporation in the basket of standard services for pregnant women. Briefly speaking, it has been shown by members of our group that introducing ASPRE model of screening and prevention of aspirin is accompanied by saving of €18,000 in immediate cost and at least ten times more of life long additional cost for caring for the mother and the newborn. Therefore we hope for a positive approval in the near coming future

• Tendering – Once reimbursement is in place, the partners will need to file for the tendering process for being suppliers of the anticipated tests/procedure which is also time consuming.

Wallac
The company aims to leverage on FMF education and dissemination campaign and participate with big emphasis on these events. The company will identify the early adaptors, who are able to be leading the convoy of adopting to new research development, either through patients driven efforts or availability of resources, the determination of local teams to provide high quality services or local government priorities. very attending governments. Yet, the company anticipates a slow rump up in the beginning due to the four listed processes above. Thus, in a timeline of 5 years the company do not yet anticipate huge growth.
Yet, the company foresees the potential is substantially larger than the revenue in the initial 5 years indicate. This is due to the prevalence of pre-eclampsia and its impact on both maternal and neonatal mortality and morbidity. Thus, implementing early pre-eclampsia screening should decrease the healthcare spending. The company will emphasize that early screening for preeclampsia ,means prevention (by aspirin) and better surveillance, and anticipate to have no ethical issues as those that are faced by identifying chromosomal aberrations as in the case of screening for Down syndrome. Therefore the uptake in number of screens, in the long run, is estimated to be higher than for Down syndrome screening.

Hylabs
All issues listed above in general and for Wallac in particular are also relevant in the case of hylabs but a much slower sale increase is anticipated given the main analysis for PP13 has yet to be completed in 2017, and that the initial increase in sale is anticipated to come from potential demand for screening in twins. The latter however, is mainly anticipated to eb associated with sale to clinical studies . The company also hope for interest in further use for research on each nucleic acid based methods and products.

Hannja
Hananja obtained GMP Manufacturing Authorization, which made it possible for Hananja ehf to receive approval for aspirin tablets from the Icelandic part of European Medicines Agency. Subsequently the company personnel received authorized certificate of compliance with GMP and GCP, as a part of ASPRE. In a due course when ASPRE analysis is completed, the company will sort to sale aspirin for pregnant women, and anticipate modest sales from it
Astraia
ASPRE also expanded the market opportunity for astraia as the company was able to combine the use of the risk prediction algorithm for preeclampsia into existing software of predicting chromosomal aberration. In this way the company will have extended services to offer to current customers and will have better chances for reaching to new customers. The company also developed a new product to enable the management of multi-centre clinical trials through the opportunity of patient record transmission from multiple sites to a central database enabling the analysis of large size studies. This development could serve the company in the future.

ASPRE algorithm for predicting the risk to develop preeclampsia
This algorithm was developed by the Fetal Medicine Foundation (FMF, beneficiary 1) based on results collected from the participating medical centres and with biochemical marker that were made available to the study by Wallac (Partner 5), and software developed, upgraded and installed by astraia (Beneficiary 4).
FMF will provide to doctors, sonographers and patients free access to the algorithm according to FMF standard practice. This will provide wide exposure to the ASPRE development, including also developing countries, young people and others who can't afford buying the complete software. This may be all that will be required in countries where medico-legal issues are only emerging. In these countries access to ASPRE algorithm through the FMF website is likely to enable the spread of ASPRE achievements. In any place the availability of FMF website create the opportunity for training and practice with the algorithm. In this stage, and probably also later, the Coordinator's reputation will be the major driver for the knowledge dissemination. The free access to the algorithm will increase the demand for ASPRE development and help turn it into a common practice!
After reaching the main pear review publication of ASPRE (most likely at the NEJM) later in 2016 and upon a successful entry into national guidelines in the coming period, ASPRE algorithm availability will drive ASPRE implementation and push for guideline changes anywhere. It will help doctors in making decisions, evaluating the need for aspirin and to know in which cases they must be insisting on compliance of the use of aspirin for a long period of time.
In some countries the medico-legal environment will obligated physicians to use the "officially, certified" algorithm and they will have to use registered software packages as provided by astraia. Otherwise they will need to locally verify FMF algorithm with their population, which is way more expensive than buying the software. In these countries ASPRE fellows will be of assets in adopting the astraia software. Yet, in some countries having access to the free FMF algorithm will remained the only way to get the medicine forward which is important for women There are countries where serum testing, history and blood pressure measurements may be the current practice. These countries will used a version of ASPRE algorithm lacking ultrasound, and therefore the use of Wallace (beneficiary 5) software may enable them to promote screening for preeclampsia. It is estimated that Viewpoint who assist in introducing ASPRE algorithm to their software used in some of the medical centres without being paid by ASPRE will also have access to ASPRE algorithm and risk prediction.

List of Websites:
Project Website:
http:// www.aspre.eu
Contact Details;
Prof. Kypros Nicolaides, Director
The Fetal Medicine Foundation (FMF)
137 Harley Street
London, W1G 6BG, UK
Tel: + 44 207 034 3070
Fax: + 44 207 034 3071
E-mail: [e-mail]

Project website2 address: www.aspre.eu

List of Beneficiaries with the corresponding contact names can be submitted without any restriction.

Beneficiary 1: The Fetal Medicine Foundation (FMF), United Kingdom
Prof. Kypros. H. Nicolaides, Male, MD
Director
The Fetal Medicine Foundation
137 Harley Street
London W1G 6BG
United Kingdom
Tel 1: [phone]
E-mail: [e-mail]
Fax: [phone]
www.fetalmedicine.org

Beneficiary 2: Hy-Laboratories Ltd (hylabs), Israel
Mr. Doron Cohen (male), MSc
Chief Executive Officer
Hy-Laboratories Ltd.
6 Menachem Plaut Str
Park Tamar, Rehovot, 7670606
Israel
Website: www.hylabs.co.il
Tel 1: [phone]
Tel 2: [phone]
E-mail: [e-mail]
Fax: [phone]
Dr. Ruti Cohen, Female, PhD
PhD, Director of Science and Marketing
Hy Laboratories Ltd.
6 Menachem Plaut Str.,
Park Tamar,
Rehovot, 7670606
Israel
Website: www.hylabs.co.il
Tel 1: [phone]
Tel 2: [phone]
E-mail: [e-mail]
Fax: [phone]

Beneficiary 3: Hananja ehf (HAN), Iceland
Prof. Sveinbjorn Gizurarson (male), PhD
Chairman
Hananja ehf. Pharmaceuticals
Aflagranda 7,
107 Reykjavík
Iceland
Tel 1: [phone]
Tel 2: [phone]
E-mail: [e-mail] & [e-mail]
Fax: [phone]
Website: www.hananja.com
Ms. Kristin Linda Ragnarsdottir (female)
Chief Executive Officer
Hananja ehf, Pharmaceuticals
Aflagranda 7
107 Reykjavík
Iceland
Tel 1: [phone]
Tel 2: [phone]
E-mail: [e-mail]
Fax: [phone]

Beneficiary 4: Astraia GmbH (AST)
Mr. Roland Denk (Male)
Chief Executive Officer
astraia software GmbH
Tel: [phone]
Phone 2 [phone]
E-mail: [e-mail]
Fax: [phone]
Street name: Occamstr 20
80802 München
Germany
Website: www.astraia.co.de
Dr. Angela Döring (female)
Head Quality Management
Phone 1: [phone]
Phone 2: [phone]
E-mail: [e-mail]
Fax: [phone]
Occamstr 20
80802 München
Germany

Beneficiary 5: Wallac Oy, Finland
Ms. Hanna Halma (female), MSc
Vice President, General Manager
Specialty Diagnostics, EMEA
Wallac Oy - PerkinElmer
Mustionkatu 6, 20750 Turku
PL 10, 20101 Turku
Finland
Tel: [phone]
Fax: [phone]
E-Mail: [e-mail]
WWW.perkinelmer.com